Mini-invasive nail versus DHS to fix pertrochanteric fractures: a case-control study.

BACKGROUND: Fixation devices to treat trochanteric fractures belong to two general categories: dynamic hip screw (DHS) type and intramedullary type implants. In spite of possible pitfalls, both are considered valid options. Comparing a sliding screw-plate system (DHS) along a mini-invasive nailing device (BCM nail) with primary insertion of the cephalic screw, sheds light on the debated management of trochanteric fractures. HYPOTHESIS: Due to its design, the BCM nailing system allows a stable internal fixation and promotes enhanced postoperative functional recovery. OBJECTIVES: To test this hypothesis in a comparative prospective case-control study using the DHS screw-plate as a reference. MATERIALS AND METHODS: Two groups of 30 patients, older than 60 years old, with trochanteric fractures were included in this study. The screw-plates were placed according to the standard method. Regarding the nailing system, the cephalic screw was positioned first, then the nail was inserted through the screw via a mini-invasive approach and locked distally using a bicortical screw. Comparison between the two groups was based on (1) operative data: operating time, intra- and postoperative blood loss; (2) immediate postoperative course: complications, length of hospital stay, delay to sitting in a wheelchair; (3) the postdischarge evolution: weightbearing, readmission to hospital; (4) functional outcomes: recovery and mobility; (5) anatomical outcomes: restitution and bone healing. RESULTS: The operating time (54+/-8.8 min vs 59+/-13.8 min) and intraoperative (1.37+/-0.98 vs 1.90+/-1.43) and at Day 3 (1.25+/-1.05 vs 1.82+/-1.5) blood loss (haemoglobin loss), were favourable to the screw-plate subgroup (p<0.05). The delay to sitting in a wheelchair (4.76+/-1.53 d vs 4+/-1.44 d) was favourable to the nail subgroup (p<0.05). There was a higher incidence of secondary displacements in the screw-plate subgroup (3/26 [11.5%] vs 0/25 [0%]) (p<0.05). The screw-plate subgroup demonstrated a poorer healing rate at 3 months (88% vs 100%) (p<0.05). Regarding functional recovery, a lesser decrease in the Parker score was observed in the nail subgroup at 3 postoperative months (2.42+/-2.3 vs 1.52+/-1.44) (p<0.05). CONCLUSION: This study has shown the benefits of the BCM nail in terms of stability. But the potential advantages of this mini-invasive technique were limited by ancillary-related difficulties which need to be rectified. These preliminary results are in favour of a further development of this innovating device.

[Extra-articular elbow arthroscopy.] / L'endoscopie extra-articulaire du coude.

Extra-articular elbow arthroscopy has to be considered as the evolution of the elbow surgery to a mini invasive endoscopically assisted surgery developed by the recent advance of the elbow arthroscopy. Various pathologies, such as lateral epicondylitis, ulnar nerve entrapment, distal Biceps tendon rupture, synovial cysts, or olecranon bursitis have been treated arthroscopically. Extra-articular pathologies can be treated through an intra-articular endoscopic approach. The true endoscopic extra-articular technique is proced through a real anatomical space or inside a space of work created de novo by the surgeon. The difficulty of using endoscopy in extra-articular pathologies of the elbow is related to the vasculo-nervous structures sourrounding the articulation wich are directly subject to potential injury. Elbow extra-articular endoscopy must be considered as a difficult and sometimes dangerous procedure reserved to experimented elbow arthroscopic surgeons. Those techniques are yet to demonstrate their superiority in term of results and security compare to the open techniques.

[Extra-articular elbow arthroscopy]. / L'endoscopie extra-articulaire du coude.

Extra-articular elbow arthroscopy has to be considered as the evolution of the elbow surgery to a mini invasive endoscopically assisted surgery developed by the recent advance of the elbow arthroscopy. Various pathologies, such as lateral epicondylitis, ulnar nerve entrapment, distal Biceps tendon rupture, synovial cysts, or olecranon bursitis have been treated arthroscopically. Extra-articular pathologies can be treated through an intra-articular endoscopic approach. The true endoscopic extra-articular technique is proced through a real anatomical space or inside a space of work created de novo by the surgeon. The difficulty of using endoscopy in extra-articular pathologies of the elbow is related to the vasculo-nervous structures sourrounding the articulation wich are directly subject to potential injury. Elbow extra-articular endoscopy must be considered as a difficult and sometimes dangerous procedure reserved to experimented elbow arthroscopic surgeons. Those techniques are yet to demonstrate their superiority in term of results and security compare to the open techniques.

Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases.

BACKGROUND: The radiographic characteristics and treatment of radiocarpal dislocation are not well defined. There have been only two reported series of more than eight patients. Thus, there are many questions concerning treatment and functional results. METHODS: Two groups of patients were defined. Group 1 included all patients with pure radiocarpal dislocation and patients with only a fracture of the tip of the radial styloid process. Group 2 included patients with radiocarpal dislocation and an associated fracture of the radial styloid process that involved more than one-third of the width of the scaphoid fossa. A retrospective review and a clinical evaluation were performed. RESULTS: From 1975 to 1998, we observed twenty-seven cases of radiocarpal dislocation. Four were displaced volarly, and twenty-three were displaced dorsally. Fourteen patients presented with associated lesions. Four patients were treated with closed reduction and immobilization in a plaster cast; five, with percutaneous Kirschner wire fixation and cast immobilization; and two, with an external fixator. Eleven patients had open reduction with Kirschner wire fixation and cast immobilization. The seven patients in Group 1 had a highly unstable injury, and four of the seven patients presented with ulnar translation of the carpus. At the time of follow-up, at an average of 26.8 months, pronation averaged 76 degrees; supination, 66 degrees; wrist flexion, 54 degrees; wrist extension, 54 degrees; radial inclination, 15 degrees; and ulnar inclination, 18 degrees. The average grip strength was 27 kg. Group 2 included twenty patients. Only thirteen, with dorsal dislocation, were evaluated at the time of follow-up, which averaged fifty-one months. At that time, six reported no pain; four, slight pain; and two, moderate pain. Pronation averaged 63 degrees; supination, 76 degrees; wrist flexion, 51 degrees; wrist extension, 56 degrees; radial inclination, 21 degrees; and ulnar inclination, 39 degrees. Grip strength averaged 38 kg. Seven patients had complications. CONCLUSIONS: On the basis of our experience and a review of the literature, we believe that patients with pure radiocarpal dislocation or with radiocarpal dislocation with a fracture of the tip of the radial styloid process should be treated with reattachment of the ligaments through a volar approach. In patients with radiocarpal dislocation and a fracture of the radial styloid process that involves more than one-third of the width of the scaphoid fossa, the ligaments are still attached to the radial fragment. We believe that in this group of patients, exact articular reduction should be performed through a dorsal approach. Additional studies are needed to support these hypotheses.

-Arthrography and computed tomography arthrography of the wrist-. / Arthrographie et arthroscanner du poignet.

After a brief review of the pertinent anatomy of joint compartments and main ligaments of the wrist, the authors present the technique of wrist arthrography and CT arthrography. They discuss the normal and pathological patterns. The main indications are the chronic painful wrist and posttraumatic wrist. Imaging can reveal ligament defects (particularly scapholunate ligament, or lunotriquetral ligament), triangular fibrocartilage tears, capsular defects, cartilage thinning, foreign bodies, synovial ganglia or synovitis of the wrist.

[Rupture of the flexor tendon of the hand caused by tuberculosis]. / Rupture à la paume des tendons fléchisseurs d'origine tuberculeuse.

A 47 years-old man presented an atraumatic, spontaneous index flexor tendons rupture. This patient has been treated two years ago for a pulmonary tuberculosis. At surgery, the flexor tendons were infiltrated by a granuloma. Histologic examination was compatible with tuberculosis sequelae. According to literature review, this is the second reported case of a tendon rupture due to tuberculosis granuloma.

Reconstruction of compound tibial and soft tissue loss using a traction histogenesis technique.

We used simultaneous bone and soft tissue transport for reconstruction of large compound tissue loss in the lower leg. We report the results and complications of a 12-patient series. The average age of the patients was 31.2 years (range 20 to 48 years). Seven patients had grade IIIB open tibial fractures, three had complications after grade II or IIIA, and two had an en-bloc resection of bone, muscle, and skin for a malignant bone tumor. Arteriography was routinely performed, and demonstrated at least one patent tibial artery. Every patient had normal sensibility of the sole. The first stage of the reconstruction was an aggressive excision of the all necrotic skin, muscle, and bone. The Ilizarov external fixator was applied and wires were secured under a tension of 100 kg, using a dynamometric tensioner. Cutaneous tissue loss was not replaced in 10 patients, when the bone was not exposed. A medial gastrocnemius flap was performed in two patients and lengthened with the bone. Corticotomy was performed 15 days after the first stage with careful respect for the periosteum. Distraction was initiated 15 days after the corticotomy. The average bone defect was 12.5 cm after initial excision. An average of 9 operative procedures and 18 months of treatment were required before bony union. The mean duration of bone transport was 6.5 months, and the mean duration of external fixation was 12 months. The final functional results were fair and only two patients returned to work. One patient had a below-knee amputation after 10 months of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Fracture of the distal radius. A prospective comparison between trans-styloid and Kapandji fixations.

We performed a prospective study on 96 patients with extra-articular or intra-articular fractures of the distal radius with a dorsally displaced posteromedial fragment. After closed reduction, we compared trans-styloid fixation and immobilisation with Kapandji fixation and early mobilisation. Forty-two patients of mean age 57.1 years +/- 18.1 (SD) were treated by trans-styloid K-wire fixation and 45 days of short-arm cast immobilisation. Fifty-four patients of mean age 57.7 years +/- 18.7 (SD) had Kapandji fixation and immediate mobilisation according to the originator. All the patients had clinical and radiological review at about six weeks and at 3, 6, 12 and 24 months after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, radial tilt, ulnar variance, and radial shortening were assessed radiologically. Statistical analysis was applied to comparisons with the normal opposite wrist. Pain and reflex sympathetic dystrophy were more frequent after Kapandji fixation and early mobilisation, but the range of motion was better although this became statistically insignificant after six weeks. The radiological reduction was better soon after Kapandji fixation, but there was some loss of reduction and increased radial shortening during the first three postoperative months. The clinical result at two years was similar in both groups.

A modified open palm technique for Dupuytren's disease. Short and long term results in 54 patients.

Fifty-four patients with Dupuytren's disease were operated on using transverse and Bruner incisions, leaving the transverse palmar and digital wounds open. The mean follow up was 6.6 years (minimum 5 years). The mean percentage correction of the overall fixed flexion deformity was 71%. The incidence of recurrence and extension of the disease were similar to other series of limited aponeurectomy. However, the postoperative complications were very much lower and the method is particularly suitable for patients over 50 years of age.

[Replacement of infected total hip prosthesis in two stages]. / Traitement des infections chroniques des prothèses totales de hanche par repose prothétique en deux temps opératoires.

Since 1975 we have treated 36 infected hip replacements by a two stage procedure in which the prosthesis and cement were first removed. Gentamicin impregnated beads were left at the sites of the prosthesis. Not less than 45 days later a fresh prosthesis was inserted into the hip. In two hips revision was not undertaken because of persistence of infection. The remaining 34 hips received a fresh prosthesis when the site was bacteriologically sterile. Gentamicin impregnated cement was used and antibiotics were given for a further three months. The functional results were satisfactory at an average of five years of follow up. Incomplete removal of methylmethacrylate was a factor in the persistence of infection and of pain in the absence of infection. The bacteriological efficacy of Gentamicin impregnated beads is uncertain, but their use gave a better functional result.

[Results of orthopedic and surgical treatment of mallet finger by subcutaneous rupture of the extensor tendon. Apropos of a series of 216 cases]. / Les résultats du traitement orthopédique et chirurgical du doigt en maillet par rupture sous-cutanée du tendon extenseur. A propos d'une série de 216 cas.

PURPOSE OF THE STUDY: To assess the late results of orthopaedic and surgical treatment for mallet finger, two groups of patients were reviewed in a retrospective study. MATERIAL AND METHODS: 156 fingers (Group I) had conservative treatment and 60 fingers (Group II) some form of surgical treatment. RESULTS: In Group I, a dorsal custom-made perforated splint maintained the distal interphalangeal joint (DIP) in extension for an average of 54 days (st13). The mean delay of presentation was 22 days (st36). Initial lack of extension was 35 degrees (st13). After an average follow-up of 154 days (st240), the lack of extension was only 7 degrees with an active range of flexion of 61 degrees (st11). 68 of these patients were reviewed for a long-term assessment (61 months). At this time, lack of extension and range of flexion were not different (respectively 5 degrees- st10 and 61 degrees- st16). In Group II, 45 per cent of patients had initially some form of orthopaedic treatment. Delay between injury and consultation was 118 days (st250). Review with a mean follow-up of 5.6 years demonstrated a lack of extension and a DIP joint flexion of 12 degrees and 53 degrees for tenodermodesis (14 cases), 2 degrees and 59 degrees for the Thompson and Littler procedures (14 cases), 1 degree and 55 degrees for the Fowler tenotomy (10 cases). DISCUSSION AND CONCLUSION: Orthopaedic treatment gave good functional results even in cases with delay of presentation. Surgery is only indicated in failure of conservative treatment. In absence of swan-neck deformity, tenodermodesis is a simple and effective technique. When a swan-neck is present, if the DIP deformity is corrected by PIP stabilization, the Fowler tenotomy is used. Otherwise, the Thompson and Littler operation allows to fully correct the deformity.

[Isolated punched-out lesions of the carpus and pain of the wrist]. / Géodes isolées du carpe et douleur du poignet.

Intra-osseous ganglia are among the more frequent causes of cystic lesions of the carpus and may be responsible for diffuse pain, possibly be related to biological activity of the lesions, or when the ganglia opens into the adjacent joint. A CT-scan is useful to determine their exact location and the presence of a cortical defect. Although not this feature is completely established, they seem to arise de "novo" from the bone although their fluid content is reminiscent of those of soft-tissue ganglia. Surgical curettage with bone grafting is only indicated when pain persists despite a period of rest.

The Hueston flap in reconstruction of fingertip skin loss: results in a series of 41 patients.

We reviewed 43 Hueston flaps in 41 patients (average age, 35 years) following distal fingertip skin loss. Mean advancement of the flap was 13 mm. Patients with single-digit injuries missed an average of 36 days off work. At the follow-up evaluation (mean, 3 years), 10 patients complained of pain (1 with functional impairment), 30 complained of cold intolerance, and 24 had nail deformities. Sensibility of advanced skin was normal by Semmes-Weinstein test in 33 cases, while two-point discrimination averaged 7 mm. This discrimination was virtually identical to contralateral digits in 31 of the cases. Overall, 30 patients were satisfied with their results, while 11 patients were mildly displeased. In 10 patients, this involved impairment of function, while the remaining patient was displeased with the appearance.

[Camptodactyly: classification and therapeutic results. Apropos of a series of 50 cases]. / Camptodactylie: classification et résultats thérapeutiques. A propos d'une série de 50 cas.

Fifty patients with camptodactyly of one or several fingers were seen in the Strasbourg SOS Main unit between 1980 and 1988. Classification of these lesions was based on the mobile or fixed nature of the deformity in flexion of the interphalangeal joint. This classification is useful for the therapeutic management. Treatment by dynamic splint for a mean duration of 20 months gives good results in fixed or mobile camptodactylies of small children, provided that this treatment is commenced as soon possible. This splint treatment also obtains favorable results in patients reaching the end of the growth period, whether their camptodactyly is mobile or even, in some cases, fixed. In every case, treatment by dynamic splint constitutes a therapeutic test (safety of the apparatus, patient's cooperation) and only forms of camptodactyly resistant to conservative treatments benefit from Malek's type of surgical correction. It must be remembered that a certain number of cases of camptodactyly have a potential for severity with time, progressing towards irreducible forms which can only be corrected by surgical treatment. Camptodactyly in adults must be analysed meticulously and only major deformities causing functional discomfort or major aesthetic prejudice should be operated.

[Simplified anesthesia for the surgical treatment of severe sprains of the metacarpophalangeal joint of the thumb]. / Anesthésie simplifiée pour le traitement chirurgical des entorses graves de l'articulation métacarpophalangienne du pouce.

A series a 40 patients with severe sprain of the medial collateral ligament of the metacarpophalangeal joint of the thumb is reported. Anesthesia was performed by infiltration of the superficial branch of the radial nerve and the palmar collateral nerves of the thumb via of the flexor tendon sheath, with 0.5% bupivacaine without adrenaline, 3-4 ml each. This technique, easy and reliable (complete success) with a prolonged analgesia, is useful in the operating room and for stress examination or dynamic X rays.

Free and island vascularized joint transfer for proximal interphalangeal reconstruction: a series of 27 cases.

Twenty-seven vascularized joints were transferred in 26 patients for proximal interphalangeal joint reconstruction: 7 heterodigital island, 7 homodigital island (distal to proximal interphalangeal), 2 free heterodigital, and 11 free second toe proximal interphalangeal. With a mean follow-up period of 37 months, mean active range of motion of heterodigital island joint was 56 degrees (mean extensor lag, 21 degrees), excepting one failure ending with an arthrodesis. Four complications occurred in the homodigital island joint series: one sepsis, one nail dystrophy, one failed distal arthrodesis, and one bone abutment in flexion. Excluding the sepsis, mean active final range of motion was 52 degrees after a mean follow-up period of 18 months. The two free heterodigital joints had 80 degrees and 65 degrees of motion. The worst results occurred in the free second toe proximal interphalangeal joints transferred, with a mean active range of motion of 33 degrees (mean extension lag 39 degrees). The main advantages of these techniques are a compound tissue transfer, rapid bone healing, good lateral stability, growth potential, and long-term cartilage preservation.

Preoperative, intraoperative, and immediate postoperative skeletal scintigraphy to locate and facilitate excision of an osteoid osteoma of the coronoid process.

We report the case of a 39-year-old woman with a 3-year history of inflammatory right elbow pain caused by an osteoid osteoma. Two hours before the operation, the patient received an intravenous injection of 350 MBq of Tc 99m dimethylaminodiphosphonate. The resection of the nidus, guided by the intraoperative scintigraphy, was easily performed and confirmed by postresection counting and an x-ray film. Three hours after the operation, new scintigraphic views without further injection of the bone-seeking radioisotope confirmed the complete removal of the nidus. When immediate postoperative scintigraphy shows the disappearance of the focal reinforcement of activity, it gives additional evidence of complete tumor resection.

Wrist arthrodesis using an embedded iliac crest bone graft.

34 patients treated by the iliac crest bone graft technique for wrist arthrodesis were reviewed. The average age was 45.6 years and the mean follow-up was 45 months. The procedure is performed through a straight ulnar approach and the head of the ulna is removed. A longitudinal trench is created in both distal radius and carpus preserving the anterior, posterior and lateral cortices. A curved trapezoidal monocortical iliac crest bone graft is embedded inside the trench. The position of the arthrodesis automatically follows the curvature of the graft. No fixation device is used. A short-arm cast is applied for 2 to 3 months. All arthrodeses except two fused within 3 months. Pain was completely relieved in 85% of the cases. Pronation and supination returned to normal 5 months post-operatively. Grip strength was increased in 80% of the cases. The carpometacarpal joints remained pain-free even when not fused. Complications were rare: two lesions of the dorsal branch of the ulnar nerve; two cases of delayed union due to errors in technique, and displacement of the graft in one case. Although it is technically demanding, the embedded iliac crest graft wrist arthrodesis improves pronation and supination as a result of resection of the distal radio-ulnar joint, preserves or improves grip strength, and relieves pain.

[Secondary localization of epithelioid sarcoma of the donor site of an inguinal flap. Apropos of a clinical case]. / Localisation secondaire d'un sarcome épithélioïde sur le site donneur d'un lambeau inguinal. A propos d'un cas clinique.

A secondary localisation of an epithelioid sarcoma appeared on the inguinal scar of a groin flap in a 28 years-old woman, 14 months after resection and coverage of the primary tumor in the palm of the right hand. The evolution was free of recurrence or metastasis, with a two-year follow-up, after surgical resection of the inguinal tumor, radiotherapy and chemotherapy. Secondary localisation of tumors in musculo-cutaneous flaps can be observed after head and neck or chest wall surgery. Contiguity propagation, or venous or lymphatic dissemination are the usual mechanisms. One must realised a biopsy preliminary to the resection of a suspicious tumor of upper or lower limb. When one needs a flap for reconstruction, one must prefer to use a local flap.

Observations on experimental flow-through venous flaps.

The aim of this work was to compare the survival of an arteriovenous island flap with the survival of an island flap with a flow-through venous supply. Our experimental studies were performed on 95 Wistar rats randomised into six groups: Group 1: Indian ink injection of flow-through venous flaps with capillary network; Group 2: control group deprived of vascularisation; Group 3: control group with arteriovenous supply; Group 4: flow-through venous flaps of group 1; Group 5: epigastric flow-through venous flaps with a main venous trunk; Group 6: histological examination of flow-through venous flaps. The survival of flaps was monitored by direct examination, histological examination, capillaroscopy, and laser Doppler. Three out of 50 flow-through venous flaps survived. There was a statistically significant difference in the delay of clinical necrosis between the composite non vascularised free grafts (2.8 +/- 1.2 days) and the flow-through venous flaps (4.1 +/- 1.3 to 4.9 +/- 1.1 days depending on the type of flap). A 20% decreased venous blood flow was observed in the flow-through venous flaps.