Purpose of the study: The goal of palliative surgical treatment of vertebral metastases is to avoid, stabilise, or improve neurological disorders and to relieve pain. We propose early treatment for fixation of threatening lesions and extensive release without resection for programmed surgery outside the emergency context.

Material and methods: From 2001 to 2005, eighty patients underwent scheduled surgery for threatening or symptomatic lesions. Mean age was 59 years (range 32–82). The primary tumour was: breast (n=35), lung (n=19), kidney (n=8), uterus (n=1), prostate (n=2), ENT (n=3), gastrointestinal (n=5), haematology (n=7). Sixty-six patients presented Frankel B to D neurological involvement. The Tokuhashi score was 8 on average (range 5–9) and the Karnofsky index 57% (range 30–70). Sixty-four patients had visceral metastases. On average 7 levels were instrumented (range 4 to 8). The procedure included laminectomy in all cases.

Results: Blood loss was 500 cc (300–2700) and operative time 110″ (65–110). Fifty-nine patients recovered one or more Frankel grade. Six patients (7%) developed a postoperative infection. The actuarial survival at one year was 78%; 95% for patients free of motor neurological involvement and 65% for the others. This difference was significant.

Discussion: Spinal metastases should be detected and treated before emergency care is required. At the present time this treatment is well programmed. Fixation without tumour resection enables prolonged survival and allows time for other treatments in a pluridisciplinary management scheme. Several therapeutic options are possible but converge towards improved quality of life.

Conclusion: Posterior tumour resection is not useful for palliative surgical management of vertebral metastases. We propose an active approach using a simple well-defined surgical procedure without waiting for development of a neurological emergency.

Purpose of the study: The purpose of this paper was to report our experience with arthroscopic treatment of tendon-related epicondylalgia resistant to well-conducted medical treatment and the long-term outcomes. From September 2000 to January 2008, 25 consecutive patients underwent arthroscopic treatment performed by the same surgeon. Twenty-two patients were available for follow-up. We reviewed 26 interventions.

Material and methods: An endoarticular technique was used, with section of the lateral capsule then the extensor carpi radialis brevis and the extensor digitorum communis. Mean patient age was 45 years (36–55); five patients had work accidents (one bilateral case). Patients were assessed clinically using the Mayo Clinic Elbow Performance Score (MEPS) and for pain at rest, during daily life activities and during exercise (scale 0–10).

Results: Mean follow-up was 51 months (17.6–88.7). Pain was scored 0.38 at rest, 0.81 for daily life activities, and 4.11 for exercise. Mean function score was 90/100. Two patients underwent revision. Sixteen patients (62%) stated they were « much better », six « better » (23%) and four unchanged (15%). Twenty-one patients (81%) were satisfied, 23 would request the same procedure (88%). There was no statistically significant difference in the subgroup of work accidents versus the other patients with p=1.35 for pain at rest; p=0.51 for pain during daily life activities, p=0.37 for pain during exercise. Two minor complications (skin burn, subcutaneous infection) were observed.

Discussion: The results show improvement postoperatively. Patient satisfaction was correlated with the clinical results and the function score. Treatment of resistant epicondylalgia remains a very controversial issue; several surgical techniques have been described with good or even excellent results. Arthroscopic treatment, inspired by the work of Kuklo, was adopted by Baker, Owens and Jerosch. Our results are equivalent to those of other arthroscopy series. Longer time before resumption of occupational activities can be explain in our opinion by the greater number of patients with an occupational accident in our series.

Conclusion: Arthroscopic resection yields satisfactory results which are sustained over time, for the treatment of resistant epicondylalgia. It is an alternative to open surgery.

Purpose of the study: Treatment of calcaneal fractures is specific because of the fact that these fractures dis-organise the subtalar joint, requiring precise reduction. The clinical result is not always satisfactory considering the efforts made to obtain reduction and fixation. Functional treatment often gives acceptable clinical results, but leaves important anatomic and functional sequelae. We developed a technique for percutaneous balloon reduction and cementoplasty similar to the method used for vertebral fractures treated with the same material.

Material and methods: We describe four cases of thalamic fractures treated surgically in a semi-emergency setting. The patients were four women, mean age 39 years (range 26–55). Fractures included vertical compression fractures of the thalamic surface in all cases. The operation was performed under radiographic control in the operative theatre and included a phase for percutaneous reduction and a phase for cemented fixation, allowing a minimal incision and control in two planes.

Results: Operative time was 30 minutes and blood loss was negligible. Bone healing with maintenance of the subtalar reduction was achieved in all cases. The clinical result was remarkable, with sedation of the pain and oedema within hours and weight bearing within a few weeks. One patient developed a lateral submaleolar impingement which required infiltration at four months. All patients were totally pain free and had no radiographic evidence of osteoarthritis at two years.

Discussion: Percutaneous reduction cemented fixation is a new method for the treatment of thalamic fractures of the calcaneum. We demonstrated the feasibility in a small series; the procedure was simple and allowed effective treatment compared with the classical methods.

Conclusion: These excellent clinical results are encouraging for the development of the technique and incite us to propose this method as the first-line treatment for displaced thalamic fractures. We are working on the development of this concept.

Purpose of the study: Treatment of irrepable massive rotator cuff tears remains a controversial issue. The purpose of this study was to assess clinical and radiological outcome in patients with a reversed shoulder prosthesis used for the treatment of irreparable massive rotator cuff tears with or without associated glenohumeral osteoarthritic degeneration.

Material and methods: Between 1996 and 2002, 55 reversed shoulder prostheses were implanted via a superolateral approach. Mean follow-up of the 15 men and 40 women (mean age 73 years, age range 57–86 years) was 34.8 months (range 24–84 months). The supraspinatus and infraspinatus tendons were retracted to the glenoid and ruptured in 100% of the patients: 27 shoulders (49%) also presented a infrascapularis tear. Glenohumeral osteoarthritis (Fukuda IV and V) was persent in 29 patients. Postoperatively, patients were assessed with the Constant score and radiographically on plain x-rays.

Results: Three patients were excluded from the analysis because of implant infection and removal before review. Subjectively, 90% of patients were satisfied or very satisfied. All items of the Constant score improved significantly (p< 0.0001). Active elevation improved from 65° to 123°. External rotation was not improved. Radiographically, there wre 41 shoulders with a grade 0, 1 or 2 notch (Nerot system), and 11 with a grade 3 or 4 notch. Thirteen patients (25%) presented heterotopic ossifications.

Discussion and conclusion: In this context, the clinical results obtained with this prosthesis are much better than with any other type of arthroplasty. Radiographically, heterotopic ossifications have a significant impact on the Constant score (p=0.015). Presence of ta glenoid notch is signifiantly associated with use of a medialized or retaining polyethylene cup (p< 0.0001). For us, loosening of the metaglenoidglenosphere bloc is related to the progression of the glenoid notch. For these reasons, it would be preferable to reserve this type of arthroplasty for patients aged over 70 years presenting an irreparable massive cuff tear with satisfactory glenoid bone stock sufficient for obtaining a good anchor for the metaglen. We recommend only using lateralized polyethylene cups.

Purpose: One of the biomechanical objectives of total knee arthroplasty (TKA) is to achieve a mechanical femorotibial axis of 180°. Frontal angulation greater or equal to 7° is a factor of poor implant survival. The development of computer-assisted navigation systems has led to the discovery of new concepts: dynamic goniometry, quantitative evaluation of ligament balance. The purpose of this study was to evaluate the influence of the rotational position of the femoral implant and its variation during flexion.

Material and methods: We reviewed the files of 50 patients who underwent surgery between October 2001 and December 2002 for computer-assisted implantation (Orthopilot(r)). We studied femorotibial axis at 0°, 30°, 60° and 90° before the bone cuts, after the tibial cuts and at the end of the procedure after definitive fixing of the implants.

Results: The population, mean age 70 years, was evenly distributed: 17 valgum and 32 varum. The mean femorotibial axis at the end of the operation with the definitive implants in place was 0° in extension with balanced ligaments (±2°) and more often increased varus at 30°, 60° and 90° flexion.

Discussion: External rotation of the femoral piece was not systematic. Certain normally aligned knees in extension after the tibial cut presented significant varus in flexion, probably due to external rotation of the femoral epiphysis. On the contrary, knees with internal rotation of the femoral epiphysis, irrespective of the cause, showed a trend to valgus during flexion. Using external rotation of the femoral implant systematically for both knee morphotypes cannot be done without deteriorating the ligament balance in certain patients.

Conclusion: The advent of navigation systems for TKA has led to the discovery of new concepts such as dynamic goniometry. This has enabled study of femorotibial alignment in flexion, the working position of the knee during walking. This study showed that systematic external rotation of the femoral implant for TKA is not appropriate for all patients.

Purpose: Filling bone defects is a major challenge in orthopaedic surgery. One of the therapeutical alternatives to combined autologous bone grafts and bone substitutes is to use a biomaterial carrying bone stem cells. The purpose of this study was to test a hybrid biomaterial in a major bone loss model in the rabbit.

Material and methods: The study material was the AN 69 hydrogel (Hospal). Twenty-four rabbits were divided into four identical groups of six individuals. Each animal underwent a unilateral resection measuring 2 cm in the mid third of the cubitus: group 1 simple resection; group 2 resection and centromedullary pin; group 3 resection, centromedullary pin and biomaterial; group 4 resection, centromedullary pin, biomaterial with bone marrow stem cells. Animal were sacrificed at six weeks. A radiograph was obtained immediately after surgery and at sacrifice. The study parameters were: new bone formation, bone healing, bone remodelling. Each criteria was assessed with a mean score (Werntz score). A pathology examination was performed in all cases to study new bone formation, polylmere degradation and inflammation.

Results: The overall radiographic score was group 1 = 2, group 2 = 8, group 3 = 24, group 4 = 42 for a maximum 62 points. Histologically, there was nonunion after simple pinning with formation of a defective callus. The nonunion persisted after pinning and hydrogel without cell seeding. New bone formation was moderate and predominated on the borders of the bone resection. After pinning associated with cell seeded hydrogel, an osteogenic lamina arose from the hydrogel network. This osteogenesis was continuous with osteogenesis originating from the bone section cut.

Discussion: These findings demonstrate that associated a hydrogel with bone stem cells can produce more significant bone formation than in controls, confirming the animal model. Treatment of major bone loss and aseptic osteonecrosis after curettage could be proposed with this new biomaterial combining a hydrogel and CD34+ stem cells in humans.

Purpose: Joint cartilage repair is one of the most widely studies aspects of orthopedic care. The tissue’s intrinsic capacity to repair degenerative, inflammatory or trauma-induce damage is low. The purpose of this study was to report early results obtained with an allograft using a hybrid biocartilage in the rabbit.

Material and methods: Chondrocytes obtained by successive enzymatic digestion of joint cartilage from the knee joint were implanted via medial arthrotomy into an osteo-cartilaginous knee defect measuring 4 cm in diameter and 3 mm in depth produced by trepanation of the tronchlea. Both knees were operated in six adult New Zealand rabbits. After eight weeks, the animals were assessed clinically then sacrificed. The femoral condyles were removed for histological study. All grafted joints were mobile and had normal function without risk of self-mutilation.

Results: The joint samples did not show any evidence of effusion. The implant site was still visible macroscopically and presented a cartilaginous surface continuous with the healthy cartilage. After HES staining, the distal pole of the implant was found to be colonised with young cartilage continuous with the trochlear cartilage. Enchondral ossification appeared to be present in the distal part of certain cartilaginous nodules with a bony lamina continuous with the adjacent subchondral bone. There was no evidence of an inflammatory reaction of the synovial and the patellar cartilage was normal.

Discussion: These preliminary results of a hybrid biocartilage graft combined with cartilage surface reconstruction and osteointegration of the deep implant without in vivo supply of growth factors are encouraging. The safety of the supporting material was demonstrated. We are currently working on developing an autograft from progenitor cells.

Purpose of the study: Sports activities requiring antepulsion, adduction and medial rotation can favor the development of posterior instability of the shoulder. Conservative treatment is indicated, but many techniques have been proposed in case of failure. All do not allow recovery of the same sports level. We report our experience with six cases of posterior shoulder instability treated with a Gosset posterior bone block.

Material and methods: We retrospectively reviewed cases treated between 1974 and 1995. Six athletes, aged 17 to 34 years (mean 25 years) underwent posterior bone block surgery using the Gosset procedure on their dominant shoulder. Three of the patients had experienced involuntary dislocation and three others involuntary and voluntary dislocation. One patient had a multidirectional hyperlaxity. Five patients had participated in rehabilitation programs for at least five months. Two patients had undergone unsuccessful bone block surgery in another unit.

Results: Stability and pain relief were achieved in all cases. Three patients recovered complete mobility. In the three others, mean limitation of mobility for the different sectors was 15°. There has been no sign of osteoarthrosis at three years follow-up. All patients have resumed their sports activities, three at the same level.

Discussion: In our experience, most surgical techniques proposed for the treatment of posterior shoulder instability are unsuccessful. The Gosset iliac bone block prolongs the articular surface. After consolidation, it allows sports activities requiring shoulder force and provides satisfactory mobility.