Designing a minimally-invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique: a cadaver study

The goal of this study was to develop a minimally-invasive, ultrasound-guided percutaneous flexor tendon sheath lavage technique on cadaver model. Two catheters were inserted using ultrasound guidance at the proximal and distal ends of the tendon sheath in 20 fingers from cadaveric forearms. Percutaneous injection of a saline solution colored with methylene blue resulted in anterograde lavage of the flexor tendon sheath. The technique was successful in 13 out of 20 cases. The proximal catheter was in the correct position in 17 cases and the distal catheter was correctly positioned in 15 cases. The flexor tendons were continuous in all cases and had puncture wounds in 9 cases. Based on our study, this minimally-invasive, ultrasound-guided percutaneous lavage of the flexor tendon sheath was effective in 65% of cases and safe in 100% of cases in the index, middle and ring fingers. If this percutaneous lavage fails, it is always possible to switch to a conventional open technique.

Ultrasound for the diagnosis of pyogenic flexor tenosynovitis

The usefulness of ultrasound for making the diagnosis of pyogenic flexor tenosynovitis (PFTS) has been demonstrated. The primary goal of this study was to show that the diameter of the flexor sheath near the A2 pulley was larger when PFTS was present compared to the healthy contralateral finger. The secondary goal was to determine the reproducibility of these ultrasound measurements. Our series included 20 patients (12 men and 8 women) operated due to PFTS. The average age was 41.7 years old. The average diameter of the digital sheath measured near the A2 pulley on transverse and longitudinal ultrasound sections was 5.01mm (transverse 5mm, longitudinal 5.03mm) on infected fingers, and 4.17mm on healthy contralateral fingers. Reproducibility, as measured by the intraclass coefficient between transverse and longitudinal values, was 0.910 for infected fingers and 0.928 for contralateral fingers, thus was excellent. Our hypothesis was confirmed. A unilateral increase of more than 20% in diameter of the flexor sheath measured in transverse or longitudinal ultrasound sections near the pulley A2 contributes to the surgical indication when a patient presents with PFTS.

Is there a relevance of suction drainage in non-septic wrist surgery?

INTRODUCTION

No rational argument leads to conclude to the benefit or the innocuousness of drainage in non-septic wrist surgery.

HYPOTHESIS

The goal of this study was to validate the hypothesis that for those indications drainage is unnecessary.

MATERIAL AND METHOD

We reviewed 1001 consecutive cases, concerning 885 patients, 58 years old in average.

RESULTS

Out of 1001 procedures, 9 patients were operated on both sides, 145 were operated twice of which 130 for the implantation and then the removal of surgical material. None were reoperated for hematomas. Three patients were initially treated for an osteosynthesis using an anterior plate of distal radius and secondarily reoperated due to sepsis, one of them twice. The material was removed from two patients. The average time of tourniquet for those 3 osteosynthesis was significantly superior (84.33min) to the average time for the 595 other anterior distal radius plates (45.35min).

CONCLUSION

The results of our study show that suction drainage in non-septic wrist surgery is unnecessary.

LEVEL OF EVIDENCE

III descriptive retrospective study.

Treatment of acute perilunate dislocations: ORIF versus proximal row carpectomy

PURPOSE

Some authors have proposed performing proximal row carpectomy (PRC) as the initial treatment for perilunate dislocations.

HYPOTHESIS

The goal of this retrospective study was to compare the results of a cohort of perilunate dislocation cases that were operated by open reduction and internal fixation (ORIF) or by PRC between 2006 and 2011.

METHODS

The cohort consisted of 21 men with a mean age of 33years, who either had an isolated perilunate dislocation (7 cases) or a fracture-dislocation (14 cases). All dislocations were dorsal, with 10 stage I and 12 stage II. Thirteen patients had been treated by ORIF (group 1) a mean of 1.2days after the injury. Eight patients had been treated by PRC (group 2) a mean of 18.7days after the injury. Immobilization time was 6-12weeks in group 1 and 2weeks in group 2.

RESULTS

The mean operative time was 95minutes in group 1 and 65minutes in group 2. After a mean follow-up of 35months, the following outcomes were found for groups 1 and 2, respectively: pain 3/10 and 1/10, strength 77% and 73%, strength in supination 79% and 93%, strength in pronation 67% and 95%, QuickDASH 27/100 and 16/100, PRWE 43/150 and 15.5/150, flexion 69% and 57%, extension 84% and 58%, pronation 97% and 103%, supination 98% and 97%. There were four cases of osteoarthritis in both groups.

CONCLUSION

Treatment of acute perilunate dislocations by PRC leads to medium-term results that are at least as good as those with ORIF treatment. The surgery duration is shorter with PRC, as is the immobilization period.

TYPE OF STUDY

Retrospective comparative.

LEVEL OF EVIDENCE

III.

Results of conservative treatment of volar plate sprains of the proximal interphalangeal joint with and without avulsion fracture

The prognosis of isolated volar plate sprains of the proximal interphalangeal (PIP) joint is related to the extension deficit. Some consider an associated avulsion fracture as a sign of severity. The goal of this study was to find out whether the outcomes of conservative treatment in PIP volar plate injury was impacted by the presence of an avulsion fracture. Our series included 75 patients, 27 years old on average, of which 58 were men. All sprains were stable. The X-rays were normal in 52 cases (group 1); an avulsion fracture was found in 23 cases (group 2). The patients were treated by buddy taping during the day and a straight finger splint at night for 3 weeks. At the last follow-up, no significant difference was found between the two groups regarding pain, extension/flexion range of motion or edema. The results of this study show that the prognosis of conservative treatment of PIP volar plate injuries does not depend on the presence of an avulsion fracture.

Establishing a reproducible protocol for measuring index active extension strength

The goal of this study was to establish a reproducible protocol to measure active extension strength in the index finger. The secondary objectives consisted in correlating the independent or associated index extension strength to the other fingers force of contraction of the extensor indicis propius with hand dominance. The population studied consisted of 24 healthy volunteers, including 19 women and 20 right-handed individuals. The independent and dependent index extension strength in each hand was measured three times with a dynamometer by three examiners at Day 0 and again at Day 7. Intra and inter-examiner reproducibility were, respectively, >0.90 and >0.75 in all cases. The independent extension strength was lower than the dependent one. There was no difference between the independent index extension strength on the dominant and non-dominant sides. The same was true for the dependent strength. Our results show that our protocol is reproducible in measuring independent and dependent index extension strength. Dominance did not come into account.

LEVEL OF EVIDENCE

II.

Proximodistal interphalangeal arthrodesis of the little finger: A series of 7 cases

As an alternative to amputation of the little finger, we report here seven cases of shortening arthrodesis carried out by resecting the middle phalanx and proximodistal interphalangeal (PDIP) arthrodesis. Our cohort consisted of 6 males and 1 female (58years average age), with a stiff little finger secondary to Dupuytren's disease or trauma. All fingers were approached dorsally; after resection of the middle phalanx and decortication of the subchondral bone, fusion of the remaining phalanges was performed using an intramedullary self-breaking screw-pin. At a mean follow-up of 34.9months, pain decreased significantly (1.4/10 versus 5.4/100 preoperatively), the QuickDASH score improved significantly (33/100 versus 51/100 preoperatively) and all the joints had fused. One patient suffered from cold intolerance. PDIP arthrodesis is an alternative salvage procedure to amputation for multioperated stiff little fingers that does not burn any bridges if it fails.