Risk factors for malunion of distal tibia fractures treated by intramedullary nailing.

BACKGROUND: The treatment of distal tibia fractures (DTF) has historically been a difficult challenge for orthopedic surgeons because of the particular characteristics of this anatomical region. Intra medullary nailing (IMN) remains the best treatment option. However, achieving and maintaining perfect reduction and stable fixation with IMN can be technically challenging due to the large medullary cavity within a short distal fragment. The aim of our study is to determine the risk factors for malunion in DTF treated with IMN. METHODS: It is a retrospective study including DTF treated surgically by IMN in the Orthopedics and Trauma Department at a tertiary hospital over a period of 7 years. The quality of reduction was evaluated by radiological assessment of the antero-posterior (AP) and lateral views of the tibia and ankle at the last follow-up. RESULTS: Our series included 90 patients with an average age of 44.8 years. Sex-ratio was 2.6. Tobacco use was reported in 35.6% of the patients. Diabetes was present in 11.1% of the patients, and 12.2% of them had open fractures. According to the OTA/AO classification, the majority of injuries were classified as type A1 (76.7%). Fibula fractures were present in 86.7% of cases. The mean follow-up was 48 months. Malunion occurred in 13 cases. Based on the univariate analysis, smoking and dynamic fixation were significantly associated with malunion. In the multiple logistic regression analysis, dynamic fixation was found to be a significant factor that increased the risk of malunion by 7.5 times. CONCLUSION: Neither patient demographics nor fracture characteristics were risk factors for malunion. Nevertheless, it should be noted that dynamic nailing must be avoided as it is associated with a higher risk of malunion. Furthermore, one to two medial to lateral distal locking screws provide sufficient stability without the need for additional fibular fixation. TRIAL REGISTRATION: Not applicable.

Comparative study of Iselin's technique for the treatment of Bennett's fracture with large and small fragments.

Objective: The thumb is very exposed to trauma due to its position and function. Fractures of the base of the first metacarpal bone are very frequent in hand traumatology. Most Bennett's fractures are treated surgically. However, the optimal surgical approach is controversial. The aim of this study is to compare the results of closed reduction and percutaneous pinning in the treatment of Bennett's fracture of the base of firsthand metacarpal in fractures with both small and large fragments. Methods: We studied retrospectively the data of 40 patients treated for a Bennett's fracture in the department of orthopaedic and traumatologic surgery between January 2016 and December 2018. The purpose of this study was to compare the functional (pain, grip strength, first web space opening and thumb opposition) and radiological (quality of reduction and arthritic changes) results of the Iselin's technique for the treatment of Bennett's fractures in two groups of patients with large and small bone fragments according to the size of articular surface detached with the antero-medial fragment (superior or inferior to 25%). Results: The average age of the patients was 34 (range = 19-66) years. Males were by far the most affected (90%). We noted 24 cases of large fragment fractures (60%) and 16 cases of small fragment fracture (40%). An excellent overall functional result was found in 68.8% of cases of small fragment fractures versus 50% of cases of large fragment fractures. Radiological results were roughly similar. Conclusion: All surgical techniques aim to restore the articular congruence to the best, maintain the opening of the first web space and obtain a stable and painless trapezo-metacarpal joint. The Iselin's technique is simple, inexpensive and easy to perform even by inexperienced surgeons. It yields satisfactory results in most cases of Bennett's fracture regardless of the size of the fragment.

Place of the reposition flap in the treatment of distal amputations of the fingers.

PURPOSE: Distal finger amputations pose a therapeutic problem with the distal fragment quality. Reimplantation remains the reference treatment for functional and aesthetic recovery of the hand. The interest of this study is to propose the reposition flap as an alternative to different hedging techniques in the proximal stump, in many situations where revascularization is impossible. It consists in osteosynthesis of the bone fragment and its coverage by a pedicled local flap. METHODS: The technique of reposition flap was evaluated retrospectively between 2003 and 2016 through a study of 13 patients compiled in Nabeul orthopedic department. For each patient, the sensitivity, the pulp trophicity, the interphalangeal mobility, the digital length, the appearance of the nail and radiological consolidation were evaluated. RESULTS: The reposition flap keeps more than 80% of the length of p3. This procedure improves nail aesthetics in comparison with the regularizations. There is no significant difference in sensitivity of the pulp or of the mobility of the distal inter-phalangeal (DIP) joint as a function of the technique studied. However there is a significant difference in average test of the Quick Dash (350 against 500 for regularizations). CONCLUSION: The reposition flap seems to be a good alternative to regularization in the context of trans-p3 fingers amputations, in which the distal fragment is not revascularizable. It allows better aesthetic and functional results.

An exceptional location of tuberculous arthritis: The metatarsal phalangeal joint.

Osteoarticular tuberculosis is a rare type of tuberculosis. The spine is the most frequent location, while peripheral locations in the limbs are rare. We report a case of tuberculous osteoarthritis of the metatarsophalangeal joint of the first ray of the foot in a 48-year-old woman. The patient presented with painful swelling of the dorsum of the big toe, insidiously evolving for 6months. Diagnosis was obtained with histological study after surgical biopsy. Antitubercular chemotherapy for 12months promoted healing. Through this clinical case the authors describe the epidemiological, diagnostic features, and treatment of osteoarticular tuberculosis and discuss the causes of delayed diagnosis often encountered in these exceptional locations and differential diagnoses, gout in particular, for this particular case.

Pseudotumoral form of soft-tissue tuberculosis of the wrist.

Tuberculosis is a major public health problem in developing countries. Hand and wrist is a rare localization for extra-pulmonary tuberculosis, a pseudotumoral form of soft tissue tuberculosis of the wrist is exceptional. We report the case of a 45-year-old male presenting with a painful swelling of the dorsal aspect of the right wrist evolving for six months. Clinical study was evoking a ganglion cyst of the wrist. Intraoperatively a pseudotumoral mass with rice bodies was found, suggesting tuberculous tenosynovitis. The histopathological study revealed caseating giant cell granulomas with epithelioid cells. Cultures on Löwenstein-Jensen medium detected Mycobacterium tuberculosis. Synovectomy with removal of all the rice bodies followed by anti-tuberculous chemotherapy provided uneventful recovery.

Pseudotumoral form of soft tissue tuberculosis of the hand: six cases.

Musculoskeletal involvement is not uncommon in extra-pulmonary tuberculosis, but the localization in the soft tissue of the hand is very rare. Diagnosis is much more difficult because of the atypical location and non-specific symptoms. We report 6 cases of pseudotumoral form of soft tissue tuberculosis of the hand treated in our department during the past 12 years. The mean age of the patients was 51 years with extremes of 44 and 63 years. A marked female predominance was observed (sex ratio = 0.2). All patients presented with swelling of the finger, two of which were painful swelling. All long fingers were involved; the thumb was involved in two cases. The histological study after excisional biopsy revealed caseating giant cell granulomas with epitheloid cells confirming the diagnosis. Antibacillary chemotherapy promoted healing and good outcome in our patients.

Carpal tunnel syndrome caused by lipoma: a case report.

Lipoma is a relatively frequent, benign soft-tissue tumor rarely located in the hand. A lipoma of the hand causing a carpal tunnel syndrome by compression of the median nerve is exceptional. We report the case of a 70-year-old female presenting with a carpal tunnel syndrome. A compression of the median nerve by a lipoma was discovered during surgery. Transverse carpal ligament release with lipoma excision and neurolysis of the median nerve were performed. Histopathological study of the resected mass was consistent with a lipoma. Two-month postoperatively, the patient recovered full hand function with entire disappearance of acroparesthesia. Carpal tunnel syndrome caused by space occupying lesions is rare. Diagnosis is difficult, usually based on the clinical study, electrophysiology and magnetic resonance imaging (MRI). Transverse carpal ligament release and excision of lipoma provides excellent functional recovery.

[Pseudotumoral villonodular synovitis : a case report]. / La synovite villonodulaire pseudotumorale : à propos d'un cas.

BACKGROUND: Pseudotumoral pigmented villonodular synovitis is rare and diagnosis is difficult. AIM: Report of new case. CASE: We report an original observation of a pseudotumoral pigmented villonodular synovitis occurred in a 28 years old patient with no recurrence after surgical treatment. A review of the literature was made in order to precise the epidemiological, diagnostic and therapeutic characteristics.

Technique and indications of elbow arthroscopy. A twelve-cases report.

AIM: Describe the technique of the elbow arthroscopy and discuss their indications through a series of 12 cases and a review of the literature. METHODS: We report a retrospective study of a short series of 12 cases of elbow arthroscopy performed on 4 years. The indications of this technique were loose bodies in 7 cases, parcellar displaced fracture of radial head in 3 cases, fracture of coronoid process in one case and osseous impingement in one case. RESULTS: We have noted no complications and at a mean follow up of 18 months (6 to 40 months) our results were almost satisfactory. CONCLUSION: Elbow arthroscopy is an effective but delicate technique. Its indications are not frequent. They are dominated by loose bodies.

[Results of unicondylar femoral fractures: a review of 28 patients]. / Resultats des fractures unicondyliennes du femur. Etude rétrospective à propos de 28 observations.

BACKGROUND: Unicondylar femoral fractures are rare. They form a particular entity of the femoral lower extremity fractures. THE PURPOSE of this work was to evaluate the anatomical and functional results of unicondylar femoral fractures on pain, mobility, walking and stability of the knee. METHODS: We reviewed, retrospectively, 28 patients presenting unicondylar femoral fracture. There were 19 men and 9 women, with average age of 54 years (22 - 87 years), victims essentially of domestic accident. The fracture was alone in 65 % of cases. According to Nordin's classification, the fracture was of type I in 3% of cases, type II in 35 % of cases, type III in 20 % of cases and type IV in 42 % of cases. Twenty five patients had a surgical treatment after a median period of 7 days post-accident, 3 patients were treated orthopedically. RESULTS: After 3 years follow up, results were noted according to MEGY's score which takes into account walking, mobility, pain and the stability. Clinically, we noted 26 good and very good results and 2 moderate results. Anatomically, we obtained 75 % of satisfactory reductions. CONCLUSION: Unicondylar femoral fractures remain rare. It is important to recognize them and to make the exact diagnosis of their type. Surgical treatment exposes old subjects to risk of dismantling anatomical osteosynthesis because of osteoporoses.

[Fracture of the radial head: the role of excision]. / Fractures de la tête radiale : place de la résection.

AIM: We assessed retrospectively forty cases of radial head fractures treated by excision. METHODS: The series is composed of men in 60% of cases and women in 40% of cases. The age of patients ranged from 15 to 68 years with an average of 37 years. According to Duparc classification, the fracture was type II in 20% of cases, type III in 32%, type IV in 42% and type V in 6%. An associated lesion in the same elbow was seen in 50% of cases; elbow dislocation was present in 38% of cases. The average of operative delay was 14 days (0 - 40 days). RESULTS: The functional result was evaluated according to clinical score of Western Orthopaedic society. The results were satisfactory. We have noted a correlation between functional result and associated lesions, the delay of excision and postoperative immobilisation. Valgus ulna and ascension of the radius was minors and well tolerated exceptly in cases of fractures associated to elbow dislocations. CONCLUSION: According to the results, we think that excision of radial head can be proposed essentially for the treatment of isolated radial head fracture.

[Arthroscopy of the shoulder. Technics and indications. About 64 cases]. / L'arthroscopie de l'épaule. Technique et indications. A propos de 64 cas.

Arthroscopic surgery replaced at present more and more conventional articular surgery because its anatomic character, its less morbidity and its more simple post-poerative care. After knee, the shoulder is considere as the articulation witch benefit of the progress of arthroscopic technics. Autors reported their experience in shoulder arthroscopy witch is introduced in the service since 1999. The gol of this study is to describe the technic of the shoulder arthroscopy and to precise its main indications.

Intraligamentous ganglion cyst of the anterior cruciate ligament (about a case).

UNLABELLED: UNKNO WLOGEMENT: Ganglion cysts have been reported in all joints, with varying frequency in location. A few cases have been described concerning ganglia of the anterior cruciate ligament (ACL) particularly intraligamentous cysts. AIM: The aim of the study is to report specific particularities of intraligamentous ganglion cyst of the ACL. CASE: We report a new case of intraligamentous ganglion cyst of the anterior cruciate ligament treated successfully with arthroscopic aspiration followed by partial excision of the cyst wall after MRI examination. The MR findings, clinical features and arthroscopic findings were evaluated comparatively. Diagnosis was confirmed by means of histological study after arthroscopic excision. The cyst was fluid-filled, with low T1-weighted signal intensity and high T2-weighted signal intensity. Pain was the most frequent clinical sign without any history of trauma. Postarthroscopy outcome was painless. Histologic diagnosis corresponded to ganglion cyst. CONCLUSION: An intraligamentous ganglion cyst of the ACL is extremely rare and suggests some diagnostic and therapeutic particularities.

[Diagnosis and treatment of Brodie's abcess in adults: about twenty cases]. / Diagnostic et traitement de l'abces de brodie chez l'adulte: a propos de vingt patients.

BACKGROUND: Brodie's abscess is a bone abscess described as a localized primary purulent collection with sclerotic wall. Since the first report of Sir Benjamin Brodie in 1832, many papers described different clinical and treatment aspects. Pathogeny and therapy still remain not clearly elucidated. AIM: The aim of our study is to describe clinical aspect and to study the result of treatment including surgery and antibiotics. METHODS: Our study is retrospective including 20 patients admitted to the author's institution for isolated bone abscess. The mean age of these patients is 30 years old (14 up to 46 years) with male predominance. Symptoms were chronic including localized pain with no systemic illness. The erythrocyte sedimentation rate was elevated in 2/3 of the cases. Roentegenogram was typical in 18 cases showing metaphysic cyst with sclerotic wall. Tibia was the most involved bone, 14 among 20 cases. Bacteriological study of the abscess pus isolated staphylococcus in 12 cases and pseudomonas in two cases. No organism was identified in the six remaining cases. Histopathological study showed chronic osteomyelitis with granulation including lymphocytes and plasma cells in all cases. Surgery and antibiotics were adequate for treatment in all cases. Our approach consisted in curettage without primary skin closure, cast immobilisation and antibiotics. RESULTS: Our patients were followed up over a median period of six years (8 months to 10 years). Overall, the results of treatment were good and in the long-term the abscess disappeared in all cases without recurrence. The erythrocyte sedimentation rate was normalized in 10 weeks and roentegenologically, the abscess disappeared progressively without osteomyelitis complication. CONCLUSION: According to our study, we believe that surgical treatment based on total excision of the bone collection and the sclerotic wall is the best method of therapy. As a matter of fact, healing was obtained without grafting in all cases and in the long-term follow up, abscess disappeared without recurrence and fistulisation.

[Use of Hoffman external fixation for extra-articular upper metaphysealtibial fractures]. / Traitement des fractures Sous-tuberositaires du tibia par le fixateur externe de Hoffman. A propos de 46 cas.

Treatment of extra-articular upper metaphyseal tibial fractures can be difficult. Orthopedic treatment is frequently complicated by second displacement These fractures are inappropriate for locked intra-medullary nailing because of the shorteness of the proximal extremity. Damages of soft tissues. frequently associated with these factures, expose internal osteosynthesis to many risks. For these reasons, we opted for external fixation. Our study was a retrospective analysis of 46 extra-articular metaphyseal tibial fractures treated by external fixation with Hoffman material. The average follow-up was 24 months. Consolidation was obtained within 4 months in average. Septic complications. inherent to the method were uncommon or minor. Functional results were satisfactory in 84% of cases. So, external fixation with Hoffman material. with particular recommandations, is a promising method for the treatment of extra-articular of proximal metaphyseal tibial fractures.

[Use of radial shortening for Kienbock disease]. / Apport de l'ostéotomie de raccourcissement du radius dans le traitement de la maladie de Kienbock: indications et résultats. A propos de 20 cas.

Kienbock disease is caused by aseptic necrosis of the lunate. The aim of this work is to evaluate the results of the radial shortening procedure for the treatment of stages II. Illa IIb of the disease. We retrospectively reviewed 20 cases of Kienbock disease. This series is composed of 9 men and 11 women. The average age was 32 years. According to Litchman's classification; 17 patients were operate on in stage III (14 IIIa; 311Ib) and 3 patients were operate on in stage III. Average of shortening was: 4 mm. the mean Follow -up was 05 years. Functional results were evaluated according to Michon score. The results were good in 18 cases and poor in 02 cases. Radiologic results were good: Ameliorations were obtained in 3 patients with stage II; 16 stabilizations in 17 patients with stage IIIa and 1 deterioration in 4 patients with stage IIIb. Radial shortening is effective in the treatment of Kienbock disease in wrists that do not have degenerative changes in adjacent carpal joints. Pain, range of motion and strength can be expected to improve but the radiographic aspect of the lunate changes is not likelly to undergo much chance, if any. Osteotomy was effective even in patients who had zero or positive ulnar variance; and an inclination angle of the distal part of the radius.