Anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a 2- to 10-year follow-up, multicenter study.

The clinical outcome of anatomical reconstruction or tenodesis in the treatment of chronic anterolateral ankle instability was assessed in a retrospective multicenter study. The anatomical reconstruction group (group A) consisted of 106 patients (mean age at operation 24 +/- 8.4 years) and the tenodesis group (group B) of 110 patients (mean age at operation 26 +/- 11.4 years). Patients were evaluated at a mean follow-up of 5.5 +/- 2.8 years in group A and 5.2 +/- 2.9 years in group B. The review protocol included patient characteristics, physical examination, two ankle scoring scales to evaluate the functional results, and standard anteroposterior and lateral radiographs to evaluate degenerative changes. Mechanical stability was evaluated using standardized stress radiographs. A larger number of reoperations was performed in group B (P = 0.008). At physical examination, more patients in group B had a smaller range of ankle motion than those in group A (P = 0.009). A larger proportion of patients in group B had medially located osteophytes, as seen on standard radiographs (P = 0.04). On stress radiographic examination, the mean talar tilt (P = 0.001) and mean anterior talar translation (P < 0.001) were seen to be significantly greater in group B than in group A. There were no differences in mean Karlsson score between the groups, but more patients in group A had an excellent result on the Good score (P = 0.011). Unlike anatomical reconstructions, tenodeses do not restore the normal anatomy of the lateral ankle ligaments. This results in restricted range of ankle motion, reduced long-term stability, an increased risk of medially located degenerative changes, a larger number of reoperations, and less satisfactory overall results.

[The recent history of substitution procedures for the anterior cruciate ligament]. / Histoire récente des substituts ligamentaires du croisé antérieur.

The evolution of operations to repair or substitute the anterior cruciate ligament is summarized for the period 1903 to the present. The increase in the understanding of the function of the ligament is described and in the light of this experience a programme for the management of these lesions is suggested. In acute lesions in a young sportsman the loss of the stability provided by the central pivot prevents competition at high level and operation to repair, substitute, or reinforce the ligament is recommended. In the older athlete non-intervention may be acceptable in view of the knowledge that the adverse mechanical consequences of a rupture of the ACL may be lessened by appropriate rehabilitation. Such measures may be successful for a couple of years, but usually, within five years, functional symptoms will appear. In patients who are middle aged, or those with no competitive need, rehabilitation only is usually adequate, and surgical reconstruction is rarely necessary. In chronic lesions operation should probably only be undertaken when instability is a notable problem. Reconstruction may be accomplished by an autograft using a bone patella bone, semi-membranosis or semi-tendonosis transfer, allograft substitution or a prosthesis.

[Combination auto-heteroplasty in ligament repair in chronic anterior laxity of the knee]. / Réparation combinée auto-hétéroplastique ligamentaire dans les laxités chroniques antérieures du genou.

From September 85 to September 88, 130 patients were treated by our own technique for chronic laxity of the knee. All the patients were examined at regular intervals (6, 12 and 24 months) both clinically and by arthroscopy. Neuromorphological studies, an experimental approach with the "Pivot" and evaluation of the results, show that surgery is indicated, especially in young patients, before intraarticular lesions appear.

The surgical treatment of fractures of the acetabulum. Results after five years and proposed new classification.

Thirty-seven fractures of the acetabulum treated surgically at the Orthopaedic Institute in Milan were reviewed 5 years after operation. The overall clinical and radiographic results over this period of time were considered to be satisfactory, but a detailed study of each case enabled us to determine some of the factors which may negatively influence the outcome of this type of fracture. These negative factors were used to devise a new classification based on whether or not there was involvement of the load bearing segment of the acetabulum and on the complexity and comminution of the fracture.

Varizing osteotomy in osteoarthrosis of the hip. (10 years follow up of 21 cases).

The authors discuss the anatomical, structural and biomechanical aspects of osteoarthrosis of the hip that are the determining factors in the success of varizing osteotomy, based on a pre-operative radiological and clinical study of their cases. In describing the surgical technique, they stress the importance of posterior capsulotomy. The case material comprises thirty-two patients, twenty-seven of whom underwent osteotomy. Five received no surgical treatment and two of those operated on had no pre-operative dysplasia. All patients were followed up roughly ten years after operation. The same criteria of assessment were used as those recorded at the time of operation and included pain, mobility, walking and radiological appearances. The results obtained confirm the effectiveness of varizing osteotomy with posterior capsulotomy, provided that it is preceded by a careful assessment of the patient to ensure that the correct indications have been observed.

Fractures and pseudarthrosis of the carpal scaphoid.

The ultimate outcome of fractures of the scaphoid bone is determined by the choice of initial treatment. The special characteristics of the blood supply to the bone, which often increase the risk of non-union, have prompted us to propose the indications for primary surgical treatment based on the radiographic appearances. The authors propose a classification of the radiographic characteristics of fractures of the scaphoid for determining at the outset the treatment most likely to achieve consolidation and hence a more rapid resumption of occupational and sports activities. They present the results obtained in the treatment of 101 recent fractures of the scaphoid, eighty-one of which they were able to follow up after at least one year. In cases of established pseudarthrosis of the scaphoid they propose a pedicled transplant technique as conforming better to the anatomical, morphological and functional pre-requisites of the operation. The results obtained in the treatment of twenty-nine cases of pseudarthrosis are presented. The case material relates to patients treated at the G. Pini Orthopaedic Institute of Milan and, in the case of sportsmen, at the Centre for sports injuries of the same institute.

An apparatus for the radiographic diagnosis of ligamentous lesions of the ankle dynamic projections.

Functional radiographic investigation is indispensable to the clinical examination of ligamentous lesions of the ankle. It facilitates correct classification of the different lesions. This correlation of clinical findings and precise radiographical images to well defined anatomo-pathological lesions is particularly important in selecting the correct treatment. An apparatus is described which makes it possible to identify more precisely ligamentous lesions of the ankle, both the abnormal tilting of the talus in A.P. views, and forward talar sliding ("angle of ballottamento") seen in lateral views. This apparatus is easy to use in the First Aid department and can be used without general or local anaesthesia.

Operative indications in fractures of the calcaneus: problems of reduction and fixation.

In fractures of the calcaneus the fundamental importance of complete restoration of the architectural structure of the bone is stressed. To this end, the technique of internal fixation calls for a special device. Three different types of plate are described and the indications for each discussed.