J.-N. Argenson

Function and quality of life following medial unicompartmental knee arthroplasty in patients 60 years of age or younger

INTRODUCTION UKA is an appropriate bone-sparing solution for focal advanced knee osteoarthritis in young patients. As the expectations of patients younger than 60 years of age are different from those in an older population, we aimed to evaluate quality of life and the quality of sports activity after UKA in this population. PATIENTS AND METHODS Sixty-five UKAs in 62 patients younger than 60 (mean age: 54.7 years; mean BMI: 28 kg/m(2)) performed between 1989 and 2006 were included. At last follow-up (minimum 2 years), before the objective evaluation, patients were asked to fill in a KOOS questionnaire and a specific sports questionnaire including the UCLA score and questions from the Mohtadi score. RESULTS With a mean follow-up of 11.2±5 years (range, 2-19 years), the KOOS score was higher than 75 points in 90% of the patients for the quality-of-life categories but also for the scores four other categories: 83.4% of the patients had resumed their sports activities and the mean UCLA score was 6.8 (range, 4-9); 90% of the patients reported no or slight limitation during sports activities. The function KSS improved from 52±4 to 95±3 points postoperatively and the Knee KSS from 50±4 to 94±4 points. With three patients undergoing revision for an isolated insert exchange, one for septic loosening and three for osteoarthritis in the external compartment, the 12-year Kaplan-Meier survivorship was 94%. DISCUSSION AND CONCLUSION These results confirmed that UKA can provide good patient-rated outcomes, which is very important in this demanding population. As for TKA, wear remains a problem in this active population. LEVEL OF EVIDENCE Therapeutic study, level IV.

Tiges fémorales sur mesure non cimentées pour séquelle de dysplasie et luxation congénitale de hanche

Resume L’etude comportait 257 cas de dysplasie et luxation congenitale de hanche, traites par tige sur mesure, etudies avec un recul moyen de 82 mois (43 a 162 mois). L’âge moyen etait de 55 ans. Le bilan radiotomodensitometrique preoperatoire a etudie : le stade de la luxation, l’inegalite de longueur, l’angle d’anteversion, le diametre de l’acetabulum. La cupule etait non cimentee avec crochet dans le trou obturateur pour guider l’implantation dans le paleo-acetabulum. La cavite endomedullaire du femur etait preparee a l’aide d’une râpe mousse a la forme de la prothese definitive et le col prothetique adapte pour chaque cas au bras de levier et a l’anteversion. Il y avait 174 dysplasies et 83 luxations. L’allongement moyen a realiser etait de 39 mm. L’angle d’helitorsion moyen etait de 28 ± 16,6 et le diametre anteroposterieur de l’acetabulum de 51 mm. Le score de Postel Merle d’Aubigne est passe de 10,4 points en preoperatoire a 16,7 points au recul. L’analyse radiographique postoperatoire a montre une osteo-integration dans 88%, une osteolyse dans 5% et un enfoncement de tige dans 1 cas. Dix hanches (3,9%) ont ete reprises. La survie etait de 95,6% (IC = 94,6 a 97,6) a 13 ans. Cette etude confirme les modifications anatomiques rencontrees dans les sequelles de dysplasie sans correlation entre l’importance de la luxation et le degre d’anteversion, difficiles a evaluer sans tomodensitometrie preoperatoire. La partie intra-medullaire de la tige non cimentee doit etre adaptee aux dimensions du canal femoral et le col prothetique adapte au bras de levier et a l’anteversion.

Reprise des descellements acétabulaires aseptiques par cupule non cimentée, vissée et allogreffe morcelée impactée

Resume La chirurgie de reconstruction acetabulaire dans les reprises de protheses totales de hanches, implique de restaurer le capital osseux, d’assurer une stabilite primaire satisfaisante et de restaurer le centre de rotation anatomique de la hanche. Le but de notre etude etait d’evaluer les resultats d’une technique de reconstruction acetabulaire associant des allogreffes morcelees impactees et anneau de soutien non cimente dans les reprises de prothese totale de hanche avec perte de substances acetabulaires de type III de l’AAOS. Cette serie retrospective homogene comporte 34 reconstructions acetabulaires pour descellement acetabulaire aseptique avec perte de substance osseuse de type III de l’AAOS associant un anneau de soutien non-cimente et une allogreffe morcelee impactee. L’analyse radiologique postoperatoire au recul portait sur la position de l’implant acetabulaire, sa stabilite, la restauration du centre de rotation de la hanche et l’integration de la greffe. Le recul moyen etait de 6,6 ans (3-13 ans). Sept patients ont presente une complication necessitant une reintervention, dont 2 avec changement d’implant acetabulaire en raison d’une infection. La survie selon Kaplan-Meier etait de 91,3 % a 10 ans. Le score de Harris moyen passait de 53 points en preoperatoire a 94 points au recul. Sur le plan radiologique aucune migration de cupule n’a ete observee, l’integration de la greffe etait bonne dans 100 % des cas et la lateralisation de la hanche etait restauree dans 66 % des cas. L’association d’une technique cumulant les avantages d’une cupule « press-fit » non cimentee et d’un anneau de recentrage a des greffes morcelees impactees a permis de repondre aux objectifs fixes dans notre etude : reconstruction osseuse, stabilite de la fixation et recentrage de la hanche dans les revisions acetabulaires avec perte de substance de type III de l’AAOS.

Lower limb length and offset in total hip arthroplasty.

Restoration of normal hip biomechanics is a key goal of total hip arthroplasty (THA) and favorably affects functional recovery. Furthermore, a major concern for both the surgeon and the patient is preservation or restoration of limb length equality, which must be achieved without compromising the stability of the prosthesis. Here, definitions are given for anatomic and functional limb length discrepancies and for femoral and hip offset, determined taking anteversion into account. Data on the influence of operated-limb length and offset on patient satisfaction, hip function, and prosthesis survival after THA are reviewed. Errors may adversely impact function, quality of life, and prosthetic survival and may also generate conflicts between the surgeon and patient. Surgeons rely on two- or three-dimensional preoperative templating and on intraoperative landmarks to manage offset and length. Accuracy can be improved by using computer-assisted planning or surgery and the more recently introduced EOS imaging system. The prosthetics armamentarium now includes varus-aligned and lateralized implants, as well as implants with modular or custom-made necks, which allow restoration of the normal hip geometry, most notably in patients with coxa vara or coxa valga. Femoral anteversion must also receive careful attention. The most common errors are limb lengthening and a decrease in hip offset. When symptoms are caused by an error in length and/or offset, revision arthroplasty may deserve consideration.

Is knee function better with contemporary modular bicompartmental arthroplasty compared to total knee arthroplasty? Short-term outcomes of a prospective matched study including 68 cases

BACKGROUND Bicompartmental knee arthroplasty (BKA) was developed to treat medial tibiofemoral and patellofemoral osteoarthritis while preserving the anterior cruciate ligament to optimise knee kinematics. Our objective here was to compare the probability of achieving forgotten knee status and the functional outcomes at least two years after BKA versus total knee arthroplasty (TKA). We hypothesised that contemporary modular BKA produced better functional outcomes than TKA after at least two years, for patients with similar pre-operative osteoarthritic lesions. MATERIAL AND METHODS We conducted a two-centre prospective controlled study of 34consecutive patients who underwent BKA between January 2008 and January 2011. Each patient was matched on age, gender, body mass index, preoperative range of knee flexion, centre, and surgeon to a patient treated with TKA. An independent observer evaluated all 68 patients after six and 12months then once a year. Forgotten knee status was defined as a 100/100 value of the Forgotten Joint Score (FJS-12) and each of the five KOOS subscales. We also compared the two groups for knee range of motion, Knee Society Scores (KSSs), Timed Up-and-Go test (TUG), and UCLA Activity Score. RESULTS At a mean follow-up of 3.8±1.7 years, the probability of forgotten knee status was significantly higher in the BKA group (odds ratio, 4.64; 95% confidence interval, 1.63-13.21; P=0.007, Chi(2) test). Mean post-operative extension was not significantly different between the groups, whereas mean range of knee flexion was significantly greater in the BKA group (130°±6° vs. 125°±8° after TKA; P=0.03). The BKA group had significantly higher mean values for the knee and function KSSs, TUG test, and UCLA score (P<0.04 for all four comparisons). CONCLUSION After at least two years, contemporary unlinked BKA was associated with greater comfort during everyday activities (forgotten knee) and better functional outcomes, compared to TKA. These short-term results require validation in randomised trials with longer follow-ups. LEVEL OF EVIDENCE III, case-control study.

Brochage mixte trans-styloïdien et intrafocal dans les fractures extra-articulaires en extension du radius distal: Étude prospective randomisée de la stabilité postopératoire comparativement au brochage intra-focal simple

PURPOSE OF THE STUDY Intra-focal pinning as described by Kapandji in 1976 is generally standard treatment of fractures of the distal radius with posterior displacement. This technique, based on the bench effect of pinning on the posterior and radial cortexes has certain limitations in the event of major posterior comminution. In order to improve stability, other authors have proposed a modification of the Kapandji technique, replacing the lateral intra-focal pin with a direct trans-styloid pin. The purpose of this prospective radiographic study was to determine whether the modified Kapandji method improves the quality of postoperative reduction and provides a gain in stability. MATERIAL AND METHODS This prospective radiographic study included 85 patients. The first group, composed of 41 patients, was treated with the standard intra-focal pinning using one or two dorsal pins and one lateral pin (group K). The second group of 44 patients was treated with one or two intra-focal pins and one lateral transfocal pin (group KM). The postoperative care was the same for the two groups. Clinical and radiographic assessment (lateral and AP views) was performed at day 21, at day 45 after removal of the pins, and at last follow-up. Two operators working independently from the surgeons measured the orientation of the radial surface on the lateral and AP views and the radioulnar variance at day 0, 21, 45 and last follow-up. RESULTS Group K included 38 patients, mean age 57 years, and group KM 40 patients, mean age 53 years. Seven patients were lost to follow-up. The two groups were comparable regarding age, gender, type of lesion. The postoperative assessment showed radial inclination of 19.3 degrees on the AP view and 3 degrees on the lateral view with 6.6 degrees radiolulnar variance for the K group. The corresponding values were 22.2 degrees , 5.3 degrees and 12.2 degrees for the KM group. Postoperatively, there was a significant difference between the groups for radial glenoid on the AP view (p=0.004) and radiolulnar variance (p<0.0001) but there were no differences on the lateral view. At day 45 postop, mean values were 17.3 degrees AP and 1.1 degrees lateral for radial inclination and 2.2 degrees for radioulnar variance in the K group with 21 degrees , 4.7 degrees and 10 degrees in the KM group. There was a difference in group K for values measured on day 0 and day 45. There was no significant difference between the values on day 0 and day 45 for the KM group. DISCUSSION AND CONCLUSION The purpose of this radiological assessment was to evaluate the efficacy of replacing the lateral intra-focal pin with a lateral transfocal pin in terms of primary stability of extra-articular fractures of the distal radius with posterior displacement. The results appear to show that this technique provides more sustained reduction during the first six weeks, particularly concerning radioulnar variance and radial glenoid inclination on the AP view, objectives needed for good clinical outcome. It also enables a notable improvement in postoperative stability while preserving the advantages of an easily reproducible minimally destructive percutaneous technique.Resume Le but de ce travail etait de savoir si l’adjonction d’une broche transfocale externe au brochage de Kapandji modifie ameliorait la qualite de reduction postoperatoire et apportait un gain de stabilite dans les fractures extra-articulaires a deplacement posterieur de l’extremite distale du radius. Nous avons realise une etude radiologique prospective incluant 85 patients pris en charge pour une fracture en extension extra-articulaire de l’extremite inferieure du radius. Le groupe K a beneficie d’un embrochage intra-focal classique, et le groupe KM a beneficie d’un embrochage avec 1 ou 2 broches intra-focales dorsales et une broche externe transfocale. Les soins postoperatoires etaient identiques dans les 2 groupes. Nous avons etudie a J1, J21, J45 et au recul l’inclinaison radiale de face et de profil et la variance radio-ulnaire. Le groupe K comportait 38 patients d’âge moyen 57 ans, et le groupe KM 40 patients d’âge moyen 53 ans. A JO, les valeurs moyennes etaient respectivement de 19,3 de face et 3 de profil pour l’inclinaison radiale et de 6,6 pour la variance radio-ulnaire dans le groupe K, et de 22,2, 5,3 et 12,2 dans le groupe KM. A J45, les valeurs moyennes etaient respectivement de 17,3 de face, de 1,1 de profil pour l’inclinaison radiale et de 2,2 pour la variance radio-ulnaire dans le groupe K et de 21, 4,7 et 10 dans le groupe KM. Il existait une difference significative dans le groupe K entre les valeurs a JO et J45. Il n’existait pas de difference significative dans le groupe KM entre les valeurs a JO et J45. La technique de Kapandji modifiee avec l’emploi d’une broche trans-styloidienne a permis un maintien de la reduction initiale plus fiable dans les six premieres semaines en particulier en ce qui concerne la variance radio-ulnaire.

Relation between lower extremity alignment and proximal femur anatomy. Parameters during total hip arthroplasty.

BACKGROUND Lower extremity alignment correlates with native femoral offset. Eventual impact of the change in femoral offset induced by total hip arthroplasty (THA) on lower extremity alignment has not been documented. HYPOTHESIS THA significantly changes lower extremity alignment, and the change correlates with the change in femoral offset. MATERIALS AND METHODS We conducted a prospective study of 200 patients with primary hip osteoarthritis or avascular femoral head necrosis who underwent cementless THA. Pre-operative computed-tomography templating was performed and the femoral component was then custom-manufactured to replicate the native femoral anatomy. Mean age was 58 years (range, 28-83 years). Before and at least two years after THA, two observers who were not involved in the surgical procedures used standing antero-posterior long-leg radiographs to determine the mechanical axis of the lower-limb (hip-knee-ankle [HKA] angle), femoral offset, neck-shaft angle (NSA), and lower-limb length discrepancy (LLLD). RESULTS Mean values pre-operatively and at last follow-up were as follows: HKA angle, 179.2° ± 3.9° (range, 170.5° to 190.5°) and 177.7° ± 3.5°(range, 173° to 187°); LLLD, -0.7 mm (range, -30 mm to +25 mm) and +5.1 mm (range, -7 mm to +21 mm); NSA, 134° ± 7.5° (range, 100° to 124°) and 135° ± 4.2° (range, 124° to 146°); and femoral offset, 42 ± 7.8 mm (range, 24 mm to 68 mm) and 49 ± 7.5 mm (range, 33 mm to 70 mm). Although THA significantly altered lower-limb alignment, univariate and multivariate analyses showed no significant association between the change in HKA angle and the change in femoral offset. DISCUSSION Lower-limb alignment was significantly affected by THA, although the HKA angle changes were small. The small impact of THA on HKA angle values may be ascribable to efforts aimed at replicating the native femoral offset during arthroplasty, as well as to the limited sample size and to potential measurement errors related to the small size of the changes. Our results suggest that, provided careful attention is directed to replicating the native femoral offset, THA in patients with limited pre-operative anatomical abnormalities may have no major impact on the biomechanical parameters of the ipsilateral knee. LEVEL OF EVIDENCE Level III, prospective diagnostic study.

Garden I femoral neck fractures in patients 65 years old and older: Is conservative functional treatment a viable option?

INTRODUCTION Internal fixation is the preferred treatment of Garden I femoral neck fractures in the elderly. High re-operation rates have however been reported, and the results of arthroplasty performed following internal fixation failure are not as good as those of primary arthroplasty. This is why we are advocating functional treatment. Our hypothesis is that this treatment leads to fewer decubitus complications than strict orthopaedic treatment and no more mechanical complications than internal fixation in a selected population sample. Therefore, the objective of our prospective work was: (1) to assess the results of functional treatment of Garden I femoral neck fractures in elderly subjects, and (2) to investigate predictive factors of secondary displacement. PATIENTS AND METHODS All patients over age 65 years, admitted for a Garden I femoral neck fracture between January 2006 and May 2008, were included in this prospective study representing 56 cases (57 fractures) with an average age of 82 years. Functional treatment was performed, including early weight-bearing mobilisation, followed by radiographic evaluation at days 2, 7, 21 and 45, then at 3, 6 and 12 months. In the absence of displacement, discharge was planned at day 5 (Non-Displaced [ND] group). Otherwise, arthroplasty was performed (Displaced [D] group). Parker score and Harris Hip Score (HHS) were used for functional evaluation. RESULTS The observed displacement rate was 33.3% (19 patients) within an average period of 10 days. In the ND group, one case of osteonecrosis was observed and treated by arthroplasty. The average Parker score was 6.9 and the HHS 82 in the ND group, and 7 and 85, respectively, in the D group. None of the factors studied (age, gender, side, fracture type, inclination angle, degree of outward displacement, sagittal displacement, general status) was statistically predictive of final displacement. DISCUSSION The medical complication rate was only 7% in our series, which seems to be lower than that resulting from orthopaedic treatment. The observed secondary displacement rate seemed to be higher than the rate found in the literature on surgical treatment (5.4 to 20%), but the osteonecrosis rate appeared to be lower (11 to 25%). In addition, surgical treatment was the purveyor of specific complications in over 10% of cases. CONCLUSIONS The present prospective study with minimum 1-year follow-up shows that functional treatment results in fewer decubitus complications than orthopaedic treatment and a rate of revision surgery comparable to internal fixation since 70% of included patients could have been successfully treated without surgical intervention. However, the investigation of a larger cohort would be necessary to identify predictive factors for the treatments failure. LEVEL OF EVIDENCE Level III prospective non-comparative cohort study.

Titanium-titanium modular neck for primary THA. Result of a prospective series of 170 cemented THA with a minimum follow-up of 5 years

BACKGROUND Although they have been in use since the end of the 1980s, modular titanium neck components are associated with a risk of wear or fracture, and their safety has recently become a subject of debate and has never been evaluated in a consecutive series of patients. The goal of this study was to evaluate: revision-free survival of these implants after a minimum follow-up of 5 years; clinical and radiographic results; and the potential complications associated with the use of modular titanium neck components. HYPOTHESIS The use of titanium modular neck on cemented titanium THA is safe at a minimum follow-up of 5 years. PATIENTS AND METHODS Between January 2006 and December 2008, we prospectively followed 170 patients (170 hips) who underwent primary anatomical THA with a modular cemented titanium stem design implant. The indications were unilateral THA for primary (n=160) or secondary (n=10) hip osteoarthritis (aseptic osteonecrosis of the femoral head or hip dysplasia). Mean age of patients was 75.4±5.8 years old (52-85), and mean BMI was 26.1±4.5 kg/m(2) (16.6-42.1). Patients were operated on by a modified Watson-Jones anterolateral approach based on preoperative 2D planning. All patients underwent annual clinical and radiological follow-up by an independent observer. RESULTS At a mean follow-up of 71±8 months (60-84), 5 patients died and 7 were lost to follow-up. There was no revision of THA after a maximum follow-up of 84 months. The Harris score improved significantly from 50.4±11.3 (0-76) preoperatively to 84.5±15.2 (14-100) at the final follow-up. There was no difference in postoperative femoral offset or the position of the center of rotation compared to the opposite side. On the other hand, the neck-shaft angle (NSA) and limb length were corrected (2±5° [-11 to +14°] and 2.16±3.6 mm [-7.4 to +12.7 mm]) respectively. Fifteen patients (9%) had limb length discrepancies of more than 5 mm and 4 patients (2%) of more than 10 mm. There were no complications due to the modular implant design. DISCUSSION Our study suggests that the use of cemented titanium implants with a modular titanium stem is safe at a follow-up of 5 years. The modular design does not prevent limb length discrepancies but restores femoral offset. LEVEL OF EVIDENCE IV: prospective, non-comparative study.

Arthroplastie totale du genou par voie mini-invasive

L’arthroplastie totale du genou procure des résultats régulièrement bons en terme de fonction du genou et de soulagement de la douleur. La réalisation technique nécessite le plus souvent une exposition suffisante pour la mise en place de l’instrumentation indispensable pour obtenir un placement satisfaisant des implants, assurant le résultat à long terme. Cette exposition consiste le plus souvent en une arthrotomie para-patellaire médiale avec une incision de 6 à 8 cm du tendon quadricipital et une éversion de la rotule pendant toute la durée de l’intervention le genou placé à 90°de flexion. Les premiers résultats encourageants obtenus après arthroplastie unicompartimentale du genou réalisée sans éversion de la rotule et par une voie d’abord limitée autorisent à envisager ce concept pour les prothèses totales du genou [Price et al. (1), Romanowski et Repicci (2), Argenson (3)]. Le but est, comme pour les prothèses unicompartimentales, d’obtenir une récupération rapide de la fonction articulaire au prix d’un traumatisme minimal au niveau des parties molles et en particulier de l’appareil extenseur [Vail-Parker (4), Goble et Justin (5)].