Total knee arthroplasty in severe haemophilic patients under continuous infusion of clotting factors.

PURPOSE: Haemophilic arthropathy is painful, invalidating and destructive. Authors report a prospective study of total knee arthroplasties in patients with severe haemophilia under continuous infusion of clotting factors. The purpose is to evaluate the benefits of continuous infusion of clotting factors regarding long-term functional improvement and radio-clinical results. METHODS: From 1998 to 2009, 20 total knee arthroplasties were implanted in 14 patients with a mean age of 36.5 years (24-56). A continuous infusion of anti-haemophilic factors was used and supervised by the physician of the Regional Haemophilia Treatment Centre (CRTH). Evaluation was clinical using the HSS and Oxford scores and radiological. RESULTS: One patient was lost to follow-up. Median follow-up is 66.5 months (6-134). Oxford score at latest follow-up is 42 (37-46). On revision, HSS score is 91 (84-96). Median flexion gain is 32.5° (-20; 75°). There is a median flexion contracture of 5° (0-15°) and a median extension improvement of 22.5°. We report 2 secondary infectious complications, concerning the same operated knee of a single patient. No post-operative haematoma was reported in our study. CONCLUSION: Total knee arthroplasty in haemophilic arthropathy improves both the function and quality of life of this group of patients. Continuous infusion of clotting factors contributes significantly to these results, by allowing early and intensive rehabilitation, and offers security regarding haemorrhagic complications commonly described in the literature and that we have not encountered in our study. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Vascular complication after percutaneous femoral cerclage wire.

Cerclage wire is an effective fracture fixation method. However, its mechanical benefits are countered by local ischemia. Its efficacy for treating femoral periprosthetic fractures has been demonstrated since femoral fixation is possible even there is a stem in the diaphysis. It securely holds the proximal femur typically with an additional plate. The development of minimally-invasive surgery with plate fixation has led to the cerclage wire being inserted percutaneously. Here, we report on a case of secondary femoral ischemia following percutaneous cerclage wire of a periprosthetic femoral fracture. This was a Vancouver type B1 fracture. On the 3rd day after admission, minimally-invasive fixation with a femoral locking plate was performed with five cerclage wires added percutaneously. During the immediate postoperative course, the patient developed ischemia of the operated leg that required vascular surgery after confirmation by CT angiography. An arterial stop was visible with deviation of the superior femoral artery, which was not properly surrounded by the cerclage wire. The latter pulled perivascular tissues towards the femur. When combined with reduced arterial elasticity due to severe atherosclerosis, it resulted in arterial plication. The postoperative course was marked by multiple organ failure and death of the patient. Percutaneous surgery is an attractive option but has risks. The presence of severe atherosclerosis is a warning sign for loss of tissue elasticity. This complication can be prevented by preparing the bone surfaces and carefully positioning the patient on the traction table to avoid forced adduction. The surgeon must also be familiar with alternative techniques to cerclage wire such as polyaxial screws and additional plates.

Ankle fusion in hemophilic patients.

INTRODUCTION: Hemophilic arthropathy is painful and disabling. We report a retrospective study of ankle fusion with intra- and peri-operative clotting factor perfusion. The objective was to assess the efficacy of maintaining perioperative clotting factor rates close to 100%, and report long-term results. The study hypothesis was that results would be good, without early hemorrhagic complications. MATERIAL AND METHOD: Between 2000 and 2013, 12 ankle fusions were performed in 9 patients, with a mean age of 39years (range, 19-58years). Anti-hemophilic factor perfusion was controlled by the reference physician of the Regional Hemophilia Treatment Center. Clinical AOFAS and Olerud scores and the Pettersson radiologic score were used for assessment. Mean preoperative AOFAS score was 22 (range, 2-55) and mean Olerud score 7 (range, 5-12). Mean preoperative factor VIII concentration was <1% (range, <1-3%). RESULTS: Mean follow-up was 8years (range, 2-16years). Mean AOFAS score at follow-up was 69 (range, 35-92) and mean Olerud score 70 (range, 30-100). Improvement mainly concerned the Pain dimension. Statistical analysis found a significant difference between pre- and post-operative clinical scores (AOFAS, P=0.004; Olerud, P=0.004). Mean factor VIII concentration at surgery was 90% (range, 24-117%), and 109% (range, 75-152%) the day following surgery. There were no cases of hematoma or surgical site infection. Radiologic fusion was systematic at a mean 3.5 months (range, 3-4months). CONCLUSION: The study hypothesis was confirmed. Ankle fusion in advanced hemophilic arthropathy improved function and quality of life. Perioperative clotting factor perfusion contributed to these good results, providing supplementary prevention of hemorrhagic risk. LEVEL OF EVIDENCE: IV, retrospective study.

Total knee arthroplasty after opening- versus closing-wedge high tibial osteotomy. A 135-case series with minimum 5-year follow-up.

INTRODUCTION: High tibial osteotomy (HTO) is effective in treating isolated medial osteoarthritis of the knee, but subsequent deterioration is inevitable, and total knee arthroplasty (TKA) is then an option. The present study sought to compare TKA following medial opening-wedge HTO (OW-HTO) versus lateral closing-wedge HTO (CW-HTO) in terms of intraoperative data and clinical results. The study hypothesis was that there is no significant difference in clinical results or complications in TKA following OW-HTO or CW-HTO. MATERIAL AND METHOD: A retrospective multicenter (9 centers) study was conducted for the French Society of Orthopedic Surgery and Traumatology (SoFCOT), including 135 TKAs following HTO (58 OW and 77 CW) at a minimum 5 years' follow-up. Mean interval between HTO and TKA was 134 months and was longer in case of CW-HTO (P<0.0001). Mean age at TKA was 65.4 years and older in case of CW-HTO (P=0.021). Tibial slope was greater in case of OW-HTO (P=0.024). Prior to TKA, 55.7% of patients could walk without canes, 98.4% found stairs difficult or impossible and only 19.1% could manage a walking distance greater than 1000m. Mean flexion was 110°; 54.2% of patients showed frontal knee stability and 87.8% sagittal stability; 60.1% had a mechanical axis in varus, without difference according to OW- or CW-HTO. RESULTS: Hardware was almost systematically removed (in 98.5% of cases): in the same step for OW-HTO (P=0.018) or often in 2 steps for CW-HTO. The primary approach was generally re-used (54.2%), but less frequently in the CW-HTO group (P=0.0004). Lateral or medial ligament release was not associated in respectively 78.2% and 79.7% of cases. The TKA implant was usually without stem (87.2%) and was fitted using a conventional technique (74.4%). At a mean 87 months' follow-up, 78.5% of patients could walk without canes, stairs were still difficult or impossible for 67%, and 74.1% could now walk further than 1000m; mean flexion was 110.5°. Overall, 91.5% of patients showed frontal knee stability and 98.2% sagittal stability, without difference according to OW- or CW-HTO. There were 15 complications within 3 months, more often in the OW-HTO group (12.3%) although not significantly, and with no difference in severity. Late complications comprised loosening (5.5%) and infection (3.6%) and were more frequent in the CW-HTO group (12%) (P<0.05). DISCUSSION: The study hypothesis was partially confirmed. The only technical differences concerned hardware removal, often performed in two steps in case of CW-HTO, and TKA approach, which differed from the primary approach in case of CW-HTO. Clinical results were comparable between OW- and CW-HTO, but late complications were more frequent in the CW-HTO group. LEVEL OF EVIDENCE: III; comparative retrospective study.

What are the risk factors for dislocation in primary total hip arthroplasty? A multicenter case-control study of 128 unstable and 438 stable hips.

INTRODUCTION: Dislocation after total hip arthroplasty (THA) is a leading reason for surgical revision. The risk factors for dislocation are controversial, particularly those related to the patient and to the surgical procedure itself. The differences in opinion on the impact of these factors stem from the fact they are often evaluated using retrospective studies or in limited patient populations. This led us to carry out a prospective case-control study on a large population to determine: 1) the risk factors for dislocation after THA, 2) the features of these dislocations, and 3) the contribution of patient-related factors and surgery-related factors. HYPOTHESIS: Risk factors for dislocation related to the patient and procedure can be identified using a large case-control study. PATIENTS AND METHODS: A multicenter, prospective case-control study was performed between January 1 and December 31, 2013. Four patients with stable THAs were matched to each patient with a dislocated THA. This led to 566 primary THA cases being included: 128 unstable, 438 stable. The primary matching factors were sex, age, initial diagnosis, surgical approach, implantation date and type of implants (bearing size, standard or dual-mobility cup). RESULTS: The patients with unstable THAs were 67±12 [37-73]years old on average; there were 61 women (48%) and 67 men (52%). Hip osteoarthritis (OA) was the main reason for the THA procedure in 71% (91/128) of the unstable group. The dislocation was posterior in 84 cases and anterior in 44 cases. The dislocation occurred within 3 months of the primary surgery in 48 cases (38%), 3 to 12 months after in 23 cases (18%), 1 to 5years after in 20 cases (16%), 5 to 10years after in 17 cases (13%) and more than 10years later in 20 cases. The dislocation recurred within 6 months of the initial dislocation in 23 of the 128 cases (18%). The risk factors for instability were a high ASA score with an odds ratio (OR) of 1.93 (95% CI: 1.4-2.6), neurological disability (cognitive, motor or psychiatric disorders) with an OR of 3.9 (95% CI: 2.15-7.1), history of spinal disease (lumbar stenosis, spinal fusion, discectomy, scoliosis and injury sequelae) with an OR of 1.89 (95% CI: 1.0-3.6), unrepaired joint capsule (all approaches) with an OR of 4.1 (95% CI: 2.3-7.37), unrepaired joint capsule (posterior approach) with an OR of 6.0 (95% CI: 2.2-15.9), and cup inclination outside Lewinnek's safe zone (30°-50°) with OR of 2.4 (95% CI: 1.4-4.0). DISCUSSION: This large comparative study isolated important patient-related factors for dislocation that surgeons must be aware of. We also found evidence that implanting the cup in 30° to 50° inclination has a major impact on preventing dislocation. LEVEL OF EVIDENCE: Level III; case-control study.

[Elbow arthroscopy]. / L'arthroscopie du coude.

This symposium of the French Arthroscopic Society is the 2005 state of the art of elbow arthrosocpy in France. A survey reports 499 cases during 2 years with a rate of complication higher than the arthroscopies of other joints (6% of minor and 1% of major complications). The main indication is the removal of loose bodies. They can come from arthritis, chondromatosis, osteochondritis or fracture. The most accurate radiologic examination is an arthroCTscan. The main pronostic factor is the cartilage status. Arthrolysis is the second indication. We performed a retrospective and a prospective studies to compare open and arthroscopic surgery. Results are almost similar with a significant higher improvement in flexion (7 degrees ) in the open group. Open surgery seems more efficient but with a franck loss of motion in the postoperative course. However, in this group elbows were preoperatively stiffer in relation with a trauma event instead of sport related microtrauma in the arthroscopically treated group. Removal of necrotic fragment combined with abrasion in osteochondritis of the capitulum yields to good results with 82% of patients resuming to sports. Long term prognosis is unknown as the joint line is narrowed at a 3 years follow up. Arthroscopy is usefull in synovial diseases as resection of synovial folds or removal of tumors like villonodular synovitis. In the treatment of epicondylitis, the results of our retrospective study are not so good as those reported in the literature. But in our comparative study the results are similar to the open surgery group. The numerous procedures and the different follow up in these two groups did not allow to give statistical analysis. Elbow arthroscopy is a hyper specialty with more and more advanced procedures.

Villonodular synovitis of the ankle. Analysis of the risk of recurrence.

INTRODUCTION: Villonodular synovitis (VNS) is a rare disease with an incidence of 1.8 per 1,000,000 inhabitants. VNS of the ankle has seldom been described and evaluated given its extreme rarity (2.5% of VNS cases). It presents an 11% recurrence rate. We report a continuous retrospective series with the main objective of clinically and radiologically evaluating these ankles searching for any risk factors of recurrence. At revision the study's main endpoint was the existence of local recurrence (radiological and clinical) and the secondary endpoint was the existence of tibiotalar osteoarthritis. The working hypothesis was that recurrence could be subclinical, warranting systematic imaging studies during follow-up. MATERIAL AND METHODS: The study was retrospective, conducted on seven patients (six males) whose mean age was 42 years treated over a period of 9 years (two diffuse forms and five localized forms). The initial treatment consisted in synovectomy via the conventional approach. Four patients also received adjuvant isotopic synoviorthesis treatment. The revision was clinical (MMTS, AOFAS, and OMAS scores) and radiological (standard and MRI) to evaluate the joint after-effects and search for recurrence. RESULTS: Six patients were seen at a mean 6.5 years of follow-up. One case of early recurrence (4 years) was noted, with a major clinical manifestation because it was associated with joint destruction requiring arthrodesis, and one case of late asymptomatic recurrence (9 years), diagnosed radiologically on the follow-up MRI. The functional results remained good at follow-up (MMTS 77%, AOFAS 71, OMAS 71). Five of the six patients returned to their daily activities. At revision, no sign of osteoarthritis was observed. No risk factor for recurrence was demonstrated. DISCUSSION/CONCLUSION: The hypothesis was confirmed with the existence of asymptomatic recurrence at revision, underscoring the value of systematic MRI at follow-up. Other than major joint destruction, the prognosis remains good even in case of recurrence. The literature emphasizes the existence of an initial diffuse form and partial surgical resection as risk factors of recurrence. None of the reports in the literature has proven that adjuvant treatment, whose modalities do not meet with consensus, reduces this risk. LEVEL OF EVIDENCE: Retrospective series, level IV.

Tibiofemoral syndesmosis injury treated by temporary screw fixation and ligament repair.

INTRODUCTION: Tibiofemoral syndesmosis injuries are common but have not been extensively researched. The primary objective of this study was to evaluate the outcomes after temporary screw fixation with ligament repair of these injuries. The secondary objective was to look for factors that could impact these outcomes. We hypothesised that this double fixation (screw+suture) would lead to good outcomes with minimal secondary opening of the syndesmosis upon screw removal. MATERIAL AND METHODS: This was a retrospective study of 285 patients with a tibiofemoral syndesmosis injury (01/2004-12/2011) who were treated by temporary tricortical or quadricortical screw fixation and ligament repair. The operated leg was unloaded for 6-8 weeks postoperative with the patient wearing a walking cast. The screw was removed in all patients before weight bearing was allowed. At follow-up, the range of motion, return to sports, pain, and functional scores (AOFAS and OMAS) were determined, and a radiological assessment was performed. RESULTS: One hundred twenty-six patients were reviewed after a mean follow-up of 5.9±5.7years (2.9-10.5). Mean plantarflexion was 95% of the contralateral side and mean dorsiflexion was 93%. Return to sports occurred after a mean of 10weeks; 83% of patients returned to their pre-injury level of participation. Pain on VAS was 0.8/10 on average. The mean AOFAS and OMAS scores were both above 90 points. At the review, 4% of screws had broken. Diastasis was found in 5.6% of cases, osteoarthritis in 6.3% and an osteophyte in 11.1% of cases, but with no clinical repercussions. No risk factors were identified. DISCUSSION AND CONCLUSION: Treatment by temporary screw fixation and ligament repair leads to good objective results, confirming our hypothesis. However, there is little published data and no consensus on the fixation method or the need to remove the screw. LEVEL OF EVIDENCE: IV, retrospective, non-comparative.

[Discoid menisci in children: clinical patterns and treatment in eighteen knees]. / Les ménisques discoïdes chez l'enfant: manifestations cliniques et indications thérapeutiques: a propos de 18 cas.

PURPOSE OF THE STUDY: Surgery is indicated when discoid menisci become symptomatic. The purpose of the surgical procedure is to resect any damaged tissue and restore the physiological shape of the meniscus. As a rule, as much meniscal tissue as possible must be spared because of the long-term deleterious effects on the cartilage of total meniscectomy. We analyzed a consecutive series of 18 cases of discoid menisci in children to search for secondary lesions and factors favoring their development in order to determine the optimal surgical procedure. MATERIAL AND METHODS: This retrospective series included 17 children (18 menisci) aged 7.5 years on average at diagnosis between 1985 and 2003. We noted the clinical manifestations, the imaging findings, time to treatment, and operative observations. The Watanabe classification was used to describe the discoid menisci. We also noted meniscal and cartilage damage and their consequences, as well as the consequences of late surgery on the type of procedure used. RESULTS: The main complaint was pain. Physical examination usually revealed a positive pivot test. Signs of osteochondral lesions of the lateral condyle were also observed in three children, and the MRI revealed degenerative menisci in four. Mean time from diagnosis to surgical treatment was 20 +/- 17 months. The Watanabe classification was type I (n=9), type II (n=5), type III (n=4). Arthroscopy revealed nine meniscal lesions and three cartilage lesions, one associated with osteochondritis. Meniscectomy was performed in eleven cases, meniscoplasty in seven. Meniscectomy was significantly more frequent (p<0.05) when there was a meniscal lesion (9/11 of the meniscectomies) and when the time from diagnosis to treatment was long (28 months versus 8 months for meniscoplasty, p<0.01). Time to surgery was associated significantly (p<0.05) with the proportion of meniscal, chondral, or osteochondral lesions. Inversely, the type of meniscus did not affect age at diagnosis, initial manifestations, or presence of a positive pivot test. DISCUSSION: While therapeutic abstention is warranted for asymptomatic menisci, surgical treatment should be undertaken if symptoms develop, irrespective of the type. If possible, surgery should be performed less than six months after diagnosis. The risk of secondary meniscal or cartilage injury increases with longer delay before surgery. Similarly, the chances of performing meniscoplasty are reduced with longer time from diagnosis to surgery. It must be recalled that the objective of conservative mensical surgery is to prevent secondary cartilage lesions after extensive meniscectomy and consequently the risk of osteoarthritis.

[Arthroscopic resection of pigmented villonodular synovitis pseudotumor of the shoulder: a case report with three year follow-up]. / Exérèse arthroscopique d'une forme pseudo-tumorale de synovite villonodulaire pigmentée de l'epaule: a propos d'un cas au recul de 3 ans.

Pigmented villonodular synovitis can be localized or diffuse. Lesions predominate in the knee but all of the joints can be involved. Thirty cases in the glenohumeral joint have been reported in the literature. The different reports to date have not identified any specific clinical signs. Our female patient presented non-specific shoulder pain which persisted for three years. The plain x-rays were normal. MRI and arthroscan revealed an intra-articular pseudotumor. Arthroscopy was performed for tumor biopsy which was followed by total resection. The diagnosis of villonodular synovitis pseudotumor suspected at arthroscopy was confirmed at the pathology examination. The functional outcome was excellent and no recurrence has been observed at three years follow-up. Arthroscopy is less aggressive than open surgery for arthrotomy. Arthroscopy must be performed for diagnostic purposes since imaging findings are not specific. Arthroscopic synovectomy is the treatment of choice for pigmented villonodular synovitis in both the diffuse and pseudotumor forms.

[Transverse radioulnar branch of the dorsal ulnar nerve: anatomic description and arthroscopic implications from 45 cadaveric dissections]. / Le rameau transverse de la branche dorsale du nerf ulnaire: anatomie et rapports avec les voies arthroscopiques du poignet: quarante-cinq dissections.

PURPOSE OF THE STUDY: We conducted an anatomic study of the transverse branch of the dorsal ulnar nerve to describe its morphology and position in relation to arthroscopic exploration portals. MATERIAL AND METHODS: Forty-five non-side-matched anatomic specimens of unknown age and gender were preserved in formol. The dorsal branch of the ulnar nerve was identified and dissected proximally to distally in order to reveal the different terminal branches. The morphometric analysis included measurement of the length and diameter of the transverse branch and measurement of wrist width. We also measured the smallest distance between the transverse branch and the ulnar styloid process, and between the branch and usual arthroscopic portals (4-5, 6R, 6U) in the axis of the forearm. RESULTS: The transverse branch was inconstant. It was found in 12 of the 45 dissection specimens (27%). In two-thirds of the specimens, the branch ran over less than 50% of the wrist width, tangentially to the radiocarpal joint. Mean nerve diameter was 1 mm. It was found 5-6 mm from the ulnar styloid process and was distal to it in 83% of the specimens. The dissections demonstrated two anatomic variants. Type A corresponded to a branch running distally to the ulnar styloid process, parallel to the joint line (10/12 specimens). Type B exhibited a trajectory proximal to the ulnar styloid process, crossing the ulnar head (2/12 specimens). The relations with the arthroscopic portals (4-5, 6R, 6U) showed that the mean distance from the branch to the portal was 3.75 mm for the 4-5 portal (distally in 11/12 specimens), 3.68 mm for the 6R portal (distally in 10/12 specimens), and 4.83 mm for the 6U portal (distally in 7 specimens and proximally in 5). DISCUSSION: To our knowledge, there has been only one report specifically devoted to this transverse branch. Two other reports simply mention its existence. According to the literature, the transverse branch of the dorsal ulnar nerve occurs in 60-80% of the cases. We found two anatomic variations different than those described in the literature. Based on our findings and data reported previously, we propose a new classification, describing two main types. In Type 1, the transverse branch arises proximally to the ulnar styloid process;type 1A and type IB are described in relation to the direction of the branch. In Type II, the branch arises distally to the ulnar styloid process;type IIA and type IIB again being described in relation to the direction of the branch. On the tangential trajectory over the radiocarpal joint, the morphometric data show a zone of risk described by a rectangle measuring 10 mm wide (6 mm distal and 4 mm proximal to the ulnar styloid process) and covering 50% of the wrist width. The relations with arthroscopic portals describe a zone of risk corresponding to a 5-7 mm radius circle centered on the portals (4-5, 6R, 6U), which includes 83% of the transverse branches.

Bone density and functional results after femoral revision with a cementless press-fit stem.

INTRODUCTION: The influence of radiographic bone density changes in the area surrounding a total hip arthroplasty (THA) revision with a cementless press-fit stem is unknown, notably in terms of functional results. We have therefore conducted a study aiming to (1) propose a radiographic method to assess bone density, (2) measure the functional effects of reduced bone density, and (3) determine the factors contributing to these modifications. HYPOTHESIS: A reduction in radiographic bone density has a negative influence on the functional result after revision using a cementless press-fit stem. MATERIAL AND METHODS: We retrospectively assessed 150 THA revisions at a mean follow-up of 6.3 ± 3.2 years (range, 2-15 years). The clinical assessment was based on the Harris Hip Score. Bone density modifications were measured radiographically and the method was evaluated. The change in bone density was classified into two groups: (1) bone density not reduced or < 2 Gruen zones (118 cases [79%]); (2) bone density reduced ≥ 2 zones (32 cases [21%]). The variables showing a potential influence were the Cortical Index (CI), the type of primary stability with the press-fit system, and the femoral implant length. RESULTS: Inter- and intraobserver reliability of radiographic bone density measurement was evaluated as moderate or good (Kappa, 0.58; 0.60 and 0.67, respectively). For the Harris Hip Score at follow-up, there was a borderline statistical relation between stages 1 and 2: for the 118 stage 1 patients, this score was 83.62 ± 11.54 (range, 27-99) versus 78.34 ± 15.98 (range, 62-91) for stage 2 patients (P = 0.09). A CI ≤ 0.44 showed mediocre bone quality contributing to decreased bone density (P < 0.02). On the other hand, there was no statistically significant relation with the type of primary fixation (P = 0.34) or the length of the implant (P = 0.23). CONCLUSIONS: A cementless revision femoral stem can induce a reduction in bone density with possible functional effects. The negative role played by bone scarcity on the functional score is confirmed, and even though the difference is not statistically significant, we suggest using a short stem when this is possible.

Critical analysis of olecranon fracture management by pre-contoured locking plates.

BACKGROUND: Fractures of the proximal ulna are rare and usually managed surgically. Strong fixation of the harware is essential to obtain good outcomes. We report our experience with pre-contoured locking plate fixation of complex olecranon fractures and present a critical appraisal of the outcomes. HYPOTHESIS: Pre-contoured locking plates provide good outcomes, but their clinical tolerance may be limited in some instances. MATERIALS AND METHODS: From September 2009 to December 2011, 28 patients were managed using a pre-contoured locking compression plate (LCP(®)). Among them, 6 were excluded because of missing data, which left 22 patients (11 males and 11 females) with a mean age of 55.7 years, including 12 who were employed. The fracture was on the dominant side in 11 patients. According to the Mayo Clinic classification, 15 fractures were type II and 7 type III. In addition to the ulnar fracture, a radial head fracture was present in 9 patients and a coronoid process fracture in 5 patients. Functional recovery was assessed using the Broberg-Morrey score and Mayo Elbow Performance Score (MEPS). Radiographs were obtained to evaluate the quality of fracture reduction and fracture healing, as well as to look for ossifications and osteoarthritis. RESULTS: Mean follow-up was 20 months. Flexion was 131°, extension loss was 9.5°, pronation was 79°, and supination was 80.5°. The mean Broberg-Morrey score was 96.7 and the mean MEPS score 96.6. Fracture healing occurred in all patients, within a mean of 10.6 weeks. Evidence of early osteoarthritis was found in 6 patients, ossifications in 3 patients, and synostosis in 1 patient. An infection was successfully treated with lavage and antibiotic therapy in 1 patient. The fixation hardware was removed in 6 patients. No prognostic factors were identified. DISCUSSION-CONCLUSION: Our hypothesis was confirmed. The outcomes are encouraging and comparable to those reported in the literature. The critical issue is the limited clinical tolerance of the plate with a high rate of posterior impingement requiring plate removal (27%). Rigorous technique is essential during plate implantation. LEVEL OF EVIDENCE: Level IV, retrospective study.

Hip arthroscopy in hereditary multiple exostoses: A new perspective of treatment.

The cases of 2 children (9 and 11 years old) with hereditary multiple exostoses disease are presented. The lesions were located primarily in the acetabular fossa of the left hip and caused pain and limitation of range of motion. Hip arthroscopy was performed to remove the exostoses without damaging the articular surfaces and the Y cartilage. After the procedure, the pain disappeared and normal range of motion was recovered for both children. Conventional surgery would have required hip dislocation to access these lesions with an increased risk of femoral head necrosis. These cases constitute a new and interesting application of hip arthroscopy.

[Osteosynthesis and radiotherapy of the proximal femur: report of 6 cases]. / Ostéosynthèse et radiothérapie du fémur proximal.

PURPOSE OF THE STUDY: Post-radiation shaft fractures of long bones are uncommon. Late or partial healing increases the risk of stress fracture. Different fixation techniques have been proposed. Treatment of radiated bone is difficult. We report a series of 6 nonunions of the proximal femur after radiotherapy. MATERIAL AND METHODS: Three patients had true fractures of irradiated bones several years after radiotherapy for bone or soft tissue tumors. Three other patients had pathological fractures or malignant osteolysis related to a myeloma and treated by osteosynthesis and post-operative radiotherapy. RESULTS: Treatment required a total of 19 surgical procedures. There were nine stress fractures of ostheosynthesis material involving locked nails, cervicodiaphyseal nails and plates. There were no vascularized grafts in this series. At last follow-up the pathological fracture had healed in three cases, was stable but not healed in two, and required prosthetic reconstruction in one. CONCLUSION: We emphasize the importance of rigorous patient selection for radiotherapy and the possible preventive effect of osteosynthesis in certain cases with a high risk of secondary fracture of an irradiated bone. Vascularized grafts may be useful for refractory nonunion and may be proposed as first line treatment for post-radiation fractures.

[A new implant for proximal humeral fracture: experimental study of the basket plate]. / Un nouvel implant pour les fractures de l'humérus proximal: la plaque à corbeille. Etude expérimentale.

PURPOSE OF THE STUDY: We conducted a comparative study of three ostheosynthesis systems for proximal humeral fractures. The conclusions led to the elaboration of a rigid extramedullary osteosynthesis implant. This novel implant allows specific fixation of the tuberosities via six adjustable and removable hooks organized like a basket. There are two versions, with and without a central cephalic locking screw. We report two static biomechanical studies conducted to analyze this material. MATERIAL AND METHODS: The two studies were performed on fresh frozen cadaver specimens with known bone density and with an experimental model of a four-fragment fracture of the proximal humerus. The first tests were designed to measure axial pressure reproducing the physiological movement applying the most stress on the head of the humerus. This allowed a global analysis of the mechanical behavior of the implant and an assessment of the contribution of the central cephalic locking screw. The second series of tests were traction tests used to analyze the behavior of the tuberosities fixed with the hooks. We assess the assemblies by measuring the mechanical resistance: rigidity of the fixation was recorded in mm/100N. Pre- and post-procedure x-rays and photographs were obtained to allow a subjective assessment of fragment displacement. RESULTS: The first series of tests demonstrated that the implant, with the central cephalic locking screw, presented good overall mechanical properties. The notion of better stability of the tuberosities obtained with the hooks, as seen during the first tests, was reinforced by the data from the second tests, although no statistically significant difference was demonstrated. We also noted that there was no statistically significant correlation between bone density and the slopes of the force-resistance curves. DISCUSSION: This prototype implant has an overall mechanical resistance equivalent to the reference implant, with at least equivalent performance. Proof of the usefulness of the central locking screw was not established, even though improved tolerance to loading by better force distribution seemed apparent. The contribution of the hook basket was not demonstrated. Data from the observations do however suggest the expectations of the implant will be fulfilled. Tests conducted on a larger scale would probably demonstrate a difference. It is clear that the small number of implants used here limited the study. Comparison with data in the literature show that this new prototype is adapted to the mechanics of the proximal humerus. Resistant to physiological stress, the implant allows pendular movement and passive physical therapy during the early post-operative period.

[Arthroscopic treatment of chronic anterior instability of the shoulder by staple capsulorrhaphy. Apropos of a series of 55 patients with a minimum of 18 months follow-up]. / Traitement arthroscopique de l'instabilité antérieure chronique de l'épaule par capsulorrhaphie avec agrafage. A propos d'une série continue de 55 cas ayant un recul supérieur à 18 mois.

PURPOSE OF THE STUDY: The authors studied the results of the arthroscopic staple capsulorrhaphy of 55 patients who had recurrent anterior shoulder instability. MATERIALS AND METHODS: There were 38 men and 17 women. The average age at operation was 30.3 years (17 to 68) and the dominant side was injured in 33 patients. 28 (51 per cent) patients had recurrent dislocations, 19 (38 per cent) patients had recurrent subluxations and 8 (14 per cent) complained of a painful shoulder with instability. Multidirectionnal hyperlaxity and glenoid rim fracture cases were excluded from this study. The average duration of symptoms was 43 months (i to 180). At operation, 46 patients had a Bankart lesion (Adolfsson A or C) and 9 had "non Bankart" lesion (Adolfsson B and intra ligamentous disruption). There were 6 (11 per cent) SLAP II lesions and 23 (42 per cent) other glenoid labral tears associated with main instability lesions. 58 staples were inserted. 53 inferior glenoid humeral ligament were fixed to the glenoid rim and in 2 cases we performed a subscapularis tendon tenodesis. RESULTS: The follow-up was continued for at least 18 months after treatment by an examiner different from the operating surgeon. (Average follow-up was 29.8 months). The results were assessed according to "Duplay" rating scale. Overall we have obtained 64 per cent excellent and good results. 71 per cent of shoulders were considered stable at revision whereas 7 per cent showed recurrent dislocation. 60 per cent of patients were able to return to their previous sport level. A limited range of motion was noted in only 11 per cent of cases. On the other hand 54 per cent of patients presented persistent pain. With regard to the shoulder stability, the factors possibly having a negative influence were the occurrence of an initial acute dislocation, the destruction of the inferior glenohumeral ligament (disruption or absence) and the sub-equatorial position of the staple on the anterior glenoid rim. Pain was more frequent in cases where there was associated subacromial impingement and where the staples had been badly positioned. DISCUSSION: We have compared our results with those of other authors who also performed stapling procedures, including different arthroscopic techniques and results of open stabilization surgery. Our results regarding shoulder instability were better than those obtained by arthroscopic sutures, equivalent to those obtained by the "Open Bankart" procedure, but less impressing than those obtained by the "Bone Block" procedure (Patte). However, pain was observed much more frequently than with all the other stabilization techniques, arthroscopic or not. CONCLUSION: Arthroscopic stapling therefore seemed to be less reliable than the "Patte Bone Block" procedure. At present, we reserve arthroscopic stabilization for patients with a good inferior glenohumeral ligament. Until an adapted biodegradable staple is perfected, we still use an anchorsuture technique to avoid pain due to metallic implant.

[Comparative study of fixation mode in total knee arthroplasty with preservation of the posterior cruciate ligament]. / Etude comparative des modes de fixation d'une arthroplastie du genou conservant le ligament croisé postérieur.

PURPOSE OF THE STUDY: We performed a prospective randomized study to compare two fixation modes, with and without cement, for total knee arthroplasty. MATERIAL AND METHODS: The study series was composed of 96 cemented or noncemented total knee arthroplasties performed between May 1993 and October 1995. The only difference was the diamond interface used for cemented prostheses and the mesh interface used for uncemented prostheses. The operator was unaware of the type of fixation until the bone slices had been obtained. We assessed outcome in 73 cases with a mean follow-up of 27 months. The two populations were comparable for preoperative clinical status, bone tophicity and surgical procedure. RESULTS: The mean duration of the operation was sgnificantly longer (> 10 min) for the cemented protheses. The complication rates were comparable but we did have two mobilizations of the tibial implant in the noncemented group. The total scores (127 +/- 29 in the cemented group versus 135 +/- 20 in the uncemented group) were significantly different. There were however more cases with degradation of the controlateral knee in the cemented group although the difference was not significant. When these cases were excluded from the analysis, the total scores for two groups were similar (143 and 140 respectively). Radiographic outcome was quite different with mobilization of the tibial implant in 2 cases and the rate of lucent borders was significantly higher in the noncemented group. DISCUSSION AND CONCLUSION: While the clinical outcome was comparable, the quality of the fixation was significantly better with cemented arthroplasty, which remains the gold standard.

[Experimental comparative study of 3 systems of osteosynthesis for proximal humeral fractures. Preliminary study of the mechanical properties of conserved trabecular bone]. / Etude comparative expérimentale de trois systèmes d'ostéosynthèse des fractures de l'humérus proximal. Etude préliminaire sur les propriétés mécaniques de l'os spongieux conservé.

PURPOSE OF THE STUDY: We have compared three systems for osteosynthesis of proximal humeral fractures on a four-fragment fracture model: Plate with tuberosity screwing (P), Kirschner wires with bone sutures (K) and an original implant, the "bilboquet" (Stryker) (B), composed of a hook for the head supported on a diaphyseal stem. MATERIAL AND METHODS: Because of the unavailability of fresh human material, we have turned to embalmed bones after having shown, on cancellous femoral head bone, the little influence of our method Vs freezing conservation. Settings were tested in compression. We measured their mechanical resistance judged on the ultimate strength and on the slope (displacement/load), to this limit. We similarly analyzed by video recording displacement of the different fragments according to four components (head slipping, its lateral displacement, its see-saw and the separation of tuberosities), to show the weak points of the three systems. RESULTS AND DISCUSSION: K was more deformable (p < 0.001) that P and B (average slopes in mm/100N to 0.67 for K, 0.42 for P and 0.43 for B). The ultimate strength differed but not significantly (average values in Newton to 1223 for K, 1601 for P and 1721 for B). We also showed for the three techniques, the significant correlation between slopes and bony densities. Video analysis showed that P opposed lateral displacement of the head and separation of tuberosities better, the resistance to slipping and see-saw seems to be improvable by greater divergence of screws or a modification of the plate (mini canon). B opposed slipping and see-saw better but its weak point was the risk of articular break-in of the hook, by defect of resistance to lateral displacement, that for us could be limited by a less peripheral position of teeth or a modification of their form. K is indeed the least effective of the four components but we think that it would be improvable by using, for example, a centro-medullary technique, allowing an internal cortical support.