Aims

MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation.

Purpose of the study: Completely arthroscopic repair of rotator cuff tears is widely considered as the standard treatment. We reviewed a multicentric retrospective series of patients.

Material and methods: This series of arthroscopic repairs of full-thickness tears of the supraspinatus and infraspinatus were assess with the Constant score together with arthroMRI or arthroscan at one year follow-up at least. Data were analyzed with SPSS10. The series included 576 patients who underwent surgery from January 2001 to June 2003. Mean age was 57.7 years, 52% males and 60% manual laborers. Mean preoperative Constant score was 46.4/100 (r13.4). The tear was limited to the supraspinatus in 69% of patients with extension to the upper third of the infraspinagus for 23.5% and to all tendons for 7.5%. The supraspinatus tear was distal in 41.7% of patients, intermediary for 44%, and retracted for 14.3%. Arthroscopic repair was performed in all cases, with locoregional anesthesia for 60.9%. Implants were resorbable for 33% and metallic for 62.1%. Acromioplasty was performed for 92.7% and capsulotomy for 14.9%.

Results: The mean subjective outcome was scored 8.89/10. The Constant score improved from 46.3±13.4 to 82.7±10.3 with 62% of patients being strictly pain free. The force score improved from 8.5±3.7 to 13.6±5.4. Outcome was excellent or very good for 94% of the shoulders at 18.5 mean follow-up. The rate of complications was 6.2% with 3.1% of patients presenting prolonged joint stiffness, 2.7% reflex dystrophy, 0.2% infection and 0.2% implant migration. The cuff was considered normal in 55.7% of the shoulders with an intratendon addition image for 19%, i.e. 74.7% non-torn cuffs. A point leakage was noted in 9.5% with pronounced leakage in 15.7%, i.e. 25.2% recurrent tears.

Discussion and conclusion: The functional outcome obtained after arthroscopic repair of rotator cuff tears is good. Arthroscopy has the advantage of a low rate of complications yet provides good clinical and anatomic results. Age is correlated with functional outcome and healing, but should not be considered as a contraindication.

Purpose of the study: A statistical analysis of correlations between clinical outcome and anatomic results after arthroscopic repair of rotator cuff tears.

Material and methods: This multicentric series of rotator cuff tears was limited to the supraspinatus and infraspinatus. The statistical analysis searched for correlations between the clinical outcome (Constant score) and anatomic results (arthroscan and arthroMRI). The series included 576 patients, mean age 57.7 years, 52%μ males and 60% manual laborers. The tear was limited to the suprapsinatus in 69% of patients, with extension to the upper third of the infraspinatus in 23.5% and all tendons in 7.5%. The supraspinatus tear was distal in 41.7% of patients, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 59.7%, 1 in 27.1%, 2 in 10.8% and 3 in 2.4%.

Results: The Constant score (46.3 preoperatively and 82.7 postoperatively) was strongly correlated with successful repair. The correlation was found for force, motion, and activity, but not for pain. The clinical outcome was correlated with extension, retraction, cleavage, and degeneration of the preoperative injury. The anatomic result was statistically less favorable for older, more extended, retracted, and cleaved tears or tears associated with fatty degeneration. Age was correlated with the extent of the initial tear and also with less favorable clinical and anatomic results. Work accidents were correlated with less favorable clinical outcome.

Discussion: The large number of anatomic controls with contrast injection facilitated demonstration of several statistically significant correlations. This enabled disclosure in a single series of evidence confirming earlier reports in the literature: repair of cuff tears improves the overall functional outcome for massive tears; the anatomic result depends on the size of the initial tear; pre-operative fatty degeneration is an important prognostic criteria; cuff healing is age-dependent.

Conclusion: Study of anatamoclinical correlations helps guide therapeutic decision making and enables the establishment of reliable prognostic criteria after arthroscopic repair of rotator cuff tears.

Thirty-six patients with anterior cruciate ligament (ACL) insufficiency and varus malalignment were treated with combined ACL reconstruction and medial opening wedge high tibial osteotomy (HTO). Average follow-up was twenty-five months. All patients had improved ligamentous stability and twenty-five patients returned to full activities. Osteotomy union rate was 100%, mechanical axis angle was corrected from six degrees varus to neutral and the mechanical axis deviation was corrected from 2cm medial to 1cm lateral. We experienced four complications, including one deep infection. Combining ACL reconstruction and HTO simultaneously accomplishes a ligamentously stable knee with corrected alignment, allowing patients to return to activity.

To determine clinical outcome after combined ACL reconstruction and medial opening wedge high tibial osteotomy (HTO).

ACL reconstruction with medial opening HTO can be a beneficial procedure in properly selected patients presenting with complaints of both pain and instability. Correction of varus mal-alignment may provide protection for articular cartilage and improve joint stability.

Concomitant medial opening HTO performed at time of ACL reconstruction allows patients to return to activities after one procedure with a ligamentously stable knee, corrected alignment, and potential protection of articular cartilage.

Thirty-six patients who underwent ACL reconstruction along with medial opening HTO were retrospectively evaluated postoperatively at an average of twenty-five months.

Average age was thirty-seven years at time of surgery. All patients were recreationally active. Pre-operatively all patients had knee pain and instability, varus angulation, and twenty-two patients had previous knee surgery. Semitendinosus/gracilis grafts were used in all patients, and osteotomies were fixed with Puddu plates. Postoperatively patients had improved ligmentous stability with radiographic and clinical evidence of osteotomy healing, and all but nine patients have returned to full activities. We experienced four complications: one ACL failure, one case of anterior laxity with tibial tunnel widening, and two infections. On average, MAD was corrected from 22mm medial to 10mm lateral; mechanical axis angle was corrected from 6.4 degrees of varus to 0.2 degrees of valgus; tibial slope was increased from 9.1 degrees to 10.3 degrees, and patellar height ratio was decreased from 0.9 to 0.8.

Purpose: Prosthetic replacement of the ankle joint is a controversial issue. Minimally invasive noncemented third-generation implants with a third component have enabled improved clinical results and prolonged mid-term implant survival. These results authorise prosthetic implantation as an alternative to arthrodesis in selected patients. New developments in prosthesis concepts and design, aimed at overcoming the insufficient results of earlier implants, require early validation with a prospective clinical and radiological follow-up. The objective of this work was to present the mid-term results with the SALTO prosthesis implanted in 42 patients.

Material and methods: Forty-two SALTO prostheses implanted between February 1997 and December 2000 were followed prospectively for two to six years. The implant design, which mimics the anatomic asymmetry of the talar dome, uses a mobile polyethylene insert and optional fibular resurfacing for optimal primary and long-term stabilisation. Data were collected prospectively using a computer database which provides the AOFAS score. Metrological analysis of the digitalized x-rays (AP, lateral and stress) were used to study the precision of the insertion, implant stability, and prosthesis kinematics. Posttraumatic osteoarthritis predominated (n=29) in this series. Mean age was 54 years (30–79).

Results: None of the patients were lost to follow-up. Three patients had a revision procedure for arthrodesis (persistent pain in two and sepsis in one). The clinical score was excellent or good in 88% of patients. The mean clinical score was 20.5 points preoperatively and 70 points at last follow-up. The radiological analysis demonstrated the precision of the insertion technique and did not disclose any evidence of significant implant mobilisation with time. There were no failures related to the lateral malleolar implant (n=12). Radiographically, mean ankle movement was 15.2–23°. Changes in the periprosthetic bone were noted.

Discussion: The quality of the results with the prosthesis under study and the short- and mid-term stability enable envisaging implantation when the local or regional anatomic conditions suggest arthrodesis would produce unsatisfactory results. The improvement in function (exceptionally total recovery) remains difficult to predict. Further follow-up of these patients is needed.

Purpose: Bilateral tears of the ACL are classically described as occurring after a first tear. Few reports have examined the underlying mechanism and the frequency and predisposing morphological factors

Material and methods: We reviewed retrospectively a series of 3722 ACL plasties performed from 1984 to 2001, including 148 patients who underwent bilateral repair. In this group, we detailed the demographic features, the time from tear to repair, the type of sports activity and focused on the radiological measurement of tibial tilt.

Results: The estimated frequency of bilateral tears was 4%. We noted that these bilateral tears were associated with: male predominance (60%), mean age 21 years (±5.5) at first tear, younger age for females, second tear at 24.5±6.5 years, predominant practice of pivot sports without contact (56%), and competition sports. The time between the two tears was 48 months on average. The rate of contralateral tears during the first postoperative year was 16%, it was 60% at three years. The mean tibial tilt was 9.91±2.87° versus 6.8±1.87° in the control population.

Discussion: Our findings were in agreement with the literature for frequency, young age at first tear, particularly for women, short time between the two tears, and type of sports activity. The high rate of contralateral tears during the first year is a significant finding. Hypotheses put forward include loss of confidence in the operated knee leading to more stress on the contralateral knee, but also poorly adapted use of the healthy knee in sports activity. Rehabilitation exercises focusing on bilateral proprioception, respecting sufficient time after the first repair before resuming sports activities, and good control of knee laxity with an ‘anatomic’ plasty appear to be important elements of prevention. The favouring role of a narrow intercondylar notch has been established in the literature. We found that tibial tilt should also be taken into consideration.

Conclusion: Careful search for predisposing factors is important because of the frequency of bilateral tears of the ACL. The rehabilitation program should be well adapted and the patient should be informed of the risk. These measures should help decrease the incidence of this relatively frequent complication.

Purpose: Cyclope syndrome is a complication which occurs after ligamentoplasty of the anterior cruciate ligament. It is characterised by permanent flexion which may or not be associated with anterior pain, cracking or hydroarthrosis, typically during exercise. The diagnosis is confirmed by MRI. Arthroscopic treatment is indicated for resection of the nodule and as needed bone plasty of the notch if permanent flexion persists. In the literature, short-term results have been disappointing. We wanted to know more about the long-term outcome.

Material and methods: From January 1992 to December 1994, 835 patients underwent bone-tension plasty. Thirty-six underwent secondary surgery for cyclope syndrome (4.3%). Mean age at revision procedure was 26.2 years (16–43). Most of the subjects were athletes. Twenty-three patients (63.9%) were seen at follow-up consultation and 16.7% responded to a telephone interview. Mean time to review was nine years (8–10 years). We used the IKDC 1999 chart for subjective assessment and clinical evaluation and measured laxity with KT1000. We also studied changes in symptoms related to cyclope syndrome.

Results: We had two cases of recurrent tears (6.9%). The mean final subjective IKDC score was 81.6 points. Half of the patients had good outcome (> 82 points) and half had disappointing results (scored 50–80 points). The final objective IKDC scoring was: A=17.4%, B=65.2%, C=8.7%, D=8.7%. Thirteen patients had persistent signs of cyclope syndrome (44.8%). Fourteen still had limited joint motion (48.3%). Fifteen reduced their physical activity level (51.7%).

Discussion: The origin of the cyclope syndrome remains controversial. It is difficult to assess the risk of recurrent tear due to the small size of the population and the long time to review in this series.

Conclusion: Cyclope syndrome does not appear to be a factor of risk of laxity but is a non-negligible factor of morbidity, even ten years later. It appears to be important to operate early in order to avoid the spiral of chronic suffering. The postoperative flexion, which had been advocated in the past, does not appear to be useful.