For many surgeons amputation is the usual treatment in sarcoma of the foot. The aim of our study was to report the functional and oncologic results of treatment in 54 sarcomas of the foot to assess if conservative treatment was acceptable

We retrospectively reviewed the records of 54 patients with sarcomas of the foot, aged 6 to 50 (mean 17), 30 females and 26 males. At time of referral, 18 had a local recurrence of a previous inadequate treatment. There were 27 soft tissue sarcomas (STS: 10 synovial sarcomas, 6 rhadomyosarcomas, 1 liposarcomas and 10 others) and 27 bone tumours (16 Ewing's, 8 chondrosarcomas, 3 osteosarcomas). Toes tumours were excluded, 18 tumours involved the metatarsal, 12 the plantar soft tissues, 11 the calcaneum, 3 the talus, 2 the midtarsal bones.

Surgery consisted in 19 resection without reconstruction, 21 resections with bone reconstruction, 9 partial amputations of the foot, and 6 trans tibial amputations.

In 34 cases surgical margins were adequate (R0), in 13 patients resection was inadequate (9 R1 and 4 R2). In 7 cases the margins were not assessed.

After a 5.5 years average follow-up (3m to 17y), 31 patients had no evidence of disease, 8 were in second remission, 4 had an evolutive disease and 11 were deceased. The mean MSTS score was 26/30 (31 cases).

In conclusion, a conservative treatment is feasible in metatarsal bones with skin coverage by flap if necessary. In STS adequate margins are difficult to achieve with a high rate of local recurrence. In calcaneus and talus, a conservative treatment is possible in tumours limited to bone after good response to chemotherapy. In other cases conservative treatment is debatable because amputation gives excellent functional results.

Purpose of the study: We present the clinical and radiologic results of a prospective series of 20 patients who had percutaneous osteosynthesis of the thoracolumbar spine using a longitudinal system with monoaxial screws.

Material and methods: Twenty patients, 12 women, were treated from February 2008 to February 2009. Mean age was 44 years (15–61 years). Fractures were from T4 to L5, five patients had two levels fractured. There were 18 Magerl A and two type B. None of the patients had neurological problems. The reduction was achieved with a postural method and instrumentation with monoaxial screws using the percutaneous longitudinal method. Two levels were instrumented for 12 patients, three levels for three and five levels for four. Vertebroplasty was associated in nine patients. Pain (VAS), vertebral kyphosis (VK), regional angle (RA) were assessed pre-, postoperatively and at last follow-up. Operative time, blood loss, and duration of hospital stay were noted. Pedicle implantations were controlled on the scanner.

Results: Mean follow-up was ten months (3–19 months). In the preoperative phase, the VAS was 7/10, VK 17 (8–26), RA 16.6 (4–30). Postoperatively VAS was 4/10), VK 8 (4–15), RA 10.4 (−3 to 27). AT last follow-up VK was 8.5 and RA 12. Mean operative time was 90 minutes (40–180). On the postoperative scan, 23 of the 106 screws implanted had an extraosseous position (21%) including seven cranial screws. None of the patients developed a neurological deficit postoperatively. The first rise from bed was on day 1 in 14 patients. Mean duration of hospital stay was eight days (6–35).

Discussion: This reduction method provides a gain in VK (−9), a value between orthopaedic treatment (−8 gain) and surgical treatment as reported at the Sofcot in 1995 (−11.1 gain). The reduction was maintained well without loss at last follow-up.

Conclusion: This technique allows assembly of more or less long rigid configurations depending on the injury levels, with satisfactory reduction which is sustained over time. Blood loss is zero with little pain in the postoperative period.

Following orthopaedic reconstruction and cranial neurosurgery, spine surgery is now entering its low invasive period. When, in 90’s, computer went routinely available in the surgical field, the main goal was to help surgeons operate on with more accuracy some difficult but standard procedures. The surgery was “computer aided”. The displayed tools on 2D or 3D images allowed surgeons to avoid permanent intra operative landmarks. Once patient personal anatomy was capture into the machine and the tools calibrated, the surgeon was able to plan and optimised ideal trajectories without direct vision to check tools position. “Navigation” starts to be more obvious to describe this intra operative control. Anyway, we still needed large exposure to get the full bone surface in order to build a 3D surface based model. This model optically localised was matched using rigid or elastic algorithm with preoperative CT scan model or bone morphing^®. Ultrasound recognition of the soft tissue/bone interface let think about trans cutaneous palpation. However, automatic segmentation of the bone surface never lead to commercially available soft. Only X-ray is commonly use during surgery to help surgeon to see tools and bone without surgical exposure. Fluoroscopy allows percutaneous trajectory as iliosacral screwing, vertebroplasty, fracture nailing et caetera. Radiation exposition could therefore be an issue for patient but also for surgeon. Fluoronavigation is a good response to percutaneous surgery. In spine no transversal view could be available. Surgeons should make mental reconstruction of the volume to perform the right trajectory. Industrial proposed intra operative tomography on C-arm with 3D reconstruction. It works well for limbs, but in thoracic and lumbar spine the large amount of surrounding soft tissues leads to low quality images. Flat panel X-ray receptor are a path to get more accurate images. Other perspectives are circular intra CT scan. The cost and the volume of machines stops the spread of such device.

Robots are used by knee surgeons but abandoned by hip surgeons. In spine tool holder robot are available in order to place a pedicular drill guide. Matching with bone is based on fluoroscopy.

Spine navigation could be useful to e-leaning and simulators too. The training of percutaneous surgery is long, because of mental matching between fluoroscopic 2D projections and the vertebra volume. We need a simulator allowing 3D virtual trajectory checked on AP and lateral view to short the learning curve.

Purpose of the study: Prenatal screening and search for risk factors has lead to early diagnosis of congenital hip dysplasia. The percent of excentration of the dysplastic hip can be quantified with ultrasonography. The purpose of this study was to evaluate the usefulness of ultrasound monitoring of confirmed hip dysplasia as a method for determining the appropriate time to discontinue treatment.

Material and methods: We collected a series of patients presenting unstable hips one month after birth. Ultrasonographic examinations were performed to quantify the instability. Initial treatment was forced abduction. If the infant’s weight was greater than 5.6 kg, a Pavlik harness was used. Physical examination and control ultrasound examinations were performed at 4, 8 and 12 weeks. Forced abduction and ultrasound surveillance were discontinued when the percent of acetabular cover was greater than 50%. Long-term surveillance consisted in physical examination and plain ap view of the pelvis at four months and at onset of walking.

Results: Ultrasound monitoring was instituted for 71 hips in 51 patients. Mean age at onset of the monitoring scheme was 37.7 days (range 38–74 days). Mean acetabular cover, as evaluated by ultrasound before treatment, was 35.5% (range 20–45%). After four weeks, mean cover for 42 hips was 54.7% (range 50–85%). For the other 29 hips, mean acetabular cover was 41.4% (range 36–47%) at four weeks. At eight weeks, 26 of these 29 hips had a mean cover of 60% (52–85%). Acetabular cover remained below 50% for three hips at twelve weeks. Mean HTE at four months was 20.7° (range 10–26°). At walking, all hips were centered and no irregularities were noted on the x-rays of the femoral nucleus.

Discussion: The majority of infants with unstable hips diagnosed at birth achieve spontaneous cure without treatment. For others, cure can be achieved with forced abduction but with a risk of osteochondritis. In our study, ultrasound monitoring enabled a reliable assessment of the proper moment to interrupt treatment.

Conclusion: Ultrasound examination of the hip joint is a satisfactory method for monitoring hip dysplasia in infants aged less than four months. It appears to be useful for determining the moment to interrupt treatment.

Purpose of the study: We describe a surgery navigation system based on virtual fluoroscopy images established with a 3D optic localizer. The purpose of this work was to check the accuracy of the system for posterior spinal implants in comparison with conventional surgery. Duration of radiation and duration of surgery were compared.

Material and methods: A 3D optic localizer was used to monitor the position of the instruments in the operative field, as well as the fluoroscopy receptor. The surgeon took two views, ap and lateral, with a total exposure of two seconds. The C arm was then removed. After image correction, the ap and lateral views were displayed on the work station screen where the computer superimposed to tools on each image. Twenty osteosynthesis procedures for implantation of pedicular screws via a posterior approach to the thoracolumbar spine were performed with this virtual fluoroscopy technique (20 patients, 68 screws). During the same study period, twenty other procedures were performed with the conventional technique (ap and lateral x-ray with the C-arm after drilling the pedicle, 20 patients, 72 screws). The position of the spinal implants was compared between the two series on the ap and lateral views and postoperative CT. Similarly time of exposure to x-rays and duration of the surgical procedure were recorded.

Results: The rate of strictly intrapedicular implantation was less than 8% (5/68 screws) in the virtual fluoroscopy series versus 15% (11/72 screws) in the conventional series. Time of exposure to radiation was significantly lower in the virtual fluoroscopy series with a 1 to 3 improvement (3.5 s versus 11.5 s on average) over the conventional method. With training, this method is not more time consuming (10 min per screw for the conventional method versus 11.25 min for virtual fluoroscopy).

Discussion and conclusion: Compared with conventional fluoroscopy, the virtual technique enables real time navigation while significantly reducing the dose of radiation, both for the patient and the surgery team. There are two types of advantages of virtual fluoroscopy over CT-based systems: first virtual fluoroscopy is immediately available without specific preoperative imaging and secondly it provides real non-magnified images acquired once during the procedure, after which the C-arm is removed. 3D virtual fluoroscopy is probably the next step but requires further experience.

Purpose of the study: Appropriate treatment of displaced supracondylar fractures of the distal humerus in children remains a controversial topic. Blount reduction followed by percutaneous or open pin fixation have been widely used. The purpose of this study was to analyze outcome after open surgical treatment of these fractures in pediatric trauma victims.

Material and methods: The study included all pediatric patients who underwent surgical treatment for displaced supracondylar fractures of the distal humerus over a ten year period. Fractures were classified III or IV according to Lagrange and Rigault. Cross pinning was used in all cases, via a posterior approach or a double lateral and medial approach. The mechanism of the fracture and pre- and postoperative vascular and neurological complications were noted. The long-term assessment included standard x-rays of the elbow joint (ap and lateral views) and a physical examination to search for misalignment and residual neurological disorders.

Results: We identified 110 patients, 61 boys and 49 girls, mean age 7.61 years (range 2–15 years). There were 96 grade IV fractures and 24 grade III. Mechanisms were: sports accident (n=44), fall from height (n=36), fall from own height (n=30). A neurological complication was observed in 29 children, skin opening in three and regressive vascular damage in six. A posterior approach was used for 95 patients and a double approach for 15. There was one revision for secondary displacement. Five patients developed transient paresthesia of the ulnar nerve which resolved without sequela. Three patients presented a moderately hypertrophic or deformed callus which had little functional impact. One patient with an open fracture required surgerical arthrolysis for stiffness six months after fracture.

Discussion and conclusion: Open surgery is a very reliable treatment for supracondylar elbow fractures with a low rate of short- and long-term complications. Ulnar nerve palsy, the classical complication of percutaneous cross pinning, can be attributed to the medial pin (7–16% of cases in the literature). The Blount method and Judet or Métaizeau fixations can sometimes be complicated by secondary displacement or a deformed callus, complications which were almost never observed in our series. The results obtained in this series favor our approach for open surgery for the treatment of displaced supracondylar fractures of the distal humerus in children.

Purpose: The purpose of this work was to study the reliability and the precision of a lumber vertebra reconstruction method using images obtained from a 3D statistical model and two calibrated radiograms. The technique is designed for surgical approach to the lumbar spine and implantation of osteosynthesis material using enhanced-reality technology.

Material and methods: A lumbar vertebra was reconstructed on several specimens using images issuing from a 3D statistical model and two calibrated radiograms. The images obtained from the model of this lumbar vertebra to be reconstructed constituted the preoperative images. Intra-operative images corresponded to two calibrated radiograms acquired with a fluoroscope using advanced technology (silicium receptor). The model was equipped with reflecting patches which can be detected in space using a 3D optical system. Correspondence between the 3D statistical model and the two calibrated radiograms was achieved with appropriate software. Navigation views were displayed on the screen to guide surgical tools at the vertebral level. Pedicular screws were implanted into several anatomic specimens to evaluate the reliability and precision of the system. The exact position of the implanted screws was established with computed tomography.

Results: This system demonstrated its reliability and precision for the reconstruction of a lumbar vertebra from a 3D statistical model and two calibrated radiograms. All the implanted screws were perfectly positioned in the pedicles. Precision was to the order of 1 mm.

Discussion: This method is a passive system not requiring intraoperative intervention. Reconstruction of a lumbar vertebra from a preoperative 3D statistical model and two intra-operative calibrated radiograms avoids the need to identify anatomic landmarks and/or surface points on the vertebra to be reconstructed. The level of precision is very similar to that obtained with CT-based systems. Preoperative CT is not needed for navigation.

Conclusion: With this system, new generation fluoroscopic equipment should appear in the operating room, allowing acquisition of successive calibrated images. The digital data could then be matched with statistical anatomic data, avoiding the need for preoperative imaging (CT or MRI). Progressive introduction of intra-operative ultrasound to replace the calibrated radiograms should open a new approach for percutaneous surgery of the lumbar spine.

Purpose: This study analysed nerve trunk injury associated with posterior fractures of the pelvic girdle, distinguishing initial post-trauma damage from morbidity correlated to treatment by reduction and iliosacral screw fixation.

Material: Fifty bone or ligament injuries to the posterior pelvic girdle were identified in 44 patients. Management included initial external reduction and differed fixation using iliosacral screws inserted under fluorescence guidance.

Methods: The metameric examination of the lumbar and sacral trunks (L2, L3, L4, L5, S1, S2, S3) was performed at admission when the patient was conscious. The postoperative work-up included a complete neurological exam and computed tomography assessment of the screw trajectory. The quality of the reduction was quantified on the anterioposterior view of the pelvis. At last follow-up, evolution of symptoms ± EMG, Trendenburg gait, Mageed score, QMS score and pain (assessed on a visual analogue scale) were recorded.

Results: Preoperatively, 14 deficits of the nerve trunks were identified. The neurological status was unknown for eleven bone and ligament injuries because the patients were sedated at admission. Postoperatively, 28 deficits were identified. Fourteen (50%) involved the lumbosacral trunks L4 and L5, five the S1 root, six L4, L5, S1 territories, and three L5 to S4.

Computed tomography demonstrated 15 extraosseous screws lying anteriorly to the sacral ala or in the sacral canal. These extraosseous screws were associated with neurological deficits in nine cases without a preoperative diagnosis. In six cases, the extra-ossesous screw was not associated with any postoperative deficit. In five cases, neurological lesions diagnosed after the operation were not associated with an extra-osseous screw. Twenty-six neurological lesions were reviewed at a mean follow-up of 25 months: improvement was observed in 19, no change in five and aggravation in two.

Conclusion: Initial diagnosis of neurological injury with precision of the localisation can be established for only half of pelvic girdle fractures. The main mechanism involves stretching of the lumbosacral trunk by displacement of the sacral ala. Injury to the superior gluteal nerve is often associated. Closed reduction or compression of a nerve trapped in the fracture gap during screw fixation could be a second mechanism. Finally, rigorous screw insertion is necessary to avoid extra-osseous trajectories lying anteriorly to the sacral ala.

Purpose: Injury of both cruciate ligaments raises difficult therapeutic problems in trauma victims. The severity of such lesions is related to the context of multiple trauma and to the general regional context associating vascular and neurological injury. Therapeutic management should be multidisciplinary to determine the appropriate strategy. Orthopaedic treatment should take into account the different diagnostic and therapeutic aspects. The purpose of this work was to detail ligament injuries observed and to assess results of treatments proposed.

Material and methods: This retrospective series included 20 patients (14 men and 6 women), mean age 33 years (18–54). Five had multiple trauma with head injuries and multiple fractures. The initial diagnosis was traumatic knee dislocation in 14 patients. Seven patients underwent emergency vascular explorations with subsequent femoropopliteal bypass (n=3). Neurological lesions included three cases of complete section of the lateral popliteal sciatic. Orthopaedic treatment was used in three cases. We used external fixation for two months on the average in three patients. Six others underwent surgery (less than eight days after injury) after obtaining an MRI. The surgical strategy was based on several arguments: age, general status, level of the ligament injury. Three patients underwent secondary surgery on the anterior cruciate ligament. Outcome was assessed at a mean follow-up of 36 months (20–60). The clinical assessment of the objective result was based on frontal and sagittal laxity. The subjective result and the level of sports activities were also recorded. Radiographically, we studied the standard x-rays in single leg stance and also the stress images using telos with anterior then posterior drawer.

Results: Excepting one case of amputation necessary due to the vascular and nervous injuries, orthopaedic treatment allowed an acceptable functional result in sedentary patients: good frontal stability and minimal anteroposterior residual laxity. Fourteen athletes underwent emergency surgery to repair the posterior cruciate ligament: posterior approaches in eight knees with injury of the floor with no posterior drawer at last follow-up; anterior approaches in six knees for suture of the posterior cruciate ligament and insertion of a synthetic ligament tutor with anterior cruciate ligament repair during the same operative time (two floor reinsertions, one patellar tendon plasty, and three Cho plasties). The stability of the posterior pivot was excellent but the tibial reinsertions of the anterior cruciate ligament failed. Seven knees required mobilisation under general anaesthesia 2.5 months later. Three knees underwent secondary anterior cruciate repair using the Kenneth Jones technique with negative Lachmann at last follow-up.

Discussion: Excepting vascular and neurological emergencies dictating the initial therapeutic attitude, our orthopaedic management was based on a detailed identification of the lesion using emergency MRI: anterior or posterior approach, anterior cruciate repair technique dependng on association with peripheral ligament injury. Good results in terms of posterior laxity were achieved in this series, confirming the importance of emergency repair of the posterior cruciate. If the medial ligaments are intact, the anterior cruciate can be repaired in the emergency setting with a Cho plasy. In other situations, we prefer waiting before surgical repair of the anterior pivot.

Purpose: The purpose of this work was to compare the precision and reliability of screw fixation using two different guiding systems. The first system was based on computed tomography (CT) imaging and the second on digitalized fluoroscopic imaging.

Material and methods: Between 1998 and 2000, 88 patients underwent spinal fixation for diverse disease states (idiopathic scoliosis in 43, and fracture, spondylolisthesis or instability in 45). Pedicular screws (n = 223) were inserted in levels T4 to S1. The passive CT navigation system was used for 73 patients (177 pedicular screws) and the fluoroscopic navigation system for 15 (46 pedicular screws). An independent observer identified the position of the pedicular screws on the postoperative CT.

Results: Among the 73 patients who underwent a CT-guided procedure (177 pedicular screws) the rate of incorrect screw position was 6.2% (11/117) with = 2 mm penetration of the cortical. Among the 15 patients who underwent a fluoroscopy-guided procedure (46 pedicular screws), the rate of incorrect screw position was 17% (8/46) again with = 2 mm penetration of the cortical. For scoliosis patients, the rate of erroneous screw insertion was 6% for CT navigation and 28% for fluoroscopic navigation. For fractures and degenerative instability, the rates were 6% and 11% respectively.

Discussion: The passive nature of the two navigation systems used do not induce any peroperative constraint on the surgeon. With the CT system, landmarks have to be collected peroperatively on the posterior arch of the operated vertebra, a step that is not needed for the fluoroscopic system. The two techniques appear to be reliable for insertion of pedicular screws. We did not have any neurological disorders in this series. It can be recalled that the conventional method produces a 15 to 40% rate of erroneous insertion. The CT system provides better results for all types of diseases; the improvement is about 6%.

Conclusion: With CT-navigation, a large portion of the per-operative radiographs are no longer necessary. Operative time is slightly longer than for the classical procedure due to the collection of the 3D information, particularly important for scoliosis. With the fluoroscopy system, no special preoperative imaging is required. Two or three peroperative radiographs are sufficient, limiting irradiation during insertion of the pedicular screws. The fluoroscopic system does not however provide 3D images.

Purpose: We present a prospective review of 30 unstable pelvic ring fractures treated with iliosacral screw fixation under fluoroscopic guidance with or without anterior osteo-synthesis.

Material and methods: Thirty patients were included between January 1997 and June 2000. They were all treated in an emergency setting by traction with or without a pelvic clamp. Osteosynthesis was deferred for a mean eight days. Percutaneous iliosacral screw fixation was used in all patients associated with symphsis osteosynthesis in eight. The radioscopic technique used three views: inlet, outlet and lateral. There were three Tile B fractures, 26 Tile C fractures and one sacral fracture. The ISS was 30.8/75. Eleven patients experienced haemorrhagic shock, 16 had injuries to the lower limbs, four had surgical urological injuries, and seven had emergency arterography. A neurology examination and CT scan were obtained pre- and postoperatively. Clinical assessment used a visual analogue scale, the Majeed score, and the WHO score. Peroperative radiation was quantified in minutes, Kvots and mA.

Results: Fifty-one screws were implanted, 24 patients with two screws. There were 12 outside the bone and seven potentially iatrogenic lesions among the 18 neurological lesions observed. Mean radiatio was 1.03 min per patient and 0.6 min per screw. Mean follow-up was 24 months (9–50). Clinically the mean scores were: Majeed 8.5/100, WHO 0.7/3, visual analogue scale 3.2/10). Twenty patients suffered pain related to associated injuries. There were three dismantelings including one requiring revision surgery. Deformed callus was: anterior vertical translation 2.9 mm, posterior vertical translation 4.5 mm and horizontal anterior translation 3 mm. There was one complication for the symphysis fixation.

Discussion: These results are comparable to those reported in the literature. Complications are less frequent with this method. External reduction is good when achieved early. This series represents a learning curve where the 12 screws in extraosseous positions occurred during our first 16 cases. Implanting two screws per articulation increases the risk of extraosseous screws. Screw insertion is safer with the lateral view.

Conclusion: This series demonstrates that iliosacral percutaneous screw fixation is a valid method for the treatment of severe fractures of the pelvic ring. The rigorous method required is emphasised.