Purpose of the study: It is currently accepted (particularly since the work by Katz et al.) that a number of factors can potentially influence the functional outcome obtained after surgical treatment of lumbar canal stenosis (LCS). Among these factors are comorbid conditions and the notion of perceived health appear to be predominant. Little work has however been focused on the influence of these same factors on the qualitative and quantitative expression of functional impairment expressed by patients before their treatment. This possible link might have an intrinsic impact on the assessment of the outcome obtained after medical or surgical treatment of LCS. We wanted to examine this question.

Material and methods: Two hundred twenty patients referred to our orthopaedic surgery consultations were included in this prospective observation study, irrespective of the type f treatment eventually proposed (medical or surgical) or the type of lumbar stenosis. Patients who had had prior spinal surgery and those treated for LCS due to spinal deformity were excluded. The degree of the functional symptoms was determined with the SF36 and a self-administered questionnaire specifically designed and validated for the evaluation of LCS. Comorbidity factors were studied individually and with the following scores: the ASA score, the FCI (Functional Comorbidity Index), the CIRS (Cumulative Illness Rating Scale, and the ICED (Index of co-existent Diseases). Univariate and multivariate analysis was used to search for correlations between expressed functional impairment and comorbid factors.

Results: Expression of a functional impairment was significantly associated with a high number of comorbidity factors. This correlation was tighter when there was no additional compressive discal factor and when the functional neurological symptoms were longstanding. The type of comorbid factor analysed did not have an impact on these results

Conclusion: The presence of comorbid factors is significantly associated with more severe expression of functional impairment related to LCS. This effect could also influence the functional outcome after treatment of LCS and should be taken into consideration.

Purpose of the study: Although the iliac autograft is the gold standard for single-level intervertebral fusion, complications and morbidity related to autologous graft harvesting from the iliac crest remain a point of concern. Bone morphogenic protein (BMP) has proven advantages for fusion of the intersomatic and posterolateral graft. This study compared the efficacy and tolerance of OP-1 compared with an autologous graft in patients with symptomatic spondylolisthesis. This study reports the preliminary results of a prospective randomised controlled trial comparing OP-1 with an iliac autologous graft for instrumented single-level posterolateral fusion for arthrodesis of grade 1 spondylolisthesis.

Material and methods: Lamino-arthrectomy associated with a posteriolateral instrumented arthrodesis with an iliac autologous graft or a mixture of OP-1 and local autologous graft material was performed in 27 patients with spondylolisthesis leading to lumboradiculalgia or neurogenic claudication. The final outcome was time to fusion at one year on the scanner and plain x-rays. The Oswestry score and pain at the harvesting site as well as side effects were also noted.

Results: The cohort included 27 patients. Three were excluded from the analysis, leaving 24 patients assessed at one year. The demographic data were comparable for the two groups regarding mean age (64 years versus 69 years for the OP-1 group). At one year, ten radiographically certain fusions were noted in the control group and eight in the OP-1 group. Two nonunions and one doubtful fusion were noted in the control group compared with three doubtful fusions in the OP-1 group. The mean Oswestry score was comparable in the two groups. The mean score in the control group improved from 49.5 to 28.5 compared with 45.9 to 29.7 in the OP-1 group. There was no secondary effect attributable to use of OP-1. There were no cases of systemic toxicity, nor heterotopic calcification or restenosis for the 11 patients in the OP-1 group.

Conclusion: A fusion rate of 73% without secondary effects attributable to OP-1 was observed in this preliminary study. This study allows the conclusion that this technique is reliable, safe and, in terms of fusion, a valid alternative to autologous iliac crest graft. The main advantage resulting from the use of OP-1 is to avoid the morbidity linked with harvesting the iliac graft.

Generally, the sacroiliac joint is not considered accessible for arthroscopy under physiological conditions. The non-injured joint is not large enough for introduction of even the smallest arthroscope into the joint space. After traumatic injury however, or in the event of an inflammatory condition or tumour formation, it is theoretically possible to position an endoscope in the joint space. Study of the anatomy of the sacroiliac joint and knowledge of the anatomic relations, particularly the vascular and nervous relations, is a prerequisite for arthroscopic exploration of the sacroiliac joint space. The posterior approach must account for the bone configuration of the iliac wing and the orientation of the sacroiliac joint line. A cadaver study confirmed the feasibility of endoscopic exploration of the sacroiliac joint via a posterior percutaneous access. Based on this anatomic experience, we positioned an arthroscope in an injured sacroiliac joint and report the different phases. A technique for obtaining a biopsy of the anterior aspect under endoscopic control has already been described, but to our knowledge, there is no arthroscopic description of the sacroiliac joint via a posterior access. Indications for arthroscopy of the sacroiliac joint remain very limited. This technique can be used to remove osteocartilaginous fragments or foreign bodies incarcerated in the joint and to obtain biopsy material, drain collections and, in the near future, should allow avivement of the cartilage surfaces with the objective of a percutaneous arthrodesis.

Purpose of the study: The objectives of this study were to measure tension force usually applied to the transplant and analyze its impact on postoperative laxity and joint mobility.

Material and methods: This was a prospective consecutive study. Inclusion criteria were: isolated tear of the anterior cruciate ligament (ACL) more than three months earlier, healthy contralateral knee, radiological anterior drawer measurements (Telos 20 kg) both pre and postoperatively, follow-up greater than six months. ACL reconstruction was achieved with a free bone-tendon-bone patellar transplant using the blind technique. A dynometer was used to measure the traction force applied by the operator using the «usual» method for the tibial fixation. The force applied (2, 4, 6, 9, or 11 kg) was recorded by the assistant and was maintained constant while screwing. Variables studied were: tension force applied to the transplant by four different operators, mobility of the two knees, differential laxity pre and postoperatively (L0 and L1) and relative gain in laxity (real gain/ideal gain).

Results: The study included 22 patients, mean age 26 years. Mean tension force applied was 7.68 kg and varied from 7.3 to 8.1 for each operator. Mean extension and flexion deficit compared with the healthy side was 1.6° and 3° respectively. There was no correlation between loss of mobility and tension applied. Mean laxities (L0 and L1) were 9.2 and 5.4 mm respectively. Mean minimal differential laxity (< 5 mm) was obtained for tension forces of 4 to 6 kg. There was no correlation between tension and L1. The relative gain was greater in the knees with tension at 6 kg. But there was no correlation between these two variables.

Discussion: This study provides the only available data on tension forces applied in routine practice. This tension does not appear to have an impact on the final joint mobility. It would appear however tht laxity would be minimal for tension forces to the order of 7 kg. These data are in agreement with reported in the literature were it is recommended to apply tension to the order of 1.5 to 7 kg.

Conclusion: It would not appear that measuring the force applied to the implant during the tibial fixation provides useful information for routine practice. The force applied in routine practice appears to give the best gain in stability without limiting joint mobility.

Purpose: The vast majority of forefoot infectious in neuropathy patients are plantar ulcers in diabetics. When conservative treatment is unsuccessful, radical treatment may be indicated, but correct choice of the amputation level is essential. The purpose of this work was to evaluate outcome after tibiocalcaneal arthrodesis achieved with an Ilizarof fixator.

Material and methods: The procedure was performed in nine patients between 1991 and 2002. Male gender predominated (seven men). Mean age was 65 years. Eight patients had diabetes and seven of them had complicated mal perforant. Two patients had bilateral involvement so a total of eleven arthrodeses were performed. The procedure began with de-articulation of the Chopard space and talectomy. After high section of the lateral maleolus, the tibia was cut flush with the joint. The calcaneal cut was vertical passing just behind the tarsal sinus. After verticalising the calcaneum, the two cut surfaces were joined. Arthrodesis was maintained with a circular Ilizarof fixator using two rings on the tibia and one on the calcaneum.

Results: At mean 20 months, we reviewed ten arthrodeses. Good results were obtained for seven and failure was observed in three (necrosis = 2 and severe suppuration = 1). All these problems resolved and fusion was achieved at five months on average. The type of diabetes, renal failure, duration of the infection, presence of severe contralateral lesions, and type of germ involved appeared to affect outcome.

Discussion: Alternatives to the Pirogoff procedure include Chopard amputation, with or without subtalar arthrodesis, and Syme amputation. The technique used in this cohort offers several advantages. The circular external fixator avoids the classic cross screwing in an infectious setting. The mechanical properties of the Ilizarof fixator favour healing and bone fusion. Finally, vericalisation of the calcaneum produces a longer stump so excessively anterior cicatrisation, which can be bothersome for the orthesis, is avoided

Conclusion: This surgical technique provides a radical treatment for proximal osteoarticular infections of the forefoot, often observed in diabetics. Indications are exceptional and should be reserved for lesions which are inaccessible to transmetatarsal amputation. The arthrodesis cannot be achieved without healthy talar stock. The procedure produces a long stable stump which is painless and easy to fit.