[Replacement arthroplasty of paralytic hip. Apropos of 18 cases]. / Arthroplastie totale de la hanche paralytique. A propos de 18 cas.

PURPOSE: Frequency of hip impairment, with sub-luxation or dislocation, during evolution of neuromuscular diseases depends on intensity and spreading of palsy. At the end of growth or at the beginning of adult life, secondary arthritis can induce pain and lack of mobility. The importance of the chondropathy and irreducible lack of congruence may doom to failure a conservative articular or periarticular surgery. Total hip arthroplasty is an alternative, but the risks of dislocation, ectopic ossifications and infection make often refute this indication. We report our experience of total arthroplasty for paralytic hip, about 18 cases. MATERIALS AND METHODS: We reviewed retrospectively 14 consecutive patients with neuromuscular disease, who had 18 total arthroplasties of paralytic hips. The origin of neuromuscular disease was cerebral for 7 patients (6 cerebral palsy: 4 spastic or athetosic tetraplegias, 1 spastic diplegia, 1 hemiplegia; 1 head trauma), 6 medullar disorders (1 Friedreich disease, 2 acute anterior poliomyelitis, 1 vascular injury, 1 malformative spine with sacral agenesis and 1 cervical spine trauma) and 1 muscular affection (Steinert disease). Mean age of the patient was 40 year old (19 to 64). Mean follow up was 5 years. Intensity and diffusion of weakness were variables, compatible with gait with or without help for 11 patients, and for 3 patients with sitting posture and transfer. The coxopathy, with pain stiffness and vicious attitudes, induced the loss of gait or sitting posture and transfer. The goal of the arthroplasty was the restitution of the initial function. 11 hip had previous surgery, with infection in 2 cases. Arthritis was secondary to hip palsy in 14 cases (4 dislocations, 6 subdislocations, 3 complications of surgery of paralytic hip dislocation in childhood, 1 nervous arthropathy), and independent of palsy in 4 cases (1 femoral head avascular necrosis ans 3 primary arthritis). The prosthesis were LFA Charnley Kerboull in all cases except 1. We used transtrochanteric approach. RESULTS: Mean follow-up is 5.6 years. Functional initial goal has been obtain in all cases. Ectopic ossifications occurred in 3 cases, without functional consequence. One acetabular loosening occurred after 13 years and has been reoperated on. There was no polyethylene wear. We noticed 1 mechanical and 2 chemical femoral loosening. Prosthetic dislocation occurred in 4 cases, always during the 4 post-operative months, without recurrence after this critical period. There were no infection. DISCUSSION: If gait is possible, there is no satisfactory alternative to total hip arthroplasty. In absence of gait, total hip arthroplasty gives also the best functional results. Girdlestone procedure is not indicated because it will induce the loss of transfer and side effects as ascension of proximal femur with recurrence of adduction bringing out pain and sometimes scabs. CONCLUSION: Total arthroplasty of paralytic hip induced restitution of initial function for all patients and an acceptable rate of complication after strict selection of patients and indications, specific operative technique and rehabilitation for each patient. This results encourage us to carry on with this therapeutic orientation.

[Natural history of scoliosis from childhood to old age]. / Histoire naturelle des scolioses de l'enfance à la vieillesse.

Idiopathic scoliosis arises at any age in childhood. Its increasing is usually progressive, following growth, with a peak at puberty. Well codified determining factors for severity are: age at beginning, angulation and bone maturation. Functional and consequential effects remain anyway limited. Many scoliosis increase in adult life, giving way to deterioration, prevailing at the lumbar level, with osteo-arthritic changes and typical patterns such as dislocation at the junctional areas. Functional repercussion may thus arise, mainly pain and, in severe thoracic scoliosis impairment of the pulmonary function. A special form of degenerative scoliosis may appear over 45 or 50 years of age with progressive backache and/or radicular pain.

[Distinctive problems of the surgical treatment of scoliosis after 50 years]. / Les problèmes particuliers du traitement chirurgical des scolioses après 50 ans.

Idiopathic scoliosis starts in childhood, still increases all along adult life, progressively deteriorates especially in lumbar area, and lately results into functional problems in elderly patients. More recently described an osteoarthritic lumbar variety of scoliosis starts "de novo" in the fifties, leading as well to surgical management, mainly in its kyphoscoliotic variety. Surgical correction procedures such as performed in young patients were progressively adjusted to elderly patients, with consideration to special conditions, such as age, general health and bone quality. Besides, orthopedic management and bracing should not be disregarded in older patients.

New universal instrumentation in spinal surgery.

A new instrumentation for posterior spinal surgery consists of metallic rods carved with diamond-shaped asperities on which vertebral hooks or screws can be screwed in any position, level, or degree of rotation. The rods are interlocked by means of devices for transverse traction (DTTs), rectangular constructs with multiple vertebral grips, the stability of which allows suppression of any postoperative external support. Initially designed to treat scoliosis, this instrumentation design allows mobilization of the vertebrae located at the apex of the curve and obtains a three-dimensional correction. Correction of the areas of the most important structural deformation can also be obtained at the level of the end vertebrae, without any need to resort to an important distraction force. The technique varies according to the various types of curvatures. Approximately 250 patients were operated upon from 1983 to 1985. In idiopathic scoliotic curvatures, the mean percentage of correction was 66%. An important improvement of the associated sagittal deformations and of the apical derotation was observed in flexible curves. In paralytic curves, particularly with a pelvic obliquity, the percentage of correction of the frontal deformation is 77%. All of the spine patients were ambulatory in the first postoperative week, without any external support, and returned to their school or family activities. In 43 patients with follow-up periods longer than two years, there were no technical errors in 38. The final angular loss of correction was less than 2 degrees in the error-free group.

Para-osteo-arthropathies in paraplegia. Personal sergical experience. / A propos des para-ostéo-arthropathies dans les paraplégies. Notre expérience chirurgicale.

The authors have observed a number of cases of ectopic ossification in patients in a rehabilitation centre for paraplegia. They review the clinical features of the condition, its frequency and its localization. The time of onset and the spontaneous evolution of the condition was found to be variable. Operations were performed on 35 joints - 16 hips, 13 knees and 6 elbows. The results are described. The authors emphasize the value of serial scintigrams before surgery to assess the maturation of ossification. Operations based on the results of such investigations appear to have been followed by a lower rate of recurrence.