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Anatomical variations in the distal insertion of the abductor pollicis longus (APL) muscle onto the 1st metacarpal bone and around the 1st carpometacarpal joint led Eduardo Zancolli to introduce a surgical yet conservative partial APL tenotomy targeting its accessory or supernumerary distal bundles. Following an anatomical and pathophysiological review, we will describe the surgical technique for this minimally invasive extra-capsular procedure. Results and operative indications of this very simple technique are reported as well, which can be performed in Dell stage I or II of trapeziometacarpal osteoarthritis when well-conducted conservative medical treatment has failed to achieve pain relief., (Copyright © 2020 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Carpal tunnel syndrome may occur in women with ipsilateral lymphedema after breast cancer treatment. Surgery on the lymphedematous arm is classically feared. Thirty-two consecutive women (mean age at cancer treatment 49 years, interquartile range (Q1;Q3) 43;56) with upper limb lymphedema after breast cancer treatment, followed in a single lymphology unit, and symptomatic carpal tunnel syndrome (electromyographically confirmed) requiring surgery were included. Lymphedema volume was calculated using the truncated cone formula, recorded before and after carpal tunnel syndrome surgery, and at each follow-up visit. Median time to lymphedema onset after cancer treatment was 19 (interquartile range (Q1;Q3) 5;73) months. Median lymphedema volume was 497 (Q1;Q3 355;793) mL before (median 4 months) and 582 (Q1;Q3 388;930) mL after carpal tunnel syndrome surgery (median 5 months) (P = 0.004). At the last follow-up post-carpal tunnel syndrome surgery (median 33 months), lymphedema volume was 447 (Q1;Q3 260;733) mL (non-significant, compared to pre-surgery volume). Regular lymphedema treatment included elastic sleeve (n = 31), low-stretch bandage (n = 20), and/or manual lymph drainage (n = 20), with no change before and after carpal tunnel syndrome surgery. All carpal tunnel syndrome clinical manifestations disappeared after surgery and none of the patients experienced local complications. Carpal tunnel syndrome may be treated surgically in women with ipsilateral upper limb lymphedema after breast cancer treatment. Although lymphedema volume increased transiently, it remained stable over long-term follow-up, with no local complications.

We report our experience with patients who underwent surgery for entrapment neuropathies involving the ulnar nerve at the wrist and into the hand and the peroneal nerve. For the ulnar nerve, the cause of the lesion was identified in all patients, generally a cyst which had developed in the Guyon canal. The patients usually recovered completely. For the peroneal nerve, there was a wide variety of causes, with mucoid cysts frequently involved. Recovery was often incomplete, because of the very marked initial axonal damage. We emphasized the need for rapid diagnosis and surgical treatment.

Objectives: Secondary upper lymphedema occurs in 15 to 20% of patients after breast cancer treatment. Surgery may be required on lymphedematous limb. The aim of our study was to analyze the effects of surgery on lymphedema volume., Methods: Nine women with upper limb lymphedema after breast cancer treatment were recruited. Mean age at time of breast cancer was 45.6 +/- 8 years. Breast cancer was localized at right side and was treated with mammectomy (n=4), radiotherapy (n=8), chemotherapy (n=4) and antiestrogen (n=5). Mean duration of lymphedema before upper limb surgery was 10 years. Six patients reported one or more previous cellulitis. Surgery was indicated for carpal tunnel syndrome (n=6), forearm (n=2) or humeral (n=1) fracture. Lymphedema volume, calculated by the difference of volume between the lymphedematous and the contralateral arm, was compared before and after surgery., Results: Six patients had carpal tunnel release by transecting the transverse carpal ligament under local anesthesia with short total time tourniquet. Humeral and forearm fractures were treated with osteosynthesis. Before surgery, lymphedema volume of upper limb was 747 +/- 315 ml. Lymphedema management included low stretch bandages, elastic sleeve, manual lymph drainage. After 8 months follow up, lymphedema volume was significantly higher, 858 +/- 293 ml (p=0.012). Mean absolute variation of lymphedema volume was 111 ml (CI 95%: 32 to 109 ml), i.e. 15% of pre surgery lymphedema volume., Conclusion: Surgery of carpal tunnel syndrome or osteosynthesis for fractures may lead to increased lymphedema volume in patients previously treated for breast cancer despite compressive therapy.

Acute mallet fingers are commonly treated by splinting. Treatment of chronic injuries is more debated. Since 1989, a "shortening and suture" technique have been used for such chronic injuries on the elongated tendon scar. Sixty six of 77 patients treated on a 10 years period were reviewed with a mean follow-up of 21 months. The mean active extension lag at the distal interphalangeal (DIP) joint was 4.5 degrees (41 degrees of improvement) with 52% of fingers which recovered a full extension, representing 77% of good and excellent results according to Abouna's and Brown's modified criteria. There were two failures which lead to reoperation, and no complication (2 painful scars and 20% of cold intolerance). We propose this safe and simple technique for chronic mallet fingers if deformity exceeds 30 degrees, for patients untreated (after the second month), or when splinting has failed. "Swan-neck" deformities were improved by an associated Fowler procedure. In case of failure, a new "shortening and suture" or a DIP arthrodesis can be discussed.

Traumatic dislocation of the pisiform bone is uncommon. The authors report a case treated by primary excision with a good result. The literature is reviewed and treatment choices are discussed.

In this study, the case has been examined of a 49-year old male who initially presented with a pathological fracture of the second metacarpal. This was first treated by curettage, iliac bone graft and internal fixation, without any complementary investigation being carried out, i.e., no preliminary biopsy and histological diagnosis were made. The results of this inadequate approach were poor: neither satisfactory fixation of the fracture nor control of the primary lesion were obtained. Moreover, the definitive diagnosis was only made four months later, when biopsy findings confirmed the presence of an osteosarcoma. After neoadjuvant chemotherapy, an en-bloc resection of the second metatarsal and the trapezoid bone was carried out. At ten months post-surgery, one and a half years after the original fracture, the hand was found to be disease-free and functioning satisfactory. However, nearly a year later the discovery of a large tumor mass at the site where the iliac bone graft was originally taken necessitated resection of the hemi-pelvis, with chemotherapy prior to resection and radiotherapy following surgery. Unfortunately, this salvage procedure did not limit the spread of the disease, and subsequent pulmonary and vertebral metastases were found, leading to the death of the patient three years after the initial fracture. This particular case underlines the fact that the basic rules for the management of malignant tumors should be taken into consideration from the onset, so that a catastrophic prognosis such as that described can be avoided.

After revealing tendon healing and the international classification adopted in 1980 for flexor tendon lesions, the author reviews the primary tendon repair procedures and the various postoperative mobilization protocols. The current tendency is towards early active mobilization with a protection orthosis. The various secondary surgical procedures are then critically discussed: secondary suture, tendon release, one-stage or two-stage tendon graft, total anterior tenoarthrolysis, tendon transfer, vascularized tendon graft, active tendon implants.

The authors review a series of 76 patients with 95 fingers involved, 66.6% of them occurring in zone II. The core stitch was performed according to the Tsuge technique (type II) combined with a peritendinous running suture. Results based on TAM were excellent or good in 60%, fair in 22%, and poor in 18%. Influencing factors were associated lesions, mainly vascular and lesions in zone II. Rupture occurred in 5% and adhesion in 22% of cases. Providing similar results to those of other techniques published in the current literature, the Tsuge techniques is preferred because it is simpler and faster to perform.

Despite the high incidence of wrist trauma, severe sprains with disruption of the ligaments are actually rare, apart from lesions of the scapholunate joint line. However, the diagnosis of severity should now be established, if not as an emergency, at least soon after the trauma, as deterioration of carpal instability always leads top osteoarthritis after a variable interval of time. When a ligament lesion is suspected, initial pain-free immobilisation, plain and dynamic x-rays followed by at least arthrography of CT arthrography, should be performed. After describing scapholunate sprain, the commonest form, the other varieties are reviewed: pyramidolunate, midcarpal, scaphotrapezoid, radiocarpal and finally inferior radioulnar sprains.

High pressure injection injuries of the hand are rare, but very severe. The material injected acts in two ways: chemical irritation as a result of its toxicity, and physical distension of tissues of the finger, which are not normally distensible, as a result of the pressure of injection of the liquid which may reach 700 kg/cm2. The main complications were necrosis and infection ending in amputation in thirty percent of the cases. Often the conserved fingers suffered cold intolerance. Therefore, the gravity of this accident has led us to believe that it is the "most urgent of hand emergencies".

The glomus tumors of the finger tip are benign. Their diagnosis is clinic but their precise localization is quite difficult by classic imaging. MRI with gadolinium injection seemed a good method to check exactly this lesion and have been tested on 20 patients suspected suffering of glomus tumor. On 18 glomus tumors surgically and histologically confirmed MRI examination have been positive for 16. In two cases MRI and surgery were negative. A good correlation seems observed with surgery for the size (7 tumor of 2 mm) the localization and osseus extension. Addition of T2 and T1 before and after injection weighted acquisitions improved the results. Precise informations on topography and size seems improved the surgical approach.

We report our experience of the use of a scalar type incision associated with a total skin graft in the treatment of recurrences of Dupuytren's contracture. This is not an original technique, but one described by Hueston in 1984, which consists of a "Fire Break" skin graft after a simple transverse incision of recurrent Dupuytren's contracture. We attribute the absence of recurrence with this graft to the impossibility of the disease to affect the thin tissue between the skin graft and the underlying tendons. Our series is composed of 25 patients, all male. The majority of these patients had undergone surgery on a single occasion before treatment of recurrences with an average time interval of seven years. In a great majority of cases the little finger was deformed and generally severely (stage III or IV). All of our patients were reviewed with a mean follow-up of 28 months after surgery, and we did not observe any recurrences under the graft. In this series, which remains too small and too recent, 67% of cases presented an acceptable result with nearly complete extension and satisfactory grasp. We do not apply this technique to the treatment of all cases of recurrent Dupuytren's contracture, but we reserve it preferentially for elderly patients, operated on several occasions for ulnar fingers especially the little finger, in digital or digito-palmar forms in which the deformity predominates on the proximal interphalangeal joint with marked digital infiltration.

Dislocation of the extensor tendon over the MP joint as a result of trauma is a rare and unrecognized injury as our six patients were only operated subsequently. The diagnosis is simple: flexion is possible, while extension is not. The patient is able to hold the extension despie resistance if the dislocation is reduced by artificial extension. X-rays eliminate any possible fracture. Six cases have revealed two different assumptions: either the two tendons (extensor digitorum communis and extensor digiti quinti proprius) are simultaneously dislocated together on the ulnar side, or they are dislocated on either sides of the joint. In the first assumption, the injury occurred ulnar-wise tearing the sagittal band. This case concerns the three older patients. The dislocation was reduced and stabilized by the Michon surgery method. The second assumption concerns the three youngest patients who suffered from a direct axial shock. This separation was reduced by suture of the two tendons on the dorsal base of the joint. The postoperative care was ensured in all cases by a splint attached to the palm, keeping the MP joint in extension and enabling immediate web-fingered reeducation. This therapeutic technique has given satisfactory results as over an average period of six years no recurrence of stiffness has been observed.

Synovectomy of twenty-three elbows was done in eighteen patients, eight to twenty-five years old, who had severe hemophilia and were followed for eighteen to seventy months. Episodes of bleeding recurred in four elbows, and moderate pain persisted in three. A significant improvement in mobility was observed for pronation-supination in nine elbows and for flexion-extension in fourteen. No radiographic evidence of arthritis was seen. Synovectomy of the elbow, performed through a single lateral incision, appears to be a valuable surgical procedure in hemophiliacs in whom non-operative treatment has failed, and resection of the radial head should be done in adults when there is moderate or severe damage to the cartilage of the radial head.

The accuracy of high-resolution real-time ultrasonic examination of the flexor tendons of the fingers was tested in a retrospective study of 27 patients treated surgically. In ruptured tendons (8 cases) the method proved sensitive and specific, except in cases of partial rupture. Ultrasound made it possible to distinguish between extrinsically developed palmar masses (8 cases) and masses involving the tendons (4 cases). A fluid collection inside the tendon sheath was detected in 5 cases of tenosynovitis, without false-positive results. The post-operative follow-up of surgically treated tendons (2 cases) was easier with ultrasound.

Thirty patients underwent a sonographic examination of the hand because of nodular masses. In 12 out of these, the surgical removal exhibited 5 benign tumors (2 giant cell tumors, 1 angioma, 1 lipoma, 1 myoma), 5 pseudo-tumors (1 granulomatous tenosynovitis, 1 nodular tendinitis, 2 sebaceous cysts, 1 synovial cyst) and 2 congenital abnormalities of the lumbrical muscles. Except the lipoma and the nodular tendinitis, all the masses were hypoechoic or anechoic. The major interest of sonography in such a disease is a precise localization of the mass and the description of its connections with the surrounding anatomical structures.

Based on the study of a homogeneous series of twenty-eight isolated median nerve injuries at the wrist, sutured as an emergency procedure, the authors determined the course and sequelae of this type of nerve lesion with no associated tendon involvement. Repair was associated with epi-perineural suture performed with an operating microscope, immobilisation in slight flexion of the wrist for three weeks and rehabilitation of sensation. 60.7% of patients obtained a good or very good results with better motor recovery than sensory recovery. Nerve contusion, loss of nerve substance with suture under tension and work accidents were factors of poor prognosis.

Seemingly spontaneous subcutaneous ruptures of the flexor tendons of the hand are not frequently encountered. The case studied is that of a young man whose deep flexor tendon of the third finger snapped during a slight effort. The histological and immunohistochemical analysis led to the conclusion that there was localization of an intra-tendinous neurofibroma, which would seem to be a so-far undescribed phenomenon. The patient presented neurofibromas elsewhere and had pigmented spots on the body, which enabled Von Recklinghausen's disease to be diagnosed.

Ultrasound enables a worthwhile static and dynamic study of the soft tissues of the hand, provided that a high-resolution real-time is used. Accurate examinations are feasible after a several months of training because of the difficulty of the anatomy. The authors, studying 200 normal hands, describe their technique based upon the use of a 7.5 MHz multifocused linear phased-array real-time transducer and the normal ultrasonic anatomy.

The consequences of the division of the pulley of the flexor hallucis longus are described. This division may be necessary for the repair of tendon or in the treatment of trigger thumb. After division, the pulley cannot be sutured and the flexor tendon remains displaced anteriorly. The authors describe a technique of repair using a flap detached from the tendon of the adductor pollicis. 6 cases have been operated on with good results.

The authors report their experience in dealing with 43 cases of secondary surgery on the flexor pollicis longus tendon between 1970 and 1982. After an anatomical and biomechanical survey, the results of the different techniques used are analyzed: tenolysis (12 cases). tenodesis (one case), one- (3 cases) or two-stage (4 cases) grafts, flexor digitorum superficialis (FDS) transfer (11 cases) and secondary sutures (12 cases). The overall outcome was very disappointing, with 50 per cent poor results. Compared with the other techniques, secondary suture fared best, and it can be combined, if need be, with tendon lengthening at the wrist and metacarpo-phalangeal pulley reconstruction. Considering these results, therapeutic indications are proposed. The functional requirements of the patient may lead to prefer simple interphalangeal fusion to any dynamic method.

The accuracy of the high-resolution real-time ultrasonic examination of the flexor tendons of the fingers of the hand has been tested on the retrospective study of 27 patients treated surgically. The method is sensitive and specific in the rupture of the tendons (8 cases), except when the latter is partial. Ultrasound enables the discrimination between palmar masses developed extrinsically (8 cases) and those involving the tendons (4 cases). A fluid collection inside the tendon's sheath has been detected in all the 5 cases of tenosynovitis, without false positive. The post-operative follow-up of operated tendons is easier by ultrasound.

Two cases were seen in elderly patients in which a carpal tunnel syndrome was present in association with an ununited scaphoid fracture. The carpus had remodelled and the lunate was dorsi-flexed. Its upper end bulged into the tunnel and was the cause of the nerve compression. It was aggravated by associated osteoarthrosis. The two cases were treated surgically by neurolysis and division of the carpal ligament and partial resection of the lunate to restore the normal concavity of the carpus.