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Ruptures of the quadriceps tendon (QT) are rare but serious injuries accounting for less than 2% of all tendon injuries around the knee. These injuries, often occurring in individuals over 40, are leading to a loss of active extension and a significant impact on knee function. While the treatment of acute QT ruptures through various reinsertion techniques has shown excellent outcomes, managing chronic injuries and failed primary repairs remains challenging due to tendon retraction and difficulties in repositioning the tendon stump. This study introduces a novel approach associating direct tendon reinsertion with metal frame reinforcement, aiming to effectively lower the retracted tendon to the proximal pole of the patella. This technique offers a promising alternative that addresses the limitations of traditional methods and potentially improves patient outcomes by providing a safe primary fixation and protection of the repair, enabling early rehabilitation and reducing the need for subsequent interventions. LEVEL OF EVIDENCE: IV; case series study., Competing Interests: Declaration of competing interest Dr Fayard is consultant for Arthrex and New Clip Technics, he has royalties from New Clip Technics and XNOV. Dr Sébastien Parratte is consultant for Zimmer Biomet, he has royalties from Zimmer Biomet and NewClip Technics, he is board member of European Knee Society., (Copyright © 2024. Published by Elsevier Masson SAS.)

Background: Porous tantalum components and augments have demonstrated short to midterm fixation stability in acetabular total hip arthroplasty (THA) revision but do not offer a novel option to decrease the postoperative dislocation rate. Recently, dual mobility (DM) cups have gained interest to decrease the prevalence of recurrent hip instability after revision hip arthroplasty, but this issue was not confirmed combined with use of tantalum reconstruction devices. Therefore, we did a retrospective study aiming to: (1) evaluate at a 5-year minimum follow-up period the dislocation rate (and other intra- and postoperative complications), (2) assess radiographic results specifically looking at osseointegration and restoration of the hip center, (3) and also clinical results in a cohort of patients who underwent complex acetabular reconstruction with trabecular metal revision components associated with a cemented DM socket., Hypothesis: Using a DM socket cemented in porous tantalum components can reach the low risk of hip dislocation reported with DM components in revision setting without increasing the risk of a mechanical failure., Methods: A cross-sectional study identified 174 THA revision including an acetabular revision. Were excluded 118 revisions with acetabular defects Type 1, 2a or 2B according to Paprosky's classification, as well as 18 hips revised without a dual mobility and 3 patients (3 hips) lost to follow-up. Were thus included in this study 35 hips (35 patients) implanted with uncemented total hip arthroplasty revision using both trabecular metal acetabular cup-cage reconstruction and a cemented DM cup. Seven hips were classified Paprosky types 2C, 15 type 3A and 13 types 3B. Patients were followed with clinical and radiological evaluation regarding dislocation rate, infection, reoperation or re-revision, osseointegration and restoration of the hip center, and functional results according to the Harris hip score and psoas impingement presence., Results: At a mean follow-up of 8.1±1.8 years (5.1-12.6), one dislocation was recorded, and one acute deep infection. No patient required a cup re-revision for septic or aseptic loosening. The survivorship at 8years regarding revision for any cause as an endpoint was 96.5% (CI95%: 92-99). Osseointegration of TM implants was analyzed and found no acetabular migration at the last follow-up in the cohort. The mean hip center position was optimized from 48±7mm (37-58) to 34±5mm (29-39) vertically and from 26±5mm (-18-36) to 24±8mm (7-31) horizontally without reaching significance (p=0.1). On the last follow-up X-rays, the mean acetabular inclination was 47̊±9̊ (32̊-61̊). According to the criteria of Hirakawa, 97.1% (34/35) of the hip centers were restored. One cup (2.9%) was more than 5mm proximally from the hip center, and none more than 10mm. Clinical results assessed a Harris Hip Score improved from 36±17 (23-62) preoperatively to 82±15 (69-93) at last follow-up (p<0.0001). Two patients (2/35, 5.7%) complained of psoas impingement., Conclusion: This study suggests effectiveness of DM cups in association with a tantalum-made acetabular shell for reconstruction of large bone defect in THRs for both solving postoperative instability and aseptic loosening without increasing the re-revision rate for any reason in a midterm follow-up., Level of Evidence: IV; observational study., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: Return to sport after Knee Arthroplasty has been investigated reporting modifications in the physical activities with a trend towards to lower impact sports after Unicompartemental Knee Arthroplasty. The purpose of this study was to analyze the return to sport level after medial unicompartmental knee arthroplasty (MUKA) in a population of osteoarthritic patients having practiced impact sport, defined with a University of California at Los Angeles activity scale (UCLA)≥9 in their pre-symptomatic arthritic period., Hypothesis: Return to an impact sport after MUKA was possible for a population of osteoarthritic patients having practiced impact sport in their pre-symptomatic arthritic period., Methods: Ninety-two MUKA with a pre-symptomatic arthritic UCLA score≥9, including 60 men (65.2%) and operated between January 2009 and September 2014, were evaluated by a dedicated survey. Informations were obtained concerning the physical activities (intensity, frequency, kind of sport, reasons to decrease or stop the physical activities in the pre- and the postoperative period). The average age was 64.9 years±6.4 (range 49-74.4). Three different periods were compared: pre-symptomatic arthritic, preoperative and postoperative period. The mean follow-up was 7.3±1.7 years., Results: The mean pre-symptomatic arthritic UCLA score was 9.9±0.3, the mean preoperative UCLA score was 7.0±2.5 (2-10) and the mean postoperative UCLA score was 7.2±2.0 (3-10). There were significant differences for the mean UCLA score values between pre-symptomatic arthritis and postoperative UCLA scores (p=0.034), however no difference was detected in mean score values before and after surgery (p=0.09). Only 32.6% (30/92) of patients had a postoperative UCLA score≥9. For patients practicing an impact sport activity (UCLA≥9) in the preoperative period (23/92; 25%), the postoperative UCLA score was at 8±1.1 (range 4-10). In this subgroup, 47.8% (11/23) of patients had a postoperative UCLA score≥9. The decline in sports in postoperative was predominantly explained by residual pain of the operated knee (31/92; 34%), precaution to not damage the prosthesis (25/92; 27%) and restrictions due to another joint (19/92; 21%)., Discussion: Return to impact sport after MUKA seems to be limited to a restrained number of patients. The main reasons to the decline in sporting activity level are linked to the residual pain of the operated knee and the precaution to not damage the prosthesis., Level of Evidence: IV, retrospective cohort study., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: Dislocation is one of the leading causes for early revision surgery after total hip arthroplasty (THA). To address this problem, the dual mobility (DM) cup was developed in the 1970s by the French. Despite the increased and, in some countries, broad use of DM cups, high quality evidence of their effectiveness compared to traditional unipolar (UP) cups is lacking. There are a few well-conducted literature reviews, but the level of evidence of the included studies was moderate to low and the rates of revision were not specifically investigated. Therefore, we did a systematic review to investigate whether there is a difference in the rate of dislocations and revisions after primary THA with a DM cup or a UP cup., Methods: We conducted a systematic literature search in PubMed, Embase and Cochrane databases in July 2019. The articles were selected based upon their quality, relevance and measurement of the predictive factor. We used the MINORS criteria to determine the methodological quality of all studies., Results: The initial search resulted in 702 citations. After application of the inclusion and exclusion criteria, eight articles met our eligibility criteria and were graded. Included studies were of medium to low methodological quality with a mean score of 14/24 (11-16) points following the MINORS criteria. In the case-control studies, a total of 549 DM cups and 649 UP cups were included. In the registry studies, a total of 5.935 DM cups and 217.362 UP cups were included. In the case-control studies, one (0.2%) dislocation was reported for the DM cups and 46 (7.1%) for the UP cup (p=0.009, IQR=0.00-7.00). Nine (1.6%) revisions, of which zero due to dislocation, were reported for the DM cup and 39 (6.0%), of which 30 due to dislocation, for the UP cup (p=0.046, CI=-16.93-5.73). In the registry studies 161 (2.7%) revisions were reported for the DM cup, of which 14 (8.7%) due to dislocation. For the UP cup, 3.332 (1.5%) revisions were reported (p=0.275, IQR=41.00-866.25), of which 1.093 (32.8%) due to dislocation (p=0.050, IQR=3.50-293.25)., Conclusion: This review suggests lower rates of dislocation and lower rates of revision for dislocation in favor of the DM cups. Concluding, DM cups might be an effective solution to reduce dislocation in primary THA. To evaluate the efficacy of DM cups compared to UP cups, an economic evaluation alongside a randomized controlled trial is needed focusing on patient important endpoints., Level of Evidence: III, systematic review of level III studies., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Non-operative treatment for impacted femoral neck fractures is a now rarely used strategy whose indications are controversial. No outcome predictors have been convincingly identified, in part due to the small sizes of available studies. We conducted a large retrospective study with the following objectives: (1) to evaluate the percentage of patients older than 65 years of age with non-operatively treated Garden I femoral neck fractures who experience secondary displacement, (2) to identify predictors of secondary displacement, and (3) to determine the frequency of non-operative treatment failure due to any cause and requiring joint replacement surgery., Hypothesis: Non-operative treatment is reliable in patients older than 65 years of age with Garden I femoral neck fractures., Material and Methods: Approval was obtained from the French data protection authority to conduct a retrospective observational study of information in the Marseille university hospitals database. Consecutive patients who were older than 65 years of age at traumatology department admission for Garden I femoral neck fractures managed non-operatively between January 2007 and December 2017 were included. Non-operative treatment consisted in a walking test on day 1 followed by radiographs on days 2, 7, 14, 21, and 45 and after 3 and 12 months. Patients with secondary displacement underwent hip arthroplasty. Demographic data, cognitive performance, and radiological parameters were collected for each patient. We evaluated the rates of secondary displacement avascular necrosis, and non-union., Results: We included 298 patients with a mean age of 82 years (range, 65-101). Mean follow-up was 5±3 years. Secondary displacement occurred in 91 (30%) patients, at a mean of 16 days (range 2-45 days) after the fracture. Avascular necrosis of the femoral head developed in 13 (4.3%) patients and non-union in 11 (3.7%) patients. Secondary displacement was significantly associated with hypnotic treatment (OR, 4.1; 95%CI, 2.2-7.5; p=0.039), institutionalisation (OR, 6.7; 95%CI, 3.1-14.8; p=0.028), a history of repeated falls (OR, 13.5; 95%CI, 6.3-8.4; p<0.0001), having three or more comorbidities (OR, 3.2; 95%CI, 1.7-5.8; p=0.046), and having dementia (OR, 3.5; 95%CI, 1.7-6.9; p=0.0003). Secondary displacement occurred in 18 (12%) of the 151 community-dwelling patients with normal cognition and no history of repeated falls compared to 37 (75%) of the 50 institutionalised patients with dementia., Discussion: Non-operative treatment was effective in 196 (66%) of 298 patients with Garden I femoral neck fractures. Significant risk factors for secondary displacement were dementia, institutionalisation, hypnotic treatment, multiple comorbidities, and a history of repeated falls. Of 151 community-dwelling patients with normal cognition and no repeated falls, 133 (88%) achieved a full recovery with non-operative treatment alone., Level of Evidence: IV, retrospective cohort study., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: Recent reports described possible mechanical factors in the development and aggravation of osteonecrosis of the femoral head (OFH), but these have yet to be confirmed on dedicated mechanical study. We therefore developed a 3D finite element model based on in-vivo data from patients with incipient OFH, with a view to determining whether the necrosis area was superimposed on the maximal stress area on the femoral head., Hypothesis: The location of the necrosis area is determined by stress on the femoral head., Material and Method: All patients from the rheumatology department with early stage OFH in our center were investigated. Analysis of CT scans showed stress distribution on the head by 3D finite elements models, enabling determination of necrosis volume within the maximal stress area and of the percentage intersection of necrosis within the stress area (%I n/s: necrosis volume in stress area divided by total stress area volume and multiplied by 100) and of stress within the necrosis area (%I s/n: stress volume in necrosis area divided by total necrosis area volume and multiplied by 100)., Results: Nineteen of the 161 patients assessed retrospectively for the period between 2006 and 2015 had incipient unilateral OFH, 10 of whom (4 right, 6 left) had CT scans of sufficient quality for inclusion. Mean age was 52 years (range, 37-81 years). Mean maximal stress was 1.63MPa, mean maximal exported stress volume was 2,236.9 mm 3 and mean necrosis volume 6,291.1 mm 3 . Mean %I n/s was 83% and mean %I s/n 35%, with no significant differences according to gender, age, side or stress volume. There was a strong inverse correlation between necrosis volume and %I s/n (R 2 =-0.92) and a strong direct correlation between exported stress volume and %I s/n (R 2 =0.55). %I s/n was greater in small necrosis (<7,000mm 3 )., Conclusion: OFH seems to develop within the maximal stress area on the femoral head. The present results need confirmation by larger-scale studies. We consider it essential to take account of these mechanical parameters to reduce failure rates in conservative treatment of OFH., Level of Evidence: IV., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: Links between sagittal spinal alignment and acetabular orientation attract considerable research attention with the goal of optimising prosthetic cup position. However, whether pelvic incidence (PI) is related to anatomic acetabular orientation remains unknown. We therefore conducted a radiological study with the following objectives: to look for correlations between PI and anatomic acetabular parameters; to describe the sacro-pubic angle (SPA), defined by fixed bony pelvic landmarks, and its relations with acetabular anteversion; and to determine whether anatomical parameters (PI and SPA) correlate with demographic characteristics., Hypothesis: PI correlates with anatomical acetabular parameters., Materials and Methods: We conducted a computed tomography (CT) study of the pelvises of 150 patients free of degenerative disease. Three parameters were measured: anatomic acetabular orientation in the Lewinnek reference plane, PI, and the SPA subtended by the line connecting the midpoint of the sacral endplate to the pubic symphysis and the anterior pelvic plane. Statistical tests were performed to look for correlations among these parameters., Results: Intra-observer and inter-observer reproducibility was considered highly satisfactory (inter-class correlation coefficient, >86% and >82%, respectively). Mean PI was 58.6°±10.2° (range, 32.8°-97.6°), with no significant differences between genders or across age groups. Mean SPA was 34.7°±5.5° (range, 18.3°-49.8°). Mean anatomic acetabular anteversion (AAA) was greater in females (23.4°; range, 11.5°-34.5°) than in males (20°; range, 7.5°-34.5°) (P<0.001). PI did not correlate with any of the acetabular parameters (PI/AAA, r=0.8 and P=0.33; PI/acetabular inclination on the horizontal, r=-0.96 and P=0.24). SPA correlated significantly with both PI (r=0.33 and P<0.001) and AAA (r=0.33 and P<0.001)., Discussion: This CT study of normal pelvises showed that AAA was significantly greater in females and that SPA correlated significantly with both PI and acetabular anteversion. SPA could serve to define the "theoretical" AAA of each individual patient and could thus be incorporated into surgical planning protocols or intra-operative guidance methods for hip replacement surgery., Level of Evidence: IV, retrospective study with no control group., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Introduction: The incidence of periprosthetic femoral fracture is constantly increasing, with high associated morbidity and mortality. Surgical treatment is guided by the Vancouver classification, but the influence of type of treatment on morbidity and mortality has been little analyzed. The theoretical advantage of implant revision over internal fixation is that it should allow earlier weight-bearing, although the impact of this on morbidity and mortality and autonomy has not been demonstrated. We conducted a case-control study, to assess the influence of type of treatment (implant revision or internal fixation) (1) on mobility and autonomy and (2) on morbidity and mortality., Hypothesis: The study hypothesis was that clinical results and morbidity and mortality do not differ between these two types of treatment., Methods: A retrospective study included 70 patients with a total of 71 femoral periprosthetic fractures treated between 2007 and 2014. Two treatment groups, comparable for mean age, gender and ASA and Parker scores, were studied. Mean age was 78±13.5years (range, 23-95years). Thirty-six fractures (50.7%) were treated by implant revision via a posterolateral approach, using a revision stem with (n=11) or without cement (n=25) (REVISION group); immediate postoperative weight-bearing was authorized. Thirty-five fractures (49.3%) were treated by open reduction and internal fixation, using a locking plate (ORIF group); weight-bearing was authorized only in the third month. Mean follow-up was 43±27months (range, 0.75-107months)., Results: Autonomy on Parker score was reduced by 2 points at 1year's follow-up. Mean preoperative scores were 7.32±1.79 (range, 3-9) and 7.43±1.79 (range, 4-9) in the REVISION and ORIF group, respectively, (p=0.8), falling to 5.06±2.6 (range, 0-9) and 4.5±2.01 (range, 0-9) respectively at follow-up (p=0.349). Sixteen patients in the REVISION group versus 13 in the ORIF group had made adaptations in their home or changed place of residence (p=0.2). At last follow-up, 18 patients (28.6%) had died: 12 (37.5%) in the ORIF and 6 (19.3%) in the REVISION group (p<0.05). Survival with death as endpoint at a mean 3.5years was 88±11% in the REVISION group versus 51±11% in the ORIF group (p=0.02). Three implant replacements were performed in each group (p=0.83). Twelve medical or surgical complications occurred in the ORIF group (37.5%) and 11 in the REVISION group (34%) (p=0.9)., Conclusion: Implant revision for periprosthetic femoral fracture showed significantly lower overall mortality than internal fixation, without difference in terms of treatment failure or complications requiring revision surgery., Level of Evidence: Level III, case-control study., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background: Previous surgical procedures raise technical challenges in performing total knee arthroplasty (TKA) and may affect TKA outcomes. Survival rates of TKA done after trauma or surgery to the knee have not been accurately determined in large populations. The objectives of this retrospective study in 263 patients with TKA after knee trauma or surgery and a follow-up of 10 years were to assess survival, functional outcomes, and the nature and frequency of complications., Hypothesis: Knee trauma or surgery before TKA increases the risk of complications and decreases implant survival., Material and Methods: Two hundred and sixty-three patients (122 [47%] females and 141 [53%] males) underwent TKA between 2005 and 2009 at nine centres in France. Mean age at surgery was 61 years. The patients had knee osteoarthritis secondary to a fracture (n=66), osteotomy (n=131), or ligament injury (n=66). Mean time from trauma or surgery to TKA was 145 months (range, 72-219 months)., Results: Major complications were infection (n=12, 4.5%), skin problems (n=8, 3%), and stiffness (n=8, 3%). Ten-year survival to implant exchange for any reason was 89%±2.8%. Flexion range increased by 2.5°±17° (p=0.02) to a mean of 110° (range, 30° to 140°); extension range increased by 4°±7° (p<0.001) to a mean of -1.19 (range, -20° to 0°). Of the 263 patients, 157 (60%) reported little or no pain at last follow-up. Mean postoperative hip-knee-ankle angle was 179°±3.2° (range, 171°-188°)., Conclusion: TKA performed after knee injury or surgery carries a risk of specific complications (infection, skin problems, and stiffness) and may have a lower survival rate compared to primary TKA., Level of Evidence: IV, retrospective cohort study., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: Kinematic (KA) and mechanical (MA) alignment techniques are two different philosophies of implant positioning that use the same TKA implants. This might generate differences in the resulting prosthetic trochleae parameters between the two techniques of alignment. Our study aim was to test the following hypotheses : (1) mechanically or kinematically aligned femoral implant understuffs the native trochlear articular surface and poorly restores the native groove orientation, and (2) the orientation of the prosthetic trochlear groove and trochlear fill are different between MA and KA., Methods: Three-dimensional models of the femur were made from segmentation of preoperative Magnetic Resonance Imaging scans (MRIs) of ten subjects with isolated medial tibiofemoral osteoarthritis. In-house planning and analysis software kinematically and mechanically aligned a modern cruciate retaining femoral component and determined differences in parameters of the trochlear fit between native and prosthetic trochleae, and between KA and MA prosthetic trochleae., Results: The MA prosthetic trochleae did not fill (understuffed) the entire length of the native medial facet and the proximal 70% of the native groove and lateral facet, and oriented the trochleae groove 8° more valgus than native. The KA prosthetic trochleae understuffed the proximal 70% of the native trochleae, and had a groove 6° more valgus than native. The KA trochleae understuffed the medial facet distally and oriented the groove 2° less valgus and 3° more internally rotated than the MA trochleae., Conclusion: MA and KA prosthetic trochleae substantially understuff and create a prosthetic groove more valgus compared to native trochlear anatomy, and they also differed between each other regarding trochleae stuffing and groove alignment. Although randomized trials have not shown differences in patellofemoral complications between KA and MA, a femoral component designed specifically for KA that more closely restores the native trochlear anatomy might improve patient reported satisfaction and function., Level of Evidence: Level 2 controlled laboratory study., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Introduction: High tibial osteotomy (HTO) is effective in treating isolated medial osteoarthritis of the knee, but subsequent deterioration is inevitable, and total knee arthroplasty (TKA) is then an option. The present study sought to compare TKA following medial opening-wedge HTO (OW-HTO) versus lateral closing-wedge HTO (CW-HTO) in terms of intraoperative data and clinical results. The study hypothesis was that there is no significant difference in clinical results or complications in TKA following OW-HTO or CW-HTO., Material and Method: A retrospective multicenter (9 centers) study was conducted for the French Society of Orthopedic Surgery and Traumatology (SoFCOT), including 135 TKAs following HTO (58 OW and 77 CW) at a minimum 5 years' follow-up. Mean interval between HTO and TKA was 134 months and was longer in case of CW-HTO (P<0.0001). Mean age at TKA was 65.4 years and older in case of CW-HTO (P=0.021). Tibial slope was greater in case of OW-HTO (P=0.024). Prior to TKA, 55.7% of patients could walk without canes, 98.4% found stairs difficult or impossible and only 19.1% could manage a walking distance greater than 1000m. Mean flexion was 110°; 54.2% of patients showed frontal knee stability and 87.8% sagittal stability; 60.1% had a mechanical axis in varus, without difference according to OW- or CW-HTO., Results: Hardware was almost systematically removed (in 98.5% of cases): in the same step for OW-HTO (P=0.018) or often in 2 steps for CW-HTO. The primary approach was generally re-used (54.2%), but less frequently in the CW-HTO group (P=0.0004). Lateral or medial ligament release was not associated in respectively 78.2% and 79.7% of cases. The TKA implant was usually without stem (87.2%) and was fitted using a conventional technique (74.4%). At a mean 87 months' follow-up, 78.5% of patients could walk without canes, stairs were still difficult or impossible for 67%, and 74.1% could now walk further than 1000m; mean flexion was 110.5°. Overall, 91.5% of patients showed frontal knee stability and 98.2% sagittal stability, without difference according to OW- or CW-HTO. There were 15 complications within 3 months, more often in the OW-HTO group (12.3%) although not significantly, and with no difference in severity. Late complications comprised loosening (5.5%) and infection (3.6%) and were more frequent in the CW-HTO group (12%) (P<0.05)., Discussion: The study hypothesis was partially confirmed. The only technical differences concerned hardware removal, often performed in two steps in case of CW-HTO, and TKA approach, which differed from the primary approach in case of CW-HTO. Clinical results were comparable between OW- and CW-HTO, but late complications were more frequent in the CW-HTO group., Level of Evidence: III; comparative retrospective study., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Objective: Intraarticular or periarticular injection of ropivacaine (RI) is an element of current knee surgery practices. The goal of this study was to determine the effects of RI on the mechanical properties of hamstring tendons. We hypothesized that RI would have a detrimental effect on the mechanical properties of periarticular soft tissues METHODS: A tensile test to failure was performed on 120 hamstring tendon segments harvested during ACL reconstruction surgery in 120 patients. Two sets of tensile tests were done. The first evaluated the effect of RI itself on the mechanical properties of tendons: 30 samples were soaked for 1hour in a 2% RI solution and compared to 30 samples soaked in a saline solution (control group). The second evaluated the effect of RI concentration on the mechanical properties of hamstring tendons: 30 samples were soaked for 1hour in a 2% RI solution and 30 samples were soaked in a 7.5% RI solution., Results: In the first test, 29 samples from each group were analyzed as two samples (one in each group) failed at the grip interface. The specimens exposed to 2% RI had lower ultimate tensile strength (Δ=4.4MPa, P=0.001), strain energy (Δ=13MPa, P=0.001) and Young's modulus (Δ=1.6MPa, P=0.02) than the specimens in the control group. There was no significant difference in the strain at failure between groups (Δ=5%, P=0.3). In the second test, one specimen from the 7.5% RI group failed during the preloading and was excluded. There was no significant difference in terms of the load at failure and ultimate tensile stress (Δ=0.45MPa, P=0.6) and strain energy (Δ=0.49MPa, P=0.49) between the two groups. There were significant differences in terms of elongation at failure (Δ=28%, P=0.0003) and Young's modulus (Δ=2.6MPa, P=0.005), with the specimens exposed to 7.5% RI undergoing greater deformation and having a lower Young's modulus., Discussion: While local RI injections are widely performed in clinical practice, the results of this in vitro study point to short-term alterations of the mechanical properties of hamstring tendons. If these results hold in vivo, this could lead to weakness of the soft tissues exposed to this product, particularly the tendons and ligaments around the injection area., Level of Evidence: Experimental study. Level 1., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Mechanically aligned (MA) total knee arthroplasty (TKA) is affected by disappointing functional outcomes in spite of the recent improvements in surgical precision and implant designs. This might suggest the existence of intrinsic technical limitations. Our study aims to compare the prosthetic and native trochlear articular surfaces and to estimate the extent of collateral ligament imbalance, which is technically uncorrectable by collateral ligament release when TKA implants are mechanically aligned., Study Hypothesis: Conventional MA technique generates a high rate of prosthetic overstuffing of the distal groove, distal lateral trochlear facet and distal lateral femoral condyle (Hypothesis 1), and technically uncorrectable collateral ligament imbalance (hypothesis 2)? Disregarding the distal femoral joint line obliquity (DFJLO) when performing femoral cuts explains distal lateral femoral prosthetic stuffing and uncorrectable imbalance (hypothesis 3)?, Methods: Twenty patients underwent a conventional MA TKA. Pre-operative MRI-based 3D knee models were generated and MA TKA was simulated. Native and prosthetic trochlear articular surfaces were compared using in-house analysis software. Following the automatic determination by the planning software of the size of the extension and flexion gaps, an algorithm was applied to balance the gaps and the frequency and amplitude of technically uncorrectable knee imbalance were estimated., Results: The conventional MA technique generates a significant slight distal lateral femoral prosthetic overstuffing (mean 0.6mm, 0.8mm, 1.25mm for the most distal lateral facet point, groove, and at the most distal point of lateral femoral condyle, respectively) and a high rate of type 1 and 2 uncorrectable knee imbalance (30% and 40%, respectively). The incidence of distal lateral prosthetic overstuffing (trochlea and condyle) and uncorrectable knee imbalance were strongly to very strongly correlated with the DFJLO (r=0.53 to 0.89)., Conclusion: Conventional MA technique for TKA generates frequent lateral distal femoral prosthetic overstuffing and technically uncorrectable knee imbalance secondary to disregarding the DFJLO when adjusting the femoral component frontal and axial rotations, respectively., Level of Evidence: level 4., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

In spite of improvements in implant designs and surgical precision, functional outcomes of mechanically aligned total knee arthroplasty (MA TKA) have plateaued. This suggests probable technical intrinsic limitations that few alternate more anatomical recently promoted surgical techniques are trying to solve. This review aims at (1) classifying the different options to frontally align TKA implants, (2) at comparing their safety and efficacy with the one from MA TKAs, therefore answering the following questions: does alternative techniques to position TKA improve functional outcomes of TKA (question 1)? Is there any pathoanatomy not suitable for kinematic implantation of a TKA (question 2)? A systematic review of the existing literature utilizing PubMed and Google Scholar search engines was performed in February 2017. Only studies published in peer-reviewed journals over the last ten years in either English or French were reviewed. We identified 569 reports, of which 13 met our eligibility criteria. Four alternative techniques to position a TKA are challenging the traditional MA technique: anatomic (AA), adjusted mechanical (aMA), kinematic (KA), and restricted kinematic (rKA) alignment techniques. Regarding osteoarthritic patients with slight to mid constitutional knee frontal deformity, the KA technique enables a faster recovery and generally generates higher functional TKA outcomes than the MA technique. Kinematic alignment for TKA is a new attractive technique for TKA at early to mid-term, but need longer follow-up in order to assess its true value. It is probable that some forms of pathoanatomy might affect longer-term clinical outcomes of KA TKA and make the rKA technique or additional surgical corrections (realignment osteotomy, retinacular ligament reconstruction etc.) relevant for this sub-group of patients. Longer follow-up is needed to define the best indication of each alternative surgical technique for TKA. Level I for question 1 (systematic review of Level I studies), level 4 for question 2., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Introduction: Treatment of medial tibiofemoral osteoarthritis with a high-tibial osteotomy (HTO) is most effective when the optimal angular correction is achieved. However, conventional instrumentation is limited when multiplanar correction is needed., Hypothesis: Use of patient-specific cutting guides (PSCGs) for HTO provides an accurate correction (difference<2°) relative to the preoperative planning., Materials and Methods: Between February 2014 and February 2015, 10 patients (mean age: 46 years [range: 31-59]; grade 1 or 2 osteoarthritis in Ahlbäck's classification) were included prospectively in this reliability and safety study. All patients were operated using the same medial opening-wedge osteotomy technique. Preoperative planning was based on long-leg radiographs and CT scans with 3D reconstruction. The PSGCs were used to align the osteotomy cut and position the screw holes for the plate. The desired correction was achieved in the three planes when the holes on the plate were aligned with the holes drilled based on the PSCG. Preoperatively, the mean HKA angle was 171.9° (range: 166-179°), the mean proximal tibial angle was 87° (86-88°) and the mean tibial slope was 7.8° (1-22°). The postoperative correction was compared to the planned correction using 3D CT scan transformations. Intraoperative and postoperative complications were assessed at a minimum follow-up of 1 year., Results: The procedure was successfully carried out in all patients with the PSCGs. On postoperative long-leg radiographs, the mean HKA was 182.3° (180-185°); on the CT scan, the mean tibial mechanical angle was 94° (90-98°) and the mean tibial slope was 7.1° (4-11°). In 19 out of 20 postoperative HKA and slope measurements, the difference between the planned and achieved correction was <2° based on the 3D analysis of the three planes in space; in the other case, the slope was 13° instead of the planned 10°. The intra-class correlation coefficients between the postoperative and planned parameters were 0.98 [0.92-0.99] for the HKA and 0.96 [0.79-0.99] for the tibial slope. There were no surgical site infections; one patient had a postoperative hematoma that resolved spontaneously., Discussion: The results of this study showed that use of PSCGs in HTO procedures helps to achieve optimal correction in a safe and reliable manner., Level of Evidence: IV - Prospective cohort study., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Successful management of large bone defects is of crucial importance when performing revision total knee arthroplasty (TKA). Trabecular tantalum cones may improve prosthesis fixation via their potential for reconstructing a stable metaphyseal support. The objective of this study was to evaluate the clinical and radiological outcomes and the complications of tantalum cones in revision TKA., Hypothesis: Trabecular tantalum cones provide stable and durable metaphyseal reconstruction when used during revision TKA., Material and Methods: Trabecular Metal™ cones (Zimmer, Warsaw, IN, USA) were used for 52 revision TKAs in 51 patients (mean age, 68±9 years) managed in two centres between 2008 and 2013. A rotating hinge prosthesis was chosen for 38 (73%) knees and a condylar constrained knee prosthesis for 14 (27%) knees, with 37 tibial and 34 femoral cones. The two most common reasons for revision surgery were aseptic loosening (n=22, 42%) and infection (n=19, 37%). The bone loss was severe in most cases. At each centre, after a mean follow-up of 34 months (range, 24-52 months), two independent observers assessed the Knee Society Score (KSS), range of motion, mechanical axis, and osteo-integration for each patient., Results: Mean KSS increased from 46 preoperatively to 77 (P=0.001) at last follow-up and the mean KSS function from 39 to 57 (P=0.007). Mean range of motion improved from 93° (45°-120°) to 110° (65°-130°) (P=0.001). Mean postoperative mechanical axis was 180° (172°-190°). Radiographic evaluation showed evidence of osteo-integration for all cones. Four revisions were performed for recurrence of infection but none for mechanical failure., Discussion: The findings of our study confirm the biomechanical and biological reliability of Trabecular Metal™ cones used to fill metaphyseal bone defects during revision TKA., Level of Evidence: IV, retrospective therapeutic study., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Final flexion mobility after a total knee arthroplasty is an important factor in patient comfort. Some patients gain in flexion mobility, others do not. Is it possible to identify the clinical factors related to the patient that predicted the final gain in flexion?, Materials and Methods: A multicenter retrospective study directed by the Société française de la hanche et du genou (SFHG) was conducted on 1601 cases of total knee arthroplasty that had presented no complications and a minimal follow-up of 2 years. The gain in flexion was assessed by the difference between the preoperative and the final range of flexion. The range of the gain in flexion was tested based on eight factors: age, gender, etiology, body mass index, frontal deformity, preoperative flexum deformity and four levels of preoperative mobility: < 90°, 90°-109°, 110°-129°, and ≥ 130°., Results: A mean gain in flexion of 8.4°±14° was found for the overall series. In 66% of cases, we found an increase of flexion and in 19% a loss of flexion. In cases with BMI higher than 35, varus deformity with an HKA angle<166°, or flessum greater than 5°, the gain in flexion was significantly higher. A significantly different gain in flexion (P<0.0001) was found in the four levels of preoperative flexion: the greatest gain in flexion was found in the "<90°" group, then this gain was less in the next two groups, to become a significant decrease in the "≥130°" group. A decrease in flexion was noted in 51% of the cases in the latter group. Other factors such as age, sex, and etiology had no influence on the gain in flexion., Discussion: After TKA, a gain in flexion was often noted. The amount of gain depended on the preoperative range of flexion: the lower this level was, the more flexion increased. The presence of a varus deformity, morbid obesity, or flessum was associated with greater gain in flexion, even if the final flexion was lower than the mean flexion in the overall population. The search for these factors made it possible to predict a gain in flexion and discuss this with the patient., Level of Evidence: Level IV. Multicenter retrospective study., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Bicompartmental knee arthroplasty (BKA) was developed to treat medial tibiofemoral and patellofemoral osteoarthritis while preserving the anterior cruciate ligament to optimise knee kinematics. Our objective here was to compare the probability of achieving forgotten knee status and the functional outcomes at least two years after BKA versus total knee arthroplasty (TKA). We hypothesised that contemporary modular BKA produced better functional outcomes than TKA after at least two years, for patients with similar pre-operative osteoarthritic lesions., Material and Methods: We conducted a two-centre prospective controlled study of 34consecutive patients who underwent BKA between January 2008 and January 2011. Each patient was matched on age, gender, body mass index, preoperative range of knee flexion, centre, and surgeon to a patient treated with TKA. An independent observer evaluated all 68 patients after six and 12months then once a year. Forgotten knee status was defined as a 100/100 value of the Forgotten Joint Score (FJS-12) and each of the five KOOS subscales. We also compared the two groups for knee range of motion, Knee Society Scores (KSSs), Timed Up-and-Go test (TUG), and UCLA Activity Score., Results: At a mean follow-up of 3.8±1.7 years, the probability of forgotten knee status was significantly higher in the BKA group (odds ratio, 4.64; 95% confidence interval, 1.63-13.21; P=0.007, Chi(2) test). Mean post-operative extension was not significantly different between the groups, whereas mean range of knee flexion was significantly greater in the BKA group (130°±6° vs. 125°±8° after TKA; P=0.03). The BKA group had significantly higher mean values for the knee and function KSSs, TUG test, and UCLA score (P<0.04 for all four comparisons)., Conclusion: After at least two years, contemporary unlinked BKA was associated with greater comfort during everyday activities (forgotten knee) and better functional outcomes, compared to TKA. These short-term results require validation in randomised trials with longer follow-ups., Level of Evidence: III, case-control study., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Although they have been in use since the end of the 1980s, modular titanium neck components are associated with a risk of wear or fracture, and their safety has recently become a subject of debate and has never been evaluated in a consecutive series of patients. The goal of this study was to evaluate: revision-free survival of these implants after a minimum follow-up of 5 years; clinical and radiographic results; and the potential complications associated with the use of modular titanium neck components., Hypothesis: The use of titanium modular neck on cemented titanium THA is safe at a minimum follow-up of 5 years., Patients and Methods: Between January 2006 and December 2008, we prospectively followed 170 patients (170 hips) who underwent primary anatomical THA with a modular cemented titanium stem design implant. The indications were unilateral THA for primary (n=160) or secondary (n=10) hip osteoarthritis (aseptic osteonecrosis of the femoral head or hip dysplasia). Mean age of patients was 75.4±5.8 years old (52-85), and mean BMI was 26.1±4.5 kg/m(2) (16.6-42.1). Patients were operated on by a modified Watson-Jones anterolateral approach based on preoperative 2D planning. All patients underwent annual clinical and radiological follow-up by an independent observer., Results: At a mean follow-up of 71±8 months (60-84), 5 patients died and 7 were lost to follow-up. There was no revision of THA after a maximum follow-up of 84 months. The Harris score improved significantly from 50.4±11.3 (0-76) preoperatively to 84.5±15.2 (14-100) at the final follow-up. There was no difference in postoperative femoral offset or the position of the center of rotation compared to the opposite side. On the other hand, the neck-shaft angle (NSA) and limb length were corrected (2±5° [-11 to +14°] and 2.16±3.6 mm [-7.4 to +12.7 mm]) respectively. Fifteen patients (9%) had limb length discrepancies of more than 5 mm and 4 patients (2%) of more than 10 mm. There were no complications due to the modular implant design., Discussion: Our study suggests that the use of cemented titanium implants with a modular titanium stem is safe at a follow-up of 5 years. The modular design does not prevent limb length discrepancies but restores femoral offset., Level of Evidence: IV: prospective, non-comparative study., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: In November 2011, the Knee Society published its new KSS score to evaluate objective clinical data and also patient expectations, satisfaction and knee function during various physical activities before and after total knee arthroplasty (TKA). We undertook the French cross-cultural adaptation of this scoring system according to current recommendations., Hypothesis: The French version of the new KSS score is a consistent, feasible, reliable and discriminating score., Patients and Methods: Eighty patients with knee osteoarthritis were recruited from two centers: one group of 40 patients had a TKA indication, while the other group of 40 patients had an indication for conservative treatment. After the new KSS score was translated and back-translated, it was compared to three other validated instruments (KOOS, AMIQUAL and SF-12) to determine construct validity, discriminating power, feasibility in terms of response rate and existence of floor or ceiling effect, internal consistency with Chronbach's alpha and reliability based on reproducibility and sensitivity to change (responsiveness)., Results: Due to missing data, two cases were eliminated. We found that the score could discriminate between groups; it had a nearly 100% response rate, a ceiling effect in the "expectations" domain, satisfactory Chronbach's alpha, excellent reproducibility and good responsiveness., Discussion: These results confirm that the French version of the new KSS score is reliable, feasible, discriminating, consistent and responsive. The novelty of this scoring system resides in the "expectations" and "satisfaction" domains, its availability as a self-assessment questionnaire and the evaluation of function during various activities., Level of Proof, Type of Study: Level III., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

In 2012, 32.3% of the French population over 18 years of age was considered overweight (25 ≤ BMI<30 kg/m(2)) and 15% obese (BMI ≥ 30 kg/m(2)). Worldwide, 2.8 million people die every year from the complications of obesity. In 2008, the prevalence of obesity was almost double that of 1980. Obesity is a genuine concern for the orthopedic surgeon, as it affects bones and soft tissues on the biomechanical and biochemical level. In traumatology, low-energy trauma is more frequent in obese patients and induces complex comminutive fractures of the extremities. In orthopedics, obesity is an independent risk factor for osteoarthritis, particularly for the knee joint. The goals of this review are to describe specific aspects of the care of obese patients in trauma and orthopedics surgery during the pre-, intra- and postoperative periods, as well as the risk-benefit ratio related to the treatment of the obese patients., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Lower extremity alignment correlates with native femoral offset. Eventual impact of the change in femoral offset induced by total hip arthroplasty (THA) on lower extremity alignment has not been documented., Hypothesis: THA significantly changes lower extremity alignment, and the change correlates with the change in femoral offset., Materials and Methods: We conducted a prospective study of 200 patients with primary hip osteoarthritis or avascular femoral head necrosis who underwent cementless THA. Pre-operative computed-tomography templating was performed and the femoral component was then custom-manufactured to replicate the native femoral anatomy. Mean age was 58 years (range, 28-83 years). Before and at least two years after THA, two observers who were not involved in the surgical procedures used standing antero-posterior long-leg radiographs to determine the mechanical axis of the lower-limb (hip-knee-ankle [HKA] angle), femoral offset, neck-shaft angle (NSA), and lower-limb length discrepancy (LLLD)., Results: Mean values pre-operatively and at last follow-up were as follows: HKA angle, 179.2° ± 3.9° (range, 170.5° to 190.5°) and 177.7° ± 3.5°(range, 173° to 187°); LLLD, -0.7 mm (range, -30 mm to +25 mm) and +5.1 mm (range, -7 mm to +21 mm); NSA, 134° ± 7.5° (range, 100° to 124°) and 135° ± 4.2° (range, 124° to 146°); and femoral offset, 42 ± 7.8 mm (range, 24 mm to 68 mm) and 49 ± 7.5 mm (range, 33 mm to 70 mm). Although THA significantly altered lower-limb alignment, univariate and multivariate analyses showed no significant association between the change in HKA angle and the change in femoral offset., Discussion: Lower-limb alignment was significantly affected by THA, although the HKA angle changes were small. The small impact of THA on HKA angle values may be ascribable to efforts aimed at replicating the native femoral offset during arthroplasty, as well as to the limited sample size and to potential measurement errors related to the small size of the changes. Our results suggest that, provided careful attention is directed to replicating the native femoral offset, THA in patients with limited pre-operative anatomical abnormalities may have no major impact on the biomechanical parameters of the ipsilateral knee., Level of Evidence: Level III, prospective diagnostic study., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Introduction: Survivorship for modern total knee arthroplasties (TKA) is not precisely known from large series, other than registries. The present retrospective study therefore analyzed 846 TKAs at a minimum 10 years' follow-up., Hypothesis: Ten-year survivorship for TKAs in a multicenter study exceeds 90%, independently of design and level of prosthetic constraint., Materials and Methods: Eight hundred and twenty-eight patients (846 TKAs) were assessed on the Knee Society score. Mean age was 71 years (range, 41-93 years); 274 males and 554 females (67%); 496 patients (60%) were active; diagnosis was principally osteoarthritis (n=752 [89%]). Most TKAs were cemented (n=704 [83%]), replacing the patella (n=668 [79%]) and sacrificed the posterior cruciate ligament (PCL) (n=707 [84%]), 65% being posterior-stabilized and 35% ultracongruent, with fixed (39%) or mobile bearing (61%)., Results: At a minimum 10 years' follow-up, mean knee score rose from 35 (15-55) to 83 points (74-95), and functional score from 24 (5-45) to 74 points (60-90); mean flexion rose from 105° (25-125°) to 112° (25-125°). Mean hip-knee-ankle angle was 179.5° (169-189°). Sixty-three (7.5%) revision surgeries were required, mainly for loosening (n=18 [2%]) or infection (n=18 [1.8%]). Overall 10-year survivorship was 92% (95% CI: 0.90-0.94). There was no significant difference in survivorship according to implant design or PCL retention. Activity level correlated with revision rate; mechanical complications were more frequent in active and infectious complications in sedentary subjects. Revision was not more frequent in TKA aligned outside the 177-183° range., Discussion: Ten-year TKA survivorship was 92%, independently of design and level of mechanical stress. Revision was mainly for infection or loosening, and not for greater than 3° axis misalignment. Mechanical complications were more frequent in younger and more active subjects, for whom therefore other treatment options or technical improvements should be sought., Level of Evidence: Level IV. Retrospective study., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Blood conservation strategies have been developed to diminish blood transfusion requirements in patients undergoing hip or knee replacement surgery. Tranexamic acid (TA) is an inexpensive antifibrinolytic agent that is little used in orthopaedic surgery due to the absence of standardised optimal administration regimens., Hypothesis: Blood transfusion requirements and induced costs can be diminished by using TA according to a standardised administration protocol in a large cohort of patients., Materials and Methods: A retrospective study in patients who underwent joint replacement surgery by a single surgeon compared two periods, 2007-2008 without TA and 2008-2009 with TA. The 451 included patients underwent primary unilateral hip (n=261) or knee (n=190) replacement for osteoarthritis. Standardised protocols were used for surgery and anaesthesia. TA was given intravenously in a dose of 1g (i.e., 15mg/kg) at incision and wound closure then at 6-hour intervals for 24 hours. Blood losses were estimated using the Mercuriali formula. Haemoglobin on D -1 and D 8 and the number and volume of autologous (from intra-operative blood salvage) and homologous blood transfusions were collected. The costs of TA, blood salvage systems, and homologous blood units were recorded. The two groups were compared using Student's test, Wilcoxon's test, and the Khi(2) test, and multivariate analyses were performed. Values of p less than 0.05 were considered significant., Results: TA use was associated with a significant decrease in the homologous blood transfusion rate (from 4% to 0%) and with 38% and 68% reductions in the rate and volume of autologous blood transfusions, respectively, due to a 34% decrease in blood losses. After taking into account the additional cost of TA therapy, there was a 25% reduction in the cost of the blood conservation strategy., Conclusion: TA therapy abolished the need for homologous blood transfusion and induced no notable side effects. TA therapy decreased the amount of blood salvaged intra-operatively, allowing a more rational use of the blood salvage system and decreasing the cost of anaesthesia., Level of Evidence: IV. Retrospective case-control., (Copyright © 2012. Published by Elsevier Masson SAS.)

Introduction: There is a lack of data on the management of osteoarthritis of the knee associated with intra-articular malunion. The present study sought to analyze and report results of total knee replacement (TKR) in this indication, including complications and technical specificities., Hypothesis: TKR for osteoarthritis of the knee associated with intra-articular malunion entails an elevated risk of complication, with impaired functional results., Objectives: To test this hypothesis in a retrospective series of 74 cases of osteoarthritis of the knee associated with intra-articular malunion., Patients and Methods: A multicenter retrospective series collated the records of 74 patients (mean age, 63 ± 14 years) who underwent TKR for post-traumatic osteoarthritis of the knee associated with intra-articular malunion between 2000 and 2008. Mean trauma-to-TKR interval was 21.8 ± 19 years (range 1 to 56 years). Patients were assessed clinically and radiologically at last follow-up, using the Knee Society score as modified by the Western France Orthopedic Society (Société orthopédique de l'Ouest)., Results: At a mean overall follow-up of 4 ± 3 years (range 1 to 9 years), mean knee score improved from 25 ± 12 to 85 ± 7 (P<0.001) and mean functional score from 52 ± 13 to 66 ± 10 (P=0.004). Mean flexion gain was 6°: mean preoperative flexion, 104° ± 28° (10° to 150°), vs. 110° ± 19° (20° to 130°) at follow-up. Nineteen patients (26%) had complications, 13 of which were severe and liable to affect the functional result: three extensor system avulsions, four infections, five cases of stiffness and one of instability., Discussion and Conclusions: The present results highlight an elevated rate of complications, with poorer clinical results than those found with osteoarthritis of the knee secondary to constitutional deformity. The initial trauma, with associated hemarthrosis, and sometimes iterative surgery to reduce and fix the initial fracture, induce fibrosis and synovial attachments, leading to stiffness and hindering exposure. The patient should be informed, and warned that postoperative flexion amplitude may be improved but is bound to remain limited, especially in case of initial stiffness., Level of Evidence: Level IV: non-comparative retrospective study., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Introduction: Over the past few years the use of arthroplasty was broadened to treating complex epiphyseal fractures at the shoulder and elbow joints. Similar trends to treat this type of fractures at the knee are less documented. Based on a multicenter retrospective series study, the aims of this work is to evaluate the short term clinical results of total knee prostheses in the management of comminuted epiphyseal fractures around the knee, to identify the technical issues and fine tune the indications., Material and Methods: Following the initiative of the French Hip and Knee Society (SFHG) and the Traumatology Study Group (GETRAUM), 26 charts from eight different centers in France were included in this multicenter retrospective series. Inclusion criteria were: primary total knee arthroplasty (TKA) in the management of complex articular fractures involving the proximal end of the tibia or distal end of the femur. Surgical features were identified and complications were analyzed. The assessment protocol at last follow-up was standardized and included patient demographic data, analysis of the Parker and IKS scores., Results: During the immediate postoperative period, six patients (23%) reported a general complication and four patients (15%) a local arthroplasty-related complication. At last follow-up (mean 16.2 months), the overall final Parker score was 6.3 (a mean decrease of 1.7) and the mean IKS knee score was 82 points for a mean function score of 54 points., Discussion: Primary TKA is a suitable management option for complex fractures in autonomous elderly patients suffering from knee osteoarthritis. The key technical details of this procedure should be respected and meticulously planned to achieve optimal results and limit the risk of complications. This risk in these acute complex fractures remains higher than after conventional TKA but comparable to that observed after TKA for post-traumatic arthritis., Level of Evidence: IV; retrospective cohort study., (Copyright © 2011. Published by Elsevier Masson SAS.)

Introduction: UKA is an appropriate bone-sparing solution for focal advanced knee osteoarthritis in young patients. As the expectations of patients younger than 60 years of age are different from those in an older population, we aimed to evaluate quality of life and the quality of sports activity after UKA in this population., Patients and Methods: Sixty-five UKAs in 62 patients younger than 60 (mean age: 54.7 years; mean BMI: 28 kg/m(2)) performed between 1989 and 2006 were included. At last follow-up (minimum 2 years), before the objective evaluation, patients were asked to fill in a KOOS questionnaire and a specific sports questionnaire including the UCLA score and questions from the Mohtadi score., Results: With a mean follow-up of 11.2±5 years (range, 2-19 years), the KOOS score was higher than 75 points in 90% of the patients for the quality-of-life categories but also for the score's four other categories: 83.4% of the patients had resumed their sports activities and the mean UCLA score was 6.8 (range, 4-9); 90% of the patients reported no or slight limitation during sports activities. The function KSS improved from 52±4 to 95±3 points postoperatively and the Knee KSS from 50±4 to 94±4 points. With three patients undergoing revision for an isolated insert exchange, one for septic loosening and three for osteoarthritis in the external compartment, the 12-year Kaplan-Meier survivorship was 94%., Discussion and Conclusion: These results confirmed that UKA can provide good patient-rated outcomes, which is very important in this demanding population. As for TKA, wear remains a problem in this active population., Level of Evidence: Therapeutic study, level IV., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Introduction: Internal fixation is the preferred treatment of Garden I femoral neck fractures in the elderly. High re-operation rates have however been reported, and the results of arthroplasty performed following internal fixation failure are not as good as those of primary arthroplasty. This is why we are advocating functional treatment. Our hypothesis is that this treatment leads to fewer decubitus complications than strict orthopaedic treatment and no more mechanical complications than internal fixation in a selected population sample. Therefore, the objective of our prospective work was: (1) to assess the results of functional treatment of Garden I femoral neck fractures in elderly subjects, and (2) to investigate predictive factors of secondary displacement., Patients and Methods: All patients over age 65 years, admitted for a Garden I femoral neck fracture between January 2006 and May 2008, were included in this prospective study representing 56 cases (57 fractures) with an average age of 82 years. Functional treatment was performed, including early weight-bearing mobilisation, followed by radiographic evaluation at days 2, 7, 21 and 45, then at 3, 6 and 12 months. In the absence of displacement, discharge was planned at day 5 (Non-Displaced [ND] group). Otherwise, arthroplasty was performed (Displaced [D] group). Parker score and Harris Hip Score (HHS) were used for functional evaluation., Results: The observed displacement rate was 33.3% (19 patients) within an average period of 10 days. In the ND group, one case of osteonecrosis was observed and treated by arthroplasty. The average Parker score was 6.9 and the HHS 82 in the ND group, and 7 and 85, respectively, in the D group. None of the factors studied (age, gender, side, fracture type, inclination angle, degree of outward displacement, sagittal displacement, general status) was statistically predictive of final displacement., Discussion: The medical complication rate was only 7% in our series, which seems to be lower than that resulting from orthopaedic treatment. The observed secondary displacement rate seemed to be higher than the rate found in the literature on surgical treatment (5.4 to 20%), but the osteonecrosis rate appeared to be lower (11 to 25%). In addition, surgical treatment was the purveyor of specific complications in over 10% of cases., Conclusions: The present prospective study with minimum 1-year follow-up shows that functional treatment results in fewer decubitus complications than orthopaedic treatment and a rate of revision surgery comparable to internal fixation since 70% of included patients could have been successfully treated without surgical intervention. However, the investigation of a larger cohort would be necessary to identify predictive factors for the treatment's failure., Level of Evidence: Level III prospective non-comparative cohort study., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)

Introduction: Most computer-assisted navigation systems used in total hip arthroplasty (THA) reference the anterior pelvic plane, which connects the anterior superior iliac spines and the pubic symphysis. The pelvic tilt is defined as the angle between this anterior pelvic plane (APP) and a vertical line in the standing position. Important interindividual variations of this angle have been reported and may affect final functional anteversion of the acetabular cup. The preoperative value of the pelvic tilt has been included in computer-assisted navigation systems to improve acetabular cup positioning. However, there is no data available which strongly confirms the consistency of this angle for each individual after hip prosthesis implantation., Hypothesis: The orientation of the APP in the standing position is not significantly modified after THA., Objectives: To evaluate in a prospective manner, the reproducibility of pelvic tilt measurement and its variability between THA preoperative and 3-year postoperative measurements., Materials and Methods: A lateral teleradiograph of the pelvis and dorsolumbar spine was obtained in the standing position preoperatively and 3 years after THA. Fifty patients undergoing THA performed by a single operator via an anterolateral approach (26 males and 24 females) were included prospectively. The pelvic tilt was measured on radiographs by two independent observers. The angle was defined as positive in case of pelvis retroversion relative to the vertical plane and negative in case of anteversion. Bland-Altman analysis was used to assess levels of agreement between both operator measurements while preoperative and last follow-up measurements were compared using the Student t-test for unpaired samples., Results: The level of agreement between measurements of both operators was satisfactory. Mean preoperative pelvic tilt was 4.68 degrees +/-0.68 S.D. (-6 degrees to 14 degrees), and 4.78 degrees +/-0.64 S.D. (-5 degrees to 14 degrees) at last follow-up. The mean difference between preoperative and last follow-up measurements was 3 degrees +/-0.3 S.D. There was no statistically significant variation between preoperative and 3-year follow-up values (p>0.05). Ninety-five percent of the patients had less than a 5 degrees difference between both measurements while 5% had a difference ranging from 5 degrees to 10 degrees ; none of the patients reported a variation greater than 10 degrees ., Discussion: Our findings show no significant variation in pelvic tilt between preoperative and 3-year follow-up values after THA. Therefore, the individual preoperative value of this angle should be integrated to achieve proper acetabular cup placement during THA especially when using computed assisted navigation based on the APP.