[Osteochondral autograft for osteochondritis dissecans of the capitulum in adolescent: report of six cases and review of the literature]. / Traitement de l'ostéochondrite disséquante du capitulum chez l'adolescent par autogreffe ostéochondrale monobloc: à propos de six cas et revue de la littérature.

PURPOSE OF THE STUDY: We present the cases of six adolescents (four high-level gymnastics specialists) with osteochondritis dissecans of the capitulum who were treated with an en bloc osteochondral autograft. There are few series of this rare condition reported in the literature. MATERIAL AND METHODS: All six patients presented pain over the lateral aspect of the elbow and limited extension; pronosupination was unaffected. Physical examination and plain X-rays enabled the diagnosis of osteochondritis dissecans. Postoperative X-rays confirmed good integration of the bone graft. These patients underwent lateral arthrotomy for curettage and avivement followed by an en bloc grafting. The graft was harvested from the homolateral knee via minimal arthrotomy, from a non-weight-bearing zone of the lateral condyle. RESULTS: At three months, complete pain-free range of motion was achieved in four of six patients. Graft integration was confirmed in all six patients on the three months plain X-rays, arthro-CT, or MRI. The four gymnastic specialists resumed their high-level sports activities at one year (at six months for one of them). DISCUSSION: Various surgical methods have been proposed. Series reported in the literature, like ours, have been small, with short follow-up. We have observed good results with an en bloc graft, encouraging us to continue with this surgical strategy.

[Arthroscopy of the ankle: a new of postero-internal point of entry]. / Arthroscopie de la cheville: un nouveau point d'entrée postéro-interne.

INTRODUCTION: The development of the indications in the arthroscopic surgery of the ankle and the narrowness of this joint impose perfectly adapted portals. Several posterior portals which allow to access to the postero medial corner of the joint have been already described, but are not satisfying. We describe, here, a new postero-medial portal which allows a safe and easy access to the posterior part of the joint. METHODS: The arthroscopy is performed with a standard arthroscope (30 degrees, 4.5 mm in diameter) and a lateral ankle distractor. The landmark for this portal is the posterior crest of the medial malleolus. Above the posterior tip of the medial malleolus, this crest is directed up and back, then its direction becomes strictly vertical. The new portal is situated there, 5 millimeters behind the crest (generally 2 centimeters above the posterior tip of the medial malleolus). A needle visualized by the anterior portal is helpful to show the right direction for the portal. After skin incision, a forceps is used to widen the portal. Then the instruments or the arthroscope can be introduced. Posterior tibial artery and nerve are protected by the tendons of tibialis posterior and flexor digitorum longus. MATERIAL: We have used this portal (instrumentation and arthroscope) in four patients (3 osteochondritis dissecans of the medial part of the talus, 1 loose body) without problem. RESULTS: This portal is safe; it does not intersect the direction of posterior tibial artery and nerve as in the postero-medial portal described by Parisien and avoids in most cases the approach described by Guhl. DISCUSSION: Because the medial malleolus is more anterior than the lateral malleolus, it allows a larger approach to the posterior part of the joint than the postero-lateral portal. We recommend it for the arthroscopic treatment of all the lesions of the postero-medial part of the joint.

[Dynamic anterior jerk of the shoulder. A new clinical test for shoulder instability. Preliminary study]. / Le ressaut dynamique antérieur de l'épaule. Un nouveau test clinique d'instabilité de l'épaule. Etude préliminaire.

PURPOSE OF STUDY: A new clinical test named "The shoulder anterior jerk test" is proposed to confirm the diagnosis of chronic shoulder anterior instability. MATERIAL: The test combines of a compression force and a translation force, applied along the arm between the humeral head and the glenoid cavity. In so doing, a subluxation of the humeral head is provoked and it is accompanied with a jerk recognised by the patient as his instability. METHODS: Three different populations of patients had been studied: Population A: 28 patients operated on for chronic anterior dislocation, uni or bilateral (32 shoulders), had been tested before the operation, without and under anesthesia. Population B: 100 patients without any problem at the shoulder, had been tested before and under anesthesia done for knee or hip surgery. Population C: 100 young sportive athletes with normal shoulder tested without anesthesia. RESULTS: Population A: The 28 patients suffering from shoulder instability had all a positive shoulder jerk test under anesthesia. Without anesthesia the test had been positive only in 10 cases (30 per cent). The jerk is potentially present for all the patients, but it is disturbed by apprehension. Population B: Among the 200 shoulders tested, 26 shoulders (17 patients) had a positive test under anesthesia (13 per cent). 5 had positive jerk test without anesthesia. Population C: 5 among the 200 shoulders tested had a positive jerk test (2.5 per cent) Under anesthesia the test has a sensitivity of 100 per cent, a specificity of 87 per cent, a positive predictive value of 55 per cent and a negative value of 100 per cent. Without anesthesia, the test has a sensitivity of 31 per cent, a specificity of 97.5 per cent, a positive predictive value of 66 per cent and a negative predictive value of 90 per cent. DISCUSSION: The instability which is shown by the jerk test is in relation with the anterior subluxation of the humeral head in front of the anterior edge of the glenoïd cavity. It reproducts, with a minimal amplitude, the clinical instability which is recognized by the patient. The test is always positive under anesthesia in case of chronic anterior instability, it may confirm pre-operative diagnosis just before the begining of the procedure and may orientate the choice of it. Apprehension is a major obstacle to the research of the jerk, but it is the same with the other classical clinical tests of the shoulder anterior instability. CONCLUSION: The anterior jerk test of the shoulder is thus a test which is able to prove the diagnosis of an anterior instability. The future will permit to confirm its efficiency and will confirm if the test may differenciate anterior and inferior instability with variation of the abduction, as it has been shown in this preliminary study.

[Anterior laxity and internal arthritis of the knee. Results of the reconstruction of the anterior cruciate ligament associated with tibial osteotomy]. / Laxité antérieure et arthrose interne du genou. Résultats de la reconstruction du ligament croisé antérieur associée à une ostéotomie tibiale.

Fifty-one knees were reviewed out of 53 which had been operated on (between 1981 and 1991) for instability due to a long-standing rupture of the anterior cruciate ligament (A.C.L.), associated with medial arthritis related to a varus deformity. They had undergone a reconstruction of the cruciate ligament using the patellar tendon (5 cases had received an artificial ligament) and a high tibial osteotomy. In 80 per cent of cases this was an opening osteotomy with interposition of a heterologous bone graft, and in 39 cases it was a closing osteotomy. The average age was 37 +/- 6 years. The oldest patient was 58 years old. 80 per cent of cases were men and 88 per cent of the patients practised sport on a regular basis at the time of the accident. The average delay before surgery was 9.5 years. Almost all the patients has already undergone a medial meniscectomy and there were deep cartilaginous lesions and the bone was exposed in 50 per cent of cases. 28 knees were reexamined after a follow-up of over 4 years. Based on the ARPEGE score the results on pain and stability were good. Return to sport has been possible for 43 per cent of patients. Pivot shift, which was constant before surgery (grade 2 or 3), disappeared in 20 cases and was estimated at grade 1 in 8 cases (of which 6 had suffered a rupture of the graft). For the 20 cases in which the reconstruction of the A.C.L. had held, the average anterior radiological subluxation was 4.3 +/- 3.2 mm (from 2 to 14 mm) and the average gain after surgery was 6.7 +/- 3.7 mm (from 2.5 to 18 mm). The femoro-tibial angle went from an average of 6 degrees of varus to 3 degrees of valgus. The opening osteotomy was more precise for correction in the frontal plane. A large valgus (over 3 degrees) was not desirable and a hypercorrection was occasionally difficult to accept by relatively young patients who are likely to take up sport again. The osteotomy often involuntarily modified the normal posterior tibial plateau slope (especially closing osteotomy). A backwards increase of the tibial plateau slope is a factor which increases the anterior subluxation of the femur on the tibia. This is confirmed before and after surgery. It seems preferable to decrease the tibial slope during the osteotomy in order to protect the A.C.L. reconstruction.(ABSTRACT TRUNCATED AT 400 WORDS)

[Distal reconstruction of the Achilles tendon with a bone-tendon graft from extensor system of the knee]. / Reconstruction distale du tendon d'Achille avec un transplant os-tendon à partir du système extenseur du genou.

PURPOSE OF THE STUDY: The authors describe a new surgical technique of tendo achilles reconstruction using bone tendon plasty from the patellar tendon, for rare chronic ruptures of the Achilles tendon flush within its calcaneal insertion, with distal loss of substance, requiring bone fixation. METHODS: The two step operation was carried out either in lateral or ventral decubitus (the latter two involving repositioning the patient): 1) Plasty harvesting. By a short anterior approach, we harvested either a strip of patellar tendon (10 mm wide) with a piece of tibia tuberosity or a strip of rectus femoris tendon (10 mm wide, up to 10-15 cm long) with a piece of patellar bone, in cases with a greater loss of substance. Tendo achilles reconstruction: following resection of fibrous tissue, and drilling of a blind calcaneous tunnel, the bone plasty is fitted into the calcaneous with interference screw for safety, the two tendon ends are superposed and sutured. The patient is placed in a cast for two months. RESULTS: Two patients (1 thirty-eight year old sportsman, 1 thirty-seven year old woman) were treated with a good morphological and functional outcome at two years. DISCUSSION: This new technique is compared with other available solutions: triceps plasty, other local tendon plasties, artificial plasties, It met the two criteria for these unusual ruptures: solid calcaneous fixation, no skin damage.

[Results of sutures of the internal meniscus associated with reconstruction of the anterior cruciate ligament in chronic knee joint instability. Apropos of 42 cases, 30 of them controlled by arthrography]. / Résultats des sutures du ménisque interne associées à des reconstructions du ligament croisé antérieur dans les instabilités chroniques du genou. A propos de 42 cas, dont 30 contrôlés par arthrographie.

PURPOSE OF THE STUDY: Most authors agree on the importance of medial meniscus preservation in the case of A.C.L. reconstructive surgery. The purpose of this study was to analyze the anatomical results of sutures of medial meniscus tears by the means of arthrography. MATERIAL: Medial meniscus 42 sutures for peripheral tears at the posterior horn (length between 10 and 50 mm, 70 per cent greater than 20 mm) had been performed through an open procedure using a posterior approach. The average age of the patients was 24 years (17-54) with a clear male predominance (64 per cent). The average age at the time of injury was 22 years, 6 months. METHODS: The patients were operated on by the same surgeon, with the same technique. Resorbable sutures were used spaced every-3 mm, and tightened outside the joint. The A.C.L. was reconstructed by a bone-patellar tendon-bone technique (modified K.G. Jones). A first series of 13-patients were no weight bearing allowed for 6 weeks post-operatively. A second series of 29 patients were allowed immediate partial weight bearing. All the patients were permitted active flexion. All the patients had been examined with a minimum of 6 months follow-up. They were all controlled clinically (results evaluated with the I.K.D.C. score) and with passive dynamic X rays to measure residual laxity. 32 patients had an arthrogram before the operation in the aim to compare with the postoperative arthrogram. 30 patients had an arthrogram after an average of 21 months. 12 patients refused follow-up arthrograms. 9 patients had arthroscopy for pain or effusion. RESULTS: All the patients obtained a range of flexion-between 90 degrees and 110 degrees at 4 weeks. A flexed contracture of 10 degrees was noted in only 1 case. Meniscal functional results were good for 32 cases after a mean follow-up of 4 years and 4 months. Arthrograms in 30 cases showed no residual tear in 19 cases (63 per cent), 3 cases had incomplete healing and 8 cases had failed. The healing was influenced by the size of the tear, its situation near the posterior wall. In the first series (no weight bearing), there were 2 failures for 9 cases and 6 out of 21 in the second series and 3 incomplete healing. There was no correlation between meniscal functional results and functional ligamentous results evaluated with the I.K.D.C. score. 9 patients had an arthroscopy and 7 out of them a meniscectomy (after 17 months 3). CONCLUSIONS: This study confirms the possibility of healing following suture of peripheral medial meniscal tears in the case of ACL reconstructive surgery (even if the tear is long). The use of arthrogram, before the operation and for anatomical control after the operation, ensures complete healing (better than M.R.I. for the suture control). Arthrography is certainly a less invasive technique than arthroscopy.

[Effect of external extra-articular ligament plasty on the results of anterior cruciate ligament reconstruction with patellar tendon, a 4 years follow-up]. / Influence d'une ligamentoplastie extra-articulaire externe sur les résultats de la reconstruction du ligament croisé antérieur avec le tendon rotulien, avec quatre ans de recul.

PURPOSE OF THE STUDY: The purpose of this study was to compare the functional results obtained when an external extra-articular plasty was added to an anterior cruciate ligament (ACL) reconstruction using an autologous bone tendon-bone patellar tendon graft. MATERIAL AND METHODS: The authors analyzed two consecutive series of 60 and 50 patients operated by the same surgeon for a chronic rupture of the anterior cruciate ligament, one by reconstruction of the cruciate ligament with a free graft of the patellar tendon supplemented by an external extra-articular plasty made with a quadriceps tendon graft and the second with an isolated free patellar tendon graft. Anterior laxity was measured before and after surgery, by dynamic X-rays and by the Medmetric KT-1000 arthrometer. Functional results were evaluated four years after operation, with the French A.R.P.E.GE score based on sport activity level and intensity. RESULTS: Anterior laxity was not different before operation in both groups and there was no difference between males and females. Medmetric KT-1000 arthrometer showed the same negative differential laxity immediately after surgery in both groups and the same evolution during the first 4 years, without any significant difference on laxity on the middle aspect of the knee. Radiological results were different. After a 4 years follow-up, anterior laxity did not show significant difference on the medial compartment of the knee (5.3 +/- 2.3 mm and 5.5 +/- 1.7 mm), but there was a significant minor laxity in the lateral compartment for the lateral extra-articular plasty group (11.0 +/- 2.3 mm against 14.8 +/- 3.8 mm)(p = 0.002). Functional results and sport activity were similar in both groups. Examination showed 4 positive pivot shift tests (2 "sliding" and 2 positive) in the group with extra-articular plasty, even though 8 positive pivot shift tests in the isolated ACL group (5 "sliding" and 3 positive) were found. DISCUSSION: This study, as well as five others studies found in literature, was not randomized. In all these series, the surgical techniques, the rehabilitation programs and the functional score evaluation were too different to allow any pertinent comparison. Extra-articular plasty helps to control the laxity of the lateral compartment of the knee which is incompletely controlled by ACL reconstruction, particularly in chronic cases. This is proved by radiological measurements and pivot shift tests. Jensen in 1983, about 205 patients with a 4 year follow-up and Noyes, which used an allograft patellar tendon, found an advantage to do extra-articular plasty. But Strum (in 1989), as O'Brien (in 1991) and Roth (in 1987), did not found any advantage with extra-articular plasty. CONCLUSION: It is therefore obvious, after a four-year follow-up, that extra-articular supplementation presents an advantage for reconstruction of the ACL. by a free graft of the patellar tendon in chronic cases. Further randomized study will confirm that isolated ACL reconstruction is possible in some well defined categories of anterior laxity.

[A prospective study of the outcome of anterior laxity of the knee after anterior cruciate ligament reconstruction with procedures using two different patellar tendon grafting methods]. / Etude prospective de l'évolution de la laxité antérieure du genou après reconstruction du ligament croisé antérieur par deux procédés utilisant différemment le tendon rotulien.

PURPOSE OF THE STUDY: The aim of this study was to evaluate postoperative evolution of anterior laxity, in order to know at what time the elongation of the reconstructed anterior cruciate ligament (ACL) begins to develop after surgery, and if there were any correlations with recuperation of knee flexion or extension. The second purpose of this study was to compare two series of patients operated on by two different procedures for a long standing ACL rupture. MATERIAL AND METHODS: Two series of patients were compared: group I (60 cases), had an ACL reconstruction using a free autologous patellar tendon graft with a bone-to-bone fixation, supplemented by an external extra-articular plasty with a strip of quadricipital tendon as a direct prolongation of the graft of the patellar tendon and patella itself. "Mac InJones", and group II (50 cases), had a reconstruction with a similar transplant, but still attached on the tibia and with a fibrous fixation through the femoral condyle and the Gerdy's tubercule (modified "Marshall-Mac Intosh"). Anterior laxity was measured using two instrumented methods; first, Medmetric knee arthrometer (KT-1000), before and after operation, then each month later during the first 6 months and yearly. On the other hand, a personal stress X-ray protocol (at 20 degrees of flexion and with application of a 9 kg load at the distal part of the thigh), was made before operation, 6 months later, and yearly during 8 years. The laxity of both medial and lateral compartments of the knee were separately measured. Laxity was studied in parallel with the recuperation of knee flexion and extension during a rehabilitation program without any limitation in both directions. RESULTS: During a period of 3 months, the laxity was arthrometrically inferior to the normal knee in the two groups, and appeared progressively. Laxity was independent from early recuperation of full range of flexion and extension. The elongation of the reconstructed ligament was showed to develop during the first 6 months and less during the following 6 months. Better results were found for group I during the earliest period with the Medmetric arthrometer, but there was no difference between both groups after 1 year and 2 years. With dynamic radiography, laxity was higher than indicated by KT-1000, and results were better for group I. Laxity was stabilized after one year and the results were still good after 8 years. DISCUSSION: KT-1000 showed a great interest for measurement of the compliance index (difference between laxity at 89 newtons and 69 newtons of traction), and can be used without any inconvenient for patients. Stress radiographs may be used for yearly controls. The radiographic method had better accuracy than KT-1000 and gave precise laxity measurements of the medial and lateral compartments of the knee. The laxity of the medial compartment showed to have a good prognostic value. CONCLUSION: Evolution of laxity is more favourable in group I with bone-to-bone ligament fixation. Recovering early and complete flexion and extension is not prejudicial for the ligament. Laxity developed between 3 and 6 months and less between 6 and 12 months. KT-1000 is able to detect laxity during early postoperative period. Dynamic radiographs are more precise to control laxity year after year. Informations concerning the two compartments of the knee are of great interest to compare different procedures and to improve new surgical techniques.

[Sequelae in the knee extensor system following graft removal for the "Mac in Jones" type procedure]. / Les séquelles survenant au niveau du système extenseur, après le prélèvement d'un transplant pour intervention de type "Mac in Jones".

PURPOSE OF STUDY: The aim of this study was to evaluate clinical and radiological sequelae following removal of part of the patellar tendon for A.C.L. reconstruction. MATERIALS AND METHODS: A consecutive and homogenous series of 100 patients operated for chronic anterior instability (66 men, 34 women; age 16 to 55 years, average: 28.5 years) was studied. The procedure involved a free patellar tendon graft harvested from the mid third of the tendon and including its bony attachments, and in particular a long strip from the patella and a strip 10 centimeters long from the rectus femoris tendon for extra-articular reconstruction. Tendon graft sites were closed. Patellae and tibial tunnels were filled with bone debris from the drilling, and the pre-patellar fascia was closed. The mean follow-up period was 35 months. pain and radiological alterations (with pre-operative X-rays as reference) were studied, particularly for: calcifications, patellar height changes using the Insall, Blackburne and Caton methods, increase in patella tip length, femoro-patellar joint alteration. RESULTS: Calcification were found in: quadriceps tendon: 24 per cent of cases (always painless), Pre-patellar: 16 per cent of cases (usually less than 5 mm), Superior patellar tendon: 47 per cent of cases (only 2 cases being painful, no unaffected tendons were painful), Inferior patellar tendon: 7 per cent of cases (1 in the mid), Tibia tunnel: 26 per cent of cases. No cases required surgical removal. Patellar tip length did not increased significantly. Patellar tendon length decreased by 1.37 mm. Patellar height measured by the Insall, Blackburne and Caton methods was not significantly affected. The femoro-patellar joint was normal in 95 per cent of cases. There were five cases of remodelling, one being painful. CONCLUSION: Graft harvested from the extension system for A.C.L. reconstruction frequently resulted in radiological sequelae but were usually asymptomatic. In most cases these calcifications concerned the superior patellar tendon, quadricipital tendon and pre-patellar zone. Patella height was not affected.

[The results after 10-16 years of the treatment of chronic anterior laxity of the knee using reconstruction of the anterior cruciate ligament with a patellar tendon graft combined with an external extra-articular reconstruction]. / Les résultats après 10 à 16 ans du traitement de la laxité chronique antérieure du genou par une reconstruction du ligament croisé antérieur avec une greffe de tendon rotulien associée à une plastie extra-articulaire externe. A propos de 138 cas.

PURPOSE OF THE STUDY: The aim of this prospective study was to evaluate the objective postoperative laxity and functional results with a minimum follow-up of 10 years (mean 11.7 +/- 2 years) in chronic anterior knee instability treated by ACL reconstruction associated to a lateral extra-articular plasty. MATERIAL AND METHODS: 138 patients of a mean age of 27.8 +/- 8.5 years had been operated. Delay between injury and operation was 4 +/- 4.8 years. The surgical "Mac Injones" procedure used a free autologous patellar tendon graft with a bone-to-bone fixation, supplemented by a lateral extra-articular plasty using a strip of quadriceps tendon as a direct prolongation of the graft of the patellar tendon and patella itself. A rehabilitation program aimed to an early recovery of a complete range of motion. Anterior laxity had been measured before and after operation using two instrumented methods, KT-1000 and stress-radiography (at 20 degrees of flexion with a 9 kg load applied at the distal part of the thigh) with measurements of the displacement in medial and lateral compartments. Tunnel positioning was appreciated radiologically. Function was evaluated using the International Knee Documentation Committee score (I.K.D.C.). RESULTS: Elongation of the reconstructed ligament occurred mainly during the first 6 month, but was independent from early full range of motion recovery. Laxity was stabilized after one year. The final laxity gain of the medial compartment was 62 per cent and for the lateral compartment 77 per cent. The pivot shift test was negative in 66 per cent, grade 2 in 4 per cent, grade 1 in 30 per cent. Functional results were excellent and good (A and B) in 60.4 per cent and 76.7 per cent returned to sports activity. 12 reconstructed ligaments reruptured. Arthritis was the cause of poor results in other cases (13.8 per cent). DISCUSSION: Lateral extra-articular plasty is unable to better control translation of the medial compartment than isolated anterior cruciate ligament reconstruction, but laxity of the lateral compartment was minimized and the pivot shift test also. Incorrect position of the anterior cruciate ligament was correlated with poor results. CONCLUSION: This documented study on laxity of the two compartments confirms the interest of each type of reconstruction, in particular extra-articular plasty when made with quadriceps tendon and so doing, preserving the iliotibial-band for the control of varus stability.

[The surgical treatment of rupture of the rectus femoris muscle in the sportsman (author's transl)]. / Traitement chirurgical des ruptures du droit antérieur (Rectus femoris) chez le sportif.

Ruptures of the middle and lower part of the rectus femoris muscle are seen essentially in the footballer during a shoot at goal. Often unrecognised initially, they warrant surgical treatment in the sportsman. The anatomical appearances of these complete or partial ruptures are described. The authors propose a new technique of reinsertion, relying upon the posterior aponeurotic layer, using non-absorbable sutures. Results were satisfactory in 10 cases out of 11.

Achilles tendon repair using a bone-tendon graft harvested from the knee extensor system: three cases.

The authors describe a new surgical technique of Achilles tendon reconstruction using bone-tendon graft from the knee extensor system. This technique is for those unusual cases of neglected or partial Achilles tendon rupture with distal tendon-substance loss at calcaneal insertion level, requiring transbone plasty fixation. Three cases are reported; the first two, followed up over a 5-year period, had excellent functional, morphological, and clinical outcomes. This new technique is compared with other available solutions: triceps plasty, other local tendon plasty, artificial plasty, and allograft.