Reliability and validity of preoperative MRI for surgical decision making in chronic lateral ankle instability.

PURPOSE: To evaluate the value of analyzing the anterior talofibular ligament (ATFL) on preoperative MRI as a decision-making tool to determine the surgical technique in patients undergoing surgery for chronic lateral ankle instability. METHODS: A retrospective study of prospective data was performed. All patients who underwent surgery between 2013 and 2016 for arthroscopic stabilization of the ankle were included. The ATFL was evaluated on preoperative MRI including axial T2-weighted images by two readers who were blinded to arthroscopic results. The arthroscopic evaluation, which was considered to be the reference examination, was performed by one senior surgeon. The main judgment criteria were two features of the ATFL: (1) absent or thin (< 1 mm thick) and (2) detached or thickened (> 3.2 mm in diameter) with or without a high intensity intraligamentous signal. Inter- and intraobserver reproducibility was evaluated by the kappa coefficient (k), and parameters of the diagnostic accuracy of preoperative MRI were analyzed. RESULTS: Twenty-two patients were included, 15 men/7 women mean age 30.3 ± 9.5 years. Fourteen patients (63.6%) underwent arthroscopic repair of the ATFL (Broström-Gould technique) and 8 patients (36.4%) an arthroscopic anatomical reconstruction of the ATFL. Intraobserver reproducibility of MRI findings was substantial (k = 0.68) and interobserver reproducibility moderate (k = 0.55) to nearly perfect (k = 0.87). Agreement between MRI and arthroscopic findings was substantial (k = 0.70). Diagnostic parameters of preoperative MRI were good for both observers: Se = 85.7-87.5%, Sp = 86.7-92.9%, PPV = 75-87.5%, NPV = 92.9%, and classification of patients was good = 86.4-90.9%. CONCLUSION: Preoperative MRI of the ATFL is a reliable and valid decisional tool to choose the surgical technique for stabilization of chronic lateral ankle instability. LEVEL OF EVIDENCE: Level II; Diagnostic study-development of diagnostic criteria on the basis of consecutive patients.

Cortical onlay strut allograft with cerclage wiring of periprosthetic fractures of the humerus without stem loosening: technique and preliminary results.

The goal of this study was to describe an internal fixation technique for periprosthetic humeral fractures using a cortical onlay strut allograft stabilized with cerclage wires and to evaluate the preliminary results of this approach. An anterolateral approach was used to direct access the fracture and to protect the radial nerve. The fracture was reduced with two forceps, under visual control. The fracture was surrounded by two hemicylinder tibial allografts, placed around the humerus with no prior reaming to create a "sarcophagus" system. The allograft was as long as possible for optimal mechanical stability, without creating impingement with the glenoid and the elbow. Final fixation of the allograft was obtained with two cerclage wires. The arm was immobilized in a simple sling. Passive then active rehabilitation was begun after 1 month. Six women, mean age 74.3 ± 10.9 years old, were included in the study between 2013 and 2015 with a mean follow-up of 10 ± 2 months. Bone union was obtained in all patients after 6 months of follow-up with no recurrent fractures.

Assessment of the feasibility of arthroscopic visualization of the lateral ligament of the ankle: a cadaveric study.

PURPOSE: An anatomical study was performed to assess the feasibility of arthroscopic visualization of the lateral ligaments of the ankle. METHODS: The fibular, talar and calcanear insertions of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) were identified by standard arthroscopy portals. After dissection of the ATFL and CFL, bone tunnels were created at the estimated centres of their footprints. Dissection was then performed to identify the footprints and their position in relation to bony landmarks. The distance from the real centre of the footprint to the corresponding tunnel entrance was measured. RESULTS: Fourteen fresh frozen ankles were included. The ATFL and CFL were identified in all cases. The centre of the fibular ATFL footprint was found to be 16.1 ± 3.5 mm from the tip of the fibula, and the talar footprint was 18.4 ± 2.8 mm from the apex of the lateral talar process. The centre of the fibular CFL footprint was 4.2 ± 0.8 mm from the tip of the fibula, and the calcaneal footprint was 18.4 ± 2.5 mm from the fibular process of the calcaneum. The fibular tunnel was 2.9 ± 3 mm proximally from the centre of the ATFL fibular footprint, the talar tunnel was 4.4 ± 3.2 mm proximally from the centre of the talar footprint, and the calcaneal tunnel was 3.3 ± 2.8 mm too anterior from the CFL calcaneal footprint. No iatrogenic lesions were noted. CONCLUSION: Arthroscopic identification of the ATFL, CFL and their corresponding footprints can be considered safe and reliable. Tunnels entrances, in preparation for arthroscopic ligament reconstruction, are precisely positioned. Arthroscopic anatomical ligament reconstruction is a feasible option.

Decision-making in massive rotator cuff tear.

Treatment of massive rotator cuff tears has developed over many years ranging from conservative treatment to open and arthroscopic repair, muscle transfers and reversed arthroplasty. The evolution of more advanced techniques in arthroscopic repair has changed the treatment approach and improved the prognosis for functional outcome despite low healing rates. Due to this rapid development, our evidence-based knowledge today is mainly founded in Level 3 and Level 4 studies. Based on the literature, the current knowledge on treatment of symptomatic massive rotator cuff tears is proposed in an algorithm. Level of evidence V.

[Management of fractures in the elderly]. / Prise en charge des principales fractures chez les personnes âgées.

Fractures in elderly people are a leading cause of hospitalisation in medical and surgical departments. There may also be a significant increase in associated morbidity and mortality, depending on the site of the fracture and the surgical, medical and paramedical management. The respect of the surgical indications and a multi-disciplinary approach are essential for ensuring high quality care.

Five-year clinical follow-up of arthroscopically treated chronic ankle instability.

INTRODUCTION: Arthroscopic treatment of lateral ankle instability is a recent innovation. In 2014, a prospective study was initiated by the French Society of Arthroscopy demonstrating the feasibility, morbidity and short-term results of arthroscopic treatment of ankle instability. HYPOTHESIS: The functional results of arthroscopic treatment of chronic ankle instability found after one year were maintained in the medium term. MATERIAL AND METHODS: The prospective follow-up of the patients included in the initial cohort was continued. The Karlsson and AOFAS scores, as well as patient satisfaction, were assessed. The causes of failure underwent univariate and multivariate analyzes. The results of 172 patients were included (40.2% ligament repairs; 59.7% ligament reconstructions). The average follow-up was 5years. The average satisfaction was 8.6/10, the average Karlsson score was 85 points and the average AOFAS score was 87.5 points. The reoperation rate was 6.4% of patients. The failures were related to an absence of sports practice, a high BMI and female gender. A high BMI and the intense sports practice were associated to ligament repair failure. The absence of sports practice and the intraoperative presence of the anterior talofibular ligament were associated to ligament reconstruction failure. DISCUSSION: Arthroscopic treatment of ankle instability confers high satisfaction in the medium term, as well as long-lasting results with a low reoperation rate. A more detailed evaluation of the failure criteria could help guide the choice of treatment between ligament reconstruction or repair. LEVEL OF EVIDENCE: II.

Preoperative Osteopathic Manipulative Therapy Improves Postoperative Pain and Reduces Opioid Consumption After Total Knee Arthroplasty: A Prospective Comparative Study.

CONTEXT: Pain is a therapeutic challenge after total knee arthroplasty (TKA), and it could lead to the overuse of opioids. Few methodologically robust clinical studies have been performed to assess the effectiveness of osteopathic manipulative therapy (OMTh; manipulative care performed by non-US-trained osteopaths) for postsurgical pain. OBJECTIVE: To evaluate the effectiveness of standardized preoperative OMTh on early postoperative pain and opioid consumption after TKA. METHODS: This comparative, nonrandomized study took place from 2013 to 2015 and included patients who had primary unilateral TKA for osteoarthritis in a knee that had not undergone any previous surgery. Patients were divided into 2 consecutive groups: 1 group received traditional preoperative management, and the other group received associated preoperative OMTh (general OMTh [rhythmic mobilization of all the body joints, from the ankles to the skull, using long-lever manipulation] and myofascial relaxation). The primary evaluation criterion was knee pain at rest 1 month after surgery: 0 (no pain) to 100 (the worst imaginable pain). The secondary evaluation criteria were: (1) knee pain while walking 1 month after surgery, (2) average weekly knee pain during the first month after surgery, (3) the presence of night pain and the consumption of sleeping pills and opioids or morphine at least once per week, (4) the International Knee Society scores and the Western Ontario and McMaster University Osteoarthritis index at postoperative 6 months and 1 year. The number of patients needed for a superiority trial was determined. RESULTS: No eligible patient refused OMTh when proposed. Seventy patients were evaluated (mean [SD] age, 75 [8] years; 47 women and 23 men). The 2 treatment groups contained 35 patients each. At postoperative month 1, the OMTh group had significantly less pain at rest (mean [SD], 6.8 [6] vs 20.9 [17.3]; P=.00001) and while walking (7.9 [9.4] vs 23.5 [20.6]; P=.0001) compared with the group that received traditional preoperative management. The consumption of opioids during the first postoperative week was significantly lower in the OMTh group (P=.0001). No statistically significant difference was found in the International Knee Society or Western Ontario and McMaster University Osteoarthritis scores between the 2 groups at 6 months and 1 year of follow-up. CONCLUSION: Standardized preoperative OMTh was found to be effective in reducing pain in the first month after TKA for osteoarthritis and significantly reduced opioid consumption during the first postoperative week.

Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients.

BACKGROUND: Chronic ankle instability (CAI) is the main complication of ankle sprains and requires surgery if non-operative treatment fails. Surgical ankle stabilisation techniques can be roughly classified into two groups, namely, repair involving retensioning and suturing of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and reconstruction using a tendon graft. Arthroscopic repair and reconstruction techniques for CAI have been introduced recently. The objective of this prospective multicentre study was to assess the feasibility, morbidity, and short-term outcomes of these arthroscopic ankle-stabilisation techniques. MATERIAL AND METHODS: Consecutive patients scheduled for arthroscopic treatment of CAI were included prospectively. Of the 286 included patients, 115 underwent ligament repair and 171 ligament reconstruction. Mean follow-up was 9.6 months (range, 6-43 months). We recorded the AOFAS and Karlsson scores, patient satisfaction, complications, and time to return to sports. RESULTS: The overall patient satisfaction score was 8.5/10. The AOFAS and Karlsson scores improved significantly between the pre- and postoperative assessments, from 62.1 to 89.2 and from 55 to 87.1, respectively. These scores were not significantly different between the groups treated by repair and by reconstruction. Neurological complications occurred in 10% of patients and consisted chiefly in transient dysesthesia (with neuroma in 3.5% of patients). Cutaneous or infectious complications requiring surgical revision developed in 4.2% of patients. DISCUSSION: Arthroscopic treatment is becoming a method of choice for patients with CAI, as it allows a comprehensive assessment of the ligament lesions, the detection and treatment of associated lesions, and repair or reconstruction of the damaged ligaments. These simple, reliable, and reproducible arthroscopic techniques seem as effective as conventional surgical techniques. The rate of cutaneous complications is at least halved compared to open surgery. CONCLUSION: Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes.

Agreement between arthroscopic and imaging study findings in chronic anterior talo-fibular ligament injuries.

BACKGROUND: Imaging studies done to evaluate chronic ankle instability (CAI) often fail to accurately detail injuries to the anterior talo-fibular ligament (ATFL) and may, therefore, also fail to provide guidance for selecting the most appropriate surgical procedure. Arthroscopy is now an indispensable tool for accurately diagnosing ATFL injuries. This study looked at agreement between arthroscopy and imaging study assessments of ATFL injuries. The primary objective was to adapt an arthroscopic classification of chronic ATFL lesions to the pre-operative imaging study findings in order to estimate the performance of computed tomography (CT)-arthrography, ultrasonography, and magnetic resonance imaging (MRI) in diagnosing ATFL lesions, using arthroscopy as the reference standard. HYPOTHESIS: Agreement between arthroscopic and imaging findings of chronic ATFL injuries can be assessed by using a shared classification developed from the arthroscopic evaluation, used as the reference standard. MATERIAL AND METHODS: A prospective multicentre study was conducted in 286 patients with arthroscopically-treated CAI. In each patient, the arthroscopic assessment of the ATFL was compared to the pre-operative findings by CT-arthrography, ultrasonography, and MRI. A classification of ATFL lesions based on the arthroscopic assessment was used to analyse the imaging studies. Using this classification, two independent observers compared the findings and evaluated the agreement between arthroscopy and imaging studies. RESULTS: Of the 286 patients, 157 had complete information on the arthroscopic assessment and on pre-operative imaging studies and were included in the analysis. Imaging studies were CT-arthrography in 49 patients, ultrasonography in 63 patients, and MRI in 45 patients; both ultrasonography and MRI were performed in 3 patients. Agreement with arthroscopy was 82% and 88.5% for CT-arthrography, 66.7% and 76.2% for ultrasonography, 70.5% and 79.5% for MRI, and 73.4% and 81.2% for all imaging studies pooled. DISCUSSION: Arthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with CAI, as it supplies far more accurate information than any of the current imaging studies and, in addition, provides a dynamic evaluation of the ligaments and assesses mechanical strength. In the study population, a simple arthroscopic evaluation consistently visualised ATFL lesions, thereby either correcting or confirming the pre-operative imaging study findings. Importantly, the arthroscopic assessment provided more accurate information on the lesions and quality of the ATFL compared to the imaging studies. Arthroscopy has improved our knowledge of chronic ATFL lesions and allowed the development of a simple but accurate four-grade classification of direct relevance to choosing the optimal therapeutic procedure. This classification must be disseminated among radiologists to improve the diagnostic performance of pre-operative imaging studies, assist surgeons in selecting the most appropriate ankle-stabilising procedure, and improve patient information. Further studies are needed to confirm the promising results reported here and the usefulness of this common arthroscopy and imaging-study classification for chronic ATFL lesions. LEVEL OF EVIDENCE: II.

Arthroscopic classification of chronic anterior talo-fibular ligament lesions in chronic ankle instability.

BACKGROUND: The surgical treatment of chronic ankle instability (CAI) relies chiefly on anterior talo-fibular ligament (ATFL) repair (with or without augmentation) or anatomical reconstruction with a tendon graft. Arthroscopy enables not only a complete assessment and the same-stage treatment of concomitant articular lesions, but also an accurate assessment of ligament lesions. Pre-operative imaging studies (MRI, CT, US) may fail to provide sufficient detail about chronic ATFL lesions to guide the decision between repair and reconstruction. The aim of this study was to develop an arthroscopic classification of chronic ATFL lesions designed to assist in selecting the optimal surgical technique. MATERIAL AND METHODS: Sixty-nine anterior ankle arthroscopy videos recorded before surgery for CAI were studied retrospectively. ATFL dissection was performed in all patients. Based on the video analysis, five ATFL grades were identified: 0, normal ATFL thickness and tension; 1, ATFL distension with normal thickness; 2, ATFL avulsion with normal thickness; 3, thin ATFL with no resistance during the hook test; and 4, no ATFL, with a bald malleolus. Intra- and interobserver reproducibility of the arthroscopic classification of chronic ATFL lesions was evaluated by computing the kappa coefficients (κ) after assessment by two independent observers. RESULTS: All 69 ATFLs were classified as abnormal (none was grade 0). Each ATFL could be matched to a grade. Intra-observer agreement was good for both observers: κ was 0.67 with 75% of agreement for one observer and 0.68 with 76% of agreement for the other observer. Inter-observer agreement was fair to good, with κ values ranging from 0.59 to 0.88 and agreement from 70% to 91%. DISCUSSION: Arthroscopic ATFL dissection is a simple procedure that provides a highly accurate assessment of ATFL lesions and mechanical resistance, focussing chiefly on the superior ATFL. Grade 1 and 2 lesions can be repaired using the Broström-Gould procedure, whereas grade 3 and 4 lesions require anatomic reconstruction with grafting. CONCLUSION: This arthroscopic classification of chronic ATFL lesions confirms the diagnostic role for arthroscopy in assessing the ligaments in patients with CAI. It is helpful for determining the best surgical technique for stabilising the ankle. These results must be confirmed in a larger study.