Radioscapholunate arthrodesis versus radiolunate arthrodesis in rheumatoid wrist surgery: Clinical and radiographic outcomes.

Radiolunate arthrodesis is a validated surgical technique in rheumatoid wrist surgery. When the radioscaphoid joint is involved or when there is radiolunate instability, a radioscapholunate arthrodesis must be preferred. The objective was to compare clinical and radiographic outcomes for both types of arthrodesis. Patients were evaluated retrospectively at a minimal follow-up of 12 months after radiolunate arthrodesis (RL-A group) or radioscapholunate arthrodesis (RSL-A group). Mean follow-up was 10.7 years (1-25 years). One hundred and one patients were included in RL-A group and 26 in RSL-A group. At follow-up, pain level was significantly reduced by 3.7 points and by 2.9 points in RL-A and RSL-A groups, respectively. Mobility in flexion/extension was significantly reduced by 25° in both groups. DASH and PRWE scores were 42.9 and 41.4 in RL-A group, 41.8 and 20.6 in RSL-A group, respectively. Larsen stage for the midcarpal joint increased significantly in both groups (+0.8 in RL-A group; +0.9 in RSL-A group), carpal height index decreased (-0.03 in RL-A group (significant); -0.02 in RSL-A group (non-significant)), carpal ulnar translation index increased (+0.038 in RL-A group; +0.037 in RSL-A group), without significant difference between both groups. Nonunion rate was significantly higher in RSL-A group (62%) than in RL-A group (30%). A pain free and functional wrist can be obtained after radiolunate and radioscapholunate arthrodesis. However, arthritis lesions and carpal deformities increased with follow-up similarly with both surgical techniques. Our results have shown that radiolunate arthrodesis remains a reliable surgical procedure for advanced rheumatoid wrist.

Results with a minimum of 10 years follow-up of the Coonrad/Morrey total elbow arthroplasty.

INTRODUCTION: Few series have evaluated the long-term results of total elbow arthroplasty (TEA). MATERIALS AND METHODS: Fifteen patients with a Coonrad/Morrey total elbow implant were reviewed with a minimum follow-up of 10 years. There were nine women and six men with a mean age of 55 years at surgery. The aetiology was rheumatoid arthritis in eight cases, post-traumatic arthritis in five, psoriatic arthritis in one, and sequelae of neonatal septic arthritis in one. The TEA was performed as primary surgery in ten cases and during a revision surgery in four. RESULTS: At 136 months average follow-up (120-160), MEPS was 82 ± 14 points (range 60-100) with a Quick DASH score of 41 points (range 13-83). Fourteen patients had no or slight pain and six had a functional range of motion. Elbow function was normal in eight of 15 patients. Radiolucent lines were found around the humerus in six cases (all of them incomplete) and around the ulnar component in eight (five of them complete) with loosening and migration of the ulnar stem occurring in two cases. Wear of the bushings was moderate in five cases and severe in two. There were ten complications with a revision needed in three cases. Revision-free survival rate for the implant was 100% at 5 years and 90% at 10 and 13 years. DISCUSSION: The Coonrad/Morrey total elbow gives long-term satisfactory results. Increased incidence of radiolucent lines around the ulnar stem and bushing wear with longer follow-up is of concern and represents the failure mode for this total elbow arthroplasty implant. LEVEL OF EVIDENCE: IV.

Outcomes of two surgical revision techniques for recurrent anterior shoulder instability following selective capsular repair.

INTRODUCTION: Conventional capsulolabral reconstruction for anterior shoulder instability fails with recurrent instability in up to 23% of cases. Few studies have evaluated surgical revision strategies and outcomes. The objective of this study was to evaluate clinical and radiographic outcomes in a homogeneous series of surgical revisions after selective capsular repair (SCR). HYPOTHESIS: Observed anatomic lesions can guide the choice between repeat SCR and coracoid transfer (Latarjet procedure). MATERIALS AND METHODS: From January 2005 to January 2009, 11 patients with trauma-related recurrent anterior shoulder instability (episodes of subluxation and/or dislocation) after SCR were included. Mean age was 31 years (range, 19-45 years). At revision, a glenoid bony defect was present in six patients. Repeat SCR was performed in five patients and coracoid transfer in six patients. RESULTS: After a mean follow-up of 40 months (range, 24-65 months), no patient had experienced further episodes of instability. However, four patients had a positive apprehension test. External rotation decreased significantly by more than 20° after both techniques. The Simple Shoulder Test, Walch-Duplay, and Rowe scores were 10.5, 79, and 85, respectively. No patient had a subscapularis tear. Of these 11 patients, nine were able to resume their sporting activities and eight reported being satisfied or very satisfied with the subjective outcome. Radiographs showed fibrous non-union of the coracoid transfer in one patient. CONCLUSION: In patients with recurrent anterior shoulder instability after SCR, repeat SCR and coracoid transfer produce similarly satisfactory outcomes. The size of the glenoid bone defect may be the best criterion for choosing between these two procedures. However, open revision surgery may decrease the range of motion, most notably in external rotation. LEVEL OF EVIDENCE: Level IV.

Long-term outcome of distal ulna resection-stabilisation procedures in post-traumatic radio-ulnar joint disorders.

INTRODUCTION: Distal radius fractures represent 20% of fractures in adults. Although good results are usually obtained with treatment, functional sequelae are not uncommon, with injury of the distal radio-ulnar joint (DRUJ) being the most frequent. Various treatments have been described to address these disorders. Distal ulna resection-stabilisation (DURS) is our technique of choice when preservation of the DRUJ is impossible. PATIENTS AND METHOD: Twenty patients operated between 1985 and 1996 were reviewed with minimum 6-year follow-up. Nine of them were men and 11 were women, with an average age 45 years. The initial trauma was a distal radius fracture in all cases. The main complaint was ulnar pain with no limitation of mobility in five patients, painful limitation of prono-supination in 14, and palmar subluxation of the ulna in one case. Radiographic evaluation and CT scan showed DRUJ incongruence in 14 patients with ulna head instability, and ulno-carpal abutment with degenerative changes at the DRUJ in six cases. In three patients, malunion of the distal radius was associated with degenerative DRUJ lesions. RESULTS: The satisfaction rate was 95% at an average follow-up of 11 years (range 6.7 to 18.6 years). Pain scores decreased progressively from 2.2 to 0.5 post-operatively. Range of motion improved in supination from 37 degrees to 80 degrees , and in pronation from 66 degrees to 84 degrees . Improvements were 15 degrees in ulnar inclination, 9 degrees in radial inclination, 16 degrees in flexion, and 23 degrees in extension. Distal ulna palpation was not painful, and no instability was observed on movement. Wrist strength was equivalent to 80.8% of the healthy contra-lateral side. Radiographic results showed no anomaly of the resected ulna, no sign of abutment on the radius and no ulnar translation of the carpus at follow-up. Only one patient, who presented algoneurodystrophic syndrome after the initial trauma, had a recurrence after DURS. DISCUSSION-CONCLUSION: DRUJ injuries are frequent in the context of wrist trauma. If not well-treated, they could lead to significant functional sequelae of the wrist. Radiographic evaluation should clarify the status of the DRUJ to choose between conservative or radical surgical treatment. If the DRUJ surfaces are preserved, conservative treatment, which consists of correcting the distal radius malunion and stabilising or shortening the ulna, is the treatment of choice. When the DRUJ surfaces are injured, DURS is our treatment of choice. This approach presents a low complication rate and more than 90% of satisfactory results, often with a pain-free wrist, functional range of motion and good strength. However, a rigorous technique, with limited ulna head resection, dorsal capsuloplasty, reconstruction of the extensor retinaculum and dorsal placement of the extensor carpi ulnaris tendon, is a prerequisite for success. LEVEL OF EVIDENCE: Level IV retrospective therapeutic study.

[Total trapeziectomy with suspension and interposition tendinoplasty for trapeziometacarpal osteoarthrisis: results at 6.5 years average follow-up]. / Trapézectomie totale avec tendinoplastie de suspension et d'interposition dans le traitement de la rhizarthrose : résultats à 6,5ans de recul moyen.

OBJECTIVES: Total trapeziectomy remains the main surgical treatment of trapeziometacarpal osteoarthritis. Little has been reported on the long-term results of this technique. We report in this study our experience with our technique of trapeziectomy associated with interposition and suspension tendinoplasty using the abductor pollicis longus tendon with 78 months average follow-up. METHODS: Eighteen patients (22 thumbs) of 62.7 years average age underwent this procedure. According to Dell classification, there were two stage II, five stage III and 15 stage IV. Signs of osteoarthritis of the scaphotrapezoidal joint were associated in 19 cases. RESULTS: At 78 months average follow-up, 73 % of the patients were painfree. Average opposition was 9.4 out of 10 according to Kapandji, the grip strength was equal to 18.5 kg and the key pinch to 4.4 kg. The quick DASH was equal to 20 over 100. Ninety-one percent of the patients were satisfied or very satisfied with the results. Space between scaphoïd and thumb metacarpal was 3.2mm and was down by 27 %. There were only two complications related to a reflex sympathetic dystrophy. DISCUSSION AND CONCLUSION: Trapeziectomy associated with interposition and suspension tendinoplasty gives satisfactory functional results which are maintained with follow-up with high satisfaction rate and low complication rate.

[Traumatic avulsion of the flexor digitorum profundus tendon. Report of 20 cases]. / Avulsion traumatique du fléchisseur profond des doigts. A propos de 20 cas.

Traumatic avulsion of the flexor digitorum profundus tendon or "jersey" finger is uncommon. Twenty patients have been reviewed at an average follow-up of seven years. Patients were seen less than three weeks from trauma in two-thirds of the cases, whereas in one third it was later. Loss of active flexion of the distal interphalangeal joint was the main complaint. Pure avulsions seen less than three weeks from the injury were all reinserted except one (10 out of 11). When the tendon avulsion was associated with a bone fragment (three cases), an osteosynthesis with K-wires was performed. Patients seen more than three weeks from the injury were treated with tendon resection in six, with a capsulodesis in four, and with a palmaris longus tendon graft in one. All reinsertions of the flexor digitorum profundus tendon performed less than three weeks from injury gave satisfactory results but a secondary rupture was observed in two. Satisfactory results were also obtained after avulsion of the tendon associated with bone fracture, but one patient developed osteoarthritis. Three out of five patients operated more than three weeks following the injury with tendon resection had satisfactory results. The patient with a palmaris longus tendon graft obtained an unsatisfactory result.

[Surgical treatment of anterior shoulder instability in rugby players: clinical and radiographic results with minimum five-year follow-up]. / Traitement chirurgical des instabilités antérieures de l'épaule chez les joueurs de rugby : résultats cliniques et radiographiques au recul minimum de cinq ans.

PURPOSE OF THE STUDY: In rugby players, 9 to 11% of injuries involve shoulder trauma. Anterior dislocation is one of the most severe accidents affecting the upper limb; recurrent dislocation, observed in more than 60%, appears to be related to the characteristic mechanism of injury in this sport (tackling). Surgical treatment for this instability is a bone block or capsulolabral repair. The purpose of this work was to evaluate outcome with minimum five-years follow-up after treatment by selective capsule repair in a homogeneous series of rugby players. MATERIAL AND METHODS: Between 1995 and 2001, 31 rugby players were reviewed at mean 82 months (range: 60 to 120 months) follow-up. Sixty-one percent were regional-level players. A tackle was involved in the instability accidents for half of the players. Age at surgery was 21 years (range: 16 to 34), on average 4.44 years (range: 2 to 20) after the instability accident. Signs of capsule hyperlaxity were noted in 16 shoulders (46%). Dislocation was noted in 27 shoulders, subluxation in five. Chronic pain and instability were noted for three shoulders. Disinsertion of the anteroinferior labrum was noted in 23 shoulders (65%) and was repaired with two, three or four anchors. Isolated capsule distension was observed in twelve shoulders. Neer capsuloplasty was performed on 33 shoulders, with complementary labral reinsertion for 21 of them. RESULTS: Ninety-seven percent of the patients were playing rugby again after surgery, the longest delay being one year after the operation. A new episode of instability after major trauma was observed in six shoulders (17%), on average 3.8 years (range: 0.5 to 6) after the operation. Isolated capsule repair had the poorest prognosis (p=0.04). Compared with the contralateral side, external rotation decreased on average 6.2 degrees (elbow to chest) and 3.4 degrees at 90 degrees abduction. Subscapular muscle force decreased on average 2.05 kg. The Rowe and Duplay-Walch scores were good or excellent for 86% and 80% of shoulders, respectively. Patient satisfaction was 88%. According to Samilson, radiographic degeneration was noted in 32% of shoulders, with stage 1 osteoarthritis in 45% and stage 2 in 23%. DISCUSSION: Young age appears to be a major factor, predictive of recurrence after a first instability accident; the type of sport would only be indirectly involved. Nevertheless, for patients playing this type of contact sports, the appropriateness of surgical stabilization can be debated; arthroscopic anatomic methods have not yet yielded results equivalent to open surgery. The results in this series are similar to those found elsewhere in the literature, but with a follow-up longer than generally reported. Anatomic reconstruction of anterior stability elements enables these patients to resume their contact sport at an equivalent level with restored joint motion.

Evaluation of the glenoid implant survival using a biomechanical finite element analysis: influence of the implant design, bone properties, and loading location.

Total shoulder arthroplasty has become a successful surgical procedure through design improvements. However, lucent lines around the glenoid component are of major concern for leading to component loosening. To better understand the mechanism causing loosening, a finite element biomechanical model of an in vivo scapula was developed. The effect of eccentric loading was analyzed on a keel glenoid and a peg glenoid implant. Results indicated that eccentric loading greatly increases stresses in the cement mantle at the bone-cement interface, and no significant difference was predicted between keel and peg implants. The results suggested that eccentric loading is a likely cause for initiation of cracks in the cement layer especially on the posterior side. Moreover, these results, compared with other studies, indicate that geometric and bone properties of the scapula may be more important factors in the success of shoulder arthroplasty than implant design.

[Partial trapezectomy with suspension and interposition tendinoplasty for trapezometacarpal osteoarthritis: 5 years results]. / Trapézectomie partielle avec tendinoplastie de suspension et d'interposition dans le traitement de la rhizarthrose: résultats à cinq ans.

OBJECTIVES: Partial trapezectomy with suspension and interposition tendinoplasty is an alternative to total trapezectomy or trapezometacarpal arthroplasty for the treatment of trapezometacarpal osteoarthritis. This technique preserves the thumb length allowing good motion and satisfactory pollicidigital strength. The purpose of the present study is to report our experience with this procedure reviewing a continuous monocentric series of 41 thumbs with an averaged follow-up of 5 years. Surgical technique, clinical and radiographic results, and indications are discussed. METHODS: Thirty-three patients (41 thumbs) of 57.4 years average age underwent this procedure. According to Dell classification there were 23 stage II, 15 stage III, and 3 stage IV. No sign of osteoarthritis of the scapho-trapezo-trapezoidal joint were noted. Clinical and radiographic evaluations were available for all the patients. Pollicidigital strength was measured with a dynamometer. RESULTS: At 57 months average follow-up, 71% of the patients had no pain. Average opposition was 9.56 out of 10 according to Kapandji, the key pinch was equal to 6.51 kg, and M1M2 space was 34 degrees . Trapezometacarpal space was 2.52 mm on average. There were only 3 complications related to a reflex sympathetic dystrophy. CONCLUSION: Partial trapezectomy with tendinoplasty gives satisfactory functional results which is maintained with follow-up. It allows recovery of a functional pollicidigital strength by limiting thumb shortening. It is a reliable procedure with a low rate of complication indicated for isolated thumb trapezometacarpal joint osteoarthritis without scapho-trapezo-trapezoidal joint involvement.

[Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 14 cases]. / Luxations traumatiques du genou associées à une interruption de l'artère poplitée: étude critique rétrospective d'une série de 14 cas.

PURPOSE OF THE STUDY: Complex femorotibial dislocation of the knee joint generally results from high-energy trauma caused by a traffic or a contact sport accident. Besides disruption of the cruciate ligaments, in 10-25% of patients present concomitant palsy of the common peroneal nerve and more rarely disruption of the popliteal artery. The purpose of this work was to assess outcome in a monocentric consecutive series of knee dislocations with ischemia due to disruption of the popliteal artery and to focus on specific aspects of management. MATERIAL AND METHODS: This retrospective series included eleven men and three women, aged 18 to 74 years (mean 47 years). The right knee was injured in five and the left knee in six. Trauma resulted from a farm accident in six patients, fall from a high level in two, a traffic accident in three and a skiing accident (fall) in one. Two other patients with morbid obesity were fall victims. Nine patients had a single injury, two presented an associated serious head injury, one a severe chest injury, and one multiple trauma with coma, chest contusion, and abdominal lesions. One patient had a fracture of the distal femur with associated ischemia. Five knee dislocations were open with a popliteal wound for three and a posteromedial wound for two. Four patients presented total sciatic nerve palsy and nine palsy of the common peroneal nerve. The dislocation was documented in ten cases: lateral (n=1), anterior (n=4), posterior (n=5). For four patients, the dislocation had been reduced during pre-hospital care. Preoperative arteriography was available for eight patients and confirmed the disruption of the popliteal artery; the diagnosis was obvious in six other patients who were directed immediately to the operative theatre without pre-operative imaging. Revascularization was achieved with a upper popliteal-lower popliteal bypass using an inverted saphenous graft. The graft was harvested from the homolateral greater saphenous vein in eight patients and the contralateral vein in six. On average, limb revascularization was achieved after 10.07 hours ischemia. Intravenous heparin was instituted for 810 days followed by low-molecular-weight heparin. The dislocation was stabilized by a femorotibial fixator in nine patients and a cruropedious cast in five. An incision was made in the anterolateral and posterior leg compartments in twelve patients. A revision procedure was necessary on day one in one patient because of recurrent ischemia; a second bypass using an autologous venous graft was successful. One other 75-year-old patient also presented recurrent ischemia on day five; the bypass was reconstructed but the patient died from multiple injuries. Seven thin skin grafts were used to cover the aponeurotomy surfaces. Mean duration of the external fixator was 3.4 months. The five patients treated with a plaster case were immobilized for 2.7 months on average. Ligament repair was performed in three patients (one lateral reconstruction and one double reconstruction of the central pivot for the two others). A total prosthesis with a rotating hinge was implanted in two patients aged 67 and 74 years after removal of the external fixator at six and seven months. Failure of the ligament repair also led to arthroplasty in a third patient. RESULTS: Blood supply to the lower limb was successfully restored as proven by the renewed coloration of the teguments and-or presence of distal pulses in 13 patients. Transient acute renal failure required dialysis in one patient. Four patients developed pin track discharges and there was one case of septic arthritis of the knee joint which was cured after arthrotomy for wash-out and adapted antibiotics. Outcome was assessed a minimum 18 months follow-up (average 22 months) for the 13 survivors. The three sciatic palsies recovered partially at five and six months in the tibial territory but with persistent paralysis in the territory of the common peroneal nerve. The nine cases of common peroneal nerve palsy noted initially regressed completely or nearly completely in three patients, partially in three and remained unchanged in three. The results were assessed as a function of the final knee procedure: outcome was satisfactory for the patients with a total knee arthroplasty. Outcome of the three ligamentoplasties was good in one, fair in one, and a failure in one (revision arthroplasty). Patients treated by immobilization without a second surgical procedure complained of joint instability with a variable clinical impact; their knee retained active flexion greater than 90 degrees and complete extension. DISCUSSION: An analysis of the literature and the critical review of our clinical experience was conducted to propose a coherent therapeutic attitude for patients presenting this type of trauma. The prevalence of disruption of the popliteal vascular supply in patients with knee dislocation is between 4 and 20%. The rate is closely related to that of injury to nerves and soft tissue. Ischemia should be immediately suspected in all cases of knee dislocation. The pedious and tibial pulses must be carefully noted before and after reduction of the dislocation to determine whether or not there is an organic arterial lesion. If the pulses are absent initially, they should be expected to reappear strong, rapidly and permanently after reduction. Otherwise, arteriography should be performed. Dislocation stretches the artery between two points of relative anchorage in the adductor ring and the soleus arcade to the point of rupture. Repair requires a bypass between the upper popliteal artery and the tibioperoneal trunk using an inverted saphenous graft because the walls are torn over several centimeters. The traumatology and vascular surgical teams must work in concert from the beginning of the surgical work-up in order to establish a coherent operative strategy founded on primary reduction of the dislocation, installation of a fixator and then vascular repair and aponeurotomy incisions. It would be preferable to wait until the bypass is proven patent and wound healing is complete before proposing ligament repair. This should be done after a precise anatomic work-up to assess each ligament lesion. Bony avulsion or simple disinsertion can however be repaired in the emergency setting at the time of the bypass as well as any ligament rupture which is obvious and-or situated on the medial collateral approach. Secondarily, elements of the central pivot can be repaired in young patients with an important functional demand. Arthroplasty is not warranted except in the elderly patient. Dissection of the popliteal fossa or debridement of the wound enables a careful anatomic assessment of the nerve trunks. In the event of a peroneal nerve disruption, it is advisable to fix the nerve ends to avoid retraction. Beyond three months without clinical or electromyography recovery, surgical exploration is indicated. In the event more than 15 cm is lost, there is no hope for a successful graft. Complete knee dislocation is extremely rare. It can be caused by high-energy trauma associated with several ligament ruptures, particularly rupture of the central pivot observed in 10-25% of cases with common peroneal nerve palsy. Compression, contusion or disruption of the popliteal artery is very rarely caused by the displacement of the femur or the tibia. Limb survival may be compromised. Mandatory emergency restoration of blood supply will modify immediate and subsequent surgical strategies. There has not however been any study exclusively devoted to double joint and vascular involvement. Our objective was to present a critical retrospective analysis of a consecutive series of knee dislocations with ischemia due to disruption of the common popliteal artery treated in a single center and to describe the specific features of management strategies for a coherent diagnostic and therapeutic approach.

[Single-plane external fixation of fresh fractures of the femur: critical analysis of 53 cases]. / La fixation externe monoplan dans les fractures récentes du fémur: etude critique d'une série de 53 cas.

PURPOSE OF THE STUDY: External fixation has not been widely used for femoral fractures and few series are reported in the literature. External fixation is generally reserved for severe open fractures, for vessel injury or multiple trauma with life threatening. We present a retrospective analysis of a serie treated in a single center in order to detail the indications of this fixation technique. MATERIAL AND METHODS: From 1984 to Jun 2002, 49 patients with femoral fractures were treated by external fixation. The series included 36 men and 13 women, mean age 31 years. All were victims of high-energy trauma: traffic accident (n = 40), fall from high level (n = 4), firearm wound (n = 5). Multiple fractures were present in all patients except seven and 24 patients had multiple injuries. Forty fractures were open fractures: two type 1, ten type 2, four type 3a, 23 type 3b and five type 3c in the Gustilo classification. Twenty-seven were shaft fractures and 26 involved the distal metaphyseoepiphyseal portion of the femur. Loss of cortical stock was noted in five cases and total loss of a segment in four. Surgery was deferred in 19 patients, mean six days. A single-plane external fixation was used (Orthofix) with a femorofemoral frontolatateral assembly. Transepiphyseal screw fixation was also used to stabilize the distal fracture in eleven cases. RESULTS: One patient with a bifocal fracture of the femur died from head trauma. Three patients required above knee amputation after failure of a vessel bypass or due to septic necrosis of the reconstruction flap. Five patients required a second reduction within days of external fixation. On the AP view, femoral alignment was successfully reestablished at +/- 5 degrees in 45 cases, ranged from 5 degrees to 10 degrees in seven and was greater than 10 degrees in one. On the lateral view, alignment was between 5 degrees and 10 degrees in 42 cases and greater than 10 degrees in one. Femur length was equal to the healthy side in 23 cases, and was shortened 1-2 cm in 26. Four metaphyseal fractures resulted in a 3 cm shortening. Bone healing time was available for 42 patients (1 death, 3 amputations, 3 lost to follow-up). Elective conversion to internal fixation was performed in ten patients (five lateral cortical plates and five centromedullary nailings). These patients all achieved first-intention bone healing with a mean time of 7.4 months. Exclusive external fixation was planned for 34 fractures. First-intention healing was achieved in 25 (17 shaft and 8 distal) without bone graft with an average time of 7.3 months. Ten patients had one or more osteitis foci on pin tracts. Two patients in this group developed recurrent fracture after removal of the external fixator. Nine fractures did not heal and required revision with centromedullary nailing (n = 5) or plate fixation with autograft (n = 4). Nailings for nonunion were successful but plate fixation was compromised by infection in one patient and recurrent fracture after plate removal in another. Fourteen patients underwent joint mobilization under general anesthesia and 14 had open arthrolysis. Mean follow-up was 2.8 years. Mean active flexion was 90 degrees (30-130 degrees). Ten patients exhibited flexion between 30 degrees and 60 degrees and 19 between 70 degrees and 100 degrees. Knee flexion was greater than 110 degrees in 15 patients. Residual 10 degrees flexion was noted in six knees. Mean leg length discrepancy was 0.4 +/- 0.6 after distal fracture and 0.8 +/- 1.3 after diaphyseal fracture. DISCUSSION: The indications and results of external fixation in this series are in line with reports in the literature. For diaphyseal fractures, healing is long and difficult, partly because of the insufficient mechanical properties of external fixation. The rate of infection and stiff knee is high, particularly for distal fractures of the femur. CONCLUSION: External fixation remains the only solution to stabilize certain open diaphyseal fractures or for patients with life-threatening multiple injuries. This techniques allows control of the other traumatic lesions while waiting for internal fixation. For fractures of the distal femur, external fixation can only be advocated for metaphyseodiaphyseal fractures with an intact or reconstructed epiphyseal portion.

[Segmental tibia fractures: a critical retrospective analysis of 49 cases]. / Fractures bifocales de jambe. Etude critique d'une série de 49 cas.

PURPOSE OF THE STUDY: Segmental tibia fracture is defined by the presence of two distinct fracture lines separating the cortical and completely isolating an intermediary segment of the tibia. Little work has been published on this clinical entity. We report a retrospective analysis of 49 patients treated in one center for segmental tibia fracture in order to determine more precisely the indications for three surgical techniques: locked intramedullary nailing with or without reaming, and external fixation. MATERIAL AND METHODS: The series included 34 men and 15 women, mean age 40.8 years. All patients had traffic accident: 25 had multiple fractures, 17 had multiple organ injury, and 9 had floating knees. There were 30 open fractures; 2 patients developed compartment syndrome. The segments were: distal-proximal metaphyso-metaphyseal (n=1), proximal diaphyso-metaphyseal (n=17), diaphyso-diaphyseal (n=27), and distal diaphyso-metaphyseal (n=4). The mean length of the intermediary segment was 14.1 cm. The emergency procedure involved intramedullary nailing with reaming (Grosse-Kempf nail) in 32 patients, intramedullary nailing without reaming in 7 patients (Collin nail in 5 and UTN in 2) and external fixation with non-transfixing pins in 10 patients (Orthofix). External fixation was converted early to intramedullary nailing in three patients (Grosse-Kempf nail in 2 and Collin nail in 1). RESULTS: Three patients were excluded: 2 underwent amputation after failure of vessel repair and 1 developed septic necrosis of a free latissimus dorsi flap; 1 patient died from multiple organ failure. Outcome at at least 18 months was known for 42 patients (4 patients lost to follow-up). There were 4 cases of post-nailing compartment syndrome; one case of deep infection on a Grosse-Kempf nail was treated by external fixation. Among the 27 patients with segment tibia fractures finally stabilized with a Grosse-Kempf nail, nonunion developed in 8; mean time to bone healing was 10 +/- 4.8 months (with dynamization in 13 patients). For the 7 external fixations, nonunion developed in 2; mean time to bone healing was 9.2 +/- 2.9 months. For the 8 nailings without reaming, nonunion developed in 2; mean time to bone healing was 9.5 +/- 2.5 months. Bone healing was not simultaneous in the two foci in more than half of patients. Two patients developed clinical sequelae of their compartment syndrome with deficient knee flexion in two. The 12 cases of aseptic nonunion were successfully treated by nailing with reaming and early weight bearing. DISCUSSION: Comparing our results with the therapeutic modalities used in published reports on segmentary tibia fractures showed that time to bone healing and the rate of nonunion were generally greater than in our series. A critical analysis of these results allows us to propose a more interventionalistic attitude before the development of late healing. We also propose a classification of segmental tibia fractures and a decisional tree for choosing between the three techniques based on the presence of soft tissue damage, the presence of compartment syndrome (nailing without reaming), and the presence of proximal or distal metaphyseal fractures (distal locked nail). Nailing with moderate reaming remains the preferred method.

[GUEPAR I total elbow arthroplasty in rheumatoid arthritis: 19 implants followed an average of 67 months]. / Prothèse totale de coude GUEPAR I dans la polyarthrite rhumatoïde: 19 cas avec un recul moyen de 67 mois.

INTRODUCTION: The GUEPAR I total elbow arthroplasty is a nonconstrained implant used since 1985. Only one multicenter study has reported the mid-term results of this implant in rheumatoid arthritis. We presented a monocentric retrospective study evaluating the results of 19 GUEPAR I total elbow arthroplasty in rheumatoid arthritis with a mean follow-up of 67 months. MATERIALS AND METHODS: Between 1988 and 1996, 19 GUEPAR I total elbow arthroplasties have been performed on 16 patients (3 bilateral). There were 15 women and one man, averaged age 58 years. Radiographically, the elbow was classified as stage IIIA in 8 cases, and stage IIIB in 11 cases, according to the Mayo Clinic classification. A triceps splitting approach with tendon reflection was performed in all cases. A postoperative immobilization at 45 degrees extension was used for all patients during 21 days averaged, and active mobilization was then started. RESULTS: At 67 months averaged follow-up (range, 2 to 12 years) the Mayo Elbow score improved from 36 to 75 points. The overall results were considered as excellent for 8, good for 5, fair for 2, and poor for 4. Nine elbows were totally painfree and six had minimum pain. Postoperative arc of motion reached 36 to 126 degrees in extension-flexion and 147 degrees in rotation. Eleven out of 19 elbows had a normal functional score. Two elbows dislocated and two others had a valgus instability lower than 10 degrees. There were thirteen complications affecting 11 of the 19 elbows (68%), and six of these eleven elbows had a revision procedure (31%): 3 peroperative medial column fractures, one postoperative medial column fracture which has been fixed, two elbow dislocated with one ulnar component revision, and 3 loosed implants which has been revised. There were persistent ulnar paresthesiae in two cases with a secondary neurolysis performed in one. Finally two infections developed 6 years after the initial procedure, one superficial, and one deep, which lead to removal of the total elbow arthroplasty. DISCUSSION-CONCLUSION: The GUEPAR I total elbow arthroplasty is a nonconstrained implant indicated essentially in rheumatoid arthritis. Without intrinsic stability this implant must be contraindicated in front of bone stock deficiency, or chronic instability of the elbow. In selected cases the GUEPAR I total elbow arthroplasty offers a painfree elbow with a functional range of motion.

[Chronic anterior shoulder dislocation treated by open reduction sparing the humeral head]. / Luxations antérieures invétérées de l'épaule traitées par réduction sanglante avec conservation de la tête humérale.

PURPOSE OF THE STUDY: Treatment options for unreduced anterior dislocation of the shoulder have varied from nonoperative treatment to different surgical options. Little has been written in the literature on the management of unreduced anterior dislocation or on the results of the different procedures. We report our experience and present the outcome after an open reduction joint-saving procedure used in five patients. MATERIAL AND METHODS: Five patients, mean age 39 years (range 17-69 years) underwent the joint-saving procedure for chronic anterior shoulder dislocation. Pain was predominant for two patients and functional impairment for three. The shoulder had been anteriorly dislocated for six weeks to up to 36 months (average 14 months). Open reduction was performed in all cases with reinsertion of the capsulo-labral complex onto the anterior glenoid rim. A bone graft was used in one patient to reconstruct an anterior glenoid bone defect involving more than half of the joint surface. No graft was used to fill the humeral head defect. RESULTS: At an average follow-up of 25 months (range 12-36 months), outcome was excellent in one patient, good in three, and poor in one (Rowe and Zarins score). Postoperatively, the overall score averaged 75 points (range 40-90). Pain score improved from 12 to 27 points. Three shoulders were totally pain free and two had mild to moderate pain. Motion improved from 12 to 28 points. Anterior active elevation averaged 126 degrees, external active rotation 17 degrees, and internal active rotation to the level of the first lumbar vertebral body. Functional score improved from 9 to 20 points. All the patients were able to perform daily living activities. The radiographic evaluation showed anterior subluxation of one shoulder one year after surgery. Osteoarthritis was also noted in one patient. No peroperative or postoperative complication was seen. DISCUSSION: Unreduced anterior shoulder dislocation should be treated with an open reduction and reconstruction of the specific lesions, unless the patient is old or debilitated. This operation can however be difficult and requires extensive soft tissue release, and occasionally use of a bone graft to reconstruct the anterior defect of the glenoid. The long-term results remain modest. When the humeral head cannot be saved because of extensive osteochondral lesions, shoulder arthroplasty must be the treatment of choice.

[Mid-term results of shoulder arthroplasty for primary osteoarthritis]. / Résultats à moyen terme de la prothèse d'épaule dans l'omarthrose primitive.

INTRODUCTION: Primary osteoarthritis of the glenohumeral joint is less common than that of the hip and knee, but it is not so rare. The use of prosthetic arthroplasty for the management of end-stage osteoarthritis remains the treatment of choice. We reviewed our experience of shoulder arthroplasties in 48 patients (51 shoulders) with 60 months average follow-up (24-124). MATERIALS AND METHODS: Forty-eight patients (51 shoulders) underwent shoulder replacement for primary osteoarthritis. There were 15 men and 36 women. Average age was 65 years. A total shoulder arthroplasty was performed in 43, and a hemiarthroplasty in 8. A Neer II monobloc implant was used in 27, and a modular implant in 24. The humeral implant was cemented in all cases but 3. An all-polyethylene cemented glenoid implant was used in all total shoulder arthroplasties. A rotator cuff tear was found in 8 cases. RESULTS: According to Neer rating scale, an excellent result was found in 19 cases (37%), a satisfactory result in 27 (53%), and a non-satisfactory result in 5 (10%). According to Constant's criteriae, pain improved from 1.5 to 12 points, activity from 7 to 16.5 points, and mobility from 14 to 31 points. Active anterior elevation improved from 73 to 140 degrees, with a gain of 67 degrees; active external rotation improved from 9 to 40 degrees, with a gain of 31 degrees. Internal rotation improved also from the ability of the thumb to reach the sacrum to T12. The ponderated Constant score calculated for 22 patients was 91 p.cent. Radiographic analysis showed lucent lines around the humeral component in 10 cases (19%), and around the glenoid in 29 cases (67%). A complete lucent line not greater than 1mm size, was present in only 15 glenoid implants (35%). There was no case of component loosening in our series at the longest follow-up, as well as no revision procedure. Only the preoperative rotator cuff status influenced statistically the final result. Best results were obtained with total shoulder arthroplasties compared to hemiarthroplasty, and with modular implants compared to monobloc. DISCUSSION: Shoulder arthroplasty has become the standard for the treatment of primary osteoarthritis. Proximal humeral head prosthetic replacement can be a very successful procedure in patients with glenohumeral arthritis; however the degree and consistency of pain relief is not as great nor as predictable as in total shoulder arthroplasties. Also, clinical results seem to deteriorate with time. Revision rate is approximatively of 20%, usually for persistant pain. The clinical results of total shoulder arthroplasty continue to be excellent with longer follow-up period. The frequency of complications and the need for revision is low. However, when revision surgery is needed, the most common reason is for glenoid loosening. Good results can be expected especially in primary osteoarthritis with pain relief in almost all cases, good motion (three-fourths or four-fifths normal), improvement of functional activities, and patient satisfaction in at least 90% of the cases.

[Tibial valgus osteotomy using a tricalcium phosphate medial wedge: a minimally invasive technique]. / Ostéotomie tibiale de valgisation par addition médiale d'un coin de phosphate tricalcique: technique dite mini invasive.

PURPOSE OF THE STUDY: We present a minimally invasive technique for tibial valgus osteotomy using a medial wedge composed of tricalcium phosphate. MATERIAL AND METHODS: The bone substitute is composed of slowly resorbable tricalcium phosphate material shaped to the desired form and having mechanical properties allowing stable osteotomy via a short incision and staple fixation. Intraoperative fluoroscopy enables a reliable and reproducible technique. A lateral fixation staple is required because there is a risk the lateral hinge could break. This technique was used for 58 knees in 55 patients (mean age 47 years). According to the Ahlback classification of femorotibial degeneration, there were 43 grade I knees, 12 grade II, and 3 grade III. RESULTS: The implant was well tolerated in all cases. Bone healing was achieved in most cases without loss of the osteotomy angle. Complications were: rupture of the lateral hinge in four cases leading to nonunion in one, one low-grade infection. Implant resorption at mid term was significant: among the 22 patients with a follow-up of more than 5 years, the implant was barely visible in 18. DISCUSSION: This technique provides an easy way to achieve tibial valgus osteotomy without compromising future intervention. The technique can be considered to be minimally invasive because of the size of the incision, the minimal fixation required, and the bone sparing effect of the bone substitute.

[Rupture of the radial collateral ligament of the fifth metacarpopharyngeal joint. A case report with Stener effect]. / Rupture du ligament latéral radial de l'articulation métacarpophalangienne du Ve doigt. A propos d'un cas avec effet Stener.

We report a case of complete rupture of the radial collateral ligament of the fifth metacarpophalangeal joint. At surgical exploration, a Stener like lesion was identified in which the ruptured and of the ligament was trapped by the proximal portion of the extensor hood and sagittal band; thus reattachment to its original site (the base of proximal phalanx) was performed. Postoperative care consisted of protected active motion exercises which were begun immediately. An early functional recovery was obtained with full range of motion, normal joint stability and complete pain relief. The purpose of this study was to present an uncommon injury and to analyse the literature.

[Painful or unstable shoulder after coracoid transfer: result of surgical treatment]. / Epaule douloureuse ou instable après butée coracoïdienne: résultat du traitement chirurgical.

INTRODUCTION: The purpose of this study was to investigate the results of revision surgery for complications related to previous coracoïd transfer for recurrent anterior instability of the shoulder. MATERIALS AND METHODS: Seventeen patients with previous surgery for anterior shoulder instability underwent a new surgical procedure, because of recurrent instability in 10, and painful shoulder with limitation of motion in 7. A soft tissue procedure (Bankart and/or capsuloplasty) was performed in the 10 unstable shoulders, and a joint debridement with removal of the coracoid transfer in the 7 painful shoulders. The subscapularis was found to be normal in only 2 cases, fibrotic in 11, thin in 3, and teared in 1. The interval between the initial procedure and the revision surgery was eleven years on average. RESULTS: At an average of 21 months follow-up, the patients were evaluated according to the Duplay scoring system. A radiographic analysis was also performed for all the patients, and a CT-examination for fourteen. The results were good or excellent for 11 patients (70% in the soft tissue procedure group, and 57% in the debridement group with removal of the coracoid transfer), fair for 4, and poor for 2. Clinical evaluation of the subscapularis showed a lag of muscle function in 10 patients. Strength in internal rotation was 3.3 kg lesser in the operated shoulder compared to the opposite side. CT-examination showed that 4 patients presented a significantly fatty degeneration of the subscapularis. Finally on radiographic examination, osteoarthritis was present in 9 patients.The most important preoperative factor that affected the final results was the number of previous surgical procedures. DISCUSSION: Recurrent instability, problems related to the bone graft or ostheosynthesis material, osteoarthritis, and neurological damage can complicate a coracoid transfer procedure. Our study shows that this procedure can also induce irreversible damage to the subscapularis muscle. CONCLUSION: Revision surgery for complications related to coracoid transfer for anterior shoulder instability is a challenging procedure. Only 2/3 of patients achieved excellent or satisfactory results. Patients with recurrent instability had better results than those with painful impingement and or osteoarthritis. The high rate of late osteoarthritis and irreversible damage of the subscapularis muscle remain sources of concern.

[Femoral shaft fractures in the elderly treated by intramedullary nailing]. / Fractures diaphysaires fémorales au-delà de 70 ans.

PURPOSE OF THE STUDY: Little work has been devoted to femoral shaft fractures in the elderly, contrasting with the data available for proximal neck or trochanteric fractures. The purpose of this study was to determine the epidemiological and clinical features of femoral shaft fractures in the elderly from a retrospective series of 58 patients who underwent locked intramedullary nailing procedures with Grosse and Kempf (GK) or long gamma (GL) nails. MATERIAL AND METHODS: The series included 38 women and 20 men, mean age 83.6 years, who suffered a fracture of the femoral diaphysis due to a fall at home (49 fractures), a traffic accident (8 fractures) or a high-energy fall (1 fracture). Prior to the fracture, 10 patients had homolateral osteoarthritis and two had a contralateral hip arthroplasty. Twenty-six patients were in very good health, 19 had a history of cardiovascular disease, 9 had diabetes and 12 suffered parkinsonian syndromes or dementia. The ASA score was I in 24, II in 23 and III in 11. The diaphyseal fracture was isolated in 31 cases and associated with trochanteric involvement in 27. The upper third of the femur was involved in 37 cases, the middle third in 7 and the lower third in 14. Generally there was a simple spiroid subtrochanteric fracture line (36 cases), or a torsion wedge with or without a proximal extension. Mean delay to surgery was 1.9 days. Subtrochanteric fractures with a proximal line were stabilized with a GL (34 nails) and diaphyseal fractures with a GK (24 nails). Mean duration of the procedure was 1.9 for GL and 2 hours for GK. In 22 cases (17 GL and 5 GK), a minimally invasive access was needed to achieve reduction or stabilization during reaming and insertion of complementary fixation (3 screw fixations, 7 cerclages). RESULTS: Six patients died before six months, 4 during the initial hospitalization. Twenty patients experienced general complications: 7 cases of phlebitis and 5 "end-of-life" syndromes. Infection occurred in 3 cases including one septic arthritis leading to a bedridden situation. A new fracture beyond the ends of the implant occurred in 2 others. The upright position was achieved within 31 days and total weight bearing within 69 days. Bone fusion was achieved at 4 months (mean). Six patients died between 6 and 12 months, giving a 20.6% mortality at 1 year. Clinical outcome at 12 months was available for 42 living patients: 21 were walking without assistance, 7 used a cane, 8 required crutches or another assistance device and 6 were bedridden. DISCUSSION: The general and functional prognosis of femoral shaft fractures in the elderly is the same as for proximal fractures. These diaphyseal fractures can be individualized due to their characteristic mechanical and anatomic features: composite fracture with a rotation element involving the distal portion of the trochanter and the proximal quarter of the diaphysis. Several types of ostheosynthesis have been proposed for fixation. Locked intramedullary nailing has been found to be effective despite the difficulty in reduction, especially for particularly proximal fractures. There is a risk of iterative fracture in the transition zones between the femoral component and the osteoporotic bone.