Clinical and radiological outcome of the Chimaera short nailing system in inter- and subtrochanteric fractures.

BACKGROUND: cephalomedullary devices are popular treatment for femoral intertrochanteric or subtrochanteric fractures. Various complications include post-surgical lateral thigh pain and cut-out. To prevent those complications, a new concept cephalomedullary device system was designed (Chimaera, Orthofix®). This study aimed to evaluate the clinical and radiological outcomes in patients with femoral intertrochanteric or subtrochanteric fractures treated with the proximal femoral cephalomedullary device system. METHODS: A prospective cohort study involved consecutive patients with Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma Association type 31-A1, 2, 3 fractures treated with the Chimaera short cephalomedullary device system from October 2016 to September 2017 at our level 1 trauma center. The Parker and Palmer mobility score and Jensen social function scores and post-surgical lateral thigh pain were assessed at 3 months post-operatively and compared to before surgery. Radiologic assessment consisted of controlling the position of the cephalic screw by using the tip-apex distance (TAD) and Cleveland zone as well as union and cut-out rates. RESULTS: We included 99 patients (79 women; 100 hips; one bilateral fracture 3 months after a first trochanteric fracture) with a mean follow-up of 2 years. The Parker and Palmer mobility score decreased by 22% at 3 months post-operatively as compared with the pre-fracture score (42/99 patients showed a return to their pre-injury level). The Jensen social function score increased by 16.5% at 3 months post-operatively as compared with the pre-fracture score (68/99 patients showed a return to their pre-injury level). No major intra-operative complication was recorded. Nine TAD scores were > 25 mm. The mean TAD was 16.5 mm (range 5-36), and the lag screw position was well positioned in most (95%) hips according to Cleveland zones. Three patients required revision surgery (one for cut-out of the lag screw, one for hip osteoarthritis and one for gluteus medius insufficiency). All patients but the one with the cut-out showed fracture union. CONCLUSION: The Chimaera short cephalomedullary device exhibited good mid-term functional and radiological outcomes.

Combination of femoral triangle block and infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) versus local infiltration analgesia for analgesia after anterior cruciate ligament reconstruction: a randomized controlled triple-blinded trial.

BACKGROUND AND OBJECTIVES: Femoral triangle block and local infiltration analgesia are two effective analgesic techniques after anterior cruciate ligament reconstruction. Recently, the iPACK block (infiltration between the popliteal artery and the capsule of the posterior knee) has been described to relieve posterior knee pain. This randomized controlled triple-blinded trial tested the hypothesis that the combination of femoral triangle block and iPACK provides superior analgesia to local infiltration analgesia after anterior cruciate ligament reconstruction. METHODS: Sixty patients undergoing anterior cruciate ligament reconstruction received general anesthesia and were randomly allocated to two groups: femoral triangle block and iPACK under ultrasound guidance or local infiltration analgesia. For each group, a total of 160 mg of ropivacaine was injected. Postoperative pain treatment followed a predefined protocol with intravenous morphine patient-controlled analgesia, acetaminophen, and ibuprofen. The primary outcome was cumulative intravenous morphine consumption at 24 hours postoperatively. Secondary pain-related outcomes included pain scores (Numeric Rating Scale out of 10) measured at 2 and 24 hours postoperatively. Functional outcomes, such as range of motion and quadriceps strength, were also recorded at 24 postoperative hours, and at 4 and 8 postoperative months. RESULTS: Cumulative intravenous morphine consumption at 24 hours postoperatively was significantly reduced in the femoral triangle block and iPACK group (femoral triangle block and iPACK: 9.7 mg (95% CI: 6.7 to 12.7); local infiltration analgesia: 17.0 mg (95% CI: 11.1 to 23.0), p=0.03). Other pain-related and functional-related outcomes were similar between groups. CONCLUSIONS: The combination of femoral triangle block and iPACK reduces intravenous morphine consumption during the first 24 hours after anterior cruciate ligament reconstruction, when compared with local infiltration analgesia, without effect on other pain-related, early, or late functional-related outcomes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03680716).

[Degenerative lesions of the anterior cruciate ligament: a frequent but poorly understood phenomenon]. / Lésions dégénératives du ligament croisé antérieur : un spectre d'entités mal connues en orthopédie.

Making more use of MRI, degenerative lesions of the anterior cruciate ligament are more frequently diagnosed. Three separates entities are reported (mucoid degeneration, ganglion cyst and mucoid degeneration with ganglion cysts) but it is probably a continuum of the same degenerative process. In middle aged individuals, it would result of repeated microtrauma in the setting of a narrow intercondylar notch and/or increased posterior tibial slope. In the older patient, it would be part of a whole organ disease with the onset of osteoarthritis. Most cases are incidental findings. For symptomatic patients, a complete resection of the ligament is our first option when conservative treatment failed. It is effective for pain relief and motion recovery. Although it produces postoperative instability, secondary reconstruction is not always required.

En raison du recours plus fréquent à l'IRM, le diagnostic de lésion dégénérative du ligament croisé antérieur augmente. La littérature distingue trois entités (dégénérescence mucoïde, kyste mucoïde, dégénérescence mucoïde et polykystique) mais il s'agit probablement d'un continuum d'atteintes dégénératives. Chez les patients jeunes, elle résulterait de microtraumatismes favorisés par une pente tibiale majorée et/ou une échancrure intercondylienne étroite. Chez les patients âgés, cette dégénérescence accompagne souvent une gonarthrose. La majorité des cas est asymptomatique. En cas d'échec du traitement conservateur, nous proposons une résection complète. Elle permet une régression nette des douleurs. Même si elle génère une instabilité, celle-ci est rarement symptomatique et une reconstruction secondaire n'est pas toujours nécessaire.

[Knee osteotomies : a renaissance ?] / Ostéotomies du genou : une renaissance ?

There is a regain of interest for knee osteotomies over the last decade. A better knowledge of their long-term benefits and potential adverse events has increased their importance in the treatment of unicompartmental osteoarthritis. Emerging indications result from increasing evidence that the control of knee alignment is crucial in knee instability, meniscal transplantation and cartilage repair.

Cette décennie a été marquée par un regain d'intérêt pour les ostéotomies autour du genou. Cet article présente les avancées qui ont permis de confirmer l'importance de cette chirurgie dans son indication historique, l'arthrose unicompartimentale. Il détaillera ensuite pourquoi la correction de l'axe mécanique s'avère de plus en plus indispensable dans le traitement de l'instabilité du genou et comme prérequis dans les procédures de greffe méniscale ou chondrale.

[Patellar instability : diagnosis and treatment]. / Instabilité rotulienne : diagnostic et traitement.

The aim of this paper is to present recent advances in surgical management of patellar instability. Several anatomical factors were reported to promote instability. We propose to classify them in two groups. Extra articular factors are valgus and torsion deformity. Articular factors include trochlea and patella dysplasia, tibial tubercle lateralization and medial patellofemoral ligament (MPFL) insufficiency. Acute patellar dislocations are treated conservatively, with exception for osteochondral and MPFL avulsion fractures that require acute reinsertion. Surgery is considered for recurrent instability. As we aim for a correction of all contributing elements, we prefer a two stages approach. Extra articular factors are treated first by osteotomy, followed by articular factors after 4-6 months. This allows separate rehabilitation protocols.

L'objectif de cet article est de détailler les progrès dans la prise en charge chirurgicale de l'instabilité rotulienne. Différents facteurs anatomiques favorisent cette instabilité. Nous proposons de les classer en deux groupes : facteurs extra-articulaires (valgus et troubles de torsion) et articulaires (dysplasies trochléenne et rotulienne, latéralisation de la tubérosité tibiale antérieure, insuffisance du ligament patello-fémoral médial (MPFL)). Le premier épisode de luxation est traité conservativement, à l'exception des fractures-avulsions ostéochondrales et du MPFL qui nécessitent une réinsertion en aigu. L'instabilité rotulienne récidivante est traitée chirurgicalement. Nous proposons une correction en deux étapes, avec un intervalle de 4-6 mois, de l'ensemble des facteurs identifiés, d'abord extra-articulaires puis articulaires.

Talus fracture in a 4-year-old child.

Fracture of the talus is uncommon in childhood. We report a case of talar neck fracture that occurred in a 4-year-old girl. We present the radiological findings, the orthopaedic follow-up and the clinical outcome.