Periprosthetic fracture in the elderly with anatomic modular cementless hemiarthroplasty

BACKGROUND

The use of an anatomic cementless stem in hemiarthroplasties for femoral intracapsular proximal fracture has been debated, notably because of bone weakness and/or morphological defects related to osteoporosis. We therefore conducted a retrospective study in subjects over 75 years of age who had received an anatomic stem partially coated with hydroxyapatite. The objectives were to determine: 1) the incidence of periprosthetic fractures (PPFs) and, 2) the influence of anatomic factors, including the Cortical Bone Ratio (CBR) (the relation between the endosteal and external diameter of the femoral diaphysis 10cm below the lesser trochanter).

HYPOTHESIS

The risk of PPF with an anatomic cementless implant is greater than with cemented stems.

MATERIAL AND METHODS

We retrospectively analyzed 233 patients followed up for 5 years after their surgery. The stem used was an anatomic stem with a modular neck partially coated with hydroxyapatite. The risk factors examined were age, gender, history of osteoporotic fractures, diverse causes of secondary osteoporosis, and proximal bone stock according to various referenced radiological indices such as the CBR.

RESULTS

Twenty patients (15%) were lost to follow-up, 74 had died (32%) but did not undergo revision for PPF, 15 of the 139 survivors at the last follow-up (10.8%) had had a PPF, five (3.6%; four females, one male) were early fractures (≤2 months after implantation), ten (7.2%; two females, eight males) were late fractures (>2 months). Male gender was protective for PPF occurrence (RR=0.129; 95%CI (0.04-0.39); P=0.0003), whereas secondary factors of osteoporosis (RR=2.035; 95%CI (1.11-3.72); P=0.0211), and CBR>0.49 (RR=227.42; 95%CI (1.072-48,226.76); P=0.0471) were found as risk factors of PPF.

DISCUSSION

The PPF rate was greater than that related to cemented stems, requiring that morphological and clinical factors of bone weakness (collected with the patient history and related to osteoporosis) be taken into account. A CBR>0.49 requires caution on the use of this type of stem.

LEVEL OF EVIDENCE

Level 4. Retrospective study.

Clinical results of endoscopic treatment without repair for partial thickness gluteal tears

INTRODUCTION

Various surgical treatments have been proposed for greater trochanteric pain syndrome (GTPS) related to gluteal tendinopathy with partial thickness tears. The clinical results of endoscopic debridement without repair of these gluteal tears are not well known. The objectives of this study were to determine if this procedure leads to: (1) reduction of pain, (2) functional improvement, (3) patient satisfaction (on scale of 0 to 10).

HYPOTHESIS

Endoscopic treatment without tendon repair provides short-term pain relief in patients with GTPS due to partial thickness gluteal tears.

MATERIAL AND METHODS

Seventeen patients (16 women, 1 man) with GTPS due to partial thickness gluteal tears that was present for at least 6 months and was refractory to conservative treatment were included in the analysis. The average age at the time of the procedure was 53.5years (17-71). Pain was evaluated with a visual analogue scale (VAS). Functional outcomes were defined using the Harris Hip Score and the UCLA activity score. Satisfaction was evaluated using a VAS and Odom's criteria.

RESULTS

The average follow-up was 37.6months (12-48). The average preoperative and follow-up values were respectively: (1) Pain: 7.2±1.1 (5-9) versus 3.3±1.9 (1-7) (P<0.001), (2) Harris score: 53.5±8.4 (36-68) versus 79.8±14.7 (45-96) (P<0.001). Seven patients (41.2%) were able to resume sports activities. The average satisfaction score for the surgery was 6.2±2.4 (0-9) at follow-up. Five patients had a poor outcome at the review: four still had pain and one had recurrence of the lateral snapping hip.

CONCLUSION

Endoscopic treatment without repair of partial thickness gluteal tears is a treatment option with modest clinical results for GTPS patients refractory to conservative treatment.

LEVEL OF EVIDENCE

IV, retrospective study.

Clinical results, radiological findings and survival of a proximally hydroxyapatite-coated hip ABG II stem at a minimum of ten years' follow-up: results of a consecutive multicentre study of 1148 hips in 1053 patients

We report a multicentre prospective consecutive study assessing the long-term outcome of the proximally hydroxyapatite (HA)-coated ABG II monobloc femoral component in a series of 1148 hips in 1053 patients with a mean age at surgery of 64.77 years (22 to 80) at a mean follow-up of 10.84 years (10 to 15.25). At latest follow-up, the mean total Harris hip score was 94.7 points (sd; 6.87; 49 to 100), and the mean Merle d'Aubigné-Postel score was 17.6 points (sd 1.12; 7 to 18). The mean total Engh radiological score score was 21.54 (sd 5.77; 3.5 to 27), with 95.81% of 'confirmed ingrowth', according to Engh's classification. With aseptic loosening or pain as endpoints, three AGB II stems (0.26%) failed, giving a 99.7% survival rate (se 0.002; 95% confidence interval (CI) 0.994 to 1) at 14 years' follow-up. The survival of patients ≤ 50 years of age (99.0% (se 0.011; 95% CI 0.969 to 1)) did not differ significantly from those of patients aged > 50 years (99.8% (se 0.002; 95% CI 0.994 to 1)). This study confirmed the excellent long-term results currently achieved with the ABG II proximally HA-coated monobloc stem. Cite this article: Bone Joint J 2013;95-B:1610-16.

Fracture of the lower cervical spine in patients with ankylosing spondylitis: Retrospective study of 19 cases

INTRODUCTION

Controversy exists surrounding optimal treatment of cervical spine fractures secondary to ankylosing spondylitis (AS).

HYPOTHESIS

The anterior approach is an effective surgical technique for these fractures and can be used to correct the AS-induced cervical-thoracic kyphosis.

MATERIALS AND METHODS

This continuous, retrospective series between 1990 and 2010 included 19 patients aged 33 to 84 years who presented with a lower cervical spine fracture in the context of AS. The average follow-up was 45 months. Sixteen of these patients were surgically treated using an anterior approach and anterior fixation. In five patients without any neurological deficit, their cervical-thoracic kyphosis was corrected during the same surgery. Regional kyphosis was measured before the surgery, immediately after the surgery and at the last follow-up.

RESULTS

Five deaths occurred; these were all patients with post-traumatic complete quadriplegia. Most the incomplete neurological problems improved (66%). In no cases did the neurological condition worsen. Among the 16 patients operated with the anterior approach, two patients also required an additional procedure with a posterior approach because of a persistent neurological deficit. The fractures in the operated patients who survived (14 patients) had healed within an average 4-month delay (range 3-7 months), without worsening of the kyphosis at final follow-up. In the five cases where the kyphosis was corrected, the correction averaged 26° (range 18-36°); there were no neurological complications.

DISCUSSION

Based on these results, we suggest using the anterior approach to perform internal fixation as a treatment for cervical fractures secondary to AS and to correct the cervical-thoracic kyphosis in patients without neurological deficits.

LEVEL OF EVIDENCE

Level IV - retrospective study.

Clinical evaluation of hip joint rotation range of motion in adults

INTRODUCTION

Data on hip joint rotation range of motion (ROM) are rare; the methods of measurement vary and reproducibility has not been evaluated, in particular in relation to the subject's position (prone or supine, seated).

HYPOTHESIS

Hip joint rotation ROM is symmetrical, and ROM is not modified by the patient's position when data is obtained.

PATIENTS AND METHODS

This series included 120 adults between 20 and 60 years old (71 women, 49 men), who had no hip, spine or lower extremity disorders. External (ER) and internal (IR) rotation ROM was obtained using a photographic method by two observers. Measurements were obtained with the patient in three positions: the dorsal decubitus (supine) (P1), and ventral decubitus (prone) (P2) with the hip in extension and seated with the hip in flexion (P3).

RESULTS

Hip rotation ROM was P1: 68.1° (ER=38.5°; IR=29.6°); P2: 77.1°(ER=41.8°; IR=35.2°); P3: 78.5° (ER=78.5°; IR=37.9°) with no significant difference among the three positions. Interobserver reproducibility was satisfactory (concordance correlation coefficient (ccc) 0.7) and was comparable in the three positions with a ccc of 0.7072 (P1), 0.7426 (P2) and 0.7332 (P3), respectively. Hip rotation ROM balance was ER predominant in 47.5%, neutral in 39.5% and IR predominant in 13%. Hip rotation ROM balance was symmetric in both hips in 73 subjects (61%). Hip rotation ROM was reduced with age (P<0.0001), and was 4.7° less in men (P=0.0078), and in overweight subjects (P<0.0006).

DISCUSSION

Our values are probably lower than those in the literature because of the difference in study population. In our series, age, BMI and gender seemed to be determining factors. Hip rotation ROM balance is usually ER predominant or neutral. Hip rotation ROM can be measured in the three positions with no significant difference, with satisfactory interobserver reproducibility for each.

TYPE OF STUDY

Diagnostic prospective study: level III.

Total ankle arthroplasty and coronal plane deformities

INTRODUCTION

There is no consensus regarding total ankle replacement (TAR) in case of arthritis associated with coronal plane deformities. The purpose of this study was to determine, based on clinical and radiographic outcomes, the technical requirements and additional procedures that should be performed in such indications.

HYPOTHESIS

Coronal deformities greater than 10° are not a contraindication to TAR if a stable and aligned ankle can be obtained after surgery.

MATERIALS AND METHODS

Of a total of 131 TAR, 21 were performed on coronal plane deformities greater than 10°. Only cases of osteoarthritis secondary to fracture or chronic instability were included. Inflammatory ankles were excluded. Twenty-one patients (15 men and 6 women), mean age 57 years old (±12) were reviewed retrospectively with a mean follow-up of 38 months (±26). Patients were divided into four groups, categorizing first, congruent and incongruent ankles, and second varus and valgus deformities. Associated procedures were performed from proximal to distal, correcting periarticular malunions first, ligament imbalances, associated deformities of the foot and equinus deformity. Revision arthrodesis and implant changes due to loosening or progressive instability were considered to be failures.

RESULTS

Surgery resulted in improved functional outcome and durable correction of the deformity, passing from 16.5° (±4.9) to 2.5° (±3.9) for varus, and from 16.7° (±5.6) to 1.4° (±2.1) for valgus. Six varus ankles required revision surgery for further corrections. Three incongruent ankles failed.

DISCUSSION

Correction of osteoarticular deformities and ligament imbalance in case of frontal deformities requires a significant number of associated procedures. Residual defects are detrimental to implant longevity and warrant further correction. Short-term results are satisfactory even for severe deformities, but require longer-term monitoring.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Distal quarter leg fractures fixation: The intramedullary nailing alone option

INTRODUCTION

Intramedullary (IM) nailing is the classical treatment for diaphyseal fractures of the tibia. Stabilizing fractures of the distal quarter is recognized as being delicate. We report a continuous, multicenter prospective study of distal tibia-fibula fractures treated with anterograde intramedullary nailing.

HYPOTHESIS

The working hypothesis was to identify the problems encountered with IM nailing alone of distal leg fractures.

PATIENTS AND METHODS

From May 2007 to November 2008, 51 fractures in 51 patients (19 females and 32 males; mean age, 46.2 years [range, 17-93 years]) were treated with IM nailing. The fractures were classified according to the association pour l'ostéosynthèse (AO) classification, with most type A1 (29/51). Thirteen fractures presented a distal articular extension treated with screws in five cases. Fixation consisted in intramedullary nailing, reamed in all cases, performed on a standard or orthopaedic surgery table. Nailing was static and distally locked (50/51). The patients were evaluated clinically and radiologically, with AP and lateral images of both legs and the Olerud score.

RESULTS

We report one death and eight patients lost to follow-up, providing 42 cases to reviewing at 1 year. The bone union rate was 97.6% in a mean 15.7 weeks. Immediately after surgery, 14 axial deviations greater than 5° were observed, mainly valgus, with only one greater than 10°. The absence of fibular fixation was the only identifiable risk factor for appearance of an initial axial deviation as well as fracture instability over time. Two infections were observed and at 6 months four secondary displacements, one of which can be explained by changing the distal locking due to infection. Four dynamizations were performed. No other risk factor was found. The mean Olerud functional score at 12 months was 83.5 points.

DISCUSSION

The clinical results are comparable to those reported in the literature. From a radiological point of view, the rates and times to bone union were identical. However, the rates of malunion were clearly higher. The risk factors for malunion found in the literature are metaphyseal enlargement, fracture comminution, a too distal location of fracture site, young patient age, patient installation on a standard operating table, and technical errors. The absence of supplementary fibular fixation, the subject of debate in the literature, was the only statistically significant point found in the present study. Nailing distal fractures of the leg provides good clinical results. However, with regard to the malunion rates, the technique must be precise and rigorous. We recommend systematic fibular fixation and use of an orthopaedic table.

LEVEL OF EVIDENCE

Level IV; cohort type prospective study.

Distal leg fractures: How critical is the fibular fracture and its fixation?

INTRODUCTION

Extra-articular distal tibia fractures include a tibial fracture line located partially or totally in the metaphyseal bone and a fibular fracture in variable areas or sometimes absent. There is no consensus in the literature on the conduct to address the fibula fracture. The main objective of this study was to assess its impact on tibial reduction and union.

HYPOTHESIS

Fibular fixation plays a positive role in reducing tibial displacement and improving mechanical stability of the entire lesion.

MATERIAL AND METHODS

This study was based on the multicenter observational group of the 2009 SOFCOT symposium, i.e., 142 metaphyseal fractures of the tibia. The fibula was intact in 10 cases and fractured in 132. In the three main categories of surgical treatment for the tibia (nailing, plating, external fixation) (126 fractures), the fibular lesion was not treated in 79 cases (61%) in this series, nine were treated with intramedullary pinning, and 38 with plate and screw fixation.

RESULTS

There was no statistical relation between the anatomic situation of the diaphysis and the anatomic type of the fibular fracture or between the anatomic type of the fibular fracture and its situation compared to the tibial fracture line. The intertubercular and neck fractures were type A1 or B1 (P<0.001) and were combined to a tibia fracture with a torsional component; the medial-diaphyseal and subtubercular fractures were associated with tibial fracture lines with a simple transversal or comminution or metaphyseal-diaphyseal component (P<0.032). The rate of pseudarthrosis of the fibular fracture was 4.7% at 1 year; in all these cases, fibular treatment had been conservative. All treatments combined, the tibial axes were statistically better corrected when the fibula was treated with fixation. In four of the 11 cases of axial tibial malunion, the primary fibular fixation caused or worsened them.

DISCUSSION

The present clinical series provides results similar to the biomechanical studies. The consequences of fibular fixation perpetuating a tibia reduction abnormality or on the contrary the absence of fibular fixation appeared as probable factors of residual reduction defects, lack of stability of the tibiofibular complex, and tibia non-union.

LEVEL OF EVIDENCE

Level IV (prospective cohort study).

Long-term results of the ABG-1 hydroxyapatite coated total hip arthroplasty: analysis of 111 cases with a minimum follow-up of 10 years

INTRODUCTION

Medium-term studies of ABG-1 cementless total hip arthroplasty have shown favorable functional results with excellent femoral component fixation but an abnormally high rate of periacetabular component osteolysis, which may require early revision.

HYPOTHESIS

The periacetabular osteolysis rate increases with time with the ABG-1 implant, leading to a high revision rate.

OBJECTIVE

The objective of this study was to test this hypothesis with a minimum follow-up of 10 years and evaluate the progression of periacetabular osteolysis and its consequences on implant fixation.

MATERIAL AND METHODS

A continuous series of 111 ABG-1 cementless prostheses implanted by a single operator with a theoretical minimum follow-up of 10 years. Seventy-five implants were analyzed with a mean follow-up of 13 years. All the prostheses had been implanted via a posterolateral approach and consisted of a 28 mm cup matching a head in zirconia and an antidislocation rim design high-density polyethylene insert.

RESULTS

Twelve cups were revised because of progressive retroacetabular osteolysis. The revisions were performed systematically although there was no pain or gross cup loosening. The revisions included resection of the granuloma, cavity filling with morselized bone grafts, and implantation of new uncemented ABG-2 cups in eight cases or cemented cups associated with a support ring in the four other cases. Thirty-two (48.5%) of the cups still in place at the end of the follow-up evaluation presented moderate and asymptomatic radiographic osteolysis, inciting close subsequent observation. No predictive factor of osteolysis onset was identified (age, body mass index, polyethylene wear, or cup orientation). None of the femoral stems was changed because of osteolysis: the only two femoral revisions resulted from periprosthetic fracture and one case of bipolar loosening. The femoral osteolysis images were small and all limited to zones 7a (18.8% of cases), 1a, and 1b (65.2% of cases). The overall survival rate of the series at 13 years of follow-up was 80.5%; the cup survival rate was 83.2%; the femoral implant, 94.3%; and failure of the femoral stem secondary to aseptic loosening was only 1.3%.

DISCUSSION, CONCLUSION

This long-term study confirms the high frequency of retroacetabular osteolysis of ABG-1 prostheses surpassing the osteolysis rate of other uncemented cups with a polyethylene insert. The absence of predictive criteria of osteolysis occurrence and the lack of symptoms warrants periodic follow-up of patients with ABG-1 cups and, if necessary, early repair of bone stock loss with grafts combined with acetabular cup revision. This procedure remains simple as long as performed before the onset of massive bone destruction, confirming the proposed revisions in this series were judicious. This study also confirms the excellent long-term fixation of the ABG-1 femoral stems derived from the osteointegration and proximal seal around the hydroxyapatite coating.

Devenir à plus de 20 ans de recul des poignets rhumatoïdes opérés (arthrodèses exclues)

PURPOSE OF THE STUDY

The absence of a medical treatment capable of successfully arresting joint destruction due to rheumatoid arthritis (RA) leaves a large domain for surgical treatment. The purpose of our work was to determine whether a clinical benefit persists in the long term (more than 20 years) despite aggravation of the radiological lesions, after surgical treatment of rheumatoid arthritis of the wrist.

MATERIAL AND METHODS

Sixteen patients with RA (13 women and 3 men, mean age 65 years), were reviewed a mean 24.8 years (range 20-33 years) after wrist surgery. Twenty-four wrists were operated for dorsal synovectomy (n=18) and Swanson radiocarpal implant (n=6). Total arthrodeses were excluded. Clinical, functional and standard and stress x-ray data were collected at last follow-up.

RESULTS

Residual pain at last follow-up in wrists which had undergone dorsal synovectomy was scored 3.1/10 on the VAS versus 5.6 preoperatively. Three-quarters of the patients stated they were satisfied with the intervention despite very weak force. Revision surgery was required in eight patients after dorsal synovectomy including three which required resection of the ulnar head, left in place after the first surgery, and three for removal of a silicon implant of the ulnar head. This implant was rapidly abandoned in our unit (as in other units). The radiological status worsened in all wrists over time, despite synovectomy. For the Swanson radiocarpal implant, residual pain was only 0.5/10 versus 6.7 preoperatively. Four implants fractured and four developed radiological signs of siliconitis with not clinical expression. Despite these complications, five of the six patients felt favorably about their intervention and the mean Leclerc function score was 78/100. Flexion-extension was 56 degrees on average. The main complaint was the lack of force.

CONCLUSION

There is a discordance between radiological and clinical results, a difference which widens with longer follow-up. A clear improvement in the pain score and the moderate functional demands of these patients are probably the reasons for their satisfaction despite radiological degradation. Many desire more wrist force. Our indications have evolved over time with the development after 1980 of the radiolunar arthrodesis procedures that we associate with dorsal synovectomy even in early-stage patients in order to limit radiological degradation and ulnar translation of the carpus. Swanson radiocarpal implants were completely abandoned in 1987 despite favorable clinical results due to the radiological degradation with bone loss and risk of siliconitis. For Simmen III wrists, total arthrodesis remains the only sure and definitive solution.

[Treatment of neurogenic heterotopic ossifications (NHO) in brain injured patients: review of literature]

This article is a review of the literature about treatment of neurogenic heterotopic ossifications (NHO) in brain injured patients, from analysis of the main data bases (Medline, Embase, Reedoc). In spite of the hope they arouse in the seventies, biphosphonates, including etidronate, have not demonstrated their efficiency to inhibit NHO in clinical practice. In fact a very early diagnosis, with the scintigraphic overactivity of the joint area and the increase of serum alkaline phosphatases, must lead to begin passive motion and postures, and may contribute to save functional range of motion. Yet, when joint stiffness or even ankylosis have led to severe functional disorders, surgery with NHO resection is the only way; it looks more reliable to manage it when NHO is mature, after a delay of more than 12 months after the first signs, but earlier operations have been reported without an enhanced risk of recurrence; this surgery must be associated with continuous passive motion for several weeks; radiation therapy and/or non-steroid anti-inflammatory drugs have been proposed in the immediate after-surgery period, but their role is still discussed.

[Intramedullary interlocking nailing for humeral fractures: report of 38 cases treated by Russel and Taylor nail]

PURPOSE OF THE STUDY

We assessed outcome after intramedullary interlocking nailing for humeral fractures to identify problems and indications in comparison with reports in the literature.

MATERIAL AND METHODS

We implanted the Russel and Taylor nail to treat 38 fresh humeral shaft non-pathological fractures using 33 anterograde insertions and 5 retrograde insertions.

RESULTS

All patients were examined at a mean follow-up of 16.3 months. Problems and complications involved 3 open procedure conversion, 3 peroperative re-fractures, 2 locking errors, 2 secondary dismantelings, 2 regressive iatrogenic palsies, and 4 cases of pain due to protruding material. First intention bone healing was achieved in 34 cases and following a revision procedure in 2. Two cases of nonunion were not reoperated. The Neer and Constant scores, used to assess functional outcome, identified 5 non-satisfactory results.

DISCUSSION

The risk of infection with locking nails is low, as is the risk of nervous complications which are generally related to traction manoeuvres during reduction. Bone healing is easily achieved if the assembly is perfectly stable. The risk of disassembly or nonunion is related to technical errors: defective locking, insufficient hold in the bone fragments. The risk of stiffness or rotator cuff tears is low, generally related to protrusion of the material and not to insertion through the cuff muscles. Retrograde insertion can be recommended for fractures of the distal third of the humeral shaft.

CONCLUSION

Insertion of the Russel and Taylor intramedullary locking nail requires a learning curve to minimize the risk of iatrogenic complications. It can be proposed for fractures of the mid-third of the humeral shaft and can be discussed for the proximal and distal thirds if perfect stability can be obtained on the short bony fragment.

[Orthopedic treatment of fifth metacarpal neck fractures: prospective study]

Many methods of treatment have been proposed for the metacarpal neck fractures of the little finger, from early mobilisation to open or closed surgical techniques. A prospective studies of 20 cases treated by a non surgical technique is presented. The reduction was performed by manipulation under local anesthesia according to the Jahss technique and a modified Thomine brace was applied for four weeks. All patients were reviewed for follow-up at 30, 60, and 180 days. The fracture displacement was initially 34 degrees. It was reduced by manipulation to 12 degrees. All fractures healed with an average final displacement of 20 degrees. At 6 months for final examination, average T.A.M. was 245 degrees, T.P.M. was 276 degrees, grip strength reached 96% of the other hand. There were 19 excellent and one bad results. In conclusion, ambulatory non surgical treatment by reduction and local immobilisation of the fractures of the fifth metacarpal provide a good final result with a low cost.

[Pseudarthrosis and non-union of disjunctive talar fractures]

PURPOSE OF THE STUDY

Neck fractures of the talus are rare. Necrosis is the complication most often observed. Mal union or non union are rarely reported: 11 cases of such complications have been treated and are presented with results of surgical treatment.

MATERIAL

Seven non unions and 4 mal unions after separation fracture of the talus, presenting with pain and deformity of the hindfoot were treated. The treatment included removal of the fibrous tissue, heel reaxation, bone grafting, peritalar joints arthrodesis.

RESULTS

Bone healing was observed in 5 of 7 non unions, and the correction of the hindfoot deformity in 9 of the 11 cases.

DISCUSSION

Non union or mal union after separation fracture of the neck of the talus are poorly tolerated, the patients walking with the foot in internal rotation, bearing most of the weight on the lateral border of the foot. Such poor course results from: the less mechanical stiffness of the medial part of the talus, the severity and the comminution of the fracture, insufficienct reduction and fixation, too early weight bearing, and is associated with degenerative changes of peritalar joints. Functional and antomical good results can be obtained with bone healing, hindfoot reaxation and peritalar arthrodesis. We emphasize the interest of X Rays in the examination and the adequacy of a good initial treatment.

[Value of external fixation in proximal tibial fractures]

PURPOSE OF THE STUDY

This study was a retrospective analysis of 39 proximal metaphyseal tibial fractures treated by Orthofix fixator in two trauma departments.

MATERIAL AND METHOD

There were 28 men and 10 women with a mean age of 49.5 years. 13 pedestrians were stroked by a car and 18 had a traffic accident on a motorcycle. In 27 cases, the fracture was open with following Cauchoix grading: 15 types 2, 6 types 1 and 6 types 3. All fractures were partially or totally included in the proximal epiphyseal square of the AO system. 14 fractures were metaphyseal, 13 diaphyso-metaphyseal and 12 had an articular irradiation. All external fixations were performed using the Orthofix device, with image intensification. A partial weight bearing was allowed for 2.4 months as an average and full weight bearing at mean 3.7 months. 7 skin grafts, 2 micro surgical (latissimus dorsi) and 2 local flaps were necessary.

RESULTS

In 3 patients this technique failed. 3 patients had an autologous bone graft at the metaphyseal and 2 at the diaphyseal fracture site. 30 patients healed without other procedure after an average delay of 5.5 months. During the healing and weight bearing time, 6 frontal deformities appeared and 5 flexion contractures were not reoperated. With a minimum follow up of one year (mean 3 years) 22 fractures had no deformity, 8 had a valgus deformity (5 degrees to 10 degrees) and 3 a varus deformity (6 to 17 degrees). For the 25 patients with an isolated proximal tibial fracture, 11 (44%) had an excellent functional result (no pain, full range knee motion, normal daily activity); 12 (48%) had a good result (episodic pain, minimally knee discomfort, flexion limitation).

DISCUSSION

Orthofix fixator appear to be a good solution for comminuted fractures. These fractures have anatomical and epidemiological particularities. AO classification system is not useful; a new one is proposed. External fixator must be placed meticulously after closed fracture reduction.

Simple arthrolysis for flexor rigidity of the proximal interphalangeal joint

The authors report 19 cases of simple arthrolysis of the proximal interphalangeal joint for flexion rigidity. Their cases were limited to isolated lesions of the joint without any flexor or extensor tendon involvement. The technique is described, and the importance of postoperative physical therapy is stressed. The results in these cases, in contrast with those in complicated cases of rigidity, are very satisfactory. The etiology is primarily sprains and dislocations of the proximal interphalangeal articulation, immobilized for too long a time in flexion (in the so-called "functional position").

Rupture of the flexor tendons of the little finger in fractures of the hook of the hamate bone. Report of two cases

Two cases of rupture of the flexor tendons of the little finger associated with a fracture of the hook of the hamate bone are presented. The preoperative diagnosis had not been made. Excision of the fractured hook and repair of the tendons by a short graft from the palmaris longus in one case and by the transfer of the superficial flexor of the ring finger in the other case gave a good final result. The authors remark on the rarity of reports of this fracture in the literature, the frequent occurrence of nonunion and the two complications which are exceptional; rupture of the flexor tendons and compression of the deep branch of the ulnar nerve. The fracture is mainly encountered in sports that require the grasping of a handle (tennis, golf, hockey, squash). The diagnosis is often missed at the onset because of not using the correct X-ray positioning: special incidence for the carpal tunnel view and a 3/4 view with the wrist in 45 degrees of supination and forced radial deviation.

First results of arthroplasty of the wrist by Swanson's implant. Twenty-five cases

We have carried out 25 arthroplasties of the wrist using the Swanson implant since 1976. The indications were primarily in rheumatoid arthritis. The operation was done for severe pain and deformity of the wrist. Results were analysed in 19 patients with a follow-up of 21-54 months. Post-operative pain relief is good. Although mobility is fair, the return of the balance of wrist motions has been recovered. The results of the Swanson implant arthroplasty are compared to dorsal synovectomy and wrist arthrodesis.

Two-step reconstruction of the flexor tendons (Hunter's technique) in the treatment of fingers "en crochet"

The authors used Hunter's technique to treat 16 cases of fixed-flexion deformity of the finger (with irreducible flexion of the joint greater then 70 degrees), secondary to lesions of the flexor tendons. The flexion deformity was corrected in 11 of the 16 cases, and active movement greater than 70 degrees was obtained in only 7 cases. Technical difficulties (particularly cutaneous problems), frequent complications, prolonged reeducation are the reasons that the indications for its use are exceptional, and why there is need for excellent cooperation by the patient.

Human composite flexor tendon allografts. A report of two cases

We report two cases in whom human composite flexor tendon allografts were used, and followed-up for more than 5 years. The results show a real improvement in function, without any complications.

Hemodialysis-related lesions of the hand

Chronic hemodialysis patients often have lesions of the hands characterized by distinctive etiopathogenic mechanisms and functional consequences. We conducted a prospective cross-sectional study in 116 patients with a mean age of 55.9 years and a mean hemodialysis duration of 8.17 years. Carpal tunnel syndrome was present in 28.4% of patients. Median nerve entrapment was bilateral in a large proportion of cases. Wasting of the lateral thenar muscles was often present at diagnosis, denoting advanced nerve compression. Amyloid was demonstrated in the carpal tunnel in 74% of cases of carpal tunnel syndrome. Digital flexor tendon lesions responsible for trigger finger or restriction of active flexion were seen in 21.5% of patients. Erosive arthropathy manifesting as deformities, pain and loss of function affected the distal interphalangeal joints in 11% of patients and the proximal interphalangeal joints or trapeziometacarpal joint in a smaller proportion of patients. Thirty per cent of patients had bony cysts located in the carpometacarpal area, carpal bones, or distal forearm bones; communication with the adjacent joint space was seen occasionally, and intracarpal derangement was a feature in some patients. Most patients had several types of lesions. The rate of occurrence of hand lesions increased markedly after ten years on hemodialysis, with devastating functional consequences.

Focal myositis: a localized form of polymyositis?

We describe an additional case of focal myositis presenting as a painful pseudotumor of the lower leg. Surgical biopsy showed typical features of myositis; the disease improved spontaneously, without clinical or biological abnormalities. Focal myositis can remain a localized process, but in some cases it can become an authentic polymyositis. These generalized forms are associated early with elevated erythrocyte sedimentation rate and/or muscular enzymes.

Swanson trapezial implant in the treatment of peritrapezial arthrosis. A study of eighty cases

Eighty cases of peritrapezial arthritis of the thumb treated by Swanson's trapezial implant have been reviewed by the authors. They advocate a slightly modified technique and emphasize the importance of "varisation" of the implant and of correct resection of the greater multangular bone. Follow-up was at least one year in all cases, maximum 10 years, the mean being 3 1/2 years. Results were judged as very good in 75% of the cases, fair in 20% and poor in 5%. This study emphasized the cases of failure by implant instability and its causes. In 8 cases, abnormal wear of the implant or of the scaphoid bone raises the question of long-term tolerance of silicone implants.

The surgical treatment of the rheumatoid wrist. Current perspectives

The authors stress the prevalence and severity of wrist involvement in rheumatoid disease. Improved knowledge of aetiopathogenesis and deformities had led to identification of the importance of the distal consequences on the digital joints of decentralization of the wrist. Synovectomy retains an important place at the onset of the disease. This may be completed by stabilization procedures (tendon transfer and partial arthrodesis). At the advanced stage of the disease, arthroplasty is currently overtaking arthrodesis. Interposition arthroplasty, with its rare indications, is now well developed. Although the solution of the future, arthroplasties lack sufficient follow up in terms of their results. The Swanson implant offers limited mobility but ensures freedom from pain and a good wrist axis. The ideal treatment of the rheumatoid wrist is oriented towards early conservative surgery and later, at an advanced stage, towards arthroplasty, the ideal technique of which remains to be discovered.

Osseous metastases in the hand. A general review of three cases

Osseous metastases in the hand are rare. The authors report 3 cases, bringing the total number of reported cases up to 106. They affect mainly men; their clinical features are local swelling and pain frequently ascribed to a trauma. The diagnosis is often mistaken, many patients being initially treated for a distal felon. Distal phalanx is the main involved area, with irregular osteolysis and cortical destruction. The etiology is quite different from that of metastases to other bones: bronchopulmonary cancer is by far the most frequent with 46% of cases, followed by breast cancer (15%). Other types of cancer are much less frequently involved. The evolution is sombre; average life expectancy is 3 1/2 months. Treatment may involve, as needed, distal digital amputation on antalgic radiotherapy.