Estabilización anterolateral del tobillo por incisión mínima con técnica de hemi-Castaing modificada / Minimal invasive anterolateral ankle stabilization with a modified Hemi-Castaing technique

Antecedentes: Las lesiones de los ligamentos laterales del tobillo son comúnmente observadas en las actividades deportivas. Se encuentran descritas múltiples técnicas para su tratamiento, todas con un último fin: lograr una adecuada estabilidad del tobillo. Las técnicas de invasión mínima y los adelantos tecnológicos en los sistemas de fijación hueso-tendón han venido ganando adeptos en la última década y han impactado también las técnicas de estabilización del tobillo. Material y métodos: Se incluyeron todos los pacientes con diagnóstico de inestabilidad lateral de tobillo que se intervinieron quirúrgicamente y se les realizó un procedimiento de Hemi-Castaing modificado con abordajes mínimos operados en el período de Mayo 2004 a Diciembre del 2007. Tenemos un seguimiento promedio de 30.3 meses. Resultados: Nuestros pacientes presentaron una buena evolución, encontramos una mejoría importante en la escala de Karlsson de 48.7 puntos (± 15.6) a 93.6 puntos (± 9.6). Los pacientes regresaron a su actividad deportiva posterior a la cirugía a los 5.72 meses en promedio (± 4.93). Tenemos una adecuada estabilización corroborada con radiografías dinámicas con sistema Telos. Con una satisfacción personal excelente y buena en 81.9% de los pacientes. Conclusiones: Las modificaciones a la técnica de Hemi-Castaing con el abordaje por incisión mínima, son seguras, reproducibles y nos dan una herramienta más para el tratamiento de esta patología y sobre todo en los casos en donde no se encuentre un adecuado tejido remanente para realizar una reparación anatómica.

Background: The lesions to the lateral ligaments of the ankle are a common sports related injury. There are multiple surgical technics to address the problem all with a common goal: achieve a proper stability of the ankle. The improvements in the minimal invasive technics as well as those in the materials to fixate bone-tissue have also impacted the technics for lateral stabilization of the ankle. Material and methods: We included all the patients with a diagnosis of lateral ankle instability which underwent surgery with a modify Hemi-Casting procedure with minimal invasive approach during the period between May 2004 and December 2007. We have an average follow-up of 30.3 months. Results: Our patients presented a good outcome with an improvement in the Karlsson's scale of 48.7 points (± 15.6) in the preoperative to 93.6 points (± 9.6) during follow-up. They returned to their sports activities after an average of 5.72 months (± 4.93). We used dynamic X-ray's taken with the Telos system and achieved 81.9% of our patients presented an excellent and good personal satisfaction. Conclusions: The modifications to the Hemi-Castaing procedure to perform it with a minimal invasive technic are reproducible and provide us with another tool for the treatment of this pathology specially in the cases where there is no sufficient tissue to perform an anatomical repair.

[Minimal invasive anterolateral ankle stabilization with a modified Hemi-Castaing technique]. / Estabilización anterolateral del tobillo por incisión mínima con técnica de Hemi-Castaing modificada.

BACKGROUND: The lesions to the lateral ligaments of the ankle are a common sports related injury. There are multiple surgical technics to address the problem all with a common goal: achieve a proper stability of the ankle. The improvements in the minimal invasive technics as well as those in the materials to fixate bone-tissue have also impacted the technics for lateral stabilization of the ankle. MATERIAL AND METHODS: We included all the patients with a diagnosis of lateral ankle instability which underwent surgery with a modify Hemi-Casting procedure with minimal invasive approach during the period between May 2004 and December 2007. We have an average follow-up of 30.3 months. RESULTS: Our patients presented a good outcome with an improvement in the Karlsson’s scale of 48.7 points (± 15.6) in the preoperative to 93.6 points (± 9.6) during follow-up. They returned to their sports activities after an average of 5.72 months (± 4.93). We used dynamic X-ray’s taken with the Telos system and achieved 81.9% of our patients presented an excellent and good personal satisfaction. CONCLUSIONS: The modifications to the Hemi-Castaing procedure to perform it with a minimal invasive technic are reproducible and provide us with another tool for the treatment of this pathology specially in the cases where there is no sufficient tissue to perform an anatomical repair.

ANTECEDENTES: Las lesiones de los ligamentos laterales del tobillo son comúnmente observadas en las actividades deportivas. Se encuentran descritas múltiples técnicas para su tratamiento, todas con un último fin: lograr una adecuada estabilidad del tobillo. Las técnicas de invasión mínima y los adelantos tecnológicos en los sistemas de fijación hueso-tendón han venido ganando adeptos en la última década y han impactado también las técnicas de estabilización del tobillo. MATERIAL Y MÉTODOS: Se incluyeron todos los pacientes con diagnóstico de inestabilidad lateral de tobillo que se intervinieron quirúrgicamente y se les realizó un procedimiento de Hemi-Castaing modificado con abordajes mínimos operados en el período de Mayo 2004 a Diciembre del 2007. Tenemos un seguimiento promedio de 30.3 meses. RESULTADOS: Nuestros pacientes presentaron una buena evolución, encontramos una mejoría importante en la escala de Karlsson de 48.7 puntos (± 15.6) a 93.6 puntos (± 9.6). Los pacientes regresaron a su actividad deportiva posterior a la cirugía a los 5.72 meses en promedio (± 4.93). Tenemos una adecuada estabilización corroborada con radiografías dinámicas con sistema Telos. Con una satisfacción personal excelente y buena en 81.9% de los pacientes. CONCLUSIONES: Las modificaciones a la técnica de Hemi-Castaing con el abordaje por incisión mínima, son seguras, reproducibles y nos dan una herramienta más para el tratamiento de esta patología y sobre todo en los casos en donde no se encuentre un adecuado tejido remanente para realizar una reparación anatómica.

An arthroscopic technique to treat the iliotibial band syndrome.

Iliotibial band syndrome (ITBS) is an overuse injury mainly affecting runners. The initial treatment is conservative. Only, in recalcitrant cases surgery is indicated. Several open techniques have been described. The purpose of this study is to evaluate the results of a standardized arthroscopic technique for treatment of a resistant ITBS. Thirty-six athletes with a resistant ITBS were treated with a standardized arthroscopic technique, limited to the resection of lateral synovial recess. Thirty-three patients were available for follow-up (mean 2 years 4 months). Thirty-two patients (34 knees) had good or excellent results. All patients went back to sports after 3 months. In two patients a meniscal lesion was found, which required treatment. One patient with only a fair result had associated cartilage lesions of the femoral condyle. Our results show that arthroscopic treatment of resistant ITBS is a valid option with a consistently good outcome. In addition, this arthroscopic approach allows excluding or treating other intra-articular pathology.

[Patellar tendon-bone autograft reconstruction of the anterior cruciate ligament for advanced-stage chronic anterior laxity: is an extra-articular plasty necessary? A prospective randomized study of 100 patients with five year follow-up]. / Intérêt d'une plastie extra-articulaire dans le traitement des laxités antérieures chroniques du genou par une autogreffe de tendon rotulien. Etude prospective randomisée d'une série de 100 cas avec 5 ans de recul.

PURPOSE OF THE STUDY: This prospective randomized study was conducted to analyze the anatomic and functional impact of an extra-articular lateral plasty associated with patellar tendon-bone autograft in anterior cruciate ligament reconstruction. MATERIAL AND METHODS: A consecutive series of 100 patients with grade II (Noyes classification) chronic anterior laxity confirmed on stress x-rays were included in the study. All patients had a positive Trillat-Lachman test, a direct anterior drawer at 90 degrees flexion confirmed on the lateral x-ray, and an instrumental differential laxity greater than 5 mm (manual arthrometry, Medmetric KT1000). Mean patient age was 27 years (range 16-29 years) and time from the accident to ligamentoplasty was 29 months (range 3-156 months). In the operating theater, the patients were assigned at random to two groups. Group 1 (50 patients) underwent arthroscopic free patellar tendon-bone autograft reconstruction of the anterior cruciate ligament. In the second group (50 patients) the same reconstruction was further supported by a lateral extra-articular plasty using the quadriceps tendon. All patients were followed prospectively. At 58 months follow-up (none of the patients were lost to follow-up) residual laxity (Medmetric KT1000) was noted and functional outcome was assessed using the IKDC criteria. The Aglietti method was used to assess the position of the drill holes. RESULTS: The two groups were strictly identical at inclusion. At last follow-up, the statistical analysis did not reveal any significant difference between the groups for subjective outcome, joint motion, instrumental residual laxity, meniscal stock, or radiological changes. The overall IKDC score was A or B in 80% of the patients in group 1 and 88% of the patients in group 2. Delay to resumed sports activities (about 12 months) was also equivalent in the two groups with a trend towards lower intensity and sports producing less stress on the knee. A minimally positive pivot test with no effect on stability was observed in 4 patients in group 1 (intra-articular plasty alone) and in 2 patients in group 2 (intra- and extra-articular plasty). 16% of the insufficient results (IKDC C and D) were related to repeated tears (n=8, 6 patients in group 1 and 2 patients in group 2, p=0.268), and failure (n=8, 4 in each group) due to defective motion and pain. Repeated tears were strongly correlated with incorrect drill hole position in the tibia (p=0.01) or femur (p=0.024). Despite the stabilization, radiological remodeling was observed in 31% of the patients in both groups. DISCUSSION: The results in this consecutive series of patients demonstrated the good results obtained with intra-articular ligamentoplasy using the mid third of the patellar tendon. The rate of repeated tears or minimally positive pivot tests was higher in group 1 with intra-articular plasty alone but did not reach statistical significance and was generally related to a technical error in positioning the autograft, making it difficult to draw any conclusion concerning the anatomic superiority of mixed plasty. CONCLUSION: At the current follow-up of 5 years, this study was unable to demonstrate any advantage of systematic conjunction of an extra-articular lateral support for advanced chronic anterior laxity of the knee treated by a free patellar tendon graft.

[Arthroscopic tibio-talar arthrodesis: limitations and indications in 20 patients]. / Arthrodèse tibio-talienne sous contrôle arthroscopique: limites et indications.

PURPOSE OF THE STUDY: The purpose of this study was to present the clinical and radiological outcome in 20 patients who underwent arthroscopic tibiotalar arthrodesis. MATERIAL AND METHODS: Between 1993 and 1999, twenty patients (twelve men and eight women) underwent arthroscopic tibiotalar arthrodesis and have been followed for a minimum of one year. Mean age at the time of the procedure was 55 years. The left side was treated in eleven patients and the right in nine. There were a variety of underlying conditions, but post-traumatic osetoarthritis predominated (ten patients); five patients had primary degenerative disease, three had "neurological" ankles, one had polyarthrtis and one necrosis of the talus. Three patients had previously undergone a double fusion and one other had had a subtalar arthrodesis. The preoperative Broquin score, which accounts for pain and walking distance, was 3.3 points on a scale of 8. The walking distance was less than 1000 meters for most of the patients. Radiographically, ten feet presented a frontal valgus deformity (mean 5.3 degrees); three had a varus deformity (mean 8 degrees) and seven were well-aligned. In the sagittal plane, there were ten cases of pes equin, including five greater than 10 degrees. The mean tibiopedal angle was 94+/-8 degrees. RESULTS: Mean hospital stay was four days. There were four complications: two superficial infections that resolved and two cases of reflex dystrophy. First-intention fusion was achieved in 17 patients (85%) after a mean 3.7 months (range 3-10 months). Three patients presented a non-union, two undergoing successful open surgery and one preferring to decline surgery on a well tolerated non-fused ankle. At last follow-up, fifteen patients were satisfied or very satisfied and five were dissatisfied. Pain was minimal or absent in 67% of the cases. The Duquennoy score was good or very good in eleven patients, fair in eight, and poor in one. Radiographical data were available for nineteen patients: four had a correct alignment in the frontal plane, eight exhibited valgus (mean 4 degrees), and seven varus (mean 8 degrees). In the sagittal plane, fifteen feet exhibited pes equin (mean 7 degrees), three a neutral position and one pes talus (4 degrees). The mean tibiopedal angle at last follow-up was 95.4 degrees. CONCLUSION: Although arthroscopic tibiotalar arthrodesis cannot improve the rate and delay to fusion in comparison with open surgery, it does reduce morbidity and the length of the hospital stay. We reserve the arthroscopic approach for ankles which are correctly or nearly correctly aligned without loss of bone stock, especially if there are local or general risk factors for open surgery.

[Ligamentoplasty of the anterior cruciate ligament after 40 years: a series of 41 patients]. / Reconstruction du ligament croisé antérieur après 40 ans: a propos de 41 cas.

PURPOSE OF THE STUDY: Ligamentoplasty for tears of the anterior cruciate ligament (ACL) is generally thought to be unreliable after the age of 40 years. The purpose of this retrospective analysis was to assess the five-year outcome after ACL plasty in patients aged over 40 at the time of surgery. MATERIAL AND METHODS: Between 1990 and 1997, 41 patients aged 44.5 +/- 4.5 years (28 men, 25 right side) underwent intra-articular reconstruction of the ACL. Clinical and radiological assessment using the IKDC criteria was obtained at a mean 62 months postoperatively using manual instrumental measurements with KT-1000. The indication for reconstruction was instability in daily life activities for 40 patients and difficulties encountered in sports activities in one; there were three cases of remodeling. Arthroscopy was used in all cases to perform a patellar tendon graft (bone-tendon-bone in 30 cases associated with extra-articular lateral reinforcement in eleven). RESULTS: There were no significant complications. Among 12 patients who initially participated in competition sports, seven were able to resume their activity at their former level. At last follow-up, global IKDC score was A for 12, B for 25, and C for three and D for one. All patients scored C or D had a poor IKDC symptom score, basically because of pain. Motion was not modified. The IKDC radiology score was A for 25, B for 15 and C for one, but the three cases of remodeling did not progress. Prognostic factors for overall IKDC result were: age of the patient at the time of reconstruction (under 45 years), and the delay to surgery for accident victims (less than one year). The following criteria had no effect at last follow-up: gender, sport practiced, type of initial laxity (anterior alone or global anterior), presence of meniscal damage, preservation of the medial and/or lateral meniscus, chondral injury observed peroperatively, and use of a lateral reinforcement. Radiographic remodeling observed in this group of 41 patients was related to delay from accident to surgery (p=0.0007) and preservation of the medial meniscus (p=0.03). Age, gender, type of activity before surgery, degree of initial and residual laxity had no statistically significant effect on remodeling. CONCLUSION: Age over 40 years is not a contraindication for arthroscopic free patellar tendon graft for the treatment of chronic anterior laxity. Using rigorous preoperative assessment criteria (delay from accident to surgery, absence of joint space narrowing on the AP and lateral view before intervention, symptomatic instability in daily life activities and motivated patient) this type of procedure can be performed safely and provides good functional outcome at five years. The current follow-up is insufficient to judge potential joint degradation. Age is not a contraindication if certain precautions are taken.