Synchronous abdominal and transsacral approach for excision of sacrococcygeal chordoma.

Sacrococcygeal chordomas are rare retrorectal tumors. The authors have been faced with one such case. They used the synchronous combined abdominosacral approach for surgical resection. Details of the surgical aspects of the technique are described. Safe resection as high as the S1-S2 interspace can be performed.

[Supple intervertebral stabilization according to Graf. Evaluation of its use and technical approach]. / La stabilisation intervertébrale souple selon Graf. Bilan d'utilisation et apports de la technique.

The authors report their clinical experience with Graf's supple intervertebral stabilization system. The results are discussed with respect to the biomechanical and clinical definitions of vertebral instability and the natural evolution of degenerative disease of the lumbar spine. The result are favorable for the cases with clinical instability, but are not as good for the degenerative cases or after discectomy. In spite of the short-term clinical benefits for the cases with pathological articular hypermobility, the authors are cautious regarding the use of this technique. They emphasize the unknown long-term clinical and biomechanical evolution and the difficulties encountered for secondary arthrodesis caused by the volume of the pedicular screws.

[Femoro-patellar prosthesis. A retrospective study of 45 consecutive cases with a follow-up of 3-12 years]. / Les prothèses fémoro-patellaires. Etude rétrospective de 45 cas successifs avec un recul de 3 à 12 ans.

Forty-five consecutive patients operated between 1986 and 1995 were evaluated to assess the long term results of patellofemoral arthroplasty. Revision had to be performed in 8 cases for the following reasons: loosening (3), lateral impingement (3), malposition (1) and persistent patella instability (1). Two groups of patients were identified based upon the preoperative assessment: 21 had primary osteoarthritis without anatomic malalignment (group C) and 24 had a history of patellofemoral instability and trochlear dysplasia demonstrated by clinical and radiological evaluation (group D). Only 43% of good results were found in group C whereas in group D, the percentage of good results was close to 83%. The most common cause of poor results in group C was the degenerative involvement of the femorotibial compartments (5 patients had to undergo total knee arthroplasty subsequently). For group D patients, femorotibial osteoarthritis was not a determinant factor as regards the outcome of patellofemoral arthroplasty. To the authors, it appears that the best indication for patellofemoral arthroplasty is femoropatellar osteoarthritis with malalignment in patients having a normal femorotibial axis even in the presence of femorotibial osteoarthritis as long as the latter does not exceed grade II.

[Selective fasicular neurotomy for spastic equinovarus foot deformity in cerebral palsy children]. / La neurotomie fasciculaire sélective dans le traitement du pied varus équin spastique de l'enfant infirme moteur d'origine cérébrale.

Spasticity is usually treated by rehabilitation, orthosis, chemical denervations, orthopaedic surgery and neurosurgery. Selective fascicular neurotomy is a neurosurgical procedure consisting in partial section of selected motor nerves innervating spastic muscles. Neurotomy is indicated in cases of localised disabling spasticity without musculotendinous shortening, resistant to chemical denervation and for which a motor nerve block with anaesthetic has given a good functional result. Neurotomy includes division of the afferent Ia and Ib fibers, unable to recover, leading to permanent disappearance of the spasticity. Neurotomy also includes section of the motor efferent fibers with transient paresis as a result. In adults, neurotomy provides functional improvement in 81 to 97% of cases. In case of posterior tibial neurotomy, improved walking stability and a decrease in foot equinus and knee recurvatum is observed. In children, the risk of deformity recurrence seems higher because of motor axonal reinnervation: indications must therefore be carefully considered and rehabilitation provided after surgery.

[Infected total knee prosthesis. Guidance for therapeutic choice]. / Les prothèses totales de genou infectées. Orientation du choix thérapeutique.

PURPOSE OF THE STUDY: The aim of the study is to assess the functional results and septic evolution in the treatment of infected total knee arthroplasties. MATERIAL AND METHODS: 22 patients were reviewed; 8 were initially treated in our institution and 14 transferred from other hospitals. Articular debridement alone leaving the prosthesis in situ was initiated in 3 of our 8 patients as well as in 6 of the transferred cases. In both groups, this procedure appeared to be a failure. Prosthetic-reimplantation procedure was elected in 10 patients either as a one-stage (5 cases) or a two-stage surgery (5 cases). This has been successfully rated in 7 cases. Femoro-tibial arthrodesis was performed in 15 patients, three of them being a failure of the prosthetic reimplantation. Follow-up ranges from 16 months to 9 years with well documented records. RESULTS: As stated earlier, articular debridement alone has not proven to be a helpful procedure since it did not eradicate the septic complication in any case. Prosthetic reimplantation has been a successful treatment in 7 of the 10 attempted cases. The one-stage procedure is providing the best functional result. Recurrent infection occurred in 3 cases: there were patients with poor host defense (diabetes, arteritis, old age, ...) with resistant bacteria complicating a hinge-knee prosthesis. Femoro-tibial arthrodesis was achieved in 10 of the 15 patients and necessitated all together 23 surgical operations. The highest union rate was observed in cases where sterile conditions were achieved, fixation being performed with an intramedullary nail. Failure of arthrodesis confines the patients in such an uncomfortable situation that 2 of them has asked for an amputation. DISCUSSION AND CONCLUSION: Early surgical debridement may occasionally salve a prosthesis when it is performed shortly after the onset of infection, in an unloosened unconstrained prosthesis infected by a low-virulence organism. In our study, no patient but one met those criteria. For those cases nevertheless, our procedure of choice is now the one-stage reimplantation who seems to be more effective for eradicating the infection and gives rise to a better clinical result. The two-stage reimplantation is the current procedure for handling an infected knee prosthesis. Some patients are still excluded from this procedure because of their poor health condition, bone loss, inadequate viability of skin and extensor mechanism or an uncontrolled sepsis. For such a case, arthrodesis remains the most reliable method of management, especially when it can be stabilized with an intramedullary fixation, which implies to perform a two-stage arthrodesis.

[Extraction of a foreign body from the elbow using arthroscopy]. / L'extraction de corps étrangers du coude par arthroscopie.

Arthroscopy of the elbow is now a good diagnostic and therapeutic method, particularly for the removal of loose bodies which are frequently found in the elbow, whatever their etiology. The authors have investigated the advantages and disadvantages of different sites of entry and the technique of removal of loose bodies in five cases. The technical ease of the procedure and the simplicity of the after-care makes it the method of choice in this condition.

Subacromial-subdeltoid lipoma arborescens associated with a rotator cuff tear.

A 44-year-old man presented with lipoma arborescens of the right shoulder, associated with a rotator cuff tear. MRI revealed villous proliferations with signal intensity of fat on all pulse sequences. At surgery, this bursa was found to contain moderately yellow cloudy fluid without fat globules. Histological examination of the lesion showed subsynovial accumulation of mature fat cells.