Results of operative treatment of gastrointestinal tract tumors in patients over 80 years of age.

Between 1981 and 1986, 140 patients over 80 years of age were operated on for a gastrointestinal tract tumor in our service. There were 24 gastric, one small-bowel, 91 colonic, and 24 rectal cancers. Only 40% of the patients were preoperatively free of any systemic disorder other than tumor. We performed surgical procedures with a curative intent for 90 (64%) of them. Our mean overall postoperative mortality was 17%, but this rate could be decreased by performing elective operations on well-prepared patients. Over 80% of the deaths were related to systemic organ failures. Eighty-three percent of the survivors (96 patients) returned to their homes; 82% (94 patients) had normal activities for their age. The actuarial survival curve showed a 50% survival rate at three years, all tumoral stages included. These results support the view that surgery is a safe, valid option in the face of gastrointestinal tract tumors in the elderly.

Non-cemented replacement of the trapeziometacarpal joint.

We treated 43 patients (38 women and 5 men) with osteoarthritis of the basal joint of the thumb by non-cemented arthroplasty of the first carpometacarpal joint as described by Ledoux. The probability of a patient avoiding revision for 12 months was 62% and for 16 months 59%. The indications for revision were aseptic loosening in 83% and luxation in 17%. The surviving prostheses were reviewed clinically and radiologically at a mean follow-up of 25.3 months. Pain on loading, movement or at rest was seen in 75% of the patients. There was significant reduction in the range of movement of the trapeziometacarpal joint and of wrist strength. Radiological assessment showed significant subsidence of the stem in the first metacarpal and migration of the cup, with the stem loose in 15% and the cup in 46%. We no longer recommend this method of joint replacement.

Cemented and non-cemented replacements of the trapeziometacarpal joint.

We performed 88 primary ball-and-socket arthroplasties of the trapeziometacarpal joint in 84 patients (69 women and 15 men) with a mean age of 61 years (37 to 81). Cemented de la Caffinière prostheses were implanted in 43 joints from 1988 to 1991 and 45 cementless Ledoux implants were used between 1992 and 1994. Of the 61 surviving prostheses still in situ, 51 were reviewed clinically and radiologically with a mean follow-up of 25 months for the Ledoux and 63 months for the de la Caffinière implant. The survival rate for the Ledoux prosthesis was 58.9% at 16 months and for the de la Caffinière implant 66.4% at 68 months. Loosening occurred in 15% of the Ledoux stems, in 46% of the Ledoux cups, in 24% of the de la Caffinière stems and in 28% of the de la Caffinière cups. Both prostheses behaved similarly, and it is clear that a constrained ball-and-socket prosthesis is not suitable for the trapeziometacarpal joint.

[Prosthetic replacement of the first carpometacarpal joint with a cemented ball and socket prosthesis (de la Caffinière)]. / Prothetischer Ersatz des Daumensattelgelenkes mit einer zementierten Kugelgelenkprothese (de la Caffinière).

We analysed the fate of 43 de la Caffinière prostheses implanted for arthrosis of the first carpometacarpal joint after a follow-up of 63 months (range 45 to 81). Ten prostheses failed. Further eight patients were lost for follow up. In the remaining 25 patients the rate of tilting of the cups (92%) was extremely high and the survival rate disappointing: 66% at 68 months. The prostheses were implanted in cancellous bone and the ball and socket reduces the moving axes of the normal joint to one center of rotation. These factors might explain the higher rate of loosening of the cups (28%), compared to 15% for the stems. In contrast, the clinical results were comparable with other operative procedures. The advantage is the brief postoperative rehabilitation period. Accordingly, this prosthesis can not be universally recommended and should be reserved for elderly patients, who must not undertake strenuous work.

[Orthopedic technique following arthrodesis of the Lisfranc joint]. / Technique orthopédique après arthrodèse de l'articulation de Lisfranc.

Of the 107 arthrodeses of the forefoot and the metatarsus performed in the 1980's, we controlled 13 arthrodeses of the Lisfranc joint. The mean time of follow-up was 2.3 years. Our postoperative results were excellent for 5 patients, good for 6 patients and fair for 2 patients. We obtained no poor results. As we found few references to the use of orthopedic techniques in the literature, it seemed of interest to study their use in our own sample. It was found that one patient did not require any orthopedic means, one patient needed orthopedic supports, 9 patients required modifications of their shoes, one patient needed an orthopedic shoe and one patient needed an orthosis. Moreover, we attempted to find which factors are associated with more complex orthopedic techniques. Our results seem to indicate that a complete arthrodesis of the Lisfranc joint requires the use of more complex orthopedic techniques than does a partial arthrodesis.

[The value of silastic prostheses in Kienböck's disease]. / La valeur des prothèses en silastic dans la maladie de Kienböck.

Eight patients underwent silicon replacement arthroplasty for treatment of Kienböck's disease between 1980 and 1984. Seven patients were available for a clinical and radiological ten-year follow-up control. A three-stemmed arthrodesis by arthrosis was done on one patient. Subjective results were good, although a reduction of one third of the mobility and strength of the wrist was noticed. Erosive osteolysis, carpal instability, radiocarpal arthrosis and a 36% reduction of the initial height of the implants was seen on the X-rays. The lytic lesion represents a progressive silicone particle-wear synovitis which threatens the future of the carpus. Nowadays, this kind of arthroplasty no longer has its place in the treatment of Kienböck's disease.

[Long-term outcome of a silastic semilunar bone prosthesis]. / Evolution à long terme des prothèses en silastic du semi-lunaire.

Eight silastic implants of the lunate bone were inserted between 1980 and 1984 on 8 patients. Seven patients were seen, at a ten year follow-up visit and were satisfied with the results. However, STT osteoarthritis secondary to the carpal collapse had to be stabilized by a triscaph arthrodesis. The clinical course showed a clear improvement of force and mobility in a first phase, followed by progressive deterioration ending in a return to preoperative values. Multiple intracarpal cysts were found radiologically in all wrists as well as in the distal radius in two cases and in the metacarpal bones in 3 cases. The height of the prosthesis was decreased by about 36%. Carpal collapse and ulnar translation showed a statistically significant progression. According to these findings, silastic prostheses should no longer be recommended.

Retrospective comparison of four intra-articular anterior cruciate ligament reconstructions using three evaluation systems.

In a retrospective study, 57 patients were examined following an intra-articular cruciate ligament reconstruction. The patients were divided into four groups according to the type of repair and the lapse of time between injury and operation. Twenty-five patients had undergone reconstruction with a semitendinosus tendon after acute instability (AST) and six, after chronic instability (CST). Eleven patients had received an acute reconstruction using the middle third of the patellar tendon (APT), as had 15 with chronic instability (CPT). The mean follow-up time was 48 months for the AST group, 60 months for the CST, 33 months for the APT, and 36 months for the CPT. In order to compare the groups, we used the Lysholm and OAK scores and the IKDC evaluation system. The only statistically significant difference found involved the IKDC evaluation system between the AST and CST groups. No significant decrease in activity level was noted in any of the groups. With the exception of the CST group, the preoperative Lachman test disappeared significantly at follow-up in all groups. The side-to-side difference of anterior tibial displacement measured with the KT 2000 at 25 degrees knee flexion and a load of 89 newtons was 1.32 mm for the APT group, 2.44 mm for the AST group, 2.47 mm for the CPT group, and 3.33 mm for the CST group. This side-to-side difference was not significant in the APT group. In the CPT group, arthrofibrosis was found in 27% of the patients, which led to reoperation. Reconstruction of the anterior cruciate ligament using the semitendinosus is no longer indicated for chronic instability. ACL-plasty with the middle third of the patellar tendon restored practically normal stability in acute ACL insufficiency.

[Vertebral arthroplasty: a new approach to spinal surgery]. / Arthroplastie vertébrale: une nouvelle approche de la chirurgie du rachis.

Surgical treatment of lumbar spine degenerative trouble was until recently limited to destructive techniques like discectomies for disk prolapse, laminectomies for narrow canal and the different way of lumbar fusion for more advanced degenerative troubles or unstable spine. Design of new materials and surgical techniques give spine surgeon an alternative to the usual techniques of surgical treatment of lumbar degenerative disk disease. They share a new concept of a more conservative surgical treatment and try to restore the function and mobility of lumbar segments, performing true arthroplasty of the lumbar spine. Here are described some of these new arthroplastic techniques, such as disk prosthesis or disk nucleus prosthesis.

[Arthroscopy of the wrist: diagnostic and therapeutic contribution]. / Arthroscopie du poignet: apport diagnostique et thérapeutique.

An arthroscopy was carried out on 23 wrist joints following trauma. There were 11 women and 12 men with a mean age of 36 years, and they were followed up for an average of 33 months. Statistically significant differences were observed in the radiolunate and scapho-lunate angles between the injured and normal sides. Arthroscopy detected 72 ligament tears, an average of 3 per wrist, compared with 1 per wrist demonstrated by arthrography. However the findings of the two investigations did not correlate, indicating that both are worth undertaking. Chondromalacia was seen in 10 wrists, mostly in the radiocarpal and mid carpal joints. On the basis of the findings at arthroscopy, conservative treatment was followed in 60% of the patients and the investigation was of great help in planning operation in the remainder.

Ten-year patient and prosthesis survival after unipolar hip hemiarthroplasty in female patients over 70 years old.

We found that 162 unipolar hemiarthroplastics of the hip were performed between 1989 and 1995 on women over 70 years of age in our institution. The mean age was 84 years (70 to 99). Cumulative survival of the prostheses was 98% at 1 year and 94% after 5 and 10 years. Of the original patients, 137 have died. Survival rate for patients was 73% at 1 year, 23% at 5 years, and 6% at 10 years. Eighteen patients could be accounted for, with a mean follow-up time of 7.7 years (5.5-11.3 years). The mean Harris hip score was 80 points (55-100). Protrusion was observed in 3 patients. The treatment of cervical neck fracture with unipolar hip prostheses is a valuable method, with a low complication rate, particularly in women over 70 years for whom life expectancy may be short.

Low reoperation rate with the Medoff sliding plate: 1 technical failure in 63 trochanteric hip fractures.

The Medoff sliding plate was designed to treat unstable intertrochanteric and subtrochanteric fractures. This plate has a dual sliding capability along both the femoral shaft and neck in order to improve bone coaptation, interfragment compression and hence load-sharing between bone and implant in hip fractures. In a retrospective study of 63 patients (mean age 82 (51-98) years) with intertrochanteric (n 44) and high subtrochanteric fractures (n 19), we assessed the results with the Medoff sliding plate. All patients, except 1 lost to follow-up, were examined clinically and radiographically. 14 patients died within 1 year, and in the other, the mean follow-up was 15 (6-30) months. 1 technical failure occurred, leading to a single reoperation. The low technical failure rate suggests that the Medoff sliding plate with combined compression modus is suitable for treating intertrochanteric and high subtrochanteric fractures.

[Radiological course of cemented and uncemented trapeziometacarpal prostheses]. / Evolution radiologique des prothèses trapézo-métacarpiennes cimentées et non cimentées.

Between 1988 and 1994, eighty-eight trapeziometacarpal arthroplasties were performed on eighty-four patients (69 females and 15 males), with a mean age of 61 years (37 to 81). Forty-five Ledoux and forty-three De la Caffinière prosthesis were implanted. Of the 61 non-reoperated prosthesis, 51 were reviewed with a mean follow-up of 25 months for the Ledoux prosthesis and 63 months for the De la Caffinière prosthesis. Survival rate was 58.8% at 16 months for the Ledoux prosthesis and 66.4% at 68 months for the De la Caffinière prosthesis, with a statistically significant difference (p < 0.001). In the Ledoux group, 15% of the shafts and 46% of the cups were loose. In the De la Caffinière group 24% of the shafts and 28% of the cups were loose. The final outcome of both prosthesis was similar, and we therefore concluded that spherical prostheses fixed in the trapezium are inadequate for the trapeziometacarpal joint.

The Burch-Schneider antiprotrusio cage in acetabular revision surgery: a mean follow-up of 12 years.

A total of 38 acetabular revisions using a Burch-Schneider antiprotrusio cage in 37 patients (18 women and 19 men), with a mean age at surgery of 75 years (range, 55-88 years), were evaluated retrospectively with a mean follow-up of 12 years (range, 8-21 years). In 2 cases with total hip dislocation and in 1 case with a deep infection, revision of the antiprotrusio cages was required. Defining every revision of the antiprotrusio cage as the endpoint of survivorship, the antiprotrusio cage showed a survival rate of 92% after 21 years. Clinical evaluation of the surviving patients showed a mean Harris hip score of 76 points (range, 20-96). Radiologic evaluation revealed that 1 antiprotrusio cage was loose and that 4 femoral stems were loose. The Burch-Schneider antiprotrusio cage compares favorably with other devices with regard to long-term implant survival rate.

Treatment of proximal humerus fracture using multiple intramedullary flexible nails.

A total of 61 patients with a proximal humeral fracture was treated between January 1996 and March 1998 by closed reduction and fracture fixation with intramedullary Prévot (or Nancy) nails. Of these, 28 female and 25 male patients with a mean age of 52 years (range 3-91 years) were reviewed clinically and radiologically with a mean follow-up of 17 months (range 4-30 months). The mean Constant score was 63, the mean Neer score 74 and the mean visual analogue scale (VAS) 73. The 14 patients under 24 years old achieved a Constant score of 86, a Neer score of 99 and a VAS of 97, while 13 patients aged between 25 and 60 years had a Constant score of 67, a Neer score of 75 and a VAS of 71. The 26 patients older than 61 years had a Constant score of 48, a Neer score of 61 and a VAS of 61. One patient with total and 6 with partial humeral head necrosis as well as 5 pseudarthroses were noted. Proximal nail perforation of the humeral head due to fracture collapse was seen in 22 cases. Complications were more frequently observed in the elderly. End results were not related to the type of fracture. This minimally invasive technique decreases the rate of occurrence of avascular necrosis of the humeral head. However, fractures are not sufficiently stabilised, mainly because of bone loss induced by impaction and osteoporosis. Bone loss remains an unsolved problem, and alternative methods such as the use of bone substitute combined with minimally invasive techniques should be studied.

[Osteoid osteoma of the hand. Case representation with special reference to magnetic resonance tomography and litrature review]. / Osteoidosteom an der Hand. Falldarstellung unter besonderer Berücksichtigung der Magnetresonanztomographie und Literaturübersicht.

The pre-operative diagnosis of osteoid osteoma of the first metacarpal bone was suggested by Magnetic Resonance Imaging in a 15 year old girl. As indicated in the literature, osteoid osteoma of the hand is relatively rare. The symptoms and the x-rays features of osteoid osteoma are essentially independent from the location consisting in rather unspecific pain and radiographically osteolytic nidus surrounded with sclerosis. In the few published cases with MR Imaging, the nidus shows high signal intensity surrounded by low signal intensity in the area corresponding to the radiographically visible sclerosis.

Analysis of two bone-prosthesis interfaces and membranes from non-cemented trapeziometacarpal prostheses.

The non-cemented Ledoux trapeziometacarpal prosthesis has a high failure rate. In order to better understand the mechanism responsible for pain and loosening, we thoroughly analysed the membranes surrounding the prosthesis and the bone-prosthesis interface in two trapezia, each containing a Ledoux cup, which were resected after unsuccessful implantation. Serial sections, perpendicular to the longitudinal axis of the implanted cup, allowed histological examination of the interface and were used to quantify bone apposition. The tissues surrounding the prosthesis showed a foreign-body reaction to particles identified as titanium. The interface showed bony integration of the cup, mainly on the radial side and on the proximal part of the cup, with an appositional index of 28%. Our findings suggest that bony apposition might not be sufficient to ensure successful anchoring of the Ledoux cup in the trapezium in the presence of an intense foreign body reaction to titanium. Moreover, the presence of metal might be secondary to micromotion of the wings of the metallic part of the cup, induced by axial movement of the underlying polyethylene during pinch grip. The combination of polyethylene as an expander and titanium may need to be reviewed.