The priority of the digital retrograde arterial flap.
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Finger Injuries↗
Biomedical subjects
C Oberlin
Publications and source records attributed to C Oberlin.
[Functional anatomy and evaluation of hand function].
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Hand↗
Responsiveness of the Cochin rheumatoid hand disability scale after surgery.
OBJECTIVE: To assess the responsiveness of the Cochin functional disability scale for the rheumatoid hand after surgery. METHOD: In a prospective study, patients with rheumatoid arthritis (RA) scheduled for surgery of the wrist and/or fingers were evaluated within 48 h before surgery and at least 6 months after surgery. Clinical outcome measures included duration of morning stiffness, total score for tenderness, total score for swelling, visual analogue scale score for pain in the hands and wrists, a score for overall mobility of the wrist and the fingers, grip and pinch strength, the Hand Functional Index (HFI), the Kapandji index and the Cochin scale. Responsiveness was assessed with the paired t-test, the effect size (ES), the standardized response mean (SRM) and the non-parametric Spearman rank correlation coefficient (r(S)). RESULTS: Fifty patients (42 women) were evaluated twice at an interval of 7.16 +/- 2.10 months (mean +/- s.d.) (range 6-15 months). Thirty-six patients (72%) were very satisfied or satisfied with the results of surgery, seven (14%) were not satisfied or dissatisfied and seven (14%) were dissatisfied or very dissatisfied. The Cochin scale score improved at the second visit (P < 0.0001), with SRM and ES values of 0.66 and 0.58 respectively. The correlation of the change in Cochin score with patient overall satisfaction was r(S) = 0.40. Among the impairment measures, grip strength showed the best responsiveness (SRM = - 0.43, ES = - 0.36, correlation with patient overall satisfaction r(S) = 0.46). The change in Kapandji index had the best correlation (r(S) = 0.51) with patient overall satisfaction but its SRM and ES values were low (- 0.19 and - 0.10 respectively). CONCLUSION: The Cochin scale is responsive and appropriate for the assessment of the effects of surgical treatments on disability in RA hands.
Adult↗
Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot.
Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.
Adolescent↗
Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect.
The authors report a simple, single-step procedure to promote the distal transfer of the instep island flap for coverage of the submetatarsal weight-bearing zone. First described in 1991 by Martin et aI, this procedure remained unknown. As opposed to the medial plantar flap, this technique proposes an instep island flap based on the lateral plantar artery. The inflow and outflow of blood is assured by the anastomosis between the dorsalis pedis and lateral plantar vessels. This approach allows for the transfer of similar tissue and provides adequate coverage of the weight-bearing zone of the distal forefoot.
Adult↗
[Partial replantation following proximal limb injury].
PURPOSE OF THE STUDY: Proximal replantation is a technically feasible but life-threatening procedure. Indications must be restricted to patients in good condition with a good functional prognosis. The goal of replantation must be focused not only on reimplanting the amputated limb but also on achieving a good functional outcome. For the lower limb, simple terminalization remains the best choice in many cases. When a proximal amputation is not suitable for replantation, the main aim of the surgical procedure must be to reconstruct a stump long enough to permit fitting a prosthesis preserving the function of the adjacent joint. If the proximal stump beyond the last joint is very short, it may be possible to restore some length by partial replantation of spared tissues from the amputated part. We present here the results we obtained following this policy. MATERIALS AND METHODS: This series included 16 cases of partial replantations, 14 involving the lower limb and 2 the upper limb. All were osteocutaneous microsurgical transfers. For the lower limb, all transfers recovered protective sensitivity following tibial nerve repair. The functional calcaeoplantar unit was used in 13 cases. The transfer of this specialized weight bearing tissue provided a stable distal surface making higher support unnecessary. In one case, we raised a 13-cm vascularized tibial segment covered with foot skin for additional length. For the upper limb, the osteocutaneous transfer, based on the radial artery, was not reinnervated, but this lack of sensitivity did not impair prosthesis fitting. RESULTS: One vascular failure was finally amputated. This was the only unsuccessful result. For all other patients, the surgical procedure facilitated prosthesis fitting and preserved the proximal joint function despite an initially very proximal amputation. DISCUSSION: The advantages of partial replantation are obvious compared with simple terminalization or secondary reconstruction. There is no secondary donor site and, because there is no major muscle mass in the distal fragment, the overall risk is very low compared with the risk of total proximal leg replantation.
Adolescent↗
Martin-Gruber communicating branch: anatomical and histological study.
We dissected 72 upper limbs of fresh cadavers and found 17 cases with a Martin-Gruber communicating branch (23.6%). These were classified into 4 types: type I (n = 5, 29.4%): communicating branch between the anterior interosseous and ulnar nn, type II (n = 3, 17.6%): Communicating branch between the median and ulnar nn., type III (n = 3, 17.6%): Communicating branch between the muscular branches to the flexor digitorum profundus m., type IV (n = 6, 35.3%): combination of type I or II and type III. At histologic examination the number and size of the nerve bundles each communicating branch contained proved to be very different. In one case of type II only a single nerve bundle was found. We suggest that the different numbers of nerve bundles innervate different amounts of the intrinsic hand musculature. The communicating branch with a single nerve bundle probably innervated only the first dorsal interosseous muscle.
Aged↗
Morphometric study of the upper intercostal nerves: practical application for neurotizations in traumatic brachial plexus palsies.
UNLABELLED: The aim of the study was a morphometric evaluation of the intercostal nerves at different levels along their course in order to determine their adequacy in neurotizing the recipient nerves. The intercostal nerves were harvested from 5 cadavers. A biopsy of the nerve was obtained at 2 levels for each nerve in the parasternal region and at the level of the mid-axillary line. The musculocutaneous nerve was isolated at its origin from the lateral cord. Each harvested specimen was embedded in paraffin and sections were made using a microtome. These sections were then stained histochemically using HPS (Hematein, Phloxine, Safran). Real-time digitalisation of the video image under the microscope was performed. The sum of the different fascicular zones is the effective sensorimotor surface of the nerve at the level being studied. RESULTS: Direct suture of the upper three intercostal nerves to the musculocutaneous nerve is always possible upto the axillary fossa. The sixth intercostal nerve can be delivered upto this level in only 50% of cases without dissection of the musculocutaneous nerve upto its entry into the coracobrachialis. The musculocutaneous nerve presents a mean surface area of 2.64 mm2 while the nerve to the biceps has a mean surface area of 0.34 mm2 i.e. a ration of 1/8. The mean surface area of the intercostal nerves at the parasternal level is 0.23 mm2 while that at the axillary level is 0.34 mm2. Thus a loss of 33% in surface area occurs between the axillary and the parasternal levels. Our study confirms the insufficiency between the surface area of the intercostal nerves and the different nerve trunks to be neurotized. The relationship between the surface area of the musculocutaneous nerve and the three intercostal nerves is 26.72% with a minimum of 17.2%. If a fourth intercostal nerve is added, this ratio nerves appears to be a superior technique. We were able to deliver the sixth intercostal nerve for a direct suture to the musculocutaneous nerve in only half the cases.
Aged↗
The beta enolase subunit displays three different patterns of microheterogeneity in human striated muscle.
In higher vertebrates, the glycolytic enzyme enolase (2-phospho-D-glycerate hydrolyase; EC 4.2.1.11) is active as a dimeric protein formed from three subunits--alpha: ubiquitous, beta: muscle specific, and gamma: neuron specific--encoded by different genes. In the present study, we have shown that an antiserum previously produced against the mouse beta beta enolase is also a specific reagent for the muscle specific human enolase. Using this antiserum to study human muscles, we demonstrated novel patterns of the beta subunit microheterogeneity which are distinctive from those observed previously in rodents and which appear to be independent of age, gender and muscular activity. Two variants of the beta subunit differing by their size have been detected: one heavy form of 46 kDa (beta H) and one light form of 45 kDa (beta L). Muscle biopsies expressed either beta H or beta L or beta H + beta L, and all muscles of an individual expressed the same variants. The products of in vitro translation of RNA prepared from human muscle displayed beta subunit variants identical to those of the protein present in the biopsy. Therefore the differences observed between individuals reveal a difference already present at the level of the RNA transcripts. These observations suggest the existence of an yet undescribed polymorphism of the human beta enolase gene which could affect the coding sequence. Comparative immunocytochemical and histochemical analyses of biopsies demonstrated that the beta subunit was expressed in all fast fibres (type II), but not in slow fibres (type I). No difference was observed in the intensity of beta enolase immunolabelling between the various types (IIA, IIAB, IIB) of fast fibres. No significant difference in fibre type composition and histological appearance was visible between muscles presenting either one of the three patterns of microheterogeneity.
Adult↗
[Partial arthrodeses of the wrist: experimental studies].
The partial arthrodeses of the wrist joint are well known as a method of treatment of several articular pathologies. Although there exists controversies about the final range of motions. In the goal to compare the state of the ligaments to the final range of motions we realised some of the most popular intracarpal arthrodeses in an anatomical laboratory. For our study we used 10 fresh cadaver specimens with the mean age of 88 years (84-95). The arthrodeses were realised with Kirschner wires. Biggest range of motion (more than 70%) was obtained after scapho-lunatum, scapho-capitatum and luno-triquetrum arthrodeses, while after luno-capitatum, scapho-luno-capitatum and triquetro-hamato-luno-caitatum it was the poorest--less than 50% of the initial state. We found a correlation between the state of the ligaments and the final results--in specimens with tears of the ligaments the results were closer to the perfect-ones from the clinical series. In our opinion the measurement of radial and ulnar deviation in clinical practice is not exact and should not be considered in the elaboration of scientific databases.
Aged↗
[Anatomic study and review of the literature on the Martin Gruber anastomosis].
We dissected 72 upper limbs of fresh cadavers and found 17 cases of the Martin-Gruber anastomosis. The incidence was 23.6%. They can be classified into 5 types. Type I (n = 5, 29.4%): Communication between the anterior interosseous and the ulnar nerves. Type II (n = 3, 17.6%): Communication between the median and the ulnar nerves. Type III (n = 3, 17.6%): Communication between the muscular branches of the flexor digitorum profundus muscle (FDP). Type IV (n = 3, 17.6%): Communication between the anterior interosseous and the ulnar nerves, the muscular branches of the flexor digitorum profundus muscle (FDP) originated from the connection. Type V (n = 3, 17.6%): The anastomotic branch originated from the median nerve and joined the ulnar at two different points as well as connecting with the ulnar branch of the FDP. Through histologic examination, we found the number and size of nerve fascicles which every connection contained to be very different. In one case of type II only one single nerve fascicle was found. We propose the hypothesis that the different amounts of nerve fascicles innervate different amounts of intrinsic hand musculature. The communication which contained one single nerve fascicle only innervate the first dorsal interosseous muscle (FDI).
Aged↗
[Anterior transbrachial approach of the coronoid apophysis].
Fractures of the coronoid process of the ulna can cause elbow instability. Treatment of these fractures, sometimes surgical, raises a problem of the incision. The incisions described to date do not provide specific exposure, or require sometimes dangerous nerve and vascular dissections. The authors propose a strictly brachial midline anterior incision. The biceps tendon is retracted laterally and the brachialis muscle is then dissociated longitudinally providing direct exposure of the coronoid process, with no risk of nerve lesions, and allowing direct screwing of the fracture.
Adult↗
Ninth annual meeting of the American Society for Peripheral Nerve. June 19-21, 1999--Los Angeles, CA.
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Animals↗
Histomorphometry of the ulnar nerve and of its branches.
A morphometric study has shown that 10% of the fibers of the ulnar nerve should suffice to reinnervate the biceps muscle in brachial plexus palsies. The aim of this study was to evaluate, by a morphometric study using computerized microanalysis, the cross-sectional surface areas of the different collateral and terminal branches of the ulnar nerve. This was expressed in terms of percentage of the cross-sectional surface area of the main trunk of the ulnar nerve. The study revealed that the branch to the flexor digitorum profundus bellies to the ring and little fingers formed 9.5% of the cross-sectional area of the ulnar nerve. Thus use of these fascicles destined for the flexor digitorum profundus, identified by intra-operative nerve stimulation, at the level of the arm would be sufficient for neurotisation of the nerve to the biceps. This has been confirmed by the initial clinical results in patients operated upon using this technique.
Aged↗
The posterior interosseous nerve and the radial tunnel syndrome: an anatomical study.
Twenty anatomical specimens were carefully studied in order to establish a possible connection between the posterior interosseous nerve and the radial tunnel syndrome. Our results show that the posterior interosseous nerve distal to the supinator muscle may be compressed by various structures. These include the distal border of the supinator muscle, the ramifications of the anterior and posterior interosseous vessels, and the septum between the extensor carpi ulnaris and the extensor digitorum minimi. The posterior interosseous nerve is also stressed during passive supination (elongation and rotation), and during passive pronation (compression). This suggests that the interosseous nerve distal to the supinator muscle should be explored in radial tunnel compression syndromes.
Aged↗
Tendon transfers to restore elbow flexion after traumatic paralysis of the brachial plexus in adults.
Loss of elbow flexion after traumatic brachial palsy produces significant functional and cosmetic problems. Although a direct approach to the neurological lesion with an attempt to reinnervate the biceps has given some encouraging results, these can be incomplete and for this reason tendon transfers still have an important role. We report the results of our series of 60 patients (54 men and 6 women) who have undergone tendon transfer between 1984 and 1994. The transfers were performed during or after nerve surgery, and we used the muscles arising from the medial epicondyle, the pectoralis minor and the triceps. Our results were judged on any improvement in shoulder stability and in the power of lateral rotation, together with the power and range of active and passive flexion of the elbow. Good results were achieved in 74% of the patients in our study, with more than 120 degrees of elbow flexion and an ability to support at least 1 kg with the elbow flexed to 90 degrees.
Adult↗
Contribution of magnetic resonance imaging for the diagnosis of median nerve lesion after endoscopic carpal tunnel release.
Deterioration of pre-existing signs or appearance of a nerve deficit raise difficult problems during the complicated course following endoscopic carpal tunnel release. One possible explanation is transient aggravation of nerve compression by passage of the endoscopy material, but these signs may also be due to incomplete section of the flexor retinaculum or an iatrogenic nerve lesion. Each case raises the problem of surgical revision. The authors report three cases of open revision in which MRI allowed a very precise preoperative diagnosis of the lesions and all of the MR findings were confirmed during surgical revision. In the first case, MRI showed section of the most radial branches of the median nerve (collateral nerves of the thumb, index finger and radial collateral nerve of the middle finger). The proximal origin of the nerve of the 3rd web space, above the retinaculum, an anatomical variant, was also identified. Section of 2/3 of the nerve of the 3rd web space, proximal to the superficial palmar arch, was observed in the second case. Simple thickening of the nerve of the 3rd web space, without disruption after opening of the perineurium, was observed in the third case. MRI therefore appears to be an examination allowing early and precise definition of indications for surgical revision in this new iatrogenic disease.
Carpal Tunnel Syndrome↗
Extensor digiti minimi tendon "rerouting" transfer in permanent abduction of the little finger.
Permanent abduction of the little finger is a bothersome deformity which usually occurs in the context of sequelae of ulnar nerve palsy (Wartenberg's sign), but also in rheumatoid arthritis. The authors report an original technique for correction of this deformity. The extensor digiti minimi tendon is sectioned at its distal insertion and transferred in the wrist through the extensor retinaculum. The "rerouted" tendon is finally resutured distally on the radial aspect of the interosseous muscle. Side-to-side suture of the transferred tendon to the extensor digitorum tendon of the little finger further reinforces the solidity of the procedure. The distal insertion of the extensor digiti minimi tendon is consequently radialized. Its new direction eliminates the abduction component, and the tendon then behaves as an active adductor of the little finger. Five cases (2 cases of ulnar nerve palsy, 3 cases of rheumatoid arthritis) are reported with a mean follow-up of 19 months. All patients have complete active adduction of the little finger in extension, with a persistent capacity for abduction. The other correction techniques published in the literature are discussed.
Adolescent↗