P. Simon

Les multiperforations des allogreffes osseuses cryoconservées

Incorporation of massive cortical bone allografts in the human is slow and remains incomplete. Late biopsies of implanted allografts or histological studies of explanted allografts always show the partial substitution of necrotic bone by new bone from the host. The aim of the present study was to evaluate the value of drilling the massive deep-frozen cortical allografts in order to induce osteogenesis. Thirteen sheep were operated on and a standard segment of the proximal ulna was removed and the gap filled either by an unperforated allograft or by a perforated one. Based on histological and microradiographic examination, a complete substitution of the perforated allografts was observed but in this model no statistically significant difference was observed between perforated and unperforated allografts. Further study is needed to assess the effect of the perforations.

Etude statistique d'une série de 355 fractures thalamiques du calcaneum

A retrospective study has been made of 355 fractures of the os calcis involving the subtalar joint in order to determine the best method of treatment. A rating system was used to assess the different types of injury. The results were correlated with the pattern of depression of the posterior articular surface, the quality of restoration of this surface and the type of trauma. We conclude that Duparc Stage V fractures require reconstruction/arthrodesis (the Stulz proceedure). Duparc Stage I fractures, and Stage III or IV with grade I depression, should be treated conservatively with early mobilisation. Stage III or IV fractures with grade II or III depression require operation in order to restore and maintain a congruent posterior joint surface to allow early mobilisation.

Reconstruction by bony allografts for malignant tumors of the skeleton at the end of growth

SummaryBetween Mai 1st, 1983 and December 1st, 1995, 57 bone tumors, mostly primitive and malignant have been referred to our department: there were 34 osteosarcomas and 15 chondrosarcomas. The primary treatment was 21 prosthesis, 11 bone allografts, 9 amputations or disarticulations, 8 Tikoff-Linberg procedures, 4 resections without reconstruction, 2 autografts reconstructions 1 spacer reconstruction and 1 Juvara technique.Among the 11 patients treated by bone allografts, there were 7 males and 4 females. The mean age was 27 years (range 12–70 years). The histological diagnosis was: osteosarcoma (6), chondrosarcoma (2), Ewing sarcoma (1), metastasis (1), recurrent giant cell tumor(1). The localisation was: femoral neck (1), femoral diaphysis (5), distal femur (2), proximal tibia (1), proximal humerus (2). The medical treatment of osteosarcomas and Ewing sarcomas included pre- and post-operative chemotherapy. The mean length of bone resection was 17.8 cm (range: 8–22 cm). Bone allografts were perforated, non irradiated, and cryopreserved at −196°C. Five allografts were intercalar femoral grafts, fixed with a Grosse and Kempf nail (2), or an AO blade plate, 2 allografts were intercalar femoro-tibial grafts (arthrodesis), with a titane nail, 2 allografts were osteo-chondral and ligamentar allografts, 1 in the distal femur (interlocking nail.) 1 in the proximal humerus (plate). 1 metaphyso-diaphyseal and tendinous allograft was the cuff of the cemented stem of a humeral prosthesis. 1 allograft was acetabular.Infectious and oncologic complications are non specific complications and occur with any reconstructive techniques. They belong to the surgery for malignant bone tumors. 3/11 patients (27%) have been reoperated for either a local recurrence, or a second malignant tumor or an infection. These major complications led to an amputation of the inferior limb in one patient (second malignant tumor) , and to an important handicape in the second patient despite a functional limb (infection). The patient with a local recurrence, was treated by a second-line chemotherapy and a second conservative surgery by an articular megaprosthesis. The present follow-up for this patient is 10 years from diagnosis, and 8 years from recurrence.Specific complications are related to the mechanical fragility of a dead bone, immunologically inert, the rehoming of which is very slow, partial and superficial. 4/11 patients (36%) were reoperated for fracture (in 2 osteo-chondral allografts), pseudarthrosis (1 tibio-femoral allograft) or pseudarthrosis and functional shrinkage (1 intercalar femoral allograft). In 3 of 4 cases, the function was restored or maintained at its previous level which was satisfactorily.Survival and disease-free survival: The mean follow-up was 62 months (range: 10–132 months). Two patients died from disease, and the third one exhibited lung metastases from an osteosarcoma.1 patient with a recurrent giant-cell tumor had no new recurrence, and 7 patients with malignant tumors were in first complete continuous remission. Of 6 osteosarcomas, the follow-up was between 7 and 11 years for 4 patients.When revised, all the 7 patients with intercalar allograft had an excellent or good functionnal result.Conclusion: We favour the reconstruction by cemented unmuffed megaprosthesis around the knee because it gives the most rapid functionnal recovery for these patients for whom the medical treatment is intensive and prolonged (osteosarcomas and Ewing sarcomas). Intercalar allograft is the unavoidable solution for some anatomical sites: its muscular surrounding is excellent at the thigh level, but it is poor between the femur and the tibia. Besides local oncologic complications, infection is the most dreadful complication. The reconstruction with an allograft exposes to the non union of the junctions, to stress fractures, to resorption which can lead to mechanical failure, and sometimes to host immune reactions against

Use of centromedullar nailing as treatment in open tibial fractures stage IIIb in the tropics

The authors report a retrospective study of 7 cases over a three-years-period. This study concerns patients treated in a tropical area in which the cutaneous tolerance of an external fixator is bad.Debridement was performed as an emergency without consideration of possible closure of the wounds. The bone was always covered at the end of the operation by a muscular pedicled flap.The fixation was performed by a reamed nail in 5 of the 7 cases.A primary consolidation was achieved in 58% of the cases.The mean time to consolidation was 7 months.RésuméLes auteurs rapportent une série rétrospective de 7 patients sur la période 1991–1993. Cette série concerne des patients traités en milieu tropical où la tolérance des fixateurs externes est très médiocre. Le parage chirurgical a été effectué en urgence sans se préoccuper d’une possibilité de fermeture. La couverture osseuse a toujours été obtenue en urgence par plastie de glissement du soléaire (2 cas) ou du jambier antérieur (4 cas). La fixation a été assurée dans 5 cas sur 7 par enclouage en urgence avec alésage, sans verrouillage. La cicatrisation dirigée est effectuée par pansements itératifs en salle d’opération jusqu’à granulation permettant une greffe de peau mince. La consolidation per primam a été obtenue dans 58% des cas. La durée moyenne de consolidation a été dans cette série de 7 mois.The authors report a retrospective study of 7 cases over a three-years-period. This study concerns patients treated in a tropical area in which the cutaneous tolerance of an external fixator is bad.Debridement was performed as an emergency without consideration of possible closure of the wounds. The bone was always covered at the end of the operation by a muscular pedicled flap.The fixation was performed by a reamed nail in 5 of the 7 cases.A primary consolidation was achieved in 58% of the cases.The mean time to consolidation was 7 months.

Place de l’enclouage centromédullaire dans le traitement des fractures ouvertes de jambe de type IIIb en milieu tropical

The authors report a retrospective study of 7 cases over a three-years-period. This study concerns patients treated in a tropical area in which the cutaneous tolerance of an external fixator is bad.Debridement was performed as an emergency without consideration of possible closure of the wounds. The bone was always covered at the end of the operation by a muscular pedicled flap.The fixation was performed by a reamed nail in 5 of the 7 cases.A primary consolidation was achieved in 58% of the cases.The mean time to consolidation was 7 months.RésuméLes auteurs rapportent une série rétrospective de 7 patients sur la période 1991–1993. Cette série concerne des patients traités en milieu tropical où la tolérance des fixateurs externes est très médiocre. Le parage chirurgical a été effectué en urgence sans se préoccuper d’une possibilité de fermeture. La couverture osseuse a toujours été obtenue en urgence par plastie de glissement du soléaire (2 cas) ou du jambier antérieur (4 cas). La fixation a été assurée dans 5 cas sur 7 par enclouage en urgence avec alésage, sans verrouillage. La cicatrisation dirigée est effectuée par pansements itératifs en salle d’opération jusqu’à granulation permettant une greffe de peau mince. La consolidation per primam a été obtenue dans 58% des cas. La durée moyenne de consolidation a été dans cette série de 7 mois.The authors report a retrospective study of 7 cases over a three-years-period. This study concerns patients treated in a tropical area in which the cutaneous tolerance of an external fixator is bad.Debridement was performed as an emergency without consideration of possible closure of the wounds. The bone was always covered at the end of the operation by a muscular pedicled flap.The fixation was performed by a reamed nail in 5 of the 7 cases.A primary consolidation was achieved in 58% of the cases.The mean time to consolidation was 7 months.

[Open fractures of the leg - Series from the University Hospital Hautepierre].

Nineteen cases were studied retrospectively between 1982 and 1993. All had been stabilised immediately by external fixators. Free or pedicle flap and early bone graft was carried out as required.Bone stability was obtained by Hoffmann or Orthofix fixators which allowed later manoeuvres for skin covers. The stabilisation by the fibula was attempted by intertibio-fibula grafting (ITF). Skin cover was obtained in 13 cases by pedicle flaps, in 4 by a free flap and 2 cases healed by secondary intention. The local flaps were 5 medial gastrocnemius or soleus flaps, 4 fasciocutaneous flaps, 3 medial gastrocnemius muscular cutaneous flaps and one cross-leg flap. These flaps were done on average at the 17th day (between 4th and 45th day). Four free flaps were done: 2 pure cutaneous flaps and 2 osteo-cutaneous flaps. A second flap was required in 3 cases because of infection or loss of soft tissue. A medial gastrocnemius flap and 2 free fibula flaps were done at the 105th and 210th day.Bony union was obtained primarily in 6 cases. Thirteen bone grafts were necessary of which 7 were done electively before three months (4 decortication grafts, 3 ITF). Additional bone graft was needed in 4 cases. Six non-unions were seen, 2 sterile which were treated by one decortication/graft and one ITF and 4 infected (21%) which were treated successfully by 2 ITF grafts and 2 free fibula flaps. Overall consolidation occurred by 9.9. months with good alignment in 15 cases. The complications were 2 varus and one 15° external rotation malunions and one shortening of 2 cm. Ankle movements were normal in 5 cases, reduced by 25% in 5 cases and by half in one case. There was one fixed equinus of 15° and one arhtrodesis. Five patients were able to run. The average number of general anaesthetics required was 5.7 and the average length of hospitalisation 120 days.In conclusion, the authors emphasise the beneficial role of early skin cover in the outcome of these fractures which is otherwise characterised by secondary contamination. They were extremely satisfied with the results of composite free grafts in cases of loss of substance of bone and soft tissue. At present, they tend towards locked nailing for these fractures preferably without reaming whenever possible. Skin cover can than be planned during the first 5 days after injury.RésuméCette série comprend 19 dossiers étudiés rétrospectivement de 1982 à 1993. Les choix ont été la stabilisation immédiate par fixateur externe, la couverture par lambeau libre ou pédiculé et un apport osseux précoce délibéré en cas de nécessité.La stabilisation osseuse a été assurée par les fixateurs externes de Hoffmann ou Orthofix qui facilitent les gestes de couverture cutanée ultérieurs. La stabilisation du péroné est recherchée dans la perspective d’une greffe intertibio-péronière (ITP). La couverture cutanée a été assuré 13 fois par lambeau pédiculé, 4 fois par un lambeau libre et deux fois par cicatrisation dirigée. Les lambeaux locaux ont été variés: 5 fois musculaires purs par jumeau interne ou soléaire; 4 fois fascio-cutanés, 3 fois musculo-cutanés du jumeau interne et un cross-leg. Ces lambeaux ont été réalisés en moyenne au 17ème jour (entre le 4ème et le 45ème jour). Quatre lambeaux libres ont été réalisés: deux cutanés purs et deux cutanés et osseux. Un deuxième lambeau a été nécessaire dans 3 cas pour cause d’infection ou de perte de substance des parties molles : un lambeau de jumeau interne et deux lambeaux péroniers libres au 105ème et 210ème jour.La consolidation a été obtenue per primam dans 6 cas. 13 greffes osseuses ont été nécessaires dont 7 de principe avant la fin du 3ème mois: 4 décortications-greffes, 3 greffes ITP. Un apport osseux complémentaire a été nécessaire dans 4 cas. 6 pseudarthroses ont été observées, deux sèches guéries par une décortication-greffe et une greffe ITP, et 4 septiques (21%) qui ont été traitées avec succès par deux greffes ITP et deux lambeaux péroniers libres. Sur l’ensemble de la série, la consolidation a été acquise à 9,9 mois avec de bons axes dans 15 cas. On peut considérer comme des complications la survenue de deux cals vicieux en varus, d’un cal en rotation externe de 15° et d’un raccourcissement de 2cm. La mobilité de la cheville est normale dans 5 cas, réduite d’un quart dans 5 cas et de moitié dans un cas. On note un équin fixé de 15° et une arthrodèse. Cinq patients sont capables de courir. Le nombre moyen d’anesthésies générales par patient est de 5,7 et la durée moyenne d’hospitalisation est de 120 jours. En conclusion, les auteurs insistent sur le rôle bénéfique joué par la couverture cutanée précoce dans l’évolution de ces fractures qui sera marquée, sans cela, par une contamination secondaire. Ils ont été très satisfaits des résultas obtenus par les greffes libres composites en cas de perte de substance tégumentaire et osseuse.Leur orientation actuelle va vers le choix de l’enclouage verrouillé pour ce type de fractures, sans alésage de préférence, chaque fois que la situation s’y prête. La couverture cutanée peut ainsi être envisagée dans les 5 jours qui suivent l’accident.Nineteen cases were studied retrospectively between 1982 and 1993. All had been stabilised immediately by external fixators. Free or pedicle flap and early bone graft was carried out as required.Bone stability was obtained by Hoffmann or Orthofix fixators which allowed later manoeuvres for skin covers. The stabilisation by the fibula was attempted by intertibio-fibula grafting (ITF). Skin cover was obtained in 13 cases by pedicle flaps, in 4 by a free flap and 2 cases healed by secondary intention. The local flaps were 5 medial gastrocnemius or soleus flaps, 4 fasciocutaneous flaps, 3 medial gastrocnemius muscular cutaneous flaps and one cross-leg flap. These flaps were done on average at the 17th day (between 4th and 45th day). Four free flaps were done: 2 pure cutaneous flaps and 2 osteo-cutaneous flaps. A second flap was required in 3 cases because of infection or loss of soft tissue. A medial gastrocnemius flap and 2 free fibula flaps were done at the 105th and 210th day.Bony union was obtained primarily in 6 cases. Thirteen bone grafts were necessary of which 7 were done electively before three months (4 decortication grafts, 3 ITF). Additional bone graft was needed in 4 cases. Six non-unions were seen, 2 sterile which were treated by one decortication/graft and one ITF and 4 infected (21%) which were treated successfully by 2 ITF grafts and 2 free fibula flaps. Overall consolidation occurred by 9.9. months with good alignment in 15 cases. The complications were 2 varus and one 15° external rotation malunions and one shortening of 2 cm. Ankle movements were normal in 5 cases, reduced by 25% in 5 cases and by half in one case. There was one fixed equinus of 15° and one arhtrodesis. Five patients were able to run. The average number of general anaesthetics required was 5.7 and the average length of hospitalisation 120 days.In conclusion, the authors emphasise the beneficial role of early skin cover in the outcome of these fractures which is otherwise characterised by secondary contamination. They were extremely satisfied with the results of composite free grafts in cases of loss of substance of bone and soft tissue. At present, they tend towards locked nailing for these fractures preferably without reaming whenever possible. Skin cover can than be planned during the first 5 days after injury.