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Purpose of the Study: Fractures of the lateral process of the talus are often not diagnosed. The cohorts of the literature are small. The aim of the study was to analyse these fractures with a large group of patients., Material and Method: Forty-four fractures in 43 patients were reviewed with an average follow-up of 17 months. The diagnosis had been made immediately in 14 cases and secondarily in 30 cases with a delay of 46 months. Patients had been evaluated with Kitaoka's score and radiographies using Hawkins classification. Fractures occurred during sport practise in 19 cases. The most frequent mechanism was association of dorsal flexion and pronation. There were associated lesions in 44% of cases., Results: In the group of delayed diagnosis, we found 14 cases of associated pseudarthrodesis and sub-talar osteoarthritis, two cases of isolated pseudarthrodesis, two cases of isolated sub-talar osteoarthritis. After treatment in this group, the result at the last follow up was very good in 15 cases (50%), good in seven cases (23%), average in seven cases (23%) and bad in one case (4%). In the group of immediate diagnosis five of 14 patients had at least one complication: 29% of pseudarthrodesis and 29% of sub-talar osteoarthritis. After treatment in this group, the result at the last follow-up was very good in eight cases (58%), good in four cases (28%) and average in two cases (14%). Immediate diagnosis was correlated with better results at the last follow-up. In the sub-group of immediate diagnosis, among patients who had an orthopaedic treatment, the rate of secondarily surgery was 42%., Conclusion: The fracture of lateral process of the talus is quite frequent and occurs among young people. Spontaneous evolution is severe with two major complications: pseudarthrodesis and sub-talar osteo-arthritis. Treatment is always required in case of displaced fracture.

Purpose of the Study: Maintaining radial length, likely to be the main challenge in the treatment of complex distal radius fractures, is necessary for complete grip-strength and pro-supination range recovery. In spite of frequent secondary displacements, bridging external-fixation has remained the reference method, either isolated or in association with additional percutaneous pins or volar plating. Also, there seems to be a relation between algodystrophy and the duration of traction applied on the radio-carpal joint. Fixed-angle volar plating offers the advantage of maintaining the reduction until fracture healing, without bridging the joint., Material and Methods: In a prospective study, forty-three consecutive fractures of the distal radius with a positivated ulnar variance were treated with open reduction and fixed-angle volar plating. Results were assessed with special attention to the radial length and angulation obtained and maintained throughout treatment, based on repeated measurements of the ulnar variance and radial angulation in the first six months postoperatively., Results: The correction of the ulnar variance was maintained until complete recovery, independently of initial metaphyseal comminution, and of the amount of radial length gained at reduction. Only 3 patients lost more than 1 mm of radial length after reduction. The posterior tilt of the distal radial epiphysis was incompletely reduced in 13 cases, whereas reduction was partially lost in 6 elderly osteoporotic female patients. There was 8 articular malunions, all of them less than 2 mm. Secondary displacements were found to be related to a deficient locking technique. Eight patients developed an algodystropy. The risk factors for algodystrophy were articular malunion, associated posterior pining, and associated lesions of the ipsilateral upper limb., Conclusion: Provided that the locking technique was correct, this type of fixation appeared efficient in maintaining the radial length in complex fractures of the distal radius. The main challenge remains the reduction of displaced articular fractures. Based on these results, it is not possible to conclude that this method is superior to external fixation.

Purpose of the Study: The aim of this study was to present our experience with hemiarthroplasty of the base of the first metacarpal for the treatment of degenerative disease of the trapeziometacarpal joint. We have used this resurfacing implant since 1995 as part of our therapeutic armamentarium together with trapeziectomy, arthrodesis and total arthroplasty., Material and Methods: The chromium-cobalt implant is inserted into the base of the first metacarpal. Three implant sizes are available. The present series included 106 implants in 87 patients, predominantly female. Mean patient age was 59.6 years. Three quarters of the patients had isolated joint degeneration. The preoperative complaint was pain (scored 3 on a 4-point scale) for 92% of patients. Joint motion was generally not impaired. Grip force was limited with less than 50% force for first finger-thumb opposition in three quarters of the patients. The anterior Gedda-Möberg approach was used in all cases. The joint was immobilized for two to three weeks postoperatively., Results: There were seven complications among the 106 cases: reflex dystrophy (n=4), global pain (n=2) and rupture of the long extensors (n=1). Sixty nine patients (83 implants) were reviewed at more than one year follow-up. Mean follow-up was 53 months (range 23 - 128 months). Activities were resumed at two months for 88% of implants with no problem for grip force for one-third and normal activity for 66%. Patient assessment was: outcome good and very good for 94%, pain free for 52%, and moderate pain without impaired activity for 43% (Kapandji opposition score was normal in 90%). Grip force was decreased in 25%. Radiographically, all implants were stable. Joint centering was improved (from 25% to 60% at last follow-up). There was no correlation between radiographic centering and clinical outcome., Discussion: This hemiarthroplasty has provided satisfactory results in terms of pain relief, joint motion, and function. There has not been any long-term radiographic problem. If revision is needed for failure, the procedure is simple and trapeziectomy, total arthroplasty or arthrodesis can be performed. The hemi-implant can be inserted after total arthroplasty. Compared with other techniques, this implant avoids the problem of silicone tolerance with the Swanson implant and has provided results superior to those of arthrodesis and trapiezectomy but slightly less satisfactory than with total arthroplasty. The indication for use of this resurfacing implant is osteoarthritis of a centered trapeziometacarpal in the young subject. The implant is contraindicated for advanced-stage disease, stiff joint with retraction of the first commissure and hyperextension of the metacarpophalangeal joint.

Purpose of the Study: We report a retrospective series of anterior marginal fractures of the distal radius treated by anterior plating in order to analyze results and identify prognostic factors., Material and Methods: This continuous series included 22 patients with an anterior marginal fracture of the distal radius treated between 1993 and 1999. Three patients were lost to follow-up. This analysis thus concerned 19 fractures in 15 men and 4 women, mean age 39 years. Surgical reduction and T-plate anterior fixation was used in all cases., Results: Mean follow-up was 26 months. Anatomic results were satisfactory in 15 patients and poor in one. Function was satisfactory in 17 patients and poor in one. We noted two types of complication: spontaneously regressive reflex dystrophy (n=2) and osteoarthritis which developed in two patients after incomplete reduction., Discussion: Anterior plating can provide satisfactory results for anterior marginal fractures of the distal radius if anatomic reduction is achieved. This method remains our preferred therapeutic approach with special attention being required for anatomic reduction.

Purpose of the Study: Ligamentoplasty using an autologous transplant provides an effective and long-lasting solution for anterior instability of the knee. The most widely used transplant is the mid third of the patellar tendon. The short- and long-term stability has been proven, but there are reports of morbidity at the donor site affecting the extensor system. Different attitudes have been proposed. Certain authors leave the site open, only suturing the peritendon. Others suture the two peripheral thirds together, either directly or after combing. This different therapeutic options may modify patellar height and affect the tissue at the donor site that some authors suggest can provide transplants for repeated ligamentoplasties. The purpose of this work was to assess the influence of closing the donor site of the patellar tendon on patellar height., Material and Method: Two groups of 40 patients were compared. These patients underwent arthroscopic ligamentoplasty for anterior instability of the knee, excluding all other knee pathology. In the first group, the pretendon fibrous plane was closed alone at the end of the procedure without bringing together the edges of the tendon donor site. In the second group, the peripheral thirds of the patellar tendon were sutured together directly. Patellar height was assessed according to Caton, to Blackburn and to Insall and Salvati on lateral views (20 degrees flexion) of the knee six months after arthroscopy., Results: Irrespective of the method used to measure patellar height, there was no statistical difference between post-operative patellar heights between the two groups (Caton=1.002 +/- 0.176/1.023 +/- 0.215; Blackburne=0.844 +/- 0.183/0.882 +/- 0.196; Insall and Salvati=1.118 +/- 0.213/1.184 +/- 0.146 for group 1 "open tendon" and group 2 "closed tendon" respectively). Pre- and post-operative heights were not different for either group (Student t - Fisher, p=0.05)., Discussion: Patellar height is not significantly changed after ligamentoplasty using the mid third of the patellar ligament with or without closing of the donor site.

A 66-year-old woman complained of pain in the left rear foot and malleoli. Standard x-ray and magnetic resonance imaging as well as laboratory tests were non-contributive. Pathology study of a bone biopsy led to the diagnosis of talar tuberculosis. A 12-month regimen combining rifampicin, isoniazid and pyrazinamide was given. Clinical improvement was achieved although the patient developed significant reflex dystrophy. The risk of degeneration compromises the functional future of the ankle joint.

Purpose of the Study: Fractures of the proximal humerus are increasingly frequent. Conservative treatment is most often proposed, but surgery must be performed when the displacement is significant and/or when the fracture is unstable. Osteoporosois and comminution are two essential elements for deciding on the surgical technique., Material and Methods: This retrospective study included 31 patients who underwent pinning from the deltoid V according to the Kapandji procedure. There were 19 females and 12 males. Mean age was 61 years. There was a fracture of one of the tuberosities in 12 cases and significant metaphyseal comminution in 8., Results: Mean follow-up was 26 months. Outcome was excellent or good in 22 cases (70.9%), fair in 4 (12.9%), and poor in 5 (16.2%). Fifteen complications were noted (48.4%): material displacement 8 cases, reflex sympathic dystrophy 3 cases, radial nerve palsy 2 cases, head osteonecrosis 1 case, and humeral fracture at the site of insertion of the K wires 1 case., Discussion: At the present time, there is no consensus for the surgical management of fractures of the proximal humerus, including proximal metaphyseal fracture with or without fracture of one of the tuberosities. Closed reduction and pinning is not really an invasive procedure, and does not injure the rotator cuff. Surgical approach at the level of the deltoid V according to the Kapandji technique avoids elbow pain and stiffness. The procedure requires a fluoroscan and experience to obtain satisfactory divergence of the K wires in the humeral head, an essential technical point. This procedure cannot be recommended for elderly patients whose bone quality is too poor to obtain good fixation of the K wires.

Purpose of the Study: The goal of this work was to evaluate outpatient rehabilitation after anterior curciate ligament reconstruction using the bone-tendon technique., Material and Methods: This was a prospective non-randomized study of 103 consecutive patients participating in the same rehabilitation program, excepting for the first month. During the first postoperative month, 55 patients (group A) attended a physical therapy outpatient clinic near their home and 48 patients (group B) followed the same rehabilitation protocol at an inpatient facility of their choice. We recorded preoperative data for age, sex, weight, height and function (sports, occupational activities). Surgery data concerned delay between severe sprain and surgery, and the exact surgical procedure used (meniscal tear, associated procedure). Clinical assessment (mobility, effusion, clinical and radiological laxity) and functional scores (Tegner, Lysholm, Arpege, IKDC) as well as delay to recovery of gait and to renewed physical activity were recorded at 3 and 6 weeks and 4, 6 and 12 months postoperatively. Two isokinetic tests were done 4 and 6 months postoperatively., Results: There was no statistical difference for the pre and peroperative data between the two groups, with the exception of meniscal tears that were more frequent in group A (p<0.05). Postoperative outcome and complications were not significantly different between the 2 groups except for greater flexion at 3 weeks in group B (related to difference in measurement date). Fifteen complications were observed in each group: 4 reflex dystrophies and 2 cyclope syndromes in each group, 5 patellar syndromes in group A and 1 in group B; 3 painful surgical wound sites in group A and 8 in group B (including one requiring revision). In group A there was one early failure due to a surgical error requiring revision. At 1 year, there were 2 cases of persistent femoropatellar syndromes, one of which occurred after reflex dystrophy. A high percentage of the patients were lost to follow-up (45% in group A and 50% in group B) and lack of randomization should also be considered when interpreting the results., Discussion: This is the first report comparing inpatient and outpatient rehabilitation protocols after anterior cruciate ligament reconstruction. The only reports in the literature have compared different ambulatory rehabilitation programs that appear to be internationally accepted as the routine procedure. The current trend towards short hospital stays for surgery is compatible with outpatient rehabilitation programs if dependent patients receive proper support from an ambulatory medical unit, a physical therapist or a home assistant. Our study demonstrated that the bone-tendon technique for anterior cruciate ligament reconstruction is compatible with an outpatient rehabilitation program if quality medical and surgical follow-up is ensured. This type of rehabilitation program gives results comparable with those obtained after inpatient programs conducted in a rehabilitation facility during the first postoperative month.

Purpose of the Study: We reviewed a series of 32 cases of recurrent hallux valgus treated by great toe metatarsophalangeal arthrodesis with a minimal 5-year follow-up., Material and Method: Mean delay from the first surgical procedure and revision surgery was 11 years. All patients complained of forefoot pain. The average angle of the phalangeal valgus was 39 degrees. Sixteen patients had metatarsalgia. The first toe metatarsophalangeal joint was evaluated according to Regnauld's classification: two grade 1, eight grade 2a, six grade 2b, sixteen grade 3. Arthrodesis was fixed with an axial screw and associated with adductor hallux plasty. Outcome was assessed at a minimum 5-year follow-up according to Kitaoka's criteria., Results: Seventy-eight percent of the patients were pain free at last follow-up. Valgus deviation of the great toe was corrected with an average angle of 19 degrees. The arthodesis healed in 90.6% of the cases. Statistical analysis showed the importance of great toe valgus pre- and postoperatively and at last assessment. Final outcome was poor in the oldest patients. The overall outcome was rated good in 84% of the cases, average in 6% and poor in 10%., Discussion: Arthrodesis of the great toe is not a disabling surgery. Interphalangeal osteoarthritis may occur due to joint overuse (12 cases). Kitaoka's series compared outcome after arthrodesis with that after conservative surgery and reported better results with arthrodesis. Revision surgery for hallux valgus using great toe metatarsophalangeal arthrodesis remains an acceptable alternative.

Unlabelled: THE PURPOSE OF THE STUDY was to evaluate interstitial laser photocoagulation for local destruction of osteoid osteoma, with computed tomographic (CT) guidance., Material and Methods: 28 patients (age range from 5 to 48 years) with presumed osteoid osteoma were treated with CT-guided interstitial laser photocoagulation of the nidus. A high power semiconductor diode laser (805 nm) with a 400 microns optical fiber was used. The fiber was introduced into the nidus through a 18-gauge needle. Around the fiber tip, well-defined coagulative necroses from 5 to 9 mm (energy delivery, 400-1000J) were obtained., Results: 27 patients had complete pain relief, which was effective within 24 hours in 18 patients. One patient had pain recurrence after 6 weeks. The remaining nidus was treated secondarily with complete relief. Treatment was unsuccessful in one patient, and surgical excision was performed. All patients were followed up for more than 1 year, with no sign of recurrence. The only notable complication was a mild reflex sympathetic dystrophy of the wrist in one patient. Sclerosis of the nidus was observed 6-12 months after the procedure., Conclusion: Percutaneous interstitial laser photocoagulation of osteoid osteoma seems to be a promising, simple, precise, and minimally invasive alternative to traditional surgical and percutaneous ablations.

A low patella is frequently a complication of a lesion of the knee but it can also present secondary symptoms of its own. The authors describe an original method for assessment of the vertical level of the patella. They have tried to establish a relationship between the low situation of the patella and pain of a certain type associated with limited flexion of the knee. Physiopathological and biomechanical evidence is taken into account. In most instances, a low patella is secondary either to a mechanical cause, natural or iatrogenic, or to an inflammatory cause such as algodystrophia. 29 patients out of 128 observed cases have been operated on. 17 of these were due to excessive transplantation of the anterior tibial tubercle. In most of the cases the tibial tubercle was transplanted upwards in association with a joint release. In only 3 cases a patellectomy was done. The results were excellent or good in half of the cases and unsatisfactory in the other half.