Purpose of the study: The purpose of using distal metaphyso-epiphyseal osteotomy to shorten the ulna is to reduce healing time compared with diaphyseal shortening and to adapt the osteotomy to the distal radioulnar anatomy and associated conditions by using a variably oblique cut.

Material and methods: Oblique metaphyso-eiphyseal osteotomy of the distal ulna was performed in sixteen patients since 2000. Fourteen presented ulnocarpal pain. Among these, eight had associated distal radioulnar pain. Two patients had pain essentially limited to the distal radioulnar area. Radiographically, there was ulnocarpal impingement in fourteen wrists, and signs of early-stage distal radioulnar osteoarthritis in five. Local regional anesthesia was used in thirteen patients who underwent surgery in an outpatient clinic. The dorsoulnar approach was used. The direction of the osteotomy cut depended on the individual condition, and distal radioulnar anatomy and stability. Two headless canulated screws were used for fixation. The elbow and wrist were immobilized for three weeks followed by self-education of pronosupination beginning with a removable orthesis to stabilize the wrist.

Results: Outcome was assessed at maximum follow-up of four years. Preoperative pain had totally resolved in fourteen wrists with residual pain at forced pronosupination in two. Wrist motion was not modified in the frontal and sagittal planes. Complete pronosupination range of motion was achieved in thirteen patients, two patients had supination limited to 20° and one had pronation and supination limited to 30°. Force was 90% compared to the opposite side. Bone healing was achieved in all patients, in 3–4 weeks for fourteen wrists and after two months of elbow and wrist immobilization in two.

Discussion: Oblique metaphyso-epiphyseal osteotomy of the distal ulna reduced the healing time compared with diaphyseal shortening osteotomies. This technique enables adaptation of the direction and orientation of the ulnar cut to the individual distal radioulnar anatomy. Favorable clinical outcome in patients with early-stage distal radioulnar osteoarthritis has led us to progressively abandon certain indications for distal resection of the ulna and the Sauvé-Kapankji operation.

Purpose: Osteosynthesis of complex subtrochanteric fractures is a difficult task. Complications are frequent and results are uncertain. Cemented fixation of pathological metastatic fractures requires a major intervention. The functional prognosis remains uncertain. Our objective was to evaluate the contribution of the long gamma nail (50 nails) in this type of situation and to determine its advantages and disadvantages.

Material and methods: The 50 long gamma nails were inserted in 23 women and 26 men who were followed eight months (4–16). We implanted 39 long gamma nails for complex subtrochanteric fractures (AO classification) in patients aged 59 years on average (19–93) and eleven nails for metastatic femur fractures in patients aged 59 years on average (19–93) with a trochanterodiaphyseal localisation. For the non-metastatic fractures, closed nailing was used in 28 patients and minimum opening for eleven. For the metastatic fractures, the primary tumour was known in eleven cases. The nailing was a preventive measure in six and performed after fracture in five. Three patients had plurifocal fractures. We analysed 43 parameters (position of the cervical screw in the four quadrants of the femoral neck and clinical and radiological features).

Results: For the 39 fractures, reduction was anatomic in 24 and with a gap in 15. The position of the cervical nail was correct in 34 cases. It was in the anterosuperior quadrant in three, the posterosuperior quadrant in one and the posteroinferior quadrant in one. Weight bearing was resumed at 1.5 months on average. Healing with total weight bearing was achieved at four months on average (maximum 8 months). Mechanical complications were: migration of the cephalic screw (n=4), rupture of the locking wings (n=9), nail fracture (n=1), non-union (n=2). Total pain relief was achieved for the eleven pathological fractures (maximum follow-up 16 months). Weight-bearing with crutches was possible in seven patients and not possible in four. There was no dismounting. Outcome was comparable with cemented osteosyntheses.

Discussion: For pathological fractures, this less aggressive osteosynthesis provides very effective pain relief. For other complex subtrochanteric fractures, complete closed nailing was not always possible.

Purpose: Talonavicular arthritis, associated or not with rear foot deformity, is common in patients with rheumatoid arthritis. The work by Steinhauser and Gérard demonstrated the usefulness of talonavicular arthrodesis for the treatment of this rear foot disorder. The purpose of this study was to assess outcome after this surgical technique in patients with rheumatoid polyarthritis.

Material and methods: Between 1988 and 1998, 26 feet (24 men, 2 women, 17 right, 7 left) were operated by the same surgeon. Mean age of the patients at surgery was 51 years. Mean delay from disease onset to talonavicular arthrodesis was 13 years. Postoperative immobilisation lasted 45 days. Mean follow-up was five years (1–10).

Results: Patients were very satisfied or satisfied in 92.3% of the cases. Mean pre- and postoperative pain score was 8.14 and 1.77 respectively (p = 0.0001). Normal shoes could be worn by 37.5 and 66.7% of the patients pre- and postoperatively. Patient independence was significantly improved (p = 0.0001). The postoperative analysis of the plantar prints demonstrated pes planus and pes cavus. In 29.2 and 12.5%, the mean postoperative tibiocalcaneal angle was 0.78° with pes varus in eight cases (2°–10°). The mean Djean angle was 122.3° and 122.8° pre- and postoperatively (p = 0.24). Three talocrural joints (11.5%) that were intact preoperatively had degraded at last follow-up. The statistical analysis showed that clinical outcome was not affected by the postoperative aspect of the foot. There were three cases of tight non-union (11.5%) two of which were asymptomatic and two cases of infection (7.5%) requiring revision surgery. These complications led to two poor outcomes.

Discussion: The rate of non-union varies in published series from 3 to 37%. The rate observed in our series has led us to delay weight bearing. The residual varus found in eight feet, related to a shortened medial column, may warrant intertalonavicular grafting.

Conclusion: Talonavicular arthrodesis is a useful procedure despite a significant risk of complications.