RESUMEN
Index pollicization in severe thumb hypoplasia or aplasia in children or for the reconstruction of a mutilated thumb in adults is a rare and technically demanding procedure. Weakness of the new thumb is routinely reported after index pollicization. An inappropriate position of the first dorsal interosseous muscle (FDIM) can partly explain this strength deficit. Here, we report an original anatomical study on FDIM transfer for reanimation of the new thumb's opposition function and its clinical application. An anatomical study was carried out on three upper limbs from fresh, non-embalmed adult cadavers. We demonstrated the feasibility of an FDIM transfer pedicled on the proper FDIM artery and the deep branch of the ulnar nerve. The proximal FDIM insertions were sutured to the lateral border of the flexor retinaculum to recreate the superficial thenar musculature. This procedure was performed on a 52-year-old man who was referred to us with swelling on his hand. We discovered a myxoid inflammatory fibroblastic sarcoma of the thumb that required proximal thumb amputation while preserving the base of the first metacarpal. To our knowledge, this is the first description of FDIM pedicled flap transfer during an index pollicization procedure among an adult population. However, in severe thumb hypoplasia or aplasia cases, this procedure is limited by the size and anatomical variations of the neurovascular structures among a population affected by radial longitudinal deficiency.
Asunto(s)
Deformidades de la Mano , Pulgar , Adulto , Niño , Humanos , Masculino , Persona de Mediana Edad , Músculos , Colgajos Quirúrgicos , Pulgar/anomalíasRESUMEN
The pedicled flap from the first dorsal branch of the proper palmar digital artery (FBPPDA) of the fingers is an option for reconstructing digital skin defects. It has the advantage of being innervated by the dorsal branch of the proper palmar digital nerve (DBPPDN) associated with the artery. However, no studies on the anatomical variations of the neurovascular pedicle have been performed yet. The objective of our study was to evaluate the anatomical variations in the neurovascular pedicle, determine its relationships with other anatomical structures, describe the dissection technique for the FBPPDA and explore potential indications. We conducted an anatomical study with eight upper limbs from fresh adult cadavers. Twenty-six fingers (6 index, 6 middle, 8 ring, 8 little) were dissected after intra-arterial silicone injection. We found a pedicle composed of the FBPPDA and the DBPPDN in all fingers. The artery arises an average 19mm from the bifurcation of the common palmar digital artery. The DBPPDN's configuration relative to the FBPPDA varied; in the main variant - found in 58% of cases - the nerve was superficial and proximal position to the artery. After its origin, the pedicle ran on the superficial aspect of the extensor hood along an oblique path from proximal to distal and from palmar to dorsal. Its path ended with its penetration into the skin paddle of the flap just upstream the proximal interphalangeal (PIP) joint. The skin paddle corresponded to the functional skin unit represented by the dorsal surface of the middle phalanx and that of the PIP joint. Its average length was 33mm (26-40) and its average width was 21mm (15-30). The arc of rotation was sufficient to reach homodigital and heterodigital cutaneous defects. Based on our findings, this flap is a reliable and reproducible option for finger skin defects. The size of its paddle and its innervation make it an interesting alternative to conventional flaps.
Asunto(s)
Dedos/irrigación sanguínea , Colgajos Quirúrgicos/irrigación sanguínea , Cadáver , Dedos/inervación , HumanosRESUMEN
The aim of this prospective study was to describe the surgical procedure and to report outcomes of computer-assisted 3D preoperative planning of corrective osteotomy for extra-articular distal radius malunions. Sixteen consecutive patients were enrolled. CT scans of both wrists were performed, and 3D bone surface models of the radii were created. Software was used to simulate the osteotomy and the reorientation of the distal radial articular surface. Patient-speciï¬c cutting and drilling guides for intraoperative guidance of the osteotomy as well as bone graft templates were also simulated. At a mean follow-up of 12 months (range 6-27) after surgery, pain was reduced from 3 to 0.3 at rest and 6.8 to 1.5 during effort according to a visual analog scale. The average wrist flexion-extension was 145° and pronation-supination was 155°. Grip strength was 91% of the contralateral side. All patients achieved primary bone union in a mean of 10 weeks (range, 7-18). Using our 3D analysis method, preoperative 3D values showed no significant difference with radiographic measurement. Moreover, there was no significant difference between the postoperative radiographic values in term of correction. This procedure provides satisfactory clinical and radiological results with minimal residual malalignment. LEVEL OF EVIDENCE: III.
Asunto(s)
Simulación por Computador , Fracturas Mal Unidas/cirugía , Osteotomía , Cuidados Preoperatorios , Fracturas del Radio/cirugía , Cirugía Asistida por Computador , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Curación de Fractura , Fracturas Mal Unidas/diagnóstico por imagen , Fuerza de la Mano , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Fracturas del Radio/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Escala Visual Analógica , Adulto JovenRESUMEN
Scapholunate (SL) instability is the most common dissociative carpal instability condition. It is the most frequent cause of wrist osteoarthritis, defined as scapholunate advanced collapse or SLAC wrist. Familiarity with the SL ligament complex is required to understand the various features of SL instability. Damage to the SL interosseous ligament is the main prerequisite for SL instability; however the extrinsic, palmar and dorsal ligaments of the carpus also come into play. When more than 6 weeks has passed since the initial injury event, SL instability is considered chronic because ligament healing is no longer possible. Before osteoarthritis sets in and when the SL instability is still reducible (scaphoid can be reverticalized), ligament reconstruction surgery is indicated. Since the end of the 1970s, various ligament reconstruction or tenodesis techniques have been described. These techniques are used in cases of chronic, dynamic or static reducible SL instability, when no repairable ligament stump and no chondral lesions are present. The aim is to correct the SL instability using a free or pedicled tendon graft to reduce pain while limiting the loss of mobility and protecting against osteoarthritis-related collapse in the long-term. We will perform a systematic review of the various tenodesis techniques available in the literature.