Elvire Servien

Posteromedial Meniscal Tears May Be Missed During Anterior Cruciate Ligament Reconstruction

PURPOSEnThis study aimed to assess the benefit of using an arthroscopic intercondylar view and a posterior medial viewing portal during anterior cruciate ligament (ACL) reconstruction in the diagnosis of posterior horn of the medial meniscus (PHMM) tears. A secondary objective was to determine clinical and radiological risk factors for the PHMM.nnnMETHODSnForty-one patients undergoing isolated ACL reconstruction were prospectively evaluated. At ACL reconstruction, the PHMM was assessed using a standard 30° arthroscope in 3 sequential stages: a classic anterolateral portal view, an intercondylar view, and a view through a posteromedial portal.nnnRESULTSnThirty-nine patients were included (12 female patients and 27 male patients). A posteromedial tear of the medial meniscus was found in 17 patients using the anterolateral portal view. The intercondylar view identified 4 new additional lesions and extensions of 3 previously identified lesions. The posteromedial portal view identified 6 new lesions and 5 extensions of known lesions compared with the anterolateral portal view. Two lesions seen through the posteromedial portal were not identified by either the anterolateral portal view or the intercondylar view.nnnCONCLUSIONSnTears of the PHMM may be underdiagnosed by intraoperative assessment using only an anterolateral portal view during ACL reconstruction. The intercondylar view combined with a posteromedial portal aids in the diagnosis of PHMM tears and should be considered in routine ACL reconstruction to assess meniscal status, particularly when the interval from injury to surgery is prolonged.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

5- to 16-year follow-up of 54 consecutive lateral unicondylar knee arthroplasties with a fixed-all polyethylene bearing.

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

A Biomechanical Evaluation of Bicortical Metal Screw Fixation Versus Absorbable Interference Screw Fixation After Coracoid Transfer for Anterior Shoulder Instability

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

Progression of medial osteoarthritis and long term results of lateral unicompartmental arthroplasty: 10 to 18 year follow-up of 54 consecutive implants

INTRODUCTIONnThe literature results of unicompartmental knee arthroplasty (UKA) for isolated lateral osteoarthritis (OA) are not as good as for isolated medial OA. In 1988 our department started using a UKA with a fixed, all polyethylene tibial component and a resurfacing femoral component. The aim of this retrospective study is to report on the progression of medial OA and the long term results of this prosthesis implanted for isolated lateral OA, at a minimum follow up of ten years.nnnMATERIALS AND METHODSnFrom January 1988 to October 2003, we performed 54 lateral UKAs in 52 patients. All patients had isolated lateral OA, which was post-traumatic in three cases. The mean age at the time of the index procedure was 72.2 ± 15.2 years. Forty-six UKAs in 44 patients were available for follow-up. The mean duration of follow-up was 14.2 years (minimum ten years; range 10.2-18 years).nnnRESULTSnAt final follow-up, seven had undergone a second operation, three were revised to total knee arthroplasty (TKA), three had medial UKAs implanted for progression of medial disease, and one was converted to TKA for tibial tray malpositioning. No revision surgery was necessary for wear, infection or progression of patellofemoral OA. The mean Knee Society Score (KSS) knee score was 95.1 points and mean KSS function score was 82.2 points. The mean range of motion was 132.6° (range, 115-150°). Implant survival was 94.4% at ten years and 91.4% at 15 years.nnnCONCLUSIONnThe use of a UKA with a fixed, all polyethylene tibial bearing and a femoral resurfacing implant is a reliable option for the management of isolated lateral knee osteoarthritis. We have demonstrated excellent functional results and implant survival in the long term. The most significant factor leading to reoperation is progression of medial disease.

Treatment of chronic disruption of the patellar tendon in Osteogenesis Imperfecta with allograft reconstruction

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

The effect of gender on outcome of unicompartmental knee arthroplasty

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

Equivalent results of medial and lateral parapatellar approach for total knee arthroplasty in mild valgus deformities.

PurposeWhen performing total knee arthroplasty (TKA) in valgus knee deformities, a medial or lateral parapatellar approach can be performed, but the lateral approach is often considered technically more difficult. The purpose of this study was to compare intra-operative, early clinical and radiological outcomes of medial and lateral parapatellar approaches for TKA in the setting of moderate knee valgus (<10°).MethodsWe prospectively analysed 424 knees with pre-operative valgus deformity between 3° and 10° that underwent TKA over an 18-year period; 109 were treated with a medial approach and 315 with a lateral approach. Intra- and post-operative outcomes and complication rates after a minimum follow-up of one year were compared.ResultsTourniquet (pu2009=u20090.25) and surgical (pu2009=u20090.62) time were similar between groups. The popliteus tendon was released more frequently in the medial-approach group (pu2009=u20090.04), while the iliotibial band was released more frequently in the lateral-approach group (pu2009<u20090.001). A tibial tuberosity osteotomy was performed more frequently in the lateral- than medial-approach group (pu2009=u20090.003). No significant differences in limb alignment (pu2009=u20090.78), or Knee Society Score (KSS) knee (pu2009=u20090.32) and function (pu2009=u20090.47) results were noted based on surgical approach, and complication rates were similar between groups (pu2009=u20090.53).ConclusionsLateral parapatellar approach is a safe and effective surgical technique for performing TKA in moderately valgus knees. These equivalent early results are encouraging for systematic use of the lateral approach in moderately valgus knees.

Chondral Injury in Patellofemoral Instability

Objective: Patellofemoral instability is common and affects a predominantly young age group. Chondral injury occurs in up to 95%, and includes osteochondral fractures and loose bodies acutely and secondary degenerative changes in recurrent cases. Biomechanical abnormalities, such as trochlear dysplasia, patella alta, and increased tibial tuberosity-trochlear groove distance, predispose to both recurrent dislocations and patellofemoral arthrosis. Design: In this article, we review the mechanisms of chondral injury in patellofemoral instability, diagnostic modalities, the distribution of lesions seen in acute and episodic dislocation, and treatments for articular cartilage lesions of the patellofemoral joint. Results: Little specific evidence exists for cartilage treatments in patellofemoral instability. In general, the results of reparative and restorative procedures in the patellofemoral joint are inferior to those observed in other compartments of the knee. Conclusion: Given the increased severity of chondral lesions and progression to osteoarthritis seen with recurrent dislocations, careful consideration should be given to early stabilisation in patients with predisposing factors.

Total knee arthroplasty after varus distal femoral osteotomy vs native knee: similar results in a case control study

PurposeThe aim of this study was to investigate the results of total knee arthroplasty (TKA) performed after varus distal femoral osteotomy (VrDFO), in comparison to a control group of TKAs performed as the primary intervention for arthrosis. Main hypothesis was that the medium term results for the two groups would be similar.MethodsAll TKAs performed after VrDFO were extracted from a single centre, prospective database of 4046 arthroplasties. A case-control study was performed with a control group comprising two TKAs performed as the primary intervention for each TKA after VrDFO, and matched for sex, age at intervention, body mass index, the type of arthrosis and the type of implant. All prostheses used a system of posterior stabilisation by a third median condyle (Laboritoire Tornier-Wright). The primary outcome measure was the post-operative Knee Society Score (KSS).ResultsFourteen TKAs after VrDFO were identified, with a median follow-up of 42xa0months (12–102xa0months). The control group comprised 28 patients. There were no significant differences between groups in terms of the matching criteria. Pre-operatively, there were no differences between groups in terms of KSS (knee and function scores), range of motion (fixed-flexion and maximum flexion), and mechanical axes on long leg films. Operative duration was identical for the two groups. In the VrDFO group there was more lateral intra-operative laxity (pu2009=u20090.006), more intra-operative complications (patella tendon injuries, pu2009=u20090.0008), and more frequent need for screw support for the tibial component due to more severe lower limb deformity (pu2009<u20090.0001). No significant difference was found between groups with regards to the post-operative KSS; median knee score was 91.7 in the VrDFO group compared to 82.3 in the control group, and function score 70.6 compared to 77.8. Range of motion was comparable between groups with median maximum flexion in the VrDFO group of 115.7° and 110.9° in the control group.ConclusionTKAs after VrDFO is uncommon and can carry an increased risk of intra-operative complications. Despite this, the medium term results are comparable to arthroplasty performed as a primary intervention. TKA should not be denied to patients with previous femoral osteotomy, but care must be taken with gap balancing and axis correction.Level of evidence3.

Short lateral posterior condyle is associated with trochlea dysplasia and patellar dislocation

PurposeSurgeons mainly consider the anterior anatomy of the distal femur in the treatment of patellar instability (PI) with trochlear dysplasia (TD). Through this research, the idea was to analyse the posterior femoral condyle length in TD. The research team posited the presence of morphological differences in the posterior part of the femoral epiphysis in TD compared to a control group. They also postulated that the posterior bicondylar angle (PCA), in the axial plane, was increased in TD.MethodsThis is a single-centre morphological study of 100 patients who had a computed tomography (CT) using the same protocol. 50 patients with PI (25 dysplasias A and 25 B-C-D according to the Dejour classification), and 50 controls were included. All patients presenting a clinical PI were considered for the study. None of these patients had undergone a surgical treatment prior to imaging. Demographic characteristics, BMI, and laterality were comparable in all patients. 20 pilot CT scans were used to establish the methodology. The following measurements were performed: anterior bicondylar angle, PCA, and condylar lengths with respect to the surgical transepicondylar axis. Ratios were calculated in relation to the femoral width. TD was classified according to the Dejour classification in grade A or grades B–C–D. An analysis of variance and a linear model were performed within some groups to investigate which parameters correlated with the classification’s grade.ResultsThis study showed a link between TD and the PCA: control group (1.4u2009±u20090.2°), type A group (1.6u2009±u20090.3°), and types B, C, D group (2.6u2009±u20090.3°) (pu2009=u20090.01). The difference between the control group and types B, C, D TD group was significant (pu2009=u20090.002). In groups B, C, D, the PCA was more important, which proves that in these groups the posterior part of the lateral condyle was relatively shorter compared to the medial condyle. The greater the dysplasia, the longer the medial condyle was in the anterior posterior (pu2009=u20090.02).ConclusionsThis study shows not only an anterior but also a posterior anomaly in PI with TD. There is a correlation between the severity of the anterior deformation and the PCA: in other words, the knee is placed in valgus in flexure which promotes the external dislocation of the patella. This anatomical study could open a field of research on the development of surgical treatments based on the correction of posterior condylar femoral anomalies in PI.Level of evidenceIII.