Introduction

The action of the radial head in the stability of the elbow is currently admitted. Its conservation is not always possible in complex fractures. The association with a posterolateral dislocation of the elbow leads to a higher risk of instability of the elbow joint and also at a longer term to degenerative changes. Some authors recommend the use of metallic radial head implant, acting as a spacer. The results seems encouraging but should the resection arthroplasty associated with the repair of the medial collateral ligament be abandoned?

Purpose of the study: We have had a growing number of revision total hip arthroplasty (rTHA) which have required femorotomy, either planned preoperatively, or required because of difficult extraction of the cemented implant. Few results have been reported in the literature. The purpose of this work was to evaluate late healing of femoral bone and complications.

Material and methods: For this retrospective analysis, we included 43 patients, mean age 66 years. These patients had a femorotomy during rTHA performed from 1997 to 2008. There were 37 revisions in an aseptic context for isolated femoral loosening (n=26), bipolar loosening (n=4), acetabular loosening (n=4), recurrent dislocation, fracture of the femoral stem, and periprosthetic fracture (n=1 each); there were six revisions in septic conditions. Techniques were: femorotomy (n=22), wide trochanterotomy measuring proximally to distally 12 cm, four cortical cuts and one oblique osteotomy to correct valgus. The reconstruction used locked femoral stems (n=17), cemented stems (n=17) and non-cemented stems (n=10). The osteotomies were closed with cerclage or steel wires.

Results: Bone healing was assessed on the plain x-rays of the hip joint at three, six and twelve months. Among the 43 patients included in this analysis, complete data were available for 37. There were 36 cases of successful healing and one case of nonunion on a wide trochanterotomy. The function outcome was assessed a mean three years.

Discussion: Femorotomy remains a difficult technique, sometimes facilitating stem extraction, but with a high risk of morbidity. The morbidity is difficult to evaluate initially, linked more with time to weight-bearing at two months on average. In this small series we nevertheless found few problems with bone healing, even in septic conditions.

Conclusion: Femorotomy remains a valid option when required. It is a difficult technique but provides reliable results in terms of complete healing three months postoperatively.

Purpose of the study: Although the role of the radial head is clearly established regarding elbow stability, it cannot always be preserved after complex fractures. Association with a posteriolateral dislocation, besides the risk of short-term recurrent dislocation, raises the problem of long-term osteoarthritic degeneration. Certain authors advocate a metal prosthesis which works like a spacer in lieu of the head; their mid-term results have been encouraging, but should complete resection with suture of the medial ligament plane be ruled out definitively?

Material and methods: We reviewed 13 files of patients who had had an initial resection of the radial head after trauma. For seven of these patients, there was an associated dislocation; the medial ligament structures were sutured. All patients were reviewed with mean 13 years follow-up (5–15) and evaluated clinically with the American Shoulder and Elbow Surgeon (ASES) system to establish the Mayo Clinic Elbow Performance (MCEP) score. Osteoarthritis of the ulnar trochlea was analysed on the plain x-rays, completed by an axial view, using the Morrey radiographic classification of 4 stages.

Results: There were not cases of recurrent dislocation. According to the Broberg and Morrey index, 92% of patients had good outcome with total resumption of occupational activities; there was no difference between patients with and without dislocation. All patients developed grade 1 or 2 osteoarthritis, with very good clinical tolerance. All were satisfied with their operation despite efforts to spare joint movements.

Discussion: The studies evaluating the use of radial head prostheses have reported similar findings for functional outcome. Radiographic degeneration of the ulnar trochlea is also comparable. Immediate rehabilitation is necessary to prevent loss of range of motion and warrants surgery to stabilize the joint as wells as possible use of an adapted dynamic orthesis.

Conclusion: Resection of the radial head without prosthetic reconstruction remains a reasonable option when the head cannot be saved. Associated dislocation implies repair of the medical collateral ligament. At long-term, the functional impairment is minimal despite the moderate osteoarthritis; the problematic of implant survival is avoided.

Introduction: Intraoperative femoral fractures occurring in cementless total hip replacement are not frequent. In a series of in 350 consecutive hip replacements 15 cases of fractures were recognized and included for this study.

Materials and Methods: The fractures mainly occured during the femoral preparation rather than during the definitive stem impaction. Accurate reduction and stable internal fixation were considered necessary intraoperatively. Nevertheless in 4 cases the fixation of the stem was converted into a conventional cemented one. Postoperatively the patients were allowed to have an immediat full weight bearing on the operated side in 5 cases.

The remainders (10 patients) had a delayed reloading on the lower limb.

In this study the clinical and radiological results of the fracture group were compared to those of a control group of 15 patients.

Results: One year after surgery the Harris Hip score was no significantly different between the groups.

Postoperative complication rate (deep venous thrombosis, infection, dislocation) were not different between the groups.

There was a significant increase of duration of the stay of the patient in the rehabilitation center (p=0.007) in the fracture group and the patient spend more time with the physiotherapist (p=0.001)as they left the center.

The fracture rate was lower when the patients were operated by a senior surgeon (p=0.021).

Discussion: These results are comparable to those of the literature. Nevertheless intraoperative fractures of the proximal femur occurring in cementless total hip replacement do not jeopardize the clinical final outcome. This study emphasizes the importance of the learning–curve in cementless THR. Additional studies could assess the real costs for the medical care of such fractures.

Introduction: The choice of a procedure for the treatment of hallux rigidus depends on the severity of the disease, patient activity level, and expectations about the surgery. For patients who have severe hallux rigidus, arthrodesis has shown good results. On the opposite the results of joint-preserving procedures are less frequently presented.

Material et Methods: The following study concerns 113 cases of hallux rigidus with a mean age of 58 years. Seventy seven percent of the patients underwent arthrodesis of the first metatarsophalangeal joint, 23 % of them had a joint preserving procedure : phalangeal osteotomy and cheilectomy and were reviewed at an average 69 months postoperatively.

Results: The patients were assessed according to the AOFAS score. In the group, which had an arthrodesis, the results were satisfactory in 85 % of the cases. In the joint preserving technique group, 80% of patients were completely satisfied, 15% were satisfied with reservation, and 5% were dissatisfied. One patient suffered continued metatarsophalangeal joint pain that led to an arthrodesis after 10 years.

Discussion: First metatarsal decompression osteotomy are known for increasing joint range of motion but the risk of complication and patient dissatisfaction is less after phalangeal osteotomy.The clinical results are frequently not correlated with the radiological data.

Conclusion: Cheilectomy is classically proposed with predictable success to treat Grade-1 and 2 and selected Grade-3 cases. Nevertheless, in our experience we proposed as an alternative to a joint preserving procedure always an arthrodesis which functional results seemed more reliable. These results encourage us in being less restrictive in the indication for a joint preserving procedure.

Purpose of the study: The efficacy of metatarsophalangeal joint (MPJ) fusion for the treatment of hallux rigidus has been well defined in the literature. There is however still some debate about the efficacy of conservative treatment, especially concerning the respective role for each of several different techniques.

Material and methods: This study reports the analysis of 113 patients treated for hallux rigidus with minimum one year follow-up. Mean age of this predominantly female population was 58 years. Fusion of the MPJ of the great toe was performed for 77% of patients and conservative treatment for 23%: isolated osteophytectomy (n=5), dorsal cheilectomy and shortening osteotomy of P1 (5 cm on average) with or without dorsal flexion for the others. The clinical outcome was assessed with the Groulier criteria.

Results: Overall outcome was satisfactory in 85% of the patients treated by MPJ fusion; MPJ pain resolved in 92%. There was however late healing or nonunion in 13% with no apparent clinical impact. Conservative treatment successfully relieved pain in 80% of patients who were able to wear ordinary shoes and had improved dorsal flexion of the MPJ.

Conclusion: The results of this study are helpful in determining the appropriate indications for surgery as a function of the clinical and radiological presentation of hallux rigidus.

Purpose of the study: Ankle sprains constitute a serious public health problem with nearly 6000 consultations daily in France. The prognosis is generally good if a precise clinical diagnosis can be established and appropriate treatment undertaken. The purpose of this study was to ascertain the pertinence of the initial physical examination which determines the treatment by correlating it with the results of a high-resolution ultrasound examination.

Material and methods: This prospective study included 23 patients, mean age 30.7 years, who were followed regularly for three months. A total of 154 ultrasound explorations were performed. The initial treatment for these patients who consulted a hospital emergency room for ankle trauma was established on the basis of the Ottawa criteria. The ankles were examined by a senior physician and an ultrasonographic exploration was performed 3.9 days on average after the first consultation in the emergency room. Standard protocols were used for the physical examination and for the ultrasonography.

Results: The initial results confirmed a lesion of the lateral collateral ligament in 91% of cases with an initial tear of the anterior talofibular ligament in half of the cases and a injury to the calcaneofibular ligament in one out of five cases. One quarter of the patients had an isolated lesion. One out of ten presented a lesion of the syndesmosis and one out of three lesions of the fibular tendons. The standard ankle examination performed by the senior physician established correct diagnosis of the precise lesion in 80% of the cases.

Discussion: Lesions of the mid food and of the syndesmosis are diagnosed clinically, ultrasonography is not contributive. The stage of the initial lesion was compared with the stage at three months: in 7 out of 10 cases, the anterior talofibular and the calcaneofibular ligaments had healed correctly. Physical examination is essential but ultrasonography provides certain complementary information at a time when the physical examination can be hindered by the pain and potentially the lesser experience of emergency room examinators.

Conclusion: In light of the evidence provided by this study, it can be confirmed that the initial diagnosis of ankle sprain established in an emergency room setting can be corrected by a physical examination performed by an experienced clinician. At the present time, it is not possible to demonstrate the specific contribution of ultrasonography for the management of ankle sprains. This would require a prospective study over a longer period and should be designed to demonstrate the relationship between injury of the fibular tendons and ankle stability.

Introduction. Knee arthrodesis is a limb salvage procedure considered as an alternative to an amputation in case of severely infected total knee arthroplasties, associated with large damage of the extensor mechanism. The techniques are various and the series in the literature not always homogenous. In this study we assessed the results of knee arthrodesis performed with two monolateral external fixators in two perpendicular planes .

Material and methods . This retrospective series of 19 knee arthrodeses was done in 18 patients, which were 65 years old on average. All patients had severe damage on their extensor mechanism associated with an infection of their implant. In all cases the infection was documented and patients were treated by antibiotics during on average 9 months. The first surgical step consisted in a debridement of the knee which was provisionally fixated with the lateral external fixator. The second step consisted in the removal of the infected implant or of the spacer . The bony surfaces were freshened and the anterior external fixator was applied with a compressive effect on the fusion site . Full weight bearing was allowed 45 days after surgery.

Results. Radiological fusion was observed in 17 cases after 4,6 months on average and the external fixators were removed after 8 months on average. Two patients experienced wound healings problems that required additional plastic surgery. Two cases were revised and bone grafting was performed. One patient suffered from malunion at the last follow up ( 7 years in this study).

Discussion. This type of fixation avoids internal fixation in septic conditions. The transquadricipital pins of the anterior fixator are well tolerated. The rigidity of the combination of two monolateral fixators in two perpendicular planes allows quick reloading , which is essential in old patients, often debilitated by numerous procedures.

Conclusion. Arthrodesis is functionally an acceptable alternative to an amputation in these patients. This technique is reliable, has the advantage of avoiding an internal device in an infected knee, of stabilizing the fusion site thanks to the biplanar fixation and of allowing quick weight bearing,.

Purpose: Osteonecrosis of the metatarsal heads is a source of metatarsalgia usually triggered by local overload. The Gauthier technique, described in 1974 consists in a dorsal flexion osteotomy with cuneiform resection of the necrotic zone. Results reported in the literature have generally been limited to mid-term. We evaluated the long-term outcome.

Material and methods: We conducted a clinical and radiological review of a small homogeneous series of ten patients (nine women and one man) who presented metatarsal head necrosis (generally the third metatarsal) causing mechanical pain. In one patient, the phalangeal surface was degenerative. Eight patients had associated asymptomatic hallux valgus which was left intact. Mean follow-up was 9.5 years (27 months – 19 years).

Results: The metatarsophalangeal joint was pain free in all patients. Mean plantar flexion was 25°, extension was free with no particular limitation. Radiographically, there was no evidence of recurrent osteochondritis nor long-term degeneration. The height of the joint space (measured by comparison with the length of the lateral sesamoid) displayed a gain in all patients postoperatively.

Discussion: The Gauthier intervention has regularly provided good short- and mid-term results with restitution of a good-quality metatarsophalangeal space. There is generally however a marked limitation of dorsal flexion. This small series with long-term follow-up demonstrates that dorsal flexion tends to normalise over time and that recurrent necrosis or osteoarthritic degeneration is not a problem. This result can be explained by the reduction of joint stress due to the shorter anteroposterior effect and the elevation of the metatarsal head. Although our one case of overall joint degeneration did not worsen, this technique is probably of limited value for advanced-stage osteonecrosis since it cannot reconstitute a healthy phalangeal cartilage damaged before the operation. Surgical correction of associated deformities of the first ray should be discussed: among the eight cases of asymptomatic hallux valgus preoperatively, three remained symptom free, five worsened, and two were treated surgically.

Conclusion: The regularly satisfactory early results of the Gauthier osteotomy performed for osteonecrosis of the metatarsal head persist in the long term and improve with time in terms of joint motion, making this method a choice technique.

Purpose: During revision procedures for total knee arthroplasty with reconstruction of the lower femur (TKA after tumour resection) it is difficult to extract the stem from the proximal femur (if noncemented) and spare bone stock. The purpose of this study was to describe and analyse aspects related to the use of a complementary approach for massive trochanterotomy allowing easier access to the centromedullary canal of the femur and thus facilitate extraction of the femoral stem and periprosthetic cement.

Material and methods: This technique was used for five patients between 1991 and 1999. There were four women and one man, aged 18–45 years. The femoral piece was changed in three patients because of a fractured non-loosened implant and in two cases because of loosening. The revision implant was a total reconstruction prosthesis in one case (Link) and a GUEPAR implant in four. Massive trochanterotomy or corticotrochanterotomy was performed in all cases sparing the muscle insertions.

Results: This retrospective analysis was performed at a mean follow-up of five years (3–12). There were no cases of loosening or implant fracture. The trochanteric fragment (or corticotrochanteric fragment) healed normally in all cases. One female patient experienced moderate pain in the sitting position related to the presence of osteosynthesis material in the hip, but no implant removal was necessary.

Conclusion: Complementary trochantotomy facilitated removal of the inferior femoral piece via a direct approach to the summit of the stem allowing direct expulsion with the periprosthetic cement. Direct vertical access to the medullary canal allows good control of the revision prosthesis and limits unnecessary bone loss without creating any particular iatrogenic problem other than longer time for trochanter healing.

Purpose: This prospective study focused on an interhospital collaboration for foot and ankle surgery. Collaboration was organised between the referring surgeon and four regional foot and ankle specialists. We evaluated concordance and discordance between expert opinions.

Material and methods: Patients for whom an opinion was requested were selected by the requesting surgeon based on problems involving diagnosis or therapeutic indications. Opinions were requested by email. Individual protocols were established for the clinical report and x-ray file of each type of condition. The final therapeutic decision was made by the requesting surgeon.

Results: Among the 450 patients seen for foot and ankle disorders, opinions were requested from experts for 30. The conditions involved: the forefoot (46%), the middle foot (16%), the hindfoot (7%) and the ankle (31%). Mean time for the response was eleven days (1–60). Experts responded to all requests (120 responses) but in four cases (3%) could not provide an opinion. The index of diagnostic agreement among the experts was 3.2/4. The index for therapeutic indications showed agreement at 2.6/4. Agreement between the therapy proposed to the patient and that proposed by the experts was 2.6/3.

Discussion: We analysed the advantages for the patient, the responsibility of the requesting and responding surgeon, and the problems related to remuneration of this type of counselling. Compared with other technologies, email was found to be simple, reliable, and low-cost with good quality images. This work showed that there was concordance between the opinions and that electronic expertise counselling is certainly very useful for foot disorders. Requests addressed to several experts increases precision and provides complementary information for difficult cases. It is important that the different participants know each other.

Conclusion: This work is the first step towards the development of a care network for foot and ankle disease enabling graduated patient management.

Purpose: Treating fractures of the femur in patients with a total hip arthroplasty is a difficult task. The frequency of these fractures is estimated at 1% to 3%. The purpose of this work was to evaluate the long-term clinical and radiological outcome and to search, by type of fracture, for factors predictive of late complications in order to improve indications.

Material and methods: Since 1985, we collected data on 29 patients (17 women and 12 men) mean age 73.3 years who had a fracture of the femur after total hip arthroplasty. By definition, intraoperative fractures were excluded. Two independent operators noted epidemiological, therapeutic and imaging data and classed the fractures using the Vancouver classification. Treatments used were noted and clinical and radiological outcomes at mean follow-up of 24 months (6–140) were analysed.

Results: Falls were the cause of the fractures in 31 patients (84%). Six of these patients had a revision prosthesis. Five fractures were in a zone of unprotected weakness. The fractures were trochanteric (n=9), periprosthetic (n=18), or below the stem (n=2). Nine patients were treated by isolated osteosynthesis and eleven by replacing the prosthesis. The Beals score was used to assess outcome taking into account the stability and the quality of the implant fixation as well as fracture realignment. In patients whose fracture was around the stem, outcome was excellent in two, good in one, and poor in four. For fractures of the lesser trochanter (n=4), outcome was excellent in two and good in two. For fractures below the stem (n=2), outcome was good in both. There was one case of deep infection.

Discussion: Considering the same types of fractures, orthopaedic treatments produced poor results (6/11), unlike prosthesis replacement (2/11) and osteosynthesis (1/9). The number of loosenings was underestimated, leading to failure of orthopaedic treatment.

Conclusion: In the event of fracture of the proximal femur in patients with a total hip arthroplasty, any suspected loosening, particularly of a cemented stem, should lead to prosthesis revision rather than orthopaedic treatment or simple osteosynthesis.

Aims: The literature usually reports in fusion of the þrst metatarsophalangeal joint different rates of union that varies with the type of device which is used for the internal þxation. Methods: Between 1988 et 1998, 110 patients had an arthrodesis of the metatarsophalangeal joint of the great toe. Two third of them had a removal of the cartilage on both side of the joint and a þxation with a proximodistal screw and a Kwire. One other third of the patient had a joint resection between two parallel saw cuts with a similar þxation as in the þrst group. Results: At time of follow-up on average 6 years after surgery radiological union was obtained in 78% of the cases in the þrst group and in 97% of the cases in the second group between 2 and 6 months postoperatively. These rates are signiþcantly different. Conclusions: Arthrodesis in these groups were performed for similar conditions: severe hallux valgus, arthritis, recurrence after bunion surgery, rhumatoid arthritis. The different rate of radiological malunion could be attributed to the better stability in the two parallel- saw cuts freshening. When the anatomic characteristics of the forefoot allow it, we recommend the articular resection between two parallel saw cuts in metatarsophalangeal fusion on the þrst ray.

Aims: The results of arthrodesis of the þrst metatarso-phalangeal joint as salvage procedures after failure in bunion surgery are well documented in the medical literature. Usually, the results may be equivalent to those of primary arthrodeses. On the other hand, joint conserving methods in case of recurrence have not the same reputation in respect to arthrodesis which appears as the gold standard

Methods: We reviewed 27 patients (28 feet) with a mean follow-up of 6.5 years (range: 1–18 years) after treatment for recurrence after bunion surgery. The patients were submitted to a joint conserving procedure on grounds of absence of degenerative condition on the metatarsophalangeal joint. The procedure corrected point by point all the characteristics of the deformity: lateral release, mobilisation of the joint, tightening of the medial capsule and osteotomies on the þrst ray.

Results: Preoperatively valgus of the great toe was on average of 38.9û. At time of follow-up (6.5 years on average) after revisional procedure, valgus of the great toe was on average 21.3û. Postoperatively 23 out of 27 patients were satisþed. The result was considered as good in 20 cases, fair in one, and poor in 7 cases.

Conclusions: In spite of technical difþculties, these results can equal those of primary bunion procedure, if all the morphological disorders are corrected. Conservative methods may be rational when the joint remains ßexible with no pain and when the morphological particularities on the forefoot are sufþciently indisputable so that their correction could cure the patient

Purpose: Lateral hypoaesthesia of the knee following peroperative section of an infrapatellar sensorial branch during anteromedial access for knee surgery is a well-known phenomenon. Development of a painful neurinoma at this level is much more exceptional but can be the cause of persistent pain, often becoming violent in the anteromedial region of the proximal tibia which may often evoke the diagnosis of mechanical failure of the prosthesis due to superficial conflict or loosening. There is relatively little in the French orthopaedic literature on this topic. We wanted to draw attention to this often missed diagnosis.

Material and methods: We report the cases of three patients with degenerative knee disease who underwent total knee arthroplasty using a posterior stablised prosthesis implanted via an anteromedial approach. Persistent pain which developed over more than six months led these patients to consult. Several surgeons evoked a “classical” cause of postoperative pain resulting from postoperative loosening but the x-ray and scintigraphy findings were inconclusive. Physical examination demonstrated dysaesthesia in the lateral infra-pateller region with a positive Tinel sign on the anteromedial aspect of the knee immediately below the tibial implant suggestive of a neurinoma of the infrapatellar branch of the saphenous nerve. An anatomic study conducted on ten knees enabled us to identify the anatomic bases necessary to achieve local anaesthesic blocks providing the pretherapeutic diagnosis. The diagnostic tests were performed with injection of 5 ml xylocaine in the subcutaneous tissue over the medial aspect of the knee upstream from the suspected neurinoma. Complete resolution of pain evaluated 10 minutes after injection led to proposing neurotomy of the infra-patellar nerve via a separate medial incision.

Results: Denervation provided immediate relief in three patients. For two, the pain and dysaesthesia regressed completely. Substantial improvement in hyperaesthesia was noted in one patient.

Discussion: The anatomic studies demonstrated that one or more branches of the infra-patellar nerve cross the mid line from the apex of the patella to the anterior tibial tuberosity in 98% of the cases. In ongoing work during revision procedures for total knee arthroplasty, we have noted hypoaesthesia or anaesthesia in the infra-patellar nerve territory in 15% of the patients. Dell reported a series of 70 patients with postoperative neurinomas of the knee and obtained 86% good results after denervation.

Conclusion: Hyperalgic iatrogenic neurinoma of an infra-patellar branch of the saphenous nerve is a certain but rare cause of pain after knee surgery, generally for prosthesis. Misdiagnosis of a mechanical complication is not uncommon. The clinically suggested diagnosis is easy to confirm by a subcutaneous local anaesthesia test. Neurotomy of the infra-patellar nerve can be proposed after failure of drug and physical treatments.

Purpose: In reports of arthrodesis of the metatarso-phalangeal joint of the great toe, differences in fusion rates have generally been determined as a function of the osteosynthe-sis material used. We studied the incidence of the type of avivement used in a group of patients fused with the same material.

Material and methods: We reviewed at six years 110 patients who underwent metatarso-phalangeal arthrodesis between 1988 and 1999. Two-thirds of the patients (77 patients) had had a simple avivement with osteosynthesis with a proximo-distal axial screw and pin. The same osteosynthesis was also performed in 33 patients who had joint resection between two parallel saw lines. Bone healing was studied on the loaded AP views.

Results: Fusion was obtained in 78% of the cases in the first group (simple avivement) and in 97% of the second within two to six months. The difference was significant, favouring parallel saw lines.

Discussion: The patients in the two groups had comparable indications for arthrodesis: advanced hallux valgus, osteoarthritis, recurrent hallux valgus after surgical treatment, inflammation. Non-fusion of metatarso-phalangeal arthrodesis of the great toe is usually well tolerated. The difference in the rate of non-fusion could be related to better stability obtained between the two parallel saw lines and to potentially more extensive vascular injury with conventional manual or motorised avivement.

Conclusion: If compatible with the anatomic characteristics of the foot, we recommend avivement by joint resection between two parallel saw lines for metatarso-phalangeal arthrodesis.