Resection of bilateral massive Achilles tendon xanthomata with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap: A case report and literature review.

Tumours of the Achilles tendon are rare. Reconstruction of the large defect following excision, however, is often a challenge and is sometimes a factor in deciding against operative treatment of a benign lesion. We report a case of excision of bilateral Achilles tendon xanthomata, with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap.

The effect of ankle and hindfoot malalignment on foot mechanics in patients suffering from post-traumatic ankle osteoarthritis.

BACKGROUND: Ankle and hindfoot malalignment is a common finding in patients suffering from post-traumatic ankle osteoarthritis. However, no studies have addressed the effect of concomitant foot deformities on intrinsic foot kinematics and kinetics. Therefore, the objective of this study was to investigate the effect of ankle and hindfoot malalignment on the kinematics and kinetics of multiple joints in the foot and ankle complex in patients suffering from post-traumatic ankle osteoarthritis. METHODS: Twenty-nine subjects with post-traumatic ankle osteoarthritis participated in this study. Standardized weight-bearing radiographs were obtained preoperatively to categorize patients as having cavus, planus or neutral ankle and hindfoot alignment, based on 4 X-ray measurements. All patients underwent standard gait assessment. A 4-segment foot model was used to estimate intrinsic foot joint kinematics and kinetics during gait. Statistical parametric mapping was used to compare foot kinematics and kinetics between groups. FINDINGS: There were 3 key findings regarding overall foot function in the 3 groups of post-traumatic ankle osteoarthritis: (i) altered frontal and transverse plane inter-segmental angles and moments of the Shank-Calcaneus and Calcaneus-Midfoot joints in the cavus compared to the planus group; (ii) in cavus OA group, Midfoot-Metatarsus joint abduction sought to compensate the varus inclination of the ankle joint; (iii) there were no significant differences in inter-segmental angles and moments between the planus and neutral OA groups. INTERPRETATION: Future studies should integrate assessment of concomitant foot and ankle deformities in post-traumatic ankle osteoarthritis, to provide additional insight into associated mechanical deficits and compensation mechanisms during gait.

Diabetic Foot Management: How Could a Procedural Pathway Improve the Surgical Outcome?

INTRODUCTION: Diabetic foot ulcer is the main aetiology for non-traumatic amputation, which is a major public health care concern. A multidisciplinary approach in the management of this pathology has been shown to improve the surgical outcome. However, there are little data available on the tools we can use to pursue this multidisciplinary approach. The main goal of this cross-sectional study was to find out whether the implementation of a specific management pathway could improve the treatment outcome in the treatment of diabetic foot. MATERIALS AND METHODS: From 2012 to 2014, we consecutively recruited patients with diabetic foot referred to Orthopaedic surgery department of our university for surgical opinion. A specific diabetic foot pathway was introduced in 2013. One group of patients who were treated with previous method were evaluated retrospectively. Another group of patients who were treated after implementation of the pathway were evaluated prospectively. We compared treatment outcome between the two groups. RESULTS: We included 51 patients. Amputation rate was similar both the groups: 74% in the retrospective group not using the new pathway versus 73% in a prospective group that used the new pathway. Revision surgery was 39% in the retrospective group and 14% in the prospective group (p=0.05). CONCLUSION: We recommend the use of this simple and cost-effective pathway to guide the interdisciplinary management of diabetic foot. A prospective study with more subjects would provide a better overview of this management pathway.

[Hallux valgus surgery in 2005. Conventional, mini-invasive or percutaneous surgery? Uni- or bilateral? Hospitalisation or one-day surgery?]. / La chirurgie de l'hallux valgus en 2005. Chirurgie conventionnelle, mini-invasive ou percutanée ? Uni- ou bilatérale ? Hospitalisation ou ambulatoire ?

There remains a good deal of controversy concerning forefoot surgery. Certain concepts such as conventional procedures, minimally invasive surgery, or percutaneous surgery are promoted because of their specific advantages including rapid recovery and compatibility with a short hospital stay or even outpatient surgery. Nevertheless, in 2005 many questions remain unanswered and highly variable practices have been basically founded on personal experience rather than scientific evidence. In addition, financial and lobbying pressure appears to have an influence on our choices, affecting the freedom of our therapeutic decision-making. Developed over a long period, conventional surgery has proven reliability, reproducibility and adaptability. Procedures termed minimally invasive are defined by the limited incision. Percutaneous surgery is not less invasive than other procedures; the techniques are performed under indirect visual control and often assisted with more or less sophisticated radioscopic techniques depending on the surgeon's own experience. In our opinion, percutaneous surgery should be considered as a new concept based on rapid and functional results. Patients often raise the question of a bilateral procedure. For hallux valgus, there is no consensus on whether unilateral or bilateral procedures are better, the best solution depending on postoperative weight bearing and thus on the technique employed. From a cost expenditures point of view, bilateral procedures have an impact. For the advantages in terms of macroeconomy for professional incapacity, the question is less univocal for healthcare authorities. Advances in perioperative anesthesia and analgesia have enabled a broader approach to ambulatory surgery. Outpatient surgery appears to have benefits in terms of organization and economics. Variables studied were as follows: duration of hospital stay, postoperative edema, number of days of sick leave and preoperative and early and late postoperative pain. Patients who underwent minimally invasive procedures had a significantly shorter hospital stay compared with three other groups. For bilateral procedures, hospital stay on average was longer than in the two other groups. There was no correlation between postoperative edema and pain or between the degree of edema at 15 days and two months. Mean sick leave was 54.6 days. This was significantly shorter for percutaneous procedures compared with conventional surgery or minimally invasive techniques. Preoperative pain was noted four to five on the Visual Analogue Scale (VAS). There was no significant difference between the different groups as a function of the type of surgery performed. Statistically, there is very little difference in the short term between the different techniques. A much longer study would be necessary to obtain evidence to guide our practices. While there is certainly no reason to condemn one method or another, surgeons must be careful about the promises given to patients which are generally based on personal experience but not necessarily supported by rigorous scientific data.

[Results of self-centering patellofemoral prosthesis: a retrospective study of 57 implants]. / Résultats de la prothèse fémoropatellaire autocentrique: à propos d'une série continue de 57 prothèses.

PURPOSE OF THE STUDY: The aim of this retrospective analysis was to report results obtained with a self-centering patellofemoral prosthesis. We wanted to determine whether self-centering still has indications for the treatment of patellofemoral osteoarthritis. MATERIAL AND METHODS: This was a continuous series of 57 knees operated on since 1986 in the same center for implantation of a self-centering patellofemoral prosthesis (Medinov then Depuy). Eight patients died and four were lost to follow-up. Two knees were excluded from the analysis after revision with a PFP. We report here the outcome of 43 prostheses at mean follow-up of six years two months (range 78 months to 15 years). The IKS score (200 points) and the ADL scale (in %) were recorded. The position of the prosthesis was assessed on plain X-rays. Mean age at implantation was 67.2 years. The main reasons for surgery were osteoarthritis secondary to dysplasia (60%) and primary disease (31.1%). RESULTS: At last follow-up, the IKS score was 157.2 points (range 76-195). The mean ADL score was 74.1/100 (48.8-96.3). The IKS evaluation showed good outcome in 66.7% of knees. The ADL scale gave a less satisfactory outcome: 57.7% good outcome for this scale which takes into account all knee functions for activities of daily life. Outcome was better among patients with trochlear dysplasia. Eleven patients (24.4%) had had revision surgery for total knee arthroplasty. Preoperatively, the trochlear angle was smaller in revision cases (p=0.023). In these patients, the first prosthesis was more anterior (p=0.004) with a greater horizontal axis (p=0.015). DISCUSSION: Our outcomes were less satisfactory than the average results in the literature. It must be noted however, that the concept of a good outcome depends on the scale used for assessment. We found in our series a 10% difference between the ADL scale and the IKS score. Independently of the assessment scale used, outcome was better in knees with osteoarthritis secondary to dysplasia. An analysis of the X-ray findings disclosed technical errors leading to failure. The outcome of patellofemoral prosthesis depends essentially on two factors: technical precision and patient selection. CONCLUSION: In light of these findings, we have come to limit still further the rare indications for patellofemoral prostheses. The typical indication is isolated advanced patellofemoral osteoarthritis secondary to patellofemoral dysplasia unresponsive to medical treatment in patients aged 50-70 years. Revision with a total knee arthroplasty required changing the patellar insert if worn. We have not had any particular problem with revision total knee arthroplasty after patellofemoral prosthesis.

Poor outcomes of fusion with Trabecular Metal implants after failed total ankle replacement: Early results in 11 patients.

INTRODUCTION: One of the reasons for revision of total ankle replacement (TAR) implants is loosening due to subchondral cysts. Reconstruction and fusion of the ankle is often the first choice for revision procedures due to the large bone defects, which are typically filled with autograft and/or allograft. Filling the defect with a trabecular metal tantalum implant is a potential alternative given the biomechanical properties of this component. HYPOTHESIS: Using tantalum as a spacer provides primary stability and contributes to fusion of the ankle joint after removal of failed TAR implants. METHODS: Eleven patients underwent arthrodesis an average of 6.9 years after TAR. The mean height of the bone defect was 32mm. It was filled with a specially designed quadrangular implant (Trabecular Metal™, Zimmer/Biomet) combined with an iliac crest graft. Ten patients underwent tibio-talo-calcaneal (TTC) arthrodesis fixed with an angled retrograde nail and one patient underwent talocrural arthrodesis fixed with two plates (anterolateral and anteromedial). The clinical, functional (AOFAS and SF36 scores) and radiological (plain X-rays and CT scan) outcomes were determined. RESULTS: At a mean follow-up of 19.3 months, the mean total AOFAS score was 56 (21-78) and the mean SF36 score was 60.5 (19-84). One patient was lost to follow-up and four patients still had pain. The tantalum implant was integrated in six patients. Five patients achieved fusion of the subtalar joint and 8 achieved fusion of the talocrural joint. Three patients required surgical revision. DISCUSSION: Our hypothesis was not confirmed. The clinical outcomes after more than 1 year of follow-up are disappointing, as was the large number of nonunion cases and the lack of tantalum integration. These technical failures can be explained by insufficient construct stability and/or insufficient implant porosity. LEVEL OF EVIDENCE: IV (retrospective cohort study).

[Anterior cruciate ligament revision: analysis and results from a series of 74 cases]. / Les reprises de ligamentoplastie du ligament croisé antérieur: analyse et résultats d'une série de 74 cas.

PURPOSE OF THE STUDY: This was a retrospective series of patients who underwent revision ligamentoplasty of the anterior cruciate ligament (ACL). We wanted to assess the functional outcome after this type of surgery and search for potential prognostic factors. MATERIAL AND METHODS: The series included 74 patients, mean age 34 years (range 21-59 years). The initial ligamentoplasty was performed with a synthetic ligament (n=16), an autograft (n=57) or an allograft (n=1). Differential laxity (KT-1000 maximal manual) was 7 +/- 2.5 mm. Anterior drawer was measured on the stress x-rays in 20 degrees flexion: medial 8 +/- 4.7 mm, lateral 8.3 +/- 4.9 mm. Mean time to revision surgery was 78 months. Reconstruction was performed arthroscopically in 69 knees. The implant used for the revision reconstruction was an autograft: patellar tendon (n=42), quadriceps tendon (n=15), hamstring tendon (n=13), patellar tendon and quadriceps tendon (MacInJones) (n=3), fascia lata (n=1). A meniscal tear was noted in 24 knees and a cartilage lesion in 35. RESULTS: Outcome was assessed at mean 21.2 months follow-up. The mean IKDC function score was 71.7 (range 21.8-100). 78% of patients considered their knee normal or nearly normal and 88% presented a positive Lachmann. Mean differential laxity measured with KT-1000 (maximal manual) was 2 +/- 1.7 mm. Stress x-rays revealed a mean differential laxity measured at 3.7 +/- 2.3 mm medially and 6.3 +/- 4.3 mm laterally. The presence of a meniscal lesion favored osteoarthritic degradation. Presence of chondral lesions altered the functional outcome significantly and limited resumption of sports activities. An initial repair using a synthetic ligament affected the functional outcome after revision surgery and favored or aggravated chondral lesions. DISCUSSION: The clinical results we have obtained with revision ACL ligamentoplasty are comparable to previous series reported in the literature. The functional outcome is not as good as after first-intention repair, especially if the initial plasty was done with a synthetic ligament and the knee presented meniscal or cartilage damage.

Metatarsalgia.

The causes of metatarsalgia are classified as primary, secondary, and iatrogenic. Anatomical and biomechanical considerations separate "static" from "propulsive" forms of metatarsalgia. The physical examination should be combined with an assessment of weight-bearing radiographs and, if needed, of ultrasound or magnetic resonance imaging scans. The first-line treatment is conservative (stretching exercises, footwear modification, insoles, and lesion debridement). Soft-tissue surgical procedures (gastrocnemius muscle recession, tendon transfer, and plantar plate repair) should also be considered. Among the various types of metatarsal osteotomy, the Weil procedure is reliable. Percutaneous methods are being developed but require evaluation. A treatment algorithm can be developed based on whether the hallux is normal or abnormal. Metatarsalgia due to inflammatory disease requires a specific treatment strategy.

[Iliopsoas bursal distension revealing complication of total hip arthroplasty: five cases]. / Masse inguinale révélatrice d'une complication d'une arthroplastie totale de hanche: A propos de 5 cas.

The iliopsoas bursa is situated immediately anterior to the hip joint. Communication can develop between a hip prosthesis and the iliopsoas bursa leading to distension and formation of an inguinal mass revealing complication of total hip arthroplasty. We report five clinical cases. The five patients with a total hip arthroplasty developed a mass in the Scarpa triangle which correlated with defective prosthesis function. We chose not to dissect the cystic mass but to treat the intra-articular cause. Symptoms resolved after the intervention in all cases. This rare condition should be envisioned if an inguinal mass develops or has a functional impact, particularly on the lymphovenous circulation. Anatomic relations can be distinguished with computed tomography. Prosthetic complications include infection, loosening or wear. The work-up should include search for infection and standard x-rays of the hip joint. Before surgery, duplex Doppler should be performed systematically to search for a thromboembolic complication.

[Congenital club foot: treatment in childhood, outcome and problems in adulthood]. / Le pied bot varus equin: traitement chez l'enfant et devenir a l'age adulte.

PURPOSE OF THE SYMPOSIUM: Treatment of idiopathic talipes varus, or congenital clubfoot, is designed to re-align the foot to alleviate pain and allow plantigrade weight bearing with adequate joint motion despite the subnormal radiographic presentation. This symposium was held to review current management practices for congenital clubfoot in children and to analyze outcome in adults in order to propose the most appropriate therapeutic solutions. MANAGEMENT OF CONGENITAL CLUBFOOT IN CHILDREN: Idiopathic talipes varus can be suspected from the fetal ultrasound. Parents should be given precise information concerning proposed treatment after birth. Deviations must be assessed in the newborn then revised regularly using objective scales during and after the end of treatment. This enables a better apprehension of the evolution in comparison with the severity of the initial deformation. Conservative treatment is proposed by many teams: a functional approach (rehabilitation and minimal use of orthetic material) or the Ponseti method (progressive correction using casts associated with percutaneous tenotomy of the calcaneal tendon) are currently preferred. If such methods are insufficient or unsuccessful, surgery may be performed as needed at about 8 to 11 months to achieve posteromedial release. Good results are obtained in 80% of patients who generally present minimal residual deformations (adduction of the forefoot, minimal calcaneal varus, residual medial rotation, limitation of dorsal flexion), which must be followed regularly through growth. The difficulty is to distinguish acceptable from non-acceptable deformation. At the end of the growth phase, severe articular sequelae are rare (stiff joint, recurrence of initial deformation, overcorrection) but difficult to correct surgically: osteotomy, tendon transfer, double arthrodesis, Ilizarov fixator. Gait analysis is essential to quantify function and obtain an objective assessment of the impact on higher joints, providing valuable guidance for surgical correction. OUTCOME IN ADULTHOOD: There have been very few studies evaluating the long-term functional outcome after treatment during childhood. According to two studies presented at this symposium (Brussels, Lausanne), results have been generally good but with subnormal radiographs irrespective of the type of treatment or how early treatment started in childhood. Hypoplasia of the talar dome is a constant finding and is correlated with limitation of dorsal flexion of the ankle joint. A small degree under-correction is often observed but well tolerated while overcorrection is generally less well tolerated. Functional outcome depends highly on preservation of subtalar joint motion. There have been no reports on the results of treatment of sequelae in adults. Most problems (pain, stiffness, osteoarthritis) are observed in the mid or rear foot. Indications for conservative surgery (osteotomy) of the mid or rear foot are rare compared with indications for combined arthrodesis. Talocrural decompensation is a turning point observed in the adult. Management at this point is difficult: fusion of the ankle worsens the situation by increasing the stress on the forefoot and aggravating the disability; implantation of an ankle prosthesis is technically difficult and remains to be fully developed. Treatment of the dorsal bunion of the great toe may require tendon transfer and/or fusion. CONCLUSION: A child born with clubfoot will never have a normal foot in adulthood. Sequelae present at the end of growth will intensify during adult life; under-correction is easier to treat in adulthood than overcorrection. The most difficult problems in adulthood are: neglected clubfoot, over correction, and degradation of the talocrural joint.

[Analysis of meniscal lesions accompanying anterior cruciate ligament tears: A retrospective analysis of 156 patients]. / Lésions méniscales constatées lors de la reconstruction du ligament croisé antérieur: siège et nature dans une série continue de 156 patients.

PURPOSE OF THE STUDY: The purpose of this retrospective study of a continuous series was to document preferential types and localizations of meniscal lesions accompanying anterior cruciate ligament tears and to demonstrate the relationships between meniscal lesions, patient age and time from trauma to surgery. MATERIAL AND METHODS: One hundred fifty-six patients with no history of meniscal lesions underwent ligamentoplasty in 2003. All procedures were performed by the same operator. The time from trauma to surgery was 31.6 months on average. This was a retrospective continuous series using data from detailed operative reports. RESULTS: An isolated lesion of the medial meniscus was observed in 25.6% of cases. There was an isolated lesion of the lateral meniscus in 21.8% and lesions of both menisci in 9%. The most frequent injury was a longitudinal fissuration, for both menisci. Patient age and time from trauma to surgery were statistically correlated with presence of a medial lesion. There was no statistical relationship for the lateral meniscus nor for type of meniscal injury. DISCUSSION: The proportion of lesions to the lateral meniscus appeared to be unaffected by age or time to surgery after trauma, suggesting that lateral meniscal lesions occurred at the time of the initial curciate injury. On the contrary, the incidence of medial lesions increased with time and patient age, confirming the important role of the medial meniscus to block anterior displacement of the knee. We thus recommend early repair of anterior cruciate ligament tears in order to avoid medial meniscectomy which would increase with increasing time from injury to surgery and thus affect the postoperative outcome.

[Axial lower limb alignment and knee geometry in patients with osteoarthritis of the knee]. / Analyse segmentaire de la déformation frontale dans les gonarthroses fémoro-tibiales latéralisées.

PURPOSE OF THE STUDY: We conducted a retrospective radiographic study to identify and quantify medial and lateral misalignments in candidates for total knee arthroplasty. MATERIAL AND METHODS: We studied a discontinuous series of 101 patients (164 knees) among candidates for total knee arthroplasty seen between 1990 and 2002. We selected a random sample for study. Exclusion criteria were any history of fracture, surgical treatment, rheumatoid disease, or congenital disorder. A first group of 136 genu varum knees was identified in 82 patients (mean age 72 years, mean weight 79 kg). A second group of 28 genu valgum knees was identified in 19 patients (mean age 67 years, mean weight 71 kg). The standard radiograms were digitalized for semi-automatic measurements using the Metros software. We recorded overall deformation, femoral valgus, tibial varus, HKA angle, HKS angle (mechanical/anatomic axis of the femur) and angle C (horizontal inclination of the ankle to the ground). All measures were compared between each other for each patient to search for relations. RESULTS: In the genu varum group (136 knees), mean overall deformation was 9 degrees , mainly due to tibial misalignment (5.5 degrees ) with a 1 degrees femoral valgus component. The HKS angle was 6.3 degrees , and lateral joint gap 4.3 degrees ; the C angle was 4 degrees . Overall varus followed tibial varus (p<0.01). Ankle inclination followed tibial varus (p<0.01). In the genu valgum group (28 knees), overall deformation was 4.2 degrees , mainly due to femoral misalignment (5.6 degrees) with 1 degrees tibial varus and a medial joint gap of 2 degrees . The HKS angle was 4.7 degrees and the mean C angle -4 degrees . Overall valgus was related to femoral valgus (p<0.001). Tibial varus was greater with greater femoral valgus (p<0.01). In both groups, the HKS angle was smaller with greater femoral valgus. DISCUSSION: Semi-automatic measurements on digitalized films enabled excellent reproducibility. Causes of error were related to limb rotation at acquisition. This study showed that genu varum worsens because of tibial wear followed by ligament distension, while for genu valgum, worsening predominantly results from femoral wear. The ankle joint line was nearly horizontal in one-third of the limbs, even when there was a major misalignment of the lower limb. The HKS angle was quite variable in both morphotypes, but was smaller with greater femoral valgus in both groups. CONCLUSION: Measuring all components involved in medial and lateral knee misalignment is very useful for understanding the morphotype of each individual knee before performing osteotomy or implanting a knee prosthesis.

[One-stage reconstruction of the two cruciate ligaments with a single autogenous graft from the extensor system: techniques and results of 25 chronic cases]. / Reconstruction simultanée des 2 ligaments croisés par un transplant autogène unique: technique et résultats à propos de 25 laxités chroniques.

PURPOSE OF THE STUDY: Chronic tears of both cruciate ligaments are rarely encountered. Management practices have varied. One-stage reconstruction of both ligaments using arthroscopically implanted allografts was proposed starting in 1996 for such chronic laxity but only 44 cases have been reported in six papers mixed in with recent cases raising very different problems. Treatments using allografts or autogenous grafts or both implanted arthroscopically have often been combined with open surgery. We report a retrospective analysis of 25 knees treated with the same technique from 1983 to 2004: reconstruction with a single transplant taken from the extensor system. MATERIAL AND METHODS: A 30-cm lenght patella tendon-patella-quadriceps tendon graft was harvested. The patellar block was fixed in a hole drilled under the tibial spine, the patellar tendon replacing the posterior cruciate ligament and the quadriceps tendon passing through the lateral condyle and replacing the anterior cruciate ligament before implantation on Gerdy's tubercle, this also creating an extra-articular plasty with the same implant. Medial, lateral and posterior plasties were performed, depending on the radiographic assessment of laxity. Twenty-five knees with major laxity and instability were operated on, including 14 in two-stage operations. The differential anterior drawer was 10+/-3 mm medially and 9+/-5 mm laterally. The posterior drawer at 70 degrees was 15+/-4 mm medially and 10+/-6 degrees laterally. The total anteroposterior laxity of the medial compartment was 29 mm, it was 30 mm for the lateral compartment. Lateral laxity was considered major (>10 degrees ) in 17 knees and medial laxity in 7. Lateral and medial laxities were associated in eleven knees. Hyper-extension was very severe in five knees. RESULTS: Functional outcome at mean 6.5 years follow-up (range 1-21) was satisfactory (except in three knees) allowing renewed occupational activity. Resumption of sports activity was less marked and none of the knees was in IKDC class A, corroborating results in the literature. Anatomic outcome was assessed on the radiological drawer decrease which was modest, mean gain in the anterior drawer measuring 4 and 5 mm in the medial and lateral compartments and mean gain in the posterior drawer measuring 5 mm medially and 3 mm laterally. Peripheral laxity was corrected for best. DISCUSSION: Classically, one or other of the cruciate ligaments is repaired, sometimes both, but in a two-stage procedure associating two different methods and autogenous tendon grafts. One-stage reconstruction of both cruciate ligaments with a single autogenous graft and a wide approach has not led to any complications. One-stage reconstruction using this technique has several advantages: one anterior incision, single transplant which also enables lateral plasty, short immobilization time with rapid rehabilitation.

[Intra-articular reconstruction of the anterior cruciate ligament with and without extra-articular supplementation by quadricipital tendon plasty: seven-year follow-up]. / Influence d'une ligamentoplastie extra-articulaire latérale sur les résultats de la reconstruction du ligament croisé antérieur avec le ligament patellaire avec 7 ans de recul.

PURPOSE OF THE STUDY: Reconstruction of the anterior cruciate ligament (ACL) is a common procedure, but use of lateral reinforcement is still a subject of debate. The purpose of this study was to compare two randomized series of ACL reconstructions, one using an intra-articular method (patellar tendon autograft) and the other an intra- and extra-articular method (Mac-InJones). MATERIAL AND METHODS: From January 1995 to March 1998, 63 knees underwent surgery for ACL reconstruction. Inclusion criteria was significant medial differential laxity measured between 7 and 12 mm on passive dynamic x-rays as 20 degrees flexion. Group 1 (patellar tendon intra-articular reconstruction) included 34 patients (27.1+/-7.5 years) and group 2 (intra-articular reconstruction plus extra-articular quadircipital tendon plasty) included 29 patients (28.5+/-12 years). The IKDC score was determined for 72% of the knees in group 1 and 68% in group 2 at seven years follow-up on average (102 and 93 months respectively). Anterior laxity was measured radiographically and with KT-1000. The position of the tunnels was controlled using the Aglietti method. RESULTS: The subjective functional score was 83.6+/-3.5 in group 1 and 83.5+/-3.5 in group 2. The overall IKDC knee score classes for group 1 were 0% A, 52.4% B, 28.6% C, and 19% D and for group 2 were 5.5% group A, 50% group B, 33.3% group C, and 11.1% group D. In group 1, the pivot test was negative in 61.9% and noted stage 1 in 28.6% and stage 2 in 9.5%. In group 2, the pivot test was negative in 78.9% and noted stage 1 in 15.8% and stage 2 in 5.3%. The KT-1000 showed no difference in gain in laxity: 31% for group 1 and 27% for group 2. Similarly, radiographically there was no difference with a 43.9% gain in differential laxity for the medial compartment and 45.3% for the lateral compartment in group 1. In group 2 the corresponding values were 51.9% and 41.8%. The position of the tunnels was the same in the two groups. DISCUSSION: In a preliminary study with two years follow-up, the results in these two series were not significantly different. It was concluded that there was not clear advantage to adding the extra-articular lateral plasty. At the present 7-year follow-up, pivoting appears to be better controlled in the lateral plasty group (p=0.23), but with no significant difference for laxity for both knee compartments. The inclusion criteria would be different today and would be based on the laxity of the lateral compartment.

[Accuracy of total knee replacement bone cuts using a conventional ancillary system: 300 Innex total knee arthroplasties]. / Précision des coupes osseuses dans l'arthroplastie totale du genou à l'aide d'un ancillaire conventionnel: trois cent poses consécutives de prothèses Innex.

PURPOSE OF THE STUDY: Short-term functional results and long-term outcome in terms of stability and wear greatly depend on the precision of the bone cuts. We wanted to know whether conventional ancillaries are still competitive in terms of accuracy in comparison with computer-assisted navigation systems. A few comparative studies favor navigation, but have generally only included a small number of patients. We studied radiographically a prospective consecutive series of 300 total knee prostheses (Innex, Zimmer) implanted with the conventional technique by the same operator. MATERIAL AND METHODS: A telegonometric view in the upright position and a short lateral view were obtained in all patients. In the AP view, implants were measured in comparison with the mechanical axis of the femur (F) and the tibia (T). On the lateral view, the prosthesis-tibial shaft angle (PT) was measured from the proximal portion of the tibial shaft and the prosthesis-femoral shaft angle (PF) from the distal portion of the femur. The same operator made all measurements using the same optimal conditions. The series included 178 women and 122 men, mean age 72 +/- 8 years who presented genu varum (n = 248 knees) and genu valgum (n = 52 knees): degenerative disease (n = 238), polyarthritis (n = 4), hemophilic arthropathy (n = 3), necrosis (n = 3), revision of unicompartmental prosthesis (n = 8), and osteotomy (n = 44). RESULTS: The standard x-ray protocol was performed at two months in all patients. The mechanical axis (HKA) was 179.4 +/- 2.4 degrees (range 173-186 degrees) and was +/- 3 degrees in 87% of knees with no difference for varum and valgum. F was 90.1 +/- 1.4 degrees (87-95), with +/- 3 degrees for 98.7%. T was 89.3 +/- 1.5 degrees (85-94) with +/- 3 degrees for 95.6%. PF was 88.6 +/- 1.6 degrees (84-93) for 87%, PT was 87 +/- 2 degrees (81-93) with +/- 3 degrees for 94%. The four cuts were within +/- 3 degrees for 227 prostheses (77%), within +/- 2 degrees for 156 (52%) and within +/- 1 degrees for 56 (18%). Measurements made again one year after implantation for 203 knees gave the same results. Operative time for implantation was 68 +/- 23 minutes for implantation and 85 +/- 23 minutes including complete closure (less than 60 minutes for 68 knees). DISCUSSION: The accuracy of each cut was satisfactory on average with a small standard deviation. Recent data in the literature show that the accuracy in our series is comparable with that obtained currently with navigation systems. In light of this experience, it can be seen that better precision can be achieved for each of the cuts. CONCLUSION: The accuracy of conventional instrumentation systems is still comparable with that obtained with computer-assisted surgery. The purpose of this study was not to question the benefit of navigation, but to establish a basis upon which progress can be measured. The results enabled a more realistic comparison of the precision of navigation systems and also can be comforting for operators still using conventional ancillaries.

Wear study of Total Ankle Replacement explants by microstructural analysis.

The implantation of Total Ankle Replacement (TAR) prostheses generally gives satisfactory results. However, a high revision rate is associated with the Ankle Evolutive System (AES) implant, due to periprosthetic osteolysis that generates significant cortical lesions and bone cysts in the periprosthetic region. Radioclinical and histological analyses of peri-implant tissues show the presence of numerous foreign particles that may come from the implant. It is known that a precocious wear of materials may lead to an important rate of foreign body in tissues and may generate osteolysis lesions and inflammatory reactions. Thus the objectives of this retrospective study of 10 AES TAR implants (recovered after revision surgeries) are to understand how the prostheses wear out, which part is the most stressed and to determine the nature and size of foreign body particles. A better understanding of friction mechanisms between the three parts of the implant and of the nature and morphology of foreign particles generated was needed to explain the in vivo behavior of the implant. This was achieved using microstuctural and tomographic analysis of both implants parts and periprosthetic tissues.

Does arthrodesis of the first metatarsophalangeal joint correct the intermetatarsal M1M2 angle? Analysis of a continuous series of 208 arthrodeses fixed with plates.

INTRODUCTION: First-ray metatarsophalangeal arthrodesis is a classic surgical procedure in the treatment of severe hallux valgus, hallux rigidus, revision surgery, and inflammatory arthritis. The objective of this study was to verify if metatarsophalangeal plate arthrodesis could correct the M1M2 intermetatarsal angle. MATERIAL AND METHODS: This prospective and continuous series (June 2007 to March 2011) included 208 patients (48% severe and/or arthritic hallux valgus, 18% hallux rigidus, 16% rheumatoid forefoot, 13% surgical revision of the first ray, 5% hallux varus), with a mean age of 62.4±9.9 years (range, 19-87 years). All the patients were operated on by a senior surgeon with the same technique: spherical avivement of the joint surfaces using reamers, osteosynthesis with an anatomic plate (Fyxis-Biotech™) in Ti.6Al.4 V alloy prebent to 5° with a phalangeal arm to receive an oblique metatarsophalangeal screw in compression, in addition to four 2.7-mm nonlocking dorsal screws. The full-scale preoperative and intraoperative angle measurements were taken on AP and lateral X-rays of the weightbearing foot, as related to the etiology and the severity of the preoperative metatarsus varus (M1M2<15°, M1M2 15-19°, M1M2≥20°). The statistical analysis was done using the StatView software. RESULTS: The mean follow-up was 18.6±12.4 months (range, 2-76 months). Nearly all of the arthrodesis patients (97%) achieved bone union, and 5% of the plates were removed. The M1P1 angle decreased from 33.8±19.7° (range, -45° to -67°) preoperatively to 13.3±5.3° (range, 0-32°) at the last follow-up, and the M1M2 angle from 14.2±5.4°(range, 0-26°) to 6.5±2.3° (range, 0-12°). The preoperative M1M2 angle was <15° in 97 patients, 15-19° for 78 patients, and ≥20° for the 33 others; at the last follow-up it was 5.8±2.1° (range, 0-10°), 6.7±2.2° (0-10°), and 8.1±2.4° (3-12°), respectively. No correction of the metatarsus varus was demonstrated in relation to etiology. The M1M2 angle was >10° in only two patients (one case of rheumatoid arthritis and one case of severe hallux valgus): 0.9%. DISCUSSION: These results show that isolated metatarsophalangeal arthrodesis of the first ray can correct metatarsus varus even in substantial deformations in any etiology. LEVEL OF PROOF: Level II cohort study.

Compared fixation and survival of 280 lateralised vs 527 standard cementless stems after two years (1-7).

BACKGROUND: Restoring the native hip anatomy increases hip prosthesis survival, whereas increased femoral lateralisation creates high torque stresses that may alter prosthesis fixation. After finding lucent lines around cementless lateralised stems (Corail™, DePuy Synthes, St Priest, France) in several patients, we evaluated the effects of lateralisation in a large case-series. The objective of our study was to compare lateralised vs standard stems of identical design in terms of radiological osteo-integration and survival. HYPOTHESIS: Lateralised stems, despite being used only when indicated by the anatomical parameters, carry a higher risk of impaired osteo-integration. MATERIALS AND METHODS: A retrospective study was conducted in 807 primary total hip arthroplasties (THAs) performed between 2006 and 2010 in 798 patients with a mean age of 65 ± 14.2 years. Lateralised stems were used in 280 cases (Corail High Offset KHO, n = 169; and Corail coxa vara KLA, n = 111 cases) and standard stems in 527 cases (Corail KA). Mean follow-up was 2.3 years (range, 1-7 years). The clinical evaluation included determination of the Postel-Merle d'Aubigné (PMA) score. Bone fixation and stability of the implants were assessed by determining the Engh and Massin score and the ARA score on the radiographs at last follow-up. Femoral, acetabular and global offset values were determined before and after THA. Nobles's Canal Flare Index was computed. Survival was estimated using the Kaplan-Meier method with surgical revision for aseptic loosening as the end-point. RESULTS: The PMA score improved from 12 (10-15) pre-operatively to 17.7 (14-18) (P < 0.05). After THA, in the lateralised stem group, femoral offset was restored in 217 (77%) hips and the mean change vs the pre-operative offset value was -2 mm; in the standard stem group, femoral offset was restored in 440 (83.5%) hips and the mean change was +1 mm. The Engh and Massin score values were similar in the standard stem and lateralised stem groups (24.4 ± 2.2 and 22.6 ± 2.4, respectively, NS). Revision for aseptic loosening was required in 5 patients with lateralised stems (3 KHO and 2 KLA) versus none of the patients with standard stems. There were no cases of excessive femoral offset and the mean change in offset was -2.3mm (-5.3 to -1.1). Noble's index was increased (4.27 ± 0.5 for the loosened lateralised stems, 3.65 ± 0.8 for the well-fixed lateralised stems and 3.82 ± 0.6 for the standard stems), with no significant difference across groups. Overall survival after 3.5 years of follow-up was 94.6% (95% confidence interval, 88.4-100%) with lateralised stems and 100% with standard stems (P < 0.05). DISCUSSION: The risk of aseptic loosening was significantly higher with the lateralised stem (5/280, 1.8%) than with the standard stem (n = 0). Our findings indicate a need for careful preparation to obtain primary fixation of lateralised stems. LEVEL OF EVIDENCE: III, retrospective case-control study.

Similar levels of pain are reported in forefoot surgery after management as a day case and admission for 48 hours: A continuous prospective study of 317 patients.

While many forefoot procedures may be performed as a day case, there are no specific guidelines as to which procedures are suitable. This study assessed the early post-operative pain after forefoot surgery performed a day case, compared with conventional inpatient management. A total of 317 consecutive operations performed by a single surgeon were included in the study. Those eligible according to the criteria of the French Society of Anaesthesia (SFAR) were managed as day cases (127; 40%), while the remainder were managed as inpatients. The groups were comparable in terms of gender, body mass index and smoking status, although the mean age of the inpatients was higher (p < 0.001) and they had higher mean American Society of Anaesthesiologists scores (p = 0.002). The most severe daily pain was on the first post-operative day, but the levels of pain were similar in the two groups; (4.2/10, SD 2.5 for day cases, 4.4/10, SD 2.4 for inpatients; p = 0.53). Overall, 28 (9%) of patients who had their surgery as a day case and 34 (11%) of inpatients reported extreme pain (≥ 8/10). There were more day case patients rather than inpatients that declared their pain disappeared seven days after the surgery (p = 0.02). One day-case patient with excessive bleeding was admitted post-operatively. Apart from the most complicated cases, forefoot surgery can safely be performed as a day case without an increased risk of pain, or complications compared with management as an inpatient.

Knee instability after injury to the anterior cruciate ligament. Quantification of the Lachman test.

We have measured anterior and posterior displacement in 563 normal knees and 487 knees with chronic deficiency of the anterior cruciate ligament (ACL). We performed stress radiography using a simple apparatus which maintained the knee at 20 degrees of flexion while a 9 kg load was applied. There was no significant difference in posterior translation dependent on the condition of the ACL. Measurement of anterior translation in the medial compartment proved to be more reliable than in the lateral compartment for the diagnosis of rupture of the ACL, with better specificity, sensitivity and predictive values. We have classified anterior laxity based on the differential anterior translation of the medial compartment and identified four grades in each of which we can further distinguish four subgrades for laxity of the lateral compartment. Within each of these subgroups, either internal or external rotation may dominate and sometimes there is a major translation of both compartments. Radiological evaluation of displacement of the knee in 20 degrees of flexion provides conclusive evidence of rupture of the ACL. A detailed study of pathological displacement is the basis for a classification of laxity. It is then possible to decide for each type of laxity, the surgical treatment which is specifically adapted to the lesion, and to define a reference value for judging outcome.