Second generation GUEPAR total arthroplasty of the thumb basal joint: 50 months follow-up in 84 cases.

BACKGROUND: Osteoarthritis of the thumb basal joint is the most common location for hand degenerative joint disease. First, carpometacarpal (CMC) joint arthroplasty is one treatment option. The purpose of this article is to present the outcome of the GUEPAR II prosthesis, a total trapeziometacarpal cemented implant of the retaining ball-and-socket design type. Numerous other advantageous features of this implant, second generation of an earlier version are explored. HYPOTHESIS: Clinical and radiological results confirm the GUEPAR II trapeziometacarpal arthroplasty as a reliable and efficient evolution of earlier prosthetic designs. MATERIALS AND METHODS: Eighty-four GUEPAR II prostheses were implanted to treat advanced and severely incapacitating first CMC osteoarthritis. The average follow-up time in this collaborative series (from 2 centers) was 50 months. RESULTS: There were no intraoperative complications and no dislocations at the final follow-up evaluation, 92% of patients were satisfied or very satisfied with their results with objective improvement of their Kapandji score. Strength was closely comparable to the nonaffected side. Radiographic studies at the final follow-up evaluations did not show (except in one socket revision instance) signs of implant loosening. On occasion, non-progressive radiolucent lines were observed. More than 80% of the patients remained pain free. CONCLUSIONS: In our series, GUEPAR II total joint arthroplasty of the thumb CMC joint has proven to be efficacious, improving motion, strength, and achieving a high degree of pain relief. Successful outcome appears in our experience contingent upon strict compliance with numerous surgical technique details. Current research focuses on improving bipolar fixation by developing press-fit cementless implants.

[Treatment of non-unions of the carpal scaphoid using a nonvascularised corticocancellous bone graft: a retrospective series of 47 cases]. / Traitement des pseudarthroses du scaphoïde carpien par greffe corticospongieuse non vascularisée: étude rétrospective de 47 cas.

OBJECTIVES: The authors report their results on the treatment of scaphoid non-unions without osteoarthritis or necrosis, by anterior nonvascularized bone graft. PATIENTS AND METHODS: Forty-seven patients treated between 1988 and 2003 were analysed with a mean follow-up of 74 months. There were 19 non-unions without carpal instability (IIA) and 28 with carpal instability (IIB). All patients were treated by an anterior approach with corticocancellous bone graft and osteosynthesis using two pins. Clinical results were analysed on pain, strength and mobility. Radiographic analysis was of union, correction of instability and occurrence of osteoarthritis. RESULTS: These were divided into stages IIA and IIB: 1) stage IIA: all cases proceeded to bony union; ten results were excellent and nine good and no instability; there was one case of osteoarthritis; 2) stage IIB: 78% of patients proceeded to bony union; one result was excellent, 17 good, four moderate and six cases remained un-united. There were 12 cases of osteoarthritis. Most of them occurred in patients with residual instability after the initial surgical procedure. CONCLUSION: Corticocancellous nonvascularized bone graft by a palmar approach is an excellent technique for treatment of scaphoid non-unions without osteoarthritis and necrosis. The presence of instability is a poor prognostic factor; its correction during the operation allows the surgeon to decrease the risk of osteoarthritis.

[Acromelic arthritis: a new entity]. / L'acropolyarthrite rhumatoïde.

PURPOSE OF THE STUDY: Few patients with rheumatoid arthritis present isolated acromelic bone and joint destructions. Concerned joints are wrist, MP, PIP, DIP and forefoot. The aim of the current study is to describe and evaluate the long-term results of wrist, hand and forefoot surgery in an acromelic arthritis group. MATERIAL AND METHODS: 93 patients with acromelic arthritis were included in the study. 202 surgical procedures were performed between 1981 and 2001 in addition to medical treatment. 93 procedures concerned dorsal wrist surgery. The mean follow-up of this group was 7 years (24 months-20 years). 78 synovectomies of radio-carpal and medio-carpal joints with a Sauvé-Kapandji procedure were performed and 10 with a radio-lunate arthrodesis and 5 with other surgeries. The main indication for surgery was severe pain. RESULTS: Functional results and radiographic evolution (Larsen X-ray classification) were studied. All patients were satisfied or very satisfied and pain was significantly reduced. Radiographic lesions progressed but Larsen's stage remained unchanged in 73% of patients. All patients with forefoot surgery recovered total walk autonomy. DISCUSSION: Acromelic arthritis is a particular form of rheumatoid arthritis that progresses very slowly. Surgery should be indicated earlier, for a better joint function stabilisation.

[Syringomyelia and associated bone and joint diseases]. / Syringomyélie et pathologies ostéo-articulaires associées.

Syringomyelia can occur in patients presenting bone and joint diseases of various origins. When joint destruction of the shoulder or elbow produces little pain, a neurological cause might be involved. In this case, the disease history can be of utmost importance because an initial diagnosis of rheumatoid polyarthritis, polyosteoarthritis, or destructive joint disease can be misleading before the syringomyelic origin of the bone and joint disease becomes patent. We report two cases illustrating this association and the diagnostic pitfalls which can delay recognition of the syringomyelia. Better awareness of the prevalence of this condition should be helpful in establishing the diagnosis and in selecting patients who can benefit from neurosurgical treatment. The two cases presented here suggest that syringomyelia could be underdiagnosed in certain patients with an initially atypical presentation. A review of the current knowledge of syringomyelia suggests that arthroplasty is generally not advisable for destroyed dislocated syringomyelic joints.

[Bipolar shoulder prosthesis for rheumatoid arthritis with irreparable rotator cuff tear: results after 5 years' follow-up]. / La prothèse humérale bipolaire dans l'épaule rhumatoïde avec rupture de coiffe irréparable. Résultats à plus 5 ans de recul.

PURPOSE OF THE STUDY: The goal of this study was to assess the clinical and radiological outcome of bipolar shoulder prosthesis in twelve shoulders with rheumatoid arthritis (RA) and irreparable rotator cuff tears. MATERIAL AND METHODS: The follow-up was more than five years (range 2-9 years). In addition, in order to investigate the effect of rheumatoid arthritis on outcome, results were compared with ten bipolar shoulder prostheses implanted for osteoarthritis with massive rotator cuff tears. RESULTS: The mean preoperative Constant score was 16.9 points with 2.6 points for pain, 4.2 points for activity, 9.5 points for motion and 0.6 points for force. The preoperative active motion was 63.8 degrees for forward flexion, 45 degrees for abduction and 12 degrees for active external rotation. At last follow-up, the average Constant score was 39.4 points with 10.7 points for pain, 10.8 points for activity, 13.8 points for motion and 4.1 points for force. Regarding the active motion, mean forward flexion was 83.7 degrees, 70.4 degrees for abduction and 29.1 degrees for external rotation. The complication rate was low, mainly superior migration due to infraspinatus tear and glenoid wear. Satisfactory deltoid arm level was achieved in all patients and no loosening was observed. Preoperative and postoperative scores of the rheumatoid group were not significantly different from the arthritis group (p<0.001). DISCUSSION: Our findings suggest that bipolar shoulder prosthesis provides a viable replacement alternative in RA combined with massive rotator cuff tear with a low rate of complication. Bipolar shoulder prosthesis demonstrates no clear superiority over conventional hemiarthroplasty regarding improved motion and glenoid wear. In addition, no significant difference with arthritis was observed (p<0.05), assuming that outcome depends principally on the preoperative condition of the rotator cuff. CONCLUSION: Some massive tears involving the subscapularis tendon can lead to anterior recurrence after bipolar shoulder prosthesis. They might be a limit to the procedure and require a reversed shoulder prosthesis or a glenohumeral arthrodesis.

Long-term review of five leg replantations: emergency strategy and examples of lengthening of the leg on nerve regeneration.

The success rate for leg replantation has improved with the development of shortening-lengthening protocols. We checked whether this success was maintained long term in five cases of emergency reimplantation. The significant initial shortening of 93 mm, on average, enabled direct internal osteosynthesis, secondary lengthening was initiated swiftly, in the proximal metaphyseal area, and average lengthening was 85 mm. Consolidation was achieved in all cases within normal time periods, with an average inequality in residual length of 8mm. The speed of nerve regeneration was on average 1.926 mm/day, twice faster than usual after simple nerve suturing. At average follow-up of more than 11 years, all patients were walking. We conclude that nerve lengthening stimulates nerve regeneration, and that the results of this protocol, involving extensive initial debridement compensated by secondary lengthening, have enabled the limitations on unilateral leg replantation to be reduced.

[Merkel cell carcinoma of the skin: two case reports located at the hand, with a review of litterature]. / Le carcinome cutané de Merkel: revue de la littérature à propos de deux localisations à la main.

The Merkel cell carcinoma of the skin are rare neuroendocrine tumours, with a dermal location. Their severity and metastatic potential are higher than cutaneous melanomas'. Two cases are reported at the hand. A review of literature displays the pejorative prognosis of these tumours. Hand surgeons must be aware of them, in order to fasten the diagnosis and include the patient among a multidisciplinary medical team.

[Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis]. / Traitement de l'arthrose scaphotrapézotrapézoidienne isolée par arthrodèse scaphotrapézotrapézoidienne: une série de 13 cas.

Scapho-trapezio-trapezoid arthrodesis was originally performed for the treatment of scapho-lunate instability. However, only a few publications have described this technique for treatment of osteoarthritis of the scapho-trapezio-trapezoid (STT) joint. The purpose of this paper is to analyze the results of triscaphoid arthrodesis for STT osteoarthritis with a long-term follow-up. Thirteen cases of osteoarthritis of the STT joint in twelve patients, all treated by STT arthrodesis, were reviewed with an average follow-up of 60 months. Pain was classified according to Alnot's classification: eight patients were classified as grade III, two as grade IV and two as grade II. The average preoperative range of motion of the wrist was 51 degrees for flexion, 39 degrees for extension, 9 degrees for radial deviation and 28 degrees for ulnar deviation. Grip strength was compared to the contralateral side. Radiographic changes were classified according to Crosby's classification, including sublevels for carpal instability. Four wrists were classified 2a and nine wrists were classified 2b. The average radio-lunate and scapho-lunate angles were 14 and 45 degrees respectively. Pain was improved in all patients (P = 0.05) all of whom were subjectively satisfied. Strength and range-of-motion did not statistically decrease after STT arthrodesis except for wrist extension (P = 0.03). Radio-lunate and scapho-lunate angles were unchanged in five patients and improved in five patients. There were four non-unions of whom two patients without pain were not re-operated. The other two were re-operated with the same technique leading to fusion. Scapho-trapezio-trapezoid arthrodesis is an efficient procedure for STT osteoarthritis with regard to pain reduction. Strength and global range-of-motion are not modified by this procedure. Moreover, as it limits carpal instability, this procedure is preferable in active patients.

[Jaccoud's arthropathy. Surgical results of 41 hands]. / La main de Jaccoud. A propos de 41 mains opérées.

Jaccoud's arthropathy, which was first described in 1869, is a rare syndrome that is characterized by a painless or relatively painless deformity of the digits II, II, IV and V with a dislocation of the extensor tendons into the metacarpal valley. When the thumb is affected, a Z deformity is observed. The present analysis was based on 40 patients (56 hands, 41 of which were operated on over the period 1989 to 2001). A distinction should be made between Jaccoud's disease following a known inflammatory arthropathy (23 hands; average patient age 55 years) and the idiopathic form of the disease (18 hands, average patient age 70 years). From a clinical point of view, a classification of the deformities is needed so that appropriate surgical treatment can be determined. In the present study, four groups were therefore proposed, in groups I and III the realignment to centre of the extensor tendons of the metacarpophalangeal joint and joint stabilization yielded 83% positive results. In groups II and IV the results were only 66% good after Swanson implant. The pathogenesis of Jaccoud's disease has not yet been determined, but now that more information has become available and a better analysis can be made of its various clinical and anatomopathological charasteristics, these should assist in defining precise surgical indications.

[Prognostic factors of axillary nerve surgery]. / Facteurs pronostiques de la chirurgie du nerf axillaire.

PURPOSE OF THE STUDY: We searched for prognostic factors which could influence outcome after surgery for traumatic lesion of the axillary nerve. MATERIAL AND METHODS: Forty-five surgical interventions to repair injured axillary nerves were preformed between 1993 and 2000. We analyzed outcome at a mean 56 Months (range 15-96). Twenty-five isolated lesions were treated by nerve graft (n=20), direct suture (n=2) or neurolysis (n=3). Four associated axillary and musculocutaneous nerve injuries were treated by axillary graft and musculocutaneous neurolysis (n=2) or double grafts (n=2). Eleven injuries involving both the axillary and suprascapular nerve were treated by double nerve graft (n=4), axillary graft with suprascapular neurolysis (n=5), or axillary graft with an irreparable suprascapulary injury (n=2). Five axillary nerve lesions were associated with lesions of the rotary cuff; treatment associated suture of the cuff (n=3) or reinsertion fixation of the tuberosities (n=2) prior to nerve repair by axillary graft (n=4) or neurolysis (n=1). RESULTS: For the isolated axillary lesions, results were very good or good for 16/20 nerve grafts, 2/2 direct sutures and 2/3 neurolyses. For the patients with an associated musculocutaneous lesion, shoulder function was considered very good for one; mean elbow flexion strength was 29% (15-50%) of the healthy side. For the eleven axillary and suprascapular injuries, outcome was very good or good for two. Very good or good results were not achieved for any of the five patients with associated cuff lesions. Factors predictive of poor outcome were a preoperative Constant score below 40 points, age over 40 Years, time to operation greater than 15 Months, and multiple nerve or associated cuff injury. DISCUSSION: The favorable prognosis of isolated lesions of the axillary nerve was confirmed. The risk of failure does however persist and is related to late management despite well defined surgical technique.

[Total elbow arthroplasty in rheumatoid arthritis using GUEPAR prosthesis]. / Prothèse totale bicompartimentaire de coude GUEPAR. Résultats dans la polyarthrite rhumatoïde (16 cas).

PURPOSE OF THE STUDY: We report a retrospective analysis of 16 patients with rheumatoid arthritis treated with a total humero-ulnar and humero-radial GUEPAR prosthesis (GIII). MATERIAL AND METHODS: The GUEPAR III elbow prosthesis is an anatomic polyethylene-metal gliding prosthesis designed to maintain physiological valgus. Right and left models are available in two sizes. On the humero-ulnar side of the prosthesis, was associated with a radial head, born on an intramedullary metallic stem, that can be fit with several sizes of mobile polyethylene cups. The 16 GIII prostheses were implanted in 1997 to 2001 in accordance with the manufacturers instructions. Mean follow-up was 2 years. RESULTS: Before surgical treatment, all patients had moderate or severe but invalidating pain. The Mayo Clinic score was 33 points. The Larsen radiographic score was grade III (7 elbows) or grade IV (9 elbows). Patients were reassessed 1 to 5 years after implantation of the GIII (mean follow-up 2 years). At last follow-up the mean Mayo Clinic score had improved from 33 to 90 points. Outcome was considered excellent for 15 elbows and fair for 1. DISCUSSION: We review the indications for total elbow arthroplasty in patients with rheumatoid arthritis. Semi-constrained prostheses are useful and necessary for the treatment of elbows exhibiting massive destruction, but the use of minimally constrained prostheses such as the GUEPAR III is becoming increasingly widespread. We use the GUEPAR III for 70% of our patients, particularly those with rheumatoid arthritis.

[Surgical replacement of the thumb saddle joint with the GUEPAR prosthesis]. / Die chirurgische Versorgung der Rhizarthrose mit der GUEPAR-Prothese.

Primary arthritis of the thumb saddle joint is very common. Among the different treatment options, the implantation of a total joint arthroplasty is an alternative. The GUEPAR prosthesis, developed by a group of French surgeons, is mainly used in elderly patients and only in cases with preserved trapezial height. This study reports the mid-term results of the second generation of this implant. The clinical results show good pain relief and good mobility of the thumb. There were a few patients with radiological signs of implant loosening, but none of them had clinical problems. The advantage of a total replacement of the saddle joint, compared to the standard resection arthroplasty, is faster rehabilitation and preservation of the length of the thumb. The new generation of the GUEPAR prosthesis has a more anatomical metacarpal stem and a modularity which allows the fit of the implants according to the anatomical situation.

[Multiple peripheral nerve tumors: update and review of the literature]. / Tumeurs multiples des nerfs périphériques: mise au point et revue de la littérature.

Multiple tumours of the peripheral nerves are seen only in neurofibromatosis. They are hereditary. They present and develop in a variety of different ways. Three main groups are distinguished: von Recklinghausen neurofibromatosis or type 1; bilateral acoustic neurofibromatosis or type 2 and schwannomatosis recently defined as type 3. The aim of this study was to clarify the clinical outcome of neurofibromatosis. The diagnosis is made purely on clinical grounds. Cranial MRI and slit lamp examination are useful for classification. Surgical management for peripheral nerve tumours is similar. Any new and rapid change noted at clinical examination (increase in volume, pain or neurological deficit) requires surgery because of potential malignant transformation of the neurofibroma into neurofibrosarcoma (type 1 only). The definitive treatment depends on the resectable character of the tumour which is usually only known after epineurotomy under operating microscope. In the event of resectable tumour (schwannoma) enucleation must be performed, preserving nerve continuity. In the event of unresectable tumour (neurofibroma), tumour resection is impossible without sacrificing nerve tissue. An epineurotomy must be performed. It prevents further deterioration. Interfascicular biopsy confirms the histological type. Our results are similar to those in other recorded studies. The unpredictable clinical course of neurofibromatosis makes prolonged follow-up mandatory.

[Resection of the first row of carpal bones: post-traumatic wrist and Kienbock's disease]. / La résection de la première rangée des os du carpe: poignet post-traumatique et maladie de Kienböck.

This study reports the outcomes of 27 proximal row carpectomies for stage II (Watson) scapholunate--(10 Slac) and scaphoid non union--(8 Snac) advanced collapse and stage III (Lichtman) Kienböck's disease (9 cases) followed for an average of respectively 72 and 50 months. Following surgical treatment, more than 80% of patients in both groups were pain free. The total arc of motion averaged 67 degrees (unchanged), for the post-traumatic arthritis, and 59 degrees for Kienböck's, a decrease of 17%. Grip strength averaged a 17% increase in comparison to the opposite size for both groups. Proximal row carpectomy showed a high degree of patient satisfaction and is a motion-preserving and grip-preserving procedure used in stage II post-traumatic arthritis but Lichtman III stage in Kienböck's disease had a comparatively poor result. Proximal row carpectomy simplifies the structure of the radiocarpal joint. When the cartilage on the capitate head and the radial lunate facet are not worn, this procedure provides a good result with respect to pain, range of motion and strength which is stable with time.

[GUEPAR radial head prosthesis for recent and old fractures: a series of 22 cases]. / La prothèse de tête radiale GUEPAR dans les fractures récentes et anciennes: à propos d'une série de 22 cas.

PURPOSE OF THE STUDY: We reviewed retrospectively outcome in 22 patients with recent or old fractures of the radial head treated with a GUEPAR radial head prosthesis. This prosthesis, derived from the GUEPAR sliding total elbow prosthesis, has a cemented mobile metal cup. MATERIAL AND METHODS: Eighteen patients underwent emergency surgery, four deferred surgery. Mean age at surgery was 41 years and mean follow-up was 18 months. The Mayo Clinic score was calculated to assess clinical outcome. Static and dynamic x-rays of the elbows and wrists were analyzed. All of the fractures were total or displaced head fractures and 72% involved elbow dislocation. The coronoid process was fixed in one patient, the olecranon in one and the medial ligaments were repaired in 5. The quality of the cartilage of the humeral condyle was checked before insertion of the prosthesis. Proper position and height of the prosthesis were carefully controlled. RESULTS: There were no complications. Outcome was good in the patients who underwent emergency surgery with a mean Mayo Clinic score of 83/100, mean force 75%, good joint motion (77 degrees pronation, 79 degrees supination), stable elbow, and no wrist problems. Outcome was not as good in patients who underwent deferred implantation, particularly for joint motion (pronation 44 degrees, supination 54 degrees ). The distal radio-ulnar ratio was not perfectly restored. Finally 4 patients required arthrolysis for limited flexion/extension, proportionally more among the deferred patients. DISCUSSION: Resection of the radial head is an alternative in case of complex fractures. There are two drawbacks. The first is an unstable elbow in valgus if the medial ligaments are damaged. The second is an ascension of the radius if the interosseous membrane is damaged. Osteosynthesis is another alternative which is difficult to achieve and does not give good results (in our experience in comparison with 20 equivalent fractures, and in the literature). The GUEPAR radial head prosthesis appears to be a good solution. It stabilizes the elbow, prevents ascension of the radius, allows early rehabilitation, and provides good subjective results, particularly after emergency surgery.

[Aseptic non-union of humeral shaft fractures treated by plating and bone grafting]. / Pseudarthroses et retards de consolidation aseptiques de la diaphyse humérale: à propos de 30 cas traités par plaque et autogreffe osseuse.

PURPOSE OF THE STUDY: Although aseptic non-union of humeral shaft fractures is generally considered to be an exceptional complication, rates in the literature have varied from 1 to 10%. Factors favoring non-union are often related to technical error or inappropriate therapeutic indication. Several types of treatment (orthopedic, locked centromedullary nailing, ascending pinning, plating, external fixation) can be proposed for humeral shaft fractures. In all cases, a precise technique and proper indication are essential for success. We reviewed the cases of 30 patients who underwent surgery for aseptic non-union of humeral shaft fractures between 1995 and 2000. MATERIAL AND METHODS: Mean patient age was 43 years. Oblique and transverse fractures of the middle third of the shaft predominated. All types of treatment had been used but most of the patients had had ascending pinning. All patients were treated with plate fixatin and a cancellous bone graft after identifying the radial nerve. RESULTS: Bone healing was achieved in all patients. Mean delay to healing was 16 weeks with good motion of the shoulder (mean elevation 136 degrees ) and elbow (mean motion 10-130 degrees ). Transient radial paresia recovered spontaneously in two patients. There was one infection. Only two patients complained of a painful arm that was not bothersome for daily activities and did not require long-term analgesia. There were no cases of radial nerve injury. Elbow function improved in 16 patients, was unchanged in 11, and showed limited extension in 3. Shoulder function improved in 15 patients and was unchanged in 15. DISCUSSION: Plate fixation is widely described in the literature for the treatment of humeral non-union. The main complications of this treatment are radial palsy and infection, reported in 5% of the series. Several recent reports have therefore advocated locked nailing or external fixation with an Ilizarov device but these techniques are difficult to use and have their own risks of complications. It is difficult to block rotation and the nail may injure the rotator cuff. Pin tract infection, nerve injury, and prolonged external fixation are other disadvantages. We therefore recommend screw plate fixation with a cancellous bone graft. Our good results combined with the very low rate of complications argue in favor of this therapeutic option.

[Guepar anatomical trapeziometacarpal prosthesis]. / La prothèse trapèzométacarpienne anatomique Guepar.

INTRODUCTION: A choice of surgical techniques of treatment for trapeziometacarpal (TMC) Osteo-Arthritis (OA) have been described. Total arthroplasty is often used, especially in France. Many papers have been published, presenting various prostheses. In English literature, this device is not thoroughly used. MATERIALS AND METHODS: [corrected] Guepar total arthroplasty is a cemented ball-in-socket prosthesis in metal-polyethylene. It includes an anatomical stem available in 4 sizes. After failure of the conservative treatment, total arthroplasty must be reserved to elderly patients, painful, with OA Dell stage III or IV aligned or not. The trapezial height must be sufficient. The authors reports the preliminary results of 64 Guepar prostheses, anatomical new design, implanted since 1995. RESULTS: Results of 63 prostheses are presented. One removal had been necessary at 9 months for metacarpal loosening (failure). Mean follow-up was 29 months. Clinical results were judged excellent or good in all cases. Regarding the radiological results, no modifications has been observed in 56 cases. Six radiolucent lines without displacement of the implants has been noted, with no incidence on clinical results. In one case, a metacarpal stem penetrated into the medullary canal in the bone axis but without any clinical modifications. DISCUSSION AND CONCLUSION: Clinically, in addition to pain relief, trapeziometacarpal prosthesis allows to preserve the first column length and to obtain a better opposition of the thumb as well of a better thumb-digits pinch, compared after trapeziectomy. Radiologically, as for total hip arthroplasty, the exact adaptation of an anatomical stem (new design) to the canal has probably a better prognosis at long term follow-up.

[Isolated traumatic serratus anterior muscle palsy]. / Paralysie isolée du muscle serratus antérieur d'origine traumatique.

PURPOSE OF THE STUDY: The serratus anterior, innervated by the long thoracic nerve, participates in shoulder abduction and elevation, stabilizing the scapula on the rib cage. Paralysis of the serratus anterior prohibits shoulder abduction and elevation beyond 90 degrees and elevation of the spinal border of the scapula. We report our experience with traumatic serratus anterior palsy. MATERIAL AND METHODS: Our series included 16 patients with traumatic unique injury to the long thoracic nerve. Mean age of the patients at the time of the accident was 27.6 years. Seven patients were not operated on due to total or partial spontaneous recovery. Scapulothoracic arthrodesis or scapulopexy was performed in nine patients. RESULTS: For the non-operated patients, mean elevation was 125 degrees at diagnosis and 145 degrees at five years follow-up with a Constant score of 85 and muscle force reaching 83% (12 kg shoulder abduction) of the healthy side. Outcome was rated very good in 4 patients, and good, fair and poor in one each. For the operated patients, elevation was 95 degrees preoperatively and 104 degrees at last follow-up. At four years follow-up mean values were: elevation 104 degrees, Constant score 75, muscle force 72% (9 kg shoulder abduction) of the healthy side. An infection required a revision procedure in one patient who recovered successfully. Outcome was rated very good in six patients and good in three. DISCUSSION: Several types of treatment have been proposed for serratus anterior palsy: non-operative care, muscle transfers mainly with pectoralis major flaps, and scapulothoracic arthrodesis. Most of the series on scapulothoracic arthrodesis have concerned fascioscapulohumeral dystrophy and cannot be compared with our patients. Data in the literature on muscle transfers, which could be considered as comparable with our trauma injuries, have demonstrated good results for shoulder motion but a limited effect on overall muscle force. In our series, scapulothoracic arthrodesis provided good results for muscle force, pain relief, and overall shoulder function, with shoulder motion being limited by the position of the arthrodesed scapula. We propose this type of treatment for serratus anterior palsy mainly for manual laborers.

[Non-traumatic osteoarthritis of the distal radio-ulnar joint: a consecutive series of 11 wrists with 42 months follow-up]. / Arthrose non traumatique radio-ulnaire distale: à propos d'une série continue de 11 poignets revus avec un recul moyen de 42 mois.

PURPOSE OF THE STUDY: Non-traumatic osteoarthritis of the distal radio-ulnar joint is generally observed in a context of chondrocalcinosis and can lead to rupture of the extensor tendons. We reviewed patients operated on in our unit between 1986 and 1988 for this condition in order to examine modalities of surgical care. MATERIAL AND METHODS: Eleven patients who underwent surgery for non-traumatic osteoarthritis of the distal radio-ulnar joint were included in the study. Demographic data, clinical signs, joint amplitudes, radiologically identified lesions, peroperative macroscopic features, and results of the microscopic examinations of the synovectomy specimen were recorded. Injury to the extensor tendons and surgical procedures used for repair were noted. Outcome was assessed clinically (pain, stability of the ulnar stump, active extension of the fingers, pronation-supination, flexion-extension) and radiologically. RESULTS: The series included 11 wrists in 8 women, mean age 73.2 years. The underlying cause was chondrocalcinosis in 9 cases and primary osteoarthritis in 2. All patients had painful pronation-supination and 9 of them had ruptured extensor tendons. There was a dorsal displacement of the ulnar head in all cases. Synovectomy-realignment-stabilization was performed using the Sauvé-Kapandji procedure in 10 wrists and resection of the ulnar head using the Darrach procedure in one. Extensor tendons were repaired by side-to-side anastomosis with neighboring tendons in 6 wrists and with grafts in 3. At a mean 42 months follow-up, 7 wrists were pain free and 4 continued to have climatic pain. The ulnar stump was stable in all cases. All the patients achieved active extension of the fingers and preserved wrist mobility. DISCUSSION: According to the literature, non-traumatic osteoarthritis of the distal radio-ulnar joint is uncommon and occurs principally in the elderly patient. The most common complication being rupture of the extensor tendons. Different treatments can be discussed, but we prefer synovectomy-realignment-stabilization using the Sauvé-Kapandji method which, in light of the results obtained in this series, can regularly provide good pain relief and good functional results when associated with tendon repair as needed and as early as possible.