[Deep inferior epigastric pedicle for microsurgical free flap transfer for contralateral thigh root coverage]. / Utilité du pédicule épigastrique inférieur profond pour le branchement microchirurgical de lambeau libre pour la couverture de la racine de la cuisse controlatéral.

Thigh loss cover after carcinologic resection of sarcomas can be complex and compromise the vascular tree of the lower limb. We report a case of a patient with recurrent sarcoma of the right thigh. After multiple resections, the femur and hip joint are exposed. The superficial and deep femoral vessels are taken in the excisional piece. The reconstruction is performed by a free musculocutaneous latissimus dorsi flap, anastomosed to the deep inferior controlateral epigastric vessels. The deep inferior epigastric vessels are of sufficient length to join the contralateral hemiabdomen after dissection with a gauge allowing microsurgical anastomoses. They can serve as recipient vessels for a flap covering the contralateral thigh.

Tibiofemoral syndesmosis injury treated by temporary screw fixation and ligament repair.

INTRODUCTION: Tibiofemoral syndesmosis injuries are common but have not been extensively researched. The primary objective of this study was to evaluate the outcomes after temporary screw fixation with ligament repair of these injuries. The secondary objective was to look for factors that could impact these outcomes. We hypothesised that this double fixation (screw+suture) would lead to good outcomes with minimal secondary opening of the syndesmosis upon screw removal. MATERIAL AND METHODS: This was a retrospective study of 285 patients with a tibiofemoral syndesmosis injury (01/2004-12/2011) who were treated by temporary tricortical or quadricortical screw fixation and ligament repair. The operated leg was unloaded for 6-8 weeks postoperative with the patient wearing a walking cast. The screw was removed in all patients before weight bearing was allowed. At follow-up, the range of motion, return to sports, pain, and functional scores (AOFAS and OMAS) were determined, and a radiological assessment was performed. RESULTS: One hundred twenty-six patients were reviewed after a mean follow-up of 5.9±5.7years (2.9-10.5). Mean plantarflexion was 95% of the contralateral side and mean dorsiflexion was 93%. Return to sports occurred after a mean of 10weeks; 83% of patients returned to their pre-injury level of participation. Pain on VAS was 0.8/10 on average. The mean AOFAS and OMAS scores were both above 90 points. At the review, 4% of screws had broken. Diastasis was found in 5.6% of cases, osteoarthritis in 6.3% and an osteophyte in 11.1% of cases, but with no clinical repercussions. No risk factors were identified. DISCUSSION AND CONCLUSION: Treatment by temporary screw fixation and ligament repair leads to good objective results, confirming our hypothesis. However, there is little published data and no consensus on the fixation method or the need to remove the screw. LEVEL OF EVIDENCE: IV, retrospective, non-comparative.

Villonodular synovitis of the ankle. Analysis of the risk of recurrence.

INTRODUCTION: Villonodular synovitis (VNS) is a rare disease with an incidence of 1.8 per 1,000,000 inhabitants. VNS of the ankle has seldom been described and evaluated given its extreme rarity (2.5% of VNS cases). It presents an 11% recurrence rate. We report a continuous retrospective series with the main objective of clinically and radiologically evaluating these ankles searching for any risk factors of recurrence. At revision the study's main endpoint was the existence of local recurrence (radiological and clinical) and the secondary endpoint was the existence of tibiotalar osteoarthritis. The working hypothesis was that recurrence could be subclinical, warranting systematic imaging studies during follow-up. MATERIAL AND METHODS: The study was retrospective, conducted on seven patients (six males) whose mean age was 42 years treated over a period of 9 years (two diffuse forms and five localized forms). The initial treatment consisted in synovectomy via the conventional approach. Four patients also received adjuvant isotopic synoviorthesis treatment. The revision was clinical (MMTS, AOFAS, and OMAS scores) and radiological (standard and MRI) to evaluate the joint after-effects and search for recurrence. RESULTS: Six patients were seen at a mean 6.5 years of follow-up. One case of early recurrence (4 years) was noted, with a major clinical manifestation because it was associated with joint destruction requiring arthrodesis, and one case of late asymptomatic recurrence (9 years), diagnosed radiologically on the follow-up MRI. The functional results remained good at follow-up (MMTS 77%, AOFAS 71, OMAS 71). Five of the six patients returned to their daily activities. At revision, no sign of osteoarthritis was observed. No risk factor for recurrence was demonstrated. DISCUSSION/CONCLUSION: The hypothesis was confirmed with the existence of asymptomatic recurrence at revision, underscoring the value of systematic MRI at follow-up. Other than major joint destruction, the prognosis remains good even in case of recurrence. The literature emphasizes the existence of an initial diffuse form and partial surgical resection as risk factors of recurrence. None of the reports in the literature has proven that adjuvant treatment, whose modalities do not meet with consensus, reduces this risk. LEVEL OF EVIDENCE: Retrospective series, level IV.

Critical analysis of olecranon fracture management by pre-contoured locking plates.

BACKGROUND: Fractures of the proximal ulna are rare and usually managed surgically. Strong fixation of the harware is essential to obtain good outcomes. We report our experience with pre-contoured locking plate fixation of complex olecranon fractures and present a critical appraisal of the outcomes. HYPOTHESIS: Pre-contoured locking plates provide good outcomes, but their clinical tolerance may be limited in some instances. MATERIALS AND METHODS: From September 2009 to December 2011, 28 patients were managed using a pre-contoured locking compression plate (LCP(®)). Among them, 6 were excluded because of missing data, which left 22 patients (11 males and 11 females) with a mean age of 55.7 years, including 12 who were employed. The fracture was on the dominant side in 11 patients. According to the Mayo Clinic classification, 15 fractures were type II and 7 type III. In addition to the ulnar fracture, a radial head fracture was present in 9 patients and a coronoid process fracture in 5 patients. Functional recovery was assessed using the Broberg-Morrey score and Mayo Elbow Performance Score (MEPS). Radiographs were obtained to evaluate the quality of fracture reduction and fracture healing, as well as to look for ossifications and osteoarthritis. RESULTS: Mean follow-up was 20 months. Flexion was 131°, extension loss was 9.5°, pronation was 79°, and supination was 80.5°. The mean Broberg-Morrey score was 96.7 and the mean MEPS score 96.6. Fracture healing occurred in all patients, within a mean of 10.6 weeks. Evidence of early osteoarthritis was found in 6 patients, ossifications in 3 patients, and synostosis in 1 patient. An infection was successfully treated with lavage and antibiotic therapy in 1 patient. The fixation hardware was removed in 6 patients. No prognostic factors were identified. DISCUSSION-CONCLUSION: Our hypothesis was confirmed. The outcomes are encouraging and comparable to those reported in the literature. The critical issue is the limited clinical tolerance of the plate with a high rate of posterior impingement requiring plate removal (27%). Rigorous technique is essential during plate implantation. LEVEL OF EVIDENCE: Level IV, retrospective study.

Minimally invasive fixation of type B and C interprosthetic femoral fractures.

INTRODUCTION: Interprosthetic femoral fractures are rare and raise unresolved treatment issues such as the length of the fixation material that best prevents secondary fractures. Awareness of the advantages of locked-plate fixation via a minimally invasive approach remains limited, despite the potential of this method for improving success rates. HYPOTHESIS: Femur-spanning (from the trochanters to the condyles) locked-plate fixation via a minimally invasive approach provides high healing rates with no secondary fractures. MATERIALS AND METHODS: From January 2004 to May 2011, all eight patients seen for interprosthetic fractures were treated with minimally invasive locked-plate fixation. Mean time since hip arthroplasty was 47.5 months and mean time since knee arthroplasty was 72.6 months. There were 12 standard primary prostheses and four revision prostheses; 11 prostheses were cemented and a single prosthesis showed femoral loosening. Classification about the hip prostheses was Vancouver B in one patient and Vancouver C in seven patients; about the knee prosthesis, the fracture was SoFCOT B in three patients and SOFCOT C in five patients, and a single fracture was SoFCOT D. Minimally invasive locking-plate fixation was performed in all eight patients, with installation on a traction table in seven patients. RESULTS: Healing was obtained in all eight patients, after a mean of 14 weeks (range, 12-16 weeks). One patient had malalignment with more than 5° of varus. There were no general or infectious complications. One patient died, 32 months after surgery. The mean Parker-Palmer mobility score decreased from 6.2 pre-operatively to 2.5 at last follow-up. Early construct failure after 3 weeks in one patient required surgical revision. There was no change in implant fixation at last follow-up. No secondary fractures were recorded. DISCUSSION: In patients with type B or C interprosthetic fractures, femur-spanning fixation not only avoids complications related to altered bone stock and presence of prosthetic material, but also decreases the risk of secondary fractures by eliminating stress riser zones. The minimally invasive option enhances healing by preserving the fracture haematoma. Thus, healing was obtained consistently in our patients, with no secondary fractures, although the construct failed in one patient. LEVEL OF EVIDENCE: Level IV.

Distal targeting device for long Gamma nail(®). Monocentric observational study.

INTRODUCTION: Intramedullary nail distal locking screws make it possible to control length and rotation but include an increased risk of radiation exposure. A distal targeting device was recently developed for long Gamma(®) nails (Stryker(®)). The aim of this practical observational study was to evaluate the reliability of this system. Our hypothesis was that the targeting device would be systematically used without conversion or complications. MATERIALS AND METHODS: All of the long Gamma(®) nails implanted between November 2011 and October 2012 were recorded: 91 nails (59W/32M, mean age 73.5years old) for 68 traumatic fractures, 14 preventive nailings and nine pathological fractures. A junior surgeon performed the procedure in 45 cases and a senior in 46 cases. The number of times the device was used, the difficulties and complications encountered, the duration of fluoroscopy and the dose of radiation were noted. Risk factors were looked for. RESULTS: The targeting device was used 79 times (the surgeon chose not to use it 11 times, and it was not available in one case). There was a measurement error in one case, therefore 78 nails could be evaluated. Three wrong positions of the distal locking screw occurred. No statistically significant risk factors were identified. Distal locking screw corresponded to 18% of the entire procedure at a radiation dose of 7.44% (this was higher with titanium nails and pathological fractures). Total fluoroscopy time was longer with junior than with senior surgeons but the dose and duration for distal locking were not different. DISCUSSION: The hypothesis was not confirmed. The device was not systematically used and the risk of complications was not null. No risk factors were identified. The distal locking screw is a difficult step but the use of the targeting device can limit the dose of radiation. This device is effective and allows young surgeons to perform distal locking without increasing the dose of radiation compared to senior surgeons. LEVEL OF EVIDENCE: Level IV, cohort study, observational prospective follow-up.

Reliability of locked plating in tibial plateau fractures with a medial component.

BACKGROUND: Tibial plateau fractures are notoriously difficult to manage, particularly when there is a medial or posteromedial component. We report a retrospective analysis of our experience with consecutive tibial plateau fractures including a medial component that were managed using a single lateral locking plate. HYPOTHESIS: Tibial plateau fractures with a medial component can be effectively managed using a single lateral locking plate. MATERIALS AND METHODS: From January 2005 to December 2008, 20 patients (ten women and ten men, mean age 47 years) were managed for tibial plateau fractures having a medial component, including five Schatzker IV, five Schatzker V, and ten Schatzker VI. One patient had an open fracture. A single lateral anatomically contoured locking compression plate (LCP™) was used with or without additional isolated screws. Mobilization was started immediately after the procedure, and non-weight-bearing was maintained for at least 6 weeks. RESULTS: All patients were followed until healing. A final evaluation was available for 13 patients after a mean of 39.1 months (12-72); five patients were lost to follow-up and two died. Early revision was needed in one patient for 20° malreduction within the fracture site. We recorded one case each of deep vein thrombosis, superficial infection, knee stiffness, and spontaneously regressive common fibular nerve dysfunction. At final evaluation (n=13), mean range of motion was 0°/2°/130° with a mean Lysholm score of 94.1 (73-100) and a mean HSS score of 93.6 (74-99). All previously employed patients returned to work at the same level after a mean of 4.5 months. Mean healing time (n=20) was 10 weeks (6-12). Initially, articular step-offs greater than 2mm were noted in five patients. At healing, no further displacements or aggravation of articular step-offs were recorded. The reductions remained stable over time. At final evaluation (n=13), mean tibiofemoral mechanical angle was 179.7° (176-184) and no patients had evidence of osteoarthritis. DISCUSSION: The radiological and clinical outcomes in our patients were satisfactory. A single lateral locked plate ensured stable reduction of tibial plateau fractures with a medial component. Biomechanical studies of these fractures have provided conflicting data on the stability of reduction using single plate systems. However, previously reported clinical outcomes are similar to those found in our study and support the effectiveness of favouring the use of single locking plate fixation. LEVEL OF EVIDENCE: Level IV, noncomparative retrospective study.

Reversed anatomic distal femur locking plate for periprosthetic hip fracture fixation.

The incidence of femoral fracture on hip prosthesis is increasing. Plate fixation is the method of choice when the prosthesis is stable. In fracture with proximal extension, the quality of the bone fixation is critical and, despite the development of anatomic plates, may be endangered when there are too few proximal screws. To resolve this issue, we recommend using a reversed LCP™ anatomic distal femoral Less Invasive Stabilization System (LISS™) locking plate: e.g., a left distal femoral plate for femoral fracture on right-hip implant. This presents several advantages: minimally invasive surgery, the introduction of the plate being facilitated by the LISS™ ancillary; ease of locking, also thanks to the ancillary; and, above all, multiple proximal trochanteric fixation thanks to the form of this anatomic distal LISS™ plate, improving proximal bone fixation. The present technical note seeks to illustrate the interest of using a "reversed" plate, in terms of simplicity of fitting and quality of reduction and consolidation, while also specifying the associated limitations and tolerance.

Minimally-invasive fixation of distal extra-articular femur fractures with locking plates: limitations and failures.

Minimally-invasive fixation using a locking plate and early motion is normal practice. However, technical errors and pitfalls are common. This surgery has a set of rules that encompass both the mechanics of the internal fixation system and the implantation itself. If these rules are not strictly followed, alignment defects and/or early failure of the fixation can occur. We analysed four cases of clinical failure that were encountered after minimally-invasive distal femoral extra-articular fixation with locking plates. The following rules must be followed with this technique: extra-articular fracture, minimally-invasive approach, long plate alternating between locking screw and empty hole (five holes on either side of fracture), bi-cortical screws, placement of locking screws near a complex fracture but away from a simple fracture. Osteoporotic bone, obesity that interferes with the instrumentation, articular fracture, horizontal fracture line and surgeon experience are all limitations of this minimally-invasive technique.