Sophie Putman

Return to sport after patellar dislocation or following surgery for patellofemoral instability

Abstract Patellofemoral instability may occur in a young population as a result of injury during sporting activities. This review focuses on return to sport after one episode of dislocation treated no operatively and as well after surgery for chronic patellofemoral instability. With or without surgery, only two-thirds of patients return to sports at the same level as prior to injury. A high-quality rehabilitation programme using specific exercises is the key for a safe return to sporting activities. To achieve this goal, recovery of muscle strength and dynamic stability of the lower limbs is crucial. The focus should be directed to strengthen the quadriceps muscle and pelvic stabilizers, as well as lateral trunk muscle training. Patient education and regularly performed home exercises are other key factors that can lead to a successful return to sports. The criteria for a safe return to sports include the absence of pain, no effusion, a complete range of motion, almost symmetrical strength, and excellent dynamic stability. Level of evidence IV.

Tantalum cones and bone defects in revision total knee arthroplasty.

Management of bone loss is a major challenge in revision total knee arthroplasty (TKA). The development of preformed porous tantalum cones offers new possibilities, because they seem to have biological and mechanical qualities that facilitate osseointegration. Compared to the original procedure, when metaphyseal bone defects are too severe, a single tantalum cone may not be enough and we have developed a technique that could extend the indications for this cone in these cases. We used 2 cones to fill femoral bone defects in 7 patients. There were no complications due to wear of the tantalum cones. Radiological follow-up did show any migration or loosening. The short-term results confirm the interest of porous tantalum cones and suggest that they can be an alternative to allografts or megaprostheses in case of massive bone defects.

The ilio-inguinal approach for recent acetabular fractures: Ultrasound evaluation of the ilio-psoas muscle and complications in 24 consecutive patients

INTRODUCTION The ilio-inguinal approach is used to achieve internal fixation of acetabular fractures. Although the outcomes of this procedure have been extensively reported, information is lacking on potential complications. More specifically, the effect on the ilio-psoas muscle, whose iliac attachments are almost completely released, has not been accurately evaluated. HYPOTHESIS Endopelvic dissection does not alter the ultrasound structure of the ilio-psoas muscle compared to the normal side at a distance from acetabular internal fixation via the ilio-inguinal approach. PATIENTS AND METHODS We retrospectively evaluated 26 patients who underwent internal fixation of acetabular fractures via the ilio-inguinal approach between 2006 and 2010. Two patients with multiple injuries died shortly after the procedure, leaving 24 patients with unilateral fractures for the study. In 2012, an observer who was not involved in the surgical treatment of these patients conducted an assessment (Oxford score except in the 8 patients who required revision surgery for arthroplasty and evaluation for a deficit of the lateral femoral cutaneous nerve in the full cohort). At the same time point, ultrasonography was performed to compare ilio-psoas muscle morphology on the two sides. Any other complications (vascular, nervous, or parietal) were recorded. RESULTS Of the 24 patients, 11 (45%) experienced complications, of whom only 3 required further surgery, 2 with infections that recovered fully after lavage and 1 with a haematoma responsible for compression of the urinary bladder. The lateral femoral cutaneous nerve was injured in 8 (33%) patients, including 4 who had achieved a full recovery at last follow-up. At last follow-up, none of the 24 patients had ultrasound evidence of a significant difference in ilio-psoas muscle size at the lateral window: mean transverse diameter was 51.8±0.8mm (range, 44-58 mm) on the operated side versus 51.7±0.79 mm (range, 44-59 mm) on the other side (P=0.9). After a mean follow-up of 49 months (range, 31-70 months), the mean Oxford score in the 16 patients who had not required further surgery was 20.5/60 (range, 12-44). DISCUSSION Our results show that, despite extensive endopelvic dissection, the ilio-inguinal approach has no effect on the ultrasound morphology of the ilio-psoas muscle. There is a high risk of injury to the lateral femoral cutaneous nerve that should be disclosed to the patient before the procedure. In contrast, no parietal complications were recorded. In selected patients, the Cole-Stoppa approach is an alternative that spares the lateral femoral cutaneous nerve. LEVEL OF EVIDENCE Level IV, retrospective study.

Head Size and Metal-on-Metal Bearings

The reintroduction of metal-on-metal (M-M) bearing components in total hip arthroplasty (THA) occurred with small-diameter heads (28–32 mm) in the late 1980s and gave excellent results up to 15 years of follow-up (Dastane et al. 2011; Grubl et al. 2007; Migaud et al. 2011). Shortly thereafter, M-M hip resurfacing (SRA) resurged, and favorable outcomes are currently reported at follow-up exceeding 12 years (Amstutz et al. 2010; Coulter et al. 2012; Treacy et al. 2011). From this rapid overview of the literature on metallic articulations, one may erroneously conclude that bearing diameter has no influence on survival of M-M articulations. Currently, there is growing controversy regarding M-M bearings considering adverse reactions to metallic debris (ARMD) and concerns about blood ion elevation (Engh et al. 2010; Glyn-Jones et al. 2009; Hart et al. 2012; Heneghan et al. 2012). In fact, these side effects were rare at the time small M-M bearings were reintroduced: Rising metallic ion levels in blood were low (Grubl et al. 2007), and aseptic lymphocytic vasculitis-associated lesions (ALVAL) were extremely uncommon (<1/15,000) with small M-M (Willert et al. 2005) while pseudotumors were marginal (1/100,000) (Gruber et al. 2007). Looking back, controversy mainly emerged after large M-M bearings were launched in the late 1990s, particularly after the introduction of large-diameter head (LDH) THA and after dissemination of SRA (Heneghan et al. 2012). The goal of this chapter is to assess if these concerns apply equally to different diameters of M-M articulations.