Sébastien Parratte

Arthroscopic Treatment of Isolated Type II SLAP Lesions Biceps Tenodesis as an Alternative to Reinsertion

Background Overhead athletes report an inconsistent return to their previous level of sport and satisfaction after arthroscopic SLAP lesion repair. Hypothesis Arthroscopic biceps tenodesis offers a viable alternative to the repair of an isolated type II SLAP lesion. Study Design Cohort study; Level of evidence, 3. Methods Twenty-five consecutive patients operated for an isolated type II SLAP lesion between 2000 and 2004 were evaluated at a mean of 35 months postoperatively (range, 24-69). Patients with associated instability, rotator cuff rupture, posterosuperior impingement, or previous shoulder surgery were excluded. Ten patients (10 men) with an average age of 37 years (range, 19-57) had a SLAP repair performed with suture anchors. Fifteen patients (9 men and 6 women) with an average age of 52 years (range, 28-64) underwent arthroscopic biceps tenodesis performed with an absorbable interference screw. Arthroscopic diagnosis and treatment were performed by a single experienced shoulder surgeon, and all patients were reviewed by an independent examiner. Results In the repair group, the Constant score improved from 65 to 83 points; however, 60% (6 of 10) of the patients were disappointed because of persistent pain or inability to return to their previous level of sports participation. In the tenodesis group, the Constant score improved from 59 to 89 points, and 93% (14/15) were satisfied or very satisfied. Thirteen patients (87%) were able to return to their previous level of sports participation following biceps tenodesis, compared with only 20% (2 of 10) after SLAP repair (P = .01). Four patients with failed SLAP repairs underwent subsequent biceps tenodesis, resulting in a successful outcome and a full return to their previous level of sports activity. Conclusion Arthroscopic biceps tenodesis can be considered an effective alternative to the repair of a type II SLAP lesion, allowing patients to return to a presurgical level of activity and sports participation. The results of biceps reinsertion are disappointing compared with biceps tenodesis. Furthermore, biceps tenodesis may provide a viable alternative for the salvage of a failed SLAP repair. As the age of the 2 treatment groups differed, these findings should be confirmed by future studies.

Cementless total hip arthroplasty using custom stem and reinforcement ring in hip osteoarthritis following developmental dysplasia.

The anatomical deformities encountered in osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH) may lead to some technical difficulties when performing total hip arthroplasty. The aim of this study is to present our experience in anatomical analysis of OA following DDH and its treatment using cementless THA with a customized stem and a reinforcement ring. In anatomic X-rays and CT-scan studies of 83 hips with osteoarthritis following DDH, a great individual variability was shown despite the subluxation class considered with a reduced mediolateral and anteroposterior dimensions of the intramedullary femoral canal in all groups. Greater anteversion (ranging from 2 to 80) in all the DDH groups and a femoral neck shaft angle increased only for femora of class II were found. Another group of 116 luxations of the hip was clinically followed. Clinical outcome was found to be not correlated with the severity of luxation. The problems encountered to restore the center of rotation in THA for DDH correlated well with the severity of dislocation. The postoperative limp was correlated with a vertical position of the acetabular component of more than 35 mm from the interteardrop line. Taking into consideration hip revision for stem or acetabular replacement, the cumulative survival rate was 94.7%+/-2.7% at 12 years. Cementless custom stem is certainly a step forward in the future of hip arthroplasty in a young and active population with DDH to probably include in a preoperative and intraoperative computer assisted surgery.

Is there a need for conservative surgery in DDH adult patients? Lessons learned after 30 years experience.

The aim of the present study is to set out our thirty-year experience in conservative surgical management of developmental dysplasia of the hip (DDH) in the young adult, using either periacetabular or intertrochanteric osteotomies. All the patients have the same radiographic assessment which allows evaluating the lateral center edge angle, the obliquity of the acetabular roof by the HTE and the anterior centre edge angle. According to the Hip Study Group classification, hips were classified as average DDH when VCE and VCA are between 25 degrees and 21 degrees, severe between 20 degrees and 5 degrees and extreme below 5 degrees. The study of the articular congruency is conducted through the surgical profile evaluating the S/FH ratio (S=projected acetabulum surface, FH=1/2 projected femoral head surface) and recentring radiographs by abduction. The presence of osteoarthritis is evaluated according to Tonnis. An additional CT-scan with intraarticular injection may actually be realized. No hip arthroscopy was performed. Several original modifications have been realized, including a single intrapelvian approach allowing all the cuts and a modification of the ischial cut (2/3 PAO) in order to leave the posterior horn attached to the ischium when the S/FH ratio is below 3/4. The femoral posterior head coverage is then not modified whereas the periacetabular fragment is moved anteriorly. In our experience, PAO is an effective procedure for patients under 30 years of age without intraarticular damage and with average or severe DDH, to avoid a total hip arthroplasty in the future. For patients over 30 years old with a beginning of osteoarthritis or extreme DDH, it seems reasonable to avoid a major operation and maybe to consider less invasive techniques to delay a total hip arthroplasty.

Is the subscapularis normal after the open Latarjet procedure? An isokinetic and magnetic resonance imaging evaluation

BACKGROUNDnThe Latarjet procedure is considered to be a violation of the subscapularis muscle. This study evaluated the postoperative status of the subscapularis through isokinetic and magnetic resonance imaging analysis after splitting. We hypothesized that compared with a healthy contralateral shoulder, there would be satisfactory recovery of subscapularis strength at the cost of some fatigability and some mild fatty infiltration.nnnMATERIALS AND METHODSnThis was a case-control retrospective study of patients who underwent a Latarjet procedure between January 2013 and January 2015. A total of 20 patients were reviewed at 1 year postoperatively. With the patient seated, strength testing of both shoulders was done (concentric, eccentric, and fatigability) with a dynamometer. Trophicity and fatty infiltration were analyzed by magnetic resonance imaging.nnnRESULTSnStrength of the internal rotators (IRs) and external rotators (ERs) of the injured shoulder was significantly lower compared with the healthy shoulder in concentric testing at 180°/s and 60°/s (13% for IR and 20% for E, Pu2009<u2009.05) and in eccentric testing at 60°/s (19% for IR and 16% for ER, Pu2009<u2009.05). A peak torque ratio (ER/IR) of the operated-on shoulder was maintained. The difference in muscular endurance was significant (Pu2009<u2009.001). There was no muscle atrophy and minimal or no fatty infiltration of the subscapularis in any patient.nnnCONCLUSIONnAt 1 year after the open Latarjet procedure, isokinetic testing showed a combined strength deficit in both internal and external rotation with a conserved muscle balance. Although no significant subscapularis fatty infiltration or atrophy was noted, there was a significant deficit in endurance compared with the healthy shoulder.

No Benefit of Computer-assisted TKA: 10-year Results of a Prospective Randomized Study

Background Previously published studies reported benefits of computer-assisted surgery (CAS) in terms of radiographic implant position in TKA, but whether these improvements result in clinically important survival differences or functional differences that a patient might perceive at a minimum 10-year followup remains largely unknown. Questions/purposes We performed a prospective randomized trial and asked whether CAS (1) improved survival free from aseptic loosening; and (2) demonstrated any clear difference in patient-reported outcomes at latest followup using validated outcome measures at minimum 10-year followup. Methods Between January 2004 and December 2005, 80 patients scheduled for TKA were randomly assigned either to the CAS group or to the conventional technique group by the Hospital Informatics Department. The patient inclusion criteria were age 20 to 80 years old, weight < 100 kg, and consent to receive a primary knee arthroplasty performed through a medial parapatellar approach by the senior author. The exclusion criteria were a history of prior knee surgery, TKA performed for a posttraumatic indication, or revision knee surgery. The first 80 patients meeting these criteria were included in the study. There were 21 women and 19 men and in each group; mean age was 66 years (range, 58-77 years), and mean body mass index was 27 ± 4 kg/m2. An initial published study using this patient group investigated only differences regarding implant positioning in the coronal and sagittal planes. This is a secondary analysis of patients from the earlier study protocol at a minimum of 10-year followup with different endpoints. Kaplan-Meier survivorship was compared between groups, and functional patient-reported outcome measures (PROMs) were evaluated using the SF-12, Knee Injury and Osteoarthritis Outcome Score (KOOS), Forgotten Joint Score, and the new Knee Society Score. Those PROMs were not available at the time of the original randomized controlled trial and we therefore do not have baseline preoperative values demonstrating that our two groups were comparable. However, our groups were created using strict randomization and were similar in terms of demographic parameters and knee deformities. Our secondary analysis was not powered for survival analysis but had 80% power to detect a difference > 6 points on the SF-12 components and > 6 points out of 100 on the KOOS subscores (published minimal clinically important difference: 8 points) at the p < 0.05 level. Results With the numbers available, there was no difference between the CAS group and the conventional TKA group in terms of survivorship free from aseptic loosening 10 years after TKA (97%, 95% confidence interval [CI], 95%-99% versus 97%, 95% CI, 95%-99%; p = 0.98). Investigation of the latest followup PROM scores showed no difference between SF-12 scores (respectively, for CAS and control patients, physical SF-12: 72 ± 12 versus 73 ± 13 mean difference 0, 95% CI -3 to 3, p = 0.9; mental SF-12: 75 ± 8 versus 73 ± 10, mean difference 2, 95% CI 0−4, p = 0.3) as well as for all KOOS subscores (all p > 0.1). Forgotten Joint Scores were similar in both groups with 83 ± 4 for CAS and 82 ± 5 for control patients (mean difference 1, 95% CI 0−2, p = 0.2). Finally, the new Knee Society Scores were not statistically different between groups with a mean objective score of 82 ± 13 for CAS patients versus 79 ± 12 for control patients (mean difference 2, 95% CI 0−5, p = 0.5) and a mean subjective score of 83 ± 11 versus 85 ± 12, respectively (mean difference 2, 95% CI 0−5, p = 0.5). Conclusions Our observations suggest that CAS used for TKA alignment with restoration of a neutral mechanical axis as the goal did not confer any substantial advantage in survivorship, function, or quality of life at 10 years after TKA. Larger studies with longitudinal collection of PROMs for functional assessment and greater numbers to assess survivorship are needed to confirm these findings. Level of Evidence: Level III, therapeutic study.

Articular-surface-based automatic anatomical coordinate systems for the knee bones

Increasing use of patient-specific surgical procedures in orthopaedics means that patient-specific anatomical coordinate systems (ACSs) need to be determined. For knee bones, automatic algorithms constructing ACSs exist and are assumed to be more reliable than manual methods, although both approaches are based on non-unique numerical reconstructions of true bone geometries. Furthermore, determining the best algorithms is difficult, as algorithms are evaluated on different datasets. Thus, in this study, we developed 3 algorithms, each with 3 variants, and compared them with 5 from the literature on a dataset comprising 24 lower-limb CT-scans. To evaluate algorithms sensitivity to the operator-dependent reconstruction procedure, the tibia, patella and femur of each CT-scan were each reconstructed once by three different operators. Our algorithms use principal inertia axis (PIA), cross-sectional area, surface normal orientations and curvature data to identify the bone region underneath articular surfaces (ASs). Then geometric primitives are fitted to ASs, and the ACSs are constructed from the geometric primitive points and/or axes. For each bone type, the algorithm displaying the least inter-operator variability is identified. The best femur algorithm fits a cylinder to posterior condyle ASs and a sphere to the femoral head, average axis deviations: 0.12°, position differences: 0.20u202fmm. The best patella algorithm identifies the AS PIAs, average axis deviations: 0.91°, position differences: 0.19u202fmm. The best tibia algorithm finds the ankle AS center and the 1st PIA of a layer around a plane fitted to condyle ASs, average axis deviations: 0.38°, position differences: 0.27u202fmm.

A 20-year follow-up evaluation of total hip arthroplasty in patients younger than 50 using a custom cementless stem

Aim: The purpose of this study is to report the 20-year follow-up of a continuous series of 232 total hip arthroplasties (THAs) performed in patients aged less than 50 at the index surgery. Patients and methods: This is a retrospective monocentric study which reports the clinical, radiographical and survival results of 232 THAs performed with a custom cementless femoral stem in 212 patients evaluated at follow-up ranging from 14 to 27u2004years. Results: At the time of follow-up, the mean Harris Hip Score was 94.1 (range 48–100). The Hip disability and Osteoarthritis Outcome Score was >80 points in all 5 categories for 146 patients (68.9%). 18 hips (8.5%) showed radiographical femoral abnormalities. 23 hips (10.8%) underwent revision of the implants. 13 were isolated cup revisions. 3 more hips had bipolar revisions for aseptic loosening at 15, 20 and 21u2004years. Taking stem revision for aseptic loosening as an endpoint, survivorship was 96.8% at 20u2004years (95% confidence interval, 95.1–98.5; patients at risk 76) and 94.5% at 25u2004years (91.7–97.3; patients at risk 12). Conclusions: The results of this study confirm that THA using this custom-designed stem can provide excellent clinical and radiographical outcomes at a mean follow-up of 20u2004years in patients younger than 50. The individual 3D femoral stem and prosthetic neck has been able to restore extra- and intramedullary functional anatomy in this young and active cohort of patients.

Surgical Technique and Long-Term Results of Bicompartmental Reconstruction with Small Implants

Treatment of limited osteoarthritis of the knee remains a challenging problem [1, 2, 3, 4]. While the therapeutic goals are to alleviate pain and restore knee function [1-4], non-operative modalities, including physiotherapy, activity modification (avoiding impact activities), anti-inflammatory medications, and bracing, often provide limited pain relief and functional improvement [1, 2, 3, 4]. Surgical management of limited arthritis of the knee can include non-prosthetic treatments such as arthroscopic debridement, meniscus transplantation, cartilage repair, high tibial osteotomy (HTO), and tibial tubercle transposition [1, 2, 3, 4, 5, 6]. Arthroplasty solutions consist of unicompartmental knee arthroplasty (UKA) and conventional total knee arthroplasty (TKA) [1, 2, 3, 4, 5, 6], both of which are expected to be efficient, durable and safe but should preserve the bone stock when possible [3]. TKA may offer durable and satisfying clinical and radiological results when arthritis involves the three compartments of the knee; however, it does not preserve either the bone stock or the ligaments [7, 8]. UKA is a bone- and ligament-sparing technique that can reliably restore knee kinematics and function in patients with arthritis limited to one compartment of the knee [9, 10, 11, 12]. The outcomes of UKA have improved since its introduction more than 30 years ago due to improvements in design, indications, materials, and surgical techniques [13, 14]. The results of UKA are reportedly better when the anterior cruciate ligament (ACL) is intact [15, 16]. Similarly, outcome and kinematic studies suggest that maintaining the ACL in bi- and tri-compartmental knee arthroplasty may be advantageous in terms of survivorship [17, 18], stair climbing ability [19], patient satisfaction, and joint kinematics [9, 17, 19, 20, 21, 22].