Separation of congenital embryonic syndactylies in children: dorsal or volar flap? About a comparative retrospective series.

Congenital syndactylies account for 1 to 2 out of 2000 birth defects. Although several types of syndactylies exist, we only studied embryonic syndactylies. The goal of our study was to compare 2 types of coverage flap for the reconstruction of the finger web spaces: a volar flap described by Blauth and a dorsal flap described by Gilbert. Between 1993 and 2015, children affected by simple and complex syndactylies (partial or complete) were treated in 2 french pediatric hospitals and were selected for our analytic, comparative, retrospective review. The 2 hospitals used different surgical techniques: one used a volar flap described by Blauth and the other a dorsal flap described by Gilbert. The children were followed up to look for signs according to the stages of the Classification of Withey and to evaluate a global result according to the score of Withey. Our secondary criteria of judgement were the aspect of the surgical scar according to the VSS (Vancouver Scar Scale) and the satisfaction of the parents and children. The age of the children, need for a surgical revision and time of last follow- up were also studied. We found statistically significant differences between group I (volar flap) and group II (dorsal flap) in favor of the volar flap: higher scores of Withey (even when the number of commissures was increasing) and better VSS (regardless of the number of web spaces treated). There was no statistically significant difference between the 2 groups in terms of age, follow-up, or rate of surgical revision. All in all, the volar flap presented less sequelae in terms of scar retraction. Regardless of the flap used, the cosmetic results of the full-thickness skin graft used impacted the result both on the receiving site (dyschromia, hairiness) and the donor site.

Minimally invasive repair of pectus excavatum in children: Results of a modified Nuss procedure.

INTRODUCTION: Pectus excavatum (PE) is the most common deformity of the anterior thoracic wall. The Nuss technique allows the thorax to be reshaped with the aid of a retrosternal metallic bar. The aim of this study is to evaluate and compare the complication rate between the original Nuss technique and a lightly modified approach. MATERIAL AND METHOD: We performed a retrospective single-center observational study based on the medical files of patients operated for PE in the Pediatric Surgery Unit between July 2004 and July 2015. We divided two patient groups according to the operating technique employed: the Nuss group (NG) and the modified Nuss group (MNG) with supplementary subxiphoid incision and bilateral thoracoscopy. RESULTS: Twenty-seven patients were included: sixteen in the NG and eleven in the MNG. No significant differences were found between the two groups for all kinds of complications: total complication rate (50% for the NG versus 54% for the MNG, P>0.05), early (31% vs 46%, P>0.05), late (19% vs 9%, P>0.05), non-serious (37% vs 36%, P>0.05) or serious (13 vs 18%, P>0.05). There was no life threatening complication in the MNG, contrary to the NG. In the two groups, a significant difference was found (P=0.029) regarding the operating time: longer operating times (80±25min) were correlated with a higher complication rate. CONCLUSION: The modified Nuss technique does not cause more complications than the original technique described by Nuss and it has the advantage to minimize the risk of heart damage.

Anatomical and functional evaluation of diaphyseal femoral fractures in children under 6 years old.

Objective : The aim of this study is to evaluate both the anatomical and functional consequences of our treatment protocol of diaphyseal femoral fractures in children under 6 years old Methods : We conducted a retrospective analysis of a series containing 50 children in Strasbourg University Hospital whom had traumatic diaphyseal femoral fractures and underwent conservative treatment by traction followed by casting with a mean follow-up period of 25 months. Results : All fractures healed without complications i.e. gait disorders, back pain and limitation of activity. Results showed a significant correlation between the initial varus angulation and shortening which could influence the final remodeling result within the first 24 months. Using the Receiver Operating Characteristic curve, we developed the Initial Displacement Index on Traction (IDIT) which is the sum of both the initial varus in degrees and the initial shortening in millimeters. Conclusion : The treatment by initial traction followed by a cast for childrens ≤ 6 years old gives clinical and radiological results comparable with those reported for immediate casting method. The hospitalization period is longer in the traction method but with less exposure to general anesthesia (GA) and risks of secondary displacements.

Popliteal artery dissection presented 12 hours after admission for a Salter III fracture of proximal tibia.

A 16-year-old boy sustained a salter III fracture of the upper tibia following a motorcycle accident. Except for well localized knee pain, the patient did not have any other symptom. Repeated clinical examination did not reveal any absent peripheral pulse. Given the state of the fracture, anatomical reduction and screw fixation was planned in the operating room.  Twelve hours after admission the patient was taken to the operating room. During the period preceding surgery he continued to have normal vascular clinical examinations. Further clinical assessment was performed in the operating room and remained to be normal. However after induction and upon extension of the lower limb, peripheral pulses in the affected side were abruptly lost. Urgent vascular exploration of the area showed a popliteal artery dissection necessitating a bypass graft to restore blood flow.  We present a review of the literature alongside a case report showing how popliteal artery pathology in a similar context can present late and be for a period of time clinically undetectable.

[Osteochondritis dissecans of the femoral condyles: report of 892 cases]. / L'ostéochondrite disséquante des condyles fémoraux.

PURPOSE OF THE STUDY: Osteochondritis rarely involves the femoral condyles. Discovery in this localization raises several questions concerning the nature of the articular cartilage, the potential for spontaneous healing, and, in the event of a free fragment, the outcome after its loss or repair. MATERIAL AND METHODS: This multicentric study included 892 pediatric and adult cases, the cutoff between two series being defined by fusion of the inferior growth plate. We excluded medical or surgical osteochondritis, cases involving the patella, osteochondral fractures, juvenile polyosteochondrosis, adult osteonecrosis, and osteochondritis beginning after the age of 50 years. RESULTS: Mean age at diagnosis was 16.5 years. Mean age at treatment onset was 22 years. Pain was the predominant symptom. 80% of cases were unilateral and 70% involved the medial condyle. The anatomic lesions were different in adults, showing more advanced degradation. At diagnosis, Bedouelle stages Ia and IIb constituted 80% of the cases observed among children while in adults, 66% were Bedouelle stages IIb to IV. Outcome was very good for the majority of children with Hughston clinical stage 4 while half of the x-rays were Hughston stage 3 and 4. There were thus a large percentage of children with abnormal xrays whose disease history was not yet terminated. In the adult series, the percentages of Hughston 3 and 4 was about the same as clinically. The x-rays were rarely perfectly normal since half of the clinical stage 3 patients were noted in stage 4. An abnormal x-ray with a very good clinical presentation was observed in a very large proportion of patients. DISCUSSION: It is difficult to interpret the plain x-ray and identify patients with a potentially unfavorable prognosis. We defined three radiographic classes: defect, nodule and empty notch. The Bedouelle classification uses information from all available explorations, particularly MRI and arthroscopy. Numerous therapeutic methods are used. Interruption of sports activities is the first intention treatment for children. Data in the literature and the findings of this symposium do not demonstrate any beneficial effect of immobilization on healing compared with simple abstention from sports activities. Transchondral perforation is a simple operation with low morbidity. In 85% of cases, it was used for lesions with an intact joint cartilage considered stable in 96% of cases. Healing was achieved in six months for 48% if the growth plate had not fused. The fragment was fixed in 43% of the cases with a loose cartilage fragment. Outcome was fair but degraded with the state of the joint cartilage and thus the stability of the fragment. Fixation must stabilize the fragment but not prevent further consolidation via osteogenesis. This is why deep perforations are drilled beyond the ossified area and additional osteochondral grafts are used. The Wagner operation gives less satisfactory results than more complicated procedures. Removal of a sequestrum is a simple, minimally invasive procedure with an uneventful postoperative period, but in the long term it favors osteoarthritic degradation, especially when performed in adults. Mosaic grafts give good mid term results. Morbidity is low especially if the grafts are harvested above the notch. The question of chondrolysis around the grafts was beyond the scope of this study. Chondrocyte grafting is difficult to accomplish and is expensive. The mid term results are good for large lesions. Osteotomy is logical only in the event of early stage osteoarthritic degradation. DECISION ALGORITHM IN CHILDREN AND ADOLESCENTS: If the plain x-ray reveals a defect (class I), simple interruption of sports activities should be proposed. Two situations can then develop. First, in a certain number of patients, the pain disappears as the defective zone ossifies progressively. Complete cure is frequent before the age of 12 years. In the second situation, the knee remains painful and the x-ray does not change or worsens to a class II nodular formation. In this case an MRI must be obtained to determine whether the joint cartilage is normal. There are two possibilities. First, the osteochondral fragment is viable and most probably will become completely re-integrated, particularly if the lesion is far from the growth plate. Necrosis is the other possibility. Transchondral perforations are needed in this case. If on the contrary the cartilage is altered, there is little hope for spontaneous cure. Arthroscopy may be needed to complete the exploration. Fragments, especially if there is a large surface area, must be fixed. Perforations to favor revascularization are certainly useful here. In the last situation (class III), the fragment wobbles on a thin attachment or has already fallen into the joint space. This is the type of problem generally observed in adults. The decision algorithm in adults is the same as in children for the rare nodular aspects (class II). There could be a discussion between transcartilage perforation and fixation. If there are a large number of fragments, fixation may not be fully successful and the lesion might be considered class III. For class III lesions, three operations can be used: removal of the sequestrum, mosaic bone-cartilage grafts, or autologous chondrocyte grafts. At the same follow-up, mosaic grafts give better results than excision of sequestra. It may be useful to remove sequestra in a limited number of situations: if there is just a small area of osteochondritis, the lesion is old and partially healed, or the zone is non weight-bearing. For other lesions, we favor mosaic grafts. We still do not have enough follow-up to assess the long-term outcome with these mosaic grafts, but simple excision clearly favors osteoarthritic degradation. Can chondrocytes grafts be compared with mosaic grafts? Chondrocyte grafts have been used for very large lesions and have given results similar to mosaic grafts. It might also be possible to combine fixation of a loose fragment and a mosaic graft. LESSONS FROM THIS STUDY: 1) The prognosis of osteochondritis is better before than after fusion of the growth plate but the lesion does not always heal in children. 2) Presence of osteochondritis requires complementary anatomic and functional exploration to determine the stability and the vitality of the fragment. 3) Attention must be taken to perform transchondral perforations early enough, particularly in children. 4) Screw fixation is not always sufficient. The trophicity of the fragment and its blood supply must be improved. 5) Mosaic grafts are preferable to excision of the fragment. 6) Chondrocyte grafts will be more widely used in the future.

Eikenella corrodens bone and hip joint infection. A case report and literature review.

Eikenella corrodens (EC) is a human commensal microorganism of the mouth flora. This bacterium is rarely reported in bone and joint infections in children, but the consequences on the joint function can be devastating and irreversible. We report the case of septic arthritis of the hip following an oral wound in a 12-year-old boy. The progression of the condition was favorable with no complications or pain observed after antibiotic treatment. Clinical and radiological examinations showed a satisfactory outcome at 6 months with no sign of recurrence or complication (growth disorder). Children's osteomyelitis and arthritis caused by EC have been mostly reported after human bites or extremity pricks. This slow-growing organism is rarely diagnosed but should be considered as a potential pathogenetic agent and treated aggressively, especially since the antibiotic therapy is simple and achieves good results. LEVEL OF EVIDENCE: Level IV.

[Discoid menisci in children: clinical patterns and treatment in eighteen knees]. / Les ménisques discoïdes chez l'enfant: manifestations cliniques et indications thérapeutiques: a propos de 18 cas.

PURPOSE OF THE STUDY: Surgery is indicated when discoid menisci become symptomatic. The purpose of the surgical procedure is to resect any damaged tissue and restore the physiological shape of the meniscus. As a rule, as much meniscal tissue as possible must be spared because of the long-term deleterious effects on the cartilage of total meniscectomy. We analyzed a consecutive series of 18 cases of discoid menisci in children to search for secondary lesions and factors favoring their development in order to determine the optimal surgical procedure. MATERIAL AND METHODS: This retrospective series included 17 children (18 menisci) aged 7.5 years on average at diagnosis between 1985 and 2003. We noted the clinical manifestations, the imaging findings, time to treatment, and operative observations. The Watanabe classification was used to describe the discoid menisci. We also noted meniscal and cartilage damage and their consequences, as well as the consequences of late surgery on the type of procedure used. RESULTS: The main complaint was pain. Physical examination usually revealed a positive pivot test. Signs of osteochondral lesions of the lateral condyle were also observed in three children, and the MRI revealed degenerative menisci in four. Mean time from diagnosis to surgical treatment was 20 +/- 17 months. The Watanabe classification was type I (n=9), type II (n=5), type III (n=4). Arthroscopy revealed nine meniscal lesions and three cartilage lesions, one associated with osteochondritis. Meniscectomy was performed in eleven cases, meniscoplasty in seven. Meniscectomy was significantly more frequent (p<0.05) when there was a meniscal lesion (9/11 of the meniscectomies) and when the time from diagnosis to treatment was long (28 months versus 8 months for meniscoplasty, p<0.01). Time to surgery was associated significantly (p<0.05) with the proportion of meniscal, chondral, or osteochondral lesions. Inversely, the type of meniscus did not affect age at diagnosis, initial manifestations, or presence of a positive pivot test. DISCUSSION: While therapeutic abstention is warranted for asymptomatic menisci, surgical treatment should be undertaken if symptoms develop, irrespective of the type. If possible, surgery should be performed less than six months after diagnosis. The risk of secondary meniscal or cartilage injury increases with longer delay before surgery. Similarly, the chances of performing meniscoplasty are reduced with longer time from diagnosis to surgery. It must be recalled that the objective of conservative mensical surgery is to prevent secondary cartilage lesions after extensive meniscectomy and consequently the risk of osteoarthritis.

[Clear-cell sarcoma of tendons and aponeuroses: three case reports]. / Sarcome à cellules claires des tendons et des aponévroses: à propos de trois cas.

Clear-cell sarcoma (CCS) of tendons and aponeuroses is a rare malignant tumor representing about 1% of soft tissue tumors. Preferentially observed in young adults in the second or third decade, the tumor generally develops in the limbs. Only 2% of SCC of tendons and aponeuroses have been reported in children less than 10 years of age. This slowly progressive tumor usually forms a painless mass. The tumor increases in size followed by metastatic dissemination to lymph nodes and the lungs. The prognosis is related to tumor size. At the present time, the recognized limit is greater than 5 cm. Early diagnosis must be achieved to enable effective treatment by carcinological surgical resection. We report the three cases of CCS of tendons and aponeuroses observed at the Strasbourg University hospital over a 35-year period. Each case had a special clinical presentation. The first patient, treated in 1967, presented tumor bone lysis on the plain x-ray, an observation rarely reported in the literature. In the second patient, treated in 2002, the tumor was discovered after trauma. This patient developed skin ulceration associated with paraplegia secondary to metastatic thoracic cord compression. The third case occurred in a 12-year-old girl, treated in 2002.

Fatal Takotsubo cardiomyopathy due to epinephrine in shoulder arthroscopy.

The authors report a case of a shoulder arthroscopy in which epinephrine saline irrigation was held responsible for acute hypertension followed by fatal Takotsubo cardiomyopathy.

Evolution of slipped capital femoral epiphysis after in situ screw fixation at a mean 11 years' follow-up: a 222 case series.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) can lead to hip impingement, more or less rapidly depending on initial slippage severity and on surgical technique. Various surgical options are applicable, including in situ fixation (ISF). The aim of the present study was to look for long-term signs of radiological impingement in hips treated for SCFE by IFS, in order to identify a slip threshold beyond which impingement more regularly appears. MATERIAL AND METHODS: A multicenter retrospective study assessed the clinical and radiological evolution of patients operated on by ISF for SCFE, with a minimum 10 year's follow-up. Coxometric analysis of postoperative and last follow-up radiographs was performed. Functional outcome was assessed on Oxford hip score and radiographic osteoarthritis on the Tönnis classification. Alpha angle was measured on lateral views to highlight hip impingement. RESULTS: Two hundred and twenty-two hips were included, with a mean 11.2 years' follow-up. Mean age at diagnosis was 12.8 years. Mean preoperative Southwick angle was 38.8°, with 43% of hips at stage I, 42% at stage II and 15% at stage III. At latest follow-up, mean Oxford score was 14.86, with 88% of hips rated Tönnis 0 or I. Only 15 cases of impingement were diagnosed. There seemed to be a non-significant trend for hip impingement in SCFE exceeding 35°. CONCLUSION: ISF led to hip impingement in moderate to severe initial epiphyseal displacement. However, in smaller displacement, the consequences were milder, with perfectly satisfactory function scores and no clinical or radiological evidence of impingement. The threshold seemed to be around 35° slippage, beyond which other surgical options than ISF should be considered. Thus, it seems reasonable to propose isolated ISF in SCFE<35° and to treat symptomatic impingement by surgery in stage II slips.

Hip arthroscopy in hereditary multiple exostoses: A new perspective of treatment.

The cases of 2 children (9 and 11 years old) with hereditary multiple exostoses disease are presented. The lesions were located primarily in the acetabular fossa of the left hip and caused pain and limitation of range of motion. Hip arthroscopy was performed to remove the exostoses without damaging the articular surfaces and the Y cartilage. After the procedure, the pain disappeared and normal range of motion was recovered for both children. Conventional surgery would have required hip dislocation to access these lesions with an increased risk of femoral head necrosis. These cases constitute a new and interesting application of hip arthroscopy.

[A new implant for proximal humeral fracture: experimental study of the basket plate]. / Un nouvel implant pour les fractures de l'humérus proximal: la plaque à corbeille. Etude expérimentale.

PURPOSE OF THE STUDY: We conducted a comparative study of three ostheosynthesis systems for proximal humeral fractures. The conclusions led to the elaboration of a rigid extramedullary osteosynthesis implant. This novel implant allows specific fixation of the tuberosities via six adjustable and removable hooks organized like a basket. There are two versions, with and without a central cephalic locking screw. We report two static biomechanical studies conducted to analyze this material. MATERIAL AND METHODS: The two studies were performed on fresh frozen cadaver specimens with known bone density and with an experimental model of a four-fragment fracture of the proximal humerus. The first tests were designed to measure axial pressure reproducing the physiological movement applying the most stress on the head of the humerus. This allowed a global analysis of the mechanical behavior of the implant and an assessment of the contribution of the central cephalic locking screw. The second series of tests were traction tests used to analyze the behavior of the tuberosities fixed with the hooks. We assess the assemblies by measuring the mechanical resistance: rigidity of the fixation was recorded in mm/100N. Pre- and post-procedure x-rays and photographs were obtained to allow a subjective assessment of fragment displacement. RESULTS: The first series of tests demonstrated that the implant, with the central cephalic locking screw, presented good overall mechanical properties. The notion of better stability of the tuberosities obtained with the hooks, as seen during the first tests, was reinforced by the data from the second tests, although no statistically significant difference was demonstrated. We also noted that there was no statistically significant correlation between bone density and the slopes of the force-resistance curves. DISCUSSION: This prototype implant has an overall mechanical resistance equivalent to the reference implant, with at least equivalent performance. Proof of the usefulness of the central locking screw was not established, even though improved tolerance to loading by better force distribution seemed apparent. The contribution of the hook basket was not demonstrated. Data from the observations do however suggest the expectations of the implant will be fulfilled. Tests conducted on a larger scale would probably demonstrate a difference. It is clear that the small number of implants used here limited the study. Comparison with data in the literature show that this new prototype is adapted to the mechanics of the proximal humerus. Resistant to physiological stress, the implant allows pendular movement and passive physical therapy during the early post-operative period.

[Reconstruction by graft and reinforcement device in severe aseptic acetabular loosening: 10 years survivorship analysis]. / Reconstruction par greffe et anneau de soutien des descellements acétabulaires aseptiques avec perte de substance osseuse sévère. Analyse actuarielle sur 10 ans.

PURPOSE OF THE STUDY: We report our experience with the treatment of aceptic acetabular loosening with important loss of bone stock using a graft and a metallic reinforcement device. MATERIAL AND METHOD: We carried out a retrospective study on 56 acetabular revision arthroplasties with severe loss of bone stock performed between November 1980 and June 1992. Mean age of the 35 females and 19 males was 68.5 years. In all cases, there was a combined lesion (cavity + segmentary) of two roofs (type 3 or 4 in the SOFCOT classification). The superior wall was concerned in all cases (80 p. 100 with a combined lesion). Reconstruction was performed using grafts (autograft (n=15), allograft (n=39) or both (n=2)) covering more than 50 p. 100 of the socket. Structural grafts were embedded into the defects in case of superior combined lesion with extension to the anterior and the posterior walls. A morselized graft was used to fill other defects. The reinforcement device was a Müller ring (n=35) or the Burch-Schneider APC (n=21). Mean follow-up was 8.75 years (range 3 - 16 years). RESULTS: There were 29 iterative aseptic loosenings of acetabular component revised or non-revised (n=11). Twenty-four of these cases had a Müller ring and 5 had a Burch-Schneider APC. The 10-year cumulative survival rate (CSR) was 0.43 +/- 0.16 and the 11-year CSR was 0.350.16 using iterative aseptic loosening as the end point. The lateral position of the hip center (p=0.02), female gender (p=0.03), and the Müller ring (p=0.0054) were statistically negative factors. The 10-year CSR was 0.44 +/- 0.18 for the Müller ring and 0.78 +/- 0.1 for the Burch-Schneider APC, the difference being statistically significant (p=0.007). These two populations were strictly comparable. CONCLUSIONS: In case of important loss of bone stock, reconstruction by grafts is widely used as reported in the literature. A metallic reinforcement device must be used to protect the graft during incorporation and to prevent late resorption. Compared with the Müller ring, the Burch-Schneider APC is much more adapted to meet these requirements, particularly when the graft covers more than 50 p. 100 of the socket.

[Comparative study of fixation mode in total knee arthroplasty with preservation of the posterior cruciate ligament]. / Etude comparative des modes de fixation d'une arthroplastie du genou conservant le ligament croisé postérieur.

PURPOSE OF THE STUDY: We performed a prospective randomized study to compare two fixation modes, with and without cement, for total knee arthroplasty. MATERIAL AND METHODS: The study series was composed of 96 cemented or noncemented total knee arthroplasties performed between May 1993 and October 1995. The only difference was the diamond interface used for cemented prostheses and the mesh interface used for uncemented prostheses. The operator was unaware of the type of fixation until the bone slices had been obtained. We assessed outcome in 73 cases with a mean follow-up of 27 months. The two populations were comparable for preoperative clinical status, bone tophicity and surgical procedure. RESULTS: The mean duration of the operation was sgnificantly longer (> 10 min) for the cemented protheses. The complication rates were comparable but we did have two mobilizations of the tibial implant in the noncemented group. The total scores (127 +/- 29 in the cemented group versus 135 +/- 20 in the uncemented group) were significantly different. There were however more cases with degradation of the controlateral knee in the cemented group although the difference was not significant. When these cases were excluded from the analysis, the total scores for two groups were similar (143 and 140 respectively). Radiographic outcome was quite different with mobilization of the tibial implant in 2 cases and the rate of lucent borders was significantly higher in the noncemented group. DISCUSSION AND CONCLUSION: While the clinical outcome was comparable, the quality of the fixation was significantly better with cemented arthroplasty, which remains the gold standard.

[Experimental comparative study of 3 systems of osteosynthesis for proximal humeral fractures. Preliminary study of the mechanical properties of conserved trabecular bone]. / Etude comparative expérimentale de trois systèmes d'ostéosynthèse des fractures de l'humérus proximal. Etude préliminaire sur les propriétés mécaniques de l'os spongieux conservé.

PURPOSE OF THE STUDY: We have compared three systems for osteosynthesis of proximal humeral fractures on a four-fragment fracture model: Plate with tuberosity screwing (P), Kirschner wires with bone sutures (K) and an original implant, the "bilboquet" (Stryker) (B), composed of a hook for the head supported on a diaphyseal stem. MATERIAL AND METHODS: Because of the unavailability of fresh human material, we have turned to embalmed bones after having shown, on cancellous femoral head bone, the little influence of our method Vs freezing conservation. Settings were tested in compression. We measured their mechanical resistance judged on the ultimate strength and on the slope (displacement/load), to this limit. We similarly analyzed by video recording displacement of the different fragments according to four components (head slipping, its lateral displacement, its see-saw and the separation of tuberosities), to show the weak points of the three systems. RESULTS AND DISCUSSION: K was more deformable (p < 0.001) that P and B (average slopes in mm/100N to 0.67 for K, 0.42 for P and 0.43 for B). The ultimate strength differed but not significantly (average values in Newton to 1223 for K, 1601 for P and 1721 for B). We also showed for the three techniques, the significant correlation between slopes and bony densities. Video analysis showed that P opposed lateral displacement of the head and separation of tuberosities better, the resistance to slipping and see-saw seems to be improvable by greater divergence of screws or a modification of the plate (mini canon). B opposed slipping and see-saw better but its weak point was the risk of articular break-in of the hook, by defect of resistance to lateral displacement, that for us could be limited by a less peripheral position of teeth or a modification of their form. K is indeed the least effective of the four components but we think that it would be improvable by using, for example, a centro-medullary technique, allowing an internal cortical support.

[Arthroscopic treatment of acetabular labrum lesions: a series of 12 patients with a 4-year follow-up]. / Traitement arthroscopique des lésions du labrum acétabulaire. A propos de 12 patients avec un recul moyen de 4 ans.

PURPOSE OF THE STUDY: The aim of this work was to report our experience with arthroscopy for the treatment of acetabular labral lesions and identify prognostic factors determining mid- and long-term outcome. MATERIAL AND METHODS: Between August 1991 and December 1997, 12 patients (ten women, two men, mean age 39 years, age range 25-61 years) underwent arthroscopic treatment of an acetabular labrum lesion. All were reviewed at a mean 4 years follow-up (18 months-8 years). Half of the patients (n =6) had a history of hip surgery: two femoral osteotomies and one acetabular bone block for congenital hip dislocation, two high-energy traumas and one traumatic dislocation. Clinical manifestations including pain (n =12), a sensation of a snag (n =10), or blockage (n =8) had developed over a mean 15 months (2-24 months). Standard x-rays evidenced early signs of degenerative disease in four cases and acetabular dysplasia in four (5 degrees

[Treatment of neglected Monteggia's fracture by ulnar lengthening using the Ilizarov technique]. / Traitement de la fracture de Monteggia négligée par allongement de l'ulna avec la technique d'Ilizarov.

We present an original method for the treatment of neglected Monteggia fractures using the Ilizarov technique. This method allows reduction without accessing the radial head by progressive ulnar lengthening after proximal subperiosteal osteotomy of the ulnar bone. We used this method in a six and a half year old girl and achieved excellent radiographical and functional results with normal joint amplitudes. In our opinion, the quality of the outcome is related to the progressiveness of the bone lengthening enabled by this technique which allows restoration of the ulnar length, preservation of the axes of both forearm bones, and controlled reduction of the radial head.

[Bilateral subtotal scapulectomy for chondrosarcoma in Ollier's disease within a 16-year interval]. / Scapulectomie subtotale bilatérale à 16 ans d'intervalle pour dégénérescence maligne d'enchondromatose multiple d'Ollier.

PURPOSE OF THE STUDY: We report the case of a young man with Ollier's disease who underwent three successive procedures for sarcomatous degeneration of some of his endochondromatous lesions. From the age of twenty, the patient required surgery for resection of a cartilage tumor of the body of L5, amputation of the right index finger, and successive right then left subtotal scapulectomy. At 40 years, the patient presents other stable lesions, mainly located on the right side of the body. We were particularly interested in the functional outcome of the two shoulders in this patient who continues to have normal social and occupational activities.

[Computed tomographic analysis of humeral retrotorsion and glenoid retroversion]. / Analyse tomodensitométrique de la rétrotorsion humérale et de la rétroversion glénoïdienne.

PURPOSE OF THE STUDY: Analysis of the anatomic relations of the humeral head and the glenoid cavity is particularly important for clinical study of shoulder arthroplasty and glenohumeral instability. Analysis of humeral retroversion and glenoid retroversion is quite difficult and data in the literature are scarse. We conducted a computed tomography (CT) analysis of stable shoulders to detail retroversion of the entire height of the glenoid cavity and to measure humeral retrotorsion using two comparative methods. We also compared glenoid retroversion and humeral retrotorsion observed in individual subjects. MATERIAL AND METHODS: This prospective study used a standardized CT analysis method. Both shoulders of 30 persons free of glenohumeral instability were studied. Two methods, described by Dähnert and Bernageau, were used to analyze humeral retrotorsion. The Benageau method was used to analyze glenoid retroversion. RESULTS: According to the Dähnert method, humeral retrotorsion was 10 degrees +/- 13 degrees; it was 24 degrees +/- 13 degrees with the Bernageau method; data dispersion was 60 degrees and 65 degrees respectively. According to the Dähnert method, retrotorsion was more pronounced on the dominant side compared with the non-dominant side. There was a significant correlation between retrotorsion values for the two sides. For 95% of the shoulders, glenoid retorversion decreased progressively from the superior part of the glenoid cavity (12.8 degrees +/- 6.4 degrees ) to the lower part (3.1 degrees +/- 4.4 degrees ). Glenoid retroversion was greater on the dominant side. For 21 of the 30 persons (70%), there was a significant correlation between retroversion for the two sides. Correlation coefficients between glenoid retroversion and humeral retrotorsion were negative. Greater humeral retrotorsion was thus related with less pronounced glenoid retroversion and vice versa. DISCUSSION: This study allowed quantification of glenoid retroversion and humeral retrotorsion. There is a spiral twist in the joint surface of the glenoid cavity with progressive decrease in glenoid retorversion from the upper to the lower part of the cavity for 95% of the shoulders. To our knowledge, this spiral twist in the glenoid cavity is not taken into consideration in any of the currently available implants. The correlation for both parameters between the right and left side is probably determined genetically. The influence of dominance could be explained by adaptation to more or less pronounced stress. The negative correlation between humeral retrotorsion and glenoid retroversion would improve glenohumeral stability. A comparative study with unstable shoulders would be required to verify this hypothesis. The validity of the Dähnert method for assessing humeral retorversion is, in our opinion, insufficiently established. The Bernageau method, which provides a direct measurement, appears to be preferable despite the difficulty in identifying anatomic landmarks.

[Failure of acetabular cups fixed with cement and thick embedded wire mesh]. / Echec d'une armature métallique grillagée pour le scellement acétabulaire.

PURPOSE OF THE STUDY: We report our experience with the SKH(R) cemented acetabular cup, analyzing the clinical and radiographic consequences of using cement armed with a thick embedded wire mesh. MATERIAL AND METHODS: Between June 1990 and June 1991, 118 total hip arthroplasties (THAs) were performed in 110 patients (8 bilateral cases) using the SKH(R) cemented acetabular cup, a self-blocking cemented femoral stem with anterograde injection made of a Ti-6Al-7Nb alloy and a 28 mm ceramic polyethylene articulation. Mean follow-up for 97 implants (91 patients) was 7.1 years (3 - 9 years). Mean age at implantation was 65 years (36 - 85 years) (43 men and 48 women). THAs were performed for degenerative joint disease (n=79) including 67 cases of primary disease, necrosis (n=11), rheumatoid disease (n=6), and fracture of the femoral neck (n=1). RESULTS: For the 118 procedures, there were 4 complications: 2 dislocations (no revision), one failure of the ceramic head and one implant infection (with revision). As assessed by the Postel-Merle-d'Aubigné score as modified by Charnley for the mobility criterion, clinical outcome was excellent or good in 82% of the cases, fair in 11% and poor in 7%. According to the Massin criteria at last follow-up, there were 13 cup loosenings (13.4%, 10 migrations and 3 total lucent lines > 1 mm); revision procedures were performed in 6 cases. A lucent line postoperatively, observed in 51% of the cases (p=0.025) and involving all or part of zone 1 in 44% (p=0.047), was predictive of acetabular failure. Linear polyethylene wear as measured manually was 0.08 mm/year (average) for non-loosened cups and 0.2 mm/year for loosened cups; the difference was significant (p=0.001). On the contrary, the thickness of the cement, measured at the limits of the three De Lee and Charnley zones, cup tilt and size, age, weight and patient activity level had no effect on failure rate. Actuarial survival of the cup at 9 years was 86.3% taking aseptic loosening (with or without revision) as the failure criterion and 93.8% taking revision for aseptic loosening as the failure criterion. DISCUSSION: These results were rather disappointing. The thick layer of cement reinforced with the wire mesh produces a metal back effect with the known consequences in terms of loosening, cement-bone lucent line, and polyethylene wear. A modification is now undergoing thermal and mechanical assessment. A thinner and tighter mesh would appear to be preferable.