Dorsally displaced distal radius fractures: comparative study of Py's and Kapandji's techniques.

INTRODUCTION: Within the framework of a regional clinical study, the radiographic results of Py's and Kapandji's fixation techniques for dorsally displaced distal radius fractures were compared. PATIENTS AND METHODS: A prospective randomised monocenter and multi-operator study (phase III clinical trial) comparing the Py's (isoelastic pinning) and Kapandji's (intrafocal pinning) techniques was conducted. Two comparable groups were established: the Py (P) and Kapandji (K) groups. The frontal radial tilt (FRT), sagittal radial tilt (SRT), radial length and ulnar variance were measured. Analysis of subjective and objective function was based on the range of motion according to six parameters, the DASH and Jakim scoring systems. The quality of anatomical restoration was assessed arthroscopically during pin removal at 6 postoperative weeks. RESULTS: Ninety-seven patients were included in the study with a follow-up period of 1 year. The preoperative FRT was 15.17° and SRT was -19.2°. At one-year follow-up, the FRT was 25.5° in the PY group and 22.6° in the K group (p=0.009), the SRT was 10.5° in the PY group and 6.7° in the K group (p=0.04). For fractures with postero-medial fragment and Gerard Marchand's fractures, the DASH score at last follow-up was 22 in the Py group, 42 and 32 respectively in the K group. The Jakim score was 71 in the PY group and 58 in the K group (p=0.03) for fractures with postero-medial fragment. There was no report of tendon rupture in our study. DISCUSSION: Besides the good results achieved with both pinning techniques in the treatment of distal radius fractures, this series also underlines the importance to adapt the type of fixation to the fracture pattern and patient. CONCLUSION: Pinning for treating dorsally displaced distal radius fractures appears a suitable option provided that the indications and the surgical technique for each method are respected. However, pinning is not suitable for all types of fractures. LEVEL OF EVIDENCE: Level II. Randomised prospective therapeutic study.

[Arthroscopic assessment of articular fractures of distal radius osteosyntheses by percutaneous pins]. / Bilan arthroscopique des fractures articulaires du radius distal ostéosynthésées par des techniques d'embrochage percutanée.

OBJECTIVES: We studied the radiological results of percutaneous pinning in articular fractures of the distal radius. We did not, thereby, have a method of direct ligamentous and articular assessment. We realized an anatomical arthroscopic assessment at six weeks of osteosynthesis of wrists. The purpose was to study the correlation between the presence of anatomical lesions and the functional result. METHODS: Thirty-five patients presenting an articular fracture with posterior displacement were included; 30 women and five men. The mean age was 62 years. All the patients were right -handed and this was the fractured side in 18 patients. The patients had clinical and radiological follow-up at three, six, 12 weeks and one year. Surgical techniques were Py or Kapandji pinning. An arthroscopy of the wrist was carried out at six weeks from the fixation at pin removal. An assessment of ligamentous lesions and quality of articular reduction was performed. RESULTS: Twenty-eight per cent of the patients had ligamentous lesions. Nine patients presented an interfragmentary distance greater than 1mm. Two patients had an articular step as high as 2mm. CONCLUSIONS: Clinical examination did not show any correlation between the anatomical imperfections noted at the time of arthroscopy and the function of the wrist at one year postoperative, regardless of the technique used.

The Valenti technique in the treatment of hallux rigidus.

INTRODUCTION: Metatarsophalangeal joint osteoarthritis of the great toe (hallux rigidus) is a frequent condition for which numerous surgical techniques have been proposed. The most used ones are cheilectomy and arthrodesis. The objectives of this retrospective study are to present the midterm results of the Valenti procedure and to compare these results with those from other recognized surgical techniques. MATERIALS AND METHODS: We conducted a retrospective analysis of a continuous group of 32 patients (41 cases) presenting hallux rigidus and treated using the Valenti technique from November 1999 to July 2004. The mean age of these patients at the time of surgery was 57 years. Forty-one percent of these patients also presented a static disorder of the foot. One or several additional procedures were undertaken, at the time of surgery, in 24% of these cases. Patients were assessed using the AOFAS score completed by the walking distance test, the gait test, the tiptoe test and self-evaluation of patient satisfaction. The radiographic work-up before surgery and at follow-up showed the progression of the joint space changes and allowed us to evaluate plantar subluxation at the base of the first phalanx under the metatarsal head. RESULTS: Twenty-four patients (32 cases) were reviewed and evaluated with a mean follow-up of 5.5 years. Two cases of reflex sympathetic dystrophy were observed as complications. The mean final score was 81 out of 100 from a preoperative score of 47 out of 100. Pain was absent or only occasional in 94% of the cases. Discomfort wearing shoes was absent or moderate in 91% of the cases. Joint range of movement was greater than 30 degrees in 72% of the cases and the toes were stable. Walking distance was unlimited in 79% of the cases. A mean 30% plantar subluxation at the base of the first phalanx was noted at follow-up, with no clinical consequence. The results were comparable irrelevantly of the hallux rigidus grade being treated. DISCUSSION: The numerous techniques proposed achieve comparable results both in terms of pain relief and functional result but each one has its own limitations. Only arthroplasties with silastic implants and the Keller technique give less satisfactory results. Arthrodesis remains the first-choice treatment for advanced hallux rigidus but failure is possible in case of technical error or malunion. Cheilectomy, a conservative intervention, is ideal for lesions that are not too advanced or remain limited to the dorsal part of the joint; this conservative option presents generally no specific complications. Prosthetic replacement--with, to date, little long-term experience for total arthroplasty--remains controversial because the results deteriorate over time. The Valenti procedure exposes the patient to a possible risk of metatarsophalangeal joint destabilization if the resection is too great, but this does not impair the final functional outcome. CONCLUSION: The arthrectomy described by Valenti is a highly reproducible intervention. We find it to be a good compromise between mobility and stability, providing good results for all hallux rigidus grades and entailing a low complication rate. LEVEL OF CLINICAL EVIDENCE: Level IV. Therapeutic Study.

[Capitolunate arthrodesis with tension band wire in wrist arthritis: twenty cases with four year follow-up]. / L'arthrodèse capitato-lunaire par hauban dans l'arthrose du poignet: à propos de vingt cas au recul moyen de 4 ans.

PURPOSE OF THE STUDY: Treatment of degenerative osteoarthritis of the wrist is aimed at preserving wrist motion and force while reducing pain. Limitation of the degenerative processes to certain joints raises the possibility of intracarpal arthrodesis, e.g. capitolunate arthrodesis. We present results of this procedure with a tension band wire in patients with arthritic degenerative disease of the wrist. MATERIAL AND METHODS: The series included 20 patients reviewed at mean 47 months. Mean age was 53.5 years. Pain was the main complaint. Wrist force and motion were decreased in all patients. All patients presented osteoarthritic disease of the wrist with preservation of the radiolunate space. The operation consisted in total scaphoidectomy and capitolunate arthrodesis maintained with a tension band wire. Force, pain (Mayo clinic score) and force (Jamar dynamometer) were recorded. The Cooney function score was determined and six patients completed the French Dash questionnaire. Radiolunate and capitolunate angles were noted as well as the index of carpal height measured preoperatively and at last follow-up. RESULTS: Nineteen of the 20 arthrodeses fused. A revision graft was successful for the one nonunion. Pain was the only clinical factor which improved significantly (p<0.0001) in all patients. Lunatum extension (DISI) and capitatum flexion did not have any effect on functional outcome. Sixteen patients resumed their activities at the same level. DISCUSSION: The results of this series are similar to those in the literature concerning four-way arthrodesis. Capitatolunate arthrodesis with partial arthrodesis of the carpus has been proposed for arthritic degeneration of the wrist with a preserved radiolunate space. We prefer this procedure to four-way arthrodesis because useful motion and wrist force are preserved with constant and effective significant pain relief.

[Pertrochanteric fractures: a randomized prospective study comparing dynamic screw plate and intramedullary fixation]. / Comparaison vis-plaque dynamique et ostéosynthèse intra-médullaire antérograde dans les fractures pertrochantériennes: une étude prospective randomisée.

PURPOSE OF THE STUDY: The objective of this study was to compare the dynamic hip screw (Synthes) and intramedullary fixation (Targon PF, Aesculap) for the treatment of pertrochanteric fractures in terms of stability, complications and cost effectiveness. MATERIAL AND METHODS: This prospective randomized study included 60 patients hospitalized in an emergency setting for pertrochanteric fractures between December 2003 and June 2004. All surgeons in our unit participated in the study. Two fixation systems were used: the Targon proximal femoral nail (Aesculap) and the screw-plate dynamic hip screw (Synthes). We noted: patient status (ASA classification), operative data (type of implant, duration), postoperative data (blood loss, radiographic findings, early complications), and outcome (Harris score, time to walking, mortality). All patients were assessed three months after surgery. The series included 60 patients, 14 men (23%) and 46 women (77%). The Targon PF nail was used for 34 patients and the DHS for 26. In the intramedullary fixation group mean age was 81 years (SD = 12.8, range 23-96); it was 82 years (SD 9.8, range 47-97) in the screw-plate group. The AO classification was: intramedullary fixation 31A1 (n = 11), 31A2 (n = 20), 31A3 (n = 3); screw-plate 31A1 (n = 14), 31A2 (n = 11), 31A3 (n = 1). Thirty-one fractures were stable, 29 unstable. Unstable fractures were treated with the Targon PF nail (n = 18) and the DHS screw-plate (n = 11). Stable fractures were treated with the Targon PF nail (n = 15) and the DHS screw-plate (n = 15). RESULTS: Mean operative time was 35 minutes for intramedullary nailing and 42 mintues for screw-plate fixation. Mean blood loss was 410 ml for intramedullary nailing and 325 ml for screw-plate fixation (p = 0.07). Mean hospital stay was the same (11 days) in both groups. At three months, mechanical complications involved migration of the cervical screw outside the femoral head for three Targon PF fixations and for two DHS fixations. Screw migration was favored by fracture instability and presence of osteoporosis. There were two deaths in the intramedullary nailing group and one in the screw-plate group. Time to walking was 20 days on average in the intramedullary nailing group and 25 days in the screw-plate group. The mean Harris hip score was 60 in the intramedullary group and 59 in the screw-plate group. DISCUSSION AND CONCLUSION: Data in the literature report an advantage for intramedullary nailing, particularly a mechanical advantage, for the treatment of pertrochanteric fractures. Our findings show that good results are obtained with the screw-plate fixation using the DHS with less blood loss and at a lower cost.