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AimsA conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability.MethodsThis was a prospective single-centre study undertaken between March 2019 and May 2021. The primary outcome was the evaluation of the reduction of the radiological deformity and the functional outcomes after WADCLR. A secondary outcome was the evaluation of the effectiveness of this technique in patients with the most severe instability (European Wrist Arthroscopy Society (EWAS) stage 5). The patients were reviewed postoperatively at three, six, and 12 months.ResultsThe study included 112 patients (70 male and 42 female). Their mean age was 31.6 years (16 to 55). A total of three patients had EWAS stage 3A injuries, 12 had stage 3B injuries, 29 had stage 3C injuries, 56 had stage 4 injuries, and 12 had stage 5 injuries. There was a significant improvement of the radiological signs in all patients with a return to normal values. There was also a significant improvement in all aspects of function except for flexion, in which the mean increase was negligible (0.18° on average). There was also a significant improvement in all criteria for patients with a stage 5 injury, except for some limitation of extension, flexion, and radial and ulnar deviation, although these showed a trend towards improvement (except for flexion).ConclusionWADCLR is a minimally invasive, easy, and reproducible technique with few complications, offering a clear improvement in function and a reduction in the radiological deformity at one year postoperatively.Cite this article: Bone Joint J 2023;105-B(3):307–314.

Grade 2 scapholunate advanced collapse (SLAC 2) can be treated by proximal row carpectomy with satisfactory results. However, this method is invasive and can limit function. The senior author had proposed an arthroscopic alternative with tendon interposition between the radius and proximal carpal row (arthroscopic interposition tendon arthroplasty [AITA]). However, this arthroscopic technique is technically difficult and requires a risky palmar arthroscopic portal. We report a modification of AITA, the one-loop arthroscopic radiocarpal tendon inter-position (1L-ARTI) that is simpler and needs only dorsal arthroscopic portals. Level of Evidence: Level V (Therapeutic)

Isolated fractures of the capitate are very rare which means that their nonunion is even rarer. Repair techniques have always been performed by open surgery which may result in loss of mobility due to the capsulotomy. The typically used surgical techniques such as arthrodesis of the carpal or wrist bones can have irreversible consequences on range of motion. No arthroscopic technique has ever been described for this condition. Here, we describe a case of isolated capitate nonunion without ligament tears or other carpal fractures in a 21-year-old male, following a capitate fracture 10 years prior. We describe our arthroscopic treatment technique for this capitate nonunion.

Scapholunate fusion appears to be an interesting surgical solution for carpal pathologies, which are sometimes difficult to manage as Kienbock's disease or chronic scapholunate instability. Open intracarpal fusion is notorious for decreasing joint range of motion due to the fusion of several carpal bones and because of the capsulotomy sectioning important ligamentous elements in carpal biomechanics. Wrist arthroscopy has already demonstrated its effectiveness in preserving joint mobility compared with open procedures. In this work, we present a detailed procedure for performing a scaphocapitate fusion under arthroscopy by specifying the key points of this procedure in our experience.

Wrist arthroscopy has become an essential method in the management of patients suffering from wrist pathologies. This technique must be mastered by residents wishing to specialize in upper limb surgery. However, no study has evaluated residents' access to wrist arthroscopy.Residents have difficulty accessing wrist arthroscopy surgery during their training.We sent out an online questionnaire to all orthopedic and plastic surgery referents in France. Data were collected over a 6-month period from December 2020 to May 2021. A descriptive statistical analysis was performed.Regarding the 98 responses obtained, we observed that 77.54% of residents have seen between 0 and 10 wrist arthroscopies and 35.71% have never seen a wrist arthroscopy. In addition, only 23.80% of residents have had access to training on cadavers, and 57.14% of residents were trained in private facilities.Access to the operating room remains difficult for residents in upper limb surgery. Our results suggest that wrist arthroscopy training could be improved. New training methods could be adapted for wrist arthroscopy and to overcome the lack of access to wrist arthroscopy for residents.IV.

Clavicle non-union is a challenging problem. Open reduction with internal fixation and autologous bone grafting is usually the first line treatment. In case of failure, the medial femoral condyle corticoperiosteal flap in association with a non-vascularized bone graft is one of the therapeutic options, which is well adapted to the clavicle anatomical characteristics. We performed a retrospective study of all patients treated with this technique in our department. Between 2014 and 2017, five patients with recalcitrant post traumatic clavicle non-unions received this surgical treatment. The average nonunion time period was 50.2 month (range 10 to 108 months), and the mean defect length was 3.4 cm (between 2 and 5 cm), defects were all located in the medial third of the clavicle Three patients achieved full consolidation with an average time of consolidation of 8,7 months (range 6 to12 months). Patients with radiological consolidation had better functional improvement and pain reduction with an average DASH score improved from 53,6 before surgery to 19,6 after consolidation (at the last follow up visit). There was one donor site complications (hematoma). The medial femoral condyle corticoperiosteal flap with non-vascularized iliac crest graft is a good option for the management of recalcitrant clavicle non-union, especially when the bone defect is small.

Microsurgery is an unusual procedure in the theatres of military operations. We sought to analyze the state of microsurgical practices in the French medical treatment facilities (MTFs) deployed around the world in the 21st century. A retrospective study was conducted among all patients who were operated on in French forward surgical facilities between 2003 and 2015. Those who underwent microsurgical procedures for nerve injury, vascular injury, or extremity reconstruction were included. Only early vascular results were assessed. Among the 2589 patients operated on for an extremity injury during the study period, 56 (2.1%) were included, with the group composed of 29 patients with isolated nerve injuries, 28 patients with nerve and arterial injuries, and two patients with isolated arterial injuries, mostly at the hand level. Nerve procedures predominantly consisted of direct suturing, although autografting and nerve transfers were also performed. Thirteen microvascular repairs were carried out, including nine cases of proximal or digital revascularization; revascularization was successful in six of the nine cases. These procedures were completed by orthopedic surgeons trained in microsurgery, mostly under loupes magnification. Routine nerve repair in the field seems to be specific to French MTFs. Salvage of amputated or devascularized fingers in the combat zone had never been reported before. Such emphasizes the need to train deployed orthopedic surgeons to perform microsurgical procedures and to equip all MTFs with basic microsurgical sets and magnification means.

Introduction: Noncombat-related hand injuries are common in current theatres of operations. Crushing is one of the most frequent mechanisms that may cause traumatic amputations of digits. In the military setting, management of these digital amputations is challenging regarding limitation in microsurgical means in medical treatment facilities and aeromedical evacuation delays out of the combat zone.Methods: Two cases of digital replantation performed in French forward surgical units are described. The first case was a complete distal amputation of the medius which was successfully replanted in the operating theatre of an aircraft carrier. No complication was observed after evacuation. Functional and aesthetic results were excellent. The second case was a ring finger avulsion revascularized in a role 2 facility in Central African Republic. Unfortunately, revascularization failed due to arterial thrombosis during evacuation.Results: Digital, hand or more proximal upper extremity replantation may be considered for isolated amputations due to work-related accidents within the combat zone. For a surgeon trained to microsurgery, a microsurgical set and magnification loupes enable to attempt such procedures in austere conditions.Discussion: The authors propose an algorithm of management in the field according to the type and level of amputation.

Qu’elles soient totales ou partielles, les amputations digitales survenant dans un contexte de guerre relevent habituellement d’un traitement radical compte tenu du mecanisme lesionnel, des lesions associees ou de l’absence de moyens microchirurgicaux. Malgre cela, des revascularisations ou replantations digitales ont ete effectuees de facon exceptionnelle sur les theâtres d’operations exterieures. Une etude observationnelle retrospective a ete effectuee au sein des formations chirurgicales de l’avant francaises entre 2010 et 2015. Ont ete inclus les patients ayant beneficie d’une revascularisation ou d’une replantation digitale. Les dossiers cliniques ont ete colliges et analyses afin de determiner le resultat vasculaire et le resultat fonctionnel. Six patients d’âge moyen 37 ans ont ete inclus. Il s’agissait d’un accident du travail dans 4 cas et d’un traumatisme balistique dans 2 cas. Un seul doigt etait en ischemie — le pouce dans 3 cas, l’index, le majeur ou l’annulaire dans les 3 autres cas. Une replantation a ete effectuee pour deux amputations distales et un ring finger. Une revascularisation a ete effectuee pour trois lesions complexes en ischemie. Les reparations arterielles ont ete effectuees sous loupes grossissantes dans la majorite des cas. Il n’a pas ete effectue de reparation veineuse. Un militaire etranger a ete rapidement perdu de vu apres evacuation. Parmi les 5 autres patients, le resultat vasculaire a ete favorable dans 3 cas et defavorable dans 2 cas de replantation. Le resultat fonctionnel a toujours ete satisfaisant, y compris dans les 2 cas ayant necessite une regularisation secondaire. Bien que limitee en effectif, cette serie n’en reste pas moins inedite. Elle montre qu’en depits d’un contexte sanitaire degrade, des revascularisations ou replantations digitales peuvent etre effectuees dans les formations chirurgicales de l’avant, lorsqu’il s’agit d’une lesion isolee et que le contexte operationnel s’y prete. Les auteurs proposent un algorithme de prise en charge fonction du type et du niveau d’amputation. Tout chirurgien militaire forme a la microchirurgie doit etre capable de tenter une revascularisation digitale en situation sanitaire precaire, a l’aide de loupes grossissantes et d’un materiel microchirurgical minimaliste.

Les fractures articulaires et extra-articulaires complexes des phalanges des doigts longs ne peuvent pas toujours beneficier d’une osteosynthese stable permettant une rehabilitation precoce. Les systemes de distraction sont alors indiques mais ne derogent pas aux risques de raideur ou d’infection pour les techniques les plus invasives. Les auteurs presentent une serie multicentrique de 30 fractures phalangiennes traitees par traction collee decoaptante (TCD). Cette technique de distraction non invasive utilisee pendant une duree de trois semaines permet de reduire par effet ligamentotaxis les foyers de fracture, avant d’enchainer sur une reeducation dynamique precoce protegee par une simple syndactylie. Les patients ont ete revus avec un recul d’un 1 an en moyenne. Les amplitudes de l’articulation concernee ont ete mesurees, la distance main–paume et l’appreciation subjective du resultat fonctionnel ont ete evaluees. Les fractures concernent 13 phalanges P1 et 17 phalanges P2. Les amplitudes en extension ont perdu 15° en moyenne, les flexions sont recuperees en moyenne jusqu’a 80°. La distance main paume a une mediane a 10 mm. Six patients sont mecontents du resultat fonctionnel et 15 patients se declarent tres satisfaits. Nous presentons les resultats cliniques et radiologiques associes a un taux moyen de satisfaction de 70 % chez les patients en termes de recuperation fonctionnelle. Ces resultats sont comparables aux techniques de reference avec les fixateurs externes en distraction, qu’ils soient statiques ou dynamiques. La TCD presente l’avantage d’etre simple, economique, rapide et sans risque de morbidite supplementaire pour un traitement efficace de ces fractures complexes des doigts longs, au pronostic souvent incertain.

RESUME La contracture psychogene est une entite mysterieuse qui entre dans le cadre des troubles de conversion, jadis regroupes sous le terme d’hysterie. Lorsqu’elle est localisee aux membres, la contracture psychogene offre le tableau clinique d’une posture en flexion ou en extension d’un ou de plusieurs segments articulaires. Cette posture, invincible a l’etat de veille, se relâche sous narcose. Les patients relevent d’une prise en charge pluridisciplinaire centree sur la filiere psychopathologique ; cependant ils sont parfois orientes a tort vers des consultations de chirurgie orthopedique dans la mesure ou le trouble de conversion est apparu a la suite d’un traumatisme ou d’une intervention chirurgicale. Il est donc de la plus haute importance, pour reprendre les mots de Freud, que les chirurgiens aient une connaissance plus intime de ces cas rebelles pour eviter des operations inutiles.