[Anterior retroperitoneal L5-S1 arthrodesis and fixation with cage and plate. Prospective study in 40 cases with a follow-up of one to 2.2 year (mean 1.5 year)]. / Arthrodèse antérieure L5-S1 par voie rétropéritonéale et fixation par cage et plaque. Etude prospective de 40 cas avec un recul d'un à 2,2 ans (moyen 1,5 ans).

PURPOSE OF THE STUDY: The aim of this prospective clinical study was to assess outcome after anterior retroperitoneal interbody arthrodesis for L5-S1 discopathy. We used a cage filled with an autologous corticocancellous graft and plate fixation. MATERIALS AND METHODS: Forty patients with low back pain unresponsive to medical treatment for more than six months were included in this series. We noted the clinical signs and radiculalgia. Patients were assessed preoperatively, postoperatively, at one year and at last follow-up using the Oswestry score and a visual analog scale (VAS). The plain X-rays disclosed 30 cases of discopathy (16 primary and 14 postdiscectomy) and 10 cases of spondylolisthesis by L5 isthmic lysis (three Meyerding grade 0 and seven grade 1). MRI revealed signs of disc degeneration in all cases with a black disc or modification of the endplate signals (Modic type 1 in 23 and type 2 in 13). The anterior retroperitoneal approach was used in all cases for complete discectomy, arthrodesis with cage insertion and an autologous corticocancellous graft harvested from the iliac bone and fixation using a triangular plate (Pyramid, Medtronic, Memphis TN). Clinical and radiographic follow-up data were available at six weeks and three, six and 12 months in addition to last follow-up. A follow-up using MRI was performed in the event of complications. RESULTS: The population was composed of 25 women and 15 men, mean age 44 years and eight months (range 29-693 years). Thirteen patients presented radiculalgia. There were no vascular or gastrointestinal complications with the anterior approach. Bone healing was achieved at one year in 38 patients (95%). The mean Oswestry score improved from 52 to 16% and the mean VAS from 7.8 to 1.83 at 18 months follow-up. All occupationally-active patients but one resumed their former activity at mean 4.7 months. There were no sexual complications in this series. Low back pain persisted in three patients and five developed transient facet joint symptoms. Two patients developed secondary radiculalgia. We noted two cases of nonunion, in one grade 1 spondylolisthesis and in one grade 1 spondlylolisthesis (with revision for complementary posterior arthrodesis and a good outcome at latest follow-up). DISCUSSION AND CONCLUSION: Anterior L5-S1 interbody fusion with a cage filled with a corticocancellous autograft fixed with a plate provides good clinical and radiographic results for the stabilization of painful discopathy. The results have been good for isolated L5-S1 discopathy and for grade 0 spondylolisthesis. The limit for this technique would appear to be grade 1 spondylolisthesis with a degraded disc. Performed via an anterior retroperitoneal approach, this method is a good alternative to the classical posterior approach, enabling very low morbidity.

[Sciatica caused by avulsion of the vertebral limbus in children]. / Sciatique de l'enfant par avulsion du listel vertébral.

PURPOSE OF THE STUDY: Sciatica is very rare in children. We report a particular from due to traumatic avulsion of the posterior vertebral limbus. The purpose of this study was to give the principal clinical and radiological aspects of this entity and to discuss the treatment which should be different from that of common adult disk herniation. MATERIALS: From 1980 to 1992, 10 children were examined for a sciatica (7 boys and 3 girls aged from 10 years 1 month to 15 years 2 months). Sciatica appeared in all cases during sport activities and sometimes after a sport accident. Lumbar spine stiffness was encountered in all cases. Radiculalgia was unilateral in 7 cases, bilateral in 3 cases, in L5 territory in 3 and S1 in 7 cases. 4 children had deficitary neurological signs: 3 abolitions of achilles reflex, 1 weakness of foot dorsi-flexors. Standard x-rays showed in 4 cases the avulsed fragment in the vertebral canal. Spondylosis was encountered in 3 cases and spondylolisthesis in one case. Diagnosis was possible in all cases with CT Scan, M.R.I., when done showed a normal disk signal. Three children were managed by a conservative treatment by rest or brace. Seven had a surgical treatment: resection of the avulsed fragment in 6 and total diskectomy in one. The mean follow-up was five years (2 to 8 years). RESULTS: There was no complication. At last follow-up all children had a good result without sciatica recurrence. DISCUSSION: Many factors allow us to think that avulsion of the vertebral rim in children is of traumatic origin. CT Scan is the best exploration for this particular lesion. It enabled evaluation of fragment volume and location. Magnetic resonance imaging showed uninjured disks. Removal of the avulsed fragment without diskectomy seems possible in children.

Distal rupture of the tendon of biceps brachii. Evaluation by MRI and the results of repair.

We report ten cases of rupture of the distal part of the tendon of biceps brachii in patients aged from 27 to 58 years. MRI allowed assessment of the degree of retraction of the tendon which was related to the integrity of the bicipital expansion. When the retraction exceeded 8 cm the expansion was always ruptured. When there was doubt, or in longstanding injury, MRI allowed the lesions to be defined. Surgical repair was by reinsertion on the radial tuberosity at one or two fixation points in eight patients and reinsertion on the anterior brachial muscle in one. The other patient refused surgery. The MRI findings were confirmed at operation. Use of fixation points allowed minimal intervention, thereby reducing the risk of damaging the radial nerve. One year after operation, dynamometric evaluation of the strength of flexion and supination confirmed that the best results were obtained by reinsertion to the radial tuberosity.

[Results of a series of deltoid flaps for the treatment of massive rotator cuff tears with an average follow-up of 3.5 years]. / Résultats d'une série de lambeaux deltoïdiens pour rupture massive de la coiffe des rotateurs avec 3.5 ans de recul moyen.

PURPOSE OF THE STUDY: We report a series of 14 patients with a massive rotator cuff tear operated on with a deltoid flap according to Augereau's technique. The aim of this study was to evaluate the benefits of this technique using Constant's scoring system. The follow up is 40 months. MATERIAL AND METHOD: 14 patients, mean age 59 years, with a total rotator cuff tear type III according to Gerber's classification were included. There was 13 total ruptures of the supra and infra spinatus tendon and one infraspinatus and subscapularis lesion. All the patients had shoulder pain, and the preoperative, Constant's score was 24.1/100. The diagnosis of the rotator cuff rupture was confirmed by X-rays, arthrography and ultra-sonography. 8 patients had a Magnetic Resonance Imaging (MRI) evaluation. The surgical procedure was the technique described by Augereau, and three patients had a resection of the distal clavicle. One patient had a small piece of dacron to reinforce the suture of a very thin deltoid flap. All the patients had a immobilization in abduction and the rehabilitation programm began immediately. RESULTS: Results on pain were good: +11.4 points according to Constant's score, but improvement strength (+0.7 point) or motion (+1 point) was not significative. Postoperative Constant's score was 46.9, ponderated score increased from 29.5 per cent to 57.5 per cent. Ten patients were very satisfied, 2 were satisfied and two were disappointed. One of them neaded shoulder arthrodesis; the other needed a new surgery to remove the piece of dacron, and was allayed with NSAI drugs. External rotation was slightly increased: +2 point. DISCUSSION: These results are similar to others series on pain relief, but the results are poor on strength restauration and on shoulder motion. This technique is a heavy surgical procedure and results are not better than arthroscopic sub acromial decompression for massive rotator cuff tear.

A study of the fasciocutaneous vascularisation of the arm. Surgical applications.

The data on the fasciocutaneous vascularisation of the medial aspect of the arm are incomplete in the literature. This study presents the methodology and results of an anatomic study on 19 upper limbs with arterial injection. The vascularisation of the upper part of this region is provided in 68% of cases by the superficial fasciocutaneous branch (SFCB) of the superior ulnar collateral artery (SUC), that of the middle and lower part by 3-4 fasciocutaneous pedicles originating from the SUC which are prolonged distally by the recurrent posterior ulnar artery. The SFCB has important relations with the ulnar nerve; it travels dorsal to the nerve in 64% of cases and then allows the raising of a distally-pedicled ulnar flap with a 3:1 ratio. In other anatomic configurations, a flap with retrograde flow supplied by the inferior pedicles of the SUC can always be raised. Its ratio is then 2:1. this flap allows coverage of all cases of posterior or anterior losses of substance at the elbow. These results supplement the data required for the raising of a distally-pedicled medial brachial flap, but also of a proximally-pedicled superior medial brachial flap and of a free superior medial brachial flap transposed by microsurgical means.

[Fractures of a single bone of the forearm in children]. / Fractures d'un seul os de l'avant-bras chez l'enfant.

A series of 69 one bone forearm fractures in children is reported. Thirty six ulna and 33 radius were involved. Average age was 7.6 years. The fracture type varied: compression fracture in 2 cases, greenstick fracture in 45 cases and impacted fracture in 22 cases. For 25 cases, a plastic bowing of the other forearm bone was associated. Treatment was immobilization without reduction (53), or reduction with anesthesia (16). One proximal radial fracture was treated with medullary nailing the 15th day, after 2 secondary displacements. Early radiological results were very good in 40 per cent, good in 32 per cent, fair in 19 per cent, and poor in 7 per cent. Eleven children with a poor or fair initial result had clinical and radiological evaluation with long term follow-up; functional and radiological results were always good or very good. The reduction of the plastic deformity as reported by Sanders allowed to achieve better early results.

[The use of Müller acetabular rings in revision surgery of total hip prosthesis. Apropos of 141 cases with a minimal 5-year follow-up]. / Utilisation des anneaux endocotyloïdiens de Müller dans la chirurgie de révision des prothèses totales de hanche. A propos de 141 cas avec un recul minimum de 5 ans.

211 acetabular reinforcement rings of Müller have been implanted when revising total hip arthroplasties, 141 were followed up for more than 5 years. In 52 per cent of cases, an acetabular reconstruction using bone grafts was associated: in 51 cases, a bank allograft was used, one third of the grafts had only a role of filling. Theses rings remained remarkably stable and there were only 2 lacks of fixation: 1.4 per cent in cases non grafted. They allowed a quick weight bearing while warranting stabilisation and protection of the grafts and recentering the hip. So their use has become systematic in THR revisions except for stage IV acetabular loosenings in which the osteosynthesis of the acetabular transverse fracture can be preferred.

[Intramedullary nailing osteosynthesis with epiphyseal fixation of fractures of the proximal humerus in adults. 1 to 3-year follow-up]. / Ostéosynthèse par broches à prise épiphysaire des fractures de l'extrémité supérieure de l'humérus chez l'adulte. 1 à 3 ans de recul.

The authors used a medullary pinning with epiphyseal fixation in the treatment of superior metaphyseal fractures of the humerus for 41 patients aged 22 to 82 years. There were 28 cases with epiphyseal fractures and 12 with metaphyseal fractures. The follow-up was 1 to 3 years. The pins were introduced through the triceps brachii after perforation of the diaphysis, 1 cm above the ulnar fossa. Results were very good. Strength returned within 8.5 weeks. There was only one case of nonunion of a proximal diaphyseal fracture due to a technical fault (diastasis between fragments). Rehabilitation began immediately, resulting in good elbow motion in 35 cases. The shoulder motion was the same as the healthy side in 36 cases, and inferior to 90 degrees of abduction in only two complex epiphyseal fracture. The proximal humerus was never perforated by the pins. The authors find this new instrumentation to be very effective.

[Metatarsal metastasis. A case treated by exeresis an reconstruction]. / Métastase métatarsienne révélatrice. Un cas traité par exérèse reconstruction.

The authors are reporting a case of an isolated metatarsal metastatic tumour revealing a light-celled kidney "adenocarcinoma". Occurring rarely, metastatic lesions of the foot, of which less than a hundred observations have been reported so far, are mainly side-effects of the uro-genital sphere and digestive cancers. In the present case, the metastatic singleness and the good control of the initial tumour justified the total removal of the first metatarsal which posed the problem of reconstruction. The use of a fibula auto-graft allowing the realisation of a double cuneo-metatarsal and metatarsal-phalangeal arthrodesis joint made it possible to resume weight bearing and walking on the second month and to preserve the functional result on the 21 st.