Biomedical subjects
D Goutallier
Publications and source records attributed to D Goutallier.
[Replacement of infected total hip prosthesis in two stages].
Since 1975 we have treated 36 infected hip replacements by a two stage procedure in which the prosthesis and cement were first removed. Gentamicin impregnated beads were left at the sites of the prosthesis. Not less than 45 days later a fresh prosthesis was inserted into the hip. In two hips revision was not undertaken because of persistence of infection. The remaining 34 hips received a fresh prosthesis when the site was bacteriologically sterile. Gentamicin impregnated cement was used and antibiotics were given for a further three months. The functional results were satisfactory at an average of five years of follow up. Incomplete removal of methylmethacrylate was a factor in the persistence of infection and of pain in the absence of infection. The bacteriological efficacy of Gentamicin impregnated beads is uncertain, but their use gave a better functional result.
Reconstruction of compound tibial and soft tissue loss using a traction histogenesis technique.
We used simultaneous bone and soft tissue transport for reconstruction of large compound tissue loss in the lower leg. We report the results and complications of a 12-patient series. The average age of the patients was 31.2 years (range 20 to 48 years). Seven patients had grade IIIB open tibial fractures, three had complications after grade II or IIIA, and two had an en-bloc resection of bone, muscle, and skin for a malignant bone tumor. Arteriography was routinely performed, and demonstrated at least one patent tibial artery. Every patient had normal sensibility of the sole. The first stage of the reconstruction was an aggressive excision of the all necrotic skin, muscle, and bone. The Ilizarov external fixator was applied and wires were secured under a tension of 100 kg, using a dynamometric tensioner. Cutaneous tissue loss was not replaced in 10 patients, when the bone was not exposed. A medial gastrocnemius flap was performed in two patients and lengthened with the bone. Corticotomy was performed 15 days after the first stage with careful respect for the periosteum. Distraction was initiated 15 days after the corticotomy. The average bone defect was 12.5 cm after initial excision. An average of 9 operative procedures and 18 months of treatment were required before bony union. The mean duration of bone transport was 6.5 months, and the mean duration of external fixation was 12 months. The final functional results were fair and only two patients returned to work. One patient had a below-knee amputation after 10 months of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
Fatty infiltration of disrupted rotator cuff muscles.
The extent of fatty infiltration of rotator cuff muscles was evaluated on computed tomography displays using a five-point scoring system in 63 shoulders before surgery for a rotator cuff tear and in 57 of these shoulders after surgical repair of the tear (the quality of cuff repair was evaluated in these 57 shoulders by arthrography, usually coupled with computed tomography, after a mean time interval of 8 months since the procedure). Preoperatively, significant fatty infiltration of the supraspinatus muscle was uncommon. Severe fatty infiltration of the infraspinatus and subscapularis muscles was seen in some patients. In most instances, fat accumulated in those muscles whose tendons were torn; however, tendon cleavage was associated with mild fatty infiltration of the corresponding muscle in some instances, and wide tears of the supraspinatus and subscapularis muscles were sometimes accompanied with severe fatty infiltration of the infraspinatus muscle. In half the cases, fatty degenerescence of the infraspinatus muscle occurred within six months of the tendon rupture. After surgery, in most shoulders without evidence of rotator cuff leakage on the postoperative arthrogram, no further accumulation of fat occurred. However, a decrease in the amount of existing fat was rarely documented and occurred only in the supraspinatus muscle. Before and after surgery, increasing severity of the fatty infiltration of the infraspinatus muscle was associated with increasing functional impairment of the same muscle. Recurrent rotator cuff tears, which involved only the supraspinatus muscle, were considerably more common when there was severe preoperative fatty infiltration of the infraspinatus muscle.(ABSTRACT TRUNCATED AT 250 WORDS)
Destructive arthropathy of the hands in chronic hemodialysis patients. A report of seven cases with pathological documentation.
Destructive arthropathy of the hands is common in chronic hemodialysis patients. The clinical and histological features in seven cases are reported. There were five females and two males aged 45 to 78 years. Hemodialysis duration at the time of surgery was 48 to 228 months (mean 92 months). Four patients had arthrodesis, two had insertion of silastic implants and one had a diagnostic surgical biopsy. The site of the surgical procedure was a distal interphalangeal joint in three patients, a proximal interphalangeal joint in one, a trapeziometacarpal joint in two, and both a proximal and a distal interphalangeal joints in one. All seven patients had severe destructive arthropathy responsible for pain and instability. Roentgenograms showed joint space obliteration and subchondral erosions or lysis, without osteophytosis. Several finger joints were involved in six of the seven patients. Histologic studies of the synovial membrane (n = 7) and subchondral bone (n = 4) found no amyloid even in the three patients with clinical or roentgenographic evidence of amyloidosis at other sites. Electron microscopy studies were done in two patients and failed to disclose crystals or amyloid. Our findings demonstrate that destructive arthropathy of the hands in hemodialysis patients is not a manifestation of dialysis-related amyloidosis. The pathophysiology of the condition remains poorly understood.
Fracture of the distal radius. A prospective comparison between trans-styloid and Kapandji fixations.
We performed a prospective study on 96 patients with extra-articular or intra-articular fractures of the distal radius with a dorsally displaced posteromedial fragment. After closed reduction, we compared trans-styloid fixation and immobilisation with Kapandji fixation and early mobilisation. Forty-two patients of mean age 57.1 years +/- 18.1 (SD) were treated by trans-styloid K-wire fixation and 45 days of short-arm cast immobilisation. Fifty-four patients of mean age 57.7 years +/- 18.7 (SD) had Kapandji fixation and immediate mobilisation according to the originator. All the patients had clinical and radiological review at about six weeks and at 3, 6, 12 and 24 months after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, radial tilt, ulnar variance, and radial shortening were assessed radiologically. Statistical analysis was applied to comparisons with the normal opposite wrist. Pain and reflex sympathetic dystrophy were more frequent after Kapandji fixation and early mobilisation, but the range of motion was better although this became statistically insignificant after six weeks. The radiological reduction was better soon after Kapandji fixation, but there was some loss of reduction and increased radial shortening during the first three postoperative months. The clinical result at two years was similar in both groups.
[Clinical and radiographic results of a continuous series of 124 type Ceraver-Osteal hip prostheses with a 9-year survival analysis].
INTRODUCTION: Since 1979, we have been using a model of cemented total hip arthroplasty (THA) with a titanium femoral stem, a 32 mm femoral head, and for some cases an alumina on alumina browing combination. We tried to appreciate the results of these different modifications with a sufficient follow-up. MATERIALS AND METHODS: Among the 124 THA, 63 sockets were made of alumina, 61 of polyethylen, 22 patients had deceased and 23 were lost for follow-up before seven years, we studied 72 THA followed between 7 and 9 years up. The cementing technique was not modified. The clinical evaluation was done using the Merle d'Aubigné-Postel hip rating scale the radiographic analysis was conducted for 79 hips. RESULTS: After 9 years 8 cups had been removed for loosening, 2 hips were operated for infection, the global survivorship without a new operation was then 88.73 per cent. Among all hips, 80 per cent were clinically rated as "fair" or better. We noticed 8 migrations among the alumina cups and 6 among those made of polyethylene. Among the 31 polyethylene cups, there were 25 lucencies between bone and cement (18 < 1 mm). Among the 48 alumina cups there were 22 lucencies just between bone and cement and 21 between cup and cement and also between bone and cement (double lucencie). The lucencies between cup and cement were more often in the lower third of the cup and 7 of the 8 migrations had double lucencies. Forty-nine percent of the femoral stems had lucencies, 40 per cent in the proximal zones. But there was just one femoral subsidence associated with the lowest distal femoral filling. So just considering the femoral subsidence the survivorship was 98.79 per cent. DISCUSSION: The clinical results of this series were as good as the more recent series. Because of the difference of radiographical aspect between the polyethylene and alumina cups, the high rate of lucencies and migration could have been interpreted as two different mechanisms. For polyethylene cups, the 32 mm femoral head is frequently associated with this complication, as it was already described in other series. For the alumina, the difference of elasticity between bone and cement should have been the principal responsible. As we considered just the migration of the stem, and although the cementing technique was simple, our rate of femoral loosening was as low as in the more recent series. The frequent proximal lucencies should may be not be considered as loosening but as consequence of the elasticity of titanium. The distal fixation obtained by a good distal femoral filling seemed to be the more important point. CONCLUSION: To reduce the acetabular loosening rate we use now a head of 28 mm for the metal on polyethylene combination, the alumina cup has been abandoned and the alumina on polyethylene combination should still be assessed. The encouraging femoral results, due to the good femoral filling and to the titanium elasticity needs to be confirmed after a longer follow-up.
[Reduction and osteosynthesis of displaced fractures of the distal third of the fifth metacarpal with central medullary bone wires].
We conducted a retrospective study of 80 patients who underwent axial K-wire osteosynthesis for a fracture of the distal third of the fifth metacarpal over an eight year period. We used a technique derived from Foucher's technique. After closed reduction, the fracture was maintained with two or three distal smoothed curved intra-medullary axial K-wires. The final functional result was identical to the opposite side in every case, although with persistent palmar tilt of 14 degrees +/- 11 degrees. The complications were rare. Rotation displacement was always well controlled. In comparison with functional treatment, we recommend this technique in cases of rotation displacement, absence of contact between the fractured ends and marked palmar tilt of the distal fragment.
[Recurvatum in arthritic genu valgum. Contraindication for osteotomy and unicompartmental prosthesis].
Nine lateral gonarthroses were accompanied by a preoperative recurvatum. The recurvatum of arthritic origin is rare. It appears only at a late stage of the arthritis evolution in the genu valgum. Considering the series results, it constitutes a contraindication to the treatment by osteotomy or by unicompartmental prosthesis.
[Treatment of metastases of thoracic and lumbar vertebrae with predominant corporeal involvement by osteotomy of the vertebral body and anterior approach with cement and screwed plate].
Forty-seven patients with predominant corporeal thoracic, thoraco-lumbar or lumbar vertebral metastases were treated surgically by corporectomy. The vertebral body was replaced by acrylic cement sustained by a vertebral U shaped plate screwed to the adjacent vertebral bodies: this corporectomy was completed in 17 cases by a posterior approach. In 9 cases it allowed to treat a posterior epiduritis. The spinal metastases were symptomatic in 45 cases (pain and/or neurologic deficit); 22 of the operated patients were bed-ridden, either due to an important pain (16), or due to a severe neurological deficit (6). In 36 cases, the intervention was done on the spinal lord segment (7 times on the upper thoracic column). The patients were authorized to get up the fifth or sixth postoperative day. The functional results, at a price of 15 per cent of mortality during the first two postoperative months, were satisfactory and stable in time (particularly, 70 per cent of the operated patients with neurologic deficits were improved and 13 of the 21 bed-ridden became autonomous). The intracanalar decompressions controlled by a postoperative myelography, were nearly always total. The sets were stables in time when the block of cement was sustained by a metallic device. The mortality and the functional failure with pain and neurological impairment occurred essentially, when there was spreading of the tumor to the peri-vertebral soft tissues and when there was epiduritis extending beyond the bone lesion. Thus, to be perfectly efficacious, the anterior surgery of the vertebral metastasis, which gives durable and better results than the posterior one, should be soon enough integrated, in the global treatment of the metastatic disease.
[Cement wedge replacing iliac graft in tibial wedge osteotomy].
The authors report their experience in substituting cement for full-thickness iliac crest wedge in medial tibial wedge osteotomy using buttress plate fixation. A review of 107 osteotomies performed between January 1985 and March 1989, demonstrated that using cement wedge do not expose to any special complication and raise the accuracy of frontal mechanical axes correction. At last, cement wedge seems not to evolve as a stranger corpus able to give long or mean terms complications; it perhaps make unnecessary bone substitute or allografts wedges.
[A case of benign chondroblastoma of the iliac wing treated by extensive exeresis and reconstruction with methylmethacrylate].
Complete remission can be achieved by extensive surgical exeresis in patients with benign chondroblastoma of the iliac wing despite the reputation of these tumors for aggressive behavior. The case of a 28-year-old male treated with extensive surgery and acrylic cement reconstruction is reported. After seven years follow-up, the functional result is satisfactory and there is no evidence of local recurrence. Use of cement obviated the need for bone grafting. However, subsequent removal of the cement proved necessary because of skin intolerance. Data from a review of the literature confirmed that iliac chondroblastoma carries a poor prognosis, mainly because of the potential for mechanical complications. The cases of malignant transformation reported occurred after radiotherapy. In the authors' opinion, extensive surgical exeresis performed as early as possible is the treatment of choice.
[Plexus nerve blocks for postoperative analgesia after orthopedic surgery of the lower limbs].
In our institution, plexus nerves blocks have been performed in seventy patients after lower limb surgery. The technique is considered as simple and reliable. The administration of a 0.375 per cent bupivacaine epinephrine containing solution allows to obtain analgesia longer than 15 hours in 45 p. 100 of the patients, devoided of side effects. Lower limb plexus nerves blocks appear as an efficient technique for postoperative analgesia following orthopaedic surgery.
[Mathematical modelling of open-wedge tibial osteotomy and correction tables].
This study analyzes mathematically the orientation of the superior tibial epiphysis in frontal and sagittal planes for knees with genu varum arthrosis. The assessment of the opening is determined mathematically for the osteotomies; this leads to the establishment of tables which can be used in practise during upper tibial osteotomies.
[Vertebral hydatidosis. Complications, contribution of modern imaging].
Vertebral hydatidosis is the commonest skeletal manifestation of echinococcosis. It is also the most serious: among 6 patients followed-up for a mean period of 10 years, all had neurological complications and only one is free of neurological sequelae at the present time (at the price of multiple spinal operations). While current medical treatment remains essential, it does not always control this skeletal parasite infestation which requires careful monitoring (CT scan, NMR) in order to detect and treat all possible recurrences.
[Value of false profile of the pelvis in the monitoring of total hip prosthesis].
The authors used a retrospective series of cases of total hip replacement with a follow-up of between 6 and 12 years, including 10 undergoing reoperation for slipping of the prosthesis, to define the value of the false lateral view of the pelvis in the monitoring of such patients. This view provides earlier detection than AP views of wearing of polyethylene which manifests itself by penetration of the femoral head into the acetabular implant. This penetration, which can be measured radiologically, is better visualised in the false lateral view of the pelvis for simple reasons of radiological incidences. The false lateral view of the pelvis has another use in the monitoring of total hip replacements. It enables visualisation of the posterior part of the acetabulum which is generally the site of first appearance of the earliest signs of slipping in the form of a thin line.
[The history of knee prosthesis].
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[Indications of prosthesis in the treatment of knee diseases].
Hinge prostheses of the knee expose to so many local or even systemic complications that they should be used only for reconstruction of the knee after tumoral excision. In all other indications, prosthesis of the knee must be semi-constrained or non-constrained. Moreover, it seems that it would be useful to choose the prosthesis that preserves the ligaments to the best, in order to reduce as much as possible the stress imposed on bone/prosthesis interfaces and to limit the size of the prosthesis that preserves the ligaments to the best, in order to reduce as much as possible the stress imposed on bone/prosthesis interfaces and to limit the size of the prosthesis on which depends the amount of bone removed and the risk of septic complications. In rheumatic diseases prosthesis of the knee is the only sensible surgical treatment. Since the inflammatory process involves all three compartments of the knee, the prosthesis must be of the three-compartment type. In degenerative (gonarthrosis) and post-traumatic diseases of the knee, prosthesis is needed only when conservative surgery (osteotomy for realignment or malunion) is inadequate, with global femorotibial or femoropatellar involvement and major laxity of the ligaments. In global femorotibial diseases the prosthesis utilized can only be three-compartmental; in one-compartment femorotibial diseases, one-compartment prosthesis is rational if there is no lesion of the capsule and ligaments. When anatomical conditions are still compatible with conservative surgery, prosthetic surgery will be preferred only when the patient's general condition requires prompt resumption of walking.(ABSTRACT TRUNCATED AT 250 WORDS)