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ABSTRACT: In patients for whom function is a priority, anatomic reduction and stable fixation are prerequisites for good outcomes. Several therapeutic options exist, including orthopedic treatment and internal fixation with pins (intra- and extrafocal), external fixation which may or may not bridge the wrist, and different internal fixation techniques with dorsal or palmar plates using or not, locking screws. Arthroscopy may be necessary in case of articular fracture. In the presence of significant metaphyseal bone defects, filling of the comminution with phosphocalcic cements provides better graft stability. The level of evidence is too low to allow recommending one type of fixation for one type of fracture; and different fixation options to achieve stable reduction exist, each with its own specific complications. With the new generations of palmar plate, secondary displacement is becoming a thing of the past.
Orthopaedics & Traumatology Surgery & Research 03/2013; · 0.94 Impact Factor
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ABSTRACT: Distal radius fractures remain the most frequent fractures in the adult. Associated osteoporosis increases morbidity risk (secondary displacement is the most frequent) and mortality risk (in women older than 60). Severity of the fracture and functional results are related to the bone mineral density. Anatomy has been recently revisited with better description of palmar and dorsal aspects in order to avoid material-related complications. Standard postero-anterior, lateral and oblique radiographs of the wrist show the fracture and the displacement. CT scan is warranted if conventional X-rays are insufficient to show the articular surface. The involvement of the metaphysis (comminution), the epiphysis (articular fracture) and the ulna is different in each case and each fracture is an association of these three components. The MEU classification describes the fracture with sufficient inter-observer reliability and intra-observer reproducibility to be a useful tool for treatment and prognosis. The PAF system is used to propose the most appropriate treatment for each patient. Anatomical reduction and stable fixation are associated with good functional results but in high demanding patients.
Chirurgie de la Main 10/2012; · 0.53 Impact Factor
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ABSTRACT: Treatment of advanced Kienböck's disease (Lichtmann IV) is commonly proximal row carpectomy or partial arthrodesis. The purpose of this study is to evaluate a more conservative treatment of advanced Kienböck's disease for young people: replacement of the lunate with a costochondral autograft. Between 2007 and 2009, four patients of mean age 40 years (32-51) were operated by two surgeons using this technique. This is a prospective study with a final follow-up by an independent operator. Mean follow-up was 27 months (6-36). Surgery is in two stages: excision of lunate and replacement with costochondral autograft taken from the ninth rib. Patients were evaluated with DASH and Cooney scores, pain, satisfaction, mobility and strength. Results show disappearance of pain at rest and during daily activities for all patients and a mean DASH of 6. Flexion-extension was 108° and grip strength 83% compared with the opposite side. Radiological evaluation showed no disease evolution. No complication was noted. Functional improvement was significant with good results compared to conventional techniques. Alternative techniques have been proposed for the replacement of the lunate, each with its specific problems. Lunate replacement by a costochondral graft is possible because studies showed vitality of this free graft up to five years. It also allows subsequent surgery. The absence of carpal collapse and good functional results are encouraging but the follow up is short. A long-term study is needed to confirm findings.
Chirurgie de la Main 06/2011; 30(3):211-7. · 0.53 Impact Factor
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ABSTRACT: Seven cases of post-traumatic intra-articular malunion of the distal radius treated using costal cartilage graft with a minimum follow-up of 2 years are reported. Location of the articular defect was dorsal in two cases and volar in the others. The approach (dorsal or volar) depended on the main location of the defect. A costal cartilage graft harvested on the eighth rib was implanted in a trough created at the epiphysis metaphyseal junction. This trough removed the defective area on the distal radius articular surface. A plate or wire fixation was used to stabilize in place the graft. Plaster cast wear was prescribed for 3 months in the first case and for 1 month in the other cases following joint reconstruction. No complications were observed. Union was achieved in all seven cases. Graft integration and viability were evaluated with MRI and biopsy. At the longest follow-up, the functional results were excellent in the first (youngest) case (male, 22 years old) in whom motion and grasp were similar to the contralateral side. In the other cases of malunion, the patients were pain-free in daily activities with a functional wrist score of 72/100 (range, 54-82) and a DASH score of 38.3 (range, 22.5-51.7). Only the case with a septic problem failed, with pain reported at follow-up. Reconstruction of a partially destroyed articular surface using a costal graft is reliable and allows filling and resurfacing an articular cartilage void. Although costal cartilage graft is currently used in maxillofacial surgery, this is the first report in post-traumatic osteoarthritis secondary to intra-articular malunion. LEVEL OF EVIDENCE: Level IV.
Orthopaedics & Traumatology Surgery & Research 06/2011; 97(4):430-7. · 0.94 Impact Factor
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ABSTRACT: Comminuted fractures of the proximal ulna are severe injuries often associated with bone and ligament injuries of the elbow joint (Monteggia lesion, radial head fractures, dislocation of the elbow). The treatment of these fractures is very demanding and the functional results often fairly mediocre due to associated injuries. Based on a single-center retrospective study, we report the results of the treatment of these fractures fixed using a double-plate technique. The aim was to evaluate the feasibility and reliability of this fixation mode and to compare it with other fractures series using a single plate fixation (in terms of bone union, elbow joint function, and complications stemming from the plates).
Eighteen patients sustained a comminuted proximal ulna fracture between 2002 and 2006. The fractures were associated in five cases with a Monteggia type lesion, in two cases with elbow dislocation, and in four cases with a Mason 3 radial head fracture. Four patients had an open fracture. These comminuted ulna fractures included nine Mayo Clinic IIIB fractures. Bone fixation was performed with two third-cylinder tubular plates, one plate on each side of the proximal ulna. This allows more versatile solutions for screw insertion. Functional assessment (according to Broberg and Morrey) and radiological evaluation (bone healing) were provided at 6 months and at the longest follow-up by an independent surgeon.
Sixteen of 18 patients achieved bone union. No septic complications occurred and no hardware removal was required on patient request. In 67% of the cases, the Morrey score indicated excellent or good results with a mean score of 82.
There are no reports in the literature on the technical point of fixation concerning complex fractures of the ulna. Two plates mean the possibility of twice the number of screw insertions for epiphyseal reconstruction . This fixation remains easy to perform and provides stable anatomic reconstruction of the ulna.
Level IV. Retrospective study.
Orthopaedics & Traumatology Surgery & Research 11/2010; 96(7):734-40. · 0.94 Impact Factor
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ABSTRACT: In digital joint defects, reconstruction is meant to obtain a stable, mobile and pain-free finger. Six patients aged 29 years in average (15-46) and who were prospectively followed-up presented with digital joint defects that affected at least half of either the proximal interphalangeal (PIP) joint or the metacarpophalangeal (MCP) joint. These defects were treated in emergency (four cases) or scheduled for an autograft of costal cartilage harvested from the ninth rib. Four digits showed lesions of the extensor system which were repaired. One digit grafted after complete amputation was no more vascularized. All patients were reviewed and prospectively followed-up by the surgeons and were also reviewed by an independent operator 16.1 months post-surgery in average (9-25). No infection occurred. None of the grafted fingers had to undergo arthrodesis or secondary amputation. One case of type 1 complex regional pain syndrome occurred. No functional or aesthetic complaint was reported, and no complication was observed at the donor site. The mean arc of motion was 33° (20-50) for the PIP joint and 37° (30-40) for the MCP joint. Mean total active motion (TAM) was 191° (160-250°), whichever the injured finger, i.e. 79.1% compared with the contralateral finger. The Buck-Gramko score averaged 11/15 (8-15). The Strickland score (interphalangeal TAM) was 57.8%, which corresponds to a medium result. The quick DASH assessment averaged 17.42 (0-47.72). Even if arthrodesis or amputation remain the conventional option in case of joint defect, prosthesis or cartilage grafting constitute solutions that allow the preservation of a functional painless finger.
Chirurgie de la Main 10/2010; 29(5):294-300. · 0.53 Impact Factor
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ABSTRACT: A prospective study is reported concerning 11 cases of bone defect of the hand and wrist treated by the induced membrane technique. Ten men and one woman with an average age of 49 yrs (17-72) sustained a high-energy trauma with severe mutilation of digit and hand but with intact pulp. Eight cases of open finger fractures with composite loss of substance and three cases of bone and joint infection (thumb, wrist, fifth finger) were included. All cases were treated by the induced membrane technique which consists in stable fixation, flap if necessary, and in filling the bone defect by a cement methyl methacrylate polymere (PMMA) spacer. A secondary procedure at two months is needed where the cement is removed and the void is filled by cancellous bone. The key point of this induced membrane technique is to respect the foreign body membrane which formed around the cement spacer creating a biologic chamber. Bone union was evaluated prospectively by X-ray and CT scan by a surgeon not involved in the treatment. Failure was defined as non-union at one year, or uncontrolled sepsis at one month. Two cases failed to achieve bone union. No septic complications occurred and all septic cases were controlled. In nine cases, bone union was achieved within four months (three to 12). Evidence of osteoid formation was determined by a bone biopsy in one case. Masquelet first reported 35 cases of large tibial non-union defects treated by the induced membrane technique. The cement spacer promotes foreign body membrane induction constituting a biological chamber. Works on animal models reported by Pellissier and Viateau demonstrated membrane properties: secretion of growths factors (VEGF, TGF beta1, BMP2) and osteoinductive cellular activity. The induced membrane seems to mimic a neoperiosteum. This technique is useful in emergency or septic conditions where bone defects cannot be treated by shortening. It avoids microsurgery and is limited by availability of cancellous bone.
Chirurgie de la Main 10/2010; 29(5):307-14. · 0.53 Impact Factor
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ABSTRACT: Five consecutive patients (mean age: 40.4 yrs (range, 19-58 yrs)), with symptomatic distal radius malunion underwent corrective opening wedge osteotomy using phosphate cement as an alternative to bone autograft, at a mean 9 months (4-16mo) of fracture. Internal fixation used a plate placed just above the distal radioulnar joint, with soft-tissue release. Radiographic and functional parameters were measured before surgery, and at 6 months and 1 year. At a mean 32.4 months (range, 16-47mo), all patients were satisfied and all the osteotomies were united. At 1 year's follow-up, wrist range of motion reached 75% compared to the contralateral side. Two biopsies performed during plate removal showed osteoid tissue at the cement-bone junction. It is reasonable to consider injectable phosphate cement as a viable alternative to bone grafting in conjunction with surgical correction of distal radius malunion. Level of evidence: level IV.
Orthopaedics & Traumatology Surgery & Research 09/2010; 96(5):574-8. · 0.94 Impact Factor
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ABSTRACT: In a growing elderly osteoporotic population, the management of distal radius fractures remains without consensus as to volar distal plate versus K-wires. The goal of this retrospective study was to evaluate these treatments in elderly people. In a series of 38 patients over 70 years, 21 were treated by a volar plate and 17 by percutaneous K-wire fixation. Follow-up was at least 6 months. Results were analyzed using the disabilities of the arm, shoulder and hand (DASH), patient-rated wrist evaluation (PRWE) and Herzberg score by an independent operator. Radiological parameters were radio-ulnar variance, radial inclination and palmar or dorsal tilt. Radio-ulnar variance was better for the plate group (-0.7mm versus -0.1mm in K-wires). Mean functional outcomes were good but there were more satisfied patients in the plate group (67% versus 39% for the K-wire group). Secondary displacements were frequent in both groups but more with K-wires (50% versus 37% in case of plates). Six articles about surgical treatment of elderly radius distal fractures were published up to 2009 showing similar results. However, they analyze only global mean scores. Volar plates give more stability and a higher rate of satisfaction, with similar results of wrist mobility and grasp strength. The main advantage of the plates is earlier return to daily activities.
Chirurgie de la Main 09/2010; 29(4):236-41. · 0.53 Impact Factor
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ABSTRACT: Antithrombotic agents are not routinely used in microsurgery for finger replantation. A prospective monocentric study of 13 cases of replantation at hand level is reported with local irrigation of anastomosis with urokinase and low-molecular-weight heparin. Thirteen consecutive patients have been included and treated in the first six hours by three senior surgeons in microsurgery. The injuries consisted in one devascularisation of hand, two complete amputations of hand, four ring fingers and six complete amputations of finger. Crush injury was always pointed in case of amputation. During anastomoses, the arterial lumina were topically irrigated with 50,000 UI of urokinase and the venous lumina by 1.2 ml of Lovenox®. Bleeding was encouraged in case of digit replantation. In all cases, patients received Aspegic® 10mg/day and Fonzylane® three times per day for three weeks. Three failures have been reported and blood transfusion was necessary in one patient. The results showed that topical irrigation with urokinase and low-molecular-weight heparin or enoxaparin solution significantly reduced the thrombosis rate at the anastomosis site of the crushed arteries in clinical practice without uncontrolled adverse effect.
Chirurgie de la Main 04/2010; 29(5):326-31. · 0.53 Impact Factor
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ABSTRACT: The purpose of the study was to evaluate the flexor digitorum superficialis flap in treatment of neuroma-in-continuity of the median nerve at the wrist. We reviewed six patients operated from September 2000 to March 2007. In all cases, daily disabling pain has been significantly reduced. Four patients are very satisfied. It is a local flap, easy to harvest with few morbidity. We compare it with the various options described for this pathology.
Chirurgie de la Main 08/2009; 28(5):301-5. · 0.53 Impact Factor
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ABSTRACT: Mac Lauglhin defects of the right humeral head developed in a 44-year-old woman with drug-resistant epileptic seizures, subsequent to recurrent posterior dislocations. The preoperative work-up demonstrated a large anterior defect corresponding to more than 50% loss of the osterochondral tissue. The humeral head lodged on the posterior rim of the scapular glenoid, like an inveterate posterior dislocation, causing major pain and joint dysfunction. After adjustment of the antiepilepsy treatment, the patient underwent joint reconstruction with a chondrocostal autograft harvested from the ninth homolateral rib combined with transfer of the lesser tubercle. At three years follow-up, the patient has a stable pain-free shoulder with a satisfactory range of motion. The graft was integrated.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 10/2008; 94(5):503-9. · 0.37 Impact Factor
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ABSTRACT: Centromedullary nailing with a Seidel nail is a validated treatment for humeral shaft fractures which some teams have abandoned due to the injury caused to the rotator muscles. The purpose of this study is to assess shoulder function (Constant and DASH) after nailing procedures and to analyze sonographic findings.
Twenty-nine patients who underwent Seidel nailing between 1996 and 2002 were reviewed by an independent operator at 36 months follow-up on average (range 11-84 months). The sex-ratio was 1.64. Mean age at surgery was 41.5 years (range 17-81 years). The dominant side was involved in 17 cases. Fracture was caused by a traffic accident in 13 cases, a fall in 12, and a blunt injury in 4. The fracture was situated in the mid third of the shaft in 19 cases, the upper third in 3, the mid and lower third in 3 and mid and upper third in 3. Mean delay before surgery was 2.4 days. Initial complications were medioulnar palsy (n=1), complete brachial palsy (n=1), partial brachial palsy (n=1). There was one open Cauchoix I fracture.
Bone healing was achieved in 27/29 patients at 3.5 months on average. Revision was required in nine patients. The Constant score was 69.1 (86.9% contralateral). The weighted Constant score was 81.7 and the DASH was 25. The Constant score was significantly better in patients aged less than 50 years and with transverse fractures. Sub-acromial space narrowing was observed in six patients at follow-up and only 9/28 sonographic examinations (32%) were normal; most shoulders presented transient healing lesions.
This series was comparable with others regarding patient satisfaction, bone healing and complications, but was less satisfactory for the Constant score and time to healing. We have found that using a subjective function score (DASH) with an objective score (Constant) enables a better assessment of shoulder function. Like Gaullier, we consider that after cuff healing, anterograde nailing does not compromise shoulder function despite the injuries observed sonographically.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 11/2006; 92(6):549-55. · 0.37 Impact Factor
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Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 07/2006; 92(4 Suppl):110. · 0.37 Impact Factor
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ABSTRACT: Two groups of patients with cubital tunnel syndrome were treated by neurolysis and medial epicondylectomy. In the first group, the operative procedure consisted solely of dividing Osborn's ligament and fascia but in the second group Osborn's ligament was reinserted after epicondylectomy to avoid dislocation of the nerve. The aim of this retrospective study was to compare the level of complete recovery after surgery and the frequency of dislocation of the nerve.
Group one: Nineteen patients, with a mean age of 47.7 (15-65), and 52% female, with the dominant hand involved in 63% cases, were treated. According to Mac Gowan's criteria, 32% of the elbows were classified preoperatively as grade I, 52% as grade II and 16% as grade III. Sensory nerve conduction velocity across the elbow was less than 40 m/s in 40% of cases. The mean duration of the disease was longer than 3 years in 16% of cases. Group two: Twenty three patients, with a mean age of 54.1 (33-75), and 56% female, with the dominant hand involved in 56% cases, were treated. According to Mac Gowan's criteria, three 17% of the elbows were classified preoperatively as grade I, 47% as grade II and 34% as grade III. Sensory nerve conduction velocity across the elbow was less than 40 m/s in 60% of cases. The mean duration of the disease was longer than 3 years in 4% of cases. Both groups were evaluated by a surgeon not involved in the treatment by clinical examination and DASH scoring.
DASH scoring is correlated with functional recovery, grip strength and Mac Gowan preoperative scoring. In group one, (divided and reinserted ligament) with younger patients, half the incidence of Mac Gowan stage II and a shorter follow up, there were no dislocations, but less complete resolution of preoperative symptoms (68%/82%) and a higher DASH scoring (30.6/24.9). In group two (resected ligament), dislocation of the nerve was noted in 17% of cases. In both groups, pain at the epicondylectomy site was noted in 20% of cases. The chance of complete recovery was inversely related to the age (>50), and to the duration of the disease (>1 year).
Surgical treatment of ulnar nerve entrapment at the elbow remains controversial. None of the presently advocated procedures (simple decompression of the ulnar nerve, medial epicondylectomy or transposition of the ulnar nerve) has proven optimal regarding long-term results. In both groups in this study, neurolysis of ulnar nerve by section of Osborn's ligament and fascia together with medial epicondylectomy proved to be an effective surgical procedure for treating grade I to II ulnar neuropathy. Section of Osborn's ligament without its reattachment is followed by more cases of complete recovery as well as more dislocation of the nerve although the latter elicited no subjective complaints from the patients. DASH scoring is effective in evaluating the recovery.
Chirurgie de la Main 07/2004; 23(3):131-6. · 0.53 Impact Factor
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ABSTRACT: Acute complete ruptures of the ulnar collateral ligament should be treated with surgical repair of the ligament. But diagnosis using ultrasound, dynamic X ray and magnetic resonance imaging are unable to diagnose surely the complete rupture. According to Rotella and Urpi if the radiograph shows no parallelism between the sesamoid bones and the metacarpal head, the injury of ulnar collateral ligament is total and complete and requires surgical reparation. The aim of this work was to verify the finding of Rotella and Urpi and the relationship between the lost of parallelism and the Stener lesion (interposition of adductor aponeurosis between the ruptured ulnar collateral ligament and its site of insertion on the base of the proximal phalanx).
Embalmed anatomical specimens were used to systematically investigate and document the role played in joint stability by each of the anatomical elements. Each ligament was sectioned and instability documented. A retrospective radiological study was performed on 93 patients who had an history of injured ulnar collateral ligament of the thumb.
The anatomical study confirmed the result of Rotella and Urpi in showing that the loss of parallelism between the sesamoid bones and the metacarpal head was associated with complete rupture of ulbnar collateral ligement The clinical study showed that the lost of parallelism was associated with a Stener lesion (N=23).
The association between the lost of parallelism of sesamoid bones and Stener lesion confirm that the rupture of all elements of the ulnar collateral ligament. This anatomical and clinical findings have to be confirmed by a prospective clinical study.
Chirurgie de la Main 26(4-5):200-5. · 0.53 Impact Factor
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ABSTRACT: Mac Lauglhin defects of the right humeral head developed in a 44-year-old woman with drug-resistant epileptic seizures, subsequent to recurrent posterior dislocations. The preoperative work-up demonstrated a large anterior defect corresponding to more than 50% loss of the osterochondral tissue. The humeral head lodged on the posterior rim of the scapular glenoid, like an inveterate posterior dislocation, causing major pain and joint dysfunction. After adjustment of the antiepilepsy treatment, the patient underwent joint reconstruction with a chondrocostal autograft harvested from the ninth homolateral rib combined with transfer of the lesser tubercle. At three years follow-up, the patient has a stable pain-free shoulder with a satisfactory range of motion. The graft was integrated.
Revue de Chirurgie Orthopédique et Réparatrice de l'Appareil Moteur. 94(5):503-509.
