Purpose of the study: Scarf osteotomy is currently the gold standard treatment for hallux valgus. The purpose of our work was to search for anatomic and clinical factors affecting the outcome.

Material and methods: This retrospective review concerned 125 osteotomies performed in 105 patients (101 women and 4 men, mean age 48 years, age range 16–75 years). For 55 cases, Scarf osteotomy was associated with osteotomy of the proximal phalanx. Osteotomies to reduce the lateral metatarsals were performed in 32 cases. Clinical outcome was assessed in terms of pain, hallux function and motion using the AOFAS and Groulier systems. AP and lateral weight-bearing views were used to assess the metatarsophalangeal, intermetatarsal, interphalangeal, PPAA, DMAA, and Djian angles and metatarsal slope.

Results: Mean follow-up was 45 months (range 24–95). The Kiaoka and Groulier score improved respectively from 50 to 84/100 points and 38 to 68/100 points (p< 0.0001). Pain relief was total or nearly total in 95% of patients. MPJ stiffness was related to gastrocnemius retraction, osteoarthritic degeneration, and residual deformation (p< 0.05). Subjectively, 72% of patients were satisfied or very satisfied, corresponding to 73% good or very good results. At last follow-up M1P1, M1M2 and DMAA had decreased significantly (p< 0.001) respectively improving from 33° to 18°, 14° to 9.5° and 13.2° to 9.4°. Conversely, mean P1P2 and PAA increased significantly (p< 0.05) because certain inter- and intraphalangeal deformations, radiographically masked by the preoperative hallux pronation, were not corrected. There were 29 recurrences (MP angle > 25°) statistically related to under correction of the intermetatarsal angles (p< 0.0001), M1M5, DMAA (p< 0.05), persistent hallomegaly (p=0.015), and presence of an oblique cuenometatarsal space (p=0.02). Recurrence was more frequent in patients with flat foot (p=0.04); greater calcanceal valgus was associated with wider MP angle (p=0.02).

Discussion and conclusion: Scarf osteotomy enabled complee correction of 80% of the deformations. To improve the final outcome, displacement of the first metatarsal should correct the metatarsus varus and the DMAA. Careful radioclinical analysis pre- and intra-operatively should held detect posterior (flat foot) and anterior (hallomegaly, inter- and intraphalangeal crossover) of the MPJ because they significantly influence persistence or recurrence of the deformation.

Purpose: Bipolar osteotomy of the first metatarsal with lateral release of the first metatarsophalangeal joint was performed in 19 cases of hallux valgus. The distal metatarsal surface was misaligned in all cases (increased DMMA). The purpose of our work was to evaluate outcome after Schnepp bipolar osteotomy.

Material and methods: The series included eleven women and three men who underwent the procedure between 1992 and 2001. All patients were reviewed retrospectively by the same clinician. Mean patient age was 56 years. Before surgery, mean values were: metatarsophalangeal valgus 39.6°, metatarsal varus 17.8°, and DMMA 21.1°. Mean foot opening measured preoperatively was 30°.

Results: The Groulier criteria, taking into consideration correction of the deformity, static disorders and function were assessed at mean follow-up of three years. Radiographically mean metatarsophalangeal valgus was 20.7°, metatarsal varus 10.3°, and DMMA 5.3°. The metatarsal span was 23°. The metatarsophalangeal joint was congruent and free of any sign of degeneration in 52%. Overall outcome was excellent or good in 57.5%, fair in 32% and poor in 10.5%.

Discussion: These results are rather modest but were obtained in a series of patients with severe hallux valgus. Bipolar osteotomy enables simultaneous correction of the phalangeal valgus, the metatarsal varus, and the increased DMMA, an advantage not obtained with any other procedure. Indications would include patients with increased DMMA > 15° or major metatarsal varus. Our series show that poor results can be observed in the event of incongruent joints, signs of osteoarthritic degeneration, or revision surgery.

Conclusion: Bipolar osteotomy of the first metatarsal remains indicated for the treatment of severe hallux valgus with increased DMMA. Metatarsophalanygeal arthrodesis should be reserved as a salvage procedure for non congruent or degenerated joints.

Purpose: Failure is still observed after 20% of acromioplasties which can be explained by acromioclavicular osteoarthritis. The purpose of this study was to demonstrate the deleterious effect of this degeneration on outcome.

Material and methods: We reviewed 103 arthroscopic acromioplasties performed in 100 patients who presented non-torn non-calcified tenopathies. Seven patients were excluded so 96 patients, 63 women and 33 men were retained for analysis. Mean age at operation was 48.2 years and mean follow-up was 3.8 years. Patients were divided into two groups on the basis of the sonographic findings: group 1 had no computed tomography (CT) signs of acromioclavicular osteoarthritis (66 patients), such signs were found in group 2 (30 patients). Each patient was reviewed clinically and CT-scan was used to diagnosis osteoarthritis classed as stage 0 to 3. Subjective outcome was assessed in terms of patient satisfaction and objectively with the Constant score.

Results: Subjectively, three-quarters of the patients in group 1 were satisfied versus one-third in group 2. The Constant score confirmed this finding with a mean 76 points in group 1 versus 68 in group 2 (the weighted score was 93.5% and 83% respectively). The weighted score showed that good or excellent results were achieved in 84.84% of the patients in group 1 and in 43% in group 2.

Discussion: Our results are in agreement with data in the literature and provide scientific evidence of the influence of acromioclavicular osteoarthritis on the failure of acromioplasty. The results in group 1 were clearly better than in group 2, proving statistically a widely accepted notion: acromioclavicular osteoarthritis compromises significantly outcome of acromioplasty. Furthermore, it is interesting to note that among the seven cases excluded (for resection of the articulation), six had satisfactory outcomes.

Conclusion: These results confirm the unfavourable influence of acromioclavicular osteoarthritis on the outcome of acromioplasty. A prospective study designed to determine the effect of simultaneous acromioclavicular resection would be useful to propose a coherent therapeutic approach.

Purpose: Mediotarsal arthrodesis can correct the deformation and relieve pain in adults with reducible talipes planovalgus. We assess clinical and radiological outcome.

Material and methods: This retrospective analysis involved 22 cases of reducible talipes planovalgus (Johson stage 2) in 19 patients (eleven men and eight women), mean age 43 years (15–75). Clinical assessment was based on pain, function and motion (AOFAS and Mann). AP and lateral weight-bearing radiographs with Meary cerclage were used to determine the Djian angle, talometatarsal alignment, talar tilt, calcaneal valgus, and stage of osteoarthritis in adjacent joints.

Results: Mean follow-up was 88 months (6–243). Two non-unions evolved favourably after cancellous graft. The Kitaoka score was 73.5 points/94 (53–94). Pain and function improved respectively from 2.8 to 1.1/4 points and 3.5 to 1.6/4 points on the de Mann scale. Flexion-extension remained unchanged. The foot was well aligned in 68% of the cases (7.5 points). Mean talar tilt and talocalcaneal divergence were normalised but defective Djian angle persisted with a broken de Meary line in 98% and 41% of cases respectively. Calcaneal valgus was reduced 6.6° (16.6 to 10°) and podoscopy showed that flat foot persisted in 86% of the cases. In 50%, neighbouring joints presented progressive osteoarthritic degeneration with clinical impact in only one patient (4.5%). Subjectively, 73% of the patients were satisfied or very satisfied and none of the patients were disappointed. The objective outcome was excellent or good in 68% of cases.

Discussion: Pain, function, motion, complications and rate of satisfaction were comparable with data in the literature (Mann, Baxter, Steinhäuser). Mediotarsal arthrodesis is effective against pain and allows satisfactory recovery of function without morbidity greater than talonavicular arthrodesis (Harper). However, while the foot is well aligned in the majority of the cases, the plantar vault is poorly restored clinically and radiologically. Compensatory over-motion of the adjacent joints probably leads to bone remodelling and moderate asymptomatic osteoarthritis seven years after the procedure.

Purpose: We evaluated the respective roles of acromioplasty and curettage of calcifications in arthroscopic treatment of calcifying tendinopathy of the rotator cuff.

Material and methods: We reviewed 41 cases of calcifying tendinopathy at mean 42 months. We retained for analysis only true calcifications identified at least 12 months after arthroscopy. All patients underwent acromioplasty and 13 underwent calcification curettage. The physical examination searched for subacromial impingement and cuff tendon suffering. The weighted Constant score was determined to assess outcome as excellent, good, fair, or poor. Patient satisfaction was assessed using three subjective questions. We searched for persistent calcification on the AP and Lamy lateral x-rays and quantified acromial resection by measuring the height of the subacromial space, the acromial arrow, and the type of acromion (Bigliani). Ultrasonography was performed to search for cuff lesions. Cuffs were classed as normal, atrophic or torn.

Results: After statistical analysis, the mean Constant score was found to have increased from 55 points to 80 points, with 88% excellent and good results (weighted Constant score > 85%). There was no significant difference between patients with and without calcification curettage (p> 0.1). Patients who were mobilised rapidly had a better outcome (p< 0.005). Subjectively, 88% of the patients were satisfied or very satisfied.These results were not correlated with duration of follow-up. The degree of preoperative calcification did not affect outcome, but persistent calcification (nine cases) had an unfavourable effect on outcome. Nevertheless, 80% of the calcifications without curettage did not resorb after acromioplasty. The type of acromion had an effect on outcome. Acromions which were not flat (type II or III) had an unfavourable influence. The degree of acromial correction had a significant effect on outcome, the Constant score increased proportionally with the height of the subacromial space and inversely with acromial arrow. Ultrasonography disclosed two cuff tears but in elderly subjects, probably due to degeneration.

Conclusion: Curettage of calcifications does not improve outcome of good quality acromioplasty. The stage of the calcification is not an indication for curettage. Furthermore, it appears that the impingement is partly the cause of persistent calcifications since 80% of them disappeared after acromioplasty alone.

Purpose: Arthroscopic tenotomy of the long head of the biceps brachial is indicated for pain relief in the treatment of unrepairable tears of the rotator cuff. The purpose of our study was to evaluate clinical and radiological outcome.

Material and methods: This retrospective study included 38 patients (21 women and 17 men) mean age 65 years (44–78) who presented rotator cuff tears that could not be repaired by suture. These patients underwent arthroscopic tenotomy associated with acromioplasty in eight cases. Preoperative imaging included arthroscan and standard radiograms to assess retraction of the supraspinatus stump and fatty degeneration. The clinical outcome was assessed with the Constant score and search for loss of biceps force (estimated in comparision of an age- and gender-matched cohort). Modifications of the subarcomial height and the stage of joint degeneration were assessed on AP radiograms (standing and reclining position).

Results: Mean follow-up was 31 months. There were no complications related to the operation. The overall constant score improved 19 points from 39 to 58 (pain +7 and motion +6.1 increased most). The activity score improved 6 points. Active joint motion in antepulsion, abduction, and lateral rotation (elbow to body) increased 36.5°, 13.1° and 20.8° respectively. The sub acromial height decreased very little (from 7.4 mm preoperatively to 7.4 mm postoperatively). We observed a 37% decrease in arm force in flexion/supination on the operated side (6.05 kg vs 9.65 kg). Subjectively, 85% of the patients were very satisfied or satisfied, 10% were disappointed and 2.5% were discontent. For 88% of the patients the decision for surgical intervention was wise.

Discussion: Tenotomy of the long head of the brachial biceps is effective for pain relief and consequently joint motion. It is a technically simple procedure which does not accelerate degeneration of the excentered joint, at the follow-up considered. It does however reduce flexion force of the arm.

Purpose: We assessed mid-term outcome of mobile cup shoulder prostheses for the treatment of degenerative shoulders with a destroyed cuff.

Material and methods: Forty-four biopolar prostheses were assessed with a mean follow-up of 32 months (range 13 – 50 months). The SOFCOT scoring chart was used. The morphological features of the different forms of shoulder degeneration with cuff destruction were analysed on standard x-rays to define anatomic conditions favourable for his type of implant.

Results: At last follow-up 86% of the shoulders exhibited little or no pain. Mean active anterior elevation was 59.6° – 82.84°, external rotation in position 1 was 8.86° to 301.68°, and internal rotation was 3.13 points to 5.68 points. The mean Constant score was 48.86 points (weighed score 69.13%). Seventy-seven percent of the patients were satisfied and had resumed their former activities. We had one anterior displacement of a shoulder with deltoid palsy and three complications requiring revision: one polyethylene insert which slipped out of the mobile cup, one conflict between the tendon of the long head of the biceps and the cup, and one anterioposterior conflict because of an oversized cup. One non-cemented prosthesis exhibited mobility at 33 months follow-up. One case of excessive lateralisation of the humerus, one mediocre joint congruency, and atrophy of the deltoid were also recorded.

The best outcomes were observed in joints with “centred” degeneration and cuff destruction. Preservation of a satisfactory centring of the cup avoided pain and enabled a mean anterior elevation of 1112.3° with a weighted Constant score of 90.5%.

For early excentred degeneration, preservation of the glenoid bone stock prevented perfect joint congruency leading to excessive lateralisation of the humerus: 20% of the shoulders remained painful and anterior elevation reached 68° with a weighted Constant score of 56%. Paradoxically, results were better in patients with severely excentered degeneration. “Acetabulation” of the shoulder preserved joint congruency and lengthened the lever arm of the deltoid by medialisation and lowering of the centre of rotation. Full pain relief was achieved in all such cases, with anterior elevation at 86° and a weighted Constant score at 78%.

Discussion: Biopolar arthroplasty is effective in shoulders with centred degeneration and cuff destruction. It is an interesting salvage solution for advanced-stage excentric degenerated shoulders beyond the limits of other implants. We propose a decisional tree based on an anatomic classification of the shoulder degeneration with cuff destruction.

Purpose: Anterior tarsectomy (Méary procedure) has proven its efficacy for surgery of talipes cavus in adults. There has not however been any publication on long-term outcome. We reviewed 39 cases of pes cavus treated by tarsectomy and followed for a mean ten years. Our objective was to confirm long-term results and assess consequences on adjacent joints.

Material and methods: Mean age of the patients was 30 years. Neurological causes predominated (57.6%). Most of the deformations were complex, involving equin and varus deformation of the hindfoot, and pronation and adduction of the forefoot. The deformations were painful in 85% of the patients We used the AOFAS functional score to assess outcome. The preoperative x-rays demonstrated a Djian angle at 100° and a Tomeno angle at 23°.

Results: Mean final score was 69.2/100. The final result was considered excellent or good in 66% of the patients. Pain regressed considerably in 75% of the patients even though only 28% of the patients were totally symptom free. There was a spontaneous 6° reduction in the calcaneus inclination. Defective correction persisted in 80% of the patients but the Tomeno angle remained below 10° in 70%. Seventy-four percent of the feet had radiographic signs of degenerative joints, particularly the sub-talar and mediotarsal joints.

Discussion: There were only two preoperative criteria with prognostic value, aetiology which influenced the functional result and freedom of the hindfoot articulation which determined capacity for correction. Alignment, particularly hindfoot alignment, and degenerative joint disease influenced the functional outcome.

There was a correlation between the anatomic presentation and function, especially evident for the Méary-Tomeno line which must be re-established. While we obtained spontaneous correction of the compensating frontal and sagittal deformations of the hindfoot, specific procedures were required to alleviate claw toes and equinism. It is also important to preserve the Lisfranc space and the Chopart space. The corrective capacity of tarsectomy is limited. To achieve satisfactory anatomic and functional results, tarsectomy must be reserved for moderate pes cavus involving a sufficiently mobile forefoot with moderate and reducible calcaneal varus where the primordial joints can be saved.

Purpose: The purpose of this work was to study the biomechanical properties of mobile cup shoulder prostheses and factors affecting their kinetics.

Material and methods: Bipolar shoulder prostheses were implanted in 39 patients with degenerative shoulders and a destroyed cuff. Radiocinematic recordings of anterior elevation and active rotation were made at a mean 32 months follow-up (13 months–550 months).

Results: Three types of biomechanical behaviour were observed for elevation movements. “Normal” behaviour was observed in 17 prostheses with preservation of the scapulohumeral rhythm and chronological participation of the three articular interfaces [intraprosthetic (head/cup), extra-prosthetic (cup/glenoid), scapulothoracic]. Mean anterior elevation was 114.7° for these shoulders. A “paradoxical” behaviour was observed in ten prostheses. Anterior elevation depended entirely on the scapulorthoracic joint, and was limited on the average to 42.5°. An “intermediate” behaviour was observed in 12 prostheses with inversion of the scapulohumearl rhythm. The glenohumeral mobility was decreased due to the absence of extraprosthetic mobility (eight cases) or intraprosthetic mobility (four cases). Mean anterior elevation in these shoulders was 80.83°. When the elevation behaviour was “normal”, the Constant score at last follow-up was significantly better compared with “intermediate” (p = 0.008) or “paradoxical” (p = 0.0001) behaviour.

Three types of biomechanical behaviour were also observed for rotation movements: a “chronological “ behaviour was observed for 15 prostheses, via extraprosthetic mobility in all. Mean external rotation was 37.33° and mean internal rotation was 6.53 points. An “anarchic” behaviour was observed in 16 prostheses with a random proportion of intra- and extraprosthetic mobility. Mean external rotation was 8.75° and mean internal rotation was 4.25 points. For shoulders with “chronological” or “anarchic” behaviour, the mean external rotation (p = 0.002) and the mean internal rotation (0.04) were statistically better than shoulders with “truncated” behaviour.

Discussion: An atrophic deltoid, mediocre joint congruency, and early-stage excentred scapular degeneration with preserved glenoid bone stock are factors favouring “paradoxical” elevation. Deltoid atrophy alone favours “truncated” rotation. This study was helpful in identifying conditions most appropriate for implanting this type of prosthesis and factors predicting postoperative outcome.

Purpose: We examined the long-term effect of the Latarjet-Patte procedure on subscapularis function and trophicity.

Material and methods: The series included 102 patients (106 shoulders) reviewed at a mean follow-up of 7.5 years. The subscapularis was opened by dissection along the direction of the fibres in 27 shoulders (group I) and via inverted-L tenotomy in 69 (group II). Duplay and Rowe scores were used to assess clinical outcome. Subscapularis function was measured with the hand-back distance and the Gerber lift-off test in comparison with a control group composed of healthy subjects in order to account for limb dominance. Computed tomography was used to measure fatty degeneration and muscle atrophy.

Results: The Duplay and Rowe scores gave 76.4% and 87.7% satisfactory results. The Duplay score was 89.9/100 in group I and 82.1 in group II (p = 0.02). The hand-back distance and muscle force as judged by the lift-off test were statistically different between the dominant and non-dominant sides (p = 0.001). Loss of muscle force was greater for dominant sides in the operated shoulders. The mobility score, the lift-off test, and the hand-back distance were significantly altered in group II patients. Fatty degeneration of the sub-scapularis was greater on the operated side (0.76 vs 0.054) (p = 0.001). It increased with age at surgery and at review (p = 0.0001), for dominant shoulders in group II (1.18 vs 0.12). It affected the Duplay score (p = 0.006), the hand-back distance, and the lift-off test (p = 0.01). Fatty degeneration was greater than 2 in 66% of the shoulders with a poor outcome and persistent apprehension in 35.3%. Subscapular atrophy was greater on the operated side (0.91 vs 1.17) (p = 0.0001) and was statistically correlated with fatty degeneration, the Duplay score, the lift-off test, and the hand-back distance. It was greater in group II (0.71) than in group I (0.2).

Discussion: Recovery of muscle force is better for dominant shoulders. Muscle trophicity and function are influenced by subscapular tenotomy that leads to significant loss of internal rotation force, atrophy, and fatty degeneration affecting final long-term outcome.

Conclusion: We recommend discission of the subscapularis for coracoid bone block procedures.

Purpose: We analysed outcome of 106 Latarjet-Patte procedures at 7.5 years mean follow-up. Computed tomography of 80 bone blocks provided further details.

Material and methods: One hundred two patients (106 bone blocks), mean age 34 years, were reviewed at a mean 7.5 years follow-up. The sex ratio was 5/1 M/F. The accident had occurred at a mean age of 22 years, by trauma in 87% of the cases, generally involving the dominant limb. Eighty-seven patients practised sports, a high-risk sport in 48% of the cases. Clinical outcome was assessed with the Duplay and Row score, radiographs and a bilateral computed tomography scan in 80 cases.

Results: Postoperative morbidity was 12% and only required revision surgery in 2.8% of the cases. Posterior pain required screw ablation in 6% of the cases. Global outcome was excellent or good in 66% of the patients and 60% of the patients who practised sports were able to resume their activities at the same level. Painless shoulders were achieved for 70% of the patients. There was one post-traumatic recurrence and residual apprehension in 13% of the cases. Grade 3 or 3 osteoarthritis was present in 15% of the cases with a clear narrowing of the joint space in 3.5%. The CT scans were less favourable, showing global or posterior joint space narrowing in 17.5% of the cases. Monocortical screwing led to nonunion in 7%. Advanced osteolysis led to pain with alteration of the functional score.

Discussion: Postoperative complications deteriorated the global result. Overly long malleolar screws led to posterior pain with fatty degeneration of the infraspinatus. Osteoarthritis and “inverted L” subscapularis were the main factors related to loss of rotation. Persistent apprehension was not related to technical error, but to exaggerated anteversion of the humeral cap, basically due to the presence of a notch. Revision scans clearly contributed to the evaluation of the bone block and its position. It allowed a more objective assessment of the osteoarthritis, showing that plain radiographs underestimated both incidence and gravity related to delay after surgery, patient age and the overhanging property of the joint stop.

Conclusion: The Latarjet-Patte procedure has given satisfactory results that can be improved with rigorous technique. Computed tomography provides a more objective analysis of the results.

Purpose: Use of nitrogen-ion implanted titanium heads appeared to us as an essential factor in the development of aseptic acetabular and femoral loosenings.

Material and methods: Our series included 62 implanted titanium heads reviewed at a mean follow-up of 84.4 months. Nine patients had died and one was lost to follow-up. The heads were combined with a titanium-sanded elastic pressfix cup in 40 cases, and with the same cup with hydroxyapatite surfacing in 12 cases. Titanium femoral stems were cemented in 16 cases and non-cemented in 36 with a titanium-sanded metaphyseal support.

Results: At mean follow-up of 84.4 months, there was a lucent line in three zones on the AP view, including 9 that were complete, in 11 cups. Acetabular osteolysis was observed around five cups and femoral osteolysis around eight stems. Mean wear was 0.18 mm per year. Considering the entire series (61 heads), there were 11 cups requiring revision for aseptic loosening at a mean 74.2 months; four stems (all without cement) that had to be replaced for aseptic loosening at 74.5 months. Polyethylene wear on the removed implants was more pronounced than for the non-revised implants (0.34 mm/year versus 0.14 mm/year, p < 0.05). Metallosis was associated in eight cases. Macroscopic analysis of the heads revealed evidence of delamination on the entire contact surface with the polyethylene. The femoral and acetabular implants did not appear to be the cause of these loosenings because associated with other types of heads (stainless steel, chromium-cobalt, alumine, zircone, niturate titanium) they did not lead to loosening except in one case (stainless steel head) out of 118.

Discussion: Titanium is known to be have poor friction properties. To improve performance, ionic implantation has been proposed. The layer of nitrogen ions projected onto the surface of the head only cover a thickness to the order of one micron. Once this protective film is rapidly dissipated by abrasion, the titanium comes in direct contact with the polyethylene, leading to important release of titanium and polyethylene particles that can cause osteolytis and aseptic loosening.

Conclusion: Close surveillance of patients with these heads is necessary to recognise wear early and propose synovectomy and head replacement in case of implant loosening.