CT scan evaluation of glenoid component fixation: a prospective study of 27 minimally cemented shoulder arthroplasties.

BACKGROUND: Glenoid component failure is the most common complication of total shoulder arthroplasty. It can be correlated with failure of the component itself to resist wear and deformation, failure of fixation or failure of the glenoid bone. Anchor Peg Glenoid component (Depuy®) seems to have a higher bone fixation in biomechanical canine model: it is a all-polyethylene, concave component with one circumferentially fluted, central, interference-fit peg and three small cemented peripheral pegs. MATERIALS AND METHODS: We realized a prospective study of Anchor Peg total shoulder arthroplasty, included 27 patients suffering from primary arthrosis or arthritis, without rotator cuff tear. A clinical and radiographic evaluation was performed at 3 months, 1 and 2 years; a CT scan was made in postoperative and analyzed central peg's bone integration 1 year later. RESULTS: Improvement of postoperative Constant score and radiographic good results were correlated with satisfactory subjective results reported by patients. We observed radiolucent lines under glenoid component in 3 cases. Twenty-six CT scans were available at 1 year: it showed complete bone integration around the central peg in 21 cases and partial peripheral bone integration in four cases. Only one patient had any tissue integration around the peg, probably because of his implantation near cortical bone of scapular spine. DISCUSSION/CONCLUSION: Long-term result of arthroplasty is correlated with glenoid durable fixation to underlying bone: this study shows higher fixation of glenoid component with bone integration of central peg. However, these results will have to be confirmed in a later revision.

Evolution of scoliosis in six children treated with growth hormone.

During a period of 6 years to 11 years, the authors have been following six girls with scoliosis and treated with growth hormone (GH) for a growth insufficiency. The treatment with GH started after the discovery of the scoliosis for five patients. Three curve progressions have been observed, but always in the puberty period. Only one progression was noticed at the beginning of the GH treatment, but it was relieved with bracing. The results of this study do not permit one to conclude that a relation exists between GH treatment and scoliotic progression. This treatment is nevertheless not devoid of side effects, and a rigorous supervision is necessary.

[Arthroscopic treatment of hematogenous infected total knee arthroplasty: 5 cases]. / Traitement arthroscopique des arthrites septiques hématogènes sur prothèse totale de genou: à propos de 5 cas.

PURPOSE OF THE STUDY: The purpose of this retrospective study was to assess the contribution of arthroscopic treatment on hematogenous infected total knee arthroplasty. MATERIAL AND METHODS: Five patients were treated for hematogenous infected total knee arthroplasty. All patients had a posterior stabilized prosthesis that had been implanted without any element suggesting primary infection. Delay to infection after arthroplasty was 25 months on the average. Arthroscopic treatment included joint wash-out and synovectomy in combination with prolonged antibiotic therapy. RESULTS: One female patient, treated within 24 hours of the onset of infection, achieved cure without recurrence at 6 months follow-up. One other female patient died. Three patients required revision surgery after failure (two reimplantations in two procedures and one reimplantation in one procedure). DISCUSSION: The gravity of hematogenous infections of total knee arthroplasty is well known. Cure requires insertion of a new implant in three-quarters of the cases. Local arthroscopic treatment is not effective unless performed very early. Beyond this delay, it can at best limit local symptoms.

[Transfer of the clavicular portion of the pectoralis major muscle in the treatment of irreparable tears of the subscapularis muscle]. / Le lambeau du chef claviculaire du grand pectoral dans les ruptures irréparables du subscapulaire.

PURPOSE OF THE STUDY: Old tears of the subscapular muscle situated in the glenoid area are not accessible to direct repair and require locoregional muscle plasty. The clavicular portion of the pectoralis major can be used for reconstruction. The purpose of this study was to describe the operative technique and examine short-term outcome. MATERIAL AND METHODS: Five patients, mean age 54 years (45-71 years) with an irreparable tear of the subscapularis in the glenoid area with fatty degeneration greater than grade two in the Goutallier classification were treated. Four had had previous surgery for acromioplasty associated with rotator cuff repair in two or implantation of a humeral prosthesis in one. The preoperative Constant score was 27.5 (mean, range=8.5-54) due to invalidating pain, limited active mobility and reduced muscle force. Gerber's lift-off test was positive for those patients for whom it could be performed. Plain x-rays evidenced anterior subdislocation of the humeral head in one case. Subscapular reconstruction was achieved using the entire clavicular portion of the pectoralis major which was dissected and sectioned at its distal insertion on the humerus then reinserted by transosseous suture onto the lesser tuberosity. The rehabilitation program started with active and passive mobility against gravity within a few days of surgery using biofeedback contraction of the muscle flap then active contractions two months postoperatively. Patients were reviewed at a mean 19 months (6-42 months) for clinical and radiological assessment. RESULTS: Four patients had a painless shoulder with a negative lift-off test. The gain in active mobility was predominantly achieved with anterior elevation and abduction. Muscle force was weak leading to a low overall Constant score at revision (mean=50, range=30-63). Radiographically, the humeral head was centered exactly as on the preoperative films. There were no cases with a new anterior subdislocation nor an aggravation of a former subdislocation. Functional outcome was better in cases with a unique tear of the subscapularis. DISCUSSION AND CONCLUSION: Open surgery is used for primary repair of recent tears of the subscapularis. This technique gives 80 p. 100 good and very good results. In case of symptomatic acromioclavicular osteoarthtisis, better long-term results can be obtained by using a tendodesis of the long biceps and resecting the lateral centimeter of the clavicle. In case of irreparable tears in the glenoid area, reconstruction by transfer of the clavicular portion of the pectoralis major can produce a stable painless shoulder with improved active moblity and normal clinical tests. This method provides anterior stability of the glenohumeral articulation and prevents any anterior subdislocation of the humeral head, thus protecting the joint from secondary degeneration.

[A propos of an unusual case of lumbar-pelvic dislocation in a suicidal jumper]. / A propos d'un cas particulier de dissociation lombo-pelvienne chez le défenestré.

PURPOSE OF THE STUDY: We report a particular case of lombo-pelvic dislocation in a suicidal jumper, characterized by a distal sacral fracture associated with bilateral fractures of both iliac wings. To our knowledge, it has yet not been described. MATERIAL AND METHODS: The patient was a 27 years old individual. On admission, he sustained the following injuries: hemodynamic shock with intraperitoneal bleeding due to disruption of the triangular ligament of the liver, which resolved with blood transfusions and did not require surgical treatment pelvic fractures initially identified as transverse fractures of both iliac wings, with bilateral avulsions of sciatic spines a compression fracture of the first lumbar vertebra without neurologic complication. In the intensive care unit, evolution was favorable. However, an incomplete cauda equina syndrome was noticed: the anal sphincter was flacid but perianal sensation to pinprick was conserved. An electromyogram showed that the latence of perineal reflexes was increased. The fracture and its displacement were recognized secondarily. A pelvic C.T. exhibited an increases in the antero-posterior dimension of the pelvic ring, due to a distal-displaced transverse sacral fracture. The proximal fragment of the sacrum remained attached to the iliac wing since sacro-iliac joints were intact, iliac wings had tilted forward, and the distal tip of the proximal sacral fragment was driven backward and inferiorly. RESULTS: The patient was maintained in the supine position during 3 months. He then rapidly recovered normal function of his lower limbs. He had normal gait patterns and pelvic static. He did not complain of any pain. Finally, the neurological deficit disappeared and he regained full sexual function and complete control of micturition. DISCUSSION: We think that this fracture should be considered as a variety of suicidal jumper's fracture described by Roy Camille et al. It has the same displacement as type 2 fracture in Roy Camille classification. In the emergency room, diagnosis is difficult, based on usual AP pelvic roentgenograms. A bilateral fracture of iliac wings in a suicidal jumper, especially if associated with bilateral sciatic spine avulsions, is an indication to a pelvic C.T.. A neurological perineal deficit should be ruled out. In our case, the perineal deficit can be attributed to the stretching of sacral roots resulting from a posterior displacement of the sacrum. The favorable evolution suggests that surgery may be not required, and there is no evidence in the literature that it would help neurological recovery. In distal fractures, the sacral canal is not narrowed, and a sacral laminectomy appears therefore not indicated. CONCLUSION: We have described a particular type of transverse fracture of the pelvis, which, in our mind, should be put in the same category as type 2 transverse fractures of the sacrum described by Roy Camille and al, in the suicidal jumper. Since there is no compression of sacral roots into the sacral canal, prolonged bedrest is likely to be the better treatment.

[Trauma-induced tears of the quadriceps tendon: 47 cases]. / Ruptures traumatiques du tendon quadricipital. A propos de 47 cas.

PURPOSE OF THE STUDY: A torn quadriceps tendon is an exceptional finding generally observed after high-energy knee trauma in patients over 40 who present a sprain-like syndrome or after low-energy trauma in elderly subjects who experience knee instability. We reviewed a series of 47 cases of traumatic quadriceps tendon tears treated between 1976 and 1996 in order to evaluate outcome after surgical repair. MATERIAL AND METHODS: Clinical diagnosis was the rule. Forty-two patients, mean age 55 years (range 17-92) were treated for tears of one or both quadriceps tendons subsequent to low-energy trauma (40 tears) or high-energy trauma in younger subjects. The diagnosis was established early in all cases except eight (diagnosis at three weeks to one year). Surgical repair was performed in all cases except one. After surgery, the knee was either immobilized with a plaster cast or held in a removable splint to allow early mobilization. RESULTS: Average time to recovery compatible with daily life or occupational activities was four months. Recovery was not complete at this time. Long-term follow-up revealed that complete recovery with very good or good subjective results was achieved in 90% of the cases. Complete joint motion and normal quadriceps force was achieved in 80% of the cases. Patients who started rehabilitation exercises early generally achieved less satisfactory results although no significant correlation was identified with objective clinical variables. DISCUSSION: Quadriceps tendon tear is a clinical diagnosis which does not require complementary exploration for confirmation. Plain x-rays may be useful to identify associated bony lesions and specific signs of tendon tears. Early surgical repair followed by complete immobilization appears to be preferable for functional recovery allowing better recovery of muscle force without compromising flexion.

[Coronal fractures of scaphoid]. / Fractures frontales du scaphoïde.

Two cases of frontal fracture of the scaphoid proximal pole after a high energy trauma are reported. Diagnosis was delayed in both cases and was only possible with a CT-scan. One fracture was slightly displaced: the patient was treated conservatively and followed during 11 years with an excellent result. The other patient was operated on because of persistent pain and malunion. Only during surgery was the correct diagnosis made and due to scaphoid malunion, a proximal row carpectomy was performed. At a post operative assessment, in both cases, X-rays showed a double contour of the proximal pole of the scaphoid. We believe than an arthroCT-scan or MRI is necessary to assess the fracture displacement and search for an associated ligamentous injury.