The autologous osteochondral grafting represents a treatment option for osteochondral lesions of the weight bearing articular surfaces of femoral condyles and talus. The aim of our study was to evaluate the MRI findings and to determine the correlation between the radiological and the functional outcome in the early follow up.

We performed a retrospective study and followed up 33 patients 1 to 4 years after osteochondral auto-grafting. The grafts were harvested from the anterolateral region on the lateral femoral condyle of the ipsilateral knee using an insider rinsing diamond bone-cutting instrument (DBCS). The grafts were implanted using press fit technique and mosaic plasty.

Sixteen (48%) women and 17 men were included in our follow up with an average age of 38.4 years (age range-16 to 58 yrs). The Lysholm and Foot and Ankle Osteoarthritis Scores were used for the assessment of the functional outcome. MRI scans were performed by all patients.

While the MRI results illustrated graft incorporation, the cartilage contour interruption, irregularity of the subchondral lamina, inhomogeneity and subchondral oedema are typical findings between host and graft tissues. The clinical outcome demonstrated pain relief and improved function. There was no statistically significant correlation between radiological and functional outcome (p>0.05).

The MRI is a well-recognised non-invasive diagnostic tool to assess the integration of osteochondral grafts and to evaluate the articular surface but it has a reduced clinical significance on the early post operative stages. The long-term prognostic value of the unsatisfying MRI results is unknown.

The osteochondral defect in the knee and ankle joint is a difficult and common problem in young population. The bone-cartilage autologous grafting represents a recently introduced treatment option for osteochondral lesions of the weight bearing articular surfaces of femoral condyles and talus.

The aim of our study was to evaluate the MRI findings, and in particular to find out about the fate and the time needed for the graft incorporation, to assess the continuity, homogeneity and smoothness of the cartilage layer of the transplant compare to the remaining cartilage, to estimate the viability of the graft and to determine the correlation between the MRI findings and the functional outcome.

We performed a prospective study and followed up 33 patients, who underwent osteochondral autografting for defects in both medial and lateral femoral condyles as well as in the talus. The grafts were harvested from the anterolateral region of the ipsilateral knee using an insider rinsing diamond bone-cutting instrument (DBCS). The grafts were implanted using press fit technique.

16(48%) women and 17 men were included in our followup with an average age of 38.4 years (age range-16to58 yrs). There were 20(60%) osteochondral defects in the femoral condyles and 13 in the talus. 13(40%) patients gave a history of trauma. All the patients were followed up with MRI scans between 1 to 4 years postoperatively.

The MRI study illustrated a cartilage contour interruption by 16(48%) patients and 19(58%) had uneven joint surface. 9(27%) of the patients were shown to have homogeneity between the graft and the surrounding bone and cartilage tissues. A subchondral oedema was observed in 2(6%) of the cases. Only 1 patient had a subchondral bone-oedema in the graft-donor site. All the autologous grafts were incorporated by 4 years as proven by MRI scans

The MRI evaluation revealed regular incorporation of the osseous part of the graft in the subchondral bone. On the contrary, cartilage layer integration was less common. The MRI findings did not show any correlation to the clinical outcome. Hangody (2003) reports all grafts to incorporate into the recipient bed and most articular surfaces to have congruency and similar appearance to the surrounding articular cartilage and bone in 6 years.

Despite using very accurate harvested autologous osteochondral cylinders, which fit exactly the defects, match precisely the corresponding chondral and osseous layers and cause no immune reactions, it was shown in this short term MRI followup that the height and the shape of the original articular surface cannot be fully restored. However the relief of symptoms and improved functional outcome are promising findings and define bone cartilage autografting as a currently efficient treatment of osteochondral lesions of knee and talus.

Purpose of the study: The reversed total shoulder prosthesis is one of the treatments currently proposed for excentered glenoid osteoarthritic degeneration with massive rotator cuff tears. In light of the mediocre or at best highly variable results obtained with osteosynthesis or humeral arthroplasty for four-fragment fractures of the proximal humerus, indications for the reversed total shoulder prosthesis have been widened to include this category of traumatology patients. The purpose of this prospective study was to report outcome with the reversed prosthesis used for complex fracture of the proximal humerus in subjects aged over 70 years.

Material and methods: Ten patients, mean age 76 years, underwent surgery performed by the same surgeon to insert a Delta (DePuy) reversed prosthesis for four-fragment complex displaced fracture of the proximal humerus. The deltopectoral approach was used for all patients. The rotator cuff status was assessed intraoperatively. Clinical (Constant score) and radiological assessment were noted at 24 months.

Results: During the operation, only three of the ten shoulders presented a full thickness rotator cuff tear. One patients developed a complication requiring revision: early dislocation revised with a retaining polyethylene insert without recurrent dislocation. There were no cases of glenoid loosening at last follow-up. The weighted Constant score was 65/100. A pain-free shoulder was achieved in all ten patients. Anterior elevation was 130° on average, internal rotation reached hand to buttocks and active external rotation 20°.

Discussion: In patients aged over 70 years presenting a complex four-fragment fracture of the proximal humerus, the reversed prosthesis enables improved function and restoration of satisfactory joint movement. Early postoperative recovery and the gain in pain relief are encouraging factors. There was however unsatisfactory restoration of active rotation. For the elderly subject, free of a massive rotator cuff tear, rapid recovery after insertion of an reversed prosthesis should be balanced against the possible preservation of active rotations with an anatomic prosthesis.

Purpose: We present a new basilar osteotomy we have called TRADE. This osteotomy uses a single flat-oblique cut to achieve lateral basimetatarsal translation with lowering and derotation.

Material: The ATLAS system was used. This system includes a four point axial staple for the phalanx and a staple plate for the metatarsus. The staple plaque was designed around the tibial osteotomy plates. It is composed of a straight plate screwed to the diaphysis. It carries two spikes at variable angles that penetrate the epiphysis perpendicularly. The desired angle is measured peroperatively and the plate is bent appropriately using a graduated template. Application of the staple plate then imposes the exact correction.

Method: We tested the basal osteotomy on five anatomic hallux valgus specimens, including one fresh specimen. We also reviewed 125 files of patients who underwent double flat-oblique osteotomy fixed with the system. Each type of hallux valgus was defined pre- and postoperatively, clinically and radiologically: four views, three to determine the orientation of the deformity in the three planes and a fourth one to assess reducibility. The operative technique involved four times. The first was often not necessary: lateral release, depending on the degree of retraction on the reduction view. The second time, the medial chevron osteotomy of the first phalanx, was almost always needed. The third time was the basimetatarsal ostetomy; the flat-oblique direction was determined from an abacus taking into account three variables: varus, rotation, lowering. The fourth time, exostosectomy with capsule retention, was not always needed. The patients experienced little pain postoperatively when the procedure was limited to the two osteotomies without affecting the soft tissues. For the 125 cases, intermetatarsal deviation was improved from 18°67 to 6°86, metatarsophalangeal angle from 33°59 to 11° and pronation from 13°42 to 0°72.

Conclusion: The TRADE osteotomy allows correction in all three planes. Correction is particularly precise in the frontal plane where the risk of undercorrection and recurrence is high. The procedure can be modulated according to the radiological presentation and can be limited to two osteotomies using short skin incisions without opening the joint.

Purpose: All displacements can be described with x, y, z coordinates. We propose an anterior view of the first metatarsal associated with a peroperative test to determine the precise position in the frontal plane, both statically and dynamically. Lateral release is an important step in surgical treatment of hallux valgus. Both the extent of release and the potential benefit of no release must be carefully evaluated. We propose a view allowing an assessment of the metatarsophalangeal reducibility.

Material and method: Peroperative test. This test explores cuneometatarsal laxity. We conducted a prospective study in 100 cases. A 12/100 pin was used to immobilise the first cuneiform and a 20/100 pin was placed in the base of the first metatarsal. A third distal pin in the neck was used to pivot the bone on its axis. A small protractor was used to measure the angle by projection with ±2.5° precision.

Modified Guntz view. This is a weight-bearing anterior view of the first metatarsal. The cassette is positioned posteriorly. The patient stands with the heal raised 40 mm on a 20mmx20mm plexiglass bar. The metatarsal diaphysis must appear perfectly vertical. An isosceles triangle is constructed on the articular facets; the base of the triangle is perfectly horizontal and defines the pronation-supination angle. We made 100 measurements and checked correlation with the peroperative test.

Reduction view. A Zimmer brace was used to reduce the varus metatarsus and adduct the toe. The metatarsophalangeal angle and the position of the sesamoids were used to assess reducibility.

Results: Pronation and/or pronation instability was = 10° in 96% of the patients. The reduction view enabled classifiation by three grades of reducibility.

Discussion: Our contribution is determining for correction of displacements taking into account the frontal plane. No other study has shown so clearly the existence of metatarsal pronation. We also confirmed the presence of a large proportion of cuneometatarsal instability. The extent of lateral release or the potential benefit of no release can now be assessed.

Conclusion: A certain number of failures have undoubtedly been related to neglect of the parameters studied here. It is indispensable to explore the frontal plane and the dynamic parameters before establishing indications for new flat-oblique metatarsal osteotomies using conventional or minimally invasive techniques.