Reliability of a CT reconstruction for preoperative surgical planning in the arthroscopic Latarjet procedure.

PURPOSE: The arthroscopic Latarjet procedure has provided reliable results in the treatment of anterior shoulder instability. However, this procedure remains technically challenging and is related to several complications. The morphology of the coracoid and the glenoid are inconsistent. Inadequate coracoid and glenoid preparing may lead to mismatching between their surfaces. Inadequate screws lengthening and orientation are a major concern. Too long screws can lead to suprascapular nerve injuries or hardware irritation, whereas too short screws can lead to nonunions, fibrous unions or migration of the bone block. The purpose of the study was to investigate the application of virtual surgical planning and digital technology in preoperative assessment and planning of the Latarjet procedure. METHODS: Twelve patients planned for an arthroscopic Latarjet had a CT scan evaluation with multi-two-dimensional reconstruction performed before surgery. Interobserver and intraobserver reliability were evaluated. The shape of the anterior rim of the glenoid and the undersurface of the coracoid were classified. Coracoid height was measured, respectively, at 5 mm (C1) and 10 mm (C2) from the tip of the coracoid process, corresponding to the drilling zone. Measurements of the glenoid width were then taken in the axial view at 25 % (G1) and 50 % (G2) of the glenoid height with various α angles (5°, 10°, 15°, 20°, 25°, 30°) 7 mm from the anterior glenoid rim. Shapes of the undersurface of the coracoid and the anterior rim of the glenoid were noted during the surgical procedure. Post-operative measurements included the α angle. RESULTS: Concerning coracoid height measurements, there was an almost perfect to substantial intra- and inter-reliability, with values ranging from ICC = 0.75-0.97. For the shape of the coracoid, concordances were, respectively, perfect (ICC = 1) and almost perfect (0.87 [0.33; 1]) for the intra- and interobserver reliabilities. Concerning the glenoid, concordance was always almost perfect for 50 % height. Concordance was almost perfect for 25 % height 15° and 30° for inter- and intraobserver, for intraobserver at 0° and 25°. All the other values were still showing moderate concordance. Shape of the coracoid analysis reproducibility was perfect for both intra- and interobserver ICC = 1. There was a total agreement (ICC = 1) between the preoperative evaluation of the shape of the glenoid and the coracoid and the intraoperative assessment. CONCLUSION: The ideal and accurate preoperative planning of screwing of the coracoid graft in the arthroscopic Latarjet can be achieved in the real surgery assisted by the virtual planning. The clinical importance of this study lies in the observation that this new preoperative planning could offer a simple, effective and reproducible tool for surgeons helping them to prepare in the best possible way a technically challenging procedure usually associated with a high rate of complications.

Preoperative CT planning of screw length in arthroscopic Latarjet.

PURPOSE: The Latarjet procedure has shown its efficiency for the treatment of anterior shoulder dislocation. The success of this technique depends on the correct positioning and fusion of the bone block. The length of the screws that fix the bone block can be a problem. They can increase the risk of non-union if too short or be the cause of nerve lesion or soft tissue discomfort if too long. Suprascapular nerve injuries have been reported during shoulder stabilisation surgery up to 6 % of the case. Bone block non-union depending on the series is found around 20 % of the cases. The purpose of this study was to evaluate the efficiency of this CT preoperative planning to predict optimal screws length. The clinical importance of this study lies in the observation that it is the first study to evaluate the efficiency of CT planning to predict screw length. METHODS: Inclusion criteria were patients with chronic anterior instability of the shoulder with an ISIS superior to 4. Exclusion criteria were patients with multidirectional instability or any previous surgery on this shoulder. Thirty patients were included prospectively, 11 of them went threw a CT planning, before their arthroscopic Latarjet. Optimal length of both screws was calculated, adding the size of the coracoid at 5 and 15 mm from the tip to the glenoid. Thirty-two-mm screws were used for patients without planning. On a post-operative CT scan with 3D reconstruction, the distance between the screw tip and the posterior cortex was measured. A one-sample Wilcoxon test was used to compare the distance from the tip of the screw to an acceptable positioning of ±2 mm from the posterior cortex. RESULTS: In the group without planning, screw 1 tended to differ from the acceptable positioning: mean 3.44 mm ± 3.13, med 2.9 mm, q1; q3 [0.6; 4.75] p = 0.1118, and screw 2 differed significantly from the acceptable position: mean 4.83 mm ± 4.11, med 3.7 mm, q1; q3 [1.7; 5.45] p = 0.0045. In the group with planning, position of screw 1 or 2 showed no significant difference from the acceptable position: mean 2.45 mm ± 2.07 med 1.8 mm, q1; q3 [1; 3.3] p = 1; mean 2.75 mm ± 2.32 med 2.3 mm, q1; q3 [1.25; 3.8] p = 0.5631. CONCLUSION: Unplanned Latarjet can lead to inaccurate screw length especially in the lower screw and can increase the risk of non-union and nerve damage. The clinical relevance of this article is that CT planning of screw length before surgery showed good results on post-operative CT.

Arthroscopic treatment of displaced tibial eminence fractures using a suspensory fixation.

BACKGROUND: Avulsion fractures of the tibial intercondylar eminence are fairly common injuries requiring surgery for the optimal functional outcome. The purpose of this study was to assess the clinical and radiological outcomes of an arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory device. MATERIAL AND METHODS: Five patients with type 2 and 3 displaced tibial intercondylar eminence fractures who received an arthroscopically assisted fixation using a double button device were enrolled from 2011 to 2012. Clinical assessment included the patient demographics, cause of injury, the delay before surgery, time for surgery, time to return to work and sport, the International Knee Documentation Committee (IKDC) and Lysholm knee scores. Stability was measured with the KT-2000 arthrometer with a force of 134 N. A side to side difference on the KT-2000 examination superior to 3 mm was considered as a significant and abnormal increase in the anterior translation. Radiological examination consisted of anteroposterior and lateral radiographs, as well as computed tomography (CT) scan of the affected knee. Clinical and radiological followup was done at 1, 2, 3, 6, and 12 months postoperatively and at final followup. CT-scan was performed before surgery and at 3 months followup. RESULTS: The median age of patients was 31 years. Mean followup was 27 ± 5.1 months. The average delay before surgery was 3 days. At final followup, the mean IKDC and Lysholm knee scores were, 93.9 and 94.5 respectively. All patients had a complete functional recovery and were able to return to work and to resume their sport activities. No secondary surgeries were required to remove hardware. No complication was noted. Bony union was achieved in all patients. CONCLUSION: The arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory system provided a satisfactory clinical and radiological outcome at a followup of 2 years.

Spontaneous Knee Ankylosis through Heterotopic Ossification after Total Knee Arthroplasty.

This paper reports on a case of total ankylosis of the knee after a cruciate-sacrificing cemented total knee arthroplasty (TKA). An 82-year-old female patient previously underwent primary TKA for osteoarthritis twenty years ago in our institution. She had recovered uneventfully and returned to her regular activities. There was no history of postsurgical trauma; however, she progressively lost knee range of motion. Radiographs revealed severe bridging heterotopic ossification.

Graft position and fusion rate following arthroscopic Latarjet.

PURPOSE: The arthroscopic Latarjet procedure is recently becoming an increasingly popular technique. Nevertheless, position and fusion of the autograft had not been well studied yet. The purpose of this study was to assess the positioning of the coracoid graft and the fusion rate on CT scan in the arthroscopic Latarjet procedure. METHODS: The study design was a prospective series of 19 consecutive patients who received arthroscopic Latarjet procedure. Radiological assessment on CT scan performed 3 months post-operatively included an analysis of the fusion and the position of the coracoid bone graft using a validated method. 02:30-04:20 was considered an ideal positioning in the sagittal view. In the axial view, the positioning was considered as flush, congruent, medial, too medial, or lateral. RESULTS: The median age of patients was 27.6 (±6.9). Mean operative time was of 161 min ±34.8. The fusion rate was of 78 %. Coracoid grafts were positioned 01:52 h (56° ± 14°) to 4:04 h (122° ± 12.5°). In the axial view, 32 % of the grafts positioning were considered as flush, 38 % as congruent, 30 % as medial, and 6 % too medial. No lateral position was noted. Two complications occurred, one graft fracture during screwing requiring opening conversion and an early case of osteolysis in a medial-positioned graft. CONCLUSION: The arthroscopic Latarjet procedure is a technically challenging technique that provides satisfactory fusion rate and graft positioning with a low complication rate. The clinical importance of this study lies in the observation that it is the first study to evaluate the position of the coracoid bone graft in arthroscopic Latarjet according to a detailed and validated method. LEVEL OF EVIDENCE: IV.

[Management of shoulder instability]. / Prise en charge de l'instabilité de l'épaule.

Management of shoulder instability. Shoulder instability is a commonly encountered problem in young active athletes. Instability is most often due to a traumatic gleno-humeral dislocation. The diagnosis is based on clinical apprehension tests and on diagnostic imaging. Most frequent lesions are Bankart lesion and Hill-Sachs injury. Shoulder instability could be managed conservatively with rehabilitation or surgically. The therapeutic indication should be discussed taking into account several criteria such as: traumatic versus atraumatic mechanisms, hyperlaxity, age, number of dislocations, type of work and sports activities and the presence of associated lesions.

Prise en charge de l'instabilité de l'épaule. L'instabilité de l'épaule est une pathologie fréquente qui touche le plus souvent des hommes jeunes et sportifs. Il s'agit le plus souvent d'une instabilité post-traumatique au décours d'une luxation gléno-humérale complète. Le diagnostic positif repose sur les tests cliniques d'appréhension ainsi que sur la réalisation d'examens d'imagerie. Les lésions les plus fréquentes sont la lésion de Bankart et l'encoche de Malgaigne. Cette instabilité peut faire l'objet d'un traitement conservateur avec rééducation ou d'un traitement chirurgical. La stratégie thérapeutique est définie en fonction du caractère traumatique ou atraumatique de l'instabilité, de la présence d'une hyperlaxité ligamentaire généralisée, de l'âge, du nombre d'épisodes de luxation, de l'activité professionnelle et sportive du patient et de la présence de lésions associées.

Outcome of arthroscopic treatment for displaced lateral clavicle fractures using a double button device.

PURPOSE: The purpose of this study was to assess the clinical and radiological outcomes of an arthroscopically assisted fixation of type IIB fractures using a double button device. METHODS: Twenty-one patients with a type IIB displaced fracture of the clavicle who received an arthroscopically assisted fixation using a double button device were enrolled from 2009 to 2011. Clinical assessment included the patient's demographics, cause of injury, delay before surgery, time for surgery, time before resuming work and sports, the Shoulder and Hand (QuickDASH) score, the Constant-Murley score and the visual pain analogue scale (VAS). Radiological examination consisted of anteroposterior and axillary radiographs. RESULTS: The median age of patients was 33 years (range 18-67). Mean follow-up was 35 ± 8.9 months (range 24-51 months). The average delay before surgery was 3 days (range 1-7). At final follow-up, the mean QuickDASH score, Constant score and VAS were respectively 3.2 ± 6 (range 0-25), 94.8 ± 9.9 (range 62-100) and 0.5 ± 1.2 (range 0-4). Seventeen (81 %) patients were able to resume work, including heavy manual labour, and to resume their sport activities as well. Postoperative complications included one transient adhesive capsulitis, a symptomatic acromioclavicular joint osteoarthritis and an implant failure with nonunion. Bony union was achieved in all other patients. CONCLUSION: This study has demonstrated that the arthroscopic treatment using a double button device was effective at providing a satisfactory functional outcome, minimizing the risk of complications and presenting low implant failure and low nonunion rates in patients with Neer type IIB fractures of the distal clavicle. Such results lead us to consider this minimally invasive technique as a first-choice treatment. LEVEL OF EVIDENCE: IV.

Visual impairment and hip fractures: a case-control study in elderly patients.

AIMS: To investigate the relationship between visual impairment and fall-related hip fracture and to determine the etiology of visual impairment in a population of elderly patients with hip fracture. METHODS: A case-control study compared 96 patients diagnosed with hip fracture to a randomly selected control group of 103 patients without hip fracture. Inclusion criteria for the case group were as follows: patients aged 60 years and over with a hip fracture. Clinical assessment included visual acuity and ophthalmic examination. RESULTS: Forty-three patients with hip fracture had a visual impairment compared to only 12 patients in the control group. Visual impairment was a significant risk factor for hip fracture (OR = 6.15; 95% CI 2.98-12.69). Twenty-seven hip fracture patients had an uncorrected refractive error compared to only 15 controls (OR = 2.78; 95% CI 0.92-8.35). There was no significant difference of dense cataract between both groups (OR = 2.28; 95% CI 0.75-6.93). Fourteen hip fracture patients had a macular degeneration compared to only 8 controls (OR = 5.63; 95% CI 1.57-20.18), and 10 patients had suspicion of glaucoma compared to only 5 controls (OR = 10.65; 95% CI 2.21-51.3). CONCLUSION: Visual impairment was significantly associated with an increased risk of hip fracture in elderly people. There are many etiologies that may contribute to hip fractures, most notably refractive error, cataract, macular degeneration and glaucoma.

Charcot spine and Parkinson's disease.

Charcot spine is rare condition whose association with Parkinson's disease (PD) has not been reported yet. The authors reported the cases of two patients with PD who developed Charcot spine. Both patients presented with a history of back pain and bilateral radicular leg pain. They had complete clinical and radiological assessment. Lumbar spine was involved in both patients. Clinical features and response to treatment were described. In the first case, circumferential fusion and stabilization were performed on the dislocated vertebral levels. A solid and stable fusion of the spine was obtained with satisfactory clinical outcome. Surgical treatment has been recommended to the other patient. In both cases, no other neurological etiology was found to account for Charcot spine. In conclusion, Charcot spine is associated with several neurological affections but has not previously been reported in association with Parkinson's disease.

Intratendinous injection of platelet-rich plasma under US guidance to treat tendinopathy: a long-term pilot study.

PURPOSE: To assess the potential therapeutic effect of intratendinous injection of platelet-rich plasma (PRP) under ultrasound (US) guidance to treat tendon tears and tendinosis in a pilot study with long-term follow-up. MATERIALS AND METHODS: The study included 408 consecutive patients referred for treatment by PRP injection of tendinopathy in the upper (medial and lateral epicondylar tendons) and the lower (patellar, Achilles, hamstring and adductor longus, and peroneal tendons) limb who received a single intratendinous injection of PRP under US guidance. Clinical and US data were retrospectively collected for each anatomic compartment for upper and lower limbs before treatment (baseline) and 6 weeks after treatment. Late clinical data without US were collected until 32 months after the procedure (mean, 20.2 months). The McNemar test and regression model were used to compare clinical and US data. RESULTS: QuickDASH score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and residual US size of lesions were significantly lower after intratendinous injection of PRP under US guidance at 6 weeks and during long-term follow-up compared with baseline (P < .001 in upper and lower limb) independent of age, gender, and type of tendinopathy (P > .29). No clinical complication was reported during follow-up. CONCLUSIONS: Intratendinous injection of PRP under US guidance appears to allow rapid tendon healing and is well tolerated.

Efficacy of intra-tendinous injection of platelet-rich plasma in treating tendinosis: comprehensive assessment of a rat model.

OBJECTIVES: To assess the potential of intra-tendinous injection of platelet rich plasma (PRP) to treat tendinosis (T+) in a rat model of patellar and Achilles T+, and evaluate its local toxicity. METHODS: Thirty rats (120 patellar and Achilles tendons) were used. We induced T+ into 80 tendons (patellar = 40, Achilles = 40) by injecting collagenase at day 0 under ultrasound (US) guidance. Clinical examination and US at day 3, followed by US-guided intra-tendinous injection of either PRP (PRPT+, n = 40) or physiological serum (ST+, n = 40, control). Follow-up was at days 6, 13, 18 and 25 using clinical, US and histological evaluation. To study PRP toxicity, we injected PRP into 40 normal tendons (PRPT-) and compared with 40 untreated normal tendons (T-). RESULTS: All PRPT+ showed better joint mobilisation compared with ST+ at day 6 (P = 0.005), day 13 (P = 0.02), day 18 (P = 0.003) and day 25 (P = 0.01). Similar results were found regarding US and histology, with smaller collagen fibre diameters (day 6, P = 0.003, day 25, P ≤ 0.004), less disorganisation and fewer neovessels (day 6, P = 0.003, day 25, P = 0.0003) in PRPT+ compared with ST+. Comparison between PRPT- and T- showed no PRP toxicity (P = 0.18). CONCLUSIONS: Our study suggests that mono-injection of PRP in T+ improves tendon healing, with no local toxicity. KEY POINTS: • We assessed the potential of platelet rich plasma (PRP) to treat tendinosis. • We treated patellar and Achilles tendinosis in a rat model. • We evaluated clinical, imaging and histological data. • Intra-tendinous PRP injection could be useful in the treatment of tendinosis.

Arthroscopic treatment of localized pigmented villonodular synovitis of the knee.

PURPOSE: The purpose of this study was to review the outcome of the arthroscopic treatment of localized pigmented villonodular synovitis of the knee and to determine the recurrence rate with clinical and magnetic resonance imaging evaluation at midterm follow-up. METHODS: Thirty consecutive patients diagnosed with localized pigmented villonodular synovitis of the knee were treated arthroscopically between 1990 and 2008. Clinical assessment was made with the use of Lysholm Knee Scale, and radiologic assessment was done by plain radiographs and magnetic resonance imaging of the knee. Recurrence rate of the disease was also estimated. RESULTS: The average follow-up was 75 months (range 12-144). The median age of the patients was 46 years (range 23-71). Symptoms were discomfort of the knee (100%), swelling (90%), locking (50%), pain (10%) and palpable mass (15%). A history of knee trauma was present in 10% of the patients. The nodules were localized in the gutters (45%), suprapatellar pouch (26%), patellar fat pad (13%), posterior compartment of the knee (13%) and in the femoral notch (9%). The median Lysholm Knee Score was 56.5 (range 53-60) and 85.5 (83-88) preoperatively and at final follow-up, respectively. No postoperative complications occurred. CONCLUSIONS: Arthroscopy is a safe and effective procedure for the treatment of localized pigmented villonodular synovitis of the knee. Magnetic resonance imaging is essential to diagnose this pathologic condition and to define accurately its localization and treatment strategy.