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Introduction The synovial wrist ganglion is a particularly common pathology of which the first "complication" is recidivism. The main objective of our study was to determine the rate of recurrence of this pathology in a series of arthroscopic patients. The secondary objective was to assess patient satisfaction well after the operation. Material and methods Our study was observational and retrospective and involved 30 patients (17 dorsal and 13 palmar cases) aged 41 years on average. The patients underwent an arthroscopic procedure for a palmar or dorsal ganglion of the wrist between March 2007 and April 2013. The data were collected by re-reading the files and conducting telephone interviews. Each patient answered a questionnaire about the operation, after-treatment, and their satisfaction well after the surgery. At the end of the interview, we calculated the Patient Rated Wrist Evaluation (PRWE) score. Results The mean follow-up was 4.6 years. A recurrence was noted in 4 (13%) cases, at an average delay of 9 months (6 months–1 year). There were only 2 patients (6.7%) that experienced the complication of complex regional pain syndrome type 1. Twenty-eight (93%) patients experienced improvement in postoperative pain. For 27 (90%) patients, firm-handed activities could be practised without limitation. The average time to resumption of activities of daily living was 27.1 days (1–240 days), resumption of firm-handed activities was 56 days (15–360 days), and return to work was 47.5 days (1–360 days). The mean PRWE score was 6.9/50 (0–34) for pain and 1.38/50 (0–8) for function. Conclusion The 13% recurrence rate is on the average of what is observed in the literature. Later satisfaction with the intervention is very good, and complications remain rare.Studies tend to show a lower rate of complications and recurrence following arthroscopic treatment, but to date, no randomized comparative series between the two methods has yet revealed any significant difference in these two points. A study of this type on a large scale could make it possible to highlight one of these treatment approaches.

In spastic patients, shortening wrist arthrodesis (SWA) is indicated in cases of severe fixed flexion contracture. At present, the most commonly used technique is dorsal plate osteosynthesis. Ideally, fixation with smaller hardware volume farther from the tendons would limit postoperative tendon irritation and reoperation rates for hardware removal. The objective of our study was to evaluate the efficacy of Rush pin SWA in adults. A retrospective study included all patients with a central neurological impairment, undergoing SWA using a Rush pin inserted through the head of the third metacarpal, and with at least 6 months' follow-up. Attainment of preoperative objectives was evaluated by Global Assessment of Response to Treatment (GART, ranging from -4 to +4) and, for functional objectives, the House score and the Frenchay Arm Test. Consolidation and any degenerative changes in the third metacarpophalangeal joint were assessed on X-ray. Fifteen patients were included, with a mean follow-up of 13 months (range, 6-29). In general, the preoperative objectives were attained: mean GART score was 2.7 (range, 1-4). Functional objectives were attained in 3 of the 11 patients followed up (27%). In all cases, the arthrodesis had healed at a mean 74 days (range, 39-102). Three had hardware removed after consolidation; 1 experienced discomfort at the head of the third metacarpal. Rush pin arthrodesis is an interesting alternative to plate arthrodesis in the management of severe wrist flexion contracture in spastic patients. It gives satisfactory results with regard to preoperative objectives and is not associated with complications. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Low back pain is a common, expensive, and disabling condition in industrialized countries. There is still no consensus for its ideal management. Believing in the beneficial effect of traction, we developed a novel external dynamic distraction device. The purpose of this work was to demonstrate that external distraction allows limiting the pressure exerted in standing-up position on the lower intervertebral discs. Numerical and cadaveric studies were used as complementary approaches. Firstly, we implemented the device into a numerical model of a validated musculoskeletal software (Anybody Modeling System) and we calculated the lower disc pressure while traction forces were applied. Secondly, we performed an anatomical study using a non-formalin preserved cadaver placed in a sitting position. A pressure sensor was placed in the lower discs under fluoroscopic control through a Jamshidi needle. The intradiscal pressure was then measured continuously at rest while applying a traction force of 200 N. Both numerical and cadaveric studies demonstrated a decrease in intradiscal pressures after applying a traction force with the external device. Using the numerical model, we showed that tensile forces below 500 N in total were sufficient. The application of higher forces seems useless and potentially deleterious. External dynamic distraction device is able to significantly decrease the intradiscal pressure in a sitting or standing position. However, the therapeutic effects need to be proven using clinical studies.

Lateral epicondylitis is a condition whose pathophysiology is poorly understood and whose optimal treatment divides physicians. Arthroscopy has proven its worth, with results similar to or better than open surgery. The purpose of this study was to look for prognostic factors for the outcomes of arthroscopic treatment of lateral epicondylitis. This was a retrospective, single-center study involving 39 cases (36 patients). Patients were split into two groups based on the Mayo Elbow Performance score (MEPS). A good result was defined as a score of 75 or better. The variables of interest were gender, age, body mass index, smoking habits, recognition as an occupational disease, duration of absence from work, cartilage involvement, presence of a capsular lesion and length of follow-up. The mean follow-up at review was 37.2 months (± 17.4). The average MEPS was 77.44 (± 15.51). Smoking was statistically related to a poor result (P = 0.0422) and a longer follow-up was statistically related to a good result (P = 0.0396). We identified two prognostic factors for lateral epicondylitis treated by arthroscopy. Smoking has a negative effect and ideally, patients should quit before surgical treatment. Time has a positive effect; thus patients should be informed that it will take several months or even years for their ailment to improve. Taking these factors into consideration will improve the functional outcomes of this surgery.

Few studies investigated whether trochlear and patellar design enhancements improve long-term outcomes of total knee arthroplasty (TKA). This study aimed to compare the long-term survival and complication rates of two consecutive generations of the same TKA system with identical tibiofemoral geometry, but different patellofemoral designs. The authors retrieved the records of 93 patients (104 knees) operated with the HLS II system and 116 patients (122 knees) operated with HLS Evolution system. Patients were evaluated preoperatively and at a minimum of 10 years noting all complications. Kaplan–Meier (KM) survival was compared for two endpoints: (1) revision of all components and (2) revision of any component. From the HLS II series, the incidence of revision of all components was 6.4%, and of any component was 9.8%. From the HLS Evolution series, the incidence of revision of all components was 4.1%, and of any component was 5.1%. Comparing the survival at equivalent follow-up of 14 years, considering revision of all components, the HLS II had higher survival than the HLS Evolution (98.9% vs 95.9%), while considering revision of any component, the HLS II had lower survival than the HLS Evolution (93.0% vs 94.9%). The differences in survival of the two implants were not significant, neither at equivalent follow-up of 14 years (n.s.), nor at maximum follow-up of each cohort (n.s.). The complication rate was higher for the HLS II series compared to the HLS Evolution (28% vs 12%, p = 0.009), but patellofemoral complications were not more frequent (8% vs 6%, n.s.). Though the differences in survival of the two implants were not significant, conflicting findings are observed due to partial revisions for patellar fractures (5 in the HLS II series and 1 in the HLS Evolution series) which could be related to patellofemoral design enhancements. This study highlights the importance of patello-femoral geometry, which is often overlooked in TKA. Retrospective comparative study, Level III.

Aggressive giant cell tumors are rare at the distal ulna. We report the results of two patients who were treated surgically using a distal ulna prosthesis stabilized by ligament reconstruction with the brachioradialis tendon. At the maximum follow-up of 18 months, the two patients were satisfied. Joint range of motion and functional scores were improved. X-rays showed no recurrence or subluxation; however gradual impingement of the ulnar notch of radius by the prosthesis was visible. Our technique seems to be a viable alternative when compared with the treatments described in other published case reports.

Our study aimed to compare the anatomical result after treatment of intraarticular distal radius fracture with locking volar plates with and without arthroscopy. This was a retrospective, single-center study of intraarticular fractures. A volar locked plate was used for fracture fixation in all patients. Twenty patients were operated on with fluoroscopy only (“plate” group) and 20 operated using arthroscopy assistance (“arthroscopy” group). All patients underwent a CT scan before surgery and at 3 months postoperative. The main outcome measure was the residual intraarticular step-off (measured in millimeters). Other studied outcomes were the residual gap between fragments and extra-articular reduction. The two groups were similar preoperatively in all aspects except the size of the gap between fragments. The residual step-off was significantly less in the arthroscopy group: 1.9 mm (Q1 1.7; Q3 2.25) for plate versus 0.8 mm (Q1 0.7; Q3 1.5) for arthroscopy (P = 0.001). The change from the preoperative to the postoperative measurement was significantly greater in the arthroscopy group: 0.1 mm (Q1 −0.5; Q3 0.8) for plate and −1 mm (Q1 −1.9; Q3 −0.6) for arthroscopy (P = 0.0002). The residual gap was similar between both groups: 2.4 mm (Q1 1.9; Q3 3.5) for plate vs. 2.3 mm (Q1 1.1; Q3 2.8) for arthroscopy (P = 0.37). The change in gap was not significantly different between the two groups: −0.9 mm (Q1 −1.8; Q3 −0.1) for plate vs. −2.9 mm (Q1 −4.4; Q3 −1.7) for arthroscopy (P = 0.32). There was no difference in the extra-articular reduction. Damage was found to the scapholunate ligament in 30% and the TFCC in 30% of arthroscopy cases. Arthroscopy improves intraarticular reduction without altering extra-articular reduction in patients with intraarticular fractures of the distal radius, and it allows for assessment and treatment of any injuries discovered. We must now follow these patients over the long-term to assess the clinical benefit. Level of evidence 3.

Summary Introduction The deep inferior epigastric perforator (DIEP) flap is a reliable and reproducible technique for autologous microsurgical breast reconstruction. Several recipient vessels sites for microvascular anastomosis have been described such as the internal thoracic vessels, the thoracodorsal vessels, and the circumflex scapular vessels. Nonetheless, the choice of the recipient site depends mainly on individual operator's experience and preferences, and currently the best recipient vessel site is under debate. This anatomical observational study aimed to determine whether anatomy could address this dilemma by determining the best vessel diameter to match the donor with these three recipient sites. Methods Our series reports 80 dissections of the three anatomical regions of interest. Forty formalin-preserved female cadavers were dissected bilaterally. Internal vessels diameter measurements were recorded with a vascular gauge ranging from 1.0 to 5.0 mm with successive half-millimeter graduations. Results The median diameter of the deep inferior epigastric (DIEA), internal thoracic (ITA), circumflex scapular (CSA), and thoracodorsal arteries (TDA) were: 2.0, 2.5, 2.5, and 1.5 mm, respectively. The median diameter of the deep inferior epigastric, internal thoracic, circumflex scapular, and thoracodorsal veins were: 3.0, 3.0, 3.0, and 2.5 mm, respectively. At the individual level, the perfect match between DIEA and ITA was significantly more frequent than between DIEA and TDA (p = 0.002), and it was more frequent between DIEA and CSA than between DIEA and TDA (p = 0.009). Conclusions This study supports the use of the internal thoracic pedicle as the first recipient vessel choice, which should be considered, at least anatomically, as the best one with the closest diameter matching with the donor pedicle.

Proximal row carpectomy (PRC) and four-corner arthrodesis (4CA) are the two most commonly performed surgical procedures to treat wrist arthritis. Postoperative strength is one of the criteria for choosing between the two techniques. Some authors believe that strength is correlated with residual carpal height. The goal of this study was to determine if postoperative carpal height was predictive of postoperative strength. This study consisted of two parts: a clinical evaluation of grip strength after 4CA or PRC; anatomical and radiological measurements of carpal height before and after 4CA or PRC. Grip strength was better preserved after PRC (87.5%) than after 4CA (76.1%), when expressed relative to the opposite hand (P=0.053). There was a significant decrease in carpal height for the PRC group with a Youm's index of 0.37 versus 0.50 for the 4CA group (P

While anatomical variations of the subscapular vessels are frequently encountered during axillary dissection, little is found in the literature. The aim of this cadaveric study was to define arterial and venous anatomical variations and frequencies of the subscapular vascular pedicle and its terminal/afferent vessels in women. We performed 80 dissections of the axillary region on forty female formalin-embalmed cadavers. Each anatomical arrangement was photographed and recorded on a scheme before analysis. We propose a new classification of the subscapular pedicle variations. We observed three types of subscapular arterial variation. The type Ia was the most frequent arrangement (71% of our dissections), the type Ib was observed in 11% and the type II in 18% of cases. We observed four types of subscapular venous variation. The type Ia was observed in 63% of cases, the type Ib in 14%, the type II in 14% and the type III in 10% of cases. This knowledge of the anatomical variation arrangement and frequencies of the subscapular vascular pedicle will assist the surgeon when dissecting the axillary region for malignant or reconstructive procedures.

Many conditions can cause foot drop, which makes walking difficult because the foot easily bumps into obstacles, or the knee must be kept more flexed than usual during the swing phase of gait, especially when going up stairs. Several techniques that have been described to correct foot drop rely on bone procedures or tendon transfer, with or without bone fixation. In this article, we describe a simple technique that is heavily used in leprosy-endemic countries and provides long-lasting results. It requires a double tendon transfer through the interosseous membrane of leg; the tibialis posterior and flexor digitorum longus are sutured to the tibialis anterior, and extensor hallucis longus and extensor digitorum longus, respectively, proximally to the extensor retinaculum.

In mutilans rheumatoid arthritis (RA) patients with major wrist destruction, wrist arthrodesis is recommended. This type of arthrodesis needs carpal reconstruction and stable fixation. The goal of this study was to assess the functional and anatomical outcomes of an iliac crest graft and internal fixation with two medullary pins. Six wrists in three patients suffering from RA were reviewed clinically and radiologically at an average follow-up of 25 months. We assessed the fusion of the iliac graft with the radius and the metacarpus, the preoperative and postoperative carpal height, and the bone stock in front of the thumb. All the patients had improved functionally. The iliac graft fused with the radius in all cases and fused with the metacarpus in 5 out of 6 cases; the non-union occurred in the wrist where only one pin was used. Restoration of carpal height was associated with improvements in hand function. The bone stock was sufficient to allow implantation of a trapezial cup during a total arthroplasty of the thumb trapeziometacarpal (TMC) joint. No major complications occurred. An iliac graft and two pins through the 2nd and 3rd metacarpals were used to reconstruct the carpal height and to obtain wrist fusion. Internal fixation with only one pin is not recommended. Functional improvement can be attributed to the normal tension within the extrinsic flexors and extensors of fingers and thumb being restored because the carpal height was restored. A secondary TMC arthroplasty is theoretically possible.

Despite advances in microsurgery, digital nerve repair remains a challenge due to the lack of reproducible procedures with satisfactory functional results. The aim of this study was to compare the sensory and functional results of direct microsurgical sutures protected by a Revolnerv(®) nerve regeneration conduit, with results of a series of direct sutures without a protective conduit in the literature. From November 2009 to April 2010, 35 patients were treated by direct epiperineural suture for digital nerve injury, protected by a Revolnerv(®) nerve regeneration conduit at the FESUM centre "SOS-mains Lesquin/CHRU de Lille". Sensory recovery was assessed by the static two-point discrimination Weber test (WS) and the Semmes-Weinstein (SW) test at postoperative months 1, 3, and 6. The final evaluation was performed after a minimum follow-up of 6 months. Statistical analysis of sensory results (WS and SW) was mainly performed with non-parametric tests (Wilcoxon, Mann and Whitney). P

Introduction Although Charnley-Kerboull metal-on-polyethylene 22.2 mm cemented total hip arthroplasty (THA) is considered to be the gold standard in France, results with this prosthesis are conflicting, in particular in relation to Scandinavian registers. The goal of this retrospective study was to confirm the validity of this prosthesis at a minimum of 10 years follow-up. Hypothesis Survival of this type of THA would fulfill NICE conditions (survival at 10 years of at least 90%). Materials and methods One hundred and five primary THA were performed in 93 patients (30 men and 63 women) mean age 72.6 years old (60–86) between January 1998 and March 2001. After a mean follow-up of 10.6 years (10–13 years), 21 patients (23 THA) were lost to follow-up and 32 (35 THA) had died leaving 40 patients (47 THA) for clinical analysis (Merle d’Aubigne and Oxford scores) and X-ray assessment. Survival was calculated with revision for any cause and radiological loosening with or without revision as end-points. Results The mean Oxford score at the final follow-up was 22/60 (13–45), the PMA score was 14.2 (11–17). Eight patients underwent revision surgery after a mean 7.5 years (2–11) (1 early dislocation and 7 acetabular cup loosenings). Survival at 10 years was 89.4% (CI95%: 78–95) for all causes of revision and 78% (CI95%: 61–91) for loosening with ( n = 7) or without ( n = 3) revision. No cases of septic or femoral loosening were observed. Twelve of the 47 revised hip replacements (25.5%) presented wear ≥ 2 mm. Discussion Although functional results were acceptable for this elderly population, survival did not reach the NICE value and was lower than results in the literature for this type of implant. Cup loosening and wear were the main causes of revision. Level of evidence IV: retrospective.

The functional consequences of spasticity can be corrected by local, pharmacological or surgical treatments once the spastic muscle has been identified. However, this diagnosis can be tricky when the muscle in question is rarely involved in spasticity or when its mechanical action is unusual or poorly characterized. Here, we present the case of a man presenting with left hemiplegia after an ischaemic stroke. His gait was perturbed by foot clonus in the sagittal plan, which persisted after selective neurotomy of the gastrocnemius and soleus but disappeared after neurotomy of the peroneus longus. Clonus triggered by pushing up under the whole of the forefoot in the direction of dorsiflexion may not be related to spasticity of the triceps surae. We recommend screening for foot clonus by first pushing up on the sole of the foot under all five metatarsals. In a second step, selectively pushing up under the first metatarsal joint enables the physician to evidence spasticity of the peroneus longus.

Tendon injuries are common in hand wounds and their functional consequences are not negligible. In emergency, tendon repairs techniques are well codified to restore function. These tendon repairs can be made in one session, in two sessions, or even use tendon transfers. Tendon transfers are not usual in the emergency but more common in the treatment of sequelae or failure of primary repair. We report one case of transfer to restore thumb flexion in emergency.

Lateral epicondylitis of the elbow is a relatively common pathology and would involve 1-3% of the overall population. Lack of consensus on surgical techniques reflects the difficulty of understanding and treating this disease. Our prospective study reports the results of its arthroscopic treatment on 14 patients operated on between 2009 and 2012. The mean follow-up was 7.15 months. All patients underwent a well conducted medical treatment for an average of 32.5 months. The operation was carried out under regional anesthesia in an outpatient. The technique included a time of joint exploration, joint capsulotomy and a transverse division of the pathological tendon of extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC). The value on the visual analogic scale (VAS) at rest and during exercise increased from 2.85 to 0.43 and from 7.71 to 2.43, respectively, then remained stable over time. Professional activity was resumed on average at 9.1 weeks. Neither intraoperative nor postoperative complications were found. No laxity was observed. The Mayo Clinic and DASH scores were significantly improved from 52.14 to 92.5 and from 54.11 to 9.7, respectively. Overall, we observed 11 very good and three good results. Although our prospective series has a few patients and limited follow-up, our results are better or similar than those reported in the literature on pain relief and functional recovery. In contrast, the average recovery of professional activity was longer. Elbow arthroscopy, less invasive than open procedures, and allowing further joint exploration, seems an excellent alternative technique in this indication.

Background Tibialis posterior transfer (TPT) is the treatment most widely used to palliate foot drop due to dorsiflexor palsy. TPT has been extensively studied in patients with peripheral neurological causes of foot drop. In contrast, data are scarce on central foot drop, in which TPT is often blamed for causing flattening of the arches. The primary objective of this study was to assess the impact on foot alignment of TPT in patients with central foot drop. The secondary objective was to determine whether TPT combined with other surgical procedures improved gait. Hypothesis TTP can induce flattening of the medial arch of the foot. Patients and Methods We retrospectively identified 13 patients managed with TPT (1 foot per patient). Mean follow-up was 65 months (range, 12–108 months). The causes were stroke (n = 5), head injury (n = 3), spinal cord injury (n = 2), cervical spondylotic myelopathy (n = 1), cerebral palsy (n = 1), and a brain tumour (n = 1). The clinical assessment focused chiefly on forefoot alignment and footprint parameters. The following variables were collected from weight-bearing radiographs: Djian-Annonier angle, Meary-Tomeno angle, lateral arch angle, and calcaneal pitch angle in the sagittal plane; talo-metatarsal angle in the transverse plane; and rearfoot valgus angle in the coronal plane. Results Of the 13 feet, 6 had normal footprint parameters and 7 pes cavus. There were no cases of flatfoot. Pronation deformities and supination deformities were each found in 2 patients. Comparing the radiographic parameters between the two feet in each patient identified differences only for the lateral arch angle and calcaneal pitch angle, which indicated pes cavus on the operated side (operated side: 142.7° [range, 136°–156°], p = 0.041; and 24° [range, 14°–33°], p = 0.028, respectively). Discussion In contrast to the working hypothesis, we found no evidence of progression to valgus flatfoot after TPT transfer performed to treat central foot drop. Level of evidence IV, retrospective study with no control group.

Background Radial nerve injury is common in humeral shaft fractures and fails to recover spontaneously in 30% of cases. Few studies have evaluated predictors of recovery. The objectives of this study were to identify predictors of radial nerve palsy recovery and to assess the usefulness of surgical radial nerve exploration in patients with preoperative radial nerve palsy. Hypothesis Factors predicting the outcome of radial nerve palsy can be identified. Methods Of 373 patients with humeral shaft fractures between 2005 and 2012, 43 had radial nerve palsy, including 23 who were lost to follow-up and 17 who were evaluated retrospectively at a mean of 26 months (range, 12–84 months) after internal fixation. The following were studied: age, smoking history, energy of the trauma, fracture type and displacement, skin integrity and intra-operative appearance of the radial nerve. Results Of the 17 palsies, 13 were present preoperatively, including 10 that recovered (PreR group) and 3 that did not recover (PreNR group). Plate fixation and radial nerve exploration were performed in all patients. Of the 10 PreR patients, 6 had nerve contusion and 2-nerve entrapment. Of the 3 PreNR patients, 2 had gross nerve damage and 1 nerve contusion and a history of spinal muscular atrophy. Only age and presence of gross nerve damage differed significantly between the PreR and PreNR groups; trends towards significant differences were noted for skin breach and fracture displacement. Of the 4 postoperative radial nerve palsies, 2 recovered fully and 2 partially; mean age was higher in the 2 patients with partial recovery. Discussion These findings are consistent with the few previous studies of outcome predictors in radial nerve palsy. Factors such as major fracture displacement and high-grade skin wounds probably promote the occurrence of gross nerve lesions. The high incidence of nerve entrapment and stretching supports routine nerve exploration during internal fixation in patients with preoperative radial nerve palsy. Level of evidence IV, retrospective study with no control group.

Introduction/Background Little is known about shoulder hypertonia in patients with brain injury. The principal aim of our study was to assess the results of spastic shoulder surgery in our team experience. Material and method Sixteen patients (18 shoulders) were retrospectively reviewed. The following were studied: etiology of hypertonia, shoulder deformation schemes, initial aims of surgery, shoulder pre- and postoperative mobility, impact of surgery on limb function when possible. None limb was functional preoperatively. Spontaneously, shoulders were all in a medial rotation, in adduction in 15 cases, in abduction in 3 cases. One had spontaneous retroposition. Therapeutic aim was hygienic in all and pain-relief in 6. Ten neurotomies of the lateral pectoral nerve (LPN), 8 intramuscular lengthening of the latissimus dorsi (LD), 9 percutaneous tenotomies of the pectoralis major (PM), one neurotomy of the motor nerve for the long head of triceps brachii (LHTB) and one intramuscular lengthening of the teres major (TM) were performed. Results Mean age at surgery was 52.1 (24–73). Etiology was vascular in 11, anoxic in 2, one had traumatic brain injury, one multiple sclerosis, one cervicarthrosic myelopathy. Preoperatively, the mean results for passive abduction of the shoulder was 50.6° (10–90) and for the passive lateral rotation was −5° (−70; 20). Postoperatively, there were respectively improved at 87.7° (60–160) and 6.7° (−20; 20). Only 3 muscles presented with residual tightness (two PM and 1TM) in patients where an isolated neurotomy of the lateral pectoral nerve (LPN) had been achieved. All of the initial objectives of the surgery were satisfied. One patient recovered a partial functionnal limb thanks to a recovered active shoulder flexion. Conclusion In classical medial rotation-adduction deformation schemes, surgery performed on the 3 main involved muscles (PM, LD, TM) offers good results in term of passive mobility of the shoulder and pain-relief.

Fascias can be used for reconstruction of gliding surfaces of upper and lower extremities or when thin, pliable coverage is required. Free large and well-vascularised fascial flaps are not very many and harvesting is seldom onto upper limb. The aim of this work was to study blood supply of the posterior brachial fascia in order to define the anatomical bases of a new free fascial flap. Our study included dissection on 18 anatomic specimens from 10 cadavers. Measures of the flap and blood supply were studied. Histological study was performed to analyse vessels location and measures into flap thickness. The posterior brachial fascia was thin, with a broad surface area and easily separable from the subcutaneous and muscular plane. Its average surface size is 115-mm length and 54-mm width. It was richly vascularised by two major pedicles: the cutaneous posterior brachial pedicule and the fascial branch of the superior ulnar collateral artery. Satellite venous elements were always present. A rich vascular network exists within the thickness of the fascia. Surgical procedure of flap harvesting is described. Harvesting of the flap can be carried out by a posteromedial approach into upper limb, without significant donor-site morbidity. This flap is adapted to cover and reconstruct gliding tendinous surfaces onto hand or fingers.

The medical art is more and more legally regulated. The case-law about civil medical liability has widely changed these past years. The reversal of the burden of proof regarding patient’s information, the presumption of responsibility in case of nosocomial infection, the medical liability without fault, the therapeutic risk and finally the law of 4 March 2002 are just a few examples of these changes. Regarding this judicial tendency of the medical practice, it appears interesting to study the contentious matters between doctors and patients in the orthopaedic and traumatologic surgery activity of a regional university hospital. Over a 20-year-period activity, at a rate of 3,000 patients per year, we found 20 files. The first complaints occurred 12 years after the medical event; they have become more frequent in the past 3 years. The most frequent reasons of complaint are the nosocomial infections and the lack of information to the patients. The rare medical errors could have had less effect if discussed beforehand with the patients. Nowadays fact sheets are available to the public and the committee for the prevention of nosocomial infection (CLIN) is positively involved. The complaints’ handling process is still slow, and therefore delays the compensation of victims. The increasing number of complaints made to the Regional commission for conciliation and compensation (CRCI) could be a solution to address those delays.

This study was undertaken to evaluate tourniquet tolerance in healthy people. An arm tourniquet was inflated to 100 mmHg above systolic blood pressure for 21 minutes. We measured pain and grip strength before, during and at various times after deflation. We tested 40 subjects (20 women and 20 men) with an average age of 38 (range 22–58) years. Eight individuals did not tolerate the tourniquet for this length of time and the test was stopped. Visual analogical scale had a globally linear increase during tourniquet application. We noted a sensation of well-being just after deflation, quickly replaced by pain in the tested limb due to limb reperfusion. We also noted a significant loss of strength in the tested limb, which completely recovered by 48 hours. We also observed a significant loss of strength in the contralateral hand, which also recovered by 48 hours. The possible reasons for these temporary losses of strength in both the ipsilateral and contralateral limbs are discussed.

Spastic pes equines, possibly associated with varus posture or spastic claw of the toes, can require neurosurgical treatment. In these cases, a selective fascicular neurotomy can be proposed, which consists of a partial section of some motor collateral branches of the tibial nerve. In order to avoid sensory and trophic complications after surgery due to an excessive manipulation of the nerve, accurate anatomical data must be collected. Therefore, biometric, histological and ultrastructural studies were carried out. A total of 50 dorsal compartments of the leg were dissected. The distance between the emergence of each muscular branch of the tibial nerve and anatomical landmarks were measured. Complementary histological study was processed on three specimens with slices stained by Masson's trichromatic method. Eventually, electronic microscopy observation was processed on two other specimens. In 16 cases (32%), we found a common muscular branch for all the muscles of the dorsal leg compartment, which emerged from the nerve trunk near the tendinous arch of the soleus (67 +/- 29 mm from the femorotibial articular line). In the other cases, muscular branches of the nerve emerged from its ventral lateral aspect, with variable origins (inferior nerve for the soleus: 82 +/- 31 mm from the femorotibial articular line, nerve for flexor digitorum longus: 116 +/- 41 mm, nerve for tibialis posterior: 106 +/- 51 mm, with a second nerve in 9/50 cases, nerve for flexor hallucis longus: 129 +/- 48 mm, with a second nerve in 6 cases). Histological and ultrastructural analysis confirmed the presence of the motor nervous fibers in the ventral lateral part of the nerve trunk. These new anatomical findings allow a more precise dissection during operative procedure, in order to avoid sensory or trophic complications.

During the last few years, several types of vascularized bone grafts have been described for the treatment of scaphoid nonunions reporting rates of union often higher than 90%. The goal of this study was to evaluate the results, complications and failures of Kuhlmann's vascularized bone graft. Thirty patients who had benefited from this graft between 2000 and 2005 were reexamined. The average age was 27 years (15-66 years). Seventeen patients were smokers. There were two cases of proximal pole necrosis. The average follow-up was 28 months (eight to 60 months). Osteosynthesis was carried out in 23 cases using a Herbert screw, in seven times with pins alone. Average immobilization time was six weeks. Twenty-two nonunions healed, that is to say a 73% union rate. Neither of the two cases of proximal pole necrosis cases united. Two articular radius fractures occurred during the harvesting of the graft. Five patients underwent a second intervention after this vascularized bone graft: four proximal row carpectomies and one conventional bone graft. Our union rate is disappointing, particularly compared to nonvascularized bone grafts for which the success rate is usually higher than 80%. This technique has many advantages thanks to its unique volar approach, but its realization requires a learning curve and important complications can occur at the beginning of experiment.

The use of Fuji films is simple but their manipulation and result interpretation seem to be difficult in the framework of medical research. The reliability and reproducibility of Fuji films have been proved by many previous studies. This study was undertaken to know precisely the articular zones of the elbow and to determine the compressive stress these areas undergo during different activities, in order to assess the importance of different articular contact areas. These data indicate the need for better-adapted elbow prosthesis and can be eventually used to design more durable prosthesis for the elbow. The compressive stress on the radial head was less than 25% in extension. The stress on the radial head varied from the neutral position (23% of the stress), to full pronation (11% of the stress) and to full supination (6% of the stress). The Humero-ulnar compartment had the maximum impact. Coronoid process seemed to be a fundamental element of the elbow joint in extension (60% of total compressive stress). The Medial humero-ulnar compartment was less stressed than the lateral compartment. The radial head does not seem to play a major role in the stability of the elbow in extension if the ulnar collateral ligament exists. The ulnar collateral ligament is essential to the elbow joint stability. The lifespan of a non-constrained prosthesis would depend on the existence of the couple: radial head/ulnar collateral ligament; the absence of radial head could compromise the humero-ulnar stability. This work paved the way for the designing of new non-constrained elbow prosthesis with the reconstruction of the radial head.

We report an unusual case of bifocal fracture of the sternal part of clavicle, combining a metaphysodiaphysal fracture of the sternal end of the clavicle, a proximal physeal fracture, and a ligament avulsion of sternoclavicular joint, without neurovascular damage. Its surgical repair used an osteosynthesis with K-wires and tension band wiring and synthetic ligamentoplasty of the anterior and posterior sternoclavicular ligaments, without any reconstruction of the costoclavicular ligament. The clinical and radiographic results at six months are presented and the operative technique used in this case of pseudodislocation of sternoclavicular joint is discussed and compared to those previously published.

Aim To evaluate efficiency of the tibialis posterior muscle transfer in patients with peripheral palsy of foot levators, and to determine occurrence of adverse effects on the static foot posture. Patients and methods Fifteen patients were evaluated retrospectively at a median 90 months follow-up (8–219). Eight patients had truncal paralysis (femoral fracture, knee sprain, total hip arthroplasty), 5 radicular (spinal trauma, disk hernia, lumbar surgery) and 2 neuropathic paralysis. The tibialis posterior was transferred on the tibialis anterior in 9 cases, on the second cuneiform twice, three times on the peroneus brevis and once on the navicular. None was associated to a Lambrinudi hind foot osteotomy. Collected data concerned (a) function: orthotics need, walking distance, and a satisfaction score (/4) (b) deficiencies: amplitude of active dorsiflexion, dorsiflexion strength and plantar footprint and (c) radiographic analysis, Djian angle and hindfoot alignment. Results The eleven patients wearing orthotics were completely weaned from it. Following the procedure, only one patient had a limited walking distance (50–200 m). The mean satisfaction score was 2/4 (−3/4). Maximum dorsiflexion meanly reached the neutral position (−20 to 15); the arc of movement averaged 11°(0–36) during analytic testing and 4,5°(0–10) when walking. Dorsiflexion strength averaged 2,75 (0–5). Eleven patients had a normal plantar footprint and 4 a cavus foot. Djian angle averaged 122 (111–130) and the hindfoot alignment angle was 5,3°valgus. The Djian angle was the only angle to be significantly different from the contralateral non operated foot (P = 0,015), with a trend to cavus foot. Discussion Tibialis posterior muscle is effective in foot-drop due to peripheral paralysis. A flat valgus foot does not appear to be a long-term complication of this procedure. On the contrary, we found a trend to cavus foot.

Objective Distal lower limb deformities are frequent after a central nervous system lesion, and have a significant impact on posture, gait and activity. This study aimed at analyse neuro-orthopaedics procedures performed in such indications, considering their timing, their main functional objectives and their global efficacy on gait and walking conditions. Methods One hundred sixty-one adult patients were assessed at the spasticity multidisciplinary consultation of Lille University hospital and then operated on in 2012 and 2013. Data were analysed retrospectively and included disease history, main functional objectives, nature of surgical procedures and their timing of realization and finally a qualitative analysis of analytic and functional results at the end of the treatment (with a one year post-surgery period). Results Patients presented with consequences of stroke (57.8%), traumatic brain injury (11.8%), cerebral palsy (9.3%); median post-lesion period was 3.5 years. The objective for patients was an improvement of gait (94.4%) and transfer (7,5%), and a reduction in walking aids (6.8%). Ninety-six patients (59.6%) were operated on twice; in this case, the first surgical phase consisted most of time in neurotomies, the second one in tendinous and articular procedures. At the end of the treatment, goals were totally reached in 2/3 of patients and at least in part in 30% of them. Kinematic abnormalities during gait (equinus, varus, valgus, toe claws) were clearly improved. Finally, the need of assistance when walking or making transfers and the need for orthotics were significantly reduced. Discussion This study confirms the efficacy of neuro-orthopaedic treatment of distal lower limb spastic deformities on gait and walking conditions. Efficacy on activities, participation and quality of life remains to be studied.

Comminuted radial head fractures are usually associated with destabilizing lesions of the elbow. The radial head prosthesis (RHP) is a therapeutic alternative when fracture fixation is impossible, as it restores one of the elbow's secondary stabilizers. The aim of this study was to assess healing of the medial collateral ligament (MCL) after implantation of a RHP. All patients implanted with a RHP during the 2003-2012 period were eligible for follow-up ultrasound evaluation of MCL healing. A clinical evaluation with standardized tests (DASH and MEPS) was performed and the patients asked to evaluate their elbow's stability during the same follow-up visit. Out of the 33 eligible patients, 20 were included with a mean follow-up of 73 months. The MCL had been torn in 15 of these 20 patients; the MCL appeared healed on the ultrasound images in 13 patients. The elbow was considered subjectively stable in 19 patients. The mean DASH score was 21.4 (±16.67) and the mean MEPS was 84.7 (±13.9); these scores were 17.19 (±14.0) and 88.3 (±10.9) for patients with a healed MCL, versus 32.5 (±10.6) and 70 (±0.0) for patients with a non-healed MCL. Our findings suggest that a torn MCL can heal after RHP implantation, even without surgical ligament repair or reattachment.

In order to later make precise the operative technique of free vascularized elbow allograft transfer, the anatomic conditions necessary for the success of such an operation are reviewed. The exact topography of the nutrient foramina of the humerus, radius, and ulna has been specified on 102 dry bones. The osseous resection at the recipient will have to be carried out on these aspects: nutrient foramina of the three bones of the elbow (at 9 cm from medial epicondyle for the humerus; at 8 cm for the two bones of forearm) in order to preserve diaphysary vascularization of the recipient. A study of arterial and venous vascularization carried out on 18 anatomic specimens showed that the osseous ends were irrigated by a periosteal arterial network and were drained in the centromedullary cavities. Systematization of the arteriovenous blood supply of the distal end of the humerus and proximal ends of the two forearm bones is proposed after dissection of 18 anatomic specimens. Arterial periosteal territories are defined. The importance of each peri articular arteriole is estimated according to the surface of its respective section. A radial, constant, and musculoperiosteal collateral artery from the brachial artery is described. It accounts for 12% (+/- 3%) of the total contribution. The recurrent radial artery is the most significant: 31% (+/- 9%) of the total contribution. The profunda brachii artery is negligible: 4% (+/- 2%) of the total contribution. As well for vascular as mechanical reasons, osteosynthesis will have to be carried out using screwed plates, the optimal location of which is specified according to the arterial periosteal cartography. Ulnar and radial nerves and, to a lesser extent, the median nerve can be harvested "en bloc" preserving their vascular supply in order to make vascularized grafts of them. Free vascularized elbow allograft transfer is technically possible, if one respects these anatomic bases.

Until now there has been no definitive anatomical study describing the area where the parotid duct enters the buccinator muscle. In this study, we performed anatomical and histological examinations to investigate the relationship between the parotid duct and the buccinator muscle. Thirty specimens (including the buccinator and the terminal portion of the parotid duct) were obtained from embalmed Korean cadavers. Dissection was performed on 22 of these specimens, and the remaining eight specimens were prepared for histological examination and stained with haematoxylin–eosin or Gomori trichrome. In all specimens, small, distinct muscle fibres originating from the buccinator muscle extended to and inserted into the terminal portion of the parotid duct. The topography of these fibres varied, and we classified them into three categories according to where they originated. Type I buccinator muscle fibres, which inserted into the terminal portion of the parotid duct, originated simultaneously from the anterior and posterior aspects of the duct (ten cases, 45.5%). Type II fibres originated from the anterior aspect of the duct and inserted into the anterior side of the duct (seven cases, 31.8%). Type III fibres originated from the posterior aspect of the parotid duct and ran anteriorly toward the duct (five cases, 22.7%). These results were confirmed in the histological examination of all eight specimens. Based on these findings, we have proposed a tentative description of the physiological role of the buccinator muscle fibres in salivary secretion and in the formation of the sialoliths.

Purpose of the study We conducted this retrospective study to analyze outcome obtained in 58 cases of carpal scaphoid nonunion treated with a non-vascularized corticocancellous graft. Our objective was to search for factors influencing outcome and identify appropriate indications. Material and methods Between 1984 and 1999, 103 patients were treated with a non-vascularized corticocancellous graft. Fifty-seven patients (58 wrists) were retained for analysis (4 deaths, 30 not attending follow-up consultation far from their residence, and 12 lost to follow-up). Mean follow-up was 106 months (range 19-212). Mean age was 36 years (20-62). Mean time to diagnosis of fracture was 35 months (6-252); the fracture was not recognized initially in 45 patients. According to the Schernberg classification, fractures were localized in zone II (n = 11), zone III (n = 40), and zone IV (n = 7). Using the Alnot classification, nonunion was grade I (n = 13), grade IIA (n = 20), grade IIB (n = 22), grade IIIA (n = 2), and grade IIIB (n = 1). Mean immobilization after grafting was 2.7 months. Results At three months, bone healing was achieved in 42 wrists. Thirty-six patients were very satisfied, 18 satisfied and four not satisfied. Twenty-seven patients presented significant pain at the graft harvesting site which regressed in all. There were no harvesting sequelae. Compared with the healthy wrist, we noted reduced flexion (8.7 degrees on average), extension (12.8 degrees on average), and radial inclination (10.5 degrees on average). Other wrist motions were not affected, particularly pronation and supination. The index of carpal height was 0.54 on average (range 0.47-0.57); carpal height was diminished in nine wrists. The radiolunate angle was 4.8 degrees on average (-17 degrees to +27 degrees). Dorsal intercalated segmental instability (DISI) was noted in twenty wrists. Bone healing was not achieved in eleven wrists, seven of which presented initial necrosis of the proximal pole. Pain improved in all patients. Persistence of DISI favored osteoarthritic degeneration. Discussion With this technique, we achieved bone healing in 81% of the cases. Non-vascularized grafting cannot provide cure in the event of advanced osteoarthrtic degeneration. Correction of DISI appears to be an indispensable element for the prevention of osteoarthritis. This technique should not be proposed for patients with a necrotic proximal pole, a vascularized graft would be preferable.

The anatomical knowledge of the dorsal aspect of the hand has been enriched these last years by a more surgically applied approach, especially of that of its integument and blood supply. The vascularization of the superficial nerves, the anastomoses between the dorsal and palmar arterial networks has allowed designing new flaps, ante- and retrograde, usable in the coverage of more and more distal defects. The extensor apparatus shows many anatomic variations, often asymptomatic, except the extensor digitorum brevis manus muscle, which can mimic a mass at the dorsal aspect of the hand.

The management of chronic instability of the scapholunate joint is controversial. We have opted for scaphocapitate arthrodesis in such cases. The aim of this study was to analyse the clinical and radiological results of this procedure. Between 1997 and 2001, 13 scaphocapitate arthrodesis were performed for this indication. Eleven using two screws, one using a single screw plus a staple, and one using a single staple alone. The average age of the patients was 40 years. There were 8 sport accidents and 5 work accidents. The average follow-up was 26 months. We analysed the functional results and measured the height of the carpus and the radio-lunar angle radiographically. We noticed a mobility loss of between 20 and 40%, especially for radial tilt and flexion. The grip strength was improved. All the patients except one have some residual pain. We noted three non-unions which required revision with eventual final consolidation. The height of the carpus was improved. The average radio-lunar angle at follow-up was 16 degrees. Only one wrist remained in DISI. The mobility of the wrist was decreased by this procedure. In all these cases the dorsal approach to the wrist which we employed was bound to decrease the mobility. The radial tilt was decreased due to the partial arthrodesis. This procedure restore the height of the carpus and partially corrects the DISI. As we were not able to obtain a pain free wrist through our procedure, we raise the question as to whether a total neurectomy of the wrist should be performed at the same time.

Resume Introduction. – La morbidite des pseudarthroses de l'humerus n'est pas negligeable, les buts de cette etude retrospective etaient d'apprecier les resultats de ces reprises difficiles et d'essayer de codifier la prise en charge chirurgicale. Patients et methodes. – Entre 1996 et 2000, 21 patients ont ete operes d'une pseudarthrose de la diaphyse humerale. A la revision, l'âge moyen etait de 40 ans. Les causes du traumatisme initial etaient : 12 AVP, sept chutes de hauteur d'homme, une defenestration, un accident de travail par machine agricole. Les localisations de la fracture etaient le plus souvent au niveau du tiers moyen. Dans 17 cas de reprise pour pseudarthrose, l'osteosynthese etait effectuee par plaque vissee. Trois patients ont beneficie d'un fixateur externe devant l'existence d'un sepsis. Un patient a ete osteosynthese par un clou verrouille de type Seidel. Dans six cas il s'agissait de la prise en charge d'une pseudarthrose iterative dont une patiente qui a ce jour n'a toujours pas consolide. Nous avons utilise le score de la Societe d'orthopedie de l'ouest (SOO). Resultats. – Selon le score d'evaluation de la « SOO » nous avons constate : dix tres bons resultats, cinq bons resultats, trois resultats moyens, un mauvais resultat. Le seul mauvais resultat correspondait a la patiente chez qui la consolidation n'a pas ete obtenue. Discussion et conclusion. – Le traitement plus precoce des pseudarthroses d'humerus parait justifie, cependant le meilleur traitement des pseudarthroses d'humerus reste celui de la prise en charge de la fracture initiale.

Osteoid osteomas are often localised in long bones but only rarely in the carpus. This is a case report of an osteoid osteoma in the trapezoid. Diagnosis was difficult and established late, due to misleading initial symptoms. Radiological examination allowed localisation of the nidus. For osteoid osteoma localised in a carpal bone, we recommend total removal without bone-graft or arthrodesis.

We report an autopsy on a 46-year-old man, a case that presented the concurrence of two rare vascular variations of the lesser omentum: aberrant right gastric vein draining directly into the liver, and multiple hepatic arteries. Although the left gastric vein emptied into the left aspect of the portal vein, the right one was found to ascend from the gastric lesser curvature along the right aspect of the common bile duct and to reach directly the porta hepatis. A left hepatic artery originating from the left gastric artery entered the porta hepatis in conjunction with the left ramus of the portal vein. A predominant right hepatic artery arose from the superior mesenteric artery and entered the porta hepatis in conjunction with the right ramus of the portal vein. The proper hepatic artery originating from the celiac artery entered the porta hepatis in conjunction with the aberrant right gastric vein. The possibility of a common underlying mechanism for these rare vascular variations is discussed.

The current authors retrospectively assessed 56 hip shelf arthroplasties (48 patients) with a mean followup of 17 years (range, 15-30 years) and 89 Chiari osteotomies (82 patients) with a mean followup of 13 years (range, 6-25 years) done in adults with painful hip dysplasia. Preoperative joint space narrowing was observed in 32 of 56 shelf arthroplasties and in 67 of 89 Chiari osteotomies. Survival rates, using hip replacement as the end point, were 37% (20% to 54%) at 20 years for shelf arthroplasty and 68% (54% to 81%) at 18 years for Chiari osteotomy. The severity of preoperative arthrosis was the main factor that impaired the survivorship of shelf arthroplasty and Chiari osteotomy. With arthritic changes without joint space narrow- ing, the 18-year survival rates were 83% (69% to 97%) for shelf ar- throplasty and 94% (89% to 99%) for Chiari osteotomy. Shelf arthro- plasty is best indicated for moderate dysplasia (center edge angle >0°) without severe arthrosis. Chiari osteotomy is best suited for severe dysplasia (center edge angle

Objective Beside the posterior leg compartment, spasticity of the hemiplegic patient can involve other muscle groups in the leg. Spasticity of the lateral compartment is responsible of a vertical clonus that may be confused with the clonus of the triceps surae (long fibular) or a transverse clonus (short fibular), and by the liveliness of the tendon reflex when striking their tendon. Beside recurrent botulinum toxin injections, this spasticity may be treated by a hyponeurotisation by partial section of the branches of the superficial fibular nerve to the muscle(s) concerned. Its technique has never been described. Material/patients and methods Twelve legs of formalin corpses have been dissected. The number of branches to PL and PB, their level of emergence from the common and deep fibular nerves, and their entry point into the muscle have been measured from the lateral femoral-tibial articular space (LTF). Results There was always a common trunk to the EDL and the EHL, arisen on average at 10.3 cm (8.2–13.6) from the LTF line. Six times out of 10 in addition to this common one (3), two (2) or three (1) additional branches to the EDL, arisen between 4.6 and 12 cm downstream the LTF line. Six times out of 10 in addition to this common trunk existed one (4) or two (2) additional branches to the EHL, arisen between 13 and 26 cm downstream the LTF line. Discussion–conclusion This first study allow establishing the surgical technique of the hyponeurotisation of PL and PB muscles. The first results are presented.

Resume L’abduction permanente du cinquieme doigt peut entrainer une gene quotidienne chez les patients presentant une paralysie ulnaire. Pour corriger cette deformation, des transferts actifs musculotendineux sont habituellement realises en utilisant l’appareil extenseur de la main. De par la variabilite anatomique de ce dernier, ces transferts actifs peuvent provoquer en postoperatoire des deficits d’extension du cinquieme doigt. L’analyse de l’orientation de ces transferts d’extenseurs montre une faible composante adductrice des forces de tension. Une correction chirurgicale par tenodese est proposee dans cette etude preliminaire. Cette plastie a pour objectif d’augmenter la composante adductrice du cinquieme doigt sans utiliser l’appareil extenseur des doigts. Les avantages et les inconvenients de cette technique sont discutes. Une evaluation clinique sera realisee ulterieurement pour confirmer la fiabilite de cette technique.

Resume Introduction . – Nous avons mene une etude prospective de l’osteosynthese en vasque sur des fractures de l’extremite distale du radius. Le but etait d’etudier les possibilites de reduction des fractures complexes et la stabilite de ce montage dans le temps. Methode . – Il s’agissait de 12 patients âges en moyenne de 47,1 ans presentant des fractures articulaires de l’extremite distale du radius. Tous les patients ont ete vus a j0, j45, a j180 et a 36 mois avec un bilan clinique (score de Herzberg) et radiologique (mesure des inclinaisons radiales, sagittales et de la variance ulnaire). Resultats . – A 36 mois, nous avions 8 bons et excellents resultats, 3 moyens et 1 mauvais. L’osteosynthese en vasque a permis des reductions satisfaisantes mais n’a pas pu empecher les deplacements secondaires dans les fractures comminutives. Discussion . – Nous pensons que l’osteosynthese en vasque est une bonne technique d’osteosynthese mais elle ne permet pas le controle de la variance ulnaire. Elle devrait etre associee a un comblement de la perte de substance osseuse dans les fractures comminutives et a un vissage epiphysaire chaque fois que cela est possible.

We led a retrospective study to determine the causes of the tendon ruptures post-operating in the surgery of the wrist rheumatoid dorsal and to estimate the clinical result. At follow-up, we measured the extension lag and the rolling-up of fingers by the distance palm-pulps. Nine patients were so revised in the average of 40 months, average age was of 50.7 years. The tendon ruptures arose in 3 months in 67% of the cases. Seven times, a procedure on the distal radio-ulnar joint had been necessary (5 Sauve-Kapandji and 2 Darrach). Thirty tendons had been concerned in this study, that is 3.3 tendons on average (1-5). Two main causes were found: attrition on the stub ulnaire and great intra-tendinous synovitis (per operating observation). At the revision, the lag extension means was 23 degrees (0-40). Rolling-up of the long fingers was complete 4 times on 7. The best results were observed after tendinous grafting or index proprius transfer with a lateral suture. Tendinous adhesions had arisen 6 times and persisted still at 3 patients. Our study underlines the interest to stabilize the stub ulnaire to prevent the post-operating ruptures and proposes a transfer or a graft in front of tendons very weakened by the synovitis.

Resume La resection de la tete radiale, comme la resection distale de l'ulna, peuvent perturber la cinematique de l'avant-bras. Les buts de cette etude retrospective etaient d'apprecier les resultats cliniques et radiographiques apres successivement osteotomie distale de l'ulna et resection de la tete radiale. Entre 1990 et 1998, 11 patients ont beneficie d'une telle procedure a l'occasion de la pose d'une prothese de coude (huit protheses Kudo et trois protheses GSB III). L'intervention sur le poignet avait consiste en cinq arthrodeses totales du poignet avec resection distale de l'ulna, quatre interventions de Sauve-Kapandji et deux interventions de Darrach. L'âge moyen des patients etait 58 ans, le recul moyen etait de 40 mois. Au recul, nous avons quantifie les douleurs du coude et du poignet selon la classification de Gschwend. Nous avons mesure le cubitus valgus de l'avant-bras, consequence de la resection de la tete radiale, et avons recherche un ressaut du moignon distal de l'ulna. Un conflit par ascension du radius etait recherche a l'examen clinique par une limitation de la flexion par effet de butee. Au recul, six patients n'avaient aucune douleur au niveau du coude et cinq gardaient des douleurs occasionnelles. Cinq poignets n'entrainaient aucune douleur, et six des douleurs occasionnelles. La mobilite du coude a ete amelioree dans tous les secteurs, sauf pour la supination. Au recul, les mobilites du poignet n'etaient pas homogenes en raison des cinq arthrodeses. Si l'on exclut ces cinq arthrodeses les mobilites moyennes etaient 10° en flexion, 16° en extension, 2° en l'inclinaison radiale, 14° en inclinaison ulnaire. A la revision, aucun ressaut n'a ete observe au niveau des articulations radio-ulnaire distale ou proximale. Nous n'avons pas observe d'instabilite des deux os de l'avant-bras. Aucun conflit proximal du moignon radial n'a ete identifie. Le cubitus valgus clinique etait de 10° en moyenne. Cette etude confirme le role predominant de la membrane interosseuse dans la stabilite des deux os de l'avant-bras.

Resume Entre 1991 et 1998, 23 fractures de l'humerus ont ete traitees par fixateur externe Orthofix ® . L'âge moyen des patients etait de 42 ans et le recul moyen de 55,5 mois. Le traumatisme initial consistait : 13 accidents de la voie publique, quatre chutes dans le cadre d'un accident domestique, deux accidents agricoles delabrants, deux accidents de sport, une agression et un traumatisme balistique. Le type de fracture a ete classe selon la classification de l'AO. Nous avons utilise la classification de Hackethal modifiee de la Caffiniere pour classer la localisation. Nous avions une majorite de fractures du 1/3 moyen, du 1/3 inferieur et une majorite de fractures polyfragmentaires. A la revision la mobilite moyenne du coude etait de 130°. Les mobilites moyennes de l'epaule etaient abduction 161°, rotation externe 69,5° et rotation interne 92,5°. Selon la classification de Stewart et Hundley, nous avions 8 excellents resultats, 7 bons resultats, 3 moyens et 2 mauvais. Nous n'avons constate aucune paralysie radiale iatrogene. Pour deux patients dont un etait deja consolide, il a ete necessaire de retirer le fixateur externe devant la mobilisation des fiches. Parmi les trois echecs : un patient qui a donc ete repris devant la mobilite des fiches et le retard de consolidation ; 2 pseudarthroses reprises par plaque et greffe osseuse autologue. Le bilan radiologique, realise chez tous les patients a la revision, ne montrait pas de cal vicieux important. Par sa rigidite et la possibilite de dynamisation secondaire, ce fixateur garde notre preference pour ce type de traitement. Nous avons considere la consolidation acquise au moment de l'ablation du fixateur. Cela explique le long delai de consolidation dans cette etude inaugurale avec ce materiel.

The aim of synovectomy-stabilization (synovectomy combined with the Sauvé–Kapandji procedure) of the rheumatoid wrist is to obtain a stable painless wrist, retaining enough mobility for function. Thirty-nine wrists were retrospectively examined, at a mean follow up of 64.8 months. The improvement in pain was very significant. We noticed a decrease in wrist motion affecting both flexion and radial deviation. The arthritic change in the wrist continued to increase. We noticed a mean ulnar shift of 2.2 mm and a mean increase in the radial deviation of the wrist of 7°. Only transfer of the extensor carpi radialis longus tendon to the extensor carpi radialis brevis tendon was effective in correcting radial deviation of the carpus. Ninety-seven per cent of patients were very satisfied or satisfied. These encouraging results, even at advanced stages of wrist arthritis, have prompted us to lessen the indications for wrist arthrodesis.