Purpose of the study: The purpose of this study was to report the results observed in a consecutive series of 54 lateral unicompartmental knee prostheses with minimum five years follow-up.

Material and methods: One hundred forty-four unicompartmental cemented HLS resurfacing prostheses were implanted with a chromium-cobalt femoral element and an all polyethylene polyethylene element. Among these consecutive implantations performed from 1998 to 2003 in accordance with indications established in 1988, 54 were lateral unicompartmental knee prostheses (37.5%) implanted in 10 men and 44 women. Mean age was 68.5 years (range 25–88). A lateral approach was used for the first six implants in this series. One patient was lost to follow-up, five died and one underwent revision for a total prosthesis. Forty-seven patients were reviewed with mean 100.9 months follow-up (64–159). Clinical data were analysed with the IKS criteria and all patients had a complete radiographic work-up before surgery and at last follow-up.

Results: In this series 96.3% of patients (n=52) were satisfied or very satisfied. Mean flexion was 133 (110–150). The mean knee score was 81.1 (25–100). Mean residual alignment was 2° valgus. A lucency was noted in 13.2% of knees, but remained stable. There was one failure requiring revision for a total prosthesis (loosening of the tibial component). The Kaplan-Meier survival was 98.1% at ten years. Three patients exhibited wear of the medial femorotibial compartment and had a medial unicompartmental implant. The overall survival (rein-tervention irrespective of reason) was 91.1%.

Discussion: Outcomes were very satisfactory, globally similar to recent series in the literature. Reliable sustainable outcomes with lateral unicompartmental implants have led us to widen our indications (moderate overweight, younger patients).

Recently in Europe, Unicompartmental Knee Arthroplasty (UKA) has regained interest in the orthopedic community; however, based on various reports, results concerning UKA for isolated lateral compartment arthritis seemed to be not as good as for medial side. In 1988 our department started using Unicondylar Knee Pros-thesis with a fixed all polyethylene bearing tibial component and resurfacing of the distal femoral condyle. The aim of this study is to report on our personal experience using this type of implant for lateral osteoarthritis with a long follow-up period.

Between January 1988 and October 2003, we performed 54 lateral UKAs (52 patients) and all were implanted for lateral osteoarthritis (3 cases of which were posttraumatic). 52 knees in 50 patients were available after a minimum duration of follow-up of five years (96.3 %). The mean age of the patients at the time of the index procedure was 72.2±1.5 years. The mean duration of follow-up was 100.9 months (range 64 – 189 months).

At follow up, 4 underwent a second surgery: one conversion to TKA for tibial tray loosening at 2 years and 3 revisions for UKA in the medial compartment. No revision surgery was necessary for wear of either of the two components, nor for infection. The mean IKS knee score was 94.9 points, with mean range of motion 132.6° (range, 115–150) and a mean IKS function score totaling 81.8 points. The average femorotibial alignment was 1.8° (range −6° to 12°). Radiolucent lines in relation to the tibial component were appreciated in 6 knees and to the femoral component in 1 knee. Implant survival was 98.08% at ten years.

The UKA with a fixed bearing tibial component and a femoral resurfacing implant is a reliable option for management of isolated lateral knee osteoarthritis. It offers excellent medium-term results for both functional level and implant survival which even currently enable us to widen our selection criteria to include younger patients or those associated with starting patellofemoral osteoarthritis.

Introduction: During total knee arthroplasty (TKA), release of the medial structures is often required in the varus knee to obtain adequate ligamentous balancing. The aim of this study is to investigate the

clinical outcome,

Materials and Methods: Between January 2000 and December 2004, 359 patients underwent a cemented posterostabilized TKA with a third condylar design (HLS prosthesis, Tornier, Grenoble, France) for primary unilateral varus osteoarthritis. One hundred twenty eight male and 231 female patients patients wer operated on at a mean age of 71 years. All patients were evaluated preoperatively and at 3 months, 6 months and 12 months postoperative.

In 255 of the 359 (71%) primary TKA’s, symmetrical gaps could be achieved by releasing the capsula and the deep MCL (group 0). In 87 cases (24%), an additional piecrust of the superficial MCL was necessary (group 1). In 55 cases out of these 87 an additional release of the insertion of the semimembranosus was performed. In 17 out of the 359 (5%), the medial tightness necessitated a distal release of the superficial MCL (group 2).

Results: All knees improved significantly postoperatively both in pain and function. Overall mean flexion at 12 months was 122 degrees.

The mean preoperative mechanical femorotibial angle (MFTA) was 174.0, 172.1 and 169.5 and was corrected postoperatively to 179.1, 179.2 and 177.6 for group 0, 1 and 2 respectively.

At 12 months, mediolateral stability was clinically evaluated as normal in 97% for group 0, 95% for group 1 and 83% for group 2. Three percent (3%), 5% and 17% has a mediolateral laxity ranging from 6–9 degrees for group 0,1 and 2, respectively.

Conclusion: Based on these results, the authors propose the following rationale: the capsule and deep MCL should always be released. In varus knees < 8°, a pie crust of the superficial MCL can be associated. In a varus knee between 8 and 10°, a release of the MCL on the tibial side is indicated. A release of the semimembranosus tendon can be associated for fixed flexion contracture. Pie crust of the MCL is a safe and reliable release technique and is able to selectively address the posterior and/or anterior fibers of the superficial MCL.

Objective: To evaluate the clinical and radiological outcome of an intra-articular bone-patellar tendon-bone (B-PT-B) anterior cruciate ligament reconstruction in combination with an extra-articular tenodesis (Lemaire procedure), at very long term follow-up.

Methods: Out of a total of 148 patients, 100 were available for clinical and/or radiological evaluation in 2006. The minimum follow-up is 21 years with a mean of 24.5 years. Outcome parameters included objective (IKDC) and subjective (KOOS) clinical scores, and radiographs (standing, TELOS).

Results: 84% of the patients were very satisfied or satisfied. The objective IKDC classification was: A=17%, B=41%, C=34%, D=8%. In 2006, 27% had narrowing < 50% (C) and 27% had narrowing > 50% (D). Onset of osteoarthritis correlated with medial meniscus status and medial femoral chondral defects. Knees with a preserved (healthy or sutured) medial meniscus had a significantly (p< 0.05) better radiological outcome. 24% had narrowing < 50% (C) and 12% had narrowing > 50% (D). Risk factors for osteoarthritis were: medial meniscectomy, residual laxity, age at intervention and femoral chondral defects.

Conclusion: The outcome of anterior cruciate ligament reconstruction using a B-PT-B in combination with extra-articular tenodesis is satisfactory in the very long term, in knees with a preserved medial meniscus and normal cartilage.

This study presents the results of 1188 original and innovative posteriorly stabilized TKA procedures in which the femoral bone stock is preserved with a shallow compartment insofar as possible. The TKA procedure is directly derived from Insall’s original technique, except for the posterior stabilisation design, where a third median condyle starts working at 30° of knee flexion.

A total of 1188 primary TKA procedures were consecutively performed in a university hospital. Average follow-up was 30 months (0–168 months). The implants were cemented (except for 35 femoral components) and the patella resurfaced (except for nine cases). Clinical results were assessed using the IKS Score. The quality of the implantation was analysed on long-leg X-rays (1175 preoperative and 883 postoperative long-leg films available at follow-up). The results showed that 95% of patients were very satisfied or at least satisfied. Knee score and functional scores were 44 and 54 preoperatively and 90 and 78 postoperatively. Mean range of motion was 116°. On X-ray analysis, the average mechanical femorotibial angle was 179° postoperatively. Survival of the implant for revision was 94.2% at 14 years. We performed 83 re-operations (nine patellar fractures, 14 infections, 12 cases of stiffness and 11 clunck syndromes), including 33 component revisions.

Clinical results compared favourably with the literature. This original posterior stabilisation design confirmed the good and excellent results at follow-up. We obtain good range of motion, and no revision was due to polyethylene wear.

Purpose: The purpose of this study was to analyse the clinical and MRI results of anterior cruciate ligament (ACL) grafts using the patellar tendon with a tibial fixation by th resorbable interference screw PLA 98 (Phusis(r)).

Material and methods: ACL grafts were performed in 182 patients between 1994 and 1997. A unique graft was used in 85 cases (Kenneth Jones), and association with Lemaire plasty in 97. The tibial fixation was achieved with the resorbable screw in all cases. Clinical and radiological data were recorded before surgery, and at one and five years. Among the 110 patients with an MRI at one year, 62 also had an MRI control at five years (57%). The antero-posteior and mediolateral tibial position was evaluated on the horizontal slices. We defined a method for evaluating the femoral position on the horizontal MRI slices. The aspect of the graft was analysed at one and five years.

Results: There were three failures (Trillat-Lachmann test). Mean residual differential laxity was 2.6 mm (Telos). At five years, 92% of patients practiced sports at a moderate or intensive level. The tibial position was good and highly reproducible (SD=0.06). Five femoral positions were not satisfactory but were not related with failure. All screws were resorbed at five years. There were two bone reactions at one year, with no relation with screw absorption (one contusion and one reflex dystrophy). At one year, the MRI with gadolinium injection visualised peripheral enhancement of the graft. At five years three transplants appeared heterogeneous, corresponding to three ruptures. Segmentary heterogenic aspects were not found to have any pathological significance.

Discussion: Evaluation of the femoral position is difficult on the MRI sagittal views. Our analysis method based on horizontal slices allowed reliable reproducible analysis. Analysis of the graft should take into consideration the time since surgery and the sequence used. There was no problem with fixation or screw absorption.

Conclusion: MRI follow-up of ACL grafts enables an analysis of the transplant positions, to follow the evolution of the graft, and to confirm the reliability and safety of the resorbable screw fixation.

Purpose: One of the difficult problems during the implantation of a total knee prosthesis is the presence of preoperative stiffness or permanent flexion.The later is a sign of advanced stage degradation due to osteoarthritis or rheumatoid arthritis. We wanted to describe the technical specificities of a total knee arthroplasty (TKA) implanted in patients with permanent flexion and to analyse long-term outcome.

Material and methods: We studied a series of 826 posterior stabilised TKA (HLS) implanted since 1988 (followed prospectively since 1995). We defined three groups of patients according to the degree of preoperative flexion: group I (0°–10°), group II (11°–20°), and group III (> 20°). We evaluated the operative technique itself, then analysed long-term clinical and radiological outcome using the IKS scores.

Results: There was no significant difference in the objective or subjective clinical or radiological outcomes in the first two groups (I and II). Outcome appeared to be less satisfactory in patients with permanent flexion greater than 20°, but the statistical analysis was not feasible.

Discussion: This study enabled us to describe the specific preoperative planning and the operative steps necessary for patients with permanent flexion preoperatively. The results of our series do no enable distinction between the long-term results in patients with < 20° flexion. Beyond this level, techniques for bony or ligamentary release influence the results which are less satisfactory. Posterior stabilisation enables release of the posterior cruciate ligament in order to improve joint recovery.

Conclusion: Preoperative planning for TKA must of course take into account bony deformation, but also preoperative joint motion. In the event of permanent flexion, the operative technique must be adapted. This allows correct position of the implant and improved joint motion.

Purpose: Associating autologous chondrocytes with a biomaterial has the advantage of facilitating fixation of graft cells and simplifies reimplantation. To evaluate the feasibility, tolerance, and efficacy of the Cartipatch(r) product, we are conducting a phase IIb study.

Material and methods: Cartilage (200–500 mg) was harvested arthroscopically from the lateral borders of the trochlea in the intercondylar space of damaged knees. After enzymatic digestion, the freed chondrocytes were cultured in monolayer in presence of autologous serum. The number of cells needed to achieve a concentration of 107/ml were suspended in an aragose and alginate solution. Before gelification, the suspension was poured into pits to obtain grafts measuring 10, 14 or 18 mm depending on the configuration of the lesion identified by MRI and arthroscopy. A specific instrument set was used to prepare one or two cavities for press fit insertion of the grafts. The grafts were justapositioned in order to best cover the damaged area.

Nineteen patients aged 16–50 years with a single osteochondral lesion or osteochondritis dessicans involving the femoral condyle but who had no other knee anomaly were included in this trial. The graft was inserted via an arthrotomy. Patients were examined preoperatively then at 3, 6, 12 and 24 months after grafting. The main evaluation criteria was improvement in the IDCD score (ICRS item) at 24 months. Secondary evaluation criteria were MRI and arthroscopic aspect associated with biopsy of the repaired tissue performed at 24 months.

Results: The first interventions required less than one hour. Patients followed the rehabilitation protocol with passive mobilisation and progressive weight bearing with no particular problem. Tolerance was good (no inflammation, adherence).

Discussion: The operative time needed to implant the graft was greatly reduced compared with classical chondrocyte grafts. Furthermore, this technique eliminates the need for periosteum suture guaranteeing a more homogeneous cell graft.

Conclusion: This short-term evaluation of the first patients is very encouraging. The first results concerning the effectiveness of this product, Cartipatch(r) are expected in the upcoming months.

Purpose: Revision total knee arthroplasty using gliding prostheses raises numerous technical difficulties. One of the main objectives is to restore the level of the joint line to correspond the space in flexion and extension and maintain patellar height. This is difficult in the event of bone loss which modifies usual landmarks. The basic problem is to find a correspondence between the preoperative planning and the intraoperative execution. We propose a simple method to achieve this objective.

Material and methods: The height of the joint line is determined indirectly from measurements of the lengths of each of the lower limb segments and the mechanical axes. Restoration of the respective lengths of the femur and tibia enables obtaining the original height of the joint line. This produces true bone balance for revision procedures where the ligament balance is limited. The surgical technique consists in drilling two holes with a 4.5 mm drill in the anterior cortical of the femur and tibia at a known distance from the joint line (8–10 cm) before removal of the implants. Once the trial pieces are in place, the distance to the joint line of each bone segment is check to adapt the prostheses. Measurement of the joint line is dependent on the tibia and the femur. It is evaluated by comparison of the lengths of the limb segments (femur and tibia) before and after operation. We measured a continuous series of 26 patients Pre and postoperative goniometry was used with the length of the contralateral fibula serving as a guide to avoid magnification effects.

Results: The mean difference in length before and after surgery was 1.15 mm for the tibia and 2.01 mm for the femur.

Discussion: It is always possible to restore femur length. The trend is globally to lengthening. This is usual and attributed to ligament balance before the operation. Restoration of the joint line is not always possible or desirable. The hole landmark method is useful and reliable to localise and restore the joint line desired by the surgeon. It is the key to restored space symmetry in flexion and extension while preserving the length of each of the bone segments to achieve bone balance.

Purpose: The purpose of this work was to report mid-term results of a series of 162 total knee prostheses with an all-polyethylene plateau.

Material and methods: Between 1989 and 1995, 162 posterior stabilised cemented HLS2 total knee prostheses with an all-polyethylene plateau were implanted during first intention arthroplasties performed by the same surgeon. 142 prostheses were reviewed at more than one year, three patients died, and 17 were lost to follow-up (10%). Clinical results were assessed with the IKS criteria. Complete x-ray data included pangonograms. Mean follow-up was 4.5 years.

Results: Ninety-six percent of the patients were satisfied or very satisfied and 95% had no pain or mild pain. Mean flexion was 114°. The mean postoperative knee score was 81/100 and mean function score was 64/100. Radiographic findings showed the good position of the implants with mean AFT at 178.6°, mean AFm at 89.1° and mean ATm at 89°. There were eight failures (4.9%) requiring replacement of a component, two for frontal laxity, three for patellar fracture, one for infection, one for aseptic loosening, and one for an oversized tibial plateau. Two revision procedures were performed without implant replacement, one for pain (biopsy) and one for arthrolysis.

Discussion: These 162 prostheses with an all-polyethyl-ene plateau were retained among a consecutive series of 893 HLS prostheses. We compared the present results with those of the metal-backed prostheses implanted in this series and with data in the literature. We found a significant correlation between the presence of tibial lucent lines and postoperative alignment defects, explained by the type of tibial component, in these 162 all-polyethyl-ene plateau prostheses. These lucent lines did not progress with time and had no clinical consequence.

Conclusion: Clinial and radiological results with total knee prostheses with an all-polyethylene plateau, i.e. without metal backing, were very good in this series. We analysed our experience in comparison with the literature, focusing on the advantages and disadvantages of these two types of components.

Purpose: Implantation of a single-compartment lateral prosthesis can be proposed to patients with primary or secondary osteoarthritis uniquely involving the lateral femorotibial compartment. Many surgeons hesitate to use this procedure which does not have a particularly good reputation. We report a series analysed retrospectively to determine the impact of aetiology, operative findings, and pre- and post-operative radiographic findings on final outcome. We searched for the ‘ideal’ indication and specific technical difficulties encountered.

Material and methods: The review included 81 single-compartment medial implants (complete pre- and postoperative radiological and clinical data were available for 87% of the files, all were reviewed). Minimum follow-up was two years (mean 6.5 years). Clinical assessment was based on the IKS score and radiological analysis included a complete series (AP, lateral, axial, full knee, preoperative stress views).

Results: Mean IKS score was clearly improved from 49/100 preoperatively to 90.2/100 postoperatively. Severe pain was noted in 12% of the patients preoperatively versus 1.2% postoperatively. Sixty-three percent of the patients had completely forgotten their knee. Mean amplitude was 0.5–123°. Clinical lateral laxity was less than 5° in 93% of the patients and the knee was stable in the sagittal plane in 96.5%. Mean function score improved from 59/100 preoperatively to 73.3/100 postoperatively, limited basically by going up and down stairs (normal values in 36% of the patients). Walking distance was greater than 1 km in 68% of the patients (29% preoperatively). In the frontal plane, the mean mechanical femorotibial angle was 183.31 ± 3.01° (189.9 ± 5° preoperatively) with a mean mechanical femoral angle of 91.06 ± 3.01 (and a mean mechanical tibial angle of 90.6 ± 1°. Implant survival at five years was 97.15% and 93.33% at ten years (three loosenings and one metallosis).

Discussion: At last follow-up, the final result was significantly affected by diverse factors: osteoarthritis status at surgery (p < 0.02), patient age (p < 0.01), raising the anterior tibial tuberosity (p < 0.01), initial aetiology. The results were compared with data in the literature and discussed by type of indication and therapeutic options for lateral femoral osteoarthritis. The problem of indications in case of tibial plateau fractures and lateral meniscectomy is discussed.

Conclusion: These clinical and radiological results show that the lateral single-compartment prosthesis is a safe and reliable procedure for the treatment of primary or secondary osteoarthritis of the lateral femorotibial compartment.

Purpose: We studied the subjective, functional and radiographic results after anterior cruciate ligament repair using the mid-third of the patellar tendon, combined with tibial osteotomy for valgisation during the same operative time.

Material and methods: Between 1983 and 1999, this procedure was performed in 66 knees. We studied 47 knees presenting a remodelled medial compartment or medial fem-orotibial narrowing greater than 50% (preosteoarthritis), excluding three AFTI, 11 lateral decoaptations, and 5 knees with excessive genu varum. We reviewed 34 knees (72.3%) in 32 patients with a mean follow-up of 10.5 years (1–16 years) using the IKDC ratings. A complete series of x-rays were obtained in 33 patients including a comparative single-leg stance view and full leg views. Mean age at surgery was 32 years (18–49); delay from accident to operation was eight years (0.5–33). There was at least one antecedent operation in 24 knee (22 medial menisci). Fourteen knees presented a remodelled medial femorotibial compartment (grade B) and 19 had a medial joint space narrowing > 50% (grade C). The lateral femorotibial compartment was remodelled in four cases (12M%).

Results: At last follow-up, 93% of the patients were satisfied or very satisfied. The mean subjective score including symptoms, function and level of activity was 78.4 (46–96.6). Intense sports activities (ski, tennis) were practised by 46% of the patients. Clinically, five knees were considered normal (A), fifteen nearly normal (B), twelve abnormal (C) and two very abnormal (D). These results were correlated with pre- and postoperative anterior translation of the tibia on single leg stance. Radiologically, among the 1′ knees with a remodelled medial femorotibial component (grade B), three progressed to grade C; among the 19 knees in grade C, two progressed to grade D (narrowing > 50%). Axial correction was significantly greater for grade B knees at review. For the lateral femorotibial compartment, 22 showed remodelling and two narrowing less than 50%. There was no correlation with axial correction. Changes in tibial tilt were studied.

Discussion, conclusion: At ten years, the combined ACL reconstruction, tibial osteotomy for valgisation, led to stabilisation of the osteoarthritic condition and most often led to a stable and satisfactory knee.