[Surgical treatment of recurrent hallux valgus]. / Traitement chirurgical des récidives d'hallux valgus.

PURPOSE OF THE STUDY: Little work has been reported on the treatment of recurrent hallux valgus. We reviewed 64 cases after surgical treatment in order to ascertain the cause of recurrence, results of the treatment given, and deduce therapeutic options and indications. MATERIAL AND METHODS: Fifty-nine patients had 64 recurrent hallux valgus bunions. Mean age of the patients was 58 years, 54 women and 5 men. The clinical and radiographic preoperative work-up led to two categories of treatments. In 35 cases, conservative treatment was used to re-align the axis by procedures on the soft tissues either alone or in combination with MacBride tendon transfers, metatarsal osteotomies, or osteotomies to shorten the first phalange. In 29 cases, metatarsophalangeal arthrodesis was used. Patient satisfaction, pain, deformation, shoe wearing and activity were recorded at follow-up. The same radiological parameters were used postoperatively to assess anatomic results. RESULTS: Mean follow-up was more than 6 years (range 2-18 years). The subjective result was good in 52 cases. The objective result was good in 50 cases and poor in 14 (including 7 cases with insufficient correction). The results were analyzed by type of treatment. DISCUSSION: The preoperative analysis demonstrated that recurrence is due to insufficient initial treatment which must take into account all the components leading to the deformation. Arthrodesis gave a good result in 83% of the cases and conservative treatment gave a good result in 71%. Thus, in our opinion, no one type of treatment of recurrent hallux valgus can be applied for all patients. Nevertheless, conservative treatment should associate complementary procedures that can be deduced from the clinical and radiological analysis.

[Treatment of spastic equinovarus foot in the hemiplegic adult by retrograde fixation of the peroneus brevis tendon onto the anterior tibialis tendon]. / Traitement du pied varus équin spastique de l'adulte hémiplégique par amarrage rétrograde du tendon du court fibulaire sur le tibial antérieur. A propos d'une série de 41 cas.

PURPOSE OF THE STUDY: The purpose of the present study was to assess the Bardot procedure in the treatment of equinovarus deformities of the foot in spastic hemiplegia. This procedure associates the fixation of the peroneus brevis distal tendon onto the tibialis anterior, heel-cord lengthening, and tenotomies of the flexores digitorum. MATERIAL AND METHODS: Fifty-six patients underwent this procedure between 1989 and 1996. The indication for surgery was equinovarus deformity in adult spastic hemiplegia. Preoperatively all the patients had an instability and 80.5 per cent of them had to wear an ankle and foot orthesis. Postoperatively forty-one patients with a mean follow up of 3.5 years (range: one to 9 years), were available for examination including 24 females and 17 males with a mean age of 46 years at time of surgery (range: 27 to 76). RESULTS: All the patients were objectively improved. Seven of them had a discreet residual varus deformity, but none felt unstable. They all were able to walk barefooted, only one patient still required an adapted shoe. The gait and the quality of live were subjectively improved for 92.7 per cent of the patients. None of the patients has been worsened. DISCUSSION: When spastic equinovarus disturbs significantly quality of live, tendon re-balancement of the hemiplegic foot should be proposed. The fixation of the distal tendon of the peroneus brevis onto the tibialis anterior is effectively performed only if this latter is efficient in the swing phase of gait. If there is no fixed contracture, neurosurgery or chemotherapy are preferable. In case of irreducible articular deformities arthrodesis could be indicated. CONCLUSION: Tendon re-balancement in hemiplegic foot using a peroneus tendon fixation onto the tibialis anterior should be carried out after examination by a team of specialists (surgeon, neurosurgeon, rehabilitation team). In such conditions it offers constantly an improvement to the patients.

[Implantation of autologous chondrocytes for cartilagenous lesions in young patients. A study of 24 cases]. / Implantation de chondrocytes autologues pour lésions cartilagineuses du sujet jeune. Etude de 24 cas.

STUDY AIM: The aim of this study was to describe the treatment of symptomatic knee cartilage defects on young active patients by autologous chondrocyte implantation and to report preliminary results in 24 patients. PATIENTS AND METHODS: Since April 1996, 24 selected patients underwent 25 implantations in five military hospitals. There were 19 men and five women (all of them practicing sports); mean age was 27. Lesions were localized on left (n = 13) and right (n = 12) aligned and stabilized knees. There were 12 isolated cartilage defects (eight OCD and four posttraumatic) and 13 associated with ligament lesions (n = 8) or multiple and severe lesions (n = 3 indication of salvage). Mean surface of cartilage defects was 6 cm2. Mean preoperative evolution was 11 months and stage was grade IV (Outerbridge) for all. The first step was arthroscopy for classification and biopsy. The second one was implantation after a 3-week delay (for the ex vivo culture) through arthrotomy, under a periosteal flap taken from tibia and sutured on the edges of the prepared defect. Weight bearing was allowed after the 6th week; MRI was performed at 6, 12, 18, 24 months. The follow up was evaluated with three scales: Lysholm 2, Tegner Activity, Cincinnati Knee Rating System. RESULTS: Postoperative complications included: algodystrophy (n = 2) and phlebitis (n = 1). Four patients were revised at 6 months, seven between 6 and 12 months, 11 after. The longest follow-up was 26 months. Results were poor in one patient (salvage). For the others, pain and swelling decreased after 6 months and disappeared after 12 months. CONCLUSION: Autologous chondrocyte implantation used in this senes and in a large international ongoing series seems to be the only procedure allowing a true long-term regeneration of cartilage defects. Some questions remain, on the biological level in relation with the use of some growth factors and the risk of chromosomic abnormalities, and on the economical level because of the high cost of this technique.