BACKGROUND CONTEXT: The ESP prosthesis is a one-piece deformable but cohesive interbody spacer. The viscoelastic prosthesis achieves 6 degrees of freedom including vertical translation to provide shock absorption. The rotation center can vary freely during motion. The prosthesis geometry allows limited rotation and translation with resistance to motion aimed at avoiding overload of the posterior facets.

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.

The objective of this study was to conduct a radiological analysis of posture before and after lumbosacral fusion to evaluate the influence of spinal alignment on the occurrence and pattern of post surgical pain. The study included 81 patients, of whom 51 had a history of previous low back surgery. We excluded patients with suspected or confirmed nonunion. In the fusion group, the 27 patients who were pain free after the procedure were compared to the 54 patients with residual pain. Thirty patients had pain only or primarily when they were standing immobile, 18 when they were sitting immobile, and six in both positions. Measurements were done on full-length lateral radiographs of the spine, with the patient standing according to Duval Beaupère criteria. The subgroup with postfusion pain was characterized at baseline by a more vertical sacrum with less sacral tilt (ST) (P < 0.0062) and more pelvic tilt (PT) (P < 0.0160). PT at last follow-up (PT fu) correlated with the presence of postfusion pain (NP: P = 0.0003). In the patients with postfusion pain, PT was almost twice the normal value. ST at last follow-up (ST fu) in the standing position was also correlated with the presence of postfusion pain (P < 0.0001) indicating that the sacrum remained abnormally vertical in the subjects with postfusion pain. Using logistic regression, the only prognostic factor for residual pain at last follow-up was ST fu. Both at pre-operative evaluation and at last follow-up, patients with pain in the standing position or in both the standing and sitting positions were characterized at pre-operative status by a more vertical sacrum with less sacral tilt. The results of this study indicate that, achieving a strong fusion should not be the only goal. Appropriate position of the fused vertebrae is also of paramount importance to minimize muscle work during posture maintenance. The main risk is failing to correct or to causing excessive pelvic retroversion with a vertical sacrum leading to a sagittal alignment that replicates the sitting position. This situation is often accompanied by loss of lumbar lordosis and adversely affects stiff or degenerative hips.

Anterior lumbar spine approaches may be indicated for fusion in degenerative lumbar spine disorders or to fill discal and bone gaps after fracture reduction. We present an anterior extraperitoneal approach applicable to any discal and vertebral levels from T12 to S1. The anatomic study, based on 25 cadavers, highlights retroperitoneal dissection principles for easy kidney and duodenopancreatic mobilisation and direct left anterior access to the entire lumbar spine. We established a precise description of the lumbar veins and the anastomoses between the left renal vein and hemiazygos system, in order to define different topographic and anatomic factors related to safe and easily reproducible approaches for cage or graft implementation. Independent of the level and previous intraperitoneal surgery, lumbar spine access with this approach safeguards the kidney, ureter, spleen, hypogastric plexus and duodenopancreatic system. Regarding operating time, blood-loss and possibilities for freshening and grafting, this technique seems an effective counterbalance to the difficulties and complex technology of endoscopic approaches. The clinical study includes our first 42 cases in traumatic and degenerative lesions. Avoiding the neurologic or hemorrhagic risk inherent in classical posterior lumbar interbody fusion (PLIF) techniques, it can be considered as a reasonable and valid alternative. This technique could be used in the near future for mini invasive discal prosthesis insertion.

Severe sprains of the cervical spine result from a traumatic rupture of the intervertebral disc and ligaments. Although rare, these lesions may lead to a significant kyphotic deformity if they are not surgically treated. The treatment of such a kyphotic deformity may consist of surgical fixation of the lesion through either an anterior or posterior approach. A retrospective study has been done examining 44 severe cervical sprains in 41 patients surgically treated through a posterior approach, using Roy-Camille plates. With an average followup of 29 months (range, 6-60 months), 73% of the patients recovered a normal range of spinal motion, with either moderate or no pain. No neurologic or vascular complications directly attributable to posterior plating and no secondary kyphosis were observed. A moderate sagittal displacement with kyphotic angulation occurred above the fusion in five patients. Posterior screw plate fixation appears to be a safe and effective treatment for severe hyperflexion sprain of the lower cervical spine in the adult.

Intraoperative ultrasonography (IOUS) was used to evaluate the location and compressive effects of intraspinal fragments in thoracolumbar fractures and the efficacy of reduction maneuvers in patients operated on for isolated or attached intraspinal fragments or for global posterior wall disruption. Dynamic IOUS was used to evaluate the effects of traction and lordosis. Fifty-eight patients were evaluated using a 7.5 MHz ultrasound probe, including 27 treated by impaction, 19 by removal of apparently isolated fragments, and 12 by traction followed by lordosis for global posterior wall disruption. IOUS had limitations and problems caused by split fragments and residual pedicular attachments that can compromise intraoperative maneuvers. The risk of secondary displacement of isolated fragments treated by impaction was very high. In particular, the pinching effect produced by T-shaped fractures was commonly responsible for secondary displacement. IOUS evaluation of canal clearance after fragment removal was satisfactory, but did not provide quantitative data. IOUS was easier to perform and apparently more reliable than intraoperative myelography. The dynamic IOUS data suggest that, except for severely tilted fragments that are completely free or remain attached to a pedicle, residual discal attachments significantly influence the likelihood of successful reduction.

An unusual case of vertical atlantoaxial dislocation without medulla oblongata or spinal cord injury is reported. The pathogenic process suggested occipito-axial dislocation. The case was treated surgically with excellent results on mobility and pain.

Summary Intraoperative ultrasonography is recommended for operations on the thoracolumbar spine to complement the information provided by standard X-ray, intensifier screen or myelography. There are no unanimates opinions concerning the impaction or exeresis of these fragments. The aim of this study was to show the advantages of intraoperative ultrasonography for anatomic determination and control of the maneuvers used. This study included 46 cases with fractures from T11 to L2. Ultrasonography was performed during the intraoperative reduction provided by the installation and the pedicular instruments. The authors stress the limits of the anatomic and geographic determination, as well as tilting of the fragments because of the size of the ultrasonographic head. The quality of the exeresis may be falsely interpreted in the presence of fragments with a section of less than 4 mm, lateralized, double fragments or in the presence of massive intraoperative haemorrhage. Analysis of the impaction results is more complicated because all of these fragments displaced themselves secondarily. The ligamentum communis vertebralis posterior has no anatomical containing role. The tilting before the impaction and the state of the overlying intervertebral disk represent essential factors for failures. Ultrasonography is better than intraoperative myelography. Nevertheless, it still needs to be complemented by intraoperative profile X-rays and a very precise preoperative CT scan of the intervertebral disk lesions analysis of complicated cases (fragments with residual pedicular attachments – type A 3.1.2.; T-like fractures – type A 3.2.1.).

Purpose of the study The authors evaluated the anatomical results and limits of the conservative treatment for displaced Colle's fracture. Material and Methods The anatomical results of 280 consecutive fractures were retrospectively analysed. Conservative treatment was performed according to Judet. Stability of the reduction was assessed for grade 0, 1, 2 of Kapandji's classification. Radiographical mean follow-up for all patient was three months (2 months to 8 years), Results In 122 cases (64 per cent) mat-union was observed. Mat-union was due in 93,5 per cent of cases (114) to secondary displacement of the distal fragment and in 6,5 per cent (8 cases) to poor reduction. Secondary displacement was essentially posterior in the sagittal plane. The principal factors of instability were radial shortening superior to 3 mm (p = 0,005), patient age of 55 years or more (p = 0,004), metaphyseal comminution (p = 0,004) and degree of primary displacement in the frontal plane (p = 0,01). Stability after reduction was determined by crossing the distal fragment in relation to the anterior cortex of the proximal fragment. There were 10,5 per cent algodystrophies and 9 per cent median nerve paresthesiae which were avoided by 45 degrees of wrist flexion. Discussion Judet's conservative treatment is indicated in extra-articular Colle's fractures (grade 0, 1 2 of Kapandji's classification), after evaluation of factors of instability, secondary displacement and mal-union. Minor mal-unions may be well tolerated, and do not seem to affect wrist function with 3 mm of radial shortening and 10 degrees of radial glenoid posterior angulation on the sagittal plane.

PURPOSE OF THE STUDY:The authors evaluated the anatomical results and limits of the conservative treatment for displaced Colle's fracture.MATERIAL AND METHODS:The anatomical results of 280 consecutive fractures were retrospectively analysed. Conservative treatment was performed according to Judet. Stability of the reduction was assessed for grade 0, 1, 2 of Kapandji's classification. Radiographical mean follow-up for all patient was three months (2 months to 8 years).RESULTS:In 122 cases (64 per cent) mal-union was observed. Mal-union was due in 93.5 per cent of cases (114) to secondary displacement of the distal fragment and in 6.5 per cent (8 cases) to poor reduction. Secondary displacement was essentially posterior in the sagittal plane. The principal factors of instability were radial shortening superior to 3 mm (p = 0.005), patient age of 55 years of more (p = 0.004), metaphyseal comminution (p = 0.004) and degree of primary displacement in the frontal plane (p = 0.01). Stability after reduction was determined by crossing the distal fragment in relation to the anterior cortex of the proximal fragment. There were 10.5 per cent algodystrophies and 9 per cent median nerve paresthesiae which were avoided by 45 degrees of wrist flexion.DISCUSSION:Judet's conservative treatment is indicated in extra-articular Colle's fractures (grade 0, 1, 2 of Kapandji's classification), after evaluation of factors of instability, secondary displacement and mal-union. Minor mal-unions may be well tolerated, and do not seem to affect wrist function with 3 mm of radial shortening and 10 degrees of radial glenoid posterior angulation on the sagittal plane.

Intraoperative ultrasonography is recommended for operations on the thoracolumbar spine to complement the information provided by standard X-ray, intensifier screen or myelography. There are no unanimates opinions concerning the impaction or exeresis of these fragments. The aim of this study was to show the advantages of intraoperative ultrasonography for anatomic determination and control of the maneuvers used. This study included 46 cases with fractures from T11 to L2. Ultrasonography was performed during the intraoperative reduction provided by the installation and the pedicular instruments. The authors stress the limits of the anatomic and geographic determination, as well as tilting of the fragments because of the size of the ultrasonographic head. The quality of the exeresis may be falsely interpreted in the presence of fragments with a section of less than 4 mm, lateralized, double fragments or in the presence of massive intraoperative haemorrhage. Analysis of the impaction results is more complicated because all of these fragments displaced themselves secondarily. The ligamentum communis vertebralis posterior has no anatomical containing role. The tilting before the impaction and the state of the overlying intervertebral disk represent essential factors for failures. Ultrasonography is better than intraoperative myelography. Nevertheless, it still needs to be complemented by intraoperative profile X-rays and a very precise preoperative CT scan of the intervertebral disk lesions analysis of complicated cases (fragments with residual pedicular attachments--type A 3.1.2.; T-like fractures--type A 3.2.1.).

Pelvic osteotomies were developed to increase or restructure the acetabular surface. Periacetabular osteotomies are considered the most difficult from the technical point of view and necessitate sufficient residual cartilaginous surface. Juxta-acetabular osteotomies avoid major disorganization of the pelvic framework and allow easier reorientation of the acetabulum. The authors present a technical variant that preserves the entire posterior column, as in the Ganz osteotomy. The effects on the vascularisation of the periacetabular region are strictly the same and there is no necrosis of the subchondral bone. This osteotomy is easier to perform, because of a single positioning associating two simultaneous approaches. The osteotomies are rectilinear and easy to check peroperatively by fluoroscopy thanks to this positioning. Another valuable aspect of this double approach consists of very easy correction of “automatic” unwanted retroversion due to the lowering of the acetabular roof. This unintended displacement is rarely reported in the literature, despite its anatomic evidence in 3-dimensional CT-scan reconstructions for pre- and peroperative evaluation.

Les auteurs ont evalue les resultats anatomiques et les limites d'un traitement orthopedique des fractures deplacees de l'extremite inferieure du radius. Les resultats anatomiques ont ete apprecies sur une serie de 280 fractures. Le traitement exclusif a ete la technique plâtree de Judet. La stabilite de la reduction a ete etudiee sur les types 0, 1, 2 de la classification de Kapandji. Le recul moyen etait de 3 mois. Les resultats montrent 64 p. 100 (122 cas) de cals vicieux qui correspondent dans 6,5 p. 100 (8 cas) a une mauvaise reduction initiale et dans 93,5 p. 100 (114 cas) a un deplacement secondaire du fragment distal. Ce deplacement tend a reproduire le deplacement initial et il se fait surtout en bascule posterieure. Les facteurs qui ont influence la stabilite du fragment distal sont: l'index radio-cubital initial superieur a 3 mm (p=0,005), l'âge du patient au-dela de 55 ans (p=0,004), l'importance de la comminution posterieure (p=0,004) et le degre de bascule frontale (p=0,01). Pour augmenter la stabilite de ces fractures, la reduction doit etre anatomique et le fragment distal doit franchir la corticale anterieure proximale. Les complications ont concerne surtout l'algodystrophie avec 10,5 p. 100 des cas et l'irritation du nerf median dans 9 p. 100 des cas. Cette derniere peut etre diminuee en evitant une hyper-reduction et en placant la main dans le plâtre avec 45° de flexion. La technique plâtree de Judet s'adresse aux fractures de Pouteau-Colles (types 0, 1, 2 de Kapandji), sous reserve d'avoir evalue les principaux risques d'instabilite, donc de deplacement secondaire et donc de cal vicieux. Les cals vicieux moderes sont susceptibles d'etre bien toleres pour la fonction du poignet et pour peu que l'index radio-cubital ne depasse pas 3 mm et la bascule posterieure 10°.

Les auteurs rapportent 5 cas d'entorses graves du rachis cervical inferieur survenues chez des sportifs traites entre 1980 et 1995 dans le service de chirurgie orthopedique du centre hospitalier de la Pitie. De nombreux sports comportent des risques de traumatisme severe du rachis cervical (rugby, equitation, sport automobile...). Les entorses graves ne sont neanmoins pas des lesions frequemment retrouvees. L'entorse grave est une pathologie traumatique rare secondaire a une rupture des elements disco-ligamentaires intervertebraux. On distingue les entorses en flexion, les plus frequentes, et les entorses en extension. Leur diagnostic est delicat car uniquement radiologique. Il s'agit d'une «subluxation» vertebrale diagnostiquee sur des radiographies du rachis cervical de profil au repos ou lors de cliches dynamiques realises a distance de l'accident. Le risque de meconnaitre une telle lesion est de la laisser evoluer vers un cal vicieux car il n'existe aucune tendance a la cicatrisation du ligament longitudinal posterieur. En cas d'entorse grave en flexion sans signe neurologique ou simple irradiation douloureuse aux membres superieurs, les auteurs proposent une fixation de l'etage lese par voie posterieure. En revanche, une entorse grave en extension necessite une stabilisation par voie anterieure.

Corrective surgery for kyphotic deformities of the spine in ankylosing spondylitis is a major surgery. for rare indications. The authors report 31 lumbar osteotomies. The goal is to correct the deformity through a posterior limited approach and to minimise the neurological risks. The modifications developed by the authors for monosegmental closing wedge osteotomies are explained. The posterior resection is rhomboid shaped with a bilateral lamina removal. An osteotomy is performed in a forwards direction on the lateral aspects of the vertebral body without bone resection. This osteoclasty allows progressive vertebral body compression. Pediclectomy is associated if the corresponding foramen at the osteotomy level becomes too narrow in the process of redressing the spine. The resection level is adjusted so that superior and inferior posterior arches come into contact with a good compression. The authors point out the risk of lateral translation. Before the osteotomy, the two adjacent vertebrae are implanted with 5-mm cylindrical pedicular screws, so that posterior fixation can be carried out at any time. Posterior monobloc fixation allows for very great compression of the osteoclasty. The authors compare the results of their experiences in opening and closing osteotomy. They progressively changed their technique for closing osteotomies, because of published vascular complications and mechanical risks (instability and pseudarthrosis in opening osteotomies). Closing osteotomy also minimises the risk of stenosis with radicular compression or traction if an important correction is performed. The level of the osteotomy varied in this series, which had a correction rate of up to 75°. The choice of level depends on secondary effects on pelvic position and projection of the centre of gravity. The preferred procedure remains a monosegmental correction because it is faster and easier, with minimum bleeding. Short monobloc posterior fixation is sufficient to maintain reduction and to obtain stability from posterior compression.

Anterolateral approach to the lumbar spine using a retroperitoneal approach is a common technique. But conventional approaches are performed laterally, resulting in parietal muscular damage, which may alter functional results. The authors present their experience about a minimized pararectal retroperitoneal approach from T12 to S1. Some anatomical aspects are important for a safe and reproductive procedure. The authors used mainly this technique in association with posterior correction and fixation in traumatic and degenerative pathologies. They point out the simplicity of this technique which is performed without special equipment. It seems a real alternative to laparoscopic techniques and micro-surgical antero-lateral interbody fusion, especially because of minimal potential complications and low post operative morbidity.