Value of arthroscopy in the management of acute lesions of the distal tibiofibular joint.

PURPOSE: Managing the distal tibiofibular (DTF) joint remains a challenge despite recent developments. Ankle arthroscopy is emerging as a diagnostic and therapeutic means. Our study aimed to compare preoperative imaging data and arthroscopic data, with the hypothesis that imaging alone is insufficient to evaluate acute laxity, and with arthroscopy as the reference examination. METHODS: All patients treated in 2023 in our department for an acute isolated DTF lesion were included prospectively. Preoperative radiographic and MRI imaging were compared with arthroscopic data. RESULTS: Ten patients were treated. For five patients, the instability was doubtful after carrying out an appropriate imaging assessment (X-rays of both ankles, MRI). For four of these five patients, instability was confirmed by arthroscopy. Arthroscopy was useful for suturing the anterior bundle of the DTF joint for two patients and allowed for verifying the reduction in the sagittal and coronal planes for two patients. No complications were detected. CONCLUSIONS: Arthroscopy in isolated acute DTF lesions seems to provide a diagnostic and therapeutic advantage. Its use may allow for exhaustive assessment and complete repair of lesions. It must be offered as soon as possible; a delay in specialized imaging may delay therapeutic care.

Return to Sport and Duty in French Military Personnel after Medial Opening Wedge High Tibial Osteotomy.

INTRODUCTION: Medial opening wedge high tibial osteotomy (MOWHTO) is a surgical option for medial femorotibial osteoarthritis, which preserves articular cartilage by correcting the extra-articular deformities of the lower limbs that cause osteoarthritis. This is an increasingly popular treatment in a population with high functional demand, such as the French military population. The aim of this study was to evaluate the rate of return to work and military activities at 6 months postsurgery and at last follow-up in this military population following MOWHTO.The hypothesis of this study was that MOWHTO enabled a majority of service members to return to the same level of activity within 6 months of surgery. MATERIALS AND METHODS: This was a retrospective, multicenter study including all French military personnel operated on for MOWHTO alone for osteoarthritis of medial compartment between 2008 and 2018 in different Military Teaching Hospitals. We excluded civilian patients. For each patient, a questionnaire was used to collect epidemiological, professional, sports, and functional data. The primary endpoint was the rate of return to work at 6 months postsurgery. We also studied the recovery of sports activities and functional results at a 6.6-year follow-up by standardized questionnaires (Tegner activity scale, Lysholm, IKDC subjective (International Knee Documentation Commitee)). RESULTS: Twenty-four MOWHTOs were performed during this period in a cohort of 22 French military personnel. Return to work at 6 months was possible in 20/24 cases (83.3%). Of the four patients who did not return to work at 6 months, two changed their activities, while the other two returned to their jobs after 6 months. The rate of resumption of sporting activities at an equal or higher level was 50% (11/22). There was no difference between pre- and postoperative Tegner Activity Scale scores at the longest follow-up (P = .08). The mean postoperative Lysholm scores were 73.5 (standard deviation 17.8) and IKDC 59 (standard deviation 8.7). No intraoperative complications were found, and one case of postoperative infection was found. CONCLUSIONS: A total of 83% of the operated soldiers were able to return to their professional activities in less than 6 months. We observed a functional improvement at the last follow-up. Comparing these results with data from civilian populations, the rate of occupational recovery is comparable. However, the return to sport is much better in the series of nonmilitary patients with approximately 90% return to work and sport in the year following surgery. MOWHTO improves the functional results of the knee, enabling a return to work and sport in most cases in young, active populations such as the French military.

First Case of Surgically Treated Chronic Exertional Compartment Syndrome of the Arm.

This paper reports the first case of chronic exertional compartment syndrome in the arm treated surgically. The diagnosis was made in a patient who is under 30 years old, military, and very athletic, with recurrent exertional pain in the anterior compartment of the arms associated with rhabdomyolysis. The high-pressure measurements in the arms' anterior compartment after exertional exercise confirmed the diagnosis. Given the patient's functional demands, a surgical treatment of fasciotomy of the anterior compartment by miniapproach was performed and allowed the resolution of symptomatology with a return to sport at the same level after 3 months.

Return to military duty following anterior cruciate ligament reconstruction is associated with preoperative Body Mass Index and postoperative physiotherapy.

PURPOSE: To determine the rate and time of return to duty following anterior cruciate ligament reconstruction (ACLR) in military members, and to determine whether their outcomes are influenced by patient characteristics or surgical parameters. METHODS: We prospectively assessed 280 military members that underwent ACLR. 27 were excluded due to multi-ligamentous injuries or revision surgery, two did not provide informed consent and 62 were lost to follow-up. Patient demographics, pre-injury physical workload, complications and whether/when patients resumed duty and sports were noted, as well as clinical outcomes at a minimum follow-up of one year, including Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), Lysholm, and Tegner scale. RESULTS: The final cohort of 189 military members (82% men) had mean age of 25.5 ± 3.4 (range,19-38) at ACLR. At 3.3 ± 1.6 years (range, 1.0-6.3), the Tegner score was 6.1 ± 2.0, Lysholm was 87.0 ± 13.7, IKDC was 80.1 ± 15.7, and KOOS was 81.1 ± 14.8. Only 144 patients (76%) resumed duty, at 9.5 ± 5.3 months (range,1-28), and 141 patients (75%) resumed sport, at 10.2 ± 6.2 months (range,1-35). Multivariable analysis revealed that return to duty was less likely in patients with higher BMI (OR,0.89;p = 0.025), but more likely in patients that followed military physiotherapy (OR,2.76;p = 0.017) and with higher pre-injury physical workload (OR,3.93;p = 0.010). CONCLUSION: At a follow-up of 3.3 ± 1.6 years, 76% returned to duty at 9.5 ± 5.3 months, and 75% returned to their main sport at 10.2 ± 6.2 months. Patients with higher BMI are significantly less likely to resume military duty and sports; those that followed military physiotherapy were most likely to resume duty, while those that had greater pre-injury physical workload were more likely to both resume duty and sport.

Does AMIC® provide improvements at least two years after surgery for knee osteochondral lesions? A multicentre retrospective study of 101 patients.

BACKGROUND: Osteochondral defects of the knee due to trauma or osteochondritis are associated with osteoarthritis in the medium term. Defects 2 to 8cm2 in size can be managed by autologous matrix-induced chondrogenesis (AMIC®), in which sub-chondral micro-fractures are created within the lesion and the defect is then covered by a matrix of type I and type III collagen to induce de novo cartilage formation. Although promising outcomes have been observed in small single-centre cohorts, the medium-term clinical and radiological effectiveness of AMIC® remains to be demonstrated in larger populations. The objective of this study was to evaluate outcomes of patients at least 2 years after AMIC® for knee osteochondral defects. HYPOTHESIS: AMIC® is associated with clinical and radiological improvements after at least 2 years. MATERIAL AND METHOD: This multicentre (16 centres), multisurgeon (18 senior orthopaedic surgeons), retrospective study included consecutive patients who underwent AMIC® with Chondro-Gide® membrane implantation between September 2011 and January 2020. The 36-item Short Form quality-of-life (SF-36) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) score were determined before the procedure and during follow-up. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed by magnetic resonance imaging 2 years after the procedure. RESULTS: In total, 101 patients aged 12 to 60 years were included. Mean follow-up was 30 months. Mean defect size was 3.44cm2 (range, 2-8cm2). Significant improvements were documented in the SF-36 score, KOOS, and IKDC score. The mean MOCART score at 2 years was 75% (range, 20-100). DISCUSSION: The AMIC® procedure was associated with significant improvements at 2.5 years in patients treated for knee osteochondral defects measuring 2 to 8cm2. This method seems to provide similar outcomes to those of other available methods with the advantages of single-step surgery and elimination of osteochondral graft donor-site complications. LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

[Orthopedic ballistic injury, a five-beat waltz]. / Blessé balistique orthopédique, une valse à cinq temps.

Two-thirds of ballistic injuries result in severe limb damage. Damage Control Orthopaedic is a surgical strategy that makes it possible to save life, limb and function using simple mnemonic markers: 5minutes, 6hours, 7 days, 8 weeks and 9 months. The many players involved in this coherent care pathway, with its multiple surgical challenges, help to meet the challenge of comprehensive rehabilitation for orthopaedic ballistic injuries.

Anterior Cruciate Ligament Reconstruction in French Army: Return to Prior Level of Running on Selected Military Tests.

INTRODUCTION: Anterior cruciate ligament (ACL) rupture is frequently encountered in athletes as well as in military personnel. In civilian population, many studies have looked at the return to sport, but return to duty in Army is a topic that requires further research.The purpose of this study was to determine through annual military fitness tests in real conditions, the return to sport in soldiers after ACL reconstruction and factors influencing failure. MATERIALS AND METHODS: This was a retrospective comparative study. Patients were all soldiers and had followed up in a Military Hospital. The SUCCESS group was military personnel who obtained a result of the specific aptitude test greater than or equal to this same test carried out before reconstruction of the ACL, the FAILURE group comprised the others. Results of the annual specific aerobic fitness tests were collected before and after ACL reconstruction. Preoperative epidemiological data, intraoperative information, and isokinetic test results were collected. RESULTS: One hundred forty four soldiers were included between January 2011 and December 2017 (94.9% of men with a median age of 27.6 years); 40.3% obtained a result greater than or equal to the preoperative fitness test after ACL reconstruction. Among the soldiers who did not regain their performance, 24.3% were declared unfit or discharged. In the FAILURE group, we found patients with a higher body mass index (25.5 vs. 24.4; P = .04), less patients with isokinetic deficit < 30% on the knee flexors and extensors (26.6% vs. 62.9%; P < .01), more long sick leave (39.5% vs. 13.7%; P < .01), and late resumption of military activities (10.5 vs. 8.9 months; P < .01). CONCLUSION: Rupture of ACL has a significant impact on the operational capacity of the French army. The proportion of return to the same level in annual specific fitness tests after ACL reconstruction is 40% among soldiers. Several variables are important to consider in the follow-up of these patients to optimize their recovery of sports performance and therefore their operational capacity.

Arthroscopic lateral ankle ligament reinsertion with reinforcement by a minimally invasive extensor retinaculum flap for chronic ankle instability.

The past decade has seen the development of numerous arthroscopic techniques for ankle ligament repair or reconstruction in the treatment of chronic lateral ankle instability. Arthroscopy allows the assessment and treatment of intra-articular pathologies and is associated with faster functional recovery. The open surgery technique described by Blanchet, combining reinsertion of the lateral collateral ligament with reinforcement by an extensor retinaculum flap, has long proven its effectiveness. The aim of this article is to describe this technique under arthroscopy.

[Initial and surgical care of foot ailments]. / Soins initiaux et chirurgicaux des dégantages du pied.

A rare lesion, limb dislocation, particularly of the foot, is extremely serious. Its initial mortality is related to hemorrhage. Its morbidity is major due to lack of skin coverage of the bones and infection with functional issues. Management remains poorly codified and unknown, and requires a multidisciplinary medical and paramedical team from pre-hospital to rehabilitation. The initial surgery is ideally conservative to control the infection and cover the persistent skin flaps. An unfavorable evolution imposes amputation, sometimes early.

Application of the Masquelet technique in austere environments: experience from a French forward surgical unit deployed in Chad.

PURPOSE: We sought to evaluate the results of the Masquelet-induced membrane technique (IMT) for long bone defect reconstruction within the limited-resource setting of a French forward surgical unit deployed in Chad. METHODS: A prospective and observational study was conducted in all patients with a traumatic segmental bone defect in any anatomical location treated by IMT from November 2015 to December 2019. Although IMT was applied by various orthopedic surgeons with variable expertise, all followed the same surgical protocol. Endpoint assessment was performed 12 months after IMT application. RESULTS: Sixteen patients with a mean age of 32.7 years were included in the study. Bone defects were located on the tibia (n = 8), the femur (n = 6) or the radius (n = 2). Thirteen bone defects were infected. After debridement, the mean bone defect length was 4.3 cm. External fixation of the tibia and femur was predominant in both stages. Bone union was achieved in only 8 of the 16 cases at a mean time of 7.6 months. All failures were related to persistent infection or insufficient fixation stability in the second stage. CONCLUSIONS: This series is the first to report IMT use in a forward surgical unit. Despite frequent complications, local patients can benefit from this procedure, which is the only available method for bone reconstruction in areas with limited medical resources. A rigorous technical completion at both stages is crucial to limit septic or mechanical failures.

Does the choice of the optic portal influence the radiographic and early functional results in acute acromioclavicular disjunctions?

Exposure of the coracoid process during arthroscopic stabilization of acute acromioclavicular disjunctions (ACDs) can be achieved either by passing an extra- articular optical portal through the subacromial space or by an intra-articular optical route through the glenohumeral joint with opening of the rotator interval. The objective of our study was to compare the impact on the functional results of these two optical routes. This was a retrospective, multicentre study that included patients operated on for an acute acromioclavicular disjunction arthroscopically. The treatment consisted of surgical stabilization under arthroscopy. The surgical indication was retained for an acromioclavicular disjunction of grade 3, 4 or 5, according to the Rockwood classification. Group 1, which consisted of 10 patients, was operated on with an extra-articular subacromial optical route, and group 2, which consisted of 12 patients, was operated on with an intra-articular optical route with opening of the rotator interval according to the habits of the surgeon. A follow-up of 3 months was performed. The functional results were evaluated for each patient using the Constant score, Quick DASH, and SSV. The delays in returning to professional and sports activities were also noted. A precise postoperative radiological analysis made it possible to analyse the quality of the radiological reduction. No significant difference between the two groups was found between the Constant score (88 vs. 90; p = 0.56), Quick DASH (7 vs. 7; p = 0.58), or SSV (88 vs. 93; p = 0.36). The times to return to work (6.8 weeks vs. 7.0 weeks; p = 0.54) and sports activities (15.6 weeks vs. 19.5 weeks; p = 0.53) were also comparable. The quality of the radiological reduction was satisfactory in the two groups and did not depend on the approach. No clinically or radiologically significant differences between the extra-articular and intra-articular optical portals in the surgical treatment of acute ACDs were found. The optical route can be chosen according to the habits of the surgeon.

Military Orthopedic Surgeons Are Not Just Traumatologists.

INTRODUCTION: Each French military orthopedic surgeon is both an orthopedic surgeon and a trauma surgeon. Their mission is to support the armed forces in France and on deployment. The aim of this study was to describe the type of orthopedic surgery performed for the armed forces in France. Our hypothesis was that scheduled surgery was more common than trauma surgery. METHODS: We conducted a retrospective descriptive analysis of the surgical activity for military patients in the orthopedic surgery departments of the four French military platform hospitals. All surgical procedures performed during 2020 were collected. We divided the procedures into the following categories: heavy and light trauma, posttraumatic reconstruction surgery, sports surgery, degenerative surgery, and specialized surgery. Our primary endpoint was the number of procedures performed per category. RESULTS: A total of 827 individuals underwent surgery, 91 of whom (11%) were medical returnees from deployment. The surgeries performed for the remaining 736 soldiers present in metropolitan France (89%) consisted of 181 (24.6%) trauma procedures (of which 86.7% were light trauma) and 555 (75.4%) scheduled surgery procedures (of which 60.8% were sports surgery). Among the medical returnees, there were 71 traumatology procedures (78%, of which 87.3% were light traumatology) and 20 procedures corresponding to surgery usually carried out on a scheduled basis (22%, of which 95% were sports surgery). CONCLUSION: Military orthopedic surgeons are not just traumatologists; their activity for the armed forces is varied and mainly consists of so-called programmed interventions.

How do patients choose their surgeon? Example of anterior cruciate ligament reconstruction.

INTRODUCTION: In this age of social media, with an ever-higher profile for surgery and rankings for the general public, patients' criteria for choosing a surgeon or team are not precisely known, especially in France. We therefore conducted a prospective study concerning anterior cruciate ligament reconstruction: (1) to determine how patients came to know their surgeon; (2) to identify factors affecting final choice. HYPOTHESIS: Patients' choice of surgeon is affected by scores found in social media and rankings found in the press. MATERIAL AND METHOD: A prospective continuous study included all patients operated on, without standardization of technique, in 3 hospitals (public and private sector). An anonymous questionnaire on surgeon selection criteria, scored 0 to 10, was distributed on a voluntary basis on the day of surgery scheduling. RESULTS: One hundred and five patients were included. They had come to know of their surgeon via family or friends or their personal physician in more than two-thirds of cases. The essential criterion of final choice was the clarity of the written and oral information provided in consultation (mean score, 8.09±1.83). Other factors included wait-time to surgery (7.39±2.25) and to first consultation (7.26±2.01) and the surgeon's reputation (7.42/10±2.43). CONCLUSION: "Word of mouth" and the quality if information provided in consultation motivated final choice, more than any influence of social media or press hospital rankings. LEVEL OF EVIDENCE: IV; prospective observational study without control group.

Retired French Military Orthopedic Surgeons' Opinions on Their Careers.

INTRODUCTION: Owing to their professional and personal experiences, retired military orthopedic surgeons' views of their careers are a unique source of inspiration. Reflecting on their experiences allows them to grasp the positive points and those that need to be improved for future generations. The purpose of this study is to gather the opinions of retired surgeons on the career of military orthopedic surgeons. METHODS: We addressed a questionnaire to all retired French military orthopedic surgeons in the database of the Chair of Applied Surgery for the Armed Forces as of December 2020, retrained in the civilian sector. A questionnaire sent by email made it possible to collect demographic, professional, and personal data about their careers. Subjective data were evaluated using a visual analog scale from 0 to 10 or a subjective qualification scale. The main assessment criterion was the average score (out of 10) of the retired surgeons' opinions on their careers. RESULTS: Fifty-two percent of retired surgeons replied (32 out of 61), with the respondents having an average age of 63 years. They had been in military retirement for an average of 14 years and had practiced for approximately 13.5 years. The majority (28 out of 32) had had a civilian activity after leaving the army. The three main reasons for leaving were the unsatisfactory working environment, the high number of deployments, and insufficient pay. Nevertheless, the respondents were satisfied with their activity, their job, and their training. The average score given for the overall opinion on their careers was 8.14/10. The three main disadvantages of the career that were noted were the quality of family life, the conditions of employment, and the financial aspects. The majority were very satisfied with the second half of their civil career. CONCLUSION: Overall, the opinion of retired French military orthopedic surgeons on their careers is very good. Their point of view provides interesting elements for reflection from both a professional point of view and a personal point of view. They were very satisfied with the quality of their training, their job, and their activity. However, the quality of their personal/family life, working conditions, and the financial aspects of the career reduced this satisfaction. The results also have potential application in improving the preparation of young military orthopedic surgeons.

Should proximal ruptures of the anterior rectus femoris muscle be treated surgically?

PURPOSE: No therapeutic consensus has been established about proximal ruptures of the rectus femoris muscle. The objective of this literature review is to determine a therapeutic course of action. METHODS: We conducted a literature review on the PubMed database using the following keywords (in French and English, respectively): "quadriceps/quadriceps", "droit antérieur/rectus femoris", "proximal/proximal", "chirurgie/surgical", "avulsion/avulsion". We collected 266 articles, 36 of them were selected, which were related to our topic: proximal rupture of the anterior rectus femoris. Patients with a proximal rupture of the rectus femoris, minor or major patient of traumatic origin were included in this study. Patients injured at another lesion level, or non-traumatic lesions of the proximal rectus femoris (tendinitis without ruptures, tumor or others) were excluded. For each patient, the indications, the type of treatment and the functional result were analyzed, with the time to recovery and the level of recovery from sports and professional activities (same sport/profession or not, same level or not) as the main criterion of judgment. Fisher exact test was used for statistical comparison. RESULTS: The aims of conservative treatment are to be pain free for the patient, to fight hematoma and to rehabilitate the injury as quickly as possible. The surgical techniques are varied, with most consisting of either a reinsertion of the musculo-tendon stump or a resection of the scar tissue with myo-tendino-aponeurotic suture in place. The functional results are good for the majority of the treatments proposed, but the conservative treatment has a shorter recovery time (3 months vs. 4 months for the best surgical results). Highly displaced bone avulsion is the only indication for first-line surgical treatment. CONSLUSION: The main disadvantage of conservative treatment is the risk of residual pain beyond 3 months (10%), justifying an MRI to guide secondary surgical treatment. We propose a treatment plan for proximal rupture of the proximal rectus femoris rupture.

Proximal tibiofibular stabilization by anatomical ligamentoplasty and diaphyseal osteotomy of the fibula / 中华创伤杂志(英文版)

Proximal tibiofibular instability is a rare condition for which treatment is poorly codified. A 21-year-old patient, a leisure sportswoman, presented a post-traumatic anterolateral instability of the proximal tibiofibular articulation without cartilage lesion. We propose an original surgical technique based on a review of the literature that combines an anatomical ligamentoplasty of the proximal tibiofibular joint and a proximal fibular diaphyseal osteotomy to reduce the distal tibiofibular mechanical stresses. This original technique allows a favorable evolution with recovery of professional and sports activities at 6 months.