[Osteochondral lesions of the talar dome: surgical treatment in a series of 30 cases]. / Lésions ostéochondrales du dôme astragalien.

PURPOSE OF THE STUDY: We reviewed 30 cases of osteochondral lesions of the astragalar vault treated surgically. MATERIAL AND METHODS: Among the 30 patients, 17 participated in sports activities and 24 had a history of trauma. Mean delay to surgery was 10 months. Treatment included osteochondritis curettage and Pridie perforations. Direct access was used in 11 cases, malleolar osteotomy in 13 and arthroscopy in 6. Cancellous bone grafts were used in 6 cases. RESULTS: Mean follow-up was 3 years 7 months (minimum 2 years). All patients had an arthroscan at last follow-up. Evaluation of post-operative outcome was based on clinical assessment and arthroscan findings. Surgical treatment provided very good results in 75 p. 100 of cases with pain relief and improved walking distance. DISCUSSION: Our cases pointed out the important contribution of the FOG (Fracture Osteonecrosis Geode) classification to pathogenic and prognostic analysis. The Berndt and Harty classifications were not found to be useful. CONCLUSION: In case of localized necrosis, we propose arthroscopic perforation curettage. In case of bone loss, a direct cancellous graft may be used.

[Hallux valgus treated by Scarf osteotomy of the first metatarsus and the first phalanx associated with an adductor plasty. Apropos of 50 cases with a 2-year follow up]. / Hallux valgus traité par une ostéotomie de Scarf du premier métatarsien et de la première phalange associée à une plastie de l'adducteur. A propos de 50 cas avec 2 ans de recul.

PURPOSE OF THE STUDY: Fifty hallux-valgus were treated with Scarf Osteotomy of the first metatarsal, associated to a phalangeal varisation or shortening osteotomy and an adductor plasty. Patients were evaluated with a minimum follow-up of two years. MATERIAL AND METHODS: Forty five females and two males were operated with an average age of fifty years. The pre operative metatarsus varus was of 15 degrees 8. Mean alignment of metatarsal bar was 31 degrees 4. The cuneo-metatarsal joint was twenty two times spheric and twenty eight times plane. The average metatarso-phalangeal great toe valgus was 39 degrees 8. RESULTS: They were appreciated with a minimal follow-up of two years, according to the 3 Groulier's criteria: correction of deformation, statics troubles, functional activity. The metatarsus varus improved with an average of 10 degrees 4, as well as the alignment of the metatarsal bar (25 degrees). The post operative average phalangeal valgus was 22 degrees 7. These results were statistically significant. Cuneo-metatarsal joint type did not influenced final result. Articular joint line was normal in 64% of cases. Global result was excellent or good in 70%, passable in 22%, and bad in 8% of cases. DISCUSSION: Scarf Osteotomy of the first metatarsal allows complete correction of metatarsus varus. The surgical approach can be proposed at every age. There are no vascular trouble or arthrosis worsening. It must be completed with a phalangeal varisation or shortening osteotomy and adductor plasty.

[Chronic lateral ankle instability: surgical treatment with periosteum ligamentoplasty and capsular ligament tension. 34 cases]. / Laxité externe chronique de cheville: traitement chirurgical par une ligamentoplastie au périoste avec remise en tension capsulo-ligamentaire. A propos de 34 cas.

PURPOSE OF THE STUDY: The authors report a series of thirty four ankle ligamentoplasties treated between 1985 and 1995. MATERIAL: Patients presented an average of 10.4 ankle sprains before surgical treatment. Pre-operative examination found instability in all cases, permanent pain in 58.8 p.cent limited mobility in 11.8 p.cent and permanent oedema in 23.5 p.cent. Surgical treatment associated ligamentoplasty with periosteum and capsular ligamentar tensionning. METHODS: Minimal follow up was two years and averaged 4 years 7 months. Post operative results were assessed according to Saillant's clinical criteria (subjective instability, sprain recurrence, pain). Radiological criteria included plain and stress X-rays (anterior drawer and varus laxity). RESULTS: The authors noticed an improvement of clinical and radiographical criteria, without ankle arthrosis or periosteum graft calcification. The global result was: 23 excellent, 4 good, 1 fair and 6 bad results. All athletes went back to sport. DISCUSSION: Results of this series with almost 80 p.cent of excellent and good results are comparabie with others techniques for ankle ligament reconstruction. CONCLUSION: This simple technique has a main advantages: no injury to the fibularis brevis tendon. Periosteum ligamentoplasty can then be suggested if lateral tibio-tarsal instabilities persist after proprioceptive physiotherapy.

[Importance of arthrodesis of the big toe combined with a metatarsal alignment according to Lelièvre in the surgery of the rheumatoid forefoot. Apropos of 70 observations]. / Intérêt de l'arthrodèse du gros orteil associée à un alignement métatarsien selon Lelièvre dans la chirurgie de l'avant pied rhumatoïde. A propos de 70 observations.

PURPOSE OF THE STUDY: The authors reviewed 70 cases of rheumatoid forefoot treated by Lelièvre, lateral metatarsal resection alignment, associated to first metatarsophalangeal joint arthrodesis. MATERIAL: Rheumatoid arthritis evolution was 20 years an average. It involved cortico-dependent polyarthritis in 48 per cent cases. Metatarsalgia were always present. METHODS: Mean follow up was 44 months (minimum 24 months) Results were analyzed according to Gainor. RESULTS: Foot pain disappeared in thirty two cases. Shoe wearing was normal 50 times. Arthrodesis fused 55 times. Lateral toes metatarsophalangeal joint space was satisfactory 28 times. Metatarsal divergence improved, 80 per cent of patients were satisfied in a subjective estimation and 85 per cent using Gainor's criteria. DISCUSSION: First-Metatarsophalangeal joint arthrodesis ensures permanent stability of the first ray and therefore an harmonious support distribution. The dorsal surgical approach allows an early weight bearing in cortico or immuno dependent patients. CONCLUSION: This technique keeps a low morbidity and ensures stable mid term results.

[Haglund disease treated by simple resection of calcaneus tuberosity. An angular and therapeutic study. Apropos of 74 cases with 2 years follow-up]. / Maladie de Haglund traitée par résection tubérositaire simple. Etude angulaire et thérapeutique. A propos de 74 cas avec deux ans de recul.

PURPOSE OF THE STUDY: The authors report the treatment of Haglund's disease, using a simple os calcis tuberosity resection. They reviewed long term results and the value of radiological criteria for pre-operative evaluation. MATERIAL: The series included 54 patients (74 feet) mostly female and young. The simple resection of os calcis tuberosity was performed without further operation or post-operative splint. METHODS: Post-operative results were appreciated according to 3 criteria: pain, functional activity and shoe wearing. Radiological criteria used Fowler and Philip angle, angle of calcaneal inclinaison, total angle, CL angle, Denis and Huber-Levernieux test and Heneghan and Pavlov parallel lines. Correlation tests with simple regression were used for statistical analysis. RESULTS: Results were graded as excellent and good in 73 per cent fair in 16.2 per cent and poor in 10.8 per cent cases. DISCUSSION: Results were compared to other series. Neither radiological criteria, angular or not, can rule out simple tuberosity resection, because results showed no relation between test and angle measurements. There is no correlation between post-operative radiographs and final result. The only efficient criteria of resection is the difference between Fowler and Philip, and CL angles. This technique may be recommended after few months of medical treatment, without using calcaneal osteotomies of Zadek type. CONCLUSION: The simple resection of os calcis tuberosity showed good results in 73 per cent cases at an average follow up of 6 years 9 months.

[Complications and failures of total ankle prosthesis. Apropos of 21 cases]. / Complications et échecs des prothèses totales de la cheville. A propos de 21 observations.

PURPOSE OF THE STUDY: The authors relate a heterogeneous series of twenty one total ankle prosthesis performed by the same surgeon with an average follow up of 37 months. MATERIAL AND METHODS: Four types of prosthesis were implanted: 4 Ramses, 8 New Jersey, 5 Star, 4 Freeman. The etiology was seven times a rheumatoid polyarthritis, ten times post-traumatic, two idiopathic arthrosis, an hemochromatosis and a late clubfoot sequelae. RESULTS: Results were appreciated according to Bousquet's criteria: 4 excellent results, 5 good, 3 fair, 9 bad. The ankle mobility was not improved by arthroplasty. We noticed 7 loosening whose 2 septic occurring between 18 and 38 months after implantation of prosthesis. DISCUSSION: This series indicates that prosthesis should be only suggested for patients over sixty years old. No difference was found between post-traumatic and rhumatoîd. The pre-operative subtalar arthrosis promoted in significant way an unexpected failure occurrence. CONCLUSION: Indications for total ankle arthroplasty must remain selected. Arthrodesis remains in the immediate future, the best solution for young patients with post-traumatic arthrosis.

[Fractures of the tarsal scaphoid]. / Fractures du corps du scaphoïde tarsien.

PURPOSE OF THE STUDY: The authors relate a series of 47 cases of tarsal scaphoid fractures, between 1976 and 1992. MATERIAL AND METHODS: These fractures occurred 11 times after a high level fall, 28 times after a motor vehicle accident and 8 times after a direct traumatism. The fracture line was vertical 35 times; horizontal 27 times. An impaction was often associated (32 cases). In 17 observations, a true enucleation occurred as a part of the fracture dislocation. Many periscaphoidal lesional associations were found. 39 fractures were fixed. Radiographs showed 30 consolidations with an anatomical reduction. 37 patients were reviewed with an average follow up of 7 years and 6 months. RESULTS: Results were assessed using Mestagh's scoring system: 7 very good, 15 good, 6 fair and 9 bad. The very good and good results represent 59 per cent. In 37 patients reviewed, the clinical investigation showed 8 deformities of valgus flat foot, a varus foot, requiring 11 times orthopedic soles wearing. 11 patients had a lameness. Radiological results showed 11 times a peri-scaphoidal arthrosis, a necrosis and 2 non union. A narrowing of the astragalo-cuneate joint line was found 8 times. DISCUSSION: Various anatomical types don't have the same prognosis. Vertical and horizontal fractures gave 18 times a very good and good result when in 11 reviewed patients with a fracture dislocation, we noticed 7 poor or bad result. An osteosynthesis by screw gives goods results when fragments are large. For compound fracture when a surgical procedure will be insufficient, the conservative treatment, if keeps a sufficient breadth of medial arch, can give a satisfactory result. An immediate astragalo-scaphoïdal arthrodesis can be suggested in front of a multi-fragmentary dislocation fracture. CONCLUSION: The scaphoïdal tarsal fracture is unusual and its diagnosis remains sometimes difficult. The treatment is often surgical by direct approach. In consideration of the pejorative post-operative outcome of fracture dislocations, some authors suggest an immediate astragalo-scapho-cuneate arthrodesis.

[Subtalar dislocations. Apropos of 35 cases]. / Les luxations sous-astragaliennes. A propos de 35 cas.

PURPOSE OF THE STUDY: The subtalar dislocation is a rare injury. The authors appreciate the difference of frequency between medial and lateral displacement, the factors likely to increase a classical favorable prognosis and the therapeutic attitude to suggest. MATERIAL AND METHODS: 35 observations were included of which two bilateral, 26 had a medial displacement, 9 a lateral displacement. Treatment was conservative in 21 cases and surgical in 14 cases. The results were analysed using Gay and Evrard's clinical scoring system at which we added radiological results. RESULTS: The average follow-up was 7 years and 7 months. The global results are 11 excellent, 13 good, 9 fair, 2 poor. DISCUSSION: The high frequency of medial displacement is explained by the fact that the subtalar joint is only really unstable in inversion. The lateral displacement is rare. The prognosis is good in pure dislocation. It is only good enough every time a fragmentary talar fracture is associated as a factor of stiffness. The 11 arthrosis cases are secondary to a dislocation associated with a talar dislocation, a scaphoid dislocation or a vascular injury. In the series, there is no syndrome of tarsal sinus, and no post traumatic instability. Talar necrosis are rare: 3 cases in this series. They occur following large dislocations at the limit of enucleation. The reduction is urgent. The treatment is more often conservative. It must be surgical in case of associated injury requiring a surgical procedure or in front of widely open dislocation. CONCLUSION: Subtalar dislocation is a rare injury. In the majority of cases, the displacement is medial. The prognosis is good in pure cases. It's only good enough every time a fragmentary talar fracture is associated as a factor of joint stiffness.

["Chevron" basal osteotomy of the middle metatarsal bones for static metatarsalgia. Apropos of 69 cases]. / Métatarsalgie statique et ostéotomie basale en chevron des métatarsiens moyens. A propos de 69 cas.

PURPOSE OF THE STUDY: Round or flat forefoot metatarsalgia are frequent and surgical techniques are various. The authors relate a series with chevron basi-metatarsal osteotomy. MATERIAL: 69 operated metatarsalgia were reviewed at a mean follow up of 5 years. METHODS: The surgical approach was dorsal, aligned on metatarsal diaphysis. The basi metatarsal "chevron shape" osteotomy was performed using an oscillatory saw, on 1, 2 or 3 metatarsi inducing lowering and shortening. This osteotomy wasn't fixed. Weight bearing was allowed at the third post-operative day. RESULTS: In 68 per cent of cases, the global result was good or very good, but it persisted 32 per cent of post-operative pain either climatic or continuous, including 29 per cent metatarsalgia. The plantar corns only disappeared one out of twice, but the shoe wearing was improved in 82.6 per cent of cases. DISCUSSION: This study showed that the results improved when 3 median metatarsal osteotomy were performed simultaneously. The forefoot morphology didn't influenced the final result. In fact, this technique includes a good result one out of twice in hollow feet. It seems that three metatarsal osteotomies induce a metatarsal elevation and shortening, once out of twice. CONCLUSION: The advantage of this technique are : a dorsal medio plantar surgical approach, an osteotomy realized in cancellous bone and no need for fixation allowing a more accurate adjustment of the metatarsal height.

[Treatment of hallux valgus by varus osteotomy of the first phalanx associated with adductor plasty]. / Hallux valgus traité par ostéotomie de varisation de la première phalange associé a la plastie de l'adducteur.

PURPOSE OF THE STUDY: Sixty two hallux valgus treated by first phalanx varus osteotomy associated to adductor hallux plasty were reviewed with a minimum follow-up of 4 years. MATERIAL AND METHODS: 48 females and 2 males were operated. Average age was 46 years. The forefoot was grecian 40 times. The pre-operative metatarsus varus was at an average of 14.2 degrees when the metatarso-phalangeal valgus was 33.3 degrees. The interphalangeal valgus was 8.25 degrees. The first phalanx base lateral translation measured an average of 5.8 mm. Sesamoids were always dislocated. 36 patients were treated in the same operative time, using this associated approach at different level. RESULTS: Results were evaluated according to 3 Groulier's criteria. In 10 cases, a post-operative pain persisted. Shoe wearing continually improved. The great toe valgus was corrected in 31 cases (50 per cent). The correction was partial in 20 cases (32.3 per cent) but on radiographs, only 34 cases (54.8 per cent) conserved a normal joint space. The first phalanx base lateral translation only improved partially. It measured an average of 408 mm. The global result was good in and very good, 67 per cent, while patients subjective estimation was good or very good in 90.3 per cent. DISCUSSION: The study of this series of first phalanx varus osteotomy associated to adductor plasty shows lateral subluxation partial correction, factor of long term modification on articular metatarso-phalangeal joint space. The adductor plasty associated to abductor disinsertion showed a results improvement compared with other published series. CONCLUSION: The first phalanx varus osteotomy associated to adductor plasty should be limited to moderate hallux valgus deformity with interphalangeal valgus and without any major articular incongruity.

[Aponeurotomy and degenerative lesions of the plantar aponeurosis. Contribution of magnetic imaging]. / Aponévrotomie et lésions dégénératives de l'aponévrose plantaire. Apport de l'imagerie par résonance magnétique.

PURPOSE OF THE STUDY: Talalgia are frequent. Their etiologies are various and diagnosis is sometimes difficult. MATERIAL: From 1980 to 1993, 12 cases of degenerative lesions of plantar aponeurosis were treated surgically. M.R.I. revealed 6 chronic aponeurositis and 6 old tears. The treatment was an aponeurectomy with resection of calcaneal spine after a conservative treatment for several months. The histological examination found inflammation in all cases (aponeurositis or rupture), a calcification of aponeurosis, a cartilaginous metaplasia and fibromatosis. METHODS: Patients were evaluated at a minimum of 2 years follow-up and a maximum of 6 years. The post-operative results were estimated using 3 criteria: pain disappearance, results on the foot static, patients functional activity. RESULTS: Global score was : 9 very good and good results, one fair result and 2 bad results. The M.R.I. realized at the time of revision revealed a good healing of plantar aponeurosis in 5 cases, defect in 1 case, inflammation in 3 cases and defect associated with inflammation in 3 cases. DISCUSSION: Surgical treatment can be suggested in failures of talalgia conservative treatment. Degenerative injuries of plantar aponeurosis, as rupture or aponeurositis may take advantage of an aponeurectomy. Short term results show pain disappearance in 75 per cent of cases without modification of the plantar arch. CONCLUSION: M.R.I. allows to explain exactly the origin of talalgia. After a failure of conservative treatment, some talalgia may take advantage of an aponeurectomy.

[Lisfranc's fracture-dislocations]. / Fractures-luxations de l'interligne de lisfranc.

PURPOSE OF THE STUDY: Classicaly Lisfranc fractures dislocations are unusual. Our study is based on 69 observations from January 1974 to January 1992. MATERIAL AND METHODS: Fractures occured during tremendous impacts with a sex ratio of two men for one woman. The authors insist on the diagnostic value of good quality standard x-rays. Using Trillat's classification, we had 19 homolateral spatular fractures dislocations, 22 homolateral columno-spatular, 8 divergent columnar and 19 divergent columno spatular. A dislocation was reduced in emergency before radiography. The treatment consisted in orthopedic reduction and plaster 7 times, percutaneous kwire 2 times, immediate arthrodesis 5 times, open reduction and internal fixation with kwires 55 times. Post-operatively, 8 complications were noticed. 11 secondary arthrodesis were made with reference to failures of previous methods. They have been performed from 9 months to 5 years after the initial traumatism due to a painful ankylosis in bad position or arthrosis. The arthrodesis was total 6 times, partial lateral 2 times, partial medial 3 times. RESULTS: 63 patients were reviewed with a minimum follow-up evaluation of two years and a maximum of 9 years. The results show that we must reduce the tarsometatarsal fracture dislocations even if the displacement is minimal and we must fix them. The most satisfactory means seem to be open reduction if the least anatomical defect exists. Immediate, total arthrodesis reposition is suitable when an important articular comminution exists. If the total secondary arthrodesis reposition gives good results, its realization is sometimes difficult. The lateral partial arthrodesis must be discontinued, because they don't seem logical. The medial partial arthrodesis didn't prove its superiority, compared with total arthrodesis. DISCUSSION: The reduction of Lisfranc's dislocation is essential. The single case not unreduced has given a bad result as shown in the litterature. When the orthopedic treatment is well-made, the result is good. The open reduction followed by an axial fixation has only given 56 per cent of good results. The main reason of these bad results is an important comminution which should have practised an immediate arthrodesis reposition and a bad reduction. We must be aware on the quality of the anatomical reduction. The secondary arthrosis appeared principally in cases where the reduction was defective (13 observations out of 50). The 5 immediate arthrodesis have all given a good result. CONCLUSION: The retrospective study of the series teaches us to reduce the tarsometatarsal fractures dislocations even if the displacement is minimal and to fix them. We must make a wider place to the immediate arthrodesis reposition.

[Robert Schumann. From music to orthopedics]. / Robert Schumann. De la musique à l'orthopédie.

The psychiatric personality of Robert Schumann has notably concerned doctors. On the contrary his right hand orthopedic impairment seems to have been neglected. Relying on some well established facts and the fingering study of certain musical works, the authors put forward a plausible diagnosis and consider a treatment which would have allowed a functional rehabilitation of the great musician and nine-fingers-handed pianist.