The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction.

Purpose of the study: The purpose of this retrospective study was to evaluate the reliability of the sural flap with a distal pedicle for covering tissue loss of the posterior aspect of the heal and the malleolar region in diabetic patients.

Material and methods: We present a retrospective consecutive series with 28 month follow-up. Thirteen flaps in 13 patients (10 men, 3 women), mean age 64 years. A homolateral flap was used in all cases, covering on average 48 cm². Substance loss involved the hind foot in ten cases and the malleolar region in three. Three patients had recent bone trauma, four had chronic osteitis and six a pressure wound involving the heel. All patients had non-insulin dependent diabetes mellitus.

Results: The flap head in 24 days on average (range 18–45), the donor site in 15 days. Eleven patients were able to wear normal shoes. At last follow-up all patients were free of infectious recurrence. There was one flap necrosis, three necrotic borders (one skin graft), two cases of venous insufficiency, and ten cases of hypoesthesia of the lateral border of the foot.

Discussion: There have not been any reports in the literature of the neurocutaneous sural flap with a distal pedicle for diabetic patients. In our series, this flap was found to be a reproducible solution for covering substance loss of the heel and malleolar region in the diabetic.

Conclusion: This flap with a long pedicle does not require microvascular qualification. It is easy to perform, induces few functional sequelae. For diabetic patients, it is an alternative to amputation, without compromising future options since the vascular and muscle stock are preserved.

Purpose of the study: Acetabular bone loss and loosening after total hip arthroplasty has been evaluated on plain x-rays (Vives, 1988; D’Antonio, 1989; Paprosky, 1994). Experience has proven that intraoperative assessment of bone loss is more important than previously thought. Our main objective was to quantify, intraoperatively, the real volume of bone loss. A secondary objective was to measure, independently of the observer, the course of acetabular loosening.

Material and method: This was a prospective series of acetabular loosenings (10 female, 4 male, mean age 68 years). Plain x-rays and computed tomography (CT) were obtained. A special image analysis software was used for the CT images after manual segmentation of the prosthetic acetabulum: automatic 3D volume and periprosthetic bone density were noted.

Results: Bone loss was divided into three stages. At stage 1, the volume lost was from 10 to 20 cm3; at stage 2, the volume loss was 20 to 40 cm3; and at stage 3 the loss was greater than 40 cm3. At six months, two hips exhibited early stage acetabular loosening with 5% lucency. The corresponding volumes between the stages observed on the plain x-rays and those measured on the CT scan did not correlate significantly.

Discussion: Compared with conventional x-ray methods for volume assessment, this computed tomography method is precise. The segmentation preparation was semi-automatic and took about 30 minutes. The prosthetic material did not hinder the image analysis. Results were produced automatically. The 3D representation enabled the operator to visualize intraopera-tively the acetabular zones the most affected, helpful for planning the procedure and choosing the implant. The density analysis gave the quality of the bone and the limit between healthy tissue, pathological tissue and the cement, increasing the volume of the bone loss.

Conclusion: These automatic measurement tools reduce analysis time. The precision of the measurements is a supplementary factor for determining the stage of the bone loss and the amount of graft tissue or bone substitute needed. This method can be used for all joints.

Between 1993 and 2002, 58 GSB III total elbow replacements were implanted in 45 patients with rheumatoid arthritis by the same surgeon. At the most recent follow-up, five patients had died (five elbows) and six (nine elbows) had been lost to follow-up, leaving 44 total elbow replacements in 34 patients available for clinical and radiological review at a mean follow-up of 74 months (25 to 143). There were 26 women and eight men with a mean age at operation of 55.7 years (24 to 77).

At the latest follow-up, 31 excellent (70%), six good (14%), three fair (7%) and four poor (9%) results were noted according to the Mayo elbow performance score. Five humeral (11%) and one ulnar (2%) component were loose according to radiological criteria (type III or type IV). Of the 44 prostheses, two (5%) had been revised, one for type-IV humeral loosening after follow-up for ten years and one for fracture of the ulnar component. Seven elbows had post-operative dysfunction of the ulnar nerve, which was transient in five and permanent in two.

Despite an increased incidence of loosening with time, the GSB III prosthesis has given favourable mid-term results in patients with rheumatoid arthritis.

Purpose: Osteosynthesis of complex subtrochanteric fractures is a difficult task. Complications are frequent and results are uncertain. Cemented fixation of pathological metastatic fractures requires a major intervention. The functional prognosis remains uncertain. Our objective was to evaluate the contribution of the long gamma nail (50 nails) in this type of situation and to determine its advantages and disadvantages.

Material and methods: The 50 long gamma nails were inserted in 23 women and 26 men who were followed eight months (4–16). We implanted 39 long gamma nails for complex subtrochanteric fractures (AO classification) in patients aged 59 years on average (19–93) and eleven nails for metastatic femur fractures in patients aged 59 years on average (19–93) with a trochanterodiaphyseal localisation. For the non-metastatic fractures, closed nailing was used in 28 patients and minimum opening for eleven. For the metastatic fractures, the primary tumour was known in eleven cases. The nailing was a preventive measure in six and performed after fracture in five. Three patients had plurifocal fractures. We analysed 43 parameters (position of the cervical screw in the four quadrants of the femoral neck and clinical and radiological features).

Results: For the 39 fractures, reduction was anatomic in 24 and with a gap in 15. The position of the cervical nail was correct in 34 cases. It was in the anterosuperior quadrant in three, the posterosuperior quadrant in one and the posteroinferior quadrant in one. Weight bearing was resumed at 1.5 months on average. Healing with total weight bearing was achieved at four months on average (maximum 8 months). Mechanical complications were: migration of the cephalic screw (n=4), rupture of the locking wings (n=9), nail fracture (n=1), non-union (n=2). Total pain relief was achieved for the eleven pathological fractures (maximum follow-up 16 months). Weight-bearing with crutches was possible in seven patients and not possible in four. There was no dismounting. Outcome was comparable with cemented osteosyntheses.

Discussion: For pathological fractures, this less aggressive osteosynthesis provides very effective pain relief. For other complex subtrochanteric fractures, complete closed nailing was not always possible.

Purpose: The morphology and mechanical function of the metatarsosesamoid joint plays an important role in metatarsal head stability. The position of the sesamoids during the development of hallux valgus was evaluated by Inges, Haines and Tourne who distinguished three stages. Cartilage lesions in the context of hallux valgus have not been analysed with precision. The purpose of our work was to identify metatarsosesamoid lesions on anatomic specimens in patients who had undergone hallux valgus surgery.

Material and methods: We dissected 12 metatarsosesa-moid joints (4 right, 13 left) from laboratory specimens and evaluated the degenerative lesions. For each specimen, we noted the metatarsophalangial angle and the AADM. We also examined 17 metatarsal specimens to determine the persistence or absence of the median crest as a sign of wear. Using the same protocol, we examined the joints surfaces and determined degenerative lesions during 20 SCARF procedures for hallus valgus.

Results: For the twelve laboratory specimens, we observed: for the plantar joint surface of M1, the joint surfaces were perfectly intact in 2 specimens, the sagittal crest was worn away in 4, degenerative lesions appeared on the medial surface in 4, and on the lateral surface in 2. For the sesamoids, the degenerative lesions involved both sesamoids in 1 specimen, the lateral sesamoid in 2, the medial sesamoid in 4, and none in 3. Lesions of the metatarsophalangial joint were diffuse in 1 case, localised in 5 and absent in 6. For the 17 metatarsals, for an AADM between 4 and 12, no lesion was found in 6 cases, degenerative lesions involving both sesamoids in 1, the lateral sesamoid in 1 and the medial sesamoid in 2. For an AADM greater than 12, the metatarso-sesamoid joints surfaces were intact in 1 case, the sagittal crest was worn off in 4, and degenerative lesions involved the medial surface in 4 and the lateral surface in 1.

Conclusion: This anatomy study demonstrated the precise topography of degenerative lesions of the metata-sosesamoid joint. This data base should be useful for evaluating functional outcome as a function of the meta-tarsosesamoid lesions in the treatment of hallux valgus.

Purpose: A pre- and postoperative radiographic analysis of 50 total knee arthroplasties (TKA) was performed to determine the femorotibial correction angle and the tibial and femoral mechanical angles obtained as a function of the initial bony deformity. The preoperative angle beyond which correction was not achieved was determined.

Material and methods: This prospective single-centre study included 50 TKA (25 men and 25 women), mean age 69.1 years (range 53–83). Degenerative disease involved the right knee in 21 cases and the left knee in 29. A Wallaby I TKA (semi-restrained with preservation of the posterior cruciate ligament) was implanted in all cases. Three angles were calculated on the AP loaded knee: AFT (femorotibial angle), AFM (femoral mechanical angle), ATM (tibial mechanical angle). For each angle, statistic analysis was performed on four groups of patients: group I: overall population, group II: patients with normal axis (178°< AFT< 182°; 88°< AFM< 92°; 88)< ATM< 92°), group III: patients with varus (AFT> 182°; AFM> 92°; ATM> 92°), and group IV: patients with valus (AFT< 178°; AFM< 88°; ATM< 88°). Non-parametric tests (Spearman rank test and MacNemar symmetry test) were performed on SAS software for statistical analysis with p< 0.05 considered as significant.

Results: Pre- and postoperative AFT showed: significant improvement of the mean (> 3.44° in group I, > 6.87° in group III, and > 6.12° in group IV). There was no significant difference in group II. Pre- and postoperative AFM showed: constant but non-significant improvement in groups I and III (> 3°) and constant and significant improvement in groups III and IV (> 2.5°). Pre- and postoperative ATM showed: significant improvement in groups I and III (> 3°), constant but non-significant improvement in group IV (n=4). There was no group II. An ATM > 94° was the threshold angle beyond which correction was not obtained.

Discussion: Taken together, the results of this study confirm the reliability of the Wallaby I instrumentation for achieving a correct postoperative mechanical axis. These results are comparable with data in the literature (with or without preservation of the posterior cruciate ligament). However, the correction of the bony deformity obtained depended uniquely on the initial deformity of the tibia. Extreme deformity of the tibia should be corrected with osteotomy or with a more restrained prosthesis.

Purpose: Reports on the histological lesions observed in patients with degenerative disease of the shoulder have generally involved only a few cases. We conducted a prospective study in 662 shoulders operated on for impingement or rotator cuff tear.

Material: The cases analysed included 402 subacromial impingements and 260 rotator cuff tears.

Methods: Pathology specimens were obtained from the subacromiodeltoid bursa, the acromion, the acromio-coracoid ligament, the acromioclavicular joint, the borders of the rotator cuff tear, and the biceps tendon. There were 2573 pathology specimens.

Results: The pathology examination revealed degenerative lesions (fibrosis, oedema, calcifications, fissuration, atrophy, delamination, fatty infiltration, necrosis, chondroid metaplasia, fragmentation), or inflammation. The subacromiodeltoid bursa presented fibrosis lesions in 3 out of 4 cases (74%). Signs of inflammation were found in 21% of the cases, oedema in 9%, and no lesion in 15%. The acromiocoracoid ligament showed oedema in 35%, fissuration in 35%, delamination in 25%, fragmentation in 11%, atrophy in 8%, fatty infiltration in 6%, necrosis in 4%, hypervascularisation in 2%, chondroid metaplasia in 1%, and no lesion in 27%. For the acromion, degenerative lesions were present in 88%, impingement in 83%, cuff tears in 92%. Lesions of the cuff in patients with tears showed degeneration in 86% (fissuration 46%, necrosis 35%, fragmentation 30%, vascular penetration with chondroid metaplasia 17%, delamination 10%, haemorrhagic remodelling 4%, adipose degeneration 3%, atrophy 2%, oedema 42%, calcifications 30%, fibrosis 26%, inflammation 7%, and no lesion 1 case). The biceps tendon showed degenerative lesions (90%), inflammation 2 cases, no lesion 3 cases. The acromioclavian joint (67 cases) showed degenerative lesions in all cases. Rotator cuff tears showed inflammatory lesions 30%, and subacromial impingement 16%.

Discussion: The statistical analysis revealed a significant correlation between the presence of a normal subacromiodeltoid bursa and the type of pathology. There was a significant statistical relationship between the presence of inflammatory lesions and the type of pathology. There was no significant correlation with the pain score. There was a significant relationship between the presence of fibrosis of the acromiocoracoid ligament and the functional score at last follow-up. The presence of ligament fibrosis would be a sign of poor prognosis. This relationship was present irrespective of the pain, force and stability scores.

Conclusion: The acromiocoracoid ligament was not found to be particularly involved suggesting that the idea of impingement should be revisited. For cases with a tear, the presence of a acromiocoracoid ligament with no histological lesion confirms that tears are not always associated with an impingement. Among cuff tear or impingement cases, there was a number of acromions with no bone lesion. Inflammatory lesions were not frequent. Unravelling the pathology of the degenerative shoulder is a complex process making interpretation and correlation with clinical signs and proposed therapeutic protocols difficult.

Purpose: The purpose of this work was to evaluate function of 256 total knee arthroplasties (TKA) (Wallaby) with preservation of the posterior cruciate ligament and to compare the femorotibial angle obtained postoperatively.

Material and methods: This prospective study included 256 consecutive TKA (cemented Wallaby 1) in 249 patients (mean age 68 years) with osteoarthritis (n=249) or rheumatoid polyarthritis (n=7). Pre- and postoperative clinical findings (HKS score, flexion, extension, laxity, walking distance, use of crutches) and AP full leg views with 20° loaded lateral views pre- and postoperatively (mechanical femoral, mechanical tibial, and femorotibial angles, tibial slope, patellar height, anterior tibial translation) were recorded.

Results: The 256 TKA were reviewed at a mean 3-year follow-up. Flexion amplitude was the evaluation criterion. Mean preoperative flexion was 109° (40–130°) with mean persistent flexion of 5° (0°–40°). Mean postoperative flexion was 98° (30–130°) with no persistent flexion. The mean preoperative femorotibial angle was 181.8° (160–201°) and was 180.4° (172–195°) postoperatively. The mean preperative mechanical femoral angle was 88° (82–96°) and 89.8° (80–96°) postoperatively. Mean mechanical tibial angle was 93° (85–104°) and 90.4° (84–86°) postoperatively.

Discussion: For certain authors, the only parameter predictive of postoperative flexion after gliding TKA with preservation of the posterior cruciate ligament is preoperative flexion. The statistical analysis of our series showed that correction of the femorotibial malalignement in the frontal plane was not correlated with postoperative knee function and precisely with postoperative flexion. Postoperative flexion was correlated with preoperative flexion. Our results on postoperative flexion of TKA related to preoperative flexion are in agreement with earlier analyses reported in the literature that do not find any absolute correlation with a neutral femorotibial angle in the frontal plane.

Conclusion: The quality of the functional outcome after total knee arthroplasty cannot be predicted solely on the correction of the initial deformity.