Introduction:. Recent studies have concluded that gender influences hip morphology at the time of surgery as well as dysplastic development of the hip. This may lead to a particular choice of implant including stem design and/or neck modularity. In this study we hypothesized that not only gender but also morphotype and etiology (primary osteoarthritis versus aseptic osteonecrosis) may be a significant factor to predict the anatomy of the hip at the time of total hip arthroplasty (THA). Methods:. We reviewed 690 patients undergoing THA for primary arthritis (OA) or avascular osteonecrosis (AVN) between April 2000 and June 2005 and stratified each into three groups based on their anatomic constitution: endomorph (EN), ectomorph (ECT), or mesomorph (ME) (determined by the ratio: pelvic width/total leg length measured on full-length X-rays). Two independent observers measured twice four parameters on preoperative CT scan: neck-shaft-angle angle (NSA), femoral offset value (FO), helitorsion (Ht) value and femoral neck anteversion (Av). Results:. No significant difference were observed between men and women for the four parameters with respectively: NSA (129.29° ± 5.6 versus 129.3° ± 5.7), Av (20.3° ± 8.6 versus 20.27° ± 8.6), FO (19.7 mm ± 3.98 versus 19.74 mm ± 3.98) and Ht (19.97° ± 12.2 for men and 19.94° ± 12.3). Significant difference were found for NSA: 130.1° ± 5.8 for ECT, 129.55° ± 6 for MES and 128.2° ± 5,1 for EN with p < 0.01. For Av, the values were: 18.9° ± 8.7 for ECT, 20.74° ± 8.1 for MES and 21.2° ± 8.95 for EN (p < 0.01). For FO the values were 19.1 mm ± 3.9 for ECT, 19.7 ± 4 for MES and and 20.44 mm ± 3.93 for EN (p < 0.01). No difference was found for Ht between the 3 groups. A significant difference was found between patients suffering from OA and AVN: mean NSA was 130.36° ± 8.79 for OA patients versus 127.35° ± 8.38 for those who had an AVN (p < 0.01). A value was 17.06° ± 8.1 for OA and 23.7 ± 7.89 for AVN (p < 0.01). FO value was 18.72 mm ± 3.71 for OA versus 20.75 mm ± 4.15 for AVN (p <0.01). And Ht was 18.94° ± 9.64 for OA and 21.05° ± 14.5 for AVN patients (p < 0.01). Discussion and conclusion:. Patients with short and wide morphotype (endomorph) had, irrespective of gender, lower values of NSA with greater anterversion and offset values, whereas patients with long and narrow morphotype (ectomorph) had higher values of NSA and smaller Av and FO (figure 1). In the same time patients suffering from AVN have lower NSA angle, lower Av, smaller FO and Ht (figure 2). Femoral stem design should allow the consideration of these differences to optimize the reconstruction of the hip at the time of THA including pre-operative and intra-operative modularity

Introduction. The gold standard for knee surgery is the restoration of the so-called «neutral mechanical alignment ». Recent literature as pointed out the patients with «constitutional varus »; in these cases, restoring neutral alignment could be abnormal and even undesirable. The same situation can be observed in patients with «constitutional valgus alignment ». To date, these outliers cases have only been explored focusing on the lower limb; the influence of the pelvic morphotype has not been studied. Intuitively, the pelvic width could be a significant factor. The EOS low dose imaging technique provides full body standing X-rays to evaluate the global anatomy of the patient. This work explores the influence of the pelvic parameters on the frontal knee alignment. Material and methods. – We included 170 patients (340 lower extremities). 2 operators performed measurements once per patient on AP X-rays. The classical anatomical parameters were:. –. Femoral mechanical angle (FMA). –. Tibial mechanical angle (TMA). –. Hip knee shaft angle (HKS). –. Hip knee ankle angle (HKA). –. Femoral and tibial lengths. The morphotype was evaluated by:. –. the distances between the center of two femoral heads (FHD), between knees (KD) and between ankles (AD). –. the medial neck-shaft angle (MNSA). –. the femoral offset. The horizontal distance between the limb mechanical axis (line passing from center of the femoral head to the center of the ankle) and the center of the knee was called the intrinsic mechanical axis deviation (IMAD) (fig 1). The horizontal distance between the pelvic mechanical axis (line from the center of the sacral plate to the center of the ankle) and the center of the knee was called the global mechanical axis deviation (GMAD) (fig 2). Inter-Operator Reliability was calculated with Intra-class Correlation Coefficient (ICC) and Inter-Reader Agreement was assessed with Bland-Altman test. A relationship between IMAD and GMAD to the other parameters was assessed using Pearson's correlation coefficient. Results. Inter-Operator Reliability was high for femoral offset, TMA and MSNA (ICC > 0,88) and very high for the other parameters (ICC > 0,93). These values are given in table 1 and all the 2D parameters are given in the table 2. IMAD was significantly correlated with HKA (r = 0,99), FMA (r = −0,58), TMA (r = −0,61) and KD (r = 0,72). GMAD was significantly correlated with HKA (r = 0,94), FMA (r = −0,53), TMA (r = −0,60) and KD (r = 0,67). Two groups were identified according to pelvic width (FHD):. Group 1 (standard patients): Pelvic width < 18 cm (164 lower extremities). Group 2 (wide pelvis): Pelvic width ≥ 18 cm (176 lower extremities). For standard patients the FHD is a significant parameter, whereas the proximal femoral anatomy (offset and MNSA) are more relevant for wide pelvis. Conclusion. Accurate analysis of the morphotype of the lower limbs is essential for planning femoral or tibial osteotomy and knee prostheses. Taking into account pelvic morphotype can provide additional informations for the axes restoration and the detection of outliers patients

This study identifies parameters that allow to foresee the necessity of soft tissue release (STR) before surgery. Femoral and tibial morphotype were defined evaluating several radiological parameters. Intra-operative STR during surgery was correlated to radiographic parameters identified. 33 cases were analysed and divided in 2 groups, release (6) no release (27), statistical evaluation has been performed using Mann-Whitney test and contingency tables for most relevant parameters. Three parameters were measured on femur and four on tibia. The results confirmed the usability of angle between femoral anatomical axis and transepicondylar axis ATA (p< 0.001) and between femoral mechanical axis and tangent to distal condyles MCA (p< 0.001 ) as predictors, among tibial parameters angle between mechanical axis and tangent to tibial plateaux gives good results (p=0.028).The use of contingency tables highlighted that the combined use of ATA and MCA, gives better specificity than the use of a single angle

Background. The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to classify the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction. Methods. We included 20 cavovarus feet from adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, 14 males). Patients included had flexible deformities, with no previous surgery. Previous work established majority of rotational deformity in cavovarus feet occurs at the talonavicular joint, which is often reduced during surgery. Using specialised software (Bonelogic 2.1, Disior) a 3-dimensional, virtual model was created. Using data from normal feet as a guide, the talonavicular joint of the cavovarus feet was digitally reduced to a ‘normal’ position. Models of the corrected position were exported and geometrically analysed using Blender 3.6 to identify anatomical trends. Results. We identified 3 types of cavovarus forefoot morphotypes. Type 1 was seen in 13 cases (65%) and was defined as a foot where only the first metatarsal was relatively plantarflexed to the rest of the foot, with no significant residual adduction after talonavicular correction. Type 2 was seen in 4 cases (20%) and was defined as a foot where the second and first metatarsals were progressively plantarflexed, with no significant adduction. Type 3 was seen in 3 cases (15%) and was defined as a foot where the metatarsals were still adducted after talonavicular de-rotation. Conclusion. We classify 3 forefoot morphotypes in cavovarus feet. It is important to recognise and anticipate the residual forefoot deformities after hindfoot correction as different treatment strategies may be required for different morphotypes to achieve balanced correction

Introduction and Objective. To estimate the prevalence of acetabular ossifications in the adult population with asymptomatic, morphologically normal hips at CT and to determine whether the presence of labral ossifications is associated with patient-related (sex, age, BMI), or hip-related parameters (joint space width, and cam- and pincer-type femoroacetabular impingement morphotype). Materials and Methods. We prospectively included all patients undergoing thoracoabdominal CT over a 3-month period. After exclusion of patients with a clinical history of hip pathology and/or with signs of osteoarthritis on CT, we included a total of 150 hips from 75 patients. We analyzed the presence and the size of labral ossifications around the acetabular rim. The relationships between the size of labral ossifications and patient- and hip-related parameters were tested using multiple regression analysis. Results. The prevalence of labral ossifications in this population of asymptomatic, non-OA hips was 96% (95%CI=[80.1; 100.0]). The presence of labral ossifications and their size were correlated between right and left hips (Spearman coefficient=0.64 (95%CI=[0.46; 0.79]), p<0.05)). The size of labral ossifications was significantly associated with age (p<0.0001) but not with BMI (p=0.35), gender (p=0.05), joint space width (p≥0.53 for all locations) or any of the qualitative or quantitative parameters associated with femoroacetabular morphotype (all p≥0.34). Conclusions. Labral ossifications are extremely common in asymptomatic, non-osteoarthritic hips. Their size is not correlated with any patient-, or hip-related parameters except for the age. These findings suggest that the diagnosis of osteoarthritis or femoroacetabular impingement morphotype should not be made based on the sole presence of acetabular labral ossifications

Introduction: To guide one’s surgical options if conservative treatment in metatarsalgia fails, a good understanding of the anatomy and the biomechanics of a normal forefoot is primordial. The recognition of a so-called ideal morphotype may serve as a guide, through technical or other means (clinical examination, X-rays, baropodometry,..), to obtain a calculated and subtle reconstruction of all the symptomatic elements. Material and Methods: Between 2000 and 2005, 68 patients were operated by the same surgeon and were all, but five, reviewed retrospectively by an independent examiner. The study of the 184 osteotomies performed (of which 177 Weil osteotomies), made use of clinical, and radiological computerised analysis. Results: We have not been able to find a significant correlation between a harmonious curve of Maestro and postoperative recurrence or transfert metatarsalgia. Discussion: The cause of transfert metatarsalgia is often hard to find. Known, and so evitable, are important shortening and a fault in the preoperative adjustment. Despite a precise preoperative planning and a perfectly performed surgical technique, the surgeon sometimes encounters the development of plantar callosities beneath metatarsal heads adjacent to the operated ones. Lots of variables are still unknown or not recognised: mobility at the Lisfranc, gastrocnemius retraction. We have noted a significant relationship between the preoperative (in-)stability and the risk of developing transfert metatarsalgia (p-value = 0.03). A metatarso-phalangeal articulation, unstable in the preop setting, has 0.36 times less the risk of leading to this complication than if the operation was performed on a stable articulation preoperatively. A stable articulation would so be an indirect sign of a good tolerance by the adjacent rays. Conclusion: One can question if the reconstruction of an architectural harmonious forefoot using the ideal curve of Maestro at any price is necessary, since we were not able do demonstrate a guaranteed postoperative pain relief. A respect of the so-called ideal morphotype of the forefoot on the dorsoplantar upright X-rays seems insufficient in the assurance of a balanced distribution of plantar pressures postoperatively. Certainly, this morphotype most probably avoids an elevated rate of complications, but may not be considered as the only criteria to be achieved. The clinical examination stays the most essential element. Only the preoperatively symptomatic and unstable metatarsals should probably undergo this osteotomy

Trochlear dysplasia is a specific morphotype of the knee, characterized by but not limited to a specific anatomy of the trochlea. The notch, posterior femur and tibial plateau also seem to be involved. In our study we conducted a semi-automated landmark-based 3D analysis on the distal femur, tibial plateau and patella. The knee morphology of a study population (n=20), diagnosed with trochlear dysplasia and a history of recurrent patellar dislocation was compared to a gender- and age-matched control group (n=20). The arthro-CT scan-based 3D-models were isotropically scaled and landmark-based reference planes were created for quantification of the morphometry. Statistical analysis was performed to detect shape differences between the femur, tibia and patella as individual bone models (Mann-Whitney U test) and to detect differences in size agreement between femur and tibia (Pearson's correlation test). The size of the femur did not differ significantly between the two groups, but the maximum size difference (scaling factor) over all cases was 35%. Significant differences were observed in the trochlear dysplasia (TD) versus control group for all conventional parameters. Morphometrical measurements showed also significant differences in the three directions (anteroposterior (AP), mediolateral (ML), proximodistal (PD)) for the distal femur, tibia and patella. Correlation tests between the width of the distal femur and the tibial plateau revealed that TD knees show less agreement between femur and tibia than the control knees; this was observed for the overall width (TD: r=0.172; p=0.494 - control group: r=0.636; p=0.003) and the medial compartment (TD: r=0.164; p=0.516 - control group: r=0.679; p=0.001), but not for the lateral compartment (TD: r=0.512; p=0.029 - control: r=0.683; p=0.001). In both groups the intercondylar eminence width was strongly correlated with the notch width (TD: r=0.791; p=0.001 - control: r=0.643; p=0.002). The morphology of the trochleodysplastic knee differs significantly from the normal knee by means of an increased ratio of AP/ML width for both femur and tibia, a smaller femoral notch and a lack of correspondence in mediolateral width between the femur and tibia. More specifically, the medial femoral condyle shows no correlation with the medial tibial plateau

Purpose: The transepicondylar axis (TECA) is an important landmark for positioning the femoral component in correct the rotation during total knee arthroplasty. In vivo studies have shown that the TECA corresponds to the flexion-extension axis of the knee joint. Two TECA have been defined in the literature depending on the landmark used for the medial epicondyle: the eminence for the “clinical” TECA and the depression for the “surgical” TECA. The purpose of the present study was to investigate in vivo the relations between the TECA and the mechanical axis of the femur (FA) and the tibia (TA) measured on computed tomography (CT) scans of the flexed knee, analysing separately the two TECAs. Material and methods: CT scans of the right knees of ten volunteers were studied. Goniometric data was acquired on the scans. Five controls with genu varum and five with genu valgum were also studied. Images were acquired at 0°, 45° and 90° flexion. The epicondyles were identified on the horizontal sections and three frontal sections parallel to the posterior cortical of the tibia were reconstructed. Superoposition of these three sections, for each flexion angle, gave a frontal section with TECA-clin, TECAsurg, TA, and the posterior bicondylar line (PBL). The angles between TECA and TA, FA and PBL were analysed during flexion. Angles were measured by the medial side. Results: TECAsurg remained perpendicular to the TA throughout flexion but with considerable interindividual variability. The mean variation during flexion was 3.4±1.5°. The FA-TECA angle was 88.5±0/8° and did not vary with morphotype. The TECA/PBL and TECA/TA angles varied with morphotype but less with flexion. Conclusion: The surgical TECA maintains constant relations with the tibial axis during knee flexion. It can thus be used as a landmark for positioning the femoral component for total knee arthroplasty in order to optimise femorotibial kinematics. The relations between the clinical TECA and the TA are variable and preoperative identification on the main medial epicondylar eminence may give variable results

Purpose of the study: Compar the position of the femoral piece in relation to the transepicondylar axis (TEA) using four different techniques for regulating rotation:. cut parallel to the posterior bicondylar line (BCL),. 3° external rotation,. spacer method,. application of the formula: rotation = 1° + space in extension/2. Material and methods: One hundred patients who underwent total knee arthroplasty (TKA) had a preoperative computed tomography (CT) scan. The surgical transepicondylar axis (TEA) and the BCL were drawn on the horizontal slices. The angle measured between these two lines (1.56°–2.5°) determined the theoretical angle of external rotation for aligning the femoral piece on the TEA. During the operation, femoral valgus was set to the HKS angle, measured by goniometry. The knife of the distal femoral cut, materializing the line perpendicular to the mechanical femoral axis, came in contact with the most distal femoral condyle (generally the medial condyle but occasionally the lateral condyle for varus femurs). The distance d between the knife and the most distal point of the condyle which remained distant was then measured. The external rotation was set at 0° and 3° with the techniques 1) and 2). For the technique 3), the asymmetry of the distal cut was projected on the posterior cut leading to an automatic rotation at an angle calculated trigonometrically. For the technique 4), the rotation was calculated as a function of the distance d. The difference between the external rotation obtained for each of these techniques and the theoretical rotation was calculated for each patient. Results: The mean error of rotation obtained for the four techniques was respectively: 2.2–1.9°; 2–1.7°; 1.8–2.2°; and 1.5–1.4° (p< 0.05). The rate of malrotations greater than 1° for the four techniques was respectively: 60%, 58%, 41% and 36%. The rate of malrotations greater than 2° was respectively: 45%, 44%, 27% and 21%. This rate varied according to the femoral morphotype. The percentage of malrotations greater than 2° by technique was as follows for femoral morphotypes normal, varus, and valgus: technique 1: 37,34,58%; technique 2: 37,53,40%; technique 3: 7.5,9,26%; technique 4:22,30,40%. Conclusion: Interindividual variations in the TEA-BCL angle explain the high rate of malrotation after regulated rotation. An adapted regulation will enable lesser risk of error. An adaptation taking into consideration the results of the preoperative CT scan appear to provide the most reliable results

Purpose: Plantar pressure sores can lead to metatarsalgia depending on the patient’s activity level and age and on the status of the muscle-tendon system and the morphology of the forefoot. In 1995, Tanaka and Maestro attempted to quantify the relative lengths of the metatarsals. The purpose of this work was to check the results reported by Maestro and to try to define a morphotype classification of the metatarsals. Material and methods: We analysed two series of normal feet: no apparent deformation, no callosity, no pain, no history of trauma or surgery. Fifty “normal” feet were selected among the personnel of the orthopaedics unit. Mean age of the 25 subjects was 30.3 ± 9.6 years, 44% were women. This series was compared with 34 “normal” feet reported by Maestro (age 55.2 ± 17.2 years, 62% women) used to define criteria for geometric progression (1995). A standing dorso-plantar radiograph was obtained with the same protocol for all patients. All radiographs were digitalized with a Vidar VXR-12 plus, then analysed by two observers with the semi-automatic FootLog measurements. The following measurements were recorded: SM4-M4 (distance between the line passing through the centre of the lateral sesmoid and perpendicular to the foot axis and the centre of the M4 head), M1 = d1 – d2 (length of the M1/SM4 head – length of the M2/SM4 head), Maestro criteria 1 = d2 – d3, Maestro 2 = d3 – d4, and Maestro 3 = d4 – d5. Results: An SM4 line passing through the mid third of the M4 head (+2mm proximally / centre M4 head / −4 mm distally) as normal. The notion of row 2 geometric progression was conserved by tolerating 20% variation (Maestro 1 ± 1 mm, Maestro 2 ± 1mm, Maestro 3 ± 2 mm). Feet were classed in four metatarsal morphology types with subgroups: normal feet (line SM4 passing through the mid third of the M4 head – geometric progression) – long M23 (SM4 line centred on the mid third of M4 – but alteration of the geometric progression) with four subgroups (long M2, long M3, long M2-3, long M23 long 2) – M4M5 hypoplasia (distal SM4 line / at mid third of M4) with four subgroups (by geometric progression: long M2, long M23, long M23 long M2) – others (long M1: M1 > 3.3 mm causing distalization of SM4). Discussion, conclusion: FootLog enables rapid radiographic measurements with excellent precision and intraobserver (variations from 0.1 to 0.2 mm and 0.1 to 0.5°) and interobserver (variations from 0.1 to 0.5 mm and 0.1 to 1°) reproducibility. In the two series of clinically “normal” feet, the measured parameters were strictly comparable. Radiologically, 31% were “normal”, and the others (30% long M23 – 37% M4M5 hypoplasia – 2% others) could be considered as predisposed to potential forefoot disorders. Finally only 48% of the subjects had the same morphotype for both feet. This study adds further precision to earlier qualitative evaluations of the forefoot architecture

Background. The knee joint morphology varies according to gender and morphotype of the patients. Objectives. To measure the dimensions of the proximal tibia and distal femur of osteoarthritic knees in a group of patients from the same ethnic group (Arabs) and to compare these measurements with the dimensions of six total knee implants. Patients and methods. Three-dimensional CT reconstructions were used to collect morphologic data from 124 osteoarthritic knees. Anteroposterior and mediolateral measurements were obtained from tibial and femoral bony resection surfaces planned for patient-specific instrumentation (Figures 1 and 2). These measurements were compared to the dimensions for six different types of knee implants. Results. The average tibial mediolateral (tML) and tibial anteroposterior (tAP) measurement for the study group were 74.36±6 mm and 48.94±4.57 mm, respectively; the medial tibial plateau was larger than lateral. The average femur mediolateral (fML) and femur anteroposterior (fAP) measurements for the same group were 72.04±6.6 and 68.1±7.75, respectively. For implant matching, the average tibial aspect ratio was 152.62±12.66 and the femoral average aspect ratio was 106.37±14.34. Differences were found between morphometric measurements of males and females with significantly higher parameters for males when compared to female when compared in AP and mediolateral dimensions. Also, 22.5% of the operated knees had mismatch within 2 size of the same implant. Conclusion. There is significant asymmetry of proximal tibial plateau and femur condyles. Our data suggest mismatch between osteoarthritic Arabian knees and implant designs. These ethnic differences should be considered when designing knee implants

More than two thirds of TKA are performed on women. Most TKA systems are based on the male anatomy. Therefore one could ask if a women specific design is needed in Knee Arthroplasty. There are two distinct types of distal femur: the normal one and the narrow one. In the narrow femur the problem of overhang can occur because for a given AP dimension (sizing of the implant) the corresponding ML dimension is too large. Many years ago these findings were already published in different articles. It is only in recent years that interest came from the industry. In our department a study project was initiated in January 2006. This led to the development of the Stature Femoral component for the Advance Medial Pivot knee prosthesis. The first one was implanted in June 2007 and since then it is used in 60% of our female patients and 11% in our male patients. The reason why it is quite often used in male patients is because not only gender influences distal femoral geometry but also morphotype is an important factor. Therefore irrespective of gender, ectomorphs will have smaller ML ratios and thus will have smaller knees and will benefit from a Stature variant. Moreover we have seen that the correct use of the Stature variant can also influence our clinical scores and our percentages of ligament releases with overall better results

Aims

Cam and pincer morphologies are potential precursors to hip osteoarthritis and important contributors to non-arthritic hip pain. However, only some hips with these pathomorphologies develop symptoms and joint degeneration, and it is not clear why. Anterior impingement between the femoral head-neck contour and acetabular rim in positions of hip flexion combined with rotation is a proposed pathomechanism in these hips, but this has not been studied in active postures. Our aim was to assess the anterior impingement pathomechanism in both active and passive postures with high hip flexion that are thought to provoke impingement.

Purpose of the study: The objective was to compare the results of ligamentoplasties with two commonly used grafts, hamstring and patellar tendon. This was a prospective randomized study. Material and methods: Between January 2001 and June 2004, 98 patients with an acute or chronic anterior cruciate ligament (ACL) tear with joint instability were included in this randomized study for arthroscopic repair. Patients were randomized to the patellar or hamstring arm. Clinical assessment was based on laxity, IKDC score, Lyscholm score, pain visual analog scale (VAS), midthigh thickness and isokinetic assessment at three months. Measurements were recorded preoperatively and at 1, 3, 6 weeks and 3, 6, and 12 months. Results: The two groups were comparable regarding gender, morphotype, associated lesions, and activity level. There was no difference in operative time or in recovery of complete extension. Anterior laxity was the same in the two groups. The isokinetic deficit appeared to be greater in the bone-tendon-bone group at three months. The IKDC and Lysholm scores were not significantly different at six and twelve months. Harvesting site morbidity was more pronounced in the bone-tendon-bone group. Conclusion: The two techniques provide good results. The bone-tendon-bone technique appears to cause greater harvesting site morbidity. While the isokinetic results appear to be better in the hamstring group, the measurements of laxity and recovery of stability did not show any difference

Purpose: The posterior cruciate ligament (PCL) has two strands, an anterolateral strand (AL) and a posteromedial strand (PM). Its femoral insertion fans out over 3 cm and cannot be replaced by a unique transplant during surgical reconstruction. The purpose of this study was to define the anatomic centre of the femoral insertion of each stand in order to identify precise and reproducible landmarks for the bone tunnels (one for each strand) used to fix the transplants during reconstruction of the PCL. Material and methods: A metallic landmark was placed on the centre of the femoral insertion of the two PCL strands in ten cadaver knees. The Metros software package was used to analyse the digitalised radiograms of each knee to determine the position of the strands on the medial condyle. Intra- and inter-observer variability was determined. Results: The AL strand was situated 31.6 + 2.45% (47.2 + 6.02% for the PM strand) from the anterior border of the notch or 41.18 + 2.73% (54.46 + 5.07% for the PM) from the anterior border of the medial condyle relative to the Blumensaat line and 16.12 + 4.45% (33.68 + 7.2 for the PM) from the apex of the notch. Discussion: Clinical and objective results of reconstruction depend on the ideal, basically femoral, position of the PCL insertions. Intraoperative identification of the ideal point for the femoral insertion can be improved with measurements made on cadaver knees. The values observed in the present study are reproducible. Presented in the form of percentages of length limiting the errors related to patient morphotype can be integrated into navigation systems

Purpose: One of the biomechanical objectives of total knee arthroplasty (TKA) is to achieve a mechanical femorotibial axis of 180°. Frontal angulation greater or equal to 7° is a factor of poor implant survival. The development of computer-assisted navigation systems has led to the discovery of new concepts: dynamic goniometry, quantitative evaluation of ligament balance. The purpose of this study was to evaluate the influence of the rotational position of the femoral implant and its variation during flexion. Material and methods: We reviewed the files of 50 patients who underwent surgery between October 2001 and December 2002 for computer-assisted implantation (Orthopilot(r)). We studied femorotibial axis at 0°, 30°, 60° and 90° before the bone cuts, after the tibial cuts and at the end of the procedure after definitive fixing of the implants. Results: The population, mean age 70 years, was evenly distributed: 17 valgum and 32 varum. The mean femorotibial axis at the end of the operation with the definitive implants in place was 0° in extension with balanced ligaments (±2°) and more often increased varus at 30°, 60° and 90° flexion. Discussion: External rotation of the femoral piece was not systematic. Certain normally aligned knees in extension after the tibial cut presented significant varus in flexion, probably due to external rotation of the femoral epiphysis. On the contrary, knees with internal rotation of the femoral epiphysis, irrespective of the cause, showed a trend to valgus during flexion. Using external rotation of the femoral implant systematically for both knee morphotypes cannot be done without deteriorating the ligament balance in certain patients. Conclusion: The advent of navigation systems for TKA has led to the discovery of new concepts such as dynamic goniometry. This has enabled study of femorotibial alignment in flexion, the working position of the knee during walking. This study showed that systematic external rotation of the femoral implant for TKA is not appropriate for all patients

Purpose of the study: The aim of this retrospective epidemiological study was to report the complete arthroscopic results concerning meniscus or cartilage injuries for procedures performed to repair the anterior cruciate ligament (ACL). The goal was to search for risk factors and improve patient care. Material and methods: Between 2000 and 2004, the same operator performed 129 consecutive ligamentoplasties to repair ACL tears. The following preoperative factors were analyzed: body weight, height, type and level of sports activity, laxity, positive pivot test, morphotype, time from accident to surgery. Meniscal lesions were identified and classified according to Trillat. The Beguin and Locker classification was used for cartilage lesions. The Panthéon-Sorbonne statistics laboratory performed the statistical analysis. Results: Meniscal lesions were found in 53.5% of knees and cartilage lesions in 24.2%. The medial meniscus was involved in 75.4% and the lateral meniscus in 20.3%, both in 4.3%. The injury could be repaired by suture or a conservative procedure for 45%. The medial compartment presented cartilage injury in 51.6% of knees, the patella in 29%, the trochlea in 19.35% and the same percentage for the lateral condyle. The degree of preoperative laxity, the time from accident to surgery and body mass index were statistically correlated with presence of a meniscal injury. Age, the degree of pre-operative laxity and body mass index were statistically correlated with presence of a cartilage injury. Discussion: Meniscal injuries are frequent in knees with ACL tears. The posterior segment of the medial ligament, which blocks anterior translation of the tibia if the ACL is absent, is predominantly involved. The amount of tibial movement below the femur and stress applied to the knee (particularly related to body mass) favor such lesions. Many lesions will heal spontaneously after surgery. Inversely others are more frequent after a longstanding tear. Cartilage injury is also frequent and occurs often on aging cartilage. The extent of tibial movements and their repetition as well as important stress are factors predictive of such injuries. Conclusion: Indications for reconstruction of the ACL in the young subject are well identified, less so in the older subject. This study confirms the usefulness of reconstructing the ACL to protect the menisci and joint cartilage. Excessive weight appears to be another important point to take into consideration for the surgical management of these patients

Periprosthetic joint infection (PJI) is a difficult complication requiring a comprehensive eradication protocol. Cure rates have essentially stalled in the last two decades, using methods of antimicrobial cement joint spacers and parenteral antimicrobial agents. Functional spacers with higher-dose antimicrobial-loaded cement and antimicrobial-loaded calcium sulphate beads have emphasized local antimicrobial delivery on the premise that high-dose local antimicrobial delivery will enhance eradication. However, with increasing antimicrobial pressures, microbiota have responded with adaptive mechanisms beyond traditional antimicrobial resistance genes. In this review we describe adaptive resistance mechanisms that are relevant to the treatment of PJI. Some mechanisms are well known, but others are new. The objective of this review is to inform clinicians of the known adaptive resistance mechanisms of microbes relevant to PJI. We also discuss the implications of these adaptive mechanisms in the future treatment of PJI.

Cite this article: Bone Joint J 2022;104-B(5):575–580.

Purpose: Constitutional factors responsible for hallux falgus and hallux rigidus remain unclear. The purpose of this work was to compare the radiological feature of the forefoot in three populations with “normal” feet, hallux rigidis, and hallux valgus. Material and methods: One standard protocol was used within the same unit to obtain dorsoplantar AP views of the foot in the standing position in all subjects. Fifty “normal” feet, with no apparent deformation, callosity, or pain, were selected among the orthopaedic unit personnel; mean age of the 25 subjects was 30.3±9.6 years, and 44% were women. The 30 patients with hallux rigidus were operated on at a mean age of 57.4±10.7 years, and 48.4% were women. The 50 patients with hallux valgus were operated on at a mean age of 50.8±12.8 year and 92% were women. All radiograms were digitalised (Vidar VXR-12 plus) and analysed by four observers using the FootLog software which provides semiautomatic measurements. The following parameters were recorded: distance between the lateral sesamoid and the second metatarsal (LS-M2), the M1P1 angle (for the diaphyseal and mechanical axes of M1), the diaphyseal and mechanical distal metatarsal articular angle (DMAA) of M1, Meschan’s angle (M1–M2–M5), the distance between a line perpendicular to the axis of the foot drawn through the centre of the lateral sesamoid and the centre of the head of M4 (MS4–M4) (a corrective factor was introduced for the MS4–M4 distance to account for the displacement of the lateral sesamoid in hallux valgus), the M1 index = d1-D2 (length of the head of M1/MS4 – length of the head of M2/MS4), maestro 1 = d2–d3, maestro 2 = d3–d4, maestro 3 = d4–d5. The measured parameters were recorded automatically on an Excel data sheet and statistical analysis was performed with SPSS 9.0. Results and discussion: Intra- and inter-observer reproducibility of measurements and morphological classifications were excellent. The LS/M2 distance was comparable in the three populations, proving that the lateral sesamoid is relatively fixed compared with the M2 and enabling its use as reference for the MS4 line. The Meschan angle did not discriminate between the three populations, likewise for the mean M1/M2 index, the M1P1, M1M2, and DMAA angles which were different in the three populations; there were 2° to 3° variations for the mechanical or shaft axis. The morphotype analysis demonstrated objective evidence of morphological differences of the forefoot in the three populations. The hallux rigidus group showed a predominance of the index plus and plus-minus with long M23 lateral patterns, while the hallux valgus group exhibited a predominance of M4M5 hypoplasia. Discussion: Morphotypic definition of the metatarsals is an interesting approach providing a measurable way of interpreting forefoot disorders and guide surgical correction. These results should be confirmed with measures in larger series, which can be accomplished with FootLog software. It would also be useful to combine radiological studies with baropodometric studies

Near 70% of failures of knee arthroplastys due to septic or aseptic mobilization are complicated because of massive loss of bone stock. In these cases surgeon have to perform a salvage procedure to restore legamentous balance, articular plane direction and axes of lower limb, finally to fill bone defects. Today intrinsic biomechanical stability of revision implant is entrust to sophisticated design and materials of custom made and modular implants. Endomedullary stem has to assolve specific functions: mechanical stability contrasting stress due to the boneloss, offering support for omoplastic or spongious bone innests in femoralor tibial defects. There are paucity of study in literature about dimension and morphology of endomedullary canal, probably because of variability between periostal andendostal anatomy in each patients, specially age related. This date has conditioned production of several number of revision stem size for all population. This anthropometric study verify presence of a particular regionin femoral and tibial endomidullar canal not dependent from sex, height, morphotype, important for a good press-fit of revision stem. Morphological date of midfemoral and tibial geometry was assessed in 50 subjects using Axial Computerized Tomography. Eleven (22%) were in men, thirty nine (78%) were in woman, with avarage of 73 years old (from 57 to 85). Exclusion criteria were previous operation at the same limb, deformity, pathology of bone metabolism. The level of sections were at 20, 18, 16 and 12 centimiters from articular plane for femur and at 8, 10, 13, 16 cm for tibia. Preliminar Ct scan with hight resolution program with bone alghoritm was performed. Axial view of any section was visualized at real dimension and maximal and minimal diameter of sections e were measured in millimiters. Areas of any section is different in each patient; this variability is greater near articular plane. Infact in our sample SD (Standard Deviation) of diameters of proximal femoral and distal tibialsections was lesser than SD of the other measurements. No difference of results about sex was noted. On base of these measuremts more proximal two femoral sections and two more distal tibial sections were considered to elaborate an ideal area for anchorage zone of anatomical revision stem. We subdivided all sample in five groups with homogeneous value of diameter in selected sections. For any groups tangent & #945; of an ideal trunk of cone including maximum and minimum value of diameter considered was computed, and the relative inclination angle. In our sample the greatest diameter in proximal femoral section was 20 mm and the lowest 10 mm; for tibial measuremnts the greatest value in distal tibial level was 18 mm and the lowest was 10 mm. Inclination angle was ever around 2° in all groups. Moreover we have calculated the presumable length of an ideal trunk of cone that includes the minimum and maximum value of femural and tibial diameter measured. About 5% of knee arthroplastys is destinated to an unsuccessfull. In many cases loosing of bone stock is huge and localized near articular plane. Afterward it’s important to restore biomechanical stability through endomedullary stem of revision implant. There are not many reports about morphology and anatomical study of femoral and tibial endomedullary canal. Many authors focus the attention on bone density or functional axes of the lower limb. Some authors studied remodelling process age-related about periostal ad endostal bone; cortical area undergoing thinning specially over fourthy years old. Our sample had mean of 73 years old: remodelling process is almost complete and then it is a good referenceto extrapolate real data about endomedullary morphology and width. Variability of data in all population about diameter of endomedullarycanal is lesser near femoral and tibial istmo, in particular around 18–20 cm from articular plane for femur and at 13–16 cm for tibia In our opinion short stem can’t guarantee good press-fit because of extreme variability of diameters in the population near knee. This anthropometric study confirm presence of anatomical area of the midfemural and tibial canal with common geometric characteristic in allpatient; it can be used to realize an anatomical stem that guarantees a good contact bone/prosthesis and then an optimal bone integration. On base of our results it is possibile realize few revision stem because in all groups of patients studied at 18–20 cm from knee for femur and at 13–16 cm for tibia, angle of inclination was ever 2°