[Anatomic danger of percutaneous section of the inter-metatarsal ligament for the treatment of Morton's neuroma]. / Dangers anatomiques de la section percutanée du ligament inter-métatarsien dans le traitement du névrome de Morton.

Certain authors have proposed percutaneous neurolysis of Morton's neuroma. We conducted a human anatomy study to assess the reliability and the iatrogenic effect of percutaneous section of the ligament. Percutaneous section of the inter-metatarsal ligament was performed on 16 fresh cadaver specimens via a dorsal approach. The plantar dissection demonstrated that the section was not complete, without associated lesion, in only six cases. Analyzing these failures, we determined the necessary procedure for correct section.

[Prospective and comparative study of minimally invasive posterior approach versus standard posterior approach in total hip replacement]. / Etude prospective comparant la voie postérieure minimale invasive versus voie postérieure standard sur prothèse totale de hanche de première intention.

PURPOSE OF THE STUDY: There have been few prospective studies comparing minimally invasive approaches for total hip replacement. We wanted to ascertain the contribution of the minimally invasive posterior approach in comparison with the standard posterolateral approach in terms of early outcome. MATERIALS AND METHODS: This was prospective comparative consecutive series of patients. Patients with major architectural problems or undergoing revision arthroplasty were excluded. One hundred ten patients (116 hips) were divided into two groups which were comparable for number of patients, gender, age, body mass index, indication for surgery, and preoperative function scores. The preoperative ASA score was lower in the minimally invasive group (p=0.04). The patients were in the lateral reclining position for the two approaches and classical instrumentation using the same implants (stems and cemented or non-cemented cups) were used. We noted operative time and blood loss (using the Brecher method based on the hematocrit at day 1 and 5 and the number of blood transfusions), postoperative pain, and implant position. Functional outcome was assessed with the modified Harris score and the WOMAC index (at 6 weeks and 3 and 6 months). Statview(R) was used to search for statistical significance considering p<0.05 as significant. RESULTS: Mean length of incision was 8.5 cm versus 15.1 cm. Mean blood loss was significantly less in the minimally invasive group (p=0.027) as was the level of postoperative pain as confirmed by the lesser consumption of morphine analgesics (p=0.006). Other operative variables as well as implant position were comparable. There were no major complications in the minimally invasive group. In the standard group, there was one case of common peroneal nerve palsy, two dislocations, and two fractures related to falls after prosthesis implantation. The WOMAC index was better after the minimally invasive approach at six weeks and at three months (p<0.05). The modified Harris score was better only at six weeks. Functional outcome and pain became comparable thereafter. DISCUSSION AND CONCLUSION: The minimally invasive posterior approach does not require an orthopedic table nor specific instrumentation. A minute procedure is required with ligature of the posteromedial circumflex artery of the thigh to improve exposure and limit intraoperative bleeding. It enables satisfactory reproducible implant positioning. Conversion to an open posterolateral approach is possible if needed. The minimally invasive posterior approach enables a reduction in intraoperative bleeding and in postoperative pain while allowing earlier more rapid rehabilitation. Early clinical outcome is better but beyond six weeks, the functional results are comparable for the two approaches. The minimally invasive posterior approach is a reliable reproducible approach with a progressive learning curve.

[Squamous-cell carcinoma and osteomyelitis: three cases and a review of the literature]. / Epithéliomas épidermoïdes et ostéomyélites chroniques: à propos de 3 cas et revue de la littérature.

Chronic osteitis and squamous-cell carcinoma is a rare but classically described association. We report three cases of chronic tibial osteitis which developed open leg trauma. During the surveillance, after a latency period of several years, local signs developed leading to biopsy which provided the diagnosis of degenerative carcinomatosis. Search for locoregional extension or metastatic dissemination was negative. All three patients underwent amputation with good results. This small series, together with a review of the literature, enabled us to describe the principle epidemiological and diagnostic features, focusing on early signs. The appropriate management scheme remains to be determined although amputation, which some may consider as a failure, should not be postponed indefinitely.

Evaluation of male sexual function after pelvic trauma by the International Index of Erectile Function.

OBJECTIVES: To assess the multifaceted male sexual function after pelvic ring fracture. METHODS: A cross-sectional study of male sexual function after pelvic ring fractures was conducted, using the International Index of Erectile Function (IIEF). The department of traumatology database was scanned (June 1996 to April 1999) for 30 to 70-year-old male patients with pelvic fracture. Seventy-six consecutive, literate patients were then contacted by mail. IIEF domain scores were calculated for all responders. Cappelleri's method for identification and grading of erectile dysfunction was applied for patients sexually active within the past 4 weeks. Student's t test was used to compare the domain scorings of patients with those of the control population used for the IIEF psychometric validation. Relationships between IIEF results and patient characteristics were sought by Spearman's rank correlation coefficient for quantitative variables and Student's t test for classes. RESULTS: Forty-six patients answered (60.1% response rate). Thirty-seven patients had experienced sexual intercourse in the past 4 weeks during which 11 patients (29.7%) had exhibited various degrees of impaired erection. As a whole, compared with the published controls a significant decrease in overall satisfaction (P <0.05) was demonstrated. Pubic diastasis was further related to impaired erectile function and overall satisfaction; we suggest that cavernosal nerves might be damaged at the time of diastasis. CONCLUSIONS: This study evidenced the impairment of sexual overall satisfaction after pelvic trauma and the specific decrease in erectile function and erection firmness and confidence associated with pubic diastasis. The IIEF questionnaire might be considered at the time of rehabilitation to identify those patients that could benefit from supportive treatments.

Assessment of the unstable shoulder by computed arthrography. A preliminary report.

The evaluation of 10 patients with subluxing and dislocating shoulder is presented. Routine radiography with special views detected the presence of Hill Sachs lesions in seven patients, but was not conclusive for three patients. Soft tissue and bone anomalies were documented by computed arthrography in all 10 patients. Computed arthrography represents a valuable tool in the diagnosis of obscure unstable shoulders.

[Closure of sternotomy with Cotrel staplers]. / Fermeture des sternotomies à l'aide des agrafes de Cotrel.

The authors describe a new method for the closure of median sternotomies based on immediate compression with two or three Cotrel-Dubousset (CD) staples. This method was effective in a series of 100 patients. It was the curative treatment of septic sternal pseudarthrosis, and has been extended to high risk patients (age, severe sternal osteoporosis, obesity, diabetes, chronic respiratory insufficiency) or when surgery requires resection of the internal mammary arteries (IMA).

[Proximal fibulo-tibial dislocation and ischemia associated with a leg fracture. Apropos of 2 cases]. / Luxation péronéo-tibiale supérieure et ischémie associées à une fracture de jambe. A propos de 2 cas.

Proximal fibulotibial dislocation may remain escape detection in leg injuries. Posterior dislocations are unusual and are associated with shortening of the limb due to the tibial fracture. Two cases of such dislocation are reported, associated with lower limb ischemia due to an injury of the arterial popliteal trifurcation. An anatomical model indicates the mechanism of this lesion. Such an unusual association has not be found elsewhere in literature.

[Fibrous dysplasia associated with intramuscular myxoma]. / Dysplasie fibreuse associée à un myxome des parties molles.

PURPOSE OF THE STUDY: The association of fibrous dysplasia and of soft tissue myxoma is rare. The authors report a new case and discuss the underlying mechanism. CASE REPORT: A 45 years male consulted for a large painful swelling of the right gluteal muscle. The CT scan revealed the soft tissue tumor associated with a bone cyst of the right pelvic bone. The mass was removed at operation and tumoral bone tissue was curetted, there were no evidence of tissue continuity between the two lesions. The histological diagnosis was intra muscular myxoma and fibrous dysplasia. DISCUSSION: Intra muscular myxoma associated to fibrous dysplasia of bone is a rare syndrome described by Mazabraud in 1957. A review of the literature until 1995 reveals that only 17 cases of this syndrome have been reported. Intra muscular myxoma is a rare benign soft tissue tumour arising from fibroblast. Fibrous dysplasia is a hamartomatous bony disorder, which appears in mono or polyostotic forms, with or without extraskeletal manifestation. CONCLUSION: It was not possible to demonstrate a clear correlation between the two lesions. The authors suggest that myxoma result from bone mechanical disorders.

[Effect of alendronate on periprosthetic bone loss after cemented primary total hip arthroplasty: a prospective randomized study]. / Action de l'Alendronate sur l'état osseux péri-prothétique après prothèse totale de hanche cimentée: étude prospective randomisée en double aveugle.

PURPOSE OF THE STUDY: Bone remodeling and osteolysis around total hip prostheses, with its inevitable corollary, prosthesis loosening, remains a difficult problem in orthopedic surgery. Alendronate (bisphosphonate) has proven its efficacy for the treatment of osteoporosis of the lumbar spine and femoral neck. A few in vitro studies have pointed out its inhibiting effect on particle-induced osteolysis. In vivo, one study has demonstrated its usefulness in preventing osteolysis around non-cemented total hip arthroplasties (THA). The purpose of this work was to study the efficacy of this agent for the prevention of changes in peri-prosthetic bone mineral density (BMD) after primary THA. MATERIAL AND METHODS: The study series included 38 patients with degenerative hip disease who underwent THA. The patients were randomized in double-blind fashion to two treatment arms: 10 alendronate and 600 mg calcium per day for 2 years (20 patients) or placebo and 600 mg calcium per day for 2 years (18 patients). Conventional x-rays and x-ray biphotonic absorptiometry (DPX) was performed on day four postop and at 3, 6, 12, and 24 months postop. The periprosthetic zones described by Grüen were used for analysis. RESULTS: DPX demonstrated a significant reduction in BMD in all patients included in the study. The bone loss was the same in both groups during the early postoperative period reaching maximum loss at 3 months. Differences were observed after this time. In the placebo group, bone loss reached a plateau at 6 months then BMD started to increase progressively, reaching 12.7% bone loss at 2 years follow-up (p<0.002). In the alendronate group, there was no plateau, BMD increased continuously starting from three months and reached 6.857% bone loss at 2 years (p<0.003). DISCUSSION: Administration of alendronate led to a significant reduction in peri-prosthetic bone loss at 2 years follow-up. These results are the first to our knowledge demonstrating the beneficial effect in vivo of alendronate on bone behavior around cemented THAs. CONCLUSION: This beneficial effect observed in vivo should be confirmed in further studies including a larger number of patients and longer follow-up. The action of alendronate could facilitate and even retard revision surgery by preserving bone stock.

[Posterior sternoclavicular luxation. Apropos of 6 cases]. / Les luxations sterno-claviculaires postérieures. A propos de 6 cas.

The authors have reviewed six retro-sternal dislocations of the clavicle. The indirect mechanism of this dislocation was in 3 cases, due to sport accidents (rugby). The radiological incidence of Heining allowed the diagnosis and the CT examination carried out the checkup of the associated lesions. The surgical reduction revealed lesions of the meniscus which were found in 3 cases out of 6 and allowed one to realize a plastic operation using the tendon of the subclavian muscle (4 times out of 6) in order to stabilize by sternoclavicular joint, as well in recent injuries as in old ones. The results were satisfactory.

[Percutaneous fluoroscopic and arthroscopic controlled screw fixation of posterior facet fractures of the calcaneus]. / Réduction et vissage percutanés des fractures thalamiques du calcaneus sous contrôle arthroscopique et fluoroscopique.

We describe a new technique for reduction and percutaneous osteosynthesis of displaced posterior facet fractures of the calcaneus which appears to overcome the problems encountered with other percutaneous methods described for this type of surgery. The method relies on the use of traction which allows automatic reduction of the greater tubersosity. The patient is installed on an orthopedic traction table. Pin traction provides anatomic reduction of the posterior articular surface and restitution of Böhler's angle under fluoroscopic and arthroscopic control. We used this technique in thirteen patients with fifteen displaced posterior facet fractures of the calcaneum. Mean patient age was 50.4 Years. Mean follow-up was twenty Months. We did not have any cutaneous or infectious complications in this short series. In the majority of the cases, the overall functional and physical results were excellent or good. The mean Böhler's angle was 27 degrees, corresponding to 83% correction compared with the healthy side. These preliminary results are encouraging. We were able to restitute calcaneum anatomy, shorten hospital stay, and avoid all skin complications. Indications for this percutaneous technique could be widened. It is a valid alternative to open treatment of posterior facet fractures of the calcaneum.

[Intraarticular fractures of the calcaneus: pathological description. Contribution of x-ray computed tomography]. / Les fractures thalamiques du calcanéum: description anatomo-pathologique. Apport de la tomodensitométrie.

Computed tomography (CT) is of cardinal importance in the study of displaced intra-articular fractures of the calcaneus, as with this imaging technique the primary fracture line of Palmer can be followed and its various locations visualised. If the three-stage classification system of these fractures as vertical, horizontal or mixed fractures, based on their radiological appearance, is adopted, a correlation can be established between the location of Palmer's line and these three anatomical types. The fundamental fracture line is medial in the vertical types, lateral in the horizontal types and is located in the centre of the posterior facet in the mixed types. It can be seen that the fundamental fracture line separates a laterally detached fragment which is always tilted, giving a vertical slope to the surface of the posterior facet which it supports and thus giving a vertical image. This fragment is itself separated from a medially detached fragment which is tilted horizontally and produces a horizontal image on the lateral view. The CT sections must be examined for the presence of a secondary sagittal line completely isolating the horizontally tilted fragment. The importance of the location of the fundamental fracture line, which is on the borderline between tilting and horizontalisation, suggests that pronation-supination of the foot is a factor in the causal mechanism of these fractures. A clear understanding of the three-dimensional position of the fragments and of their displacement, essentially defined by the location of the fracture line, is a prequisite before attempting surgical reduction of calcaneal fractures.

Recurring intraprosthetic dislocation of rotating-hinge total knee prosthesis. Effect of implant design on intrinsic stability.

During total knee replacement, hinged total knee implants are used in cases where ligament balancing cannot be achieved with less-constrained implants. The case of a patient who experienced two episodes of intraprosthetic dislocation of his rotating-hinge total knee prosthesis is described. There are very few reports of this type of dislocation with these implants. The implant's design, particularly of the hinge, plays an important role in stability. The balance between the flexion and extension spaces is very important even when using a hinged total knee implant. The role of the extensor mechanism in anteroposterior stability is reviewed, along with simple ways to augment it.

Total hip revision using a cup design with a peg to treat severe pelvic bone defects.

When dealing with severe bone loss during acetabular revision of a total hip arthroplasty, it can be difficult to find a reliable anatomical structure to ensure high-quality primary fixation of the cup. Since 2003, we have been using an implant with a long peg that is anchored into the iliac isthmus. This structure is usually intact, even in the most severe situations of bone loss. The use of this specially designed component provides satisfactory mechanical reconstruction in cases that can be quite challenging (Paprosky and SOFCOT stage 3). The length and postoperative care for the procedure remain the same and early weight bearing is possible. The specific principles applying to this procedure, along with the anatomical features of the iliac isthmus, the implantation technique and our initial results are described in detail.

Primary tumor of the periacetabular region: resection and reconstruction using a segmental ipsilateral femur autograft.

INTRODUCTION: Bone reconstruction, after periacetabular tumour removal, is a complex procedure that carries a high morbidity rate and can result in poor clinical outcomes. Among the available options, the Puget pelvic resection-reconstruction procedure uses an autograft from the ipsilateral proximal femur to restore the anatomical and mechanical continuity of the pelvic ring before inserting an acetabular implant. HYPOTHESIS AND GOALS: This reconstruction technique satisfactorily restores the pelvic anatomy such that functional results and morbidity are comparable to alternative reconstruction techniques. PATIENTS AND METHODS: This was a retrospective study of 10 patients with an average age of 38.2 years (range 19 to 75) at the surgical procedure (performed between 1986 and 2007). There were five chondrosarcomas, three Ewing tumours, one plasmacytoma and one giant cell tumour. The position of the hip centre of rotation after reconstruction and autograft integration were evaluated on radiographs. Functional results were evaluated through the Musculoskeletal Tumor Society (MSTS) score and the Postel and Merle d'Aubigné (PMA) score. RESULTS: At the time of review, one patient was lost to follow-up and four had died. On radiographs, the hip centre of rotation after reconstruction was higher by a median value of 15 mm (range 5 to 35) and more lateral by a median value of 6mm (range -5 to 15). Upon evaluation of radiographs at a median time of 40 months (range 6 to 252 months), the autograft was completely integrated in five patients and partially integrated in three patients (two patients had a local recurrence). There were no cases of autograft fracture or non-union at the junctions of the graft. The median MSTS score was 25 out of 30 (range 20 to 29), or 83% (range 67 to 97%) at the median clinical follow-up of 82 months (range 49 to 264). The median PMA score was 13 out of 18 (range 12 to 18). All living patients were walking without assistance. Five patients required nine surgical revisions. Seven were attributed directly or indirectly to local recurrence; one revision was performed because of instability and one because of early acetabular loosening at 9 months. CONCLUSION: This challenging procedure provides satisfactory mechanical and anatomical results, while restoring hip anatomy and function. The primary cause of failure in this series was local recurrence of the tumour, which highlights the need to carefully select the indications and optimize the surgical tumour resection.