Needle arthroscopy in anatomical reconstruction of the lateral ankle: a report of three cases with a parallel comparison to the standard arthroscopy procedure.

PURPOSE: This study evaluates the use of the needle arthroscopy in anatomical reconstruction of the lateral ankle. We hypothesized that the needle arthroscopy would allow anatomical reconstruction to be performed under arthroscopy. METHODS: Three patients underwent treatment of chronic ankle instability. The comparative procedure was performed in the following four steps: 1) anteromedial articular exploration (medial/lateral gutter/anterior chamber/syndesmosis); 2)creation of the talar tunnel via the anteromedial arthroscopic approach; 3) anterolateral fibular tunneling; and 4) positioning of the graft by the anteromedial arthroscopic approach. For each of these steps, the planned procedure using the needle arthroscope was compared to the standard arthroscope. For each step, the planned procedure using the needle arthroscopy was compared to the standard arthroscope and the act was classified based on level of difficulty: facilitated, similar, complicated and impossible. RESULTS: The exploration of the medial and lateral gutter, the creation of the tunnel of the talus and graft positioning were not accomplished using the needle arthroscope. While the syndesmosis visualization was facilitated by the needle arthroscope in comparison to the standard arthroscope. CONCLUSION: The anatomical reconstruction of the lateral ankle, using the needle arthroscopy-only approach, was impossible in all three cases, regarding: ankle joint exploration, creation of the tunnel of the talus and graft positioning. The needle arthroscope should not be considered as a "mini arthroscope" but as a new tool with which it is necessary to rethink procedures to take advantage of the benefits of this instrument.

Functional assessment of transplantar nailing for ankle fracture in the elderly: 48 weeks' prospective follow-up of 14 patients.

INTRODUCTION: Retrograde transplantar intramedullary nailing (TIMN) is a recently described option for ankle fracture in elderly patients with multiple comorbidity contraindicating classical internal fixation. The main objective of the present study was to assess mobility after TIMN for ankle fracture in the elderly. The secondary objective was to assess complications. HYPOTHESIS: Retrograde TIMN provides reliable fixation of ankle fracture in the elderly, enabling early resumption of walking. MATERIAL AND METHODS: Fourteen patients, with a mean age of 79.6years (range: 65-99years), with fracture of the ankle or tibial pilon treated by retrograde TIMN, were prospectively included over a 1-year period (2014-2016). Full weight-bearing with walking cast boot was authorized as of day 1. Mobility was assessed on Parker score in consultation at 6, 12, 24 and 48 weeks. RESULTS: Ten patients were followed up. Mean Parker score was 3.6 (range: 1-5) preoperatively, and 2.4 (range: 1-5) and 2.7 (range: 1-5) at 24 and 48 weeks, respectively: i.e., not significantly different from preoperative values (p=0.057 and p=0.054, respectively). There were no decubitus-related complications. Two patients (20%) showed other complications, including 1 deep infection requiring material ablation. Consolidation was systematic, without hindfoot malunion. DISCUSSION: Retrograde TIMN appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated. It allowed immediate resumption of weight-bearing and early rehabilitation, with no increased morbidity or mortality. LEVEL OF EVIDENCE: IV.

Recovery after shoulder arthroscopy: Inpatient versus outpatient management.

INTRODUCTION: Shoulder arthroscopy is particularly suited to outpatient surgery, thanks to advances in anesthetic and analgesic techniques. The main goal of this study was to compare postoperative recovery after shoulder arthroscopy between outpatient and inpatient management. HYPOTHESIS: There is no difference in functional recovery between inpatient and outpatient management. MATERIALS AND METHOD: A single-center, single-operator prospective study was conducted. Both groups received patient-controlled analgesia via an interscalene catheter. The inclusion criterion was shoulder arthroscopy for rotator cuff tendinopathy. The choice between inpatient and outpatient management was left to the patient. The study endpoint was postoperative recovery assessed on QOR-15 at days 1, 2, 3, 4 and 7 and on Quick-DASH at 6 weeks. RESULTS: Forty-nine patients were included, divided into 2 groups. The outpatient (OP) and inpatient (IP) groups were comparable. Reconstructive surgery accounted for 54% of cases in OP versus 62% in IP. There was no significant difference in recovery in the first postoperative days (QOR-15) or at 6 weeks (Quick-DASH) (p>0.05). Pain on visual analog scale (VAS) was significantly greater in OP after discharge home. DISCUSSION: No significant difference in postoperative recovery was observed between groups. Nevertheless, pain management and patient information for outpatients need improving. LEVEL OF EVIDENCE: II, comparative study.

Anatomic validation of the lateral malleolus as a cutaneous marker for the distal insertion of the calcaneofibular ligament.

PURPOSE: An anatomic study was performed to confirm whether the lateral malleolus could serve as a simple and reproducible anatomic reference for the distal insertion of the calcaneofibular ligament (CFL). METHODS: Dissection was performed after placement of a Kirschner wire to simulate the calcaneal tunnel for the distal insertion of the CFL. The skin was penetrated 1 cm distal and posterior to the tip of the lateral malleolus. The main information recorded was the distance from the Kirschner wire to the centre of the distal insertion of the CFL. Other elements were noted (characteristics of the CFL, distance between the distal insertion of the CFL-peroneal tubercle, nerve or tendon injuries). RESULTS: Thirty ankles were dissected. The mean distance from the Kirschner wire to the centre of the distal insertion of the CFL was 2.4 ± 1.8 mm. Only one case of peroneal injury was noted. The sural nerve was usually located a mean 1.8 ± 1.1 mm from the Kirschner wire. The posterior tibial vascular pedicle was a mean 27.8 ± 3.5 mm from the point of exit of the Kirschner wire. CONCLUSION: Using the lateral malleolus as the cutaneous reference for the distal insertion of the CFL seems to be more reliable than the pure arthroscopic technique. This study describes a percutaneous technique to obtain a calcaneal tunnel for distal insertion of the CFL. The sural nerve is at the greatest risk of injury with this technique and requires careful subcutaneous incision to prevent injury. This new percutaneous technique is less invasive than a purely arthroscopic technique and more accurately identifies the location of the tunnel. It can be used to do calcaneal tunnel in clinical practice during anatomic ligament reconstruction for chronic ankle instability.

Early strength recovery after anterior cruciate ligament reconstruction using the fascia lata.

INTRODUCTION: After undergoing anterior cruciate ligament (ACL) reconstruction, patients must recover at least 80% of their hamstring and quadriceps strength to be able to return to sports without risk to the graft. Harvesting of the patellar tendon leads to large deficits in quadriceps strength, while harvesting the hamstring tendons leads to large deficits in hamstring strength. However, there are no published studies on the strength deficit after ACL reconstruction with the fascia lata. The objective of this study was to evaluate the results of isokinetic testing in patients who underwent ACL reconstruction with a fascia lata graft and to analyze the individual factors affecting these results. The hypothesis was that preserving the quadriceps and hamstrings would lead to satisfactory isokinetic testing results by preserving the physiological balance between the flexor and extensor mechanisms in the leg. MATERIALS AND METHODS: In this retrospective, single-center study, 53 patients had their quadriceps and hamstring strength recovery evaluated 6 months and 1 year post-ACL reconstruction by concentric isometric testing at a slow (90°/s) and fast velocity (240°/s). These results were analyzed as a function of individual characteristics such as age, sex, preinjury level and type of sports activity, and IKDC and Lysholm scores. RESULTS: The quadriceps strength deficit at the slow and fast velocities was 27.5% and 22.5% at 6 months and 15.5% and 11% at 1 year, respectively. The hamstring strength deficit at the slow and fast velocities was 12.1% and 7% at 6 months and 8% and 6.4% at 1 year, respectively. The quadriceps to hamstring ratio at the slow and fast velocities was 66.7±16.5 and 71.3±15.5 at 6 months, and 61.1±14.9 and 67.6±12.5 at 1 year. Being less than 25 years of age, having a subjective IKDC grade or Lysholm score above 90, and being a professional athlete were significant predictors of better muscle strength recovery. DISCUSSION: Isokinetic testing at 6 months and 1 year after ACL reconstruction surgery using the fascia lata showed that the quadriceps to hamstring ratio is close to physiological standards. LEVEL OF EVIDENCE: IV retrospective study.

Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature.

Anterior cruciate ligament (ACL) reconstruction can be performed with an autograft, which is most often harvested from the patient's hamstring tendon (HT) or patellar tendon (PT). However, autograft harvesting leads to morbidity that is by no means insignificant. A systematic review of literature was performed to define the incidence of complications related to graft harvesting and the methods to prevent these complications. In March 2017, a systemic review of literature was performed using the keywords"harvesting", "harvest", "morbidity", "complication", "cruciate ligament". No time limit was applied. The studies had to be written in French or English with their abstract available online. This initial search based on the title and abstract identified 133 articles. Two independent observers analyzed each article entirely, including the references. In all, 36 articles were retained. The main complication of HT harvesting was sensory deficit because of damage to the infrapatellar branches of the saphenous nerve. This complication occurred in 39.7% to 88% of patients. This risk can be reduced by using a horizontal or oblique incision. The main complication following PT harvesting is anterior knee pain, reported in up to 46% of patients. There are substantial numbers of short-, medium- and long-term complications related to the harvesting of the two main ACL autografts. Effective means of prevention exist to reduce the risk of these complications. LEVEL OF EVIDENCE: II Systematic review of literature.

Giant cell tumor of tendon sheath: Open surgery or arthroscopic synovectomy? A systematic review of the literature.

PURPOSE: Giant cell tumor of tendon sheath (GCTTS), formerly known as pigmented villonodular synovitis (PVNS), is a benign, locally aggressive, proliferative disorder of the synovium involving a joint, bursa, or tendon sheath. Treatment of GCTTS involves early surgical resection to limit articular destruction and the risk of recurrence. Synovectomy remains the treatment of choice for GCTTS, but without clear consensus to make an open or arthroscopic synovectomy and no certainty on the responsibility of surgery in the evolution towards the degenerative osteoarthritis. The aim of this study was to evaluate the long-term clinical outcomes and the rate of recurrence of open or arthroscopic excision of GCTTS of the four most frequently involved joints: the shoulder, hip, knee and ankle. METHODS: We performed a systematic review of literature in September 2015. The keywords were "villonodular synovitis" AND "surgical treatment". The two authors analyzed 413 articles, according to title and abstract. Forty articles were selected, read entirely and references were analyzed. RESULTS: Thirty-three articles were selected. CONCLUSION: Our review of literature showed that arthroscopic excision is effective for localized type of GCTTS for all four joints. In diffuse type GCTTS, the efficacy of arthroscopic synovectomy has only been shown for the knee joint. In the other joints, early diagnosis can improve clinical outcomes, but we cannot certify that surgical treatment avoids osteoarthritis degradation. STUDY DESIGN: Review of literature, level of evidence IV.

Localized and diffuse forms of tenosynovial giant cell tumor (formerly giant cell tumor of the tendon sheath and pigmented villonodular synovitis).

Tenosynovial giant cell tumor (TSGCT) is a rare benign tumor arising from joint synovia, bursae and tendon sheaths. Their variable clinical presentation is related to variations in site and progression. Localized forms are most frequent in the hands, and diffuse forms in the knee. MRI is necessary and sometimes sufficient for diagnosis. Treatment strategy is guided by progression, symptomatology, location and diathesis. Optimally complete resection is the principle of first-line treatment. Radiation therapy is effective and targeted therapies are promising; both should especially be considered in case of relapse.

Discontinuation of Plavix® (clopidogrel) for hip fracture surgery. A systematic review of the literature.

The elderly population is increasing worldwide, associated with an increase in diseases related to aging, such as hip fractures. These patients are sometimes treated with clopidogrel. There are no arguments at present to clearly determine the risk/benefit ratio of early surgical management of traumatic hip fractures in patients treated with clopidogrel (perioperative blood loss, postoperative complications). The goal of this systematic review of the literature was to show that early surgical management (<48h) of patients treated with clopidogrel does not increase postoperative morbidity or mortality. Systematic review of the literature: level of evidence IV. A bibliographic search was performed in July 2015 in PubMed, Embase and Cochrane databases using the MeSh keywords "Clopidogrel or Plavix®" AND "hip fracture". Two of the authors analyzed 48 articles based on the title and abstract. Twenty-one articles were selected and read completely with an analysis of the references. Nine articles were chosen. Early surgical management (<48h) of patients receiving clopidogrel did not increase mortality at 30days, 3months or 1 year (between 25 and 30% mortality at 1 year) and did not result in an increase in perioperative bleeding. The risk/benefit ratio of early surgical management of patients with hip fractures receiving clopidogrel is good; morbidity and mortality are not increased in these patients if surgery is performed immediately or less than 48h after admission. LEVEL OF EVIDENCE: IV.

Arthroscopic anatomical reconstruction of the lateral ankle ligaments: A technical simplification.

Anatomical reconstruction of the lateral ankle ligaments has become a pivotal component of the treatment strategy for chronic ankle instability. The recently described arthroscopic version of this procedure is indispensable to ensure that concomitant lesions are appropriately managed, yet remains technically demanding. Here, we describe a simplified variant involving percutaneous creation of the calcaneal tunnel for the distal attachment of the calcaneo-fibular ligament. The rationale for this technical stratagem was provided by a preliminary cadaver study that demonstrated a correlation between the lateral malleolus and the distal footprint of the calcaneo-fibular ligament. The main objectives are simplification of the operative technique and decreased injury to tissues whose function is crucial to the recovery of proprioception.

What type of imaging work-up will help to confirm the diagnosis of gossypiboma in the limb? Review of literature.

UNLABELLED: Gossypiboma imaging features are not well known and are often confused with soft tissue tumours. Publications on this topic mainly consist of case reports and small cohorts. Its appearance on various imaging modalities is not well defined. This led us to carry out a review of literature to determine specifically: (1) which imaging modalities should be used in cases of suspected gossypiboma, (2) what are the most common imaging findings that contribute to the diagnosis of gossypiboma. An exhaustive review of literature was carried out in June 2015 in the Medline, PubMed and Cochrane databases using the keywords "gossypiboma/textiloma/foreign body". We found 205 articles describing one or multiple cases of gossypiboma in various locations. Of these, the 32 articles that had imaging data were chosen - 16 for the limbs and 16 for other locations. The type of imaging carried out, description of the gossypiboma and circumstances of the discovery and occurrence were recorded. Descriptive statistics were generated to define the type of imaging used and the various findings. Imaging consisted of X-rays in 21/32 cases (66%), computed tomography (CT) in 14/32 cases (43%), magnetic resonance imaging (MRI) in 21/32 cases (65%) and ultrasonography in 14/32 cases (43%). On X-rays, bone involvement was found in 9/15 cases (60%); there was peripheral contrast product uptake on the CT scans in 9/14 cases (64%), a hypointense signal on T1-weighted sequences on MRI in 6/13 cases (46%) and lack of vascularisation in 8/13 cases (62%) and a acoustic shadow on ultrasonography in 9/14 cases (64%). In a patient presenting with a soft tissue lump and history of surgery, an imaging work-up including X-rays, ultrasonography and MRI must be performed. Bone involvement on X-rays, acoustic shadowing on ultrasonography and hypointense signal on T1-weighted MRI sequences with lack of vascularisation in combination with a history of surgery can bring up the possibility of gossypiboma. If there is a possibility of soft tissue tumour, the case should be discussed in a multidisciplinary meeting and a biopsy should be performed first. LEVEL OF EVIDENCE: IV - systematic analysis of published retrospective studies.

Total talar fracture - long-term results of internal fixation of talar fractures. A multicentric study of 114 cases.

INTRODUCTION: Displaced talar neck and body fractures are rare and challenging for the surgeon. Results are often disappointing due to inadequate reduction or internal fixation and high rates of osteoarthritis and osteonecrosis. Very few published series describe the long-term results after internal fixation of talar factures. One of the goals of the 2011 SOO meeting symposium was to specifically evaluate the long-term results after internal fixation of talar fractures. This study included only central fractures. MATERIAL AND METHODS: We reviewed the results of 114 central talar fractures that had been treated by internal fixation between 1982 and 2006 in nine hospitals in the Western part of France. The clinical and radiological follow-up was 111 months on average. All the patients with a radiological assessment had at least 5 years of follow-up. RESULTS: Poor reduction was apparent in 33% of cases. The average Kitaoka score was 70/100, which corresponds to an average functional level. At the last follow-up evaluation, 34% of cases had osteonecrosis and 74% had peritalar osteoarthritis. Secondary fusion was required in 25% of cases with an average follow-up of 24 months. DISCUSSION: The complication rate for talar fractures was high, mostly due to osteonecrosis and osteoarthritis; these conditions had an impact on the final outcome. The outcome could be improved by better evaluating these fractures with a CT scan, developing dual surgical approaches to best preserve the bone vascular supply and achieve better reduction, and improving the internal fixation hardware, especially the use of plates for comminuted fractures.

Total talar fracture - inter- and intra-observer reproducibility of two classification systems (Hawkins and AO) for central talar fractures.

INTRODUCTION: We evaluated the inter- and intra-observer reproducibility of two classification systems for central talar fractures (Hawkins, as modified by Canal and Kelly and then by us; AO/AOT). HYPOTHESIS: The analysis and classification of these fractures will be better with CT scans than with X-rays. MATERIAL AND METHODS: Four observers evaluated 39 X-ray and CT scan files twice in the span of six weeks; each evaluation entailed classifying the fractures and describing their main features. Cohen's Kappa coefficient for inter-rater agreement was calculated and analysed. RESULTS: The inter- and intra-observer reproducibility with CT scans was better with X-rays for most of the parameters evaluated. The modified Hawkins classification provided better reproducibility than the AO/AOT one. However, this classification system was not perfect, even after modifications and use of CT scans. DISCUSSION: CT scans are an essential tool for the analysis of all talar fractures. We modified the Hawkins classification (as modified by Canal and Kelly) to include a Type 0 (no displacement or less than 2mm), include frontal body fractures that are displaced like neck fractures and take into account comminuted fractures and other trauma in the area. LEVEL OF PROOF: IV - retrospective clinical study.