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.

Portable device for measuring isometric plantar-flexion force after open Achilles repair: Retrospective cohort of 30 recreational athletes with one-year minimum follow-up.

BACKGROUND: Plantar flexion force in recreational athletes after repair of Achilles tendon tears has rarely been reported, due to the lack of a widely available and fast measurement method. Knowledge of this parameter would allow optimisation of muscular and sports recovery. The main objective of this study was to measure the isometric force of the triceps surae at least 1 year after unilateral Achilles-tendon repair, comparatively to the unaffected side, using a portable device. The secondary objectives were to compare Achilles tendon and calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test versus the normal side and to assess functional scores at last follow-up. HYPOTHESES: (i) Plantar flexion force does not differ significantly between the operated and contralateral sides. (ii) Calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test do not differ significantly between the operated and contralateral sides. PATIENTS AND METHODS: This single-centre retrospective study included patients aged 18 to 65 years with a history of open repair of an acute unilateral Achilles tear at least 1 year earlier. Plantar flexion force, calf-muscle trophicity, dorsiflexion, and the heel-to-floor distance were measured on both sides and compared. The ATRS, VISA-A score, and EFAS score were determined. All complications were recorded. RESULTS: The study included 30 patients with a mean follow-up of 20.3 months (range, 12-28 months). The operated side had significantly lower values for isometric triceps surae force, calf circumference, and heel-to-floor distance compared to the contralateral side (p<0.0001). Tendon width was significantly greater on the operated side (p<0.0001). Dorsiflexion did not differ significantly between sides (p=0.106). Mean functional score values were 91.5±6 for the ATRS (maximum, 100), 85±12 for the VISA-A score (maximum, 100), and 19.5±4 for the EFAS score (maximum, 24). DISCUSSION: Isometric triceps-surae force measured using a portable device at least 1 year after open surgical Achilles-tendon repair was significantly decreased compared to the contralateral side. Calf circumference and heel-to-floor distance were also significantly lower. These data indicate a need for improved monitoring of triceps surae recovery to optimise rehabilitation and sports resumption. LEVEL OF EVIDENCE: IV, retrospective comparative cohort study.

Validation of an Automated Optical Scanner for a Comprehensive Anthropometric Analysis of the Foot and Ankle.

Background: Our objective was to conduct a comprehensive analysis of the reproducibility of foot and ankle anthropometric measurements with a three-dimensional (3D) optical scanner. Methods: We evaluated thirty-nine different anthropometric parameters obtained with a 3D Laser UPOD-S Full-Foot Scanner in a healthy population of twenty subjects. We determined the variance of the measurements for each foot/ankle, and the average variance among different subjects. Results: For 40 feet and ankles (15 women and 5 men; mean age 35.62 +/- 9.54 years, range 9-75 years), the average variance was 1.4 ± 2 (range 0.1 to 8). Overall, the mean absolute measurement error was <1 mm, with a maximum variance percentage of 8.3%. Forefoot and midfoot circumferences had a low variance <2.5, with variance percentages <1%. Hindfoot circumferences, malleolar heights, and the length of the first and fifth metatarsal to the ground contact points showed the highest variance (range 1 to 7). Conclusions: The UPOD-S Full-Foot optical Scanner achieved a good reproducibility in a large set of foot and ankle anthropometric measurements. It is a valuable tool for clinical and research purposes.

Advantages of ultrasound identification of the distal insertion of the calcaneofibular ligament during ligament reconstructions.

INTRODUCTION: In lateral ankle instability, anatomical ligament reconstructions are generally performed using arthroscopy. The ligament graft is passed through the talar, fibular and calcaneal tunnels, reconstructing the anterior talofibular and calcaneofibular (CFL) bundles. However, the calcaneal insertion of the CFL needs to be performed in an extra-articular fashion, and cannot be carried out under arthroscopy, thus requiring specific anatomical landmarks. For obtaining these landmarks, methods based on radiography or surface anatomy have already been described but can only offer an approximate identification of the actual CFL anatomical insertion point. In contrast, an ultrasound technique allows direct visualization of the insertion point and of the sural nerve that may be injured during surgery. Our study aimed to assess the reliability and accuracy of ultrasound visualization when performing calcaneal insertion of the CFL with specific monitoring of the sural nerve. MATERIALS AND METHODS: Our anatomical study was carried out on 15 ankles available from a body donation program. Ultrasound identification of the sural nerve was obtained first with injection of dye. A needle was positioned at the level of the calcaneal insertion of the CFL. After dissection, in all the ankles, the dye was in contact with the sural nerve and the needle was located in the calcaneal insertion area of the CFL. The mean distance between the sural nerve and the needle was 4.8 mm (range 3-7 mm). DISCUSSION AND CONCLUSION: A pre- or intra-operative ultrasound technique is a simple and reliable means for obtaining anatomical landmarks when drilling the calcaneal tunnel for ligament reconstruction of the lateral plane of the ankle. This tunnel should preferably be drilled obliquely from the heel towards the subtalar joint (1 h-3 h direction on an ultrasound cross section), which preserves a maximum distance from the sural nerve for safety purposes, while allowing an accurate anatomical positioning of the osseous tunnel.

Assessment of the Efficiency of Measuring Foot and Ankle Edema with a 3D Portable Scanner.

Background: To prospectively evaluate the reliability of a portable optical scanner compared to the water displacement technique for volumetric measurements of the foot and ankle and to compare the acquisition time associated with these two methods. Methods: Foot volume was measured in 29 healthy volunteers (58 feet, 24 females and 5 males) by a 3D scanner (UPOD-S 3D Laser Full-Foot Scanner®) and by water displacement volumetry. Measurements were performed on both feet, up to a height of 10 cm above the ground. The acquisition time for each method was evaluated. The Kolmogorov-Smirnov test, Lin's Concordance Correlation Coefficient, and a Student's t-test were performed. Results: Mean foot volume was 869.7 +/- 165.1 cm3 (3D scanner) versus 867.9 +/- 155.4 cm3 (water-displacement volumetry) (p < 10-5). The concordance of measurements was 0.93, indicative of a high correlation between the two techniques. Volumes were 47.8 cm3 lower when using the 3D scanner versus water volumetry. After statistically correcting this underestimation, the concordance was improved (0.98, residual bias = -0.03 +/- 35.1 cm3). The mean examination time was 4.2 +/- 1.7 min (3D optical scanner) versus 11.1 +/- 2.9 min (water volumeter) (p < 10-4). Conclusions: Ankle/foot volumetric measurements performed using this portable 3D scanner are reliable and fast and can be used in clinical practice and research.

Reliability of a new computerized equinometer based on Silfverskiöld test to measure gastrocnemius tightness.

BACKGROUND: Several tools exist to measure tightness of the gastrocnemius muscles; however, few of them are reliable enough to be used routinely in the clinic. The primary objective of this study was to evaluate the intra- and inter-rater reliability of a new equinometer. The secondary objective was to determine the load to apply on the plantar surface of the metatarsal heads to achieve the highest reliability when measuring gastrocnemius tightness. METHODS: The equinometer consisted of a goniometer and an electronic dynamometer, hooked up to a computer. Three raters carried out three trials of passive dorsiflexion by applying controlled pressure to the metatarsal heads of both ankles in 29 healthy subjects under two experimental conditions: knee extended (KE) and knee flexed at 30 degrees (KF). The equinometer continuously recorded the ankle dorsiflexion values (in °) corresponding to each 1 N interval of plantar pressure between 4 N and 20 N. The intra- and inter-rater reliability of the ankle dorsiflexion were evaluated through the intra-class correlation (ICC) coefficients in each of the pressure intervals. RESULTS: The intra-rater ICC in KE and KF was between 0.84 and 0.98. The inter-rater ICC in KE and KF was between 0.59 and 0.92. The pressure interval between 14 N and 15 N had the highest intra-rater (ICC = 1) and inter-rater reliability (0.87≤ICC≤0.99). A more refined analysis of this interval found that a load of 14.5 N yielded the best reliability. CONCLUSIONS: This compact equinometer has excellent intra-rater reliability and moderate to good inter-rater reliability. Since this reliability is optimal in the 14-15 N range, this load should be used going forward in clinical practice, especially when aiming to define a pathological threshold for tightness of the gastrocnemius muscles.

Gait analysis after total hip arthroplasty by direct minimally invasive anterolateral approach: A controlled study.

INTRODUCTION: Clinical and functional improvement after minimally invasive total hip arthroplasty (THA) has become increasingly controversial. The minimally invasive anterolateral approach (MIALA) allows rapid recovery resulting in a reduced need for rehabilitation. Alterations in muscle and static balance have previously been demonstrated. Results in the context of quantified gait analysis (QGA) and MIALA compared to an asymptomatic population remain unknown beyond one year postoperatively. Thus, the main objective of this controlled study was to compare the spatiotemporal parameters of gait, obtained using a QGA, beyond one year postoperatively in subjects operated on for THA by MIALA, with a group of asymptomatic subjects of the same age. The secondary objectives of the study were to compare the other QGA and EMG data acquired in operated subjects with asymptomatic subjects. HYPOTHESIS: We hypothesized that QGA and EMG parameters would not normalize beyond one year postoperatively. PATIENTS AND METHODS: Thirty-one subjects were recruited, including 16 patients (68 years old; IQR: 65-70) who underwent MIALA, at 15.5 months postoperatively (IQR: 13-17) and 15 asymptomatic subjects (62 years old; IQR: 61-71). Subjects underwent QGA and maximal isometric muscle force tests on the gluteus medius, gluteus maximus, Tensor Fascia Lata (TFL) and Sartorius muscles. Spatiotemporal gait parameters were the primary endpoint. The other QGA parameters: kinetics (characteristic values of vertical ground reaction forces, peak hip moments) and kinematics (hip joint amplitudes and pelvic mobility in the frontal and sagittal plane) constituted the secondary criteria. RESULTS: Five subjects were excluded for unrestored offset. Walking speed was lower in operated patients (1.03m/s versus 1.18m/s, p=0.005). Maximal isometric muscle force moments were lower in patients operated on for the gluteus maximus and medius as well as the TFL (p<0.005). The vertical ground reaction forces were lower for the operated patients for the loading phase (FzFCmax, p=0.001), the single stance phase (FzSPmin, p=5.05.10-2) and the swing phase (FzTOmax, p=0.0002). The moments were lower in the sagittal plane for the operated patients (0.6N.m for the operated versus 1.1N.m for the asymptomatic, p=0.02). The pelvic amplitudes in the sagittal plane were lower for operated patients (3.3° versus 7.2°, p=0.05). DISCUSSION: Our hypothesis appears to be validated. Gait deficits persisted beyond one year postoperatively after THA with MIALA. A decrease in walking speed, maximal isometric muscle force of the gluteus medius and gluteus maximus and TFL was observed, as well as a decrease in propulsive force and peak hip moment. Functionally, these results could signify muscle damage following surgery, requiring rehabilitation for improved muscle function. LEVEL OF PROOF: III: Non-randomized controlled trial.

MRI assessment of minimally invasive anterolateral approaches in total hip arthroplasty.

INTRODUCTION: Total hip arthroplasty (THA) on a minimally invasive anterolateral (MIAL) approach frequently leads to gluteus minimus and gluteus medius lesions, and sometimes to tensor fasciae latae (TFL) denervation. We therefore developed compensatory strategies, which we assessed on pre- and post-operative MRI: 1) to assess gluteus minimus and gluteus medius fatty infiltration (FI), 2) to assess TFL FI, and 3) to assess FI in the other periarticular muscles. HYPOTHESIS: The modified MIAL approach reduces the rate of gluteus minimus and gluteus medius lesion. MATERIALS AND METHODS: A continuous prospective single-surgeon series of THA using a MIAL approach included 25 patients. Femoral implantation was performed with the hip in extension so as to distance the proximal femur from the gluteals, avoiding muscle trauma. The superior gluteal nerve branch in the space between the gluteus medius and TFL, running toward the TFL, was systematically released and protected. MRI was performed preoperatively and at 3 months and 1 year post-surgery. FI was analyzed according to the Goutallier classification in all periarticular muscles. RESULTS: One patient lacked preoperative MRI and was excluded, leaving 24 patients, for 72 MRIs. In 10/24 patients (41.7%) the gluteus minimus and in 8/24 patients (33.3%) the anterior third of the gluteus medius showed ≥2 grade increase in FI between preoperative and 1-year MRI, with significant increases in both at 3 months (p<0.001) and 1 year (p<0.001). At least a 2 grade increase in FI at 1 year was seen in 1 patient (4.2%) in the TFL, in 2 (8.3%) in the piriformis, and in 1 (4.2%) in the obturator internus. There were no significant differences in FI between preoperative, 3-month or 1-year MRI in any other periarticular muscles. CONCLUSION: Femoral implantation in hip extension did not reduce the rate of gluteal lesions, which remained frequent. In contrast, release of the superior gluteal nerve branch could be effective in conserving TFL innervation. Some rare lesions of the proximal part of the pelvi-trochanteric muscles were also observed. LEVEL OF EVIDENCE: IV, Prospective case series.

Comparative MRI assessment of three minimally invasive approaches in total hip arthroplasty.

INTRODUCTION: Minimally invasive approaches (direct anterior approach: DAA; minimally invasive anterolateral: MIAL; piriformis-sparing posterior approach: PSPA) are widely used for total hip arthroplasty (THA), with a muscle-sparing objective. There are no published comparative studies of muscle damage secondary to these approaches. The aim of the present study was to compare fatty infiltration (FI) on MRI induced by DAA, MIAL and PSPA in THA 1) in the tensor fasciae latae (TFL) and sartorius muscles, 2) in the gluteal muscles, and 3) in the pelvitrochanteric muscles. HYPOTHESIS: Greater FI is induced by DAA in anterior muscles, by MIAL in gluteal muscles and by PSPA in pelvitrochanteric muscles. MATERIALS AND METHODS: Three continuous prospective series of THA by DAA, MIAL and PSPA included 25 patients each. MRI was performed preoperatively and at 1 year postoperatively. FI was graded on the Goutallier classification in all periarticular hip muscles. Muscles showing ≥2 grade aggravation at 1 year were considered damaged. RESULTS: Nine patients whose preoperative MRI was uninterpretable were excluded. In all, 66 patients (21 DAA, 24 MIAL and 21 PSPA) with 132 MRI scans were analyzed. TFL was damaged in 2/21 DAA patients (9.5%), 1/24 MIAL patients (4.2%) and 0/21 PSPA patients (0%). There were no sartorius lesions. The anterior third of the gluteus medius was damaged in 8/24 MIAL patients (33.3%) and the gluteus minimus in 10/24 (41.7%), compared to 1/21 DAA patients (4.8%) and 0/21 PSPA patients (0%). The mid and posterior thirds of the gluteus medius and the gluteus maximus were never damaged. The piriformis muscle was damaged in 3/21 DAA patients (14.3%), 2/24 MIAL patients (8.3%) and 2/21 PSPA patients (9.5%). The obturator internus was damaged in 4/21 DAA patients (19%), 1/24 MIAL patients (4.2%) and 16/21 PSPA patients (76.2%). The obturator externus and quadratus femoris were mainly damaged in PSPA patients: respectively, 5/21 (23.8%) and 4/21 patients (19%)). CONCLUSION: The muscle-sparing properties of minimally invasive hip approaches are only theoretical. In the present series, there were rare TFL lesions with DAA and MIAL. Gluteus medius and minimus lesions were frequent in MIAL. Pelvitrochanteric muscles lesions were more frequent in PSPA, but found in all 3 approaches. These findings should help guide surgeons in their choice of approach and in informing patients about the damage these minimally invasive approaches can cause. LEVEL OF EVIDENCE: III, prospective comparative study.

Quantitative gait analysis after total hip arthroplasty through a minimally invasive direct anterior approach: A case control study.

INTRODUCTION: Total Hip Arthroplasty (THA) leads to excellent clinical and functional results. The Minimally Invasive Anterior Approach (MIAA) theoretically allows rapid recovery and a reduction in the need for rehabilitation, but alterations in muscle and static balance have previously been demonstrated. Kinetic, kinematic and muscular alterations have been shown to persist up to 1year postoperatively but data beyond 1year postoperatively is lacking. Thus, the objective of this study was to compare the data from Quantitative Gait Analysis (QGA) coupled with electromyography (EMG), of patients one year postoperatively with THA through MIAA, compared to an asymptomatic control group. HYPOTHESIS: We hypothesized that QGA and EMG parameters would not normalize beyond one year postoperatively. PATIENTS AND METHODS: Twenty-seven patients were recruited, including 15 subjects (64.6±6.6years) operated on by MIAA, who at 15.9±3.1months postoperatively, along with 12 asymptomatic control subjects (68.9±9.7years), who underwent QGA and maximal isometric muscle strength tests, coupled with EMG on the gluteus medius and maximus, Tensor Fascia Lata (TFL) and Sartorius muscles. The spatiotemporal parameters of walking (step length, walking speed, cadence, single leg support time), kinetics (vertical ground reaction forces, hip moments in the 3 planes) and kinematics (coxofemoral and pelvic amplitudes) were analyzed. RESULTS: The walking speed was lower on the non-operated side of the experimental subjects (0.96ms-1 compared to 1.13ms-1 for asymptomatic [p=0.018]), as was the step length on the operated side (0.53m compared to 0.60m for asymptomatic [p=0.042]). Maximal isometric muscle strength was lower in subjects operated on for the gluteus maximus and medius (p=0.004), compared to asymptomatic subjects. Moments were lower in the subjects operated on in extension (0.72Nm on the operated side, 0.75Nm on the non-operated side compared to 1.06Nm for asymptomatic [p=0.007 and p=0.024]) and lateral rotation (0.09Nm on the operated side, 0.05Nm on the non-operated side compared to 0.16Nm for asymptomatic subjects [p=0.009 and p=0.0005]). Hip adduction amplitudes were lower on the operated side compared to asymptomatic subjects (3.93° versus 9.14° for asymptomatic [p=0.005]). Pelvic amplitudes in the frontal plane were lower amongst operated subjects (0.44° against 1.97° for asymptomatic [p=0.041]). Pelvic amplitudes in the sagittal plane were higher in the operated subjects (15.74° on the operated side, 15.43° on the non-operated side compared to 9.65° for asymptomatic [p=0.041 and p=0.032]). DISCUSSION: Our initial hypothesis was validated, since walking deficits persisted beyond one year postoperatively after THA through MIAA. A decrease in maximal isometric muscle strength of the gluteus medius and gluteus maximus was observed, as well as an alteration of kinetic and kinematic parameters in the sagittal and frontal planes. The results were in agreement with the literature and reflected the establishment of compensatory mechanisms to overcome alterations in joint strength and range more than one year postoperatively. These results would allow rehabilitation programs to be more specific and would justify a study on the other approaches for THA. LEVEL OF EVIDENCE: III; non-randomized control trial.

Malpractice claims in forefoot surgery.

Foot and hallux valgus surgery are amongst the most commonly performed surgeries, with a growing number of procedures leading to litigation. The aim of this conference is to provide an update on the causes of malpractice claims and the associated risk factors. What are the causes of litigation? Acute or chronic residual pain, stiffness, metatarsalgia, consolidation delays, secondary displacements, suboptimal results are the most common causes found in litigious proceedings. What are the risk factors? Surgeon-related and patient-related risk factors exist. Percutaneous surgery or the development of outpatient hospitalization are not specific risk factors. From the point of view of practitioners, the application and traceability of recommendations for antibiotic prophylaxis, for thromboembolic disease, or for the checklist are essential, allowing causes of blame to be easily avoided. Information is fundamental. Since the Law of the 4th of March 2002, the surgeon-patient relationship has changed. Pre-operative information archived in the practitioner's file is essential. This includes written and oral information which is consented to and understood by the patient. Thus, the understanding and compliance with immediate post-operative instructions or adherence to the post-operative program are success factors regarding the surgical outcome. The patient must also be informed and aware of their own individual risk factors (e.g. smoking and immunosuppression, particularly) which require greater caution. What is the best way to reduce the risk of these claims being made? It is about traceability: traceability of clinical examination, procedures, information and exchanges with the patient. It is only under this principle that the surgeon-patient relationship can be clearer, respectful and consequently less conducive to litigation. LEVEL OF EVIDENCE: V; expert opinion.

Stabilometric assessments of two rehabilitation protocols on postural parameters after posterior total hip arthroplasty: A prospective randomized comparative study.

INTRODUCTION: After total hip arthroplasty (THA), patients continue to have muscular, functional and postural deficits. The literature seems to support the use of postoperative rehabilitation, especially self-directed programs. However, there is no set protocol for the management of postural disorders. Therefore, the purpose of this study was to compare postural parameters of a group of patients who underwent posterior THA followed by 2 different types of rehabilitation (stabilometric platform (SP) and home-based self-directed protocols) with a control group of operated patients who did not undergo rehabilitation and a control group of age-matched asymptomatic subjects. HYPOTHESIS: We hypothesized that rehabilitation would normalize the stabilometric parameters. PATIENTS AND METHODS: A total of 67 subjects were enrolled in this study (mean age 67.85±1.22years) and divided into 4 groups. Forty-one of these subjects had undergone a posterior THA were randomly assigned between D10 and D21 to one of the following 3 groups: no rehabilitation control group (THACG=14), supervised rehabilitation with a stabilometric platform group (RSPG=16), and a self-directed home-based rehabilitation group (SDHRG=11). The 4th group was a control group made up of 26 age-matched asymptomatic nonoperated subjects (CG55-80). These rehabilitation protocols lasted 3weeks. At the end of the 3weeks, the groups performed the same stabilometric single leg and double leg stance tests (considering lower limb dominance) on an SP. RESULTS: No significant differences were observed between groups in the bipedal stance, except between the CG55-80 and the THACG, where a higher energy expenditure was observed in the THACG during the static stance with eyes open (EO) and eyes closed (EC): increase in the path length (Plength) covered by the center of pressure (COP) (EO: p=01; EC: p=03) and the average velocity (Vavg) of the COP (EO: p=01; EC: p=03). These differences were not observed in the SDHRG and RSPG whether they were compared with one another or with both control groups. In the unipedal stance, subjects in the RSPG and SDHRG showed greater muscle activity in the anterior and posterior chains and hip abductors, and used less energy to maintain the stance than those in the CG55-80, regardless of lower limb dominance: decrease in the mediolateral range of COP displacement (Xrange) (hip abductor muscles) (p=02) and anteroposterior range of COP displacement (Yrange) (anterior and posterior chains) (p=3.49.10-3), 95% confidence ellipse area (Earea) of COP data (p=1.47.10-3), Plength (p=04) and Vavg (p=04). The RSPG had a smaller Earea than the SDHRG (p=04), demonstrating a better postural stability during the unipedal stance performed on the dominant operated leg. DISCUSSION: Our results were consistent with the literature on the benefits of rehabilitation after THA, thus confirming our hypothesis that rehabilitation normalized stabilometric parameters between D31-D45, depending on the subjects. These results provide new information regarding rehabilitation techniques to be implemented postoperatively after a THA. A home-based self-directed rehabilitation program is just as effective as an SP program in managing postural disorders. LEVEL OF EVIDENCE: II; randomized controlled trial with low statistical power.

MRI assessment of piriformis-sparing posterior approach in total hip arthroplasty.

INTRODUCTION: In total hip arthroplasty (THA), the posterior approach is the most common throughout the world. Dislocation is one of the main complications incurred, but the risk may be reduced by sparing posterior structures. Thus, piriformis-sparing posterior approaches (PSPA) were described, and satisfactory conservation of the muscle was reported. On the other hand, a recent cadaver study reported occult intrapelvic piriformis lesions in 91% of cases. In the light of this discordance, we performed pre- and postoperative MRI in THA by PSPA: 1) to assess the fatty infiltration of the piriformis induced by the approach, with particular attention to intrapelvic lesions; and 2) to assess fatty infiltration of the other periarticular muscles. HYPOTHESIS: The piriformis muscle will show little fatty infiltration following PSPA. MATERIALS AND METHODS: A continuous prospective single-surgeon series of THA by PSPA included 25 patients. MRI was performed preoperatively and at 3 months and 1 year postoperatively. Fatty infiltration was assessed on the Goutallier classification in all periarticular muscles. RESULTS: Preoperative MRI was lacking in 4 patients, who were excluded from analysis; 21 patients with MRI were thus analyzed. In the piriformis muscle, there was no significant change in fatty infiltration between preoperative and 3-month (p=0.29) or 1-year (p=0.41) MRI. Two of the 21 patients (9.5%) showed grade 3 or 4 fatty infiltration at 1 year, compared to 0/21 (0%) preoperatively; both showed sacral avulsion of the piriformis. Significant differences between preoperative and 1-year MRI were found for the obturator internus and externus, with grade 3 or 4 infiltration at 1 year in 14 cases for the obturator internus (14/21: 66.7%), in 3/21 for the obturator externus (14.3%) and in 6/21 for the quadratus femoris (28.6%), compared to respectively 0/21 (0%), 0/21 (0%) and 3/21 (14.3%) preoperatively. There were no significant differences for any of the other periarticular muscles. CONCLUSION: PSPA in THA ensured good conservation of the piriformis. There may, however, be rare and irreversible sacral lesions invisible intraoperatively. LEVEL OF EVIDENCE: IV; prospective case series.

Impact of intertendinous connections between the flexor digitorum brevis and longus on percutaneous tenotomy for the treatment of claw toes: an anatomic and ultrasound study.

PURPOSE: Selective percutaneous tenotomy of the flexor digitorum longus (FDL) is a treatment for claw toes that gives astonishingly good functional results despite tendon sacrifice. However, the involution of the FDL tendon stump after tenotomy is unknown. The aim of our study was to assess the involution of the tendon stump after selective percutaneous tenotomy of the FDL. METHODS: The study included two parts. In the clinical part, an ultrasound analysis of 15 FDL tenotomies in 7 patients was carried out 3 months post-surgery. In the anatomic part, the feet of 10 bodies donated to science were dissected and examined anatomically. RESULTS: The proximal stump of the FDL was located near the base of the proximal phalanx and moved synchronously with the flexor digitorum brevis (FDB).Separating the FDB and FDL revealed a large tissue connection between the plantar surface of the tendinous chiasm of the FDB and the dorsal part of the FDL. These connections had significant resistance ranging from 2 to 9 Newtons depending on the toe. Tenotomy of the FDL followed by proximal traction of it led to retraction of the stump up to the base of the proximal phalanx and transfer of its action to the FDB by tensioning the intertendinous structure. Histologically, these structures were mostly comprised of tendon connective tissue. Their vascular component was small. CONCLUSION: The presence of this intertendinous connection leads, in the case of isolated tenotomy of the FDL, to equivalent transfer of the latter to the FDB.

Podoscopic classification of second toe deformities.

BACKGROUND: The AFCP (French Association of Foot Surgery) classification was recently introduced as a reliable and quick visual method for the assessment of sagittal plane deformities of the second toe. The aim of this study was four-fold: (1) to describe a new toe-ground area score (TAS) as an additional dynamic tool of such classification, (2) to verify whether all second toe deformities could be classified, (3) to assess the TAS intra- and inter-observer reliability and (4) to evaluate the TAS learning curve. METHODS: In this retrospective study 52 s toes were evaluated using a podoscope. Ten foot and ankle surgeons assessed independently standardised videos of each case acquired in a blinded fashion. Assessment was repeated three times, 15 days apart. Intra- (Intraclass Correlation Coefficient or ICC) and inter-observer reliability (Fleiss' Kappa coefficient) were calculated. Mean time to assess a deformity was also recorded. RESULTS: All the 522 observations (52 feet assessed by 10 surgeons) were successfully rated using the TAS. Intra- and inter-observer reliability were substantial for the first round (ICC: 0.79; Kappa: 0.76) and excellent for the second (ICC: 0.88; Kappa: 0.8) and third round (ICC: 0.84; Kappa: 0.81). Mean assessment time ± standard deviation was 22 ± 11 s per case for the last two rounds. CONCLUSIONS: The TAS has been proven reliable and quick in the assessment of second toe deformities. When combined with a static segmentary classification of the toe (such as the AFCP classification) it might provide further dynamic informations about the ability of the toe to engage the ground. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Fatty muscle infiltration of the hip lateral rotator muscles following direct anterior minimally invasive total hip arthroplasty.

INTRODUCTION: There is no consensus as to the best surgical approach to use when doing total hip arthroplasty (THA). There has been renewed interest in recent years in so-called anatomic minimally invasive direct anterior approaches (DAA). However, their reduced impact has not been confirmed with imaging data. This led us to carry out a prospective study to 1) evaluate fatty infiltration (FI) of muscles around the hip joint and 2) analyze how this FI changes over time. HYPOTHESIS: THA done by the DAA induces FI of the anterolateral muscles around the hip adjacent to the approach. MATERIAL AND METHODS: A continuous case series of THA by DAA using a traction table was done by a single experienced surgeon. MRI images (GE Optima* MR360 1.5T) were taken preoperatively, then at 3 months and 1 year after the THA surgery. Muscle FI was classified as described by Goutallier by an independent radiologist on all the muscles around the hip joint. A Wilcoxon test was used to compare the preoperative MRI data to the data at 3 months and 1 year postoperative. RESULTS: Sixty-nine MRI examinations were done in 23 patients. Two were not interpretable because the patient moved during the preoperative acquisition. No intraoperative or postoperative complications were reported. None of the patients had hip pain or limped at 1 year postoperative. The FI was significantly worse from the preoperative MRI to the 3-month postoperative MRI (p=0.02) and 1-year MRI (p=0.0007) in the internal obturator muscle and at 1 year in the piriformis muscle (p=0.04). There was no significant difference for the other muscles. The rectus femoris, superior and inferior gemellus muscles and the quadratus femoris could not be analyzed. DISCUSSION: Our hypothesis was not confirmed, although we had a paradoxical finding of muscle FI in the posterior lateral rotator muscles not the anterolateral muscles after THA by DAA. These lesions may be secondary to detachment or denervation of these muscles when elevating the femur to prepare the femoral canal or insert the stem. LEVEL OF EVIDENCE: IV; Prospective case series.

Intra- and inter-observer reliability of the AFCP classification for sagittal plane deformities of the second toe.

BACKGROUND: The French Association of Foot Surgery (AFCP) recently proposed a morphological classification of lesser toe deformities, describing the position of each joint (metatarsophalangeal or MTP, proximal interphalangeal or PIP and distal interphalangeal or DIP) in relation to their anatomic position in the sagittal plane. A study was designed to test its reliability for assessment of sagittal plane deformities of the second toe. METHODS: In this retrospective study 55 toes (55 feet, 50 patients) were evaluated. Eleven foot and ankle surgeons assessed independently standardized photographs of each case acquired in a blinded fashion. Assessment was repeated three times, each 15 days apart. Intra- (Intraclass Correlation Coefficient or ICC) and inter-observer reliability (Fleiss' Kappa coefficient) were calculated for each joint. RESULTS: Intra- and inter-observer reliability were moderate for the MTP joint (ICC range, 0.54-0.61) (Kappa range, 0.53-0.61) and substantial for the PIP (ICC range, 0.60-0.71) (Kappa range, 0.68-0.75) and DIP joints (ICC range, 0.69-0.78) (Kappa range, 0.74-0.78). Mean assessment time±standard deviation was 35±10s per case. CONCLUSIONS: The AFCP classification proved itself reliable in the assessment of sagittal plane defomities of the second toe among eleven foot and ankle surgeons. It is based only on a visual description of the deformity, and does not provide informations on either the clinical reducibility of the deformity and the radiographic joint status. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Electromyographic study of hip muscles involved in total hip arthroplasty: Surprising results using the direct anterior minimally invasive approach.

BACKGROUND: The functional and clinical benefit of minimally invasive total hip arthroplasty (THA) is well-known, but the literature reports impaired gait and posture parameters as compared to the general population, especially following use of the anterior minimally invasive approach, which has more severe impact on posture than the posterior approach. The reasons for this impairment, however, remain unexplained. We therefore conducted a surface electromyography (sEMG) study of the hip muscles liable to be affected by arthroplasty surgery: gluteus maximus (GMax), gluteus medius (GMed), tensor fasciae latae (TFL), and sartorius (S). The study addressed the following questions: (1) Is bipodal and unipodal GMed activity greater following anterior THA than in asymptomatic subjects? (2) Is a single manual test sufficient to assess maximal voluntary contraction (MVC) in hip abductors (GMax, GMed, TFL) and flexors (TFL, S)? HYPOTHESIS: Bipodal and unipodal GMed activity is greater following anterior THA than in asymptomatic subjects. METHOD: Eleven patients with anterior THA and 11 asymptomatic subjects, matched for age, gender and body-mass index, were included. Subjects underwent 3 postural tests: bipodal, eyes closed (BEC), unipodal on the operated side (UOP), and unipodal on the non-operated side (UnOP), with unipodal results averaged between both sides in the asymptomatic subjects. Data were recorded from 4-channel EMG and a force plate. EMG test activity was normalized as a ratio of MVC activity. RESULTS: Postural parameters (mean center of pressure displacement speed) were poorer and sEMG activity higher in anterior THA than asymptomatic subjects (p<0.005). On the BEC test, GMax and GMed activity was higher on both operated and non-operated sides than in asymptomatic controls (respectively, 0.15±0.12 and 0.12±0.6 versus 0.07±0.06 for GMax, and 0.13±0.08 and 0.13±0.08 versus 0.08±0.05 for GMed; p<0.05). On unipodal tests, both UOP and UnOP GMed activities were higher than in controls (respectively, 0.51±0.3 and 0.48±0.27 versus 0.28±0.13; p<0.04); GMax and TFL activities were higher than in controls only on the UOP tests (respectively, 0.49±0.43 versus 0.24±0.18, and 0.23±0.17 versus 0.12±0.16; p<0.05). DISCUSSION: sEMG activity in the hip abductors, which are the main stabilizing muscles for the pelvis, is increased following anterior THA, in parallel with impaired postural parameters. This finding may be due to intraoperative TFL and S neuromuscular spindle lesion. The present preliminary study is to be followed up by a comparison of all 3 common minimally invasive approaches (anterior, anterolateral and posterior) using the same study protocol. LEVEL OF EVIDENCE: III, prospective case-control study.

Functional Results of the ROCC® Mobile Bearing Knee. 602 Cases at Midterm Follow-Up (5 to 14 Years).

UNLABELLED: We report midterm results of a prospective continuous cohort of ROCC® Total Knee Arthroplasties (TKA). Between 2001 and 2008, all primary TKA patients (n=500) received 602 ROCC saddle-shaped rotating platform TKAs. Mean follow-up was 7.5 years (5-13) (>10 years in 123 knees). 82 patients (93 knees) died; 20 patients (21 knees) were lost to follow-up. Active flexion improved from 119° (10°-150°) to 127° (90°-155°) and Knee Society knee score from 39±11 to 94±9. Two knees were reoperated for aseptic loosening: Kaplan-Meier 14-year survivorship with aseptic loosening as end-point was 99.4% (95% CI, 99.8-100). UCLA mean score increased from 3.8/10 at baseline to 7.3/10 at last FU, 91% recovering pre-disease activity, and 27% with UCLA score ≥8/10. ROCC TKA demonstrated solid midterm survivorship without activity-related complications. LEVEL OF EVIDENCE: Therapeutic, Level IV.