Isolated Kaposi sarcoma of the finger pulp in an AIDS patient

A 63-year-old woman with long-standing AIDS and previous Kaposi sarcomas of the lower limb presented to our consultation complaining of a painful left ring finger with pulp enlargement. X-rays revealed an osteolytic lesion of the distal phalanx. We suspected an isolated osseous Kaposi sarcoma and at surgery we found a hemorrhagic lesion with bone extension into the phalanx. Bone involvement is rare in Kaposi sarcoma and even rarer in patients without a cutaneous location.

The intra-operative radius joystick test to diagnose complete disruption of the interosseous membrane

Disruption of the interosseous membrane is easily missed in patients with Essex-Lopresti syndrome. None of the imaging techniques available for diagnosing disruption of the interosseous membrane are completely dependable. We undertook an investigation to identify whether a simple intra-operative test could be used to diagnose disruption of the interosseous membrane during surgery for fracture of the radial head and to see if the test was reproducible. We studied 20 cadaveric forearms after excision of the radial head, ten with and ten without disruption of the interosseous membrane. On each forearm, we performed the radius joystick test: moderate lateral traction was applied to the radial neck with the forearm in maximal pronation, to look for lateral displacement of the proximal radius indicating that the interosseous membrane had been disrupted. Each of six surgeons (three junior and three senior) performed the test on two consecutive days. Intra-observer agreement was 77% (95% confidence interval (CI) 67 to 85) and interobserver agreement was 97% (95% CI 92 to 100). Sensitivity was 100% (95% CI 97 to 100), specificity 88% (95% CI 81 to 93), positive predictive value 90% (95% CI 83 to 94), and negative predictive value 100%). This cadaveric study suggests that the radius joystick test may be useful for detecting disruption of the interosseous membrane in patients undergoing open surgery for fracture of the radial head and is reproducible. A confirmatory study in vivo is now required.

The middle radioulnar joint and triarticular forearm complex

The forearm is composed of the radial and ulnar shafts, which are linked by the interosseous membrane and intercalated between the elbow and wrist. The radius and ulna are connected by three joints, the proximal, middle, and distal radioulnar joints. The forearm ensures pronation/supination and longitudinal load transfer. The biomechanical and clinical relevance of the proximal and distal radioulnar joints is well established. In contrast, the middle radioulnar joint was considered relatively unimportant until studies published in the last decade showed that it fulfils crucial biomechanical functions and is of considerable clinical significance. We believe the conventional concept in which the forearm is viewed as part of either the elbow or the wrist is outdated and that a more relevant concept describes the forearm as a triarticular complex that functions as a full-fledged entity. In this concept, the three forearm radioulnar joints (proximal, middle, distal) work together to provide stability, mobility and load transfer. Here, we will argue for the relevance of the triarticular complex concept based on published data about forearm biomechanics and pathological conditions.

Pulmonary embolism following thrombosis of the brachial vein after shoulder arthroscopy. A case report

Thromboembolic complications are very rare after arthroscopic surgery of the shoulder. We report the case of a 25-year-old who presented thrombophlebitis of the brachial vein complicated by pulmonary embolism following arthroscopic surgery for posterior instability of the shoulder. No hemostasis impairment was found in this patient. The factors arguing in favor of thrombosis that had been retained from the literature were the lateral decubitus position with traction of the limb in its axis, prolonged surgical time, use of interscalene brachial plexus block, and a general condition susceptible to thrombosis (personal or family history of thromboembolism, genetic risk factor for thrombosis, smoking, obesity, neoplasia). There are currently no guidelines on the need for thromboembolism prevention during shoulder arthroscopy.

[Elbow arthroscopy]

This symposium of the French Arthroscopic Society is the 2005 state of the art of elbow arthrosocpy in France. A survey reports 499 cases during 2 years with a rate of complication higher than the arthroscopies of other joints (6% of minor and 1% of major complications). The main indication is the removal of loose bodies. They can come from arthritis, chondromatosis, osteochondritis or fracture. The most accurate radiologic examination is an arthroCTscan. The main pronostic factor is the cartilage status. Arthrolysis is the second indication. We performed a retrospective and a prospective studies to compare open and arthroscopic surgery. Results are almost similar with a significant higher improvement in flexion (7 degrees ) in the open group. Open surgery seems more efficient but with a franck loss of motion in the postoperative course. However, in this group elbows were preoperatively stiffer in relation with a trauma event instead of sport related microtrauma in the arthroscopically treated group. Removal of necrotic fragment combined with abrasion in osteochondritis of the capitulum yields to good results with 82% of patients resuming to sports. Long term prognosis is unknown as the joint line is narrowed at a 3 years follow up. Arthroscopy is usefull in synovial diseases as resection of synovial folds or removal of tumors like villonodular synovitis. In the treatment of epicondylitis, the results of our retrospective study are not so good as those reported in the literature. But in our comparative study the results are similar to the open surgery group. The numerous procedures and the different follow up in these two groups did not allow to give statistical analysis. Elbow arthroscopy is a hyper specialty with more and more advanced procedures.

Traitement arthroscopique des kystes synoviaux dorsaux du poignet

Incidentally discovered in 1987, arthroscopic treatment of dorsal wrist ganglia is based on our knowledge of their physiopathology which in turn benefits from the arthroscopic wrist evaluation. Dorsal wrist ganglia arise in the radiocarpal space from the dorsal part of the scapholunate ligament and migrate along the dorsal wrist capsule. According to their position above or under the dorsal intercarpal ligament, their cutaneous projection may vary. The basis of the arthroscopic treatment of wrist ganglia is, as with open surgery, the capsular resection in front of their origin. Arthroscopic resection is made either from dorsal radio-carpal or midcarpal approaches with little morbidity. Scars are unnoticeable, wrist mobility and strength close to normal by three months, which is the delay for dorsal wrist pain, always very limited, to disappear. The recurrence rate is however still debatable. Close to zero in some series, we had almost 20% recurrence rate in our series, with half of patients who reccur after two years follow-up. This variability in the recurrence rate also exists with open techniques. The only prospective and randomized study available to date found no differences between the two techniques, according to the recurrence rate.

[Arthroscopic treatment of dorsal wrist ganglia]

Incidentally discovered in 1987, arthroscopic treatment of dorsal wrist ganglia is based on our knowledge of their physiopathology which in turn benefits from the arthroscopic wrist evaluation. Dorsal wrist ganglia arise in the radiocarpal space from the dorsal part of the scapholunate ligament and migrate along the dorsal wrist capsule. According to their position above or under the dorsal intercarpal ligament, their cutaneous projection may vary. The basis of the arthroscopic treatment of wrist ganglia is, as with open surgery, the capsular resection in front of their origin. Arthroscopic resection is made either from dorsal radio-carpal or midcarpal approaches with little morbidity. Scars are unnoticeable, wrist mobility and strength close to normal by three months, which is the delay for dorsal wrist pain, always very limited, to disappear. The recurrence rate is however still debatable. Close to zero in some series, we had almost 20% recurrence rate in our series, with half of patients who reccur after two years follow-up. This variability in the recurrence rate also exists with open techniques. The only prospective and randomized study available to date found no differences between the two techniques, according to the recurrence rate.

Résection arthroscopique des kystes synoviaux dorsaux du poignet : à propos de 54 cas

INTRODUCTION

Ganglion cyst of the wrist can, some time, need surgery. Different arthroscopic technical procedures have been described. We report our experience in all articular resection of dorsal ganglion cyst of the wrist.

OBJECTIVES

Evaluation of efficiency of resection of dorsal ganglion cyst of the wrist by of arthroscopic resection of the pedicle.

METHODS

Fifty-four cysts of 52 patients have been evaluated retrospectively. Operative data, pain, strength, recurrence and complications have been collected.

RESULTS

Average follow up was 28 months (6 to 78). Return to work was 8,8 days, operative time 41 minutes (25 to 90). In 67% cases, the operation was judged easy. Three surgeries had to be performed open. Complications were one hematoma and one neurodystrophy. Pain decrease from 3,37 to 1,76 on analogical pain scale. Flexion was 89% of opposite side, extension 88%. Sixteen recurrences (29.7%) were found. Sixty percent of those recurrences occurred during the first year experience. But independently of experience, the operative performance was foun difficult in 1 time on 3.

CONCLUSION

Endoarticular arthroscopic resection of the pedicle of ganglion cyst is not so reproducible. In experimented hands, it remains a difficult procedure after a long learning curve with a recurrence rate 3 times higher from what is reported in literature for open surgery. For our discharge, our long follow-up can contain some cases of de novo cyst explaining this high rate, the learning curve is certainly the main reason for our high recurrence.

Ligamentoplasty of the forearm interosseous membrane using the semitendinosus tendon: anatomical study and surgical procedure

Total longitudinal disruptions of the interosseous membrane can allow proximal radius migration and are seen in Essex-Lopresti lesions. We propose an original technique of ligamentoplasty using the semitendinosus tendon. The graft corresponds to the forearm rotation axis for an optimized isometry and longitudinal stabilization. Our ligamentoplasty technique was performed on ten fresh frozen right forearms. We successively assessed the innocuousness, efficiency and resistance of the ligamentoplasty. The ligamentoplasty induced neither passive limitation of pronation-supination nor neurovascular lesions. It prevented from radius proximal migration. The mean load to failure was 28 kg at both ulnar and radial sides of the graft. Our technique is original for the type and position of the graft. It seems safe, efficient and resistant enough for in vivo procedures. This technique decreases longitudinal loads on the radius. It should be indicated in patients with Essex-Lopresti syndrome, in association with radial head internal fixation or arthroplasty.

Difficultés du transfert d’information en vue d’un consentement éclairé

PURPOSE OF THE STUDY

Delivering information to the patient, an ethical obligation recognized for years, has recently become a legal obligation. Proof of information delivery has become the legal responsibility of the surgeon. We conducted a prospective study to evaluate the quality of information transfer by assessing patient comprehension of information delivered in an orthopedic surgery unit.

MATERIAL AND METHODS

All patients attending consultations before undergoing arthroscopic treatment for rotator cuff tendinopathy were enrolled in this study when the consultation was conducted in the presence of an observer. Two questionnaires, one for the patient and one for the surgeon, were used to collect given information about the pathological condition, the modalities of treatment, and the expected results of the treatment and its complications.

RESULTS

All 21 patients included in the study considered they had been well informed and that they had understood their pathological condition as well as the complications of the proposed treatment. However, agreement between their stated comprehension and the information delivered was poor, varying from 15 to 50%. Furthermore, 90% of the patients stated they had understood the potential complications of the surgical procedure, despite the fact that the consulting surgeons had not (generally) provided information on such complications.

DISCUSSION

There is a gap between what the surgeon says (or thinks he/she says) and what the patient understands. Potential biases in this study (non-unbiased observer) might explain this discordance which was probably related to the unequal relationship between the patient and the physician for any consultation. Therefore, the basis of informed consent cannot be found in the details concerning complications actually delivered to the patient. Surgeons must become aware that the patients understand very little of their explanations. This does not mean that the information should not be delivered but on the contrary that it must be. The important point is not necessarily the information content but rather the quality of the human relationship enabling information transfer.

Traitement arthroscopique de l’épicondylalgie d’origine tendineuse

The purpose of the study was to report our experience in a preliminary series of patients who underwent arthroscopic treatment of tennis elbow in order to appreciate effectiveness of this method. Between September 2000 and February 2004, we treated arthroscopically fourteen patients with epicondylitis which failed to respond to medical treatment given for a mean duration of 15.8 months. We used the technique described by Baker in 1999. Briefly, the external capsule was sectioned followed by section of the extensor carpi radialis brevis and extensor digitorum communis insertions on the epicondyle. Section was continued until muscle fibers were visible. Mean patient age was 45 years (range 36-55). Five patients were victims of occupational accidents and one had an occupational disease. One patient suffered from fibromyalgia. All patients were reviewed at a mean follow-up of 11.5 months. We used the Mayo Clinic score to assess outcome which was excellent or good in nine patients, fair in one and poor in four. Despite these modest preliminary results, arthroscopy appears to be well indicated for this pathological condition. The ideal treatment remains a question of discussion.

[Coronal fractures of scaphoid]

Two cases of frontal fracture of the scaphoid proximal pole after a high energy trauma are reported. Diagnosis was delayed in both cases and was only possible with a CT-scan. One fracture was slightly displaced: the patient was treated conservatively and followed during 11 years with an excellent result. The other patient was operated on because of persistent pain and malunion. Only during surgery was the correct diagnosis made and due to scaphoid malunion, a proximal row carpectomy was performed. At a post operative assessment, in both cases, X-rays showed a double contour of the proximal pole of the scaphoid. We believe than an arthroCT-scan or MRI is necessary to assess the fracture displacement and search for an associated ligamentous injury.

L'antibioprophylaxie en chirurgie de la main : à la recherche d'un consensus

Antibioprophylaxy in surgery follows, in France, the guidelines published by the French Society of Anesthesia [Société française d'Anesthésie et reanimation (SFAR)]. However these guidelines were mostly made for prosthetic and traumatologic surgery of the lower limb and guidelines for upper limb and hand surgery have been made by extrapolation. The French Society for Surgery of the hand has made multiples studies including: a survey to precise the infection rate for hand surgery which has been estimated to be around 0.1%. A search in the international literature, according to the classification criteria proposed by the "Agence Nationale D'accréditation et d'Evaluation Sanitaire (ANAES)" to better define correct antibioprophylaxy that should be used in hand surgery. Results of those surveys have been presented by national experts at the French Society Meeting of 2003. The attendance was given the opportunity to answer questions from the experts. A jury was present and its conclusion are reported here. Except for total wrist prosthesis and for surgical procedures that last more than 2 hours, there are very few indications for an antibioprophylaxy in hand surgery. In cases where an antibioprophylaxy is needed, the jury recommends that the guidelines proposed by the SFAR, regarding the choice of antibiotics, should be followed.

[Factual surgery or surgery founded on facts]

In the late 90s, teachers at McMaster's university (Canada) decided to export in clinical practice a teaching concept they had developed which included, among other concepts, a critical analysis of the medical literature. "Evidence-Based Medicine" (EBM) has since been adopted by many medical specialities or physicians as a reference in their practice of medicine. However, evidence-based medicine in its definition had three legs. Critical analysis of medical literature is the most known. The analysis is based on methodological principles that have been developed by statisticians and epidemiologists, principles which are not very familiar to surgeons. The other two legs are less known, but are important. The patient is still in the very middle of the EBM's principles. It is for him, the patient with his demands, that the physician must find a solution that may be not available in the literature. The surgeon, the third leg of the system, must be involved; he must listen to the patient, understand his particular demands, and find, for him the best answers to the question asked by the patient. It is the surgeon's responsibility to be the interface between science and one individual patient. Evidence-based medicine is a new model of the relationship between patients and physicians.

[Reasons why musicians consult hand surgeons]

PURPOSE OF THE STUDY

Musicians occasionally consult orthopedic surgeons, particularly upper limb specialists. We wanted to learn more about the reasons why musicians attend orthopedic clinics.

MATERIAL AND METHODS

We analyzed retrospectively 227 case files of musicians who consulted our center between 1994 and 2001. We noted patient related factors (age, gender, musical experience, level of performance, daily practice schedule) and their reasons for consulting (pain, discomfort, advice). We studied the medical history of the patients and searched for predisposing or triggering elements. We also recorded therapeutic options proposed.

RESULTS

Our series included 119 men (52%) and 108 women, mean age 35 years with 27 years of musical experience on the average. Instruments played were mainly the piano (41%), the violin (19%), and the guitar (15%). Patients playing wind instruments, who consult more often for ENT problems, were exceptional. On the average, the patients played their instrument 4 hours daily. One-third of the patients were high-level amateurs, one-third were professionals, and one-quarter were lower-level amateurs. There was a small proportion of soloists or professors. Two-thirds of the musicians presented disorders of the musculoskeletal system, particularly trauma sequelae. Signs of overuse were present in 18% of the patients, mainly women, signs of misuse due to inappropriate or defective technique in 8.8%, and dystonia in 5.7%. Psychological problems were noted in 4 patients. More than one half of the patients had obtained medical advice prior to consulting an orthopedic surgeon and the very large majority had been referred by specialized physical therapists. A surgical procedure was proposed for only 19% of the patients presenting an orthopedic disorder.

DISCUSSION

This study presents a diversified panel of musicians consulting orthopedic surgery clinics. Practicing schedules varied in the study population from one to five hours daily. More than half the patients complained of pain but 18% consulted because they perceived a problem when playing and 17% consulted simply for advice. Our findings recall that musicians comprise a sensitive population requiring careful overall management. Unlike series published to date, we had a majority of men. Problems involving an orthopedic disorder or trauma and trauma sequelae predominated. In the literature, diagnosis has been oriented by the specialty of the consulting physician. We found that our patients who suffered from overuse had often recently changed their habitual practicing methods or conditions. The diagnosis of misuse was facilitated when the patient was examined with his/her instrument. The low rate of dystonic disorders was probably related to the fact that nearly half of our patients were followed regularly by a physical therapist. We did not observe any case of excessive laxity or Linburg Comstock syndrome which exceptionally have functional impact. The very large majority of our patients were referred by physical therapists and when surgery was necessary, the procedure was performed in accordance with accepted rules concerning the therapeutic management of musicians.

[Soft-tissue chondroma of the hand: a case report and analysis of diagnostic procedures for extra-osseous cartilaginous lesions of the hand]

We report a case of a chondroma found in the soft tissues of the hand. Reports in the literature show that this cartilaginous tumor is a rare slowly-evolving benign tumor. Diagnosis is difficult as standard x-rays show variable images depending on the degree of calcification. Magnetic resonance imaging is helpful in orienting the diagnosis and delimiting the tumor but is not always useful in determining its exact origin. Positive diagnosis is provided by the pathology examination, but confirmation may be difficult to establish. We stress the importance of repeated microtrauma in the development of soft-tissue chondroma. Surgical treatment is the only successful solution but recurrence is not exceptional.

[Treatment of post-traumatic nail bed deformities with split-thickness nail bed grafts]

INTRODUCTION

Split-thickness nail bed graft have been proposed for treatment of post-traumatic nail bed dystrophies. Only three papers reported good results in 60 to 90% of cases. We report our experience.

MATERIAL AND METHODS

We reviewed 18 cases of split-thickness nail bed grafts from operative and consultation files and photographs. Evaluation was made using criteria as the nail plate shape, its adhesion on the nail bed, patient satisfaction and possible sequelae on the donor finger. RESULTANTS: Thirteen patients have been reviewed with a sufficient follow-up to assess the results. In 13 cases, the graft was taken from the hallux. The nail-bed graft was used for hallux reconstruction two times, the thumb six times, index six times, middle and ring finger one each, and the little finger two times. In every patient the graft was molded using either the patient nail or the nail plate from the donor finger. Clinical results were excellent in five cases, good in three and poor in five cases. Five failures were due to wrong indications in three cases in which matrix problem has been underestimated, and infectious failures in two cases. Fifteen per cent of our patients had some sequelae on the donor finger.

[The DASH questionnaire. French translation of a trans-cultural adaptation]

The DASH (Disability of Arm-Shoulder-Hand) is a self-administered questionnaire developed in 1994 by representatives of the Institute for Work & Health (IWH) and the American Academy of Orthopaedic Surgeons (AAOS). It measures the physical disability and symptoms for all upper limb disorders in a heterogeneous population and for acute as well as chronic disorders. The original american version has been already tested for reliability and validity. Interest in the DASH was raised by several European publications. It appeared that the DASH could provide a common measure for upper extremity physical disability in Northern America and European countries. For this cross-cultural adaptation, we followed the guidelines developed by the Institute for Work & Health and American Academy of Orthopaedic Surgeons. Five translations and two "back-translations" were compared, aiming to semantic, idiomatic, experimental and conceptual equivalence. The final version has been tested in 223 patients presenting a variety of traumatic or non traumatic disorders. 208 questionnaires (93%) were valid because there was less than 4 missing answers. This final version has been proposed to American Academy of Orthopaedic Surgeons in order to be endorsed as an official translation. This could improve assessment for international studies by establishing standard measures.