Dynamometric measurement of the grasp strength is commonly used in wrist assessment. On the other hand measurement of the pronation-supination (PS) strength has been few studied. The longitudinal forearm rotation needs integrity of the two radioulnar joints and of the antebrachial interosseous membrane. The strength developed during PS assesses also trophicity of pronator and supinator muscles. A PS dynamometer (Baseline ®, AREX) is now available for such measurements. The aims of this study were: 1) to study the best way to neutralize the shoulder movements of abduction-adduction, 2) to find the values of PS Strength in a healthy population, and 3) to study correlations between this PS force and several biometric items.

A first series of measurements des PS strength was performed thanks to the Baseline dynamometer in 8 people, in association with two devices neutralizing the shoulder movements of abduction-adduction, in repeated campaigns allowed the authors to determine and keep the better one for optimal measurements following campaigns.

To assess the normal values of PS Strength in a healthy population, 38 healthy volunteers from both genders and different ages, classified according their age class, from three different forearm position: neutral, from 90 ° of supination and 90 ° of pronation.

Finally, statistical analysis looked for correlations between PS strength and some biometric data.

Manipulations beginning from a neutral position of forearm were the most reliable. The mean strength within the whole studied sample (76 wrists, 17 male, 21 female) was 10.6 N.m (standard deviation SD 3.26) for the supination and 13.9 N.m (standard deviation 4.19) for the supination.

The dominant side exhibited a PS strength superior by 7.5% to that of the non-dominant side. Male gender, the height and weight of the body, forearm circumference displayed positive relationships with PS strength.

Mean values of PS strength, measured from a neutral forearm rotation and with the best device to neutralize the shoulder movements, in a healthy population of 38 volunteers, allowed the authors establishing reference values. They will allow precise comparisons between the values found in patients suffering from forearm and/or wrist pathology and the healthy population, taking into account the age, gender and hand dominance.

In rheumatoid arthritis (RA), non constrained or semi-constrained prostheses can be used. The authors used the Kudo III, IV or V or iBP prostheses 54 times from 1994 to 2003. After initial satisfactory results, they had to change one or both implants for several reasons: humeral stem fracture (5 cases), unipolar humeral loosening (1 case), ulnar loosening without laxity (8 cases), polyethylene wear (11 cases), due to progressive ulnar collateral ligament lengthening and progressive valgus deformity, without or with metallosis, due to contact between Cr-Co humeral component and titanium alloy ulnar component, chronic infection (1 case). When the local conditions were satisfactory (bone stock, ligament balance), the fractured or loosened component was changed. When the conditions were bad (poor bone stock, ligament misbalance, metallosis), both implants were removed; posterior humeral and/or medial or lateral ulnar window were used to removed the uncemented stems still osteointegrated. All the bipolar operations used the Coonrad-Morrey prosthesis, but the last case a Discovery prosthesis. The operative tricks are described, the management of the extensor apparatus is discussed, the clinical outcomes (especially the extensor apparatus function, most often weak) and the radiographic outcomes are presented.

Purpose of the study: This retrospective study evaluated the results, complications and sequelae of 22 free fibular flaps used for bone reconstructions of the limbs assessed at mean 44.4 months.

Material and methods: The tissue loss was the result of trauma in 20 patients and followed cancerology surgery in two. The localisations involved the upper limb in 15 patients and the lower limb in seven. Mean length of bone loss was 11.1 cm. Six injuries required skin cover in addition to the fibular flap. Five patients had had a cement spacer. Fixation methods were: internal fixation (n=14) and external fixation (n=8). Classical vessel anastomosis (one vein, one artery) was used in eight patients and a bridge method (recipient site artery by a fibular artery) in 14 patients.

Results: Bone healing was achieved in 15 patients in 6.7 months on average. Healing was secondary in four patients after corticocancellous grafting. Three flaps failed. Factors significantly associated with favourable healing were: long time from trauma to flap repair, small size of the initial skin opening, first-intention Masquelet, internal fixation, and first-intention cancellous autologous graft. Early postoperative complications of the recipient site included two haematomas and three superficial skin deficiencies. Two graft fractures occurred in one patient and healed after orthopaedic treatment. There were few donor site problems: two early haematomas and two retractions of the flexor hallucis longus. Mean morbidity scores revealed very good results: 1.23/16 with the Point Evaluation System, 93.16/100 for the Karlsson score, and 94.29100 for the Kitaoka score. Globally, the functional assessment of the fibular flap was excellent for three patients, good for eleven, fair for four and poor for one.

Discussion: Our healing rates and durations were not statistically different from earlier reports in the literature. We focused on rigorous preparation in terms of debridement and antibiotic therapy, insertion of a spacer, internal fixation, and complementary first-intention autologous bone graft. In addition, we propose a bridging anastomosis which simplifies the technique and gives the same results as the classical anastomosis methods.

Fasciae represent a very interesting source of thin, well vascularized soft tissue, which allows gliding of the underlying tendons, especially for coverage of particular anatomical zones, such as the dorsal aspect of the hand and fingers. Some fasciae (such as the fascia temporalis free fiap) have already been used in this way as free fiaps for the coverage of the extremities. The aim of this study was to investigate the blood supply of the posterior brachial fascia (PBF), in order to precise the anatomical bases of a new free fascial fiap.

Our study was based on dissections of 18 cadaveric specimens from 10 formalin preserved corpses. Six upper limbs were used to fictively harvest this fiap

The PBF was thin; its surface was broad, easily separable of the overlying subcutaneous and underlying muscular planes in its upper two thirds. It was richly blood supplied by two main pedicles:

the posterior brachial neurocutaneous branch and

The well vascularized area was 115mm long and 54mm broad in average. These two pedicles were quite constant (respectively 17 cases and 14 cases out of the 18 specimens) and of sufficient caliber to allow microsurgical anastomoses in good conditions. A rich venous network, satellite of the arteries, was always present. An arterial by-pass between both arterial pedicles could spare venous sutures when both arterial pedicles are present and communicating within the fascial depth (13 cases out of 18). Harvesting the fiap was easy through a posteromedial approach in a patient in supine position. The donor site could always be closed and its scare was well acceptable.

The first clinical case is presented in a patient suffering from recurrent tendinous adhesions at the dorsum of the hand after a close trauma with extensive hematoma, after failure of 2 previous tenolyses. After a third tenolysis, the free PBF fiap was performed. The fascia was covered with a free skin graft at day 6. The coverage was nice and the outcome of the tenolysis at 6 month was -15/80 (active motion) and +20/100 (passive motion).

The distal interphalangeal (DIP) joints of the fingers are prone to functional impotence in some degenerative diseases. In this case, different surgical techniques can be used, from DIP arthrodesis to joint denervation, much more confidential, which aims to preserve an already reduced mobility.

The four fingers (except the thumb) of 6 fresh hands from different cadavers were dissected under optic magnification. Two DIP joints were harvested from fresh dissected hands, in order to follow with the microscope the course of the nerve branchlets up to their articular entry. These two specimens were decalcified, and then embedded in paraffin. The blocks were serially cut in 5μm slices (1 slice each 250μm), which were observed at 25 and x100 magnification, after Masson’s trichrom staining.

A constant proximal articular branch, arising from the proper digital palmar nerve, was exclusively devoted to joint supply. This branch was located medially and arose in average at 7 mm from its entry point in the joint, where it was accompanied by small arterial branches. Before its entry into the inferomedial part of the DIP joint, it ran under the flexor digitorum profun-dus tendon. It then could divide into 2 or 3 branchlets. The proper digital palmar nerve abandoned, along its course, some nerve fibers to the tendinous synovium and neighboring structures. Then, ending its course, it gave off a distal articular branch, hidden among numerous cutaneous branches for the fingertip. The DIP joint nerve supply seems so under the exclusive dependence of the proper digital palmar nerve without any input from the dorsal side. On the histological slices, the nerves were mainly observed in peri- and intracapsular situation.

Could cutting these two articular nerves be sufficient to relieve pain from the DIP? This is what we are investigating through a clinical series; the first results are presented here.

Purpose of the study: The latissimus dorsi free flap is widely used for reconstruction of large tissue defects. It is always difficult however to explain the procedure to the patient, particularly the potential sequelae. The purpose of this work was to assess sequelae affecting shoulder function and the esthetic aspect of the harvesting site.

Material and methods: We reviewed 16 patients (17 harvestings) aged 37.8 years on average (range 22–62 years), twelve men and four women, at mean follow-up of 4.5 years. All flaps had been harvested to reconstruct tissue defects of the lower limb. Eleven were semi-emergency procedures, four for chronic defects or reconstruction after tumor resection. We assessed the esthetic aspect of the harvesting zone and shoulder function suing Cybex 6000 (comparative isokinetic tests of the two shoulders). The Dash score was noted.

Results: Functional impairment was minimum in all patients. The Dash score was 17.5%. (compared with the opposite side was: 27% abduction, 22% extension and 10% rotation. Adduction, flexion and external rotation were preserved. The esthetic aspect was acceptable but not negligible. Obesity appeared to accentuate disgraceful scars.

Discussion and conclusion: The latissimus dorsi free flap is often indicated for reconstruction of significant tissue defect. Shoulder function is largely preserved. Patients should be informed about the major scar. The side to be harvested should be discussed with the patient, even in the emergency situation.

Purpose of the study: Appropriate management of chronic sprains of the scapholunate joint remains a subject of debate. Different surgical techniques have been proposed, from partial arthrodesis of the carpus to ligamentoplasty. We opted for scaphocapitatum arthrodesis. The purpose of this report was to assess clinical and radiological outcome.

Material and methods: From 1997 to 2001, 13 arthrodeses (13 patients) were performed for this indication. The procedure involved two screws (n=11), one screw and stapling (n=1), and stapling alone (n=1). A free autologous graft was used in all cases. Mean patient age was 40 years (12 males and one female). These patients were victims of sports accidents (n=8) or occupational accidents (n=5). Mean follow-up was 26 months (range 24–31 months). Variables noted were joint mobility, pain, grasp force and pinch force. Wrist x-rays were used to measure the height of the carpus and the radio-lunate angle.

Results: A 31% loss in the radial inclination was noted as as a 14.5% loss in the ulnar inclination. Dorsal flexion of the wrist declined from 60° to 48°, palmar flexion from 47° to 28°. Stiffness mainly involved the radial inclination and palmar flexion. Grasp and Pinch forces improved (125° on average). All patients excep one presented residual pain. Six patients complained of pain only for efforts and six presented invalidating pain. Only seven patients were able to resume their occupational activity. There were three cases of nonunion which required revision to achieve final bone healing (poor outcome). Carpal height improved (0.47±0.54). The mean radiolunate angle at last follow-up was 11°. DISI persisted in only one wrist.

Discussion: This technique reduced wrist mobility. For all patients, the dorsal approach to the wrist produced inevitable stiffness. Radial inclination declines due to the intracarpal fusion. This arthrodesis enabled restitution of the carpal height and partially corrected for the DISI. This operation did not provide pain relief but did not alter the carpal x-ray. We raise the question of the pertinence of associating this type of arthrodesis with total denervation of the wrist.