Y. Tropet

Closed traumatic rupture of the ring finger flexor tendon pulley

We report an unusual case of closed traumatic rupture of the ring finger flexor tendon pulley not previously reported in the literature. This injury occurred in a 21-year-old athlete during rockclimbing. Lack of flexion of the distal interphalangeal joint was accompanied by a palpable subcutaneous cord on the palmar side of the proximal phalanx. A simple repair of the pulley was done. The postoperative functional result was satisfactory.

Reconstruction des pertes de substance osseuse du membre supérieur par la technique de la membrane induite, étude prospective à propos de neuf cas

INTRODUCTION Bone defect in the upper limb remain infrequent with few reported in the literature. Their reconstruction raises the problem of bone union of non weight-bearing segments as well as the function of adjacent joints. We report a monocentric continuous series of nine patients treated with the induced membrane technique (Masquelet technique). PATIENTS AND METHODS Nine patients with a mean age of 39.2 years (17-69) presented with a bone defect of the humerus (six cases) or one of two bones (three cases). Diaphyseal (six cases) or metaphyseal (three cases) defects were secondary to trauma in three patients, to non-union in four others and following tumors for the other two. The mean defect was 5.1cm (2.5-9). Reconstruction was done by initial filling using a spacer in cement, followed by a cancellous bone graft within the induced membrane. BMPs growth factor was used in two cases. RESULTS Bone union was achieved in eight out of nine cases with a follow-up of 23 months (8-52) after the first stage, and 17 months (6-49) following filling by the graft. One patient did not want the second stage done before one year. The failure was in a very non-compliant patient who had a bone substitute associated with aBMP. Two septic non-unions were cured. Shoulder and elbow functional outcomes were comparable to the controlateral side for humeral defects; pronosupination decreased by 17% for the cases of reconstruction of two bones. DISCUSSION The technique of the induced membrane allows filling of a large bone defect, while avoiding vascularised bone autografts and their morbidity. It requires two procedures but can be used in emergency or after failure of other interventions. It is a reliable, and reproducible technique where the only limit is the cancellous bone stock. Following the series of Masquelet, Apard and Stafford in the lower limb, and the series of Flamans in the hand, this is the first report of reconstruction of defect in the upper limb using this technique.

Article originalReconstruction des pertes de substance osseuse du membre supérieur par la technique de la membrane induite, étude prospective à propos de neuf casInduced membrane technique for the reconstruction of bone defects in upper limb. A prospective single center study of nine cases

INTRODUCTION Bone defect in the upper limb remain infrequent with few reported in the literature. Their reconstruction raises the problem of bone union of non weight-bearing segments as well as the function of adjacent joints. We report a monocentric continuous series of nine patients treated with the induced membrane technique (Masquelet technique). PATIENTS AND METHODS Nine patients with a mean age of 39.2 years (17-69) presented with a bone defect of the humerus (six cases) or one of two bones (three cases). Diaphyseal (six cases) or metaphyseal (three cases) defects were secondary to trauma in three patients, to non-union in four others and following tumors for the other two. The mean defect was 5.1cm (2.5-9). Reconstruction was done by initial filling using a spacer in cement, followed by a cancellous bone graft within the induced membrane. BMPs growth factor was used in two cases. RESULTS Bone union was achieved in eight out of nine cases with a follow-up of 23 months (8-52) after the first stage, and 17 months (6-49) following filling by the graft. One patient did not want the second stage done before one year. The failure was in a very non-compliant patient who had a bone substitute associated with aBMP. Two septic non-unions were cured. Shoulder and elbow functional outcomes were comparable to the controlateral side for humeral defects; pronosupination decreased by 17% for the cases of reconstruction of two bones. DISCUSSION The technique of the induced membrane allows filling of a large bone defect, while avoiding vascularised bone autografts and their morbidity. It requires two procedures but can be used in emergency or after failure of other interventions. It is a reliable, and reproducible technique where the only limit is the cancellous bone stock. Following the series of Masquelet, Apard and Stafford in the lower limb, and the series of Flamans in the hand, this is the first report of reconstruction of defect in the upper limb using this technique.

Treatment of trapeziometacarpal osteoarthritis by partial trapeziectomy and costal cartilage autograft. A review of 100 cases.

PURPOSE Trapeziectomy remains the surgery of choice in the treatment of trapeziometacarpal osteoarthritis. Some authors consider the collapse of the trapezial space responsible for a loss of strength and intracarpal deformities. We report our experience of partial trapeziectomy with chondrocostal autograft as an interposition material. METHODS The study included100 thumbs in 82 patients with a mean age of 64.6 years (47-82). Mean follow-up was 68 months (4-159). Partial trapeziectomy was carried out through a dorsal approach. The graft was harvested through a direct approach of the 9th rib. RESULTS Our results were similar to those obtained with alternative techniques, except for strength where the gain is improved. No intracarpal deformities were seen. There was no sign of graft wear; the length of the thumb ray is preserved. The results are stable over time, and the morbidity of the costal donor site is negligible. The interposition of a hardwearing biological material and its association with partial trapeziectomy enable to restore the thumb stability and strength.

Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery

Breast reconstruction with adipocutaneous free flap from the abdominal wall combines the benefits of abdominoplasty to those of a prosthesis-free breast reconstruction. The deep inferior epigastric artery perforator (DIEP) flap is supplied by intramuscular perforators from the deep inferior epigastric artery (DIEA). It consists of the dissection of perforating branches of the DIEA within the rectus abdominis muscle, thus sparing both muscle and fascia. Preoperative imaging in the planning of DIEP flap surgery has been shown to facilitate faster and safer surgery. This review article aims to discuss advantages and drawbacks of current imaging modalities for mapping the course of perforating vessels in the planning of DIEP flap surgery, and to present state-of-the-art imaging techniques.

Post-traumatic reconstruction of digital joints by costal cartilage grafting: A preliminary prospective study

In digital joint defects, reconstruction is meant to obtain a stable, mobile and pain-free finger. Six patients aged 29 years in average (15-46) and who were prospectively followed-up presented with digital joint defects that affected at least half of either the proximal interphalangeal (PIP) joint or the metacarpophalangeal (MCP) joint. These defects were treated in emergency (four cases) or scheduled for an autograft of costal cartilage harvested from the ninth rib. Four digits showed lesions of the extensor system which were repaired. One digit grafted after complete amputation was no more vascularized. All patients were reviewed and prospectively followed-up by the surgeons and were also reviewed by an independent operator 16.1 months post-surgery in average (9-25). No infection occurred. None of the grafted fingers had to undergo arthrodesis or secondary amputation. One case of type 1 complex regional pain syndrome occurred. No functional or aesthetic complaint was reported, and no complication was observed at the donor site. The mean arc of motion was 33° (20-50) for the PIP joint and 37° (30-40) for the MCP joint. Mean total active motion (TAM) was 191° (160-250°), whichever the injured finger, i.e. 79.1% compared with the contralateral finger. The Buck-Gramko score averaged 11/15 (8-15). The Strickland score (interphalangeal TAM) was 57.8%, which corresponds to a medium result. The quick DASH assessment averaged 17.42 (0-47.72). Even if arthrodesis or amputation remain the conventional option in case of joint defect, prosthesis or cartilage grafting constitute solutions that allow the preservation of a functional painless finger.

Fractures comminutives du radius distal traitées par ostéosynthèse et substitut osseux injectable : Étude prospective de 39 cas

Resume La comminution dans les fractures du radius distal est un element souvent neglige dans l’analyse de la fracture. La combler permet d’eviter une modification de la variance ulnaire par tassement du foyer fracturaire. Ce tassement peut survenir apres la sixieme semaine, apres l’ablation du materiel, et perturber la pronosupination. L’utilisation de substituts osseux injectables permet de combler la comminution en s’adaptant au defect grâce a leur phase pâteuse quelle que soit leur composition chimique ou leur mode de durcissement qui survient en quelques minutes. Ces substituts ne sont pas des colles ou des adjuvants qui remplacent la fixation osseuse. Les auteurs rapportent leur experience de l’adjonction d’un substitut injectable associe a une osteosynthese dans 48 cas de fracture du radius distal prises en charge entre 1998 et 2001et revus avec un recul moyen de 46 mois (36-56). Quatre perdus de vue et 5 cals vicieux initiaux ont ete exclus de l’evaluation finale. Trois algodystrophies ont ete rapportees. Trente-neuf patients ont pu etre evalues par un operateur independant. Il s’agissait de fractures A dans 26 cas, de fractures B dans 15 cas, et de fractures C dans 7 cas selon la classification de l’AO osteosynthesees par broches (32 cas), par plaque posterieure (14 cas) ou par fixateur externe (2 cas). Le score fonctionnel de Herzberg atteignait 84/100 (54-100), le score radio clinique de Gartland et Werley atteignait 4,6 (0-11) avec 89 % d’excellents et bons resultats, le DASH atteignait 23,6 (5,8-62,7). La variance ulnaire etait inchangee ou s’etait modifiee de moins de 2 mm entre la periode postoperatoire immediate et le plus grand recul dans 88 % des cas. Seule la survenue d’un syndrome du canal carpien apres fuite en avant du substitut a pu etre imputee a celui-ci.

Apport de la radioscintigraphie quantitative dans les traumatismes du poignet avec radiographies initiales normales: Étude prospective de 154 cas

Resume Les fractures du scaphoide carpien doivent etre diagnostiquees rapidement afin d’eviter la pseudarthrose generatrice d’arthrose du poignet a laquelle expose leur meconnaissance. Meme si la plupart des patients beneficient d’un examen clinique minutieux et radiologique adequat, un certain nombre de fractures passent encore inapercues. La radioscintigraphie quantitative est une nouvelle technique d’imagerie medicale, validee dans une etude precedente qui associe scintigraphie osseuse quantitative et fusion numerique entre image scintigraphique et image radiologique. Elle est susceptible de diagnostiquer des fractures occultes au niveau du poignet et l’objectif de cette etude etait d’evaluer la frequence des fractures occultes au niveau du poignet diagnostiquees grâce a la radioscintigraphie quantitative. Une etude prospective a ete menee de novembre 1994 a mars 1999 pour evaluer les resultats de cet examen chez les patients presentant apres un traumatisme du poignet une symptomatologie clinique evoquant un processus fracturaire au niveau du poignet mais avec un bilan radiologique standard juge normal initialement. Avant sa realisation, certains patients avaient beneficie ulterieurement de plusieurs series de radiographies a quelques semaines d’intervalle pour rechercher le pourcentage de fractures devenues secondairement visibles sur les radiographies. Le bilan radiologique des patients a ete revu avec les donnees de la radioscintigraphie quantitative. Cent cinquante-quatre patients ont ete inclus. L’examen radioscintigraphique a permis de diagnostiquer des fractures chez 61 patients dont 56 avec un seul foyer de fracture et 5 avec plusieurs sites fracturaires ; 39,6 % des poignets examines presentaient une ou plusieurs fractures occultes dont 41 % de fractures du scaphoide carpien. Les fractures occultes au niveau du poignet et notamment au niveau du scaphoide carpien sont frequentes. La repetition du bilan radiologique ne permet pas d’augmenter le taux de mise en evidence de ces fractures. La tomodensitometrie peut etre prise a defaut dans la recherche de fractures occultes. L’IRM est l’examen cle dans le bilan d’une symptomatologie fracturaire du poignet mais reste peu disponible actuellement. La scintigraphie osseuse est classiquement peu specifique. La radioscintigraphie quantitative, examen rapidement disponible et peu couteux, semble actuellement le meilleur outil pour diagnostiquer les fractures occultes du poignet. Elle doit permettre d’eviter l’evolution d’une fracture negligee du scaphoide carpien vers la pseudarthrose et l’arthrose, aux consequences individuelles, sociales et medico-legales serieuses.

Trapezo-metacarpal and metacarpo-phalangeal dislocation of the thumb associated with a carpo-metacarpal dislocation of the four fingers.

The authors report a case of combined dorsal fracture-dislocations of all 4 fingers, palmar trapezo-metacarpal dislocation and metacarpophalangeal dislocation of the thumb following a motorbike accident. These exceptional lesions were treated as an emergency by reduction and pinning. With a follow-up of 13 years, the patient still worked as an electrician.

Immediate active mobilisation after flexor tendon repairs in Verdan's zones I and II: A prospective study of 20 cases

The authors report their experience with early active mobilisation after repair of complete sections of the flexor tendons within the digital tendon sheath. This is a prospective study carried out over 2 years and represents 20 repairs. The tendons were repaired using a double-loop looking suture of Tsuge (with PDS 4/0) associated with a peritendinous overrun using Prolene 6/0 via a volar Bruner-type incision. Post-operatively, a plaster splint holding the wrist in 30 degrees of flexion, the MP joints in 90 degrees of flexion and allowing complete active flexion of the finger protected the suture site. As soon as the dressings could be reduced (the 5th day post-operatively), the patient was encouraged to actively and synchronously flex all the fingers together as many times as possible during the day. After removal of the plaster splint at one month, the patients were entrusted to a physiotherapist with a view to regain full extension of the wrist and the fingers. We did not note a single case of breakdown of the repair. The mean active mobility (TAM according to Strickland) of the repairs in zone I was of the order of 70% while that for repairs in zone II was 85%. Immediate active mobilisation was not found to compromise, in any way, the results of associated digital nerve repairs. Despite the modest results, this simple-to-understand protocol is directed at present for injuries with a poor initial prognosis (contused and lacerated tendons, associated fractures, and non-motivated patients). Improvement in the quality of suture material should, in future, extend the indications for immediate active mobilisation to all fresh sutures of the flexor tendons.