Arthroscopic Bristow-Latarjet combined with bankart repair restores shoulder stability in patients with glenoid bone loss.

BACKGROUND: Arthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure. QUESTIONS/PURPOSES: We determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout. METHODS: Between July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed. RESULTS: At latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion. CONCLUSIONS: The arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Single-radius, multidirectional total knee replacement.

PURPOSE: The present study was designed to evaluate the mid-term (5- to 8-year) survival rate of a new total knee replacement (TKR) with a single-radius femoral component and a multidirectional, highly congruent tibial component, in comparison with an historical group (TKR with multi-radius design and fixed bearing). METHODS: Four hundred and thirty patients were included, of which 369 patients (86 %) completed the 5-year follow-up with Knee Society Score evaluation and radiograph examination (study group = 387, control group = 83). RESULTS: There was a significant improvement for all analysed items between pre-operative status and late follow-up. Mean knee score was 93 ± 9 points in the study group and 88 ± 16 points in the control group (p < 0.001). Mean flexion angle was not different (118 ± 11 vs. 114 ± 13 degrees). Mean functional score was 87 ± 16 points in the study group and 71 ± 24 points in the control group (p < 0.001). Survival rate at 5-year follow-up was 98.8 % (vs. 98.0 %) for mechanical revisions only, and 96.4 % (vs. 98.1 %) for all revisions. CONCLUSIONS: The new TKR allowed obtaining significantly better results than the fixed-bearing TKR. These results are in line with the best series published in the current literature, but there was no evidence of any superiority of this TKR against already published standards.

Results of forty two computer-assisted double level osteotomies for severe genu varum deformity.

PURPOSE: The goal of this article was to present the clinical and radiological results of 42 severe genu varum operated on between August 2001 and June 2010 using computer navigation. METHODS: All the osteotomies were navigated using the Orthopilot® device (B-Braun-Aesculap, Tuttlingen, Germany). The procedure was performed such that after inserting the rigid bodies and calibrating the lower leg, we first made the femoral closing wedge osteotomy (from four to seven mm) which was fixed by an AO T-Plate, and then, after checking the residual varus, the tibial opening wedge osteotomy was made using a Biosorb® wedge (Tricalcium phosphate, SBM, Lourdes, France) and a plate (AO T-plate or C-plate). RESULTS: All the patients were assessed at a mean follow-up of 46 ± 27 months (range, 12-108). The mean Lyshölm-Tegner score was 83.3 ± 7.5 points (62-91) and the mean KOOS score was 95.1 ± 3.2 points (89-100). Forty patients were satisfied (22) or very satisfied (18) with the result. Regarding the radiological results, the goal was reached in 92.7% of cases and the mean HKA angle was 181.83° ± 1.80° (177-185°). At that mid-term follow-up no patient had revision to a total knee arthroplasty. CONCLUSION: Computer-assisted double level osteotomy in severe genu varum is a reliable, reproducible, and accurate technique. This procedure, which is very delicate, especially in reaching pre-operative objectives, is simplified by computer-assistance.

The surgical treatment of peroneal tendinopathy (excluding subluxations): a series of 17 patients.

Peroneal tendon pathology is rare, but is probably underestimated because it is frequently undiagnosed. It should always be in the differential diagnosis of lateral ankle pain. Surgical treatment of peroneal tendinopathy is indicated after failure of conservative measures. The aim of this retrospective study is to evaluate the medium-term clinical results of 17 patients operated for peroneal tendinopathy without tendon subluxation. A series of 17 patients composed of 7 women and 10 men with a mean age of 53.6 ± 4.6 (range 45 to 60) years were reviewed. The mean preoperative Kitaoka score was 46.7 ± 17.1 (range 25 to 69) points. All patients had radiological evaluation, which demonstrated hindfoot varus in 6 of the 17. Surgical interventions comprised synovectomy, debridement, suture-tubularization, fibrous resection, or tenodesis depending on the preoperative findings and also a valgus osteotomy (Dwyer) in 6 cases and ankle ligament reconstruction (modified Blanchet) in 1 case. All patients were reviewed clinically with a mean follow-up of 4.3 ± 3.8 years (range 16 months to 14 years). Average time to return to sport was 8.5 ± 10.4 months (range 3 months to 3 years). The mean time to return to work was 2.5 ± 1.9 (range 0 to 6) months. The mean postoperative Kitaoka score was 90.1 ± 11 (range 64 to 100) points with a statistically significant improvement to the preoperative score (p < .0001). Sixteen patients were satisfied or very satisfied with their treatment (94.1%). Surgical treatment of peroneal tendinopathy after failed conservative treatment leads to significantly improved function. It is a simple treatment to undertake, which gives a good outcome for both the patient and surgeon.

Mini-open latarjet procedure for recurrent anterior shoulder instability.

Anterior shoulder instability is a common problem. The Latarjet procedure has been advocated as an option for the treatment of anteroinferior shoulder instability. The purpose of this paper is to explain our surgical procedure titled "Mini-open Latarjet Procedure." We detailed patient positioning, skin incision, subscapularis approach, and coracoid fixation. Then, we reviewed the literature to evaluate the clinical outcomes of this procedure.

Outcome of opening wedge high tibial osteotomy augmented with a Biosorb® wedge and fixed with a plate and screws in 124 patients with a mean of ten years follow-up.

The objective of this work was firstly to evaluate the long-term results of medial opening wedge high tibial osteotomy (HTO) and secondly to evaluate the tolerance and integration of a Biosorb® wedge (ß Tricalcium Phosphate, SBM Company, Lourdes, France). The series consisted of 124 knees in 110 patients, 74 men and 36 women, with mean age of 53.23±10.68 years (range 32-74) and treated between June 1995 and November 2000 for medial compartment knee osteoarthritis by the senior author. The mean preoperative Lysholm and Tegner functional score was 65.44±13.32 (range 27-80) and the preoperative HKA angle was 172.51°±3.8° (range 162-179°). According to the modified Ahlbäck classification there were 27 stage I, 42 stage II, 44 stage III and 11 stage IV knees. All patients were reviewed clinically and radiologically with a mean follow-up of 10.39±1.98 years (range 8-14 years). Immediate postoperative complications consisted of nine undisplaced lateral tibial plateau fractures of no clinical significance, two deep vein thromboses and three pulmonary emboli which resolved with appropriate treatment. At a later stage, there were seven delayed unions without development of pseudarthrosis, and three screw breakages when the AO T-plate was used, leading to a secondary angulation in one case, requiring revision by femoral osteotomy. Postoperative mean weightbearing HKA angle was 182°±1.8° (range 178-186°) and 73.4% of axes were 184°±2°. Fifteen knees (12.1%) underwent total knee arthroplasty (TKA) after a mean delay of 8.87±3.04 years and were excluded from the final analysis. Concerning the long-term results (n = 107 knees), the mean Lysholm-Tegner score was 88±12.7 points (51-100) and the KOOS score was 86±14.6 points (25-100) with 94 patients satisfied or very satisfied (87.85%). In terms of the HTO survivorship curve, with failure consisting of revision to TKA or another operation, survival was 88.8% at five years and 74% at ten years. Concerning Biosorb®, this was completely integrated in 100% of cases and there was complete resorption in 12.1% of cases and greater than 50% resorption in 52.3% of cases.

Arthroscopic Bankart-Bristow-Latarjet procedure: the development and early results of a safe and reproducible technique.

PURPOSE: To evaluate the reproducibility and safety of a novel arthroscopic technique combining a Bristow-Latarjet procedure with a Bankart repair and to report the early clinical and radiologic results. METHODS: Forty-seven consecutive patients with glenoid bone loss and capsular deficiency were treated with this all-arthroscopic technique; six patients had a failed arthroscopic capsulolabral repair. The coracoid fragment was osteotomized, passed with the conjoined tendon through the subscapularis muscle, and fixed in the standing position with a cannulated screw on the abraded glenoid neck. The capsule and labrum were then reattached on the glenoid rim, leaving the coracoid bone block in an extra-articular position. Potential intraoperative and postoperative complications were recorded. All patients were reviewed and had postoperative radiographs; 35 had computed tomography scans. RESULTS: The procedure was performed entirely arthroscopically in 41 of 47 patients (88%); a conversion to open surgery was needed in 6 patients (12%). The axillary nerve was identified in all cases, and no neurologic injuries were observed. No patient had any recurrence of instability at the most recent follow-up (mean, 16 months). The mean Rowe score was 88 ± 16.7, and the mean Walch-Duplay score was 87.6 ± 12.9. The Subjective Shoulder Value was 87.5% ± 12.7%. The bone block was subequatorial in 98% of the cases (46 of 47) and flush to the glenoid surface in 92% (43 of 47); it was too lateral in 1 (2%) and too medial (>5 mm) in 3 (6%). There was 1 bone block fracture and 7 migrations. CONCLUSIONS: The arthroscopic Bristow-Latarjet-Bankart procedure is reproducible and safe. This procedure allows restoration of shoulder stability in patients with glenoid bone loss and capsular deficiency, as well as in the case of failed capsulolabral repair. Arthroscopy offers the advantage of providing adequate visualization of both the glenohumeral joint and the anterior neck of the scapula, allowing accurate placement of the bone block and screw. Surgeons should be aware that the procedure is technically difficult and potentially dangerous because of the proximity of the brachial plexus and axillary vessels. Training on cadaveric specimens and transition from open to mini-open and, finally, to all arthroscopic is recommended. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic Bankart-Bristow-Latarjet (2B3) Procedure: How to Do It and Tricks To Make it Easier and Safe.

The all-arthroscopic technique that the authors propose combines a Bristow-Latarjet procedure with a Bankart repair. This combined procedure provides a triple blocking of the shoulder (the so-called 2B3 procedure): (1) the labral repair recreates the anterior bumper and protects the humeral head from direct contact with the coracoid bone graft (Bumper effect); (2) the transferred coracoid bone block compensates for anterior glenoid bone loss (Bony effect); and (3) the transferred conjoined tendon creates a dynamic sling that reinforces the weak anteroinferior capsule by lowering the inferior part of the subscapularis when the arm is abducted and externally rotated (Belt or sling effect). The procedure combines the theoretic advantages of the Bristow-Latarjet procedure and the arthroscopic Bankart repair, eliminating the potential disadvantages of each. The extra-articular positioning of the bone block together with the labral repair and capsule retensioning allows the surgeon to perform a nearly anatomic shoulder repair. This novel procedure allows the surgeon to extend the indications of arthroscopic shoulder reconstruction to the subset of patients with recurrent anteroinferior shoulder instability with glenoid bone loss and capsular deficiency. It is an attractive surgical option to treat patients with a previous failed capsulolabral repair for which the surgical solutions are limited.

Long-term clinical results of the Oxford medial unicompartmental knee arthroplasty.

The purposes of this study were to investigate the mode of failure and survivorship of an independently performed series of medial Oxford unicompartmental knee arthroplasties. The study included 43 knees in 40 patients with a mean follow-up of 14.88 years: 13 knees (11 patients) had revision surgery (30%), and ten patients required conversion to total knee prosthesis. The mean International Knee Society (IKS) scores at the time of the revision were 145.52 [standard deviation (SD): 39.90, range: 167-200]. The overall alignment of the knee was restored to neutral, with a hip-knee-ankle (HKA) angle average of 178° (SD: 3.21°, range: 170-186°). Survivorship, as defined by an endpoint of failure for any reason, showed that the survival rate at five years was 90%, at ten years 74.7% and at 15 years 70%. Excluding inappropriate patient selection and surgeon-associated failures, our survival analysis plot is much improved: survivorship at five years is 94.5%, at ten years 85.7% and at 15 years 80.4%. The Oxford meniscal bearing arthroplasty offers long-term pain relief with good knee function. Unfortunately, we demonstrated a high complication rate, with some of the failures encountered indicating that the surgical technique is very demanding.

Computer-assisted osteotomies for genu varum deformity: which osteotomy for which varus?

High tibial osteotomy (HTO) is commonly used for genu varum deformity in young and active patients. Corrective valgus osteotomy may however lead to an oblique joint line in cases of associated femur varum or absence of tibia vara. The over-correction, needed to obtain good long-term clinical results, may increase the obliquity even more. To avoid this drawback, the authors suggest use of an accurate and reproducible radiological protocol including at least a standing AP long-leg X-ray to measure not only the hip-knee-ankle (HKA) angle but also the medial distal femoral mechanical angle (MDFMA) and the medial proximal tibial mechanical angle (MPTMA). These measures will guide the surgeon to choose the best indication, including HTO, double level osteotomy (DLO) and distal femoral osteotomy (DFO). Computer-navigation of the osteotomies is the best choice to achieve the preoperative goal. This paper will present the pre- and perioperative protocols of HTO and DLO and the rationale behind this way of thinking.