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Abstract Our study aims to investigate if the ratios proposed by Insall-Salvati and Caton-Deschamps follow the theory of normal distribution levels in a healthy population. 434 skeletal mature, healthy knees were obtained from a CT-scan-based modelling system (SOMA). Patellae height ratios were measured using the Insall-Salvati ratio and the Caton-Deschamps index. The patella height ratios of the sample population were plotted on a quantile plot and diagnosed as patella alta, baja or normal using the original ratio definitions. The study population patella height values at the 95th, 98th and 5th centiles were identified and compared to those described as alta or baja by Insall-Salvati and Caton-Deschamps. This meant that if the patient had patella alta, this would be defined as a ratio of ≥ 1.2 and hypothesised that this would align at the 98th centile of the study population, whilst if diagnosed as patella baja (≤ 0.74), this should align at the 5th centile of the population. The inter-rater reliability of both ratios was calculated using kappa statistics. Two authors made all calculations and compared them for consistency using the intraclass correlation coefficient. For the Insall-Salvati ratio, the study population’s value at the 98th centile was equivalent to what Insall-Salvati describes as alta, a ratio of ≥ 1.2. In the study population, patients are overdiagnosed if using the Insall-Salvati ratio as patella baja ≤ 0.74, as the value at the 5th centile in the study population was 0.59. Using the Caton-Deschamps index, the 95th centile was 1.3, higher than the patella alta ratio determined by Caton as a ratio ≥ 1.2. Using Caton-Deschamps, patients are being underdiagnosed if utilising a patella baja ratio of ≤ 0.6. In our population, the 5th centile was 0.75. The two ratios had a kappa coefficient of 0.01, which indicates poor inter-rater reliability. Depending on the ratio used, caton-Deschamps and Insall-Salvati ratios diagnose patients as alta or baja differently. The current patella height ratios have originated from very small, select population samples. The future of patella height discussion should begin with data representing large populations. Then, we can discuss the upper and lower limits of abnormality.

Background: It is estimated that surgical procedures account for 20%-30% of the greenhouse gases emissions from health-care systems. Total knee replacements (TKR) are one of the most frequently performed procedures in orthopaedics. The aim of this study was to identify and quantify the environmental impacts generated by TKRs, the factors that generate the most emissions, and those that can be easily modified. Methods: To calculate the life cycle carbon footprint of a posterior stabilized cemented TKR performed in a single orthopaedic surgery department, 17 TKRs performed between October 12 and 20, 2020 by 4 senior surgeons were analysed. The analysis of the life cycle included the manufacture of the implant, from raw materials to distribution; the journey made by patients and staff; and the surgery including all consumables required to facilitate the procedure. Results: The overall life cycle carbon footprint of a single TKR was 190.5 kg of CO2. This consisted of 53.7 kg CO2 (28%) for the manufacture of the prosthesis, 50.9 kg CO2 (27%) for travel, 57.1 kg CO2 (30%) for surgery, and 28.8 kg CO2 (15%) for waste management. This is comparable to a New York-Detroit direct flight. Conclusions: The production of a total knee prosthesis, throughout its life cycle, generates emissions with important consequences on the environment and therefore on our health. Although much data are currently missing to make precise estimates, and especially regarding benefits in terms of patient function and its impact on carbon emissions, these data serve as a starting point for other more detailed or comparative studies.

Aims: Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods: We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results: Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion: Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494.

Abstract Purpose The Pivot Shift (PS) test is a complex clinical sign that assesses the internal rotation and anterior tibial translation, which occurs abnormally in ACL deficient‐knees. Because of the high inter‐observer variability, different devices have been designed to characterize this complex movement in quantitative variables. The objective of this pilot study is to validate the reproducibility of intraoperative quantitative assessment of the PS with a smartphone accelerometer. Methods Twelve ACL‐injured knees were included and compared with the contralateral uninjured side. The PS was measured by two independent observers utilizing a smartphone accelerometer and graded according to the IKDC classification. Measurements were taken preoperatively, intraoperatively and postoperatively. Intraoperative readings were taken during each stage of reconstruction or repair of meniscoligamentous lesions including meniscal lesions, ramp lesions, ACL reconstruction and lateral tenodesis. Reproducibility of the measurements were evaluated according to an intraclass correlation coefficient (ICC). Results The intra‐observer reliability was good for the first examiner and excellent for the second examiner, with the ICC 0.89 [0.67, 0.98] p

Patellar lower-pole fractures occur in relatively young patients after eccentric contraction of the quadriceps or direct trauma. Early diagnosis and adequate treatment lead to excellent outcomes and prevent tendon retraction and scarring. The aim of surgical treatment is to restore articular congruence and reestablish the extensor mechanism of the knee. All surgical treatments (sutures and tension band wiring, separate vertical wiring or augmented with Krackow sutures, wiring through screws, basket plate, hook plate) use additional hardware. We propose a hardware-free technique using ipsilateral hamstring augmentation.

Abstract  Recent literature suggests patients achieve substantial short-term functional improvement after combined bicompartmental implants but longer-term durability has not been documented. We therefore asked whether (1) bicompartmental arthroplasty (either combined medial unicompartmental knee arthroplasty (UKA) and femoropatellar arthroplasty (PFA) or medial UKA/PFA, or combined medial and lateral UKA or bicompartmental UKA) reliably improved Knee Society pain and function scores; (2) bicompartmental arthroplasty was durable (survivorship, radiographic loosening, or symptomatic disease progression); (3) we could achieve durable alignment; and (4) the arthritis would progress in the unresurfaced compartment. We retrospectively reviewed 84 patients (100 knees) with bicompartmental UKA and 71 patients (77 knees) with medial UKA/PFA. Clinical and radiographic evaluations were performed at a minimum followup of 5 years (mean, 12 years; range, 5–23 years). Bicompartmental arthroplasty reliably alleviated pain and improved function. Prosthesis survivorship at 17 years was 78% in the bicompartmental UKA group and 54% in the medial UKA/PFA group. The high revision rate, compared with total knee arthroplasty, may be related to several factors such as implant design, patient selection, crude or absent instrumentation, or component malalignment, which can all contribute to the relatively high failure rate in this series. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Total hip arthroplasty in dysplastic hips is challenging because of the modified anatomy of the proximal femur and acetabulum. We studied three-dimensional anatomic parameters in 247 dysplastic hips from 218 adult patients using radiographs and computed tomography, and analyzed the consequences for total hip arthroplasty. A cohort of 310 primary osteoarthritic hips was used as a control group. According to the classification of Crowe et al, 78 of the dislocated hips were graded Class I, 26 as Class II, 20 as Class III or IV, and 169 dysplastic hips had no subluxation. Compared with primary osteoarthritis, the intramedullary femoral canal had reduced mediolateral and anteroposterior dimensions. With high grade subluxations the femoral neck shaft angle decreased but with low grades, especially in Class II, the neck shaft angle increased. The proximal femur had more anteversion with individual variations ranging from 1° to 80°. The true acetabulum had a reduced anteroposterior diameter. The large individual morphologic variability across all levels of dysplastic hips suggests the femoral prosthesis cannot be chosen on the basis of the severity of the subluxation alone. [ABSTRACT FROM AUTHOR]

Unicompartmental knee arthroplasty is a logical procedure when the lesion is limited to one femorotibial compartment. The procedure can now be performed through a mini-incision to provide quicker recovery because the extensor mechanism disruption is minimized. We have found the length of the incision varies according to patient mass and muscle tone. Specific instrumentation limited to the replaced compartment and using either an intra- or extramedullary femoral technique provides femorotibial component alignment and allows slight undercorrection of the deformity. Radiographic assessment demonstrates precise implantation of the components is possible with a mini-incision, which is believed important for the long-term results of the arthroplasty. The functional evaluation of patients implanted with unicompartmental knee arthroplasty performed through a mini-incision suggests appropriate kinematics can be restored after the procedure, enhancing the importance of a functional anterior cruciate ligament.Level of Evidence: Level V, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Fixation of the graft during anterior cruciate ligament reconstruction surgery has been the subject of numerous technical innovations but still remains a challenge. This article describes a novel technique of graft fixation for hamstring tendon reconstruction: the Cage For One system (Sacimex, Aix-en-Provence, France). The technique uses only the semitendinosus tendon, which is looped to create a 4-strand graft. Leaving the gracilis tendon intact probably reduces the loss of knee flexion strength. The graft is indirectly anchored into both tunnels with polyetheretherketone cages by use of polyethylene terephthalate tape strips. Both cages and strips are magnetic resonance imaging compatible and do not create artifacts. The tunnels are drilled by an outside-in method with minimal incisions. This type of fixation creates a 360° bone contact at 1.5 cm in each tunnel and is compatible with double-bundle reconstruction. This easy-to-use novel technique of fixation for anterior cruciate ligament reconstruction produces a strong 4-strand graft while harvesting only the semitendinosus tendon and leaving the gracilis tendon intact to reduce flexion strength loss and preserve rotatory stability of the knee. It creates an immediate solid fixation that is independent of graft integration in the early postoperative period, allowing the patient to start immediate rehabilitation without the use of a brace.