Aim

The primary objective is to evaluate the diagnostic performance of inoculating homogenized tissue and bone biopsies in blood culture bottles (BCB) for patients with (suspected) orthopaedic device-related infections. As secondary objective the time to positivity (TTP) of BCB and Wilkins-Chalgren broth (conventional method) will be evaluated.

Introduction

Transosseous flexion-distraction injuries of the spine typically require surgical intervention by stabilizing the fractured vertebra during healing with a pedicle-screw-rod constructs. As healing is taking place the load shifts from the implant back to the spine. Monitoring the load-induced deflection of the rods over time would allow quantifiable postoperative assessment of healing progress without the need for radiation exposure or frequent hospital visits. This approach, previously demonstrated to be effective in assessing fracture healing in long bones and monitoring posterolateral spinal fusion in sheep, is now being investigated for its potential in evaluating lumbar vertebra transosseous fracture healing.

Stand-alone anterior lumbar interbody fusion (ALIF) provides the opportunity to avoid supplemental posterior fixation. This may reduce morbidity and complication rate, which is of special interest in patients with reduced bone mineral density (BMD). This study aims to assess immediate biomechanical stability and radiographic outcome of a stand-alone ALIF device with integrated screws in specimens of low BMD.

Eight human cadaveric spines (L4-sacrum) were instrumented with SynFix-LR™ (DePuy Synthes) at L5/S1. Quantitative computed tomography was used to measure BMD of L5 in AMIRA. Threshold values proposed by the American Society of Radiology 80 and 120 mg CaHa/mL were used to differentiate between Osteoporosis, Osteopenia, and normal BMD. Segmental lordosis, anterior and posterior disc height were analysed on pre- and postoperative radiographs (Fig 1). Specimens were tested intact and following instrumentation using a flexibility protocol consisting of three loading cycles to ±7.5 Nm in flexion-extension, lateral bending, and axial rotation. The ranges of motion (ROM) of the index level were assessed using an optoelectronic system.

BMD ranged 58–181mg CaHA/mL. Comparison of pre- and postoperative radiographs revealed significant increase of L5/S1 segmental lordosis (mean 14.6°, SD 5.1, p < 0.001) and anterior disc height (mean 5.8mm, SD 1.8, p < 0.001), but not posterior disc height. ROM of 6 specimens was reduced compared to the intact state. Two specimens showed destructive failure in extension. Mean decrease was most distinct in axial rotation up to 83% followed by flexion-extension.

ALIF device with integrated screws at L5/S1 significantly increases segmental lordosis and anterior disc height without correlation to BMD. Primary stability in the immediate postoperative situation is mostly warranted in axial rotation. The risk of failure might be increased in extension for some patients with reduced lumbar BMD, therefore additional posterior stabilization could be considered.

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Purpose of the study: Different metatarsal osteotomies performed via a percutaneous approach can be used to correct hallux valgus. The purpose of this work was to analyse the clinical and radiographic results of percutaneous treatment of hallux valgus using a distal wedge osteotomy of the metatarsal.

Material and methods: This was a consecutive prospective series of 125 cases of hallux valgus treated by the same surgical technique, distal wedge osteotomy of the metatarsal without fixation. Percutaneous lateral arthrolysis and percutaneous varus correction of the first phalanx were associated. The AOFAS function score for the forefoot was determined preoperatively and at last follow-up. Time to normal shoe wearing and to resumption of occupational activities were also noted. Angle correction was determined on the anteroposterior weight-bearing image. All patients were reviewed at mean 20 months (range 12–40).

Results: The AOFAS forefoot function score was 46/100 preoperatively and 87/100 at last follow-up. Mean motion of the metatarsophalangeal joint was 95 preoperatively and 80 postoperatively. Mean metatarsophalangeal valgus was 30 preoperatively and 12 at last follow-up. The mean intermetatarsal angle improved from 13 to 8 and the orientation of the joint surface of the first metatarsal (DMAA) improved from 11 to 7. The metatarsophalangeal joint of the first ray was congruent in 45% of the feet preoperatively and in 88% postoperatively. Mean time to wearing normal shoes was seven weeks for the treatment of hallux valgus alone and three months for surgery of the first ray and lateral rays.

Discussion: Percutaneous treatment of mild to moderate hallux valgus by distal wedge osteotomy of the metatarsal enables good clinical and radiographic improvement. The surgical technique requires experience with percutaneous surgery of the forefoot to avoid the main complications: secondary displacement in elevates and excessive shortening of the first metatarsal. This technique restores metatarsophalangeal congruence of the first ray compared with Isham-Reverdin osteotomy.

Purpose of the study: The purpose of this work was to analyse the results of infection in patients with joint prostheses implanted after septic arthritis, distinguishing evolving versus cured arthritis.

Material and methods: This was a retrospective series of 70 cases of septic arthritis (in 69 patients) including 7 patients with mycobacterial infections and 63 patients with ordinary germ infections. For the seven mycro-bacterial infections (five Mycobacterium tuberculosis and two Mycobacterium xenopi), the arthroplasty was implanted on evolving arthritis and in two on arthritis considered cured. For the 63 cases of common germs (70% staphylococcal infections), the septic arthritis was considered evolving in 36 and cured in 27. For half of the cases, the arthritis was blood-borne and localised in the knee. For cases considered evolving, the arthroplasty was generally a two-phase procedure (32/36 cases). Adapted antibiotics were associated for 93 days on average (45–180). For arthritis considered cured, the arthroplasty was implanted on average 53 months (range 6–700) after the infectious episode, generally in a one-phase procedure (22/27). Adapted antibiotics were associated for 80 days on average in seven patients because of positive intraoperative samples. One patient was lost to follow-up before two years and all others were reviewed with at least two years follow-up (mean 5 years, range 2–13 years).

Results: For the seven cases of mycobacterial arthritis, one patient was lost to follow-up, six had no signs of infection at mean 7 years follow-up. For the other cases, 89% of patients who had a prosthesis for evolving arthritis were considered as cured, 6% relapsed before 18 months and 6% presented a new infection with a different germ. For arthroplasty after assumed cured arthritis, 81% of patients were considered cured, 15% relapsed before 18 months and 4% presented a new infection with another germ.

Discussion: Arthroplasty is the treatment of choice for septic evolving septic arthritis, enabling cure in more than 80%, irrespective of the causal germ, and whether cure of the infection was apparently achieved or not.

Introduction: Determination of the origin of chronic foot pain in osteoarthritis (OA) is challenging since clinical examination of the foot faces a complex anatomy with several joints, osseous, and non-osseous structures contributing to the symptoms. Non-invasive imaging methods (Rx, CT, MRI) show a poor correlation with pain degree. Studies using functional imaging based on the detection of activated osteoblasts with 99mTc-Dicarboxypropandiphosphate (DPD) to indicate painful facet joints show promising results, but so far no evaluation for chronic OA pain conditions in foot joints has been conducted and the diagnostic potential was limited due to poor spatial resolution of the scintigraphic assessment.

Single Photon Emission Computed Tomography – Computed Tomography (SPECT-CT) combines metabolic information with an exact anatomical localization. We hypothesised that diagnostic infiltration with a local anaesthetic of a painful hindfoot or midfoot joint showing 99mTc-DPD-uptake in SPECT-CT, leads to a positive OA pain response.

Methods: 26 patients with chronic OA pain and radiological signs of OA in a hindfoot or midfoot joint (27 feet) were included. Plain radiography was performed to detect degenerative changes and to rule out pathologies different from OA. Pain status was measured by Visual Analogue Scale (VAS). AOFAS hindfoot/midfoot score and SF-36–score were documented. All patients received a 99mTc-DPD SPECT-CT (Symbia T2, Siemens). The localisation of 99mTc-DPD-uptake and consequently the site of infiltration were defined. The infiltration was performed with a local anaesthetic (bupivacaine) and iodine solution under CT-guidance with exact documentation of the contrast media deposit by CT. Pain status was assessed directly post-infiltration. Pain relief in responders was defined as reduction of VAS-score > 50% immediately after infiltration, partial response as reduction of < 50%.

Results: Infiltration was performed in 26 hindfoot joints and 5 midfoot as indicated by 99mTc-DPD-uptake in SPECT-CT. Subsequent CT control scans showing contrast media depot confirmed exact successful infiltration in all indicated joints. In 22 patients an immediate significant (p< 0.01) postinterventional pain reduction of VAS more than 50% was observed. Mean VAS before infiltration was 5.77 (range 2–10; SD 2.22) and 0.82 (range 0–4; SD 1.26) immediately after infiltration. Two patients showed a partial response and one patient showed no pain resolution after infiltration.

Conclusion: The results show a significant correlation of uptake and pain resolution after infiltration allowing precise identification of OA hindfoot joints as pain inducing foci. SPECT-CT offers good prediction of outcome after infiltration improving the localisation of the pain inducing joint, thus aiding in pre-operative planning.

Purpose: Osteoarthritis (OA) is a common disease with increasing prevalence and rising socioeconomic burden. Of all symptoms accompanying OA, pain is the most disabling and frequent and the major reason why patients affected seek medical help. The determination of the origin of chronic foot OA pain is challenging since clinical examination of the foot faces a complex anatomy with several joints, osseous, and non-osseous structures contributing to the symptoms. For OA non-invasive imaging methods like plain radiograph, CT or MRI underestimate the degree of degenerative changes and show a poor correlation with pain degree. Studies using functional imaging based on the detection of activated osteoblasts with 99mTc-Dicarboxypropandiphosphate (DPD) to indicate painful facet joints in the lower spine show promising results, but so far no evaluation for chronic OA pain conditions in foot joints has been conducted and the diagnostic potential was limited due to poor spatial resolution of the scintigraphic assessment. Single Photon Emission Computed Tomography – Computed Tomography (SPECT-CT) is a new hybrid technique combining metabolic information with an exact anatomical localization. We hypothesised that diagnostic infiltration with a local anaesthetic of a painful hindfoot or midfoot joint showing 99mTc-DPD-uptake in SPECT-CT, leads to a positive OA pain response.

Method: 26 patients with chronic OA pain and radiological signs of OA in a hindfoot or midfoot joint (27 feet) were included. Plain radiography was performed to detect degenerative changes and to rule out pathologies different from OA. Pain status was measured by Visual Analogue Scale (VAS). AOFAS hindfoot/midfoot score and SF-36-score were documented.. All patients received a 99mTc-DPD SPECT-CT (Symbia T2, Siemens). The localisation of 99mTc-DPD-uptake and consequently the site of infiltration were defined. The infiltration was performed with a local anaesthetic (bupivacaine) and iodine solution under CT-guidance with exact documentation of the contrast media deposit by CT. Pain status was assessed directly post-infiltration. Pain relief in responders was defined as reduction of VAS-score > 50% immediately after infiltration, partial response as reduction of < 50%.

Results: Infiltration was performed in 26 hindfoot joints and 5 midfoot as indicated by 99mTc-DPD-uptake in SPECT-CT. Subsequent CT control scans showing contrast media depot confirmed exact successful infiltration in all indicated joints. In 22 patients an immediate significant (p< 0.01) postinterventional pain reduction of VAS more than 50% was observed. Mean VAS before infiltration was 5.77 (range 2–10; SD 2.22) and 0.82 (range 0–4; SD 1.26) immediately after infiltration. Two patients showed a partial response and one patient showed no pain resolution after infiltration.

Conclusion: The results show a significant correlation of uptake and pain resolution after infiltration allowing precise identification of OA hindfoot joints as pain inducing foci. Non-invasive SPECT-CT offers good prediction of outcome after infiltration improving the localisation of the pain inducing pathology, thus aiding in pre-operative planning and avoiding unnecessary interventions, as diagnostic infiltrations, with its possible risks and side effects.

Proximally-coated non-cemented tapered femoral stems have demonstrated excellent long-term clinical results. However, there is sparse literature reporting the incidence of failure of osteointegration in patients with this stem design. The aim of this study is to report this incidence and identify factors which may increase its risk.

206 elective primary total hip arthroplasties were performed consecutively with a single stem design over a three-year period. All patients were evaluated clinically and radiographically. Radiographic parameters were analyzed for any potential risk factors that may predispose to failure of osteointegration.

Three of 206 hips failed to osteointegrate and subsequently underwent revision surgery, for an incidence of 1.5%. The average time to revision was 1.2 years. The presenting complaint was persistent pain and radiographs revealed a progressive linear lucency at the proximal implant-bone interface in all three patients. Each patient had been implanted with a large-sized stem that had achieved a diaphyseal fit radiographically. This cohort had a statistically lower canal-flare index (p < 0.05) when compared to the rest of the study group. At the time of surgery, all stems were found to be loose and were easily removed.

Failure of osteointegration in this type of stem is an uncommon but serious complication that may necessitate revision surgery. Risk factors predisposing to a failure to osteointegrate are a mismatch between the patient’s proximal femoral geometry and the stem, specifically a large stem in a Dorr type C femur, leading to a diaphyseal rather than a metaphyseal wedge.

Purpose of the study: We present our experience with the distal-based sural flap for lower leg tissue defects.

Material and methods: This consecutive retrospective series included 45 flaps in 45 patients, 36 men and 9 women, mean age 50 years. The size and the cause of the tissue loss were described as were the patients’ history and risk factors. The distally-based fasciocutaneous sural flap was used in all cases. The postoperative period as well as the quality of the final cover were analyzed.

Results: At mean follow-up of 45 months, 43 of the 45 faciocutaneous flaps survived. Cover of initial tissue defect was complete in 41 cases and partial in two. Two flaps failed, leading to limb amputation. For the 25 patients with no risk factor, all flaps resulted in perfect tissue cover. In the 20 patients with risk factors, perfect cover was achieved for 16; only 10 of 20 flaps had an uneventful history with simple healing process; partial necrosis developed in eight flaps and two flaps failed.

Discussion: The Distally-based fasciocutaneous sural flap is a very reliable method offering many possibilities for covering lower limb tissue loss from the upper third of the leg to the ankle and hindfoot. The limitations are patient-related. There are thus many indications. For bone infections, one stage tissue cover can be achieved by integrating the flap as part of the overall treatment for the bone-related injury. This flap has an excellent vascular supply which increases the local concentration of systemic antibiotics. The distally-based sural flap can also be used successfully in traumatology.

Conclusion: The distally-based sural flap is reliable and relatively easy to perform. It provides excellent cover for most tissue losses situated on the lower half of the leg and ankle. The limitations are patient-related.

Purpose of the study: When infection occurs on solid bone tissue, the problems which arise concern filling the bony defect, achieving effective antibiotic therapy at the bone level, and correct cutaneous coverage. We present our experience in the management of 80 cases of bone infection on continuous bone tissue of the lower limb.

Material and methods: This was a retrospective series of 80 cases of bone infection on continuous bone in the lower limb in 77 patients, mean age 45 years. The infection had on average persisted for 13 years and the patients had undergone on average six operations at the infected site. Bone infection was a posttraumatic complication in three-quarters of the cases and localized in the tibia in half. The general and local status was assessed for each patient using the Cierny-Mader classification. All patients underwent surgery using the same operative protocol: resection, filling, bone cutaneous cover. We describe the different operative phases and the techniques employed. Patients free of clinical or biological signs of recurrent infection two years after hospital management were considered cured.

Results: All patients were reviewed, there were no patients lost to follow-up. At mean follow-up of four years, 81% of patients were considered cured. Recurrent infection was observed in 14% of cases, requiring revision on average two years after initial management. For 5% of the cases, the initial treatment failed and was followed by amputation. Poor general or local status and extensive diffuse osteitis were factors predictive of poor cure of the infection.

Discussion: We discuss the different causes and pathogenic mechanisms of osteitis on continuous bone. Surgical techniques are compared. Bone infection on continuous bone is an ideal indication for muscle or fas-ciocutaneous flaps for filling bone cavities and achieving cutaneous cover. The different modalities and duration of antibiotic therapy are discussed.

Conclusion: Bone infection on continuous bone is a specific often poorly individualized clinical situation. A specific surgical protocol is indicated to fill bony defects, and achieve cutaneous cover and thus definitive cure.

Introduction: The emergence of multidrug resistant Gram negative bacilli susceptible to hardly any beta lactam compound has led to infections close to a therapeutic dead end. In such circumstances, Imipenem-cilastatin (I-C) is often the only remaining therapeutic option. We report our experience with the prolonged administration of high-doses of I-C in the treatment of osteoarticular infections with bacteria resistant to other beta-lactam agents (or 4^l generation cephalosporins in 14 cases).

Materials and methods: Our retrospective study over 7 years included 29 patients with septic arthritis (n=3) continuous osteitis (n=6), septic non-union(n=12) and prosthetic joint infections (n=8). Treatment included an extensive surgical debridement and post-operative combination antibiotherapy with intravenous I-C and aminoside (54%) and/or fluoroquinolones (46%) and/or fosfomycin (29%). Associated microorganisms requiring yet additional antimicrobial agents were associated in 17 (59%) cases. I-C was maintained for an average of 46 days (extremes 21–90), at an average dose of 3,8g/day (extremes 2–6). The bacteria warranting I-C were cephalosporinase hyperproducing Enterobacter cloacae (38%), extended spectrum beta-lactamases producing enterobacteria (31%), Pseudomonas aeruginosa (21%) and/or Acinetobacter baumanii (21%).

Results: Early outcome was favorable in 24 patients (82%). Two patients relapsed with the bacteria requiring I-C. Three failed to negate succion fluid cultures : one was discharged with no change in his condition, one agreed to a leg amputation and the third died of candidemic septic shock in SICU with drainage fluid still bactériologie ally positive. Repeated secondary colonization and systemic infection with yeasts led to a monitoring of yeast load. Per os amphotencin B and immediate treatment of urinary colonization prevented further systemic dissemination of candical infections. No other tolerance incidents were noted. Acquired resistance occurred only once in a P. aeruginosa isolate while Imipenem-cilastatin was chosen to cover an ESBL producing Escherichia coli. Secondary treatment with ceftazidime was then successful in eradicating P. aeruginosa.

Conclusion: I-C has been widely used for the treatment of mixed flora infections as a wide spectrum antibiotic.

We report good tolerance of high posology long term administration in documented osteoarticular indications if yeast colonization is properly monitored, and eradication rates are comparable to those reported in infections with susceptible bacteria.

Purpose: We reviewed retrospectively 349 cases of infected total hip arthroplasty treated by prosthesis replacement. The surgical strategy, 127 single-stage procedures and 222 two-stage procedures, was determined by the surgeon on a case by case basis.

Material and methods: At least one positive sample during the clinical history was required for inclusion in the series. Results of all bacteriological samples collected pre- and intra-operatively were noted. Samples were considered reliable if obtained from a deep site (puncture, biopsy, intraoperative specimen) and non-reliable if obtained from any other site. We studied the agreement between preoperative and intraoperative samples, taking the intraoperative samples as the reference, in order to determine the effect of complete preoperative knowledge of the causal germ on the outcome of infection treatment at last follow-up.

Results: For single-stage replacement procedures, preoperative samples were reliable in 74 cases (58%) and non reliable in seven (6%); they were sterile or absent in 46 cases (36%). Intra-operative samples were positive in 103 cases (81%). Agreement between the preoperative and intraoperative samples was observed in 48 cases (38%). The rate of success was not different if the surgeon had or did not have reliable knowledge of the causal germ(s) preoperatively: successful treatment in 66 cases (89%) with knowledge and successful in 46 cases (87%) without knowledge. For two-stage procedures, preoperative samples were reliable in 155 cases (70%) and non-reliable in 15 (7%); they were sterile or absent in 52 cases (23%). Intraoperative samples were positive in 178 cases (80%). Agreement between preoperative and intraoperative samples was observed in 107 cases (48%). The rate of success was not different if the surgeon had or did not have reliable knowledge of the causal germ(s) preoperatively: successful treatment in 133 cases (86%) with knowledge and successful treatment in 56 cases (84%) without knowledge.

Conclusion: Reliable preoperative knowledge of the causal germ(s) did not affect the rate of success for single-stage or two-stage total hip arthroplasty replacement procedures. These findings do not corroborate the notion that it is absolutely necessary to recognise the germ(s) causing the infection before undertaking a single-stage replacement procedure.

Purpose: We report results of management of infected total knee arthroplasty (TKA). Our aim was to analyse the different therapeutic options and identify factors predictive of cure.

Material and methods: This retrospective multicentric analysis included a consecutive series of 179 cases of infected TKA. Revision TKA was performed for 77 knees in two operative times, 30 in one operative time. Synovecetomy was performed for 26 knees, arthrodesis for 36 and amputation for nine. Minimum follow-up was two years. For each case, we assessed cure of infection and functional outcome. Non-parametric statistical tests were used to compare outcome.

Results: Mean follow-up was 41.2 months. There was a 17% death rate during the first two years after management of infected TKA. Cure was achieved in two-thirds of the revised cases (in one or two operative times) and in 54% of the synovectomy cases. Arthrodesis yielded cure in 50%. Staphylococci was identified in 65%. The functional outcomes of revised prostheses (two times) was less satisfactory if the anterior tibial tubercle was removed, if the extensor system was involved, or if a flap cover was necessary (p< 0.05). There was no significant difference in functional outcome for one-time and two-time operations. Cure was achieved in 95% of the synovectomies performed before 16 days. Relapse occurred in 95% of those performed after 56 days. Arthrodesis performed in patients with major bone loss failed. Among the arthrodesis failures, 50% were related to mechanical failure and the other 50% to recurrent infection.

Discussion: We discuss these results and indications for different treatments of infected total knee arthroplasty. For each therapeutic option, we analysed factors allowing hope for cure and good functional outcome.

Conclusion: The objective of treatment of an infected TKA is to achieve cure and maintain satisfactory function, often a difficult goal to reach. Major mutilating surgery can be avoided by early adapted care.

Introduction: Open reduction and internal fixation (ORIF) is considered the treatment of choice in dislocated unstable pelvic fractures. However ORIF has several drawbacks, such as considerable soft tissue trauma, a substantial intraoperative blood loss and up to 25% infectious complications. To overcome these problems mini-invasive osteosynthesis techniques have been developed.

Methods: Analysis of the problem revealed necessary changes on the level of intraoperative imaging, surgical approach, reduction devices and technology integration. Intraoperative imaging with computertomography gives all the time an appropriate representation of the real position of bony fragments of the pelvis. A new type of axial reduction clamps allows fracture reduction through small incisions. Preshaped plates can be pushed underneath the soft tissue. Computer navigation helps to place screws in a save manner percutaneously.

Results: We present the setting of a new multifunctional image guided therapy suite, which is an optimal platform for mini-invasive treatment of fresh dislocated anterior and posterior pelvic ring fractures, as well as for percutaneous treatment of pelvic non unions. The technique of reduction and fixation of an anterior pelvic ring fracture through two small incisions instead of a full ilio-inguinal approach is shown. A case of percutaneous bone grafting of a delayed union of the sacrum is presented.

Conclusions: Mini-invasive osteosynthesis techniques require appropriate imaging tools, new reduction devices and most notably special skills. However all together may reduce severe side effects of conventional pelvic surgery.

Purpose: It is known that severe distention of the inferior glenohumeral ligament (IGHL) during anteror-inferior shoulder instability is an important factor of poor functional prognosis after arthroscopic stabilisation. O. Gagey proposed a clinical test to assess laxity of the IGHL. The purpose of this study was to assess the laxity of the IGHL using a dynamic radiological test (AP view in passive abduction of the glenohu-meral joint) and to correlate findings with arthroscopic observations..

Material and methods: We performed a prospective study in 21 patients scheduled for arthroscopic stabilisation for anteroinferior shoulder instability. Mean age was 24.6 years, 17 men and 4 women. The test was performed in the supine position with a strictly AP view of the shoulder. Bilateral comparative images were obtained. The shoulder was brought to forced passive abduction in neutral rotation without general anaesthesia or locoregional anaesthesia. The angle between the axis of the humeral diaphysis and the line passing through the inferior border of the glenoid cavity and the lateral border of the scapular tubercle was measured. Vuillemin has demonstrated that this test is reliable and reproducible. During arthroscopy performed for diagnostic and therapeutic purposes, the degree of distension was quantified using the Detrisac classification of four stages. We considered that stages 3 and 4 were frank pathological distension. We used the threshold of 15° for the difference between the healthy and pathological side for the radiological test. We assessed the ability to demonstrate severe laxity of the IGHL.

Results: For differences in abduction less than 15°, the test sensitivity was 77%, specificity 91%, positive predictive value 87% and negative predictive value 84%.

Discussion: A careful physical examination and appropriate complementary tests are essential for the evaluation of anteroinferior instability of the shoulder joint in order to obtain a precise diagnosis and search for contraindications for arthroscopic cure. The rate of recurrence after arthroscopic stabilisation remains above that obtained with open techniques. It has been demonstrated that major laxity of the IGHL constitutes a relative contraindication for arthroscopic stabilisation. Radiographic measurements provide precise information for evaluating the laxity of the IGHL. Taking a positive threshold of 15° difference identifies 87% of the cases of Detrisac stage 3 or 4 ligament distension.

Conclusion: We propose a preoperative complementary test using standard x-rays together with our dynamic radiological test of passive shoulder abduction. If the difference between the healthy and pathological side is greater or equal to 15°, the therapeutic strategy should include not only reinsertion of the rim but also retight-ening the ligament complex, or open stabilisation.

Purpose: Treatment of non-infected nonunion of the leg is a difficult challenge. Several technical solutions have been proposed. The purpose of this work was to assess the results achieved in patients treated with the Kuntscher technique and to detail indications.

Material and methods: Twenty-two patients who underwent surgery between 1987 and 1997 using the Kuntscher technique (reaming, renailing) for tibial nonunion were reviewed. There were 19 men and three women, mean age 36 years (range 16–58). Minimal follow-up was two years. The initial treatment consisted in non-locked cen-tromedular nailing the cruropedious (n=21) and screw-plate fixation (n=1). There were ten open fractures: Gustilo I (n=3), II (n=7). We noted: time to revision, time to healing, preoperative and last follow-up alignment, size and type of bone loss (fragment or segment), complementary procedures, complications.

Results: We had one infectious failure (Kuntschner nine months after screw-plate fixation, infection diagnosed at two months, bone healing after removal of the nail, reaming, external fixation and fibular strut with cancellous graft). There were no other complications. One patient was lost to follow-up at three months; this patient had a medial fragmental gap measuring 1 cm with a radiologically solid fracture at last follow-up. All other patients healed within a mean 3.44 months (2.5–10). Mean time before revision was six months (2.5–12). Segmental loss was 3–8 cm in six patients. There was not defective alignment at healing. A fibular osteotomy was performed in five cases. Complete weight bearing was initiated early in 15 patients (with crutches in seven).

Discussion: In our experience, the Kuntscher technique is a simple and effective method for the treatment of non-infected tibial nonunions. It is indicated for small gaps or small-sized segmental losses. The rapidity of the healing and the generally uneventful healing period suggest this method should be proposed early after diagnosis of nonunion.