P. Merloz

Anterior Cruciate Ligament Reconstruction Using Navigation A Comparative Study on 60 Patients

Background Poor outcome in anterior cruciate ligament reconstruction is often related to tunnel position. Hypothesis Improving accuracy of the tunnel position will lead to improved outcome. Study Design Randomized controlled trial; Level of evidence, 1. Methods Sixty patients were randomized to either standard instrumentation or computer-assisted guides to position the tibial and femoral tunnels. The results were evaluated on clinical outcome based on International Knee Documentation Committee form (laxity) and radiologic assessment: radiologic Lachman (Telos at 150 and 200 N) and analysis of the tunnel positions. Results International Knee Documentation Committee laxity was level A in 22 knees in the conventional group (mean, 1.5 mm at 200 N) compared with 26 navigated knees (mean laxity, 1.3 mm; P= .49). Laxity was less than 2 mm in 96.7% of the navigated group and 83% of the conventional group (P= .292). The variability of laxity in the navigated group was significantly less than in the conventional group, with the standard deviation of the navigated group being smaller than that in the conventional group (P= .0003 at 150 N and .0005 at 200 N Telos). A significant difference (P= .03) was found between the groups in the ATB value (distance between the projection of the Blumensaat line on the tibial plateau and the anterior edge of the tibial tunnel), characterizing the sagittal position of the tibial tunnel (negative ATB values imply graft impingement in extension). In the conventional group, mean ATB was –0.2 (–5 to + 4), whereas it was 0.4 (0 to 3) in the navigated patients. There were no negative ATB values in the navigated group. Conclusion This study confirms that the accuracy and consistency of tibial tunnel position can be improved by the use of computer-assisted navigation and that the clinical result in terms of laxity is more reliable.

Lésions neurologiques des fractures de l'anneau pelvien : À propos d'une série prospective continue de 50 lésions pelviennes postérieures opérées par vissage ilio-sacré

PURPOSE OF THE STUDY The purpose of this study was to analyze lesions to the lumbosacral plexus related to pelvic injury and its treatment. MATERIAL AND METHODS Forty-four patients presented 50 posterior osteoligamentary lesions of the pelvic girdle. All patients except eight had other injuries. Mean ISS was 27/75. Posterior lesions were: iliosacral disjunction (n=23), extra-foraminal fracture of the sacrum (n=4), transforaminal fracture (n=22), intra-foraminal fracture (n=1). Vertical posterior displacement was > 1 cm for 24 posterior lesions. Orthopedic reduction was performed at admission for all patients. Fluoroscopy-guided percutaneous lag screw fixation was performed in all cases, on the average eight days after the accident. Neurological involvement was evaluated at admission, after surgery, and at last follow-up. Data were recorded for skeletal muscles, lower limb dermatomes, tendon reflexes, and anal tone. Screw emplacement was checked on the CT-scan. Outcome was assessed subjectively with the Majeed score, a self-administered visual analog scale, and use of antalgesic drugs according to the WHO classification. RESULTS The neurological examination could not be performed for ten patients at admission. Postoperatively, there was a neurological deficit associated with 26 osteoligamentary lesions (23 lesions of the lumbosacral trunk, 14 lesions of the S1 spinal nerve, 3 lesions of the pudendal nerve, 12 lesions of the superior gluteal nerve, and 10 lesions of the femoral nerve). Patients with neurological involvement had experienced more severe trauma. The iliosacral screw was partially extra-osseous in thirteen cases, with an associated iatrogenic neurological deficit in seven. At mean follow-up of 20 Months (range 4-50) there persisted ten major sequelae including eight cases of hallux extensor deficit. DISCUSSION Neurological involvement is underestimated during the acute phase of trauma. After recovery, only the manifestations of major injuries persist. The prognosis is poor in the event of a stretched lumbosacral trunk or gluteal nerve due to iliosacral disjunction. Prognosis is good for nerve contusion due to sacral fracture because of early reduction. The femoral nerve is generally injured by compression due to a peri-fracture hematoma; recovery is the rule. Iliosacral screwing requires rigorous technique by a skilled and experienced surgeon. CONCLUSION About 52% of posterior osteoligamentary injuries are associated with neurological symptoms. After recovery, permanent deficit persists in 21.7%. The most common sequelae are hallux extensor and gluteus medius palsy due to stretching of the lumbosacral trunk.

Epiphyseal stapling of the proximal tibia for idiopathic genu valgum.

PurposeThe purpose of this study is to evaluate the clinical and radiological outcomes of hemiepiphysiodesis with a single medial staple of the proximal tibia in idiopathic genu valgum angular correction.MethodsA retrospective review was performed identifying nine adolescents (18 knees) treated for idiopathic adolescent genu valgum by means of a bilateral hemiepiphysiodesis with a single staple of the proximal tibia. The intermalleolar distance (IMD) and hip–knee–ankle angle were measured at skeletal maturity.ResultsThe IMD and hip–knee–ankle angle were reduced in all patients at skeletal maturity.ConclusionHemiepiphysiodesis with a single medial staple of the proximal tibia seems to be a reliable and safe alternative method to achieve correction of an idiopathic genu valgum.