Tri-calcium phosphate ceramics and allografts as bone substitutes for spinal fusion in idiopathic scoliosis as bone substitutes for spinal fusion in idiopathic scoliosis: comparative clinical results at four years.

The authors present the results of a comparative study of two series of posterolateral arthrodeses for scoliosis performed using COTREL DUBOUSSET instrumentation. Fifty-four consecutive patients underwent surgery for idiopathic scoliosis using the same technique. Thirty received a graft consisting of a mixture of corticocancellous autologous and allogenic bone frozen at -80 degrees, and 24 patients were grafted with a mixture of cortico-cancellous autologous bone and sticks of tricalcium phosphate (TCP, Biosorb, SBM, Lourdes, France). All patients were seen at three, six and twelve months, then once a year for at least four years with clinical and radiological evaluation at each visit. At the final follow up visit, no radiologic signs of pseudoarthrosis were found in either group with a minimum follow-up of 4 years. The appearance of bone callus was considered satisfactory at 6 months in all cases; moreover callus seemed to be more important in the TCP series, although this assessment was subjective. TCP resorption was total after 2 years, while allograft fragments were visible on x-rays after 2 years. Minor mechanical complications occurred but did not influence the results. Loss of correction was 8% of that initially obtained in the allograft group and 2% in the TCP group. Loss of correction did not progress after 6 months in the TCP group and after 2 years in the allograft group. Based upon this experience, the use of synthetic bone substitutes such as TCP would appear to be a valuable alternative to allografts in posterolateral spinal arthrodesis for idiopathic scoliosis, and it would eliminate the risk of viral contamination inherent to allograft implantation. To our knowledge, there have been no previous comparative studies concerning the use of tricalcium phosphate versus allograft in the literature.

Distal rupture of the tendon of biceps brachii. Evaluation by MRI and the results of repair.

We report ten cases of rupture of the distal part of the tendon of biceps brachii in patients aged from 27 to 58 years. MRI allowed assessment of the degree of retraction of the tendon which was related to the integrity of the bicipital expansion. When the retraction exceeded 8 cm the expansion was always ruptured. When there was doubt, or in longstanding injury, MRI allowed the lesions to be defined. Surgical repair was by reinsertion on the radial tuberosity at one or two fixation points in eight patients and reinsertion on the anterior brachial muscle in one. The other patient refused surgery. The MRI findings were confirmed at operation. Use of fixation points allowed minimal intervention, thereby reducing the risk of damaging the radial nerve. One year after operation, dynamometric evaluation of the strength of flexion and supination confirmed that the best results were obtained by reinsertion to the radial tuberosity.

[Acromio-clavicular joint cyst. Surgical treatment]. / Kyste de l'articulation acromio-claviculaire. Traitement chirurgical.

A chronic cyst of the acromioclavicular joint was treated in 3 patients who were followed up for an average period of 26 months. All three were over 60 years old and presented with a massive rupture of the rotator cuff with a subnormal range of passive motion; active motion was variably affected and was painful. The patients underwent resection of one cm of the lateral end of the clavicle, together with resection of the cyst and synovectomy of the upper part of the pathologic humero-acromial joint; the coraco-acromial ligament was left in place. With a mean follow-up of 26 months, the 3 patients have significant pain relief and no cyst has recurred. The authors propose a mechanism to explain the persistence of the cysts in patients with massive rotator cuff tear: elevation of the arm brings the humeral head upwards and forces synovial fluid into the acromioclavicular joint through a perforation in the frayed capsule; this communication is later obstructed by synovial fringes which prevent drainage of the fluid. Excision of the synovium cures the problem.

[Results of a series of deltoid flaps for the treatment of massive rotator cuff tears with an average follow-up of 3.5 years]. / Résultats d'une série de lambeaux deltoïdiens pour rupture massive de la coiffe des rotateurs avec 3.5 ans de recul moyen.

PURPOSE OF THE STUDY: We report a series of 14 patients with a massive rotator cuff tear operated on with a deltoid flap according to Augereau's technique. The aim of this study was to evaluate the benefits of this technique using Constant's scoring system. The follow up is 40 months. MATERIAL AND METHOD: 14 patients, mean age 59 years, with a total rotator cuff tear type III according to Gerber's classification were included. There was 13 total ruptures of the supra and infra spinatus tendon and one infraspinatus and subscapularis lesion. All the patients had shoulder pain, and the preoperative, Constant's score was 24.1/100. The diagnosis of the rotator cuff rupture was confirmed by X-rays, arthrography and ultra-sonography. 8 patients had a Magnetic Resonance Imaging (MRI) evaluation. The surgical procedure was the technique described by Augereau, and three patients had a resection of the distal clavicle. One patient had a small piece of dacron to reinforce the suture of a very thin deltoid flap. All the patients had a immobilization in abduction and the rehabilitation programm began immediately. RESULTS: Results on pain were good: +11.4 points according to Constant's score, but improvement strength (+0.7 point) or motion (+1 point) was not significative. Postoperative Constant's score was 46.9, ponderated score increased from 29.5 per cent to 57.5 per cent. Ten patients were very satisfied, 2 were satisfied and two were disappointed. One of them neaded shoulder arthrodesis; the other needed a new surgery to remove the piece of dacron, and was allayed with NSAI drugs. External rotation was slightly increased: +2 point. DISCUSSION: These results are similar to others series on pain relief, but the results are poor on strength restauration and on shoulder motion. This technique is a heavy surgical procedure and results are not better than arthroscopic sub acromial decompression for massive rotator cuff tear.

Traumatic tear of the rotator interval.

We studied 10 patients with capsular tear of the glenohumeral joint in the rotator interval -- the triangular space separating the supraspinatus and subscapular tendons. The patients, manual laborers and athletic people, had no previous shoulder pain. Tears appeared after forced internal rotation caused by trauma. The pain was anterior and radiated distally. Pain was absent at rest but recurred immediately after activity was resumed. On examination, range of motion was normal. Hawkins' impingement sign and the palm-up test usually caused pain. Radiographic findings were normal. Arthrography showed leakage of contrast medium into the subscapularis fossa. The tear was not visualized with ultrasonography or magnetic resonance imaging. Eight patients underwent an operation consisting of minimal acromioplasty with coracoacromial ligament resection, coracoidplasty, and suture of the rotator interval. All patients had relief of pain and return of full function.

[Deep muscular lipoma of the shoulder. Apropos of 4 cases]. / Lipomes musculaires profonds de l'épaule. A propos de 4 cas.

PURPOSE OF THE STUDY: The authors report 4 cases of inter and intra-muscular lipoma of the shoulder and make a review of the diagnosis of this localization. MATERIAL AND METHODS: All 4 cases had shoulder pain and some limitation of shoulder motion, one had hypoesthesia on the lateral side of the arm. 3 had magnetic resonance imaging (MRI) and two ultrasonography examination, three of them had a surgical resection and for one surgery was considered too aggressive and had a MRI control one year later. RESULTS: There was no problem for the surgical procedure and the histology confirmed the diagnosis. The last patient had a rehabilitation program and the MRI control showed lesion stability. DISCUSSION: Lipoma are rare, X-rays, ultra-sonography and CT scans are not sufficient, MRI is the best exploration to differentiate lipoma and lipo-sarcoma, but the main problem is for low grade sarcoma. Histology is the only way to make the diagnosis with the whole tumor.

Epicondylitis after treatment with fluoroquinolone antibiotics.

We report two cases of epicondylitis of the elbow occurring after treatment with fluoroquinolone antibiotics. Both patients had intense pain which appeared very shortly after the first dose of the drug and was not relieved by conservative treatment. Ultrasonography revealed extensive inflammatory lesions with pseudonecrotic areas. MRI confirmed the lesions and also showed a subclinical abnormality of the adjoining tendons. The persistent nature of the pain was the indication for surgical release of the extensor mechanism. After operation pain disappeared completely and the patients were able to return to their normal activities. Lesions of the tendo Achillis are a well-known side-effect of treatment with fluoroquinolone. Our two cases show that such lesions may occur elsewhere. They also indicate the need for caution when prescribing these antibiotics to patients at risk of tendon lesions, such as top-level sportsmen or patients on dialysis or steroid treatment.

Influence of porosity on the mechanical resistance of hydroxyapatite ceramics under compressive stress.

Calcium phosphate ceramics are biocompatible and may develop interactions with human living bone tissues. They are used clinically on the surface of orthopaedic implants to improve primary fixation or in the form of porous blocks. Their brittleness is often advanced as a limitation of their common clinical use. In order to study the influence of porosity on the mechanical strength of calcium phosphate ceramics, we have tested 150 cylindrical hydroxyapatite samples with open porosity. The total porous volume of the ceramics has been varied from 20% to 60% and the pore size from 5 microns to 400 microns. The result indicates that not only total porosity but also pore size can influence compressive strength, which is in good agreement with theoretical work. After mathematical treatment of the results, the experiments have been modelled in the form of a polynomial equation which can be used to predict and optimize mechanical strength. Moreover, this work supports the fact that compressive strength of controlled open porosity implants can be comparable with that of cancellous or cortical human bone, and suggests that porosity should be fitted to clinical application.

A study of the fasciocutaneous vascularisation of the arm. Surgical applications.

The data on the fasciocutaneous vascularisation of the medial aspect of the arm are incomplete in the literature. This study presents the methodology and results of an anatomic study on 19 upper limbs with arterial injection. The vascularisation of the upper part of this region is provided in 68% of cases by the superficial fasciocutaneous branch (SFCB) of the superior ulnar collateral artery (SUC), that of the middle and lower part by 3-4 fasciocutaneous pedicles originating from the SUC which are prolonged distally by the recurrent posterior ulnar artery. The SFCB has important relations with the ulnar nerve; it travels dorsal to the nerve in 64% of cases and then allows the raising of a distally-pedicled ulnar flap with a 3:1 ratio. In other anatomic configurations, a flap with retrograde flow supplied by the inferior pedicles of the SUC can always be raised. Its ratio is then 2:1. this flap allows coverage of all cases of posterior or anterior losses of substance at the elbow. These results supplement the data required for the raising of a distally-pedicled medial brachial flap, but also of a proximally-pedicled superior medial brachial flap and of a free superior medial brachial flap transposed by microsurgical means.

[Epicondylitis induced by fluoroquinolones in athletes. Apropos of 2 cases]. / Epicondylites induites par les fluoroquinolones chez le sportif. A propos de 2 cas.

Epicondylitis occurred in two leisure athletes who were taking fluoroquinolones. No similar cases have been reported in the literature. In both cases, pain occurred early after initiating drug therapy. Pain was intense and was not controlled by usual care. Echography demonstrated major inflammatory lesions with pseudo-necrosis. Magnetic resonance imaging confirmed the lesions and gave evidence of infraclinical lesions of the adjacent tendons. Surgical disinsertion of the epicondyles with biopsy was indicated due to the persistent pain. Histological examination revealed unspecific lesions of hyalin degeneration and a few giant cells in one case. Pain disappeared after surgery and the patients were able to return to their work, but neither was able to continue his sports activity. Lesions of the Achilles tendon have been observed in patients taking fluoroquinolone and the two cases reported here confirm the possibility of other localizations. Care must therefore be taken when prescribing these antibiotics in patients at risk (dialysis patients, those on corticosteroids, high-performance athletes).

Isolated avulsion fracture of the lesser tubercle of the humerus in children.

Isolated avulsion fracture of the lesser tuberosity of the humerus has been reported in few instances. We present a case in a 15-year-old boy who was injured 2 years earlier. Clinical, radiological and interoperative findings are presented and discussed.

[Tissue and systemic diffusion of idrocilamide after cutaneous administration]. / Diffusion tissulaire et systémique de l'idrocilamide après application cutanée.

Experimental findings have demonstrated that idrocilamide exhibits antiinflammatory and muscle relaxant properties due at least in part to tissular effects. Percutaneous diffusion of a 10% glycero-alcoholic idrocilamide solution was studied in ten patients scheduled to undergo total knee replacement. Four 200-mg doses of idrocilamide were applied to the suprapatellar area at 12-hour intervals before surgery. Pain was evaluated using a visual analog scale before and after treatment. Surgery was performed 1.75 to 3.5 hours after the last idrocilamide dose. Idrocilamide was assayed using high performance liquid chromatography in tissue, plasma, and joint fluid specimens taken during the surgical procedure. Topical administration of idrocilamide on healthy skin produced significant concentrations of the drug in all the tissue specimens, including subcutaneous fat, muscle, tendon, synovium, and knee capsule. Tissue levels were consistently higher than synovial fluid and plasma levels, indicating that little systemic diffusion occurred. Idrocilamide levels in potential target tissues might influence clinical effects.

[The use of Müller acetabular rings in revision surgery of total hip prosthesis. Apropos of 141 cases with a minimal 5-year follow-up]. / Utilisation des anneaux endocotyloïdiens de Müller dans la chirurgie de révision des prothèses totales de hanche. A propos de 141 cas avec un recul minimum de 5 ans.

211 acetabular reinforcement rings of Müller have been implanted when revising total hip arthroplasties, 141 were followed up for more than 5 years. In 52 per cent of cases, an acetabular reconstruction using bone grafts was associated: in 51 cases, a bank allograft was used, one third of the grafts had only a role of filling. Theses rings remained remarkably stable and there were only 2 lacks of fixation: 1.4 per cent in cases non grafted. They allowed a quick weight bearing while warranting stabilisation and protection of the grafts and recentering the hip. So their use has become systematic in THR revisions except for stage IV acetabular loosenings in which the osteosynthesis of the acetabular transverse fracture can be preferred.

[Intramedullary nailing osteosynthesis with epiphyseal fixation of fractures of the proximal humerus in adults. 1 to 3-year follow-up]. / Ostéosynthèse par broches à prise épiphysaire des fractures de l'extrémité supérieure de l'humérus chez l'adulte. 1 à 3 ans de recul.

The authors used a medullary pinning with epiphyseal fixation in the treatment of superior metaphyseal fractures of the humerus for 41 patients aged 22 to 82 years. There were 28 cases with epiphyseal fractures and 12 with metaphyseal fractures. The follow-up was 1 to 3 years. The pins were introduced through the triceps brachii after perforation of the diaphysis, 1 cm above the ulnar fossa. Results were very good. Strength returned within 8.5 weeks. There was only one case of nonunion of a proximal diaphyseal fracture due to a technical fault (diastasis between fragments). Rehabilitation began immediately, resulting in good elbow motion in 35 cases. The shoulder motion was the same as the healthy side in 36 cases, and inferior to 90 degrees of abduction in only two complex epiphyseal fracture. The proximal humerus was never perforated by the pins. The authors find this new instrumentation to be very effective.

[Metatarsal metastasis. A case treated by exeresis an reconstruction]. / Métastase métatarsienne révélatrice. Un cas traité par exérèse reconstruction.

The authors are reporting a case of an isolated metatarsal metastatic tumour revealing a light-celled kidney "adenocarcinoma". Occurring rarely, metastatic lesions of the foot, of which less than a hundred observations have been reported so far, are mainly side-effects of the uro-genital sphere and digestive cancers. In the present case, the metastatic singleness and the good control of the initial tumour justified the total removal of the first metatarsal which posed the problem of reconstruction. The use of a fibula auto-graft allowing the realisation of a double cuneo-metatarsal and metatarsal-phalangeal arthrodesis joint made it possible to resume weight bearing and walking on the second month and to preserve the functional result on the 21 st.

[2-stage reconstruction in large loss of substance of the thigh using a fasciocutaneous flap and later on massive bone allograft]. / Reconstruction en deux temps d'une large perte de substance de la cuisse par lambeau fascio-cutané puis allogreffe osseuse massive.

The authors are reporting an observation in a 60 years old patient, of a serious gaping after a traumatism of the thigh with a massive loss of skin and muscles on the lateral aspect and a comminuted fracture the femoral diaphysis over 14 cm. There was no major vascular nervous lesion and after some time of paring and monitoring a fascio-cutaneous fore-inner flap of the thigh was realized. In the second stage, after the closing-up, a frozen-kept femoral allo-transplant was fitted and kept in by means of a bolted nailing. 36 months after the traumatism the transplant was assimilated and the patient was able to walk without any stick. The lack of any serious nervous vascular lesion in this particular case led to realize a rarely employed flap which enabled to solve the problem of the loss of the skin and muscles quickly and to realize the reconstruction by means of a massive bone allo-transplant, the only alternative to obtain a functional member.

[The distally based sural fascio-cutaneous flap. A new technic for the coverage of loss of substance of the lower leg]. / Le lambeau cutanéo-aponévrotique sural à base distale. Une arme nouvelle pour la couverture des pertes de substance du tiers inférieur de la jambe.

Prognosis of compound open fractures has been transformed by the use of plastic surgery to cover wounds. However, loss of substance of lower third of leg remains a delicate problem frequently requiring the use of microsurgical techniques by experienced teams. The sural cutaneo-aponeurotic distal base flap, the subject of a detailed anatomical study by the authors, can resolve the problem without affecting muscle capital and at the price of minor esthetic sequelae. Results in two clinical cases confirm reliability of this flap.