A swan neck deformity (SND) can be well tolerated for a long time, until the appearance of a disabling "snapping finger". In its most advanced condition, the other hand is needed to initiate finger flexion. We propose a technique of extra-articular, subcutaneous ligament reconstruction with an "inverted king post-truss" configuration use in roofs and to reinforce railway bridges. An artificial ligament (MaxBraid™ polyethylene surgical suture, 5 metric, Biomet) makes a figure of eight between transosseous tunnels in the proximal and middle phalanges, crossing over top of the A3 pulley. We limited our series to severe SND cases with "snapping finger". We excluded isolated SNDs without functional disability. Eleven patients were followed for 3.4 years on average. The cause was an acute injury 8 times (7 balloon accidents), rheumatoid arthritis 2 times and overuse once (saxophone). Only one case was a poor outcome of mallet finger. The 11 patients were reassessed by a telephone survey. Two patients underwent reoperation: one for a ligament rupture, the other one for a knot that became untied. One patient had a suspected late rupture but without recurrence of the disabling snapping finger. The 11 patients considered themselves improved by the intervention. Nine patients did not notice any difference between their operated finger and the contralateral side. Return to manual activity was possible once the skin had healed. The technique is simpler than the spiral oblique retinacular ligament (SORL) reconstruction technique described by Thomson-Littler and also less demanding because it does not involve the distal interphalangeal joint. It requires only a short incision in the volar crease of the proximal interphalangeal joint. No tendon or ligament is sacrificed. Neither postoperative immobilization nor lengthy physical therapy is needed. Complications can be avoided by selecting the appropriate artificial ligament material and careful knot tying.

Objectives. - Roseland (R) prosthesis is a ball and socket prosthesis, physiological and not anatomical. This study wants to demonstrate by a quality life questionnaire (quick DASH described by Dubert et al., 2001 [1]) that Roseland (R) prosthesis gives to patients a trapeziometacarpal joint native capacities.Patients and methods. - An exterior examinator reviewed prospectively 68 patients having a mean age of 61,1 years at surgery with 11 bilateral cases that is 79 prothesis. With a mean follow-up of 43.8 months, we value by Kapandji's opposition, first comisssural penning, quality of life and patient's satisfaction.Results. - Three patients have been excuded: two of them had got post-traumatic dislocation: one trapezium fracture, one unknown reason. The third patient had got osteophytis with "came" effects. We keep 65 patients with 84,6% satisfying and very satisfaying. 75,4% of patients have a capacity of 80% and more of their joint, 40% of them had got 100%.Discussion. - Roseland (R) prosthesis has good results because it agrees with already known principles as on its own concept: rotula prothesis gives three axes mobility, as on its own conception: metarcarpal stem with a palmar "T" shaped against rotation and bone saving, a cup with equatorial ring to prevent burying of the spongy bone. Componenents are recovered by hydroxyapatite to favour osteo-integration with less loosening than ciment. An accurate technique avoids dislocations traps: trapezium implant centring, internal osteophytis removal. An accurate indication: trapeziometarpal joint osteoarthritis only (second degree's Dell classification).Conclusion. - Roseland (R) prosthesis reproduces a satisfactory and functional joint for 84,6% of cases. These good results can be obtained by accurate indication (Dell II) and contra-indication (osteoarthritis around trapezium except trapeziometacarpal of course). (C) 2010 Elsevier Masson SAS. All rights reserved.

The Pins and Rubber Traction System (PRTS) can be used to treat proximal interphalangeal intra-articular fractures. Our experience is that outcomes are not always excellent and that many patients have reduced joint function or residual deformities. The aim of this study was to evaluate the reasons behind the poorer outcomes of some of the patients treated with this system. A retrospective clinical and radiological evaluation was performed on 15 patients after a minimum of 2 years' follow-up. The mean interphalangeal joint flexion range was 66 degrees (range 0-100) in our series. The review of the literature shows an average active interphalangeal joint flexion of 78 degrees (range 64-95). Reasons for this difference include preoperative delay, technical deficiencies, the learning curve, a lack in postoperative physiotherapy and degenerative changes due to the longer follow-up. Although the Pins and Rubber Traction System seems a simple procedure, a learning curve is necessary to avoid pitfalls.

We describe 6 cases of severe filamentous fungal infections after widespread tissue damage due to traumatic injury in previously healthy people. Additionally, we report 69 cases from an exhaustive 20-y review of the literature to investigate the epidemiological and clinical features, the prognosis and the therapeutic management of these post-traumatic severe filamentous fungal infections. Traffic (41%) and farm accidents (25%) were the main causes of injury, which involved either the limbs only (41%) or multiple sites (41%). Necrosis was the main symptom (60%) and Mucorales (72%) and Aspergillus (11%) were the 2 most frequent fungi causing infection. These infections required substantial surgical debridement or amputation (96%) associated with aggressive antifungal therapy (81%), depending on the responsible fungi. This study underlines the need for early, repeated and systematic mycological wound samples to guide and adapt surgical and antifungal management in these filamentous fungal infections.

BACKGROUND:Flexor tendon grafting represents the most common modality for secondary restoration of flexor tendon function. Tendon grafting is either performed in 1 or 2 stages. This study attempts to evaluate the clinical outcome of 1-stage and 2-stage grafting in children.METHODS:A retrospective review was performed identifying 20 children treated for secondary rupture of the flexor digitorum longus by means of a tendon graft. There were 17 boys and 3 girls with a mean age of 10.8 years (range: 3 to 15) at the time of surgery. The preoperative condition of each operated finger was graded by the digital damage classification recommended by Merle and Dautel. Functional status was obtained throughout follow-up using the Strickland classification.RESULTS:There were 10 children in grade 1, 6 grade 2, and 4 grade 3 according to Merle and Dautel classification. The delay between the initial trauma or primary procedure and the secondary surgical procedure averaged 7.5 months for 1-stage grafting and 9 months for 2-stage grafting (range: 1 mo to 2 y). The median Strickland index was 70 (range: 55 to 114) for 1-stage grafting and 66 (range 0 to 103) for 2-stage grafting, which was not statistically different (P=0.1).CONCLUSIONS:The functional outcome seems to depend on the initial severity index. One-stage grafting is a relevant procedure when pulleys are intact and the range of motion is complete. When neurovascular bundles are injured a 1-stage grafting should not be tempted. Satisfactory results are expected with 2-stage grafting providing the principles of this procedure are carefully adhered to.LEVEL OF EVIDENCE:Level 4.

Le lambeau neurocutané sural à pédicule distal (Masquelet et al., 1992) s'est avéré être une technique utile pour la reconstruction des pertes de substances de l'extrémité distale du membre inférieur. Nous rapportons notre expérience d'une série de 60 cas de couverture du pied, de la cheville et du tiers distal de jambe avec 58 succès et deux échecs. Une nécrose totale est survenue à la suite d'une erreur technique lors de la dissection du pédicule, alors que le second échec était dû à de sévères troubles vasculaires du membre inférieur. Dans 14 cas, nous avons observé une congestion veineuse partielle avec une légère épidermolyse ou une nécrose marginale mais elles ont toutes évolué favorablement. Notre expérience nous a incités à augmenter la largeur du pédicule pour éviter la congestion veineuse de la palette cutanée chez les 17 patients qui présentaient un trouble vasculaire distal (diabète, artériosclérose) et/ou une neuropathie du membre inférieur. Dans 18 cas, quand la tunnellisation de la peau entre le point pivot et la perte de substance à couvrir était trop hasardeuse, nous avons eu recours à un pédicule externe provisoire et l'avons sevré quelques semaines plus tard ou greffé. Le lambeau sural à pédicule distal de réalisation simple, en une étape, sans sacrifice vasculaire, de faible rançon cicatricielle et sans séquelles majeures, est une technique de choix pour la couverture des pertes de substance du tiers distal de jambe, de la cheville, et de la face dorsale du pied ; la zone portante du talon exceptée.

Two million people in Europe suffer with rheumatoid arthritis (RA). Among them 75% are women and the disease typically occurs around 45 years of age. Hand and wrist are almost always involved (over 80% of patients) and 70% of them will be obliged to stop their job. The ulnar drift of the metacarpophalangeal (MCP) joints is present in more than 36.5% of the cases in women.

The distally based sural neurocutaneous flap (Masquelet et al., 1992) has proved to be a useful technique for lower limb skin defect reconstruction. We report our experience in a 60 case series for the coverage of foot, ankle, and distal third of the leg with success in 58 cases and 2 failures. For one of these, a total necrosis occurred after a technical problem when harvesting the pedicle, while the second failure was due to a severe inferior limb vascular disability. In 14 cases, a partial venous congestion with a slight epidermolysis or a marginal necrosis was observed but it resolved without sequel. Seventeen patients presented with distal vascular impairment and/or neuropathies (i.e. diabetes mellitus, arteriosclerosis, vascular lesions) of the inferior limb and our experience favour a larger pedicle trimming than in normal cases to avoid venous congestion of the skin paddle. In 18 cases, when undermining of skin between the pivot-point and the defect site to be covered was too hazardous, we used an external pedicle either temporary and severed a few weeks after or skin grafted. This is a helpful mean when local condition of the skin to be undermined for pedicle tunnelling may interfere with the final issue. This one-stage simple technique, without major vascular sacrifice and with minor consequences at the donor site, is reliable for the distal third of the inferior limb, ankle, and dorsal foot aspect reconstruction, the heel-bearing zone excepted.

Purpose: The purpose of this work was to assess the mechanical axis of 28 computer-assisted osteotomies (group A) with 28 manual osteotomies (group B) selected at random from 140 osteotomies performed between January 1997 and December 2000. Material and methods: The populations were comparable for age, gender, side, degree of osteoarthritis (modified Ahlback stages) and varus malalignment (group A: 173±3.80° (160°–178°), group B 172.8±3.18° (164°–178°) using a pangonometer to measure the HKA angle). For 52 knees, open-wedge tibial osteotomy was performed and fixed with a tricalcium phosphate wedge (Biosorb(r)) and an AO T-plate. For four knees (two in group A and two in group B), a double tibial (open wedge) and femoral (closed wedge) osteotomy was used due to genu varum measuring greater than 15°. Preoperative planning for the classical method used a plumb line from the centre of the femoral head identified fluoroscopically. The Orthopilot(r) computer-assisted method also relied on preoperative planning but intraoperative control was based on computer acquisitions of the centre of the hip, the knee and the ankle. The objective of the intervention was to obtain a mechanical axis between 182° and 186°. All knees were evaluated with pangonometry at three months to check axis correction. Results: In group A, the mean postoperative HKA was 183±0.99° (181°–185°). In group B it was 184±2.28° (181°–189°). The objective was attained in 96% of knees in group A and in 71% in group B, giving a statistical difference between the absolute data (p=0.0248) and between the standard deviations (p=0.0015). Conclusion: Computer-assisted osteotomy to correct for genu varum using the Orthopilot(r) method is feasible and remarkably reproducible. In our hands Orthopilot(r) enabled attaining the surgical objective set preoperatively. The kinetics of the acquisition of the centre of the hip, the knee, and the ankle associated with palpation of remarkable extra-articular points is an excellent method avoiding the need for intra-articular palpation which might complicate the surgical procedure.

Purpose: The purpose of this work was to assess the mechanical axis of 28 computer-assisted osteotomies (group A) with 28 manual osteotomies (group B) selected at random from 140 osteotomies performed between January 1997 and December 2000. Material and methods: The populations were comparable for age, gender, side, degree of osteoarthritis (modified Ahlback stages) and varus malalignment (group A: 173±3.80° (160°–178°), group B 172.8±3.18° (164°–178°) using a pangonometer to measure the HKA angle). For 52 knees, open-wedge tibial osteotomy was performed and fixed with a tricalcium phosphate wedge (Biosorb(r)) and an AO T-plate. For four knees (two in group A and two in group B), a double tibial (open wedge) and femoral (closed wedge) osteotomy was used due to genu varum measuring greater than 15°. Preoperative planning for the classical method used a plumb line from the centre of the femoral head identified fluoroscopically. The Orthopilot(r) computer-assisted method also relied on preoperative planning but intraoperative control was based on computer acquisitions of the centre of the hip, the knee and the ankle. The objective of the intervention was to obtain a mechanical axis between 182° and 186°. All knees were evaluated with pangonometry at three months to check axis correction. Results: In group A, the mean postoperative HKA was 183±0.99° (181°–185°). In group B it was 184±2.28° (181°–189°). The objective was attained in 96% of knees in group A and in 71% in group B, giving a statistical difference between the absolute data (p=0.0248) and between the standard deviations (p=0.0015). Conclusion: Computer-assisted osteotomy to correct for genu varum using the Orthopilot(r) method is feasible and remarkably reproducible. In our hands Orthopilot(r) enabled attaining the surgical objective set preoperatively. The kinetics of the acquisition of the centre of the hip, the knee, and the ankle associated with palpation of remarkable extra-articular points is an excellent method avoiding the need for intra-articular palpation which might complicate the surgical procedure.

Cette étude avait pour but d’évaluer les résultats des reconstructions digitales par transfert partiel d’orteil chez l’adulte. Pour tous les patients, la reconstruction microchirurgicale était secondaire à une amputation de la pulpe ou à une destruction articulaire traumatique de l’IPP. Dix-huit transferts partiels d’orteil ont été réalisés depuis décembre 1997. La série incluait 9 transferts pulpaires, 4 transferts articulaires de l’IPP et 4 transferts composites ostéo-onychopulpaires taillés sur mesure. L’âge moyen de la population était de 27 ans (9 à 41 ans). À huit reprises il s’agissait d’une reconstruction du pouce ; dans 10 cas la reconstruction intéressait un doigt long, dont tous les transferts articulaires. Le délai moyen entre le traumatisme et la reconstruction microchirurgicale était de 1,3 mois. Douze fois il s’agissait d’un transfert à pédicule court, la dissection s’arrêtant à la face dorsale de la première commissure du pied. Elle a comme principal avantage de limiter la rançon cicatricielle sur le site donneur. Trois patients ont dû être repris en urgence pour une révision des sutures artérielles. Malgré cela, un transfert a évolué vers la nécrose. La sensibilité des pulpes transférées a été évaluée par le test de Weber. Les résultats montraient une discrimination comprise entre 7 et 11 mm avec un recul moyen de 14,3 mois. L’aspect esthétique était jugé bon malgré une dystrophie unguéale modérée chez les patients ayant bénéficié d’un transfert composite distal. Tous les patients, à l’exception d’un, ayant bénéficié d’une reconstruction pulpaire du pouce ont jugé le résultat très bon. Dans chaque cas, la marche a pu être reprise au 5e jour postopératoire et le port de chaussures fermées a été possible environ 1 mois après l’intervention. Le résultat des transferts articulaires a été jugé bon avec un enroulement digital satisfaisant, malgré un déficit d’extension de l’IPP de 30° en moyenne. Au terme de cette série encore relativement courte, il apparaît que le transfert partiel d’orteil répond au mieux aux objectifs fonctionnels et esthétiques de la prise en charge des pertes de substances étendues et/ou composites des doigts. Les propriétés de resensibilisation et la possibilité de transférer tout ou partie du complexe unguéal en fait notre choix privilégié pour la reconstruction digitale distale. Le transfert articulaire nous semble également tout à fait justifié notamment chez l’adulte jeune malgré des résultats imparfaits.

Nous rapportons une évaluation clinique et radiologique rétrospective de 67 prothèses trapézométacarpiennes HAC mises en place entre 1994 et décembre 1995. Deux groupes homogènes de patients ont été comparés. Le premier groupe (MHACTHAC) concerne 40 prothèses trapézométacarpiennes dont les implants trapéziens et métacarpiens sont revêtus d’hydroxyapatite, le second (MHACTC) concerne 27 prothèses dont seul l’implant métacarpien est revêtu d’HAC, l’implant trapézien étant cimenté. Soixante-sept prothèses chez 60 patients ont été revues entre novembre et décembre 1999, au terme d’un recul moyen de 5 ans et 5 mois. Les deux populations étudiées ( MHACTHAC et MHACTC), présentaient des critères et données préopératoires équivalents. La population essentiellement féminine (respectivement 83 et 81 % ), de terrain le plus souvent non manuel ou manuel léger, était âgée en moyenne de 61 et 57 ans au moment de l’intervention. Tous les patients rapportaient des douleurs de la base du pouce invalidantes (constantes dans respectivement 78 et 73 %) depuis en moyenne 5 ans. Le stade de Dell était évalué dans chaque série à II dans 56 et 46 % des cas et à III dans 38 et 46 %. Sur le plan clinique, au terme du recul, la persistance de douleur de la base du pouce a été évaluée, de même que l’opposition et l’ouverture commissurale. Les forces globales (grasp) et pollici-polidigitales (pinch) ont été mesurées puis comparées au côté controlatéral. Les bilans radiographiques ont permis d’évaluer l’ostéointégration des prothèses trapézométacarpiennes. La présence de toute complication, en particulier de liserés, de luxation ou descellement prothétique, de fracture du trapèze a été recherchée. Les résultats cliniques au terme du recul, sont excellents dans les deux groupes et non significativement différents. Si le taux de descellements trapéziens, respectivement de 1/40 pour le groupe MHACTHAC et de 4/27 pour le groupe MHACTC n’est statistiquement pas différent (p > 0,05), le taux de fractures trapéziennes révèle quant à lui, une différence significative à 5 ans au profit de l’implant trapézien HAC (p = 0,03 au test de Khi 2 modifié selon Yates). Certes les effectifs concernés restent modestes, mais cette étude permet de comparer deux prothèses à un seul critère près : implant trapézien cimenté versus implant trapézien HAC. Ces résultats confortent l’intérêt du revêtement hydroxyapatite par rapport à l’utilisation de ciment pour l’ostéo-intégration, et la tolérance à moyen et long terme des prothèses trapézométacarpienne.