Surgical Treatment of a Symptomatic Diaphyseal Tibiofibular Synostosis in a Professional Rugby Player: A Case Report and Literature Review.

CONTEXT: Diaphyseal tibiofibular synostosis (DTS) is a rare pathology with unknown origin especially occurring in intensive sport athletes. No therapeutic guideline has been well established in the literature. CASE PRESENTATION: A rare case of DTS in a 26-year-old professional rugby player has been described. A 5-month exhaustive conservative treatment including physiotherapy and oral medication has been achieved but failed. Management and Outcomes: Following the conservative treatment failure, the DTS has been widely removed including the adjacent interosseous membrane, and the patient could return to competition at the same level after 5 months of convalescence. No recurrence has been revealed at a 35-month follow-up at least. CONCLUSION: In accordance with the literature data and even if the pathophysiology remains obscure, resection of DTS seems to be the adapted treatment to allow and to reduce professional athletes' recovery time at the same sport level. The resection including a part of the tibiofibular interosseous membrane could avoid the occurrence of recurrence. Conservative treatment should be reserved for senior patients with a low sport activity.

Return to Sport After Primary and Revision Anterior Cruciate Ligament Reconstruction: A Prospective Comparative Study of 552 Patients From the FAST Cohort.

BACKGROUND: Few studies have reported the return-to-sport rate at 1-year follow-up after primary and revision anterior cruciate ligament (ACL) reconstruction. PURPOSE: To compare the return-to-sport rate 1 year after primary and revision ACL reconstruction in the same cohort according to 2 modalities: any kind of sport and the patient's usual sport at the same level as before the injury. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A single-center, prospective cohort study of patients undergoing ACL reconstruction (French prospective Acl STudy [FAST]) was begun in 2012. A comparative study was performed based on a retrospective analysis of data collected prospectively. Included were all athletes aged 18 to 50 years who underwent primary or revision isolated ACL reconstruction between 2012 and 2014. Two groups were formed: primary reconstruction and revision reconstruction. The main criterion was return to sport at 1-year follow-up (yes/no); secondary criteria were return to the usual sport at 1-year follow-up, knee function (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS] scores), and psychological readiness (ACL-Return to Sports after Injury [ACL-RSI] score) at 6 months and 1 year. RESULTS: A total of 552 patients (primary reconstruction group: n = 497, revision reconstruction group: n = 55) were included in the study. There were 373 men and 179 women (mean [±SD] age, 30.2 ± 8.4 years). No significant difference in the return-to-sport rate was found between the 2 groups at 1-year follow-up (primary reconstruction group: 90.9%, revision reconstruction group: 87.3%; P = .38), but patients in the primary reconstruction group resumed their usual sport significantly more often (primary reconstruction group: 63.6%, revision reconstruction group: 49.1%; P = .04). Eight (1.4%) retears occurred during a new sport-related injury within a mean 8.9 ± 2.9 months: 7 (1.4%) in the primary reconstruction group and 1 (1.8%) in the revision reconstruction group ( P = .8). At 1-year follow-up, functional scores were significantly better in the primary reconstruction group for subjective IKDC (82.6 ± 13.3 vs 78.4 ± 16.6; P = .04); KOOS Symptoms/Stiffness (73.3 ± 15.2 vs 67.7 ± 19.6; P = .02), Activities of Daily Living (96.3 ± 6.4 vs 94.3 ± 9.1; P = .04), Sport (79.7 ± 19.1 vs 69.1 ± 24.8; P = .0004), and Quality of Life (69.6 ± 22.7 vs 54.7 ± 24.8; P < .00001) subscales; and ACL-RSI (65 ± 23 vs 49.5 ± 24.8; P < .00001). On multivariate analysis, patients who were more likely to resume their usual sport at 1 year were high-level players (odds ratio [OR], 2.2) who underwent primary reconstruction (OR, 2.0) and had better KOOS Quality of Life (OR, 1.7) and subjective IKDC (OR, 2.1) scores at 6-month follow-up without complications or retears during the first postoperative year (OR, 2.6). CONCLUSION: At 1-year follow-up, there was no significant difference in the return-to-sport rate between primary and revision ACL reconstruction. Patients who underwent primary reconstruction returned to their usual sport significantly more often. TRIAL REGISTRATION: NCT02511158 ( ClinicalTrials.gov identifier).

The split portal: Description of a new accessory posterior portal for arthroscopic shoulder instability procedures.

PURPOSE: Open approach to the posterior shoulder during bone block for posterior shoulder instability is challenging. Anatomical study was performed to identify landmarks of a portal, avoiding soft tissue damage, between the infraspinatus (IS) and teres minor (TM) muscles and distant from the supra-scapular nerve (SSN) for arthroscopic shoulder bone block. METHODS: Eight fresh-frozen cadaveric shoulder specimens were used. The arthroscope was introduced through the soft point (SP). A guide wire was placed through the SP, in the rotator interval direction. A posterior open dissection exposed the split between the IS and TM. A new guide wire was placed into the split, parallel to the first wire, to locate the new posterior arthroscopic approach. Ten distances were measured to define the safe position. RESULTS: The mean values were: SP to split IS-TM: 2 ± 0.2 (2-2.8); spinal bone to split IS-TM: 5 ± 0.5 (3-6.2); split IS-TM to posterior glenoid 6 o'clock: 1.3 ± 0.3 (0.6-1.6), 9 o'clock: 1.5 ± 0.3 (1-1.9), and 12 o'clock: 2 ± 0.1 (2.1-2.4); SSN to posterior glenoid 6 o'clock: 2.4 ± 0.2 (2.1-2.6), 9 o'clock: 1.7 ± 0.1 (1.5-1.8), and 12 o'clock: 1.5 ± 0.3 (1.2-2.1); and SSN to split IS-TM: 2 ± 0.3 (1.2-2.1). CONCLUSION: This preliminary anatomical study described a posterior arthroscopic portal located 2 cm under the SP, parallel to the SP portal direction, and finishing between 7 and 8 o'clock at the posterior rim of the glenoid. For arthroscopic shoulder bone block, this portal can avoid muscle and SSN lesions.

The risk of dislocation after total hip arthroplasty for fractures is decreased with retentive cups.

PURPOSE: Total hip arthroplasty (THA) has been efficacious for treating hip fractures in healthy older patients. However, in those patients with fractures a widely variable prevalence of dislocation has been reported, partly because of varying durations of follow up for this specific end-point. The purpose of the present study was to determine the cumulative risk of dislocation in these patients with fractures and to investigate if retentive cups decrease the risk of dislocation. METHODS: Between 2000 and 2005, 325 patients with neck fracture underwent primary THA using a retentive (325 hips) cup. The results of these 325 acetabular cups were compared to 180 THA without retentive cups performed for neck fractures in the same hospital between 1995 and 2000 by the same surgical team. The mean age of the 505 patients was 75 years (range 65-85). All patients were followed for a minimum of five years for radiographic evidence of implant failure. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation and recurrent dislocation was calculated with use of the Kaplan-Meier method. RESULTS: For patients without retentive cups, the cumulative risk of a first-time dislocation was 5 % at one month and 12 % at one year and then rose at a constant rate of approximately 1 % every year to 16 % at five years. For patients with retentive cups, the cumulative risk of a first-time dislocation was 1 % at one month, 2 % at one year and then did not changed at five years. There were no differences in the mortality rates or in loosening rates among the treatment groups. The rate of secondary surgery was highest in the group without retentive (10 % for recurrent dislocation) compared with 1 % in the group treated with retentive cups. In absence of retentive cups, multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were 80 years old or more (as compared with those who were less than 80 years old) was 1.5. Two underlying diagnoses occurring during follow up-cognitively impaired patients or neurologic disease-were also associated with a significantly greater risk of dislocation in absence of retentive cup. For these patients the risk was also decreased with a retentive cup. CONCLUSION: With standard cups the incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are old female patients and those with a diagnosis of neurologic disease. Retentive cups in these patients are an effective technique to prevent post-operative hip dislocation.