What happens to endoscopic/arthroscopic tenotomies with iliopsoas impingement in the medium term? Review of a prospective cohort of 64 patients with a minimum follow-up of 5 years.

INTRODUCTION: The occurrence of iliopsoas impingement (IPI) after total hip arthroplasty (THA) is a proven risk factor for negative outcomes. Endoscopic or arthroscopic tenotomies of the iliopsoas offer a surgical solution with short-term results that have already been validated in prospective multicenter series. We carried out a review of the patients at more than 5 years of follow-up in order to assess the stability of the results over time. HYPOTHESIS: Our main hypothesis was that endoscopic/arthroscopic tenotomies allow stable medium-term resolution of the painful symptoms of IPI. Our secondary hypothesis was that medium-term survival was satisfactory. MATERIAL AND METHOD: This study is a continuation of a multicenter prospective series. Patients were contacted through multiple channels in order to: obtain an Oxford score, assess for satisfaction, psoas irritation, and daily pain on a visual analogue scale (VAS). RESULTS: Of 64 patients in the original study, 57 were contacted. The Oxford score at the last follow-up was 40.7±7.7 [12-48]. There was a significant difference between the Oxford scores preoperatively, at 8 months and at the last follow-up. The mean satisfaction out of 10 was 8.0±2.1 [1-10]. We found 84% satisfaction at 5 years against 83% at 8 months. The VAS was 2.1±2.3 [0-10]. A straight leg psoas sign was present in 19.6% (10/51) of patients at 5 years, compared to 15.6% (8/51) at 8 months. The sign disappeared in four cases, while it reappeared during the interval in six cases. Survival was 91.2% (95% CI: 80.2-96.3) at 5 years. CONCLUSION: Endoscopic/arthroscopic iliopsoas tenotomies represent a permanent medium-term solution to treat IPI after THA. The existence of a force differential or an acetabular overhang does not seem, within a certain limit, to impact the results in the medium term. LEVEL OF EVIDENCE: IV; prospective series without control group.

Labral tears in hip dysplasia and femoroacetabular impingement: A systematic review.

INTRODUCTION: Hip dysplasia and femoroacetabular impingement are pathologies whose impact on the function and survival of the hip joint is no longer debated. Labral tears may be present and impact the prognosis of the causal pathology. Labral tear management lacks consensus and still raises several questions, thus we conducted a systematic analysis to clarify: 1) What is its prevalence in hip dysplasia and femoroacetabular impingement? 2) Does it modify the symptomatology of the causal pathology? 3) Is its repair better than resection or abstention? MATERIAL AND METHOD: A systematic literature review was carried out following the PRISMA guidelines, using the Medline and Embase databases and including all articles in French or English, written until June 2022 referring to labral tears in hip dysplasia and femoroacetabular impingement. The articles were analyzed by 2 surgeons in order to select them according to a predefined algorithm. 1) Articles were selected by title from the search results. 2) A selection based on the abstract was then made. 3) A final selection was made upon complete reading. 4) In the event of a discrepancy during the selection, a third co-author was contacted for a final decision. 5) Data extraction was then carried out by the two readers using a preformatted sheet. RESULTS: Of the 1177 articles identified, 43 articles were kept for the final analysis. The prevalence of labral tears was on average 78.80±4.7% [17 to 100%] in dysplasia and 93.8±16.8% [33% to 100%] in impingement. The review did not reveal any symptomatology specific to the labral tear. In dysplasia, 5 comparative studies were analyzed. A single study on shelf arthroplasties demonstrated the negative impact of a labral tear in the event of resection on survival compared to no tear (83% versus 15.2% (p=0.048)). Regarding impingements, 8 comparative studies were analyzed. At 7 years of follow-up, only one study found a significant and clinically relevant functional gain in terms of MCID (minimal clinically important difference) for labral repair compared to debridement on the mHHS score (p=0.008), SF-12 score (p=0.012), and pain scale (p=0.002). One study showed superiority of repair over labral debridement in terms of 10-year survival (78% 95% CI [64-92%] vs 46% 95% CI [26-66%] (p=0.009)). DISCUSSION: The literature analysis was heterogeneous with a few comparative studies and predominantly short periods of follow-up. Understanding labral pathology and its impact requires differentiating between the different tear categories and proposing treatment to restore or preserve the biomechanical properties of the joint. LEVEL OF EVIDENCE: IV, Systematic Review of Level 1-4 Evidence.

The torsion of the proximal femur in cementless total hip arthroplasty: a 3-dimensional evaluation.

INTRODUCTION: The anatomy of the proximal femur at the time of total hip arthroplasty has been widely studied but the horizontal plane was never considered, or only limited to the torsion of the femoral neck. METHODS: Using CT-scan images from a group of 178 patients scheduled for cementless total hip arthroplasty (THA), we analysed the evolution of the torsion of the proximal femoral metaphysis, in reference to the posterior bicondylar plane of the femur. The evolution of the torsion, between 20 mm below the centre of the lesser trochanter and 20 mm above, was evaluated. RESULTS: In cases of primary osteoarthritis, osteonecrosis, rheumatoid arthritis and epiphysiolysis capitis femoris, the mean torsion decreased from 46° to 20° without significant differences in average values between the different diagnoses, but important individual variations were found. In the groups of dysplasia and congenital hip dislocation, the torsion values were significantly higher, decreasing in mean from 59° to 25° and 63° to 34° respectively, and with important individual variations. CONCLUSIONS: These data are important when using cementless femoral stems, since an ideal fit-and-fill in the proximal femur zone has been shown to positively influence bone ingrowth of the stem. However, a strict adaptation of the stem to the medullary canal, without considering its torsion, can lead to an increased or decreased torsion of the prosthesis neck and thus to an instability of the arthroplasty. For these reasons, if a perfect adaptation of the stem to the intramedullary anatomy and an optimal reconstruction of the extramedullary anatomy are to be achieved, 3-dimensional planning should ideally be obtained for every patient. This will allow the best stem choice adapted to every single patient and every kind of anatomy.

Arthroscopic acetabular labrum suture.

It is essential to be aware of the anatomy and biomechanics of the acetabular labrum in order to understand why it should be conserved. Vascularization comes from the capsule and also from the bone. The joint side contains numerous nerve endings, which explains why labral lesions are painful. It is involved in joint stabilization by maintaining a negative pressure inside the joint able to resist distraction. It acts as a seal. There are two main suture techniques: trans- and peri-labral. Translabral suture is better suited to a wide and solid labrum free of degenerative lesions. Both techniques should be known, and may be associated. Results are comparable. It is essential to manage the underlying pathology responsible for the labral lesion. Joint degeneration is associated with poor prognosis. It needs to be recognized and discussed with the patient, to avoid unrealistic expectations.

Impact of bone deformities and labral and cartilage lesions on early functional results of arthroscopic treatment of femoroacetabular impingement.

INTRODUCTION: Femoroacetabular impingement (FAI) is a frequent cause of inguinal pain. Treatment failure rates range between 2.9% and 13.2%. The aim of the present study was to assess the impact of preoperative bone deformities (BD), labral lesions (LL) and cartilage lesions (CL) on clinical results of arthroscopic treatment of FAI. MATERIAL AND METHOD: A prospective operational study included patients undergoing hip arthroscopy for FAI. All patients had full radiographic work-up and clinical assessment on Non-Arthritic Hip Score (NAHS), preoperatively and at 1year. Hips with Tönnis grade>1, coxa profunda [VCE (vertical center edge angle)>35°] or borderline dysplasia (VCE<25°) were excluded. The Czerny classification was used for the labrum and the Beck classification for the cartilage. The aim of the study was to assess the impact of preoperative BD, LL and CL on clinical results of arthroscopic treatment of FAI. The study hypothesis was that type of lesion does not influence early functional results at 1year, whatever the technique used for the labrum. RESULTS: One hundred and ninety-seven patients were included. Mean preoperative NAHS was 59.1±17.5. There were 145 patients with labral suture (73.6%), 42 with labral debridement (21.3%) and 10 with conservative treatment (5.1%). At 1year, mean NAHS was 88.1±15.3: i.e., a significant improvement (p<2.2×10-16). Improvement was also significant in the debridement, non-operative and suture subgroups. BD showed significant correction in the overall population (alpha angle 48.2° postoperatively versus 66.7° preoperatively; crossing sign in 14.5% versus 62.9% of cases). There were no significant differences in functional scores according to extension or type of labral or cartilage lesion. At follow-up, 3 patients (1.5%) required repeat arthroscopy. CONCLUSION: The present study showed that early functional results of arthroscopic treatment of FAI were unaffected by the severity of bone deformity (alpha and VCE angles), or extension or type of labral or cartilage lesion. Regardless of BD, LL and CL, 1-year clinical progression was satisfactory when all bone deformities were treated by the arthroscopic procedure. LEVEL OF EVIDENCE: IV; prospective non-comparative study.

Does labral repair have a clinical benefit during arthroscopic treatment of femoro-acetabular impingement? Prospective multicentre study with 2-year follow-up.

INTRODUCTION: Hip arthroscopy has emerged as an effective tool for treating labral tears associated with femoro-acetabular impingement (FAI). OBJECTIVE: Compare the effectiveness of debridement versus labral repair on functional outcomes at 2 years after hip arthroscopy and evaluate the influence of the repair technique. HYPOTHESIS: There is no statistical difference in short-term functional outcomes between debridement and repair. The type of repair technique has no influence on functional outcomes. METHODS: From July 2017 to June 2018, a prospective study was done at 10 participating hospitals specialised in hip preservation surgery. Patients over 18 years of age, who underwent hip arthroscopy for a labral tear due to femoro-acetabular impingement, were enrolled. Patients underwent either labral repair or debridement. The labral repairs were performed with either the loop or mattress technique and functional outcomes were evaluated using the Non-Arthritic Hip Score (NAHS). RESULTS: One hundred and eighty-seven patients who underwent arthroscopic treatment for FAI were enrolled; 42 (22.5%) underwent labral debridement and 145 (77.5%) underwent labral repair. In the repair group, 66 (46%) were mattress sutures and 79 (54%) were loop sutures. Mean patient age was 33.3±10.3 (18-63) and 38% of patients were women (n=71). Mean follow-up was 16.2 months (10-26.4). The mean NAHS improved from 47.3 to 72.8 (p<0.05) at final follow-up. There was no significant difference between the repair and debridement groups (p>0.05). There was no significant difference between the mattress and loop repair subgroups (p>0.05). CONCLUSIONS: There is no statistical difference in short-term functional outcomes between debridement and repair. The type of repair technique has no influence on functional outcomes. LEVEL OF EVIDENCE: II, prospective cohort study.

Limitations of arthroscopy for managing coxa profunda.

Coxa profunda is a complex entity that can result in femoro-acetabular impingement (FAI). A meticulous evaluation of the type of acetabular overcoverage is essential to determine which treatment is best suited to each individual patient. Focal overcoverage with no posterior impingement can be treated by arthroscopic recontouring of the disproportionate acetabular wall. Any femoral deformities should be managed during the same procedure. General overcoverage, with predominant postero-inferior impingement, requires open surgery to obtain access to the entire acetabular rim. Rim resection should be sparing, to avoid removing an excessive proportion of the joint surface, yet sufficient to eliminate the impingement. In the event of protrusio acetabuli, which is the extreme form of coxa profunda, reverse peri-acetabular osteotomy should be considered, particularly if the acetabular roof angle is reversed. In some patients, chiefly those with coxa vara, valgus femoral osteotomy should be considered as a means of redirecting the loads towards the acetabular roof, thereby diminishing the forces that tend to drive the femoral head deeper into the socket.

Simultaneous and multisite measure of micromotion, subsidence and gap to evaluate femoral stem stability.

The initial stability of cementless femoral components is crucial for the long-term success of total hip arthroplasty. This has been reported in animal and clinical studies. Until now, the stability was evaluated by the measurement of relative micromotion on a few simultaneous locations around the stem in cadaveric experiments. This paper presents an extended experimental setup to measure simultaneously local micromotion, subsidence and gap on hundreds of points at the bone-stem interface. This technique we applied to anatomical and straight stems in three pairs of cadaveric femurs. Measurements were in agreement with typically reported values. Conversely to other methods, which measure micromotion between implant and bone anchoring points of the measuring device, our method provides local micromotion between stem surface and adjacent bone surface. The observed variation of micromotion at the peri-implant surface confirms the importance of this simultaneous measure on a lot of points around the implant.

A new technique to measure micromotion distribution around a cementless femoral stem.

The interfacial micromotion is closely associated to the long-term success of cementless hip prostheses. Various techniques have been proposed to measure them, but only a few number of points over the stem surface can be measured simultaneously. In this paper, we propose a new technique based on micro-Computer Tomography (µCT) to measure locally the relative interfacial micromotions between the metallic stem and the surrounding femoral bone. Tantalum beads were stuck at the stem surface and spread at the endosteal surface. Relative micromotions between the stem and the endosteal bone surfaces were measured at different loading amplitudes. The estimated error was 10 µm and the maximal micromotion was 60 µm, in the loading direction, at 1400 N. This pilot study provided a local measurement of the micromotions in the 3 direction and at 8 locations on the stem surface simultaneously. This technique could be easily extended to higher loads and a much larger number of points, covering the entire stem surface and providing a quasi-continuous distribution of the 3D interfacial micromotions around the stem. The new measurement method would be very useful to compare the induced micromotions of different stem designs and to optimize the primary stability of cementless total hip arthroplasty.

Painful total hip replacement due to sciatic nerve entrapment in scar tissue and lipoma.

Painful total hip replacement remains a challenging problem because of the large amount of possible diagnoses. We report about a 64-year-old female patient who was misdiagnosed during 4 years as psychiatric. She suffered of excruciating left retrotrochanteric pain after the implantation of a cementless total hip replacement and revision because of recurrent hip dislocations. Walking was limited to short distances using two crutches. The work-up at this time included the usual diagnoses and remained unsuccessful. No loosening, infection or malposition of the prosthesis could be found, and she had no neurologic deficits in her operated leg. An MRI was obtained to visualize the retrotrochanteric soft tissues and showed a tight scar surrounding the sciatic nerve, which was also compressed by an adjacent lipoma. Therefore, she was reoperated on to remove the lipoma and the scar tissue around the sciatic nerve. To decrease the risk of recurrent scarring around the sciatic nerve, an adhesion barrier was applied before closure. One year after the operation, the patient has no neurologic deficit, no more pain and is able to walk unlimited distances without crutches. Scar tissue around the sciatic nerve is frequently observed during revision surgery. However, we feel that sciatic nerve entrapment by scar tissue should be a part of the differential diagnosis of painful THR. MRI may be a useful tool to achieve this diagnosis.

[Technique and value of direct MR arthrography applying articular distraction]. / Arthro-IRM directe en traction axiale: technique et intérêt.

Direct MR arthrography has a better diagnostic accuracy than MR imaging alone. However, contrast material is not always homogeneously distributed in the articular space. Lesions of cartilage surfaces or intra-articular soft tissues can thus be misdiagnosed. Concomitant application of axial traction during MR arthrography leads to articular distraction. This enables better distribution of contrast material in the joint and better delineation of intra-articular structures. Therefore, this technique improves detection of cartilage lesions. Moreover, the axial stress applied on articular structures may reveal lesions invisible on MR images without traction. Based on our clinical experience, we believe that this relatively unknown technique is promising and should be further developed.

[Clinical pathway in traumatology, a fashion or need?]. / Itinéraire clinique en traumatologie, une mode ou un besoin?

A clinical route is defined as a "set of methods and instruments to members of a multidisciplinary and Interprofessional team to agree on the tasks for a specific patient population. This is a program of care to ensure the provision of quality care and efficient realization". The University Hospital is not immune to this phenomenon. In the Department of the musculoskeletal system, a first project of this kind concerns the fracture of the proximal femur in the elderly.

A new conservative-dynamic treatment for the acute ruptured Achilles tendon.

INTRODUCTION: There is a trend towards surgical treatment of acute ruptured Achilles tendon. While classical open surgical procedures have been shown to restore good functional capacity, they are potentially associated with significant complications like wound infection and paresthesia. Modern mini-invasive surgical techniques significantly reduce these complications and are also associated with good functional results so that they can be considered as the surgical treatment of choice. Nevertheless, there is still a need for conservative alternative and recent studies report good results with conservative treatment in rigid casts or braces. PATIENTS/METHOD: We report the use of a dynamic ankle brace in the conservative treatment of Achilles tendon rupture in a prospective non-randomised study of 57 consecutive patients. Patients were evaluated at an average follow-up time of 5 years using the modified Leppilahti Ankle Score, and the first 30 patients additionally underwent a clinical examination and muscular testing with a Cybex isokinetic dynamometer at 6 and 12 months. RESULTS: We found good and excellent results in most cases. We observed five complete re-ruptures, almost exclusively in case of poor patient's compliance, two partial re-ruptures and one deep venous thrombosis complicated by pulmonary embolism. CONCLUSION: Although prospective comparison with other modern treatment options is still required, the functional outcome after early ankle mobilisation in a dynamic cast is good enough to ethically propose this method as an alternative to surgical treatment.

[Pelvic trauma]. / Traumatismes du bassin.

Pelvic trauma A great variety of very polymorphous lesions of pelvic trauma are deffering from each other by their context, their anatomical aspect and therapeutic implication. In the isolated acetabular fractures, function is mainly at stake. The management consists mainly of re-establishing a joint congruence to prevent early coxarthrosis. Pelvic fractures often occur in violent trauma and are associated with visceral lesions, putting vital prognosis at stake. In case of hemodynamic shock, external fracture stabilization when it is indicated associated to embolisation of pelvic bleeding if necessary and after external fixation are preponderant.

Gerdy tubercle osteotomy in surgical approach of posterolateral corner of the knee.

Posterolateral corner (PLC) injuries of the knee are uncommon injury patterns that may result in significant degrees of functional disability. When surgery is necessary to address this injury a good knowledge of anatomy and a good surgical exposure is the mainstay. This report reviews the complex anatomy of the posterolateral corner (PLC) of knee and describes the osteotomy of Gerdy tubercle as a technical variant to approach this anatomical region. This surgical step allowing a good mobilisation of the multiple layers of ilio-tibial tract from distal to proximal makes an excellent exposure of the PLC structures with absence of morbidity.

[Differential diagnosis of groin pain]. / Diagnostics différentiels des douleurs inguinales.

Groin pain is frequent but often problematic as it covers a very broad differential diagnosis. The localisation of pain in one of the five anterior hip regions helps to establish a precise diagnosis and an adapted treatment. We review the differential diagnosis and treatment of anterior hip pain.

[Amputations of the lower extremity]. / Amputations du membre inférieur.

Still nowadays amputations are frequently performed in our country. In diabetic patients the incidence of an amputation is 25 times higher than in the normal population. All possibilities of revascularisation or limb salvage must be excluded by a multidisciplinary approach before choosing an amputation. Once the decision is taken the good level of amputation and the correct technique have to determined. The goal of this article is to describe which clinical and paraclinical parameters will help the surgeon to choose the best level of amputation, which techniques are to be used for the amputation and to finally give some information about re-education and the fitting of an orthesis or prosthesis.

Arthroscopic psoas tenotomy.

Tenotomy may be indicated for psoas tendinitis or painful snapping if conservative treatment remains unsuccessful. Because of significant complications with open techniques, endoscopic operations have been developed. We present a new arthroscopic technique to access and release the psoas tendon from the hip joint. This procedure can be performed in addition to other arthroscopic procedures of the hip joint or alone. To exclude additional hip disease, a diagnostic round of the joint should be completed. After hip arthroscopy of the central compartment has been performed, traction is released and the 30 degrees arthroscope is placed via the proximal anterolateral portal lying on the anterior femoral neck. The medial synovial fold can be identified. This fold lies slightly medially underneath the anteromedial capsule at the level of the psoas tendon. The arthroscope is turned toward the anterior capsule. Sometimes, the tendon shines through a thin articular capsule, or it may even be accessed directly via a hole connecting the hip joint and the iliopectineal bursa at the level of the anterior head-neck junction. If this cannot be done, an electrothermic probe is introduced via the anterior portal to make a 2-cm transverse capsular incision. The tendon is released with the back side of the electrothermic device turned to the iliacus muscle that lies anterior to the psoas tendon. A complete release is achieved when the tendon stumps can be seen gapping at a distance and the fibers of the iliacus muscle are visible. The first 9 patients who underwent surgery performed according to this technique developed no complications, and their hip flexion strength was restored to normal within 3 months.