[Total elbow joint allograft for long term posttraumatic osteoarticular loss. Follow-up results at twelve years]. / Allogreffes d'articulation totale du coude dans les pertes de substance ostéo-articulaire post-traumatiques étendues. Résultats à 12 ans de recul.

PURPOSE OF THE STUDY: Elbow joint allograft (EJA) involving the entire joint (distal humerus, proximal radius and ulna, capsuloligament structures) is a salvage technique proposed in massive bone loss, particularly in young subjects where total elbow prosthesis is contraindicated. We report our experience with seven patients, analyzing the long-term clinical and radiological outcome. MATERIAL AND METHODS: This retrospective study included seven patients, mean age 42 years (21-70). All had experienced severe elbow trauma. Two patients had associated neuromuscular or vascular lesions. All patients underwent at least one surgical procedure on the affected elbow. The preoperative status of the skin cover was crucial. Both longitudinal and circumferential retraction were observed. We used preoperative skin expansion in one patient and a pediculated musculocutaneous latissimus dorsi flap in one other. A posterior and median approach was used conserving tricipital continuity. The ulnar nerve was transposed anteriorly. The allograft was prepared, carefully preserving the capsule and ligaments. Adaptation required cutting the extremities of the humerus and radius and total resection of the radial head except in one patient. Stable plate fixation was completed by an iliac cancellous graft screwed to the humerus and the ulna. The Morrey score was used to assess clinical outcome. The Larsen and Allieu classifications were used to assess radiological outcome. RESULTS: There was one early failure requiring revision for arthrodesis. Assessment of long-term outcome concerned six patients. Mean follow-up was 12 years (7-15 years). The Morrey score improved in six patients and five of them were satisfied. None of the patients complained of invalidating pain and elbow motion was not functional in only one (- 30 degrees - 100 degrees ). For all patients except one, instability was proportional to the duration of the graft and worsened with time. For five out of six patients, significant radiological degradation of the elbow joint was associated with bone lysis which increased with time. DISCUSSION: The allograft acts like a spacer and does not transmit pain impulses. The absence of the pain signal leads to overuse of the grafted joint and osteoarticular destruction. Despite radiological degradation, this procedure provides satisfactory and painless elbow function in most patients. The clinical and radiological features do not follow the same pattern. But we did not have any cases of disassembly or nonunion. Preoperative planning and plastic surgery have enabled us to control the cutaneous portal. We did not have any postoperative infections. Joint allograft is a salvage solution for major osteoarticular loss in young patients desiring conserved joint function and for whom a total elbow prosthesis is contraindicated. It restores bone stock, enables mid-term potential for joint function, and does not compromise surgical revision. CONCLUSION: It remains an exceptional indication which is technically difficult. Resorption of the allograft is constant at long term. Clinically, instability worsen functional outcome. The future for this technique depends on progress in immunology and cryobiology. At the present time, composite total elbow prostheses with an allograft combine the advantages of restored bone stock and arthroplasty.

[Triple fracture of the superior shoulder suspensory complex]. / Triple fracture du complexe suspenseur superieur de l'epaule: presentation d'un cas.

The authors present the case of a displaced fracture of the coracoid process associated with a displaced fracture of the acromion, an undisplaced fracture of the clavicule and fractures of the first to fifth ribs. Open reduction of the coracoid process fracture was performed. At the last follow-up, the coracohumeral distance was restored (10 mm), but the acromiohumeral distance in the sagittal place was decreased (5 mm). The authors recommend open reduction of displaced fractures around the rotator cuff to limit the risk of impingement between the cuff and the coracoid process or the acromion.

[Transcranial Doppler sonography as an intraoperative monitoring procedure. Initial experiences in aortocoronary bypass operations]. / Die transkranielle Dopplersonographie als intraoperatives Uberwachungsverfahren. Erste Erfahrungen bei aortokoronaren Bypassoperationen.

Changes in blood velocity in the middle cerebral artery (MFV) were investigated by transcranial Doppler sonography (TCD) in 24 patients undergoing aortocoronary bypass grafting before, during, and after extracorporeal circulation (ECC). Simultaneously, mean arterial blood pressure (MABP), PaCO2, PaO2, and hematocrit were recorded. During ECC, an increase in MFV could be observed that was most pronounced during the early bypass stages. After ECC, MFV decreased slightly but was significantly higher than before ECC. No linear relationship between MFV and MABP could be registered except for the early bypass stage. Neither duration of ECC nor aortic clamping time showed any correlation with MFV augmentation. Mean PaCO2 was held constant (36 mmHg) with PaO2 being at least 120 mmHg. After removal of the aortic clamp, high-frequency Doppler signals probably caused by air or fragment embolization were detected in some patients. Our data support previous observations of increased cerebral blood flow during nonpulsatile ECC. During short episodes of low-pressure perfusion after initiation of ECC, cerebral autoregulation seemed impaired. However, our results do not support the concept of complete loss of autoregulation during ECC. Compared to the xenon technique of measuring cerebral blood flow, TCD allows noninvasive and continuous evaluation of cerebral hemodynamics, thus offering new possibilities of monitoring cerebral blood supply intraoperatively.