Delayed closed reduction of rotatory atlantoaxial dislocation in an adult.

We report a case of rotatory atlantoaxial dislocation due to a rugby injury in an adult. The patient presented with torticollis 4 weeks after the injury. The neurological evaluation was normal. Reduction proved difficult to obtain and required 10 days of skull traction followed by gentle manipulation. After reduction, dynamic cervical radiographs showed no instability and magnetic resonance imaging (MRI) confirmed that the transverse ligament was intact. After 6 weeks of immobilization in a Minerva jacket, a dynamic rotatory computed tomography (CT) scan confirmed that the atlantoaxial joint was stable. Such cases of atlantoaxial joint dislocation in adults treated by traction after a considerable delay are rare. In our patient, demonstration by MRI that the transverse ligament was intact led to the decision to use conservative therapy, which proved successful.

[Ipsilateral hip and femoral shaft fractures: components of therapeutic choice]. / Fractures homolatérales de la diaphyse et du col fémoral: éléments de choix thérapeutique.

PURPOSE OF STUDY: Ten cases of ipsilateral hip and femoral shaft fractures were reviewed. MATERIAL AND METHODS: All patients were treated operatively for both fractures between 1988 and 1997 in Pitié Hospital. Five were treated with antegrade reamed intramedullary nails and cancellous screw fixation of the femoral neck, and 5 by long Gamma nail. The shaft fractures were fixed prior to definitive neck stabilization. RESULTS: Ipsilateral hip and femoral shaft fractures accounts for 5.6 p. 100 of the whole femoral shaft fractures registered in the same period. All cases occurred in young adults and resulted from high-energy impaction injuries. There were numerous associated injuries and all patients were polytrauma. The hip fracture was initially overlooked in 1 case without subsequent nonunion or avascular necrosis. At a mean follow-up examination of 22 months, two-thirds had a good result and one-third a fair or a poor result. Nonunion of the femoral neck occurred in one patient as a result of initial displacement and subsequent malreduction, while all shaft fractures united. DISCUSSION: X-ray films of the hip should be done in all cases of femoral shaft fracture in order to decrease the high incidence of missed femoral neck fractures in ipsilateral injuries of the femur. The results indicate that patients with ipsilateral fractures of the femoral neck and shaft can obtain good results when rigid anatomic stabilization of the femoral neck is performed. The femoral shaft fracture is given first priority and is reduced and immobilized with antegrade closed intramedullary nailing. The femoral neck fracture is then treated with cancellous screw fixation or compression screw with long Gamma nail. CONCLUSION: The authors recommend the use of a long Gamma nail to fix this dual fracture whenever possible.

[Direct cost assessment of wrist fractures]. / Evaluation du coût direct des fractures du poignet.

PURPOSE OF THE STUDY: The cost effectiveness of wrist fractures in 1996 at Pitié-Salpétrière Hospital in Paris has been thoroughly analysed. The purpose of this retrospective study was to identify the factors responsible for the variation in the treatment cost of those fractures. MATERIAL AND METHODS: Cost, hospital stay, functional status, ASA score and surgical treatment were analysed in 53 patients with a median age of 57 years. RESULTS: The mean cost per patient was 6,120 FF divided as follows: 26.1% for pre-operative care, 36.4% for surgical procedures, 37.5% for post-operative care. The mean hospital stay was 4.3 days. The cost of personnel (43%) and medical investigations (35%) were the two main sources of hospital expenses beside medical materials (12.5%), hostelry (5.5%), and drugs (4%). DISCUSSION: The duration of hospital stay, the age and the type of the fracture were the only factors that affected statistically the mean cost per patient. Furthermore, factors related to the patient as sex, place of residence prior to admission, functional status, ASA score, had no influence on cost variation. CONCLUSION: Therefore, the best way to reduce the cost of wrist fractures management is to minimize the hospital stay before and after surgical procedure to avoid a lengthy and costly hospital stay and to minimize the abuse utilisation of systematic medical investigations.

Surgery of the deformities in ankylosing spondylitis: our experience of lumbar osteotomies in 31 patients.

Corrective surgery for kyphotic deformities of the spine in ankylosing spondylitis is a major surgery for rare indications. The authors report 31 lumbar osteotomies. The goal is to correct the deformity through a posterior limited approach and to minimise the neurological risks. The modifications developed by the authors for monosegmental closing wedge osteotomies are explained. The posterior resection is rhomboid shaped with a bilateral lamina removal. An osteotomy is performed in a forwards direction on the lateral aspects of the vertebral body without bone resection. This osteoclasty allows progressive vertebral body compression. Pediclectomy is associated if the corresponding foramen at the osteotomy level becomes too narrow in the process of redressing the spine. The resection level is adjusted so that superior and inferior posterior arches come into contact with a good compression. The authors point out the risk of lateral translation. Before the osteotomy, the two adjacent vertebrae are implanted with 5-mm cylindrical pedicular screws, so that posterior fixation can be carried out at any time. Posterior monobloc fixation allows for very great compression of the osteoclasty. The authors compare the results of their experiences in opening and closing osteotomy. They progressively changed their technique for closing osteotomies, because of published vascular complications and mechanical risks (instability and pseudarthrosis in opening osteotomies). Closing osteotomy also minimises the risk of stenosis with radicular compression or traction if an important correction is performed. The level of the osteotomy varied in this series, which had a correction rate of up to 75 degrees. The choice of level depends on secondary effects on pelvic position and projection of the centre of gravity. The preferred procedure remains a monosegmental correction because it is faster and easier, with minimum bleeding. Short monobloc posterior fixation is sufficient to maintain reduction and to obtain stability from posterior compression.

[Possibilities of anterior approach to the lumbar spine by minimal retroperitoneal access. Anatomical bases. Technical principles and initial results]. / Les possibilités de l'abord antérieur du rachis lombaire par voie rétro-péritonéale minimisée. Bases anatomiques. Principes techniques et premiers résultats.

Anterolateral approach to the lumbar spine using a retroperitoneal approach is a common technique. But conventional approaches are performed laterally, resulting in parietal muscular damage, which may alter functional results. The authors present their experience about a minimized pararectal retroperitoneal approach from T12 to S1. Some anatomical aspects are important for a safe and reproductive procedure. The authors used mainly this technique in association with posterior correction and fixation in traumatic and degenerative pathologies. They point out the simplicity of this technique which is performed without special equipment. It seems a real alternative to laparoscopic techniques and micro-surgical antero-lateral interbody fusion, especially because of minimal potential complications and low post operative morbidity.

[Destabilization after surgical treatment of narrow lumbar canal: when should arthrodesis be performed?]. / Déstabilisation après cure chirurgicale de canal lombaire étroit: quand faut-il faire une arthrodèse?

Post-operative spine displacement occurs by excessive or aggravated vertebral sliding. Sex and age, anatomics factors (pre-operative displacement, intersomatic discs quality, hyperlordosis) and operative factors (extensive laminectomy, artherectomy) are predisposing factors. The risk of post-operative vertebral displacement is calculated by a fine pre and per-operative analysis of these pre-disposing factors: Tolerance to post-operative spinal displacement cannot be foreseen and surgical recovery may be difficult whenever.

[Surgical treatment of symptomatic thoracic disk hernia: anterior or posterolateral approach?]. / Traitement chirurgical des hernies discales dorsales symptomatiques: abord antérieur ou postéro-latéral?

From 1981 to 1994, 16 patients with 18 thoracic disk hernias due to degenerative disease (n = 13), trauma (n = 4) or Scheuermann's disease (n = 1) received surgical treatment. Most were situated from T6 to T12. There were 10 medial hernias and 8 lateral hernias. Symptom duration was a mean 23 months at surgery including spinal pain (n = 13) and spinal syndrome (n = 9). Posterolateral access was used in 13 cases and the anterior route in 2, both requiring a graft. After a follow-up of 5 years 1 month, functional and subjective results were excellent or good in 83% of the cases, acceptable in 6% and poor in 11%. Two failures with the posterolateral route corresponded to one patient with initial trauma-induced paraplegia and another with neurological aggravation after the first laminectomy. In our experience, the posteriolateral route is preferred to allow good visual control even in cases involving several levels. Secondary laminectomy may be performed without risking displacement. The presence of the Adamkiewicz artery on the same side and at the same level dictates use of the anterior route which may soon be replaced by video-assisted thoracoscopy to avoid resection of the rib.

[Surgical treatment of deformities of the thoracic and lumbar spine by posterior spinal osteotomy]. / Traitement chirurgical des déformations du rachis dorsal et lombaire par ostéotomie vertébrale postérieure.

From 1987 to 1993, we performed spinal osteotomy with posterior closing-wedge using a single-operation technique in 20 patients with kyphosis. Spinal deformity resulted from mal union after spinal injury in 13 patients and from ankylosing spondylarthritis in 7. Mean duration of the procedure was 4 h 15 min (range 2 h 30 min to 7 h) for mal union and 3 hours (2 h 30 to 4 h) for ankylosing spondylarthritis. Intraoperative blood loss was estimated at 1.8 liters (0.5-4) and 1 liter (0.5-1.5) respectively. Osteotomy was performed at L3 in all cases of spondylarthritis with a mean 30 degrees correction (24-37 degrees) which was maintained after 5 to 18 months follow-up (mean 10 months). For mal union, the mean angular correction was better and more stable after 3 to 84 months (mean 23 months) for the thoracic or thoraco-lumbar segments than for the lumbar spine. Functional results were excellent or good for 11 patients, acceptable for 1 and poor for 1. Three patients with recurrent radiculalgia with mal union were cured after the operation while the neurological status of the paraplegic patients remained unchanged. There were no fatal complications nor neurological or vascular complications among the 20 patients. There were 4 complications in patients with an abnormal callus including 3 mechanical complications and one deep infection. For spondylarthritis, there were no complications at maximum follow-up.

[Surgery of the upper cervical spine in rheumatoid arthritis. Indications and results apropos of 28 cases]. / La chirurgie du rachis cervical supérieur dans la polyarthrite rhumatoïde. Indications et résultats à propos de 28 cas.

PURPOSE OF THE STUDY: The goal of this study was to precise indications and surgical techniques for stabilisation with or without decompression of the upper cervical spine instability in rheumatoid arthritis. MATERIAL AND METHODS: 28 patients presenting upper cervical spine disease have been reviewed (mean age 57 years). These patients had been suffering from severe diffuse arthritis during an average of 14.5 years. The anterior atlanto-axial dislocation was most frequent (25 times), 1 posterior dislocation and 2 vertical dislocations. Odontoid lysis was noted 19 times. A subluxation of the lower cervical spine was present in 12 patients. SURGICAL TECHNIQUE: C1-C2 arthrodesis was performed 12 times (9 times with a loop wire and 3 isthmo-pedicular screws C2-C1), occipito-cervical arthrodesis with plates 16 times. Operative traction was necessary 5 times. The associated surgical gestures included 3 times a laminectomy, 2 times an enlargement of the occipital foramen, 1 section of the Arnold nerve. In 2 patients was associated a fixation of the lower cervical spine. RESULTS: With an average of 27 months follow-up, functional results (classified according to Ranawat's criteria) were satisfactory in 14 patients, improved in 7 patients, unchanged in 4 and bad in 3. The reduction of the anterior displacement in 25 patients was complete 11 times, partial 17 times and null 3 times. The reduction of the vertical displacement was complete once, partial 3 times. Arthrodesis fusion was obtained in 19 cases, 5 times it was a fibrous union and 4 pseudarthrosis occurred, all with C1-C2 loop wire. The rate of complications was high: 2 infections on bone site grafting requiring reoperation, 2 infections with secondary septicemia after lack of reduction. DISCUSSION AND CONCLUSION: Occipito-cervical arthrodesis is necessary as soon as the patient presents neurological signs. When there is an anterior dislocation associated with vertical dislocation, if there is posterior dislocation in case of osteoporosis of the posterior C1-C2 arc, or destabilisation of the lower cervical spine. C1-C2 arthrodesis is suggested when there is no important neurological signs, when displacement is limited to a pure anterior dislocation and in young patient with good bone quality.

[Reduction and osteosynthesis with pin fixation of wrist fractures. A comparative study between Kapandji's and Py's techniques]. / Réduction et synthèse par brochage des fractures du poignet. Etude comparative entre la technique de Kapandji et la technique de Py.

MATERIAL: 62 fractures of the distal radius were treated by pin fixation: Kapandji's intra focal pinning in 28 cases (Group "K") and Py's elastic pinning in 34 cases (group "P"). The two groups were comparable as to the type of fractures (Castaing classification). Theoretical principles were analyzed and compared. RESULTS: Final radiographic results showed the same proportion (75 per cent) of anatomic reduction in both groups. There were 21.4 per cent (6/28) hyporeductions in group K, and 23.5 per cent (8/34) hypereducations in group P. Hyporeduction was moderate with good functional results. Hypereduction in group P was often associated with bad functional results, 5 out of the 6 bad results of all the cases. The functional result, with a follow up of 7 months (4 to 10), was 76 per cent of excellent and good results, 85 per cent in group K, 70 per cent in group P. DISCUSSION: Kapandji's technique seemed more reliable than Py's technique. We propose a technical variation to minimize hyporeduction in Kapandji's technic: increasing the pin's angulation. CONCLUSION: Py's technic conserves one indication: intra operative failure of Kapandji's technique in very osteoporotic bone.

[Neurologic complications of surgery of the spine in adults]. / Complications neurologiques de la chirurgie du rachis de l'adulte.

Spine surgery exposes to neurological complications. There were 170 immediate complications of spine surgery at Pitiè-Salpétrière Hospital out of 2,855 reviewed (5.95%) during 9 years. The nature of the complication (radicular or medullar), severity and evolution were quite different but less than 2.76% where permanent. Among them, 1.43% were major neurological complications. The "high risk" etiologies were cervical stenosis and primitive malignant tumors. The major cause for these complications was due to surgical procedure in 60% of the cases.

Treatment of lower cervical spinal injuries--C3 to C7.

Injuries of the lower cervical spine are categorized according to the morbid anatomy of the lesion. Most often, such injuries are successfully treated by surgery through a posterior approach. After anatomic restoration, internal fixation with plates and screws provides for stability and arthrodesis. Of 221 cases of lower cervical spine injuries, posterior stabilization was accomplished in 89%. There was no secondary displacement in 85% of cases.

[Stress fractures of the tarsal navicular. Apropos of 20 cases]. / Les fractures de fatigue du scaphoïde tarsien (os naviculaire). A propos de 20 cas.

Twenty cases of tarsal navicular stress fractures were observed in 17 patients. These fractures are rare, often go unrecognized, and are reputed to unite with difficulty. A clue to diagnosis was given by the description (young athletic person in sports involving sudden starts and stops). The lesion was not always visible on X-rays of the foot in supination and dorsal flexion (only 10 out of 20 in this series). Use of tomography and tomodensitometry was essential. Treatment was based on compressing the fracture with a screw without grafting or freshening, followed by immobilization of the foot with a cast and no weight bearing for 45 days. Union occurred in 19 out of the 20 cases. Thirteen patients were able to practice their sport without a loss of performance after a period ranging from 3 to 14 months. Treatment varied given the risk of spontaneous non union: incomplete fractures discovered early often responded to orthopedic treatment; fractures associated with large intra-osseous lytic lesions required addition of bone grafting. These fractures can be prevented through the use of inner arch supports especially if a predisposing factor exists such as a short first metatarsal bone.

Resultado del tratamiento en 69 casos operados con disquectomía percutánea en el hospital de Salpetrie-Pitie, París Francia / Results of treatment of lumbar herniated disc by percutaneous discectomy, automated or manual in the Salpetrie-Pitie Hospital of Paris, France

Se presenta una serie de 69 pacientes de ambos sexos con edades entre 17 y 80 años con promedio de 43, en quienes intervinieron un total de 79 discos herniados intervertebrales lumbares por medio de disquectomía percutánea manual o mecanizada en el Hospital Salpetrie-Pitie de París, Francia, de 1948 a marzo de 1989. Los resultados a un mínimo de seis meses después de la cirugía fueron excelentes y buenos en el 100%de los casos de edad menor de 30 años; en el 71%en los pacientes de 30 a 55 años y solamente en el 33%de los pacientes mayores de 55 años.

[Old traumatic lesions of the dorsal and lumbar spine]. / Lésions traumatiques anciennes du rachis dorsal et lombaire.

The authors present 71 cases of malunion or old traumatic lesions. They result from an unadapted initial surgical or functional treatment. The pain symptoms are in the form of vertebral pain or nerve root pain, often associated with signs of neurological deficit. The authors emphasize the stability or instability of the lesion in order to assess its reducibility. The radiographic exploration (dynamic views, MRI, CT, medullary arteriography) would serve as a guide for the treatment strategy. The authors do not report any case of permanent postoperative neurological aggravation. Three surgical options are analyzed (anterior approach, posterior approach and "three-stage" surgery). An enlarged posterior approach enables treatment and reduction of all malunions, except if a medullary feeder artery is present on the site of the lesion. The pain symptoms improve in 87% of all cases. The authors do not report any permanent postoperative neurological aggravation.

[Treatment of complete lumbar disk herniation by percutaneous discectomy]. / Le traitement de la hernie discale lombaire par discectomie percutanée.

Percutaneous diskectomy is a new treatment used in surgery of the spine for the treatment of herniated lumbar disks. The idea is to carry out an exeresis with a posterolateral percutaneous approach on a part of the herniated intervertebral disk; while always remaining outside the spinal canal. This technique eliminates the risks of fibrosis or arachnoiditis. It is carried out under local anesthesia, reduces the surgical insult and requires only a short stay in hospital. Between 1984 and 1988, 188 operations using this technique were carried out on L3-L4, L4-L5 and L5-S1. Of the first 100 cases studied, we note: 71% good and very good results for radiculalgia after a time lapse of more than a year, 51% good and very good results for low back pain; 16% of the patients required a surgical approach after percutaneous diskectomy. The authors specify the advantages and the indications of this surgical technique, which complements the traditional lumbar intervertebral disk surgery.

[Recent ligament lesions of the knee]. / Lésions ligamentaires récentes du genou.

In every case knee injury, it is imperative not to miss a possible lesion of the ligaments and, when such a lesion is present, to evaluate its severity. The practitioner who examines the injured knee in an emergency therefore plays a crucial role in taking a definite attitude when faced with lesions. Before any treatment is envisaged the lesion must be precisely diagnosed. This requires a very strict examination based on the patient's history and on clinical tests that are often simple. At the slightest suspicion of severe lesion of the ligaments, a specialist must be called in to complete the investigation, if necessary by testing under general anaesthesia and/or by performing an arthroscopy.