Abstract: Introduction Distal metatarsal osteotomies have been described for surgical treatment of hallux valgus with good results. The aim of this study is to review the results of 299 consecutive hallux valgus cases treated by minimally invasive distal metatarsal osteotomy, S.E.R.I. (Simple, Effective, Rapid, Inexpensive).

Abstract: Background Hemi-and total-replacement of the first metatarsophalangeal joint (MTP1) remains controversial due to failures observed in earlier decades. The TOEFIT-PLUS™ system was developed in part to address these earlier failures, but published reports investigating its use have been limited.

Abstract: With reference to the data reported in the literature and to the anatomical vascular basis, the authors expose different techniques and maneuvers used for dissection of gastrocnemius flaps. The use of muscular and myocutaneous gastrocnemius flaps and some modifications of the standard surgical technique aiming to gain more versatility are described. So that, the range of these flaps can be planned to cover the greatest part of the lower extremity of the leg.

Abstract: The scarf osteotomy is now well recognised as reliable and effective to contribute to the correction of the majority of hallux valgus. The challenge remains for the correction of severe deformities with metatarsus varus angle >18° and Distal Metatarsal Articular Angle (DMAA) >15°. In order to significantly improve in 3D the metatarsal head displacements, our scarf design became more oblique, shorter and if necessary a medial wedge removal from the plantar fragment was done to supinate the head. And gradually, with the amount of the horizontal translation, there was no space left for any screw. A bone cerclage with an absorbable suture in order to obtain distally a constrained fixation, and proximally an impacted autologus bone grafting (distal wedge of the dorsal M1 fragment) have been done. The immediate weight-bearing ambulation allowed with always a sole of total contact cast for two weeks (only this method is able to decrease the weight on the foot <20 Mpa), followed by post-operative shoe wearing for a month, have not been changed. The M1P1 angle, the M1M2 angle and the DMAA angle had been measured after bone fusion on a weight-bearing dorsoplantar X-ray, on the different series of moderate and severe hallux valgus. Results: For the two screws series (1993–1995) 49 cases: M1P1 = 12.67° +−7.22°, M1M2 = 7.93° +− 2.61°, DMAA = 13.5° =− 4.5°. For the one screw series (1996–1998) 37 cases: M1P1 =13.11°+− 6.67°, M1M2 = 7.44°=−2.51°, DMAA= 6.89°+−4.27°. For the “no screw series” (since 1999) 33 cases: M1P1 = 7.07° +− 4.84°, M1M2 = 6.51° +− 2.36°, DMAA = 7° +− 3.8°. It appears that the correction is better without screw fixation, especially for M1P1 and M1M2 angles.

Abstract: In the literature, there is no consensus on the value of uncoated cementless femoral stems. We asked whether the results obtained with a grit-blasted titanium surface would prove the usefulness of this implant at an intermediate follow-up time. Three hundred and sixty five patients (376 hips) underwent primary total hip arthroplasty (THA) using the SL-Plus stem in combination with a ceramic-PE articulation. At a minimum follow-up time of 10.0 years (mean 10.2 years; range, 10.0 to 12.6 years), 229 stems (60.9%) were available for analysis. Five revisions were performed, one because of low-grade infection, one because of an aseptic loosening, another one because of a traumatic subsidence and two because of periprosthetic fractures. The 10-year survivorship with revision for any reason as event of interest was 98.3% (95% CI: 96.0%–99.3%). Radiologically two stems were diagnosed to be loosened at follow-up. Osteolytic lesions were detected in 5 patients. The implant survivorship with revision and radiographic sign of loosening as event of interest was 95.7% (95% CI: 89.0%–98.4%) at the time of maximum follow-up (12.6 years). Radiolucent lines (RLs) occurred in 27.9% mostly in positions 1 and 7. In the age group less than 70 years of age, 35% were found to show RLs, in the age group older than 70 years of age only 12.5% showed RLs. The five patients with osteolytic lesions were all from the age group ≤ 70 years. These intermediate results document that primary implants with a grit-blasted titanium surface ensure an excellent intermediate-term outcome clinically and with regards to the survival rate. It also confirms our approach not to accept any age limits for selecting patients for cementless THAs. A prospective study will have to show whether additional hydroxyapatite (HA)-coating can improve the radiologic outcome.

Abstract: The concept of dual mobility cup has been developed to associate the advantages of the low friction total hip arthroplasty with those of large femoral head diameter, with the goal of preventing the dislocations. In this study, 100 primary THA and 34 revision THA with the use of dual mobility cup were analyzed clinically and radiological over a period of fellow up of ten years. It appears that the dual mobility cup is effective against dislocation. Any concerns regarding the survival of this type of prosthesis can be relativized. Literature datas indicate that mean total volumetric wear is of the same order as that reported for Charnley prosthesis with a head of 22,2 mm. However, uncertainty regarding the problem of intraprosthetic dislocation did persist.

Abstract: The correction of hallux valgus has been dramatically improved by the scarf 1st metatarsal osteotomy, which brings great versatility for covering all the indications Its strong fixation allows an early functional recovery; the long-term follow-up confirms the reliability of this procedure, which can be combined with other osteotomies and soft tissue procedures However, the surgeon has to determine pre and intraoperatively the correction that has to be applied; this technique is not difficult but has to be performed accurately This is the interest of this article, which emphasizes the technical features that have to be applied

Abstract: The present paper provides a review of the properties of UHMWPE for total joint replacement and of some key features of its technology. The first paragraphs describe the basic physical and chemical properties of UHMWPE, as well as the main processing and sterilisation methods. The following paragraphs are devoted to the chemical processes that lead to oxidative degradation of the polymer, to its practical outcomes and to the contemporary strategies of packaging which aim to minimize this drawback. Finally, the causes and the effects of wear and debris production are examined and, in the last sections, recent advances and future developments in crosslinking and stabilization are briefly described.

Abstract: Once routinely used, trochanteric osteotomy in total hip arthroplasty now is usually limited to difficult primary and revision cases. Many variations of the osteotomy and many various techniques for the trochanter reattachment have been described. Our specific surgical technique is presented as well as its advantages and drawbacks. Primary total hip arthroplasty procedures requiring the enhanced exposure provided by trochanteric osteotomy is needed in patients with hip ankylosis or fusion, protrusio acetabuli, proximal femoral deformities, developmental dysplasia, or abductor muscle laxity. Trochanteric osteotomy, in revision arthroplasties, facilitates the removal of well-fixed femoral components and enhance acetabular exposure. In all cases trochanteric osteotomy remains useful to preserve the periarticular muscles and restore the geometry of the artificial hip which are the best ways to prevent dislocation.

Abstract: The second generation of metal-on-metal prostheses appeared at the end of the 1980’s as a serious alternative to metal on polyethylene bearing couples. Short-term clinical results were promising; however certain questions remain concerning clinical, radiological and biological aspects. Release of chromium and cobalt from the bearing couple is one of these aspects. The aim of this study is to analyse the results of a series of 97 cemented total hip prostheses comprising a titanium femoral stem and the Metasul® metal-metal bearing couple. Mean follow-up was nine years (7–12 years). Complications were marked by 12 revisions, out of which two were for recurrent early dislocations, eight for clinical and radiological failure, and two for worrying radiological alterations. During these revisions, we observed a serious infiltration of metal debris four times, leading to an alternative strategy using an alumina-alumina bearing couple. Three more revisions are planned for rapidly evolving radiological alterations. Thirty implants showed radiological signs of preoccupying deterioration on the acetabular side. Eight segmentary femoral osteolysis have been observed. Twelve patients suffer from recurrent subluxation. Concerning the global evolution of metal serum levels, cobalt remains stable after five years. The values are three to four times above those of a non-exposed subject, but largely below toxic ratios. The evolution of serum chromium levels is similar to cobalt. Implantation of two prostheses in one same patient leads to significant increase in serum metal ratios. This series raises questions concerning the reliability of the metal-on-metal bearing couple. Osteolysis is an unsolved problem. Today, cemented fixation is debatable although this series doesn’t allow this parameter to be held directly responsible. Nothing points to any shortcomings concerning the taper fixation or the metallurgy of the femoral stem. The study of the serum metal levels seems a good indicator of the impingement situations and the functioning of the bearing couple.

Abstract: A renewal of interest occurred for surgical approaches to implant hip prostheses after the emergence of the concept of Minimal Invasive Surgery (MIS), making muscle and soft tissue sparing a major issue. Each surgical approach may be abridged to spare soft tissue and to improve rehabilitation. However, in this point of view, each approach reveal drawbacks in terms of installation, instrumentation, intraoperative ROM testing as well as extension in the event of intraoperative complications. The goal of this paper was to report an objective and careful assessment of advantages and concerns regarding each approach promoted by experts. The six most common approaches used in France (anterior, posterior, Watson-Jones supine and lateral, lateral with hemimyotomy or transtrochanteric) performed by experts were assessed to deal with specific problems. Clinical charts and X-rays of 15 patients, representing complex situations, were submitted independently to the six experts. This selection was designed to assess the ability for each approach to deal with specific issues. The less invasive is the approach, the less is the ability to adapt to complex situations (femoral deformity, stiffness, removal of femoral or acetabular fixation devices). The anterior and anterolateral are the less invasive because they use intermuscular intervals, but these approaches do not allow an easy extension and/or produce limited access to the proximal femur and the pelvic bone. The lateral and posterolateral approaches are more invasive but they allow versatility regarding correction of femoral deformity, extensive acetabular access to insert cages or to remove previous fixation devices. It is difficult to recommend one hip surgical approach; none has proven its superiority in controlled studies. Admittedly, the anatomical studies formally show the less invasive character of certain hip approaches. However, these latter have drawbacks that can limit the utilisation and/or the diffusion to all the centers. The conclusions of this expert meeting result rather from individual experiences and must be interpreted with prudence.

Abstract: The osteotomy of the first phalanx of the great toe has been described by Akin as early as in 1925. Since that time this technique and its modifications have been widely in clinical use and were mostly described as additional correction manoeuvre combined with standard metatarsal osteotomies like scarf or chevron osteotomies. As the so-called Akin osteotomy mostly is used as a surplus procedure scientific evaluation of this osteotomy itself can rarely be found. Different fixation techniques like k-wire-, wire, staple-thermo-staple-or screw-fixations are in use. The result are the follow up of 135 patients out of more than 200 operated patients treated with forefoot realignemant procedure because of hallux valgus with a follow up of at least 1 year.

Abstract: The anterolateral approach to the hip, described in 1936 by Sir Watson Jones, still is in current use when implanting THA. This mini-invasive approach, in which neither muscle nor tendon is divided, is developed using the space between the gluteus medius and the tensor fascia lata. The surgical technique is described in the supine position, using a special skin incision and personal modifications in order to preserve the abductor muscles. The use of special reamers and the lowering of the legs allow easy preparation of the femur and constant preservation of the gluteus medius and the superior gluteal nerve. Advantages claimed for this approach in the supine position are an accurate positioning of the cup, a very low rate of dislocation, low vascular or neurological risks and a low rate of deep veinous thrombosis. The complications, indications and limitations of such an innovative technique are also evoqued here.

Abstract: Described in 1981 by the Chinese authors Yang Kuofan et al. [1] as a free flap, then in 1982 by Lu et al. [2] as a retrograde flow pedicle flap, this fasciocutaneous flap is designed at the level of the anterior and external faces of the forearm, and vascularized by the radial artery via a network of septal arteries. Prior to utilization it must be reversed on its distal pedicle. This flap allows repairing cutaneous substance loss of the whole hand and fingers. The emergence of the Chinese flap in the 1980’s resulted in a regression of the Mac Gregor groin flap that was widely used at this time [3,4]. Nevertheless, other forearm flaps, less “expensive” in terms of vascular involvement [5–9] have reduced its indications. The Chinese flap however keeps two essential indications: the multi-finger important defect that no other forearmflapmay cover; and composite substance loss of the thumb (despite the fact that the Chinese flap shares these indications with interosseous artery composite flaps).

Abstract: The latissimus dorsi muscle is the largest muscle in the body, measuring up to 20 × 40 cm. The latissimus dorsi muscle is the largest single transplantable block of vascularised tissue allowing coverage of larger wounds. It is one of the most versatile free musculocutaneus flaps available. Its size allows it to be used to cover defects of great magnitude. The ability to tailor and trim the muscle, taking only the size required, dramatically increases its versatility. The muscle is extremelymalleable andmay be folded, turned, rolled under and stuffed into cavities and wounds of all sizes and shapes with cut component [1].

Abstract: The approach of the hip joint by an anterior hemimyotomy (AHM) of the gluteus medius was developed by J.M. Thomine and has been used since 1983 on 10,000 patients. This approach is based on the section of the anterior part of this muscle along the anterior edge of the greater trochanter. The potential inconvenience of this section is to weaken the muscular abductor system. Some experimental studies were led in order to evaluate the functional consequences of this muscular section. The abductor strength was measured with a dynamometer on 37 patients operated on a single hip. No significant difference existed after two years, between the operated hip and the normal hip. Out of 30 patients operated upon, on one side only, a post-operative study was performed relating to walking with the movement analysis device VICON. It showed a Trendelenburg sign, which was underlined with an average of 6° in the third month, but no significant difference was found between the two sides after a whole year. This transgluteal method also constitutes a risk for postoperative ossifications. We have studied this risk on a total of 65 patients operated on over two years ago for a total hip arthroplasty (THA) following primitive osteoarthritis articular destruction; 37% had no ossification, 43% had Brooker 1, and 20% had Brooker 2. No worse ossifications were detected and their functional implications were not significant using the Merle d’Aubigne evaluation (the average score being 17.85, 17.76 and 17.58). The implant position together with the good feedback from the preoperative plans, demonstrated that this approach authorised a sufficient exposure and low bleeding (on average 400 g) for primary arthroplasty. Finally, an on-going prospective study of 212 prosthetic hips showed that the dislocation rate was inferior to 0.5% in the two postoperative years.

Abstract: The mini invasive corrective surgery of static disorders of the forefoot is an undisputable progress because of its decreased morbidity with a simplified functional postoperative follow-up. These indications have been limited for a long time to mild deformities due to the creation of simple basi-metatarsal osteotomies or sub capital osteotomies of the first metatarsal thus limiting a more generalised application of these techniques in the more compound feet conditions. The combination of these two osteotomies allows to envisage the reaxation of major deformity but they can also apply in cases of mild or moderate deformities with additional metatarsus varus and angular deviation of the de metatarsal head with a DMAA >6°. The application of this double osteotomy is however delicate if one complies with the very principle of the mini invasive surgery which aims at preserving the possibility to return to an immediate postoperative weight-bearing on the forefoot with a final simple setting of the corrections by a strapping bandage, thus excluding any osteosynthesis. The risk to have a “floating” bone segment is high between the two osteotomies, with a secondary fracture deformity and a loss of the correction. To avoid these hurdles, we complied with a precise surgical timing, and with some technical rules, which allowed us to achieve the final expected result.

Abstract: A mini-invasive surgery implies a diminution of the morbidity of the surgical procedure, which relies on three conditions: not only a reduction of the skin incision, but also a limited dissection applied to the approach and the preparation, and a surgical step resulting in as little bleeding, debris, heat and fibrosis as possible. The recent, rapid and varied evolution of the mini-invasive techniques, concerns all the surgical disciplines, and reflects the technical progress, the very prevailing concern for morbidity risk, competition and fashion phenomena. However, this evolution also attests to the excellence of the surgical techniques. In the surgery of the hallux valgus, we are less focused, on the correction methods, which are now reliable, and our main concern for perfection is centered on the reduction of the approaches. The technique we are reporting is only one of the possible procedures of mini-invasive surgery of the hallux valgus.

Abstract: To avoid cement stem debonding of the Charnley prosthesis, I modified in 1972 the geometry of this prosthesis to subject the cement only to stresses it can resist and protect it against harmful stresses. This was done by giving the stem such a shape that the stresses within the cement would be decreased to a level consistent with its physical properties. On the acetabular size, there has been no modification of the Charnley acetabular component, I only specified how to prepare the acetabulum and implant the socket in order to make it in mechanical harmony with the bone cavity.

Abstract: Assessment of possible low-wear with some former metal-on-metal (MoM) total hip arthroplasties (THA) led to the reintroduction of metallic bearings in the late 80’s. The author reports on two studies of Metasul-28 mm cementless THA. In the first one in a general population, impingement has been the main cause of osteolysis and Co level survey has been a good indicator of Metasul bearing behaviour. In the second study, in a group of 83 less than 50-year-old and active patients, Metasul bearings showed good wear resistance at 7.2 years mean follow-up. In both studies, no general toxic effect could have been detected thus far. According to the current knowledge, it is always reasonable to expect low-wear and better THA longevity with use of MoM bearings under the following conditions: 1) use of a CoCr alloy with high carbide concentration; 2) reduce impingement risk (head without sleeve, slimmer as possible neck, perfectly adapted Morse cone from the same manufacturer, well — oriented components); and 3) prefer cementless acetabular fixation.

Abstract: The lateral arm flap is a versatile fasciocutaneous flap that may be used locally on the upper extremity or as a microvascular free flap. Since the flap’s description by Song et al. in 1982 [1], its ease of harvesting and the constancy of its vascular pedicle have made the lateral arm free flap an important component in the armamentarium of hand and reconstructive surgeons. The ability to harvest this flap in the same operative field as the recipient defect on the same upper extremity is a major asset in hand surgery.

Abstract: The sandwich operation in the surgical cure of the hallux valgus is an original technique. This evolution sprang from the limitations of the Petersen operation. It consists in a conservative arthroplasty of the 1st phalanx of the great toe combined with the Petersen technique. It allows three spatial modifications of the great toe deformity: a shortening, a rotation and a varisation.

Abstract: The fixation of the acetabular component remains — even today — the “weakest link” of a total hip prosthesis. The long-term performances of a prosthetic implant depend on several parameters of very different natures. Although in the last ten years emphasis has been put on new sets of problems — especially the bearing couple wear rate — one should neither forget nor underestimate the major contribution to longevity provided by the nature and quality of the bone-implant interface taken into account almost 20 years ago owing to HA-coatings. It is clear that until now, HA-coatings have given lesser performance in the cups than in the stems, as demostrated by survival rates that are significantly lower.

Abstract: Hydroxyapatite (HA) coating is not a sine qua non condition to achieve long-lasting acetabular cup fixation on the acetabular side of cementless primary THA, where HA acts only as an adjuvant for early osteo-integration, but is not a guarantee for a long-lasting bone-implant anchorage. Of a series of 633 Alloclassic-CSF grit blasted and non-HA-coated titanium threaded cups, ten only were revised for all causes (five for infection) with no aseptic loosening. Thirteen-year survivorship with acetabular cup revision for any reason and aseptic loosening as end point was 98% (95% confidence interval, 86.9–99.7%) and 100% (90.4–100%), respectively. Failure of non-smooth cementless acetabular components might not be related to unability to achieve secure early osteo-integration, but to the difficulty to maintain it with time, either due to: 1) poor liner locking mechanism; 2) conventional PE wear; or mainly 3) to acetabular bone stress shielding that could weaken the supporting bone at longer follow-up. None of these three factors can be addressed by HA coating. In fact, better strain distribution to the acetabular bone to prevent stress shielding osteopenia and the bearing materials really matter.

Abstract: Pure alumina ceramic has been, in clinical, used in orthopaedics since 1971 and currently up to five million components have been implanted. Alumina offers advantages like stability, biocompatibility and low wear, however it has limited strength. Applications are limited by design considerations. Engineers in biomaterials have worked on improving the performances of the material by optimising the manufacturing process. To fulfil surgeons and patients increasingly exacting requirements, ceramists have also developed a new ceramic composite, the alumina matrix composite (AMC). This material combines the great principles of reinforcement of ceramics with its tribological qualities and presents a better mechanical resistance than alumina. The examination of the tribological situation of AMC, especially under challenging condition of hydrothermal ageing, shows the aptitude of this material in wear applications. The US Food and Drug Administration has approved the ceramic ball heads articulating against polyethylene inserts. Since its introduction, more than 65,000 ball heads and 40,000 inserts of the Alumina Matrix Composite have been implanted. With a six-year clinical experience, no complication has been reported to the manufacturer. Improved toughness and the excellent wear, makes it a potentially more flexible alternative to the more traditional alumina for hip prostheses.

Abstract: Numerous surgical techniques have been proposed for the surgical treatment of hallux valgus. Some of them only concern soft tissues; others combine a surgery on the soft tissues with a procedure on the bone structures. The technique we present combines a basimetatarsal valgization by subtractive external osteotomy with a wide metatarso-phalangeal freeing. The basimetatarsal osteotomy allows to correct the deformities in the three planes of space. The basi phalangeal osteotomy is not systematic but is proposed in case of severe hallux valgus, superior to 45° or in case of hallomegalia (gigantism of hallux).

Abstract: Some patients with grossly deficient soft-tissue attachments or neurologic impairment are often submitted to recurrent dislocation after total hip arthroplasty. This multifactorial complication is difficult to treat. For theses indications, we have developed a cemented constrained cup using a mobile retentive ring in a groove bellows the head equatorial plane. According to a retrospective series of 113 patients (40 for revision surgery and 73 for primary surgery) with 33.7 months of average clinical follow-up, we use this retentive cup to restore and maintain hip stability. This preliminary study needs to be continued for a longer period in order to obtain further information on development of radiolucent lines.

Abstract: Losses of skin substance of the dorsal face of the hand occasionally justify resorting to cover flaps when the noble elements (bones, tendons) are whether damaged or exposed. Few flaps allow filling in these losses of substance. Among those, which do, posterior interosseous reverse flap is indicated in some cases. We will present the technique and the main indications for the posterior interosseous flap. It is an island flap receiving reverse-flow vascularisation by the posterior interosseous artery. This flap is harvested from the second proximal quarter of a line extending from the lateral epicondyle of humerus to the ulnar head. The antebrachial fascia is incised longitudinally on the ulnar extensor of wrist and digiti minimi. The cutaneous flap is raised from radial to ulnar while sectioning the different intermuscular septa. Only the septum dividing the digiti minimi and ulnar extensor of wrist is preserved because it contains the pedicle. Once the main pedicle is identified, the skin paddle can be raised from proximal to distal. Then the septum holding the pedicle is detached from the ulna through to the distal radio-ulnar articulation, level with the bone surface. This flap is appropriate for losses of skin substance of the dorsal face of the hand extending to the first phalanxes and the first commissure. It can also be used to cover the anterior face of the wrist and is perfectly suited for retraction of the first commissure. Contrarily to the Chinese and ulnar flaps, it does not cause any damage to any significant arterial axis. Its main drawback is the scar on the donor site, which is often unsightly, while in the child; direct closure is possible in most cases.

Abstract: The arthrodesis of the metatarso-phalangeal joint of the hallux remains a reliable method in the treatment of the severe deformities caused by rheumatoid affection, recurrences of hallux valgus, iatrogenic varus and arthrosic hallux valgus (hallux rigidus). This operation is not crippling since the talocrural and interpahalangeal joints are preserved. The technique using a set of concentric drills allows a better positioning of the great toe, however it seems to generate a higher partial fusion rate but without repercussions on the final functional result. The metatarso-phalangeal arthrodesis of the great toe is a tried-and-tested method described by Groulier et al. [1]. A certain number of studies, mostly Anglo-Saxon, report it as early as the end of last century. Its merits have been gradually emphasized for the revisions or to treat the severe deformities of the great toe, either with arthrosis complications, painful stiffening or metatarsalgiae. The arthrodesis of the metatarso-phalangeal of the hallux was first stated in 1894 as a successful treatment, achieving good and stable results in case of severe hallux valgus. Varied techniques of arthrodesis of the metatarso-phalangeal of the hallux have been described and 60 different types have been listed.