[Soft tissue metastatic tumors of the fingers. Six cases]. / Tumeurs métastatiques des parties molles des doigts. A propos de six cas.

Soft tissue metastases of the fingers are rare. The authors report six new cases. The clinical presentation is variable and can cause difficulty in diagnosis. The bad prognosis of these lesions is emphasized.

[Mri and surgical indications in perforating ulcer in diabetic patients]. / IRM et indications chirurgicales, dans le mal performant chez le diabétique.

The authors report a series of thirty-six perforating ulcers of the foot in diabetic patients, evaluated using M.R.I. M.R.I. showed osteomyelitis in 16 cases, cellulitis in 15 cases, osteoarthropathies in 21 cases, tenosynovitis of flexor tendons in 2 cases, oedema in 2 cases and abscess in one case. In 19 cases, M.R.I. was used to improve diagnostic accuracy. The medical treatment made use of thermo-moulded soles allowing for the recovery of walking, with a hole facing the perforating ulcer of the foot. The application of insulin-soaked sponges in the event of clean perforating ulcer of the foot and iodized solution in the event of infected perforating ulcer of the foot promoted healing. The treatment was only conservative, when the lesions were limited to the soft tissues. Surgical treatment was performed in 19 cases due to a global involvement of soft and osteoarticular tissues. In fourteen cases the surgical treatment was limited and was performed through the perforating ulcer. Resection of metatarsal heads or metatarso-phalangeal joints was performed in 10 cases, with resection of surrounding pathologic tissue. The surgical treatment was limited to the soft tissues in 6 cases. In 4 cases, M.R.I. findings resulted into a transmetatarsal amputation because the vascular plexus was of poor quality and infection spread from the perforating ulcer to the dorsal aspect of the foot. In our opinion, dorsal infectious involvement in a perforating ulcer of the foot, is a factor of poor prognosis. A below-knee amputation has been performed in one patient.

[A defective callus of the trapezoid bone diagnosed by 3-dimensional scanner]. / Cal vicieux du trapézoïde diagnostiqué par scanner tridimensionnel.

The authors report a case of a trapezoid fracture which was diagnosed only when it was malunited. This malunion was shown only by 3-dimensional C.T. imaging.

[Fractures of the tarsal scaphoid]. / Fractures du corps du scaphoïde tarsien.

PURPOSE OF THE STUDY: The authors relate a series of 47 cases of tarsal scaphoid fractures, between 1976 and 1992. MATERIAL AND METHODS: These fractures occurred 11 times after a high level fall, 28 times after a motor vehicle accident and 8 times after a direct traumatism. The fracture line was vertical 35 times; horizontal 27 times. An impaction was often associated (32 cases). In 17 observations, a true enucleation occurred as a part of the fracture dislocation. Many periscaphoidal lesional associations were found. 39 fractures were fixed. Radiographs showed 30 consolidations with an anatomical reduction. 37 patients were reviewed with an average follow up of 7 years and 6 months. RESULTS: Results were assessed using Mestagh's scoring system: 7 very good, 15 good, 6 fair and 9 bad. The very good and good results represent 59 per cent. In 37 patients reviewed, the clinical investigation showed 8 deformities of valgus flat foot, a varus foot, requiring 11 times orthopedic soles wearing. 11 patients had a lameness. Radiological results showed 11 times a peri-scaphoidal arthrosis, a necrosis and 2 non union. A narrowing of the astragalo-cuneate joint line was found 8 times. DISCUSSION: Various anatomical types don't have the same prognosis. Vertical and horizontal fractures gave 18 times a very good and good result when in 11 reviewed patients with a fracture dislocation, we noticed 7 poor or bad result. An osteosynthesis by screw gives goods results when fragments are large. For compound fracture when a surgical procedure will be insufficient, the conservative treatment, if keeps a sufficient breadth of medial arch, can give a satisfactory result. An immediate astragalo-scaphoïdal arthrodesis can be suggested in front of a multi-fragmentary dislocation fracture. CONCLUSION: The scaphoïdal tarsal fracture is unusual and its diagnosis remains sometimes difficult. The treatment is often surgical by direct approach. In consideration of the pejorative post-operative outcome of fracture dislocations, some authors suggest an immediate astragalo-scapho-cuneate arthrodesis.

[Bipolar dislocation of the first metatarsal bone]. / A propos d'une luxation bipolaire du premier métatarsien.

Simultaneous dislocation of the first cuneometatarsal joint and metatarsophalangeal joint is a rare injury. The case of a 22-year-old man is reported, but no previous cases have been reported in the literature. The treatment by closed reduction and pinning was very classical. Occasionally the reducibility of the metatarsophalangeal joint may be made more difficult by the interposition of a sesamoid bone. The simultaneous dislocation occurred because the injury was very severe. After 2 years, the function and mobility of the toe were normal, but radiographs revealed modifications of the Lisfranc joint.

[Amputation below the elbow made possible by emergency covering of the stump with a free parascapular flap]. / Amputation en dessous du coude autorisée par la couverture en urgence du moignon avec un lambeau libre parascapulaire.

The extent of the damage in a case of complex trauma of the upper limb required amputation. After debridment cleaning, there was not enough soft tissue to cover a stump below the elbow. The joint was saved by amputating below the elbow and covering during the same operation with a free parascapular flap.

[Lisfranc's fracture-dislocations]. / Fractures-luxations de l'interligne de lisfranc.

PURPOSE OF THE STUDY: Classicaly Lisfranc fractures dislocations are unusual. Our study is based on 69 observations from January 1974 to January 1992. MATERIAL AND METHODS: Fractures occured during tremendous impacts with a sex ratio of two men for one woman. The authors insist on the diagnostic value of good quality standard x-rays. Using Trillat's classification, we had 19 homolateral spatular fractures dislocations, 22 homolateral columno-spatular, 8 divergent columnar and 19 divergent columno spatular. A dislocation was reduced in emergency before radiography. The treatment consisted in orthopedic reduction and plaster 7 times, percutaneous kwire 2 times, immediate arthrodesis 5 times, open reduction and internal fixation with kwires 55 times. Post-operatively, 8 complications were noticed. 11 secondary arthrodesis were made with reference to failures of previous methods. They have been performed from 9 months to 5 years after the initial traumatism due to a painful ankylosis in bad position or arthrosis. The arthrodesis was total 6 times, partial lateral 2 times, partial medial 3 times. RESULTS: 63 patients were reviewed with a minimum follow-up evaluation of two years and a maximum of 9 years. The results show that we must reduce the tarsometatarsal fracture dislocations even if the displacement is minimal and we must fix them. The most satisfactory means seem to be open reduction if the least anatomical defect exists. Immediate, total arthrodesis reposition is suitable when an important articular comminution exists. If the total secondary arthrodesis reposition gives good results, its realization is sometimes difficult. The lateral partial arthrodesis must be discontinued, because they don't seem logical. The medial partial arthrodesis didn't prove its superiority, compared with total arthrodesis. DISCUSSION: The reduction of Lisfranc's dislocation is essential. The single case not unreduced has given a bad result as shown in the litterature. When the orthopedic treatment is well-made, the result is good. The open reduction followed by an axial fixation has only given 56 per cent of good results. The main reason of these bad results is an important comminution which should have practised an immediate arthrodesis reposition and a bad reduction. We must be aware on the quality of the anatomical reduction. The secondary arthrosis appeared principally in cases where the reduction was defective (13 observations out of 50). The 5 immediate arthrodesis have all given a good result. CONCLUSION: The retrospective study of the series teaches us to reduce the tarsometatarsal fractures dislocations even if the displacement is minimal and to fix them. We must make a wider place to the immediate arthrodesis reposition.

[Hallux valgus treated by shortening of the first phalanx with trans-epiphyseal impaction and adductor plasty. Apropos of 49 cases with 5-years follow-up]. / Hallux valgus traité par raccourcissement de la première phalange avec réenclavement dia-épiphysaire associé à la plastie de l'adducteur. A propos de 49 cas avec 5 ans de recul.

PURPOSE OF THE STUDY: 49 cases of hallux-valgus were treated by a shortening of the phalanx with impaction according to the technic described by Regnauld, associated with a plasty of the adductor. Patients were evaluated with a follow-up greater than 5 years. MATERIAL AND METHODS: 32 female and 5 male patients were treated. 63 per cent patients were between 30 and 60 years old. The preoperative average of metatarsus varus was 12 degrees 1. The length of first metatarsal was inferior to the second in 30 cases. The preoperative average of first phalange valgus was 30 degrees. Every operated foot had an Egyptian morphotype. Sesamoids were consistently dislocated. Associated lesion were: 19 flat feet, 10 round fore-feet, 9 clinodactylies treated during the same procedure. RESULTS: They were evaluated according 3 Groulier's criteria: the correction of deformation, static disturbances, and professional activities. The phalangeal valgus was corrected in 37 cases (72 per cent). 33 feet were painless (67 per cent). The dorsal flexion of the first toe was superior to 60 degrees in 38 cases (77 per cent). Metatarsus varus was consistently reduced. 2 permanent metatarsalgia and 4 plantar corns persisted. 76 per cent of operated patients were able to wear shoes normally with a normal perimeter of walking. At X-ray examination, the head of first metatarsal was unchanged in all cases. The joint space was normal in 39 cases (79 per cent). The base of first phalanx was normal in 25 cases (51 per cent). 37 feet had centered sesamoïds. In total, we noticed: 37 very good and good results (72 per cent), 8 moderate results (17 per cent), bad results (9 per cent). DISCUSSION: The operative technic gives a stable shortening of the first phalanx without material and allows the early weight bearing. The abductor of the great toe is a stronger muscle than adductor, allows rotational correction and the alignment of the first phalanx on the first metatarsal. We agree with criteria of bad prognosis proposed by Groulier: age, valgus flat foot, the duration and the importance of deformation, the presence of osteoarthritis. CONCLUSION: The abductor plasty and soft tissue operation contributes to the durable correction of hallux valgus. Shortening must preserve the vascularization of the proximal end of the phalangeal. This operation should be reserved for young patients, without signs of articular cartilage degeneration and having an Egyptian foot.

[The Sixtine metatarsophalangeal prosthesis at first glance. Preliminary results in 74 cases]. / La prothèse métatarso-phalangienne Sixtine du premier rayon. Résultats préliminaires, à propos de 74 cas.

The Sixtine prosthesis is a metallic, hemiconical, flat concave, metatarsophalangeal interposition prosthesis, with a rim on the phalangeal end, with a lateral capsular fixation or a temporary fixation by axial pinning. Seventy-four cases using a Sixtine prosthesis were reviewed with a minimum follow-up of 2 years. The range of motion was improved (+12.4 degrees), as was the phalangeal valgus (18.2 degrees for 30.2 degrees), but weight bearing on the ventral side of the first toe was very often lost in spite of the complete preservation of the flexor hallucis brevis. The complication rate was 9.5% with 8% subluxations, which do not influence the final result. The comparison of patients who kept the prosthesis, and of patients in whom the prosthesis was systematically retrieved after one year, shows that the prosthesis may be left in place and that retrieval is only indicated in cases of complications or subluxation.

[Metatarsalgia and modified Helal's operation. Apropos of a series of 40 cases]. / Métatarsalgies et intervention de Helal modifiée. A propos d'une série de quarante cas.

The authors report a series of 40 cases of metatarsalgia operated according to a modified Helal technique. The mid-diaphyseal osteotomy was situated obliquely inferoanteriorly at an angle of 45 degrees on the metatarsal diaphysis. Twenty cases of hallux valgus were operated during the same procedure Surgery allowed a reduction in pain and hyperkeratosis in 67.5% of patients. Comparison of the results obtained with those reported in the literature confirms that the osteotomy must be metaphyseal and that weight bearing must be early and effective.

[Metastatic lesions of soft tissue of the fingers. Apropos of a case treated by excision and immediate reconstruction]. / Lésions métastatiques des parties molles des doigts. A propos d'un cas traité par exérèse et reconstruction immédiate.

Soft tissue metastases of the fingers are rare. The authors report a new case. This case was not treated by an amputation but by a resection and immediate coverage with an homodigital reverse pedicle flap.

[Revision of interlocking rod for loosening of THP. Concept--preliminary results]. / Tige de reprise verrouillée pour descellement de P.T.H. conception--résultats préliminaires.

This revision rod, used temporarily, is interlocked in the distal healthy part of the femur. It is indicated in the treatment of loosening, even with extensive destruction, whether this is done by filling the fragile part of the femur with bone chips and marrow or by reconstruction accomplished by gliding the femoral heads on the rod. The clinical results were observed for 21 replacements, performed between 1987 and 1990, for the following indications: 14 loosenings, of which 10 had major bone defects; 4 fractures, of which 3 received a prosthesis; 2 infected resection prostheses; and one broken porous metal Judet prosthesis. There was one failure due to flare-up of infection in a prosthesis that was initially infected. The complete treatment, with implantation of a standard prosthesis, was only performed in 5 cases. We left the revision rod in place in elderly patients, in major reconstructions, or when the patients refused a new operation. The anatomical results are encouraging. There was good assimilation of the bone grafts, confirmed by histology in cases of revision. There was no rupture or displacement of the material. The functional results were good with respect to pain and range of motion; they were less good with respect to stability, as could be expected in repeatedly operated patients.

[Achromic ungual melanoma. Apropos of a case]. / Mélanome unguéal achromique. A propos d'une observation.

A 55-year-old woman presented with suppurative paronychia that became chronic. In fact, this was an exceptional case of amelanotic subungual melanoma. This case is compared with a general review of subungual melanomas. Diagnosis is often delayed, due to the difficulty caused by the misleading clinical symptoms.

[Respective indications for free and pedicle flaps of the latissimus dorsi in maxillofacial surgery]. / Indications respectives du lambeau libre et pédiculé de latissimus dorsi en chirurgie maxillo-faciale.

Retrospective analysis of 41 cases of transfer of free and pedicle musculocutaneous flaps of latissimus dorsi for selected or obligatory maxillofacial indications resulted in the review and critical assessment of the different modes of utilization of these flaps. Experience acquired, and continuously updated by new scientific data or a new clinical case, justifies the use of this exceptional technic, which should not be extended to include those cases able to be treated by simpler, more reliable methods. Similarly the fact that this muscle can be transferred using a microsurgical technic cannot enlarge its use beyond that motivated by reasoned medical imperatives. Modalities of preparation of the flap are described and its multiple applications demonstrated using several examples: indications for latissimus dorsi flap in maxillofacial surgery and reasons for performance of micro-anastomotic transfer.