Prevention of postoperative venous thrombosis: a randomized trial comparing unfractionated heparin with low molecular weight heparin in patients undergoing total hip replacement.

A double blind randomized trial comparing subcutaneous enoxaparin (40 mg once daily) with standard unfractionated calcium heparin administered at a dose of 5,000 units every 8 hours in patients undergoing elective hip replacement has been performed. Treatment regimens began 12 hours preoperatively with enoxaparin, 2 hours preoperatively with standard unfractionated calcium heparin, and were continued for 15 days or until discharge. Venography was performed in all patients. Two hundred thirty-seven patients were included in the study: 113 received unfractionated heparin and 124 received enoxaparin. The incidence of proximal deep vein thrombosis was reduced from 18.5% in the unfractionated heparin group to 7.5% in the enoxaparin group (p = 0.014), and the incidence of total deep vein thrombosis was similarly reduced from 25% to 12.5% (p = 0.03). There were two major bleeding episodes and one minor bleed in the enoxaparin group compared to two minor bleeds in the unfractionated heparin group. Patients who received enoxaparin required fewer red blood cell transfusions and had a significantly higher hemoglobin on postoperative days 3 and 4. Thus prophylaxis with enoxaparin, 40 mg once daily, is simple, safe and more effective than standard low dose unfractionated heparin in preventing deep vein thrombosis in patients undergoing elective hip replacement.

[Double-blind randomized comparative study of enoxaparin and standard heparin in the prevention of thromboembolic disease during insertion of total hip replacement]. / Etude comparative en double aveugle randomisée de l'enoxaparine et de l'héparine standard dans la prévention de la maladie thrombo-embolique lors de la mise en place d'une prothèse totale de hanche.

237 patients with a non-traumatic disease of the hip requiring total hip replacement entered a multicentre trial. Treatments were allocated at random in a double-blind manner: 113 patients received 5000 IU of standard heparin t.d.s.; 124 patients received enoxaparin 40 mg once a day. Treatment lasted from 10 to 15 days until bilateral ascending phlebography of the lower limbs (BAPLL) was performed. Its effectiveness was assessed by the results of BAPLL, by evaluation of the risk of bleeding on examination of the surgical wound, by the units of blood required for perfusion and by daily blood count and differential. BAPLL was performed in 228 patients: 15 phlebographies (12.5 p. 100) were positive in the 120 assessed patients of the enoxaparin group, while 27 (25 p. 100) were positive in the 108 assessed patients of the standard heparin group (p = 0.014). Proximal deep vein thrombosis was significantly (p = 0.03) less frequent in the enoxaparin group (7.5 p. 100) than in the standard heparin group (18.5 p. 100). Pulmonary embolism was observed in a patient on standard heparin. The units of blood required for perfusion were significantly (p = 0.03) smaller in the enoxaparin group (3.37 +/- 1.81 U) than in the standard heparin group (3.84 +/- 1.70 U). Thus, one single subcutaneous injection of enoxaparin 40 mg daily was significantly more effective and safer than standard heparin 5000 IU t.d.s. in the prevention of deep vein thrombosis after total hip replacement.

[MRI in the pre-operative evaluation of lesions of the rotator cuff]. / Apport de l'IRM dans le bilan pré-chirurgical des lésions de la coiffe des rotateurs.

The authors report a series of 38 patients who had been examined by MRI and then operated for a rotator cuff syndrome. The correlation between the description of the cuff lesions after MRI and the surgical observations were excellent for 37 patients. In one case MRI showed a false image of tear of the supra spinatus m. on its anterior edge. This was due to a bad knowledge of the anatomy of the muscle and tendon and to a poor orientation of the frontal cut plane. This study was complete with MRI and anatomic study of 12 non embalmed cadaveric shoulders. The results showed that MRI was very sensitive (0.93) and specific (0.94) for the diagnosis of rotator cuff tears. MRI allowed also to show partial tears of the tendons of the rotator cuff. The authors propose a MRI classification of cuff lesions which permits to establish a good surgical planning.

[Evaluation of therapeutic trials published apropos of antibiotic prophylaxis in orthopedic surgery]. / Evaluation des essais thérapeutiques publiés sur l'antibioprophylaxie en chirurgie orthopédique.

The authors review all the randomized clinical trials published since 1970 which evaluate the efficacy of antibiotic prophylaxis in orthopaedic surgery. Evaluation of the quality of these trials was based on two clinical and four methodological criteria. They also take into account reports which aim to define the best antibiotic prophylactic protocol, particularly with regard to the duration of treatment. In conclusion, although the majority of trials do not escape criticism, the efficacy of antibiotic prophylaxis in orthopaedic surgery can be considered as demonstrated. The duration of treatment is still an open problem. At the present time, the duration of drainage defines the length of antibiotherapy.

[Isolated traumatic dislocation of the extensor carpi ulnaris tendon]. / Luxation traumatique isolée du tendon cubital postérieur.

The authors describe one case of post-traumatic dislocation of the extensor carpi ulnaris tendon. They found eleven other cases reported in the literature. The type of lesion should be looked for in cases of trauma to the wrist without a bony lesion. The treatment should be surgical when function is impaired, either shortly after the initial trauma or if the dislocation becomes habitual. The aim is to reconstruct a tendon sheath. The results were generally satisfactory.

[70 patients operated on for sciatica without herniated disk]. / A propos de 70 sciatiques sans hernie discale opérées.

Seventy patients suffering from sciatica were operated in whom no disc herniation was found. In 42 instances, compression of bony origin was found. These cases were either due to general narrowing of the spinal canal with signs in the distribution of several roots with neurological intermittent claudication, or to narrowing of the lateral recess or intervertebral foramen with involvement of only one root. Decompressive surgery was always beneficial for pain. In 20 instances a disc was found to be only bulging; disc excision was performed in 17 of these patients. In 8 instances, no abnormality was found. Some patients were nevertheless cured by disc excision, a single laminectomy being useful. The incidence of additional psychological problems is discussed. It is concluded that the clinical signs should guide the surgeon rather than the radiological findings in decisions for surgical treatment. Patients who have been correctly treated by conservative means for an adequate time should be systematically operated on if they have not shown sufficient clinical improvement.

[Functional and mechanical anatomy of arm elevation]. / Anatomie fonctionnelle et mécanique de l'élévation du bras.

Experimental work on the functional anatomy of the shoulder has involved a study of the conditions involved in elevation of the arm. Movements of the upper limb are organised round a very special alignment of the scapulo-humeral joint whose geometric features and exact position have been determined. The ligaments of the joint play a major role in the controlling the attainment of this alignment. The value of this alignment in the physiology of the shoulder is demonstrated. A new terminology of shoulder movement is suggested.

[Nontraumatic aseptic osteonecrosis of the femoral head. Etiopathogenic, developmental and therapeutic considerations: review of the literature]. / Ostéonécrose aseptique non traumatique de la tête fémorale. Considérations étiopathogéniques, évolutives et thérapeutiques: revue de la littérature.

Aseptic non-traumatic necrosis of the femoral head occurs in patients with very unusual general state of health. Despite the fact that the metabolic abnormalities are better known today, many problems with regard to prognosis and treatment remain. According to the author's experience and, review of the literature, the authors consider that the production of tissue repair with hypervascularity is an aggravating factor. Disturbance of lipoproteins plays a major aetiological role. Decompressive forage should be reserved for the early stages. Secondary degenerative arthritis is almost constant after conservative surgery in cases that have been assessed. The authors obtained good results after Luck's adjusted cups and they consider that this is a reliable procedure. They have observed a high level of septic complications after total prosthesis. It is thought that this is related to the general condition of the patient.

[Total shoulder replacement by an unconstrained prosthesis. Report of 38 cases (author's transl)]. / Une prothèse totale d'épaule non rétentive. A propos de 38 cas.

The authors have operated on 38 patients using an original type of unconstrained prosthesis with fixation to the acromion. One prosthesis had to be removed for sepsis, 5 have dislocated and 32 are stable. Most of the cases were improved as regards pain but 14 shoulders remained very stiff. The indications for surgery are discussed, the state of the rotator cuff being particularly important.

[Recent fractures of the scapula. Apropos of 43 cases]. / Les fractures récentes de l'omoplate. A propos de 43 cas.

The authors have studied a series of 43 fractures of the scapula. They confirm the results are generally good. However, 12 displaced fractures of the neck of the scapula have been seen. All were treated conservatively with only one good result, the other results being fair or poor. These results are explained by the fact that displaced fractures of the neck disorganize the coraco-acromial arch. This type of fracture should be surgically treated as an articular fracture by open reduction and plate fixation. Fractures of the glenoid should also be treated surgically.

[Contribution of MRI to the preoperative evaluation of rotator cuff tears]. / Apport de l'IRM dans le bilan pré-chirurgical des lésions de la coiffe des rotateurs.

The authors report a series of 38 patients who had been examined by MRI and then operated for a rotator cuff syndrome. The correlation between the description of the cuff lesions after MRI and the surgical observations were excellent for 37 patients. In one case MRI showed a false image of tear of the supra spinatus m. on its anterior edge. This was due to a bad knowledge of the anatomy of the muscle and tendon and to a poor orientation of the frontal cut plane. This study was completed with MRI and anatomic study of 12 non embalmed cadaveric shoulders. The results showed that MRI was very sensitive (0.93) and specific (0.94) for the diagnosis of rotator cuff tears. MRI allowed also to show partial tears of the tendons of the rotator cuff. The authors propose a MRI classification of cuff lesions which permits to establish a good surgical planning.

[Experimental study of dislocations of the scapulohumeral joint]. / Etude expérimentale des luxations antéro-internes ou erecta de l'articulation scapulo-humérale.

One may produce easily an experimental dislocation (anterior or erecta) of the scapulohumeral joint. The authors discuss, the experimental model then they describe the anatomical lesion produced through the experimental dislocation of 32 shoulders and the correlation observed after RMI assessment of 24 recurrent dislocations. The tear of the inferior glenohumeral ligament is constant, in 20 per cent of the cases the tear lies on the anterior aspect of the glenoid, in the other cases the tear was found on its humeral side. Whatever the situation of the tear of the inferior glenohumeral ligament, the lesion of the labrum was constant. The erecta dislocation was produced with the same movement but with a particular tear of the glenohumeral ligament: the tear was longitudinal. The experimental dislocation needs, in 7 or 8 cases, a desinsertion of the deep aspect of the rotator cuff. The Hill Sachs lesion occurs when the humerus falls along the chest wall after the dislocation. In 50 per cent of the patients, MRI shows modifications of the cuff which are compatible with our results. Hills Sachs lesions appear to be constant after MRI examination.

[Total radiocarpal prosthesis. Preliminary study]. / Prothèse totale radio-carpienne. Etude préalable.

The mechanical requirements before satisfactory muscular balance in a total wrist prosthesis have been studied in 25 cadavers. The centre of rotation was determined in X-Rays; it was localised in the sagittal plane crossing the axis of the forearm and in the frontal plane situated in front of the axis of the forearm. A graphic model of the wrist was then established. A total prosthesis was then designed, made up of two components with a torus surface. This prosthesis was found to be compatible with the wrist model. Movement required forces only slightly greater than normal muscular activity. One male was operated on using this prosthesis. The result was satisfactory after one year.

[The stage of articular destruction in the rheumatoid hand]. / Main rhumatoïde au stade des destructions articulaires

Function incapacitation of the hand in rheumatoid arthritis was studied on 33 patients (54 hands). 35 were operated on. All cases had reached the stage of articular destructions. The authors emphasize the importance of preserved proximal inter-phalangeal joint for digito-palmar pinch. Thumb unstability was not severely disabling as long as the other digits were normal. However, when it was associated with hyperextension deformities of the other fingers, the hand became useless. Surgical indications in rheumatoid hand were detailed. The importance of restoring thumb function was pointed out.

[Cysts of the external meniscus]. / Les kystes dl ménisque externe

The authors have treated 20 cases of cyst of the laternal meniscus of the knee. In most of the cases, the diagnosis was made late. The clinical, radiological and pathological features are described and the etiological factors are discussed. Complete meniscectomy relieved the symptoms in 17 cases.

[The total shoulder prosthesis]. / Prothèse totale de l'épaule.

Prosthetic shoulder replacement is impeded by two main obstacles: the articular cavity is very shallow, and the small glenoid surface rests on a narrow neck to which prosthetic pieces are difficult to attach. The principal, currently used prostheses are non-retentive models which reproduce the anatomy of the joint. They differ from each other mainly in the glenoid piece pattern which may be sealed only to the glenoid cavity or also fixed onto the acromion. On the whole, the clinical results reported are encouraging, particularly as regards the absence of pain, but the radiological course of the glenoidal sealing is a source of concern. Obvious unsealing is rare, but cracks between bone and cement are very frequent and some of them become wider as time goes by. In addition, there is still no satisfactory solution to the problem of big rotator cuff tears. This type of prosthesis must be envisaged with caution and should be reserved to very painful shoulders, but it would be wise not to wait until the rotator cuff is destroyed. The best indications are glenohumeral osteoarthritis, rheumatoid arthritis and necrosis of the tumoral head.