Three-dimensional reconstruction of the hand from biplanar X-rays: Assessment of accuracy and reliability

BACKGROUND

Functional disorders of the hand are generally investigated first using conventional radiographic imaging. However, X-rays (two-dimensional (2D)) provide limited information and the information may be reduced by overlapping bones and projection bias. This work presents a three-dimensional (3D) hand reconstruction method from biplanar X-rays.

METHOD

This approach consists of the deformation of a generic hand model on biplanar X-rays by manual and automatic processes. The reference examination being the manual CT segmentation, the precision of the method was evaluated by a comparison between the reconstructions from biplanar X-rays and the corresponding reconstructions from the CT scan (0.3mm section thickness). To assess the reproducibility of the method, 6 healthy hands (6 subjects, 3 left, 3 men) were considered. Two operators repeated each reconstruction from biplanar X-rays three times to study inter- and intra-operator variability. Three anatomical parameters that could be calculated automatically from the reconstructions were considered from the bone surfaces: the length of the scaphoid, the depth of the distal end of the radius and the height of the trapezius.

RESULTS

Double the root mean square error (2 Root Mean Square, 2RMS) at the point/area difference between biplanar X-rays and computed tomography reconstructions ranged from 0.46mm for the distal phalanges to 1.55mm for the bones of the distal carpals. The inter-intra-observer variability showed precision with a 95% confidence interval of less than 1.32mm for the anatomical parameters, and 2.12mm for the bone centroids.

DISCUSSION

The current method allows to obtain an accurate 3D reconstruction of the hand and wrist compared to the traditional segmented CT scan. By improving the automation of the method, objective information about the position of the bones in space could be obtained quickly. The value of this method lies in the early diagnosis of certain ligament pathologies (carpal instability) and it also has implications for surgical planning and personalized finite element modeling.

LEVEL OF PROOF

Basic sciences.

Tendon transfer from a re-innervated triceps to the biceps for restoration of elbow flexion in total brachial plexus palsy

OBJECTIVES

This study aimed to evaluate the outcomes of the tendon transfer from a reinnervated triceps to biceps in the context of total brachial plexus palsy.

METHODS

We conducted a retrospective study. Patients had reinnervation of the triceps either by spontaneous recovery or by nerve transfer. Functional results were assessed by strength and range of motion. The level of patient satisfaction was measured on a scale from 0 to 10.

RESULTS

Six patients (6 transfers) were included. Two triceps had spontaneous reinnervation and the other four through neurotization of intercostal nerves. All patients recovered strength to M4 in flexion with an average secondary deficit of 10° (5°-15°). The mean level of satisfaction was measured at 7/10 (6-8).

CONCLUSIONS

This tendon transfer is a reliable and simple solution for supportive restoration of elbow flexion. Systematic reinnervation of active extension of the elbow should be proposed for the gain in function that it represents but also for the supportive therapeutic opportunity that it offers should nerve surgery for elbow flexion fail.

LEVEL OF EVIDENCE: 4

Improving the detection of subscapularis tears using a specific transverse CT arthrography image

BACKGROUND

The prevalence of subscapularis (SSC) tendon tears is often underestimated. This negatively impacts the shoulder function because the SSC muscle is a powerful internal rotator. The primary aim of this study was to compare a blended clinical and radiological preoperative index of suspicion for SSC tears to the arthroscopic findings. The secondary aim was to compare the surgeon's and radiologist's index of suspicion to determine which is more accurate.

HYPOTHESIS

Analyzing a transverse image passing under the tip of the coracoid process, in combination with clinical examination, will be the standard for detecting SSC tears.

METHODS

This prospective study enrolled 50 consecutive patients who underwent shoulder arthroscopy. Preoperatively, four clinical tests were doneto detect SSC tears: lift-off, internal rotation lag sign, bear-hug, belly-press. A CT arthrography slice passing under the coracoid process tip was analyzed by the surgeon. The surgeon deduced a radiological index of suspicion for SSC tears then a blended clinical and radiological index of suspicion based on the clinical examination. Lastly, the surgeon looked at the radiologist's findings and index of suspicion for a lesion. The three indexes of suspicion were compared with the actual arthroscopy findings.

RESULTS

The surgeon's blended clinical and radiological index of suspicion was similar to his radiological index. Both of the surgeon's indexes of suspicion were higher than the radiologist's. The prevalence of SSC tears was 58 %.

DISCUSSION

We recommend doing multiple clinical tests as they complement each other in detecting SSC tears, since each one activates a different portion of the muscle. We advise surgeons to supplement their clinical examination by analyzing a specific image of the tendon below the coracoid, as the reference view for the starting point of SSC tears.

LEVEL OF EVIDENCE

IV, prospective diagnostic study on consecutive patients.

Capitate pyrocarbon prosthesis in radiocarpal osteoarthritis

Scapholunate dissociation or scaphoid pseudarthrosis may lead to osteoarthritis of the wrist. When osteoarthritis affects the midcarpal joint, proximal row carpectomy is no longer possible and only 4 corners fusion or capitolunate arthrodesis may be indicated. However, in some cases, osteoarthritis or bone necrosis may involve the lunatum, making partial arthrodeses impossible. Total arthrodesis may be proposed in such cases, but with a loss of range-of-motion. Total prosthesis may be considered but the results of this procedure are not always encouraging. Consequently, in these situations, we perform pyrocarbon prosthesis implant, replacing the head of the capitatum. This article describes the procedure and the results of a preliminary study.

Restoration of active fingers flexion with tensor fascia lata transfer in total brachial plexus palsy

In total brachial plexus palsy, fingers flexion restoration is a real challenge. Nerve surgery can generally restore shoulder abduction and elbow flexion. However, results of nerve grafts or nerve transfers are generally poor for hand function. As a matter of fact, the long distance between nerve sutures and terminal nerve branches in muscles decreases the rate of reinnervation. When finger flexion occurs, strength is generally weak and function remains fair. Therefore, we proposed a new technique to restore fingers flexion. The tensor fascia lata tendon is harvested and sutured between the biceps and flexor digitorum profundus (FDP) tendons. When elbow is flexed, the biceps muscle contraction pulls FDP tendons resulting in a partial but strong hand occlusion. This technique is an alternative to free muscle transfers or nerve surgery with reliable results.

Capitolunate Arthrodesis With Compression Screws

Scapholunate dissociation or scaphoid pseudarthrosis may lead to wrist osteoarthritis. When osteoarthritis concerns the midcarpal joint, proximal row carpectomy is not possible. Only 4-corner or capitolunate arthrodesis may be indicated. In this procedure, pseudarthrosis was frequently described in literature. However, in these series, fixation was performed with pins or staples. Type and position of the device are important to obtain carpal bones fusion. The efficiency of compression screws has been validated in scaphoid fracture or pseudarthrosis. Moreover, the axial position of the screws, parallel to the physiological wrist loads, may participate to improve bone fusion. Therefore, we present our technique of capitolunate arthrodesis with compression screws fixation through a dorsal approach.

Technique of the double nerve transfer to recover elbow flexion in C5, C6, or C5 to C7 brachial plexus palsy

In C5, C6, or C5-to-C7 root injuries, many surgical procedures have been proposed to restore active elbow flexion. Nerve grafts or nerve transfers are the main techniques being carried out. The transfer of ulnar nerve fascicles to the biceps branch of the musculocutaneous nerve is currently proposed to restore active elbow flexion. Recovery of biceps muscle function is generally sufficient to obtain elbow flexion. However, the strength of elbow flexion is sometimes weak because the brachialis muscle is not reinnervated. Therefore, the transfer of 1 fascicle of the median nerve to the brachialis branch of the musculocutaneous nerve may be proposed to improve strength of the elbow flexion. We describe the technique of this double transfer to restore elbow flexion. The results concerning 5 patients are presented.

Extensor tenodesis for plexic hands with C7 to T1 or C8, T1 root avulsions: a new technique

In C7 to T1 or C8, T1 root avulsion palsies, restoration of finger active extension is not possible. Only tenodesis may restore hand opening in active wrist flexion. Many techniques have been described to restore this motion. In routine techniques, extensor tendons are fixed on radius or sutured on dorsal retinaculum. However, in these procedures, progressive tendon lengthening or ruptures may occur and salvage procedure may be difficult to perform. Therefore, we proposed a new extensor tenodesis technique. The extensor digitorum communis tendons are sutured on the paralyzed flexor digitorum superficialis tendons through interosseous membrane. This procedure allows performing a strong tendon to tendon suture more resistant than radius or retinaculum fixation. As other tenodesis techniques, wrist flexion has to be active to obtain hand opening.

Syndrome du canal carpien: information et consentement éclairé

Patients must be informed of the benefits and risks before any surgical procedure. This information must be clear, honest, specific and complete in order that the patient can give his or her informed consent. This information has to be given face to face, however paper may be used to emphasize certain points and aid retention of information. We studied information sheets for carpal tunnel release given out in ten different hand surgery centres. Different points were identified to analyse each form. From this analysis, a literature review and recent law texts, we propose a new information sheet for carpal tunnel release.

Traitement de l'arthrose scaphotrapézotrapézoidienne isolée par arthrodèse scaphotrapézotrapézoidienne: une série de 13 cas

Scapho-trapezio-trapezoid arthrodesis was originally performed for the treatment of scapho-lunate instability. However, only a few publications have described this technique for treatment of osteoarthritis of the scapho-trapezio-trapezoid (STT) joint. The purpose of this paper is to analyze the results of triscaphoid arthrodesis for STT osteoarthritis with a long-term follow-up. Thirteen cases of osteoarthritis of the STT joint in twelve patients, all treated by STT arthrodesis, were reviewed with an average follow-up of 60 months. Pain was classified according to Alnot's classification: eight patients were classified as grade III, two as grade IV and two as grade II. The average preoperative range of motion of the wrist was 51 degrees for flexion, 39 degrees for extension, 9 degrees for radial deviation and 28 degrees for ulnar deviation. Grip strength was compared to the contralateral side. Radiographic changes were classified according to Crosby's classification, including sublevels for carpal instability. Four wrists were classified 2a and nine wrists were classified 2b. The average radio-lunate and scapho-lunate angles were 14 and 45 degrees respectively. Pain was improved in all patients (P = 0.05) all of whom were subjectively satisfied. Strength and range-of-motion did not statistically decrease after STT arthrodesis except for wrist extension (P = 0.03). Radio-lunate and scapho-lunate angles were unchanged in five patients and improved in five patients. There were four non-unions of whom two patients without pain were not re-operated. The other two were re-operated with the same technique leading to fusion. Scapho-trapezio-trapezoid arthrodesis is an efficient procedure for STT osteoarthritis with regard to pain reduction. Strength and global range-of-motion are not modified by this procedure. Moreover, as it limits carpal instability, this procedure is preferable in active patients.

[A new cause for iatrogenic lesion of the ulnar nerve at the arm: contraceptive hormonal implant. Report of two cases]

The authors describe two cases of iatrogenic lesions of the ulnar nerve at the arm level after insertion of contraceptive hormonal implants. The presence of only a thin subcutaneous fat layer on the medial side of the arm in slim women, exposes the ulnar nerve to danger during the insertion or withdrawal of the implant. We therefore advise the insertion of such implants on the medial side of the thigh in slim women. We equally recommend that withdrawal of non-tangible devices implanted on the medial side of the arm or in case of neurologic symptoms, even transitory, be done by a trained microsurgeon.

[Neonatal Volkmann's compartment syndrome. A report of two cases]

Neonatal Volkmann's compartment syndrome is a rare entity. This diagnosis may be suspected when a case presents cutaneous damage associated with poor hand and wrist function after delivery. We present two such cases of neonatal Volkmann compartment syndrome with long term clinical and x-ray follow-up. In our patients, a hand surgeon was not consulted in the perinatal period and early fasciotomy was not performed. No particular aetiology or associated cerebrovascular accident was found. A series of operations was necessary in order to improve function of the hand. Neonatal Volkmann compartment syndrome must be recognised early in order to enable further investigation of any underlying condition and to perform early surgical decompression. Long term clinical and x-ray follow-up is necessary to prevent and treat wrist deformation and finger contractures.

Rotations of three-joint fingers: a radiological study

The aim of the current study was to test a protocol of quantification of phalangeal three-dimensional (3D) rotations during flexion of three-joint digits. Three-dimensional-specific software was developed to analyze CT reconstruction images. A protocol was carried out with six fresh-frozen upper limbs from human cadavers free from any visible pathology (three females, three males). CT millimetric slices were done for reconstruction of hand bone units. Orthonormal coordinate systems of inertia were calculated for each unit. Three-dimensional phalangeal rotations were estimated between two static positions (fingers in extension and in a fist position). Results were displayed for the joints of each three-joint finger with calculation of 3D rotations. Mean longitudinal axial rotations of metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints ranged from 14 degrees pronation to 19 degrees supination. The index finger was in a global pronation position (4/6 specimens). The fourth and fifth fingers were in a global supination position in every case. The third finger was in a more variable global rotation (pronation in 2/6 specimens). MCP, PIP and DIP flexion angles ranged respectively from 71 degrees to 89 degrees, 65 degrees to 87 degrees, and 41degrees to 77 degrees. Lateral angles ranged from 19 degrees (ulnar angulation) to 23 degrees (radial angulation). The study of phalangeal rotations was possible in spite of a heavy protocol. This protocol could be partially automatated to speed up the analyses. Longitudinal axial rotations could be analyzed, in addition to flexion/extension or abduction/adduction rotations. CT scan reconstructions would be helpful for investigating pathological fingers. Abnormal rotations of digits could be quantified more precisely than during a current clinical examination of the hand.

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

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

Chronic compartment syndrome of the forearm in competitive motor cyclists: a report of two cases

Exertional compartment syndrome of the forearm is rare. However, it should be considered in cases of a painful forearm during motorcycle racing. Pressure measurements of all compartments during exercises that simulate the actions of racing confirm the diagnosis. An exertional electromyography may be useful to reveal a nerve compression associated with the compartment syndrome. Fasciotomy of the affected compartments allows relief of symptoms and return to previous activities in all cases.

Tumeurs desmoïdes et plexus brachial

The aim of our paper is to assess the functional results and specific difficulties encountered in the treatment of desmoid tumors located near the brachial plexus. Seven patients with a desmoid tumor in this region were followed for at least 2 years (average 59 months). All patients were managed operatively. The resection was marginal in 6 patients and intralesional in one. Three patient had postoperatively chemotherapy and 1 patient had radiation therapy. At review, none of the 7 patients had had to undergo upper limb amputation and the mean functional results were good or excellent in 6 patients (mean MSTS = 72.8). The margins of desmoid tumor resection have to be wide to avoid local recurrence. However, nerves and blood vessels have to be preserved in order to maintain upper limb function and there may well be a need for adjuvant therapy.

[Venous drainage in retrograde pedicle flaps: experimental study in rats]

This study was performed to investigate the venous drainage in reverse island groin flaps in a rat model. Two groups of 10 rats were studied. All rats of group A had a groin reverse flap with a complete pedicle (artery and venae comitantes). In rats of group B, an arterial groin reverse flap (artery without venae comitantes) was performed. For the two groups, the perivascular tissue was excised. Nine flaps in the group A and seven flaps in the group B, survived without partial or complete necrosis. Microscopic examination showed venous dilatation in the two groups. There was no significant difference between the two groups. These results confirm that venous drainage of the arterial reverse flow flap without venae comitantes is performed by venae arteriosa. However, venae comitantes probably ensure venous drainage when they are respected.

[Surgical decompression of cervical arthrotic myelopathies: comparison of surgical anterior and posterior approaches]

PURPOSE OF THE STUDY

Operative treatment of cervical myelopathy has focused on decompression of the spinal cord to avoid neurological deterioration. Anterior or posterior operative techniques have been used to decompress the canal with variable success. The purpose of this study was to compare surgical results after subtotal corporectomy or discectomy with an anterior approach and laminectomy or laminoplasty with a posterior approach.

MATERIAL AND METHODS

We reviewed 30 patients with cervical spondylolitic myelopathy who had undergone surgery between 1989 and 1998. Mean age was 55.8 years (range 28 to 82). There were 23 men and 7 women. An anterior approach was used for 14 patients to achieve subtotal corporectomy or anterior discectomy with strut grafting. A posterior approach was used in another 14 patients to achieve laminectomy or laminoplasty. Both anterior and posterior approaches were used for two patients. The severity of the pre- and postoperative neurological deficits was assessed with the Nurick scale.

RESULTS

Average follow-up was 35.7 months (range 8 to 120). Neurological status improved in 83% of the patients. Improvement was better for those operated with the anterior approach for pain or brachialgia. The duration of the posterior procedures was, however, shorter with less blood loss. There was no statistical difference between the anterior or posterior approaches for motor function, sensory function, gait anomalies, or complications.

CONCLUSION

Surgical treatment is effective in cervical spondylolitic myelopathy. The anterior approach is preferred in case of pain or brachialgia; the posterior approach is indicated in case of poor health status or for bedridden patients.

[The superolateral approach for shoulder prosthesis]

We describe a superolateral approach to the shoulder for implantation of total shoulder prostheses or humeral prostheses. The advantages of this approach include preservation of the supraspinatus tendon and an excellent exposure of the posterior part of the glenoid cavity. We illustrate this approach with three clinical examples: total shoulder arthroplasty with reconstruction of the posterior part of the glenoid using a screwed autograft for central degeneration with posterior wear of the glenoid, intermediate arthroplasty for excentric degeneration with irreparable rotator cuff tears, and simple humeral arthroplasty with bone suture of the tuberosities for cephalotuberosity fracture.

Exertion induced rhabdomyolysis of the long head of the triceps

The case is reported of bilateral rhabdomyolysis of the long head of the triceps following intensive exercise in a 30 year old male weightlifter. The diagnosis was based on myalgias localised to one muscle and raised levels of muscle enzymes. Magnetic resonance imaging helped to locate the site and extent of muscular involvement. Treatment consisted of complete rest and adequate intravenous perfusion to allow clearance of the clinical and biological abnormalities and prevent renal involvement.

[The posterior interosseous flap in the child: 13 case reports]

INTRODUCTION

The posterior interosseous flap is used to cover skin defects in the hand, wrist, forearm and elbow. It is currently, commonly indicated for adults, but it may be used for child too.

MATERIALS AND METHOD

Twelve children underwent a posterior interosseus flap (13 flaps). Their ages ranged from 3 to 17.5 years with a mean of 6.5 years. There were seven boys and five girls. The flaps were used to treat different type of lesions: the most frequent etiology was burn injuries or sequels (nine patients), there were one extravasation of anticarcinogenic agent, one syndactyly and one arthrogryposis. The localizations of the skin loss were the first web space (six patients), the dorsal hand (five patients) and the elbow (two patients).

RESULTS

The average of the operation was eighty minutes. The survival of the flaps was excellent. Only one flap had a partial necrosis.

CONCLUSION

Posterior interosseus flap may be used in coverage of children's limb. The diameter of the vessels is not a difficulty in the flap dissection. As the adults, the viability of the flap is excellent and allows to cover most of the skin defect of the dorsal hand or elbow.

The posterolateral portal: A new approach for shoulder arthroscopy

Since the beginning of shoulder arthroscopy, many different approaches were described for Bankart repair to allow visualization and treatment. The anterior portals do not allow access to the posterior and inferior part of the glenoid. We present a new instrumental portal for shoulder arthroscopy. This approach is perfectly safe, without any anatomic risk. It is particularly helpful in the correct treatment of an anterior Bankart lesion, in repairing posterior and inferior extensions of a Bankart lesion, and in performing a plication in multidirectional hyperlaxity.

[Isolated fifth digit localization in Dupuytren's disease]

Isolated fifth digit localisation in Dupuytren's disease has a bad reputation. A series of this injury is reported with a special attention on recurrences. This series is composed of 30 cases in 26 patients (four bilateral cases): the majority of patients were male and 53.5 y was the average age. Extension loss of MP and PIP joints were present in 25 cases, MP isolated extension loss in two cases and PIP in three cases. The treatment performed was a percutaneous needle technique in five cases, surgical fasciectomy in 24 cases using a zigzag palmodigital longitudinal fasciectomy approach in 18 cases, an open palm technique in six cases and one isolated laterodigital flap. Assessment of correction was based on Tubiana's classification. Average follow-up was 22 months. Postoperative course was uneventful except for one case of precarious vascularisation which leads to an amputation. For the digitopalmar localisations: 15 stage 0 or 1, 7 stage 2, 1 stage 3 and 1 stage 4. Improvement percentage was 0.60 in combined cases, 0.65 in cases with a MP loss and 0.46 in PIP loss. Five recurrences were noted. Literature on this topic is coherent with the fact that isolated involvement of the fifth digit carry a bad prognosis, mainly due to the high recurrence rate in our series as in other papers. In severe injuries, an imperfect result should be the aim to prevent vasculonervous complications.

Coverage of large skin defects of the pediatric upper extremity

Reconstructive surgery of the locomotion apparatus in children has been built from several surgical advances. It is a specific activity that cannot be detached from all other orthopedic pediatric surgery. The care of problems in a child must be provided with a holistic point of view: It cannot be the addition of different techniques done by different surgeons. Bone morphology has a close relationship with the soft tissues; an injury of the envelope has consequences for growth harmony.

[False popliteal aneurysm after tibial osteotomy: a case report]

A 55-year-old man developed a pseudoaneurysm of the popliteal artery after tibial valgization osteotomy performed for degenerative genu varum. A tourniquet was used for the procedure. A wedge osteotomy was performed two centimeters under the joint line; the correction angle was ten degrees. Immediately after the end of the procedure, the distal pulses disappeared for ten minutes. Doppler exploration of the arterial network did not demonstrate any anomaly. Ten days postoperatively, the patient complained of sudden onset pain in the knee and tension in the popliteal fossa. Arteriography demonstrated a pseudo-aneurysm of the popliteal artery. The lesion caused an interruption of arterial flow and was successfully treated by emergency resection and suture.