Subtalar arthrodesis using a single compression screw: a comparison of results between anterograde and retrograde screwing.

INTRODUCTION: The primary objective of this study was to compare the radiological and clinical results of anterograde and retrograde screwing in subtalar arthrodesis using a single compression screw. The secondary objective was to evaluate the subjective results and consolidation of this procedure. The hypotheses were that isolated screw fixation was sufficient to achieve good consolidation and that there was no difference between the two techniques with a similar rate of bone fusion. METHODS: This is a monocentric, retrospective, radio-clinical study based on 99 patients (101 feet), 58 males and 41 females, with an average age of 64 years. The main aetiology was post-traumatic osteoarthritis, which represented 51% of cases. Two groups were formed: group A (52 feet) consisting of fixed arthrodesis with ascending (retrograde) screwing and group D (49 feet) consisting of fixed arthrodesis with descending (anterograde) screwing. The two groups were statistically comparable in terms of demographic data as well as aetiologies and comorbidities. Arthrodeses which were not fused at 6 months were reassessed at one year and in the event of any radio-clinical doubt regarding consolidation, an additional CT scan was prescribed. Average post-operative follow-up was 11 ± 5 years (2-27 years). RESULTS: Ninety-two arthrodeses (93%) were fused at one year and 9 were considered to be in non-union, 5 (9.8%) in group A, and 4 (8.3%) in group D. We recorded 30 complications, 22 of which were due to a conflict with the screw head, 18 (34.5%) in group A and 4 (8.3%) in group D (p = 0.03). Conflict between the screw head and the heel led to the removal of the screw after consolidation of the arthrodesis. The clinical results were evaluated using Odom's criteria. Nine per cent of patients described their results as excellent, 29% as good, 51% as satisfactory and 11% found the result to be poor. CONCLUSION: The fusion rate for isolated compression screw arthrodesis is good, and there is no difference between anterograde and retrograde screws. However, the discomfort caused by the screw head being insufficiently embedded in the retrograde group led to a non-negligible number of additional surgeries to remove the screw.

Lateral ligament reconstruction procedures for the ankle.

Capsule/ligament lesions of the lateral compartment of the ankle lead to lateral laxity, which is a prime contributor to chronic ankle instability. Lateral ligament reconstruction stabilizes the joint. Exhaustive preoperative clinical and paraclinical work-up is essential. The present article classifies, presents and criticizes the main techniques in terms of long-term stabilization and reduction of osteoarthritis risk. Anatomic ligament repair with reinforcement (mainly extensor retinaculum) or anatomic ligament reconstruction are the two recommended options. Non-anatomic reconstructions using the peroneus brevis should be abandoned. Arthroscopy is increasingly being developed, but results need assessment on longer follow-up than presently available. Postoperative neuromuscular reprogramming is fundamental to optimal recovery. Finally, the concept of complex ankle instability is discussed from the diagnostic and therapeutic points of view. The various forms of ligament reconstruction failure and corresponding treatments are reported.

Radiologic analysis of hindfoot alignment: Comparison of Méary, long axial, and hindfoot alignment views.

BACKGROUND: Among radiographic views available for assessing hindfoot alignment, the antero-posterior weight-bearing view with metal cerclage of the hindfoot (Méary view) is the most widely used in France. Internationally, the long axial view (LAV) and hindfoot alignment view (HAV) are used also. The objective of this study was to compare the reliability of these three views. HYPOTHESIS: The Méary view with cerclage of the hindfoot is as reliable as the LAV and HAV for assessing hindfoot alignment. MATERIAL AND METHODS: All three views were obtained in each of 22 prospectively included patients. Intra-observer and inter-observer reliabilities were assessed by having two observers collect the radiographic measurements then computing the intra-class correlation coefficients (ICCs). RESULTS: The intra-observer and inter-observer ICCs were 0.956 and 0.988 with the Méary view, 0.990 and 0.765 with the HAV, and 0.997 and 0.991 with the LAV, respectively. Correlations were far stronger between the LAV and HAV than between each of these and the Méary view. Compared to the LAV and HAV, the Méary view indicated a greater degree of hindfoot valgus. DISCUSSION: Intra-observer reliability was excellent with both the LAV and HAV, whereas inter-observer reliability was better with the LAV. Excellent reliability was also obtained with the Méary view. Combining the Méary view to obtain a radiographic image of the clinical deformity with the LAV to measure the angular deviation of the hindfoot axis may be useful when assessing hindfoot malalignment. A comparison of the three views in a larger population is needed before clinical recommendations can be made. LEVEL OF EVIDENCE: II, prospective study.

[Congenital club foot: treatment in childhood, outcome and problems in adulthood]. / Le pied bot varus equin: traitement chez l'enfant et devenir a l'age adulte.

PURPOSE OF THE SYMPOSIUM: Treatment of idiopathic talipes varus, or congenital clubfoot, is designed to re-align the foot to alleviate pain and allow plantigrade weight bearing with adequate joint motion despite the subnormal radiographic presentation. This symposium was held to review current management practices for congenital clubfoot in children and to analyze outcome in adults in order to propose the most appropriate therapeutic solutions. MANAGEMENT OF CONGENITAL CLUBFOOT IN CHILDREN: Idiopathic talipes varus can be suspected from the fetal ultrasound. Parents should be given precise information concerning proposed treatment after birth. Deviations must be assessed in the newborn then revised regularly using objective scales during and after the end of treatment. This enables a better apprehension of the evolution in comparison with the severity of the initial deformation. Conservative treatment is proposed by many teams: a functional approach (rehabilitation and minimal use of orthetic material) or the Ponseti method (progressive correction using casts associated with percutaneous tenotomy of the calcaneal tendon) are currently preferred. If such methods are insufficient or unsuccessful, surgery may be performed as needed at about 8 to 11 months to achieve posteromedial release. Good results are obtained in 80% of patients who generally present minimal residual deformations (adduction of the forefoot, minimal calcaneal varus, residual medial rotation, limitation of dorsal flexion), which must be followed regularly through growth. The difficulty is to distinguish acceptable from non-acceptable deformation. At the end of the growth phase, severe articular sequelae are rare (stiff joint, recurrence of initial deformation, overcorrection) but difficult to correct surgically: osteotomy, tendon transfer, double arthrodesis, Ilizarov fixator. Gait analysis is essential to quantify function and obtain an objective assessment of the impact on higher joints, providing valuable guidance for surgical correction. OUTCOME IN ADULTHOOD: There have been very few studies evaluating the long-term functional outcome after treatment during childhood. According to two studies presented at this symposium (Brussels, Lausanne), results have been generally good but with subnormal radiographs irrespective of the type of treatment or how early treatment started in childhood. Hypoplasia of the talar dome is a constant finding and is correlated with limitation of dorsal flexion of the ankle joint. A small degree under-correction is often observed but well tolerated while overcorrection is generally less well tolerated. Functional outcome depends highly on preservation of subtalar joint motion. There have been no reports on the results of treatment of sequelae in adults. Most problems (pain, stiffness, osteoarthritis) are observed in the mid or rear foot. Indications for conservative surgery (osteotomy) of the mid or rear foot are rare compared with indications for combined arthrodesis. Talocrural decompensation is a turning point observed in the adult. Management at this point is difficult: fusion of the ankle worsens the situation by increasing the stress on the forefoot and aggravating the disability; implantation of an ankle prosthesis is technically difficult and remains to be fully developed. Treatment of the dorsal bunion of the great toe may require tendon transfer and/or fusion. CONCLUSION: A child born with clubfoot will never have a normal foot in adulthood. Sequelae present at the end of growth will intensify during adult life; under-correction is easier to treat in adulthood than overcorrection. The most difficult problems in adulthood are: neglected clubfoot, over correction, and degradation of the talocrural joint.

[Posterior ankle impingement syndrome: a retrospective study in 21 cases treated surgically]. / Le syndrome du carrefour postérieur de la cheville: étude rétrospective à propos de 21 cas traités chirurgicalement.

PURPOSE OF THE STUDY: The purpose of this work was to describe the posterior ankle impingement syndrome and to present a retrospective analysis of results after surgical treatment in 21 patients with a mean five years follow-up. MATERIAL AND METHODS: Twenty-one patients with a posterior ankle impingement syndrome underwent surgery between 1991 and 1999. There were 17 men and four women, mean age 33 years (18-45); 71% practiced sports, half at the competition level. For 71% of the patients, there was an acute fracture with nonunion of the posterior process of the talus; a microtrauma context was identified in 29%. The physical examination revealed pain at passive forced plantar flexion in 94% of patients with limping during exercise in 88%. Plain x-rays showed a long tail on the talus in 87% of the patients, a short tail in 9%, and a trigone bone in 4%. The posterior malleolus (or third tibial malleolus) was remodeled in 9%. Other examinations performed preoperatively completed the topographic analysis: 99Tc bone scintigraphy, computed tomography with 2D reconstruction and horizontal slices, MRI. The patients were placed in the ventral prone position for surgery via a para-achilles approach, medial in ten patients and lateral in eleven. Bone resection with combined arthrolysis of the subtalar and tibiotalar joints was performed in 20 patients (17 with nonunion of the posterior talar process, one with a trigone bone, two with malformed callus of the posterior malleolus). A soft tissue procedure was also performed in three patients (resection of a synovial cyst in one, tenosynovectomy of the long flexor of the great toe in two). RESULTS: All patients were reviewed clinically and radiographically (plain x-rays). The AOFAS score was determined. There were no cases of infection. Mean follow-up was five years (range 3-10). Results were excellent with a mean Kitaoka score of 90/100, varying with cause and type of procedure performed. Only one patient was dissatisfied (Kitaoka score 67/100); this patient presented residual dysesthesia in the territory of the posterior tibial nerve. In 90% of the patients, there was no sign of degeneration of the peritalar joints (two patients exhibited minimal remodeling of the posterior subtalar joint). 90% of the patients were satisfied or very satisfied. DISCUSSION: The posterior ankle impingement syndrome includes several pathological entities with similar clinical expression. It involves both bony and soft tissue elements in the posterior peritalar region. Repeated or acute forced plantar flexion is the main cause. Complementary explorations (bone scintigraphy, CT, MRI) besides standard radiography, are indispensable to obtain a definitive diagnosis and demonstrate the functional and mechanical impairment. Surgical treatment is simple via a posterior approach (posterolateral or posteromedial)) and in our hands has provided very good results without arthritic consequences at mid-term.

Iatrogenic hallux varus surgical procedure: a study of 14 cases.

Hallux varus occurs most frequently as a result of excessive surgical correction of musculoligamentous imbalance around the metatarsophalangeal (MTP) joint of the great toe (lateral release and medial capsuloligamentous tensioning). If untreated, the condition may lead to motion loss and degenerative arthritis. In this series, 14 cases of hallux varus were treated. Medial arthrolysis was done in each case. In five cases, reconstruction of the lateral ligament (with a 1.5-mm Ligapro suture), using a new technique, accompanied the medial release. Arthrodesis of the MTP was done in nine cases treated when there was already stiffness and arthrosis. According to a 100-point scoring system, the results were excellent in 56% and good in 44% of the MTP joint arthrodesis cases. Results were excellent in 100% of the mobilizing technique cases using Ligapro suture.

Reconstruction of the lateral ankle ligaments using an inferior extensor retinaculum flap.

The aim of this study was to assess the results of 32 cases of chronic ankle instability. These were treated by ligament shortening and reinforced with an inferior extensor retinaculum flap. All patients complained of persistent functional instability unrelieved with proprioceptive exercises. Results were assessed clinically (pain, instability, recovery of sports activity, mobility) and radiologically (correction of laxity on stress x-rays). This enabled us to draw up a revision score on a scale of 100 points. We obtained a mean score of 86.7 points (45-100 points), and subjective results showed that 88% of the patients were satisfied with the surgery.

[Desmoid fibroma of soft tissues of extra-abdominal sites: review of the literature apropos of a case located at the posterior face of the thigh]. / Les fibromes desmoïdes des parties molles à localisation extra-abdominale: revue de la littérature à propos d'un cas situé à la face postérieure de la cuisse.

The authors report a case of desmoid fibroma on the posterior surface of the thigh in a woman during the post-partum period. This is a rare site for this tumour. CT scan combined with MRI appears to be useful for diagnosis. Treatment is strictly surgical, but depends on the histological benign nature and the local malignancy. Surgery is generally conservative with risks of recurrence and occasionally amputation is necessary.

[Joint lesions of the first column of thumb]. / Les lésions articulaires de la première colonne du pouce.

Lesions involving the thumb from the interphalangeal joint to the trapezo-metacarpal (TM) joint are very frequently the result of sports injuries. The authors discuss the most frequent lesions: 1) Dislocations of the metacarpo-phalangeal (MP) joint of the thumb which can be reduced in almost every case by means of well conducted orthopaedic manoeuvres. 2) Sprains of the MP joint of the thumb, very common lesions the severity of which must not be underestimated and which always require surgical treatment in the serious lesions, regardless of the compartment involved (radial or ulnar). 3) Bennett's fractures or fracture-dislocations of the TM joint; when neglected inadequately treated, these lesions lead to disabling post-traumatic arthritis of the TM joint. A poor result of treatment for any one of these three lesions always compromises opposition of the thumb and/or the strength of pollico-digital grip.

[Meniscal sutures combined with the reconstruction of the anterior cruciate ligament. Comparative results between sutures of chronic and recent lesions: 102 cases]. / Les sutures méniscales associées à la réfection du ligament croisé antérieur. Résultats comparés des sutures des lésions récentes et chroniques: 102 cas.

The authors report the results of 102 meniscal sutures (53 lateral meniscus and 49 medial meniscus) done on 85 persons (86 knees) with laxity of the knee (54 acute laxities and 32 chronic laxities). All the sutures were done by posterior arthrotomy, while reconstruction of anterior cruciate ligament. Among the operations done on anterior cruciate ligaments, we find 45 reconstructions using MacIntosh procedure, 37 CHO method and 3 reconstructions using Lemaire procedure. 78 per cent of the sutures of the recent injuries were placed in a post-operative plaster cast, on the other hand, none of the chronic injuries was splinted. All the knees (except 1) were followed up within an interval of time of 1 year minimum to 4 years maximum. 3 sutures of fresh medial meniscus tear were reoperated on and one suture of old tear was reoperated. None of the lateral meniscus sutures, old or new was reoperated. 27 "objective" controls were done: 5 by arthrography, 4 by arthroscopy and 18 by magnetic resonance imaging (M.R.I.). Of the 18 controlled sutures by M.R.I., 13 (that is, 76, 5 per cent) presented a high signal as if they had a "wound" or persistent injury, this was found within a context of knees without any symptoms. Therefore the sutures of medial meniscus associated with laxity heal very well. It would be even better if they were in the chronic laxity stage (1 did not succeed out of the 22) than in the acute laxity stage (3 failures out of 27). The sutures of lateral meniscus healed very well in the chronic and in the old laxity stages (total success in both stages). The M.R.I controls for the 18 meniscus sutures presented the problem of the sutured meniscus future.

[Isolated rupture of the tendon of the supra spinatus muscle. Results of 49 surgical repair]. / Les ruptures isolees du tendon du muscle supra-epineux. Resultats de 49 reparations chirurgicales.

PURPOSE OF THE STUDY: The purpose of this study was to assess the results of surgical repairs in 49 << isolated >> tears of the supra- spinatus in 49 patients, 32 males and 17 females. MATERIAL AND METHODS: The average age at operation was 54,2 years (35 to 72) and the dominant side was injured in 30 patients (12 opposite side and 5 unknown). According to Constant's score the pain was permanent in 23 patients, it occurred at moderate exertion in 21 patients and at important exertion in 5. The average pain duration was 43,4 months (0 to 360 months). The range of motion was normal (40 points) in 24 patients, diminished in 15 (30 points), very diminished (10 points) in 7 and the shoulder was stiff in one patient (2 files were uncomplete). All the patients were disturbed in daily living activity and the strength assessment was disturbed because of the pain. In all cases we performed an anterior acromioplasty. At operation, 39 patients had an isolated tear of the supra-spinatus and 10 an associated tear of the long head of the biceps (7 tendinities, 1 dislocation and 2 ruptures). The size of the rupture was less than 2 cm2 in 21 cases comprised between 2 and 5 cm2 in 27 and greater than 5 cm2 in one case. The surgical procedure was a Neviaser's technique in 4 cases, a single suture in 19, a transosseous suture in 19 and a deltoid muscular flap in 7 cases (large retracted tear), in addition we performed 14 resections of the distal end of the clavicle and 4 tenodesis of the long head of the biceps. RESULTS: The results were assessed according to Constant's score on 46 patients (3 lost to follow-up), the average follow-up was 31,5 months (12 to 86). The average scores were: pain 12,3 points (3 to 15), range of motion 35,5 (14 to 40), daily living activity 17,4 (8 to 20), and strength 11,4 (<> side = 14,8 points). The total Constant's scores were 75,7 per cent (actual score) and 88,3 per cent (weighted score), according to the weighted score 24 patients had 100 per cent; 9 were comprized between 85 and 100, 5 between 65 and 85, and 8 were less than 65 per cent. The average post-operative acromio-humeral height was 9,84 mm (pre-operative height = 11 mm). DISCUSSION - CONCLUSION: If we compare the results in terms of surgical procedure the difference was not statistically significant although the transosseous suture was not so good: single suture 91,5 per cent, deltoid muscular flap 90,9 per cent, Neviaser's technique 87 per cent, and transosseous suture 79,1 per cent. Nevertheless the results are not so good (p = 0,01) if it is an industrial injury and if the post operative acromio-humeral height is diminished. On the other hand, age, sex, duration of the pain, occupation, tenodesis of the long head of the biceps and resection of the distal end of the clavicle don't have any pejorative influence on the results.

[A morphometric study of the femoro-patellar joint from lateral x-ray view]. / Etude morphométrique de l'articulation fémoro-patellaire à partir de l'incidence radiologique de profil.

PURPOSE OF THE STUDY: The goal of this study was to specify criteria of femoro-patellar joint normality on lateral view. MATERIAL: This study was based on radiological examination of 102 knees in 51 adults (average age 26.1 years). It concerned 29 women and 22 men that had never suffered from their knee and were supposed healthy. METHODS: The radiological protocol was the following: a lateral view at 45 degrees of flexion, two lateral views in extension, with and without quadriceps contraction. The analysis was focused on patellar surface aspect, its height, its depth and covering measurement. RESULTS: We found 83.7 per cent of so-called "normal" patellar surface, and 12.7 per cent of "abnormal" patellar surface (dysplasia) in the absence of pain. DISCUSSION: We have confirmed figures advanced in others series of the literature concerning patellar height and patellar surface, as well as patellar surface depth and covering. We have underlined the interest of lateral views; in extension with quadriceps contracted and relaxed. Finally, we have defined a trochleo-patellar sign that allows to correlate patellar height to patellar surface height (ITP = 0.35 to 0.84). CONCLUSION: This study insists on the interest of radiological lateral views of the knee and determine criteria for normalities.

[Biomechanical comparative study of three types of osteosynthesis in the treatment of supra and intercondylar fractures of the humerus in adults]. / Etude biomécanique comparative de trois types d'ostéosynthèse pour les fractures sus et intercondyliennes de la palette humérale de l'adulte.

PURPOSE OF THE STUDY: Supra and intercondylar fractures are the most common fractures of the distal end of the humerus in adult. An osteosynthesis consisting of a plate is the treatment of choice. But location and type of plate always remain open for debate. The authors present the results of an in vitro biomechanical study, which compared the stiffness of three types of osteosynthesis commonly used in these fractures. MATERIAL AND METHODS: The devices were on one hand the premolded lateral plate of Lecestre and Dupont (Howmedica) used alone or in conjunction with a medial 1/3 tubular plate of the AO group, and on the other hand a posterior plate, of which we are developing a new model, the Lambda plate (Protek) "Y"-shaped, monoblock, flat and molded on the humerus during operation. The study compared these different methods of fixation on fresh human humeri. In a first part, the posterior plate was compared to the single lateral one; in a second part, the posterior plate was compared to the coupled lateral and medial plates. The three plates were made of identical material. Both studies used eight pairs of bones with supra and intercondylar fractures realized by sawing. Each bone of a pair was fixed with one of the two types of device. Each humerus underwent different loading forces; sagittal bending (anterior and posterior) and torsion. The displacements were recorded using a calibrated measuring device coupled to two displacement sensors. The stiffness was calculated on force/displacement curves. RESULTS: In anterior bending, the Lambda posterior fixation was significantly stiffer than the single lateral one (p < 0.05) (239 +/- 109 versus 129 +/- 65 N/mm), and was not significantly different of the bilateral fixation (229 +/- 93 versus 224 +/- 108 N/mm). In posterior bending, the mean stiffness of the Lambda fixation was not significantly different to that of the lateral fixation (91 +/- 27 versus 91 +/- 52 N/mm), and less than that of the bilateral one (130 +/- 39 versus 170 +/- 70 N/mm), but not significantly. In torsion the mean stiffness of the Lambda fixation was superior to that of the lateral one (146.75 +/- 50.66 versus 119.75 +/- 58.8 Nm/rad), and bilateral one (233.31 +/- 107.47 versus 212.31 +/- 113.55 Nm/rad), but again not significantly. DISCUSSION: The ideal osteosynthesis for the fractures of the humeral distal doesn't exist, because the bone undergoes antero-posterior and posteroanterior cyclical forces during elbow flexion. Therefore the best device should be placed on both sides of the bone, but anatomical reasons make this location impossible. According to our study, we think the "less worst" device is the posterior one using the Lambda plate. Its symmetrical design allows a best loading distribution on the two columns. Its thickness compensates for its posterior location and the short interval between two holes allows to put many screws (4 to 6) into the epiphysis. All supra and intercondylar fractures, comminuted or not, can be treated with this material. The single lateral device isn't still enough. Its stiffness mainly depends on the orientation of the oblique screw in the medial column. But the design of this column doesn't always allow for an optimal location of the screw, which is the reason of several failures. The bilateral device gives a stiffness, comparable to the posterior one, but doesn't allow as many screws as the Lambda plate in the epiphysis. Therefore, it can't be used in very distal fractures. CONCLUSION: In spite of the progress of the material and the accuracy of the indications, the treatment of supra and intercondylar fractures of the distal end of the humerus is always a difficult problem. The devices have to be as stable as possible to allow an early motion. The best one should be placed on both sides of the distal humerus, because of the sagittal cyclic forces it undergoes, but this location is anatomically impossible. Our study concludes that the device using the Lambda plate i

[Anterior instability of the shoulder associated with fracture of the coracoid process. Apropos of 3 cases]. / L'instabilité antérieure de l'épaule associée à la fracture du processus coracoïde. A propos de trois cas.

PURPOSE OF THE STUDY: The aim of this paper is to present an unusual lesion associating anterior instability of the shoulder with a fracture of the horizontal part of the coracoid process. It emphasizes surgical treatment using the Latarjet procedure. MATERIAL AND METHODS: Three cases are presented: One case was a recurrent anterior dislocation of the shoulder associated with a fracture of the horizontal part of the coracoid process; an other case was a painful shoulder associated with pseudarthrosis of the coracoid process and a fracture of the anterior and inferior edge of the glenoid. In the last case there was a recurrent dislocation of the shoulder associated with a pseudarthrosis of the coracoid process detected intra-operatively. All the patients were operated on using the Latarjet's procedure using the fractured coracoid process. RESULTS: The three cases had a good result. DISCUSSION: The association of an anterior dislocation of the shoulder and a fracture of the coracoid process is very unusual. It is often unrecognized because of poor knowledge of this lesion or a poor quality of the radiograms performed in the emergency room. The most likely mechanism is a direct impact of the humeral head against the coracoid process during the dislocation. The fracture is located (as in our 3 cases) at the horizontal part of the coracoid process near its elbow and they are often associated lesions at the anterior and inferior edge of the glenoid. The diagnosis requires good quality radiograms and a Garth's view systematically performed after reducing the dislocation. When the shoulder is painful or unstable, surgical treatment is performed and the Latarjet's procedure takes care of the pseudarthrosis and the instability of the shoulder. CONCLUSION: Isolated fractures of the coracoid process are probably uncommon. When there is a fracture of the horizontal part of the coracoid process anterior instability of the shoulder should be suspected. This is the case when the shoulder has never been dislocated and when the standard radiograms are "normal" without "crossing lesions" at the anterior and inferior edge of the glenoid or at the humeral head (Hill-Sach lesion).

[The role of a shortening osteotomy of the first phalanges associated with soft-tissue release in the surgical treatment of hallux valgus]. / Place de l'ostéotomie d'accourcissement de la première phalange associée à libération des parties molles dans le traitement chirurgical de l'hallux valgus.

The Authors report the results of 120 hallux valgus operated on 76 patients from January 1983 to June 1988. The operative procedure associated bunionectomy, tenotomy of the abductor hallucis which was resected from the base of the first phalanx and from the lateral sesamoid, shortening osteotomy of the proximal phalanx and finally adjustment of the sesamoids under the head of the first metatarsal. When there was an important metatarsus varus, a basilar osteotomy of the first metatarsal was associated (10 cases about 120). The results were appreciated functionally (pain, range of motion, easiness for putting on one's shoes) and anatomically (radiological correction of the deformity). The total result included anatomical and functional results. Anatomically, 110 feet had sesamoids perfectly adjusted (that is 92.5 per cent), 9 had an inadequate adjustment (first degree). The metatarsus varus was always improved except 3 cases; in these cases a basilar metatarsal osteotomy would have to be performed. The valgus of the big toe was corrected in 88 per cent of the cases (104 feet had a valgus lower than 15 degrees). A varus of the big toe was found in 6 cases (5 per cent). One was lower than 5 degrees; it was nevertheless included with the good results (very well endured). 5 were more than 10 degrees and were included with the poor results. Finally, we took notice of 4 degenerative changes of the first metatarso-phalangeal joint. The total results found 90 per cent of good and very good results, 6 per cent of fair results and 4 per cent of poor results.

[Rehabilitation of the knee movement after ligamentoplasty using Mac Intosh's procedure augmented by Kennedy-Lad: a comparison between recent and old rupture of the anterior cruciate ligament]. / La récupération de la mobilité du genou après ligamentoplastie type Mac Intosh renforcé par Kennedy-Lad: étude comparative entre rupture récente et rupture ancienne du ligament croisé antérieur.

About 60 ligamentoplasties of the A.C.L. using the Mac Intosh procedure with augmentation by the Kennedy-Lad, the authors compare the rehabilitation of knee motion between fresh tears (30 cases) and old tears (30 cases) of the A.C.L. operated on by the same procedure. All the operations were performed by the same surgeon. The rehabilitation program was the same for everybody; no plaster cast, total weight-bearing after the 15th day, no more crutches-stick after the 21th day and beginning of flexion on the 12th day, 88 per cent of the knees were rehabilitated by the same physiotherapists. The plaster cast is usually incriminated to be the main reason of post-operative knee stiffness. But no plaster cast for fresh A.C.L. tear also give such a stiffness (16.5 per cent). The authors think that the initial injury increased by the surgical trauma, for a non conditioned patient are the main factors of post-operative stiffnesses. This study justifies the late reconstruction of "isolated" A.C.L. tears (between the 2nd and 3rd month), after "cooling down" of the lesions.

[Evaluation of a long-distance data transmission network in foot and ankle surgery]. / Evaluation d'une consultation en réseau avec télétransmission des données en chirurgie de la cheville et du pied.

PURPOSE OF THE STUDY: This prospective work was designed to evaluate the concordance of the opinions of four experts interrogated via a long-distance inter-hospital data transmission system by an orthopedic surgeon seeking advise on foot and ankle surgery patients. MATERIAL AND METHODS: The surgeon requested advice concerning patients presenting difficult diagnostic or therapeutic situations. The requests were submitted via email to four experts working in regional referral centers. A standardized method defined by pathological categories was used for case description and imaging. RESULTS: Requests concerning 30 among 450 patients presenting surgical foot and ankle disorders were addressed to the experts. The surgical problem involved the forefoot (46%), the mid foot (16%), the hind foot (7%) and the ankle (31%). Mean delay to response was 11 days. The index of diagnostic agreement was 3.2/4 and the index of therapeutic agreement was 2.6/4. DISCUSSION: This study was designed to analyze the operating procedures involved (respective responsibility of the requesting surgeon and the regional experts, remuneration due to the different participants) and the potential patient benefit. The appropriateness of the email transmission system was also examined. For this type of study, email transmission was indicated because of the low cost, easy use, and image quality. This work illustrated the very good diagnostic and therapeutic concordance between experts in foot and ankle surgery and thus demonstrated the potential usefulness of long-distance expert systems. Furthermore, implication of several experts provided greater precision and complementary information facilitating management of difficult cases.

[Arthroscopic meniscectomy. Comparison of the functional results of meniscectomy in patients above and under 45 years of age. Apropos of 107 cases]. / La méniscectomie arthroscopique. Résultats fonctionnels comparés des méniscectomies avant et après 45 ans. A propos de 107 cas.

A comparative retrospective study of 107 cases of arthroscopic meniscectomies performed between December 1985 and December 1988 on 52 operated patients under 45 (P1 = 54 knees) and 52 operated patients over 45 (P2 = 53 knees). Those two populations have been selected among 292 isolated meniscal lesions files (without anterior cruciate ligament tear) operated for arthroscopic meniscectomy between 1985 and 1988. There were 81 medial meniscus lesions, 16 lateral meniscus lesions and 10 bi-meniscal lesions. The follow-up was for 1 to 5 years with a score of 70.3 per cent functional satisfactory results for the above 45 years (P2) and a score of 89.4 per cent below 45 (P1). Regarding the medial meniscus lesions only, we count 76 per cent (P2) satisfactory results versus 87.5 per cent (P1). This assessment can be easily explained by the variety of meniscal lesions (8 degenerative meniscal lesions among P2 namely 15 per cent), by associated cartilage lesions of the medial compartment of the knee (medial condyle: P2 = 37.75 per cent, medial tibial plateau: P2 = 41.5 per cent) and by genu varum deformity. However, in spite of this significant statistical difference (alpha < 0.05), we don't think we should condemn the arthroscopic meniscectomy over 45: the morbidity is very low and if some patients were not cured, the majority of them said that they improved after the operation. The cartilaginous degenerations of the medial compartment, discovered during arthroscopy, in a context of genu varum, don't need any tibial osteotomy at first, especially if they are asymptomatic and without tibia varum.

[Tibiotarsal arthrodesis: value of external fixator associated with in situ cancellous bone graft. Initial results apropos of 18 cases]. / L'arthrodèse tibio-tarsienne: intrêt du fixateur externe associé à une greffe osseuse fragmentée in situ. Résultats préliminaires à propos de 18 cas.

Tibio-talar arthrodesis poses some problems and the most frequent are non-union and varus malalignment of the ankle joint. The aim of this report was to present a new technique of ankle joint arthrodesis. The principles of this procedure are as follows: firstly, the external fixation (A.L.J.) is framed, secondly, perpendicular cuts are made in the tibial plafond and talus through an anterior longitudinal approach; and thirdly, the gap is filled with cancellous bone graft which is taken preferably on the iliac crest. If the back-foot is not correctly lined up preoperatively, the external device is framed in two steps: the first step consists in putting the pins. Then perpendicular cuts are made, and the back-foot is correctly lined up using calcaneal pins. The second step consists in connecting tibial pins and foot pins using union-rods. The last step of the procedure is to fill the gap with cancellous bone graft. The external fixation device is removed after 45 days and a shortleg walking cast is put for 45 days. Between 1981 and 1992, 18 arthrodesis were performed on various diagnosis: 9 post-traumatic tibio-talar osteoarthritis, 4 residual neurologic diseases, 2 rheumatoid arthritis and 3 recent post-traumatic lesions. There were 17 patients (one bilateral case), 4 females and 13 males; the middle age at the time of operation was 44.5 years (20 to 60) and there were 10 right ankles and 8 left. The tibio-talar arthrodesis was performed alone in 14 cases, but it was associated with a talo-calcaneus arthrodesis in 4 cases. The after care was without complications except 3 pins infection which cured with antibiotics. All the cases had a good bony union within 3 to 6 months and the orientation of the backfoot was always satisfactory without varus malalignment. All the patients could put one's shoes without having recourse to orthopaedic shoes. In conclusion, this operative procedure seems to minimize the problems and pittfalls of the ankle arthrodesis.

[Anatomo-clinical consequences of the vertical sectioning of the subscapular muscle in Latarjet intervention]. / Conséquences anatomo-cliniques de la section verticale du muscle sub-scapulaire dans l'intervention de Latarjet.

UNLABELLED: The goal of this study was to assess the effects of the vertical section of the subscapularis muscle (internal rotation and muscular degeneration) during Latarjet procedure. MATERIAL AND METHODS: From October 1st, 1990, to June 30th, 1991, 40 patients were operated according to Latarjet for chronic anterior shoulder instability. A vertical section of the subscapular muscle was performed. Except for one female patient, all of them practiced sports. Preoperative delay between first dislocation and surgery averaged 59 months. Postoperative rehabilitation was aimed at external rotation, recovery began 48 hours after surgery, without specific indications as far as internal rotation was concerned. Sports activity was resumed 90 days after surgery. 38 were reviewed after 4 years. Clinical review was made according to Constant's score and by measuring strength, and amplitude of internal rotation. Radiological assessment of the shoulders was made with standard x-rays and CT. RESULTS: For global results, we noted absence of recurrence, a weighted Constant score of 88 per cent, 87 per cent of patients satisfied or very satisfied, 55 per cent of the osteoplastic ridge were on level, 16 per cent were retracted, and 29 per cent overlapped, 19 per cent non union or ridge lysis, 21 per cent glenohumeral osteophytosis. As far as clinical results are concerned, no significant difference was noted associated to osteoplastic ridge position. Internal rotation was assessed by measuring the distance hand to back (lift-off test). On the operated side it averaged 6 cm (0-18 cm), on the other side 13 cm (2-21 cm). The difference between each side was statistically very significant (p = 0.0001). Strength in internal rotation on the operated side averaged 3 kg (0-8 kg), on the other side, 6 kg (2-10 kg). The difference between each side was statistically very significant (p < 0.0001). CT was carried out on thickness and degeneration of the subscapular muscle (n = 29). Thickness of the subscapular muscle (operated side) average 10.5 (5-17 mm) after surgery, and 14.6 mm before surgery. It was thimer than on the contralateral shoulder 21 mm (10-33 mm). In both cases (shoulder before and after surgery, operated and contralateral shoulder), the difference was statistically significant. Degeneration of the subscapular muscle showed 4 stage 0, 13 stage 1, 5 stage 2, 6 stage 3, and 1 stage 4. A non statistical correlation was noted, between muscle degeneration and functional result, strength in internal rotation, distance hand to back. DISCUSSION: This series confirms efficiency and low morbidity of Latarjet procedure. Nevertheless, assessment of the subscapular muscle shows that 50 per cent of its strength and 50 per cent of its thickness were lost, 4 years after surgery. A significant degeneration (stages 2.3.4) was found in 41 per cent of the patients. This limitation is related to the trans-subscapular approach and to the absence of internal rotation postoperative rehabilitation. CONCLUSION: A randomized study comparing the vertical trans-subscapular approach to the horizontal trans-subscapular one would determine the better procedure.