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This magnetic resonance imaging study examined the most frequent anatomical variants of the anterior communicating artery (ACoA) complex of the cerebral arterial circle, and aimed to determine whether they were associated with ACoA complex aneurysm. The study enrolled 669 patients. Using three-dimensional time-of-flight magnetic resonance angiography, 617 patients were classified into the following groups based on the anatomical variation in the ACoA complex: no ACoA complex anomaly; ACoA complex aneurysm; and vascular anomaly distant from the cerebral arterial circle. Of the 617 classified subjects, the classical anatomical description applied to 48.73% in the no ACoA complex anomaly group and 37.5% in the ACoA complex aneurysm group. One variant (left anterior cerebral artery segment A1 hypoplasia) was significantly more frequent in the ACoA complex aneurysm group. There was no sex difference in the prevalence of any variant. Anatomical variants of the ACoA complex of the cerebral arterial circle were found in almost half of the subjects. One variant seemed to be associated with a higher likelihood of an aneurysm, but causality could not be inferred.

Introduction Large cutaneous defects exposing the whole tibial crest are difficult to cover and are conventionally best treated with free flaps. This article describes a technical modification of the adipofascial flap in this indication. Methods The “flip-flap” is vascularized by the posterior tibial artery perforators harvested on the medial aspect of the leg. The hypodermal and fascial tissue is de-epidermized and elevated from the posterior midline up to the medial edge of the soleus muscle, then folded over the exposed tibial crest like a page of a book. Results A 27 × 6 cm effect was successfully covered on a 72 year-old patient with vascular status precluding free flap. The flap healed by day 21. Discussion/conclusion This technical modification is simple and allows coverage of large tibial crest skin defect when a free flap is not possible.

Introduction When treating comminuted radial head fractures that cannot be adequately fixed, the next option is arthroplasty (radial head replacement). We hypothesized that the radiological and functional outcomes of bipolar mobile cup radial head arthroplasty is not influenced by the length of follow-up but instead by the correct positioning of the implant intraoperatively and by the presence of associated bone or ligament injuries. Patients and methods Between May 1998 and December 2016, 82 cases of radial head arthroplasty were performed at our hospital. The mean age of patients at the time of arthroplasty was 53 years (22–81). Ligament or bone injuries complicated the radial head fractures in 70% of patients. Results For the final assessment, 41 patients were reviewed and included in the statistical analysis with a mean of 82 months (12–228). The mean MEPS at the final assessment was 88.7 (61–100). There were 23 excellent, 9 good, 9 average and 0 poor results. The average DASH score was 18.7 (0–55). The average VAS for pain was 1.0 (0–5). Five patients (12%) required surgical revision, including one implant change. Our statistical analysis found no relationship between follow-up time and functional outcomes. The appearance of periprosthetic radiolucent lines was not affected by the length of follow-up. Associated bone or ligament injuries significantly increased the probability of periprosthetic radiolucent lines, humeroulnar joint degeneration and decentering of the implanted cup. Radiological evidence of a suspended implant was associated with significantly worse functional outcomes. Conclusion This study confirms the long-term stability of the clinical outcomes of radial head arthroplasty. There was no relationship between worsening radiological appearance of the implant and the clinical outcomes. It is critical that this implant not be oversized or suspended, as this can trigger premature capitellar erosion and painful stiffness of the operated elbow. Level of evidence IV; systematic retrospective analysis.

Hip fracture is a frequent and serious condition in the elderly. We conducted a retrospective cohort study to answer the following questions: (1) Could treatment in an orthogeriatric unit help to reduce the average length of stay for patients aged over 75 years admitted to hospital for the treatment of a hip fracture?; and (2) Could such treatment influence the post-operative outcomes of patients with hip fracture? Our study included 534 patients admitted to hospital between January 2017 and December 2018 for surgical treatment of a hip fracture. We compared 246 patients who received traditional orthopaedic care with 288 patients treated in an orthogeriatric unit. Our cohort included 410 women (77%). The average age was 87.5 ± six years, and 366 patients (68%) were living at home prior to the fracture. A statistically significant difference in median length of stay (from 10 to 9 days) was observed between patients who did and did not receive orthogeriatric unit treatment (groups 1 and 2; 95% CI: 0.64; 2.59; p = 0.001). There was no difference in pre-operative delay, intra-hospital mortality rate, place of recovery, rate of institutionalisation after six months, or the number of new fractures at 6 months between the groups. The mortality rate after six months was 23.6% and 21.3% in groups 1 and 2, respectively; the difference was not significant. Orthogeriatric unit treatment reduced the median length of stay by one day, in line with most previous studies. According to Pablos-Hernandez et al., multifaceted orthogeriatric treatment is most effective. In our study, only 38% of the patients received surgical treatment within 48 hours, where early surgery is key for reducing the length of hospital stay. The intrahospital mortality rate was 2.6%, which is comparable to literature data. The discharge rate did not differ by orthogeriatric treatment status, which is also consistent with previous findings (e.g. Gregersen et al.). Lastly, the mortality rate after six months was slightly reduced by orthogeriatric care. In line with this, Boddaert et al. reported a difference in mortality rate after six months between groups who did and did not receive orthogeriatric treatment (15% vs. 24%).

Introduction Cartilage repair usually involves in non-vascularized osteochondral or chondral grafts with some drawbacks potentially linked to the lack of vascular supply in those grafts. The aim of this study was to describe a surgical approach for harvesting a vascularized chondrocostal graft, to study the vascular supply to the perichondrium and finally to describe the perichondrium micro-vascularization in order to know how such grafts could be used in cartilage repair surgery. Materials and methods We harvested and studied 18 costal cartilages harvested from 12 fresh anatomical subjects. The anatomic pieces were injected with a radio-opaque tracer, analyzed macroscopically, then a plain X-rays and CT scan analysis with three-dimensional rendering was performed in order to evaluate the characteristics of the different patterns of their vascularization. Results The surgical approach to harvest a vascularized 5th chondrocostal graft is explained in detail. All of the cartilages were vascularized by the internal thoracic artery and harvested with a pedicle of an average length of 34 mm and diameter of 2.14 mm. In all specimens, perichondrium vascularization arises from both superior and inferior intercostal branches. Anastomoses between inferior and superior intercostal branches are always found in all specimens at the level of the epichondrium. Conclusions The anatomic approach for harvesting a vascularized chondrocostal graft is simple and only slightly differs from the approach described for harvesting a non-vascularized chondrocostal graft. The vascular supply to the perichondrium of such a vascularized chondrocostal graft is sustained by the internal thoracic vessels which have a sufficient diameter and length to allow easy micro-anastomosis. The organization of the micro-vasculature within the perichondrium allows the graft to be tailored to a large cartilage defects and also to small bipolar cartilage defects.

Approximately 80% of patients are satisfied with the outcome of arthrodesis of the hallux metatarsophalangeal (MTP) joint. The hypothesis of this study was that MTP arthrodesis does not influence the walking cycle. The aim of this study was to evaluate the effect of MTP arthrodesis on gait cycle and to measure the functional outcome of MTP arthrodesis after a minimum of two year follow-up. This was an observational prospective cohort study performed at a single centre that included 26 patients (32 ft) who underwent unilateral or bilateral MTP arthrodesis during the period 2004–2014. An X-ray assessment based on the American Orthopaedic Foot and Ankle Society score was performed pre-operatively and at the last follow-up (average follow-up duration 8.3 years). The walking cycle was analysed at the final follow-up using a GAITRite® treadmill test. Twenty unilateral and six bilateral MTP arthrodeses were included in this study. The average age of the patients was 70 years. No significant difference was found in the walking cycle between the operated and non-operated sides for unilaterally MTP arthrodesis. However, we observed a non-significant increase in the percentage of contact time after MTP arthrodesis (65% on the operated side vs. 63% on the non-operated side). We also observed a significant decrease in the average walking rate, and a decrease in walking speed, in cases of bilateral MTP arthrodesis compared with normal walking cycle data from a laboratory study. MTP joint arthrodesis does not appear to have any effect on the walking cycle, but reduced patient pain and increased the walking distance. The patients reported satisfaction with the surgical outcomes and would recommend it to a relative with the same pathology.

The anterior abdominal muscle wall has a strong aesthetic connotation, primarily because of the classical anatomical description of the rectus abdominis muscle in the collective consciousness. However, the morphological reality of the general population considerably deviates from this description. Therefore, we investigated the anthropometric characteristics correlated with the anatomy of the rectus abdominis muscle. We performed a computed tomography scan anatomical study of recti abdominis muscles in 86 patients with no history of abdominal surgery. We noted the transverse and anteroposterior measurements of the rectus abdominis muscle, the transverse measurement of the linea alba, and the cutaneous and muscular abdominal perimeters. We compared these morphological elements with anthropometric data (sex, age, weight, height, and body mass index [BMI]). BMI was positively correlated with cutaneous abdominal perimeter (r = 0.89, p

Resume Introduction La couverture des pertes de substance (PDS) cutanee etendues de la crete tibiale est difficile et conventionnellement traitee par lambeaux libres (LL). Cet article decrit une modification technique du lambeau adipo-fascial dans cette indication. Methodes Il s’agit d’un lambeau vascularise par les perforantes de l’artere tibiale posterieure preleve au depend de la face mediale de jambe. Le tissu hypodermique et fascial est desepidermise et leve de la ligne mediane posterieure jusqu’au bord medial du muscle soleaire puis retourne a 180° sur la PDS a la facon des pages d’un livre. Resultats Le lambeau Flip-Flap a permis la couverture d’une PDS de 27 cm sur 6 cm chez un patient de 72 ans ayant un etat vasculaire incompatible avec la realisation d’un LL. La cicatrisation du lambeau etait acquise a J21. Discussion/conclusion Cette modification technique simple permet la couverture des PDS etendues de la crete tibiale lorsqu’un LL est impossible.

Introduction L’anatomie est une des disciplines fondamentales les plus plebiscitees par les etudiants en medecine. Elle apporte des acquisitions theoriques indispensables a leur pratique clinique ulterieure. Les methodes pedagogiques d’enseignement de l’anatomie ont evoluees avec les moyens technologiques et les problemes ethiques. Nous avons donc voulu evaluer le ressenti des etudiants sur cette evolution et rechercher une influence du contexte socio-culturel. Materiel et methode Nous avons realise une enquete sous la forme d’un questionnaire adresse aux etudiants de 80 universites de medecine de 34 pays differents et de 9 convictions religieuses differentes. Une premiere partie du questionnaire concernait les informations personnelles et professionnelles. Une seconde partie concernait les modalites d’enseignement de l’anatomie. Une troisieme partie concernait les impressions ressenties et les besoins concernant cet enseignement. Resultats Nous avons recueillis 808 reponses (258 hommes, 550 femmes), majoritairement de France et d’Europe. Les cours magistraux dispenses partout a des volumes horaires variables ont une place satisfaisante pour plus de 50 % des etudiants qui souhaitent a plus de 70 % qu’ils demeurent ainsi. Les travaux pratiques sont domines par les dissections pratiquees dans 61 % des facultes (82 % des etudiants). Seulement 8 % des etudiants se disent opposes a la dissection et la majorite evoquent un manque de pertinence pedagogique au moment et dans le mode de leur pratique plutot qu’une raison socio-culturelle. Discussion et conclusion Si l’enseignement de l’anatomie varie selon les universites, les ressentis et les attentes concernant son etude restent homogenes. La volonte globale est la perpetuation des methodes classiques mais avec une orientation de plus en plus tournet vers des applications cliniques [1] et le developpement des methodes utilisant les technologies de simulation [2] .

Introduction L’imagerie medicale est indispensable pour le praticien, mais elle est de comprehension difficile pour le patient qui souhaite visualiser sa pathologie. Le developpement de l’imagerie et des reconstructions en 3 dimensions (3D) ameliore la prise en charge therapeutique. En prenant l’exemple des tumeurs renales, nous avons evalue l’interet de la reconstruction 3D pour la comprehension et l’information des patients. Materiel et methodes Nous avons effectue une modelisation 3D d’une tumeur renale (logiciel OsiriX™) a partir d’images de tomodensitometrie et traite les images pour mettre en evidence la lesion dans son environnement anatomique. Nous avons soumis des sujets sains a un questionnaire evaluant leur interet pour la visualisation d’une lesion tumorale renale. L’imagerie tomodensitometrique en coupe axiale (2D) puis la reconstruction 3D ont ete presentees aux sujets puis nous avons compare leurs impacts pedagogiques dans la comprehension de la pathologie. Resultats Parmi les 263 reponses obtenues, 93,9 % des sujets declarent aimer l’idee de pouvoir visualiser la tumeur s’ils etaient concernes par cette pathologie. La satisfaction de la visualisation de la lesion est de 33,5 % avec une imagerie 2D contre 88,2 % avec une imagerie 3D (p Discussion et conclusion L’interet d’une representation 3D parait evidente et a ete montree dans le cadre de modelisation par impression 3D [1] mais il semble que la simple reconstruction en imagerie 3D montree au patient ameliore sa comprehension et donc son information. Cette pratique peut etre developpee dans de nombreuses specialites.

Background The indications of non-operative treatment of undisplaced femoral neck fractures are controversial. The objective of this study was to assess whether two computed tomography (CT) parameters, the femoral neck impaction angle (IA) and the femoral neck posterior tilt angle (PTA), were effective in predicting the risk of secondary displacement after non-operative treatment of Garden I femoral neck fractures in patients aged 65 years or over. Hypothesis The working hypotheses were that the IA in the coronal plane and PTA in the axial plane predicted secondary displacement after non-operative treatment of Garden I femoral neck fractures, could be reproducibly and reliably measured on CT scans, and could serve to identify Garden I fractures at risk for secondary displacement after non-operative treatment. Methods Forty-nine patients aged 65 years or over with Garden I fractures treated non-operatively were included in a prospective single-centre study. CT images were used to measure the IA as the position of the fracture line relative to the femoral head in the coronal plane and the PTA as the position of the femoral head centre relative to the femoral neck axis in the axial plane. Results After non-operative treatment, secondary displacement occurred in 22 (45%) patients. The PTA was not significantly different between the groups with vs. without secondary displacement (p = 0.62). IA values ≤ 135° were significantly associated with secondary displacement (odds ratio, 11.73; 95% confidence interval [95%CI], 3.04–45.28; p = 0.004). An IA ≤ 135° was 72.73% sensitive and 81.48% specific for predicting secondary displacement. IA measurement was reproducible, with intra-class and inter-class Cohen's kappa values of 0.94 (95%CI, 0.90–0.97) and 0.9011 (95%CI, 0.83–0.94), respectively. Discussion The IA measured on CT images may hold promise for identifying Garden I hip fractures at high risk for secondary displacement after non-operative treatment. IA measurement is reproducible and reliable and may help to determine the indications of non-operative treatment. Level of evidence II, prospective cohort study.

Resume Objectif Preciser les indications du traitement fonctionnel des fractures trans-cervicales Garden 1 de la personne âgee (≥65 ans) a l’aide de la mesure scanographique de l’angle d’impaction du col femoral (ICF) et de l’angle de tilt posterieur du col femoral (TPCF). Methodes Quarante-neuf patients presentant une fracture trans-cervicale Garden 1 ont beneficie d’un scanner pour la mesure de deux angles. L’angle ICF etait defini comme la position relative de la ligne fracturaire avec le centre de la tete femorale dans le plan coronal ; l’angle TPCF etait defini comme la position relative du centre de la tete femorale avec l’axe du col femoral dans le plan axial. Resultats Vingt-deux DS ont ete observes chez 45 % des patients. Il n’existait aucune difference significative en ce qui concerne la valeur de l’angle TPCF entre les groupes DS et non-DS (p = 0,62). Un angle ICF ≤ 135 degres a pu etre considere comme un facteur predictif de DS : OR = 11,73 (IC 95 % [3,04–16] [3,04–45,28] [3,04–45] [3,04–45,28] p = 0,004). Le test de depistage pour les fractures de type Garden 1 a risque de DS utilisant un seuil d’angle ICF de 135° avait obtenu une sensibilite de 72,73 % et une specificite de 81,48 %. La mesure de l’angle ICF est reproductible avec un coefficient respectif intraclasse et interclasse Kappa de 0, 94 (IC 95 % [0,90–0,97]) et 0,9011 (IC 95 % [0,83–0,94]). Discussion — conclusion La mesure de l’angle ICF peut etre utilisee comme test de depistage des fractures trans-cervicales Garden 1 a risque de DS. Ce test est fiable et reproductible et permettrait de preciser les indications du traitement fonctionnel. Niveau de preuve II, cohorte prospective.

Resume Introduction Le syndrome de compression du nerf ulnaire au coude est le deuxieme syndrome de compression nerveuse au membre superieur apres le syndrome du canal carpien. De nombreux auteurs prennent le parti d’exclure les nerfs ulnaires instables en cas de neurolyses endoscopiques. Lors de l’analyse de la litterature, l’instabilite pre- ou peroperatoire ne semble pas influencer de facon defavorable les resultats cliniques. L’objectif de ce travail prospectif etait de preciser les indications et les resultats des neurolyses endoscopiques du nerf ulnaire au coude. Materiel et methodes Il s’agit d’une etude prospective, monocentrique. L’indication operatoire etait posee lorsqu’il existait une symptomatologie clinique de compression du nerf ulnaire au coude confirmee par la realisation d’un electromyogramme. L’instabilite du nerf ulnaire en pre- ou peroperatoire n’etait pas une contre-indication (Childress A). Les patients ont systematiquement ete revus a 12 mois postoperatoire. Resultats Notre analyse statistique porte sur 17 patients. En ce qui concerne le score de Bishop modifie, les resultats etaient excellents et bons dans 88 % des cas avec 4 excellents resultats, 11 bons et 2 moyens. En ce qui concerne l’instabilite preoperatoire du nerf ulnaire, nous n’avons pas observe de difference d’evolution fonctionnelle en fonction de ce caractere. Discussion Dans cette etude, nous avons pris le parti de ne pas exclure les nerfs ulnaires instables type Childress A. Les resultats cliniques de ces patients etaient comparables aux autres patients. Niveau de preuve Therapeutique, IV.

Background Ulnar nerve entrapment at the elbow is the second most common nerve entrapment syndrome at the upper limp, after carpal tunnel syndrome. Many surgeons feel that ulnar nerve instability contra-indicates endoscopic nerve release. Published studies, however, found no evidence that pre-operative or intra-operative ulnar nerve instability adversely affected clinical outcomes. The objective of this prospective study was to define the indications and describe the outcomes of endoscopic ulnar nerve release at the elbow. Hypothesis Endoscopic ulnar nerve release at the elbow is a valid option even in patients with ulnar nerve instability and regardless of the severity of the compression. Material and methods We conducted a prospective single-centre study of patients scheduled for surgery based on clinical and electromyographic manifestations of ulnar nerve entrapment at the elbow. Ulnar nerve instability (incomplete dislocation, i.e., Childress A) before or during surgery was not a contra-indication to the procedure. The patients were re-evaluated 12 months after surgery. Results Seventeen patients were included in the statistical analysis. The modified Bishop's score indicated excellent or good outcomes in 15 (88%) patients (excellent in 4 and good in 11) and a fair outcome in 2 patients. Functional outcomes were not associated with the presence of ulnar nerve instability before surgery. Discussion We elected to include patients with Childress A ulnar nerve instability. Clinical outcomes in these patients were similar to those in patients without ulnar nerve instability. Level of evidence IV, open prospective study of treatment outcomes.

Background In elderly patients, distal radius fractures frequently occur in osteoporotic bone and may be nonreconstructable. It is our hypothesis that a hemiarthroplasty replacment of the articular surface can provide satisfactory results in terms of range of motion, pain, and function for immediate salvage of a fracture that is not amenable to internal fixation. Methods Between July 2009 and January 2012, eight elderly patients were treated with insertion of a Sophia distal radius implant (Biotech, Paris, France). Inclusion criteria consisted of an isolated AO type C2 distal radius fracture in patients over 70 years old. All patients were reviewed by an independent surgeon. Results The mean follow-up was 25 months (range, 17-36 months). Mean wrist range of motion (ROM) was 45° (40-50°) of flexion, 44° (40-50°) of extension, and a mean pronation-supination arc of 160°. Mean grip force was 18 kgf. The mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) was 18.2/100 (6.82-29.55), and the mean visual analog scale (VAS) was 2.33 (0-4). X-ray images did not demonstrate implant loosening or ulnar translation of the carpus. Conclusions The Sophia hemiarthroplasty provided rapid recovery of independence in elderly patients with a nonreconstructable comminuted distal radius fracture.

Les pertes de substances cartilagineuses sont un veritable enjeu therapeutique. Certaines techniques font appel a un resurfacage par greffons chondrocostaux. Le but de cette etude est d’analyser la vascularisation d’un lambeau chondrocostal pour une utilisation en tant que lambeau libre vascularise. Nous avons utilise dans cette etude 6 greffons chondrocostaux preleves sur 4 sujets anatomiques frais au niveau de la cinquieme jonction chondrocostale, pedicules sur l’artere thoracique interne. Nous les avons ensuite prepares par injection de traceur radio-opaque. Nous avons ensuite realise une analyse macroscopique, radiographique et scanographique avec reconstructions afin d’evaluer les caracteristiques du greffon et de son pedicule. Sur les six greffons, cinq ont permis d’apporter des informations sur la vascularisation (echec d’une injection). Les dimensions moyennes etaient de 45 mm de longueur, 24 mm de largeur et 12 mm d’epaisseur, avec une longueur moyenne de portion cartilagineuse de 16 mm. La longueur moyenne du pedicule vasculaire etait de 37 mm, avec une distance moyenne entre le pedicule et la jonction osteo-chondrale de 8 mm. Les greffons comprenaient tous une artere et une veine, avec un diametre moyen de 1,6 mm pour l’artere. Pour tous les greffons, nous avons observe une vascularisation du perichondre costal par l’artere thoracique interne. Cette vascularisation etait, dans tous les cas, distribuee directement via les arteres intercostales superieures et inferieures. Nous avons egalement pu observer un riche reseau anastomotique intercostal aux faces anterieures et posterieures, avec visualisation de communicantes arterielles. Dans tous les cas, une vascularisation du perichondre anterieur etait retrouvee. La vascularisation du perichondre posterieur a ete observee dans quatre cas sur cinq. Dans un cas, la vascularisation perichondrale posterieure provenait directement de l’artere thoracique interne. Le lambeau chondrocostal est un lambeau richement vascularise dont l’utilisation en tant que lambeau libre pedicule pourrait etre interessant pour le resurfacage de pertes de substances cartilagineuses avec une modularite anatomique basee sur les anastomoses vasculaires qui semble interessante pour une adaptation aux differents types de surfaces articulaires, d’autant plus qu’il apporte une quantite de cartilage pouvant pallier a des defets cartilagineux relativement etendus, notamment au membre superieur. Cette vascularisation pourrait etre un atout pour apporter des solutions durables en evitant les modifications histologiques a type de metaplasies osseuses des portions cartilagineuses de ces greffons et ainsi de perenniser l’efficience de ce type de greffes a long terme.

Introduction L’objectif de cette meta-analyse etait d’evaluer les resultats des reparations nerveuses differees et ainsi de determiner un delai maximum preoperatoire de prise en charge chirurgicale. Methodes Sur 2704 articles, nous avons inclus 48 articles soit 765 cas de reparations nerveuses differees. Pour chaque cas nous avons note le delai preoperatoire de prise en charge, le resultat au dernier recul, le nerf repare et son site lesionnel, l’âge et la technique operatoire. Un bon resultat sensitif etait cote a plus de S3 et un bon resultat moteur etait cote superieur ou egal a M4 (echelles du British Medical Research Council). Le pourcentage de bons resultats en fonction du delai preoperatoire etait rendu en fonction du nerf. Resultats Pour le nerf ulnaire le delai limite de prise en charge est de 6 mois (81 % de bons resultats sensitivomoteurs versus 25 % apres 6 mois). Pour le nerf radial le delai limite de prise en charge est de 3 mois (100 % de bons resultats sensitivomoteurs versus moins de 59 % apres 3 mois). Pour le nerf median les resultats sensitifs sont constamment bons (93 %) independamment du delai de prise en charge, cependant les resultats moteurs sont moins bons apres 3 mois (94 % versus 58 %). Les nerfs axilaires et spinaux donnent constamment de bons resultats sensitivomoteurs quel que soit le delai de prise en charge - 92 % de bons resultats. Les nerfs sciatiques et fibulaires donnent peu de bons resultats sensitivomoteurs, quel que soit le delai de prise en charge - moins de 44 % de bons resultats. Les transferts nerveux distaux semblent donner de meilleurs resultats que les greffes nerveuses conventionelles - plus de 81 % de bons resultats pour des delais preoperatoires de plus de 6 mois tous nerfs confondus. Conclusion Cette meta-analyse nous permet de preciser nos indications de reparation nerveuse peripherique differee et ainsi de choisir la technique chirurgicale la plus adaptee.