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When? Only patients with high-grade trochlear dysplasia types B and D, in which the prominence of the trochlea (supratrochlear spur) is over 5 mm, recurrent patellar dislocation, and maltracking. How? Sulcus deepening trochleoplasty: modifies the trochlear shape with a central groove and oblique medial and lateral facets; decreases the patellofemoral joint reaction force by reducing the trochlear prominence (spur); and reduces the tibial tubercle and the trochlear groove value by a proximal realignment. Pros: This procedure is highly effective in restoring patellofemoral stability and satisfying the patients. Cons: The patients must be aware of the risk of continuing residual pain and range-ofmotion limitation and that the development of patellofemoral osteoarthritis is not predictable.

Resume Introduction Chez un patient au-dela de 50 ans, la litterature est peu fournie, mais les resultats apres chirurgie sont bons, sous reserve que les patients aient ete bien selectionnes. Dans cette tranche d’âge, il est cependant habituel de proposer un traitement non chirurgical, les patients preferant le plus souvent diminuer leurs activites sportives. Les resultats du traitement conservateur restent acceptables mais avec un risque important d’instabilite residuelle, de lesions associees secondaires et d’une modification des activites. L’objectif principal de ce travail etait de comparer les resultats de la prise en charge chirurgicale et non chirurgicale d’une rupture du LCA chez des patients de plus de 50 ans. Les objectifs secondaires etaient : de rechercher l’existence d’eventuels facteurs pronostics de mauvais resultats fonctionnels, et de comparer du point de vue epidemiologique les deux groupes en cherchant les arguments cliniques pouvant aider a la decision therapeutique. L’hypothese etait que les resultats sont comparables entre les 2 groupes. Materiel et methode Le suivi a ete prospectif sur un collectif de 320 patients (92 non operes [GNO], 228 operes [GO]). Les donnees epidemiologiques classiques etaient notees. En pre- et postoperatoire la laxite clinique, la laximetrie differentielle, les scores KOOS, IKDC, Tegner, ACL-RSI et l’evaluation radiologique ont ete realises. Les donnees per-operatoires etaient notees. Les complications precoces et tardives etaient colligees. Resultats Tous les patients etaient revus. Le patient type etait une femme, mais qui etait plus âgee, moins sportive, avec un genou plus stable et une repercussion fonctionnelle moins marquee dans le GNO. Les scores fonctionnels etaient ameliores pour les 2 groupes, mais ils etaient meilleurs pour le GO avec des scores d’activite sportive egalement meilleurs. Pour le GNO la laximetrie au recul etait liee a un Jerk franc preoperatoire (p = 0,024). Le facteur de mauvais pronostic pour le score IKDC etait l’existence d’une laxite differentielle preoperatoire importante (p = 0,06). Concernant le GO l’importance de la laximetrie au recul etait liee a un Jerk explosif preoperatoire (p Discussion/Conclusion Les resultats sont satisfaisants dans les 2 groupes, avec une augmentation significative des scores fonctionnels quelle que soit la prise en charge therapeutique, mais sont meilleurs pour le groupe opere. Pour le GNO les sports pivots sont difficilement praticables, avec une baisse des scores d’activite sportive. En cas de laxite importante au moment du diagnostic un traitement chirurgical doit etre propose. Niveau d’evidence III ; serie prospective comparative non randomisee.

Purpose To update previously published outcomes (at 2-8 years) of second revision anterior cruciate ligament reconstruction (ACLR) combined with tibial deflexion osteotomy (TDO), after an interval of 5 more years (at 7-15 years), and monitor evolution of clinical scores and progression of osteoarthritis. Methods The initial retrospective consecutive series included nine patients that underwent one-stage second revision ACLR with TDO, all of whom were contacted for second follow-up at minimum 7 years. An independent observer collected IKDC-SKF, the Lysholm score, and assessed radiographs for signs of osteoarthritis. Results Of the nine original patients, seven were assessed at the clinic, one could only be assessed by telephone, and one was lost to follow-up. At final follow-up of 9.9 ± 3.0 years, the eight patients assessed maintained or improved clinical scores, compared to the previous follow-up at 4.0 ± 2.9 years. The mean Lysholm score improved from 73.8 ± 5.8 (65-82) to 84.5 ± 11.9 (59-95), and IKDC improved from 71.6 ± 6.2 (62-79) to 82.9 ± 12.1 (61-98). Of the three patients that had signs of arthritis at the previous follow-up, the stage of osteoarthritis increased in one (from grade 2 to grade 3), remained unchanged in one, and could not be assessed in one. Conclusion At 7-15 years following second revision ACLR with TDO, patients maintained or improved clinical scores compared to the previous follow-up at 2-8 years, without retears or reoperations. Although eight of the nine knees had meniscectomies or meniscal sutures, osteoarthritis progressed in only one of the six knees that had signs of arthritis at the previous follow-up. These results confirm that TDO can protect the ACL graft from retear, with minimal progression of osteoarthritis and/or risks of meniscal tears, suggesting that correction of excessive tibial slope should be considered when performing ACLR, whether a revision or primary procedure.

Resume La dysplasie de trochlee est caracterisee par un defaut de creusement de la trochlee, a l’origine d’une trochlee plate, voire convexe. C’est le facteur de risque principal de la luxation patellaire. L’indication chirurgicale repose sur la connaissance et l’identification des dysplasies de trochlee, surtout celles de haut grade, qui sont depistees par l’examen clinique, l’analyse de l’imagerie standard et en coupes, et la quantification des facteurs d’instabilite associes. Une strategie therapeutique peut alors etre definie en utilisant le « menu a la carte » corrigeant un par un ces facteurs de risques. La trochleoplastie de creusement qui permet de corriger la forme de la trochlee est le traitement etiologique de ce type de dysplasie. Elle donne de meilleurs resultats sur le taux de recidive de luxation mais a la reputation d’enraidir le genou et d’etre source d’arthrose femoro-patellaire. L’indication de trochleoplastie est portee devant une instabilite patellaire objective, associee a une dysplasie de haut grade type B ou D. Elle doit etre systematiquement associee a une reconstruction du ligament femoro-patellaire medial. La section du retinaculum lateral est systematique car la bascule patellaire n’est jamais reductible dans ces dysplasies de haut grade. La trochleoplastie permet de corriger a la fois le defaut de creusement, de supprimer la proeminence et de permettre un realignement proximal. Ses complications sont principalement la raideur et les douleurs liees a la persistance ou l’apparition de lesions cartilagineuses. Au total, la trochleoplastie doit etre indiquee 1/en premiere intention dans l’instabilite patellaire objective associee a une dysplasie de haut grade et 2/en cas de recidive dans les dysplasies de haut grade ayant deja fait l’objet d’interventions sans trochleoplastie. Le but de ce travail est de faire sur le point sur la trochleoplastie en repondant aux questions suivantes : Comment definir la dysplasie de haut grade ? Quels sont les points essentiels de leur analyse clinique et radiologique ? Quels sont les facteurs de risque associes de luxation patellaire ? Quelles sont les techniques de trochleoplastie ? Quels resultats en attendre ? Niveau de preuve V ; avis d’expert.

The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision.The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document.The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below.ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance.II.

To determine whether patient-specific instrumentation (PSI), computer-assisted surgery (CAS) or robot-assisted surgery (RAS) enable more accurate rotational alignment of the tibial baseplate in primary total knee arthroplasty (TKA) compared to conventional instrumentation, in terms of deviation from the planned target and the proportion of outliers from the target zone. The authors independently conducted three structured electronic literature searches using the PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases from 2007 to 2020. Studies were included if they compared rotational alignment of the tibial baseplate during TKA using conventional instrumentation versus PSI, CAS, and/or RAS, and reported deviation from preoperatively planned rotational alignment of the tibial baseplate in terms of absolute angles and/or number of outliers. Methodological quality of eligible studies was assessed by two researchers according to the Downs and Black Quality Checklist for Health Care Intervention Studies. Fifteen studies, that reported on 2925 knees, were eligible for this systematic review, of which 6 studies used PSI, and 9 used CAS. No studies were found for RAS. Of the studies that reported on angular deviation from preoperatively planned rotational alignment, most found smaller deviations using PSI (0.5° to 1.4°) compared to conventional instrumentation (1.0° to 1.6°). All studies that reported on proportions of outliers from a target zone (± 3°), found lower rates of outliers using PSI (0 to 22%) compared to conventional instrumentation (5 to 96%). Most studies reported smaller angular deviation from preoperatively planned rotational alignment using CAS (0.1° to 6.9°) compared to conventional instrumentation (1.1° to 7.8°). Of the studies that reported on proportions of outliers from a target zone (± 3°), most found fewer outliers using CAS (10 to 61%) compared to conventional instrumentation (17 to 78%). This systematic review and meta-analysis revealed that both CAS and PSI can improve the accuracy of rotational alignment of the tibial baseplate by decreasing angular deviation from the preoperatively planned target and reducing the proportion of outliers from the target zone. The clinical relevance is that PSI and CAS can improve alignment, though the thresholds necessary to grant better outcomes and survival remain unclear. IV.

Purpose: The European Society for Sports traumatology, Knee surgery and Arthroscopy (ESSKA) identified the need to develop a core curriculum for clinical specialists that work within the interest areas of ESSKA. A research-based approach was used to define a set of core competencies which could be used to map all of their educational activities, resources and development priorities. This paper describes the aims, development, results and implications of this competency-based core curriculum for orthopaedic conditions relevant to ESSKA members. Methods: A Core Curriculum Working Group, with leaders and other experts representing the main specialist areas within ESSKA, reviewed existing curricula and the literature in their own specialist areas. Applying expert group methodology, they iteratively developed a draft list of 285 core competencies for Orthopedic specialists within 6 specialist areas of Knee, Shoulder, Foot/Ankle, Hip, Elbow/Forearm and Sports/Exercise. All ESSKA members were then asked to comment and rate the importance of these competencies, and the Working Group used these findings to critically review and refine the curriculum. Results: The expert groups defined 56 competencies related to 10 Knee pathologies; 67 related to 15 Shoulder pathologies; 45 related to 9 Foot/Ankle pathologies; 41 related to 6 Hip pathologies; and 34 related to 12 Elbow/Forearm pathologies and 42 related to 8 Sports/Exercise pathologies. Survey respondent mean ratings were at least ‘Important’ for all competencies, and the Working Group used these results to separate the competencies into three levels of importance. Conclusion: A competency-based core curriculum for Orthopedic specialists was achieved through a systematic and scholarly approach, involving both expert opinion and engagement of the wider ESSKA membership, identifying 285 treatment competencies in 6 specialist areas. It is now being used to guide educational and strategic development for ESSKA and should also be of interest to the wider orthopedic and sports medicine communities.

The patellofemoral joint (PFJ) is a highly complex structure. The clinical presentation of PFJ instability contains a spectrum of manifestations (with symptoms like pain, subjective instability, pseudolocking and true dislocation) that can be subtle and very difficult to correctly diagnose and treat. In 1987, in an edition of the Journees Lyonnaises de Chirurgie du Genou, Henri Dejour and Gilles Walch precisely set the basic principles and diagnostic rationale for patellar instability, describing four major anatomical factors leading to instability: trochlear dysplasia, abnormal patellar height, high tibial tubercle to trochlear groove distance and high patellar tilt. In addition to these major predisposing anomalies, secondary instability factors had been identified, such as torsional and lower limb alignment anomalies and muscular weaknesses or imbalance. In PFJ instability a complete and careful analysis of the patient’s medical history, clinical and imaging evaluation is essential to properly assess the presence of anatomical anomalies, instability predisposing factors and subsequent surgical indications. After collecting all information, it is of a paramount importance to correctly select which patients are eligible for surgical interventions. Surgical treatment often includes a combination of procedures rather than any isolated one to correct each of the detected abnormalities as described in the algorithm ‘le menu a la carte’ presented by Henri Dejour in 1987. The main objective of PFJ surgery is the prevention of recurrent dislocations. Therefore the treatment algorithm consists of a list with each etiological anatomical abnormality (with correspondent thresholds) and its individual corrective procedures. The surgeon will need to combine soft tissue and bony procedures to address all the involved factors, each corrected individually.

Trochlear dysplasia has been recognized as the most common factor in patients with patellofemoral dislocation. Trochleoplasty is a surgical procedure whose primary goal is to modify the femoral trochlea's abnormal shape in patients suffering from patellar instability, requiring good surgical skills, correct indication, and accurate patient information.The review aims to describe preoperative planning, patient selection, most common surgical techniques, and clinical results of trochleoplasty in patellar instability in a reproducible manner.Trochleoplasty can be considered a general term to describe a group of different procedures that reduce trochlear dysplasia's impact on patellar instability, aiming to restore patella-trochlear congruency, remove the supratrochlear bump, allowed a new groove positioning and are generally associated with other procedures. Recent studies showed satisfactory long-term results with the restoration of patellar stability, improving radiological findings of patellofemoral instability.Trochleoplasty is a technically demanding technique, requiring careful patient selection, detailed knowledge, and surgical skills to avoid severe complications. Good patient satisfaction with a low risk of significant complications such as patellofemoral arthritis has been revealed. In conclusion, trochleoplasty should be systematically included in the treatment of patellar dislocation, if indicated.V.

As the incidence of anterior cruciate ligament (ACL) reconstructions continues to increase, the rate of revision surgery continues to climb. Despite advances in the technical aspects and rehabilitation protocols following primary ACL surgery, the rate of revision and even re-revision remains higher than desired.

Trochleoplasty in patellofemoral instability has always been controversial. Most authors recognize the fundamental role of trochlear dysplasia in the genesis of patellar dislocation, and some strongly defend correcting the abnormality, yet others find it too dangerous or unnecessary. Misunderstanding or undervaluation of trochlear dysplasia leads to inappropriate or failed patellofemoral (PF) surgery, the iatrogenic complications of which are well known. Many surgeons miss a key aspect of trochlear dysplasia: the overhang or the prominence of the trochlea relative to the anterior femoral cortex, characterized by a supra-trochlear spur. Trochleoplasty should not be performed as a secondary or revision procedure, but as a primary procedure with clear indications, and the key to improved outcomes is to ensure the right indication for each patient, which can only be determined by understanding the extent of dysplasia in both the axial and sagittal planes.

Resume Introduction La reconstruction du LCA est de plus en plus proposee chez des patients de plus de 50 ans. La chirurgie avait cependant mauvaise reputation dans cette categorie d’âge en raison essentiellement de complications a type de raideur. Une serie prospective de patients de plus de 50 ans operes d’une reconstruction du LCA (groupe 1) a ete comparee dans la meme periode a une population de patients de moins de 40 ans (groupe 2). L’hypothese principale de cette etude etait que la chirurgie du LCA donne les memes resultats fonctionnels apres 50 ans qu’avant 40 ans, sans augmentation du taux de complications. Methodes Il s’agissait d’une etude prospective multicentrique non randomisee de suivi clinique. Le suivi a ete prospectif sur un collectif de 228 patients de plus de 50 ans et 130 patients de moins de 40 ans, au sein de 10 centres prives et public. Les donnees epidemiologiques etaient notees. En pre- et postoperatoire la laxite clinique, la laximetrie differentielle, les scores KOOS, IKDC, Tegner, ACL-RSI et l’evaluation radiologique ont ete realises. Les donnees per-operatoires etaient notees. Les complications precoces (survenant avant 3 mois) et tardives (au-dela de 3 mois) etaient colligees. Les scores fonctionnels au dernier recul (14,2 mois (3,5–30,5) pour le groupe 1 et de 20,5 mois (11,4–29,4) pour le groupe 2) etaient compares entre les 2 groupes. Resultats L’etude epidemiologique a mis en evidence des differences entre les deux groupes : predominance des femmes dans le groupe 1, (59 % versus 35 %), un delai accident-chirurgie plus eleve dans le groupe 2 (23,6 semaines versus 8,7), une predominance des sports pivot-contact (sports d’equipe) dans le groupe 2 (49 % versus 6 %) et une predominance des sports pivot dans le groupe 1 (Ski). De meme, le score de Tegner etait plus faible apres 50 ans (5,2 versus 7,6). Nous avons retrouve plus de lesions meniscales dans le groupe 1 (68 % versus 36 %) et 76 % de lesions chondrales (versus 10 %). La laxite initiale etait identique (6,5 mm dans le groupe 1 et 6,7 mm dans le groupe 2). Le type de chirurgie utilise est similaire avec 86 % de greffe aux ischio-jambiers pour le groupe 1 et 89 % dans le groupe 2. Les complications precoces etaient plus importantes dans le groupe 1 (hematome) et le taux de complications tardives etait similaire. Au dernier recul, la laxite mesuree etait identique dans les deux groupes avec 2,2 mm de laxite residuelle. On retrouvait aussi le meme taux de test de Lachman avec arret dur et d’absence de ressaut rotatoire. Le resultat sur la qualite de vie a montre un score KOOS plus favorable dans le groupe 2 meme si le score ACL-RSI est identique. Le resultat global IKDC etait legerement meilleur dans le groupe 2 bien explique par l’existence des lesions arthrosiques chez les patients plus âges. Conclusion La chirurgie du LCA apres 50 ans donne de bons resultats, elle permet de corriger la laxite de la meme maniere que chez un patient de moins de 40 ans et avec les memes techniques et sans plus de complications. Le retour au sport se fait dans des delais similaires avec un retour au niveau initial. Niveau d’evidence III, etude prospective comparative non-randomisee.

Resume Introduction La population mondiale vieillit dans de bonnes conditions de sante, les patients âges de plus de 50 ans representent une part importante de la population active et sportive, avec une hausse des ruptures du ligament croise anterieur (LCA). Autrefois reservee aux jeunes sportifs, la reconstruction du LCA semble donner de bons resultats pour cette population. Le choix de la greffe et de son mode de fixation reste jusque-la empirique, sans etude menee sur leur influence sur les resultats cliniques et paracliniques. Afin de repondre a cette question, nous avons realise une etude chez des patients de plus de 50 ans operes d’une reconstruction du LCA en fonction du type de greffe et de son mode de fixation femorale. Hypothese Notre hypothese etait que la technique operatoire n’influencait pas les resultats cliniques ni la laximetrie. Materiel et methodes Dans cette etude portant sur 2 series multicentriques, retrospective entre le 1er janvier 2011 et le 31 decembre 2015 et prospective entre le 1er janvier 2016 et le 30 juin 2017, nous avons inclus respectivement 398 patients et 228 patients, avec un recul moyen respectivement de 42,7 mois et 14,2 mois. Le critere de jugement principal etait clinique avec les scores KOOS et Tegner. Le critere de jugement secondaire etait paraclinique avec la laximetrie differentielle. Les tests statistiques ont ete realises a l’aide des Wilcoxon rank sum tests et Kruskal-Wallis Tests avec un seuil de significativite p ≤ 0,05. Resultats Le nombre de plasties aux ischio-jambiers etait respectivement de 269 (67,6 %) et 197 (86,4 %) contre respectivement 124 (31,2 %) et 31 (13,6 %) pour les plasties utilisant l’appareil extenseur. Les fixations femorales etaient : 81 fixations corticales (20,4 %), 112 en press-fit (28,1 %) et 205 (51,5 %) avec une vis d’interference dans la serie retrospective, contre respectivement 135 (59,2 %), 17 (7,5 %) et 76 (33,3 %) dans la serie prospective. En analyse multivariee il n’y avait aucune difference significative en termes de scores KOOS, score Tegner et laximetrie differentielle entre les differents types de plasties et de mode de fixation femorale dans la serie retrospective. Dans la serie prospective, nous retrouvions, d’une part, une laximetrie superieure de 0,6 mm avec les plasties aux ischio-jambiers (p = 0,007), et d’autre part une laximetrie superieure de 0,3 mm (p = 0,029) et un score Tegner moyen inferieur de 0,5 points (p = 0,033) pour les plasties au Tendon rotulien en press-fit en comparaison aux fixations corticales, mais pas de difference de score KOOS. Ces differences n’avaient pas de significativite clinique. Discussion Les differentes techniques de reconstruction du LCA apres 50 ans donnent des resultats comparables. Leur choix peut etre fait en fonction des habitudes du chirurgien, sans se preoccuper de l’âge des patients. Niveau de preuve IV.

To determine demographic, anatomic, and surgical factors associated with static and dynamic Anterior Tibial Translation (ATT) following ACL reconstruction. The hypothesis was that both static and dynamic ATT would be greater in knees with high tibial slope or that required meniscectomy. The authors prospectively enrolled 280 consecutive patients that had primary ACL reconstruction using hamstring autografts at one center for which preoperative tear type, meniscal tears, and medial tibial slope were documented. A total of 137 were excluded due to concomitant extra-articular tenodesis or surgical antecedents on either knee, and 18 were lost to follow-up, leaving 125 that were evaluated at a minimum of 6 months including: static ATT on monopodal weight-bearing radiographs, and dynamic ATT on differential stress radiographs using the Telos™ device. Both postoperative static and dynamic ATT were strongly associated with preoperative static and dynamic ATT (respectively, β = 0.068 and β = 0.50, p

Place: France; International audience; INTRODUCTION: In patients aged over-50 years, although data are sparse, results of anterior cruciate ligament (ACL) surgery are good if selection is correctly performed. However, non-operative treatment is usually proposed for this age group, as patients generally prefer just to scale down their sports activities. Non-operative results are acceptable, but with a high risk of residual instability, secondary lesions and lifestyle alteration. The main aim of the present study was to compare results between surgical versus non-surgical treatment of ACL tear in over-50 year-olds. Secondary objectives comprised assessing prognostic factors for poor functional outcome, and comparing the 2 groups epidemiologically to identify clinical decision-making factors. The study hypothesis was that results are comparable between operative and non-operative treatment of ACL tear.MATERIAL AND METHOD: Three hundred twenty patients were followed up prospectively: 92 non-surgical (NS group) and 288 surgical (S group). Classical epidemiological data were collected. Clinical laxity, differential laximetry, KOOS, IKDC, Tegner and ACL-RSI scores and radiologic assessment were collected pre- and postoperatively, as were intraoperative data. Early and late complications were collected.RESULTS: All patients were followed up. Patients were principally female, and were older, less athletic, with more stable knee and less severe functional impact in the NS group. Functional scores improved in both groups, and especially in group S, where sports scores were also better. In the NS group, laximetry at follow-up correlated with preoperative marked pivot-shift (p=0.024). Severe differential laxity was predictive of poor IKDC score (p=0.06). In the S group, laximetry at follow-up correlated with preoperative explosive pivot-shift (p\textless0.001), lateral meniscal lesion (p=0.007), use of hamstring tendon (p=0.007), and non-operated early complications (p=0.004). Factors for poor global KOOS score in group S comprised female gender (p\textless0.001), high BMI (p\textless0.001) and skiing (p=0.038). Factors for poor Tegner scores comprised skiing or team sport (p\textless0.05), isolated moderate medial osteoarthritis (p=0.01), and non-operated early complications (p=0.022). Factors for poor IKDC score comprised female gender (p=0.064), and non-operated early complications (p=0.019). Complications did not differ between groups. DISCUSSION/CONCLUSION: Results were satisfactory in both groups, with significant improvement in functional scores, but were better in group S. For NS patients, pivot sport was barely feasible and sports activity scores decreased. In case of severe laxity at diagnosis, surgical treatment should be proposed.LEVEL OF EVIDENCE: III; non-randomized prospective comparative series

PurposeTo determine whether isokinetic muscle recovery following ACLR using a hamstring tendon (HT) would be equivalent (non-inferior) in knees that had high-grade pivot-shift and adjuvant modified Lemaire procedure versus knees that had minimal pivot-shift and no adjuvant modified Lemaire procedure.MethodsWe evaluated 96 consecutive patients that underwent primary ACLR. Nine were excluded because of contralateral knee injury, and of the remaining 87, ACLR was performed stand-alone in 52 (Reference group), and with a Lemaire procedure in 35 (Lemaire group) who had high-grade pivot-shift, age 20°. At 6 months, isokinetic tests were performed at 240°/s and 90°/s to calculate strength deficits of hamstrings (H) and quadriceps (Q). At 8 months, patients were evaluated using IKDC, Lysholm, and Tegner scores.ResultsCompared to the Reference group, the Lemaire group were younger (23.0 ± 2.5 vs 34.2 ± 10.5,p = 0.021) with a greater proportion of males (80% vs 56%,p p = 0.011). IKDC and Lysholm scores were similar in both groups, but Tegner scores were higher in the Lemaire group (median, 6.5 vs 6.0,p = 0.024).ConclusionsACLR with a modified Lemaire procedure for knees with rotational instability grants equivalent isokinetic muscle recovery as stand-alone ACLR in knees with no rotational instability. For ACL-deficient knees with high-grade pivot-shift, a Lemaire procedure restores rotational stability without compromising isokinetic muscle recovery.Study designLevel III, comparative study.

Trochlear dysplasia may be asymptomatic and benign, or could engender patellar instability and degenerative arthritis. Autologous chondrocyte implantation is demonstrating promising outcomes for the treatment of patellofemoral cartilage lesions, but may not suffice for knees with underlying mechanical anomalies as trochlear dysplasia, where adjuvant trochleoplasty or tibial tubercle osteotomy may be required to prevent patellofemoral instability and to protect the graft from wear and damage. Rigorous radiographic assessment is important to discern the type of dysplasia, notably the presence of a potentially pathogenic supra-trochlear spur. Trochleoplasty or other realignment procedures such as tibial tubercle osteotomy should be considered where necessary to correct underlying trochlear deformities and thereby avoid iatrogenic complications or failure.

PURPOSE: Several studies report satisfactory clinical outcomes following ACLR in older patients, but none evaluated the effects of meniscal and cartilage lesions. The aim was to evaluate the influence of meniscal and cartilage lesions on outcomes of ACLR in patients aged over 50years. METHODS: The authors prospectively collected records of 228 patients that underwent primary ACLR, including demographics, time from injury to surgery, whether injuries were work related, and sports level (competitive, recreational, or none). At a minimum follow-up of 6months, knee injury and osteoarthritis outcome scores (KOOS), International Knee Documentation Committee (IKDC) score and Tegner activity level were recorded, and differential laxity was measured as the side-to-side difference in anterior tibial translation (ATT) using instrumented laximetry devices. Regression analyses were performed to determine associations between outcomes and meniscal and cartilage lesions as well as nine independent variables. RESULTS: A total of 228 patients aged 54.8?±?4.3years at index ACLR were assessed at a follow-up of 14.3?±?3.8months. KOOS subcomponents were 85?±?13 for symptoms, 91?±?10 for pain, 75?±?18 for daily activities, 76?±?18 for sport, and 88?±?12 for quality of life (QoL). The IKDC score was A for 84 (37%) knees, B for 96 (42%) knees, C for 29 (13%) knees, and D for 8 (4%) knees. Tegner scores showed a decrease (median 0, range -4 to 4) and differential laxity also decreased (median - 4, range - 23.5 to 6.0). KOOS symptoms worsened with higher BMI (p?=?0.038), for women (p?=?0.007) and for knees that had medial meniscectomy (p?=?0.029). KOOS pain worsened with higher BMI (p???0.001), for women (p?=?0.002) and for knees with untreated (p?=?0.047) or sutured (p?=?0.041) medial meniscal lesions. Differential laxity increased with follow-up (p?=?0.024) and in knees with lateral cartilage lesions (p?=?0.031). CONCLUSION: In primary ACLR for patients aged over 50years, female gender and medial meniscal lesions significantly compromised KOOS symptoms and pain, while lateral cartilage lesions significantly increased differential laxity. Compared to knees with an intact medial meniscus, those with sutured or untreated medial meniscal lesions had worse pain, while those in which the medial meniscus was resected had worse symptoms. These findings are clinically relevant as they could help surgeons with patient selection and adjusting expectations according to their functional demands. LEVEL OF EVIDENCE: III.

PurposeThe importance of meniscus integrity in the prevention of early osteoarthritis is well known, and preservation is accepted as the primary goal. The purpose of the ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) European consensus on traumatic meniscus tears was to provide recommendations for the treatment of meniscus tears based on both scientific evidence and the clinical experience of knee experts.MethodsThree groups of surgeons and scientists elaborated and ratified the so-called formal consensus process to define the recommendations for the management of traumatic meniscus tears. A traumatic meniscus tear was defined as a tear with an acute onset of symptoms caused by a sufficient trauma. The expert groups included a steering group of eight European surgeons and scientists, a rating group of another nineteen European surgeons, and a peer review group. The steering group prepared twenty-seven question and answer sets based on the scientific literature. The quality of the answers received grades of A (a high level of scientific support), B (scientific presumption), C (a low level of scientific support) or D (expert opinion). These question and answer sets were then submitted to and evaluated by the rating group. All answers were scored from 1 (= totally inappropriate) to 9 (= totally appropriate) points. Thereafter, the comments of the members of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the finalized question and answer sets were submitted for final review by the peer review group composed of representatives of the ESSKA-affiliated national societies. Eighteen representatives replied.ResultsThe review of the literature revealed a rather low scientific quality of studies examining the treatment of traumatic meniscus tears. Of the 27 questions, only one question received a grade of A (a high level of scientific support), and another received a grade of B (scientific presumption). The remaining questions received grades of C and D. The mean rating of all questions by the rating group was 8.2 (95% confidence interval 8.1–8.4). A general agreement that MRI should be performed on a systematic basis was not achieved. However, MRI was recommended when arthroscopy would be considered to identify concomitant pathologies. In this case, the indication for MRI should be determined by a musculoskeletal specialist. Based on our data, stable left in situ lateral meniscus tears appear to show a better prognosis than medial tears. When repair is required, surgery should be performed as early as possible. Evidence that biological enhancement such as needling or the application of platelet-rich plasma would improve healing was not identified. Preservation of the meniscus should be considered as the first line of treatment because of an inferior clinical and radiological long-term outcome after partial meniscectomy compared to meniscus repair.DiscussionThe consensus was generated to present the best possible recommendations for the treatment of traumatic meniscus tears and provides some groundwork for a clinical decision-making process regarding the treatment of meniscus tears. Preservation of the meniscus should be the first line of treatment when possible, because the clinical and radiological long-term outcomes are worse after partial meniscectomy than after meniscus preservation. The consensus clearly states that numerous meniscus tears that were considered irreparable should be repaired, e.g., older tears, tears in obese patients, long tears, etc.Level of evidenceII

The first techniques about patellar osteotomies were proposed in the 1970s for the treatment of patellar chondromalacia or patellofemoral pain, with questionable results. More recent papers reported the use of patellar osteotomy for the treatment of patellar instability.

Patellofemoral (PF) disorders are a very special entity in knee practice, and although they are very common to encounter, very often their treatment is cumbersome and time-consuming for both the patient and the surgeon. The cornerstone of most PF pathology is the abnormal tracking of the patella over the trochlea, which may extend from obvious patellar dislocation to insidious abnormal patellar tracking. The anatomy is central and gives often the solution to classify and treat the patients. Two big entities could be seen the pain and the instability with dislocations but more often there is and overlapping between both which could lead to miss diagnosis and iatrogenic treatment [1].

Patellofemoral pain (PFP) is one of the most common knee problems in sport medicine, especially among running and jumping sports like basketball.

Stability of the knee is controlled by both soft tissue and bony elements, which are responsible for the overall balance of the joint on both coronal and sagittal plane. The main actors in the control of sagittal stability of the knee are anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posteromedial and posterolateral structures, the menisci, and the posterior tibial slope (PTS). Correction of the tibial slope may be performed in two different situations: anterior closing-wedge osteotomy to correct excessive PTS or anterior opening-wedge osteotomy to increase PTS and to correct a pathologic genu recurvatum. The aim of this chapter is to describe these two procedures. Tibial slope management during frontal high tibial osteotomy (HTO) will not be discussed in this chapter.

Stability of the knee is controlled by both soft tissue and bony elements, which are responsible for the overall balance of the joint in both coronal and sagittal planes.

Several predisposing factors, mostly congenital, may lead to chronic patellar instability; those factors have a high genetic incidence. Henry Dejour described four major instability factors: trochlear dysplasia, patella alta, excessive distance between tibial tubercle and trochlear groove, and excessive patellar tilt. Trochlear dysplasia is the main determinant; it is present in 96% of the objective patellar dislocation population (at least one patellar dislocation). In case of severe trochlear dysplasia and chronic patellar instability, it is necessary to surgically address the deformity to achieve stability and congruency. Different surgical techniques have been described: the lateral facet-elevating trochleoplasty (Albee’s procedure), the Bereiter trochleoplasty, the arthroscopic deepening trochleoplasty, and the sulcus-deepening trochleoplasty. This latter will be described in this chapter.

Objectives: The objective is to discover the long-term outcome of ACL reconstruction associated with tibial slope correction osteotomy for a second ACL tear. This study is preceded by an initial publication with a 4-year follow-up. The hypothesis was stable functional scores and the absence of osteoarthritis progression. Methods: The initial consecutive retrospective series included 9 patients who had a revision surgery for ACL reconstruction associated with single-stage OTDF. They were reviewed by an independent observer for a second follow-up with a minimum retrospect of 7 years. The analysis was based on IKDC-SKF and Lysholm scores, and radiographic analysis. Results: Of the original 9 patients, 7 were seen again, 1 was only interviewed by telephone, and 1 was lost to follow-up. At the last follow-up of 9.9 ± 3.0 years, all 8 patients had stable or improved functional scores compared to the previous follow-up. The mean Lysholm score increased from 73.8 ± 5.8 (65-82) to 84.5 ± 11.9 (59-95) and the mean IKDC-SKF score increased from 71.6 ± 6.2 (62-79) to 82.9 ± 12.1 (61-98). Of the six patients who already had proof of osteoarthritis at the previous follow-up, the grade of osteoarthritis increased for two (with a history of meniscectomy, from grade 2 to grade 3 and from grade 1 to grade 3) but remained stable for three patients and could not be assessed for one. Conclusion: At 7-15 years (mean: 9.9 years), patients’ functional scores were stable or improving compared to the previous 2-8 year follow-up period, with no new tear or revision surgery. This validates tibial slope correction after recurrent ACL tears with an increase in the tibial slope

Trochlear dysplasia consists in deficient trochlear concavity, giving rise to a flat or convex trochlea, and is the main risk factor for patellar dislocation. Surgical indications depend on familiarity with trochlear dysplasias, and especially those of high grade, identified on clinical examination and standard and cross-sectional imaging, and on quantification of associated instability factors. Treatment strategy is accordingly determined "à la carte" to correct these factors one by one. Sulcus deepening trochleoplasty corrects the morphology and is the appropriate etiological treatment. It gives good results in terms of recurrence of dislocation, but tends to cause knee stiffness and patellofemoral osteoarthritis. Indications are based on objective patellar instability associated to high-grade B or D dysplasia. Medial patellofemoral ligament reconstruction should be systematically associated. The lateral retinaculum is systematically sectioned, as patellar tilt is never reducible in such high-grade dysplasia. Trochleoplasty corrects the sulcus defect, resolves protrusion and enables proximal realignment. The main complications are stiffness and pain due to persistence or onset of cartilage lesions. Trochleoplasty is indicated: 1) in first line for objective patellar instability associated with high-grade dysplasia; or 2) for recurrence in high-grade dysplasia previously managed by other surgery. The aim of the present study was to review the literature on trochleoplasty and address the following questions: how to define high-grade dysplasia? What are the key clinical and radiologic points? What are the risk factors for patellar dislocation? What trochleoplasty techniques are available? What results can be expected? Level of evidence: V; expert opinion.

The aim of this study was to determine patient and anatomic factors that influence anteroposterior and rotational laxity in knees with ACL tears. Based on the findings of biomechanical studies, we hypothesized that static and dynamic anterior tibial translation (ATT) as well as positive pivot shift would increase with female gender, tibial slope, and meniscal tears. The authors prospectively collected preoperative data and intraoperative findings of 417 patients that underwent ACL reconstruction. The exclusion criteria were: revision ACL procedures (n = 53), other surgical antecedents (n = 27), prior osteotomies (n = 7) or concomitant ligament tears on the ipsilateral knee (n = 34), and history of ACL tears in the contralateral knee (n = 45), leaving a study cohort of 251 patients. Their preoperative anteroposterior knee laxity was assessed objectively using ‘static’ monopodal weight-bearing radiographs and ‘dynamic’ instrumented differential measurements of ATT. Rotational laxity was assessed subjectively using the pivot shift test. Multivariable regression showed that static ATT increases only with tibial slope (β = 0.30; p

Background: Results of anterior cruciate ligament (ACL) reconstruction are traditionally excellent in younger and nonarthritic patients. During the past few decades, people older than 60 years have become more active than ever, with more demanding physical lifestyles. An increase also has been noted in active patients with diagnosed ACL injuries. More patients are requesting treatment for ACL deficiency in hopes of returning to preinjury levels of activity. Purpose: The aims of this study were to evaluate the results of ACL reconstruction in patients older than 60 years in terms of functional recovery, return to sports, and postoperative incidence of osteoarthritis and to compare their results with published results of different age groups. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients older than 60 years with isolated ACL tear and no established osteoarthritic lesions (Ahlbäck grade 1 or no arthritis) who were treated from 2008 to 2013 were retrospectively included in this study. Primary ACL reconstruction was performed with the same technique in all patients by means of single-bundle autologous hamstring tendon graft. Meniscal injuries were treated with partial debridement when required. No further treatment on cartilage lesions was performed. Postoperative rehabilitation was the same in every case. The International Knee Documentation Committee (IKDC) objective grade, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were assessed before and after surgery, and the Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score was recorded during the final follow-up. Postoperative incidence of osteoarthritis was evaluated on weightbearing radiographs during final follow-up, and anteroposterior laxity was measured pre- and postoperatively with the use of stress radiographs. Results: Twelve patients with mean age (±SD) of 61.0 ± 1.4 years at the time of surgery were included. They were followed-up for a mean period of 49.6 ± 24.0 months. Eight patients had associated meniscal tears, and 6 patients had International Cartilage Repair Society stage 1 or 2 chondral lesions. Preoperatively, the objective IKDC grades were B in 4 patients, C in 5, and D in 3. After surgery, the IKDC grades were A in 4 patients, B in 7, and grade C in 1. The mean subjective IKDC and Lysholm scores were a respective 43.4 ± 8.4 and 55.7 ± 12.4 preoperatively and 83.8 ± 9.4 and 93.2 ± 9.0 at the final follow-up ( P < .05). Ten patients (83%) reported recovery of sports activities, with 6 patients (50%) reaching the same level as before injury. The mean ACL-RSI score was 76.2%. Preoperatively, 50% (n = 6) of patients had Ahlbäck stage 1 medial compartment arthritis, versus 58% (n = 7) at the final follow-up ( P = nonsignificant). The side-to-side difference in anterior tibial translation on stress radiographs was 7.2 ± 6.4 mm preoperatively and 1.9 ± 4.3 mm postoperatively ( P < .05). No major complications were reported. Conclusion: ACL reconstruction in active patients older than 60 years without arthritis restored knee stability in all treated cases. In these patients, as in younger age groups, ACL reconstruction showed good results on functional recovery while not increasing the risk of midterm functional knee deterioration or evolution of knee arthritis. The majority of patients returned to activities at their preinjury level. These data show that older and active patients with nonarthritic ACL-deficient knees need not be excluded from surgical treatment.

Item does not contain fulltext BACKGROUND: The goal of patellofemoral arthroplasty (PFA) is to replace damaged cartilage and correct underlying deformities to reduce pain and prevent maltracking. We aimed to determine how PFA modifies patellar height, tilt, and tibial tuberosity-trochlear groove (TT-TG) distance. The hypothesis was that PFA would correct trochlear dysplasia or extensor mechanism malalignment. METHODS: The authors prospectively studied a series of 16 patients (13 women and 3 men) aged 64.9 +/- 16.3 years (range 41-86 years) who received PFA. All knees were assessed preoperatively and 6 months postoperatively using frontal, lateral, and "skyline" x-rays, and computed tomography scans to calculate patellar tilt, patellar height, and TT-TG distance. RESULTS: The interobserver agreement was excellent for all parameters (intraclass correlation coefficient >0.95). Preoperatively, the median patellar tilt without quadriceps contraction (QC) was 17.5 degrees (range 5.3 degrees -33.4 degrees ) and with QC was 19.8 degrees (range 0 degrees -52.0 degrees ). The median Caton-Deschamps index was 0.91 (range 0.80-1.22) and TT-TG distance was 14.5 mm (range 4.0-22.0 mm). Postoperatively, the median patellar tilt without QC was 0.3 degrees (range -15.3 degrees to 9.5 degrees ) and with QC was 6.1 degrees (range -11.5 degrees to 13.3 degrees ). The median Caton-Deschamps index was 1.11 (range 0.81-1.20) and TT-TG distance was 10.1 mm (range 1.8-13.8 mm). CONCLUSION: The present study demonstrates that beyond replacing arthritic cartilage, trochlear-cutting PFA improves patellofemoral congruence by correcting trochlear dysplasia and standardizing radiological measurements as patellar tilt and TT-TG. The association of lateral patellar facetectomy improves patellar tracking by reducing the patellar tilt.

International audience; Background: A consequence of the steady growth in the worldwide population of elderly individuals who remain in good health and continue to engage in sports is an increase in the incidence of anterior cruciate ligament (ACL) rupture occurring after 50 years of age. ACL reconstruction was formerly reserved for young athletes but now seems to produce good outcomes in over 50s. The type of graft and graft fixation method were selected empirically until now, given the absence of investigations into potential relationships of these two parameters with the outcomes. The objective of this study was to assess associations linking the type of graft and the method of femoral graft fixation to outcomes in patients older than 50 years at ACL reconstruction. Hypothesis: The operative technique is not associated with the clinical outcomes or differential laxity. Material and methods: A multicentre retrospective cohort of 398 patients operated between 1 January 2011 and 31 December 2015 and a multicentre prospective cohort of 228 patients operated between 1 January 2016 and 30 June 2017 were conducted. Mean follow-up was 42.7 months in the retrospective cohort and 14.2 months in the prospective cohort. The primary evaluation criterion was the clinical outcome as assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Activity Score (TAS). Differential laxity was the secondary evaluation criterion. The Wilcoxon rank sum test and Kruskal-Wallis test were used to compare groups, and p-values < 0.05 were considered significant. Results: In the retrospective and prospective cohorts, hamstring tendons were used in 269 (67.6%) and 197 (86.4%) patients and extensor apparatus tendons in 124 (31.2%) and 31 (13.6%) patients. Femoral fixation in the retrospective cohort was cortical in 81 (20.4%) cases, by press-fit in 112 (28.1%) cases, and by interference screw in 205 (51.5%) cases; corresponding figures in the prospective cohort were 135 (59.2%), 17 (7.5%), and 76 (33.3%). The multivariate analysis of the retrospective data identified no significant associations of graft type or femoral fixation type with the KOOS, TAS, or differential laxity values. In the prospective cohort, hamstring grafts were associated with 0.6 mm of additional laxity (p = 0.007); compared to cortical fixation, press-fit fixation of patellar tendon grafts was associated with 0.3 mm of additional laxity (p = 0.029) and a 0.5-point lower TAS value (p = 0.033), with no difference in KOOS values. None of these differences were clinically significant. Discussion: The various ACL reconstruction techniques used in patients older than 50 years produce similar outcomes. The technique can be chosen based on surgeon preference without regard for patient age. Level of evidence: IV.