[ADI-R and ADOS and the differential diagnosis of autism spectrum disorders: Interests, limits and openings]. / L'ADI-R et l'ADOS face au diagnostic différentiel des troubles du spectre autistique : intérêts, limites et ouvertures.

INTRODUCTION: Current developments in international public health are leading qualified authorities to release clinical practice guidelines for Autism Spectrum Disorders (ASD) assessment and diagnosis. Such documents incorporate procedures that rely on the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) which are considered to be the "gold standard" assessment measures in the evaluation of ASD. Although these tools do prove their effectiveness in the evaluation of autistic symptomatology, they nevertheless stumble whenever the situation becomes more complex and reveal differential diagnostic issues in infantile and adult autism cases. This differential diagnostic issue remains significant in the clinical practice of daily life and has strong implications for the course of therapeutic treatment. OBJECTIVES: Our objective is to underline and nuance the metrological qualities of the ADI-R and the ADOS in the differential diagnosis of autistic disorders by presenting a synthesis of recent studies, thus supporting the interest of maintaining an open debate on diagnostic practices. METHODS: Our selective review of the recent literature focuses on studies that confront the ADI-R and the ADOS - used either independently or in a combination - with various differential issues in adulthood and childhood autism in order to highlight their qualities and limits. RESULTS: The ADI-R is a semi-structured interview applied by trained examiners and applied to relatives and/or caregivers who collect developmental information about the patient's first years of life on a variety of behaviors and skills. It is therefore relatively dependent on the availability and personal bias of the interviewed third parties. Metric features highlighted by the reviewed studies straightforwardly reveal a certain effectiveness of the tool and a good discrimination of childhood disorders. At the same time, the tool's discriminatory capacity seems insufficient when applied to toddlers, very young children, and adults alike. The latter seems particularly true when it comes to differentiating between autistic and schizophrenic spectrum disorders. The ADOS is a semi-structured standardized observation assessment tool that has experienced several successive developments, such as optimizations concerning the sensitivity of its cutoffs. Many works have contributed to building such a tool with reliable and solid metric qualities which nevertheless retain important biases such as the subjectivity of the caregiver or the evaluator during the scoring process. For assessments of autistic children the tool still has a good diagnostic validity but seems to retain cases of incorrect diagnosis of ASD (false positives). In other words, disorders or developmental disabilities of some children and adolescents could not be distinguished from ASD when relying on this test alone. The ADOS Module 4, designed for the diagnosis of adolescents and adults with fluent speech, has undergone less updating. This revisited algorithm has metrological qualities useful for clinicians and remains one of the few available tools for this population. Unfortunately, its diagnostic accuracy is lower when applied to women, the elderly, people with personality disorders or higher intellectual abilities, or for the discrimination between ASD and schizophrenia. Overall, scores from these two instruments bring strong evidence of their usefulness in the diagnostic process of ASD, provided that they are used with caution and a critical clinical perspective, and only as a secondary technical support. Their use in combination is effective since they are complementary and compensate for each other's limitations. However, their globalized hegemony as "gold-standard" tools constitutes a setback insofar as it constrains the diagnosis of ASD to a set of stereotyped items. The latter in turn sets a normative model of autism that excludes other phenotypic forms, especially in the case of women and the elderly. Finally, the discrimination between autism and psychosis for children seems to remain an insoluble task even for the ADI-R/ADOS combination. CONCLUSIONS: The problematics of differential diagnosis remain critical for clinical approaches to autism. Therefore, formalizations of the diagnostic procedures must be able to remain open-minded and accompanied by a creative clinical approach, especially in the case of complex situations that are not soluble by means of conventional diagnostic tools. One possibility may lie in the deepening of the phenomenological approach to autism as an attempt to model the subjective phenomena of autistic subjects and thus operationalize elements that serve the diagnostic process. In the same way, a psychodynamic epistemology could help clinicians to go beyond the consideration of observable behaviors and scores, introducing a psychoanalytic point of view that interfaces objective behaviors with the individual's dynamic intrapsychic functioning. This project could be articulated with projective methodologies - notably the Rorschach test - which respects the needs for standardization and quantification of conventionally used diagnostic tools.

No-go decision: A newly identified adverse event in orthopaedic surgery - causes and medico-legal implications.

BACKGROUND: No-go designates a decision not to perform surgery when it becomes apparent that safety and/or feasibility requirements are not met. No-go decisions can occur at any time between patient admission to a hospital department and immediately before the first incision. The primary objective of this study was to assess the causes of no-go decisions reported as healthcare-associated adverse events (HAAEs). HYPOTHESIS: Most no-go decisions in orthopaedic surgery are related to problems with medical devices. MATERIAL AND METHODS: A preliminary retrospective study assessed HAAEs reported over the 1-year period from 1st October 2014 to 30th September 2015, using the risk-management tool ALARM. A prospective survey was then performed by emailing a 15-item questionnaire to the 1828 members of Orthorisq (the French orthopaedic surgeon accreditation agency). Responses were either yes/no or open. Statistical comparisons were performed, using the paired Wilcoxon signed-rank test to estimate p values. RESULTS: Among reported HAAEs, 5.6% were no-go decisions. Of the 101 reported no-go decisions, 43.5% and 45.2% were due to problems with managing implantable medical devices in the retrospective and prospective assessments, respectively. In over 85% of cases, surgery was cancelled or postponed. Over half the no-go decisions were associated with unnecessary anaesthesia. Checklist completion was performed in only half the cases and was not associated with no-go decisions (p>0.8). DISCUSSION: This study provides descriptive data on no-go decisions in orthopaedic surgery. Healthcare professionals use many methods to enhance patient safety by preventing adverse events or diminishing their impact. Errors in managing implantable medical devices are the leading cause of no-go decisions. The current checklist is not appropriate for managing implantable medical devices in orthopaedic surgery, in part because it does not include checking devices upon receipt. Before surgery, patients should be informed of the risk of a no-go decision, since unnecessary anaesthesia occurs in over half the cases. LEVEL OF EVIDENCE: IV, prospective study.

The concept of a waiting period for preoperative patient consent: Prospective study of 51 shoulder arthroscopy cases.

INTRODUCTION: The French Code of Public Health (CSP) does not explicitly require that patients should be given a certain amount of time to think about a procedure, except for cosmetic surgery, where 15 days is required (Art. L 6322-2 CSP). We hypothesized that patients require a waiting period during their decision-making process for scheduled shoulder arthroscopy procedure. MATERIALS AND METHODS: This prospective observational study of 51 patients analysed the concept of a waiting period based on a 10-item questionnaire. A comparative statistical approach was used and the P values were calculated using a paired Wilcoxon rank-sum test. RESULTS: Of the 51 patients, 42 (82%) rejected the concept of a waiting period before the procedure and 37 patients (73%) did not want a mandatory waiting period imposed by law. DISCUSSION: This study looked at the decision-making process during scheduled orthopaedic surgery and differentiated between the conscious and unconscious approach corresponding to an active and passive waiting period. A waiting period does not allow patients to make a conceptually deliberative decision that conforms to the criteria defined by the French Health Authority. This study rejects the need for a mandatory waiting period imposed on surgeons and patients as it does not integrate itself into the informative model of ethical decision-making for scheduled shoulder arthroscopy. TYPE OF STUDY: Prospective, observational; level of evidence IV.

[The practice of episiotomy in France 10 years after the recommendations of CNGOF: What inventory?]. / La pratique de l'épisiotomie en France 10 ans après les recommandations du CNGOF : quel état des lieux ?

Since its creation, the practice of episiotomy has evolved, being influenced by several factors. Various stances on its use were stated, until the eventual reduction of this practice, as suggested by numerous practical guides. In 2005, the National College of Obstetricians and Gynecologists in France published its French Guidelines for Clinical practice in this area. Today, it seems appropriate to focus on the evolution of the use of episiotomy, ten years after the publication of these recommendations. The authors propose a literature review, browsing through all the available epidemiological data in France related to episiotomy, recording all national statistics and some local trends, as there are regional specificities. This review allows to follow the overall evolution of the practice of episiotomy in France between 1981 and 2014, and to identify territorial disparities. Finally, in the specific context of the practice of episiotomy in French gynecological and obstetrics field, the authors conclude it by considering the possible evolution of this surgical practice, as well as, the Clinical Practice Recommendations related to it.

Second generation GUEPAR total arthroplasty of the thumb basal joint: 50 months follow-up in 84 cases.

BACKGROUND: Osteoarthritis of the thumb basal joint is the most common location for hand degenerative joint disease. First, carpometacarpal (CMC) joint arthroplasty is one treatment option. The purpose of this article is to present the outcome of the GUEPAR II prosthesis, a total trapeziometacarpal cemented implant of the retaining ball-and-socket design type. Numerous other advantageous features of this implant, second generation of an earlier version are explored. HYPOTHESIS: Clinical and radiological results confirm the GUEPAR II trapeziometacarpal arthroplasty as a reliable and efficient evolution of earlier prosthetic designs. MATERIALS AND METHODS: Eighty-four GUEPAR II prostheses were implanted to treat advanced and severely incapacitating first CMC osteoarthritis. The average follow-up time in this collaborative series (from 2 centers) was 50 months. RESULTS: There were no intraoperative complications and no dislocations at the final follow-up evaluation, 92% of patients were satisfied or very satisfied with their results with objective improvement of their Kapandji score. Strength was closely comparable to the nonaffected side. Radiographic studies at the final follow-up evaluations did not show (except in one socket revision instance) signs of implant loosening. On occasion, non-progressive radiolucent lines were observed. More than 80% of the patients remained pain free. CONCLUSIONS: In our series, GUEPAR II total joint arthroplasty of the thumb CMC joint has proven to be efficacious, improving motion, strength, and achieving a high degree of pain relief. Successful outcome appears in our experience contingent upon strict compliance with numerous surgical technique details. Current research focuses on improving bipolar fixation by developing press-fit cementless implants.

[Treatment of non-unions of the carpal scaphoid using a nonvascularised corticocancellous bone graft: a retrospective series of 47 cases]. / Traitement des pseudarthroses du scaphoïde carpien par greffe corticospongieuse non vascularisée: étude rétrospective de 47 cas.

OBJECTIVES: The authors report their results on the treatment of scaphoid non-unions without osteoarthritis or necrosis, by anterior nonvascularized bone graft. PATIENTS AND METHODS: Forty-seven patients treated between 1988 and 2003 were analysed with a mean follow-up of 74 months. There were 19 non-unions without carpal instability (IIA) and 28 with carpal instability (IIB). All patients were treated by an anterior approach with corticocancellous bone graft and osteosynthesis using two pins. Clinical results were analysed on pain, strength and mobility. Radiographic analysis was of union, correction of instability and occurrence of osteoarthritis. RESULTS: These were divided into stages IIA and IIB: 1) stage IIA: all cases proceeded to bony union; ten results were excellent and nine good and no instability; there was one case of osteoarthritis; 2) stage IIB: 78% of patients proceeded to bony union; one result was excellent, 17 good, four moderate and six cases remained un-united. There were 12 cases of osteoarthritis. Most of them occurred in patients with residual instability after the initial surgical procedure. CONCLUSION: Corticocancellous nonvascularized bone graft by a palmar approach is an excellent technique for treatment of scaphoid non-unions without osteoarthritis and necrosis. The presence of instability is a poor prognostic factor; its correction during the operation allows the surgeon to decrease the risk of osteoarthritis.

[Acromelic arthritis: a new entity]. / L'acropolyarthrite rhumatoïde.

PURPOSE OF THE STUDY: Few patients with rheumatoid arthritis present isolated acromelic bone and joint destructions. Concerned joints are wrist, MP, PIP, DIP and forefoot. The aim of the current study is to describe and evaluate the long-term results of wrist, hand and forefoot surgery in an acromelic arthritis group. MATERIAL AND METHODS: 93 patients with acromelic arthritis were included in the study. 202 surgical procedures were performed between 1981 and 2001 in addition to medical treatment. 93 procedures concerned dorsal wrist surgery. The mean follow-up of this group was 7 years (24 months-20 years). 78 synovectomies of radio-carpal and medio-carpal joints with a Sauvé-Kapandji procedure were performed and 10 with a radio-lunate arthrodesis and 5 with other surgeries. The main indication for surgery was severe pain. RESULTS: Functional results and radiographic evolution (Larsen X-ray classification) were studied. All patients were satisfied or very satisfied and pain was significantly reduced. Radiographic lesions progressed but Larsen's stage remained unchanged in 73% of patients. All patients with forefoot surgery recovered total walk autonomy. DISCUSSION: Acromelic arthritis is a particular form of rheumatoid arthritis that progresses very slowly. Surgery should be indicated earlier, for a better joint function stabilisation.

[Syringomyelia and associated bone and joint diseases]. / Syringomyélie et pathologies ostéo-articulaires associées.

Syringomyelia can occur in patients presenting bone and joint diseases of various origins. When joint destruction of the shoulder or elbow produces little pain, a neurological cause might be involved. In this case, the disease history can be of utmost importance because an initial diagnosis of rheumatoid polyarthritis, polyosteoarthritis, or destructive joint disease can be misleading before the syringomyelic origin of the bone and joint disease becomes patent. We report two cases illustrating this association and the diagnostic pitfalls which can delay recognition of the syringomyelia. Better awareness of the prevalence of this condition should be helpful in establishing the diagnosis and in selecting patients who can benefit from neurosurgical treatment. The two cases presented here suggest that syringomyelia could be underdiagnosed in certain patients with an initially atypical presentation. A review of the current knowledge of syringomyelia suggests that arthroplasty is generally not advisable for destroyed dislocated syringomyelic joints.

[Bipolar shoulder prosthesis for rheumatoid arthritis with irreparable rotator cuff tear: results after 5 years' follow-up]. / La prothèse humérale bipolaire dans l'épaule rhumatoïde avec rupture de coiffe irréparable. Résultats à plus 5 ans de recul.

PURPOSE OF THE STUDY: The goal of this study was to assess the clinical and radiological outcome of bipolar shoulder prosthesis in twelve shoulders with rheumatoid arthritis (RA) and irreparable rotator cuff tears. MATERIAL AND METHODS: The follow-up was more than five years (range 2-9 years). In addition, in order to investigate the effect of rheumatoid arthritis on outcome, results were compared with ten bipolar shoulder prostheses implanted for osteoarthritis with massive rotator cuff tears. RESULTS: The mean preoperative Constant score was 16.9 points with 2.6 points for pain, 4.2 points for activity, 9.5 points for motion and 0.6 points for force. The preoperative active motion was 63.8 degrees for forward flexion, 45 degrees for abduction and 12 degrees for active external rotation. At last follow-up, the average Constant score was 39.4 points with 10.7 points for pain, 10.8 points for activity, 13.8 points for motion and 4.1 points for force. Regarding the active motion, mean forward flexion was 83.7 degrees, 70.4 degrees for abduction and 29.1 degrees for external rotation. The complication rate was low, mainly superior migration due to infraspinatus tear and glenoid wear. Satisfactory deltoid arm level was achieved in all patients and no loosening was observed. Preoperative and postoperative scores of the rheumatoid group were not significantly different from the arthritis group (p<0.001). DISCUSSION: Our findings suggest that bipolar shoulder prosthesis provides a viable replacement alternative in RA combined with massive rotator cuff tear with a low rate of complication. Bipolar shoulder prosthesis demonstrates no clear superiority over conventional hemiarthroplasty regarding improved motion and glenoid wear. In addition, no significant difference with arthritis was observed (p<0.05), assuming that outcome depends principally on the preoperative condition of the rotator cuff. CONCLUSION: Some massive tears involving the subscapularis tendon can lead to anterior recurrence after bipolar shoulder prosthesis. They might be a limit to the procedure and require a reversed shoulder prosthesis or a glenohumeral arthrodesis.

Long-term review of five leg replantations: emergency strategy and examples of lengthening of the leg on nerve regeneration.

The success rate for leg replantation has improved with the development of shortening-lengthening protocols. We checked whether this success was maintained long term in five cases of emergency reimplantation. The significant initial shortening of 93 mm, on average, enabled direct internal osteosynthesis, secondary lengthening was initiated swiftly, in the proximal metaphyseal area, and average lengthening was 85 mm. Consolidation was achieved in all cases within normal time periods, with an average inequality in residual length of 8mm. The speed of nerve regeneration was on average 1.926 mm/day, twice faster than usual after simple nerve suturing. At average follow-up of more than 11 years, all patients were walking. We conclude that nerve lengthening stimulates nerve regeneration, and that the results of this protocol, involving extensive initial debridement compensated by secondary lengthening, have enabled the limitations on unilateral leg replantation to be reduced.

[Merkel cell carcinoma of the skin: two case reports located at the hand, with a review of litterature]. / Le carcinome cutané de Merkel: revue de la littérature à propos de deux localisations à la main.

The Merkel cell carcinoma of the skin are rare neuroendocrine tumours, with a dermal location. Their severity and metastatic potential are higher than cutaneous melanomas'. Two cases are reported at the hand. A review of literature displays the pejorative prognosis of these tumours. Hand surgeons must be aware of them, in order to fasten the diagnosis and include the patient among a multidisciplinary medical team.

[Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis]. / Traitement de l'arthrose scaphotrapézotrapézoidienne isolée par arthrodèse scaphotrapézotrapézoidienne: une série de 13 cas.

Scapho-trapezio-trapezoid arthrodesis was originally performed for the treatment of scapho-lunate instability. However, only a few publications have described this technique for treatment of osteoarthritis of the scapho-trapezio-trapezoid (STT) joint. The purpose of this paper is to analyze the results of triscaphoid arthrodesis for STT osteoarthritis with a long-term follow-up. Thirteen cases of osteoarthritis of the STT joint in twelve patients, all treated by STT arthrodesis, were reviewed with an average follow-up of 60 months. Pain was classified according to Alnot's classification: eight patients were classified as grade III, two as grade IV and two as grade II. The average preoperative range of motion of the wrist was 51 degrees for flexion, 39 degrees for extension, 9 degrees for radial deviation and 28 degrees for ulnar deviation. Grip strength was compared to the contralateral side. Radiographic changes were classified according to Crosby's classification, including sublevels for carpal instability. Four wrists were classified 2a and nine wrists were classified 2b. The average radio-lunate and scapho-lunate angles were 14 and 45 degrees respectively. Pain was improved in all patients (P = 0.05) all of whom were subjectively satisfied. Strength and range-of-motion did not statistically decrease after STT arthrodesis except for wrist extension (P = 0.03). Radio-lunate and scapho-lunate angles were unchanged in five patients and improved in five patients. There were four non-unions of whom two patients without pain were not re-operated. The other two were re-operated with the same technique leading to fusion. Scapho-trapezio-trapezoid arthrodesis is an efficient procedure for STT osteoarthritis with regard to pain reduction. Strength and global range-of-motion are not modified by this procedure. Moreover, as it limits carpal instability, this procedure is preferable in active patients.

[Jaccoud's arthropathy. Surgical results of 41 hands]. / La main de Jaccoud. A propos de 41 mains opérées.

Jaccoud's arthropathy, which was first described in 1869, is a rare syndrome that is characterized by a painless or relatively painless deformity of the digits II, II, IV and V with a dislocation of the extensor tendons into the metacarpal valley. When the thumb is affected, a Z deformity is observed. The present analysis was based on 40 patients (56 hands, 41 of which were operated on over the period 1989 to 2001). A distinction should be made between Jaccoud's disease following a known inflammatory arthropathy (23 hands; average patient age 55 years) and the idiopathic form of the disease (18 hands, average patient age 70 years). From a clinical point of view, a classification of the deformities is needed so that appropriate surgical treatment can be determined. In the present study, four groups were therefore proposed, in groups I and III the realignment to centre of the extensor tendons of the metacarpophalangeal joint and joint stabilization yielded 83% positive results. In groups II and IV the results were only 66% good after Swanson implant. The pathogenesis of Jaccoud's disease has not yet been determined, but now that more information has become available and a better analysis can be made of its various clinical and anatomopathological charasteristics, these should assist in defining precise surgical indications.

[Prognostic factors of axillary nerve surgery]. / Facteurs pronostiques de la chirurgie du nerf axillaire.

PURPOSE OF THE STUDY: We searched for prognostic factors which could influence outcome after surgery for traumatic lesion of the axillary nerve. MATERIAL AND METHODS: Forty-five surgical interventions to repair injured axillary nerves were preformed between 1993 and 2000. We analyzed outcome at a mean 56 Months (range 15-96). Twenty-five isolated lesions were treated by nerve graft (n=20), direct suture (n=2) or neurolysis (n=3). Four associated axillary and musculocutaneous nerve injuries were treated by axillary graft and musculocutaneous neurolysis (n=2) or double grafts (n=2). Eleven injuries involving both the axillary and suprascapular nerve were treated by double nerve graft (n=4), axillary graft with suprascapular neurolysis (n=5), or axillary graft with an irreparable suprascapulary injury (n=2). Five axillary nerve lesions were associated with lesions of the rotary cuff; treatment associated suture of the cuff (n=3) or reinsertion fixation of the tuberosities (n=2) prior to nerve repair by axillary graft (n=4) or neurolysis (n=1). RESULTS: For the isolated axillary lesions, results were very good or good for 16/20 nerve grafts, 2/2 direct sutures and 2/3 neurolyses. For the patients with an associated musculocutaneous lesion, shoulder function was considered very good for one; mean elbow flexion strength was 29% (15-50%) of the healthy side. For the eleven axillary and suprascapular injuries, outcome was very good or good for two. Very good or good results were not achieved for any of the five patients with associated cuff lesions. Factors predictive of poor outcome were a preoperative Constant score below 40 points, age over 40 Years, time to operation greater than 15 Months, and multiple nerve or associated cuff injury. DISCUSSION: The favorable prognosis of isolated lesions of the axillary nerve was confirmed. The risk of failure does however persist and is related to late management despite well defined surgical technique.

[Total elbow arthroplasty in rheumatoid arthritis using GUEPAR prosthesis]. / Prothèse totale bicompartimentaire de coude GUEPAR. Résultats dans la polyarthrite rhumatoïde (16 cas).

PURPOSE OF THE STUDY: We report a retrospective analysis of 16 patients with rheumatoid arthritis treated with a total humero-ulnar and humero-radial GUEPAR prosthesis (GIII). MATERIAL AND METHODS: The GUEPAR III elbow prosthesis is an anatomic polyethylene-metal gliding prosthesis designed to maintain physiological valgus. Right and left models are available in two sizes. On the humero-ulnar side of the prosthesis, was associated with a radial head, born on an intramedullary metallic stem, that can be fit with several sizes of mobile polyethylene cups. The 16 GIII prostheses were implanted in 1997 to 2001 in accordance with the manufacturers instructions. Mean follow-up was 2 years. RESULTS: Before surgical treatment, all patients had moderate or severe but invalidating pain. The Mayo Clinic score was 33 points. The Larsen radiographic score was grade III (7 elbows) or grade IV (9 elbows). Patients were reassessed 1 to 5 years after implantation of the GIII (mean follow-up 2 years). At last follow-up the mean Mayo Clinic score had improved from 33 to 90 points. Outcome was considered excellent for 15 elbows and fair for 1. DISCUSSION: We review the indications for total elbow arthroplasty in patients with rheumatoid arthritis. Semi-constrained prostheses are useful and necessary for the treatment of elbows exhibiting massive destruction, but the use of minimally constrained prostheses such as the GUEPAR III is becoming increasingly widespread. We use the GUEPAR III for 70% of our patients, particularly those with rheumatoid arthritis.

[Surgical replacement of the thumb saddle joint with the GUEPAR prosthesis]. / Die chirurgische Versorgung der Rhizarthrose mit der GUEPAR-Prothese.

Primary arthritis of the thumb saddle joint is very common. Among the different treatment options, the implantation of a total joint arthroplasty is an alternative. The GUEPAR prosthesis, developed by a group of French surgeons, is mainly used in elderly patients and only in cases with preserved trapezial height. This study reports the mid-term results of the second generation of this implant. The clinical results show good pain relief and good mobility of the thumb. There were a few patients with radiological signs of implant loosening, but none of them had clinical problems. The advantage of a total replacement of the saddle joint, compared to the standard resection arthroplasty, is faster rehabilitation and preservation of the length of the thumb. The new generation of the GUEPAR prosthesis has a more anatomical metacarpal stem and a modularity which allows the fit of the implants according to the anatomical situation.

[Multiple peripheral nerve tumors: update and review of the literature]. / Tumeurs multiples des nerfs périphériques: mise au point et revue de la littérature.

Multiple tumours of the peripheral nerves are seen only in neurofibromatosis. They are hereditary. They present and develop in a variety of different ways. Three main groups are distinguished: von Recklinghausen neurofibromatosis or type 1; bilateral acoustic neurofibromatosis or type 2 and schwannomatosis recently defined as type 3. The aim of this study was to clarify the clinical outcome of neurofibromatosis. The diagnosis is made purely on clinical grounds. Cranial MRI and slit lamp examination are useful for classification. Surgical management for peripheral nerve tumours is similar. Any new and rapid change noted at clinical examination (increase in volume, pain or neurological deficit) requires surgery because of potential malignant transformation of the neurofibroma into neurofibrosarcoma (type 1 only). The definitive treatment depends on the resectable character of the tumour which is usually only known after epineurotomy under operating microscope. In the event of resectable tumour (schwannoma) enucleation must be performed, preserving nerve continuity. In the event of unresectable tumour (neurofibroma), tumour resection is impossible without sacrificing nerve tissue. An epineurotomy must be performed. It prevents further deterioration. Interfascicular biopsy confirms the histological type. Our results are similar to those in other recorded studies. The unpredictable clinical course of neurofibromatosis makes prolonged follow-up mandatory.

[Resection of the first row of carpal bones: post-traumatic wrist and Kienbock's disease]. / La résection de la première rangée des os du carpe: poignet post-traumatique et maladie de Kienböck.

This study reports the outcomes of 27 proximal row carpectomies for stage II (Watson) scapholunate--(10 Slac) and scaphoid non union--(8 Snac) advanced collapse and stage III (Lichtman) Kienböck's disease (9 cases) followed for an average of respectively 72 and 50 months. Following surgical treatment, more than 80% of patients in both groups were pain free. The total arc of motion averaged 67 degrees (unchanged), for the post-traumatic arthritis, and 59 degrees for Kienböck's, a decrease of 17%. Grip strength averaged a 17% increase in comparison to the opposite size for both groups. Proximal row carpectomy showed a high degree of patient satisfaction and is a motion-preserving and grip-preserving procedure used in stage II post-traumatic arthritis but Lichtman III stage in Kienböck's disease had a comparatively poor result. Proximal row carpectomy simplifies the structure of the radiocarpal joint. When the cartilage on the capitate head and the radial lunate facet are not worn, this procedure provides a good result with respect to pain, range of motion and strength which is stable with time.

[GUEPAR radial head prosthesis for recent and old fractures: a series of 22 cases]. / La prothèse de tête radiale GUEPAR dans les fractures récentes et anciennes: à propos d'une série de 22 cas.

PURPOSE OF THE STUDY: We reviewed retrospectively outcome in 22 patients with recent or old fractures of the radial head treated with a GUEPAR radial head prosthesis. This prosthesis, derived from the GUEPAR sliding total elbow prosthesis, has a cemented mobile metal cup. MATERIAL AND METHODS: Eighteen patients underwent emergency surgery, four deferred surgery. Mean age at surgery was 41 years and mean follow-up was 18 months. The Mayo Clinic score was calculated to assess clinical outcome. Static and dynamic x-rays of the elbows and wrists were analyzed. All of the fractures were total or displaced head fractures and 72% involved elbow dislocation. The coronoid process was fixed in one patient, the olecranon in one and the medial ligaments were repaired in 5. The quality of the cartilage of the humeral condyle was checked before insertion of the prosthesis. Proper position and height of the prosthesis were carefully controlled. RESULTS: There were no complications. Outcome was good in the patients who underwent emergency surgery with a mean Mayo Clinic score of 83/100, mean force 75%, good joint motion (77 degrees pronation, 79 degrees supination), stable elbow, and no wrist problems. Outcome was not as good in patients who underwent deferred implantation, particularly for joint motion (pronation 44 degrees, supination 54 degrees ). The distal radio-ulnar ratio was not perfectly restored. Finally 4 patients required arthrolysis for limited flexion/extension, proportionally more among the deferred patients. DISCUSSION: Resection of the radial head is an alternative in case of complex fractures. There are two drawbacks. The first is an unstable elbow in valgus if the medial ligaments are damaged. The second is an ascension of the radius if the interosseous membrane is damaged. Osteosynthesis is another alternative which is difficult to achieve and does not give good results (in our experience in comparison with 20 equivalent fractures, and in the literature). The GUEPAR radial head prosthesis appears to be a good solution. It stabilizes the elbow, prevents ascension of the radius, allows early rehabilitation, and provides good subjective results, particularly after emergency surgery.