Purpose of the study: The purpose of this study was to evaluate and compare the functional and radiographic results of these two surgical techniques using a prospective study.

Material and methods: This study involved two consecutive series of 70 patients with a posterior fracture of the distal radius. Mixed multiple pinning (MMP) consisted in the combination of two styloid pins and two infrafocal dorsal pins. The anterior plate was a locked ITS. The patients decided when it was appropriate to wear a brace postoperatively. Functional assessment used the range of motion, the Quick DASH score, and a self-evaluation of the number of days the brace was worn. Ulnar variance, sagittal and frontal inclination of the radial epiphysis were measured pre- and postoperatively at 45 days.

Results: At mean follow-up of 11.8 months (3–34), the functional outcome was comparable in the two groups but the patients with a plate fixation wore the brace less. Radiographically, there was no loss of final reduction with the plate fixation whereas with the pinning, there was a progressive loss of ulnar variance and less than 2% over-reduction. Major complications (tendon tears, nerve injury) were less frequent with pinning.

Conclusion: Globally, plate fixation enabled more rapid mobilisation of the wrist. Nevertheless this method has its drawbacks (duration of the operation, material availability, cost). In our opinion the mixed multiple pinning method is the treatment of choice for fractures free of major instability or anterior or circumferential comminution.

In this lecture I will present an update on the activities of the European KCK (KidsCancerKinome) consortium. Nine European research centers devoted to molecular-biologic, pharmacologic and clinical studies of childhood cancers and two SMEs are engaged in the KidsCancerKinome consortium. The research centers already have an established collaboration for pre-clinical evaluation of anti-cancer compounds in the European ‘Innovative Therapies for Children with Cancer’ consortium (ITCC).

The KidsCancerKinome consortium aims to perform a comprehensive analysis of the human protein kinase family in childhood tumors, as protein kinases are excellent targets for small inhibitory molecules designed for adult tumors, and many more of such drugs are currently in development. Six aggressive childhood tumors, killing ~2000 children in Europe annually, will be addressed, i.e Ewing sarcoma, osteosarcoma, rhabdomyosarcoma, neuroblastoma, medulloblastoma and ALL.

The KCK consortium has generated gene expression profiles (Affy U133plus2 arrays) of > 500 tumor samples form those six tumortypes. We have performed extensive analyses of mRNa expression of human kinases. Examples of interesting expression patterns of the human kinome will be presented. Detailed analyses for the first 5 kinases for which targetted drugs are available, i.e. PI3K, IGF1R, AURKA+B, and CDK2 will be presented.

Lentiviral shRNA mediated knockdown of kinase protein expression has been used in cell lines to validate those kinases as drug targets.

Many novel kinase inhibitors are under development for adult oncology and KCK will test their in vitro activity against the tumor-driving kinases identified in this program. We are currently testing small molecule inhibitors for the first 5 kinases. For those kinases that have no small molecule inhibitors, a novel generation of siRNA based nucleic acid drugs (LNAs), produced by the Santaris company, will be applied and tested in vitro. Successful small molecule inhibitors and LNAs will be taken further to in vivo validation in established xenograft models of the six childhood tumor types. Pharmaco-kinetic studies of these drugs will finally prepare them.

Purpose of the study: Unlike thoracic and abdominal stab wounds, little has been reported about blade wounds to the forearm. We report a serie of machete wounds to the forearm treated in the Caribbean island Martinique, between 1997 and 2004.

Material and methods: This study included 14 open fractures of the forearm caused by machete wounds. This retrospective analysis was based on the patient files. We studied the mechanism of the fracture, the type and level of the fractures, the associated lesions, the type of treatment given, and complications observed.

Results: Mean follow-up was seven months. Among the 14 patients studied, 14 presented an ulnar fracture, and five a radial fracture. Five patients suffered a complete amputation of the hand. Ten patients (71%) also had associated tendon injuries, all on the ulnar side. Three associated vascular injuries were noted (21%), two on the ulnar side. There were four nerve lesions (29%) involving the ulnar nerve alone (n=2),the ulnar and medial nerves (n=1) or all of the nerve trunks (n=1). The fractures involved the distal third of the forearm in nine patients (64%) and were comminutive for ten (71%). A complete fracture was noted in twelve patients (86%) with a partial fracture in two. Osteosynthesis was performed in all cases. There were nine complications: early infection (n=2, due to late referral), stiff joints (n=6, 43% including tendon retraction in five), nonunion (n=2, one repeated case) and one late healing at one year. Motor and sensorial sequelae were observed at last follow-up in all patients with an initial nervous lesion.

Discussion: The mean follow-up in our patients was short because of the specific context (homelessness, drug addiction). Most of our patients refused medical follow-up. The strong predominance of bony or soft tissue injuries observed on the ulnar side of the forearm corresponds to the mechanism of defense used by the victims. Despite the fact that the wounds were soiled and that the patients failed to comply with medical advice, the rate of early and secondary infection was low. Stiff joints due to tendon retractions and motor deficits were however frequent and compromised the functional outcome.

Conclusion: Fractures of the forearm by machete wounds generally occur in a typical situation of self defense. The characteristic injury to the ulnar side of the forearm results from this mechanism. Tendon and nervous complications are common and cause invalidating sequelae. Secondary infection is exceptional. Prolonged regular follow-up could probably improve the functional outcome of these particular injuries.

Purpose of the study: The major functional impairment which results from femoral head necrosis in patients with sickle-cell anemia leads to implantation of a total hip arthroplasty (THA) in many of these often young patients. Intra- and postoperative complications are frequent.

Material and methods: In order to better understand the causes of these complications, and to search for ways of preventing them, we analyzed the cases of 35 sickle-cell anemia patients with 38 THA. Mean patient age was 36.4 years for these 22 women and 13 men. Twenty-eight patients had SS hemoglobin, five AS hemoglobin, and two presented sickle-cell-thalassemia (S-ß-hemoglobin). Mean follow-up was 7.6 years (range 2–29 years).

Results: Fifteen patients underwent revision surgery (39%) on average 4.8 years after primary implantation for loosening (n=13) or infection (n=2). Five other prostheses presented peripheral lucent lines (13%). The overall complication rate was 64% (shaft fractures, sickle cell crisis, dislocation or loosening, infection). One patient developed an early superficial infection which resolved. One other patient required revision for severe pain and prosthesis misalignment (flexion-external rotation) but with normal cell counts and a simply inflammatory synovial fluid. The presence of slowly progressive degenerative disease in a patient with severe pain should be carefuly identified before undertaking THA. Systematic samples are necessary. The femor-related complications in this series were: two intraoperative shaft fractures, one fracture below the stem during the first six months, and intraoperative shaft reaming in two. Femoral shaft morphological anomales must be identified preoperatively to enable a proper surgical plan. Small-size femoral stems should be available and zones of sclerosis in the canal must be identified. Cup-related complications are more difficult to analyze. The bony structure of the acetabulum was often remodeled, with very weak cancellous bone. Avivement of the acetabulum must be performed prudently manually or with a well controlled motor.

Discussion: Series report few cases in the literature, on average 22 cases (8–36). Mean follow-up was 5.1 years (range 4.6–9.5). The overall rate of complications was 42% (33–59) except for one series with only 2.8%. The rate of deep infection was 14.8% on average (0–36.4).

Conclusion: The decision to implant a THA in these young patients must be made conjointly with the patient. Multidisciplinary management before surgery is essential. Precise planning must take into consideration all the potential pitfalls. Special attention must be given to hemodynamic balance, intra- and postoperative oxygenation and the hemoglobin level.

Purpose of the study: Three-bone arthrodesis, described in 1997, is designed for radiocarpal osteoarthritis with mediocarpal extension. The procedure consists in a capitolunohamate fusion after resection of the scaphoid and the triquetrum. It is associated with carpal shortening proportional to the degree of preoperative wrist stiffness. The objective is to achieve less stiffness than with four-bone fusion.

Material and methods: To verify our hypothesis, the first 24 patients (25 wrists) were reviewed with mean 5.2 years (2–8.5 years) follow-up. All wrists were painful and stiff, and presented radiocarpal and mediocarpal osteoarthritis. There were twelve SLAC III, nine SNAC III and four SCAC III. Mean age was 59 years (range 37–79 years). Mean preoperative range of motion was 50.5° flexion-extension (range 10–105°), mean force was 17 kg (range 10–35 kg). Radiological assessment was performed preoperatively and at last follow-up to determine the Youm index (carpal height) and the Bouman index (carpal translation) and to study the radiolunate joint space.

Results: At last follow-up, all patients had improved but one. Ten wrists were pain free twelve caused some pain at forced wrist movements, and two caused pain daily but at a level below the preoperative level. One patient still suffered from severe pain and required revision for total radiocarpal arthrodesis. The final mean flexion-extension range of motion was 67.8°, for a 13.3° gain in extension and a 3.8° gain in flexion. Ulnar inclination was improved 14° on average. Mean force was 24 kg (73% of healthy side), for a 40% improvement over the pre-operative force. RAdiographically, there was one case of capitolunate nonunion. The radiolunate space remained unchanged. Carpal height decreased 15% on average and the Bouman index increased from 0.90 to 0.93 with no significant ulnar misalignment on the carpus.

Discussion: For pain and force, these results are similar to those achieved with four-bone fusion. The overall results for range of motion are however better for flexion-extension and unlar inclination. In our practice, we have decided to replace the four-bone technique by three-bone fusion because the outcome is a less stiff wrist with a simpler surgical technique. Better results are obtained for stiffer wrists which achieve a significant improvement in motion due to carpal shortening.

Purpose of the study: Analyze failures (recurrent anterior instability) and other complications (pain, stiffness) compromising the overall outcome after arthroscopic anterior shoulder stabilization.

Material and methods: We studied failures and complications in a consecutive inaugural series of 43 patients undergoing an arthroscopic Bankart procedure for chronic anterior shoulder instability. The procedure was performed with knitted resorbable threads on metallic anchors. Outcome was reviewed at mean 26 months (range 6–63 months). There were 19 recurrent dislocations, 12 recurrent subluxations, 4 cases of recurrent subluxation and dislocation and 6 cases of painful unstable shoulder. Mean patient age was 35.6 years (range 19–59 years). Thirty-two patients practiced sports, including 21 who practiced high-risk sports.

Results: One patient, a competition basketball player, presented recurrent traumatic dislocation due to a violent shock after premature resumption of sports activities five months after surgery. There were no recurrent dislocations among the subluxation cases. Pain persisted in three of the six painful unstable shoulders. Sixteen patients presented persistent apprehension but none complained of instability. Nine patients had a positive relocation test. Limited external rotation of less than 30% as observed in five patients and of 30–50% in two. Residual pain was observed in 14 patients (33%) (when carrying a heavy load with the arm hanging along the body, with fatigue, and for forced movements without warm-up in the morning). For four patients, pain occurred in the armed position. Seventeen patients (43%) interrupted their sports activity. The Duplay score showed 13 (30%) fair and poor objective overall results. Subjectively, only seven patients (15%) were only partially satisfied or dissatisfied.

Discussion: Analysis of failures and complications disclosed a discordance between the low rate of failure using the classical definition (recurrent dislocation or subluxation) and the high rate of fair or poor overall outcomes. Residual pain and non-resumption of sports activities appeared to be the major problems. These two factors were analyzed in detail to compare this series with data in the literature. It was found that non-resumption of sports activities is not always related to shoulder instability or apprehension and that pain is often related to associated injury (SLAP, cuff). Conversely, pain associated with a positive relocation test should be considered as a true recurrence, especially in a subject who was unable to resume sports activities.

Purpose: Orthopaedic treatment of Achilles tendon tears was detailed by Rodineau. Equine immobilisation for eight to twelve weeks without weight bearing is necessary. The rate of recurrent tears varies from 10 to 20%. Conventional surgery provides very low re-tear rates but can lead to cutaneous complications in 10 to 20% of cases. In 2001, Moller et al. conducted a prospective comparison between surgical and functional treatment in 112 patients followed for two years. The rates of recurrent tears were 1.7% for surgery versus 20.8% for functional treatment. The percutaneous suture with Tenolig(r) has not totally eliminated these problems and raises a cost issue. The Achillon procedure is presented as a minimally invasive technique which does not appear to be extremely easy to perform. Several other techniques have been proposed using an external fixator (Nada, 1985), subcutaneous arthroscopy (Aldam, 1989), or a transverse miniincision (Thermann, 2001). The oldest truly percutaneous method was published by Ma and Griffith in 1977. In 2001, Lim et al. conducted a prospective comparison between conventional surgery and percutaneous treatment using the Ma and Griffith method on 66 patients reviewed at six months. Average immobilisation was 12.4 weeks. There were seven infections (21%) in the surgery cohort versus three cases of painful nodules (9%) in the percutaneous cohort in addition to one case of sural nerve paraesthesia.

Material and methods: The percutaneous technique we used was derived from the Ma and Griffith technique. The purpose of this percutaneous technique is to obtain rapidly and easily a solid suture which can be achieved under local anaesthesia at little cost. We developed a special needle with an eye which accepts the type of thread desired. Early in our experience, we used a non-resorbable thread (Ethicon(r) N1) but because of painful nodules we changed to a resorbable thread (Vincryl n2) used for a double suture. The suture is performed under local anaesthesia, the patient in the ventral supine position. An equine plaster boot is worn for three weeks followed by a 90° boot with a walking heal for another three weeks during which weight bearing is allowed. From 1999 to 2002, we have used this technique for 43 patients (28 men and 15 women), mean age 51 years.

Results: The only complications were one case of superficial infection, one painful subcutaneous nodule, and one sural thrombophlebitis. There were no cases of recurrent tear or sural neurinoma.

Discussion: The contraindications for this technique are old tears, recurrent tears, and tears too close to the cal-caneal insertion.

Conclusion: This technique is easy to perform and low-cost. The suture is solid allowing rapid recovery without cutaneous complications.

Purpose: Patients with advanced Blount disease present severe metaphyseal varus associated with an oblique medial tibial plateau. Prior to 1987, we used tibial wedge osteotomy to correct the varus deformation and in certain situations also raised the medial plateau with the wedge. From 1987, we performed both procedures during the same operation. The purpose of this work was to describe our technique and evaluate the results of the dual technique.

Material and methods: Between 1987 and 2000, we performed 31 dual procedures. Fifteen patients who had advanced-stage Blount disease were seen late (eight before complete fusion of the growth cartilage and seven as adults). Thirteen children presented recurrent varus deformation after osteotomy during childhood. One patient presented tibia vara during adolescence and three others had poly-epiphyseal dysplasia. Mean age at osteotomy was 17 years (range 10–40). For all patients, the operative technique consisted in lateral closed wedge osteotomy associated with a second access for an oblique osteotomy directed towards the tibial spikes to insert the lateral wedge medially and raise the medial plateau. A mid-third fibular osteotomy was also performed together with stapling for tibial epiphysiodesis superior and lateral when the growth cartilage was still active. We recorded pre- and postoperatively: mechanical femoro-tibial angle, the tibial and femoral mechanical angles to determine intra-osseous deformation, the slope of the medial plateau, and the length of the lower limbs at the end of growth.

Results: Mean follow-up was eight years. Fusion was achieved in all patients. The mechanical femoro-tibial angle was 148.5 (mean) preoperatively giving 31.5° (20–42) varus and 178° postoperatively. The mean femoral mechanical angle was 94°, giving 4° valgus (range 88–102°) preoperatively, with no change postoperatively. The mean mechanical tibial angle was 71° preoperatively (intra-osseous varus of 19°) and 89° postoperatively. The medial tibial plateau slope was 45° preoperatively and 22° postoperatively. Leg length discrepancy was 2.2 cm at last follow-up (range 0.5–5 cm).

Discussion: Different techniques have been described for correcting two deformation components during the same operation. Here, we used the metaphyso-epiphyseal oblique osteotomy technique. This technique assumes that the medial part of the cartilage has already fused and requires fusion of the lateral part when it is active. Currently, we use chondrodiastasis with a special external fixator when the cartilage is still active. This corrects the alignment and raises the plateau, treating the length discrepancy by lengthening. The dual osteotomy technique is reserved for patients with total physis fusion. A long-term analysis after dual osteotomy in comparison with chondrodiastasis will be needed to determine the relative merits of the two techniques and the frequency of secondary osteoarthritis. This work is being conducted at the orthopaedic surgery department of the Fort-de-France University Hospital in Martinique.

Purpose: Treatment of major bone loss still raises difficult reconstruction problems. For bone tumours, massive resection prostheses allow rapid reconstruction of the architecture and satisfactory function. Several publications have reported the use of autoclave-sterilised cortical autografts for the treatment of bone tumours but only two old publications (1961) have used this method for the treatment of major bone loss in limb traumatology.

Case report: A 17-year-old male patient was transported from a neighbouring island after a motorcycle accident. The patient presented Cauchoix stage 2 fracture of the lower end of the femur with bone lose measuring 11 cm. The complete diaphysometaphyseal segment was recovered on the road and was brought in a sack. Emergency debridement was performed followed by complete skin closure and transcalcaneal traction. The femoral cortical fragment was cleaned and sterilised in the autoclave with one cycle at 121°C for 20 minutes at 1.3 bars. Twenty days later, osteosynthesis was performed using a large 95° Muller plate via a lateral approach. The cortical segment was put in position enabling complete recovery of length, alignment and rotation. Rehabilitation was initiated postoperatively. Total weight bearing began at three months and nautical sports (wind surf, surfing) at six months. Complete recovery of motion was achieved (heal-buttocks). Extension was normal and symmetrical both actively and passively with no recurvatum.

Results: Successive postoperative x-rays taken at 1.5 and 4 months and 1, 2, 3, 4, 6, and 7 years showed excellent graft incorporation. Healing of the metaphyseal and diaphyseal interfaces was complete at two years. Biopsy of the metaphyseal zone showed a normal bone structure.

Discussion: This exceptional case illustrates the capacity of this method to allow total recovery of function, an outcome rarely achieved after such important bone loss.

An extra articular correction may be necessary in osteoarthritis with an important post traumatic or congenital deformity. In the last 5 years we performed 11 TKR associated with a tibial (9 cases) or a femoral Osteotomy (2 cases), in one time surgery. The average intra osseous deformity was 14°. The technical problems are different in varus and valgus knees.

1- Which type of osteotomy ? In varus knees with a tibial deformity (6 cases) we use a hight tibial valgus osteotomy with opening wedge. Pre operative planning with long standing X rays allows precise determination of the amount of correction needed. A rigide wire, driven up to the fibular head, is placed. A provisional wedge of the desired size (degree of correction) is maintened temporarily by a staple, which will be removed later. Once the correction has been performed and maintened, the standard instrumentation to implant the prosthesis is used. In valgus knees with a tibial deformity (2 cases) a hight tibial closing wedge osteotomy, and in valgus knees with a femoral deformity (2 cases), a low femoral closing wedge osteotomy, are used. In all cases a medial approach without any release and without fibular osteotomy is performed.

2- Which kind of prosthesis?

Two degrees of constraint are possible in fonction of particular needs.

Most of the time, a non-constrained PS articular implants will be used and when more constraint will be needed (in lateral instability), CCK-type articular surfaces will be choised.

In all cases, a stem will have to be, associated with the osteotomy (tibial or femoral). Different diameters will allow a good press-fit and if necessary, an offset stem will be used.

3- Associated osteosynthesis or not? Stability provided by the press-fit stem may allow not to use an osteosynthesis in most than 50% of cases. If a doubt remains about stability, a small plate can bee added on the medial tibial side of the tibia.

4- Which immediate post-op follow-up?

Full weight bearing will be immediate. A splint will be used only for walking during six weeks. A standard rehabilitation protocole will be followed. In our 11 patients with a short follow up (1 to 5 years) complications consisted in one hematom and one phlebitis. Post-operative alpha angle was 96° and beta angle 91°. TKR with an associated osteotomy seems to be a possible alternative when osteoarthritis is associated with an important extra articular deformity.

Purpose: Loosening remains a problem with semi-constrained total elbow prostheses. The trend in recent years has been to improve prosthesis design to achieve stability of the humeral implant. We report a small series of nine Coonrad-Morrey total elbow prostheses where three early loosenings were observed in the ulnar implant. We attempt to analyse the causes and present a review of the recent literature.

Material and methods: Nine patients, mean age 60 years, age range 57–63 years, underwent total elbow arthroplasty with a Coonrad-Morrey prosthesis for rheumatoid disease (n=5), stiff degenerative joints after trauma (n=3, flexion-extension 20°), floating joint after trauma (n=1). The posterolateral approach described by Bryan and Morrey was used for eight elbows and the posterior approach for one. Clinical and radiological results were assessed with the performance index and the Mayo clinic score respectively.

Results: Mean follow-up was 3.6 years (1.5–4.7). Outcome was very good or good for seven elbows (score > 75 and > 50), fair for one (< 50) and poor for one (< 25). Three elbows were pain free, two presented pain during movement against force. Flexion was greater than 120° in four elbows (all four rheumatoid polyarthritis). Radiologically, we observed three cases of ulnar implant loosening with two type IV lucent lines, and one type III line. There was one humeral implant with a lucent line which did not change over time (type I). The two cases of type IV lines were associated with radial and anterior translation migration of the prosthetic stem with effraction or lysis of the ulnar cortical. The three ulnar loosenings appeared between the second and third postoperative year on two post-trauma stiff degenerative elbows (flexion-extension < 20°) and one rheumatoid elbow. At last follow-up, there was one poor result requiring revision surgery, one fair result, and one very good result (totally asymptomatic type 4 lucent line).

Discussion: The causes of these loosenings were studied: difficult cementing technique in a tight canal, mediocre primary stability of the ulnar implant opposing the excellent fit of the humeral implant with an encased graft under the anterior wing, excessive constraint. Our results are similar to those reported by Hilebrand who had 30% evolving ulnar lucent lines and suggest that we should reserve this prosthesis for unstable elbows.

Purpose: Most series on revision total knee arthroplasty (TKA) have cited femorotibial instability as a frequent cause of failure, after loosening and patellar complications. The purpose of this study was to analyse TKA failure due to femorotibial instability and to search whether an initial defect in technique or indication was the cause of stability and thus to draw therapeutic conclusions for revision surgery.

Material and methods: Between 1989 and 2000, 43 aseptic TKA required revision with implant replacement (tibial, femoral or both). During the same period 1013 first-intention TKA were implanted. Among the failures, implant loosening (femoral, tibial or both) was noted as the cause in 22 cases, isolated femorotibial instability in 15. Among the 22 loosenings, there were seven cases of femorotibial instability not related to implant migration or wear. We retained the 22 cases of femorol instability related to ligaments (15 cases of isolated instability and 7 cases associated with loosening) for study. Clinical data recorded were: initial diagnosis, patient age and sex, manifestations of instability, time to revision after first intervention. Radiological data recorded were: type of prosthesis implanted, implant position (alpha and beta angles), pre- and postoperative mechanical femorotibial alignment, tibial slope, tibial and femoral mechanical angles (searching for extra-articular deformation).

Results: The 22 revisions conserned 17 women and five men. Signs were pain and sensation of instability. Mean time to revision was two years eight months for isolated instability and six and one half years for instability associated with loosening. Prostheses were implanted in different units and thus varied: all were semi-constrained implants. Among the 22 instabilities leading to revision, we found 13 frontal instabilities, three sagittal instabilities, and six global instabilities. Analysis of the patient files demonstrated that failure could be explained in 19 cases by several defects, sometimes associated: insufficient release during initial intervention (medial or lateral release), excessive release (n=1), varus or valgus frontal or tibial cut, excessive tibial slope, internal rotation of the femoral or tibial implant, extra-articular deformation corrected intra-articularly (n=4), insufficient medial collateral ligament with major genu valgum (n=3). Certain failures were particular for certain implants, posterior laxity after implant with preservation and insufficiency of the posterior cruciate ligament, dislocaton of a posterior stabilised implant (n=1).

Discussion: This analysis of factors contributing to failure by femorotibial instability demonstrated that the majority of the cases have a technical explanation: 1) defective cuts and ligament imbalance are frequent; the cut or ligament release should be revised when changing the prosthesis. 2) Ligament insufficiency generally involving the medial collateral ligament in knees with major genu valgum; a more constrained prosthesis should be used or, as advocated by some, ligamentoplasty. 3) Extra-articular deformations are generally observed in knees with major genu varum; osteotomy may be needed if the extra-articular deformation exceeds 10°.

Conclusion: Femorotibial instability is a frequent cause of early failure of TKA. Greater precision in prosthesis implantation and correct ligament balance as well as proper choice of the degree of constraint should allow reduction of this frequency.

Purpose: Necrosis of the navicular bone, described by Müller then Weiss in 1927, is an uncommon finding, unlike talonavicular degeneration which is a rather frequent complication of talipes planovalgus. Between 1985 and 2000, we cared for 25 patients with this condition. The purpose of this retrospective analysis was to describe the clinical and radiological presentation and attempt to reconstruct its natural history with the aim of determining therapeutic indications.

Material and methods: We analysed 25 cases of navicular bone necrosis observed in 14 women and 3 men (eight bilateral cases). Mean age of the patients was 39 years (range 16–59). The diagnosis of necrosis was established on the basis of structural alterations (densification, bone defects) and in the more advanced cases, flattening and “expulsion” of the navicular bone. We looked for clinical signs and described the radiological aspect of the necrotic zone. A computed tomography was available in 14 cases and magnetic resonance imaging in the five most recent cases.

Results: Pain was the major sign in all cases. One-third of the cases occurred in a foot with prior planovalgus. History taking revealed elements suggestive of an aetiology in three cases: probable Köhler-Mouchet disease in a 16-year-old boy, sickle cell disease in a 35-year-old man, and prolonged walking with signs suggesting stress fracture in a 40-year-old woman. In the other 19 cases (11 women and 1 man, 7 bilateral cases), necrosis was considered idiopathic. Radiologically, we used the Ficat classification (described for hips): stage 0 with normal x-ray and strong uptake on scintigram (n=1), stage 1 with a normally shaped navicular bone but condensation or bone defect, stage 2 with modification of the shape of the bone without signs of degeneration, stage 3 where changes in the shape of the bone are associated with narrowing of the talonavicular then cuneonavicular space. Computed tomography included frontal and horizontal slices as well as lateral reconstructions indispensable to assess the posterior part of the interarticular spaces. Treatment was surgical in 12 cases and medical in 13. Well tolerated forms were treated with plantar ortheses with regular surveillance. Surgical procedures included triple arthrodesis (early in our experience), mediotarsal arthrodesis (n=2), talonavicular arthrodesis (n=7) and talocuneate arthrodesis with replacement of the scaphoid by an iliac graft (n=2). The natural course of necrosis was studied in the cases without surgery. The first sign was medial mediotarsal pain. At this stage scin-tigraphy or MRI was required for positive diagnosis. At stage 0 condensation of the navicular bone, confirmed by computed tomography, preceded bone flattening then expulsion upwardly and medially, sometimes with fragmentation and onset of talonavicular degeneration. Cuneonavicular degeneration appeared to occur later (except in one case). Long-term results of surgery were good with pain relief and renewed activity.

Discussion: The clinical presentation initially described as Müller-Weiss disease or scaphoiditis, which concerns a bilateral condition generally occurring after trauma and sometimes with a favouring factor (alcoholism, osteoporosis), appears somewhat different from our description. Mechanical factors predominated in our patients and the aetiologies were quite similar to those observed in Kienböck syndrome. Excessive pressure on the navicular bone, which leads to avascular necrosis, flattening, and expulsion, is undoubtedly the essential cause of this condition. It is well tolerated in some individuals and can lead to spontaneous fusion. In this situation, treatment can be limited to surveillance or orthopaedic care. If the functional impact is important, surgical treatment can be proposed, generally limited to talonavicular arthrodesis. If the navicular bone is sclerosed and flat, the remaining fragment can be replaced by an iliac graft to achieve talocuneate fusion.

Conclusion: Necrosis of the navicular bone appears to be less uncommon than in the classical description, particularly in black women aged 25–50 years. A more precise study of favouring anatomic factors (length of the medial ray, size of the talar neck, depression of the medial arch) could provide further information concerning the aetiology which appears to be similar to that of Kienböck disease.