Re-ruptures and early outcomes after surgical repair of acute Achilles tendon ruptures: prospective, comparative multicenter study.

PURPOSE: The primary objective of this study was to compare the re-rupture rate, clinical results, and functional outcomes six months after the surgical repair of an acute Achilles tendon rupture between three different techniques (open repair, percutaneous repair with the Tenolig®, and minimally invasive repair). METHODS: A prospective, comparative, multicenter, non-randomized study was performed and included 111 patients who had an acute ruptured Achilles tendon: 74 underwent an open repair, 22 underwent a percutaneous repair using the Tenolig® and 15 had a minimally invasive repair. At six months follow-up we analyzed the number of re-ruptures, phlebitis, infections, complex regional pain syndrome, clinical outcomes (muscle atrophy, ankle dorsal flexion), functional scores (ATRS, VISA-A, EFAS, SF-12), and return to running. RESULTS: There were more re-ruptures (p=0.0001) after repair with the Tenolig® (27%) than with open repairs (1.3%) and minimally invasive repairs (0%). The rate of other complications was not different. No clinical differences were found between the three groups. Only some functional scores EFAS Total (p=0.006), and VISA-A (p=0.015) were worse in the Tenolig® group. All the other results were similar between the three groups. CONCLUSION: Despite heterogeneous studies in literature, the results of this comparative and prospective study between three surgical techniques of Achilles tendon repair confirmed that Tenolig® repair increased the rate of early re-rupture compared to open or minimally invasive techniques.

Does hip joint positioning affect maximal voluntary contraction in the gluteus maximus, gluteus medius, tensor fasciae latae and sartorius muscles?

BACKGROUND: Minimally invasive total hip arthroplasty (THA) is presumed to provide functional and clinical benefits, whereas in fact the literature reveals that gait and posturographic parameters following THA do not recover values found in the general population. There is a significant disturbance of postural sway in THA patients, regardless of the surgical approach, although with some differences between approaches compared to controls: the anterior and anterolateral minimally invasive approaches seem to be more disruptive of postural parameters than the posterior approach. Electromyographic (EMG) study of the hip muscles involved in surgery [gluteus maximus (GMax), gluteus medius (GMed), tensor fasciae latae (TFL), and sartorius (S)] could shed light, the relevant literature involves discordant methodologies. We developed a methodology to assess EMG activity during maximal voluntary contraction (MVC) of the GMax, GMed, TFL and sartorius muscles as a reference for normalization. A prospective study aimed to assess whether hip joint positioning and the learning curve on an MVC test affect the EMG signal during a maximal voluntary contraction. HYPOTHESIS: Hip positioning and the learning curve on an MVC test affect EMG signal during MVC of GMax, GMed, TFL and S. METHODS: Thirty young asymptomatic subjects participated in the study. Each performed 8 hip muscle MVCs in various joint positions recorded with surface EMG sensors. Each MVC was performed 3 times in 1 week, with the same schedule every day, controlling for activity levels in the preceding 24h. EMG activity during MVC was expressed as a ratio of EMG activity during unipedal stance. Non-parametric tests were applied. RESULTS: Statistical analysis showed no difference according to hip position for abductors or flexors in assessing EMG signal during MVC over the 3 sessions. Hip abductors showed no difference between abduction in lateral decubitus with hip straight versus hip flexed: GMax (19.8±13.7 vs. 14.5±7.8, P=0.78), GMed (13.4±9.0 vs. 9.9±6.6, P=0.21) and TFL (69.5±61.7 vs. 65.9±51.3, P=0.50). Flexors showed no difference between hip flexion/abduction/lateral rotation performed in supine or sitting position: TFL (70.6±45.9 vs. 61.6±45.8, P=0.22) and S (101.1±67.9 vs. 72.6±44.6, P=0.21). The most effective tests to assess EMG signal during MVC were for the hip abductors: hip abduction performed in lateral decubitus (36.7% for GMax, 76.7% for GMed), and for hip flexors: hip flexion/abduction/lateral rotation performed in supine decubitus (50% for TFL, 76.7% for S). DISCUSSION: The study hypothesis was not confirmed, since hip joint positioning and the learning curve on an MVC test did not affect EMG signal during MVC of GMax, GMed, TFL and S muscles. Therefore, a single session and one specific test is enough to assess MVC in hip abductors (abduction in lateral decubitus) and flexors (hip flexion/abduction/lateral rotation in supine position). This method could be applied to assess muscle function after THA, and particularly to compare different approaches. LEVEL OF EVIDENCE: III, case-matched study.

Short-term comparison of postural effects of three minimally invasive hip approaches in primary total hip arthroplasty: Direct anterior, posterolateral and Röttinger.

INTRODUCTION: There is renewed interest in total hip arthroplasty (THA) with the development of minimally invasive approaches. The anterior and Röttinger approaches are attractive for their anatomical and minimally invasive character, but with no comparative studies in the literature definitely suggesting superiority in terms of quality of functional recovery. We therefore performed a case-control study, assessing: 1) whether the postural parameters of patients operated on with the anterior, Röttinger and posterior minimally invasive approaches were similar to those of asymptomatic subjects, and 2) whether there were any differences in postural parameters between the three approaches at short-term follow-up. HYPOTHESIS: We hypothesized that the anterior and Röttinger approaches are less disruptive of postural parameters than the posterior approach. METHODS: Seventy subjects (44 primary THA patients and 26 asymptomatic control subjects) were enrolled. Operated subjects were divided into 3 experimental groups corresponding to the 3 minimally invasive approaches: posterior (n=14), anterior (n=15) and Röttinger (n=15). Two single-leg stance tests (left followed by right leg stance; 10s per test) were carried out on a stabilometric platform, within 2months after surgery for all THA patients, and for controls. Six significant parameters were selected for statistical analysis: test performance, mediolateral and anteroposterior displacements of the center of pressure (CP), path length, average CP displacement speed, and the ellipse containing 95% of CP projections. Non-parametric statistical tests were used to compare groups. RESULTS: There was no difference between the 3 study groups and the control group according to age, gender, BMI, or side (or between study groups regarding WOMAC score). No significant differences between approaches were found for success on postural tests (P=0.14). Subjects operated on with the anterior or Röttinger approach showed significant differences from asymptomatic subjects for 2 postural parameters: path length (Röttinger P=0.04, anterior P=0.03) and average CP displacement speed (Röttinger P=0.04, anterior P=0.03). Subjects operated on through the posterior approach showed no significant differences from asymptomatic subjects. DISCUSSION: The study hypothesis, that the anterior and Röttinger approaches for hip arthroplasty are less disruptive of postural parameters than the posterior approach, was not confirmed. The anterior and Röttinger approach groups showed higher average CP displacement speed and path length, suggesting that they use up more energy resources to maintain static balance. The posterior approach had the least impact on postural parameters in the first 2 postoperative months. LEVEL OF EVIDENCE: III, case-control study.

Anterior knee laxity measurement: comparison of passive stress radiographs Telos(®) and "Lerat", and GNRB(®) arthrometer.

INTRODUCTION: In patients with anterior cruciate ligament (ACL) tears, anterior laxity can be measured using stress radiographs or more recently introduced electronic measurement devices. HYPOTHESIS: The GNRB(®) arthrometer offers a radiation-free method of measuring anterior knee laxity whose diagnostic value is identical to that of Telos(®) or Lerat stress radiographs. PATIENTS AND METHODS: One hundred and fifty-seven patients (40 years [18-69]) scheduled for knee arthroscopy were evaluated using the GNRB(®) and two series of stress radiographs of both knees, one obtained using a 250-N Telos(®) device and the other using the technique described by Lerat (posterior translation of the femur/tibia under a 9-kg loading device). Arthroscopic evaluation of the ACL served as the reference standard for assessing the diagnostic performance of the radiological and instrumental laxity measurements. RESULTS: Under arthroscopic examination, the ACL was normal in 50.3%; "healed to roof of the notch" (partial tear) in 9.6%, "posterolateral bundle preserved" (partial tear) in 7.0%, "healed to the posterior cruciate ligament" (PCL) in 17.8%, and "empty notch" (complete tear) in 15.3%. In partial ACL tears, no significant differences in anterior laxity were found across the three measurement techniques. Telos(®) and GNRB(®) laxities were greater in the complete-tear group than in the normal-ACL, partial-tear, and healed-to-PCL groups. With the Lerat technique, the only significant differences were between the complete-tear group and the normal-ACL and partial-tear groups. Telos(®) and GNRB(®) showed similar diagnostic performance (sensitivity>62%, specificity>75%), whereas the Lerat technique lacked sensitivity (sensitivity=43.2%, specificity=82.7%) at 3mm. DISCUSSION: Diagnostic performance was lower in our study than in earlier reports. The GNRB(®) performed as well as Telos(®). The non-irradiating nature of GNRB(®) assessments allows repeated measurements for therapeutic or diagnostic purposes. LEVEL OF EVIDENCE: Level III, prospective case-control study.

Surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: when gloves should be changed.

INTRODUCTION: Double gloving is recommended in orthopedic surgery, notably in total hip arthroplasties (THA) to prevent contamination of the surgical site. HYPOTHESIS: Systematic glove changes during the key phases of hip prosthesis implantation reduce the frequency of occult perforations and bacterial loading of glove surfaces. PATIENTS AND METHODS: During 29 THA implantation procedures, we evaluated the bacterial contamination of the outer glove surface and its perforation rate. Contaminations were sought by placing the gloved fingertips on blood geloses (incubation, 48 h at 37°C), and perforations were sought using a water test (NF EN 455-1). RESULTS: One intervention was excluded from the study because an initial contamination was detected, leaving 28 cases analyzed. Fifteen interventions (53.6%) presented contaminated geloses (26 contaminated glove changes for 3.38% of the gloves used). These contaminations were found on the gloves of all of the gloved personnel, with no distinction as to the right or left side. Thirty-eight percent of the contaminations occurred during joint reduction, whereas the other surgical stages grouped 15-26% of the contaminations (P<0.05). Twenty-nine bacteria were identified: 62% coagulase-negative staphylococci (16% of which were methicillin-resistant). Twenty-eight perforations were identified (3.5% of the gloves used), 67.8% of which were located on the operator and 64.3% on the dominant side. Eighty percent of the perforations occurred during the "surgical incision" and the "cup and stem implantation" stages (respectively, 5.0% and 5.5% of the gloves used during the surgical time) (P<0.05), without being associated with an increased risk of bacterial contamination. At the 12-month clinical follow-up, no infectious complications were found. On the gloves worn by the 20 surgical team members contaminated during these 28 surgical procedures, replacing contaminated gloves with new sterile gloves rendered all the bacteriological samples of the subsequent surgical stages negative in 16 cases (80%). DISCUSSION: Increasing the number of outer glove renewals, notably during certain surgical stages at risk for contamination (prosthesis reduction) or perforation (surgical incision/femoral cementing) can reduce the risk of contamination and perforation. The bacteria isolated suggest a cutaneous origin. Regularly changing gloves has resulted in a sterile state in 80% of cases. LEVEL OF EVIDENCE AND TYPE OF STUDY: Level III prospective diagnostic study.

A prospective clinical and radiological study comparing hydroxyapatite-coated with cemented tibial components in total knee replacement.

This prospective study compares the outcome of 157 hydroxyapatite (HA)-coated tibial components with 164 cemented components in the ROCC Rotating Platform total knee replacement in 291 patients. The mean follow-up was 7.6 years (5.2 to 11). There were two revisions for loosening: one for an HA-coated and one for a cemented tibial component. Radiological evaluation demonstrated no radiolucent lines with the HA-coated femoral components. A total of three HA-coated tibial components exhibited radiolucent lines at three months post-operatively and these disappeared after three further months of protected weight-bearing. With HA-coated components the operating time was shorter (p < 0.006) and the radiological assessment of the tibial interface was more stable (p < 0.01). Using revision for aseptic loosening of the tibial component as the end point, the survival rates at nine years was identical for both groups at 99.1%. Our results suggest that HA-coated components perform at least as well as the same design with cemented components and compare favourably with those of series describing cemented or porous-coated knee replacements, suggesting that fixation of both components with hydroxyapatite is a reliable option in primary total knee replacement.

Open and subcutaneous recent tibialis anterior tendon ruptures: does postoperative immobilization method influence outcome?

UNLABELLED: We report on seven traumatic lesions of the tibialis anterior tendon (one subcutaneous rupture and six open tears) in seven injured patients of mean age 45 years [17-79] all managed by direct suture and immobilization either using a cast boot (four cases) or a lower leg external fixator (three cases). After a mean follow-up of 31 months (6-50), external fixation achieved favourable clinical results with no specific complication. External fixation improves the conditions for suture efficiency, provides full immobilization and facilitates wound care in patients at a high risk of developing cutaneous complications. In accordance with data published in the literature, immobilization by means of a windowed cast boot achieved satisfactory results in patients with no risk factors. This method compatible with early mobilization avoids placement of a posterior splint which could induce slackening and weakening of tendon repair. LEVEL OF EVIDENCE: Retrospective study (Level IV).

Laxity measurements using stress radiography to assess anterior cruciate ligament tears.

INTRODUCTION: The clinical diagnosis of the anterior cruciate ligament (ACL) tear is based on demonstrating anterior subluxation of the tibia on the femur. In any of the following perspectives, diagnostic (cutoff value confirming rupture), prognostic (treatment efficacy), and therapeutic (laxity influencing the treatment), this laxity can be measured on stress X-rays. WORKING HYPOTHESIS: The diagnostic value of dynamic radiographs is low for ACL rupture. Passive Telos(®) X-rays have better diagnostic value, better radiologic quality, and are easier to carry out than active Franklin-type X-rays. MATERIAL AND METHODS: A cohort of 112 patients (28 females, 84 males; mean age, 33.7 years [range, 18-72 years]) with an indication for knee arthroscopy were studied prospectively. Before undergoing the arthroscopic treatment, two series of images of both knees were taken: one series of passive anterior drawer dynamic X-rays on a Telos(®) device at 250 N and a series of active anterior drawer dynamic X-rays according to Franklin (contraction of the quadriceps against 7 kg of weight at the ankle). The arthroscopic evaluation of the ACL (reference status) was compared to the anterior laxity measurements (absolute and differential) of each knee compartment (medial, lateral, and average) to determine the diagnostic value of the two radiological tests. RESULTS: We found 70 patients with an "arthroscopically ruptured ACL", 32 with an "arthroscopically healthy ACL", and 10 with a "partial rupture". The measurement of the anterior drawer values on the dynamic X-rays (active and passive) by two independent observers was reliable and reproducible (ICC>0.80), particularly when using the medial compartment (ICC=0.96) and the differential values eliminating the interobserver measurement error and interindividual laxity variations. In terms of X-ray technique, the active images were more frequently painful and the radiographic result showed less good quality than the Telos images. The anterior drawer values in the "healthy ACL" group were significantly less than in the "ruptured ACL" group for the Telos(®) images, whether the measurements were absolute or differential. For the Franklin images, this difference was only significant for the absolute values. Used for diagnosis (4-mm differential on the medial compartment), the passive dynamic images had lower diagnostic values (Se=59% and Sp=90%) than the series reported in the literature, which were marked by great heterogeneity. CONCLUSION: The measurement of anterior drawer values on Telos(®) and Franklin dynamic X-rays is a reliable and reproducible measurement, particularly when using the medial compartment and differential measurements. This small series did not demonstrate a diagnostic value for the Franklin images, contrary to the Telos(®) X-rays. Used for diagnostic purposes, the Telos(®) images had a low sensitivity; consequently, they should be used preferentially for prognostic or therapeutic purposes. LEVEL OF EVIDENCE: Level III, prospective case-control study.

Pin track induced fractures around computer-assisted TKA.

BACKGROUND: Navigation tracker pins rigidly fixed to bone is a prerequisite for computer-assisted total knee arthroplasty. The first cases of fracture on navigation tracker pin sites have recently been reported. HYPOTHESIS: The risk of fracture depends first on diaphyseal placement of the tracker pins, and second on "transcortical" tangential route of the tracker pin as well as failure to obtain rigid fixation. MATERIAL AND METHODS: In a continuous series of 385 total knee arthroplasties, five patients (four women, one man) on average 73.2 years old (range: 65-79 years old) have sustained femoral fractures at the tracker pin site (incidence 1.3%). We investigated the demographic and radiological factors contributing to this complication. RESULTS: The patients with fractures were obese or overweight with an average body mass index of 32.56 (range: 25.14-39.45) but this was not statistically different from the BMI of the population of patients without fractures. The average delay from arthroplasty to fracture was 12.6 weeks (range 7-21). The fracture was always preceded by several days of thigh pain and occurred after a minor trauma. The fractures were always simple originating from the tracker pin site. In four out of five cases, the tracker pins were placed in the diaphyseal femur, and in all cases at least one pin was transcortical. Closed endomedullary nailing or ORIF were performed in five cases, with no bone graft. Union was obtained with functional results that were equivalent to those before the fracture. DISCUSSION: Fractures at the navigation tracker pin site are a complication which must be understood and explained to patients undergoing computer-assisted TKA because of the 1.3% incidence described in our series. The circumstances systematically associated with this type of fracture were: occurrence a certain amount of time after arthroplasty in obese patients who had pain before the fracture occurred. These fractures are favored by suboptimal placement of the tracker pins, especially in the lower diaphysis of the femur and transcortical fixation of at least one of the pins. Treatment included stable osteosynthesis and did not affect the results of total knee arthroplasty. The development of thigh pain some time after surgery in high risk patients (obesity, tracker pin site in the lower diaphysis, transcortical fixation) should suggest this diagnosis and weight-bearing should be avoided because these fractures are assimilated with stress fractures. Bicortical metaphyseal fixation should be the preferred tracker pin positioning for navigated total knee arthroplasty. LEVEL OF EVIDENCE: Level IV retrospective study.

[Arthroscopic partial trapezectomy. A radio-anatomical study about 14 cases]. / Trapézectomie partielle arthroscopique : étude radioanatomique de 14 cas.

OBJECTIVES: The aim of the study was to assess the accessibility of the trapezium surface to arthroscopic resection related to the degenerative stage, to define the surgical approach and to determine the efficacy of the X-rays for evaluating the amount of resected bone. METHODS: Fourteen trapezectomies were performed on seven cadaveric specimens using an arthroscopic procedure. Pre- and post-procedure X-rays were used to assess the initial trapeziometacarpal osteoarthritis and the resection performed. Each subject was randomized for using two posterior portals or two posterior portals and one anterior portal. At the end of the procedure, a dissection was performed for evaluating the quality of resection and the anatomical relationship of each surgical approach. RESULTS: The stages of preprocedure osteoarthritis were comparable between the two sides of the same cadaveric specimen. On post-procedure X-rays, the resection appeared complete in only six out of 14 wrists. During dissection, no injury to neurovascular structures was observed, and the resection was visible macroscopically in 11/14 wrists. Three resections were incomplete, i.e., less than 20 % of total trapezial surface: two of them were seen in the most osteoarthritic cases of the study. CONCLUSIONS: The arthroscopic approach presents an opportunity to access the entire trapezial surface, even if a high stage of osteoarthritis appears to be a risk for incomplete resection. The addition of a systematic anterior approach to the traditional dorsal approach does not increase the accessibility. Although radiography is not the most appropriate tool to assess the resected surface, it does help to locate the defects of resection and can guide the surgical procedure in situations where there is a risk of incomplete resection.

Cementless cups do not increase osteolysis risk in metal-on-metal total hip arthroplasty. Apropos of 106 cases.

BACKGROUND: Metal-on-metal bearings in total hip arthroplasty (THA) were introduced to reduce the production of wear debris and debris-induced periprosthetic osteolysis. Analysis of various series according to the type of selected acetabular fixation highlights different evolutions: favourable results with uncemented cups contrasting with loosening and radiolucent lines (RLL) evolution for cemented cups. HYPOTHESIS: Combining metal-on-metal bearings to uncemented cups does not increase the osteolysis risk at a minimum 5 years' follow-up. MATERIALS AND METHODS: From January 1999 to December 2002, 106 Metasul THAs were implanted in 95 patients using a Hardinge anterolateral approach (40 women and 55 men with an average age of 59.2 years). The cups were of cementless, hydroxyapatite-coated Cedior type (Zimmer) housing a Metasul insert in a polyethylene sandwich. The femoral stem used was the cemented Acora, then the Exafit (Zimmer) type with Metasul 28-mm head mounted on a 8/10 Morse taper. Patients were evaluated clinically using the Postel-Merle-d'Aubigné (PMA) scoring system and radiologically using various markers: cup inclination angle, eventual RLL presence, appearance of osteolysis images, ectopic ossifications and finally, eventual implant migration. In the eventuality of suspected RLL evolution or osteolysis, advanced imaging was performed; joint aspiration liquid and cobalt serum level were studied. RESULTS: We reviewed 94 prostheses (85 patients) with an average follow-up of 6.4 years (4.3 to 9.3 years, median of 6.3 years). The rate of patient loss from follow-up and death was 12.1%. The PMA score of non-revised patients increased from 11.4+/-1.5 to 17.6+/-0.2 at follow-up. We numbered ten re-operations not attributable to the type of bearings used. Three revisions were directly related to the metal-on-metal bearing: two metallosis due to impingement and one case of hypersensitivity. Cup inclination angle was 45.7+/-5.49 degrees . No implant migration was noted during the follow-up duration. Only one cup undergoing revision presented a substantial osteolysis. On the femoral side, with non-revised implants, we observed 13 cement/bone RLL images around nine femoral stems and six calcar resorptions. The survival rate at more than 6 years was 95.8% (91.8-99.8) for the cups and 94.8% (90.3-99.2) for the femoral stems (95% confidence interval). DISCUSSION: The present study confirms our hypothesis: with Metasul bearings equipped cementless cups, the rates of aseptic loosening, RLL or acetabular osteolysis are low and remain stable over time, unlike the results observed for Metasul series with polyethylene directly cemented on bone. Specific complications, such as metallosis due to impingement and hypersensitivity, can rarely be encountered. These results encourage us to continue employing metal-on-metal bearings with non-cemented cups in active patients. LEVEL OF EVIDENCE: Level IV: Therapeutic study.

[Treatment of thoracolumbar junction burst fractures (Magerl A3) by balloon kyphoplasty: anatomic study]. / Traitement des burst fractures (Magerl A3) de la charnière thoracolombaire par cyphoplastie à ballonnets: étude anatomique.

PURPOSE OF THE STUDY: Balloon kyphoplasty is a not widely used method for the treatment of vertebral burst fractures with displacement of the posterior wall. The purpose of this study was to measure the posterior height of the vertebral body and the posttraumatic canal surface area before and after balloon kyphoplasty for the treatment of burst fractures (Magerl A3). MATERIAL AND METHODS: This anatomic study was conducted on ten experimental burst fractures of the thoracolumar junction prepared on cadaver specimens. The surface area of the canal and the height of the posterior wall were measured by computed tomography before and after balloon kyphoplasty. These two variables were then compared with search for correlation. RESULTS: The posttraumatic canal surface area increased significantly after kyphoplasty (p=0.02). Gain in posterior height was not significant and there was no correlation between the two variables. Cement leakage into the canal was not observed. DISCUSSION: It is known that balloon kyphoplasty can re-establish anterior height and correct for the posttraumatic kyphosis in patients with compression fractures of osteoporotic vertebrae. The present cadaver study shows that when the posterior wall is displaced posteriorly, balloon expansion does not exaggerate the wall displacement. On the contrary, the posttraumatic canal surface area is increased due to the ligamentotaxis effect. CONCLUSION: Balloon kyphoplasty could be an alternative to posterior instrumentation for burst fractures without associated neurological deficit, even if the posterior wall is damaged. This technique can be used to reduce and stabilize the fracture while sparing the adjacent levels and limiting the risk inherent with an extensive surgical approach.