A multicenter, randomized, open-label, controlled study comparing the efficacy, safety and cost-effectiveness of a sequential therapy with RV4104A ointment, ciclopiroxolamine cream and ciclopirox film-forming solution with amorolfine nail lacquer alone in dermatophytic onychomycosis.

BACKGROUND: The efficacy of topical antifungals is controversial. OBJECTIVE: To compare the efficacy and safety of a sequential(SEQ) treatment with chemical nail avulsion and topical antifungals to amorolfine nail lacquer in dermatophytic onychomycosis. METHODS: This was a randomized,parallel-group, controlled study comparing a 36-week SEQ treatment with chemical nail avulsion with RV4104A ointment(class I medical device containing 40% urea) followed by ciclopirox cream for 8 weeks and ciclopirox nail lacquer for 25 weeks (SEQ group) to amorolfine nail lacquer for 36 weeks (AMO group). Patients had to have a big toenail onychomycosis,sparing the matrix. The primary efficacy criterion was complete cure at week 48. A cost-effectiveness analysis was performed. RESULTS: A total of 142 patients were randomized. The complete cure rate at week 48 was significantly higher in the SEQ group than in the AMO group (36.6 vs. 12.7%, p = 0.001). Clinical cure at week 48 was observed in 53.5% of patients in the SEQ group versus 17% in the AMO group (p < 0.01). The cost of cure per patient was 50% lower with SEQ treatment (EUR 33) compared with amorolfine(EUR 76). CONCLUSION: A treatment of onychomycosis comprising chemical avulsion of the pathological nail, ciclopirox cream and nail lacquer is significantly more effective than amorolfine nail lacquer.

Scoliosis and fused ribs. A case report.

STUDY DESIGN: This case report illustrates a scoliotic patient with congenital fusion of several ribs associated with a thoracic curvature. OBJECTIVES: To report the procedure used to correct scoliosis in association with congenitally fused ribs. SUMMARY OF BACKGROUND DATA: All cases of congenitally fused ribs reported in the literature are associated with malformed vertebrae. For this reason, the only proposed treatment for patients with progressive scoliosis is a spinal fusion. This report presents the first case of progressive scoliosis associated with fused ribs, but without vertebral malformation, that was managed by resection of these ribs. METHODS: When worsening of the thoracic scoliosis was observed from 30 degrees at 13 months to 44 degrees at 4 years, the three fused ribs were resected en bloc. No spinal fusion was performed. The spine was held in correction by a localizer cast for 3 months. RESULTS: Fourteen years after treatment, the spine is almost normal; thoracic and lumbar curves are 10 degrees. CONCLUSIONS: When malformed fused ribs are on the concave side of a progressive scoliosis with no vertebral malformation at the same level, resection of these ribs is probably an efficient and sufficient method of treatment.

[A new method of osteosynthesis in proximal humeral fractures: a new internal fixation device. Apropos of 17 cases followed over more than 2 years]. / Une nouvelle méthode d'ostéosynthèse des fractures de l'extrémité supérieure de l'humérus: l'implant bilboquet. A propos de 17 cas revus à plus de 2 ans.

PURPOSE OF THE STUDY: The authors describe a new internal fixation device, and report on 17 proximal humeral fractures managed with this technique. MATERIAL AND METHODS: The fracture patterns, using Neer's classification were: 9 displaced three-part fractures, 4 displaced four-part fractures and 4 interior fracture dislocations (mean age of the patients: 70 years). The device is a two-part titanium device. The humeral component has a long vertical stem cemented in the humeral shaft; and a short proximal portion set at an angle of 135 degrees on the stem, with a neck and a Morse taper cone. The other part is a crown-shaped stapple, whose base is a perforated disk with a central Morse taper socket. The rim of the crown has five prongs which, together with the central socket, are impacted in the cancellous bone of the humeral head. The taper of the humeral component is inserted into the central socket of the stapple to provide fracture fixation. Tuberosities are reattached to the shaft with non absorbable sutures. RESULTS: Mean follow-up was 29 months. The global ratings were as follows: 4 excellent results, 6 good results, 4 fair results, 3 poor results. Mean active forward flexion: 100 degrees, and mean active external rotation 22 degrees. After exclusion of the 4 fracture-dislocations, the global rating became: 4 excellent results, 5 good results, 3 fair results, 1 poor result. Mean active forward flexion: 110 degrees and mean active external rotation: 31.5 degrees. There were no case of avascular necrosis in 13 patients. Complications requiring surgery occurred in one case: an upper protrusion of the stapple which required replacement of the stapple by a prosthetic humeral head. Other complications included: 2 asymptomatic partial protrusions of the stapple, 2 complete and two partial avascular necrosis in fracture-dislocations. DISCUSSION: Except for the fracture-dislocations our device confers several major benefits. The humeral head is preserved. Typical problems associated with joint replacement (dislocations, loosening, glenoid degeneration) are avoided. Humeral head conservation enhances healing of the tuberosities. Fixation could always be obtained, regardless of the complexity of the fracture pattern. An hemiarthroplasty (e.g. in case of avascular necrosis) is possible by the modular design of the device.

Cementless primary total hip replacement. Four to eight year results with the Zweymüller-Alloclassic prosthesis.

One hundred and twenty-nine consecutive cementless primary total hip arthroplasties with Zweymüller-Alloclassic grit-blasted titanium components were evaluated prospectively at an average follow-up of 5.9 years. The clinical results were graded as excellent or good in 116 hips (90%), fair in 12, and poor in one due to a fracture of the femoral shaft at operation leading to early stem loosening and delayed ring loosening. Failure was defined as definite aseptic loosening, and the final survivorship at 8 years was 99.3% for the SL-stem, and 99.1% for the CSF-threaded cup. These early results compare favourably with those of total hip arthroplasties using new cementing techniques.

Grit-blasted titanium femoral stem in cementless primary total hip arthroplasty: a 5- to 10-year multicenter study.

A total of 133 cementless primary total hip arthroplasties using the Zweymuller-Alloclassic grit-blasted titanium tapered stem were performed in 3 institutions. The patient cohort was divided into 2 subgroups, nonselected and selected, on the basis of excellent bone stock and age (<65 years old at surgery). Acetabular components were all cementless, and bearing surfaces were all alumina-ceramic on polyethylene. After a 7.3-year average follow-up period (range, 5-10 years), 118 primary femoral replacements in 109 patients could be reviewed fully. Mean age at surgery was 55.7 years (range, 27-84 years). According to the Merle d'Aubigne and Charnley rating system, clinical results were graded excellent and good in 89% of hips and fair in 11%. Radiologically, early subsidence >2 mm could be detected in 4 hips (3.4%). Calcar atrophy and spot welds were noted in 77% and 82% of hips. Femoral osteolysis granuloma was noted in 4 hips (3.4%). There has been no stem fracture and no ceramic head breakage. The survivorship at 10 years with definite femoral aseptic loosening (radiographic failure) as the endpoint was 100% (95% Wilson confidence interval, 78.4%-100%; worst scenario, 95.4%). A significant difference between the nonselected and selected patient subgroups was observed only for early reoperation (P =.03) and proximal stress shielding (P =.01). Press-fitting but not filling the femoral canal with a rough titanium, straight, tapered femoral component represents, at intermediate follow-up, a promising cementless option in primary total hip arthroplasty.

A new internal fixation technique for fractures of the proximal humerus--the Bilboquet device: a report on 26 cases.

We describe a novel internal fixation device and report on 26 patients (mean age, 70 years) whose proximal humeral fractures were managed with this technique. The 2-part titanium implant consists of a circular staple impacted into the humeral head cancellous bone and a spigoted diaphyseal stem that inserts into the staple "cup." Of the 26 cases reviewed, 16 had 3-part fractures and 10 had 4-part fractures. Mean follow-up was 25.9 months. In the 16 3-part fractures, the mean active forward elevation was 114 degrees and the results were as follows: excellent, 7; good, 5; fair, 3; poor, 1. In the 10 4-part fracture patients, the mean active forward elevation was 101 degrees and the results were as follows: excellent, 2; good, 4; fair, 3; poor, 1. There were 5 cases of avascular necrosis and 1 case of tuberosity nonunion. Only 2 cases needed conversion to hemiarthroplasty. The new technique should simplify the surgery of these fractures and reduce the need for arthroplasty.