Search

PURPOSE: The purpose of this study was to analyse the results of total knee arthroplasty (TKA) in stiff knees (flexion ?90° and/or flexion contracture ?20°). Our hypothesis was that despite having poorer results than those obtained in a "standard" population and a high rate of complications, TKA was a satisfactory treatment in patients with osteoarthritis of the knee associated with significant stiffness. METHODS: Three hundred and four consecutive primary HLS TKAs (Tornier), whose data were prospectively collected between October 1987 and October 2012, were retrospectively analysed at a mean of 60 months (range, 12-239) postoperatively. Two groups, those with a "flexion contracture" and those with a "flexion deficit", were assessed for postoperative range of motion (as integrated to the Knee Society score [KSS]), physical activity level and patient satisfaction. RESULTS: At the latest follow-up, range of motion was significantly improved, as was the KSS. Ninety-four percent of patients were satisfied or very satisfied, and activity levels were increased after surgery. The complication rate, however, was high in patients with a preoperative flexion deficit (17%). Pain and residual stiffness were the most common complications. CONCLUSION: TKA provides satisfactory results in patients with knee osteoarthritis associated with significant pre-operative stiffness. The surgical plan should be adapted to anticipate complications, which are particularly frequent in the presence of a flexion deficit.

This chapter describes our technique for arthroscopic single-bundle reconstruction of the posterior cruciate ligament (PCL) with quadriceps tendon autograft. This technique can be adjusted to achieve a double-bundle reconstruction.

Long-term survival in total knee arthroplasty (TKA) depends on multiple factors, including restoration of mechanical alignment and obtaining optimal ligament balance. The aim of this study was to document the results of single-stage TKA combined with high tibial osteotomy for managing femorotibial arthrosis with significant frontal-plane deformity. Patients with osteoarthritis of the knee and extra-articular deformity in > 10° and operated between 1997 and 2001 were reviewed retrospectively. In each case, a high tibial osteotomy combined with a posterior stabilised TKA was performed. Patients were assessed using the Knee Society Score (KSS). The femorotibial mechanical angle was measured on radiographs pre- and postoperatively and at the most recent follow-up. Fifteen knees in 12 patients were included in the study. Mean age was 68.2; average follow-up was 78 months (22.1–145.9). The KSS improved significantly from 47.1 (28–58) to 60.7 (40–94) points (p

Comment on Results and complications of single-stage total knee arthroplasty and high tibial osteotomy. Int Orthop. 2014

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.

Resume Les lesions du ligament collateral lateral sont rares mais demandent le plus souvent une reparation chirurgicale. Nous ne decrirons pas dans ce chapitre les techniques palliatives telles que les tenodeses ou les plasties au fascia lata, ni les plasties anteroexternes dites plasties anti-ressaut. Notre expose est consacre a la greffe du ligament collateral lateral, technique de choix dans la reconstruction externe ainsi qu'aux reconstructions posteroexternes. Les lesions du point d'angle posteroexterne (PAPE), de diagnostic difficile, necessitent souvent un geste de plastie visant a controler l'hyperrotation externe.

Resume L'atteinte ligamentaire peripherique interne est frequemment associee a la rupture du ligament croise anterieur (LCA). La prise en charge de cette lesion combinee reste difficile a l'heure actuelle car aucune etude ne prouve reellement la superiorite d'un traitement conservateur sur la reconstruction chirurgicale. Il est indispensable de faire un diagnostic precis a l'aide d'un examen clinique complet et de l'analyse de l'imagerie par resonance magnetique (IRM). En fonction du contexte, dont les imperatifs sportifs du patient, de l'importance de la laxite interne et du caractere aigu ou chronique de la lesion, un geste chirurgical specifique se discute, associe a la reconstruction du LCA. Diverses techniques chirurgicales sont envisageables en fonction du type et de la localisation lesionnels. La reeducation postoperatoire semble primordiale afin d'eviter la raideur, principal ecueil de ce geste chirurgical combine.

High tibial osteotomy (HTO) is frequently used to treat varus osteoarthritis in younger patients with the goal of delaying the need for total knee arthroplasty (TKA). While it has been reported that the results of TKA following HTO are worse than those in patients without prior knee surgery, the influence of osteotomy technique (medial opening-wedge versus lateral closing-wedge) has not been explored. The purpose of this study was to evaluate the influence of HTO technique on the performance and results of TKA.A total of 141 TKA's performed in 118 patients with prior HTO (24 opening wedge and 117 closing wedge) were reviewed at a mean follow-up of two years. Reviewed data included intra-operative factors (tourniquet time, the need for additional exposure, and intra-operative complications), clinical results (International Knee Score (IKS)) and radiographic assessment of limb alignment.The average IKS knee and function scores improved from 54.0 and 60.3 to 87.0 and 79.5 (p 0.0001). There was no significant difference in IKS scores based on osteotomy technique. There was a trend toward an increased need for tibial tubercle osteotomy in the closing wedge group. There was an increased need for extensive medial release in the opening wedge group and extensive lateral release in the closing wedge group. No differences in tourniquet time, complication rates, or hip-knee-ankle angle were noted between the two groups.Radiographic limb alignment, patient-reported outcomes, and complication rates are equal in patients undergoing TKA after opening and closing wedge HTO.

Introduction L’objectif de cette etude etait de rapporter les resultats a long terme, d’une serie continue de patients apres chirurgie en un temps, combinant une reconstruction du ligament croise anterieur (LCA) a une osteotomie tibiale de valgisation (OTV), dans le cadre d’une arthrose femoro-tibiale interne (AFTI) debutante sur un morphotype en genu varum. Notre hypothese etait que cette chirurgie combinee autorisait durablement un retour au sport, avec des resultats cliniques et radiographiques stables dans le temps. Materiel et methodes Entre 1995 et 2013, tous les patients operes d’une autogreffe du LCA, par transplant os–tendon patellaire–os, associee a une OTV par ouverture interne pour laxite anterieure chronique et AFTI debutante ont ete inclus. L’evaluation etait faite a l’aide des scores de Tegner, IKDC (subjectif et objectif), Lysholm et le nouveau score IKS. L’analyse radiologique portait sur des radiographies en appui monopodal, en schuss, une pangonometrie, des radiographies en stress (Telos® a 150 N) et une incidence femoro-patellaire. Resultats Trente-cinq patients (36 genoux) etaient analyses a 9,8 ans (2,4–20,3 ans) de recul moyen. L’âge moyen lors de la chirurgie etait de 39,1 ans ± 9,1. Au recul, 91,4 % avaient repris une activite sportive au moins de loisir (Tegner 3). 11 patients avaient repris le sport au meme niveau (31,4 %), dont 6 en competition. La diminution moyenne du score de Tegner par rapport a l’etat pre-traumatique etait de 0,8 point (p > 0,001). Vingt-neuf pour cent des patients reprenaient une activite tres intense ou intense selon la classification IKDC. Les scores moyens IKDC, Lysholm et IKS patient etaient respectivement de 71,8 ± 14,9, 82,1 ± 14,1 et 144,5 ± 28,5 au recul. La laxite anterieure differentielle etait de 5,1 mm ± 3,8. L’axe du genou etait de 175,8°±2,6 en preoperatoire et de 180,8°±2,7 au recul. Une progression arthrosique femoro-tibiale interne, femoro-tibiale externe et femoro-patellaire etait retrouvee dans respectivement 33 % (p > 0,05), 17 % (p > 0,001), et 23 % des cas (p > 0,01). Vingt-deux genoux ne presentaient aucune evolution arthrosique femoro-tibiale. Conclusion Dans cette serie, la reconstruction combinee du LCA associee a une OTV a permis aux patients presentant une gonarthrose interne debutante et une instabilite chronique anterieure de retrouver un genou stable a presque 10 ans de recul. La reprise du sport au meme niveau pre-traumatique n’a pu cependant etre possible que pour environ 1/3 des patients, avec une progression de l’arthrose femoro-tibiale dans 39 % des cas.

Introduction L’utilisation croissante des implants cotyloidiens a double mobilite a recemment participe a diminuer le taux de luxation postoperatoire, principale complication apres protheses totales de hanche (PTH) par voie posterieure. A contrario, peu de donnees sont disponibles concernant l’utilisation de la double mobilite par voie anterieure, la luxation etant theoriquement plus rare et l’exposition plus exigeante. Notre hypothese etait que la double mobilite peut etre utilisee par voie anterieure sans augmenter le risque de complications per- et postoperatoires ou les malpositions d’implants. Materiel Entre juin 2013 et octobre 2015, 201 PTH de premiere intention, avec implant double mobilite furent realisees par voie anterieure, sans extension de table. L’âge moyen etait de 72 ans (extremes 39–92), avec 35 % d’hommes, l’IMC moyen de 26 kg cm2 (17–44). Le score preoperatoire moyen de Harris etait de 49 (6–83). Les donnees operatoires et les complications etaient relevees retrospectivement. Le positionnement des implants et l’inegalite de longueurs des membres inferieurs (ILMI) etaient evalues sur des radiographies a 2 mois. Les scores fonctionnels etaient notes a 2 mois et un an. Resultats Le recul moyen etait de 16 mois (4–33). Aucune luxation ou complication vasculo-nerveuse ou infection n’a ete relevee. Deux fractures non deplacees du grand trochanter ont ete retrouvees au controle radiologique, sans necessiter d’osteosynthese, avec une consolidation et l’absence de boiterie au dernier recul. Un changement de cupule a ete realise pour conflit du psoas, secondaire a un defaut d’anteversion. L’ILMI etait en moyenne de 2 mm, 96 % des patients avaient une inegalite inferieure a 10 mm. L’inclinaison moyenne de la cupule etait de 43,9°C ± 6,9, l’anteversion moyenne de 25,5°C ± 5,3. L’alignement moyen de la tige etait de 1,9°C ± 1,4 en varus. L’offset total de hanche etait retabli a 10 mm pres pour 88 % des patients. Le score moyen de Harris a 2 mois etait de 86 (51–100) et de 95 a 1 an (60–100). Discussion La voie anterieure sans table orthopedique associee a un implant double mobilite n’augmente pas le risque de complications, ou de mauvais positionnement des implants. Il convient cependant d’etre attentif a l’anteversion cotyloidienne de ces implants, une anteversion trop faible exposant au risque de conflit du psoas. Cette strategie presente un interet pour les patients a risque de luxation, tout en permettant un controle precis des longueurs des membres inferieurs et un resultat fonctionnel satisfaisant.

Introduction Le diagnostic de patella alta n’est pas rare et se traduit frequemment par une instabilite femoro-patellaire. L’evolution arthrosique peut parfois conduire a l’implantation d’une prothese totale de genou (PTG), avec des complications femoro-patellaires potentiellement plus frequentes. Nous avons souhaite etudier les resultats des PTG sur patella alta en les comparant a un groupe temoin presentant une hauteur rotulienne normale. Notre hypothese etait que les resultats seraient moins bons en cas de patella alta preoperatoire. Materiel et methodes Les PTG sur patella alta et avec hauteur rotulienne normale ont ete dissociees en 2 groupes grâce a l’index de Blackburne-Peel, au sein d’une base de donnees monocentrique prospective de 4071 protheses. Les caracteristiques cliniques et radiologiques moyennes pre et postoperatoires ont ete comparees entre les 2 groupes, ainsi que les complications a moyen terme. Les implants etaient des protheses postero-stabilises par 3 e condyle (laboratoire Tornier-Wright), de differentes generations. Le critere de jugement principal etait le score IKS postoperatoire. Les tests de Student et du χ 2 etaient utilises pour l’analyse des donnees. Resultats Trois cent trente protheses sur patella alta et 3301 avec hauteur rotulienne normale ont ete operees entre novembre 1987 et septembre 2015, avec un recul moyen de 39,6 mois (12-239 mois). Avant l’intervention, aucune difference n’etait retrouvee entre les 2 groupes pour le score IKS (genou et fonction), les mobilites (flessum et flexion maximale) et les axes mecaniques sur la pangonometrie. Le groupe des PTG sur patella alta retrouvait un taux d’arthrose du compartiment externe plus important (26,2 % contre 17,7 %, p p p = 0,87) et score fonction a 80,4 contre 77,9 ( p = 0,07). Les mobilites du genou etaient comparables - flexion maximale moyenne de 118,7° pour les PTG sur patella alta contre 118,2° pour les PTG avec hauteur rotulienne normale ( p = 0,64). Le taux de patients satisfaits etait identique entre les 2 groupes (91,9 % contre 92,9 %, p = 0,08). A moyen terme les PTG sur patella alta presentait significativement moins de raideur (0,6 % contre 1,5 %, p p = 0,02). Discussion conclusion L’implantation d’une PTG sur patella alta permet d’obtenir des resultats cliniques et radiologiques a moyen terme equivalents aux PTG avec hauteur rotulienne preoperatoire normale, mais le taux de subluxation rotulienne plus eleve incite a etre attentif a la course rotulienne dans cette situation.

The purpose of this article is to update the orthopedic community on the role of lateral extra-articular tenodesis in the management of anterior cruciate ligament-deficient knees. Information includes historical perspective, current applications and techniques, and a review of published outcomes.

The popliteus tendon is known to play a key role in the stability of the posterolateral corner of the knee. While prior work suggests that isolated sectioning of the popliteus tendon has little consequence for the static stability of the knee following TKA, no studies have evaluated the effect of iatrogenic popliteal tendon injury on patient oriented outcome and knee function following TKA. The aims of this study are (1) to compare patient-oriented outcome scores of patients who suffered an iatrogenic injury to the popliteus tendon with a control group without such an injury and (2) to identify risk factors associated with iatrogenic injury to the popliteus tendon.Fifteen patients with an iatrogenic complete transection of the popliteus tendon during TKA were compared to the 666 patients who underwent TKA during the same time period without popliteus tendon injury.Postoperatively, IKS knee scores were similar between the two groups; however, significantly lower IKS function scores were noted in the study group (71 ± 31) compared to the control group (86 ± 19) (p = 0.0036). Iatrogenic popliteal tendon injury was only noted to occur in patients in whom components of size four or smaller were used.Intraoperative complete section of the popliteus tendon during the performance of TKA results in decreased IKS functional scores two to three years postoperatively. Patients with smaller knees may be at higher risk for this complication.

Knee joint stability is determined by the ligament and capsular complex combined with intact osteocartilaginous structures. The ligaments are described as dense connective collagenous tissue bands that connect one bone to another. Their purpose is to support loads of tension, particularly on their long axis, allowing joint stability and guiding knee joint movement.

Background: High tibial osteotomy (HTO) is a common treatment for medial compartment arthritis of the knee in younger, more active patients. An HTO also potentially affects leg length. Mathematical models predict that the osteotomy type (medial opening-wedge vs lateral closing-wedge) and the magnitude of the correction determine the change in leg length, but no in vivo studies have been published.Purpose: This study was undertaken to quantify and compare leg-length change after opening-wedge and closing-wedge HTO.Study Design: Cohort study; Level of evidence, 3.Methods: Thirty-two medial opening-wedge and 32 lateral closing-wedge HTOs were selected from patients treated at the authors’ institution. Preoperative and postoperative coronal plane alignment and leg length were measured and surgical details were collected.Results: The 64 osteotomies were performed at an average age of 57 years. The mean opening wedge was 9.3 mm and the mean closing wedge was 8.0 mm. Mean knee alignment changed from 174° preoperatively to 183° postoperatively in both groups. In the medial opening-wedge group, entire leg length changed from 836.3 ± 63.5 mm to 841.8 ± 64.1 mm, an increase of 5.5 ± 4.4 mm ( P < .0001). Tibia length changed from 368 ± 30.9 mm to 372.3 ± 31.2 mm, an increase of 4.3 ± 2.3 mm ( P < .0001). In the lateral closing-wedge group, entire leg length changed from 840.6 ± 51.5 mm preoperatively to 837.9 ± 52.0 mm postoperatively, a decrease of 2.7 ± 4.0 mm ( P = .0008). Tibia length changed from 365.1 ± 23.2 mm to 361 ± 22.9 mm, a decrease of 4.1 ± 2.9 mm ( P < .0001). The difference in mean leg-length change between opening-wedge and closing-wedge osteotomies was 8.2 ± 5.9 mm ( P < .0001).Conclusion: Both medial opening-wedge and lateral closing-wedge HTO can result in significant leg-length change, but changes are generally less than mathematical models predict.

Postoperative varus alignment has been associated with lower IKS scores and increased failure rates. Appropriate positioning of TKA components therefore is a key concern of surgeons. However, obtaining neutral alignment can be challenging in patients with substantial preoperative varus deformity and it is unclear whether residual deformity influences revision rates.We asked: (1) in patients with preoperative varus deformities, does residual postoperative varus limb alignment lead to increased revision rates or lower IKS scores compared with correction to neutral alignment, (2) does placing the tibial component in varus alignment lead to increased revision rates and lower IKS scores, (3) does femoral component alignment affect revision rates and IKS scores, and (4) do these findings change in patients with at least 10° varus alignment preoperatively?From a prospective database, we identified 553 patients undergoing TKAs for varus osteoarthritis. Patients were divided into those with residual postoperative varus and those with neutral postoperative alignment. Revision rates and International Knee Society (IKS) scores were compared between the two groups and assessed based on postoperative component alignment. Survival analysis was conducted with revision as the endpoint. The analysis was repeated in a subgroup of patients with at least 10° preoperative varus. Minimum followup was 2 years (median, 4.7 years; range, 2-19.8 years).The two groups had similar survival rates to 10 years and similar IKS scores. Varus tibial component alignment and valgus femoral component alignment were associated with lower mean scores. Revision rates and scores were similar in a subgroup of patients with substantial preoperative varus.Our data suggest residual postoperative varus deformity after TKA does not increase survival rates at medium-term in patients with preoperative varus deformities, providing tibial component varus is avoided. Tibial component varus negatively influences IKS score.Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The success of posterior cruciate ligament (PCL) reconstruction is dependent on appropriate tunnel placement. Computed tomography (CT) provides detailed images of intra-articular osseous anatomy. The objective of this study was to analyze by CT the position of femoral and tibial tunnels relative to intra-operative goals following arthroscopic-assisted PCL reconstruction. Nineteen patients who underwent single-bundle PCL reconstruction were evaluated 16 months post-operatively. Each underwent a CT scan and tunnel locations were identified in the coronal, sagittal, and axial planes. The coronal plane tibial tunnel location was within 5mm of the intra-operative goal (48% of the total tibial plateau width from the medial border of the plateau) in 16 patients (84%). The sagittal plane tibial tunnel location was within 5mm of the intra-operative goal (the middle of the posterior half of the retrospinal surface) in 14 patients (74%). In the sagittal plane, the femoral tunnel location was within 5mm of the intra-operative goal (10mm from in the distal articular margin of the medial femoral condyle) in 15 patients (79%). In the notch, the femoral tunnel was between 10:30 and 11:30 for left knees or between 12:30 and 1:30 for right knees (the intra-operative goal was 11 o'clock for left knees and 1 o'clock for right knees) in 18 patients (95%). Arthroscopic PCL reconstruction results in tunnel positions near intra-operative goals. Further work is necessary to define CT-specific criteria for the assessment of PCL tunnel position.

The clinical and radiographic results of 54 knees (52 patients) with a unicondylar knee arthroplasty (UKA) with fixed-all polyethylene bearing implanted for lateral osteoarthritis were studied at 5- to 16-year follow-up (mean, 100.9 months). Four underwent second surgery: 1 conversion to total knee arthroplasty and 3 received UKA in the medial compartment. The mean International Knee Society knee score was 94.9 points, with a mean range of motion of 132.6° and a mean International Knee Society function score totaling 81.8 points. Implant survival was 98.08%at 10 years. These excellent results suggest that UKA with fixed-all polyethylene bearing is a reliable option for management of isolated lateral knee osteoarthritis. Keywords: knee, unicompartmental arthroplasty, lateral osteoarthritis.

Purpose The purpose was to evaluate the load to failure of 2 coracoid fixation techniques after transfer of the coracoid to the anterior glenoid neck. Methods Ten cadavers (mean age, 87 years; range, 74 to 96 years) underwent the Bristow conjoined tendon tenodesis technique as described by Boileau et al. (bioabsorbable interference screw fixation of a coracoid bone plug) in 1 shoulder and the Latarjet-Patte coracoid transfer popularized by Walch (fixation with 2 screws through a larger piece of the coracoid) in the opposite shoulder. The force on the conjoined tendon required to pull the coracoid off of the anterior glenoid was recorded, along with the mode of construct failure. Results The median ultimate failure load was 110 N (range, 35 to 170 N) in the interference screw group and 202 N (range, 95 to 300 N) in the bicortical screw group ( P = .002). The mode of failure of the interference screw technique was complete avulsion of the bone plug from the socket in 6 cases (60%) and fracture of the bone plug in 4 (40%). The mode of failure of the bone block technique was a vertical fracture through both screw holes in 7 cases (70%), a horizontal fracture through the distal screw hole in 2 (20%), and an intratendinous rupture of the conjoined tendon in 1 (10%). Conclusions Fixation of a coracoid bone block to the anterior glenoid neck with 2 bicortical metal screws is stronger than fixation of a coracoid bone plug with an absorbable interference screw. Clinical Relevance These data may influence surgeons' decisions regarding coracoid fixation as well as postoperative rehabilitation after coracoid transfer.

No report has specifically addressed the question of the influence of gender on outcome following unicompartmental knee arthroplasty (UKA). To clarify this issue, we studied two groups of 40 patients of each gender, matched by pre-operative clinical and radiological presentation, and with post-operative follow up of at least 2 years. The mean age at operation was 71 years and the mean follow-up was 5.9 years. In both groups, IKS score improved significantly, but without difference based on gender. No difference was found between groups in terms of range of motion, alignment, or radiologic progression of arthritis. These results suggest that when utilizing specific patient selection criteria, gender does not influence outcome following UKA. Unicompartmental knee arthroplasty (UKA) - Gender

The aim of this study is to analyse the influence of femoral cement on clinical and radiological results after total knee arthroplasty.Preoperatively 130 patients were randomly assigned to treatment in either the Cement Group or the Hybrid Group. The International Knee Society scores, femoral radiolucent lines and bone transparencies were compared.There were no significant differences concerning postoperative knee and function scores. We observed a significant difference in radiolucent lines (Cement Group, 24%; Hybrid Group, 2%; P0.001) as well as bone transparencies (Cement Group, 21%; Hybrid Group, 62%; P0.001). All radiolucent lines measured less than 2 mm in width.Cementing the femoral component of a total knee arthroplasty does not appear to influence the clinical results. A longer follow-up period is required to determine the influence of radiological findings on final outcome.

We present a case of chronic disruption of the patellar tendon in a patient with Osteogenesis Imperfecta. This patient was treated with a customized extensor mechanism allograft. Results were excellent at 5 years follow up. To our knowledge this treatment has not previously been published in this situation. We present this as a reliable treatment option.

Background: Total knee arthroplasty can involve substantial blood loss. We prospectively studied a consecutive series of patients undergoing primary total knee arthroplasty to assess the influence of femoral cementing on perioperative blood loss. We hypothesized that an uncemented femoral component is a risk factor for bleeding. Methods: A semiconstrained posterior stabilized prosthesis was used in all patients. Preoperatively, 130 patients were randomly assigned to either the cement group (Group 1) or the hybrid group (Group 2). We selected all patients who underwent a knee replacement through a medial parapatellar approach (n = 107). Group 1 consisted of forty-two women and twelve men ranging in age from fifty-six to eighty-five years. Group 2 consisted of thirty-seven women and sixteen men ranging in age from fifty-six to eighty-five years. The hemoglobin and hematocrit levels were recorded preoperatively and five days postoperatively for each patient. The volumes of postoperative suction drainage and the rate of blood transfusion were recorded. Results: No differences between the two groups were identified with regard to hemoglobin and hematocrit levels, total measured blood loss, postoperative drainage amounts, or transfusion rates. The total measured blood loss was 1758.9 mL for Group 1 and 1759 mL for Group 2. Conclusions: Cementing the femoral component during a total knee arthroplasty does not appear to influence the amount of perioperative blood loss or the need for postoperative blood transfusion.

The flexion of the femoral component in the sagittal plane in unicompartmental knee arthroplasty (UKA) was analyzed radiographically in this study. Thirty medial and 30 lateral UKAs were included. The sagittal flexion angles were measured both relative to the posterior femoral cortex and midline sagittal distal femoral axis. Both of the measurement methods revealed that the femoral components were inserted in a significantly more flexed fashion in the medial UKA group. Neither preoperative nor postoperative tibial slope did have any significant effect on the sagittal flexion angle. To the best of our knowledge, this is the first study demonstrating an angular difference in the sagittal flexion of the femoral components between medial and lateral UKAs.

A patellar dislocation is most likely a result of a number of anatomic and physiologic factors causing a failure of the extensor mechanism to deliver the patella into the femoral sulcus. The Lyon group has reported this experience in several articles [5,7,9,17–20]. In the episodic patellar dislocation (EPD) patient population, several morphological anomalies have been identified that facilitate or allow patellar dislocation [18]. The radiographic examination will detect, in more than 96% of cases, at least one of the four following features in EPD group: (1) trochlear dysplasia, (2) Patella Alta, (3) tibial tubercle-trochlear groove distance (TT-TG) >20 mm, and (4) patellar tilt >20°. The aim of the distal realignment is to correct one or two identifiable “main factors” for EPD, while the “fundamental factor,” i.e., trochlear dysplasia, itself may not be corrected. In order to lower or medialize the distal extensor mechanism, different surgical techniques have been proposed and described. They all have in common that these techniques transfer the distal insertion of the patellar tendon [3,15,16].

The possibility to return to sporting activity can be an important consideration in the decision-making process in femorotibial osteoarthritis. We analyzed functional outcomes and sport participation in a continuous series of HTO and asked whether this procedure could match expectations in active and motivated patients. We retrospectively investigated activities, sports participation, and the level of satisfaction in 139 patients with unilateral noncomplicated HTO. The study included 41 women and 98 men with a mean age of 59 years and a mean 50 months of follow-up. Eighty-seven patients (63%) reported that their knee was “normal,” and eighty-six patients (62%) felt that their activities were limited by their knee. A total of 78 patients (56%) reported that they were as active as they expected to be before the intervention. Of these patients, 98% were satisfied. Of the patients who were not as active as they thought they would be, 51% were satisfied (P

According to literature, knee arthroscopy is a minimal invasive surgery performed for minor surgical trauma, reduced morbidity and shortens the hospitalization period. Therefore, this type of surgery before total knee arthroplasty (TKA) could be considered a minor procedure with minimum postoperative complication. A retrospective and cohort series of 1,474 primary TKA was performed with re-assessment after a minimum follow-up period of 2 years: 1,119 primary TKA had no previous surgery (group A) and 60 primary TKA had arthroscopic debridement (group B). All the patients underwent a clinical and radiological evaluation as well as IKS scores. Statistical analysis of postoperative complications revealed that group B had a higher postoperative complication rate (P < 0.01). In this group, 30% of local complications were re-operated and 8.3% of these cases underwent revision TKA (P < 0.01). The mean interval between arthroscopy and primary TKA was 53 months. However, statistical analysis did not reveal a direct correlation between arthroscopy/primary TKA interval and postoperative complications/failures (P = 0.55). The Kaplan-Meier survival curves showed a survival rate of 98.1 and 86.8% at 10 years follow-up for groups A and B, respectively. Our data allow us to conclude that previous knee arthroscopy should be considered a factor related to postoperative primary TKA outcomes as demonstrated by the higher rate of postoperative complications and failures (P < 0.001) as well as a worse survival curve than group A.

Summary Unicompartimental knee arthroplasty outcome is sometimes compared to total knee arthroplasty but various implant parameters might greatly influence this outcome. The objectives of this study were to report the results of a consecutive series of 172 all-polyethylene unicompartmental knee arthroplasties (UKAs) and to detail possible factors of success and failure. Hypothesis It is possible to outline implant and technique factors determining success or failure in unicompartimental knee arthroplasty. Materials and methods One hundred seventy-two HLS-type cemented resurfacing UKAs, with the femoral implant made of chrome-cobalt and the tibial implant tibial entirely in polyethylene (without anchorage studs) were consecutively implanted between 1988 and 2004 in 134 patients (111 females and 23 males) in our center according to the indications established in 1988, using the same technique for each surgery. The patients’ mean age was 72.2 years (range, 25–90 years). The review rate was 83.7% (144 UKAs), with a mean follow-up of 62.3 months (range, 24–160 months). The series included 84 medial UKAs and 60 lateral UKAs. The clinical data were analyzed using the IKS criteria and the patients had a complete radiological evaluation before surgery and at the last follow-up. Results The rate of satisfied or very satisfied patients was 97.2%. No pain or slight pain was found in 81% of the cases. The mean flexion was 133° (range, 85–150°). The mean knee score varied from 63.6 before surgery to 91.5 (90.4 for medial UKAs and 92.9 for lateral UKAs) and the function score from 63.6 to 83.8 (84.7 for medial UKAs and 82.6 for lateral UKAs). The mean range of motion was 133° (range, 85–150°), better than the medial UKAs for osteonecrosis. The mean residual deformity was 4° varus for the medial UKAs and 2° valgus for the lateral UKAs. A radiolucency was found in 23% of the cases (20% tibial and 3% femoral), nonprogressive in all cases. In 87.2% of the cases, the opposite femorotibial compartment remained radiologically normal. No progression to osteoarthritis in the femoropatellar joint required additional surgery. Sixteen patients required revision surgery: in six cases, the implant was removed and a total prosthesis implanted (one late infection, one case of involvement of the opposite compartment, and four cases of tibial component loosening). In the other cases, one tibial baseplate was changed, five arthroscopies were done, and four unicompartmental knee replacements were done on the opposite compartment. The Kaplan-Meier survival rate (taking into account the revisions with implant change) was 95.6. The results of this series were very satisfactory and were similar to recent series in the world literature that showed survival rates between 90 and 98% at 10 years, rates that are equivalent to those found for total knee replacements. The mean flexion range of motion found was higher than the majority of other recent series, probably because of the precise patient selection in the present study, a minimally invasive approach, and the femoral implant design with an ascending condylar posterior cut. The deterioration of the contralateral compartment is frequently reported, but was perhaps prevented by the absence of overcorrection and patient selection. In this series, none of the UKAs was revised for wear. We explain this by the systematic preservation of a moderate undercorrection, particularly for medial UKAs, the quality of the polyethylene, and a selection based on patient weight and age. Conclusions The option of an all-polyethylene tibial implant, with minimal bone cuts (femoral resurfacing), makes excellent long-term results possible. Level of Evidence: Level IV. Therapeutic Study.

The purpose of this study was to analyze the in vivo dimensions of each tibial plateau for planning of unicompartmental knee arthroplasty (UKA), and to compare the morphometric data to the dimensions of nine current designs of UKA tibial components. Thirty-seven knees (31 females and 6 males) operated on with UKA were studied. All patients were examined postoperatively using computed tomography (CT). There were 18 lateral and 19 medial UKAs. On the CT scan, each operated tibial plateau was measured in the transverse plane at the resection level, just below the full polyethylene tibial component. We measured the length of the anteroposterior (AP) cut as well as the maximal mediolateral dimension of the resected plateau (perpendicular to the AP cut). We compared the measurements with nine current UKA systems: Accuris (Smith and Nephew), Advance (Wright Medical), HLS Uni Evolution (Tornier), Miller-Galante and 'ZUK' (Zimmer), Oxford and Oxford a (Biomet), Preservation (DePuy) and Unix (Stryker). There was good correlation between patient height and mediolateral dimension (r = 0.6), and between patient height and area of total tibial plateau (r = 0.7). The anteroposterior dimension was greater for the medial plateau (mean 50.8 mm, SD 3.3) than for the lateral plateau (mean 47.2 mm, SD 3.3). This difference was statistically significant (P = 0.0016). Some UKA implants are designed with an asymmetric femoral component, but none have an asymmetric tibial component. The present study suggests, however, that the shape of the medial tibial plateau differs from that of the lateral plateau. This difference can lead to mediolateral overhang for medial UKA, if the surgeon aims for optimal anteroposterior coverage.

The objective of this study was to investigate the influence of tibial tubercle osteotomy on postoperative outcome, intra- and postoperative complications, as well as postoperative clinical results and failures in primary total knee arthroplasty (TKA). In a continuous, consecutive series of 1474 primary TKA, we analysed 126 cases where a tibial tubercle osteotomy approach was performed and 1348 cases without tibial tubercle osteotomy. Before surgery, all patients underwent a systematic assessment that included a clinical examination, radiographs (stress hip-knee-ankle film [pangonogram], weight bearing, anteroposterior knee view, schuss view, profile and patellar axial view at 30 degrees, stress valgus and varus view) and International Knee Society scores. When analysing intraoperative complications, tibial plateau fissures or fractures and tibial tubercle fracture were considered as complications relating to the tibial tubercle osteotomy group (p

Many authors presented the epicondylar axis as the fixed axis of rotation of the femoral condyles during flexion of the knee. Positioning of the femoral component of a total knee arthroplasty (TKA) based on the epicondyles has been proposed. This work is a critical analysis of this concept. Metallic bodies were inserted at the level of collateral ligament insertions on 16 dried femurs, allowing us to locate the surgical epicondylar axis. The dried femurs were studied using standard radiographs and CT-scan. CT cuts were made perpendicular to the epicondylar axis. The medial mechanical femoral angle and the epicondylar angle were measured on the radiographs. The posterior and distal epiphyseal rotations relative to the epicondylar axis (Posterior Condylar Angle, PCA, and Distal Condylar Angle, DCA, respectively) were measured on the CT-scans. PCA and DCA values were compared. The centre of the posterior femoral condyles was located on sagittal reconstructions using the tangent method and was confirmed with circular templates, and then compared to the location of the epicondyles. Circle-fitting of the entire femoral condylar contours centred on the epicondyles was also tried. The mechanical femoral axis was nearly perpendicular to the epicondylar axis but with important variations. The average PCA and DCA were 1.9 degrees +/- 1.8 degrees and 3.1 degrees +/- 2.1 degrees , respectively. No relationship could be established between the mechanical femoral angle and the PCA. The individual differences between the PCA and the DCA averaged 2.2 degrees . A significant distance was found between the centre of the condylar contours and the epicondyles: 6.5 mm in average on the lateral side (range 2.3-11.3 mm) and 8.4 mm on the medial side (range 4.0-11.6 mm). Circle-fitting of the entire medial or lateral femoral condylar contours centred on the epicondyles was not possible. The centre of the posterior femoral condyles is significantly different from the epicondylar axis, thus refuting the conclusions of previous authors. Furthermore, considering the differences between the distal and posterior condylar angles shown here, as well as the difficulty of repeatably locating the epicondyles during surgery, using the epicondylar axis as the only landmark to position the femoral component during a first intention TKA is not recommended. The surgical epicondylar axis does not appear to be an adequate basis for the understanding of the shape of the distal femur.

Introduction Les complications mecaniques a moyen et long terme representent une part importante des evenements secondaires a la chirurgie prothetique du genou, souvent lies au dessin de l’implant utilise. Le but de cette etude est d’evaluer leur proportion pour un type d’implant donne, et ainsi permettre au chirurgien d’apporter une information claire au patient. Materiel et methode Nous avons realise une etude descriptive retrospective monocentrique sur une serie de 4014 protheses totales de genou consecutives de premiere intention (protheses postero-stabilisees par troisieme condyle, laboratoire Tornier). Nous avons rapporte les differentes complications mecaniques secondaires, ainsi que le taux de reintervention necessaire. Nous avons egalement compare les resultats fonctionnels et la satisfaction des patients presentant ces complications par rapport aux autres patients de la serie. Nous avons enfin compare la survie des implants entre ces deux groupes, avec un recul moyen de 40 mois. Resultats Au dernier recul, on denombrait 192 complications mecaniques (hors infection) (4,78 %) chez 177 patients (4,41 %). La complication mecanique principale etait la raideur avec 67 patients (1,67 %) - 43 avaient subi une mobilisation sous anesthesie (1,07 %) et 12 une nouvelle intervention (0,3 %). Les fractures representaient la seconde complication avec 54 patients (1,35 %) - 33 fractures de la rotule (0,82 %), 9 du femur (0,22 %) et 11 du tibia (0,27 %). Les clunk syndromes etaient la troisieme grande complication avec 25 patients (0,62 %) dont 19 reoperes (0,47 %). Les complications directement liees a l’implant recensaient 21 patients (0,52 %) - 18 descellements aseptiques (0,45 %, dont 3 a la rotule, 9 au tibia, 2 au femur et 3 globaux), 2 usures du polyethylene (0,05 %) et 1 rupture d’implant (0,02 %). Enfin, 11 patients avaient une laxite pathologique (0,27 %, dont 9 secondaires a un defaut d’equilibrage dans le plan frontal et 2 dans le plan sagittal), 10 une instabilite rotulienne (0,25 %) et 4 une rupture de l’appareil extenseur (0,1 %). La survie des implants etait de 76,84 % pour le groupe avec complication mecanique contre 99,04 % pour le groupe sans complication, avec une difference significative (p Conclusion cette serie consecutive de 4014 protheses postero-stabilisees par 3e condyle retrouve 4,78 % de complications mecaniques a 40 mois de recul. Un descellement ou une instabilite etait exceptionnellement rapportes. Ces resultats sont comparables a ceux rapportes dans les grandes series de protheses postero-stabilisees plus contraintes type plot-cams.

Introduction Le delai de remise en charge complete apres osteotomie tibiale de valgisation par ouverture interne reste controverse. Hypothese L’utilisation de plaques d’osteosyntheses a vis verrouillees permet un appui complet d’emblee, sans difference sur les scores fonctionnels par rapport a une reprise de l’appui a deux mois. Patients et methode Une etude prospective randomisee a inclus 50 patients, âges de 40 a 65 ans, operes sous la responsabilite de quatre chirurgiens senior entre janvier 2008 et septembre 2012. La technique etait identique - osteotomie d’ouverture interne, plaque a vis verrouillees (TomoFix™, Synthes)absence de greffe. La correction ne devait pas exceder 10°. La randomisation se faisait au hasard, l’appui etait autorise d’emblee ou differe de 2 mois. Le suivi etait de 1 an, les scores IKSIKDC, l’EVA douleur et des radiographies etaient realises en preoperatoire et durant le suivi. Les complications etaient relevees. Resultats Le score IKDC passait de 49,7 A 18,5 en preoperatoire a 68,8 A 13,8 au controle a un an dans le groupe appui immediat (p Discussion L’osteotomie par ouverture interne sans greffe osseuse avec plaque a vis verrouille permet un appui complet d’emblee sans perte de correction. La remise en charge precoce n’a pas eu d’influence sur les resultats fonctionnels a un an. La douleur reste le principal frein.

Introduction Il a recemment ete reproche aux protheses unicompartimentales (PUC) de resurfacage une restitution aleatoire de l’interligne articulaire. La chirurgie robotique est un des outils qui devrait permettre d’optimiser le niveau de cet interligne apres PUC. L’objectif de ce travail etait d’analyser ce parametre dans une etude cas-temoins comparant chirurgie robotique et technique conventionnelle. Patients et methode Nous avons analyse de maniere retrospective les donnees collectees prospectivement de 2 groupes de patients apparies operes d’une PUC par resurfacage entre 2013 et 2015 avec le meme implant (HLS Uni evolution, TORNIER y). Nous avons compare un groupe ayant eu une chirurgie conventionnelle (groupe temoin, n = 25) et un groupe ayant eu une chirurgie assistee par robotique (groupe robot, n = 25). Les groupes etaient composes de 17 femmes et 8 hommes, les etiologies etant une arthrose chez 20 patients et une necrose condylienne chez 5 patients dans chaque groupe. Pour evaluer la restitution de l’interligne articulaire, nous avons employe 2 methodes validees sur des radiographies preoperatoires et postoperatoires a 2 mois de recul, en appui. On se referait a l’angle entre l’interligne articulaire et la corticale laterale du femur (methode 1) et a l’angle entre l’interligne articulaire et l’axe centro-medullaire du femur (methode 2). Une valeur positive representait une distalisation de l’interligne articulaire. Resultats Cinquante PUC ont ete analysees chez 48 patients - 16 PUC internes et 9 PUC externes dans chaque groupe. La preservation de l’interligne articulaire etait significativement amelioree dans le groupe robotique par rapport au groupe temoin : +1,6 mm (max : 6, min : −3, ecart-type : 2,12) vs + 5,0 mm (9, 2, 2,11) (p Conclusions Cette etude montre grâce a deux methodes de mesure validees que la restauration de l’interligne articulaire pour les PUC de resurfacage peut etre amelioree par la robotique. Cela pourrait permettre d’eviter les douleurs tibiales dues a une resection osseuse trop importante comme cela a pu etre reproche a ce type d’implant. Une amelioration des scores cliniques reste a demontrer sur des etudes avec un suivi a long terme.

It remains unproven that playing football increases the risk of osteoarthritis of the knee. However, injuries caused by playing football are without doubt an important factor in the onset of osteoarthritis. Strenuous sport activities induce the majority of detachments or ruptures of the medial meniscus, especially as a complication of ACL rupture. Direct trauma to joint surfaces can lead to osteoarthritis. In addition, indirect trauma can occur as a consequence of cruciate ligament or meniscal injuries that result in repetitive, abnormal, anterior tibial translation. Such translation generates shear forces in cartilage, leading to premature osteoarthritis.

Summary Background Rotation of tibial component has not been analysed in literature for unicompartmental knee arthroplasty. The purpose of the study was to determine and compare the rotation of medial and lateral unicompartmental knee arthroplasty (UKA) tibial components. We assumed both components (lateral and medial) were positioned with external rotation. Material and methods Eighteen lateral and 19 medial UKA patients were scanned postoperatively in neutral position with computed tomography enabling lower extremity three-dimensional image acquisition from the hip to the ankle. All the patients were operated by three different senior surgeons using the same surgical technique. From the reconstructions we measured the two-dimensional (2D) rotation of the tibial components. Results The rotation of the tibial component was external (mean 6.5°, SD 5.1°) for the medial UKA and external (mean 7.3°, SD 10.3°) as well for the lateral UKA. The difference was statistically insignificant (p = 0.717). Discussion This study presents the first 2D in vivo analysis accurately determining and comparing medial and lateral UKA component rotation. Despite a wide range of value, we found both components were indeed externally rotated. The variability in implant positioning was observed despite the rigorous performance of an experienced surgeon using routine techniques in patients selected under routine criteria. Further analysis of these patients for satisfaction and implant survivorship in relation to implant rotation may give us an optimal range for the tibial component. If it is found that this ideal range cannot be consistently obtained with current surgical techniques then there may be a case for the use of a navigation system. Level of evidence Level IV Retrospective study.

Introduction Les donnees de la litterature concernant les reprises iteratives de prothese totale du genou (RRPTG) sont peu nombreuses. Les causes de faillite des reprises de PTG (RPTG) sont le sepsis, les problemes concernant l’appareil extenseur, le descellement aseptique et moins frequemment les problemes d’instabilite femoro-tibiale. Le choix de la contrainte est un probleme recurrent lors de la programmation de ces RRPTG. Nous avons voulu nous appuyer sur notre experience clinique (etude retrospective) pour preciser les arguments dictant le choix de cette contrainte. Materiel et Methodes Entre 1990 et 2006, 16 RRPTG ont ete realisees dans le service, chez 11 femmes et 5 hommes (7 genoux droits, 9 gauches). L’âge moyen au moment de l’intervention etait de 70 ans. 8 RRPTG concernaient des RPTG de type charniere rotatoire. Les causes d’echec de ces RPTG etaient une facture sur prothese, un descellement aseptique ou une rupture d’axe. 8 RRPTG concernaient des RPTG de type postero stabilisees (dont 1 de type CCK). Les causes d’echec etaient une fracture sur prothese, un descellement aseptique, une instabilite femoro-tibiale ou un conflit des implants avec les parties molles du fait d’un mauvais positionnement. Resultats La totalite des RPTG charniere rotatoire ont ete reprises par des RRPTG de meme type. 50 % des RPTG postero-stabilisees ont ete reprises par des RRPTG de meme contrainte : le probleme etait osseux (fracture ou descellement) mais avec des ligaments collateraux competents (objectives par des cliches en stress). L’autre moitie des RPTG postero-stabilisees a necessite une RRPTG charniere rotatoire : une defaillance des ligaments collateraux etait suspectee (d’origine mecanique ou associee a une pathologie neurologique) ou bien il s’agissait d’un echec de reprise par CCK. Discussion Si la reprise d’une PTG charniere peut faire discuter une RPTG postero-stabilisee, la reprise d’une RPTG charniere necessite l’utilisation d’une RRPTG charniere rotatoire. Par contre en cas de reprise d’une RPTG postero-stabilisee, le recours a une RRPTG charniere n’est pas obligatoire. Il dependra essentiellement de l’etat des ligaments collateraux. D’autres facteurs secondaires, sont egalement a prendre en consideration : la raideur, une modification de la hauteur de l’interligne ou des pertes osseuses consequentes peuvent conduire a preferer une prothese charniere. Conclusion Si l’utilisation d’une prothese charniere dans les reprises iteratives de PTG est un choix frequemment adopte par les chirurgiens, ce n’est pas la seule option. Dans certains cas (25 % dans notre experience), une RRPTG postero-stabilisee peut etre realisee.