Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year.

OBJECTIVE: The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results. HYPOTHESES: There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols. METHODS: This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review. RESULTS: Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07). CONCLUSIONS: This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes. LEVEL OF EVIDENCE: III; retrospective comparative, non-randomized.

Functional and radiologic outcomes of non-displaced scaphoid waist fractures in adolescents approaching skeletal maturity: Comparison between conservative treatment and percutaneous screw fixation.

BACKGROUND: Treatment of scaphoid waist fractures is generally conservative in children but surgical in adults, given the relatively high risk of non-union in adults. In adolescents, the required therapeutic strategy is less well defined. The objective of this study was to compare the radiographic and clinical parameters, and the rate of complications, between non-surgical orthopedic treatment (OT) and surgical treatment (ST) by percutaneous screw fixation of these fractures in adolescents approaching skeletal maturity. HYPOTHESIS: ST of non-displaced scaphoid waist fractures in adolescents allows radiographic union, a functional result and a complication rate comparable to that of ST. METHODS: This single-center retrospective study included patients who presented with a non-displaced scaphoid waist fracture, with a chronological age (CA) and a bone age (BA) between 14 and 18 years. Clinical and radiographic parameters and complications were analyzed during the trauma and at one year, including functional scores, between two groups of patients; OT and ST. RESULTS: Thirty-seven patients had OT (63.8%) and 21 had ST (36.2%). The median CA was 16 years [14.25-16]. The median BA was 16 years [15;17] according to the Greulich and Pyle method and corresponded to R9 [R7-R10] and U7 [U7;U8] according to the Distal Radius and Ulnar (DRU) classification system. All non-unions were found in the OT group (23.4% vs. 0%, p=0.019). The duration of immobilization (8 weeks) and the number of consultations were higher after OT than ST. Functional scores were lower in patients with non-union after OT (p≤0.002) CONCLUSION: OT of scaphoid waist fractures in adolescents results in a higher rate of non-union than ST, similar to the rate found in adults. Findings from this study recommend a surgical approach by percutaneous screw fixation. LEVEL OF EVIDENCE: III; comparative retrospective study.

Patellar dislocation recurrence after pediatric MPFL reconstruction: Bone tunnels and soft tissues versus suture anchors and interference screw.

BACKGROUND: Several Medial Patellofemoral Ligament (MPFL) reconstruction techniques have been developed, and those with soft tissue fixation are often preferred in children because they allow the growth cartilage to be preserved. Nevertheless, the recurrence rate of patellar dislocation varies widely from one series to another, with no clear superiority of one technique in the pediatric setting. The objectives of this study were to compare the results of two tendon graft fixation techniques (tendon-tendon fixation and anchor-screw fixation) by analyzing: 1) the rate of patellar dislocation recurrence, 2) clinical outcomes, 3) tourniquet time and 4) complication rate. HYPOTHESIS: The two tendon graft fixation techniques used in MPFL reconstruction are equivalent in terms of the patellar dislocation recurrence rate. PATIENTS AND METHODS: This is a retrospective comparative study including 57 patients with a median age of 14 years (12-15 years) who underwent MPFL reconstruction between 2016 and 2020. The tendon graft was fixed upon itself, after passing through a patellar tunnel (Group A: tendon-tendon fixation; n=29) or by two anchors and an interference screw (Group B: anchor-screw fixation; n=28). The preoperative radiographic data were comparable in the two groups: patellar height [A: 1.3 (interquartile range (IQR): 1.2-1.4) / B: 1.2 (IQR: 1-1.4) (p=0.21)], tibial tuberosity to trochlear groove (TTTG) distance [A: 16 (IQR: 13-19) / B: 13.5 (IQR: 11.5-18.8) (p=0.12)], patellar tilt [A: 25 (IQR: 20-35) / B: 24.5 (IQR: 21-32) (p=0.93)]. For each technique, the rate of patellar dislocation recurrence, clinical and functional results (Kujala score, Marx activity score, Lille patellofemoral score), complications (pain, stiffness, revision) were analyzed. In addition to MPFL repair, 13 patients (2 in Group A, 11 in Group B) underwent additional orthopedic procedures to enhance patellar stability. RESULTS: no patients were lost to follow-up and the median follow-up was 30 months (IQR: 20-38). The dislocation recurrence rate was higher in Group A, 6.9% (2/29) compared to none in Group B. The clinical results were comparable for the two groups with a Kujala score [A: 94 (IQR: 89-100) / B: 92 (IQR: 87.5-94.5) (p=0.12)]; Marx score [A: 10 (IQR: 7-11) / B: 9.5 (IQR: 7.5-12) (p=0.89)] and Lille patellofemoral score [A: 97 (IQR: 91-100) / B: 94 (IQR: 90-98) (p=0.21)]. The tourniquet time was shorter in Group A than in Group B, 61minutes (IQR: 52-71) versus 85minutes (IQR: 55-115) (p=0.024) excluding additional orthopedic procedures. The complication rate was 17.2% (5/29) in Group A (dislocation n=2, stiffness n=2, ATT (anterior tibial tuberosity) revision with screw removal n=1) and 10.7% (3/28) in B (pain n=1, ATT revision with screw removal n=2) (p=0.35). CONCLUSION: Clinically, anchor-screw fixation appears to reduce the risk of patellar dislocation recurrence but this could not be statistically tested. On the other hand, the two techniques are comparable in terms of the functional results. LEVEL OF EVIDENCE: III; retrospective case-control study.

The too-long anterior process and osteochondral lesion of the talus: Is there an anatomical predisposition? A case-control study on 135 feet.

INTRODUCTION: The too-long anterior process (TLAP) increases mechanical stress on the hindfoot and could lead to osteochondral lesions of the talus (OLT) by localized hyper-pressure. The purpose of this study is to investigate an association between TLAP and OLT in children. METHODS: This is a retrospective, multicenter, case-control study conducted between 2010 and 2020. The OLT group was compared to a control group (CoG). TLAP is characterized by a distance between the anteromedial process of the calcaneus and the navicular bone (CN) of< 5 mm. RESULTS: Forty-three feets were included in the OLT group and 92 in the CoG. The OLT group had a lower CN distance on CT than the CoG, a median of 2.8 mm versus 3.75 mm (p = 0.002); 86% of patients (37 feet/43) in the OLT group had a CN distance of< 5 mm (OR=3.0 [1.1; 9.5], p = 0.023) compared to 67% in the CoG. DISCUSSION: The OLT group had an increased risk of developing TLAP compared to the CoG. LEVEL OF EVIDENCE: III.

BONE PERFUSION AND ADIPOSITY BEYOND THE NECROTIC ZONE IN FEMORAL HEAD OSTEONECROSIS: A QUANTITATIVE MRI STUDY.

PURPOSE: To describe bone perfusion and adiposity beyond the necrotic zone with quantitative MRI techniques in osteonecrosis of the femoral head (ONFH). METHOD: In this cross-sectional multicentre study, we recruited patients suffering from late-stage ONFH or hip osteoarthritis. Hip MRI included quantitative MRI sequences: chemical-shift imaging and dynamic contrast-enhanced MRI. We drew regions of interest inside the necrotic zone (inner necrosis and its border) and outside (femoral head, neck and greater trochanter) in ONFH. In the control group, regions of interest were drawn in the femoral head, femoral neck and the greater trochanter. For each region of interest, we measured fat fraction, and calculated semi-quantitative (area under the curve, initial slope) and pharmacokinetic perfusion parameters (Ktrans and Kep). RESULTS: Thirty-two male adults (mean age 58 ±â€¯9 years, range 38-74 years) were included. Sixteen patients formed the ONFH group and fifteen the control group; one was excluded. In the normal-appearing non-necrotic part of the femoral head, fat fraction was not significantly different in comparison with controls (p = 1), but Ktrans was significantly lower than in controls (0.012 ±â€¯0.018 vs. 0.027 ±â€¯0.045; p = 0.05). This perfusion parameter reflects exchanges between blood microvessels and bone marrow. CONCLUSIONS: Our results question the concept of adipose toxicity on the macroscopic scale, and bring up the concept of regional ischemic penumbra that goes beyond the visible necrotic zone. Further studies are required to test these hypotheses in larger populations and earlier disease states.

T1-weighted MRI images accurately represent the volume and surface of architectural mineral damage of osteonecrosis of the femoral head: Comparison with high-resolution computed tomography.

The potency of magnetic resonance imaging (MRI) to measure the exact extent of osteonecrosis of the femoral head (ONFH) remains uncertain. The objective of this study was to determine if the volume of necrosis assessed with MRI accurately reflects the volume of architectural mineral alterations in osteonecrosis of the femoral head by comparison with high-resolution microfocus X-ray computed tomography (HR-µCT). Fourteen male patients aged 53 years [46.2;59.0] suffering from ONFH were prospectively enrolled to undergo preoperative MRI and ex vivo analysis using HR-µCT. The necrotic zone on T1-weighted MRI scans was defined as total necrosis (delimited by the low-signal peripheral band) or dark necrosis (low-signal lesions only). The HR-µCT scans delimited outer necrosis and inner necrosis by including or excluding the sclerotic zone. The intra-class correlation coefficient (ICC) was calculated to compare the agreement of surface areas and volumes of necrosis measurements with the two techniques. There was an overall excellent agreement between MRI dark necrosis volume and HR-µCT outer necrosis volume (ICC=0.91[0.54;0.98]) while the MRI total necrosis volume showed poor agreement with both HR-µCT delimitations of necrosis volume. For surface area, agreement between MRI dark necrosis and HR-µCT delimitations was good for inner necrosis (ICC=0.70[0.21;0.9]) and moderate for outer necrosis (ICC=0.58[0.07;0.85]). This study demonstrates that measurement of the MRI lesions provides a reliable assessment of the extent of ONFH-related architectural damage.

Activity level recovery after acute Achilles tendon rupture surgically repaired: a series of 29 patients with a mean follow-up of 46 months.

BACKGROUND: Achilles tendon rupture is a common injury but its optimal management is still controversial. When decided, surgical repair can be performed by open or percutaneous techniques. Till now, there is no agreement on the ideal type of surgical management. PURPOSE: To compare the outcomes of the percutaneous and open surgical treatment for acute Achilles tendon rupture and to assess the postoperative activity level recovery. METHODS: Between 2008 and 2013, 29 patients were surgically treated for acute Achilles tendon rupture in our institution. 16 patients were operated by percutaneous technique and 13 by open repair. All patients received the same postoperative rehabilitation protocol. Patients were evaluated objectively and subjectively after an average of 46 months (23-91). RESULTS: 96.6% of patients had excellent and good results according to subjective assessment. No significant difference was observed with respect to the examined clinical variables between the open and percutaneous repair groups. 20.68% of patients had minor complications related to the operation with lesser complications in the percutaneous group. 89.6% of patients resumed sport activity with an average delay of 7,7 months (4-24) and 57,7% of them resumed at a level equal or superior to their level before injury, with higher rate in the percutaneous group. CONCLUSION: Percutaneous technique has similar satisfactory outcomes to open surgery in repairing acute ruptured Achilles tendon with lesser complications and higher activity level recovery rate. LEVEL OF EVIDENCE: Retrospective comparative study. Level III.

Perfusion of subchondral bone marrow in knee osteoarthritis: A dynamic contrast-enhanced magnetic resonance imaging preliminary study.

The role of inflammation in the pathogenesis of osteoarthritis is being given major interest, and inflammation is closely linked with vascularization. It was recently demonstrated that dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) could identify the subchondral bone marrow vascularization changes occurring in osteoarthritis in animals. These changes appeared before cartilage lesions were visible and were correlated with osteoarthritis severity. Thus the opportunity to obtain an objective assessment of bone vascularization in non-invasive conditions in humans might help better understanding osteoarthritis pathophysiology and finding new biomarkers. We hypothesized that, as in animals, DCE-MRI has the ability to identify subchondral bone marrow vascularization changes in human osteoarthritis. We performed knee MRI in 19 patients with advanced knee osteoarthritis. We assessed subchondral bone marrow vascularization in medial and lateral femorotibial compartments with DCE-MRI and graded osteoarthritis lesions on MR images. Statistical analysis assessed intra- and inter-observer agreement, compared DCE-MRI values between the different subchondral zones, and sought for an influence of age, sex, body mass index, and osteoarthritis garde on these values. The intra- and inter-observer agreement for DCE-MRI values were excellent. These values were significantly higher in the femorotibial compartment the most affected by osteoarthritis, both in femur and tibia (p<0.0001) and were significantly and positively correlated with cartilage lesions (p=0.02) and bone marrow oedema grade (p<0.0001) after adjustment. We concluded that, as in animals, subchondral bone marrow vascularization changes assessed with DCE-MRI were correlated with osteoarthritis severity in humans.

Changes in prevalence of calcaneal spurs in men & women: a random population from a trauma clinic.

BACKGROUND: This study reports the changing prevalence of ankle (Achilles and plantar) spurs with age, in order to comment on their significance to rheumatologists. METHODS: 1080 lateral ankle radiographs from each of 9 (50 men and 50 women) age cohorts from 2 to 96 years old of patients attending a trauma clinic were examined and spurs classified as small or large. RESULTS: The prevalence of both Achilles and plantar spurs in relation to the age categories and sex was variable. Overall, there was 38% of the population who had a spur (Achilles or plantar) and only third (11%) with spurs at both sites (Achilles and plantar). Large spurs were more prevalent in older individuals (40 to 79 years). There were no large plantar spurs in individuals <40 years of age and only 2% for the Achilles. The prevalence of spurs (Achilles and plantar) was significantly higher for woman than men in individuals <50 years of age. There was a notable moderate positive correlation (r = 0.71) between both plantar and Achilles spurs for women <30 years of age but no correlation for men (r = -0.03). CONCLUSION: Plantar and Achilles spurs are highly prevalent in older people and the radiographic appearance of spurs differs between men and women. In individuals < 50 years of age, spur (Achilles and plantar) formation is more common in women than in men. Additionally, there was a notable moderate positive correlation between Achilles and plantar spurs for women <30 years of age.

Association between individual quadriceps muscle volume/enthesis and patello femoral joint cartilage morphology.

INTRODUCTION: The aim of this study was to determine the association between individual quadriceps muscle volumes and the quadriceps enthesis structures and cartilage morphology at the patellofemoral joint (PFJ). METHODS: We studied 12 cadavers (age 75 ± 5 years). For both legs, individual quadriceps muscles (vastus lateralis (VL), rectus femoris (RF), vastus intermedialis (VI) and vastus medialis (VM)) were dissected and their volumes measured. Cartilage areas at the PFJ were classified using the International Cartilage Repair Society (ICRS) score. Histological sections were evaluated at the quadriceps tendon enthesis (laterally, centrally and medially). Several variables were calculated on the binary images based on two-dimensional analysis. These were apparent bone area (BA) and apparent trabecular thickness (TH). A Spearman rank test was used to determine the strength of correlation between individual quadriceps muscles volume, the structure of the quadriceps tendon enthesis and the ICRS score. RESULTS: The thickness of calcified fibrocartilage tissue was significantly greater in the central part of the enthesis than both medially (P = 0.03) and laterally (P = 0.04). Uncalcified fibrocartilage was significantly thicker laterally (P = 0.04) and centrally (P = 0.02) than medially. Muscle volume was highest (P <0.05) for the VL, followed by the VI, VM and RF. There was no association between total and individual muscle volumes and ICRS or BA. However, there was a strong positive correlation (r = 0.81) between the VL/VM volume ratio and BA ratio (bone volume at the lateral part divided by bone volume at the medial part). There was a moderate positive correlation between VL/VM and ICRS (r = 0.65) and between ICRS and BA ratio (lateral/medial; r = 0.74). CONCLUSIONS: Individual and total quadriceps volumes were not correlated with cartilage loss at the PFJ or fibrocartilage thickness. However, both VL/VM and BA ratio (lateral/medial) were positively correlated with ICRS scoring and therefore could be a tool for predicting degree of PFJ osteoarthritis severity.