Athletic pubalgia: Return to play after targeted surgery

BACKGROUND

Surgery for athletic pubalgia usually consists in abdominal wall repair combined with routine bilateral adductor tenotomy. We currently confine the surgical procedure to the injured structure(s) (abdominal wall only, adductor tendon only, or both) to limit morbidity and expedite recovery. Outcomes of this à la carte approach are unclear. The objectives of this retrospective study were to determine the return to play (RTP) time, evaluate the potential influence of injury location, and assess the frequency of recurrence or contralateral involvement.

HYPOTHESIS

À la carte surgery for athletic pubalgia is associated with similar RTP times as the conventional procedure and is not followed by recurrence.

MATERIAL AND METHODS

Consecutive adults younger than 40 years of age who underwent surgery for athletic pubalgia with injury to the abdominal wall and/or adductor attachment sites between 2009 and 2015 were included. Patients with intra-articular hip disorders, isolated pubic symphysis involvement, or herniation were not eligible. The diagnosis was established clinically then confirmed by at least one imaging technique (ultrasonography plus either a radiograph of the pelvis or magnetic resonance imaging of the pelvis). The criterion for performing surgery was failure of appropriate conservative therapy followed for at least 3 months.

RESULTS

Of the 27 included patients, eight had abdominal wall involvement only, seven adductor tendon involvement only, and 12 both. Overall, 25 (92.6%) patients returned to play at their previous level, after a mean of 112±38 days (range, 53-223 days), and experienced no recurrence during the 1-year follow-up. Mean RTP time was significantly shorter in the group with abdominal wall injury only (91.1±21.0 days) compared to the groups with adductor tendon injury only (101.7±42.0 days) or combined injuries (132.5±39.0) (p=0.02).

DISCUSSION

In patients with athletic pubalgia, à la carte surgery confined to the injured structure(s) produces excellent RTP outcomes. RTP time is shortest in patients with isolated lower abdominal wall injuries.

LEVEL OF EVIDENCE

IV, retrospective study with no control group.

Biomechanical study of dynamic changes in L4-L5 foramen surface area in flexion and extension after implantation of four interspinous process devices

BACKGROUND

Lumbar spinal stenosis is a major public health issue. Interspinous devices implanted using minimally invasive techniques may constitute an alternative to the reference standard of bony decompression with or without intervertebral fusion. However, their indications remain unclear, due to a paucity of clinical and biomechanical data. Our objective was to evaluate the effects of four interspinous process devices implanted at L4-L5 on the intervertebral foramen surface areas at the treated and adjacent levels, in flexion and in extension.

MATERIALS AND METHOD

Six fresh frozen human cadaver lumbar spines (L2-sacrum) were tested on a dedicated spinal loading frame, in flexion and extension, from 0 to 10 N·m, after preparation and marking of the L3-L4, L4-L5, and L5-S1 foramina. Stereoscopic 3D images were acquired at baseline then after implantation at L4-L5 of each of the four devices (Inspace(®), Synthes; X-Stop(®), Medtronic; Wallis(®), Zimmer; and Diam(®), Medtronic). The surface areas of the three foramina of interest were computed.

RESULTS

All four devices significantly opened the L4-L5 foramen in extension. The effects in flexion separated the devices into two categories. With the two devices characterized by fixation in the spinous processes (Wallis(®) and Diam(®)), the L4-L5 foramen opened only in extension; whereas with the other two devices (X-Stop(®) and Inspace(®)), the L4-L5 foramen opened not only in extension, but also in flexion and in the neutral position. None of the devices implanted at L4-L5 modified the size of the L3-L4 foramen. X-Stop(®) and Diam(®) closed the L5-S1 foramen in extension, whereas the other two devices had no effect at this level.

CONCLUSION

Our results demonstrate that interspinous process devices modify the surface area of the interspinous foramina in vitro. Clinical studies are needed to clarify patient selection criteria for interspinous process device implantation.

LEVEL OF EVIDENCE

Level IV. Investigating an orthopaedic device.

Adjacent segment disease after anterior cervical interbody fusion: a multicenter retrospective study of 288 patients with long-term follow-up

INTRODUCTION

Cervical discectomy with interbody fusion is a common procedure in spinal surgery. The resultant biomechanical alterations accelerate degeneration of the adjacent segment, but the contribution of natural degeneration to adjacent segment disease is unclear.

OBJECTIVE

To assess the long-term rate of surgery to discs adjacent to cervical interbody fusion; and to assess the associated incidence of cervico-brachial neuralgia and radiological degeneration of adjacent discs.

MATERIAL AND METHOD

A multicenter retrospective study included anterior cervical discectomy patients at a minimum of 10 years' follow-up. Clinical variables comprised pain, use of analgesics and surgical revision. Functional assessment was performed on the Neck Disability Index (NDI). Radiologic degeneration was assessed on the Goffin score based on cervical spine X-ray.

RESULTS

Two hundred and eighty-eight patients were contacted and filled out the clinical questionnaire. Among the patients, 153 underwent radiological reassessment. Mean age was 46 years (range, 16-73 years). Mean follow-up was 14.5 years (12-18 years). The rate of surgical revision on a disc adjacent to the primary level was 5.9%. Frequent attacks of cervico-brachial neuralgia were reported in 20.5% of cases. Radiologic adjacent segment degeneration was found in 81.3% of cases over follow-up. There was a significant correlation between degree of radiologic adjacent segment degeneration and NDI (P=0.02).

DISCUSSION

Degeneration adjacent to discectomy/fusion is partly due to aging. The present findings, however, agree with the literature and indicate accelerated degeneration in adjacent segments. These findings should be taken into account in treatment decision-making and suggest a possible interest of more physiological surgery such as arthroplasty.

LEVEL OF EVIDENCE

IV - Multicenter retrospective study.

Revisiting the spectrum of lower motor neuron diseases with snake eyes appearance on magnetic resonance imaging

BACKGROUND AND PURPOSE

The 'snake eyes' sign refers to bilateral hyperintensities of the anterior horns on axial spinal cord imaging. Based on sporadic reports, it has been associated with a range of lower motor neuron (LMN) syndromes, such as spondylotic amyotrophy and Hirayama disease, as well as spinal cord infarction. The objective of our study was to comprehensively characterize the full diagnostic spectrum of LMN syndromes with this radiological clue and discuss potential aetiological factors.

METHODS

A large patient cohort with snake eyes sign and upper limb LMN degeneration was recruited from three French neuromuscular units. Patients underwent detailed electrophysiological, radiological, clinical and anamnestic profiling.

RESULTS

Twenty-nine patients were ascertained and followed up for 9.5 ± 8.6 years. The majority of the patients were male (86.2%) with a mean age of 37.3 ± 14.4 years. Symptoms were bilateral in most cases (86.2%). Patients with predominantly proximal and distal deficits were equally represented (44.8% and 55.2%, respectively). A history of preceding trauma or intense physical activity was confirmed in 58.6% of the cases; 27.6% of the patients were given an initial clinical diagnosis of amyotrophic lateral sclerosis (ALS), and 51.7% were originally suspected to have multifocal motor neuropathy. None of the patients developed ALS on longitudinal follow-up.

CONCLUSION

The snake eyes sign on magnetic resonance imaging is associated with a wide spectrum of neurological conditions and is more common in young men with a history of strenuous activity or antecedent trauma. The recognition of this syndrome is crucial as many of these patients are initially misdiagnosed with ALS.

Accuracy of the preoperative planning for cementless total hip arthroplasty. A randomised comparison between three-dimensional computerised planning and conventional templating

INTRODUCTION

A high accuracy was recently reported for the three-dimensional (3D) computerised planning of total hip arthroplasty (THA), comparing well with navigation regarding leg length and femoral offset. However, there is no randomised study comparing 3D preoperative planning with conventional 2D templating in terms of accuracy and clinical relevance.

HYPOTHESIS

The 3D preoperative planning has a higher accuracy than the conventional 2D preoperative templating regarding the implants size and their positioning.

PATIENTS AND METHODS

A prospective comparative randomised study was carried out from 2008 to 2009, including two groups of 30 patients who underwent THA for primary osteoarthritis. One surgeon performed all the surgical procedures using a minimally invasive direct anterior approach. In one group, the planning was made on calibrated X-rays using 2D templates. In the other group, a CT-scan based 3D computerised planning was performed with dedicated software. The reconstructed hip final anatomy was compared postoperatively to the preoperative planning and the accuracy was expressed as the mean difference (±SD) between the planned positioning and the final positioning of the implants.

RESULTS

The prediction rate for the stem and the cup sizes were respectively of 100% and 96% in the 3D group versus 43% for both components in the 2D group. When combining both components, the prediction rate was 96% in the 3D group versus 16% in the 2D group. In the 3D group, a high accuracy was achieved for the planning of the leg length (-1.8±3.6 mm ranging from -8 to+4mm) and the femoral offset (-0.07±2.7 mm ranging from -5 to+4mm) versus 1.37±6.4mm ranging from -9 to 13 mm and 0.33±5.7 mm (-16 to 11 mm) in the 2D templating group (P<0.0001).

DISCUSSION

The 3D planning gives a higher accuracy than conventional 2D templating in forecasting the size of cup and the stem. This contributes to the prediction for leg length and offset that is more reliable with the 3D technique. This study suggests that 3D planning CT-scan data is an attractive alternative to navigation to restore these parameters. The high accuracy achieved by a low-experience surgeon suggests that 3D planning may help shorten the learning curve when using the minimally invasive direct anterior approach.

LEVEL OF EVIDENCE

Level III low-powered prospective randomized trial.

Iliac crest bone graft harvesting complications: A case of liver herniation

The iliac crest is an easily accessible donor site offering a relatively large and safe supply of bone. There are however possible complications; residual pain frequently, and more rarely herniation. This latter's true incidence is unknown in a literature review, which found 15 articles. We report a case of liver herniation in a 64-year-old overweight lady after harvesting bone from her iliac crest. The clinical diagnosis was confirmed by CT scan. Despite an appropriate surgical repair, the hernia recurred. This serious complication of bone harvesting from the iliac crest, and possible other undesirable events described, prompted reconsideration of our harvesting techniques, and the use in our unit of bone substitutes or cell therapy to fill bone defects.

Clinical, radiological and histological evaluation of biphasic calcium phosphate bioceramic wedges filling medial high tibial valgisation osteotomies

We report clinical, radiological and histological findings following high tibial valgisation osteotomy (HTVO) using micro-macroporous biphasic calcium phosphate wedges fixed with a plate and locking screws. From 1999 to 2002, 43 knees were operated on and studied prospectively. All underwent clinical and radiological follow-up at days 1, 90, and 365 to evaluate consolidation and bone substitute interfaces. Additionally, biopsies were taken for histology at least 1 year after implantation from 10 patients who requested plate removal. Radiologically, consolidation was observed in 98% of cases. At 1 year, correction was unchanged in 95% of cases. Histological analysis revealed considerable MBCP resorption and bone ingrowth, both into the pores and replacing the bioceramic material. Polarised light microscopy confirmed normal bony architecture with trabecular and/or dense lamellar bone growth at the expense of the wedge implants. X-ray and micro-CT scan revealed a well organised and mineralised structure in the newly-formed bone. This study shows that using MBCP wedges in combination with orientable locking screws and a plate is a simple, safe and fast surgical technique for HTVO. The is the first study to examine the results by histological analysis, which confirmed good outcomes.

The mini-invasive anterior extra peritoneal approach to the pelvis

Retroperitoneal pelvic tumours are rare and their surgical approach is challenging. Various surgical approaches have been proposed. We present here an original mini-invasive anterior retroperitoneal approach the pelvic retroperitoneum, which was successful in a 26-year-old woman who had a benign schwannoma of the left sacral plexus. This technique presents advantages over other techniques that were considered in this case, as the least invasive and safest procedure.

[Biphasic ceramic wedge and plate fixation with locked adjustable screws for open wedge tibial osteotomy]

PURPOSE OF THE STUDY

The aim of this radiological study was to evaluate the use of a biphasic ceramic wedge combined with plate fixation with locked adjustable screws for open wedge tibial osteotomy.

MATERIAL AND METHODS

Twenty-six consecutive patients (27 knees) underwent surgery between December 1999 and March 2002 to establish a normal lower-limb axis. The series included 6 women and 20 men, mean age 50 years (16 right knees and 11 left knees). Partial weight-bearing with crutches was allowed on day 1. A standard radiological assessment was performed on day 1, 90, and 360 (plain AP and lateral stance films of the knee). A pangonogram was performed before surgery and at day 360. Presence of a lateral metaphyseal space, development of peripheral cortical bridges, and osteointegration of the bone substitute-bone interface were evaluated used to assess bone healing. The medial tibial angle between the line tangent to the tibial plateau and the anatomic axis of the tibia (beta) was evaluated to assess preservation of postoperative correction. The HKA angle was determined.

RESULTS

Three patients were lost to follow-up and 23 patients (24 knees) were retained for analysis. At last follow-up, presence of peripheral cortical bridges and complete filling of the lateral metaphyseal space demonstrated bone healing in all patients. Good quality osteointegration was achieved since 21 knees did not present an interface between the bone substitute and native bone (homogeneous transition zone). The beta angle was unchanged for 23 knees. A normal axis was observed in patients (16 knees) postoperatively.

DISCUSSION

Use of a biphasic ceramic wedge in combination with plate fixation with locked adjustable screws is a reliable option for open wedge tibial osteotomy. The bone substitute fills the gap well. Tolerance and integration are optimal. Bone healing is achieved. Plate fixation with protected weight bearing appears to be a solid assembly, maintaining these corrections.

[Sagittal changes induced by knee arthroplasty: a radiologic study]

PURPOSE OF THE STUDY

To quantify the modifications occurring on the femoral side, after Total Knee Arthroplasty, we describe a method of measurements in the sagittal plane on standardized X-rays.

MATERIAL AND METHODS

We report the clinical and radiologic results of a prospective study of 80 cases of Total Knee Arthroplasty performed with the same prosthesis. We eliminated twenty cases with incorrect X-rays. Measurements were done on 60 preoperative X-rays and 60 postoperative X-rays. The aim of the measure was to quantify the modifications induced by the prosthesis on the trochlear groove and on the tibio-femoral joint line in full extension and in flexion, to eliminate individual femoral diameter was used as a reference in order to cancel variations in X-rays magnification. We first validated the two perpendicular reference axis on which we based all the measurements.

RESULTS

No significative difference was found on the position of the tibio-femoral joint line in flexion. The tibio-femoral joint line in extension was significantly moved distally. The prosthesis was placed too distally, therefore we changed the operative procedure. No significative difference was found on the position of the anterior trochlear groove.

DISCUSSION

With this method, the anatomic variations of the femoral profiles can be quantified, therefore, further prosthesis shapes can be improved. Radiological follow-up of knee prosthesis and comparison of the influence of different prosthesis can be made by these measures.

[Tibia vara in adolescents. Apropos of 19 cases]

PURPOSE OF THE STUDY

Clinical, and radiological aspects and treatment of adolescent tibia have been studied in a review of 19 children native of the Caribbean.

MATERIAL

23 cases of adolescent tibia vara in 19 children have been collected (14 males and 5 females, aged from 9 to 14).

METHODS

Clinical aspects (weight, lower limb axis), radiological signs (aspect of the physis, mechanical axis, epiphyseal slope) were studied pre and post-operatively.

RESULTS

All the boys presented an important overweight. Pain was the first symptom, characterized by a progressive varus deformity on a leg which was previously straight. Radiological findings consisted in metaphyseal varus and widening of the medial part of the physis. Mechanical femoro-tibial axis varied from 10 degrees to 55 degrees varus, medial epiphyseal slope from 12 degrees to 30 degrees. Average mechanical femoral angle was 92 degrees and accounted for a mean femoral varus deformity of 4 degrees. 23 knees were operated, 4 after fusion of the whole physis. 10 lateral hemi-epiphysiodesis were performed with a mean correction of 4 degrees every year until fusion. In 3 cases a tibial osteotomy was made in a second time, at the end of growth. In 6 cases of late treated patients, an isolated tibial osteotomy of valgisation was performed. In 7 cases of important deformity before closure of the physis, tibial osteotomy was associated with lateral epiphysiodesis. In one case, a lateral closing wedge osteotomy was performed, associated to an elevation of the medial tibial plateau and a lateral hemi-epiphysiodesis.

DISCUSSION

Histopathological examination of the physis showed similarities between adolescent tibia vara, infantile tibia vara and Slipped capital femoral epiphysis: the entire physeal plate was involved. Concerning pathogenesis of adolescent tibia vara, mechanical factors are predominant, with abnormal pressures across the medial part of the physis.

CONCLUSION

Adolescent tibia vara occur in obese black children and can be considered as an epiphysiolysis of the upper end of the tibia.

Ossification of the ligamenta flava with severe myelopathy in a black patient. A case report

STUDY DESIGN

A case of symptomatic ossification of ligamenta flava in a black man from Martinique (French West Indies) is reported.

OBJECTIVES

To show that ossification of ligamenta flava may be observed in racial groups other than Japanese people and that the postoperative prognosis of symptomatic ossification of ligamenta flava is not always excellent.

SUMMARY OF BACKGROUND DATA

Ossification of ligamenta flava causing slowly progressive myelopathy or radiculopathy is rare. It usually occurs in the lower thoracic spine. Ossification of ligamenta flava has mainly been described as occurring in Japanese people and very rarely in Caucasians. Diagnosis is based on a computed tomographic scan or magnetic resonance imaging, and postoperative prognosis is usually good.

METHODS

Low thoracic ossification of ligamenta flava was diagnosed in a black man from Martinique, based on the computed tomographic scan data and on the histopathologic examination of the removed tissue. The patient was clinically evaluated before and 1 year after the operation. A postoperative computed tomographic scan was performed. A magnetic resonance image was not available in this case.

RESULTS

The patient exhibited severe subacute myelopathy. After decompression, the neurologic recovery was incomplete. A postoperative computed tomographic scan showed complete excision of ossification of ligamenta flava and decompression of the spinal cord.

CONCLUSIONS

Ossification of ligamenta flava may occur in black people. An incomplete postoperative recovery may be observed in such cases of unusual subacute compressive myelopathy.

[Apropos of a case of chondromyxoid fibroma of the talus. A review of the literature]

PURPOSE OF THE STUDY

Chondromyxoid fibroma (CMF) is a very rare tumor. CMF represents less than 1p. 100 of all benign osseous tumors. The upper part of the tibia is the most frequent localization. We report the second case of talus tumor published in the world literature.

MATERIAL AND METHODS

A 20 years old man presented a lytic tumor of the talus. The histology diagnosed a Chondromyxoid fibroma. A complete excision was made. An autologous bone graft associated with blocks of coral were used for reconstruction.

RESULTS

After six months sport activities were authorized. After 10 years follow-up, there is no recurrence, the coral has progressively disappeared, replaced by host bone.

DISCUSSION

Only one case of talus tumor has been published in world literature. Feldman has collected 189 cases of CMF published before 1970. After 1970, 297 new cases published. Analysis of these 486 cases pointed out the frequency of differents localizations.

CONCLUSION

This very rare tumor frequent between 10 and 30 years of age. The foot is the second localization after the tibia. A surgical conservative treatment with complete excision is recommended even in case of recurrence. Radiotherapy must be avoided in any case because of the risk of malignant degeneration.

[Rupture of the distal tendon of the biceps brachialis: apropos of 43 cases]

PURPOSE OF THE STUDY

Rupture of the distal tendon of the biceps is an uncommon occurrence. 43 cases were analyzed in a multicentric study in order to define etiological factors and treatment of this lesion.

MATERIAL AND METHODS

43 cases were reviewed from Fort de France, Paris, Marseille, Lyon and Suresnes. There were only male patients with an average age of 50 years. The mechanism of injury, the clinical and radiographic features, the anatomical findings and the results of surgical treatment were analyzed. 4 patients were treated conservatively and 39 surgically. In 28 cases, anatomical reattachment of the tendon was performed. In 11 cases the tendon was simply attached to the brachialis anterior muscle.

RESULTS

The mechanism of injury in all patients was passive extension against active flexion 17 patients had sustained injury while engaged in sports activities and 17 during domestic activities. Most of the patients were diagnosed clinically. Ultrasound and CT scan was useful in cases seen a long time after injury. In 34 cases avulsion of the bicipital tuberosity was found. Subjective results were good in 28 cases and poor in 5 cases. Objective testing was performed one year after injury using the criteria described by Baker: flexion and suppination force (maximum force) and endurance (ability to perform repeated contractions). Following attachment to the brachialis anterior, there was an average loss of 33 per cent of flexion strength and 52 per cent of supination strength. Following anatomical reattachment, the loss was 5 per cent for flexion and 15 per cent for supination. There were two cases of radial nerve palsies and 1 case of radio-ulnar synostosis.

DISCUSSION

Attachment of the biceps brachialis tendon to the brachialis anterior muscle is unable to restore supination force. Complications only occur following anatomical reattachment. Radial nerve palsies can be avoided by using two separate incisions as described by Boyd.

CONCLUSION

Surgical reinsertion onto the radial tuberosity restore more strength. Attachment to the brachialis muscle can be sued in cases seen a long time after injury.