Purpose of the study: Basal joint osteoarthritis remains one of the most invalidating degenerative diseases of the upper limb. Most patients are women and the main symptom is pain. Several surgical approaches can be used: total trapeziectomy with or without a ligament reconstruction for intermetacarpal stabilization associated or not with tendon interposition (possibly with a synthetic insert); cemented or non-cemented trapezio-metacarpal prosthesis and arthrodesis. The purpose of this work was to report our experience with the modified Eaton-Littler technique and determine the current contribution of total trapeziectomy – ligament reconstruction – tendon interposition.

Material and methods: We report a series of 26 patients who underwent surgery between 1994 and 2002 for trapezium resection associated with intercarpal ligamentoplasty and «anchovy» interposition using a flexor carpi radialis hemi-tendon. The series involved 21 patients, 16 women and 5 men, with invalidating basal joint osteoarthritis unresponsive to medical treatment. The Dell classification was stage II and III. Mean age was 58.6 years. Five patients underwent surgery on both wrists. One patient had had a prior operation on one side and a Swanson implant on the other. The mean follow-up was 66.1 months (range 25–131 months).

Results: For these 22 cases, outcome at last follow-up was satisfactory with complete resolution of pain, excellent joint mobility with a mean Kapandji score of 9.5/10 (range 8–10). Half of the wrists exhibited deficient pinch and grasp force. Mean postoperative force was 20 kg (range 8–28 kg). Radiographically, scaphometacarpal collapse was nearly complete in all cases. For four cases, outcome was considered poor because of nearly constant pain with reduced mobility and a mean Kapandji score of 5/10. Three patients developed a reflux dystrophy: one of these patients achieved a final satisfactory result. There had been no revisions at last follow-up.

Discussion: All the proposed techniques appear to give good results in terms of pain relief. Trapiezectomy with ligamentoplasty appears to provide good results at mean six months follow-up, results which are reliable and sustained over time. Trapezio-metacarpal prostheses give good immediate results in selected patients but the rate of failure at mid-term remains high, mainly due to loosening. Second generation cemented prostheses are promising. Trapezial implants have specific complications. Trapeiometacarpal arthrodesis gives good stability of the thumb column and is particularly indicated for young active patients with less consideration on the esthetic aspect of their hand, keeping in mind the significant rate of nonunions.

Conclusion: Despite the significant progress achieved with trapeziometacarpal prosthetic arthroplaasty, we still believe that complete resection of the trapezium with ligament reconstruction associated with tendon interposition remains the gold standard in terms of patient satisfaction and reliable results for the surgical treatment of basal joint osteoarthritis.

Purpose: Percutaneous suture of the Achilles tendon is an excellent alternative to open surgery with the known risk of cutaneous and septic complications and also to orthopaedic surgery with the risk of recurrence. We propose our technique of percutaneous suture applied in a series of 76 patients.

Material and methods: Achilles tendon sutures were performed from 1998 to 2002 in 76 patients (17 women), mean age 41 years (22–66). The procedure was conducted under local anaesthesia in the outpatient setting. A resorbable knitted thread mounted on a needle was used to make the two-point frame percutaneous suture. The patients were immobilised for three weeks (average). The Thermann scores, modified by McComis, were determined and the objective Cybex test at 30 and 60/s was used to measure peak torque, power, and maximal power followed by 30 cycles at 120/s to evaluate muscle fatigability.

Results: Mean follow-up was 35 months (10–66). Outcome scores (maximum 100 points) showed excellent or good results in 73 patients and poor results in three. Mean operative time was 15 minutes with no immediate complications. Weight bearing was allowed as early as day 1 (range d1-d20) and patients resumed their occupational activities on day 40 (d8-d100). Sports activities were resumed at six months (4–8 months). Ankle motion was symmetrical and pain free in 73 patients. Calf circumference was 2 cm less than on the contralateral side (0.5-3.0). There were two cases of recurrent tears in patients with poor outcome. Decreased muscle force involving the triceps was never greater than 35% compared with the healthy side (Cybex).

Discussion: The objective Cybex measurements were tightly correlated with the McComis scores. This percutaneous technique does not require removal of the material and is perfectly reproducible in outpatients under local anaesthesia. It is an inexpensive method but remains contraindicated for tears seen late, recurrent tears, or very distal tears.

Conclusion: The very good results obtained in this series suggest we should continue with this low-cost percutaneous method.

Purpose: Progress in medical and surgical management has reduced the incidence of osteitis. Nevertheless, this type of complication remains a difficult therapeutic challenge for frail polyoperted patients exposed to infection for several months. Based on a technique developed by A.C. Masquelet and cooperative work with the infectiology unit, we propose an alternative to eminent amputation.

Material and methods: The series included eighteen surgery patients (fifteen men and three women, mean age 37 years) Mean follow-up was fifteen months. Fourteen patients had undergone one or several operations. Bone loss varied from 5 to 17 cm with shaft loss in ten patients and metaphyseal loss in eight. Fifteen reconstructions involved the lower limb: three femurs, nine tibias and three tarsal bones. Three cases involved the upper limbs: elbow, radius, and radiocarpal bones, one each. Meti-R bacilli were identified in eleven patients. Reconstruction was based on the Masquelet spacer technique to induce membranes in all cases. External fixation was used in sixteen cases and pinning in two. A second operation was performed after normalisation of biological parameters and wound healing.

Results: There were no early complications. Late wound healing required a secondary flap in three patients. There was one graft failure after early reinfection. The spacer was in place for a mean four months. Healing was achieved at six months on the average. A second graft was required in two patients.

Discussion: This series demonstrates the usefulness of this bone reconstruction method irrespective of the soft tissue trophicity and the degree of bone loss. It allows maximal debridement of infected tissue, the only method allowing effective eradication of infection. The close cooperation with the infectiology unit was particularly helpful for the management of the more difficult cases allowing bone grafting beyond usual limits.