[Comminuted intra-articular fractures of the distal humerus in elderly patients]. / Fractures articulaires complexes de l'extrémité distale de l'humérus chez le sujet âgé

Treatment of comminuted intra-articular fractures of the distal humerus in elderly patients remains a challenge in trauma surgery. These fractures are rare, but their frequency increases. Our multicenter studies collected 238 cases of comminuted intra-articular fractures of the distal humerus in patients older than 65: two hundred and five cases for the retrospective study, 33 for the prospective study with a minimum follow-up of six months. The following criterias were studied: age, sex, state of health (with ASA score), functional scores (with Katz score), osteoporosis by the OST score and dual X-ray absorptiometry. The results were evaluated according to the Mayo Elbow Performance Score (Morrey) and the Quick DASH. X-ray studies were performed in order to assess both results for prosthesis and osteosynthesis. The following criteria were studied: bone healing, quality of reduction, signs of arthritis (Broberg-Morrey), prosthetic position, mechanical complications, prosthesis fixation. There were 80% of women in good health according to the ASA score (more than 70% of ASA 1 or 2). Most of them (80%) were self-governing and living at home. Hundred and seventy-two patients had an osteosynthesis and 44 had a prosthetic reconstruction (like Coonrad-Morrey prosthesis). Patients treated with osteosynthesis were younger (mean age was 77) than those treated with prosthetic reconstruction (mean age 81). Mean follow-up was 32 months. Results of osteosynthesis were good and excellent for 77% of the patients. Complications occurred for 20% of patients with a reoperation rate of 13%. Results of prosthetic reconstruction were good and excellent for 83% of the patients with 14% of complications and 6% of reoperation. Prosthetic reconstruction seemed to be better than osteosynthesis according to the Mayo Clinic score (84 points versus 77 points for the retrospective study and 95 points versus 75 points for the prospective study). However, the statistical analysis was not significant. Treatment of these fractures must be discussed according to the physiological status of the patient and the fracture patterns (scan evaluation). In conclusion, osteosynthesis remains the standard treatment when stable fixation is feasible. However, prosthetic reconstruction should be discussed for dependant patients or with comorbidity factors, bad bone quality leading to poor osteosynthesis or complex fracture.

Pharmacokinetics, uses, and limitations of vancomycin-loaded bone cement.

We have studied the mechanical and pharmacokinetic characteristics of an industrially-prepared bone cement containing 3 g of vancomycin per 60 g cement. A low viscosity cement was selected, to increase contact between the antibiotic and the infected surfaces. Resistance of compression (95 mPa) was well above the required standard (70 mPa) and similar to that of other cements with or without gentamicin. The concentrations in blood, urine and bone were measured in mg/l and mg/kg, and compared to the break point (BP) of susceptibility tests, which must be obtained to achieve control of infection. Diffusion tests were conducted in vitro (elution in saline from rods), and in 30 sheep femora implanted with the cement in vivo. In the animal study, bone levels during the first three months were three-fold higher than the BP (i.e., were > or = 12 mg/l) in 92% of specimens from all areas of bone studied and at all times since implantation; they exceeded five times the BP in 56% of specimens and were never lower than twice the BP. The mean level was four times the BP after six months and fell sharply during the next six months. A pharmacokinetic study in ten patients who had a primary total hip arthroplasty with vancomycin-loaded cement as prophylactic antibiotic therapy showed that blood levels were lower than 3 micrograms/ml, i.e., 30 times lower than the toxic threshold (90 micrograms/ml). Vancomycin was undetectable in urine after the tenth day. The levels in drainage fluids were five times the BP after 24 h and equal to it after four days. None of the ten patients treated prophylactically with vancomycin-loaded cement developed evidence of allergy, toxicity, intolerance or loosening during a two year period. No adverse events were recorded in 17 other patients treated with a vancomycin (2 g) plus gentamicin (0.8 g) loaded cement as adjuvant therapy for severe prosthetic infection.

Rotation osteotomies for osteonecrosis of the femoral head.

Twenty consecutive rotation osteotomies for idiopathic necrosis of the femoral head with an average followup of 6.5 years were reviewed. The original technique used a nail plate for rotation and fixation of the fragments and proved to be reliable for precision of rotation, osteotomy fusion, and absence of mechanical or vascular complications. There were 16 anterior extension Sugioka osteotomies with 52 degrees average rotation, and four posterior flexion Kempf osteotomies with 77 degrees average rotation. The status of 18 surgically treated hips after 5 years was seven failures, two fair results, and nine satisfactory results. Rotation osteotomies are recommended only when the necrotic zone of the femoral head can be removed from the major weightbearing zone of the acetabulum, when the hip is in extension. In Sugioka's anterior rotation, the necrotic zone, although unloaded in extension, usually remains in contact with the acetabular major bearing zone (40 degrees around apex) in hip flexion. Thus, it is recommended only for Ficat Stage 2 nonflattened heads. In Kempf's posterior rotation, the necrotic zone is unloaded in hip extension and flexion, so Stage 3 is not a contraindication for this osteotomy. In addition, osteotomies are not recommended when the necrosis extends deeper than the proximal third of the femoral head. In these large necroses, there may be an overloading of the healthy part of the rotated head, resulting in its secondary mechanical deterioration. If these conditions are fulfilled, rotation osteotomy of the proximal femur may, in patients younger than 45 years of age, delay for a decade the degradation of hips with idiopathic osteonecrosis.

[Guépar's total radio-carpal prosthesis in the surgery of the rheumatoid wrist. Apropos of 72 cases reviewed]. / La prothèse totale radio-carpienne Guépar dans la chirurgie du poignet rhumatoïde. A propos de 72 cas revus.

PURPOSE OF THE STUDY: Total wrist arthroplasty is an alternative to arthrodesis in the treatment of the rheumatoid wrist. MATERIAL AND METHODS: Seventy-two GUEPAR total wrist arthroplasties in sixty-four patients with rheumatoid arthritis were reviewed 1 to 10 years after the operation (average follow-up of 4 years). GUEPAR total wrist arthroplasty is a bicondylar prosthesis. The radial component made of polyethylene is cemented in the radius. The carpal component made of metal is fixed by two screws in the second and the third metacarpal. This component is constitued by two pieces: a perforated lower part permitting the passage of the screws and its metacarpal fixation and a biconvex cover fixed on the lower part by a micro-screw. RESULTS: In preoperative evaluation, all patients had severe pain and loss of function. Post-operatively, 89 per cent had no pain or mild pain and 96 per cent had better function. The average arc of flexion-extension was 47 degrees preoperatively and 39 degrees postoperatively. There were no deep infections or dislocations. Seventy percent of the patients were satisfied but eleven wrists (15 per cent) required revision: 5 cases for prosthesis revision and 6 cases for implant removal and arthrodesis. Prosthesis revisions were justified by the unscrewing of the carpal component micro-screw: they gived good results. Arthrodesis was required for 4 radial component loosening and for 2 important bone resorptions under the carpal component. Radial component loosening was associated in 3 cases with unscrewing of the micro-screw. Radiographical analysis showed in nearly all cases of this serie a bone resorption under the carpal component. This resorption was 2 mm wide at an average of to 2 years and 4 mm wide at 4 years. DISCUSSION: Clinical results of this study are good but eleven wrists required revision. Nine of these revisions were due to anomalies of first prosthesis: the unscrewing of the carpal component micro-screw was accountable to abnormal use of polyethylene with reaction of the wear products and loosening of the radial component. This problem is now resolved. More disquieting is the bone resorption under the carpal component. In fact, this resorption was constant and evolutive. It was very likely due to micro-movements between the metacarpal screws and the carpal lower part. Also, the conception of the metacarpal-fixation of this prosthesis must be revised. CONCLUSION: In rheumatoid arthritis, wrist arthrodesis gives good results if nothings affects the fingers, elbow or shoulder. If they are affected, total wrist arthroplasty is an alternative. Long term loosening of total wrist arthroplasty is a significant problem so its indication must be reserved for old patients.

[Rupture of the flexor tendons after partial arthrodesis of carpus in the rheumatoid wrist]. / Ruptures de tendons fléchisseurs après arthrodèse partielle du carpe dans le poignet rhumatoïde.

The author report two ruptures of flexor digitorum tendons in a series of thirteen partial wrist arthrodeses in rheumatoid arthritis. These ruptures occurred as a result of attrition at the radial epiphysis after reduction of anterior subluxation of the carpus.

[Transtrochanteric rotation osteotomies for osteonecrosis of the femoral head. Apropos of 20 cases]. / Osteotomies trans-trochanteriennes de rotation pour osteonecrose de la tete femorale (20 cas).

PURPOSE OF THE STUDY: Twenty consecutive rotation osteotomies for idiopatic necrosis of the femoral head were reviewed with an average follow-up of 6,5 years, in order to evaluate an original technique (which uses a nail plate for rotation and fixation of the fragments), and to determine the middle term results (and therefore indications) of anterior and posterior rotation osteotomies. TECHNIQUE: rotations were achieved by rotating the femoral head with the nail of the nail plate, and without dissection of the posterior vascular bundle. We performed 16 anterior rotation osteotomies (according to Sugioka, with an average rotation of 52 degrees) and 4 posterior rotation osteotomies (described by Kempf, with an average rotation of 77 degrees). Only two patients were lost after 2 years follow-up (with good result), and the radio-clinical outcome of 18 operations at 5 years was known. RESULTS: Global results were : 7 failures, 3 fair and 10 very good or good. In the 4 posterior rotations (Kempf) we achieved 4 very good results, even in Ficats stage 3. In the 16 anterior rotations we could in all cases obtain, on the hip in extension, an almost complete discharge of the necrotic zone, as after osteotomy it was no more in front of the acetabular major bearing zone (defined as an angle of 40 degrees around the apex of the femoral head on the lateral Lequesne view). We obtained 6 good and very good results, 3 fair, and 7 failures requiring a THR. There were 2 factors of poor prognosis : Stage of the necrosis, as we observed 4 failures in the 4 Ficat's stage 3, and only 3 failures in the 12 stage 2. Depth of the necrosis, as we achieved 6 very good and good results and 1 poor in the 7 cases when it was no more than 1/3 of the head diameter. But in the 9 cases where depth was over one third there were 3 fair and 6 poor results. DISCUSSION: Our technique proved to be reliable as it achieved the rotation planned before operation (only one hypo-correction of 15 degrees) and bone fusion, allowing full weight bearing at 3 months in all cases. No extension of the necrotic area was observed. Posterior rotation osteotomy was followed by long term favorable results, may be because it achieves an anatomic discharge of the necrotic zone not only when the hip is in extension, but also when the hip is flexed. Anterior rotation is only recommended when : a rotation not exceeding 60 degrees (therefore without risks for the posterior bundle) allows a discharge of the necrotic zone when the hip is in extension. The necrosis is stage 2. In Stage 3 a progressive arthritis may occur as, in hip flexion, the necrotic sector of the non spherical head comes in front of the acetabular major bearing zone. The depth of the necrosis does not exceed 1/3 of the femoral head, such as in cases of a very large necrosis, mechanical degradation of the non necrotic part of the head may occur, even if discharge of the necrosis is achieved. CONCLUSION: Transtrochanteric rotation osteotomy may delay of a decade or more the occurring of osteoarthritis, if its indications are restricted to patients under 40, suffering from idiopatic necrosis. In our series Sugioka osteotomy gave good results in stage 2 when necrosis depth was no more than 1/3 of the head diameter. Posterior osteotomy allows a better discharge of the necrotic zone and thus may be proposed in less restricted conditions.

[Reconstruction of isolated traumatic amputation of the thumb. Role of annular pollicization]. / Reconstruction des amputations traumatiques isolées du pouce. Place de la pollicisation de l'annulaire (15 cas).

Fifteen pollicisations of undamaged ring fingers were carried out after isolated thumb amputations, occurring most of the time above the MP in manual workers. All these patients were re-examined with a minimum two years' follow-up and an average 5 years'. There was no complication, and all the patients operated on resumed an active work at the fifth postoperative month on average. Early rehabilitation was favoured by bone fixation of the first metacarpal with an intramedullary peg, and by careful cinematisation (reinsertion of all extensors, cinematisation by the flexor pollicis longus). The results showed that this procedure was the surgery of choice for isolated amputations of the thumb occurring in manual workers at the level of or above the MP. Indeed, if it is compared with transfers of the 2nd toe, pollicisation is characterized by its reliability, an early return to work, a greater range of active motion (60 degrees instead of 30 degrees), pulp-pinch and key-pinch figures at 54 per cent, a hand-grasp (70 per cent) identical or better, a touch sensibility two or three times as good (Weber at 5 mm), a better cold tolerance (no professional disability), and by the fact that there is no discomfort at the level where the transplanted digit was removed.

[Ulnar translocation of the carpus after surgery of the rheumatic wrist. Review of 54 cases]. / Le glissement ulnaire du carpe après chirurgie du poignet rhumatoïde (54 cas revus).

Fifty-four rheumatoid wrists, on which synovectomy and caput ulnar resection had been performed, were re-examined 1 to 8 years after the operation (average follow-up: 3.8 years). The clinical results were good, and the wrists pain-free in 91 per cent of cases, with a low rate of synovitis recurrence (4 per cent), and 88 per cent of the mobility in the sagittal plane was preserved. Radiological examination revealed a moderate aggravation of carpite over the years. This evolution was not linked, however, to the fact that no intracarpal synovectomy was performed in our series since a similar evolution has been reported by authors who carry out this synovectomy. Ulnar translocation of the carpus was commonly measured in relation to the ulna axis, but as the latter tends to get into a more medial position after the surgery this analysis was incorrect. Ulnar translocation should be measured in relation to the axis of the radius, which remains in the same position. Studied in this way, the average translocation in this whole series was 2 mm. A comparative study of the operated wrist and the non-operated wrist in 27 patients revealed a significant aggravation (p < 0.2) of ulnar translocation of the carpus at radiological stages 2 and 3. This translocation remained however minimal. A combined transfer of the extensor carpi radialis brevis or longus onto the extensor carpi ulnaris did not slow down ulnar translocation of the carpus, but the other hand it improved the correction of radial deviation of the carpus and ulnar deviation of the fingers.

[Post-traumatic algodystrophy in children]. / Algodystrophie post-traumatique chez l'enfant.

The authors report two cases of Reflex Sympathetic Dystrophy (RSD) significant by their releasing factor: initial trauma followed by surgical act. They describe the particularities of RSD in children compared with RSD in adult: differents localizations, X Ray films often normals or showing a local homogeneous osteoporosis, bone scintigraphy with variable result (increased or normal or less uptake of isotope), more rapidly favorable evolution.