Effectiveness, safety, and cost-utility of a knee brace in medial knee osteoarthritis: the ERGONOMIE randomized controlled trial.

OBJECTIVE: This pragmatic, multicenter, open-label, randomized controlled trial (RCT) aimed to compare the effectiveness, safety, and cost-utility of a custom-made knee brace versus usual care over 1 year in medial knee osteoarthritis (OA). DESIGN: 120 patients with medial knee OA (VAS pain at rest >40/100), classified as Kellgren-Lawrence grade II-IV, were randomized into two groups: ODRA plus usual care (ODRA group) and usual care alone (UCA group). The primary effectiveness outcome was the change in VAS pain between M0 and M12. Secondary outcomes included changes over 1 year in KOOS (function) and OAKHQOL (quality of life) scores. Drug consumption, compliance, safety of the knee brace, and cost-utility over 1 year were also assessed. RESULTS: The ODRA group was associated with a higher improvement in: VAS pain (adjusted mean difference of -11.8; 95% CI: -21.1 to -2.5); all KOOS subscales (pain: +8.8; 95% CI: 1.4-16.2); other symptoms (+10.4; 95% CI: 2.7-18); function in activities of daily living (+9.2; 95% CI: 1.1-17.2); function in sports and leisure (+12.3; 95% CI: 4.3-20.3); quality of life (+9.9; 95% CI: 0.9-15.9), OAKHQOL subscales (pain: +14.8; 95% CI: 5.0-24.6); and physical activities (+8.2; 95% CI: 0.6-15.8), and with a significant decrease in analgesics consumption at M12 compared with the UCA group. Despite localized side-effects, observance was good at M12 (median: 5.3 h/day). The ODRA group had a more than 85% chance of being cost-effective for a willingness-to-pay threshold of €45 000 per QALY. CONCLUSIONS: The ERGONOMIE RCT demonstrated significant clinical benefits of an unloader custom-made knee brace in terms of improvements in pain, function, and some aspects of quality of life over 1 year in medial knee OA, as well as its potential cost-utility from a societal perspective.

Arthroscopy-assisted Trillat procedure for anterior shoulder instability: Surgical technique and preliminary clinical results.

The Trillat procedure performed as open surgery to treat anterior shoulder instability has been proven effective in preventing recurrences and restoring range of motion. An arthroscopically assisted variant of the Trillat procedure is described here, together with the preliminary clinical results in 18 patients treated between 2011 and 2014. After a mean follow-up of 24.7±9.8 months, the clinical outcomes were very satisfactory, with a Walch-Duplay score of 81.5±18.0, a Rowe score of 83.6±16.0, and 94% of satisfied or very satisfied patients. Mean operative time was 55±13min. No recurrences were recorded. As an easily performed procedure that provides good clinical outcomes, the arthroscopically assisted Trillat procedure is a simple and reproducible alternative to arthroscopic Latarjet procedure, which is still reserved for highly experienced surgical teams.

Modified iliofemoral approach with osteotomy of the iliac crest, sparing the abdominal muscles, for the treatment of acetabular fracture.

Treatment of acetabular fracture is complex, requiring adapted and often extensive surgical approaches. We describe a modified iliofemoral approach, with the particularity of including iliac crest osteotomy sparing abdominal muscles to allow direct control of reduction while respecting the abdominal muscles, creating a workspace as close to the fracture as possible, without involving the inguinal canal or femoral vascular-neural bundle. In 15 complex fractures, the technique provided 13 excellent or good reductions and 13 excellent or good results according to the Matta criteria. This approach can be combined with others, such as a posterior approach, thus providing an alternative to the ilioinguinal approach in the treatment of complex acetabular fracture.

Duocentric® reversed shoulder prosthesis and Personal Fit® templates: innovative strategies to optimize prosthesis positioning and prevent scapular notching.

We describe our experience with a new system of patient-specific template called Personal Fit(®), which is unique in shoulder surgery and used in combination with Duocentric(®) prosthesis. The reverse prosthesis's concept is the invention of Paul Grammont, developed with Grammont's team of Dijon University as from 1981, which led to the first reversed total shoulder prosthesis called Trumpet in 1985. The Duocentric(®) prosthesis developed in 2001 is the third-generation prosthesis, coming from the Trumpet and the second-generation prosthesis Delta(®) (DePuy). This prosthesis provides a novel solution to the notching problem with an inferior overhang integrated onto the glenoid baseplate. Personal Fit(®) system is based on reconstructing the shoulder joint bones in three dimensions using CT scan data, placing a landmark on the scapula and locating points on the glenoid and humerus. That will be used as a reference for the patient-specific templates. We study the glenoid position planned with Personal Fit(®) software relative to native glenoid position in 30 cases. On average, the difference between the planned retroversion (or anteversion in one case) and native retroversion was 8.6°.

Intra-articular osteoid osteoma of the hip misdiagnosed by MRI: an unusual cause of unexplained hip pain.

Osteoid osteoma is a common benign bone tumor affecting the young adult with typical clinical and radiographic presentation in its most common locations. However, when arising in unusual intra-articular locations, diagnosis may appear confusing and lead to delayed management. We present the case of a 24-year-old man with intra-articular osteoid osteoma of the hip involving the posteroinferior quarter of the femoral head. This unusual location was at the origin of unexplained pain and delayed diagnosis made 18 months after the onset of symptoms since the initial magnetic resonance imaging (MRI) examination could not identify the lesion whereas it was detected on bone scintigraphy and thin slice CT imaging. Due to the complex location providing difficult access for radioguided techniques, an open surgical management was suggested and performed through a limited posterolateral approach with no hip dislocation, after identification of the circumflex pedicle. Following complete surgical excision of the tumor, the diagnosis could be confirmed after histopathologic analysis. No recurrence was observed.

The Unispacer™ unicompartmental knee implant: its outcomes in medial compartment knee osteoarthritis.

INTRODUCTION: A new concept has been recently developed for use in the treatment of isolated medial tibiofemoral osteoarthritis: the Unispacer™ implant. This mobile interpositional, self-centering implant replicates the meniscal shape. This mini-invasive device does not require bone cuts or component fixation. The implant trajectory is guided by the medial condyle. HYPOTHESIS: The Unispacer™ knee implant enhances knee function in the treatment of isolated tibiofemoral osteoarthritis graded 2 and 3 according to Ahlbäck radiographic evaluation scale. MATERIAL AND METHODS: This prospective study involved 17 Unispacer™ knee systems implanted in 16 patients between April 2003 and March 2009 within the frame of a clinical research project (CRP). Patients were clinically (IKS score) and radiographically evaluated during a mean follow-up period of 40 months. RESULTS: Nine patients (10 implants) had a IKS score>160. The mean overall knee score at reassessment, including failures, increased from 51 points preoperatively to 78 points postoperatively. The mean overall Knee Society Function score increased from 55 preoperatively to 75/100 postoperatively. The reported complication rate was 35% (pain or implant instability). One-third of the failures were not technique- or implant-related but rather induced by the use of an inappropriate width in the frontal plane. DISCUSSION: Good results regarding pain relief and function are reported when using a mobile implant with no peripheral overhang which could be responsible for medial capsuloligamentous impingement. The Unispacer™ has three theoretical advantages: no bone resection, no implant fixation, no polyethylene wear debris. On the basis of its uncertain clinical results and high revision rate (six cases out of 17), we do not recommend this system despite the expected improvements on this range of implants. LEVEL OF EVIDENCE: Level III, prospective study.

[Acute osteomyelitis. A rare erysipelas differential diagnosis]. / Ostéomyélite aiguë. Un diagnostic différentiel rare d'érysipèle.

INTRODUCTION: Acute haematogenous osteomyelitis, whose clinical features may mimic erysipelas, is an uncommon disease in adults. OBSERVATION: A 56 year-old man was hospitalized for a suspicion of leg erysipelas. Oral and intravenous antibiotic therapy was inefficient. Magnetic Resonance Imaging (MRI) of the leg revealed osteomyelitis with subperiosteal abscess. Change of antibiotics and surgical debridement improved the patient's condition. DISCUSSION: Erysipela is a common disease which most often responds to anti-streptococcal therapy. Unfavourable evolution under antibiotherapy must lead to consider necrotizing fasciitis but also acute osteomyelitis. In these cases MRI is necessary. In our observation, the leg pain which preceded other signs of local inflammation, suggested the existence of primitive bone infection which further diffused in soft tissues, thus explaining the erysipelatoid aspect.

[Fat embolism with lung hemorrhage]. / Embolie graisseuse à forme hémorragique pulmonaire.

Post-traumatic fat embolism was disclosed by a picture of alveolar hemorrhage. Acute hypoxemia associated with dense bilateral pulmonary infiltrates was observed in a 21 year-old woman, 4 days after an accident with closed tibial fracture. Cruoric pulmonary thromboembolism was ruled out, as was an acute pulmonary edema. Neither infectious nor immunologic etiology was found. The diagnosis of alveolar hemorrhage was based on bronchoalveolar lavage. Lipid droplets in macrophages stained by "Oil Red O" established the relationship with fat embolism. The outcome was favorable. The association of fat embolism and alveolar hemorrhage has already been reported, but remains rare.

[Retrosternal dislocation of the clavicle complicated by subclavian venous thrombosis. Case report and review of the literature]. / Luxation rétro-sternale de la clavicule compliquée d'une thrombose veineuse sous-clavière. A propos d'un cas et reveu de la littérature.

Retrosternal dislocation of the clavicle is a highly uncommon lesion. Diagnosis may be delayed with the risk of discovery after severe complications resulting from the protrusion of the medial part of the clavicle into the anterosuperior mediastinum. Currently, diagnosis is based on computed tomographic findings. We report a case of retrosternal dislocation of the clavicle complicated by subclavian venous thrombosis and review the therapeutic indications proposed in the literature.

Chronic recurrent multifocal osteomyelitis causing spinal cord compression.

Chronic recurrent multifocal osteomyelitis (CRMO) is a very rare condition of unknown etiology and most commonly occurs during childhood or adolescence. The purpose of this paper is to present a case of CRMO in a vertebral location with severe kyphosis, spinal cord compression, and neurological dysfunction requiring anterior decompression and fusion. After 12 weeks, the patient was physically able to return to school. At 2-year follow-up, neurological and functional outcomes are fair. Magnetic resonance imaging shows good restoration of the sagittal spine alignment despite residual mild kyphosis, and restoration of a normal sagittal diameter of the spinal canal.

Ipsilateral omovertebral bones in the levator scapulae muscle and the rhomboid muscle in a Sprengel deformity: case report.

Our interest was stimulated by the uncommon case of a 4-year-old girl who presented a Sprengel deformity associated with two omovertebral bones on the same side. The first omovertebral bone was situated in the levator scapulae muscle and the second omovertebral bone was lying in the rhomboid muscle. The removal of these two bones was combined with a Woodward procedure to obtain a good correction.

[Anterior spinal fusion by thoracoscopy. A non-traumatic technique]. / La spondylodèse antérieure sous thoracoscopie: une technique atraumatique.

PURPOSE OF THE STUDY: Video assisted thoracic surgery (VATS) is a new modality which allows visualization of, and access to the intrathoracic organs without thoracotomy. Recently, this technique has been used for anterior thoracic spine approach to perform surgery which previously required standard postero-lateral thoracotomy. The authors report their initial experience of anterior spinal fusion using thoracoscopy and give a detailed description of their surgical procedure. MATERIAL AND METHODS: This technique, started on June 1993, was performed only in one level 1 in 10 patients who had thoracic spine trauma with fracture or luxation. The procedure was performed in the lateral decubitus position. The patient was prepared in the standard manner for a full thoracotomy. Surgical instruments that are needed for conversion to an open procedure must be in the operative room. Ventilation was stopped to the ipsilateral lung. Lung's collapse of the surgical side was obtained with a double lumen tube. Carbon dioxide (CO2) insufflation was used to further collapse. The first thoracoscopic portal was placed through the sixth or seventh intercostal space in the posterior axillary line, which was the safest place. All subsequent portals were placed under thoracoscopic visualization, in a triangular way as recommended by Landreneau (1992). Only open trocars were used to avoid complication of CO2 insufflation. Once the target level has been defined, a needle was placed into the disc space and roentgenographic confirmation obtained. The parietal pleura was then divided using monopolar electrocautery. Segmental vessels of the operation field lied transversely across the midportion of the vertebral body. They were mobilised and systematically ligated with endoscopic clip to simplify the procedure. Then the intervertebral space was opened and bone and disc were removed, restricted to the anterior and middle third. The graft was placed into the thoracic cavity by using a high density calcium hydroxyapatite ceramic block. Peroperative radiologic control ascertained the good position of the implant. At the end of the procedure a chest tube was placed through the lower trocar site and the lung re-expanded. A post operative CT Scan controlled good position of the graft and complete lung expansion. Contra-indications for VATS are previous surgical procedures or empyema causing extensive pleural adhesions. Procedures not appropriate for VATS approach are some that require anterior instrumentation for stabilisation, burst fracture, or fracture with posterior wall involved. RESULTS: The planned procedure was accomplished in all but one patient who required conversion to an open procedure because of segmental artery bleeding. Mean operative time was 1 h 45 mm, and mean estimated blood loss was 650 cc. There was no complication from CO2 insufflation neither postoperative complication. With an average of 2 years follow up, anterior grafting is as good as an open technique, radiologic evaluation according to Uchida (1990) showed good incorporation of each block without any radiolucent line or displacement. DISCUSSION: According to literature this technique was performed safely in 10 cases, especially without any respiratory complications and chronic pain (impairement of pulmonary function, re-expansion failure, incisional complications, rib fractures, chronic pain and malfunction of the chest wall, limitation of shoulder girdle motion) which are considered to be the main disadvantage of traditional thoracotomy. Many authors previously used VATS for multi level thoracic discectomy for correction of spinal deformities (Mack 1995), spinal reconstructive surgery (Mac Afee 1995) or removal of protrude thoracic disc (Rosenthal 1994). CONCLUSION: This original technique demonstrates that thoracoscopy for anterior thoracic surgery is better for the patients, reducing surgical trauma of the chest wall and to the lung parenchyma (in term of post operative comfort, sh

[Scaphoid and lunate palmar divergent dislocation. Apropos of a case]. / La luxation palmaire et divergente scapho-lunaire. A propos d'un cas.

UNLABELLED: A case of palmar dislocation of the scaphoid and lunate which where dissociated from each other is reported with a 3.5 years follow up. A 32 years old man fell while reading his motorcycle. He landed on his left hand dorsiflexed. There was no skin dilaceration and neuro-vascular status of his hand was intact. X-rays showed a palmar dislocation of the scaphoid and lunate with a large gap between the two bones. The lunate was also completely dissociated from the triquetrum and the capitate. Distal pole of the scaphoid remained in contact with the trapezium. The patient was taken to the operating room, and after unsuccessful closed reduction, an open reduction through a palmar approach was performed. A complete disruption of the anterior capsule was founded and all perilunate ligaments were completely disrupted. Reduction was easy under direct vision, and the anterior capsule was repaired. A non displaced trapezium fracture seen at surgery was fixed with a Kirschner wire. A long arm cast applied for 6 weeks. At 3.5 years follow-up, the patient had an almost full range of motion and no residual pain. Power grip was 25 per cent reduced in comparison with the opposite side. X-rays showed a palmarflexed scaphoid and Magnetic Resonance imaging showed no evidence of avascular necrosis. DISCUSSION: Simultaneous dislocation of scaphoid and lunate as a unit or with a large gap between the two bones are extremely rare injuries. In all cases already reported, results were briefly presented without any available clinical and radiological data because patients were lost for follow-up. In our case report, the anatomy and kinematics of the wrist showed the lack of our initial treatment with a single volar approach, anterior capsular reparation and a long arm cast alone. In fact, at 3.5 years follow up, ligamentous healing was inadequate to control compressive forces across the wrist and the scaphoid volarflexed despite a good alignement in the cast. Although the functional results is good, radiological outcome is far from being good. This case demonstrated that even in early treatment with a good position of carpal bones in the sole cast, healing of the ligamentous system without loosing reduction is difficult. CONCLUSION: In such a case, and with a low rate of avascular necrosis in perilunate dislocations treated early we suggest an open reduction and internal fixation (O.R.I.F.) to prevent carpal instability. We recommend combined volar and dorsal approaches for repairing anterior and posterior ligaments (especially interosseous ligaments on both sides of the lunate), associated with a stabilization of the entire carpum by scapho-lunate, triquetro-lunate, and capito-lunate Kirschner wire fixation.

Brachialis arteria rupture following closed posterior elbow dislocation. Case report and literature review.

Although isolated posterior closed elbow dislocation occurs frequently, associated disrupted brachialis arteria is an uncommon complication which is rarely encountered. The rarity of this complication makes adequate management of this injury controversial, but arterial reconstruction remains the treatment of choice and is recommended despite reports of success following simple arterial ligation. Complications such as intermittent claudication or gangrene of the hand are possible if brachial artery flow is not restored.

[Surgical approach to the axillary nerve via an anterior trans-coracoid route]. / Abord chirurgical du nerf circonflexe par voie antérieure transcoracoïdienne.

The surgical approach to the circumflex nerve is difficult. Based on an illustrative clinical example, the authors describe a method using a coracoid osteotomy that permits a simplified approach to the circumflex nerve. This trick permits en bloc retraction of the superficial plane of the brachial plexus without sectioning of the muscle and without excessive traction on the musculocutaneous nerve. The stable fixation of the coracoid at the end of the procedure permits early and effective rehabilitation.

[The thoraco-lumbar junction. Orientation of zygapophyses, mamillary process and vertebral rotation]. / La jonction thoraco-lombaire. Orientation des zygapophyses, tubercules mamillaires et rotation vertébrale.

The orientation of the zygapophyseal joints at the thoraco-lumbar level is an important factor involved in the axial rotation of the human spine. The functional role of the Mamillary Processes (MP) is unknown. This study was carried out on 55 adult dried spines. The aims were 1) to record the interzygapophyseal joint angles. 2) to determine morphological and functional angle types. 3) to correlate the various types and the corresponding MP lengths. 4) to propose hypotheses about the MP role. There were 2 distinct morphotic types founded on 2 different populations of angles clearly visible on histograms at the T12 level and statistically detectable at the T11 and L1 levels. T11-T12-L1 realized an homogeneous anatomical unit with 2 separate groups depending on the zygapophyseal joint orientations. A functional classification was also possible depending on the location of the geometric axial center of rotation. The "thoracic" type which center was on vertebral body. 95% of T10 vertebrae and 88% of T11 vertebrae belonged to the "thoracic" type whereas 97% of L1 ans 98% of L2 belonged to the lumbar type. At the T12 level, we found 35% of "thoracic" type and 65% of "lumbar" type. Long MP were found on "lumbar" type vertebrae with little interzygapophyseal angles (p < 0.001). "Anatomical" types were not related to different MP lengths. On the contrary, the "functional" classification showed shorter MP on "thoracic" type vertebrae than on "lumbar" vertebrae (1.9 +/- 2.9 mm vs 4.5 +/- 3 mm, p < 0.03). A large interzygapophyseal angle is known to enhance the axial rotation of the thoraco-lumbar junction. We infer that MP also play a role in axial rotation.(ABSTRACT TRUNCATED AT 250 WORDS)