Philippe Neyret

Double incision iso-anatomical ACL reconstruction: the freedom to place the femoral tunnel within the anatomical attachment site without exception

AimThe present paper describes the rationale behind the surgical technique and the clinical results of the iso-anatomical, single bundle bone patellar-tendon bone anterior cruciate ligament (ACL) reconstruction.Method Using a second incision on the distal lateral femur an outside-in femoral tunnel is drilled. Guided by a special aiming device it is possible to place the femoral tunnel in the centre of the ACL footprint in every single case. ConclusionSince every crucial step of the procedure is under visual control, the technique is safe and reliable, which is mirrored by good clinical results.

Osteotomy for Slope Correction Following Failed ACL Reconstruction

Anterior cruciate ligament (ACL) injury and its subsequent reconstruction are increasingly common. Numerous authors have stressed that successful revision ACL reconstruction depends on identification and treatment of the reason for failure of the primary reconstruction. Relatively little attention has been paid to the influence of tibial slope on stability and the need for ACL revision. The goal of this chapter is to explore the role of tibial deflexion osteotomy in improving the outcome of revision ACL reconstruction. We recommend addressing tibial slope in patients with a posterior tibial slope greater than 13° who are undergoing revision ACL reconstruction. The technique described below involves the use of an anterior closing-wedge osteotomy to decrease tibial slope. This procedure may improve outcomes in carefully selected patients, although current research is quite limited. Further work is needed to confirm the utility of this approach and more clearly define indications.

Fractures fémorales et tibiales autour des prothè;ses de genou

Selon les donnees de la litterature, la frequence des fractures autour des protheses totales de genou (PTG) varie de 0,3 a 2,5 % (1, 9). Elles peuvent survenir tant en cours d’intervention que dans la periode postoperatoire parfois tres eloignee, au femur ou au tibia, en region diaphysaire ou metaphyso-epiphysaire periprothetique. Ces parametres interviennent dans la prise en charge des lesions, mais il faut egalement tenir compte du degre de deplacement de la fracture et de la stabilite de l’implant. L’etude de 45 dossiers representant 35 fractures periprothetiques du femur et 10 du tibia va permettre de preciser leurs caracteristiques et leur prise en charge.

Revision Total Knee Arthroplasty: Surgical Technique in Dealing with Extensor Mechanism Failure

Extensor mechanism failure is a challenging issue after total knee arthroplasty. Under this term, several scenarios can be included, varying from patellar instability to patellar fracture or loosening and patellar or quadriceps tendon failure. Most of these complications may have a devastating influence on limb function with a major impact on the quality of life. Since the etiology is often multifactorial, patient’s history as well as clinical presentation must be carefully evaluated. Imaging study may be an additional tool in doubtful cases. The choice between conservative or surgical treatment must take into account all these aspects. However, whereas conservative management of patellar fractures is usually successful, patellar or quadriceps tendon ruptures often require surgical repair or reconstruction. In the same way, patellar loosening requires surgical approach. The treatment of patellar instability is complex and requires the precise definition of the risk factors. However, since the majority of these factors are related to poor surgical technique at the time of the first implant, revision of the femoral and tibial components is often required.

Return to Play Following Meniscal Injuries

Meniscal injuries are frequent in soccer players, and surgical indications are well established in the general population. For high-level soccer players, indications remain similar but with additional specific features linked to the need for a fast recovery. Meniscal repair is critical for tears with high healing potential. Repair results in better long-term clinical outcomes and decreases the osteoarthritis risk relative to partial meniscectomy. However, the reoperation rate is higher than for partial meniscectomy, with the risk to delay return to sport. Even in cases without complication, the rehabilitation time for repair is longer, and the operation remains challenging in many cases. Meniscectomy, in contrast, is a fast and easy procedure with low risk of short-term failure or reoperation. It allows fast recovery and an early return to sport. However, the risk of osteoarthritis at mid- to long term is high. Lateral meniscectomy in particular, particularly in cases with significant resection, results in poorer outcomes and exposes the patient to the risk of rapid chondrolysis. High-level players want a fast return to pre-injury level of play, but they are also a population at risk to develop early osteoarthritis. The therapeutic strategy must consider the immediate career of players and also long-term clinical outcomes. The rehabilitation plan and time required to return to sport depend strongly on treatment choice.

Screw and cement augmentation of tibial defects in primary total knee arthroplasty: satisfactory midterm outcomes

Objective There are several options for dealing with tibial bone defects during total knee arthroplasty (TKA) in severe primary osteoarthritis. The aim of this study was to report the midterm results of TKA with screw and cement augmentation of moderate-sized tibial bone defects. Methods Patients with osteoarthritis who had posterior stabilised TKA with screw and cement augmentation of the tibia were reviewed retrospectively. Patients were assessed preoperatively and at follow-up using the International Knee Society Knee Score (KS) and Function Score (FS), and radiographic analysis of alignment and signs of loosening. Results Twenty knees in 19 patients were included in the study. The mean age was 71 years; mean follow-up was 58 months. KS improved from 46 to 76 and FS from 51 to 92. The femorotibial mechanical angle changed from 174 to 178. There were no signs of osteolysis or loosening, and no revisions. Radiolucent lines at the cement bone interface were common but non-progressive. Conclusions Midterm clinical and radiographic results of TKA with screw and cement augmentation for moderate tibial defects were satisfactory. Level of evidence V.

Extra-articular Plasty with ACL Reconstruction: Long-Term Results of Associated Procedure

The aim of surgical management of the anterior cruciate ligament (ACL)-deficient knee is to restore knee stability, allowing return to activity and preventing secondary injury. Unfortunately, even in the face of technological advances in modern day ACL reconstruction, problems of persistent anterolateral rotational laxity exist. Recent research has therefore focused on the anterolateral structures and hence anterolateral reconstructions as a method to better control rotation. This paper provides an historical perspective on the use of lateral extra-articular reconstruction and where these procedures may be best utilised in todays ACL reconstruction algorithm.

Knee Rotation: The Lyon School

Persistent problems with rotational control in modern reconstructive techniques have lead to a resurgence of interest in the concept of lateral reinforcement. In this article, we examine the history of lateral extra-articular procedures, the reasons for renewed interest in the technique, recent research lending support to lateral procedures, and our current personal technique.

Anatomy, Physiology, and Biomechanics of the Native Knee

The knowledge of anatomy, physiology, and biomechanics of the knee is fundamental to fully understand the different surgical pathologies. In fact, the different approaches of the knee are based on precise anatomical criteria, in order not to harm the important structures. In addition, knee arthroplasty is based on the precise knowledge of the physiological movement of the joint and on its biomechanics to reproduce as accurately as possible the native knee. The knee is a complex joint, where each anatomical structure has a specific and important role, explaining the abundance pathology and its consequences for the patient. The physiological movement of the knee is not just a simple flexion-extension, but includes rotation, translation and angulation, allowing precise positioning and load transfer through the lower limb. The goal of this chapter is to help surgeon understand knee anatomy for his professional practice.

43 Exposure for Revision Total Knee Replacement

Exposure for revision total knee arthroplasty (TKR) is the first surgical step and one of the most important ones. Proper exposure and adequate visualization are key factors in the success of revision TKR. Exposure must be planned preoperatively, based on previous incisions, range of motion, patella height, and primary TKR components which need to be removed. Vascularization of the anterior knee soft tissues must be known by the surgeon to prevent complications as skin necrosis. Most revisions can be done through the standard medial parapatellar approach with slight modifications such as the quadriceps snip, as well as complete intraarticular excision of scar tissue. In a knee that has had a number of revisions and is stiff and in which exposure is predicted to be difficult, more extensive approaches achieving a wider exposure such as V-Y quadricepsplasty or tibial tubercle osteotomy can be performed. The choice of exposure is made in a stepwise manner, starting with the medial parapatellar approach and progressing as required.