[Treatment of proximal humeral fractures by Telegraph nail: prospective study of 34 cases]. / Traitement des fractures de l'extrémité proximale de l'humérus par clou Télégraph: étude prospective de 34 cas.

PURPOSE OF THE STUDY: Many developments have been devoted to improving osteosynthesis of proximal humeral fractures, but indications remain controversial. Anterograde nailing using a locked self-stabilizing nail is an attractive conception which has provided promising results. The purpose of this study was to assess the early results observed in a series of patients treated with a first-intention Telegraph nail. MATERIAL AND METHOD: Thirty-four patients were reviewed for a prospective clinical and radiological assessment. Mean follow-up was 13.6 months (range 3-34 months). Mean age at the time of the accident was 68 years (20-90 years). There were 24 women and 10 men: the left shoulder was fractured in 22 patients. All fractures healed within 1 to 4 months. Groups for statistical analysis were determined by type of fracture using the Neer and Duparc classifications. Qualitative functional analysis used the Constant score in comparison with the opposite side. Anatomic analysis of fracture reduction after healing was based on plain x-rays (ap view in neutral rotation) by measuring the angle of inclination of the head in relation to the diaphyseal axis (alphaF). Normal was 45 degrees; reduction was considered adequate for an alphaF angle between 30 degrees and 60 degrees. The lateral view was used to search for posterior or anterior tilt of the humeral head. RESULTS: Necrosis of the humeral head was observed in four shoulders (11.8%). Three of them after displaced joint fractures. These cases were retained for the analysis. Considering all patients in the study, the raw mean Constant score was 62 points and the age- and sex-weighted score was 82.5%. For two- and three-fragment extra-articular fractures, the mean Constant score was 82.3% (21 shoulders); it was 89% for simple joint fractures (5 shoulders) and 79% for complex joint fractures (8 shoulders). The differential Constant scores, comparing the healthy side with the operated shoulder, showed a difference of 20 points on average (range 0-43 points). 52.9% of patients reviewed displayed mild deficit, 20.6% moderate deficit, and 26.5% major deficit. The mean alphaF angle was 38 degrees (range 0-80 degrees). Reduction was considered good in 18 shoulders with a mean Constant score of 88.7%. Reduction was considered poor in 16 shoulders with a mean Constant score of 75.6%. Four shoulders exhibited posterior tilt of the humeral head, all associated with healing in a valgus position. DISCUSSION: The Telegraph nail provides reliable fixation for the treatment of extra-articular and simple articular fractures of the proximal humerus. Dislocated fractures are classical indications for arthroplasty, with acceptable results for a only slightly invasive procedure. The risk of osteonecrosis does not necessarily deteriorate shoulder function and secondary revision for insertion of a prosthesis is still possible. The radio-clinical correlations show the importance of reduction quality to obtain a good final clinical result. Among the nine cases of poor outcome, six were related to a misaligned callus with persistent valgus deviation of the head (alpha F<30 degrees ) and in some cases, excessive posterior tilt. The solidity and stability achieved with the Telegraph nail enabled healing in all cases of fracture in this series with immediate postoperative reduction in most. The stability being related to the quality of bone stock, primary arthroplasty remains an important indication when it appears that a solid osteosynthesis cannot be achieved.

[A rare cause of cauda equina syndrome: primary epidural lymphoma]. / Une cause rare de syndrome de la queue de cheval: Le lymphome epidural primitif.

INTRODUCTION: Primary epidural lymphoma is generally manifested by isolated epidural involvement. On rare occasions it can lead to cauda equina syndrome. CASE: A 56-year-old man was hospitalized for lumbago, weakness in the legs and sphincter problems. A dorsolumbar MRI revealed that the anterior and posterior peridural space from D11 to L3 was filled by a mass compressing the marrow and compacting the roots. The L2 to L4 laminectomy revealed an extradural tissue leading to the diagnosis of large B-cell lymphoma. Metastatic workup demonstrated unremarkable findings. DISCUSSION: Primary epidural lymphoma accounts for less than 10% of epidural tumours and less than 1% of non-Hodgkin lymphomas. Its clinical manifestations are related to the tumoral process or involvement of medullar vessels. It can be, but rarely is, manifested by cauda equina syndrome. Diagnosis is based on histological analysis of tissue taken during the decompression laminectomy. Prognosis is relatively good.

[Congenital tarsal synostosis]. / Les synostoses congénitales du tarse.

Tarsal coalition results from the fusion of at least two tarsal bones. The clinical and radiological pictures depend on the anatomic location of the coalition. Calcaneonavicular and talonavicular coalitions are the most frequent features which may result in peroneal spastic flat foot; however they are symptomless in most cases. Tarsal coalitions are usually evident on plain X-ray films using appropriate incidences. In selected cases, partial talocalcaneal coalition requires CT scan or MRI. No treatment is needed for asymptomatic conditions. Painful spastic flat foot must be treated conservatively by limiting sport activity as a first step treatment. In case of persistent symptoms, cast with correction of deformities under general anesthaesia is recommended. Surgery is needed only in case of failure of previous treatment, requiring resection of the bony bridge and sometimes triple foot arthrodesis.

[Scaphoid fracture associated with displaced fracture of the distal end of the radius in children. Apropos of a case]. / Fracture du scaphoïde associée à une fracture déplacé de l'extrémité inférieure du radius chez l'enfant. A propos d'un cas.

A child of 13 years, victim of a fall on his wrist at dorsal flexion position; he presented a scaphoid fracture associated with a displaced fracture of the distal end of the radius. The radius fracture was reduced under general anesthesia, by external manoeuvre; the consolidation was obtained after 10 weeks of plaster cast immobilization. The follow-up was of two years, with a good clinical and radiological result in spite of a non union of the Ulnar-styloid. It is important to remember this exceptionnel association in children not to forget the scaphoid fracture.

[Congenital convex talus. Methods and results of a single-stage surgical correction]. / Le pied convexe congénital. Technique et résultats de la correction opératoire en un seul temps.

PURPOSE OF THE STUDY: The aim of this study was to emphasize the anatomical particularities of congenital vertical talus. We propose a one stage operative procedure adapted to the deformities. MATERIALS AND METHODS: A retrospective study of 24 children with congenital vertical talus was conducted. An etiology was observed in 58 per cent of cases and 42 per cent were considered as idiopathic. From a radiological analysis of 39 feet, we precise the anatomical particularities. We used anteroposterior and lateral X-ray and lateral stress views with maximal plantar and dorsal flexion. Most of the lesions were localized in the midtarsal joint. The irreducibility of the talonavicular dislocation is the predominant lesion. It is usually associated with a disorientation of the cubocalcaneal joint. The articular surfaces are disorganized with a dorsal orientation. There is a variable amount of equinus deformity in the hindfoot. However the talocalcaneal divergence angle is nearly normal. The forefoot is most of the times in eversion but sometimes in inversion. PROCEDURE: All children were treated initially by physiotherapy. We recommend operative treatment for them between one to two years old. After a soft tissue release, the talonavicular dislocation and the hind foot equinus deformity is reduced simultaneously. The subtalar joint is respected and not opened. Retracted tendons may be an obstacle to the reduction. They must be lengthened if necessary especially the Achilles tendon, the peronei, the extensors and the tibialis anterior. Reduction is maintained by a K wire transfixing the midtarsal joint. RESULTS: Clinical results were difficult to evaluate. Out of 24 operated feet, a satisfactory outcome had been achieved in 15 feet. All were plantigrad and 18 had a good cosmetically aspect. The only bad result concerned an old case which was not operated by this technique. DISCUSSION AND CONCLUSION: Conservative treatment is usually unsuccessful in congenital vertical talus. Numerous procedures have been advocated for the surgical correction of this deformity. Some authors advised excision of the navicular, full open peritalar release or extraarticular talocalcaneal arthrodesis. These are often extensive procedures and most are performed in two stages. Recently, one stage operative procedure was proposed. It allows a good correction with the respect of the subtalar joint and a lower risk of talus avascular necrosis. Furthermore it is more adapted to the deformity with a less extensive scar and a better respect of the anatomy.

Determination of debrisoquine and metabolites in human urine by gas chromatography-mass spectrometry.

A gas chromatographic-mass spectrometric analysis has been developed for the determination of debrisoquine and its metabolites in the urine of healthy individuals (controls) and patients with chronic renal failure. The sensitive and specific assay comprises selected-ion monitoring of the drug and the metabolites 4-hydroxydebrisoquine and 8-hydroxydebrisoquine using guanoxan as the internal standard. The limit of detection is ca. 0.2 microgram/ml. The clinical study shows that the healthy individuals and patients with chronic renal failure can be divided in two groups of extensive metabolizers and poor metabolizers, respectively. The extensive metabolizers excreted large amounts of 4-hydroxydebrisoquine and minor amounts of 8-hydroxydebrisoquine. The poor metabolizers excreted small amounts of 4-hydroxy metabolite, and no 8-hydroxydebrisoquine was detected in the urine.