The effect of ankle and hindfoot malalignment on foot mechanics in patients suffering from post-traumatic ankle osteoarthritis.

BACKGROUND: Ankle and hindfoot malalignment is a common finding in patients suffering from post-traumatic ankle osteoarthritis. However, no studies have addressed the effect of concomitant foot deformities on intrinsic foot kinematics and kinetics. Therefore, the objective of this study was to investigate the effect of ankle and hindfoot malalignment on the kinematics and kinetics of multiple joints in the foot and ankle complex in patients suffering from post-traumatic ankle osteoarthritis. METHODS: Twenty-nine subjects with post-traumatic ankle osteoarthritis participated in this study. Standardized weight-bearing radiographs were obtained preoperatively to categorize patients as having cavus, planus or neutral ankle and hindfoot alignment, based on 4 X-ray measurements. All patients underwent standard gait assessment. A 4-segment foot model was used to estimate intrinsic foot joint kinematics and kinetics during gait. Statistical parametric mapping was used to compare foot kinematics and kinetics between groups. FINDINGS: There were 3 key findings regarding overall foot function in the 3 groups of post-traumatic ankle osteoarthritis: (i) altered frontal and transverse plane inter-segmental angles and moments of the Shank-Calcaneus and Calcaneus-Midfoot joints in the cavus compared to the planus group; (ii) in cavus OA group, Midfoot-Metatarsus joint abduction sought to compensate the varus inclination of the ankle joint; (iii) there were no significant differences in inter-segmental angles and moments between the planus and neutral OA groups. INTERPRETATION: Future studies should integrate assessment of concomitant foot and ankle deformities in post-traumatic ankle osteoarthritis, to provide additional insight into associated mechanical deficits and compensation mechanisms during gait.

Diabetic Foot Management: How Could a Procedural Pathway Improve the Surgical Outcome?

@#Introduction: Diabetic foot ulcer is the main aetiology for non-traumatic amputation, which is a major public health care concern. A multidisciplinary approach in the management of this pathology has been shown to improve the surgical outcome. However, there are little data available on the tools we can use to pursue this multidisciplinary approach. The main goal of this cross-sectional study was to find out whether the implementation of a specific management pathway could improve the treatment outcome in the treatment of diabetic foot. Materials and Methods: From 2012 to 2014, we consecutively recruited patients with diabetic foot referred to Orthopaedic surgery department of our university for surgical opinion. A specific diabetic foot pathway was introduced in 2013. One group of patients who were treated with previous method were evaluated retrospectively. Another group of patients who were treated after implementation of the pathway were evaluated prospectively. We compared treatment outcome between the two groups. Results: We included 51 patients. Amputation rate was similar both the groups: 74% in the retrospective group not using the new pathway versus 73% in a prospective group that used the new pathway. Revision surgery was 39% in the retrospective group and 14% in the prospective group (p=0.05). Conclusion: We recommend the use of this simple and costeffective pathway to guide the interdisciplinary management of diabetic foot. A prospective study with more subjects would provide a better overview of this management pathway.

Poor outcomes of fusion with Trabecular Metal implants after failed total ankle replacement: Early results in 11 patients.

INTRODUCTION: One of the reasons for revision of total ankle replacement (TAR) implants is loosening due to subchondral cysts. Reconstruction and fusion of the ankle is often the first choice for revision procedures due to the large bone defects, which are typically filled with autograft and/or allograft. Filling the defect with a trabecular metal tantalum implant is a potential alternative given the biomechanical properties of this component. HYPOTHESIS: Using tantalum as a spacer provides primary stability and contributes to fusion of the ankle joint after removal of failed TAR implants. METHODS: Eleven patients underwent arthrodesis an average of 6.9 years after TAR. The mean height of the bone defect was 32mm. It was filled with a specially designed quadrangular implant (Trabecular Metal™, Zimmer/Biomet) combined with an iliac crest graft. Ten patients underwent tibio-talo-calcaneal (TTC) arthrodesis fixed with an angled retrograde nail and one patient underwent talocrural arthrodesis fixed with two plates (anterolateral and anteromedial). The clinical, functional (AOFAS and SF36 scores) and radiological (plain X-rays and CT scan) outcomes were determined. RESULTS: At a mean follow-up of 19.3 months, the mean total AOFAS score was 56 (21-78) and the mean SF36 score was 60.5 (19-84). One patient was lost to follow-up and four patients still had pain. The tantalum implant was integrated in six patients. Five patients achieved fusion of the subtalar joint and 8 achieved fusion of the talocrural joint. Three patients required surgical revision. DISCUSSION: Our hypothesis was not confirmed. The clinical outcomes after more than 1 year of follow-up are disappointing, as was the large number of nonunion cases and the lack of tantalum integration. These technical failures can be explained by insufficient construct stability and/or insufficient implant porosity. LEVEL OF EVIDENCE: IV (retrospective cohort study).

Metatarsalgia.

The causes of metatarsalgia are classified as primary, secondary, and iatrogenic. Anatomical and biomechanical considerations separate "static" from "propulsive" forms of metatarsalgia. The physical examination should be combined with an assessment of weight-bearing radiographs and, if needed, of ultrasound or magnetic resonance imaging scans. The first-line treatment is conservative (stretching exercises, footwear modification, insoles, and lesion debridement). Soft-tissue surgical procedures (gastrocnemius muscle recession, tendon transfer, and plantar plate repair) should also be considered. Among the various types of metatarsal osteotomy, the Weil procedure is reliable. Percutaneous methods are being developed but require evaluation. A treatment algorithm can be developed based on whether the hallux is normal or abnormal. Metatarsalgia due to inflammatory disease requires a specific treatment strategy.

Wear study of Total Ankle Replacement explants by microstructural analysis.

The implantation of Total Ankle Replacement (TAR) prostheses generally gives satisfactory results. However, a high revision rate is associated with the Ankle Evolutive System (AES) implant, due to periprosthetic osteolysis that generates significant cortical lesions and bone cysts in the periprosthetic region. Radioclinical and histological analyses of peri-implant tissues show the presence of numerous foreign particles that may come from the implant. It is known that a precocious wear of materials may lead to an important rate of foreign body in tissues and may generate osteolysis lesions and inflammatory reactions. Thus the objectives of this retrospective study of 10 AES TAR implants (recovered after revision surgeries) are to understand how the prostheses wear out, which part is the most stressed and to determine the nature and size of foreign body particles. A better understanding of friction mechanisms between the three parts of the implant and of the nature and morphology of foreign particles generated was needed to explain the in vivo behavior of the implant. This was achieved using microstuctural and tomographic analysis of both implants parts and periprosthetic tissues.

Compared fixation and survival of 280 lateralised vs 527 standard cementless stems after two years (1-7).

BACKGROUND: Restoring the native hip anatomy increases hip prosthesis survival, whereas increased femoral lateralisation creates high torque stresses that may alter prosthesis fixation. After finding lucent lines around cementless lateralised stems (Corail™, DePuy Synthes, St Priest, France) in several patients, we evaluated the effects of lateralisation in a large case-series. The objective of our study was to compare lateralised vs standard stems of identical design in terms of radiological osteo-integration and survival. HYPOTHESIS: Lateralised stems, despite being used only when indicated by the anatomical parameters, carry a higher risk of impaired osteo-integration. MATERIALS AND METHODS: A retrospective study was conducted in 807 primary total hip arthroplasties (THAs) performed between 2006 and 2010 in 798 patients with a mean age of 65 ± 14.2 years. Lateralised stems were used in 280 cases (Corail High Offset KHO, n = 169; and Corail coxa vara KLA, n = 111 cases) and standard stems in 527 cases (Corail KA). Mean follow-up was 2.3 years (range, 1-7 years). The clinical evaluation included determination of the Postel-Merle d'Aubigné (PMA) score. Bone fixation and stability of the implants were assessed by determining the Engh and Massin score and the ARA score on the radiographs at last follow-up. Femoral, acetabular and global offset values were determined before and after THA. Nobles's Canal Flare Index was computed. Survival was estimated using the Kaplan-Meier method with surgical revision for aseptic loosening as the end-point. RESULTS: The PMA score improved from 12 (10-15) pre-operatively to 17.7 (14-18) (P < 0.05). After THA, in the lateralised stem group, femoral offset was restored in 217 (77%) hips and the mean change vs the pre-operative offset value was -2 mm; in the standard stem group, femoral offset was restored in 440 (83.5%) hips and the mean change was +1 mm. The Engh and Massin score values were similar in the standard stem and lateralised stem groups (24.4 ± 2.2 and 22.6 ± 2.4, respectively, NS). Revision for aseptic loosening was required in 5 patients with lateralised stems (3 KHO and 2 KLA) versus none of the patients with standard stems. There were no cases of excessive femoral offset and the mean change in offset was -2.3mm (-5.3 to -1.1). Noble's index was increased (4.27 ± 0.5 for the loosened lateralised stems, 3.65 ± 0.8 for the well-fixed lateralised stems and 3.82 ± 0.6 for the standard stems), with no significant difference across groups. Overall survival after 3.5 years of follow-up was 94.6% (95% confidence interval, 88.4-100%) with lateralised stems and 100% with standard stems (P < 0.05). DISCUSSION: The risk of aseptic loosening was significantly higher with the lateralised stem (5/280, 1.8%) than with the standard stem (n = 0). Our findings indicate a need for careful preparation to obtain primary fixation of lateralised stems. LEVEL OF EVIDENCE: III, retrospective case-control study.

Does arthrodesis of the first metatarsophalangeal joint correct the intermetatarsal M1M2 angle? Analysis of a continuous series of 208 arthrodeses fixed with plates.

INTRODUCTION: First-ray metatarsophalangeal arthrodesis is a classic surgical procedure in the treatment of severe hallux valgus, hallux rigidus, revision surgery, and inflammatory arthritis. The objective of this study was to verify if metatarsophalangeal plate arthrodesis could correct the M1M2 intermetatarsal angle. MATERIAL AND METHODS: This prospective and continuous series (June 2007 to March 2011) included 208 patients (48% severe and/or arthritic hallux valgus, 18% hallux rigidus, 16% rheumatoid forefoot, 13% surgical revision of the first ray, 5% hallux varus), with a mean age of 62.4±9.9 years (range, 19-87 years). All the patients were operated on by a senior surgeon with the same technique: spherical avivement of the joint surfaces using reamers, osteosynthesis with an anatomic plate (Fyxis-Biotech™) in Ti.6Al.4 V alloy prebent to 5° with a phalangeal arm to receive an oblique metatarsophalangeal screw in compression, in addition to four 2.7-mm nonlocking dorsal screws. The full-scale preoperative and intraoperative angle measurements were taken on AP and lateral X-rays of the weightbearing foot, as related to the etiology and the severity of the preoperative metatarsus varus (M1M2<15°, M1M2 15-19°, M1M2≥20°). The statistical analysis was done using the StatView software. RESULTS: The mean follow-up was 18.6±12.4 months (range, 2-76 months). Nearly all of the arthrodesis patients (97%) achieved bone union, and 5% of the plates were removed. The M1P1 angle decreased from 33.8±19.7° (range, -45° to -67°) preoperatively to 13.3±5.3° (range, 0-32°) at the last follow-up, and the M1M2 angle from 14.2±5.4°(range, 0-26°) to 6.5±2.3° (range, 0-12°). The preoperative M1M2 angle was <15° in 97 patients, 15-19° for 78 patients, and ≥20° for the 33 others; at the last follow-up it was 5.8±2.1° (range, 0-10°), 6.7±2.2° (0-10°), and 8.1±2.4° (3-12°), respectively. No correction of the metatarsus varus was demonstrated in relation to etiology. The M1M2 angle was >10° in only two patients (one case of rheumatoid arthritis and one case of severe hallux valgus): 0.9%. DISCUSSION: These results show that isolated metatarsophalangeal arthrodesis of the first ray can correct metatarsus varus even in substantial deformations in any etiology. LEVEL OF PROOF: Level II cohort study.

Comparison of quality of life following total ankle arthroplasty and ankle arthrodesis: Retrospective study of 54 cases.

INTRODUCTION: The benefit of ankle arthroplasty compared to arthrodesis continues to be debated, but the quality of life after these two interventions has rarely been assessed. We conducted a case-control study to compare quality of life and functional and athletic ability. HYPOTHESIS: Functional results, athletic ability, and quality of life after total ankle arthroplasty (TAA) are better than after ankle arthrodesis. MATERIAL AND METHODS: Two continuous series of 59 TAAs and 46 arthrodeses (operated on between 1997 and 2009) were evaluated retrospectively using a questionnaire including the functional items of the AOFAS score, the Foot Function Index (FFI) score, the Foot Ankle Ability Measure (FAAM), and the SF-36. RESULTS: Eighty-three responses (79% of the overall series) were matched in two groups: 32 TAAs [age at the intervention, 51.4years (range, 21-63years); follow-up, 52.2months (range, 30-146months); age at revision, 55.8years (range, 26-67years); BMI, 27.7 (range, 21.7-36.7)] and 22 arthrodeses [age at intervention, 50.1years (range, 24-72years); follow-up 57.9months (range, 12-147months); age at revision 54.9 years (range, 31-75years); BMI, 26.8 (range, 17.6-37)] (NS on all items between the two groups). The pain results were better after TAA, but with no statistically significant difference: AOFAS pain, (/40) 28.1±8.2 vs. 24.5±9.6; FFI pain, 16.6±18.8 vs. 24.3±21.5. The overall FFI score (/100) was better (P=0.048) after TAA (16.2±16.5 vs. 24.8±18.2). The overall mean athletic level compared to the state prior to the injury was relatively low in both groups, but significantly (p=0.007) higher in the TAA group: FAAM sports score (/100), 49.5±24.4 vs. 29.8±26.2. The quality-of-life scores, SF-36 physical health, mental health, and general health were not significantly different after TAA and arthrodesis: mental health score, 63.1±14.7 vs. 57.8±21.5; physical health score, 61.3±17.8 vs. 53.7±23.9, overall score, 63.2±16.4 vs. 55.9±23.5. DISCUSSION: Very few publications describe activities and quality of life after TAA and arthrodesis. Despite weaknesses, this comparative study demonstrates a tendency toward better functional results after TAA than after ankle arthrodesis, without the difference between the two groups being very significant. On the other hand, there was no difference in terms of quality of life. After the doubts raised by publications on severe periprosthetic osteolysis at the intermediate term with certain TAA models, these results encourage pursuit of implantation and development of TAA. LEVEL OF PROOF: Comparative retrospective. Level III study.

Histologic study of periprosthetic osteolytic lesions after AES total ankle replacement. A 22 case series.

INTRODUCTION: Medium-term results for total ankle replacement (TAR) are in general satisfactory, but there is a high redo rate for periprosthetic osteolysis associated with the AES implant. HYPOTHESIS: Comparing radioclinical findings and histologic analysis of implant revision procedure specimens can account for the elevated rate of osteolysis associated with the AES TAR implant. MATERIAL AND METHOD: In a prospective series of 84 AES TAR implants (2003-2008), 25 underwent revision for osteolysis (including three undergoing revision twice) at a mean 59.8 months. Eight patients had hydroxyapatite (HA) coated models and the others had titanium-hydroxyapatite (Ti-HA) coatings. Radiographs were systematically analyzed on Besse's protocol and evolution was monitored on AOFAS scores. The 94 specimens taken for histologic analysis during revision were re-examined, focusing specifically on foreign bodies. RESULTS: Macroscopically, no metallosis or polyethylene wear was found at revision. AOFAS global and pain scores fell respectively from 89.7/100 at 1 year postoperatively to 72.9 before revision and from 32.5/40 to 20.6/40, although global scores were unchanged in 25% of patients. Radiologically, all patients showed tibial and talar osteolytic lesions, 45% showed cortical lysis and in 25% the implant had collapsed into the cysts. All specimens showed macrophagic granulomatous inflammatory reactions in contact with a foreign body; the cysts showed necrotic remodeling. Some of the foreign bodies could be identified on optical histologic examination with polyethylene in 95% of the specimens and metal in 60% (100% of HA-coated models and 33.3% of Ti-HA-coated models). Unidentifiable material was associated: a brownish pigment in Ti-HA-coated models (33.3%) and flakey bodies in 44.4% of the HA-coated models and 18.2% of the Ti-HA-coated models. DISCUSSION: The phenomenon of periprosthetic osteolysis is still poorly understood, although implant wear debris seems to be implicated. All the patients with HA-coated implants with modular tibial stem had metal particles in the tissue around the implant, although their exact nature could not be determined. The double-layer Ti-HA coating may induce delamination by fretting while the biological bone anchorage is forming. LEVEL OF EVIDENCE: Prospective cohort study - Level IV.

Scarf osteotomy versus metatarsophalangeal arthrodesis in forefoot first ray disorders: comparison of functional outcomes.

INTRODUCTION: Scarf osteotomies of the first metatarsal and metatarsophalangeal arthrodesis are the two most frequent surgical forefoot reconstructive procedures. HYPOTHESIS: We compared functional results of isolated arthrodesis of the first metatarsophalangeal joint with an isolated Scarf osteotomy of the first metatarsal. MATERIALS AND METHODS: This was a retrospective, observational, continuous study of patients operated between 1993 and 2008. After patients who had undergone a procedure on the lateral rays, extremely elderly patients, lost to follow-up patients and those with incomplete questionnaires had been excluded, there remained two comparable groups of 25 patients. Mean age was 60 in the arthrodesis group [41-70] and 59.8 in the Scarf group [47-71]. The Scarf group included 25 hallux valgus (100%) compared to 16 hallux valgus (64%) and nine hallux rigidus (36%) in the arthrodesis group. Complications were recorded. Evaluation of functional results was based on the most recent functional or quality of life scores (AOFAS, FFI, FAAM, SF 36) and a questionnaire on physical and athletic ability. RESULTS: There was no significant difference in the rate of complications between the two groups. There was no difference in pain according to the AOFAS score with 35.6/40 (± 6.5) in the Scarf group and 34.5 (± 5.9) in the arthrodesis group. Global satisfaction was also similar between the Scarf and arthrodesis groups: 91.4% and 90% of very satisfied or satisfied patients, respectively. The FFI score was higher in the Scarf group than in the arthrodesis group: 8.6 (± 20.1) and 19.8 (± 17.7) respectively. Functional results were better in the Scarf group than in the arthrodesis group with a FAAM Daily Activity score of 80.2 (± 12.1) compared to 68 (± 7.2), a FAAM Sports Activity score of 29.7 (± 6.7) compared to 25.2 (± 7.6) and a FAAM Global Function score of 94% (± 10.8) compared to 87% (± 15.7), respectively. The Global SF36 score was higher in the Scarf group than in the arthrodesis group: 70.9% (± 14.1) and 62.3% (± 20.6) respectively, which was due to a higher Mental Health score in the Scarf group: 68.7% (± 14.2) and 60.4% (± 19.3) respectively. In the area of sports activities the Scarf group practiced more hiking than the arthrodesis group (74% versus 42% respectively). There was no difference for other activities. DISCUSSION AND CONCLUSION: This study provides detailed information on the level of physical and sports activities that are practiced following these procedures, so that the patient can be better informed.

Resection of bilateral massive Achilles tendon xanthomata with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap: A case report and literature review.

Tumours of the Achilles tendon are rare. Reconstruction of the large defect following excision, however, is often a challenge and is sometimes a factor in deciding against operative treatment of a benign lesion. We report a case of excision of bilateral Achilles tendon xanthomata, with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap.

Diabetic foot: the orthopedic surgery angle.

As diabetes takes on pandemic proportions, it is crucial for the orthopedic surgeon to be aware of the issues involved in diabetic foot. Ulceration is related to neuropathy and to arterial disease, a vital prognostic factor for healing; infection plays an aggravating role, increasing the risk of amputation. At-risk feet need to be screened for. Ulcer classification is essential, to set treatment strategy and determine prognosis. Before any treatment is decided on, neuropathy, vascular insufficiency and infection should individually be assessed by clinical examination and appropriate additional work-up. Despite the International Consensus on the Diabetic Foot recommendations, management of diabetic foot in Europe still varies greatly from country to country, very few of which have established reference centers. Management of diabetic foot remains multidisciplinary; but it has been shown that the orthopedic surgeon should play a central role, providing a biomechanical perspective so as to avoid complications recurrence. Strategy notably includes prevention of at-risk foot, revascularization surgery (which should systematically precede orthopedic surgery in case of critical vascular insufficiency), and treatment of ulcers, whether these latter are associated with osteitis or not. Indications for "minor" amputation should be adequate, and meticulously implemented. "Acute foot" is a medical emergency, entailing massive empirically selected I.V. antibiotics to "cool" the lesion. Prophylactic surgery to limit further risks of ulceration is to be indicated with caution and only when clearly justified. France urgently requires accredited specialized multidisciplinary centers to manage severe lesions: deep and infected ulceration, advanced arteriopathy, and Charcot foot arthropathy.

Total ankle arthroplasty in France.

OBJECTIVES: After more than 10 years' experience in France, the French Foot Surgery Association (Association française de chirurgie du pied [AFCP]) presents an update on mobile-bearing ankle prostheses, based on a multicenter study. META-ANALYSIS - BIOMECHANICS - ASSESSMENT AND INDICATIONS: A preliminary comparative meta-analysis of the literature studies on ankle and prosthesis biomechanics, reviews validated indications and contra-indications, and details clinical and radiological outcomes assessment protocols. PROFESSIONAL SURVEY: Sixty-three surgeons (95% AFCP members) answered a professional online survey, by email or regular post: 70% performed total ankle replacement (TAR), 39% of them at least two per year and 16% more than 10 per year, resulting in 317 TARs per year or 50% of the French activity and 312 arthrodeses per year or 17% of the French activity - which gave the survey considerable power. In 2004-2005, 46% of the TARs implanted were AES, 38% Salto and 9% Hintegra. GAIT ANALYSIS FOLLOWING TAR: This study included two series of patients (15 in Brussels and six in Paris) with laboratory gait analysis preoperatively and at 6 months' and 1 year's FU. Following TAR, speed, cadence and strides increased and mean total work approximated normal values. These two independent studies quantified the advantages of TAR over arthrodesis. MULTICENTER STUDY: This retrospective study had a minimum follow-up of 1 year. Results were not distinguished between the four types of prosthesis (approved by the French Healthcare Agency [HAS]) involved. Inclusion criteria for operators were: AFCP membership, and experience of more than 20 prostheses of a given type. Twelve out of 15 centers responded and undertook to include continuous series. Data were centralized on a dedicated anonymous online site. Five hundred and ninety-two TARs (388 Salto, 173 AES, 22 Hintegra, nine Star) in 555 patients (mean age, 56.4 years; range 17-84 yrs) were included. Indications were post-traumatic arthritis (48%), arthritis associated with laxity (15%), inflammatory arthropathy (20%), primitive arthritis (9%), prosthetic revision (2%), and miscellaneous (5%). Sixty-one percent of operations included associated procedures: 208 Achilles lengthenings, 45 subtalar arthrodeses, nine calcaneal osteotomies and 45 lateral ligament reconstructions. Complications comprised 53 malleolar fractures, and 39 cutaneous and seven infections (9%). At a mean 37 months' FU, 87.5% of patients were satisfied or very satisfied; mean functional score was 82.1/100; radiographic mobility, 23.2 degrees ; and total SF 36 score (on the Short Form Health Survey), 66. X-ray found stable anchorage in 98% of cases, cysts in 15%, and calcification in 4%. REVISION FOR FAILURE: Overall cumulated survivorship was 88% at 71 months: 22 patients underwent arthrodesis (61% satisfied), and 10 implant replacement (50% satisfied). CONCLUSION: This multioperator, multi-implant series of 592 patients confirmed literature data. Prospective follow-up of the cohorts managed in these expert centers is essential, in order to make available long-term data.

Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options?

This paper purpose is to suggest an in-depth approach to diagnose the causes and lesions associated with and consecutive to chronic ankle instability due to ankle collateral ligament laxity. The different therapeutic and medicosurgical options adapted to this diagnostic approach are identified. The diagnostic aim is to precisely locate the ligamentous injuries of the tibiofibular, subtalar, talar and calcanean system, to identify the predisposing factors such as the hindfoot morphology, and any lesions associated with chronicity: anterolateral impingement, fibular injury, osteochondral lesions of the talus dome and early osteoarthritis. Clinical tools are used in particular to identify areas of pain and for comparative analysis of mobility and laxity (ligament testing). There are also radiological tests, weight-bearing plain X-ray (stress X-ray), (alignment of the hind foot, with a Meary view [metal wire circling the heel], arthrosis), dynamic images to confirm and quantify laxity (manually, with a Telos device, with patient-controlled varus) and also more sophisticated techniques (ultrasound, CT arthrogramm, gadolinium enhanced MRI, MR arthrogramm) to identify ligament, tendon and cartilage damages. They are adapted to the lesions which have been identified in the diagnostic work-up: conservative first, to treat proprioceptive deficits (a new neuromuscular reprogramming technique which emphasizes muscle preactivation) and any static disorders (plantar orthotics); then surgical, to repair any collateral ligament (or sometimes subtalar) injury with three types of procedures: tightening the capsuloligamentous structures, ligament reconstruction with reinforcement (using the fibrous periosteum, the frondiform ligament (of Retzius) or tendinous reconstruction with the plantaris muscle, the peroneus tertius or even the calcanean tendon) and tendon tansfer procedures using all or part of the peroneus brevis (whole peroneus brevis and half peroneus brevis procedures). Any additional surgical procedures which may be indicated based on the results of the diagnostic work-up are performed at the same time as primary surgery when possible as needed (medial complex repair, calcaneal realignment osteotomies, talus osteochondral injuries debridment or fixation, anterior and posterior impingement suppression, tendon tears repair). The goal of this diagnostic and therapeutic approach is to stop the progression of laxity and to protect the ankle against degenerative arthritis, which is the main risk in these chronic conditions.

Chronic lateral ankle instability surgical repairs: the long term prospective.

UNLABELLED: The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction. MATERIAL AND METHODS: A multicenter retrospective review was performed on 310 lateral ankle ligament reconstructions, with a mean 13-year-follow-up (minimum FU: 5 years). Male subjects (53%) and sports trauma (78%) predominated. Mean duration of instability was 92 months; mean age at surgery was 28 years. Twenty-eight percent of cases showed subtalar joint involvement. Four classes of surgical technique were distinguished: C1, direct capsular ligamentous complex reattachment; C2, augmented repair; C3, ligamentoplasty using part of the peroneus brevis tendon and C4, ligamentoplasty using the whole peroneus brevis tendon. Clinical and functional assessment used Karlsson and Good-Jones-Livingstone scores; radiologic assessment combined centered AP and lateral views, hindfoot weight-bearing Méary views and dynamic views (manual technique, Telos or self-imposed varus). RESULTS: The majority of results (92%) were satisfactory. The mean Karlsson score of 90 [19-100] (i.e., 87% good and very good results) correlated with the subjective assessment, and did not evolve over time. Postoperative complications (20%), particularly when neurologic, were associated with poorer results. Control X-ray confirmed the very minor progression in degenerative changes, with improved stability; there was, however, no correlation between functional result and residual laxity on X-ray. Unstable and painful ankles showed poorer clinical results and more secondary osteoarthritis. Analysis by class of technique found poorer results in C4-type plasties and poorer control of laxity on X-ray in C1-type tension restoration. DISCUSSION: The present results confirm the interest of lateral ankle ligamentoplasty in the management of instability and protection against secondary osteoarthritis, and of precise lesion assessment (CT-scan/MRI) to adapt surgery to the ligamentary and associated lesions. LEVEL OF EVIDENCE: Level IV. Retrospective therapeutic study.

[Results of self-centering patellofemoral prosthesis: a retrospective study of 57 implants]. / Résultats de la prothèse fémoropatellaire autocentrique: à propos d'une série continue de 57 prothèses.

PURPOSE OF THE STUDY: The aim of this retrospective analysis was to report results obtained with a self-centering patellofemoral prosthesis. We wanted to determine whether self-centering still has indications for the treatment of patellofemoral osteoarthritis. MATERIAL AND METHODS: This was a continuous series of 57 knees operated on since 1986 in the same center for implantation of a self-centering patellofemoral prosthesis (Medinov then Depuy). Eight patients died and four were lost to follow-up. Two knees were excluded from the analysis after revision with a PFP. We report here the outcome of 43 prostheses at mean follow-up of six years two months (range 78 months to 15 years). The IKS score (200 points) and the ADL scale (in %) were recorded. The position of the prosthesis was assessed on plain X-rays. Mean age at implantation was 67.2 years. The main reasons for surgery were osteoarthritis secondary to dysplasia (60%) and primary disease (31.1%). RESULTS: At last follow-up, the IKS score was 157.2 points (range 76-195). The mean ADL score was 74.1/100 (48.8-96.3). The IKS evaluation showed good outcome in 66.7% of knees. The ADL scale gave a less satisfactory outcome: 57.7% good outcome for this scale which takes into account all knee functions for activities of daily life. Outcome was better among patients with trochlear dysplasia. Eleven patients (24.4%) had had revision surgery for total knee arthroplasty. Preoperatively, the trochlear angle was smaller in revision cases (p=0.023). In these patients, the first prosthesis was more anterior (p=0.004) with a greater horizontal axis (p=0.015). DISCUSSION: Our outcomes were less satisfactory than the average results in the literature. It must be noted however, that the concept of a good outcome depends on the scale used for assessment. We found in our series a 10% difference between the ADL scale and the IKS score. Independently of the assessment scale used, outcome was better in knees with osteoarthritis secondary to dysplasia. An analysis of the X-ray findings disclosed technical errors leading to failure. The outcome of patellofemoral prosthesis depends essentially on two factors: technical precision and patient selection. CONCLUSION: In light of these findings, we have come to limit still further the rare indications for patellofemoral prostheses. The typical indication is isolated advanced patellofemoral osteoarthritis secondary to patellofemoral dysplasia unresponsive to medical treatment in patients aged 50-70 years. Revision with a total knee arthroplasty required changing the patellar insert if worn. We have not had any particular problem with revision total knee arthroplasty after patellofemoral prosthesis.

[Hallux valgus surgery in 2005. Conventional, mini-invasive or percutaneous surgery? Uni- or bilateral? Hospitalisation or one-day surgery?]. / La chirurgie de l'hallux valgus en 2005. Chirurgie conventionnelle, mini-invasive ou percutanée ? Uni- ou bilatérale ? Hospitalisation ou ambulatoire ?

There remains a good deal of controversy concerning forefoot surgery. Certain concepts such as conventional procedures, minimally invasive surgery, or percutaneous surgery are promoted because of their specific advantages including rapid recovery and compatibility with a short hospital stay or even outpatient surgery. Nevertheless, in 2005 many questions remain unanswered and highly variable practices have been basically founded on personal experience rather than scientific evidence. In addition, financial and lobbying pressure appears to have an influence on our choices, affecting the freedom of our therapeutic decision-making. Developed over a long period, conventional surgery has proven reliability, reproducibility and adaptability. Procedures termed minimally invasive are defined by the limited incision. Percutaneous surgery is not less invasive than other procedures; the techniques are performed under indirect visual control and often assisted with more or less sophisticated radioscopic techniques depending on the surgeon's own experience. In our opinion, percutaneous surgery should be considered as a new concept based on rapid and functional results. Patients often raise the question of a bilateral procedure. For hallux valgus, there is no consensus on whether unilateral or bilateral procedures are better, the best solution depending on postoperative weight bearing and thus on the technique employed. From a cost expenditures point of view, bilateral procedures have an impact. For the advantages in terms of macroeconomy for professional incapacity, the question is less univocal for healthcare authorities. Advances in perioperative anesthesia and analgesia have enabled a broader approach to ambulatory surgery. Outpatient surgery appears to have benefits in terms of organization and economics. Variables studied were as follows: duration of hospital stay, postoperative edema, number of days of sick leave and preoperative and early and late postoperative pain. Patients who underwent minimally invasive procedures had a significantly shorter hospital stay compared with three other groups. For bilateral procedures, hospital stay on average was longer than in the two other groups. There was no correlation between postoperative edema and pain or between the degree of edema at 15 days and two months. Mean sick leave was 54.6 days. This was significantly shorter for percutaneous procedures compared with conventional surgery or minimally invasive techniques. Preoperative pain was noted four to five on the Visual Analogue Scale (VAS). There was no significant difference between the different groups as a function of the type of surgery performed. Statistically, there is very little difference in the short term between the different techniques. A much longer study would be necessary to obtain evidence to guide our practices. While there is certainly no reason to condemn one method or another, surgeons must be careful about the promises given to patients which are generally based on personal experience but not necessarily supported by rigorous scientific data.

[Anterior cruciate ligament revision: analysis and results from a series of 74 cases]. / Les reprises de ligamentoplastie du ligament croisé antérieur: analyse et résultats d'une série de 74 cas.

PURPOSE OF THE STUDY: This was a retrospective series of patients who underwent revision ligamentoplasty of the anterior cruciate ligament (ACL). We wanted to assess the functional outcome after this type of surgery and search for potential prognostic factors. MATERIAL AND METHODS: The series included 74 patients, mean age 34 years (range 21-59 years). The initial ligamentoplasty was performed with a synthetic ligament (n=16), an autograft (n=57) or an allograft (n=1). Differential laxity (KT-1000 maximal manual) was 7 +/- 2.5 mm. Anterior drawer was measured on the stress x-rays in 20 degrees flexion: medial 8 +/- 4.7 mm, lateral 8.3 +/- 4.9 mm. Mean time to revision surgery was 78 months. Reconstruction was performed arthroscopically in 69 knees. The implant used for the revision reconstruction was an autograft: patellar tendon (n=42), quadriceps tendon (n=15), hamstring tendon (n=13), patellar tendon and quadriceps tendon (MacInJones) (n=3), fascia lata (n=1). A meniscal tear was noted in 24 knees and a cartilage lesion in 35. RESULTS: Outcome was assessed at mean 21.2 months follow-up. The mean IKDC function score was 71.7 (range 21.8-100). 78% of patients considered their knee normal or nearly normal and 88% presented a positive Lachmann. Mean differential laxity measured with KT-1000 (maximal manual) was 2 +/- 1.7 mm. Stress x-rays revealed a mean differential laxity measured at 3.7 +/- 2.3 mm medially and 6.3 +/- 4.3 mm laterally. The presence of a meniscal lesion favored osteoarthritic degradation. Presence of chondral lesions altered the functional outcome significantly and limited resumption of sports activities. An initial repair using a synthetic ligament affected the functional outcome after revision surgery and favored or aggravated chondral lesions. DISCUSSION: The clinical results we have obtained with revision ACL ligamentoplasty are comparable to previous series reported in the literature. The functional outcome is not as good as after first-intention repair, especially if the initial plasty was done with a synthetic ligament and the knee presented meniscal or cartilage damage.