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Resume Introduction Le conflit femoro-acetabulaire (CFA) est une cause frequente de douleur inguinale. Son traitement a un taux d’echec entre 2,9 % et 13,2 %. L’objectif de notre etude etait d’etudier l’influence des deformations osseuses (DO), lesions labrales (LL) et cartilagineuses (LC) preoperatoires sur les resultats cliniques de patients ayant beneficie d’un traitement arthroscopique du CFA. Materiel et methode Une etude prospective operationnelle a inclus des patients operes d’une arthroscopie de hanche pour CFA. Les patients avaient un bilan radiographique complet en preoperatoire et a un an ainsi qu’un score de NAHS pour l’evaluation clinique. Les hanches > Tonnis 1, les coxa profunda (VCE > 35) et les dysplasies limites (VCE Resultats Cent quatre vingt dix sept patients ont ete inclus. Le score NAHS moyen preoperatoire etait de 59,1 ± 17.5.145 patients ont beneficie d’une suture labrale (73,6 %), 42 d’une resection labrale (21,3 %) et 10 d’un traitement conservateur (5,1 %). Au recul d’un an, le NAHS moyen etait de 88.1 ± 15,3. L’amelioration etait significative (p Conclusion Notre etude a montre que le resultat fonctionnel precoce du traitement arthroscopique des CFA n’etait pas influence par l’importance de la deformation osseuse (angle alpha et VCE), par l’extension ou le type de lesion labrale, ainsi que par le type ou l’extension de cette lesion chondrale. Dans notre etude, quelles que soient les DO, LL et LC, l’evolution clinique a un an est satisfaisante si l’ensemble des anomalies osseuses est pris en compte lors du traitement arthroscopique. Niveau de preuve IV ; etude prospective non comparee

Resume Il est indispensable de connaitre l’anatomie et la biomecanique du labrum acetabulaire pour comprendre qu’il faut s’efforcer de le preserver. Sa vascularisation provient de la capsule et aussi de l’os. Sa face articulaire contient de nombreuses terminaisons nerveuses qui expliquent que les lesions labrales soient douloureuses. Il participe a la stabilisation de l’articulation par le maintien d’un vide intra-articulaire, capable de resister a une force de distraction. C’est un joint d’etancheite. Il existe deux principales techniques de suture, trans- et perilabrale. La technique translabrale est mieux adaptee en cas de labrum large, solide et depourvu de lesions degeneratives. Il faut connaitre les deux, que l’on associe parfois. Leurs resultats sont comparables. Le traitement de la pathologie sous-jacente, a l’origine de la lesion labrale est primordial. La degenerescence articulaire est de mauvais pronostic. Elle doit etre reconnue et discutee avec le patient pour eviter des attentes qui seraient decues.

Resume Introduction L’arthroscopie de hanche s’est imposee comme un moyen de traitement efficace des lesions labrales associees au conflit femoro-acetabulaire. Objectif Rapporter l’influence des techniques de debridement et de reparation sur les resultats fonctionnels a 2 ans de recul et evaluer l’influence de la technique de reparation. Hypothese Il n’y a pas de difference significative dans les resultats fonctionnels a court terme suite a un debridement ou une reparation labrale. Le type de suture n’a pas d’influence sur les resultats fonctionnels a court terme. Methodes De juillet 2017 a juin 2018, les donnees de dix centres specialises en chirurgie conservatrice de la hanche ont ete recueillies. Tous les patients de plus 18 ans ayant beneficie d’une arthroscopie de hanche pour lesion labrale sur conflit femoro-acetabulaire ont ete inclus. Il s’agissait soit d’un debridement, soit d’une reparation labrale. Les reparations labrales etaient realisees suture translabrale ou perilabrale. Le score fonctionnel d’evaluation etait le Non Arthritic Hip Score (NAHS). Results Au total, 187 patients ont beneficie d’une arthroscopie de hanche pour lesion labrale sur conflit femoro-acetabulaire, 42 (22,5 %) ont beneficie d’un debridement et 145 (77,5 %) ont beneficie d’une reparation. Dans le groupe reparation, 66 (45,8 %) etaient translabrales et 79 (54,2 %) etaient perilabrales. La moyenne d’âge etait de 33,3 ± 10,3 (18–63), dont 37,6 % (71) de femmes. Le suivi moyen etait de 16,2 mois (10–26,4). Le NAHS moyen s’est ameliore de 47,3a 72,8 (p 0,05). Il n’y avait pas de difference significative entre les groupes reparations translabrale et perilabrale (p > 0,05). Conclusions Il n’y a pas de difference significative dans les resultats fonctionnels a court terme apres reparation labrale ou debridement. Le type de suture labrale n’influence pas les resultats fonctionnels a court terme. Niveau d’etude II, cohorte prospective.

Hip dysplasia and femoroacetabular impingement are pathologies whose impact on the function and survival of the hip joint is no longer debated. Labral tears may be present and impact the prognosis of the causal pathology. Labral tear management lacks consensus and still raises several questions, thus we conducted a systematic analysis to clarify: 1) What is its prevalence in hip dysplasia and femoroacetabular impingement? 2) Does it modify the symptomatology of the causal pathology? 3) Is its repair better than resection or abstention?A systematic literature review was carried out following the PRISMA guidelines, using the Medline and Embase databases and including all articles in French or English, written until June 2022 referring to labral tears in hip dysplasia and femoroacetabular impingement. The articles were analyzed by 2 surgeons in order to select them according to a predefined algorithm. 1) Articles were selected by title from the search results. 2) A selection based on the abstract was then made. 3) A final selection was made upon complete reading. 4) In the event of a discrepancy during the selection, a third co-author was contacted for a final decision. 5) Data extraction was then carried out by the two readers using a preformatted sheet.Of the 1177 articles identified, 43 articles were kept for the final analysis. The prevalence of labral tears was on average 78.80±4.7% [17 to 100%] in dysplasia and 93.8±16.8% [33% to 100%] in impingement. The review did not reveal any symptomatology specific to the labral tear. In dysplasia, 5 comparative studies were analyzed. A single study on shelf arthroplasties demonstrated the negative impact of a labral tear in the event of resection on survival compared to no tear (83% versus 15.2% (p = 0.048)). Regarding impingements, 8 comparative studies were analyzed. At 7 years of follow-up, only one study found a significant and clinically relevant functional gain in terms of MCID (minimal clinically important difference) for labral repair compared to debridement on the mHHS score (p = 0.008), SF-12 score (p = 0.012), and pain scale (p = 0.002). One study showed superiority of repair over labral debridement in terms of 10-year survival (78% 95% CI [64-92%] vs 46% 95% CI [26-66%] (p = 0.009)).The literature analysis was heterogeneous with a few comparative studies and predominantly short periods of follow-up. Understanding labral pathology and its impact requires differentiating between the different tear categories and proposing treatment to restore or preserve the biomechanical properties of the joint.IV, Systematic Review of Level 1-4 Evidence.

International audience; Coxa profunda is a complex entity that can result in femoro-acetabular impingement (FAI). A meticulous evaluation of the type of acetabular overcoverage is essential to determine which treatment is best suited to each individual patient. Focal overcoverage with no posterior impingement can be treated by arthro-scopic recontouring of the disproportionate acetabular wall. Any femoral deformities should be managed during the same procedure. General overcoverage, with predominant postero-inferior impingement, requires open surgery to obtain access to the entire acetabular rim. Rim resection should be sparing, to avoid removing an excessive proportion of the joint surface, yet sufficient to eliminate the impingement. In the event of protrusio acetabuli, which is the extreme form of coxa profunda, reverse peri-acetabular osteotomy should be considered, particularly if the acetabular roof angle is reversed. In some patients, chiefly those with coxa vara, valgus femoral osteotomy should be considered as a means of redirecting the loads towards the acetabular roof, thereby diminishing the forces that tend to drive the femoral head deeper into the socket.

Resume La coxa profunda est une entite complexe pouvant entrainer un conflit femoro-acetabulaire. Une analyse meticuleuse du type de surcouverture acetabulaire est essentielle pour pouvoir proposer le traitement adequat au patient : en cas de surcouverture focale, sans conflit posterieur, un recontourage arthroscopique de la paroi excessive peut etre effectue. Bien entendu, les eventuelles deformations femorales devront egalement etre considerees en meme temps. En cas de surcouverture globale, principalement avec un conflit postero-inferieur, un traitement chirurgical ouvert sera necessaire, donnant acces a la circonference complete du cotyle. La resection du bord acetabulaire doit etre effectuee parcimonieusement afin d’eviter d’enlever trop de surface articulaire, mais neanmoins suffisamment pour traiter le conflit adequatement. En cas de protrusion, cas extreme de coxa profunda, la realisation d’une osteotomie periacetabulaire inverse devra etre envisagee, principalement si l’angulation du toit du cotyle est inversee. Parfois, en cas de coxa vara principalement, une osteotomie femorale de valgisation devra etre discutee afin d’orienter la charge plus en direction du toit du cotyle et ainsi diminuer les contraintes visant a approfondir la tete femorale dans l’articulation.

Introduction: The anatomy of the proximal femur at the time of total hip arthroplasty has been widely studied but the horizontal plane was never considered, or only limited to the torsion of the femoral neck. Methods: Using CT-scan images from a group of 178 patients scheduled for cementless total hip arthroplasty (THA), we analysed the evolution of the torsion of the proximal femoral metaphysis, in reference to the posterior bicondylar plane of the femur. The evolution of the torsion, between 20 mm below the centre of the lesser trochanter and 20 mm above, was evaluated. Results: In cases of primary osteoarthritis, osteonecrosis, rheumatoid arthritis and epiphysiolysis capitis femoris, the mean torsion decreased from 46° to 20° without significant differences in average values between the different diagnoses, but important individual variations were found. In the groups of dysplasia and congenital hip dislocation, the torsion values were significantly higher, decreasing in mean from 59° to 25° and 63° to 34° respectively, and with important individual variations. Conclusions: These data are important when using cementless femoral stems, since an ideal fit-and-fill in the proximal femur zone has been shown to positively influence bone ingrowth of the stem. However, a strict adaptation of the stem to the medullary canal, without considering its torsion, can lead to an increased or decreased torsion of the prosthesis neck and thus to an instability of the arthroplasty. For these reasons, if a perfect adaptation of the stem to the intramedullary anatomy and an optimal reconstruction of the extramedullary anatomy are to be achieved, 3-dimensional planning should ideally be obtained for every patient. This will allow the best stem choice adapted to every single patient and every kind of anatomy.

It is essential to be aware of the anatomy and biomechanics of the acetabular labrum in order to understand why it should be conserved. Vascularization comes from the capsule and also from the bone. The joint side contains numerous nerve endings, which explains why labral lesions are painful. It is involved in joint stabilization by maintaining a negative pressure inside the joint able to resist distraction. It acts as a seal. There are two main suture techniques: trans- and peri-labral. Translabral suture is better suited to a wide and solid labrum free of degenerative lesions. Both techniques should be known, and may be associated. Results are comparable. It is essential to manage the underlying pathology responsible for the labral lesion. Joint degeneration is associated with poor prognosis. It needs to be recognized and discussed with the patient, to avoid unrealistic expectations.

Place: France; International audience; INTRODUCTION: Femoroacetabular impingement (FAI) is a frequent cause of inguinal pain. Treatment failure rates range between 2.9% and 13.2%. The aim of the present study was to assess the impact of preoperative bone deformities (BD), labral lesions (LL) and cartilage lesions (CL) on clinical results of arthroscopic treatment of FAI. MATERIAL AND METHOD: A prospective operational study included patients undergoing hip arthroscopy for FAI. All patients had full radiographic work-up and clinical assessment on Non-Arthritic Hip Score (NAHS), preoperatively and at 1year. Hips with Tönnis grade\textgreater1, coxa profunda [VCE (vertical center edge angle)\textgreater35°] or borderline dysplasia (VCE\textless25°) were excluded. The Czerny classification was used for the labrum and the Beck classification for the cartilage. The aim of the study was to assess the impact of preoperative BD, LL and CL on clinical results of arthroscopic treatment of FAI. The study hypothesis was that type of lesion does not influence early functional results at 1year, whatever the technique used for the labrum. RESULTS: One hundred and ninety-seven patients were included. Mean preoperative NAHS was 59.1±17.5. There were 145 patients with labral suture (73.6%), 42 with labral debridement (21.3%) and 10 with conservative treatment (5.1%). At 1year, mean NAHS was 88.1±15.3: i.e., a significant improvement (p\textless2.2×10(-16)). Improvement was also significant in the debridement, non-operative and suture subgroups. BD showed significant correction in the overall population (alpha angle 48.2° postoperatively versus 66.7° preoperatively; crossing sign in 14.5% versus 62.9% of cases). There were no significant differences in functional scores according to extension or type of labral or cartilage lesion. At follow-up, 3 patients (1.5%) required repeat arthroscopy. CONCLUSION: The present study showed that early functional results of arthroscopic treatment of FAI were unaffected by the severity of bone deformity (alpha and VCE angles), or extension or type of labral or cartilage lesion. Regardless of BD, LL and CL, 1-year clinical progression was satisfactory when all bone deformities were treated by the arthroscopic procedure. LEVEL OF EVIDENCE: IV; prospective non-comparative study.

Resume Introduction Le conflit cupule-psoas est une cause de douleurs anterieures apres prothese totale de hanche (PTH). Sa prise en charge peut etre conservatrice, endo/arthroscopique ou chirurgicale par revision acetabulaire. Peu d’etudes evaluent ces differents traitements. Notre hypothese etait que la technique endo/arthroscopique permet une resolution rapide de la symptomatologie douloureuse du conflit cupule-psoas, avec un faible taux de complications. Methodes Cette etude prospective, multicentrique incluait 64 tenotomies endoscopiques ou arthroscopique pour conflit cupule-psoas sur 8 centres. Le suivi moyen etait de 8 mois, avec un suivi minimum de 6 mois, sans perdu de vue. Le score d’Oxford, l’indice de satisfaction des patients, la douleur anterieure et la force musculaire de l’iliopsoas etaient evalues au dernier recul. Les complications ou reprises chirurgicales etaient colligees. Parmi, 44 % des patients ont recu une reeducation postoperatoire. Resultats Au dernier recul, 92 % des patients etaient ameliores pour la douleur. Le score Oxford, la force musculaire et la douleur en flexion de hanche etaient ameliores significativement. Le taux de complications etait de 3,2 %, avec une resolution totale. Le sejour moyen etait de 0,8 nuits. Pour deux patients l’arthroscopie a permis de diagnostiquer une metallose et d’orienter vers une reprise acetabulaire. Seule la presence du debord radiologique de cupule sur le profil est predictive du resultat. La reeducation a permis une recuperation significativement plus importante de la force musculaire. Conclusion La tenotomie endo/arthroscopique pour conflit cupule-psoas sur PTH permet de diminuer significativement les douleurs anterieures dans plus de 92 % des cas. Le risque minime de complications en fait le premier choix therapeutique a considerer, apres traitement conservateur. L’arthroscopie permet egalement de reajuster le diagnostic en cas de pathologie articulaire associee. Un debord sur la radiographie de profil preoperatoire est le critere le plus predictif du resultat, et guidera la prise en charge.

Introduction Impingement between the acetabular component and the iliopsoas tendon is a cause of anterior pain after total hip replacement (THR). Treatment can be non-operative, endoscopic or arthroscopic, or by open revision of the acetabular component. Few studies have assessed these options. The present study hypothesis was that endo/arthroscopic treatment provides rapid pain relief with a low rate of complications. Methods A prospective multicenter study included 64 endoscopic or arthroscopic tenotomies for impingement between the acetabular component and the iliopsoas tendon, performed in 8 centers. Mean follow-up was 8 months, with a minimum of 6 months and no loss to follow-up. Oxford score, patient satisfaction, anterior pain and iliopsoas strength were assessed at last follow-up. Complications and revision procedures were collated. Forty-four percent of patients underwent rehabilitation. Results At last follow-up, 92% of patients reported pain alleviation. Oxford score, muscle strength and pain in hip flexion showed significant improvement. The complications rate was 3.2%, with complete resolution. Mean hospital stay was 0.8 nights. In 2 cases, arthroscopy revealed metallosis, indicating revision of the acetabular component. The only predictive factor was acetabular projection on oblique view. Rehabilitation significantly improved muscle strength. Conclusion Endoscopic or arthroscopic tenotomy for impingement between the acetabular component and the iliopsoas tendon following THR significantly alleviated anterior pain in more than 92% of cases. The low complications rate makes this the treatment of choice in case of failure of non-operative management. Arthroscopy also reorients diagnosis in case of associated joint pathology. Projection of the acetabular component on preoperative oblique view is the most predictive criterion, guiding treatment.

True retroversion of the acetabulum, defined as positive cross-over sign, positive posterior wall sign, and positive ischiatic spine sign, is one possible etiology of femoroacetabular impingement. Several treatments have been proposed, going from rim trimming to reorientation of the acetabulum. The choice of treatment is critical for long-term survival of the joint. Radiological diagnosis of retroversion, indications, and surgical technique of reverse periacetabular osteotomy and simultaneous femoral offset correction are presented.

Sternoclavicular dislocations represent a rare injury. Based on our clinical experience with a patient showing an anterior subluxation after reduction of a posterior traumatic dislocation, we review the literature. The emergent reduction of the dislocation is mandatory, always keeping in mind the potentially devastating neurovascular complications. If the treatment of a residual anterior instability remains controversial, a residual posterior instability should be treated by a surgical procedure. The optimal treatment depends mainly on each surgeon's choice and practice.

Painful total hip replacement remains a challenging problem because of the large amount of possible diagnoses. We report about a 64-year-old female patient who was misdiagnosed during 4 years as psychiatric. She suffered of excruciating left retrotrochanteric pain after the implantation of a cementless total hip replacement and revision because of recurrent hip dislocations. Walking was limited to short distances using two crutches. The work-up at this time included the usual diagnoses and remained unsuccessful. No loosening, infection or malposition of the prosthesis could be found, and she had no neurologic deficits in her operated leg. An MRI was obtained to visualize the retrotrochanteric soft tissues and showed a tight scar surrounding the sciatic nerve, which was also compressed by an adjacent lipoma. Therefore, she was reoperated on to remove the lipoma and the scar tissue around the sciatic nerve. To decrease the risk of recurrent scarring around the sciatic nerve, an adhesion barrier was applied before closure. One year after the operation, the patient has no neurologic deficit, no more pain and is able to walk unlimited distances without crutches. Scar tissue around the sciatic nerve is frequently observed during revision surgery. However, we feel that sciatic nerve entrapment by scar tissue should be a part of the differential diagnosis of painful THR. MRI may be a useful tool to achieve this diagnosis.

The purpose of this study was to determine the impact of axial traction during acquisition of direct magnetic resonance (MR) arthrography examination of the knee in terms of joint space width and amount of contrast material between the cartilage surfaces. Direct knee MR arthrography was performed in 11 patients on a 3-T MR imaging unit using a T1-weighted isotropic gradient echo sequence in a coronal plane with and without axial traction of 15 kg. Joint space widths were measured at the level of the medial and the lateral femorotibial joint with and without traction. The amount of contrast material in the medial and lateral femorotibial joint was assessed independently by two musculoskeletal radiologists in a semiquantitative manner using three grades ('absence of surface visualization, 'partial surface visualization or 'complete surface visualization'). With traction, joint space width increased significantly at the lateral femorotibial compartment (mean = 0.55 mm, p = 0.0105) and at the medial femorotibial compartment (mean = 0.4 mm, p = 0.0124). There was a trend towards an increased amount of contrast material in the femorotibial compartment with axial traction. Direct MR arthrography of the knee with axial traction showed a slight and significant increase of the width of the femorotibial compartment with a trend towards more contrast material between the articular cartilage surfaces.

Introduction: There is a trend towards surgical treatment of acute ruptured Achilles tendon. While classical open surgical procedures have been shown to restore good functional capacity, they are potentially associated with significant complications like wound infection and paresthesia. Modern mini-invasive surgical techniques significantly reduce these complications and are also associated with good functional results so that they can be considered as the surgical treatment of choice. Nevertheless, there is still a need for conservative alternative and recent studies report good results with conservative treatment in rigid casts or braces. Patients/method: We report the use of a dynamic ankle brace in the conservative treatment of Achilles tendon rupture in a prospective non-randomised study of 57 consecutive patients. Patients were evaluated at an average follow-up time of 5years using the modified Leppilahti Ankle Score, and the first 30 patients additionally underwent a clinical examination and muscular testing with a Cybex isokinetic dynamometer at 6 and 12months. Results: We found good and excellent results in most cases. We observed five complete re-ruptures, almost exclusively in case of poor patient's compliance, two partial re-ruptures and one deep venous thrombosis complicated by pulmonary embolism. Conclusion: Although prospective comparison with other modern treatment options is still required, the functional outcome after early ankle mobilisation in a dynamic cast is good enough to ethically propose this method as an alternative to surgical treatment

Between January 1996 and July 2003, 93 consecutive patients operated on with a diagnosis of olecranon fractures were identified from our trauma unit files. Fourteen transolecranon fracture-dislocations were found after a retrospective X-radiographic evaluation. Eight patients were women and six were men, with a mean age of 54 years. There were 4 noncomminuted olecranon fractures, treated with K-wires and single tension-band wiring. The remaining 10 fractures were complex fractures, treated in 3 cases with multiple K-wires and single tension-band wiring, in 2 by use of one-third tubular plates, in 1 with a 3.5-mm dynamic compression plate, and in the remaining 4 with 3.5-mm reconstruction plates. Ligament repair was not performed in any case. Three patients needed reoperation because of early failure of primary fixation. Patients were reviewed at a mean follow-up of 3.6 years. Two reported difficulties in daily activities, none with any symptoms of elbow instability. According to the Broberg and Morrey score, 4 patients had excellent results, 6 had good results, 2 had fair results, and 2 had poor results. Four patients showed signs of degenerative arthritis on the radiographs obtained at follow-up. We conclude that transolecranon fracture-dislocation is an underreported and misdiagnosed injury. Various fixation techniques can restore the anatomic relationships and contour of the trochlear notch; the imperative goal is to obtain a good stable primary fixation and allow early active mobilization.

International audience; Introduction: Periprosthetic femur fracture (PFF) is a serious complication after total hip arthroplasty that can be treated using different internal fixation devices. However, the outcomes with curved non-locking plates with eccentric holes in this indication have not been reported previously. The objectives of this study were to determine: (1) the union rate; (2) the complication rate; (3) autonomy in a group of patients with a Vancouver type B PFF who were treated with this plate. Hypothesis: Use of this plate results in a high union rate with minimal mechanical complications. Materials and methods: Forty-three patients with a mean age of 79 years +/- 13 (41-98) who had undergone fixation of Vancouver type B PFF with this plate between 2002 and 2007 were included in the study. The time to union and Parker Mobility Score were evaluated. The revision-free survival (all causes) was calculated using Kaplan-Meier analysis. The average follow-up was 42 months +/- 20 (16-90). Results: Union was obtained in all patients in a mean of 2.4 months +/- 0.6 (2-4). One patient had varus malunion of the femur. The Parker Mobility Score decreased from 5.93 +/- 1.94 (2-9) to 4.93 +/- 1.8 (1-9) (P=0.01). Two patients required a surgical revision: one for an infection after 4.5 years and one for stem loosening. The survival of the femoral stem 5 years after fracture fixation was 83.3% +/- 12.6%. Conclusion: Use of a curved plate with eccentric holes for treating type B PFF led to a high union rate and a low number of fixation-related complications. However, PFF remains a serious complication of hip arthroplasty that is accompanied by high morbidity and mortality rates. (C) 2015 Elsevier Masson SAS. All rights reserved.

Purpose To report the middle term results of partial coccygectomy in a consecutive series of 15 patients with chronic coccygodynia. Methods Fifteen patients with chronic coccygodynia were referred to our outpatient clinics. The patients were investigated with dynamic lateral radiography and magnetic resonance imaging (MRI). We diagnosed a posttraumatic coccygodynia with instability of the coccygeal segment and performed a partial coccygectomy after failure of the conservative treatment. Results All patients underwent subjective and objective assessment after a mean time of 2.8 years from surgery. There were 11 excellent, 3 good, and 1 fair results. The mean time of improvement was 15 weeks, and no further improvement was observed after 6 months. Conclusion Partial coccygectomy is a good therapeutic option for posttraumatic coccygodynia. Dynamic radiography is a useful tool to differentiate posttraumatic from idiopathic coccygodynia. MRI may be useful for further evaluation of the patients after inconclusive dynamic radiography.

Objective: To evaluate the results of closed and open grade I and II tibial shaft fractures treated by reamed nail and unreamed nailing. Subjects and Methods: Between 1997 and 2000, 119 patients with tibial shaft fractures were treated with reamed tibial nails. Postoperatively 96 patients (70 closed and 26 grade I and II open fractures) were followed clinically and radiologically for up to 18 months. The nail was inserted either by patellar tendon splitting or by nonsplitting technique. The nail was inserted after overreaming by 1.5 mm. Postoperatively, patients with isolated tibial fracture were mobilized by permitting partial weight bearing on the injured leg for 6 weeks. Patients with associated ankle fractures were allowed to walk with a Sarmiento cast. Results: Postoperatively, 6 (6.3%) patients developed a compartment syndrome after surgery. In 48 (50%) cases, dynamization of the nail was carried out after a mean period of 12 weeks for delayed union. Overall, a 90.6% union was obtained at a mean of 24 weeks without difference between closed or open fractures. Two (2.1%) patients with an open grade II fracture developed a deep infection requiring treatment. A 9.4% rate of malunion was observed. Eight (8.3%) patients developed screw failure without clinical consequences. At the last follow-up, 52% of patients with patellar tendon splitting had anterior knee pain, compared to those (14%) who did not have tendon splitting. Conclusion: Reamed intramedullary nail is a suitable implant in treating closed as well as grade I and II open tibial shaft fractures.

Objective: To present four cases of tuberculosis of the greater trochanter. Case Presentation and Intervention: The four cases (3 females and 1 male), aged 45–70 years, presented with mechanical pain in the trochanteric area associated with progressive swelling in the 3 female patients in whom mobility was also restricted. X-ray revealed a mass in 2 females; CT scan and MRI exhibited an abscess in the 3 females. Histological and bacteriological examinations showed Mycobacterium bovis in the 3 females and M. tuberculosis in the male. In the females, tritherapy and surgery were performed, while in the male quadritherapy and surgery. All the patients recovered and were followed up for 4–9 years. Conclusion: These cases show that both chemotherapy and surgery must be synergic if tuberculosis is diagnosed and an abscess is confirmed by imaging.

Arthroscopy of the peripheral compartment has contributed to a better understanding of the functional anatomy and pathologic conditions of the hip joint. The development of new concepts such as femoroacetabular impingement has led to a tremendous improvement of its technique, which has opened a field of new therapeutic options. This report presents established and latest techniques for hip arthroscopy without traction of the peripheral compartment of the hip. Detailed steps for patients positioning, portal placement, and a diagnostic round trip are included.

Die optimale Behandlung einer Acetabulumfraktur beim betagten Patienten ist und bleibt ein Diskussionsthema. Der behandelnde Arzt muss zwischen konservativer Behandlung, geschlossener Reduktion mit perkutaner Fixation, offener Reduktion mit Osteosynthese oder primare/sekundarer Hufttotalprothese (HTP) eine Entscheidung treffen, wobei jede dieser Behandlungsformen ihre Vor- und Nachteile mit sich bringt. Zwischen Februar 1998 und Dezember 2000 wurden prospektiv an unserer Klinik 15 Patienten (2-mal Querfrakturen, 8-mal T-Frakturen, 2-mal Querfrakturen mit dorsaler Pfannenrandfraktur, 2-mal Frakturen des dorsalen Pfeilers und des dorsalen Pfannenrandes und eine 2-Pfeiler-Fraktur) mit einem durchschnittlichen Alter von 81 Jahren, mittels Kabelcerclage und primarer HTP behandelt. Alle Patienten wurden nach durchschnittlich 36 Monaten nachuntersucht. Trotz eines Patienten mit 3 Huftluxationen innerhalb der ersten 10 Monaten, wurde bei allen Patienten ein sehr gutes oder gutes Ergebnis erreicht. Wahrend diesem relativ kurzen Zeitraum kam es radiologisch zu einem Verlust der Reposition der Fraktur von maximal 1 mm, einer Pfannenmigration von maximal 3,2 mm und es wurde keine Pseudarthrose oder Implantatlockerung festgestellt. Die hier vorgestellte Behandlungsform ist unserer Meinung nach eine gute Behandlungsmoglichkeit von Huftpfannenfrakturen beim geriatrischen Patienten. Sie bedarf jedoch noch eines groseren Patientenkollektivs und einer langeren Verlaufskontrolle um eine definitive Aussage treffen zu konnen.

The purpose of this study is to retrospectively evaluate 18 consecutive cases of peritalar dislocations referred to our department during a period of 25 years and to delineate the factors influencing long-term prognosis. There were 13 (73%) medial and 5 (27%) lateral dislocations. Six patients (33%) suffered an open injury, including 2 of 13 (15%) medial and 4 of 5 (80%) lateral dislocations. Associated fractures involving the hindfoot or forefoot were noted in 7 feet, including 3 of 5 lateral dislocation cases. Reduction was accomplished under general anesthesia; in no case was open reduction necessary. In 4 of 6 open injuries with associated fractures, temporary fixation with Kirschner wires was performed. Patients were immobilized in a plaster cast for 4 weeks, or for 6 weeks in the presence of fracture, followed by weightbearing as tolerated. At a mean follow-up of 10.2 years (range, 4 to 26 years), 10 patients (56%) showed excellent results; all had sustained a closed medial low-energy dislocation. There were 3 cases (17%) with fair results and 5 cases (28%) with poor results. Forty-five percent of patients showed a restriction of activity, a reduction of subtalar range of motion, and moderate or severe radiographic signs of hindfoot degenerative arthritis. There were no cases of talar avascular necrosis, and in no case was secondary surgery necessary. Lateral dislocation and open medial dislocations with concomitant fractures showed a greater potential for poor prognosis. The results were independent from period of cast immobilization, suggesting that 4 to 6 weeks of immobilization provides acceptable long-term results.

To the Editor We read the article “Increased Anteversion of Press-fit Femoral Stems Compared With Anatomic Femur” by Emerson with interest [4]. Emerson studied the antetorsion of femoral stems compared with the anatomic antetorsion, based on preoperative MRI studies. However, he does not state specifically how the measures were done. Figure 1 suggests the reference plane is defined as a transverse plane of the pelvis, which is acceptable for measuring anteversion of the acetabulum, but not for antetorsion of the femur. Femoral antetorsion is defined as the angle between the posterior bicondylar plane of the femur and the axis of the femoral neck and therefore needs images at the level of the femoral condyles and the femoral neck to be adequately measured [3]. This technique also was used in a recently published study which compares CT with MRI antetorsion values [2]. Furthermore, the method of measurement used during operations is subject to multiple errors, even if the position of the lesser trochanter is used classically as a reference for femoral torsion during intramedullary nailing [9]. In addition, it seems difficult to correlate MRI values and intraoperative values as the measures are not based on the same reference points. In the Discussion, Emerson stated that “ Because this study is looking at the differences between the preoperative and postoperative angles, the actual angles are not important. Of importance is how the two compare and whether ‘natural anteversion’ has been restored”. However, this statement seems questionable, as it is recognized that antetorsion of the prosthetic femoral neck should be between 10° to 30° to avoid impingement and instability [2, 4, 6]. Hisatome and Doi stated “The best amount of femoral anteversion for the total hip stem has not been determined, although it is generally agreed to be between 10° to 20° [4] and 10° to 30° [2]” [6]. Furthermore, antetorsion is variable among individuals and therefore, only restoring individual antetorsion with the femoral stem may lead to instability of the hip if the patient initially has excessive antetorsion or retrotorsion [1, 2, 5, 8, 12]. Therefore, we think that an analysis of restoration of preoperative antetorsion is of marginal interest and one rather should aim at restoration of physiologic relationships between femoral neck orientation and acetabular orientation [6]. Emerson described what he called “head antetorsion”, which in fact represents the neck antetorsion, and an “anatomic antetorsion”, which was called “helitorsion” in previous studies [5, 8]. The normal values of antetorsion and helitorsion vary widely among individuals depending on the underlying disorder, and it was shown that the value of femoral torsion, or helitorsion, influences orientation of the stem in terms of antetorsion [1, 5, 8]. This explains why Emerson finds differences between the preoperative and the postoperative antetorsion values. To adequately analyze antetorsion and helitorsion of each patient, use of a preoperative CT scan is mandatory [8, 10]. For this reason, we suggest the use of three-dimensional (3-D) planning of total hip prostheses based on a dedicated CT scan protocol to be able to analyze the particular anatomy of each patient and to adequately reconstruct the hip on an individual basis is an interesting alternative to standard planning, which ignores the femoral torsion problem as it is based on two-dimensional rather than 3-D analysis [11]. If a routine CT scan for every patient may seem impractical, its cost and radiation have been evaluated [7]. For us, the important additional information gained with the CT scan largely outweighs the potential negative effects of this examination.

A clinical route is defined as a "set of methods and instruments to members of a multidisciplinary and Interprofessional team to agree on the tasks for a specific patient population. This is a program of care to ensure the provision of quality care and efficient realization". The University Hospital is not immune to this phenomenon. In the Department of the musculoskeletal system, a first project of this kind concerns the fracture of the proximal femur in the elderly.

Direct MR arthrography has a better diagnostic accuracy than MR imaging alone. However, contrast material is not always homogeneously distributed in the articular space. Lesions of cartilage surfaces or intra-articular soft tissues can thus be misdiagnosed. Concomitant application of axial traction during MR arthrography leads to articular distraction. This enables better distribution of contrast material in the joint and better delineation of intra-articular structures. Therefore, this technique improves detection of cartilage lesions. Moreover, the axial stress applied on articular structures may reveal lesions invisible on MR images without traction. Based on our clinical experience, we believe that this relatively unknown technique is promising and should be further developed.

The interfacial micromotion is closely associated to the long-term success of cementless hip prostheses. Various techniques have been proposed to measure them, but only a few number of points over the stem surface can be measured simultaneously. In this paper, we propose a new technique based on micro-Computer Tomography (μCT) to measure locally the relative interfacial micromotions between the metallic stem and the surrounding femoral bone. Tantalum beads were stuck at the stem surface and spread at the endosteal surface. Relative micromotions between the stem and the endosteal bone surfaces were measured at different loading amplitudes. The estimated error was 10 μm and the maximal micromotion was 60 μm, in the loading direction, at 1400 N. This pilot study provided a local measurement of the micromotions in the 3 direction and at 8 locations on the stem surface simultaneously. This technique could be easily extended to higher loads and a much larger number of points, covering the entire stem surface and providing a quasi-continuous distribution of the 3D interfacial micromotions around the stem. The new measurement method would be very useful to compare the induced micromotions of different stem designs and to optimize the primary stability of cementless total hip arthroplasty.

Infection of an intervertebral disk is a serious condition. Diagnosis often is elusive and difficult. It is imperative to obtain appropriate microbiological specimens before initiation of treatment. The authors describe a 51-year-old woman with lumbar spondylodiscitis that was because of infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging confirmed the diagnosis, but computed tomography-guided fine needle biopsy did not provide adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. The authors believe that this minimally invasive procedure should be performed when computed tomography-guided fine needle biopsy does not provide a microbiologic diagnosis in spondylodiscitis.

Pelvic trauma A great variety of very polymorphous lesions of pelvic trauma are deffering from each other by their context, their anatomical aspect and therapeutic implication. In the isolated acetabular fractures, function is mainly at stake. The management consists mainly of re-establishing a joint congruence to prevent early coxarthrosis. Pelvic fractures often occur in violent trauma and are associated with visceral lesions, putting vital prognosis at stake. In case of hemodynamic shock, external fracture stabilization when it is indicated associated to embolisation of pelvic bleeding if necessary and after external fixation are preponderant.

Groin pain is frequent but often problematic as it covers a very broad differential diagnosis. The localisation of pain in one of the five anterior hip regions helps to establish a precise diagnosis and an adapted treatment. We review the differential diagnosis and treatment of anterior hip pain.

Still nowadays amputations are frequently performed in our country. In diabetic patients the incidence of an amputation is 25 times higher than in the normal population. All possibilities of revascularisation or limb salvage must be excluded by a multidisciplinary approach before choosing an amputation. Once the decision is taken the good level of amputation and the correct technique have to determined. The goal of this article is to describe which clinical and paraclinical parameters will help the surgeon to choose the best level of amputation, which techniques are to be used for the amputation and to finally give some information about re-education and the fitting of an orthesis or prosthesis.

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22–41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.

Posterolateral corner (PLC) injuries of the knee are uncommon injury patterns that may result in significant degrees of functional disability. When surgery is necessary to address this injury a good knowledge of anatomy and a good surgical exposure is the mainstay. This report reviews the complex anatomy of the posterolateral corner (PLC) of knee and describes the osteotomy of Gerdy tubercle as a technical variant to approach this anatomical region. This surgical step allowing a good mobilisation of the multiple layers of ilio-tibial tract from distal to proximal makes an excellent exposure of the PLC structures with absence of morbidity.

Objective: To report a rare case of lumbar vertebral subluxation associated with spontaneous reduction in an adolescent treated conservatively. Clinical Presentation and Intervention: A 14-year-old male victim of a snowboard accident, which caused a lumbar spinal injury, was referred to the emergency room with significant lumbar pain. Neurologic examination was normal. Radiographic assessment at admission showed a unilateral left lateral subluxation of the L2-L3 vertebrae without associated fractures. These findings were confirmed by CT scan and a surgical management was decided. The preoperative MRI performed 24 h after the accident, however, revealed the spontaneous reduction of the subluxation, and an associated tear of the quadratus lumborum and the psoas muscles on the right side at the level of L2, L3 and L4. Following these findings conservative treatment with a plaster brace for 2 months was carried out. The brace was removed after 2 months. The patient had no pain and the range of motion of his lumbar spine was normal. Three months after injury, sports activities were resumed. At follow-up of 24 months, the patient was free of pain and radiographs showed a right positional bending without rotational or translation anomaly. Conclusion: To date, this is the first case of subluxation without fracture in a child, presenting without neurological deficit and where spontaneous reduction occurred. In this case, conservative treatment was effective and the outcome at 2-year follow-up was excellent.

We prospectively evaluated the results of our custom cementless femoral stems to ascertain whether this technology produced reasonable clinical function, complication rates, and loosening rates at midterm. Fifty-seven consecutive patients had surgery in 62 hips for primary osteoarthritis at a mean age of 57 years using a three-dimensional computed custom cementless stem. Patients were reviewed at a mean followup of 94.9 months. At review, the mean Harris hip score was 98.8 points (range, 84-100) compared with 61.1 (range, 28-78) points preoperatively. No patient complained of thigh pain. No migration or subsidence was observed. All stems were considered stable according to the radiographic criteria defined by Engh et al. There were no dislocations, no infections, and no reoperations. Our results are comparable with published results from clinical and radiologic points of view. Two problems remain unsolved: the price of a custom stem is twice as expensive as a standard stem; and we need longer term results before definitely recommending this technology as a reasonable alternative to current arthroplasties in younger patients. The data support the continued exploration of this technology with controlled clinical followup.Therapeutic study, Level II-1 (prospective cohort study). See the Guidelines to Authors for a complete description of levels of evidence.

Eighteen patients with acetabular fractures, with a mean age of 76 years, were treated with cable fixation and acute total hip arthroplasty. Nine were T-shaped fractures, 4 associated transverse and posterior wall, 2 transverse, 2 posterior column and posterior wall, and 1 anterior and posterior hemitransverse fractures. One patient experienced 3 episodes of hip dislocation within 10 months after surgery. All the others had a good outcome at a mean follow-up time of 36 months. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This option provides good primary fixation, stabilizes complex acetabular fractures in elderly patients, and permits early postoperative mobilization.

To evaluate the results of retrograde percutaneous screw fixation (PSF) in minimally or undisplaced acetabular fractures in a geriatric population.Between July 1998 and July 2001, 21 consecutive patients with an acetabular fracture underwent fluoroscopic guided percutaneous fixation. The mean age was 81 years (range 67--90 years). In all cases, the fracture was minimally or undisplaced (2mm). Two cannulated cancellous 7.3mm screws were inserted in a retrograde fashion to stabilise the posterior and the anterior column. Bed to chair transfer began after 24h. Weight bearing as tolerated was allowed at 4 weeks.Eighteen patients were reviewed at a mean of 3.5 years (range 2--5 years). Soft tissue dissection was minimal. There were no intraoperative or postoperative complications. At the latest follow-up there was no radiographical evidence of secondary displacement of fragments, degenerative changes, or screw failure. Fractures healed at a mean time of 12 weeks (range 8--15 weeks). Clinical results were satisfactory in 17 patients.Our results show that percutaneous screw fixation under fluoroscopic control is a safe technique to treat some pattern of acetabular fracture.

Injuries of peroneal tendons are rare. Diagnosis of traumatic rupture is often late and presents as chronic ankle instability. A case of a complete traumatic rupture of both peroneal longus and brevis tendons with acute clinical and radiological diagnosis is presented. Surgical repair was performed by direct end-to-end suture on the 4th day after trauma, with excellent functional outcome at 1-year follow-up.

Infection of an intervertebral disk is a serious condition. Diagnosis often is elusive and difficult. It is imperative to obtain appropriate microbiological specimens before initiation of treatment. The authors describe a 51-year-old woman with lumbar spondylodiscitis that was because of infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging confirmed the diagnosis, but computed tomography-guided fine needle biopsy did not provide adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. The authors believe that this minimally invasive procedure should be performed when computed tomography-guided fine needle biopsy does not provide a microbiologic diagnosis in spondylodiscitis.

To The Editor: We read with interest the article entitled “Operative Compared with Nonoperative Treatment of a Thoracolumbar Burst Fracture without Neurological Deficit. A Prospective, Randomized Study” (2003; 85:773-81), by Wood et al. The authors speak about “stable” burst fractures of the thoracolumbar junction. The inclusion criteria included the absence of a posterior column lesion (except for a laminar fracture, which was neither an exclusionary criterion nor a contraindication for nonoperative treatment). The first definition categorizes the fractures as burst type-A3 fractures according to the AO classification system1, which is widely used. A laminar fracture, however, indicates a posterior column lesion, thereby categorizing the fracture as type B1 according to the AO classification1. According to the criteria described by Denis2 and Louis and Goutallier3, a type-A3 burst fracture, by definition, represents an unstable lesion as two of three columns are involved and a type-B1 fracture represents a highly unstable lesion as three columns are involved. Therefore, we think that it is incorrect to speak about a “stable” burst fracture. Furthermore, we fear that comparing operative treatment with nonoperative treatment on the basis of the follow-up data for forty-seven (89%) of fifty-three patients is misleading. We do not believe that it is advisable to test for significant differences between two small groups of patients because of the possibility of inducing … Corresponding author: Kirkham B. Wood, MD Massachusetts General Hospital 15 Parkman Street Wang Ambulatory Center Suite 503 Boston, MA 02114 kbwood{at}partners.org