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.

Large diameter head metal-on-metal bearings total hip arthroplasty: preliminary results

INTRODUCTION

Although the use of the metal-on-metal bearings has been validated over the long term in total hip arthroplasty (THA) for standard 28 and 32 mm diameters, and over the medium term in resurfacing procedures, the use of larger metal head size in conventional THA has not yet been extensively reported.

HYPOTHESIS

The large-diameter metal-on-metal head is beneficial in terms of implant stability without altering the result in terms of function and bone fixation compared to the standard 28 and 32 mm diameters.

OBJECTIVE

The objective was to test this hypothesis by assessing the short-term clinical and radio graphic results of a metal-on-metal large-diameter heads THA system, using cups from the resurfacing hip concept.

MATERIAL AND METHODS

We conducted a retrospective study on a continuous series of 106 uncemented acetabular cups (Durom) implanted in 102 patients (mean age, 66 years): 93 cases of primary or secondary coxarthrosis, 11 cases of aseptic osteonecrosis, one fracture of the femoral neck, and one case of rheumatoid arthritis of the hip. At 30 months of follow-up,the Harris Hip Score and the Merle d'Aubigné (PMA) score were calculated. The radiological investigation included comparison of the implant head with native head diameters, variations of acetabular center of rotation, inspection for implant migration, and search for a gap or radiolucent line.

RESULTS

The series included two post-traumatic dislocations as well as spontaneously receding tendinitis of the gluteus medius with no further recurrence. The mean Harris Hip Score improved from 49.3 preoperatively to 91.6 at the latest follow-up and the mean PMA score ranged from 12 to 17. The results were excellent for 70 cases, good for 31 cases, fair for three cases, and poor for two cases. In the last five cases, the overall results were undermined by low pain subscore,with no identifiable explanation. Restoration of the original head diameter was verified for 65 hips. No cup migration was observed. Measurement of the acetabular centre of rotation showed a mean lateralization of 1.1mm. Of the 67 immediate postoperative gaps, only two did no disappear at follow-up. Implant head diameter, cup position, and the existence of a gap were not correlated with the clinical results.

DISCUSSION

These results are comparable to 28 mm-diameter metal-on-metal heads in uncemented cups but with improved stability but without demonstrable alteration of the quality of the bone fixation. We found no mechanical or medical cause that could explain the five cases of persistent pain leading to fair or poor results. Long-term follow-up will validate these theoretical advantages in terms of wear and implant survival.

LEVEL OF EVIDENCE

IV. Retrospective series.

Relationship between ultrastructure and biomechanical properties of the knee meniscus

The purpose of this study was to determine the biomechanical properties of the knee meniscus and to relate them to its ultrastructure. The knee joint menisci are semicircular, fibrocartilaginous structures interposed between the femoral and tibial condyles. For a long time, they were considered to be embryologic vestiges. This study describes the response of the knee joint meniscus to circumferential, radial and axial compressive forces. The results show an anisotropic response of the knee joint meniscus to unconfined compression. The Young's modulus increased approximately twofold between vertical and circumferential or radial directions with a 10 mm/min-compression rate. This response is probably a direct consequence of the orientation of collagen fibres.

Fractures récentes de la tête radiale associées à une instabilité du coude traitées par prothèse à cupule mobile de Judet

PURPOSE OF THE STUDY

Fracture of the radial head associated with elbow instability is infrequent. We report a retrospective series of floating Judet prostheses implanted for comminutive fractures of the radial head associated with elbow laxity caused either by dislocation or rupture of the medial collateral ligaments.

MATERIAL AND METHODS

The series included ten patients who underwent surgery from October 1996 to September 2002 at the Amiens University Hospital. The indication for radial head prosthesis was established in the emergency setting for fracture unamendable by osteosyntheis and elbow laxity. Mean age was 48.2 years (25-69). All patients were seen at mean follow-up of 31.7 months (18-48). According to the Mason classification as modified by Johnson, all patients had type 4 fracture. A Judet radial head prosthesis with a floating metallic cup was implanted in all patients. An investigator other than the operators evaluated outcome using the Mayo Clinic criteria.

RESULTS

Joint motion as measured by goniometry was: mean flexion 121degrees (90-140 degrees), mean extension deficit 20 degrees (5-60 degrees), mean pronation 45 degrees (0-85 degrees), mean supination 42.5 degrees (0-90 degrees). The Mayo clinic score was excellent in 3, good in 2, fair in 3, and poor in 2 (prosthesis dislocation in one and hung prosthesis requiring removal in one). Four patients developed periarticular ossifications compromising the final result.

DISCUSSION

The floating Judet prosthesis allows optimal adaptation of the implant to anatomy and function. For us, these implants are indispensable when the radial head fracture is associated with elbow instability. The indication for prosthesis may be questionable if the non-fixed fracture is free of associated ligament injury, as suggested by the good long-term reported after simple resection. Rigorous operative technique is crucial, with careful restitution of the radial height. The quality of the result is related to the degree of capsule and ligament injury even after optimal implant positioning. Preventive treatment against periarticular ossification should be systematic.

[Core decompression of the femoral head for avascular necrosis]

PURPOSE OF THE STUDY

Core decompression of the femoral head is a conservative surgical treatment with controversial efficacy. We studied retrospectively a series of 32 cases of femoral head osteonecrosis treated by core decompression between 1988 and 2000 in 25 patients. We examined the epidemiological and clinical features as well as the laboratory findings, comparing cases requiring secondary hip replacement and those who had a favorable outcome. We search for prognostic factors.

MATERIAL AND METHODS

The series included 32 hips, one case was lost to follow-up. Mean age at decompression was 41.3 years (22-55). In eight hips, osteonecrosis was favored by corticosteroid treatment, in three by chronic alcoholism, and in one by hypertriglyceridemia. No favoring factors were present for 20 hips. According to the ARCO classification there were 15 stage I hips, 13 stage II, 3 stage III, and one stage IV. Core decompression was centered in 24 hips and mean time to decompression was 6.4 months (14 days to 40 months). We reviewed hips without a total prosthesis using the Postel-Merle-d'Aubigne function score and for the radiological assessment the ARCO stage and the Koo index.

RESULTS

Favorable outcome was noted in 12 hips. Total hip arthroplasty was required for 19, one hip was lost to follow-up. Mean follow-up in the success group was 82 months (26-176) and mean "time of participation" in the failure group was 11 months (1-38). Mean survival after core decompression was 14 months. Time between onset of symptoms and decompression did not influence outcome. Lesions which remained asymptomatic before decompression remained stable. The stage I hips did not have more favorable outcome than the stage II hips (p < 0.05). Stage III or IV hips had unfavorable outcome. Hips with a Koo index > 40 had a poor outcome (p < 0.05).

DISCUSSION

Epidemiological factors which can worsen outcome after core decompression for osteonecrosis are controversial in the literature. Early stage disease (I or II) is considered as an ideal indication for decompression, but is insufficient alone to guarantee success. As other authors, we consider that ARCO stage III and IV and a Koo index > 40 are contraindications for decompression. Improved outcome after core decompression can only be achieved by limiting indications.

Luxation tibio-fibulaire proximale : témoin d’un traumatisme grave de la jambe et du genou

PURPOSE OF THE STUDY

Dislocation of the proximal tibio-fibular joint is a rare lesion generally described in athletes. In our experience, high-energy trauma in traffic accident victims was a frequent cause. Dislocation of the proximal tibio-fibular joint is generally described as anterolateral, posteromedial, superior, or subluxation. We describe an inferior form of dislocation.

MATERIALS AND METHOD

The study population included eight men aged 21-55 years (mean 31 years). One patient had bilateral dislocation. There were four superior, one posterior, and four inferior dislocations. All patients also had an associated fracture of the tibia which was an open fracture in eight cases. Five patients suffered a lesion to the common fibular nerve. Three had tibial nerve involvement in a context of inferior disclocation. The lateral collateral ligament was torn in six cases. The central pivot was involved in four. Two patients had an avulsion of the patellar ligament on the tibial tuberosity. Five patients had vessel damage. Three required emergency amputation. Two patients (one superior and one inferior dislocation) underwent emergency bypass surgery but required below-knee amputation later due to persistent ischemia. All dislocations, excepting the one case of complete fibular avulsion and one emergency above knee amputation were treated by transarticular screw fixation of the proximal tibio-fibular joint.

RESULTS

Mean follow-up was 5.8 years (1-9 years). At last follow-up, there were no cases of instability or pain in the proximal tibio-fibular joint. The patient with an initial neurapraxia in territory of the common fibular nerve recovered totally. The five amputated patients had prostheses and walked without crutches.

DISCUSSION

Dislocation of the proximal tibio-fibuilar joint is a rare entity, but the frequency is probably underestimated. The dislocation can go unrecognized in patients with multiple injuries. Careful search should nevertheless be undertaken due to the risk of secondary involvement of the common fibular nerve. The Harrisson and Hindenach classification, inspired by the Lyle classification, does not mention inferior dislocation of the proximal tibio-fibular joint, a recently described entity. Our series included dislocations resulting from high-energy trauma associated with numerous ligament, nerve, and vessel injuries. In this context, dislocation of the proximal tibio-fibular joint constitutes an epiphenomenon.

Évaluation au recul de 5 ans de 100 cupules impactées sans ciment de type Duraloc®

PURPOSE OF THE STUDY

The longevity of an acetabular implant depends in part on its resistance to mechanical stress. Long-term stability of an uncemented cup requires stable primary fixation. This can be achieved with press-fit components.

MATERIAL AND METHODS

One hundred forty-nine Duroloc press-fit acetabular implants were studied after a minimum follow-up of 60 months. Among these 149 cups, 100 were analyzed with a mean follow-up of 60 months. Twenty-two patients were lost to follow-up, 19 were contacted by telephone, and eight had died. Clinical and radiological criteria were used to assess outcome. Digitalized x-rays were processed with Imagika (View Tec, Saint-Maurice, France) to determine the position of the implant in two-dimensional space, inclinaison, anteversion, polyethylene wear, bone-implant contact, and presence of ossifications. Seventy percent of the patients underwent arthroplasty for degenerative hip disease.

RESULTS

The cohort included 40 women and 60 men. Mean age at surgery was 59.4 years, range 30-80 years. The Postel-Merle-d'Aubigne score improved from 10 to 16. Mean polyethylene wear was 0.5 mm with an annual rate of 0.087 mm/yr. Among the 57 cup-bone spaces present postoperatively, 41 had filled at last follow-up (78%). There were no cases of osteolysis. Peri-prosthetic ossifications were observed in 50 patients (16 stage I, 12 stage II, 19 stage II, and 3 stage IV). Medial displacement of the cup > 4 mm was observed in one patient and ascension > 4 mm in four patients who had no other sign of loosening. Complications were: dislocation (n=15), phlebitis (n=2), sciatalgia (n=1) and infection (n=1).

DISCUSSION

This retrospective series revealed an unacceptable dislocation rate with no correlation with implant positioning error in comparison with the biomechanical position of the healthy hip. The non-hemispheric shape of the implant and the beveled edge of the polyethylene insert could be implicated, particularly since none of the implants had a polyethylene overhang. The mean annual wear (0.087 mm) was relatively high compared with cemented cups. Age was the only factor correlated with wear. Migrations were difficult to interpret. Medialization or ascension of the implant was not associated with any clinical sign suggestive of loosening. The poor reproducibility of the x-rays cannot explain these findings. Secondary repositioning of the implant might be involved.

CONCLUSION

The high rate of dislocation and the frequency of excessive wear have led us to abandon this implant for more hemispheric cups.

Arthrodèse de cheville pour échec d’arthroplastie totale

We report outcome in eight cases of ankle arthrodesis after failure of a total ankle prosthesis.

MATERIAL AND METHODS

This series included eight patients, mean age 57 years (range 36-76) who had initially: post-traumatic talocrural joint degeneration (n=4), rheumatoid polyarthritis (n=3), idiopathic talocrural degeneration (n=1). Three patients had a New Jersey (DePuy) cemented prosthesis, four had a Star (Link) uncemented prosthesis and one, whose implantation was performed in another institution, had a spherical cemented prosthesis. The preoperative Kitaoka score was 19.1 (0-32). Seven patients had subtalar joint degeneration; one patient had a subtalar arthrodesis. The tibial component was cemented alone in two patients, the talar piece in three (two with talar fracture). Failure resulted from loosening, talus fracture or deep infection. Bipolar loosening was observed in two patients. Time to revision was 36 months (range 4-108). Arthrodesis was associated with an iliac graft for seven patients: several tricortical grafts (vertical alignment of the corticals) and cancelous grafts for filling. The height of the graft was adjusted to the substance loss. A bone graft could not be used in one patient who had a deep infection. The arthrodesis was fixed with an anterior plate bridging the talocrural space in six patients, with an external fixator in infected patient, with a conventional centromedullary tibial nail transfixing the talocrural joint and planted in the talus and the calcaneus in one. Outcome was assessed with the Kitaoka score. Mean follow-up was 56 Months (range 10-114).

RESULTS

The overall Kitaoka score improved to 54/100 (range 42-70) at last follow-up. The arthrodesis provided improvement in all patients although the final outcome was still considered poor in three patients. Radiographic healing was obtained in seven patients at a mean 3.1 months (range 2.5-6). Wound healing was slow in two patients. One patient developed a deep infection early.

DISCUSSION

The rate of fusion was 87%. This is in the general range reported in the literature; use of an iliac graft allows preserving joint height but because of the poor bone quality often encountered, residual bone stock may be insufficient to achieve complete fixation with screwing. Plate fixation appears to be a better way of achieving fixation. This provides a rate of fusion comparable with earlier series where external fixation was generally employed. For us, external fixation should be reserved for infected cases. Use of a conventional anterograde nail can be another solution in the event of poor bone quality. The overall result remains relatively modest although all the patients achieved a functional gain with arthrodesis. The results obtained are less satisfactory than after first-intention ankle arthrodesis.

[Gluteus medius tendon tear and degenerative hip disease]

We report three cases of gluteus medius tendon tears discovered fortuitously in patients undergoing total hip arthroplasty. The tears were not suspected from the initial clinical presentation. Sutures were possible in only one patient. Outcome of the hip arthroplasty was very good in all three patients despite lack of tendon repair in two.

[Triple arthrodesis in the management of acquired flatfoot deformity in the adult secondary to posterior tibial tendon dysfunction. A retrospective study of 20 cases]

The authors have reviewed 20 cases of valgus flatfoot deformity in the adult, secondary to insufficiency of the tibialis posterior tendon, which were treated by triple arthrodesis from 1983 to 1998. The longitudinal arch was flat grade 3 in 18 cases and grade 2 in two. The rearfoot was in valgus in all cases. Dorsal flexion of the ankle was limited to 5 degrees with a short Achilles tendon in 10 cases Djian-Annonier's angle was 134 degrees on average. The talocalcaneal divergence was 32 degrees. Diffuse osteoarthritis was present preoperatively in 14 cases. Fusion of the arthrodesis was achieved in 18 cases. There were two nonunions: one affecting the talonavicular joint, and the other, the talonavicular and calcaneocuboid joint. Results evaluated according to Kitaoka's criteria were excellent in 35%, good in 35%, fair in 20% and poor in 10%. Xrays showed progression of osteoarthritis. These results were not as good as in Fortin and Waling's series but we did not use iliac grafts. There was no instance of talus necrosis. The nonunion rate was higher than in other series at the talonavicular level. In order to improve the results, we now believe that bone resection must be kept minimal and bone grafts should be used, in addition to internal fixation. Triple arthrodesis was found to give good result in the treatment of acquired flat foot deformity due to insufficiency of the tibialis posterior tendon. However on the long term it promotes degenerative changes in neighbouring joints.

[Anterior tarsectomy for cavus foot. Retrospective study of 52 cases]

The authors reviewed 34 patients treated by tarsectomy for idiopathic pes cavus deformity between 1977 and 1996. Fifty two feet were treated surgically. All patients had undergone previous conservative treatment. The average age was 40 years. Podoscopic examination revealed 24 cavus feet stage 2, 28 cavus feet stage 3, adduction of the forefoot in 15 cases and an equinus deformity in 8 cases. On radiographic examination, Djian-Annonier's angle was 108 degrees on average. All patients were evaluated with a minimum ot two years follow-up, according to the evaluation system of the Massachusetts General Hospital. With an average follow-up of six years and six months, overall results were; 65.5% very good and good, 21% fair, 13.5% poor. The morphological correction was poor in 9 cases. Djian-Annonier's angle was 125 degrees on average. A number of cavus feet do not justify surgical treatment, because they are well tolerated, sometimes with orthopedic orthoses. Tarsectomy must be avoided in neurological conditions. We do not advise release of soft tissue or Dwyer's calcaneal osteotomy. In our opinion, the choice indication for anterior tarsectomy is the nonrigid cavus foot. It must be combined with lengthening of the Achilles tendon when a deficit of dorsiflexion of the foot persists following tarsectomy. According to their importance, associated deformations will be treated in the same operative session or not.

[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.

[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.

[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.

[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.