Purpose: The risk of recurrence and progression to chronic instability after a first episode of anteromedial shoulder dislocation is high in young patients. Risk assessment has varied in published reports but is constantly high in subjects aged less than 25 years. The injuries occurring during the first episode are poorly identified and rarely treated. We thus propose an arthroscopic assessment for young subjects with sports activities to identify lesions and achieve stabilisation after the first dislocation. The purpose of this work was to report the lesions observed and present our surgical protocol.

Material and methods: Between February 2002 and March 2003, we included fifteen patients in a prospective study. All patients were aged 17–25 years at the first episode of traumatic anteromedial dislocation of the shoulder. The patients were informed of the “usual” orthpaedic treatment and of the risk of recurrence. We proposed an arthroscopic assessment of their lesions and concomitant treatment. All patients accepted this therapeutic alternative. All procedures were performed by the same operator within ten days of dislocation. Patients were immobilised for 21 days with an elbow to body brace followed by rehabilitation in an outpatient setting, avoiding external rotation for 21 days. The Duplay score was determined.

Results: In this prospective series of patients, we identified a haematoma, a Malgaigne notch, and disinsertion of the anteroinferior capsulolabral complex in all patients. We were unable to find any glenoid or ligament injury on the humerus. The cuff was intact in all patients except one who had a deep wound of the supraspinatus. Lesion suture with resorbable anchors was satisfactory in 14 patients. We have not observed any recurrences. Physical examination did not disclose any apprehension and there has been no case of altered external rotation (< 5).

Conclusion: Considering the major risk of recurrent dislocation after a first episode in these young patients, we have studied an alternative to orthopaedic treatment. All patients accepted the proposed arthroscopic treatment. All patients presented capsulolabral detachment which was easily treated. At last follow-up, all patients have recovered a pain-free stable shoulder. This was a small series with a short follow-up so these results must be considered with caution. They are nevertheless very encouraging.

Purpose: The purpose of our retrospective analysis was to describe results of arthroscopic treatment of painful ankle instability without clinical or radiological laxity.

Material and methods: Eighteen patients, mean age 27 years (seven men and nine women) were operated on by the same surgeon between 1999 and 2000. Sixteen patients (90%) were reviewed by an independent investigator at 20±4 months. Fifteen patients were athletes, ten at the competition level, and five had amateur sports activities. The accident caused forced inversion in 15/16 cases, during sports activities in 85.5% of the cases. Mean age at injury was 17±6 years. Mean time between the accident and arthroscopy was eight years. All patients had pain in the anterolateral region associated with effusion in 50% and apprehension or instability for daily life activities. Standard x-rays were normal in fourteen patients (87.5%). Comparative stress images did not demonstrate pathological laxity. Complementary imaging (MRI, CT scan, arthroscan, ultrasonography) was obtained in six patients with 50% negative results. Arthroscopy revealed anterior tissue interposition (antero lateral in thirteen patients (81%) and anteromedial and anterolateral in three) which was removed with the shaver. Joint cartilage was intact in fifteen patients (81.25%).

Results: At last follow-up, functional outcome was good in all patients who had all resumed their sports activities. Subjectively, six patients felt they had normal function, seven nearly normal function and three abnormal function (81% satisfied or very satisfied). Six patients were symptom free even during intense physical activity. Eight patients reported some difficulties for strenuous exercise and two for moderate exercise. Joint motion was normal in ten patients and 5° dorsal flexion deficit was observed in six. There were no recurrent sprains. The x-ray was normal and identical to the initial image in 87.5% of the patients. Globally, 87.5% of the patients had good or excellent outcome. Two patients had fair or poor outcome.

Discussion: Diagnosis of anterolateral ankle conflict can be established in patients with a compatible history and a typical clinical presentation with normal x-rays. Arthroscopic treatment can remove tissue interposition allowing good functional results and total recovery of sports activities. Complementary MRI or arthroscan have little specificity and poor sensitivity.

Purpose: The MacIntosch method for reconstruction of the anterior cruciate ligament using a free intra-articular plasty with an extra-articular reinforcement was the classical treatment during the eighties for chronic anterior laxity. In 1992, we reported our short-term resuls in 180 cases. The purpose of this report is to analyse the results in 112 of these 180 cases with a mean follow-up of 14 years.

Material and methods: One hundred twelve knees operated between 1982 and 1987 were included in this study. There were 82 men (73.2%) and 30 women (26.8%), mean age 24.9±5.8 years. Mean follow-up was 165.3 ± 25.9 months. Mean delay from accident to repair was 30.9 months (3–144) and meniscectomy was performed in 88% of the cases, mainly for contact pivot sports (85%). All patients had an overt laxity (advanced in 73.2% or isolated in 26.9%). The MacIntosh plasty performed by arthrotomy used a patellar tendon with a quadriceps tendon band prolongation. Arthros-copy was performed prior to surgery in all cases. If the transplant was implanted over the top, the radiographic analysis of the tunnel position was only made for the tibia. An independent examiner reviewed all the patients clinically and radiographically using the IKDC criteria with instrumental KT 1000 measurements.

Results: Sports activities were resumed in 78% of the cases with a trend towards pivot sports without contact practised in an amateur setting. Subjectively, 69.6% of the patients were very satisfied and 25% were satisfied. The click was abolished in 83% of the cases, was minimal in 15% and overt in 2%. The medial meniscus was intact in 40% of the cases with only 10 secondary meniscal tears 14 years later. The residual manual maximal traction differential at KT 1000 was 1 ± 1.225 mm and the mean compliance was 1.69 ± 1 mm. The overall IKDC score was: 31% A, 47/6% B, 19.1% C, 1.9% D. X-rays were normal in 17%, showed remodelling in 55.4%, and joint narrowing < 50% in 23.8% and > 50% in 3.8%. For patients with an intact medial meniscus, joint narrowing was observed in 5.5% compared with 24% after resection of the medial meniscus. There were two repeat tears in this series compared with 22 tears of the contra-lateral anterior cruciate ligament. The unsatisfactory results (22%) were related to anatomic failure (two cases) and functional problems (18 cases, defective mobility and pain). The prognostic factors were age at time of operation and preservation of the medial meniscus.

Conclusions: This study confirms the persistently good clinical and functional results 14 years after plasty using the patellar tendon associated with lateral reinforcement. Ligament stabilisation was satisfactory but it must be recalled that at 14 years, the functional needs were different for these knees. The radiological course was more worrisome with joint narrowing in 27.6% of the cases.