Athletic pubalgia: Return to play after targeted surgery.

BACKGROUND: Surgery for athletic pubalgia usually consists in abdominal wall repair combined with routine bilateral adductor tenotomy. We currently confine the surgical procedure to the injured structure(s) (abdominal wall only, adductor tendon only, or both) to limit morbidity and expedite recovery. Outcomes of this à la carte approach are unclear. The objectives of this retrospective study were to determine the return to play (RTP) time, evaluate the potential influence of injury location, and assess the frequency of recurrence or contralateral involvement. HYPOTHESIS: À la carte surgery for athletic pubalgia is associated with similar RTP times as the conventional procedure and is not followed by recurrence. MATERIAL AND METHODS: Consecutive adults younger than 40 years of age who underwent surgery for athletic pubalgia with injury to the abdominal wall and/or adductor attachment sites between 2009 and 2015 were included. Patients with intra-articular hip disorders, isolated pubic symphysis involvement, or herniation were not eligible. The diagnosis was established clinically then confirmed by at least one imaging technique (ultrasonography plus either a radiograph of the pelvis or magnetic resonance imaging of the pelvis). The criterion for performing surgery was failure of appropriate conservative therapy followed for at least 3 months. RESULTS: Of the 27 included patients, eight had abdominal wall involvement only, seven adductor tendon involvement only, and 12 both. Overall, 25 (92.6%) patients returned to play at their previous level, after a mean of 112±38 days (range, 53-223 days), and experienced no recurrence during the 1-year follow-up. Mean RTP time was significantly shorter in the group with abdominal wall injury only (91.1±21.0 days) compared to the groups with adductor tendon injury only (101.7±42.0 days) or combined injuries (132.5±39.0) (p=0.02). DISCUSSION: In patients with athletic pubalgia, à la carte surgery confined to the injured structure(s) produces excellent RTP outcomes. RTP time is shortest in patients with isolated lower abdominal wall injuries. LEVEL OF EVIDENCE: IV, retrospective study with no control group.

Mid-term survivorship of Mini-keel™ versus Standard keel in total knee replacements: Differences in the rate of revision for aseptic loosening.

INTRODUCTION: To reduce the size of the surgical incision, modular mini-keel tibial components have been developed with or without extensions for the Nexgen™ MIS Tibial Component. Although a smaller component could theoretically result in defective fixation, this has never been evaluated in a large comparative series. Thus, we performed the following case control study to: (1) evaluate intermediate-term survival of a modular "mini-keel" tibial component compared to a reference standard keel component from the same line of products (Nexgen LPS-Flex Tibial Component, Zimmer); (2) to identify any eventual associated factors if the frequency of loosening was increased. HYPOTHESIS: The rate of revision for aseptic tibial loosening is comparable for both components. MATERIALS AND METHODS: This comparative, retrospective, single center series of 459 consecutive total knee arthroplasties (TKA) was performed between 2007 and 2010: with 212 modular "mini-keel" (MK) tibial components and 247 "standard" (S) components. Survival, rate of revision for aseptic tibial loosening and identification of a radiolucent line were analyzed at the final follow-up. RESULTS: After a median follow-up of 5years, the rate of revision for tibial aseptic loosing was significantly higher in the MK group with 12 cases (5.7%) and 4 cases in the S group (1.6%) (P=0.036). The use of the MK component appears to be a prognostic factor for surgical revision (hazard ratio=3.86 (1.23-11.88), P=0.02) but not for the development of a radiolucent line (HR=1.75 (0.9-3.4), P=0.097). The mean delay before revision was 38months (8-64) in the MK group and 15.2months (8-22) in the S group (P=0.006). Individual factors, such as gender, body mass index (BMI) and pre- or postoperative alignment were not prognostic factors for revision or radiolucent lines. CONCLUSION: The modular "mini-keel" tibial component was associated with a greater risk of revision for tibial component loosening. LEVEL OF EVIDENCE: Case control study, III.

Complications in posteromedial arthroscopic suture of the medial meniscus.

INTRODUCTION: All-inside posteromedial suture for lesions of the posterior horn of the medial meniscus in anterior cruciate ligament (ACL) repair provides effective freshening and good healing. HYPOTHESIS: The posteromedial portal provides satisfactory healing rates without increasing morbidity or complications rates. MATERIAL AND METHODS: Intra- and postoperative complications were collected for a consecutive single-center series of 132 patients undergoing posteromedial hook suture of the medial meniscus in ACL repair. Meniscal healing was assessed as the rate of recurrence of symptomatic medial meniscus lesions (Barret criteria) and on revision surgery, if any, in terms of the aspect and extent of the iterative lesion. The severity of any sensory disorder was assessed by questionnaire. RESULTS: The intraoperative complications rate was 1.5% (2 saphenous vein punctures). At a mean 31months (range, 28-35months), there was no loss to follow-up. Twelve patients (9%) showed symptomatic recurrence of the medial meniscus lesion, requiring 10 repeat surgeries. In 6 cases (4.5%), the iterative lesion involved a smaller, more central part of the meniscus anterior to the sutures, of "postage-stamp" effect, possibly implicating the suture hook and/or non-absorbable sutures. There were no cases of infection or fistula. Postoperative hematoma occurred in 7% of patients. In total, 1.8% reported dysesthesia areas equal to or greater than the size of a credit card (45cm2). DISCUSSION: Some retears, or "partial failures", may implicate a new lesion caused by the suture hook and possibly prolonged by non-resorbable sutures. Hematoma and sensory disorder rates were comparable to those reported in isolated ACL repair without posteromedial portal. CONCLUSION: The present results show that posteromedial arthroscopic hook suture in posterior medial meniscus tear provides good healing rates without increased morbidity due to the supplementary portal. LEVEL OF EVIDENCE: IV.

Arthroscopic treatment of painful Sinding-Larsen-Johansson syndrome in a professional handball player.

Sinding-Larsen-Johansson (SLJ) syndrome is a type of osteochondrosis of the distal pole of the patella most often caused by repeated microtrauma. Here, we describe the case of a professional athlete with painful SLJ syndrome treated arthroscopically. A 29-year-old male professional handball player presented with anterior knee pain that persisted after 4 months of an eccentric rehabilitation protocol and platelet-rich plasma injections. Despite this conservative treatment, the patient could not participate in his sport. The SLJ lesion was excised arthroscopically, which led to complete disappearance of symptoms and return to competitive sports after 5 months.

Diaphyseal tibiofibular synostosis in professional athletes: Report of 2 cases.

Anterior leg pain is common in professional athletes and tibiofibular synostosis is reported to be a rare cause of anterior compartment pain or ankle pain related to sports activities. The management and appropriate treatment of this condition in professional athletes is controversial and the literature on the topic is sparse. Distal synostosis is usually related to ankle sprain and syndesmotic ligament injury, and proximal synostosis has been linked to leg length discrepancy and exostosis. Mid-shaft synostosis is even less common than proximal and distal forms. We present the treatment of mid-shaft tibiofibular synostosis in 2 cases of professional athletes (soccer and basketball player), along with a review of the literature. When diaphyseal synostosis is diagnosed, first-line conservative treatment, including ultrasound-guided steroid injection is recommended. However, if it does not respond to conservative management, surgical resection may be indicated to relieve symptoms.

Flexor digitorum brevis tendon transfer to the flexor digitorum longus tendon according to Valtin in posttraumatic flexible claw toe deformity due to extrinsic toe flexor shortening.

Claw toe deformity after posterior leg compartment syndrome is rare but incapacitating. When the mechanism is flexor digitorum longus (FDL) shortening due to ischemic contracture of the muscle after posterior leg syndrome, a good treatment option is the Valtin procedure in which the flexor digitorum brevis (FDB) is transferred to the FDL after FDL tenotomy. The Valtin procedure reduces the deformity by lengthening and reactivating the FDL. Here, we report the outcomes of FDB to FDL transfer according to Valtin in 10 patients with posttraumatic claw toe deformity treated a mean of 34 months after the injury. Toe flexion was restored in all 10 patients, with no claw toe deformity even during dorsiflexion of the ankle.