[Hydroxyapatite-coated Esop modular femoral stem: three to ten year outcome in 155 cases]. / La prothèse fémorale Esop revêtue d'hydroxyapatite à modularité métaphysodiaphysaire: résultats à 5 ans de recul moyen d'une cohorte de 155 implants.

PURPOSE OF THE STUDY: Primary and secondary stability of the Esop prosthesis depends exclusively on cementless metaphyseal anchoring. This modular implant is composed of an hydroxyapatite-coated metaphysis on which a diaphyseal piece is added intraoperoperatively simply to act as a centering device. The purpose of this retrospective analysis of a consecutive series was to assess primary and secondary stability of the Esop implant by measuring axial migration over time. MATERIAL AND METHODS: Between 1995 and 2001, 172 primary total hip arthroplasties (THAs) were performed with the Esop femoral implant and the Atlas III acetabular implant. Six patients lost to follow-up and eleven patients who died were excluded from the analysis. The review thus concerned 155 THA in 128 patients (66 women and 32 men), mean age 57 years (age range 28-77 years), 53% with an occupational activity at the time of surgery. Degenerative hip disease and aseptic osteonecrosis were present in 87% of patients. Imagika, a dedicated software, was used to measure axial migration and overall offset of the THA at four distinct times: on the immediate pre- and postoperative films, after introduction of weight-bearing, and at last follow-up (mean 61 months, range 35-114 months). Survival and clinical and radiographic outcome were also assessed with the Postel-Merle-d'Aubigné (PMA) score. RESULTS: THA survival was 98%, all causes of failure included. The PMA score showed 97% excellent, very good or good outcome. Axial migration greater than 5 mm was demonstrated in ten hips (6.4%). Among these ten, seven exhibited migration during the first month than did not move further up to last follow-up. Comparison between the pre- and postoperative images revealed a 10 mm reduction in offset in 38% of hips, showing that the hip rotation center was medialized. DISCUSSION: Migration observed in ten implants corresponded to restablization at weight-bearing in seven. There was no correlation with the clinical outcome or poor radiological osteointegration. CONCLUSION: Primary and secondary stabilization of the Esop implant is satisfactory. In this series, the rotation center of the hip was globally medialized so that it would be useful to have available lateralized implants.

[Long-term results of midtarsal arthrodesis for flatfoot in adults]. / Résultats à long terme du traitement du pied plat valgus de l'adulte par arthrodèse médiotarsienne.

PURPOSE OF THE STUDY: Arthrodesis proposed for the surgical treatment of reducible pes planovalgus (flatfoot) in adults is designed to relieve pain and correct the deformity. The purpose of this work was to present the radiological and clinical results obtained with midtarsal arthrodesis performed in 22 cases of pes planovalgus. MATERIAL AND METHODS: This study concerned 22 cases of reducible flatfoot (Johnson grade 2) in 19 patients (11 males, 8 females, mean age 43 years, age range 15-75 years). Clinical outcome was assessed in terms of pain, function and motion using the AOFAS and Mann classifications. Radiological assessment (loaded anteroposterior and lateral views with Méary cerclage) noted the Djian angle, talometatarsal alignment, talar slope, calcaneal slope, calcaneal valgus, and osteoarthritis stage in adjacent joints. RESULTS: Mean follow-up was 7 years 4 months (range 6 months-20 years 3 months). Two nonunions resolved favorable after cancellous grafting. The Kitaoka score was 73.5/100 points (range 53-94). Pain and function improved from 2.8 to 1.1 points (/4 points) and from 3.45 to 1.6 points (/4) on the Mann scale. Flexion-extension remained unchanged. The foot was aligned correctly in 68% of cases. The mean talar slope and the talocalcaneal divergence were normal at last follow-up but there was a persistent undercorrection of the Djian angle in 68% of the feet and a break in the Méary line in 41%. Calcaneal valgus was reduced 6.6 degrees (16.6 to 10 degrees ) but the podoscope footprint was still the flatfoot type in 86% of the feet. For 50%, the neighboring joints presented progressive osteoarthritic degeneration. Subjectively the patients were very satisfied or satisfied with minor reservations for 73%. None of the patients was disappointed with the results. The objective outcome was excellent or good in 68% of the feet. DISCUSSION AND CONCLUSION: The results in terms of pain relief, function, motion, complications, and rate of satisfaction were comparable with results presented in the literature. Midtarsal arthrodesis provides effective pain relief and satisfactory functional recovery without creating any morbidity greater than simple talonavicular fusion. Nevertheless, it was noted that while correct alignment is achieved in the majority of cases, the clinical and radiological restoration of plantar cavum is limited. Furthermore compensatory hypermobility of the adjacent joints leads to the development of moderate osteoarthritic remodeling which remains asymptomatic more than seven years after the operation.

[Clinical results of resection arthroplasty for infected shoulder arthroplasty]. / Résultats de la résection arthroplastique dans les arthroplasties d'épaule infectée.

PURPOSE OF THE STUDY: Infection is a rare complication of shoulder arthroplasty. Various therapeutic solutions have been proposed: antibiotics alone, one-stage or two-stage reimplantation, surgical or arthroscopic cleaning without prosthesis removal, scapulohumeral arthrodesis or simple arthroscopic resection. We evaluated the mid-term clinical outcome after resection arthroplasty for the treatment of infected shoulder arthroplasty. MATERIAL AND METHODS: The series included ten infected arthroplasties in ten patients. Mean duration of implantation was two years seven months (range nine months to five years). Bacteriological diagnosis was established from intraoperative articular samples or systematic samples taken during surgical revision procedures: meti-S Staphylococcus aureus strains (n=4), coagulase-negative Staphylococcus (n=5 including three S. epidermidis) Streptococcus mitis (n=1) and Citrobacter koseri (n=1). The mean Constant score before revision was 58 (range 23-77). Subjective patient satisfaction before surgical revision was rated good in six cases, fair in one and poor in three. Surgery associated removal of the implant, complete resection of the cement, resection of the fistular tracts, wide debridement of infected tissues and total synovectomy. RESULTS: Patients were seen at an average follow-up of three years eight months. The objective functional outcome measured with the Constant score was only fair, 28 points (range 20.6-36), and corresponded to a loss of 29 points compared with the preoperative score. This was explained mainly by lower scores for joint motion, function and muscle force but with persistently satisfactory scores for pain. All patients remained pain-free (daytime and nighttime). Patient satisfaction was rated good for two, fair for five and mediocre for three. Clinical and biological proof of eradicated infection was obtained in all patients. DISCUSSION: Infection remains a serious devastating problem for shoulder arthroplasty with an important functional impact. Resection only has a modest clinical effect. Precise identification of the causal germ with institution of adapted antibiotic therapy is required for eradication of the infection. Early diagnosis is probably the most important parameter affecting clinical outcome and surgical options. Functional results after resection arthroplasty are modest. This procedure should be reserved for patients with reduced functional demands. Improved management of the infectious load and reduction of diagnostic delay should help improve functional outcome and favor use of stow-stage procedures for reinsertion.

Function of subscapularis after surgical treatment for recurrent instability of the shoulder using a bone-block procedure.

We compared the long-term function of subscapularis after the Latarjet procedure using two surgical approaches. We treated 102 patients (106 shoulders) with a mean age of 26.8 years (15 to 51) with involuntary unidirectional recurrent instability. The operation was carried out through an L-shaped incision with trans-section of the upper two-thirds of the muscle in 69 cases and with a subscapularis split in 37. All clinical results were assessed by the Rowe and the Duplay scores and the function of subscapularis by evaluating the distance and strength at the lift-off position. Bilateral CT was performed in 77 patients for assessment of fatty degeneration. The mean follow-up was 7.5 years (2 to 15) and 18% of cases were lost to follow-up. The mean Duplay score was 82 of 100 for the L-shaped incision group and 90 of 100 for those with a subscapularis split (p = 0.02). The mean fatty degeneration score was 1.18 after an L-shaped incision compared with 0.12 after subscapularis split (p = 0.001). The subscapularis split approach is therefore recommended.

[Clinical results of arthroscopic tenotomy of the long head of the biceps brachii in full thickness tears of the rotator cuff without repair: 40 cases]. / Résultats de la ténotomie arthroscopique du chef long du biceps brachial dans les ruptures transfixiantes de la coiffe des rotateurs non réparées: a propos de 40 cas.

PURPOSE OF THE STUDY: Appropriate treatment of irreparable rotator cuff tears in patients without osteoarthritic shoulder joints remains a subject of debate. Medical treatment, a substitution muscle flap, and palliative arthroscopic treatment have been proposed. Arthroscopic tenotomy of the long head of the biceps brachii is warranted because this tendon is often the cause of part or all of the pain. If there is a full thickness tear of the rotator cuff, the exposed tendon of the long head of the biceps brachii can, because of its anterosuperior position, become impinged against the acromial vault during forward flexion. The purpose of this work was to evaluate the mid-term clinical and radiological results of arthroscopic tenotomy of the long head of the biceps brachii during treatment of full thickness tears of the rotator cuff. MATERIAL AND METHODS: The series included 40 shoulders operated on for tenotomy alone (n=32) or in combination with acromioplasty (n=8). The long head of the biceps brachii was in place in 23 shoulders (58%), displaced in seven and subluxed in five. The position was not determined in five. At last follow-up, the mean rough Constant score was 58 points, giving a gain of 20 points. The gain for pain was +7.1 points, +6.4 points for activity, and +6.6 points for motion. After the operation, muscle force for elbow flexion-supination was decreased 40% compared with an age-, sex- and dominance-matched control group. 86% of the patients were satisfied with the outcome and only two patients were disappointed by the asymmetry of arm muscle volume. Radiographically, at last follow-up there were no signs of superior excentration of the humeral head and the subacromial space, which measured 7.38 mm preoperatively was 7.19 mm postoperatively. Likewise only two shoulders progressed to excentered osteoarthritis at 41 and 72 months. DISCUSSION: Mid-term results of arthroscopic tenotomy of the long head of the biceps brachii are satisfactory. The technique is simple and has limited functional consequences. The procedure has an undeniable impact on pain and has allowed a 34 degree gain in anterior flexion of the shoulder. Complementary acromioplasty was not found to provide a supplementary benefit in this series. Nevertheless, the degradation of the result in one female patient at six years suggests we should be prudent concerning the long-term benefit of this procedure which should be reserved for irreparable tears in patients with minimal functional demands.

[Comparative study of the treatment of fractures of the head of the radius by resection or by Swanson's silastic implant]. / Etude comparative du traitement des fractures de la tête radiale par résection ou par implant en silastic de Swanson.

The authors report 62 fractures of the head of the radius treated either by excision or silastic implant arthroplasty. Fifty-two patients were reviewed with a mean follow-up period of 5 years (range 1 to 13). Of 22 prosthetic replacements, 12 were satisfactory while of 30 excisions only 10 were rated good or excellent. Excision usually yielded valgus deformity of the elbow (range 9 to 35 degrees) and with a risk of shortening of the radius. Range of flexion-extension was identical after both procedures but pronation supination was better after prosthesis replacement (78/70) than after radial head excision (65/60) 3 fractures of the implant were found at 6, 9 and 10 years postoperatively; only one of them was associated with pain and required removal of the loose fragments.

[Traumatic posterior dislocation of the shoulder in adults. Apropos of 25 cases]. / Les luxations traumatiques postérieures de l'épaule chez l'adulte. A propos de vingt-cinq cas.

In a series of 25 traumatic posterior dislocations of the shoulder treated from 1960 to 1985, 16 were overlooked and the time from injury to treatment ranged from 3 weeks to 14 months. 11 cases were secondary to motor vehicle accident and 14 occurred after a convulsive fit. Early closed reduction was effective in only 4 cases; in 2 cases, reduction was unstable and further screwing of an associated fracture of the tuberculum majus was performed to prevent redislocation; 3 locked dislocations necessitated open reduction and stabilization by subscapularis transposition into the defect of the humeral head. Most of the 16 chronic unreduced dislocations were treated by the same procedure. Overall, 21 cases were reviewed with a mean follow-up of 14 years. Functional outcome was more often satisfactory in acute (5/7) than in old unreduced dislocations (6/14). Mc Laughlin or Neer's procedures yielded good results in 9 out of 14 cases; they are indicated irrespective of the patient's age whenever Mc Laughlin's notch does not involve more than one third of the articular surface of the humeral head.

[Normal and pathological aspects of the glenoid labrum in opaque arthro-scanner]. / Aspects normaux et pathologiques du bourrelet glénoïdien en arthroscanner opaque.

The morphology of the glenoid labrum was studied by CT arthrography in 88 patients. These were divided in 2 groups. In the first group, the patients underwent CT arthrography for a clinical instability of the shoulder. The second group was the reference group to study the morphology of the glenoid labrum, it included patients with rotator cuff tears or other pathology of the shoulder, without clinical instability. We described the normal labrum which presents important morphologic variations. Its study may be difficult because of the proximity of capsular structures of the shoulder, mainly the gleno-humeral ligaments. The normal variants and the pathologic aspects of the labrum were studied: the clefts, tears and degenerative phenomenous. The cleft aspect was studied comparatively in the instable population and in the reference population.

Patellar metastasis from a large bowel adenocarcinoma.

Although bone tumors are often located in the knee area, primary tumors of the patella are rare (6, 8), and patellar metastases even rarer. A few cases were reported in the literature, originating from the breast, lung, kidney, uterine cervix and oesophagus. We report a case, for the first time to our knowledge, of a patellar metastasis from a large bowel carcinoma.

[Injuries to the upper tibial epiphysis. Apropos of 20 cases]. / Les traumatismes épiphysaires supérieurs du tibia. A propos de 20 cas.

The authors report 20 cases of injuries involving the proximal tibial epiphysis (16 avulsion fractures of the tibial tubercle, 4 epiphyseal fractures), occurring in adolescents engaged in athletics, in 3/4 of the cases. Sixteen displaced fractures needed open reduction and internal fixation with screw(s). Leg shortening (12 mm) occurred in a 14 year-old male with a displaced fracture of both the tibial tubercle and proximal epiphysis, in which premature ossification had taken place; fixation with Kirschner wires would have been the treatment of choice before closure of the tibial epiphysis. At follow-up, function was acceptable in all cases; all the patients had returned to full daily activity and no further surgical procedures were needed. Long-term knee laxity became obvious in one patient, however, with repeated fracture of the tibial tubercle. Associated ligamentous and meniscal tears should therefore be sought on early clinical examination and confirmed by arthroscopy or arthrotomy after surgical fixation.

[Clinical and radiologic outcome of humeral implants in shoulder arthroplasty]. / Devenir clinique et radiologique des implants huméraux des arthroplasties d'épaule.

The clinical and radiological evolution of the glenoid socket in total shoulder arthroplasty is well documented, whereas evaluation of the humeral component has received much less attention. The outcome of 40 humeral replacements performed in 39 patients was studied with a minimum follow-up of one year. There were 26 Neer prostheses, 9 Modular Shoulder prostheses and 5 Aequalis prostheses. Twenty-nine prostheses were implanted with cement and 11 were cementless. The clinical and radiological results were assessed according to the scoring system used for the 1994 symposium of SO.F.C.O.T. X rays in the coronal plane were used to assess the position of the stem, radiolucencies around the humeral component and the percentage of the cross-section of the diaphysis filled by the humeral stem. The average follow-up period was respectively 55.6 months for the Neer prostheses, 17.9 months for the Modular Shoulder prostheses and 12.4 months for the Aequalis prostheses. Radiolucent lines were noted in 20 cases, all with uncemented humeral components. Two prostheses were loose; however, none required revision. The underlying pathology, surgical approach, position of the humeral component, implant design or association with glenoid resurfacing were not correlated with the presence of radiolucent lines or with a loose implant. Cementless fixation was the only parameter statistically related with the presence of radiolucent lines. This report confirms the good results obtained with cemented humeral prostheses. Radiological evaluation of the smooth cementless humeral implant showed many progressive radiolucent lines, without clinical expression. The authors analyze the various studies in the literature and discuss the interest of cementless implants with ingrowth surface.

[Cauda equina syndrome due to early postoperative migration of an adipose tissue flap following laminectomy]. / Syndrome de la queue de cheval par migration post-opératoire précoce d'un lambeau graisseux après laminectomie.

The authors reported an early case of cauda equina syndrome after hemilaminectomy and discectomy for lumbar disc herniation. CT-scan revealed the migration of the free fat graft used for preventing peridural scar formation. Removal of the graft resulted in total patient's recovery.

[Original treatment of a supramalleolar pseudarthrosis in an impaired position]. / Traitement original d'une pseudarthrose supra-malléolaire en position vicieuse chez une personne âgée.

The authors report the case of a nonunited supra-malleolar fracture with severe angulation in an elderly patient. Poor vascular condition and severe osteoporosis prevented the use of either a surgical approach or internal fixation. Gradual realignment and union were nevertheless achieved within 6 months post operatively using the "Sequoïa" external fixation system, while weight-bearing was continued throughout the course of treatment.

[Simple tibiotalar luxation. Apropos of 16 cases]. / Les luxations tibio-astragaliennes pures. A propos de 16 observations.

Tibiotalar dislocations without fracture are extremely rare lesions. This series included 16 patients, 12 of whom have been examined clinically and radiographically. The purpose of this study was to specify the injury mechanism of the various anatomical types and to assess the long term outcome. The group included eight posteromedial dislocations (50%), four posterior dislocations (25%), one anterior dislocation, one high variety, one of the Huguier type, and one complex dislocation. The sex ratio was 14 males/2 females with an average age of 37 years. In half of the cases, dislocations were open. The average follow-up period was 11 years (range, 1 to 26 years). The eight closed dislocations and the open case type I according to the Cauchoix classification received non-operative treatment by reduction in the emergency room and immobilization in a plaster cast for 6 weeks. The seven patients who presented open dislocations Cauchoix type 2 and type 3 were treated by surgical debridement and ligament repair, followed in all cases by a plaster cast boot, and in two cases by temporary transplantar pinning. Twelve patients were reexamined clinically according to the Gay and Evrard modified score, and were radiographically evaluated with lateral and anteroposterior views focused on the tibiotalar joint, on both sides, static and dynamic. Anatomical factors resulting in predisposition such as medial malleolus shortness or lack of coverage of the talus have been evaluated. No patient presented tibiotalar joint instability. A 5 degrees to 10 degrees loss in the range of dorsiflexion was frequently observed. Two patients presented joint stiffness. In four cases, patients complained about paresthesias in the areas of the anterior tibial nerve or intermediary dorsal cutaneous nerve. Four cases of degenerative arthritis were radiographically observed, two of which presented an overall narrowing of the joint over 50%. Degenerative arthritis had occurred within the first four years in these 4 cases. The talus coverage index was similar to the standard population. Shortness of the medial malleolus was present in only two cases. The long-term prognosis after tibiotalar dislocation without fracture proves to be good. One should favor orthopedic treatment. The absence of tibiotalar instability argues against carrying out emergency ligamentous repair. Evolution towards degenerative arthritis is to be anticipated in 25% of cases, especially following open dislocations, or if transplantar pinning was required due to instability of the initial reduction.

[Long-term results of proximal osteocartilaginous autografts in extensive cartilagenous destruction of the knee. Apropos of 5 cases]. / Résultats a long terme de l'autogreffe ostéo-cartilagineuse de voisinage dans les destructions cartilagineuses etendues du genou. A propos de 5 cas.

Five patients with a large defect in the articular cartilage at the knee joint were treated by transplantation of an autogenic osteochondral fragment. The graft was harvested from the posterior portion of the ipsilateral femoral condyle in 4 cases of osteochondritis dissecans, and from the lateral third of the patella pedicled on the patellar ligament in one case of posttraumatic necrotic collapse of the lateral tibial plateau. One patient underwent concomitant high tibial osteotomy. Two months postoperatively bony union was achieved in all cases but in one case, the grafted articular cartilage did not survive after weight bearing because of an overlooked varus deformity. At the follow-up examination (8 to 20 years) all 5 patients were asymptomatic ; the range of flexion was somewhat restricted (120 degrees) ; roentgenogram revealed slight narrowing of the articular space or at least flattening of the grafted zone and subchondral osteosclerosis. At arthroscopic exploration, the grafted zones were recognizable from the surrounding cartilage, and histologic examination of their border revealed fibrocartilage and proliferating vessels; late gonarthrosis might ensue over time. Therefore the procedure should be performed only in large osteochondral defects where neither reattachment of a loose body, nor hemiarthroplasty, nor isolated osteotomy are suitable and before degenerative changes have developed. Morever any associated varus deformity requires concomitant correction by high tibial osteotomy to relieve stress from the graft.

Accidental subcutaneous injection of elemental mercury. A case report.

Subcutaneous injection of elemental mercury is a very rare situation. The authors report the case of a 31-year-old man who accidentally injected an unknown quantity of metallic mercury into his left forearm. Several surgical procedures were required to reduce the blood and urinary levels of mercury. However, the patient never developed clinical signs of chronic poisoning. This observation confirms the lower risk of acute or chronic poisoning in subcutaneous injection of mercury and the need for early excision of contaminated tissue.

[Treatment of post-traumatic epiphysiodesis of the radius with osteotomy of the 2, bones of the forearm]. / Traitement de l'épiphysiodèse post traumatique du radius par ostéotomie des 2 os de l'avant-bras.

The authors report a case of posttraumatic closure of the distal radial epiphysis. Wrist pain, grip weakness and gross deformity warranted surgical correction of the discrepancy between radial and ulnar lengths. Simultaneous osteotomy of the radius and shortening of the ulna offer a less destructive alternative to both cosmetic and functional disorders at the wrist than the Kapandji-Sauvé procedure.

[Carpal tunnel syndrome in patients on hemodialysis (apropos of 17 cases)]. / Le syndrome du canal carpien chez l'hémodialysé (à propos de 17 cas).

This work is based on a series of 12 patients on hemodialysis who were operated on for a carpal tunnel syndrome, 66% of whom were seen with an average follow-up of 39 months (range 4 to 99 months). The operation was performed bilaterally on 5 occasions, which brings the number of hands operated to 17. Of the hemodialyzed patients 9.2% presented with median nerve compression. The main etiologies of renal insufficiency were chronic, interstitial nephropathies (5 cases) and chronic glomerular nephropathies (5 cases). All the patients were operated without a pneumatic tourniquet in order to preserve arteriovenous fistula permeability. In addition to division of the flexor retinaculum, 3 approaches to the Guyon canal, 3 anterior epineural membrane removals and 8 partial synovectomies of the flexors were performed. The postoperative evaluation included bilateral clinical and electromyographic analysis of both hands. In this study, the authors indicate the preferential appearance of certain sequelae specific to this type of syndrome for the hemodialyzed patient, and they propose therapies which could reduce their incidence. The use of electromyograms for systematic screening must be considered within the scope of earlier performance of surgery, this would help avoid irreversible neurological lesions.

[Extensive coxo-femoral resection with preservation of the thumb for prosthesis. An alternative to disarticulation at the hip]. / Technique de résection coxo-fémorale élargie avec conservation d'un moignon appareillable. Une alternative à la désarticulation de la hanche.

To avoid the severe mutilation of a hip disarticulation and to improve limb-fitting, a method of partial limb preservation is proposed. Two cases of septic arthritis of the hip with neurological and atrophic lesions sufficient to justify disarticulation are described. Disarticulation was avoided by partial conservation of the thigh with an extensive resection of the upper end of the femur, a through-knee amputation and a large posterior musculo-cutaneous flap including the triceps surae whose muscle provided a good cover for an end-bearing myoplasty. The stump obtained was of good quality which, though a little unstable, was firm and well provided with muscle which allowed early mobilization with a temporary prosthesis and later limb-fitting with much more satisfactory function than that in a hip disarticulation.

[Results of subtalar arthrodesis for traumatic sequelae of the hindfoot]. / Résultats de l'arthrodèse sous-astragalienne pour séquelles traumatiques de l'arrière-pied.

Sixty-seven arthrodeses of the hind foot were done for sequellae of trauma. Forty-one cases were old fractures of the calcaneus. The technique was either the use of a cylindrical bone graft, or fixation of the joint by a screw after removal of the cartilage and correction of deformity when necessary. On 12 occasions the mid-tarsal joints were also fused. Several instances of delayed skin healing were seen after a lateral approach and the use of a bone graft to correct valgus deformity. Only two-thirds of the patients had a satisfactory result. Some developed arthrosis in the joints of the forefoot. The main cause of failure was persistent deformity particularly in varus. When there was no pre-operative deformity the use of a cylindrical graft seemed better than complete excision of articular cartilage which led to two post-operative deformities. The mid-tarsal joint should not be systematically fused.