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Resume Le « reaming-irrigating-aspirating » (RIA) est un dispositif qui permet un alesage centromedullaire des os longs, combine a une irrigation et une aspiration. L’utilisation premiere du RIA est le recueil du produit d’alesage, sous forme d’une pâte epaisse de particules osseuses dont l’analyse a revele la riche teneur en cellules souches et en facteurs de croissance. La quantite de greffe osseuse, extraite d’un femur d’adulte, correspond au volume d’os spongieux preleve sur deux cretes iliaques, anterieure et posterieure. L’assemblage du dispositif et la technique d’utilisation requierent un apprentissage pour eviter une fracture du femur, principale complication potentielle. Les indications electives de la greffe RIA sont le comblement des epiphyses et les pertes de substance metaphysaires. Les pertes de substance diaphysaires peuvent egalement etre traitees par greffe RIA sous reserve que la greffe soit placee dans un systeme contraint (membrane induite) pour eviter sa dispersion dans les parties molles, et qu’elle soit aeree par un materiau poreux pour favoriser sa revascularisation. Les autres indications du RIA concernent le traitement des infections osseuses et l’enclouage des fractures pour limiter le risque d’embolie graisseuse.

Resume Introduction Le traitement d’une perte de substance osseuse (PSO) diaphysaire post-traumatique fait appel a de nombreuses techniques parmi lesquelles figurent les techniques de mobilisation osseuse : raccourcissement isole, compression-distraction dans le foyer, raccourcissement suivi d’allongement dans une corticotomie a distance du foyer, transfert osseux segmentaire. Patients et methodes Cette etude multicentrique retrospective a regroupe 38 dossiers : 22 PSO diaphysaires initiales et 16 secondaires, parfois associees a une perte de substance metaphysaire ou metaphyso-epiphysaire, qui interessaient l’humerus, l’avant bras, le femur et le tibia. Ces techniques ont ete utilisees principalement au membre inferieur (33 cas) et majoritairement a la jambe (22 cas) chez des hommes jeunes. Resultats La consolidation a ete acquise 37 fois sur 38 apres un delai moyen de 14,9 mois (six a 62 mois) Une moyenne de 4,3 interventions secondaires ont ete requises pour obtenir la consolidation ; une greffe osseuse, notamment a ete necessaire au site de contact pour les transferts osseux segmentaires. Discussion De nombreuses techniques peuvent etre proposees pour traiter une PSO post-traumatique. Aucune ne repond a toutes les situations. Les techniques de mobilisations osseuses ont leur place et leurs indications. Le raccourcissement isole s’adresse au PSO n’excedant pas 3 cm, a l’humerus notamment, et dans une moindre mesure au membre inferieur. Le raccourcissement associe a un allongement trouve son interet au femur et au tibia pour des PSO jusqu’a 6 cm. Le transfert osseux segmentaire est la seule technique qui permette de traiter une PSO associe a un raccourcissement, au membre inferieur. Pour les grandes PSO au-dela de 10 cm, le transfert osseux segmentaire est particulierement indique. Mais la tendance pour ces grandes PSO est dans l’hybridation des procedes. L’espace de migration d’un segment osseux peut, par exemple, etre prepare par une technique de membrane induite. Niveau de preuve IV : etude retrospective.

Resume La perte de substance osseuse (PSO) diaphysaire est un probleme difficile a resoudre en traumatologie en raison notamment des lesions des parties molles et de la frequence d’une infection associee. Le Symposium 2010 de la Societe francaise de chirurgie orthopedique et traumatologique (Sofcot) a permis de confirmer les conclusions issues d’experiences anterieures isolees. L’etude, retrospective et multicentrique, a concerne 204 dossiers de PSO diaphysaires des os longs (humerus, radius, ulna, femur, tibia). Les techniques de reconstruction osseuse etaient les greffes traditionnelles, les transferts vascularises, les techniques de mobilisation osseuse, la technique de la membrane induite et la technique de Papineau. La consolidation a ete acquise dans 93 % des cas, dans un delai moyen de 14,7 mois. Le delai de consolidation n’etait pas lie a l’etendue de la perte de substance et etait similaire quelle que soit la technique. La technique de la membrane induite, par la simplicite de sa mise en œuvre et son caractere programme en deux temps en cas d’infection, a ete la technique la plus utilisee dans cette serie. Les facteurs de mauvais pronostic etaient l’infection, les lesions importantes des parties molles et l’exposition initiale du foyer de fracture. Les grands principes qui gouvernent la reconstruction d’une PSO sont la guerison prealable de l’infection associee et la reparation des parties molles chaque fois que faire se peut. La tendance actuelle est a l’hybridation des procedes de reconstruction en elaborant des strategies s’appuyant a la fois sur le raccourcissement delibere, toutes les formes de greffe traditionnelle, la mobilisation osseuse et la membrane induite. Au segment jambier, la greffe intertibiofibulaire doit etre consideree comme la cle de voute de toute reconstruction etendue. Niveau de preuve Niveau IV : etude d’observation retrospective.

Summary Introduction The treatment of posttraumatic diaphyseal bone defects (BD) calls on a number of techniques including bone transport techniques: isolated shortening, compression-distraction at the fracture site, shortening followed by lengthening in a corticotomy distant from the site and segmental bone transport. Patients and methods The multicenter retrospective study combined 38 cases: 22 cases of initial diaphyseal bone defect and 16 cases of secondary diaphyseal BD, sometimes associated with metaphyseal or metaphyseal-epiphyseal BD, involving the humerus, the forearm, the femur and the tibia. These techniques were mainly used on the lower extremity (33 cases), for the most part on the tibia (22 cases) in young men. Results Bone healing was acquired in 37 cases out of 38 after a mean 14.9 months (range, 6–62 months). A mean 4.3 secondary interventions were required to obtain final union; most notably, a bone graft was necessary at the docking site for the segmental bone transport procedures. Discussion Many reconstruction techniques can be proposed to treat posttraumatic BD. None responds to all situations. Bone transport techniques have their place and their indications. Isolated shortening is intended for bone loss not exceeding 3 cm, notably in the humerus and to a lesser degree in the lower extremity. Shortening associated with lengthening is valuable in the femur and the tibia for bone loss up to 6 cm. Segmental bone transport is the only technique that can treat bone defects associated with shortening in the lower limb. For substantial bone loss beyond 10 cm, segmental bone transport is particularly indicated. However, these cases of substantial bone loss tend to be resolved by a hybridization of the procedures. The distraction gap of a bone segment can, for example, be prepared using an induced-membrane technique. Level of evidence Level IV. Retrospective study.

Resume Introduction Les fractures interprothetiques sont une entite rare et grave, source de difficultes de consolidation et de stabilisation en raison de conditions mecaniques defavorables liees a la fragilite osseuse et a l’encombrement prothetique. Le but de ce travail etait de souligner les difficultes de prise en charge de ces fractures, les options therapeutiques et les constatations realisees amenant a proposer un complement aux classifications de Vancouver pour la hanche et de la Societe francaise de chirurgie orthopedique et traumatologique (Sofcot) pour le genou. Materiel et methodes Il s’agit d’une serie retrospective multicentrique de 14 fractures femorales interprothetiques dont huit cas de type double C (type C pour la hanche et le genou) de cinq cas de type C autour de la hanche et type B autour du genou et un cas de type double B (type B pour la hanche et le genou). Ces fractures etaient survenues sur un implant standard (n = 15) ou de revision (n = 13). Ainsi, dans six cas la fracture concernait un femur envahi par une quille d’extension femorale de prothese totale de genou (PTG) et dans huit cas, il s’agissait de PTG sans quille diaphysaire femorale, assimilables a des fractures type C. Resultats Aucune des six fractures sur PTG contrainte a quille n’a consolide de premiere intention alors que sept des huit fractures de type C ont consolide de premiere intention. A terme, 12 cas ont evolue favorablement au prix de trois reprises par femur complet, un patient decedait a six mois non consolide et non repris, et un patient restait en attente d’un femur prothetique complet. Discussion Pour decrire l’etat du femur intermediaire et son envahissement medullaire, nous proposons l’ajout d’une classe D aux classifications Sofcot et Vancouver, correspondant aux fractures interprothetiques survenant autour d’une PTG avec quille d’extension diaphysaire. L’osteosynthese d’une fracture interprothetique doit faire appel a une fixation longue pontant les deux protheses. En cas d’implant descelle, un changement peut etre propose, mais en cas d’extension diaphysaire, le femur residuel entre les extensions diaphysaires doit etre protege des pics de contraintes par une plaque etendue en amont et en aval. Face a un stock osseux limite, par osteolyse ou en raison d’un envahissement medullaire femoral initial, qui plus est si un ou deux des implants sont descelles, l’indication d’un femur prothetique complet peut etre discutee car les possibilites de consolidation apparaissent limitees en raison d’une situation mecanique precaire. Niveau de preuve Type IV retrospectif.

We report the rare case of a patient with an avascular necrosis of the proximal part of the capitate, with a review of the literature. The patient was treated by a resurfacing prosthesis of the proximal part of the capitate. At 22 month of follow up, the patient had a good functional result. Resurfacing prosthesis is a good therapeutic option in case of proximal capitate avascular necrosis when there is no more place for conservative surgery.

Resume Les auteurs rapportent deux cas de luxations spatulaires dorsales completes associees a des lesions de la main et des os de l’avant-bras. Ces luxations sont rares, de diagnostic clinique et radiologique difficile. Ces cas sont originaux par l’association de luxations spatulaires avec des lesions des deux os de l’avant-bras. Ils permettent d’insister sur la necessite d’etablir un bilan lesionnel complet. La prise en charge therapeutique doit etre immediate et debuter par la synthese des lesions proximales pour eviter toute incoercibilite. Ces elements sont determinants pour le pronostic fonctionnel.

SummaryThe “Reamer-Irrigator-Aspirator” (RIA) is a device that provides continuous irrigation and aspiration during intramedullary reaming of long bones. The RIA system is first used to collect the reaming material from medullary cavities, a thick paste of finely morselized osseous particles containing significantly elevated levels of stem cells and growth factors as reported by quantitative analyses. The volume of bone graft material available from an adult femur corresponds to the amount of cancellous bone graft obtained from both the anterior and posterior iliac crests. The assembly and technicalities of the RIA system require a training period to prevent any femoral fracture, which appears to be the major RIA-related complication. The elective indications for RIA bone grafting are filling of bone defects in the epiphyseal and metaphyseal regions. Diaphyseal defects may also be managed using the RIA system provided the graft is placed in a constrained system (induced membrane) to prevent dispersion of the graft into the surrounding soft tissues and is aerated with a porous material to promote its revascularization. Other RIA indications include debriding intramedullary infections and reaming for intramedullary nailing of long bone fractures to reduce the risk of fat embolization.

We report the rare case of a patient with an avascular necrosis of the proximal part of the capitate, with a review of the literature. The patient was treated by a resurfacing prosthesis of the proximal part of the capitate. At 22 month of follow up, the patient had a good functional result. Resurfacing prosthesis is a good therapeutic option in case of proximal capitate avascular necrosis when there is no more place for conservative surgery.

Resume Affection rare, souvent chronique, l'ischemie digitale peut etre aigue, necessitant un traitement chirurgical d'urgence. 5 cas sont rapportes : 3 aigus, 2 chroniques. Les trois ischemies aigues sont survenues 2 fois dans le cadre de troubles de rythme, une fois en rapport avec un anevrysme de l'artere cubitale. Le traitement a consiste en 2 thrombectomies, avec sympathectomie digitale microchirurgicale, et resection de l'anevrysme. La recuperation clinique et fonctionnelle est complete dans ces trois cas. Dans les 2 cas chroniques, une etiologie a ete retrouvee : il s'agit d'un diabete commun et d'une maladie de Buerger. Le traitement medical a ete suivi dans ces deux cas d'une sympathectomie thoracique avec necrosectomie secondaire necessaire a la demande. En conclusion, le pronostic, dans les cas aigus, est lie a la rapidite de la levee de l'obstacle arteriel associee a une sympathectomie digitale. En cas d'ischemie chronique, l'evolution est fonction de l'efficacite du traitement medico-chirurgical et du stade de la maladie causale.

The authors report two cases of complete dorsal carpometacarpal dislocations associated with lesions of the hand and the two bones of forearm. These dislocations are rare, and their clinical and radiological diagnosis is difficult. These cases are original through the association of carpometacarpal dislocation with lesions of the two bones of forearm. They demonstrate the need to stress the importance of a complete evaluation of the patient. Treatment must be immediate and begin with the osteosynthesis of the proximal lesions to avoid any irreducibility. These elements will determine the functional outcome.

The authors report two cases of reconstruction of a mutilated thumb by progressive elongation of the first metacarpal without the need for bone grafts, using a minifixation elongation device, which is very easy to use. It allows distraction which can be performed by the patient himself and adjustment to the desired length, up to 40 mm.

Ischaemic fingers, a rare, generally chronic disease, may sometimes be acute, requiring emergency surgical treatment. Five cases are reported: 3 acute and 2 chronic. The 3 cases of acute ischaemia occurred in the context of cardiac arrhythmias in 2 cases and an aneurysm of the ulnar artery in 1 case. Treatment consisted of 2 thrombectomies with microsurgical digital sympathectomy thrombectomies with microsurgical digital sympathectomy and resection of the aneurysm. Complete clinical and functional recovery was obtained in these three cases. The 2 cases of chronic ischaemia were due to diabetes and Buerger's disease. In both cases, medical treatment was followed by thoracic sympathectomy with secondary resection of necrotic tissue as required. In conclusion, the prognosis in the acute cases depends on the rapidity of correction of the arterial obstruction associated with digital sympathectomy. In the case of chronic ischaemia, the clinical course depends on the efficacy of medico-surgical treatment and the severity of the underlying disease.

Summary Introduction Interprosthetic fracture is a rare but serious entity, impairing consolidation and stability due to adverse mechanical conditions related to bone fragility and implant volume. Objective The present study highlights the difficulties involved in managing such fractures, details treatment options and reports findings leading to a proposed additional grade in the comparable Vancouver (hip) and French Orthopedic and Traumatologic Surgery Society (Societe francaise de chirurgie orthopedique et traumatologique: SoFCOT) (knee) classification systems. Patients and methods A multicenter retrospective series included 14 interprosthetic femoral fractures: eight type double C (type C for both hip and knee), five type C for hip and B for knee, and one type double B (type B for both hip and knee) on the Vancouver and SoFCOT classifications. Fracture occurred on standard (n = 15) or revision (n =13) implants. Six cases involved a femoral shaft encumbered by a total knee replacement (TKR) femoral extension stem and eight cases TKR without femoral long stem, assimilable to type C fracture. Results None of the six fractures proximal to a constrained TKR with stem-achieved union by primary intention, whereas seven of the eight type-C fractures did so. Finally, 12 cases showed favorable evolution, with three secondary total femur replacements (TFR) and one death at 6 months without bony union or revision and one patient waiting for TFR. Discussion To describe the status of the intermediate femur and its medullary canal encumbrance, we propose adding a category D to the SoFCOT and Vancouver classifications, corresponding to interprosthetic fracture on TKR with diaphyseal extension stem. Interprosthetic fracture internal fixation should begin with long devices bridging the two prostheses. When the implant is loose, it may be replaced; in case of diaphyseal extension, however, the residual femur between the two extensions should be protected against peak stress by a plate extending upward and downward. In case of limited bone stock, due to osteolysis or initial femoral medullary canal compromise, especially if one or both implants are loose, TFR may be indicated as consolidation, is jeopardized by the uncertain mechanical situation. Level of evidence Level IV, retrospective study.

The authors describe a case of anevrysmal cyst of the clavicle seen in a five-year-old girl. Both clinical and radiological diagnosis proved impossible. Complementary investigations did not settle the question. surgical excision was decided on. In spite of an unfavorable macroscopic aspect, histological examination determined the nature of the tumor. The authors emphasize the great value of resorting to all branches of medical investigation when dealing with bone tumors. Before affirming a good prognosis, or, on the opposite, suggesting extensive and mutilating surgery, the utmost caution is required.

After a precise review of the numerous parameters studied classically in AP and lateral films of the feet under load, the authors emphasis 5 measurements which are easy to determine and which they feel to objectively cover all the deformities which may be found in the static flat foot. These are: Talo-calcaneal divergence in AP and lateral views, the angle between the calcaneum and the floor, the lateral cavitation index and, finally, the angle of the axis of the talus and of the 2nd metatarsal in AP. A score of 20 is attributed to each. A score of 0 to 20 is attributed to each of these points, with a possible total, therefore, of 100. A study of 119 cases of flat foot in the child treated surgically over a period of 6 years made it possible to draw the distinction between the severe flat foot requiring operation and with a total of less than 45 points, and flat foot requiring medical orthopaedic treatment only (more than 45), the score for the normal foot being of the order of 90 points. This radiological study also makes it possible to distinguish, amongst flat feet in children, straight flat foot with collapse of the medial arch but no valgus of the forefoot and valgus flat foot where there is pronation of the calcaneum and abduction of the forefoot. This distinction is important since it determines the choice of operation. Thus in a case of valgus flat foot Judet's so-called "horseman" operation is indicated whilst in a flat foot without valgus, transposition of the tibialis anterior is preferable. In many cases, the lesion is mixed and both surgical gestures are required.