Diabetic Foot Management: How Could a Procedural Pathway Improve the Surgical Outcome?

Introduction:

Diabetic foot ulcer is the main aetiology for non-traumatic amputation, which is a major public health care concern. A multidisciplinary approach in the management of this pathology has been shown to improve the surgical outcome. However, there are little data available on the tools we can use to pursue this multidisciplinary approach. The main goal of this cross-sectional study was to find out whether the implementation of a specific management pathway could improve the treatment outcome in the treatment of diabetic foot.

Materials and Methods:

From 2012 to 2014, we consecutively recruited patients with diabetic foot referred to Orthopaedic surgery department of our university for surgical opinion. A specific diabetic foot pathway was introduced in 2013. One group of patients who were treated with previous method were evaluated retrospectively. Another group of patients who were treated after implementation of the pathway were evaluated prospectively. We compared treatment outcome between the two groups.

Results:

We included 51 patients. Amputation rate was similar both the groups: 74% in the retrospective group not using the new pathway versus 73% in a prospective group that used the new pathway. Revision surgery was 39% in the retrospective group and 14% in the prospective group (p=0.05).

Conclusion:

We recommend the use of this simple and cost-effective pathway to guide the interdisciplinary management of diabetic foot. A prospective study with more subjects would provide a better overview of this management pathway.

Similar levels of pain are reported in forefoot surgery after management as a day case and admission for 48 hours

While many forefoot procedures may be performed as a day case, there are no specific guidelines as to which procedures are suitable. This study assessed the early post-operative pain after forefoot surgery performed a day case, compared with conventional inpatient management.

A total of 317 consecutive operations performed by a single surgeon were included in the study. Those eligible according to the criteria of the French Society of Anaesthesia (SFAR) were managed as day cases (127; 40%), while the remainder were managed as inpatients.

The groups were comparable in terms of gender, body mass index and smoking status, although the mean age of the inpatients was higher (p < 0.001) and they had higher mean American Society of Anaesthesiologists scores (p = 0.002). The most severe daily pain was on the first post-operative day, but the levels of pain were similar in the two groups; (4.2/10, sd 2.5 for day cases, 4.4/10, sd 2.4 for inpatients; p = 0.53). Overall, 28 (9%) of patients who had their surgery as a day case and 34 (11%) of inpatients reported extreme pain (≥ 8/10). There were more day case patients rather than inpatients that declared their pain disappeared seven days after the surgery (p = 0.02). One day-case patient with excessive bleeding was admitted post-operatively.

Apart from the most complicated cases, forefoot surgery can safely be performed as a day case without an increased risk of pain, or complications compared with management as an inpatient.

Cite this article: Bone Joint J 2015;97-B:1645–50.

Distal osteotomy of the lateral metatarsals: a series of 72 cases comparing the Weil osteotomy and the DMMO percutaneous osteotomy

INTRODUCTION

A Weil osteotomy with internal fixation can match the preoperative plan by precisely setting the metatarsal length; however 10 to 30% of patients end up experiencing postoperative stiffness. A percutaneous distal metatarsal mini-invasive osteotomy (DMMO) is a purely extra-articular technique; metatarsal length is set automatically upon weight bearing of the foot. The goal of this study was to compare these two osteotomy techniques when performed on the three or four most lateral metatarsals.

HYPOTHESIS

A DMMO will result in better joint motion than a Weil osteotomy.

PATIENTS AND METHODS

This was a retrospective, single center, single surgeon study with 72 patients. Group 1 consisted of 39 patients operated by the DMMO technique. Group 2 consisted of 33 patients operated by the standard Weil osteotomy technique. In some cases, a procedure on the first ray (Scarf or fusion) was also performed. The age, gender and procedures on the first ray were comparable for both groups. Patients were evaluated with clinical (AOFAS score) and radiological outcomes (Maestro criteria) at 3 and 12 months minimum follow-up.

RESULTS

Sixty-seven patients were seen again with an average follow-up of 14.8 months (range 12-24). The postoperative AOFAS score was comparable in both groups (86.5 and 85.3, respectively). The joint range of motion was comparable in both groups. Static problems (oedema, metatarsalgia, hyperkeratosis and dislocation) were comparable at the last follow-up. The metatarsalgia recurred in four patients from group 1 and five patients from group 2. After 3 months, oedema and metatarsalgia were significantly greater in group 1. Radiological measurements (M1P1angle, M1M2angle and Maestro criteria) were comparable. Metatarsal head recoil was identical between each ray in group 1. At the last follow-up, all the osteotomy sites had achieved union.

DISCUSSION AND CONCLUSION

The results of static metatarsalgia treatment were comparable when using a DMMO or Weil osteotomy. However the DMMO had longer postoperative recovery, notably because of oedema. The percutaneous DMMO technique did not improve joint range of motion.

LEVEL OF EVIDENCE

III, comparative retrospective study.

[Congenital club foot: treatment in childhood, outcome and problems in adulthood]

PURPOSE OF THE SYMPOSIUM: Treatment of idiopathic talipes varus, or congenital clubfoot, is designed to re-align the foot to alleviate pain and allow plantigrade weight bearing with adequate joint motion despite the subnormal radiographic presentation. This symposium was held to review current management practices for congenital clubfoot in children and to analyze outcome in adults in order to propose the most appropriate therapeutic solutions.

MANAGEMENT OF CONGENITAL CLUBFOOT IN CHILDREN

Idiopathic talipes varus can be suspected from the fetal ultrasound. Parents should be given precise information concerning proposed treatment after birth. Deviations must be assessed in the newborn then revised regularly using objective scales during and after the end of treatment. This enables a better apprehension of the evolution in comparison with the severity of the initial deformation. Conservative treatment is proposed by many teams: a functional approach (rehabilitation and minimal use of orthetic material) or the Ponseti method (progressive correction using casts associated with percutaneous tenotomy of the calcaneal tendon) are currently preferred. If such methods are insufficient or unsuccessful, surgery may be performed as needed at about 8 to 11 months to achieve posteromedial release. Good results are obtained in 80% of patients who generally present minimal residual deformations (adduction of the forefoot, minimal calcaneal varus, residual medial rotation, limitation of dorsal flexion), which must be followed regularly through growth. The difficulty is to distinguish acceptable from non-acceptable deformation. At the end of the growth phase, severe articular sequelae are rare (stiff joint, recurrence of initial deformation, overcorrection) but difficult to correct surgically: osteotomy, tendon transfer, double arthrodesis, Ilizarov fixator. Gait analysis is essential to quantify function and obtain an objective assessment of the impact on higher joints, providing valuable guidance for surgical correction.

OUTCOME IN ADULTHOOD

There have been very few studies evaluating the long-term functional outcome after treatment during childhood. According to two studies presented at this symposium (Brussels, Lausanne), results have been generally good but with subnormal radiographs irrespective of the type of treatment or how early treatment started in childhood. Hypoplasia of the talar dome is a constant finding and is correlated with limitation of dorsal flexion of the ankle joint. A small degree under-correction is often observed but well tolerated while overcorrection is generally less well tolerated. Functional outcome depends highly on preservation of subtalar joint motion. There have been no reports on the results of treatment of sequelae in adults. Most problems (pain, stiffness, osteoarthritis) are observed in the mid or rear foot. Indications for conservative surgery (osteotomy) of the mid or rear foot are rare compared with indications for combined arthrodesis. Talocrural decompensation is a turning point observed in the adult. Management at this point is difficult: fusion of the ankle worsens the situation by increasing the stress on the forefoot and aggravating the disability; implantation of an ankle prosthesis is technically difficult and remains to be fully developed. Treatment of the dorsal bunion of the great toe may require tendon transfer and/or fusion.

CONCLUSION

A child born with clubfoot will never have a normal foot in adulthood. Sequelae present at the end of growth will intensify during adult life; under-correction is easier to treat in adulthood than overcorrection. The most difficult problems in adulthood are: neglected clubfoot, over correction, and degradation of the talocrural joint.

Masse inguinale révélatrice d’une complication d’une arthroplastie totale de hanche

The iliopsoas bursa is situated immediately anterior to the hip joint. Communication can develop between a hip prosthesis and the iliopsoas bursa leading to distension and formation of an inguinal mass revealing complication of total hip arthroplasty. We report five clinical cases. The five patients with a total hip arthroplasty developed a mass in the Scarpa triangle which correlated with defective prosthesis function. We chose not to dissect the cystic mass but to treat the intra-articular cause. Symptoms resolved after the intervention in all cases. This rare condition should be envisioned if an inguinal mass develops or has a functional impact, particularly on the lymphovenous circulation. Anatomic relations can be distinguished with computed tomography. Prosthetic complications include infection, loosening or wear. The work-up should include search for infection and standard x-rays of the hip joint. Before surgery, duplex Doppler should be performed systematically to search for a thromboembolic complication.

Précision des coupes osseuses dans l’arthroplastie totale du genou à l’aide d’un ancillaire conventionnel

PURPOSE OF THE STUDY

Short-term functional results and long-term outcome in terms of stability and wear greatly depend on the precision of the bone cuts. We wanted to know whether conventional ancillaries are still competitive in terms of accuracy in comparison with computer-assisted navigation systems. A few comparative studies favor navigation, but have generally only included a small number of patients. We studied radiographically a prospective consecutive series of 300 total knee prostheses (Innex, Zimmer) implanted with the conventional technique by the same operator.

MATERIAL AND METHODS

A telegonometric view in the upright position and a short lateral view were obtained in all patients. In the AP view, implants were measured in comparison with the mechanical axis of the femur (F) and the tibia (T). On the lateral view, the prosthesis-tibial shaft angle (PT) was measured from the proximal portion of the tibial shaft and the prosthesis-femoral shaft angle (PF) from the distal portion of the femur. The same operator made all measurements using the same optimal conditions. The series included 178 women and 122 men, mean age 72 +/- 8 years who presented genu varum (n = 248 knees) and genu valgum (n = 52 knees): degenerative disease (n = 238), polyarthritis (n = 4), hemophilic arthropathy (n = 3), necrosis (n = 3), revision of unicompartmental prosthesis (n = 8), and osteotomy (n = 44).

RESULTS

The standard x-ray protocol was performed at two months in all patients. The mechanical axis (HKA) was 179.4 +/- 2.4 degrees (range 173-186 degrees) and was +/- 3 degrees in 87% of knees with no difference for varum and valgum. F was 90.1 +/- 1.4 degrees (87-95), with +/- 3 degrees for 98.7%. T was 89.3 +/- 1.5 degrees (85-94) with +/- 3 degrees for 95.6%. PF was 88.6 +/- 1.6 degrees (84-93) for 87%, PT was 87 +/- 2 degrees (81-93) with +/- 3 degrees for 94%. The four cuts were within +/- 3 degrees for 227 prostheses (77%), within +/- 2 degrees for 156 (52%) and within +/- 1 degrees for 56 (18%). Measurements made again one year after implantation for 203 knees gave the same results. Operative time for implantation was 68 +/- 23 minutes for implantation and 85 +/- 23 minutes including complete closure (less than 60 minutes for 68 knees).

DISCUSSION

The accuracy of each cut was satisfactory on average with a small standard deviation. Recent data in the literature show that the accuracy in our series is comparable with that obtained currently with navigation systems. In light of this experience, it can be seen that better precision can be achieved for each of the cuts.

CONCLUSION

The accuracy of conventional instrumentation systems is still comparable with that obtained with computer-assisted surgery. The purpose of this study was not to question the benefit of navigation, but to establish a basis upon which progress can be measured. The results enabled a more realistic comparison of the precision of navigation systems and also can be comforting for operators still using conventional ancillaries.

Évaluation des séquelles du site donneur du lambeau libre de fibula. À propos de 42 cas consécutifs

Donor site morbidity after free fibula flap was assessed in 42 patients, 37 of whom had undergone mandibular reconstruction and five proximal humerus. Lower limb reconstructions were excluded. The study comprised functional assessment with two international orthopaedic scales (Karlsson and Kitaoka); comparative lower limb clinical and X-ray assessment. Mean Karlsson score was 90.4/100 with 52% of excellent, 36% of good, and 12% of medium results. Mean Kitaoka score was 93.7/100 with 64% of excellent, and 36% of good results. Fifty-two percent of patients were pain free, 29% had pain on walking on uneven terrain, and 19% occasionally; 7% experienced instability. For 76%, physical activity was unrestricted. Clinical examination found no alteration in hindfoot axis, no joint laxity, mild and acceptable reduction in hallux plantar flexion power in 76% cases, and superficial fibular nerve hypoesthesia in 5% of cases. Methodology and results are detailed and compared to the literature. In conclusion, we found only slight morbidity and free fibula flap remains our first choice as bone flap.

Knee instability after injury to the anterior cruciate ligament. Quantification of the Lachman test

We have measured anterior and posterior displacement in 563 normal knees and 487 knees with chronic deficiency of the anterior cruciate ligament (ACL). We performed stress radiography using a simple apparatus which maintained the knee at 20 degrees of flexion while a 9 kg load was applied. There was no significant difference in posterior translation dependent on the condition of the ACL. Measurement of anterior translation in the medial compartment proved to be more reliable than in the lateral compartment for the diagnosis of rupture of the ACL, with better specificity, sensitivity and predictive values. We have classified anterior laxity based on the differential anterior translation of the medial compartment and identified four grades in each of which we can further distinguish four subgrades for laxity of the lateral compartment. Within each of these subgroups, either internal or external rotation may dominate and sometimes there is a major translation of both compartments. Radiological evaluation of displacement of the knee in 20 degrees of flexion provides conclusive evidence of rupture of the ACL. A detailed study of pathological displacement is the basis for a classification of laxity. It is then possible to decide for each type of laxity, the surgical treatment which is specifically adapted to the lesion, and to define a reference value for judging outcome.

Knee instability after injury to the anterior cruciate ligament

We have measured anterior and posterior displacement in 563 normal knees and 487 knees with chronic deficiency of the anterior cruciate ligament (ACL). We performed stress radiography using a simple apparatus which maintained the knee at 20° of flexion while a 9 kg load was applied. There was no significant difference in posterior translation dependent on the condition of the ACL. Measurement of anterior translation in the medial compartment proved to be more reliable than in the lateral compartment for the diagnosis of rupture of the ACL, with better specificity, sensitivity and predictive values.

We have classified anterior laxity based on the differential anterior translation of the medial compartment and identified four grades in each of which we can further distinguish four subgrades for laxity of the lateral compartment. Within each of these subgroups, either internal or external rotation may dominate and sometimes there is a major translation of both compartments.

Radiological evaluation of displacement of the knee in 20° of flexion provides conclusive evidence of rupture of the ACL. A detailed study of pathological displacement is the basis for a classification of laxity. It is then possible to decide for each type of laxity, the surgical treatment which is specifically adapted to the lesion, and to define a reference value for judging outcome.

Achilles tendon repair using a bone-tendon graft harvested from the knee extensor system: three cases

The authors describe a new surgical technique of Achilles tendon reconstruction using bone-tendon graft from the knee extensor system. This technique is for those unusual cases of neglected or partial Achilles tendon rupture with distal tendon-substance loss at calcaneal insertion level, requiring transbone plasty fixation. Three cases are reported; the first two, followed up over a 5-year period, had excellent functional, morphological, and clinical outcomes. This new technique is compared with other available solutions: triceps plasty, other local tendon plasty, artificial plasty, and allograft.

[The results after 10-16 years of the treatment of chronic anterior laxity of the knee using reconstruction of the anterior cruciate ligament with a patellar tendon graft combined with an external extra-articular reconstruction]

PURPOSE OF THE STUDY

The aim of this prospective study was to evaluate the objective postoperative laxity and functional results with a minimum follow-up of 10 years (mean 11.7 +/- 2 years) in chronic anterior knee instability treated by ACL reconstruction associated to a lateral extra-articular plasty.

MATERIAL AND METHODS

138 patients of a mean age of 27.8 +/- 8.5 years had been operated. Delay between injury and operation was 4 +/- 4.8 years. The surgical "Mac Injones" procedure used a free autologous patellar tendon graft with a bone-to-bone fixation, supplemented by a lateral extra-articular plasty using a strip of quadriceps tendon as a direct prolongation of the graft of the patellar tendon and patella itself. A rehabilitation program aimed to an early recovery of a complete range of motion. Anterior laxity had been measured before and after operation using two instrumented methods, KT-1000 and stress-radiography (at 20 degrees of flexion with a 9 kg load applied at the distal part of the thigh) with measurements of the displacement in medial and lateral compartments. Tunnel positioning was appreciated radiologically. Function was evaluated using the International Knee Documentation Committee score (I.K.D.C.).

RESULTS

Elongation of the reconstructed ligament occurred mainly during the first 6 month, but was independent from early full range of motion recovery. Laxity was stabilized after one year. The final laxity gain of the medial compartment was 62 per cent and for the lateral compartment 77 per cent. The pivot shift test was negative in 66 per cent, grade 2 in 4 per cent, grade 1 in 30 per cent. Functional results were excellent and good (A and B) in 60.4 per cent and 76.7 per cent returned to sports activity. 12 reconstructed ligaments reruptured. Arthritis was the cause of poor results in other cases (13.8 per cent).

DISCUSSION

Lateral extra-articular plasty is unable to better control translation of the medial compartment than isolated anterior cruciate ligament reconstruction, but laxity of the lateral compartment was minimized and the pivot shift test also. Incorrect position of the anterior cruciate ligament was correlated with poor results.

CONCLUSION

This documented study on laxity of the two compartments confirms the interest of each type of reconstruction, in particular extra-articular plasty when made with quadriceps tendon and so doing, preserving the iliotibial-band for the control of varus stability.

[Effect of external extra-articular ligament plasty on the results of anterior cruciate ligament reconstruction with patellar tendon, a 4 years follow-up]

PURPOSE OF THE STUDY

The purpose of this study was to compare the functional results obtained when an external extra-articular plasty was added to an anterior cruciate ligament (ACL) reconstruction using an autologous bone tendon-bone patellar tendon graft.

MATERIAL AND METHODS

The authors analyzed two consecutive series of 60 and 50 patients operated by the same surgeon for a chronic rupture of the anterior cruciate ligament, one by reconstruction of the cruciate ligament with a free graft of the patellar tendon supplemented by an external extra-articular plasty made with a quadriceps tendon graft and the second with an isolated free patellar tendon graft. Anterior laxity was measured before and after surgery, by dynamic X-rays and by the Medmetric KT-1000 arthrometer. Functional results were evaluated four years after operation, with the French A.R.P.E.GE score based on sport activity level and intensity.

RESULTS

Anterior laxity was not different before operation in both groups and there was no difference between males and females. Medmetric KT-1000 arthrometer showed the same negative differential laxity immediately after surgery in both groups and the same evolution during the first 4 years, without any significant difference on laxity on the middle aspect of the knee. Radiological results were different. After a 4 years follow-up, anterior laxity did not show significant difference on the medial compartment of the knee (5.3 +/- 2.3 mm and 5.5 +/- 1.7 mm), but there was a significant minor laxity in the lateral compartment for the lateral extra-articular plasty group (11.0 +/- 2.3 mm against 14.8 +/- 3.8 mm)(p = 0.002). Functional results and sport activity were similar in both groups. Examination showed 4 positive pivot shift tests (2 "sliding" and 2 positive) in the group with extra-articular plasty, even though 8 positive pivot shift tests in the isolated ACL group (5 "sliding" and 3 positive) were found.

DISCUSSION

This study, as well as five others studies found in literature, was not randomized. In all these series, the surgical techniques, the rehabilitation programs and the functional score evaluation were too different to allow any pertinent comparison. Extra-articular plasty helps to control the laxity of the lateral compartment of the knee which is incompletely controlled by ACL reconstruction, particularly in chronic cases. This is proved by radiological measurements and pivot shift tests. Jensen in 1983, about 205 patients with a 4 year follow-up and Noyes, which used an allograft patellar tendon, found an advantage to do extra-articular plasty. But Strum (in 1989), as O'Brien (in 1991) and Roth (in 1987), did not found any advantage with extra-articular plasty.

CONCLUSION

It is therefore obvious, after a four-year follow-up, that extra-articular supplementation presents an advantage for reconstruction of the ACL. by a free graft of the patellar tendon in chronic cases. Further randomized study will confirm that isolated ACL reconstruction is possible in some well defined categories of anterior laxity.

[Chronic external instability of the ankle. Contribution of dynamic radiographies, x-ray computed tomography and x-ray computed tomographic arthrography]

We retrospectively evaluated the anterior talo fibular ligament and the tarsal sinus of 17 patients who had complained of chronic ankle external instability. This study based on both surgery and CT-arthrography findings shows the pathologic or normal aspects of the talo-fibular anterior ligament (normal, lax, fibrosis residue, ruptured). It confirms the good anatomic analysis of the tarsal sinus, in particular the anterior talo-calcaneal interosseous ligament and the search for fibrosis. We underline that capsular distension due to subtalar laxity is not detected with medical imaging. Compared with surgery (all patients), CT arthrography demonstrated the different aspects of the anterior talo fibular ligament injuries (normal, lax, discontinuous).

[A prospective study of the outcome of anterior laxity of the knee after anterior cruciate ligament reconstruction with procedures using two different patellar tendon grafting methods]

PURPOSE OF THE STUDY

The aim of this study was to evaluate postoperative evolution of anterior laxity, in order to know at what time the elongation of the reconstructed anterior cruciate ligament (ACL) begins to develop after surgery, and if there were any correlations with recuperation of knee flexion or extension. The second purpose of this study was to compare two series of patients operated on by two different procedures for a long standing ACL rupture.

MATERIAL AND METHODS

Two series of patients were compared: group I (60 cases), had an ACL reconstruction using a free autologous patellar tendon graft with a bone-to-bone fixation, supplemented by an external extra-articular plasty with a strip of quadricipital tendon as a direct prolongation of the graft of the patellar tendon and patella itself. "Mac InJones", and group II (50 cases), had a reconstruction with a similar transplant, but still attached on the tibia and with a fibrous fixation through the femoral condyle and the Gerdy's tubercule (modified "Marshall-Mac Intosh"). Anterior laxity was measured using two instrumented methods; first, Medmetric knee arthrometer (KT-1000), before and after operation, then each month later during the first 6 months and yearly. On the other hand, a personal stress X-ray protocol (at 20 degrees of flexion and with application of a 9 kg load at the distal part of the thigh), was made before operation, 6 months later, and yearly during 8 years. The laxity of both medial and lateral compartments of the knee were separately measured. Laxity was studied in parallel with the recuperation of knee flexion and extension during a rehabilitation program without any limitation in both directions.

RESULTS

During a period of 3 months, the laxity was arthrometrically inferior to the normal knee in the two groups, and appeared progressively. Laxity was independent from early recuperation of full range of flexion and extension. The elongation of the reconstructed ligament was showed to develop during the first 6 months and less during the following 6 months. Better results were found for group I during the earliest period with the Medmetric arthrometer, but there was no difference between both groups after 1 year and 2 years. With dynamic radiography, laxity was higher than indicated by KT-1000, and results were better for group I. Laxity was stabilized after one year and the results were still good after 8 years.

DISCUSSION

KT-1000 showed a great interest for measurement of the compliance index (difference between laxity at 89 newtons and 69 newtons of traction), and can be used without any inconvenient for patients. Stress radiographs may be used for yearly controls. The radiographic method had better accuracy than KT-1000 and gave precise laxity measurements of the medial and lateral compartments of the knee. The laxity of the medial compartment showed to have a good prognostic value.

CONCLUSION

Evolution of laxity is more favourable in group I with bone-to-bone ligament fixation. Recovering early and complete flexion and extension is not prejudicial for the ligament. Laxity developed between 3 and 6 months and less between 6 and 12 months. KT-1000 is able to detect laxity during early postoperative period. Dynamic radiographs are more precise to control laxity year after year. Informations concerning the two compartments of the knee are of great interest to compare different procedures and to improve new surgical techniques.

[Results of posterior lumbar intersomatic fusion in the treatment of isthmic spondylolisthesis. Apropos of 27 cases followed over more than 10 years]

PURPOSE OF THE STUDY

Posterior lumbar interbody fusion (PLIF) as described by Cloward, with laminectomy of the entire separate neural arch in spondylolisthesis, is a difficult operation. The purpose of this study is to evaluate the results of PLIF with autologous bony graft, without reduction or instrumentation in grade I and II spondylolisthesis.

MATERIAL

The authors report the results of a series of 36 cases of spondylolisthesis (out of a series of 160 cases) operated on with PLIF, after a minimum of 10 years of follow-up (mean: 11.8 years, 10-16 years). 9 patients were lost for follow-up, 27 had been examined clinically and radiologically. 19 males and 8 females. Mean age 29.6 years (14 to 50). The series consisted in 24 lumbo-sacral disc and 3 L4-L5 disc fusion. Before operation, 25 patients suffered backache and 20 had sciatic. Mean preoperative listhesis according to Boxall was 29 per cent.

METHODS

PLIF had been done with autologous bony graft and neural decompression without reduction. The thickness of the space had been restored with special progressive distractor. Postoperative back cast was used during 6 months.

RESULTS

Postoperative nerve roots complications occurred in 4 cases and were regressive within 3 months. Results were excellent in 17 cases, good in 7 cases and poor in 3 cases. Patients returned to work after 9.8 months (13.6 months for heavy work). 26 patients had solid tomographic interbody fusions. No additional subluxation was noted. In 10 per cent of the cases the graft was partially crammed. In 7 cases a degenerative aspect of the upper disc was noted (symptomatic in 6 cases). The sagittal balance of the spine evaluated with a specific index showed persistent abnormality in 50 per cent of the cases but PLIF brought a significant improvement in 26 per cent.

DISCUSSION

The rate of fusion is better than in series using bony allografts and better than in series using anterior interbody fusion. The analysis of the adjacent discs shows that it is not necessary to extend fusion to the upper disc. Instrumentation had not been used in this series but a cast seems to be indispensable. Instrumentation with plates and pedicular screws should be able to give more stability but is often responsible of iatrogenic lesions at the articular facets.

CONCLUSION

This study confirms the good results obtained by PLIF with nerve roots decompression in spondylolisthesis. Fusion is stable and does not accelerate degenerative lesion of the upper disc.

[Hereditary motor and sensory neuropathy of Charcot-Marie-Tooth disease]

Charcot-Marie-Tooth disease (Hereditary Motor and Sensory Neuropathy) sometimes begins during childhood and can lead to learning and/or orthopedic disabilities. Due to the genetic and clinical heterogeneity of the disease, the diagnosis is based on a familial study of clinical, electromyographic and pathological abnormalities. Two major types of Charcot-Marie-Tooth disease have been described. Type 1 is characterized by a decrease in nerve conduction velocities and by a peripheral nerve hypertrophy due to myelinic alterations, while type 2 is the consequence of axonal alterations. Although type 1 and type 2 patients share similar clinical symptoms, type 2 patients have normal nerve conduction velocities and histological signs of axonal damage. Several genes involved in this disease have been recently located, and, in certain cases, an individual and direct diagnosis is available if the familial abnormality is related to chromosome 17.

[Anterior laxity and internal arthritis of the knee. Results of the reconstruction of the anterior cruciate ligament associated with tibial osteotomy]

Fifty-one knees were reviewed out of 53 which had been operated on (between 1981 and 1991) for instability due to a long-standing rupture of the anterior cruciate ligament (A.C.L.), associated with medial arthritis related to a varus deformity. They had undergone a reconstruction of the cruciate ligament using the patellar tendon (5 cases had received an artificial ligament) and a high tibial osteotomy. In 80 per cent of cases this was an opening osteotomy with interposition of a heterologous bone graft, and in 39 cases it was a closing osteotomy. The average age was 37 +/- 6 years. The oldest patient was 58 years old. 80 per cent of cases were men and 88 per cent of the patients practised sport on a regular basis at the time of the accident. The average delay before surgery was 9.5 years. Almost all the patients has already undergone a medial meniscectomy and there were deep cartilaginous lesions and the bone was exposed in 50 per cent of cases. 28 knees were reexamined after a follow-up of over 4 years. Based on the ARPEGE score the results on pain and stability were good. Return to sport has been possible for 43 per cent of patients. Pivot shift, which was constant before surgery (grade 2 or 3), disappeared in 20 cases and was estimated at grade 1 in 8 cases (of which 6 had suffered a rupture of the graft). For the 20 cases in which the reconstruction of the A.C.L. had held, the average anterior radiological subluxation was 4.3 +/- 3.2 mm (from 2 to 14 mm) and the average gain after surgery was 6.7 +/- 3.7 mm (from 2.5 to 18 mm). The femoro-tibial angle went from an average of 6 degrees of varus to 3 degrees of valgus. The opening osteotomy was more precise for correction in the frontal plane. A large valgus (over 3 degrees) was not desirable and a hypercorrection was occasionally difficult to accept by relatively young patients who are likely to take up sport again. The osteotomy often involuntarily modified the normal posterior tibial plateau slope (especially closing osteotomy). A backwards increase of the tibial plateau slope is a factor which increases the anterior subluxation of the femur on the tibia. This is confirmed before and after surgery. It seems preferable to decrease the tibial slope during the osteotomy in order to protect the A.C.L. reconstruction.(ABSTRACT TRUNCATED AT 400 WORDS)

[Value of hypovolemia in subarachnoid hemorrhage]

Hypovolemia seems a commun state in patients with subarachnoid hemorrhage. It has been further suggested that hypovolemia could cause ischemia if vasospasm is present. Total blood volume and red blood cells volume determined in 84 consecutive patients volume of distribution (of 51Chromium labeled autologous red cells, shows an hypovolemia in 70% of these patients). Associated hypomotremia requires Na restitution with normovolemic hemodilution to facilitate cerebral blood flow.