[Merkel cell carcinoma of the skin: two case reports located at the hand, with a review of litterature]

The Merkel cell carcinoma of the skin are rare neuroendocrine tumours, with a dermal location. Their severity and metastatic potential are higher than cutaneous melanomas'. Two cases are reported at the hand. A review of literature displays the pejorative prognosis of these tumours. Hand surgeons must be aware of them, in order to fasten the diagnosis and include the patient among a multidisciplinary medical team.

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.

Ostéite du trapèze à Ralstonia pickettii : à propos d'un cas et revue de la littérature

An immunocompromised 29-year-old man presented with a Ralstonia pickettii osteomyelitis affecting the trapezium bone. The patient underwent two surgical debridement stages, including trapezectomy and long-term drainage. The type of the contaminant organism and the trapezium localization make this observation atypical.

Rotations of three-joint fingers: a radiological study

The aim of the current study was to test a protocol of quantification of phalangeal three-dimensional (3D) rotations during flexion of three-joint digits. Three-dimensional-specific software was developed to analyze CT reconstruction images. A protocol was carried out with six fresh-frozen upper limbs from human cadavers free from any visible pathology (three females, three males). CT millimetric slices were done for reconstruction of hand bone units. Orthonormal coordinate systems of inertia were calculated for each unit. Three-dimensional phalangeal rotations were estimated between two static positions (fingers in extension and in a fist position). Results were displayed for the joints of each three-joint finger with calculation of 3D rotations. Mean longitudinal axial rotations of metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints ranged from 14 degrees pronation to 19 degrees supination. The index finger was in a global pronation position (4/6 specimens). The fourth and fifth fingers were in a global supination position in every case. The third finger was in a more variable global rotation (pronation in 2/6 specimens). MCP, PIP and DIP flexion angles ranged respectively from 71 degrees to 89 degrees, 65 degrees to 87 degrees, and 41degrees to 77 degrees. Lateral angles ranged from 19 degrees (ulnar angulation) to 23 degrees (radial angulation). The study of phalangeal rotations was possible in spite of a heavy protocol. This protocol could be partially automatated to speed up the analyses. Longitudinal axial rotations could be analyzed, in addition to flexion/extension or abduction/adduction rotations. CT scan reconstructions would be helpful for investigating pathological fingers. Abnormal rotations of digits could be quantified more precisely than during a current clinical examination of the hand.

Cicatrisation sur tuteur synthétique dans les ruptures récentes du ligament croisé postérieur

PURPOSE OF THE STUDY

Treatment of recent laxity of the posterior cruciate ligament is not standardized. The purpose of this work was to analyze results of reconstruction with adjunction of a synthetic ligament for major recent isolated or combined laxity of the posterior cruciate ligament (triades, pentades or dislocations). Our hypothesis was that the synthetic ligament acts like a tutor for healing of the torn ligament.

MATERIAL AND METHODS

This retrospective analysis included 14 patients (1 woman and 13 men), mean age 27 years. All were competition athletes except one who did not practice sports. Three quarters of the patients were traffic accident victims. The series included three isolated posterior ligament tears, six combined laxities, and five knee dislocations. Average posterior laxity was 24 mm preoperatively. The procedure was performed 7 to 53 days after the accident. Arthroscopic reconstruction was performed for six patients and arthrotomy for eight. All associated lesions were repaired during the same procedure except for two cases (one anterior cruciate ligament and one popliteal tendon). Posterior cruciate ligament repair was achieved with the adjunction of a polyester ligament (LARS) using a one or two strand technique. Patients were reviewed at 36 months mean follow-up (10 - 88 months). The IKDC score was determined. A posterior drawer was measured manually with Telos at 70 degrees.

RESULTS

Five stiff knees required either mobilization under anesthesia or arthrolysis. One tear occurred late after the accident during a new trauma. Subjectively, two patients were very satisfied, eight satisfied and three disappointed. Mean knee motion measurements were 6/0/130 degrees . A differential posterior drawer persisted in twelve knees. The Telos measurement of posterior drawer changed from a mean 24 mm to a mean 8 mm. The overall IKDC score was A: 0, B: 7, C: 3, and D: 2. Persistent posterior laxity was the predominant cause of poor scores. Outcome was less satisfactory for all items of posterolateral laxity. There was no difference between the 2- and 4-strand techniques. There were no cases of morbidity (synovitis, spontaneous tear) directly related to the synthetic ligament.

DISCUSSION

The gain in posterior laxity was substantial. Results depended on associated lesions, particularly lateral involvement (stiffness, IKDC score) rather than the repair technique. The synthetic ligament appeared to play the role of a tutor: a single strand measuring 6 mm in diameter is sufficient. This technique spares tendon stock and could be proposed for major posterior cruciate ligament laxity. A longer follow-up will be necessary to confirm the durable stability.

Fiabilité de l’arthromètre KT-1000 pour la mesure de la laxité antérieure du genou

PURPOSE OF THE STUDY

The purpose of this study was to compare the reliability and the reproducibility of both the KT-1000 arthrometer (Medmetric) and Telos for measuring anterior knee laxity. The Telos was used as the reference technique.

MATERIAL AND METHODS

Criteria for inclusion were preoperative anterior knee laxity, normal contralateral knee, and intra-articular surgery to reconstruct the anterior cruciate ligament. Between January 1st, 2000 and October 31st, 2001, 147 patients were operated on for knee instability using an autograft (BPTB or hamstring tendons). For each patient, comparative measurements were made for both knees preoperatively and postoperatively with an average follow-up of 16 months. Measurements with the KT-1000 apparatus were made with forces of 67 N, 89 N, 134 N and manual maximal force. For the Telos, a force of 250 N was used as recommended by the manufacturer. We also evaluated intraobserver variation between the two devices.

RESULTS

The anterior translation preoperatively as measured by the KT-1000 at 89N was 4.2 +/- 2.4 mm and 6.3 +/- 2.5 mm at maximal manual force. The result for Telos was 3.0 +/- 3.6 mm. The data scatter obtained with Telos was wider than with KT-1000 (p<0.03). The sensitivity of Telos was 72% with 28% false negatives. With KT-1000, sensitivity increased as tensile force increased. Sensitivity was 65% at 89N, 73% at 134N and 92% at maximal manual force. The concordance between the KT1000 and Telos data was low for either preoperative (10%) or postoperative (30%) measurements.

DISCUSSION AND CONCLUSION

In this study, the results of sensitivity and reproducibility as well as the minimal scatter of the values demonstrated the reliability of KT-1000 for measuring anterior translation of the knee. We recommend routine use of the KT-1000 device for measuring knee laxity. The low sensitivity and the high rate of false negative observed with Telos raises the question of its use a reference technique.

Three-dimensional rotations of human three-joint fingers: an optoelectronic measurement. Preliminary results

Longitudinal axial rotations of phalanges during flexion motions of digits have scarcely been analyzed with current anatomical or radiological methods. Recent optoelectronic systems were developed for three-dimensional (3D) kinematic analysis of human motion. These systems have the advantages of being non-invasive and non-irradiating. The current study was based on the VICON optoelectronic system. A validation of the protocol was made among a sample of volunteers for further direct clinical applications. An experimental protocol was set up with adaptations to the requirements of finger analyses (multiple infrared markers inside small-sized capture volumes). The set-up and the protocol details are described. Kinematic studies consisted in recording the movements of the right hand of six volunteers (free from any visible pathology). Results were displayed for the joints of each three-joint finger with calculation of 3D rotations. Metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) flexion angles ranged from 78 degrees to 118 degrees, 72 degrees to 119 degrees and 9 degrees to 66 degrees respectively. Lateral angles ranged from 5 degrees to 39 degrees (MCP), 4 degrees to 39 degrees (PIP) and 4 degrees to 30 degrees (DIP). Mean longitudinal axial rotations of MCP, PIP and DIP joints ranged from 11 degrees pronation to 26 degrees supination. The index finger was in a global pronation position (five of the six specimens). The fourth and fifth fingers were in a global supination position in every case. The third finger was in a more variable global rotation (pronation in four of the six specimens). An experimental protocol using an optoelectronic system (VICON) has been developed for a kinematic analysis of three-joint finger. A global measure study should be initiated among a wider sample of adults. A database should be created with direct clinical applications. Patients' kinematic deficits could be graded either for standard movements (flexion/extension and abduction/adduction) or for longitudinal axial rotations.

Facteurs pronostiques de la chirurgie du nerf axillaire

PURPOSE OF THE STUDY

We searched for prognostic factors which could influence outcome after surgery for traumatic lesion of the axillary nerve.

MATERIAL AND METHODS

Forty-five surgical interventions to repair injured axillary nerves were preformed between 1993 and 2000. We analyzed outcome at a mean 56 Months (range 15-96). Twenty-five isolated lesions were treated by nerve graft (n=20), direct suture (n=2) or neurolysis (n=3). Four associated axillary and musculocutaneous nerve injuries were treated by axillary graft and musculocutaneous neurolysis (n=2) or double grafts (n=2). Eleven injuries involving both the axillary and suprascapular nerve were treated by double nerve graft (n=4), axillary graft with suprascapular neurolysis (n=5), or axillary graft with an irreparable suprascapulary injury (n=2). Five axillary nerve lesions were associated with lesions of the rotary cuff; treatment associated suture of the cuff (n=3) or reinsertion fixation of the tuberosities (n=2) prior to nerve repair by axillary graft (n=4) or neurolysis (n=1).

RESULTS

For the isolated axillary lesions, results were very good or good for 16/20 nerve grafts, 2/2 direct sutures and 2/3 neurolyses. For the patients with an associated musculocutaneous lesion, shoulder function was considered very good for one; mean elbow flexion strength was 29% (15-50%) of the healthy side. For the eleven axillary and suprascapular injuries, outcome was very good or good for two. Very good or good results were not achieved for any of the five patients with associated cuff lesions. Factors predictive of poor outcome were a preoperative Constant score below 40 points, age over 40 Years, time to operation greater than 15 Months, and multiple nerve or associated cuff injury.

DISCUSSION

The favorable prognosis of isolated lesions of the axillary nerve was confirmed. The risk of failure does however persist and is related to late management despite well defined surgical technique.

Measurement of three-joint-finger motions: reality or fancy? A three-dimensional anatomical approach

Various anatomical publications have reported two-dimensional studies with flexion/extension or abduction/adduction motion analysis, but longitudinal axial rotations (LAR) of three-joint fingers have rarely been mentioned. The aim of our study was to determine the maximal passive motions of three-joint-fingers and to measure the passive LAR of phalanges during a flexion/extension movement. A protocol of anatomical dissection was carried out with 22 fresh-frozen limbs from 11 human cadavers free from any visible pathology. The sample consisted of six females and five males with a mean age of 75.7 years (range 65-94 years). Passive motions of fingers excluding the thumb were analyzed with a wire circling technique. Extreme flexion/extension angles and adduction/abduction laxities were measured for each joint. LAR angles of distal bony segment position were evaluated in comparison with the proximal bony segment position in extreme flexion or extension. The results were recorded for the joints of each three-joint-finger. No difference was statistically related to sex or right/left-sided criteria ( p>0.05). Passive LARs were measured in spite of an aggressive anatomical protocol. A small database was set up. LARs were an important third type of motion. They should be analyzed during a routine clinical examination of patients' hands as well as flexion/extension or abduction/adduction motions.

The cubital tunnel: anatomical study of its distal part

Different levels of ulnar nerve compression have been reported (the medial intermuscular septum, the posterior compartment of the arm, soft tissue or bony abnormalities of the cubital tunnel). In some rare cases, compression can lie in a 10-cm long tunnel, distal to Osborne's ligament, between the humeral head of the ulnar flexor muscle of wrist (FCU) and the medial epicondylar muscles. Only few publications mention this fact as a factor of residual or recurrent symptoms after common surgical procedures. However, a distal pathology of the cubital tunnel has proved to be the only factor of nerve entrapment in our clinical practice. Specific anatomical dissection of this area was carried out to find and classify the anatomical structures that may play a role in ulnar nerve distal compression. Twenty-four embalmed limbs from 13 cadavers were dissected. The purpose of this study was to find anatomical fibrous structures at an average of 10 cm from the medial epicondyle. Anatomical structures were classified into five types: no aponeurosis between the FCU and the medial epicondylar muscles (54.2% of cases), a fibrous band taut between the FCU and the fourth- and fifth-finger ulnar insertions of the flexor digitorum superficialis (FDS) (8.3%), a thin (20.8%) or thick (4.2%) partial aponeurosis between the FCU and the medial epicondylar muscles, and total aponeurosis (12.5%). Anatomical variations of the distal cubital tunnel were divided in five types, but their clinical significance remains unclear.