Aim

Our hospital is a referral center for Bone and Joint Infection (BJI) with a 15-bed orthopedic unit. Patients benefit from a multidisciplinary team management (surgeons, anesthetists, infectious disease physicians, microbiologists, dietician etc.). Computerized drug prescriptions are performed by anesthetists, surgical residents, surgeons and infectious disease physicians. Since 2015, a pharmacist has been included in ward rounds and in weekly multidisciplinary consultative meetings, where antibiotic treatment strategies are decided for hospitalized patients. This work aimed to assess the impact of a pharmacist in this unit to limit prescription errors.

Purpose of the study: Different metatarsal osteotomies performed via a percutaneous approach can be used to correct hallux valgus. The purpose of this work was to analyse the clinical and radiographic results of percutaneous treatment of hallux valgus using a distal wedge osteotomy of the metatarsal.

Material and methods: This was a consecutive prospective series of 125 cases of hallux valgus treated by the same surgical technique, distal wedge osteotomy of the metatarsal without fixation. Percutaneous lateral arthrolysis and percutaneous varus correction of the first phalanx were associated. The AOFAS function score for the forefoot was determined preoperatively and at last follow-up. Time to normal shoe wearing and to resumption of occupational activities were also noted. Angle correction was determined on the anteroposterior weight-bearing image. All patients were reviewed at mean 20 months (range 12–40).

Results: The AOFAS forefoot function score was 46/100 preoperatively and 87/100 at last follow-up. Mean motion of the metatarsophalangeal joint was 95 preoperatively and 80 postoperatively. Mean metatarsophalangeal valgus was 30 preoperatively and 12 at last follow-up. The mean intermetatarsal angle improved from 13 to 8 and the orientation of the joint surface of the first metatarsal (DMAA) improved from 11 to 7. The metatarsophalangeal joint of the first ray was congruent in 45% of the feet preoperatively and in 88% postoperatively. Mean time to wearing normal shoes was seven weeks for the treatment of hallux valgus alone and three months for surgery of the first ray and lateral rays.

Discussion: Percutaneous treatment of mild to moderate hallux valgus by distal wedge osteotomy of the metatarsal enables good clinical and radiographic improvement. The surgical technique requires experience with percutaneous surgery of the forefoot to avoid the main complications: secondary displacement in elevates and excessive shortening of the first metatarsal. This technique restores metatarsophalangeal congruence of the first ray compared with Isham-Reverdin osteotomy.

Introduction: Lateral meniscectomies lead to degenerative arthritis and therefore meniscus transplantation has been considered. In literature, this procedure appears to have good clinical results. The aim of this study was to evaluate our clinical results at mid-term follow-up and to correlate these results to the morphology and position of the transplanted meniscus.

Material and methods: Twenty-eight patients operated in 4 surgical centers, were retrospectively reviewed following lateral meniscal allograft transplantation. The mean age of the patients was 34 years (range, 18 to 50 years). Before surgery, all these patients suffered of permanent lateral femorotibial pain without radiological knee arthritis. The knees were all stable or stabilized, without axial malalignment of the lower limbs or corrected by a concomitant high tibial osteotomy. Arthroscopic procedure was performed for 9 patients and arthrotomy for 19 patients. Different techniques of fixation of the transplant were used, with or without bone plugs. The associated procedures were 2 ACL reconstruction, 3 high tibial varus osteotomies, and 1 mosaicplasty. The IKDC score were used for the analysis of the functional results. An arthroTDM or an arthro MRI was used to analyse the morphology and position of the transplanted meniscus.

Results: The mean follow-up was 35 months (range, 12 months to 6 years). The mean post-operative subjective IKDC score was 65.5 points (range, 19.5 to 89 points). There were 2 failures associated with a fast arthritic evolution and 2 functional bad results. The others 24 patients (85%) were satisfied or very satisfied, with a real improvement of the pain and the function. Seventeen patients (60%) have started again a sportive activity superior than the one pre-operating. At the last follow-up, all transplanted meniscus have healed, but the morphology and position of the transplanted meniscus was not always normal with absence of the middle segment in 3 cases; its extrusion in 9 cases, a posterior segment shortened or partially hurt in 5 cases and its absence in 3 cases. Better results were associated with good meniscus positioning and morphology.

Discussion: Our works confirm that lateral meniscal allograft is a therapeutic option with favourable results in terms of pain reduction and functional improvement in the medium term for symptomatic patients after lateral meniscectomy. Our results are comparable with those of the literature. The allograft is technically reliable, reproducible notably for the methods of fixation. A long term follow-up is necessary to evaluate the benefit of these grafts on the protection of the cartilage.

Purpose of the study: Spontaneous repair of lost deep chondral tissue is minimal in the knee joint. A clinical trial of chondrocyte autografts as described by Brittberg and Peterson was undertaken by the Nantes University Hospital and the French Society of Arthroscopy in 1999.

Material and methods: Twenty-eight patients, mean age 28 years, underwent surgery in eight centers. Etiologies were: osteochondritis (n=14), isolated posttraumatic chondorpathy (n=7), chondropathy and full-thickness ACL tear (n=7). All lesions involved the condyles and were deep (ICRS grades 3 and 4). Mean surface area involved after debridement was 490 mm2 (range 150–1000 mm2). Patients were followed three years after the autologous grafting to assess functional outcome. An MRI was obtained at 2–3 years. Thirteen control arthroscopy procedures were performed including eight with biopsy specimens for histology and immunohisto-chemistry studies.

Results: Twenty-six patients were reviewed at more than two years. There were no general complications, three patients presented a partial avulsion of the graft treated by arthroscopy and one underwent arthrolysis at six months. Function improved in all patients except three and pain improved in all. The ICRS score improved from 43 points (range 19–70) to 77 points (range 39–84). Sixteen control MRIs were available and showed that the graft was hypertrophic in eleven cases, on level in four, and insufficient in one. Marginal integration was good in 11 cases and partial in five. Subchondral integration was complete in ten cases and mediocre in six. The arthroscopic score was nearly normal (score 8–11) in eight cases and abnormal in five (score 4–7). The histological class according to Knutsen (hyaline richness) was: one in group 1 (> 60%), three in group 2 (> 40%), four in group 3 (< 40%) and one in group 4 (bony or fibrous tissue). Function score (r=0.78 and MRI score (r=0.76) were correlated with arthroscopic sores. There was no correlation with the histological results.

Discussion: Clinical outcome was improved in more than 80% of cases, similar to results reported for histological series. The arthroscopic and histological results were equivalent to those reported by Knutsen but inferior to those reported by Bentley or Peterson.

Purpose of the study: The incidence and type of complications observed with arthroscopic procedures remains a timely subject, particularly as the use of new techniques becomes increasingly widespread.

Material and methods: In cooperation with the members of ISAKOS, The International Society of Arthroscopy, Knee surgery and Orthopaedic Surgery, we instituted two studies: a retrospective study of upper limb arthroscopy complications and a prospective incidence study during a 30-day inclusion period with patient review at one month and quality-of-life scoring.

Results: The retrospective study analyzed complications of 57,604 arthroscopic procedures of the upper limb performed by 99 surgeons from 38 countries. Neurological complications, though generally transient, were the most frequent and were related to traction, locoregional anesthesia or the operative technique. Four deaths were recorded, all anesthesia-related. The prospective study included 364 patients operated on by 50 surgeons. There were 16 initial complications (4.39%): material problem (n=12), three intraoperative bleeding (n=3), atelectasia (n=1). The rate of conversion was 2.47%. At one month, there were five complications reported in 133 patients (3.75%): anesthesia-related problem (n=1), bleeding (n=1), synovial fistula (n=1), reflex dystrophy (n=2). There were no infections and no neurological lesions. The one-month outcome was considered good or excellent by 98.5% of surgeons.

Discussion and conclusion: The results of these surveys are in agreement with data in the literature where the rate of complications is higher in prospective studies than in retrospective studies. The prospective study did not disclose any neurological complication while arthroscopy of the upper limb is generally considered to raise the risk of with this type of complication. This study recalls that although arthoscopy has enabled a decreased incidence in complications compared with open surgery, it is not a benign intervention and can produce complications.

Purpose: We reviewed retrospectively 22 patients with recent and old fractures of the radial head treated with the GUEPAR radial head prosthesis which has a mobile metal cup derived from the GUEPAR gliding total elbow prosthesis.

Material and methods: Among the 22 patients, 13 underwent surgery in an emergency setting and four underwent a secondary procedure. Mean age was 41 years and follow-up was 18 months. The Mayo Clinic score was noted. Fractures were total or disengaged cervical fractures and in 72% of the elbows dislocation was associated. The coronoid process was fixed in one elbow, the olecranon in one and the medial ligaments were repaired in five. The status of the humeral condyle was examined in detail before insertion of the prosthesis. We also were particularly attentive concerning the height position of the prosthesis.

Results: There were no complications. Outcome was good among the patients undergoing an emergency procedure with a mean Mayo Clinic score of 83/100, mean force 75%, good motion, particularly 77° pronation, and 79° supination, with good stability and absence of wrist problems. The patients who underwent a secondary procedure had less satisfactory results, particularly for motion (44° pronation and 54° supination). The distal radioulnar index was not perfectly restored. Finally four patients had arthrolysis for limited flexion/extension, three of them in the secondary group.

Discussion: Resection of the radial head is an alternative for complex fractures that has its inconveniences. The first is that it destabilises the elbow in valgus position in the event of injury to the medial ligaments and the second is the ascension of the radius in the event of injury to the interosseous membrane. Fixation is another alternative, but it is difficult and has not provided good results in our hands or in the literature (we have compared this series with a series of 20 fixations for equivalent fractures). The prosthesis appears to be a good solution: it stabilises the elbow, prevents ascension of the radius, allows early rehabilitation, and provides good subjective outcome, particularly in emergency cases.

Purpose: A prospective multicentric study was conducted in a concentric and consecutive series of 204 patients operated on between Mai 1999 and August 2001 for fracture of the proximal femur. The purpose of this study was to assess quality of life after surgery in patients undergoing implantation of the Intermedia® prosthesis.

Material and methods: Mean patient age was 79.6± 8.6 years), 18.8% men. Most of the fractures were Garden III and IV fractures (87.4%) and 90.9% were recent (< 21 d). The intermediary Intermedia® prosthesis was implanted via the posterolateral approach in 73.9% of the patients with acetabular preparation in 13.7%; a head with a restraining skirt was used in 20.8%. The Robinson score for motion, lifestyle, degree of osteoporosis (Singh score), history (ASA), psychomotor index (Hodkinson score) were determined preoperatively (19/26 (±6.89). The Merle d’Aubigné score was calculated at one year. Adaptation of the femoal stem (3 sizes) to the shaft was assessed on standard x-rays. The Kobayashi method was used to study stem to shaft fit; this score gives a rate of shaft filling used to determine whether the self-blocking contact was well achieved with the three stem sizes available.

Results: There were eleven (5.4%) posterior dislocations including four which were reduced orthopaedically. Among the 203 patients, 40 (19.7%) were lost to follow-up and 34 died. The Merle d’Aubigné score at one year showed 84.7% satisfactory results (excellent, very good, good). Preoperatively 59% of the patients were independent and 7% resided in nursing homes, these figures at one year were 55.5% and 5% respectively. Radiologically, the rate of migration (impaction) was 3.9% at one year. Stem-to-shaft fit was, according to Kobayashi for the proximal, middle, and distal portions 73%, 75% and 75% respectively.

Discussion: Mortality due to fracture of the proximal femur is high (16.7% at one year). Morbidity was due to infection (1%) and eleven displacements (5.4%). The difference in motion and lifestyle between the pre- and postoperative period was not significant. Simplification of the implantation procedure by using three stem sizes did not produce any radiological differences at one year.

Purpose: This study was conducted to analyse the importance of the Malgaigne notch and its position on standard x-rays taken in internal rotation or on arthroscan in patients treated for anterior instability of the shoulder. Our purpose was to search for criteria perdictive of outcome of arthroscopic stabilisation of the shoulder joint using the Bankart method.

Material and methods: Fifty-four patients were reviewed to determine the postoperative Duplay score. Mean follow-up was 68 months (32–100). Mean age at surgery was 29 years. We divided the patients into three populations as a function of preoperative symptoms: population A two dislocations or more, population B one dislocation then episodes of subluxation, population C no dislocation but pain. We divided this population according to the Duplay score. Group 1 patients had a fair or poor outcome, Group 2 patients had a good or excellent outcome. We reviewed 54 radiograms using patterns of increasing size (mm by mm) to assess the radius of the humeral head and the depth of the notch. We evaluate the reproducibility of this method by comparing the readings of ten senior orthopaedic surgeons. There were no false positives or false negatives. Variance of the measures taken by the ten surgeons was 0.67 at 1.31 mm, a small variance. We compared the ratio between the radius of the humeral head and the depth of the notch in the different groups.

Results: The Malgaigne notch was significantly deeper in population A (19%) than in population B (14%) or population C (14.3%). This suggests that the size of the notch has an effect on symptomatology of shoulder instability. The notch was also significantly deeper in group 1 patients (fair or poor outcome) (21%) than in group 2 (good or excellent outcome) (16%) (p=0.05).

Discussion: Beyond a threshold set at 15%, there were 54% fair or poor results. The position of the notch in height was significantly different in population A compared with populations B and C (p=0.01). It appears to be higher in case of true recurrent dislocation. We did not demonstrate any statistical link between the position of the notch on the CT scan and surgical outcome. This study demonstrates the importance of information on the internal rotation images in choosing the proper type of surgery for shoulder instability.

Purpose: It is known that severe distention of the inferior glenohumeral ligament (IGHL) during anteror-inferior shoulder instability is an important factor of poor functional prognosis after arthroscopic stabilisation. O. Gagey proposed a clinical test to assess laxity of the IGHL. The purpose of this study was to assess the laxity of the IGHL using a dynamic radiological test (AP view in passive abduction of the glenohu-meral joint) and to correlate findings with arthroscopic observations..

Material and methods: We performed a prospective study in 21 patients scheduled for arthroscopic stabilisation for anteroinferior shoulder instability. Mean age was 24.6 years, 17 men and 4 women. The test was performed in the supine position with a strictly AP view of the shoulder. Bilateral comparative images were obtained. The shoulder was brought to forced passive abduction in neutral rotation without general anaesthesia or locoregional anaesthesia. The angle between the axis of the humeral diaphysis and the line passing through the inferior border of the glenoid cavity and the lateral border of the scapular tubercle was measured. Vuillemin has demonstrated that this test is reliable and reproducible. During arthroscopy performed for diagnostic and therapeutic purposes, the degree of distension was quantified using the Detrisac classification of four stages. We considered that stages 3 and 4 were frank pathological distension. We used the threshold of 15° for the difference between the healthy and pathological side for the radiological test. We assessed the ability to demonstrate severe laxity of the IGHL.

Results: For differences in abduction less than 15°, the test sensitivity was 77%, specificity 91%, positive predictive value 87% and negative predictive value 84%.

Discussion: A careful physical examination and appropriate complementary tests are essential for the evaluation of anteroinferior instability of the shoulder joint in order to obtain a precise diagnosis and search for contraindications for arthroscopic cure. The rate of recurrence after arthroscopic stabilisation remains above that obtained with open techniques. It has been demonstrated that major laxity of the IGHL constitutes a relative contraindication for arthroscopic stabilisation. Radiographic measurements provide precise information for evaluating the laxity of the IGHL. Taking a positive threshold of 15° difference identifies 87% of the cases of Detrisac stage 3 or 4 ligament distension.

Conclusion: We propose a preoperative complementary test using standard x-rays together with our dynamic radiological test of passive shoulder abduction. If the difference between the healthy and pathological side is greater or equal to 15°, the therapeutic strategy should include not only reinsertion of the rim but also retight-ening the ligament complex, or open stabilisation.

Purpose: The risk of recurrence would be greater after arthroscopic treatment of shoulder instability compared with open repair. We wanted to find what effect bone lesions and more particularly posterosuperior notch in the humerus have on outcome after arthroscopic management of shoulder instability.

Material and methods: We made a retrospective analysis of 60 patients who underwent an arthroscopic procedure between February 1993 and December 1998. Mean age was 28 years three months. All patients in this series had a bony notch measured on the preoperative scan. Six measurements were made to determine the volume of the notch approximated to the half volume of a revolution ellipse. The ratio of this volume to total volume of the humeral head (approximated as a sphere) was also calculated. The glenoid cavities were classed in four groups: normal, abrasion, fracture, amputation. Operative result was assessed with the Duplay score at a mean follow-up of 42.7 months.

Results: Outcome was excellent in 24 patients, good in 14, fair in seven, poor in five including four related to recurrent instability, and a failure in ten requiring reoperation. The rate of recurrence with reoperation was 16.6%. Notch volumes varied from 0 to 4792 mm³ (mean 1019±1253). The notch/ head ratio ranged from 0 to 10.5% (mean = 2.28±2.63). Only 12 patients (20%) did not have a bony notch; 11 of them had an excellent or good result. Mean volume of the notch in patients with excellent, good, or fair outcome (group A) was 639.72 mm³. Mean volume of the notch in the failure cases (group B) was 2158.11 mm³. Glenoid cavity classes in group A were 17 normal, 20 abrasion, 8 fracture, 0 amputation. In group B the classes were 2 normal, 9 abrasion, 2 fracture, 2 amputation. The volume of the notch was significantly correlated with outcome (Spierman test). There was no significant correlation for the glenoid cavity.

Discussion: Despite the absence of a significant correlation with the glenoid cavity classes, the presence of a glenoid lesions in cases with a bony notch smaller than 500 mm³ had an important impact in three out of the four failures (two amputations and one fracture). Considering a threshold value of 1000 mm³, the rate of failure was 7.7% irrespective of the glenoid lesions and 52.5% if glenoid amputations and fractures were excluded.

Conclusion: It would appear that arthroscopic treatment should be reserved for patients with a small humeral notch (< 1000 mm³). Glenoid lesions should also be quantified in patients with small notches.

Purpose of the study: We compared in vitro the efficacy of screw-plate fixation versus double screw fixation on a model of type 2 Schatzker fracture of the lateral tibial plateau.

Materials and methods: Ten screw-plate fixations using a lateral prebent plate and 10 double-screw fixations (6.5 mm screws) were made on 10 pairs of non-embalmed cadaver knees after simulation of type 2 Schatzker fractures. The strength of each fixation was tested with a compression device. Criteria indicating failure were displacements greater than 2 mm of one or more fracture lines. The force applied at rupture and the stiffness of each type of fixation were compared. Wilcoxon’s test was used for statistical analysis.

Results: Force at rupture and stiffness of the fixation were similar for the two types of fixation. There was no statistical difference (p > 0.05) between the screw-plate and the double-screw fixations.

Discussion: Our findings on a model of type 2 Schatzker fractures are in agreement with previous data obtained by other authors working on models of type 1 Schatsker fractures. The biomechanical stability of the double-screw fixation is as good as that obtained with screw-plate fixation for the treatment of fractures of the lateral tibial plateau.