Aims

The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness.

Abstract

Introduction: Femoroacetabular Impingement had been until now an unknown pathology. It causes pain in the movements of flexion-adduction-internal rotation, due to a bump effect between the head-neck surface of the femur and the anterior acetabular rim.

Material and Method: We analysed our 14 first patients, 3 operated bilaterally with 1 year F.U.. In bilateral cases, the time between both operations ranged from 5 to 8 weeks. Mean Age: 36 years (27 to 48), all sports active patients.. The technique that we used was through our modified Hueter approach . The superoanterior rim of the acetabulum was excised as well as the deformity at the femoral side that causes a less femoral neck-offset. For that purpose we used special maxilofacial-reamers instead of chisels. In this way we avoid any bleeding from the femoral neck. With this technique we avoid a Trochanter osteotomy, as performed by other authors (Ganz, Trousdale) .

Results: Pain relief was obtained 4 weeks after surgery in 13 from 14 patients. Mean hospitalization time was 2,6 days (2 to 5). Improvement in ROM was significative (p= 0,006): from −17 mean internal rotation (−14 to −28) at 80 flexion to +23 mean one month postop internal rotation (14 to 32).There was a significant improvement of hip score according to Merle d’Aubigne evaluation (p=0,017): 13,8 points preop (13 to 15) to 16,9 at F.U. (16–18). Neither Trendelemburg nor osteonecrosis was observed in any patient, as possible complications related to the approach. Mean time of rehabilitation was 3,8 weeks ( 3 to 5). All patients returned to their respective sports activities

Discussion: The Modified Femoroacetabular Osteoplasty allows rapid improvement of the normal hip motion , relatively short rehabilitation time and sports resumption as well. However midterm new osteoarthritic changes had to be assessed, although clinical and functional improvement has been evident. This surgical procedure makes us think about other alternatives to hip endoprosthesis in young adults.

Introduction: knee revision in absence of Extensor Mechanism has been always a challenging problem in Orthopaedics. Many authors are in favour to abandone any endoprosthetic substitution in front of such a situation.

We think osteotendinous allografts, in this particular case whole Extensor Mechanism allografts, could play an essential role before any Knee Arthrodesis.

Material and Method: From 1999 up to 2004 11 patients (4 male, 7 female) (mean age 72, range 68 to 86) underwent to a whole Extensor Mechanism allografting procedure. Mean follow up was 2.7 years (1 to 5 years).

In the first four cases a whole Extensor Mechanism allograft was implanted, while the next seven cases the allograft was reinforced by means of a Leeds-Keio Dacron band.

Results: There was no infections in this serie. The mean obtained R.O.M. in the first three months was – 5 of active extension (range 0 to −15) and 95 active flexion (range 80 – 110). However 3 from the 4 former operated cases had a progressive loss of active extension up to −25 (range −20 to −35) at 18 months, that did not increase after this period. Ultrasonic exams showed a lengthening of the patellar tendon in these cases. None of these 3 patients wished to undergo to a patellar tendon reinforcement.

On the other hand those later cases, where patellar tendon was reinforced did not show any change over the time (at 18 months mean active extension was maintained to −5 (range 0 to 15)

Conclusions: Extensor mechanism allografts are very useful in difficult knee revisions with absence of extensor mechanism, so that knee arthrodesis is not the method of choice for these patients. However augmentation of patellar tendon is necessary to maintain with the years an active extension.

Introduction: Chiari osteotomy with capsuloplasty is an acetabulum-widening osteotomy which makes it possible to substantially correct dysplastic hips. This paper presents an overview of the results obtained after 25 years.

Materials and methods: Between 1983 and 2002, 127 Chiari osteotomies were carried out. 103 were revised (59 women, 40 men , 4 bilateral). Mean follow up: 11.2 years (range: 1 to 20 years). The endpoints were: operative time, VCA angles, acetabular inclination, pre-post-follow up CE angle, Merle d’Aubigne score, preop and postop Ahlbach score.

Results: Operative time: 1h 42′ (range: 57′ – 3h 10′). Ahlbach I – 26, II – 59, III – 18, IV – 0. Associated operations: Femoral osteotomy 77, varus-derotation osteotomy 36, Reconversion 31, Trochanteric retensioning. M 69. Angles measurement: preop: CE 5° (−34°−25°), VCA 18° (7°–26°), Tönnis 56° (43°–61°). Postop: CE 34° (10°–55°), VCA 31° (26°–39°), Tönnis 40° (38°–44°). Mean increase in acetabular inclination:16°. Merle d’Aubigné: preop 14.3(7–17), Follow-up 16.2(12–18). Excellent-good results 89(86.4%), Fair-poor results 14(14.6%) 2 went on to THA; Mean osteotomy displacement 26 mms (18–39). Invariability Ahlbach changes: If preop I 24/26(92.3%), if preop II 42/59(71.2%), if preop III 5 /18 (27.7%). Survival rate: 81.76% after 10 years.

Discussion and conclusions: Long term results seem satisfactory, with a survival rate of 81.76% after 10 years. This is a technique of choice in dysplasias with a new cup and in non-congruent hips, generally associated to a femoral osteotomy (77/103). It is crucial to perform the preop planning using Pawels test.