Preoperative planning of tibial tubercle medialisation according to the trochlear groove angle.

The tibial tubercle-trochlear groove distance (TT-TG) was first described four decades ago. Since then, a considerable body of research has become available on the pathophysiology of chronic patellar instability, whose diagnosis and treatment remain challenging. Tibial tubercle medialisation can correct an abnormal TT-TG. Preoperative planning based on the TT-TG and trochlear angle may avoid both under-correction inducing persistent instability and overcorrection responsible for pain. Preoperative planning should be patient-specific. With appropriate preoperative planning, compensation for moderate trochlear dysplasia can be achieved without any additional procedure.

[RESEARCH DEVELOPMENT OF REVERSE TOTAL SHOULDER ARTHROPLASTY].

OBJECTIVE: To investigate the development and clinical application of the reverse total shoulder arthroplasty. METHODS: The relative publications on reverse total shoulder arthroplasties were extensively reviewed and analyzed. RESULTS: Reverse total shoulder arthroplasty has extensive indications, especially for pseudoparalysis caused by irrepairable rotator cuff tears with forward or upper shift of the humeral head and intact function of deltoid. The clinical research results indicate that the short-term results are satisfactory, but there are some special complications, such as scapular nothching, instability and limities of internal and external rotation. While performing this kind of operation, the selection of the approach, the determination of the prosthetic rotation center should be considered well, and the bone graft should be paid attention to when the bony defect of the glenoid and proximal humerus exists. CONCLUSION: The using time of the reverse total shoulder arthroplasty is short, so the long-term results should be observed. The development of computer assisted technique is hopeful to be improve the results of the reverse total shoulder arthroplasty.

Coracoid process x-ray investigation before Latarjet procedure: a radioanatomic study.

BACKGROUND: The purpose of this study was to determine whether a preoperative radiologic assessment of the coracoid process is predictive of the amount of bone available for coracoid transfer by the Latarjet procedure. MATERIAL: Thirty-five patients with anterior instability undergoing a Latarjet procedure were included. A preoperative radiologic assessment was performed with the Bernageau and true anteroposterior (true AP) views. METHODS: The length of the coracoid process was measured on both radiographic views and the values were compared with the length of the bone block during surgery. Statistical analysis was carried out by ANOVA and Wilcoxon tests (P < .05). RESULTS: On radiologic examination, the mean coracoid process length was 29 ± 4 and 33 ± 4 mm on the Bernageau and true AP views, respectively. The mean bone block length during surgery was 21.6 ± 2.7 mm. A significant correlation was found (P = .032) between the coracoid process length on the true AP view and the intraoperative bone block length. DISCUSSION: Preoperative planning for the Latarjet procedure, including graft orientation and screw placement, requires knowledge of the length of coracoid bone available for transfer. This can be facilitated with the use of preoperative standard radiographs, thus avoiding computed tomography. This planning allows the detection of coracoid process anatomic variations or the analysis of the remaining part of the coracoid process after failure of a first Latarjet procedure to avoid an iliac bone graft. CONCLUSION: Radiologic preoperative coracoid process measurement is an easy, reliable method to aid preoperative planning of the Latarjet procedure in primary surgery and reoperations.

Long-term functional and structural outcome in patients with intact repairs 1 year after open transosseous rotator cuff repair.

HYPOTHESIS: Tendon-to-bone suture and a fatty degeneration index (FDI)

Bone morphing system for rotational alignment in total knee arthroplasty / 中国组织工程研究

BACKGROUND: Previous total knee arthroplasty trials have demonstrated that using Bone Morphing(R) based computer-assisted system surgeon can accurately perform three-dimensional prosthesis position and restore the lower limbs mechanical axis, reduce patellofemoral joint complications, balance ligaments so as to obtain good clinical outcomes.OBJECTIVE: To quantitatively analyze rotational alignment of components in total knee arthroplasty and to validate the accuracy and the effectiveness of Bone Morphing(R) based computer-assisted system in qualitative practicing.DESIGN, TIME AND SETTING: Retrospective case analysis was performed in the Orthopaedic and Traumatic Department, Henri Mondor Hospital between November 2002 and June 2003.PARTICIPANTS: A total of 21 knees of 21 patients with tri-compartment osteoarthritis, failed to the conservative medical treatment, were selected, including 14 genu varum and 7 genu valgum. All patients underwent primary total knee arthroplasty, with posterior stabilized total knee prosthesis (Hermes(R) Ceraver, France).METHODS: Using Bone Morphing(R) based Ceravision system, all patients underwent total knee arthroplasty. The computer system provided prosthesis proposal, guided surgeon to conduct osteotomy after installing osteotomy location device. The lower limb alignment deviation should be within (180±3)°, and frontal laxity within ±3° using varus/valgus stress test. The prosthesis was fixed after appropriate prosthesis rotation alignment.MAIN OUTCOME MEASURES: Based on the relative preoperative, intraoperative and postoperative data from clinical check-up, the X-ray films and the intraoperative components rotational alignment real-time records in CD Rom as well as the range of motion and the frontal laxity of knee at three months postoperatively were analyzed. RESULTS: For the achievement of proper lower limb alignment and normal frontal laxity of knee, intra-operative performance was realized with rotational alignment of femoral components from internal rotation (IR)1° to external rotation (ER) 5°, tibial components from 0° to ER 5°. For varus knees, femoral components were ER1°- ER5°, tibial components ER2°-ER5°; for valgus knees, femoral components were IR1°-ER 4°, tibial components 0°-ER 4°. Three months after surgery, mean flexion angle measured as range of motion (ROM) was 115°(105°-130°), and no knee pain, patellar instability or dislocation or abnormal knee frontal laxity was found.CONCLUSION: Using Bone Morphing(R) computer-assisted system can optimize the individual components rotation alignment accurately, obtain good symmetric space of extension/flexion of knee joint, maintain tension and balance stability of ligament, and avoid patellofemoral complications.

Total shoulder arthroplasty using the superior approach: influence on glenoid loosening and superior migration in the long-term follow-up after Neer II prosthesis installation.

Glenoid component loosening and superior humeral translation are common after Neer II total shoulder arthroplasty using the anterior approach. To determine whether the superior approach reduced these complications, we retrospectively reviewed 20 shoulders in 16 patients. Both components were cemented. Patient satisfaction, unweighted Constant score, and imaging studies were evaluated at a mean of 3.5 years and at a mean of 11.1 years. Fourteen patients were satisfied or very satisfied. The mean unweighted Constant score improved from 25/100 preoperatively to 57/100 after 3.5 years and to 51/100 after 11.1 years. Pain relief contrasted with low strength. Radiolucent lines appeared around 95% of glenoid components and 20% of humeral stems. Computed tomography showed severe glenoid osteolysis in 3 of 13 shoulders. Humeral superior translation did not occur. This study confirms the glenoid component fixation issue. The superior approach may reduce the risk of humeral superior translation and radiologic glenoid component loosening.

[Bone morphing system for rotational alignment in total knee arthroplasty].

OBJECTIVE: To investigate the qualitative rotation alignment of components in total knee arthroplasty and the accuracy and the effectiveness of Bone Morphing computer assisted system when qualitatively practicing. METHODS: From November 2002 to June 2003, 21 patients with three compartments osteoarthritis (21 knees) were treated by primary total knee arthroplasty after the conservative medical treatment failed, with the assistance of a "Bone Morphing" Ceravision System, implanted posterior stabilized total knee prosthesis. Twenty-one patients included 5 males (5 knees) and 16 females (16 knees) with an average age of 72.4 years (64-79 years). The locations were left knee in 10 cases and right knee in 11 cases. The patients suffered from knee pain and limitation of movement from 2 to 10 years. There were 14 genu varum and 7 genu valgum preoperatively. The relative preoperative, intraoperative and postoperative data from clinical check-up, the X-ray films and the intraoperative components rotational alignment real-time records in CD Rom were analyzed. RESULTS: All operative incisions healed up by first intension. Twenty-one patients were followed up 12-16 months (mean 13.3 months). For the achievement of proper lower limb alignment and normal frontal laxity of knee, rotational alignment of femoral components was from internal rotation (IR) 1 degree to external rotation (ER) 5 degrees, tibial components from IR 0 degree to ER 5 degrees. In patients with genu varum, the rotational alignment of the femoral components was ER 1 degree-ER 5 degrees, of tibial components ER 2 degrees-ER 5 degrees. In patients withgenu valgum, the rotational alignment of femoral components was IR 1 degree-ER 4 degrees, of tibial components IR 0 degree-ER 4 degrees. After 3 months of operation, the mean flexion angle measured as range of motion (ROM) was 115 degrees (105-130 degrees), the frontal laxsity measured as 0.2-0.5 cm (mean 0.27 cm) of internal laxity and 1.0-2.5 cm (mean 1.7 cm) for external laxity, there were no knee pain, paterllar instability or dislocation and abnormal knee frontal laxity. CONCLUSION: Using Bone Morphing computer-assisted system can optimise the individual components rotation alignment accurately.

Influence of lower-limb torsion on long-term outcomes of tibial valgus osteotomy for medial compartment knee osteoarthritis.

BACKGROUND: The results of tibial osteotomy used to treat osteoarthritis of the medial compartment of the knee deteriorate over time even when the initial correction is optimal. Studies have shown that tibial and femoral torsion and the femorotibial index (tibial torsion minus femoral torsion) contribute, together with coronal malalignment, to the development of single-compartment knee osteoarthritis. The objective of our study was to evaluate the impact of femoral and tibial torsion and of coronal realignment on the long-term clinical and radiographic outcomes of valgus tibial osteotomy. METHODS: A function score was calculated for sixty-eight patients at a mean of thirteen years after the osteotomy. Anteroposterior single-leg-stance radiographs were used to evaluate loss of the femorotibial joint space. Goniometry was used to measure coronal malalignment preoperatively, at one year, and at the time of the last follow-up, and postoperative computed tomography was performed to measure femoral anteversion and tibial torsion and to calculate the femorotibial index. We looked for associations linking body mass index, initial loss of joint space, coronal malalignment, femoral and tibial torsion, the femorotibial index, and functional outcomes. RESULTS: Worse outcomes were associated with changes in coronal alignment (>/=2 degrees ) over time, which were associated with deterioration of the femorotibial space. Femoral anteversion was significantly greater in patients in whom valgus increased over time than in those in whom valgus decreased over time. Stability of coronal alignment seemed to be dependent on a linear relationship between the femorotibial index and the degree of postoperative realignment. A body mass index of >25 kg/m(2) was associated with a long-term loss of coronal realignment. Preoperative loss of the medial femorotibial joint space, coronal alignment at one year, and age were not associated with secondary malalignment or functional outcomes. CONCLUSIONS: Long-term success of a valgus tibial osteotomy is related to the stability over time of the postoperative coronal realignment. Therefore, the results of our study suggest that modifying the realignment according to the extent of femoral anteversion may improve long-term outcomes.

[Bone morphing system for ligament balancing in total knee arthroplasty].

OBJECTIVE: To investigate effectiveness of applying the Bone Morphing based image-free computer-assisted system for the ligament balancing management in the total knee arthroplasty (TKA). METHODS: Between November 2002 and June 2003, twenty-one posterior stabilized total knee prostheses (Craver, France) were implanted in 21 patients using the Bone Morphing based image-free Ceravision system. This cohort included 5 men and 16 women with an average age of 72.4 years, two undergoing high tibial osteotomy and 1 undergoing distal femoral osteotomy before. The preoperative deviation was measured by the full-length AP X-rays. The knees were in varus deviation in 14 patients and in valgus deviation in 7 patients, with an average of 2.36 degrees (varus 13 degrees-valgus 13 degrees). The frontal X-rays of the knee were assessed, the mean value of the varus force-stress test was 8.47 degrees (varus 2 degrees-varus 20 degrees), and the mean value of the valgus force-stress test was 3. 63 degrees (varus 7 degrees-valgus 12 degrees). RESULTS: With the Ceravision-recorded data, the intraoperative alignment was assessed, the mean lower limb axis was 3.33 degrees (varus 12 degrees-valgus 10 degrees), and compared with the preoperative data, the difference was significant (P < 0.05); the mean value of the varus force-stress test was 6. 47 degrees (varus 0 degree - varus 24 degrees), the mean value of the valgus force-stress test was 4.32 degrees (varus 8 degrees-valgus 15 degrees), and compared with the preoperative data, the difference was significant (P < 0.05). The post-prosthetic alignment on Ceravision with a deviation of 0.175 degrees (varus 2 degrees-valgus 3 degrees) was compared with the postoperative alignment by the full-length AP X-rays, with a deviation of 0.3 degrees (varus 3.5 degrees-valgus 1.5 degrees), the difference wasn't significant (P > 0.05). The clinical check-up performed 3 months after operation showed that the average range of movement (ROM) was 115 degrees (105-130 degrees), the mean frontal laxity was 0.27 mm (0.2-0.5 mm). The femoral and tibial components were implanted in the satisfactory 3 dimensional position without ligament imbalance in all the patients, and there were no instability or patella complications. CONCLUSION: Utilization of the Bone Morphing based image-free computer-assisted system can achieve an accurate component 3 dimensional alignment, optimal bone resection, optimal control of surgical decision in releasing the soft tissues, rotating the femoral component to gain an extension/flexion rectangular gap, and managing the ligament balancing so as to achieve a satisfactory initial clinical outcome. This system can be routinely used in the TKA.

Surgical treatment of destructive cervical spondyloarthropathy with neurologic impairment in hemodialysis patients.

STUDY DESIGN: We have retrospectively reviewed 11 chronic hemodialysis patients with cervical destructive spondyloarthropathy responsible for neural impairment 1 year after surgery and at last follow-up. OBJECTIVE: To evaluate clinical and radiologic outcomes, and necessity of vertebral block excision. SUMMARY OF BACKGROUND DATA: Destructive spondyloarthropathy of the cervical spine is associated with long-term hemodialysis for chronic kidney failure. Spinal cord compression and neurologic troubles occur in a few cases. Surgical treatment remains controversial because these are debilitated patients with multiple organ failures. METHODS: All 11 patients had unstable cervical spondylolisthesis, and 10 had kyphotic vertebral fusion involving at least 2 vertebrae. We performed interbody bone grafting (cement in 1 case) and stabilized with a plate. In 6 of the 10 patients with vertebral block, excision of the block was performed. RESULTS: No patients were lost to follow-up. One patient died 2 days after the operation. There were 2 other patients who required early surgical revision (i.e., a corporectomy followed by early graft expulsion). Bone healing settled in all patients. One year after surgery, patients had almost complete resolution of the pain and satisfactory neurologic recovery. Improvement was evaluated according to the Nurick classification. CONCLUSION: Functional and neurologic results were similar whether the patients did or did not undergo vertebral block excision, suggesting that stabilizing the unstable level may be sufficient in patients with neurologic impairment. Excision of spontaneous vertebral blocks should be avoided to minimize the morbidity of surgery in these debilitated patients with a limited life expectancy.

Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears.

Two hundred twenty shoulders with a rotator cuff tear repaired by simple tendon-to-bone suture were analyzed to determine whether the severity of presurgical fatty degeneration had an influence on their anatomic and functional outcome. Fatty degeneration was evaluated for each muscle with the 5-stage grading system developed by Goutallier et al. A global fatty degeneration index (GFDI), the mean value of the 3 muscles, was calculated for each shoulder. Cuff integrity was evaluated by magnetic resonance imaging (116 cases) or computed arthrotomography scan (104 cases) at a mean 37 months' follow-up, and functional outcomes were evaluated with the Constant score. A recurrent tear was found in 79 cases (36%) and was more frequently encountered in posterosuperior tears. The likelihood of a recurrent tear was greater for tendons whose muscle showed fatty degeneration greater than grade 1. Fatty degeneration of the infraspinatus or subscapularis muscles had an influence on supraspinatus tendon outcome. A GFDI lower than 0.5 was necessary to yield less than 25% retears. The mean global Constant score was 75 at revision, significantly lower when a retear was present (70.5 versus 77.5). In the subgroup of watertight cuffs, it was lower when GFDI was higher. Fatty degeneration is an important prognostic factor in rotator cuff surgery.

Shoulder surgery: from cuff repair to joint replacement. An update.

REPAIRING FULL THICKNESS CUFF TEARS.--Despite the sound rationale for repairing full-thickness rotator cuff tears, the procedure may fail to restore cuff integrity, which is indispensable to optimal cuff function. The functional role of each cuff muscle and the factors associated with anatomic failure (particularly those related to the muscles and tendons) provide a basis for rational patient selection and for determination of the best surgical strategy on a case-by-case basis. SHOULDER ARTHROPLASTY IN PATIENTS WITH GLENOHUMERAL JOINT DISEASE.--Total shoulder arthroplasty in patients with glenohumeral joint disease provides better outcomes than humeral hemiarthroplasty. The choice between a semi-constrained total prosthesis and a reverse constrained total prosthesis should be based on the nature of the joint disease (either centered humeral head or normal cuff function or migrated humeral head and abnormal cuff function). At present, only the semi-constrained total prosthesis has been proved effective in the long-term when used in a patient with a centered humeral head and active cuff. This provides additional support for repairing cuff tears whenever possible in patients who are still young.

Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study.

BACKGROUND: The alumina ceramic femoral head was introduced for total hip arthroplasty approximately thirty years ago. One of its main drawbacks was the risk of implant fracture. The aim of this study was to examine the results of revision total hip replacement performed specifically to treat a fracture of a ceramic femoral head and to identify technical factors that affected the outcomes. METHODS: One hundred and five surgical revisions to treat a fracture of a ceramic femoral head, performed at thirty-five institutions, were studied. The patients were examined clinically by the operating surgeon at the time of the last follow-up. The surgeon provided the latest follow-up radiographs, which were compared with the immediate postoperative radiographs. The success of the revisions was assessed with Kaplan-Meier survivorship analysis, with the need for repeat revision as the end point. We evaluated the complication rate and radiographic changes indicative of implant loosening. The average duration of follow-up between the index revision and the last clinical and radiographic review was 3.5 years (range, six months to twenty years). RESULTS: Following the revisions, radiographic evidence of cup loosening was seen in twenty-two hips (21%) and radiographic evidence of femoral loosening was seen in twenty-two (21%). One or several repeat revisions were necessary in thirty-three patients (31%) because of infection (four patients), implant loosening (twenty), osteolysis (eight), or fracture of the revision femoral head component (one). The survival rate at five years was 63% (95% confidence interval, 51% to 75%). The survival rate was significantly worse when the cup had not been changed, when the new femoral head was made of stainless steel, when a total synovectomy had not been done, and when the patient was less than fifty years old. CONCLUSIONS: Fracture of a ceramic femoral head component is a rare but potentially serious event. A suitable surgical approach, including total synovectomy, cup exchange, and insertion of a cobalt-chromium or new ceramic femoral ball minimizes the chance of early loosening of the implants and the need for one or more repeat revisions. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]).

In vivo kinematics for subjects with and without an anterior cruciate ligament.

The objective of the current study was to compare kinematic patterns of anterior cruciate retaining total knee arthroplasty and posterior stabilized total knee arthroplasty. Fifteen patients received an anterior cruciate retaining total knee arthroplasty and 15 received a posterior stabilized total knee arthroplasty. All total knee arthroplasties were clinically successful (Hospital for Special Surgery score > 90). Each patient was examined during level walking using fluoroscopy. Femorotibial contact paths for the medial and lateral condyles were determined using a computer automated model-fitting technique. Ten of 15 (67%) patients receiving an anterior cruciate retaining total knee arthroplasty and 12 of 15 patients (80%) receiving a posterior stabilized total knee arthroplasty experienced anterior contact at some phase of the gait cycle. Anterior contact in anterior cruciate retaining total knee arthroplasty can be attributed to the presence of the anterior cruciate ligament, resisting the anterior tibial shear forces during gait. The reason for anterior contact observed in posterior stabilized total knee arthroplasty is unclear, possibly related to the sagittal topography (dwell-point position) of the tibial component. Increased axial rotation was seen in anterior cruciate retaining total knee arthroplasty possibly because of the preservation of the four-bar linkage within the knee. Patients receiving an anterior cruciate retaining total knee arthroplasty experienced kinematic patterns more similar to the normal knee.