Five-year clinical follow-up of arthroscopically treated chronic ankle instability.

INTRODUCTION: Arthroscopic treatment of lateral ankle instability is a recent innovation. In 2014, a prospective study was initiated by the French Society of Arthroscopy demonstrating the feasibility, morbidity and short-term results of arthroscopic treatment of ankle instability. HYPOTHESIS: The functional results of arthroscopic treatment of chronic ankle instability found after one year were maintained in the medium term. MATERIAL AND METHODS: The prospective follow-up of the patients included in the initial cohort was continued. The Karlsson and AOFAS scores, as well as patient satisfaction, were assessed. The causes of failure underwent univariate and multivariate analyzes. The results of 172 patients were included (40.2% ligament repairs; 59.7% ligament reconstructions). The average follow-up was 5years. The average satisfaction was 8.6/10, the average Karlsson score was 85 points and the average AOFAS score was 87.5 points. The reoperation rate was 6.4% of patients. The failures were related to an absence of sports practice, a high BMI and female gender. A high BMI and the intense sports practice were associated to ligament repair failure. The absence of sports practice and the intraoperative presence of the anterior talofibular ligament were associated to ligament reconstruction failure. DISCUSSION: Arthroscopic treatment of ankle instability confers high satisfaction in the medium term, as well as long-lasting results with a low reoperation rate. A more detailed evaluation of the failure criteria could help guide the choice of treatment between ligament reconstruction or repair. LEVEL OF EVIDENCE: II.

PT4: New arthroscopic technique for isolated reconstruction of the anterior talofibular ligament using a quadrupled plantaris tendon.

The strategy for surgical treatment of chronic ankle instability is becoming increasingly refined. In instances of isolated symptomatic non-repairable anterior talofibular ligament (ATFL) injury, there is a surgical indication for isolated ATFL reconstruction. However, we feel that the typical gracilis tendon graft is not always appropriate. Interest in using the plantaris tendon as a graft has picked up since a biomechanics study found the tensile strength of a quadrupled plantaris tendon is comparable to that of the ATFL. Here, we describe an original arthroscopic technique for isolated ATFL reconstruction using a quadrupled plantaris tendon (PT4) graft.

Diagnosis and treatment of tibiofibular syndesmosis lesions.

The tibiofibular syndesmosis is a fibrous joint essential for ankle stability, whence the classical comparison with a mortise. Syndesmosis lesions are quite frequent in ankle trauma. This is a key element in ankle stability and lesions may cause pain or instability and, in the longer term, osteoarthritis. The lesions are often overlooked due to diagnostic difficulties, but collision sport with strong contact is the main culprit. Diagnosis, whether in the acute or the chronic phase, is founded on an association of clinical and paraclinical signs. Cross-sectional imaging such as MRI is fundamental to confirming clinical suspicion. Absence of tibiofibular diastasis no longer rules out the diagnosis. Stress CT and the introduction of weight-bearing CT are promising future diagnostic tools. Exhaustive osteo-ligamentous ankle assessment is necessary, as syndesmosis lesions may be just one component in more complex rotational instability. Therapeutically, arthroscopy and new fixation techniques, such as suture buttons, are opening up new perspectives, especially for chronic lesions (>6months). The present anatomic, epidemiological, diagnostic and therapeutic review does not preclude further clinical studies of rotational ankle instability with its strong risk of osteoarthritis.

Agreement between arthroscopic and imaging study findings in chronic anterior talo-fibular ligament injuries.

BACKGROUND: Imaging studies done to evaluate chronic ankle instability (CAI) often fail to accurately detail injuries to the anterior talo-fibular ligament (ATFL) and may, therefore, also fail to provide guidance for selecting the most appropriate surgical procedure. Arthroscopy is now an indispensable tool for accurately diagnosing ATFL injuries. This study looked at agreement between arthroscopy and imaging study assessments of ATFL injuries. The primary objective was to adapt an arthroscopic classification of chronic ATFL lesions to the pre-operative imaging study findings in order to estimate the performance of computed tomography (CT)-arthrography, ultrasonography, and magnetic resonance imaging (MRI) in diagnosing ATFL lesions, using arthroscopy as the reference standard. HYPOTHESIS: Agreement between arthroscopic and imaging findings of chronic ATFL injuries can be assessed by using a shared classification developed from the arthroscopic evaluation, used as the reference standard. MATERIAL AND METHODS: A prospective multicentre study was conducted in 286 patients with arthroscopically-treated CAI. In each patient, the arthroscopic assessment of the ATFL was compared to the pre-operative findings by CT-arthrography, ultrasonography, and MRI. A classification of ATFL lesions based on the arthroscopic assessment was used to analyse the imaging studies. Using this classification, two independent observers compared the findings and evaluated the agreement between arthroscopy and imaging studies. RESULTS: Of the 286 patients, 157 had complete information on the arthroscopic assessment and on pre-operative imaging studies and were included in the analysis. Imaging studies were CT-arthrography in 49 patients, ultrasonography in 63 patients, and MRI in 45 patients; both ultrasonography and MRI were performed in 3 patients. Agreement with arthroscopy was 82% and 88.5% for CT-arthrography, 66.7% and 76.2% for ultrasonography, 70.5% and 79.5% for MRI, and 73.4% and 81.2% for all imaging studies pooled. DISCUSSION: Arthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with CAI, as it supplies far more accurate information than any of the current imaging studies and, in addition, provides a dynamic evaluation of the ligaments and assesses mechanical strength. In the study population, a simple arthroscopic evaluation consistently visualised ATFL lesions, thereby either correcting or confirming the pre-operative imaging study findings. Importantly, the arthroscopic assessment provided more accurate information on the lesions and quality of the ATFL compared to the imaging studies. Arthroscopy has improved our knowledge of chronic ATFL lesions and allowed the development of a simple but accurate four-grade classification of direct relevance to choosing the optimal therapeutic procedure. This classification must be disseminated among radiologists to improve the diagnostic performance of pre-operative imaging studies, assist surgeons in selecting the most appropriate ankle-stabilising procedure, and improve patient information. Further studies are needed to confirm the promising results reported here and the usefulness of this common arthroscopy and imaging-study classification for chronic ATFL lesions. LEVEL OF EVIDENCE: II.

Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients.

BACKGROUND: Chronic ankle instability (CAI) is the main complication of ankle sprains and requires surgery if non-operative treatment fails. Surgical ankle stabilisation techniques can be roughly classified into two groups, namely, repair involving retensioning and suturing of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and reconstruction using a tendon graft. Arthroscopic repair and reconstruction techniques for CAI have been introduced recently. The objective of this prospective multicentre study was to assess the feasibility, morbidity, and short-term outcomes of these arthroscopic ankle-stabilisation techniques. MATERIAL AND METHODS: Consecutive patients scheduled for arthroscopic treatment of CAI were included prospectively. Of the 286 included patients, 115 underwent ligament repair and 171 ligament reconstruction. Mean follow-up was 9.6 months (range, 6-43 months). We recorded the AOFAS and Karlsson scores, patient satisfaction, complications, and time to return to sports. RESULTS: The overall patient satisfaction score was 8.5/10. The AOFAS and Karlsson scores improved significantly between the pre- and postoperative assessments, from 62.1 to 89.2 and from 55 to 87.1, respectively. These scores were not significantly different between the groups treated by repair and by reconstruction. Neurological complications occurred in 10% of patients and consisted chiefly in transient dysesthesia (with neuroma in 3.5% of patients). Cutaneous or infectious complications requiring surgical revision developed in 4.2% of patients. DISCUSSION: Arthroscopic treatment is becoming a method of choice for patients with CAI, as it allows a comprehensive assessment of the ligament lesions, the detection and treatment of associated lesions, and repair or reconstruction of the damaged ligaments. These simple, reliable, and reproducible arthroscopic techniques seem as effective as conventional surgical techniques. The rate of cutaneous complications is at least halved compared to open surgery. CONCLUSION: Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes.

Arthroscopic classification of chronic anterior talo-fibular ligament lesions in chronic ankle instability.

BACKGROUND: The surgical treatment of chronic ankle instability (CAI) relies chiefly on anterior talo-fibular ligament (ATFL) repair (with or without augmentation) or anatomical reconstruction with a tendon graft. Arthroscopy enables not only a complete assessment and the same-stage treatment of concomitant articular lesions, but also an accurate assessment of ligament lesions. Pre-operative imaging studies (MRI, CT, US) may fail to provide sufficient detail about chronic ATFL lesions to guide the decision between repair and reconstruction. The aim of this study was to develop an arthroscopic classification of chronic ATFL lesions designed to assist in selecting the optimal surgical technique. MATERIAL AND METHODS: Sixty-nine anterior ankle arthroscopy videos recorded before surgery for CAI were studied retrospectively. ATFL dissection was performed in all patients. Based on the video analysis, five ATFL grades were identified: 0, normal ATFL thickness and tension; 1, ATFL distension with normal thickness; 2, ATFL avulsion with normal thickness; 3, thin ATFL with no resistance during the hook test; and 4, no ATFL, with a bald malleolus. Intra- and interobserver reproducibility of the arthroscopic classification of chronic ATFL lesions was evaluated by computing the kappa coefficients (κ) after assessment by two independent observers. RESULTS: All 69 ATFLs were classified as abnormal (none was grade 0). Each ATFL could be matched to a grade. Intra-observer agreement was good for both observers: κ was 0.67 with 75% of agreement for one observer and 0.68 with 76% of agreement for the other observer. Inter-observer agreement was fair to good, with κ values ranging from 0.59 to 0.88 and agreement from 70% to 91%. DISCUSSION: Arthroscopic ATFL dissection is a simple procedure that provides a highly accurate assessment of ATFL lesions and mechanical resistance, focussing chiefly on the superior ATFL. Grade 1 and 2 lesions can be repaired using the Broström-Gould procedure, whereas grade 3 and 4 lesions require anatomic reconstruction with grafting. CONCLUSION: This arthroscopic classification of chronic ATFL lesions confirms the diagnostic role for arthroscopy in assessing the ligaments in patients with CAI. It is helpful for determining the best surgical technique for stabilising the ankle. These results must be confirmed in a larger study.

Modeling and determination of directionality of the kerf in epifluorescence sharp bone trauma analysis.

Characteristics of sharp bone trauma can be extremely useful to determine the origin of cut marks and to provide information regarding the context of death. Using human ribs and clavicle bones, this study analyzes the characteristics of bone kerfs made by different bladed implements, thanks to epifluorescence macroscopy. This technique, which is a nondestructive tool that uses autofluorescence of bones, documents bone damage precisely with high resolution. Both qualitative and quantitative criteria are analyzed. Our results identify unique class characteristics on bone lesions, allowing modeling kerf depending on the weapon, regardless of the type of bone that is wounded. Moreover, we demonstrate for the first time microscopic criteria of directionality, using fluorescence excitation. Orientation of cracks, flakes, and lateral pushing back especially helps in determining the tip and the end of the lesion, leading to the position of the aggressor. Kerf wall characteristics and striation location are also very useful. Epifluorescence macroscopy could be a new tool of choice in anthropology through cut mark analysis in establishing how the blade was used and providing details about the blow.

Anatomic variations of the renal vessels: focus on the precaval right renal artery.

The aim of this study was to determine the prevalence of precaval right renal artery and to investigate the distribution of renal arteries and veins. We discuss a theory of development of renal vascular variants. We retrospectively reviewed 120 arterial phase contrast material-enhanced spiral computerized tomography scans of the abdomen (1- to 2-mm section thickness) performed during a two-month period. Forty percent of the study group (48 patients) had one artery and one vein on each side, with typical course. There was a 9.17% prevalence of precaval right renal artery: 10 patients had a lower pole accessory artery in precaval position and one patient had the main and the accessory arteries that pass anterior to the inferior vena cava. In these cases, associated variations of renal vessels were higher than in the patients without precaval artery variant. There were multiple arteries in 28.3% of the right kidneys and in 26.7% of the left ones. Variants of the right renal vein consisted in multiple veins in 20% (24 cases). We detected no case of multiple left renal veins, but we described variations of its course (circum- or retroaortic vein) in 9.17% (11 cases). Twenty-six patients (21.7%) had associated variations of the renal pedicle. The current technical support allows for a minimally invasive study of vessels anatomy. In our study the prevalence of a precaval right renal artery appears to be higher than previously reported (9.17%). Knowledge on anatomical variations of right renal artery and associated renal vessels variations has major clinical implications.

The anconeus, an active lateral ligament of the elbow: new anatomical arguments.

PURPOSE: As there are a few detailed anatomical studies of the active function of anconeus muscle in stabilizing the elbow, we aimed to look for anatomical features confirming its role as an active stabilizer of the humero-ulnar joint. METHODS: Thirty fresh unembalmed elbows from 15 cadavers were dissected. We examined the anatomy, insertions, relationships and orientation of the muscle fibres of the anconeus. RESULTS: The anconeus lies in a separate compartment from the other forearm muscles, but in continuity with the extensor (triceps) compartment of the arm. In all the cases, at its proximal extremity we observed continuity of muscle and tendon with the vastus lateralis of the triceps brachii. The muscle fibres run downward and backward, parallel to the fibres of vastus lateralis of the triceps, when the elbow is in extension. Its deep aspect adheres closely to the lateral joint capsule of the humero-ulnar joint. CONCLUSION: The new anatomical characteristics of the anconeus revealed in this study make this muscle a digastric head of triceps brachii that coapts the ulna to the humerus and so reduces varus instability. The close relationships between triceps brachii and the anconeus on one hand and between the joint capsule and the anconeus on the other make the latter muscle an active lateral stabilizer of the elbow.

Correlations between effective permeability and marrow contact channels surface of vertebral endplates.

Homeostasis of the intervertebral disc relies on nutrient supply and waste clearance through the dense capillary network that is in contact with the cartilage endplate (CEP). We developed a micro-computerized tomography (micro-CT) method to quantify the marrow contact channel surface (MCCS) with the CEP and to validate the hypothesis according to which MCCS was correlated to the effective permeability of the vertebral endplate (VEP) and influenced by the mechanical stimuli. The influence of compression loading on local vascularization was investigated. Six 4-week-old skeletally immature pigs were instrumented with left pedicle screws and rod at both T5-T6 and L1-L2 levels to create asymmetrical spine tethers. After 3 months of growth, three cylindrical specimens of the VEP (one central and two lateral right and left) were obtained from both the instrumented and the control levels. We used a previously validated method for measuring permeability. Micro-CT analysis (resolution 12 microm) yielded a gray-scale 2D-image of the discal end of each specimen converted into a binary 2D-image to derive the MCCS. Correlations between MCCS and effective permeability were assessed. Effective permeability and MCCS were significantly decreased compared to the control group especially on the tethered side (-41.5%, p = 0.004 and -52.5%, p = 0.0009, respectively). Correlations were significant and showed maximal value (r(2) = 0.430, p < 0.0001) on the tethered side involving maximal compressive loadings. Mechanical stimuli, due to unbalanced growth, altered the vascularization and the convective properties of the CEP. The cascade of mechanobiological events should offer perspectives for research on disc degeneration and attempted treatment.

A case of malignant primary non-Hodgkin's lymphoma in skeletal muscle treated by exclusive chemotherapy.

Malignant non-Hodgkin's lymphoma (MNHL) is a frequent tumour but a primary intra-muscular location is exceptional. Standard treatment combines wide surgical removal with chemotherapy and radiotherapy. The functional consequences of this large excision are sometimes very unsatisfactory. We report the case of an intra-muscular MNHL of the posterior and internal part of the thigh. The diagnostic was established thanks to selective biopsies. The treatment was purely medical and conservative with chemotherapy after a multidisciplinary oncological discussion. Three years after the treatment, the general state of health is excellent with no signs of local or remote recurrence.

Anterolateral mini-invasive versus posterior mini-invasive approach for primary total hip replacement. Comparison of exposure and implant positioning.

INTRODUCTION: We conducted a prospective study to compare the exposure and implant positioning in primary total hip replacement through the anterolateral minimally invasive (ALMI) approach versus the posterior minimally invasive (PMI) approach. MATERIALS AND METHODS: We applied these techniques to 2 consecutive groups (33 and 43 patients, respectively) comparable preoperatively. All the patients received the same cementless stem and acetabular component. RESULTS: There were neither significant difference in femoral or acetabular component positioning nor in limb-length discrepancy. Acetabular exposure was easy through the ALMI approach. Femoral exposure was more difficult as fractures of the trochanter and femoral perforation in our study show. CONCLUSION: For us, exposure and implant positioning through the ALMI approach and the PMI approach are comparable and reliable. However, we recommend caution during the initial learning curve in osteoporotic patients due to the higher rate of peroperative complications for the ALMI approach.

Cementless modular hip arthroplasty as a salvage operation for failed internal fixation of trochanteric fractures in elderly patients.

Failure of internal fixation of trochanteric fractures requires repeat surgery in order to avoid the risks of complications affecting bedridden patients. This study was conducted to assess the results of hemi- or total hip arthroplasty with a cementless modular femoral stem, as a salvage operation following early mechanical failure of internal fixation. Twenty nine patients with a mean age of 81.1 years (70-91) were included in the study. Fractures extending into the diaphysis and pathological fractures were excluded, as well as patients who presented late complications. A cementless modular stem designed for metaphyso-diaphyseal anchorage was used in all cases. Twenty-two patients underwent hemiarthroplasty and seven total hip arthroplasty. Four patients died within one year and two were lost to follow-up. The remaining 23 patients were followed for a mean of 20 months (range: 6-89). At the time of last follow-up, 20 were ambulatory with (11 cases) or without support (9 cases) and three were bedridden. There were no intra- or postoperative femoral fractures. Two patients presented an early dislocation after bipolar hemiarthroplasty. One was successfully treated by closed reduction; the other underwent revision with a dual mobility acetabular component because of recurrent dislocation. All the patients reported significant pain relief and functional improvement. Subsidence of the stem greater than 5 mm was noted in three cases, without clinical consequences. The cementless modular femoral stem used in this study appeared as a reliable implant. Primary arthroplasty with such an implant could be considered in selected cases such as markedly unstable fractures and in osteoporotic elderly patients.

Learning curve for a modified Watson-Jones minimally invasive approach in primary total hip replacement: analysis of complications and early results versus the standard-incision posterior approach.

We analysed the learning curve of an anterolateral minimally invasive (ALMI) approach for primary total hip replacement (THR). The first 42 THR's with large-diameter heads implanted through this approach (group 1) were compared to a cohort of 58 THR's with a 28-mm head performed through a standard-incision posterior approach (group 2). No selection was made and the groups were comparable. Implant positioning as well as early clinical results were satisfactory and were comparable in the two groups. In group 1, the rate of intraoperative complications was significantly higher (greater trochanter fracture in 4 cases, cortical perforation in 3 cases, calcar fracture in one case, nerve palsy in one case, secondary tilting of the metal back in 2 cases) than in group 2 (one nerve palsy and one calcar crack). At 6 months, one revision of the acetabular cup was performed in group 1 for persistent pain, whereas in group 2, we noted 3 dislocations (2 were revised) and 2 periprosthetic femoral fractures. Our study showed a high rate of intra- and perioperative complications during the learning curve for an ALMI approach. These are more likely to occur in obese or osteoporotic patients, and in those with bulky muscles or very stiff hips. Postoperative complications were rare. The early clinical results are excellent and we may expect to achieve better results with a more standardised procedure. During the initial period of the learning curve, it would be preferable to select patients with an appropriate morphology.