Harvest of cortico-cancellous intramedullary femoral bone graft using the Reamer-Irrigator-Aspirator (RIA).

The "Reamer-Irrigator-Aspirator" (RIA) is a device that provides continuous irrigation and aspiration during intramedullary reaming of long bones. The RIA system is first used to collect the reaming material from medullary cavities, a thick paste of finely morselized osseous particles containing significantly elevated levels of stem cells and growth factors as reported by quantitative analyses. The volume of bone graft material available from an adult femur corresponds to the amount of cancellous bone graft obtained from both the anterior and posterior iliac crests. The assembly and technicalities of the RIA system require a training period to prevent any femoral fracture, which appears to be the major RIA-related complication. The elective indications for RIA bone grafting are filling of bone defects in the epiphyseal and metaphyseal regions. Diaphyseal defects may also be managed using the RIA system provided the graft is placed in a constrained system (induced membrane) to prevent dispersion of the graft into the surrounding soft tissues and is aerated with a porous material to promote its revascularization. Other RIA indications include debriding intramedullary infections and reaming for intramedullary nailing of long bone fractures to reduce the risk of fat embolization.

Bone transport techniques in posttraumatic bone defects.

INTRODUCTION: The treatment of posttraumatic diaphyseal bone defects (BD) calls on a number of techniques including bone transport techniques: isolated shortening, compression-distraction at the fracture site, shortening followed by lengthening in a corticotomy distant from the site and segmental bone transport. PATIENTS AND METHODS: The multicenter retrospective study combined 38 cases: 22 cases of initial diaphyseal bone defect and 16 cases of secondary diaphyseal BD, sometimes associated with metaphyseal or metaphyseal-epiphyseal BD, involving the humerus, the forearm, the femur and the tibia. These techniques were mainly used on the lower extremity (33 cases), for the most part on the tibia (22 cases) in young men. RESULTS: Bone healing was acquired in 37 cases out of 38 after a mean 14.9 months (range, 6-62 months). A mean 4.3 secondary interventions were required to obtain final union; most notably, a bone graft was necessary at the docking site for the segmental bone transport procedures. DISCUSSION: Many reconstruction techniques can be proposed to treat posttraumatic BD. None responds to all situations. Bone transport techniques have their place and their indications. Isolated shortening is intended for bone loss not exceeding 3cm, notably in the humerus and to a lesser degree in the lower extremity. Shortening associated with lengthening is valuable in the femur and the tibia for bone loss up to 6cm. Segmental bone transport is the only technique that can treat bone defects associated with shortening in the lower limb. For substantial bone loss beyond 10cm, segmental bone transport is particularly indicated. However, these cases of substantial bone loss tend to be resolved by a hybridization of the procedures. The distraction gap of a bone segment can, for example, be prepared using an induced-membrane technique. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Interprosthetic femoral fractures: analysis of 14 cases. Proposal for an additional grade in the Vancouver and SoFCOT classifications.

INTRODUCTION: Interprosthetic fracture is a rare but serious entity, impairing consolidation and stability due to adverse mechanical conditions related to bone fragility and implant volume. OBJECTIVE: The present study highlights the difficulties involved in managing such fractures, details treatment options and reports findings leading to a proposed additional grade in the comparable Vancouver (hip) and French Orthopedic and Traumatologic Surgery Society (Société française de chirurgie orthopédique et traumatologique: SoFCOT) (knee) classification systems. PATIENTS AND METHODS: A multicenter retrospective series included 14 interprosthetic femoral fractures: eight type double C (typeC for both hip and knee), five type C for hip and B for knee, and one type double B (type B for both hip and knee) on the Vancouver and SoFCOT classifications. Fracture occurred on standard (n=15) or revision (n =13) implants. Six cases involved a femoral shaft encumbered by a total knee replacement (TKR) femoral extension stem and eight cases TKR without femoral long stem, assimilable to type C fracture. RESULTS: None of the six fractures proximal to a constrained TKR with stem-achieved union by primary intention, whereas seven of the eight type-C fractures did so. Finally, 12 cases showed favorable evolution, with three secondary total femur replacements (TFR) and one death at 6 months without bony union or revision and one patient waiting for TFR. DISCUSSION: To describe the status of the intermediate femur and its medullary canal encumbrance, we propose adding a category D to the SoFCOT and Vancouver classifications, corresponding to interprosthetic fracture on TKR with diaphyseal extension stem. Interprosthetic fracture internal fixation should begin with long devices bridging the two prostheses. When the implant is loose, it may be replaced; in case of diaphyseal extension, however, the residual femur between the two extensions should be protected against peak stress by a plate extending upward and downward. In case of limited bone stock, due to osteolysis or initial femoral medullary canal compromise, especially if one or both implants are loose, TFR may be indicated as consolidation, is jeopardized by the uncertain mechanical situation.

[Avascular necrosis of the capitate: a case report and a review of the literature]. / Ostéonécrose aseptique du grand os et traitement : à propos d'un cas et d'une revue de la littérature.

We report the rare case of a patient with an avascular necrosis of the proximal part of the capitate, with a review of the literature. The patient was treated by a resurfacing prosthesis of the proximal part of the capitate. At 22 month of follow up, the patient had a good functional result. Resurfacing prosthesis is a good therapeutic option in case of proximal capitate avascular necrosis when there is no more place for conservative surgery.

[Combined carpometacarpal dislocations, hand lesions and fractures of the two bones of the forearm: a report of two cases]. / Luxations spatulaires et lésions associées de la main et des deux os de l'avant-bras. A propos de deux cas.

The authors report two cases of complete dorsal carpometacarpal dislocations associated with lesions of the hand and the two bones of forearm. These dislocations are rare, and their clinical and radiological diagnosis is difficult. These cases are original through the association of carpometacarpal dislocation with lesions of the two bones of forearm. They demonstrate the need to stress the importance of a complete evaluation of the patient. Treatment must be immediate and begin with the osteosynthesis of the proximal lesions to avoid any irreducibility. These elements will determine the functional outcome.

[Forum: reconstruction of the traumatised thumb. Reconstruction of the amputated thumb by progressive lengthening of the 1st metacarpal using mini-fixator. Apropos of 2 clinical cases]. / Forum: la reconstruction du pouce traumatique. Reconstruction du pouce amputé par allongement progressif du premier métacarpien, à l'aide d'un mini-fixateur. A propos de deux cas cliniques.

The authors report two cases of reconstruction of a mutilated thumb by progressive elongation of the first metacarpal without the need for bone grafts, using a minifixation elongation device, which is very easy to use. It allows distraction which can be performed by the patient himself and adjustment to the desired length, up to 40 mm.

[Management of digital ischemia. 5 cases]. / Conduite à tenir devant une ischémie digitale. A propos de cinq cas.

Ischaemic fingers, a rare, generally chronic disease, may sometimes be acute, requiring emergency surgical treatment. Five cases are reported: 3 acute and 2 chronic. The 3 cases of acute ischaemia occurred in the context of cardiac arrhythmias in 2 cases and an aneurysm of the ulnar artery in 1 case. Treatment consisted of 2 thrombectomies with microsurgical digital sympathectomy thrombectomies with microsurgical digital sympathectomy and resection of the aneurysm. Complete clinical and functional recovery was obtained in these three cases. The 2 cases of chronic ischaemia were due to diabetes and Buerger's disease. In both cases, medical treatment was followed by thoracic sympathectomy with secondary resection of necrotic tissue as required. In conclusion, the prognosis in the acute cases depends on the rapidity of correction of the arterial obstruction associated with digital sympathectomy. In the case of chronic ischaemia, the clinical course depends on the efficacy of medico-surgical treatment and the severity of the underlying disease.

[Aneurysmal cyst of the clavicle : an uncommon lesion and a difficult diagnosis (author's transl)]. / Le kyste anévrismal de la clavicule. Une lésion rare. Un diagnostic difficile.

The authors describe a case of anevrysmal cyst of the clavicle seen in a five-year-old girl. Both clinical and radiological diagnosis proved impossible. Complementary investigations did not settle the question. surgical excision was decided on. In spite of an unfavorable macroscopic aspect, histological examination determined the nature of the tumor. The authors emphasize the great value of resorting to all branches of medical investigation when dealing with bone tumors. Before affirming a good prognosis, or, on the opposite, suggesting extensive and mutilating surgery, the utmost caution is required.

[Bacteriophage therapy of septic complications of orthopaedic surgery (author's transl]. / Bactériophages et chirurgie orthopédique. A propos de sept cas.

Seven septic cases have been treated by bacteriophage; two infections after insertion of a hip prosthesis, two septic arthritis of the knee, one osteomyelitis of the tibia, one septic non-union of the femur and one septic complication following Harrington rodding. Only specific phages were used in association with several types of surgical procedure. The technique of treatment is described. All cases were long-term infections with resistant organisms. Results were good in five, fair in one and one case was a failure. It is concluded that phage therapy may be helpful in the treatment of long-term infections.

[Reflections concerning the radiological assessment of static flat foot in the child (author's transl)]. / Réflexions à propos du bilan radiographique dans le pied plat statique de l'enfant.

After a precise review of the numerous parameters studied classically in AP and lateral films of the feet under load, the authors emphasis 5 measurements which are easy to determine and which they feel to objectively cover all the deformities which may be found in the static flat foot. These are: Talo-calcaneal divergence in AP and lateral views, the angle between the calcaneum and the floor, the lateral cavitation index and, finally, the angle of the axis of the talus and of the 2nd metatarsal in AP. A score of 20 is attributed to each. A score of 0 to 20 is attributed to each of these points, with a possible total, therefore, of 100. A study of 119 cases of flat foot in the child treated surgically over a period of 6 years made it possible to draw the distinction between the severe flat foot requiring operation and with a total of less than 45 points, and flat foot requiring medical orthopaedic treatment only (more than 45), the score for the normal foot being of the order of 90 points. This radiological study also makes it possible to distinguish, amongst flat feet in children, straight flat foot with collapse of the medial arch but no valgus of the forefoot and valgus flat foot where there is pronation of the calcaneum and abduction of the forefoot. This distinction is important since it determines the choice of operation. Thus in a case of valgus flat foot Judet's so-called "horseman" operation is indicated whilst in a flat foot without valgus, transposition of the tibialis anterior is preferable. In many cases, the lesion is mixed and both surgical gestures are required.