[Femoral neck fractures in patients over 50 years old]. / Les fractures du col du fémur après 50 ans.

INTRODUCTION: Despite many papers and instructional course lectures, therapeutic guidelines are not clearly defined about treatment of femoral neck fractures. The aim of this multicentric French symposium was to prospectively study the results of current therapeutic options in order to propose scientifically proven options. MATERIAL AND METHODS: Three prospective studies were carried out in order to answer to these questions: (1) is it possible with anatomical reduction and stable fixation to lower the non union and osteonecrosis rate? (2) is functional treatment of Garden 1 fractures successful in more than 65 years patients? (3) what criteria are useful to choose the kind of arthroplasty for more than 65 years patients? RESULTS: For the 64 patients between 50 and 65 years old included in the first study, 44 ORIF and 17 prostheses were performed. No open reduction was performed in this series despite a 34% malreduction rate. The risk for displacement after functional treatment of Garden 1 fractures is 31%. For patients over 65 years old, almost fractures are treated in this series by an arthroplasty. The one-year mortality rate after displaced femoral neck fracture was 17%. Functional results were better in total hip prosthesis group than in bipolar or unipolar group. Non cemented stems were not safer than cemented ones in frail patients. DISCUSSION AND CONCLUSIONS: For young patients, ORIF should be the treatment of choice: the initial displacement and its effects on the femoral head vascularisation, the quality of reduction and fixation are the two most significant factors for good outcome. For Garden 1, fractures in patients 65 years old or more, it is proposed to performed an internal fixation despite in two thirds of the cases, it should be unnecessary because non identification of predictive factors of failure. For patients over 65 years old, the type of arthroplasty to perform in displaced fractures is to be chosen according to the preoperative mobility and comorbidities. Because of acetabular erosion with long-term follow-up, it is clearly indicated to perform total hip replacement for patients with life expectancy of 10 years or more. For frail patients, unipolar arthroplasty is the best option. The place for bipolar or uncemented implants is not yet well-defined and more prospective trials are needed. In this multicentric study, results appear quite different in terms of mortality, or functional status. These differences seem to be related to technical choice, geriatric care, nutritional consideration or surgical organisation, all factors that may be of major importance for prognostic.

[Internal fixation of proximal humerus fracture by "palm tree" pinning]. / Ostéosynthèse des fractures de l'humérus proximal par brochage en palmier.

PURPOSE OF THE STUDY: Fractures of the proximal humerus are increasingly frequent. Conservative treatment is most often proposed, but surgery must be performed when the displacement is significant and/or when the fracture is unstable. Osteoporosois and comminution are two essential elements for deciding on the surgical technique. MATERIAL AND METHODS: This retrospective study included 31 patients who underwent pinning from the deltoid V according to the Kapandji procedure. There were 19 females and 12 males. Mean age was 61 years. There was a fracture of one of the tuberosities in 12 cases and significant metaphyseal comminution in 8. RESULTS: Mean follow-up was 26 months. Outcome was excellent or good in 22 cases (70.9%), fair in 4 (12.9%), and poor in 5 (16.2%). Fifteen complications were noted (48.4%): material displacement 8 cases, reflex sympathic dystrophy 3 cases, radial nerve palsy 2 cases, head osteonecrosis 1 case, and humeral fracture at the site of insertion of the K wires 1 case. DISCUSSION: At the present time, there is no consensus for the surgical management of fractures of the proximal humerus, including proximal metaphyseal fracture with or without fracture of one of the tuberosities. Closed reduction and pinning is not really an invasive procedure, and does not injure the rotator cuff. Surgical approach at the level of the deltoid V according to the Kapandji technique avoids elbow pain and stiffness. The procedure requires a fluoroscan and experience to obtain satisfactory divergence of the K wires in the humeral head, an essential technical point. This procedure cannot be recommended for elderly patients whose bone quality is too poor to obtain good fixation of the K wires.

Complications and functional evaluation of 17 saddle prostheses for resection of periacetabular tumors.

Seventeen saddle prostheses were inserted between 1988 and 1997 after resection of periacetabular tumors. The tumors involved the zones II and III of Enneking classification in 13 patients, the zones I and II in 2 patients, and the zone II in 2 patients. The tumors included 11 chondrosarcomas, 3 Ewing sarcomas, 2 giant cells tumors, and 1 metastasis of renal carcinoma. The tumoral resection was wide "en bloc" in 14 cases, marginal in 2 cases, and intratumoral in 1 case. The mean follow-up period of the patients is 42 months ranging from 8 to 84 months. Local recurrences occurred in five cases and metastases in four cases. Five patients died of tumoral disease and one of intercurrent disease. Complications were observed in 11 cases (65%) including nerve damages (3 cases), deep infections (3 cases), upward migrations of the saddle (4 cases), saddle dislocations (3 cases), sacroiliac subluxations (2 cases), and mechanical failures (2 cases). The modified Musculoskeletal Tumor Society Score (MSTS) and the Toronto Extremity Salvage Score (TESS) were used for functional analysis. Functional results were available for only nine patients of the series with a mean MSTS of 17 points ranging from 11 to 23 points and a mean TESS of 58 points ranging from 39 to 95 points. The saddle prosthesis provided in all cases of this series an early painfree weight-bearing reconstruction with minimal limb shortening, but the functional results remained fair in most patients due to a limited range of motion and a poor abductor strength.

[Isolated fifth digit localization in Dupuytren's disease]. / L'atteinte isolée du cinquième rayon dans la maladie de Dupuytren.

Isolated fifth digit localisation in Dupuytren's disease has a bad reputation. A series of this injury is reported with a special attention on recurrences. This series is composed of 30 cases in 26 patients (four bilateral cases): the majority of patients were male and 53.5 y was the average age. Extension loss of MP and PIP joints were present in 25 cases, MP isolated extension loss in two cases and PIP in three cases. The treatment performed was a percutaneous needle technique in five cases, surgical fasciectomy in 24 cases using a zigzag palmodigital longitudinal fasciectomy approach in 18 cases, an open palm technique in six cases and one isolated laterodigital flap. Assessment of correction was based on Tubiana's classification. Average follow-up was 22 months. Postoperative course was uneventful except for one case of precarious vascularisation which leads to an amputation. For the digitopalmar localisations: 15 stage 0 or 1, 7 stage 2, 1 stage 3 and 1 stage 4. Improvement percentage was 0.60 in combined cases, 0.65 in cases with a MP loss and 0.46 in PIP loss. Five recurrences were noted. Literature on this topic is coherent with the fact that isolated involvement of the fifth digit carry a bad prognosis, mainly due to the high recurrence rate in our series as in other papers. In severe injuries, an imperfect result should be the aim to prevent vasculonervous complications.

[Vascularization of the trochanter fragment after digastric trochanterotomy in man]. / Vascularisation du fragment trochantérique après la trochantérotomie digastrique chez l'homme.

We examined the human vascular anatomy to the greater trochanter after digastric trochanterotomy, using some injection techniques and practiced the trochanterotomy (digastric, classic). We found 3 major sources of blood supply to the greater trochanter: the proximal soft tissues, including the gluteus medius and minimus, were mainly vascularized from the internal iliac artery system, and the distal soft tissues, including the vastus lateralis, were vascularized from the branches of the lateral circumflex femoral artery (LCFA). A third possible source of blood circulation came from the LCFA, but this branch was only found in 12 to 15 samples. Many vascular structures from the LCFA were concentrated in the anterior half of the vastus lateralis muscle which were deeply imbedded and ran upward to the trochanteric insertion of the vastus lateralis muscle. The distance from the superior tip of the greater trochanter to the point at which the first branch of the descending branch of the LCFA enters into the vastus lateralis muscles was from 65 mm. to 125 mm. The descending branch was found consistently in all 20 samples. Our results proved that with digastric trochanterotomy, we can preserve all three sources of vascularization whereas with classic trochanterotomy the supply from the transverse and descending branches of the LCFA are lost.

Blood supply of the greater trochanter after trochanterotomy.

The human vascular anatomy to the greater trochanter after a trochanterotomy (digastric, standard) was examined using injection techniques. Three major sources of blood supply to the greater trochanter were found: the proximal soft tissues, including the gluteus medius and minimus vascularized mainly from the internal iliac artery system; the distal soft tissues, including the vastus lateralis, vascularized from the descending branches of the lateral circumflex femoral artery; and a third possible source of blood circulation came from the transverse branch of the lateral circumflex femoral artery. Many vascular structures from the lateral circumflex femoral artery were concentrated in the anterior half of the vastus lateralis muscle. Perfusion with a latex oxide mixture and angiography after trochanterotomy proves that by using a digastric trochanterotomy, the transverse and descending branches of the lateral circumflex femoral artery to the greater trochanter thus can be preserved. With a standard trochanterotomy, the supply from the transverse and descending branches of the lateral circumflex artery are lost. These results therefore suggest that a digastric trochanterotomy is superior to a standard trochanterotomy because the blood supply of the trochanter is preserved.

Malignant giant-cell tumours of bone. Clinico-pathological types and prognosis: a review of 29 cases.

Twenty-nine patients with malignant giant-cell tumours of bone (GCT) were followed-up for between 6 months and 18 years. Seventeen of the tumours were primary and 12 were due to malignant degeneration of initially benign lesions. The clinical features did not differ from those of benign GCT, except for a higher incidence in the distal tibia and sacrum. Anaplastic GCTs were included in the study because their clinical and radiographic features and prognosis were no different from those of the GCT grade III of Jaffe. Eighteen of the tumours were grade III, and 11 were anaplastic. This retrospective study was intended to assess the effects of chemotherapy and surgery for malignant GCT. Three treatment groups were selected, in which treatment was either by surgery alone, surgery plus chemotherapy, or radiotherapy alone.--The prognosis was poor and the 5 year tumour-free survival rate in the series was 50%. The prognosis was the same for primary as for secondarily malignant tumours. There was no statistical difference in survival between malignant grade III and anaplastic malignant tumours. The one-year survival rate for patients treated by chemotherapy and surgery was statistically higher (chi2 test) than for persons treated by surgery alone. However, the five-year survival rate and the actuarial survival curves were not statistically different in the two groups (log rank test).--Chemotherapy appears to be of some value in the treatment of these malignant tumours but a larger series is required to confirm the efficacy of this approach.

[Fractures of the wrist with cartilage rupture in young adults. Apropos of 18 cases]. / Les fractures du poignet avec enfoncement cartilagineux de l'adulte jeune. A propos de dix-huit cas.

Distal radius impaction fractures are not rare. They present a dual problem for the surgeon: the difficulty of establishing the exact pathological anatomy of the fracture, and of obtaining stable anatomic reduction. The authors report their experience of 18 distal radius impaction fractures in young patients after violent trauma (motor vehicle accident). We subdivided these fractures using Kapandji and Müller's classifications: 12 type 9 or C3, 4 type 5 or B1 and 2 type 4 or C1. The mean depth of impaction of the scaphoid fossa or lunate fossa ("die punch fracture"), or centrally was measured at 5 mm on preop X-rays or on CT scan. After radiographs of the wrist in traction under anaesthesia, open reduction was performed in 14 cases (78%). A volar approach with plate fixation was performed in 3 cases. A dorsal approach with internal fixation with k-wires and an external fixator was performed in the other 11 cases. A bone graft was necessary in 10 cases when the bone defect was significant. The four remaining patients were treated with percutaneous k-wires and external fixation. We reviewed these 18 patients after a mean follow-up of 27 months. The mean age at the time of the accident was 37 years. The results were graded on the Green and O'Brien scale. Results were excellent in 1 case, good in 11 cases, fair in 5 cases, and poor in 1 case. We believe that impaction fractures always require open reduction with or without the addition of bone graft depending on the degree of the impaction. This is because of the risk of arthritic degeneration with this kind of fracture, with articular incongruence (more than 2 mm), and with chondral injuries on the radial or the carpal aspect of the wrist joint. Also, when there is a distal radio-ulnar joint injury (D.R.U.J. dislocation or distal head ulna fracture), the joint must always be stabilized to avoid secondary displacement.

Subacute osteomyelitis presenting as a bone tumour. A review of 21 cases.

Twenty-one patients with subacute osteomyelitis who were initially considered to have bone tumours were reviewed, with an average follow up of 3 years. The clinical symptoms were not specific and laboratory investigations were normal. The radiographic findings were limited osteolysis surrounded by bone sclerosis in 14 cases, osteolysis without definite borders in 6, and onion-layer periosteal bone formation in one. The preoperative diagnoses included osteoid osteoma, osteosarcoma, chondroblastoma, Ewing's sarcoma, giant cell tumour, fibrosarcoma, eosinophilic granuloma, and bone tumour of unknown aetiology. The definitive diagnosis was made by surgical biopsy, histology and cultures which grew staphylococcus in 9 cases. The gross specimens all showed lymphocytes, plasma cells and granulation tissue with osteogenesis. All the patients recovered completely; 17 were treated with antibiotics and immobilisation, and 4 did not need an antibiotic. There was no recurrence of infection after curettage and excision of the infected tissues.