Medial closing-wedge distal femoral varus osteotomy: Symptoms and functional impact in cases of associated patellofemoral osteoarthritis. A two-year follow-up prospective pilot study.

PURPOSE: To date, indications for distal femoral varus osteotomy (FVO) in cases of associated patellofemoral osteoarthritis (PFO) have yet to be clarified. The purpose of this prospective study is to assess the short-term symptoms, functional and radiological impact of a medial closing-wedge femoral varus osteotomy on the patellofemoral joint in patients with valgus deformities who are afflicted with lateral tibiofemoral osteoarthritis (LTFO) associated with PFO. METHODS: Fourteen patients (15 knees) received a medial closing-wedge femoral varus osteotomy. The functional impact of an FVO on the patellofemoral joint was assessed based on the KOOS-PF (Knee Injury and Osteoarthritis Outcome Score-Patellofemoral Subscale), the Kujala score and the patellofemoral symptoms. Realignment of the patella was measured by the Merchant's patellofemoral congruence angle. The pre- and post-operative symptoms and functional scores were compiled prospectively and compared two years after the surgery. RESULTS: The Kujala patellofemoral functional scores and the KOOS-PF showed considerable improvement with a differential of +37.5 points ± 20.4 and +42.7 points ± 19.3 (p < .01) respectively. The average Merchant's congruence angle went from 8.8° laterally to 3.6° medially, resulting in medialization of the patella, with a significant difference (p < .01). Based on the specific clinical analysis of the patellar joint, preoperative J-sign was identified in 26.7% of patients (n = 4) and was not found during postoperative examination (p = .1). Preoperative apprehension test was identified in 33.3% of patients (n = 5) against 13.3% (n = 2) after surgery (p = .39). Preoperative pain extension test was identified in 40% of patients (n = 6) against 20% during postoperative clinical analysis (p = .43). DISCUSSION: Although the threshold of significance for patellofemoral symptoms was not reached, the medial closing-wedge femoral varus osteotomy induces a significant medialization of the patella (Merchant's congruence angle) and improves short-term functional results even with co-existing patellofemoral osteoarthritis. Due to the lack of specificity of the patellofemoral scores, patellofemoral osteoarthritis improvement is difficult to determine on its own, but does not represent a contraindication to FVO. LEVEL OF EVIDENCE: III. Prospective clinical study.

Associated relaps factors in Le Fort I osteotomy. A retrospective study of 54 cases.

PURPOSE: The Le Fort I osteotomy (LFI) procedure is commonly used to restore morpho-functional balance. The goal of maxillofacial surgeons with this procedure is to achieve occlusal stability. To identify factors associated with relapse after maxillary advancement in cleft lip and palate patients, the one-year post-operative stability of Le Fort I osteotomy was evaluated. METHODS: Horizontal and vertical relapse were analysed on lateral cephalograms by retrospectively using tracing paper in an orthonormal landmark in 54 patients undergoing unilateral cleft lip and palate surgery who were monitored at Nantes University Hospital. The lateral cephalograms were performed pre-operatively, immediately post-operatively, and after one year. Several variables were studied such as population data, intra-operative and post-operative surgical treatment, and surgical movement. RESULTS: At point A, the subspinale point, the mean advancement during surgery was 4.2 mm, with a relapse of 0.8 mm (20.1%). The mean downward movement was 2.0 mm in 26 patients who had a clockwise rotation of the maxilla, with a relapse of 0.6 mm (28.4%). The mean upward movement was 2.3 mm in 27 patients who had a counterclockwise rotation, with a deterioration of 0.2 mm (7%). A 7-millimetre surgical advancement corresponded to the threshold value beyond which relapse appeared to be significantly greater but still less than two millimetres in 75% of cases. CONCLUSION: The degree of advancement appears to be the only variable correlated with the amplitude of the relapse.

Reverdin-Isham procedure for mild or moderate hallux valgus: clinical and radiographic outcomes.

BACKGROUND: In the last decade, interests in minimal incision surgery have been growing. Theoretically, this kind of procedure could decrease time to recovery and rehabilitation, with a reduction in morbidity. The present study assessed clinical and radiological outcomes and complications of percutaneous surgery for mild-to-moderate hallux valgus using Reverdin-Isham and Akin osteotomies without fixation after 60 months of follow-up. METHODS: A series of 48 patients (57 cases) with medium-to-moderate hallux valgus underwent the same percutaneous surgery, between 2003 and 2011. Data collection involved preoperative dorsal flexion, plantar flexion, M1P1, M1M2, DMAA angles, AOFAS scale score, and subjective satisfaction. RESULTS: AOFAS scale score rose from a preoperative median of 55.9-89.2/100 postoperatively (p < 0.001); 51 surgical procedures (89.5%) were considered as satisfactory or very satisfactory by patients at the end of follow-up. Hallux valgus and distal metatarsal articular angle (DMAA) were significantly reduced (29.3° and 14.1°-15.4° and 7.7°, p < 0.001, respectively). There was a significant increase in MTPJ 1 stiffness (p < 0.001). DISCUSSION: Percutaneous correction by Reverdin-Isham and Akin osteotomies seems to be effective in isolated medium-to-moderate hallux valgus. Stiffness observed is comparable to other percutaneous and open procedures but needs to be compared in a randomized controlled clinical trial to extra-articular percutaneous procedures without capsule detachment in association with an internal fixation which allows an early mobilization. LEVEL OF CLINICAL EVIDENCE: IV.

Case Report: Bothrops lanceolatus Snakebite Surgical Management-Relevance of Fasciotomy.

Bothrops lanceolatus is an endemic Crotalidae species in Martinique, where approximately 30 cases of envenoming are managed yearly. Envenoming characteristics from Bothrops species include local tissue damage, systemic bleeding, and hemodynamic alterations. We hereby report a case of severe envenomation following B. lanceolatus snakebite to the right calf. Severe local manifestations developed progressively up to the lower limb despite adequate antivenom therapy. Systemic manifestations of venom also occurred, resulting in intensive care therapy. Surgery exploration revealed soft tissue necrosis, friability of the deep fascia, and myonecrosis. The patient needed multiple debridement procedures and fasciotomy of all leg compartments and anterior compartment of the thigh. Diagnosis of necrotizing fasciitis was confirmed by positive Aeromonas hydrophila blood cultures. This clinical case illustrates that major soft tissue infection, including necrotizing fasciitis may occur after snakebite. Abnormal coagulation tests should not delay surgical management, as severe envenoming is a life-threatening condition.

Arthroscopic suture repair of acute quadriceps tendon ruptures.

Acute quadriceps tendon ruptures disrupt the continuity of the extensor mechanism and must be treated surgically. Tendon reattachment with suture anchors has recently been shown to be biomechanically superior to reattachment through transosseous tunnels. In this context, arthroscopy is an interesting alternative. It can limit postoperative wound healing and infectious complications, while ensuring functional outcomes that are equivalent to standard techniques. The goal of this technical note is to describe an original, reproducible method for arthroscopic reattachment of the quadriceps tendon with suture anchors. Four patients were operated using this technique in a pilot study. No wound healing, infectious complications or re-tears were observed. At 6 months' postoperative, the mean subjective IKDC score was 85.8/100.

Reproducibility of three-dimensional posterior cranial base angles using low-dose computed tomography.

OBJECTIVES: One of the key aspects of three-dimensional (3D) craniofacial cephalometry is the measurement of posterior cranial base angle as this area is deeply involved in craniofacial development. The purpose of our retrospective study was to define the best reproducible 3D posterior cranial base angles among five 3D angles transposed from 2D cephalometry (Cousin, BL1 of Ross and Ravosa, Bjork, Delaire, CBA4 of Liberman) and seven 3D angles based on physical anthropology studies and on new concepts (R1 to R7). The null hypothesis was that all 3D posterior cranial base angles were equally reproducible. MATERIAL AND METHODS: We used a preoperative low-dose computed tomography (CT) data from 20 adult patients undergoing orthognathic surgery after approval by local ethical committee. Two independent observers performed two series of 23 3D landmark identifications on 3D CT surface rendering of each patient using Maxilim software. Then, the same observers performed twice 3D cephalometric analyses (23 landmarks, 4 midpoints, 19 planes) that provided the automatic measurement of 12 posterior cranial base angles. RESULTS: Inter-observer correlation coefficient varied from 0.545 (Cousin) to 0.695 (CBA4 of Liberman) and from -0.177 (R2) to 0.827 (R4). CONCLUSIONS: The null hypothesis was rejected. The most reproducible angle was 3D angle R4 based on "basion," "superior optic" (right, left), and "crista galli inferior" landmarks. CLINICAL RELEVANCE: R4 angle might be used as reference 3D posterior cranial base angle in further clinical studies involving 3D cephalometry as a diagnostic tool for orthodontics and for orthognathic surgery.

Do outcomes of outpatient ACL reconstruction vary with graft type?

BACKGROUND: Studies establishing the feasibility of anterior cruciate ligament (ACL) reconstruction as an outpatient procedure in France were usually conducted with hamstring tendon grafts. The objective of this study was to evaluate the outcomes of outpatient ACL reconstruction according to whether the graft was harvested from the hamstring tendons or patellar tendon. HYPOTHESIS: Outpatient ACL reconstruction can be performed using any type of graft. METHODS: A single-centre retrospective study was conducted in consecutive patients older than 16 years who had primary ACL reconstruction using patellar tendon or hamstring tendons, with or without lateral tenodesis. Patients who underwent other procedures on bones or peripheral ligaments and those with a previous history of ACL reconstruction were excluded. The primary evaluation criterion was the occurrence of complications within 45 days after surgery. Secondary evaluation criteria were the visual analogue scale (VAS) for pain during the first 3 postoperative days, patient satisfaction on day 3, and the IKDC and Lysholm clinical scores on day 45. RESULTS: The analysis included 104 knees (one knee per patient). Hamstring tendons were used in 77 (74%) knees and patellar tendon in 27 (26%) knees. In the hamstring group, 2 (2.6%) patients spent the first postoperative night in the hospital and 2 others were re-admitted. No hospitalisations were recorded in the patellar-tendon group. None of the patients required revision surgery within 45 days of the reconstruction procedure. None of the postoperative criteria studied showed statistically significant differences between the two groups. DISCUSSION: ACL reconstruction can be performed on an outpatient basis using any type of graft. The main determinants of successful outpatient ACL reconstruction are a standardised clinical management strategy and an appropriate anaesthesia protocol. LEVEL OF EVIDENCE: Level IV, retrospective study.

Comparative reproducibility of TELOS™ and GNRB® for instrumental measurement of anterior tibial translation in normal knees.

BACKGROUND: TELOS™ is among the reference tools for the instrumental measurement of anterior tibial translation during the initial work-up and follow-up of patients with injuries to the anterior cruciate ligament (ACL). GRNB(®) is a non-irradiating but recently developed tool for which only limited data are available. HYPOTHESIS: The GRNB(®) offers better reproducibility than TELOS™ for measuring anterior tibial translation without rotation in normal knees. MATERIAL AND METHODS: We retrospectively evaluated instrumental laxity measurements in normal knees. Data were available for 60 TELOS™ measurements (9kg load) and 57 GNRB(®) measurements (89N and 134N loads). For each instrument, we compared the absolute variation in anterior tibial translation between two measurements performed 6 months apart. For each GNRB(®) measurement, patellar pressure was recorded. RESULTS: No significant differences were found between mean (± SD) variations in translation between the two instruments. A greater than 2.5mm variation between the two measurements was significantly more common with TELOS™ than with GRNB(®) (P<0.05, Chi(2) test). GRNB(®) translation values did not correlate with patellar pressure. DISCUSSION: The GNRB(®) device offers greater reproducibility than TELOS™ when used to quantitate anterior tibial translation. The limited sample size may have prevented the detection of a significant difference between mean values. In addition, disadvantages of the TELOS™ include radiation exposure of the patient, operator-dependency of measurements made on the radiographs, and absence of a biofeedback system to limit hamstring contraction. GNRB(®) does have hamstring contraction biofeedback control but uses another parameter, namely, patellar pressure, for which the optimal value is unknown. Quadriceps and hamstring co-contraction induced by excessive patellar pressure may influence anterior tibial translation. The optimal patellar pressure value needs to be determined.

Reliability of a new hip lateral view to quantify alpha angle in femoroacetabular impingement.

BACKGROUND: Radiographic measurement of the alpha angle (AA) in femoroacetabular impingement (FAI) is not well codified and invasive techniques such as MR- or CT-arthrography remain the gold standard. Excessive acetabular coverage described in pincer-type FAI can be seen on plain radiographs but has never been quantified and anterior center edge (ACE) angle, described on the false-profile view (FP) to measure anterior acetabular coverage has never been evaluated in FAI. HYPOTHESIS: In this study we wanted to determine if a plain radiograph could efficiently measure AA compared to CT-arthrography and if ACE could quantify the acetabular coverage in FAI. MATERIALS AND METHODS: We developed a hip view combining a lateral view and a FP, called profile view in impingement position (PIP). Twenty-six patients operated for FAI had CT-arthrography, PIP and FP. Nineteen control subjects had the PIP. AA were measured twice by three raters and ACE once. We compared AA measured on patients between CT and PIP, on PIP between patients and controls, ACE measured on patients between PIP and FP, and did a reproducibility analysis. Means were compared by paired or unpaired t-tests; reproducibility was measured by intraclass correlation coefficient (ICC). RESULTS: Mean AA was 65.8° (range, 48-85°) on CT-arthrography and 63.9° (range, 50-87°) on PIP (P>0.05). ICC for PIP measures were 0.8-0.9 for intra-rater and 0.6-0.9 for inter-rater reliability. Mean AA on PIP in patients was 63.3° (range, 52-87°) and 44.9° (range, 34-67°) in controls (P<0.001). Mean ACE was 26.8° (range, 14-41°) on PIP and 32.8° (range, 18-56°) on the FP (P=0.015). DISCUSSION: The PIP is a reliable view to measure the AA in FAI as measures on PIP and CT-arthrography were not significantly different with a good reproducibility. All of the painful hips and 2 controls had an AA>50°. PIP was not efficient to measure ACE. LEVEL OF EVIDENCE: Level III, case-control study.

Scapulo-humeral arthrodesis using a pedicled scapular pillar graft following resection of the proximal humerus.

BACKGROUND: Scapulo-humeral arthrodesis (SHA) is a proven reconstruction method in patients with proximal humerus malignancies requiring resection of the shoulder abduction apparatus (rotator cuff and deltoid muscles) or its nerve supply. Standard practice consists in using a pedicled fibular flap. We use instead a pedicled autologous bone graft harvested from the ipsilateral scapular pillar. HYPOTHESIS: The objective of this study was to assess functional outcomes and radiological healing after SHA using a pedicled scapular pillar graft. MATERIALS AND METHODS: We retrospectively reviewed the charts of the 12 patients managed at a single center by a single surgeon between 1994 and 2011. SHA was performed using a vascularised ipsilateral scapular pillar graft after proximal humerus resection to treat a bone malignancy. The graft was harvested from the ipsilateral scapular pillar, pedicled on the circumflex scapular artery, fitted into the remaining proximal humerus, and secured to the glenoid using screws. A humerus-scapular spine plate was added to stabilize the arthrodesis. Radiographic results were assessed on standard radiographs obtained at last follow-up. Functional outcomes were evaluated using the MusculoSkeletalTumour Society (MSTS) score and Toronto Extremity Salvage Score (TESS). RESULTS: After a mean follow-up of 4.9 years, 87.5% of SHA junctions were healed, mean MSTS score was 71%, and mean TESS score was 70%. DISCUSSION: The outcomes in our patients were similar to those reported after SHA using a pedicled fibular flap. However, our technique does not require microsurgery. It is simple, reproducible, and effective. Its indications of choice are intra- or extra-articular resection of the proximal humerus including the attachments of the rotator cuff and deltoid muscle tendons or the nerves supplying these muscles. LEVEL OF EVIDENCE: Level IV (retrospective study).

Critical study of resection margins in adult soft-tissue sarcoma surgery.

INTRODUCTION: Resection margins constitute a recognized risk factor for local recurrence, but their impact on survival is less clear. HYPOTHESIS: Infiltrative proliferation and satellite nodules are prognostic factors for local and systemic aggressiveness. TYPE OF STUDY: Retrospective cohort study. PATIENTS AND METHODS: In 105 patients under curative treatment, resection quality was assessed on UICC criteria (R0/R1) and on a modified version (R0M/R1M) taking account of proliferation contours and satellite nodules for narrow margins (<1mm). Uni- and multi-variate analysis was performed, and Kaplan-Meier survival curves were compared on log-rank. RESULTS: Mean 5-year local recurrence-free survival (LRFS) was 0.64 [0.52-0.76] after R1 surgery, 0.9 [0.85-0.95] after R0, 0.64 [0.519-0.751] after R1M and 0.92 [0.87-0.96] after R0M. Resection type according to R classification correlated with disease-free survival (DFS) (P=0.028), but not with metastasis-free survival (MFS) (P=0.156). Resection type according to RM classification correlated with DFS and MFS. Multivariate analysis disclosed correlations between LRFS rate and RM resection type (HR 6.77 [1.78-25.7], P=0.005), DFS rate and RM resection type (HR 2.83 [1.47-5.43], P=0.001) and grade (HR=3.17 [1.38-7.27], P=0.003), and MFS and grade (HR=3.96 [1.50-10.5], P=0.006). DISCUSSION: The microscopic aspect of the proliferation contours and presence of satellite nodules were confirmed as prognostic factors for local and systemic aggressiveness. They impact both disease-free survival and metastasis-free survival in case of margins less than 1mm. Their systematic consideration may help identify patients with elevated systemic risk. LEVEL OF EVIDENCE: IV.

Development of a per-operative procedure for concentrated bone marrow adjunction in postero-lateral lumbar fusion: radiological, biological and clinical assessment.

PURPOSE: Addition of bone marrow to the bone graft in the postero-lateral lumbar arthrodesis is a widely used technique. Bone marrow brings stem cells and growth factors contained in the platelets, favorable for bone growth. Adjunction of concentrated bone marrow should create better conditions and may increase bone growth. METHODS: Simple blind randomized clinical, prospective, monocentric trial was conducted. Fifteen patients underwent lumbar arthrodesis. During surgery, a fraction of the bone marrow harvested was centrifuged. One side received this concentrate with autologous bone and ceramics; the other side received the same graft with unconcentrated bone marrow. A quantitative study, realised with a volume calculating software on CT-scan images, determined the cortical bone volume in the graft post-operatively and at 3 months. The osteoprogenitor cells, nucleated cells and platelet concentrations were determined. RESULTS: The biological study found an average concentration of six times for the nucleated cells, 3.5 times for the platelets and 2.2 times for the osteoprogenitor cells. The comparison of the mean cortical bone volumes post-operatively and at 3 months was not significantly different. CONCLUSIONS: Despite the concentration obtained, there was no increase of bone growth by adding concentrated bone marrow. However, the number of stem cells in bone marrow was low and maybe a stronger concentration is needed to obtain a difference. The 3D reconstruction of the graft and the analysis of the graft's volume using a novel software was efficient according to the similarity of the graft's volume post-operatively in all patients.

Applications in hip pathology.

Everyday clinical practice frequently leads us to suspect a close relationship between the lumbar spine and the hip-joints. Sagittal balance fundamentally expresses a postural strategy mobilizing the dynamic structure of the lumbar-pelvic-femoral complex in an authentic balance by which obligatory coupled movements transmit stresses in a single structure, the spine, to the two-part structure of the lower limbs, and vice-versa. Flexion contracture is a frequent hip pathology, but congenital dislocation and ankylosis of the hip have the greatest impact on the spine, due to excessive mechanical strain and/or spinal malalignment, which is initially supple but becomes fixed. Clinical analysis, backed up if necessary by infiltration tests and imaging, guides indications for surgical management. These considerations suggest a general attitude that considers not just the hip itself, for which the patient is consulting, but the lumbar-pelvic-femoral complex as a whole (and also the knee) before undertaking total hip replacement. Femoro-acetabular impingement is a recently described pathology associating morphological hip-joint abnormality and labral and joint cartilage lesions, leading to early osteoarthritis of the hip. Abnormal spinal or pelvic parameters have not been found associated with femoro-acetabular impingement. Congenital pelvic tilt is a benign and often overlooked pathology in children. Supra- and infra-pelvic pelvic tilt in childhood palsy raises the difficult strategic issue of how to get these children in their wheelchair with a well-balanced spine over a straight pelvis and frontally and sagittally balanced hips.