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Summary Introduction Knee arthrodesis may be the last possible option for infected total knee arthroplasty (TKA) patients and in revision cases involving severe bone loss and/or extensor mechanism damages. Success in these situations depends on achieving good fixation assembly stability. We report bone fusion results using a fixation technique combining cross-pinning by two Steinman pins with a single-frame external fixator. Remission of infection at long-term follow-up was an additional criteria assessed for those cases initially treated for sepsis. Hypothesis This fixation modality improves fusion rates. Patients and methods In six of this series of eight patients (mean age: 59 years), surgery was performed in a context of infection: five cases of infected TKA, and one case of septic arthritis. In the other two cases, arthrodesis was respectively indicated for a severe post-traumatic stiffness compounded by extensor system rupture and for a fracture combined to a complete mechanical implant loosening. In three of the six infection cases, arthrodesis was performed as a single-stage procedure. All patients were operated on using the same technique: primary arthrodesis site stabilization by frontal cross-pinning with two Steinman pins, followed by installation of a sagittal external fixator frame. Results were assessed at a mean 8 year follow-up. Results All the arthrodeses showed fusion at a mean 3.5 months (range: 2.5 to 6 months) postoperative delay without reintervention. Weight-bearing was resumed at 2 to 3 months. The external fixator was removed at a mean 5.2 months. No recurrence of infection was observed over a mean follow-up of 8.2 years (range: 1 to 15 years). Three complications occurred: one hematoma, managed surgically; one supracondylar fracture treated orthopedically; and one osteitis, managed by surgical curettage. Discussion This knee arthrodesis technique proved effective, with no failures in this short series, especially in cases of primary infection. It is a reproducible means of osteosynthesis, with little subsequent morbidity. Fixation in two orthogonal planes seemed to provide the stability required to achieve bone fusion. This assembly avoids internal fixation, which is never risk-free in a context of primary sepsis. Level of evidence Level IV. Retrospective study.

Adequate (wide or marginal and uncontaminated) margins and reconstruction are difficult to achieve when performing an internal hemipelvectomy for bone sarcomas involving the sacroiliac joint. We evaluated whether adequate surgical margins could be achieved and if functional outcomes could be predicted based on the type of resection and reconstruction. Forty patients had resections of the sacroiliac joint. Vertical sacral osteotomies were through the sacral wing (n = 2), ipsilateral sacral foramina (n = 27), sacral midline (n = 9), or contralateral foramina (n = 2). Iliac resections were Type I, Type I-II with partial or total acetabular re-section, or Type I-II-III. Surgical margins were adequate in 28 of 38 patients (74%), two (7%) of whom experienced local recurrence, compared with seven of 10 (70%) patients with inadequate margins. Reconstruction consisted of restoring continuity between the spine and pelvis. Resection of the entire acetabulum and removal of the lumbosacral trunk were the two main determinants of function, as assessed using the Musculoskeletal Tumor Society score. There were no life-threatening or function-threatening complications. Internal hemipelvectomy with a limb salvage procedure can be achieved with adequate surgical margins in selected patients. Functional outcomes can be predicted based on the type of resection and reconstruction, which helps the surgeon plan the procedure and inform the patient.

Isolated injuries of the scapho-trapezial ligament complex are not well recognized. The ligament complex comprises the stout scapho-trapezial ligament, the floor of the flexor carpi radialis (FCR) tendon sheath and the scapho-capitate ligament. Between August 1991 and May 1992, we diagnosed and treated four cases of partial chronic post-traumatic lesions of this ligament complex. There was chronic pain at the base of the thenar eminence and instability of the thumb-index-middle finger pinch. Standard X-rays were normal. The diagnosis of ligament rupture was confirmed by mid-carpal arthrography showing filling of the sheath of FCR tendon. Surgical exploration showed complete rupture of the tendon sheath of FCR in two cases, associated in the other two cases with complete rupture of the scapho-trapezial ligament. Direct repair of the ligamentous elements was performed in all cases. The tendon of FCR was sutured to the tubercle of scaphoid to protect and to reinforce the ligament repair. The patients have been followed-up for between 6 and 12 months. All four patients recovered normal pinch strength to the middle finger. One patient suffered from chronic pain at work.

The treatment of chronic osteomyelitis with large skin defects at the foot or the ankle is uneasy. In such cases, free muscular flaps are currently advised but they are less reliable in patients with medical diseases. In such difficult cases we have used the distally based soleus island flap, vascularized with retrograde flow on the posterior tibial artery. The technique and the indications of this flap are discussed.This flap has been used for seven patients with bone infection and skin defects measuring an average of 10 x 7 cm. The preoperative arteriography had to find the whole three arteries at the leg, with a good distal anastomotic arcade. The soleus muscle was raised with the posterior tibial artery, after it was ligated proximally and dissected up to the tarsal tunnel.All of the seven flaps totally survived, except one that a marginal necrosis treated by excision and iterative dissection of the pedicle for a more distal repositioning. No clinical vascular deficiency was found on the legs. At the last review, all the osteomyelitis were cured.The soleus island flap, distally vascularized on the posterior tibial artery, is a reliable flap, useful for the coverage of the distal leg, from the ankle to the very distal foot. Harvesting a major artery at the leg should be weighed against the failure of a free flap in high risk patients.

Posterior Wallaby I is a fixed polyethylene tibial plateau prosthesis enabling preservation of the posterior cruciate ligament (PCL). Its asymmetrical and divergent femoral condyles articulate with also asymmetrical tibial plateaus. The purpose of this prospective study was to analyze outcome of the first 425 Wallaby I prosthesis of the Guepar group implanted for first-intention treatment.These 425 prostheses were implanted from December 1992 to February 1995 by senior and junior surgeons. Mean patient age at implantation was 70.5 years. 91% had primary or secondary osteoarthritis and only 8.9% had inflammatory rheumatoid disease. The mean preoperative IKS score was 25.34 points and the IKS function score was 29.04. 10.35% of knees were aligned normally (mechanical axis between 2 degrees varus and 3 degrees valgus) according to the IKS criteria (Ewald), 24% presented valgusor = 4 degrees and 65.6% varusor = 3 degrees. All tibial and patellar components (except one) were cemented, 5.8% of the femoral pieces were inserted without cement. All but 11 patellae were resurfaced. Clinical outcome was assessed with the IKS score and radiological outcome with the IKS criteria. The patella was considered to be tilted when the alpha angle was5 degrees and dislocated when the AA' distance was5 mm. The chi-square test was used for comparison of quantitative variables (significance set at 0.05).Early postoperative complications were rare: two infections cured with debridement-lavage and antibiotics without removal of the prosthesis, one peronal nerve palsy which regressed partially, ten late unions without clinical consequence (particularly in the inflammatory rheumatoid patients). Twenty-six prostheses were followed less than one year (eight patients died and eighteen were lost to follow-up) and 84 less than five years (27 patients died and 57 lost to follow-up before five years). 315 prostheses were followed for more than five years (5-9 years) with a mean follow-up of 6.3 years. Among the 399 prostheses followed for one year or more, we noted: four infections including three requiring change of the prosthesis (one cured by arthroscopic lavage), two aseptic loosenings which were revised (one global one tibial), one tibial loosening and three patellar loosenings which were not revised, and two femoral ossifications limiting joint motion but improved by arthrolysis and resection of the ossifications. Three patients experienced anterior pain requiring secondary patellar resurfacing in two and section of the lateral patellar wing in one. Ninteen patellar fractures (4.7%) were noted, including 17 with no significant functional impact which were not revised. The mean IKS knee score among prostheses followed for five years was 90.5 points, with mean motion 110.5 degrees. Mean IKS function score was 61.63 points. 72.9% of the knees were aligned, 22.2% in varus and 4.9% in valgus. The mechanical axis of 94.3% of the knees was between 5 degrees varus and 5 degrees valgus. Prosthesis survival at eight years (Kaplan-Meier method) was 97.7% considering all reasons for prosthesis removal and 98.5% for removal for aseptic loosening.This prospective multicentric study demonstrated that the results obtained with the Wallaby I prosthesis are as good as those obtained with other prostheses sparing the PCL and published in the literature. Preservation of the PCL enables better knee stability, correct motion (110.5 degrees in our series) with almost no radiological wear of the tibial polyethylene at eight years. The only worrisome complication is patellar fracture.

We wanted to check whether the differences in joint kinematics between the normal and prosthesis knee, with or without preservation of the posterior cruciate ligament, have an effect on knee flexion-extension during gait and on gait performance.A control group of nine subjects was compared with two groups of subjects with total knee prostheses, with (n = 10 patients) or without (n = 6 patients) preservation of the posterior cruciate ligament. Gait was studied on flat ground at three different walking speeds. We measured the principal temporospatial gait parameters as well as knee flexion and extension angles using continuous electrogoniometry. Non-parametric statistical tests were used to analyze data due to the small number of subjects in each group.The flexion-extension cycles were different between the control group and the prostheses groups, but there was no difference between the two prostheses groups. Measurements made during gait confirmed this result, demonstrating a modification of the temporospatial parameters and a decrease in knee flexion during weight bearing in the prostheses groups compared with the control group. The statistical analysis demonstrated a correlation between these two results.The individual nature of gait parameters hindered data analysis. Indeed, there are many different ways to walk "normally". We were however able to demonstrate the following points. The theoretical differences in joint kinematics between prostheses with or without preservation of the posterior cruciate ligament did not have any effect on gait. There were however significant differences between the control group and the prostheses groups, and these differences depended on walking speed. The most interesting results concerned the changes in the weight-bearing phase. Flexion during this phase was related to walking speed and was decreased in amplitude in both prostheses groups. This lesser amplitude in knee flexion probably affected the quality of gait because it was correlated with decreased temporospatial parameters related to gait performance.This decreased amplitude of flexion during gait, which cannot be expected from motion measurements without weight bearing, can be explained by an interaction between joint kinematics, the musculoligamentary system and the locomotor schema.

We wanted to develop a gait evaluation protocol using an electrogoniometric device allowing simpler measurements than optoelectronic recordings.Gait was studied in a group of nine healthy subjects, mean age 58 years, walking on flat ground at three different speeds. We recorded the knee flexion and extension angles and the main temporospatial gait parameters. The principal conditions required for considering gait to be normal were taken from the literature.The subjects exhibited gait cycles which were normal in 83% of the cases for both knees at all three walking speeds. In 17% of the cases, the subjects walked with a flexed knee or without flexion during the weight-bearing phase. Knee motion was symmetrical between the right and left knee in all subjects. Increased walking speed was associated with increases temporospatial parameters and greater flexion and extension angles, particularly during the weight-bearing phase. There was a correlation between the weight-bearing flexion phase and stride length.The walking distance was moderate but sufficient to avoid the influence of the start and stop cycles. The electrogoniometers were small and did not perturb walking. Certain temporospatial parameters could not be measured directly but could be estimated. We checked that the results corresponded with data in the literature. Lateralization (right, left dominance) did not influence knee movement. Flexion during weight-bearing could influence gait quality by affecting the balance between gravity and quadriceps muscle force, particularly when considering forces used to progress forward. Knee motion varies with walking speed and depends not only on overall knee motion measured without weight bearing, but probably also on the interaction between joint kinematics, the musculoligamentary system, and the locomotor schema.

We conducted a prospective study to determine the therapeutic impact of systematic culture of suction drainage collections in Altemeier class I and II procedures.We examined the following questions: how many microbiologically positive samples and infections of the operative site were present in the included patients? for positive cases, what was the antibiotic prescription (excluding antibiotic prophylaxy protocols planned before surgery for cleaning)? if the sample was positive in a patient with no clinical infection, what antibiotics were prescribed?A total of 1039 samples were collected in 470 patients undergoing Altemeier class I and II procedures. One hundred five cultures were positive in 34 patients who had undergone major surgery. There were 11 postoperative infections during the study period. Mean delay to diagnosis of infection was 19.5 days. Only one infected patient with positive drainage samples developed an infection on the 7(th) day; the causal germ was different from that identified in the drainage collection. Only one of the patients with a positive drainage sample was given antibiotics, but this treatment was initiated at peroperative reception of the laboratory results.Our findings demonstrate that systematic samples of drainage collections make no contribution to therapeutic decision making in patients undergoing class I and II surgery.

Unlike injuries involving only one of the forearm bones, complex lesions of the proximal end of the radius and the ulna are particularly unstable. Various situations-Monteggia fracture, transolecraneal dislocation, or fracture-dislocation-are encountered. The classification systems proposed to date and recalled here are insufficient, making it difficult to provide optimal therapy and also hindering comparison between published series. We propose a descriptive classification including all the anatomic varieties of complex fractures of the proximal end of the radius and the ulna. This classification is based on our experience with 38 cases and takes into account 4 basic elements: the height of the ulnar fracture line, the direction of the displacement of the proximal radius, the association of a fracture of the proximal radius and/or of the coronoid process.

Complex lesions of the proximal end of the radius and ulna are uncommon and generally associate a fracture of the proximal ulna and a dislocation of the radial head, which also may be fractured. We assessed the effect of the type of fracture and treatment on functional outcome and complications.Thirty-eight adults (25 men and 13 women) were treated for complex fractures of the proximal end of the radius and ulna. For 25 of them, mean follow-up was 2.4 years. For the ulna, there was an epiphyseal fracture in 10 cases, a metaphyseal-epiphyseal fracture in 16 and a diaphyseal fracture in 12. The coronoid process was fractured in 20 cases and the proximal radius in 19. There was an anterior displacement in 24 cases. There were 9 open fractures and 13 patients had another injury of the upper limb. Functional outcome was assessed with a 100 point scale using subjective (pain) and objective (active motion, muscle force, stability) criteria.For the 25 fractures with more than 1 year follow-up, outcome was very good in 8, good in 6, fair in 8 and poor in 3. The pain and muscle force scores followed a similar pattern. Motion appeared as the determining factor for good outcome. Seven early revisions (2 for deep infections, 2 for disassembly of the fixation system, 3 for insufficient fixation) were required among the 38 patients. Among the late complications, there were 3 nonunions, 5 misalignments, and 4 proximal radio-ulnar synostoses. Six elbows required revision to restore motion.Certain characteristics of the fractures were predictive of poor outcome: skin opening, association with a lesion of the homolateral upper limb, mirror lesion of the lateral condyle, metaphyseal-epiphyseal fractures, communitive fractures, presence of a fracture of the radial head or the coronoid process.Complex proximal fractures of both bones of the forearm threaten the functional prognosis of the upper limb due to the risk of stiffness. Successful treatment depends on three factors: stable anatomic reconstruction of the ulnar articulation, and reconstruction of the lateral column and the coronoid process, necessary for a stable elbow. In addition, early mobilization, possible with a stable osteosynthesis, is indispensable for recovering useful joint movement.

In this study, the case has been examined of a 49-year old male who initially presented with a pathological fracture of the second metacarpal. This was first treated by curettage, iliac bone graft and internal fixation, without any complementary investigation being carried out, i.e., no preliminary biopsy and histological diagnosis were made. The results of this inadequate approach were poor: neither satisfactory fixation of the fracture nor control of the primary lesion were obtained. Moreover, the definitive diagnosis was only made four months later, when biopsy findings confirmed the presence of an osteosarcoma. After neoadjuvant chemotherapy, an en-bloc resection of the second metatarsal and the trapezoid bone was carried out. At ten months post-surgery, one and a half years after the original fracture, the hand was found to be disease-free and functioning satisfactory. However, nearly a year later the discovery of a large tumor mass at the site where the iliac bone graft was originally taken necessitated resection of the hemi-pelvis, with chemotherapy prior to resection and radiotherapy following surgery. Unfortunately, this salvage procedure did not limit the spread of the disease, and subsequent pulmonary and vertebral metastases were found, leading to the death of the patient three years after the initial fracture. This particular case underlines the fact that the basic rules for the management of malignant tumors should be taken into consideration from the onset, so that a catastrophic prognosis such as that described can be avoided.

Between 1990 and 1997, 18 patients with a mean age of 55.5 years (11 females, 7 males) underwent surgical treatment for a metastasis from thyroid cancer involving the axial skeleton. At the time of surgery all patients had a poor prognosis: 7 metastases revealed the thyroid cancer, all 18 patients had a neurological or mechanical complication, 9 had multiple metastases, all were over 40 years of age. After arteriography with embolization, the surgical procedure consisted of curettage of the tumor and reconstruction, followed by treatment with iodine 131. The survival rate 3 years after surgery was 50%. At the last review, the functional outcome was good and 17 patients had total neurological recovery. Four complications occurred: 1 operative hemorrhage, 3 postoperative infections. Four patients had local recurrence of the metastasis with a one-year survival rate of 20%. When the thyroid cancer was revealed by the axial metastasis, the 3-year-survival rate was 42%. In cases with huge metastases, the 3-year-survival rate was 71%. It appears from these data that surgical treatment of metastases from thyroid cancer in the axial skeleton still achieves a good functional outcome even in cases where neurological or mechanical complications had occurred before surgery.

Arthroscopic arthrolysis is a reliable technique for the treatment of knee stiffness due to arthrofibrosis following ligament replacement or following the treatment of knee fracture. However, its use is uncommon for this indication in total knee arthroplasty (TKA). In this study, we questioned whether or not arthroscopy is a reliable technique for treatment of knee stiffness following TKA, due to arthrofibrosis.Four men mean aged 54 (38-70) underwent knee arthroscopy for a history of arthrofibrosis following TKA. In two cases the arthrofibrosis had appeared after a primary TKA done for limited range of motion and in two other cases had followed a revision arthroplasty. The mean knee flexion before the TKA was 80 degrees (40-110) and it was 105 degrees (100-120) after performing the TKA. The knees were not mobilized under anesthesia though the mean flexion was 75 degrees (60-80) 15 days after the TKA. The indication for arthroscopy was a painless limited range of motion of the knee. The arthroscopy was performed 6 months (2.5-12) after the TKA and at this time the flexion was limited to 65 degrees (60-80). The extension was limited in 2 cases to 10 degrees and 30 degrees. Patients were evaluated an average of 20 months (8-36) after the arthroscopy. With 2 peripatellar portals we sectioned the adhesions in the suprapatellar pouch, the 2 retinaculars and the adhesive bands in the 2 gutters. Two anterior additional portals were used in case of extension lag. A suction drain was placed and the portals were sutured. A continuous passive motion machine was started in the recovery room.The mean operating time for arthroscopic arthrolysis was 38 minutes (30-60). The mean knee flexion was 116 degrees (100-130) at the end of arthroscopy and was 93 degrees (75-110) at the last review. The mean flexion improved by 31 degrees (15-50). The mean flexion improved by 45% (25-83). The 2 extension lags decreased respectively from 30 degrees to 10 degrees and from 10 degrees to 0 degree. For these 2 patients the increase in range of motion was 70 degrees and 40 degrees respectively. The average amount of bleeding was 200 ml (86-520). There were no complications.Few surgeons are experienced in arthroscopy for knee stiffness after TKA. Our results are similar to those reported by most authors. Regarding the technique, the section of the two retinaculars is necessary for the mobility of the patellar and most of the mobility is gained after the release of the gutters. The use of only two portals avoids damaging the TKA component and decreases the theoretical risk of infection. The major loss of motion after arthrolysis occurred during the first days following the arthroscopy. This is why we recommend using a regional anesthesia for the arthroscopy and during the following days to allow intensive mobilization of the knee. The arthrolysis should be done from 3 to 6 months after the TKA for better results.Arthroscopy for the treatment of knee stiffness, due to arthrofibrosis, following TKA is a useful, reliable and safe technique.

To assess the prevalence of lead intoxication in children in a defined low-risk population at the new levels recommended by the Centers for Disease Control and Prevention.During an 11-month period, whole blood lead tests were performed on 4678 children at routine well-child visits at 9 months and 2 years of age. For the last 8 months of the study, parents were asked to complete a prescreening risk factor questionnaire at these visits. The questionnaire and blood lead results were then matched. Data were collected from October 1, 1991 through August 31, 1992.The study subjects were all enrolled in Group Health, Inc, a large health maintenance organization. Its 17 staff model clinics serve urban and suburban populations in the Minneapolis-St. Paul area. More than 95% of the population had coverage based on employment, not Medicaid.Results indicated that 2.5% (n = 119) of the children had BPb levelsor = 10 micrograms/dL. Urban clinics had rates of elevated BPb levels three to eight times those of suburban clinics (P.00001), but the number of elevated BPb levels at the suburban clinics was greater than expected. BPb levels were significantly higher in summer and fall (P.00001). The prescreening questionnaire addressed five areas potentially associated with risk according to the literature: housing, siblings with lead poisoning, parental hobbies or work involving lead, proximity to highways, and use of cultural medicines. Positive correlations were found between elevated BPb levels and residences built before 1950 (P.00001). For children living in housing built before 1950, positive correlations were found between elevated blood lead levels and peeling paint (P.01) or remodeling (P.0001).Children who are at low socioeconomic risk but who live in housing built before 1950 are at increased risk for lead poisoning. The risk is greater if the house has peeling paint and especially if there is recent or ongoing renovation. Recommendations based on these results and the Centers for Disease Control and Prevention guidelines are made for screening programs in similar populations, and for the need to increase community awareness concerning this issue.

After defining the respective indications for the various knee prostheses: single-compartment, three-compartment sliding and hinge prostheses, essentially based on the preoperative radiological assessment, the authors emphasise the value of such films in operative planning. They then describe the radiological criteria of correct implantation of the three different types of prosthesis. Lastly, they stress the value of regular radiological follow-up of these arthroplasties looking for possible complications such as instability, loosening, wear and infection, which may alter the patient's osteoligamentous capital and his functional prognosis.

Isolated injuries of the scapho-trapezial ligament complex are not well recognized. The ligament complex comprises the stout scapho-trapezial ligament, the floor of the flexor carpi radialis (FCR) tendon sheath and the scapho-capitate ligament. Between August 1991 and May 1992, we diagnosed and treated four cases of partial chronic post-traumatic lesions of this ligament complex. There was chronic pain at the base of the thenar eminence and instability of the thumb-index-middle finger pinch. Standard X-rays were normal. The diagnosis of ligament rupture was confirmed by mid-carpal arthrography showing filling of the sheath of FCR tendon. Surgical exploration showed complete rupture of the tendon sheath of FCR in two cases, associated in the other two cases with complete rupture of the scaphotrapezial ligament. Direct repair of the ligamentous elements was performed in all cases. The tendon of FCR was sutured to the tubercle of scaphoid to protect and to reinforce the ligament repair. The patients have been followed-up for between 6 and 12 months. All four patients recovered normal pinch strength to the middle finger. One patient suffered from chronic pain at work.

With reference to a series of thirty synovectomies of the wrist in patients with rheumatoid arthritis, the authors report the results observed after an average interval of three years and six months. There was a remarkable reduction in pain in three-quarters of the cases. On the other hand, loss of mobility was noted in 15 patients. Resection of the cubital head was carried out in half of the cases. This was followed in two cases by internal translocation of the carpus, and in three cases by internal translocation combined with cubital inclination of the hand. The results of the tenddon repairs carried out in six patients have been completely satisfactory. A study of the present cases and of data from the literature confirms the local prophylactic value of tenosynovectomy which may also prevent tendon ruptures. The best result are seen in the less evolutive forms in which the risk of relapse is least, and in cases in which surgery is carried out on stable wrists with cartilage showing little alteration. In the presence of inferior radiocubital arthritis the resection must be systematic as it makes it possible to carry out a complete synovectomy of this joint. The authors compare the value of surgical synovectomy of the wrist with that of radioactive synoviorthesis.

A better knowledge of the leg skin blood supply has recently revived interest in the cross-leg technique for skin grafts. It is now possible to delineate on each leg two flaps that contain arteries and veins. The internal saphenous flap, taken on the internal aspect of the leg is fed by the cutaneous branch of the greater anastomotic artery, satellite of the internal saphenous nerve, while the external saphenous flap, located on the postero-external aspect of the leg, is fed by 2 cutaneous branches of the popliteal artery or gemellar arteries. The length to width ratio of these flaps varies from 3 to 4, which is both safe and reliable and provides for supple handling of the pedicles and increased patient's comfort.

A 9-year-old girl had apparent recurrence of rheumatic fever while receiving monthly benzathine penicillin injections. A review of pharmacokinetc studies on the subject suggests that this is a real risk. A need for review of the current recommendations for rheumatic fever prophylaxis is suggested.

The authors report a case of haemorrhage due to cephalexin therapy. The bleeding started after an orthopedic operation in a patient without renal failure, receiving 3 g/day of cephalexin. Platelet function was very abnormal at the time of the haemorrhage with a bleeding time of over 20 minutes, which returned to normal when treatment was stopped. This case seems to be similar to other reports of haemorrhages during treatment with other beta-lactams.

This study reviewed 6 cases of post-traumatic dislocation of the superior tibia-fibular joint. It was associated 5 times over six to a tibial fracture or major ligament lesion of the knee. The authors have made a review of the literature on this rare injury. The purpose of this paper is to insist on the necessity of an early diagnosis allowing a simple treatment and good results.

A case of volar dislocation involving the four ulnar metacarpals treated by open reduction and fixation with Kirschner wires is reported. A review of the literature leads the authors to suggest several pathogenic hypotheses. The mechanism may be direct or indirect according to whether the trauma is sustained on the metacarpal heads or on the bases of the metacarpals. Emergency treatment by open reduction and fixation usually provides excellent results.

The authors have treated 105 articular fractures of the calcaneum. Three methods were tested: open reduction and fixation, conservative treatment with early mobilization, primary subtalar arthrodesis. The final results were satisfactory in 85% of the cases. However the three above groups were hardly comparable. Details on the radiological study of these fractures are given. The authors conclude that when osteosynthesis obtained a perfect anatomical reduction, functional results were good. But perfect reduction was rarely obtained. Final results could be improved by a better selection of the surgical cases and a better surgical technique.

Eschars located in the sacral and ischiatic areas raise problems of recovering when much tissue has been lost. The usual techniques, such as dermoepidermal grafts or local skin flaps, are difficult to perform and have a high failure rate. In contrast, musculo-cutaneous flaps are excellent both to fill and to cover the raw areas. Three types of flap have been used successfully by the authors in 12 consecutive patients, some of whom had paraplegia. Two of them involve the greatest gluteal muscle which is divided into two heads according to blood supply. The "butterfly" flap uses the upper heads of the two muscles, on either side of the midline, with the corresponding skin territories ; it is most useful to cover wide sacral areas. In the "pendular" flap, the lower head of one of the greatest gluteal muscles is mobilized to cover a moderate loss of tissue in the ischiatic area. Finally, the "kite" flap concept is based on bringing up the ischio-crural muscles to cover wide ischiatic eschars.

A number of techniques have been developed to prevent or treat painful neuromas in the hand. Intra-osseous implantation of the ends of the nerves, as described by Boldrey in 1943, has only been extensively applied over recent years. Between 1977 and 1983, we used this technique to treat twenty eight cases of painful neuromas in a group of twenty patients. All but two of the patients were permanently improved and the best results were obtained in neuromas of the anterior branch of the radial nerve.