Femoral and tibial bone torsions associated with medial femoro-tibial osteoarthritis. Index of cumulative torsions.

Frontal plane varus deviation is one of the mechanisms hypothesized to be involved in the pathogenesis of medial compartment osteoarthritis of the knee. But only a few authors have suggested a role for tibial and femoral torsion. In the current study, CT scan was used to measure bone torsion. The torsional morphology of the lower limb was defined by the "index of cumulative torsions" (ICT). The resulting values were compared to the frontal angular deviation data. The effects of tibial and femoral torsion on the position of the lower limb during the stance phase of walking and the consequences for the knee are discussed.

[Osteoarticular disease in adults in France. A survey of 2000 persons]. / Pathologie ostéo-articulaire de l'adulte en France. Enquête auprès d'un énchantillon de 2000 personnes.

PURPOSE OF THE STUDY: Seeking for a global epidemiology data on bone and joint disease in adults in France, we analyzed the problems related to bone and joint disease in a sample population to determine healthcare needs. We also examined patient referral and demand for surgical care for bone and joint disease and the degree of patient satisfaction. MATERIAL AND METHODS: A telephone interview was conducted in a randomly sampled population of adults living in France to determine their demographic characteristics and bone and joint conditions and surgical care reported by the interviewees. Before standardizing, the sample population in the 60-year and older group was increased in order to obtain more precise information concerning degenerative joint disease. The sample included 1000 persons aged under 60 years and another 1000 persons aged over 60 years. The sample populations were matched to the French population for sex and age distribution. One hundred personal face-to-face interviews were also conducted with 100 persons residing in a nursing home. The two surveys were conducted in June and July 1999. RESULTS: Extrapolation of the data obtained to the French population yielded a total of 12 million adults affected by a bone and joint condition during the year preceding the survey. Considering both study samples, the most frequent localizations concerned the spine and the knees. The distribution of the other localizations was age and sex dependent. The percentage of trauma-induced conditions was 31%, predominantly in men under the age of 60 years and in institutionalized individuals. Extrapolation yielded a total of 5.4 million persons who had (or expected to have) a surgical intervention due to a bone and joint condition. The percentage of surgical treatment was highest for fractures (41%) and extravertebral osteoarthritis (18%). Extrapolation to the French population yielded 0.55 million persons aged over 60 years with a hip prosthesis and 0.27 million with a knee prosthesis. Seventy-six percent of the individuals who had undergone surgery for a conditions unrelated to trauma felt their quality of life had been improved. For those who had surgery for a trauma-induced condition, 85% considered they had minimal or no sequelae. Information provided by the surgeon concerning surgical care was thought to be insufficient by 23% of the operated individuals and 43% of those who had a joint prosthesis stated they had not been informed that their implant might be changed. Management of postoperative pain was thought to be insufficient by 36% of the operated individuals. DISCUSSION: Due to the wide field of investigation and the methodology used to collect these data, our findings cannot be easily compared with other epidemiological data. They must be considered with caution due to the sampling bias of a telephone interview and also to the bias introduced by the simplified nosology scheme used for the questionnaire and the fact that no medical validation was performed. These data do however show that a large number of adults are concerned, notwithstanding conditions occurring before the age of 18 years with the frequency of accidents during childhood and adolescence. The data collected confirm the priorities set within the framework of the Bone and Joint Decade 2000-2010.

Prospective randomized comparison between a dynamic hip screw and a mini-invasive static nail in fractures of the trochanteric area: preliminary results.

OBJECTIVES: This study aimed at comparing the results obtained with a sliding screw plate and an experimental device including a small-diameter nail that can be placed with a mini-invasive approach and provides a stable fixation. DESIGN: Randomized prospective study. SETTING: University hospital. PATIENTS: The study included two groups with thirty fractures of the trochanteric area. INTERVENTIONS: In both groups, the surgical procedure was carried out on patients placed on a traction table in a supine position, under an x-ray amplifier. Sliding screw plates (THS) were set in place according to the usual open technique. Nails were placed through a twenty-millimeter supratrochanteric cutaneous incision. This experimental system comprised a locked intramedullary nail with two nonparallel seven-millimeter cervicocephalic screws. MAIN OUTCOME MEASURES: The comparison between the two groups was based on the surgical procedure (time, duration of x-ray irradiation, and total blood loss); the initial postoperative period (complications, duration of hospital stay, and the time before returning home); the time before full weight bearing became effective; the functional and social recovery; mortality; and the quality of immediate and final anatomic restitution and healing. RESULTS: Operating time (p < 0.001) and blood loss (p < 0.001) were lower in the nail group, and no blood transfusion was required. Postoperative pain (p < 0.01), time necessary to support full weight bearing (p < 0.02), and time before returning home (p < 0.05) were reduced in the nail group. All fractures healed in the same amount of time, with good anatomic results in the nail group, whereas ten impactions beyond ten millimeters occurred in the plate group. No difference was found between the two groups in walking ability and autonomy recovery, but hip function (p < 0.05) was better in the nail group. CONCLUSION: This preliminary clinical study has shown the advantages of this mini-invasive technique. It could not evaluate all the possible disadvantages inherent in the method. These points will be evaluated in a multicenter study justified by these preliminary results.

[Primary intraosseous rhabdomyosarcoma]. / Rhabdomyosarcome intra osseux primitif.

We report a case of primary intraosseous pleiomorphic rhabdomyosarcoma located in the pelvis of a 21-year-old woman followed for 4 years. The lytic tumor involved the acetabulum and the isthma with moderate extension to soft tissue. First line chemotherapy was unable to arrest tumor progression. Hemipelvectomy with saddle prosthesis reconstruction was performed, but septic complications dictated a secondary inter-ilio-abdominal amputation. Recurrence-free remission was achieved for 4 years, suggesting this was indeed a primary tumor. Primary intraosseous rhabdomyosarcomas are exceptional. Bone localizations generally suggest metastasis from a primary tumor often situated in an intraperitoneal localization. When search for a primary tumor is negative, intraosseous lesions can be considered as primary tumors warranting curative treatment. Radical surgical resection is recommended within the framework of a multidiscipinary management protocol associating radiotherapy and chemotherapy to improve prognosis.

Evolution of chronic recurrent multifocal osteitis toward spondylarthropathy over the long term.

OBJECTIVE: To retrospectively assess, with a sufficiently long followup (mean 11.6 years; median 9 years), the long-term outcome of chronic recurrent multifocal osteitis (CRMO), a multifocal, inflammatory bone disease. METHODS: Patients included were 8 children/adolescents and 7 adults with no family history of rheumatic disease who had been diagnosed as having CRMO between 1979 and 1995. Ten patients had undergone at least 1 bone biopsy of the lesions, with histologic examination and multiple cultures. In 1996, in addition to an in-depth interview, 12 patients underwent an extensive physical examination, laboratory evaluation, HLA-A, B, C, and DR typing, bone radiography and scintigraphy, and computed tomography scan of the sternoclavicular and sacroiliac joints. RESULTS: Remission was observed in 3 patients. The other 12 patients developed various associations of vertebral (n = 10), sacroiliac (n = 6), anterior thoracic (n = 7), peripheral articular (n = 2), enthesopathic (n = 4), or dermatologic (palmoplantar pustulosis in 3 cases and psoriasis in 2) involvements. Spine involvement was the most common and occurred the earliest (median time to appearance after the onset of osteitis 5.63 years). Clinical sacroiliitis was always unilateral. No patients carried the HLA-B27 haplotype. CRMO responded well to nonsteroidal antiinflammatory drugs. Twelve patients met the European Spondylarthropathy Study Group criteria for spondylarthopathy. CONCLUSION: After 10 years, CRMO had usually evolved to spondylarthropathy, but with certain features not usually seen in the latter: predominantly, unilateral sacroiliitis, no familial form, and no link with HLA-B27.

[Failure of locked centro-medullary nailing in pseudarthrosis of the humeral diaphysis]. / Echec de l'enclouage centro-médullaire verrouillé des pseudarthroses de la diaphyse humérale.

PURPOSE OF THE STUDY: The aim of this work was to assess results after treatment by nailing of nonunion of the humeral shaft. In particular, we focused on consolidation and factors predictive of failure. MATERIAL AND METHOD: A prospective study was conducted in 13 consecutive patients presenting aseptic nonunion of the humeral diaphysis. There were five cases after orthopedic treatment and eight cases after internal fixation. Two patients had iterative nonunions. Locked nailing was performed with three successive types of nails: the Seidel nail in four cases, the Russel Taylor nail in seven, and the ACE nail in two. Anterograde nailing was used for the first three cases and retrograde nailing for the others. All patients were followed regularly in our department. Last follow-up was one to seven years after nailing. RESULTS: Five nonunions (38%) did not consolidate after locked nailing. Consolidation was achieved in the other patients after four to 18 months. The anatomic result was good in these patients. Between the success and failure groups, there was no significant difference in age, gender, type of fracture, first intention treatment, delay from fracture to nailing, type or diameter of the nail, surgical access or not to the fracture site during nailing, or duration of complementary fixation. Anterograde nail insertion, used in our first three patients in this series, appeared to affect shoulder function. The retrograde route was used in other patients and did not appear to have any impact on the elbow itself or the elbow region. DISCUSSION: This clinical study was unable to identify clinical factors explaining failures but did provide several arguments suggesting that defective primary stability of the initial fixation could be incriminated in the failures. CONCLUSION: Centromedullary locked nailing is a simple technique with potential for resolving difficult problems of nonunion. Good functional outcome can be obtained when consolidation is achieved. Rather than abandoning this technique, it would be advisable to conduct further research to determine what factors are determinant in its failures.

[Transgluteal approach to the hip by anterior hemimyotomy of the gluteus medius]. / Abord transglutéal de hanche par hémimyotomie antérieure du gluteus medius.

Authors describe a transgluteal approach of the hip which is not based on the somewhat unsure common insertion of gluteus medius and vastus lateralis. Anatomical basis and technical particularities of division of anterior part of gluteus medius, of gluteus minimus and capsule are given which allow preservation of gluteal nerve, stability of the joint, and solid reparation of abductor muscles.

[Skin and muscle flaps to cover and fill chronic open osteitis of the tibia. Results with 10 cases]. / Les lambeaux cutanés et musculaires de couverture et de comblement des ostéites chroniques exposées du tibia. Résultats à propos de 10 cas.

Chronic osteomyelitis is a severe long-term bone infection which retains its mechanical qualities. The authors report 10 cases of osteomyelitis of the tibia treated by muscular and fascio-cutaneous flaps and reviewed at one year follow-up. Four cases concerned the third upper part of the tibia, 3 the middle and 3 the lower third. Two total failures at the third lower part and three complications which finally healed with delay were observed. The results of this small series compared with the reports in the literature suggest the value of large excision with coverage by a well vascularized flap and the need for antibiotics. The choice of flap is related to type and site of the bone defect. Another question should be raised concerning the surgical strategy in one--or two--stage management and the duration of antibiotic therapy.

Long-term functional prognosis of posterior injuries in high-energy pelvic disruption.

OBJECTIVE: This study sought to identify the long-term functional results of various posterior pelvic lesions and to determine whether such injuries benefit from exact reduction. DESIGN: Consecutive cohort of patients admitted for pelvic disruption between 1980 and 1990. SETTING: University hospital. PATIENTS: Eighty-eight pelvic fractures in eighty-eight patients were classified according to the instability and anatomy of the posterior injury. Simple fractures of the pubic rami, minimally displaced fractures with pubic diastasis of less than 2.5 centimeters, and fractures without other pelvic lesions (type B1 lesions, stage 1 in the Tile classification) were all excluded. Patients with sequelae of associated lesions that could render functional evaluation difficult were also excluded. INTERVENTIONS: The initial status of the patient and the type of fracture determined the treatment. In the anteroposterior compression injuries group, an external fixator using the double-frame Hoffmann device was applied in twenty-eight cases to reduce a large external horizontal displacement, either immediately to control bleeding or later as definitive treatment when anterior internal fixation was not possible. Anterior internal fixation with a plate was used six times to repair a symphyseal disruption. In vertical shear injuries, tibial skeletal traction was used for six weeks as an attempt to stabilize vertical instability. In ten patients, traction alone was used. In other cases, traction was used in conjunction with an external fixator or internal pubic fixation. In impacted lateral compression injuries, simple bed rest for six weeks was used in cases of stable lesions. Skeletal traction was applied in ten patients of this group because of a potential vertical instability, particularly in cases with a comminuted sacral lesion. MAIN OUTCOME MEASURES: Anatomic diagnosis and evaluation of the reduction were made using anteroposterior, inlet, and outlet radiographs of the pelvic ring. To assess reduction, vertical, anteroposterior, and rotatory displacement was measured. Functional results were qualified based on the injury pattern and the quality of the final reduction and were then quantified according to the grading proposed by Majeed. RESULTS: Functional results varied according to injury anatomy, with fractures of the iliac wing and sacroiliac (SI) fracture-dislocations having the best prognosis. The quality of reduction did not affect the functional results. Conservative methods such as skeletal traction and external fixation generally gave satisfactory functional results. Conversely, however, pure SI lesions were associated with poor functional results, especially if reduction was not exact. CONCLUSIONS: This study shows that when the posterior injury is a fracture of the iliac wing or a mixed fracture with SI propagation, a long-term satisfactory functional result can be obtained without an exact reduction even in cases of vertical instability. Simple methods are usually sufficient, and it seems unnecessary to propose more aggressive treatment. It is important, however, to recognize that SI fracture-dislocations (17 percent in this series) seem to be quite different from pure SI disruptions in terms of persistent pain. Moreover, it appears that exact reduction of pure SI lesions is critical for good functional results, something that is difficult to obtain with conservative procedures. Sacral fractures represent a special problem for the surgeon because of the frequency of fair results in which neurologic lesions whose pathophysiology is poorly known seem to be responsible.

[Kinematics of the healthy and arthritic hip joint during walking. A study of 136 subjects]. / Cinématique de la coxofémorale saine et arthrosique durant la marche. Etude de 136 sujets.

PURPOSE OF THE STUDY: The study aimed to analyze the spatiotemporal parameters and 3-dimensional pelvic and hip kinematic components during gait in two groups: patients with a primitive osteoarthritis of the hip and control normal subjects. MATERIAL: The study included 51 patients, ranged from 42 to 81 years, and 86 normal subjects. METHOD: Gait analysis was performed using the optoelectronic system VICON with 5 cameras in free-speed conditions. Functional grading of the patients was assessed by Lequesne's score. Thickness of the hip cartilage was measured on pelvis AP radiograph. A preliminary study was performed to measure reliability of the data on 11 patients. RESULTS: At the initial stage of osteoarthritis, speed, cadence, stride length and hip flexion-extension motion appeared as very close to normal data. After this initial stage, there was a statistical relationship between these parameters and arthritis functional grading. Pelvis rotation around the vertical axis did not change according to severity of functional grading. The mean value of this component of pelvis motion was 10 degrees in the pathological group, whereas it was 8 degrees in the female normal group, and 7 degrees in the male group. There were no significant relationship between radiographical thickness of hip cartilage and functional grading of patients or gait parameters. DISCUSSION: This study demonstrates that spatiotemporal gait parameters and kinematic data appear as quantitative index which could be used in future studies. It also shows that pelvic rotation is greater in pathological group than in normal subjects, even in the extreme beginning of the hip osteoarthritis. This particularity can be explained as a very early consequence of the arthritis or, in the opposite, as risk factor.

[Malignant transformation of multiple chondroma. Apropos of a case]. / Transformation maligne des lésions d'enchondromatose multiple. A propos d'un cas.

Malignant transformation of multiple chondromas observed in Ollier's disease is a well known possibility. In the clinical case of a 52 year old woman reported here, the sarcomatous transformation of two endochondromatous foci occurred successively in less than one year. One was located in the calcaneus, the other within the proximal metaphysis of the ipsilateral fibula. This case is worth reporting for two reasons: the successive occurrence of these sarcomatous lesions led to a amputation below the knee, later completed by an extended radical resection of the fibula. This combination allowed to preserve the knee with a good functional result and without local recurrence, this clinical case may be compared with that reported by Goodman in 1984. Both cases show that sarcomatous transformations may occur almost simultaneously after a long quiscent period and suggest the existence of a factor that could trigger or favor a malignant transformation process.

[Recent palmar dislocations of the proximal interphalangeal joint]. / Luxations palmaires récentes de l'articulation interphalangienne proximale.

PURPOSE OF THE STUDY: Recent anterior dislocations of the proximal interphalangeal (PIP) joint are uncommon injuries. Chronic and irreducible dislocations have been most often reported. This study aims to precise the anatomic and radiologic aspects of these lesions about three cases, and to compare these cases and their treatment with thirteen cases published in the literature between 1966 and 1994. MATERIAL AND METHODS: Three patients presented an anterior dislocation of the PIP joint after direct or twisting traumatism. One had an avulsion of the central slip of the extensor tendon and remained unstable after closed reduction needing pin fixation. Two had a longitudinal tear between central and lateral bands of the tendon with an entrapment of the condyle of the proximal phalanx, and the dislocations were irreducible. After open reduction, the joint was stable. RESULTS: The first case showed a limited flexion after three months. In the two other cases without rupture, full range of motion was recovered after two months. DISCUSSION: These cases have been compared with thirteen cases of recent papers from nine authors. Two types of anterior dislocations of the PIP joint may be described. TYPE I: Without rupture of the central slip fo the extensor tendon. One distal condyle of the proximal phalanx is entrapped between the central slip and a lateral band of the extensor tendon, that are separated by a longitudinal partial tear. The deformity is made by flexion, axial rotation and lateral displacement of the middle phalanx. Open reduction is required and may carry out good functional result. TYPE II: With rupture of the central slip of the extensor tendon. These very unstable lesions need a fixation after closed or open procedure. The treatment is often lately carried out, and the results not so good as in type I. CONCLUSION: Two different types of PIP joint anterior dislocations are described. Earlier diagnosis and surgical treatment can allow early rehabilitation and better final functional results.

Anatomic basis of the transgluteal approach to the hip-joint by anterior hemimyotomy of the gluteus medius.

The authors present a study of the intrinsic anatomy of the gluteus medius m, and of its innervation through the caudal branch of the superior gluteal n. The existence of an intramuscular tendon in the thickness of the gluteus medius was constantly prooved in 40 muscles. The relations of the intrinsic fibrous structure of the muscle and its innervation were studied. The authors deduce from that the topography of a gluteus medius incision, with respect to a safety area towards its innervation, which leads to an exposure of the acetabulum that is satisfying and gives opportunities of a sound repair after the surgery of the hip joint through the transgluteal approach. They propose the "anterior hemimyotomy of the gluteus medius m" designation.

[Long-term results of condylar reconstruction using patella as vascularized graft]. / Résultats lointains des reconstructions condyliennes par la rotule pédiculée.

PURPOSE OF THE STUDY: In 1966, R. Merle d'Aubigné published 4 cases of unicondylar destructions (due to trauma or tumor) reconstructed with the patella replacing the joint surface. Since this time the same technique has been used in 6 other cases. The results of these 10 patients are studied. MATERIAL AND METHOD: Six of the examined patients were treated initially for a giant cell tumor, 1 for a low-grade osteosarcoma, and 3 for post traumatic arthritis. The patellar transplant remains vascularized by it's supero-medial vascular bundle. The femoral condyle was affected in 9 cases, the tibial plateau in one. RESULTS: The long term follow-up of these 10 patients revealed unexpected satisfactory results. None of the operated knees was clinically "excellent", due to instability or axial deterioration, but function remained correct, with a good range of motion, active professional possibilities, and, often, regular practice of some sports, like skiing or tracking. Function was not correlated with radiological aspect. The arthritic remodeling of the knee was obvious in all of the cases, and regularly increasing. Five of the 10 knees had to be reoperated (one or several times): 3 during the first months of follow-up (1 for sepsis, 2 for supracondylar fractures), 5 during the first years, to improve function (2 arthrolysis, 2 valgus osteotomies, 1 loose bodies removal). Three patellar plasties had to be converted into a total knee prosthesis, after 8, 27 and 40 years. The follow-up of the 7 patients still walking on their patellar plasty is of 2, 4, 17, 19, 24, 24 and 25 years. DISCUSSION AND CONCLUSION: Condylar reconstruction using a vascularized patellar transplant is mechanically speaking an approximative, obsolete and rather rough procedure. Nowadays one would prefer a knee prosthesis, with or without auto or allografts, preserving the patella. The immediate functional result would certainly be better, but the future remains uncertain. The patellar plasty can delay for 10, 20 years or even more the time of a prosthesis. This technique might also be useful in countries where prosthetic implants are not easily available.

Leiomyosarcoma of the tibia. Report of a case.

A 48-year-old man with an unremarkable medical history was admitted for a painful swelling over the anteromedial aspect of his right leg. Radiographs disclosed heterogeneity of the proximal tibia, with increased uptake on the bone scan. Computed tomography findings consisted of heterogeneity of the proximal tibial metaphysis and diaphysis with subtle cortical osteolysis, periosteal appositions and soft tissue involvement. Magnetic resonance images showed low signal from the metaphysis, diaphysis and soft tissues on T1 sections that enhanced after gadolinium and converted to high signal on T2 images. Lung metastases were also found. Histologic features were consistent with leiomyosarcoma, which was considered to have originated in the tibia since no other primary localization was found. Combination chemotherapy was successful in eliminating the clinical manifestations and clearing the lung metastases. Six months later, the same chemotherapy regimen failed to improve a local and pulmonary recurrence and the patient died a few months later. Primary leiomyosarcoma of bone is a rare tumor, of which one of the most characteristic locations is the proximal third of the tibia. Magnetic resonance imaging with both T1- and T2-weighted sequences is essential to evaluate intramedullary and soft tissue tumor spread. To our knowledge, there are no characteristic signal patterns allowing to differentiate leiomyosarcoma from other primary malignancies of bone. Immunohistochemical and electron microscope studies are useful diagnostic tools.