This review article provides a current concepts overview of osteochondral defects of the talus, with special emphasis on treatment options, their indications and future developments. Osteochondral defects of the talar dome are mostly caused by a traumatic event. They may lead to deep ankle pain on weight-bearing, prolonged swelling, diminished range of motion and synovitis. Plain radiographs may disclose the lesion. For further diagnostic evaluation, computed tomography (CT) and magnetic resonance imaging (MRI) have demonstrated similar accuracy. Computed tomography is preferred for preoperative planning. Treatment options are diverse and up to the present there is no consensus. Based on the current literature, we present a treatment algorithm that is mainly guided by the size of the lesion. Asymptomatic or low-symptomatic lesions are treated nonoperatively. The primary surgical treatment of defects up to 15 mm in diameter consists of arthroscopic debridement and bone marrow stimulation. For large cystic talar lesions, retrograde drilling combined with a bone graft is an important alternative. In adolescents or in (sub)acute situations, in which the fragment is 15 mm or larger, fixation of the fragment is preferred. Osteochondral autograft transfer and autologous chondrocyte implantation (ACI), with or without a cancellous bone graft, are recommended for secondary cases as well as large lesions.
Free-hip movement is necessary for good spinal function. Limitation generally affects extension. The range of hip extension from the standing position can be considered as the hip's "extension reserve". The amplitude of this reserve must be known because any deficit requires a pathological solicitation of the vertebral column. Measurement of the extension reserve of the hip is useful for analyzing spinal disease and for preoperative planning. Physical examination can measure extension, but cannot differentiate movement produced by the hip from that originating in the spine. We have been unable to locate any radiographic method in the literature. The purpose of this study was to evaluate radiographic measurements and to propose a novel method. The study was conducted with 37 patients with spinal disease. Two radiographic methods were compared. Four lateral views, including the lumbar spine, the pelvis and the femur were obtained in each patient: neutral position, retroversion of the pelvis and extension of each hip in lunge position. The X-rays were digitalized for computer processing. The extension reserve of the hip was calculated for each radiographic method. Extension reserve was defined as the difference in the pelvis-femoral angle between the neutral position and extension. There was a positive correlation between the two methods (p < 0.0006; p < 0.0009). Mean extension using the pelvis retroversion method was 1.8 degrees +/- 6.77; with the hip-extension method, it was hip I (side with the superior value): 15.9 degrees +/- 6.57; hip II 10.0 degrees +/- 7.89. The pelvis-retroversion method gave a tower measurement compared with the lunge position method (p < 0.0001). For 13 of 37 subjects (35%), this method gave negative values, that is, failure of the measurement method. The method of hip extension in lunge position was superior to the pelvis-retroversion method, which gave lower measurements that were often incoherent and unable to provide specific information for each hip. The method using the lunge position for hip extension appears to be preferable. We are currently conducting a clinical trial to include extension reserve in the analysis of sagittal balance and for determining curvature corrections. We propose a mathematical formula using extension reserve for determining sagittal correction. Radiographic determination of extension reserve of the hip joint is of major importance for assessing spinal disease in addition to its contribution to the analysis of hip and pelvic disease. The methods presented here enable radiographic measurement of the extension reserve of the hip. (C) 2008 Elsevier Masson SAS.
Calcifying tendinitis is a frequent shoulder disease but the surgical treatment is still debatable. The authors of this symposium reviewed retrospectively 450 patients treated by arthroscopal excision for calcifying tendinitis. Imaging were used to assess the cuff status in every case. The minimum follow-up was five years except for subscapularis and infraspinatus calcification (minimum two years). At the same time, we led a prospective study evaluating the prevalence of the calcifications on 1276 asymptomatic shoulders. The prevalence of rotator cuff calcification was 7.3%, with a female predominance specially in the operated group. Calcifications have been found as well in patients more than 70 years old. The inter- and intraobserver agreement for the A-B-C classification was poor, specially to differentiate the type A and B calcifications. The long-term follow-up allows to prove that the calcifying tendinitis is temporary without any relation with rotator cuff rupture. Recurrence of the calcific deposit after complete disappearance was never observed and the rate of full thickness tears was 3.9% at an average of nine years follow-up (mean age 56 years). These findings allowed to conclude than cuff suture after removing the deposit is not mandatory. However, the preoperative cuff status had a significant influence on the functional results at follow-up. Preoperative associated partial tear of the cuff or a preoperative positive Jobe test affected significantly the results and increased the rate of full thickness tear at follow-up. The subscapularis calcifications were rare (6% of the calcifications) and were associated with further deposit on the cuff. Infraspinatus calcifications were more frequent (20%), mostly associated to over tendons calcifications. The arthroscopic treatment obtained good results independently from the calcification location but the surgical approach should be adapted. Functional results were lower after removing a type C calcification. Acromioplasty improved the results when the calcification was associated with an aggressive acromion or a partial cuff tear. (C) 2008 Publie par Elsevier Masson SAS.
Bicipitoradial bursitis is a rare condition: we found 36 cases reported in the Literature, none in children. The main manifestation is a painful tumefaction. We report a case observed in an adolescent whose magnetic resonance imaging findings were compatible with a malignant tumor. Surgical biopsy enabled the correct diagnosis of inflammatory synovium without signs of malignancy compatible with bicipitoradial bursitis. Complete cure was achieved without resection. (c) 2008 Elsevier Masson SAS.
Thoracolumbar fractures are frequent and the functional outcomes are sometimes severe. This multicentric study, including five medical centers, was performed to evaluate the long-term outcomes of the patients. One hundred and thirty six patients with thoracolumbar fracture (T11 to L2) was evaluated with a minimal follow-up of two years. Every one had a clinical exam with a score of Oswestry and an X-Ray study (before and after treatment and at revision). Most of them presented compression fractures, the most often at L1 level. On X-rays, a gain was noted on the vertebral kyphosis immediately after surgery, but there is a toss of correction over time whatever the treatment. The clinical outcomes for the patients were great, with an Oswestry average score of 6,4. A correlation was noted between this functional score and vertebral kyphosis. So, an anterior column strengthening (isolated or performed during the surgery) could improve these functional outcomes. Moreover, the Thoraco Lumbar Injury Severity Score (TLISS) seems to be a simple organigram to determine the most appropriate, treatment of these fractures, with particular attention to the distraction mechanism or posterior ligamentous complex lesions. However, RMI before surgery is necessary to evaluate these lesions. (C) 2008 Elsevier Masson SAS. Tous droits reserves.
PURPOSE OF THE STUDY:Fractures of the lateral process of the talus are often not diagnosed. The cohorts of the literature are small. The aim of the study was to analyse these fractures with a large group of patients. MATERIAL AND METHOD:Forty-four fractures in 43 patients were reviewed with an average follow-up of 17 months. The diagnosis had been made immediately in 14 cases and secondarily in 30 cases with a delay of 46 months. Patients had been evaluated with Kitaoka's score and radiographies using Hawkins classification. Fractures occurred during sport practise in 19 cases. The most frequent mechanism was association of dorsal flexion and pronation. There were associated lesions in 44% of cases. RESULTS:In the group of delayed diagnosis, we found 14 cases of associated pseudarthrodesis and sub-talar osteoarthritis, two cases of isolated pseudarthrodesis, two cases of isolated sub-talar osteoarthritis. After treatment in this group, the result at the last follow up was very good in 15 cases (50%), good in seven cases (23%), average in seven cases (23%) and bad in one case (4%). In the group of immediate diagnosis five of 14 patients had at least one complication: 29% of pseudarthrodesis and 29% of sub-talar osteoarthritis. After treatment in this group, the result at the last follow-up was very good in eight cases (58%), good in four cases (28%) and average in two cases (14%). Immediate diagnosis was correlated with better results at the last follow-up. In the sub-group of immediate diagnosis, among patients who had an orthopaedic treatment, the rate of secondarily surgery was 42%. CONCLUSION:The fracture of lateral process of the talus is quite frequent and occurs among young people. Spontaneous evolution is severe with two major complications: pseudarthrodesis and sub-talar osteo-arthritis. Treatment is always required in case of displaced fracture.
Purpose of the study. - Traumatic hip dislocation is a rare event in children. Appropriate management remains a subject of debate. The purpose of this study was to investigate the epidemiological, therapeutic features of this situation and the long-term outcome after treatment.Material and methods. - This was a retrospective analysis of 15 traumatic hip dislocations collected over a period of 20 years in pediatric patients with at least two years follow-up. We searched for predisposing factors and factors affecting prognosis.Results. - The series included 11 boys and three girls, mean age eight years. Dislocation was posterior in 13 hips and anterior in two. Time to reduction was less than 3 h in eight cases, 3-6 h in five and greater than 6 h in two. After reduction, traction was performed in nine children, for 20 days on average, followed in five cases by immobilization for 40 days on average. Five hips were immobilized directly after reduction. We identified two groups by age: group 1 with dislocations in children aged less than six years (seven children) were characterized by low-energy trauma. Dislocation was not associated with other lesions. Predisposing factors (overt ligament hyperlaxity, insufficient superolateral head cover, coax valga) were noted in six children. Reduction was simple. Later treatment consisted in immobilization with a pelvispedious cast for 30-45 days. Group 2 were dislocations in children aged over six years (seven children) victims of high-energy trauma. Associated injuries were frequent. Predisposing factors were not present. At mean 11 years follow-up, at[ hips are considered normal clinically. The radiograph was normal for 14 hips. In one case, there was a slight coax magna. In three patients, defective femora[ head cover persisted. Coxa valga persisted in two patients.Discussion. - Traumatic dislocation of the hip joint is rare in very young children, but results from a minimally traumatic event. This suggests the presence of predisposing factors in this category of patients, particularly capsuloligamentary hyperlaxity. After reduction, immobilization can be recommended. Traumatic hip dislocations in children are different from the adult variety due to their rarity, the general absence of associated fractures, easy reduction and better prognosis. The epidemiological and therapeutic features in children older than six years are however similar to those in adults. (C) 2008 Elsevier Masson SAS. Tous droits reserves.
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 white 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. (C) 2008 Elsevier Masson SAS. Tous droits reserves.
This prospective multicentric study concerns 418 anterior cruciate ligament tears. It correlates the arthroscopic data's and the clinical and radiological data's. Four types of anterior cruciate ligament tears were identified. Complete tears, postero lateral bundle preserved, heating on the posterior cruciate Ligament and heating in the notch. The statistical correlations had shown a highest laxity in the complete tear group with a highest rate of soft Lachman and gross pivot shift, a highest incidence of medial meniscus tears was also noted and a Longer delay between injury and surgery, 24 months for the complete tear group and seven months for the postero lateral bundle group. The mean medial compartment laxity, side to side, in the postero lateral bundle group was 4.93 mm and 7.93 mm in the complete tear group. These data could help the surgeon in his surgical planning especially in case of partial tears. (C) 2008 Elsevier Masson SAS. Tous droits reserves.
PURPOSE OF THE STUDY:Early loosening, before a three-year follow-up, has been observed with cemented cups having a metal-on-metal insert in a polyethylene cup. The metal-on-metal bearing has been incriminated as the source of the problem because of its rigidity (particularly for small cups measuring less than 50 mm) and the creation of stress conditions unfavorable for a cemented fixation. The purpose of this retrospective study was to determine whether this phenomenon is observed when the cement is fixed not directly into the bone, but via a Muller reinforcement ring.MATERIAL AND METHODS:From 1998 to 2004, 23 arthroplasties using a cemented Metasul cup in a reinforcement ring were implanted in 22 patients (16 women and six men) aged on average 44 years (range 24-56 years). The series included six primary total hip arthroplasties (three for dysplasia, two for protrusions, one for rheumatoid arthritis and one for arthritic degradation) and seventeen revisions (two septic). The Metasul cup (Zimmer-Centerpulse) combined a 28 mm modular head anchored in a femoral implant (two cemented, 21 pressfit) and a polyethylene cup with a Metasul insert (13 of 23 measuring<50mm). In all cases, the cup was fixed with low-viscosity cement in a Myller metal reinforcement ring fixed with screws (Zimmer-Centerpulse). All patients were reviewed clinically and radiographically at a mean 5-year follow-up (range 3-8 years). Acetabular and femoral fixation were analysed (search for lucency and implant migration).RESULTS:Revision was not necessary in any patient for failure of the acetabular fixation. The mean Postel-Merle-d'Aubigné score improved from 12.9 points (range 7-17) to 17.5 points (range 16-18). The radiographic analysis did not reveal any sign of lucency between the cup and ring, nor any migration of the ring. There was no evidence of femoral osteolysis but one femoral revision was needed due to fracture of the lateral cortical identified six weeks after implantation.DISCUSSION AND CONCLUSION:Cementing the metal-on-metal cup into a reinforcement ring can avoid the risk of loosening observed after direct cementing into bone. In our study, the large number of small cups (13/23) would have been expected to produce a high rate of acetabular lucent lines and/or a high rate of early revision, as reported by others, as early as 24 months. Our series was also different from others by the use of pressfit femoral implants in most patients, which should reduce the risk of cement debris in the bearing. Longer follow-up will be necessary to confirm the good results observed to date which suggest that direct cementing of the cup into the bone should be incriminated rather than the metal-on-metal bearing to explain the reported failure of cemented Metasul cups.
Objective. - To assess the mid-term patient outcome after operative treatment of a displaced intra-articular calcaneal fracture according to Palmer.Materials and methods. - Eighteen operatively treated intra-articular fractures of the calcaneus in 16 patients (nine mates, seven females) were retrospectively reviewed. Mean age at surgery was 35 years (range, 17-61 years). Two patients had a bilateral fracture. According to Rev Chir Orthop 79 (1993) 49-57, five fractures (28 percent) were classified as vertical, three as horizontal (17 percent), and 10 (55 percent) as combined. Mean preoperative Bohler angle was -4 degrees (range, -42-26 degrees). An extended lateral approach to the calcaneus was used in each case. A cortical bone autograft was firmly impacted in the sub thalamic void after reduction. Stabilization was achieved by two or three axial Kirschner wires and one or two screw(s) inserted in a transverse position. Patients were evaluated at the Last follow-up by physical examination and by the functional score described by Foot Ankle Int 15 (1994) 349-353. Bohler's angle was measured on the immediate postoperative radiographs and at the last follow-up, and compared when possible with the noninjured side.Results. - Follow-up ranged from 12 to 38 months (average, 23 months). One patient (one calcaneus) required a subtalar arthrodesis for advanced osteoarthritis. One patient (one calcaneus) experienced reflex sympathetic dystrophy. No skin complication was noted. At the last follow-up evaluation, mean Kitaoka score was 74 (range, 34-98). Functional score was considered good or excellent in 11 cases (64.7 percent), fair in three (17.6 percent) and poor in three (17.6 percent). Mean Bohler angle was 23.4 degrees (range, 5-40 degrees) postoperatively and 22.7 degrees (range, 0-38 degrees) at the last follow-up. A modest loss of correction was observed in four cases. Final Bohler angle was at least 85 percent comparatively to the healthy side in 10 cases among 14 unilateral fractures. Functional score correlated well with restoration of Bohler's angle.Discussion and conclusion. - Operative treatment of intra-articular calcaneal fractures according to Palmer provided encouraging results, since restoration of Bohler's angle was obtained. Main advantages include an absence of hardware prominence, resulting in an absence of skin complication, and a stable fixation. (C) 2007 Elsevier Masson SAS. Tous droits reserves.
Le secteur libéral à l’hôpital public a été créé par la réforme Debré de 1958. Ce secteur a été tour à tour critiqué, modifié, supprimé, recréé, réglementé. La dernière modification est celle du décret du 15/05/2008, indiquant que la redevance des praticiens utilisant ce secteur était de 40 % sur la totalité des honoraires en CHU et de 20 % en CHR.
We report the case of a 15-year-old girt who suffered an indirect knee trauma. The standard X-rays revealed a tract of ivory-like bone partially obstructing the medullary canal of the femur and the tibia. Magnetic resonance imaging produced a hypointense signal on the T1 and T2 sequences. The radiographic diagnosis was melorheostosis which was confirmed on the biopsy specimen which ruled out other diagnoses. The MRI also revealed a tear of the anterior cruciate ligament, treated conservatively. Clinical and radiological surveillance were proposed for the melorheostosis. (C) 2008 Elsevier Masson SAS. Tous droits reserves.
Purpose of the study. - Dislocation is a well-known complication of total hip arthroplasty. The risk can be reduced to one or two cases per thousand using a double mobility cup. The survival rate achieved with the Bousquet implant is 95% at 10 years. The complications with this implant are early mobilization and inguinal pain. An overly large cup and insufficient primary and secondary fixation can be implicated. The design of the original implant was later modified to limit these early complications. The purpose of this work was to check the validity of the changes made.Patients and methods. - The chromium-cobalt moulded cup was used. The outer surface of this cup presents large geometric striations and is coated with hydroxyapatite. The cup has the shape of a half sphere of 180 degrees and a posterior wall prolongation measuring 6.5 mm. Three mechanisms were used for the primary fixation: an asymmetrical growth ring, four anchorage stems, and a superior screw. Two hundred cups were implanted in 194 patients. The femora[ piece was a Charnley stainless steel implant (n = 139), a titanium SEM, implant (n = 59) or another implant (n = 12). Cement was used for 193 implantations. The series included 97 women and 103 men with osteoarthritis (n = 180), necrosis (n = 16), surgery for fracture and primary arthroplasty (n = 9). The Harris and Postet-Merle-d'Aubigne scores were noted. Eight radiographic criteria were analyzed to assess the position of the cup and the radiological course of the interface.Results. - Mean time to surgery was six years. Mean age at surgery was 70 years (range: 32-91) and varied depending on the operators from 67 to 73 years. At last follow-up: 17 patients had died, eight were lost to follow-up and five were bedridden. Three patients underwent revision surgery. Thus, this analysis included 170 prostheses followed for more than five years (mean: six years, range: 5-7 years). The Harris score improved from 48 to 92 and the Postel-Merle-d'Aubigne score from 2/5/4 to 5.8/5.9/5.5 (range: 4-6/5-6/1-6). None of the patients complained of anterior pain during hip flexion against resistance. Cup inclination was 46 degrees on average (range: 62-22 degrees). Medialization, lateralization or ascension greater than 10 mm of the centre of rotation was not observed on the postoperative films. At last follow-up, no measurable mobilization or migration could be identified on plain X-rays. Lucent lines, condensations and bony defects around the cup, when visible postoperatively, were not found on the last follow-up X-rays. There were two cemented femoral pieces, which developed a lucent tine in the nonspecific metaphyseal area. There were no cases of granuloma and no cam effect. Three patients underwent revision for femoral loosening, fracture of the femur below the prosthesis, and hematogenous infection. There were no cases of dislocation.Discussion. - Changing the design of the implant to modify its volume, material and primary fixation has eliminated the early mobilizations and inguinal pain described for the original Bousquet cup. These options have not had any deleterious effect on prosthesis stability. The question of long-term wear remains an important problem and requires optimization: a neck as thin as possible, optimized surfacing, elimination of laser marks, extraction leads, head skirts. (C) 2007 Elsevier Masson SAS. Tous droits reserves.
Introduction.-Hip dislocation in nonambulatory multiply handicapped children (particularly in cerebral palsy [CP]) is a common and severe problem involving painful transportation and uneasy positioning, usually resulting from major anatomical osteoarticular and soft tissue disorders. Therefore, proximal femoral resection is seen as a salvage procedure whose primary purpose is to provide children and their caregivers with better comfort during activities of daily living thus allowing improved sitting tolerance in the wheelchair and painless nursing care.Materials and methods.-A series of 21 proximal femoral resections performed on 16 patients with a mean age at surgery of 12 years, and a follow-up period of 21 years (from 1984 to 2005) were retrospectively reviewed. All patients suffered from painful dislocation of the hip. Sixteen of the hips (76%) had been managed previously with bony and soft tissue surgery. Femoral resection was performed in the basicervical region in eight hips and distal to the lesser trochanter in 13 hips.Results.-At a mean follow-up of five years and eight months, 18 of the 21 painful hips reported to be painless (86%). All preoperative stiffness and deformity of the hip joints was corrected, resulting in floppy, mobile hips with an increased range of motion after surgery. Femoral stump, regarding the acetabulum was above in three hips, at the same level in 18 and never below. The proximal end of the femoral shaft could often been palpated but did not reveal any skin irritation. The formation of heterotopic bone was discernible in five hips (24%). However, it did not affect the functional outcomes.Discussion.-Soft-tissue releases combined with femoral and pelvic osteotomies have reported poor results with regard to their long-term inefficacy in children. The outcomes of our series support these findings, since surgical procedures had been performed previously in 76% of the hips. Therefore, we believe that proximal femoral resection is a promising and reliable surgical treatment option to address such failures, in case of severe and painful deformities of the hip. The success of our series corroborates Widemann, Mc Carthy and Abu-Rajab encouraging results on proximal femoral resection. Postoperatively, we advise placement of a hip spica cast immobilization with a soft cotton lining to prevent pressure sores from developing. This surgical procedure seems to be an appropriate management in nonambulatory multiply handicapped children reporting more promising results than other surgical treatment options such as rotational osteotomy, arthrodesis or even arthroptasty. (C) 2008 Elsevier Masson SAS.
