Synchronous abdominal and transsacral approach for excision of sacrococcygeal chordoma.

Sacrococcygeal chordomas are rare retrorectal tumors. The authors have been faced with one such case. They used the synchronous combined abdominosacral approach for surgical resection. Details of the surgical aspects of the technique are described. Safe resection as high as the S1-S2 interspace can be performed

Les prothèses fémoro-patellaires. Etude rétrospective de 45 cas successifs avec un recul de 3 à 12 ans.

Forty-five consecutive patients operated between 1986 and 1995 were evaluated to assess the long term results of patellofemoral arthroplasty. Revision had to be performed in 8 cases for the following reasons: loosening (3), lateral impingement (3), malposition (1) and persistent patella instability (1). Two groups of patients were identified based upon the preoperative assessment: 21 had primary osteoarthritis without anatomic malalignment (group C) and 24 had a history of patellofemoral instability and trochlear dysplasia demonstrated by clinical and radiological evaluation (group D). Only 43% of good results were found in group C whereas in group D, the percentage of good results was close to 83%. The most common cause of poor results in group C was the degenerative involvement of the femorotibial compartments (5 patients had to undergo total knee arthroplasty subsequently). For group D patients, femorotibial osteoarthritis was not a determinant factor as regards the outcome of patellofemoral arthroplasty. To the authors, it appears that the best indication for patellofemoral arthroplasty is femoropatellar osteoarthritis with malalignment in patients having a normal femorotibial axis even in the presence of femorotibial osteoarthritis as long as the latter does not exceed grade II

The Treatment of Spastic Equinovarus Foot after Stroke

Spastic equinovarus foot (SEF) is a major cause of disability in stroke patients. Treatments are multimodal and include rehabilitation, orthosis, botulinum toxin injections, alcohol and phenol nerve blocks, functional neurosurgery (neurotomy and intrathecal baclofen) and orthopedic surgery (tendon transfer or lengthening). Precise knowledge of the cause of the equinovarus deformity (muscle spasticity, shortening, and/or weakness) with clinical examination, diagnostic nerve blocks with anesthetics, and gait analysis may help to determine the most appropriate treatment for each patient. This article summarizes current approaches to the assessment and treatment of SEF. In contrast with the number of treatments available, there are a lack of comparative studies to guide therapeutic decisions, which actually depend more on personal experience than on scientific guidelines

Les prothèses totales de genou infectées. Orientation du choix thérapeutique.

PURPOSE OF THE STUDY: The aim of the study is to assess the functional results and septic evolution in the treatment of infected total knee arthroplasties. MATERIAL AND METHODS: 22 patients were reviewed; 8 were initially treated in our institution and 14 transferred from other hospitals. Articular debridement alone leaving the prosthesis in situ was initiated in 3 of our 8 patients as well as in 6 of the transferred cases. In both groups, this procedure appeared to be a failure. Prosthetic-reimplantation procedure was elected in 10 patients either as a one-stage (5 cases) or a two-stage surgery (5 cases). This has been successfully rated in 7 cases. Femoro-tibial arthrodesis was performed in 15 patients, three of them being a failure of the prosthetic reimplantation. Follow-up ranges from 16 months to 9 years with well documented records. RESULTS: As stated earlier, articular debridement alone has not proven to be a helpful procedure since it did not eradicate the septic complication in any case. Prosthetic reimplantation has been a successful treatment in 7 of the 10 attempted cases. The one-stage procedure is providing the best functional result. Recurrent infection occurred in 3 cases: there were patients with poor host defense (diabetes, arteritis, old age, ...) with resistant bacteria complicating a hinge-knee prosthesis. Femoro-tibial arthrodesis was achieved in 10 of the 15 patients and necessitated all together 23 surgical operations. The highest union rate was observed in cases where sterile conditions were achieved, fixation being performed with an intramedullary nail. Failure of arthrodesis confines the patients in such an uncomfortable situation that 2 of them has asked for an amputation. DISCUSSION AND CONCLUSION: Early surgical debridement may occasionally salve a prosthesis when it is performed shortly after the onset of infection, in an unloosened unconstrained prosthesis infected by a low-virulence organism. In our study, no patient but one met those criteria. For those cases nevertheless, our procedure of choice is now the one-stage reimplantation who seems to be more effective for eradicating the infection and gives rise to a better clinical result. The two-stage reimplantation is the current procedure for handling an infected knee prosthesis. Some patients are still excluded from this procedure because of their poor health condition, bone loss, inadequate viability of skin and extensor mechanism or an uncontrolled sepsis. For such a case, arthrodesis remains the most reliable method of management, especially when it can be stabilized with an intramedullary fixation, which implies to perform a two-stage arthrodesis

[Infected Knee Prosthesis - Guidance for the Therapeutic Choice]

Purpose of the study The aim of the study is to assess the functionnal results and septic evolution in the treatment of infected total knee arthroplasties. Material and Methods 22 patients were reviewed; 8 were initialy treated in our institution and 14 transferred from other hospitals. Articular debridement alone leaving the prosthesis in situ was initiated in 3 of our 8 patients as well as in 6 of the transferred cases. In both groups, this procedure appeared to be a failure. Prosthetic-reimplantation procedure was elected in 10 patients either as a one-stage (5 cases) or a two-stage surgery (5 cases). This has been successfully rated in 7 cases. Femoro-tibial arthrodesis was performed in 15 patients, three of them being a failure of the prosthetic reimplantation. Follow-up ranges from 16 months to 9 years with well documented records. Results As stated earlier, articular debridement alone has not proven to be a helpfull procedure since it did not eradicate the septic complication in any case. Prosthetic reimplantation has been a successfull treatment in 7 of the 10 attempted cases. The one-stage procedure is providing the best functionnal result. Recurrent infection occured in 3 cases: there were patients with poor host defense (diabetes, arteritis, old age,...) with resistant bacteria complicating a hinge-knee prosthesis. Femoro-tibial arthrodesis was achieved in 10 of the 15 patients and necessitated all together 23 surgical operations. The highest union rate was observed in cases where sterile conditions were achieved, fixation being performed with an intramedullary nail. Failure of arthrodesis confines the patients in such an uncomfortable situation that 2 of them has asked for an amputation. Discussion and conclusion Early surgical debridement may occasionnaly salve a prosthesis when it is performed shortly after the onset of infection, in a unloosened unconstrained prosthesis infected by a low-virulence organism. In our study, no patient but one met those criteria. For those cases nevertheless, our procedure of choice is now the one-stage reimplantation who seems to be more effective for eradicating the infection and gives rise to a better clinical result. The two-stage reimplantation is the current procedure for handling an infected knee prosthesis. Some patients are still excluded from this procedure because of their poor health condition, bone loss, inadequate viability of skin and extensor mechanism or an uncontrolled sepsis. For such a case, arthrodesis remains the most reliable method of management, especially when it can be stabilized with an intramedullary fixation, which implies to perform a two-stage arthrodesis

Tibial nerve block with anesthetics resulting in achilles tendon avulsion.

Diagnostic tibial nerve block with anesthetics is a common and safe procedure for the management of the spastic equinovarus foot. Side effects have been rarely reported. We present the case of a hemiplegic patient with a spastic equinovarus foot who presented with an avulsion fracture of the calcaneum at the insertion of the Achilles tendon consecutive to a diagnostic tibial nerve block with anesthetic agents. Although rare, such a complication should be considered when the Achilles tendon is shortened and when the patient is suspected of bone osteoporosis or dystrophy

Neurologic Hip Disorders Treated By Femoral Shortening and Lesser Trochanter Detachment

In a group of 40 children with cerebral palsy (CP), myelomeningocele, or sequelae of previous tenotomy and neurotomy, a specific surgical approach was used to correct various type of hip disorders: migrating hip, subluxated or luxated hip, compressed hip, and wind-blown hip, especially in quadriplegia. Osteotomy is performed at the intertrochanteric area, where a segment of femur (3-5 cm) is removed and the lesser trochanter is released, allowing the psoas muscle to reinsert in a more proximal position. Based on the concept of imbalance between predetermined bone growth and passive adaptation of muscles, we postulated in 1982 that a reduction in bone length should have an effect on surrounding muscles, allowing them the possibility of working in better anatomic conditions. With our procedure, we obtain major release of muscle tension around the hip-release of hamstring, psoas, and tensor of fascia lata-and consequently a wide range of passive motion of the hips as well as the knees. Long-lasting effects are preserved only by use of regular splinting for a prolonged time. In hip luxation, reduction can be obtained by this extraarticular approach, without need to open the joint. A pelvic procedure is performed only when the acetabulum shows marked changes. In five children with CP, the procedure was combined with shortening of the patellar tendon to reactivate the extensor mechanism of the knees. We consider this specific approach a safe procedure that leaves the neural anatomy undisturbed and allows early ambulation, usually at 4 weeks. It may be used as a salvage procedure and as the initial treatment step for various neurologic hip disorders