Femoral and tibial bone torsions associated with medial femoro-tibial osteoarthritis. Index of cumulative torsions.

Frontal plane varus deviation is one of the mechanisms hypothesized to be involved in the pathogenesis of medial compartment osteoarthritis of the knee. But only a few authors have suggested a role for tibial and femoral torsion. In the current study, CT scan was used to measure bone torsion. The torsional morphology of the lower limb was defined by the "index of cumulative torsions" (ICT). The resulting values were compared to the frontal angular deviation data. The effects of tibial and femoral torsion on the position of the lower limb during the stance phase of walking and the consequences for the knee are discussed.

Open and subcutaneous recent tibialis anterior tendon ruptures: does postoperative immobilization method influence outcome?

UNLABELLED: We report on seven traumatic lesions of the tibialis anterior tendon (one subcutaneous rupture and six open tears) in seven injured patients of mean age 45 years [17-79] all managed by direct suture and immobilization either using a cast boot (four cases) or a lower leg external fixator (three cases). After a mean follow-up of 31 months (6-50), external fixation achieved favourable clinical results with no specific complication. External fixation improves the conditions for suture efficiency, provides full immobilization and facilitates wound care in patients at a high risk of developing cutaneous complications. In accordance with data published in the literature, immobilization by means of a windowed cast boot achieved satisfactory results in patients with no risk factors. This method compatible with early mobilization avoids placement of a posterior splint which could induce slackening and weakening of tendon repair. LEVEL OF EVIDENCE: Retrospective study (Level IV).

Direct neurectomy of the motor branches of the tibial nerve in hemiplegic adults: an assessment with a mean follow-up period of 11 years.

INTRODUCTION: Neurectomy of the tibial nerve plays a major role in the relief of disabling spasticity, which is refractory to drug treatment and physiotherapy. Although the immediate postoperative results are generally satisfactory, few evaluations of the procedure's long-term efficacy have been published. OBJECTIVE: To estimate the long-term efficacy of total or partial neurectomy of the motor branches of the tibial nerve (combined with additional orthopaedic surgery in some cases). METHOD: A descriptive, retrospective study of 25 brain-damaged patients having undergone neurectomy at least 4 years ago. RESULTS: The mean post-neurectomy follow-up period was 11 years. Twenty patients became less dependent on the use of walking aids. Of the 18 patients unable to walk barefoot before surgery, 11 could do so after surgery. Of the 12 patients unable to walk on uneven ground before surgery, seven could do so afterwards. The walking distance increased for 20 patients. In 22 cases, the spasticity disappeared immediately after the operation and did not reappear in the long-term. In three other cases, spasticity persisted postoperatively and, in the long-term, affected the soleus (the denervation of which had been incomplete or not performed). Eighty-three percent of the patients were satisfied with the operation's outcome. CONCLUSIONS: The observed maintenance of the benefits of total or partial neurectomy after an average follow-up period of 11 years confirms the value of this procedure. The few mediocre outcomes (observed in cases of partial neurectomy of the soleus) are in agreement with literature reports and emphasize the role of the soleus in this pathology.

Clinical examination of the foot and the ankle. Data collection and interpretation of the pathogenic causal sequence of disorders.

The clinical examination remains the irreplaceable stage in assessing foot and the ankle disorders. It comprises a complete inventory of the patient's complaints and the data obtained from the physical examination. Afterwards, it should concentrate on establishing consistency between symptoms that can be disparate, to link them in a logical pathogenic causal pattern to be used in developing a treatment programme. These correlations are the most often obvious and only require confirmation with standard X-rays. In the absence of consistency, and if a diagnosis is difficult to establish, recourse to more sophisticated investigations (CT scan, MRI or an intra-articular local anaesthetic test) becomes worthwhile. To achieve maximum value, the physical examination must be based on prerequisite knowledge of functional anatomy, admittedly basic but covering all the bone and joint, ligament, muscle, skin and neurovascular components. All these structures being closely interrelated. This organization allows for remarkable protection mechanisms and the capacity to endure considerable cyclic stress. This interdependence can also command chains of injury difficult to unravel. The examination must thus be methodical and comprehensive: history taking (ranking of symptoms, evaluation of the patient's psychological profile); physical examination, standing, on a podoscope, gait analysis, lying down (trophic disorders, joint range of motion, muscle testing); standard X-rays, always weight bearing. This discursive organization, essential in everyday practice, avoids the sequence "symptom --> MRI --> surgical indication" which is a professional and intellectual deviance; it enables the development, in terms of advantages against risks, or an appropriate treatment plan in the best conditions.

Anatomical comparative study of two vascularized bone grafts for the wrist.

Atrophic scaphoid non-union and lunate necrosis can be treated with vascularized bone grafting; through a posterior approach as described by Zaidemberg, based on a supraretinacular artery, or through an anterior approach, based on the volar carpal artery, according to Kuhlmann's procedure. The aim of our study was to determine the area covered by each of these two grafts and their respective future applications. Fifteen hands from eight adult human cadavers, free of any scar, were dissected after injection of colored fluid latex, through dorso-radial approach for Zaidemberg's graft and through volar approach for Kuhlmann's. We observed the morphological parameters of the pedicles and the arc of rotation of each flap. The volar vascularized graft had a constant origin and it could be transferred to the scaphoid, the lunate and the scapholunate joint. The posterior graft of Zaidemberg was technically more difficult to harvest because of the anatomical variations. It made it possible to reach the scaphoid, the trapezium and the scaphotrapeziotrapezoid joint line. Both these two vascularized bone grafts represent interesting procedures for treatment of scaphoid non-union or lunate necrosis, or intracarpal bones arthrodesis. They bring various possibilities of bone covering, related to specific area of mobilization and are not opposite procedures, but have different targeted indications. One must better define the respective places of the vascularized bone grafts, compared with the traditional free (non-vascularized) graft.

Thigh abscess as a complication of continuous popliteal sciatic nerve block.

We present a case report of severe localized infection after continuous popliteal sciatic nerve block. The report highlights the importance of meticulous asepsis and possibly limiting the duration of catheter use.

[Evaluation of continuous nerve block for postoperative pain management in orthopaedic surgery]. / Evaluation de la mise en place d'un protocole d'analgésie postopératoire par cathéter périnerveux.

OBJECTIVE: After orthopaedic surgery, continuous nerve block analgesia provides effective postoperative pain relief. The practical use of these techniques may present problems. The purpose of this study was to assess the development of continuous block procedure for postoperative pain based on quality standard management and the effectiveness of initial training as an adjunct for introduction of these techniques. MATERIALS AND METHODS: A staff committee of anaesthesiologists established a specific practical working protocol. The medical and paramedical teaching sessions were immediately evaluated using a questionnaire. RESULTS: 214 consecutive patients were included. The incidence of side effects and complications were higher in the beginning of protocol. Constant improvement of these results was observed throughout the study. The rate patients with pain were 10%. The analysis of medical evaluation should permit to determine an acceptable level of quality. Most patients were satisfied with their management. CONCLUSION: Pain management quality assurance program provided an improvement in efficacy of postoperative pain management in our protocol. Further, evaluation may be required to assess the complete benefits of this new protocol as regards postoperative pain.

Intermittent dislocation of the flexor hallucis longus tendon.

Dislocation of the flexor hallucis longus tendon is an exceptional occurrence. To our knowledge, this is the first case ever reported of an intermittent dislocation in a 17-year-old woman; she was a synchronised swimmer. She consulted for a right internal retro-malleolar syndrome. Voluntary "snap" was triggered by a mechanism which combined maximal ankle dorsiflexion and interphalangeal plantar flexion of the toes. Non-enhanced dynamic helical CT and axial MRI were performed, which revealed the dislocation of the right flexor hallucis longus tendon outside the posterior intertubercular talar groove. Static and dynamic imaging would appear to be required to make this uncommon diagnosis.

[Osteoid osteoma after an old femoral shaft fracture]. / Ostéome ostéoïde sur le site d'une fracture diaphysaire ancienne du fémur.

An osteoid osteoma was discovered at the site of fusion of a mid-third femoral shaft fracture in an 18-year-old girl. This unusual localization was revealed by persistent pain after ablation of the material after fracture healing. Postoperatively, a discharge from the skin wound that persisted for a few days, raised the differential diagnosis between low-grade bone infection and an osteoid osteoma suggested by the patient's age and the clinical presentation. Computed tomography and leukocyte-labeled bone scintigraphy provided the diagnosis of osteoid osteoma that was confirmed at pathology examination after resection. Isotopic mapping of this very small intraosseous lesion that exhibited strong isotope uptake was particularly contributive.

Prospective randomized comparison between a dynamic hip screw and a mini-invasive static nail in fractures of the trochanteric area: preliminary results.

OBJECTIVES: This study aimed at comparing the results obtained with a sliding screw plate and an experimental device including a small-diameter nail that can be placed with a mini-invasive approach and provides a stable fixation. DESIGN: Randomized prospective study. SETTING: University hospital. PATIENTS: The study included two groups with thirty fractures of the trochanteric area. INTERVENTIONS: In both groups, the surgical procedure was carried out on patients placed on a traction table in a supine position, under an x-ray amplifier. Sliding screw plates (THS) were set in place according to the usual open technique. Nails were placed through a twenty-millimeter supratrochanteric cutaneous incision. This experimental system comprised a locked intramedullary nail with two nonparallel seven-millimeter cervicocephalic screws. MAIN OUTCOME MEASURES: The comparison between the two groups was based on the surgical procedure (time, duration of x-ray irradiation, and total blood loss); the initial postoperative period (complications, duration of hospital stay, and the time before returning home); the time before full weight bearing became effective; the functional and social recovery; mortality; and the quality of immediate and final anatomic restitution and healing. RESULTS: Operating time (p < 0.001) and blood loss (p < 0.001) were lower in the nail group, and no blood transfusion was required. Postoperative pain (p < 0.01), time necessary to support full weight bearing (p < 0.02), and time before returning home (p < 0.05) were reduced in the nail group. All fractures healed in the same amount of time, with good anatomic results in the nail group, whereas ten impactions beyond ten millimeters occurred in the plate group. No difference was found between the two groups in walking ability and autonomy recovery, but hip function (p < 0.05) was better in the nail group. CONCLUSION: This preliminary clinical study has shown the advantages of this mini-invasive technique. It could not evaluate all the possible disadvantages inherent in the method. These points will be evaluated in a multicenter study justified by these preliminary results.

[Experimental study of compression by Herbert screw in carpal scaphoid fracture]. / Fracture du scaphoïde carpien traitée par vis de Herbert.

PURPOSE OF THE STUDY: The purpose of this experimental work was to obtain a radiographical assessment of the effect of the compression achieved with the Herbert screw due to its different thread diameters by comparing the real and expected reduction of interfragment gap (IFG) on cadaver bones. To better understand and define the limits of this "self-compressing" effect and to study the usefulness of screw sizes smaller than the scaphoid, we measured the maximal and mean reduction of IFG without using the instrumentation. MATERIAL AND METHODS: Twelve scaphoids were obtained from fresh cadavers. The scaphoid holes were drilled and tapped in the largest axis of the scaphoid, in a central position parallel to an anti-rotation wire. A transverse osteotomy was made in the mid third of the scaphoid to simulate a Schernberg grade III fracture. The real IFG reduction was defined as the difference between the gap measured before and after screwing. The expected IFG reduction was defined by multiplying the number of screw turns by the pitch height per turn. RESULTS: On the reduction average, a Herbert screw produced a 1.1 mm IFG reduction. The maximal reduction IFG measured was 1.5 mm. For 7 cases, the real IFG reduction was larger than expected, for 4 cases it was smaller than expected and for 1 case the difference was considered negligible. The Fisher test did not demonstrate any significant statistical difference between the real and expected IFG reduction for all scaphoids. The operator perceived a subjective sensation of compression after one screw turn that continued up through the last turn. DISCUSSION: The Herbert screw develops maximal compression force when all the screw threads are totally anchored in the bone. The interfragment gap closes linearly, bringing the two bone fragments together. However, failure can result if the gap is too wide (>2 mm), the screw is poorly positioned, or there is an inappropriate correspondence between screw length and diameter and scaphoid size. Unlike spongy bone screws, the Herbert screw has a round non-conical tip thread and a shallow thread that do not bring the bone fragments together. The perception of compression corresponds to the passage of the screw through the spongy bone and not to real narrowing of the gap between the fragments. In clinical practice, because of the use of instrumentation for open surgery in carpal scaphoid fracture, it is not necessary to rely on these data, but they can be useful for percutaneous screw insertion without a guidewire and without prior compression or for another localization. Peroperative radiographs should be obtained to assess the quality of the screw position and check reduction and the reality of the compression.

[Transgluteal approach to the hip by anterior hemimyotomy of the gluteus medius]. / Abord transglutéal de hanche par hémimyotomie antérieure du gluteus medius.

Authors describe a transgluteal approach of the hip which is not based on the somewhat unsure common insertion of gluteus medius and vastus lateralis. Anatomical basis and technical particularities of division of anterior part of gluteus medius, of gluteus minimus and capsule are given which allow preservation of gluteal nerve, stability of the joint, and solid reparation of abductor muscles.

Taenia crassiceps invasive cysticercosis: a new human pathogen in acquired immunodeficiency syndrome?

A fluctuant, painful, subcutaneous, and intermuscular tumor developed in a 38-year-old man with severe acquired immunodeficiency syndrome (AIDS) in which immunodeficiency was severe. Surgery revealed lesions that formed a multilocular pouch embedded in deep tissues in the forearm filled with tapiocalike material containing a viscous fluid, granules, and cysticercilike small vesicles. Pathologic and parasitologic evaluation showed cysticerci embedded in a fibrocollagen reaction with inflammatory granulomatous reaction. Each cysticercus contained an invaginated scolex with two rows of small (i.e., 80 microm) and large (i.e., 114 microm) rostellar hooks, identical to larva of Taenia crassiceps. All clinical, parasitologic, and pathologic features of these cysticerci were very different from those of all other larval cestode (i.e., Taenia solium cysticercosis, coenurosis, sparganosis, cysticercosis due to Taenia saginata [Cysticercus bovis], primary and secondary hydatidosis [Echinococcus species]). T crassiceps cysticerci usually develop in subcutis and pleuroperitoneal cavities of rodents, whereas the adult tapeworm is commonly found in the digestive tract of foxes. Biologic properties of T crassiceps cysticerci and epidemiologic characteristics of pandemic human immunodeficiency virus (HIV) could eventually indicate new potential cases of T crassiceps cysticercosis in humans.

Long-term functional prognosis of posterior injuries in high-energy pelvic disruption.

OBJECTIVE: This study sought to identify the long-term functional results of various posterior pelvic lesions and to determine whether such injuries benefit from exact reduction. DESIGN: Consecutive cohort of patients admitted for pelvic disruption between 1980 and 1990. SETTING: University hospital. PATIENTS: Eighty-eight pelvic fractures in eighty-eight patients were classified according to the instability and anatomy of the posterior injury. Simple fractures of the pubic rami, minimally displaced fractures with pubic diastasis of less than 2.5 centimeters, and fractures without other pelvic lesions (type B1 lesions, stage 1 in the Tile classification) were all excluded. Patients with sequelae of associated lesions that could render functional evaluation difficult were also excluded. INTERVENTIONS: The initial status of the patient and the type of fracture determined the treatment. In the anteroposterior compression injuries group, an external fixator using the double-frame Hoffmann device was applied in twenty-eight cases to reduce a large external horizontal displacement, either immediately to control bleeding or later as definitive treatment when anterior internal fixation was not possible. Anterior internal fixation with a plate was used six times to repair a symphyseal disruption. In vertical shear injuries, tibial skeletal traction was used for six weeks as an attempt to stabilize vertical instability. In ten patients, traction alone was used. In other cases, traction was used in conjunction with an external fixator or internal pubic fixation. In impacted lateral compression injuries, simple bed rest for six weeks was used in cases of stable lesions. Skeletal traction was applied in ten patients of this group because of a potential vertical instability, particularly in cases with a comminuted sacral lesion. MAIN OUTCOME MEASURES: Anatomic diagnosis and evaluation of the reduction were made using anteroposterior, inlet, and outlet radiographs of the pelvic ring. To assess reduction, vertical, anteroposterior, and rotatory displacement was measured. Functional results were qualified based on the injury pattern and the quality of the final reduction and were then quantified according to the grading proposed by Majeed. RESULTS: Functional results varied according to injury anatomy, with fractures of the iliac wing and sacroiliac (SI) fracture-dislocations having the best prognosis. The quality of reduction did not affect the functional results. Conservative methods such as skeletal traction and external fixation generally gave satisfactory functional results. Conversely, however, pure SI lesions were associated with poor functional results, especially if reduction was not exact. CONCLUSIONS: This study shows that when the posterior injury is a fracture of the iliac wing or a mixed fracture with SI propagation, a long-term satisfactory functional result can be obtained without an exact reduction even in cases of vertical instability. Simple methods are usually sufficient, and it seems unnecessary to propose more aggressive treatment. It is important, however, to recognize that SI fracture-dislocations (17 percent in this series) seem to be quite different from pure SI disruptions in terms of persistent pain. Moreover, it appears that exact reduction of pure SI lesions is critical for good functional results, something that is difficult to obtain with conservative procedures. Sacral fractures represent a special problem for the surgeon because of the frequency of fair results in which neurologic lesions whose pathophysiology is poorly known seem to be responsible.

Molecular diagnosis of Ureaplasma urealyticum in an immunocompetent patient with destructive reactive polyarthritis.

Polymerase chain reaction (PCR) amplification, which is a useful method for detecting infectious agents in joints, has potential utility in the molecular diagnosis of venereal-associated arthritis. Among pathogens detected by this technique, Ureaplasma urealyticum, which is primarily associated with reactive arthritis (ReA), is also implicated in septic arthritis in immunocompromised patients. We report here a case of destructive polyarthritis, initially suggestive of septic arthritis, in an immunocompetent patient whose PCR positivity for U. urealyticum DNA in one joint, in conjunction with the disease outcome and histologic findings, led to the diagnosis of destructive ReA.

[Unstable fractures of the distal radius: a new classification]. / Instabilité des fractures de l'extrémité inférieure du radius: classification analytique à visée thérapeuthique.

We have carried out a retrospective study of 100 fractures of the distal radius which were classified according to 3 principal factors, namely the amount of displacement (D), the involvement of the epiphysis (E), and the degree of metaphyseal comminution (M). Each of these 3 groups was further divided into 4 levels of increasing instability. The fractures were assessed 3 months after injury. Most occurred in old patients with low grades in the DEM scale, often in association with osteoporosis and following a simple fall. Metaphyseal comminution and the degree of displacement did not correlate with the degree of osteoporosis. The highest grades of epiphyseal lesions occurred in young patients, and intact epiphyses were seen in the more osteoporotic population. The Kapandji technique, using 3 Kirschner wires, was used in 58 cases, mostly with low grades of DEM, and gave satisfactory results, but in 14% anterior carpal translation was noted. This may lead to anterior instability. External fixation was employed in 32 patients with higher grade fractures. A good anatomical result was usually obtained but the wrists were more stiff. In 7 of these patients fixation of articular fragments by wires was also needed. Reduction and immobilisation in a cast was undertaken in 7 cases with variable results. Double cortical pinning was used in 3 patients and was useful in the highest grades of displacement. We outline a scheme for treatment based on our classification.

[Anatomical and functional results of the external fixation of upper metaphyseal tibial fractures]. / Résultats fonctionnels et anatomiques du traitement par fixation externe des fractures métaphysaires de l'extrémité supérieure de jambe.

PURPOSE OF THE STUDY: This study aimed to evaluate a method for the treatment of upper tibial metaphyseal fractures using an external epiphysodiaphyseal fixation with the double-frame Hoffmann device. MATERIALS AND METHODS: The study included 48 patients (37 men and 11 women) aged 16 to 82 years. The tibial fracture was simple in 15 cases, included a metaphyseal comminution, partial in 3 cases and total in 30. In 13 patients, there was also a simple articular fracture. The fracture was opened in 24 cases (type I in 10, type II in 7 and type III in 7 cases). METHODS: The gap and displacement evaluation between the fragments after reduction was made on postsurgical roentgenograms; its was considered as complete when all fragments were in contact with each other, without frontal or anteroposterior translation above 5 mm. Healing was defined as a complete bone continuity providing a painless load bearing. The patients were clinically and radiologically reexamined with a mean follow-up of 15.45 months (5 to 62 months). RESULTS: After healing, there were 2 cases of angular deformities in patients whose autonomy was otherwise already reduced. Twenty-three patients had a minor pin tract infection. There was 3 cases of secondary osteitis after a type-III open fractures and 3 other deep septic complications without functional consequences. Forty-one fractures healed without bone graft in a mean time of 18 +/- 7.6 weeks. Healing did not seem to statistically depend on the opening nor on the type of fracture, but rather on the association with a peroneal fracture and the loss of cohesion between the fragments. The duration of professional invalidity evaluated in 20 cases, varied between 4 to 21 months (means: 11.3 months), and none of the patients had to modify his activity because of the tibial fracture. At follow-up, no patient complained of invalidating pain. Thirty-two patients recovered a satisfactory knee joint mobility and among the 16 others, in only 3 no particular reason was found to explain the deficit. DISCUSSION: While good anatomic and functional results lead us to keep the principle of external fixation, it seems however necessary to modify the modalities of the treatment in order to improve healing conditions, especially by improving the cohesion of the fragments through secondary minimal internal fixation. The use of dynamic axial fixation devices could therefore bring a theoretical advantage, but it must be proven that they produce in this site a primary stabilization which is a good as that obtained with Hoffmann's device.

[Experimental study of the stabilization capability of upper metaphyseal tibial fractures by different types of external fixators]. / Mesure expérimentale de la capacité de stabilisation des fractures metaphysiares supérieures de jambe par différents types de fixations externes.

PURPOSE OF THE STUDY: The major problem in external fixation of upper metaphyseal tibial fractures with a double-frame Hoffmann device is poor healing. With a dynamic fixation, it would be possible, with no change in technique, to compress the fracture site in a second phase, and therefore to facilitate the healing process. However, a new fixation device should not compromise the primary stability of the fixation. The aim of this experimental study on cadavers was to compare, in conditions very close to a clinical situation, the initial stabilization capability of five types of external fixation. MATERIAL: Five types of external fixators were tested on cadavers specimens: 1. a standard double-frame Hoffmann device; 2. a double-frame Hoffmann's device sagittaly reinforced with two additional anterior-posterior half-pins; 3. a type-1 axial dynamic fixation device using 6-mm conical pins; 4.a type-2 dynamic axial fixation device with 5-mm cylindrical pins; and 5. a mixed device including an lizarov-type epiphyseal fixation and a monoplane diaphyseal fixation. METHODS: The metaphyseal fracture was simulated by a transversal resection of a 20-mm segment. Specimens received by increments a load of up to 310 N, with which it was possible to determine stiffness components in valgus/varus, flexion/extension, rotation around the vertical axis and axial vertical displacement. The bone mineral content of the specimens was measured by Di Energy X-ray Absorptiometry. RESULTS: The stabilization characteristics of type-1 axial dynamic fixation were identical to those of the standard Hofmann's device in flexion/extension and in rotation as well as axially, but a greater mobility in valgus/varus was observed. The sagittal reinforcement of Hoffmann's device increased its rigidity in flexion/extension. The mixed lizarov fixation was stiffer than the standard Hoffmann's device in rotation; it was equivalent in valgus/varus and flexion/extension and less stiff in axial vertical displacement. In this study it was showed that the individual variability of bone mineral content is a negligible parameter. DISCUSSION: The experimental behaviour of the mixed Ilizarov device gives to assume that it may facilitate the healing process without endangering the primary stability of the fixation. However, this theoretical advantage should be validated in a randomized prospective clinical study.