Purpose: In 1996, we reported the results of 65 coracoid blocks for chronic anterior instability. We found 6% true recurrence and 34% persistent apprhension. In order to improve these results, we modified our operative technique, associating capsuloplasty in the event of hyperlaxity. The purpose of the present work was to assess mid-term results.

Material and methods: Eighty-eight coracoid blocks were performed between 1995 and 2000 by the same operator. In 41 cases, the classical technique was used. In 47 cases we associated capsuloplasty. The indication for surgery was documented recurrent instability in all cases, with radiographic, MRI or endoscopic confirmation of an anteroinferior capusloligament lesion. Capsuloplasty was associated if signs suggested hyperlaxity: self-reducing dislocation, absence of notch, external rotation arm to body (RE1) greater than 80°, presence of a significant groove, laxity of the inferior flap of a T capsulotomy. Mean patient age was 24 years (14–42) and mean follow-up was 40 months (24–60). Clinical results were assessed with the Duplay criteria and three x-rays were obtained (standard AP, Lamy lateral view and glenoid lateral view).

Results: Eighty-five percent of the patients achieved a good or very good result according to the Duplay criteria. Eighty-eight percent of the blocks held without modification and 12% developed osteolysis. There were no cases of degeneration. One patient experienced recurrent dislocaion. The rate of persistent apprehension declined (12%) compared with our earlier experience. This improvement was achieved at the cost of greater loss of RE1 in the group with capsuloplasty (−20° versus −8°), but without impact on sports activity (82£% returned to their sports activities including 72% at the same level without significant difference between the groups with and without capsulotomy).

Discussion: These results demonstrate that capsuloplasty is warranted if there are signs of hyperlaxity. This technique allowed us to improve results concerning recurrence and persistent apprehension at the cost of less mobility but without effect on sports activities. We detail the objective criteria used to define hyperlaxity and describe the usual clinical expression of radiographic, arthroscopic, and arthroscopic findings.

Purpose: Reconstruction using a revascularised fibula has advantages in terms of remodelling the transplant to the stress forces and of better resistance against infections. Osteosynthesis offers mechanical advantages (stabilisaton facilitating primary and stress fracture healing) but with the risk of preventing hypertrophy of the fibula which is not exposed to the stress forces.

Material and methods: Our series of 25 vascularised fibular transfers (maximum follow-up 15 years) concerned post-trauma tissue loss (11 cases) and tumour resections (14 cases). For this study of remodelling, we retained only oncological reconstructions because in the event of trauma sequelae, many factors can interfer (infection, preservation of the homolateral fibula with tibial tissue loss). None of the patients were lost to follow-up and remodelling was assessed at two years or more.

Results: There was one failure requiring leg amputation (infected nonunion of the distal tibia on a radiated osteo-sarcoma). All the other fibulae healed. Three metaphyseal resections of the distal femur were assembled with a lateral plate using the fibula as a medial strut under compression. This type of assembly favours remodelling and excellent results were obtained in three cases. Five arthrodeses of the knee were performed using a fibula with a femorotibial nail. Healing was slow and the fibula thickened little, particularly when it was simply apposed on the tutor (three cases) rather than encased under compression (two cases). For five proximal humeri, use of a thin plate in three cases (forearm plate) was sufficient to allow healing without inhibiting remodelling.

Discussion: For the lower limb, good remodelling is obtained with an assembly allowing compression of the fibula placed medially to the shaft alignment. For metaphyseal loss, we advise a lateral plate with a fibular strut medially. For arthrodesis, a nail is probably more prudent. The position of the lateral tutor decreases the stress on the fibula and is recommended less than the medial strut position. For the humerus, synthesis is required but may be minimal to allow optimal remodelling.

Conclusion: Vascularised fibula transfer is a reliable technique which can be recommended for major resections (mean 160 mm) in active subjects. Axial compression forces applied to the graft and use of light osteosynthesis appear to favour healing and remodelling.