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Revue de Chirurgie Orthopédique et Traumatologique 10/2009; 95(6):543-546.
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ABSTRACT: With the advent of locking screws fixation devices, came new problems when removing internal fixation hardware. The objective of this study was to evaluate these problems and their possible solutions. The first problem was screws jamming on the plate, secondary to either initial poor screwing technique (with inadequate placement of the targeting device) or use of excessive force (when screwing in the screws without using the torque-controlling screwdriver). Treatment consists of destroying the screw heads using tungsten drills. The screw bodies can then be extracted using a trephine drill. The second problem involves destruction of the recess of the screw head. It can be secondary to overly forceful screw insertion or risky screw extraction. This can be treated using a specific conical left-turn screwdriver, assuming that the screw/plate thread is still intact. Finally, the screw recess can be filled. The plate itself may be a source of problems when being extracted because the screw holes left free also have been filled. Lever arm maneuvers to raise the fibrous bridges and substantial traction along the axis can be useful. These problems are more frequent with minimally invasive surgery. The consequences of this fixation type's hardware removal surgery are multiple: lengthened operative time, risk of secondary maximally invasive surgery, presence of metallic shavings residues in cases of screw head destruction, and the risk of iterative fracture secondary to trephine drill use. Prevention is thus essential. It is based on rigorous technique in placing the targeting device, drilling, and inserting screws, the systematic use of the torque-controlling screwdriver, and the verification of proper screw position. The locking compression plate (LCP) material is highly effective but its removal should not become challenging. Level of evidence: Level V.
Orthopaedics & Traumatology Surgery & Research 08/2009; 95(5):373-6. · 0.94 Impact Factor
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ABSTRACT: Tears of the scapholunate ligament are usually diagnosed during an arthro-CT or arthro-MRI examination. Typically, the contrast agent passes from one joint to the other. In certain cases, fibrous scar tissue devoid of any mechanical effect may block the passage and lead to an erroneous interpretation of the images. We reviewed retrospectively patients who underwent arthroscopic treatment for scapholunate tears and who had normal arthro-CT images. We searched for specific aspects suggestive of ligament injury. Analysis of the arthro-CT images demonstrated that a bulge of the scapholunate ligament could be noted in patients whose diagnosis of scapholunate ligament injury was established arthroscopically. We propose that appropriate lecture of wrist images can identify scapholunate ligament injury in patients wrongly considered to be free of wrist injury, but who actually have an occult injury to the scapholunate ligament.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 05/2008; 94(2):182-7. · 0.37 Impact Factor
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ABSTRACT: We report a consecutive prospective series of femoral fractures on previous implants. The purpose was to assess treatment with locking compression plates and total weight-bearing.
From June 2002 to December 2005, we treated 21 patients (16 women, five men) for fractures on previous implants: total hip arthroplasty (n=11), total knee arthroplasty (n=1), unicompartmental prosthesis (n=1), gamma nail (n=4), hip screw (n=1). Mean patient age was 75.8 years (range 39-90). Osteosynthesis was performed on an orthopedic table or on a standard table using a minimally-invasive approach for fixation with a locking compression plate (Synthes) LCP) to bridge the implants in place and avoid any zone of weakness. The rehabilitation protocol included immediate total weight bearing.
At last follow-up there were three deaths and one failure so that there were 17 patients with a mean follow-up of 15.9 months (range 6-45 months). The following outcomes were noted. Minimally-invasive surgery was used in 18 cases, access to the fracture focus in three. Total weight bearing was possible immediately after surgery in 12 patients and partial weight bearing (20 kg) for two. There were two infections, two general complications and one early displacement. Healing was achieved at 6-10 weeks. Misalignment greater than 10 degrees was noted in three cases.
This work illustrates the use of locking plates for minimally-invasive repair of fractures on previous implants with total weight bearing. This technique combines the principles of closed fixation and preservation of the fracture hematoma with material stability. In this form, use developed progressively. It is now common practice to use plate fixation for femoral fractures. The LISS system was then developed progressively for minimally-invasive repair of distal fractures. We widened the concept to include more proximal approaches. The use of the locking screws in the plate corresponds to what could be called an internal external fixator with three pins (two corresponding to the cortical screws plus the plate), which enable a solid fixation. Screw hold seems to be sufficient to allow early weight bearing.
Locking plates have been shown to be an effective treatment for femoral fractures on previous implants allowing a stable fixation sufficient for early weight bearing.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 03/2008; 94(1):26-36. · 0.37 Impact Factor
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ABSTRACT: We report a case of a woman presenting with a long-term non-healing wound below the tibial tubercle that underwent a successful sartorius muscle flap. We performed an anatomical study of the vascularisation of the sartorius muscle. The vascular supply to the distal part of the sartorius muscle was studied in 15 limbs by dissection and after red ink and latex injections. The artery of the sartorius muscle flap arises most of the time from the saphenous artery or the descending genicular artery and is supplied through anastomoses by branches of the posterior tibial artery and the medial inferior genicular artery. The flap is useful for covering wounds around the knee, as well as the proximal and the middle thirds of the leg. The surgical technique is relatively simple, with a low morbidity from muscle harvesting.
Journal of Plastic Reconstructive & Aesthetic Surgery 02/2008; 61(1):50-4. · 1.49 Impact Factor
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ABSTRACT: Morphological and morphometric studies of the wrist ligaments are scarce. The radiocapitatum and scapholunate ligaments play a pivotal role in wrist stability. Classically, a posterior approach is used for arthroscopic procedures, but an anterior approach should be possible. We conducted a cadaver study to search for new anterior portals for wrist arthroscopy.
Twenty-five formol-treated upper limbs were dissected. The classical anterior approach for open wrist surgery was executed. The different elements of the capsule-ligament system of the anterior aspect of the wrist were identified and labeled. The dissection was then extended to the ulna in search of soft points which were identified and evaluated. The different structures generally identified during wrist arthroscopy were noted.
Two potential portals were identified in all wrists: one between the radiolunate ligament and the radio-scapho-capitatum ligament on the radial aspect and one between the radio-lunate ligament and the ulno-lunate ligament. Arthroscopic exploration enabled observation of the scapho-lunate ligament, the luno-triquetral ligament, the triangular complex of the carpus, and the entire inferior aspect of the radial joint surface, with no risk of vessel or nerve injury because of the exposure allowed by the osteosynthesis approach.
Wrist arthroscopy is now accepted as a reliable technique not only for diagnostic purposes but also for therapeutic interventions for the treatment of fractures of the lower radius. Most of the arthroscopic portals described in the literature are posterior. The anterior portals described here do not involve any vascular or neurological risk since the radial approach is made under visual control by extension of the open anterior approach and on the ulnar side the noble structures are positioned medially to the ulnar flexor tendon of the carpus. This enables good triangulation necessary for the usual arthroscopic procedures. Finally, these portals have no supplementary morbidity which would be the case with percutaneous portals (injury to the medial nerve, the radial vasculonervous bundle, the radial flexor tendon).
These new arthroscopic portals are complementary to the anterior approach for open wrist surgery and enable a natural extension of joint exploration via both the radial and ulnar approaches described in this study.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 07/2007; 93(4):339-43. · 0.37 Impact Factor
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ABSTRACT: Fractures of the distal radius are common. No one implant has demonstrated superior efficacy in terms of maintaining the reduction over time. We report our experience with plate fixation using a locking screw.
Between September 2003 and June 2004, 67 displaced fractures of the distal radius were treated by plate fixation using the LCP-DRP 2.4 (Synthès). Three different plates (anterior, posterior, and external) were used. The patients wore a removable anatomic brace for three weeks. Self-controlled rehabilitation exercises began directly after surgery with mobilization of the digital chains. The Fernandez, Castaing and AO classifications were noted. Ulnar variance, anteversion of the radial glenoid, radial slope and the alpha angle were measured intraoperatively and at last follow-up to assess maintenance of reduction over time. The DASH test and Green and O'Brien and PRWE scores were used to assess clinical outcome.
Mean follow-up was eight months. Mean age was 55.8 years. Eight patients were lost to follow-up. The analysis included 59 patients who could respond to the questionnaires. Bone healing was achieved at six weeks. There were no cases of secondary displacement nor loss of reduction. The Green and O'Brien score was good or very good for 85%. The mean DASH was 20.6 and the mean PRWE 32.8.
The appropriate fixation method for distal fractures of the radius remains a controversial issue, leading to a variety of materials and fixation methods. Primary stability achieved with the locking screw in a plate enables early mobilization associated with more rapid recovery of function. The absence of secondary displacement, irrespective of the quality of the underlying bone enabled us to achieve equivalent results in young patients and older patients with osteoporotic bone. This study also confirmed the preference for the anterior approach, irrespective of the direction of the displacement. To date, no other material has enabled equivalent results. This is a major achievement in terms of fixation stability.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 12/2006; 92(7):663-72. · 0.37 Impact Factor
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ABSTRACT: Clear-cell sarcoma (CCS) of tendons and aponeuroses is a rare malignant tumor representing about 1% of soft tissue tumors. Preferentially observed in young adults in the second or third decade, the tumor generally develops in the limbs. Only 2% of SCC of tendons and aponeuroses have been reported in children less than 10 years of age. This slowly progressive tumor usually forms a painless mass. The tumor increases in size followed by metastatic dissemination to lymph nodes and the lungs. The prognosis is related to tumor size. At the present time, the recognized limit is greater than 5 cm. Early diagnosis must be achieved to enable effective treatment by carcinological surgical resection. We report the three cases of CCS of tendons and aponeuroses observed at the Strasbourg University hospital over a 35-year period. Each case had a special clinical presentation. The first patient, treated in 1967, presented tumor bone lysis on the plain x-ray, an observation rarely reported in the literature. In the second patient, treated in 2002, the tumor was discovered after trauma. This patient developed skin ulceration associated with paraplegia secondary to metastatic thoracic cord compression. The third case occurred in a 12-year-old girl, treated in 2002.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 11/2005; 91(6):569-74. · 0.37 Impact Factor
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ABSTRACT: We report four cases of flexor tendon ruptures which occurred after distal radial fracture and reviewed the 25 other cases reported in the literature since 1932. Analysis of these 29 cases disclosed the causes of these ruptures. A deformed callus after distal radial fracture or presence of an anterior osteosynthesis plate can under certain conditions lead to secondary flexor tendon tears. It was also found that tears of the flexor pollicis longus rupture predominate, followed by injury to the flexor digitorum profundis and superficialis of the index finger. Other tendons have only been involved in only a few cases. In order to avoid this complication, we propose systematic removal of anterior plates or secondary replacement if the reduction is not totally anatomic. Surgeons should recall the importance of anatomic reduction of distal radial fractures.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 10/2005; 91(5):476-81. · 0.37 Impact Factor
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ABSTRACT: Acute compartment syndrome of the leg is generally a consequence of trauma. Exercise-induced acute compartment syndrome of the leg is an exceptional clinical entity observed in the context of a chronic compartment syndrome or as an isolated acute syndrome subsequent to an intense effort. Our patient was a young athlete with no history of exercise-induced leg pain. Following a soccer game, he developed an acute leg syndrome involving the anterolateral compartment of both legs. The diagnosis was not suggested by the patient's history (no notion of chronic compartment syndrome) nor the natural history of the condition but was retained on the basis of the clinical presentation and course then confirmed by intramuscular pressure measurements. Emergency treatment by fasciotomy under general anesthesia in the operating room led to cure with no sequela. The fasciotomy was closed on day 9 with simple skin sutures. Surgeons should be aware that acute exercise-induced compartment syndrome (with the risk of severe functional consequences) may be the cause of unexplained intense leg pain. The diagnosis is established on the basis of clinical findings and measurement of intramuscular pressures. Pain is the cardinal sign, sometimes associated with sensorial deficit. The compartment is hard and painful at palpation. Passive stretching exacerbates the pain. Compartment pressure is required for certain diagnosis, most Authors accepting > 30mmHg as a positive test. Emergency fasciotomy is required.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 04/2004; 90(2):165-70. · 0.37 Impact Factor
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ABSTRACT: We report our experience with arthroscopy-guided treatment of fractures of the distal radius.
Between November 2001 and June 2002, 16 patients (10 men, 6 women, mean age 51 years, age range 24-75 years) underwent arthroscopy-guided treatment of articular fractures of the distal radius. Patients were installed with the arm held in a horizontal position with a brace, the wrist under traction. The same procedure was used in all cases: introduction of the arthroscope, joint cleaning and shaving, search for lesions, arthroscopy-guided treatment. Kirschner 2-mm pins were used for fixation in all cases, combined with 1.2-mm pins in the event of ligament injury.
Arthroscopic exploration revealed cartilage impaction in 25% of the wrists and ligament injuries in 30%. One fixation disassembled and was not remounted. There were two cases of reflex dystrophy. There were no arthroscopy-related complications. Bone healing was achieved in eight weeks in all cases. The mean DASH score was 22.5 at six months follow-up (range 3-10). DISCUSSION CONCLUSION: Arthroscopy-guided treatment of fractures of the distal radius was attempted for the first time in the early 90s. Per-operative arthroscopy enables a good view of the fracture and associated lesions (cartilage impaction, scapholunate, lunotriquetral ligament injury) and facilitates control of the reduction. Arthroscopy is technically simple and is the technique of choice due to the lack of morbidity. Several authors have reported their experience in more or less extensive series. Two notions should be emphasized. First, defective intra-articular reduction greater than 1 mm may lead to osteoarthritis of the wrist in 90% of the cases. Secondly, intra-operative imaging (fluoroscopy) does not provide sufficient precision to visualize a 1-mm stairstep in the articular surface, raising the risk of radiocarpal degeneration at mid term despite often satisfactory postoperative x-rays. We thus propose intra-operative arthroscopy to control the treatment of all articular wrist fractures, with or without displacement, in order to ensure satisfactory reduction with less than 1-mm defect in the articular surface and to search for and treat any associated bone or ligament injuries not diagnosed before surgery.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 11/2003; 89(6):515-23. · 0.37 Impact Factor
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ABSTRACT: Osteoblastoma is an uncommon benign bone tumor diagnosed in about 1% of primary bone tumors. Predominantly observed in the axial skeleton, it can be observed in long bones (20%), generally in the diaphysis (80% of the long bone localizations). In typical cases, standard imaging is highly suggestive of the diagnosis. The typical image is a "lytic" zone surrounded by bony condensation, and a minimal osteosclerotic reaction peripherally, rarely invading the soft tissues. Diagnosis is confirmed at pathology: osteoblast-like cells disseminated in an abundant conjunctive background surrounded by immature richly vascularized bone. The tumor we report presented an unusual localization and an atypical aspect on the imaging studies. Located in the tibial epiphysis, this osteoblastoma invaded the soft tissues, as seen on the CT and MRI studies which visualized an encapsulated tumor with a calcified shell and a liquid-like tumefaction suggestive of a tumor arising from the synovial.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 06/2003; 89(3):266-71. · 0.37 Impact Factor
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ABSTRACT: We report the case of a traffic accident victim who suffered major tissue loss of the heal. We used two pediculated flaps to close the gap in a single procedure. The remaining tissue presented zones of necrosis from the plantar aspect to the posterior half of the calcaneum, up to the insertion of the calcaneus tendon, extending 5 cm on the posterior aspect of the heal. We decided to combine a medial plantar flap with a lateral supramalleolar flap. The thick medial plantar flap allowed cover of the calcaneum and sensitivity. The calcaneus tendon was covered with the lateral supramalleolar flap. The thickness of the flap was adapted to match the tissue defect. At six months, the patient had recovered walking function with satisfactory weight bearing on the heal. Flap sensitivity was satisfactory with no slipping phenomenon.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 03/2003; 89(1):75-8. · 0.37 Impact Factor
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ABSTRACT: Trauma led to bilateral rotatory atlantoaxial dislocation in a 23-year-old woman. Clinical diagnosis of this uncommon dislocation of the cervical spin is generally difficult and often made late. Typical signs include pain in the upper cervical spine and a fixed rotated position of the head. Integrity of the transverse ligament of the atlas is a determining factor for atlantoaxial stability and allows orthopedic treatment after reduction using moderate traction on the head. As for most authors, orthopedic was successful in our patient who totally recovered cervical spine mobility without pain.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 11/2002; 88(6):613-9. · 0.37 Impact Factor
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ABSTRACT: Post-radiation shaft fractures of long bones are uncommon. Late or partial healing increases the risk of stress fracture. Different fixation techniques have been proposed. Treatment of radiated bone is difficult. We report a series of 6 nonunions of the proximal femur after radiotherapy.
Three patients had true fractures of irradiated bones several years after radiotherapy for bone or soft tissue tumors. Three other patients had pathological fractures or malignant osteolysis related to a myeloma and treated by osteosynthesis and post-operative radiotherapy.
Treatment required a total of 19 surgical procedures. There were nine stress fractures of ostheosynthesis material involving locked nails, cervicodiaphyseal nails and plates. There were no vascularized grafts in this series. At last follow-up the pathological fracture had healed in three cases, was stable but not healed in two, and required prosthetic reconstruction in one.
We emphasize the importance of rigorous patient selection for radiotherapy and the possible preventive effect of osteosynthesis in certain cases with a high risk of secondary fracture of an irradiated bone. Vascularized grafts may be useful for refractory nonunion and may be proposed as first line treatment for post-radiation fractures.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 06/2002; 88(3):271-8. · 0.37 Impact Factor
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ABSTRACT: The Swedish Arthroplasty Registry experience with cemented primary total hip arthroplasty (THA) has pointed out age below 65 and high activity level as 2 major factors impairing THA long-term outcome. The aim of this study was to provide intermediate results of cementless femoral replacement in primary THA with use of the Alloclassic-SL grit-blasted titanium stem in "high risk" groups of patients.
From June, 1988 to June, 1992, 127 cementless primary THA's were consecutively performed in<65 year old patients in 2 institutions. Acetabular components were all cementless (threaded cup in 74%) and bearing surfaces were all alumina-ceramic 28mm heads on polyethylene (PE). Five patients (6 hips) died and 6 other hips were lost to follow-up before the 5-year minimum follow-up. Thus, 115 hips in 106 patients could be fully reviewed after a 8.2 year average follow-up period (range, 5 to 12 years). Mean age at surgery of the 62 male and 44 female patients was 52 years (range, 27 to 65 years).
Of the index group (127 hips), intra-operative fracture of the greater trochanter and early dislocation were noted in 4.7% and 3.2% of hips, respectively. Of the study group (115 hips), clinical results according to the Merle d'Aubigné and Charnley rating system were graded excellent and good in 94% of hips and fair in 6% (7 hips), with no poor result. Radiologically, early subsidence of more than 2mm could be detected in 8 hips (7%). Calcar atrophy and spot welds were noted in 81% and 89% of hips, respectively. Proximal reactive and lucent lines and mild proximal stress shielding were observed in 10.5% and 4.3% of hips, respectively. Ten-year survivorship with stem revision for any reason as the end point was 99.2% (92.4-99.9) (1 stem exchanged and reoriented for immediate dislocation). One revision is pending for extensive femoral osteolysis due to polyethylene (PE) wear. There was no stem fracture and no ceramic head breakage thus far. Overall PE-wear rate ranging 1-2 mm was detected in 13 hips (9.6%) and femoral osteolysis in 4 hips (3.5%).
Mid-term results of this cementless straight taper at 10 year are at least equal to those of well performing cemented components, even in "high risk" groups of patients. Conversely, 28mm alumina-ceramic heads can reduce but not prevent the occurrence of PE-wear in such a healthy and active population.
Press-fitting but not filling the femoral canal with rough titanium straight tapers like the Alloclassic-SL femoral component represent a promising alternative to modern femoral cementing technique in primary THA. Improvement is expected through the use of more wear resistant bearing surfaces.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 01/2002; 87(8):802-14. · 0.37 Impact Factor
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ABSTRACT: In this retrospective study 50 humeral fractures (36 acute, 6 pathological fractures and 8 non-unions) were treated by retrograde locked bundled Marchetti nailing. No intraoperative complications occurred. Postoperative complications included 7 non-unions (4/36 acute fractures and 3/8 delayed union), and 2 intraarticular penetrations of the secondary nails. However, at the subsequent removal of the implant 5 supracondylar fractures occurred.
International Orthopaedics 02/1999; 23(6):320-4. · 2.03 Impact Factor
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ABSTRACT: The authors report a retrospective study of 307 trochanteric fractures treated with a sliding screw-plate (trochanteric hip screw, THS) between January 1989 and December 1994. Mechanical failure was uncommon (3.6%); cutting-out of the screw was the main complication. The revision rate was also low (4%); the 12 cases included 5 total hip replacememts and 2 sliding-screw replacements. Whatever the fracture type, the main factors preventing mechanical failure were the quality of the fracture reduction, the good positioning of the screw in the femoral head and the range of postoperative sliding of the screw. Of those patients who had previously lived at home, 20% were able to return there directly while 73% were admitted to a rehabilitation center, old people's home or medical unit. At the date of the last follow-up, 72% of patients who initially lived at home had returned there but 24% were still dependent. These results confirm the effectiveness of the device, provided the initial surgical indications and technical operating conditons are satisfactory.
European Journal of Orthopaedic Surgery & Traumatology 01/1998; 8(1):47-52. · 0.10 Impact Factor
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ABSTRACT: The aim of this retrospective study of 56 cases was to determine the risks and the limits of the Marchetti bundle nail in the treatment of femoral shaft fractures. According to the AO classification, 25 fractures were in category A, 20 in category B, 7 in category C and 4 were distal metaphysio-diaphyseal fractures with intercondylar separation classified as 33C2. Intraoperative complications were not directly related to the type of nail. Postoperative complications included nonunion, delayed union, malunion such as axial deformity, and shortening. We conclude that the Marchetti bundle nail is a successful method for the treatment of femoral shaft fractures taking into consideration the short operation time, the efficacy of distal locking and the lack of preliminary reaming. Moreover, it is clear that our results were prejudiced due to our learning experience with this new implant. Proximal locking should only be carried out when indicated, in order to prevent delayed union. It may be combined with interfragmental screw fixation, and this is useful in the treatment of complex supracondylar fractures.
International Orthopaedics 02/1997; 21(5):318-22. · 2.03 Impact Factor
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O Feugeas,
N Guriec,
A Babin-Boilletot,
L Marcellin, P Simon,
S Babin,
A Thyss,
P Hofman,
P Terrier,
C Kalifa,
M Brunat-Mentigny,
L M Patricot,
F Oberling
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ABSTRACT: The usual therapy of osteosarcoma is neoadjuvant chemotherapy, followed by surgery, then by postoperative chemotherapy. There is no prognostic factor to predict, at diagnosis, the histologic response and final outcome. Inactivation of the retinoblastoma-susceptibility gene RB is associated with the pathogenesis of several human cancers. In primary osteosarcomas, loss of heterozygosity (LOH) at the RB locus has been found in greater than 60% of cases. The aim of this study was to determine the potential early prognostic value of LOH of RB gene on the biopsy material at diagnosis.
Forty-seven patients with primary osteosarcoma, treated in four French institutions, were studied. LOH was studied by polymerase chain reaction (PCR) of an informative RB DNA polymorphism.
Assessment of LOH at the RB gene could be completed on 34 heterozygous patients only. LOH was found in 24 cases (70%). The event-free survival (EFS) rate at 60 months is 100% for patients without LOH, 43% for all patients with RB LOH, and 65% for nonmetastatic patients with RB LOH. The difference in EFS is highly significant at P = .008 and P = .024, respectively. Histologic response after preoperative chemotherapy did not show significant correlation with LOH status.
RB gene LOH appears to be an early predictive feature for osteosarcomas that indicates a potential unfavorable outcome. RB LOH study might shortly help to identify high-risk patients earlier. If this is verified, therapy could then be adapted earlier to the individual's real risk of relapse.
Journal of Clinical Oncology 03/1996; 14(2):467-72. · 18.37 Impact Factor
