Yves Allieu

Dupuytren's disease, carpal tunnel syndrome, trigger finger, and diabetes mellitus

A comparative prospective study of 120 adult diabetics (60 insulin dependent, 60 non-insulin dependent) and 120 non-diabetic adults as controls showed significantly higher incidence of Dupuytrens disease, limited joint motion, carpal tunnel syndrome, and flexor tenosynovitis in the diabetic population. Of the diabetic patients one third had a mild non-progressive form of Dupuytrens disease, which commonly involved the long and ring rays. Limited joint motion was noted in a third of diabetics, and carpal tunnel syndrome was observed in 15-25%, and flexor tenosynovitis in about a fifth. Limited joint motion co-existed with Dupuytrens disease in 57% of insulin-dependent diabetics. Diabetic polyneuropathy was found in two thirds of insulin-dependent diabetics and in one third of non-insulin dependent diabetics. All these hand changes were more marked in insulin-dependent diabetics and they showed a positive correlation with increasing age of the patient, duration of the diabetes, and the presence of a microangiopathy.

Radiocarpal dislocations : Classification and proposal for treatment a review of twenty-seven cases

Background: The radiographic characteristics and treatment of radiocarpal dislocation are not well defined. There have been only two reported series of more than eight patients. Thus, there are many questions concerning treatment and functional results. Methods: Two groups of patients were defined. Group 1 included all patients with pure radiocarpal dislocation and patients with only a fracture of the tip of the radial styloid process. Group 2 included patients with radiocarpal dislocation and an associated fracture of the radial styloid process that involved more than one-third of the width of the scaphoid fossa. A retrospective review and a clinical evaluation were performed. Results: From 1975 to 1998, we observed twenty-seven cases of radiocarpal dislocation. Four were displaced volarly, and twenty-three were displaced dorsally. Fourteen patients presented with associated lesions. Four patients were treated with closed reduction and immobilization in a plaster cast; five, with percutaneous Kirschner wire fixation and cast immobilization; and two, with an external fixator. Eleven patients had open reduction with Kirschner wire fixation and cast immobilization. The seven patients in Group 1 had a highly unstable injury, and four of the seven patients presented with ulnar translation of the carpus. At the time of follow-up, at an average of 26.8 months, pronation averaged 76; supination, 66; wrist flexion, 54; wrist extension, 54; radial inclination, 15; and ulnar inclination, 18. The average grip strength was 27 kg. Group 2 included twenty patients. Only thirteen, with dorsal dislocation, were evaluated at the time of follow-up, which averaged fifty-one months. At that time, six reported no pain; four, slight pain; and two, moderate pain. Pronation averaged 63; supination, 76; wrist flexion, 51; wrist extension, 56; radial inclination, 21; and ulnar inclination, 39. Grip strength averaged 38 kg. Seven patients had complications. Conclusions: On the basis of our experience and a review of the literature, we believe that patients with pure radiocarpal dislocation or with radiocarpal dislocation with a fracture of the tip of the radial styloid process should be treated with reattachment of the ligaments through a volar approach. In patients with radiocarpal dislocation and a fracture of the radial styloid process that involves more than one-third of the width of the scaphoid fossa, the ligaments are still attached to the radial fragment. We believe that in this group of patients, exact articular reduction should be performed through a dorsal approach. Additional studies are needed to support these hypotheses.

Injured metamere and functional surgery of the tetraplegic upper limb

The size of injured metamere (IM) in tetraplegia exhibits a high variability that explains the different clinical presentations in patients who have the same neurologic level. Even when functional electrical stimulation is not planned, the lower motor neuron (LMN) integrity of paralyzed muscles must be evaluated, especially in patients with high-level tetraplegia. During the acute phase, detecting the size of the IM is important to prevent supination contracture and stiffness of the thumb and finger joints. When planning functional surgery, the LMN integrity of intrinsic muscles helps the surgeon adapt his surgical procedures. Assessing IM size must be integrated systematically into the evaluation of tetraplegic patients.

Clinical and radiologic outcomes of pyrocarbon radial head prosthesis: midterm results

BACKGROUND The modular pyrocarbon (MoPyC) radial head prosthesis (Tornier, Saint-Ismier, France) is a monoblock modular radial head prosthesis. This study assessed midterm outcomes after implantation of the prosthesis. MATERIALS A retrospective study was conducted of a consecutive cohort of 65 patients who underwent radial head replacement with the MoPyC prosthesis from January 2006 to April 2013. Indications were fractures, early or late failures from orthopedic or fixation treatments, and revisions after another implant. Patients were observed for >2 years for range of motion, pain, and stability; function by the Mayo Elbow Performance Score (total score, 100) and grip strength were assessed. Quality of stem implantation, bone resorption around the neck, and periprosthetic lucency were noted and quantified on radiographs. Capitellum shape and density as well as humeroulnar aspect (river delta sign) were evaluated. Complications and revision procedures were noted. RESULTS We evaluated 52 of 65 patients (mean follow-up, 46 ± 20 months; range, 24-108). The Mayo Elbow Performance Score was 96 ± 7; pain score, 42 ± 7/45; and motion score, 18 ± 2/20. Function and stability were excellent. Radiology revealed 92% of patients with cortical resorption around the neck without mechanical failure. Bone resorption was mostly anterior and lateral; it resolved within the first year and thereafter was stable. Eight patients underwent revision surgery for stiffness. No implant failures were noted. CONCLUSION Results of the MoPyC radial head prosthesis appear to be satisfactory. Bone resorption around the neck (stress shielding) is frequent and stable after 1 year and does not impair stem fixation. The MoPyC prosthesis appears to be a reliable solution for replacing the radial head.

Transfer of a Severely Damaged Digit to Reconstruct an Amputated Thumb

We retrospectively reviewed the results of reconstruction of a traumatically amputated thumb with use of an adjacent severely damaged digit in twenty-seven patients (twenty-five male and two female patients). The mean duration of follow-up was nine years (range, two to twenty-one years). The mean age at the time of the reconstruction was thirty-four years (range, thirteen to fifty-six years). Five patients had the reconstruction on the day of the injury and twenty-two, after a mean delay of five months (range, fifteen days to thirteen months). Segments of the index finger were used in twenty-two patients; of the long finger, in four patients; and of the ring finger, in one patient. There were four complications: necrosis of the dorsal skin in one patient, reflex sympathetic dystrophy in one patient, and contracture of the first web space in two patients. Discriminative sensibility was ten millimeters or less, according to the Weber test, in twenty-four thumbs. Cortical integration with reference to the recipient thumb, on stimulation of the pollicized segment, was good in ten patients. Eleven patients could achieve tip-to-tip contact between the thumb and the little finger and twenty-five patients, between the thumb and the most radial finger. The ability to perform activities of daily living was considered good for ten patients, fair for eleven, and poor for six. Only digits with a nail, either present on the transferred segment or as a result of a free vascularized nail transfer, were considered to have a good cosmetic result. Although these results are far from impressive, the reconstruction is a viable alternative for selected patients because it maintains the ability to grasp objects and to oppose the digits.

Allogreffes d’articulation totale du coude dans les pertes de substance ostéo-articulaire post-traumatiques étendues: Résultats à 12 ans de recul

Resume L’allogreffe d’articulation totale du coude comprenant l’extremite distale de l’humerus et proximale des deux os de l’avant-bras, ainsi que les formations capsulo-ligamentaires est un procede de sauvetage indique dans les cas de perte de substance osteo-articulaire majeure lorsque les autres techniques de reconstruction ont ete ecartees, notamment chez les sujets jeunes pour lesquels l’implantation d’une prothese totale de coude est contre-indiquee. Notre serie comportait 7 patients (âge moyen : 42 ans). Dans tous les cas, il s’agissait de sequelles post-traumatiques avec perte de substance osteo-articulaire vues secondairement et ayant toutes subi auparavant au moins une operation sur le coude atteint. L’evaluation de l’etat cutane preoperatoire a ete primordiale. Il existait dans tous les cas une retraction des parties molles autour de la perte de substance osteo-articulaire. Nous avons eu recours dans 3 cas a une expansion cutanee preoperatoire et, dans un cas, a un lambeau pedicule cutaneo-musculaire de grand dorsal. Nous avons utilise une voie d’abord posterieure et mediane en conservant la continuite tricipitale. Le nerf ulnaire a ete systematiquement transpose. L’adaptation de l’allogreffe a necessite une recoupe des extremites osseuses humero-ulnaires et une resection de la tete radiale dans tous les cas sauf un. L’osteosynthese stable, par plaque, a ete completee par une autogreffe spongieuse iliaque vissee au niveau humeral et au niveau ulnaire. Tous les patients ont subi un controle radio-clinique regulier. Nous avons utilise le score de Morrey pour evaluer le resultat clinique. Pour l’interpretation des images radiologiques, nous avons utilise la classification de Larsen et celle d’Allieu. L’etude a long terme a porte sur 6 cas, 1 cas etant un echec precoce repris par arthrodese. Le recul moyen est de 12 ans (7 a 15 ans). Le score de Morrey a ete ameliore dans 6 cas. Un seul n’avait pas retrouve une mobilite du coude situee dans un secteur fonctionnel (– 30°/100°). Dans tous les cas sauf un, nous avons constate une instabilite proportionnelle a l’anciennete de la greffe et s’aggravant avec le temps. Dans 5 cas sur 6, il existait une degradation articulaire radiologique importante associee a une lyse osseuse augmentant avec le recul. L’allogreffe agit comme un espaceur et ne transmettrait aucune information douloureuse. L’absence de frein douloureux engendrerait un surmenage articulaire et une destruction osteo-articulaire. Malgre cette degradation radiologique, cette technique permet d’obtenir un coude fonctionnellement satisfaisant et indolore. On constate ainsi une absence de parallelisme radio-clinique. Une osteosynthese rigide et l’adjonction systematique d’une autogreffe ont permis de maitriser le risque de pseudarthrose. L’infection reste la complication la plus redoutee. La planification tegumentaire preoperatoire et les techniques de chirurgie plastique associees ont permis le controle de cette porte d’entree infectieuse cutanee. Nous ne proposons cette intervention qu’aux larges pertes de substance osteo-articulaire chez les sujets jeunes desireux de conserver la fonction articulaire et pour lesquels la prothese totale de coude est contre-indiquee. Il s’agit d’une technique de sauvetage articulaire qui permet de reconstituer le capital osseux. Elle demeure une intervention d’indication exceptionnelle, techniquement difficile. A long terme, la resorption de la greffe est constante. Sur le plan clinique, l’instabilite degrade le resultat fonctionnel. L’avenir de cette procedure passera par les progres de l’immunologie et de la cryobiologie. Pour l’instant, les protheses totales de coude composites manchonnees avec une allogreffe osseuse combinent les avantages de la reconstitution du stock osseux et de l’arthroplastie.Purpose of the study Elbow joint allograft (EJA) involving the entire joint (distal humerus, proximal radius and ulna, capsuloligament structures) is a salvage technique proposed in massive bone loss, particularly in young subjects where total elbow prosthesis is contraindicated. We report our experience with seven patients, analyzing the long-term clinical and radiological outcome.PURPOSE OF THE STUDY Elbow joint allograft (EJA) involving the entire joint (distal humerus, proximal radius and ulna, capsuloligament structures) is a salvage technique proposed in massive bone loss, particularly in young subjects where total elbow prosthesis is contraindicated. We report our experience with seven patients, analyzing the long-term clinical and radiological outcome. MATERIAL AND METHODS This retrospective study included seven patients, mean age 42 years (21-70). All had experienced severe elbow trauma. Two patients had associated neuromuscular or vascular lesions. All patients underwent at least one surgical procedure on the affected elbow. The preoperative status of the skin cover was crucial. Both longitudinal and circumferential retraction were observed. We used preoperative skin expansion in one patient and a pediculated musculocutaneous latissimus dorsi flap in one other. A posterior and median approach was used conserving tricipital continuity. The ulnar nerve was transposed anteriorly. The allograft was prepared, carefully preserving the capsule and ligaments. Adaptation required cutting the extremities of the humerus and radius and total resection of the radial head except in one patient. Stable plate fixation was completed by an iliac cancellous graft screwed to the humerus and the ulna. The Morrey score was used to assess clinical outcome. The Larsen and Allieu classifications were used to assess radiological outcome. RESULTS There was one early failure requiring revision for arthrodesis. Assessment of long-term outcome concerned six patients. Mean follow-up was 12 years (7-15 years). The Morrey score improved in six patients and five of them were satisfied. None of the patients complained of invalidating pain and elbow motion was not functional in only one (- 30 degrees - 100 degrees ). For all patients except one, instability was proportional to the duration of the graft and worsened with time. For five out of six patients, significant radiological degradation of the elbow joint was associated with bone lysis which increased with time. DISCUSSION The allograft acts like a spacer and does not transmit pain impulses. The absence of the pain signal leads to overuse of the grafted joint and osteoarticular destruction. Despite radiological degradation, this procedure provides satisfactory and painless elbow function in most patients. The clinical and radiological features do not follow the same pattern. But we did not have any cases of disassembly or nonunion. Preoperative planning and plastic surgery have enabled us to control the cutaneous portal. We did not have any postoperative infections. Joint allograft is a salvage solution for major osteoarticular loss in young patients desiring conserved joint function and for whom a total elbow prosthesis is contraindicated. It restores bone stock, enables mid-term potential for joint function, and does not compromise surgical revision. CONCLUSION It remains an exceptional indication which is technically difficult. Resorption of the allograft is constant at long term. Clinically, instability worsen functional outcome. The future for this technique depends on progress in immunology and cryobiology. At the present time, composite total elbow prostheses with an allograft combine the advantages of restored bone stock and arthroplasty.

General indications for functional surgery of the hand in tetraplegic patients

General indications for surgery of the upper limb cannot be codified and do not follow any general rules. Each case is different, and a successful outcome depends on the experience acquired by a specialized surgeon, the team that surrounds the patient, and the customization of treatment to the personality and wishes of the patient. In addition, direct and caring human contract between the surgeon and his patient are fundamental. Today, many tetraplegic patients who are confined to their wheelchairs spend much of their time on the computer, eager to obtain as much information as possible about their condition from the Internet. One must stress, however, the risks of the false and partial information they might find. Surgical indications should be assessed only after a clinical evaluation and a long and personal discussion between the surgeon and the patient, who in this way establish a covenant between them. In the 21st century, patients will continue to become better informed, but the surgeon will maintain his role as mediator between the patient and surgery.

Compression of the ulnar nerve in Guyon's canal by pseudotumoral calcinosis in systemic scleroderma.

We report one case of ulnar nerve compression in Guyon’s canal due to calcium deposits in a 50-year-old woman with long standing systemic scleroderma. To our knowledge, this is the second known case. The symptoms consisted of a motor and partial sensory disturbance. Calcification of the piso-triquetral joint was prolonging into Guyon’s canal, lifting its contents, and into the subcutaneous tissue of the ulnar border of the wrist. Excision of calcium deposits and of the pisiform in combination with external neurolysis of the ulnar nerve resulted in complete relief of symptoms.

Flexor Origin Slide for Contracture of Spastic Finger Flexor Muscles A Retrospective Study

BACKGROUND Contracture of the wrist and extrinsic finger flexor and pronator muscles is a common consequence of central nervous system disorders. The proximal release of the extrinsic flexor and pronator muscles was first described by Page and Scaglietti for a Volkmann contracture. The aim of the present study was to assess the amount of increase in extension and the improvements in global hand function that can be expected following this lengthening procedure in patients with central nervous system disorders. METHOD A single-center retrospective review of patients with central nervous system lesions and contractures of the wrist and extrinsic finger flexor and forearm pronator muscles, causing aesthetic, hygienic, or functional impairment, was carried out. The Page-Scaglietti technique was used for all interventions. Before the operation, motor nerve blocks were used to distinguish between spasticity and contractures with surgical intervention only for contractures. The Zancolli and House classifications were used to evaluate improvements. RESULTS Data from fifty-four hands and fifty patients (thirty-five men and fifteen women) were evaluated. The mean duration of follow-up (and standard deviation) was 26 ± 21 months (range, three to 124 months). The mean gain (and standard deviation) in wrist extension with fingers extended was 67° ± 25° (range, -10° to 110°). Preoperatively, no hands were classified as Zancolli Group 1, whereas twenty-five hands were classified as Zancolli Group 1 at the latest follow-up review. Ten nonfunctional hands (rated as House Group 0 or Group 1) became functional as a supporting hand postoperatively. Zancolli and House classifications increased significantly (p < 0.01) postoperatively. In twelve cases, a partial recurrence of the deformity occurred. In seven of these cases, surgery unmasked spasticity or contracture of the intrinsic muscles, which required further intervention. CONCLUSION The Page-Scaglietti technique appears to improve range of motion and function in people with wrist and finger contractures due to central nervous system disorders.

Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients: TECHNIQUE AND RESULTS

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2 degrees pronation (-70 degrees to 80 degrees ) to 95.8 degrees supination (80 degrees to 140 degrees ). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6 degrees (60 degrees to 90 degrees ) in pronation and 50.4 degrees (0 degrees to 90 degrees ) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.