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Optimal functional reconstruction of the palmar surface of the hand requires good sensibility especially for the thumb and the radial side of the fingers. We report the long-term results of a distally based radial forearm flap (RFF) used for soft tissue coverage in the palm, index and middle finger and an end-to-side neurorrhaphy between the lateral antebrachial cutaneous nerve (LACN) and the proper palmar digital nerve of the middle finger to restore sensation. At 5 years' follow-up, the patient's sensory recovery was assessed through static and moving two-point discrimination, light touch sensation, pain perception, hot and cold temperature perception, an electrophysiological study and sweat test. An S3+ sensory recovery on the British Medical Research Council scale, as modified by Mackinnon and Dellon, was noted together with a good perception in the palm compared to decreased perception in the volar surface of the proximal phalanx. These findings prove that the RFF can provide good functional coverage of the palm together with good sensitivity by end-to-side reinnervation.

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BACKGROUND: Little is known about clinical improvement in the non-operated hand after unilateral surgery for patients who present with bilateral carpal tunnel syndrome (CTS). In this prospective study of patients with bilateral CTS, we evaluated the clinical effects on the non-operated hand following unilateral contralateral carpal tunnel surgical release. MATERIAL AND METHODS: During a consecutive period of 22 months, 69 patients with bilateral CTS underwent unilateral open carpal tunnel release. Bilateral subjective and objective evaluations were performed pre-operatively, at days 2, 15 and 180 after surgery. Subjective evaluations, analysed with Student t test, included the Boston-Levine symptom severity score and a visual analogue scale including pain, nocturnal symptoms and numbness. A telephone survey was conducted 12 months after surgery. RESULTS: The Boston-Levine severity score of the contralateral non-operated hand decreased from 2.70 pre-operatively to 1.70 at 2 days (p < 0.001). The visual analogue pain score decreased at 2 days for 61 patients (88 %), whereas the nocturnal symptoms decreased or disappeared in 63 cases (91 %) and the paresthesia in 52 cases (75 %) (ps < 0.001). These beneficial effects were stable in time with no statistically significant change at 180 days. Overall, 58 patients (84 %) observed a total resolution or a significant improvement in their symptoms at 6 months. At 12 months, 100 % of patients responded to a telephone survey. Fifty one of them (74 %) reported minimal or no symptoms on the non-operated hand. Linear regression (analysis of variance [ANOVA]) showed that gender, age, professional status, duration of pre-operative symptoms and severity of electrophysiological disturbances were not predictive of post-operative evolution in the non-operated hand after unilateral surgery for CTS.

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Tendon adhesions in zone IV after proximal phalangeal fractures are common and may lead to loss of range of motion at the proximal interphalangeal joint. The type of fracture, surgical technique and rehabilitation strategy also influence the final functional outcome. Plate fixation is a reliable solution in cases of comminuted phalangeal fracture. This article describes how adhesions between the plate and extensor apparatus in cases of comminuted fractures of the proximal phalanx can be reduced by using an adipofascial flap.

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Masson's tumour is a rare benign neoplasm of vascular origin characterized histologically by papillary endothelial hyperplasia. Unlike previous scientific articles we report a case of a "rapid growing" lesion in a 73-year-old man underlining the clinical features to distinguish this uncommon lesion from other neoplasms of vascular origin.

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Proximal row carpectomy (PRC) is a well-accepted procedure for the treatment of early post-traumatic degenerative disease of the wrist. Much less frequently, PRC has been advocated as an emergency procedure for irreparable fracture-dislocation of the wrist. Our objective was to compare the results of PRC in patients having undergone this procedure in the two contexts. We conducted a retrospective analysis of the clinical and radiographic results of six patients treated by emergency PRC as compared to six patients who underwent elective PRC. The mean follow-up was 36 months. Both the patient's satisfaction and the grasp of the wrist joint were significantly better in patients who underwent PRC emergency as compared to those having undergone elective PRC. Quick DASH score, radiographic results, and return to work were also more favourable in these patients, but the difference between the two groups was not significant. This study confirms that PRC is a valuable salvage technique indicated in early posttraumatic wrist collapse. Moreover, when performed in emergency, the procedure shows even better subjective and objective results, allowing a majority of patients to return to their previous job.

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Kirschner wire (K-wire) fixation is a common technique aimed at treating unstable distal radius fractures. We report our experience with extrafocal K-wire fixation in the treatment of unstable distal radius fractures in 34 patients (AO classification: 10 A2, 5 A3, 14 C1, and 5 C2). The patients' median age was 63 years (range, 16-87 years). K-wires remained in place for a median duration period of 42 days, and a splint was applied during 44 days in median. The median follow-up was 2.5 years (range, 1.3-5 years). At the final follow-up examination, all patients were assessed clinically and bilateral radiographs were taken. The median final range of motion was 69 degrees /64 degrees for extension/flexion, 88 degrees/82 degrees for pronation/supination and 36 degrees/21 degrees for ulnar/radial deviation. Grip strength was 81% of the contralateral side. Using the Gartland-Werley score, 12 patients (35%) had excellent results, 17 (50%) good, and five patients (15%) had fair results. The median final radiographic dorsal tilt was 4.5 degrees (range, 0-14 degrees) and 79% of patients had a loss of volar reduction (median 8 degrees). Radial inclination was in median 20 degrees (range, 10-32 degrees) with 82% of the patients with loss of reduction (median 5 degrees). Radial shortening was in median 0.9 mm (range, -2 to +5 mm) and 62% of patients had median loss of radial length of 1.1mm. Radial shortening was the major source of pain due to ulnar impingement. We found a high complication rate, with 15 patients (44%) suffering from at least one of the 30 reported complications. We did not find any direct correlation between radiographic results and mobility. Although good clinical outcome may be obtained, K-wire fixation cannot be routinely recommended.

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BACKGROUND: Evaluation of diagnostic accuracy of high-spatial-resolution sonography (HSR-S) in occult scaphoid fractures. PATIENTS AND METHODS: HSR-S was performed in 24 patients with clinically suspected fracture and normal radiographs. Three levels of clinical suspicion were considered (high, intermediate, and low). Three levels of sonographic suspicion were defined on the basis of cortical interruption, radiocarpal effusion, and scapho-trapezium-trapezoid effusion. Three positive criteria were interpreted as being highly indicative of fracture. Data from sonograms were compared with computed tomography (CT) scans. RESULTS: CT scanning demonstrated a fracture of the scaphoid in five patients. The global sensitivity of HSR-S for detection of occult scaphoid fracture was 100% and the specificity 79%. All patients with demonstrated occult fracture had a high sonography index of suspicion. A high sonography index of suspicion was correlated with 100% sensitivity, specificity, positive predictive value, and negative predictive value. CONCLUSION: HSR-S is a reliable, available, and cost-effective method in early diagnosis of occult fractures of the scaphoid. The presence of three defined criteria is required to assess the diagnosis.

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We report the results of a new bone-tendon ligamentoplasty for the reconstruction of chronic injuries of the ulnar collateral ligament at the metacarpophalangeal joint of the thumb. The mean follow-up period was 36 months. Using the Glickel grading system, seven patients had excellent results and one patient had good results. The mean loss of pinch strength was 10% compared with the contralateral thumb. The mean loss of motion at the MP joint was 8%. This technique successfully restores the desired long lasting stability while maintaining mobility of the thumb's metacarpophalangeal joint.

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INTRODUCTION: Consolidation problems may complicate plate fixation of metacarpal fractures. It was our clinical impression that the fracture's morphology and the patient's occupation may influence this complication. METHOD: Retrospective study on 104 extra-articular metacarpal fractures. Time to union, presence of consolidation problems and time to return to work were correlated with fracture pattern (transverse/non-transverse), presence of soft tissue injury, type of patients and type of plate. RESULTS: Twelve patients (15%) experienced consolidations problems: 8 patients within the transverse fracture pattern group (29.6%) and 4 patients (7.4%) within the non-transverse fracture group. The difference was significant (P = 0.01). Manual workers were found to be more likely than non-manual workers to have consolidation problems (p < 0.01) in both groups of fractures. There was no correlation between consolidation problems and hand dominance (P = 0.76), soft tissue injury (P = 0.24) or type of plate (P = 0.34). DISCUSSION: We found a significant correlation between fracture patterns, patients' profession and consolidation problems. Despite technical advances in plate design, management of such fractures by plating remains fraught with complications, demands meticulous handling of soft tissue and does not allow for technical error.

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This study compares the direct and indirect costs of conservative and minimally invasive treatment for undisplaced scaphoid fractures. Costs data concerning groups of non-operated and operated patients were analysed. Direct costs were higher in operated patients. Although highly variable, indirect costs were significantly smaller in operated patients and the total costs were higher in non-operated patients. In conclusion, operative treatment of scaphoid fractures is initially more expensive than conservative treatment but markedly decreases the work compensation costs.

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STUDY AIM: The purpose of this study was to assess the quality of life following lower limb amputation for vascular disease. PATIENTS AND METHODS: Thirty-six vascular patients operated on for 40 major amputations were reviewed to assess demographic and clinical characteristics, possibilities of prosthesis, perception of health problems and social adaptation. These data were correlated with general satisfaction and quality of life ratings, using the Nottingham Health Profile. RESULTS: The average stay in hospital was 109 days. Thirteen patients (36%) died in hospital, 23 others (64%) were discharged, but only ten patients (28%) were able to go back home. The global mortality rate at 1 year was 44%. Eighteen patients (78%) were initially fitted but only seven (30%) were fully independent. Eight patients only (35%) were satisfied at the end of treatment. Patient's satisfaction was influenced by the level of his amputation, the presence of residual pain and by his mobility, but it was independent of prosthetic equipment. CONCLUSION: Quality of life of vascular amputated patients is poor and marked by persistent pain and considerable handicaps in mobility, limiting social activities and relationship. The patients' satisfaction and quality of life appear to be related to their ability to manage social relations. Amputation should be considered as the first step towards rehabilitation and not the end of the treatment. It is only through a multidisciplinary approach that the quality of life of amputated patients can be improved.

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An easy venous access improves the quality of life of patients who need prolonged intravenous therapy. In the case of vena cava superior syndrome the classic access in the jugular or subclavian vein can be difficult or even impossible. We report on seven implantations of Port-a-Cath in the inferior vena cava for patients presenting contra-indications to classic venous access to the vena cava superior (five cases of vena cava superior compression syndrome, one tracheostomy and one extended tumor of thoracic wall). We describe the operative technique and we analyze the indications, the results and the complications of this rarely used technique.

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The splenic cyst occurs rarely, is benign and often asymptomatic. Surgery is the therapy of choice as soon as the size reaches 2 centimeters. Following the exclusion of an echinococcus infection, the cyst can be treated either by complete resection or by fenestration. Recently laparoscopy has been demonstrated to be a useful alternative to open surgery in the treatment of selected splenic cysts. We report 3 cases successfully operated with conventional surgical procedures and, based on the literature, we review the history, the physical signs, the investigations and the surgical procedures.

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The PEG-ileus is a complication of the intestinal migration of the "bumper". The resulting obstruction or perforation is usually located in the ileum. Patients with hernias, who have a possible or known intrinsic or extrinsic stenosis or who have been X-rayed in the area of the small pelvis, are not suitable for the application of Korula's "migration"-technique with the scheduled intestinal elimination of the "bumper". "Bumpers" that are allowed to remain in the stomach for a long time lose their elasticity and frequently cause a PEG-ileus. When choosing the type of gastrostomy, we should consider which technique could be used in the case of a change or a removal of the material.

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BACKGROUND: We evaluated the advantages and risks of laparoscopic cholecystectomy during pregnancy in symptomatic patients. MATERIAL AND METHODS: Three gravid women at an estimated 14 to 26 weeks gestational age underwent laparoscopic cholecystectomy for symptomatic cholelithiasis or biliary pancreatitis. One patient was obese. The operation was successfully completed under tocolytic medication. DISCUSSION: Although rare, gallbladder disease is the second most common abdominal condition during pregnancy requiring operation, being second only to appendicitis. Medical management is the most common approach to treatment, and the surgical intervention is reserved for patients who fail to respond to conservative methods or who have choledocholithiasis, biliary obstruction or pancreatitis. The laparoscopic approach is controversial, and some authors still agree that pregnancy is a contra indication to laparoscopic cholecystectomy. We report our experience with three laparoscopic cholecystectomies performed without complication during pregnancy. On the basis of our experience and a review of the literature, we believe that the laparoscopic cholecystectomy, undertaken preferentially during the second trimester, is a valid alternative to classic management in terms of risks for the foetus and comfort for the mother.

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