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: 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.

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: 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: The aim of this prospective study was to assess functional outcome one year after meniscal repair and to correlate them with healing as assessed by arthroscan performed systematically at six months. Follow-up was 12 to 28 months.

Material and methods: Forty one meniscal repairs were included (28 medial and 13 lateral menisci). There were 33 longitudinal vertical tears, five horizontal cleavages in young athletes, one hypermobile meniscus and two complex lesions. The meniscal repair was associated with ACL reconstruction in 26 cases. In six cases, meniscal repair was an open procedure, in 34 a medial arthroscopic procedure and in one a combined arthroscopic open technique. 71% of the tears were recent, 29% were chronic. Mean length of the lesion was 21 mm. Physical examinations were performed in all patients at six weeks, and 3, 6, and 12 months. The

IKDC score was established preoperatively and at 6 and 12 months. An arthroscan was obtained at six months.

Results: There were no neurological complications related to the open approach. In three cases, the suture was loose but without subsequent intra-articular loss. There were no infections. Three patients presented recurrent meniscal tears 12 to 26 months postoperatively: secondary meniscectomy in one and a new repair in another. Therapeutic abstention was proposed for the third (a hypermobile meniscus). Mean subjective IKDC score was 67.0 points preoperatively, 73.2 at six months and 83.6 at one year. Moderate pain persisted at one year in four patients. The six-month arthroscan showed complete or incomplete (but greater than 50%) healing of the meniscal surface in 33 cases and less than 50% healing in 8. Radiologically, healing was similar for medial and lateral repairs. The joint surface was normal in all cases on the plain x-ray.

Discussion: AT 12–28 months follow-up, the rate of recurrence was low (3/41), less than in a retrospective review reported by the French Society of Arthroscopy with the same follow-up. The technique has improved.

Conclusion: The one-year functional outcome is good. Complete healing as assessed on the arthroscan does not indicate the functional outcome at this follow-up.

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: 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: 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.

Purpose: The collagen meniscus implant (CMI, Sulzer) is a meniscal substitute with a collagen matrix serving as a tutor for autologous regeneration of meniscal tissue. The goal is to prevent mid-term degradation after meniscectomy. The CMI is inserted arthroscopically. The purpose of this multicentric European study was to verify the safety, technical feasibility, and short-term clinical efficacy of the CMI in a population of patients undergoing medial meniscectomy. The long-term results should be obtained within a delay of five years at least.

Material and results: The series included patients with medial meniscus lesions alone, with or without lesions of the anterior cruciate ligament (present in 44% of the patients and repaired at the same time). Patient consent was obtained in all cases (in France in accordance with the Huriet law). Patients with lesions of the lateral ligament, associated trade IV cartilage lesions, or lesions of the posterior cruciate ligament were excluded. The study included 98 patients, mean age 33 years. Four patients were excluded from the analysis due to complications. Currently, 66 patients are available for evaluation one year after insertion of the CMI. Subjective outcome, the Lysholm score, and x-ray and MRI findings were recorded. Evaluation up to five years follow-up is scheduled.

Results: Complications: There were four early complications: infectious arthritis (n=1), puriform arthritis without germ (n=2), implant rupture (n=1). There were no implant-related postop complications.

Clinical results: At one year follow-up, the Lysholm score was 97. Pain was mild (1 on the visual analogue scale) and was only observed in one out of six patients: 87% of the patients had a normal or nearly normal knee.

Radiological results: There were no radiological signs of early degeneration. It was difficult to interpret the MRI results which visualised a structure with an intermediary signal in the form of a meniscal triangle. MRI did on show any sign of deleterious effect on the neighbouring cartilage.

Discussion: This technique for replacing the meniscus is an alternative to allogenic grafting. These preliminary results must of course be interpreted with caution. They show that arthroscoic implantation of the CMI is feasible but difficult. There was no evidence of an immunological reaction. Complications were related to the operative difficulty. Clinical results were satisfactory at one year, particularly in terms of pain. On the other hand, the biomechanical value of the implant cannot be assessed until longer follow-up data becomes available.

Conclusion: In light of the operative difficulty, the long postoperative recovery due to the rehabilitation protocol, the CMI should be used for symptomatic knees after meniscectomy, particularly in case of anterior laxity.

Purpose: Rapidly destructive degeneration of the hip joint is a condition whose relations with habitual degenerative hip disease are poorly understood. This uncommon condition is observed in 5 to 10% of patients with degenerative hips and almost always requires arthroplasty; The objectives of this retrospective study were to determine the distinctive radiological and clinical features of this condition and assess long-term outcome after total hip arthroplasty in these patients.

Material and methods: The study concerned 100 total hip arthroplasties performed between 1984 and 1088 in 67 men and 11 men, mean age 71 years with rapidly destructive degeneration of the hip joint. All arthroplasties were implanted via the transtrochanteric approach with cemented Charnley-Kerboul implants. Mean follow-up was seven years ten months.

Results: There were seven complications: two nonunions of the trochanter, three extensive periprosthetic ossifications, one recurrent case of dislocation, and one late infection by blood stream dissemination. At last follow-up, 95 hips exhibited excellent or very good function (Poste-Merle-d’Aubigné classification). Fixation was stable for 94 ace-tabular implants and 97 femoral implants. Six acetabular implants and three femoral implants had loosened. These femoral loosenings were always associated with acetabular loosening. Four hips required revision surgery: one for non-union of the trochanter, one for septic loosening, and two for asepctic loosening.

Discussion: This study confirmed the radiological definition and the clinical features of this condition and demonstrated the reliability of the pathology examination of the femoral head and the articular capsule. Among the different hypotheses put forward to explain this condition, we cannot retain the presence of joint over-use, or use of anti-inflammatory drugs, nor infirm a micro-crystalline or vascular origin. Nevertheless, the vascular phenomena observed in the femoral head are comparable to those observed in joint lesions subsequent to ischaemia. Total hip arthroplasty causes considerable blood loss, estimated at 2706 ml (haematocrit 35%), apparently much higher than during arthroplasties using an identical technique for patients with the usual form of degenerative hip disease. Excepting this fact, complications, clinical outcome and arthroplasty longevity were not different than those generally observed.

Purpose of the study: Extensive loss of femoral bone subsequent to implant loosening raises an unsolved problem. The purpose of this work was to examine mid-term results of 18 iterative total hip arthroplasties with femoral reconstruction using massive allografts performed between 1986 and 1997.

Materials and methods: Using the Vives classification, the femoral bone lesions were grade 3 (n = 2) and grade 4 (n = 16). The reconstruction was achieved with radiated massive allografts measuring 11 to 35 cm implanted in a split host femur. Charnley-Kerboull implants with a long stem were cemented in the reconstructed femurs.

Results: Mean follow-up was 4 years 10 months (range 2 to 9 years). Nine complications in 7 hips were observed: 6 trochanter nonunions, two recurrent prosthesis dislocations and 1 femoral fracture. At last follow-up, the functional result was excellent or very good in 12 hips (Merle d’Aubigné classification). A stable fixation persisted for 15 implants and 3 had loosened. Graft-host femur consolidation was achieved in all cases except 1. There were 3 cases with extensive resorption of the graft including 2 associated with loosening of the femoral component.

Discussion: Reconstruction of the femur after extensive bone loss using a massive allograft appears to be a useful method for restoring bone tissue and providing immediate mechanical support for the femur.