Elvire Servien

The Influence of Obesity on the Complication Rate and Outcome of Total Knee Arthroplasty: A Meta-Analysis and Systematic Literature Review

BACKGROUND The increase in the number of individuals with an unhealthy high body weight is particularly relevant in the United States. Obesity (body mass index ≥ 30 kg/m2) is a well-documented risk factor for the development of osteoarthritis. Furthermore, an increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades. The primary aim of this systematic literature review was to determine whether obesity has a negative influence on outcome after primary total knee arthroplasty. METHODS A search of the literature was performed, and studies comparing the outcome of total knee arthroplasty in different weight groups were included. The methodology of the included studies was scored according to the Cochrane guidelines. Data extraction and pooling were performed. The weighted mean difference for continuous data and the weighted odds ratio for dichotomous variables were calculated. Heterogeneity was calculated with use of the I2 statistic. RESULTS After consensus was reached, twenty studies were included in the data analysis. The presence of any infection was reported in fourteen studies including 15,276 patients (I2, 26%). Overall, infection occurred more often in obese patients, with an odds ratio of 1.90 (95% confidence interval [CI], 1.46 to 2.47). Deep infection requiring surgical debridement was reported in nine studies including 5061 patients (I2, 0%). Deep infection occurred more often in obese patients, with an odds ratio of 2.38 (95% CI, 1.28 to 4.55). Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason, was documented in eleven studies including 12,101 patients (I2, 25%). Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30 (95% CI, 1.02 to 1.67). CONCLUSIONS Obesity had a negative influence on outcome after total knee arthroplasty.

In Vivo Positioning Analysis of Medial Patellofemoral Ligament Reconstruction

Background: Several techniques have been described for reconstruction of the medial patellofemoral ligament (MPFL). The anatomical insertion of the MPFL has been defined; however, there are no reports describing the accuracy of femoral graft positioning assessed postoperatively. Purpose: To analyze our femoral tunnel positioning for MPFL reconstruction in correlation with our clinical results. Study Design: Case series; Level of evidence, 4. Methods: The authors reported a prospective series of 29 MPFL reconstructions with a minimum follow-up of 24 months. The tunnel positioning analysis was performed using plain radiographs and magnetic resonance imaging at 1-year follow-up. Results: Twenty-nine femoral tunnels were analyzed; 20 femoral tunnels (69%) were considered to be in good position on plain radiographs. On magnetic resonance imaging, the authors found 19 femoral tunnels (65%) in a proper location, 5 (17.5%) in a high position, and 5 in an anterior and/or high position. Conclusion: The study highlights the difficulty of reproducible MPFL reconstruction. The surgical procedure continues to be improved and finding a reliable technique to anatomically place the graft remains challenging. Verifying femoral tunnel placement radiographically may be recommended during surgery.

Tibial Tuberosity Transfer for Episodic Patellar Dislocation

Numerous surgical techniques have been described to address episodic patellar dislocations. Some of them involve the soft tissues whereas others primarily address a bony correction. Four principal anatomic factors have been identified that increase the risk for episodic patellar dislocations: trochlear dysplasia, patella alta, patellar tilt, and an excessive tibial tubercle-trochlear groove distance. A treatment algorithm has been proposed to correct each of these factors. It includes the tibial tuberosity transfer, which is able to correct both a patella alta and an excessive tibial tubercle-trochlear groove distance. The tibial tuberosity can be transferred distally or medially or more frequently a combination of both. It will realign the extensor mechanism and increase patellofemoral stability. This procedure may be associated with a medial patellofemoral ligament reconstruction in case of excessive patellar tilt or rarely with a trochleoplasty for major abnormal patellar maltracking.

Current knowledge in the anatomy of the human anterior cruciate ligament.

The anterior cruciate ligament (ACL) is one of the most frequently studied structures of the musculoskeletal system and continues to stimulate debate and challenges among researchers and surgeons. The ultimate goal of anatomic reconstruction surgery is to restore the native anatomy as much as possible. However, this requires thorough knowledge of its anatomy. The aim of this article is to review the current knowledge of the anatomy of ACL along with its macrostructural and ultrastructural properties.

Tibial tubercle osteotomy in primary total knee arthroplasty: A safe procedure or not?

The objective of this study was to investigate the influence of tibial tubercle osteotomy on postoperative outcome, intra- and postoperative complications, as well as postoperative clinical results and failures in primary total knee arthroplasty (TKA). In a continuous, consecutive series of 1474 primary TKA, we analysed 126 cases where a tibial tubercle osteotomy approach was performed and 1348 cases without tibial tubercle osteotomy. Before surgery, all patients underwent a systematic assessment that included a clinical examination, radiographs (stress hip-knee-ankle film [pangonogram], weight bearing, anteroposterior knee view, schuss view, profile and patellar axial view at 30 degrees, stress valgus and varus view) and International Knee Society scores. When analysing intraoperative complications, tibial plateau fissures or fractures and tibial tubercle fracture were considered as complications relating to the tibial tubercle osteotomy group (p<0.001, p=0.007). With a 2-year minimum follow-up, there was no statistical difference in the number of revisions carried out in the two study groups (p=0.084). However, postoperative tibial tubercle fracture and skin necrosis were significantly related to the osteotomy (p=0.001 and p</=0.001, respectively). Tibial tubercle osteotomy cannot be considered an entirely safe procedure in primary TKA as it is associated with local complications, particularly skin necrosis and fracture of the tibial tubercle. Therefore, tibial tubercle osteotomy should be performed only when necessary, i.e. in cases where there are difficulties gaining adequate surgical exposure, ligament balance and correct implant positioning. The procedure also demands considerable surgical experience to achieve a good outcome.

ACL reconstruction and extra-articular tenodesis.

The purpose of this article is to update the orthopedic community on the role of lateral extra-articular tenodesis in the management of anterior cruciate ligament-deficient knees. Information includes historical perspective, current applications and techniques, and a review of published outcomes.

Facteurs d’erreur de la mesure per et postopératoire de la médialisation de la tubérosité tibiale antérieure: Étude tomodensitométrique

PURPOSE OF THE STUDY The purpose of this study was to evaluate the practical application of computed tomography (CT) measurements of the TT-TG (tibial tuberosity--trochlear groove) distance in patients undergoing surgery for patellar instability. MATERIAL AND METHODS We reviewed retrospectively 42 patients (30 women, 12 men) who underwent surgery for patellar instability between 1989 and 2002. Objective evidence of unilateral instability was present in 36 patients and of bilateral instability in 6. Pre- and postoperative CT-scans of both knees were examined for each patient to measure the TT-TG distance for both knees (n = 48 knees). We also studied the difference in two consecutive TT-TG measurements made on 36 non operated knees. For the 48 operated knees, we compared the CT measurement of medialization (difference between the pre- and postoperative TT-TG) and the measurement made intraoperatively. RESULTS For the 36 non-operated knees, the mean difference between two consecutive TT-TG measurements was 3.2 mm (range 0-13 mm). This difference was significant. For the 48 operated knees, medialization measured on the CT-scan was 8.6 mm on average. Medialization effectively measured intraoperatively was 6.9 mm on average for the same series of knees. Comparing these two types of measurement, the difference expressed in absolute value was 4.6 mm (range 0-20 mm). This corresponded to a 67% difference (4.6/6.9) for the TT-TG measurement compared with surgically performed medialization. DISCUSSION For some authors, preoperative measurement of the TT-TG distance remains a useful tool for establishing therapeutic choices for patellar instability. It must be recalled however that the measurement error is to the order of 3.25 mm. Use of the TT-TG for postoperative assessment is however a much more difficult technique since the anatomic landmarks have been modified by surgery. A rigorously applied standard radiographic protocol is required. The surgeon can then conduct a critical analysis of the landmarks retained, the slices used and the values obtained.Resume Le but de cette etude etait d’evaluer la validite sur le plan pratique de la mesure par tomodensitometrie de la distance TAGT dans la prise en charge chirurgicale de l’instabilite rotulienne. Nous avons etudie retrospectivement une serie de 42 patients operes entre 1989 et 2002 d’une instabilite rotulienne objective (6 cas bilateraux). Pour chacun, une tomodensitometrie des deux genoux avait ete realisee en pre et en postoperatoire. Nous avons mesure la TAGT pour chaque genou a partir de ces 84 scanners. Pour les genoux controlateraux (n = 36) : nous avons etudie la difference entre les 2 mesures scanner consecutives de la TAGT. Pour les genoux operes (n = 48) : nous avons compare la mesure par le scanner de la medialisation effectuee (en comparant les TAGT preoperatoires et postoperatoires) avec la mesure durant l’operation de cette medialisation. Les resultats ont ete les suivants : pour les genoux controlateraux (n = 36) : la difference, en valeur absolue, etait en moyenne de 3,2 mm (min 0, max 13) avec un ecart-type de 2,9 mm. La difference constatee entre les 2 mesures consecutives de la TAGT etait significative (p = 0,03). Pour les genoux operes (n = 48) : la medialisation mesuree au scanner etait en moyenne de 8,6 mm. La discordance etait (en valeur absolue) de 4,6 mm en moyenne lors de la mesure tomodensitometrique par rapport au geste de medialisation realise. Il faut donc garder a l’esprit la marge d’erreur de l’ordre de 3,2 mm lors de l’interpretation de la mesure preoperatoire de la TAGT. L’utilisation de la TAGT dans l’evaluation postoperatoire est une technique radiologique exigeante, du fait de la modification des reperes anatomiques par la chirurgie. La redaction d’un protocole, strictement respecte, est imperative et l’analyse critique des valeurs trouvees doit rester du domaine du chirurgien.

Prise en charge de la synovite villonodulaire hémopigmentée du genou et de ses récidives : À partir d'une série rétrospective de 28 cas

PURPOSE OF THE STUDY The objective of this retrospective study was to analyze clinical observations in pigmented villonodular synovitis (PVNS) of the knee as well as response to treatment in order to better define the diagnostic approach and surgical treatment and follow-up of this rare benign proliferative disease of the synovial observed primarily in the knee joint. MATERIAL AND METHODS Twenty-eight patients (13 men and 15 women) were treated for PVNS in our unit between 1996 and 2004. Twenty patients had diffuse disease and eight localized disease. In the localized forms, symptoms mimicked those provoked by intra-articular foreign bodies or meniscal tears (n = 6) and had been present for 14 months on average at first consultation. Mean age at treatment onset was 40 years (range 20-62). Arthroscopic or open surgery was used for resection. In the diffuse forms, symptoms had begun 15 months on average before first consultation and were mainly spontaneous hemarthrosis or diffuse non-specific knee pain. Mean age at treatment onset was 38 years (range 15-59). Bone lesions were observed in four patients. Synoviorthesis or surgical synovectomy were performed. Mean follow-up was 97 months (range 12-309). Outcome was compared between the different aspects of localized and diffuse PVNS and treatment modalities. RESULTS In the localized forms, there were no complications after surgical treatment and there were no cases of recurrence (one surgical revision at four months following incomplete resection). For the diffuse forms, the cumulative recurrence rate was 50%. Mean time to recurrence was 37 months. Three patients developed a stiff knee after open synovectomy. Surgical treatment was required in four patients seen late after development of bony lesions (total knee arthroplasty in three). Clinical outcome was good with a gain in knee flexion. DISCUSSION MRI is essential for the topographic diagnosis and to guide surgical treatment. In severe or advanced primary diffuse disease or in the event of local recurrence, adjuvant synoviorthesis can be proposed four to eight weeks after initial surgery. The risk of recurrence for diffuse forms warrants an annual MRI for the first four years.

Patellar Tendon Tenodesis in Association With Tibial Tubercle Distalization for the Treatment of Episodic Patellar Dislocation With Patella Alta

Background: The association between patella alta and episodic patellar dislocation (EPD) has been well described, but its pathophysiology is not completely clear. Patella alta causes decreased contact between the patella and trochlea and decreased resistance to lateral translation of the patella. Additionally, increased patellar tendon length may allow pathologically increased coronal plane patellar motion. It may thus be desirable to address the length of the patellar tendon itself rather than just its insertion site. Hypothesis: Tenodesis of the patellar tendon in association with tibial tubercle distalization in patients with EPD and abnormally long patellar tendons (>52 mm) results in significant reduction in patellar tendon length, prevention of further patellar dislocation, and good knee function at long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Twenty-seven knees in 22 patients with EPD and patella alta were treated with patellar tendon tenodesis and tibial tubercle distalization. Following tubercle distalization, the patellar tendon was tenodesed into the original location of the tibial tubercle with suture anchors. Changes in patellar tendon length and patellar height were measured radiographically. Any recurrent dislocation was documented, and patients completed an International Knee Documentation Committee (IKDC) subjective form at a mean of 9.6 years (range, 6-14 years) after surgery. Results: The mean length of the patellar tendon decreased from 56.3 ± 2.7 mm to 44.3 ± 8.6 mm (P < .0001). The Caton-Deschamps index decreased from 1.22 ± 0.17 to 0.95 ± 0.22 (P < .0001), and the Insall-Salvati ratio decreased from 1.42 ± 0.17 to 0.91 ± 0.18 (P < .0001). No patellar dislocations occurred postoperatively. The mean postoperative subjective IKDC score was 75.6 ± 9.5. Conclusion: Patellar tendon tenodesis and tibial tubercle distalization result in normalization of patellar tendon length, a stable patellofemoral joint, and good long-term knee function in patients with patella alta and EPD.

Partial ACL reconstruction with preservation of the posterolateral bundle

INTRODUCTION Over the past decade, our understanding of the anterior cruciate ligament (ACL) has evolved considerably. Based on this knowledge, ACL reconstruction techniques have changed and selective reconstruction procedures have been developed for partial tears. Our hypothesis was that stability and function can be restored to the knee with selective bundle reconstruction of partial ACL tears and preservation of the residual fibers. MATERIALS AND METHODS This was a multicenter retrospective study of 168 partial reconstructions of the anteromedial (AM) bundle of the ACL with preservation of the posterolateral (PL) bundle. All patients underwent a clinical evaluation based on the objective and subjective IKDC scores and the Lysholm score after a mean follow-up of 26 months (12-59 months). Preoperative and postoperative instrumental measurement of knee laxity was performed by arthrometer and/or by (Telos(®)) stress radiography. Statistical analysis and comparison was performed between pre- and postoperative results. RESULTS The preoperative and postoperative subjective IKDC scores were 63.7 and 90.5 at the final follow-up respectively (P<0.001). The preoperative and postoperative Lysholm scores were 80 and 95.5 respectively (P<0.001). Preoperatively, most patients were classified C on the objective IKDC score. At the final follow-up 92% of the patients were classified A or B (P<0.001). Differential preoperative laxity was 5.5mm (range: 0-14 mm) and 1.1mm (range: 0-4mm) at the final follow-up (P<0.00001). DISCUSSION AND CONCLUSION Our study confirms that selective reconstruction of the AM bundle of the ACL with preservation of the PL bundle restores stability and function to the knee. Special attention should be paid to the size of the graft used to avoid excess tissue in the intercondylar notch.