Subtalar arthrodesis using a single compression screw: a comparison of results between anterograde and retrograde screwing.

INTRODUCTION: The primary objective of this study was to compare the radiological and clinical results of anterograde and retrograde screwing in subtalar arthrodesis using a single compression screw. The secondary objective was to evaluate the subjective results and consolidation of this procedure. The hypotheses were that isolated screw fixation was sufficient to achieve good consolidation and that there was no difference between the two techniques with a similar rate of bone fusion. METHODS: This is a monocentric, retrospective, radio-clinical study based on 99 patients (101 feet), 58 males and 41 females, with an average age of 64 years. The main aetiology was post-traumatic osteoarthritis, which represented 51% of cases. Two groups were formed: group A (52 feet) consisting of fixed arthrodesis with ascending (retrograde) screwing and group D (49 feet) consisting of fixed arthrodesis with descending (anterograde) screwing. The two groups were statistically comparable in terms of demographic data as well as aetiologies and comorbidities. Arthrodeses which were not fused at 6 months were reassessed at one year and in the event of any radio-clinical doubt regarding consolidation, an additional CT scan was prescribed. Average post-operative follow-up was 11 ± 5 years (2-27 years). RESULTS: Ninety-two arthrodeses (93%) were fused at one year and 9 were considered to be in non-union, 5 (9.8%) in group A, and 4 (8.3%) in group D. We recorded 30 complications, 22 of which were due to a conflict with the screw head, 18 (34.5%) in group A and 4 (8.3%) in group D (p = 0.03). Conflict between the screw head and the heel led to the removal of the screw after consolidation of the arthrodesis. The clinical results were evaluated using Odom's criteria. Nine per cent of patients described their results as excellent, 29% as good, 51% as satisfactory and 11% found the result to be poor. CONCLUSION: The fusion rate for isolated compression screw arthrodesis is good, and there is no difference between anterograde and retrograde screws. However, the discomfort caused by the screw head being insufficiently embedded in the retrograde group led to a non-negligible number of additional surgeries to remove the screw.

Radiologic analysis of hindfoot alignment: Comparison of Méary, long axial, and hindfoot alignment views.

BACKGROUND: Among radiographic views available for assessing hindfoot alignment, the antero-posterior weight-bearing view with metal cerclage of the hindfoot (Méary view) is the most widely used in France. Internationally, the long axial view (LAV) and hindfoot alignment view (HAV) are used also. The objective of this study was to compare the reliability of these three views. HYPOTHESIS: The Méary view with cerclage of the hindfoot is as reliable as the LAV and HAV for assessing hindfoot alignment. MATERIAL AND METHODS: All three views were obtained in each of 22 prospectively included patients. Intra-observer and inter-observer reliabilities were assessed by having two observers collect the radiographic measurements then computing the intra-class correlation coefficients (ICCs). RESULTS: The intra-observer and inter-observer ICCs were 0.956 and 0.988 with the Méary view, 0.990 and 0.765 with the HAV, and 0.997 and 0.991 with the LAV, respectively. Correlations were far stronger between the LAV and HAV than between each of these and the Méary view. Compared to the LAV and HAV, the Méary view indicated a greater degree of hindfoot valgus. DISCUSSION: Intra-observer reliability was excellent with both the LAV and HAV, whereas inter-observer reliability was better with the LAV. Excellent reliability was also obtained with the Méary view. Combining the Méary view to obtain a radiographic image of the clinical deformity with the LAV to measure the angular deviation of the hindfoot axis may be useful when assessing hindfoot malalignment. A comparison of the three views in a larger population is needed before clinical recommendations can be made. LEVEL OF EVIDENCE: II, prospective study.

Lateral ligament reconstruction procedures for the ankle.

Capsule/ligament lesions of the lateral compartment of the ankle lead to lateral laxity, which is a prime contributor to chronic ankle instability. Lateral ligament reconstruction stabilizes the joint. Exhaustive preoperative clinical and paraclinical work-up is essential. The present article classifies, presents and criticizes the main techniques in terms of long-term stabilization and reduction of osteoarthritis risk. Anatomic ligament repair with reinforcement (mainly extensor retinaculum) or anatomic ligament reconstruction are the two recommended options. Non-anatomic reconstructions using the peroneus brevis should be abandoned. Arthroscopy is increasingly being developed, but results need assessment on longer follow-up than presently available. Postoperative neuromuscular reprogramming is fundamental to optimal recovery. Finally, the concept of complex ankle instability is discussed from the diagnostic and therapeutic points of view. The various forms of ligament reconstruction failure and corresponding treatments are reported.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy.

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Chronic ankle instability: biomechanics and pathomechanics of ligaments injury and associated lesions.

The objective of this study was to evaluate the conditions of ankle stability and the morphological and/or lesional factors in sprains that determine when instability becomes chronic. It is based on a review of the literature and the data from the 2008 Sofcot symposium. The biomechanics of the ankle cannot be reduced to a simple flexion-extension movement with one degree of freedom as characterized by the talocrural joint: its function cannot be dissociated from the subtalar joint, allowing the foot to adapt to the ground surface. Functional stability is related to the combination of the particular biometry of the joint surfaces and a multiaxial ligament system. The bone morphology of the talus, shaped like a truncated cone, explains the potential instability in plantar flexion; the radii of curvature of the talar dome have a variable mediolateral distribution: most often the medial radius of curvature is inferior to the lateral radius of curvature (66%), sometimes equal (19%), or inverted (15%). Joint kinematics, combining rotation and slide, can therefore be modulated by the talar morphology, explaining the occurrence of at-risk ankles. Ligament stability relies on the organization in three parts of the lateral collateral ligament and the specific subtalar ligaments: the cervical and the talocalcaneal interosseous ligament. The different injury mechanisms are largely responsible for the sequence of ligament lesions: the most frequent is inversion. The first ligament stabilizers correspond to the cervical and anterior talofibular ligaments; the talocalcaneal ligament, by its oblique orientation, is solicited when there is a dorsal varus-flexion component. In chronic instability, these mechanisms explain the onset of associated lesions (impingement, osteochondral lesions, fibular tendon pathology), which can play a role in instability syndrome. Ligament lesions determine laxity, characteristic of mechanical instability. Functional instability goes along with proprioceptive deficiency. There are postural factors such as varus of the hindfoot that favor instability. Knowledge of all these factors, often associated, will provide a precise lesional assessment and treatment adapted to the instability.

Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options?

This paper purpose is to suggest an in-depth approach to diagnose the causes and lesions associated with and consecutive to chronic ankle instability due to ankle collateral ligament laxity. The different therapeutic and medicosurgical options adapted to this diagnostic approach are identified. The diagnostic aim is to precisely locate the ligamentous injuries of the tibiofibular, subtalar, talar and calcanean system, to identify the predisposing factors such as the hindfoot morphology, and any lesions associated with chronicity: anterolateral impingement, fibular injury, osteochondral lesions of the talus dome and early osteoarthritis. Clinical tools are used in particular to identify areas of pain and for comparative analysis of mobility and laxity (ligament testing). There are also radiological tests, weight-bearing plain X-ray (stress X-ray), (alignment of the hind foot, with a Meary view [metal wire circling the heel], arthrosis), dynamic images to confirm and quantify laxity (manually, with a Telos device, with patient-controlled varus) and also more sophisticated techniques (ultrasound, CT arthrogramm, gadolinium enhanced MRI, MR arthrogramm) to identify ligament, tendon and cartilage damages. They are adapted to the lesions which have been identified in the diagnostic work-up: conservative first, to treat proprioceptive deficits (a new neuromuscular reprogramming technique which emphasizes muscle preactivation) and any static disorders (plantar orthotics); then surgical, to repair any collateral ligament (or sometimes subtalar) injury with three types of procedures: tightening the capsuloligamentous structures, ligament reconstruction with reinforcement (using the fibrous periosteum, the frondiform ligament (of Retzius) or tendinous reconstruction with the plantaris muscle, the peroneus tertius or even the calcanean tendon) and tendon tansfer procedures using all or part of the peroneus brevis (whole peroneus brevis and half peroneus brevis procedures). Any additional surgical procedures which may be indicated based on the results of the diagnostic work-up are performed at the same time as primary surgery when possible as needed (medial complex repair, calcaneal realignment osteotomies, talus osteochondral injuries debridment or fixation, anterior and posterior impingement suppression, tendon tears repair). The goal of this diagnostic and therapeutic approach is to stop the progression of laxity and to protect the ankle against degenerative arthritis, which is the main risk in these chronic conditions.

Chronic lateral ankle instability surgical repairs: the long term prospective.

UNLABELLED: The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction. MATERIAL AND METHODS: A multicenter retrospective review was performed on 310 lateral ankle ligament reconstructions, with a mean 13-year-follow-up (minimum FU: 5 years). Male subjects (53%) and sports trauma (78%) predominated. Mean duration of instability was 92 months; mean age at surgery was 28 years. Twenty-eight percent of cases showed subtalar joint involvement. Four classes of surgical technique were distinguished: C1, direct capsular ligamentous complex reattachment; C2, augmented repair; C3, ligamentoplasty using part of the peroneus brevis tendon and C4, ligamentoplasty using the whole peroneus brevis tendon. Clinical and functional assessment used Karlsson and Good-Jones-Livingstone scores; radiologic assessment combined centered AP and lateral views, hindfoot weight-bearing Méary views and dynamic views (manual technique, Telos or self-imposed varus). RESULTS: The majority of results (92%) were satisfactory. The mean Karlsson score of 90 [19-100] (i.e., 87% good and very good results) correlated with the subjective assessment, and did not evolve over time. Postoperative complications (20%), particularly when neurologic, were associated with poorer results. Control X-ray confirmed the very minor progression in degenerative changes, with improved stability; there was, however, no correlation between functional result and residual laxity on X-ray. Unstable and painful ankles showed poorer clinical results and more secondary osteoarthritis. Analysis by class of technique found poorer results in C4-type plasties and poorer control of laxity on X-ray in C1-type tension restoration. DISCUSSION: The present results confirm the interest of lateral ankle ligamentoplasty in the management of instability and protection against secondary osteoarthritis, and of precise lesion assessment (CT-scan/MRI) to adapt surgery to the ligamentary and associated lesions. LEVEL OF EVIDENCE: Level IV. Retrospective therapeutic study.

[Congenital club foot: treatment in childhood, outcome and problems in adulthood]. / Le pied bot varus equin: traitement chez l'enfant et devenir a l'age adulte.

PURPOSE OF THE SYMPOSIUM: Treatment of idiopathic talipes varus, or congenital clubfoot, is designed to re-align the foot to alleviate pain and allow plantigrade weight bearing with adequate joint motion despite the subnormal radiographic presentation. This symposium was held to review current management practices for congenital clubfoot in children and to analyze outcome in adults in order to propose the most appropriate therapeutic solutions. MANAGEMENT OF CONGENITAL CLUBFOOT IN CHILDREN: Idiopathic talipes varus can be suspected from the fetal ultrasound. Parents should be given precise information concerning proposed treatment after birth. Deviations must be assessed in the newborn then revised regularly using objective scales during and after the end of treatment. This enables a better apprehension of the evolution in comparison with the severity of the initial deformation. Conservative treatment is proposed by many teams: a functional approach (rehabilitation and minimal use of orthetic material) or the Ponseti method (progressive correction using casts associated with percutaneous tenotomy of the calcaneal tendon) are currently preferred. If such methods are insufficient or unsuccessful, surgery may be performed as needed at about 8 to 11 months to achieve posteromedial release. Good results are obtained in 80% of patients who generally present minimal residual deformations (adduction of the forefoot, minimal calcaneal varus, residual medial rotation, limitation of dorsal flexion), which must be followed regularly through growth. The difficulty is to distinguish acceptable from non-acceptable deformation. At the end of the growth phase, severe articular sequelae are rare (stiff joint, recurrence of initial deformation, overcorrection) but difficult to correct surgically: osteotomy, tendon transfer, double arthrodesis, Ilizarov fixator. Gait analysis is essential to quantify function and obtain an objective assessment of the impact on higher joints, providing valuable guidance for surgical correction. OUTCOME IN ADULTHOOD: There have been very few studies evaluating the long-term functional outcome after treatment during childhood. According to two studies presented at this symposium (Brussels, Lausanne), results have been generally good but with subnormal radiographs irrespective of the type of treatment or how early treatment started in childhood. Hypoplasia of the talar dome is a constant finding and is correlated with limitation of dorsal flexion of the ankle joint. A small degree under-correction is often observed but well tolerated while overcorrection is generally less well tolerated. Functional outcome depends highly on preservation of subtalar joint motion. There have been no reports on the results of treatment of sequelae in adults. Most problems (pain, stiffness, osteoarthritis) are observed in the mid or rear foot. Indications for conservative surgery (osteotomy) of the mid or rear foot are rare compared with indications for combined arthrodesis. Talocrural decompensation is a turning point observed in the adult. Management at this point is difficult: fusion of the ankle worsens the situation by increasing the stress on the forefoot and aggravating the disability; implantation of an ankle prosthesis is technically difficult and remains to be fully developed. Treatment of the dorsal bunion of the great toe may require tendon transfer and/or fusion. CONCLUSION: A child born with clubfoot will never have a normal foot in adulthood. Sequelae present at the end of growth will intensify during adult life; under-correction is easier to treat in adulthood than overcorrection. The most difficult problems in adulthood are: neglected clubfoot, over correction, and degradation of the talocrural joint.

[Posterior ankle impingement syndrome: a retrospective study in 21 cases treated surgically]. / Le syndrome du carrefour postérieur de la cheville: étude rétrospective à propos de 21 cas traités chirurgicalement.

PURPOSE OF THE STUDY: The purpose of this work was to describe the posterior ankle impingement syndrome and to present a retrospective analysis of results after surgical treatment in 21 patients with a mean five years follow-up. MATERIAL AND METHODS: Twenty-one patients with a posterior ankle impingement syndrome underwent surgery between 1991 and 1999. There were 17 men and four women, mean age 33 years (18-45); 71% practiced sports, half at the competition level. For 71% of the patients, there was an acute fracture with nonunion of the posterior process of the talus; a microtrauma context was identified in 29%. The physical examination revealed pain at passive forced plantar flexion in 94% of patients with limping during exercise in 88%. Plain x-rays showed a long tail on the talus in 87% of the patients, a short tail in 9%, and a trigone bone in 4%. The posterior malleolus (or third tibial malleolus) was remodeled in 9%. Other examinations performed preoperatively completed the topographic analysis: 99Tc bone scintigraphy, computed tomography with 2D reconstruction and horizontal slices, MRI. The patients were placed in the ventral prone position for surgery via a para-achilles approach, medial in ten patients and lateral in eleven. Bone resection with combined arthrolysis of the subtalar and tibiotalar joints was performed in 20 patients (17 with nonunion of the posterior talar process, one with a trigone bone, two with malformed callus of the posterior malleolus). A soft tissue procedure was also performed in three patients (resection of a synovial cyst in one, tenosynovectomy of the long flexor of the great toe in two). RESULTS: All patients were reviewed clinically and radiographically (plain x-rays). The AOFAS score was determined. There were no cases of infection. Mean follow-up was five years (range 3-10). Results were excellent with a mean Kitaoka score of 90/100, varying with cause and type of procedure performed. Only one patient was dissatisfied (Kitaoka score 67/100); this patient presented residual dysesthesia in the territory of the posterior tibial nerve. In 90% of the patients, there was no sign of degeneration of the peritalar joints (two patients exhibited minimal remodeling of the posterior subtalar joint). 90% of the patients were satisfied or very satisfied. DISCUSSION: The posterior ankle impingement syndrome includes several pathological entities with similar clinical expression. It involves both bony and soft tissue elements in the posterior peritalar region. Repeated or acute forced plantar flexion is the main cause. Complementary explorations (bone scintigraphy, CT, MRI) besides standard radiography, are indispensable to obtain a definitive diagnosis and demonstrate the functional and mechanical impairment. Surgical treatment is simple via a posterior approach (posterolateral or posteromedial)) and in our hands has provided very good results without arthritic consequences at mid-term.

[Evaluation of a long-distance data transmission network in foot and ankle surgery]. / Evaluation d'une consultation en réseau avec télétransmission des données en chirurgie de la cheville et du pied.

PURPOSE OF THE STUDY: This prospective work was designed to evaluate the concordance of the opinions of four experts interrogated via a long-distance inter-hospital data transmission system by an orthopedic surgeon seeking advise on foot and ankle surgery patients. MATERIAL AND METHODS: The surgeon requested advice concerning patients presenting difficult diagnostic or therapeutic situations. The requests were submitted via email to four experts working in regional referral centers. A standardized method defined by pathological categories was used for case description and imaging. RESULTS: Requests concerning 30 among 450 patients presenting surgical foot and ankle disorders were addressed to the experts. The surgical problem involved the forefoot (46%), the mid foot (16%), the hind foot (7%) and the ankle (31%). Mean delay to response was 11 days. The index of diagnostic agreement was 3.2/4 and the index of therapeutic agreement was 2.6/4. DISCUSSION: This study was designed to analyze the operating procedures involved (respective responsibility of the requesting surgeon and the regional experts, remuneration due to the different participants) and the potential patient benefit. The appropriateness of the email transmission system was also examined. For this type of study, email transmission was indicated because of the low cost, easy use, and image quality. This work illustrated the very good diagnostic and therapeutic concordance between experts in foot and ankle surgery and thus demonstrated the potential usefulness of long-distance expert systems. Furthermore, implication of several experts provided greater precision and complementary information facilitating management of difficult cases.

[Acute anterior instability of the shoulder: short- and mid-term outcome after conservative treatment]. / Les instabilités antérieures aiguës de l'épaule: résultats à court et moyen terme du traitement orthopédique.

PURPOSE OF THE STUDY: We assessed short and mid-term outcome after emergency care for acute anterior instability of the shoulder. MATERIALS AND METHOD: Between October 1990 and May 1996, 233 shoulders (206 anteromedial dislocations, 21 dislocations with spontaneous reduction, and 6 painful shoulders with unknown instability) were treated, mainly orthopedically. The series included 165 men and 68 women, mean age 42 years (range 13-95 years). One hundred fifty-eight practiced sports more or less regularly (73% of the 216 patients) and a sports accident was involved in 121 cases (52.8%). Besides the usual lesions secondary to bone displacement, there were 51 fracture-avulsions of the greater tuberosity, 7 major fractures of the anteroinferior border of the glenoid cavity, 2 fractures of the coracoid process, 10 nerve lesions (6 axillary nerve palsies and 4 partial palsies of the brachial plexus) and 10 rotator cuff tears. Orthopedic reduction was performed in the emergency room in all patients with a dislocated shoulder (82%). Immobilization, elbow to body, was prescribed for 8 to 15 days. Sixteen patients (6.8%) underwent surgery during the days following reduction, 8 for displaced fracture of the greater tuberosity, 7 for important fracture of the glenoid cavity and 1 for avulsion of the rotator cuff. RESULTS: Patient files (n=210) or phone interviews (n=185) were used to assess outcome. Mean follow-up was 38 months (12 - 72 months). All nerve lesions regressed within a few weeks without sequelae. We had 6 cases of retractile capsulitis and 4 cases of reflex dystrophy that regressed totally in 3 to 6 months. Recurrent dislocation was observed in 52 cases (24.7% recurrence rate) with 29 occurring within one year (55.8%). Among the 145 other shoulders, 84 recovered completely (58%), 52 were occasionally bothersome (36%), 8 exhibited repeated subdislocation (5.5%) and one remained pseudoparalytic. Among the factors favoring recurrence, we found patient age (higher risk in younger subjects) and lack of rehabilitation (p<0.05). DISCUSSION: Acute anterior dislocation of the shoulder is frequent, but emergency surgical repair is rarely needed (15 cases in our series, 6.9%). Mid-term recurrence is not as frequent as is often thought, warranting the choice of first intention orthopedic care. Our findings demonstrated that emergency surgery is not indicated in most cases of anterior shoulder instability, even with the arthroscopic approach, especially since the results of this method remain unclear.

[Comparative biomechanical study of 3 types of osteosynthesis of the Duparc grade IV fractures of the calcaneus: value of triangular internal fixation]. / Etude biomécanique comparée de 3 ostéosynthèses des fractures enfoncements du calcaneum stade IV de Duparc. Intérêt du montage en triangulation.

PURPOSE OF THE STUDY: We present an in vitro biomechanical study performed to evaluate and compare, for an experimentally produced fracture of the calcaneum (Duparc grade IV), the reaction of 3 standard models of internal fixation commonly used in these fractures and which occupy different volumes. MATERIALS AND METHODS: We compared different methods of fixation using fresh human calcanei. In two experimental series, we compared triangular internal fixation (3 1/4 tube AO plates Saragaglia), Y internal fixation (2 1/3 tube AO plates Bezes), isolated screw technique (three 3.5 diameter screws, two 4.5 diameter screws). The plates and screws were made of identical material (316L). Both series used 8 pairs of bone (talo-calcaneum system) with the same fracture submitted to a 200N to 1000N load. Stiffness and movement were analyzed using 8 references on the calcaneum. RESULTS: The stiffness and movement analysis with 8 references points demonstrated the superior resistance to bending with the triangular internal fixation. Fixation stability was significantly better than with the Y or screw technique. DISCUSSION: This study underlined the importance of triangular trabecular organization of cancellous bone on calcaneum biomechanics. We showed that the 3 (anterior, posterior and inferior) trabeculae must be repaired in calcaneum fractures to achieve horizontal and vertical stability of the talar joint. CONCLUSION: In our hands, restoration of the triangular architecture of calcaneum fractures, to resemble a roof truss, where the talus is fixed to the triangle vertex, is fundamental to obtain a rigid and stable internal fixation.

Surgical treatment of bi- and trimalleolar ankle fractures: should the medial collateral ligament be sutured or not?

In Weber type A, B, and C fractures there is no census or whether or not to suture the ruptured medial collateral ligament. From May 1990 to December 1994, operations were performed on 48 patients with such lesions. Thirty-three cases were reviewed, 29 males and four females, with an average age of 39 years (range, 15-73 years). In 22 cases there was an isolated fracture of the lateral malleolus, and in 11 cases the fracture was associated with a posterior malleolus fracture. There were tibiotalar dislocations in nine cases. Fifty-eight percent of the injuries were caused by sports activities and 27% by an ordinary fall. After a preoperative external reduction, the lateral and posterior (if necessary) fractures were anatomically and rigidly fixed (plate, pins, and wire) without any suture of the medial ligament. Medial tibiotalar and tibiofibular diastasis were totally reduced as shown during intraoperative radiographs. The follow-up at time of review was 27 months on average (range, 9 months-5 years). Functional results were excellent and good in 82.5% of cases, with a return to sports activities at a mean time of 4.3 months. X-rays were considered as normal in 73% of cases, with an anterior impingement syndrome in 15% and calcifications of the medial collateral ligament in 12%. Stress radiographs in valgus talar tilt (n = 24) were normal in all cases. The authors suggest new surgical guidelines in ankle fractures with a medial collateral rupture, based on fracture stabilization, with ligament tears left unexplored (medial, tibiofibular, and syndesmotic ligaments), and early mobilization.

[Anatomo-clinical consequences of the vertical sectioning of the subscapular muscle in Latarjet intervention]. / Conséquences anatomo-cliniques de la section verticale du muscle sub-scapulaire dans l'intervention de Latarjet.

UNLABELLED: The goal of this study was to assess the effects of the vertical section of the subscapularis muscle (internal rotation and muscular degeneration) during Latarjet procedure. MATERIAL AND METHODS: From October 1st, 1990, to June 30th, 1991, 40 patients were operated according to Latarjet for chronic anterior shoulder instability. A vertical section of the subscapular muscle was performed. Except for one female patient, all of them practiced sports. Preoperative delay between first dislocation and surgery averaged 59 months. Postoperative rehabilitation was aimed at external rotation, recovery began 48 hours after surgery, without specific indications as far as internal rotation was concerned. Sports activity was resumed 90 days after surgery. 38 were reviewed after 4 years. Clinical review was made according to Constant's score and by measuring strength, and amplitude of internal rotation. Radiological assessment of the shoulders was made with standard x-rays and CT. RESULTS: For global results, we noted absence of recurrence, a weighted Constant score of 88 per cent, 87 per cent of patients satisfied or very satisfied, 55 per cent of the osteoplastic ridge were on level, 16 per cent were retracted, and 29 per cent overlapped, 19 per cent non union or ridge lysis, 21 per cent glenohumeral osteophytosis. As far as clinical results are concerned, no significant difference was noted associated to osteoplastic ridge position. Internal rotation was assessed by measuring the distance hand to back (lift-off test). On the operated side it averaged 6 cm (0-18 cm), on the other side 13 cm (2-21 cm). The difference between each side was statistically very significant (p = 0.0001). Strength in internal rotation on the operated side averaged 3 kg (0-8 kg), on the other side, 6 kg (2-10 kg). The difference between each side was statistically very significant (p < 0.0001). CT was carried out on thickness and degeneration of the subscapular muscle (n = 29). Thickness of the subscapular muscle (operated side) average 10.5 (5-17 mm) after surgery, and 14.6 mm before surgery. It was thimer than on the contralateral shoulder 21 mm (10-33 mm). In both cases (shoulder before and after surgery, operated and contralateral shoulder), the difference was statistically significant. Degeneration of the subscapular muscle showed 4 stage 0, 13 stage 1, 5 stage 2, 6 stage 3, and 1 stage 4. A non statistical correlation was noted, between muscle degeneration and functional result, strength in internal rotation, distance hand to back. DISCUSSION: This series confirms efficiency and low morbidity of Latarjet procedure. Nevertheless, assessment of the subscapular muscle shows that 50 per cent of its strength and 50 per cent of its thickness were lost, 4 years after surgery. A significant degeneration (stages 2.3.4) was found in 41 per cent of the patients. This limitation is related to the trans-subscapular approach and to the absence of internal rotation postoperative rehabilitation. CONCLUSION: A randomized study comparing the vertical trans-subscapular approach to the horizontal trans-subscapular one would determine the better procedure.

Reconstruction of the lateral ankle ligaments using an inferior extensor retinaculum flap.

The aim of this study was to assess the results of 32 cases of chronic ankle instability. These were treated by ligament shortening and reinforced with an inferior extensor retinaculum flap. All patients complained of persistent functional instability unrelieved with proprioceptive exercises. Results were assessed clinically (pain, instability, recovery of sports activity, mobility) and radiologically (correction of laxity on stress x-rays). This enabled us to draw up a revision score on a scale of 100 points. We obtained a mean score of 86.7 points (45-100 points), and subjective results showed that 88% of the patients were satisfied with the surgery.

[A morphometric study of the femoro-patellar joint from lateral x-ray view]. / Etude morphométrique de l'articulation fémoro-patellaire à partir de l'incidence radiologique de profil.

PURPOSE OF THE STUDY: The goal of this study was to specify criteria of femoro-patellar joint normality on lateral view. MATERIAL: This study was based on radiological examination of 102 knees in 51 adults (average age 26.1 years). It concerned 29 women and 22 men that had never suffered from their knee and were supposed healthy. METHODS: The radiological protocol was the following: a lateral view at 45 degrees of flexion, two lateral views in extension, with and without quadriceps contraction. The analysis was focused on patellar surface aspect, its height, its depth and covering measurement. RESULTS: We found 83.7 per cent of so-called "normal" patellar surface, and 12.7 per cent of "abnormal" patellar surface (dysplasia) in the absence of pain. DISCUSSION: We have confirmed figures advanced in others series of the literature concerning patellar height and patellar surface, as well as patellar surface depth and covering. We have underlined the interest of lateral views; in extension with quadriceps contracted and relaxed. Finally, we have defined a trochleo-patellar sign that allows to correlate patellar height to patellar surface height (ITP = 0.35 to 0.84). CONCLUSION: This study insists on the interest of radiological lateral views of the knee and determine criteria for normalities.

[Biomechanical comparative study of three types of osteosynthesis in the treatment of supra and intercondylar fractures of the humerus in adults]. / Etude biomécanique comparative de trois types d'ostéosynthèse pour les fractures sus et intercondyliennes de la palette humérale de l'adulte.

PURPOSE OF THE STUDY: Supra and intercondylar fractures are the most common fractures of the distal end of the humerus in adult. An osteosynthesis consisting of a plate is the treatment of choice. But location and type of plate always remain open for debate. The authors present the results of an in vitro biomechanical study, which compared the stiffness of three types of osteosynthesis commonly used in these fractures. MATERIAL AND METHODS: The devices were on one hand the premolded lateral plate of Lecestre and Dupont (Howmedica) used alone or in conjunction with a medial 1/3 tubular plate of the AO group, and on the other hand a posterior plate, of which we are developing a new model, the Lambda plate (Protek) "Y"-shaped, monoblock, flat and molded on the humerus during operation. The study compared these different methods of fixation on fresh human humeri. In a first part, the posterior plate was compared to the single lateral one; in a second part, the posterior plate was compared to the coupled lateral and medial plates. The three plates were made of identical material. Both studies used eight pairs of bones with supra and intercondylar fractures realized by sawing. Each bone of a pair was fixed with one of the two types of device. Each humerus underwent different loading forces; sagittal bending (anterior and posterior) and torsion. The displacements were recorded using a calibrated measuring device coupled to two displacement sensors. The stiffness was calculated on force/displacement curves. RESULTS: In anterior bending, the Lambda posterior fixation was significantly stiffer than the single lateral one (p < 0.05) (239 +/- 109 versus 129 +/- 65 N/mm), and was not significantly different of the bilateral fixation (229 +/- 93 versus 224 +/- 108 N/mm). In posterior bending, the mean stiffness of the Lambda fixation was not significantly different to that of the lateral fixation (91 +/- 27 versus 91 +/- 52 N/mm), and less than that of the bilateral one (130 +/- 39 versus 170 +/- 70 N/mm), but not significantly. In torsion the mean stiffness of the Lambda fixation was superior to that of the lateral one (146.75 +/- 50.66 versus 119.75 +/- 58.8 Nm/rad), and bilateral one (233.31 +/- 107.47 versus 212.31 +/- 113.55 Nm/rad), but again not significantly. DISCUSSION: The ideal osteosynthesis for the fractures of the humeral distal doesn't exist, because the bone undergoes antero-posterior and posteroanterior cyclical forces during elbow flexion. Therefore the best device should be placed on both sides of the bone, but anatomical reasons make this location impossible. According to our study, we think the "less worst" device is the posterior one using the Lambda plate. Its symmetrical design allows a best loading distribution on the two columns. Its thickness compensates for its posterior location and the short interval between two holes allows to put many screws (4 to 6) into the epiphysis. All supra and intercondylar fractures, comminuted or not, can be treated with this material. The single lateral device isn't still enough. Its stiffness mainly depends on the orientation of the oblique screw in the medial column. But the design of this column doesn't always allow for an optimal location of the screw, which is the reason of several failures. The bilateral device gives a stiffness, comparable to the posterior one, but doesn't allow as many screws as the Lambda plate in the epiphysis. Therefore, it can't be used in very distal fractures. CONCLUSION: In spite of the progress of the material and the accuracy of the indications, the treatment of supra and intercondylar fractures of the distal end of the humerus is always a difficult problem. The devices have to be as stable as possible to allow an early motion. The best one should be placed on both sides of the distal humerus, because of the sagittal cyclic forces it undergoes, but this location is anatomically impossible. Our study concludes that the device using the Lambda plate i

[Pseudotumor manifestation of metallosis in a hip prosthesis]. / Manifestation pseudo-tumorale d'une métallose sur prothèse de hanche--à propos d'un cas.

A pseudo-tumour due to metallosis is described in association with an iso-elastic hip replacement. This is a relatively rare lesion which may be difficult to diagnose. Scintigraphy and radiography may be helpful in distinguishing the lesion from a primary or secondary neoplasm, but the presence of osteolysis adjacent to the prosthesis will suggest the true nature of the lesion.