Surgery in reference centers improves survival of sarcoma patients: a nationwide study.

BACKGROUND: NETSARC (netsarc.org) is a network of 26 sarcoma reference centers with specialized multidisciplinary tumor boards (MDTB) aiming to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB and expert pathological review are mandatory for sarcoma patients nationwide. In the present work, the impact of surgery in a reference center on the survival of sarcoma patients investigated using this national NETSARC registry. PATIENTS AND METHODS: Patients' characteristics and follow-up are prospectively collected and data monitored. Descriptive, uni- and multivariate analysis of prognostic factors were conducted in the entire series (N = 35 784) and in the subgroup of incident patient population (N = 29 497). RESULTS: Among the 35 784 patients, 155 different histological subtypes were reported. 4310 (11.6%) patients were metastatic at diagnosis. Previous cancer, previous radiotherapy, neurofibromatosis type 1 (NF1), and Li-Fraumeni syndrome were reported in 12.5%, 3.6%, 0.7%, and 0.1% of patients respectively. Among the 29 497 incident patients, 25 851 (87.6%) patients had surgical removal of the sarcoma, including 9949 (33.7%) operated in a NETSARC center. Location, grade, age, size, depth, histotypes, gender, NF1, and surgery outside a NETSARC center all correlated to overall survival (OS), local relapse free survival (LRFS), and event-free survival (EFS) in the incident patient population. NF1 history was one of the strongest adverse prognostic factors for LRFS, EFS, and OS. Presentation to an MDTB was associated with an improved LRFS and EFS, but was an adverse prognostic factor for OS if surgery was not carried out in a reference center. In multivariate analysis, surgery in a NETSARC center was positively correlated with LRFS, EFS, and OS [P < 0.001 for all, with a hazard ratio of 0.681 (95% CI 0.618-0.749) for OS]. CONCLUSION: This nationwide registry of sarcoma patients shows that surgical treatment in a reference center reduces the risk of relapse and death.

Complex fractures of the acetabulum: Should the enlarged iliofemoral approach be abandoned? Results at 20 years' follow-up.

INTRODUCTION: Among the various options for internal fixation of acetabular fractures, the enlarged iliofemoral approach is less often used, being more invasive, although providing greater exposure enabling control of all components in complex fractures. Even so, the impact of its invasiveness has not been confirmed, and long-term results are not known. We therefore performed a retrospective study, aiming: to assess long-term functional outcome, and; to assess associated morbidity. HYPOTHESIS: The enlarged iliofemoral approach allows precise reduction, with favorable long-term outcome. MATERIAL AND METHODS: Between 1992 and 1997, 15 patients were operated on for complex acetabular fracture by a single surgeon using an enlarged iliofemoral approach. Two patients were excluded due to lack of follow-up data, leaving 13 patients for analysis: 3 simple transverse fractures, 4 transverse+posterior wall fractures, 4 anterior column+posterior hemi-transverse fractures, one T-shaped fracture and one 2-column fracture. There were 4 cases of posterior dislocation of the hip, and 8 of intrapelvic protrusion. Surgical morbidity was assessed in terms of operative time, number of packed red blood cell transfusions, iatrogenic lesions or postoperative complications, rehabilitation time, and hospital stay. Functional assessment at follow-up used the WOMAC index and Harris score; radiologic assessment used the Kellgren-Lawrence score for osteoarthritis and Brooker score for ossification. RESULTS: Reduction was in all cases anatomic. There were no intra- or post-operative complications. Median number of packed red blood cell transfusions was 5 [range, 3-10]. Median operative time was 4hours [3-6]. Median hospital stay was 6 weeks [6-8], to allow systematic traction with early postoperative mobilization. Weight-bearing was resumed at a median 8 weeks [8-12]. At a median 22 years' follow-up [20-24], median Harris score was 83.5 [63-92] and median WOMAC index 24.5 [1-52]. All patients showed Brooker 1 or 2 ectopic ossification and moderate osteoarthritis. Two underwent subsequent arthroplasty (at 1 and 11 years after the index procedure). DISCUSSION: The enlarged iliofemoral approach allowed anatomic reduction of acetabular fracture. It provided very good long-term results, without excessive morbidity. LEVEL OF EVIDENCE: IV, retrospective non-controlled study.

Litigation in orthopedic surgery: What can we do to prevent it? Systematic analysis of 126 legal actions involving four university hospitals in France.

INTRODUCTION: Orthopedic surgery produces 20% of medical malpractice claims. However only a few studies have examined the reasons for and consequences of these disputes, and they have usually been limited to a single hospital. This led us to perform a retrospective analysis of the claims at four teaching hospitals in northwestern France. The goals were (1) to describe the circumstances that led to these claims and recommend ways to prevent them, and (2) to describe the conduct of the proceedings and their financial and social outcomes. HYPOTHESIS: A systematic analysis of litigation cases will provide accurate information on the circumstances leading to these claims. METHODS: The study included 126 disputes settled between 2000 and 2010 and related to orthopedic or trauma care given at one of four teaching hospitals in northwestern France. The method of recourse, grounds of the complaint, type of surgical procedure, expert findings and amount of the award were systematically analyzed. RESULTS: Of these 126 cases, 54 (43%) of them were submitted to the French CRCI (regional conciliation and compensation commission), 48 (39%) to the French administrative courts and 51 (41%) were settled amicably. Multiple methods of recourse were used in 21% of cases (n=27/126). The average length of administrative court proceedings was 36.7±27 months [4-102], which was significantly longer than the CRCI proceedings (22.7±17.9 months [3-80]) or out-of-court settlement (23.7±21.5 months [0-52]) (p<0.0001). Damages were sought for medical error or treatment-related risk in 67.5% of the complaints (n=85/126), and for failure to inform in 15.8% of cases (n=20/126). There was a suspected surgical site infection in 79.3% of cases (n=100/126). There were multiple grounds for complaint in 68.3% of cases (n=86/126). Poor communication between the physician and patient was identified in 26.2% of cases (n=33/126). Damages were awarded in 25% of cases (n=31/126), with an average award of €58,303±€91,601 [0-357,970]. CONCLUSION: The primary grounds for legal action are infection-related complications combined with a deterioration in the doctor-patient relationship. Disputes could be prevented by continuing efforts to combat hospital-acquired infections and providing better communications training. LEVEL OF PROOF: IV (retrospective study).

Validity of rotational laxity coupled with anterior translation of the knee: A cadaveric study comparing radiostereometry and the Rotab®.

BACKGROUND: In current practice, anterior cruciate ligament (ACL) tears can be diagnosed using several devices to measure anterior tibial translation and rotational knee laxity, but these measures are never collected together. The Rotab®, which yields simultaneous measurements of anterior tibial translation and passive lower limb rotation under stress, would therefore be advantageous in current practice, but its reliability has never been tested. AIM OF STUDY: To evaluate the accuracy and reliability of the Rotab® compared to the reference system, radiostereometric analysis (RSA). METHODS: This anatomical study was conducted on 14 lower limbs collected from fresh cadavers. Simultaneous measurements of anterior tibial translation and rotation were obtained with both systems, with antero-posterior (AP) forces of 134N and 250N using the Rotab®. Measurements were made on intact ACL and then repeated after ACL section. Variables were analyzed in univariate analysis by ANOVA, and the intraclass correlation coefficient (ICC) between the systems was determined by the Bland and Altman method. RESULTS: The difference between the two methods for evaluating anterior tibial translation was 0.05±0.98mm at 134N and 0.29±1.04mm at 250N. The correlation between the tests was high (r134=r250=0.97, p=0.8). The difference between the two methods for rotational laxity was 0.69±2.7° at 134N and 0.5±0.6° at 250N. The Rotab® showed a significant difference only at 250N for rotational laxity after the ACL tear. CONCLUSION: The Rotab® is a reliable device to measure rotational laxity coupled with anterior translation of the knee.

Outcome of patients with streptococcal prosthetic joint infections with special reference to rifampicin combinations.

BACKGROUND: Outcome of patients with streptococcal prosthetic joint infections (PJIs) is not well known. METHODS: We performed a retrospective multicenter cohort study that involved patients with total hip/knee prosthetic joint (THP/TKP) infections due to Streptococcus spp. from 2001 through 2009. RESULTS: Ninety-five streptococcal PJI episodes (50 THP and 45 TKP) in 87 patients of mean age 69.1 ± 13.7 years met the inclusion criteria. In all, 55 out of 95 cases (57.9 %) were treated with debridement and retention of the infected implants with antibiotic therapy (DAIR). Rifampicin-combinations, including with levofloxacin, were used in 52 (54.7 %) and 28 (29.5 %) cases, respectively. After a mean follow-up period of 895 days (IQR: 395-1649), the remission rate was 70.5 % (67/95). Patients with PJIs due to S. agalactiae failed in the same proportion as in the other patients (10/37 (27.1 %) versus 19/58 (32.7 %); p = .55). In the univariate analysis, antibiotic monotherapy, DAIR, antibiotic treatments other than rifampicin-combinations, and TKP were all associated with a worse outcome. The only independent variable significantly associated with the patients' outcomes was the location of the prosthesis (i.e., hip versus knee) (OR = 0.19; 95 % CI 0.04-0.93; p value 0.04). CONCLUSIONS: The prognosis of streptococcal PJIs may not be as good as previously reported, especially for patients with an infected total knee arthroplasty. Rifampicin combinations, especially with levofloxacin, appear to be suitable antibiotic regimens for these patients.

The role of Intraoperative 3D navigation for pelvic bone tumor resection.

UNLABELLED: Interventional 3D analysis is often used for surgery of the spine. The goal of this study was to describe the technique and initial results of intraoperative 3D CT navigation (O-Arm, Medtronic, Louisville, CO, USA) for surgery of the pelvis. Six patients were included, five with primary bone tumors and one with post-traumatic non-union. All CT procedures were completed without modifying the surgical technique, except one case in which the device had to be reinstalled during surgery. The duration of surgery was not increased and lasted for a mean 224minutes (96-380). Recorded radiation was between 450-1125mGrey/cm. All procedures were performed according to the preoperative plan resulting in systematic resection with a safe surgical margin (R0). One surgical site infection occurred. Although these operations could have been performed without 3-D navigation, this technique provided continuous intraoperative control and safety. LEVEL OF EVIDENCE: IV.

Do temperature variations at the bearing surface during gait affect polyethylene wear in Charnley low-friction arthroplasty of the hip? Simulator study comparing UHMWPE and highly cross-linked polyethylene.

INTRODUCTION: There are significant individual variations in the polyethylene (PE) wear of Charnley total hip arthroplasty (THA) in published studies. This could be in part related to variations in hip joint kinematics with abnormal heating at the metal/PE interface. The objectives of our hip simulator experiment were: (1) to measure PE wear as a function of hip kinematics and temperature variations at the interface; (2) to compare ultra-high molecular weight polyethylene (UHMWPE) to latest generation highly cross-linked PE (XLPE). HYPOTHESIS: Our hypothesis was that PE wear is correlated with temperature increases at the interface and thereby hip joint kinematics. MATERIAL AND METHODS: A simulator study was performed with four UHMWPE cups (Initiale™, Amplitude, Valence, France) and two XLPE cups (X3, Stryker, Kalamazoo, Michigan, USA) subjected to 5 million cycles each. The temperature at the femoral head/cup interface was measured every 500 cycles and implant dimensions were measured every 1 million cycles. RESULTS: The average temperature was 42°C for 1Hz and 50°C for 1.5Hz, no matter the type of PE tested. There was a large difference between UHMWPE and XLPE in their roughness, but no temperature variations or wear effects. Femoral head penetration after the first 1 million cycles was 0.18mm for the XLPE and 0.075mm UHMWPE on average. Between 1 and 5 million cycles, the penetration was less than 0.1mm per million cycles, with XLPE being similar to UHMPWE. DISCUSSION: Our study found a significant temperature increase at the bearing interface as a function of frequency. But there was no correlation between temperature variations and PE degradation. However, shear stresses were under-estimated because our simulator could not reproduce abduction and adduction movements. Our hypothesis was not confirmed because PE deformation was not correlated to temperature variations. XLPE was not better than UHMWPE in the particular conditions of this study. Simulator studies are limited because of the lack of standards on cycling and the simulator bath. LEVEL OF EVIDENCE: III-prospective case-control study in vitro.

Ankle fractures in the elderly: Treatment and results in 477 patients.

INTRODUCTION: In the elderly, ankle fractures are likely to cause specific complications and have a major impact on their autonomy. The goal of this multicentre study was to assess these outcomes in a geriatric population treated operatively. MATERIAL AND METHODS: This retrospective study included 477 patients with ankle fractures treated surgically between 2008 and 2014. The minimum age was 60years for women and 70 for men. Patients with a tibial pilon fracture or less than 3months' follow-up were excluded. Functional (autonomy and comorbidities) and radiological assessments were performed before surgery and at the review. RESULTS: The cohort was 81% female (384 women, 93 men) and had median age of 74years. The preoperative autonomy was 7.8 points on average using the Parker score. Most of the fractures were either Weber type B (n=336) or type C (n=114). At the follow-up, the mean autonomy score was 7.3 points. The fibula was fixed with a plate and screws in 69% of cases (n=325), with additional internal malleolar fixation was carried out in some cases. A satisfactory result, defined as 2 points or less reduction in the Parker score, was found in 89.9% of patients; 71.8% had not lost any autonomy. The main risk factors for loss of autonomy were being more than 80years of age (OR=2.93, P<0.001), poor surgical reduction (OR=2.8, P<0.01), the presence of two or more comorbidities (OR=2.71, P<0.001), being female (OR=2.19, P<0.043) or having a Weber type C fracture (OR=2.05, P=0.023). DISCUSSION: The functional results are satisfactory overall following standard surgical treatment consisting of internal malleolar and fibular fixation for ankle fractures in the elderly. We identified five factors that greatly impact functional recovery. LEVEL OF EVIDENCE: IV.

Conversion of total shoulder arthroplasty to reverse shoulder arthroplasty made possible by custom humeral adapter.

Reverse shoulder arthroplasty (RSA) is increasingly being used to revise anatomical total shoulder arthroplasty cases. This procedure's high complication rate has been reduced by the availability of modular shoulder systems, which allows the humeral component to be preserved during the conversion. This case report describes the revision of an anatomical shoulder implant inserted in 1998. Polyethylene wear and the resulting metal-on-metal contact had caused metallosis. Since the existing humeral implant was not compatible with standard conversion products, the manufacturer provided a custom humeral adapter that allowed the humeral stem to be preserved. This approach greatly simplified the surgical procedure and resulted in good anatomical and clinical outcomes after 9 months of follow-up.

Minimally invasive posterior approach in the popliteal fossa for semitendinosus and gracilis tendon harvesting: an anatomic study.

INTRODUCTION: Harvesting the semitendinosus (ST) and gracilis (GR) tendons at the anteromedial side of the knee may be hampered by a conjoint tendon insertion on the tibial metaphysis and an accessory bundle between the ST and the medial gastrocnemius. Locating and sparing the terminal branches of the saphenous nerve are difficult on an anteromedial approach. The principal objective of the present anatomic study was to assess the feasibility of ST and GR harvesting from a minimally invasive posterior approach in the popliteal fossa. The secondary objective was to analyze the risk of saphenous nerve branch lesion during harvesting. METHOD: Ten cadaver knees, free of scarring, were used. The whole body was positioned supine. The tendons were located in the popliteal fossa with the knee in 30° flexion. A mini-incision was performed in the fossa. The ST and GR tendons were located, and retrograde followed by anterograde stripping was performed. Tendon lengths and diameters were measured. The knees were then dissected to check for saphenous nerve branch lesions (anterior, infrapatellar and posterior branches). RESULTS: The GR and ST tendons were respectively located at 14.4 and 24 mm from the medial edge of the knee. In 90% of cases, there was an accessory ST bundle toward the medial gastrocnemius muscle, 26 mm below the posterior edge. Tendons could be harvested without deviation of the stripper. Knee dissection did not find any saphenous nerve branches, these being protected by the sartorius fascia. DISCUSSION: Posterior ST and GR tendon harvesting in the popliteal fossa is reliable and reproducible. It allows easy sectioning of the accessory ST bundle, without deviation during retrograde stripping. Unlike anterior harvesting, which leads to a rate of saphenous branch lesion of 50-78%, posterior harvesting protects the nerve branches by keeping away from the sartorius. LEVEL OF EVIDENCE: Level 4.

Secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. A 55 case series.

INTRODUCTION: Secondary intramedullary nailing (SIN) following external fixation (EF) of tibial shaft fracture is controversial, notably due to the infection risk, which is not precisely known. The present study therefore analysed a continuous series of tibial shaft SIN, to determine (1) infection and union rates, and (2) whether 1-stage SIN associated to EF ablation increased the risk of infection. HYPOTHESIS: Factors exist for union and onset of infection following tibial shaft SIN. MATERIALS AND METHODS: A retrospective series of SIN performed between 1998 and 2012 in over 16-year-old patients with non-pathologic tibial shaft fracture was analysed. EF pin site infection was an exclusion criterion. Fractures were graded according to AO and Gustilo classifications. Study parameters were: time to SIN, 1- versus 2-stage procedure, bacteriologic results on reaming product, post-nailing onset of infection, and time to union. RESULTS: Fifty-five patients (55 fractures) were included. There were 16 closed and 39 open fractures: 7 Gustilo type I, 26 type II and 6 type IIIA; 33 AO type A, 14 type B and 8 type C. Mean time to SIN was 9 ± 9.6 weeks (range, 4 days to 12 months). There were 23 1-stage procedures, and 32 two-stage procedures with a mean 12-day interval (range, 4-30 days). Twelve reaming samples were biologically positive without secondary infection. There were 4 septic complications (3 abscesses, 1 osteomyelitis), and 1 aseptic non-union required re-nailing. The union rate was 96%. The sole factor of poor prognosis was severity of fracture opening. One-stage SIN did not increase infection risk. DISCUSSION: The present results were better than reported in the literature, where the rates of Gustilo IIIA and IIIB fracture and pin site infection are, however, higher. Tibial shaft SIN is a reliable procedure, with infection risk correlating with Gustilo type and time to surgery. Surgery should be early, before onset of EF pin site infection. A 1-stage attitude appears feasible in early SIN. LEVEL OF EVIDENCE: Level IV. Retrospective study type.

Radiographic evaluation of a novel horizontal dorsal intercarpal capsulodesis as a treatment of pre-arthritic scapholunate dissociation: a cadaver study.

Dorsal capsulodesis is an important part of the treatment of pre-arthritic scapholunate instability. We designed an experimental study using 14 fresh-frozen cadaver wrists to demonstrate the efficacy of a new horizontal dorsal intercarpal capsulodesis. We sectioned the scapholunate ligament to create a scapholunate dislocation. Several radiographic views, static and 'in stress', were recorded and we statistically compared the scapholunate interval before and after the section of the scapholunate ligament, and after the creation of the capsulodesis. The results showed a significant decrease of the scapholunate interval after the creation of the capsulodesis, especially in neutral and maximal ulnar deviation of the wrist. They also proved that our cadaveric model is reliable. This study demonstrated that this novel capsulodesis reduces the scapholunate interval in a cadaveric model.

Reducible valgus flat-foot: assessment of posterior subtalar joint surface displacement by posterior arthroscopy during sinus tarsi expansion screwing.

INTRODUCTION: Subtalar arthroereisis corrects childhood and adult reducible valgus flat-foot in certain indications. Inserting an expansion screw in the sinus tarsi simultaneously corrects the calcaneal valgus of the talocalcaneal divergence and first-ray pronation if these are reducible. The displacement induced in the posterior subtalar joint (decoaptation, translation, rotation) is, however, poorly known. The present study involved arthroscopic assessment of posterior subtalar joint surface displacement during insertion of a talocalcaneal arthroereisis screw, with the hypothesis that displacement varies in three dimensions according to screw size. MATERIAL AND METHOD: Eight specimens were used for the study. All ankles were supple, taken from adult subjects. A 4.5-mm arthroscope was used and measurements were taken with a graduated palpator in the posterior subtalar joint. Three sinus tarsi expansion screws of incremental diameter were assessed. Before and after insertion measurements were made of posterolateral and posteromedial talar exposure on the calcaneus, anteroposterior and lateromedial translation, and talocalcaneal joint-line opening. RESULTS: Medial rotation, varization and anterior translation of the calcaneus were comparable in all cases. Mean lateral opening of the posterior subtalar joint was 0.88 mm with 8-mm screws and 1.25 mm with 16-mm screws. Significant differences between 8 and 16 mm screws were found for lateral subtalar joint opening (P=0.028) and for lateromedial translation (P=0.004). CONCLUSION: Sinus tarsi expansion screwing corrects hindfoot valgus and talocalcaneal divergence by inducing medial translation of the calcaneus under the talus and talar medial rotation and varization, proportional to screw size (medial translation and lateral opening of the subtalar joint). LEVEL OF EVIDENCE: III.

Locked plating for internal fixation of the adult distal femur: influence of the type of construct and hardware on the clinical and radiological outcomes.

INTRODUCTION: Distal femoral fractures are rare and serious. Along with traditional internal fixation, new, dedicated hardware have appeared (distal nails, locked plating). We report the results of a multicenter prospective study of these fractures treated with locked plating. HYPOTHESIS: The short-term results are satisfactory and related to the type of construct and the hardware used, with better results for elastic assemblies and titanium implants. MATERIALS AND METHODS: From June 2011 to May 2012, 92 patients, mean age 64 years, were included in 12 centres. The fractures were classified as follows: 44 type A, 7 type B, and 41 type C according to the AO classification. Thirteen fractures were open. The plates were uniaxial. The assemblies were elastic in 52 cases, rigid in 26, and unconventional in 14. RESULTS: Seventy-six patients underwent a radiological follow-up at 6 months and 66 patients had a clinical result evaluated at 1 year. The mean range of motion was 100° and the mean IKS score was 122. The bone union rate was 87% within 12 weeks. Seven valgus, two varus, ten flexion deformities, and three recurvatum greater than 5° were observed (19.5%). Revisions involved two cases with loss of fixation, five cases of infection, and one case of arthrofibrosis (requiring arthroscopic arthrolysis). Secondary bone grafting was carried out in seven cases (four successfully). No influence of the type of assembly or the hardware used was demonstrated. DISCUSSION: The results remain modest, underscoring the severity of these fractures. Neither the type of construct nor the hardware used influenced the radiological and clinical outcomes. The hypothesis was not confirmed. LEVEL OF EVIDENCE: Level IV prospective, non-comparative study.

Increased prevalence of psoriasis in patients with coronary artery disease: results from a case-control study.

BACKGROUND: The incidence of myocardial events has been reported to be increased in patients with psoriasis. OBJECTIVES: To investigate whether psoriasis is an independent risk factor for coronary artery disease (CAD). METHODS: We compared the prevalence of psoriasis between case patients with a diagnosis of CAD based on coronary angiography findings and control patients with no CAD referred to the emergency surgery department for an acute noncardiovascular condition. Case and control patients were examined for the presence of psoriasis by two dermatologists. The prevalence of psoriasis was compared among patients with CAD according to CAD severity. Five-hundred cases and 500 age- and sex-matched controls were included. RESULTS: Using matched univariate analysis, the prevalence of psoriasis was about twofold higher in CAD case patients than in control patients [8·0% vs. 3·4%, odds ratio (OR) 2·64; 95% confidence interval (CI) 1·42-4·88]. Using unconditional multivariate analysis, the association of psoriasis with CAD appeared to be borderline significant (OR 1·84; 95% CI 0·99-3·40). Psoriasis in patients with CAD was significantly associated with three-vessel involvement relative to one-or two-vessel involvement (13·1% vs. 6·1%; OR 3·07; 95% CI 1·50-6·25). CONCLUSIONS: The prevalence of psoriasis is twofold higher in patients with CAD than in control patients without CAD. It is associated with a more severe coronary artery involvement.

Total fractures of the tibial pilon.

Complete fractures of the tibial pilon are rare and their treatment difficult. The pathophysiology includes three groups: (A) high-energy trauma (motor vehicle injuries), with severe articular and soft tissue lesions, (B) rotation trauma, (skiing accidents), with modest articular and soft tissue damage, and (C) low-energy trauma in elderly people. These three groups occasion very different problems and complications. In emergency situations, these fractures should be stabilized, most often using external fixation to restore length and prepare definitive fixation. The second stage can be applied once soft tissue healing is achieved. Two methods are discussed: internal plating and definitive external fixation. The first goal of treatment is to restore the articular surface, although this does not always prevent secondary arthritis. The second is to restore correct positioning of the foot as regard to the leg. The complication rate is high. Neither of the two fixation techniques has proven to be more effective. In group B, the two methods are similar, but external fixation seems to be safer in group A.

Posterior tibial tendoscopy: Description of an accessory proximal portal and assessment of tendon vascularization lesion according to portal.

BACKGROUND: Posterior tibial tendoscopy was codified in 1997 by Van Dijck, who described a portal between 1.5 and 2cm proximally and distally to the tip of the medial malleolus. However, this approach does not allow proximal exploration of the posterior tibial tendon (PTT). We here describe an accessory portal 7cm proximal to the medial malleolus, enabling complete PTT exploration. METHODS: Posterior tibial tendoscopy was performed on 12 cadaver specimens, mapping PTT exploration and vascularization. RESULTS: The accessory portal enabled the whole PTT to be explored, from the myotendinous junction to the entry into the retromalleolar groove. PTT observation quality was improved compared to using a submalleolar portal. Dissection confirmed systematic presence of a vincula on the posterior side of the tendon, connected to the flexor digitorum longus (FDL) tendon, containing collateral vessels of the posterior tibial artery. None of these elements were damaged by the tendoscopy as long and the scope and motorized instruments were not rotated on the posterior side of the supramalleolar part of the PTT. CONCLUSIONS: This accessory entry portal provides complete PTT exploration without the risk of neurovascular bundle lesion.

Lumbar spinal stenosis: which predictive factors of favorable functional results after decompressive laminectomy?

BACKGROUND AND PURPOSE: Long-term results of decompressive laminectomy in degenerative lumbar stenosis have been studied in only six prospective studies. The objective of our study was to evaluate the functional outcome at long term of patients after decompressive laminectomy in lumbar stenosis and to determine predictive factors of favorable outcome. METHODS: A prospective cohort data were collected by an independent observer five years after decompressive laminectomy for degenerative lumbar stenosis. The endpoint was the assessment of the Beaujon score for functional evaluation. The result was considered as favorable if the Beaujon score increased by at last five points between the preoperative stage and at follow-up examination. Logistic regression was then performed with univariate and multivariate analysis to reveal predictive factors of good long-term outcome (P≤0.05). RESULTS: The preoperative characteristic of our population (n=98) was a mean age of 67.3±8.8 years, a low comorbidity (mean Charlson score=2.8±1.5), overweight status (BMI=29.4±6.3) and the mean Beaujon score was 9.3±3.1. At five years after surgery, the mean Beaujon score became 14.1±4.2. Favorable functional outcome concerned 45.9% of our series. The predictive factor of favorable outcome identified in the univariate analysis the neurological deficit (P=0.05) and in the multivariate analysis the low comorbidity (P=0.01). CONCLUSION: The long-term results of surgical treatment of lumbar spinal stenosis were moderate with an improved outcome in 49.5% of cases in our study. The only independent factor to a favorable outcome was the low comorbidity.

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.