Etude anatomique pour l'abord endoscopique de l'espace scapulo-thoracique (dangers des nerfs spinal accessoire, dorsal de la scapula et supra-scapulaire)

PARIS6-Bibl. St Antoine CHU (751122104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Sectioning of the anterior intermeniscal ligament changes knee loading mechanics

International audienceIntroduction: The aim of this cadaver research project was to describe the biomechanical consequences of AIML resection on menisci function under load conditions in full extension and 60° flexion. Methods: Ten unpaired fresh frozen cadaveric knees were dissected leaving the knee joint intact with its capsular and ligamentous attachments. The femur and tibia were sectioned 15 cm from the joint line and mounted onto loading plateform. A linear motion x-y table allows the tibial part of the joint to freely translate in anterior-posterior direction. K-scan sensors, were used to define contact area, contact pressure and position of pressure center of application (PCOA). Two series of analysis were planed: before and after AIML resection, mechanical testing were performed with specimens in full extension and 60° of flexion to approximate heel strike and foot impulsion during the gait. A standard compression load of 1400 N at full extension and 700N at 60° flexion was applied. Results: Sectioning of the AIML produced mechanical variations bellow the two menisci when specimens were at full extension and loaded to 1400N: increasing of mean contact-pressure (delta 0.4+/-0.2MPa, + 15% variation p=0.008) and maximum contact-pressure (delta 1.50+/-0.8MPa, 15% variation p<0.0001), decreasing of tibio-femoral contact area (delta 71+/-51mm2,-15% variation p<0.0001) and PCOA (delta 2.1+/0.8mm). At 60° flexion, significant differences regarding lateral meniscus mechanical parameters was observed before and after AIML resection : mean contact pressure increasing (delta 0.06+/-0.1MPa, +21% variation p=0.001), maximal contact-pressure increasing (delta 0.17+/-0.9MPa, +28% variation p=0.001), mean contact area decreasing (delta 1.84+/-8mm2 4% variation p=0.3), PCOA displacement to the joint-center (mean displacement 0.6+/-0.5mm). Conclusion: The section of the intermeniscal ligament leads to substantial changes in knee's biomechanics, increasing femoro-tibial contact pressures, decreasing contact areas and finally moving force center of application which becomes more central inside of the joint

Sectioning of the anterior intermeniscal ligament changes knee loading mechanics

International audienceIntroduction: The aim of this cadaver research project was to describe the biomechanical consequences of AIML resection on menisci function under load conditions in full extension and 60° flexion. Methods: Ten unpaired fresh frozen cadaveric knees were dissected leaving the knee joint intact with its capsular and ligamentous attachments. The femur and tibia were sectioned 15 cm from the joint line and mounted onto loading plateform. A linear motion x-y table allows the tibial part of the joint to freely translate in anterior-posterior direction. K-scan sensors, were used to define contact area, contact pressure and position of pressure center of application (PCOA). Two series of analysis were planed: before and after AIML resection, mechanical testing were performed with specimens in full extension and 60° of flexion to approximate heel strike and foot impulsion during the gait. A standard compression load of 1400 N at full extension and 700N at 60° flexion was applied. Results: Sectioning of the AIML produced mechanical variations bellow the two menisci when specimens were at full extension and loaded to 1400N: increasing of mean contact-pressure (delta 0.4+/-0.2MPa, + 15% variation p=0.008) and maximum contact-pressure (delta 1.50+/-0.8MPa, 15% variation p<0.0001), decreasing of tibio-femoral contact area (delta 71+/-51mm2,-15% variation p<0.0001) and PCOA (delta 2.1+/0.8mm). At 60° flexion, significant differences regarding lateral meniscus mechanical parameters was observed before and after AIML resection : mean contact pressure increasing (delta 0.06+/-0.1MPa, +21% variation p=0.001), maximal contact-pressure increasing (delta 0.17+/-0.9MPa, +28% variation p=0.001), mean contact area decreasing (delta 1.84+/-8mm2 4% variation p=0.3), PCOA displacement to the joint-center (mean displacement 0.6+/-0.5mm). Conclusion: The section of the intermeniscal ligament leads to substantial changes in knee's biomechanics, increasing femoro-tibial contact pressures, decreasing contact areas and finally moving force center of application which becomes more central inside of the joint

Reconstructions multiligamentaires du genou par allogreffes : résultats cliniques et laxité postopératoire objective

International audienceBackground: Surgical treatment of multiligament knee injuries (MLKIs) leads to better outcomes but there are controversies about optimal surgical strategies. Debates remain about timing of surgery: acute, staged or delayed and about graft choice: autograft, allograft or a combination of both. Therefore, we performed a retrospective study aiming to evaluate postoperative laxity using stress radiographs and clinical outcomes after one-stage reconstructions of injured ligaments using non-irradiated, fresh-frozen allografts.Hypothesis: MLKIs treated by one-stage reconstructions using non-irradiated, fresh-frozen allograft may lead to satisfactorily postoperative laxity and clinical outcomes.Methods: Between November 2013 and July 2015, 23 patients with MLKIs underwent one-stage reconstruction using allograft. Knee injuries were defined according Schenk classification of Knee Dislocation (KD). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, and the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form at a minimum follow-up of 24 months. Postoperative anterior, posterior, varus, and valgus laxities were assessed using stress radiographs and expressed as side-to-side differences (SSD) in millimeters.Results: Three of 23 patients were lost to follow-up. There were 6 KD-I, 12 KD-III, and 2 KD-IV lesions, 12 lateral-side and 10 medial-side lesions, and 13 acute and 7 chronic cases. Three patients had associated neurovascular injuries. Mean follow-up was at 29.4±6.1 months. Mean valgus SSD was 0.2mm±1.4mm (range, -2.1-2.2mm), mean varus SSD was 1.4mm±2.5mm (range, -1.7-6.0mm), mean posterior SSD was 7.2mm±3.9mm (range, 1.2-16.0mm), mean anterior SSD was 3.6mm±5.1mm (range, -4.8-16.8mm). Overall IKDC ratings were: 4 grade A, 3B, 7C, and 6D. Three patients complained of postoperative instability, with an IKDC rating of D. The mean subjective IKDC score was 67.2±19.6, the mean Lysholm Knee Scoring Scale was 77.3±16.5, and the mean KOOS results were 78.5±16.6 for pain, 67.7±17.4 for symptoms, 86.5±14.2 for daily activities, 56±25.4 for sports, and 47.2±28.6 for quality of life. Nineteen of 20 patients returned to sport-6 to the same level. One patient underwent an arthroscopic arthrolysis due to postoperative arthrofibrosis.Conclusions: Using non-irradiated allografts for one-stage reconstructions of all the injured ligaments in MLKIs is effective and safe. Anteroposterior stability was difficult to restore, but patients returned to their daily activities and sometimes to their sports activity at the same preinjury level.Level of evidence: Level IV, case series.Introduction: Le traitement chirurgical des lésions multiligamentaires (MLKIs) est actuellement préféré au traitement fonctionnel mais il persiste des interrogations concernant la meilleure stratégie chirurgicale. Le meilleur moment pour opérer, des greffes autologues ou hétérologues, une chirurgie en un temps ou en séquentielle. Le but de cette étude était d’évaluer les résultats laximétriques des reconstructions multiligamentaires par allogreffes en un temps. L'hypothèse était que l'utilisation de ces allogreffes congelées et non irradiées donne une laxité résiduelle faible et des résultats cliniques satisfaisants. Méthode: Entre novembre 2013 et juillet 2015, 23 patients présentant une MLKIs ont eu une reconstruction multiligamentaire en un temps par allogreffe. La classification utilisée était celle de Schenk (KD). Les résultats fonctionnels étaient évalués par les scores de KOOS (Knee injury and Osteoarthritis Outcome Score), de Lysholm, et IKDC (International Knee Documentation Committee Subjective Knee Evaluation Form) au recul minimum de 24 mois. Les laxités postopératoires comparatives ont été évaluées par radiographies en stress (valgus, varus, tiroir antérieur et postérieur) et exprimées en millimètres de différentielle (SSD) pour chaque laxité opérée. Résultats: Trois patients ont été perdus de vue. Il y avait 6 lésions KD-I, 12 KD-II et 2 KD-IV, 12 lésions latérales et 10 médiales, 13 lésions aiguës et 7 chroniques. Trois patients présentaient des lésions neurovasculaires associées. Le recul moyen était de 29,4 ± 6,1 mois. La différentielle de laxité moyenne en valgus forcé était de 0,2 mm ± 1,4 mm (−2,1–2,2 mm), de 1,4 mm ± 2,5 mm (−1,7–6,0 mm) en varus forcé. Le tiroir postérieur moyen différentiel était de 7,2 mm ± 3,9 mm (1,2–16,0 mm), de 3,6 mm ± 5,1 mm pour le tiroir antérieur (−4,8–16,8 mm). L'IKDC objectif était réparti comme suit : 4 grade A, 3B, 7C, et 6D. Trois patients se plaignaient d'instabilité résiduelle. Le score IKDC subjectif postopératoire moyen au recul était de 67,2 ± 19,6, Le score Lysholm de 77,3 ± 16,5. Le profil moyen des paramètres KOOS était de 78,5 ± 16,6 pour la douleur, 67,7 ± 17,4 pour les symptômes, 86,5 ± 14,2 pour les activités quotidiennes, 56 ± 25,4 pour les sports, 47,2 ± 28,6 pour la qualité de vie. Dix-neuf patients ont refait du sport, 6 au même niveau. Un patient a eu une arthrolyse arthroscopique pour raideur résiduelle. Conclusions: Les reconstructions multiligamentaires du genou en un temps par allogreffe non irradiée sont fiables et efficaces. Il persiste fréquemment une laxité antéropostérieure mais les patients retrouvent une vie quotidienne normale et parfois la capacité de reprendre leurs sports au même niveau. Niveau de preuve: Niveau IV, Étude de cohorte

Multiligament knee injuries treated by one-stage reconstruction using allograft: Postoperative laxity assessment using stress radiography and clinical outcomes

International audienceBackground: Surgical treatment of multiligament knee injuries (MLKIs) leads to better outcomes but there are controversies about optimal surgical strategies. Debates remain about timing of surgery: acute, staged or delayed and about graft choice: autograft, allograft or a combination of both. Therefore, we performed a retrospective study aiming to evaluate postoperative laxity using stress radiographs and clinical outcomes after one-stage reconstructions of injured ligaments using non-irradiated, fresh-frozen allografts. Hypothesis: MLKIs treated by one-stage reconstructions using non-irradiated, fresh-frozen allograft may lead to satisfactorily postoperative laxity and clinical outcomes. Methods: Between November 2013 and July 2015, 23 patients with MLKIs underwent one-stage reconstruction using allograft. Knee injuries were defined according Schenk classification of Knee Dislocation (KD). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, and the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form at a minimum follow-up of 24 months. Postoperative anterior, posterior, varus, and valgus laxities were assessed using stress radiographs and expressed as side-to-side differences (SSD) in millimeters. Results: Three of 23 patients were lost to follow-up. There were 6 KD-I, 12 KD-III, and 2 KD-IV lesions, 12 lateral-side and 10 medial-side lesions, and 13 acute and 7 chronic cases. Three patients had associated neurovascular injuries. Mean follow-up was at 29.4 ± 6.1 months. Mean valgus SSD was 0.2 mm ± 1.4 mm (range, −2.1–2.2 mm), mean varus SSD was 1.4 mm ± 2.5 mm (range, −1.7 – 6.0 mm), mean posterior SSD was 7.2 mm ± 3.9 mm (range, 1.2 – 16.0 mm), mean anterior SSD was 3.6 mm ± 5.1 mm (range, − 4.8 – 16.8 mm). Overall IKDC ratings were: 4 grade A, 3B, 7C, and 6D. Three patients complained of postoperative instability, with an IKDC rating of D. The mean subjective IKDC score was 67.2 ± 19.6, the mean Lysholm Knee Scoring Scale was 77.3 ± 16.5, and the mean KOOS results were 78.5 ± 16.6 for pain, 67.7 ± 17.4 for symptoms, 86.5 ± 14.2 for daily activities, 56 ± 25.4 for sports, and 47.2 ± 28.6 for quality of life. Nineteen of 20 patients returned to sport—6 to the same level. One patient underwent an arthroscopic arthrolysis due to postoperative arthrofibrosis. Conclusions: Using non-irradiated allografts for one-stage reconstructions of all the injured ligaments in MLKIs is effective and safe. Anteroposterior stability was difficult to restore, but patients returned to their daily activities and sometimes to their sports activity at the same preinjury level. Level of evidence: Level IV, case series

Litigation in arthroscopic surgery: a 20-year analysis of legal actions in France

International audiencePurpose The main objective of this study was to identify the epidemiological characteristics of litigation following arthro-scopic procedures, performed in private practice and public hospitals in France. The secondary objective was to establish a risk profile for medical malpractice lawsuits after arthroscopic surgery. Methods All court decisions related to arthroscopic surgery between 1994 and 2020 were collected and reviewed cases from the two main French legal databases (Legifrance and Doctrine). Data were retrospectively collected and included: gender, joint and defendant's specialty involved, reason behind the lawsuit, initial indication and the type of arthroscopic procedure performed. The final verdicts as well as the indemnity awarded to the plaintiff (if any) were recorded. Results One-hundred eighty cases met the inclusion criteria of the study and were analyzed: 58 cases were before administrative courts and 122 were before civil courts. An orthopaedic surgeon was involved alone or in solidum in 45.6% of cases (82/180), followed by anesthesiologists in 5.6% (10/180). The private surgery center or public hospital were implicated in 63.9% (115/180) of cases. The 2 most common joints involved in litigation following arthroscopic surgery were the knee (82.2%, n = 148) and the shoulder (11.1%, n = 20). The main reasons behind the lawsuit were related to postoperative infection in 78/180 cases and to a musculoskeletal complication in 45/180 cases (25%). A failure to inform was also reported in 34/180 cases (18.9%). Of the 180 cases, 122 cases (67.8%) resulted in a verdict for the plaintiff. The average indemnity award for the plaintiff was 77.984 euros [2.282-1.117.667]. A verdict for the plaintiff was significantly associated with postoperative infection or a wrong-side surgery, while technical error and musculoskeletal complications were more significantly likely to result in a verdict in favor of the defendant (p = 0.003). Conclusion This study evaluated and mapped lawsuits following after arthroscopic surgery in France over a period of more than 20 years. The main joint involved in lawsuits was knee. The main causes of lawsuits following arthroscopic surgery were related to postoperative infection, musculoskeletal complications and failure to inform. Level of Evidence Level IV