Fundaments: The surgical management of proximal femoral extra-capsular fractures in the elderly remains controversial. Bone quality and purchase of the cephalic screw are the main limitations of the currently available therapeutic options, dynamic hip screws-blade and proximal femoral nailing systems being the standard fixation Methods: which however report a revision rate of 7% due to mechanical failures. Main complications include implant-related fractures and cut out of the head-neck device with subsequent penetration into the acetabulum. The new PFNATM helical blade appears to improve the stability of the whole construct by providing better compaction of the cephalic cancellous bone around the blade.

Hypothesis, Type of Study: We conducted a retrospective radiographic-clinical study of a series of PFNATM osteosyntheses. Assessment of the mid-term results was based on the hypothesis that the PFNATM would reduce the occurrence of secondary deviations.

Materials and Methods: Between 2006 and 2008, 108 osteosyntheses were performed. Only traumatic fractures were included in this study. Parker’s quality of life scoring system (0 to 9) and Harris hip score (0 to 100) were used for functional evaluation. The PFNA blade position was assessed using intraoperative radiographs while a postoperative radiographic control was performed during follow-up to evaluate the occurrence of complications.

Results: 98 patients (98 hips) were reviewed at a mean follow-up of 5.3 months +/− 1.5. At last follow-up, the mean Parker score had decreased by 2.3 points and the Harris hip score by 24 points. All fractures united at an average time of 10.4 weeks (+/− 2.1). Six complications were reported (6.1%). They included 3 infections of the operative site and 3 cut-out of the femoral head. Three patients required reoperation for removal of the helical blade (3%): Two for significant migration and one for intra-acetabular penetration.

No statistically significant risk factors could be observed. However, the three cut-out of the femoral head occurred in unstable fractures (type 31-A.2 and 31-A.3 according to the AO classification) with mispositioning of the helical blade.

Discussion: Extra-capsular proximal femoral fractures are common in the elderly population but there is currently no ideal implant available. Unstable fractures as well as mispositioning of the head/neck device are considered risk factors for secondary varus deviation and external rotation. The new PFNATM helical blade has been rarely studied. It appears as a reliable osteosynthesis option since it reports encouraging results at a mean follow-up of 6 months. However, our results do not give evidence of the superiority of the helical blade over the neck screw.

Introduction: The scarf osteotomy is a reliable technique in bunion surgery. A so-called « self stable technique» was developed in our department since 1992. We report the results of retrospective study including two groups of patients which had a scarf osteotomy. In the first group they had an internal fixation and in the second one an ‘selfstable technique’ with no device.

Material and methods: One hundred and seventy one patients operated for hallux valgus were reviewed for this study. There were 105 feet operated with the so called ‘self stable techniqu’, using modified saw cuts and 103 had the conventional technique with an internal fixation. All patients had a clinical and radiological pre- and postoperative examination. The result was assessed according to the AOFAS Score.

Results: The follow-up was on average 6.3 years (ranging from 2 to 13 years). The result was considered satisfactory globally in 74% of the cases, 76% in the « selfstable group and 72% in the conventional group. All items were significantly improved in both groups and the good results remained with time: improvement in shoe wear, pain, angular corrections. The hallux valgus angle decreased from 34° to 16°, there was no difference between both groups. The first intermetatarsal angle changed from 15° to 10. No significant difference was found in term on bone healing and complications between both groups.

Discussion: These results are comparable with those of the literature. The « selfstable technique » is significantly identical to the conventional one. The patients have the same rate of complications. The corrections that this osteotomy is able to offer are not altered by the change of fixation of the osteotomy.

Conclusion: This modified scarf osteotomy of the first metatarsal provides equivalent long-term results in our experience.

Purpose of the study: The efficacy of metatarsophalangeal joint (MPJ) fusion for the treatment of hallux rigidus has been well defined in the literature. There is however still some debate about the efficacy of conservative treatment, especially concerning the respective role for each of several different techniques.

Material and methods: This study reports the analysis of 113 patients treated for hallux rigidus with minimum one year follow-up. Mean age of this predominantly female population was 58 years. Fusion of the MPJ of the great toe was performed for 77% of patients and conservative treatment for 23%: isolated osteophytectomy (n=5), dorsal cheilectomy and shortening osteotomy of P1 (5 cm on average) with or without dorsal flexion for the others. The clinical outcome was assessed with the Groulier criteria.

Results: Overall outcome was satisfactory in 85% of the patients treated by MPJ fusion; MPJ pain resolved in 92%. There was however late healing or nonunion in 13% with no apparent clinical impact. Conservative treatment successfully relieved pain in 80% of patients who were able to wear ordinary shoes and had improved dorsal flexion of the MPJ.

Conclusion: The results of this study are helpful in determining the appropriate indications for surgery as a function of the clinical and radiological presentation of hallux rigidus.

Purpose of the study: Chronic foot compartment syndrome is a rather new notion illustrated by four cases reported in the international literature. We report a new case with bilateral involvement. The diagnosis was established by dynamic thallium scintigraphy and suggested that a less invasive management would be appropriate.

Case report: A 32-year-old male Foreign Legion recruit developed exercise-induced pain in the medial portion of the plantar aspect of both feet. The pain persisted for several months and resisted medical treatment. No medical or surgical event could be identified in the patient’s history. Pain developed systematically with exercise which had to be interrupted. It regressed progressively after interruption of exercise. The physical examination and podoscopy were not contributive. Laboratory tests, plain x-rays, MRI, and bone scintigraphy were normal. The diagnosis of chronic foot compartment syndrome was entertained. Dynamic thallium-201 scintigraphy was performed on both feet to compare the soft tissue images. Intense uptake was observed on the early images and late images of the plantar vault. These images, present on both feet, were considered compatible with chronic foot compartment syndrome. Positive diagnosis was confirmed with pressure measurements in the medial compartment. Fasciotomy was performed for the medial compartment. The patient was able to run normally at one month with complete regression of the symptoms. The patient was symptom free at two years.

Discussion: Compartment pressure measurements currently constitute the gold standard diagnostic approach. MRI, Doppler, spectroscopy, and scintigraphy have been proposed. For this functional disorder, which occurs only after exercise, we consider that compartment pressure measurement is overly invasive and painful. Furthermore, dynamic thallium-201 scintigraphy has been found to be as reliable as pressure measurements. Comparative studies would be required to determine the best evidence-based choice.

Conclusion: Chronic foot compartment syndrome is a rare entity observed in the active young subject. The medial compartment is always involved. Fasciotomy is effective treatment. Compartment pressure measurements remain the gold standard but dynamic scintigraphy would be a promising examination which merits evaluation.