[Imaging of complications following hip arthroplasty]. / Imagerie des complications des prothèses totales de hanche.

Acute complications include fractures and prosthesis dislocations. Most chronic complications involve mechanical or septic loosening and aggressive granulomatosis. Greater trochanteric pseudarthrosis, periprosthetic soft tissue ossifications or prosthesis conflict with the psoas muscle can also be responsible for groin pain. Most complications are detected with serial plain radiographs, but additional imaging techniques including CT scan and scintigraphy are sometimes necessary for pretreatment diagnosis. Pain generally indicates a complication but aggressive granulomatosis can be asymptomatic, thus warranting systematic annual plain radiographic control.

Trauma emergency unit: long-term evaluation of a quality assurance programme.

OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme.

[Value of the surgical approach through the patellar tendon for intramedullary nailing of the tibia and the femur]. / Intérêt de la voie transtendineuse sous-rotulienne pour l'enclouage des diaphyses du membre inférieur.

The goal of this study was to propose a new approach of the upper tibia for intramedullary nailing. Since two years, the authors performed a transversal skin incision superior to the distal end of the patella. The patellar tendon is dissociated and the tibia is perforated through the anterior intercondylar area. The advantages of this approach versus classical techniques are discussed. This approach allows isolated tibial or femoral nailing but also both nailings during the same procedure.

[Reflections on recent ruptures of the diaphragm. Apropos of 45 cases]. / Réflexions sur les ruptures récentes du diaphragme. A propos de 45 cas.

Trauma-induced ruptures of the diaphragm are very exceptional but are regularly encountered in trauma surgery units. Closed ruptures occur in 60 to 80% of diaphragm lesions in European series, 9 times out of 10 after traffic accidents. Large American trauma centers however, have had more experience with stab of firearm wounds. The diagnosis raises many problems and requires further exploration after the standard chest x-ray. We discuss the different explorations which can be contributive in both emergency and non-emergency situations. The most appropriate therapeutic approach is also discussed. Should thoracotomy or laparotomy be used? What precautions are required prior to surgery? Can laparoscopy be useful?

[Treatment of complex fractures of the ankle and their sequellae using trans-plantar intramedullary nailing]. / Traitement des fractures complexes du cou-de-pied et de leurs séquelles par enclouage transplantaire verrouillé.

UNLABELLED: Nine patients were treated for complex tibial pilon and talus fractures or non unions from 1990 to 1997 using intramedullary nails introduced through the calcaneus. All patients were followed until healing. The average follow-up was 14 months. Failure of the procedure was defined by the occurrence of complications or reintervention. We used a modified Seidel nail in 5 cases, a tibial shaft nail in 3 cases, and a special nail in one case. All nails but two were locked. CASES: These arthrodeses were performed for treatment of sequels from open talus fractures. Transplantar nailing was performed between 9 months and 3 years after arthrodesis, because of non union. In two cases fusion was obtained at 3 and 8 months postoperatively. In the third case non union occurred due to instability of fixation (the nail was unlocked). Replacement by an interlocked nail was performed through a proximal tibial approach, and healing was obtained in 6 months. PSEUDARTHROSES: 2 CASES: These two cases presented comminuted tibial pilon and open talus fractures in association with vascular and tendon lesions. They had previously undergone debridement and external fixation. Transplantar nailing was performed 8 and 10 months after trauma using a locked modified Seidel nail. Radiographic fusion was obtained in 5 months. PRIMARY SURGERY: 4 CASES: The first two cases were foot reimplantations after traumatic amputation. Skeletal stabilization was obtained using a transplantar locked tibial nail. Revascularization attempts failed and an amputation was performed on the fourth day in one case. The reimplantation succeeded in the second case. Radiographic fusion was obtained in 2 months. The third case was a distal tibial shaft fracture. The patient was an obese mentally deficient and invalid woman. Bone union was achieved in four months. The last case was a primary arthrodesis for post-trauma necrosis of the talus. Radiographic fusion was observed 45 days after operation. Transplantar locked nailing offers an optimal stabilization for complex ankle fractures. We had two failures not related with the principle of the technique. We think that transplantar nailing is best indicated to obtain tibiotalar or tibiocalcaneal arthrodesis and to treat compound ankle fractures. Another indication could be distal tibial shaft fractures in invalid or mentally deficient patients.

Incidence and preventability of adverse events in the emergency room of an orthopaedic traumatologic surgery unit.

This paper reviews the nature and the frequency of adverse events in the everyday functioning of a French trauma emergency unit, and evaluates the feasibility of their detection by the means of a daily record review. A senior surgeon identified the adverse events by reviewing the complete record with a minimal 6-months follow-up for every patient attending the emergency unit during a 10-week period. To test the reliability of this review, a blind re-review of all records corresponding to the detected adverse events, mixed with an equal number of controls, was carried out by two independent experts. The review of the 2604 records identified 210 medical adverse events, most of them occurring early in the care process. Sixty-seven per cent of the adverse events involved prevention failure, mainly for tetanus but also for thrombosis and rabies. For the other 33% it was possible to determine two situations with a high risk of adverse event: body contusions following a traffic accident and metacarpo-phalangeal thumb sprains. The re-review evaluated the positive predictive value of the initial review to be 97.5% and its negative predictive value to be 96%. It is concluded that the review of the initial record by a single senior is effective in detecting the adverse events. Prevention of two-thirds of them could be possible by the implementation and monitoring of protocols.

Fractures of the radial head and associated elbow injuries in children.

Fractures of the radial head are frequently associated with elbow injuries in children. Thirty-seven patients with this association treated at the Nancy Children's Hospital were analyzed to ascertain the mechanism and the unfavorable factors of prognosis. The mechanism responsible was a valgus strain on the elbow at the moment of impact, associated with forces of compression and distraction. At an average follow-up of 2 years, 76% excellent and good results were obtained. Conservative treatment was always effective in minimally displaced fractures. With surgical reduction by closed intramedullary pinning (CIMP), there were only three failures in severely displaced fractures. With open reduction, results were always poor; 88% patients with fair and poor results had an associated fracture of the olecranon. The unfavorable prognostic factors were the severity of the initial tilting and displacement, the presence of associated elbow injuries, the inadequacy of reduction, and the open reduction procedure.

[Additional supra-malleolar osteotomy]. / L'ostéotomie supramalléolaire d'addition.

This old operation is rarely practiced and it appeared interesting to precise its technique and indications from a short series. In the majority of our cases, a valgus type osteotomy by medial graft addition was performed. One or more prismatic triangular graft are taken from the full thickness of the iliac crest. The respect of the fibula protects the periostal hinge on the other side of the surgical approach; so the graft under pressure will have rapid and constant consolidation. Tibial osteosynthesis is facultative. We can distinguish major indications of that type of osteotomies: supramalleolar malunion, while the fracture of the fibula associated to the tibia is a contra-indication for that operation. The other indications are the distortion of the pilon articular surface and old ligamentous lesions leading to osteoarthritis. In some cases, it is appropriate to realise valgisation of the articular surface, with an overcorrection to harmonise the pressure on articular surfaces; on that condition, an osteotomy of the fibula has to be discussed. The rapid and constant good results obtained with those iliac crest grafts interposed between the two fragments of the tibia contrast with those hazardous results of inlay or onlay grafts, free from all mecanical sollicitations.

[Ascending intramedullary nailing of the femur. Technique. Initial results. Indications]. / L'enclouage centromédullaire ascendant et verrouillé du fémur. Technique. Premiers résultats. Esquisse des indications.

Some fractures of the distal third of the femur are not good indications for the centromedular locked nailing technique where the nail in inserted through the greater trochanter. Indeed, unsatisfactory reduction and stabilization are often obtained. Inversely, when the nail is inserted upwardly from the knee joint after drilling an orifice in the trochlea and the condyles, the mechanical locking is very close to the knee joint and, when the subtrochanter region is reached, the nail automatically aligns the fracture. The implant temporarily used was a centromedular tibial nail rotated by 180 degrees and mechanically locked near the knee under fluoroscopic control near the lesser trochanter. Five trauma cases were treated with this technique. Early results have been encouraging, similar to those obtained for nailing with closed surgery. These results would suggest that upward nailing should be conceived for particular indications: fractures of the supracondyle area, spiral and comminutive fractures of the distal third of the femur, certain fractures of the supra and inter condyle area.

[Osteosynthesis of the odontoid process by a clover-shaped plate]. / L'ostéosynthèse par la plaque en trèfle des fractures de l'apophyse odontoïde.

UNLABELLED: The goal was to design an osteosynthesis material able to stabilize after reduction a fracture of the odontoid process without C1-C2 arthrodesis. MATERIAL AND METHODS: The implant comprises a clover shaped plate which has to be applied on one hand on the anterior face of the dens (one leaf), and on the other hand on the anterior face of C3 (2 leaves are applied with a screw one screw for each leaf). A barrel fastened to the 3 leaves (implanted on the anterior face of the leaves, at their junction) gives way to a vertically oriented screw which will carry out dens fixation. The screw makes the compression possible. Placement through a pre-sterno-mastoid-approach, needs a special plate support and 18/10 Kirchner pins preparing the passage of the screw. RESULTS: This screw-plate designed for dens fractures (especially those with anterior displacement incompatible with a simple screwing) led to bone union in all cases. A C2-C3 subluxation operated on with the same technique was reduced and stabilized: a C2-C3 ankylosis was the consequence of a C2-C3 arthrodesis combined with the osteosynthesis. No complication was observed. DISCUSSION AND CONCLUSION: This technique is the only one able to perform dens osteosynthesis without implying postoperative immobilization. It is a significant advantage in elderly or multitrauma patients. A part from dens fractures, it can also help to manage dislocations, subluxations and serious C2-C3 sprains and even combinations as fractures of the odontoid process with axis pedicles fractures.

[Intra-medullary nailing of radius neck fractures in adult]. / L'embrochage centro-medullaire dans les fractures du col du radius de l'adulte.

Fractures of the neck of the radius (Mason's type IV) are rarely seen in the adult although they are the most frequent in the child. There is no satisfactory treatment at the present time and the authors present 2 cases treated by intramedullary nailing with good results. This technique was described by Metaizeau and al for the child.The first case was a woman 46 years old presenting a dislocation of the left elbow with a radial neck fracture Mason's type IV. The angulation between the radial head and the diaphysis was 55°. The dislocation was spontaneously reduced and an intramedullary nailing was performed on the radial neck fracture. Six months later the mobility of the elbow was normal except 10° loss of extension. The X-rays showed a radial head with no evidence of necrosis, and no residual angulation.The second case is a 25-year-old man with a Mason's type IV radial neck fracture. The angulation was 50°. At 6 months of follow up the elbow still had 15° loss of extension. The X-rays appearances were the same that for the first case.The procedure is detailed. The entry point is at the distal metaphysis. A kirschner wire is curved at its extremity and pushed into the medullary canal. The radial head is pinned by the sharp curved extremity of the wire. A rotating motion of the wire allows reduction and fixation of the fracture.The authors experience and the 6 cases presented by Keller shows that intramedullary nailing seems a good solution for fixation of the radial neck fractures.

[Peritrochanteric fractures treated with a lamina-plate with stay]. / Fractures péri-trochantériennes ostéosynthésées par Lame-plaque à étai.

60 peritrochanteric fractures treated with a lamina-plate with stay were studied. Their socio-professional caracteristics were similar to the whole sample. The functionnal results and the Duke's score were lower than the other osteosyntheses methods, despite a low number of complications. These results could be explained by systematic early weight bearing for the patients. This causes pain which is not well endured by patients included in this study. These patients, in good general and intellectual health, are able to bear, and prefer, prolonged decubitus (without pain). But while early weight bearing is not a priority for this population, it remainds fundamental for the patients with low intellectual function, who most frequently present with this type of fracture.

[Inter-trochleo-bicondylar fracture of the femur. An unusually traumatic lesion. Mechanism. Therapeutic implications]. / La fracture inter-trochléo-bicondylienne du fémur. Une lésion traumatique exceptionnelle. Mécanisme. Implications thérapeutiques.

UNLABELLED: The authors present a curious type of fracture of the distal end of the femur. They discuss the mechanism and the factors responsible for that lesion. The treatment and results are finally presented. MATERIAL: A 65 years old female, submitted to a crash accident while driving a car, with a seat in maximaly low position. She presented a bilateral open transverse fracture of the patella associated in the right limb to a fracture line between condyles and the patellar surface of the femur. METHOD: Bilateral osteosynthesis of both patella had been realised in emergency through a transverse approach. Through the fractured right patella two anteroposterior screws had been used to fix the fractured femur. RESULT: A plaster cst had been used for three weeks. Full weight bearing was permitted after three months. Full range of motion of both knees was noticed after six months follow-up. DISCUSSION: The femoral fracture could have been fixed by another device like D.C.S. platescreen but it would be weaker. That type of fracture was produced because of flexed low position of the knee at the moment of the accident. Usually, supra-condylar femoral fractures are due to a force vector applied on the upper extremity of the tibia without any patellar fracture. In our case, the patella involved associated to a fracture line between the condyles and the patellar surface. The structural anatomy (noeud sutural de Chevrier) explains the solidarity of the two femoral condyles.

[Pure dislocations of the tibio-talar joint. Apropos of 9 cases]. / Les luxations tibio-tarsiennes pures. A propose de 9 cas.

PURPOSE OF THE STUDY: The authors relate nine cases of pure traumatic dislocation of the tibio talar joint and propose to evaluate the clinical and radiological results at a long term follow-up (mean 12 years). MATERIAL AND METHODS: The series included 9 patients (7 men and 2 women) the average age was 33,2 years. The injury was a road traffic accident in 5 cases. Pure dislocation variety of the ankle joint was medial and posteromedial in 6 cases. Open skin injury was found in 7 cases. The mean follow-up was 12 years (5-19 years). 6 patients were reviewed by the same surgeon, 6 patients were examined clinically and with ankle X-rays. All patients except one were treated by reduction, immobilization with a plaster cast for 6 to 8 weeks. The joint was examined radiographically to detect the presence of tibio talar diastasis and degenerative arthritis. RESULTS: At term we had two very good results and 3 good results (no pain or pain occasionally). We have found in 5 cases a degenerative arthritis to the ankle joint (joint narrowing <50 per cent in 3 cases, > to 50 per cent in 2 cases). No joint instability was noted at revision. DISCUSSION: Pure traumatic dislocation of the tibio talar joint is a rare injury. Medial and posteromedial variety are not frequent. Immediate gravity is dominated by vascular and septic complications and long term result by degenerative arthritis. CONCLUSION: The authors think that closed dislocations need orthopedic treatment (closed reduction and immobilization with a plaster cast for 6 weeks), on the other hand, open dislocation need surgical treatment (reduction, ligamentous reconstruction and immobilization in a plaster cast for 6 weeks).

Introduction.

The number of femoral fractures after hip arthroplasty has increased proportionally to the number of hip arthroplasties. Eleven university-orthopaedic centers in eastern France co-operated to review 250 femoral fractures in relation to hip prothesis. This is the largest published review. The aims of this retrospective study were: - an epidemiologic study of the predisposing factors of these fractures, - to define a protocol of therapeutic indications.

[Materiel and method]. / Matériel et méthode.

This retrospective, multicentre study has collected 250 cases of fractures of the femur following arthroplasty of the hip and covers a 20 year period from the 25/01/73 to the 30/05/93 (51 peroperative fractures and 199 fractures at some time after arthroplasty). There were 157 women and 93 men whose average age was 73 years for the 199 post operative fractures. The average period between arthroplasty and the fracture is 5 years. A common questionnaire was used by all the centres involved in this study in order to codify conditions of surgery, pre and post fracture X ray examinations and the different treatments and their complications.

Conclusions.

The main objectives of this retrospective multicentric study were to define the predisposing factors and methods of treatment. The common predisposing factor is the femoral fragilization due to loss of "bone stock" (secondary to osteopathies or tumor, or especially prosthetic loosening). More specific factors are iatrogenic. For intraoperative fractures we found reoperation, excessive mobilisation of the femur and excessive diaphyseal reaming. For postoperative fractures we found coticotomy and screw hole distal from the tip of the stem, or a gap between another implant wich induced a gradient of elasticity. The therapeutic indications follow the Johansson classification:Type I fractures: If the stability of the prothesis is good: - with a transverse fracture line: functional treatment (off-loading for 45 to 60 days), - with a spiral fracture line: internal fixation using a rigid plate or cerclage wire. If prosthesis loose:- revision arthroplasty with a long stem prothesis is the ideal, - if the general status is too poor, orthopaedic treatment is indicated.Type II fractures: If good stability of the prothesis: internal fixation using a rigid plate. Bone grafting is not necessary. If prosthesis loose: revision arthroplasty with long stem prothesisType III fractures: Altought the ideal seems revision arthroplasty using long stem prothesis, we think that internal fixation by plate with perfect operative technique is indicated for these old and vulnerable patients. Considering the therapeutic indications we suggest a modification of the Johansson's classification:Type I fracture: - Ia: stability of the prothesis, - Ib: loosening prothesis.Type II fracture: - IIa: stability of the prothesis, - IIb: loosening prothesis.Type III fracture: - IIIa: proximal fracture, - IIIb : distal fracture.

[Massive osteolysis : two cases displaying extreme clinical aspects]. / L'ostéolyse massive idiopathique : les aspects extrêmes de deux observations.

We have come across two cases of massive osteolysis showing completely opposite clinical aspects. The first case is a young man aged 28 showing osteolysis of the distal third of the right ulna. His disease was discovered after performing X-rays for minor trauma of the right forearm. He had never complained of his arm before and he only displayed a loss of 45° in pronation. We noted that osteolysis could already be seen on X-ray at plaster removal after 45 days of immobilisation, although the osteolysis was not noticed on the first X-rays.The second case concerns a 17-year-old man who was known to have a massive osteolysis of the pelvis ring and who had used a wheel-chair from the age of 8. While hospitalized for a severe infection of the testicles and scrotum, he developped a recurrent chylothorax that required surgical pleurodesis. This young man displayed no radiological evidence of this disease above the pelvis.A review of the literature allows us to clarify the still obscure pathogenic aspects of massive osteolysis, its classification, the different forms that may be encountered and the keys to diagnosis. The authors caution against aggressive treatment in certain areas where the disease remains benign.

[The role of posterior bracket plate osteosynthesis in the treatment of compression-extension fractures of the distal end of the radius]. / La place de l'ostéosynthèse à la plaque console postérieure dans le traitement des fractures de l'extrémité inférieure du radius, par compression-extension.

Osteosynthesis without immobilisation of compression-extension fractures by means of a posterior plate was studied in prospective series with a minimum follow-up of six months (first group: 73 patients) and a minimum follow-up of one year (second group: 63 patients). The clinical results were evaluated and showed several complications (no infection, but reflex sympathetic dystrophy, paresthesia, unsightly scars). The clinical and radiological findings (radio-ulnar index) could improve with several technical devices, now used.