Le système Navitrack® permet-il de mieux atteindre l'objectif de longueur et de latéralisation du membre inférieur lors d'une prothèse totale de hanche ?

L'inégalité de longueur des membres inférieurs après PTH est une complication à l'origine de douleurs, d'impotence fonctionnelle et de litiges. Une augmentation de l'offset de plus de 5 millimètres péjore les résultats fonctionnels. Or, les méthodes de planification et de mesure peropératoires manquent de précision. Il s'agissait d'une étude prospective comparant 50 PTH naviguées et 50 PTH non naviguées en deux séries continues. La technique opératoire utilisait le système Navitrack®, système passif de chirurgie assistée par ordinateur sans imagerie complémentaire. Nous n'avons pas retrouvé de différence significative entre les deux séries pour l'objectif de longueur ou pour la restitution de l'offset global. Le nombre limité des effectifs, qui pouvait méconnaitre une différence significative, et l'analyse radiographique, qui comporte des approximations, représentaient des limites de cette étude. D'autres systèmes de navigation des PTH permettent d'améliorer la position des implants mais posent le problème de la fiabilité du plan pelvien antérieur et du rallongement de la durée opératoire. Malgré le caractère séduisant de ce type de système simplifié qui ne s'intéresse qu'à la longueur et à l'offset global, nos résultats ne nous permettent pas pour le moment de recommander l'utilisation systématique de cette technologie.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Combined Anterior Cruciate Ligament Primary Repair With an Autograft Reconstruction

Anterior cruciate ligament (ACL) reconstruction using an autograft gives good results that could provide improved failure rates. ACL augmentation saving the remnant has demonstrated advantages, such as saving vascular supply and nerve receptors, which could be useful for healing. Conversely, isolated repair techniques are gaining interest but do not give good results because structural augmentation is necessary to reinforce the repair and expect healing. We describe a technique combining the advantages of both techniques with an autograft using the semitendinosus and repair of the remnant. This combined technique allows protection and redirection of the remnant, improves graft incorporation, and covers more graft by suturing the remnant around an autologous graft

Suspensory Fixation Device for Use With Bone–Patellar Tendon–Bone Grafts

Good to excellent results at long-term follow-up have been published for bone–patellar tendon–bone (BTB) graft anterior cruciate ligament reconstruction. Fixation using screws historically has been the most common choice for femoral and tibial bone blocks, but screws present several disadvantages, which include the risk of blowout (for which prevention implies having to shift the position of the tunnel anteriorly), as well as lesions of the bone blocks and tendons. This article describes a technique using Pullup BTB adjustable–loop length suspensory fixation (SBM, Lourdes, France) on the femoral and tibial sides. The graft is harvested and prepared classically. This device combines the advantages of suspensory fixation (precise position of the tunnel, high tensile strength), with the advantages of the adjustable loop (control of bone block position within the femoral tunnel, possibility of retightening the graft) and allows for double passage of the loop through each bone block for increased safety. So, it could represent an interesting and secure option for anatomic reconstruction of the anterior cruciate ligament when a BTB graft is chosen

The capsular line reference, a new arthroscopic reference for posterior/anterior femoral tunnel positioning in anterior cruciate ligament reconstruction

Abstract Background Femoral malposition is the first cause for graft rupture during ACL reconstruction. Arthroscopic landmarks can be difficult to identify. So, landmark has to be found for reliable tunnel placement. A proximal-distal reference was described as “Apex reference” reported by Hart et al. but no posterior/anterior reference exists in the literature. The purpose of this study was to do a 3D CT-scan assessment of the femoral tunnel positioning using the Capsular Line Reference (CLR) as a landmark for posterior/anterior placement in ACL reconstruction. We hypothesized the CLR could provide a precise and reliable antero/posterior femoral tunnel positioning less than 2 mm from the Bernard & Hertel posterior quarter. Methods Seven cadaveric knee specimens with a mean age of 79.2 ± 11 years were used. Using standard approaches, the CLR was identified corresponding to a white line (the capsule) appearing at the posterior border of the femoral condyle after bony debridement of the medial and posterior part of the lateral femoral condyle. The center of the tunnel was marked. An inside-out technique with anteromedial drilling technique was performed using an 8-mm diameter reamer. The distal femurs were sawed and a CT-scan was done for each specimen to obtain 3-dimensional image reconstructions. These 3D reconstructions were analyzed to measure the position tunnel center on the posterior/anterior axis and the distance from the posterior/anterior quadrant according to the Bernard & Hertel method. Results The mean position for the posterior/anterior axis was 27.0 ± 1.8% (25–28.9) with a median of 26.9%. The position from the first quarter of the Bernard & Hertel method was 0.9 ± 0.8 mm (0–1.8) with a median of 0.8 mm. Conclusion The CLR is a reliable and reproducible arthroscopic landmark to place the femoral tunnel for ACL reconstruction in the anterior/posterior axis. Proximal/distal position depends on the choice of the surgeon to reproduce anteromedial or posterolateral fibers

Patellar Tendon Reconstruction Using Hamstring Tendon and Adjustable Suspensory Cortical Fixation

Chronic patellar tendon rupture is a rare injury; extensor mechanism impairment leads to great disability in daily life. The delayed diagnosis and reconstruction of chronic patellar tendon ruptures are technically challenging. Numerous surgical procedures have been described with bone-tendon-bone graft, hamstring graft, artificial ligament, and allograft. We describe safe, reproducible anatomic reconstruction of the patellar tendon using hamstring tendon and adjustable suspensory fixation. After harvesting of the hamstrings, the graft is prepared with 2 adjustable suspensory fixation devices. Then, a complete tibial tunnel and a patellar tunnel with a socket are drilled with the appropriate diameter, and the graft is pulled through the tunnels. Finally, the suspensory fixation devices on the tibial and patellar sides are tensioned. The aim of this procedure is to obtain complete mobility of the knee, using a procedure similar to anterior cruciate ligament reconstruction in graft preparation

Better clinical outcomes and faster weight bearing after medial opening-wedge high tibial osteotomy using allogeneic than synthetic graft: A secondary analysis of a Francophone Arthroscopy Society Symposium

International audienceIntroductionAlthough an autogenous graft has the highest rate of bone union to fill the void created in medial opening wedge high tibial osteotomy (MOWHTO), it also has some disadvantages, such as prolonged surgical time, donor site pain and morbidity. Two possible candidates for ideal grafts to replace autogenous grafts are allogeneic and synthetic graft, which are free from donor site pain and morbidity. However, previous reports comparing the clinical results of allogeneic to synthetic graft have been limited and controversial. The purpose of this study is to compare radiological findings and clinical outcomes of using synthetic versus allogenic graft to fill the void created in MOWHTO.HypothesisThe present clinical study hypothesized that allogenic graft to fill the void would allow the higher rate of bone union and better clinical outcomes.Material and methodsThis study compared the clinical and radiological outcomes of 95 patients who received MOWHTO to fill the void with either synthetic or allogenic graft (44 in Syn group, 51 in Allo group). Preoperatively and postoperatively, all patients were clinically evaluated; Return to work, Tegner activity score, and the Western Ontario and Macmaster University scores were reported. Radiographically, osteoarthritis grade and pre- and postoperative parameters were reported, including Hip-knee-ankle angle, mechanical lateral distal femoral angle, medial proximal tibial angle, joint line convergence angle, proximal posterior tibial angle, and limb length discrepancy. Perioperative details and complications were also reported.ResultsMean follow-up (months) were 24.0±1.3 in Syn group and 26.8±1.2 in Allo group (p=0.13). The postoperative improvement of pain and global WOMAC scores in Allo group were significantly better than in Syn group (ΔPain of WOMAC: Syn group 27.8±4.4, Allo group 49.3±3.8, p value <0.001*) (ΔGlobal score of WOMAC: Syn group 16.7±3.2, Allo group 37.4±4.9, p value=0.002*). The risk of hinge fracture in Syn group was significantly higher than in Allo group (Hinge fracture by Takeuchi grade (0/1/2/3): Syn group 37/3/3/1, Allo group 43/8/0/0, p value=0.04*). The timing of full weight bearing in Allo group was significantly earlier than in Syn group (Weight Bearing (1=FWB, 2=PWB 3wk, 3=PWB 6wk): Syn group 2.7±0.1, Allo group 2.3±0.1, p value=0.01*).DiscussionThe use of allogenic graft to fill the void in MOWHTO does not show superiority in bone union compared to synthetic graft, however it improves pain, function, decreases the risk of hinge fracture and allows faster weight bearing than synthetic graft.Level of proofIII; Case-control study

Osteotomies for genu varum: should we always correct at the tibia? A multicenter analysis of practices in France

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Coverage of the Anterior Cruciate Ligament Femoral Footprint Using 3 Different Approaches in Single-Bundle Reconstruction A Cadaveric Study Analyzed by 3-Dimensional Computed Tomography

International audienceBackground: Performing a single-bundle anterior cruciate ligament (ACL) reconstruction within the femoral footprint is important to obtain a functional graft and a stable knee. Hypothesis: There will be a significant difference in the ability of 3 ACL reconstruction techniques to reach and cover the native femoral footprint. Study Design: Controlled laboratory study. Methods: The percentage of the ACL footprint covered by the femoral tunnel was compared after 3 different techniques to target the footprint: transtibial (TT), inside-out/anteromedial (IO), and outside-in/transfemoral (OI). Fourteen cadaveric knee specimens with a mean age of 67.5 years were used. For each knee, the TT technique utilized a 7.5-mm offset guide, the IO technique was performed through an accessory anteromedial portal, and the OI technique was carried out through the femur from the external wall of the lateral condyle. Entry points in the footprint were spotted with markers, and orientations (sagittal and frontal) of each drill guide were noted. The distal femurs were sawed and scanned, and 3-dimensional image reconstructions were analyzed. The virtual drilled area (reamer diameter, 8 mm) depending on the entry point and the sagittal/frontal orientation of the drill guide was calculated and reported for each of the 3 techniques. The distance from the tunnel center to the ACL center, percentage of the femoral tunnel within the ACL footprint, and percentage of the ACL footprint covered by the tunnel were calculated and statistically compared (analysis of variance and t test). Results: The average distance to the native femoral footprint center was 6.8 2.68 mm for the TT, 2.84 1.26 mm for the IO, and 2.56 +/- 1.39 mm for the OI techniques. Average percentages of the femoral tunnel within the ACL footprint were 32%, 76%, and 78%, and average percentages of the ACL footprint covered by the tunnel were 35%, 54%, and 47%, for the TT, IO, and OI techniques, respectively. No significant difference was observed between the IO and OI techniques (P = .11). The TT approach gave less satisfactory coverage on all testing criteria. Conclusion: The IO and OI techniques allowed for creation of a tunnel closest to the ACL femoral footprint center. Despite this fact and even if the average percentage of the drilled area included in the femoral footprint was close to 80% for these 2 techniques, the average percentage of the ACL footprint covered by the tunnels was <55% for all 3 techniques. Coverage of the ACL footprint depended on the entry point, orientation, and diameter of the drilling but also on the size of the footprint. Clinical Relevance: To improve the coverage of the native femoral footprint with a single-bundle graft, in addition to the entry point it may also be necessary to consider the orientation of the drilling to increase the dimensions of the area while respecting the anatomic constraints of the femoral bone and graft geometry