Purpose of the study: The cervicobrachial outlet syndrome is an anatomic and clinical entity related to intermittent or permanent compression of the brachial plexus trunks, and/or the subclavian artery and vein as they pass through six successive spaces in the thoracic cervicobrachial outlet, including the intercostoscalenic space. The purpose of this work was to evaluate the feasibility of endoscopic exploration of the infra-clavicular portion of the outlet and the options for therapeutic interscalenic release.

Material and methods: Cadaver study of 12 shoulders: 3 male, 3 female.

dissection of the supra and infra-clavicular region (n=3) to identify zones of potential impingement and determine the structures constituting the outlet;

Results: The medial and lateral clavicular approaches identified two zones of less risk considering the proximity of the neck vessels and the phrenic and suprascapular nerves. A first, it was difficult to localize the brachial plexus endoscopically. This was achieved after dissection and insertion of landmarks. Five endoscopic procedures had to be performed to localize the plexus and starte the interscalenic release. Minute identification of the entry points for the trocars, as a perfect orientation of the instruments was necessary to achieve the procedure. The control dissections did not identify any vessel or nerve injury.

Discussion: Few data in the literature examine the question of endoscopic interscalenic release. Unlike Krishnan and Pinzer, we found that endoscopic exploration of the outlet at possible, but difficult, procedure. Use of an arthropump remains to be evaluated because of the distension and impregnation of the tissues. Insufflations with CO2 might be an alternative.

Conclusion: To our knowledge, a supra-clavicular approach for endoscopic exploration of the brachial plexus has not been described. Exploration of the outlet via this approach might be a less invasive procedure than conventional surgery. Complementary research is necessary to evaluate the morbidity of the different techniques.

Purpose: The diversity of treatments proposed for septic nonunion of the femur demonstrates the lack of consensus. Treatment modalities validated for the leg appear to be transposable to the femur. The purpose of this work was to compare different treatments used in our centre and identify optimal management practices.

Material and methods: We report a retrospective series of eleven patients (nine men and two women) who developed septic nonunion of the femur subsequent to trauma (n=9) or tumour (n=2). Sepsis developed early in seven cases and late in four. Mean time to treatment was 34.8 months. We based our strategy on a succession of steps starting with cure of the soft tissue and bone infection, before attempting reconstruction and consolidation.The first step involved fixation, antibiotic therapy and interposition of an acrylic spacer. The second step involved bone reconstruction, removal of the spacer, vascularised fibular graft associated with a cancellous bone graft (n=4) or massive cancellous graft inserted into the pseudomembrane created by the spacer (n=7).

Results: Mean time to resolution of the infection was 10.9 months. Cure could not be achieved in three patients. Bone continuity was achieved in 8.8 months on average. The time to bone healing (i.e. duration of external fixation) was 22 months. Refracture occurred in four patients. Consolidation was not achieved in two patients.

Discussion: During the second step, we preferred massive cancellous bone reconstruction due to easier technique, shorter healing time, and better adaptation of the reconstruction volume. Optimal time for the first step is about six months in order to avoid recurrent infection. Our healing times are similar to those reported by others: the healing index (time to healing divided by gap length) was close to that obtained with the compression-distraction technique. Refractures related to specific mechanical problems inherent in the femur lead to longer time for external fixation, minimum 13 months.

Purpose: Trapezometacarpal osteoarthritis is frequent in women aged over 50 years. Surgical cure may be needed after failure of well conducted medical treatment. When the trapezeal bone stock is insufficient for implantation of a total prosthesis, total trapezectomy can relieve the pain. This procedure is generally associated with stabilization ligamentoplasty of the first ray. The purpose of this study was to demonstrate the feasibility of this procedure using an arthroscopic approach and to detail the technique and its limitations.

Material and methods: This study was conducted on twelve cadaver specimens from eleven women and one man, mean age 85 years. Radiographs were obtained to confirm the trapezometacarpal osteoarthritis. Standard arthroscopic material used for the wrist was employed (2.4 mm optic, mini-shaver). Two portals on either side of the abductor pollicis lungus tendon were used to approach the trapezometacarpal joint. Total trapezectomy was performed with the mini-shaver distal to proximal. A tendon band measuring 6 to 7 cm was fashioned from the abductor pollicis longus tendon via a proximal contraincision. This band inserted on the first metacarpal was passed through two bone tunnels bored in the base of the first and second metacarpals then fixed to the base of the second metacarpal. Operative time was noted. The quality of the bone resection was determined on postoperative radiographs and open inspection.

Results: Arthroscopic total trapezectomy with stabilisation ligamentoplasty was achieved in all cases and evaluated radiographically and at open inspection. No lesions to noble elements were observed.

Discussion: This minimally invasive technique for trapezectomy associated with stabilisation ligamentoplasty was found to be feasible but did require a certain degree of learning. We were unable to identify any procedure-related morbidity, particularly concerning the sensorial branch of the radial nerve to the thumb.

Conclusion: The results of this preliminary study are encouraging and suggest a clinical trial should be conducted to prove the advantages of this technique in terms of morbidity and socioeconomical cost.