Purpose of the study: We reviewed traumatic distal leg amputations managed in our unit between 1990 and 1993. Reimplantation or unilateral emergency revascularization were undertaken in five cases.

Material and methods: The initial loss of length was considerable (range 8.5–12 cm) allowing direct internal fixation, protected with an external fixator bridging the ankle, and direct vasculonervous suture. Secondary lengthening was undertaken early in the proximal metaphyseal zone before sensorial recovery was complete.

Results: Healing was achieved within a normal delay in all cases. Nerve regeneration was monitored from the site of the microsuture by following the progression of the Tinel sign along the repaired nerve trunks; this defined the rate of regeneration. Our observations showed that nerve lengthening above the site of the microsurgical suture did not hinder nerve regeneration and even appear to stimulate it.

Conclusion: This strategy of extensive initial debridement compensated for by significant but well-tolerated secondary lengthening enabled us to broaden indications for unilateral leg reimplantations. The quality of the functional results at follow-up extending up to 15 years is probably one of the reasons justifying this strategy.

Purpose of the study: Fragile bone and weak soft tissues can create a serious challenge for arthroplasty of the rheumatoid arthritis shoulder. Patients seen late after rotator cuff tears become irreparable may also present a stiff shoulder, further complicating the procedure.

Material and methods: The purpose of this study was to assess outcome at more than five years in a prospective series of 12 patients with rheumatoid arthritis of the shoulder with an irreparable rotator cuff tear treated with a hemiarthroplasty with a mobile cup. The radiological and clinical results were compared with those obtained in a control series of ten bipolar humeral prostheses implanted for centered or excentered degenerative disease with irreparable cuff tears.

Results: The mean preoperative Constant score was 16.9 points: pain 2.5, activity 4.2, active mobility 9.5, strength 0.7. Active ROM was 63.8° for anterior elevation, 45° for abduction, and 12° for external rotation. At last follow-up, the mean postoperative Constant score was 39.4 points: pain 10.7, activity 10.8, active mobility 13.8, strength 4.1. Mean active anterior elevation was 83.7°, abduction 70.4°, and external rotation 29.1°. Outcome was not significantly different from the control group with degenerative joint disease (p< 0.05).

Discussion: The overall Constant score, especially the pain score, was significantly improved (p< 0.05). Improvement in joint motion was modest but comparable with other series in the literature and even better than with conventional hemiarthroplasty for the same indication. There were few complications, mainly superior subluxation favored by the preoperative infra-scapularis or infraspinatus tears. Glenoid wear was significant despite the dual mobility concept. There were no cases of loosening.

Conclusion: These results show that hemiarthroplasty with a mobile cut provides acceptable mid-term results for the advanced-stage rheumatoid shoulder with an irreparable rotator cuff tear. Results in this series were comparable with that in the control group of patients with degenerative joint disease. Consequently, the status of the rotator cuff appears to be more important that the inflammatory or degenerative etiology. Certain cuff tears involving the infrascapularis raise the risk of superoanterior instability and could be a limitation for this method. A more constrained prosthesis might be advisable.

Purpose: Isolated tumours of the peripheral nerves are exceptional and benign in 90% of the cases. They develop from the constitutive elements of the nerve and correspond to schwannomas in 80% of cases. Other tumours are much more rare and exhibit wide histological variability.

Material and methods: Fifty-one patients were reviewed at mean 4.6 years. Forty-one had a resectable tumour: schwannoma (n=39), intranervous lipoma (n=2). Ten an unresectable tumour: solitary neurofibroma (n=5), peri-nervous hemangioma (n=3), neurofibrolipoma (n=2). We detailed the type of lesion, diagnostic elements, and results of complementary explorations. Enucleation was performed for resectable tumours. Epineurotomy for decompression with systematic interfascicular biopsy was performed in the event of an unresectable tumour.

Results: Postoperative neurological deficits were exceptional and transient. In a first case, prognosis was excellent due to the absence of recurrence or degeneration. In the second, neurological disorders persisted but decreased (paraesthesia). The course remained stable.

Discussion: Our findings are in line with reports in the literature. The diagnosis of nerve tumour should be entertained in the event of tumefaction along a nerve trajectory or if palpation triggers pain. MRI is the most powerful complementary exploration, particularly for deep tumours. The nature of the tumour, its benignity, and the possibility for resection can be suspected on the basis of clinical and complementary findings, but surgery and pathology examination of the surgical specimen are required for confirmation. Preservation of nerve continuity is the key to the therapeutic approach. For resectable tumours, exceptional persistence of symptoms should be followed by a new exploration to search for small unrecognised tumour(s) at the same operative site. For all other cases, recent and rapid changes in the clinical presentation is a sign of recurrence and requires appropriate intervention. To our knowledge, malignant degeneration has never been observed.

Conclusion: First-intention resection of a nerve with a nerve tumour is never indicated.

Purpose: We conducted a retrospective study of 20 total elbow prostheses GUEPAR humerocubital and humeroradial (G3) implanted in 19 patients with rheumatoid arthritis. This anatomic metal-polyethylene prosthesis is available in a left and right model and in two sizes, large and small. A radial head prosthesis is now available in addition to the humerocubital prosthesis. The radial head prosthesis has an intramedullary metallic stem and a mobile polyethylene cup which comes in several sizes.

Material and methods: Among 20 prostheses implanted between 1997 and 2001, four were first-generation prostheses which did not have a radial head. At three to four years, these four prostheses developed valgus instability with deterioration of the polyethylene of the cubital piece requiring revision with a new generation GUEPAR associated with a radial head. This gave two good results and two failures revised with a semi-constrained prosthesis. For the 16 other cases of rheumatoid disease, the G3 humerocubital prosthesis associated with a radial head was inserted. These 16 prostheses were followed two years and were retained for this analysis. The posterior approach was used with inverted-V section of the triceps using the surgical technique recommended by the promoters. Patients had permanent severe to moderate pain. The Mayo Clinic score (1992 including daily life activities) was 33/100. Radiographically, seven elbows were Larsen grade III, nine grade IV, seven grade IIA and nine grade IIIb (Larsen classification modified by the Mayo Clinic).

Results: All patients were reviewed with mean follow-up of two years (1–5). The Mayo Clinic score improved from 33/100 to33/90 with outcome considered excellent in 15 elbows and fair in one.

Discussion: We recommend total elbow prostheses for rheumatoid arthritis patients. Semi-constrained prostheses have indications in certain cases of massive destruction, but the minimally or non-constrained gliding prostheses, such as the GUEPAR prosthesis, are part of the evolution of these prostheses, just as was the case for knee prostheses. These good results can be expected to persist over time.

Purpose: We reviewed retrospectively 22 patients with recent and old fractures of the radial head treated with the GUEPAR radial head prosthesis which has a mobile metal cup derived from the GUEPAR gliding total elbow prosthesis.

Material and methods: Among the 22 patients, 13 underwent surgery in an emergency setting and four underwent a secondary procedure. Mean age was 41 years and follow-up was 18 months. The Mayo Clinic score was noted. Fractures were total or disengaged cervical fractures and in 72% of the elbows dislocation was associated. The coronoid process was fixed in one elbow, the olecranon in one and the medial ligaments were repaired in five. The status of the humeral condyle was examined in detail before insertion of the prosthesis. We also were particularly attentive concerning the height position of the prosthesis.

Results: There were no complications. Outcome was good among the patients undergoing an emergency procedure with a mean Mayo Clinic score of 83/100, mean force 75%, good motion, particularly 77° pronation, and 79° supination, with good stability and absence of wrist problems. The patients who underwent a secondary procedure had less satisfactory results, particularly for motion (44° pronation and 54° supination). The distal radioulnar index was not perfectly restored. Finally four patients had arthrolysis for limited flexion/extension, three of them in the secondary group.

Discussion: Resection of the radial head is an alternative for complex fractures that has its inconveniences. The first is that it destabilises the elbow in valgus position in the event of injury to the medial ligaments and the second is the ascension of the radius in the event of injury to the interosseous membrane. Fixation is another alternative, but it is difficult and has not provided good results in our hands or in the literature (we have compared this series with a series of 20 fixations for equivalent fractures). The prosthesis appears to be a good solution: it stabilises the elbow, prevents ascension of the radius, allows early rehabilitation, and provides good subjective outcome, particularly in emergency cases.

Purpose: Scaphotrapezotrapezoidal (STT) pain is common but often asymptomatic. Medical treatment may be proposed if symptoms become bothersome. In case of failure, several surgical solutions may be proposed. The purpose of this work was to assess outcome in a series of eleven STT arthrodeses performed for isolated STT osteoarthritis.

Material and methods: Ten patients, three men and seven women (11 hands), mean age 63 years, developed STT osteoarthritis which was treated by arthrodesis. All patients experienced pain for daily life activities and had diminished wrist movement. According to the Crosby radiographic classification, three were one grade I, four grade II, and five grade II with carpal misalignmen t. One patient had chondrocalcinosis and six had tendinitis of the flexor carpi radialis. The anterior approach was used for three patients and the lateral approach for seven. Nine patients had an iliac graft to fill bony defects resulting from anterior wear. Pin fixation was used in six cases and staple fixation in five. An antebrachiopalmar cast was maintained for at least six weeks after surgery.

Results: At mean follow-up of 62 months, the pain score improved in all patients (p=0.05). There was no significant difference in motion, excepting decreased wrist extension (12°, p=0.03). Grasp and pinch force were not modified by STT arthrodesis. All patients were able to resume their former recreational and occupational activities. There was no worsening of the five cases with intracarpial deaxation. Four patients developed non-union (three pin fixations, one staple fixation), which was symptomatic in only two. These patients underwent successful revision using the same fixation technique. There were no complications.

Discussion: Like other series reported in the literature, our series of STT arthrodeses demonstrated effective pain relief. However, unlike former work, we were unable to obtain a significant reduction in the radial inclination force, or radio-carpal conflict. The other therapeutic option is resection of the distal pole of the scaphoid which provides more rapid clinical results but which leads to inevitable misalignment of the carpus.

Conclusion: We have decided to retain STT arthrodesis with iliac graft for patients with STT osteoarthritis, especially for young patients.

Solitary tumors of the peripheral nerves are uncommon and found to be benign in 90 p. 100 of the cases. They develop from the elements constituting the nerve and are generally schwannomas (80 p. 100). Other tumors are much more exceptional and exhibit wide histological variability.

The diagnosis of a tumor of the peripheral nerve must be envisaged for all cases with tumefaction or pain on the path of a nerve exacerbated at percussion. Magnetic resonance imaging is the preferred exploration technique, particularly useful in case of a deep tumor.

Preservation of nerve continuity is the underlying goal of the therapeutic strategy, irrespective of the type of tumor. Extricable tumors are to be distinguished from inextricable tumors. Extricable tumors (schwannomas, intranervous lipomas) displace nerve fiber bundles without penetrating into the bundle itself and can thus be resected without interrupting nerve continuity. Prognosis is excellent if no recurrence or degeneration occurs. In case of persistent symptoms, a new exploration may be required to search for other localized tumor(s) unperceived at the first procedure. Inextricable tumors (solitary neurofibromas, hemangiomas of the Schwann sheath, neurofibrolipomas) infiltrate the structural elements of the nerve fibers making complete excision impossible without altering the nerve fibers. Epineurotomy (associated with an interfascicular biopsy for pathology examination) allows decompression and can often provide symptom relief although moderate paresthesia may persist. Patients must be informed of this possibility prior to surgery. Any recent and rapidly evolving modification in the clinical findings is suggestive of recurrence and should be followed by revision exploration. Malignant degeneration has not been observed in solitary tumors to our knowledge. Our own experience with 51 cases is generally in agreement with reports in the literature.

Purpose: Nonunion of the humeral shaft is an uncommon complication of diaphyseal fractures. The rate of nonunion reported in the literature is nevertheless very variable, ranging from 1 to 10%. There are many causal and favouring factors often related to a technical error or poor therapeutic indication. There are several ways to treat humeral shaft fractures (orthopaedic treatment, locked centromedullary nail, ascending pinning, plate fixation, external fixation). Rigorous technique and rigorous indications are the key to success.

Material and methods: We reviewed 35 patients with aseptic nonunion of the humeral shaft between 1995 and 2000. The nonunion resulted from imperfect initial treatment in 24. Mean age was 44 years; fracture of the mid third of the shaft was oblique or transverse in general; all types of initial treatments had been used but ascending pins predominated (16 cases). All patients were reoperated for external plate fixation with a cancellous or corticocancellous bone graft after identifying the radial nerve.

Results: All patients achieved consolidation within a mean delay of 15 weeks with good shoulder (mean elevation 135°) and elbow (mean 10–130°) amplitudes. There were two cases of transient radial paresis with spontaneous recovery. Only two patients experienced mild arm pain that did not required long-term antalgesic treatment. There were no injuries to the femorocutaneous nerve at the site of graft harvesting.

Discussion: Plate fixation for nonunion of the humerus is widely described in the literature. The main complications with this method include radial paralysis and infection. For this reason, several recent reports have advocated locked nailing or external fixation of the Ilizarov type. These methods are technically difficult and are not free of their own complications. We thus recommend screw plate fixation (eight cortical screws on either side of the nonunion) associated with cancellous bone grafts. The results in our series with almost no complications favour this option.

Purpose: The serratus anterior, innervated by the Charles Bell nerve, contributes to dynamic abduction and elevation of the shoulder by stabilising the scapula on the thorax. Abduction and elevation beyond 90° or movement of the spinal border of the scapula is impossible in case of serratus anterior paralysis.

Material and methods: This series included 16 patients with traumatic damage to the Charles Bell nerve leading to unique paralysis of the serratus anterior. Mean age of the patients at diagnosis was 27.5 years. Nine patients underwent scapulothoracic arthrodesis or scapulopexia and seven patients were not operated due to spontaneous total or partial recovery.

Results: Initial elevation in the non operated group was 125°. At five years elevation was 145°, Constant score was 85, and shoulder abduction force was 12 kg (83% of the contralateral force). Final outcome was very good in four patients, good in one, fair in one and poor in one (the fair and poor outcomes involved severe pain for one and major loss of force for the other). Preoperative elevation in the operated group was 95°, reaching 104° at last follow-up. At four years, elevation was 104°, Constant score was 75, and shoulder abduction force was 9 kg (72% of the contralateral force). One case of infection required revision and healed satisfactorily. Outcome was very good in six patients and good in three.

Discussion: Several types of treatment can be proposed: non-surgical care, muscle transfer basically with the pectoralis major, and scapulothoracic arthrodesis. The principal series reported in the literature on scapulothoracic arthrodesis concern patients with fascioscapulohumeral dystrophy and are not comparable with our series. It would be possible to compare our patients with series of post-trauma paralysis using muscle transfer which have given good results for mobility but limited improvement in global muscle force. In our patients, scapulothoracic arthrodesis gave good results in terms of muscle force, pain and overall shoulder function; mobility was fixed by the position of the scapula in the arthrodesis. We advocate this method for the treatment of serratus anterior paralysis mainly in manual labourers.

Purpose of the study: Proximal replantation is a technically feasible but life-threatening procedure. Indications must be restricted to patients in good condition with a good functional prognosis. The goal of replantation must be focused not only on reimplanting the amputated limb but also on achieving a good functional outcome. For the lower limb, simple terminalization remains the best choice in many cases. When a proximal amputation is not suitable for replantation, the main aim of the surgical procedure must be to reconstruct a stump long enough to permit fitting a prosthesis preserving the function of the adjacent joint. If the proximal stump beyond the last joint is very short, it may be possible to restore some length by partial replantation of spared tissues from the amputated part. We present here the results we obtained following this policy.

Materials and methods: This series included 16 cases of partial replantations, 14 involving the lower limb and 2 the upper limb. All were osteocutaneous microsurgical transfers. For the lower limb, all transfers recovered protective sensitivity following tibial nerve repair. The functional calcaeoplantar unit was used in 13 cases. The transfer of this specialized weight bearing tissue provided a stable distal surface making higher support unnecessary. In one case, we raised a 13-cm vascularized tibial segment covered with foot skin for additional length. For the upper limb, the osteocutaneous transfer, based on the radial artery, was not reinnervated, but this lack of sensitivity did not impair prosthesis fitting.

Results: One vascular failure was finally amputated. This was the only unsuccessful result. For all other patients, the surgical procedure facilitated prosthesis fitting and preserved the proximal joint function despite an initially very proximal amputation.

Discussion: The advantages of partial replantation are obvious compared with simple terminalization or secondary reconstruction. There is no secondary donor site and, because there is no major muscle mass in the distal fragment, the overall risk is very low compared with the risk of total proximal leg replantation.

Purpose: Trauma to the radial collateral ligaments requires the same attention as trauma to the ulnar ligaments. Damage is uncommon due to the particular anatomic position, but nevertheless a distinct clinical entity.

Material and methods: We report a retrospective analysis of 14 patients, eight who underwent emergency surgery and six with trauma sequelae. Mean follow-up was 22 months and mean age 37 years. Among the recent lesions, the pain score (scale from 1 to 5) was 4.5) and the instability score (scale from 1 to 3) was 3. Palmar subdislocation was 4.8 mm and laxity was 16.7°. Among the old lesions (> 1 month) the corresponding data were pain 3.3, instability 2.5, palmar sub-dislocation 4.2 mm, laxity 19.1°. Two patients had signs of osteoarthritis. At surgery, the phalanx and metacarpus were equally injured. Associated lesions (capsule, short abductor) were present in 78% of the patient. The radial collateral ligaments and the soft tissue were reinserted or retightened in all cases. One patients required arthrodesis due to cartilage damage.

Results: Among the recent injuries, 71% reached a good subjective result: amplitude loss (flexion/extension) was 17°, force was 75% and laxity was 5°. Two patients had palmar subdisloction. Among the older lesions, a good subjective result was achieved in 66%: loss of amplitude case 32°, force was 69% and laxity was 8°. Palmar subdislocation was 2 mm on the average. We had two cases of persistent dysaesthesia.

Discussion: Radial injury appears to be falsely benign because the Stener lesion is not found on this side of the metacarpophalange. The importance of the injury in these traumas is related to the vulnerability of the dorsal region of the medial collateral ligament and is probably the cause of poor outcome after surgery for older lesions with palmar dislocation which is difficult to correct. We advocate emergency surgery for a wide range of indications. We always operate major radial laxity (> 35°) or laxity associated with palmar subdislocation. For other cases, we use the anterior forced drawer view to disclose potential associated dorsal injury.

A mucoid pseudocyst of a peripheral nerve is a rare and benign tumour of controversial origin. We have reviewed ten patients with a mean follow-up of 3.2 years. The tumour affected the common peroneal nerve in eight and the ulnar nerve in two. The mean time between the onset of symptoms and diagnosis was 7.4 months (1.2 months to 2 years). On examination, there was pain in eight patients and swelling in seven. Motor deficit in the corresponding nerve territory was found in all. The diagnosis was usually confirmed by MRI. Treatment was always surgical.

All the patients recovered, with a mean time to neurological recovery of 10.75 months. Recurrence was seen in only one patient and was treated successfully by further surgery. Our results are similar to those reported by other authors. A successful surgical outcome depends on early diagnosis before neurological damage has occurred.