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La technique d’anesthesie par wide awake local anesthesia no tourniquet (WALANT) est deja utilisee pour de nombreux gestes en chirurgie de la main. L’osteosynthese sous WALANT des fractures du radius distal est un challenge recent. Cette procedure permet de tester la stabilite du montage sous mobilisation active en peroperatoire. Nous avons evalue la faisabilite et les resultats cliniques de cette technique. Trente patients ayant beneficie d’une osteosynthese du radius distale par plaque verrouillee anterieure ont ete inclus prospectivement. Les criteres d’eligibilite etaient : âge entre 18 et 65 ans, pas d’anticoagulants et fracture fermee du radius distal. Deux groupes comparables (groupe A : WALANT n = 10 ; groupe B : anesthesie locoregionale n = 20) ont ete formes. En postoperatoire, les patients ont ete evalues cliniquement (EVA ; mobilites ; QuickDash ; reprise du travail) et radiologiquement a 6 semaines et 3 mois. L’âge moyen etait de 54,5 ans (± 6,5). Vingt-trois patients avaient une profession manuelle. Les fractures etaient toutes a deplacement posterieur avec un refend articulaire dans 9 cas du groupe A vs 14 du groupe B. L’EVA moyen durant le geste anesthesique etait similaire dans les deux groupes (0,2[±0,1] vs 0,3[±0,1], p = 0,32). Un pic de douleur (EVA = 2) a ete observe chez 3 patients dans le groupe A lors de manœuvres de reduction peroperatoire. L’EVA etait a 0 dans les deux groupes durant le geste chirurgical sans necessite d’adjonction d’antidouleur. Le temps chirurgical etait similaire entre les deux groupes (38,5 vs 32,7 min, p = 0,12). En postoperatoire, les patients du groupe WALANT n’etaient pas immobilises et l’auto-reeducation etait debutee. Les patients du groupe ALR etaient immobilises dans une attelle anterieure et l’auto-reeducation etait debutee a 3 semaines. L’amelioration des mobilites etait significativement plus importante dans le groupe A a 6 sem et 3 mois et l’EVA similaire dans les deux groupes. Le score QuickDash etait significativement plus faible dans le groupe WALANT aux deux evaluations. La reprise du travail etait significativement plus precoce dans le groupe A (7,8 j vs 34,6 jours, p = 8E-5). Le suivi radiologique etait sans anomalie. L’osteosynthese du radius distale peut etre realiser en securite sous WALANT. Cette procedure des resultats cliniques satisfaisants plus precoce que par ALR. Elle constitue une alternative majeure pour cette population active jeune.

Summary Context Meniscal lesions and isolated anterior cruciate ligament (ACL) knee injuries are common. In 2006, about 130,000 patients were admitted to hospital for meniscal surgery and 35,000 for ACL surgery in France. Surgical techniques and indications have evolved over recent years, and interest in meniscus preservation has increased due to the higher risk of femorotibial osteoarthritis following meniscectomy. Objectives To encourage good practices in meniscal lesions surgery (particularly meniscus preservation) and to clarify indications and techniques in ACL reconstruction surgery. Methods A systematic review of the literature (1996–2007) was performed. It was submitted to a multidisciplinary working group of experts in the field (n = 10) who drafted an evidence report and clinical practice guidelines which were subsequently amended in the light of comments from 50 peer reviewers. Main recommendations (i) Meniscal repair should only be used to heal peripheral meniscal lesions affecting healthy meniscal tissue (injury) in vascularised areas (red-red zone or red-white zone). The current trend is towards use of hybrid implants (fixation material combined with suture wire) and an exclusively arthroscopic technique. (ii) Traumatic meniscal lesions do not always require a meniscectomy; no surgery or meniscal repair should systematically be considered. (iii) The assessment and management of non-traumatic degenerative meniscal lesions depend on the extent of cartilage damage. (iv) All ACL ruptures do not require reconstructive surgery. The indication for reconstruction is based on symptoms, in particular functional instability. As far as acute ACL injuries are considered, reconstruction by arthroscopy should preferably be delayed to reduce the thromboembolic events or joint stiffness. (v) Bone-tendon-bone graft and hamstring tendon reconstruction give similar results. (vi) Lateral tenodesis should be limited to specific cases.

Resume L’etude rapporte les resultats d’une serie continue, prospective, multicentrique de 425 protheses Wallaby I ® conservant le ligament croise posterieur, posees par le groupe Guepar de 1992 a 1995. Le composant femoral de cette prothese presente des condyles asymetriques et divergents pour se rapprocher le plus possible de la cinematique du genou normal. Le plateau tibial en polyethylene est fixe. L’âge moyen des patients (70,5 ans), la repartition homme (28,3 %) et femme (71,7 %), l’etiologie (91 % d’arthrose primitive ou secondaire) et la deviation preoperatoire des genoux (65,6 % de varus > a 3° et 24 % de valgus > a 4°) etaient identiques a ceux qui sont publies dans la litterature pour ce type de prothese. Vingt-six protheses ont ete suivies moins de 1 an, 84 moins de 5 ans et 315 5 ans ou plus. Parmi les 399 genoux suivis plus de 1 an, il y a eu 4 infections (1 %) dont 3 ont necessite le changement de prothese, 3 fractures du femur toutes post-traumatiques, 2 descellements (1 global et 1 tibial) ayant necessite une reprise, 1 descellement tibial et 3 descellements rotuliens non-repris. Trois patients presentaient des douleurs anterieures du genou traitees avec succes par 2 resurfacages secondaires de la rotule et 1 section de l’aileron rotulien externe. Dix-neuf fractures de rotules (4,7 %) (dont 17 decouvertes fortuitement) constituaient la complication la plus frequente, sans retentissement fonctionnel. Le score moyen IKS genou postoperatoire etait de 90,5 points et le score moyen IKS fonction de 61,6 points. La mobilite moyenne etait de 110,5° ; 72,9 % des genoux etaient axes suivant la classification radiologique IKS, La survie de cette prothese a 8 ans (suivant Kaplan Meier) etait de 97,7 % quelle que soit la raison du changement de prothese et de 98,5 % en ne prenant comme evenement que la reprise pour descellement aseptique. Ces bons resultats corroborent ceux qui sont publies dans la litterature concernant les protheses conservant le ligament croise posterieur a plateau tibial fixe.

We have carried out a prospective, randomised study designed to compare the long-term stability of the stem of cementless femoral implants with differing surface configurations. A total of 50 hips (46 patients) was randomised into two groups, according to whether the medullary stem had been grit blasted (GB) or coated with hydroxyapatite (HA). Both femoral prostheses were of the same geometrical design. We used Ein Bild Roentgen Analyse femoral component analysis (EBRA-FCA) to assess the stability of the stem. The mean follow-up was for 8.66 years. The mean migration of the stem was 1.26 mm in the HA group compared with 2.57 mm in the GB group (Mann-Whitney U test, p = 0.04). A mixed model ANOVA showed that the development of subsidence was statistically different in the two groups during the first 24 months. After this subsidence increased in both groups with no difference between them. Our results indicate that, with the same design of stem, HA coating enhanced the stability of the femoral stem when compared with GB stems.

Summary Background Alumina-on-alumina bearings have been accepted as a valuable alternative for young and active patients. Alumina fractures, and socket loosening were the main complications reported. But, with the increasing number of prostheses implanted, noise occurrence appeared as a new concern. The primary aim of the present study was to quantify the prevalence of noticing noise in a population having received alumina-on-alumina total hip arthroplasty as well as its eventual impact on outcome. Patients and methods Two hundred and eighty-four ceramic-on-ceramic hips were performed in 238 patients from January 2003 to December 2004. The average age was 52.4 ± 13.4 years (range, 13 to 74 years). All the hips received the same prosthesis (Ceraver-Osteal™) with alumina bearing components (Ceraver-Osteal™): 32 mm liners were used for cups of 50 mm or larger and 28 mm liners for cups smaller than 48 mm; the minimal alumina thickness was 6 mm. The acetabular component (Cerafit™) was hemispherical, coated with a hydroxyapatite layer and press-fit fixed. The stem (Cerafit™) was a straight tapered cementless stem, fully coated with a hydroxyapatite layer. Clearance between femoral head and liner was between 20 and 50 microns. A retrospective survey was conducted by an independent surgeon who did not participate to surgery in 2007. He conducted phone interviews of patients using a standard questionnaire. No suggestion was offered on how they could describe the noise and they felt free to use the word that they considered to be the most adapted. Satisfaction was evaluated. When the noise was present, X-rays were taken to assess if sign of bearings fracture was present. Results Four patients (six hips) died of unrelated causes during the follow-up period. Three patients (three hips) live outside France and could not be followed (1.3%). Nine patients (10 hips) could not be traced and were considered lost to follow-up (3.8%). Two hundred and twenty-two patients with 265 hips, therefore, were included (nine using bearing components in 28 mm diameter and 265 in 32 mm). Twenty-eight hips experienced noise generation (10.6%). It was defined as a snap for six patients, as a cracking sound by six, as rustling by six patients, as a squeaking by seven patients (2.6%), a tinkling by two patients, one patient was unable to define the sound she felt. No factor related to the patient influenced the occurrence of noise. Twelve patients were dissatisfied with the result of their hip prosthesis, five of them experienced noise (41.7%); 210 were satisfied or very satisfied, 23 of them experiencing noise (11%); this difference was significant (P = 0.002). Conclusion The origins of noise occurrence are unknown. Squeaking may be related to generation of stripe wear and absence of sufficient lubrication. Other types of noise can be due to microseparation, occult dislocation, impingement between the femoral neck and the acetabular rim. Level of evidence Level IV. Retrospective study.

Total hip arthroplasty with all alumina bearings in young patients give acceptable results but it is difficult surgery. The main problem is related to socket fixation. There is an apparent improvement with metal backed alumina that needs to be confirmed with long-term results.

Summary Background Alumina-on-alumina bearings have been accepted as a valuable alternative for young and active patients. Alumina fractures, and socket loosening were the main complications reported. But, with the increasing number of prostheses implanted, noise occurrence appeared as a new concern. The primary aim of the present study was to quantify the prevalence of noticing noise in a population having received alumina-on-alumina total hip arthroplasty as well as its eventual impact on outcome. Patients and methods Two hundred and eighty-four ceramic-on-ceramic hips were performed in 238 patients from January 2003 to December 2004. The average age was 52.4 ± 13.4 years (range, 13 to 74 years). All the hips received the same prosthesis (Ceraver-Osteal™) with alumina bearing components (Ceraver-Osteal™): 32 mm liners were used for cups of 50 mm or larger and 28 mm liners for cups smaller than 48 mm; the minimal alumina thickness was 6 mm. The acetabular component (Cerafit™) was hemispherical, coated with a hydroxyapatite layer and press-fit fixed. The stem (Cerafit™) was a straight tapered cementless stem, fully coated with a hydroxyapatite layer. Clearance between femoral head and liner was between 20 and 50 microns. A retrospective survey was conducted by an independent surgeon who did not participate to surgery in 2007. He conducted phone interviews of patients using a standard questionnaire .No suggestion was offered on how they could describe the noise and they felt free to use the word that they considered to be the most adapted. Satisfaction was evaluated. When the noise was present, X-rays were taken to assess if sign of bearings fracture was present. Results Four patients (six hips) died of unrelated causes during the follow-up period. Three patients (three hips) live outside France and could not be followed (1.3%). Nine patients (ten hips) could not be traced and were considered lost to follow-up (3.8%). Two hundred and twenty-two patients with 265 hips therefore were included (nine using bearing components in 28 mm diameter and 265 in 32 mm). Twenty-eight hips experienced noise generation (10.6%). It was defined as a snap for six patients, as a cracking sound by six, as rustling by six patients, as a squeaking by seven patients (2.6%), a tinkling by two patients, one patient was unable to define the sound she felt. No factor related to the patient influenced the occurrence of noise. Twelve patients were dissatisfied with the result of their hip prosthesis, five of them experienced noise (41.7%); 210 were satisfied or very satisfied 23 of them experiencing noise (11%); this difference was significant (P = 0.002). Conclusion The origins of noise occurrence are unknown. Squeaking may be related to generation of stripe wear and absence of sufficient lubrication. Other types of noise can be due to microseparation, occult dislocation, impingement between the femoral neck and the acetabular rim. Level of evidence Level IV. Retrospective study.

To study the results of facet joint intraarticular steroid injections in patients with symptomatic lumbar facet joint synovial cysts.Data from 30 patients (age range, 44-82 years; mean age, 67 years) with nerve root pain due to a lumbar facet joint synovial cyst and treated with facet joint steroid injection were retrospectively studied. On the basis of MacNab criteria, the clinical course of nerve root pain was evaluated after 1 (n = 30) and 6 (n = 28) months. Data from long-term follow-up (mean, 26 months) were also available in 14 nonsurgically treated patients.After 1 month, the nerve root pain outcome was excellent or good in 20 patients (67%) and fair or poor in 10 (33%). After 6 months, 10 (50%) of these 20 patients still had excellent or good results, and 18 (60%) of the 30 patients had a fair or poor clinical status, 14 of whom underwent surgery; two patients (7%) were lost to follow-up. Excellent and good results were maintained at further follow-up (range, 9-50 months).One-third of patients with symptomatic lumbar facet joint synovial cysts had long-lasting acceptable benefit from facet joint steroid injections in this study. Steroid injection should be indicated before surgery.

This little book aims to inform its readers about the current advances in computer-assisted total knee replacement. The first two chapters discuss what constitutes a ‘perfect’ total knee replacement and how this goal was achieved before computer-assisted surgery. The following three chapters

BackgroundThe best means of ensuring knee stability after anterior cruciate ligament (ACL) reconstruction remains a core debate in sports medicine.HypothesisThere is no difference between ACL reconstruction with patellar tendon or hamstring tendon autografts with regard to postoperative knee laxity and instability.Study DesignMeta-analysis of individual patient data.MethodsPooled analysis of individual patient data from 6 published randomized clinical trials included 423 patients with symptomatic unilateral anterior cruciate ligament injury randomly assigned to reconstruction with patellar tendon or hamstring tendon autograft. Knee instability, defined as a positive pivot-shift test result, was the primary outcome, and knee laxity, defined as a positive Lachman test result, was the secondary outcome. Odds ratios were computed before and after adjustment for potential confounders and trial effect. Regression analyses were performed to look for effects of covariates on outcomes, and mixed-effects models were used to account for a trial effect. Sensitivity analyses were conducted to explore the effects of missing data and excluding each trial.ResultsAnterior cruciate ligament reconstruction with patellar tendon autograft was significantly associated with a decreased risk of a positive pivot-shift test result (adjusted odds ratio, 0.46; 95% confidence interval, 0.24–0.86; P = .016). The risk of having a positive Lachman test result was not significantly different between the 2 groups. The estimated treatment effect was not substantially changed by differences in handling missing data or exclusion of any of the trials. A positive pivot-shift test result was more common in female ( P = .003) and younger patients ( P = .017).ConclusionPostoperative knee instability was less common after ACL reconstruction with patellar tendon autograft than with hamstring tendon autograft.