Brice Rubens-Duval

Total knee arthroplasties from the origin to navigation: history, rationale, indications

Since the early 1970s, total knee arthroplasties have undergone many changes in both their design and their surgical instrumentation. It soon became apparent that to improve prosthesis durability, it was essential to have instruments which allowed them to be fitted reliably and consistently. Despite increasingly sophisticated surgical techniques, preoperative objectives were only met in 75% of cases, which led to the development, in the early 1990s, in Grenoble (France), of computer-assisted orthopaedic surgery for knee prosthesis implantation. In the early 2000s, many navigation systems emerged, some including pre-operative imagery (“CT-based”), others using intra-operative imagery (“fluoroscopy-based”), and yet others with no imagery at all (“imageless”), which soon became the navigation “gold standard”. They use an optoelectronic tracker, markers which are fixed solidly to the bones and instruments, and a navigation workstation (computer), with a control system (e.g. pedal). Despite numerous studies demonstrating the benefit of computer navigation in meeting preoperative objectives, such systems have not yet achieved the success they warrant, for various reasons we will be covering in this article. If the latest navigation systems prove to be as effective as the older systems, they should give this type of technology a well-deserved boost.

Moore I postero-medial articular tibial fracture in alpine skiers: Surgical management and return to sports activity

PURPOSE Over the past 10 years, like many authors, we observed an increasing number of Moore I tibial plateau fractures related to alpine skiing for which the surgeon may face difficult choices regarding surgical approach and fixation means. Some authors have recently been suggesting a posterior approach associated to open reduction and osteosynthesis by a buttress plate. But in our knowledge there is no specific study on sports activity recovery after Moore I tibial fractures. The aim of this work was to assess sports activities and clinical outcomes after surgically treated Moore I tibial plateau fractures in an athletic population of skiers. METHODS We conducted a prospective case series between 2012 and 2014. This included fifteen patients aged 39.6±7 years whom presented with a Moore I tibial plateau fracture during a skiing accident. 12 cases (80%) presented with an associated tibial spine fracture. Treatment consisted of a standard antero-medial approach, with a medial para patellar arthrotomy to allow direct visualisation of articular reduction and spinal fixation. Two or three 6.5mm long cancellous bone screws were placed antero-posteriorly so as to ensure perfect compression of the fracture site. Radiological and functional results were assessed by an independent observer (Lysholm-Tegner, UCLA, KOOS scores) at the longest follow-up. RESULTS Mean follow-up was 18.2±6 months (12-28). An immediate postoperative anatomical reduction was achieved in all cases and remained stable in time. At last follow-up Lysholm mean score was 85±14 points (59-100), UCLA score was 7.3±1.6 (4-10) and Tegner score was 4.6±1.3 (3-6). Mean KOOS score was 77±15 (54-97). 87% of patients had resumed their skiing activity and 93% were satisfied or very satisfied from their post-operative surgical outcome. We observed no pseudarthrosis or secondary varus displacement. CONCLUSION In our series 87% of patients had resumed back to their sporting activities. Surgical management of Moore I tibial plateau fractures by isolated antero-posterior screwing provides excellent clinical and radiological results. The anteromedial incision has a dual advantage of anatomical reduction, tibial spine fixation (in 80% of our cases) and posteromedial fragment reduction.

Doubles ostéotomies assistées par ordinateur dans les grands genu varum

PURPOSE OF THE STUDY The aim of this work was to assess radiographic outcome after double femoral and tibial osteotomy for severe genu varum. Among 197 computer-assisted osteotomies performed in our department between August 2001 and February 2006, 16 (8.1%) were double level osteotomies. MATERIAL AND METHODS Five women and nine men, mean age 51.19+/-11.15 years (range 20-63 years) underwent surgery (both sides for two men). The right side was involved in nine cases, the left in seven. Inclusion criteria were genu varum>10 degrees and/or a mechanical femur angle > =90 degrees in a context of a varus tibial mechanical axis. Exclusion criteria were a femoral mechanical angle at 90 degrees and a tibial mechanical angle>88 degrees. Using the modified Ahlbäck classification, the knees were: grade 2 (n=1), grade 3 (n=9), grade 4 (n=4) and grade 5 (n=1). One patient did not present osteoarthritic degradation but a particularly unaesthetic deformity. The radiological femorotibial mechanical angle (HKA) measured preoperatively was on average 168.44 degrees +/-2.42 degrees (range 164 degrees -173 degrees). The average preoperative femoral mechanical angle was 87.38 degrees +/-2.45 degrees (range 81 degrees -90 degrees) and the mechanical tibial angle was 84.5 degrees +/-2.19 degrees (range 80 degrees -88 degrees). The main preoperative objective was to obtain a mechanical femorotibial angle of 182 degrees +/-2 degrees without an oblique joint space giving a tibial mechanical angle of 90+/-2 degrees). All operations were computer-assisted using the Orthopilot navigation system. After acquisition of the mechanical axis, the closed wedge lateral distal femoral osteotomy was performed first to achieve the desired femoral correction. The open wedge proximal medial tibial osteotomy was then performed to obtain the planned femorotibial mechanical axis. A control goniometry in the weight bearing position was obtained three months postoperatively. RESULTS There were no complications. The mean preoperative computer-measured HKA was 168.63 degrees +/-2.22 degrees (range 164 degrees -173 degrees), i.e. an angle corresponding perfectly with the preoperative goniometry. After the osteotomies, the mean computer-measured mechanical angle was 183 degrees +/-0.94 degrees (range 181 degrees -184 degrees). Three months after the operation, the weight-bearing goniometry gave a mean HKA angle at 181.25 degrees +/-1.84 degrees (range 177 degrees -184 degrees). The mean femoral mechanical angle was 93.13 degrees +/-2.25 degrees (range 89 degrees -97 degrees) and the mean tibial mechanical angle was 90.31 degrees +/-1.20 degrees (range 88 degrees -92 degrees). The preoperative objective was achieved in 14 of the 16 patients (87.5%). The two failures were undercorrections (177 degrees and 179 degrees). Joint spaces were not oblique on the x-rays. DISCUSSION Tibial osteotomy is an excellent method for the treatment of osteoarthritic genu varum. However, in patients with very severe deformity, femoral varus is also involved so that the overcorrection necessary to achieve a good result (3-6 degrees valgus) could often produce an oblique joint space corresponding to excessive tibial valgus. Since osteotomy is generally considered as a palliative measure before later implantation of a total prosthesis, an oblique joint surface would compromise the success of the subsequent surgery. Double-level osteotomy is a way to avoid this problem, keeping in mind that the risk of over or under correction is not negligible for this difficult operation. We used our experience with computer-assisted navigation for total knee arthroplasty and for tibial osteotomy to prepare this technique for double-level osteotomy. CONCLUSION Computer-assisted double-level osteotomy is a reliable, accurate and reproducible method for the treatment of severe genu varum. The two failures observed in this series were within a tolerable range (177 degrees and 179 degrees). The use of a navigation procedure simplifies a technique which in general requires skillful application to achieve the preoperative objective. The development of this technique is important in order to avoid an oblique joint space which can compromise the success of subsequent prosthesis implantation.

Concept of Combined Femoral and Tibial Osteotomies

&NA; Medial knee osteoarthritis is not uncommon, and high tibial osteotomy (HTO) for some surgeons is a unique treatment option for young and active patients. However, the deformity is not always located at the level of proximal part of the tibia and the overcorrection needed to achieve a lasting functional result can lead to an oblique joint line. To avoid this undesirable effect to the joint line, a double‐level osteotomy (DLO), one at the distal part of the femur and another one at the proximal part of the tibia, is a viable option. The aim of this article is to present the preoperative radiological assessment, the operative procedure, the indications of HTO, distal femoral osteotomy (DFO), and DLO presenting the rationale behind the treatment options. Long‐leg radiographs are mandatory to measure the hip‐knee‐ankle angle, and the femoral and tibial mechanical axes to plan the location of the osteotomy. The best indication for DLO is a severe varus knee deformity with femoral and tibial mechanical axes in varus. This argument can be applied to a genu valgum deformity, especially when the femur is in valgus as well as the tibia, which is not rare. Although the operative technique is demanding, the biggest challenge is not the procedure itself but rather how to reach the exact degree of overcorrection. Computer‐assisted surgery is a good alternative and can improve the accuracy of the surgery.

Prothèse totale du genou assistée par ordinateur après ostéotomie tibiale d’ouverture médiale : résultats à moyen terme d’une étude cas-témoin de 90 cas

Introduction : L’objectif de ce travail etait de comparer les resultats a moyen terme des protheses totales de genou (PTG) post-osteotomie tibiale de valgisation d’ouverture mediale (post-OTOM) a ceux des PTG de premiere intention (PTG1). L’hypothese etait que les PTG post-OTOM avaient des resultats identiques aux PTG1. Methodes : La serie 1 etait composee de 45 PTG post-OTOM, 30 hommes et 10 femmes, âges en moyenne de 69 ± 7 ans (54-82). Celle-ci a ete comparee a une serie 2 composee de 45 PTG1, 30 hommes et 10 femmes, âges en moyenne de 69 ± 7 ans (55-78). Le score IKS moyen etait respectivement de 91 ± 22,5 points (42-129) et de 86 ± 18 points (38-116). L’angle HKA moyen preoperatoire etait respectivement de 179° ± 5° (169°-193°) et de 173° ± 7,5° (161°-193°) et l’angle mecanique tibial (AMT) moyen de 90,5° ± 4° (82 - 102°) (dont 24 genoux avec un AMT en valgus) et de 85,5° ± 3,5° (79°-93°). Resultats : Tous les patients ont ete revus a un recul moyen de 47 ± 25 mois (18-114) pour la serie 1 versus 57,5 ± 24,5 mois (24-102). Le score IKS moyen etait de 184 ± 6 points pour la serie 1 (172-200) versus 185 ± 8,5 (163-200) pour la serie 2 (p = 0,872). 37 et 38 patients etaient respectivement tres satisfaits ou satisfaits de l’intervention. L’angle HKA moyen etait de 180,5° ± 2,5° versus 181° ± 2° (p = 0,122) et l’AMT moyen de 89° ± 1,5° versus 90° ± 1° (p=0,001). Les resultats des 24 genoux avec AMT en valgus etaient statistiquement non differents. Conclusion : Les PTG post-OTOM, meme avec un AMT preoperatoire en valgus, ont des resultats identiques aux PTG1.

275 Résultats à moyen terme de 10 reprises chirurgicales d’échecs d’intervention de Latarjet pour instabilité antérieure de l’épaule

Introduction L’objectif de ce travail etait d’evaluer les resultats a moyen terme de 10 echecs d’intervention de Latarjet realisee pour instabilite anterieure de l’epaule en sachant que nous avons considere comme echec toute recidive de la luxation. Materiel et methodes Entre 1995 et 2004, nous avons opere 10 echecs d’intervention de Latarjet, 4 provenaient du service et 6 d’une autre structure. il s’agissait de 2 femmes et 8 hommes ages de 28 + /- 9 ans (17 a 43) au moment de la reprise. Le delai moyen entre chirurgie initiale et reintervention etait de 4,6 + /- 6,1 ans (2 mois a 19 ans)avec 4 echecs dans la premiere annee postoperatoire.Il y avait 5 sportifs (pivots contact) et 5 sedentaires. La recidive etait survenue dans 3 cas au decours d’un traumatisme violent et dans 7 cas au decours d’un traumatisme modere.Les radiographies apres recidives montraient 2 lyses de la butee, 5 pseudarthroses et 3 butees parfaitement fusionnees. 8 epaules ont ete traitees par une nouvelle butee selon la technique d’Eden-Hybbinette et 2 epaules par capsulo-myoplastie. 8 operes sur 10 ont ete revus par un examinateur independant pour evaluation clinique (score de Duplay) et radiologique. Resultats A la revision, le recul moyen etait de 6.75 + /- 1.75 ans (5 a 9) et 2 operes etaient perdus de vue. Les 2 patients du groupe myoplastie et 6 du groupe Eden-Hybbinette ont pu etre revus. Dans ce dernier groupe, nous avons retrouve 2 echecs dont un a necessite une reintervention pour capsulo-myoplastie complementaire en presence d’une butee partiellement lysee. Les resultats cliniques etaient bons avec un score de Duplay global de 76,25 + /- 19,95 points (40 a 100)dont 7 operes (87,5 %) avec un score superieur ou egal a 70 points. Nous n’avons pas collige de nouvelle recidive de la luxation. Sur le plan radiologique, nous avons note, dans le groupe Eden-Hybbinette, une progression de l’arthrose de 37,5 % des cas (Samilson 0 a Samilson I dans 2 cas et Samilson I a Samilson II dans 1 cas). Conclusion Les echecs d’intervention de Latarjet peuvent etre reoperes avec des resultats a moyen terme tout a fait honorables. En cas de lyse de la butee, une nouvelle butee de crete iliaque peut etre envisagee en lui associant une capsulo-myoplastie. Si la butee est en place et parfaitement fusionnee, une capsulo-myoplastie peut suffire.

Computer-Assisted High Tibial and Double Level Osteotomies for Genu Varum Deformity

We have utilized computer navigation to perform osteotomies around the knee. The goal of this article is to present our rationale, indications, and surgical technique of computer-assisted high tibial and doublelevel osteotomies for genu varum deformity. The results are based on 2 studies: (1) a comparative cohort study of computer-assisted versus conventional high tibial osteotomy, showing a 96% reproducibility in achieving a mechanical axis of 184 T 2 degrees in the computer-navigated group versus 71% in the conventional osteotomy group (P G 0.0015); (2) a prospective study on double-level osteotomy showing that the preoperative goal (182 T 2 degrees) has been achieved in 91% of the cases.

Doubles ostéotomies assistées par ordinateur dans les grands genu varum: Résultats préliminaires à propos de 16 cas

Resume L’objectif de ce travail etait d’evaluer les resultats radiologiques de la double osteotomie (femorale distale et tibiale proximale) realisee dans le cadre de grands genu varum. Entre aout 2001 et fevrier 2006, nous avons realise 16 doubles osteotomies parmi 197 osteotomies du genou assistees par ordinateur, soit 8,1 %. Nous avons opere 5 femmes et 9 hommes âges en moyenne de 51,19 +/-11,15 ans (20 a 63), 2 hommes ont ete operes des 2 cotes. Le cote droit etait interesse dans 9 cas (7 cotes gauches). Les criteres d’inclusion etaient un genu varum superieur a 10° et/ou un angle mecanique femoral inferieur ou egal a 90° dans un contexte d’axe mecanique tibial en varus. Les criteres d’exclusion etaient un angle mecanique femoral superieur a 90° et un angle mecanique tibial superieur a 88°. Il s’agissait, selon la classification de Ahlback modifiee, d’un stade 2, de 9 stades 3, de 4 stades 4 et d’un stade 5. Une patiente n’avait pas d’arthrose mais une deformation particulierement inesthetique. L’angle femoro-tibial mecanique (angle HKA) radiologique moyen preoperatoire etait de 168,4° +/- 2,2° (164° a 173°). L’angle mecanique femoral preoperatoire moyen etait de 87,38° +/- 2,45° (81° a 90°) et l’angle mecanique tibial de 84,5° +/- 2,19° (80° a 88°). L’objectif principal etait d’obtenir un axe femoro-tibial mecanique a 182° +/- 2° sans interligne oblique soit un angle mecanique tibial a 90° +/- 2°. L’objectif secondaire etait d’avoir un angle mecanique femoral inferieur ou egal a 95° (93° +/- 2°). Toutes les interventions ont ete realisees avec assistance par le systeme de navigation Orthopilot TM . Apres acquisition de l’axe mecanique a l’aide de l’ordinateur, on realisait, dans un premier temps, l’osteotomie femorale distale de fermeture laterale et dans un deuxieme temps l’osteotomie tibiale haute d’ouverture mediale. Nous n’avons pas eu de complication. L’axe mecanique moyen peroperatoire donne par l’ordinateur etait de 168,63° +/ 2,22° (164° a 173°) soit un angle superposable a la gonometrie preoperatoire. Apres les osteotomies, l’axe mecanique moyen donne par l’ordinateur etait de 183° +/- 0,97° (181° a 184°). Trois mois apres l’operation, la gonometrie en charge montrait un axe moyen a 181,25° +/- 1,84° (177°-184°). L’angle mecanique femoral moyen etait de 93,13° +/- 2,25° (89° a 97°) et l’angle mecanique tibial de 90,31° +/- 1,20° (88° a 92°). L’objectif preoperatoire a ete atteint dans 14 cas sur 16 (87,5 % des cas). Aucune radio ne montrait d’interligne oblique.