Introduction

The value of collared stems for uncemented implants remains controversial. Some comparative studies have demonstrated advantages of collared stems regarding the potential for subsidence. Other studies with longer follow-up have shown no adverse effect of the use of a collar regarding the femoral component survivorship. To date, the adequate size of the collar with regards to the anatomy of the proximal femur has never been studied.

The goal of this study was to assess whether the size of the collar needs to be adjusted according to the size of the femoral component used, and according to the use of a standard or a lateralized component.

Introduction

Primary mechanical fixation and secondary biologic fixation determine the fixation of an uncemented femoral component. An optimized adequacy between the implant design and the proximal femur morphology allows to secure primary fixation.

The femoral antetorsion has to be considered in order to reproduce the center of rotation.

A so-called «corrected coronal plane » including the center of the femoral head has therefore been defined. The goal of this study was to evaluate the proximal metaphysal volume and to design a straight femoral component adapted to this corrected coronal plane.

Purpose of the study: Grafting the anterior cruciate ligament with a bone-tendon-bone free transplant injures the harvesting site, causing sensorial disorders by injuring the infrapatellar nerve in 70% of the cases. Mini-invasive techniques can limit these complications. The purpose of this work was to analyse the feasibility of a mini-invasive technique using a single incision.

Material and methods: A prospective comparative study was conducted in our unit to compare a group of “classical” harvesting via an anteromedial incision and a “mini-invasive” technique using a incision centred on the patella with the graft being harvested with a specially designed harvesting instrument. Each group was composed of 20 patients. The patients were reviewed six to eight months postoperatively. Clinical assessment (IKDC, Lillois score, analysis of sensorial impairment) was associated with the radiographic and ultrasound analysis. Radiographic laxity was assessed on the stress views at 15 kg. The ultrasound study analysed the patellar tendon and the peritendon. Significance for statistical tests was set at 0.05 with correlation coefficients (R) determined with a covariance matrix ½ Log([1 + R]/[1−R]).

Results: The grafts harvested by the classical method presented good characteristics in all cases whereas this was true for only 45% of the mini-invasive grafts. Anterior pain was noted in 22% of patients in the classical group and in 33 of the mini-invasive group. There was no correlation between anterior knee pain and knee walking or thickness of the peritendon. A correlation was found between knee walking and asymmetry of the patellar tendon thickness in the mini-invasive group. The subjective IKDC score was the same in the two groups and the IKDC objective score was not significantly different (94% (A or B) in the classic group and 81% (A or B) in the mini-invasive group.

Conclusion: This mini-invasive technique with a single incision respects the infrapatellar branches of the medial saphenous nerve in 95% of the cases. But the quality of the graft is less satisfactory than with the classical harvesting technique. A correlation was found between the form of the anterior tibial tubercle which could be used to better define the ideal indication for this technique which remains a difficult procedure.

Purpose of the study: The purpose of this work was to search for a relationship between the size of the femoral cam, the presence of cup retroversion, and the presence of labral or chondral lesions on the arthroscan in patients with an asymptomatic femoroacetabular impingement.

Material and method: Fifty arthroscans were obtained to explore impingements. The patients complained of groin or trochanteric pain limiting their physical activities. Generally signs of an anterosuperior impingement were demonstrated with flexion-adduction-internal rotation. The localization, dimensions and depth of the cartilage lesions were measured on the arthroscan. The sagittal slice was used to describe the acetabular chondral lesions anteriorly to posteriorly in clockwise manner. Presence of an associated labral lesion was noted. A second operator measured the hip joint anomalies causing the impingement: Notzli’s alpha angle was measured to search for a cam effect and the femoral offset was noted.

Results: The presence of a femoral cam or a decreased femoral offset were found in all cases. Mean alpha angle was 65°; mean offset was 0.09. Acetabular retroversion was identified in 24 patients (48%). Chondral lesions were a constant finding and were superficial (type 1& 2) in 32 patients (64%) and deep (type 3& 4) in 18 patients (36%). Labral lesions were found in 28 patients (56%). The depth of the chondral lesions, like the presence of a labral lesion, were correlated significantly with increased alpha angle and patient age. There was conversely no correlation with the presence of acetabular retroversion.

Discussion: This study confirmed the close relationship between femoroacetabular impingement by a cam effect and the severity of labral lesions and acetabular cartilage lesions. These lesions can favour degeneration, explaining the early centred or posterinferior damage observed in young patients with satisfactory acetabular cover.

Purpose of the study: Locked centromedullary nailing has proven efficacy for the treament of tibial shaft fractures but its use remains controversial for the most distal fractures. The purpose of this work was to assess clinical and radiological outcome of nailing procedures used to treat fractures of the lower quarter of the leg.

Material and methods: Fifty-eight fractures of the lower quarter of the leg were treated by locked centromedul-lary nailing between 1999 and 2002. All patients were included in the analysis. Twenty-four patients aged 44 years on average (range 18–68 years) were reviewed by an independent operator at mean 43.2 months follow-up (range 18–70). Four types of nail were used, on an orthopedic table for 47 procedures and with a hanging leg for 11. The fibula was not fixed.

Results: Early complications were: compartment syndrome (n=2) and infection (n=3). Postoperative alignment was anatomic or good in 86%. Mean time to weight bearing was 66 days (range 0–180). Nonunion occurred in six patients who required revision. Secondary displacement was noted in ten patients. Knee motion was normal in all patients and ankle motion was normal in 80%. Mean time to resumed occupational activity was 5.7 months (range 1–18). At last follow-up, bone healing had been achieved in all patients.

Discussion: As compared with data in the literature, we found that locked centromedullary nailing allows early weight bearing with less risk of infection for radiological results comparable with those obtained with plate fixation. The secondary displacements resulted from defective locking of inappropriately adapted materials (holes insufficiently distal).

Conclusion: Locked centromedullary nailing is a treatment of choice for fractures of the distal quarter of the leg. Use of new nails with more distal holes should improve outcome by allowing distal locking with at least two screws in all cases.

Purpose of the study: Appropriate treatment for fractures of the distal radius with dorsal displacement remains a subject of debate. Intrafocal pinning is the most widely used technique in France. Plate fixation has been developed to avoid secondary displacement and stiffness sometimes observed after pinning. We compared three osteosynthesis techniques for the same type of fracture (extra-articular with dorsal displacement).

Material and methods: Sixty-two consecutive patients underwent osteosynthesis using the following techniques successively: posterior plates [20 patients mean age 59.9 years (range 25–87 years)], intra and extra-focal pînning [22 patients mean age 55.6 years (range17–83 years)], the anterior plate [20 patients mean age 57.1 years (range 17–78 years)]. An independent operator evaluated all patients using the Herzberg, Gartland and Werley and Dash scores. The radial slope in the frontal plane, sagittal tilt, and ulnar variance were measured and compared between the preoperative and last follow-up values. Kruskall-Wallis or ANOVA were applied as appropriate for continuous variables and the chi-square test for non-continuous variables. P< 0.05 was considered significant.

Results: Mean operative time was equivalent for the two plate fixation techniques and twice as long as for pinning. There were more complications in the posterior plating group (32%) and less satisfactory function score despite a two-fold longer follow-up and a smaller number of operators. The best results were obtained with the anterior plating group in terms of range of motion (flexion-extension), Dash, preservation of ulnar variance and presence of a largest number of excellent and very good outcomes according to Gartland. The pinning group provided the best results in terms of sagittal slope. The pinning and anterior plating groups had equivalent range of motion for supination pronation and the same rate of complications (5%). Irrespective of the treatment arm, the Herzberg scores and the Gartland and Dash scores were better: in men, in patients aged less than 30 years, in patients with an associated fracture of the apex of the ulnar syloid process rather than its base.

Discussion: While posterior plate fixation is logical (approach on the side of the injury), the technique is difficult and can lead to nerve and tendon complications. For these extra-articular fractures, pinning like anterior plating can provide good functional results. Pinning is a rapid procedure and anterior plates do not have to be removed, allowing more rapid recovery of total independence.

Purpose: We studied the subjective, functional and radiographic results after anterior cruciate ligament repair using the mid-third of the patellar tendon, combined with tibial osteotomy for valgisation during the same operative time.

Material and methods: Between 1983 and 1999, this procedure was performed in 66 knees. We studied 47 knees presenting a remodelled medial compartment or medial fem-orotibial narrowing greater than 50% (preosteoarthritis), excluding three AFTI, 11 lateral decoaptations, and 5 knees with excessive genu varum. We reviewed 34 knees (72.3%) in 32 patients with a mean follow-up of 10.5 years (1–16 years) using the IKDC ratings. A complete series of x-rays were obtained in 33 patients including a comparative single-leg stance view and full leg views. Mean age at surgery was 32 years (18–49); delay from accident to operation was eight years (0.5–33). There was at least one antecedent operation in 24 knee (22 medial menisci). Fourteen knees presented a remodelled medial femorotibial compartment (grade B) and 19 had a medial joint space narrowing > 50% (grade C). The lateral femorotibial compartment was remodelled in four cases (12M%).

Results: At last follow-up, 93% of the patients were satisfied or very satisfied. The mean subjective score including symptoms, function and level of activity was 78.4 (46–96.6). Intense sports activities (ski, tennis) were practised by 46% of the patients. Clinically, five knees were considered normal (A), fifteen nearly normal (B), twelve abnormal (C) and two very abnormal (D). These results were correlated with pre- and postoperative anterior translation of the tibia on single leg stance. Radiologically, among the 1′ knees with a remodelled medial femorotibial component (grade B), three progressed to grade C; among the 19 knees in grade C, two progressed to grade D (narrowing > 50%). Axial correction was significantly greater for grade B knees at review. For the lateral femorotibial compartment, 22 showed remodelling and two narrowing less than 50%. There was no correlation with axial correction. Changes in tibial tilt were studied.

Discussion, conclusion: At ten years, the combined ACL reconstruction, tibial osteotomy for valgisation, led to stabilisation of the osteoarthritic condition and most often led to a stable and satisfactory knee.