Dynamometric measurement of the grasp strength is commonly used in wrist assessment. On the other hand measurement of the pronation-supination (PS) strength has been few studied. The longitudinal forearm rotation needs integrity of the two radioulnar joints and of the antebrachial interosseous membrane. The strength developed during PS assesses also trophicity of pronator and supinator muscles. A PS dynamometer (Baseline ®, AREX) is now available for such measurements. The aims of this study were: 1) to study the best way to neutralize the shoulder movements of abduction-adduction, 2) to find the values of PS Strength in a healthy population, and 3) to study correlations between this PS force and several biometric items.

A first series of measurements des PS strength was performed thanks to the Baseline dynamometer in 8 people, in association with two devices neutralizing the shoulder movements of abduction-adduction, in repeated campaigns allowed the authors to determine and keep the better one for optimal measurements following campaigns.

To assess the normal values of PS Strength in a healthy population, 38 healthy volunteers from both genders and different ages, classified according their age class, from three different forearm position: neutral, from 90 ° of supination and 90 ° of pronation.

Finally, statistical analysis looked for correlations between PS strength and some biometric data.

Manipulations beginning from a neutral position of forearm were the most reliable. The mean strength within the whole studied sample (76 wrists, 17 male, 21 female) was 10.6 N.m (standard deviation SD 3.26) for the supination and 13.9 N.m (standard deviation 4.19) for the supination.

The dominant side exhibited a PS strength superior by 7.5% to that of the non-dominant side. Male gender, the height and weight of the body, forearm circumference displayed positive relationships with PS strength.

Mean values of PS strength, measured from a neutral forearm rotation and with the best device to neutralize the shoulder movements, in a healthy population of 38 volunteers, allowed the authors establishing reference values. They will allow precise comparisons between the values found in patients suffering from forearm and/or wrist pathology and the healthy population, taking into account the age, gender and hand dominance.

In rheumatoid arthritis (RA), non constrained or semi-constrained prostheses can be used. The authors used the Kudo III, IV or V or iBP prostheses 54 times from 1994 to 2003. After initial satisfactory results, they had to change one or both implants for several reasons: humeral stem fracture (5 cases), unipolar humeral loosening (1 case), ulnar loosening without laxity (8 cases), polyethylene wear (11 cases), due to progressive ulnar collateral ligament lengthening and progressive valgus deformity, without or with metallosis, due to contact between Cr-Co humeral component and titanium alloy ulnar component, chronic infection (1 case). When the local conditions were satisfactory (bone stock, ligament balance), the fractured or loosened component was changed. When the conditions were bad (poor bone stock, ligament misbalance, metallosis), both implants were removed; posterior humeral and/or medial or lateral ulnar window were used to removed the uncemented stems still osteointegrated. All the bipolar operations used the Coonrad-Morrey prosthesis, but the last case a Discovery prosthesis. The operative tricks are described, the management of the extensor apparatus is discussed, the clinical outcomes (especially the extensor apparatus function, most often weak) and the radiographic outcomes are presented.

Purpose of the study: This retrospective study evaluated the results, complications and sequelae of 22 free fibular flaps used for bone reconstructions of the limbs assessed at mean 44.4 months.

Material and methods: The tissue loss was the result of trauma in 20 patients and followed cancerology surgery in two. The localisations involved the upper limb in 15 patients and the lower limb in seven. Mean length of bone loss was 11.1 cm. Six injuries required skin cover in addition to the fibular flap. Five patients had had a cement spacer. Fixation methods were: internal fixation (n=14) and external fixation (n=8). Classical vessel anastomosis (one vein, one artery) was used in eight patients and a bridge method (recipient site artery by a fibular artery) in 14 patients.

Results: Bone healing was achieved in 15 patients in 6.7 months on average. Healing was secondary in four patients after corticocancellous grafting. Three flaps failed. Factors significantly associated with favourable healing were: long time from trauma to flap repair, small size of the initial skin opening, first-intention Masquelet, internal fixation, and first-intention cancellous autologous graft. Early postoperative complications of the recipient site included two haematomas and three superficial skin deficiencies. Two graft fractures occurred in one patient and healed after orthopaedic treatment. There were few donor site problems: two early haematomas and two retractions of the flexor hallucis longus. Mean morbidity scores revealed very good results: 1.23/16 with the Point Evaluation System, 93.16/100 for the Karlsson score, and 94.29100 for the Kitaoka score. Globally, the functional assessment of the fibular flap was excellent for three patients, good for eleven, fair for four and poor for one.

Discussion: Our healing rates and durations were not statistically different from earlier reports in the literature. We focused on rigorous preparation in terms of debridement and antibiotic therapy, insertion of a spacer, internal fixation, and complementary first-intention autologous bone graft. In addition, we propose a bridging anastomosis which simplifies the technique and gives the same results as the classical anastomosis methods.

Fasciae represent a very interesting source of thin, well vascularized soft tissue, which allows gliding of the underlying tendons, especially for coverage of particular anatomical zones, such as the dorsal aspect of the hand and fingers. Some fasciae (such as the fascia temporalis free fiap) have already been used in this way as free fiaps for the coverage of the extremities. The aim of this study was to investigate the blood supply of the posterior brachial fascia (PBF), in order to precise the anatomical bases of a new free fascial fiap.

Our study was based on dissections of 18 cadaveric specimens from 10 formalin preserved corpses. Six upper limbs were used to fictively harvest this fiap

The PBF was thin; its surface was broad, easily separable of the overlying subcutaneous and underlying muscular planes in its upper two thirds. It was richly blood supplied by two main pedicles:

the posterior brachial neurocutaneous branch and

The well vascularized area was 115mm long and 54mm broad in average. These two pedicles were quite constant (respectively 17 cases and 14 cases out of the 18 specimens) and of sufficient caliber to allow microsurgical anastomoses in good conditions. A rich venous network, satellite of the arteries, was always present. An arterial by-pass between both arterial pedicles could spare venous sutures when both arterial pedicles are present and communicating within the fascial depth (13 cases out of 18). Harvesting the fiap was easy through a posteromedial approach in a patient in supine position. The donor site could always be closed and its scare was well acceptable.

The first clinical case is presented in a patient suffering from recurrent tendinous adhesions at the dorsum of the hand after a close trauma with extensive hematoma, after failure of 2 previous tenolyses. After a third tenolysis, the free PBF fiap was performed. The fascia was covered with a free skin graft at day 6. The coverage was nice and the outcome of the tenolysis at 6 month was -15/80 (active motion) and +20/100 (passive motion).

The distal interphalangeal (DIP) joints of the fingers are prone to functional impotence in some degenerative diseases. In this case, different surgical techniques can be used, from DIP arthrodesis to joint denervation, much more confidential, which aims to preserve an already reduced mobility.

The four fingers (except the thumb) of 6 fresh hands from different cadavers were dissected under optic magnification. Two DIP joints were harvested from fresh dissected hands, in order to follow with the microscope the course of the nerve branchlets up to their articular entry. These two specimens were decalcified, and then embedded in paraffin. The blocks were serially cut in 5μm slices (1 slice each 250μm), which were observed at 25 and x100 magnification, after Masson’s trichrom staining.

A constant proximal articular branch, arising from the proper digital palmar nerve, was exclusively devoted to joint supply. This branch was located medially and arose in average at 7 mm from its entry point in the joint, where it was accompanied by small arterial branches. Before its entry into the inferomedial part of the DIP joint, it ran under the flexor digitorum profun-dus tendon. It then could divide into 2 or 3 branchlets. The proper digital palmar nerve abandoned, along its course, some nerve fibers to the tendinous synovium and neighboring structures. Then, ending its course, it gave off a distal articular branch, hidden among numerous cutaneous branches for the fingertip. The DIP joint nerve supply seems so under the exclusive dependence of the proper digital palmar nerve without any input from the dorsal side. On the histological slices, the nerves were mainly observed in peri- and intracapsular situation.

Could cutting these two articular nerves be sufficient to relieve pain from the DIP? This is what we are investigating through a clinical series; the first results are presented here.

Introduction: Trapeziometacarpal prosthesis allows to reach faster mobility and usefull thumb than trapeziectomy. But successfull Implantation of the trapezium cup depends on the bone stock and the jig. An anatomical and biomechanical study is presented followed by a prospective clinical evaluation of the impllantation af a screwed trapezium cup to define the best way to reach the center of the trapezium.

Matériel et méthodes: Cadaver study: 11 screwed trapezium implant have been implanted on cadaver (age > 70 yo, alcool conservation). 5 implants with 5 spires and 6 implants with 3 spires have been tested. Extraction tests have been performed after Xray evaluation of the position of the implant. 2 series of test were done in the subgroup of trapezium with 3 spires. Ergonomic and dynamometric jig to implant the trapezium cup has been invented to avoid fracture during implantation.

Clinical study: 58 trapezium cup have been implanted in 6 months with evaluation of the position of the implant in the center of the trapezium.

Résultats: Best bone stock was identified on medial border of trapezium. Only 1/5 trapezium cup with 5 spires was extracted (120N). In the subgroup of trapezium with 3 spires, if only 2 spires were screwed (first serie of test) the extraction load reached 103, 24N (57–133). If 3 spires were screwed (second serie of test) the extraction load reached 89,5 N (45–137). Trapezium was stronger in male than in female No trapezium fracture have been pointed, but slight fissuration of the lateral border were observed in 4 cases after é series of test. The multicenter study allowed to validate the the operative technique of implantation: key point were reported as: optimal view on the borders of the trapezium, implantation of a pin in the center of the trapezium under Xray control and preparation of the bone with approproate jig around the well positionned pin. 2 fractures of the trapezium were observed explained by the implantation of the trapezium cup without help of the Xray control. Each time the surgeon has pinned with no fluoroscopic assistance, the pin was never in the center of the trapezium.

Discussion: The two main complication of trapezio metacarpal prosthesis remain the instability with dislocation and loosening. Such implant is not recommended if trapezium is less than 8 mm. The key point of such procedure remain the implantation of the cup in the trapezium. Bone stock is more important on medial side and implantation of the cup in the center of the bone needs fluorocopic even if the surgeon is an experimented one. 3 spires in the bone of the tested screwed cup remain efficient to reach sufficent extraction load.

Purpose of the study: The latissimus dorsi free flap is widely used for reconstruction of large tissue defects. It is always difficult however to explain the procedure to the patient, particularly the potential sequelae. The purpose of this work was to assess sequelae affecting shoulder function and the esthetic aspect of the harvesting site.

Material and methods: We reviewed 16 patients (17 harvestings) aged 37.8 years on average (range 22–62 years), twelve men and four women, at mean follow-up of 4.5 years. All flaps had been harvested to reconstruct tissue defects of the lower limb. Eleven were semi-emergency procedures, four for chronic defects or reconstruction after tumor resection. We assessed the esthetic aspect of the harvesting zone and shoulder function suing Cybex 6000 (comparative isokinetic tests of the two shoulders). The Dash score was noted.

Results: Functional impairment was minimum in all patients. The Dash score was 17.5%. (compared with the opposite side was: 27% abduction, 22% extension and 10% rotation. Adduction, flexion and external rotation were preserved. The esthetic aspect was acceptable but not negligible. Obesity appeared to accentuate disgraceful scars.

Discussion and conclusion: The latissimus dorsi free flap is often indicated for reconstruction of significant tissue defect. Shoulder function is largely preserved. Patients should be informed about the major scar. The side to be harvested should be discussed with the patient, even in the emergency situation.

Purpose of the study: Appropriate management of chronic sprains of the scapholunate joint remains a subject of debate. Different surgical techniques have been proposed, from partial arthrodesis of the carpus to ligamentoplasty. We opted for scaphocapitatum arthrodesis. The purpose of this report was to assess clinical and radiological outcome.

Material and methods: From 1997 to 2001, 13 arthrodeses (13 patients) were performed for this indication. The procedure involved two screws (n=11), one screw and stapling (n=1), and stapling alone (n=1). A free autologous graft was used in all cases. Mean patient age was 40 years (12 males and one female). These patients were victims of sports accidents (n=8) or occupational accidents (n=5). Mean follow-up was 26 months (range 24–31 months). Variables noted were joint mobility, pain, grasp force and pinch force. Wrist x-rays were used to measure the height of the carpus and the radio-lunate angle.

Results: A 31% loss in the radial inclination was noted as as a 14.5% loss in the ulnar inclination. Dorsal flexion of the wrist declined from 60° to 48°, palmar flexion from 47° to 28°. Stiffness mainly involved the radial inclination and palmar flexion. Grasp and Pinch forces improved (125° on average). All patients excep one presented residual pain. Six patients complained of pain only for efforts and six presented invalidating pain. Only seven patients were able to resume their occupational activity. There were three cases of nonunion which required revision to achieve final bone healing (poor outcome). Carpal height improved (0.47±0.54). The mean radiolunate angle at last follow-up was 11°. DISI persisted in only one wrist.

Discussion: This technique reduced wrist mobility. For all patients, the dorsal approach to the wrist produced inevitable stiffness. Radial inclination declines due to the intracarpal fusion. This arthrodesis enabled restitution of the carpal height and partially corrected for the DISI. This operation did not provide pain relief but did not alter the carpal x-ray. We raise the question of the pertinence of associating this type of arthrodesis with total denervation of the wrist.

Thirty-nine cementless hip replacements using metal-on-metal articulation were consecutively implanted in thirty patients less than fifty years of age and compared with a matched control group of cementless replacements using ceramic-on-polyethylene articulation. The Harris hip score at follow-up (minimum five years) for the metal-on-metal was 94.9 (range, 74–100). After the same follow-up, the results of the ceramic-on-polyethylene were significantly worse: nine osteolyses and seven surgical revisions related to wear. Five-year survival rates were 97% +/− 2% for the ceramic-on-polyethylene and 100% for the metal-on-metal. The metal-on-metal may be recommended to prevent wear problems in younger and more active patients.

The aim of the current study was to assess the results of metal-on-metal articulating components inserted as a primary hip replacement in patients under the age of fifty, comparated with a matched control group using ceramic-on-polyethylene.

Patients and methods

The inclusion of patients was: under fifty years of age and a diagnosis of arthrosis or necrosis of the femoral head.

Femoral stem and cup migration was detected. A variation over five millimeters between the follow-up radiographs was considered as migration.

At the follow-up in 2003, the cobalt concentrations in the whole blood were assessed in the metal-on-metal cohort. The detection limit of cobalt in the whole blood was 0.06 μg/L.

None of the components had migration.

At a mean follow-up of sixty-nine months, the median concentration of cobalt in the whole blood was 0.62μg/L. Only eight patients had cobalt levels greater than 1 μg/L.

Considering a reoperation with the exchange of one of the components as end point, the five year survival rates were 100% for the metal-on-metal group and 97% + 2 for the ceramic-on-polyethylene group. Our study suggests that the metal-on-metal articulation gives a significant improvement in terms of resistance to wear when compared with these conventional bearing components. Our results suggest the metal-on-metal articulation with cementless components can be recommended in the young and active patient to prevent the occurrence of wear and osteolysis. A careful assessment of patients with high levels of whole-blood cobalt should be performed.

Funding: Aucun

Purpose: Arthodesis is the conventional treatment for the rheumatoid wrist. In the event of severe bilateral disease, bilateral arthrodesis can be discussed as an alternative to unilateral arthrodesis an contralateral prosthesis. We wanted to know the functional outcomes after bilateral arthrodesis.

Material and methods: This retrospective analysis involved seven patients (one man and six women), mean age 46 years (28–69) who underwent total bilateral arthrodesis of the wrist for inflammatory joint disease (six rheumatoid, one chronic juvenile arthritis). Mean follow-up was five years. The patients were reviewed clinically and radiographically. We noted goniometric measurements of the upper limbs, the Jebsen hand function test (for activities of daily life), force (wrist and grip), and the Buck-Gramcko-Lohmann evaluation.

Results: On average, the position achieved after arthrodesis was 2° flexion (−5° to +10°) with 6° ulnar inclination (−5° to +20°). Radiological fusion was achieved in all cases. At last follow-up, we noted that three patients had resumed their occupational activities, one had been reclassified as handicapped, and one as disabled. One patient was a housewife and one other woman was retired. The Jebsen hand test showed that our patients could perform 32 of the 49 daily activities (65%). Daily activity was noted excellent in three patients, good in two and fair in two. The Buck-Gramcko-Lohmann score was fair 6.8/10 (2–10) corresponding to good outcome. All patients were satisfied with the outcome.

Discussion: Daily life activities could be performed readily after bilateral arthrodesis of the wrist. Perineal hygiene was possible for five of our patients. The only problems concerned activities requiring force and fine movements, because of the apprehension and the lack of fine dexterity. Poor results could be attributed to metacarpophalangeal deformations and decreased grip force. We observed an 80% reduction in force compared with a representative population of non-operated patients with rheumatoid disease. Bilateral arthrodesis is a valid alternative to bilateral arthroplasty or combined arthrodesis prosthesis implantation. It does not expose the patients to the risk of mechanical arthroplasty.

Purpose: Femoral revision can be difficult when associated with important loss of bone stock and femoral deformation, particularly when the deformation prevents using a long prosthesis despite major loss where it would be useful. We describe a novel technique allowing a simultaneous solution to these two problems and report preliminary results in five patients.

Material and methods: The technique was applied in five patients. Briefly, one or several osteotomies at different levels were performed to correct the deformation in one or more planes, and fixed with a locked femoral implant. Femorotomy was associated in four patients to facilitate removal of prior implants and constituted one of the correction osteotomies. In one patient, non-union of the greater trochanter was treated with a plated autograft. The series included three men and one woman, mean age 72 years (65–83). According to the SOFCOT score, femoral bone loss was grade II in four patients and grade III in one. All femurs had varus deformation (mean 21°, range 16°–40°), and two femurs exhibited permanent flexion (40° and 45°). One shaft osteotomy was used in four patients and two osteotomies in one. The locked femoral implant measured 250 mm in three and 300 mm in two.

Results: Mean follow-up was 3.5 years (0.5–5). One patient committed suicide at six months. The mean Postel Merle d’Aubigné score improved from 9.4 (7–11) to 16.4 (15–18). The trochanter non-union and all osteotomies head at three to four months except one case of shaft non-union which was well tolerated (PMA=16, in a patient without femorotomy who did not require recalibration of the proximal femur). In these healed cases, remodelling and/or spontaneous reconstruction of the femur was observed without grafting for the shaft. There was no stress shielding aspect in the patients with the longest follow-up although they had non-cemented stems with distal locking and no surface treatment.

Conclusion: The technique proposed for this specific indication enables resolution of the double problem of fixation and correction of deformation while allowing spontaneous reconstruction around the non-cemented locked implant. Use of femorotomy is recommended to allow recalibration and stabilisation of the proximal femur around the stem. Longer follow-up is needed to ascertain longevity of the spontaneous reconstruction. Nevertheless, these non-reintegrated implants behave like locked centromedullary nailing.

Purpose: The purpose of this retrospective study was to detail factors influencing outcome of corticocancellous grafts for the treatment of scaphocarpal non-union and to determine ideal indications.

Material and methods: Between 1984 and 1999, this grafting technique was used for 103 patients; we retained for analysis 57 wrists (58 nonunions). Mean follow-up was 106 months. Mean age was 36 years. For 45 patients, non-union occurred because of misdiagnosis. According to the Schernberg classification, eleven nonunions were in zone II, 40 in zone III, and seven in zone IV. Time from fracture to treatment was 35 months on average. The Alno classification of non-union was: stage I=13, stage IIA=20, stage IIA=22, stage IIIA=2, stage IIIB=1. The graft was harvested from the pelvis in 50 cases. Osteosynthesis was associated with a graft in 33 of the 58 cases. Postoperative immobilisation was maintained for 2.7 months on average. Bone healing was achieved within thee months.

Results: Thirty-six patients were very satisfied. Twenty-seven had significant pain on the pelvic harvesting site (50 harvestings). Wrist motion was 56.2° flexion, 56° extension, 83° supination, 83° pronation, and 11° radial and 32.7° ulnar inclination. Thumb opposition was noted 9.4/10 and average contraopposition was 4. Mean index of carpal height was 0.547. The mean radiolunate angle was 4.8°. A DISI deformation was observed for 20 wrists. Thirty-six patients (62%) developed little or no osteoarthritis. The rate of bone healing was 81% but eleven nonunions did not heal, including seven cases of necrosis of the proximal pole. The absence of DISI deformation correction at the time of grafting favoured development of radiocarpal osteoarthritis. The presence of necrosis favoured persistent non-union. Concomitant osteosynthesis did not improve the healing rate.

Discussion: Treatment of scaphoid non-union with a corticocancellous graft remains the choice alternative, providing 81% healing. Grafts consolidation must occur at the radial epiphysis in order to limit painful sequelae. This procedure can be performed for patients with a DISI deformation, but vascularised grafts should be preferred in the event of necrosis of the proximal pole of the scaphoid.

Aims: The goal was to determine if young patients respect the instructions for medical supervision control instructions after a total hip arthroplasty (THA). Methods:We performed 50 THA (Harris cups and ABG I stems) in 39 patients, mean age 38 years ± 11 (15–58). There were thirty-eight 28mm femoral heads (30 zirconia, 8 chromium-cobalt) and 12 chromium-cobalt heads in 22mm. Each patient was told how necessary a regular medical supervision was with the following schedule: controls at 2 months, 1 year then every two years. In 2000, all the patients were evaluated (no lost for follow-up). Wear was measured according to Livermore with a digitizer. Results: At 72 ± 14 months of follow-up (5–9 years), 51% of the patients (20/39) did not come back for the intermediate controls. No factor could be accounted for that, except being a male (p=0.04). Wear was rather severe (average 0.23 mm/year). 37% of the patients with a severe wear (> 0.2 mm/year) did not come back for intermediate controls and were all free of symptoms. There were 3 revisions because of wear (> 2 mm) and 3 others hips are awaiting revision because of wear. Three of these 6 patients did not come back for intermediate examination. The 28mm heads induced more wear than the 22mm heads (p=0.008). No other factor was related to how severe wear was (age, sex, activity or thickness of polyethylene inserts). Moreover the zirconia did not reduce wear. Conclusion: In spite of the recommendations, half of the patients did not respect the medical supervision schedule and that was unpredictable. We recommend a careful follow-up of young patients after a THA in order to detect wear (usually free of symptoms). Moreover our study underlined that the zirconia wasn’t so efficient to prevent wear phenomena.

Aims: Henri Dejour promoted a mechanism involving a third femoral condyle to achieve Posterior Stabilization (PS) in total knee arthroplasty (TKA) introducing the HLS II prosthesis. This retrospective study was conducted to assess the behavior of such PS mechanism. Methods: Between 1992 and 1993, 105 HLS II prostheses (94 patients) were consecutively inserted (78% arthrosis, 19% rheumatoid arthritis). No patient was lost for follow-up but 14 had died, 6 were unable to walk (severe neurological disorder), 4 were contacted by phone. Consequently, 70 patients (77 TKA) mean aged 66 years (22–79) were assessed after a mean follow-up of 7 years (6–8). All the components were fixed with cement and patellar resurfacing was always performed. Results: The knee IKS score increased from de 27 points [0–63] before surgery to 81 [21–100] at follow-up and functional IKS from 35 points [0–75] to 64 [0–100] (p< 0,0001). Similarly range of motion improved from 114° [60°–140°] to 116° [80°–135°] (NS). At follow-up, 86% of the patients were able to practice stairs (13% without support and 28% in alternative manner) against 52% before surgery (1% without support and 1% in alternative manner) (p=0,001). Tibial bone-cement radiolucencies were observed without loosening in 30% (all < 1 mm and non- progressive) mainly related to severe preoperative varus deformation (p = 0.01). One late infection required reoperation. Ninety months survival was 97% ± 1.3% with reoperation related to infection or mechanical disorder as end-point. Conclusion: The posterior stabilization, by means of a third condyle, allowed a satisfactory range of flexion and improved ability to practice stairs. Mid-term follow-up did not identified adverse effects of this PS mechanism on component fixation or knee stability.

Purpose: Reconstruction of long bones with significant loss of bone stock is a major challenge particularly if the gap is greater than 5 cm. Complementary bone resection is often necessary. A conventional cancellous graft may be used when loss of bone substance is not too extensive, but when the defect extends over several centimeters a vascularised bone graft with a microanastomsed fibular graft may be indicated. This technique is widely used for the lower limb but rarely applied for the forearm. The purpose of this work was to examine the modalities and report our experience.

Material and methods: This retrospective study included six microvascularised free fibular grafts performed to reconstruct the forearm bones after massive loss of bone stock. The mean age of the five men and one woman was 34 years. Bone loss (mean 10 cm, range 6 – 18 cm) involved the radius in five cases and the ulna in one. All six patients were victims of crush injuries with open fractures and expulsion of part of the forearm skeleton. Initial treatment included debridement, wound closure, and temporary external fixation. The fibular graft was performed eight weeks (mean) after trauma in five patients and six months after trauma in the sixth patient who also had multiple autologous cancellous grafts which left a nonunion of the ulna and an 18 cm defect. The Meyer method using a saphenous loop was used for vessel anastomosis in five cases. A vascularised fibular bypass was used in one. Osteosynthesis was achieved with screw or plate fixation.

Results: Bone healing was achieved in all patients four to six months after grafting. Mean follow-up was three years (range 1–5). There were no secondary fractures. Mean flexion-extension of the elbow was 100° at last follow-up. Mean pronation-supination was 100°.

Discussion and conclusion: Free fibular transfer enabled reconstruction of the forearm skeleton after massive bone loss. The vascularised graft shortened time to bone healing for these extensive defects with a mechanical quality superior to that obtained with conventional non-vascularised grafts. These vascularised grafts can be indicated for infected nonunion because the vascularised graft favours antibiotic diffusion.

Purpose: Crush injury of the upper limb often causes bone and soft tissue damage leading to a paralytic hand. We report our experience with reactivating wrist and finger flexion using a neurotised latissimus dorsi transfer in patients with volkmann syndromes of the forearm.

Material and methods: Mean patient age was 25 years and mean follow-up was three years. The surgical procedure consisted in a free latissimus dorsi flap with arterial suture onto the ulnar artery and neurotisation using the largest median nerve branch innervating the finger flexors. The muscle was fixed proximally on the medial epicondyle; the distal fibrous lamina was divided for suture to the deep flexor tendons. Mobilisation started 21 days after surgery.

Results: The four-month electromyogram demonstrated reinnervation of the latissimus dorsi. The patient recovered thumb-index opposition with flexion of the long fingers enabling daily life activities. All patients required occupational reclassification but stated they were satisfied with the operation. Flexion of the fingers and wrist was active and was not obtained by tenodesis.

Discussion and conclusion: Volkmann syndrome leaves serious sequelae after crush injury to the forearm. The usual surgical techniques enable reduction of claw fingers by distention but do not, due to muscle necrosis, enable proper function. The free latissimus dorsi transfer method improves trophicity of the forearm and, by neurotisation, enables active hand flexion. Because the nervous pedicle of the flap is short, recovery is rapid, avoiding degeneration of the transferred muscle.

Purpose: Management of extensive tibial loss raises the question of indications for vascularised grafts. These techniques depend on the number of functional vascular trunks available. We developed a modified technique which allows using this type of graft without sacrificing the tibial pedicle, making it usable when only one trunk remains functional. We use the fibular arterial supply to bridge the remaining axis. The purpose of this work was to detail the modalities of this technique and provide early results.

Material and method: Since 2000, we have reserved this technique for infected nonunion with loss of tibial tissue extending over 5 cm in patients who decline amputation. Four patients (four men, mean age 30 years) underwent the procedure. The initial trauma resulted from a motorcycle (n=3) or firearm (n=1) accident. The patients were referred to our unit within three months on the average. Prior treatments (cancellous graft in an open or intrafocal procedure) had failed in all patients who presented persistent infection. Antibiotics were administered until bone healing in all patients. Mean length of the gap was 10 cm (7 – 15 cm). The composite graft (skin and fibula with a vascularised fibular bundle) was raised from the contralateral limb and cross-leg anastomosed proximally and distally on the receiver anterior tibial bundle (all four cases).

Results: All fractures consolidated between six and twelve months after initiating management of this technique. Bone and soft tissue losses healed without shortening. There were not repeated fractures after mean follow-up of twelve months (range eight months to two years). No complementary bone graft was necessary. Infection resolved in all patients.

Discussion and conclusion: As for classical vascularised fibula grafts, this technique enables controlling bone and soft tissue problems together (composite graft). The graft is vascularised favouring antibiotic diffusion. The mechanical quality is better than with a pure cancellous graft but longer follow-up would be required to determine the rate of repeated fractures. This technique broadens indications for vascularised fibula grafts which can be used in unfavourable vascular contexts where only one or two leg trunks persist.

Purpose: The few reports of long-term outcome of Kien-böck disease are helpful in establishing therapeutic indications.

Material and methods: Between 1970 and 1995, radius shortening procedures were performed in 44 patients. Among these 31 patients (eight women and 23 men), mean age 32 years (18–48) at surgery, with 33 operated wrists (18 right, 11 left, 2 bilateral, 19 dominant hands) were reviewed clinically (25 patients by an independent observer, three by their family physician) and radiologically (26 patients) or responded to a phone interview (five patients) at a mean 12 years follow-up (4–19 years). Four patients had died, nine were lost to follow-up. Before surgery the pain was intense (Michon scale): 32 grade I, one grade II. According to Lichtman, there were three grade I, seven grade II, eighteen grade IIIa and five grade IIIb. There was one case of haematoma and one reflex dystrophy, five late consolidations and five nonunions (three diaphyseal out of eight and two metaphyseal out of 25).

Results: The Michon pain score was variable, 11 grade IV, six grade III, nine grade II, but also seven grade I and four secondary arthrodeses. Postoperative amplitudes ere: flexion 50°, extension 53°, abduction 20°, adduction 29°, pronation 83°, supination 74°. Mean amplitudes increased for flexion (+12°), extension (+13°), abduction (+6°), and adduction (+11°), but decreased for pronation (−3°) and supination (−13°). The postoperative wrist fore (Jamar) was 32 kg (80° of other side). Eighteen patients were able to resume an occupational activity, requiring equivalent (14 patients, including 12 manual labourers) or greater (two patients) wrist force. At last follow-up the Lichtman classification was one grade I, four grade II, eight grade III1, three grade IIIb, and seven grade IV. The pre- to postoperative radiography comparison (26 wrists) showed two improvements, seven stabilisations, 14 aggravations, and three arthrodeses. There were also three cases of ulnocarpal impingement (one reoperated). Discussion: the factors predictive of good outcome were minimally advanced disease (Lichtman), little reduction in lunatum height (Stahl), absence of carpal collapse (McMurtry), absence of complication.

Conclusion: Shortening of the radius is an excellent procedure to Lichtman grade IIIa. Results are less satisfactory for grade IIIb but still acceptable compared with resections of the first row or intracarpal arthrodesis. To avoid the risk of ulnocarpal impingement, it would be preferable to reorient the glenoid or shorten the capitatum rather than shorten the radius in patients with a normal radioulnar index.

Purpose of the study: There are few reports onlong-term outcome after Bankart procedure. The purpose of this study was to determine the rate of recurrent dislocation, the clinical results and the incidence of glenohumeral osteoarthritis after a minimum 10-year follow-up.

Material and methods: Ninety-seven Bankart procedures were performed in 97 patients between 1972 and 1986 for treatment of anterior shoulder instability with recurrent dislocations. We retrospectively reviewed 74 patients and obtained 64 complete radioclinical evaluations for an average follow-up of 16 years. Clinical evaluation was based on the G. Walch and the Duplay group score but for easier comparisons, we also calculated the Rowe et al. score. Radiographical evaluation was established on the Samilson and Prieto classification but real glenohumeral osteoarthritis with joint narrowing was noted independently as grade four. We also studied the contralateral shoulder.

Results: At last follow-up, 7 shoulders (9.5%) had recurrent dislocation, but two of them occurred subsequent to severe trauma over 18 months. Most patients (95%) were satisfied or very satisfied. Six patients (8.1%) had persistent apprehension but in some it was not due to anterior apprehension. According to the Duplay score (or the Rowe score), 25 shoulders (44.6%) had an excellent result (35/61.4%) 16 (28.6%) a good result (7/12.3%), 11 (19.7%) a fair result (11.19.3) and 4 (5.4%) a poor result (4/7%). Operated shoulders were pain free for 75% and painful for forced movements only for 25%. External rotation at 90° of abduction was reduced by 8.7 ± 15.7°. There was no limitation of internal rotation. Patients returned to preoperative sports activities at the same level for 70.9% and at a lower level for 12.7%. According to the Samilson classification, 7 (13%) of the shoulders had grade 2 and 2 (3.7%) had grade 3 glenohumeral osteoarthritis. We found 4 cases (7.4%) of real glenohumeral osteoarthritis (grade four) and 2 of these patients had contralateral osteoarthritis of a non unstable shoulder. There was no perioperative complication.

Discussion: In our hands the Bankart procedure is appeared as a safe procedure with a low rate of glenohumeral osteoarthritis and a high rate of patient satisfaction.

Purpose: The synovectomy-reaxation-stabilisation (SRS) procedure classically involves tenosynovectomy of the extensors, articulr synovectomy, partial deinnervation of the wrist, and tendon transfer. The purpose of this study was to: 1) evaluate functional and radiographic results, 2) search for possible correlations between results and the extent of articular synovectomy or type of tendon transfer.

Material and methods: Between 1984 and 1998, an SRS procedure was performed in 75 patients, 14 were excluded: seven had died, five were lost to folow-u and two had had wrist arthrodesis. A total of 73 wrists were analysed in 61 patients. Mean follow-up was 70 months and mean patient age was 53 years. Functional assessment was based on the Gschwend pain scale.

Results: Before surgery, 94% of the patients had grade III or IV pain. At last follow-up, 93% of them grade 0 or I. The gain in pain was greatest for patients with severe carpitis. At last follow-up, the wrist was stiff; stiffness basically involved flexion with 43° pre and 27° postoperatively, radial inclination 13° pre and 9° postoperatively, and pronation in patients with advanced Larsen grade preoperatively. Extension, ulnar inclination, and supination were improved 5° to 10°. Extension of the synovectomy to carpal joints had a stiffening effect. Before the operation, 25 wrists were in Larsen grades 0, 1 and 2 and 48 wrists were in Larsen grades 3 or 4. At last follow-up, there were nine wrists in Larsen grades 0, 1, or 2 and 64 in Larsen grades 3 or 4. Carpitis thus continued to evolve and the height of the carpus declined. Ulnar translation of the carpus progressed a mean 2 mm. Spontaneous radial inclination of the wrist was aggravated by a mean 3°. The frontal position of the wrist was better after transfer of the long radial extensor of the carpus on the short radial extensor of the carpus than for transfer on the ulnar extensor of the carpus or without transfer.

Discussion: Our pain results are in agreement with data in the literature but we did not observe preserved or improved mobility. Extended synovectomy appeared to have a stiffening effect. Progression of the ulnar translation of the carpus was less pronounced with simple resection of the head of the ulna. It was better to transfer the long radial extensor of the carpus on the short radial extensor of the carpus to correct for frontal deviation of the carpus.