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Understanding the biomechanics of the trapeziometacarpal (TMC) or first carpometacarpal (CMC1) joint, the pathophysiology of basal thumb arthritis, the design and performance of surgical procedures require a solid anatomical basis. This review of literature summarizes the most recent data on the descriptive, functional, and comparative anatomy of healthy and arthritic TMC joints.

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.

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.

Resume Introduction Le nerf radial est souvent atteint dans les fractures humerales ; 30 % ne recuperent pas spontanement. Les facteurs pronostiques de ces paralysies sont peu etudies dans la litterature. Les objectifs etaient de : 1) determiner les facteurs pronostiques des paralysies radiales, 2) evaluer l’interet de l’exploration du nerf dans les paralysies preoperatoires. Hypothese Des facteurs pronostiques des paralysies radiales peuvent etre identifies. Methodes Trois cent soixante-treize patients ont presente une fracture de la diaphyse humerale entre 2005 et 2012. Quarante-trois presentaient une paralysie radiale ; 26 etaient perdus de vue. Dix-sept patients operes etaient revus retrospectivement a 26 mois (12–84). Les criteres etudies etaient : l’âge, le tabagisme, l’energie du traumatisme, le type et le deplacement fracturaire, l’ouverture cutanee et l’aspect du nerf en peroperatoire. Resultats Treize des 17 paralysies etaient preoperatoires. Trois etaient deficitaires (groupe PRD), 10 ont completement recupere (groupe PRND). Une osteosynthese par plaque a ete realisee chez tous, ainsi qu’une exploration du nerf radial. Dans le groupe PRND, on retrouvait un nerf contus chez 6 patients et incarcere dans 2 cas. Dans le groupe PRD, deux presentaient des lesions nerveuses macroscopiques et le troisieme un nerf contus avec antecedent d’amyotrophie spinale. Seuls l’âge et la presence de lesion nerveuse macroscopique etaient significativement differents entre les deux groupes ; on notait une tendance a la difference significative concernant l’ouverture cutanee et le deplacement fracturaire. Quatre des 17 paralysies etaient postoperatoires. Deux ont completement recupere et deux partiellement. La moyenne d’âge de ces deux derniers etait plus elevee. Discussion Ces resultats sont semblables a ceux des rares series s’interessant aux facteurs pronostiques des paralysies radiales. Les facteurs tels que le deplacement fracturaire important, une ouverture cutanee de haut grade doivent favoriser les lesions nerveuses macroscopiques. L’incidence elevee de nerf incarceres et etires rend le controle systematique du nerf radial souhaitable lors de l’osteosynthese en cas de paralysie radiale preoperatoire. Niveau de preuve Niveau IV, etude retrospective sans groupe temoin.

Several techniques have been described for fusion of the distal interphalangeal joint. The intramedullary Lync® implant (Novastep™) may be superior to other options as it is available in straight or bent configurations, does not need to be removed and does not require fingertip incisions. The objective of our prospective study was to determine the effectiveness of finger distal interphalangeal (DIP) arthrodesis with Lync® implants. Between February 2016 and June 2017, we performed 22 cases of DIP arthrodesis with this implant. Pain was assessed with a visual analog scale, the joint range of motion was measured using a digital goniometer, the pulp to palm distance was measured using a ruler, and the QuickDASH Questionnaire was filled out. AP and lateral X-rays were used to look for secondary displacement at 3 weeks and joint fusion at 6 weeks, 3 months, 6 months and 12 months. The primary endpoint was clinical and radiological union defined as the presence of trabecular bone bridges across the arthrodesis site. The patients’ mean age was 57.8 years ± 9.9 (36–73). The mean follow up was 10 months ± 4.9 (3–15). The pre-operative pain level was 6/10 ± 2.4 (0–10) and it was 1.3/10 ± 1.7 (0–6) at 3 months post-operative (P

Extensive anatomical knowledge is needed in order to correctly treat distal radius fractures: normal and pathological osteology of the distal radius, distal radio-ulnar joint and radiocarpal joint-both on the descriptive and functional level-the neurovascular and muscular environments of the distal radius-which are essential to the surgical approaches-and the angles that need to be restored during the reduction. All of these concepts are broached in this article.

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

Resume Introduction Le transfert du muscle tibialis posterior (TTP) est le traitement palliatif le plus realise pour pallier le deficit neurologique des releveurs du pied. S’il a ete bien etudie apres atteinte peripherique, il reste peu evalue en cas d’atteinte centrale, ou il est souvent accuse de provoquer un effondrement de la voute du pied. Aussi nous avons mene une etude retrospective afin de : (1) de mesurer son retentissement sur la statique du pied, (2) savoir si ce transfert associe a d’autres gestes chirurgicaux permettait une amelioration des conditions de marche. Hypothese Le TTP peut provoquer un effondrement de l’arche mediale du pied. Patients et methodes Treize patients (13 pieds) ont ete revus a 65 mois (12–108) apres une chirurgie incluant un TTP. Les etiologies etaient 5 accidents vasculaires cerebraux, 3 traumatismes crâniens, 2 traumatismes medullaires, une myelopathie cervicarthrosique, une paralysie cerebrale et une tumeur cerebrale. Cliniquement, les principales evaluations portaient sur la statique de l’avant-pied et le type d’empreinte plantaire au podoscope. Radiographiquement, on relevait sur des cliches en charge, (1) sagittalement : l’angle de Djian, l’angle de Meary-Tomeno, l’angle de l’arche laterale et l’inclinaison calcaneenne, (2) transversalement et frontalement, l’angle talo-metatarsien et l’angle Djian-Annonier. Resultats Cliniquement, on relevait 6 empreintes plantaires normales et 7 pieds creux. Aucun ne presentait de pied plat. Deux patients presentaient des deformations en pronation et 2 en supination. Radiologiquement, les seules les differences entre les 2 pieds concernaient l’angle d’arche laterale et l’angle d’inclinaison calcaneenne en faveur de pieds creux du cote opere (respectivement, cote opere, 142,7° [136–156] ; p = 0,041 et 24° [14–33] ; p = 0,028). Discussion Contrairement a notre hypothese, on ne notait pas de tendance a la decompensation en pied plat valgus des patients avec atteinte centrale chez qui a ete realise un transfert du tibial posterieur sur le dos du pied. Niveau de preuve IV, etude retrospective sans groupe temoin.

Déclaration de liens d’intérêtsRecherches cliniques/travaux scientifiques : oui [KERIMEDICAL].Consultant, expert : oui [KERIMEDICAL].; International audience; Les lésions nerveuses sans perte de substance de la main et des doigts sont des causes fréquentes de prise en charge chirurgicale aux urgences. La suture directe peut être accompagnée de la mise en place d’une gaine de couverture apportant une protection neurorégénératrice.L’objectif de notre étude est de rechercher l’apport biomécanique de l’utilisation des gaines de chitosan (REAXON®) dans les sutures directes nerveuses.Nous avons réalisé une étude in vitro anatomique, comparative, contrôlée en ouvert sur des nerfs digitaux propres et communs. Après dissection de nerfs issus de cadavres, des segments nerveux calibrés ont été répartis dans 3 groupes de suture nerveuse. Un groupe avec suture simple directe (groupe 1), un groupe avec suture directe simple associée à la mise en place d’une gaine REAXON® (groupe 2). Enfin, un groupe avec mise en place d’une gaine REAXON® sans suture nerveuse directe (groupe 3). La force de rupture de la suture a été évaluée pour chaque groupe sur cellule d’effort Dynacell® 3000 N. La médiane de rupture a été calculée pour chaque groupe et comparée entre les groupes par un test de Kruskal-Wallis.La force de rupture médiane du groupe suture simple est de 2,97 [2,5–3,7] Newtons (N) ; pour le groupe tube seul la force de rupture médiane est de 1,82 [1,7–2,3] N. Enfin, pour le groupe suture associée au tube la force médiane de rupture est de 4,17 [3,2–4,7] N. Il n’existe pas de différence significative entre les groupes suture simple et tube seul (p = 0,1209) ni entre les groupes suture simple et suture associée au tube (p = 0,3853). Il existe une différence significative entre les groupes suture associée au tube et tube seul (p = 0,0011).La mise en place d’une gaine de protection REAXON® ne semble pas apporter de supériorité mécanique comparativement à la suture simple. La mise en place d’une gaine REAXON® sans suture nerveuse est associée à de moindres performances mécaniques et une rupture plus précoce qu’avec suture simple nerveuse.

Elbow dislocation can lead to instability and stiffness of the elbow. The main goal of this study was to list the initial elbow ligaments injuries caused by simple posterolateral elbow dislocations. The secondary goals were to assess ligament healing 2 months after the initial dislocation, to research a correlation between ligaments injuries and clinical course, and to search for predictive factors of instability. Patients who had simple posterolateral elbow dislocation for the first time between January 2015 and May 2016 were included. Each patient had an MRI scan of their traumatised elbow on the day of the dislocation and then again 2 months later. The assessment was performed thanks to a clinical examination and calculation of functional recovery scores. The Mann–Whitney U test was used to research a correlation between the healing of ligaments injuries and clinical course. Twenty-five patients were included in the study. The initial MRI scans showed 70% and 54% ligament rupture, respectively, for the anterior band (ant MCL) and the posterior band (post MCL) of the medial collateral ligament (MCL), as well as 79% for the ulnar (ULCL) and 50% for the radial (RLCL) lateral collateral ligaments. The healing rate 2 months after dislocation was fairly low from 18% for the ULCL up to 41% for the anterior band of the MCL. No correlation was found between the ligament healing noticeable on MRI scans and clinical course. No elbow instability was diagnosed during the 4-month follow-up. Elbow dislocation is particularly damaging for ligaments. There is no predominance on medial or lateral ligament for rupture. The low healing rate 2 months after the initial dislocation could be explained by performing a follow-up MRI scan too early.

Resume Introduction La dystonie en extension de l’hallux et/ou des petits orteils peut etre observee dans le cadre de lesions pyramidales et extrapyramidales et entrainer des douleurs des orteils concernes, spontanees ou a la marche, des difficultes et un inconfort lors de l’habillage ou le chaussage et des lesions cutanees des orteils. L’objectif de cette etude etait d’evaluer l’efficacite et la tolerance de la neurotomie des branches du nerf fibulaire profond destinees aux muscles long extenseur de l’hallux (LEH) et/ou long extenseur des orteils (LEO) dans le cadre du traitement de la dystonie en extension de l’hallux et/ou des orteils. Patients et methode Une neurotomie fibulaire profonde a ete realisee chez 20 patients ( n = 19 pour le LEH, n = 6 pour le LEO). Efficacite et tolerance du traitement ont ete analysees retrospectivement et via une entrevue telephonique permettant de mesurer l’impact subjectif sur les differentes genes du patient et son niveau de satisfaction. Resultats La dystonie avait disparu totalement dans 15 cas (75 %), elle persistait a un niveau minime chez les autres patients. Les patients rapportaient une diminution du niveau de douleurs ( p p Discussion La neurotomie des branches du nerf fibulaire profond pour le LEH et/ou le LEO semble etre un traitement efficace de l’hyperextension de l’hallux et/ou des orteils et de ses consequences chez le patient adulte neurologique. Cependant, ces resultats preliminaires encourageants doivent etre confirmes par des travaux prospectifs a plus long terme. Niveau de preuve IV.

Resume De nombreuses affections sont responsables d’un pied tombant, qui gene considerablement la marche, le pied butant facilement sur un obstacle, ou le genou devant etre plus flechi que normalement au cours de la phase oscillante du pas, notamment lors de la montee des escaliers. Plusieurs techniques ont ete decrites afin d’y remedier, faisant appel a des gestes osseux ou a des transferts tendineux, plus ou moins a fixation osseuse. Les auteurs decrivent une technique simple, tres pratiquee en zone d’endemie lepreuse, et qui donne des resultats durables ; elle fait appel a un double transfert tendineux a travers la membrane interosseuse crurale, utilisant le tibial posterieur et le long flechisseur des orteils qui sont sutures en amont du retinaculum des extenseurs, respectivement au tibial anterieur et aux longs extenseurs de l’hallux et des orteils.

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.

Resume Introduction La prothese totale de hanche (PTH) cimentee metal-polyethylene en calibre 22,2 mm de type Charnley-Kerboull est consideree comme le gold standard en France, mais fait l’objet de resultats discordants notamment dans les registres scandinaves. Cette etude retrospective avait pour but de verifier la validite de ce concept au recul minimal de 10 ans. Hypothese La survie de ce modele d’arthroplastie remplit les conditions du NICE (survie a 10 ans depassant 90 %). Patients et methodes Cent cinq arthroplasties primaires ont ete effectuees chez 93 patients (30 hommes et 63 femmes) âges en moyenne de 72,6 ans (60–86) entre janvier 1998 et mars 2001. Au recul moyen de 10,6 ans (10–13 ans), 21 patients (23 PTH) etaient perdus de vue et 32 (35 PTH) decedes laissant 40 patients (47 PTH) pour l’analyse clinique (score de Merle d’Aubigne et d’Oxford) et radiographique. La survie a ete calculee avec pour censure les reprises toutes causes confondues et les descellements radiologiques repris ou non. Resultats Le score d’Oxford moyen au recul etait de 22 (13–45), le score PMA de 14,2 (11–17). Huit patients ont ete repris au recul moyen de 7,5 ans (2–11) (1 luxation precoce et 7 descellements acetabulaires). La survie a 10 ans etait 89,4 % (IC95 % : 78–95) pour toute cause de reprise et 78 % (IC95 % : 61–91) pour les descellements repris ( n = 7) ou non ( n = 3). Aucun descellement septique ni femoral n’etait observe. Douze des 47 protheses revues (25,5 %) presentaient des usures ≥ 2 mm. Discussion Bien que les resultats fonctionnels soient acceptables compte tenu de l’âge eleve de la population, la survie n’atteignait pas la valeur du NICE et etait inferieure aux taux habituellement retrouves dans la litterature pour ce type d’implant. Les descellements des cupules et l’usure etaient les principales causes de revision. Niveau de preuve IV : retrospectif.

L’arthrose carpo-metacarpienne (CMC) ulnaire est une pathologie rare. Traumatique dans la grande majorite des cas, elle est, quand elle devient symptomatique, source de douleurs sur le versant ulnaire du poignet et d’une diminution de la force de serrage. L’objectif principal de cette etude est d’evaluer les resultats de l’arthroplastie par implant en Pyrocarbone Pyrocardan® dans le traitement l’arthrose CMC ulnaire post-traumatique. Les criteres d’evaluation cliniques etaient : la douleur (EVA), la force de serrage au test de Jamar comparee au cote oppose, la distance entre l’extremite distale du 5e rayon et l’extremite distale du 4e rayon comparee au cote oppose, la reprise de l’activite professionnelle, la satisfaction du patient et le score Quick DASH. Radiologiquement, nous avons recherche une mobilisation de l’implant. Six patients ont beneficie d’une arthroplastie par implant en Pyrocarbone (Pyrocardan®) pour une arthrose CMC ulnaire symptomatique. Le groupe etait compose de six hommes. La main dominante etait atteinte pour tous les patients. L’âge moyen etait de 38,25 ans. L’ensemble des patients a beneficie au prealable d’un traitement medical. Le delai moyen entre le traumatisme et la chirurgie etait de 23,72 mois. Le recul moyen etait de 14,5 mois. L’EVA moyenne etait de 2,4. La force de serrage moyenne etait de 60,12 % par rapport au cote oppose. Il n’existait pas de raccourcissement du rayon concerne. Le Quick DASH moyen etait de 39. Nous avons objective une mobilisation de l’implant dans un cas. Deux patients n’ont pas repris leur activite professionnelle et cinq patients etaient satisfaits par l’intervention. Malgre le faible recul et le faible nombre de patients, les resultats de notre etude semblent prometteurs. L’implant (Pyrocardan®) apparait comme une alternative simple a la procedure de Dubert en cas d’arthrose carpo-metacarpienne ulnaire, notamment en cas d’atteinte du 4e rayon. L’arthroplastie par implant en Pyrocarbone (Pyrocardan®) apparait comme une intervention efficace en termes de douleur et de fonctionnalite. Il ne faut cependant pas sous-estimer le risque de mobilisation secondaire, complication inherente a toute arthroplastie prothetique. L’arthroplastie par implant en Pyrocarbone (Pyrocardan®) apparait comme une intervention efficace en termes de douleur et de fonctionnalite.

Les lesions proximales du nerf ulnaire donnent de mauvais resultats sur la fonction intrinseque de la main. La neurotisation de la branche profonde du nerf ulnaire par le NIOA est une solution therapeutique qui permet de diminuer la distance de repousse nerveuse et le delai de reinnervation. Cependant, en cas de lesions hautes combinees des nerfs ulnaire et median, seul le nerf radial reste disponible comme nerf donneur. Nous avons etudie la faisabilite du transfert des branches motrices du court extenseur du pouce et long abducteur du pouce sur la branche motrice du nerf ulnaire. Vingt-trois avant-bras ont ete disseques. Sur 18 sujets, 9 hommes et 9 femmes. Nous avons mesure les distances entre la branche profonde du nerf ulnaire et les nerfs court extenseur et long abducteur du pouce ainsi que leur distance par rapport a l’epicondyle lateral, la styloide radiale et l’os pisiforme. Des prelevements histologiques ont ensuite ete realises sur 8 pieces pour obtenir un compte d’axones. La suture directe etait possible dans 8 cas sur 23 sinon la distance moyenne entre les branches donneuse et receveuse etait de 3,1 cm. Le compte axonal du nerf ulnaire retrouvait en moyenne 708 axones (206–1221). Les rapports de comptes axonaux entre la branche profonde du nerf ulnaire et du court extenseur ou du long abducteur du pouce etaient respectivement de 10,7 et 3,6. Plusieurs difficultes techniques ont ete rencontrees, la difference de calibre importante, pour laquelle des manchons multiplicateurs sont a l’essai et la necessite d’une greffe nerveuse dans deux tiers des cas. La neurotisation de la branche profonde du nerf ulnaire par la branche du nerf du court extenseur ou du long abducteur du pouce est techniquement realisable. Cependant, la grande difference des calibres nerveux ainsi que la necessite d’une greffe interposee ne permettent pas d’en faire un transfert fiable.

Alors que l’importance du retablissement du retour veineux sur le pronostic des replantations digitales est fondamentale, l’anatomie veineuse de la main et des doigts est peu connue par rapport a l’anatomie arterielle. Les donnees disponibles dans la litterature sur le sujet sont rares. L’objectif de cette etude anatomique descriptive etait d’etudier l’anatomie veineuse de la main et des doigts. Notre serie rapporte les resultats descriptifs issus de 10 dissections de mains, de differents sujets non formoles. Les mains avaient ete prealablement injectees par une solution coloree de gelose a 30 % (n = 5) ou de latex (n = 5) avant d’etre dissequees sous grossissement optique (×4). Chaque piece anatomique etait photographiee avant d’etre analysee. Les injections ont mis en evidence le systeme veineux dorsal mais egalement palmaire superficiel et profond. Il existait une veine latero-ungueale constante, presente sur tous les doigts longs et le pouce. Enfin la presence de valvules anti-reflux a hauteur de la phalange moyenne des doigts longs a ete observee. A notre connaissance, peu d’etudes anatomiques ont ete realisees sur le sujet et les connaissances anatomiques de ce systeme veineux des doigts et de la main doivent etre actualisees. La connaissance, a priori, de la disposition du systeme veineux de la main et des doigts devrait aider le chirurgien lorsqu’il est confronte aux replantations digitales, en particulier distales (zones II et III d’Ishikawa).

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.

Resume Objectifs Les techniques chirurgicales du traitement de la deformation des doigts longs en col-de-cygne sont multiples et nous souhaitions evaluer les resultats de la tenodese de l’articulation interphalangienne proximale (IPP) sur des deformations souples reductibles passivement, chez des patients porteurs d’une affection rhumatismale. Methodes Vingt-trois doigts chez huit patients ont ete traites par tenodese de l’IPP a l’aide d’un hemi-tendon flechisseur superficiel suture a la poulie A2. L’intervention etait menee par voie palmaire, l’immobilisation postoperatoire de l’IPP a 20° de flexion etait observee pendant quatre semaines. Les patients etaient revus a 61 mois de recul en moyenne dans le cadre d’une etude retrospective. Resultats La mobilite de l’IPP etait amelioree en flexion de 26° au prix d’un flessum induit de 4°. La flexion moyenne postoperatoire etait de 65°. L’hyperextension de l’IPP etait corrigee de 33°. Pour quatre doigts d’une meme patiente la correction etait insuffisante. Le deficit d’extension de l’interphalangienne distale (IPD) etait corrige completement dans 70 % des cas, partiellement dans 30 % des cas. Tous les patients etaient ameliores sur le plan fonctionnel. On rapporte au total 19 excellents et bons resultats, quatre resultats moyens. Aucune complication majeure n’est a deplorer. Conclusions Cette tenodese apparait fiable et les resultats sont perennes. Elle reste notre solution de choix pour le traitement des cols-de-cygne souples rhumatismaux.

The design and the realization of vascularized osseous grafts at the hand and the wrist require a precise knowledge of the general and regional anatomy. This article gives first a progress report on current knowledge about the general organization of arterial and venous vascularization, of the long bones (number and localization of the nutrient foramina, communication between the epiphyseo-metaphyseal and diaphyseal networks) and of the short bones, in the adult and the child, before the closing of the growth plate. The general organization of arterial vascularization of the hand and the wrist is pointed out, with the current nomenclature and the contribution of the recent publications, in particular in these, which relate to the distal extremity of the radius. The vascularization of each bone (radius and ulna, carpal bones, metacarpals and phalanges) is then described; making way, the anatomical bases of each vascularized bone graft, which can be harvested there, are described. The last technical projections are included, in particular the realization of the reverse flow vascularized bone grafts harvested from the metacarpals. This article still gives a progress report on the osseous vascularization of the short bones, in particular of those which are exposed the most to the osteonecrosis (scaphoid, lunatum). It has the ambition to light the reader and to prepare him (her) with the reading of the following chapters.

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.

Resume La rhizarthrose du pouce est le siege le plus frequent d’arthrose au niveau de la main. L’arthroplastie par prothese est une des options therapeutiques de la rhizarthrose du pouce. Nous rapportons ici les resultats cliniques et radiographiques de la prothese Guepar. Prothese totale, de type rotule, retentive, dont les deux implants sont cimentes. La tige metacarpienne est anatomique, triangulaire a la coupe, conique, remplissant le canal medullaire, munie d’une collerette qui s’appuie sur la surface de coupe du metacarpien. La cupule trapezienne en polyethylene est disponible retentive ou non retentive. Son diametre externe est de 9 mm en distal et 8 mm en proximal, sa hauteur est de 6,5 mm. Elle autorise un debattement angulaire de 50°, faible par rapport aux autres protheses disponibles mais proche de la mobilite physiologique de l’articulation trapezometacarpienne. Cette limitation est liee au caractere retentif de la cupule, solution au probleme de l’instabilite de certaines protheses trapezometacarpiennes. Nous avons revu 84 protheses, mises en place pour rhizarthrose invalidante au recul moyen 50 mois (12–115), issues d’une etude retrospective bicentrique. La serie (55 femmes et 13 hommes) comportait une majorite de femmes (82 %). L’âge moyen a l’operation etait de 61 ans (46–77 ans), la mediane etait de 60 ans. Le cote dominant a ete opere dans 52 % des cas. Au recul, 92 % des patients etaient satisfaits ou tres satisfaits du resultat obtenu. Pour pres de 80 % des patients, les douleurs residuelles etaient absentes ou minimes. Le score de Kapandji moyen apres l’operation etait de 9,5 ± 1,2 ; 91 % des patients avaient un score superieur ou egal a 8. Le score preoperatoire de Kapandji etait de 8,8 ± 1,5. La force moyenne etait comparable a celle du cote oppose. En effet, les forces moyennes du cote opere et du cote oppose etaient respectivement de 6 kgf ± 2,7 contre 5,8 kgf ± 2,3 pour la pince terminolaterale, de 4 kgf ± 2,1 contre 4,2 kgf ± 1,7 pour la pince terminoterminale et de 20,8 kgf ± 9,5 contre 20,4 ± 9,8 kgf pour le grasp. Parmi les 84 cas operes, seuls trois cas d’algodystrophie etaient a deplorer. Aucune complication peroperatoire et aucune luxation n’etaient deplorees. Des liseres periprothetiques etaient souvent presents sur les radiographies realisees a la revision, mais ceux-ci etaient stables dans le temps et asymptomatiques. La conservation de l’os cortical du trapeze (grâce a un fraisage parfaitement centre) apparait indispensable a la bonne evolution du scellement de la cupule dans le trapeze. La cimentation de la piece metacarpienne doit etre realisee en pression afin d’eviter toute mobilisation secondaire de la tige metacarpienne. Une seule reprise chirurgicale a ete necessaire dans la serie pour un descellement symptomatique de la cupule trapezienne. Actuellement, nous avons fait evoluer cet implant vers une gamme sans ciment, dans l’espoir d’ameliorer la fixation bipolaire de cette prothese.

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.

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.

Resume Les auteurs rapportent le cas rare d'un athlete ayant une rupture complete du triceps brachial survenant dans le cadre d'une tendinopathie degenerative chronique severe induite par des exercices forces d'halterophilie et des injections repetees de corticosteroides. Une reconstruction tendineuse par une autogreffe tendineuse au DIDT (tendons semi-tendineux et gracilis) a ete necessaire. Le bon resultat fonctionnel obtenu et l'analyse de la litterature nous amenent a discuter de l'apport de l'autogreffe au DIDT en cas de reinsertion directe impossible du triceps brachial a l'olecrâne (retraction ou perte de substance tendineuse d'origine degenerative ou post-traumatique) ou en cas d'insuffisance evoluee du triceps brachial (chirurgie de reprise des arthroplasties totales de coude).

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.

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.