A study of 28 flat bone osteosarcomas: prognostic factors and early and long-term outcome.

Limited information is available on clinical management of Flat Bone Osteosarcomas (FBOS). We retrospectively analysed prognostic factors and outcome. Twenty-eight patients were treated in our institution. Survival curves were obtained by the Kaplan-Meier method and compared with the log-rank test. The overall survival (OS) rates at 5 and 10 years were 52.4% and 45.8% respectively. The event-free survival (EFS) rates at 5 and 10 years were 41.5%. The factors influencing EFS in univariate analysis were location, metastatic disease at diagnosis, effect of neoadjuvant chemotherapy, histological response and adequate local tumour control. Location, metastatic disease at diagnosis, effect of neoadjuvant chemotherapy, histological response and local recurrence were statistically correlated with OS. Multivariate analysis retained metastatic disease at diagnosis as prognostic factors of EFS and OS. Our results suggest a more favourable outcome of FBOS as the use of a treatment scheme based on the protocols for long bone osteosarcomas. However, an adequate local treatment is essential to ensure a better outcome.

Amputation versus conservative treatment in severe open lower-limb fracture: A functional and quality-of-life study.

INTRODUCTION: Severe lower-limb trauma is a major event in a patient's life, and treatment is a challenge that has not been sufficiently studied. The main objective of the present study was to assess the difference in disability between amputees and patients who kept their leg after severe open lower-limb fracture. HYPOTHESIS: The study hypothesis was that amputation allows better functional recovery and quality of life, in the same time-frame. MATERIALS AND METHODS: All male and female patients aged over 18 years admitted to one of the trauma centers of Marseille (France) for major lower-limb trauma with Gustilo IIIb or IIIc fracture were included. Minimum follow-up was 2 years. Two groups were distinguished according to primary treatment: lower-limb salvage, or amputation. Rates of infection and of surgical revision, hospital stay, functional parameters (walking distance, standing, use of canes, running, jumping, driving, and physical and occupational activity) and quality of life (MOS SF-36 score) were compared between groups. RESULTS: The conservative treatment group comprised 27 patients, and the amputation group 24. Rates of infection and of surgical revision and hospital stay were significantly lower in the amputation group (P<0.02). All functional parameters (except return to work) and overall quality of life were significantly better in the amputation group. There was no significant inter-group difference in MOS mental score. CONCLUSION: In severe lower-limb trauma, amputation seems to give better functional and quality-of-life results. It did not, however, improve return to work, and was not better accepted psychologically than long and complex conservative management. LEVEL OF EVIDENCE: IV, retrospective study.

[Knee arthrodesis with a double mono-bar external fixators to salvage infected knee arthroplasty: retrospective analysis of 18 knees with mean seven-year follow-up]. / Arthrodèse du genou par double fixateur externe monobarre en contexte infectieux: à propos d'une série de 18 cas avec un recul moyen de 7 ans.

PURPOSE OF THE STUDY: Knee arthrodesis is sometimes the only alternative to amputation in patients with an infected knee prosthesis or in major bone damage with loss of the extensor system. We hypothesized that arthrodesis with a double mono-bar external fixators would be a valid technical solution enabling simple fixation sufficiently rigid to control infection. The main objective of our study was to assess outcome with this technique in terms of fusion. The secondary objective was to check remission of the infection at last follow-up for the infection cases. MATERIAL AND METHODS: Mean follow-up in this retrospective analysis of 18 knee arthroplasties in 17 patients was 85 months. Mean patient age was 65 years. All patients presented destruction of the extensor system associated with infection on a total knee arthroplasty (n=14) or joint destruction (n=4). The first operative stage involved insertion of a temporary external fixator using a lateral bar to align the limb. The infected knee prosthesis was then removed or a spacer was inserted. After avivement of the bone surfaces, compression was applied with an external fixator using an anterior bar. Early weight bearing was encouraged. The lateral fixator was removed at 45 days and the anterior fixator at bone healing. RESULTS: First-intention fusion was achieved in 16 of the 18 knees at mean five months (range 3-8 months). Fusion was achieved in one case after surgical revision using a bone autograft. Nonunion persisted in the other patient. Mean time to removal of the anterior fixator was 7.5 months (range 6-12 months). Remission of infection was noted at last follow-up in all patients with infection. DISCUSSION: This technique provides effective treatment for infected knee prostheses or major joint destruction with loss of the extensor mechanism. Joint fusion limits function but is a better solution than above knee amputation. The rigid fixation achieved with two single-bar fixators positioned perpendicularly enables rapid weight bearing, a capital element for these often bedridden elderly patients with multiple co-morbidities. The essential element for fusion is a solid fixation. The use of external fixators also avoids implanting material in septic tissues. Associated with medical treatment for the infection we have been able to achieve complete remission of infection in all patients who underwent arthrodesis for an infected knee arthroplasty.

Does curettage-cement packing for treating giant cell tumors at the knee lead to osteoarthritis?

INTRODUCTION: Giant cell tumors (GCTs) make up 15 to 20% of bone-related tumors in adults. They are often found around the knee in the metaphysis and epiphysis area, contacting the joint cartilage. The aims of our study were to evaluate the presence of early knee osteoarthritis (OA) in patients with GCTs in the knee area treated by curettage-cement packing, and to evaluate whether replacing subchondral bone with acrylic cement has an effect on the functional outcomes and quality of life. MATERIAL AND METHODS: This was a retrospective study of all patients operated between 2000 and 2010 by the same specialized surgical team. Functional outcomes and quality of life were evaluated in each patient using the Knee Injury and Osteoarthritis Outcome (KOOS), the Musculoskeletal Tumor Society Score (MSTS) and the Short Form-36 (SF-36). The presence of OA was evaluated in a full radiological work-up comparing the operated knee with the healthy contralateral knee. Knee OA was defined as grade 3 or grade 4 radiographic findings based on the Kellgren and Lawrence classification, and a significant difference between the operated and contralateral knee. RESULTS: Nineteen patients were included in this study. The average follow-up was 120 months (range 60-180). Four patients (21%) had radiographic KL-3 and one patient (5%) had KL-4. Eight patients (42%) had recurrence of the GCT. The distance between the tumor and cartilage, and the area of the subchondral bone invaded by the tumor appeared to contribute to OA progression. DISCUSSION: Resection of GCTs around the knee by curettage-cement packing did not have an effect on development of OA. In the four patients who developed knee OA, the tumor was located less than 3mm from the joint cartilage and took up more than 90% of the epiphysis. Based on these observations, there seems to be a strong correlation between the development of knee OA and the small quantity of subchondral bone left after curettage. The functional outcomes and quality of life were similar no matter the knee OA grade in patients. Replacing subchondral bone by cement had no effect on quality of life in this study. LEVEL OF EVIDENCE: IV (retrospective study).

Prognostic factors for the recurrence of myxoid liposarcoma: 20 cases with up to 8 years follow-up.

INTRODUCTION: Myxoid liposarcomas (MLS) are the second most common type of liposarcoma. Although some MRI findings are distinctively characteristics of MLS, the diagnosis can be tricky in tumors with a large portion of round cells (RC). Known predictors of an unfavorable outcome include age, tumor size, high RC content and positive resection margins. The goal of this retrospective study was to define prognostic factors for recurrence, with special emphasis on the percentage of RCs and medical care provided in a non-specialized center. PATIENTS AND METHODS: Twenty patients (11 women, 9 men) with a mean age of 44.3 years (18-73) were reviewed after a mean of 55.9 months. Six of these patients had been operated at a non-specialized center. The diagnostic MRI was read by a specialized radiologist and the resection procedures performed by two specialized surgeons. Tumors were labeled as either "pure myxoid liposarcoma" or "myxoid/round-cell liposarcoma". The local recurrence-free survival rate and mortality rate were calculated. RESULTS: Fifteen patients had undergone an MRI during the initial assessment. The typical MRI findings of MLS were present in four of them. The MRI suggested a non-specific lesion in the other 11 patients. After correlation with pathology findings, these tumors contained more than 5% round cells. The fourteen patients treated at our facility had undergone a biopsy, while none of the ones treated outside did. Five patients had R0 resection margins and 15 had R1 margins. Prognostic factors for recurrence consisted of age, tumor size >10 cm, R1 resection margins, FNCLCC grade 2+R1 margins, medical care at a non-specialized center, and >5% round cells. There were eight local recurrences and three metastases (15%). Two patients died (90% overall survival rate). DISCUSSION: The risk of local recurrence was 3.86 times greater in this study when the tumor contained more than 5% RCs, which is consistent with published data. The MLS diagnosis was made only four times based on the initial MRI because misleading nature of high RC tumors. R1 resection margins are a risk factor for local recurrence. However, cases with R1 margins have a recurrence rate that is similar to R0 cases when the surgery is performed at a specialized cancer center. Treatment of MLS in a non-specialized center is a key negative prognostic factor. The reported rate of metastasis varies. Atypical extrapulmonary localizations are common, and often multifocal. MRI has been shown to be superior at detecting secondary lesions and some have suggested that a full-body MRI should be performed. CONCLUSION: Prognostic factors for the recurrence of myxoid liposarcomas have been identified. MRI analysis is not definitive and must be supplemented by a biopsy.

Application of bone graft to the medial side of the first metatarsal head in the treatment of hallux varus.

BACKGROUND: Hallux varus deformity is not frequent, is usually acquired, and is poorly tolerated by patients. A common cause is the resection of an excessive amount of the head of the first metatarsal during an operation performed to correct a hallux valgus deformity. The purpose of this study was to evaluate the results of application of bone graft to the medial aspect of the first metatarsal head in order to restore missing bone after resection of an excessive amount of bone during a bunionectomy. METHODS: Of thirty patients who had a hallux varus deformity that was treated operatively, eight (ten feet) had bone-grafting to the medial aspect of the first metatarsal head. Six patients (seven feet) were available for evaluation at an average of 8.6 years (range, two to twenty-two years) postoperatively. The original reasons for the consultation for the hallux varus deformity were pain in the great toe, discomfort with shoewear, and the cosmetic appearance of the deformity. The pain typically was located on the medial aspect of the great toe and was caused by the pressure of the shoe; the pain usually was aggravated by walking. Preoperatively, the passive range of dorsiflexion averaged 72 degrees (range, 60 to 80 degrees); the passive range of plantar flexion, 12 degrees (range, 10 to 20 degrees); and the varus deformity, 18 degrees. RESULTS: Six of the seven feet had a satisfactory result. The pain associated with the varus deformity had disappeared in all patients. One patient was dissatisfied because of 20 degrees of valgus angulation. The passive range of dorsiflexion averaged 63 degrees (range, 60 to 70 degrees), and all patients had 10 degrees of plantar flexion. Overall, the valgus angulation of the metatarsophalangeal joint averaged 19 degrees (range, 16 to 22 degrees). There was no recurrence or persistence of the varus deformity. In three feet, the joint space was reduced, but this did not jeopardize the clinical result. CONCLUSIONS: A bone graft screwed onto the medial aspect of the metatarsal head provided a good result. This technique is indicated when the varus deformity is related to a previous resection of an excessive amount of bone during a bunionectomy and when the deformity is passively reducible to neutral.

Pigmented villonodular synovitis of the foot and ankle: a report of eight cases.

Eight cases of pigmented villonodular synovitis of the foot and ankle are reported. The purpose of this study was to analyze the manifestation of pigmented villonodular synovitis in the foot and to evaluate treatment options. There were four cases in the ankle and hindfoot, one in the first tarsometatarsal joint, and three in the toes. In seven of eight cases, diagnosis was confirmed by magnetic resonance imaging (MRI) scans. The tenosynovial form was found in the toes and the articular form in the hindfoot and ankle. Surgical treatment was performed in all cases: one arthroscopically assisted synovectomy in the ankle joint, two talocrural arthrodeses, one subtalar arthrodesis, one tarsometatarsal arthrodesis, and tumor removal on the toes with arthrodesis of the distal interphalangeal (DIP) joint in two cases. Average follow-up was 4 years. Recurrence occurred in one toe and led to partial amputation. Malunion in one ankle arthrodesis was operated on again with no sign of recurrence. In the toes, the lesion had a tumoral feature; the bone was infiltrated by soft tissue, and the surgical procedure was local removal of the tumor. In the hind-foot, the lesions were intra-articular and required synovectomy, usually with an arthrodesis. In the midfoot, there was a large extraosseous tumor surrounding tendons with destructive articular lesions.

[Sagittal load-bearing tomography of the forefoot and static metatarsalgia]. / Tomographies sagittales en charge de l'avant-pied et métatarsalgies statiques.

We describe the use of weight-bearing foot tomograms. The outline of the food is drawn so as the axes of the metatarsal beyond the toes on the AP plain radiogram and the tomograms are done successively on each metatarsal. This morphological, but also functional, analysis enables exact diagnosis of excessive loading on the metatarsal head. This procedure is used in case of metatarsalgia with normal metatarsal length and in late post-traumatic sequellae of the forefoot. Surgical correction can then be precisely performed.

[Ewing's sarcoma of the soft tissues: apropos of 3 cases and review of the literature]. / Sarcome d'Ewing des parties molles: à propos de 3 cas et revue de la littérature.

Three cases of extraosseous Ewing sarcoma are reported. This pathology of the young adult is very rare as shown by the review of the literature. Clinical or imaging (CT or MRI) findings are non-specific and diagnosis is based on histology. Nonetheless, this diagnosis should be considered in all patients with primary soft tissue tumors.

[Temporal, kinetic and kinematic asymmetry in gait initiation in one subject with hemiplegia]. / Asymétries chronométriques, cinétiques et cinématiques de l'initiation de la marche chez un sujet hémiplégique.

OBJECTIVE: To investigate the temporal, kinetic and kinematic asymmetry of gait initiation in one subject with hemiplegia with an equinus varus foot. MATERIAL AND METHODS: A kinetic analysis with two AMTI force plates and a kinematic analysis with an ELITE optoelectronic system of gait initiation were performed in one subject with hemiplegia. RESULTS: The duration of the gait initiation phases was asymmetrical. The monopodal phase was shorter when the affected lower limb was supporting than when the healthy one was supporting. The propulsion resulted from the force exerted on the healthy lower limb. The distribution of body weight on the lower limbs was asymmetrical. Body weight support was more important on the healthy side than on the affected side. Maximal extension of the ankle on the hemiplegic side occurred during the swing phase. Ground clearance was increased by elevating the knee higher on the affected side than on the healthy side during the swing phase. Initial contact with the floor was performed with the foot flat on the affected side. CONCLUSION: This preliminary study has shown that gait initiation in one subject with hemiplegia was asymmetrical in kinetics and kinematics. The results concerning kinematics have not been reported previously for gait initiation in subjects with hemiplegia. The study of gait initiation should allow for better understanding postural and movement control strategies developed by patients with hemiplegia.

[Triple fracture of the superior shoulder suspensory complex]. / Triple fracture du complexe suspenseur superieur de l'epaule: presentation d'un cas.

The authors present the case of a displaced fracture of the coracoid process associated with a displaced fracture of the acromion, an undisplaced fracture of the clavicule and fractures of the first to fifth ribs. Open reduction of the coracoid process fracture was performed. At the last follow-up, the coracohumeral distance was restored (10 mm), but the acromiohumeral distance in the sagittal place was decreased (5 mm). The authors recommend open reduction of displaced fractures around the rotator cuff to limit the risk of impingement between the cuff and the coracoid process or the acromion.

[Retrospective analysis of 78 surgically repaired fractures of the radial head]. / Analyse rétrospective d'une série de 78 fractures de la tête radiale opérées.

The authors present a analysis of 78 cases of radial head fracture operated in the same department. 16 cases were added to the first study of 62 cases operated between 1967 and 1988 and published in 1991. According to the Mason classification modified by Morrey, there were 22 type II, 24 type III and 32 type IV. Surgical treatment consisted in an osteosynthesis in 35 cases, a fracture fragment excision in 9 cases, a resection of the head in 24 cases, a silastic prosthesis in 10 cases. The results have been studied on a functional and radiological basis with follow-up from 2 to 23 years (mean 5 years). The authors noted the good results of the type II fractures which had an osteosynthesis, the satisfactory results in more than 50% of the cases with resection of the radial head. The comparison of both series established the absence of prosthesis in the recent one. The poor results of the comminutive fractures with elbow dislocation lead the authors to consider the prothesis in these fractures, as a possible indication.

[Reconstruction-arthrodesis of the first metatarsophalangeal joint iatrogenic bone defects]. / Reconstruction-arthrodèse des pertes de substances osseuses iatrogènes métatarso-phalangiennes du premier rayon.

PURPOSE OF THE STUDY: Arthrodesis-reconstruction for metatarsophanlangeal bone defects of the great toe after hallux valgus or hallux rigidus is rarely performed and only a few series are found in the literature. In these series, retarded bone fusion, skin rupture, and interphalangeal intolerance (both clinically and radiologically) have been frequent. The purpose of this work was to determine what parameters contribute to minimizing these postoperative risks. MATERIAL AND METHODS: Thirteen patients, mean age 60 years, were reviewed at a mean follow-up of 7 years. Mean delay from initial surgery to revision surgery was greater than 6 years. Preoperative complaints included metatarsophalangeal pain and especially transfer metatarsalgia. The procedure used corticocancellous bone grafting associated with osteosynthesis and unloading of the forefoot for three months. RESULTS: Eleven of the 13 patients achieved full relief of their metatarsophalangeal pain and metatarsalgia. Twelve of the 13 patients had a satisfactory great toe axis, including 2 who had a secondary osteotomy for correction. Bone fusion was achieved in all 13 patients; one at 8 months. Mean lengthening was 5.1 mm; reconstruction with the corticocancellous graft reconstruction generally filled the bone defect resulting from ablation of the joint prosthesis in 7 cases. The interphalangeal joint was pain free at last follow-up in all cases despite radiological evidence of suffering in one (similar to the situation before the revision surgery). DISCUSSION AND CONCLUSION: Correct position of the arthrodesis is essential to alleviate transfer metatarsalgia. A moderate lengthening of the great toe can minimize the risk of skin rupture. In order to preserve the interphalangeal joint, the position of the arthrodesis must be precise both in the sagittal and horizontal plane, leaving sufficient valgus and avoiding the need for temporary interphalangeal pinning.

[Fractures of the radial head. Analysis of a series of 62 surgically treated cases]. / Fractures de la tête radiale. Analyse d'une série de 62 cas traités chirurgicalement.

The authors present a retrospective analysis of 62 cases of radial head fracture operated between 1967 and 1989. According to the Mason classification modified by Morrey, there were 11 Type II fractures, 22 Type III fractures and 129 Type IV fractures. Surgical treatment consisted of one of the following: osteosynthesis, fracture fragment excision, or ablation of the head with or without silastic prosthesis. The results have been studied on a functional and radiological basis with follow-up from 2 to 23 years (mean: 5 years). Finally, the authors report the following indications: internal fixation for large two or three-part fractures, resection of the head in cases of comminution, and the lesions they judge to have a poor prognosis (Type IV).

[Complications associated with the use of first generation Harris-Galante porous-coated acetabular component after a mean follow-up of 7 years]. / Complications liées à l'utilisation de la cupule de Harris-Galante de première génération au recul moyen de 7 ans.

MATERIAL AND METHODS: Hundred and twelve hip were studied in 107 patients with a mean follow-up of 7 years (range, 6-9 years). Harris and Postel-Merle d'Aubigné clinical hip scores were used. The prosthetic components were evaluated using radiographic criteria. RESULTS: The mean Harris score was 91 (range, 34-100). The incidence of proximal pain was 3.7 p. 100 in anterior area and also 3.7 p. 100 in posterior area. Radiolucent lines were present in one acetabular zone in 28.5 p. 100 of cases, in two zones in 26 p. 100, in all three zones in 5.5 p. 100. No statistical significant corelation was identified relating pain and radiolucent lines. The mean rate of linear wear per year was 0.1 millimeter. A statistically significant corelation was identified relating a linear wear per year above 0.12 millimeter and the presence of radiolucent lines. A major polyethylene wear (from 2.75 to 3.5 millimeters) was found in 5 cases. One of them had an acetabular osteolysis. One acetabular liner was found unstable in the metal shell during a hip revision for a major wear. Two patients had a dislocation of the liner in the metal-back. Eight hips needed a revision surgery, always for a failure of the polyethylene liner, never for a loosening between the socket and the acétabulum. DISCUSSION AND CONCLUSION: The acetabular component bone fixation of this Harris-Galante prosthesis appears optimum. The polyethylene wear and the unstability between the polyethylene cup and the metal socket need to stop using this component. The fixation between his two parts have to be improved.

[The rafter osteotomy of the first metatarsal with immediate weight bearing in the treatment of anterior and medial pes cavus in adults]. / L'ostéotomie en chevron du premier métatarsien avec mise en charge immédiate dans le traitement du pied creux antéro-interne de l'adulte.

The difficulty of the exact adjustment of the first metatarsal's raising by dorsal cuneiform cutting and osteosynthesis, brought the authors to prefer proximal rafter osteotomy of the first metatarsal in the treatment of adult's anterior and medial pes cavus. Early weight bearing with a plaster cast or a wooden-shoe allowed the spontaneous raising of the metatarsal and an equal distribution of load between all the metatarsals. The excellent results reached by that single procedure in nine cases during ten years justify to suggest it for treatment of adult's anterior and medial pes cavus.

[Posterior position of acetabular component of a total hip prosthesis: possible cause of lower limb rotation problem]. / Positionnement postérieur du composant cotyloidien d'une prothèse totale de hanche: cause possible d'un trouble de rotation du membre inférieur.

INTRODUCTION: The authors report the case of an internal rotation of the lower limb, lately ascribed to a posterior placement of the acetabular component during total hip arthroplasty. MATERIAL AND METHOD: A 58 years old female had an irreducible internal rotation of the right hip 3 years after total hip arthroplasty for arthritis. When the hip was extended, the lower limb showed an irreducible internal rotation of 45 degrees. In flexion of the hip this rotation disappeared. AP radiograms showed femur and femoral stem in internal rotation, a healed fracture of the acetabulum, and the acetabular component seemed to be in correct position. On CT scan the acetabular component was 4 cm posterior to the anatomic location, although there was no abnormal anteversion of the stem and acetabular component. Revision, with relocation of the acetabular component, corrected lower limb rotation. DISCUSSION: Posterior position of the acetabular component has not been described as a cause of lower limb malrotation. Normally the strength of the external hip rotators muscles is three times as important as of the internal rotators. The transverse acetabular fracture led to backwards placement of the acetabular component and yelded in an automatic internal rotation of the femur, because the trochanter kept an anatomical position in the horizontal plane. The posteriorised rotation center of the hip had changed the balance of the different rotator muscles, some of them, originally external rotators, becoming internal rotators.

[Arthrodesis of the first metatarsophalangeal joint]. / L'arthrodèse de la première articulation métatarso-phalangienne.

INTRODUCTION: The goal of this study was to evaluate the place of arthrodesis of the first metatarso-phalangeal joint in surgery of the fore foot. MATERIAL AND METHOD: The authors studied 225 arthrodesis of the first metatarso-phalangeal joint. 195 had a follow up of from two to fifteen years. The indications were: hallux valgus 52.5 per cent, hallux rigidus 20 p. 100, rheumatoid arthritis 12.5 per cent. The procedure used a stable axial fixation with an antero-posterior screw. The preparation of the joint surfaces allowed equalization of the length of the first two toes. RESULTS: The study found a patient subjective satisfaction rate of 89.6 per cent. There was no pain for 90 per cent of them. Activities returned to normal 80 per cent of patients. There was radiographic evidence of lack of fusion in 25 cases (13 per cent). Only two cases were painful and justified a revision. In 15 per cent of the cases slight pain at the inter phalangeal joint was noted due to excessive joint function. DISCUSSION: The best results were obtained with a dorsal flexion angle between twenty and thirty degrees. Restricted dorsal flexion concerning ankle or inter phalangeal joint is a contra-indication of the procedure. Stable fixation is essential but weight bearing on the fore-foot is not allowed for six weeks. CONCLUSION: Arthrodesis of the first metatarso-phalangeal joint restores painless satisfying function and normal use of shoes.

[Results of treatment of hallux valgus by the modified McBride technic with or without complementary phalangeal or metatarsal osteotomy]. / Résultats du traitement de l'hallux valgus selon la technique de McBride "modifiée" avec ou sans ostéotomie phalangienne ou métatarsienne complémentaire.

This study reports an analysis of a series of 316 cases of hallux valgus treated by a method derived from McBride's operation with some modifications and combined with bony procedures designed to correct abnormalities of bony architecture, in particular osteotomy to shorten an excessively long proximal phalanx. Two hundred feet were reviewed with a follow-up between 1 and 13 years. The results, which were satisfactory in 80 per cent of cases, were analysed according to the usual parameters of pain and deformity in relation to the pre-operative findings and the surgical methods used. The failures and complications were analysed. The results of this study makes it possible to determine the indications for and to appreciate the value and advisability of technical modifications.

[Evaluation of a long-distance data transmission network in foot and ankle surgery]. / Evaluation d'une consultation en réseau avec télétransmission des données en chirurgie de la cheville et du pied.

PURPOSE OF THE STUDY: This prospective work was designed to evaluate the concordance of the opinions of four experts interrogated via a long-distance inter-hospital data transmission system by an orthopedic surgeon seeking advise on foot and ankle surgery patients. MATERIAL AND METHODS: The surgeon requested advice concerning patients presenting difficult diagnostic or therapeutic situations. The requests were submitted via email to four experts working in regional referral centers. A standardized method defined by pathological categories was used for case description and imaging. RESULTS: Requests concerning 30 among 450 patients presenting surgical foot and ankle disorders were addressed to the experts. The surgical problem involved the forefoot (46%), the mid foot (16%), the hind foot (7%) and the ankle (31%). Mean delay to response was 11 days. The index of diagnostic agreement was 3.2/4 and the index of therapeutic agreement was 2.6/4. DISCUSSION: This study was designed to analyze the operating procedures involved (respective responsibility of the requesting surgeon and the regional experts, remuneration due to the different participants) and the potential patient benefit. The appropriateness of the email transmission system was also examined. For this type of study, email transmission was indicated because of the low cost, easy use, and image quality. This work illustrated the very good diagnostic and therapeutic concordance between experts in foot and ankle surgery and thus demonstrated the potential usefulness of long-distance expert systems. Furthermore, implication of several experts provided greater precision and complementary information facilitating management of difficult cases.