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Summary Introduction The aim of this study was to define a new index to measure lateral patellar displacement (LPD) using nuclear magnetic resonance imaging (MRI), an axial index of engagement of the patella (AEI) obtained from two different axial MRI views then to validate its use in a prospective series of patients presenting an objective patellar instability (OPI). Materials and methods One huundred and thirty-five patients with OPI and no history of surgery of the patella were included in a prospective study organized by the French Society of Arthroscopy performed between June 2010 and August 2012. All patients underwent axial and sagittal MRI. The AEI was obtained by projecting predefined patellar and trochlear landmarks (cartilaginous landmarks) on 2 different axial MRI views (one trochlear and one patellar). The results were compared with a series of controls ( n = 45). Results The preoperative AEI of the patella was 0.94 ± 0.09 for the control group and 0.84 ± 0.16 for OPI group ( P = 0.000016). The AEI could be obtained in 100% of the cases if it was measured on 2 MRI views while it could not be measured in 38.5% of the cases if the measurement was only obtained from one MRI view or whenever the widest part of the patella was not across from the femoral trochlea. The AEI did not significantly depend on dysplasia or the presence of a supratrochlear spur. The lowest AIE values were associated with trochlear dysplasia with a supratrochlear spur ( P = 0.0023) and a more prominent trochlea ( P = 0.0016). The AEI was correlated with patellar tilt ( P P Discussion AEI is a new index to measure LPD. It can be obtained in all cases because it is obtained from two different MRI views. The normal value is close to 1. It can be used to measure patellar instability on the axial plane in patients with OPI, especially in the most severe cases. Level of evidence III, prospective case control study.

Resume Introduction La patella alta est un des facteurs principaux de l’instabilite femoro-patellaire. Son importance est liee a un engagement reduit de la patella dans la trochlee pendant les premiers degres de flexion. L’evaluation de la hauteur patellaire est basee sur des radios conventionnelles, sur le scanner et plus recemment sur l’IRM. L’objectif de ce travail multicentrique prospectif est de decrire un nouvel index pour evaluer l’engagement sagittal fonctionnel de la patella dans la trochlee. Materiel et methode Cent trente-cinq patients avec une luxation patellaire objective ont ete prospectivement inclus dans une etude entre avril 2010 et septembre 2011. Ils ont ete compares a un groupe temoin de 45 patients. Tous les patients ont eu une IRM standard et un bilan radiographique complet. L’engagement sagittal etait mesure en etablissant un ratio entre les surfaces articulaires patellaire et trochleenne mesuree sur 2 coupes IRM differentes. Resultats L’engagement sagittal moyen de la patella etait de 0,43 ± 18. Il allait de 0,02 a 0,91 dans les instabilites patellaires objectives contre 0,42 ± 11 (0,22 a 0,55) dans le groupe temoin. Dans le groupe de luxation patellaire objective, l’index de Caton-Deschamps moyen etait de 1,18 ± 21 (0,71 a 1,91). Il y avait 58 patients avec une patella alta dont l’index sagittal d’engagement etait de 0,39 ± 18 (0,002 a 0,87). L’engagement sagittal etait significativement plus haut dans le groupe de luxation patellaire objective qui n’avait pas de patella alta (0,46 ± 16) (0,1 a 0,91). Discussion Cette etude introduit une methode pour quantifier l’engagement sagittal de la patella en utilisant l’IRM. L’engagement fonctionnel de la patella avec la trochlee dans le plan sagittal peut etre un instrument supplementaire aux methodes de mesure de hauteur patellaire. La mesure combinee de la hauteur et de l’engagement permettront d’affiner les indications d’abaissement de la tuberosite tibiale. Niveau de preuve II, etude prospective non randomisee.

Resume La chirurgie de revision des reconstructions du ligament croise anterieur suit l’accroissement du nombre de chirurgies primaires. Leur frequence et les problemes specifiques qu’elle pose ont fait l’objet d’une etude multicentrique au sein de la Societe Francaise d’Arthroscopie. Il s’agissait de 293 patients ayant eu un traitement arthroscopique d’un echec d’une premiere reconstruction du ligament croise anterieur a l’exclusion des protheses ligamentaires. Une etude retrospective avec un recul minimum de 24 mois et une etude prospective avec un recul minimum de 6 mois ont ete conduites. Le genou controlateral devait etre sain et le ligament croise posterieur intact. La serie retrospective comportait 189 patients d’âge moyen 28 ans, le delai entre les deux chirurgies etait de 5 ans (5 mois a 15 ans). Le geste initial etait une greffe os tendon rotulien os (KJ) dans 72 % des cas, les tendons de la patte d’oie (DIDT) dans 25 % et un tendon quadricipital 3 %. La chirurgie de revision a ete 52 % un KJ, 36 % un DIDT et 10 % un tendon quadricipital. Il y a eu un retour externe associe dans 61 % des cas. Une etude particuliere a porte sur 57 patients qui avaient au moins 5 ans de recul afin d’analyser le devenir a long terme. La serie prospective comportait 104 patients d’âge moyen 28 ans au moment de la chirurgie de revision. Le geste initial etait, dans 63 % des cas, un KJ et 37 % un DIDT avec 17 % de retour externe. La revision se repartissait en 54 % de KJ et 46 % de DIDT avec 50 % de retour externe. La cause de l’echec etait dominee par les erreurs techniques (50 %) particulierement un tunnel femoral trop anterieur (40 %). La deuxieme cause d’echec etait un traumatisme certain, 27 % dans la serie retrospective et 35 % dans la serie prospective. Le resultat subjectif a toujours ete ameliore dans les deux series. La laximetrie au KT 1000 manuel maximum (MM) passait de 7,1 a 2,8 mm au dernier recul dans la serie retrospective et de 7 a 2 mm dans la serie prospective. Le score IKDC global etait 26 % de A, 46 % de B, 25 % de C et 3 % de D en retrospectif et 38 % de A, 46 % de B et 16 % de C dans la serie prospective. Le score IKDC global etait statistiquement meilleur dans la serie prospective, il n’etait pas influence par le type de greffe utilisee pour la revision, ni par le changement de ce type de greffe entre les deux chirurgies ni par le cote preleve. Le pourcentage de patients ayant eu une meniscectomie a un quelconque moment de leur evolution etait de 73 % dans la serie retrospective et 66 % dans la serie prospective. Cette meniscectomie avait une influence sur le score IKDC global et sur la laxite finale. L’utilisation d’un retour externe apportait une amelioration significative de la laxite sans toutefois influencer le score IKDC global. Les erreurs techniques restent au centre des causes d’echec depuis de nombreuses annees quel que soit le pays. La multiplicite des operateurs pratiquant peu de ces operations et une meilleure expertise des tunnels en sont la cause. La recherche d’une cause d’echec est un element determinant dans l’analyse clinique et radiologique preoperatoire. Le scanner est apparu essentiel dans l’evaluation de la position des tunnels et du capital osseux. Le choix du type de greffe et le cote du prelevement restent une question d’ecole, les autogreffes representant le choix de reference. Le resultat clinique objectif est inferieur a la chirurgie premiere mais le taux de complication est faible. L’evolution a long terme est plus arthrogene que lors d’une chirurgie premiere, cette degradation articulaire est correlee a la presence de lesions meniscales. Le resultat se degrade avec le temps, 56 % des patients a plus de 5 ans ont des signes radiologiques d’arthrose. Le nombre tres eleve de meniscectomies est correle a cette degradation. Les meilleurs resultats sont retrouves parmi les genoux qui presentaient une anomalie des tunnels lors de la premiere chirurgie. L’echec d’une premiere reconstruction doit etre assume par le chirurgien afin de realiser sans attendre une chirurgie de revision et limiter ainsi les gestes intermediaires qui ne font qu’aggraver le pronostic arthrogene. La revision des premieres reconstructions du LCA est une chirurgie sure, a condition de realiser un bilan preoperatoire extremement soigneux au centre duquel se trouve la recherche de la cause de l’echec.

Resume L’objectif de cette etude est de decrire l’IRM des lesions meniscales mediales avec deplacement d’un fragment meniscal vers les structures capsuloligamentaires mediales et de confronter les resultats avec l’arthroscopie. Sur une periode de 22 mois (mai 2003 a fevrier 2005) nous avons selectionne 39 patients dont l’IRM du genou montrait un fragment meniscal deplace le long des structures capsuloligamentaires collaterales mediales. Ces 39 patients representaient 15 % des lesions meniscales deplacees diagnostiquees en IRM (272) et 2 % des IRM du genou realisees pendant la duree de l’etude (2239). En IRM, nous avons etudie la migration du fragment meniscal et les anomalies morphologiques du menisque lese. Dans 16 cas, nous avons confronte les resultats de l’IRM avec l’arthroscopie. Dans 25 cas (65 %), le fragment meniscal etait deplace vers le bas, le long du plateau tibial medial et le plus souvent (64 %) en dedans du ligament tibial collateral. Dans 14 cas (35 %), le fragment meniscal etait deplace vers le haut, le long du condyle femoral medial, et dans 93 % des cas en avant du ligament tibial collateral medial. Dans 95 % des cas, l’IRM montrait une amputation du bord libre du segment posterieur et/ou du segment moyen du menisque medial ou une diminution de la hauteur du segment posterieur du menisque medial. Dans 14 cas sur 16, l’arthroscopie confirmait la lesion meniscale et la localisation du fragment meniscal deplace. Dans deux cas, l’arthroscopie confirmait la lesion meniscale sans pouvoir mettre en evidence le fragment meniscal deplace.

Resume Les auteurs presentent une serie retrospective et multicentrique qui a rigoureusement collige 103 dossiers de patients porteurs d’une laxite « isolee » du ligament croise posterieur (LCP). Tous les patients ont ete revus cliniquement (avec la meme fiche de revision) et radiologiquement avec une mesure de la laxite posterieure (en Telos a 15 kg). Au terme de cette etude, lorsque la rupture du LCP est isolee (sans atteinte ligamentaire peripherique associee). — la ligamentoplastie, toutes methodes chirurgicales confondues, a permis d’ameliorer de facon tres significative la fonction du genou, le niveau d’activite et le niveau sportif ; toutefois, la fonction postoperatoire du genou reste significativement moins bonne qu’avant l’accident; — le resultat subjectif est bon, il conditionne la reprise sportive mais il est independant du degre de laxite residuelle; — la ligamentoplastie du LCP ne permet pas de controler totalement la laxite posterieure ; on peut attendre un gain moyen de 6 mm (50 %) ; — techniquement, la reconstruction ligamentaire arthroscopique d’un seul faisceau sans renfort synthetique, quel que soit le type de greffon (tendon rotulien, tendon quadricipital ou ischio-jambier), fixe sur le tibia par une double fixation, semble pouvoir etre conseillee; — fonctionnellement, l’appui immediat semble pouvoir etre donne en preferant une reeducation en decubitus ventral. Le faible recul moyen de cette serie (4 ans) n’a pas permis d’evaluer le benefice ou le risque que pouvait avoir une ligamentoplastie du LCP sur l’arthrose.

We describe a technique for patellar stabilization by reconstruction of the medial patellofemoral ligament with the gracilis tendon. The tendon is anchored posteriorly on the soft tissue of the medial femoral epicondyle and anteriorly on the medial border of the patella. The plasty is completed by suture of the medial patellar wing. Inferior or medial transposition of the tibial tubercle may be associated. We have used this technique since 1995 for 145 knees with patellar instability. The small incisions have the advantages of minimally invasive surgery, particularly for the postoperative period and the cosmetic effect.

SummaryIntroductionPatella alta is one of the primary factors of patellofemoral instability and its importance lies in the reduced engagement between patella and trochlea during the early degrees of flexion. The evaluation of patellar height is based on conventional x-rays, CT scan and, more recently, MRI. The objective of this multicentric prospective study is to describe a novel index to assess in the sagittal plane the functional engagement between patella and trochlea.Materials and methodsOne hundred and thirty-five patients with objective patellar dislocation were prospectively enrolled between April 2010 and September 2011 and were compared with a second group of 45 controls. All patients underwent a standard MRI and a complete radiographic study. Sagittal engagement was measured as the ratio between the articular cartilage of the patella and the trochlear cartilage length measured on two different MRI slices.ResultsThe mean Sagittal Patellofemoral Engagement (SPE) index was 0.43±0.18 and ranged from 0.02 to 0.913 in the Objective Patellar Dislocation group versus 0.42±0.11 range 0.22 to 0.55 in controls. In the Patellar Dislocation group the mean Caton-Deschamps index was 1.18±0.21 (range 0.71 to 1.91). There were 58 patients with patella alta, in whom the mean SPE was 0.39±0.18 (range 0.02 to 0.87). Sagittal engagement was significantly higher when compared with patients in the Patellar Dislocation group who had no patella alta (mean 0.46±0.16, range 0.1–0.913).DiscussionThe present study introduces a new method to measure the SPE with the use of MRI. The evaluation of the functional engagement of the patella with the femoral trochlea in the sagittal plane can serve as a supplementary tool to the existing methods of evaluating patellar height, and may help to better identify the cases where inadequate engagement is recorded despite the absence of patella alta, so that the need for tibial tuberosity osteotomy may be re-assessed.Level of evidenceLevel 3.

Displaced meniscus tears generally result from bucket handle tears with subsequent migration of the meniscal fragment into the intercondylar notch. More rarely, the fragment may move into the meniscal recesses. In this situation, the displaced fragment may be difficult to individualize arthroscopically, so preoperative imaging is crucial. Several studies have demonstrated the reliability of magnetic resonance imaging (MRI) for the diagnosis of meniscus injury with fragment displacement in the intercondylar notch. There have been few studies devoted to fragment displacement into the collateral capsuloligamentary structures. The purpose of this study was to describe MRI findings of medial meniscus tears with displaced fragment in the meniscal recesses.This prospective study was conducted over a 22-month period (May 2003 - February 2005). During this period, we selected 39 patients whose knee MRI displayed a meniscal fragment within the medial collateral recesses. These 39 patients accounted for 15% of knees with MRI-diagnosed meniscal tears (n=272) and 2% of the knee MRI examinations performed during the study period (n=2239). One the MRI series, we studied fragment migration and morphological anomalies of the injured meniscus. For 16 knees, MRI findings could be compared with arthroscopy findings.For 25 knees (65%), the meniscal fragment had migrated downward along the medial tibial plateau and generally (64%) medially to the collateral tibial ligament. For 14 knees (35%) the meniscal fragment had migrated upward, along the medial femoral condyle in 93%, anteriorly to the medial collateral tibial ligament. For 95%, the MRI demonstrated rupture along the free border of the posterior segment and/or the mid segment of the medial meniscus or a decreased height of the posterior segment of the medial meniscus. For 14 of 16 cases, arthroscopy confirmed the meniscal tear and the localization of the displaced fragment. For two knees, arthroscopy confirmed the presence of the meniscal tear but could not identify the displaced meniscal fragment.Meniscal tears with fragment displacement into the meniscal recesses has been associated with displacement of a horizontal fissuration which flap tears described arthroscopically by DJ Dandy. Other authors consider these tear flaps as oblique fissurations. In our study, it was sometimes difficult to determine the exact site and orientation of the initial meniscal tear so it is quite likely that meniscal tears with a displaced fragment in the meniscal recesses could correspond to complex predominantly horizontal or oblique meniscal fissurations. The common feature is the presence of an unstable meniscal flap susceptible to migrate. Our findings are in agreement with the literature. Regarding the two cases where the MRI findings could not be confirmed arthroscopically, the MRI visualized a characteristic image of a meniscal fragment displaced downwardly, lying between the medial tibial plateau and the collateral tibial ligament. Arthroscopy visualized the meniscal tear but failed to visualize the displaced fragment. This might be because mobile meniscal fragments return into the joint interspace when the meniscus is manipulated arthroscopically. Small meniscal fragments might also be inaccessible arthroscopically.

We present a retrospective multicentric series of carefully selected patients presenting "isolated" laxity of the posterior cruciate ligament.The series included 103 patients who were reviewed clinically (with a dedicated review chart) and radiographically with measurement of posterior laxity (Telos 15 kg).In these patients with an isolated injury of the PCL (without associated injury of the peripheral ligament)The short follow-up of this series (four years) does not enable an assessment of the risk or benefit of PCL ligamentoplasty for arthrosic knees.

We describe a technique for patellar stabilization by reconstruction of the medial patellofemoral ligament with the gracilis tendon. The tendon is anchored posteriorly on the soft tissue of the medial femoral epicondyle and anteriorly on the medial border of the patella. The plasty is completed by suture of the medial patellar wing. Inferior or medial transposition of the tibial tubercle may be associated. We have used this technique since 1995 for 145 knees with patellar instability. The small incisions have the advantages of minimally invasive surgery, particularly for the postoperative period and the cosmetic effect.

The authors report 26 cases of surgically treated degenerative spondylolisthesis. Twelve patients complained of permanent uni or bilateral sciatica. All the others had a syndrome of intermittent claudication with pain and paresthaesia. The authors stress once again the highly evocative nature of this syndrome which reflects involvement of the nerve roots in the stenosed lumbar canal. Treatment consisted of lamino-arthrectomy which resulted in the disappearance of symptoms in most of cases. In four cases, vertebral slipping worsened during the post-operative cowise with, in three cases a recurrence of symptoms necessitating a complementary arthrodesis. This risk of increased slipping is a result of the instability created by the arthrectomy, especially when it is bilateral, and has led the authors to widen their indications for routine complementary postero-lateral arthrodesis.

Degenerative spondylolisthesis is one important type of spinal stenosis. The spinal canal stenosis varies in degree. This is the result of anterior slipping of the whole vertebra, usually L4 on L5. The clinical picture is not greatly different from that observed in the other types of lumbar canal stenosis. The surgical management involves decompression of the cauda equina by laminectomy. Often this is associated with arthrectomy to decompress the nerve roots. Extensive excision of the neural arch may result in further spinal instability for which spinal fusion is generally advisable.

The authors report 18 cases of arthrosic sciatica due to toot compression in the lateral recess by posterior corporeal and/or posterior apophyseal osteophytosis. The authors study the clinical and radiological characteristics that may indicate the diagnosis and discuss the different mechanisms by which vertebral arthrosis can lead to radicular compression. When surgery is necessary because of the persistent nature of the sciatica, a broader approach should be undertaken than that required for excision of the disc, in order to explore fully the roots, the multiplicity of possible compression sites being one of the essential characteristics of these cases of arthrosic radiculopathy. Study of the literature and of the series of sciatica patients operated upon by the authors shows that although discal hernia is far from being the most frequent cause of common sciatica, arthrosic compression is a cause that cannot be ignored, especially in aged subjects.