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The author relates his 40 years of experience in the field of functional surgery of the tetraplegic upper limb (FSTUL). After having introduced and developed this specialty in France, he disseminated it to various countries where he saw a large number of patients and acquired extensive experience. He presents his personal progression and discusses the recent therapies in this field. FSTUL is a personalize surgery, with each case being unique. It must, first and foremost, take into consideration the real wishes of a motivated and well-informed patient and consider the type of spinal cord injury (not only the upper level of the lesional segment but also the extent of the sub-lesional segment). The surgical indication and rehabilitation are very important factors in the outcome. The main goal of FSTUL is rapid social reintegration of the patient; in some cases, this could involve fewer surgical procedures and shorter stays in rehabilitation centers. FSTUL is in constant evolution and can be improved; it is a useful but not well-known surgery.

The numerous surgical techniques proposed for treating thumb basal joint arthritis (osteotomy of the first metacarpal, trapezial osteotomy, simple trapeziectomy, trapeziectomy with implant, total joint prosthesis, arthroplasty by interposition, etc.) necessitate an anatomically based radiological evaluation of the different pathological forms of thumb basal joint arthritis. Here, the author defines three parameters: narrowing of the trapeziometacarpal (TM) joint space: TMA; TM instability and subluxation: TM I; scaphotrapeziotrapezoid damage: STT. Four stages of TM osteoarthritic deterioration are defined: TMA0: no joint narrowing (painful and unstable joint); TMA1: narrowing50%; TMA2: narrowing50%; TMA3: disappearance of the joint space, bone erosions. For TM instability/subluxation: TMI 0: reducible subluxation (unstable and painful TM); TMI 1: reducible subluxation but with imperfect reintegration; TMI 2: non-reducible subluxation1/3; TMI 3: subluxation1/3. For STT damage, STT 0: radiograph is normal but anatomical damage is visible intraoperatively; STT 1: joint space narrowing50%; STT 2: joint space is barely visible; STT 3: presence of erosion, sclerosis, irregularities. He outlines the shortcomings of the often-used Dell and Eaton-Littler classifications. A prospective study involving multiple cases having the same anatomical and radiological appearance that are assessed with sufficient follow-up is needed to standardize the modalities of surgical treatment.

Background The modular pyrocarbon (MoPyC) radial head prosthesis (Tornier, Saint-Ismier, France) is a monoblock modular radial head prosthesis. This study assessed midterm outcomes after implantation of the prosthesis. Materials A retrospective study was conducted of a consecutive cohort of 65 patients who underwent radial head replacement with the MoPyC prosthesis from January 2006 to April 2013. Indications were fractures, early or late failures from orthopedic or fixation treatments, and revisions after another implant. Patients were observed for >2 years for range of motion, pain, and stability; function by the Mayo Elbow Performance Score (total score, 100) and grip strength were assessed. Quality of stem implantation, bone resorption around the neck, and periprosthetic lucency were noted and quantified on radiographs. Capitellum shape and density as well as humeroulnar aspect (river delta sign) were evaluated. Complications and revision procedures were noted. Results We evaluated 52 of 65 patients (mean follow-up, 46 ± 20 months; range, 24-108). The Mayo Elbow Performance Score was 96 ± 7; pain score, 42 ± 7/45; and motion score, 18 ± 2/20. Function and stability were excellent. Radiology revealed 92% of patients with cortical resorption around the neck without mechanical failure. Bone resorption was mostly anterior and lateral; it resolved within the first year and thereafter was stable. Eight patients underwent revision surgery for stiffness. No implant failures were noted. Conclusion Results of the MoPyC radial head prosthesis appear to be satisfactory. Bone resorption around the neck (stress shielding) is frequent and stable after 1 year and does not impair stem fixation. The MoPyC prosthesis appears to be a reliable solution for replacing the radial head.

Los miembros superiores de los pacientes tetraplejicos son su unico elemento motor y su unica fuente de autonomia. La cirugia funcional se dirige a mejorar esta autonomia mediante la redistribucion del capital muscular restante para utilizarlo de forma optima. Esta cirugia es relativamente reciente y se rige por unos principios especificos cuyas bases fueron enunciadas por Moberg. Requiere una colaboracion medico-quirurgica especializada estrecha. El numero de musculos utilizables para transferirlos depende del nivel de lesion medular, que permite distinguir las tetraplejias altas, medias y bajas. El triceps braquial esta paralizado en las tetraplejias altas y algunas tetraplejias medias. La restauracion de la extension activa del codo es prioritaria y puede lograrse con la transferencia de la porcion posterior del deltoides o del biceps braquial. La creacion de una pinza policidigital pasiva (key grip) o activa, que es la unica posibilidad en las tetraplejias altas (donde el unico musculo utilizable que queda es el braquiorradial), puede completarse en las tetraplejias medias (donde dos o tres musculos son transferibles) mediante la restauracion de una prension digitopalmar. En las tetraplejias bajas, donde pueden utilizarse muchos musculos no paralizados, la cirugia funcional no es especifica de la tetraplejia y se parece a la de las paralisis nerviosas perifericas. La cirugia funcional del miembro superior de los pacientes tetraplejicos esta en constante evolucion. Muy recientemente, las transferencias nerviosas, que pueden utilizarse cuando el segmento sublesional medular es activo, parecen ser prometedoras. Esta cirugia debe adaptarse a cada caso, pues cada tetraplejico es diferente a los demas: nivel de la lesion medular, asi como extension del segmento medular sublesional, estado de las articulaciones de la mano y, sobre todo, exigencia personalizada de cada paciente tetraplejico.

Resume Nous rapportons un cas de luxations multiples des articulations carpo-metacarpiennes des doigts longs survenues apres un traumatisme ferme de la main droite lors d’un match de volley-ball. Il s’agit de luxations dorsales carpo-metacarpiennes des doigts longs (pouce exclu), sans aucune fracture associee. Nous les avons traitees par une reduction a foyer ouvert, apres echec du traitement orthopedique puis stabilisation par embrochage suivie d’une immobilisation de 4 semaines. La reeducation a ete debutee precocement et poursuivie plusieurs semaines apres ablation des broches. Au dernier recul de 8 mois, le resultat fonctionnel etait satisfaisant, avec une bonne force musculaire et une recuperation complete de la mobilite du poignet, des doigts en flexion-extension. Le patient a pu reprendre ses activites quotidiennes et sportives. La difficulte du diagnostic, le mecanisme de survenue ainsi que le traitement sont discutes.

The adult spastic hand, of varying causes, but dominated by vascular hemiplegia and brain damage, associates motor disorders and problems of tonus. The variety of forms of brain damage explains the wealth and diversity of the symptoms. These symptoms, often the most serious along with cognitive disorders, justify the expression "central neurological hand". Each case is an individual one. The effect on the hands may be unilateral or bilateral with spasticity involving the fingers/thumb/wrist. The clinical evaluation leading to a decision tree must take into account spasticity, retraction and paralysis, for each muscle. When completed by anesthetic motor blocks, spasticity and/or retraction, damage to extrinsic and/or intrinsic muscles of the fingers may be differentiated. This repeated multidisciplinary evaluation makes it possible to distinguish between "non functional hands", "functional hands" and "potentially functional hands". In the first instance, surgery can only improve the esthetic aspect or facilitate nursing. In the second instance, correcting spasticity may improve function. The treatment of spasticity is based on inhibiting spasticity (by injecting botulinum toxin or surgical motor hyponeurotisation) and reinforcing the non-spastic antagonist muscles via tendon transfer or tenodesis. Surgery is indicated to correct muscular retraction and deformities. The functional indications are highly selective and their limited results only allow a "supporting hand" to be constructed at best. The non-functional indications lead to a codified intervention whose results will greatly improve the management of these patients.

Resume Entre novembre 2001 et janvier 2008 sur 110 patients operes pour mains spastiques, 56 patients (68 mains) presentaient une atteinte intrinseque des doigts longs (interosseux et abducteur de l’auriculaire). Il s’agissait d’adultes (d’âge moyen 42 ans). L’indication a ete fixee lors de consultations multidisciplinaires integrant la realisation de blocs neuromusculaires selectifs differenciant d’une part atteinte des muscles extrinseques et intrinseques et, d’autre part spasticite et retraction. L’objectif du traitement etait fixe sous forme d’un contrat passe avec le patient et/ou sa famille : hygienique, esthetique et antalgique dans 15 cas, hygienique et antalgique dans 32 cas et fonctionnel dans 21 cas. Il a ete effectue quatre neurectomies sur la branche motrice du nerf ulnaire, 54 tenotomies des interosseux, 18 tenotomies de l’abducteur de l’auriculaire, six desinsertions proximales des interosseux. Sur 67 mains operees associant chirurgie des flechisseurs extrinseques et des intrinseques, 63 ont eu un bon resultat d’emblee defini comme la realisation du contrat fixe. Il y a eu quatre recidives dont deux ont necessite une reprise chirurgicale avec un bon resultat final. Les auteurs insistent sur la frequence des mains spastiques mixtes chez l’adulte cerebrolese. Malgre des resultats fonctionnels modestes, la correction des mains presentant des problemes hygieniques et douloureux ainsi que l’amelioration esthetique font de cette chirurgie correctrice des mains spastiques mixtes (spasticite des extrinseques et des intrinseques) une chirurgie gagnante qui doit etre connue.

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

Resume Introduction La main non fonctionnelle des patients cerebroleses, depuis l’article de Braun, n’a pas inspire beaucoup de publications. Le traitement chirurgical a pour objectif d’ouvrir la main pour des raisons hygieniques et esthetiques. La technique consiste a allonger l’appareil flechisseur extrinseque. Hypothese Le but de ce travail etait d’evaluer le transfert des flechisseurs extrinseques superficiels sur les profonds selon Braun. Patients et methodes Notre serie comportait 15 patients, d’âge moyen 55 ans, operes d’une intervention de Braun pour une main non fonctionnelle centrale, soit 19 mains. Des gestes complementaires ont ete realises en fonction de l’etat local (neurotomie de la branche profonde du nerf ulnaire, arthrodese radiocarpienne, tenotomie des flechisseurs du poignet et du long flechisseur du pouce, tenodese des radiaux). Les resultats ont ete evalues par l’analyse de l’ouverture des doigts et par une grille specifique (Mini Hand Score [MHS]) cotee de 6 (aucune gene) a 20 (gene majeure). Resultats Le recul moyen etait de six mois. Nous avons observe des resultats imparfaits : ouverture insuffisance du pouce, spasticite des intrinseques et hyperextension du poignet. Le MHS preoperatoire etait en moyenne de 13,87/20 et de 9,67/20 en postoperatoire, avec une difference tres significative. Discussion Notre systeme d’evaluation de la main non fonctionnelle (MHS), facile a utiliser, s’est avere tres efficace a demontrer l’amelioration du resultat postoperatoire. L’originalite de notre serie etait de montrer que l’intervention princeps decrite par Braun n’etait en fait realisee isolement qu’exceptionnellement et qu’un geste technique complementaire devait etre envisage quasi systematiquement. Tous les patients de notre serie ont ete suivis lors de consultations collegiales multidisciplinaires ou l’entourage du patient etait convie a donner son point de vue. Niveau de preuve Etude retrospective IV.

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2 degrees pronation (-70 degrees to 80 degrees ) to 95.8 degrees supination (80 degrees to 140 degrees ). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6 degrees (60 degrees to 90 degrees ) in pronation and 50.4 degrees (0 degrees to 90 degrees ) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.

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

Resume La main de l’hemiplegie est une main spastique et paralytique par atteinte neurologique centrale. Il faut differencier deux tableaux tout a fait differents : la main de l’hemiplegique cerebrale infantile souvent « chirurgicale » et qui a fait l’objet de la quasi-totalite des travaux sur la chirurgie de la main hemiplegique et la main du cerebrolese adulte (apres hemiplegie vasculaire ou traumatisme crânien). Dans ce second tableau, les indications a visee fonctionnelle sont beaucoup plus rares, du fait des troubles cerebraux des fonctions superieures associes. Cependant, les indications dans un but d’hygiene et esthetique y sont frequentes et font de cette chirurgie, souvent mal connue et qui cependant peut ameliorer grandement la fonction globale de ces malades, une chirurgie gagnante. Les indications chirurgicales sont fondees sur une etude clinique precise de la main completee par l’utilisation de blocs anesthesiques, une etude electromyographique et l’utilisation de la toxine botulique. Outre ce bilan lesionnel, elles doivent tenir compte d’un bilan general et cognitif. Il est ainsi possible de distinguer deux types de main : une main potentiellement fonctionnelle pouvant recuperer apres traitement des possibilites fonctionnelles qui ne sont jamais totales mais permettent de retrouver une « main d’appoint » ; une main potentiellement non fonctionnelle, qui reste fonctionnellement inutilisable. Le but de la chirurgie est de corriger des desequilibres musculaires entre agonistes et antagonistes et les deformations osteoarticulaires qu’ils engendrent. Pour ce faire, on peut agir sur le nerf (hyponeurotisation, neurectomie, intervention neurochirurgicale) ou sur le muscle, en relâchant les muscles agonistes (desinsertion musculaire, allongement tendineux) ou en renforcant l’action des muscles antagonistes par transferts tendineux. La stabilisation articulaire du poignet, des chaines digitales et du pouce en bonne position fait appel aux arthrodeses ou aux tenodeses.

Resume L’arthrodese scapulo-humerale trouve sa principale justification dans les sequelles de paralysies du plexus brachial. Elle reste, par contre, une intervention d’indication controversee et limitee dans le cadre des etiologies non neurologiques. Nous rapportons une serie de 8 arthrodeses d’epaule dans des etiologies non neurologiques, afin de determiner et preciser la place de cette intervention de nos jours. Il s’agissait d’une serie de 8 patients, 5 hommes et 3 femmes d’âge moyen 47 ans (23-87). Le cote opere a ete 2 fois le cote dominant et 6 fois le non dominant. 7 des patients avaient eu au moins une intervention chirurgicale au prealable. L’arthrodese a ete realisee une fois pour une reaction a corps etranger sur tendon prothetique de coiffe, 2 fois pour osteonecrose cephalique post-traumatique, 3 fois pour omarthrose excentree avec rupture massive de coiffe, et 2 fois pour omarthrose avec instabilite multidirectionnelle. Dans tous les cas, sauf un, l’arthrodese a ete realisee par voie posterieure avec pour osteosynthese un vissage interne associe a un fixateur externe laisse en place en moyenne 2 mois et demi. Tous les patients, sauf un, etaient satisfaits du resultat de l’intervention (le motif de satisfaction portant essentiellement sur la disparition des douleurs). Les mobilites actives moyennes etaient de 75° en flexion, 65° en abduction (la position moyenne de l’arthrodese etant de 20° en flexion, 25° en abduction et 30° en rotation interne). Deux groupes ont ete individualises pour l’analyse du score de Constant absolu. Le score a ete ameliore de 16 points (24 a 40) pour le groupe des omarthroses sans instabilite (le score de la douleur passant de 3 a 13) et diminue de 14 points (66 a 52) pour le groupe avec instabilite (imputable a la baisse des mobilites, le score moyen des mobilites passant de 38 a 14). Parmi les complications, on retrouvait une paralysie radiale, une pseudarthrodese, et un œdeme declive du membre superieur. L’arthrodese d’epaule n’est pas qu’une intervention dont les objectifs sont limites a l’obtention de l’indolence et de la stabilite. Elle doit pouvoir assurer une recuperation fonctionnelle utile (main-bouche, main-perinee et pince brachio-thoracique). Sa place se situe donc, la ou l’arthroplastie prothetique trouve ses limites (arthrites infectieuses, omarthrose evoluee chez le sujet jeune, perte du stock osseux glenoidien et echec de traitement des instabilites multidirectionnelles avec arthrose). Sa predictibilite et sa constance en terme de resultat, nous font pencher pour ce type d’intervention dans ces indications qui restent rares.

Resume Introduction. – Les auteurs presentent leurs premiers resultats du traitement de l'arthrose scaphotrapezotrapezoidienne par arthroplastie d'interposition utilisant un nouvel implant en pyrocarbone. Le but de cet implant apres resection du pole distal du scaphoide est de restaurer la mobilite scaphotrapezotrapezoidienne en evitant la destabilisation du carpe. Materiel et methode. – L'etude retrospective porte sur 15 cas chez 12 patients (10 femmes et 2 hommes d'âge moyen 65 ans) operes entre 1994 et 2002 revus avec un recul moyen de quatre ans (1 a 8 ans). L'indication chirurgicale a ete portee pour des douleurs resistantes au traitement medical (8,5 en moyenne sur l'echelle VAS). Les resultats postoperatoires ont ete analyses avec le systeme informatique EVAL. Dans tous les cas les radiographies statiques postoperatoires ont ete completees par des radiographies dynamiques en flexion–extension et inclinaison radiale–inclinaison cubitale. Resultats. – La douleur a disparu ou a diminue dans tous les cas avec une cotation moyenne de deux. La mobilite postoperatoire comparee au cote sain a montre une tres legere diminution de l ' inclinaison radiale (moins de 10°) et de l'extension du poignet (moins de 15°). La force de prehension digitopalmaire a ete similaire au cote oppose, y compris durant les echanges rapides. La force de la pince pollicidigitale a montre une legere diminution (inferieure a 0,8 kg) sans consequence fonctionnelle. L'exploration radiologique postoperatoire a confirme la bonne stabilite et la mobilite de la prothese dans tous les mouvements du poignet. L'angle radiolunaire postoperatoire etait identique a l'angle radiolunaire peroperatoire mais n'a subi aucune modification en DISI dans le temps. Conclusion. – Les bons resultats de cette premiere experience et la simplicite de la technique confirment l'interet de cet implant en pyrocarbone qui ne necessite aucune fixation ou ligamentoplastie associee dans le traitement de l'arthrose scaphotrapezotrapezoidienne. Cet implant en cas d'echec constate avec un plus long recul ne compromettra pas l'utilisation d'une autre technique chirurgicale.

Resume La main de l’hemiplegie est une main spastique et paralytique par atteinte neurologique centrale. Il faut differencier deux tableaux tout a fait differents : la main de l’hemiplegique cerebrale infantile souvent « chirurgicale » et qui a fait l’objet de la quasi-totalite des travaux sur la chirurgie de la main hemiplegique et la main du cerebrolese adulte (apres hemiplegie vasculaire ou traumatisme crânien). Dans ce second tableau, les indications a visee fonctionnelle sont beaucoup plus rares, du fait des troubles cerebraux des fonctions superieures associes. Cependant, les indications dans un but d’hygiene et esthetique y sont frequentes et font de cette chirurgie, souvent mal connue et qui cependant peut ameliorer grandement la fonction globale de ces malades, une chirurgie gagnante. Les indications chirurgicales sont fondees sur une etude clinique precise de la main completee par l’utilisation de blocs anesthesiques, une etude electromyographique et l’utilisation de la toxine botulique. Outre ce bilan lesionnel, elles doivent tenir compte d’un bilan general et cognitif. Il est ainsi possible de distinguer deux types de main : une main potentiellement fonctionnelle pouvant recuperer apres traitement des possibilites fonctionnelles qui ne sont jamais totales mais permettent de retrouver une « main d’appoint » ; une main potentiellement non fonctionnelle, qui reste fonctionnellement inutilisable. Le but de la chirurgie est de corriger des desequilibres musculaires entre agonistes et antagonistes et les deformations osteoarticulaires qu’ils engendrent. Pour ce faire, on peut agir sur le nerf (hyponeurotisation, neurectomie, intervention neurochirurgicale) ou sur le muscle, en relâchant les muscles agonistes (desinsertion musculaire, allongement tendineux) ou en renforcant l’action des muscles antagonistes par transferts tendineux. La stabilisation articulaire du poignet, des chaines digitales et du pouce en bonne position fait appel aux arthrodeses ou aux tenodeses.

Resume Les causes des paralysies radiales hautes sont dominees par les fractures humerales et les compressions extrinseques. Une etiologie moins frequente regroupe l’ensemble des paralysies radiales dites spontanees. Le tableau clinique habituel comporte une paralysie unilaterale d’installation plutot rapide, de localisation brachiale haute et complete, accompagnee de douleurs du bras ; une activite musculaire intense du membre superieur est souvent notee dans les heures precedant l’installation de la paralysie. Si certaines vont regresser rapidement, d’autres persistent, necessitant une exploration precise (EMG, echographie a haute resolution du nerf, bilan inflammatoire). L’analyse des differents cas operes (aspects de torsion parfois multiple et de striction severe du nerf), des etudes anatomiques de la gouttiere de torsion humerale, et la revue de la litterature ont permis d’expliquer ces paralysies. Leur origine semble liee a une predisposition anatomique de la partie basse de la gouttiere humerale (arcade fibreuse, vaste externe), et a des phenomenes dynamiques (mobilites du nerf) entrainant un cisaillement du nerf radial ; des facteurs systemiques ont egalement ete decrits, mais dont l’importance est mal evaluee. Le traitement comporte, en cas de non-recuperation, une neurolyse extra et intrafasciculaire sous systeme grossissant des le 2e mois, avec resection des facteurs extrinseques eventuels.

Resume L’activite des centres FESUM de France, Belgique et Suisse a ete evaluee de facon prospective pendant une semaine en juin 2002. La participation a ete de 90 % en France et 30 % dans les autres pays francophones. Un total de 2360 fiches ont ete analysees concernant essentiellement de jeunes adultes actifs. La plupart des patients sont arrives au centre FESUM par un vehicule non specialise (86 %). Plus de la moitie des patients ont ete traites en consultation externe (66 %). L’hospitalisation de jour a concerne 29 % des patients alors que seulement 4,6 % ont ete hospitalises. Les accidents de travail ne representent que 28 % des accidents. Plus de la moitie (62 %) sont des accidents domestiques. Les traumatismes fermes representent 50 % des cas. Parmi les traumatismes ouverts, il s’agissait d’une amputation complete dans 33 cas. Dans 32 % des cas, la gravite initiale permet de prevoir d’emblee des sequelles definitives. La moitie (45 %) des patients a beneficie d’un traitement chirurgical. Un geste microchirurgical a ete effectue dans 15 % des cas, dont six replantations. Presque tous les patients (95 %) ont ete traites le jour meme de leur presentation au centre FESUM. Le traitement a ete considere comme retarde a cause d’un dysfonctionnement a l’interieur de la structure FESUM dans 113 cas (5 %). D’apres cette etude, on peut estimer que la FESUM prend actuellement en charge environ 120 000 patients par an, dont 54 000 necessitant une intervention chirurgicale. On estime le nombre d’urgences mains et poignets par an en France a plus de 1,4 millions. L’amelioration du tri des patients dans les centres d’urgence est donc une tâche prioritaire. Nos efforts d’organisation reposent actuellement sur plusieurs projets : diffusion d’une fiche d’orientation a l’usage des urgentistes, diffusion d’un numero de telephone unique, reevaluation de l’importance de la chirurgie de la main dans la formation universitaire, constitution de reseaux de soins. Un nouvel audit sera mis en route au mois de mars 2003.

Resume Dans cette etude seront traites les syndromes canalaires des nerfs median, ulnaire, radial et cutane lateral de l’avant-bras au coude et a l’avant-bras. Les compressions a caractere proprement canalaire se voient lorsque le nerf s’engage dans un veritable tunnel osteo-fibreux avec incompatibilite entre le contenant (tunnel osteo-fibreux) et le contenu (nerf, tendon, …). Cependant, au coude et a l’avant-bras, les nerfs sont egalement exposes a des compressions essentiellement dynamiques et sont secondaires aux rapports anatomiques changeants entre le nerf et son environnement tendino-musculaire et aponevrotique lors des mouvements de flexion-extension du coude ou de prono-supination de l’avant-bras. Ce facteur dynamique sera systematiquement recherche lors de l’interrogatoire et par des tests dynamiques appropries que nous detaillerons dans cette etude.

Resume Introduction Nous presentons un implant original, l’implant adaptatif du scaphoide proximal (APSI), en pyrocarbone, dont la forme permet une mobilite adaptative lors des mouvements de la premiere rangee des os du carpe. Cet implant qui remplace le pole proximal du scaphoide a pour but de traiter l’arthrose styloscaphoidienne et de prevenir, en restituant la hauteur de la premiere rangee du carpe, l’evolution vers le collapsus carpien et l’arthrose : ‘SNAC wrist’ apres p'seudarthrose du scaphoide ; et ‘SLAC wrist’ apres disjonction scapholunaire. Materiel et methode Notre serie retrospective comprend 25 cas revus et analyses avec un recul moyen de six ans (entre trois et dix ans) par un observateur independant a l’aide d’un systeme expert informatique EVAL : 1) quatorze cas correspondaient a des pseudarthroses evoluees du scaphoide (‘SNAC wrist’) ; 2) dix cas etaient secondaires a des disjonctions scapholunaires (‘SLAC wrist’) ; 3) un cas correspondait a un collapsus carpien avec siliconite secondaire a un implant partiel de scaphoide en silicone pour pseudarthrose d’une fracture stade II. Resultats La douleur, presente dans tous les cas, et motif de la consultation preoperatoire a disparu dans 60 % des cas, ne persistant qu’a l’effort dans 28 % des cas. Ainsi, 88 % des patients ont ete satisfaits et ont repris leurs activites professionnelles au meme poste ou leurs activites sportives au meme niveau. La mobilite et la force de serrage digitopalmaire et pollicidigitale evaluees par rapport au cote sain ont ete ameliorees. Sur le plan radiologique on ne deplore aucune luxation de l’implant. Les cliches dynamiques en flexion extension et en inclinaison frontale confirment sa mobilite adaptative. Dans tous les cas la hauteur du carpe a ete maintenue. L’angle radiolunaire est reste inchange dans quinze cas, ameliore dans six cas et aggrave dans quatre cas. Deux mauvais resultats correspondent a des sequelles de disjonction scapholunaire avec translation ulnaire et DISI important en preoperatoire. Conclusion Les premiers resultats de l’implant que nous presentons « APSI » sont prometteurs dans les pseudarthroses polaires proximales pour lesquelles un traitement curatif n’est plus possible et permettent d’eviter l’evolution vers le collapsus carpien ('SNAC wrist’). Dans les sequelles de disjonction scapholunaire (‘SLAC wrist’) ou les lesions ligamentaires sont importantes la mise en place de l’implant ne resout pas le probleme de la destabilisation ligamentaire qui necessite un traitement approprie supplementaire.

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

Resume Les auteurs ont analyse retrospectivement 7 cas de replantations digitales, realisees entre 1985 et 1996 et concernant 7 hommes âges de 60 a 71 ans. Il s'agissait de 2 amputations du pouce, d'une amputation de l'index, de 2 amputations du medius, d'une amputation de l'annulaire et d'un arrachement par bague de l'auriculaire. Le mecanisme lesionnel etait 4 fois une lesion par scie circulaire, une lesion par hache, un ecrasement et 1 arrachement. Trois echecs peroperatoires ont ete notes, ayant necessite une regularisation en urgence, ainsi qu'un echec precoce par thrombose arterielle chez un patient tabagique, necessitant une regularisation au 2e jour. Ces 4 echecs ont concerne des amputations de doigts longs par scie circulaire dans le cadre de lesions complexes multidigitales, de mauvais pronostic et survenant sur un terrain vasculaire defavorable. Nous avons compte 3 succes: les 2 amputations du pouce ainsi que l'arrachement par bague de l'auriculaire. Ces 3 patients ont recupere une bonne fonction de leur main. Nous avons retrouve des caracteristiques communes: excellent etat general, non tabagique, patients motives et cooperants, lesion unidigitale, amputation relativement franche, bonnes conditions de conservation du doigt ampute. L'âge eleve du patient ne doit pas contre-indiquer une replantation digitale. Le mecanisme lesionnel et le terrain general du patient sont des criteres majeurs de pronostic. Dans des conditions de pronostic favorable, un bon resultat fonctionnel peut etre espere.

Resume L'evaluation de la fonction des tendons flechisseurs est un probleme complexe encore tres controverse. De nombreuses propositions ont ete faites depuis la premiere cotation de Boyes en 1950. Nous faisons une presentation et une etude critique des methodes les plus utilisees: le T.A.M., celle de Kleinert et celle de Buck-Gramcko. Nous presentons une methode personnelle, utilisable en toute zone, eliminant l'action des intrinseques et faisant apparaitre des effets de tenodese. Cette methode a ete correlee a celle de Kleinert, de Buck-Gramcko et de Strickland, a propos de l'analyse des resultats de 165 sutures tendineuses. Ces resultats se situent a mi-chemin, entre la methode la plus optimiste (Buck-Gramcko) et la plus severe (Strickland). Par ailleurs, les auteurs proposent une methode originale d'evaluation de la fonction des tendons extenseurs, extrapolee de celle qu'ils utilisent pour les tendons flechisseurs.

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

Resume Dans les cas d'arthrose evoluee du poignet, lorsque les interlignes articulaires radio-carpien et medio-carpien sont detruits, nous proposons le transfert en ilot de l'articulation radio-cubitale inferieure. Nous avons etudie la vascularisation de l'articulation radio-cubitale inferieure a partir des arteres interosseuses sur 40 membres superieurs de cadavres frais. L'etude anatomique a montre que le reseau perioste epiphysaire dorsal etait alimente dans tous les cas par la perforante inferieure de l'interosseuse anterieure et 38 fois sur 40 par l'artere interosseuse posterieure. Il est possible de prelever l'articulation radio-cubitale inferieure en bloc et de la faire pivoter de 90° de maniere a placer l'interligne articulaire en radio-carpien tout en conservant sa vascularisation sur le pedicule interosseux anterieur. Nous presentons avec notre premier cas clinique la technique operatoire. Cette nouvelle intervention represente une alternative non prothetique a l'arthrodese.

Notre prise en charge du traitement des lesions des extenseurs a la main remonte a 1971. Yves Allieu ramenait des Etats-Unis la technique du Barb Wire (1–3), un fil d’acier avec deux harpons places dans le tendon et complete par une suture. Il s’agissait en fait d’une suture bloquee. Mais, lors de la dynamisation de la suture, le plomb proximal libere entrainait de nombreux sepsis.

We assessed the length-tension relationship of the posterior deltoid to triceps transfer in 8 tetraplegics (n = 11 transfers) and compared the results to the length-tension relationship of the normal triceps measured in a check sample composed of 9 able bodied, right handed women. We designed a device to lock the arm and forearm and used a force transducer to assess the torque output isometrically. The muscle was tested at 6 different lengths (130, 110, 90, 70, 45 and 0 degree of elbow flexion) with the shoulder abducted at 90 degrees. As expected, the transfer behaved differently from the normal triceps. The mean maximum torque recorded was 7.8 Nm in patients while it was 27 Nm in the check sample. When compared, the absolute values (ie values expressed with a dimension of torque) were significantly different between groups (0.00001 < p < 0.002). The expression of this relation (ie the relative values expressed as percentage of maximum values) revealed significant statistical differences (p < 0.002) at 90 and 70 degrees of elbow flexion; the peak torque was recorded at 130 degrees in patients while it was recorded at 110 degrees in the check sample, with a plateau between 110 degrees and 70 degrees. On the other hand, if the length-tension relationship was fairly similar among subjects of the check sample, it exhibited tremendous differences among patients; it seemed that initial tension given by the surgeon represented a variable difficult to control without a device dedicated to that task.

The adult spastic hand, of varying causes, but dominated by vascular hemiplegia and brain damage, associates motor disorders and problems of tonus. The variety of forms of brain damage explains the wealth and diversity of the symptoms. These symptoms, often the most serious along with cognitive disorders, justify the expression "central neurological hand". Each case is an individual one. The effect on the hands may be unilateral or bilateral with spasticity involving the fingers/thumb/wrist. The clinical evaluation leading to a decision tree must take into account spasticity, retraction and paralysis, for each muscle. When completed by anesthetic motor blocks, spasticity and/or retraction, damage to extrinsic and/or intrinsic muscles of the fingers may be differentiated. This repeated multidisciplinary evaluation makes it possible to distinguish between "non functional hands", "functional hands" and "potentially functional hands". In the first instance, surgery can only improve the esthetic aspect or facilitate nursing. In the second instance, correcting spasticity may improve function. The treatment of spasticity is based on inhibiting spasticity (by injecting botulinum toxin or surgical motor hyponeurotisation) and reinforcing the non-spastic antagonist muscles via tendon transfer or tenodesis. Surgery is indicated to correct muscular retraction and deformities. The functional indications are highly selective and their limited results only allow a "supporting hand" to be constructed at best. The non-functional indications lead to a codified intervention whose results will greatly improve the management of these patients.

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

Between November 2001 and January 2008, 56 patients (68 hands) out of 110 patients operated for spastic hand deformities, presented with spasticity of the intrinsic muscles of the long fingers (interosseii and the abductor pollicis brevis). All patients were adults (mean age 42.1 years). The surgical indication was discussed during multidisciplinary consultations with selective nerve blocks enabling us to distinguish between extrinsic and intrinsic pathologies on the one hand and muscular spasticity and tendon retractions on the other hand. The aim of the treatment was defined in a "contract" signed with the patient and/or his family. It was hygienic, aesthetic and analgesic in 15 cases, hygienic and analgesic in 32 cases and functional in 21 cases. Four hands were treated by neurectomy of the ulnar nerve's motor ramus, 54 by tenotomies of the interosseous muscles, 18 by tenotomy of the abductor digiti minimi, six by metacarpal disinsertion of the interosseous muscles. On a total of 67 hands operated associating surgery of the extrinsic and intrinsic flexors, 63 had good primary results as defined in the contract. We noted four relapses, two of which required revision. The authors emphasize the frequency of mixed spastic hands in adults after cerebral palsy. However modest the functional results may be, correction of hygienic and pain problems of non-functional hands as well as aesthetic improvements make surgery of the mixed spastic hand a successful intervention, which should be shared.

Resume Onze patients porteurs d'une maladie de Kienbock au stade III de Decoulx avec horizontalisation du scaphoide, ont ete traites par arthrodese scapho-trapezo-trapezoidienne. Les gestes associes ont ete un implant du semi-lunaire 6 fois, une lunarectomie 3 fois, un accourcissement du radius une fois. Le recul moyen est de 40 mois (extremes de 12 a 84 mois). Aucune complication de l'arthrodese n'est a signaler. 7 patients sur 11 ont une disparition quasi complete des douleurs. La force jugee par l'etude du « graspest en moyenne de 66 % de celle du cote sain. La mobilite du poignet n'est surtout limitee qu'en inclinaison radiale. On note une correlation positive entre la bonne reduction du scaphoide et l'absence d'arthrose radio-carpienne pre-operatoire d'une part et les bons resultats cliniques d'autre part. Il n'est pas apparu de difference significative entre les divers gestes associes sur le semi-lunaire. L'arthrodese STT nous parait etre une option interessante dans le traitement de la maladie de Kienbock au stade III evolue car elle diminue les contraintes sur la colonne du semi-lunaire et traite l'horizontalisation du scaphoide.

The authors relate their experience of thirty digital artery sympathectomies in twenty-four fingers. Ten men and two women were operated: six crush injuries to fingers, three Raynaud's disease and two Buerger disease and one scleroderma. All presented digital vascular insufficiency. The pre-operative arteriogram always revealed more extensive thrombosis than suspected by the clinical symptoms. In this way we performed a segmental arterial sympathectomy depending on the site of the thrombosed artery. The follow-up was five years. The immediate postoperative results were excellent. Five years later the results depended on the nature of the initial disease.

Resume Il a longtemps ete reproche a l'utilisation du lambeau inguinal pedicule en chirurgie d'urgence de la main traumatique, la position declive du membre superieur avec tendance a l'œdeme, et la difficulte d'entreprendre une reeducation precoce par la position fixee a l'abdomen de la main traumatisee. Les auteurs a la lumiere d'une large experience de 76 lambeaux realises en urgence sur plus de 100 effectues ces dix dernieres annees, decrivent leur technique de prelevement qui conduit a la realisation d'un tube ferme et long, compatible avec une indispensable reeducation precoce, permettant egalement la mise en place eventuelle d'orthese.

Resume Les auteurs rapportent l'observation d'un jeune homme victime d'une avulsion tendineuse sous-cutanee des tendons flechisseurs profonds et superficiels du quatrieme et du cinquieme doigts gauches par blast. Au plan therapeutique, les flechisseurs profonds ont ete reinseres en trans-osseux avec excision des superficiels. Le resultats fonctionnel est bon. Les ruptures traumatiques des tendons flechisseurs des doigts sont rares, la rupture simultanee des tendons flechisseurs superficiel et profond est encore plus rare. Cette pathologie est encore mal connue, les indications therapeutiques imprecises.

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

Scapulohumeral arthrodesis is mainly used for the treatment of sequelar injury after brachial plexus palsy. Indications are however controversial and limited to patients with non-neurological shoulders. We report a series of eight shoulder arthrodeses performed on non-neurological shoulders in order to determine and detail the current role of this procedure.The series included eight patients, five men and three women, mean age 47 years (23-87). The dominant side was operated on in two patients and the non-dominant side in six. Seven patients had had at least one shoulder procedure prior to arthrodesis. Arthrodesis was performed for foreign body reaction on a tendon prosthesis in one patients, posttraumatic head necrosis in two, off-centered degenerative joint disease with full thickness rotator cuff tear in three, and multi-directional instability on degenerative joint disease in two. Arthrodesis was performed via a posterior approach in all patients but one using screw fixation associated with external fixation left in place for 2.5 months on average.All patients except one were satisfied with the outcome (basically because of pain relief). Mean active motion was 75 degrees flexion, 65 degrees abduction (arthrodesis at 20 degrees flexion, 25 degrees abduction and 30 degrees internal rotation). Two groups were identified to analyse the absolute Constant score. The score improved 16 points (from 24 to 40) in the group of patients without instability (pain score improved from 3 to 13) and decreased 14 points (from 66 to 52) in the group with instability (due to decreased motion, the mean motion score declining from 38 to 14). Complications included one radial palsy, one nonunion, and one gravity edema of the upper limb.Shoulder arthrodesis is more than a salvage method to reduce pain and gain stability. The objective should be to recover useful function (hand-mouth, hand-perineum, brachio-thoracic function). It should be used when prosthetic arthroplasty is not possible (infectious arthritis, advanced degenerative disease in young subjects, loss of glenoid bone stock, failure after treatment of multidirectional instability with degenerative disease). Shoulder arthrodesis still has rare indications because of the predictability of sustained outcome.

The authors propose a scaphotrapeziotrapezoidal (STT) arthroplasty using a discoid pyrocarbon implant. The aim of this prosthesis is to restore the scapho-trapezial mobility without destabilising the carpal bones (unlike with a simple resection of the distal scaphoid pole).This technique was used in 15 cases from 1994 to 2002. 12 patients (10 females and 2 males), mean age 65 years) have been reviewed with a mean follow-up of 4 years (1 to 8). Surgical indication was pain refractory to medical treatment (average 8.5 on V.A.S.). Pre-operative mobility showed a loss of radial deviation and dorsal flexion. The severity of the pain did not allow evaluation of the pre-operative strength. Post-operative results were assessed with the EVAL computerised system, static and dynamic X rays were performed in all cases.Pain decreased to an average of 2. The mobility compared to the healthy side showed a slight loss of radial deviation (less than 10 degrees) and in wrist extension (less than 15 degrees). Grip strength was similar to the normal side, even during rapid exchanges. Pinch grip evaluation showed a slight decrease (0.8 kg) which did not compromise normal function of the first ray. No implant luxation was observed in the radiological study. Angular measurements did not show any modification in DISI and other static angles remained unchanged. Dynamic sagital and frontal views confirmed the good mobility of the prosthesis which adjusts its position to the scaphoid movements.The good results, the simple surgical procedure, the absence of complications, the lack of a need for any fixation or ligamentoplasty all confirm the advantages of this pyrocarbon implant in the treatment of STT arthrosis. Furthermore, in cases of failure, it is possible to use any other revision procedure.

The absence of a medical treatment capable of successfully arresting joint destruction due to rheumatoid arthritis (RA) leaves a large domain for surgical treatment. The purpose of our work was to determine whether a clinical benefit persists in the long term (more than 20 years) despite aggravation of the radiological lesions, after surgical treatment of rheumatoid arthritis of the wrist.Sixteen patients with RA (13 women and 3 men, mean age 65 years), were reviewed a mean 24.8 years (range 20-33 years) after wrist surgery. Twenty-four wrists were operated for dorsal synovectomy (n=18) and Swanson radiocarpal implant (n=6). Total arthrodeses were excluded. Clinical, functional and standard and stress x-ray data were collected at last follow-up.Residual pain at last follow-up in wrists which had undergone dorsal synovectomy was scored 3.1/10 on the VAS versus 5.6 preoperatively. Three-quarters of the patients stated they were satisfied with the intervention despite very weak force. Revision surgery was required in eight patients after dorsal synovectomy including three which required resection of the ulnar head, left in place after the first surgery, and three for removal of a silicon implant of the ulnar head. This implant was rapidly abandoned in our unit (as in other units). The radiological status worsened in all wrists over time, despite synovectomy. For the Swanson radiocarpal implant, residual pain was only 0.5/10 versus 6.7 preoperatively. Four implants fractured and four developed radiological signs of siliconitis with not clinical expression. Despite these complications, five of the six patients felt favorably about their intervention and the mean Leclerc function score was 78/100. Flexion-extension was 56 degrees on average. The main complaint was the lack of force.There is a discordance between radiological and clinical results, a difference which widens with longer follow-up. A clear improvement in the pain score and the moderate functional demands of these patients are probably the reasons for their satisfaction despite radiological degradation. Many desire more wrist force. Our indications have evolved over time with the development after 1980 of the radiolunar arthrodesis procedures that we associate with dorsal synovectomy even in early-stage patients in order to limit radiological degradation and ulnar translation of the carpus. Swanson radiocarpal implants were completely abandoned in 1987 despite favorable clinical results due to the radiological degradation with bone loss and risk of siliconitis. For Simmen III wrists, total arthrodesis remains the only sure and definitive solution.

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

Elbow joint allograft (EJA) involving the entire joint (distal humerus, proximal radius and ulna, capsuloligament structures) is a salvage technique proposed in massive bone loss, particularly in young subjects where total elbow prosthesis is contraindicated. We report our experience with seven patients, analyzing the long-term clinical and radiological outcome.This retrospective study included seven patients, mean age 42 years (21-70). All had experienced severe elbow trauma. Two patients had associated neuromuscular or vascular lesions. All patients underwent at least one surgical procedure on the affected elbow. The preoperative status of the skin cover was crucial. Both longitudinal and circumferential retraction were observed. We used preoperative skin expansion in one patient and a pediculated musculocutaneous latissimus dorsi flap in one other. A posterior and median approach was used conserving tricipital continuity. The ulnar nerve was transposed anteriorly. The allograft was prepared, carefully preserving the capsule and ligaments. Adaptation required cutting the extremities of the humerus and radius and total resection of the radial head except in one patient. Stable plate fixation was completed by an iliac cancellous graft screwed to the humerus and the ulna. The Morrey score was used to assess clinical outcome. The Larsen and Allieu classifications were used to assess radiological outcome.There was one early failure requiring revision for arthrodesis. Assessment of long-term outcome concerned six patients. Mean follow-up was 12 years (7-15 years). The Morrey score improved in six patients and five of them were satisfied. None of the patients complained of invalidating pain and elbow motion was not functional in only one (- 30 degrees - 100 degrees ). For all patients except one, instability was proportional to the duration of the graft and worsened with time. For five out of six patients, significant radiological degradation of the elbow joint was associated with bone lysis which increased with time.The allograft acts like a spacer and does not transmit pain impulses. The absence of the pain signal leads to overuse of the grafted joint and osteoarticular destruction. Despite radiological degradation, this procedure provides satisfactory and painless elbow function in most patients. The clinical and radiological features do not follow the same pattern. But we did not have any cases of disassembly or nonunion. Preoperative planning and plastic surgery have enabled us to control the cutaneous portal. We did not have any postoperative infections. Joint allograft is a salvage solution for major osteoarticular loss in young patients desiring conserved joint function and for whom a total elbow prosthesis is contraindicated. It restores bone stock, enables mid-term potential for joint function, and does not compromise surgical revision.It remains an exceptional indication which is technically difficult. Resorption of the allograft is constant at long term. Clinically, instability worsen functional outcome. The future for this technique depends on progress in immunology and cryobiology. At the present time, composite total elbow prostheses with an allograft combine the advantages of restored bone stock and arthroplasty.

We report one case of ulnar nerve compression in Guyon’s canal due to calcium deposits in a 50-year-old woman with long standing systemic scleroderma. To our knowledge, this is the second known case. The symptoms consisted of a motor and partial sensory disturbance. Calcification of the piso-triquetral joint was prolonging into Guyon’s canal, lifting its contents, and into the subcutaneous tissue of the ulnar border of the wrist. Excision of calcium deposits and of the pisiform in combination with external neurolysis of the ulnar nerve resulted in complete relief of symptoms.

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