Posterior shoulder instability managed by arthroscopic acromial pediculated bone-block. Technique.

In posterior shoulder instability (recurrent dislocation, involuntary posterior subluxation or voluntary subluxation that has become involuntary), surgery may be considered in case of failure of functional treatment if there are no psychological contraindications. Acromial bone-block with pediculated deltoid flap, as described by Kouvalchouk, is an alternative to iliac bone-block, enabling triple shoulder locking by the blocking effect, the retention hammock provided by the deltoid flap and posterior capsule repair. Arthroscopy allows shoulder joint exploration and diagnosis of associated lesions, with opening and conservation of the posterior capsule; it greatly facilitates bone-block positioning and capsule reinsertion. The present report describes the procedure in detail. LEVEL OF EVIDENCE: Technical note.

[The accessory soleus muscle: a report of 21 cases and a review of the literature]. / Le muscle soléaire accessoire: à propos de 21 observations et revue de la littérature.

PURPOSE OF THE STUDY: Well known to anatomy specialists, the accessory soleus muscle was first demonstrated to be involved in painful syndromes in 1965 (Dunn). This supranumerary muscle situated in front of the calcaneum can be taken for a soft tissue tumor. The purpose of this work was to report a series of 21 patients with an accessory soleus muscle and to present the characteristic features, diagnostic methods, and treatment indications and modalities. MATERIAL AND METHODS: This series included 20 patients (one symptomatic bilateral case), fourteen men and six women, mean age 25 years. Seventeen patients practiced sports and ten had had a prior operation. All patients complained of exercise-related pain. The physical examination was normal with the exception of a tumefaction, which was soft at rest and hard at triceps contraction against resistance, lying laterally to the Achilles tendon. We studied plain x-rays, ultrasound studies, computed tomographies, and electromyograms and later MRI which became the reference method to demonstrate the details of normal muscle structure. Ten patients (one bilateral case) were not particularly bothered by the supernumerary muscle. Functional treatment was given and provided patient satisfaction. For the other ten patients, who wished to continue their physical activities, two underwent fasciotomy (including our first case where fasciotomy was undertaken because a tumor was suspected) and eight underwent resection of the supranumerary muscle. RESULTS: The patients were followed for 6 to 19 years. Outcome was very good in all patients who were free of pain and had complete joint movement with symmetrical muscle force. Normal sports activities were resumed. DISCUSSION: The accessory soleus muscle is found in 10% of individuals. It is often asymptomatic. The muscle inserts on the anterior aspect of the soleus muscle or on the posterior aspect of the tibia or the muscles of the deep posterior compartment. It lies anterior to the calcaneal tendon and terminates on the calcaneal tendon or the superior or medial aspect of the calcaneus via fleshy fibers or a distinct tendon. Frequent in primates, this anatomic variant is present during embryological development. Its persistence depends on phylogenetic evolution. Among other hypotheses (exercise-induced intermittent claudication, compression of the tibial nerve, excessive tension on the nerve innervating the accessory soleus muscle), this supranumerary muscle is generally considered to be the cause of a localized compartment syndrome. Pain experienced during exercise is the only symptom regularly reported by patients. A careful examination is required to rule out another local cause. Besides tumefaction lateral to the Achilles tendon, often found bilaterally, there is no other clinical sign. Plain x-rays, ultrasound and computed tomography simply demonstrate a "mass" in front of the Achilles tendon. MRI is the examination of choice enabling confirmation of the muscle nature of the mass and ruling out the possible diagnosis of tumor. Since there is no risk of aggravation, surgical treatment can be avoided if there is no complaint. If the patient is seriously impaired, surgery can be proposed. In our opinion, complete resection of the supernumerary muscle is the safest solution and should be preferred over simple fasciotomy.

[Muscular conflict in the peroneal retinaculum caused by supernumerary muscular fascicles of the peroneus brevis. Apropos of 2 cases]. / Conflit musculaire dans la gouttière rétro-malléolaire par faisceaux musculaires surnuméraires du court péronier latéral (peroneus brevis). A propos de deux cas.

The authors describe two cases of muscular conflict in the peroneus retinaculum due to supernumerary muscular fascicules initiating a dislocation of the peroneal tendons. Removing the extra muscular portion brought about complete recovery in both cases.

[Irradiation of bone homografts. Their use following tumor resection. Apropos of 4 cases]. / Irradiation des homogreffes osseuses. Leur utilisation après résection pour tumeur. A propos de quatre observations.

Since 1978 gamma irradiation has been used for sterilization of bone allografts. The radiation source used was Co 60 (2.5 to 3 megarads). Which was applied at the Atomic Centre of Saclay. The technique of sterilization is absolutely reliable at relatively low cost. It allows pieces of bone from cadavers to be harvested several hours after death, without special aseptic precautions. It appears to diminish antigenicity of the graft very little and incorporation is perhaps slowed down. The grafts did not become radioactive. The graft is carefully packed and frozen as soon as it is taken from the cadaver. Freezing is continued during the irradiation process and the graft may then be stored for several months. This technique was used for reconstruction after tumor resection twice in the knee, once in the pelvis and once in the fibula. There was no postoperative infection. Scintigraphy showed satisfactory incorporation. In one case of replacement of the femoral condyle the cartilage of the graft was replaced by the intact articular cartilage of the patient. Later, this articular cartilage was shown to be necrotic and a total prosthesis was inserted. The fibular graft was secondarily complicated by a fracture. Sterilization using irradiation makes bone harvesting in cadavers easier and allows bone banks to be established. It should lead to more extensive use of allograft bone.

[Results of surgical treatment for rupture of the achilles tendon]. / Bilan du traitement chirurgical des ruptures du tendon d'achille

The authors analyse the results obtained on 53 cases of rupture of the Achillis tendon. Early minor complications were numerous (26 p. 100) the average follow-up, in 38 cases, was about 6 years. A number of ankle limitations, triceps weakness were noted. All patient had a calf atrophy. Final results were not related to the surgical technique (suture or grafting using plantaris). The authors conclude that the results obtained after surgical treatment are not as good as generally thought.

[Ruptures of the Achilles tendon. Comparison of the results of surgical and nonsurgical treatment]. / Les ruptures du tendon d'Achille. Comparaison des résultats du traitement opératoire et non opératoire.

The authors have compared the results obtained in 76 cases of rupture of the tendo Achillis treated conservatively with a previously published series of cases treated surgically. The same assessment of the results was used. The main complication of surgical treatment was skin necrosis; the main complication of conservative treatment was recurrent rupture. To objective assessment, the loss of strength in the triceps surae was about 20 p. 100 in both series. Subjectively, the conservatively-treated patients seemed more satisfied. These findings support the conclusions of other published comparative studies that conservative treatment is worthwhile since it avoids general anaesthesia and hospital treatment. It is indicated when the conditions are favourable. Surgical treatment should be used in young athletes because healing is quicker in cases of recurrent rupture or old ruptures.

[Pyramidal syndrome. Apropos of 4 cases treated by surgery and review of the literature]. / Le syndrome du pyramidal. A propos de 4 cas traités chirurgicalement et revue de la littérature.

PURPOSE OF THE STUDY: The authors report 4 observations of Piriformis syndrome, defined as a truncked sciatalgy with sciatic nerve and branches located compression at the buttock passing through the subpiriformis canal. MATERIAL: 4 sportive patients, 26 to 41 years old have been treated surgically after an average of one year and a half of evolution and failure of conservative treatments. The surgical procedure consisted in section of the piriformis muscle and neurolysis of the sciatic nerve. METHODS: The follow-up ranged from one year and a half. The observations were confronted with 11 english language publications, representing 20 observations. RESULT: 2 excellent results. One fair. The result of the last patient is uninterpreted due to a post-operative deficiency of the inferior gluteus nerve. But the pre-operative symptomatology has completely disappeared. DISCUSSION: Symptomatology associated a trunked sciatalgy arising during effort and during a long time sitting position, without lumbar pain. Paresthesy and dyspareunia can sometimes added. The specifics clinical signs are pain induced by palpation at the sacrum lateral edge, perception of a tense piriformis ("sausage shaped mass"), pain reproduction by stretching the piriformis (Freiberg) or by its opposite tensing (Pace and Nagle, Beatty). The complementary exams first allow to eliminate all rachidian or discal aetiology. The diagnosis is based on CT, MRI and bone scan which can show modifications of the piriformis muscle and especially the electrommyogram which confirms the syndrome and specifies the compression level. The aetiology is changeable, mainly represented by modification of piriformis (hypertrophy, contracture or micro traumatisms due to sport or after-effects of direct traumatism) and by anatomical modifications of the sciatic nerve, passing completely or in part through the muscle. First, the treatment must be conservative by sport rest, correction of occupational diseases, local injections and especially stretchings. The results are more often favourable. In case of failure and diagnosis certitude, the surgical treatment is the neurolysis of the sciatic nerve and the muscle section at the musculo-tendinous junction. CONCLUSION: This syndrome must be known but, in spite of its proved authenticity now, must stay an exceptional diagnosis and be based on irrefutable criteria.

[Anterior snapping of the hip associated with the ilial psoas]. / Les ressauts antérieurs de hanche liés au psoas iliaque.

UNLABELLED: Anterior snapping of the hip was first described in 1951 by Nunziata and Blumenfeld. The aim of this study, based upon a personal series and backed up by literature reports, is a current review of this common clinical condition, usually asymptomatic, but sometimes painful especially in athletes. MATERIAL AND METHOD: 12 cases in 11 patients were treated surgically: 4 men and 7 women, mean age 25 years, 7 of them regularly involved in sport. The onset of the snapping was sudden in 6 cases, related to a precise movement, while in 6 cases pain preceded the gradual development of snapping. Pain may coincide with snapping, or may be of a "chronic" nature after exercise. The problem had been present for 2 years on average before treatment. Surgery consisted of posterior psoas aponeurotic fascia division and was sufficient in 11 cases. In one patient, disappearance of snapping was obtained only after division of the ilio-femoral ligaments. Mean postoperative follow-up was 6.5 years (1 to 12 years). Pain disappeared in all patients. A slight, intermittent and asymptomatic snapping persisted in 3 cases. All athletes regained their previous performance level. DISCUSSION: CLINICAL: Symptoms consist of a dull, deep clicking sensation in the groin during active mobilization of the hip. It never occurs with passive mobilization. The entire problem is that of attributing painful symptomatology to snapping. ANATOMICAL STUDY: In almost all cases, snapping is due to a sudden movement of the psoas aponeurotic fascia on the ilio-pectinate eminence. Other causes have been reported: ilio-femoral ligaments on the femoral head, rectus femoris or psoas tendon on bony crests or of psoas on the cotyloid cup of an artificial hip. INVESTIGATIONS: These are primarily designed to rule out any other cause of snapping or inguinal pain (foreign body, acetabular labrum lesion, etc). Bursography and dynamic ultrasonography identify the snapping site, but it is sometimes difficult to confirm that this is responsible for painful symptoms. TREATMENT: If such responsibility is confirmed, and if any psychological component can be ruled out, this should first be "medical" by stretching and local injections in the serous bursa. Surgery should consist in division of the psoas aponeurotic fascia, leaving the muscle fibers intact. The procedure should be performed under sensory epidural anesthetic, the only way of ensuring peroperatively that snapping has disappeared. Division of the psoas distal tendon at the lesser trochanter is not appropriate.

[Osteochondral lesions of the dome of the talus with partial necrosis. Surgical treatment by curettage and filling]. / Les lésions ostéochondrales du dôme astragalien avec nécrose partielle. Leur traitement chirurgical par curetage et comblement.

There are several types of lesions of the talus, including non united fractures and true osteochondritis in adolescents. This article focuses on lesions of the dome of the talus having a large subchondral necrotic zone. The etiology of these lesions is unclear. Even when they result from trauma, this may not be the sole cause. Thirty-three similar cases were studied, allowing analysis of the radiological appearance and the value of arthro scanner data. All the cases were treated by surgery (and were subsequently classified histologically). The necrosis was treated by curettage and filling with cancellous bone grafts taken from the lower tibial epiphysis. Twenty-seven patients were followed up at least one year (average 3 years 3 months). The outcome was functionally good or very good in twenty-two cases. The anatomical reconstruction was scored by radiology as very good in nineteen patients and satisfactory in five, who had irregularities and non-homogenous appearance of the talar dome. These results justify the use of curettage and filling. Arthroscopic techniques, although appropriate for simple ablations of osteochondral fragments, do not appear to be satisfactory for treating lesions including subchondral necrosis. Filling can only be performed surgically.

[Treatment of posterior instability of the shoulder joint using an acromial stop with a pediculated deltoid flap]. / Le traitement des instabilités postérieures de l'épaule par butée acromiale pédiculée à un lambeau deltoïdien.

Our purpose has been to describe an original surgical technique without describing all the problems concerning the posterior instability. The original technique has a double effect: active with the muscular flap and passively mechanic, if necessary, by the bone graft. Five patients have been treated with this technique with a follow-up of one year and a half. 4 females and 1 male with an average age of 32 years 1/2. 2 were recurrent posterior instability, one unintentional and 2 intentional subluxations. 2 were epileptics. In all cases, the disparition of the instability was obtained. Full range of movement and sport were resumed at the former level. On X-rays, the humeral head was centered. By its double mechanism, active with the muscular flap and possibly passive with the bone graft, this technic is reliable to treat the majority of posterior instability. It combines the way of action searched in physiotherapy and capsulomyoplasties to center the humeral head and this one by the bone graft in case of posterior glenoid fracture or dysplasia. It doesn't have the insufficiencies of physiotherapy or capsulomyoplasties in posterior traumatic instabilities, nor from the classical bone graft over the glenoid posterior wall, cause of osteoarthritis and pain.

[Chronic stress-related compartment syndrome of the forearm]. / Le syndrome d'effort chronique des loges antérieures de l'avant-bras.

The chronic anterior compartment syndrome of the forearm is a rare pathology (3 cases have been already published), and of new knowledge. Three new cases on 2 patients (one on both sides) are described here. The authors describe recent advances about physiopathology, exploration and surgical treatment. It is due to strenuous activity using flexor muscles of the forearm without any release period (here motor cyclist competition). The symptom was pain at the anterior forearm similar to cramp. The most important for diagnosis was to measure the pressure after activity. The threshold level read after activity was up to 30 mm of Hg, with a very slow coming back to normal value. The isotopic scanner with hydroxyl methylene di-phosphonate (HMDP), after activity, showed a delay of arrival of the tracer and a stasis. RMI seems to give abnormal modification of the signal. The only treatment was surgical and an open fasciotomy of superficial and deep fascia must be done, with opening of the muscle's perimysium. The patients became painfree and resumed their sport after surgical treatment.

[Surface arthroplasty of the knee by marmor prosthesis. Study of 35 unicompartimental prosthesis seen with a follow-up of 1 to 5 years (author's transl)]. / Arthroplastie de surface du genou par la prothèse de Marmor. Etude de 35 prothèses uni-compartimentales revues avec un recul de 1 à 5 ans.

The Marmor prosthesis may be used for a surface arthroplasty of the knee by means of a system of unicompartmental modules including 4 sizes of condylar ramps and 6 thicknesses of tibial plateaux in two widths. It is thus possible to treat one or both compartments and correct any axial deviation. The operative technique must be careful and accurate with regard to the positioning of the prostheses and the choice of thickness of the plateau to be inserted. Preoperative radiological assessment must be very precise, and include in particular films with monopodal weight bearing and in forced position in order to study the joint surfaces and predict the correction which must be applied. Fifty operations have been performed (in 37 cases for osteoarthrosis), but the essential aim of the present study is to report the results of 35 unicompartmental prostheses with a follow-up of 1 to 5 years (mean : 2 years and 2 months). Thirty results were assessed as good or very good. The most spectacular features were freedom from pain and the rapidity with which the results were obtained. They would seem to be clinically stable. Nevertheless, the development of 3 deteriorations of the tibial plateau after Marmor would appear to contraindicate the use of 6 mm thickness plateaux. In contrast to widespread opinion, the remaining compartment does not degenerate, so long as it was normal preoperatively and there has not been any hypercorrection of the deviation after unicompartimental arthroplasty. Nevertheless, the latter has its limits and whilst it may play a role in the treatment of certain cases of osteoarthrosis of the knee, it cannot replace either tibial osteotomy for correction of the axis or bicompartimental prostheses or total prostheses anchored in the diaphysis, which also have their indications.