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The inability to predict if a metabolically bioactivated compound will cause toxicity in later stages of drug development or post-marketing is of serious concern. One approach for improving the predictive success of compound toxicity has been to compare the gene expression profile in preclinical models dosed with novel compounds to a gene expression database generated from compounds with known toxicity. While this guilt-by-association approach can be useful, it is often difficult to elucidate gene expression changes that may be related to the generation of reactive metabolites. In an effort to address this issue, we compared the gene expression profiles obtained from animals treated with a soft-electrophile-producing hepatotoxic compound against corresponding deuterium labeled analogues resistant to metabolic processing. Our aim was to identify a subset of potential biomarker genes for hepatotoxicity caused by soft-electrophile-producing compounds. The current study utilized a known hepatotoxic compound N-methylformamide (NMF) and its two analogues labeled with deuterium at different positions to block metabolic oxidation at the formyl (d(1)) and methyl (d(3)) moieties. Groups of mice were dosed with each compound, and their livers were harvested at different time intervals. RNA was prepared and analyzed on Affymetrix GeneChip arrays. RNA transcripts showing statistically significant changes were identified, and selected changes were confirmed using TaqMan RT-PCR. Serum clinical chemistry and histopathologic evaluations were performed on selected samples as well. The data set generated from the different groups of animals enabled us to determine which gene expression changes were attributed to the bioactivating pathway. We were able to selectively modulate the metabolism of NMF by labeling various positions of the molecule with a stable isotope, allowing us to monitor gene changes specifically due to a particular metabolic pathway. Two groups of genes were identified, which were associated with the metabolism of a certain part of the NMF molecule. The metabolic pathway leading to the production of reactive methyl isocyanate resulted in distinct expression patterns that correlated with histopathologic findings. There was a clear correlation between the expression of certain genes involved in the cell cycle/apoptosis and inflammatory pathways and the presence of reactive metabolite. These genes may serve as potential genomic biomarkers of hepatotoxicity induced by soft-electrophile-producing compounds. However, the robustness of these potential genomic biomarkers will need to be validated using other hepatotoxicants (both soft- and hard-electrophile-producing agents) and compounds known to cause idiosyncratic liver toxicity before being adopted into the drug discovery screening process.

Purpose of the Study: 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., Material and Methods: 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., Results: 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., Discussion: 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.

Air cleanliness control in operating rooms is based on air filtration, and targets the lowest density of particules and bacteria. Legally, the equipment must be periodically verified during periods of inactivity. Most airborne bacteria are of human origin. There is no fixed ratio between the particle count and the level of bacterial contamination. A study of different types of operating room at Besançon Medical Center reached the following conclusions:--Controls are also required during periods of activity.--Bacteriological testing is crucial.--Unidirectional airflow, especially of the horizontal type, is superior to other forms of isolation. The authors propose a "Functionality index", calculated as follows: bacterial count during use of the room minus bacterial count during non use/the number of people in the room. Efficient equipment would have a low index, which would be unmodified by the number of persons present.

Purpose of the Study: Injury of the proximal interphalangeal joint (PIP) with loss of bone and soft tissue (joint surface, tendon, skin cover) can compromise finger vascularization. Fusion or amputation is often proposed. We report our experience with another solution, emergency implantation of the Swanson implant., Material and Methods: Thirteen patients, mean age 47.4 years (range 18-76) underwent emergency surgery between 1997 and 2003. In twelve patients, the finger injury occurred when working with wood. For ten of the thirteen patients, the injury occurred during recreational activity. The index was involved when only one ray was injured. The thumb was spared in all patients. Joint tissue was lost in all patients. The head of P1 was injured in all cases creating a situation incompatible with fusion without loss of finger length. All patients underwent an emergency surgery for complete reconstruction of the PIP joint with Swanson implant, tendon reconstruction or suture, and skin cover performed during the same procedure., Results: Ten patients, 16 implants, were reviewed at mean 2.7 years (range 1-6 years). Mean flexion reached 41.8 degrees (range 20-80 degrees). Maximal amplitude of flexion was achieved at one year and remained unchanged thereafter. There were no cases of infection, or secondary amputation. Two implant fractures were noted with no functional impact at six years. There were four cases of instability., Discussion: Most reports in the literature concern composite blast or firearm injuries. Ours appears to be the first series involving injuries occurring while working with wood. Most of the lesions caused by the circular saw were tangential, damaging the dorsal aspect of several PIP joints. Classically, it would be logical to propose arthrodesis if the bone and cartilage loss is not excessive, but with the loss of joint motion provided by implants. Like Nagle, we propose emergency implantation of a Swanson prosthesis if soft tissue and tendon reconstruction can be achieved, avoiding amputation. Although the technique is relatively simple, implantation of a Swanson prosthesis implies certain prerequisites, particularly ligament repair and correct alignment. Oversized implants appear to be better. We did not have to perform any secondary arthrodesis.

Purpose of the Study: Pluridisciplinary management of patients with metastasis to the femur is well defined, but the choice between palliative surgery or abstention must be decided on the basis of a few evaluated prognostic criteria. We report a series of 24 cases of metastasis to the weakened or fractured femur which was evaluated with the Tokuhashi score and treated by surgery., Material and Methods: Sixteen women and eight men, mean age 71 years (58-89) underwent centromedullary nailing of the femur. These patients had metastases from breast cancer (n = 13 of the 16 women). Twenty of the 24 patients also had other metastases. The Tokuhasi score was > 6 in 16/24 patients. Fourteen patients had pain which did not respond to morphine. Thirteen had fractures and eleven weakened femurs. Time to surgery was six days (1-15). A full nail was inserted in four patients and a reconstruction nail in twenty., Results: Operative time was 93 minutes (57-123). Blood loss was 200 ml (150-350). There were no intraoperative complications (fat embolism) excepting increased comminution. Hospital stay was 23 days (8-55). Survival was 148 days (8-510) for patients with fractures and 272 days (12-730) for patients with weakened femurs. Eight patients with a fractured femur died (six within the first three postoperative weeks), two among those with preventive nailing. On average, weight bearing among the surviving patients with nailing for fracture was achieved on the 57th postoperative day (30-90). Only six patients required morphine early after surgery. Centromedullary nailing successfully relieved pain in all patients with an isolated metastasis. Mean survival in patients with a Tokuhashi score < 3 was 2.1 months. It was 17 months in those whose score was > 6., Conclusion: Centromedullary nailing for fractured or weakened femur due to metastasis is a useful therapeutic solution for patients with short life expectancy. With this technique, antalgesics can be reduced while preserving independence as long as possible. The Tokuhashi score is easy to establish. If it is less than 3, centromedullary nailing should not be attempted due to the short expected survival.

Non-union of long bone fractures is considered as multifactorial. The management of this entity continues to be difficult often requiring multiple procedures with unpredictable results. Bone morphogenetic proteins (BMPs) are power agents being used in the clinical setting for a variety of pathological conditions where tissue regeneration is required. This article analyses the currently existing evidence of the efficacy of BMPs for the management of non-union of long bone fractures.

Purpose of the Study: Radioscaphoid osteoarthritis is usually a complication of scaphoid pseudarthrosis or chronic scapholunate disjunction. As an alternative to the classical surgical techniques used for this lesion, we propose a novel reconstruction method consisting In partial proximal resection of the scaphoid associated with interposition of a biological spacer composed of a osteocartilaginous rib graft. The purpose of this study was to present the technical aspects of this procedure and to report preliminary results in ten patients with radioscapular osteoarthritis treated between 1994 and 2001., Material and Methods: We performed a retrospective analysis of the ten patients who underwent surgery from 1994 to 2001 for early-stage radioscaphoid osteoarthritis associated with scaphoid osteoarthritis in eight and chronic scapholunate disjunction in two. The procedure consisted in partial resection of the proximal portion of the scaphoid and insertion of an osteocartilaginous autograft harvested from a rib. Outcome was based on the clinical results (pain, motion, grip force, activity) and patient satisfaction. Bone healing was measured with plain x-rays and vitality of the osteocartilaginous graft with MRI., Results: Mean follow-up was 4.6 years. Clinical outcome was considered excellent or good in eight patients, fair in one and poor in one (graft dislocation). All patients were satisfied or very satisfied except one (one failure). Radiological healing was achieved at three months in nine patients. Four patients underwent an MRI examination at thirteen months which demonstrated, in all patients: no sign of necrosis, healing of the graft-scaphoid interface, and no bony metaplasia in the cartilage., Discussion: Compared with partial carpal arthrodesis and resection of the first row of the carpus, this palliative technique can be used to reconstruct the proximal portion of the carpal scaphoid in young patients with early-stage radioscaphoid osteoarthritis. As for arthroplasty or scaphoid implants, our goal was to achieve a satisfactory scaphoid height using a biological spacer after resection of the proximal 3/4 of the bone. The results of this technique are encouraging but must be examined with precaution due to the small number of patients and the short follow-up to date.

Treatment of unreconstructible comminuted fractures of the radial head remains a therapeutic challenge. Thirty two patients sustained unreconstructible radial head fracture between 1969 and 1999 and have been treated by resection (16 patients), by Swanson implant (8 patients), or by Judet prosthesis (8 patients). The three groups of patients were reviewed clinically and radiologically by two surgeons not involved in their treatment. Functional outcomes of the elbow (Morrey scoring-SOO scoring system, instability, cubitus valgus) and involvement of the wrist (pain, grasp, RUD instability) were evaluated with a mean follow up of 15 years (6-27.7). Elbow or wrist arthritis, ulnar variance, and evolution of Swanson implants were evaluated on standard radiographs. The Judet prosthesis group was evaluated with DASH scoring. Half of the patients were male and 1/3 had a work-related injury. Regarding the following criteria, there was no significant difference between the resection and the Swanson group: Morrey scoring 77/100, SOO scoring 7.4/11, mean flexion was 130 degrees, mean deficient extension was 18 degrees, mean pronation 60 degrees, mean supination 67 degrees, grasp reached 90% of the controlateral side. Arthritis was noted with the same frequency at the elbow (87%), and wrist levels (66%) in each group. Ninety four percent (94%) of patients in the resection group and 89% in the Swanson group were satisfied. Excellent and good results were reported more frequently in the Swanson group (37% resection group, 51% Swanson group). In the resection group the following complications were significantly more frequent: ulnar nerve irritation (2 x), ulnar head dislocation (2 x), ulnar head instability (3 x), para articular ossification (5 x), ulnar variance positive in all cases (mean value 3.20 mm). In the Swanson group only two implants were found to be destroyed at follow-up. In the prosthesis group function and satisfaction were higher than the two other groups but with a shorter follow up. Excellent and good results were reported in 62.5% cases with a DASH scoring between 0 and 16.7. Comminuted fractures of the radial head treated by resection or Swanson implant are both followed by fair results (same functional scoring). Only the level of complications differs between groups: at elbow level for Swanson group, at wrist level for the resection group. Patients in the Swanson group were most frequently satisfied. Metal radial head implant is an attractive solution yielding good functional outcomes in recent reported limited series and in our personal experience, but with a very short follow-up.

Purpose of the Study: Comminution is often neglected in patients presenting fractures of the distal radius. Use of injectable bone substitutes can fill the gap left by comminution, avoiding radial shortening and loss of prono-supination., Material and Methods: Forty-eight patients with a distal fracture of the radius were treated by osteosynthesis and injectable cement between 1998 and 2001. These patients were reviewed at mean follow-up of 46 months (36-56). Dorsal displacement was present in all cases and the AO classification was A (n=26), B (n=15), C (n=7). Fixation was achieved with pins (n=32), posterior plate (n=14), and external fixator (n=2) before injection of the bone substitute. Outcome was evaluated with the Herzberg score, the Gartland and Werley score and DASH by an independent operator., Results: Four patients were lost to follow-up and five who developed a deformed callus after the initial osteosynthesis were excluded from the analysis. The Herzberg functional score reached 84 (range 54-100) and the Gartland and Werley radioclinical score was 4.6 (0-11) with 89% excellent and good outcomes. DASH was 23.6 (5.8-62.7). Ulnar variance was unchanged or changed less than 2 mm between the immediate postoperative period and last follow-up in 88% of patients. There was one carpal tunnel syndrome related to anterior cement leakage. Three biopsies were performed and revealed a "humid sand" aspect six months after injection as well as presence of osteoblasts within the bone substitute. There was no or very little resorption., Discussion: Several authors have demonstrated the biomechanical and functional effects of filling the comminution gap to avoid radial shortening. The first reported cases, then later prospective series, favored the use of injectable cements for patients with comminution. Cement used in our patients allowed preservation enables preservation of normal ulnar variance in addition to filling the gap. Like any bone substitute, it is an attractive alternative to other filling methods (ceramic graft) offering two advantages: adaptation to the bone defect and primary stability. This easy-to-use cement is resorbed slowly. Because of high cost, it may be reserved for patients with important functional needs.

Purpose of the Study: Fractures of the scaphoid must be diagnosed quickly to avoid persistent nonunion and the risk of osteoarthritis. Despite meticulous physical examination and adequate x-ray detection, numerous occult fractures still go unrecognized. The aim of this prospective study was to analyze the pertinence of quantitative radio-scintigraphy (QRS) presently used for the diagnosis of occult wrist fractures., Material and Methods: Quantitative radio-scintigraphy (QRS) is a new imaging technique associating quantitative bone scan and numerical fusion between bone scan images and x-ray images. We conducted a prospective study between November 1994 and March 1999 to evaluate the pertinence of this examination technique for the diagnosis of occult wrist fractures in patients presenting clinical symptoms suggestive of wrist fracture but whose plain x-rays were initially considered normal. Further some patients had several series of plain x-rays performed at several week intervals in order to search for fractures becoming progressively visible on plain x-rays. After the QRS data was acquired, these patients' x-rays were reviewed again. We also compared the cost of QRS, repeated x-rays, bone scan and MRI at the Besançon University Hospital., Results: QRS was performed in all 154 patients and revealed 61 fractures (56 single-line and 5 multiple-line fractures). Thus 43.5% of these patients had occult wrist fractures (41% of which involved the carpal scaphoid)., Discussion: Occult fracture of the wrist, particularly the carpal scaphoid, is frequent. Repeated x-ray examination does not increase the rate of detection of these fractures. Bone scans may also fail to reveal occult fractures. MRI is a key examination in the assessment of wrist fracture symptoms, but is presently not available in all institutions. Bone scan is classically insufficiently precise. QRS is a rapidly available low-cost examination which we have found to be indispensable for the diagnosis of occult wrist fractures. With early QRS diagnosis, the risk of neglected carpal scaphoid fracture and subsequent nonunion and osteoarthritis together with the personal, social, and medicolegal consequences can be avoided.

Introduction: 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., Material and Method: 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., Results: 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)., Discussion: 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.

Introduction: The aim of this study was to evaluate subjective and functional results of a prospective continuous series of immediate tendon-to-bone repair of the F.D.L. using a miniaturized anchor., Method: Seven patients have been operated by the same surgeon in emergency for a section of the FDL in zone one. Distal tendon-to-bone re-attachment has been realized using a mini-G II Mitek anchor suture. Five of the patient were male, four of them being manual workers. Only one had a work accident. According to Leddy and Packer's classification one patient had a stage 1 lesion and the six others had stage two lesions. The injured fingers showed associated lesions in four cases. Rehabilitation consisted of early active mobilization protected by a Duran-type splint. All the patients had been examined by an independent surgeon at 10 months follow-up. Mean age at that time was 32 years., Results: One patient was very satisfied with his results while the six others were satisfied. Two minor complications were encountered, one of them being directly in relation to the implant. Total Active Motion (TAM) summed up to 92% of the arch of motion of the normal controlateral finger. Pinch-force reached 81% compared to that of the controlateral finger. Two patients described no pain. Mean eviction from work was 70 days., Discussion: Tendon-to-bone repair of the FDL using an anchor seems to give good results on pain, TAM and on force. The only complication due to the implant did not have any functional incidence. The series of Marin Braun on 77 cases of such repairs using a barb-wire show similar results compared to the implant used in our series. However, anchor sutures have several advantages compared to a transcutaneous device: they reduce the risk of infection, of nail dystrophy and they offer a better comfort to the patient.

One case of isolated traumatic dislocation of the radial head in a 59-years-old female secondary to an injury in pronation and extension of the non dominant left elbow is reported. Treatment consisted of immediate closed reduction followed by immobilisation in a plaster cast with the elbow flexed at 110 degrees, for 10 days. An MRI scan 2 months after the injury showed the lesion of annular ligament which did not have any clinical consequences. At 5 years follow-up, functional outcome is excellent compared to the normal contralateral elbow with no difference between both sides. Only 20 cases of isolated traumatic dislocation of the radial head in the adult have been reported in the last 30 years, and there are no guidelines for treatment. Thirteen were treated conservatively with no recurrence. Typical clinical presentation is a maintenance of flexion and extension following the injury, but complete loss of pronation and supination. This case is the first case reported in the french literature treated conservatively and with a 5-years follow-up.

Human bone marrow mesenchymal stem cells (MSC) generate, via a fibroblast colony-forming unit (CFU-F), osteo-chondroblastic cells as well as adipocytes and stromacytes. To date, these stem cells are isolated indirectly using a cell culture method and phenotyped as CD45 negative while the in vivo counterparts are undetermined. Our aim was to develop a direct selection method and to determine the phenotype of the MSC isolated in this way. Mesenchymal cells were selected with anti-CD49a and/or anti-CD45 antibodies using either flow cytometry or a magnetic beads method. All CFU-F were always detected in the small population of CD49a-positive cells. These CFU retained their differentiation potential and gave rise to osteo-chondroblastic cells, adipocytes and stromacytes. Phenotypic studies on uncultured cells revealed a CD45med,low, CD34low, HLA-II- cell population. Flow cytometry cell sorting showed that MSC with CFU-F potential were obtained only from a CD49a+/CD45med,low population. In addition, when cultured, they clearly became CD45-, CD34-, HLA-II-, CD49a+. These results confirmed that MSC can be directly selected easily from human bone marrow using magnetic beads without altering their differentiation potential. These cells expressed mildly the haematopoietic marker CD45, which was dramatically downregulated by in vitro culture. The expression of CD45 coupled to CD49a thus enabled direct selection of the MSC.

Nineteen cases of high pressure injection injuries in the hand were treated between 1973 and 1998. Same surgical treatment plan was followed in all cases: excision of the penetration point, irrigation, debridement and synovectomy if opening of the flexor sheath was noted, and skin closure to allow early mobilisation. All cases concerned men, work injuries, and volar aspect of the hand. The elapsed time between injection and initial surgery ranged from 1 hour to 1 month with a mean of 6.5 days. Eighteen patients out of 19 were reviewed with a mean follow up of 12 years. In 11/19 cases, (58%) oil was injected. The results of oil injection cases have been analysed: the quantity of oil and the preoperative delay (if more ten hours) are associated with poor functional results or complications. Two amputations, two cases of skin necrosis at the injection point, and one case of infection are reported. One case of oleoma of the thumb is described. The specificity of injuries by industrial oil under pressure must be known: paint or white spirit are more toxic than oil which was in all cases injected in the dominant hand (no high pressure injection tool but a defect in the pipe). An important inflammatory reaction with functional sequelae is caused by foreign bodies in oil. Extraction of oil off the injured tissues is difficult because oil is not visible. A specific information is necessary for farmers and truck driver, very exposed population.

We report a case of microsurgical replantation of a degloved finger in a manual worker. Four months following replantation, avascular necrosis of the middle and distal phalanges was apparent. Amputation at the level of the proximal phalanx was performed. Re-plantation is the solution of choice for such degloving injuries, but a different flap can be used if replantation is not possible. Avascular necrosis of bone is an unfrequent complication, but surgeons should be aware of it.

Distal radius fractures remain a challenge. No one osteosynthesis procedure can solve all the problems. A method of analysis is necessary in order to choose the best tools. Open treatment of the fracture is logical but rarely performed. A review of the literature and the experience of the authors are reported in order to analyse the correct place of dorsal plating in distal radius fracture with dorsal displacement. The learning curve of the operative procedure and the design of the implants can explain the occurrence of several complications. The dorsal plate is effective against secondary dorsal displacement. This demanding procedure must be compared with other reported procedures (pining and external fixator) to define the advantages and disadvantages.

Introduction: The presence of distal intermetacarpal anastomoses between dorsal and palmar vascular networks makes it possible to dissect and isolate Distally Based Dorsal Hand (DBDH) flaps. Quaba and Davidson first described this possibility. The purpose of this paper is to report our experience using the DBDH flap to reconstruct complicated defects of the long fingers., Material and Method: We are reporting our experience in eight cases (seven performed in emergency) where such a flap was used to cover dorsal traumatic skin defects of the long fingers. The average age was 40.3 years, ranging from 25 to 67 years. All the patients were males, seven of them had a job at the time of injury and the last one had already retired when injured., Results: All the eight flaps survived, sometimes with minor complications. Only one case developed a whole-thickness distal necrosis treated successfully by regular dressings. In one case, a Z-plasty was performed to correct a retraction in the 2nd web-space two months after surgery., Discussion: Many flaps have been described to cover dorsal skin defects in the fingers. All of them display some advantages and some disadvantages. The use of this flap allows coverage of vast skin defects and thereby early finger mobilisation. The surgical technique is rather easy, and it does not require microsurgical experience. Skin grafting to cover donor site is not always necessary.

The purpose of this study was to report the authors' experience with emergency reconstruction of severe tibial shaft fractures. Five male patients were admitted to the emergency room with a grade IIIB open tibial shaft fracture with bone loss (average age, 33 years; age range, 18-65 years). Injuries were the result of motorcycle accidents (N = 2), pedestrian accidents (N = 1), gunshot wound (N = 1), and paragliding fall (N = 1). Primary emergent one-stage management for all patients consisted of administration of antibiotics, debridement, stabilization by locked intramedullary nailing, bone grafting from the iliac crest, and coverage using free muscle flaps (four latissimus dorsi and one gracilis). The average follow-up was 21 months (range, 8 months-3.5 years). Partial weight bearing with no immobilization was started at 3 months, and full weight bearing began 5 months after trauma. No angular complications and no nonunions were observed. There was one case of superficial infection without osteitis. All fractures healed within 6 months in 4 patients and within 10 months in 1 patient. At the last follow-up examination, ankle and knee motion was normal and no pain was noted, except for 1 patient who had associated lesions (ankle motion reduced by 50%). Aggressive emergency management of severe open tibial fractures provides good results. It improves end results markedly, not only by reducing tissue loss from infection, but also reducing healing and rehabilitation times.

We present our therapeutic strategy for the treatment of type IIIB open tibial fractures. It involves emergency internal stabilisation of the bone by locked intra-medullary nailing when appropriate and skin cover using either a pedicled or free muscle flap. Where there is bone loss, a cancellous iliac graft is performed at the same time. Eighteen cases of type IIIB open tibial fractures treated between 1986 and 1995 were analysed. There were 17 men and 1 woman; the average age was 35 years. Each of the 18 patients underwent wound debridement as a primary emergency procedure with no secondary reoperation. Bone fixation was performed by locked intra-medullary nailing (AO nail, How Medica) 6-10 h after trauma. A primary cancellous iliac bone graft was performed in three cases. Cover was applied immediately after nailing (muscular pedicle flaps in 12 cases, muscular free flaps in 6 cases). Local flap cover led to two failures: both these fractures were followed by postoperative complications. The 6 free muscle flaps were successful. The average time to bone union was 6.5 months (range: 3-18.5 months) according to clinical criteria and 9 months (range: 4-27 months) according to radiological criteria. Out of the 18 fractures, 13 were primarily united (72.2% of cases); 3 involved osteitis and 2 nonunion. Sixteen patients were examined again with a mean follow-up of 4.8 years (range: 1-11 years). Six moderate malunions occurred; none needed surgical reoperation. Ankle motion was normal in 7 cases and reduced to below 50% in 9 cases when compared with the healthy ankle. Thirteen patients resumed their previous professional activities. This surgical strategy reduces bone union time, the number of operations and the time spent in hospital; it improves functional results.

The authors report a case of arterial pseudoaneurysm occurring 3 months after reimplantation of the hand in contact with the radial anastomosis. This complication, related to the initial mechanism of avulsion, although nonspecific, required rapid surgical revision as only one patent artery was present.

The authors report a case of combined dorsal fracture-dislocations of all 4 fingers, palmar trapezo-metacarpal dislocation and metacarpophalangeal dislocation of the thumb following a motorbike accident. These exceptional lesions were treated as an emergency by reduction and pinning. With a follow-up of 13 years, the patient still worked as an electrician.

Study Aim: The aim of this study was to report the long term functional results after replantation of the hand in eight patients., Materials and Methods: Between 1977 and 1995, hand replantation was performed in eight cases (six males and two females). Mean age at the time of injury was 31 years (24-47 years). The dominant hand was amputated in half of the cases. In two cases, the soft tissue lesions were severe; in the six other cases, the wound was clean-cut. The level of amputation was transmetacarpal (n = 2), carpal (n = 2), wrist (n = 2), distal part of the forearm (n = 2)., Results: The mean convalescence time was 16 months (from 6 months to 2 years). The degree of disability ranged from 40 to 65%. Patient follow-up lasted 2 to 20 years (mean: 11 years). The return of discriminative sensitivity of the digits was noted in six cases. The active motion of the fingers was satisfactory in all cases, but intrinsic muscle function was weak or absent. Pinch and grasp strength was reduced from 10 to 60% (when compared to the non-damaged hand). One patient resumed his prior occupation, and another resumed his occupation part-time. The six other patients found new occupations., Conclusion: All the patients achieved a useful function of their replanted hand in their daily, spare-time and professional activities.

The authors analyse 5 cases of gunshot wounds involving limbs with a diaphyseal fracture of the radius and ulna: 3 of the cases concern the radius and ulna and the remaining 2 involve the tibial bone. These wounds were encountered in civilian practice (3 rixes, 2 gun-shot injuries). In all of the cases, the emergency treatment consisted of extensive debridment, bone fixation by intramedullary nailing in most cases, cancellous iliac bone grafting in 2 cases, cover with a Latissimus dorsi free flap in 1 case. In all of the cases, development was free of infections bone union time was 3 to 12 months; last functional results were satisfactory.

The authors report their experience with early active mobilisation after repair of complete sections of the flexor tendons within the digital tendon sheath. This is a prospective study carried out over 2 years and represents 20 repairs. The tendons were repaired using a double-loop looking suture of Tsuge (with PDS 4/0) associated with a peritendinous overrun using Prolene 6/0 via a volar Bruner-type incision. Post-operatively, a plaster splint holding the wrist in 30 degrees of flexion, the MP joints in 90 degrees of flexion and allowing complete active flexion of the finger protected the suture site. As soon as the dressings could be reduced (the 5th day post-operatively), the patient was encouraged to actively and synchronously flex all the fingers together as many times as possible during the day. After removal of the plaster splint at one month, the patients were entrusted to a physiotherapist with a view to regain full extension of the wrist and the fingers. We did not note a single case of breakdown of the repair. The mean active mobility (TAM according to Strickland) of the repairs in zone I was of the order of 70% while that for repairs in zone II was 85%. Immediate active mobilisation was not found to compromise, in any way, the results of associated digital nerve repairs. Despite the modest results, this simple-to-understand protocol is directed at present for injuries with a poor initial prognosis (contused and lacerated tendons, associated fractures, and non-motivated patients). Improvement in the quality of suture material should, in future, extend the indications for immediate active mobilisation to all fresh sutures of the flexor tendons.

Dorsal dislocation of the thumb interphalangeal joint is rare. Only very few cases of irreducible dislocation has been reported at this joint. The authors report a case of compound irreducible dislocation due to the palmar plate interposition. The sesamoid, the flexor pollicis longus have been reported to block reduction of the dorsal dislocation of the thumb interphalangeal joint doctors on casualities should not insist if reduction is not easily obtained, the patient should then be guide towards a surgical team for surgical treatment.

Seven cases of acute and closed traumatic dislocation of the trapezio-metacarpal joint treated by percutaneous pinning adapted by Wiggins are reported with an average follow-up of eight years. Seven patients (five men and two women) aged 18 to 62 were treated. The injury was due to a road traffic accident in four cases. The dominant hand was injured in six cases. The metacarpal base was always dislocated dorsally and closed reduction always remained unstable. All cases consisted of closed dislocation but in two cases dislocation was associated with upper limb fractures. On the initial radiographs no patients had degenerative changes. All patients were treated as an emergency or the following during the days injury by reduction and stabilization by one or two percutaneous kirschner wires followed by a scaphoid cast for three to six weeks. All patients were followed and reviewed for this study between two and thirteen years (mean eight years) after injury. Enquiries were made about return to work, pain, stability, range of movement, key-pinch and grasp compared with the uninjured side. The joint was examined radiographically with particular attention to the presence of subluxation and degenerative changes. 2 patients with associated complex injury of the upper limb developed reflex sympathetic dystrophy. 2 patients had moderate pain, 2 patients had limitation of joint movement, 1 patient presented a reduction of strength (pinch and grasp) but none had subluxation, instability, or degenerative changes. Closed reduction and stabilization by percutaneous pinning is a simple method and gives good or excellent results in the treatment of acute traumatic dislocation of the trapezio-metacarpal joint.

60 peritrochanteric fractures treated with a lamina-plate with stay were studied. Their socio-professional caracteristics were similar to the whole sample. The functionnal results and the Duke's score were lower than the other osteosyntheses methods, despite a low number of complications. These results could be explained by systematic early weight bearing for the patients. This causes pain which is not well endured by patients included in this study. These patients, in good general and intellectual health, are able to bear, and prefer, prolonged decubitus (without pain). But while early weight bearing is not a priority for this population, it remainds fundamental for the patients with low intellectual function, who most frequently present with this type of fracture.

The authors report the results of 30 Swanson implants, inserted immediately, or secondarily in complex trauma of the proximal interphalangeal joint of long fingers in 24 patients (19 men, 5 women). All patients were reviewed by the same examiner with a mean follow-up of 7 years (range: 17 months-17.2 years). All implants were inserted secondarily after the accident, except in 7 cases in which the local conditions led the operator to insert the implant immediately. At review, 20 implants were still in place, 6 patients had requested amputation, and arthrodesis had been performed in 4 cases. The mean range of movement was -13,4 degrees to 37 degrees, i.e. a mean amplitude of 23.6 degrees. The lateral stability of the operated finger was considered to be satisfactory in 50% of cases, and the patient was satisfied with the operation in 65% of cases. The authors consider that useful mobility of the proximal interphalangeal joint should be preserved whenever possible. The Swanson implant is currently a useful alternative to amputation or arthrodesis, especially as it does not compromise these procedures if they are required subsequently.

A series of 13 cases of Kienbock's disease, treated by shortening of the radius, operated between 1975 and 1995, is presented. This series consisted of 7 males and 6 females with a mean age of 27.5 years (range: 17 to 37 years). The dominant hand was affected in 12 cases. 6 men and 5 women performed heavy work. The mean period between the first symptoms and the operation was 18 months (range: 3 months to 6 years). In 10 cases, pain was severe and limited activities; in 3 cases, pain was moderate with partial limitation of activity. 8 cases had a mobility greater than 75% compared to the healthy side. 5 cases had a mobility of approximately 50%. None of the cases had a mobility less than 25%. Strength was not measured preoperatively with the JAMAR dynamometer. The standard radiographic assessment included an AP palm-plate film (raised palm) and a true profile on a small board. This radiographic assessment established, for each case: the Decoulx and Lichtmann classification, the radioulnar index, the angle of the radial slope and the lunate fossa, collapse of the carpus according to Youm and McMurtry. There were two stage 1, three stage 2, eight stage 3 (six stage 3A, and two stage 3B) and no stage 4. The radioulnar index was negative in 10 cases, zero in 1 case, and positive in 2 cases. The mean angle of the radial slope was 23 degrees, the mean angle of the lunate fossa was 10.8 degrees, the mean height of the carpus was 0.476. The incision was anterior in 7 cases, and posterolateral in 6 cases. The mean shortening was 5 mm (range: 4 to 6 mm). Patients were reviewed with a mean follow-up of 5 years (range: 10 months to 12 years). The analysis according to Michon's criteria revealed 3 excellent results, 9 good results, 1 moderate result and no poor results. All patients were able to resume their previous occupation. Five no longer had any pain, 6 had moderate and rare pain, 2 patients presented pain limiting activity. 10 patients presented a mobility greater than 75% compared to the healthy side. In 2 cases, the mobility was greater than 50%. In 9 cases, the strength was greater than 75% compared to the healthy side, and in 4 cases, it was greater than 50%. Radiological assessment, all stages combined, showed 4 improvements, 7 stabilizations, 2 deteriorations. There was no correlation between the height of the carpus (which varied only very slightly postoperatively) and the clinical or radiological course. In this series of 13 patients; shortening osteotomy gave results on all stages of the disease. There was no correlation between the clinical and radiological course of the lunate, and the following factors: age, preoperative radiographic stage, instability of the carpus, position of the plate. On the basis of the results of our series, it appears important to increase the angle of the lunate fossa and to obtain an angulation greater than 12 degrees 5 and to maintain a negative radioulnar index. The 2 cases of radiological deteriorations corresponded to a positive postoperative radioulnar index, while the index remained negative in the 4 cases of improvement; all cases in which the angulation of the lunate fossa was greater than 12 degrees stabilized or improved radiologically, regardless of the preoperative stage. Despite contradictory theories, we believe, in the light of our series, that an angulation of the lunate fossa greater than 12 degrees and that a negative radioulnar index appear to be decisive criteria in the course of Kienböck's disease treated by shortening of the radius.

A liquid chromatographic (LC) method was evaluated for the determination of free and total carbohydrates in soluble coffee. Samples are solubilized in water for free carbohydrates or hydrolyzed with 1.00N hydrochloric acid for total carbohydrates. An aliquot of the sample solution is analyzed on a pellicular anion-exchange polystyrene-divinylbenzene column using pure water as the mobile phase. Carbohydrates are quantitated by a pulsed amperometric detector. All major carbohydrates found in soluble coffee are determined in a single run. The technique allowed the detection of fraudulent addition of coffee husks or parchments as well as cereals or caramelized sugar for the 63 commercial products analyzed. High levels of free mannitol, free fructose, free glucose, sucrose, total glucose, and total xylose are a good indication of adulteration. Data were compared with those obtained from separate enzymatic determinations and from a different LC procedure. A close agreement among the methods was observed. However, the original method was superior in precision and was the only procedure that enabled the quantitation of all major carbohydrates. The technique is, therefore, a very powerful tool for routine analysis and for purity assessment of soluble coffee.