Purpose of the study: The purpose of the study was to present the clinical and arthroscan results obtained in a prospective series of 32 patients who underwent Bankart arthroscopy. We wanted to identify concrete applications.

Material and methods: These 32 patients presented unidirectional anterior shoulder instability with a history of true dislocation. Unstable painful shoulders, multidirectional dislocations, and HAGL injuries were excluded as well as rotator cuff tears. An arthroscopic treatment was used in all cases, followed by the same rehabilitation protocol. All patients were reviewed at six months. External rotation (RE1 and RE2) and Gagey hyperabduction were noted as well as the Walch-Duplay, Rowe, and ISIS scores. Plain x-rays and an arthroscan were obtained preoperatively and postoperatively. Attention was focused on passage bone lesions, healing, and changes in volume of the inferior recessus after surgery.

Results: Mean follow-up was 17.1 months (range 6.5–31.3), mean age 26.3 years (range 17–46), sex-ration predominantly male: 4.3/1. Hyperlaxity was noted for 53.1% of the shoulders. The overall subjective result was unchanged since the conclusions at the 1993 SFA while the overall objective result improved. There was a significantly favourable absence of preoperative passage bone lesions. The negation of the Gagey sign and the decrease in external rotation were signs of restoration of effective capsule tension (p< 0.05) which was ofen associated with a decline in the volume of the inferior recessus, although the difference has not yet reached the level of significance.

Discussion: The very favourable results in cases free of preoperative bone lesions are in favour of early surgery, perhaps after a first dislocation. Negation of the Gagey sign and decreased external rotation are two simple reproducible postoperative signs useful for assessing the efficacy of anterior and inferior capsule tension; complementary imaging may not be necessary. Evaluation of the volume of the inferior recessus needs to be continued using a precise reproducible protocol taking into account for the rotation of the upper limb and the quantity of contrast product injected into the joint.

Conclusion: This study demonstrated results comparable with publications in the literature allowing a direct clinical application for postoperative assessment. Inclusion of new cases should confirm the pertinence of arthroscan measurement of the volume of the inferior recessus.

Purpose of the study: Spontaneous repair of lost deep chondral tissue is minimal in the knee joint. A clinical trial of chondrocyte autografts as described by Brittberg and Peterson was undertaken by the Nantes University Hospital and the French Society of Arthroscopy in 1999.

Material and methods: Twenty-eight patients, mean age 28 years, underwent surgery in eight centers. Etiologies were: osteochondritis (n=14), isolated posttraumatic chondorpathy (n=7), chondropathy and full-thickness ACL tear (n=7). All lesions involved the condyles and were deep (ICRS grades 3 and 4). Mean surface area involved after debridement was 490 mm2 (range 150–1000 mm2). Patients were followed three years after the autologous grafting to assess functional outcome. An MRI was obtained at 2–3 years. Thirteen control arthroscopy procedures were performed including eight with biopsy specimens for histology and immunohisto-chemistry studies.

Results: Twenty-six patients were reviewed at more than two years. There were no general complications, three patients presented a partial avulsion of the graft treated by arthroscopy and one underwent arthrolysis at six months. Function improved in all patients except three and pain improved in all. The ICRS score improved from 43 points (range 19–70) to 77 points (range 39–84). Sixteen control MRIs were available and showed that the graft was hypertrophic in eleven cases, on level in four, and insufficient in one. Marginal integration was good in 11 cases and partial in five. Subchondral integration was complete in ten cases and mediocre in six. The arthroscopic score was nearly normal (score 8–11) in eight cases and abnormal in five (score 4–7). The histological class according to Knutsen (hyaline richness) was: one in group 1 (> 60%), three in group 2 (> 40%), four in group 3 (< 40%) and one in group 4 (bony or fibrous tissue). Function score (r=0.78 and MRI score (r=0.76) were correlated with arthroscopic sores. There was no correlation with the histological results.

Discussion: Clinical outcome was improved in more than 80% of cases, similar to results reported for histological series. The arthroscopic and histological results were equivalent to those reported by Knutsen but inferior to those reported by Bentley or Peterson.

Purpose of the study: The objective was to analyse shoulder motion, particularly abduction and anterior elevation, in patients with an reversed prosthesis. A radiocinematographic study enable an analysis of the movements of the prosthesis it self and movements due to scapulothoracic participation.

Material and methods: This study was based on the analysis of 33 patients with an reversed shoulder prosthesis. A videoscopic recording (25 images per second) of anterior elevation from a workstation used for abduction arteriography was used. The Constant score was noted and a standard x-ray work-up (four views) was obtained for all patients.

Results: The cohort was a homogeneous continuous series of 21 women and 12 men, mean age 72.5 years (range 39–84). Two modes of motion were observed. The first (group 12, n=17 shoulders) was «monoarticular»: shoulder motion was almost exclusively related to movement of the scapulothoracic junction. Abduction did not exceed 90°. The second mode (group 2, n=16 shoulders) was «bi-articular»: joint motion began with the prosthesis (50° on average) followed by scapulothoracic participation (50° on average). The implant then was involved in the final part of the motion (in six of the 16 shoulders in group 2) to complete the range of motion exceeding 120° abduction and anterior elevation.

Discussion: This study confirmed the presence of an initial intrinsic mobility of the prosthesis followed by scapulothoracic participation. It was noted however, that for the majority of cases, the intrinsic mobility of the prosthesis was limited. In all cases, the range of motion recorded by clinical examination was greater than the range of motion measured objectively by radiocinematography.

Discussion: This study demonstrated the in vivo mobility of the reversed prosthesis. However, a range of motion greater than 100° anterior elevation and abduction is exceptional. Clinical findings reflect imperfectly the real mobility of this type of prosthesis.

Purpose of the study: Morton neurinoma is a well defined anatomic entity despite certain questions about the pathogenic mechanisms. Diagnosis of the metatarsalgia sometimes produced can be difficult due to the frequency of an associated static metatarsalgia. Magnetic resonance imaging has not met expectations. We have oriented our research towards ultrasonography which can provide high quality information with good reliability.

Material and methods: We reviewed the files of 11 patients with Morton neurinoma which led to 14 operations (bilateral cases or two localizations on the same foot). The series included three men and eight women, mean age 56 years. The operation was conducted under locoregional anesthesia and consisted in tumor resection via the plantar commissure, with removal of the entire neurinoma. Ultrasonography used a high-frequency probe (6–13 MHz linear scan). The compartments were studied via the plantar aspect and the dorsal aspect using static and stress positions. MRI had been performed in two patients before the ultrasound.

Results: Eight of the eleven patients had an associated syndrome (hallux valgus, disharmonious length with mid metatarsal weight bearing). Objective signs (Mudler’s sign, hyoesthesia), were noted in seven patients. The neurinoma was confirmed in all cases at surgery; in two cases, ultrasonography demonstrated a neurinoma where the MRI had been negative. The operative specimen was typical. Two compartments were explored because of the ultrasound results which were highly suggestive; two tumors were demonstrated at surgery. Clinical outcome at mean seven months was good in ten patients and fair in one.

Discussion: Ultrasonography should no longer be considered as «operator-dependent». It enables the detection of mid-sized neurinomas measuring about 2 cm. Magnetic resonance imaging has been less productive for diagnosis; many studies have been reported without surgical confirmation of MRI-negative cases. False negatives are frequent and patient follow-up is insufficient to determine whether the symptoms persist or resolve after surgery.

Conclusion: Ultrasonography is a simple examination devoid of iatrogenic risk. The use of stress images has greatly improved performance. This low cost examination may not however be necessary because the diagnosis of Morton is basically clinical.

Purpose: The purpose of this study was to evaluate the sensitivity and specificity of magnetic resonance imaging (MRI) in the diagnosis of medial and lateral meniscal injury in operated and non-operated knees.

Material and methods: This prospective longitudinal study was conducted between January 1st 1995 and December 31st 1997. Each patient had a physical examination, a standard radiography study, and an MRI and an arthroscopy. The MRI was performed with two machines running at 1.5 Tesla and 0.5 Tesla. Spin-echo T2 slices were obtained in the saggital plane, and spin-echo fat saturation slices in the frontal and axial planes. Arthroscopy was performed and/or controlled by the same operator.

Results: The protocol included 132 patients. Ten patients (ten knees) had another arthroscopy after arthroscopic meniscectomy. Mean time between the physical examination and MRI was 57 days, it was 69 days between MRI and arthroscopy. Sensitivity, specificity, positive predictive value, negative predictive value and precision were, respectively, 94.8%, 61.%, 86.7%, 81.5% and 85.6% for the medial meniscus and 73%, 93.3%, 76% 93.5% and 90.1% for the lateral meniscus.

Discussion: Arthroscopy remains the gold standard for prospective comparative studies (Reigher 1986, Jackson 1988, Kelly 1991). MRI is the examination of choice for the diagnosis of meniscal injury in non-operated knees (Polly 1988). Most false positives concern injuries located on the posterior part of the medial meniscus. For radiologists (Mink 1988), these false negatives would result from poor analysis by the arthroscopic surgeon (Quinn 1991). Arthroscopists point out that radiologists overestimate injuries of the posterior segment (Barronian 1989, Fischer 1991, Spiers 1994). These false negatives involve the lateral meniscus (Cheung 1997). Our study corroborates the results reported in the literature. For repeated arthroscopies, no conclusion can be drawn from the interval of confidence observed in a population of ten knees. Nevertheless, in these knees, the MRI provided a good means of identifying recurrent lesions of both the medial and lateral menisci.

Conclusion: The physical examination provide a strong clue to meniscal injury in non-operated knees, so it is not necessary to perform an MRI before arthroscopy In all other cases, particularly there is recurrence, MRI can identify injury to the medial or lateral menisci with good sensitivity and specificity. In most cases, if the MRI is negative, it is not necessary to perform arthroscopy to search for a meniscal injury.

Purpose: Despite the development of new imaging techniques (MRI, CT scan) longitudinal studies of total hip arthroplasty (THA) are still conducted with conventional radiographs. New techniques for conventional radiograpy such as luminous screens with memory raise the question of longitudinal study in patients with THA where the new screen-film might produce artefacts.

Material and method: This prospective study examined intermethod and interobserver agreement. Thirty-seven patients were included in the series from July 1st, 1998 and September 30, 1998. Each patient had a double radiography series: three plain films using the conventional technique (C) and three digitalized screen films (D). The C were taken with a 1/1 ratio on a Philips Diagnost 90 table and developed using the Kodak M6 method using a 36 x 43 cm cassette for the pelvic x-ray and a 24 x 30 cm cassette for the x-ray of the prosthetic hip. The D were made on the Philips Diagnost 90 table and developed with the Agfa ADC70 procedure on a memory screen with a 5 pl/mm spatial resolution for 36 x 43 cm for the pelvic x-ray and 28 x 35 for the prosthetic hip. The same operator performed the complete radiography series in the same patient (C and D). The images were read examining the cement/bone interfaces and the prosthesis/cement interfaces looking for the classical radio-lucent lines in the De Lee and Charnley sectors. The presence and the thickness of the radiolucent line were classed in three groups: no line, line less than 2 mm, line greater than 2 mm. For each patient, the films were placed in anonymous folders and two subgroups were selected at random for the readers (a radiologist and an orthopaedic surgeon) who did not read successively the same films for the same patient. The results were recorded with an Excel data sheet and the statistical analysis was done with the BMDP software.

Results: Thirty-seven patients were included (22 women and 15 men) with 40 THA. Mean age was 64 years (42–86). Mean follow-up of the THA was 25 months (2–248). Four patients had mechanical pain or deceased joint amplitude and 33 patients had no clinical sign. Only one lucent line was found measuring less than 2 mm in the 1st quadrant of the cup and the 3, 4, and 5 zones on the AP view and the 10, 11, 12 zones on the lateral view on the tail of the pros-thesis. In this study, the kappa value was less than 0.5 for the mean concordance according to the Landis and Koch classification. The Kappa was higher for the intermethod analysis irrespective of the reader, than for the interobserver analysis.

Discussion, conclusion: Independent readers of the two types of images (C and D) did not demonstrate any difference for cemented or noncemented prosthesis in a longitudinal study of THA. The reproducibility between the C and D techniques was small. However, our study only analysed a few of the numerous radiographic signs considered to favour loosening (stress shielding, lucent lines etc.…). However, the analysis of the Kappa results demonstrated mean concordance between the techniques better than mean concordance between observers.

Purpose: The purpose of this study was to analyse total shoulder arthroplasty failures and the outcome after simple ablation of the prosthesis or revision with a Grammont inverted prosthesis.

Material and methods: This was a longitudianal prospective study of patients with a failed shoulder prosthesis who underwent either simple ablation of the prosthesis or revision athroplasty with an inverted Grammond prosthesis. Clinical (Constant score) and radiographic analysis was performed before revision and at last follow-up using identical criteria. The shoulder prosthesis was removed in case of failure due to infection. For all other causes of failure, an inverted Grammond prosthesis was implanted.

Results: The series included nine patients (eight women and one man) reoperated between January 1st 1995 and December 31st 1999. Mean follow-up was 47 months (12–108). Delay between the first procedure and revision surgery was 26 months (6–72). The cause of the failure of the first implant was: infection (four patients), dislocation (one patient), three-tendon rotator cuff tears (four cases). The overall Constant score before revision surgery was 18.5 (6–30). Mean Constant score at last follow-up was 40.1 (35–54). Mean gain in pain score was 9.4 points (0–15) and mean gain in hand position was 2.75 points (0–10).

Discussion: Complications after shoulder arthroplasty are not uncommon (14% according to Wirth, 1994) and treatment is difficult (Sperling 1999). Instability, rotator cuff tears, glenoid loosening, and infection are the most frequent causes of failure (Wirth 1994). The patients in this series had a very poor Constant score involving all the subscores, although deterioration of the pain score predominated. The gain, both with ablation and revision total shoulder arthroplasty, was greater than 25 points on the average. This gain was proportional to the initial score before revision and patients who had a revision total shoulder arthroplasty had a better gain (p < 0.001). Simple implant ablation did however improve the mean Constant score among patients with infection whose initial score was lower than the others (p < 0.001). the final outcome was moderate. The only patients who recovered muscle force were those who had a total revision prosthesis (p < 0.05).

Conclusion: Revision of a shoulder prosthesis gives disappointing results in terms of absolute outcome score, even though the gain over the initial functional situation is encouraging. Simple ablation of an implant is still indicated in certain patients, in particular those who have an initial Constant score under 20 points.