Anesthesia and analgesia methods for outpatient anterior cruciate ligament reconstruction.

INTRODUCTION: More and more anterior cruciate ligament (ACL) reconstructions are being performed as outpatient surgery in France, because of economic considerations. Postoperative pain is the most common reason for delayed discharge that could require hospitalization, and the main reason for unanticipated hospital admission. The purpose of this study was to define the best anesthesia and analgesia methods for ACL reconstruction. MATERIALS AND METHODS: This was a prospective, multicenter, comparative study performed between January 2014 and April 2015. Inclusion criteria were ACL reconstruction in patients above 15 years of age performed as an outpatient surgical procedure. The anesthesia techniques analyzed were general anesthesia, spinal anesthesia and quadruple nerve blockade. The analgesic methods studied were single-shot nerve blocks, continuous nerve blocks, peri-articular and intra-articular local infiltration analgesia (LIA), non-steroidal anti-inflammatory agents (NSAIDs) and intravenous corticosteroids. The main outcome criterion was pain on a visual analog scale (VAS). The secondary outcome criteria were delayed discharge of a patient who had undergone outpatient surgery, consumption of opioids and complications for the various anesthesia techniques and analgesia methods. RESULTS: In all, 680 patients were included in this study, which was 63% of the ACL reconstruction procedures performed during this period. The study population was 69% male and 31% female, with an average age of 30 years. Twenty-three patients (3.4%) could not be discharged on the day of surgery. No correlation was found with the anesthesia technique used. NSAID treatment was protective relative to delayed discharge (P=0.009), while opioid consumption was a risk factor (P<0.01). There were no differences in the pain levels related to the type of anesthesia. Peri-articular LIA of the hamstring tendon harvest site was effective. Intra-articular LIA did not provide better analgesia. Continuous nerve block had complication rates above 13%. DISCUSSION: All types of anesthesia were compatible with outpatient ACL reconstruction. No gold standard analgesia method can be defined based on this study's findings. However, we recommend multimodal analgesia associating peri-articular LIA or one-shot sensory saphenous nerve block, NSAIDs and corticosteroid treatment, and cryotherapy. LEVEL OF EVIDENCE: II, prospective comparative non-randomized study.

French prospective multicenter comparative assessment of ambulatory surgery feasibility in anterior cruciate ligament reconstruction.

INTRODUCTION: The main objective of this multicenter study was to assess the feasibility of ambulatory surgery in France in anterior cruciate ligament (ACL) reconstructions for any technique or graft used (hamstring, patellar tendon, fascia lata). We hypothesized that a dedicated organization would guarantee the patient's safety. PATIENTS AND METHODS: A multicenter, non-randomized, prospective, comparative study, conducted within the SFA symposium was conducted between January 2014 and March 2015, included all the patients operated on for arthroscopic ACL reconstruction using different surgical techniques. The outpatient group (OP) included patients eligible for day surgery who provided informed consent; the conventional hospitalization group (CH) comprised patients declined for outpatient surgery for organizational reasons. The main outcome was failure of the admission mode defined by hospitalization of a patient undergoing outpatient surgery or rehospitalization within the 1st week after discharge. The secondary outcomes were assessment of pain and postoperative complications. A total of 1076 patients were studied with 680 in the OP group and 396 in the CH group. The mean age was 30years±9years. In the CH group, the mean hospital stay was 2.7±0.8days. RESULTS: Twenty-three OP patients were hospitalized or rehospitalized (3.4%). Thirty-six (5.2%) early postoperative complications were noted in the OP group and 17 (4.3%) in the CH group (non-significant difference). Mean postoperative pain on D0-D4 and satisfaction were comparable between the two groups. CONCLUSION: This prospective multicenter study observed no serious incidents. In a selected population, the risks are comparable to those of conventional hospitalization. Outpatient ACL surgery is therefore feasible in France in 2016. LEVEL OF PROOF: III: case-control study.

Pain after out-patient vs. in-patient ACL reconstruction: French prospective study of 1076 patients.

BACKGROUND: Anterior cruciate ligament (ACL) repair is increasingly performed on an out-patient basis. In France, however, concern about post-operative pain remains a strong barrier to out-patient ACL repair. The primary objective of this study was to compare post-operative pain after ACL repair as out-patient versus in-patient surgery. The secondary objectives were to assess the time-course of post-operative pain and to identify factors associated with pain intensity. MATERIAL AND METHODS: A multicentre, prospective, comparative, non-randomised study was conducted in France for the French Society for Arthroscopy (SFA) symposium. Patients who underwent primary ACL repair between January 2014 and March 2015 were included if they were eligible for out-patient surgery. The choice between out-patient and in-patient surgery was based on organisational and logistical considerations. Pain intensity was self-evaluated by the patients using a visual analogue scale (VAS), pre-operatively then in the evening after surgery, during the night after surgery, and 1, 3, and 5 days after surgery. The patients performed the evaluations at home using websurvey.fr® software. Demographic data, the characteristics of the surgical procedure, and the IKDC and Lysholm scores before and after surgery were collected. RESULTS: Of the 1076 patients included in the study, 680 had out-patient surgery and 396 in-patient surgery. Mean age was 30±9 years. The two groups were comparable at baseline. Pain intensity was not significantly different between the two groups at any of the measurement time points. Pain intensity showed a peak on post-operative day 1 that was similar in the two groups. The initial post-operative pain intensity score predicted subsequent pain intensity: patients with VAS scores <2 on the day of surgery also had low pain scores after surgery. In both groups, factors associated with greater pain intensity were age <25 years, high pre-operative pain score, and surgery performed after noon. Neither surgical technique nor concomitant lesions and methods used to treat them were associated with pain intensity. Risk factors for severe post-operative pain (VAS score >7) in the out-patient group were younger age, female gender, pre-operative VAS score >3, and tourniquet time >50minutes. CONCLUSION: Pain intensity is similar after out-patient and in-patient ACL repair. Concern about pain should not be a barrier to performing ACL repair on an out-patient basis. Our data on the time-course of the pain and factors associated with greater pain intensity should prove useful for improving patient management after ACL repair. LEVEL OF EVIDENCE: Level III, case-control study.

Analysis of short and long-term results of horizontal meniscal tears in young adults.

INTRODUCTION: Symptomatic horizontal meniscal tears are rare but worrisome lesions in young adults. These are overuse injuries not amenable to the classic arthroscopic sutures. An open meniscal repair allows the meniscal lesion to be suture vertically, perpendicular to its in the vascularized zone. The purpose of this study was to evaluate the short and long-term clinical and radiological outcomes of the aforementioned surgical technique. MATERIAL AND METHOD: The first cohort consisted of 24 patients operated between 2009 and 2011 (6 women, 18 men; mean age 26years) having 11 lateral and 13 medial meniscal tears. The second cohort was of 10 patients operated between 2001 and 2002 (3 women, 7 men; mean age 24years) having 8 lateral and 2 medial meniscal tears. Patients were reviewed at the last follow-up using the IKDC, Lysholm and KOOS scores. Patients in the first cohort had an MRI, while those in the second cohort had X-rays. RESULTS: Eighteen patients in the first cohort were reviewed with a mean follow-up of 2 years (12-45 months) and 9 patients from the second cohort were reviewed after 10years (97-142 months). In the first cohort, one patient required secondary menisectomy. The mean Lysholm score was 90 and the subjective IKDC was 85. Every MRI examination found reduced extent and intensity of the hyperintense signal. In the second cohort, no patients required secondary meniscectomy. Two patients had joint space narrowing (less than 50%) on radiographs. The mean Lysholm score was 99 and the subjective IKDC was 91. CONCLUSION: Open repair of horizontal meniscal tears in young adults leads to good subjective and objective results in the short term, which are maintained in the long-term. LEVEL OF EVIDENCE: Level IV - retrospective study.

Meniscal survival rate after anterior cruciate ligament reconstruction.

BACKGROUND: Meniscal suture provides well-documented benefits. Integrity of the cruciate ligaments of the knee is a prerequisite for meniscal healing. Nevertheless, reconstruction of the anterior cruciate ligament (ACL) does not consistently prevent recurrent tearing of a sutured meniscus. We evaluated meniscal survival rates, 5 and 10 years after meniscal suture concomitant with an ACL reconstruction. We compared the outcomes of these repaired menisci to those in which no menisci tears were detected during ACL reconstruction. METHODS: In this multi-centric retrospective study, we included two groups. One group consists of patients who underwent a meniscal repair. This group was further divided into two subgroups based on whether follow-up was 5 years (n=76) or 10 years (n=39). The control group included 120 patients with normal menisci observed during surgery. We studied meniscal survival rates in each group, and we analyzed risk factors associated with the recurrence of meniscal lesions. RESULTS: The 5-year meniscal survival rate was significantly higher in the control group than in the meniscal-repair group (95% vs. 80%, respectively; P=0.0029). The controls group also had a higher meniscal survival rate after 10 years, although the difference was not statistically significant (88% vs. 77%, P=0.07). A difference in knee laxity greater than 4mm was associated with a 5-fold increase in the risk of recurrent meniscal tears (P=0.0057). After 5 years, the risk of recurrence was higher for the medial than for the lateral meniscus, whereas after 10 years the difference was no longer statistically significant. DISCUSSION: Although insufficient healing after meniscal suturing contributes to the risk of further meniscal tears, new lesions can develop in menisci that were undamaged at the time of ACL reconstruction. The risk of a new meniscal lesion is strongly associated with inadequate control of antero-posterior and rotational laxity. Some apparently "new menisci lesions" seems to have been missed during ACL reconstruction. LEVEL OF EVIDENCE: IV, retrospective study.

Meniscectomy versus meniscal repair: 10 years radiological and clinical results in vertical lesions in stable knee.

INTRODUCTION: Surgical management of meniscal lesion consists of either a meniscectomy or meniscal repair. Although repair offers immediate recovery after surgery, it is also associated with higher rates of revision. A meniscectomy, on the other hand is known to be associated with an early onset of osteoarthritis. The present study compared clinical and radiological results at 10 years between meniscectomy and meniscal repair in isolated vertical lesion in an otherwise stable knee. The hypothesis was that repair shows functional and radiological benefit over meniscectomy. PATIENTS AND METHOD: A multi-centric retrospective comparative study of 32 patients (24 male, 8 female). Mean follow-up was 10.6 years (range, 10-13 years). There were 10 meniscal repairs (group R) and 22 meniscectomies (group M), in 17 right and 15 left knees. Mean age at surgery was 33.45±12.3 years (range, 9-47 years). There were 28 medial and 4 lateral meniscal lesions; 26 were in the red-red zone and 6 in red-white zone. RESULTS: Functional score: KOOS score was significantly higher in group R than M on almost all parameters: 98±4.69 versus 77.38±21.97 for symptoms (P=0.0043), 96.89±7.20 versus 78.57±18.9 for pain (P=0.0052), 99.89±0.33 versus 80.88±19.6 for daily life activities (P=0.0002), 96.11±9.83 versus 54.05±32.85 for sport and leisure (P=0.0005), but 91±16.87 versus 68.15±37.7 for quality of life (P=0.1048). Radiology score: in group R, 7 patients had no features of osteoarthritis, and 2 had grade 1 osteoarthritis. In group M, 5 patients had grade 1 osteoarthritis, 10 grade 2, 3 grade 3 and 3 grade 4. Mean quantitative score was 0 (mean, 0.22±0.44) in-group R and 2 (mean, 2.19±0.98) in group M (P<0.0001). DISCUSSION: At more than 10year's follow-up, functional scores were significantly better with meniscal repair than meniscectomy on all parameters of the KOOS scale except quality of life. Functional and radiological scores correlated closely. These results show that meniscal repair for vertical lesions in stable knees protects against osteoarthritis and is therefore strongly recommended. LEVEL OF EVIDENCE: IV; retrospective study.

Natural history of partial anterior cruciate ligament tears: a systematic literature review.

INTRODUCTION: Partial anterior cruciate ligament (ACL) tear is frequent, and indications for surgery may be raised by a diagnostic aspect associating slight laxity with no clear pivot-shift. Unlike that of complete ACL tear, the natural history of partial tear remains controversial. MATERIAL AND METHOD: A systematic literature review searched for referenced publications on the natural history of partial ACL tear. Twelve specific articles were retrieved. Initial diagnosis was systematically confirmed on arthroscopy, without ACL surgery. The following criteria were analyzed: firstly, preoperative: confirmation of inclusion criteria, preoperative clinical data, follow-up, arthroscopic lesion assessment, Lachman test, Pivot shift test, hemarthrosis, associated lesions and secondly, follow-up: Lachman test, Pivot shift test, revision surgery, functional clinical scores, pain, sport and return to sport, meniscal events. RESULTS: Preoperatively, Lachman tests were positive (soft or delayed) in a mean 49.7% of cases (range, 0-100%); pivot shift test was systematically negative. At a mean 5.2 years' follow-up, Lachman test was "positive" in 47.6% of cases (range, 38-59%), with positive pivot shift test in 26.3% (range, 5-51%). 54.3% patients reported pain (range, 36-64%), and mean Lysholm score was 88.4 (17-100%). Fifty-two percent (21-60%) of patients resumed sport at their previous level. DISCUSSION/CONCLUSION: The natural history of non-operated partial ACL tear is good over the medium term, especially if patients limit their sports activities. The greater the functional instability, the more frequent is residual pain. Laxity, although not quantified, seems to progress with time, with a positive pivot shift test emerging in a quarter of cases. Functional management may be recommended in non-athletic patients without meniscal lesion, but surgical treatment may be recommended in other patients. Indications for ACL reconstruction are thus the same in partial as in complete tear.

Anterior cruciate ligament reconstruction in partial tear: selective anteromedial bundle reconstruction conserving the posterolateral remnant versus single-bundle anatomic ACL reconstruction: preliminary 1-year results of a prospective randomized study.

INTRODUCTION: Partial tears of the anterior cruciate ligament (ACL) are frequent. Conserving ACL remnants is central to the concept of anatomic, biomechanical and biological reconstruction. The interest of such conservation remains theoretical. The present hypothesis was that selective anteromedial (AM) bundle reconstruction is preferable to the standard single-bundle reconstruction in partial ACL tear. MATERIALS AND METHODS: A multicenter prospective randomized study recruited 54 partial ACL tears operated on either by selective AM bundle reconstruction (Group 1, n=29) or by standard anatomic single-bundle reconstruction (Group 2, n=25). All patients were clinically assessed on subjective and objective IKDC, Lysholm and KOOS scores, with a minimum 12 months' follow-up. Comparative pre- to postoperative anterior laxity was measured on the Rolimeter(®) device, with statistical analysis of results. RESULTS: There were no significant preoperative differences between the two groups. All patients were followed-up at 6 months and 1 year. Mean subjective IKDC scores for groups 1 and 2 respectively were 55.8 and 56.8 preoperatively versus 86.2 and 85.7 at 1 year; Lysholm scores were 69.9 and 71.1 versus 90.9 and 91.8. These inter-group differences were non-significant. Differential laxity for groups 1 and 2 respectively was 5.0mm (range, 2-10) and 5.1mm (2-12) preoperatively (P=0.73), versus 1.2mm and 1.9 mm postoperatively (P=0.03). DISCUSSION AND CONCLUSION: In partial ACL tear, selective AM bundle reconstruction conserving the posterolateral bundle remnant provides clinical results comparable to the standard single-bundle technique, with better control of anterior laxity. Longer follow-up, however, will be needed to compare evolution in anterior and rotational laxity and in subjective results over time.

Partial ACL reconstruction with preservation of the posterolateral bundle.

INTRODUCTION: Over the past decade, our understanding of the anterior cruciate ligament (ACL) has evolved considerably. Based on this knowledge, ACL reconstruction techniques have changed and selective reconstruction procedures have been developed for partial tears. Our hypothesis was that stability and function can be restored to the knee with selective bundle reconstruction of partial ACL tears and preservation of the residual fibers. MATERIALS AND METHODS: This was a multicenter retrospective study of 168 partial reconstructions of the anteromedial (AM) bundle of the ACL with preservation of the posterolateral (PL) bundle. All patients underwent a clinical evaluation based on the objective and subjective IKDC scores and the Lysholm score after a mean follow-up of 26 months (12-59 months). Preoperative and postoperative instrumental measurement of knee laxity was performed by arthrometer and/or by (Telos(®)) stress radiography. Statistical analysis and comparison was performed between pre- and postoperative results. RESULTS: The preoperative and postoperative subjective IKDC scores were 63.7 and 90.5 at the final follow-up respectively (P<0.001). The preoperative and postoperative Lysholm scores were 80 and 95.5 respectively (P<0.001). Preoperatively, most patients were classified C on the objective IKDC score. At the final follow-up 92% of the patients were classified A or B (P<0.001). Differential preoperative laxity was 5.5mm (range: 0-14 mm) and 1.1mm (range: 0-4mm) at the final follow-up (P<0.00001). DISCUSSION AND CONCLUSION: Our study confirms that selective reconstruction of the AM bundle of the ACL with preservation of the PL bundle restores stability and function to the knee. Special attention should be paid to the size of the graft used to avoid excess tissue in the intercondylar notch.

Autologous chondrocyte implantation in a novel alginate-agarose hydrogel: outcome at two years.

Autologous chondrocyte implantation is an established method of treatment for symptomatic articular defects of cartilage. CARTIPATCH is a monolayer-expanded cartilage cell product which is combined with a novel hydrogel to improve cell phenotypic stability and ease of surgical handling. Our aim in this prospective, multicentre study on 17 patients was to investigate the clinical, radiological, arthroscopic and histological outcome at a minimum follow-up of two years after the implantation of autologous chondrocytes embedded in a three-dimensional alginate-agarose hydrogel for the treatment of chondral and osteochondral defects. Clinically, all the patients improved significantly. Patients with lesions larger than 3 cm(2) improved significantly more than those with smaller lesions. There was no correlation between the clinical outcome and the body mass index, age, duration of symptoms and location of the defects. The mean arthroscopic International Cartilage Repair Society score was 10 (5 to 12) of a maximum of 12. Predominantly hyaline cartilage was seen in eight of the 13 patients (62%) who had follow-up biopsies. Our findings suggest that autologous chondrocyte implantation in combination with a novel hydrogel results in a significant clinical improvement at follow-up at two years, more so for larger and deeper lesions. The surgical procedure is uncomplicated, and predominantly hyaline cartilage-like repair tissue was observed in eight patients.

[The ACL tear from the pre-operative analysis to a 2-year follow-up, influence of the graft choice on the subjective and objective evaluation]. / La rupture du ligament croisé antérieur, de l'analyse préopératoire du type de rupture à l'évaluation finale à deux ans, retentissement selon le transplant choisi sur les résultats subjectifs et objectifs.

This study is a synthesis of three series. The first study was prospective on 418 patients with an anterior cruciate ligament (ACL) tear (group I). Two population of ACL ruptures were identified. One population with a postero-lateral bundle preserved in 16%, the mean medial anterior tibial translation side to side was 4.97 mm, the Lachman test was delayed in 40% with no or glide pivot shift in 73%. The second population with a complete ACL tear had a mean medial anterior tibial translation side to side of 7.93 mm, the Lachman test was soft in 98% with gross pivot shift in 80%. The second study was a retrospective study on 258 patients (group II) at 26 months follow-up, it correlated the impact of the type of graft on the clinical objective and subjective results. Twenty-eight percent had anterior knee pain, 33% for the patellar tendon and 25% for the hamstrings, the subjective IKDC was significantly lower for the painful knees, and 68% of the patellar tendon had a hypoesthesia and only 32% for the hamstrings. The ability to walk on the knee was 68% for the hamstrings and 35% for the patellar tendon. The third study was retrospective on 127 patients, 24 months after ACL reconstruction (group III), all were tested on a isokinetic machine for the extensor, the flexor and the internal rotator. In the total population, a 10% extensor and flexor deficit and a 5% rotator deficit was noted. A significant difference between patellar tendon and hamstrings in terms of muscular recovery was found. It pointed out that a more specific rehabilitation should be done on the hamstring group. The muscular recovery was correlated to the highest subjective score. This study allowed the surgeon to be more specific in the ACL tear definition, to adapt the graft choice to the type of sport activity but also to the type of work the patient does and finally to modify the rehabilitation protocol for the hamstring technique.

[Clinical, radiological and arthroscopic analysis of the ACL tear. A prospective study of 418 cases]. / Analyses clinique, radiologique et arthroscopique de la rupture du LCA. Etude prospective de 418 cas.

This prospective multicentric study concerns 418 anterior cruciate ligament tears. It correlates the arthroscopic data's and the clinical and radiological data's. Four types of anterior cruciate ligament tears were identified. Complete tears, postero lateral bundle preserved, healing on the posterior cruciate ligament and healing in the notch. The statistical correlations had shown a highest laxity in the complete tear group with a highest rate of soft Lachman and gross pivot shift, a highest incidence of medial meniscus tears was also noted and a longer delay between injury and surgery, 24 months for the complete tear group and seven months for the postero lateral bundle group. The mean medial compartment laxity, side to side, in the postero lateral bundle group was 4.93 mm and 7.93 mm in the complete tear group. These data could help the surgeon in his surgical planning especially in case of partial tears.

[Isokinetic assessment with two years follow-up of anterior cruciate ligament reconstruction with patellar tendon or hamstring tendons]. / Evaluation isocinétique à deux ans de ligamentoplasties du ligament croisé antérieur au tendon rotulien et aux ischiojambiers.

This retrospective multicentric study was designed to assess the outcome of quadriceps and hamstrings muscles two years after Anterior Cruciate Ligament (ACL) reconstruction and compare muscles recovery depending on the type of graft and individual variables like age, gender, level of sport, but also in terms of discomfort, pain and functional score. The results focused on the subjective and objective IKDC scores, SF36, the existence or not of subjective disorders and their location. The review included isokinetic muscle tests concentric and eccentric extensors/flexors but also internal rotators/external rotators with analysis of mean work and mean power. One hundred and twenty-seven patients were included with an average age 29 years (+/-10). They all had an ACL reconstruction with patellar tendon or hamstring tendon with single or double bundles. In the serie, the average muscles deficit at two years was 10% for the flexors and extensors but with a significant dispersion. Significant differences were not noted in the mean values of all parameters in term of sex or age (over 30 years or not), neither the type of sport, nor of clinical assessment (Class A and B of objective IKDC score), nor the existence of anterior knee pain. There was a relationship between the level of extensor or flexor recovery and the quality of functional results with minimal muscle deficits close to 5% if the IKDC score was over 90 and deficits falling to 15% in the group with IKDC score less than 90. The type of reconstruction (patellar tendon versus hamstrings) had an influence on the muscle deficit. For extensors, the recovery was the same in the two groups, more than 90% at two years and the distribution of these two populations by level of deficit was quite the same. For flexors, residual deficits were significantly higher in the hamstrings group on the three studied parameters whatever the speed and the type of contraction (concentric or eccentric) with an average deficit of 14 to 18%, while, in the patellar tendon group, there was a dominance over the opposite side of 2 to 3% in concentric contraction. The hamstrings deficit appears to be "harvest dependent". For internal rotators, a significantly higher deficit is observed in eccentric contraction for the hamstrings group. The residual hamstrings deficits were related to the number of tendons harvested: -7% when there was no harvest, 7% with one tendon harvested and 17% with two tendons harvested. The relationship between the level of recovery of the quadriceps muscle and hamstrings at two years and the quality of functional results incite, regarding the significantly higher deficit of flexors in ACL reconstructions with hamstrings, to change the rehabilitation programs and especially on early rehabilitation of hamstrings in eccentric mode in the early weeks postoperative considering the harvest site as an equivalent of muscle tear.

[Adult lateral meniscus]. / Le ménisque latéral de l'adulte.

Meniscal lesion does not mean meniscectomy and this is particularly true for the lateral meniscus. The reputation of mildness of the meniscectomy is usurped. The rate of joint space narrowing after lateral meniscectomy is of 40% at a follow-up of 13 years compared to 28% for the medial meniscus (symposium SFA 1996). Several arguments explain those results: biomechanical: the lateral meniscus contributes to the congruence; particularly the lateral meniscus is the zone where antero-posterior translational during knee flexion is 12 mm. The pejorative effects of lateral meniscectomy have conducted, more though to the medial meniscus, to the concept of meniscal economy. Lateral meniscectomy must be as partial as possible. Particularly, a discoid meniscus presenting a complete tear should be treated by a meniscoplasty in order to shape the meniscus in a more anatomic form than a total meniscectomy. Lateral meniscectomy is indicated in complex or horizontal cleavage, symptomatic, on stable knees. A particular case is the cyst of the lateral meniscus. It is a cystic subcutaneous formation, usual consequence of a horizontal cleaved meniscus of which the particularity is that it opens besides the articulation. The strategy must not consist in the isolated treatment of the cyst. This pathology should be addressed by an arthroscopic meniscectomy reaching the meniscosynovial junction at the level of the cyst. Meniscal repair must be proposed every time if possible. Criteria of reparability are better studied on MRI. Preoperatively MRI is the first choice radiological exam. Two essential indications can be held back: the vertical peripheral longitudinal lesion is on the non-vascularized area, and the horizontal cleaving of the junior athlete (if the cleaving remains purely intra meniscal). Meniscal repair is highly performed when the meniscal tear is associated to a rupture of the ACL (simultaneous reconstruction of the LCA). Postoperative outcome is different of that of a "simple" arthroscopic meniscectomy. The healing process being slow, it suits to protect the suture by a splint in the first month, and with an exclusion of sports with knee torsion during 6 months. Functional results (absence of secondary meniscectomy) and anatomical results (reality of the cicatrisation) are good in 77% of cases (symposium of the French Society of Arthroscopy 2003) at a follow-up of 55 months. Survivorship analysis indicates that majority of the failures occur within two years: this testifies a default of primary cicatrisation. At the studied follow-up, meniscal repair was efficient to protect the cartilage. Lateral meniscus results are better that medial meniscus one. Those data support indications: All suspicion of meniscal lesion must have an MRI preoperatively to confirm the lesion, to localize her and to search criteria of reparability; All vertical longitudinal peripheral lesions can and must be repaired especially in young patients and children; All horizontal cleaving of the junior athletes should be treated by open repair; surgical abstention must be proposed when the lesion is non symptomatic, or when lesion is limited and associated to an ACL tear (in that case isolated ACL reconstruction is proposed), or when clinical symptoms are minimal; Meniscectomy, always arthroscopic, is proposed for a symptomatic lesion in the avascular zone or for a deep horizontal cleavage or a complex tear; Tear of the discoid meniscus should be treated by meniscoplasty. A painful knee after lateral meniscectomy might be due to a too limited initial meniscectomy: an iterative meniscectomy may be indicated or lateral femorotibial arthritis, especially after subtotal or total meniscectomy. In this last case and after failure of usual medical treatment such as viscosupplementation surgery may be indicated. Osteotomy in order to unload the lateral femorotibial compartment gives a partial response as the shearing forces remain. This osteotomy is indicated only if the lower limb axis is normal or in valgus. Meniscal allograft is an option in young patients in grade I or II arthritis. Results are promising. Rene Verdonk's series show a survivorship analysis of 75% at 7 years. Early diagnosis of a postmeniscectomy syndrome before cartilaginous lesions occur is essential for an adapted treatment. In conclusion, lateral meniscectomy are less frequent than those of the medial meniscus but their prognosis is less favorable. They should be early diagnosed (MRI). Treatment options are various: abstention, meniscectomy, and repair. Painful post lateral meniscectomy syndrome may be treated by a new surgical option: meniscal allograft.

["Isolated" injury of the posterior cruciate ligament. Surgical treatment of isolated posterior cruciate ligament tears: a multicentric retrospective study of 103 patients]. / Traitement chirurgical d'une rupture isolée du ligament croisé postérieur: résultats d'une série rétrospective multicentrique de 103 patients.

PURPOSE OF THE STUDY: We present a retrospective multicentric series of carefully selected patients presenting "isolated" laxity of the posterior cruciate ligament. MATERIAL AND METHODS: The series included 103 patients who were reviewed clinically (with a dedicated review chart) and radiographically with measurement of posterior laxity (Telos 15 kg). RESULTS: In these patients with an isolated injury of the PCL (without associated injury of the peripheral ligament) DISCUSSION: The short follow-up of this series (four years) does not enable an assessment of the risk or benefit of PCL ligamentoplasty for arthrosic knees.

[Intraarticular fractures of the calcaneus: pathological description. Contribution of x-ray computed tomography]. / Les fractures thalamiques du calcanéum: description anatomo-pathologique. Apport de la tomodensitométrie.

Computed tomography (CT) is of cardinal importance in the study of displaced intra-articular fractures of the calcaneus, as with this imaging technique the primary fracture line of Palmer can be followed and its various locations visualised. If the three-stage classification system of these fractures as vertical, horizontal or mixed fractures, based on their radiological appearance, is adopted, a correlation can be established between the location of Palmer's line and these three anatomical types. The fundamental fracture line is medial in the vertical types, lateral in the horizontal types and is located in the centre of the posterior facet in the mixed types. It can be seen that the fundamental fracture line separates a laterally detached fragment which is always tilted, giving a vertical slope to the surface of the posterior facet which it supports and thus giving a vertical image. This fragment is itself separated from a medially detached fragment which is tilted horizontally and produces a horizontal image on the lateral view. The CT sections must be examined for the presence of a secondary sagittal line completely isolating the horizontally tilted fragment. The importance of the location of the fundamental fracture line, which is on the borderline between tilting and horizontalisation, suggests that pronation-supination of the foot is a factor in the causal mechanism of these fractures. A clear understanding of the three-dimensional position of the fragments and of their displacement, essentially defined by the location of the fracture line, is a prequisite before attempting surgical reduction of calcaneal fractures.