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 position of the femoral implant in external rotation remains a controversial issue. It can be determined using bone landmarks (Whiteside line, parallel to the biepicondylar axis, 3° external rotation from the posterior condylar plane). For the last seven years, we have related femoral rotation to the orientation of the tibial cut in order to ensure good femorotibial stability in flexion using specific instruments (Cores®). This prospective study was conducted to examine the position of the femoral implant determined with this method and to measure the position from bone landmarks.

Material and methods: Twenty consecutive patients were included in this study. Bilateral computed tomographic measurements were made before and after surgery. Joining 8mm/8 slices were obtained for the femoral necks and 5mm/3 slices for the knees. The angle of femoral torsion was defined in two ways: the first by the angle formed between the axis of the femoral neck (on two superimposed slices) and the tangent to the most posterior part of the femoral condyles; the second by the angle formed between the epidondylar line and the posterior condylar line.

Results: The preoperative scans demonstrated that the angle between the biepicondylar line and the posterior condylar line was 5.8±1.5°. Using Cores®, led to an external rotation of the femoral implant to 2.7±0.6°. The postoperative scans demonstrated that the angle between the biepicondylar line and the posterior condylar prosthetic play was a mean 3.3°. The measurements using the femoral neck were less precise, with, in one case, an external rotation of 5°. The patella was well balanced postoperatively (irrespective of the external rotation position of the femoral implant).

Discussion: The angle of about 6° between the biepicondylar line and the posterior plane of the condyles has also been reported by others (Beaufils, Matsuda). To obtain a rectangular space in flexion, the posterior condyle cuts are more important medially than laterally. We found a correlation between the correction provided by the specific instrument set and the difference in the posterior condyle cuts, demonstrating the intraoperative precision of Cores®. It is difficult to orient the femoral piece parallel to the biepicondylar axis. This study demonstrates that there always remains 2 to 3° of inclination of the biepi-condylar axis from the posterior condylar plane.

Conclusion: The positioning the femoral implant parallel to the biepicondylar line leads to inducing an important external rotation. While using 3° rotation systematically would reduce the risk of internal malrotation, we feel it better to adapt the rotation to each individual knee depending on the anatomic presentation. Cores® enables positioning the femoral implant in external rotation as a function of the ligament balance obtained in flexion after peripheral tension is applied. This enables avoiding medial femorotibial laxity in flexion.

Purpose: Arthroscopic reconstruction of the anterior cruciate ligament (ACL) with a free patellar tendon graft is a classical method for the treatment of anterior knee laxity. The purpose of this study was to analyse clinical and radiological outcome in 218 cases at five years and to search for prognostic factors.

Material and methods: Between 1993 and 1994, arthroscopic repair of the ACL was performed in 218 knees with two independent tunnels using a free patellar graft. This prospective study included 177 knees reviewed at a mean 67±7 months follow-up using the IKDC criteria and instrumental manual KT-1000 laxity measurements. The series included 67.4% men and 32.6% women, mean age 26.7 years (14–59). Delay from the accident to surgery was a mean 22.3 months (1–228 months). Two medial, 15 lateral and five medial and lateral meniscectomies had been performed before the operation studied. The position of the tunnels was studied using the Aglietti method. Differences were considered significant at p < 0.05.

Results: Sports activities could be resumed in 87% of the cases at the same level for 62% with a mean delay of 12 months. Subjectively, the patients were satisfied or very satisfied in 86% of the cases. Symptom score was A in 50%, B in 38%, C in 8.3% and D in 3.7%. Maximal manual residual differential measured with KT-100 was 0.75 ± 2.3 mm with an abolished click in 82% of the cases and a glide in 12%. Sceondary medial meniscectomy was performed in 19 cases. At last follow-up the meniscal material was intact in 127 cases (60%). Overall IKDC score for the 177 cases reviewed was: A 57%, B 24%, C 9%, D 9%. Radiographically, the knee was normal in 66.6% of the cases, remodelled in 29.6%, and exhibited joint space narrowing less than 50% in 13.4% and overall osteoarthritis in 0.6%. The Aglietti lateral score as 25.5±7% for the tibia and 66.3±7.2% for the femur. During follow-up, there were 13 cases of recurrent tears related to repeated sports trauma or poor femoral position. During this same period, there were 20 tears of the contralateral ACL. Functional outcome was correlated with the presence of a medial meniscus, the length of delay from accident to surgery, and the presence of radiological evidence of residual laxity.

Conclusion: This study demonstrated that chronic anterior laxity of the knee, treated with a free patellar tendon graft implanted arthroscopically provides good restoration of the knee in 82% of the cases with little residual laxity. Joint space narrowing was found in 1% of the cases and was strongly correlated with the status of the medial meniscus that should be preserved. The number of recurrent tears was equivalent to the number of contralateral tears observed during the same period.

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.