The ALR-RSI score can be used to evaluate psychological readiness to return to sport after acute Achilles tendon tear.

PURPOSE: The return to sport is one of the main goals following Achilles tendon tear repair. Several psychological factors influence the return to sport after a sports injury. The traditional tools to assess the return to sport do not take into account psychological factors. The ankle ligament reconstruction-return to sport injury (ALR-RSI), validated for ankle instability, is a score to evaluate psychological readiness to return to sport. The goal of this study was to validate the ALR-RSI score for the assessment of the readiness to return to sport after Achilles tendon repair. METHODS: The ALR-RSI score, adapted from the anterior cruciate ligament-return to sport injury (ACL-RSI) score used following knee ligament reconstruction, was validated according to the international COSMIN methodology. Patients operated for Achilles tendon repair responded to the questionnaire during the rehabilitation period. The EFAS, FAAM and VISA-A scores were used as reference questionnaires. RESULTS: A total of 50 patients were included. The ALR-RSI score was strongly (r > 0.5) correlated to the EFAS score: r = 0.68 [0.50-0.80] the FAMM sport score: r = 0.7 [0.52-0.84] the FAAM AVQ score (r = 0.6 [0.35-0.78]), and the VISA-A score (r = 0.54 [0.26-0.76]). The discriminant validity was good with the ALR-RSI, which was significantly lower in the patients that did not return to sport: 60.7 (40-81.4) compared to those that did: 83.2 (64.3-100) p = 0.001. Reproducibility was excellent with an intra-class correlation coefficient ρ of 0.99 [097-1.00]. The internal consistency was excellent (alpha coefficient = 0.95). CONCLUSION: The ALR-RSI score provides a valid, reproducible assessment of the psychological readiness to return to sport in patients who undergo surgical Achilles tendon suture repair. LEVEL OF EVIDENCE: III.

Impact of the national prevention policy and scrum law changes on the incidence of rugby-related catastrophic cervical spine injuries in French Rugby Union.

BACKGROUND AND AIMS: Catastrophic cervical spine injuries are rare in rugby union but require close monitoring. The aim of this study was to analyse the incidence of severe cervical spine injuries and determine the impact of a national prevention programme and new scrum rules implemented by the French Rugby Union. METHODS: A prospective study was performed between 2006 and 2013 including all players affiliated to the French Rugby Union. All cervical spine injuries resulting in death, tetraplegia or a permanent neurological deficit were included. Prevention programmes were implemented from 2007 to 2013 and a change in scrum rules in 2010. To measure the impact of rule changes, results between 2006-2010 and 2010-2013 were compared using a Poisson regression. RESULTS: Altogether, 31 injuries were observed and the mean annual incidence was 1.6 per 100 000 players. There were significantly more injuries in senior players compared to junior players (3.5 vs 0.6 per 100 000 players; CI 95% (2.1 to 4.9) vs (0.1 to 1.0)). Incidence decreased from 1.8 in 2006 to 1.0 per 100 000 players in 2013 (p<0.0001). After 2010, there were significantly fewer injuries during scrums (p=0.02). In contrast, there were significantly more injuries in backs during 2010-2013 compared to 2006-2010 (p=0.003). CONCLUSIONS: The incidence of catastrophic cervical spine injuries has declined in French Rugby Union. The implementation of specific prevention programmes and scrum law changes has notably resulted in a decrease in scrum injuries in forwards. This prospective study should be continued to monitor the future progression of injuries and adapt prevention programmes accordingly.

Peri-articular local infiltration analgesia versus femoral nerve block for postoperative pain control following anterior cruciate ligament reconstruction: Prospective, comparative, non-inferiority study.

INTRODUCTION: Femoral nerve block (FNB) is considered as a major advance in anterior cruciate ligament (ACL) reconstruction as it reduces the need for parenteral opioids. However, the incidence of transient or even permanent neurological deficits due to the FNB is estimated at 1.94% after knee surgery. The primary objective of this study was to compare local infiltration analgesia (LIA) to FNB during ACL reconstruction procedures. The study hypothesis was that LIA was not less effective than FNB on early postoperative pain. PATIENTS AND METHODS: A retrospective analysis of data collected prospectively in the FAST cohort included a series of continuous patients who underwent primary repair for isolated ACL with a hamstring graft in 2013-2014. Changes in our anesthesia practices over time allowed us to form three successive groups: Group 1 - FNB, Group 2 - FNB+LIA, Group 3 - LIA only. Ultrasound-guided FNB was done pre-operatively. The LIA was done at the end of the procedure by the surgeon with systematic infiltration of all skin incisions and the hamstring donor site; no intra-articular injections were performed. The primary endpoint was the average early postoperative pain (Days 0-3) described by the patient on a visual analogue scale (0-10). Sample size calculation pointed to 36 subjects being needed per group for a non-inferiority study. RESULTS: The study involved 126 patients: G1=42, G2=38, G3=46. The patients were comparable at enrolment. The average early postoperative pain levels were 3.1±2.4, 2.8±2.0 and 2.5±2.2, respectively (P=0.66). A trend toward higher intake of tramadol was noted in the LIA group on D0 to D3, with a significant trend test on Day 1 (P=0.03) and Day 2 (P=0.02). CONCLUSION: After reconstruction of isolated ACL tears with a hamstring graft, FNB is not more effective than LIA on patients' early postoperative pain. Patients who received a FNB consumed significantly less opioid-like analgesics. LEVEL OF EVIDENCE: III - Prospective, comparative, non-randomized study.

Outpatient Latarjet surgery for gleno-humeral instability: Prospective comparative assessment of feasibility and safety.

BACKGROUND: Some surgical procedures are rarely done on an outpatient basis. The primary objective of this study was to assess the safety of outpatient surgical shoulder stabilisation using the Latarjet procedure. HYPOTHESIS: The Latarjet procedure is safe when performed on an outpatient basis provided the patients are managed according to a specifically designed programme starting at the decision to undergo surgery and ending at the end of the early postoperative period. PATIENTS AND METHODS: Consecutive patients with unidirectional anterior shoulder instability managed in 2013-2014 by primary open, minimally invasive surgery involving coracoid process transfer as described by Latarjet was included prospectively. One of the surgeons routinely offered outpatient surgery to patients who met none of the usual exclusion criteria (age>60years, ASA 3-4, and long distance from home to hospital). Standardised protocols were applied for anaesthesia and analgesia. The primary evaluation criterion was failure of the admission modality, defined as inpatient admission of a patient after outpatient surgery either without prior discharge or within 1week after discharge. Secondary evaluation criteria were early postoperative symptoms and functional outcomes after at least 1year. All self-reported criteria were entered online by the patients. RESULTS: Of 46 included patients, 17 had outpatient surgery and 29 inpatient surgery. There were 41 males and 5 females, with a mean age of 25.3±6.4years. No significant baseline differences were found between the two groups. None of the outpatients required inpatient admission or readmission. No postoperative complications were recorded. After a mean follow-up of 18.5±5.2months, the two groups showed no significant differences for return to sports, apprehension, avoidance behaviours, or functional outcomes. Most patients were satisfied with their management and outcomes. CONCLUSION: No serious adverse events were recorded in this first French prospective evaluation of the safety of open, minimally invasive shoulder stabilisation by the Latarjet procedure performed on an outpatient basis. Thus, in selected patients, the risks of outpatient surgery are similar to those of inpatient surgery. LEVEL OF EVIDENCE: III, prospective, comparative, non-randomised study.

Inefficacy of Kinesio-Taping(®) on early postoperative pain after ACL reconstruction: Prospective comparative study.

INTRODUCTION: Kinesio-Taping(®) (K-Tape) is used in sports traumatology with the aim of reducing pain and improving blood and lymph circulation. The main objective of the present study was to assess the efficacy of K-Tape on early postoperative pain after anterior cruciate ligament (ACL) reconstruction. The study hypothesis was that K-Tape significantly decreases pain. METHOD: A prospective non-randomized comparative study was conducted in 2013-2014 and included all patients who underwent primary ACL reconstruction by hamstring graft. Analgesia was standardized. Two groups, "K-Tape" and "controls", were formed according to the days on which the study physiotherapist was present. The K-Tape compression/decompression assembly was applied immediately postoperatively and maintained for 3days. Patients filled out online questionnaires. The main assessment criterion was mean postoperative pain (D0-D3) on a 0-to-10 scale. Secondary criteria were analgesia intake on the three WHO levels, awakening during the night of D0 due to pain, signs of postoperative discomfort, and patient satisfaction. RESULTS: Sixty patients (30 per group) were included, 57 of whom could be assessed: 28 K-Tape, 29 controls; 44 male, 13 female; mean age, 30.9±8.9 years. At inclusion, the two groups were comparable. There was no significant difference in mean (D0-D3) knee pain intensity: 3.8±2.2 for K-Tape, and 3.9±2 for controls (P=0.93). Analysis of variance (ANOVA) found no significant intergroup difference in evolution of pain (P=0.34). There were no other significant differences on the other assessment criteria. CONCLUSION: K-Tape showed no efficacy on early postoperative pain following ACL reconstruction. LEVEL OF EVIDENCE: III; prospective non-randomized comparative study.

Diagnostic value of the GNRB ® in relation to pressure load for complete ACL tears: A prospective case-control study of 118 subjects.

INTRODUCTION: The GNRB(®) is a reliable, validated arthrometer. A pressure pad exerts 0 to 250 Newtons of pressure on the upper calf. The goal of this study was to compare the diagnostic value of the different pressure loads that are usually applied for the diagnosis of complete anterior cruciate ligament (ACL) tears. Our hypothesis was that a load of 200N would be sufficient to diagnose these tears. PATIENTS AND METHODS: A prospective comparative case-control study was performed in 2012. One group included all the male athletes aged 15 to 21 who presented with a complete ACL tear confirmed by arthroscopy (the study group). The control group included male soccer players in a training center aged 15 to 19 with no history of knee injuries (the control group). Anterior laxity was measured in both knees by the same experienced operator using the GNRB(®) system. The main judgment criteria were the diagnostic values of each pressure load evaluated by the area under the curve (AUC), from "Null" (AUC < 0.5) to "Perfect" (AUC = 1). RESULTS: This study included 118 men: 64 in the study group, mean age 18.1 ± 2.3-years-old, who were mainly soccer players (39/64) or rugby men (16/64) and 54 control subjects, mean age 17.3 ± 1.5-years-old. Three hyperalgesic patients could not receive a pressure load of 250N. The mean differential laxity was significantly higher in the control group, whatever the pressure load (P < 10(-5)). The test was "highly informative" for all loads (0.9 ≤ AUC < 1). Analysis of the AUC revealed a diagnostic value in descending order of: 200N(0.97[0.94-1]) > 134N(0.97[0.93-0.99]) > 250N(0.96[0.93-0.99]) > 89N(0.95[0.90-0.99]). CONCLUSION: The GNRB(®) at 200N was shown to be sufficient to diagnose complete ACL tears. Applying a pressure load of 250N does not appear to be useful.

Postoperative discomfort after outpatient anterior cruciate ligament reconstruction: a prospective comparative study.

INTRODUCTION: The principal objective of the present study was to compare rates of postoperative discomfort after anterior cruciate ligament (ACL) reconstruction between inpatient (In) and outpatient (Out) management. PATIENTS AND METHOD: A single-surgeon non-randomized prospective comparative study included patients undergoing primary surgery for isolated ACL tear by short hamstring graft in 2012-13. The Out group comprised patients eligible for and consenting to outpatient surgery and the In group, those not eligible or not consenting. The principal assessment criterion was onset of at least 1 symptom of postoperative discomfort (SPD): anxiety, nausea and vomiting, malaise, vertigo or stomach pain, between postoperative days 0 and 3. Secondary assessment criteria were difficulty in getting to sleep, getting up during the night, regular walking or going out, number of episodes of knee pain and waking because of pain. All criteria were assessed on-line by the patient. RESULTS: One hundred and thirty-three patients filled out the questionnaire, 70 in the Out group and 63 in the In group; 42 females, 91 males; mean age, 30±9 years. Between D0 and D3, the proportion of patients with ≥l SPD was comparable between groups (Out 37% vs In 41%, P=0.62). Out-group patients had significantly less difficulty sleeping the first postoperative night (P=0.01), got up significantly more often during the first night after surgery (P<0.0001), more often walked regularly on day 1 (P=0.03), and were significantly less often woken by pain during the first night (P=0.003). Risk factors for SPD were female gender (OR=4.8±1.9) and postoperative complications (OR=3.8±2.5). CONCLUSION: Patients undergoing ACL reconstruction on an outpatient basis did not show more symptoms of postoperative discomfort than those managed as conventional inpatients. LEVEL OF EVIDENCE: IV; prospective comparative study.

Translation, cross-cultural adaptation and validation of the French version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale.

PURPOSE: The aim of this study was to translate, adapt and validate in French the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), a 12-item English language scale assessing the psychological impact of returning to sports after ACL reconstruction. METHODS: The ACL-RSI scale was forward and back translated, cross-culturally adapted and validated using international guidelines. The study population included all patients who were active in sports and underwent primary arthroscopic ACL reconstruction. The control group included subjects with no history of knee trauma. At the 6-month follow-up, the study population completed the ACL-RSI scale twice within 3-4 days, Knee injury and Osteoarthritis Outcome Score (KOOS) and subjective International Knee Documentation Committee (IKDC) scores. Statistical tests assessed the construct validity, discriminant validity, internal consistency, reliability and feasibility of the ACL-RSI scale. RESULTS: Ninety-one patients with ACL tears and 98 control subjects were included: mean age 31.7 ± 8.1 and 21.8 ± 2, respectively. The ACL-RSI scores were correlated with all KOOS sub-categories (r = 0.22-0.64, p < 0.05) as well as the subjective IKDC score (r = 0.42, p < 0.00001). The mean scores of the study and control groups were significantly different (62.8 ± 19.4 vs. 89.6 ± 11.5, p < 0.00001), and scores were significantly better in patients who returned to the same sport (72.1 ± 21.4 vs. 60.3 ± 18.1, p = 0.008). Internal consistency was high (α = 0.96). Test-retest reproducibility was excellent: ρ = 0.90 (0.86-0.94), p < 0.00001. Administration time was 1.32 ± 0.7 mn, and all items were answered. CONCLUSION: This study showed that the cross-cultural adaptation of the English version of the ACL-RSI was successful and validated in a French-speaking population. The discriminant capacity of the scale between patients who underwent reconstruction and healthy subjects was confirmed. LEVEL OF EVIDENCE: II.

Complete paralysis of the quadriceps secondary to post-traumatic iliopsoas hematoma: a systematic review.

PURPOSE: Paralysis of the femoral nerve secondary to compression by a hematoma of the iliopsoas is rarely post-traumatic. The acute surgical removal of hematoma seems the treatment of choice. The main objective of this systematic review was to determine the optimal delay between the trauma and surgery, to obtain a total functional recovery. METHODS: A search was performed via PubMed. The inclusion criteria were the studies in English language, reporting the results of the treatment of femoral nerve palsy secondary to compression by a post-traumatic hematoma of the iliopsoas. The primary evaluation criterion was the clinical recovery of femoral nerve function. The secondary criteria were the delay of recovery and the delay between the trauma and surgery. RESULTS: Thirteen studies were identified, only case reports. Sixteen patients were included, mean age 16.6 ± 3.4 years, 11 men and 5 women. The injury was associated with the sports practice in 12/16 (75 %) cases. Neurological symptoms developed about 5 days after injury. Femoral palsy was complete in 8 patients and partial in 8 patients. The mean delay between the injury and the diagnosis was 7.3 (2-25) days in conservative group and 17.8 (4-45) days in surgical group. Seven patients were managed conservatively, 6 partial paralysis and 1 total paralysis, and 9 surgically, 7 total paralysis and 2 partial paralysis. The recovery was total in 13/14 patients (seven surgical treatment and six conservative management) and partial in one patient who was managed conservatively despite a total paralysis. The delay of total recovery varied from 1 month to 6 weeks in conservative group and 3 months to 2 years in surgical group. CONCLUSION: This systematic review seems to indicate that whatever the delay, surgery is necessary in case of complete paralysis of the femoral nerve secondary to compression from a post-traumatic hematoma of the iliopsoas muscle.

Outpatient surgery feasibility in anterior cruciate ligament reconstruction: a prospective comparative assessment.

INTRODUCTION: The main objective of this study was to assess the feasibility of outpatient surgery in anterior cruciate ligament (ACL) reconstruction. We hypothesized that if the patient underwent the procedure within a dedicated organization, safety would be ensured. PATIENTS AND METHODS: A non-randomized, prospective, comparative, single-operator study conducted in 2012-2013 included all patients undergoing first-line surgery for ACL arthroscopic reconstruction using a short hamstring graft. The outpatient group (OP) included patients who were eligible for outpatient surgery and provided consent; the conventional hospitalization group (CH) comprised those patients not suitable for outpatient surgery and those who refused it. The main evaluation criterion was failure of the admission modality defined as hospitalization of a patient who had undergone outpatient surgery or rehospitalization in the first week after discharge. The secondary evaluation criteria were the rate of postoperative complications, postoperative pain, use of analgesics, and patient satisfaction. A total of 138 patients were included: 71 in the OP group and 67 in the CH group, with a mean age of 29.6±9 years. Twenty-nine percent of the patients refused outpatient surgery. In the CH group, the mean hospital stay lasted 2.7±0.8 days. RESULTS: One patient in the OP group was hospitalized with localized bleeding and there were no rehospitalizations. Six early postoperative complications were noted in each group. The mean postoperative pain on D0-D4 and patient satisfaction were similar in the two groups. CONCLUSION: This prospective study encountered no serious events after outpatient ACL reconstruction surgery. In a selected population, the risks are comparable to those in conventional hospitalization. LEVEL OF EVIDENCE: Level III, comparative study.

Sensitivity and specificity of bell-hammer tear as an indirect sign of partial anterior cruciate ligament rupture on magnetic resonance imaging.

PURPOSE: The main purpose of this study was to evaluate the usefulness of the bell-hammer sign in the diagnosis of partial tears of the anterior cruciate ligament (ACL) of the knee on MRI. METHODS: A retrospective study was performed including all patients who underwent ACL reconstruction for partial or complete tears from 2008 to 2009. The diagnosis of partial or complete ACL tears was based on the appearance of the ligament bundles and the signal quality on MRI. On arthroscopy, which is considered the gold standard, each bundle was classified as normal, partially or completely torn depending on the extent of the rupture and the quality of the remaining fibres. The study included 312 patients, 83 women and 229 men (mean age 33.3 ± 19.6 years). A diagnosis of a tear was made in all patients on preoperative MRI. Arthroscopy did not show any normal ACL, 247/312 (79.2 %) complete tears and 65/312 (20.8%) partial tears, 50/65 (76.9%) on the anteromedial bundle (AM) and 15/65 (23.1%) the posterolateral bundle. RESULTS: The bell-hammer sign was found on MRI in 13/312 patients (4.5%). It involved 9/65 (13.8%) partial tears, all in the AM bundle, and 4/247 (1.6%) complete tears, significantly more frequent in cases of partial rupture (p < 0.0001). MRI diagnosed a partial tear in 15/65 cases without the bell-hammer sign (sensitivity CI 95% = 23.1 ± 10%, specificity CI 95% = 95.9 ± 2.5%) and with the bell-hammer sign in 23/65 cases (sensitivity CI 95% = 35.4 ± 11%, specificity CI 95% = 93.9 ± 3%). The association of the bell-hammer sign with conventional radiological diagnostic criteria has improved diagnosis performance of MRI for partial tears but not significantly (ns). CONCLUSION: The most important interest of the bell-hammer sign in the day-to-day clinical work is to suggest partial tears on MRI. It aids making a diagnosis, but its absence does not exclude partial ACL rupture. LEVEL OF EVIDENCE: Diagnostic study, Level II.

Partial tears of the anterior cruciate ligament: diagnostic performance of isotropic three-dimensional fast spin echo (3D-FSE-Cube) MRI.

PURPOSE: To compare the performance of 3D-FSE-Cube MRI to arthroscopy, the reference test for the diagnosis of partial anterior cruciate ligament (ACL) tears. METHODS: A retrospective study was performed including all patients who underwent surgery for an ACL tear in our Sports Surgery Unit from January 2008 to December 2009. All patients underwent a preoperative MRI, conventional 2D or 3D-Cube. The diagnosis of a partial tear was based on the appearance of the ligament bundles and signal quality on MRI, and on the continuity of the fibers on arthroscopy and the quality of the remaining ligament. Sixty-four of the 312 included patients underwent MRI 3D-Cube and 248 conventional 2D-MRI. The series included 82 women and 223 men, mean age 33.3 ± 19.6 years. Arthroscopy did not reveal any normal ACL, 247/312 (79.2 %) complete tears, and 65/312 (20.8 %) partial tears, with 50/65 (76.9 %) involving the anteromedial bundle and 15/65 (23.1 %) the posterolateral. RESULTS: The results of MRI 3D-Cube were as follows: sensitivity 95 % CI = 62.5 ± 23.7 %, specificity 95 % CI = 93.7 ± 6.9 %, likelihood ratio LR(+) = 9.9, LR(-) = 0.4 and accuracy 85.9 %. Results of conventional 2D-MRI were as follows: sensitivity 95 % CI = 10.2 ± 8.5 %, specificity 95 % CI = 96.5 ± 2.5 %, LR(+) = 2.9, LR(-) = 0.9 and accuracy 79.4 %. The diagnostic performance of MRI 3D-Cube was better than conventional 2D-MRI. CONCLUSION: The diagnostic performance of MRI 3D-Cube in partial ACL tears was good and significantly better than conventional 2D-MRI. The likelihood of having a positive test was 9.9 times higher in a patient with a partial tear. A negative result did not exclude this diagnosis.

Validity of GNRB® arthrometer compared to Telos™ in the assessment of partial anterior cruciate ligament tears.

PURPOSE: The main goal of this study was to compare the results of the GNRB(®) arthrometer to those of Telos™ in the diagnosis of partial thickness tears of the anterior cruciate ligament (ACL). METHODS: A prospective study performed January-December 2011 included all patients presenting with a partial or full-thickness ACL tears without ACL reconstruction and with a healthy contralateral knee. Anterior laxity was measured in all patients by the Telos™ and GNRB(®) devices. This series included 139 patients, mean age 30.7 ± 9.3 years. Arthroscopic reconstruction was performed in 109 patients, 97 for complete tears and 12 single bundle reconstructions for partial thickness tears. Conservative treatment was proposed in 30 patients with a partial thickness tear. The correlation between the two devices was evaluated by the Spearman coefficient. The optimal laxity thresholds were determined with ROC curves, and the diagnostic value of the tests was assessed by the area under the curve (AUC). RESULTS: The differential laxities of full and partial thickness tears were significantly different with the two tests. The correlation between the results of laxity measurement with the two devices was fair, with the strongest correlation between Telos™ 250 N and GNRB(®) 250 N (r = 0.46, p = 0.00001). Evaluation of the AUC showed that the informative value of all tests was fair with the best results with the GNRB(®) 250 N: AUC = 0.89 [95 % CI 0.83-0.94]. The optimal differential laxity threshold with the GNRB(®) 250 N was 2.5 mm (Se = 84 %, Sp = 81 %). CONCLUSION: The diagnostic value of GNRB(®) was better than Telos™ for ACL partial thickness tears.

Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee: recurrence rate and functional outcomes after a mean follow-up of seven years.

BACKGROUND: Pigmented villo-nodular synovitis (PVNS) is an uncommon proliferative condition of the synovial membrane that chiefly affects the knee. Arthroscopic synovectomy may carry lower morbidity rates but higher recurrence rates than open synovectomy. Here, our objective was to evaluate recurrence rates and functional outcomes after primary arthroscopic synovectomy for PVNS of the knee. HYPOTHESIS: Primary arthroscopic synovectomy preserves knee function while producing low recurrence and complication rates. MATERIALS AND METHODS: We retrospectively included consecutive patients with histologically documented PVNS managed with primary arthroscopic synovectomy at two centres between 1998 and 2011. Twenty-three patients, 13 men and 10 women with a mean age of 41 ± 12 years, were reviewed including 16 patients with nodular and 7 with diffuse form of this disease. Patients with localized disease underwent partial synovectomy and those with diffuse disease complete synovectomy followed by chemical synovectomy of any residual lesions. The primary outcome measure was recurrence. Secondary outcome measures were the Tegner-Lysholm and Ogilvie-Harris scores. RESULTS: Follow-up data were obtained after a mean of 7 ± 4 years in 21 patients (14 with nodular and 7 with diffuse disease), of whom 2 had recurrences, after 2 and 5 years, respectively. At last follow-up, neither patient had any evidence of recurrence. The mean Tegner-Lysholm score was significantly improved (from 68 ± 10 to 90 ± 8, P=0.0004) and the mean Ogilvie-Harris score indicated excellent function (11 ± 1). DISCUSSION: Primary arthroscopic synovectomy ensures satisfactory control of PVNS while preserving knee function. A full recovery remains possible even in patients with diffuse disease. In the event of a recurrence, open synovectomy can be performed.

Anterior cruciate ligament tear during the menstrual cycle in female recreational skiers.

INTRODUCTION: Women run a 4-8-fold greater risk of anterior cruciate ligament (ACL) tear than men, and especially during the pre-ovulation stage of their cycle. The main study objective was to describe the distribution of ACL lesions according to menstrual cycle in a large population of female recreational skiers. MATERIALS AND METHODS: A prospective study was conducted during the 2010-11 ski season on women sustaining ACL tear during skiing. Patients filled out a questionnaire during consultation with the mountain physician, including date of last menstrual period (LMP) and contraceptive method. Fifty-seven of the 229 patients with diagnosed ACL tear were excluded from analysis, 41 being post-menopausal (mean age, 47 ± 9 years), and 16 having irregular cycles or LMP>30 days. One hundred and seventy-two patients (mean age, 34 ± 8.7 years) were thus included. RESULTS: Fifty-eight women (33.72%) were in follicular phase, 63 (36.63%) in ovulatory phase and 51 (29.65%) in luteal phase; difference with respect to the theoretic distribution regardless of menstrual phase was highly significant: χ(2)=48.32; P=0.00001. Fifty-three of the 172 women (30.8%) were taking oral contraceptives. ACL tear was 2.4-fold more frequent in pre-ovulatory than post-ovulatory phase, whether in women using oral or other contraceptives: 85/119 (71.4%) vs. 36/53 (67.9%); P=0.64. CONCLUSION: ACL tear risk in skiing in women is not constant over the menstrual cycle, being 2.4-fold more frequent in pre-ovulatory (follicular and ovulatory) than post-ovulatory phase (luteal). Oral contraception seems not to exert any protective effect. LEVEL OF EVIDENCE: Level IV. Retrospective cohort study.

Returning to sports after surgical repair of acute proximal hamstring ruptures.

PURPOSE: Although the treatment of choice for acute proximal hamstring ruptures is now surgical repair, this technique is relatively new and requires further evaluation. Our hypothesis was that patients return to sports at the same level after surgical repair as before injury. METHODS: From 2002 to 2011, a prospective observational study including 34 patients, mean age 39.3 ± 11.4 years old underwent surgical repair of an acute proximal hamstring rupture. Surgical, rehabilitation and follow-up protocols were standardized. Mean follow-up was 27.2 ± 22.9 months and there were no lost to follow-up. The primary outcome was the level of activity on the UCLA and Tegner scores. RESULTS: The mean UCLA score was 9.1 ± 1.3 before injury and 8.7 ± 1.7 at the final follow-up (p = 0.03). The median Tegner activity level was 6 (range, 4-10) before injury and 6 (range, 3-10) at the final follow-up (p = 0.05). The two scores were correlated (r = 0.76, p = 0.00001). Patients returned to sports within a mean 5.7 ± 1.6 months, at the same level in 27 patients (79.4 %) and at a lower level in 7 patients (20.6 %). The average hamstring/quadriceps ratio at 240°/second was 54.7 ± 8.6 % which was positively correlated to the level of activity on the UCLA score (r = 0.49, n.s.). The level of satisfaction was related to their level of activity at the final follow-up (p = 0.03). CONCLUSION: Although surgical repair of acute proximal hamstring ruptures has significantly improved the functional prognosis of patients it remains a serious condition that can compromise future sports activities. LEVEL OF EVIDENCE: Case-control study, Level III.

Surgical technique for repair of acute proximal hamstring tears.

The surgical technique for repair of acute proximal hamstring tears is relatively recent. Installation of the patient is critical. The approach is either vertical under the gluteal fold in case of a complete tear with tendon retraction of more than 6 cm, or horizontal in the gluteal fold for retraction of less than 6 cm or for partial tears. After identification and neurolysis of the sciatic nerve, transosseous tendon reinsertion is performed with three or four metal or resorbable suture anchors. A rigid brace keeping the leg at 30° of flexion is worn for few days, then replaced by an articulated knee brace for 45 days, which limits extension but allows full flexion. Rehabilitation is begun early. Thirty-four patients underwent surgery for acute proximal hamstring tear and received this treatment. All of the athletic patients were able to return to their pre-injury activities after a mean 5.7 ± 1.6 months (2.3-9.3 months).

[Early failure of anterior bone block in multidirectional shoulder instability: a case report]. / Echec précoce d'une butée antérieure d'épaule dans le traitement d'une instabilité multidirectionnelle.

We report the case of a 47-year-old female patient who developed predominantly anterior multidirectional glenohumeral instability. After rehabilitation, this patient was treated surgically with an anterior coracoid bone block using the Latarjet technique. The second postoperative day, the control scan revealed posterior glenohumeral dislocation. The patient underwent a second operation for a posterior iliac block. At last clinical follow-up (six years), the patient had normal shoulder motion; shoulder function was considered excellent using the clinical scores. We recall the pathogenic hypotheses explaining multidirectional shoulder instability and discuss the proposed treatments. This case illustrates the difficult diagnosis and therapeutic management of multidirectional instability. Under general anesthesia, examination showed that posterior laxity predominated while paradoxically, the patient presented predominantly anteromedial dislocations. This case is also exceptional by the development of posterior dislocation, an unusual postoperative complication after an anterior bone block; we describe the therapeutic options. In the event of multidirectional instability with bone injuries, we recommend a block in the direction of the instability. Preoperative examination under general anesthesia can be helpful in understanding the mechanism of residual postoperative instability, which would require complementary surgical stabilization.