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.

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.

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 of the study: Isthmic reconstruction has been proposed as an alternative to spinal fusion for the treament of symptomatic spondylolysis unresponsive to conservative treatment. The purpose of this work was to assess long-term outcome after isthmic reconstruction according to R. Louis.

Material and methods: Fifty-one patients were reviewed at four to 23 years. The sex ratio was 3F/1M; age range was 11 to 43 years. The surgical method included: 1) isthmic reconstruction using a graft followed by temporary screw-plate fixation; 2) ablation of implants, verification of the fusion and intervertebral mobility, arthrolysis as needed. Pain and resumption of occupational and sports activities were used to assess clinical outcome. Radiological criteria included linear and angular measurements in the sagittal plane, isthmic consolidation, slipping, disk height, intersegmentary angular mobility.

Results: Clinically, outcome was very good or good in 75% of the cases, fair in 21% and poor in 4%. For L5 reconstructions, outcome was very good or good in 83.5% and fair in 16.5%. Mean relative overall gain was 66%, reaching 72% for L5 reconstructions and only 31% for L3 or L4 reconstructions. Patients resumed their occupational activities in 92% of the cases. Most of those with sports activities resumed practice. Radiologically, fusion was achieved in 70% of the cases. The rate of consolidation was 80% for L5. Reduction in the immediately caudad and cephalad disk height was 33% for L5 reconstructions. Mobility was reduced 63% for the L5-S1 space and 50% for the L4-L5 space. Clinical outcome was correlated with isthmic consolidation. Residual mobility was inversely proportional to the duration of osteosynthesis.

Conclusion: Isthmic reconstruction using a graft and temporary ostheosynthesis is a surgical method providing very good anatomic isthmic consolidation. Despite the need for two operations and the relative stiffness of the immedicately caudad space, this procedure can provide good functional results and avoid the need a few years later for a more complex operation.

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.