Two auricular epithesis surgical cases retained by a custom titanium implant: result at four years

INTRODUCTION

This article aims at describing the four-year outcome of a surgical procedure implanting a patient specific epithesis system in two patients.

TECHNICAL NOTE

After virtual 3D reconstruction of the anatomy and mirroring of the healthy ear, the position of the three Locator^® attachments were optimized in the software to embed them as accurately as possible in the planned episthesis antihelix. The personalized plate bearing the three Locator^® implants was then manufactured. Ten osteosynthesis screws were placed around the abutments to ensure bone anchorage. Post-operative antibiotic therapy was prescribed for the duration of ten days. The episthesis was placed two months post-operatively. The follow-up for each patient was 65 and 57 months respectively with no complications to report.

CONCLUSION

3D planning assists the surgeon and eliminates several constraints related to the placement of bone implants. It assists the surgical procedure and improves both the aesthetics and functional result of the surgery.

Viabilidade da técnica de transposição uretral pré-púbica mediante secção peniana em cadáveres de cães

RESUMO Descreve-se a viabilidade da técnica cirúrgica de transposição uretral pré-púbica em cadáveres de cães machos, adultos, advindos de um hospital veterinário, a fim de se avaliar a manutenção da luz uretral a partir de um desvio uretral pré-púbico, descrevendo-se detalhadamente a abordagem e as estruturas anatômicas envolvidas. A técnica consistiu inicialmente da orquiectomia, seguida de celiotomia retroumbilical, tração vesical cranial, secção transversa da uretra membranosa a 1cm caudal à próstata, espatulação e reparo da borda livre. A seguir, divulsão e secção do pênis 1,5cm caudal ao osso peniano, espatulação da borda uretral peniana e transposição desta em direção à cavidade abdominal, fazendo-se anastomose por meio de sutura interrompida simples à uretra membranosa. Foi mensurado o comprimento uretral desde o meato externo até o início da uretra prostática em dois momentos: pré e pós-transposição. Ao final, avaliou-se, por meio de uretrografia retrógrada de contraste positivo, o diâmetro e o selamento na anastomose uretral e o fluxo do contraste até a bexiga. A transposição uretral pré-púbica é uma técnica cirúrgica exequível, anatomicamente compatível com a espécie canina e capaz de manter o diâmetro uretral e o fluxo do contraste de forma satisfatória, com manutenção estética externa idêntica a um cão macho orquiectomizado.

Eliminação de Dioctophyme renale pela urina em canino com dioctofimatose em rim esquerdo e cavidade abdominal - Primeiro relato no Rio Grande do Sul

RESUMO Dioctophyme renale é um parasito que afeta tanto animais como humanos e tem como órgão de eleição o rim direito. Relata-se o caso clínico-cirúrgico de um paciente canino com histórico de eliminação de três exemplares de D. renale pela urina e presença de parasitos no rim esquerdo e na cavidade abdominal. No Hospital de Clínicas Veterinárias da Universidade Federal de Pelotas, foram realizados exames pré-cirúrgicos, entre eles a ultrassonografia abdominal, que identificou a localização dos nematódeos, e o exame de Doppler pulsado dos vasos intrarrenais, que demonstrou aumento nos índices resistivos nas regiões avaliadas. O paciente foi conduzido para a realização de laparotomia exploratória, sendo removidos 23 parasitos da cavidade abdominal. A presença de D. renale causa graves lesões nos rins e nos demais órgãos da cavidade abdominal, sendo essencial o diagnóstico precoce e a remoção dos nematódeos para recuperação do paciente.

[Asian tiger mosquito bites: perception of the affected population after Aedes albopictus became established in Spain]

INTRODUCTION

The presence of Aedes albopictus was detected in Spain in 2004 and it has now become fully established, causing significant discomfort among the population in the affected areas.

OBJECTIVES

The aim of this study was to investigate the impact of the arrival of A albopictus and its subsequent establishment on the population a year after being detected in Spain.

MATERIAL AND METHODS

A survey questioned 309 users of the Valldoreix-Sant Cugat Healthcare Center about their knowledge of Aedes albopictus, the characteristics of bites by this insect, and their attitude to prevention and treatment.

RESULTS

Ninety one percent of respondents knew about the tiger mosquito. Sixty-one percent (66 % of women and 53 % of men) had reported suffering bites attributed to this insect. The most common type of bite was a small swelling (78 %) and the most common site was the legs (93 %). Children had a greater number of lesions and a more generalized distribution. Blistering lesions were more frequent in women. Itching was very intense (65 %), particularly in women (71 %) and children (76 %). The majority of patients (80 %) did not seek attention from their health care services and 36 % consulted their pharmacist. Fifty percent (61 % of women and 47 % of men) treated their bites, mainly with topical corticosteroids (56 %) and antihistaminics (26 %). Forty-six percent of respondents mainly children reported use of insect repellents.

CONCLUSION

The arrival of the Asian tiger mosquito has had a major impact on the population, with a lower quality of life and a deterioration in skin health, due to the numerous and irritating bites.

[Congenital dermatofibrosarcoma protuberans: a case report]

Dermatofibrosarcoma protuberans is a rare low-grade fibrohistiocytic tumor with onset normally at ages between 20 and 50 years. It presents as a violaceous plaque or macule with an appearance suggestive of vascular lesion, on which nodular lesions appear later. Histological diagnosis is based on the presence of a spindle-cell tumor arranged in small bundles in a characteristic cartwheel pattern. The local recurrence rate is high but metastases are rare. The treatment is surgical resection with wide margins. The tumor rarely affects children under 16 years of age and it is even less common at birth--only 27 congenital cases have been described in the literature. We describe the case of a 10-year-old boy with dermatofibrosarcoma protuberans present since birth and currently without signs of recurrence.

Atrophic dermatofibroma accompanied by aneurysmatic characteristics

A 40-year-old man presented a painful haemorrhagic plaque on his chest in the same location where a nodular lesion had been presented for many years. After 2 months, the plaque was replaced by a depressed lesion. The lesion diagnosed as an anetoderma was excised and the biopsy showed an atrophic dermatofibroma accompanied by aneurysmatic characteristics.

[Eosinophilic ulcer of the oral mucosa: 11 cases]

BACKGROUND

The eosinophilic ulcer is a lesion of the oral mucosa, that has been infrequently described in the literature. This is a benign and self-limiting lesion of unknown origin.

CASE REPORTS

In this article, eleven new cases of eosinophilic ulcer of the oral mucosa are presented. The clinical, histologic and evolutive features are reviewed.

DISCUSSION

Recurrent trauma is clearly involved in the pathogenesis of this entity.

Structural organization of the enteric nervous system in the cattle esophagus revealed by wholemount immunohistochemistry

In ruminants the motility patterns of the esophageal tube are characterized by physiological regurgitations including both anterograde and retrograde peristaltic movements. These complex motor functions require an elaborated enteric nervous system (ENS) for the generation of the underlying intrinsic reflex circuits. The structural organization of the esophageal ENS was studied in fetuses of cattle (n=6) by means of wholemount preparations obtained from different segments of the esophagus. Demonstration of nerve cells, ganglia and nerve fibers strands (NFS) was achieved by immunohistochemistry using the general neuronal marker protein gene product (PGP) 9.5. The myenteric plexus represented the most prominent nerve network composed of differently shaped ganglia and interconnecting NFS. Frequenitly the myenteric ganglia were arranged in two separate layers interweaving with the adjacent muscle coat. From the cervical towards the thoracic segment of the esophagus the density and size of myenteric ganglia increased and the NFS exhibited thicker diameters. The submucosal and mucosal plexus consisted of NFS ramifying throughout the tela submucosa and the lamina propria mucosae. The networks showed no evidence of ganglia nor single nerve cells. The findings illustrate that intrinsic esophageal nerve cells are confined to the myenteric plexus. Since the esophageal tube has no secretory functions, secreto-motor neurons are not required in the submucosal and mucosal plexus layers. The structural organization of the intramural nerve networks--in particular the specific arrangement of the myenteric plexus--reflects the substantial contribution of the esophageal ENS to the coordination and mediation of esophageal motility in ruminants.

[Risk of deep infection in first-intention total hip replacement. Evaluation concerning a continuous series of 790 cases]

OBJECTIVE

Deep infections of the operative site is a rare but serious complication of first intention total hip arthroplasties. French data on infections are sparse. We studied the incidence, characteristics and potential risk factors for these infections in a consecutive series of 790 total hip arthroplasties performed as first intention implantations in a University Hospital in France.

PATIENTS AND METHODS

All patients undergoing first intention total hip arthroplasty surgery between November 1995 and May 1999 were included in this study. Demographic, clinical, therapeutic and surgical data were collected. Deep infection was defined as proven presence of microorganisms in at least two preoperative samples during revision surgery. Patients were followed for 1 month to 4 years. Potential risk factors were identified with univariate analysis. Chi square and exact Fisher test were used.

RESULTS

The overall incidence of deep infections was 1.11 per 100 implantations (95% CI 0.84-2.70). Delay to development ranged from 14 days to 32 months. Eleven infections were proven within the first year and 3 after one year. Two risk factors were identified: absence of systemic antibiotic prophylaxis (RR = 4.74, p = 0.03) and drainage discharge after 48 hours (RR = 3.62, p = 0.02). Other variables associated with infection with a relative risk greater than 2 were obesity, corticosteroid therapy, development of a hematoma, or difficult postoperative wound healing.

CONCLUSION

The incidence observed in this series is slightly higher than generally reported in the world literature. It would be important to write an antibiotic prophylaxis protocol with prescription of systemic antibiotics for all operated patients in order to reduce this incidence. Other measures that could improve the quality of care should also be taken: re-evaluation of preoperative skin preparation protocols, systematic screening of patients carrying Staphylococcus aureus before implantation and proper care for these patients.

Subcutaneous nodules in Whipple's disease

BACKGROUND

Cutaneous findings other than hyperpigmentation are rare in Whipple's disease.

CASE REPORT

We present the case of a 59-year-old man previously diagnosed with Whipple's disease by duodenal biopsy, who developed red-brown, painful, subcutaneous nodules on the buttocks, thighs, arms and legs. Biopsy of these nodules showed a septal panniculitis and foamy macrophages containing PAS-positive, diastase resistant intracytoplasmic material, characteristic of Whipple's disease and similar to that observed in the duodenal biopsy. Ultrastructurally, this material in the histiocytes corresponded to degenerated bacilli.

CONCLUSIONS

This is the fourth documented case of subcutaneous involvement by Whipple's disease. One should consider the possibility of Whipple's disease in any patient who presents with symptoms compatible with that condition who demonstrates septal panniculitis with a large amount of foamy histiocytes.

[Recurrent hallux valgus treated with metatarsophalangeal arthrodesis. A series of 32 patients]

PURPOSE OF THE STUDY

We reviewed a series of 32 cases of recurrent hallux valgus treated by great toe metatarsophalangeal arthrodesis with a minimal 5-year follow-up.

MATERIAL AND METHOD

Mean delay from the first surgical procedure and revision surgery was 11 years. All patients complained of forefoot pain. The average angle of the phalangeal valgus was 39 degrees. Sixteen patients had metatarsalgia. The first toe metatarsophalangeal joint was evaluated according to Regnauld's classification: two grade 1, eight grade 2a, six grade 2b, sixteen grade 3. Arthrodesis was fixed with an axial screw and associated with adductor hallux plasty. Outcome was assessed at a minimum 5-year follow-up according to Kitaoka's criteria.

RESULTS

Seventy-eight percent of the patients were pain free at last follow-up. Valgus deviation of the great toe was corrected with an average angle of 19 degrees. The arthodesis healed in 90.6% of the cases. Statistical analysis showed the importance of great toe valgus pre- and postoperatively and at last assessment. Final outcome was poor in the oldest patients. The overall outcome was rated good in 84% of the cases, average in 6% and poor in 10%.

DISCUSSION

Arthrodesis of the great toe is not a disabling surgery. Interphalangeal osteoarthritis may occur due to joint overuse (12 cases). Kitaoka's series compared outcome after arthrodesis with that after conservative surgery and reported better results with arthrodesis. Revision surgery for hallux valgus using great toe metatarsophalangeal arthrodesis remains an acceptable alternative.

[Interpositioned metallic prosthesis for hallux rigidus: review of 42 cases with a metatarsophalangeal prosthesis]

PURPOSE OF THE STUDY

We report outcome at a mean 4.8 years follow-up in 42 patients with hallux rigidus treated by metatarsophalangeal interposition thin prosthesis flat concave with a lateral capsular fixation.

MATERIALS AND METHODS

The 42 patients were treated from 1987 to 1997. Sixtine prostheses were implanted for osteoarthritis was grade I (n=2), grade II (n=28), and grade III (n=12). Groulier's clinical criteria and Regnauld's radiologic criteria were used to assess outcome.

RESULTS

We observed 22 very good, 12 good, 4 fair, and 4 poor results. There was no significant modification in the forefoot morphology.

DISCUSSION

The Sixtine prosthesis provided a global improvement in pain and motion though there was an important difference between patients with grade I and grade II osteoarthritis, who experienced major improvement, and those with grade III disease. A good overall result requires proper prosthetic centering. Subluxation or translation does not appear to be compatible with good results. Among 3 cases with overt dislocation, 1 recovered an acceptable articular space with a good overall result. Two poor results and 3 fair results were observed in patients with condensation of the phalangeal base. These bone condensations appeared in postoperative Egyptian feet. The Sixtine prosthesis may protect the interphalangeal articular space of the great toe, avoiding damage and rearward displacement of sesamoid bones. It ensures primary stability and may be left in place.

CONCLUSION

We found that the Sixtine prosthesis is best indicated in hallux rigidus patients with grade II osteoarthritis.

[Complete transverse fractures of the talus: value of magnetic resonance imaging for detection of avascular necrosis]

The authors report a series of 32 complete transverse fractures of the neck or body of the talus. The fractures occurred mostly in young males, as a result of motor vehicle accidents. The fracture line was transverse in the neck or body of the talus in 20 cases, sagittal in four and comminuted in eight cases. Using Hawkins' classification, there were 10 type I, 16 type II, and 6 type III fractures. The treatment was conservative in 8 cases and surgical in 24. The patients were evaluated clinically and radiologically with an average follow-up of 7 years. All patients underwent radiological study at follow-up and 17 underwent NMR evaluation. Eleven underwent NMR evaluation at final follow-up, and the other 6 early in their postoperative evolution. The postoperative results were evaluated based upon clinical and radiological criteria. The clinical result was good or very good in 37.5% of cases. Segmental necrosis of the talar body was noted in 6 cases and complete necrosis in 5, which required arthrodesis in 8 cases. Avascular necrosis is a common complication. Its frequency depends on the type and displacement of the fracture. If it becomes symptomatic, the only treatment is tibiotalar or tibiotalocalcaneal arthrodesis. The contribution of NMR is very important, as it gives the positive diagnosis as well as information regarding evolution. Complete transverse fractures of the talar neck or body are rare; their treatment only gives a little over one third good and very good results in the long term. NMR gives the diagnosis early and shows the extent of necrosis. It can have predictive value for the collapse risk and guide reeducation with or without weight bearing.

[Surgical treatment of chronic Achilles tendiopathies. Report of 52 cases]

PURPOSE OF THE STUDY

We reviewed a series of 52 cases of chronic Achilles tendinopathy treated surgically by release of the fascia cruris, resection of peritendon, longitudinal incision of the tendon and occasional excision of intratendinous lesions.

MATERIALS AND METHODS

The mean course prior to surgery was about 18 months. Twenty-six patients practiced sports. Complaints were bilateral in 12 cases. Pain was always present. Ultrasound exploration evidenced paratendinitis (n=21), tendinosis (n=22) and paratendinitis with tendinosis (n=9) (Puddu classification). Patients were reviewed after a minimal 2-year follow-up. Results were assessed on the basis of clinical findings.

RESULTS

Mean follow-up was 5 years 6 months. Twenty-nine patients were free of pain. The range of motion was normal in 48 cases and 29 patients resumed sports activities at the same level as prior to surgery. Outcome was very good in 29 patients, good in 14 average in 6 and poor in 3.

DISCUSSION

Stiffness of the tibio-tarsal joint can be avoided by proper mobilization. Outcome appears to be better in middle-aged patients. Poor outcome is closely related to amyotrophy. The presence of a foot deformity does not appear to have an unfavorable influence on outcome. The Achilles tendon must not be infiltrated. Ultrasound is highly contributive, but MRI provides a more accurate analysis.

CONCLUSION

Surgical treatment of chronic Achilles tendinopathies can be proposed when conservative treatment has been unsuccessful. Outcome is better in young active patients and in cases where paratendinitis predominates.

Pustular vasculitis of the hands. Report of two men

Pustular vasculitis of the hands has been described in 6 women, as a distinct entity limited to the dorsa of the hands similar to that seen in Sweet’s syndrome but with severe leukocytoclastic vasculitis. We describe 2 men with identical lesions and discuss this new entity.

[Osteochondral lesions of the talar dome: surgical treatment in a series of 30 cases]

PURPOSE OF THE STUDY

We reviewed 30 cases of osteochondral lesions of the astragalar vault treated surgically.

MATERIAL AND METHODS

Among the 30 patients, 17 participated in sports activities and 24 had a history of trauma. Mean delay to surgery was 10 months. Treatment included osteochondritis curettage and Pridie perforations. Direct access was used in 11 cases, malleolar osteotomy in 13 and arthroscopy in 6. Cancellous bone grafts were used in 6 cases.

RESULTS

Mean follow-up was 3 years 7 months (minimum 2 years). All patients had an arthroscan at last follow-up. Evaluation of post-operative outcome was based on clinical assessment and arthroscan findings. Surgical treatment provided very good results in 75 p. 100 of cases with pain relief and improved walking distance.

DISCUSSION

Our cases pointed out the important contribution of the FOG (Fracture Osteonecrosis Geode) classification to pathogenic and prognostic analysis. The Berndt and Harty classifications were not found to be useful.

CONCLUSION

In case of localized necrosis, we propose arthroscopic perforation curettage. In case of bone loss, a direct cancellous graft may be used.

[Malleolar fractures. Predictive factors for secondary osteoarthritis. Retrospective study of 32 cases]

The authors report a series of 32 ankle fractures treated by internal fixation and reviewed with a follow-up of more than 15 years. The series includes 12 fibular, 14 bimalleolar and 6 trimalleolar fractures. Following Weber's classification, there were 4 type A, 18 type B and 10 type C fractures. The postoperative x-ray showed 28 anatomy reductions; shortening of the fibula from 3 to 5 mm was noted in 4 cases. Clinical results were evaluated according to Kitaoka's criteria, and radiological results according to Magnusson's criteria. Statistical analysis was made with a Chi-square test. The retrospective review at an average follow-up of 15 years showed 19 painfree ankles, normal mobility in 22 cases, absence of edema in 18. The shoe-wear was normal in 30 cases. Walking had returned to normal in 23 cases but radiography showed narrowing of the tibiotalar joint line in 12 cases and lengthening of the medial malleolus in 16. Narrowing of the tibiotalar joint space was associated with lengthening of the medial malleolus in 10 cases. The objective results were rated as follows: 23 good, 8 fair, and 1 poor. With a follow-up of 15 years, we noted degenerative changes in the ankle in 37% of cases in spite of an anatomic reconstruction which had been perfect in 28. Shortening of the fibula, observed in 4 cases, was associated with subsequent ossification below the medial malleolus corresponding to avulsion of the non sutured medial collateral ligament. Nevertheless, degenerative changes of the ankle were clinically well-tolerated. The long term result of internal fixation of malleolar fractures was good. This was achieved only through perfect restoration of the joint anatomy. Contrary to other series, non-operative repair of the medial collateral ligament was associated with long team degenerative changes and reduced mobility of the joint. We therefore now advocate surgical repair of the medial collateral ligament.

[Gauthier's subcapital osteotomy in the treatment of metatarsophalangeal luxation of the 2nd ray. Apropos of 44 cases with 5 year followup]

The authors report on a series of 44 metatarsophalangeal dislocations of the second ray which were treated surgically using Gauthier's technique. The patients were 44 middle-aged women. The surgical indication was a dislocation of the 2nd metatarsophalangeal joint with hallux valgus. There was excess length of the second metatarsal ray or acquired shortness of the first metatarsal. The treatment always included an osteotomy of the neck maintained by a transosseous pin. The average follow-up was 8 years and 3 months (minimum 5 years). Postoperative results were evaluated using clinical and radiological criteria. Surgical treatment gave 68.2% very good and good results and 4 recurrences of dislocation. The results in this series are identical with those in other series reported, but the backward displacement of the head of second metatarsal was found to be limited. Weil's osteotomy seems to provide better results because it better restores the relative lengths of the metatarsals and often makes interphalangeal arthroplasty unnecessary. Gauthier's metatarsal osteotomy is an easy procedure which effectively improves static metatarsalgia, but it provides limited metatarsal shortening. Weil's osteotomy is preferable in cases with long lateral metatarsals.

[Uretero-acetabular fistula after removal of a septic total hip prosthesis]

The authors report a case of an uretero-acetabular fistula after a Girdlestone procedure. The reason of ablation was an infected hip prosthesis. The urinary fistula was treated with an uretero-ileoplasty and hip infection with a two stages procedure. There was no recurrence of infection at two years follow-up. Different causes of this urinary complication are discussed.

[Long-term outcome following surgical repair of ruptures of the fibular collateral ligament of the ankle. A report of 50 cases]

The authors report their findings in a series of 49 patients with 50 acute ankle sprains, who underwent surgical repair of their ruptured fibular collateral ligaments. All patients were selected for surgical treatment based upon the findings on stress-films taken under anesthesia, showing a laxity at least superior by 10 degrees to the value found on the contralateral ankle. All patients were reviewed 2 to 12 years after operation. Clinical evaluation was based upon Duquennoy's criteria, and dynamic x-rays were performed in all patients to evaluate residual laxity. The clinical results were good or excellent in 78% of patients, fair in 14% and poor in 8%. Seven patients (14%) complained of subjective instability. Stress films showed residual laxity from 5 to 10 degrees in 10 patients (20%). The authors conclude that their findings do not support the alleged superiority of surgical repair over conservative management of severe ankle sprains.

[Hallux valgus treated by Scarf osteotomy of the first metatarsus and the first phalanx associated with an adductor plasty. Apropos of 50 cases with a 2-year follow up]

PURPOSE OF THE STUDY

Fifty hallux-valgus were treated with Scarf Osteotomy of the first metatarsal, associated to a phalangeal varisation or shortening osteotomy and an adductor plasty. Patients were evaluated with a minimum follow-up of two years.

MATERIAL AND METHODS

Forty five females and two males were operated with an average age of fifty years. The pre operative metatarsus varus was of 15 degrees 8. Mean alignment of metatarsal bar was 31 degrees 4. The cuneo-metatarsal joint was twenty two times spheric and twenty eight times plane. The average metatarso-phalangeal great toe valgus was 39 degrees 8.

RESULTS

They were appreciated with a minimal follow-up of two years, according to the 3 Groulier's criteria: correction of deformation, statics troubles, functional activity. The metatarsus varus improved with an average of 10 degrees 4, as well as the alignment of the metatarsal bar (25 degrees). The post operative average phalangeal valgus was 22 degrees 7. These results were statistically significant. Cuneo-metatarsal joint type did not influenced final result. Articular joint line was normal in 64% of cases. Global result was excellent or good in 70%, passable in 22%, and bad in 8% of cases.

DISCUSSION

Scarf Osteotomy of the first metatarsal allows complete correction of metatarsus varus. The surgical approach can be proposed at every age. There are no vascular trouble or arthrosis worsening. It must be completed with a phalangeal varisation or shortening osteotomy and adductor plasty.

[Percutaneous tenorrhaphy for Achilles tendon rupture. Study of 29 cases]

PURPOSE OF THE STUDY

Closed percutaneous repair, described first by Ma and Griffith in 1977, have bridged the gap between surgical and conservative treatment of Achilles tendon rupture. The purpose of this study was to evaluate the results of percutaneous repair.

MATERIAL AND METHODS

Between 1994 and 1996, 28 patients (18 male, 10 female) with 29 spontaneous ruptures of the Achilles tendon (one bilateral case) underwent percutaneous repair based on approximation and bringing closer both ends of the ruptured tendon using a subcutaneous suture. Material used was 2 Dacron yarn suture 30 cm length fitted with a 5 mm wide harpon and with its other end crimped into a malleable needle 12 cm length. Early mobilization was encouraged, partial weight bearing allowed at 3 weeks and full weight bearing at 6 weeks. Sutures were removed at 8 weeks without anesthesia. Two patients were lost for follow up after complication, one foreign patient returned to his country with good results, 26 tendons underwent physical examination at an average follow up of 15 months; 20 underwent ultrasound examination and Cybex testing.

RESULTS

Two patients experienced reruptures after suture removal; 2 patients fell a few days after repair and had rupture of the suture; both were treated with a cast. There were no infection, skin necrosis, hematoma, neurological injuries, or deep vein thrombosis. Eighteen patients were free of pain, 7 had intermittent pain and one permanent pain. Active and passive ankle motion were similar to the contralateral side. Calf circumference measurements on the repaired and normal extremities showed a difference of less than 3 cm in 4 cases, less than 2 cm in 13 cases and 9 patients had symmetrical calves. The average difference between the width of the repaired and normal tendon was 0.5 cm. Clinical documentation of muscle strength was normal in 9 cases, decreased in 14 cases. Three tendons could not be tested. Using the Trillat and Mounier-Kuhn score, 12 patients were rated excellent; 7 good, 7 fair and 4 poor (4 complications). Ultrasound examination demonstrated homogeneous and fibrilate structure in 10 cases. The width of the tendon was found increased in all cases. The strength, power and endurance testing performed on Cybex at 90 degrees and 180 degrees/second and compared to the normal ankle, averaged 65 p. 100 for plantar flexion.

DISCUSSION

Complication rate of operative and conservative treatment were compared to percutaneous repair. The results of Cybex testing points out the advantages of early mobilization after Achilles tendon rupture treatment. Ultrasound examination is useful to guide post operative rehabilitation and sports activities. All patients return to work more quickly after percutaneous repair.

CONCLUSION

Percutaneous repair of the Achilles tendon is a simple, easy and reliable technique. It seems to fulfil the required conditions: bringing closer tendon ends, maintenance of strong contact, preservation of all anatomical and histological factors inducing healing and a rapid return to social and working activities.

[Chronic lateral ankle instability: surgical treatment with periosteum ligamentoplasty and capsular ligament tension. 34 cases]

PURPOSE OF THE STUDY

The authors report a series of thirty four ankle ligamentoplasties treated between 1985 and 1995.

MATERIAL

Patients presented an average of 10.4 ankle sprains before surgical treatment. Pre-operative examination found instability in all cases, permanent pain in 58.8 p.cent limited mobility in 11.8 p.cent and permanent oedema in 23.5 p.cent. Surgical treatment associated ligamentoplasty with periosteum and capsular ligamentar tensionning.

METHODS

Minimal follow up was two years and averaged 4 years 7 months. Post operative results were assessed according to Saillant's clinical criteria (subjective instability, sprain recurrence, pain). Radiological criteria included plain and stress X-rays (anterior drawer and varus laxity).

RESULTS

The authors noticed an improvement of clinical and radiographical criteria, without ankle arthrosis or periosteum graft calcification. The global result was: 23 excellent, 4 good, 1 fair and 6 bad results. All athletes went back to sport.

DISCUSSION

Results of this series with almost 80 p.cent of excellent and good results are comparabie with others techniques for ankle ligament reconstruction.

CONCLUSION

This simple technique has a main advantages: no injury to the fibularis brevis tendon. Periosteum ligamentoplasty can then be suggested if lateral tibio-tarsal instabilities persist after proprioceptive physiotherapy.

[Femoropatellar osteoarthritis treated by prosthesis. Retrospective study of 50 implants]

MATERIAL AND METHODS

51 prosthesis were performed in 47 patients and were studied in order to assess long term results. One patient was lost for follow up. The diagnosis was: primitive arthritis in 48 knees and post traumatic arthritis in 3 knees. 25 knees had patellofemoral subluxation, 16 patients had been previously operated on patellofemoral joint. The average age at the time of surgery was 60.5 years and follow up time averaged 3 years. 22 prosthesis had more than 4 years follow-up. The operations were performed using a lateral approach with tibial tubercle osteotomy and lateral patellar retinaculum release. The trochlear component was asymetric and made of chrome cobalt alloy; the patellar component was shaped in polyethylene. Both components were cemented.

RESULTS

Using the Guepar scoring system, 41 (82 per cent) PFA were rated excellent or good and 9 poor. Post operative roentgenograms demonstrated patellofemoral alignment in all knees, even in cases of preoperative patellar subluxation, without tilting of the patella. Follow up roentgenograms demonstrated progressive but moderate deterioration of the tibio femoral joint in 9 cases. In 3 cases, more severe tibio femoral arthritis were treated by T.K.R one to three years after P.F.A. In one of these knees, we discovered an asymptomatic loosening of trochlear component. The last 6 poor results were always due to persistent pain.

DISCUSSION

The purpose of this study was to assess the results of P.F.A. and to clarify the indications. It appears that the 82 per cent success rate of this study may be compared with the results of literature. All the authors have found P.F.A. to be a viable solution, preferable to patellectomy (even in older patients) or isolated patellofemoral realignment. The clinical and radiological results did not deteriorate with time. Persistent patellofemoral malalignment was not observed in this study thanks to the use of a lateral approach. The presence of tibio femoral arthritis adversely affected the outcome, but accelerated changes on the tibio femoral joint after P.F.A. were not observed.

[Haglund disease treated by simple resection of calcaneus tuberosity. An angular and therapeutic study. Apropos of 74 cases with 2 years follow-up]

PURPOSE OF THE STUDY

The authors report the treatment of Haglund's disease, using a simple os calcis tuberosity resection. They reviewed long term results and the value of radiological criteria for pre-operative evaluation.

MATERIAL

The series included 54 patients (74 feet) mostly female and young. The simple resection of os calcis tuberosity was performed without further operation or post-operative splint.

METHODS

Post-operative results were appreciated according to 3 criteria: pain, functional activity and shoe wearing. Radiological criteria used Fowler and Philip angle, angle of calcaneal inclinaison, total angle, CL angle, Denis and Huber-Levernieux test and Heneghan and Pavlov parallel lines. Correlation tests with simple regression were used for statistical analysis.

RESULTS

Results were graded as excellent and good in 73 per cent fair in 16.2 per cent and poor in 10.8 per cent cases.

DISCUSSION

Results were compared to other series. Neither radiological criteria, angular or not, can rule out simple tuberosity resection, because results showed no relation between test and angle measurements. There is no correlation between post-operative radiographs and final result. The only efficient criteria of resection is the difference between Fowler and Philip, and CL angles. This technique may be recommended after few months of medical treatment, without using calcaneal osteotomies of Zadek type.

CONCLUSION

The simple resection of os calcis tuberosity showed good results in 73 per cent cases at an average follow up of 6 years 9 months.

[Complications and failures of total ankle prosthesis. Apropos of 21 cases]

PURPOSE OF THE STUDY

The authors relate a heterogeneous series of twenty one total ankle prosthesis performed by the same surgeon with an average follow up of 37 months.

MATERIAL AND METHODS

Four types of prosthesis were implanted: 4 Ramses, 8 New Jersey, 5 Star, 4 Freeman. The etiology was seven times a rheumatoid polyarthritis, ten times post-traumatic, two idiopathic arthrosis, an hemochromatosis and a late clubfoot sequelae.

RESULTS

Results were appreciated according to Bousquet's criteria: 4 excellent results, 5 good, 3 fair, 9 bad. The ankle mobility was not improved by arthroplasty. We noticed 7 loosening whose 2 septic occurring between 18 and 38 months after implantation of prosthesis.

DISCUSSION

This series indicates that prosthesis should be only suggested for patients over sixty years old. No difference was found between post-traumatic and rhumatoîd. The pre-operative subtalar arthrosis promoted in significant way an unexpected failure occurrence.

CONCLUSION

Indications for total ankle arthroplasty must remain selected. Arthrodesis remains in the immediate future, the best solution for young patients with post-traumatic arthrosis.

[Importance of arthrodesis of the big toe combined with a metatarsal alignment according to Lelièvre in the surgery of the rheumatoid forefoot. Apropos of 70 observations]

PURPOSE OF THE STUDY

The authors reviewed 70 cases of rheumatoid forefoot treated by Lelièvre, lateral metatarsal resection alignment, associated to first metatarsophalangeal joint arthrodesis.

MATERIAL

Rheumatoid arthritis evolution was 20 years an average. It involved cortico-dependent polyarthritis in 48 per cent cases. Metatarsalgia were always present.

METHODS

Mean follow up was 44 months (minimum 24 months) Results were analyzed according to Gainor.

RESULTS

Foot pain disappeared in thirty two cases. Shoe wearing was normal 50 times. Arthrodesis fused 55 times. Lateral toes metatarsophalangeal joint space was satisfactory 28 times. Metatarsal divergence improved, 80 per cent of patients were satisfied in a subjective estimation and 85 per cent using Gainor's criteria.

DISCUSSION

First-Metatarsophalangeal joint arthrodesis ensures permanent stability of the first ray and therefore an harmonious support distribution. The dorsal surgical approach allows an early weight bearing in cortico or immuno dependent patients.

CONCLUSION

This technique keeps a low morbidity and ensures stable mid term results.

Seizures and neuronal damage induced in the rat by activation of group I metabotropic glutamate receptors with their selective agonist 3,5-dihydroxyphenylglycine

While it is well documented that the overactivation of ionotropic glutamate receptors leads to seizures and excitotoxic injury, little is known about the role of metabotropic glutamate receptors (mGluRs) in epileptogenesis and neuronal injury. Intracerebroventricular (i.c.v.) infusion of the group I mGluR specific agonist (R,S)-3,5-dihydroxyphenylglycine (3,5-DHPG) (1.5 micromol) to conscious rats produced severe and delayed seizures (onset at 4 hr) in 70% of the animals. The i.c.v. infusion of the group I mGluR non-selective agonist 1S,3R-1-aminocyclopentane-1,3-dicarboxylic acid (1S,3R-ACPD) (2 micromol) produced a similar rate of severe seizures, but with an early onset (0.6 hr). The analysis of motor activity showed that 3,5-DHPG elicited higher central stimulatory action than did 1S,3R-ACPD. Histopathological analysis of the hippocampus showed that 3,5-DHPG produced severe neuronal damage mainly in the CA1 pyramidal neurons and, to a lesser extent, in the CA3. Although 1S,3R-ACPD infusion also induced a slight injury of the CA1 and CA3 pyramidal neurons, damage was greater in the CA4 and dentate gyrus cells. In conclusion, the in vivo activation of group I mGluRs with the selective agonist 3,5-DHPG produces hyperexcitatory effects that lead to seizures and neuronal damage, these effects being more severe than those observed after infusion of the non-selective agonist 1S,3R-ACPD.

[Mri and surgical indications in perforating ulcer in diabetic patients]

The authors report a series of thirty-six perforating ulcers of the foot in diabetic patients, evaluated using M.R.I. M.R.I. showed osteomyelitis in 16 cases, cellulitis in 15 cases, osteoarthropathies in 21 cases, tenosynovitis of flexor tendons in 2 cases, oedema in 2 cases and abscess in one case. In 19 cases, M.R.I. was used to improve diagnostic accuracy. The medical treatment made use of thermo-moulded soles allowing for the recovery of walking, with a hole facing the perforating ulcer of the foot. The application of insulin-soaked sponges in the event of clean perforating ulcer of the foot and iodized solution in the event of infected perforating ulcer of the foot promoted healing. The treatment was only conservative, when the lesions were limited to the soft tissues. Surgical treatment was performed in 19 cases due to a global involvement of soft and osteoarticular tissues. In fourteen cases the surgical treatment was limited and was performed through the perforating ulcer. Resection of metatarsal heads or metatarso-phalangeal joints was performed in 10 cases, with resection of surrounding pathologic tissue. The surgical treatment was limited to the soft tissues in 6 cases. In 4 cases, M.R.I. findings resulted into a transmetatarsal amputation because the vascular plexus was of poor quality and infection spread from the perforating ulcer to the dorsal aspect of the foot. In our opinion, dorsal infectious involvement in a perforating ulcer of the foot, is a factor of poor prognosis. A below-knee amputation has been performed in one patient.

[Labeled leukocyte scintigraphy and total hip prosthesis]

During the last few years, labelled leukocyte scintigraphy has become a decisive tool in the diagnosis of bone infections. However, this test may sometimes be deceptive as far as hip prostheses are concerned. The authors have carried out a retrospective study of 62 labelled leucocyte scintigraphies performed for suspected infection of a hip prosthesis. The comparison of the results with the different clinical, biological and radiological factors and the follow up of the patients allows determination of the sensitivity and specificity of this test which are 41% and 100% respectively. The results reported in the literature and the indications for this examination are discussed.

[A defective callus of the trapezoid bone diagnosed by 3-dimensional scanner]

The authors report a case of a trapezoid fracture which was diagnosed only when it was malunited. This malunion was shown only by 3-dimensional C.T. imaging.

Mycobacterium kansasii infection limited to the skin in a patient with AIDS

We describe a case of cutaneous Mycobacterium kansasii infection in a 56-year-old man with acquired immunodeficiency syndrome, who received treatment with trimethoprim-sulphamethoxazole for Pneumocystis carinii pneumonia. Resolution of the cutaneous lesion was observed without specific treatment.

[Treatment of hallux valgus by varus osteotomy of the first phalanx associated with adductor plasty]

PURPOSE OF THE STUDY

Sixty two hallux valgus treated by first phalanx varus osteotomy associated to adductor hallux plasty were reviewed with a minimum follow-up of 4 years.

MATERIAL AND METHODS

48 females and 2 males were operated. Average age was 46 years. The forefoot was grecian 40 times. The pre-operative metatarsus varus was at an average of 14.2 degrees when the metatarso-phalangeal valgus was 33.3 degrees. The interphalangeal valgus was 8.25 degrees. The first phalanx base lateral translation measured an average of 5.8 mm. Sesamoids were always dislocated. 36 patients were treated in the same operative time, using this associated approach at different level.

RESULTS

Results were evaluated according to 3 Groulier's criteria. In 10 cases, a post-operative pain persisted. Shoe wearing continually improved. The great toe valgus was corrected in 31 cases (50 per cent). The correction was partial in 20 cases (32.3 per cent) but on radiographs, only 34 cases (54.8 per cent) conserved a normal joint space. The first phalanx base lateral translation only improved partially. It measured an average of 408 mm. The global result was good in and very good, 67 per cent, while patients subjective estimation was good or very good in 90.3 per cent.

DISCUSSION

The study of this series of first phalanx varus osteotomy associated to adductor plasty shows lateral subluxation partial correction, factor of long term modification on articular metatarso-phalangeal joint space. The adductor plasty associated to abductor disinsertion showed a results improvement compared with other published series.

CONCLUSION

The first phalanx varus osteotomy associated to adductor plasty should be limited to moderate hallux valgus deformity with interphalangeal valgus and without any major articular incongruity.

[Tenography in tenosynoviopathies of the posterior tibial tendon]

PURPOSE OF THE STUDY

The authors wanted to study diagnosis contribution and therapeutic importance of tenography in posterior tibial tendon tenosynoviopathies.

MATERIAL

The series included 42 patients (26 females and 16 males) from 23 to 69 years old. The affection had a course for about two years. A trigger or promoter factor was founded in 32 cases. Clinical examination found only 12 standard feet. Biological exams were normal.

METHODS

All patients had a tenography. When tenosynoviopathy was diagnosed, the surgeon injected cortivazol in the sheath by the catheter, within the extra-tendinous space. In case of treatment failure, a synovectomy was realized with possible tendinous suture, under the protection of a weight bearing plaster cast for 21 days.

RESULTS

Pathological features: we have founded 26 major irregularities of the sheath, extensive with scalloped outlines of which 8 were supra-malleolar and 18 sub-malleolar, 15 irregularities located at the level of the sheath outline of which 4 were supra-malleolar and 11 sub-malleolar and with a tear of 1 cm length. Long term results: among 36 reviewed patients, pain disappeared in 29 cases, after only one injection (21 cases), or after a surgical treatment (8 cases).

DISCUSSION

Tenography has for us great interest for the diagnosis of a tenosynoviopathy, allowing in the same time an extra-tendinous injection of corticoid in the sheath itself. But it doesn't always allow to make a diagnosis of a tendinous tear. A part of our failures can be secondary to these tears. According to our results it could be recommended to practice in a first time a tenotomodensitometry (teno TDM). In case of a tear, a surgical treatment by synovectomy with suture may be proposed first, for a tenosynoviopathy an injection must be realizes.

CONCLUSION

Tenography allows a precise diagnosis and in the same time, a treatment by injection. The tendinous tears require a surgical suture but are better diagnosed on a teno TDM.