Biomedical subjects
T Ait Si Selmi
Publications and source records attributed to T Ait Si Selmi.
[Knee para-articular flexion and extension osteotomies in adults].
The present review analyzes the rare indications for sagittal knee osteotomies either for some complex cases of capsular and ligamentous laxities in combination with or without bony deformities in the sagittal plane. A thorough clinical and radiological analysis of the patients' knees is mandatory. We routinely recommend lateral standing X-rays to assess not only the bony structures, but also an abnormal knee laxity in the sagittal plane. We present different surgical options and preliminary results of these technically demanding procedures.
Anterior cruciate reconstruction combined with valgus upper tibial osteotomy: 12 years follow-up.
A retrospective review of 29 patients (30 knees) was carried out who had previously undergone a single-stage combined ACL reconstruction with valgus upper tibial osteotomy for chronic ACL rupture coupled with early medial tibio-femoral arthritis. Of the 30 knees, 19 (63%) had had a previous medial meniscectomy. Major complications occurred in two knees resulting in stiffness. At a mean of 12 years follow-up (6-16 years) only five knees (17%) had progressed one arthritis grade. Fourteen patients (47%) returned to intensive sports, and a further 11 (37%) played moderate sports. The mean difference in anterior tibial translation with the opposite normal knee was 3 mm at review. It was concluded that the combined operation has a low morbidity, controls anterior laxity, allows many patients to return to sports, and does not result in a rapid progression of osteoarthritis.
[Study of the patellar apex in objective patellar dislocation].
PURPOSE OF THE STUDY: The purpose of this work was to study the morphology of the patella in search of dysplasia typical of objective patellar dislocation. MATERIAL AND METHODS: One hundred forty patients (190 knees), 80 women and 60 men, who underwent surgery between 1988 and 1999 were included in this study. Mean age was 22.6 years (range 13-47). Patellar morphology was analyzed on the preoperative lateral x-rays (n=190) taken at 30 degrees flexion. The apex of the patella was measured as well as the length of the patellar tendon. The width of the patella was measured on the computed tomography scan (n=158). For 64 knees, magnetic resonance images of the patella were available on which the length and width of the patella, the articular surface, and the patellar tendon were measured. Ninety contralateral knees were symptom free and x-rays were available for 67. RESULTS: According to the Grelsamer classification, 80% of the patellae presented a normal apex. The length of the patellar apex was significantly shorter when the patellar ligament was longer. Using the Wiberg classification, men had more dysplasic patellae (grade C) (p=0.007). There was also a correlation between the Wiberg classification and the Maldague classification. The length of the medial border of the patella and the patellar angle were 2 factors directly related to the Wiberg classification. Mean width of the patella was 39.1 mm (computed tomography measurements). The mean length of the patellar tendon was 53.8 on the magnetic resonance images with a mean articular surface measuring 30.8 mm, a mean patellar length measuring 40.6 mm, and a mean width measuring 38.7 mm. There was no correlation between trochlear dysplasia and patellar morphology. DISCUSSION: There is little data in the literature concerning patellar morphology since Wiberg's work in 1941. The hypothesis of patellar dysplasia rather than trochlear dyplasia, the principal factor involved in objective patellar dislocation, has not been explored extensively. The presence of a hypoplasic medial border, Wiberg grade C, or a short patellar apex suggests that a particular patellar morphotype would be involved in objective patellar dislocation.
[Arthroscopic reconstruction of the anterior cruciate ligament].
PURPOSE OF THE STUDY: We report a retrospective series of 83 patients (86 knees) who underwent reconstruction surgery for chronic anterior knee laxity. The purpose of this study was to analyze mid-term results and assess prognosis factors. MATERIAL AND METHODS: All patients underwent artrhoscopic reconstruction of the anterior cruciate ligament using a central one-third patellar tendon graft. Full follow-up data were available for 51 patients (52 knees) and partial data for 24 others (25 knees). Eight patients (9 knees) were lost to follow-up. The IKDC criteria were used to analyze outcome at a mean 6 years post-surgery. RESULTS: Graft failure was observed in 5 knees and a graft tears after a new sprain was seen at 3 years. The patients were satisfied or very satisfied in 88.5% of the cases. The Trillat-Lachman test revealed a persistent dampened brake in 5 knees and a frank click in 4 (7.7%). Complete movement was recovered in all knees excepting 2 exhibiting persistent flexion. Residual laxity (active Lachman test) was 5 mm in 81.5% of the cases, between 6 and 10 mm in 17%, and greater than 10 mm in only 1 case (2.5%). IKDC scores were A=25%, B=50%, C=21% and D=4%. Forty-two patients (61%) returned to their sports activities and 9 of the 12 high-level athletes resumed competition at the same level as preoperatively. Arthroscopy enabled a well- or very well-positioned femoral tunnel in 88% of the cases, conditioning final IKDC outcome (p<0.02). There was a correlation between the meniscal status and residual laxity. DISCUSSION: This study demonstrated a high proportion (21%) of patients with an incomplete repair (21% IKDC class C) with a residual laxity greater than 5 mm and a late hard brake. Simple patellar tendon graft provided insufficient repair of the anterior cruciate ligament. The subjective outcome was better than the objective outcome since 88.5% of the patients were satisfied or very satisfied (patients seen at last follow-up or contacted by telephone). Good objective outcome was correlated with good femoral position of the transplant and preservation of the meniscus. Failures were explained by poor position of the transplant, long-standing laxity, and renewal of sports activities too early. CONCLUSION: Arthroscopic repair of the anterior cruciate ligament is a reliable procedure, but as failures are observed, indications should take into consideration the type of laxity and the status of the meniscus. For unique anterior laxity, the central one-third patellar tendon graft gives good results. For advanced anterior laxity, augmentation with an extra-articular lateral tenodesis would be necessary.
[Seventeen year outcome after anterior cruciate ligament reconstruction with a intact or repaired medial meniscus].
PURPOSE OF THE STUDY: Ten-year outcome of anterior cruciate ligament (ACL) reconstruction was previously reported (1992-1993) for 148 patients who had ACL free grafts associated with extra-articular tenodesis. In this retrospective study, we examined the functional and radiological changes observed 17 years after surgery in patients whose menisci were intact or repaired at ACL reconstruction (46 cases). These patients were operated on between 1978 and 1983. MATERIAL AND METHODS: Between January and April 1999, 28 patients were reviewed clinically and radiographically. Nine other patients responded to a questionnaire and three of them sent their x-rays. Two patients had died since the last review and 7 were lost to follow-up. Mean age at follow-up was 41 years. The IKDC classification was A 18.5%, B 51%, C 22.2%, D 7.4% in 26 patients reviewed with the passive radiological Lachman. At subjective analysis (n=37), 70% of the patients were very satisfied and 27% were satisfied. At radiological analysis (n=31), the AP or lateral single-limb stance views and the AP two-limb weight bearing views at 45% flexion demonstrated preosteoarthritis in 22% and osteoarthritis in 3%. Residual anterior tibial translation was the same at 11 years and 17 years follow-up. DISCUSSION: This study clearly demonstrates that ACL reconstruction associated with extra-articular tenodesis can provide good functional and radiological results at 17 years mean follow-up for patients with preserved (sound or sutured) menisci. The status of the medial meniscus at long-term follow-up appears to be the key feature determining the low rate of degenerative changes.
[Peroperative accidental contamination of bone-tendon-bone graft for the reconstruction of the anterior cruciate ligament. Report of 4 cases].
PURPOSE OF THE STUDY: The aim of this paper is to report the outcome in four patients in whom the graft (bone-patellar tendon-bone) was dropped onto the operating-room floor during anterior cruciate ligament reconstruction, and was then re-implanted after decontamination by topic antibiotic treatment. MATERIAL AND METHODS: Between 1992 and 1996, 1038 anterior cruciate ligament reconstructions were performed. In four cases, the bone-patellar-tendon-bone graft was dropped onto the operating theater floor. The graft was then soaked in rifamycin at a concentration of 0.8 mg/ml in normal saline for 10 mn, and soaked in gentamycin at 0.6 mg/ml for a further 10 mn. Finally, the graft was washed in physiological saline. All cases had been given a loading dose of second generation cephalosporin (cefamandole), after deflating the tourniquet. Post-operatively, the patients were given amoxicillin and clavulanic acid for 15 days. The patients were reviewed radiologically and clinically (IKDC form) with a mean follow-up of 24 months. RESULTS: Post operatively all patients had an uncomplicated recovery. No wound problems was observed in 3 of the four patients achieved an IKDC grade A knee. The final patient had a grade B, after 55 month follow-up. All patients recovered their initial sport level. The radiological Lachman test shows a mean differential value of 0.3 mm. DISCUSSION: Dropping the graft during ACL reconstruction is a very rare problem. In this event, the surgeon can choose several options: Harvesting an other site, sterilizing the graft by irradiation, autoclaving, ethylene oxyde..., or using a topical antibiotic treatment. Cooper showed, in an in vitro study that the contamination rate was halved by antibiotic soaking of the graft. CONCLUSION: We used a topic antibiotic treatment with success in all four cases. We feel warranted the implantation of a graft which has been dropped, and then antibiotic soaked. The patient should of course be informed and told to report any sign or symptom of infection. On the strength of this result, we would like to propose a decontamination protocol which can be used in this sort of incident, fortunately very rare.
[Total knee prosthesis and simultaneous corrective tibial osteotomy, for osteoarthritis and severe congenital tibia varum deformity].
INTRODUCTION: Restoration of the normal mechanical axis of the knee and balancing of the surrounding soft tissues have been shown to have an important bearing on the final outcome of total knee arthroplasty. In knees with severe congenital varum deformity these goals may be difficult to achieve. MATERIAL AND METHODS: In four patients with osteoarthritis and severe congenital knee varum deformity of more than 15 degrees, we performed a high tibial valgus osteotomy with opening wedge, combined during the same procedure with total knee arthroplasty. RESULTS: As correction of the extra-articular deformity was obtained by the osteotomy, in none of the cases it was necessary to perform extensive soft tissue release or advancement to restore alignment. Postoperative X-rays demonstrated restoration of the normal mechanical axis in three cases, but in one case the angular correction of the osteotomy was insufficient and we observed a 9 degrees residual varus deformity. DISCUSSION: The osteoarthritic knee must be mechanically realigned for any total knee arthroplasty to be successful in the long term. Most commonly angular deformities are manifestations of the arthritis process, but sometimes, like in congenital varus deformity of the tibia, part of the deformation can be extra-articular in origin. In these cases, restoring alignment and stability may be difficult to achieve. The association of high tibial valgus osteotomy with total knee arthroplasty permits the correction of the extra-articular deformity, by the osteotomy, without performing extensive soft tissue release, as would be needed in total knee arthroplasty alone. CONCLUSION: Total knee arthroplasty associated with high tibial valgus osteotomy seems to be a technically satisfying alternative in patients with osteoarthritis and severe congenital varus deformity of the tibia.