Initial disc structural preservation in type A1 and A3 thoracolumbar fractures.

PURPOSE: Despite a sizable amount of literature, the optimal management of thoracolumbar fractures remains controversial and many authors assume the existence of disc lesions in Magerl type A fractures. The purpose of the study was to assess the intervertebral discs in these fractures at the time of trauma. The hypothesis was that there was no change in shape and signal intensity of the discs initially. METHODS: Fifty-one patients diagnosed with 87 types A1 and A3 thoracolumbar fractures were enrolled in a prospective study. MRI analysis involved evaluation of disc signal, height and morphological modifications according to Oner's classification. RESULTS: No signal intensity modification was identified on MRI. Disc morphology was either normal or altered with creeping of discal tissue in the vertebral endplate depression. Overall, 98% of the discs were either type 1 or type 3. Mean disc height on MRI was 1.03 ± 0.36 initially. CONCLUSIONS: In this study, MRI showed that no loss of height occurred in discs adjacent to fractured vertebra and that there was no major alteration of the disc in terms of signal intensity and morphology. Therefore, the intervertebral disc should not be removed in Magerl type A fractures. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Ceramic-on-ceramic total hip arthroplasty: is squeaking related to an inaccurate three-dimensional hip anatomy reconstruction?

Many factors were incriminated in the squeaking generation in ceramic-on-ceramic total hip arthroplasty (THA), including the cup positioning and design. However, the influence of the stem orientation has not been investigated and the true three-dimensional hip anatomy has never been compared to the contralateral healthy hip. Three patients, who underwent unilateral ceramic-on-ceramic THA, complained of squeaking. CT-scans were performed to compare the true three-dimensional hip anatomy to the contralateral healthy hip. All patients presented evidence of posterior neck-rim impingement with a two-fold increase in the global anteversion (above 75°) comparatively to the healthy hip. The excess of anteversion was on the cup side in 2 cases and on the stem side in 1 case. We conclude that squeaking in ceramic-on-ceramic THA could be related to a poor accuracy of 3D hip anatomy reconstruction which generated a posterior impingement and subsequent anterior edge loading because of excessive global anteversion.

Treatment of chronic Achilles tendon rupture by shortening suture and free sural triceps aponeurosis graft.

INTRODUCTION: The Bosworth technique is old but still widely used. It involves problems of precisely determining the length of the Achilles tendon and of a volume effect in the turndown area. HYPOTHESIS: A new reconstruction technique is assessed, based on free sural triceps aponeurosis transfer without turndown, associated to tendon shortening suture. MATERIALS AND METHODS: Twenty-three patients were assessed by AOFAS score and clinical examination (plus MRI in 14 cases) at a mean 24.5 months' follow-up. Mean age was 52.1 years. Mean pre-operative AOFAS score was 63.6/100. RESULTS: Mean postoperative AOFAS score was 96.1. Mean graft length was 7.5 cm. Surgical revision was required for one case of postoperative infection. Twelve patients resumed leisure sports at their previous level by a mean 9.4 ± 2 months; three competitive sportsmen resumed sport at their previous level by a mean 7.6 months. None were dissatisfied or disappointed with their operation. MRI performed at 1 year found increased tendon volume without abnormality in 57% of cases; 43% showed abnormal images. DISCUSSION: Functional results were comparable to literature reports. It can be difficult to determine Achilles length for the Bosworth technique: this is made easier by conserving a fibrous support of a length determined with reference to the healthy side. The technique avoids aponeurosis turndown, and thus avoids the problem of plasty volume effect. The two cases of cutaneous complication occurred in the two most elderly patients, raising the question of the indications for reconstructive surgery in the elderly. The abnormalities found on MRI concerned scar tissue remodeling in patients with good or excellent clinical results. LEVEL OF EVIDENCE: Level IV, retrospective study.

Anterior cruciate ligament reconstruction with fascia lata using a minimally invasive arthroscopic harvesting technique.

Anterior cruciate ligament (ACL) reconstruction using the fascia lata has undergone a number of technical modifications since the work of Hey-Groves, MacIntosh, and Jaeger. Arthroscopy has simplified this technique, notably in the positioning of the tunnels. Minimally invasive harvesting through two lateral proximal and distal approaches considerably reduces cosmetic problems. The femoral tunnel is made from the outside to the inside using a specific targeting device, and the transplant harvest site is closed using the Jaeger procedure so as not to weaken lateral knee stabilizing structures. This procedure consists in opening the lateral intermuscular septum 1cm from the femur to let it shift laterally and allow the transplant harvesting area to be closed. This technique uses a fascia lata transplant, the harvesting of which has shown few iatrogenous complications but requires rigorous adherence to certain rules.

Accuracy of the preoperative planning for cementless total hip arthroplasty. A randomised comparison between three-dimensional computerised planning and conventional templating.

INTRODUCTION: A high accuracy was recently reported for the three-dimensional (3D) computerised planning of total hip arthroplasty (THA), comparing well with navigation regarding leg length and femoral offset. However, there is no randomised study comparing 3D preoperative planning with conventional 2D templating in terms of accuracy and clinical relevance. HYPOTHESIS: The 3D preoperative planning has a higher accuracy than the conventional 2D preoperative templating regarding the implants size and their positioning. PATIENTS AND METHODS: A prospective comparative randomised study was carried out from 2008 to 2009, including two groups of 30 patients who underwent THA for primary osteoarthritis. One surgeon performed all the surgical procedures using a minimally invasive direct anterior approach. In one group, the planning was made on calibrated X-rays using 2D templates. In the other group, a CT-scan based 3D computerised planning was performed with dedicated software. The reconstructed hip final anatomy was compared postoperatively to the preoperative planning and the accuracy was expressed as the mean difference (±SD) between the planned positioning and the final positioning of the implants. RESULTS: The prediction rate for the stem and the cup sizes were respectively of 100% and 96% in the 3D group versus 43% for both components in the 2D group. When combining both components, the prediction rate was 96% in the 3D group versus 16% in the 2D group. In the 3D group, a high accuracy was achieved for the planning of the leg length (-1.8±3.6 mm ranging from -8 to+4mm) and the femoral offset (-0.07±2.7 mm ranging from -5 to+4mm) versus 1.37±6.4mm ranging from -9 to 13 mm and 0.33±5.7 mm (-16 to 11 mm) in the 2D templating group (P<0.0001). DISCUSSION: The 3D planning gives a higher accuracy than conventional 2D templating in forecasting the size of cup and the stem. This contributes to the prediction for leg length and offset that is more reliable with the 3D technique. This study suggests that 3D planning CT-scan data is an attractive alternative to navigation to restore these parameters. The high accuracy achieved by a low-experience surgeon suggests that 3D planning may help shorten the learning curve when using the minimally invasive direct anterior approach. LEVEL OF EVIDENCE: Level III low-powered prospective randomized trial.

Distal partial ruptures of triceps brachii tendon in an athlete.

Distal brachii triceps tendon rupture is rare. Partial lesions are not so well defined. If functionally they are well tolerated in patients with low functional demand, management guideline is not so clear for sportsmen. To our best knowledge, there is no reported technique for the repair of partial forms. A 28-year-old patient was operated on for a partial triceps rupture. He underwent a transosseous olecranon suture of the tricipital tendon, with a side-to-side suture to the healthy residual tendon. The patient was assessed at 2 years follow-up with the DASH score. He had painless and mobile elbow with no effusion and returned to sport 4 months after his surgical repair. The extension strength was comparable to the healthy side (5/5). The DASH score was 1,7 for global score, and 6,3 for work and sport modules. Partial rupture of brachii triceps tendon is not well tolerated in high functional demand patients. We think that patients should be operated in these situations and may achieve excellent results. Postoperative management is crucial to achieve good results as well as in complete rupture.

Infected total hip arthroplasty revision: one- or two-stage procedure?

INTRODUCTION: Better outcomes have been reported for two-stage total hip arthroplasty (THA) revision for infection. However, one-stage revision arthroplasty remains an attractive alternative option since it requires only one operation. A decision tree has been developed by the authors in order to determine which type of surgical procedure can be performed safely. The goal of this study was to assess this decision tree for THA replacement in the case of a peri-prosthetic infection. HYPOTHESIS: A one-stage procedure may be as successful as a two-stage procedure provided some criteria are fulfilled. METHODS: A prospective study included 84 patients, all diagnosed with infected THA who had prosthesis replacement. A one-stage exchange was performed in 38 cases and a two-stage procedure in 46 cases. A two-stage procedure was decided in the case of important bone loss or unidentified germ. Postoperatively, patients received intravenous antibiotics (six weeks), then oral antibiotics (six weeks). The main evaluation criterion was the rate of infection eradication at 2 years minimal follow-up since surgery. If new infection was suspected, a hip aspiration was performed to determine whether it was non-eradication (same germ) or a new re-infection (other germ), which was not considered as a failure. RESULTS: The initial infection was cured in 83 out of 84 patients (98.8%), 38 (100%) for the one-stage group and 45 (97.8%) for the two-stage group. Three patients were re-infected with different germs in the two-stage group. Eighty out of 84 (95.2%) patients were infection free, all patients (100%) of the one-stage group and 42 patients (91.3%) of two-stage group. DISCUSSION: If some selection criteria were respected, a high success rate in THA replacement for infection may be achieved with a one-stage procedure. It permits to reduce the costs with no loss of chance for the patients. The decision tree was validated. LEVEL OF EVIDENCE: Level III; prospective case control study.

Posterior tibial slope changes after opening- and closing-wedge high tibial osteotomy: a comparative prospective multicenter study.

INTRODUCTION: Valgus high tibial osteotomy is considered to be an effective treatment for unicompartmental medial osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. However, the effects on posterior tibial slope of closing- or opening-wedge osteotomies remain controversial. HYPOTHESIS: We analyzed the modifications of tibial slope after opening- and closing-wedge high tibial osteotomies and compared the results of these two procedures. We hypothesized that there was no difference in postoperative tibial slope between opening and closing-wedge osteotomies. PATIENTS AND METHODS: This prospective consecutive nonrandomized multicenter study was conducted between January 2008 and March 2009 and included 321 patients: 205 men and 116 women. A total of 224 patients underwent an opening-wedge high tibial osteotomy and 97 a closing-wedge osteotomy. The mean age was 52 years ± 9 and the mean body mass index was 28kg/m(2) ± 5. The main etiology was primary arthritis. Posterior tibial slope was measured preoperatively and at the last follow-up on a lateral radiograph in relation to the posterior tibial cortex. RESULTS: In the opening-wedge group, a definite 0.6° increase in tibial slope (P=0.016) was observed. In the closing-wedge group, a definite 0.7° decrease in tibial slope (P=0.02) was found. Fourteen percent of the opening-wedge osteotomies increased tibial slope by 5° or more versus only 2% of the closed-wedge osteotomies (P<0.001). Twelve percent of the closing-wedge high tibial osteotomies led to a decrease of 5° or more of the tibial slope versus 7% of the opening-wedge osteotomies (P<0.02). DISCUSSION AND CONCLUSION: These results confirm what is generally reported in the literature, i.e., an increase in tibial slope in opening-wedge high tibial osteotomy and a decrease in the slope in closing-wedge osteotomies. These tibial slope changes appear to be very limited in this series, less than 1° on average. However, there was a bias since the open-wedge technique was preferred in cases with substantial varus deformity. We emphasize the importance of surgical technique to avoid alteration of the tibial slope, particularly in opening-wedge high tibial osteotomy for which we recommend a release of posterior soft tissue and a complete osteotomy of the posterior cortex of the tibia. LEVEL OF EVIDENCE: III. Prospective consecutive nonrandomized multicenter study.

Anterior shoulder instability arthroscopic treatment outcomes measures: the WOSI correlates with the Walch-Duplay score.

PURPOSE: New techniques and instrumentation for arthroscopic management of shoulder instability require accurate measurement tools to investigate possible clinical improvements. The aim of the study was to assess the self-administrated Western Ontario Shoulder Instability Index (WOSI), which is a subjective quality of life measurement tool specific to shoulder instability, and also to validate this score by comparison with the Walch-Duplay score, which is the gold standard score used in Europe. These two scores had never been compared. METHODS: Forty-eight patients, who underwent arthroscopic surgery for anterior shoulder instability, were evaluated using the WOSI and the Walch-Duplay score at 42.7 months' follow-up. The correlation between these two scores was investigated. RESULTS: The WOSI significantly correlated with the Walch-Duplay score (global score, and specific items of pain, stability, return to activity). The standard correlation coefficient was 0.8 and the Lin correlation coefficient was 0.65. The WOSI did not correlate with the mobility item of the Walch-Duplay score. DISCUSSION: The WOSI was found to correlate with the Walch-Duplay score. However, the WOSI was more sensitive than the Walch-Duplay score for the assessment of patient satisfaction. It is likely that both self-administrated questionnaires and physical examinations are complementary for an accurate investigation of the functional objective and subjective outcome after shoulder stabilization surgery. TYPE OF STUDY: Retrospective. Level IV.

Total hip arthroplasty dislocation rate following isolated cup revision using Hueter's direct anterior approach on a fracture table.

INTRODUCTION: Instability is a major complication after revision total hip arthroplasty. Studies in the literature have shown that the dislocation rate after primary arthroplasties by anterior approach on a fracture table is satisfactory, but the rate of instability following revision surgery is not known. HYPOTHESIS AND AIMS: We hypothesized that the Hueter direct anterior approach would result in a lower rate of postoperative dislocation following revision surgery. This hypothesis was tested in a series of isolated acetabular component replacements. PATIENTS AND METHODS: Seventy-three consecutive isolated acetabular component replacements were performed between January 2000 and December 2007. Twelve revisions using constrained liners or dual mobility cups were excluded, thus 61 revisions in 59 patients, mean age 65.8-year-old (range 27-86) were included. The indications for revision arthroplasty were: 51 (83.6%) cases of aseptic loosening, five (8.2%) non-integration of cementless cups, three (4.9%) cases of instability, one (1.6%) case of impingement with the psoas and one (1.6%) case of excessive (3cm) lengthening. Acetabular bone defects were moderate, with 12 stage I, 26 stage II, 19 stage III, and only four stage IV defects on the SOFCOT bone stock deficiency score. There was no acetabular reconstruction in 18 cases, while there were four isolated reconstruction cages and 39 cages with a graft. The replacement cup was cemented in 52 cases and cementless in nine. Inclination and anteversion were measured by the Pradhan method on standard X-rays. RESULTS: Results were evaluated after a mean follow-up of 2.4 years±1.7 years (1-7 years). Four dislocations were observed (6.6%) all anterior and early in the postoperative period (less than 2 months): three patients had a single episode of dislocation and one patient again underwent revision cup replacement by Hueter anterior approach for recurrent anterior dislocation. The only factor associated with a risk of dislocation was a high body mass index: 29.7±0.8 in the group with dislocation compared to 25.6±3.2 in the group without (P=0.008). A high number of prior interventions was also a significant risk factor (P=0.045). On the other hand, there was no difference in cup inclination or femoral offset between the group with dislocation and that without. DISCUSSION: Although the rate of dislocation is higher than after primary THA by anterior approach, it remains acceptable for revision THA and is similar to rates observed with other approaches. The literature does not clearly establish that one surgical approach is better than another in terms of instability. This study was limited by the absence of CT-scan measurements of component orientation both preoperatively to evaluate the femoral component which is preserved, as well as during follow-up to evaluate cup angle and compare the groups with and without dislocation. CONCLUSION: The Hueter direct anterior approach is a viable option for isolated cup revision, as long as femoral loosening has been excluded, and the orientation of the preserved femoral component is known. LEVEL OF EVIDENCE: Level IV; retrospective study.

Iliac crest bone graft harvesting complications: A case of liver herniation.

The iliac crest is an easily accessible donor site offering a relatively large and safe supply of bone. There are however possible complications; residual pain frequently, and more rarely herniation. This latter's true incidence is unknown in a literature review, which found 15 articles. We report a case of liver herniation in a 64-year-old overweight lady after harvesting bone from her iliac crest. The clinical diagnosis was confirmed by CT scan. Despite an appropriate surgical repair, the hernia recurred. This serious complication of bone harvesting from the iliac crest, and possible other undesirable events described, prompted reconsideration of our harvesting techniques, and the use in our unit of bone substitutes or cell therapy to fill bone defects.

Total hip arthroplasty revision due to infection: a cost analysis approach.

INTRODUCTION: The treatment of total hip arthroplasty (THA) infections is long and costly. However,the number of studies in the literature analysing the real cost of THA revision in relation to their etiology, including infection, is limited. The aim of this retrospective study was to determine the cost of revision of infected THA and to compare these costs to those of primary THA and revision of non-infected THA. MATERIALS AND METHODS: We performed a retrospective cost analysis for the year 2006 using an identical analytic accounting system in each hospital department (according to internal criteria) based on allotment of direct costs and receipts for each department. From January to December 2006, 424 primary THA, 57 non-infected THA revisions and 40 THA revisions due to infection were performed. The different cost areas of the patient's treatment were identified.This included preoperative medical work-up, medicosurgical management during hospital stay,a second stay in an orthopedic rehabilitation hospital (ORH) and post-hospitalisation antibiotic therapy after revision due to infection, as well as home-based hospitalisation (HH) costs, if this was the selected alternative option. We used the national health insurance fee schedule found in the "Common classification of medical procedures" and the "General nomenclature of professional procedures" applicable in France since September 1, 2005. Hospital costs included direct costs (hospital overhead costs) and indirect costs, (medical, surgical, technical settings and net general service expenses). The calculation of HH costs and ORH costs were based on the average daily charge of these departments. The cost of primary THA was used as the reference.We then compared our surgical costs with those found for the corresponding comparable hospital stay groups (Groupes homogènes de séjour). RESULTS: The average hospital stay (AHS) was 7.5 +/- 1.8 days for primary THA, 8.9 +/- 2.2 days for non-infected revisions and 30.6 +/- 14.9 days for revisions due to infection. The rate of transfer to a rehabilitation hospital (ORH) was 55% for primary THA, 77% in non infected revision cases and 65% in revisions due to infection. Moreover, 30% of these infected THA were prescribed HH. Non-infected THA revisions cost 1.4 times more than primary THA. THA revisions due to infection cost 3.6 times more than primary THA. DISCUSSION: The economic impact of THA infections is considerable. The extra costs are mainly due to an extended hospital stay and to longer rehabilitation consuming significant substantial human and material resources. CONCLUSION: The cost of treating infected THA is high. Treatment strategies should therefore be optimised to increase the success rate and minimise total costs. LEVEL OF EVIDENCE: Level IV. Economic and decision analyses, retrospective study

[Treatment of FAI via a minimally invasive ventral approach with arthroscopic assistance. Technique and midterm results]. / Behandlung des FAI durch einen minimal-invasiven ventralen Zugang mit arthroskopischer Unterstützung. Technik und mittelfristige Ergebnisse.

Femoroacetabular impingement (FAI) may be considered as an important cause of hip pain among young patients. A new surgical technique using a mini open anterior Hueter approach with arthroscopic assistance was developed in our department in 1999. The goal of our study was to evaluate the midterm clinical results and the quality of life after cam resection, rim trimming, and labrum refixation using this technique. The first 100 hips operated on using this technique were evaluated with the Nonarthritic Hip Score (NAHS) at a mean follow-up of 54 months. The mean age of the patients was 33.4 years, with 50 men and 47 women. At the last follow-up, the mean NAHS score increased significantly from 54.5+/-12 by 29.6 points to 84.3+/-16 (p<0.001). The clinical result was very good in 40 cases, good in 38 cases, fair in 8 cases, and poor in 14 patients. Eleven hips developed osteoarthrosis and finally had a total hip replacement. One patient had a femoral neck fracture at 3 weeks postoperatively. The best results were obtained in patients under 40 years of age (53 patients) and with a Tönnis osteoarthrosis grade of 0, 90% of whom had a very good or good result at a mean follow-up of 55 months. Refixation of the labrum was not significantly correlated with a higher NAHS (87+/-11 versus 82+/-19, p=0.13) at the last follow-up. Resection of cam FAI of the femoral head-neck junction using a mini anterior Hueter approach with arthroscopic assistance is a safe and effective technique in treating young adults with femoroacetabular impingement. This technique offers direct visualization of the anterior femoral head-neck junction and is less invasive than the surgical dislocation approach.

Accuracy of reconstruction of the hip using computerised three-dimensional pre-operative planning and a cementless modular neck.

Pre-operative computerised three-dimensional planning was carried out in 223 patients undergoing total hip replacement with a cementless acetabular component and a cementless modular-neck femoral stem. Components were chosen which best restored leg length and femoral offset. The post-operative restoration of the anatomy was assessed by CT and compared with the pre-operative plan. The component implanted was the same as that planned in 86% of the hips for the acetabular implant, 94% for the stem, and 93% for the neck-shaft angle. The rotational centre of the hip was restored with a mean accuracy of 0.73 mm (SD 3.5) craniocaudally and 1.2 mm (SD 2) laterally. Limb length was restored with a mean accuracy of 0.3 mm (SD 3.3) and femoral offset with a mean accuracy of 0.8 mm (SD 3.1). This method appears to offer high accuracy in hip reconstruction as the difficulties likely to be encountered when restoring the anatomy can be anticipated and solved pre-operatively by optimising the selection of implants. Modularity of the femoral neck helped to restore the femoral offset and limb length.

Fractures of the lateral process of the talus. Retrospective study of 44 cases.

PURPOSE OF THE STUDY: Fractures of the lateral process of the talus often go undiagnosed. The cohorts reported in the literature are small. The aim of the study was to analyze these fractures with a large group of patients. MATERIALS AND METHODS: Forty-four fractures in 43 patients were reviewed with a mean follow-up of 17 months. The diagnosis had been made immediately in 14 cases and secondarily in 30 cases with a delay of 46 months. Patients were evaluated with Kitaoka's score and X-rays using Hawkins classification. Fractures occurred during sports in 19 cases. The most frequent mechanism was association of dorsal flexion and pronation. There were associated lesions in 44% of cases. RESULTS: In the delayed diagnosis group, we found 14 cases of associated pseudarthrosis and subtalar osteoarthritis, two cases of isolated pseudarthrosis and two cases of isolated subtalar osteoarthritis. After treatment, the result at the last follow-up was excellent in 15 of these cases (50%), good in seven cases (23%), fair in seven cases (23%) and poor in one case (4%). In the immediate diagnosis group, five of 14 patients had at least one complication: 29% pseudarthrosis and 29% subtalar osteoarthritis. After treatment, the result at the last follow-up in this group was excellent in eight cases (58%), good in four cases (28%) and fair in two cases (14%). Immediate diagnosis was correlated with better results at the last follow-up. In the immediate diagnosis group, among patients who had orthopedic treatment, the rate of secondary surgery was 42%. CONCLUSION: Fracture of the lateral process of the talus is quite frequent and occurs among young people. Spontaneous progression is severe, with two major complications: pseudarthrosis and subtalar osteoarthritis. Treatment is always required in case of displaced fracture.

[Reproducibility of whole lower limb X-rays made in supine position after total knee replacement: comparison with reproducibility of whole lower limb X-rays of normal knees]. / Reproductibilité des gonométries en position couchée après implantation d'une prothèse totale de genou. Comparaison avec la reproductibilité des gonométries des genoux non prothésés.

PURPOSE OF THE STUDY: Outcomes after total knee replacement are correlated with the postoperative HKA angle. Therefore, it seems crucial to determine the precision of the whole lower limb X-rays which are currently used to determine the frontal knee alignment. The aim of the study was to analyze the precision of the whole lower limb X-Rays made in supine position, after total knee replacement. MATERIAL AND METHOD: A prospective study included 100 knees which were analyzed with two whole lower limb X-rays made at eight days interval. Seventy knees were non-replaced and 30 had total replacement with a posterior stabilized knee prosthesis. The X-rays were made in supine position and neutral rotation using the patella as a reference mark. One independent observer compared the HKA angle on the two consecutive X-Rays in order to evaluate the reproducibility of the X-Rays. RESULTS: In the group of patients with total knee replacement, the reproducibility was poor with a low correlation coefficient (0.5) and a poor precision of 5 degrees . On the contrary, in the non-replaced knee group, the reproducibility was very good with a high correlation factor between the two X-rays (0.99, p<0.0001) and a very good precision of 1.7 degrees (p<0.05). The group of patients with an HKA angle of less than 8 degrees had a significantly better precision (1.5 degrees ) than the group of patients with an angle HKA above 8 degrees (3 degrees , p<0.04). CONCLUSION: Reproducibility and precision of whole lower limb X-rays made in supine position is poor in patients with total knee replacement. Thus, we should be very careful for the analysis of the influence of the mechanical axis on the outcomes after total knee replacement.

[Fractures of the lateral process of the talus. Retrospective study of 44 cases]. / Fractures et séquelles de fractures de l'apophyse latérale du talus. Etude rétrospective à propos de 44 cas.

PURPOSE OF THE STUDY: Fractures of the lateral process of the talus are often not diagnosed. The cohorts of the literature are small. The aim of the study was to analyse these fractures with a large group of patients. MATERIAL AND METHOD: Forty-four fractures in 43 patients were reviewed with an average follow-up of 17 months. The diagnosis had been made immediately in 14 cases and secondarily in 30 cases with a delay of 46 months. Patients had been evaluated with Kitaoka's score and radiographies using Hawkins classification. Fractures occurred during sport practise in 19 cases. The most frequent mechanism was association of dorsal flexion and pronation. There were associated lesions in 44% of cases. RESULTS: In the group of delayed diagnosis, we found 14 cases of associated pseudarthrodesis and sub-talar osteoarthritis, two cases of isolated pseudarthrodesis, two cases of isolated sub-talar osteoarthritis. After treatment in this group, the result at the last follow up was very good in 15 cases (50%), good in seven cases (23%), average in seven cases (23%) and bad in one case (4%). In the group of immediate diagnosis five of 14 patients had at least one complication: 29% of pseudarthrodesis and 29% of sub-talar osteoarthritis. After treatment in this group, the result at the last follow-up was very good in eight cases (58%), good in four cases (28%) and average in two cases (14%). Immediate diagnosis was correlated with better results at the last follow-up. In the sub-group of immediate diagnosis, among patients who had an orthopaedic treatment, the rate of secondarily surgery was 42%. CONCLUSION: The fracture of lateral process of the talus is quite frequent and occurs among young people. Spontaneous evolution is severe with two major complications: pseudarthrodesis and sub-talar osteo-arthritis. Treatment is always required in case of displaced fracture.

Influence of lower-limb torsion on long-term outcomes of tibial valgus osteotomy for medial compartment knee osteoarthritis.

BACKGROUND: The results of tibial osteotomy used to treat osteoarthritis of the medial compartment of the knee deteriorate over time even when the initial correction is optimal. Studies have shown that tibial and femoral torsion and the femorotibial index (tibial torsion minus femoral torsion) contribute, together with coronal malalignment, to the development of single-compartment knee osteoarthritis. The objective of our study was to evaluate the impact of femoral and tibial torsion and of coronal realignment on the long-term clinical and radiographic outcomes of valgus tibial osteotomy. METHODS: A function score was calculated for sixty-eight patients at a mean of thirteen years after the osteotomy. Anteroposterior single-leg-stance radiographs were used to evaluate loss of the femorotibial joint space. Goniometry was used to measure coronal malalignment preoperatively, at one year, and at the time of the last follow-up, and postoperative computed tomography was performed to measure femoral anteversion and tibial torsion and to calculate the femorotibial index. We looked for associations linking body mass index, initial loss of joint space, coronal malalignment, femoral and tibial torsion, the femorotibial index, and functional outcomes. RESULTS: Worse outcomes were associated with changes in coronal alignment (>/=2 degrees ) over time, which were associated with deterioration of the femorotibial space. Femoral anteversion was significantly greater in patients in whom valgus increased over time than in those in whom valgus decreased over time. Stability of coronal alignment seemed to be dependent on a linear relationship between the femorotibial index and the degree of postoperative realignment. A body mass index of >25 kg/m(2) was associated with a long-term loss of coronal realignment. Preoperative loss of the medial femorotibial joint space, coronal alignment at one year, and age were not associated with secondary malalignment or functional outcomes. CONCLUSIONS: Long-term success of a valgus tibial osteotomy is related to the stability over time of the postoperative coronal realignment. Therefore, the results of our study suggest that modifying the realignment according to the extent of femoral anteversion may improve long-term outcomes.