[Combined tibio-talar and subtalar arthrodesis by retrograde nail in hindfoot rheumatoid arthritis]. / Arthrodèse combinée tibio-talienne et sous-talienne par clou transplantaire dans l'arrière pied rhumatoïde.

PURPOSE OF THE STUDY: Many techniques for ankle arthrodesis have been described. Some are not applicable to patients with severe rheumatoid arthritis (RA) because of osteopenia and deformities. This study describes a new surgical technique for arthrodesis in painful valgus deformity of the hind-foot in advanced rheumatoid arthritis (RA) with severe osteopenia. MATERIALS: The present series included 9 patients. Eleven talocrural and talocalcaneal arthrodeses were performed for degenerative changes secondary to RA involving hind-foot joints. All patients were reviewed after an average follow-up of 6 years. Mean duration of RA was 34 years. All patients had severe osteopenia, including major deformations of the hind-foot in 5 cases. METHODS: After removal of talocrural and talocalcaneal articular surfaces using an anterolateral approach, deformities were corrected by removal of an appropriate bone wedge. A Küntscher nail was then positioned in the calcaneal plantar cortical through the plantar surface of the foot and driven proximally into the medullary canal of the tibia through the talus. This nail allowed both deformity correction and fixation. Aftercare required immobilization in a short leg cast. Weight bearing was allowed with the cast approximately 5 weeks after surgery. The ankle was immobilized for 7.5 weeks. DISCUSSION: Results showed a 80 per cent fusion rate. Two non-unions occurred (one recurrence of valgus deformity after early nail migration requiring removal of the nail; and the other asymptomatic). A complication occurred in one foot (delayed healing). At follow-up, all patients but one were satisfied with respect to pain relief and residual deformities. Our results are comparable with those of other series and should be considered in the context of severe RA. CONCLUSION: This technique of vertical retrograde transarticular nailing allows an easy control of hind-foot deformities correction. Other techniques are preferable in case of solid bone. This technique is an acceptable alternative in advanced RA.

Histological features of large bone allografts.

We performed biopsies during reoperation for minor complications in two active young patients 9 and 19 months after massive bone allograft implantation for bone tumour. The grafts were dead and resorption-apposition activity, when present, was predominantly in subperiosteal areas. Inflammatory infiltration was very seldom found. Features considered as 'microfractures' or 'microcracks' were noted in the cortical ring together with the formation of woven bone, in areas with remodelling. Such cracks are likely to be of mechanical origin and do not inevitably lead to complications.

[Filling of bone defects using biphasic macroporous calcium phosphate ceramic. Apropos of 23 cases]. / Comblements osseux par céramique phosphocalcique biphasée macroporeuse. A propos de 23 cas.

PURPOSE OF THE STUDY: The authors report their experience with the use of a biphasic macroporous calcium phosphate bone substitute. MATERIALS AND METHODS: In 23 cases (22 patients) a biphasic macroporous calcium phosphate ceramic was used to fill a pathological bone defect. The ceramic used in this study was a macroporous (400 to 600 mu) component consisting of 60 per cent hydroxyapatite and 40 per cent beta-tricalcium phosphate. It was in the form of granules (2 to 3 mm), sticks (20 x 5 x 5 or 10 x 5 x 5 mm) or custom made blocks. In 6 cases, the ceramic was used alone; in 12 cases with autologous bone marrow and in 5 cases with autologous cancellous bone grafts. In 14 cases, the bone defect was due to conservative treatment of a benign tumor, in 3 cases due to aseptic post-traumatic non union, in 3 cases due to wide resection for malignant tumors of the pelvis and in 3 cases following osteotomy. Post operative assessment was made from clinical, radiographic and histological findings. RESULTS: 2 patients died 6 and 8 months post operatively and 2 were lost to follow up at 2 and 5 months with both having good clinical and radiographic results when last seen. For the remaining 19 cases, the average follow-up was 20 months (from 6 to 62 months). No local, regional or general deleterious effects were noted. Radiologically the bone ceramic junction healed in all cases except 2 within 3 months. In these last two cases, healing required 6 and 7 months. No radiolucent line appeared around the ceramic. No stress fractures occurred in the substitute. Histologically, 3 biopsies showed new bone formation throughout the ceramic with apposition of a well differentiated lamellar bone directly apposed to the ceramic. DISCUSSION: Animal experimentations have proven the interest of similar ceramics: macroporosity enhances bone rehabilitation and the biphasic characteristics associate the advantages of slow resorption of hydroxyapatite and more easily resorbed beta-calcium phosphate. No deleterious clinical, radiographical or histological effects were observed, confirming the biocompatibility of this substitute. Despite the poor mechanical properties of this macroporous ceramic before implantation, good clinical and radiographic results suggest improvement of these properties in the composite new formed bone-ceramic after implantation. CONCLUSION: We believe that macroporous biphasic ceramic is a good substitute for use in bone defects when good primary mechanical stability and contact with the host bone are present. Further clinical and experimental studies are necessary to determine the limits of such a substitute in terms of volume and to control its mechanical properties following implantation.

[Cover of trochanter pressure sores by V-Y musculocutaneous flap of the fascia lata]. / Couverture des escarres trochantériennes par lambeau musculo-cutané de fascia lata en V-Y.

Authors report their experience with the V-Y advancement flap in the coverage of trochanteric pressure sores. Nine flaps have been performed concerning 7 patients. Trochanteric sores in paraplegia or tetraplegia may lead to suppurative arthritis of the hip, with a risk of anaerobic infection and acute septicaemia. The treatment has to be as complete as possible. The trochanteric sore is debrided, with special attention given to removing all necrotic material, the surrounding bursa, and the bony prominence of the greater trochanter. The debrided trochanteric region is then covered by a well-vascularized and thick tissue. We observed only one complication at the donor site which can be closed primarily by this technique. The V-Y advancement technique is a new, simple and safe design of tensor fasciae latae flap. The defect is covered by the thicker and the best vascularized portion of the musculo-cutaneous flap. It allows preservation of other donor sites of the gluteal region to cover other sores, which are often associated.

[Value of cutaneous expansion in the repair of skin defects after posterior surgical intervention on the spine]. / Intérêt de l'expansion cutanée dans les reprises des voies d'abord postérieures du rachis.

Tissue expansion spreads widely its field of application through the treatment of large cutaneous defects. Spinal surgery represents a new field for this technique. Iterative and large posterior midline approach can lead to skin necrosis and deep infection which imposes a second look attempt with ablation of orthopaedic devices. Tissue expansion associated with advancement flaps represents a less aggressive choice to treat such post-surgical complications saving regional skin and muscles rather than with conventional flaps. The authors report four cases in which such a technique was applied with long term satisfactory results.

[Acetabulum without cement. Short-term results of a series of 112 threaded cups]. / Cotyles sans ciment. Résultats à court terme d'une série de 112 cupules vissées.

Between January 1982 and December 1987 we used 112 threaded acetabular cups in 102 patients undergoing total hip replacement. The clinical and radiographic results of 107 implants are reported in this survey. Using the functional grading of the hip advocated by Merle d'Aubigné and Postel, 62% can be classified as excellent, very good or good. On x-ray only 35% of the cups show neither radiolucency at the bone-implant interface nor migration of the component. There is a statistically significant correlation between a radiolucency in 2 of the 3 areas at the bone-implant interface and the clinical result. The revision rate for failure of the cup is 11.6% (13 implants). The actuarial survival of the threaded cup decreased from 0.95 in the 1st year to 0.75 in the 5th year after implantation. Analysis of our failures and of published data suggest that the problem lies in the lack of primary bone integration. We describe our difficulties in assessing risk factors, in interpreting the radiographs and in the intraoperative determination of component instability. The disappointing short term results have prompted us to abandon the use of threaded cups.

[Fracture of the femoral neck complicating algodystrophy of the hip during pregnancy. Apropos of 2 cases]. / Fracture du col du fémur compliquant une algodystrophie de hance au cours de la grossesse. A propos de 2 observations.

The authors report 2 cases of fracture of the femoral neck in pregnant women. This is a serious complication of a poorly understood disease, algodystrophy of the hip during pregnancy (transient osteoporosis of the hip of pregnancy, as referred by Anglo-saxon practitioners), whose main clinical, paraclinical and course characteristics are reported. The risk of subcapital fracture is maximal during the period of term, justifying recumbency in painful forms. In spite of the phantom appearance of the femoral head and neck, this type of fractures should not be confused with tumoral osteolysis, since they always unite within usual intervals.

[Mechanical changes in the femur induced by a joint prosthesis. Comparative extensometric studies]. / Les perturbations mécaniques du fémur, induites par la prothèse articulaire. Etudes extensométriques comparatives.

This study using electrical extensometry is aimed at comparing the relative deformations of the same fresh femur before and after the successive implantation of the following titanium prostheses: a cement-free prosthesis with metaphyseal endocortical support, a cemented prosthesis with, then without collar, and finally a screwed titanium prosthesis. The 56 deformation measurement paths produce an overall exploration of the behavior of the femur. The results applied to the same straight section of the femur are different from those of earlier works. The density of the measurement areas has particularly been increased in the upper metaphysis by the use of bidirectional gages. The loading device ensures the absence of variations of the external stress torsion transmitted to the femur between the individual prostheses. The results recorded with the cement-free prosthesis with metaphyseal endocortical support and with the collar-free cemented prosthesis are very similar. The incidence of the "collar effect" is very low in spite of optimal in vitro implantation conditions ensuring good contact between the collar and the neck of the femur. The screwed prosthesis is the implant that most stiffens the upper end of the femur. The testing procedure chosen has allowed recording the deformations caused by the mere insertion of the implants and the bone. The importance of the upper metaphysea endocortical support of the cement-free, screwless implant contributes in ensuring a better primary anchorage, producing stresses that will then foster the secondary anchorage through endosteal osteogenesis.

[Degenerative lumbar stenoses: value of the Cotrel-Dubousset instrumentation combined with lamino-arthrectomy. Apropos of 16 cases]. / Sténoses lombaires dégénératives: intérêt de l'instrumentation de Cotrel-Dubousset associée à la lamino-arthrectomie. A propos de 16 cas.

Sixteen patients suffering from degenerative lumbar stenosis with or without spondylolisthesis underwent surgery following medical treatment failure; symptoms consisted of intermittent claudication, radiculalgia, and lumbago. In all cases, treatment involved dural and nerve root release with extensive lamino-arthrectomy, followed by arthrodesis using the Cotrel and Dubousset Instrumentation with posterolateral arthrodesis in order to avoid postoperative spinal instability. One case met with failure, owing to peridural fibrosis caused by a previous operation, while fifteen good to excellent results were obtained as evaluated according to Stauffer and Coventry criteria.

Macroporous calcium phosphate ceramic performance in human spine fusion.

With a background of experimental studies on macroporous biphasic calcium phosphate (MBCP) in canine spine fusion, MBCP was investigated in 11- to 18-year-old patients with scoliosis treated by spinal fusion. Twelve cases were chosen for whom enough bone graft was difficult to obtain (severe neurologic scoliosis and osteogenesis imperfecta). MBCP blocks were used in combination with a specific strong fixation (Cotrel-Dubousset instrumentation). Clinical and roentgenogram assessments were performed up to 24 months. In two cases, biopsies were obtained. Histologic, ultrastructural, and microanalysis studies demonstrated the effectiveness of MBCP implants combined with a strong stabilization as bone graft substitutes for spine fusion. Clinical and biologic assessments were normal, and the histologic and ultrastructural evaluation demonstrated the bioactivity and the osteoconduction of this material. Partial resorbability of the MBCP blocks involved lamellar bone formation at the expense of the ceramic.

[Extensometry and primary anchorage of femur implants. Study of the upper metaphyseal intracortical support of the B.P.R cement-less implant]. / Extensométrie et ancrage primaire d'implants fémoraux. Etude de l'appui endocortical métaphysaire supérieur de l'implant sans ciment B.P.R.

This study uses extensometry to compare the distribution of strain on a fresh femur before and after implantation of various titanium prostheses: one is a cementless implant with metaphyseal endosteal support; the second is a cemented prosthesis with and without calcar collar contact; the last is a titanium implant with fixation by screens. The precision of the measurements have been improved particularly in the proximal metaphyseal area using bidirectional gauges. The system of loading permits comparison of the different implants and the results obtained with the B.P.R. prosthesis compared with the cemented implant without calcar contact are very close. The effect of the collar appears very limited despite the optimal conditions of the in vivo implantation that improve the calcar-collar contact. The screw implant increases the stress shielding of the proximal area of the femur. The different steps of the experiment illustrate the strain distribution in relation to the implantation of the devices and the contact bone prosthesis. The significant endosteal fixation of the B.P.R. prosthesis in the proximal metaphyseal area allows a better primary anchorage which increases distribution of the stress and therefore results in better secondary fixation by bony ingrowth.

Impact of surgical stress on the haemodynamic profile of isoflurane-induced hypotension.

It has been suggested that stimulation of adrenoreceptors could be responsible for some of the haemodynamic effects of isoflurane. But there are no solid data demonstrating the role of sympatho-adrenal stimulation induced by pain during isoflurane administration. The impact of surgical stress on the haemodynamic profile of isoflurane-induced hypotension has been investigated in 28 patients (47-76 years), scheduled for total hip arthroplasty. After premedication with morphine hydrochloride (0.1 mg/kg), patients were randomly assigned to receive either no fentanyl (control group) or fentanyl (5 micrograms/kg before tracheal intubation, 5 micrograms/kg before skin incision, and 2 micrograms/kg each 15 min during the 1st hour). Isoflurane was given to maintain mean arterial blood pressure in the range 6.7-8 kPa in both groups. Haemodynamic data and blood samples for determination of plasma renin activity (PRA) and epinephrine (E) and norepinephrine (NE) levels were collected before and during hypotension. The fentanyl group and the control group differed significantly during hypotension: heart rate, cardiac index, oxygen consumption and E, NE and PRA were lower (P less than 0.01) in the fentanyl group than in control group. Fentanyl lowered the required concentration of isoflurane to achieve the same degree of hypotension (end-tidal concentration: 0.8 +/- 0.2% in the fentanyl group and 1.4 +/- 0.15% in the control group; P less than 0.001). Our results demonstrate that the cardiovascular effects of higher isoflurane concentrations in the absence of narcotic analgesia are counterbalanced by adrenergic stress stimulation of released epinephrine and norepinephrine. Among the likely reasons for catecholamine release during isoflurane administration, inadequate analgesia may be considered.

[5-year results of Salter's osteotomy in the treatment of congenital hip dislocation. Apropos of 30 cases]. / Résultats à 5 ans de l'ostéotomie de Salter dans le traitement de la luxation congénitale de la hanche (LCH). A propos de 30 cas.

Residual dysplasia and iatrogenic osteochondritis are two complications of treatment of congenital dislocation of the hip. Confidence is placed in the use of slow orthopedic reduction with a combined stabilizing Salter's osteotomy. This method was applied in 20 cases while in 10 patients a Salter's operation was performed for confirmed failure of orthopedic therapy. These were cases of severe dislocation, the mean age of the patients when starting treatment being 11 months. The mean age at the last follow-up examination was 5 years, when confirmation was obtained of the excellent clinical result, and particularly the radiographic outcome with normal cotyloid angles and good anterior cover. Pelvic osteotomy when mean age was 22 months produced as near as possible a normal hip before 6 years of age, without altering growth of the surperior extremity of the femur.

[Bilateral traumatic dislocation of the hip. Report on three cases (author's transl)]. / Luxations traumatiques bilatérales de hanche. A propos de 3 cas.

Three patients with simultaneous bilateral traumatic dislocation of the hip have been treated, one case developing double intra-articular incarceration after orthopedic reduction. This type of lesion is reputed to be extremely rare, but a review of the published literature demonstrated that more than 100 cases have probably been described.

[Synovial hemangioma of the knee. Report of one case (author's transl)]. / L'hémangiome synovial du genou. A propos d'un cas.

Hemangioma of the synovial membrane is encountered in young adults in the form of a palpable articular tumour. The muscle wasting in the quadriceps is out of proportion with the clinical signs and should lead one to suspect the diagnosis. Lengthening of the limb on the side of the lesion by arterio-venous shunt is not rare. Histologically, hemangioma is a vascular tumour and there is the same difficulty in classification as for all vascular tumours. Synovectomy removing the tumour is the operation of choice. Relapse is possible leading to total removal of the synovial membrane. Complementary radiotherapy does not have a clearly defined place in treatment.