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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.

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.

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.

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

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.

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.

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.

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.

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.

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