[Comminuted intra-articular fractures of the distal humerus in elderly patients]. / Fractures articulaires complexes de l'extrémité distale de l'humérus chez le sujet âgé

Treatment of comminuted intra-articular fractures of the distal humerus in elderly patients remains a challenge in trauma surgery. These fractures are rare, but their frequency increases. Our multicenter studies collected 238 cases of comminuted intra-articular fractures of the distal humerus in patients older than 65: two hundred and five cases for the retrospective study, 33 for the prospective study with a minimum follow-up of six months. The following criterias were studied: age, sex, state of health (with ASA score), functional scores (with Katz score), osteoporosis by the OST score and dual X-ray absorptiometry. The results were evaluated according to the Mayo Elbow Performance Score (Morrey) and the Quick DASH. X-ray studies were performed in order to assess both results for prosthesis and osteosynthesis. The following criteria were studied: bone healing, quality of reduction, signs of arthritis (Broberg-Morrey), prosthetic position, mechanical complications, prosthesis fixation. There were 80% of women in good health according to the ASA score (more than 70% of ASA 1 or 2). Most of them (80%) were self-governing and living at home. Hundred and seventy-two patients had an osteosynthesis and 44 had a prosthetic reconstruction (like Coonrad-Morrey prosthesis). Patients treated with osteosynthesis were younger (mean age was 77) than those treated with prosthetic reconstruction (mean age 81). Mean follow-up was 32 months. Results of osteosynthesis were good and excellent for 77% of the patients. Complications occurred for 20% of patients with a reoperation rate of 13%. Results of prosthetic reconstruction were good and excellent for 83% of the patients with 14% of complications and 6% of reoperation. Prosthetic reconstruction seemed to be better than osteosynthesis according to the Mayo Clinic score (84 points versus 77 points for the retrospective study and 95 points versus 75 points for the prospective study). However, the statistical analysis was not significant. Treatment of these fractures must be discussed according to the physiological status of the patient and the fracture patterns (scan evaluation). In conclusion, osteosynthesis remains the standard treatment when stable fixation is feasible. However, prosthetic reconstruction should be discussed for dependant patients or with comorbidity factors, bad bone quality leading to poor osteosynthesis or complex fracture.

Non-invasive imaging correlates with histological and molecular characteristics of an osteosarcoma model: application for early detection and follow-up of MDR phenotype.

BACKGROUND: In an orthotopic rat osteosarcoma model, histological and molecular findings were compared with the results of non-invasive imaging methods to assess disease progression at the primary site, the pattern of metastatic dissemination and the chemoresistance phenotype. MATERIALS AND METHODS: Primary tumor engraftment, vascularization, growth and metastatic spread were evaluated using 18FDG tomoscintigraphy. Bone neoformation in the primary tumor and metastasis was determined using 18FNa confirmed by classical histological studies. Chemoresistance phenotype was assessed by analysis of MDR1 and MRP1 genes expression compared to 99mTc MIBI imaging. RESULTS: 99mTc MIBI imaging correlated with the overexpression of the MDR1 and MRP1 genes. 18FDG, 18FNa and 99mTc tomoscintigraphies revealed that the pattern of vascularization, bone neoformation and hematogeneous metastatic dissemination in our animal model mimics its human counterpart. CONCLUSION: Multimodality, non-invasive imaging is a valid surrogate marker of histological and molecular characteristics in an orthotopic osteosarcoma model in immunocompetent rats; it allows extensive in vivo follow-up of osteosarcoma, including longitudinal analysis of chemoresistance.

[Intra-articular fracture of the distal humerus: outcome after osteosynthesis in patients over 60]. / Résultats de l'ostéosynthèse des fractures articulaires de la palette humérale chez le sujet âgé

PURPOSE OF THE STUDY: This is a retrospective analysis of patients aged over 60 years treated in a single center for intra-articular fractures of the distal humerus. Outcomes were compared with published results for osteosynthesis and arthroplasty. MATERIAL AND METHODS: The cohort included 34 patients (36 fractures) reviewed at mean 35 months. Mean age was 77.6 years. Fracture types were: C1: 8, C2: 10, C3: 18. The transtricipital posteromedial approach was used in the majority of patients. Fixation was achieved with a prebent lateral plate (n=11 fractures), a Y-plate (n=9), two plates (n=4), pins or screws (n=9) and an external fixator (n=3). Outcome was assessed with the Mayo elbow score, the Bröberg radiographic score and patient satisfaction. The social impact was also noted. RESULTS: The mean Mayo elbow score was 73.3; outcome was excellent (n=13), good (n=8), fair (n=5) and poor (n=10). Pain persisted in 23 patients. The mean range of movement was 80 degrees . Patient satisfaction remained good. Ten patients did not recover their preoperative level of autonomy. Radiological signs of osteoarthritis were noted for 75% of patients and nonunion of the humeral fracture in 32%. There were three superficial infections and four neurological lesions. DISCUSSION: Good and very good outcome was noted for 59% of the osteosyntheses in this series, compared with 71% in the literature. The rate for arthroplasty is 95%. The mean range of motion is 101 degrees , 17% of patients with a prosthesis complain of pain, 5% develop a superficial infection and 6.5% suffer neurological injury. The estimated rate of revision for arthroplasty is 11% at 7 years. CONCLUSION: Beyond the age of 65 years and based on evidence reported in the literature, it would be advisable to prefer another mode of treatment for these intra-articular fractures, for example elbow arthroplasty, particularly for comminutive fractures on osteoporotic bone.

[Total hip arthroplasty for treatment of acute acetabular fracture in elderly patients]. / L'arthroplastie totale de hanche dans le traitement des fractures récentes de l'acétabulum du sujet âgé

PURPOSE OF THE STUDY: The standard treatment of displaced acetabular fractures is open reduction and internal fixation (ORIF). In elderly patients, ORIF may not be the best option because of osteoporotic bone and the necessary period of bed rest. Primary total hip arthroplasty (THA) for displaced acetabular fractures was initiated by Westerborn in 1954. Since then, several authors described their experience and since 1986 many studies have reported good results with this type of treatment. This study assessed outcome obtained in patients treated by primary THA for acetabular fracture in the orthopedic department of the Dupuytren Teaching Hospital in Limoges. MATERIAL AND METHODS: Between 1981 and 2001, 16 patients, mean age 76.1 years (range 64-89) were treated with primary THA for recent displaced acetabular fractures. Bone loss was quantified using the SOFCOT classification for acetabular revision THA: stage III was noted in four patients (25%) and stage IV in twelve (75%). No attempts were made to achieve anatomic reduction of fracture fragments, but a reinforcement ring was used, coupled with autologous bone graft for the acetabulum. All patients were assessed clinically using the Postel-Merle d'Aubigné et Harris scores and the Devane activity scale. Radiographs were used to assess union and signs of loosening according to De Lee and Charnley and the Gruen classifications. Ossifications were quantified with the Brooker classification. RESULTS: Mean follow-up was three years. The mean Harris hip score was 73.6 (range 47-93), and the mean Postel-Merle d'Aubigné score 13.8 (range 10-17). Twelve patients (75%) returned to their initial activity level on the Devane scale; only four decreased their daily activity by one level. All patients but one were satisfied. There was one case of partial neurological sensorial deficit. There were no postoperative dislocations. All fractures healed. There were six cases (37%) of heterotopic bone formation including grade IV ossification in one patient with a stiff hip which required surgical resection. There were five cases of radiolucent halo in one zone of the cup, and one case in two zones; all these lucencies were non-progressive and there was not sign of loosening at last follow-up. DISCUSSION: Orthopedic treatment for displaced acetabular fractures in elderly patients may not be suitable because of the risk of complications due to the prolonged period of decubitus. ORIF requires one surgery, but may nevertheless lead to a second operation because of osteoarthritis. Primary THA has many advantages: full weight bearing is achieved rapidly, decubitus complications are avoided, functional outcome was good with union for all of the fractures in our series. Nevertheless, despite differences between surgical procedures reported in the literature, ectopic ossifications are common and the overall rate of dislocation reaches 7% considering all reported series. CONCLUSIONS: In selected patients with a displaced acetabular fracture, we believe that an acute THA may provide several advantages including only one procedure and quick weight bearing with a lower rate of decubitus complications. In this small series, functional outcome was good for most of the patients who recovered their initial activity level.

Learning the skills needed to perform shoulder arthroscopy by simulation.

INTRODUCTION: Simulation for arthroscopy helps surgical trainees develop their surgery skills in a safe environment. This teaching technique has become more widespread in recent years because of the need to provide surgeons in training with an alternative to the current methods. We hypothesized that a resident in surgery could acquire the skills needed to perform arthroscopic shoulder surgery by working on a simulator. MATERIAL AND METHODS: The study was conducted over a 4-month period from June to September 2016. All the surgeons and residents in our department participated in the study. We recorded each participant's age, sex, dominant hand, and video gaming experience. We used the Arthro Mentor™ simulator from Simbionix (now 3D Systems). Testing was carried out at the start and end of training to evaluate the participant's skills and their progression. The changes were evaluated statistically. RESULTS: Fourteen surgeons were included in the study. They were split into two groups: controls and residents. There was a statistically significant improvement in the intern group between the overall pre-test score and the overall post-test score. There was no significant improvement in the overall score of the control group between the pre-test and post-test. DISCUSSION: For surgeons in training, shoulder arthroscopy simulation helps them acquire the skills needed to perform arthroscopy such as hand-eye coordination, triangulation and the ability to work in three-dimensions based on two-dimensional visual information. We believe that the benefit of simulation resides in learning the skills needed to perform a surgical procedure, not in learning the procedure itself. LEVEL OF EVIDENCE: III-case-control study.

Lung metastases of diffuse giant cell tumour of the fibular tendon sheath at the ankle: A case report.

Diffuse giant cell tumours of the tendon sheaths are described in the literature as locally aggressive soft-tissue tumours. We report the case of a 56-year-old male with a history of multiple surgical procedures for a giant cell tumour of the fibular tendon sheath at the right ankle. The multiple recurrences prompted monitoring by positron-emission tomography, which showed lung tumours. Biopsies confirmed that the tumours were metastases from the giant cell tumour of the tendon sheath. In patients with recurrent and/or diffuse giant cell tumour, positron-emission tomography is an effective monitoring tool.

Pyoderma gangrenosum or necrotising fasciitis? Diagnostic and therapeutic wanderings.

A case of post-traumatic lower-limb pyoderma gangrenosum (PG) in a 77-year-old female is reported. The diagnosis of PG is frequently one of exclusion, and it is therefore unsurprising that the condition was initially mistaken for necrotising fasciitis then for necrotising bacterial dermo-hypodermitis. Medical and surgical treatment for those conditions proved ineffective. This fact, together with the atypical presentation, promoted a re-evaluation of the diagnosis. The clinical findings and investigation results converged to suggest PG, and a therapeutic trial was initiated. The good treatment response and negative findings from tests for other conditions established the diagnosis of post-traumatic PG.

Comminuted fractures of the radial head treated by the Judet floating radial head prosthesis.

Excision is not a suitable treatment for all comminuted fractures of the radial head. In elbows where instability can be predicted, a replacement arthroplasty of the radial head is more effective. The aim of this paper was to present the medium-term results of the Judet floating radial head prosthesis. This operation was performed on 14 patients between 1992 and 2003, of whom 12 were reviewed at a mean follow-up of five years and three months (1 to 12 years). The outcome was assessed using the Mayo elbow performance score and a modified Disability of Arm Shoulder Hand (DASH) questionnaire. There were six excellent results, four good, one fair and one poor, as graded by the Mayo score. The mean DASH score was 23.9/100 (0 to 65.8/100). The only significant complication occurred in one patient who developed a severe complex regional pain syndrome. There were no patients with secondary instability of the elbow, implant loosening, cubitus valgus, osteoporosis of the capitellum, or pain in the forearm and wrist. Our experience, combined with that of other authors using this device, has encouraged us to continue using the Judet prosthesis in comminuted fractures of the elbow where instability is a potential problem.

Endoscopic ulnar nerve release at the elbow: Indications and outcomes.

BACKGROUND: Ulnar nerve entrapment at the elbow is the second most common nerve entrapment syndrome at the upper limp, after carpal tunnel syndrome. Many surgeons feel that ulnar nerve instability contra-indicates endoscopic nerve release. Published studies, however, found no evidence that pre-operative or intra-operative ulnar nerve instability adversely affected clinical outcomes. The objective of this prospective study was to define the indications and describe the outcomes of endoscopic ulnar nerve release at the elbow. HYPOTHESIS: Endoscopic ulnar nerve release at the elbow is a valid option even in patients with ulnar nerve instability and regardless of the severity of the compression. MATERIAL AND METHODS: We conducted a prospective single-centre study of patients scheduled for surgery based on clinical and electromyographic manifestations of ulnar nerve entrapment at the elbow. Ulnar nerve instability (incomplete dislocation, i.e., Childress A) before or during surgery was not a contra-indication to the procedure. The patients were re-evaluated 12 months after surgery. RESULTS: Seventeen patients were included in the statistical analysis. The modified Bishop's score indicated excellent or good outcomes in 15 (88%) patients (excellent in 4 and good in 11) and a fair outcome in 2 patients. Functional outcomes were not associated with the presence of ulnar nerve instability before surgery. DISCUSSION: We elected to include patients with Childress A ulnar nerve instability. Clinical outcomes in these patients were similar to those in patients without ulnar nerve instability. LEVEL OF EVIDENCE: IV, open prospective study of treatment outcomes.

Selective killing of osteosarcoma cells in culture after retroviral mediated gene transfer of a herpes simplex thymidine kinase suicide gene.

As conventional therapy of osteosarcoma is aggressive and its success relatively poor, notably in cases relapse, we investigated the therapeutic effect of retroviral herpes simplex thymidine kinase (HSV1-TK) gene transfer into a human osteosarcoma cell line. Transfected target cells are sensitive to ganciclovir (GCV) (IC50 0.1 microM), and a potent bystander effect, by which cell death can be induced in HSV1-TK negative dividing cells located in the vicinity of HSV1-TK positive ones, is demonstrated. This is significant for clinical applications as no available gene transfer method can achieve 100% transduction to target cells.

Treatment of experimental osteosarcoma tumors in rat by herpes simplex thymidine kinase gene transfer and ganciclovir.

Previous results have demonstrated the efficiency of Herpes simplex type 1 thymidine kinase (HSV1-TK) retroviral gene transfer and ganciclovir (GCV) treatment of a human osteosarcoma cell line resulting in the death of the cell population and a proximal bystander effect; therefore, we investigated gene therapy on an in vivo osteosarcoma rat model. For in vivo experiments, small fragments of tumor were grafted onto rats in a paratibial position. Seven days after the graft, packaging cells (psi CRIP-TK and psi CRIP-LLZ) were inoculated into tumor mass, followed by GCV administration. In vivo results showed the efficiency of this system that allowed the reduction of the tumor mass and prevented lung metastasis appearance, which represents the normal evolution. This type of treatment seems promising for rapidly proliferating tumors such as osteosarcoma; the lower IC50 makes this system particularly attractive as clinically doses may be of low magnitude to prevent secondary effects in patients.

Effects of alumina and zirconium dioxide particles on arachidonic acid metabolism and proinflammatory interleukin production in osteoarthritis and rheumatoid synovial cells.

We describe a model which can be used for in vitro biocompatibility assays of biomaterials. We studied the in vitro response of human osteoarthritis or rheumatoid arthritis fibroblast-like synoviocytes to Al2O3 or ZrO2 particles by analysing the production of interleukin-1 (IL-1) and interleukin-6 (IL-6) and the metabolism of arachidonic acid via lipoxygenase and cyclo-oxygenase pathways. Our results show that, in these cells and under our experimental conditions, Al2O3 and ZrO2 did not significantly modify the synthesis of IL-1 and IL-6 or the metabolism of arachidonic acid.

Intradiscal injection of triamcinolone hexacetonide for acute, subacute, and chronic sciatica. Results at 3 months an open-prospectus study of 30 cases and review of the literature.

The authors report an open study of 30 cases of intradiscal injection of triamcinolone hexacetonide in the treatment of sciatica. The patients were monitored at months 1 and 3. The results were judged to be good in 36.6% of the cases, moderate in 36.6% and poor in 26.7% of the cases. Two adverse effects were reported: 1 case of reversible urinary retention and 1 case of deficiency of the dorsiflexor muscles of the foot. The good results reported in previous series were only found in this study when the indications were restricted to certain favourable prognostic factors: duration of sciatica less than 6 months and CAT-scan appearance of discal hernia. This technique has the advantage of being simple, economical and nonallergic. On the basis of the encouraging results of the initial series, this technique should be considered as an interesting therapeutic alternative in sciatica. Larger series and double-blind studies, however, are necessary to confirm the initial results.

[Long-term 10-year outcome after chemonucleolysis for lumbar disc herniation]. / Résultats à long terme de la chimionucléolyse pour hernie discale lombaire.

PURPOSE OF THE STUDY: We studied the efficacy of papaine for treatment of herniated discs at a mean 10-year follow-up and compared results with other series and other treatments. MATERIAL AND METHODS: From an initial group of 160 patients, 96 patients, 53 men and 43 women, mean age 39 years, were selected for evaluation. These patients had 46 L4L5 herniations and 50 L5S1 herniations. All 96 patients were operated in the same department and received the same dose of papaine under the same anesthesia conditions. All patients were followed regularly to 3 months postoperatively then were reviewed 3 to 17 years after surgery. Inquiries were made about return to work, pain, and activity. Physical examination and x-rays were obtained for all patients. RESULTS: There were no neurological complications in our series. Seventeen patients required a second procedure for sciatic pain. Most of the patients continued their normal occupational and social activities after papaine treatment, but many of them had chronic lumbar pain. DISCUSSION: Our results were comparable with series reporting a similar long follow-up. Surgery is more efficient than papaine but long-term results are equivalent. CONCLUSION: Chemopapaine treatment provided good long-term results in our patients, similar to surgery. Chemonucleolysis may be employed as first line treatment for young patients with non-excluded disc herniation with sciatic pain.

[Extra-spinal cause of recurrent sciatalgia after disk surgery: a case report]. / Récidive sciatalgique de cause extra-rachidienne après chirurgie discale. A propos d'un cas.

There is a general consensus concerning the clinical and radiological approach to diagnosis and proper management strategy in patients with sciatalgia subsequent to disk herniation. Recurrent herniation is the most probable diagnosis when pain recurs the same territory long after surgery. Despite advances in computed tomographic and magnetic resonance imaging, it may be difficult to identify the real source of the pain in some patients. We report a patient with renal cell cancer who developed recurrent sciatic pain which did not respond to disk surgery. This case illustrates the need for an extensive work-up before implicating the spine as the cause of recurrent sciatalgia.

[Aneurysmal bone cyst of the patella. A case report and literature review]. / Kyste anévrismal de la rotule.

We report a case of an aneurysmal cyst localized in the patella of a 37-year-old man. The lesion was secondary to a chondroblastoma at six years follow-up after initial curettage and bone graft. It were no recurrence. Treatment of aneurysmal cysts depends on the degree of articular involvement. We made a detailed study of 11 cases of this rare localization of aneurysmal cysts reported in the literature.

[Tibio-talar arthrodesis: long term influence on the foot]. / Etude de la tolérance à long terme de l'arthrodèse talo-crurale.

PURPOSE OF THE STUDY: The aim of this study was to evaluate the long-term effect of tibiotalar arthrodesis on function, clinical and radiological tolerance, and subtalar joints. MATERIAL AND METHODS: We reviewed 37 cases of tibiotalar arthrodesis in 27 young patients who were generally manual workers. Their mean age at surgery was 46 years and mean follow-up at review was 12.8 years (range 5-26 years). Functional outcome was assessed with the Duquennoy scale. We reviewed the anterioposterior and lateral weight-bearing views as well as the lateral view in dorsal and forced plantar flexion. RESULTS: Mean functional outcome was good and very good in 66% of the cases, fair in 30% and poor in one case. Total pain relief had been achieved in 45% of the cases with a mean walking distance of 1500 m without crutches. Residual mobility at last follow-up was 13 degrees for the mediotarsal joint. This mobility allowed the arthrodesed foot to adapt to gait. Radiologically, fusion had been achieved in 83% of the cases within 3 months. The overall functional score fell off proportionally with the degree of arthrodesis valgus starting at 5 degrees. Likewise pes equinus > 10 degrees led to pain and reduced motion. The subtalar joints were affected in all cases, leading to poor adaptation of the foot on uneven ground. Grade 1 osteoarthritis affected the mediotarsal joint and was more marked in case of equine fixation. DISCUSSION: Our results are similar to those reported in the literature. We had 4 cases of nonunion in patients with risk factors previously discussed in the literature. CONCLUSION: Arthrodesis remains a useful method for treating talocrural osteoarthritis, providing good long-term results. The position of the fixation should be 90 degrees in the sagittal plane and 0 degrees to 5 degrees valgus in the frontal plane.

[Extradural spinal cysts: an uncommon cause of back pain. Review of the literature apropos of a case]. / Les kystes spinaux extra-duraux: une cause exceptionnelle de douleurs vertébrales. Revue de la littérature à propos d'une observation.

The authors report the case of an extradural spinal cyst in a patient whose only complaint was lumbar pain and review the literature. Among the 186 cases found, only 21 presented with isolated back pain. Indeed, neurologic signs such as paresthesias and radicular pain are most frequently encountered. Standard radiographic X-rays suggest the diagnosis by demonstrating widening of the interpedicular distance on the anteroposterior view, and bone erosion or scalloping of the posterior surface of the vertebral bodies on lateral view. Myelography most often confirms the diagnosis with opacification of the cyst. However, the least invasive and most accurate examination is undoubtedly magnetic resonance imaging, which demonstrates the cyst and its location even if the communicating orifice is obstructed. These cysts are very probably of congenital origin and are caused by a herniation of the arachnoid through an aplastic area of the dura mater. Treatment is always surgical with, if possible, ligature at the base and cyst removal. Following surgery, the pain disappears and the neurologic signs very often regress.

[Elastofibroma in the scapular region. A case report and review of the literature]. / Elastofibrome de l'espace scapulo thoracique. Revue de la littérature à propos d'un cas.

PURPOSE OF THE STUDY: We report a case of elastofibroma and have collected 280 cases in the literature. MATERIAL AND METHODS: A 56 year-old man presented with a right subscapular mass. The patient was asymptomatic but he reported a "clicking"sensation associated with mobilization of the shoulder. Physical examination revealed a round mass clearly demonstrated with forward elevation of the arm. The MRI scan showed a heterogeneous soft tissue composed of inhomogeneous density with areas of more intense signal suggesting adipose tissue. The tumor was surgically excised and the diagnosis of elastofibroma was established by histopathologic examination. RESULTS: Six months after removal of the mass, there were no functional complications. DISCUSSION: Elastofibromas usually occur in active patients generally older than 55 years of age. They are typically located in the right subscapular region. The tumor remains asymptomatic in more than 50 percent of cases. 25 percent of the patients may report a simple discomfort sometimes with a "clicking" or "catching" sensation associated with mobilization of the arm. Pain is present in less than 10 percent of cases. Physical examination may reveal a rubbery, asymptomatic mass located in the subscapular region and barely noticable when the arm lies again the chest. Plain radiographs and preoperative laboratory data were unremarkable. CT scan or MRI scan may show an heterogeneous fibrous mass of intermediate density with entrapped signals of higher intensity. However, a definitive diagnosis requires a biopsy showing the distinctive feature of elastofibroma: elastic fibers in a collagenized fibrous tissue with entrapped adipose tissue. Pathogenesis of elastofibromas may result from the friction of the scapula against the thorax thus generating tumor growth. CONCLUSION: Complete surgical excision in symptomatic patients is considered to be the treatment of choice. However, once the diagnosis of elastofibroma has been established, excision of lesions smaller than 5 cm can be avoided in asymptomatic patients.

[Perforation of the sigmoid colon secondary to acetabular fracture]. / Perforation sigmoïdienne consécutive à une fracture de l'acétabulum.

Traumatic lesions of the colon associated with fracture of the acetabulum occurs in less than 2% of the cases. Direct perforation of the colon by a bony spike, which occurred in our patient, is even more exceptional. We were unable to find any other case reported in the literature. This case illustrates the importance of looking for intestinal lesions in all patients with pelvic injury presenting an unexplained infectious syndrome. Imaging provides clear evidence for avoiding late diagnosis and life-threatening situations.