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.

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: 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: 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: We report the results of a prospective consecutive series of 25 patient with non-degenerative chondral lesions treated by mosaicplasty osteochondral grafts.

Material and method: The main group was composed of 22 knees, including 16 with osteochonritis dissecans, five with cartilage damage concomitant with chronic anterior laxity, and one with necrosis of the medial condyle. The other lesions involved the talus. Mean patient age was 28 years. Mean follow-up was 13 months (range 1 – 39 months). Among the knee group, 15 patients underwent standard mosaicplasty. The lesion measured 1.96 cm2 on the average. For the other cases, associated procedures included: valgus tibial osteotomy (n=4), anterior ligamentoplasty (n=3). There were few complications except one case of infection. Clinical assessment was based on the new ICRS chart (with an updated IKDC subjective score sheet). The subjective IKDC score was 48.7% preoperatively.

Results: Mean coverage of the lesion was 68.5%. Solitary mosaicplasty provided good results. The subjective IKDC score was 67.5% and 77% of the patients experienced little or no pain in their knee. Two-thirds of the patients scored their performance at 8 or more on the 10 point scale. The objective IKDC score gave 11/15 A and 4/15 B. There was one complication related to the donor site causing femoropatellar impingement after harvesting substantial graft material. Recovery was more difficult for patients with associated procedures and results were less satisfactory. All patients underwent an MRI at six months that showed in general a good morphological aspect.

Discussion: The technique used is particularly important due to a number of pitfalls and difficulties requiring much surgical skill. While we have found that most associated procedures such as grafting the anterior cruciate ligament are warranted, the appropriateness of an associated osteotomy would be highly debatable. Lesions measuring more than 3 cm2 correspond to the limit of this technique.

Conclusion: Mosaicplasty is a reliable method for cartilage repair. Long-term assessment will allow better indications and identification of any iatrogenic factors in order to determine the appropriate place for this technique among the other methods used for cartilage repair.

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: The purpose of this work was to analyse functional results in patients with objective patellar instability who underwent surgery between 1988 and 1999.

Material and methods: One hundred eighty knees, 140 patients, were included in this series. Minimum follow-up was two years, and the mean follow-up was five years (range 24 – 152 months). The IKDC 99 subjective knee chart was used for postoperative assessment. This chart has ten items for sports activities and functional status of the knee for everyday activities. Eighty-three percent of the patients (118 patients) responded to the questionnaire.

Results: Clinical assessment was available for 98 patients (63%) and phone interview data for 29 (20%). Subjectively, 111 (94.87%) patients were very satisfied, five (4.27%) were satisfied, and one was dissatisfied. We assessed results by pain level (37.6% mild or weather-related pain), residual oedema, sensation of blockage (15.8%), instability, daily activities (68% with difficulty in the kneeling position), sports activity and level.

Discussion: Certain authors (Insall) question the pertinence of operating objective patellar instability because of the risk of secondary femoropatellar degeneration. For us, surgical treatment is indicated when there has been at least one dislocation associated with morphological anomalies. We have not observed any cases of femoroatellar degeneration among our patients who were operated on more than ten years ago. The patients’ own subjective assessment shows that surgical treatment with medialisation and/or lowering of the tibial tuberosity has been effective with a very excellent rate of satisfaction. The quality of the results is directly related to correct treatment of the lesions (for patients without recurrent dislocation) and systematic analysis of the different factors contributing to patellar instability (trochlear dyplasia, patellar height, quadriceps dyplasia, length of the patellar tendon). Our rate of revision appears to be low but was directly related to the young age of this population and is close to or above the revision rates observed in series with follow-ups greater than two years.

Conclusion: Surgery for objective patellar instability gives good mid- and long-term results. The subjective IKDC score allows precise self-evaluation. We have not been able to find any correlation between subjective results and objective results.

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.

Purpose of the study: We reviewed 69 consecutive cases of total knee arthroplasty revisions to analyze the causes of failure.

Material and methods: Sixty-nine total knee arthroplasty revisions were required between 1990 and 1997 for non-septic failure. Five categories of failures were identified: 30 loosenings including 11 with an initial malposition (varus position of the tibial component in 8 cases), 14 laxities (medial in 5, lateral in 5 and anteroposterior in 4), 11 stiff knees with no other clinical or radiological anomaly, 6 patellar failures (2 dislocations, 2 cases of excessive wear, 2 painful knees with a Freeman prosthesis), and 8 cases of painful knees with no other detectable anomaly.

Results: A three-phase reconstruction procedure was used after removing the failing TKA:1) reconstruction of the tibia with replacement of lost bone, 2) reconstruction of the femur with balanced flexion determining the size of the implant, 3) balanced extension determining the distal/proximal position of the femoral component. A “simple” sliding prosthesis was used in 16 cases, a modular reconstruction prosthesis in 40 cases and a hinge prosthesis in 13 cases. Mean follow-up for functional and radiographic assessment after revision surgery was 37 months (59 cases) with a minimum follow-up of 1 year. The best outcome was observed in the “loosening”, “laxity”, and “stiffness” patients. Outcome was less favorable for the group “isolated pain” with IKS functional scores of 35.5 ± 16 and 52.5 ± 21.

Discussion: In 36 p. 100 of cases, TKA failure was related to a technical mistake (component malposition, poor ligament alignment). In 33 p. 100, failure was patient related (multiple procedures, congenital hip dysplasia, rheumatoid arthritis...). Outcome after revision TKA was less favorable than after primary TKA, particularly in case of painful knees with no other detectable anomaly.

Conclusion: Surgical revision of TKA must follow a rigorous procedure with a detailed preoperative work-up. The decision for revision must not be made unless a precise anomaly has been identified.

We reviewed 195 knees in 167 patients at least 20 years after a rim-preserving meniscectomy. They were considered in two groups: 102 knees had had an intact anterior cruciate ligament (ACL), and 93 had had an unrepaired rupture. More patients with a ruptured ACL had downgraded their sport activity by five years after meniscectomy. The incidence of radiographic osteoarthritis was about 65% at 27 years in patients with a ruptured ligament, and 86% in those followed up for over 30 years. In the ligament-deficient group 10% had had operations for osteoarthritis, and another 28% had had other operations, mainly further meniscectomies. Only 6% of those with an intact ligament had needed a second operation after meniscectomy and at long-term follow-up 92% of them were satisfied or very satisfied. Only 74% of the ligament-deficient patients were satisfied with their result. The long-term outcome after rim-preserving meniscectomy depends mainly upon the state of the anterior cruciate ligament.