OBJECTIVES

The use of a mobile bearing has been suggested to decrease the rate of patellar complications after total knee arthroplasty (TKA). However, to resurface or retain the native patella remains debated. Few long-term results have been documented. The present retrospective study was designed to evaluate the long-term (more than 10 years) results of mobile bearing TKAs on a national scale, and to compare pain results and survivorship according to the status of the patella.

The primary hypothesis of this study was that the 10 year survival rate of mobile bearing TKAs with patella resurfacing will be different from that of mobile bearing TKAs with native patella retaining.

Osteotomies for valgus deformity are much less frequent than those for varus deformity as evidenced by published series which are, on one hand, less numerous and on the other hand, based on far fewer cases. For genu varum deformity, it has been proved that navigation allows to reach easier the preoperative correction goal. Our hypothesis was that navigation for genu valgum could be as accurate as for genu varum deformity. The aim of this paper was to present the mid-term results of 29 computer-assisted osteotomies for genu valgum deformity performed between September 2001 and March 2013.

The series was composed of 27 patients (29 knees), 20 females and 7 males, aged from 15 to 63 years (mean age: 42.4+/−14.3 years). The preoperative functional status was evaluated according to the Lyshölm-Tegner score. The mean score was of 64+/−20.5 points (18–100). The stages of osteoarthritis were evaluated according to modified Ahlbäck's criteria. We operated on 12 stage 1, 9 stage 2, 5 stage 3 and 1 stage 4. 2 female patients had no osteoarthritis but a particularly unesthetic deformity (of which one was related to an overcorrected tibial osteotomy). The pre and postoperative HKA angle was measured according to Ramadier's protocol. We measured also the medial tibial mechanical angle (MTMA) and the medial femoral mechanical angle (MFMA). The mean preoperative HKA angle was 189.3°+/−3.9° (181° to 198°); the mean MFMA was 97.2° +/− 2.6° (93° to 105°) and the mean MTMA was 90.1° +/− 2.8° (86° to 95°). The goal of the osteotomies was to obtain an HKA angle of 179° +/− 2° and a MTMA of 90°+/2° in order to avoid an oblique joint line. We performed 24 femoral osteotomies (14 medial opening wedge and 10 lateral closing wedge) and 5 double osteotomies (medial tibial closing wedge + lateral opening wedge osteotomy). The functional results were evaluated according to Lyshölm-Tegner, IKS and KOO Scores, which were obtained after revision or telephone call.

We did not find any complication except a transient paralysis of the common fibular nerve. 23 patients (4 lost to follow-up) were reviewed at a mean follow-up of 50.9+/−38.8 months (6–144). The mean Lyshölm-Tegner score was 92.9+/−4 points (86–100), the mean KOO score 89.7+/−9.3 (68–100), the mean IKS ≪knee≫ score 88.7 +/−11.4 points (60 à 100) and the mean ≪function≫ score 90.6 +/−13.3 points (55–100). 22 of the 23 reviewed patients (25 knees) were very satisfied or satisfied of the result. Regarding the radiological results, the mean HKA angle was of 180.1°+/−1.9° (176° to 185°), the mean MFMA of 90.7°+/−2.5° (86°-95°) and the mean MTMA of 89.1°+/−1.9° (86°-92°). The preoperative goal was reached in 86.2% (25/29) of the cases for HKA angle and in 100% of the cases for MTMA when performing double level osteotomy (5 cases). At this follow-up, no patient was revised to TKA.

Computer-assisted osteotomies for genu valgum deformity lead to excellent results a mid-term follow-up. Navigation is very useful to reach the preoperative goal.

Direct arthroscopic cartilage assessment remains the gold standard. It is recommended by the International Cartilage Repair Society (ICRS) to systematically assess cartilage status during arthroscopy but this examination is highly subjective, poorly reproducible, time-consuming and lacks precision. US has shown good potential for cartilage evaluation but is limited in extra-articular conditions. It is also difficult to manually maintain a perfect perpendicularity between the ultrasound beam and the curved surface of the cartilage. Therefore, we have developed a navigated intra-articular US probe (NIAUS). The NIAUS probe could contribute to a more exhaustive and direct intra-articular evaluation of cartilage integrity. Navigation enables control of the US echo pulse perpendicularity and its localisation relative to the joint. Our objectives were (1) to evaluate automatic cartilage thickness measurement with the NIAUS probe in comparison to high definition MRI on cartilage samples, (2) to generate a real-time 3D map of the thickness parameter on samples, and (3) to demonstrate the feasibility of a full NIAUS probe cartilage scan on a specimen distal femur in arthroscopic conditions.

The NIAUS probe is a 4.5mm probe consisting of a 64 element linear array transducer with a central frequency of 13 MHz and a motorised head. The NIAUS probe is navigated. The rotating US head position is controlled by navigation in order to enable constant perpendicular acquisition of cartilage. The NIAUS probe thickness measurement (1) was evaluated on bone and cartilage samples of 9 tibial plateaus. The cartilage thickness was measured via automatic segmentation. Each sample was also scanned in a high resolution MRI (4,7 Tesla) and cartilage thickness was semi-automatically extracted for comparison. During NIAUS scan, (2) a visual 3D map was generated. Finally (3), we scanned two distal femurs with the NIAUS probe in arthroscopic navigated conditions on one specimen and a 3D map of the distal femur thickness was generated in real time.

NIAUS thickness measurement (1) absolute error compared to MRI for 9 plateaus ranged from 0.15mm to 0.32mm in median, p25=0.07 and 0.18, p75=0.28 and 0.5 respectively. 3D maps of the sample cartilage thickness (2) were generated in real time during the NIAUS scan. The cadaveric procedure (3) was conducted without incident via the two anterior portals and a 3D map of the distal femurs cartilage thickness was generated.

A precise US arthroscopic grading and scoring of cartilage during surgery could help for better standardisation, prediction of results and making “live” decisions. Our in vitro experiment shows good results compared to MRI for NAIUS cartilage thickness measurement, and our cadaveric study demonstrate the feasibility of a NIAUS scan in arthroscopic conditions. Our results are encouraging and a clinical trial is currently being designed for preliminary in vivo NIAUS evaluations of cartilage thickness compared to MRI.

INTRODUCTION

Polyethylene wear is one of the reasons for failure of total knee replacement (TKR). There are several reasons for wear, and the femoro-tibial contact area is an important factor. Mobile bearing, highly congruent prostheses might be more resistant to polyethylene wear than fixed bearing, incongruent prostheses. We evaluated the 5- to 8-year experience of three university departments by using an original system with following highlights: implantation with a navigation system, extended congruency up to 90° of flexion, floating polyethylene component with non-limited movements of rotation, antero-posterior translation and medio-lateral translation.

Polyethylene wear is one of the reasons for failure of total knee replacement (TKR). There are several reasons for wear, and the femoro-tibial contact area is an important factor. Mobile bearing, highly congruent prostheses might be more resistant to polyethylene wear than fixed bearing, incongruent prostheses. We evaluated the five- to eight-year experience of three university departments by using an original system with following highlights: implantation with a navigation system, extended congruency up to 90° of flexion, floating polyethylene component with non-limited movements of rotation, antero-posterior translation and medio-lateral translation.

347 patients have been operated on in the three participating departments with this new prosthesis system between 2001 and 2004, and have been prospectively followed with clinical and radiologic examination with a minimal follow-up time of five years. There were 246 women and 101 men, with a mean age of 67 years.

Clinical and functional results have been analyzed according to the Knee Society scoring system. Accuracy of implantation has been assessed on post-operative long leg antero-posterior and lateral X-rays. Survival rate up to eight years has been calculated according to Kaplan and Meier, with mechanical revision or any revision as end-points.

Complete patient history was obtained by 319 cases (92%). The mean clinical score was 93 points. The mean pain score was 47 points. The mean flexion angle was 118°. The mean functional score was 87 points. An optimal correction of the coronal femoro-tibial axis was obtained in 94% of the cases. Survival rate after eight years was 98.8% for mechanical revisions and 95.5% for all revisions.

We confirmed the influence of the navigation system on the accuracy of implantation. The clinical and functional results after five to eight years are in line with the better results of the current literature after conventional implantation of non-congruent prostheses. The survival rate is comparable to the current standards. The influence of the design on polyethylene wear will need a longer follow-up.

Double level osteotomy (DLO) for severe genu varum is not a common technique. We performed our first computer-assisted double level osteotomy (CADLO) in March 2001 and we published our preliminary results in 2005 and 2007. The rationale to perform this procedure is to avoid oblique joint line in order to have less difficulty in case of revision to a total knee arthroplasty (TKA). The goal of this paper is to present the results of 37 cases operated on between August 2001 and January 2010.

The series was composed of 35 patients (two bilateral), nine females and 26 males, aged from 39 to 64 years old (mean age: 50.5 +/− 7.5). We operated on 20 right knees and 17 left ones. The mean BMI was 29.3 +/− 4.3 for a mean height of 1.71 m and a mean weight of 85.8 kg. The functional status was evaluated according to the LYSHÖLM and TEGNER score. The mean score was of 42.4 +/− 8.9 points (22–69). According to modified AHLBÄCK criteria we operated on seven stage 2, 22 stage 3, five stage 4 and two stage 5. We measured HKA (Hip-Knee-Ankle) angle using RAMADIER's protocol and we also measured the femoral mechanical axis (FMA) and the tibial mechanical axis (TMA) to pose the right indication. These measures were respectively: 168° +/− 3.4° (159°–172°), 87.5° +/− 2.1 (83°–91°) for the FMA and 83.7° +/− 2.6° (78°–88°) for the TMA.

The inclusion criteria were a patient younger than 65 years old with a severe varus deformity (more than 8° − HKA angle ≤ to 172°) and a FMA at 91° or less. All the osteotomies were navigated using the ORTHOPILOT® device (B-BRAUN-AESCULAP, TUTTLINGEN, GERMANY). The procedure was performed as follows: after inserting the rigid-bodies and calibrating the lower leg, we did first the femoral closing wedge osteotomy (from 4 to 7 mm) which was fixed by a an AO T-Plate, and secondly, after checking the residual varus, the high tibial opening wedge osteotomy using a BIOSORB® wedge (Tricalcium phosphate) and a plate (AO T-plate or C-plate). The goals of the osteotomy were to achieve an HKA angle of 182° +/− 2° and a TMA angle of 90° +/− 2°.

The functional results were evaluated using the LYSHÖLM-TEGNER score and the KOOS score. The patients answered the questionnaire at revision or by phone, and the radiological results were assessed by plain radiographs and standing long leg X-Rays between three and six months postoperatively.

We had no complication in this series but one case of recurrence of the deformity related to an impaction of the femoral osteotomy on the medial side. Two patients were lost to follow-up after removing of the plates (24 months) but were included in the results because the file was complete at that date. All the patients were assessed at a mean follow-up of 43 +/− 27 months (12–108). The mean LYSHÖLM-TEGNER score was 78.7 +/− 7.5 points (59–91) and the mean KOOS score was 94.9 +/− 3.3 points (89–100). Thirty-five patients were satisfied (18) or very satisfied (17) of the result. Only two were poorly satisfied. Regarding the radiological results, if we exclude the patient who had a loss of correction, the goals were reached in 32 cases (89%) for the HKA angle and in 31 cases (86%) for the TMA with only one case at 93°. The mean angles were: 181.97° +/− 1,89° (177°–185°) for HKA, 89.86° +/− 1,85° (85°–93°) for TMA and 93.05° +/− 2.3° (89°–99°) for FMA. At that mid-term follow-up no patient had revision to a total knee arthroplasty.

DLO is a very demanding technique. Navigation can improve the accuracy of the correction compared to non computer-assisted osteotomies. The functional results are satisfying and the satisfaction of the patients is very high. Despite the difficulty of the procedure, complications are, in our hands, very rare. We recommend DLO for severe genu varum deformity in young patients to avoid oblique joint line, which will be difficult to revise to TKA.

Navigation of Uni knee arthroplasty (UKA) is not common. Usually the software includes navigation of the tibial as well as the femoral implant. In order to simplify the surgical procedure we thought that navigation of the tibial plateau alone could be a good option. Since 2005 we have been using a mobile bearing UKA of which the ancillary is based on dependent bone cuts. The tibial cut is made first and the femoral cut is automatically performed using cutting blocks inserted between the tibial cut and the distal end of the femur. Although we are satisfied with this procedure, it is not rare we have some difficulties getting the right under correction needed to get a good long-term result. The aim of this paper was to present our computer-assisted UKA technique and our preliminary radiological results in genu varum (17 cases) as well as genu valgum (6 cases) deformities.

The series was composed of 23 patients, 10 females and 13 males, aged from 63 to 88 years old (mean age: 75 +/− 8). The mean preoperative HKA (Hip-Knee-Ankle) angle was: 172.35° +/− 2.31° (167° to 176°) for the genu vara and 186.33° +/− 2.87° (182° to 189°) for the genu valga.

The goal of the navigation was to get an HKA angle of 177° +/− 2° for genu varum deformity and 183° +/− 2° for genu valgum.

We used the SURGETICS® device (PRAXIM, GRENOBLE, FRANCE) in the first six cases and the ORTHOPILOT® device (B-BRAUN-AESCULAP, TUTTLINGEN, GERMANY) in the other cases. The principles are the same for both devices. The 1rst step consists in inserting percutaneously the rigid-bodies on the distal end of the femur and on the proximal end of the tibia. Then, we locate the center of the hip by a movement of circumduction, the center of the ankle by palpating the malleoli and the center of the knee by palpating intra articular anatomic landmarks to get the HKA angle in real time. This step is probably the most important because it allows checking the reducibility of the deformity in order to avoid an over correction when inserting a mobile bearing prosthesis. The 3^rd step consists in navigation of the tibial cut such as the height of the resection, the tibial slope (3 to 5° posterior tibial slope) and the varus of the implant (2 to 3°). Once the tibial cut was done, we must use the conventional ancillary to perform the femoral bone cuts (distal and chamfer). The last step consists in inserting the trial implants and checking the HKA angle and the laxity of the medial or lateral side.

We used postoperative long leg X-Rays to evaluate the accuracy of navigation and plain radiographs to evaluate the right position of the implant.

As far as genu varum deformity was concerned, the mean postoperative HKA angle was 177.23° +/− 1.64° (173°–179°). The preoperative goal was reached in 94% of the cases. Moreover, this angle could be superimposed on the peroperative computer-assisted angle, which was 177° +/− 1.43° (p>0.05). For genu valgum, the mean postoperative HKA angle was 181° +/− 1.41° (179°–183°). The preoperative goal was reached in 66% of the cases but the series is too short to give any conclusion.

The navigation of tibial plateau alone can be used with accuracy, provided one has the right ancillary to use dependent bone cuts. The procedure is quick and needs only one tibial cutting guide equipped with a rigid-body. Our results, especially in genu varum deformity, are quite remarkable. Regarding genu valgum, the results seem to be less accurate, but the software was designed for medial UKA and the series is short, so, it is too soon to extrapolate any conclusion. The main interest in this navigation is to avoid too much under correction and even better to avoid over correction when the deformity is over reducible. Indeed, when one uses a mobile bearing plateau, the risk is to have a dislocation of the meniscus. So, when tightening the collateral ligaments, checking the lower limb axis may persuade not to use a mobile bearing plateau but rather a fixed plateau.

Purpose of the study: The purpose of this work was to analyse the long-term results obtained with 43 medial Oxford unicompartmental prostheses implanted from 1988 to 1994 for varus deviation of the knee.

Material and methods: Initially, the series included 56 patients (59 prostheses), but data were incomplete for nine patients who had died and five who were lost to follow-up. The analysis thus included 40 patients (74%): 16 were living at the time of this review (40%), 14 had died (35%) and ten had a total knee arthroplasty after failure of the Oxford prosthesis (25%). Mean age at initial surgery was 68.83±7.54 years (range 47–86). There were 13 surgical revisions: four for loosening, three for deterioration of the lateral compartment of the knee, two for repeated meniscal dislocation, two for rupture of the femoral implant and one repeated revision for impingement between the meniscal element and the femoral condyle. For ten knees, we replaced the implant with a total knee arthroplasty and in three others, we changed the meniscal piece.

Results: One year after the initial operation, the overall IKS score was 189.67±14.43 points (115–200), i.e. 93% good and very good outcomes. Regarding the initial radiographic results, overall varus of the lower limb had improved from 171.31±0.46 (161–180) preoperatively to 178±3.21 (170–186) postoperatively. Sixty-three percent of the patients had normal alignment or slight undercorrection (0–4), 19% had a greater undercorrection (5–9), 2% an excessive undercorrection (10), and 16% an over correction (181–186). At review, mean follow-up was 14.8±1.16 years (13–17) and mean patient age was 82 years (n=16). The mean overall IKS was 145.52±39.90 points. Sixty-nine percent of the patients were satisfied or very satisfied with the prosthesis. The prosthesis survival was 93% at one year, 90.5% at five years, 74.7% at ten years and 70.1% at fifteen years.

Discussion: Globally, the unicompartmental Oxford prosthesis has not provided in our hands the results we expected. Certain failures could undoubtedly have been avoided and should be included in the learning curve. Nevertheless, this prosthesis is certainly difficult to insert and carries a non-negligible risk of undercorrection, especially when the deviation is overcorrectible and care is taken to avoid dislocation of the meniscal element.

Purpose of the study: The purpose of the study was compare dislocation rates of total hip arthroplasties (THA) implanted with a dual-mobility cup versus those implanted with a conventional cup.

Material and method: The first series (DM) included 105 patients who underwent first-intention THA implanted by one operator (DS) from January 2005 to June 2007. Dual mobility cups with a 28 mm head were implanted. There were 60 women and 45 men, mean age 76.6±5.65 years (range 53–93). Degenerative disease predominated (n=95, 90.%). The cups were Novae press-fit (SERF) (n=94), Stafit (Zimmer° 5N+5°? Avantage (Biomet) (n=5), and Gyros (Depuy) (n=1). The second series (S) included 108 patients who underwent the same procedure performed by the same operator (DS) from January 2003 to June 200 for the same indication. This series was the control series. There were 56 women and 52 men, mean age 74.19±5.9 years (range 53–87). Degenerative disease predominated (n=100, 92.6%). All implantations used metal-polyethylene bearing with a 28 mm head. The implants were St Nabor cups (Zimmer) (n=44), Cédior cups (Zimmer (n=41), and sealed cups (n=22). The same femoral stem with a 12–14 cone was used in both series. The reduced posterior approach was used in all cases without section of the pyramidal tendon. Inclusion required at least one year follow-up. Fischer’s test was used to compare dislocation rates. Other variables were analysed with the chi-square test.

Results: Regarding the dual-mobility cup series (DM) there were no cases of dislocation. In the conventional cup series (S) there were five early dislocations (< 3 months), giving a rate of 4.63%. although the dislocation rate was obviously higher in the S series, the difference was at the limit of significance (p=0.0597). In addition, the DM population was slightly older than the S series (p=0.0026).

Purpose of the study: The objective of this study was to investigate a new test (the bear-hug test) in search of a more sensitive way of diagnosing small infrascapular tears. The bear-hug test was compared with other tests (lift-off, belly-press, Napoleon).

Material and methods: From January to March 2004, 68 patients were scheduled for arthroscopic shoulder surgery. We searched for correlations between the preoperative clinical results and the anatomic observations during the diagnostic phase of the arthroscopy.

Results: The prevalence of infrascapularis lesions was 29.4%. Forty percent of the infrascapularis lesions had not been identified by any of the clinical diagnostic tests. The bear-hug test was the most sensitive (60%) compared with the belly-press test (40%), the Napoleon test (25%), and the lift-off test (17.6%). The lift-off test was the most specific (specificity 100%) versus 97.9% for the Napoleon test, 97.9% for the belly-press test and 91.7% for the bear-hug test. The bear-hug test was more sensitive than the Napoleon test and the lift-off test with statistically significant difference, irrespective of the size of the tear (p< 0.05), but this difference was not found for the belly-press test (p> 0.06). Conversely, for small tears (50%), there was a statistically significant difference in favor of the bear-hug test (Se bear-hug 50%; Se belly-press 21.4%; p< 0.035). The bear-hug test was thus moe sensitive for diagnosing small tears of the upper third of the infrascapularis. A positive bear-hug or belly-press tes would suggest at least a 30% infra-scapularis tear, while a positive Napoleon test suggests at least a 50% tear. The lift-off test is only positive when 75% of the infraspinatus is injured.

Conclusion: The sensitivity of the bear-hug test optimizes chances of detecting a tear of the infrascapularis at the physical examination. Combining all of these tests is useful for predicting the size of the tear.

Purpose of the study: Treatment of distal fractures of the radius with posterior displacement remains a controversial issue. In the past, the anterior approach used for osteosynthesis failed to enable sustained reduction. With the recent development of locked plating systems, it might be useful to revisit this technique.

Material and methods: Between November 2001 and April 2003, 23 patients (15 females, 8 males), mean age 55 years (range 17–75 years) were treated with an LCP 3.5 T plate (Mathys Medical SA, Bettlach, Switzerland). The anterior Henry approach was used. There were 16 extra-articular fractrures and seven with an associated intra-articular fracture line. Radiographic analysis searched for secondary displacement and was coupled with clinical examination with force measurement (DASH). The Herzberg score used for the SOFCOT 1999 symposium was noted.

Results: Eighteen patients were reviewed with mean follow-up of 16 months. Radiologically, all fractures had healed at twelve months, with only one case of secondary loss of reduction. According to the SOFCOT symposium criteria, bone healing was anatomic for 13 cases and with moderate misalignment for five. Wrist force (Jamar) on the operated side was 95% of the opposite side. The mean DASH was 22.7. The Herzberg outcome was: excellent (n=9), good (n=6), fair (n=3), and poor (n=0). Complications were: reflex dystrophy (n=4), carpal tunnel syndrome (n=1), cheloid scar (n=1), irritation of the common extensor of the fingers (n=1).

Discussion: Secondary displacement after fracture of a posteriorly displaced fracture of the distal radius frequently lead to misalignment which is often poorly tolerated. The LCP system maintains a stable reduction long enough to reduce the rate of secondary displacement.

Conclusion: A comparative study of the commonly applied techniques (pinning) would be necessary to define the appropriate indications for this more costly technique.

Purpose of the study: The purpose of this study was to assess radiological outcome of double (femoral and tibial) osteotomy for severe genu varum. Between August 2001 and November 2004, eleven double osteotomies were performed amoung a series of 157 knee osteotomies (7%).

Material and methods: The series included four women and seven men, mean age 48.5 years (range 20–62 years). The right knee was involved in seven. One femal patient presented a particularly serious deformity but without oseoarthritic degeneration of the knee joint. The ten other patients all presented overtly degenerative knees. According to the Ahlback modified classification there were six grade III knees, three grade IV and one grade V. Mean preoperative radiological varus was 167.5±2.1° (ange 164–170°°. Orthopilot® was used in all cases. The first step was to insert percutaneously rigid bodies, one into the distal femur and the other into the proximal tibia. Kinematic acquisitions of the hip, the knee and the tibiotalar joint yielded the HKA for the lower limb. The second step was to perform the closed wedge lateral femoral osteotomy (5–6°) which was stabilized with an AO T-plate. The final step was to perform an open-wedge medial tibial osteotomy. After checking the desired alignment (182±2°) on the monitor, the osteotomy was fixed with Biosorb® and plated with an AO LCP.

Results: There were no complications. The mean intraopeartive HKA was 168.1±2.21° (range 164–170°), identical with the preoperative findings. After osteotomy, the mean angle provided by the computer system was 182.7±1.1° (range 182–184°). Three months after surgery, the mean alignment on the standing x-ray was 180.8±1.6° (range 177–182°). The preoperative objective was achieved for all knees but one (91% success). There were no x-rays with an oblique joint space.

Conclusion: Computer-assisted double osteotomy for major genu varum is a reliable accurate and reproducible technique. Use of a navigation simplifies a generally difficult procedure known to require much surgical skill to achieve the preoperative goal. This technique can be considered as an important development since it can help avoid an oblique joint space which can give rise to further problems and the need for a subsequent prosthesis.

Introduction The aims of this paper was to check the main clinical features of the posterior ankle impingment syndrom and to evaluate the results of the surgical treatment according to a retrospective study. Material and Methods 21 patients (17 males,4 females),(mean age of 33 years)were operated on between 1991 and 1999. 71 % had sporting activities. Plantar flexion were painful in 94 % of cases with various radiological changings of the posterior process of the talus and soft tissues surrounded (XRays, radionucleid imaging, CTscan and MRI). A posterior approach were performed with bone resection and peritalar joints debridment. Results All the patients were clinically and radiologically reviewed using AOFAS score. The mean follow-up was of 5 years(range 3 to 10 years). No septic evolution were reported. The overall functional results were excellent with a mean AOFAS score of 90/100 points with no degenerative changings in the peritalar joints. The patients were satisfied in 90 % of the cases Discussion-Conclusion Surgical managment is a successful and reliable procedure to treat the posterior ankle impingment syndrom, very frequent in sporting population and nowadays well documented by conventional Xrays and uptodate radiological examinations.

Introduction: Previously, we noticed loss of initial reduction with conventional palmar plate osteosynthesis for dorsally displaced distal radius fractures. Locking Compression T plate may provide more stable fixation and we report our early experience.

Materials and methods: Between November 2002 and April 2003, 23 patients (15 women, 8 men), mean age 55, (17–80) underwent open reduction and internal fixation using 3.5 mm locking compression oblique T plate (SYNTHES) through a Henry ‘s approach and a 2 weeks plaster cast immobilisation. All fractures were dorsally displaced. According to AO classification there were 15 A3 and 8 C1 and C2 fracture. 18 patients could be reviewed with a mean follow up of 16 months (6 to 30) Pre operatively, radial inclination was 11.7 ° (0–20), dorsal angulation 25.9 ° (8–48) and ulnar variance:4 mm (0–10)

Results: Post-operatively, radial inclination was 23,2. ulnar variance: 1,2 mm and ventral angulation 4,6 °. At one year follow-up, there was no loss of post-operative reduction. According to SOFCOT ‘s criteria, there were 13 anatomical results and 5 moderate malunion. According to Green and O ‘Brien’s criteria, there were 9 excellent, 6 good, 3 fair and no poor results. Mean DASH score was 22.8 (5.8 – 62.5). Strengh and pinch were respectively 95 % and 91 % when compared with the opposite side. There were 6 complications concerning 4 reflex sympathetic dystrophy, one carpal tunnel syndrome and one hypertrophic scar.

Discussion: In our experience, classic palmar plate fixation showed inability for maintaining reduction during time. Locking Compression 3,5 T plate by a palmar approach which is a demanding technique, avoids loss of post-operative recution

Conclusion Locking Compression 3.5 T Plate by palmar approach is an effective treatment for dorsally displaced distal radius fracture but the plate itself and ancillary tools have to be improved to reduce operatively difficulty.

Purpose: The purpose of this work was to evaluate clinical and radiological results of surgical treatment of 80 calcaneum fractures involving the posterior talar process using 1/4 tubes used for triangulation fixation.

Material and methods: The series involved 73 patients (seven bilateral fractures), 56 men and 17 women, average age 39.6 years (15–67) who were treated between 1990 and 1999. Patients were victims of 34 home accidents (46.6%), 19 sports accidents (26%), 14 occupational accidents (19.2%), and six traffic accidents (8.2%). The Duparc classification was: type 2 (n=2) type 3 (n=17), type 4 (n=51), and type 5 (n=10). Junior surgeons performed most of the procedures who used seven ‘inverted-V’ assemblies and 73 triangular assemblies. Forty-two patients (47 fractures) were reviewed (58.8% of fractures) clinically and radiologically to assess stability of the fixation (Boehler angle and talocalcaneal angle) and search for osteoarthritis.

Results: Mean follow-up was six years (1.5–11.5). There were few complications: four late healing (5%), five reflex dystrophy (6.3%) and two infections (2.5%) (Met-S Staphylococcus aureus and Bacterium bovis corineus. Subjectively, 93.5% of patients were satisfied or very satisfied. At last follow-up, the Boehler angle was 27.5±6.7°. The subtalar space was normal or nearly normal in 46.8% and narrowed or destroyed (osteoarthritis) in 53.2%. The Kitaoka function score (AOFAS) was 73.2 points on average with 44.7% excellent or good results and 44.8% fair results. The SOFCOT score was very good, good, or rather good in 63.8% and fair in 10.3%; it was also noted that among the 25.5% poor results, three patients required secondary subtalar arthrodesis. 86% of the patients resumed their occupational activities and 63% of the patients practicing sports resumed their activities.

Conclusion: Osteosynthesis of calcaneum fractures using 1/4 tubes used in a triangular configuration provides stable fixation (little secondary loss of Boehler angle) with a satisfactory cutaneous impact (few cases of skin necrosis). The subjective outcome is very satisfactory. Objective outcome may appear disappointing but is generally related to the severity of the fracture (76% types 4 and 5) or type of fixation configuration.

Purpose: Chronic ankle instability is generally related to lateral laxity of the tibiotalar joint. Stress x-rays may however be negative. Varus of the hindfoot is another possibility. In such cases, it would be logical to propose Dwyer valgus osteotomy of the calcaneum. The objective of this work was to review patients who underwent Dwyer osteotomy from 1992 to 2000.

Material and methods: The series included fifteen patients, nine men and six women, who complained of chronic ankle instability with no evidence of laxity. All presented a varus hindfoot (mean 5°, range 3–10°). Thirteen patients practiced sports, including eight at the competition level. Sixty percent had experienced instability accidents during sports activities. Associated lesions were fissures of the fibular tendons (n=2), osteochondral lesion of the talar dome (n=1), Haglund disease (n=1) and stage II pes cavus (n=2). Lateral closed Dwyer osteotomy was performed in all cases, generally with fixed with two screws in a 2-hole 1/3 plate. Associated procedures were: lateral ligamentoplasty (n=1), osteotomy to raise M1 (n=2), regularisation of an osteochondral lesion of the talar dome (n=1), Zadek osteotomy (n=1) and anterior arthrolysis (n=1). The same surgeon reviewed the patients clinically and radiologically, independent of the operator.

Results: Mean follow-up was 3.5 years (range 1–9, SD 2.5). There were no complications except one case of cutaneous necrosis in the patient who had simultaneous osteotomy and ligamentoplasty. Instability resolved in all patients. Ten patients experienced minor episodic pain (50% during sports activities). Eleven patients (70%) resumed their sports activities within eight months (3–36) and 33% at their former level. The mean Kitaoka score was 92 (85–100) and 80% of the patients were satisfied or very satisfied.

Conclusion: Dwyer osteotomy provides quite satisfactory results for patients with chronic ankle instability without evidence of laxity and hindfoot varus. When a complementary ligamentoplasty appears to be necessary, it is preferable to wait for a second operation in order to avoid the risk of cutaneous necrosis.

Purpose: The aim of this work was to evaluate functional and anatomic results of MacIntosh quadriceps plasty reinforced with a free fascia lata transplant used for the treatment of severe anterior laxity of the knee.

Material and methods: We considered severe laxity to be defined as a differential greater than 10 mm (manual Lachmann maximum on KT1000) compared with the healthy side and/or an explosive pivot test scored +++ and/or absolute laxity measured at 20 mm. This retrospective series included 108 patients treated between 1995 and 1998 by the same operator (DS). There were 70 men and 38 women, mean age 29±8.7 years (15–52). Average time from trauma to treatment was 38 months (2–324). Among the 98 patients practicing sports, 47 (43.5%) practiced pivot sports with contact and 51 (47.2%) practiced pivot sports without contact. Mean preoperatiove laxity KT1000 was 18±3 mm (13–30) on the diseased side and 5.34±1.9 mm on the healthy side (15 knees excluded due to rupture of the contralateral anterior cruciate ligament). Mean differential laxity was 12.6±2.3 mm (9–21) and in 44 patients (40.8%) the pivot test was scored +++. Only 37 knees (34%) were totally free of meniscal lesions. Outcome was evaluated by an independent operator using the IKDC method.

Results: Results were analysed for 71 patients (37 lost to follow-up giving a review rate of 65.8%) with a mean follow-up of 63.4±12.9 months (40–86). Absolute postoperative laxity was 8.9±2.9 mm (2–18) and differential laxity was 2.6±2.3 (−2 to +8) giving a mean gain in laxity of 10 mm. The pivot test was negative in 73.2% of the knees, 22% were scored +, and 4.2% ++. The overall IKDC score was 87.3±9.6 (56–100). 90% of the patients were satisfied or very satisfied with outcome. Furthermore, 80.3% of patients were able to resume their sports activities at the same or higher level.

Conclusion: Mixed plasty using the MacIntosh method with lateral reinforcement using the fascia lata enables effective treatment of severe anterior laxity of the knee. Few studies have differentiated laxity according to severity. Prospective randomised studies devoted to patients with very severe laxity are needed to confirm the results of this technique in comparison with isolated plasty of the anterior cruciate ligament without lateral reinforcement.

Purpose: The purpose of this work was to assess the mechanical axis of 28 computer-assisted osteotomies (group A) with 28 manual osteotomies (group B) selected at random from 140 osteotomies performed between January 1997 and December 2000.

Material and methods: The populations were comparable for age, gender, side, degree of osteoarthritis (modified Ahlback stages) and varus malalignment (group A: 173±3.80° (160°–178°), group B 172.8±3.18° (164°–178°) using a pangonometer to measure the HKA angle). For 52 knees, open-wedge tibial osteotomy was performed and fixed with a tricalcium phosphate wedge (Biosorb(r)) and an AO T-plate. For four knees (two in group A and two in group B), a double tibial (open wedge) and femoral (closed wedge) osteotomy was used due to genu varum measuring greater than 15°. Preoperative planning for the classical method used a plumb line from the centre of the femoral head identified fluoroscopically. The Orthopilot(r) computer-assisted method also relied on preoperative planning but intraoperative control was based on computer acquisitions of the centre of the hip, the knee and the ankle. The objective of the intervention was to obtain a mechanical axis between 182° and 186°. All knees were evaluated with pangonometry at three months to check axis correction.

Results: In group A, the mean postoperative HKA was 183±0.99° (181°–185°). In group B it was 184±2.28° (181°–189°). The objective was attained in 96% of knees in group A and in 71% in group B, giving a statistical difference between the absolute data (p=0.0248) and between the standard deviations (p=0.0015).

Conclusion: Computer-assisted osteotomy to correct for genu varum using the Orthopilot(r) method is feasible and remarkably reproducible. In our hands Orthopilot(r) enabled attaining the surgical objective set preoperatively. The kinetics of the acquisition of the centre of the hip, the knee, and the ankle associated with palpation of remarkable extra-articular points is an excellent method avoiding the need for intra-articular palpation which might complicate the surgical procedure.

Aims: Hindfoot deformity in varus position is an aetiology of chronic ankle instability without laxity. In this condition, a Dwyer osteotomy has to be performed.

Methods: Between 1992 and 2000, 15 patients have been operated on, with this technique. The mean varus deformity was of 5û (3û to 10û).13 patients had sporting activities, 8 of them in competition. Instability during sporting activity were present in 60% of cases. Associated lesions were reported in 6 cases. A Dwyer procedure using a 1/3 tube plate þxed with two screws were performed in all cases. Associated procedures were performed at the same time as such as a lateral ligamentoplasty or a þrst metatarsal osteotomy. All patients were reviewed clinically and radiologically using AOFAS score.

Results: The mean follow-up was of 3.5 years (1 to 9 years). The only one complication reported was a skin necrosis, treated by a cutaneous ßap in a patient operated on with Dwyer and ligamentoplasty in the same procedure. No ankle instability was reported. Mild pain was reported in 10 patients and 50% of them only for sporting activities.11 patients returned to sporting activity and 33% of them at the same level. The mean Kita-oka score was of 92 (85 to 100). The patients were satisþed and very satisþed in 80 of cases.

Conclusions: Dwyer lateral closing wedge calcaneal osteotomy is successful for the treatment of chronic ankle instability without laxity and with varus hindfoot deformity. When laxity is associated with varus deformity an operative procedure in two steps is necessary to avoid wound complication. Dwyer osteotomy has to be performed þrst.

Purpose: Over recent years, several authors have estimated that the distal femur presents an epiphyseal torsion which can be measured intraoperatively or on the preoperative scan. This measurement does not however take into account the dynamic mechanical axis, particularly the mechanical axis at 90° flexion when walking. We used a computer-assisted navigation system (Ortho-pilot®) to attempt to measure femoral rotation by dynamic gonometry in extension and 90° flexion before and after implantation of a total knee arthroplasty.

Material and methods: We recorded the preoperative (Rx) and intraoperative (Orthopilot) HKA in extension and in 90° flexion before and after implantation of 50 total knee prostheses (Search®, Aesculup, AG, Tuttlingen) and again postoperatively (Rx). The series included 19 knees with genu valgum (mean HKA 187.36±5.4°, range 181°–203°), 30 knees with genu varum (HKA 169.2±4.11, range 160°–176°), and one normal axis knee.

Results: The radiographic values obtained preoperatively were confirmed by Orthopilot, respectively 186.68±5.25° and 169.76±3.84° in extension. At 90° flexion, HKA was 178.63±5.7° before implantation for genu valgum giving a significant varus due to lateral opening during flexion,and 171.6±4.15° for genu varum, showing persistence of varus. After implantation of the total knee prosthesis, the values were as follows. For the genu varum: HKA in extension 180.57±0.82° and HKA in 90° flexion 176.86±2.55° giving a mean residual varus of 3.16±2.86° (from 4–8° varus) without external rotation of the femoral implant. For genu valgum, HKA in extension was 179.60±0.92° and HKA in 90° flexion was 176.1±3.23°, giving a mean residual varus of 3.26±2.86° (0–10° varus), recalling that in the event of genu valgum we impose external rotation due to the frequent hypoplasia of the lateral condyle.

Discussion: Orthopilot-assisted implantation of total knee prostheses provides new information concerning dynamic gonometry, particularly the varus or valgus in flexion, which corresponds to measuring natural external or internal rotation. Measuring epiphyseal torsion of the distal femur with classical methods does not take into account the global rotation of the femur which is often an external rotation (up to 8° for genu varum). Systematic implantation of the femoral component in external rotation raises the risk of increasing considerably the varus forced to the implant during flexion.