The Joint Belgian – Syrian Meeting With the collaboration of the Syrian Orthopaedic Association and the C.H.I.R.E.C. Orthopaedic Surgery Department "Current TRENDS IN ARTHROSCOPIC Surgery and SURGERY Of KNEE, HIP AND SHOULDER" - April 6-7, 2006
		ABSTRACTS - REPORTS
	Contribution of bone densitometry in the follow-up of THA Dr Jean-marie Baillon, MD. Dr Renaud Baillon, MD. Dr Eric Laurent, MD. Mini battle HTO vs UKA Dr M. Clemens, MD. Dr G. Merjaneh, MD. Mini battle HTO vs UKA Dr M. Collette, MD. Surgical treatment of bone tumors around the Knee in skelettally immature individuals Dr M. Gebhart, MD. How I fix my ACL grafts in children J. F. Huylebroek, MD. Post operative  analgesia after Total Knee Arthroplasty Fr. Lamesch, MD. Arthroscopic repair of rotator cuff tears: pros and cons Dr G. Merjaneh, MD. Painful non-traumatic knee in children Dr M. Peetres, MD. ACL reconstruction using double thickness hamstrings autografts Experience of 11 years Dr M. Clemens, MD. Dr G. Merjaneh, MD. Contribution of bone densitometry in the follow-up of THA   Dr. Jean-marie BAILLON ,MD, Dr. Renaud BAILLON ,MD. Dr. Eric LAURENT ,MD. 06/04/2006 Edleb Spring forum   Dept. of Orthopaedics, Clinique E. Cavell 1180 Brussels Dept. of Orthopaedics, CHU St Pierre, 322 rue Haute, 1000 Bxl      Dept. of Radio-Isotopes, CHIREC, 32 rue E. Cavell, 1180 Bxl   Dual-energy X-ray absorptiometry (DEXA) enables measurement of femoral bone mineralisation adjacent to a total hip arthroplasty (THA). ln a prospective study of 69 patients, we investigated the bone remodelling around a cementless anatomic stem coated proximally with hydroxyapatite. On each scan, the bone mineral density (BMD) was calculated for 7 regions of interest as described by Gruen et al. (1987). The results were plotted as percentage change in BMD over time relative to the similar controlateral regions of interest.   By 3 months after operation, patients showed a decrease in bone mineral density statistically significant in all regions with a maximum loss at the lateral cortex. At twelve months, we observed a general upward trend although the levels had not returned to controlateral values (except for the tip of the stem). Different behaviours were outlined according to sex and the implant's positioning. Finally, we compared the data from the DEXA to the bone scan which gave information on the bone turnover. Thanks to these investigations, we were able to determine the "normal" pattern of evolution relative to that anatomic stem.   At the present time, we are studying an identical stem without the collar, another anatomic stem with a distal centraliser and a totally different concept of THA. The behaviours of BMD will also be presented.   Further works are required to discover the correlation between changes in periprosthetic BMD and the long-term clinical results. Retour haut de page Mini battle HTO vs UKA   Dr M. Clemens, MD, Dr G.Merjaneh, MD, E.Cavell, Bruxelles 06/04/2006 Edleb Spring forum   From September  1999, to December 2005, we have performed 57 cases opening wedge osteotomy with minimum use of fluoroscopy.   We have encountered some problems with classical dome osteotomy:   1- Vicious callus, can make the placement of TKA very difficult 2- Non-union osteotomy of fibula, and some nerve problem 3- Higher risk of infection   We have also found similar problems with the closing wedge osteotomy, especially the risk of hypercorrection.   So, we have moved later on to perform for almost all cases, the opening wedge technique using the Puddu plate, which has many advantages comparing to other techniques:   1- Osteotomy of fibula is not required 2- The design of the plate avoid secondary subsidence 3- The reconstruction of the deformity is more anatomical 4- We can avoid the hypercorrection, because the angle is checked during the procedure   We have to be aware about the risk of patella baja if the opening wedge exceed 12.5 mm. Retour haut de page Mini battle HTO vs UKA   Dr M.Collette, MD, E. Cavell, Bruxelles 06/04/2006 Edleb Spring forum   The surgical treatment for a unicompartmental knee osteoarthritis (medial or lateral) has always been somewhat controversial.   Some surgeons would firmly recommend to do osteotomies whereas some other would definitely be in favour of unicompartmental knee arthroplasties . However,there has been a general agreement among surgeons to rather perform osteotomies among young people and athroplasties in elderly patients.   Considering the substantial improvements in orthopaedic supplies as well as in surgical techiques of knee arthoplasties during the last decade,there has been a tendency to extend arthroplasties indications and to lower down the age right to do an arthroplasty rather than an osteotomy.   The reasons for selecting either of these solutions are reviewed and discussed in order to clarify ,if possible, the best way of making this often difficult decision in the light of these recent technical progress. Retour haut de page SURGICAL TREATMENT OF BONE TUMORS AROUND THE KNEE IN SKELETTALLY IMMATURE INDIVIDUALS   M. GEBHART, M.D.   Jules Bordet Institute, Edith Cavell Institute Department of Orthopedic Surgery Free University of Brussels 06/04/2006 Edleb Spring forum    Bone sarcomas, such as classical osteosarcomas, Ewing’s sarcomas, although rare, arise often about the knee joint in pediatric or adolescent patients, whereas chondrosarcomas and other malignant tumors are encountered in a rather adult patient population. In the past, most of these tumors were treated by amputation. Since the 1970’s a great effort has been made to avoid amputation by performing limb sparing procedures.   This has been possible by the concomitant advent of more effective chemotherapy, by improved knowledge of tumor behavior, better tumor imaging and by the development of custom-made or modular massive prostheses or by the use of massive bone allografts. Limb sparing procedures became possible in adult patients, whereas in children none of these reconstructive procedures could be done because of small size and reduced diameter of bone leading to major limb length discrepancy and loosening of the prosthetic devices. Instead of amputation, Van Nes turniplasties have been largely performed in children with sarcomas around the knee. This operation consists of reusing the leg in order to obtain a limb lengthening amputation. After en-bloc tumor resection, the leg is turned around 180° and tibia is fixed to femur. This procedure has proven to be highly effective in terms of functional outcome, but more and more patients refuse this operation because of unacceptable esthetical results. Another more classic procedure is arthrodesis either by a turn-up, turn-down operation of femur and tibia or by interposition of vascularized or not vascularized fibula grafts. This leads to a stiff knee joint and major limping.   More recently, custom-made prostheses have been developed with a telescoping devise manipulated by mechanical lengthening using a screw driver. Expansion is obtained by multiple operations with a major risk of infection. On the other hand, expansion of the prosthesis is limited by soft tissues like muscles, vessels and nerves, so that rehabilitation is difficult after the prosthetic lengthening procedure. Another more recent prosthetic device avoids multiple reoperations by using an electromagnetic field heating up plastic rings contained within the prosthesis. The lengthening process is induced by melting a plastic ring while allowing a metallic spring to expand. The spring will push the telescopic device of the prosthesis. Again prosthetic expansion is brutal and rehabilitation may be difficult.   Another type of this prosthetic device is using an external magnet in order to action an intraprosthetic magnet: as a result there is a very slow growth of the expanding prosthesis. The telescopic element of the prosthesis is pushed very slowly by a cyclic movement of the magnet and growth is almost physiologic. No special rehabilitation is needed. Retour haut de page HOW I FIX MY ACL GRAFTS IN CHILDREN    J F HUYLEBROEK M.D. , Brussels Belgium  06/04/2006 Edleb Spring forum   ABSTRACT HOW I FIX MY ACL GRAFTS IN CHILDREN J F HUYLEBROEK M.D. Brussels Belgium INTERNATIONAL CONGRESS    “WHAT’S NEW IN KNEE SURGERY” CHIREC - BRUSSELS BELGIUM 18th of February 2006   The reconstruction of the ACL in children and adolescents presents its own problems. Should we delay the reconstruction to skeletal maturity? Epidemiology: increasing. Treatment of the ACL- insufficient knee in youngsters remains a dilemma: poor outcome against risk of growth perturbances.   Problems of correct diagnosis are discussed and some useful tips are explained to get a correct and faster diagnosis. The natural history is discussed according to the literature. Why is there a problem of partial tears in children and adolescents? The determinants of surgical decision and timing making are presented. Surgical treatment fears exist on the femoral side and on the tibial side. Different operative procedures and the respective pros and cons are discussed. Some data from the animal research can help us in determining the technique that we could use or work out. Why are the results in young athletes not as good as in our normal patient-population? The technique I’m using today is proposed: timing of the procedure, discussion with the parents: what can we promise?   Further:  graft choice, tunnel placement, fixation devices, XRay control, and navigation. Patient demographics and preliminary results, compared to the world literature, are presented. Some future directions are suggested: computer help, biochemical changes in ACL-injured children, better meta-analysis of the reported series. Retour haut de page POST OPERATIVE  ANALGESIA AFTER TOTAL KNEE ARTHROPLASTY   Fr.Lamesch M.D., Institut Médical Edith Cavell Bruxelles 06/04/2006 Edleb Spring forum      The goal of an effective post-operative analgesia after TKA is to have a pain free patient at rest and during physiotherapy. The best way to obtain such a result is to combine parenteral or enteral administration of different analgesic drugs with the use of regional anaesthetic techniques.   Non steroidal anti-inflammatory drugs should be associated to paracetamol and, if required, to more potent analgesics such as tramadol, codeine, tilidine...or even stronger opioids such as morphine, piritramide or equivalent.   They better will be given parenterally (LV.,LM. or P.C.A.) during the first 24 to 48 hours and then switched to an oral administration. That will give a satisfactory analgesia to the patient at rest and in the late post-operative period.   There is a great variety of regional anaesthetic techniques which can provide excellent post-operative analgesia. Spinal or epidural administration of local anaesthetics and/or opioids delivered on a single shot, continuous or P.C.A. mode is very effective but can be related to problematic side effects such as hypotension, urinary retention, bilateral motor blockade, pruritus, respiratory depression...   Lumbar plexus block or femoral nerve block and associated techniques ( 3 in 1 ) block, fascia iliac compartment block, are easy to perform and are probabIy the first choice techniques. They can be delivered on a single shot (which can be easiIy repeated), continuous or P.C.A.mode (more complicated and expensive) and they are related to very few side effects (motor blockade of the quadriceps muscle).   Sciatic nerve block can sometimes be required in case of heavy pain in the popliteal fossa. The introduction of a thin catheter ( eg. an epidural catheter) in the operated knee allowing the injection or perfusion of a local anaesthetic drug is very effective as well, but great care should be given to avoid infection.   Local ice application (cold-pack) is also a very helpful technique. One should adapt the analgesic strategy to the disponibility of the caring staff. lt should not represent an excessive overload in caring and supervision, complicated and time consuming procedures will lead to more complications and side effects and give a decrease in effectiveness. Economical factors are also to be taken in account for the choice of analgesic techniques, the more expensive ones are not necessariIy the better ones. The key to good post-operative analgesia is to combine the different techniques, giving priority to effectiveness, simplicity and safety.   My personal way to procede is to give peroperativeIy a spinal anaesthesia ( combined with a sedation or light general anaesthesia) to which a small dose of morphine is usually added, which gives a good analgesia at rest for the next 12 to 24 hours( anti – emetics are added) .   A femoral nerve block is performed at the end of the procedure and eventually repeated on the next day to permit a pain free physiotherapy. NSAIDs are given unless contraindicated and paracetamol combined to more potent drugs are administered on request. Retour haut de page Arthroscopic repair of rotator cuff tears: pros and cons     Dr G.Merjaneh, MD, E.Cavell, Bruxelles 06/04/2006 Edleb Spring forum     Introduction: Surgery of the rotator cuff is well known today. The open repair has shown reliable results in terms of pain relief and improved shoulder function. The development of arthroscopic techniques has given us a new approach to this pathology, and to treat it in a new way.   Material and methods: This technique is challenging and high demanding procedure with a steep learning curve for the surgeon, but much easier and less invasive for patients in terms of morbidity, pain and rehabilitation after surgery. More than 50% of surgical procedures performed are done by arthroscopy. However open rotator cuff repair has some inherent disadvantages. Detachment of the deltoid may result in significant morbidity. The open technique may require a long period of limited motion resulting in greater stiffness. Arthroscopically assisted mini-open repairs and, more recently, completely arthroscopic repairs of the rotator cuff have been developed and increasingly are being applied. Both techniques avoid detachment of deltoid. They have the added benefit of arthroscopic evaluation of the glenohumeral joint, and especially to estimate the quality and position of the long head of biceps tendon. It is also possible to have a good idea about the quality of the deep side ( inferior articular surface) of the suprspinatus and infraspinatus tendon.   Conclusion: The completely arthroscopic cuff repair has several potential advantages over the open and mini-open techniques, first is the decreased disruption of the soft tissues, which may result in less scarring and adhesions. This procedure is the most cosmetically appealing of the techniques. Reduced post operative pain is most likely but not yet proved. Finally, if technical difficulties arise, the conversion to a mini-open repair can be done easily. Now, in a few studies, arthroscopic cuff repair techniques have shown its efficacy and promise as an alternative to mini-open or open repair. But, these good results have been at the hands of a few surgeons who have extensive experience and advanced skills in arthroscopy of the shoulder. We still need long term studies to evaluate the real outcome of treatment and demonstrate its effectiveness. Retour haut de page   Painful non-traumatic knee in children   Dr Peetres M, E, Cavell Bruxelles 06/04/2006 Edleb Spring forum   Painful non-traumatic knee in children Pr Peetres M, E, Cavell Bruxelles   The growth process during childhood and sports activity lead to an increasing number of consultations for knee disorders. The consulting physician must make his diagnosis on the basis of an assessment of case history and a thorough clinical examination.   Well-selected complementary but limited examinations should enable him to determine whether the disorder is functional, inflammatory, tumoral or psychological origin.   Once the preliminary diagnosis has been made, further complementary examinations are then necessary to establish the definitive diagnosis.   In the majority of cases of pain associated with functional disorders, suspending sports activity and also some physiotherapy will result in the disappearance of the particular symptomatology.   ACL reconstruction using double thickness hamstrings autografts Experience of 11 years            Dr M.Clemens, Dr G.Merjaneh. E.Cavell,Bruxelles 06/04/2006:   Edleb Spring forum   We have performed  975 cases of ACL reconstructions using the hamstrings tendons (Gracilis and semitendinosus) from December 1994 till December 2005. We started with the Mitek anchor technique fixation and have been using for over 3 years in the beginning, before shifting to Transfix Arthrex technique fixation since 1998.   The major problem with the first technique is the fixation of the graft in both femoral and tibial sides. This kind of fixation is too distal and far from the graft on its articular side, which gives some bad mechanical effects. We may notice the windscreen wiper effect and the bungee effect. We have observed a significant tunnel widening only in 14% of cases, but no correlation have been noticed with the clinical results.   Some measurements have been taken to improve the technique in order to reduce the rate of tunnel widening: 1- We do use now drills with size that increases by 5 mm steps, just to match with graft diameter. 2- We have longer tibial interference screws called delta screw which goes till the level of tibial plateau, giving a cortico-cancellous bone interference fixation. Retour haut de page