Synthesis of the 19th ArgoSpine Symposium.

After a short introduction of the meeting by the President 2015, Wilco Peul, the opening lecture was delivered by Bart Koes, who dealt with Health Technology Assessment and Guidelines. Then, it was the turn of Carmen Vleggert to show whether there was any Evidence for the Use of Implants in Spinal Stenosis. The final presentation of this session was delivered by Björn Strömqvist who dealt with Surgery for Lumbar Disc Herniation, patients' selection and outcomes. Developing the subject of "Do Not's", Jeremy Fairbank described the UK experience for Low Back Pain. Yves Coppens then took over and further elaborated on "Lucy's legacy". Prof. Coppens recalled that Lucy is a partial skeleton of a pre-human found in Ethiopia among other remains. Prof. Alan Crockard offered what he called "a whimsical view" of his practice of Craniocervical Surgery. Wafa Skalli was asked to speak about Finite Element Analysis of the Spine and Arts et Métiers Paris Tech where there is a long tradition of close collaboration between engineers and clinicians. Rune Hedlund, who will serve as 2016 Symposium President, further elaborated on Scoliosis with a focus on Unsolved Issues in Adolescent Idiopathic Scoliosis Treatment.

Synthesis of the 18th ArgoSpine Symposium.

The subject of this 18th Symposium of ArgoSpine Association was the space of the intervertebral discs. Space of the intervertebral discs must be initially defined anatomically and histologically. A geometrical rebuilding in 3D is possible and must allow a modeling of the intervertebral discs. The physiology of the disc, its nutrition, must be known, in particular that of the center of the disc. The disc constitutes the base of the balance of the rachis, balances which can be only dynamic. The degenerative cascade by the loss of the proteoglycans involves the loss of the biomechanical properties of the disc. The consequences of this degenerative cascade are the base of all the vertebral pathology of origin of the intervertebral discs and even of the posterior articular facets. The origin of the pains and the diagnosis, especially at the lumbar level, are studied by the speakers. Traumatology of the intervertebral discs is the object of a particular chapter. Finally, the average therapeutic ones, that is, decompression of the intervertebral discs, fusion of the intervertebral discs, the recovery of mobility of the intervertebral discs, and the capacity of restoration of space of the intervertebral discs, are studied in detail. The infection of the disc is studied in detail.

[Clear-cell sarcoma of tendons and aponeuroses: three case reports]. / Sarcome à cellules claires des tendons et des aponévroses: à propos de trois cas.

Clear-cell sarcoma (CCS) of tendons and aponeuroses is a rare malignant tumor representing about 1% of soft tissue tumors. Preferentially observed in young adults in the second or third decade, the tumor generally develops in the limbs. Only 2% of SCC of tendons and aponeuroses have been reported in children less than 10 years of age. This slowly progressive tumor usually forms a painless mass. The tumor increases in size followed by metastatic dissemination to lymph nodes and the lungs. The prognosis is related to tumor size. At the present time, the recognized limit is greater than 5 cm. Early diagnosis must be achieved to enable effective treatment by carcinological surgical resection. We report the three cases of CCS of tendons and aponeuroses observed at the Strasbourg University hospital over a 35-year period. Each case had a special clinical presentation. The first patient, treated in 1967, presented tumor bone lysis on the plain x-ray, an observation rarely reported in the literature. In the second patient, treated in 2002, the tumor was discovered after trauma. This patient developed skin ulceration associated with paraplegia secondary to metastatic thoracic cord compression. The third case occurred in a 12-year-old girl, treated in 2002.

Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach.

In a prospective study, eight consecutive patients with nine ruptures of the distal biceps tendon underwent repair through a single incision. All patients were satisfied with their clinical results and had full ranges of elbow and forearm motion. There were no radial nerve injuries and no radio-ulnar synostoses. Isokinetic testing, after correction for dominance, demonstrated a 6% strength deficit, but 7% higher endurance in the repaired extremity for the flexion-concentric test, and no strength deficit and 13% higher endurance for supination. The improved endurance is probably explained by initial reduced effort due to apprehension which minimized subsequent fatigue.

[Long-term survival rate of tibial osteotomies for valgus gonarthrosis]. / Taux de survie à long terme des ostéotomies tibiales de valgisation pour gonarthrose.

PURPOSE OF THE STUDY: High tibial osteotomy (HTO) is a routine procedure for medial gonarthrosis. Mid-term results are known to be satisfactory, but they deteriorate with longer follow-up. The authors present a long term survival analysis of 109 out of 111 consecutive HTO with a minimal potential follow-up of ten years. MATERIAL AND METHODS: 111 patients were consecutively operated on for isolated primary varus gonarthrosis between 1977 and 1985: 57 men and 54 women, with a mean age of 53 years (range, 27 to 79 years). X-ray measurements were done on stance, hip-ankle view. Global axial deformation was defined as the angle between mechanical axes of femur and tibia. The respective part of congenital and degenerative tibial deformation was assessed according to Dejour. The angle between femoral and tibial bicondylar lines, representing lateral instability, was added to the tibial degenerative deformation to represent the total degenerative deformation. The goal of correction was a 3 to 7 degree mechanical valgus angulation. At the time of bone healing, 82 patients (74 per cent) had an optimal correction. Two patients were excluded from the follow-up study because of a severe complication (1 bacterial arthritis and 1 tibia non union) which could interfere with the long term result. The 109 remaining patients were followed for a minimal period of 1 year (mean: 8.4 years). GUEPAR pain grading and the occurrence of a revision were prospectively analyzed. 57 non reoperated patients could be re-examined at a mean maximal follow-up of 13.5 years (range, 10 to 18 years). Failure was defined as either the occurrence of a grade 2 or 3. GUEPAR pain during the whole follow-up, or a clinical or functional Knee Society score < 80 points at final follow-up, or revision. Failure and revision rates were calculated according to Kaplan and Meier. RESULTS: 11 patients were reoperated on before final examination (10 per cent): 2 medial unicondylar and 9 total knee prostheses. At final follow-up, the mean clinical and functional scores were respectively 87.0 points (range, 24 to 100 points) and 86.3 (range, 45 to 100 points). The cumulative failure rate was 33 per cent after 10 years and 54 per cent after 15 years; the respective revision rates were 9 per cent and 19 per cent. A pre-operative total degenerative deformation superior to 3 degrees led to a 3.5 fold increased failure rate (p < 0.000,1). A pre-operative medial joint space narrowing over the half of the normal, lateral one led to a 2.2 fold increased failure rate (p = 0.014). An optimal post-operative correction led to a 3.2 fold decreased failure rate (p = 0.000,1). For a given total degenerative deformation, patients with a congenital deformation superior to 5 degrees had a significant lower failure rate (p < 0.000,1). No factor significantly influenced the revision rate. DISCUSSION: Ideal patients for HTO, with an expected survival rate of 100 per cent after 13 years, have moderate degenerative changes and a congenital deformation superior to 5 degrees. Patients with advanced degenerative changes and no congenital deformation experienced a 35 per cent failure rate after 10 years. In this population, unicondylar replacement should be considered as a valuable alternative.

[Proximal tibial meniscal slope: a comparison with the bone slope]. / La pente méniscale de l'extrémité proximale du tibia: comparaison avec la pente osseuse.

PURPOSE OF THE STUDY: X-ray measurements of the proximal tibial slope only study bony structures, without considering cartilage and meniscil thickness. It is well known that the posterior horn of the meniscil is thicker than the anterior one, and this could decrease the bony postero-distal slope. The aim of this study was to measure the meniscal slope, including cartilage and meniscil, and to compare it to the usual bony slope. MATERIAL AND METHODS: 19 knee cadaver specimens without meniscal or chondral lesions were studied. Four metallic clamps were inserted at the most anterior or posterior part of the medial or lateral meniscosynovial border. Lateral plain X-ray was taken for each knee. The bony proximal tibial slope and the medial and lateral meniscal slopes were measured and compared for each knee. Paired Wilcoxon T-test and correlations were calculated with a 5 per cent significant limit. RESULTS: The mean paired difference between bony slope and medial or lateral meniscal slope was -6 degrees: the actual meniscal slope was less oblique than the bony slope, and it was almost perpendicular to the proximal tibial axis. There was a very significant correlation between bony and medial meniscal slopes. There was no correlation between bony and lateral meniscal slopes, nor between medial and lateral meniscal slopes. DISCUSSION: These results suggest that the proximal tibial meniscal slope, which is the mechanically active one, is less oblique than the usually measured bony slope. Medial meniscal slope and bony slopes are very strongly correlated for one given knee. But medial and lateral meniscal slopes can be very different for one given knee. CONCLUSION: These results could have an influence on the design of total or unicondylar knee replacements: the polyethylene slope of the tibial surface, which should reconstruct the natural articular design, should reproduce the meniscal, and not the bony slope. The medial and lateral slopes, should perhaps be individually reconstructed.

[Madelung's deformity - Why choose the Sauvé-Kapandji osteotomy?] / Maladie de Madelung ­ Pourquoi avoir choisi une ostéotomie selon Sauvé-Kapandji?

For bilateral Madelung's deformity in a 14-year-old girl we did the Sauvé and Kapandji operation without additional radius osteotomy. The operation was justified by the protrusion of the head of the ulna, the limitation of the rotation and diminution of the strength of the wrist, and inability to do sporting activity. The clinical findings were referred to the instability of the inferior radio ulnar joint There was no pain. The post operative review showed no pain, with recovery of grasp and of sporting activity (gymnastic and dance). The esthetic result satisfied the surgeon and the patient The operation permitted repositioning of the inferior radio ulnar joint. We have not seen synostosis of the osteotomy and the width of it increased progressively without radiological and physical instability of the inferior radio ulnar joint. The literature study allows us to discuss the different treatment possibilities and to explain our choice.The simplicity of this operation is interesting, because it was possible to stabilize the carpal joint, with abolition of the physical problems of this youg girl, without the needing osteotomy of the radius, which takes longer to recover, in those cases without pain before the operation.

[Thoracic outlet syndrome. A study of 45 cases treated between 1975 and 1993]. / Syndrome de la traversée thoraco-cervico-brachiale. Étude de 45 cas traités entre 1975 et 1993.

Since 1970 we have experience of more than 100 cases of the thoracic outlet syndrome. We have rewied 45 patients operated on between 1975 and 1993.The cause, in agreement with the literature, was in 30% a road accident (cervical spine and clavicular disease), in 54% malformations (cervical rib) with a similar frequency of involvement with neurological pathology of the upper limb.We always found a vascular symptomatology, wich increased in shoulder abduction. In 82% of the cases we found an associated neurological deficit. The diagnosis was confirmed with electromyography and arteriography.The treatment was in initially medical and in resistant case, surgery was performed. We have use a supra-clavicular approach with scalenotomy of the scalenus anterior muscle, resection of the distal part of the cervical rib or an anterior fibrous band. We did not do (first operation) a resection of the first rib throught a transaxillary approach, in order to avoid elongation of the brachialplexus roots.We found 80% good results from the opinion of the patients and after clinical examination.We have operated on 6 recurrent cases throught a supra-clavicular approach (fibrous sheath) or by trans axillary approach with resection of the first rib in case of lack of response to scalenotomy.

[Intra-operative fractures in hip arthroplasties: predisposing factors]. / Fractures per-opératoires : facteurs favorisants.

In a multi center study 51 cases of intraoperative femoral fractures in THA from 6 medical centers of eastern France were analysed with respect to epidemiology and predisposing factors. The male/female rate was 0,5 and the average age 73 years.The fractures involve the diaphysis in 33% and a cortical defect in 33%. The fracture occured in 50% of cases during reaming, or impaction of the femoral stem, and in 25% of cases during dislocation, these findings correspond to those described in the literature.The predisposing factors are of two types :- The rarefaction of the bone mineralisation due to the age and high proportion of females. 33% of the cases are a fracture of the femoral neck (elderly women).- Reoperation (27 cases) with 22 replacement of THA. In these cases of loosening, the fragility of the cortical bone (cement granuloma, chamber of mobility) is well known. On the other hand, we did not find that calcification or ankylosis are predisposing factors (only 8/51).

[The "Oxford" unicondylar knee prostesis (UCP): 21 reviewed cases]. / La prothèse unicompartimentale (PUC) "Oxford" A propos de 21 genoux revus.

The unicompartimental knee prosthesis known as "Oxford" is a non constraint prosthesis, entrusting the whole of its stability to an intact ligamentary apparatus. Where the support surfaces of most prostheses remain limited, even punctiform, the originality of the Goodfellow prosthesis lies in the fact that the prosthetic condyle, whatever the flexion angle is, leans against a mobile prosthetic meniscus with spheric superior concavity of the same radius as the condylian radius, which increases considerably the prosthetic leaning surfaces and therefore lessens the pressure constraints. The superior surface, concave, of this prosthetic meniscus takes charge of the rolling, where the inferior plane surface realizes the gliding on the metallic tibial plate. The total conformity of the components minimizes the forces of friction.Between July 1988 and March 1993, 24 patients underwent the placing of UCP. Three patients died and 2 were lost of sight. 19 patients could be seen again or checked, corresponding of 21 operated knees. Two knees benefited from the start from UCP (medial and lateral) and 2 knees had a UCP in the first instance and then a second UCP in the compartment left safe primarily. For the 21 UCP, there are 16 medial and 3 lateral. Our mean drawback is of 3 years and 3 months, all the drawbacks being superior to 1 year and 4 months. The mean age is of 64 years. There were 17 female and 2 male patients. The mean weight is of nearly 80 kg (79,8) and nearly 52% of the operated patients have an important overweight (Body Mass Index superior to 30). Preoperative clinical analysis. It is based on a retrospective study of files using the quotation described by AUBRIOT for the «GUEPAR¼ group. This one establishes a gradation of four levels for each of the three criteria retained (Pain, Mobility, Instability), thus determining a global result imposed by the lowest level retained.For walking, other factors than just the state of the operated knee may intervene, this being the reason why it doesn't show in this chart. The GUEPAR group quantifies it with letters A, B, C, D.Concerning pain, all 21 knees were quoted as "Bad" in preoperative. Pain constitutes the decisive argument for the operative indication. In our series, only one knee had an average amplitude, all the others had a mobility superior to 89°. In 5 cases there was a flessum between 11 and 20° (penalizing of a level). Concerning walking and stability, they were taken into account, thanks to a precise questionnaire about the daily life acts. Concerning the walking perimeter, it was found as unlimited (A) in 1 case, superior to 500 m (B) in 2 cases, inferior to 500 m (C) in 17 cases and limited to home (D) in 1 case. The early after effects. At the end of the intervention, the knee is placed into a splint with limited flexion. As soon as the second day the patient is sat on the border of his bed. The first partial support at the third of the body weight is authorized between the fourth and the fifth day, when at the same time flexion exercises on electrical splint are started, as soon as the Redon draining is removed. The average hospitalization length was of a fortnight. Among secondary late complications and retakes, let us stop on meniscal luxations which constitute a specific complication of the Oxford arthroplasty. They concern 3 times the medial compartment and 4 lateral compartment. They happened in 1 case early, at D 22, in 3 cases within the 6 first months and in 3 cases after 2 years. They were treated : 3 times by reduction under general anæsthetic, no more ; 3 times changing the meniscusus for a meniscusus of superior size and once by placing a total prosthesis at the place of the UCP. The deteriorations of the opposed compartment not prosthesized occured in three cases. They were treated by unicompartmental additional arthroplasty in two cases and by total prosthesis in the third case. The clinical results on pain are very satisfactory as from the early check up onwards we have 17 successes (no pain 11 cases and occasional pains 6 cases) and as after 3 years and 5 months in average, we have 19 successes (no pain : 10 cases - occasional pain : 9 cases). At the maximal drawback, the mobility is quoted very good in 7 cases and good in 13 cases, mean in 1 case. At the latest check up, we note an excellent stability in 17 cases and good in 3 cases, that is to say 20 successes and 1 case of stability quoted as mean. At the latest check up we note 17 successes (A and B) and 4 relative failures (C) concerning the quality of walking.At the question «are you pleased with the intervention and would you advise it to a friend?¼ and with the nuance «very pleased¼ and «simply satisfied¼, we get 10 cases «very pleased¼, 8 cases «pleased¼ and 3 cases «moderately satisfied¼; only those 3 cases advise against the intervention. The radiological results are less satisfying as they show frequent imperfections : • for the 16 medial UCP : only 9 cases hypocorrected or normo axed, but 1 case strongly hypocorrected (residual varus of 7°) and 6 hypercorrected cases. • for the 5 lateral UCP : 3 normo-axed cases, 1 case strongly hypocorrected (residual valgus of 6°) and 1 case strongly hypercorrected (10° varus). • the failures due to rapid deterioration of the non prosthetized compartment occurred on hypercorrected knees. • on 21 knees, 14 borders of tibial plate were noticed, out of which 9 had no plate displacement and 5 had a slight displacement, at the origin of a small angular loss. • accumulations of cement on the tibial side, towards the back or in medial were noticed in 8 cases, which explains a slope of the tibial plate to the back inferior to 5° in 11 cases (should be of 7°). • 4 femoral components seem to be too posterior and one shows curved.In total, only 7 cases out of 21 were estimated with no peculiarities on the radiological point of view. It seems difficult to place a UCP well. The meniscal luxations are favored by an alignment rotational defect of the tibial plate, specially for the lateral UCP, the meniscus coming to hit the lip of the tibial plate during the lifting from a sitting position. For 5 of these luxations, we must recognize the existence of a ligamentary collateral laxity which should have altered the surgical indication either to an osteotomy, or to a total arthroplasty. Conclusions. Under the condition of respecting the absolute counter indications, of thoroughly evaluating the relative counter indications and of reducing at the best the defects linked to the surgical technique, the unicompartmental arthroplasty, including that of Oxford, gives good functional results after more than three years. In our series, the result on pain is constant if we exclude the cases with risk with ligamentary laxity and that of centered gonarthrosis at obese subject, that is to say 15 successes on 15 knees thus selected retrospectively. The gain on mobility is weak, of 5° in average. The result on stability is, as for pain, excellent, if we exclude the cases with risk, as we get then also 15 successes on 15 knees. Concerning the global result according to the quotation of Aubriot-Guepar, we note 14 successes and 1 relative failure. 4 knees were bad indications and should have benefited from a total arthroplasty or from an osteotomy.

Biomechanical evaluation of different instrumentation for spinal stabilisation.

The varying problems following arthrodesis of the lumbar spine with rods or plates (too much rigidity for the first and insufficient stability for the second) have led us to conceive another type of material, flexible but with enough stability, to favorise healing of bone graft, and decrease the induced pathology on adjacent levels. An experimental study of three types of material: rigid, semi-rigid and flexible was performed on eighteen fresh cadaver spinal segments without and then with discectomy and corporectomy to find out the various types of behaviour. The flexible device seems more supple than the other materials tested: more mobility, less stiffness. Rising hysteresis is explained by plastic deformation. The semi-rigid device presents strong osseous stresses on the L3 level and a large hysteresis corresponding most likely to a mobility between the screws and plates. The rigid device has less mobility, especially in torsion, ascribed to the transverse connection. The stability is high with a small hysteresis. This is of value for bone loss or instability with displacement of the vertebral body.The second study was a modeling of the flexible device validated by comparison to the experimental study. The strains in the wire were high, decreasing with increasing diameter, but is still lower than the elastic limit. The proximity of the elastic limit may allow plastic deformation of the wire. Howewer less strains were found on the screw fixation but increase with the increase diameter of the wire. The influence of the bone quality on the behavior of the device was demonstrated.

[Surgery for backache]. / Chirurgie de la lombalgie.

All types of lumbar pain are of course not an indication for surgery. However, an operation may bring relief from lymbodynia in given conditions, owing to the better knowledge of spinal physiopathology and to the evolution of the surgical technique. This is the case for intervertebral disk pathology, lesions of the posterior articular structures, lumbar canal stenosis, vertebral tumors or malunions, as well as for some cases of painful frontal or sagittal deviation of the spine. State-of-the art techniques utilize arthrodesis, often with a plate or CD-material osteosynthesis, but future surgery should be aimed at preserving motion.

[Study by radioactive microspheres of bone microcirculation in aseptic osteonecrosis of the femoral head]. / Etude par microsphères radioactives de la microcirculation osseuse dans l'ostéonécrose aseptique de la tête fémorale.

Thirty-two hips affected by aseptic necrosis, four of them post-traumatic and 12 contralateral hips thought to be healthy have been studied by combining superselective arteriography with the injection of radioactive microspheres. It has been possible to show that aseptic necrosis begins with a global ischaemia and is followed by an incomplete revascularisation leaving a necrotic area. On the border between the two areas hypervascularity produces a zone of fragility where microfractures develop with detachment of a sequestrum. The presumed opposite hip is almost always, even in traumatic lesions, the site of a hypovascularity which seems to suggest a predisposition to the lesion. There is a correlation between radiological and clinical worsening and the development of revascularisation in the femoral head.

Sacral meningeal arteriovenous fistula fed by branches of the hypogastric arteries and drained through medullary veins.

The authors report a new case of intraspinal extra-medullary meningeal arteriovenous fistula draining through medullary veins. Discovered in a 33-year-old black man suffering from a cauda equina syndrome, this malformation suspected in myelography was confirmed by a selective angiographic procedure of both internal iliac arteries. This investigation specified the sacral site of the fistula as well as its feeding arteries from several branches of the left and right internal iliac arteries and its posterior and intra-meningeal venous medullary drainage. An embolization procedure followed by a surgical approach and a second embolization session brought a fair improvement to this young patient who could walk again. The acquired traumatic origin of the fistula is discussed for this patient who had been previously operated at his L5-S1 level.