Introduction

Proper rotational alignment of the tibial component in total knee arthroplasty (TKA) could be achieved using several techniques. The self adjustment methodology allows the alignment of the tibial component under the femoral component after several flexion-extension movements. Our hypothesis was that this technique allowed a posterior tibial component alignment parallel to the femoral component posterior bicondylar axis. The aim of this study was to access this hypothesis using a post-operative CT-scan study.

The bare area of the humeral head is limited in front by the cartilage and backwards by the insertion of the Infra Spinatus tendon. There are few references in the current literature. The aim of this work was to precise the anatomic description of the bare area and to compare the size of this area in patients with anterior shoulder instability and patients without anterior shoulder instability.

Purpose of the study: The purpose of this retrospective multicentric analysis was to study the functional and radiological outcomes at more than 20 years of 89 arthroscopic lateral menisectomy procedures performed on stable knees.

Materialandmethod:The series included 89 arthroscopic lateral meniscectomies performed on knee with intact anterior cruciate ligaments (ACL). Mean follow-up was 22±3 years; 56 male, mean BMI 25±4, mean age at meniscectomy 35 years, mean age at last follow-up 57 years. Most of the injuries were vertical (41%), complex (22%) and radial (20%) lesions. The middle segment was involved in 79%. The meniscectomy removed more than one-third of the meniscus in 67%. All patients were reviewed by an independent operator for subjective assessment KOOS (100% normal) and IKDC, and for objective clinical and radiological measurements (IKDC). P< 0.05 was considered statistically significant. There was no independent control group.

Results: Revisions were performed for 16% of the knees. Intense or moderate activity was maintained by all patients. The subjective IKDC score was 71.1±23, comparable with an age and gender matched population. The mean KOOS score was 82% for pain, 80% for symptoms, 85% for daily activities, 64% for sports, and 69% for quality of life. The rate of of osteoarthritis was 56%, and 44% of patients had a difference between the two knees for osteoarthritis. The incidence of osteoarthritis was 53% and shift to valgus on the arthritic side was significantly associated with osteoarthritis, while the opposite side was well aligned. The knee was pain free in 27% of patients. Significant factors for good prognosis were age less than 38 years at first operation, moderate BMI, and minimal cartilage damage (grade 0 or 1).

Conclusion: After the first postoperative year after arthroscopic lateral meniscectomy on a stable knee, the results remain stable and satisfactory for more than 22 years. Nevertheless, patients aged over 40 with a high BMI and cartilage damage at the time of the first operation have a less encouraging prognosis.

Purpose of the study: Tibial osteotomy to correct for varus deformity is a well defined procedure. Survival has reached 80% at ten years. Nevertheless, a number of early failures are related to inadequate initial correction. Computer assisted surgery has demonstrated its efficacy for knee arthroplasty. We hypothesised that it could also improve the reliability of correction for tibial osteotomy.

Material and method: From 2007, in a prospective case-control study, 34 tibial wedge osteotomies were performed, 17 were computer assisted (Navitrack, Orthosoft) with plate fixation (Tomofix, Synthès) without wedge insertion; the objective was valgus measuring 2 to 5°.

Results: The two series were comparable for age (54.2±6 and 55.7±4.5), body mass index (28.9±6.2 and 28.7±5.7), and varus deformity (7.2±3 and 6.2±6) respectively in the standard and navigated groups. Osteoarthritis was more severe in the navigated group, with five patients stage 2 and 12 stage 2 versus one stage 1, 12 stage 2 and 4 stage 3 in the standard group (p=0.0152). The duration of the operation was not longer in the navigation group (p)0.2779). Comparisons were made for alignment at three months, between the groups and in relation to the preoperative data. There was no significant difference between the intraoperative navigation alignment and the alignment measured at 3 months: 3.6±6 and 2.5±3 at 3 months (p=0.2187). At 3 months, there was no significant difference in alignment between the two groups with 3.22 and 2.5±1.6 valgus in the standard and navigation groups respectively (p=0.2136). The objective was achieved in 25 patients: 12 in the standard group and 13 in the navigated group. In the navigation group, there were four failures, no cases of over correction, two cases of insufficient valgus at 1.5, one neutral alignment, and one recurrent varus. In the standard group, there were five failures with two over corrections at 7 and 8, two under corrections at 0 and 1, and 1 recurrent varus at 4.

Discussion: We were unable to prove that navigation improves the reliability of the correction but it did appear to avoid important errors, particularly over correction. Few series have compared standard varus navigated osteotomies, and all published series have been small. Our study has the advantage of being monocentric with two comparable series of patients. The sample size nevertheless remains small and the follow-up short.

Purpose of the study: Navigated surgery for implantation of knee prostheses has demonstrated pertinence in terms of quality and regularity of the implantation. This technique requires insertion of rigid position captors in the bone during the operation. We report a series of five femoral fractures which occurred on the pin tracts in a consecutive series of 385 patients and analyse the causes and means of prevention.

Material and methods: This was a retrospective clinical and radiographic analysis of five patients among our consecutive series of 385 patients, who suffered fractures on navigation pin tracts.

Results: There were five femoral fractures, in four women and one man, mean age 73.2 years (65–79). The mean body mass index was 32.56 (24.15–39.45). The rate of this complication was 1.3%. The fractures occurred on average 12.6 weeks (range 7–21) after implantation of the prosthesis. The fractures were always preceded by thigh pain and occurred in a context of minor or indirect trauma. The fracture lines always started from a pin tract orifice. In four of five cases, the pins had been inserted in a diaphyseal zone and at least one was in a transcortical position. The five fractures healed with no functional sequel at last follow-up after osteosynthesis with a nail or plate and no complementary bone graft.

Discussion: The incidence of these fractures on navigation pin tracts is estimated at 1.3%. Surgeons must be aware of this complication and describe the risk to patients. These fractures occur late after the implantation, in obese patients, after an episode of thigh pain. Treatment requires stable osteosynthesis but does not compromise the knee prosthesis. These fractures are favoured by low and transcortical diaphyseal position of navigation pins. Prevention requires implantation of bicortical metaphyseal navigation pins. The development of pain in the thigh late after a knee prosthesis implantation, in a favouring context (obese patient, low diaphyseal pin orifice, transcortical tract) should suggest possible fracture requiring complete rest.

Purpose of the study: Conservative surgical treatment of osteochondritis dissecans (OCD) in adults raises the problem of integration of the sequestered bone. Mechanical techniques using screw fixation are often insufficient to achieve healing. Adjunction of a biological fixation with osteochondral graft tissue for a mosaicplasty might favour integration of the fragment. The purpose of this study was to assess the short-term outcomes in an initial series using a technique called fixation plus where screw fixation is associated with mosaiplasty.

Material and methods: This was a retrospective analysis of eight adults who underwent surgery from 2003 to 2008 for stage IIB or III (Bedouelle) OCD of the medial condyle. Loss of subchondral tissue could be filled with a cancellous graft. Clinical and radiographic (Hugston) parameters were noted. At three months, the screws were removed arthroscopically. The ICRS-OCD score was noted. At six months, five patients had an arthroMRI to evaluate fragment integration, determine its signal and vitality.

Results: Mean follow-up was 17.4 months (range 3–36). The Hugston score improved from 1.6 (0–3) preoperatively to 3.4 (2–4) postoperatively and the radiological score from 2.5 (2–4) to 3.2 (3–4). The arthroscopy performed to remove the screws revealed integration of the OCD fragment. The ICRS-OCD score was I in two cases, II in five and III in one. The postoperative arthroMRI confirmed continuity with the cartilage at the periphery of the fragment, with no passage of contrast agent into the defect.

Discussion: Screw fixation of OCD fragments is often followed by nonunion and thus failure. Moasaicplasty is an alternative but does not preserve quality cartilage cover (curvature, thickness, cover). The technique proposed here ensures osseous integration of he fragment, complete cartilage cover, and a smaller number of osteochondral pits. Fixation Plus associates mechanical and biological fixation with good preliminary clinical results. Comparative longer term assessment is needed to confirm its pertinence.

Purpose of the study: Certain patients with a total knee arthroplasty (TKA) require large range of flexion postoperatively to enable squatting and sitting cross-legged. Several factors have an effect on this flexion, including prosthesis design. The purpose of this study was to examine the influence of prosthesis design on intra- and postoperative flexion of three modes of TKA with a pure rotational mobile plateau: two NexGen posterostabilised (PS) prostheses (LPS-Standard and LPS-Flex) and one ultracongruent prosthesis (SAL). It was hypothesised that PS prostheses would have a better flexion than the ultracongruent prosthesis and that the flexion would be greater with the LPS-Flex than the LPS-standard.

Material and methods: This was a prospective randomised study of consecutive patients from January 2006 to January 2007 to compare maximal flexion for each model. All patients requiring a first-intention TKA were included in this study. Seventy-tow TKA were studied: LPS-standard (n=24), LPS-Flex (n=22), SAL (n=26). Flexion was measured pre and postoperatively goniometrically. Intraoperative measures were made with the navigation system (Navitrack-Orthosoft). Minimum follow-up was one year.

Results: There was a significant difference in flexion, intraoperatively and at last follow-up, in favour of the PS models over the ultracongruent SAL. Conversely, there was no significant difference between the LPS-standard and the LPS-Flex. The analysis of factors predictive of flexion were the SAL model with a negative influence (loss of 8° intraoperatively [p< 10-4] and 15° at one year [p< 10-4] compared with the LPS models). Preoperative flexion appeared to be a positive predictive factor (p=0.00023).

Discussion: The design of the TKA has an influence on knee flexion: from implantation, flexion of the PS models was superior to the ultracongruent model, a difference which persisted late after the operation. For the PS models, the LPS-Flex model presented as a large flexion model did not, in our study, demonstrate its superiority over the LPS-standard model, irrespective of the time of the comparison. It should be noted that for implantation the LPS-Flex model required a posterior cut 2mm more than for the LPS-standard. Good preoperative flexion is an essential factor for obtaining good postoperative flexion, irrespective of the model implanted.

Introduction: Clinical presentation of mucoid degeneration of the anterior cruciate ligament (MDACL) associated knee flexion limitation and posterior knee pain. Treatment needs an anterior cruciate ligament resection, with some questions about harmlessness of this procedure. Our hypothesis was that arthroscopic MDACL treatment is an effective procedure for pain and mobility but creates some anterior knee laxity.

Materials and Methods: This is a retrospective cohort study including 29 cases of MDACL (19 men, 8 women). Mean age was 49 years (range 28 to 68). Mean follow-up was 6 years. Diagnosis was done associated clinical and MRI criteria and was confirmed using Mc Intyre’s arthroscopic criteria. A histological analysis was done in 18 cases. Postoperative functional evaluation was done using IKDC and KOOS score. Knee laxity was appreciated using clinical evaluation and radiological evaluation by TELOS measurement. Statistical analysis was done using Student t-test (level of significance: p< 0.005).

Results: Preoperatively, posterior knee pain was present in 23 knees, and knee flexion limitation in 14 cases. In 10 cases, MDACL was initially misdiagnosed with an inappropriate primary operative treatment. None of theses patients have an anterior knee laxity. Partial anterior cruciate ligament resection was done in 12 cases and complete resection in 17 cases. Meniscectomy was associated in 11 cases. In cases with histological study, diagnosis was always confirmed. After resection knee was painless in 27 cases, and knee flexion increase was 21.52°. A positive Lachman’s test was noted after surgery in all cases, (with a positive Jerk test in 8 cases). Postoperative radiological laxity was greater on the operated side (operated knee vs normal knee: 12.64 /4.33 mm, p< 0.001) Two young patients have need secondary an ACL reconstruction. Two old patients have needed secondary knee prosthesis after 2 and 3 years. Mean postoperative IKDC score was 71.19 (range 42.53 to 91.95) and mean postoperative KOOS score was 78.16 (range 26.40 to 99). Statistical analysis have showed better results for patient older than 50 years, after partial resection and for patient without meniscal associated lesions.

Discussion: Mucoid degeneration of the anterior cruciate ligament should not be confused with anterior cruciate ligament ganglia. Accurate diagnosis could be done using clinical, MRI and arthroscopic diagnosis criteria’s. Arthroscopic treatment of MDACL is an efficient procedure for knee pain and to restore a better knee flexion. However, this procedure created a signifiant anterior knee laxity and could lead in some cases to knee instability especially in young patients.

Introduction: Lateral meniscectomies lead to degenerative arthritis and therefore meniscus transplantation has been considered. In literature, this procedure appears to have good clinical results. The aim of this study was to evaluate our clinical results at mid-term follow-up and to correlate these results to the morphology and position of the transplanted meniscus.

Material and methods: Twenty-eight patients operated in 4 surgical centers, were retrospectively reviewed following lateral meniscal allograft transplantation. The mean age of the patients was 34 years (range, 18 to 50 years). Before surgery, all these patients suffered of permanent lateral femorotibial pain without radiological knee arthritis. The knees were all stable or stabilized, without axial malalignment of the lower limbs or corrected by a concomitant high tibial osteotomy. Arthroscopic procedure was performed for 9 patients and arthrotomy for 19 patients. Different techniques of fixation of the transplant were used, with or without bone plugs. The associated procedures were 2 ACL reconstruction, 3 high tibial varus osteotomies, and 1 mosaicplasty. The IKDC score were used for the analysis of the functional results. An arthroTDM or an arthro MRI was used to analyse the morphology and position of the transplanted meniscus.

Results: The mean follow-up was 35 months (range, 12 months to 6 years). The mean post-operative subjective IKDC score was 65.5 points (range, 19.5 to 89 points). There were 2 failures associated with a fast arthritic evolution and 2 functional bad results. The others 24 patients (85%) were satisfied or very satisfied, with a real improvement of the pain and the function. Seventeen patients (60%) have started again a sportive activity superior than the one pre-operating. At the last follow-up, all transplanted meniscus have healed, but the morphology and position of the transplanted meniscus was not always normal with absence of the middle segment in 3 cases; its extrusion in 9 cases, a posterior segment shortened or partially hurt in 5 cases and its absence in 3 cases. Better results were associated with good meniscus positioning and morphology.

Discussion: Our works confirm that lateral meniscal allograft is a therapeutic option with favourable results in terms of pain reduction and functional improvement in the medium term for symptomatic patients after lateral meniscectomy. Our results are comparable with those of the literature. The allograft is technically reliable, reproducible notably for the methods of fixation. A long term follow-up is necessary to evaluate the benefit of these grafts on the protection of the cartilage.

Purpose of the study: Survival of a total hip arthroplasty (THA) mainly depends on the choice of the implant and the quality of the implantation. Use of minimally invasive approaches remains a subject of controversy due to the uncertain implant position and questions concerning increased perioperative complications. The purpose of this work was to assess these two elements in a consecutive series of patients who underwent THA implanted via the minimally invasive anterolateral approach described by Rottinger.

Materials and Methods: This was a consecutive series of 130 patients (84 female, 46 male, mean age 69 years, age range 46–91) operated by the same surgeon. Mean follow-up was twelve months (range 6 – 24 months). The clinical parameters studied were: the pre–and post-operative Postel-Merle-d’Aubigné (PMA) score, mean operative time, presence of perioperative surgical complications. Radiographic parameters studied were lucent lines (De Lee and Gruen), homogeneous cementing of the femoral piece, axial position of the femoral implant, angle of acetabular inclination, acetabular anteversion (Hassan), and any leg length discrepancy.

Results: Intraoperative complications were: one intraoperative mobilisation of a press-fit cup, one trochanter fracture. Postoperatively, the rate of dislocation was 2.3%. In 3.8% of the patients developed skin lesions or a local haematoma but none with infection. Mean operative time was 107 minutes (range 80–210). Mean postoperative PMA score was 17.4 versus 12.4 preoperatively. Patients were able to walk without limping 3.3 months postoperatively (range 0.5–12 months). Mean cup inclination and anteversion were 46.1° (28–60°) and 12.3° (0–35°) respectively. Leg length discrepancy was +4.8mm on average (operated side). Femoral alignment was ±3° relative to the femoral axis in 83% of hips. Homogeneous cementing of the femoral stem was noted in 84%. There was a learning curve with an 11% complication rate for the first twenty hips versus 4% for the remainder of the hips in this series.

Discussion: In our hands, the minimally invasive anterolateral approach described by Rottinger enables proper reproducible THA implantation. The rate of intraoperative complications is low. There is a learning curve which was an estimated twenty cases in our series. This method has become our first-intention option for implantation of THA.

Purpose of the study: Injury to the infrapatellar branches of the medial saphenous vein are incriminated in disorder of the anterior aspect of the knee after bone-tendon-bone ligamentoplasty procedures. We have demonstrated in an anatomic study the usefulness of a minimal two-way approach for harvesting the patellar transplant in order to preserve the nerve branches. The purpose of this clinical study was to evaluate the feasibility of this method and its impact on the sensitivity of the anterior aspect of the knee after ligamentoplasty in comparison with the usual harvesting technique.

Material and methods: This non-randomized prospective controlled contemporary study included 47 consecutive patients. The graft was harvested via two vertical incisions, one on the apex of the patella, the other on the eminence of the anterior tibial tuberosity. After harvesting the patellar splint, discision of the patellar tendon fibers was performed subcutaneously to the tibial tuberosity. Before removing the graft via the tibial incision with a forceps inserted via the inferior incision without injuring the peritendon. A tibial piece was then harvested. The ligamentoplasty was performed as usual using two anterolateral and anteromedial arthroscopic portals. The tibial tunnel was drilled first on the tibial tuberosity. These 47 knees were compared with 34 knees where the conventional approach was used (control group). We assess: harvesting time, width of the tendon transplant, quality of the graft, requirement to convert to conventional harvesting technique. Patients were reviewed at six weeks, three months and six months to assess anterior pain, dysesthesia, surface area of hypo or anesthesia and at six months kneeling problem.

Results: Conversion was not necessary for any of the knees. Mean harvesting time was 17 minutes (control group ten minutes). A good quality graft was obtained in all cases. Thirty-five patients were reviewed at six months. No sensorial disorders were noted in 18 patients. Sensorial disorders were noted in 17 patients (permanent hypoesthesia in the control group). None of the patients presented anesthesia. The mean surface area presenting a sensorial disorder was 13.6 cm² at six weeks (37.8 cm² in the control group) and 8.85 cm² at six months (23.4 cm² in the control group). Mean gain compared with the control group was 62%. There were two cases of anterior pain at six months and no case of dysesthesia. Sixteen patients could kneel normally (none in the control group); kneeling was not possible in one patient.

Discussion: The infrapatellar branches of the medial saphenous nerve are often injured when harvesting a bone-tendon-bone graft for ligamentoplasty. Anterior disorders would in part be correlated with the degree of sensorial impairment on the anterior aspect of the knee. The subcutaneous harvesting technique presented here with two minimal incisions appears to be an attractive alternative.

Conclusion: Our study confirmed the feasibility of this harvesting technique which significantly reduces the surface area of sensorial disorders and avoids most kneeling problems.

Purpose of the study: Recent studies have demonstrated that navigation systems provide highly accurate cuts for orthogonal alignment of the lower limb. The accuracy has not to our knowledge been assessed for rotation. Rotation of the femoral piece, which results from a strategy independent of the bone cut, is designed to «correct» for epiphyseal torsion of the distal femur and thus obtain a biepicondylar axis parallel to the «surgical» posterior bicondylar line described by Berger (line drawn between the medial sulcus and the lateral epicondyle), i.e. forming un angle of 2° with the anatomic biepicondylar line described by Yoshioka (line from the medial to lateral condyles). The purpose of this study was to access the precision of navigation rotation.

Material and methods: This prospective consecutive study included 40 osteoarthritic knees undergoing total knee arthroplasty (TKA). The anatomic angle of distal femoral torsion (Yoshioka angle: angle formed by the posterior bicondylar line and the biepicondylar line) was measured on the pre- and post(3 months)-operative scans. Navigation (Navitrack, Zimmer) used the rotation given by the preoperative scan to guide the femoral cut with the objective of achieving a residual Yoshioka angle of 2°, i.e. parallel to Berger’s surgical biepicondylar line. The postoperative HKA measured on the pangonogram in the standing position was 179.6±2° with 85% of patients between −2° and +2°, confirming the reliability of the navigation system.

Results: The mean preoperative epiphyseal rotation of the distal femur was 6.4±1.8°. The mean postoperative measurement was 1.1±2.4°. Eighty percent of patients were within ±2° of the objective.

Discussion: We demonstrated in previous work that navigation-based rotation using intraoperative data is satisfactory as long as the degree of rotation is based on the preoperative scan (and thus takes into account the wide rang of distal femur torsion). Navigation-based rotation is a progress compared with standardized rotation. The few errors observed were related to insufficient identification of the posterior bicondylar line during navigation or to difficulties in interpreting the postoperative scan.

Purpose of the study: This prospective anatomic study was conducted to analyze meniscal healing after arthroscopic repair.

Material and method: Two preliminary studies (a radio-anatomic study and a comparative arthroscan-arthros-copy study) were conducted to define strict radiological criteria (contiguous slices or spiral acquisition)which could be interpreted by all observers. Sixty-five vertical meniscal lesions were included in the study and divided into four groups according to localization (medial or lateral) and knee stability (stable or associated ligamentoplasty). Arthroscopic repair was performed in all cases. Mean length of the lesions was 20.31±6 mm. Minimum follow-up was six months. The work-up included an arthroscan and the IKDC function score.

Results: The work-up could be interpreted for 62 knees. The overall outcome according to Henning was: 42% complete healing, 31% incomplete, 27% failure. Healing outcome was similar for lesion in a red-red zone (73%) or a red-white zone (70%). The healing surface could be assess for 43 knees: 37% complete healing, 21% partial healing of more than half of the initial tear, 12% partial healing of less than half of the tear, and 12% failure. The analytic results of 17 medial repairs on stable knees yielded: 9 complete, 2 partial, 4 failure, with IKDC (79, 68, 73 points) having no significant influence. For the 24 medial repairs on unstable knees outcome was: complete healing in 10, partial in 6 and a good IKDC score (80.85 points). Functional outcome was poor for the eight failures (67 points). Lateral repairs on 11 stable knees yielded: complete healing in 2 (IKDC 76 points), partial in four (IKDC 94 points) and failure in five (IKDC 82 points). For the ten unstable knees, complete healing was achieved in five and partial healing in five with good patient satisfaction (IKDC 80.70 points).

Conclusion: Methodologically, arthroscan provided a good assessment of healing. The notion of the healing surface appears to be more appropriate than thickness, since partial healing can transform an unstable knee into a stable one. Clinically, in one third of the knees, meniscal healing could not be achieved. This failure was more frequent and less well tolerated for the medial lesions. For the lateral lesions, incomplete healing was more frequent, perhaps in relation to meniscal mobility and the associated ligamentoplasty which apparently protected the meniscal repair. In this series, meniscal healing did not have a significant influence on the functional outcome.

Purpose of the study: The purpose of rotating the femoral piece, using an indepenent cut strategy, is to «correct» for epiphyseal torsion of the distal femur and thus obtain a biepicondylar axis parallel to the posterior bicondylar axis. It is known however that epiphyseal torsion of the distal femur is highly variable from one individual to another. Intraoperative identification of the biepicondylar line enables appropriate rotation, as long as the data collected are reliable. The purpose of this study was to determine the reliability of intraoperative biepicondylar axis measurements made with navigation systems and to compare the results with the preoperative scan taken as the gold standard.

Material and methods: This prospective study included 60 degenerative knees undergoing total knee arthroplasty. The angle of epiphyesael rotation of the distal femur was measured on the preoperative computed tomography scan and intraoperatively with the navigation system which identified the biepicondylar line and the posterior bicondylar line. Statistical regression lines were determined.

Results: The rotation measured on the preoperative scan was 7.1±2.4° and by the intraoperative navigation system 3.2±4.3°. There was a very weak statistical correlation between the preoperative measurement and the intraoperative navigation measurement (p=0.234, R =0.320).

Discussion: Intraoperative identification of the biepicondylar axis is not reliable. Navigation does not enable an accurate assessment of the distal epiphyseal torsion of the femur and thus the proper rotation to give to the femoral piece. The only reliable measurement of the epiphyseal rotation of the distal femur is made on the preoperative computed tomography.

Ligamentoplasty resorting to autogenous bone-tendon-bone grafts represents an effective long-lasting remedy to the anterior instability of the knee. If this indication has proved effective regarding the stability, the sampling of a piece of the extensor system often brings about a certain morbidity. Various approaches have been advocated concerning the tendinous site: some leave it open, others suture one of the peripheral thirds of the remaining tendon to the other. These various technical choices are likely to alter the morbidity and the patellar level, together with the tissue nature of the site of sampling. The purpose of this study was to assess the effect of the suture of the site of sampling on the patellar level, after a ligament plastic surgery resorting to a bone-tendon-bone graft. To this end, a group of 40 patients whose tendinous site of sampling had been left open was compared to another group of patients whose peripheral thirds of the remaining patellar tendon had been sutured one to the other.

The patellar level was assessed with Caton’s, Black-burne’s and Insall and Salvati’s methods on x-rays first taken before and then 6 months after the operation. To analyse the results, we resorted to the reduced gap method and the Student-Fisher one for the comparison between quantitative and qualitative variables, and to the correlation coefficient method for the comparison between quantitative variables.

The post-operative values of Caton’s, Blackburne’s and Insall and Salvati’s indexes were respectively 1.002, 0.844, and 1.188 for patients whose patellar tendon had been left open, and 1.023, 0.882, and 1.184 for patients whose tendinous edges had been sutured up. The discrepancy between those values had no statistical significance.

Suturing the site of sampling in a bone-tendon-bone ligament plastic surgery has no effect on the patellar level.

Purpose: The purpose of this work was to evaluate radiographically architectural changes in the knee caused by open medial tibial osteotomy fixed with a Puddu plate.

Material and methods: Forty-three patients (45 knees) operated on between 1999 and 2002 were reviewed retrospectively. Osteotomy was performed for femorotibial osteoarthritis of the medial compartment in 39 knees, laxity in three and both in three. There were 16 women and 27 men, mean age 55 years (22–73). Standard x-rays of the knee (AP, lateral 30° flexion) and telemetric films obtained preoperatively and at bone healing were analysed by two independent observers (a junior and a senior). We noted: mechanical axis (HKA), presence of epiphyseal varus and its correction, patellar height (Caton-Deschamps index), and tibial slope. The alpha risk was set at 5% for statistical analysis.

Results: Complications included two cases of non-union which required revision. Measures were reproducible between the two observers (p> 0.5). Mean HKA at bone healing was 183.53±2.28° for an expected correction of 184.14±0.93 (p=0.0112). Osteotomy achieved correction of constitutional varus in 25/36 knees (p=0.014). In the nine knees without constitutional varus, an oblique tibiotalar space was observed in five. Preoperative patella was 0.86±0.13 versus 0.69±0.16 postoperatively (p=0.021). The position of the plate on the medial aspect of the metaphysic was posterior in 28 knees and middle in 17 but with no impact on tibial slope related to plate position (p=0.175).

Discussion: Open medial tibial osteotomy with Puddu plate fixation enabled us to achieve the desired correction which persisted to bone healing and to correct constitutional varus when present, an important element for ligament balance in the event a secondary total knee arthroplasty would become necessary. In our series, we did not find any changes in the posterior slope related to the position of the plate as has been reported by others. Conversely, we did observe a decrease in patellar height.

Purpose: Posterior arthroscopy is generally performed by alternating visual control using the optic introduced via one of the anterior portals which is slid into the slit via the contralaeral posterior compartment. These two “crossed” posterior portals provide access to the posterior part of the menisci and to the condyle but remain oblique. Any sagittal partition separating the posterior compartments limits visual and instrument access to the posterior part of the articular cavity. The purpose of this work was to describe a novel back-and-forth technique for posterior arthroscopy which allows posterior access to the central pivot.

Material and methods: The conventional posteromedial access was used. The optic was introduced to visualise the posterior cruciate ligament and the posterior partition, and when in contact with it, to push it forward. The optic was then replaced by a round-headed instrument to perforate the partition above the posterior cruciate ligament and penetrate into the lateral compartment. The instrument was pushed against the posterolateral wall determining the point of the corresponding portal. A motorised knife was introduced into the end of the canula then brought into the medial compartment. The posterior partition was resected, creating a single posterior space which could be examined under direct visual control. During an anatomy study, we examined the relationship between the noble elements in the popliteal fossa and the different instruments used during this procedure. Fifteen patients with villonodular synovitis underwent exclusively arthroscopic synovectomy using this approach.

Results: We did not have any case of vessel or nerve injury and had no recurrence at mid-term. Postoperatively, patient comfort was much better than after arthrotomy synovectomy.

Discussion: This difficult method requires an excellent knowledge of the position of the different anatomic elements in the popliteal fossa close to the posterior part of the articulation. This combined posterior approach facilitates access to the posterior part of the articular cavity of the knee and offers a new approach to the posterior cruciate ligament as well as broader indications for arthroscopic synovectomy with more complete resection. It does not allow access to the submeniscal folds nor to the fibulotibial articulation.

Purpose: The purpose of this work was to present clinical and radiographic results of our experience with the Exeter technique for femoral reconstruction during revision total hip arthroplasty.

Material and methods: Eighteen patients (18 hips) underwent surgery between 1994 and 2001 and were reviewed a mean 3.5 years (1–7.5). Mean age was 67.2 years (27–78). These patients had aseptic loosening (17 hips) or septic loosening (1 hip). The femoral loosening was stage II in six hips and stage III in twelve according to the SOFCOT classification. The mean preoperative Postel Merle d’Aubigné (PMA) score was 13.6 [pain 3.4 (2–5), motion (5.9, function 3.8 (2–6)]. Postoperative assessment noted complications, the PMA score and radiographically, search for lucent lines, graft aspect, and cortical classification (Gie). Prosthesis migration was measured with the EBRAFCA method. The alpha risk was set at 5% for statistical analysis.

Results: Five complications were noted: three greater trochanter fractures, one sernsorimotor ischiatic deficit, one infraprosthetic fracture at 4.5 months. The overall mean PMA score at last follow-up was 17 [pain 5.4 (3–6), motion 6, function 5.6 (4–6)]. Radiographically thirteen hips exhibited cortical thickening with incorporation of the graft, with one case of isolated cortical thickening. One case could not be analysed (metal mesh). The EBRA analysis was used in 14 hips. After the stage II lesions, median descent was 2.8 mm (1.55–6.25) versus respectively 6.5 mm (2.1–8.7) in stage III (p=0.35)].

Discussion: The Exeter technique is one solution for femoral bone stock loss during revision THA. This technique has provided good clinical outcome (overall final PMA 17 versus 13). Radiographically, in the majority of the cases, graft integration was satisfactory with no sign of loosening. Prosthetic descent (EBRA analysis) was slightly greater than published results but there was no correlation with the initial lesion or the clinical outcome.

Conclusion: The Exeter technique is reliable and effective. It provides a less aggressive solution compared with other techniques for femoral bone loss.

Purpose: Treatment of recent lesions of the posterior cruciate ligament (PCL) is not standardised. Decisions depend on the patients age and activity level, the degree of laxity, and the presence of combined lesions. Surgical solutions included PCL repair with suture, reconstruction with an autograft or allograft, or synthetic plasty. The purpose of this study was to analyse the results of synthetic reconstruction plasty for knees with important recent laxity of the PCL alone or in association with other lesions (triads, pentades, dislocations). We hypothesised that the synthetic ligament serves as a tutor guiding healing of the ruptured ligament.

Material and methods: The series included 14 consecutive patients, 1 women, 13 men, mean age 27 years who were reviewed retrospectively. These patients were treated for isolated PCL tears (laxity > 15 mm) (n=3), PCL tears combined with laxity (medial or lateral) (n=6) or dislocation (n=5). Mean posterior laxity was 24 mm. The operation was performed 3 to 50 days after trauma using the LARS method (polyester ligament, 6 or 8 mm, 1 or 2 strands). All associated lesions were repaired during the same procedure except one A CL and one posterolateral angle which were treated secondarily. Mean follow-up was 36 months (10–88). All patients were seen for consultation except one who responded to a questionnaire. The IKDC score and Telos laxity measurements were noted.

Results: In five knees, stiffness required mobilisation or arthroscopic arthrolysis. A secondary tear confirmed arthroscopically occurred in one case after a new trauma. Subjectively, two patients were very satisfied, eight were satisfied and three were disappointed. Final motion was: 6/0/130. Direct clinical posterior drawer was present in twelve cases: the Telos differential was 8 mm (24 mm preoperatively). The overall IKDC score was A=0, B=7, C=3, D=2. Persistent posterior laxity was the worst item. Outcome was less satisfactory for all items for posterolateral laxity. There was no difference between the one- and two-strand plasties.

Discussion: We did not have any complications directly related to the synthetic ligament (synovitis, spontaneous tear). There was a significant gain in posterior laxity. Outcome depended on associated lesions, particularly lateral lesions (stiffness, IKDC score), rather than the surgical technique used to repair the PCL. The synthetic ligament appears to play its role as a tutor, a single strand measuring 6 mm in diameter is sufficient.

Conclusion: This technique spares the tendon stock and can be proposed for recent tears of the PCL with major laxity. A longer term follow-up is needed to confirm the persistence of the improvement in laxity.

Meniscus repair is now an accepted procedure, but many questions remain, regarding the results, indications versus meniscal resection. How to assess the results of meniscal repair?

Clinical results doesn’t allow to assess the healing rate. Some failure of healing can be asymptomatic. There is thus a need for an objective assessment of the healing process: by arthroscopy (but it is invasive); by MRI but the hypersignal in the meniscus area is difficult to interpret. The best way seems to be arthro CT, even if it is a quite invasive technique.

Indications: Indications mainly depend on two factors: location of the lesion stability of the knee

1. Location of the lesion.

In case of lesions in the red-red zone or red-white zone: the healing potential is good ameniscectomy would be total and would lead to secondary degenerative changes. it is thus the best indications for meniscal repair

In case of lesions in the white-white zone: the healing potential is poor the meniscectomy would be partial with usual good long term results.

Indications for meniscal repair should be very selective in this occurrence

2. Etiology

2.1. ACL Tears Meniscectomy is the key of degenerative process after ACL rupture. ACL reconstruction is able to preserve meniscal status

We must thus preserve the menisci as much as possible: by doing a meniscal repair in case of unstable extended lesions by abstention if he meniscal is table.

In all the cases, ACL should be reconstructed.

Results of meniscal repair in this context are good both in terms of clinical results and healing rate

Isolated meniscal repair should be only considered in presence of 4 criteria: symptomatic meniscal lesion, no functional instability, non repairable meniscal lesion, low demanding patient

2.2. Stable Knees

Meniscectomy remains the most frequent procedute in this condition with good functional results. But, according to the long term FU results (> 10year) (multi-centre study of the SFA 1996), the rate of asymptomatic knees is only 60% on the medial side, and 50% on the lateral side. The rate of joint line narrowing is 28% on the MM and 40% on the lateral side. The recovery after lateral meniscectomy is often long with a high rate of rearthroscopy (14%). There is a specific complication on the lateral side: rapid chondrolysis by young patients.

Meniscal repair should be thus proposed as often as possible

The best indcation is a peripheral vertical lesion by a young patient.

The rate of secondary meniscectomy is about 10% but the rate of complete healing is only 50 to 60% according to the literature.

Prognostic factors are: time to surgery: recent lesions have a better prognosis (12 weeks ?) extension of the lesion side of the lesion: lateral lesion is better than medial one.

Intrameniscal horizontal cleavage grade 2 lesion by young patients is a specific indication which gives good results and avoids a total meniscectomy.

Conclusion: Meniscectomy and meniscal repair are not opposite techniques but complementaries technique.

Meniscal repair should be recommended for red-red or red-white zone to preserve the meniscus and thus the cartilage, specially on ACL unstable knees, lateral side, young patients (children+++).

But many questions remain: which strength do we need ? what about shear forces is there any secondary degenerative changes of the meniscal tissue with an increasing risk of iterative tear which long term results with the new devices ?