Subacromial temperature profile during bipolar radiofrequency use in shoulder arthroscopy. Comparison of Coblation® vs. VAPR®.

BACKGROUND: The use of bipolar electrodes for arthroscopic procedures carries a theoretical ex vivo risk of inducing burn injuries. Few studies have measured the in vivo temperatures produced by bipolar electrodes during arthroscopy, and their results are conflicting. The objective of this study was to evaluate the temperature profile within the subacromial space during shoulder arthroscopy with two different electrode systems. HYPOTHESIS: The primary hypothesis was that the two electrode systems produced similar temperature variations and peak temperatures. The secondary hypothesis was that neither electrode system produced irrigation-fluid temperatures above the tissue-damage threshold. MATERIAL AND METHODS: A comparative, prospective, single-centre, single-surgeon, single-blind study was conducted to compare the Coblation® system (Smith&Nephew, Andover, MA, USA) and the VAPR® system (DePuy Synthes Mitek Sports Medicine, Raynham, MA, USA) in 13 patients undergoing shoulder arthroscopy. A temperature probe inserted into the subacromial space was used to record temperatures at 10-second intervals for 60seconds during continuous radiofrequency application. RESULTS: Mean baseline temperature was 21.4±0.7°C with VAPR® and 23.0±2.2°C with Coblation®. No significant between-group differences were found during the first 40seconds. The mean peak temperature reached after 60seconds was 25.0±1.9°C with VAPR® and 27.9±2.8°C with Coblation® (P<0.05). DISCUSSION: Few studies have compared the in vivo temperatures produced during arthroscopy by different electrode systems. In vivo studies have established that temperature increases can cause tissue damage, particularly to chondrocytes, and that the irrigation flow rate plays a key role in lowering the in vivo temperatures. Our study showed a significant difference between the two electrode systems after 50seconds of use, with lower temperatures with the VAPR®. Nevertheless, neither system increased the irrigation-fluid temperatures above the tissue-damage threshold. Both systems can be used safely, provided the manufacturer instructions are followed and the irrigation system is effective. LEVEL OF EVIDENCE: II (prospective randomized trial).

Could the orthopaedic surgeon deployed in austere setting perform flaps on the leg?

The orthopaedic military surgeons deployed in operations are led to perform soft tissue coverage on the lower limb. The purpose of this study was to evaluate if flaps performed by surgeons' non-specialist in reconstructive surgery are associated with good outcome. All patients operated for a flap on the leg in French Forward Surgical Team deployed in theatre of operations between 2003 and 2013 were retrospectively reviewed. Forty-nine patients were included, for a total of 54 flaps' procedures. Indications were open fractures in 25 cases and osseous infections in 29 cases. No flap was performed on French soldiers. All the flaps were pedicle. Outcome was favourable for more than 90% of flaps with no statistical difference between muscular and fasciocutaneous flap and with regard to the indication. In conclusion, an orthopaedic surgeon deployed in austere setting with significant good outcome can perform reconstructive surgery with legs' flaps.

Limb reconstructive surgery in austere settings: use of flaps in French forward surgical facilities.

INTRODUCTION: Military surgeons deployed abroad must achieve soft tissue coverage under austere conditions. HYPOTHESIS: A non-specialized surgeon can achieve soft tissue coverage with good results. MATERIAL AND METHOD: This is a retrospective study of all patients who underwent soft tissue coverage in French forward surgical units between 2003 and 2013. RESULTS: In all, 81 flaps were constructed. Open fractures (39%) were the leading indication, followed by osseous infections (35%). Most flaps were for legs (70%) and hands (25%). Only pedicle flaps were used. The success rate was 91%. DISCUSSION: Flaps can be constructed by orthopedic surgeons who are not specialized in reconstructive surgery, in austere settings and with good results. This procedure must be part of a global strategy of limb reconstruction, especially in cases of bone and joint infection. Pedicle flaps, especially muscular, appear more reliable and are to be preferred. The training of the surgeons deployed abroad must include flap surgery.

Patellar lateral closing-wedge osteotomy in habitual patellar dislocation with severe dysplasia.

The "à la carte" surgical strategy for treating patellar instability developed in Lyon, France, is well known. The corrective procedures are planned based on a preoperative analysis of the morphological abnormalities. Among factors responsible for patellofemoral incongruity, patellar dysplasia is among the most challenging to correct. We report a case of habitual patellar dislocation with severe patellar dysplasia that required a complex surgical strategy including patellar lateral closing-wedge osteotomy to improve patellofemoral congruity. This treatment was effective in ensuring stability and function. This complementary technical procedure can be useful in some patients with major patellofemoral instability.

When the tendon autograft is dropped accidently on the floor: A study about bacterial contamination and antiseptic efficacy.

BACKGROUND: Inadvertent contamination of the autograft can occur during anterior cruciate ligament (ACL) reconstruction if the autograft is dropped on the floor during surgery. A study was undertaken to determine the incidence of contamination when a graft is dropped on the operating room floor and the efficacy of antimicrobial solutions to decontaminate it. METHODS: Samples from 25 patients undergoing ACL reconstruction with a hamstring tendon were sectioned and dropped onto the floor. Cultures were taken after immersion in antiseptic solutions (a chlorhexidine gluconate solution (group 1), a povidone-iodine solution (group 2), and a sodium hypochlorite solution (group 3)). A fourth piece (group 0) was cultured without being exposed to any solution. Cultures of a floor swab were taken at the same time. RESULTS: The floor swab cultures were positive in 96% of cases. The rate of contamination was 40% in group 0, 8% in group 1, 4% in group 2, and 16% in group 3. There was a significant difference between groups 1 and 2 and group 0 (p<0.05) but not between groups 3 and 0. CONCLUSIONS: Immersing a graft dropped on the floor during surgery in a chlorhexidine gluconate solution or povidone-iodine solution significantly reduces contamination of the graft. Soaking of the hamstring autograft in one of these solutions is recommended in the case of inadvertent contamination. CLINICAL RELEVANCE: Laboratory investigation (level 2).

[Medical and economic impact of a haemostatic sealant on the rate of transfusion after total knee arthroplasty]. / Impact médicoéconomique d'une colle hemostatique sur le taux de transfusion après prothèse totale de genou.

OBJECTIVES: Blood loss reduction in total knee arthroplasty (TKA) contributes to the prevention of morbidity and mortality and in the management of health care costs. Fibrin haemostatic sealant have controversial effectiveness in reducing postoperative blood loss and transfusion requirements. Our study evaluated the medical and economic benefits of this treatment with the assumption that it decreases the frequency of blood transfusion after TKA. METHODS AND PATIENTS: Our single-center and randomized study included 60 patients pose unilateral primary TKA for osteoarthritis. Distribution was done in 2 groups of 30 patients each. Group 1 patients treated with a dose of 5 mL Evicel®, compared to untreated group 2. Were collected the number of patients transfused. The treatment cost was compared to the sealant cost. RESULTS: Results are not statistically significant. Two patients were transfused in group 1 and 3 in group 2 (P=0.64). The treatment cost for 30 patients is 13,500 €, for a savings of cells packed at 187 €, an additional cost of 13,313 € in group 1. CONCLUSION: The use of fibrin haemostatic sealant in TKA did not induce a significant difference in terms of blood or transfusion savings, with a significant cost. We do not recommend its routine use in TKA.

Outcomes of talar dome osteochondral defect repair using osteocartilaginous autografts: 37 cases of Mosaicplasty®.

BACKGROUND: The indications of osteochondral autograft implantation using the Mosaicplasty(®) technique were only recently extended to osteochondral lesions of the talus (OLT), a site for which no medium- or long-term outcome data are available. Our objective here was to evaluate medium-term outcomes in case-series of patients who underwent Mosaicplasty(®) for OLT repair. HYPOTHESIS: Mosaicplasty(®) provides good medium-term outcomes with low morbidity when used for OLT repair. PATIENTS ET METHODS: We retrospectively reviewed cases of Mosaicplasty(®) for OLT repair, performed in combination with malleolar osteotomy on the side of the OLT, at either of two centres, between 1997 and 2013. Pre-operative clinical data were collected from the medical records and all patients were re-evaluated. We studied 37 patients with a mean age of 33 years. RESULTS: Mean follow-up at re-evaluation was 76 months. Mean AOFAS score at re-evaluation was 83 (range, 9-100). A work-related cause to the OLT was associated with significantly poorer outcomes (P=0.01). AOFAS values were significantly better in patients whose OLT size was 0.5 to 1cm(2). The Ogilvie-Harris score at last follow-up was good or excellent in 78% of patients. No patient experienced morbidity related to the malleolar osteotomy. Persistent patellar syndrome was noted in 6 patients. DISCUSSION: In our case-series, Mosaicplasty(®) for OLT repair provided good medium-term outcomes in 78% of patients. Nevertheless, the donor-site morbidity should be borne in mind. Mosaicplasty(®) deserves to be viewed as a reference standard method for OLT repair. LEVEL OF EVIDENCE: IV, retrospective study.

French surgical experience in the role 3 medical treatment facility of KaIA (Kabul International Airport, Afghanistan): the place of the orthopedic surgery.

INTRODUCTION: In 2009, the French took command of the Medical Hospital (MH) or Role 3 Hospital at KaIA (Kabul International Airport) within the framework of its role in the military mission Operation Pamir in Afghanistan. The goal of this study was to analyze the volume of orthopedic surgical activity for the last four years, to identify its specificities and to improve training of military orthopedic surgeons. HYPOTHESIS: Orthopedic surgery is the most important activity in the field and surgeons must adapt to situations and injuries that are different from those encountered in France. PATIENTS AND METHODS: All patients operated on between July 2009 and June 2013 were prospectively included in an electronic database. The analysis included the number of surgical acts and patients, the types of injuries and the surgical procedures. RESULTS: Forty-three percent (n=1875) of 4318 procedures involved orthopedic surgery. Half of these were emergencies. French military personnel represented 17% of the patients, local civilians 47% and children 17%. Half of the procedures involved the soft tissues, 20% were for bone fixation and 10% for surgery of the hand. The rate of amputation was 6%. The diversity of the surgical acts was high ranging from emergency surgery to surgical reconstruction. DISCUSSION: The activity of this Role 3 facility is comparable to that of other Role 3 facilities in Afghanistan, with an important percentage of acts involving medical assistance to the local population and scheduled surgeries as well as primary and/or secondary management of the wounded. The diversity of surgical acts confirms the challenge of training military orthopedic surgeons within the context of the hyperspecialization of the civilian sector. Specific training has been organized in France by the École du Val de Grâce. Specific continuing education is also necessary. LEVEL OF EVIDENCE: IV (retrospective review).

Interest of an intraoperative limb-length and offset measurement device in total hip arthroplasty.

INTRODUCTION: Total hip arthroplasty (THA) seeks to restore a stable, mobile and pain-free joint. This requires good implant positioning and peroperative restoration of limb-length and femoral offset. HYPOTHESIS: A mechanical measurement device (length and offset optimization device [LOOD]) fixed to the pelvis can optimize lower-limb length and offset control during THA performed on a posterolateral approach. PATIENTS AND METHODS: Two prospective THA series were compared: 32 using the LOOD and 26 without. Patients with more than 5mm preoperative limb-length discrepancy were excluded. The intraoperative target was to restore individual anatomy. Radiographic analysis was based on pre- and postoperative AP pelvic weight-bearing views in upright posture, feet aligned, with comparison to peroperative LOOD data. RESULTS: Mean deviation from target length (i.e., pre- to postoperative length differential) was 2.31 mm (range, 0.04-10.6mm) in patients operated on using the LOOD versus 6.96 mm (0.01-178 mm) without LOOD (P=0.0013). Mean deviation from target offset was 3.96 (0.45-13.50) mm with LOOD versus 10.16 (0.93-28.81) without (P=0.0199). There was no significant difference between operative and radiographic measurements of length deviation using LOOD (P=0.4); those for offset, however, differed significantly (P=0.02). DISCUSSION: The LOOD guides control of limb-length and offset during THA on a posterolateral approach. Reliability seems to be better for limb-length than for offset. It is a simple and undemanding means of controlling limb-length and offset during THA. LEVEL OF EVIDENCE: III, prospective case-control study.

Mosaic osteochondral transplantations in the knee joint, midterm results of the SFA multicenter study.

INTRODUCTION: There are several possible options to treat focal articular cartilage defects of the knee. The aim of this study was to evaluate the results and prognostic factors cartilage defects of the knee treated by autologous osteochondral mosaicplasty after more than five years of follow-up. PATIENTS AND METHODS: One hundred forty-two cases were included in this retrospective multicenter study. Etiologies included osteochondral fractures (n=79), and osteochondritis dissecans (n=61). Mean age of patients was 31. There was a majority of men (76%). Mean BMI was 25 (range: 21-41). Fifty-three percent of the knees had a history of surgery. Mean delay between the accident and surgery was 2.5 years. Mean area of the defect was 2.29 cm(2) (range: 0.3-12.25 cm(2)). The depth of the defect was 3 or 4 on the ICRS score in 97% of cases. An additional surgical procedure was associated with mosaicplasty in 14% of the cases. The follow-up evaluation was based on the Hughston score, the ICRS score, the IKDC subjective score, and the IKDC radiological score. Evaluation of control MRI was based on a modified MOCART score. RESULTS: The mean follow-up was 96 ± 28 months. There were complications in 19 patients. Patients were able to begin athletic activities again after a mean 35 weeks. Most patients (81.8%) were satisfied or very satisfied. There was a significant improvement (p<0.001) in the ICRS, IKDC function and Hughston scores at follow-up. The factors for a good prognosis were: male gender, medial femoral condyle defects, osteochondritis dissecans, deep, small defects, and the shortest possible delay to surgery. Obesity, smoking, work-related accidents, the level of sports practiced, the percentage of coverage of the defect, the number of plugs, and associated lesions did not have a statistically significant effect on the functional results in the final follow-up. DISCUSSION: Autologous osteochondral mosaicplasty seems to be a reliable technique in the short and intermediate term. It has the advantage of being less expensive than reconstructive techniques, is a one-step surgical procedure and results in immediate restoration of cartilage surface. Nevertheless, this is a difficult technique, which may result in complications and requires articular harvesting. This technique is limited by the size of the defect to be treated. The primary indication is deep, small defects on the medial femoral condyle.

Treatment of knee cartilage defect in 2010.

Treatment of knee cartilage defect, a true challenge, should not only reconstruct hyaline cartilage on a long-term basis, but also be able to prevent osteoarthritis. Osteochondral knee lesions occur in either traumatic lesions or in osteochondritis dissecans (OCD). These lesions can involve all the articular surfaces of the knee in its three compartments. In principle, this review article covers symptomatic ICRS grade C or D lesions, depth III and IV, excluding management of superficial lesions, asymptomatic lesions that are often discovered unexpectedly, and kissing lesions, which arise prior to or during osteoarthritis. For clarity sake, the international classifications used are reviewed, for both functional assessment (ICRS and functional IKDC for osteochondral fractures, Hughston for osteochondritis) and morphological lesion evaluations (the ICRS macroscopic evaluation for fractures, the Bedouelle or SOFCOT for osteochondritis, and MOCART for MRI). The therapeutic armamentarium to treat these lesions is vast, but accessibility varies greatly depending on the country and the legislation in effect. Many comparative studies have been conducted, but they are rarely of high scientific quality; the center effect is nearly constant because patients are often referred to certain centers for an expert opinion. The indications defined herein use algorithms that take into account the size of the cartilage defect and the patient's functional needs for cases of fracture and the vitality, stability, and size of the fragment for cases of osteochondritis dissecans. Fractures measuring less than 2 cm(2) are treated with either microfracturing or mosaic osteochondral grafting, between 2 and 4 cm(2) with microfractures covered with a membrane or a culture of second- or third-generation chondrocytes, and beyond this size, giant lesions are subject to an exceptional allografting procedure, harvesting from the posterior condyle, or chondrocyte culture on a 3D matrix to restore volume. Cases of stable osteochondritis dissecans with closed articular cartilage can be simply monitored or treated with perforation in cases of questionable vitality. Cases of open joint cartilage are treated with a PLUS fixation if their vitality is preserved; if not, they are treated comparably to osteochondral fractures, with the type of filling depending on the defect size.

Knee osteochondral fractures in skeletally immature patients: French multicenter study.

INTRODUCTION: Femoral or patellar osteochondral fractures complicating patellar dislocation are more frequently observed in adolescents than in adults. These incidental lesions of vulnerable joint cartilage are often neglected in the initial phase, which is regrettable given their good capacity for healing after repositioning. The objective of this study was to investigate the characteristics and analyze the results of repositioning these fractures in skeletally immature patients. MATERIAL AND METHODS: This retrospective multicenter study grouped 14 patients and knees (seven females). The mean age at the time of the accident was 12.9 years (range, 11.2-14.9 years) for the girls and 14 years (range, 12.2-15 years) for the boys. These fractures involved the lateral condyle in nine cases and the patella in five cases. The injury mechanism was secondary to demonstrated patellar dislocation (n=9) or a direct impact (n=4). In nine cases out of 14, a leisure sports accident was the cause. The injury was treated a mean 5.2 days (range, 0-20 days) after the accident. All of the detached fragments were repositioned surgically with screw fixation (n=5), resorbable pins (n=5), or pull-out suture (n=4). Biological glue was added for six patients. Patellar stabilization was associated during the same procedure in two cases. RESULTS: No postoperative complications were observed. The results at the mean follow-up of 30 months (range, 15-89 months) showed no revision for failure, with all of the fractures demonstrating union at the final examination. The mean IKDC 2000 subjective score was 88±6 (range, 79-98) out of 100 points. The subjective satisfaction level was very satisfied in two cases and satisfied in the 12 others. The final IKDC score was A for eight patients, B for five patients, and C for one patient. Three patients underwent secondary patellar stabilization surgery. CONCLUSION: Better knowledge of this fracture and attentive reading of the radiographic images of a knee with hemarthrosis should result in more frequent diagnosis of this condition and adapted treatment. Unexplained hemarthrosis in a context of trochlear dysplasia should be considered to be associated with an OCF until proof of the contrary. A fragment released in a weightbearing zone should ideally be repositioned within 10 days but remains possible at 2 months. It regularly provides bone union and good results in children.

Vascular lesions associated with bicruciate and knee dislocation ligamentous injury.

INTRODUCTION: The incidence of associated vascular lesions in biligamentous cruciate injuries of the knee ranges from 16 to 64%, with a mean rate of 30%. Treatment of ischemic vascular lesions associated with ligaments injury is well established, comprising emergency arterial vascular repair, most of the times combined to external fixation. In the absence of clinical symptoms of vascular lesion, some authors recommend systematically performing arteriography, while others advocate selectively prescribing this examination in doubtful clinical situations. The present study analyzed data extracted from the prospective series of the 2008 SOFCOT Symposium (dedicated to management of bicruciate knee lesions) and from an analysis of the literature, with emphasis on developing a diagnostic strategy for vascular lesions associated with bicruciate lesions. MATERIAL AND METHODS: This multicenter prospective study included all patients treated in the reference centers for dislocation or bicruciate lesion of the knee between January 2007 and January 2008. All patients underwent early objective vascular imaging. RESULTS: Sixty-seven patients were included. Mean dislocation reduction time was 2 hrs 45 min (max, 21 hrs). There were nine vascular lesions (12%). Absence of vascular lesion could be confirmed in 58 of the 59 patients exhibiting presence of peripheral pulses at initial examination. In one case, a vascular lesion was found on early imaging, but with no clinical consequence. In all eight cases with associated clinical pulse abnormality, complementary vascular check-up confirmed the presence of a vascular lesion. Angioscan induced no error of vascular assessment in this series, with no false positives or false negatives. One patient underwent amputation for critical ischemia. Three patients had vascular surgical treatment, two not undergoing secondary ligament surgery. Four of the five patients whose vascular lesion was conservatively managed by simple observation were able to undergo the scheduled treatment for their ligament lesions. DISCUSSION: At initial examination, it is essential to look for the peripheral pulse. In case of ischemic syndrome, the priority is a revascularization procedure associated to intraoperative arteriography. In case of abnormal pulse without obvious ischemia, emergency imaging (usually arteriogram or angioscan) is essential. Where there is no initial clinical vascular abnormality, good practice is less clearly cut. Initially, present pulses are found in a mean 30% (17-55%) of cases of popliteal artery lesion, according to the series. Different authors draw diverging conclusions from this fact. For some, the absence of frank abnormality on clinical examination is sufficient to exclude not any possible anatomic vascular lesion but any vascular lesion requiring surgery. However, even without pulse abnormality, we consider systematic imaging to be justified, partly by the difficulty of ensuring strict monitoring, and partly by the decompensation risk of clinically asymptomatic intimal lesions during the ligament surgery under consideration in most cases. Although many authors cling to the dogma of late emergency arteriography, recent reports argue against this attitude. Angio-MRI has good diagnostic value, but in practice is difficult to obtain in emergency. We would rather advocate angioscanning, which is easily available in emergency and does not incur the risk of local complication associated with arteriography.

Bicruciate ligament lesions and dislocation of the knee: mechanisms and classification.

Knowledge of the mechanisms of bicruciate lesions and dislocation of the knee enables analysis and classification in terms of injuries' location and type, guiding surgery and facilitating assessment. Careful history taking and clinical examination shed light on the mechanism involved, but exact identification of the lesion further requires examination under anesthesia and static and dynamic X-rays and MRI, which together enable precise determination of lesion type and location. There are two types of mechanism: gaping, causing ligament tear; and translation, causing detachment. When a single mechanism is involved, the lesion is said to be "simple". Simple gaping causes bicruciate lesions without medial, lateral or posterior dislocation. Simple translation causes pure anterior or posterior dislocation. Gaping and translation may also occur in combination, causing dislocation with peripheral tearing. There are two types of classification: descriptive, based on X-ray findings--i.e., static classification; and physiopathological, based on clinical and dynamic X-ray findings. MRI further explores ligament detachment and bone lesions that are inaccessible to clinical and conventional X-ray examination. Physiopathological assessment-based techniques enable surgical procedure to be refined, defining the surgical approach according to lesion location and differentiating between lesions requiring repair (tears) and those with a good likelihood of spontaneous healing (capsuloperiosteal detachment). The classification advocated here is largely inspired by that of Neyret and Rongieras, extended to include dislocation with single bicruciate ligament lesion. It covers peripheral lesions completely, specifying type (tear or detachment) and including all bicruciate lesions as well as dislocations.

Osteoid osteoma distal to a hip arthroplasty.

The authors report a case of osteoid osteoma distal to a hip prosthesis in a 56-year-old patient. This rare association was difficult to diagnose; at first, the pain seemed to be of mechanical origin, suggesting a delayed painful reaction to the prosthesis. The results of bone scan as well as the CT scan ones helped orient the diagnosis. Excision biopsy, using bone trephining, completed by an iliac bone auto-graft resulted in a cure with no residual instability of the prosthesis above the tumor. Bone scan with radio-isotopes to localize the lesion was particularly helpful in this instance to secure the final diagnosis.

Iliac bone-block autograft for posterior shoulder instability.

INTRODUCTION: Posterior shoulder instability is a rare condition, representing only 4% of all shoulder-joint instabilities. Numerous surgical techniques are used to treat it when conservative functional treatment proves to be insufficient. This retrospective study relates to 8 patients, presenting recurrent posterior shoulder instability, all treated with a posterior iliac bone-block procedure. The results were assessed both clinically and with contemporary imaging techniques. MATERIALS AND METHODS: A unique identical surgical technique was used in all these cases including a posterior deltoid head detachment, an infraspinatus muscle dissociation and a bone-block positioning intended to extend and enlarge the glenoid cavity rather than to act as an actual block. Seven of these 8 cases were posttraumatic (including 2 with a concomitant congenital hyperlaxity past history) and the non-traumatic 1 was secondary to an epileptic seizure episode. All the patients had a typical posterior shoulder instability clinical presentation in the form of recurrent true dislocation incidents. In 6 cases, imaging revealed lesions of the humeral head or the glenoid cavity. These lesions were displacement-related anterior impaction defects of the humeral head (McLaughlin lesion) and/or a fracture (or erosion) of the posterior glenoid rim. Mean postoperative follow-up was 34 months. RESULTS: No cases of postoperative suprascapular nerve deficit were observed. All patients recovered normal joint range of motion in abduction and anterior elevation; in 3 patients, however, external rotation ended up being limited by an average 20 compared to the opposite side. The mean Constant score was 96.25 points and the mean Duplay score 90. Only 4 patients were able to return to their preoperative sports activity level. Three required an additional procedure, 2 for hardware removal and 1 for posterior deltoid repair, which all lead to an uneventful evolution. Imaging at follow-up (X-ray or CT) did not show any instance of bone-block pseudoarthrosis or osteolysis nor did it exhibit glenohumeral early degenerative changes. In all, at a mean 3 years' follow-up, the present series showed satisfactory results in 80% of cases. A literature review found comparable results for bone-block stabilization procedures. No recurrences of instability are reported with this technique, the main difficulty of which residing in the correct positioning of the bone-block. The stabilizing efficacy and low subsequent arthritic changes of the iliac posterior bone-block graft procedure seem thus confirmed by these encouraging results. DISCUSSION AND CONCLUSION: The iliac posterior shoulder bone-block is effective in managing instances of involuntary posterior shoulder instability. A review of the literature confirmed these satisfactory results in terms of non-recurrence, pain relief and function recovery with this technique; the main difficulties of this technique remains in the correct positioning of the bone-block and the proper orientation of the fixation screws.

Knee MR-arthrography in assessment of meniscal and chondral lesions.

INTRODUCTION: No study, so far in France, has investigated the diagnosis value of knee MR-arthrography since the recent approval of intra-articular gadolinium use, by this country's healthcare authorities. This study objective is to verify the MR-arthrography superiority on conventional knee MRI, in meniscus and cartilage knee lesions diagnosing accuracy both in regard to sensitivity and specificity. HYPOTHESIS: MR-arthrography, represents in some pathologic situations, a more accurate source of information than conventional MRI. MATERIALS AND METHODS: Over a 27 months period, 25 patients, scheduled to undergo a knee arthroscopy volunteered, after having been fully informed of the possible interest and risk of the MR-arthrography examination, to participate in this study. Twenty-one of them were finally included since in four cases the surgical indication was not confirmed. The group consisted of 15 males and six females with an average age of 35.7 years. All of them consecutively underwent conventional MRI, MR-arthrography finally followed by arthroscopy. The MRI and MR-arthrograms results were compared to the arthroscopy findings using the nonparametric Kappa test. RESULTS: To diagnose meniscal tears, statistical agreement measure for MRI with arthroscopy was good (K=0.69) but not as good as the MR-arthrography/arthroscopy agreement which, by itself was excellent (K=0.84). As a diagnosis tool, the sensitivity and specificity of MR-arthrography (respectively 100 and 89.6%) were much higher than the corresponding values observed in conventional MRI (92.3 and 82.8%, respectively) which nonetheless remain satisfactory. The meniscal tears characterization seemed to be better interpreted using MR-arthrography. As far as the chondral lesions in this series, they were predominantly located on the patellar surface and in the medial femorotibial compartment. For diagnosing the latter, the MRI/arthroscopy agreement was good (K=0.70) but not as good as the MR-arthrography/arthroscopy agreement (K=0.805) which can be rated excellent. The detection sensitivity thus increased by 10% with gadolinium intra-articular injection. However, assessment accuracy of the lesions depth was mediocre, with frequent errors for the intermediary stages. DISCUSSION: Intra-articular gadolinium injection improved MRI performances for numerous reasons: filling the joint, reinforcing the synovial fluid signal, and enhancing anatomic structures contrast on the T1-weighted sequences images. In this study, MR-arthrography appeared to be superior to conventional MRI in meniscal and cartilaginous lesions diagnosis, confirming the results previously obtained in other countries. In light of these results and other data from the literature, MR-arthrography can be indicated as an alternative to CT-arthrography in various clinical situations: detection of recurrent tears on operated menisci, search for cartilaginous lesions or foreign bodies in the joint space, and preoperative assessment before chondral repair procedures. However, conventional MRI remains the reference examination for studying cartilage, because the low resolution of MR-arthrography limits its performances in quantitative assessment of lesions depth.

[First treatment of distal loss of tissue on lower limbs. About 15 cases]. / Stratégie thérapeutique initiale dans les pertes de substance distales du membre inférieur d'origine traumatique. A propos de 15 cas.

Distal extremity of lower limb sustains the complications of loss of tissue: problem of coverage (cutaneous and tendon necrosis, osteoarticular infection. The whole point of the surgery is to fight against the infection by repeated debridments, against the deformations or their correction by early osteosynthesis (pins and external fixation). The coverage is very important in this treatment: either with Vacuum-Assisted Closure (VAC) and skin graft or fasciocutaneous flap. In spite of this management, the after-effects are important although the conservative treatment is the determining factor of satisfaction.