Dominique Saragaglia

Posterior approach and dislocation rate: A 213 total hip replacements case-control study comparing the dual mobility cup with a conventional 28-mm metal head/polyethylene prosthesis

INTRODUCTION Dislocation is a frequent complication of total hip arthroplasties (THA) especially in older patients, especially when using a posterior approach. In these cases, dual mobility (DM) cups developed by Gilles Bousquet in 1975 can be indicated to reduce this complication risk. HYPOTHESIS Dual mobility cups reduce the rate of dislocation in primary total hip arthroplasty using posterior approach in a single-surgeon series. AIM Test this hypothesis in a controlled study to compare the rate of dislocation in primary total hip arthroplasties done in patients over 50 years old either with a dual mobility cup or a conventional metal-on-polyethylene 28-mm diameter head. PATIENTS AND METHODS Two consecutive series of primary total hip replacements were performed by a single surgeon using a posterolateral approach. The piriformis tendon was left intact. The DM series included 105 patients who underwent arthroplasty between January 2005 and June 2007 with a dual mobility cup (60 women and 45 men, mean age 76.6±5.65 years old [53-93]). The control series (S series) included 108 patients who underwent arthroplasty (56 women and 52 men, mean age 74.2±5.9 years old [53-87]) with a conventional 28-mm polyethylene cup between January 2003 and June 2005. All hip replacements included a 28-mm metal-polyethylene cup and a 12-14-mm Morse taper. Both groups were comparable for gender, diagnosis, body mass index, type of anesthesia and ASA score distribution. All patients included in this series had a minimum follow-up of 1 year. RESULTS There were no dislocations in the DM series and five early dislocations (before the third month) in the S series for a rate of 4.63%. Although the rate of dislocation was higher in the S series (4.63% vs 0%), the difference was barely significant (P=0.0597). DISCUSSION This study comparing the incidence of dislocations after THA with conventional or dual mobility cups, shows that even using a posterior approach and in older patients, dual mobility cups increase stability with no postoperative dislocations. Although results are barely significant, a larger series should confirm the benefit of this implant. In this series, morbidity was not increased with dual mobility cups. LEVEL OF EVIDENCE Level III: retrospective case-control study.

Computer-assisted total knee replacement arthroplasty

The reliability of techniques to position a total knee replacement (TKR) is still limited by the relative inaccuracy of the instrumentation. The main obstacle encountered by mechanical instrumentation systems is the inconsistency of the reference points. These reference points are the centers of joint articulation that will allow the establishment of the mechanical axis for the lower limb. These references guide the placement of the bone-cutting guides. At present, it is impossible to accurately locate these articular centers preoperatively. This handicaps the accuracy of the mechanical instruments and limits their accuracy. The goal of the total knee instrumentation procedure is to achieve cuts that are perpendicular to the mechanical axes of the femur and the tibia. The longevity of total knee arthroplasty is closely related to its intraoperative positioning. The computer-assisted procedure offers an effective and novel positioning method that improves the accuracy of the surgical technique of the TKR. We have chosen to present the steps of the computer-assisted TKR technique next to the corresponding steps of a currently available, mechanically based technique that is representative of many that are presently in use.

Acute and old ruptures of the extensor apparatus of the knee in adults (excluding knee replacement)

Rupture of the extensor apparatus of the knee in adults is infrequent and dominated by patellar fracture, which in our experience is six times as frequent as quadriceps or patellar tendon tear. Patellar fracture poses few diagnostic problems and treatment is now well codified. Tension-band osteosynthesis is generally used, involving two longitudinal K-wires and wire in a figure-of-eight pattern looped over the anterior patella; sometimes, for more complex fractures, cerclage wiring is added to the tension band. Non-union is rare and generally well tolerated. Quadriceps tendon tear mainly affects patients over 40 years of age, in a context of systemic disease. Diagnosis is easily suggested by inability to actively extend the knee, but is unfortunately still often overlooked in emergency. In most cases, early surgical management is needed to reinsert the tendon at the proximal pole of the patella by bone suture. For chronic lesions, it is often necessary to lengthen the quadriceps tendon by V-Y plasty or the Codivilla technique. Patellar tendon tear, on the other hand, typically occurs in patients under 40 years of age, often involved in sports. Diagnosis is again clinically straightforward, but again may be missed in emergency, especially in case of incomplete tear. Surgery is mandatory in all cases. The procedure depends on the type of lesion: either end-to-end suture or transosseous reinsertion. In most cases repair is protected by tendon augmentation. Old lesions often require tendon graft or a tendon-bone-tendon-bone graft taken from the opposite side.

Computer-assisted osteotomies for genu varum deformity: which osteotomy for which varus?

High tibial osteotomy (HTO) is commonly used for genu varum deformity in young and active patients. Corrective valgus osteotomy may however lead to an oblique joint line in cases of associated femur varum or absence of tibia vara. The over-correction, needed to obtain good long-term clinical results, may increase the obliquity even more. To avoid this drawback, the authors suggest use of an accurate and reproducible radiological protocol including at least a standing AP long-leg X-ray to measure not only the hip–knee–ankle (HKA) angle but also the medial distal femoral mechanical angle (MDFMA) and the medial proximal tibial mechanical angle (MPTMA). These measures will guide the surgeon to choose the best indication, including HTO, double level osteotomy (DLO) and distal femoral osteotomy (DFO). Computer-navigation of the osteotomies is the best choice to achieve the preoperative goal. This paper will present the pre- and perioperative protocols of HTO and DLO and the rationale behind this way of thinking.

Reconstruction of the Lateral Ankle Ligaments Using an Inferior Extensor Retinaculum Flap

The aim of this study was to assess the results of 32 cases of chronic ankle instability. These were treated by ligament shortening and reinforced with an inferior extensor retinaculum flap. All patients complained of persistent functional instability unrelieved with proprioceptive exercises. Results were assessed clinically (pain, instability, recovery of sports activity, mobility) and radiologically (correction of laxity on stress x-rays). This enabled us to draw up a revision score on a scale of 100 points. We obtained a mean score of 86.7 points (45–100 points), and subjective results showed that 88% of the patients were satisfied with the surgery.

Acute quadriceps tendon ruptures: A series of 50 knees with an average follow-up of more than 6 years

INTRODUCTION Quadriceps tendon ruptures are rare and mainly affect patients over 40 years of age who have a systemic disease. The aim of this study was to evaluate the functional and radiological outcomes following surgical repair of acute quadriceps tendon ruptures. METHODS This retrospective study included 68 knees in 65 patients (three women, 62 men), having an average age of 55.2 ± 13.9 years. The Lysholm and Tegner scores, patient satisfaction, range of motion and X-rays were evaluated. RESULTS Fifty knees were evaluated with a mean follow-up of 76±67 months (12-253 months). The average Lysholm score was 93.7±10 (range 56-100, median 99) and 49 of 50 knees (98%) had good or very good subjective results. The average Tegner score was 3.4±1.6 (range 1-9, median 4). At the last follow-up, the average active flexion was 133°±10.8° (range 110°-150°, median 130°). Minor or moderate patellofemoral osteoarthritis was found in 24% of knees, but this was attributed to the surgery or initial injury in only 8% of cases. For 97% of active patients, the surgical repair allowed them to return to work in their pre-injury occupations. CONCLUSION Quadriceps tendon ruptures have a good prognosis if they are diagnosed quickly. Treatment consists of surgery and postoperative immobilization for at least 6 weeks. An intensive rehabilitation protocol is also needed to recover good knee function. LEVEL OF EVIDENCE Level IV. Retrospective study.

Acute traumatic patellar tendon rupture: Early and late results of surgical treatment of 38 cases

INTRODUCTION Acute patellar tendon rupture is easy to diagnose but is still often overlooked. The aim of this study was to assess early and late results of surgical treatment of acute patellar tendon rupture. Our hypothesis was that functional outcome is satisfactory. METHODS A retrospective study included 38 knees in 37 patients (4 female, 33 male). Mean age was 42.6 ± 9.9 years (range, 23-81 years). Lesions comprised 15 tendon body ruptures, 20 avulsions from the tip of the patella and 3 avulsions from the anterior tibial tuberosity. Tendon repair was protected in more than 95% of cases by a reinforcement frame: hamstring (21 cases), synthetic ligament (12 cases) or metallic wire (3 cases). Results were evaluated in 2 steps: on patient files at a mean follow-up of 7.1 months (range, 3-24 months) to assess complications and early functional and radiological results; and by phone at a mean follow-up of 9.3 years (range, 19-229 months) in order to assess long-term functional outcome on Lysholm score and patient satisfaction. RESULTS Thirty-one knees were assessed at a mean 7.1 months. Mean knee flexion was 128.5° ± 7.5° (range, 85°-150°), extension -1° (range, -15° to 0°) and Caton-Deschamps index 0.96 (range, 0.57-1.29). Twenty-three knees were further assessed at a mean 9.3 years. Mean Lysholm score was 93.7 points (range, 61-100). Ninety-six percent of patients were satisfied or very satisfied with the result. All had returned to their previous job, and 20 had returned to sports activities, including 8 at pretrauma level. CONCLUSION Patellar tendon rupture has good prognosis if diagnosis and surgical treatment is early.

Return to sports after autogenous osteochondral mosaicplasty of the femoral condyles: 25 cases at a mean follow-up of 9 years.

INTRODUCTION Autogenous osteochondral mosaicplasty is the most common cartilage restoration technique in standard clinical practice. The purpose of this study was to evaluate the return to sports 9 years after mosaicplasty of the femoral condyles. HYPOTHESIS The long-term results of an osteochondral autograft show that patients can regain their pre-injury activity level. MATERIAL AND METHODS This study is based on a series of 25 patients with a mean age of 28.9 years (range, 16-44 years) who had stage 3 or 4 chondral lesions of the femoral condyles (according to the ICRS or ICRS-OCD scores). The origin of the lesion was osteochondritis dissecans (13 knees), osteochondral fracture sequelae (ten knees), or aseptic osteonecrosis (two knees). The average size of the lesion was 2.11 ± 0.9 cm(2). Ten patients (40%) had an associated procedure during the osteochondral autograft. The patients were assessed clinically (IKDC and Lysholm-Tegner scores) and radiographically by a reviewer independent of the team of operators. RESULTS All patients were re-examined at a mean follow-up of 9 years (range, 6-15 years), with 84% satisfied or very satisfied with the procedure. The average IKDC was 74.5 ± 18.5 points. The average Lysholm score was 87.3 ± 11.6 points. The average Tegner score ranged from 6.35 ± 1.53 points prior to surgery to 5.60 ± 1.64 points after surgery (P = 0.001). The average loss was 0.64 points for patients whose presurgery Tegner score was greater than or equal to 7 (P = 0.019) and 0.3 points if lower than 7. The radiologic evaluation of 21 patients showed complete osteointegration of the grafts in 90% of cases. CONCLUSION The results of the femoral condyle mosaic autografts are satisfactory, a mean of 9 years after surgery. The most active patients lowered their activity level while the more sedentary did not have to adapt their lifestyle.

Ostéosynthèse antérieure par plaque à vis verrouillée LCP 3.5® dans les fractures de l’extrémité inférieure du radius à déplacement postérieur. À propos de 24 cas

PURPOSE OF THE STUDY Fracture of the distal radius with posterior displacement is the most common wrist fracture. Pinning is generally proposed. The problem is that a secondary displacement may persist, even for the least complex fractures. With the advent of the fixed-angle plate with a self-locking screw, we considered using this method in combination with an anterior approach to the radius. We report our preliminary results. MATERIAL AND METHODS From November 1 to March 31, 2003, among the 195 fractures of the distal radius with posterior displacement which we treated in our unit, 135 were treated with orthopedic reduction, 36 with Kapandji pinning and 24 with a T-shaped anterior locking compression plate (Synthès, LCP 3.5. During the early part of this series, the LCP was used for emergency situations in young adults with a posterior displacement exceeding 20 degrees . Starting in November 2002, the technique was also proposed for revisions for secondary displacements after orthopedic reduction or pinning procedures. Secondary displacement was noted on the standard X-rays and the clinical analysis included a measurement of muscle strength, the DASH score and the clinical evaluation score used by the SOFCOT symposium in November 2000. RESULTS Twenty-four patients (14 female, 10 male, mean age: 54.5 years) presented 14 extra-articular fractures and ten articular fractures. At admission, mean frontal inclination of the radial glenoid was 13 degrees with a posterior displacement of 25.45 degrees and an ulnar variance measuring+4mm. Eighteen patients were reviewed at mean 16 months follow-up. Mean frontal inclination of the glenoid was 23.95 degrees with mean anteversion 5.45 degrees . Using the SOFCOT criteria, 11 outcomes were anatomic and seven presented moderate displaced healing. The wrist force (Jamar was 95% of the value measured on the healthy side. The mean DASH score was 38.47. Outcome was considered excellent for nine cases, good for six, fair for three and poor for zero. Complications were: reflex dystrophy (n=4), carpal tunnel syndrome (n=1), cheloid scar (n=1), glenoids in the pulse gutter (n=10), and secondary fracture along the upper border of the plate (n=3). CONCLUSION This study demonstrated that, used on the anterior aspect of the radius, the locking compression plate provides satisfactory treatment for fractures of the distal radius with posterior displacement. Because of the angular stability, the reduction can be maintained over time so that secondary displacement is no longer a problem. This is a difficult technique which requires particular skill. We no longer recommend the LCP 3.5 plate due to the poorly adapted ergonometry, the late fracture over the plate and the fact that the material is not removed.

Meniscoplasty for lateral discoid meniscus tears: Long-term results of 14 cases

INTRODUCTION Discoid lateral meniscus lesions are relatively rare. The objective of this study was to determine the long-term results of 14 cases of discoid lateral meniscus tears treated by arthroscopic meniscoplasty between July 1991 and May 2009, and to assess the development of osteoarthritis in the lateral compartment. METHODS The series consisted of 10 patients (14 knees): 3 girls under the age of 15, 3 men and 4 women aged from 16 to 47 years (mean age: 31.4±11.1 years). The main reason for consultation was pain in 10 cases, locking in 2 cases and pain associated with locking in 2 cases. The diagnosis was confirmed preoperatively by MRI in 10 cases, CT-arthrography in 1 case and arthrography in 3 cases. The indication for surgery was made because of a symptomatic discoid lateral meniscus. All cases were treated by arthroscopic meniscal reshaping. Functional results were evaluated using the Lysholm-Tegner, IKDC, KOOS and satisfaction scores. Radiological results were evaluated based on the modified Alhbäck classification for osteoarthritic (OA) changes. RESULTS No complications were found. Two patients were lost to follow-up. The remaining eight patients (12 knees) were reviewed at a mean of 157.5±72.1 months (61-276). The mean Lysholm-Tegner score was 88.9±10.6 points (67-100), the mean KOOS was 92.4±9.5 (65-100) and the mean IKDC score was 85.4±16.5 points (65-100). All eight of the reviewed patients were satisfied or very satisfied with the result. Radiological analysis found that five knees had no signs of OA, five knees had stage 1, one had stage 2 and one had stage 3. At last follow-up, no patient had been reoperated. CONCLUSION Meniscoplasty of discoid lateral meniscus tears leads to excellent long-term functional results despite signs of osteoarthritic changes in the lateral compartment of the knee. LEVEL OF EVIDENCE IV (retrospective study).