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.

It has been suggested that an increased posterior tibial slope (PTS) and a narrow notch width index (NWI) increase the risk of anterior cruciate ligament (ACL) injury. The aim of this study was to establish why there are conflicting reports on their significance. A total of fifty patients with a ruptured ACL and 50 patients with an intact ACL were included in the study. The group with ACL rupture had a statistically significantly increased PTS (p < 0.001) and a smaller NWI (p < 0.001) than the control group. When a high PTS and/or a narrow NWI were defined as risk factors for an ACL rupture, 80% of patients had at least one risk factor present; only 24% had both factors present. In both groups the PTS was negatively correlated to the NWI (correlation coefficient = -0.28, p = 0.0052). Using a univariate model, PTS and NWI appear to be correlated to rupture of the ACL. Using a logistic regression model, the PTS (p = 0.006) and the NWI (p < 0.0001) remain significant risk factors. From these results, either a steep PTS or a narrow NWI predisposes an individual to ACL injury. Future studies should consider these factors in combination rather than in isolation.

Purpose of the study: Compar the position of the femoral piece in relation to the transepicondylar axis (TEA) using four different techniques for regulating rotation:

cut parallel to the posterior bicondylar line (BCL),

Material and methods: One hundred patients who underwent total knee arthroplasty (TKA) had a preoperative computed tomography (CT) scan. The surgical transepicondylar axis (TEA) and the BCL were drawn on the horizontal slices. The angle measured between these two lines (1.56°–2.5°) determined the theoretical angle of external rotation for aligning the femoral piece on the TEA. During the operation, femoral valgus was set to the HKS angle, measured by goniometry. The knife of the distal femoral cut, materializing the line perpendicular to the mechanical femoral axis, came in contact with the most distal femoral condyle (generally the medial condyle but occasionally the lateral condyle for varus femurs). The distance d between the knife and the most distal point of the condyle which remained distant was then measured. The external rotation was set at 0° and 3° with the techniques 1) and 2). For the technique 3), the asymmetry of the distal cut was projected on the posterior cut leading to an automatic rotation at an angle calculated trigonometrically. For the technique 4), the rotation was calculated as a function of the distance d. The difference between the external rotation obtained for each of these techniques and the theoretical rotation was calculated for each patient.

Results: The mean error of rotation obtained for the four techniques was respectively: 2.2–1.9°; 2–1.7°; 1.8–2.2°; and 1.5–1.4° (p< 0.05). The rate of malrotations greater than 1° for the four techniques was respectively: 60%, 58%, 41% and 36%. The rate of malrotations greater than 2° was respectively: 45%, 44%, 27% and 21%. This rate varied according to the femoral morphotype. The percentage of malrotations greater than 2° by technique was as follows for femoral morphotypes normal, varus, and valgus: technique 1: 37,34,58%; technique 2: 37,53,40%; technique 3: 7.5,9,26%; technique 4:22,30,40%.

Conclusion: Interindividual variations in the TEA-BCL angle explain the high rate of malrotation after regulated rotation. An adapted regulation will enable lesser risk of error. An adaptation taking into consideration the results of the preoperative CT scan appear to provide the most reliable results.

Autologous chondrocyte implantation is an established method of treatment for symptomatic articular defects of cartilage. CARTIPATCH is a monolayer-expanded cartilage cell product which is combined with a novel hydrogel to improve cell phenotypic stability and ease of surgical handling. Our aim in this prospective, multicentre study on 17 patients was to investigate the clinical, radiological, arthroscopic and histological outcome at a minimum follow-up of two years after the implantation of autologous chondrocytes embedded in a three-dimensional alginate-agarose hydrogel for the treatment of chondral and osteochondral defects.

Clinically, all the patients improved significantly. Patients with lesions larger than 3 cm² improved significantly more than those with smaller lesions. There was no correlation between the clinical outcome and the body mass index, age, duration of symptoms and location of the defects. The mean arthroscopic International Cartilage Repair Society score was 10 (5 to 12) of a maximum of 12. Predominantly hyaline cartilage was seen in eight of the 13 patients (62%) who had follow-up biopsies.

Our findings suggest that autologous chondrocyte implantation in combination with a novel hydrogel results in a significant clinical improvement at follow-up at two years, more so for larger and deeper lesions. The surgical procedure is uncomplicated, and predominantly hyaline cartilage-like repair tissue was observed in eight patients.

Endoscopic methods of ACL reconstruction have shown some disadvantages such as the inability to freely position the femoral tunnel. Moreover, this technique dictates relatively vertical and central non anatomical graft placement compared to the more horizontal and lateral course of the native ACL. The ACL presents a collection of individual fibers that are grouping in two distinct bands, anteromedial (AM) and posterolateral (PL). The most anterior fibers of AM band are the most isometric. The majority of ACL fibers lie posteriorly to the isometric point on the medial wall of the femoral condyle. These fibers are lax during flexion and tight in extension. This behaviour was defined “favourable non isometry”. The “favourable non isometry” is very interesting because increased knee loading often occurs at flexion angles of less than 60 degrees. Classic two-incision technique, using a rear-entry drill, our two-incision technique, or the Clancy anatomic endoscopic technique using flexible reamers and use of different not commonly arthroscopic portals seems to allow a predictable, near-anatomic placement of femoral tunnel.

Purpose: Bilateral tears of the ACL are classically described as occurring after a first tear. Few reports have examined the underlying mechanism and the frequency and predisposing morphological factors

Material and methods: We reviewed retrospectively a series of 3722 ACL plasties performed from 1984 to 2001, including 148 patients who underwent bilateral repair. In this group, we detailed the demographic features, the time from tear to repair, the type of sports activity and focused on the radiological measurement of tibial tilt.

Results: The estimated frequency of bilateral tears was 4%. We noted that these bilateral tears were associated with: male predominance (60%), mean age 21 years (±5.5) at first tear, younger age for females, second tear at 24.5±6.5 years, predominant practice of pivot sports without contact (56%), and competition sports. The time between the two tears was 48 months on average. The rate of contralateral tears during the first postoperative year was 16%, it was 60% at three years. The mean tibial tilt was 9.91±2.87° versus 6.8±1.87° in the control population.

Discussion: Our findings were in agreement with the literature for frequency, young age at first tear, particularly for women, short time between the two tears, and type of sports activity. The high rate of contralateral tears during the first year is a significant finding. Hypotheses put forward include loss of confidence in the operated knee leading to more stress on the contralateral knee, but also poorly adapted use of the healthy knee in sports activity. Rehabilitation exercises focusing on bilateral proprioception, respecting sufficient time after the first repair before resuming sports activities, and good control of knee laxity with an ‘anatomic’ plasty appear to be important elements of prevention. The favouring role of a narrow intercondylar notch has been established in the literature. We found that tibial tilt should also be taken into consideration.

Conclusion: Careful search for predisposing factors is important because of the frequency of bilateral tears of the ACL. The rehabilitation program should be well adapted and the patient should be informed of the risk. These measures should help decrease the incidence of this relatively frequent complication.

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: Cyclope syndrome is a complication which occurs after ligamentoplasty of the anterior cruciate ligament. It is characterised by permanent flexion which may or not be associated with anterior pain, cracking or hydroarthrosis, typically during exercise. The diagnosis is confirmed by MRI. Arthroscopic treatment is indicated for resection of the nodule and as needed bone plasty of the notch if permanent flexion persists. In the literature, short-term results have been disappointing. We wanted to know more about the long-term outcome.

Material and methods: From January 1992 to December 1994, 835 patients underwent bone-tension plasty. Thirty-six underwent secondary surgery for cyclope syndrome (4.3%). Mean age at revision procedure was 26.2 years (16–43). Most of the subjects were athletes. Twenty-three patients (63.9%) were seen at follow-up consultation and 16.7% responded to a telephone interview. Mean time to review was nine years (8–10 years). We used the IKDC 1999 chart for subjective assessment and clinical evaluation and measured laxity with KT1000. We also studied changes in symptoms related to cyclope syndrome.

Results: We had two cases of recurrent tears (6.9%). The mean final subjective IKDC score was 81.6 points. Half of the patients had good outcome (> 82 points) and half had disappointing results (scored 50–80 points). The final objective IKDC scoring was: A=17.4%, B=65.2%, C=8.7%, D=8.7%. Thirteen patients had persistent signs of cyclope syndrome (44.8%). Fourteen still had limited joint motion (48.3%). Fifteen reduced their physical activity level (51.7%).

Discussion: The origin of the cyclope syndrome remains controversial. It is difficult to assess the risk of recurrent tear due to the small size of the population and the long time to review in this series.

Conclusion: Cyclope syndrome does not appear to be a factor of risk of laxity but is a non-negligible factor of morbidity, even ten years later. It appears to be important to operate early in order to avoid the spiral of chronic suffering. The postoperative flexion, which had been advocated in the past, does not appear to be useful.

Purpose: The purpose of this study was to compare, at ten years follow-up, the clinical and radiological results obtained in two series of patients who underwent patellar tendon ligmentoplasty for anterior cruciate ligament tears. One series was operated in an acute setting (before 45 days) and the other for chronic lesions.

Material and methods: In 1986 and 1987, we performed patellar ligamentoplasty for anterior cruciate ligament tears in 230 knees. Mean delay to surgery was ten days for 77 knees (53 reviewed with clinical and radiological evaluation and 12 with questionnaires, i.e. 84%). For 153 knees surgery was performed for chronic lesions (107 reviewed with clinical and radiological evaluation and 12 with questionnaires, i.e. 77%). The IKDC chart was used to assess outcome with KT 2000 measurements on the loaded images.

Results: There was a significant difference between the two series for: overt meniscal tears at the time of surgery (58% in the chronic series and 11% in the acute series, p < < 1%); osteoarthritic (26% chronic versus 6% acute, p < 1%); overall IKDC score (96% for acute versus 84% for chronic, p < 3%). The same was true for subjective assessment (normal for 95% of the acute knees versus 65% for the chronic knees) and for rate of recurrent tears (2% for acute and 9% for chronic). There was no significant difference between the series for clinical signs (pain, swelling, apprehension), mean residual laxity as measured by KT 2000, although it was greater for the chronic knees (+2.6%) than for the acute knees (+2.3%). Permanent flexion was not significantly different between the series (31% for chronic and 28% for acute) although the reason was different since for the chronic series, subsequent meniscectomy was necessary.

Conclusion: Patellar ligamentoplasty performed in an acute setting provides better clinical and radiological outcome. It stabilises the knee better before possible development of a meniscal lesion that may precipitate osteoarthritis.

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.

Purpose: The purpose of our study was to evaluate, in a context of laxity, the incidence of meniscal lesions and their treatment on the osteoarthritic evolution after more than ten years. In 1986 and 1987, we operated 230 knees with tears of the anterior cruciate ligament using a patellar graft. Among these knees, 184 (80%) were reviewed clinically and radiographically for this study.

Material and methods: Ninety patients (49%) had healthy menisci at the operation and did not have a secondary meniscal procedure; 94 patients (51%) had a meniscal procedure before, during or after the plasty. Among these, 13 (14%) had had an earlier meniscectomy, 18 (19%) had had meniscectomy at the time of the plasty (two revisions), 35 (37%) had had sutures (five secondary failures), ten (11%) had had a long injury left in place (four revisons), and 18 (19%) with normal knees at the time of the plasty had a secondary meniscectomy.

Results: We compared the radiological results in these different populations (osteoarthritis with remodelling compared with normal images). There was a significant difference between the population with normal knee images and the population with meniscal lesions irrespective of the time of treatment (prior meniscectomy, concomitant meniscectomy and plasty, healthy menisci at the time of plasty but secondary meniscectomy). There was no significant difference between the knees with normal menisci and those with sutured menisci.

Conclusion: Saving the meniscus has a major effect on the radiological evolution of the knee. Thus isolated meniscectomy should not be performed for laxity in young patients; meniscal lesions should be sutured at the time of ligamentoplasty.