Anatomically based radiological classification of thumb basal joint arthritis

The numerous surgical techniques proposed for treating thumb basal joint arthritis (osteotomy of the first metacarpal, trapezial osteotomy, simple trapeziectomy, trapeziectomy with implant, total joint prosthesis, arthroplasty by interposition, etc.) necessitate an anatomically based radiological evaluation of the different pathological forms of thumb basal joint arthritis. Here, the author defines three parameters: narrowing of the trapeziometacarpal (TM) joint space: TMA; TM instability and subluxation: TM I; scaphotrapeziotrapezoid damage: STT. Four stages of TM osteoarthritic deterioration are defined: TMA0: no joint narrowing (painful and unstable joint); TMA1: narrowing <50%; TMA2: narrowing>50%; TMA3: disappearance of the joint space, bone erosions. For TM instability/subluxation: TMI 0: reducible subluxation (unstable and painful TM); TMI 1: reducible subluxation but with imperfect reintegration; TMI 2: non-reducible subluxation <1/3; TMI 3: subluxation>1/3. For STT damage, STT 0: radiograph is normal but anatomical damage is visible intraoperatively; STT 1: joint space narrowing <50%; STT 2: joint space is barely visible; STT 3: presence of erosion, sclerosis, irregularities. He outlines the shortcomings of the often-used Dell and Eaton-Littler classifications. A prospective study involving multiple cases having the same anatomical and radiological appearance that are assessed with sufficient follow-up is needed to standardize the modalities of surgical treatment.

[Past, present and future of vascularised bone transfers in the hand and wrist]

The author specifies the aims and indications for simple or compound pedicle or free vascularised bone and bone and joint grafts (VBGs and VBJGs). He relates the history of VBGs whose indications for the wrist are often many and varied for the treatment of scaphoid non-union and Kienböch's disease. Within the hand the indication for compound VBGs is dominated by thumb reconstruction (skin and bone grafts). Compound VBGs and VBJGs used in an emergency for hand trauma, harvested from another irrecoverable long finger (bank finger) are extremely varied and adapted to each particular case. For secondary joint reconstruction in the adult, VBJGs must be discussed along with prosthetic arthroplasties (radio-carpal, lower radio-ulnar, trapezo-metacarpal, interphalangeal). For children VBJGs with an included growth plate maintain their indication. The immediate future of VBGs is that of a better knowledge of bone necrosis and bone innervation as well as an improvement in surgical techniques: microsurgery and robotics, mini-invasive surgery (wrist arthroscopy). The near future for VBGs is to control bone consolidation thanks to progress in the bio-engineering of bone tissue, which may make them obsolete and, for VBJGs, vascularised joint allografts, thanks to progress in immunosuppressant treatments. Although the immediate future and this near future may be envisaged according to the current advances, the same is not true for the distant future which remains totally unforeseeable, although this might involve regeneration and construction of organs by man himself.

Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients

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° pronation (−70° to 80°) to 95.8° supination (80° to 140°). 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° (60° to 90°) in pronation and 50.4° (0° to 90°) 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.

[Primary flexor tendon ruptures of the little finger within the carpal tunnel. Proposed classification based on six clinical cases and review of the literature]

Six cases of primary flexor tendon rupture of the little finger within the carpal tunnel are presented. All of them were attritional ruptures caused by a rough hook of the hamate. These ruptures are rare. They have their place among the flexor tendon ruptures of the wrist and the palm. Ultrasound may by helpful to determine the level of rupture. The surgical treatment consists of excision of the hook of the hamate and tendon repair.

[Scapulohumeral arthrodesis for non-neurological shoulder: a study of 8 cases]

PURPOSE OF THE STUDY

Scapulohumeral arthrodesis is mainly used for the treatment of sequelar injury after brachial plexus palsy. Indications are however controversial and limited to patients with non-neurological shoulders. We report a series of eight shoulder arthrodeses performed on non-neurological shoulders in order to determine and detail the current role of this procedure.

PATIENTS AND METHODS

The series included eight patients, five men and three women, mean age 47 years (23-87). The dominant side was operated on in two patients and the non-dominant side in six. Seven patients had had at least one shoulder procedure prior to arthrodesis. Arthrodesis was performed for foreign body reaction on a tendon prosthesis in one patients, posttraumatic head necrosis in two, off-centered degenerative joint disease with full thickness rotator cuff tear in three, and multi-directional instability on degenerative joint disease in two. Arthrodesis was performed via a posterior approach in all patients but one using screw fixation associated with external fixation left in place for 2.5 months on average.

RESULTS

All patients except one were satisfied with the outcome (basically because of pain relief). Mean active motion was 75 degrees flexion, 65 degrees abduction (arthrodesis at 20 degrees flexion, 25 degrees abduction and 30 degrees internal rotation). Two groups were identified to analyse the absolute Constant score. The score improved 16 points (from 24 to 40) in the group of patients without instability (pain score improved from 3 to 13) and decreased 14 points (from 66 to 52) in the group with instability (due to decreased motion, the mean motion score declining from 38 to 14). Complications included one radial palsy, one nonunion, and one gravity edema of the upper limb.

DISCUSSION AND CONCLUSION

Shoulder arthrodesis is more than a salvage method to reduce pain and gain stability. The objective should be to recover useful function (hand-mouth, hand-perineum, brachio-thoracic function). It should be used when prosthetic arthroplasty is not possible (infectious arthritis, advanced degenerative disease in young subjects, loss of glenoid bone stock, failure after treatment of multidirectional instability with degenerative disease). Shoulder arthrodesis still has rare indications because of the predictability of sustained outcome.

Traitement de l'arthrose S.T.T. par un Implant en pyrocarbone. Premiers résultats

INTRODUCTION

The authors propose a scaphotrapeziotrapezoidal (STT) arthroplasty using a discoid pyrocarbon implant. The aim of this prosthesis is to restore the scapho-trapezial mobility without destabilising the carpal bones (unlike with a simple resection of the distal scaphoid pole).

METHOD

This technique was used in 15 cases from 1994 to 2002. 12 patients (10 females and 2 males), mean age 65 years) have been reviewed with a mean follow-up of 4 years (1 to 8). Surgical indication was pain refractory to medical treatment (average 8.5 on V.A.S.). Pre-operative mobility showed a loss of radial deviation and dorsal flexion. The severity of the pain did not allow evaluation of the pre-operative strength. Post-operative results were assessed with the EVAL computerised system, static and dynamic X rays were performed in all cases.

RESULTS

Pain decreased to an average of 2. The mobility compared to the healthy side showed a slight loss of radial deviation (less than 10 degrees) and in wrist extension (less than 15 degrees). Grip strength was similar to the normal side, even during rapid exchanges. Pinch grip evaluation showed a slight decrease (0.8 kg) which did not compromise normal function of the first ray. No implant luxation was observed in the radiological study. Angular measurements did not show any modification in DISI and other static angles remained unchanged. Dynamic sagital and frontal views confirmed the good mobility of the prosthesis which adjusts its position to the scaphoid movements.

CONCLUSION

The good results, the simple surgical procedure, the absence of complications, the lack of a need for any fixation or ligamentoplasty all confirm the advantages of this pyrocarbon implant in the treatment of STT arthrosis. Furthermore, in cases of failure, it is possible to use any other revision procedure.

Devenir à plus de 20 ans de recul des poignets rhumatoïdes opérés (arthrodèses exclues)

PURPOSE OF THE STUDY

The absence of a medical treatment capable of successfully arresting joint destruction due to rheumatoid arthritis (RA) leaves a large domain for surgical treatment. The purpose of our work was to determine whether a clinical benefit persists in the long term (more than 20 years) despite aggravation of the radiological lesions, after surgical treatment of rheumatoid arthritis of the wrist.

MATERIAL AND METHODS

Sixteen patients with RA (13 women and 3 men, mean age 65 years), were reviewed a mean 24.8 years (range 20-33 years) after wrist surgery. Twenty-four wrists were operated for dorsal synovectomy (n=18) and Swanson radiocarpal implant (n=6). Total arthrodeses were excluded. Clinical, functional and standard and stress x-ray data were collected at last follow-up.

RESULTS

Residual pain at last follow-up in wrists which had undergone dorsal synovectomy was scored 3.1/10 on the VAS versus 5.6 preoperatively. Three-quarters of the patients stated they were satisfied with the intervention despite very weak force. Revision surgery was required in eight patients after dorsal synovectomy including three which required resection of the ulnar head, left in place after the first surgery, and three for removal of a silicon implant of the ulnar head. This implant was rapidly abandoned in our unit (as in other units). The radiological status worsened in all wrists over time, despite synovectomy. For the Swanson radiocarpal implant, residual pain was only 0.5/10 versus 6.7 preoperatively. Four implants fractured and four developed radiological signs of siliconitis with not clinical expression. Despite these complications, five of the six patients felt favorably about their intervention and the mean Leclerc function score was 78/100. Flexion-extension was 56 degrees on average. The main complaint was the lack of force.

CONCLUSION

There is a discordance between radiological and clinical results, a difference which widens with longer follow-up. A clear improvement in the pain score and the moderate functional demands of these patients are probably the reasons for their satisfaction despite radiological degradation. Many desire more wrist force. Our indications have evolved over time with the development after 1980 of the radiolunar arthrodesis procedures that we associate with dorsal synovectomy even in early-stage patients in order to limit radiological degradation and ulnar translation of the carpus. Swanson radiocarpal implants were completely abandoned in 1987 despite favorable clinical results due to the radiological degradation with bone loss and risk of siliconitis. For Simmen III wrists, total arthrodesis remains the only sure and definitive solution.

Glenohumeral arthrodesis in upper and total brachial plexus palsy. A comparison of functional results

We have compared the functional outcome after glenohumeral fusion for the sequelae of trauma to the brachial plexus between two groups of adult patients reviewed after a mean interval of 70 months. Group A (11 patients) had upper palsy with a functional hand and group B (16 patients) total palsy with a flail hand. All 27 patients had recovered active elbow flexion against resistance before shoulder fusion. Both groups showed increased functional capabilities after glenohumeral arthrodesis and a flail hand did not influence the post-operative active range of movement. The strength of pectoralis major is a significant prognostic factor in terms of ultimate excursion of the hand and of shoulder strength. Glenohumeral arthrodesis improves function in patients who have recovered active elbow flexion after brachial plexus palsy even when the hand remains paralysed.

Allogreffes d’articulation totale du coude dans les pertes de substance ostéo-articulaire post-traumatiques étendues

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.

Naissance et évolution de la FESUM (Fédération européenne des services d’urgences mains)

The European Federation of Hand Emergency Services (FESUM) was founded in France in 1979 and established all over the country and extended to other European countries in 1989. The aim of this federation is to assure the best possible treatment for hand injuries, thanks to the coordination of the orthopaedic or plastic surgery department which satisfy the standards established and controlled by the federation as well as the development and research in the field of hand trauma and applications of microsurgery. In collaboration with the French Society of Hand Surgery and the French College of Hand Surgery, it fulfills a triple mission of treatment, teaching and research in the specific field of this surgery. The author evokes the present role of the FESUM and the future problems to be solved in order to develop this specialized surgery which plays a major social and economic role.

Huit jours d’urgences mains

All the FESUM centers in France, Belgium and Switzerland were invited to participate in this prospective audit, during 1 week in June 2002. In these FESUM centers, the patients are operated by senior hand surgeons or trainees graduated with a microsurgical and a hand surgery University degrees. All acute hand disorders, requiring surgery or not, were to be included. For every case, a standardized form was to be filled. This form included 22 fields concerning the specificities of the patient, the circumstances of the accident, the lesions and initial treatment up to exit of the patient out of the Hand Center. Out of the 43 French centers, 38 (90%) participated in this study, but only 30% in the other French speaking countries. A total of 2360 forms were completed and analyzed, representing a mean of 8 forms per day center (6-147). The population was predominantly active men with a mean age of 31. Manual workers represented 41%, scholars 33%. Most of them came to the Hand Center with a non-specilized vehicle (86%). Emergency medical transportation was required in 130 cases (5.8%). A majority of the patients were treated on an outdoor basis. A 1-day admission concerned 29% of the patients, and 4.6% have been admitted on an indoor basis during several days. Work accident represented 28% of all the cases, while the majority was daily living (62%) or sport (15%) accidents. Closed trauma represented 50% of the cases. Amongst open trauma (974 cases), 862 were simple skin lacerations, 156 skin loss, 140 extensor tendon lacerations, 70 flexor tendon lacerations. A preliminary wound exploration had been performed in a non-specialized center in 124 cases (12%). Complete amputation of some part was observed in 33 cases. In 32%, the initial severity of the lesion led to expect some degree of definitive consequences. Some kind of anesthesia was required in 43% of the cases (local in 41%, troncular in 19%, plexical in 28% and general in 9%). A surgical procedure was performed in 45% of the patients. Microsurgery was necessary in 15%, six of which were replantations. The period between presentation to the Hand Center and treatment was less than 1 day in 95% of the cases. Time of treatment was considered to be delayed in 113 cases (5%). Following this audit, it is considered that the FESUM centers make provision for the care of 120,000 cases per year, 54,000 of which needing a surgical procedure. This may be a small part of the total load of emergency hand surgery throughout the country (generally estimated over 1.4 million), but compares quite favorably with other European studies. We believe that improvement relies essentially on a better orientation of the patients whether they need a simple skill or specialist skill treatment. An information leaflet about orientation of hand trauma has been distributed to non-specialized emergency centers. Hand surgery training must be reevaluated inside the universitary system to avoid a dramatic lack of hand surgeons within a few years. A new audit will be presented next year.

[Four-bone fusion of the wrist: review of 17 cases at an average 3.4 years follow-up]

PURPOSE OF THE STUDY

We reviewed retrospectively outcome after intracarpal arthrodesis for advanced-stage osteoarthritis of the wrist.

MATERIAL AND METHODS

Among the 20 patients who underwent a four-bone fusion between 1989 and 1998 in our unit, 17 were available for analysis. Mean age of the study population was 41.5 years. These young patients had an occupational activity and 80% of them were manual laborers. Preoperatively, pain was the main complaint; 95% of the patients considered pain to be invalidating. Grip force was 48.5% compared to the healthy side. Joint amplitudes were limited in all patients: flexion-extension 85 degrees, radio-ulnar inclination 22.5 degrees with 12.5 degrees for the ulnar side. Mean loss of motion compared with the healthy side was 32.5% for flexion-extension, and 44% for radio-ulnar inclination. The preoperartive radiograph showed degenerated capito-lunate joints in 63% of the cases, degenerative scapho-capital joints in 58% and total loss of the radio-scaphoid joint space in 100%. Degeneration was considered to be global in 58% of the wrists.

RESULTS

Mean follow-up for the 17 wrists studied was 3.4 years (range 1-10). At last follow-up, 41% of the wrists were pain free, 24% were painful occasionally, and 35% were bothersome for heavy work. The patients did not express any difficulties in daily activities. Grip force was only slightly improved with a 7.5% gain over the preoperative value. Joint motion at last follow-up was, on the average, 70 degrees flexion-extension (40 degrees flexion and 30 degrees extension) and 35 degrees radio-ulnar inclination (17.5 degrees ulnar). Eleven patients (65%) had resumed their occupational activities at the same level two months after surgery. Outcome was deemed satisfactory by 65% of the patients, fair by 17.5%, and poor by 17.5% (3 patients). Radiological fusion was achieved in 16 wrists at a mean 4.5 weeks. Mean carpal height was 0.42 compared with 0.52 for the healthy side and 0.47 preoperatively. There was no significant relationship between carpal height and poor outcome.

DISCUSSION

Data in the literature are in agreement with the good results obtained for pain and activity level despite the inconstant effect on grip force and joint amplitude.

CONCLUSION

Four-bone fusion is an effective treatment for patients with advanced-stage osteoarthritis of the wrist where the level of degeneration rules out resection. The consequences of total wrist arthroplasty are much more invalidating.

[Nerve entrapment syndrome of the elbow and forearm]

In this study we will discuss entrapment of the median, ulnair, radial and lateral antebrachial nerves of the elbow and the forearm. Compression of the nerves may occur when they traverse a tunnel and an incompatibility exists between the diameter of the tunnel and its contents (e.g. nerves, tendons,...). However, at the elbow and the forearm the nerves are also exposed to particularly dynamic compressions. This is due to anatomical relationships changing between the nerve and its surrounding muscles, tendons and aponevroses during the motion of flexion-extension of the elbow and the prono-supination of the forearm. The possibility of this dynamic factor should be thoroughly explored during the examination through appropriate dynamic tests as described in this study.

[Pollicization, remains of the past or current operation]

Pollicization is a long time honored operation but more recent introduction of microsurgical techniques allowing toe to thumb transfers has changed the indications in trauma and congenital malformations. We reviewed two series of patients to assess the long-term result in both traumatized and malformed hands. Twenty-seven pollicized mutilated fingers were reviewed with a mean follow up of 9.5 years; the longest follow up published in the literature. Despite the age quite advanced of the population and multidigital amputations (more than two fingers were amputated in 16 cases), 21 patients had a good or fair result on a global score including mobility, sensibility, daily use, cortical integration, cold intolerance or pain and appearance. In congenital malformations, hypoplasia or aplasia of the thumb in presence of long fingers remains one of the best indication of pollicization. Out of 35 operated children, 27 were reviewed with a sufficient follow up (mean 6 years) to assess the result. Sensibility and growth were excellent (3 cases need some secondary shortening) mobility was close to normal in 61% of cases but the main concern was the strength which reached only 42% of the standard.

Intercostal nerve transfer classification

We report a new classification of intercostal nerve transfer. The specific application in brachial plexus reconstruction is described. This method was applied in intercostal nerve transfer to the musculocutaneous nerve in 15 patients. In type 1, "MOTOR to MIXED" transfer one harvest only the intercostal main motor branch which is connected at the trunk of the musculocutaneous nerve, without fascicular specificity. In type 2, "MIXED to MIXED" transfer, based on neural cartography, the main motor branch and its sensitive accessory anterior branches are connected to the musculocutaneous nerve trunk, in attempt to connect the motor fascicules together at the center and also the sensory fascicules together, at the circumference. In type 3, "MOTOR to MOTOR" transfer, the intercostal main motor branch is connected to the musculocutaneous motor branch directly destined to the biceps brachialis. The aim of this work is to evaluate the results between different series.

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 degrees; supination, 66 degrees; wrist flexion, 54 degrees; wrist extension, 54 degrees; radial inclination, 15 degrees; and ulnar inclination, 18 degrees. 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 degrees; supination, 76 degrees; wrist flexion, 51 degrees; wrist extension, 56 degrees; radial inclination, 21 degrees; and ulnar inclination, 39 degrees. 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.

[A adaptive proximal scaphoid implant]

INTRODUCTION

In this study, the insertion of a pyrocarbon implant (APSI) has been described, which is shaped to allow adaptive mobility during carpal movement in the first row of carpals. This implant replaces the proximal part of the scaphoid; it is designed to treat styloscaphoid arthritis, and to prevent further deterioration and carpal collapse by restoring the first carpal row to its original height, i.e., 'SNAC wrist' after scaphoid pseudoarthritis, and 'SLAC wrist' following scapho-lunate dissociation.

MATERIALS AND METHOD

This retrospective series included 25 cases which were examined and analyzed at an average of six years post-surgery (between three and ten years) by an independent observer using the EVAL expert database system: 1) 14 cases involved pseudoarthritis, which developed from the scaphoid ('SNAC wrist'); 2) ten cases were connected with scapho-lunate nonunion ('SLAC wrist'); 3) one case involved carpal collapse with siliconite, which had previously been inserted as a scaphoid silicone partial implant for the treatment of pseudoarthritis involving a stage II fracture.

RESULT

In all cases, the reason for the preoperative-consultation for degenerative arthritis was the presence of pain, which post-surgery was no longer apparent in 60% of cases, and only persisted during effort in 28% of cases. Thus 88% of the patients were satisfied with the results, and were able to resume their normal professional and sports activities at the same level as before. Strength connected with digitopalmar grip and pinch force were found to have increased compared to the function in the healthy hand. No implant dislocation was detected by radiological investigation. Dynamic X-rays of the implant in flexion, extension, and frontal inclination confirmed this adaptive mobility. Carpal height was in all cases maintained. The radio-lunate angle remained unchanged in 15 cases, was improved in six cases, and was worse in four cases. Two poor results were connected with severe ligament lesions prior to surgery.

CONCLUSION

The preliminary results regarding the APSI implant seem to be promising for cases of polar pseudoarthritis in which curative treatment is no longer possible. This technique avoids further deterioration and carpal collapse ('SNAC wrist'). However, in cases of scapho-lunate nonunion ('SLAC wrist') where ligament lesions are severe, this method does not resolve the problem of ligament destabilization, which requires further treatment.

Assessment of hand after brain damage with the aim of functional surgery

The semiology of the hand after brain damage is really rich. Its clinical evaluation remains quite difficult and must be integrated in the neuro-orthopedic and cognitive context. Deficiency, neuropsychological, analytic and functional status, must be assessed before any surgical decision aiming the improvement of prehension. Neuropsychological evaluation precise the hemispheric specialization: right hemisphere lesions conduct to unilateral spatial neglect while left hemispherical lesions determine language troubles and gesture impairment (apraxia). The analytical evaluation describes motor and sensitive function and assesses spasticity and pain. Concerning the functional assessment, the Enjalbert's score seems to be the most adapted to the upper limb. The assessment of hand deficiency and its origin is necessary to orientate the surgical decision and includes the Zancolli classification for the fingers and wrist and the House classification for the thumb. These classification used for cerebral palsy seems to be insufficient for all the different situations occurring after brain damage. A new classification is proposed based on 3 parameters: fingers extension, thumb abduction and supination. Surgical decision should be examined only after an adapted rehabilitation program.

[Finger replantation after 60 years of age. Apropos of 7 cases]

The authors analysed retrospectively 7 cases of digital replantation in 7 men aged from 60 to 71 years, performed between 1985 and 1996. There were 2 amputations of the thumb, 1 of the index, 2 of the middle finger, 1 of the fourth and 1 of the fifth finger. 4 failures of replantation were noted. These 4 failures always concerned amputations of long digits by a circular saw with associated complex multidigital injuries of bad prognosis and in combination with a poor vascular status. We had 3 successful results: the 2 amputations of the thumb and the ring finger of the auricular. All these 3 patients recovered a good hand function. We found some common characteristics in this group of patients: excellent general condition, non smoker, good motivation and cooperation, injury of one digit, clear amputation (except the ring finger), correct conservation of the amputated part. The advanced patient's age does not represent a contraindication for digital replantation. The injury mechanism and the general condition of the patient represent major criteria of prognosis. In favourable circumstances, a good functional result can be expected.

Functional and histologic effects of a free nonvascularised muscle graft implanted into a reinnervated muscle after prolonged denervation

Striated muscle atrophy and degeneration, which increase with the delay of denervation, represent two of the main causes for poor recovery following delayed nerve repair. The present study, using a rat model, tests the hypothesis that an adjunction of small, free, nonvascularised muscle grafts of contralateral healthy triceps into a chronically denervated triceps improves muscle regeneration and recovery following sciatic nerve repair delayed for 3 months. Our experiments seem to show a relative increase in mechanical properties in animals in which free muscle graft into the triceps was performed 3 weeks following nerve repair. The improvement of the regenerative process of muscles which have suffered a long period of denervation should be considered as an additional therapeutic procedure in the case of late nerve repair.

[Evaluation of the function of the flexor and extensor tendons of the hand]

Evaluation of the function of flexor tendons is a complex problem with a lot of controversies. Many propositions have been done since the first quotation of Boyes in 1950. Were are making a presentation and a critical analysis of the most used methods: T.A.M., Kleinert's classification, and the one described by Buck-Gramcko. We are presenting a personal method, useful in every zone, eliminating the action of the intrinsics and showing certain tenodesis effects. This method has been compared to those of Kleinert, Buck Gramcko and Strickland, using the analysis of the results of 165 tendon sutures. Our results are situated in between the most optimistic method (Buck-Gramcko) and the most severe method (Strickland). Moreover, the authors propose an original method of evaluation of the extensor tendon function extrapolated from the one used for the flexor tendons.

[Transverse fracture of the upper sacrum with major displacement. CT reconstruction: case report]

PURPOSE OF THE STUDY

Transverse fractures of the upper sacrum are rare. We report a case with major displacement and neurological impairment. The use of 3D computed tomography (CT) reconstruction to facilitate preoperative planning and surgical procedure is discussed.

MATERIALS AND METHODS

A 49-year-old depressive woman jumped from the second floor in an attemp to commit suicide. She presented an absence of motor reponse in L5 region on both sides, hypoesthesia of S1 dermatome, perineal problems including saddle hypoesthesia and a hypotonic anal sphincter. Radiologic investigation showed a transverse fracture of the upper sacrum with major displacement. CT with 3D reconstruction visualized the course of the different fracture lines on the different levels of the sacrum. Open reduction, extensive laminectomy and internal fixation were performed 6 days following the injury.

RESULTS

After a 1-year post-operative follow up, complete neurological recovery with normal walking and full perineal sphincter control was observed.

DISCUSSION AND CONCLUSION

Fractures of the upper sacrum with major displacement are exceptional. They require well prepared surgical management. CT series with 3D reconstruction allow an analysis of the course of the different sagittal fracture lines to facilitate surgical planning.

[Linburg-Comstock syndrome. Epidemiologic and anatomic study, clinical applications]

The Linburg-Comstock (LC) syndrome is distinguished by the inability to actively flex the interphalangeal (IP) joint of the thumb without simultaneously flexing the distal IP joint of the index finger. Any resistance to this 'parasitic' reaction causes pain on the palmar side of the wrist or in the distal part of the forearm; this is due to an anomalous tendinous connection between the flexor pollicus longus (FPL) and the flexor digitorum profundus (FDP). An epidemiological study was carried out on 264 individuals (a total of 528 hands were examined), and the LC syndrome was found in 98 subjects (37%); women were more frequently affected than men, and bilaterally rather than unilaterally. In addition, we dissected 26 fresh cadaver upper limbs, and in seven cases found an anomalous connection between FPL and FDP. We also examined the case of a young violinist with bilateral LC syndrome, who complained of pain in the distal part of the left forearm after prolonged musical exercises. Surgical investigation determined a complete fusion between FPL and FDP of the index with a common tendon. Treatment consisted of splitting this common tendon to form two separate tendons, thereby permitting a certain degree of independence between the thumb and index finger, and which considerably improved the violinist's musical performance. A review of the literature showed that there was a large quantity of anatomical descriptions available on these types of connection. Certain publications also provide an extremely precise report on the anthropological significance of these anomalies.

Dynamic radial translation instability of the carpus

We report a case of a dynamic radial translation instability of the carpus, secondary to avulsion of the ulnocarpal ligaments and attenuation of the short radiolunate ligament. In addition, there was a peripheral detachment of the distal radioulnar ligaments causing distal radioulnar instability. Reattachment of the avulsed ligaments combined with a Sauvé-Kapandji procedure resulted in an excellent function, which was maintained 10 years after surgery.

Congenital pseudarthrosis of both forearm bones: long-term results of two cases managed by free vascularized fibular graft

We analyzed the clinical and radiographic outcome of 2 cases of congenital pseudarthrosis of both forearm bones managed by free vascularized fibular grafts. The follow-up periods were 17 and 13 years, respectively. The first patient, a 4-year-old girl, had reconstruction of both the radius and ulna by a vascularized fibular graft, restoring pronation/supination to 110 degrees. The second patient, a 17-year-old boy, underwent a 1-bone forearm procedure using a vascularized fibular graft. After surgery, he had a stable forearm that was shortened by approximately 15 cm. In these 2 cases of congenital pseudarthrosis of both forearm bones, bone union was obtained by means of vascularized fibular graft.

Long-term results of unconstrained Roper-Tuke total elbow arthroplasty in patients with rheumatoid arthritis

We evaluated the long-term results of 12 unconstrained Roper-Tuke total elbow replacements that were performed in 12 patients with rheumatoid arthritis from 1983 to 1989. The mean follow-up period was 9.5 years (range 8 to 13 years). We used the Ewald elbow-scoring system to chart results. This showed that the scores for the 12 elbows had improved from an average preoperative score of 39 points (range 17 to 72 points) to an average postoperative score of 80 points (range 45 to 97 points). The greatest improvements were in terms of pain relief, function, and range of motion. Eight elbows were free of pain by the end of follow-up. Average elbow flexion increased from 115 degrees before operation to 140 degrees after operation, and pronation and supination increased from 52 degrees to 61 degrees and 42 degrees to 71 degrees, respectively. Radiographs of the 12 elbows showed constant wear of the ulnar polyethylene with loosening of 2 ulnar components. Revision of the prosthesis was necessary in 2 elbows because of aseptic loosening. Complications included 1 subluxation, 1 supracondylar fracture, and 2 ulnar neuropathies. Despite some excellent clinical results with a follow-up of over 10 years, the authors no longer recommend the use of this kind of elbow prosthesis in patients with rheumatoid arthritis because of the high complication rate and the impossibility of adapting this implant in the event of bone loss. The authors propose a new classification of humeral bone loss that will allow for better planning of primary and revision total elbow arthroplasties.

[Traumatic etiology of Kienboeck's disease. (Perilunate subluxations and semilunate necrosis)]

The authors have studied the incidence of lunate necrosis in 110 perilunate dislocations. Twenty-one cases (19%) developed a necrosis. The classification into three types, according to the amount of damage to the perilunar ligaments, is of prognostic value. There is no risk of necrosis in type 1, 17% in type II, and 50% in type III. An associated fracture of the scaphoid does not modify the risk. In neglected lesions, reduction of the lunate dislocation should be attempted, even at a late date, the risk of necrosis then being 50%. Surgical reduction increases the risk of secondary necrosis to a greater extent than does orthopedic treatment, but it is generally use in the most complex cases too. The authors advocate a closed reduction with percutaneous pin fixation.

[Peri-trapezial arthrotic lesions]

The usual concept of arthrosis of the base of the thumb as a carpometacarpal arthrosis has been replaced by the concept of its being a pantrapezial arthrosis involving all of the peritrapezial joint spaces. In the pathogenesis of pantrapezial arthrosis, the static role of the shaft of the thumb, and the strains from pinching movements between the thumb and fingers are of predominant importance. The lack of satisfactory radiographic technique up to now has made the evaluation of this joint difficult, but the possibility of trapezometacarpal dysplasias favoring arthrosis should be considered. The treatment of an arthrosis of the basal joint of the thumb is surgical when medical treatment has not been successful. The various techniques, which currently are numerous, are given in detail. Carpo-metacarpal arthrodesis has still some precise indications. Arthroplasties have superseded the usual trapezectomy which, nevertheless, seemed to give satisfactory results. The various techniques of arthroplasty and their respective indications according to individual patients, and the anatomic type of the arthrosis of the base of the thumb are discussed.

[Development of surgical indications in the treatment of rheumatoid wrist. Report on experience based on 603 surgical cases, 1968-1994]

The author relates his experience in surgical treatment of the rheumatoid wrist based on a consecutive series of 603 cases operated from 1968 to 1994. His therapeutic indications have changed over the years after a retrospective study of the long-term results. He distinguishes conservative surgery, which combines dorsal synovectomy and relaxation stabilisation of the wrist (also called surgery of the dorsal wrist) from total arthrodesis and arthroplasty of the wrist. The results of conservative surgery after a follow-up of more than five years confirm that the disease continues in spite of synovectomy. Furthermore, relaxation stabilisation using soft tissue (extensor retinaculum and tendon transfer) is not sufficient to stabilise the wrist. Most of the time, this has to be completed by a partial radiocarpal arthrodesis. This is indicated when the carpus shows a medial translation or early in potentially progressive forms (Larsen Stage 1). In advanced forms conservative surgery consisting of partial radiocarpal arthrodesis is only indicated when the midcarpal joint appears functional after dynamic radiological examination. The author used the Swanson implant to perform 70 arthroplasties from 1973 to 1988. Long-term results show a large number of complications, which increased progressively with time. The Swanson implant was therefore abandoned in 1988. In 12 cases operated from 1979 to 1984 wrist arthroplasty was performed using Jackson's technique which consists of resection-interposition of a silastic sheath. This technique was also abandoned in 1984 due to the variable and unpredictable results obtained. At the present time, the author:-does not perform arthroplasties; increasingly completes surgery of the dorsal wrist by radiolunate arthrodesis;-has noted an increase in indications for total wrist arthrodesis. He emphasizes the importance of long-term evaluation of surgical results in rheumatoid arthritis.

Simple arthrolysis for flexor rigidity of the proximal interphalangeal joint

The authors report 19 cases of simple arthrolysis of the proximal interphalangeal joint for flexion rigidity. Their cases were limited to isolated lesions of the joint without any flexor or extensor tendon involvement. The technique is described, and the importance of postoperative physical therapy is stressed. The results in these cases, in contrast with those in complicated cases of rigidity, are very satisfactory. The etiology is primarily sprains and dislocations of the proximal interphalangeal articulation, immobilized for too long a time in flexion (in the so-called "functional position").

Rupture of the flexor tendons of the little finger in fractures of the hook of the hamate bone. Report of two cases

Two cases of rupture of the flexor tendons of the little finger associated with a fracture of the hook of the hamate bone are presented. The preoperative diagnosis had not been made. Excision of the fractured hook and repair of the tendons by a short graft from the palmaris longus in one case and by the transfer of the superficial flexor of the ring finger in the other case gave a good final result. The authors remark on the rarity of reports of this fracture in the literature, the frequent occurrence of nonunion and the two complications which are exceptional; rupture of the flexor tendons and compression of the deep branch of the ulnar nerve. The fracture is mainly encountered in sports that require the grasping of a handle (tennis, golf, hockey, squash). The diagnosis is often missed at the onset because of not using the correct X-ray positioning: special incidence for the carpal tunnel view and a 3/4 view with the wrist in 45 degrees of supination and forced radial deviation.

First results of arthroplasty of the wrist by Swanson's implant. Twenty-five cases

We have carried out 25 arthroplasties of the wrist using the Swanson implant since 1976. The indications were primarily in rheumatoid arthritis. The operation was done for severe pain and deformity of the wrist. Results were analysed in 19 patients with a follow-up of 21-54 months. Post-operative pain relief is good. Although mobility is fair, the return of the balance of wrist motions has been recovered. The results of the Swanson implant arthroplasty are compared to dorsal synovectomy and wrist arthrodesis.

Two-step reconstruction of the flexor tendons (Hunter's technique) in the treatment of fingers "en crochet"

The authors used Hunter's technique to treat 16 cases of fixed-flexion deformity of the finger (with irreducible flexion of the joint greater then 70 degrees), secondary to lesions of the flexor tendons. The flexion deformity was corrected in 11 of the 16 cases, and active movement greater than 70 degrees was obtained in only 7 cases. Technical difficulties (particularly cutaneous problems), frequent complications, prolonged reeducation are the reasons that the indications for its use are exceptional, and why there is need for excellent cooperation by the patient.

[Anatomical study of interosseous flaps and the concept of postero-anterior interosseous flap. Preliminary report]

The postero-anterior interosseous flap uses the distal network of the posterior and anterior interosseous arteries. With this flap the authors would like to point out all the possibilities of reverse fascio-cutaneous flaps offered by the interosseus arteries. An anatomic study has been carried out with both a literature review and a cadaveric study. The authors studied the distal interosseous anatomy on 40 fresh upper arms after colored latex injection of the anterior interosseous artery near its origin. A distal anastomosis between anterior and posterior interosseous arteries was present in 38 cases. This anastomosis was situated at an average of 25 mm from the radio-carpal joint. The authors found the fascio-cutaneous artery branch of the anterior interosseous flap in 40 cases, but its origin is variable. Therefore, the anterior interosseous flap was possible in every case but the pedicle length was variable. The surgical technique must begin by a distal exploration of the vascular network. After this exploration the flap is chosen in function with the anatomic possibilities and the cutaneous defect. The authors have already used several kinds of reverse interosseous flap: anterior (6 cases), posterior (11 cases) and recently, postero-anterior (2 cases). With the postero-anterior flap the authors will show the large range of flap possibilities offered by the interosseous arteries for the cutaneous defects of the dorsum of the hand.