[Patellar fracture after anterior cruciate ligament reconstruction using a bone patellar tendon bone transplant: a comparative study of two harvesting techniques]. / Fracture de la patella après prélèvement os-tendon patellaire-os pour ligamentoplastie de reconstruction du ligament croisé antérieur : incidence du type de prélèvement.

PURPOSE OF THE STUDY: We studied the incidence and the impact of patellar fracture after anterior cruciate ligament (ACL) reconstruction, comparing two harvesting techniques. MATERIAL AND METHODS: Series A included Kenneth Jones ligamentoplasties (n=1234). The distal and central part of the patella were harvested using an oscillating saw and a gouge. Series B included 676 Mac InJones reconstructions performed during the same period. The patellar cut was done from porximal to distal its attachment were harvested with a manual wire saw. The bony harvesting site was filled with cancellous bone. RESULTS: There were three postoperative transversal patellar fractures (0.24%), all in series A. Functional outcome was disappointing but there was no impact on knee stability. DISCUSSION: The fact that the Mac InJones technique does not involve a transversal cut would apparently prevent secondary fracture.

[Results of self-centering patellofemoral prosthesis: a retrospective study of 57 implants]. / Résultats de la prothèse fémoropatellaire autocentrique: à propos d'une série continue de 57 prothèses.

PURPOSE OF THE STUDY: The aim of this retrospective analysis was to report results obtained with a self-centering patellofemoral prosthesis. We wanted to determine whether self-centering still has indications for the treatment of patellofemoral osteoarthritis. MATERIAL AND METHODS: This was a continuous series of 57 knees operated on since 1986 in the same center for implantation of a self-centering patellofemoral prosthesis (Medinov then Depuy). Eight patients died and four were lost to follow-up. Two knees were excluded from the analysis after revision with a PFP. We report here the outcome of 43 prostheses at mean follow-up of six years two months (range 78 months to 15 years). The IKS score (200 points) and the ADL scale (in %) were recorded. The position of the prosthesis was assessed on plain X-rays. Mean age at implantation was 67.2 years. The main reasons for surgery were osteoarthritis secondary to dysplasia (60%) and primary disease (31.1%). RESULTS: At last follow-up, the IKS score was 157.2 points (range 76-195). The mean ADL score was 74.1/100 (48.8-96.3). The IKS evaluation showed good outcome in 66.7% of knees. The ADL scale gave a less satisfactory outcome: 57.7% good outcome for this scale which takes into account all knee functions for activities of daily life. Outcome was better among patients with trochlear dysplasia. Eleven patients (24.4%) had had revision surgery for total knee arthroplasty. Preoperatively, the trochlear angle was smaller in revision cases (p=0.023). In these patients, the first prosthesis was more anterior (p=0.004) with a greater horizontal axis (p=0.015). DISCUSSION: Our outcomes were less satisfactory than the average results in the literature. It must be noted however, that the concept of a good outcome depends on the scale used for assessment. We found in our series a 10% difference between the ADL scale and the IKS score. Independently of the assessment scale used, outcome was better in knees with osteoarthritis secondary to dysplasia. An analysis of the X-ray findings disclosed technical errors leading to failure. The outcome of patellofemoral prosthesis depends essentially on two factors: technical precision and patient selection. CONCLUSION: In light of these findings, we have come to limit still further the rare indications for patellofemoral prostheses. The typical indication is isolated advanced patellofemoral osteoarthritis secondary to patellofemoral dysplasia unresponsive to medical treatment in patients aged 50-70 years. Revision with a total knee arthroplasty required changing the patellar insert if worn. We have not had any particular problem with revision total knee arthroplasty after patellofemoral prosthesis.

Effects of radiograph projection parameter uncertainty on TKA kinematics from model-image registration.

Model-image registration techniques have been used extensively for the measurement of joint kinematics in vivo. These techniques typically utilize an explicit measurement of X-ray projection parameters (principal distance, principal point), which is easily done for prospective studies. However, there is vast opportunity to derive useful information from previously collected clinical radiographic films where the projection parameters are unknown. The purpose of this study was to determine variation in measured knee arthroplasty kinematics when the X-ray projection parameters were unknown, but bounded. Based on the clinical radiographic protocol, a nominal principal point was chosen and eight additional points +/-2 and +/-5 cm in the horizontal and vertical directions were defined. Tibiofemoral kinematics were determined for all nine projection parameter sets for a series of 10 lateral radiographs. In addition, the principal distance was varied +/-15 cm and tibiofemoral kinematics were determined for these two projection sets. Measured joint kinematics varied less than 0.6 degrees and 0.4 mm for +/-2 cm variations in principal point location, and 0.7 degrees and 0.6 mm for +/-5 cm variations in principal point location. Measured joint kinematics varied less than 0.6 degrees and 0.7 mm for +/-15 cm variations in principal distance. Variation in X-ray principal point and principal distance over clinically bounded ranges has a small effect on knee arthroplasty kinematics computed from model-image registration with high-quality clinical radiographs.

[Anterior cruciate ligament revision: analysis and results from a series of 74 cases]. / Les reprises de ligamentoplastie du ligament croisé antérieur: analyse et résultats d'une série de 74 cas.

PURPOSE OF THE STUDY: This was a retrospective series of patients who underwent revision ligamentoplasty of the anterior cruciate ligament (ACL). We wanted to assess the functional outcome after this type of surgery and search for potential prognostic factors. MATERIAL AND METHODS: The series included 74 patients, mean age 34 years (range 21-59 years). The initial ligamentoplasty was performed with a synthetic ligament (n=16), an autograft (n=57) or an allograft (n=1). Differential laxity (KT-1000 maximal manual) was 7 +/- 2.5 mm. Anterior drawer was measured on the stress x-rays in 20 degrees flexion: medial 8 +/- 4.7 mm, lateral 8.3 +/- 4.9 mm. Mean time to revision surgery was 78 months. Reconstruction was performed arthroscopically in 69 knees. The implant used for the revision reconstruction was an autograft: patellar tendon (n=42), quadriceps tendon (n=15), hamstring tendon (n=13), patellar tendon and quadriceps tendon (MacInJones) (n=3), fascia lata (n=1). A meniscal tear was noted in 24 knees and a cartilage lesion in 35. RESULTS: Outcome was assessed at mean 21.2 months follow-up. The mean IKDC function score was 71.7 (range 21.8-100). 78% of patients considered their knee normal or nearly normal and 88% presented a positive Lachmann. Mean differential laxity measured with KT-1000 (maximal manual) was 2 +/- 1.7 mm. Stress x-rays revealed a mean differential laxity measured at 3.7 +/- 2.3 mm medially and 6.3 +/- 4.3 mm laterally. The presence of a meniscal lesion favored osteoarthritic degradation. Presence of chondral lesions altered the functional outcome significantly and limited resumption of sports activities. An initial repair using a synthetic ligament affected the functional outcome after revision surgery and favored or aggravated chondral lesions. DISCUSSION: The clinical results we have obtained with revision ACL ligamentoplasty are comparable to previous series reported in the literature. The functional outcome is not as good as after first-intention repair, especially if the initial plasty was done with a synthetic ligament and the knee presented meniscal or cartilage damage.

[Intra-articular reconstruction of the anterior cruciate ligament with and without extra-articular supplementation by quadricipital tendon plasty: seven-year follow-up]. / Influence d'une ligamentoplastie extra-articulaire latérale sur les résultats de la reconstruction du ligament croisé antérieur avec le ligament patellaire avec 7 ans de recul.

PURPOSE OF THE STUDY: Reconstruction of the anterior cruciate ligament (ACL) is a common procedure, but use of lateral reinforcement is still a subject of debate. The purpose of this study was to compare two randomized series of ACL reconstructions, one using an intra-articular method (patellar tendon autograft) and the other an intra- and extra-articular method (Mac-InJones). MATERIAL AND METHODS: From January 1995 to March 1998, 63 knees underwent surgery for ACL reconstruction. Inclusion criteria was significant medial differential laxity measured between 7 and 12 mm on passive dynamic x-rays as 20 degrees flexion. Group 1 (patellar tendon intra-articular reconstruction) included 34 patients (27.1+/-7.5 years) and group 2 (intra-articular reconstruction plus extra-articular quadircipital tendon plasty) included 29 patients (28.5+/-12 years). The IKDC score was determined for 72% of the knees in group 1 and 68% in group 2 at seven years follow-up on average (102 and 93 months respectively). Anterior laxity was measured radiographically and with KT-1000. The position of the tunnels was controlled using the Aglietti method. RESULTS: The subjective functional score was 83.6+/-3.5 in group 1 and 83.5+/-3.5 in group 2. The overall IKDC knee score classes for group 1 were 0% A, 52.4% B, 28.6% C, and 19% D and for group 2 were 5.5% group A, 50% group B, 33.3% group C, and 11.1% group D. In group 1, the pivot test was negative in 61.9% and noted stage 1 in 28.6% and stage 2 in 9.5%. In group 2, the pivot test was negative in 78.9% and noted stage 1 in 15.8% and stage 2 in 5.3%. The KT-1000 showed no difference in gain in laxity: 31% for group 1 and 27% for group 2. Similarly, radiographically there was no difference with a 43.9% gain in differential laxity for the medial compartment and 45.3% for the lateral compartment in group 1. In group 2 the corresponding values were 51.9% and 41.8%. The position of the tunnels was the same in the two groups. DISCUSSION: In a preliminary study with two years follow-up, the results in these two series were not significantly different. It was concluded that there was not clear advantage to adding the extra-articular lateral plasty. At the present 7-year follow-up, pivoting appears to be better controlled in the lateral plasty group (p=0.23), but with no significant difference for laxity for both knee compartments. The inclusion criteria would be different today and would be based on the laxity of the lateral compartment.

[Analysis of meniscal lesions accompanying anterior cruciate ligament tears: A retrospective analysis of 156 patients]. / Lésions méniscales constatées lors de la reconstruction du ligament croisé antérieur: siège et nature dans une série continue de 156 patients.

PURPOSE OF THE STUDY: The purpose of this retrospective study of a continuous series was to document preferential types and localizations of meniscal lesions accompanying anterior cruciate ligament tears and to demonstrate the relationships between meniscal lesions, patient age and time from trauma to surgery. MATERIAL AND METHODS: One hundred fifty-six patients with no history of meniscal lesions underwent ligamentoplasty in 2003. All procedures were performed by the same operator. The time from trauma to surgery was 31.6 months on average. This was a retrospective continuous series using data from detailed operative reports. RESULTS: An isolated lesion of the medial meniscus was observed in 25.6% of cases. There was an isolated lesion of the lateral meniscus in 21.8% and lesions of both menisci in 9%. The most frequent injury was a longitudinal fissuration, for both menisci. Patient age and time from trauma to surgery were statistically correlated with presence of a medial lesion. There was no statistical relationship for the lateral meniscus nor for type of meniscal injury. DISCUSSION: The proportion of lesions to the lateral meniscus appeared to be unaffected by age or time to surgery after trauma, suggesting that lateral meniscal lesions occurred at the time of the initial curciate injury. On the contrary, the incidence of medial lesions increased with time and patient age, confirming the important role of the medial meniscus to block anterior displacement of the knee. We thus recommend early repair of anterior cruciate ligament tears in order to avoid medial meniscectomy which would increase with increasing time from injury to surgery and thus affect the postoperative outcome.

[Axial lower limb alignment and knee geometry in patients with osteoarthritis of the knee]. / Analyse segmentaire de la déformation frontale dans les gonarthroses fémoro-tibiales latéralisées.

PURPOSE OF THE STUDY: We conducted a retrospective radiographic study to identify and quantify medial and lateral misalignments in candidates for total knee arthroplasty. MATERIAL AND METHODS: We studied a discontinuous series of 101 patients (164 knees) among candidates for total knee arthroplasty seen between 1990 and 2002. We selected a random sample for study. Exclusion criteria were any history of fracture, surgical treatment, rheumatoid disease, or congenital disorder. A first group of 136 genu varum knees was identified in 82 patients (mean age 72 years, mean weight 79 kg). A second group of 28 genu valgum knees was identified in 19 patients (mean age 67 years, mean weight 71 kg). The standard radiograms were digitalized for semi-automatic measurements using the Metros software. We recorded overall deformation, femoral valgus, tibial varus, HKA angle, HKS angle (mechanical/anatomic axis of the femur) and angle C (horizontal inclination of the ankle to the ground). All measures were compared between each other for each patient to search for relations. RESULTS: In the genu varum group (136 knees), mean overall deformation was 9 degrees , mainly due to tibial misalignment (5.5 degrees ) with a 1 degrees femoral valgus component. The HKS angle was 6.3 degrees , and lateral joint gap 4.3 degrees ; the C angle was 4 degrees . Overall varus followed tibial varus (p<0.01). Ankle inclination followed tibial varus (p<0.01). In the genu valgum group (28 knees), overall deformation was 4.2 degrees , mainly due to femoral misalignment (5.6 degrees) with 1 degrees tibial varus and a medial joint gap of 2 degrees . The HKS angle was 4.7 degrees and the mean C angle -4 degrees . Overall valgus was related to femoral valgus (p<0.001). Tibial varus was greater with greater femoral valgus (p<0.01). In both groups, the HKS angle was smaller with greater femoral valgus. DISCUSSION: Semi-automatic measurements on digitalized films enabled excellent reproducibility. Causes of error were related to limb rotation at acquisition. This study showed that genu varum worsens because of tibial wear followed by ligament distension, while for genu valgum, worsening predominantly results from femoral wear. The ankle joint line was nearly horizontal in one-third of the limbs, even when there was a major misalignment of the lower limb. The HKS angle was quite variable in both morphotypes, but was smaller with greater femoral valgus in both groups. CONCLUSION: Measuring all components involved in medial and lateral knee misalignment is very useful for understanding the morphotype of each individual knee before performing osteotomy or implanting a knee prosthesis.

[One-stage reconstruction of the two cruciate ligaments with a single autogenous graft from the extensor system: techniques and results of 25 chronic cases]. / Reconstruction simultanée des 2 ligaments croisés par un transplant autogène unique: technique et résultats à propos de 25 laxités chroniques.

PURPOSE OF THE STUDY: Chronic tears of both cruciate ligaments are rarely encountered. Management practices have varied. One-stage reconstruction of both ligaments using arthroscopically implanted allografts was proposed starting in 1996 for such chronic laxity but only 44 cases have been reported in six papers mixed in with recent cases raising very different problems. Treatments using allografts or autogenous grafts or both implanted arthroscopically have often been combined with open surgery. We report a retrospective analysis of 25 knees treated with the same technique from 1983 to 2004: reconstruction with a single transplant taken from the extensor system. MATERIAL AND METHODS: A 30-cm lenght patella tendon-patella-quadriceps tendon graft was harvested. The patellar block was fixed in a hole drilled under the tibial spine, the patellar tendon replacing the posterior cruciate ligament and the quadriceps tendon passing through the lateral condyle and replacing the anterior cruciate ligament before implantation on Gerdy's tubercle, this also creating an extra-articular plasty with the same implant. Medial, lateral and posterior plasties were performed, depending on the radiographic assessment of laxity. Twenty-five knees with major laxity and instability were operated on, including 14 in two-stage operations. The differential anterior drawer was 10+/-3 mm medially and 9+/-5 mm laterally. The posterior drawer at 70 degrees was 15+/-4 mm medially and 10+/-6 degrees laterally. The total anteroposterior laxity of the medial compartment was 29 mm, it was 30 mm for the lateral compartment. Lateral laxity was considered major (>10 degrees ) in 17 knees and medial laxity in 7. Lateral and medial laxities were associated in eleven knees. Hyper-extension was very severe in five knees. RESULTS: Functional outcome at mean 6.5 years follow-up (range 1-21) was satisfactory (except in three knees) allowing renewed occupational activity. Resumption of sports activity was less marked and none of the knees was in IKDC class A, corroborating results in the literature. Anatomic outcome was assessed on the radiological drawer decrease which was modest, mean gain in the anterior drawer measuring 4 and 5 mm in the medial and lateral compartments and mean gain in the posterior drawer measuring 5 mm medially and 3 mm laterally. Peripheral laxity was corrected for best. DISCUSSION: Classically, one or other of the cruciate ligaments is repaired, sometimes both, but in a two-stage procedure associating two different methods and autogenous tendon grafts. One-stage reconstruction of both cruciate ligaments with a single autogenous graft and a wide approach has not led to any complications. One-stage reconstruction using this technique has several advantages: one anterior incision, single transplant which also enables lateral plasty, short immobilization time with rapid rehabilitation.

[Accuracy of total knee replacement bone cuts using a conventional ancillary system: 300 Innex total knee arthroplasties]. / Précision des coupes osseuses dans l'arthroplastie totale du genou à l'aide d'un ancillaire conventionnel: trois cent poses consécutives de prothèses Innex.

PURPOSE OF THE STUDY: Short-term functional results and long-term outcome in terms of stability and wear greatly depend on the precision of the bone cuts. We wanted to know whether conventional ancillaries are still competitive in terms of accuracy in comparison with computer-assisted navigation systems. A few comparative studies favor navigation, but have generally only included a small number of patients. We studied radiographically a prospective consecutive series of 300 total knee prostheses (Innex, Zimmer) implanted with the conventional technique by the same operator. MATERIAL AND METHODS: A telegonometric view in the upright position and a short lateral view were obtained in all patients. In the AP view, implants were measured in comparison with the mechanical axis of the femur (F) and the tibia (T). On the lateral view, the prosthesis-tibial shaft angle (PT) was measured from the proximal portion of the tibial shaft and the prosthesis-femoral shaft angle (PF) from the distal portion of the femur. The same operator made all measurements using the same optimal conditions. The series included 178 women and 122 men, mean age 72 +/- 8 years who presented genu varum (n = 248 knees) and genu valgum (n = 52 knees): degenerative disease (n = 238), polyarthritis (n = 4), hemophilic arthropathy (n = 3), necrosis (n = 3), revision of unicompartmental prosthesis (n = 8), and osteotomy (n = 44). RESULTS: The standard x-ray protocol was performed at two months in all patients. The mechanical axis (HKA) was 179.4 +/- 2.4 degrees (range 173-186 degrees) and was +/- 3 degrees in 87% of knees with no difference for varum and valgum. F was 90.1 +/- 1.4 degrees (87-95), with +/- 3 degrees for 98.7%. T was 89.3 +/- 1.5 degrees (85-94) with +/- 3 degrees for 95.6%. PF was 88.6 +/- 1.6 degrees (84-93) for 87%, PT was 87 +/- 2 degrees (81-93) with +/- 3 degrees for 94%. The four cuts were within +/- 3 degrees for 227 prostheses (77%), within +/- 2 degrees for 156 (52%) and within +/- 1 degrees for 56 (18%). Measurements made again one year after implantation for 203 knees gave the same results. Operative time for implantation was 68 +/- 23 minutes for implantation and 85 +/- 23 minutes including complete closure (less than 60 minutes for 68 knees). DISCUSSION: The accuracy of each cut was satisfactory on average with a small standard deviation. Recent data in the literature show that the accuracy in our series is comparable with that obtained currently with navigation systems. In light of this experience, it can be seen that better precision can be achieved for each of the cuts. CONCLUSION: The accuracy of conventional instrumentation systems is still comparable with that obtained with computer-assisted surgery. The purpose of this study was not to question the benefit of navigation, but to establish a basis upon which progress can be measured. The results enabled a more realistic comparison of the precision of navigation systems and also can be comforting for operators still using conventional ancillaries.

Comparison of reconstruction of the anterior cruciate ligament with and without a Kennedy ligament-augmentation device. A randomized, prospective study.

In a randomized, prospective study, sixty-four patients who were operated on for a torn anterior cruciate ligament were divided into two groups: thirty patients (the control group) had repair with the Marshall-MacIntosh technique alone, and thirty-four patients had repair with the same technique but with the addition of a Kennedy ligament-augmentation device. The preoperative characteristics were essentially identical in the two groups. The postoperative management, resumption of athletic activities, and occurrence of complications were also similar. All patients were followed for more than two years. No significant functional or clinical difference between the two groups was found with respect to residual laxity determined either from dynamic radiographs or with the KT-1000 arthrometer. There was no evidence that the addition of the Kennedy ligament-augmentation device gave results that were superior to those obtained with the Marshall-MacIntosh technique alone.

Knee instability after injury to the anterior cruciate ligament. Quantification of the Lachman test.

We have measured anterior and posterior displacement in 563 normal knees and 487 knees with chronic deficiency of the anterior cruciate ligament (ACL). We performed stress radiography using a simple apparatus which maintained the knee at 20 degrees of flexion while a 9 kg load was applied. There was no significant difference in posterior translation dependent on the condition of the ACL. Measurement of anterior translation in the medial compartment proved to be more reliable than in the lateral compartment for the diagnosis of rupture of the ACL, with better specificity, sensitivity and predictive values. We have classified anterior laxity based on the differential anterior translation of the medial compartment and identified four grades in each of which we can further distinguish four subgrades for laxity of the lateral compartment. Within each of these subgroups, either internal or external rotation may dominate and sometimes there is a major translation of both compartments. Radiological evaluation of displacement of the knee in 20 degrees of flexion provides conclusive evidence of rupture of the ACL. A detailed study of pathological displacement is the basis for a classification of laxity. It is then possible to decide for each type of laxity, the surgical treatment which is specifically adapted to the lesion, and to define a reference value for judging outcome.

[Morphological types of the lower limbs in femoro-patellar disequilibrium. Analysis in 3 planes]. / Les morphotypes des membres inférieurs dans les déséquilibres fémoro-patellaires. Analyse dans les 3 plans.

The authors describe the relationship between the variations in the morphology of the lower limbs in case, torsional variances in femur and tibia, genu vara and genu valga with the instability of the patella.

[Treatment problems in old and recent rupture of the lateral knee ligament]. / Les problèmes posés par les ruptures ligamentaires du compartiment externe du genou, fraîches et anciennes.

The authors have treated 31 fresh ruptures of the lateral ligament and 104 cases of chronic instability of the lateral side of the knee. In recent ruptures the results obtained after surgical repair were not as gratifying as those obtained after injuries of the medial ligament. The cases operated upon were tears of the lateral ligament associated with ruptures of one or both cruciate ligaments. The frequency of rupture of the popliteus tendon is emphasized. The authors recommend, when necessary, a double surgical approach both laterally and posteriorly and plaster cast immobilization for more than 6 weeks. Tendon transfer in recent lesions have been done when suture of a cruciate ligament was impossible. The results of several procedures for chronic instability were analysed; transposition of the patellar ligament, transposition of the head of the fibula, or tightening of the lateral structures of the knee (capsule, ligament, popliteus tendon). Associated lesions of the cruciate ligament were treated by tendon transfer. Poor results were obtained in those presenting with fixed varus deformities. The authors conclude that such deformities should be corrected by osteotomy.

[Patella infera. Apropos of 128 cases]. / Les rotules basses. A propos de 128 observations.

A low patella is frequently a complication of a lesion of the knee but it can also present secondary symptoms of its own. The authors describe an original method for assessment of the vertical level of the patella. They have tried to establish a relationship between the low situation of the patella and pain of a certain type associated with limited flexion of the knee. Physiopathological and biomechanical evidence is taken into account. In most instances, a low patella is secondary either to a mechanical cause, natural or iatrogenic, or to an inflammatory cause such as algodystrophia. 29 patients out of 128 observed cases have been operated on. 17 of these were due to excessive transplantation of the anterior tibial tubercle. In most of the cases the tibial tubercle was transplanted upwards in association with a joint release. In only 3 cases a patellectomy was done. The results were excellent or good in half of the cases and unsatisfactory in the other half.

[The treatment of genu recurvatum (author's transl)]. / Le genu recurvatum et son traitement par ostéotomie tibiale.

50 cases of genu recurvatum were classified into three types: osseous (malunion, epiphysiodesis), capsular and ligamentous (congenital hyper-extension, sequelae of old ligament rupture) and combination of the two types. The author's have analysed the results of 44 surgical procedures. The main procedure practised has been an opening wedge osteotomy of the upper end of the tibia above the level of the tibial tubercle with a graft to fill the gap. It is important to avoid distal displacement of the patella by detachment of the tibial tubercle and reattachment more proximally at the end of the surgical procedure. Osteotomy is always indicated but should be combined with a capsular repair or combined types. The results are satisfactory especially in cases due to premature closure of the growth plate.

[Replacement of both cruciate ligaments with a single transplant from the extensor system. Bicross quadricipital ligamentoplasty]. / Remplacement des deux ligaments croisés avec un transplant unique provenant du système extenseur. Ligamentoplastie quadricipitale bicroisée.

The authors describe a new procedure for replacement of both cruciate ligaments. They use a single anterior approach and a unique transplant, consisting of a long band including part of the patellar tendon, part of the patella and part of the quadriceps tendon. The technique is indicated in some cases of major instability of the knee.

[Fracture-dislocation of the tarso-metartarsal joint. Classification. Treatment. Apropos of 81 cases]. / Les fractures-luxations tarso-métartarsiennes. Classification. Traitement. A propos de 81 cas

The authors have treated eighty-one cases of fracture-dislocation of the tarso-metarsal joint and have studied 232 cases reported in the literature. They suggest a modification of previous classifications. In their conclusions, they consider that purely conservative treatment is inadequate. Reduction, when obtained by closed methods, should be maintained by Kirschner wires. Open reduction should be done when closed methods do not produce a perfec reduction. When several articular fractures are present, they advocate immediate reduction and arthrodesis. The results obtained after secondary arthrodesis were not as good as those obtained after primary arthrodesis.

[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.

[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.