Purpose of the study: From November 2001 to January 2008, among 110 patients who underwent surgery for spastic hands due to a central neurological disorder, the management involved surgical treatment of long finger intrinsic and extrinsic deformities in 57 brain injury adults.

Material and methods: At least one procedure for the intrinsics and one for the extrinsics was performed during the same operative. Twelve patients had bilateral operations. The goal of the surgery and the treatment was established during multidisciplinary consultations with rehabilitation physicians, neurologists, surgeons and anaesthesists after a minute physical examination with selective neuromuscular blocks to differentiate muscle spasicity and tendon retraction from extrinsic and intrinsic disorders. The objective was established in the form of a contract with the patient and the family: hygiene and analgesia (47 patients), aesthetic aspect (15 patients, and/or function (21 patients.) For the spasticity and/or retraction of the exrinsics, we used 23 transfers of the FCP to the FCS, 6 Z lengthening of the FCP and the FCS, 14 intramuscular lengthening of the FCP and 11 of the FCS, 10 Page interventions, 10 selecive muscle disinsertions from the epitrochlears and one FCS tenotomy. Concerning the spasticity and/ol retraction of the intrinsic, we performed 4 neurotomies of the deep motor branch of the ulnar nerve, 48 interosseous tenotomise, 6 proximal disinsertions with mobilisation of the interosseous, 18 tenotomies of the 5th adductor, and 29 distal tenotomise of the extensor system.

Results: Outcome was good for 60 of the 69 operated hands (achievement of contract: function 18, aesthetic 14, hygiene 44). Seven hands required revision with a good final result for six of them. One patient developed reflex dystrophy.

Discussion: In adults, despite the modest functional results achieved in only one-third of the patients, corrective surgery for spastic mixed extrinsic and intrinsic deformities provides an important improvement for these patients.

Purpose: Although hamstring retraction is a frequent complication of spastic hypertoniq, very few series have been reported in adults. The purpose of this study was to evaluate results of therapeutic modalities proposed: distal hamstring tenotomy and use of an external fixator in case of permanent knee flexion.

Material and methods: This retrospective series included 37 cerebral palsy patients, 59 with permanent knee flexion. Mean flexion was 69° (20–130°). Mean motion was 61° (10–100°). Deformation of the supra and infra joints was present in 82%. There were 22 patients with bilateral permanent knee flexion. Simple tenotomy of the sartorius, the semitendinous and the gracilis with lengthenings of the semimembranous and biceps. Disinsertion of the gastrocnemius and section of posterior aponeurosis were associated as needed. Postoperative immobilization was achieved with a Zimmer cast in case of moderate flexion and with an external femorotibial fixator in case of major deformation. Postoperative rehabilitation exercises performed several times daily were initiated in all patients.

Results: At mean follow-up of 641 days, residual flexion was 6° (0–40°) and mean joint motion was 111°. All knees were stable. Three dehiscent wounds required surgical repair. The function objective, established pre-operatively, was achieved or exceeded.

Discussion: When postoperative immobilization is necessary, external fixation limits cutaneous risks and facilitates rehabilitation. It appears to be better than successive cases. Unlike other authors, we did not find section of the posterior cruciate ligament to be necessary.

Conclusion: Distal hamstring tenotomy associated with postoperative immobilization with an external fixator is a reliable and effective technique for the treatment of permanent knee flexion in cerebral palsy adults.

Purpose: We analysed prospectively our experience with the zincrone-polyethylene bearing for total hip arthroplasty for implantations performed between 1987 and 1997. This bearing is designed to reduce in vivo wear due to the excellent biological qualities of this ceramic.

Material and methods: Total hip arthroplasty was performed on 867 hips over the ten year period (1987–1997) in patients followed for mean seven years. All had titanium or stainless steel stems with a cemented or press fit cup (inner diameter 26-mm or 28-mm). We used Y-TZP zircone, a polycrystalline tetragonal-phase zircone stabilised by adjunction of ytterium (Prozyr). Mean patient age was 58 years (17–87). Mean body weight was 70 kg (40–125) and mean height was 167 cm (140–196). The sex-ratio was 1.3.

Results: Overall survival determined with the Kaplan-Meier method was 60% at 13 years (95%CI=55–65%). Revisions (all causes including infection) were performed on 118 hips. To our knowledge, for the entire cohort, one patient presented a zircone head fracture. Radiographic analysis showed a particular type of fracture related to isolated acetabular loosening. Comparative analysis of this type of loosening for 785 heads (26-mm) and 92 heads (28-mm) was not significant (log rank test). Taking surgical revision as the endpoint for isolated acetabular failure, implant survival at 13.5 years was 74% (95%CI=68–80), confirming the particular mode of failure with this bearing.

Discussion: This prospective analysis showed the absence of superiority of the zircone head in vivo for reduction of wear in comparison with metal heads in young subjects. The purely epidemiological data reveal formal evidence of the deleterious nature of zircone in contradiction with the expected beneficial tribiological effect. We have no physicochemical explanation for these failures. The pathology findings were non-specific, but the failure was real.

Conclusion: Considering these findings, we have abandoned use of this ceramic since 1997.

Aims: The diagnosis of a prosthetic joint infection is difþcult, but crucial for appropriate treatment. Scintigraphy with speciþc markers for infection (labeled white cells or immunoglobulin-G) has been reported as a more reliable diagnostic tool than clinical assessment (fever, þstula), laboratory studies [polynuclear neutrophils blood count (PNC), erythrocyte rate sedimentation (ESR), and C-reactive protein (CRP)], and preoperative aspiration. Methods: In the þrst part of this study, we retrospectively reviewed 230 patients admitted with a suspected prosthetic joint infection and compared the validity of these different diagnostic tools. 209 patients had an infection. Results: Pain, fever, ESR, and PNC are unreliable for identifying occult infection. The presence of a þstula is inconstant, but when present is very reliable to detect infection. Our study revealed sensitivity, speciþcity, positive and negative predictive value as follows: CRP: 97%, 81%, 98%, 71% respectively; aspiration: 82%, 94%, 99%, 43% respectively, and labelled scintigraphy 74%, 76%, 91%, 44% respectively. In the second part, we reviewed 23 articles which included 1,722 prosthetic joints with preoperative evaluation of infection. Conclusions: Both our study and the literature review indicate that CRP and joint aspiration are the best tools to diagnose prosthetic joint infection.

Purpose: Talipes equinus is a frequent deformity observed in patients with central nervous disease. The surgical strategy is based on an assessment of the spasticity and retraction elements in the deformity and the presence or not of antagonistic muscles. We propose a codified treatment strategy and present results obtained over the last two years.

Material and methods: All patients who underwent surgical treatment for central neurological talipes equinus between 1998 and 1999 were included in this study. All patients were seen by the orthopaedic surgeon and the physical education and rehabilitation physician at the preoperative consultation. Selective neuromotor nerve blocks completed the physical exam in order to assess spasticity and retractions (soleus, gastocnemius, flexor digitalis). Functional antagonistic or transferable muscles were identified. A function contract was established with the patient. All patients were operated on by the same surgeon and were reviewed late after surgery by an independent clinician. Gain in joint movement and function were recorded as well as any complications.

Results: Thirty-five patients underwent surgery (42 feet). The analytic results were good: mean gain in joint movement = 37.5°.

The functional objectives (walking for 31 patients, verticalisation for ten, comfort for one) were achieved in all patients except five. There was one taluseversus, one anterior subluxation of the talus, one persistent stepping. For two patients underlying neurological disorders did not allow fulfilment of the contract. There were also three cases of claw toes with moderate functional impact.

Discussion: Preponderant retraction makes it difficult to assess antagonistic and intrinsic muscles, leading to the complications observed. A dynamic EMG recording might provide a solution. Functional outcome depends on correct assessment of the underlying neurological status.

Conclusion: The good results achieved in this series of patients validates the proposed decisional algorithm. The surgical strategy must be inscribed within a functional contract established with each individual patient.

Purpose: Multiple deformations of the lower limbs are common orthopaedic complications of central nervous system disease. Assessment is difficult. Intrathecal Liorésal® was proposed for the patients to establish the relative effects of spasticity and musculotendinos retraction and define a medico-surgical therapeutic strategy.

Material and methods: Between January 1999 and December 2000, 31 patients consulted for persistent knee flexion. Baclofen tests (75 – 100 μg Baclofen intrathecal) were performed in ten patients because the relative contribution of spasticity and retraction was difficult to assess. The anti-spasticity effect was observed within the first hour, with a maximal effect between the second and fourth hour. Motor function, joint motion, and function were tested during this time interval. The test was repeated approximately three days later, sometimes with higher doses depending on the level of the anti-spastic effect. Residual orthopaedic limitations were explained by musculotendinous retractions.

Results: For the ten evaluated patients, three presented musculotendinous retractions amendable by surgical treatment (tendon lengthening, proximal disinsertion), sometimes in combination with arthrolysis. For the seven patients who had hypertonic spastic contractions, medical treatment was given with, for three patients, continuous intrathecal Lioresal via pump delivery. There was a correlation between the deformation assessed after the test and the test conducted under general anaesthesia during the procedure in all patients.

Discussion: Other methods for evaluating orthopaedic deformities of the lower limbs can be used. Selective motor blocks using local anasethetics are generally reserved for patients with localised stiffness or when it may be difficult to achieve in certain patients (hip flexion). Mobilisation under general anaesthesia is another solution, but does not allow an assessment of functional gain, particularly if the goal is walking. The intrathecal Baclofen test not only allows an accurate assessment of orthopaedic retraction, but also an assessment of the functional impact of the spasticity, sometimes useful for verticalisation or walking.

Conclusion: The Baclofen intrathecal test is a simple test with a particular place in the preoperative and functional assessment of neuro-orthpaedic stiffness of the lower limbs.

Purpose: Patients hospitalized for osteomyelitis due to multi-resistant strains are often given prolonged parenteral antibiotics. Ambulatory parenteral antibiotic therapy is an alternative allowing outpatient care. The purpose of this study is to assess tolerance, cost and efficacy of this type of treatment.

Material and methods: Thirty-nine patients followed for osteomyelitis were included in this study. These patients were given antibiotics in a continuous infusion using a portable diffuser connected to an implanted chamber. Mean duration of treatment was four months, range 1.5–12 months. The follow-up team included the primary care physician, an infectious diseases specialist, and a nurse with special training in prolonged ambulatory antibiotic treatments. Results of weekly blood tests were transmitted to the referral hospital physician. Adverse effects and cost of prolonged ambulatory antibiotic therapy were recorded. Cost included costs for nurses, physical therapists, and physicians as well as drugs, supplies and laboratory tests. The cost of hospitalisation was determined on the basis of the standard cost for one day of hospitalisation in France.

Results: There were three cases of thrombophlebitis and one case of allergic reaction, both required re-hospitalisation. Cure was achieved in 93% of the patients. Mean follow-up since cure with discontinuation of the antibiotics was 18 months (14–22). Home care was possible in 100% of the patients and 23% of the patients were able to resume their occupational activity; 25% resumed their schooling. Self-administered schemes were possible in 23% of the patients. Compared with conventional hospitalisation, ambulatory parenteral antibiotic therapy enabled a cost savings of 1352 euros per patient.

Discussion: These results demonstrate that ambulatory antibiotic therapy is a very good alternative to classical hospitalisation enabling low morbidity, early resumption of social activities without loss of efficacy.