Reconstruction of the iliac bone using the homolateral femur after resection for pelvic tumor.

The authors have treated three patients with extensive involvement of the acetabular and peri-acetabular bone by a malignant tumour. One had a metastasis from a carcinoma of the thyroid, one from a carcinoma of the breast and one a plasmacytoma. In all three cases, the upper part of the femur was unaffected. It was used to replace the resected pelvic bone and fixed to the remaining bone by screws and plates. An acetabular cup was cemented into the transplanted bone, which itself was replaced by a massive femoral prosthesis. This technique allowed the patients to resume weight bearing rapidly. Two patients were alive and walked satisfactorily after two and four years respectively. The third died five months after the surgical procedure.

[Double measurement of the Böhler angle: prognostic value of radiological angles in posterior facet fractures of the calcaneus]. / La double mesure de l'angle de Böhler.

In 1931, Böhler proposed that measuring the radiological angle of the tuberosity could be useful in posterior facet fractures of the calcaneus to evaluate initial damage as well as reduction quality. In opposition to the 1998 SOFCOT symposium, certain authors considered that the Böhler angle has no prognostic value. Progress in pathological anatomy has helped to better understand posterior facet fractures, justifying the use of a "double measurement". The fundamental fracture line separates the posterior facet into a lowered medial fragment and a pivoted lateral fragment. The double contour of the posterior facet visualized radiographically allows measurement of a medial Böhler angle and a lateral Böhler angle. It is demonstrated that is the smaller the medial Böhler angle, the greater the subtalar degeneration. Surgical restoration of a satisfactory Böhler angle is a necessary prerequisite for a good outcome. "Double measurement" of the Böhler angle on the lateral view contributes to the prognostic value of this historical angle.

[Simple screw fixation for calcaneal fractures: 60 cases with preoperative computed tomography analysis]. / Résultats de l'ostéosynthèse par vissage simple des fractures thalamiques du calcaneus. A propos de 60 cas analysés par tomodensitométrie 3D pré-opératoire.

PURPOSE OF THE STUDY: In accordance with the conclusions established at the SOFCOT symposium in 1988, we propose surgical treatment of displaced fractures of the calcaneus with screw fixation after reduction. We developed an original classification system of 3D computed tomography images which allows a precise description of the fractures and guides joint and calcaneal body reconstructions. The purpose of this work was to provide a precise analysis of operated fractures in order to identify prognostic factors and validate use of exclusive screw fixation for calcaneal fractures. MATERIALS AND METHODS: This series included 60 operated articular fractures of the calcaneus. The Uthéza classification was: 12 vertical, 7 horizontal with 1 fracture line, 3 horizontal with 2 fracture lines, 23 mixed with 1 fracture line and 15 mixed with 2 fracture lines. 3D computed tomography evidenced the fundamental fracture lines and their anterior extension. Fixation was achieved with one screw inserted in a transverse position under the posterior facet and one oblique screw from the greater tuberosity to the sustentaculum tali. The medial and lateral Böhler angles were measured on plain x-rays. The analysis included search for a double line on the posterior talocalcaneal facet, secondary body displacement, the position of the oblique screw and the degree of posttraumatic subtalar wear. The clinical criteria established in the 1988 SOFCOT guidelines were recorded. Analysis of variance, Pearson and Spearman coefficients, and RIDITS analysis (the most powerful method available for evidencing a relationship between two qualitative variables one of which is ordinal) were used to search for prognostic elements and correlations. RESULTS: No severe complications were encountered with the wide lateral access. A negative medial Böhler angle was significantly correlated with an additional posterior facet line. A mean 80 p. 100 reduction in the lowering of the medial part of the posterior facet and an 87 p. 100 reduction in lateral pivoting were achieved irrespective of the type of fracture. Minimal secondary body displacements were significantly related to anchorage of the oblique screw outside the sustentaculum tali. Functional outcome was satisfactory (very good + good + average) in 75 p. 100 of the cases and physical outcome in 50 p. 100 (very good + good) irrespective of the type of fracture. Outcome was significantly correlated with reduction in the Böhler angle, double lines on the posterior facet, secondary displacement and osteoarthritis. DISCUSSION: The 3D analysis of posterior facet fractures using our classification was useful in guiding reconstruction with correction of the medial lowering and the lateral pivoting. A negative medial Böhler angle was a factor of poor prognosis: more posterior facet lines, joint wear and deterioration of the functional and physical outcome. Good outcome required good reduction of the Böhler angle and good anchorage of the oblique screw in the sustentaculum tali. Good subtalar mobility was associated with pain relief. Uniform anatomic and pathologic classifications and precise analysis criteria are needed for pertinent comparison between series and proper definition for indications for first-line reconstruction-arthrodesis. CONCLUSION: Measurement of the medial Böhler angle improves the sensitivity of revision criteria for articular fractures of the calcaneus. Screw fixation has proven its reliability.

Experimental study of the subtalar joint axis: preliminary investigation.

An experimental study of the subtalar joint has been conducted with the aim of establishing its axis of movement as well as analysing the associated movement. For description of the axis, CT data for five positions of a single foot were reconstructed using a 3D programme, the 3D data was processed by Patran software. Measures of angular displacements were made from three amputated feet placed in a specially constructed foot frame. Four instantaneous axes of movement could be defined. Calculation of displacements showed an important rolling of the calcaneus (45 degrees). Tacking was evident in inversion, with an opposite displacement between the front and rear part of the calcaneus, whereas during eversion tacking affected only the rear part of the bone: these results were confirmed by 3D reconstructions. Henke's axis was described as that for the talonavicular joint, but acceptable for the subtalar joint. Several authors investigating the coordinates of this axis have reported large differences and described screw-like movements, the latter being incompatible with a fixed axis: instantaneous axes, however are compatible with a screw-like movement. The subtalar joint appears to work as a pivot joint during inversion and as a plane joint during eversion. Although Henke's axis has pedagogical value the subtalar joint has a series of instantaneous axes.

[3-dimensional imaging of thalamic fractures of the calcaneum. Validation of classifying fractures into 3 forms]. / L'imagerie en trois dimensions dans les fractures thalamiques du calcaneum. Validation de la classification de ces fractures en trois formes.

UNLABELLED: Three dimensional CT scans enables to visualize the calcaneum and to follow the fracture pattern without any risk of errors. PURPOSE OF THE STUDY: This technique has been used to validate our previous classification (using three forms: vertical, horizontal, and mixed) which resulted from a two dimensional tomodensitometric study. MATERIAL: The study was based on a series of 74 fractures, all of them studied with 3D CT and 71 of which were operated. METHOD: The previous classification relied on correlation between lateral radiographs and position on coronal CT plane of the Palmer's fracture line. This we called the Fundamental Line (FL); so the vertical form had medial fundamental line, with thalamic verticalization; and so that the horizontal form with thalamic horizontalization had a lateral FL; the mixed form had a medio thalamic FL with double contoured image. RESULTS: In vertical fractures (16 cases, i.e. 20 per cent), the FL was seen denting the thalamus inwards, continuing forward and damaging the forward facet in about two thirds of cases. The thalamic fragment tilted on its axes frequently, with a great rotation movement; in about half cases, it extended backwards (propagated variation). This lateral fragment, called "cortico thalamic" (CT) explained the vertical thalamic x-ray image. In the horizontal fractures (15 cases, i.e. 20 per cent), the FL dents the thalamus outwards, the medial fragment, pushed downwards, explaining the horizontal image. In the mixed cases (40 cases i.e. 55 per cent) the FL was medio thalamic; the two fragments, downed medially and tilted laterally, are of equivalent importance, hence the double contoured image. In half cases, an accessory line separates the sustentaculum tali, creating the two lined mixed form (14 cases i.e. 35 per cent of the mixed). In those cases, the medial thalamic fragment is unsoldered, when in 50 per cent of cases (i.e. 7 out of 14), the pre-thalamic line, following the sinus tarsi, separates it from the forward part and completely isolates it. Therefore, the initial classification in three forms was in fact confirmed. Moreover, the fundamental line appears in all three forms, being the boundary between the lateral thalamic fragment (always tilted) and the medial fragment (always pushed downside). The anterior of cuboidian joint facets are frequently damaged by the forward prolongation of the Fundamental Line according to studied cases. DISCUSSION: This three form classification emphasizes the role of the Fundamental Line, which in effect acts as a boundary between the two typical displacements of this fracture: downward or rotation movement of the thalamic fragments (since it is there that the main displacements occur). A comparison with the Eastwood and Sanders classifications has been carried out. CONCLUSION: This three dimensional CT approach validates, visualizes and completes the three form classification. This will help us to understand fracture displacements in different forms, and therefore, the particular fracture reduction and osteosynthesis best suited for each case.

[Fibrous dysplasia associated with intramuscular myxoma]. / Dysplasie fibreuse associée à un myxome des parties molles.

PURPOSE OF THE STUDY: The association of fibrous dysplasia and of soft tissue myxoma is rare. The authors report a new case and discuss the underlying mechanism. CASE REPORT: A 45 years male consulted for a large painful swelling of the right gluteal muscle. The CT scan revealed the soft tissue tumor associated with a bone cyst of the right pelvic bone. The mass was removed at operation and tumoral bone tissue was curetted, there were no evidence of tissue continuity between the two lesions. The histological diagnosis was intra muscular myxoma and fibrous dysplasia. DISCUSSION: Intra muscular myxoma associated to fibrous dysplasia of bone is a rare syndrome described by Mazabraud in 1957. A review of the literature until 1995 reveals that only 17 cases of this syndrome have been reported. Intra muscular myxoma is a rare benign soft tissue tumour arising from fibroblast. Fibrous dysplasia is a hamartomatous bony disorder, which appears in mono or polyostotic forms, with or without extraskeletal manifestation. CONCLUSION: It was not possible to demonstrate a clear correlation between the two lesions. The authors suggest that myxoma result from bone mechanical disorders.

Study of the intraosseous vessels of the femoral head in patients with fractures of the femoral neck or osteoarthritis of the hip.

Bearing in mind earlier studies which established a link between arteriosclerosis and mineral loss, or fragility of the bones, and also our recent study showing that patients with arterial disorders of the lower limbs also suffered from osteoporosis, we carried out a histological study of the number and appearance of the intraosseous vessels and trabecular bone volume in the femoral heads of patients undergoing surgery for either fracture of the femoral neck or osteoarthritis of the hip. The number of thick-walled vessels, arterioles or arterial capillaries was significantly diminished in the femoral heads of patients with fractures of the femoral neck (p = 0.007). In addition, in the latter patients, arteriosclerotic vascular lesions (rupture of the internal elastic lamina, medial thickening and fibrosis) were more frequent than in patients with osteoarthritis of hip. The possibility that, through chronic ischemia, arteriosclerosis may lead to disturbance of bone remodelling and loss of the mechanical properties of bone has not been contradicted by these findings.

[Intraarticular fractures of the calcaneus: pathological description. Contribution of x-ray computed tomography]. / Les fractures thalamiques du calcanéum: description anatomo-pathologique. Apport de la tomodensitométrie.

Computed tomography (CT) is of cardinal importance in the study of displaced intra-articular fractures of the calcaneus, as with this imaging technique the primary fracture line of Palmer can be followed and its various locations visualised. If the three-stage classification system of these fractures as vertical, horizontal or mixed fractures, based on their radiological appearance, is adopted, a correlation can be established between the location of Palmer's line and these three anatomical types. The fundamental fracture line is medial in the vertical types, lateral in the horizontal types and is located in the centre of the posterior facet in the mixed types. It can be seen that the fundamental fracture line separates a laterally detached fragment which is always tilted, giving a vertical slope to the surface of the posterior facet which it supports and thus giving a vertical image. This fragment is itself separated from a medially detached fragment which is tilted horizontally and produces a horizontal image on the lateral view. The CT sections must be examined for the presence of a secondary sagittal line completely isolating the horizontally tilted fragment. The importance of the location of the fundamental fracture line, which is on the borderline between tilting and horizontalisation, suggests that pronation-supination of the foot is a factor in the causal mechanism of these fractures. A clear understanding of the three-dimensional position of the fragments and of their displacement, essentially defined by the location of the fracture line, is a prequisite before attempting surgical reduction of calcaneal fractures.

[Proximal fibulo-tibial dislocation and ischemia associated with a leg fracture. Apropos of 2 cases]. / Luxation péronéo-tibiale supérieure et ischémie associées à une fracture de jambe. A propos de 2 cas.

Proximal fibulotibial dislocation may remain escape detection in leg injuries. Posterior dislocations are unusual and are associated with shortening of the limb due to the tibial fracture. Two cases of such dislocation are reported, associated with lower limb ischemia due to an injury of the arterial popliteal trifurcation. An anatomical model indicates the mechanism of this lesion. Such an unusual association has not be found elsewhere in literature.

Risk factors for hip fracture. MEDOS study: results of the Toulouse Centre.

The development of preventive strategies for hip fractures requires better identification of risk factors. The MEDOS study was designed to study prospectively the incidence of hip fracture in 14 centres from six countries and characterise risk factors. At one centre (Toulouse), data were gathered from questionnaires completed by 386 cases of hip fracture aged over 50 years and 848 age- and sex-matched controls over a 12-month period. Of the 935 variables of the MEDOS questionnaire, 235, grouped into 56 items, were statistically analysed. Odds ratios (and 95% confidence intervals) were estimated for each variable from a multiple stepwise logistic regression model. The population comprised 19.2% men and 80.8% women, with a mean age of 80 +/- 8.8 years; 80% were living in an urban area and 76% with their family. Of the 17 significant variables, moderate excess weight and a high nutritional intake of calcium were associated with a decreased risk of hip fracture. Loss of autonomy, a higher height than normal (> 1SD), and a history of previous fractures significantly increased the risk of fracture. Interestingly, all these variables accounted for only 18% of the risk of hip fracture.

[Osteoid osteoma of the trapezoid bone]. / Ostéome ostéoïde du trapézoïde.

The present report describes a case of osteoid osteoma of the trapezoid. It'is an unusual localisation. Synovitis was the first clinical symptom. Tomograms allowed diagnosis and guided the treatment. Radical excision prevented recurrence.

[Posterior sternoclavicular luxation. Apropos of 6 cases]. / Les luxations sterno-claviculaires postérieures. A propos de 6 cas.

The authors have reviewed six retro-sternal dislocations of the clavicle. The indirect mechanism of this dislocation was in 3 cases, due to sport accidents (rugby). The radiological incidence of Heining allowed the diagnosis and the CT examination carried out the checkup of the associated lesions. The surgical reduction revealed lesions of the meniscus which were found in 3 cases out of 6 and allowed one to realize a plastic operation using the tendon of the subclavian muscle (4 times out of 6) in order to stabilize by sternoclavicular joint, as well in recent injuries as in old ones. The results were satisfactory.

[A large vascularized allograft of the femoral diaphysis in man]. / Une allogreffe massive vascularisée de diaphyse fémorale chez l'homme.

A fresh vascularised femoral allograft was used to replace a 27 centimetre section of the diaphysis of the femur following a crush injury in a 35 year old man. The technique of operation and details of management are described. After nine months the graft junctions were incorporated, and vascular perfusion was satisfactory.

[Reconstruction of the iliac bone using the homolateral femur after resection for pelvic tumor]. / Reconstruction de l'os iliaque à l'aide du fémur homolatéral après résection pour tumeur pelvienne.

The authors have treated three patients with extensive involvement of the acetabular and periacetabular bone by a malignant tumour. One had a metastasis from a carcinoma of the thyroid, one from a carcinoma of the breast and one a plasmocytoma. In all three cases, the upper part of the femur was unaffected. It was used to replace the resected innominate bone and fixed to the remaining bone by screws and plates. An acetabular cup was cemented into the transplanted bone, which itself was replaced by a massive femoral prosthesis. This technique allowed the patients to resume weight bearing rapidly. Two patients were alive and walked satisfactorily after two and four years respectively. The third died five months after the surgical procedure.