Does partial tear repair of adjacent tendons improve the outcome of supraspinatus tendonfull-thickness tear reinsertion?

BACKGROUND: Partial tearing of the infraspinatus and/or subscapularis tendon(s) is frequently associated with supraspinatus full-thickness tears. However, limited data regarding its influence on supraspinatus surgical repair is available. PURPOSE: Our aim was to assess the functional and anatomical outcomes of open repair of supraspinatus full-thickness tears combined with adjacent partial tearing, comparatively to a control. METHODS: We retrospectively identified 22 patients (22 shoulders) with a partial tear, most of them being a delamination tear, of the infraspinatus and/or subscapularis tendons associated with a complete detachment of the supraspinatus tendon. Twenty-seven patients (27 shoulders) treated for an isolated complete detachment of the supraspinatus tendon by open repair served as controls. The mean age was 58 years. A proximalized trans-osseous reinsertion of the supraspinatus tendon was combined with a curettage-closure of the delamination tear. Patients were evaluated with standardized MRI at last follow-up. RESULTS: At a mean of 75-month follow-up, the presence of a partial tear of either infraspinatus or subscapularis, or both, did not influence function and healing rates of supraspinatus tendon repair. Conversely to the control, when a retear occurred, the functional score tended to worsen. Preoperatively, fatty muscular degeneration was more pronounced when a partial tear was present. Fatty degeneration worsened regardless of repair healing. CONCLUSION: Open reinsertion of a supraspinatus full-thickness tear associated with a thorough treatment of partial tear of adjacent tendons led to optimal functional and anatomical mid term outcomes. Our results suggest the presence of a partial tear of adjacent tendons could be associated with poorer function in case of supraspinatus tendon re-rupture. LEVEL OF EVIDENCE: Level III case-control study.

Treatment of chronic Achilles tendon rupture by shortening suture and free sural triceps aponeurosis graft.

INTRODUCTION: The Bosworth technique is old but still widely used. It involves problems of precisely determining the length of the Achilles tendon and of a volume effect in the turndown area. HYPOTHESIS: A new reconstruction technique is assessed, based on free sural triceps aponeurosis transfer without turndown, associated to tendon shortening suture. MATERIALS AND METHODS: Twenty-three patients were assessed by AOFAS score and clinical examination (plus MRI in 14 cases) at a mean 24.5 months' follow-up. Mean age was 52.1 years. Mean pre-operative AOFAS score was 63.6/100. RESULTS: Mean postoperative AOFAS score was 96.1. Mean graft length was 7.5 cm. Surgical revision was required for one case of postoperative infection. Twelve patients resumed leisure sports at their previous level by a mean 9.4 ± 2 months; three competitive sportsmen resumed sport at their previous level by a mean 7.6 months. None were dissatisfied or disappointed with their operation. MRI performed at 1 year found increased tendon volume without abnormality in 57% of cases; 43% showed abnormal images. DISCUSSION: Functional results were comparable to literature reports. It can be difficult to determine Achilles length for the Bosworth technique: this is made easier by conserving a fibrous support of a length determined with reference to the healthy side. The technique avoids aponeurosis turndown, and thus avoids the problem of plasty volume effect. The two cases of cutaneous complication occurred in the two most elderly patients, raising the question of the indications for reconstructive surgery in the elderly. The abnormalities found on MRI concerned scar tissue remodeling in patients with good or excellent clinical results. LEVEL OF EVIDENCE: Level IV, retrospective study.

Anterior dislocation of a total hip replacement. Radiographic and CT-scan assessment. Behavior following conservative management.

BACKGROUND: Hip dislocation is one of the most frequent complications of total hip replacement. The direction of dislocation matters. Most dislocations are posterior; anterior dislocation remains rare and its treatment is controversial. STUDY OBJECTIVES: To clinically and radiologically evaluate the outcomes of the conservative (orthopaedic without revision surgery) treatment of anterior hip dislocations after total hip replacement by immobilisation of the hip in 45 degrees flexion, 10 to 20 degrees abduction and neutral rotation (deck chair position). MATERIALS AND METHODS: Between 1997 and 2007, 19 patients (11 women, 7 men), aged between 36 and 89 years old (average age 64.6 years), operated on for hip osteoarthritis using a posterolateral approach, presented with anterior dislocation of their cemented total hip arthroplasty. Instability during extension associated with external rotation was noted at surgery in eight cases. Ten dislocations occurred in the immediate postoperative period (within 48 hours) and nine within an average postoperative delay of 39 days (6-82). After reduction of the dislocation by closed manipulation, the patients were treated by immobilisation in the deck chair position for an average of 2 weeks (10-21 days). Radiological and functional assessment (based on the Merle d'Aubigné score [PMA]) was performed on average at 4 years after surgery. The inclination of the cup in the frontal plane and any lengthening of the operated extremity were measured on an AP pelvic plain film with the patient in the standing position. Cup and femoral stem anteversion were calculated by CT-scan in 16 cases. RESULTS: At the last follow-up, four patients had had recurrent anterior dislocations (one patient had had two dislocations). They were again treated with immobilisation in the deck chair position for two weeks without further recurrence. None of the patients underwent revision surgery on the temporarily unstable operated hip. Thirteen patients had no pain and eleven had an unlimited walking perimeter. The final average PMA score was 16 (12-18). The patients who presented with one or two recurrences had a PMA of 18 in the final follow-up. Six patients presented with at least 5 mm of shortening (average: 10 mm, maximum 25 mm) with one case of 10 mm of lengthening. The average cup inclination angle in frontal plane views was 48 degrees (40-57 degrees). It was more than 50 degrees in seven cases. The average cup anteversion in CT-scan was 30 degrees (14-60 degrees). The average femoral anteversion in CT-scan was 24 degrees (3-52 degrees). A total of 12 implants (eight cups and four femoral stems) had at least 25 degrees excessive anteversion on CT-scan assessment. DISCUSSION, CONCLUSION: Anterior dislocation after total hip replacement is associated with approximately 10 degrees of excessive femoral and acetabular anteversion respectively. Nevertheless, correction of these architectural anomalies is not necessary because immobilisation in the deck chair position for 2 weeks effectively prevents recurrence and results in satisfactory medium-term functional results.

Results of open reduction and cortico-cancellous autograft of intra-articular calcaneal fractures according to Palmer.

OBJECTIVE: To assess the mid term patient outcome after operative treatment of a displaced intra-articular calcaneal fracture using the modified Palmer technique. MATERIALS AND METHODS: Eighteen operatively treated intra-articular fractures of the calcaneus in 16 patients (nine males, seven females) were retrospectively reviewed. The mean age at surgery was 35 years (range, 17-61 years). Two patients had a bilateral fracture. Following Utheza, five fractures (28%) were classified as vertical, three as horizontal (17%) and 10 (55%) as combined. Mean preoperative Böhler angle was -4 degrees (range, -42 to 26 degrees ). An extended lateral approach to the calcaneus was used in each case. A cortical bone autograft was firmly impacted in the subthalamic void after reduction. Stabilization was achieved by two or three axial Kirschner wires and one or two screws inserted in a transverse position. Patients were evaluated at the last follow-up by physical examination and by the functional score described by Kitaoka. Böhler's angle was measured on the immediate postoperative radiographs and at the last follow-up, and compared when possible with the noninjured side. RESULTS: Follow-up ranged from 12 to 38 months (mean, 23 months). One patient required a subtalar arthrodesis for advanced osteoarthritis. One patient experienced reflex sympathetic dystrophy. No skin complication was noted. At the last follow-up evaluation, the mean Kitaoka score was 74 (range, 34-98). The functional score was considered good or excellent in 11 cases (64.7%), fair in three (17.6%), and poor in three (17.6%). The mean Böhler angle was 23.4 degrees (range, 5-40 degrees ) postoperatively and 22.7 degrees (range, 0-38 degrees ) at the last follow-up. A modest loss of correction was observed in four cases. The final Böhler angle was at least 85% compared to the healthy side in 10 cases out of 14 unilateral fractures. The functional score correlated well with restoration of Böhler's angle. DISCUSSION AND CONCLUSION: Operative treatment of intra-articular calcaneal fractures following a modified Palmer technique provided encouraging results, since restoration of Böhler's angle was obtained. The main advantages include an absence of hardware prominence, resulting in an absence of skin complications, and a stable fixation.

[Results of open reduction and cortico-cancellous autograft of intra-articular calcaneal fractures according to Palmer]. / Résultats du traitement des fractures articulaires du calcaneus par relèvement à foyer ouvert et greffe systématique selon la méthode de Palmer. A propos de 18 cas.

OBJECTIVE: To assess the mid-term patient outcome after operative treatment of a displaced intra-articular calcaneal fracture according to Palmer. MATERIALS AND METHODS: Eighteen operatively treated intra-articular fractures of the calcaneus in 16 patients (nine males, seven females) were retrospectively reviewed. Mean age at surgery was 35 years (range, 17-61 years). Two patients had a bilateral fracture. According to Rev Chir Orthop 79 (1993) 49-57, five fractures (28 percent) were classified as vertical, three as horizontal (17 percent), and 10 (55 percent) as combined. Mean preoperative Böhler angle was -4 degrees (range, -42-26 degrees ). An extended lateral approach to the calcaneus was used in each case. A cortical bone autograft was firmly impacted in the sub thalamic void after reduction. Stabilization was achieved by two or three axial Kirschner wires and one or two screw(s) inserted in a transverse position. Patients were evaluated at the last follow-up by physical examination and by the functional score described by Foot Ankle Int 15 (1994) 349-353. Böhler's angle was measured on the immediate postoperative radiographs and at the last follow-up, and compared when possible with the noninjured side. RESULTS: Follow-up ranged from 12 to 38 months (average, 23 months). One patient (one calcaneus) required a subtalar arthrodesis for advanced osteoarthritis. One patient (one calcaneus) experienced reflex sympathetic dystrophy. No skin complication was noted. At the last follow-up evaluation, mean Kitaoka score was 74 (range, 34-98). Functional score was considered good or excellent in 11 cases (64.7 percent), fair in three (17.6 percent) and poor in three (17.6 percent). Mean Böhler angle was 23.4 degrees (range, 5-40 degrees ) postoperatively and 22.7 degrees (range, 0-38 degrees ) at the last follow-up. A modest loss of correction was observed in four cases. Final Böhler angle was at least 85 percent comparatively to the healthy side in 10 cases among 14 unilateral fractures. Functional score correlated well with restoration of Böhler's angle. DISCUSSION AND CONCLUSION: Operative treatment of intra-articular calcaneal fractures according to Palmer provided encouraging results, since restoration of Böhler's angle was obtained. Main advantages include an absence of hardware prominence, resulting in an absence of skin complication, and a stable fixation.

[A prosthetic joint infection caused by Streptococcus pneumoniae: a case report and review of the literature]. / L'infection à pneumocoque sur prothèse. A propos d'un cas et revue de la littérature.

We report a case of hematogenous streptococcus pneumoniae infection of a total knee arthroplasty observed in an 82-year-old woman who initially presented a lung infection. The therapeutic approach was largely dictated by the patient's precarious general status. Arthroscopic washings were associated with adapted antibiotics followed by removal of the prosthesis and replacement with a spacer. The patient declined further intervention so the prosthesis was not reimplanted. Hematogenous infections of joint prostheses are rarely caused by such streptococcal species. Since this is a well known germ, it would be logical to apply the usual rules for treatment of infected prostheses caused by sensitive germs. However, the analysis of the present case and a review of the literature shows that various therapeutic approaches have been used. These infections appear to be more common in seriously ill patients which could explain this variability. Mortality is high. The number of reported cases is too small to propose a specific treatment.

[One-year follow-up of 466 nerve decompressions in 123 lepers during multidrug therapy in Madagascar]. / Résultats à un an de 466 décompressions nerveuses réalisées chez 123 lépreux en cours de polychimiotherapie à Madagascar.

Surgical decompression of nerves in patients with leprosy is a simple procedure that can be used in developing countries. At the leprosy center of Ambatoabo on the east coast of Madagascar, 466 nerve decompressions were performed on 123 subjects and results were evaluated by the same examiner 15 months later. All subjects were undergoing multidrug therapy at the time of the procedure. The decision to perform surgery was based on recent onset of sensory and motor neurologic signs and on progression or persistence of symptoms despite administration of prednisolone. Decompression led to pain relief in 100% of cases and regression of sensory disturbances in 97%. Sensory recovery in the plantar ulcers of the foot was obtained in 80% of cases and motor performance improved in 61%. These favorable results confirm the value of surgical decompression to prevent sequels of leprosy and the feasibility of this procedure in remote areas.

[Results of 466 nerve decompressions in 123 leprosy patients during polychemotherapy with a minimum follow-up of one year. Value of preventive surgery in a leprosy control program]. / Résultats de 466 décompressions nerveuses chez 123 lépreux en cours de polychimiothérapie avec un recul minimum de un an. Intérêt de la chirurgie préventive dans un programme de lutte contre la lèpre.

The clinical expression of leprosy is primarily cutaneous but its serious neurologic manifestations are maiming. Mutilations mainly of limb ends are due to peripheric nerves compression and may appear before or during the clinical treatment of the illness. Their appearance which is not automatically related to multiple Hansen's bacilli, may be prevented surgically by nervous decompression. The authors report their experiences of 466 nervous decompressions of 123 patients (89 men and 34 women), among them, 14 were pauci-bacillary and 109 multi-bacillary. They conclude that very good results (complete recovery or improvement of sensitivity, disappearing of pain) have been obtained through simple and easy-to-learn surgeries.

[Post-traumatic osteolysis of the distal end of the clavicle. Contribution of MRI]. / Ostéolyse post-traumatique de l'extrémité distale de la clavicule. Apport de L'RM.

The authors describe a case of post-traumatic osteolysis of the clavicle. The clinical and roentgenographic aspects are well known. But regarding the lytic X ray aspect, another diagnosis, particularly a tumor may be evoked. Scintigraphy and computed tomograms can take a part in the diagnosis. But scanograms are uneasy to do in this region. The MRI allows to delimit the lesion, and the hypointense signal in T1 and T2 weighted sequences directs to a fibrosis in the area between the end of the clavicle and the acromion. In this case report, the relation between the MRI findings and the pathological aspects was good.

[Fractures of the capitellum humeri with late discovery]. / Les fractures du capitellum huméral de découverte tardive.

Four patients with an old fracture of the capitellum humeri were treated by simple excision of the fragment. The results were good in two patients and fair in the two others. The event of a painless period in two cases raised the problem of the limits with the osteochondritis dissecans.

[Extra-abdominal desmoid fibroma and pulmonary metastases. (New Caledonia)]. / Fibrome desmoïde extra-abdominal et métastases pulmonaires. (La Nouvelle-Calédonie).

A 22 years old Melanesian patient had a tumor in the anterior and external side of the left leg. Three times, this tumor had a surgical treatment, by resection, then an amputation of the leg. Always, its histological aspect was agreeing with a desmoid fibroma. After an evolution of 23 months time, metastases appeared in the lungs. Most of the authors don't agree the existence of metastases in these tumors. Four observations were reported in the literature, including one in 1989. They emphasize the difficulties of the histological diagnosis of these tumors. The metastases seems to be an argument in the evolution, which incites to modify the initial diagnosis as a fibrosarcoma in spite of the lack of obvious histological malignancy.

[Surgical treatment of neglected elbow dislocations. Report of 81 cases]. / Traitement chirurgical des luxations négligées du coude. A propos de 81 observations.

The neglected dislocations of the elbow are rare in Europe. In Africa, amongst 81 operated cases, during 10 years, 52 were seen again, with a follow-up between 4 months and 7 years. From this group, the authors are trying to define the place of open reductions and resections of the lower end of humerus. The surgical indications were set up in accordance with functional discomfort. The results of open reductions and those of resections were satisfactory, respectively in 72 per cent and 74 per cent of the cases in flexion-extension movement, and 31 per cent and 41 per cent in the pronosupination. The open reduction remains often possible, even after significant delay. The resections are more mutilating, and they involve risks of laxity. They should be reserved to immediate and late failures. The place of the prosthetic surgery in this ailment is not yet defined.

[Resection of the distal part of the humerus in neglected elbow dislocations. Apropos of 23 case reports]. / La résection de la palette humérale dans les luxations négligées du coude. A propos de 23 observations.

The authors describe the results obtained in 23 resections of the lower extremity of the humerus in neglected elbow dislocation examined after periods of between 7 years to 4 months. Results on elbow mobility are satisfactory in more than 70% of the cases, taking into consideration initial disability. But the cost of such intervention to be paid is often a laxity of the elbow and diminished strength. Indications are inveterate disabling dislocation, in case of immediate or late failure of open reductions.

[Open reduction of the elbow. Apropos of 29 neglected dislocations]. / La réduction à foyer ouvert du coude. A propos de 29 luxations négligées.

The authors describe results and technical difficulties faced in a series of 29 elbow dislocations using the open technic, then observed over a period between 5 years and 4 months. Results obtained are satisfactory, taking into consideration the primary stiffness. Results on stability are better than those obtained by resection of the lower part of the humerus. Dislocations by the open technic have to be envisaged first in neglected luxations. Indications are limited to patients crippled and limited to non-functional position.

[Cutaneous malignant melanomas in New Caledonia. Study of the Cancer Registry (1977-1987)]. / Les mélanomes malins cutanés en Nouvelle-Calédonie. Etude du Registre des Cancers (1977-1987).

Investigation of cancer registration files in New Caledonia over a period of 11 years (1977-1987) draws the following conclusions: --The uncorrected incidence rate of cutaneous malignant melanoma is 3.63/100,000 inhabitants/year, for all ethnic groups together. --The incidence rate in the "non-European" population is 0.6/100,000 inhabitants/year. This low incidence and the anatomo-clinical manifestations observed (lentiginous melanoma of extremities) are common in coloured people. --The incidence rate in the "European" population is 8.75/100,000 inhabitants/year is noticeably higher than the incidence in the metropolitan population. Such conclusions are in accordance with the admitted data regarding epidemiology of cutaneous melanoma in high insolation countries. Cumulated incidence rate and topography of lesions are similar in this series whatever the sex.

[Chondrosarcoma with a myxoid component. Apropos of a "giant" tumor recurrence]. / Chondrosarcome à composante myxoïde. A propos d'une récidive tumorale "geante".

Reporting on a giant tumorous recurrence of a chondrosarcoma with a myxoid component, without perceptible locoregional or general extension, the authors recall the possible long-term evolution of this type of tumor. They underline the difficulty of anatomopathologic diagnosis of tumors with cartilaginous structure, and the necessity for frequent monitoring after exeresis.

[Blount's disease. Apropos of a case in a melanesian child]. / La maladie de Blount. A propos d'un cas chez un enfant mélanésien.

Reporting on a case of Blount's disease in a melanesian child in New Caledonia, the authors review the up-to-date knowledge on such an uncommon chondrodystrophy, striking black and Scandinavian children preferentially.

[Malignant melanoma among the ethnic Melanesian population of New Caledonia]. / Mélanomes malins dans l'ethnie mélanésienne de Nouvelle-Calédonie.

Melanesian population amounts to 61,270 out of 145,368 inhabitants in New Caledonia according to the last census. Melanesians of phototype VI have no predisposition in regard to malignant melanoma. From 1977 to 1987, 7 cases have been reported. Localisations are always in some zones not exposed to sunlight: 3 acral-lentiginous melanoma of the sole, 2 tumorous nodules of the anus margin and the vulva, 2 choroidal localisations. So, incidence of cutaneous malignant melanoma is very low (0.7/100,000 per annum) and in accordance with classical data regarding black people. But one has to keep in mind its being in some characteristic localisations. All the above referred cases have been detected at an advanced local extension.