[The unstable shoulder in young subjects. Surgical experience]. / L'épaule instable des sujets jeunes. Expérience chirurgicale.

The stability of the scapulo humeral joint depends on three anatomical factors: bony: surface and integrity of the glenoid cavity. ligamentous: joint capsula and labrum glenoïdale. muscular: coordination and condition of the components of the rotator cuff that maintains the humeral head in the center of the joint, whatever be the position of the arm. Clinically, the most frequent aspect is the anterior recurrent dislocation, occurring in young patients.... Other forms are possible: posterior, multi directional, associated with a lesion of the rotator cuff in elderly patients.... Lately a new aspect was described: the painful and unstable shoulder. It is observed in high level sportsmen, who practice throwing sports. The only treatment is surgical. Two kinds of techniques are currently used: preglenoid transfer of the coracoid process, and different kinds-of capsuloplasty. Arthroscopy allows a more precise diagnose, but is not yet a good therapeutic procedure. Surgical treatment avoids recurrence in more than 95% of cases, but clinical osteoarthritis of the gleno humeral joint is observed in about 10% of cases after a long follow up (more than 10 years).

Arterial and lymphatic supply of the knee integuments.

The surgical approach to the anterior knee region carries a risk for postoperative integument infection and skin necrosis. A hypothesis is that surgical approach may damage integumental blood supply and additionally the lymphatic drainage from the foot and leg. The goal of this study was to describe the arteries and lymphatics directly affected by the antero-medial approach. Injection of the femoral a. was used to identify the femoral and popliteal aa. and their branches distributed to the integument of the anterior, medial and lateral aspects of the knee. Lymphatic injection into the plantar aspect of the first toe was also performed to identify the subdermal lymphatics traversing the area. Our results showed that most of the blood supply arises from the medial aspect of the knee integuments. However, subcutaneous arterial anastomoses provide a significant blood-supply when there is interruption of the medial vessels as seen in the medial surgical approach to the knee. Most of the lymphatic drainage originating from the foot crosses the knee region on the medial side, opposite or below the tibial tuberosity. Because the subdermal arterial network is well-developed, the medial approach for knee surgery does not endanger the anterior knee integuments as long as the lateral vascular supply is preserved. However, this approach may interrupt the lymphatic circulation, particularly in the case of an extended incision, which could explain postoperative edema and an increased rate of wound infection.

[Additive medial osteotomy of the tibia locked with a coral callus. First results apropos of 38 operations]. / Ostéotomie tibiale d'addition interne calée par un coin corail. Premiers résultats à propos de 38 interventions.

We inserted a calibrated coral callus to lock addive medial osteotomy of the tibia in 38 patients. We followed these patients for 1 to 6 years evaluating clinical, radiological and histological outcome. Rehabilitation was very insufficient. In our later cases, the porosity of the coral insert was improved, apparently facilitating bone penetration.

[Surgical treatment of the rheumatoid hand]. / Traitement chirurgical de la main rhumatoïde.

In rheumatoid arthritis, involvement of the hand is serious, frequent and occurs early. It reaches synovial sheets, articular or tendinous, and causes painful and invalidating deformities. Our experience, based on 537 operations of the hand, indicates that reconstructive surgery can be practised at all levels. For the wrist, inferior radio ulnar arthrodesis strengthens the articulation and eradicates pain when performed in the early stage. Segmentar resection of ulnar diaphysis ensures the conservation of "prono- supination". In the case of destruction or luxation of the wrist, a choice has to be made between prosthesis and arthrodesis. We tend to prefer the latter which confers a strong, painless and definitive articulation. Ulnar deviation of metacarpo-phalangeal articulations of long fingers can be corrected by ligamentar or tendinous plasties. But the results are not always durable and they cannot be used when the articulations are destroyed. In that case prostheses have to be implanted. Swanson's silastic implants enable to straighten the fingers and to suppress pain but ensure a limited mobility. Likewise, interphalangeal deviations generally call for implants or arthrodeses. Trapezo-metacarpal or phalangeo-metacarpal deformities of the thumb are stabilised by arthrodeses, ensuring a strong and painless prehension. In conclusion, reconstructive surgery allows many possibilities but its results are often incomplete. It is therefore advisable to perform synovectomy as early as possible before the occurrence of deformities. Surgical synovectomy competes with isotopic, chemical or corticoid synoviosthesis. But at tendinous level, synovectomy alone should be used, since it gives excellent results. Even though rehabilitation after synovectomies is not always easy, we hope that it will prevent the occurrence of articular or tendinous destruction for many years.

[Trapezoid-metacarpal arthrodesis]. / L'arthrodèse trapézo-métacarpienne.

There is no ideal surgical indication for rhizoarthrosis of the trapezoid-metacarpal joint. Fusion using two screws or a screw and a pin allow solidification after minimal immobilization for 45 days with the thumb placed in front of the index. A 1 to 21 year follow-up (mean 68 months) of 30 hands showed 23 cases of arthrosis and 7 cases of polyarthritis. Overall results were good in 17 cases, acceptable in 8 and poor in 5. Pain relief was obtained or improved in 90% of the cases. Radiographically, pseudarthrosis was seen in 10%. No reoperations were required. Fusion is an alternative to other surgical approaches allowing pain relief and solid grip without the major problems related to prostheses.

[Biomechanics of the shoulder and its surgical consequences: personal experience operating on 250 shoulders]. / Conception biomécanique de l'épaule et ses conséquences chirurgicales: réflexions à propos d'une expérience personnelle sur 250 épaules opérées.

Functional anatomy induces functional surgery. According to the anatomy of the locomotor apparatus, biomechanics opens the way to a more logical surgery. Two main concepts rule the study of the shoulder: the articular complex; the muscular chain. The articular complex: the scapulo- humeral joint is the main of the motion. The 50% remaining are due to the movements of the scapula around the thorax. The muscular chain: sixteen muscles are concerned in shoulder motion. They are classified in two principal groups: long muscles, fixing the scapula upon the thorax short muscles are disposed in two plans: superficial (deltoïd) deep, called the rotator cuff (subs scapularis; supraspinatus; infra-spinatus; teres minor). They only produce motion of the humerus on the scapula. The lateral elevation of the arm relies on the harmonious contraction of all these muscles. The mechanical environment of the cuff, particularly of the supra spinatus is not a favorable one: poorly vascularised, overworking, it goes through a narrow osteo fibrous tunnel. This produces irritation or rupture of the muscle. The surgery is indicated only in case of medical treatment failure. It has two alternative purposes, either to suppress the anterior conflict between the acromial vault and the cuff, or to repair a rupture of the supra spinatus. The acromioplasty is a benign operation that gives excellent results: 65% recover a normal shoulder. We notice 10 to 15% failures (105 cases. Follow up one to ten years). The surgery of reinsertion of the supra spinatus is a little more difficult and the results are less convincing: 36% good and excellent results; 43% fair; 21% failures (82 cases. Follow up one to fifteen years).

[Characterization of biomechanical behavior of the lumbosacral spine in dogs. Characteristics related to spondylosis and disk degeneration]. / Caractérisation du comportement biomécanique du rachis lombo-sacré chez le chien. Particularités associées à la spondylose et à la dégénérescence discale.

The in vitro and static biomechanical behaviour of vertebrae with spondylosis were compared with that of healthy vertebrae. In the dog, spondylosis predominates in the lombo-sacral spine which was chosen as an animal model for spontaneous spondylosis. Fourteen surgical specimens were take from German shepherd dogs which had been submitted to right and left lateral flexion, saggital flexion and dorsal flexion. Angular displacements were recorded with an analyser of spinal movement. Our results demonstrated diseased vertebrae have more flexibility than healthy vertebrae in the sagittal and frontal planes than but less so for dorsal flexion. In Addition, diseased vertebrae tend to move upward during lateral flexion. Exeresis of ligament and capsular structures has allowed us to demonstrate the importance of these structures in maintaining spine stability in the sagittal plane and in joint coaptation. Exeresis of the facet joints led to the demonstration of the role of these structures in the maintenance of spine stability in the transverse plane in cases of disc degeneration.

The distal ligamentous complex of the scaphoid and the scapho-lunate ligament. An anatomic, histological and biomechanical study.

22 fresh cadaver specimens have been examined to study the anatomy, histology and biomechanical features of the ligaments of the proximal and distal poles of the scaphoid. The biomechanical study was carried out by two methods: an analytical one on an Instron machine, and a global one in situ. The different experiments show the predominant rôle of the distal ligamentous complex of the scaphoid over the scapho-lunate ligament. This contrasts with the generally accepted concept and modifies the management of lateral carpal instability.

[Plexus nerve blocks for postoperative analgesia after orthopedic surgery of the lower limbs]. / Blocs nerveux tronculaires à visée analgésique après chirurgie orthopédique des membres inférieurs.

In our institution, plexus nerves blocks have been performed in seventy patients after lower limb surgery. The technique is considered as simple and reliable. The administration of a 0.375 per cent bupivacaine epinephrine containing solution allows to obtain analgesia longer than 15 hours in 45 p. 100 of the patients, devoided of side effects. Lower limb plexus nerves blocks appear as an efficient technique for postoperative analgesia following orthopaedic surgery.

[Shoulder prosthesis]. / La prothèse totale d'épaule.

In our department, 25 shoulder prostheses were laid in 24 patients. The main indication remains omarthritis with or without necrosis (13). Fifteen Neer's prostheses (13 total, 2 simple humeral ones) were laid. The posterior approach was chosen in 14 cases. Out of the 20 shoulders reviewed, 8 presented with preoperative muscle atrophy, 8 with no postoperative muscle atrophy, including 8 with posterior approaches. In 4 cases of posterior approach, postoperative atrophy of the infraspinatus muscle was noted, but these four patients were all satisfied or very satisfied. The analysis was carried out according to our grading (0 to 20) of Neer's prostheses. The overall results are excellent for simple humeral prostheses on traumatic lesions. In the other cases, the main benefit is obtained for shoulders in a stable state. The improvement remains poor for the mobility and function of the shoulder. The patients are satisfied on a whole, especially with the improvement of pain.

[Surgical debridement of epicondyles. A 10-year follow up of 100 cases]. / Le débridement chirurgical des épicondyliens. 100 cas suivis dix ans.

A single method was used in all cases: debridement of the radial head and exeresis of the apophysis. The statistics presented are derived from 100 elbows operated in 90 patients between 1970 and 1988. Fifty-four (54%) of the patients were men. Thirty-one (31) of the patients regularly took part in sport. Eighty-seven (87) cases were subjected to histopathological examination. Eighty-two (82) showed major signs of insertion tendinitis. With a mean follow-up of 7 years 4 months, the rate of good or very good results was 88% in subjective terms and 85% in objective terms. It was possible to examine 34 elbows on two occasions, 4 and 12 years after the surgery. No long-term self-deterioration or recurrence was observed. Fair or poor results were obtained in cases of malingerers claiming occupational accident, patients who had too quickly recommended physically demanding work, and cases associating other lesions (cervico-brachial neuralgia, epitrochleitis). All of these cases involved dubious indications for surgery. To conclude, this method is obviously intended only for cases in which medical treatment has been unsuccessful (and these are unusual). In nearly 9 out of 10 such cases, the procedure achieves an improvement.

[Surgical treatment of anterior instability of the shoulder using an anteglenoid stop]. / Traitement chirurgical des instabilités antérieures de l'épaule par butée pré-glénoïdienne.

102 instable shoulders (either instable shoulders in athletes or true recurrent dislocation) have been stabilized by a Latarjet-type anteglenoid stop. In 3/4 of cases the patients were young men under 30 years of age, and 3/4 of the patients were athletes, most often of a high level. The diagnosis is based on history taking, as the clinical examination is virtually negative. The radiological assessment is easy: no arthrography, CT or other complex examinations are required. Bernageau's false-profile glenoid view shows lesions of the anterior edge of the glene in 95% of all cases. The operated patients were followed up for 6 months to 20 years (average distance 5 years). No recurrence of dislocation has been noted. Instability was experienced in only one case. Minimal pain is noted in 45% of all cases. A lower sporting performance than before the first dislocation was achieved in 7 cases, ie. about 10%. Normal articular motion is recovered except for outward rotation, which is generally decreased by about fifteen degrees. This perfectly settled, ironed-out procedure certainly is reliable. One point is worth discussing: does the formation of an intraarticular bony stop predispose to later arthrosis? This is what we are attempting to define for the patients we have operated first.

[Elastometric study of the distal scaphoid ligamental complex and the scapho-lunar ligament]. / Etude élastométrique du complexe ligamentaire scaphoïdien distal et du ligament scapho-lunaire.

Six wrists from fresh cadavers have formed the subject of a functional, histological and biomechanical study. This one has been realized by two methods: the one analytical, the other in the whole and in situ. The diverse experiences show up the pre-eminent role of the distal scaphoid ligamentous complex relative to the scapholunar ligament. This fact is in opposition to the generally admitted theories. It modifies the therapeutic approach to lateral carpal instabilities.

[Viability of new valvular homografts. Myth or reality?]. / La viabilité des nouvelles homogreffes valvulaires. Mythe ou réalité?

Use in cardiac surgery of aortic homografts as a valvular substitute is old and was specially developed in France by F. Fontan. In fact, these first allografts were non-viable and the results, in aortic position, were not better than current bioprosthesis. Renewed interest is related to the important notion of "viability" allowed by an immediate procurement (organ donors), preparation in nutrient medium RPMI with low doses of antibiotics and final storage at -196 degrees C (cryopreservation). We have reviewed our initial experience concerning 32 implanted homografts in children either in reconstruction of the right ventricular outflow tract (in many forms of congenital heart disease) or in aortic position. No mortality was observed. The only failure was due to an initial sizing mistake leading to an aortic valve replacement at 13 months. No late deterioration (mean follow-up: 12.5 months) was detected by echocardiography. These results seem to confirm other larger series (as O'Brien's, Brisbane, Australia). Biologic, histological and immunological assessments of "viable" homografts are discussed. The limits of the technique are reported.