Xavier Roussignol

Multifocal Joint Osteonecrosis in Sickle Cell Disease

The purpose of this study was to evaluate the frequency of multifocal osteonecrosis in patients with sickle cell disease. Between 1980 and 1989, 200 patients with sickle cell disease were treated in our institution for osteonecrosis. The patient population consisted of 102 males and 88 females with a mean age of twenty-six years at the time of presentation (range, eighteen to thirty-five years) and was followed until the year 2005. This cohort of patients was follow-up during average 15 years (until the year 2005). Multifocal osteonecrosis was defined as a disease of 3 or more anatomic sites. At the time of presentation, 49 patients were identified as having multifocal osteonecrosis. At the most recent follow-up, 87 patients had multifocal osteonecrosis. So at the last follow up among these eighty-seven patients, the occurrence of osteonecrosis was 158 lesions of the proximal femur associated with 151 proximal humerus osteonecroses, thirty-three lateral femoral condyle osteonecroses, twenty-eight distal femoral metaphysis osteonecroses, twenty-seven medial femoral condyle osteonecroses, twenty-three tibial plateau osteonecroses, twenty-one upper tibial metaphysis osteonecroses and forteen ankle osteonecroses. The total number of osteonecrosis was 455 in these 87 patients. The epiphyseal lesions were more frequent than the metadiaphyseal lesions excepted in the proximal tibia (Table 3). In conclusion, in patients with sickle cell disease, the risk of multifocal osteonecrosis is very high. In patients with hip osteonecrosis, the other joints should be evaluated with radiograph and MRI if the joint is symptomatic. In patients with osteonecrosis of the knee, shoulder or ankle, the patients’ hip should be evaluated by radiographs or MRI, regardless of whether the hip is symptomatic.

Ceramic-on-ceramic THA associated with fewer dislocations and less muscle degeneration by preserving muscle progenitors.

BackgroundDislocation is a common complication after total hip arthroplasty (THA). Although the etiology of dislocation is multifactorial, longer-term changes in muscle such as atrophy may influence the risk of prosthetic dislocation. Biological differences in wear products generated by different bearing surfaces may influence differences in the appearance of periarticular muscle after THA; however, such bearing-associated differences to our knowledge have not been studied in vivo, and few studies have evaluated bearing-associated differences in dislocation risk.Questions/purposes(1) Is there a correlation between the postoperative risk of dislocation at revision and the bearing surfaces of the primary arthroplasty? (2) Is there a higher extent of fatty muscle atrophy on CT scan in hips with osteolysis (polyethylene hips) as compared with hips without osteolysis (ceramic-on-ceramic hips)? (3) Are these two abnormalities (bone osteolysis and fatty atrophy) associated with a decrease of mesenchymal stem cells (MSCs) in bone and in muscle?MethodsWe retrospectively evaluated 240 patients (240 hips) who had a THA revision (98% of which, 235 of the 240, were isolated acetabular revisions) and a normal contralateral hip. All patients had received the same implants for the primary arthroplasty (32-mm head) except for bearing surfaces (80 hips with ceramic-on-ceramic, 160 with polyethylene). No differences were noted between the groups in terms of age, sex, body mass index, proportion of patients who had a dislocation after the index arthroplasty but before the revision, and proportion of the patients with stem loosening in addition to acetabular loosening. Indications for revision generally were cup loosening. The revisions in the hips with polyethylene bearings generally had more acetabular bone loss, but the position of the center of the cup and the orientation of the cup were similar after reconstruction in the two groups. Before revision, osteolysis, muscle atrophy, and fatty degeneration were evaluated on CT scan and compared with the contralateral side. Bone muscle progenitors were evaluated by bone marrow MSCs and satellite cells for muscle. At revision, all the hips received the same implants with the same head diameter (32 mm) and a standard liner. Revisions were performed between 1995 and 2005. The followup after revision was at a mean of 14 years (range, 10–20 years) for ceramic revision and 12 years (range, 10–20 years) for polyethylene hips, and there was no differential loss to followup between the groups.ResultsMore hips with polyethylene liners at the time of index arthroplasty dislocated after revision than did hips with ceramic liners (18% [29 of 160] compared with 1% [one of 80]; odds ratio, 17.5; 95% confidence interval, 2.3363–130.9100; p = 0.005). For the 80 hips with ceramic-on-ceramic, no osteolysis was detected before revision; there was no muscle fatty degeneration of the gluteus muscles on CT scan or histology. For the 160 hips with polyethylene liners, osteolytic lesions on the acetabulum and femur were observed in 100% of the hips. The increased atrophy of the gluteus muscles observed on CT scan correlated with the increase of osteolysis (r = 0.62; p = 0.012). The surgical limbs in the patients with polyethylene hips as compared with ceramic-on-ceramic hips demonstrated a greater reduction in cross-sectional area (respectively, 11.6% compared with 3%; odds ratio, 3.82; p < 0.001) and radiological density (41% [14.1/34.1] compared with 9%; odds ratio, 6.8; p = 0.006) of gluteus muscles when compared with the contralateral normal side. (41% compared with 9%; odds ratio, 6.8; p = 0.006).ConclusionsCeramic bearing surfaces were associated with fewer dislocations after revision than polyethylene bearing surfaces. The reasons of the lower rate of dislocation with ceramic-on-ceramic bearings may be related to observed differences in the periarticular muscles (fat atrophy or not) with the two bearing surfaces.Level of EvidenceLevel III, therapeutic study.

Fifteen Year Outcome of the Ceraver Hermes Posterior-Stabilized Total Knee Arthroplasty: Safety of the Procedure with Experienced and Inexperienced Surgeons

We wished to determine whether total knee replacement (TKA) performed by young surgeons increased rates of mortality and complications compared with TKA performed by senior surgeons using the same model of arthroplasty. There were no significant pre-operative differences between the groups in terms of age, gender, height, weight, body mass index, diagnosis, comorbidity and duration of follow-up, which was a mean of 15 years in both groups. Hence, we assessed the 15 year survival of the first 150 Ceraver Posterior-Stabilized total knee arthroplasties undertaken by young surgeons (aged of less than 30 years) in formation in a single university hospital setting (Group B). We used survival curve analysis, with strict definitions regarding end-points, and evaluated a number of different endpoint criteria to assess the outcome and to compare the results with those obtained by the two seniors (aged of more than 40 years) with their 50 first implantations (Group A). The clinical results and survival rate of implants at intermediate to long-term follow-up were similar in both Groups. Kaplan-Meier survival analysis, with revision as the endpoint for failure, showed that the rate of survival at ten years was 96% (95% CI, 93 to 100) in both groups. At fifteen years the rate of survival was 91% (95% CI, 85 to 97) in group B, and 92% (95% CI, 90 to 94) in group A. The implant used in this series appears particularly safe since the usual complications observed with posterior stabilized arthroplasties were not observed even with young surgeons.

Fixation of the Cemented Stem: Clinical Relevance of the Porosity and Thickness of the Cement Mantle

The aim of this review paper is to define the fixation of the cemented stem. Polymethyl methacrylate, otherwise known as “bone cement”, has been used in the fixation of hip implants since the early 1960s. Sir John Charnley, the pioneer of modern hip replacement, incorporated the use of cement in the development of low frictional torque hip arthroplasty. In this paper, the concepts of femoral stem design and fixation, clinical results, and advances in understanding of the optimal use of cement are reviewed. The purpose of this paper is to help understanding and discussions on the thickness and the porosity of the cement mantle in total hip arthroplasty. Cement does not act as an adhesive, as sometimes thought, but relies on an interlocking fit to provide mechanical stability at the cement–bone interface, while at the prosthesis– cement interface it achieves stability by optimizing the fit of the implant in the cement mantle, such as in a tapered femoral stem.

Anatomic Feasibility Study of Posterior Arthroscopic Tibiotalar Arthrodesis

Background: Operative indications for an anterior arthroscopic tibiotalar arthrodesis are well defined. A posterior approach with the patient in a prone position may be indicated when the anterior approach is precluded by the soft tissue condition or for a 1-step procedure associated with posterior approach subtalar fusion. Methods: An anatomic study assessed the feasibility of posterior arthroscopic tibiotalar fusion and sought to determine arthroscopy entry points, mortise cartilage freshening quality, and the risk of osseous, tendinous, vascular, and neural complications. Twenty-two zones of the fibular tibiotalar mortise were mapped from 10 specimens. Medial and lateral para-Achilles arthroscopic portals were used with a 4 mm 30-degree arthroscope. Chondral resection was performed with a motorized burr, curette, and osteotome. Results: The entire plafond of the tibia could be debrided in all cases, whereas the talar dome was debrided in its entirety in 20% of cases; in 80%, only the posterior two-thirds could be treated with the anterior portion approaching the neck of the talus being poorly accessible. More than 50% of the area of the malleolar grooves was debrided. There was 1 medial malleolar fracture and 1 peroneal artery lesion. Conclusion: The technique was shown to be feasible if there was no frontal hindfoot deformity or tibiotalar equinus preventing satisfactory resection of the posterior and anterior talar cartilage. Clinical Relevance: This study demonstrated that a posterior approach arthroscopic ankle fusion would lead to adequate joint preparation. This procedure reduces the risk of nerve damage.

131 Arthrodèse sous talienne par technique arthroscopique : technique et indications. Résultats préliminaires d’une série prospective de 21 cas d’arthrodèse avec 1 an de recul moyen

Introduction Le premier travail sur l’arthroscopie sous-talienne a ete publie par Parisien dans Foot & Ankle en 1986 et encore aujourd’hui tres peu d’equipe en ont l’experience. Nous exposons notre propre experience en ce domaine, en rapportant les resultats d’une serie prospective de 21 arthrodeses revues a 1 ans de recul moyen. Materiel et Methode La technique initiale utilisait (14 patients) deux voies d’abord antero- et postero-laterales en decubitus dorsal tel que le preconisaient Parisien ou Frey ; le nettoyage initial du sinus du tarse par la voie anterieure permettait d’aborder la sous-talienne posterieure par en avant, et l’avivement sous-talien se poursuivait avec la voie postero-externe (instrumentation motorisee et curettes). Un vissage canule talo-calcaneen etait realise par une courte incision anterieure, au moyen d’une vis de diametre 6,5. Les derniers patients inclus (7 patients dans cette serie) ont beneficie d’une approche posterieure differente en decubitus ventral avec un optique 4 par deux voies para tendineuse telles que les a decrites Van Dijk pour traiter les conflits posterieurs de la cheville. Cette voie d’abord permettait l’exposition complete de l’articulation sous-talienne posterieure. La fixation a ete la encore assuree par une vis canulee calcaneo-talienne postero-anterieure. Resultats Il s’agissait donc du suivi prospectif de 18 hommes et 3 femmes d’âge moyen 50 ans (33-75) revus a 12 mois de recul minimum. Parmi les etiologies, on notait seize sequelles traumatiques (fracture calcaneenne et/ou talienne), deux sequelles de laxite chronique, une atteinte degenerative, une arthropathie inflammatoire (spondylarthrite ankylosante) et une rupture ancienne du tibial posterieur. Au recul maximum 19 patients ont fusionne en huit semaines de premiere intention. Un patient a presente une algodystrophie documentee et traitee trois autres ont du voir leur materiel retire pour gene sans influence sur le resultat final. Discussion et Conclusion Les scores d’evaluation SFMCP et AOFAS sont respectivement de 73 et 78/100, ce qui atteste d’un bon resultat pour une technique d’arthrodese. Deux patients ont ete reopere a ciel ouvert avec mise en place d’un greffon iliaque pour pseudarthrodese aseptique. Ces patients avaient eu un appui a J21 par botte de marche. On ne note aucune complication septique. Compte tenu de ces resultats et de la morbidite quasi-nulle de cette technique, il s’agit donc pour nous chaque fois qu’elle est realisable (presence d’un interligne visible radiologiquement et surtout scannographiquement, destruction articulaire axee) de la technique de choix d’arthrodese de l’articulation sous-talienne en privilegiant l’abord posterieur para-achileen et fusion isolee de la sous-talienne posterieure.

RETRACTED: Posterior Arthroscopic Tibiotalar Arthrodesis: Anatomic Feasibility Study

ABSTRACT Anterior arthroscopic tibiotalar arthrodesis has been well codified. A posterior approach with the patient in prone position is indicated when the anterior approach is precluded by soft tissue issues or for a 1‐step procedure associated with posterior subtalar fusion. In an anatomic study, we assessed the feasibility of posterior arthroscopic tibiotalar fusion and sought to determine the arthroscopy entry points, mortise cartilage freshening quality, and risk of osseous, tendinous, vascular, and neural complications. We mapped 22 zones of the fibular tibiotalar mortise from 10 specimens. Medial and lateral para‐Achilles arthroscopic approaches were used, with a 4‐mm arthroscope at 30°. For chondral resection, we used a motorized burr, curette, and osteotome. The entire plafond of the tibial mortise could be freshened in all cases, but the talar dome could be freshened in its entirety in only 20% of cases. In 80%, only the posterior two thirds could be treated, because the anterior portion descending to the neck of the talus was poorly accessible. More than 50% of the area of the malleolar grooves was freshened. One medial malleolar fracture and one posterior fibular artery lesion developed. Thus, the technique was shown to be feasible, if no frontal hindfoot deformity or tibiotalar equinus is present, which would prevent satisfactory resection of the posterior and anterior talar cartilage. The procedure allows for single‐step associated subtalar fusion, requiring 2 complementary arthroscopic approaches, 1 cm distally. &NA; Level of Clinical Evidence: 5

Brièveté des gastrocnémiens et pathologies du pied. Une physiopathologie controversée

RésuméIntroductionLa brièveté des gastrocnémiens est fréquente. Elle est associée à de nombreuses pathologies du pied et de la cheville. La physiopathologie de cette association n’est pas clairement établie. Nous avons réalisé une revue de la littérature afin d’apprécier les connaissances scientifiques actuelles sur l’impact d’une brièveté des gastrocnémiens sur la marche. Nous espérions ainsi affiner la compréhension de cette association entre brièveté des gastrocnémiens et pathologies du pied et de la cheville.Matériel et méthodeLa revue de la littérature a été effectuée à partir des moteurs de recherche Pubmed, Springer-Link et Science Direct.RésultatsLes études basées sur des constatations cliniques et sur un raisonnement biomécanique semblent en accord pour admettre qu’une limitation de la dorsiflexion de cheville au passage du pas par mise en tension des gastrocnémiens impliquerait une hyperpression sur l’avant-pied.Les études en laboratoires de marche ne mettent pas en évidence de diminution de la dorsiflexion de cheville au passage du pas, ni d’augmentation de la pression plantaire, chez des patients présentant une brièveté des gastrocnémiens. En revanche, elles mettent en évidence des mouvements définis comme compensateur par les auteurs, en particulier la présence d’un flessum de genou au passage du pas chez les patients rétractés.ConclusionsIl existe une discordance entre la croyance commune et les résultats d’analyse de marche en laboratoire à ce sujet. Les connaissances scientifiques actuelles ne permettent pas d’expliquer l’augmentation de la prévalence des pathologies du pied et de la cheville chez les patients présentant une brièveté des gastrocnémiens.AbstractIntroductionIsolated gastrocnemius tightness is common and often associated with ankle and foot pathologies. The pathophysiology of this association is not clearly established. A review was performed to assess repercussion of gastrocnemius tightness on gait, and to evaluate scientific knowledge on this field.Materials and methodsThe review was conducted using the Pubmed, SpringerLink and Science Direct databases.ResultsStudies based on clinical findings and biomechanical basis, seem to show, that ankle dorsiflexion limitation during swing phase of gait, due to gastrocnemius tightening, lead to forefoot hyperpressure. These findings are not observed in dynamic optoelectronic studies involving patients with gastrocnemius tightness; in which knee flessum during swing phase seems to be a compensatory mechanism.ConclusionsThere is a difference between the common belief and laboratory analysis results on this subject. Current scientific knowledge cannot explain the increased prevalence of foot and ankle pathologies in patients with gastrocnemius tightness.

Original ResearchPosterior Arthroscopic Tibiotalar Arthrodesis: Anatomic Feasibility Study

ABSTRACT Anterior arthroscopic tibiotalar arthrodesis has been well codified. A posterior approach with the patient in prone position is indicated when the anterior approach is precluded by soft tissue issues or for a 1‐step procedure associated with posterior subtalar fusion. In an anatomic study, we assessed the feasibility of posterior arthroscopic tibiotalar fusion and sought to determine the arthroscopy entry points, mortise cartilage freshening quality, and risk of osseous, tendinous, vascular, and neural complications. We mapped 22 zones of the fibular tibiotalar mortise from 10 specimens. Medial and lateral para‐Achilles arthroscopic approaches were used, with a 4‐mm arthroscope at 30°. For chondral resection, we used a motorized burr, curette, and osteotome. The entire plafond of the tibial mortise could be freshened in all cases, but the talar dome could be freshened in its entirety in only 20% of cases. In 80%, only the posterior two thirds could be treated, because the anterior portion descending to the neck of the talus was poorly accessible. More than 50% of the area of the malleolar grooves was freshened. One medial malleolar fracture and one posterior fibular artery lesion developed. Thus, the technique was shown to be feasible, if no frontal hindfoot deformity or tibiotalar equinus is present, which would prevent satisfactory resection of the posterior and anterior talar cartilage. The procedure allows for single‐step associated subtalar fusion, requiring 2 complementary arthroscopic approaches, 1 cm distally. &NA; Level of Clinical Evidence: 5

Place des platelet rich plasma en pathologie traumatique et dégénérative du pied et de la cheville. Revue de la littérature

RésuméIntroductionLes platelet rich plasma (PRP) sont utilisés depuis une dizaine d’années dans la pathologie dégénérative et traumatique de l’appareil locomoteur par les médecins du sport, les rhumatologues, les radiologues et les chirurgiens orthopédiques. Les indications se multiplient actuellement avec malheureusement un fréquent défaut de preuve en ce qui concerne l’efficacité des PRP pour ces nouvelles indications…Le but de cet article était d’effectuer une revue de la littérature afin de préciser le niveau de preuve d’efficacité des PRP dans cinq grandes pathologies.Matériel et méthodesPour cette revue de la littérature, nous avons utilisé les moteurs de recherche Pubmed et ScienceDirect. Les mots clés utilisés pour la recherche étaient [platelet rich plasma], [foot], [ankle]. Les articles retenus étaient ceux qui traitaient de l’intérêt des PRP dans l’arthrose tibiotalienne, les tendinopathies, les ruptures du tendon calcanéen, les fasciites plantaires et la consolidation osseuse. Les séries de quelques cas étaient exclues. Les articles devaient être postérieurs à 2010.RésultatsQuinze articles répondaient aux critères d’inclusion. Dans l’arthrose de cheville, l’injection de PRP serait plus efficace que la viscosupplémentation ou l’injection de corticostéroïdes. Les articles valident les données observées dans la gonarthrose. Dans la fasciite plantaire, les PRP semblaient aussi efficaces que les injections de corticostéroïdes. Dans la rupture du tendon calcanéen, il n’existait aucun intérêt à injecter des PRP dans le site de rupture. Dans la tendinopathie chronique du tendon calcanéen, les études de cas montraient un bénéfice sur la douleur et la fonction dans les mois qui suivent l’injection. Par contre, la seule étude de niveau 1 ne retrouvait aucune différence significative par rapport à l’injection d’un placebo… PRP et consolidation osseuse: la bibliographie était pauvre. Un seul article non randomisé montrait un intérêt pour l’arthrodèse tibiotibiale.DiscussionL’évaluation du bénéfice réel des PRP est difficile en raison des variations intra- et interindividuelles des taux plaquettaires. Contrairement à un agent pharmacologique, nous ne connaissons pas la concentration de facteurs de croissance injectés avec le PRP. La littérature en ce qui concerne l’arthrose tibiotalienne confirme les données de la gonarthrose. Les PRP ne sont pas validés dans la rupture du tendon calcanéen. Dans la pathologie dégénérative du tendon calcanéen, les études ne sont pas concordantes. Il existe cependant des biais importants en fonction du site d’injection (intra- ou péritendineux). Il existe également le biais de l’effet « peignage » lié à l’injection en intratendineux. En ce qui concerne la consolidation osseuse, une seule série semblait montrer un bénéfice pour l’arthrodèse tibiotalienne.ConclusionLe niveau de preuve de la place des PRP dans l’arthrose du pied et de la cheville est équivalent à celui de la gonarthrose. En ce qui concerne la pathologie tendineuse dégénérative, le niveau de preuve est insuffisant, avec de nombreux biais et des études contradictoires. La place des PRP dans la consolidation des fractures et pseudarthroses du pied n’est pas suffisamment étudiée.AbstractIntroductionPlatelet rich plasma (PRP) has been used for around ten years in degenerative and traumatic diseases of the locomotor apparatus by sports physicians, rheumatologists, radiologists and orthopaedic surgeons. Indications are currently increasing, unfortunately, however, there is a lack of evidence regarding the efficacy of PRP in these new indications. The aim of this article is to carry out a review of the literature, in order to state the level of evidence for the efficacy of PRP in five major diseases.Materials and methodsFor this literature review, the Pubmed and ScienceDirect search engines were used. The key words used for the search were [Platelet rich plasma], [Foot], [Ankle]. The articles selected were those that dealt with the benefit of PRP in tibiotalar arthritis, tendinopathies, ruptures of the Achilles tendon, plantar fasciitis and bone consolidation. Series of several cases were excluded. Articles needed to be from before 2010.ResultsFifteen articles met the inclusion criteria. For arthritis of the ankle, the PRP injection was more effective than viscosupplementation or the injection of corticosteroids. The articles validate the data observed for gonarthrosis. For plantar fasciitis, PRP appeared to be as effective as corticosteroid injections. In ruptures of the Achilles tendon: there was no benefit seen for the injection of PRP into the rupture site. For chronic tendinopathy of the Achilles tendon: cases studies showed a benefit in terms of pain and function in the months following the injection. However, the only level 1 study did not find any significant difference compared with the placebo injection. PRP and bone consolidation: the number of articles was small. A single non-randomised study showed a benefit for talotibial arthrodesis.DiscussionAn assessment of the actual benefits of PRP is difficult, due to both the intra- and inter-individual variations of platelet levels. Unlike a pharmacological agent, the concentration of growth factors injected with PRP is not known. Literature regarding tibiotalar arthritis confirms the data for gonarthrosis. PRP is not validated for use in Achilles tendon rupture. In degenerative conditions of the Achilles tendon, studies are not consistent. However, there is considerable bias towards the injection site (intra or around the tendon). There is also bias regarding the “combing” effect linked to the intratendon injection. Regarding bone consolidation, only one series appeared to show a benefit in tibiotalar arthrodesis.ConclusionThe level of evidence regarding the place of PRP in arthrosis of the foot and ankle is equivalent to that for gonarthrosis. Regarding degenerative tendon conditions, the level of evidence is inadequate, with numerous bias and contradictory studies. The place of PRP in the consolidation of fractures and pseudoarthrosis of the foot has not been adequately studied.Introduction Platelet rich plasma (PRP) has been used for around ten years in degenerative and traumatic diseases of the locomotor apparatus by sports physicians, rheumatologists, radiologists and orthopaedic surgeons. Indications are currently increasing, unfortunately, however, there is a lack of evidence regarding the efficacy of PRP in these new indications. The aim of this article is to carry out a review of the literature, in order to state the level of evidence for the efficacy of PRP in five major diseases.