The differentiation of prehypertrophic into hypertrophic chondrocytes drives an OA-remodeling program and IL-34 expression

OBJECTIVES

We hypothesize that chondrocytes from the deepest articular cartilage layer are pivotal in maintaining cartilage integrity and that the modification of their prehypertrophic phenotype to a hypertrophic phenotype will drive cartilage degradation in osteoarthritis.

DESIGN

Murine immature articular chondrocytes (iMACs) were successively cultured into three different culture media to induce a progressive hypertrophic differentiation. Chondrocyte were phenotypically characterized by whole-genome microarray analysis. The expression of IL-34 and its receptors PTPRZ1 and CSF1R in chondrocytes and in human osteoarthritis tissues was assessed by RT-qPCR, ELISA and immunohistochemistry. The expression of bone remodeling and angiogenesis factors and the cell response to IL-1β and IL-34 were investigated by RT-qPCR and ELISA.

RESULTS

Whole-genome microarray analysis showed that iMACs, prehypertrophic and hypertrophic chondrocytes each displayed a specific phenotype. IL-1β induced a stronger catabolic effect in prehypertrophic chondrocytes than in iMACs. Hypertrophic differentiation of prehypertrophic chondrocytes increased Bmp-2 (95%CI [0.78; 1.98]), Bmp-4 (95%CI [0.89; 1.59]), Cxcl12 (95%CI [2.19; 5.41]), CCL2 (95%CI [3.59; 11.86]), Mmp 3 (95%CI [10.29; 32.14]) and Vegf mRNA expression (95%CI [0.20; 1.74]). Microarray analysis identified IL-34, PTPRZ1 and CSFR1 as being strongly overexpressed in hypertrophic chondrocytes. IL-34 was released by human osteoarthritis cartilage; its receptors were expressed in human osteoarthritis tissues. IL-34 stimulated CCL2 and MMP13 in osteoblasts and hypertrophic chondrocytes but not in iMACs or prehypertrophic chondrocytes.

CONCLUSION

Our results identify prehypertrophic chondrocytes as being potentially pivotal in the control of cartilage and subchondral bone integrity. Their differentiation into hypertrophic chondrocytes initiates a remodeling program in which IL-34 may be involved.

Painful posterior shoulder instability: Anticipating and preventing failure. A study in 25 patients

BACKGROUND

Painful posterior shoulder instability (PPSI) is the least common of the three clinical patterns of posterior shoulder instability. PPSI is defined as pain combined with anatomical evidence of posterior instability but no instability events.

MATERIAL AND METHOD

We studied a multicentre cohort of 25 patients with PPSI; 23 were identified retrospectively and had a follow-up of at least 2 years and 2 patients were included prospectively. Most patients engaged in sports.

RESULTS

All 25 patients underwent surgery, which usually consisted in arthroscopic capsulo-labral reconstruction. The outcome was excellent in 43% of patients; another 43% had improvements but reported persistent pain. The pain remained unchanged or worsened in the remaining 14% of patients. Causes of failure consisted of a missed diagnosis of shoulder osteoarthritis with posterior subluxation, technical errors, and postoperative complications. The main cause of incomplete improvement with persistent pain was presence of cartilage damage.

CONCLUSION

Outcomes were excellent in patients who were free of cartilage damage, bony abnormalities associated with posterior instability (reverse Hill-Sachs lesion, erosion or fracture of the posterior glenoid), technical errors, and postoperative complications.

Clinical outcomes of posterior bone block procedures for posterior shoulder instability: Multicenter retrospective study of 66 cases

BACKGROUND

The posterior bone block procedure is a well-known treatment option for posterior shoulder instability. The goal of this retrospective multicenter study was to evaluate the clinical and radiological outcomes of this procedure.

MATERIAL AND METHODS

The study cohort consisted of 66 patients (55 men, 11 women) with an average age of 27.8 years who were evaluated clinically and radiologically using a standardized questionnaire after posterior bone block surgery.

RESULTS

The Constant score significantly improved postoperatively (P<0.0001). The postoperative Walch-Duplay score was 81.5. The Rowe score was 86.5 points. The pain level (VAS) was significantly reduced after this procedure (P<0.0001). Eighty-five percent of patients were satisfied or very satisfied with the outcome.

CONCLUSION

This multicenter study of 66 patients shows that the posterior bone block procedure is an effective technique with good subjective and objective outcomes; however, the possibility of complications cannot be ignored.

CLINICAL STUDY

Level of evidence IV.

Preliminary clinical outcomes of Latarjet-Patte coracoid transfer by arthroscopy vs. open surgery: Prospective multicentre study of 390 cases

BACKGROUND

The Latarjet-Patte procedure consisting in transfer and screw fixation of the coracoid process to the anterior glenoid is a treatment of reference for anterior shoulder instability. Over time, surgical innovations translated into a number of improvements and, in late 2003, an arthroscopically assisted variant of the procedure was described.

OBJECTIVE

To evaluate and compare clinical outcomes of the modified Latarjet-Patte procedure performed by open surgery, arthroscopy with screw fixation, or arthroscopy with endobutton fixation.

MATERIAL AND METHOD

A total of 390 patients who underwent surgery to treat anterior shoulder instability between March 2013 and June 2014 were included and divided into three groups depending on whether they were managed using open surgery with screw fixation, arthroscopy with screw fixation, or arthroscopy with endobutton fixation. Clinical findings were recorded pre-operatively then 6 months post-operatively and at last follow-up (mean, 27.7 months). Range of motion and apprehension test (arm in external rotation at 0°, 90°, and 140° of abduction) were assessed and the Walch-Duplay and modified Rowe scores were determined.

RESULTS

Motion range restriction was minimal with all three techniques, and motion range continued to improve throughout follow-up. Apprehension in external rotation was noted at 90° of abduction in 11% of cases and at 140° of abduction in 4% of cases. The mean total Walch-Duplay score improved from 46 pre-operatively to 90.6 and the mean total modified Rowe score from 46 pre-operatively to 91.1. By statistical analysis, external rotation at 90° of abduction and internal rotation at 0° of abduction were better after open surgery, but the differences were of limited clinical significance. Recurrence was noted in 3.3% of cases, nerve injury in 0.8%, and infection in 1.5%.

CONCLUSION

In this study, the three techniques produced similar clinical outcomes, with a stable shoulder and no joint stiffness.

Functional outcomes after open versus arthroscopic Latarjet procedure: A prospective comparative study

INTRODUCTION

The Latarjet procedure provides effective stabilization of chronically unstable shoulders. Since this procedure is mainly performed in a young athletic population, the functional impact is significant. Published data does not shed light on the time needed to recover work-related or sports-related function. Performing this procedure arthroscopically may improve functional recovery. This led us to carry out a prospective, multicenter study to compare the functional recovery after arthroscopic versus open Latarjet procedure.

MATERIAL AND METHODS

Between June and November 2014, 184 patients were included in a prospective multicenter study: 85 in the open group and 99 in the arthroscopy group. The patients were evaluated preoperatively with the WOSI score. The early postoperative pain was evaluated on D3, D7 and D30. The WOSI score was determined postoperatively at 1, 3, 6 and 12 months of follow-up.

RESULTS

The functional scores of the shoulder in both cohorts were identical overall preoperatively. In the immediate postoperative period, the arthroscopy group had statistically lower pain levels on D3 and D7. The postoperative WOSI was improved in both groups at 3 months, then continued to improve until it reached a plateau at 1 year. The WOSI score was better in the arthroscopy group at 3 months, but better in the open group at 6 months.

CONCLUSION

This study found that a Latarjet procedure performed arthroscopically generates less immediately postoperative pain than when it is performed as an open procedure. The Latarjet procedure (whether open or arthroscopic) improves shoulder function, with normal function returning after 1 year.

Arthroscopy and obesity

Obesity is a major public health issue, as incidence is rising in all developed countries, although the proportion is lower in Europe than in the U.S. Over and above the metabolic consequences and increased risk of diabetes, cardiovascular pathology and certain forms of cancer, the present study focuses on osteoarticular risk, and in particular on pathologies manageable by arthroscopy. It also analyzes results and complications specific to arthroscopy in these indications. Meniscal and ligamentous pathologies of the knee, rotator-cuff pathology in the shoulder and tendon pathology in the elbow were not significantly elevated, although a trend emerged. In contrast, there was significant elevation of Achilles and plantar aponeurosis pathology. In terms of postoperative complications, thromboembolic risk was elevated, but there were not significantly more complications specific to arthroscopy. Finally, subjective results were comparable to those for non-obese patients.

LEVEL OF EVIDENCE

Review.

Prognostic factors to succeed in surgical treatment of chronic acromioclavicular dislocations

INTRODUCTION

Treatment of chronic acromioclavicular joint dislocation (ACJD) remains a poorly known and controversial subject. Given the many surgical options, it is not always easy to determine which steps are indispensable.

METHODS

This article reports a multicenter prospective study. The clinical and radiological follow-up involved a comparative analysis of the preoperative and postoperative data at 1 year, including pain (visual analogue scale), subjective functional incapacity (QuickDASH), and the objective Constant score, as well as a comparative analysis of vertical and horizontal movements measured on simple x-rays.

RESULTS

Based on a series of 140 operated ACJDs, we included 24 chronic ACJDs. The mean time to surgery was 46 weeks (range, 1 month to 4 years). The patients' mean age was 41 years, with a majority of males (75%), 72% of whom participated in recreational sports. Professionally, 40% of the subjects had jobs involving manual labor. We noted 40% grade III, 24% grade IV, and 36% grade V injury according to the Rockwood classification. In 92% of cases, coracoclavicular stabilization was provided by a double button implant, reinforced with a biological graft in 88% of the cases. In 29%, millimeters to centimeters of the distal clavicle were resected and acromioclavicular stabilization was associated in 54%. We observed complications in 33% of the cases. At 1 year postoperative, 21 patients underwent clinical and radiological follow-up (87.5%). Only 35% of the patients were satisfied or very satisfied, whereas 100% of them would recommend the operation. Full-time work was resumed in 91% of the cases and all sports could be resumed in 86%. The pre- and postoperative values at 1 year changed as follows: the mean Constant score improved from 61 to 87 (p=0.00002); the subjective QuickDASH score decreased from 41 to 9 (p=0.00002); and radiologically significant reduction of the initial displacement was observed in the vertical plane (p<10(-3)) and the horizontal plane (p=0.022).

CONCLUSION

In this study, the favorable prognostic factors found were: time to surgery less than 3 months (p=0.02), associated acromioclavicular stabilization, and postoperative immobilization with a sling extended to 6 weeks. However, resection of the distal clavicle did not influence the final result.

LEVEL OF PROOF

Level II prospective non-randomized comparative study.

Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?

BACKGROUND

The primary objective was to evaluate correlations linking anatomical to functional outcomes after endoscopically assisted repair of acute acromioclavicular joint dislocation (ACJD).

HYPOTHESIS

Combined acromioclavicular and coracoclavicular stabilisation improves radiological outcomes compared to coracoclavicular stabilisation alone.

MATERIAL AND METHODS

A prospective multicentre study was performed. Clinical outcome measures were pain intensity on a visual analogue scale (VAS), subjective functional impairment (QuickDASH score), and Constant's score. Anatomical outcomes were assessed on standard radiographs (anteroposterior view of the acromioclavicular girdle and bilateral axillary views) obtained preoperatively and postoperatively and on postoperative dynamic radiographs taken as described by Tauber et al.

RESULTS

Of 116 patients with acute ACJD included in the study, 48% had type III, 30% type IV, and 22% type V ACJD according to the Rockwood classification. Coracoclavicular stabilisation was achieved using a double endobutton in 93% of patients, and concomitant acromioclavicular stabilisation was performed in 50% of patients. The objective functional outcome was good, with an unweighted Constant's score ≥ 85/100 and a subjective QuickDASH functional disability score ≤ 10 in 75% of patients. The radiographic analysis showed significant improvements from the preoperative to the 1-year postoperative values in the vertical plane (decrease in the coracoclavicular ratio from 214 to 128%, p=10(-6)) and in the horizontal plane (decrease in posterior displacement from 4 to 0mm, p=5×10(-5)). The anatomical outcome correlated significantly with the functional outcome (absolute R value=0.19 and p=0.045). We found no statistically significant differences across the various types of constructs used. Intra-operative control of the acromioclavicular joint did not improve the result. Implantation of a biological graft significantly improved both the anatomical outcome in the vertical plane (p=0.04) and acromioclavicular stabilisation in the horizontal plane (p=0.02). The coracoclavicular ratio on the anteroposterior radiograph was adversely affected by a longer time from injury to surgery (p=0.02) and by a higher body mass index (BMI) (p=0.006). High BMI also had a negative effect on the difference in the distance separating the anterior edge of the acromion from the anterior edge of the clavicle between the injured and uninjured sides, as assessed on the axillary views (p=0.009).

CONCLUSION

This study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint. Coracoclavicular stabilisation alone is not sufficient, regardless of the type of implant used. Implantation of a biological graft should be considered when the time from injury to surgery is longer than 10days. The weight of the upper limb should be taken into account, with 6weeks of immobilisation to unload the construct in patients who have high BMI values.

LEVEL OF EVIDENCE

II, prospective non-randomised comparative study.

Differential expression of interleukin-17 and interleukin-22 in inflamed and non-inflamed synovium from osteoarthritis patients

OBJECTIVE

Synovitis associated with osteoarthritis (OA) is directly responsible for several clinical symptoms and reflects OA's structural progression. This study sought to analyze the expression of proinflammatory mediations, including Interleukin (IL)-17 and IL-22, which play key roles in regulating inflammatory processes, in inflamed and non-inflamed areas of osteoarthritic synovium.

METHODS

Synovium from knees of 32 OA patients were collected at surgery. Macroscopic evaluation of inflammation enabled inflamed and non-inflamed areas to be separated. Samples were incubated to obtain tissue-conditioned media. Quantitative mRNA expression of proinflammatory mediators was analyzed by RT-PCR and protein levels by ELISA and gelatin zymography. Immunohistochemistry and histology were performed.

RESULTS

Inflamed synovium were characterized by increased leukocyte infiltration and a higher vessel-to-tissue area ratio than non-inflamed tissues. Macrophages, T and B lymphocytes, and some neutrophils were found only in the inflamed tissue, and only in the subintimal layer. Levels of proinflammatory cytokines and MMP-9 were significantly higher in tissue-conditioned media from inflamed than non-inflamed tissues. Inflamed areas were associated with higher expression of IL-17 and IL-22, both correlated with the combined release of IL-6, IL-23, and TGFβ1.

CONCLUSION

Our results showed that inflammatory cytokines, including IL-17 and IL-22, are expressed at higher levels by inflamed OA synovium and suggest IL-22 involvement in OA pathophysiology. This study will help identify new therapeutic strategies for OA, especially the targeting of IL-22 to decrease inflammation.

Contribution of MRI and CT arthrography to the diagnosis of intra-articular tendinopathy of the long head of the biceps

INTRODUCTION

Clinical diagnosis of biceps tendinopathy is difficult to make because of the poor sensitivity of existing clinical tests. The goal of this study was to determine whether MRI or CT arthrogram could contribute to the diagnosis of tendinopathy in the intra-articular portion of the long head of biceps (LHB), while using macroscopic findings during shoulder arthroscopy as a reference.

MATERIAL AND METHODS

A prospective, single-centre study was performed over a 4-month period. The radiology part of the study was carried out by a radiologist experienced in shoulder imaging. The arthroscopy part of the study was conducted while the biceps was being evaluated for treatment purposes. The study included 87 patients having an average age of 45.7 years (range 17-78). Fifty-eight patients underwent CT arthrography and 38 underwent an MRI. Seven patients underwent both imaging exams. One patient was removed from the study because of a spontaneous LHB rupture. The demographics of the two study populations were equivalent.

RESULTS

For the diagnosis of tendinopathy of the intra-articular portion of the long head of biceps, the CT arthrogram had a sensitivity of 71.43%, specificity of 100%, positive predictive value of 100% but a negative predictive value of 67.74%. For the diagnosis of tendinopathy of the intra-articular portion of the long head of biceps, the MRI had a sensitivity of 42.85%, specificity of 75%, positive predictive value of 50% but a negative predictive value of 69.23%.

CONCLUSION

This study showed that radiological diagnosis of tendinopathy of the long head of biceps remains challenging. Nevertheless, CT arthrography is more sensitive and specific than MRI in identifying this disorder.

LEVEL OF EVIDENCE

III (case-control study).

Optimization of bone-block positioning in the Bristow-Latarjet procedure: a biomechanical study

BACKGROUND

In the Bristow-Latarjet procedure, optimal positioning of the coracoid bone-block on the anterior aspect of the glenoid (standing or lying on the glenoid rim) remains debated. A biomechanical study assessed the effect of the position of the bone-block with its attached conjoint tendon on anterior and inferior stabilization of the humeral head.

MATERIALS AND METHODS

The Bristow-Latarjet procedure was performed on 8 fresh cadaveric shoulders. The bone-block size was systematically at 2.5×1×1 cm. Anterior translation of the humeral head was stress induced under 30-N traction, in maximum external rotation at 0° and at 90° abduction: respectively, adduction and external rotation (ADER), and abduction and external rotation (ABER). Under radiological control, displacement of the center of the humeral head was compared with the glenoid surface at the 3, 4 and 5 o'clock (medial, antero-inferior and inferior) positions for the 2 bone-block positionings.

RESULTS

The lying position at 4 o'clock substantially decreased anterior and inferior displacement of the humeral head respectively in ADER and ABER; and in ABER it also tended to decrease anterior translation, but not significantly. The standing bone-block position did not affect translation.

CONCLUSIONS

Positioning the bone-block so that it lies on the anterior aspect of the glenoid in the middle of the antero-inferior quarter of the rim at 4 o'clock can decrease anterior displacement of the humeral head and inferior glenohumeral translation, especially in ADER for anterior displacement and in ABER for inferior displacement.

STUDY DESIGN

Laboratory study.

Arthroscopic classification of posterior labrum glenoid insertion

PURPOSE

We performed a prospective arthroscopic study to explore the variability of the posterior labrum glenoid insertion. We aimed to classify the insertions and to explore whether these insertions can be identified by pre-operative arthro-CT scan.

PATIENTS AND METHODS

From January to December 2011, 86 patients were prospectively included in the current study. During arthroscopy, anterior labrum was evaluated and posterior labrum was assessed in 3 different locations: superior, medial, and inferior. For each segment, the labrum was considered normally inserted (directly to the glenoid cartilage), medialized (inserted at the posterior part of the glenoid bone, without direct contact with the cartilage), torn (macroscopic degenerative changes, tears, fragments) or absent (agenesis). Imaging was analyzed segment by segment by an experienced osteoarticular radiologist, using the same classification.

RESULTS

Four types of posterior labrum insertions were identified. Type 1, 60% of the cases, corresponded to a posterior labrum totally inserted in the glenoid, with direct contact with the cartilage. Type 2, 20% of the cases, represented medialized insertion of the superior segment. Type 3, 15% of the cases, represented an associated medialization of the superior and medial segment of the posterior labrum. Type 4 is a medialized insertion of the all-posterior labrum. Fifty-six shoulders were used for arthro-CT and arthroscopy correlation: for the superior segment (n=22/56), the sensitivity of arthro-CT to identify an abnormal insertion when the labrum is medialized was 68.18%, specificity 70.59%, positive predictive value (PPV) 60%, and negative predictive value (NPV) 77.42%. For the medial segment (n=16/56), the sensitivity of arthro-CT to identify an abnormal insertion when the labrum is medialized was 81.25%, specificity 57.50%, PPV 43.33% and NPV 88.46%. For the inferior segment (n=5/56), the sensitivity was 100%, specificity 47.60%, PPV 15.63% and NPV 100%.

CONCLUSION

The current study points out the high variability of shoulder posterior labrum glenoid insertion, and thus the risk of misdiagnosis with posterior labral tears, especially in posterior instability and also the risk of considering as labral lesions some non-pathological aspects.

LEVEL OF EVIDENCE

Level III. Anatomic prospective study.

Current concept for the use of PRP in arthroscopic surgery

PRP is commonly used in sports medicine and because it is supposed to increase healing capacities of damaged tissues, it is expected to be increase efficiency or god clinical outcomes when added to arthroscopic surgical procedure. The current review of literature explores the evidence-based medicine supporting the use of PRP in three arthroscopic related disorders. Regarding cartilage lesions of the knee, many studies are exploring several aspect of cartilage lesion treatment. It appears that PRP, in some protocols with specific concentration, should be more efficient than current therapies in the treatment of early stages of knee OA, but only in the field of rheumatology or sport medicine, not when used during surgery. PRP have been used in ACL reconstruction, no benefit has been reported in any study regarding clinical or radiological outcomes. In shoulder cuff disorder, to date, no clinical benefit nor increased healing rate have been clearly reported. Thus, in 2013, it is clear that there is no evidence base medicine data supporting the use of PRP in arthroscopic surgery.

Complex proximal humeral fractures: a prospective study of 22 cases treated using the "Bilboquet" device

INTRODUCTION

Despite recent improvements in surgical devices, complex proximal humerus fractures internal fixation still encounters frequent mechanical failures.

HYPOTHESIS

The aim of this study was to confirm that the Bilboquet device (a design mimicking the cup-and-ball game) helps solving mechanical difficulties associated with these fractures internal fixation and to present a simplified version of the original surgical procedure.

PATIENTS AND METHOD

This non-randomised prospective study included 22 fractures in 22 patients, mean age: 70 years. According to the Neer classification there were three-part fractures in seven cases and four-part fractures in 15 cases. Fractures were all reduced and treated by internal fixation in a simplified surgical procedure using the Bilboquet device.

RESULTS

Mean postoperative follow-up was 34 months. The mean Constant score was 66 and the weighted Constant score was 86. Mean active forward elevation was 108° and mean active external rotation was 28°. No per- or postoperative complications occurred. Initial reduction of the tuberosity was incomplete in four cases. Union was obtained in all fractures. There was no secondary tilting of the head, and no migration or pseudarthrosis of the tuberosities. Five patients developed postoperative avascular necrosis of the humeral head.

DISCUSSION

The Bilboquet staple component provides a supporting platform for the entire humeral head area. This peripheral stabilization associated with tension band wiring explains the lack of secondary displacement in these cases. Although the Bilboquet device provides a solution to the mechanical problems of complex fractures of the proximal humerus, it does not solve the problem of secondary avascular necrosis of the humeral head, which occurred in 23% of the patients in this series and in 33% of patients in the four-part fractures subgroup.

LEVEL OF EVIDENCE

IV (non-randomised prospective study).

Can we improve the indication for Bankart arthroscopic repair? A preliminary clinical study using the ISIS score

The objectives of this study on arthroscopic treatment of chronic anterior shoulder instability were the collection of the current practices for this indication, their development as reported in the literature, and the analysis of preliminary results on a multicenter prospective series of Bankart arthroscopic procedures undertaken using a common technique on patients selected based on the Instability Severity Index Score (ISIS). This procedure predominates in the English-speaking world, whereas the Latarjet protocol is preferred in France. The choice between the two seems to be cultural since neither technique could be demonstrated to be superior in an analysis of 171 responses to an Internet questionnaire in this study. The literature reports disappointing results in the Bankart arthroscopic procedure and recent articles have researched the predictive factors for its failure. Eleven centers prospectively included 125 patients from 1 December 2007 to 30 November 2008. The inclusion criteria were recurrence of anterior instability and an ISIS less than or equal to four points out of 10. All the selected patients underwent capsuloligamentous reinsertion with a common minimal technique of at least three anchors and four sutures with the same postoperative protocol. At a mean follow-up of 18 months, four patients (3.2%) had experienced recurrence. For the 84 patients reexamined at 1 year, the Walch-Duplay and Rowe scores were, respectively, 88.4 and 87.8 points out of 100. Subjectively, 88.1% of the patients declared they were satisfied and would undergo the intervention again. This study confirmed the use of the ISIS as a consultation tool. Only continuation of the study with a minimum follow-up of 3 years will allow us to validate the lower limit of the ISIS below which this technique could be proposed provided that it respects the technical prerequisite of at least four capsuloligamentous sutures.

Interest of complementary inferior glenohumeral ligament fixation in capsulo-labral repair for shoulder instability: A biomechanical study

Arthroscopic repair of Bankart lesions is part of the arsenal available to the shoulder surgeon to manage chronic anterior instability of the shoulder. Despite improvements in technique, rates of recurrence remain high. Some factors relate to the patients and their lesions, others to technique.The hypothesis that insufficient repair may be the cause of failure in Bankart arthroscopy was investigated in an anatomic and biomechanical study. Bankart lesions were made on 12 cadaver shoulders and repaired using two suture techniques. The aim was to investigate whether there was any biomechanical interest in reinforcing the labrum and capsule suture by a complementary inferior gleno-humeral ligament (IGHL) suture to double the labral repair. No significant difference in overall resistance was found between the two techniques. Failure generally started from the superior suture, and the present findings suggest that special attention should be paid to superior reinsertion. In the present model, complementary IGHL fixation did not alter the biomechanics of repair. Failure of repair can be traced to the superior suture.

[Isolated gonococcal tenosynovitis. Case report and review of literature]

Isolated gonococcal tenosynovitis is rare, and is part of disseminated gonococcal infection. It is due to blood-borne contamination of the flexor tendon sheath. One to 3% of gonococcal mucosal infections develop disseminated infections. Tenosynovitis is present in two-thirds of cases, sometimes in association with arthritis and skin rash. We report a case of a 26-year-old man with isolated gonococcal tenosynovitis of the thumb, with no other medical history, occurring 15 days after unprotected sex. Except local inflammatory signs of the thumb extending to the wrist, and a biological inflammatory syndrome, the patient had no arthritis, skin or mucosa symptoms. Immediate surgical drainage was performed under antibiotic cover with 3rd generation cephalosporin. All bacteriological samples were negative, except for one blood culture positive for Neisseria gonorrhoeae. Thus, in case of an asymptomatic patient with suspected gonococcal infection through a mucus portal, a precise examination, including geographical and sexual history, and a review of screening are recommended. Although the pathophysiology of gonococcal tenosynovitis is still obscure, the best prevention remains that of sexually transmitted diseases.

Arthroscopic treatment of a fresh lunate bone fracture detaching the scapholunate ligament

Fractures of the lunate bone are rare and usually treated by prolonged immobilization. We report a fracture of the dorsal pole of the lunate bone detaching the scapholunate ligament. The clinical presentation was equivalent to an acute disruption of this ligament. Percutaneous screw repair of the bone fragment was performed under wrist arthroscopy. The patient kept an analgesic splint for five days and early mobilization was provided. After 6 weeks, the patient had returned to his previous level of activity with normal wrist motion and full strength. Screw fixation under arthroscopy is minimally invasive and provides accurate restoration of the lunar anatomy, yielding good functional results after a short recovery period. This treatment offers a satisfactory alternative to prolonged immobilization and ensures good reduction and compression of the fracture. We present a detailed description of the surgical technique and its results.

Percutaneous retrograde screw fixation of non-displaced fractures of the scaphoid waist: an antirotation wire may not be necessary

Some authors recommend using an antirotation wire when performing percutaneous screw fixation of acute non-displaced scaphoid waist fractures. The aim of this study of 21 cadaveric wrists was to assess the usefulness of such a wire in Herbert's B2-type fractures. A B2-type fracture was created experimentally on each scaphoid. An antirotation wire was inserted in eight wrists. Retrograde percutaneous fixation using a double-threaded headless cannulated screw was performed on all wrists. Computed tomography was used to measure interfragmentary rotation. No interfragmentary rotation was noted in either group. Our study suggests that using an antirotation wire may be unnecessary when performing retrograde percutaneous screw fixation of isolated B2-type scaphoid fractures.

Stigmasterol: a phytosterol with potential anti-osteoarthritic properties

OBJECTIVE

Although most studies have focused on the cholesterol-lowering activity of stigmasterol, other bioactivities have been ascribed to this plant sterol compound, one of which is a potential anti-inflammatory effect. To investigate the effects of stigmasterol, a plant sterol, on the inflammatory mediators and metalloproteinases produced by chondrocytes.

METHOD

We used a model of newborn mouse chondrocytes and human osteoarthritis (OA) chondrocytes in primary culture stimulated with or without IL-1beta (10 ng/ml), for 18 h. Cells were pre-incubated for 48 h with stigmasterol (20 microg/ml) compared to untreated cells. We initially investigated the presence of stigmasterol in chondrocyte, compared to other phytosterols. We then assessed the role of stigmasterol on the expression of various genes involved in inflammation (IL-6) and cartilage turn-over (MMP-3, -13, ADAMTS-4, -5, type II collagen, aggrecan) by quantitative Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR). Additional experiments were carried out to monitor the production of MMP-3 and prostaglandin E2 (PGE(2)) by specific immuno-enzymatic assays. We eventually looked at the role of stigmasterol on NF-kappaB activation by western blot, using an anti-IkappaBalpha antibody.

RESULTS

After 18 h of IL-1beta treatment, MMP-3, MMP-13, ADAMTS-4, but not ADAMTS-5 RNA expression were elevated, as well as MMP-3 and PGE(2) protein levels in mouse and human chondrocytes. Type II collagen and aggrecan mRNA levels were significatively reduced. Pre-incubation of stigmasterol to IL-1beta-treated cells significantly decreased these effects described above (significant reduction of MMP-3 mRNA in human and mouse, MMP-3 protein in mouse, MMP-13 mRNA in mouse and human, ADAMTS-4 mRNA in human, PGE(2) protein in human and mouse) Finally, stigmasterol was capable of counteracting the IL-1beta-induced NF-kappaB pathway.

CONCLUSION

This study shows that stigmasterol inhibits several pro-inflammatory and matrix degradation mediators typically involved in OA-induced cartilage degradation, at least in part through the inhibition of the NF-kappaB pathway. These promising results justify further ex vivo and in vivo investigations with stigmasterol.

Pulmonary embolism following thrombosis of the brachial vein after shoulder arthroscopy. A case report

Thromboembolic complications are very rare after arthroscopic surgery of the shoulder. We report the case of a 25-year-old who presented thrombophlebitis of the brachial vein complicated by pulmonary embolism following arthroscopic surgery for posterior instability of the shoulder. No hemostasis impairment was found in this patient. The factors arguing in favor of thrombosis that had been retained from the literature were the lateral decubitus position with traction of the limb in its axis, prolonged surgical time, use of interscalene brachial plexus block, and a general condition susceptible to thrombosis (personal or family history of thromboembolism, genetic risk factor for thrombosis, smoking, obesity, neoplasia). There are currently no guidelines on the need for thromboembolism prevention during shoulder arthroscopy.

[Rupture of axillary artery and brachial plexus paralysis as complications of recurrent anterior glenohumeral dislocation: a case report]

The authors report a case of transection of the axillary artery and brachial plexus paralysis following recurrent anterior glenohumeral dislocation. Subsequent vascular reconstruction was performed using a venous interposition graft. The brachial plexus was explored at the same time and found to be in continuity. Neurological recovery was complete within a few months.

Magnetic resonance imaging as a tool to predict reparability of longitudinal full-thickness meniscus lesions

Prediction of meniscus reparability is useful for surgeons to optimise surgical scheduling and to inform patients about postoperative management. This study was designed to determine the accuracy of MRI in predicting the reparability of longitudinal full-thickness meniscus lesions. We studied 100 MRIs of longitudinal full-thickness medial or lateral meniscus lesions located from the meniscosynovial junction to the axial part of the meniscus. The MRI criteria of reparability were a peripheral rim smaller than 4 mm and a lesion longer than 10 mm. At arthroscopy the menisci were considered as reparable when the lesion was located in red-red or red-white zones and when it was more than 1 cm in length. A heterogeneous or homogeneous aspect of the meniscus body was also considered. The length of the meniscus lesion averaged 17.6 mm and the thickness of the rim 3.4 mm. A heterogeneous signal of the axial fragment and of the rim was found in 11 cases and in 48 cases, respectively. In 90 cases, there was no difference between the MRI-predicted reparability and the arthroscopic findings. Global sensitivity of MRI to determine reparability of full-thickness meniscus lesions was 94%, increasing to 96% for the medial meniscus and dropping to 83% for the lateral meniscus. Global specificity was 81%, and was higher for the lateral meniscus (90%) than for the medial one (82%). Global positive predictive value was 0.94 and global negative predictive value was 0.82. A heterogeneous aspect of the rim did not compromise arthroscopic reparability whereas a heterogeneous aspect of the axial fragment indicated an irreparable meniscus. The described MRI criteria can predict meniscus reparability. Their accuracy is limited for lateral meniscus lesions close to the popliteal hiatus and for very young active patients in whom repair of white-white lesions can be attempted. Longitudinal full-thickness meniscus lesions are a good indication for repair in young active patients.

Traitement arthroscopique des kystes synoviaux dorsaux du poignet

Incidentally discovered in 1987, arthroscopic treatment of dorsal wrist ganglia is based on our knowledge of their physiopathology which in turn benefits from the arthroscopic wrist evaluation. Dorsal wrist ganglia arise in the radiocarpal space from the dorsal part of the scapholunate ligament and migrate along the dorsal wrist capsule. According to their position above or under the dorsal intercarpal ligament, their cutaneous projection may vary. The basis of the arthroscopic treatment of wrist ganglia is, as with open surgery, the capsular resection in front of their origin. Arthroscopic resection is made either from dorsal radio-carpal or midcarpal approaches with little morbidity. Scars are unnoticeable, wrist mobility and strength close to normal by three months, which is the delay for dorsal wrist pain, always very limited, to disappear. The recurrence rate is however still debatable. Close to zero in some series, we had almost 20% recurrence rate in our series, with half of patients who reccur after two years follow-up. This variability in the recurrence rate also exists with open techniques. The only prospective and randomized study available to date found no differences between the two techniques, according to the recurrence rate.

[Arthroscopic treatment of dorsal wrist ganglia]

Incidentally discovered in 1987, arthroscopic treatment of dorsal wrist ganglia is based on our knowledge of their physiopathology which in turn benefits from the arthroscopic wrist evaluation. Dorsal wrist ganglia arise in the radiocarpal space from the dorsal part of the scapholunate ligament and migrate along the dorsal wrist capsule. According to their position above or under the dorsal intercarpal ligament, their cutaneous projection may vary. The basis of the arthroscopic treatment of wrist ganglia is, as with open surgery, the capsular resection in front of their origin. Arthroscopic resection is made either from dorsal radio-carpal or midcarpal approaches with little morbidity. Scars are unnoticeable, wrist mobility and strength close to normal by three months, which is the delay for dorsal wrist pain, always very limited, to disappear. The recurrence rate is however still debatable. Close to zero in some series, we had almost 20% recurrence rate in our series, with half of patients who reccur after two years follow-up. This variability in the recurrence rate also exists with open techniques. The only prospective and randomized study available to date found no differences between the two techniques, according to the recurrence rate.

[Total knee arthroplasty for recent severe fracture of the proximal tibial epiphysis in the elderly subject]

PURPOSE OF THE STUDY

Bone comminution, serious cartilage damage, and the poor mechanical quality of osteoporotic bone create a difficult challenge for osteosynthesis of joint fractures in the elderly subject. Poor results with certain hip, elbow and shoulder fractures have lead certain authors to propose emergency arthroplasty in selected cases. We report our experience with four knee arthroplasties implanted for recent severe fracture of the proximal tibial epiphysis in elderly subjects.

MATERIAL AND METHODS

Four independent patients aged over 75 years presented a severe comminutive fracture of the proximal epiphysis of the tibia (Three Schatzker 5, one Schatzker 4). After obtaining the patients' informed consent, early knee arthroplasty was performed. A long-stem cemented tibial piece was used on which the epiphysis was reconstructed. Implants providing support for ligament deficits were used in all cases. Immediate weight-bearing was authorized.

RESULTS

Follow-up ranged from two to seven years. The IKS function score (15, 60, 100, 100) depended on the patient's general status. The IKS knee score was excellent for three knees (90, 95, 95), and fair in one (45). Re-operations were not needed in any of the patients. All x-rays showed bone healing with correctly aligned limbs (less than 2 degrees deformation). There were no lucent lines at last follow-up.

DISCUSSION

Early arthroplasty for complex fractures of the proximal epiphysis of the tibia is a realistic option. Using a cemented long-stem tibial piece ensures primary stability sufficient for early weight-bearing before bone healing. Use of a constrained prosthesis, or better a hinged prosthesis, can be questioned but avoids the difficulty of ligament balance on an osteoporotic knee with a destroyed joint surface. None of the patients required reoperation and the results in terms of pain were excellent. The overall outcome depends on the general status of the patient.

Résection arthroscopique des kystes synoviaux dorsaux du poignet : à propos de 54 cas

INTRODUCTION

Ganglion cyst of the wrist can, some time, need surgery. Different arthroscopic technical procedures have been described. We report our experience in all articular resection of dorsal ganglion cyst of the wrist.

OBJECTIVES

Evaluation of efficiency of resection of dorsal ganglion cyst of the wrist by of arthroscopic resection of the pedicle.

METHODS

Fifty-four cysts of 52 patients have been evaluated retrospectively. Operative data, pain, strength, recurrence and complications have been collected.

RESULTS

Average follow up was 28 months (6 to 78). Return to work was 8,8 days, operative time 41 minutes (25 to 90). In 67% cases, the operation was judged easy. Three surgeries had to be performed open. Complications were one hematoma and one neurodystrophy. Pain decrease from 3,37 to 1,76 on analogical pain scale. Flexion was 89% of opposite side, extension 88%. Sixteen recurrences (29.7%) were found. Sixty percent of those recurrences occurred during the first year experience. But independently of experience, the operative performance was foun difficult in 1 time on 3.

CONCLUSION

Endoarticular arthroscopic resection of the pedicle of ganglion cyst is not so reproducible. In experimented hands, it remains a difficult procedure after a long learning curve with a recurrence rate 3 times higher from what is reported in literature for open surgery. For our discharge, our long follow-up can contain some cases of de novo cyst explaining this high rate, the learning curve is certainly the main reason for our high recurrence.

[Pre-operative diagnosis of bucket-handle meniscal tears: clinical evaluation and value of arthroscan and MRI radiological criteria]

PURPOSE OF THE STUDY

It is important for both the patient and the surgeon to determine whether a meniscal lesion can be repaired before undertaking surgery. The purpose of this study was to examine the pertinence of clinical signs and determine the value of imaging findings for the preoperative diagnosis of bucket-handle meniscal tears. This preliminary study was conducted before undertaking an analysis of preoperative criteria of reparability in a homogeneous group of meniscal lesions.

MATERIAL AND METHODS

This retrospective series included 33 arthroscopically-proven bucket-handle meniscal tears in patients who underwent arthrography and/or arthroscan and/or MRI preoperatively. The images were reviewed by two senior radiologists who established a consensus diagnosis. Clinically, the type of blockage and the presence of permanent flexion before surgery were noted. The following items were noted on the imaging results: fragment displacement (fragment in the notch on the coronal slice) anterior megahorn, double PCL, and serpent sign on the sagittal slice. Longitudinal, transversal extension and position of the bucket-handle were noted. We searched for correlations with the intraoperative findings.

RESULTS

Fourteen patients had a history of knee blocking and 15 had permanent flexion before surgery. Only 10 patients had the typical association of blocking and flexion. Certain diagnosis of bucket-handle meniscal tear was provided by MRI (13/15), arthroscan (6/7), and arthrography (10/24) giving an equivalent sensitivity for the two slice imaging techniques. The sign of a fragment in the notch on the coronal slice was a constant finding. The double PCL sign was sensitive for medial meniscal tears and for lateral meniscal tears with associated ACL tears. The diagnosis was successfully established in all 9 patients who underwent several explorations (2 or 3). Buckle-handle meniscal tear was not identified in 9 patients (arthrography 7, MRI 2).

DISCUSSION

Our findings demonstrate that the preoperative diagnosis of bucket-handle meniscal tears cannot be properly established on clinical criteria of typical blocking and/or permanent flexion. They confirm that arthrography is not contributive to diagnosis and that the absence of a slice image is detrimental to diagnosis. The sensitivity of the two slice imaging methods was similar. The key sign was the presence of a fragment in the notch on the coronal slice; in the three cases where this sign was absent, the reason was found to be the small size of the displaced fragment (resolution limit) and time between imaging and arthroscopy. The characteristic features of the bucket-handle lesions observed in this series are exactly the same as reported in earlier reports but to our knowledge provide the first data on comparative performance of arthroscan and MRI.

CONCLUSION

The noninvasive nature of MRI and the possibility of assessing the meniscal wall and the quality of the meniscal tissue make MRI the exploration of choice for preoperative assessment of meniscal tears.

[Reasons why musicians consult hand surgeons]

PURPOSE OF THE STUDY

Musicians occasionally consult orthopedic surgeons, particularly upper limb specialists. We wanted to learn more about the reasons why musicians attend orthopedic clinics.

MATERIAL AND METHODS

We analyzed retrospectively 227 case files of musicians who consulted our center between 1994 and 2001. We noted patient related factors (age, gender, musical experience, level of performance, daily practice schedule) and their reasons for consulting (pain, discomfort, advice). We studied the medical history of the patients and searched for predisposing or triggering elements. We also recorded therapeutic options proposed.

RESULTS

Our series included 119 men (52%) and 108 women, mean age 35 years with 27 years of musical experience on the average. Instruments played were mainly the piano (41%), the violin (19%), and the guitar (15%). Patients playing wind instruments, who consult more often for ENT problems, were exceptional. On the average, the patients played their instrument 4 hours daily. One-third of the patients were high-level amateurs, one-third were professionals, and one-quarter were lower-level amateurs. There was a small proportion of soloists or professors. Two-thirds of the musicians presented disorders of the musculoskeletal system, particularly trauma sequelae. Signs of overuse were present in 18% of the patients, mainly women, signs of misuse due to inappropriate or defective technique in 8.8%, and dystonia in 5.7%. Psychological problems were noted in 4 patients. More than one half of the patients had obtained medical advice prior to consulting an orthopedic surgeon and the very large majority had been referred by specialized physical therapists. A surgical procedure was proposed for only 19% of the patients presenting an orthopedic disorder.

DISCUSSION

This study presents a diversified panel of musicians consulting orthopedic surgery clinics. Practicing schedules varied in the study population from one to five hours daily. More than half the patients complained of pain but 18% consulted because they perceived a problem when playing and 17% consulted simply for advice. Our findings recall that musicians comprise a sensitive population requiring careful overall management. Unlike series published to date, we had a majority of men. Problems involving an orthopedic disorder or trauma and trauma sequelae predominated. In the literature, diagnosis has been oriented by the specialty of the consulting physician. We found that our patients who suffered from overuse had often recently changed their habitual practicing methods or conditions. The diagnosis of misuse was facilitated when the patient was examined with his/her instrument. The low rate of dystonic disorders was probably related to the fact that nearly half of our patients were followed regularly by a physical therapist. We did not observe any case of excessive laxity or Linburg Comstock syndrome which exceptionally have functional impact. The very large majority of our patients were referred by physical therapists and when surgery was necessary, the procedure was performed in accordance with accepted rules concerning the therapeutic management of musicians.

[Re-infection with a different strain after prosthesis revision for bacterial infection: 13 cases]

PURPOSE OF THE STUDY

Treatment of an infected arthroplasty is always a delicate task. Multidisciplinary management involving surgeons, clinicians, bacteriologists, and the patient may be long and not always successful. Rare re-infections caused by a bacterial strain different from the initial strain may be a cause of failure. We analyzed cases of re-infection with a different strain in search of an explanation.

MATERIAL AND METHODS

We reviewed 13 cases of re-infection in 12 patients with 7 hip and 5 knee arthroplasties. The causal germ had been clearly identified by the bacteriology laboratory during the first infection. The antibiotic regimens were confirmed by the medical team. All patients underwent surgery in our unit. At the time of the second infection, the implant had been removed, had been left in place, or had been changed. We recorded the new strains isolated and studied their antibiotic susceptibility profile. Treatment protocols and biological and functional results were analyzed.

RESULTS

A mean 27 months after the re-infection, clinical and biological success had been achieved in 7 cases. The failures more frequently corresponded to cases where the first infection was caused by an aggressive germ and where the second germ was found during reimplantation.

DISCUSSION

Theoretically a change in the causal germ could be explained by an insufficient initial biological analysis with an unrecognized or masked germ, by peroperative contamination subsequent to the difficulties observed in these hospitalized patients, and finally by secondary contamination. We recall the criteria of secondary infection (free interval, distant infectious focus, time sequence), measures taken to prevent peroperative infections, and conditions for optimal bacteriological sampling. If no resistance emerges after the first antibiotic treatment, there could nevertheless be a selection of conditions enabling growth of germs infrequently encountered. We stress that re-infection should not be considered necessarily as a failure of initial management but can, in certain cases, be considered as a de novo infection, and treated as such.