Introduction

Numerous types of graft can be used for revision of anterior cruciate ligament (ACL) reconstruction. The goal of our studies was to analyze mid term outcomes of revision of anterior cruciate ligament reconstructions conducted by means of ipsilateral bone -patellar tendon -bone (B-PT-B) transplant.

Introduction

There is a challenge to detect partial tear of the ACL, the number of bundle injured and the proportion of fibers torn. The MRI was shown efficient to individualize the two anteromedial (AM) and posterolateral (PL) bundles of the ACL. The purpose of this study was to assess the ability of the MRI to detect partial tears of the ACL on axial views to display the AM and PL bundles.

Mobile-bearing total knee arthroplasty was developed to provide low contact stress and reasonably unrestricted joint motion. We studied the results of a cementless, posterior cruciate ligament (PCL)-retaining total knee arthroplasty (TKA), with a mobile-bearing insert in rotation and anterior-posterior (AP) translation (Innex^® Anterior-Posterior Glide, Zimmer).

Kinematic analyses were performed on a series of 51 primary TKA. The patients’ mean age was 71±8 years at operation. Patients were studied at 23 months average follow-up with weight-bearing radiographs at full-extension, 30° flexion and maximum flexion (“lunge” position). Three dimensional position and orientation of the mobile-bearing relative to the femoral and the tibial component during flexion were determined using model-based shapematching techniques.

The average weight-bearing range of implant motion was 110°±14°. In flexion, the mobile-bearing was internally rotated 3°±3° with respect to the femoral component (p< 0.0001) and the tibial tray was internally rotated 5°±7° with respect to the mobile-bearing (p< 0.0001). On average, the mobile-bearing did not translate relative to the tibial base plate from full extension to 45° flexion [0±2 mm (range −5 mm to 6 mm)]. However, the mobilebearing did translate anteriorly 1±2 mm (range −2 mm to 9 mm, p< 0.0001) between 45° flexion and maximal flexion.

We conclude that the mobile-bearing insert showed a progressive increase in internal rotation during flexion. Most of this rotational mobility occurred between the mobile insert and the tibial base plate. With flexion, AP translation did occur between the femoral component and mobile-bearing, and between the mobile-bearing and tibial base plate, but mobile-bearing translation was unpredictable with this unconstrained design.

Purpose of the study: The purpose of this study was to use weight-bearing radiographies to study the mobility of the polyethylene insert in relation to the femoral and tibial components of a total knee arthroplasty (TKA) with preservation of the posterior cruciate ligament and a mobile plateau with rotation and anterioposterior translation (INNEX^® Anterior-Posterior Glide, Zimmer).

Material and methods: A 3D kinematic study of the femoral and tibial component and the mobile insert was conducted on a series of 51 first-intention TKA using a computer-assisted matching system between 3D prosthetic models and the radiographic silhouette of the implants.

Results: At mean 23 months postoperatively, the poly-ethylene tibial insert exhibited an increase in its internal rotation during flexion. This rotation, knee extended, was limited to rotation between the insert and the tibial base. With increased flexion, there was an increase in the value and the portion of rotation involving the femoral component in relation with the mobile tibial insert.

Discussion: The degree of insert mobility has varied depending on the report. Certain authors have reported relatively limited mobility because of a minimally congruent superior surface allowing anteroposterior and mediolateral translation as the femur glided over the insert. Others report mobility of the mobile plateau in relation to the tibial base and minimal rotation of the femoral component. Rotation of the polyethylene insert in TKAs with a mobile plateau appears to be quite variable. With the LCS AP Glide prosthesis, anteroposterior translation of the mobile plateau was measured at a mean 5.6 mm (1–1.125 mm). Paradoxical anterior translation, rather than posterior translation, of the mobile plateau with flexion has been reported in a few patients.

Conclusion: The mobile plateau has exhibited progressive increase in internal rotation with flexion. We have concluded that the major part of the mobility occurs between the mobile plateau and the tibial base. However, with flexion, the femoral component increased its mobility over the plateau. During flexion, anteroposterior translation occurred between the femoral piece and the tibial insert, and between the tibial insert and the tibial base, but the direction of the translation of the mobile tibial insert appeared to be unpredictable with the non-constrained prosthesis used for this study.

Purpose of the study: Revision ligamentoplasty can improve function and laxity control but with a less satisfactory result than obtained after primary reconstruction. The purpose of this study was to report management practices and results of revision ACL reconstructions and to assess the course of meniscocartilage damage and determine causes of failures.

Material and method: This was a consecutive series of ten patients, mean age 30 years (range 17–48) who underwent arthroscopic reconstruction. The review was retrospective. Criteria for failure were redevelopment of instability and/or pain, objective laxity, and a KT-100 differential greater than 5 mm. The IKDC protocol was used for the clinical and radiographic assessment. Goniometry, arthroscan and MRI were also performed. The position of the tunnels was analysed according to the Aglietti criteria. The type of surgery, transplant used and status of the menisci and cartilage were analysed.

Results: Mean follow-up of the second revision was 38 months. At last follow-up, seven patients had a global IKDC score of A or B. Two patients had resumed regular sports activities at the same level as before the first tear, four at a lower level. Four had interrupted their sports activities. At the second revision, two patients exhibited medial femorotibial narrowing measured at less than 50%, three had a remodelled medial femorotibial compartment and one a remodelled lateral compartment. All had a partial homolateral meniscectomy and seven had cartilage injuries (3 ICRS III and 1 ICRS IV). At the successive interventions, the number of meniscal lesions, meniscetomies, and cartilage lesions increased (p=0.016, 00098 and 0.0197 respectively). ICRS grade II and IV cartilage lesions were associated with an overall C or D IKCD (p=0.0472). The cartilage lesions were more frequent in knees with meniscal lesions and meniscectomies. The causes of failure of the primary ligamentoplasty and of the first revision (six and seven patients respectively) were poor position of the tunnels (respectively 4 and 1 patients).

Discussion: In 70% of the patients outcome after repeated revision was good or excellent, although the quality declined with increasing number of revisions, in relation to the development of meniscal and cartilaginous lesions. These latter were more frequent and more severe, related to recurrent laxity. Failures were mainly due to recurrent trauma followed by technical errors.

Purpose of the study: Anteversion of the cup during total hip arthroplasty (THA) is crucial for preventing the risk of dislocation. Interest has recently focused on an anatomic element often observed in the operative field during hip surgery: the transverse acetabular ligament (TAL). The TAL has become a landmark both for conventional procedures (Beverland) and for computed-assisted surgery. The purpose of this original research was to study the anteversion of the TAL in relation to the anterior pelvic plane in order to determine whether it could be a valid landmark for positioning the cup using the Lewinnek criteria (35±20° anteversion according to the Murray definition).

Material and methods: Eight laboratory cadavers (three male, five female, mean age 82±3.3 years) were dissected; the pelvis was removed. Fifteen fresh healthy hips (free of trauma or degenerative disease) were also used for the study. The orientation of the peri-acetabular structures was measured with the probe of the BrainLab^® navigation system and the Motion Analysis^® system (Santa Rosa. CA) at the laboratory of biomechanics and biomechanical shocks (INRETS, Bron). The Lewinnek reference plane (anterior pelvic plane) was defined from the anterosuperior iliac spines and the pubic tubercles.

Results: The anatomic version of the TAL varied from −8 to +13.3 (mean 1.9); the anatomic version of the horns of the semilunate surface from −12.2 to +14 (mean 3); for the labrum the figures were +17.4 to +41.8 (mean 26.63). Anteversion of the TAL and the horns were well correlated (r=0.8) significantly (p=0.001).

Discussion: There is no other study concerning the anatomic orientation of the TAL, the horns and the labrum. Archbold was the first to consider the TAL (1000 cases, posterolateral access, 28 mm head) as a reliable constant landmark for positioning the cup (0.6% dislocation). In our study, the anatomic version of the TAL was found outside the safety zone of Lewinnek. This is a supplementary argument for questioning the reliability of the Lewinnek criteria based solely on nine cases of dislocation and criticised by several authors (non-specific for each patient).

Conclusion: Anteversion of the labrum is situated within this safety zone. The TAL does not position the cup in the Lewinnek safety zone, which remains controversial.

Purpose of the study: From a biomechanical view, the medial force stabilising the patella is assured for 50 to 60% by the medial patellofemoral ligament (MPFL). The purpose of this cadaver study was to present a precise description of the anatomic features of the MPFL concerning its femoral insertion, its relations with the oblique vastus medialis (OVM) and its relation with the medial collateral ligament (MCL) in order to optimise surgical reconstruction.

Material and methods: This cadaver study was performed on 23 knees from fresh cadavers. All measures were made knee flexed 30° by the same operator. Insertions of the OVM on the MPFL, when present, were identified. The length of the zone of reflexion was recorded. For these measurements, a orthonormal landmark centred on the femoral insertion of the MPFL was established. This landmark was used to position the medial epicondyle and the adductor tubercle for each knee.

Results: The MPFL was found in all 23 knees (100%); the length of the MPFL was 57.7±5.8 mm; its femoral insertion measured 12.2±2.6 mm (8–136); its patellar insertion measured 24.4±4.8 mm. A junction between the OVM and the MPFL was found for all 23 knees (100%). This zone appeared to be a veritable reflexion zone with the OVM fibres arching over the MPFL fibres for a length of 25.7±6 mm.

Discussion: Our study confirms the constant presence of the MPFL, observed in 100% of the knees studied. During the reconstruction of the MPFL, the key point is the position of the femoral insertion of the ligament, in order to restore the native femoral insertion of the MPFL surgically and thus attempt to recreate perfect isometry of the graft. The graft must be positions 10 mm posteriorly to the medial epicondyle and 10 mm distally to the adductor tubercle. In our cadaver the MPFL, the main medial stabilising force of the patella was a constant finding, always located in the second thickness of the medial plane of the knee.

Conclusion: We detailed the native femoral insertion of the MPFL and described its relations with the medial femoral epicondyle and the adductor tubercle using an orthonormal landmark. Long-term function of the graft depends on proper positioning.

Introduction: Autologous chondrocyte implantation was introduced in 1994 by Brittberg and Peterson for the treatment of large full-thickness focal chondral defects. The purpose of the present study was to evaluate the mid-term results of this technique in a group of patients with post-traumatic chondral defects of the knee.

Materials and Methods: Fifteen patients underwent autologous chondrocyte implantation between 2001 and 2006 and were prospectively assessed preoperatively, at 3, 6, 9, 12 months, 3.5 years and last follow-up with use of standard rating scales (IKDC subjective score, pain Visual Analogic Scale (VAS), Brittberg and Peterson’s score). The inclusion’s criteria were: pain VAS more than 40/100, age between 18 and 50 years, focal chondral defect in weight bearing area grade 3 or 4 and informed and signed consent. Patients with varus or valgus deformities with malalignement more than 5 degrees, knee instabilities and signs of arthritis on radiographs were excluded. The same experienced surgeon performed all the procedures.

Results: Fourteen patients were reviewed at the latest follow-up. The mean age of the patients at the time of autologous chondrocyte transplantation was 37.7 years (range, 30 to 45). The mean duration of symptoms was 2.9 years (0.5 to 7). Nine patients (83%) had previous operations on the index knee. The defect was located on the medial femoral condyle in 11 patients and on the lateral femoral condyle in 3. The mean lesion size was 1.80 cm² (range, 1.5 to 3.5 cm²) after débridement. After a mean duration of follow-up of 6 years (3.3–7.8), 84% of the patients had improvement on a patient self-assessment questionnaire. The IKDC subjective score and Brittberg-Peterson’s score were all improved. The mean IKDC subjective score increased from 40 (27.6–65.5) preoperatively to 60.2 (35.6–89.6) at the latest evaluation. The mean pain VAS decreased from 66.3 (44–89) to 23.2 (0–77). The Brittberg and Peterson’s score decreased from 54.4 (11.8–98.2) to 32.9 (0–83.9). Two patients (16.7%) felt no improvement by the chondrocyte transplantation at the last follow-up. Two complications occurred: graft periosteum hypertrophy treated by débridement and a pulmonary embolus.

Discussion: Our results are similar than those reported in the literature. These outcomes are encouraging and need further follow-up to confirm the long-term efficacy of autologous chondrocyte implantation.

The purpose of this study was to compare 2 different strategies of management for ACL rupture in skeletally immature patient.

In group 1, patients were treated in a children hospital by ACL reconstruction with open physis. In group 2, patients were treated in an adult hospital by delayed reconstruction at skeletal maturity assessed radiologically.

Fifty six consecutive patients were included in this retrospective study. Mean time from injury to surgery in group 1 and 2, was 13.5 and 30 months, respectively.

In the overall series, a long time from injury to surgery increased the number of medial meniscal tear (p< 0.0001), but had no influence in the number of lateral meniscal tear (p=0.696). Patients in group 2 exhibited a higher rate of medial meniscal tears (41%) compared to group 1 (16%) (p=0.01). Both groups had the same rate of lateral meniscal tears (p=1). Despite there was no difference between the 2 studied groups in type and location of menisci lesion, patients in group 2 underwent more partial menisectomy (63%) than patients in group 1 (16%) (p=0,014).

One temporary tibial valgus deformity was reported and spontaneously resolved. No definitive growth disturbance was noticed. At 27 months mean follow-up, patients in group 1 expressed better subjective IKDC than in group 2. Objective IKDC and radiological results were similar in both groups.

Early ACL reconstruction in skeletally immature patient, especially if the patient is more than one year to be skeletally mature, has to be promoted despite of growth disturbance risk. This strategy will decrease medial meniscus lesions and partial meniscectomies which occurred more frequently when ACL reconstruction had been delayed until skeletal maturity.

Introduction: The anterior cruciate ligament (ACL) can be anatomically divided into two bundles: the anteromedial (AM) and the posterolateral (PL). These two bundles have unique contributions to load transfer across the knee joint.

Material and Methods: We retrospectively reviewed the clinical results of a consecutive series of 25 patients who underwent partial ACL reconstruction. In 22 cases AM bundle reconstruction was performed, and in 3 patients isolated PL bundle reconstruction was performed.

The 25 patients included 7 women and 18 men with an average age of 29.2 years at the time of surgery.

Preoperative evaluation was conducted using manual Lachman test, pivot-shift tests, KT-1000, magnetic resonance imaging and passive stress radiographs of both knees. In all cases preoperative clinical evaluation was graded C as per the IKDC scoring system. The preoperative side-to-side anterior laxity measured by means of the KT-1000 was 5.8 mm in case of AM bundle rupture and 4.3 mm in case of PL bundle rupture.

All the patients underwent single-bundle reconstruction of the ACL under arthroscopic assistance (one single incision technique).

In case of AM bundle repair, the type of graft used was all autologous and included bone-patellar tendon-bone in 14 cases, 4-strand hamstring tendons in 5 cases and 2-strand hamstring tendons in 3 cases.

In case of PL bundle repair, 2-strand hamstring tendons transplant was used in the 3 cases.

Results: In all cases, postoperative clinical evaluation was graded A as per the IKDC knee examination scoring system. No abnormal sagittal laxity was found with the Lachman manual test. Postoperative IKDC knee subjective evaluation score averaged 81.3 % [58–95] at an average of 9 months follow-up.

Postoperative side-to-side anterior laxity measured with KT-1000 averaged 0.46 mm in case of AM bundle rupture and 0.5 mm in case of PL bundle rupture.

Postoperatively, all the patients had full extension of the knee. The flexion was the same as contra lateral knee in 92 % of the cases. We had no postoperative complication.

Discussion: Diagnosis of partial ACL rupture is often difficult. If the AM bundle is torn, the Lachman manual test is soft and the pivot-shift test is more often equal or glide. If the Lachman manual test is intermediary between firm and soft and the pivot-shift test is clunk, PL rupture has probably occurred.

The size of the graft was smaller than in one bundle procedures and was matched with the size of the bundle reconstucted. Peroperative technical difficulties were to preserve the healthy bundle and to drill the femoral tunnel in case of posterolateral bundle reconstruction.

Conclusion: This study showed consistent postoperative results. If partial rupture of the ACL can be diagnosed, isolated AM or PL bundle reconstruction should be considered.

Purpose of the study: The correct position of the femoral and tibial tunnes for anterior cruciate ligament (ACL) reconstruction is a determining factor for favorable outcome. We used a novel computer-assisted system which enables intraoperative localization of the tunnel centers on the lateral view of the knee before drilling. This technique uses fluoroscopy combined with a passive system for computer-assisted image acquisition and processing to provide the surgeon with the desired positions. We report the anatomic and clinical results observed in a prospective series comparing this technique with the classical technique of independent blind tunnels.

Material and methods: Thirty-seven patients underwent computer-assisted surgery and 36 classical surgery without computer assistance performed by a senior surgeon. Mean patient age was 27 years in both groups. The patients were reviewed at mean 2.2 years (range 1–4.5 years). Data recorded included the KT-1000 laxity, radiographic drawer and the IKDC score (1999).

Results: Mean time from ACL tear to reconstruction was 30 months in both groups. Computer assistance increased operative time 9.3 minutes (range 4–13). The IKDC score was 67.9% A, 29.7% B, and 2.7% C in computer-assistance surgery patients and 60% A, 37.1% B and 2.9% B for classical surgery patients. The mean IKDC function score was 89.7/100 for the computer-assisted patients and 89.5/100 for the others. Mean manual maximal laxity (KT-1000) was 7 mm before surgery and less than 2 mm at last follow-up. Differential laxity was less than 2 mm in all patients who underwent computer-assisted surgery and in 97.7% of the others. The mean differential laxity for the medial compartment as measured on the postoperative stress films was 2.4 mm (range 0–12 mm) for computer-assisted surgery patients and 3 mm (range 0–10 mm) for the others. In the computer-assised surgery patients, the femoral tunnels were centered on a smaller area. There was not significant difference in the IKDC score, the KT-1000 findings and the stress x-rays between the two techniques.

Conclusion: The results of these two techniques in this report are similar to data reported in the literature. Computer-assistance enables more accurate and reproducible tunnel positioning with no significant clinical impact.

Purpose of the study: The pathophysiology of reflex dystrophy or type I complex regional pain syndrome remains poorly understood, but the cost is considerable in terms of public health expenditures both for programmed and emergency orthopedic surgery. We present a historical cohort assessed to evaluate the usefulness of vitamin C for the prevention of reflex dystrophy in programmed foot and ankle surgery.

Material and methods: The study included two groups of patients treated in two successive periods: July 2002 to June 2003 and July 2003 to June 2004. All patients underwent foot and ankle surgery performed by the same senior surgeon. Diabetic feet were excluded. The first group (185 feet, 177 patients) was not given any particular preventive treatment. The second group (235 feet, 215 patients) was given one gram vitamin C for 45 days. The diagnosis of reflex dystrophy was retained on the basis of clinical and radiological arguments noted at follow-up visits with the operator. Several factors were studied: gender, age, type of disease condition, history of reflex dystrophy, psychological context, duration of tourniquet, cast immobilization.

Results: Reflex dystrophy occurred in 18 feet in group

1 (9.6%) and in 4 (1.7%) in group 2. The difference was significant. Presence of a history of dystrophy was significantly associated with development of dystrophy (RR=10.4). A psychological context appeared to increase the risk of dystrophy (RR 2.6) but did not reach significance. There was no statistical relationship with age, gender, duration of tourniquet, type of disease condition, or surgical procedure performed.

Discussion: Vitamin C has been found to be effective in the prevention of reflex dystrophy after wrist fractures. Data in the literature is scarce on dystrophy of the foot and ankle. Our study provided objective evidence of the usefulness of vitamin C for the prevention of reflex dystrophy in foot and ankle surgery patients, a complication frequently observed in our control group (9.6%). The psychological context and history of dystrophy increase the risk of dystrophy.

Conclusion: Vitamin C is associated with a lower risk of reflex dystrophy in the postoperative period after foot and ankle surgery. We advocate preventive treatment with vitamin C.

Purpose of the study: The aim of this retrospective study was to analyze the results obtained with the femoropa-tellar self-centering prosthesis and to confirm its usefulness and limitations for the treatment of femoropatellar osteoarthritis.

Material and methods: This continuous series of 57 patients, mean age 65.6 years underwent surgery fro 1986 to 2003 for implantation of a self-centering prosthesis. Most (60%) presented osteoarthritis on a dysplasic knee; others presented primary osteoarthritis (31%) or trauma sequelae (9%). Mean follow-up was 74.5 months (range 12–180 months). Functional outcome was assessed with the IKS and activity daily living (ADL) scales. The radiographic study enabled 3D analysis of the implant position.

Results: At last follow-up, the mean IKS score was 157.3/200. The mean ADL score was 73.8 (range 48.8–96.3). The IKS score gave 66.7% good and the ADL score, which takes into consideration all daily life functions, 57% very good outcome. Outcome was best in patients with trochlear dysplasia. The eleven knees requiring revision for a total knee arthroplasty (24%) had initially a narrower trochlear angle (p=0.02) and a thicker patella (p=0.02). In these patients, the initial prosthesis protruded more anteriorly (p=0.004) and the horizontal axis was greater (p=0.02).

Discussion: The results of this series are less satisfactory than in the literature, but assessments may depend on the scores used since there was a 10% difference between the ADL and IKS scores. The results were better in the group of patients undergoing surgery for osteoarthritis due to dysplasia, in agreement with De Cloedt and Argenson. Analysis of the radiological parameters enabled identification of technical errors leading to failure. A successful femoropatellar prosthesis depends basically on two factors: technical precision and patient selection.

Conclusion: These results led us to avoid widening indications for femoropatellar prostheses, which are already in our experience rather limited (2%). For us, patients aged 50–70 years with advanced-stage femo-ropatellar osteoarthritis due to dysplasia and no other anomaly and who have not responded to conservative treatment would be the population of choice. The lack of any technical problem for revision total knee arthroplasty is an argument in favor of the femoropatellar prosthesis.

Purpose of the study: Reconstruction of the anterior cruciate ligament (ACL) has become a common procedure. We compared two randomized series: intra-articular (Kenneth-Jones) versus intra- and extra-articular (MacInJones).

Material and methods: From January 1995 through March 1998, 73 knees were treated surgically for differential medial laxity measured at 7 to 12 mm on passive stress x-rays in 20° flexion. Group 1 (ACL reconstruction alone) included 34 patients (aged 27.1±7.5 years). Group 2 (ACL reconstruction plus extra-articular plasty) included 29 patients (aged 28.5±12 years). Function was scored 72% in group 1 and 68% in group 2 at mean seven years follow-up (102 and 93 months follow-up respectively). Anterior laxity was measured radiographically and with KT-1000 and the position of the tunnels was assessed according to Aglietti.

Results: According to the IKDC, functional outcome was 83.9±3.1 in group 1 and 83.3±3.6 in group 2. The overall IKDC classification was 0A, 57.8% B, 26.3% C, and 15.7% D for group 1 and 58% A, 52.9% B, 29.4% C, and 11.7% D for group 2. The pivot-shift test was negative in 61.1% of group 1 knees (27.7% grade 1 and 11.1% grade 2) and negative in 83.3% of group 2 knees (16.6% grade 1). In group 1, the radiological drawer showed 46.09% improvement in the differential laxity for the medial compartment and 41% for lateral compartment. In group 2 the corresponding improvements were 44.8% and 44.6%. There was no difference in tunnel position between the two groups.

Discussion: The two-year results of this series did not provide any evidence favoring a clear advantage of complementary lateral plasty. At seven years follow-up, the pivot-shift test appeared to favor associated lateral plasty (p=0.09), but with no significant difference in laxity for the two compartments.

Conclusion: Anterior laxity was only incompletely controlled by both reconstruction techniques. In this context of relatively limited laxity (7–12 mm initially), at seven years follow-up there was no certain advantage of complementary lateral extra-articular plasty in combination with ACL reconstruction.

Purpose: Failed anterior cruciate ligament reconstruction as defined by recurrent pathologic laxity, is increasingly commonplace. We reviewed 77 patients who had undergone unsuccesful anterior cruciate ligament surgery to correct persisting instability, and who underwent revision surgery.

Material and Methods: During the first operative treatment, were used synthetic ligament in 18 cases, autograft in 54 cases, extra-articular plasty in 4 cases, allograft in 1 case and primary repair in 1 case. For revision, we used autograft in all cases according to differents anatomicals factors: 41 patellar tendons, 15 quadriceps tendons and 17 hamstring tendons. 46 patients had meniscectomy during one of the two surgeries ; 19 patients had cartilage lesions (grade 3 or 4).

For clinical evaluation, we used the IKDC score (1999), and laxity measurement with the KT-1000 arthrometer and stress X-rays.

The mean follow-up was 24 months.

Results The mean IKDC subjective score was 71,5 and 75% of knee were considered as normal or nearly normal. The surgery was successfull in objectively improving the stability in most of patients with a KT-1000 differential maxi-manual of 2 1,7 mm.

We found no statistical difference between the three groups of graft used for revision. The results are a trend toward less good results, when patients had a meniscec-tomy. Subjectively the result were worse in cases of cartilage lesion. In fact, no patient who had grade IV lesion returned to there previous level activity (pre-operative level activity). The worse results are in the group of failed synthetic ligaments.

Conclusion ACL revision surgery leads to poorer results than primary surgery.

There was no clinical difference for the revision, whether we used autograft of patellar tendon, quadriceps tendon or hamstring tendon with an adapted fixation device.

On the other hand, meniscal or cartilage lesion or the use of synthetic grafts are factors of poor clinical outcome.

Purpose: The posterior cruciate ligament (PCL) has two strands, an anterolateral strand (AL) and a posteromedial strand (PM). Its femoral insertion fans out over 3 cm and cannot be replaced by a unique transplant during surgical reconstruction. The purpose of this study was to define the anatomic centre of the femoral insertion of each stand in order to identify precise and reproducible landmarks for the bone tunnels (one for each strand) used to fix the transplants during reconstruction of the PCL.

Material and methods: A metallic landmark was placed on the centre of the femoral insertion of the two PCL strands in ten cadaver knees. The Metros software package was used to analyse the digitalised radiograms of each knee to determine the position of the strands on the medial condyle. Intra- and inter-observer variability was determined.

Results: The AL strand was situated 31.6 + 2.45% (47.2 + 6.02% for the PM strand) from the anterior border of the notch or 41.18 + 2.73% (54.46 + 5.07% for the PM) from the anterior border of the medial condyle relative to the Blumensaat line and 16.12 + 4.45% (33.68 + 7.2 for the PM) from the apex of the notch.

Discussion: Clinical and objective results of reconstruction depend on the ideal, basically femoral, position of the PCL insertions. Intraoperative identification of the ideal point for the femoral insertion can be improved with measurements made on cadaver knees. The values observed in the present study are reproducible. Presented in the form of percentages of length limiting the errors related to patient morphotype can be integrated into navigation systems.

Purpose: Several studies have reported results of anterior cruciate ligament (ACL) reconstruction showing the influence of the position of the transplant. We choose the anatomic position. In order to optimise this position, we developed a navigation system using intraoperative fluoroscopic imaging.

Material and methods: Thirty-five patients underwent ACL reconstruction using the computer-assisted technique. We used a fluoroscope connected to the computer equipped with an acquisition module and an image processing module which captures the lateral view of the knee provided by the fluoroscope. Surgery was performed arthroscopically. After inserting landmarks (mini-screws for the femoral end and pins for the tibial end) on the theoretically ideal positions, the computer determined the theoretical anatomic position of the tibial and femoral insertions of the ACL. The position was then validated or modified and re-validated. Postoperative radiograms (lateral view of the knee) were used to analyse the position in relation to the anatomic centre of the ACL insertion. Two groups of patients matched for sex and age were compared, 35 patients undergoing ACL reconstruction with the navigation technique versus 35 patients undergoing the same procedure without navigation. Results were compared with the nonparametric Wilcoxon test.

Results: Computer-assisted positioning provided a mean difference of 5.1±1.3 mm between the centre of the transplant and the theoretical ideal point compared with 7.7±1.9 mm without assistance.

Discussion: Comparison using adapted statistical tests (Wilcoxon text) demonstrated a significant difference (p=0.001) between the two groups. These findings demonstrate the improved precision and reproducibility achieved with the navigation technique.

Conclusion: This technique allows the surgeon to obtain an excellent precision of the transplant insertion with excellent reproducibility. There are two drawbacks: the longer operative time (mean 15±7 minutes) and radiation exposure. But this technique is simple, easy to use and low-cost.

Aims: Functional results of anterior cruciate ligament (ACL) is closely related to the anatomical position of the graft. Femoral or tibial miss placements are associated with increase laxity, decrease range of motion. Based on anatomical dissections we developed a triangle method able to be used as fluoroscopic intra-operative landmark to increase the reproductibility of the placements. Methods: A lateral X ray of normal knee is mandatory before the surgical procedure. During the ACL reconstruction using patellar tendon a pin is placed to determine the tibial tunnel, and a small screw is inserted at the femoral ACL location. Under imagine intensifier, a lateral X ray of the operated knee is realised. The picture is exported and analysed on a PC computer. The surgical placement is compared with the ACL center position according to the triangle method. 35 knees have been operated and compared with 35-paired knees operated with the same technique and operator. Results: The mean distance between the ACL center and the surgically chosen femoral position is 7.5 ± 1.9 mm for the standard surgery and 4.9 ± 1.3 mm for the fluoroscopy based surgical navigation. The Wilcoxon test for small-paired series indicates a statistical significance (p=0.001). The mean extra operative time is 15 ± 7mn. Conclusion: This technique is simple, easy and rather fast. It gives to the surgery a significative improvement for positioning the ACL graft on the femoral side. It has to be confirmed for larger and by long term clinical results.

Aims:ACL revision surgery is a second-generation type of knee ligament surgery. The artificial ligaments, the imperfect mastering of arthoscopic assisted surgery and the absence of clinical and radiological analysis of peripheral laxities are among the main factors for failures. Methods:43 patients of a mean age of 29y were previously operated between 1 and 5 times.14 artificial ligaments, 23 patellar tendons and 4 hamstrings tendons failed as a first ACL reconstruction. The mean time between the first operation and the index revision was 44 months. In 6 cases an additional HTO was used. Different tendon grafts were used: quadriceps 11, patellar 19 and hamstrings 8. In 3 occasions an additional extra articular reefing was used. The patients were reviewed by one independent observer using KT 1000, Stress X rays, IKDC form (2000). The mean follow up is 35 months (11–123)Results:The IKDC score in pre operative time was 19 D, 21 C and 1B. At the review the score is 2A, 28 B, 9C, 2D. The functional IKDC form show 37.5% of remaining pain, 44% of stiffness sensation and 12.5% of instability. The mean functional improvement is 44%. The mean laxity improvement is 5.3mm for KT1000 and 4.5mm for stress X rays. Conclusions:Revision ACL surgery is not as good as primary surgery. The reconstruction is technically difficult and must be ‘à la carte’ in order to take in account several simultaneous problems: bone defect, cartilage abnormalities, skin and ligament insufficiencies.

Purpose: Constitutional factors responsible for hallux falgus and hallux rigidus remain unclear. The purpose of this work was to compare the radiological feature of the forefoot in three populations with “normal” feet, hallux rigidis, and hallux valgus.

Material and methods: One standard protocol was used within the same unit to obtain dorsoplantar AP views of the foot in the standing position in all subjects. Fifty “normal” feet, with no apparent deformation, callosity, or pain, were selected among the orthopaedic unit personnel; mean age of the 25 subjects was 30.3±9.6 years, and 44% were women. The 30 patients with hallux rigidus were operated on at a mean age of 57.4±10.7 years, and 48.4% were women. The 50 patients with hallux valgus were operated on at a mean age of 50.8±12.8 year and 92% were women.

All radiograms were digitalised (Vidar VXR-12 plus) and analysed by four observers using the FootLog software which provides semiautomatic measurements. The following parameters were recorded: distance between the lateral sesamoid and the second metatarsal (LS-M2), the M1P1 angle (for the diaphyseal and mechanical axes of M1), the diaphyseal and mechanical distal metatarsal articular angle (DMAA) of M1, Meschan’s angle (M1–M2–M5), the distance between a line perpendicular to the axis of the foot drawn through the centre of the lateral sesamoid and the centre of the head of M4 (MS4–M4) (a corrective factor was introduced for the MS4–M4 distance to account for the displacement of the lateral sesamoid in hallux valgus), the M1 index = d1-D2 (length of the head of M1/MS4 – length of the head of M2/MS4), maestro 1 = d2–d3, maestro 2 = d3–d4, maestro 3 = d4–d5. The measured parameters were recorded automatically on an Excel data sheet and statistical analysis was performed with SPSS 9.0.

Results and discussion: Intra- and inter-observer reproducibility of measurements and morphological classifications were excellent. The LS/M2 distance was comparable in the three populations, proving that the lateral sesamoid is relatively fixed compared with the M2 and enabling its use as reference for the MS4 line. The Meschan angle did not discriminate between the three populations, likewise for the mean M1/M2 index, the M1P1, M1M2, and DMAA angles which were different in the three populations; there were 2° to 3° variations for the mechanical or shaft axis. The morphotype analysis demonstrated objective evidence of morphological differences of the forefoot in the three populations. The hallux rigidus group showed a predominance of the index plus and plus-minus with long M23 lateral patterns, while the hallux valgus group exhibited a predominance of M4M5 hypoplasia.

Discussion: Morphotypic definition of the metatarsals is an interesting approach providing a measurable way of interpreting forefoot disorders and guide surgical correction. These results should be confirmed with measures in larger series, which can be accomplished with FootLog software. It would also be useful to combine radiological studies with baropodometric studies.

Purpose: The collagen meniscus implant (CMI, Sulzer) is a meniscal substitute with a collagen matrix serving as a tutor for autologous regeneration of meniscal tissue. The goal is to prevent mid-term degradation after meniscectomy. The CMI is inserted arthroscopically. The purpose of this multicentric European study was to verify the safety, technical feasibility, and short-term clinical efficacy of the CMI in a population of patients undergoing medial meniscectomy. The long-term results should be obtained within a delay of five years at least.

Material and results: The series included patients with medial meniscus lesions alone, with or without lesions of the anterior cruciate ligament (present in 44% of the patients and repaired at the same time). Patient consent was obtained in all cases (in France in accordance with the Huriet law). Patients with lesions of the lateral ligament, associated trade IV cartilage lesions, or lesions of the posterior cruciate ligament were excluded. The study included 98 patients, mean age 33 years. Four patients were excluded from the analysis due to complications. Currently, 66 patients are available for evaluation one year after insertion of the CMI. Subjective outcome, the Lysholm score, and x-ray and MRI findings were recorded. Evaluation up to five years follow-up is scheduled.

Results: Complications: There were four early complications: infectious arthritis (n=1), puriform arthritis without germ (n=2), implant rupture (n=1). There were no implant-related postop complications.

Clinical results: At one year follow-up, the Lysholm score was 97. Pain was mild (1 on the visual analogue scale) and was only observed in one out of six patients: 87% of the patients had a normal or nearly normal knee.

Radiological results: There were no radiological signs of early degeneration. It was difficult to interpret the MRI results which visualised a structure with an intermediary signal in the form of a meniscal triangle. MRI did on show any sign of deleterious effect on the neighbouring cartilage.

Discussion: This technique for replacing the meniscus is an alternative to allogenic grafting. These preliminary results must of course be interpreted with caution. They show that arthroscoic implantation of the CMI is feasible but difficult. There was no evidence of an immunological reaction. Complications were related to the operative difficulty. Clinical results were satisfactory at one year, particularly in terms of pain. On the other hand, the biomechanical value of the implant cannot be assessed until longer follow-up data becomes available.

Conclusion: In light of the operative difficulty, the long postoperative recovery due to the rehabilitation protocol, the CMI should be used for symptomatic knees after meniscectomy, particularly in case of anterior laxity.

Purpose: Since 1996, our multidisciplinary medicosurgical team has decided to propose orthopaedic treatment for diabetic perforating ulcers with osteitis, cellulitis, or necrosis (“cooling down” the acute infected ulcers before programmed surgery) rather than conservative treatment with prolonged antibiotic therapy. We present here a prospective study of 44 cases of diabetic perforating ulcers.

Material and methods: Thirty-two diabetic patients underwent surgery: 77% males, mean age 65.2±8.6 year (range 43–86 years), 87% type 2 diabetes, 52% with a history of perforating ulcers, 45% with minor amputations, and 14% with history of vascular surgery. The lesions—perforating ulcer with osteitis (n=34), vascular necrosis of the toes (n=2), “acute feet” with cellulitis (n=8)—had progressed over 13.2±15.1 weeks. The preoperative work-up included: bacteriology samples 89%; standard x-rays of the foot 100% (osteitis 84%); duplex Doppler of the lower limb arteries 77% (tibial arteriopathy 87%); double bone scintigraphy 34% (osteitis 93%); TcPO2 (40±14mmHg); arteriography 27%; vascular surgery consultation 18%. Before surgery, 77% of the patients were hospitalised in an endocrinology unit (13±3 days) and 88% were on an antibiotic regimen for 26±18 days (50% i.v.).

Orthopaedic surgery (without tourniquet, anaesthesia block, mean duration 53±24 min) involved: partial resection of a toe 23%; amputation of a ray 36% (first ray one, second ray five, third ray one, fourth ray two, fifth ray six); transmetatarsal amputation 32%; resection of the metatarsal heads 4%; calcanectomy (n=1); below knee amputation (n=1); and systematic and multiple samples for bacteriology (deep soft tissue and bone tissue) and for pathology.

Results: Mean hospital stay in the surgery unit was 4±1 days, followed by 18±10 days in the endocrinology unit with antibiotics (oral for 88%) for 34±22 days, 91% of the lesions healed within 33±18 days; four required repeated procedures (two transmetatarsal amputations, one amputation of the first ray, one lower limb amputation); three lesions relapsed.

The peroperative bacteriology samples of the deep soft tissue and bone tissue demonstrated, in comparison with the preoperative samples, that antibiotics had sterilised only 14% of the lesions; with discordant comparison in 40%, partial concordance in 24%, and total concordance in 24%. For the diagnosis of osteitis (confirmed by histology of peroperative bone samples), the x-ray interpretations were largely confirmed (79% exact diagnosis, 87% sensitivity, false positives 12%), as were the bone scintigrams with labelled polymorphonuclears (exact diagnosis 93%, sensitivity 93%, false positives 7%).

Conclusion: This prospective study demonstrated the advantages of programmed surgery over emergency surgery, including for “acute feet”: limited resection, primary suture, rapid wound healing, short antibiotic treatment. It raises some questions concerning the validity of non-surgical bacteriological samples for perforating ulcers, even when performed under rigorous conditions (unique strain isolated from 76% of the samples) and on the possibility of antibiotic pressure on bacterial selection.

Purpose: We analysed knee prostheses preserving the posterior cruciate ligament (or both cruciates) performed after tibial osteotomy. We determined outcome as a function of any tibial callus deformation created by the tibial osteotomy.

Material and methods: This retrospective study included a consecutive series of 56 knee prostheses with preservation of the posterior cruciate ligament (n=43) or both cruciate ligaments (n=13). The patients had undergone prior tibial osteotomy for valgisation (n=47) or varisation (n=9). Seven groups were defined as a function of the preoperative tibial angle prior to TKA. The angle were measured with telegonometry. Minimum follow-up was one year, mean follow-up 4.1±2.8 years.

Results: The tibial tuberosity was raised in 15 cases. If there was major valgus or rotation deformation, tibial osteotomy was associated with the prothesis (n=9). At last follow-up, the mean IKSg, IKSf and HSS scores were 81.5, 77.6, and 82.3 respectively. The mean femorotibial angle was 177.4±4.2°. The mean tibial angle was 87.8±3° and the mean femoral angle was 89.8±2°. Preoperative tibial deformation was not influenced by clinical results. In case of preoperative tibial deformation situated between 5° valgus and 5° varus, operation time, blood loss, and femoraotibial axis at last follow-up were not significantly different. To correct for tibial valgus greater than 7°, tibial osteotomy was associated with prosthesis implantation during the same operative time in six out of thirteen cases. For preoperative tibial varus greater than 5°, the femorotibial axis was less well corrected.

Discussion: These clinical results were comparable to those reported in other series with preservation or not of the posterior cruciate ligament. Correction of the femorotibial angle was less satisfactory than in certain series, but the deformation and the surgical history were among the most marked in the literature. Preservation of the posterior cruciate ligament (or both cruciates) appears to have increased the technical difficulties for upper tibia exposure and position of the tibia implant. For tibial callus with valgus greater than 7°, the prostheses cannot be expected to provide a solution alone and osteotomy should be associated. For tibial callus with 5° or more varus, the indication for associated tibial osteotomy merits discussion.

Purpose: We reviewed retrospectively 40 ligamentoplasties of the anterior cruciate ligament in patients who had undergone several prior reconstructions (1 to 6). The initial operation had used a synthetic ligament in 13 cases, patellar tendon in 23 and divers implants in four.

Material and methods: Forty patients, 12 women and 28 men, with recurrent ligament tears where reoperated by the same surgeon. Mean age was 28.5 years (16–51). Mean follow-up after the last operation was 27 months. All patients were reviewed (history, physical examinatin and KT 1000); 20 of them responded to a self-administered questionnaire using the IKDC chart later after the clinical review, and 23 of the 40 had radiographs to measure laxity. Arthroscopic reconstruction was used in 33 cases. A surgical procedure was necessary on a peripheral ligament in six cases and osteotomy for tibial valgisation in one. Reconstruction was achieved with the quadriceps tendon in 11 cases, the patellar tendon in 18, the hamstrings in eight and Mac in Jones in three. The IKDC score was used for clinical assessment with manual arthrometric measurement of laxity. Radiographs were obtained to measure the anterior drawer of the medial and lateral compartments of both knees for right-left and pre-postoperative comparisons.

Results: The initial handicap was marked (IKDC: 18 D, 21 C, 1 B). Reconstruction was good or very good in 72.5% of the knees (IKCD: 2 A, 27 B, 10 C, 1 D). Self-evaluation revealed 25% painful knees for intense activities. Laxity was improved with a mean differential gain of 5.35 mm of the maximal pre- and postoperative KT 100 (7.24 versus 1.89). Among the 24 knees with radiographic assessment, the mean differential preoperative was 9.14 mm preoperatively and 4.69 mm at last follow-up giving a gain of 4.45 mm. One athlete was able to resume sports activities at the same or higher level and others at a lower level.

Discussion, conclusion: This study confirms that the results obtained after revision repair are less satisfactory than after primary repair. This homogeneous (one operator) and large series with a sufficient follow-up can be compared with the rare published series. Each ligament reconstruction is specific and warrants a specific surgical approach adapted to each individual case.

Purpose: There are three main causes of failure after valgisation osteotomy of the tibia requiring repeated osteotomies: insufficient valgus, excessive valgus, or loss of the valisation correction after a variable delay. The purpose of this study was to evaluate outcome after repeated oseotomies performed in relatively young patients or too active to propose arthroplasty. The technical problems were different for each aetiology.

Material and methods: The series included 47 knees operated on between 1974 and 1998 after a first osteotomy performed at a mean age of 46 years. Mean delay between the two operations was five years (1 to 12). A medial closure osteotomy had been performed at the first operation in 34 cases and a lateral opening osteotomy in 13. For the 19 knees with valgus, the second osteotomy was a medial closure in 14 and a lateral opening in five. A repeat valgisation was performed in 28 cases, 18 by lateral closure, one by medial opening and nine by curviplanar osteotomy. The IKS score was determined to assess function. The femoraotibial axes (HKA angle) were determined on full stance views. The Ahl-back osteoarthritis grading was used. For 17 patients who had undergone operations in other institutions, exact measurements were not always available concerning the preoperative status and the initial correction.

Results: The overall IKS score for function improved in 87% of the cases with a mean follow-up of five years. The IKS knee score improved from 73 to 89 points and the IKS function score from 65 to 81 points. For the 19 over-corrections, the mean HKA angle was changed from 190° to 184°. For the 28 under-corrections, the mean HKA angle was changed from 173° to 182°. The tibial tilt remained unchanged at 7° as did lateral gapping at 3°. Delay to consolidation was a mean 96 days.

Discussion: Revision osteotomies performed for correction defects should be distinguished. For these procedures, it would be logical to expect a good result if a 3 to 5 degree valgus is achieved. Revisions after a long period (33 cases) are different; required for wear, these cases correspond to progressive loss of the initial osteotomy effect. These patients are often candidates for prosthesis if seen after 70 years. Good results can however be obtained with a second osteotomy irrespective of the initial technique. We prefer reoperating with medial opening after initial lateral closure.

Purpose: Several techniques have been described for the treatment of unstable fractures of the upper humerus. None appear to be appropriate for subtuberosity fractures, associated or not with a fracture of the trochiter or impacted valgus cephalotuberosity fractures, allowing a stable fixation with anatomic reduction while preserving blood supply to the bone fragments. For the last year, we have studied prospectively a percutaneous minimally invasive technique for this type of fracture. Our preliminary results are analysed here.

Material and methods: We used this technique for 12 patients aged 30 to 87 years with five displaced subtuberosity fractures, six subtuberosity fractures with a trochiter fracture and one impacted valgus cephalotuberosity fracture. Excepting the cephalotuberosity fracture, the joint fragment of the head was reduced by external manipulation under image amplifier guidance. Fixation was achieved with two 25/10 threaded pins inserted percutaneously in retrograde fashio from the anterolateral cortical to the humeral shaft. For eight cases, a third pin was inserted percutaneously from the trochiter to the medial cortical of the humerus. When percutaneous reduction of the trochiter was impossible (three cases) and for the cephalotuberosity fracture, we used a minimal transdeltoid lateral incision to reduce the trochiter and achieve reduction.

Results: Reduction was very satisfactory in all cases. There was one superficial infection that required pin withdrawal at three weeks leading to the only secondary displacement that was minimal and tolerable. We removed the pins after a mean two months. There were no nonunions. Seven patients have a follow-up greater than six months and exhibited a Constant score of 87% (71% to 100%).

Discussion: This techniques has provided very satisfactory results for rapid and stable fixation of the cephalic fragment without loss of blood supply and with a material easy to remove.

Conclusion: These early results are very encouraging and incite us to pursue this technique and analyse long-term results.

Purpose: Plantar pressure sores can lead to metatarsalgia depending on the patient’s activity level and age and on the status of the muscle-tendon system and the morphology of the forefoot. In 1995, Tanaka and Maestro attempted to quantify the relative lengths of the metatarsals. The purpose of this work was to check the results reported by Maestro and to try to define a morphotype classification of the metatarsals.

Material and methods: We analysed two series of normal feet: no apparent deformation, no callosity, no pain, no history of trauma or surgery. Fifty “normal” feet were selected among the personnel of the orthopaedics unit. Mean age of the 25 subjects was 30.3 ± 9.6 years, 44% were women. This series was compared with 34 “normal” feet reported by Maestro (age 55.2 ± 17.2 years, 62% women) used to define criteria for geometric progression (1995). A standing dorso-plantar radiograph was obtained with the same protocol for all patients. All radiographs were digitalized with a Vidar VXR-12 plus, then analysed by two observers with the semi-automatic FootLog measurements. The following measurements were recorded: SM4-M4 (distance between the line passing through the centre of the lateral sesmoid and perpendicular to the foot axis and the centre of the M4 head), M1 = d1 – d2 (length of the M1/SM4 head – length of the M2/SM4 head), Maestro criteria 1 = d2 – d3, Maestro 2 = d3 – d4, and Maestro 3 = d4 – d5.

Results: An SM4 line passing through the mid third of the M4 head (+2mm proximally / centre M4 head / −4 mm distally) as normal. The notion of row 2 geometric progression was conserved by tolerating 20% variation (Maestro 1 ± 1 mm, Maestro 2 ± 1mm, Maestro 3 ± 2 mm). Feet were classed in four metatarsal morphology types with subgroups: normal feet (line SM4 passing through the mid third of the M4 head – geometric progression) – long M23 (SM4 line centred on the mid third of M4 – but alteration of the geometric progression) with four subgroups (long M2, long M3, long M2-3, long M23 long 2) – M4M5 hypoplasia (distal SM4 line / at mid third of M4) with four subgroups (by geometric progression: long M2, long M23, long M23 long M2) – others (long M1: M1 > 3.3 mm causing distalization of SM4).

Discussion, conclusion: FootLog enables rapid radiographic measurements with excellent precision and intraobserver (variations from 0.1 to 0.2 mm and 0.1 to 0.5°) and interobserver (variations from 0.1 to 0.5 mm and 0.1 to 1°) reproducibility. In the two series of clinically “normal” feet, the measured parameters were strictly comparable. Radiologically, 31% were “normal”, and the others (30% long M23 – 37% M4M5 hypoplasia – 2% others) could be considered as predisposed to potential forefoot disorders. Finally only 48% of the subjects had the same morphotype for both feet. This study adds further precision to earlier qualitative evaluations of the forefoot architecture.