Download pdf - 255 Intervention de Page dans les rétractions des fléchisseurs d’origine neurologique centrale

Flexor Origin Slide for Contracture of SpasticFinger Flexor Muscles

A Retrospective Study

Camille Thevenin-Lemoine, MD, Philippe Denormandie, MD, Alexis Schnitzler, MD, Christine Lautridou, MD,Yves Allieu, MD, and Francxois Genet, MD, PhD

Investigation performed at the Departments of Orthopaedic Surgery and Physical Medicine and Rehabilitation,Hopital Raymond Poincare, Garches, France

Background: Contracture of the wrist and extrinsic finger flexor and pronator muscles is a common consequence ofcentral nervous system disorders. The proximal release of the extrinsic flexor and pronator muscles was first described byPage and Scaglietti for a Volkmann contracture. The aim of the present study was to assess the amount of increase inextension and the improvements in global hand function that can be expected following this lengthening procedure inpatients with central nervous system disorders.

Method: A single-center retrospective review of patients with central nervous system lesions and contractures of thewrist and extrinsic finger flexor and forearm pronator muscles, causing aesthetic, hygienic, or functional impairment, wascarried out. The Page-Scaglietti technique was used for all interventions. Before the operation, motor nerve blocks wereused to distinguish between spasticity and contractures with surgical intervention only for contractures. The Zancolli andHouse classifications were used to evaluate improvements.

Results: Data from fifty-four hands and fifty patients (thirty-five men and fifteen women) were evaluated. The meanduration of follow-up (and standard deviation) was 26 ± 21 months (range, three to 124 months). The mean gain (andstandard deviation) in wrist extension with fingers extended was 67� ± 25� (range, 210� to 110�). Preoperatively, nohands were classified as Zancolli Group 1, whereas twenty-five hands were classified as Zancolli Group 1 at the latestfollow-up review. Ten nonfunctional hands (rated as House Group 0 or Group 1) became functional as a supporting handpostoperatively. Zancolli and House classifications increased significantly (p < 0.01) postoperatively. In twelve cases, apartial recurrence of the deformity occurred. In seven of these cases, surgery unmasked spasticity or contracture of theintrinsic muscles, which required further intervention.

Conclusion: The Page-Scaglietti technique appears to improve range of motion and function in people with wrist andfinger contractures due to central nervous system disorders.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Deformities of the hand may occur following centralnervous system disorders such as stroke, spinal cordinjury, traumatic brain injury, or cerebral palsy, de-

spite medical treatment, regular follow-up visits, and rehabil-itation. Spasticity, along with impairments of motor andsensory function and coordination, can lead to contractures ofthe extrinsic and/or intrinsic muscles of the wrist and hand,

resulting in complex deformities and loss of function. Whenthe deformity is not permanent but is purely related to spas-ticity, it can be treated by repeated botulinum toxin injec-tions1,2, chemical neurolysis3,4, or partial neurectomy. However,if there are contractures, surgical intervention may be indi-cated. It is often difficult to estimate the functional potential asit usually depends on the motor capacity of antagonist muscles,

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support ofany aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission ofthis work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Noauthor has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influencewhat is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the onlineversion of the article.

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COPYRIGHT � 2013 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2013;95:446-53 d http://dx.doi.org/10.2106/JBJS.K.00190

which can be masked by spasticity and the deformities. Motornerve blocks are a useful and relatively safe way to evaluatemuscle function in the case of complex deformities caused by

central nervous system damage. In 1975, Zancolli described theuse of nerve blocks to assess the strength and any overactivity ofthe antagonist muscles prior to surgical interventions on

TABLE I Clinical Assessments for Each Etiology (Fifty-four Surgical Interventions)

Etiology

Clinical AssessmentAnoxia(N = 3)

Cerebral Palsy(N = 11)

Meningo-Encephalitis(N = 3)

Stroke(N = 11)

Traumatic Brain Injury(N = 26)

Preoperative wristextension*

Fingers flexed 260.0 ± 30.0 222.7 ± 32.9 23.3 ± 30.6 10.9 ± 26.8 226.7 ± 33.1Fingers extended 273.3 ± 15.3 260.5 ± 14.9 251.7 ± 7.6 244.1 ± 20.6 254.2 ± 22.0

Postoperative wristextension*

Fingers flexed 23.3 ± 15.3 24.1 ± 20.0 23.3 ± 20.8 41.8 ± 15.9 14.0 ± 15.0Fingers extended 213.3 ± 7.6 16.4 ± 20.1 23.3 ± 20.8 24.5 ± 21.3 7.1 ± 16.6

Preoperative Zancolliclassification†

0 0 0 0 0 01 0 0 0 0 02A 0 0 0 3 72B 3 5 0 1 93 0 6 3 7 10

Postoperative Zancolliclassification†

0 0 0 0 0 01 3 4 2 2 142A 0 1 0 3 12B 0 1 0 0 53 0 5 1 6 6

Preoperative Houseclassification†

0 2 5 1 5 101 1 2 1 3 112 0 3 1 1 03 0 1 0 2 34 0 0 0 0 15 0 0 0 0 16 0 0 0 0 07 0 0 0 0 0

Postoperative Houseclassification†

0 0 5 1 5 51 2 0 0 1 2

2 0 0 0 1 23 1 0 0 2 44 0 2 0 1 55 0 2 0 1 66 0 2 0 0 27 0 0 2 0 0

*The values are given as the mean and the standard deviation, in degrees. †The values are given as the number of hands.

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 95-A d NU M B E R 5 d M A R C H 6, 2013FL E XO R OR I G I N SL I D E F O R CO N T R AC T U R E O F SPA S T I C

FI N G E R F L E XO R MU S C L E S

spastic hands5. More recently, several studies demonstrated theuse of motor nerve blocks as a diagnostic tool for the assess-ment of spasticity prior to any treatment6,7. After an effectiveblock, it is possible to ascertain if the extrinsic and intrinsicflexor muscles are merely spastic or if contractures are alsopresent. A motor nerve block also enables a better assessmentof the strength of the antagonist muscles (extensors and supi-nators) preoperatively.

Because these patients have multifactorial and complexproblems, it is very important to carry out a precise assessmentof the neurological and orthopaedic status and functional po-tential as well as the goals that the patient desires from surgicaltreatment. In patients with central nervous system disorders,it is sometimes difficult to assess the degree of active musclecontrol present, because it is masked by the forearm, wrist, andfinger deformations. Consequently, a hygienic and aestheticgoal might be determined and a surgical technique such as thesuperficialis-to-profundus tendon transfer described by Braunet al.8 might be carried out, losing the possibility for a maximalfunctional recovery. As explained by Keenan et al.9, the Brauntechnique is primarily used for nonfunctional hands with se-vere deformations and is often avoided when volitional controlis present because of the sacrifice of the flexor digitorum pro-fundus9-12. One of the surgical techniques that can be used inthe case of common contracture of the extrinsic finger flexormuscles after central nervous system disorders is proximal re-lease, as described by Page13 and Scaglietti14. The technique wasoriginally described as a treatment for the sequelae of theVolkmann ischemic contracture and was later applied to spastichands by Inglis and Cooper15 and Swaeson16.

The aim of the present study was to assess improvementsin wrist extension following the release of wrist and finger flexorand pronator muscle contractures and the impact on global handfunction in patients with disorders of the central nervous system.

Materials and Methods

This study was a single-center retrospective study of patients with centralneurological damage who underwent upper-limb surgery in our hospital

between August 2001 and October 2011. All patients who received the Page-Scaglietti surgical technique were included except for those who required anarthrodesis (typically when the wrist was fixed in >90� flexion). All the inter-ventions were performed by one surgeon (P.D.).

The study was approved by an institutional review board.Data from fifty patients (thirty-five men and fifteen women) were in-

cluded during the study period. Four patients had bilateral surgery; thus, fifty-four hands were included (Table I). The mean age (and standard deviation) atthe time of surgery was 32 ± 14 years (range, fifteen to sixty-five years). Theneurological deficit was unilateral in twenty-two cases and bilateral in twenty-eight cases. The etiologies included cerebral palsy (ten patients [eleven hands]),traumatic brain injury (twenty-five patients [twenty-six hands]), stroke (elevenpatients, nine with ischemic stroke and two with hemorrhagic stroke [elevenhands]), anoxia (two patients [three hands]), and meningo-encephalitis (twopatients [three hands]).

EvaluationThe patients were assessed during multidisciplinary consultations that involvedthe orthopaedic surgeon, physical medicine and rehabilitation physicians,physiotherapists, and nurses, as well as the patient’s family.

Twenty-two patients underwent an above-the-elbow median nerveblock to distinguish between spasticity and contracture of the extrinsic flexormuscles of the wrist and fingers, as well as to evaluate the strength of themuscles antagonistic to the deformity (supinators as well as wrist and fingerextensors). The involvement of the intrinsic muscles was also assessed while theblock was in effect as intrinsic muscle involvement can be masked by spasticityor contracture of the extrinsic muscles. To determine if these muscles weresimply spastic or also contracted, an ulnar nerve block was carried out, prox-imal to the elbow if, during the median nerve block, tension remained on thering and small fingers and the flexor carpi ulnaris muscle, or an ulnar nerveblock was carried out proximal to the wrist if the intrinsic hand muscles wereinvolved.

Wrist motion was evaluated passively with the fingers in both ex-tended and flexed positions during the preoperative and postoperative clin-ical evaluations. Spontaneous forearm rotation was qualified as neutral,pronation, or supination. Each hand was categorized according to the Zan-colli classification

17(see Appendix). Functional ability was evaluated with use

of the House classification18

(see Appendix). To determine how the patientused the arm preoperatively, he or she and a family member (or caregivers)were asked to complete a questionnaire that was not validated and was basedon the ABILHAND Questionnaire

19, a validated questionnaire that consists

of common activities of daily living that the patient scores regarding if he orshe uses the affected hand to carry out the activity (yes or no). During theconsultation, the patient was asked what he or she hoped to obtain fromsurgery. Questioning of the patient was very precise, particularly if the patientreported that the hand or arm was not used. Functional ability was assessed bythe multidisciplinary team, including use of motor nerve blocks and func-tional tests. At the end of the consultation, the multidisciplinary team pro-posed their view of the patient’s problem, and the goal of surgery wasclassified into one of three categories: functional, with the type of functionexpected to be gained (grasp, key grip, improvement of the opening time ofthe hand); aesthetic (open hand); or hygienic and analgesic (prevention ofskin ulcerations). An agreement regarding the goal of surgery was then es-tablished with the patient and his or her family on the basis of the evaluationto ensure that the patient had realistic expectations. In the sample of patientsincluded, the goals were functional (thirty cases), hygienic and analgesic(nine cases), or aesthetic (fifteen cases). Goal attainment was evaluated atthree months, six months, and one year postoperatively by the surgeon or aphysical medicine and rehabilitation physician. This type of agreement issystematically determined in our institution for patients who are neurolog-ically disabled. It is very important in this population because patients fre-quently have unrealistic expectations and are also often afraid to lose thefunction that they have.

Surgical Technique (Figs. 1 and 2)A medial forearm approach was used in all cases with an incision from themedial humeral epicondyle to the base of the ulna. The ulnar nerve was pro-tected. Transposition of the ulnar nerve was never necessary as, following therelease, it was not under tension even with the wrist and fingers maximallyextended. The flexor digitorum profundus was detached from the ulna andinterosseous membrane. Care was taken not to damage the common inter-osseous artery. The flexor digitorum superficialis and flexor carpi radialiswere detached from the medial epicondyle. The flexor pollicis longus wasdetached from the radius by passing over the radial vessels. Intramuscular orz-lengthening of the tendon was performed on the flexor carpi ulnaris if nec-essary to release residual contractures. In patients in whom pronation andsupination were well balanced or if supination prevailed, the pronator teresmuscle was spared during proximal release to avoid occurrence of an imbalancetoward supination

8: the muscle was thus left attached on the medial humeral

epicondyle and distally the pronator teres tendon was separated from the fingerflexors. If the wrist extensors were unable to extend the wrist to neutral, wristbalance was restored by means of a tenodesis of the extensor carpi radialis brevisor a transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis

20.

After surgery, an above-the-elbow cast was used to immobilize the wrist and

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fingers in maximum extension for three weeks, with the elbow in 90� flexionand the forearm in neutral pronation and supination. This was followed byphysiotherapy and static finger and wrist extension splinting for three weeks(with the elbow completely free). During the first forty-five days, physiotherapyfocused on passive and active mobilization of the wrist and fingers in extension.No flexion of the fingers or the wrist was permitted. The splint was to be wornfull-time. After forty-five days, mobilization in flexion was started, and thesplint was only worn at night.

Statistical AnalysisData are reported as the mean, range, standard deviation, and numbers andpercentages. Student t tests were used to compare changes in wrist extensionbetween preoperative measurement and the latest follow-up. A Wilcoxonsigned-rank test with continuity correction was used to compare orderedqualitative data (House and Zancolli classifications). All p values were two-tailed, and significance was set at p < 0.05.

Source of FundingThis project received no external funding.

Results

The mean duration of follow-up (and standard deviation)was 26 ± 21 months (range, three to 124 months).

The mean wrist extension (and standard deviation) withthe fingers flexed (metacarpophalangeal, proximal interpha-langeal, and distal interphalangeal joints) was 219� ± 35�(range, 290� to 45�) before surgery and 21� ± 20� (range, 220�to 60�) after surgery, corresponding to a mean improvement(and standard deviation) of 39� ± 28� (range, 0� to 105�) (p <0.01). This improvement was due to the increased length of theextrinsic wrist flexor muscles.

The mean wrist extension (and standard deviation) withthe fingers extended (metacarpophalangeal, proximal inter-phalangeal, and distal interphalangeal joints) was 254� ± 220�

(range, 290� to 220�) before surgery and 12� ± 21� (range,230� to 50�) after surgery, corresponding to a mean im-provement (and standard deviation) of 67� ± 25� (range, 210�to 110�) (p < 0.01). This improvement was due to the increasedlength of the finger flexor muscles.

None of the involved hands were classified as ZancolliGroup 1 before surgery, whereas twenty-five hands were classifiedas Zancolli Group 1 at the latest follow-up assessment (Fig. 3).

All patients agreed that their treatment goal had beenachieved. Eight patients with an initial hygienic and aestheticgoal gained additional functional abilities (these patients wereclassified as House Group 3 and above). The preoperativepotential had been underestimated for these patients due to theseverity of their deformities.

Figures 3 and 4 show the results of the Zancolli classifica-tions and House classifications preoperatively and postoperatively.Improvements were significant (p < 0.01) for both scales followingsurgery; the sum of the Wilcoxon signed-rank test was 78 for theZancolli classifications and 190 for the House classifications.

Pronation and supination balance was qualified as neu-tral in thirty-four cases, with all but one of these having thepronator teres muscle spared during the proximal muscle re-lease. Following surgery, forearm rotation remained neutral inthirty-one cases and became pronated in two cases. For onepatient, a complete muscle release was performed, which re-sulted in fixed supination post-surgery. Of the nineteen pro-nated hands, fourteen gained a neutral position postoperativelyand five remained pronated after complete muscle release. Onehand was presented along with a spontaneously supinatedforearm; this patient had had a traumatic brain injury. Intwenty-one hands, lengthening of the flexor carpi ulnaris

Fig. 1

Photograph showing a surgical procedure in

which the flexor-pronator muscles were released

before lengthening.

Fig. 2

Photograph showing a surgical procedure in which,

after lengthening, the fingers can be extended.

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following proximal release was necessary to gain a neutralposition of the wrist. Tenodesis of the wrist extensors was donein ten cases, a flexor carpi ulnaris to extensor carpi radialisbrevis transfer in one case, and an extensor carpi ulnaris toextensor carpi radialis brevis transfer in ten cases to stabilize thewrist20. In all of these cases, the deformity was caused by dis-placement of the extensor carpi ulnaris tendon in front of theulnar styloid pulling the wrist strongly into flexion. The

transfer of the extensor carpi ulnaris to the extensor carpi ra-dialis brevis decreased the force toward wrist flexion andprovided substantial assistance for wrist extensor tenodesis.

One hand had an early postoperative complication ofpoor superficial wound-healing that resolved with local treat-ment (Table II). Among the twenty complications more thansix weeks postoperatively, twelve were partial recurrences withpersistent wrist flexion (eight were treated by means of surgical

Fig. 3

Bar graph showing the improvement of the Zancolli classification between groups of patients before and after surgery; the sum of the Wilcoxon signed-rank

test was 78 (p < 0.01).

Fig. 4

Bar graph showing the improvement of the House classification between groups of patients before and after surgery; the sum of the Wilcoxon

signed-rank test was 190 (p < 0.01).

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revision and four were treated by means of a nonsurgical ap-proach), one was a fixed forearm supination deformity (treatedby means of a nonsurgical approach), and seven were un-masked spasticity or contracture of the intrinsic muscles (threewere treated by means of surgical revision and four were treatedby means of a nonsurgical approach) (Table II).

Discussion

Avariety of surgical techniques exist to correct pronation-flexion deformities of the wrist, a common deformity oc-

curring because of disorders of the central nervous system21-23. Thechoice of the appropriate technique depends on the severity of themuscle contractures, joint stiffness, antagonist muscle strength,and the functional potential that is masked by the deformity.

A thorough assessment prior to surgery is essential andshould include a preoperative use of the hand, an agreementwith the patient regarding the surgical goal, and the patient’sneurological and orthopaedic status. This strategy allowsavoiding any errors that may seriously affect his or her function.

The flexor origin slide procedure, described in 192313 anddeveloped in 195714 for extrinsic flexor contractures of centralneurological origin, has been shown in many studies but has beenless commonly used since the development of the superficialis-to-profundus tendon transfer described by Braun et al.24. Braunet al. criticized the Page-Scaglietti technique because of its com-plexity and tendency to result in supination deformities8. TheBraun intervention has the advantage of being a very simpletechnique but has three main problems. First, it frequently causes

TABLE II Early and Late Postoperative Complications

Postoperative Complication Treatment

Early (less than six weeks)Superficial scar under the splint Local

Late (six weeks or more)Partial recurrences with persistent wrist flexion Medical approach (four cases)

Splint (one case)

Botulinum toxin injection of extrinsic wrist flexor muscles (three cases)

Surgical revision (eight cases)

Wrist arthrodesis with proximal row carpectomy (two cases)

Wrist flexor aponeurotomy with extensor carpiulnaris and extensor carpi radialis brevis transfer (one case)

Z-lengthening of the flexor carpi radialis and palmarislongus transection (one case)

Tenotomy of the flexor digitorum superficialis and flexordigitorum profundus and disinsertion of the adductor pollicis (one case)

Tenotomy of the flexor digitorum superficialis, flexor pollicislongus, and thenar muscle disinsertion (one case)

Intramuscular fractional lengthening of the flexor digitorumsuperficialis (fourth finger) with thenar muscle liberation andfixation of the proximal interphalangeal joint (third and fourth fingers)(one case)

Tenodesis of the wrist extensors with a repeat flexor digitorumsuperficialis, flexor digitorum profundus, flexor pollicis longuslengthening (one case)

Postoperative fixed supination deformity(preoperatively balanced pronation and supinationwith complete proximal muscle release includingpronator teres carried out)

Medical approach (one case)Botulinum toxin injection of supinator muscles

Postoperative unmasking of intrinsicmuscle spasticity or contracture

Medical approach (four cases)Botulinum toxin injection of intrinsic muscles in the thumb (two cases)and in the second and third fingers (two cases)

Surgical revision (three cases)

Thumb arthrodesis (one case)

Distal tenotomy of the intrinsic muscles of the long fingers (one case)

Neurectomy of the deep motor branch of the ulnar nerve (one case)

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swan-neck deformities in the fingers because of the reducedtension of the flexor digitorum superficialis, especially in the caseof spasticity of the intrinsic hand muscles3. Second, there is oftena loss of muscle strength because the muscle length/tension ratioon the Blix curve is altered25, reducing the efficiency of themuscle. In contrast, proximal release increases efficiency by al-tering the range of motion within which the muscle contracts.Third, this intervention may irreversibly over-lengthen the fingerflexors, which can prevent potential functional recovery. Thepotential for functional recovery is sometimes very difficult toevaluate preoperatively, despite multidisciplinary evaluations in-cluding the use of motor nerve blocks. Surgeons should thereforebe very wary about the use of irreversible surgical procedures. Inpatients with central nervous system damage, it is often difficultto quantify overactivity of the antagonist muscles that is maskedby the wrist flexion deformity. If wrist extensor activity is un-derestimated, the Braun technique may result in permanent wristextension, which can also be troublesome. Although the Page-Scaglietti procedure is not a reversible surgical procedure, thenatural reinsertion of the proximal part of the muscles conservesmotor ability and therefore functional potential. Moreover, themean gain in wrist and finger extension found in the presentstudy (67�) using the Page-Scaglietti procedure is similar to thegain reported in other studies using other techniques: Braunet al.8 reported 56� with wrist and finger extension, and Inglis andCooper15 reported 51� with active wrist and finger extension.Therefore, as specified by Keenan et al.9, when a functional im-provement is expected or a potential is suspected, we suggest thatinterventions that conserve all of the extrinsic finger flexorsshould be carried out. For deformities with <10� wrist flexioncontracture (with fingers extended), we propose an aponeurot-omy; for deformities between 10� and 70� wrist flexion con-tracture, we believe that the Page-Scaglietti procedure is a goodalternative to the Braun procedure; and for deformities with >70�wrist flexion contracture, we propose a z-lengthening, tendon bytendon. For patients in whom functional improvements are notexpected, the Braun procedure appears to be appropriate becauseof its simplicity.

The release of the pronator teres muscle may affect thebalance of forearm pronation and supination. In the presentstudy, one case of fixed supination occurred following a com-plete proximal muscle release of the flexor-pronator muscles.This complication had already been described by Braun et al.8.The preoperative evaluation must therefore be extremely pre-cise and, in patients in whom the forearm is in a neutral orsupinated position before surgery, the technique described hereof selective release of the flexors while sparing the pronatorteres muscle seems to prevent fixed supination deformities.

Our policy is therefore only to release the pronator teres muscleif the hand is pronated preoperatively. Equally, the release ofcontractures of the extrinsic flexor muscles may reveal othermuscle imbalances that were previously masked. These im-balances may include spasticity of the intrinsic hand muscles,or contracture and wrist instability because of weak wrist ex-tensors. It is important that the patient and his or her family areaware that additional surgical interventions may be necessary.

The release of the extrinsic wrist and finger flexor andpronator muscles is an intervention that provides a chance forthe recovery of hand and wrist function. Surgeons wishing totreat hand deformities secondary to central neurological dis-orders should be aware of this technique because, although it isa technically demanding procedure, it can achieve substantialcorrection of flexion deformities while preserving musclefunction. The difficulty is often determining a realistic surgicalgoal for the patient. Although multidisciplinary assessment andthe use of motor nerve blocks can help to differentiate betweenspasticity and contracture, other problems may remainmasked. It is difficult to fully determine the role of spasticity ofthe intrinsic hand muscles or weak or spastic antagonist musclesin the preoperative assessment. Although surgery for spastichands may have relatively limited functional results, thesemodest gains are often rewarding for the patient.

AppendixTables showing the Zancolli classification and the Houseclassification are available with the online version of this

article as a data supplement at jbjs.org. n

Camille Thevenin-Lemoine, MDPhilippe Denormandie, MDAlexis Schnitzler, MDChristine Lautridou, MDYves Allieu, MDFrancxois Genet, MD, PhDDepartments of Orthopaedic Surgery(C.T.-L., P.D., C.L., and Y.A.) and Physical Medicine and Rehabilitation(A.S. and F.G.), Hopital Raymond Poincare,104 Boulevard Raymond Poincare,92380 Garches, France.E-mail address for C. Thevenin-Lemoine: [email protected] address for P. Denormandie: [email protected] address for A. Schnitzler: [email protected] address for C. Lautridou: [email protected] address for Y. Allieu: [email protected] address for F. Genet: [email protected]

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