Search

Resume Dans le traitement chirurgical du pied plat valgus reductible de l’adulte, l’arthrodese mediotarsienne a pour objectifs l’indolence et la correction de la deformation. Le but du travail etait l’evaluation radio-clinique des resultats de cette intervention. L’etude retrospective portait sur 22 pieds plats valgus reductibles chez 19 patients âges en moyenne de 43 ans (15-75). La revision clinique et radiographique etait realisee au recul moyen de 7 ans et 4 mois (6 mois-20 ans et 3 mois). Nous avons deplore deux pseudarthrodeses d’evolution favorable apres greffe spongieuse. A la revision, le score de Kitaoka etait de 73,5 points/100 (de 53 a 94). La douleur et la fonction etaient significativement ameliorees mais l’amplitude globale du pied en flexion/extension restait inchangee. Le pied etait axe dans 68 % des cas. La pente talienne et la divergence talo-calcaneenne etaient normalisees mais il persistait un defaut de correction de l’angle de Djian et une cassure de la ligne de Meary dans, respectivement, 68 et 41 % des cas. Le valgus calcaneen etait reduit de 6,6° (16,6° a 10°). Dans 50 % des cas, les articulations voisines presentaient une progression de la degenerescence arthrosique. Subjectivement, 73 % des patients etaient tres satisfaits et satisfaits. Objectivement, 68 % des resultats etaient excellents ou bons. Le recours a l’arthrodese mediotarsienne a permis une amelioration globale de la douleur ainsi qu’une recuperation fonctionnelle satisfaisante sans morbidite superieure a une simple arthrodese talo-naviculaire. Nos resultats restent, en ce sens, comparables a ceux de la litterature. Neanmoins, la restauration de la voute plantaire reste cliniquement et radiographiquement limitee. D’autre part, devant la frequence des remaniements arthrosiques, certes moderes et souvent asymptomatiques, des articulations voisines et face a la difficulte des patients jeunes a reprendre une activite sportive, les solutions chirurgicales conservatrices devraient certainement etre preferentiellement choisies.

Resume Le principe de stabilite primaire et secondaire de la prothese Esop repose sur un ancrage metaphysaire exclusif, non cimente. Cet implant modulaire est compose d’une metaphyse revetue d’hydroxyapatite, sur laquelle est adaptee en peroperatoire une piece diaphysaire jouant un role de simple centreur. L’objectif de cette etude retrospective continue etait d’evaluer les stabilites primaire et secondaire de l’implant Esop en mesurant la migration axiale au cours du temps. Entre 1995 et 2001, 172 PTH utilisant l’implant Esop et l’implant acetabulaire Atlas III, ont ete implantees dans notre service. Apres exclusion des patients decedes et perdus de vue nous avons revu 155 PTH chez 66 femmes et 32 hommes, d’âge moyen 57 ans, dont 53 % exercaient une activite professionnelle au moment de l’intervention. La coxarthrose et l’osteonecrose aseptique representaient 87 % des etiologies. Nous avons mesure a l’aide du logiciel Imagika la migration axiale et l’offset global des PTH a 4 periodes distinctes. Nous avons egalement analyse la survie et les resultats cliniques et radiographiques de cette serie grâce aux scores PMA. Le taux de survie des PTH de notre serie etait de 97,81 % (IC a 95 % 7,77 ; 8,03.), toutes causes confondues. Le score PMA retrouvait 97 % de resultats excellents, tres bons ou bons. Une migration de plus de 5 mm a ete mise en evidence dans 10 cas (6,4 %). Sur ces 10 cas, 7 avaient migre dans le premier mois, puis n’avaient pas evolue lors de la revision. L’offset femoral global etait diminue de plus de 10 mm dans 38 % des cas, temoignant de la medialisation du centre de rotation de la hanche. La stabilite primaire et secondaire de l’implant Esop est satisfaisante. La migration observee sur 10 implants correspondait dans 7 cas a un recalage lors de la remise en charge. Le centre de rotation de la hanche subissait globalement une medialisation : dans ces cas il serait interessant de disposer d’implants lateralises.

Resume L’infection d’une arthroplastie d’epaule est une complication rare pouvant repondre a diverses possibilites therapeutiques allant de l’antibiotherapie isolee a la depose des implants. Ce travail evalue les resultats cliniques et infectieux obtenus par la resection arthroplastique sans reimplantation secondaire dans les infections subaigues et chroniques d’arthroplasties d’epaule. La serie se composait de 10 arthroplasties revues au recul moyen de 3 ans et huit mois. Le diagnostic bacteriologique identifiait essentiellement des souches de Staphylococcus aureus sensibles a la meticilline et des staphylocoques a coagulase negative. Le traitement chirurgical associait dans tous les cas a la depose prothetique, une ablation complete du fourreau de ciment, l’excision des trajets fistuleux et un debridement large des tissus infectes associe a une synovectomie etendue. Si l’indolence etait obtenue dans tous les cas, le score de Constant a la revision n’etait que de 28 points, ainsi, le resultat subjectif etait juge moyen ou mediocre a huit reprises. Les resultats infectieux etaient plus encourageants puisque l’eradication clinique et biologique de l’infection etait obtenue dans tous les cas au prix d’un protocole d’antibiotherapie prolongee et adaptee aux donnees microbiologiques. Les resultats cliniques des resections arthroplastiques sont modestes et cette intervention doit etre reservee aux patients a faible demande fonctionnelle. L’amelioration de la prise en charge infectieuse et la reduction des delais diagnostiques doivent permettre d’ameliorer les resultats fonctionnels en developpant les techniques de rescellements en un ou deux temps.

Resume Le but de ce travail etait d’evaluer les resultats cliniques et radiologiques a moyen terme des tenotomies arthroscopiques du chef long du biceps brachial dans le traitement des ruptures jugees irreparables de la coiffe des rotateurs. La serie se composait de 40 epaules operees d’une tenotomie isolee dans 32 cas et associee a une acromioplastie dans 8 cas. Le recul moyen etait de 30 mois. La rupture de la coiffe interessait le seul supra-epineux dans 11 cas, le supra-epineux et l’infra-epineux dans 12 cas, le supra-epineux et le subscapularis dans 9 cas et les trois tendons dans 8 cas. A la revision, le score de Constant brut moyen etait de 58 points soit un gain de 20 points. Le gain concernait la douleur (+ 7,1 points), le niveau d’activite (+ 6,6 points) et la mobilite (+6,4 points). Seule la force musculaire en flexion-supination du coude etait diminuee par l’intervention puisque les mesures realisees sur les patients operes revelaient une diminution de 40 % comparativement a une serie temoin appariee a l’âge, au sexe et en tenant compte de la dominance du membre. L’analyse radiographique au recul ne revelait pas de tendance generale a l’excentration superieure de la tete humerale ou au developpement d’une omarthrose secondaire. Toutefois, 2 patients, au recul de 41 et de 72 mois, avaient developpe une arthose excentree. Les resultats a moyen terme de la tenotomie arthroscopique du chef long du biceps brachial sont satisfaisants au prix d’un geste techniquement simple aux consequences fonctionnelles limitees. Toutefois, la degradation du resultat chez une patiente au recul de 6 ans doit nous rendre prudent sur le benefice a long terme de cette intervention.

Resume Neuf cas de metatarsus elevatus acquis ou horizontalisation du premier metatarsien avec hallux flexus ( dorsal bunion ) ont ete traites par une technique chirurgicale associant resection cuneiforme plantaire de la base du premier metatarsien ou du premier cuneiforme ; desinsertion distale et deroulement du tendon long flechisseur de l’hallux au-dessous de la base du premier metatarsien puis reinsertion sur un lambeau capsulaire dorsal distal de l’articulation metatarso-phalangienne ; desinsertion distale du tendon tibial anterieur et tenodese au tendon tibial posterieur. Apres embrochage d’alignement du premier rayon pendant un mois, l’appui avait ete autorise. Les resultats enregistres au recul moyen de 11 ans sont satisfaisants sur le plan morphologique : aucune recidive de la deformation n’a ete enregistree, il n’existe aucune instabilite residuelle du premier rayon. Seul subsiste un leger enraidissement de l’articulation metatarso-phalangienne sans remaniement arthrosique.

Resume Le but de cette etude etait d’evaluer les descellements aseptiques de protheses totales de hanche observes a l’occasion de la revision de deux types de cupules acetabulaires (186 au total) a 84 mois de recul et de rechercher leur origine. Dans cette serie, differents types de tiges (avec ou sans ciment) et de tetes etaient utilisees. Parmi celles-ci, 62 tetes en titane implante. Quarante-sept patients porteurs de 52 tetes en titane implante ont ete revus. Les caracteristiques physico-chimiques et metallurgiques d’une tete en titane implante retiree lors d’une reprise ont pu egalement etre etudiees. L’usure annuelle moyenne etait de 0,18 mm/an. On deplorait 13 reprises pour descellement aseptique. Dans ces cas, l’usure etait de 0,34 mm/an. Il s’y associait une metallose dans 8 cas. Les memes types d’implants acetabulaires et femoraux associes a d’autres types de tetes ne donnaient lieu qu’a un seul descellement aseptique sur 118 cas. L’etude en microscopie electronique mettait en evidence des rayures, et la disparition de la couche d’ions azote a la surface de la tete en titane implante. C’est pour ameliorer les performances tribologiques du titane, qu’a ete proposee l’implantation ionique ou projection d’ions azote a la surface de la tete sur une epaisseur d’environ un micron. Le nombre important de descellements aseptiques, l’usure du polyethylene, la metallose et les modifications observees a la surface de la tete, mettent en avant la responsabilite des tetes en titane implante dans ces descellements aseptiques. Ce traitement de surface ne permet donc pas une bonne protection de la tete. Les patients toujours porteurs de ces tetes doivent faire l’objet d’une surveillance etroite afin de depister precocement un descellement aseptique et une metallose.

The aims of this study were to (a) provide an accurate description of the anterior talo-fibular ligament (ATFL) multifasciculated feature by means of cadaver study, and (b) to further delineate contour and signal variations on MR images related to this feature in a group of asymptomatic subjects. After MR imaging, three cadaveric feet were frozen and cut in the coronal plane. The ATFL were harvested and sent to pathology. Another cadaveric foot was dissected. The MR imaging was performed in 3 healthy volunteers and 19 patients without pathology of the ATFL. For both cadaveric feet and subjects, MR imaging protocol consisted of axial and coronal proton-density (PD) and T2-weighted turbo-spin-echo (TSE) sequences (TR/TE: 3500 ms/17-119 ms). On MR images, ATFL signal and fascicle numbers were assessed, respectively, in the axial and coronal planes. Gross anatomy and pathology confirmed the ATFL bifasciculated aspect. On cadaveric coronal MR images, 3 of 4 ATFLs were bifasciculated and one of four was striated. On patients' coronal MR images, 2 of 22 of the ATFL were monofasciculated, 12 of 22 bifasciculated, and 8 of 22 striated. On axial MR images, 16 of 22 of the ATFL demonstrated a low signal intensity and 8 of 22 an intraligamentous subtle increased signal intensity. Two of 22 of the ATFL had contour irregularities. Isolated anterior talo-fibular intraligamentous signal abnormalities or contour irregularities on axial PD and T2-weighted MR images with an otherwise normal ATFL aspect on coronal MR images and no other MRI criteria for ankle sprain may reflect normal anatomy.

Resume Notre serie regroupe 55 patients adultes operes d'une fracture bicondylienne de type C (A.O.) de l'extremite distale de l'humerus avec un recul moyen de 108 mois. Les fractures se repartissaient en 15 type C1, 6 type C2 et 34 type C3. L'osteosynthese a ete principalement realisee par une plaque laterale premoulee dans 31 cas, par deux plaques posterieures dans 18 cas, par un vissage en triangulation isole chez quatre patients et par des broches dans deux cas. La voie d'abord posterieure trans-olecranienne intra-articulaire a ete utilisee dans 37 cas (67,27 %). Nous avons utilises trois scores d'evaluation fonctionnelle (SO.F.C.O.T., Mayo-Clinic, H.S.S.). L'osteosynthese par plaques posterieures a obtenu un resultat satisfaisant dans 78,57 % a 92,86 % des cas alors que l'osteosynthese par plaque laterale premoulee a donne un resultat satisfaisant dans 73,68 % a 76,32 % des cas selon le score d'evaluation utilise ; cette difference n'etait pas statistiquement significative. Les osteosyntheses par vis et par broches n'ont obtenues que des mauvais resultats. L'evaluation du secteur de mobilite en flexion-extension retrouve une valeur moyenne de 103°. Cette valeur est satisfaisante, car elle correspond au secteur de mobilite fonctionnelle utile (superieur a 100°). La flexion a ete superieure a 120° dans 70,90 % des cas, le deficit d'extension etait superieur a 45° chez 18,18 % des patients. La revue de nos cas et de la litterature nous incite a poursuivre dans la voie de l'osteosynthese en adaptant les indications au type de fracture et en utilisant une technique bien codifiee. Les resultats sont independants de l'âge des patients. Le demontage de la synthese ne donne que des mauvais resultats surtout s'il n'est suivi que d'une immobilisation plâtree. La mauvaise reduction, source d'arthrose, de perte de substance osseuse, de butoirs et de calcifications, ne fait qu'aggraver le pronostic fonctionnel.

A case of compression of the deep branch of the ulnar nerve associated with pseudarthrosis of the base of the fifth metacarpal and the upper shaft of the fourth metacarpal is reported. The delayed procedure consisted in volar decompression of the ulnar nerve by dividing the pisi-hamate ligament and plating and grafting of both fractures. The patient achieved marked improvement four weeks post-operatively and had complete functional recovery at follow-up of 16 years after injury without narrowing of the hamato-metacarpal joint despite synostosis of the bases of the medial metacarpals.

The major ruptures of the rotators cuff point out the problem of their surgical repair. Various techniques are described in the literature, among them the deltoid flap technique, described by Apoil and Augereau. This technique points out the problem of a few cases of flap early necrosis (Saragaglia). We studied the deltoid arterial blood supply on 40 cadaveric shoulder, after coloured injection into the subclavian artery. Our study included 40 macroscopic and 15 radiographic observations. The thoracoacromial artery gave off two collaterals to the anterior part of the deltoid muscle. The first one, called the deltoid artery, ran into the anterior part of the deltoid, near the deltopectoral line. In 53%, it gave off a first superior collateral branch, which ran at 3 cm under the clavicle. The second one, called the acromial artery, ran deep to the anterior part of the deltoid muscle, near the clavicle and the acromion. The posterior circumflex humeral artery was the most important artery. It supplied the posterior and middle parts of the deltoid muscle. The anterior circumflex humeral artery supplied the anterior part of the deltoid muscle in 63%. In ten cases, we dissected a deltoid flap. In all the cases, the acromial artery was cut near the acromion. When the deltoid artery gives off its superior collateral branch, it was always cut. Then, this flap was only vascularized by its inferior aspect. These results show that the flap is located in a poorly supplied area. Thus, the flap necrosis could be explained by an insufficient anastomotic network. An operative technique modification could avoid this complication.

Metal ion release was assessed in 31 patients with loosening of total hip replacements (THR). Three types of alloys were used for these prostheses: stainless steel (9/31), Ni-Cr-Mo (5/31) and Co-Cr (17/31). The exposure periods were from 2 to 15 years.Intracellular deposits were observed in macrophages, fibroblasts, histiocytes and numerous multinucleated giant cells. X-ray microprobe analyses by energy dispersive spectrometry (EDS) on ultrathin sections revealed the presence of elements contained in the alloys (Ni, Cr, Fe, Mo) and of additional elements, in particular P, CI, Ca and S. Co was only detected in wear particles. Metal distribution in tissues and body fluids was related to the alloys used. Stainless steel THR induced the lowest metal concentrations, Ni-Cr-Mo alloys showed high increases of Ni and Cr. Co-Cr alloys induced very high Co levels: 100- to 400-fold concentrations in body fluids and 600- to 1000-fold concentrations in tissues with respect to normal upper levels. The metal clearing was studied in three patients with Co-Cr-THR. Two years after removal, only Ni reached normal values. The sometimes alarming high concentrations should lead to a systematic follow up and surveillance of patients.

La formation des adduits de Cu + avec une ou deux molecules d'alcane est etudiee a l'aide d'un spectrometre de masse multiquadripole. Les cations alcalins ne reagissent pas dans ces conditions, en accord avec une plus forte liaison etablie par Cu + . L'association de Cu + avec le cyclohexane suit une cinetique du premier ordre en cyclohexane, ce qui correspond a une duree de vie remarquablement longue du complexe excite intermediaire. Les adduits sont d'autant plus stables que la molecule d'alcane est moins rigide

Subcoracoid impingement is a rare but well-know cause of anterior shoulder pain in throwing and overhead athletics. Bulging of the walls or the contents of the coracohumeral space may hamper the smooth gliding of soft tissue between the coracoid process and glenohumeral joint, especially in forward elevation and internal rotation of the arm. Following is a case report of subcoracoid impingement caused by an accessory coracobrachialis muscle in an alpinist treated by resection of the muscular supernumerary slip.

Central fracture dislocation of the hip with associated fracture of the femoral neck is rare. Treatment of choice consists of open reduction of the displacement and internal fixation of both fractures. Nevertheless, inadequate reduction of the burst fracture of the acetabulum may lead to hip arthritis, and the surgical approach to the femoral neck jeopardizes its vitality. In elderly patients early full motion and prompt physical rehabilitation can be achieved by total hip arthroplasty after fusion of the displaced femoral head to the acetabular wall.

Arthrodesis proposed for the surgical treatment of reducible pes planovalgus (flatfoot) in adults is designed to relieve pain and correct the deformity. The purpose of this work was to present the radiological and clinical results obtained with midtarsal arthrodesis performed in 22 cases of pes planovalgus.This study concerned 22 cases of reducible flatfoot (Johnson grade 2) in 19 patients (11 males, 8 females, mean age 43 years, age range 15-75 years). Clinical outcome was assessed in terms of pain, function and motion using the AOFAS and Mann classifications. Radiological assessment (loaded anteroposterior and lateral views with Méary cerclage) noted the Djian angle, talometatarsal alignment, talar slope, calcaneal slope, calcaneal valgus, and osteoarthritis stage in adjacent joints.Mean follow-up was 7 years 4 months (range 6 months-20 years 3 months). Two nonunions resolved favorable after cancellous grafting. The Kitaoka score was 73.5/100 points (range 53-94). Pain and function improved from 2.8 to 1.1 points (/4 points) and from 3.45 to 1.6 points (/4) on the Mann scale. Flexion-extension remained unchanged. The foot was aligned correctly in 68% of cases. The mean talar slope and the talocalcaneal divergence were normal at last follow-up but there was a persistent undercorrection of the Djian angle in 68% of the feet and a break in the Méary line in 41%. Calcaneal valgus was reduced 6.6 degrees (16.6 to 10 degrees ) but the podoscope footprint was still the flatfoot type in 86% of the feet. For 50%, the neighboring joints presented progressive osteoarthritic degeneration. Subjectively the patients were very satisfied or satisfied with minor reservations for 73%. None of the patients was disappointed with the results. The objective outcome was excellent or good in 68% of the feet.The results in terms of pain relief, function, motion, complications, and rate of satisfaction were comparable with results presented in the literature. Midtarsal arthrodesis provides effective pain relief and satisfactory functional recovery without creating any morbidity greater than simple talonavicular fusion. Nevertheless, it was noted that while correct alignment is achieved in the majority of cases, the clinical and radiological restoration of plantar cavum is limited. Furthermore compensatory hypermobility of the adjacent joints leads to the development of moderate osteoarthritic remodeling which remains asymptomatic more than seven years after the operation.

Primary and secondary stability of the Esop prosthesis depends exclusively on cementless metaphyseal anchoring. This modular implant is composed of an hydroxyapatite-coated metaphysis on which a diaphyseal piece is added intraoperoperatively simply to act as a centering device. The purpose of this retrospective analysis of a consecutive series was to assess primary and secondary stability of the Esop implant by measuring axial migration over time.Between 1995 and 2001, 172 primary total hip arthroplasties (THAs) were performed with the Esop femoral implant and the Atlas III acetabular implant. Six patients lost to follow-up and eleven patients who died were excluded from the analysis. The review thus concerned 155 THA in 128 patients (66 women and 32 men), mean age 57 years (age range 28-77 years), 53% with an occupational activity at the time of surgery. Degenerative hip disease and aseptic osteonecrosis were present in 87% of patients. Imagika, a dedicated software, was used to measure axial migration and overall offset of the THA at four distinct times: on the immediate pre- and postoperative films, after introduction of weight-bearing, and at last follow-up (mean 61 months, range 35-114 months). Survival and clinical and radiographic outcome were also assessed with the Postel-Merle-d'Aubigné (PMA) score.THA survival was 98%, all causes of failure included. The PMA score showed 97% excellent, very good or good outcome. Axial migration greater than 5 mm was demonstrated in ten hips (6.4%). Among these ten, seven exhibited migration during the first month than did not move further up to last follow-up. Comparison between the pre- and postoperative images revealed a 10 mm reduction in offset in 38% of hips, showing that the hip rotation center was medialized.Migration observed in ten implants corresponded to restablization at weight-bearing in seven. There was no correlation with the clinical outcome or poor radiological osteointegration.Primary and secondary stabilization of the Esop implant is satisfactory. In this series, the rotation center of the hip was globally medialized so that it would be useful to have available lateralized implants.

Infection is a rare complication of shoulder arthroplasty. Various therapeutic solutions have been proposed: antibiotics alone, one-stage or two-stage reimplantation, surgical or arthroscopic cleaning without prosthesis removal, scapulohumeral arthrodesis or simple arthroscopic resection. We evaluated the mid-term clinical outcome after resection arthroplasty for the treatment of infected shoulder arthroplasty.The series included ten infected arthroplasties in ten patients. Mean duration of implantation was two years seven months (range nine months to five years). Bacteriological diagnosis was established from intraoperative articular samples or systematic samples taken during surgical revision procedures: meti-S Staphylococcus aureus strains (n=4), coagulase-negative Staphylococcus (n=5 including three S. epidermidis) Streptococcus mitis (n=1) and Citrobacter koseri (n=1). The mean Constant score before revision was 58 (range 23-77). Subjective patient satisfaction before surgical revision was rated good in six cases, fair in one and poor in three. Surgery associated removal of the implant, complete resection of the cement, resection of the fistular tracts, wide debridement of infected tissues and total synovectomy.Patients were seen at an average follow-up of three years eight months. The objective functional outcome measured with the Constant score was only fair, 28 points (range 20.6-36), and corresponded to a loss of 29 points compared with the preoperative score. This was explained mainly by lower scores for joint motion, function and muscle force but with persistently satisfactory scores for pain. All patients remained pain-free (daytime and nighttime). Patient satisfaction was rated good for two, fair for five and mediocre for three. Clinical and biological proof of eradicated infection was obtained in all patients.Infection remains a serious devastating problem for shoulder arthroplasty with an important functional impact. Resection only has a modest clinical effect. Precise identification of the causal germ with institution of adapted antibiotic therapy is required for eradication of the infection. Early diagnosis is probably the most important parameter affecting clinical outcome and surgical options. Functional results after resection arthroplasty are modest. This procedure should be reserved for patients with reduced functional demands. Improved management of the infectious load and reduction of diagnostic delay should help improve functional outcome and favor use of stow-stage procedures for reinsertion.

Appropriate treatment of irreparable rotator cuff tears in patients without osteoarthritic shoulder joints remains a subject of debate. Medical treatment, a substitution muscle flap, and palliative arthroscopic treatment have been proposed. Arthroscopic tenotomy of the long head of the biceps brachii is warranted because this tendon is often the cause of part or all of the pain. If there is a full thickness tear of the rotator cuff, the exposed tendon of the long head of the biceps brachii can, because of its anterosuperior position, become impinged against the acromial vault during forward flexion. The purpose of this work was to evaluate the mid-term clinical and radiological results of arthroscopic tenotomy of the long head of the biceps brachii during treatment of full thickness tears of the rotator cuff.The series included 40 shoulders operated on for tenotomy alone (n=32) or in combination with acromioplasty (n=8). The long head of the biceps brachii was in place in 23 shoulders (58%), displaced in seven and subluxed in five. The position was not determined in five. At last follow-up, the mean rough Constant score was 58 points, giving a gain of 20 points. The gain for pain was +7.1 points, +6.4 points for activity, and +6.6 points for motion. After the operation, muscle force for elbow flexion-supination was decreased 40% compared with an age-, sex- and dominance-matched control group. 86% of the patients were satisfied with the outcome and only two patients were disappointed by the asymmetry of arm muscle volume. Radiographically, at last follow-up there were no signs of superior excentration of the humeral head and the subacromial space, which measured 7.38 mm preoperatively was 7.19 mm postoperatively. Likewise only two shoulders progressed to excentered osteoarthritis at 41 and 72 months.Mid-term results of arthroscopic tenotomy of the long head of the biceps brachii are satisfactory. The technique is simple and has limited functional consequences. The procedure has an undeniable impact on pain and has allowed a 34 degree gain in anterior flexion of the shoulder. Complementary acromioplasty was not found to provide a supplementary benefit in this series. Nevertheless, the degradation of the result in one female patient at six years suggests we should be prudent concerning the long-term benefit of this procedure which should be reserved for irreparable tears in patients with minimal functional demands.

We compared the long-term function of subscapularis after the Latarjet procedure using two surgical approaches. We treated 102 patients (106 shoulders) with a mean age of 26.8 years (15 to 51) with involuntary unidirectional recurrent instability. The operation was carried out through an L-shaped incision with trans-section of the upper two-thirds of the muscle in 69 cases and with a subscapularis split in 37. All clinical results were assessed by the Rowe and the Duplay scores and the function of subscapularis by evaluating the distance and strength at the lift-off position. Bilateral CT was performed in 77 patients for assessment of fatty degeneration. The mean follow-up was 7.5 years (2 to 15) and 18% of cases were lost to follow-up. The mean Duplay score was 82 of 100 for the L-shaped incision group and 90 of 100 for those with a subscapularis split (p = 0.02). The mean fatty degeneration score was 1.18 after an L-shaped incision compared with 0.12 after subscapularis split (p = 0.001). The subscapularis split approach is therefore recommended.

Radiocarpal dislocation is an uncommon entity in traumatology. Proper management depends on the type of dislocation and the presence of concomitant injury. The purpose of this study was to detail the pathogenesis of radiocarpal dislocation and describe its complications and treatment.Twelve radiocarpal dislocations were reviewed retrospectively. Nine were associated with multiple trauma. For this review, physical examination was performed to determine the functional status, presence of pain, joint motion, and grip force. The Green and O'Brien score as modified by Cooney was used to assess function. Grip force was measured with a Jamar dynamometer and weighted by the non-dominant/dominant ratio. Dumontier and Moneim classifications were used to define different types of radiocarpal dislocation. Radiological evaluation was based on anteroposterior (ulnar and radial inclination) and lateral views of the wrist.Dorsal displacement was observed for nine dislocations. All were associated with fractures (eleven fractures of the lateral cuneal process and eight fractures of the styloid process). Other associated injuries were distal radioulnar dislocation and intracarpal sprains (two scapholunate and two lunotriquetral). There were three median nerve compressions which all regressed without sequelae. Ten patients were treated by styloradial osteosynthesis alone and two patients by capsule-ligament suture via an anterior approach. Pinning was used to stabilize the two lunotriquetral injuries and the one neglected radioulnar dislocation.At last follow-up (mean 46.2 months), the overall functional outcome was satisfactory. The Green and O'Brien (modified by Cooney) score was excellent for one patient, fair for eight, and mediocre for three (75% satisfactory results). Distal radioulnar degeneration developed in the patient who had a neglected radioulnar dislocation. Three cases of radiocarpal degeneration were observed in patients with neglected scapholunate sprains whose wrist was symptomatic at last follow-up.Radiocarpal dislocation is associated with intracarpal fracture and/or injury. Intracarpal injury must be treated in order to limit the risk of future degeneration. Pure radiocarpal dislocation (or in association with a minimal fracture of the styloid) should be treated surgically, irrespective of the approach, in order to achieve capsule-ligament suture. Other radiocarpal dislocations can be simply reduced with osteosynthesis of associated fractures. Intracarpal and/or distal radioulnar lesions must be stabilized. Osteosynthesis or capsule-ligament suture must be achieved to obtain a satisfactory clinical result.

Nine cases of acquired metatarus elevatus or horizontalization of the first metatarsal with hallux flexus (dorsal bunion) were treated surgically associating: plantar wedge resection of the base of the first metatarsal or the first cuneiform; distal disinsertion of the long hallux flexor which was then positioned under the base of the first metatarsal and finally fixed on the distal dorsal segment of the metatarsophalangeal capsule; distal disinsertion of the anterior tibial tendon and tenodesis of the posterior tibial tendon. Weight bearing was allowed after pinning for one Month to position the axis of the first ray. Morphological results, recorded at 11 Years follow-up (mean) were satisfactory. There were no recurrent deformations and no residual instability of the first ray. The only observation was a minimal stiffness of the metatarsophalangeal joint with no tendency to degeneration.

The purpose of this study was to determine the frequency of aseptic loosening among a series of total hip arthroplasties evaluated at 84 months and to search for the cause. Two types of acetabular cups had been implanted. It was hypothesized that the ion coating of the titanium head could be involved in the deterioration of titanium/polyethylene implants.Two non-cemented acetabular cups differing only by the presence or not of a hypoxyapatite coating were studied. Different types of femoral heads (stainless steal, chromium-cobalt, alumina, zincrona, nitrurated titanium, ion-coated titanium) and femoral stems (with or without cement) were implanted. Sixty-two ion-coated titanium heads were implanted and 47 patients with 52 heads were reviewed. Clinical outcome was assessed with the Postel-Merle-d'Aubigné score and the Livermoore method was used for radiological assessment of the bone-implant interface and polyethylene wear. The physico-chemical properties of one titanium head explanted after aseptic loosening were also studied.At 84 months follow-up, the mean clinical score was 15.8/18 points. Mean polyethylene wear was 0.18 mm/year. There were 13 revisions for aseptic loosening: two bipolar, nine acetabular and two femoral. Mean wear for the explanted implants was 0.34 mm/year. Metallosis was observed in eight cases. Arthroplasties with the same types of femoral stem and acetabular implants but with other types of heads (stainless steal, chromium-cobalt, alumina, zincrona, nitrurated titanium) led to only one case of aseptic loosening among 118 implantations. Electron microscopy demonstrated the presence of scratch lines, disappearance of the nitrogen ion layer, decreased hardness, and increased roughness of the titanium head.The poor friction properties of titanium are well known. To improve performance, ion coating has been proposed. This technique consists in projecting nitrogen ions onto the surface of the head to form a surface coating measuring about one micron. The high incidence of aseptic loosening, polyethylene wear, metallosis, and modifications of the head surface (disappearance of the nitrogen ion layer, scratch marks, etc.) suggest ion-coated titanium heads could be the cause of these aseptic loosenings.Ion-coating has not provided good protection of the titanium head. Patients with this type of head should be followed carefully in order to detect aseptic loosening or metallosis early.

We reviewed, at a mean follow-up of 7.5 years, overall functional outcome, bony architecture of the humerus predisposing to anterior instability, and treatment failure after 106 Latarjet-Patte procedures performed in 102 patients (mean age 34 years).The reproducibility of computed tomographic findings was validated prior to analysis. There were 5 men for 1 woman in this series. The initial injury, occurring at the age of 22 years on the average, was caused by trauma in 87% of the patients and generally involved the dominant upper limb. Ninety-seven patients practiced sports activities, a high risk sport for 48%. Clinical outcome was assessed with the Duplay score. Standard x-rays were also obtained, with bilateral computed tomography in 80 patients.The osteosynthesis screw had to be removed in 6% of the cases due to posterior pain. The Latarjet-Patte procedure yielded 76.4% excellent or good results according to the Duplay scoring system. Sixty percent of the competition-level athletes like amateur athletes resumed their former sports activities at the same level. Seventy-percent of the patients were pain free. At last follow-up, complaints of pain, generally minor pain, were related to age of onset of instability, preoperative pain, and presence of joint degeneration. Loss of rotation was less than 11 degrees (mean). There was one case of recurrence subsequent to secondary trauma and 13.2% of the patients experienced residual apprehension. This lack of perfect stability was not related to a technical error but rather to a functional section of the head cartilage which remained in an overly anterior position because of a Malgaigne notch extending to the surface. Grade 2 or 3 joint degeneration was observed in 15% of the patients. It was related to duration of follow-up, patient age, mode of instability, and overlap of the bone block. Standard x-rays underestimated the incidence and degree of joint degeneration since the computed tomographic analysis revealed 17.5% of joint space narrowing (overall or posterior). Single cortex screwing led to nonunion, observed in 7% of the cases. Advanced osteolysis led to pain with altered overall function.Operated patients appear to have a constitutional morphology predisposing to anterior instability due to more marked bicipital lateralization than seen in controls. The differences concerning humeral version are less pronounced. There was a difference in version, independently of the presence of a notch, between the unstable and the healthy side. Conversely, in comparison with controls, a more anterior sector of the head cartilage (secondary anteversion) was only seen in patients with a notch.We consider that preoperative measurement of humeral retroversion and lateralization of the bicipital gutter can be helpful in establishing a precise therapeutic indication. Rather than searching for a constitutionally anomalous retroversion, we advocate searching for a more anterior functional section of the head cartilage (aggravated anteversion) caused by the presence of a Malgaigne notch on the unstable side (retroversionor =0 degrees ). When this anomaly is present, we prefer associating a derotation retroversing osteotomy of the humerus with the classical technique. This should avoid persistent residual apprehension.

The aim of this study was to investigate the presence of fibrocartilage within the distal posterior tibial tendon (PTT) before its division correlating with size and signal variation on MR images through a radio-anatomic and pathologic study. Eight fresh cadaveric feet underwent MR imaging were cut into 4-mm slices in the axial plane. The PTT specimens were harvested at the tendon distal portion before its division and sent to pathology. Thirty-three asymptomatic subjects underwent axial double-echo turbo-spin-echo MR imaging. Proximal and distal PTT signal and diameter were evaluated. In cadavers, every PTT flared distally. Intratendinous fibrocartilage and ossified sesamoid were found in, respectively, 87.5 and 12.5% of the cases. Distal PTT flaring was demonstrated in 100% of the asymptomatic subjects (mean diameter 8 mm). An intratendinous high signal intensity on proton-density-weighted images and sesamoid bone were evidenced in, respectively, 36 and 33% of the cases. Proximally, PTT presented a 4-mm mean diameter and was hypointense in 100% of the cases. Only one accessory navicular bone was detected. Laterally off-centered increased intratendinous signal intensity as well as PTT distal widening with otherwise normal MR imaging features are related to an intratendinous fibrocartilage.

This study was undertaken to determine the reproducibility of measurements of fatty degeneration of the rotator cuff using computed tomography (CT).Fifty-six patients who had undergone surgery for rotator cuff tear were included in this retrospective study. The extent of fatty infiltration was evaluated on CT scans with soft tissue windows in all 56 shoulders using a five-stage scoring system described by Goutallier. Five independent observers made the assessments. The same operation was repeated one month later to test intraobserver agreement. Four parameters were recorded: fatty infiltration of three muscles (supraspinatus, infraspinatus, subscapularis), and overall fatty infiltration grading. Interobserver variability was determined for each parameter using the intercorrelation coefficient (a test of reproducibility of quantitative measurements).The most reproducible measurement was the overall fatty infiltration grade. For this parameter, interobserver agreement was good with an intercorrelation coefficient of 0.75. The interval of confidence was +/- 0.5. Intraobserver agreement depended on the observer's level of experience. It was good for overall fatty infiltration grade assess by three senior observers (r=0.78) and moderate for two junior observers.The overall fatty infiltration grade is a reproducible parameter that should be used to evaluate the degree of fatty infiltration as the safety margin of this value (graded 0 to 4) is about 0.5. Fatty infiltration of a torn cuff would not be the only criterion to improve indications for treatment of rotator cuff tears.

An original method of CT measurement of the lateralization of the humeral intertubercular groove is described based on geometric construction following Thales theorem. A study of intra- and interobserver reproducibility was done of this measurement and humeral retroversion on 32 healthy volunteers. The results show good reproducibility of these measurements. The average value of humeral retroversion was lower than the average values found in the literature: 11.71 degrees on average on the dominant side and 7.03 degrees on average on the non-dominant side with a large spread of values. The reasons for these differences are discussed. The average values of lateralization of the intertubercular groove were 114.97 degrees on the dominant side and 121.9 degrees on the non-dominant side. These CT measurements are important to consider in the pathophysiology of chronic anterior instability of the shoulder.

The dissection of 37 cadavers has shown that in only a third of cases, the sural nerve comes from the communication between the medial cutaneous nerve, derived from the tibial nerve, and the communicating branch of the lateral cutaneous nerve of the leg which comes from the lateral popliteal nerve. The communication is most often at the junction between the proximal two-thirds and distal third of the leg, on average 2 mm below the transverse crease of the popliteal fossa. The medial cutaneous nerve was absent in only one case. On the other hand, in 11 cases the lateral cutaneous nerve or its communicating branch was missing. In 12 cases without any anastomoses, the route of the sural nerve was followed by the medial cutaneous nerve of the leg in 9 cases and by the lateral cutaneous nerve in 3 cases. The majority of branches to the proximal half of the calf came from the lateral cutaneous nerve. In the lower part of the leg, the sural nerve and/or the medial cutaneous nerve gave numerous branches to the Achilles’ tendon and to the integuments of the lateral aspect of the heel and lateral malleolus.

We report two cases of osteoid osteoma located in the bicipital tuberosity of the radius. This unusual localization illustrates the clinical polymorphism frequently observed in osteoid osteomas of the elbow and consequently the tendency to late diagnosis. Resistant contraction of the brachial biceps, in forearm pronation, suggests the need for complementary exams, particularly computed tomography. Surgical resection via anterior access can control pain and prevent recurrence.

A case of compression of the deep branch of the ulnar nerve associated with pseudarthrosis of the base of the fifth metacarpal and the upper shaft of the fourth metacarpal is reported. The delayed procedure consisted in volar decompression of the ulnar nerve by dividing the pisi-hamate ligament and plating and grafting of both fractures. The patient achieved marked improvement four weeks post-operatively and had complete functional recovery at follow-up of 16 years after injury without narrowing of the hamato-metacarpal joint despite synostosis of the bases of the medial metacarpals.

For many authors, the insertion of the long head of the biceps brachii muscle is exclusively or mainly located on the supraglenoid tubercle. The aim of this work was to study the insertion of the long head of the biceps brachii at macroscopic and microscopic examinations. 31 shoulders of macerated cadavers of both sex (age range: 52-92 years) were dissected by a posterior approach in order to study the glenoid labrum and the origin of the long head of the biceps brachii muscle. At macroscopic examination two types of the proximal part of the long head of the biceps brachii were demonstrated: a flattened shape in 84% of the cases and a hemicylindrical shape in 16% of the cases. Four types of origin were demonstrated at dissection: in 64.5% of the cases the tendon inserted mainly on the postero-superior part of the labrum, in 19.4% of the cases the tendon inserted both on the postero-superior and postero-anterior labrum, in 6.4% of the cases it inserted only on the supraglenoid tubercle and in three cases the tendon inserted on the intertubercular groove. The histologic examination performed on 6 superior part of the bicipitolabral complex have all shown that the tendinous fibers blended with the glenoid labrum. The examination performed on an complete labrum demonstrated tendinous fibers within the glenoid labrum up to the junction between the postero-superior and postero-inferior part of the labrum.

Variations of the radial artery are common in man. A high origin, due either to precocious bifurcation or to persistent duplication of the brachial artery, and the presence of a superficial dorsal ramus in the forearm suggest hemodynamic insufficiency of the axial vascular network allowing persistence of certain portions of the superficial system of the upper limb. Confusion of these unusual arteries with the subcutaneous veins may explain the accidental injection of drugs and distal necrosis of the limb. Knowledge of these variations may facilitate ascending catheterization of the cardiac cavities.

A statistical study of a group of 50 patients determined the mean difference in grip strength between the dominant and non-dominant hands. For every position of the wrist a mean non-dominant/dominant ratio was calculated. This ratio, 87% in the neutral position, was then used to assess grip strength in relation to the dominance of the injured limb in 15 patients who had undergone 16 radial head excisions, a mean time of 74.4 months earlier. Using this method as a correction factor, results vary considerably according to the functional scoring system used. Loss of grip strength was more frequent and more pronounced in men who had been operated on and in those whom a statistical increase in distal radio-ulnar variance was noted. Loss of grip strength was also greatest when the dominant hand had undergone surgery. Excision of the radial head is still indicated in isolated and comminuted fractures when internal fixation is not possible, especially in less active patients when the non-dominant side is affected.

Management of patients with massive irreparable rotator cuff tears associated with severe glenohumeral joint degeneration presents a difficult clinical challenge. The present study reports on 24 patients with disabling shoulder pain due to rotator cuff arthropathy treated using a bipolar arthroplasty.Between 1995 and 1997, a bipolar shoulder arthroplasty (Biomet, Warsaw, In) was used in 24 patients (25 shoulders) with rotator cuff arthropathy. Patients were monitored for an average of 14.5 months (range 12 to 24 months). The coracoacromial ligament was maintained in all patients to provide anterosuperior stability. The rotator cuff was irreparable and no attempt was made to cover the superior defect. Postoperative results were reviewed with the Constant score and the Swanson score. In order to verify the head-shell motion and to analyze the dynamic comportement of bipolar arthroplasties, we recorded anterior active elevation and active rotations with video-fluoroscopy.At final the follow-up, 21 shoulders had no or slight pain. Average active flexion improved to 84.8 degrees after operation from 62.4 degrees beforehand. 13 patients achieved more than 90 degrees of active flexion after operation. Active external rotation improved from a mean 3 to 28.8 degrees. Before surgery the average Constant score was 17.62. Postoperatively, the average Constant score was 46.97 and the average Swanson score was 23.13. Complications requiring reoperation occurred in 2 cases: 1 component dislocation (Head-shell), 1 subluxation of the long head of the biceps. Radiographic evaluation at follow up demonstrated no humeral stem loosening or component migration and no bony erosion of the coracoacromial arch. Rupture of the infraspinatus tendon (absolute Constant score: p = 0.04, adjusted Constant score: p = 0.02, Swanson score: p = 0.03, Functional score: p = 0.04), preoperative anterior subluxation of the humeral head (absolute Constant score: p = 0.03, adjusted Constant score: p = 0.05, anterior elevation: p = 0.01, functional score: p = 0.04), preoperative narrowing of the acromio-humeral interval (adjusted Constant score: p = 0.02, overall mobility: p = 0.02, anterior elevation: p = 0.03) may jeopardize the subsequent success of bipolar shoulder arthroplasty. The results of this study suggest that the radius curvature of the shell must match that of the bony surface of the glenoid and the coracoacromial arch (absolute Constant score: p = 0.003, adjusted Constant score: p = 0.005, overall mobility: p = 0.002, anterior elevation: p = 0.0008, functional score: p = 0.002). Recording of anterior active elevation with video-fluoroscopy allowed to identify 3 different types of movements after bipolar shoulder arthroplasty. Recording of internal and external rotation allowed to distinguish 2 differents types of movements. Motion appeared to occur between the bipolar shell and the head. The amount of motion was variable and depended on the biomechanics.Bipolar shoulder arthroplasty is an effective surgical option for patients with massive irreparable tears of the rotator cuff with concomitant glenohumeral arthritis. Satisfactory pain relief and modest gains in motion result in significant functional improvement in this "low functional demand" population. Predictive factors have been identified and should be discussed before surgery.

The clinical and radiological evolution of the glenoid socket in total shoulder arthroplasty is well documented, whereas evaluation of the humeral component has received much less attention. The outcome of 40 humeral replacements performed in 39 patients was studied with a minimum follow-up of one year. There were 26 Neer prostheses, 9 Modular Shoulder prostheses and 5 Aequalis prostheses. Twenty-nine prostheses were implanted with cement and 11 were cementless. The clinical and radiological results were assessed according to the scoring system used for the 1994 symposium of SO.F.C.O.T. X rays in the coronal plane were used to assess the position of the stem, radiolucencies around the humeral component and the percentage of the cross-section of the diaphysis filled by the humeral stem. The average follow-up period was respectively 55.6 months for the Neer prostheses, 17.9 months for the Modular Shoulder prostheses and 12.4 months for the Aequalis prostheses. Radiolucent lines were noted in 20 cases, all with uncemented humeral components. Two prostheses were loose; however, none required revision. The underlying pathology, surgical approach, position of the humeral component, implant design or association with glenoid resurfacing were not correlated with the presence of radiolucent lines or with a loose implant. Cementless fixation was the only parameter statistically related with the presence of radiolucent lines. This report confirms the good results obtained with cemented humeral prostheses. Radiological evaluation of the smooth cementless humeral implant showed many progressive radiolucent lines, without clinical expression. The authors analyze the various studies in the literature and discuss the interest of cementless implants with ingrowth surface.

The authors report their experience of Zadek's wedge osteotomy in the treatment of posterior talalgia in adults and evaluate the various radiographical measurements for calcaneus deformity measurement....This procedure was performed in 27 patients with a total of 36 calcanea treated between 1985 and 1996. The sex ratio was 20 women for 7 men with an average age of 27 years. Prior to this osteotomy nine feet were operated by resection of the postero-superior tuberosity with recurrence of pain and disability, and two patients presented an inflammatory arthritis.For the surgical procedure, the patient was placed in lateral position. Skin incision was five to six centimeters long, curvilinear along the lateral side of the tendo achillis. Two dorsal pins were inserted, creating a triangle so that the apex pointed plantarly and the base dorsally. The sagittal saw was then used to create a wedge osteotomy with a dorsal base of seven to ten millimeters. A screw was then driven across the osteotomy site for ultimate fixation.Eighty per cent (29 osteotomies) of patients had been examined clinically and radiologically with a mean follow-up of 29 months. Considering pain, daily activity and discomfort with footwear, results were excellent in 12 cases, good in 10, fair in 5 and poor in two cases. No radiological criteria used for the diagnosis of Haglund's disease were absolutely reliable. The "total angle" of Ruch, the "c.l angle" of Chauveaux and the "parallel pitch lines" of Heneghan reflect the amount of deformation most accurately, but especially, the calcaneal inclination angle was always increased (16 cases between 18 degrees and 30 degrees, 6 cases30 degrees). All patients had a weight-bearing calcaneal talus, either alone or in the context of posterior pes cavus.This study confirms the responsibility of rearfoot morphostatic disorders in posterior talalgia and the goods results obtained by Zadek osteotomy.

The purpose of this paper is to report our experience with revision shoulder arthroplasty failure. The surgical options and principles chosen to affect the best treatment are discussed. Reoperation after shoulder arthroplasty was performed in 23 patients and was always a challenging and technically difficult procedure. The pathogenesis of failed shoulder arthroplasty was directly related to the original shoulder pathology and the type of shoulder arthroplasty performed (hemi-or total arthroplasty). The common causes of failures of shoulder arthroplasties which led to revision surgery were: anterior instability (5 cases), posterior instability (3 cases), glenoid loosening (4 cases), rotator cuff pathologies (3 cases), glenoid erosion after hemiarthoplasty (2 cases), infection (3 cases), failure of tuberosity fixation (3 cases) and limited motion because of stiffness (one case). While pain relief was often obtained after revision shoulder arthroplasty, functional result was less predictable and was sometimes compromised by the condition of the soft tissues.

Although the precise radiographic analysis of the fractures of the proximal humerus allowed by modern imaging techniques has clarified the therapeutic indications, difficulties in interpretation do not make it any easier to choose the right technique from the many proposed. Classical open internal fixation has certainly yielded disappointing functional results, especially when performed with bulky implants not adapted to high fractures, comminutive fractures, and osteporotic bone. However, although it solves the difficult technical problems of reconstructing the proximal humerus, a prosthesis is not the universal solution to displaced fracture. Finally, the acute proximal humerus fractures for which a shoulder replacement is indicated are: (a) four-part displaced fractures and fracture-dislocations, (b) selected three-part fractures in elderly patients with osteopenic bone stock, (c) some head-splitting fractures, in which the articular segment is split with displacement, (d) some impression fractures involving about half or more of the articular surface.

This article addresses the recognition, etiology, treatment and prevention of complications of total shoulder arthroplasty observed in theAequalis multicenter study. Ten intraoperative humeral fractures were observed: three fractures occurred in the greater tuberosity and seven spiroid fractures occured in the diaphysis and were related to forceful external rotation during exposure of the humeral head. Two late postoperative fractures occurred and were secondary to trauma. Locoregional complications include three hematoma, three deep infections and ten nerve injuries. Anterior instability (five cases) was either traumatic (two cases) or atraumatic (three cases), following previous surgery and was typically associated with disruption of the anterior shoulder repair in all cases. Revision surgery for repair of the subscapularis was performed with simple sutures in three cases but necessitated a pectoralis major transfer in one case and a bone-quadriceps tendon graft in one case. Posterior instability occurred early on three occasions and was related to insufficient correction of excessive glenoid wear with plastic deformation and incompetence of the posterior capsule. Anterosuperior instability occurred in three cases and was related to superior cuff rupture or deltoid loss. Glenoid loosening required revision in four cases. No humeral loosening occurred with the cemented components while eleven humeral loosening and subsidence were observed with the twenty press-fitted components. A glenoid erosion occurred in two cases of hemiarthroplasty, a dissociation of the polyethylene from the metal tray in one case and a persistent stiff shoulder in one case.

To evaluate the early results of the Aequalis prosthesis, a prospective multicenter study was undertaken. The clinical and radiological results of the first 417 shoulder prostheses implanted have been evaluated with a minimum of 12 months of follow-up. Some details regarding the entire series are given here.

The major ruptures of the rotators cuff point out the problem of their surgical repair. Various techniques are described in the literature, among them the deltoid flap technique, described by Apoil and Augereau. This technique points out the problem of a few cases of flap early necrosis (Saragaglia). We studied the deltoid arterial blood supply on 40 cadaveric shoulder, after coloured injection into the subclavian artery. Our study included 40 macroscopic and 15 radiographic observations. The thoracoacromial artery gave off two collaterals to the anterior part of the deltoid muscle. The first one, called the deltoid artery, ran into the anterior part of the deltoid, near the deltopectoral line. In 53%, it gave off a first superior collateral branch, which ran at 3 cm under the clavicle. The second one, called the acromial artery, ran deep to the anterior part of the deltoid muscle, near the clavicle and the acromion. The posterior circumflex humeral artery was the most important artery. It supplied the posterior and middle parts of the deltoid muscle. The anterior circumflex humeral artery supplied the anterior part of the deltoid muscle in 63%. In ten cases, we dissected a deltoid flap. In all the cases, the acromial artery was cut near the acromion. When the deltoid artery gives off its superior collateral branch, it was always cut. Then, this flap was only vascularized by its inferior aspect. These results show that the flap is located in a poorly supplied area. Thus, the flap necrosis could be explained by an insufficient anastomotic network. An operative technique modification could avoid this complication.

Five patients with a large defect in the articular cartilage at the knee joint were treated by transplantation of an autogenic osteochondral fragment. The graft was harvested from the posterior portion of the ipsilateral femoral condyle in 4 cases of osteochondritis dissecans, and from the lateral third of the patella pedicled on the patellar ligament in one case of posttraumatic necrotic collapse of the lateral tibial plateau. One patient underwent concomitant high tibial osteotomy. Two months postoperatively bony union was achieved in all cases but in one case, the grafted articular cartilage did not survive after weight bearing because of an overlooked varus deformity. At the follow-up examination (8 to 20 years) all 5 patients were asymptomatic ; the range of flexion was somewhat restricted (120 degrees) ; roentgenogram revealed slight narrowing of the articular space or at least flattening of the grafted zone and subchondral osteosclerosis. At arthroscopic exploration, the grafted zones were recognizable from the surrounding cartilage, and histologic examination of their border revealed fibrocartilage and proliferating vessels; late gonarthrosis might ensue over time. Therefore the procedure should be performed only in large osteochondral defects where neither reattachment of a loose body, nor hemiarthroplasty, nor isolated osteotomy are suitable and before degenerative changes have developed. Morever any associated varus deformity requires concomitant correction by high tibial osteotomy to relieve stress from the graft.

Tibiotalar dislocations without fracture are extremely rare lesions. This series included 16 patients, 12 of whom have been examined clinically and radiographically. The purpose of this study was to specify the injury mechanism of the various anatomical types and to assess the long term outcome. The group included eight posteromedial dislocations (50%), four posterior dislocations (25%), one anterior dislocation, one high variety, one of the Huguier type, and one complex dislocation. The sex ratio was 14 males/2 females with an average age of 37 years. In half of the cases, dislocations were open. The average follow-up period was 11 years (range, 1 to 26 years). The eight closed dislocations and the open case type I according to the Cauchoix classification received non-operative treatment by reduction in the emergency room and immobilization in a plaster cast for 6 weeks. The seven patients who presented open dislocations Cauchoix type 2 and type 3 were treated by surgical debridement and ligament repair, followed in all cases by a plaster cast boot, and in two cases by temporary transplantar pinning. Twelve patients were reexamined clinically according to the Gay and Evrard modified score, and were radiographically evaluated with lateral and anteroposterior views focused on the tibiotalar joint, on both sides, static and dynamic. Anatomical factors resulting in predisposition such as medial malleolus shortness or lack of coverage of the talus have been evaluated. No patient presented tibiotalar joint instability. A 5 degrees to 10 degrees loss in the range of dorsiflexion was frequently observed. Two patients presented joint stiffness. In four cases, patients complained about paresthesias in the areas of the anterior tibial nerve or intermediary dorsal cutaneous nerve. Four cases of degenerative arthritis were radiographically observed, two of which presented an overall narrowing of the joint over 50%. Degenerative arthritis had occurred within the first four years in these 4 cases. The talus coverage index was similar to the standard population. Shortness of the medial malleolus was present in only two cases. The long-term prognosis after tibiotalar dislocation without fracture proves to be good. One should favor orthopedic treatment. The absence of tibiotalar instability argues against carrying out emergency ligamentous repair. Evolution towards degenerative arthritis is to be anticipated in 25% of cases, especially following open dislocations, or if transplantar pinning was required due to instability of the initial reduction.

The authors report two cases of ulnar nerve compression at the wrist due to arthrosynovial cysts arising from the hamatotriquetral joint. The absence of strict parallelism between the type of neurological deficit observed, the site of the cyst and the site of compression requires ulnar nerve release as far as its division in the pisi-unciform hiatus, where the section of the hypothenar fibrous arcade and pisi-unciform ligament is essential. Complete recovery of these 2 patients confirmed the favourable prognosis of this form of compression provided surgical treatment is performed early and rigorously.

The authors report a rare case of a histologically proven intraosseous ganglion found in the calcaneus. A 59 year old carpenter was referred to our institution because of progressive talalgia with swelling of the hindfoot, increasing with prolonged standing and walking at job. X rays showed a multilobular radiolucent cyst developed in the anterior part of the left calcaneus, outlined by a rim of sclerotic bone. A lateral cortical split revealed by CT was deemed to be a traumatic communication with the soft tissue. At biopsy, a gelatinous and hematic content was noted but pathologic examination of the cyst walls failed to reveal the diagnosis; there were no malignant cells. 5 weeks later, the cyst and its contents were excised through lateral approach and the defect filled with cancellous bone graft. At pathological examination, a final diagnosis of ganglion cyst was determined. One year after surgery, the patient was asymptomatic; no sign of recurrence was observed. Intraosseous ganglia are benign subchondral cysts which rarely involve foot bones. When pain becomes consistent and swelling occurs because of overlooked fracture, malignant bone tumors should be ruled out. Histological examination is mandatory to confirm the diagnosis. Excision of the cyst and bone grafting are effective; recurrence is infrequent.

The purpose of this report was to study the repercussions of rotator cuff condition on unconstrained shoulder arthroplasty results.Between 1986 and 1993, 40 unconstrained shoulder prostheses were performed (24 total and 16 hemiarthroplasties). At the time of the operation, rotator cuff condition was reported to be normal in 15 shoulders, atrophic in 10, scarred in 3, torn in 12. Clinical and radiographical results were analyzed and supplemented with a rotator cuff echography. Postoperative follow-up averaged 42.25 months (12 to 97 months).When the rotator cuff was intact at the time of operation, clinical results were the best at the time of review. Constant score, overall mobility, forward elevation, external rotation with the elbow along the side were better for intact than for atrophic, scarred or torn rotator cuffs (p0.01). Ruptures repaired by local tissue transfer or trapezo deltoidal flap substitution (3 cases) gave satisfactory results, whereas two dacron cuff prostheses failed. In the non repaired ruptures (7 cases), arthroplasty resulted in 3/4 fair or poor results. At the time of review, the total incidence of postoperative rotator cuff tears was high (12 cases), functional repercussions were variable. Among the 15 rotator cuff tears observed at the time of the review, the long head of the biceps was present and in place in 9 cases and ruptured in 6 cases. In these latter cases, Constant score (p0.01), the forward elevation (p0.01), external rotation with elbow along side (p0.05) and overall mobility (p0.05) were worse; moreover, humeral head superior migration was greater (p0.01).Our study confirms the superiority of clinical results when the cuff was intact at the time of the operation. The repair of rotator cuff tears seems to be justified. When the rupture has not been repaired, clinical results were fair or poor in 5 cases out of 7, the initial rupture spread to the other tendons in 3 cases out of 7. Secondary ruptures were frequent (12 cases). No predictive factor was identified, but an overlapping of the greater tuberosity appears to be detrimental. Among rotator cuff tears present at the time of review, long head of the biceps rupture jeopardized clinical results and was associated with a proximal migration of the humeral head which was significantly more severe than with an intact non displaced long head of the biceps.During unconstrained shoulder prosthesis implantation, it is therefore recommend to systematically repair any associated rotator cuff rupture, in order to avoid any greater tuberosity overlap relative to the prosthetic head and to preserve the long head of the biceps tendon which limits upward migration of the humeral head and improves prosthetic kinetics.

The aim of this study was to appreciate the results of the modified Fowler's procedure in the surgical treatment of forefoot deformities due to rheumatoid arthritis.If the principles of the metatarsophalangeal resection through a dorsal transverse incision were conserved, we progressively modified the initial procedure with renunciation to the plantar skin incision, preservation of a skin bridge between the medial and transverse dorsal approach, using centro medullary pins to hold in position toes alignment and making an arthrodesis of the first metatarsophalangeal joint. Ten patients (17 surgical procedures) were clinically and roentgenographically reviewed at an average follow-up of 27.3 months (Range : 12 and 53 months).Clinical results according to the Gainor scale showed an increase of the overall score from 3.4 points to 11.2 points at revision. Twelve foot were rated excellents and five goods. Seventy per cent of patients had no pain and 58 per cent used a normal footwear. Radiographical and clinical analysis showed that an egyptian foot remained in nine cases, podoscopic examination revealed frequently a lack of footrest on lateral toes without functional implications. Delayed wound healing were observed in four cases with good evolution.With this surgical procedure, our functional results were encouraging and we recommend it in severe deformities of the rheumatoid foot with fixed metatarsophalangeal dislocations and bone defect of the metatarsal heads.