Does antero-lateral ankle impingement exist?

Antero-lateral ankle impingement syndrome (ALAIS) is a well-established clinical entity that is a common consequence of ankle sprains. Injury to the anterior talo-fibular ligament plays a key role in the genesis of ALAIS. Arthroscopic antero-lateral synovectomy is the standard of care. However, this treatment approach may deserve to be challenged, as it does not include any procedure on the ligaments, despite the presence in some patients of lateral rotational micro-instability of the ankle, without objective laxity. Consequently, we reviewed current data on ALAIS and its links to ankle instability, from the dual perspective of diagnosis and treatment.

Posterior tibial tendon transfer in the spastic brain-damaged adult does not lead to valgus flatfoot.

BACKGROUND: We studied the possible development of valgus flat foot after transfer of the posterior tibial tendon to the lateral cuneiform, used for surgical restoration of dorsiflexion in brain-damaged adult patients with spastic equinovarus foot. METHODS: Twenty hemiplegic patients were reviewed with a mean postoperative follow-up of 57.9 months. Weightbearing radiographs, static baropodometry analysis and functional evaluation were used to assess postoperatively outcomes. RESULTS: On the operated side, weightbearing radiographs showed an absence of medial arch collapse and a symmetrical and physiological hindfoot valgus; static baropodometric analysis showed a reduced plantar contact surface with a pes cavus appearance. The surgical procedure yielded good functional results. Nineteen patients were satisfied with the outcome of their surgery. CONCLUSIONS: Our findings support that transfer of the posterior tibial tendon does not lead to valgus flat foot in the spastic brain-damaged adult, and is still a current surgical alternative for management of spastic equinovarus foot.

[Statistical analysis of the factors that increase perioperative bleeding in trochanteric fractures]. / Análisis estadístico de los factores que aumentan el sangrado perioperatorio en las fracturas trocantereas.

OBJECTIVE: The objective of this study was to determine the major risk factors for bleeding in patients with a pertrochanteric fracture in order to plan the transfusion strategy and to overcome the problem of post-surgical anaemia. Various factors were analysed, including the taking of anticoagulant and/or anti-platelet treatment, the type of fracture, type of anaesthesia, and the type of osteosynthesis used. MATERIAL AND METHODS: A retrospective study was performed on 307 patients over 75 years old, operated on between the years 2005 and 2009. RESULTS: Bleeding was less in simple, non-comminuted fractures, in patients operated on using a mini-invasive screw-plate, in women, and in patients who did not take any anticoagulant or antiplatelet treatment.The only statistically independent factor associated with bleeding was fracture comminution. DISCUSSION: In this study we have seen that patients operated on using a Gamma(®) and DHS(®) nail are transfused more than in those operated on using PPCP(®) and Traumax(®) plate. Evans fractures 1 or 2, A 2.2, or A 2.3, cervical-trochanteric or simple pertrochanteric fractures bled less than Evans 4 or 5, the rest of the type AO fractures, and the complex pertrochanteric fractures. CONCLUSIONS: The precise analysis of the type of fracture is important, particularly in older and fragile patients, to be able to anticipate the need for transfusion. Thus useless and costly, and sometimes dangerous transfusions may be avoided.

Patient information ahead of anterior cruciate ligament reconstruction: Experience in a university hospital center.

INTRODUCTION: Patient information is the requisite first step in securing informed consent ahead of surgery, and is legally mandatory. The study hypothesis was that this information is deficient in a significant proportion of cases. This was tested on a clinical audit. The principal objective was to quantify the rate of correct patient information communication. The secondary objectives were to assess the quality of the information provided by the physician as compared to other sources, and to assess the resultant patient satisfaction. MATERIALS AND METHODS: A targeted clinical audit included all patients undergoing isolated anterior cruciate ligament (ACL) reconstruction in 2009 and 2010. The information provided was analyzed from emergency admission through to the specialized orthopedic consultation, where all information should in principle be traceable in the patient's file. Concordance with information gleaned by the patient himself/herself was also assessed. RESULTS: Seventy of the 93 patients recruited responded to the study questionnaire (75%). Forty-two had received primary care in the Emergency Department, where 67% had been informed about the ACL tear. Surgery-related information could be traced in 61% of cases; surgery had been discussed in the Emergency Department itself in half of the cases, but only 16% had been informed of the duration of the interruption of sports activity and 21% of the duration of time off work and the need for early rehabilitation. Following the orthopedic consultation, 100% of patients knew that they had an ACL tear, but surgery had been spelled out in detail for only 80%, complications for 70%, foreseeable outcome for 30%, rehabilitation for 20% and time off work for 60%. Thirty-eight patients had retrieved information from the Internet; concordance with hospital information was rated at 5.6/10 for the Emergency Department and 7.5/10 for the orthopedic consultation. DISCUSSION: The quality of patient information remains deficient. Traceability of information in the patient's file was only 61%. In the Emergency Department, information comprised diagnosis and referral to specialist consultation. In the orthopedic consultation, information focused on surgical procedure more than on postoperative course. Family doctors and physical therapists also have a role to play, but other sources, such as validated brochures including recommended web-sites, could improve patient information. LEVEL OF EVIDENCE: IV, retrospective study.

Análisis estadístico de los factores que aumentan el sangrado perioperatorio en las fracturas trocantereas / Statistical analysis of the factors that increase perioperative bleeding in trochanteric fractures

Objetivo. El objetivo de este estudio era buscar los factores de riesgo de sangrado mayor en pacientes con una fractura pertrocantérica para planificar la estrategia transfusional y luchar contra la anemia posquirúrgica. Se analizaron diferentes factores como: la ingesta de tratamiento anticoagulante y/o antiagregante, el tipo de fractura, el tipo de anestesia y el tipo de osteosíntesis empleada. Material y métodos. Se realizó un estudio retrospectivo sobre 307 pacientes intervenidos con más de 75 años de edad entre el 2005 y el 2009. Resultados. El sangrado fue menor en las fracturas simples no conminutas, en los pacientes intervenidos mediante un tornillo-placa miniinvasivo, en las mujeres y en los pacientes que no tomaban ningún anticoagulante o antiagregante. El único factor estadísticamente independiente relacionado con el sangrado era la conminución fracturaria. Discusión. En este estudio hemos visto que los pacientes intervenidos con clavo Gamma® y DHS® se transfunden más que en los intervenidos con PPCP® y placa Traumax®. Las fracturas Evans 1 o 2, A 2.2. o A 2.3, las cervicotrocantéricas o pertrocantéricas simples sangraban menos que las Evans 4 o 5, el resto de los tipo AO y las fracturas pertrocantéricas complejas. Conclusiones. El análisis preciso del tipo de fractura es importante, especialmente en los pacientes mayores y frágiles, para poder anticiparse a la necesidad de transfusión. Así se podrían evitar las transfusiones inútiles, costosas y a veces peligrosas (AU)

Objective. The objective of this study was to determine the major risk factors for bleeding in patients with a pertrochanteric fracture in order to plan the transfusion strategy and to overcome the problem of post-surgical anaemia. Various factors were analysed, including the taking of anticoagulant and/or anti-platelet treatment, the type of fracture, type of anaesthesia, and the type of osteosynthesis used. Material and methods. A retrospective study was performed on 307 patients over 75 years old, operated on between the years 2005 and 2009. Results. Bleeding was less in simple, non-comminuted fractures, in patients operated on using a mini-invasive screw-plate, in women, and in patients who did not take any anticoagulant or antiplatelet treatment.The only statistically independent factor associated with bleeding was fracture comminution. Discussion. In this study we have seen that patients operated on using a Gamma® and DHS® nail are transfused more than in those operated on using PPCP® and Traumax® plate. Evans fractures 1 or 2, A 2.2, or A 2.3, cervical-trochanteric or simple pertrochanteric fractures bled less than Evans 4 or 5, the rest of the type AO fractures, and the complex pertrochanteric fractures. Conclusions. The precise analysis of the type of fracture is important, particularly in older and fragile patients, to be able to anticipate the need for transfusion. Thus useless and costly, and sometimes dangerous transfusions may be avoided (AU)

Surgery for femoroacetabular impingement using a minimally invasive anterolateral approach: analysis of 118 cases at 2.2-year follow-up.

INTRODUCTION: Treatment of femoroacetabular impingement (FAI) has progressed over time from using long incisions and dislocation to using arthroscopic surgery. Minimally invasive treatment has rarely been evaluated and a minimally invasive, anterolateral approach has not been used up to now for this indication. A prospective, on-going study was performed to evaluate surgical treatment of FAI with a minimally invasive, anterolateral approach. HYPOTHESIS: Femoral neck, acetabulum and labrum abnormalities can be corrected without significant morbidity using a minimally invasive, anterolateral approach without dislocation. PATIENTS AND METHODS: Treatment of 120 FAI cases (108 patients, 16 women, 92 men, 12 bilateral cases during one surgical session), average age: 34 years (18.9-63.5 years), was done prospectively and in an uninterrupted series. Two cases were lost to follow-up; 106 patients (118 FAI cases) were evaluated with a follow-up of at least 1 year. Assessments consisted of the Non-Arthritic Hip Score (NAHS), WOMAC, measurement of internal rotation with 90° flexion and the Nötzli alpha angle on an A/P radiograph in 45° of flexion, 45° abduction and 30° external rotation. RESULTS: Blood loss averaged 1.2g/dl (range 0.5 to 2.7g/dl) and the average operative time was 44.9 minutes (range 30 to 65). With an average follow-up of 2.2 years (range 12 to 54 months), the NAHS changed by 32.5 points (P<0.0001), internal rotation by 19.0° (P<0.0001) and the alpha angle by -24.9° (P<0.0001). Eight surgical revisions were required (6.8%) (four haematomas, two capsular debridement, two additional procedures on the acetabulum) and these had a good outcome; there were no nerve-related or infection-related complications. Four failures (3.5%) were revised by arthroplasty (two patients experienced residual pain and two patients rapidly progressed to osteoarthritis). Eighteen cases progressed by only one Tönnis stage. Brooker stage II and III ossification were observed in 12 cases (10.2%) but these did not affect the functional score and range of motion improvement. DISCUSSION: This approach, which can be learned and performed quickly, does not require any specific materials and yields a reliable surgical procedure without major complications. This short-term study, where the central cartilaginous compartment was not explored and the labrum was not sutured, comprised a consecutive, non-selected series of patients (independent of age, weight, osteoarthritis stage) and had encouraging results. LEVEL OF EVIDENCE: Level III, prospective study, no control group.

Accuracy of 3D reconstructions based on cone beam computed tomography.

Three-dimensional imaging of teeth will increase its impact in clinical practice if reconstructions are metrically accurate. We hypothesized that, with cone beam computed tomography (CBCT) data, three-dimensional images of teeth can be reconstructed with the same accuracy and precision as with in vitro micro-computed tomography (micro-CT) data acquisition, the current reference standard. We used a sample of CBCT and micro-CT data taken of tooth germs. Volumes obtained with CBCT and micro-CT devices were statistically similar (n = 120, Passing-Bablok regression). Geometric deviations between CBCT and micro-CT three-dimensional surface reconstructions did not show any areas of important and systematic errors. Future investigations with the use of larger samples may also demonstrate that CBCT data will be helpful for a more in-depth study of other aspects of dental morphology--for example, assessing tooth development. With sufficient accuracy for clinical situations, potential future medical applications of such measurements with CBCT are envisaged.

Tamponade following sternoclavicular dislocation surgical fixation.

The authors report a case of posterior sternoclavicular dislocation surgically reduced and stabilized with tenodesis, according to the Burrows technique completed by temporary wire fixation. The patient presented postoperative pericardiac tamponade appearing progressively from brachiocephalic blood vessels bleeding. Emergency drainage was surgically placed associated with removal of the material, thus curing the patient. This complication, although exceptional, formally contraindicates the use of wire fixation in surgery of the sternoclavicular joint.

[Prospective and comparative study of minimally invasive posterior approach versus standard posterior approach in total hip replacement]. / Etude prospective comparant la voie postérieure minimale invasive versus voie postérieure standard sur prothèse totale de hanche de première intention.

PURPOSE OF THE STUDY: There have been few prospective studies comparing minimally invasive approaches for total hip replacement. We wanted to ascertain the contribution of the minimally invasive posterior approach in comparison with the standard posterolateral approach in terms of early outcome. MATERIALS AND METHODS: This was prospective comparative consecutive series of patients. Patients with major architectural problems or undergoing revision arthroplasty were excluded. One hundred ten patients (116 hips) were divided into two groups which were comparable for number of patients, gender, age, body mass index, indication for surgery, and preoperative function scores. The preoperative ASA score was lower in the minimally invasive group (p=0.04). The patients were in the lateral reclining position for the two approaches and classical instrumentation using the same implants (stems and cemented or non-cemented cups) were used. We noted operative time and blood loss (using the Brecher method based on the hematocrit at day 1 and 5 and the number of blood transfusions), postoperative pain, and implant position. Functional outcome was assessed with the modified Harris score and the WOMAC index (at 6 weeks and 3 and 6 months). Statview(R) was used to search for statistical significance considering p<0.05 as significant. RESULTS: Mean length of incision was 8.5 cm versus 15.1 cm. Mean blood loss was significantly less in the minimally invasive group (p=0.027) as was the level of postoperative pain as confirmed by the lesser consumption of morphine analgesics (p=0.006). Other operative variables as well as implant position were comparable. There were no major complications in the minimally invasive group. In the standard group, there was one case of common peroneal nerve palsy, two dislocations, and two fractures related to falls after prosthesis implantation. The WOMAC index was better after the minimally invasive approach at six weeks and at three months (p<0.05). The modified Harris score was better only at six weeks. Functional outcome and pain became comparable thereafter. DISCUSSION AND CONCLUSION: The minimally invasive posterior approach does not require an orthopedic table nor specific instrumentation. A minute procedure is required with ligature of the posteromedial circumflex artery of the thigh to improve exposure and limit intraoperative bleeding. It enables satisfactory reproducible implant positioning. Conversion to an open posterolateral approach is possible if needed. The minimally invasive posterior approach enables a reduction in intraoperative bleeding and in postoperative pain while allowing earlier more rapid rehabilitation. Early clinical outcome is better but beyond six weeks, the functional results are comparable for the two approaches. The minimally invasive posterior approach is a reliable reproducible approach with a progressive learning curve.

Prospective and comparative study of the anterolateral mini-invasive approach versus minimally invasive posterior approach for primary total hip replacement. Early results.

The interest in minimally invasive approaches for total hip replacement (THR) has not waned in any way. We carried out a prospective and comparative study in order to analyse the interest of the anterolateral minimal invasive (ALMI) approach in comparison with a minimally invasive posterior (MIP) approach. A group of 35 primary THRs with a large head using the ALMI approach was compared with a group of 43 THR performed through a MIP approach. The groups were not significantly different with respect to age, sex, bony mass index, ASA score, Charnley class, diagnoses and preoperative Womac index and PMA score. The preoperative Harris Hip Score was significantly lower in the ALMI group. The duration of surgical procedure was longer and the calculated blood loss more substantial in the ALMI group. The perioperative complications were significantly more frequent in this group, with four greater trochanter fractures, three false routes, one calcar fracture, and two metal back bascules versus one femoral fracture in MIP group. Other postoperative data (implant positioning, morphine consumption, length of hospital stay, type of discharge) are comparable, such as the early functional results. No other complication has been noted during the first 6 months. The ALMI approach uses the intermuscular interval between the tensor fascia lata and the gluteus medius. It leaves intact the abductor muscles, the posterior capsule and the short external rotators. The early clinical results are excellent, despite the initial complications related to the initial learning curve for this approach and the use of a large head. The stability and the absence of muscular damage should permit acceleration of the postoperative rehabilitation in parallel with less perioperative complications after the initial learning curve.