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Implant malpositioning, joint line (JL) lowering, and malalignment have been identified as risk factors for implant failure in unicompartmental knee arthroplasty (UKA). The aims of this study were to compare the accuracy of implant positioning in robotic-assisted UKA versus conventional UKA in a large cohort and examine the correlation with implant survival at mid-term follow-up.This retrospective study included 356 medial UKAs from 2011 to 2019. The radiological measurements performed were coronal positioning of tibial implant according to Cartier angle (Δ Cartier), posterior tibial slope (PTS), residual hip-knee-ankle (HKA), and JL restoration. Outliers were defined as follows: post-operative HKA 175° or 180°, Δ Cartier 3° or - 3°, JL change ≥ 2 mm, and PTS 2° or 8°. The survival probability was reported at the last follow-up.Out of the 356 knees included, 159 underwent conventional UKA (44.5%) and 197 (55.5%) robotic-assisted UKA. The mean follow-up was 61.3 months ± 24.0. Robotic UKA was associated with better accuracy compared to conventional UKA in relation to HKA (67% vs 56%, p = 0.023), JL restoration (70% vs 44%, p 0.0001), PTS (83% vs 55%, p 0.0001), and tibial varus restoration (65% vs 55%, p = 0.049). Implant survival in the robotic group was found to be superior at the last follow-up (96.4% versus 87.3% at 9 years, p = 0.004).Robotic assistance in patients undergoing medial UKA was associated with better accuracy compared to conventional UKA with respect to tibial implant positioning, post-operative limb alignment, and JL restoration. This was translated in improved survival at mid-term follow-up favouring the robotic group.

Image-based robotic tools improve the accuracy of unicompartmental knee arthroplasty (UKA) positioning, but few studies have examined its effect on axial alignment. The aim of this study was to compare the characteristics of tibial and femoral implant positioning, mainly the tibial rotation, during medial or lateral UKA, performed with an image-based robotic assisted system.A total of 71 UKA performed between September 2021 and June 2022 (53 medial and 18 lateral) were analyzed. All data regarding implant positioning (rotation, coronal and sagittal alignment) for tibial and femoral components were obtained using MAKO® software (Stryker®, Mahwah, USA) intra-operatively.The lateral UKA had a mean internal tibial rotation of 15.4 ± 3°, a mean external femoral rotation of 0.96 ± 2.4°, and a mean tibial slope of 4.7 ± 1.3°. The medial UKA had a mean internal tibial rotation of 0.18 ± 2.7°, a mean internal femoral rotation of 0.35 ± 2.2°, and a mean tibial slope of 5.4 ± 1.3°. The tibial rotations, femoral valgus, tibial varus and tibial size significantly differed between medial and lateral UKA (p 0.05). There was no significant difference in femoral rotation, flexion, femoral size, slope, and polyethylene thickness between medial and lateral UKA.Medial and lateral UKA had significantly different implantation characteristics related to the biomechanics of the knee compartments. Image-based robotic UKA allowed precise femorotibial positioning per-operatively to match native kinematic alignment.

BACKGROUND: The anterior tibial translation (ATT) in case of Anterior Cruciate Ligament (ACL) tear can lead to dynamic alterations of the extensor apparatus biomechanics. The aim of this study is to evaluate the dynamic effect of isolated ACL deficiency on patellar height. The hypothesis is that the ATT of ACL-insufficient knees dynamically reduces patellar height. METHODS: Skeletally mature patients who underwent ACL reconstruction using hamstring graft between January and December 2018 were included in this study. The Posterior Tibial Slope (PTS), Caton–Deschamps (CDI), modified Insall–Salvati (MISI), and Blackburne–Peel (BPI) indices were calculated in standard lateral and TELOS X-rays. The mean of the measurements calculated between two observers was used to compare these parameters. RESULTS: 95 patients (M: 57; F: 38; 95 knees) were included in the study with a mean age of 31.8 years (16–56 years old). Significant patellar height reduction (CDI: 0.11 [− 0.32; 0.31]; MISI: 0.09 [− 0.66; 0.30]) was reported in TELOS compared with standard lateral knee radiography (p

There is relative paucity in the literature concerning outcomes after robotic-assisted Patellofemoral Arthroplasty (PFA). The aims were (1) to evaluate outcomes in patients undergoing PFA with inlay or onlay components, with or without robotic arm assistance and (2) to identify risk factors of poor outcomes after PFA. This retrospective study included 77 PFA for isolated patellofemoral joint osteoarthritis, assigned to three groups (18 conventional technique, 17 image-free robotic-assisted system and 42 image-based robotic-assisted system). The demographic data were comparable between the three groups. The clinical outcomes assessed were: Visual Analogue Scale, Knee Society Score, Kujala score and satisfaction rate. The radiological measures were: Caton Deschamps index, patellar tilt and frontal alignment of the trochlea. Functional outcomes, satisfaction rate and residual pain were comparable between the three groups. Patellar tilt improvement was superior when a robotic device was used (either image-based or image-free) compared to the conventional technique. There were three revisions (3.9%) at the last follow-up related to femorotibial osteoarthritis progression. Multivariate analysis found no significant risk factors for poor outcomes, with respect to the surgical technique or implant design. Functional outcomes and revisions rate after PFA were comparable between the surgical techniques and implants. Robotic-assisted systems were associated with a superior improvement of the patellar tilt compared to the conventional technique.

Functional alignment (FA) is a novel philosophy to deliver a total knee arthroplasty (TKA) that respects individual bony and soft tissue phenotypes within defined limitations. The purpose of this paper is to describe the rationale and technique of FA in the valgus morphotype with the use of an image-based robotic-platform. For the valgus phenotype the principles are personalized pre-operative planning, reconstitution of native coronal alignment without residual varus or valgus of more than 3°, restoration of dynamic sagittal alignment within 5° of neutral, implant sizing to match anatomy, and achievement of defined soft tissue laxity in extension and flexion through implant manipulation within the defined boundaries. An individualized plan is created from pre-operative imaging. Next, a reproducible and quantifiable assessment of soft tissue laxity is performed in extension and flexion. Implant positioning is then manipulated in all three planes if necessary to achieve target gap measurements and a final limb position within a defined coronal and sagittal range. FA is a novel TKA technique that aims to restore constitutional bony alignment and balance the laxity of the soft tissues by placing and sizing implants in a manner that respects variations in individual anatomy and soft tissues within defined limits.

Resume Introduction L’arthrose femoro-patellaire (AFP) est habituellement associee a de l’arthrose femoro-tibiale. L’etude de sa forme isolee a revele l’implication de facteurs de risque specifiques. La dysplasie de trochlee (DT) influe sur la repartition des contraintes au sein de l’articulation femoro-patellaire et favorise la survenue d’une arthrose. L’association entre la DT et l’AFP isolee a ete analysee sans distinction entre l’AFP de la facette interne, globale, ou de la facette externe. Notre hypothese etait qu’il existe une forte prevalence de DT chez des patients souffrant d’arthrose femoro-patellaire externe isolee (AFPEI). L’objectif de cette etude etait de mesurer la prevalence de la DT au sein d’une population d’AFPEI symptomatique et d’en etudier les facteurs favorisants. Patients et methodes Quatre-vingt-quatre patients (101 genoux) ont ete operes d’une patellectomie verticale externe (PVE) pour une AFPEI symptomatique entre novembre 1998 et septembre 2019. Les caracteristiques demographiques, cliniques et radiographiques ont ete recueillies retrospectivement sur les donnees preoperatoires. L’analyse de la DT a ete realisee en aveugle par deux chirurgiens sur les radiographies de profil. Resultats La prevalence de la DT dans notre etude etait de 88,1 %. Le stade de DT etait significativement plus avance chez les patients operes avant 45 ans (64,5 % de stades 2 et 3, p = 0,019). Il y avait chez les cas non dysplasiques significativement plus de deformations en valgus (83,3 %, p = 0,042) et de surpoids (IMC 32 ± 4,1, p Conclusion La DT est un facteur de risque connu d’AFP. Dans notre etude elle etait presente dans pres de 9 cas d’AFPEI sur 10. Ces resultats renforcent l’hypothese de son role dans la survenue d’une AFPEI. La DT influe egalement sur la precocite des symptomes douloureux conduisant a une intervention. Le surpoids et la deformation en valgus sont des facteurs favorisants d’AFPEI. Niveau de preuve IV ; etude transversale.

The aim of the study was to compare clinical and radiological outcomes between primary and aseptic revision TKAs using the same posterior-stabilised (PS) prosthesis. The authors hypothesised similar outcomes between both groups for selected patients. This retrospective, case–control study assessed 36 patients who underwent aseptic revision TKA compared to a match group of 72 primary TKA. Both groups had the same PS design implant (ANATOMIC®, Amplitude, Valence, France). The International Knee Society (IKS) score, radiological outcomes (postoperative alignment, patellar tilt and radiolucent lines), re-intervention and revision rate were compared between the two groups with a minimum follow-up of 3 years. The final study cohort included 29 patients and 63 patients respectively in the revision and primary group, with a mean follow-up of 49.1 months (range 36.1–69). Postoperatively, there was no significant difference in IKS scores between the two groups [169.8 for the revision group and 179.6 for the primary group (p = 0.09)]. No statistical difference was observed for post-operative satisfaction 86.2% versus 92.1% (p = 0.46). Between the two groups, there was no difference in mean radiological assessment, including radiolucent lines (p = 0.7). There was no significant difference for overall implant survivorship 96.5% versus 100% (p = 0.13) at 36 months. Similar clinical, radiological and survivorship outcomes were found between rTKA and primary TKA groups using the same PS level of constraint in patients undergoing revision surgery for aseptic indications at 3-year follow-up. Use of PS implants in rTKA for the correct indication suggests this to be a safe approach at least in the medium term. IV, retrospective case–control study.

Literature regarding outcomes in patients over 80 years old after total knee arthroplasty (TKA) is inconsistent. We aimed to compare implant survivorship and functional outcomes between elderly patients (≥ 80 years) and younger patients ( 80 years) following TKA, using a single modern posterior-stabilized (PS) prosthetic design.This is a retrospective cohort study of 80 patients over 80 years old who underwent TKA between January 2015 and December 2016, who were compared with younger patients (60-75 years old) operated during the same period. Patients were matched with a ratio of 1:3 based on logistic regression analysis of gender and body mass index. All patients received the same cemented PS prosthesis with a fixed bearing polyethylene insert, with or without patellar resurfacing. Implant survival and patient-reported outcome measurements were compared between the two groups. At last follow-up, data were available for 41 knees in the elderly group (including 17 patients who died before 5-year follow-up) and 123 knees in the younger group.Functional results were better at final follow-up in the group 80 years with a significantly higher Knee Society Function Subscore (88.6 ± 16.9 vs 79.4 ± 22.1, p 0.01), but no significant differences in Knee Subscore and global Knee Society Score (p 0.05), nor regarding maximum flexion (121° ± 12 and 117° ± 13, p = 0.08). The implant survivorship was 100.0% after a mean 64.4-month follow-up (range 60-78), without revision requiring removal of the implant in any group. The survival rate without any reoperation was 97.6% (95% CI 93.0-100.0) in the elderly group and 95.9% (95% CI 92.5-99.5) in the younger group (p = 0.64).At a minimum of 5-year follow-up, there was no revision surgery and a very low rate of complications requiring reoperations both in the group over 80 years of age and in the younger population, with the use of a PS prosthesis. The functional results were slightly lower for elderly patients and correlate with the lower functional demands of this population. The indication for TKA, especially with a PS implant, may be encouraged in appropriately selected elderly patients.III (retrospective cohort study).

The purpose of the study was to compare clinical and radiological results between kinematic alignment (KA) and mechanical alignment (MA) with a posterior-stabilized (PS) total knee arthroplasty (TKA) with a post-cam mechanism at a minimum follow-up of 3 years. The authors hypothesized a higher risk of aseptic loosening when performing KA using PS TKA. A retrospective monocentric single surgeon case control study was performed comparing 100 matched patients who had TKA performed using a MA philosophy to 50 patients receiving TKA with a KA technique between January 2016 and October 2017. All patients had the same knee prosthesis (GMK primary posterior-stabilized, Medacta®, Switzerland). Patient specific cutting blocks were used in both groups and a restricted KA (rKA) was aimed in the KA group. A hybrid cementation technique was performed. The new Knee Society Score (KSS) and radiological assessment were collected preoperatively and at the final follow-up. Comparisons between groups were done with the T test or Fisher exact test. Global survival curves were estimated with Kaplan–Meier model. Significance was set at p

In total knee arthroplasty (TKA), knee phenotypes including joint line obliquity are of interest regarding surgical realignment strategies. The hypothesis of this study is that better clinical results, including decreased postoperative knee pain, will be observed for patients with a restored knee phenotype. A retrospective analysis was performed on prospective data, including 1078 primary osteoarthritic knees in 936 patients. The male:female ratio was 780:298, mean age at surgery was 71.3 years ± 8.0. International Knee Society Scores and standardized long-leg radiographs (LLR) were collected preoperatively and at 2 years follow-up after TKA. Patients were categorized using the Coronal Plane Alignment of the Knee (CPAK) classification including the lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) measured on LLR by a single observer, allowing knee phenotypes to be categorized considering the arithmetic hip–knee–ankle (aHKA) angle (MPTA-LDFA) as measure of constitutional alignment, and joint line obliquity (JLO) (MPTA + LDFA). Clinical results were compared between patients with surgically restored preoperative constitutional knee phenotype to patients without restored constitutional knee phenotypes. Descriptive data analysis such as means, standard deviations and ranges were performed. T tests for independent samples were performed to compare group differences. Comparisons of categorical data were performed using the χ2 test. Significance was set at p

The aim of this systematic review was to compare relevant health economic consequences of the CT-based robotic-arm-assisted system versus conventional Uni-compartmental Knee Arthroplasty (UKA). In November 2020, A PRISMA systematic review was conducted using four databases (Pubmed, Scopus, Cochrane and Google Scholar) to identify all comparative studies reporting health economic assessments, such as robotic system costs, consumable costs, surgical revision rate, operating time, length of stay, and inpatient care costs. A total of nine comparative studies published between 2014 and 2020 were included in this systematic review. There was a moderate risk of bias as assessed using the ROBINS-I Tool. The CT-based robotic-arm-assisted system seemed to be associated with a lower risk of revision, decreased analgesia requirements during hospitalization, a shorter length of stay, and lower inpatient care costs compared to a conventional technique. CT-based robotic-arm-assisted system for UKA appears to be an economically viable solution with a positive health economic impact as it tends to decrease revision rate compared to conventional UKA, improve post-operative rehabilitation and analgesia management. Post-operative inpatient care costs seem lower with the robotic-assisted system but depend on institutional case volume and differ among health systems. More studies are needed to confirm cost-effectiveness of CT-based robotic-arm-assisted system based on different health systems. Systematic review, Level IV

Femorotibial alignment is crucial for the outcome of unicompartmental knee arthroplasty (UKA). Robotic-assisted systems are useful to increase the accuracy of alignment in UKA. However, no study has assessed if the femorotibial alignment measured by the image-free robotic system is reliable. The aim of this study was to determine whether measurement of the mechanical femorotibial axis (mFTA) in the coronal plane with handheld robotic assistance during surgery is equivalent to a static measurement on radiographs and to a dynamic measurement during walking. Twenty patients scheduled for robotic-assisted medial UKA using handheld technology were included in this prospective study. Three measurements of the frontal femorotibial axis were compared: intra-operative acquisition by computer assistance (dynamic, non-weightbearing position), radiographic measurements on long leg X-ray (static, weightbearing position), and by gait analysis during walking (dynamic, weightbearing position). There was no significant difference in the mFTA between computer (174.4 ± 3.4°), radiological (173.9 ± 3.3°), and gait analysis (172.9 ± 5.1°) measurements (p = 0.5). There was a strong positive correlation (r = 0.6577355, p = 0.0016) between robotic-assisted measurements and gait analysis. There was no significant difference in the femorotibial axis measured by the image-free robotic assistance, from the preoperative radiographs or by gait analysis. The reliability of intra-operative measurements of the frontal femorotibial axis by these robotic-assisted systems is acceptable.

Resume Introduction Les blessures de l’epaule des rugbymen professionnels sont frequentes, souvent liees a des traumatismes de haute intensite. Leur prevention par une evaluation isocinetique fait partie integrante de la preparation physique des joueurs. Cependant, les profils isocinetiques des muscles rotateurs internes (RI) et externes (RE) d’epaule des joueurs de rugby, precedemment definis, ne prennent pas en compte leur poste de jeu. Le but de cette etude etait de comparer le profil isocinetique des muscles RE et RI des joueurs de rugby en fonction de leur poste : avants et arrieres. Methodes Quarante-deux joueurs de rugby professionnels etaient evalues. Un dynamometre Con–Trex etait utilise pour tester les muscles RI et RE des deux epaules. Les donnees etaient obtenues successivement en mode concentrique a 60°/s et 240°/s puis en mode excentrique a 60°/s. Le pic de couple (PC), le pic de couple rapporte au poids des RI et RE et le ratio RE/RI etaient mesures a chaque vitesse angulaire. Resultats Le pic de couple des RI et RE etait plus eleve pour les avants par rapport aux arrieres pour le cote dominant pour tous les modes de contraction (p 0,05), sur le ratio RE/RI (p > 0,05) et sur le ratio mixte (p = 0,54). Conclusion Les avants avaient une plus grande force musculaire des epaules que les arrieres. En rapportant les resultats au poids, la force musculaire et le profil isocinetique etaient similaires.

Robotically assisted total knee arthroplasty (RA-TKA) is an emerging surgical tool. The purpose of this study was to analyze the length of time taken to perform the key steps of a RA-TKA for a surgeon and centre new to the MAKO robotic system.This was a prospective cohort study of the first 50 patients undergoing TKA using a robotic platform (Mako, Stryker, Kalamazoo, MI, USA) performed by a single surgeon. Each key surgical step was recorded. The first 50 patients were chronologically allocated into five groups of ten and compared.Mean operation length was 59.4 ± 7.4 min with significant improvement after 30 cases. A significant effect on certain steps of the surgery also occurred over 50 cases: after 30 cases for pre-operative planning (3.8 min in group 1 versus 1.2 min in group 4, p 0.005), ten cases for registration time (5.2 min in group 1 versus 3.8 in group 2, p = 0.039) and ten cases for tibial cutting time (1.6 min in group 1 versus 1.3 in group 2, p 0.005). Nurse setup, femur cutting, and intraoperative planning did not demonstrate a significant improvement in time over 50 cases.A significant decrease in total operating length occurred after the 30th case. Anatomical registration and tibial cutting time demonstrated the largest improvements. MAKO image-based robotically assisted TKA is not a time-intensive intervention for both the surgeon and scrub nursing staff, and significant improvements in total surgical time occurs early in the learning phase.

Purpose The ability of kinematic alignment (KA) to consistently restore trochlea anatomy in total knee arthroplasty (TKA) is unknown despite recreation of constitutional anatomy being its rationale for use. The purpose of this study was to assess if alignment choice in TKA effects the ability to restore the native trochlea groove. Methods One hundred and twenty-two consecutive patients undergoing robotic-assisted TKA using the MAKO image-based robotic platform had simulated femoral components placed according to kinematic, mechanical and functional alignment principals. Implant position and trochlea restoration between groups were compared. Restoration was assessed by shift (medial–lateral) and depth relative to the native groove from three consistent points; full extension (0°), mid-flexion (30°–40°) and deep flexion (70°–80°). Results Three hundred and sixty-six alignment options were analysed. Femoral alignment was significantly different between groups. Of KA, 13.1% compared to 3.3% of FA plans were outside safe coronal boundaries. The trochlear groove was translated the most by MA compared to KA and FA (full extension, MA 7.84 ± 1.99 mm lateral to the native groove, KA 6.40 ± 2.43 mm and FA 6.88 ± 1.74 mm, p ≤ 0.001). In full extension, FA most closely restored the trochlear groove depth in all three positions of flexion. Conclusion Alignment philosophy led to significant differences in trochlea groove recreation. A kinematically placed femoral component led to positioning considered unsafe in over 13% of cases. A functionally placed femoral component most closely restored trochlea depth in all three positions of flexion.

Anterior cruciate ligament (ACL) deficiency can be a consequence or a cause of femoro-tibial osteoarthritis (OA). Several studies have published satisfactory outcomes of unicompartimental knee arthroplasty (UKA) and combined ACL reconstruction despite its absence classically being considered a contraindication. A major challenge in the ACL deficient knee is obtaining appropriate gap balancing and limb axis. Robotically assisted UKA allows for precise control of these factors; however, it's utilisation as a tool with combined ACL reconstruction and UKA has not been described. The purpose of this study was to evaluate the clinical and radiological outcomes of robotically assisted UKA with combined ACL reconstruction.This was a retrospective single-centre study of ten patients operated by a single surgeon from 2016 to 2020. All surgery was performed using a cemented fixed bearing UKA prosthesis (Journey uni, Smith and Nephew®) (8 medial, 2 lateral) inserted with the assistance of an image-free robotic-assisted system (BlueBelt, Navio, Smith and Nephew®). All ACL reconstructions were performed using hamstring autograft. Clinical assessment included International Knee Score (IKS) score, Tegner score and patient satisfaction. Radiological assessment was performed to assess radiolucent lines, progression of OA in the other compartments, Hip-Knee-Ankle angle and Posterior Tibial Slope.There were eight females (80%), mean age was 57 ± 7 [48-70], mean BMI was 26 ± 3 [22-31]. The mean follow-up was 45 months ± 13 months [24-66]. Mean post-operative IKS knee and function score were respectively 96 ± 4.5 [88-100] and 93 ± 8.2 [74-100], mean Tegner score was 4.5 ± 1.4 [3-6]. Nine patients (90%) returned to sport; one patient (10%) was dissatisfied because of residual pain preventing a return to a desired level of sport. 100% of the radiological objectives were achieved. No radiolucent lines were seen at the last follow-up. There were two re-operations (20%) for stiffness requiring arthroscopic arthrolysis at two and three months respectively following surgery, with full recovery of the flexion at the last follow-up in both cases. No other complications were observed.Robotic UKA associated with ACL reconstruction provides satisfactory early patient outcomes and accurate implant positioning. The first results in terms of return to sports were promising.

There are increased surgical considerations when revising total knee arthroplasty (TKA) in active patients. Few studies have assessed if a semi-constrained [Total Stabilized (TS)] prostheses has similar knee biomechanics to a primary posterior stabilized (PS) prosthesis. The aim was to compare the gait parameters in patients with PS or TS TKA and normal controls. 32 patients with TKA were prospectively included with either a primary PS (n = 15) or a revision TS (n = 17) prosthesis. Gait analysis was performed at 6 months postoperatively for each patient, with an optoelectronic knee assessment device (KneeKG®) assessing the displacement of the tibia relative to the femur during the different gait phases (flexion/extension, anterior/posterior translation, adduction/abduction, internal/external rotation). A control group (n = 12) of healthy knees was compared with the TKA groups. There were no significant kinematic differences between PS and TS groups. The maximum knee flexion during gait was 53° ± 8.1° in the PS group vs 52° ± 8.7° in the TS group. The antero-posterior translation was similar in both group (2.3 ± 0.5 mm vs 2.6 ± 0.9 mm, respectively). Peak varus angle during loading and swing phase was slightly higher in the TS group (2.7° ± 0.7° and 5.2° ± 0.9°) than in the PS group (2.9° ± 0.6° and 5.6° ± 1.2°), without significant difference. The ranges in internal/external rotation were similar between PS and TS TKA (3.7° ± 0.5° vs 3.3° ± 0.6°, respectively). Both designs approached closely the normal gait patterns of the control group except in the frontal plane. Single radius TS TKA has gait parameters similar to single radius PS TKA. Use of a single radius TS TKA in revision TKA is not detrimental to a patient’s gait pattern. Both designs approached closely the normal gait patterns of the control group. Prospective, case–control study; Level III.

In recent studies, robotic-assisted surgical techniques for unicompartmental knee arthroplasty (UKA) have demonstrated superior implant positioning and limb alignment compared to a conventional technique. However, the impact of the robotic-assisted technique on clinical and functional outcomes is less clear. The aim of this study was to compare the gait parameters of UKA performed with conventional and image-free robotic-assisted techniques. This prospective, single-center study included 66 medial UKA, randomized to a robotic-assisted (n = 33) or conventional technique (n = 33). Gait knee kinematics was assessed on a treadmill at 6 months to identify changes in gait characteristics (walking speed, each degree-of-freedom: flexion–extension, abduction–adduction, internal–external rotation, and anterior–posterior displacement). Clinical results were assessed at 6 months using the IKS score and the Forgotten Joint Score. Implants position was assessed on post-operative radiographs. Post-operatively, the whole gait cycle was not significantly different between groups. In both groups, there was a significant improvement in varus deformity between the pre- and post-operative gait cycle. There was no significant difference between the two groups in clinical scores, implant position, revision, and complication rates. No difference of gait parameters could be identified between medial UKA performed with image-free robotic-assisted technique or with conventional technique. Prospective randomized controlled trial. Level of evidence I.

Aims Ideal component sizing may be difficult to achieve in unicompartmental knee arthroplasty (UKA). Anatomical variants, incremental implant size, and a reduced surgical exposure may lead to over- or under-sizing of the components. The purpose of this study was to compare the accuracy of UKA sizing with robotic-assisted techniques versus a conventional surgical technique. Methods Three groups of 93 medial UKAs were assessed. The first group was performed by a conventional technique, the second group with an image-free robotic-assisted system (Image-Free group), and the last group with an image-based robotic arm-assisted system, using a preoperative CT scan (Image-Based group). There were no demographic differences between groups. We compared six parameters on postoperative radiographs to assess UKA sizing. Incorrect sizing was defined by an over- or under-sizing greater than 3 mm. Results There was a higher rate of tibial under-sizing posteriorly in the conventional group compared to robotic-assisted groups (47.3% (n = 44) in conventional group, 29% (n = 27) in Image-Free group, 6.5% (n = 6) in Image-Based group; p < 0.001), as well as a higher rate of femoral under-sizing posteriorly (30.1% (n = 28) in conventional group, 7.5% (n = 7) in Image-Free group, 12.9% (n = 12) in Image-Based group; p < 0.001). The posterior femoral offset was more often increased in the conventional group, especially in comparison to the Image-Based group (43% (n = 40) in conventional group, 30.1% (n = 28) in Image-Free group, 8.6% (n = 8) in Image-Based group; p < 0.001). There was no significant overhang of the femoral or tibial implant in any groups. Conclusion Robotic-assisted surgical techniques for medial UKA decrease the risk of tibial and femoral under-sizing, particularly with an image-based system using a preoperative CT scan. Cite this article: Bone Joint J 2021;103-B(4):610–618.

Resume Contexte L’epidemiologie des lesions meniscales sur genou stable a ete etudiee mais leur topographie precise reste mal connue. Les types lesionnels sont reputes differents selon le type de pathologie, la limite n’est pas toujours evidente entre une lesion traumatique pure et une lesion degenerative. Un questionnaire a ete cree en 2010 par l’ISAKOS avec pour objectif d’homogeneiser leur evaluation. Cette etude avait pour objectif principal de rapporter la topographie precise des lesions meniscales chirurgicales (c’est-a-dire operees) du genou stable, ainsi que leur type. Les objectifs secondaires etaient d’analyser la relation entre le type lesionnel et la presence de lesion cartilagineuse du compartiment femoro-tibial concerne, ainsi que l’âge de survenue des lesions. Hypotheses Les hypotheses etaient l’existence d’une correlation entre le type lesionnel et la presence de lesion cartilagineuse, et d’une difference entre les moyennes d’âge selon le type lesionnel avec une survenue plus jeune des lesions verticales, chez des patients operes. Patients & methodes Il s’agit d’une etude descriptive epidemiologique ; le recueil de donnees etait prospectif avec un remplissage systematique du questionnaire ISAKOS. Mille quatre cent vingt-quatre lesions isolees d’un menisque sur genou stable, operees entre 2010 et 2017, dont 253 du menisque lateral (ML), et 1171 du menisque medial (MM), ont ete incluses. L’âge operatoire moyen etait respectivement de 36 et 47 ans. Resultats Le type lesionnel le plus frequent etait vertical (39 % au ML, 38 % au MM). Les localisations preferentielles etaient « posterieure + moyen» et « moyen » (22 % chacun) au ML, « posterieure » au MM (56 %). Les lesions etaient majoritairement peripheriques (zone 1) au ML (46 %), plutot en zone 2 au MM (46 %). Dans les lesions verticales mediales, l’âge moyen etait de 43 ans (SD = 14), significativement inferieur (p Discussion Cette etude permet de decrire avec un effectif important la topographie precise des lesions meniscales isolees sur genou stable grâce au questionnaire ISAKOS. Nos hypotheses ont ete verifiees du cote medial mais pas du cote lateral. Niveau de preuve III ; etude prospective comparative non randomisee bien menee.

Patellar tracking problems represent 2–10% of complications of total knee arthroplasties (TKA) in valgus knees. However, there are no studies assessing patellar tracking according to the severity of the valgus deformity. The hypothesis was that lateral approach TKA in severe valgus deformity provides equivalent patellar tracking to that in knees with mild valgus deformity. Between 1988 and 2016, 77 TKAs were performed via a lateral approach on a severe valgus deformity (HKA > 195°). Forty-three TKAs performed without tibial tubercle osteotomy and with complete radiological data were included in this study. These were compared with 86 matched TKAs performed via a lateral approach with a mild valgus deformity (HKA between 181° and 190°). Patellar tilt and patellar position were assessed by axial view radiographs at the last follow-up. Complications and clinical outcomes were also evaluated. The follow-up was mean 52 ± 21 months in the severe valgus group. No significant differences were found between the severe valgus deformity group and the mild valgus deformity groups in patellar tilt (1.6° ± 6.6° versus 1.9° ± 3.2°, respectively) or patellar subluxation. There were complications in 12% (n = 5) and 11% (n = 9) of the severe valgus group and the mild valgus group respectively, without significant difference. There was no significant difference in extensor mechanism complication rate (2.3% versus 4.7%, respectively). Lateral parapatellar approach, without tibial tubercle osteotomy, for TKA in severe valgus deformity results in good patellar tracking. With this approach, the extensor mechanism complication rate in severe valgus deformity was not higher than for mild valgus deformity. III.

Reverse shoulder arthroplasty (RSA) is often indicated in elderly patients with displaced proximal humerus fractures (PHF). The rate of greater tuberosity (GT) healing varies from 37 to 90% in this population. The aim of this study was to assess greater and lesser tuberosity (LT) fixation and healing on CT scan after RSA for PHF. Our hypothesis was that both GT and LT healing leads to better functional results after RSA for fracture. Our retrospective cohort consisted of 28 patients treated with an RSA for a four-part PHF during the inclusion period. The mean age at surgery was 77 years. Clinical examination and CT scan were performed at a minimum one year follow-up to assess tuberosity position and healing. The GT healed in 22 patients (78.5%), the LT in 24 patients (87.5%) and both tuberosities were healed in 20 patients (71.5%). Constant score was significantly improved with GT, LT and both tuberosity healing (p = 0.05, p = 0.04 and p = 0.02 respectively). Motion in anterior elevation was improved with GT and both tuberosity healing (p = 0.01 and p = 0.04 respectively). Motion in external rotation was improved with GT and both tuberosity healing (p = 0.01 and p = 0.02 respectively). GT and LT healing was associated with better functional results and active motion. Anatomical reduction and consolidation of both tuberosities is beneficial with a cumulative effect for functional recovery.

Greater trochanter (GT) fractures affect 0.6–29% of patients after direct anterior approach (DAA) total hip arthroplasty (THA). Given the growing popularity of this approach, this study aimed to assess the evolution of the GT fractures during the learning curve, their risk factors and their consequences. 537 total hip arthroplasties were retrospectively included from May 2013 to December 2017 in a single academic centre. Patient characteristics, perioperative management, clinical consequences and postoperative radiographs were analysed. GT fractures represented 2.4% (n = 13) of the THA, and there was not a decrease with experience. The GT fracture patients did not require any additional support during the surgery, and full weight bearing was always allowed without any restriction. This complication only happened in females, with the risk significantly increased in those > 70 years old (OR = 4.9). There was no specific consequence during the follow-up, mean HHS score was 98.5 and all of the patients were satisfied or very satisfied postoperatively. Older osteoporotic women are known to be at risk for GT fracture during DAA THA. Those results reinforce the argument in favour of proper patient selection in DAA to lower the complications since it does not improve with surgeon’s experience. Retrospective, consecutive case series; Level IV.

Evidence is emerging that tibio-femoral compartmental balancing is related to clinical outcomes after total knee arthroplasty (TKA). The purpose of this study was to assess if kinematic alignment (KA) delivered a balanced knee in flexion and extension after TKA on varus deformity, compared to functional alignment (FA).This single-centre retrospective cohort study assessed 110 consecutive TKAs performed with an image-based robotic system for pre-operative varus deformity. The ligament balancing in the medial and lateral femorotibial compartments was assessed intra-operatively with a robotic system to evaluate if a KA plan would deliver a balanced knee. Balance was considered achieved if tibio-femoral compartments (medial/lateral) were equal to or less than 1.5 mm, or if the estimated final gap position more than 2 mm from the global implant thickness (17 mm). Implant positioning was modified within limits previously defined for a FA philosophy to achieve balancing. Resection thickness and implant positioning were compared with the KA plan and after the FA adjustments; and also, between the patients with a final balanced knee in extension and at 90° of flexion.A total of 102 patients were eligible for final analysis. Mean age was 67.3 ± 8.2 years, average BMI was 29.1 ± 5.2 kg/mKA failed to deliver a balanced TKA in more than 50% of cases, especially regarding the flexion gap. Consideration of soft tissue laxity led to significantly less bone resection, with more externally rotated femoral component and more varus tibial component.

Sex differences in muscle fiber-type composition have been documented in several muscle groups while the hamstring muscle fiber-type composition has been poorly characterized. This study aimed to compare the semitendinosus muscle composition between men and women. Biopsy samples were obtained from the semitendinosus muscle of twelve men and twelve women during an anterior cruciate ligament reconstruction. SDH and ATPase activities as well as the size and the proportion of muscle fibers expressing myosin heavy chain (MyHC) isoforms were used to compare muscle composition between men and women. The proportion of SDH-positive muscle fibers was significantly lower (37.4 ± 11.2% vs. 49.3 ± 10.6%, p 0.05), and the percentage of fast muscle fibers (i.e., based on ATPase activity) was significantly higher (65.8 ± 10.1% vs. 54.8 ± 8.3%, p 0.05) in men versus women. Likewise, men muscles exhibited a lower percentage of the area that was occupied by MyHC-I labeling (35.6 ± 10.1% vs. 48.7 ± 8.9%; p 0.05) and a higher percentage of the area that was occupied by MyHC-IIA (38.3 ± 6.7% vs. 32.5 ± 6.5%; p 0.05) and MyHC-IIX labeling (26.1 ± 9.6% vs. 18.8 ± 8.5%; p = 0.06) as compared with women muscles. The cross-sectional area of MyHC-I, MyHC-IIA, and MyHC-IIX muscle fibers was 31%, 43%, and 50% larger in men as compared with women, respectively. We identified sex differences in semitendinosus muscle composition as illustrated by a faster phenotype and larger muscle size in men as compared with women. This sexual dimorphism might have functional consequences.

To report the long-term clinical outcomes after isolated medial patellofemoral ligament reconstruction (MPFLr) to treat recurrent patellar instability.This was a single-center study of patients undergoing an isolated MPFLr between 2000 and 2011. All patients underwent reconstruction using hamstring autograft. The inclusion criteria were a minimum 10-year follow-up period and skeletally mature patients with more than 1 episode of patellar dislocation who underwent MPFLr without an associated bony procedure.A total of 54 knees were available for final analysis. The mean follow-up period was 12.3 years (range, 10-14 year). The mean age at surgery was 25 years. No patients had patellofemoral arthritis (PFA) prior to surgery. Preoperatively, the mean Caton-Deschamps index was 1.1 and the mean tibial tubercle-trochlear groove distance was 14.9 ± 2 mm (range, 7-17 mm). All patients had trochlear dysplasia according to the Dejour classification. At final follow-up, the mean Kujala score was 82.9 ± 15.3; mean International Knee Documentation Committee score, 78.3 ± 18.5; and mean Tegner score, 4.0 ± 1.7. Patients with an unsatisfactory outcome as determined by a Kujala score lower than 80 had a higher Caton-Deschamps index preoperatively and were more likely to be female patients; however, neither factor reached significance. Of the patients, 33 (66%) had no radiographic evidence of PFA whereas 15 (30%) had Iwano stage 1 and 2 had Iwano stage 2 (4%). At final follow-up, 4 patients (7.4%) had recurrent instability requiring revision surgery.Isolated MPFLr with gracilis tendon autograft in appropriately selected patients is an effective long-term treatment for recurrent patellofemoral instability with low rates of recurrence. One-third of patients exhibit radiographic evidence of PFA more than 10 years after isolated MPFLr.Level IV, case series.

Background: The optimal orientation of the anterolateral extra-articular reconstruction (ALLR) femoral tunnel to avoid collision with the anterior cruciate ligament reconstruction (ACLR) femoral tunnel is not clearly defined in the literature. Purpose: To define the optimal combination of orientations of the ALLR femoral tunnel and the ACLR femoral tunnel using an inside-out technique to minimize risk of collision between these tunnels. Study Design: Descriptive laboratory study. Methods: Three-dimensional reconstruction of magnetic resonance imaging scans of 40 knees after an isolated ACLR with an inside-out femoral technique was used to assess the collision risk between ACLR and virtual ALLR tunnels. The optimal ACLR tunnel orientation was defined as having the safest distance from the ALLR tunnel. A second collision analysis was performed on all patients presenting with an optimal orientation of the ACLR tunnel to then define the optimal ALLR tunnel orientation. The potential for trochlear damage was also studied. A collision risk of 0% to 5% was considered acceptable and referred to as “low risk.” Results: The only ALLR tunnel orientation presenting a low risk of collision with the ACLR tunnel was with an axial angle of 40° anteriorly and a coronal angle of 0°. This orientation presented a 48% risk of trochlear damage with the guide wire of the ALLR tunnel. The more posterior the orientation of the ACLR, the larger the distance from the ALLR tunnel. Among the 22 patients presenting with an optimal ACLR tunnel (alpha angle superior to 40°), the ALLR tunnels aimed with 1 of these 3 orientations presented a low risk of tunnel collision and trochlear damage: 40° axial and 10° coronal, 35° axial and 5° coronal, or 30° axial and 0° coronal. Conclusion/Clinical Relevance: To minimize risk of tunnel collision or trochlear damage when combining an inside-out ACLR with an ALLR, the ACLR tunnel should be performed with a posterior orientation (alpha angle >40°), and the ALLR tunnel should be aimed with 1 of 3 orientations: 40° axial and 10° coronal, 35° axial and 5° coronal, or 30° axial and 0° coronal.

Background The type of total knee arthroplasty (TKA) fixation (cemented or uncemented) is still subject to debate. The aim of this study is to assess the survival rate, clinical outcomes, and radiological results of TKA according to the fixation type. Methods A total of 130 patients were randomly assigned to either the cement group (cemented femoral and tibial implants) or the hybrid group (cemented tibial implant, uncemented femoral implant). The inclusion criteria were patients between 50 and 90 years old who underwent primary TKA for osteoarthritis between 2004 and 2005 without a history of open knee surgery. Revisions and complications were reported, as well as clinical scores and radiological signs of loosening. Results One hundred eighteen patients had complete data at 10 years of minimum follow-up (59 in each group). The mean age was 72 years old. The mean follow-up was 13 years. The survival rate was 98% at 13 years in both groups (1 aseptic loosening at 2 years in the cement group, 1 septic loosening in the hybrid group). The complication rate in the cement group was 8.5% (n = 5) vs 12.1% (n = 7) in the hybrid group (P = .8). The clinical results were not significantly different. In the cement group, 25% of patients (n = 15) had radiolucent lines at 10 years. In the hybrid group, 33% of patients had bone transparencies, not evolving or symptomatic. Conclusion At a minimum follow-up of 10 years, there were no significant differences between cemented TKA and hybrid TKA for the survivorship, the complication rate, the clinical scores, or the radiological signs of loosening. Level of Evidence I.

PURPOSE: Cup positioning is important for optimum hip stability, avoiding component impingement and decreasing both bearing surface wear and revision rate. Transitioning from posterior approach in a lateral position to direct anterior approach (DAA) in a supine presents unique challenges for surgeons. The aim of this study was to examine the learning curve when using standard instrumentation that was not specific to DAA. METHODS: A consecutive retrospective series of 537 total hip arthroplasty by DAA from May 2013 to December 2017. Cup positioning was analysed on radiographs and classified whether inside or outside two safe zones (inclination 30-50° and anteversion 10-30°). The demographic data (age, BMI, gender, neck shaft angle (NSA)), surgeon's dominant side and experience were assessed as risk factors. RESULTS: Eighty per cent of cups (n=426) were in the combined safe zones. Eighty-eight per cent (n=470) were in appropriate anteversion and 87% (n=463) abduction. Two factors that were significant were identified: Cups of left hips operated by right-handed surgeons were more anteverted (OR=4.06) and more vertical (OR=2.23); females had a higher anteversion of the cup (OR=2.42). Obesity, age and NSA were not risk factors for cup malposition. There was a spike of cups too horizontal at the beginning of the experience (OR=3.86), and no learning curve was observed in the other orientations. CONCLUSION: With our DAA technique using standard instrumentation, there were no risk factors linked to the patient identified for cup malposition. DAA-specific instrumentation is not required to achieve optimum positioning of the cup. Surgeon has to be aware of an excess of abduction at the beginning of his experience and an excess of anteversion and adduction when performing THA on the opposite side of his dominant hand.

The aim of this study was to evaluate the radiographic effect of sagittal tibial osteotomy (STO), flexion tibial osteotomy (FTO) and deflexion tibial osteotomy (DTO) around the knee. It has been hypothesized that proximal STO modifies patellar height and could cause varus/valgus changes of the anatomical tibial axis: The purpose of the study was to verify this and to analyse these modifications. Patients underwent proximal STO in our department between 2007 and 2018: overall 28 consecutive patients (19 males, 9 females; 28 knees). Twelve patients underwent DTO, and 16 patients underwent FTO. Two independent observers measured the pre-operative and post-operative radiological indexes: posterior tibial slope, Caton-Deschamps Index (CDI) and Modified Insall-Salvati Index (MISI) in the lateral views; medial Tibial Plateau-Tibial Shaft (mTPTS) and medial Femoral Shaft-Tibial Shaft (mFTA) anatomical angles were measured in the frontal plane. No complications were reported at the average follow-up of 1.6 ± 1.1 years. The mean mTPTS significantly increased from 0.6° ± 2.4° pre-operatively to 2.9° ± 2.6° of varus post-operatively (DTO (pre-operative 0.3 ± 3.1°, post-operative 2.4 ± 2.1°, ns); FTO (pre-operative 0.9 ± 1.9°, post-operative 3.2 ± 3.0°, P

Background: Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone–patellar tendon–bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients. Purpose: The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire). Results: Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups ( P = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy. Conclusion: There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome.