Endoscopic treatment of gluteus medius tendon tear.

Tears in the gluteus medius and minimus tendons are a common cause of greater trochanter pain syndrome (GTPS). Given the non-specific clinical signs and imaging findings, they are often misdiagnosed, with delayed treatment. The lesions can show several aspects: trochanteric bursitis, simple tendinopathy, partial or full-thickness tear, tendon retraction, or fatty degeneration. Non-surgical treatment associates physical rehabilitation and activity modification, oral analgesics, anti-inflammatories and peri-trochanteric injections (corticosteroids, PRP). In the event of symptoms recalcitrant to medical treatment, surgery may be indicated. A 5-stage classification according to intraoperative observations and elements provided by MRI is used to guide technique: isolated bursectomy with microperforation, single or double row tendon repair, or palliative surgery such as muscle transfer (gluteus maximus with or without fascia lata). The development of conservative hip surgery now makes it possible to perform all of these surgical techniques endoscopically, with significant improvement in functional scores and pain in the short and medium term and a lower rate of complications than with an open technique. However, tendon retraction and fatty degeneration have been reported to be factors of poor prognosis for functional results and tendon healing and palliative tendon transfer gives mixed results for recovery of tendon strength. It is therefore preferable not to wait for the onset of Trendelenburg gait to propose endoscopic repair of the gluteus medius tendon in case of pain with a tear visible on MRI and failure of more than 6 months' medical treatment. Based on expert opinion, this article provides an update on the diagnosis of gluteus medius lesions, treatment, and in particular the place of endoscopy, indications and current results. LEVEL OF EVIDENCE: V.

Separation of planar chiral ferrocenes by capillary electrokinetic chromatography and liquid chromatography.

Capillary electrokinetic chromatography (CEKC) and liquid chromatography (LC) methods were explored for the enantiomeric separation of six unsymmetrically disubstituted ferrocene derivatives. In normal-phase mode liquid chromatography, the use of n-heptane, ethanol or isopropanol with 1% n-butylamine as mobile phase on six polysaccharide-based columns, allowed to fully separate the enantiomers of three compounds out of the six (i.e 7-chloro-N-(2-((dimethylamino)methyl)ferrocenyl)quinolin-4-amine (ferroquine) (compound 1), 1-[(1S)-(1-Aminoethyl)]-2-(diphenylphosphino)ferrocene (compound 5) and 1-[(1R)-1-(Dicyclohexylphosphino)ethyl]-2-(diphenylphosphino)ferrocene (compound 6). Among the columns used, the Lux i-Cellulose-5 was the most effective. In capillary electrokinetic chromatography, a phosphate buffer of 25 mM concentration and pH equal to 2.5 was chosen as background electrolyte, leading to cationic ferrocene derivatives. The addition of neutral cyclodextrins was undertaken first and native ß- or γ-cyclodextrins were found to resolve the enantiomers of two derivatives. Then, 15 mM of anionic cyclodextrins were added to the background electrolyte. The use of SBE-ß-CD, S-ß-CD or S-γ-CD have allowed the separation of the enantiomers for most of the ferrocene derivatives studied with high resolution values in short migration time. For instance, for 1-(R)-2-(Diphenylphosphino)ethyldi-tert-butylphosphine ferrocene (compound 2), the migration times were less than 2 minutes and the resolution value was equal to 3.52 in short-end mode with 15 mM S-ß-CD, at 25 kV and 25°C. Finally, a dual cyclodextrins system was tested using 15 mM of S-ß-CD plus 15 mM HP-γ-CD in the phosphate buffer. This system allowed the improved separation of two ferrocene derivatives with an unusual resolution value equal to 41.5 in long-end mode. Overall, CEKC showed better enantioseparating power of the six chiral ferrocenes studied than liquid chromatography.

Supercritical fluid chromatography for separation of chiral planar metallocenes.

Unsymmetrically disubstituted metallocene derivatives, characterized as the first sandwich structure, have found interest in asymmetrical synthesis and in medicinal chemistry as well. Besides, they present a particular case of chirality. Twenty original and six commercially available molecules presenting either i) a planar chirality or ii) an asymmetrical carbon containing group or iii) being symmetrically substituted were analyzed in supercritical fluid chromatography on eleven polysaccharide-based chiral stationary phases with carbon dioxide containing 30% of methanol or 2-propanol as a co-solvent mobile phase. A basic additive, either diethylamine, triethylamine or n-butylamine was also required at 1% to the co-solvent for elution. While some of the tested chiral stationary phases provided enantioseparation for the racemates, chlorinated cellulosic phases proved to be both highly retentive and highly enantioselective towards these particular species with the highest rate of success compared to their non-chlorinated counterparts. For instance, the resolution value was equal to 14.1 for one ferrocene derivative in one-hour analysis time on cellulose tris(3,5-dichlorophenylcarbamate) column with 30% 2-propanol/1% n-butylamine while a single peak was observed under the same conditions on cellulose tris(3,5-dimethylphenylcarbamate) column. Experimental parameters were arbitrarily set at 150 bar outlet pressure, 40 °C temperature and 3 mL/min flow-rate.

Long-term outcome for repair of osteochondral lesions of the talus by osteochondral autograft: A series of 56 Mosaicplasties®.

INTRODUCTION: The present study analyzed results in 56 osteochondral Mosaicplasty® autografts for osteochondral lesion of the talus (OLT) at more than 5 years' follow-up. HYPOTHESIS: Mosaicplasty® shows long-term efficacy and low morbidity in the treatment of OLT. PATIENTS AND METHODS: A multicenter retrospective study included patients treated by Mosaicplasty® with more than 5 years' follow-up. Preoperative data were collected from medical files, and all patients were reassessed. AOFAS scores and FAOS were calculated at last follow-up. Imaging comprised standard radiographs and MRI or CT arthrography of the ankle. RESULTS: Fifty-six patients were included, with a mean age of 34 years (range, 18-60 years). Seventeen involved work accidents. Mean follow-up was 8.5 years (range, 5-20 years). Mean AOFAS score at follow-up was 80.6±19.4 and mean FAOS 77.8±21.5. Work accident, preoperative osteoarthritis and untreated laxity correlated significantly with poorer results. At last follow-up, 22 patients (39%) showed signs of osteoarthritis. There was no morbidity implicating the malleolar osteotomy. There were 11 cases (20%) of persistent patellar syndrome at the donor site. DISCUSSION: The present results were comparable to those reported elsewhere, showing that functional results of Mosaicplasty® autograft for OLT do not deteriorate over the long term. Work accidents correlated significantly with poorer functional outcome. Any associated instability must always be treated. Malleolar osteotomy provides good exposure without additional morbidity. LEVEL OF EVIDENCE: IV; retrospective study.

Osteochondral lesion of the talus: What are we talking about?

INTRODUCTION: The analysis of osteochondral lesions of talus (OLT) is currently mostly descriptive, not permitting an understanding of the different nosological frameworks of these lesions. Better knowledge of the characteristics of patients with OLT should make it possible to optimize the surgical indications and anticipate the associated lesions, which should not be overlooked. The main objective of this study was, therefore, to assess the characteristics of patients with OLT, and to analyze the lesions encountered. HYPOTHESIS: OLTs correspond to variable entities responding to specific treatments. MATERIAL AND METHOD: This was a prospective multicenter descriptive study including all patients operated on for an OLT, aged between 15 and 65 years, across 10 French specialist centers. The demographic, clinical and radiological data of the patients were analyzed. RESULTS: OLTs predominantly affect males and patients in their thirties. Two types of OLT should be distinguished: a lateral OLT; smaller and more superficial, most often presenting with painful instability, in the context of trauma, and a medial OLT; more frequent, wider and deeper. DISCUSSION: Two nosological frameworks exist for OLTs, and correspond to precise surgical indications: medial lesions of more than 10mm2 and more than 5mm in depth, with isolated anteromedial pain and significant functional impairment, most often idiopathic, generally requiring treatment by osteochondral autografts. Lateral lesions less than 5mm in depth and less than 10mm2, often superficial, following trauma or ankle laxity, associated with lateral ligament damage in one-third of cases, and a clinical presentation associated to instability and pain, requiring treatment most often by microfracture with associated ligament repair. LEVEL OF EVIDENCE: III.

Safety of malleolar osteotomies in surgery for osteochondral lesions of the talus.

The talus is a central bone in the hindfoot that is difficult to access surgically. Performing a medial or lateral malleolar osteotomy in the management of an osteochondral lesion of the talus (OLT) is a feared procedure amongst surgeons and their patients. The objective of this study was to assess the complications inherent to malleolar osteotomies in the treatment of OLTs. HYPOTHESIS: The use of a standardized protocol concerning the technical performance and osteosynthesis of malleolar osteotomies results in fewer postoperative complications than a non-standardized protocol. MATERIALS AND METHOD: This is a comparative study comprising a prospective multicenter non-randomized series with a standardized protocol for performing malleolar osteotomies, and a multicenter retrospective series without a standardized protocol. We included all patients aged 16 to 65 years with symptomatic OLTs, resistant to more than 6-months of well-conducted medical treatment, for whom surgery was considered. The minimum follow-up was 1 year for the prospective study, and 5 years for the retrospective study. A total of 86 and 97 patients were included in the prospective and retrospective studies, respectively. Of these 183 patients, 86 patients (33 prospective and 53 retrospective) underwent medial or lateral malleolar osteotomies as part of their surgery for OLT. Complications specific to the osteotomy procedures such as scar tissue, surgical site infection, non-union, articular malunion, neurological lesions or surgical revision, were investigated. RESULTS: No specific complication was found to be associated to the malleolar osteotomy. No surgical revision was directly linked to the osteotomy procedure. No significant difference was found between the two series. DISCUSSION: There was no evidence of morbidity related specifically to medial or lateral malleolar osteotomies. A standardized protocol, subject to rigorous technical implementation, does not improve results after malleolar osteotomy. The fear associated with this malleolar osteotomy procedure seems unfounded. LEVEL OF EVIDENCE: IV.

ACL injuries before 15 years of age: could the young become an athlete?

PURPOSE: The purpose of this study was to systematically assess the possibility for a patient younger than 15 to return to a competitive level of sport following an ACL injury. METHODS: Four databases were analyzed (PubMed, MedLine, Cinahl, Cochrane Library and LISTA). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to guide the screening of the literature. Studies about functional and surgical treatments were included with a minimum of 5 years of mean follow-up. Methodological quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale. RESULTS: Ten studies were included, corresponding to a total of 217 patients. All studies were retrospective with level 4 evidence. Seven studies reported results of a transphyseal technique reconstruction, two studies a physeal-sparing reconstruction, and one studied the results of a repair (« healing response ¼). Only one study compared functional treatment and surgery. The mean age of patients at the time of surgery was 12.29 years (range 2-16) with a mean follow-up of 7.9 years (range 5.5-18.3). Return to sport was possible for 80 to 100% of patients (average of 91.7%) at the final follow-up but the level for return to sport was reported in only four studies and found between 61 and 89% for return to the same level and at 42% for return to a competitive level. Evolution of the Tegner score was analyzed in five studies and was reported to decrease at the follow-up in three studies. ACL re-ruptures can be considered as failure of the graft (nine studies with surgical technique) and occurred with an average of 16%. CONCLUSION: This review demonstrate that ACL reconstruction is superior to conservative treatment and 'healing response' in terms of revision rates and knee laxity. Return to sport is possible for more than 4/5 of patients but only two thirds of them were able to return to the same level or to competitive level, and failure rates of the graft were not superior to global population. However, qualities of included studies and variability of treatment limited the clinical application of results. Despite this, patients and parents should be informed that ACL injuries are lesions that may influence the level of sport at a 5-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review.

Risk factors for cut-out after internal fixation of trochanteric fractures in elderly subjects.

INTRODUCTION: Proximal femoral fracture is associated with severe morbidity and mortality and high socioeconomic costs. The main mechanical complication of internal fixation in trochanteric fracture is lag-screw cut-out through the femoral head. Several factors are involved, but remain controversial. The aim of the present study was to determine risk factors for cut-out in internal fixation of extracapsular proximal femoral fracture. METHODS: A single-center retrospective study was conducted on a continuous series of 228 patients aged over 75 years, operated on for trochanteric fracture by gamma3 nail or DHS screw plate between July 2009 and December 2014. RESULTS: Thirteen patients experienced mechanical failure of the internal fixation (5.7%). Tip-apex distance (TAD) differed significantly between the group with cut-out (32.69mm) and the group with consolidation (23.70mm; p-value=0.003052). Cut-out rate was 0.89% in good reduction, versus 9.64% in moderate and 12.12% in poor reduction (p-value=0.002693). In contrast, there were no significant differences according to age, type of fracture, or severity of osteoporosis. CONCLUSION: To minimize mechanical complications exacerbating morbidity and mortality, great attention should be paid to fracture reduction and lag-screw positioning. LEVEL OF EVIDENCE: IV, retrospective study.

Reliability and validity of preoperative MRI for surgical decision making in chronic lateral ankle instability.

PURPOSE: To evaluate the value of analyzing the anterior talofibular ligament (ATFL) on preoperative MRI as a decision-making tool to determine the surgical technique in patients undergoing surgery for chronic lateral ankle instability. METHODS: A retrospective study of prospective data was performed. All patients who underwent surgery between 2013 and 2016 for arthroscopic stabilization of the ankle were included. The ATFL was evaluated on preoperative MRI including axial T2-weighted images by two readers who were blinded to arthroscopic results. The arthroscopic evaluation, which was considered to be the reference examination, was performed by one senior surgeon. The main judgment criteria were two features of the ATFL: (1) absent or thin (< 1 mm thick) and (2) detached or thickened (> 3.2 mm in diameter) with or without a high intensity intraligamentous signal. Inter- and intraobserver reproducibility was evaluated by the kappa coefficient (k), and parameters of the diagnostic accuracy of preoperative MRI were analyzed. RESULTS: Twenty-two patients were included, 15 men/7 women mean age 30.3 ± 9.5 years. Fourteen patients (63.6%) underwent arthroscopic repair of the ATFL (Broström-Gould technique) and 8 patients (36.4%) an arthroscopic anatomical reconstruction of the ATFL. Intraobserver reproducibility of MRI findings was substantial (k = 0.68) and interobserver reproducibility moderate (k = 0.55) to nearly perfect (k = 0.87). Agreement between MRI and arthroscopic findings was substantial (k = 0.70). Diagnostic parameters of preoperative MRI were good for both observers: Se = 85.7-87.5%, Sp = 86.7-92.9%, PPV = 75-87.5%, NPV = 92.9%, and classification of patients was good = 86.4-90.9%. CONCLUSION: Preoperative MRI of the ATFL is a reliable and valid decisional tool to choose the surgical technique for stabilization of chronic lateral ankle instability. LEVEL OF EVIDENCE: Level II; Diagnostic study-development of diagnostic criteria on the basis of consecutive patients.