According to the National Health Authority [NHA], “ambulatory surgery remains underdeveloped in France: about 40% of surgical interventions vs 80% in the US". In this context, the team of the orthopaedic department of Hospital Group [GH] of La Rochelle has developed a peri-scar intra-operative injection protocol of ropivacaine and dexamethasone. This injection with analgesic aim seeks a faster and less painful post-operative support of traumatic bone surgeries of the forefoot. Using before and after cost-utility analysis, this work proposes to determine the most efficient strategy from hospital perspective, by linking consumption of resources and control of post-operative pain as main clinical outcome. Our work is an observational study with two arms (before any treatment vs peri-scar intra-operative injection of ropivacaine and dexamethasone protocol) without randomization groups. Comparative statistical analysis has done. The assessment of post-operative pain has been extracted from the patient records. The utility values were extracted from a pain/utility value mapping from the literature. Costs are derived from the readjusted NSCMC (National Study of Common Methodology Costs) scale. After 28 months of collection, the control group consisted of 51 patients and the study population of 30 patients. Implementation of the new protocol means a significant reduction in pain (Mann-Whitney-Wilcoxon test and Fisher exact test) and, in parallel, an increase in the utility score of 0.025 units in the population treated by post-operative injection. The decrease in costs is € 59.5. This represents around € 430,000 saved by QALY gained. The studied strategy is therefore dominant: less costly and more efficient. The protocol appears dominant in clinical and economical terms.

Introduction. - A surgical technique is described to preserve the pronator quadratus muscle when fixing distal radius fractures with volar locking palmar plates.Technique. - Using a classic volar Henry approach to the wrist, the fibrous distal attachments of the pronator quadratus muscle are released. The locking palmar plate is passed under the pronator quadratus muscle and its correct placement is checked by fluoroscopy. Locking screws are inserted through mini-incisions in pronator quadratus.Discussion. - The pronator quadratus muscle plays an important role in wrist function, both in forearm pronation and as a stabilizer of the distal radioulnar joint. Mechanical impingement between the volar plate and the flexor tendons can cause adherences, ruptures and tenosynovitis. These should be reduced if pronator quadratus were intact.Conclusion. - Preservation of the pronator quadratus muscle is possible for the majority of the fractures of the distal radius treated with locking volar plate osteosynthesis. (C) 2009 Elsevier Masson SAS. All rights reserved.

Les fractures du rachis thoracolombaire sont fréquentes avec un retentissement fonctionnel qui peut être sévère. Cette étude multicentrique réunissant cinq centres a été réalisée afin d’évaluer le devenir à long terme de ces patients. Nous avons ainsi revu 136 patients atteints d’une fracture du rachis thoracolombaire (de T11 à L2), avec un recul minimum de deux ans. Tous ont bénéficié d’un examen clinique avec calcul du score fonctionnel d’Oswestry et d’une étude radiologique (avant traitement, après traitement et à la révision). La plupart des patients présentaient des fractures en compression, touchant le plus souvent le niveau L1. Radiologiquement, il existait un gain sur la cyphose vertébrale en postopératoire immédiat avec une perte de correction avec le temps et quel que soit le traitement proposé. Sur le plan fonctionnel, les patients allaient bien, avec un score d’Oswestry global moyen de 6,4. Une corrélation nette était cependant notée entre ce score fonctionnel et la cyphose vertébrale, ce qui peut nous faire penser qu’un renforcement de la colonne antérieure (réalisée de façon isolée ou en association au traitement chirurgical) pourrait améliorer ce résultat fonctionnel. De plus, le thoracolumbar injury severity score (TLISS) semble représenter un organigramme clair pour la prise en charge de ces fractures, en insistant sur les lésions en distraction et l’atteinte du complexe ligamentaire postérieur, avec cependant la nécessité de réaliser une IRM préopératoire.

Thoracolumbar fractures are frequent and the functional outcomes are sometimes severe. This multicentric study, including five medical centers, was performed to evaluate the long-term outcomes of the patients. One hundred and thirty six patients with thoracolumbar fracture (T11 to L2) was evaluated with a minimal follow-up of two years. Every one had a clinical exam with a score of Oswestry and an X-Ray study (before and after treatment and at revision). Most of them presented compression fractures, the most often at L1 level. On X-rays, a gain was noted on the vertebral kyphosis immediately after surgery, but there is a toss of correction over time whatever the treatment. The clinical outcomes for the patients were great, with an Oswestry average score of 6,4. A correlation was noted between this functional score and vertebral kyphosis. So, an anterior column strengthening (isolated or performed during the surgery) could improve these functional outcomes. Moreover, the Thoraco Lumbar Injury Severity Score (TLISS) seems to be a simple organigram to determine the most appropriate, treatment of these fractures, with particular attention to the distraction mechanism or posterior ligamentous complex lesions. However, RMI before surgery is necessary to evaluate these lesions. (C) 2008 Elsevier Masson SAS. Tous droits reserves.

Purpose of the study Many different osteotomies can be used for the treatment of hallux valgus. The purpose of this study was to evaluate the Scarf osteotomy associated or not with phalangeal osteotomy and to search for deformation cutoff points beyond which corrections appear to be difficult to achieve.Material and methods This retrospective analysis included 87 patients (123 feet) among 130 who underwent hallux valgus surgery between October 1993 and November 2000. Mean follow-up was four years eight months. The serie included 83 women and 4 men. Mean age at surgery was 53.5 years. A Scarf diaphyseal osteotomy was performed in all patients associated or not with phalangeal osteotomy. Each patient was reviewed clinically and radiographically with anteroposterior and lateral views of the foot in the standing position.Results 84.6% of the patients were satisfied or very satisfied. There was a correlation between the index of satisfaction and clinical symptoms (metatarsalgia, stiff hallux, pain over exostosis). There was a statistically significant decrease in hallux valgus (31.20 to 17.5°), of metatarsus varus (12.1° to 7.50), and articular angle of the distal metatarsus (13.3° to 11.1°). Patients who had phalangeal osteotomy achieved the best hallux valgus correction (15° versus 21.4°). Mean shortening of the first metatarsus was 2.2 mm with a decrease in the metatarsus-ground angle (190 versus 20.1°). Cutoff limits for deformations which are difficult to correct satisfactorily were M1M2 angle ≥ 15° and distal metatarsal articular angle ≥ 13°. The overall Groulier score showed 70.7% very good and good results, 27.6% fair results and 1.7% poor results.Discussion The Scarf technique is a reliable method to achieve significant correction of hallux valgus deformation. It requires a rigorous technique with specific attention to the elevation of the first metatarsus and excessive shortening, two factors favoring metatarsalgia. Adding a phalangeal osteotomy can improve the radiological result, but it is very difficult to obtain satisfactory correction if the initial deformations are severe and associated. Rotation of the plantar fragment helps for better orientation of the articular surface of the first metatarsus but limits the correction of the metatarsus varus. Function is the basic objective of hallux valgus surgery and patient satisfaction is related solely to clinical symptoms.

Many different osteotomies can be used for the treatment of hallux valgus. The purpose of this study was to evaluate the Scarf osteotomy associated or not with phalangeal osteotomy and to search for deformation cutoff points beyond which corrections appear to be difficult to achieve.This retrospective analysis included 87 patients (123 feet) among 130 who underwent hallux valgus surgery between October 1993 and November 2000. Mean follow-up was four years eight months. The serie included 83 women and 4 men. Mean age at surgery was 53.5 years. A Scarf diaphyseal osteotomy was performed in all patients associated or not with phalangeal osteotomy. Each patient was reviewed clinically and radiographically with anteroposterior and lateral views of the foot in the standing position.84.6% of the patients were satisfied or very satisfied. There was a correlation between the index of satisfaction and clinical symptoms (metatarsalgia, stiff hallux, pain over exostosis). There was a statistically significant decrease in hallux valgus (31.2 degrees to 17.5 degrees ), of metatarsus varus (12.1 degrees to 7.5 degrees ), and articular angle of the distal metatarsus (13.3 degrees to 11.1 degrees ). Patients who had phalangeal osteotomy achieved the best hallux valgus correction (15 degrees versus 21.4 degrees ). Mean shortening of the first metatarsus was 2.2 mm with a decrease in the metatarsus-ground angle (19 degrees versus 20.1 degrees ). Cutoff limits for deformations which are difficult to correct satisfactorily were M1M2 angle > or = 15 degrees and distal metatarsal articular angle > or = 13 degrees . The overall Groulier score showed 70.7% very good and good results, 27.6% fair results and 1.7% poor results.The Scarf technique is a reliable method to achieve significant correction of hallux valgus deformation. It requires a rigorous technique with specific attention to the elevation of the first metatarsus and excessive shortening, two factors favoring metatarsalgia. Adding a phalangeal osteotomy can improve the radiological result, but it is very difficult to obtain satisfactory correction if the initial deformations are severe and associated. Rotation of the plantar fragment helps for better orientation of the articular surface of the first metatarsus but limits the correction of the metatarsus varus. Function is the basic objective of hallux valgus surgery and patient satisfaction is related solely to clinical symptoms.

Nous avons realise une elude retrospective de 87 patients, soit 124 pieds, operes d'hallux valgus selon la technique de scarf associee ou non a une osteotomie phalangienne. Le recul moyen est de 4 ans et 8 mois. Chaque patient a ete revu et a beneficie d'un examen clinique et de radiographies de l'avant-pied de face et de profil en charge. Les patients etaient satisfaits el tres satisfaits dans 84,7 % des cas. Une correlation a ete notee entre la satisfaction des patients et les signes cliniques que sont les metalarsalgies, la raideur de l'hallux et la douleur en regard de l'exostose. Une correction significative des deformations principales etait retrouvee et les patients ayant eu une osteotomie phalangienne presentaient une meilleure amelioration du valgus phalangien. Un raccourcissement significatif du premier metatarsien etait note ainsi qu'une diminution significative de l'angle d'attaque par rapport au sol. Nous avons trouve des valeurs limites de deformations a partir desquelles il devenait plus difficile d'obtenir des corrections satisfaisantes. La technique de scarf est fiable et cette chirurgie reste essentiellement fonctionnelle, la satisfaction des patients n'etant lie qu'a des symptomes cliniques. L'adjonction d'une osteotomie phalangienne permet d'ameliorer le resultat radiologique. La rotation du fragment plantaire autorise un meilleur controle de l'orientation de la surface articulaire mais au detriment de la correction la translation. Mais cette technique doit etre rigoureuse car il faut faire attention a l'elevation du premier metatarsien et a son raccourcissement excessif responsables de metatarsalgies et il est d'autant plus difficile d'obtenir des corrections satisfaisantes que les deformations initiales sont importantes.