[Imaging of complications following hip arthroplasty]. / Imagerie des complications des prothèses totales de hanche.

Acute complications include fractures and prosthesis dislocations. Most chronic complications involve mechanical or septic loosening and aggressive granulomatosis. Greater trochanteric pseudarthrosis, periprosthetic soft tissue ossifications or prosthesis conflict with the psoas muscle can also be responsible for groin pain. Most complications are detected with serial plain radiographs, but additional imaging techniques including CT scan and scintigraphy are sometimes necessary for pretreatment diagnosis. Pain generally indicates a complication but aggressive granulomatosis can be asymptomatic, thus warranting systematic annual plain radiographic control.

Trauma emergency unit: long-term evaluation of a quality assurance programme.

OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme.

[Reflections on recent ruptures of the diaphragm. Apropos of 45 cases]. / Réflexions sur les ruptures récentes du diaphragme. A propos de 45 cas.

Trauma-induced ruptures of the diaphragm are very exceptional but are regularly encountered in trauma surgery units. Closed ruptures occur in 60 to 80% of diaphragm lesions in European series, 9 times out of 10 after traffic accidents. Large American trauma centers however, have had more experience with stab of firearm wounds. The diagnosis raises many problems and requires further exploration after the standard chest x-ray. We discuss the different explorations which can be contributive in both emergency and non-emergency situations. The most appropriate therapeutic approach is also discussed. Should thoracotomy or laparotomy be used? What precautions are required prior to surgery? Can laparoscopy be useful?

[Treatment of complex fractures of the ankle and their sequellae using trans-plantar intramedullary nailing]. / Traitement des fractures complexes du cou-de-pied et de leurs séquelles par enclouage transplantaire verrouillé.

UNLABELLED: Nine patients were treated for complex tibial pilon and talus fractures or non unions from 1990 to 1997 using intramedullary nails introduced through the calcaneus. All patients were followed until healing. The average follow-up was 14 months. Failure of the procedure was defined by the occurrence of complications or reintervention. We used a modified Seidel nail in 5 cases, a tibial shaft nail in 3 cases, and a special nail in one case. All nails but two were locked. CASES: These arthrodeses were performed for treatment of sequels from open talus fractures. Transplantar nailing was performed between 9 months and 3 years after arthrodesis, because of non union. In two cases fusion was obtained at 3 and 8 months postoperatively. In the third case non union occurred due to instability of fixation (the nail was unlocked). Replacement by an interlocked nail was performed through a proximal tibial approach, and healing was obtained in 6 months. PSEUDARTHROSES: 2 CASES: These two cases presented comminuted tibial pilon and open talus fractures in association with vascular and tendon lesions. They had previously undergone debridement and external fixation. Transplantar nailing was performed 8 and 10 months after trauma using a locked modified Seidel nail. Radiographic fusion was obtained in 5 months. PRIMARY SURGERY: 4 CASES: The first two cases were foot reimplantations after traumatic amputation. Skeletal stabilization was obtained using a transplantar locked tibial nail. Revascularization attempts failed and an amputation was performed on the fourth day in one case. The reimplantation succeeded in the second case. Radiographic fusion was obtained in 2 months. The third case was a distal tibial shaft fracture. The patient was an obese mentally deficient and invalid woman. Bone union was achieved in four months. The last case was a primary arthrodesis for post-trauma necrosis of the talus. Radiographic fusion was observed 45 days after operation. Transplantar locked nailing offers an optimal stabilization for complex ankle fractures. We had two failures not related with the principle of the technique. We think that transplantar nailing is best indicated to obtain tibiotalar or tibiocalcaneal arthrodesis and to treat compound ankle fractures. Another indication could be distal tibial shaft fractures in invalid or mentally deficient patients.

Incidence and preventability of adverse events in the emergency room of an orthopaedic traumatologic surgery unit.

This paper reviews the nature and the frequency of adverse events in the everyday functioning of a French trauma emergency unit, and evaluates the feasibility of their detection by the means of a daily record review. A senior surgeon identified the adverse events by reviewing the complete record with a minimal 6-months follow-up for every patient attending the emergency unit during a 10-week period. To test the reliability of this review, a blind re-review of all records corresponding to the detected adverse events, mixed with an equal number of controls, was carried out by two independent experts. The review of the 2604 records identified 210 medical adverse events, most of them occurring early in the care process. Sixty-seven per cent of the adverse events involved prevention failure, mainly for tetanus but also for thrombosis and rabies. For the other 33% it was possible to determine two situations with a high risk of adverse event: body contusions following a traffic accident and metacarpo-phalangeal thumb sprains. The re-review evaluated the positive predictive value of the initial review to be 97.5% and its negative predictive value to be 96%. It is concluded that the review of the initial record by a single senior is effective in detecting the adverse events. Prevention of two-thirds of them could be possible by the implementation and monitoring of protocols.

[Ascending intramedullary nailing of the femur. Technique. Initial results. Indications]. / L'enclouage centromédullaire ascendant et verrouillé du fémur. Technique. Premiers résultats. Esquisse des indications.

Some fractures of the distal third of the femur are not good indications for the centromedular locked nailing technique where the nail in inserted through the greater trochanter. Indeed, unsatisfactory reduction and stabilization are often obtained. Inversely, when the nail is inserted upwardly from the knee joint after drilling an orifice in the trochlea and the condyles, the mechanical locking is very close to the knee joint and, when the subtrochanter region is reached, the nail automatically aligns the fracture. The implant temporarily used was a centromedular tibial nail rotated by 180 degrees and mechanically locked near the knee under fluoroscopic control near the lesser trochanter. Five trauma cases were treated with this technique. Early results have been encouraging, similar to those obtained for nailing with closed surgery. These results would suggest that upward nailing should be conceived for particular indications: fractures of the supracondyle area, spiral and comminutive fractures of the distal third of the femur, certain fractures of the supra and inter condyle area.

[Peritrochanteric fractures treated with a lamina-plate with stay]. / Fractures péri-trochantériennes ostéosynthésées par Lame-plaque à étai.

60 peritrochanteric fractures treated with a lamina-plate with stay were studied. Their socio-professional caracteristics were similar to the whole sample. The functionnal results and the Duke's score were lower than the other osteosyntheses methods, despite a low number of complications. These results could be explained by systematic early weight bearing for the patients. This causes pain which is not well endured by patients included in this study. These patients, in good general and intellectual health, are able to bear, and prefer, prolonged decubitus (without pain). But while early weight bearing is not a priority for this population, it remainds fundamental for the patients with low intellectual function, who most frequently present with this type of fracture.

[Intra-medullary nailing of radius neck fractures in adult]. / L'embrochage centro-medullaire dans les fractures du col du radius de l'adulte.

Fractures of the neck of the radius (Mason's type IV) are rarely seen in the adult although they are the most frequent in the child. There is no satisfactory treatment at the present time and the authors present 2 cases treated by intramedullary nailing with good results. This technique was described by Metaizeau and al for the child.The first case was a woman 46 years old presenting a dislocation of the left elbow with a radial neck fracture Mason's type IV. The angulation between the radial head and the diaphysis was 55°. The dislocation was spontaneously reduced and an intramedullary nailing was performed on the radial neck fracture. Six months later the mobility of the elbow was normal except 10° loss of extension. The X-rays showed a radial head with no evidence of necrosis, and no residual angulation.The second case is a 25-year-old man with a Mason's type IV radial neck fracture. The angulation was 50°. At 6 months of follow up the elbow still had 15° loss of extension. The X-rays appearances were the same that for the first case.The procedure is detailed. The entry point is at the distal metaphysis. A kirschner wire is curved at its extremity and pushed into the medullary canal. The radial head is pinned by the sharp curved extremity of the wire. A rotating motion of the wire allows reduction and fixation of the fracture.The authors experience and the 6 cases presented by Keller shows that intramedullary nailing seems a good solution for fixation of the radial neck fractures.

Introduction.

The number of femoral fractures after hip arthroplasty has increased proportionally to the number of hip arthroplasties. Eleven university-orthopaedic centers in eastern France co-operated to review 250 femoral fractures in relation to hip prothesis. This is the largest published review. The aims of this retrospective study were: - an epidemiologic study of the predisposing factors of these fractures, - to define a protocol of therapeutic indications.

[Materiel and method]. / Matériel et méthode.

This retrospective, multicentre study has collected 250 cases of fractures of the femur following arthroplasty of the hip and covers a 20 year period from the 25/01/73 to the 30/05/93 (51 peroperative fractures and 199 fractures at some time after arthroplasty). There were 157 women and 93 men whose average age was 73 years for the 199 post operative fractures. The average period between arthroplasty and the fracture is 5 years. A common questionnaire was used by all the centres involved in this study in order to codify conditions of surgery, pre and post fracture X ray examinations and the different treatments and their complications.

Conclusions.

The main objectives of this retrospective multicentric study were to define the predisposing factors and methods of treatment. The common predisposing factor is the femoral fragilization due to loss of "bone stock" (secondary to osteopathies or tumor, or especially prosthetic loosening). More specific factors are iatrogenic. For intraoperative fractures we found reoperation, excessive mobilisation of the femur and excessive diaphyseal reaming. For postoperative fractures we found coticotomy and screw hole distal from the tip of the stem, or a gap between another implant wich induced a gradient of elasticity. The therapeutic indications follow the Johansson classification:Type I fractures: If the stability of the prothesis is good: - with a transverse fracture line: functional treatment (off-loading for 45 to 60 days), - with a spiral fracture line: internal fixation using a rigid plate or cerclage wire. If prosthesis loose:- revision arthroplasty with a long stem prothesis is the ideal, - if the general status is too poor, orthopaedic treatment is indicated.Type II fractures: If good stability of the prothesis: internal fixation using a rigid plate. Bone grafting is not necessary. If prosthesis loose: revision arthroplasty with long stem prothesisType III fractures: Altought the ideal seems revision arthroplasty using long stem prothesis, we think that internal fixation by plate with perfect operative technique is indicated for these old and vulnerable patients. Considering the therapeutic indications we suggest a modification of the Johansson's classification:Type I fracture: - Ia: stability of the prothesis, - Ib: loosening prothesis.Type II fracture: - IIa: stability of the prothesis, - IIb: loosening prothesis.Type III fracture: - IIIa: proximal fracture, - IIIb : distal fracture.

[Massive osteolysis : two cases displaying extreme clinical aspects]. / L'ostéolyse massive idiopathique : les aspects extrêmes de deux observations.

We have come across two cases of massive osteolysis showing completely opposite clinical aspects. The first case is a young man aged 28 showing osteolysis of the distal third of the right ulna. His disease was discovered after performing X-rays for minor trauma of the right forearm. He had never complained of his arm before and he only displayed a loss of 45° in pronation. We noted that osteolysis could already be seen on X-ray at plaster removal after 45 days of immobilisation, although the osteolysis was not noticed on the first X-rays.The second case concerns a 17-year-old man who was known to have a massive osteolysis of the pelvis ring and who had used a wheel-chair from the age of 8. While hospitalized for a severe infection of the testicles and scrotum, he developped a recurrent chylothorax that required surgical pleurodesis. This young man displayed no radiological evidence of this disease above the pelvis.A review of the literature allows us to clarify the still obscure pathogenic aspects of massive osteolysis, its classification, the different forms that may be encountered and the keys to diagnosis. The authors caution against aggressive treatment in certain areas where the disease remains benign.

[The role of posterior bracket plate osteosynthesis in the treatment of compression-extension fractures of the distal end of the radius]. / La place de l'ostéosynthèse à la plaque console postérieure dans le traitement des fractures de l'extrémité inférieure du radius, par compression-extension.

Osteosynthesis without immobilisation of compression-extension fractures by means of a posterior plate was studied in prospective series with a minimum follow-up of six months (first group: 73 patients) and a minimum follow-up of one year (second group: 63 patients). The clinical results were evaluated and showed several complications (no infection, but reflex sympathetic dystrophy, paresthesia, unsightly scars). The clinical and radiological findings (radio-ulnar index) could improve with several technical devices, now used.

[Correction of malunion of femoral fractures by Ilizarov's device in children]. / Correction des cals vicieux du fémur de l'enfant par l'appareil d'Ilizarov.

Cast immobilisation of femoral fractures in children may sometimes be subject to important displacements. Absence of survey leads to malunions which may make a secondary correction necessary. In two such cases the authors used Ilizarov's external fixation which allowed correction of both angulation and shortening without direct approach. Rapid healing occurred. The authors made a comparative analysis of the different possibilities for treatment of these severe femoral malunions.

[Arm lengthening in children. Report of 4 cases]. / Les allogements du bras chez l'enfant. A propos de 4 observations.

The principle of osteogenesis under stretch elaborated by Pr. G.A. Ilizarov around 1970 comfort our decision for limb lengthening for it does not need in most cases hemorrhagic operations nor use of bone grafts. Pathological shortening of the humerus may be due to various causes: monomelic dystrophy due to epiphysiodesis of humeral superior growing plate with or without humerus varus, sequelae of neonatal septic osteoarthritis of the shoulder joint are the more frequent etiologies. On the other hand, the fibrous dysplasia, osteochondromatosis (Ollier's disease), sequelae to trauma or iatrogenic etiologies are infrequent. Resulting length discrepancy are very important from 11 to 15 cm and more when growth is achieved. Functional disorders are delayed as compared to the lower limb for each upper limb acts independently to each other. However above 6 cm discrepancy coordinated movements become more difficult or impossible especially above 8 cm discrepancy. The authors reported 4 cases of arm lengthening concerning teenagers by Ilizarov's technique with a discrepancy between 10 to 14 cm. One of the humerus was previously treated by Wagner's technique which allow us to make a comparative analysis of both methods. Technical instructions, incidents and accidents occurring during lengthening, healing delays and functional and esthetic results are discussed in recent publications on this subject.

[A mucoid pseudo-cyst of the peripheral nerve. Apropos of a surgical case]. / Pseudo-kyste mucoïde des nerfs périphériques. A propos d'un cas opéré.

The authors report a case of a twelve old young man, operated on for a ganglion cyst of the common peroneal nerve. The lesion is rare, and is characterized by an accumulation of a mucoïd substance in the sheath, compressing progressively the fibres of the nerve. The case was revealed with pain, paralysis and tumefaction of the nerve. The pathogenic is uncertain. An early treatment, consisting of evacuation of the cyst and interfascicular neurolysis through the dissecting microscope, obtains usually a good functional result.

[Labor trauma-induced epiphysiolysis of the proximal femur. 4 cases]. / Geburtstraumatische Epiphysenlösung des proximalen Femurs. 4 Fälle.

The authors report on 4 cases of obstetrical traumatic slipping of the upper femoral epiphysis. Firstly, they emphasise the difficulties of diagnosis because trauma is often missed. In two cases the delivery was a cesarean section (in the same clinic!). Wrong diagnoses are: --neonatal septic arthritis with swelling and inflammation of the hip, lateral deviation of the metaphysis on the x-ray. Nevertheless, there are no signs of an infectious disease and symptoms begin at birth. --congenital dislocation of the hip but clinical testing of stability is painful and doubtful. Secondly, when diagnosis is uncertain, a joint aspiration confirms haemarthrosis, and arthrography shows the displacement of the epiphysis on the metaphysis. Finally, the authors explain their therapeutic procedure: three times orthopaedic treatment with traction and spica cast for 2 months, a pin osteosynthesis in one case. Prognosis was favourable in two cases, but the two other cases present a lateral rotation of the leg in relation to a retroversion of the femoral head.