Introduction:

High tibial osteotomy (HTO) is a common treatment for medial compartment arthritis of the knee in younger, more active patients. The HTO shifts load away from the degenerative medial compartment and into the lateral compartment. This change can be accomplished with either a lateral closing or a medial opening wedge HTO. An HTO also potentially affects leg length. Mathematical models predict that the osteotomy type (opening versus closing) and the magnitude of the correction determine the change in leg length, but no in vivo studies have been published. The purpose of this study is to quantify and compare leg length change following opening and closing wedge HTO.

Background:

Appropriate positioning of total knee arthroplasty (TKA) components is a key concern of surgeons. Post-operative varus alignment has been associated with poorer clinical outcome scores and increased failure rates. However, obtaining neutral alignment can be challenging in cases with significant pre-operative varus deformity

For many patients, UKA is a good alternative to total knee arthroplasty (TKA) or high tibial osteotomy (HTO). Strong evidence that gender influences outcomes following UKA could alter UKA selection criteria. No prior series has been specifically designed and matched to compare outcomes based on gender. The purpose of this study was to elucidate the effect of gender on the clinical outcome of UKA while controlling for other variables that may affect outcome.

Between 1988 and 2006, 257 UKA's were carried out in our department. We studied two groups of 40 patients of each gender, matched by pre-operative clinical and radiological presentation, and with post-operative follow up of at least 2 years. The mean age at operation was 71 years and the mean follow-up was 5.9 years. In both groups, IKS score improved significantly.

When comparing the male and female groups post-operatively, no significant differences were found between IKS knee or function scores, limb alignment, or the incidence of radiolucent lines. No difference was found between groups in terms of range of motion or radiologic progression of arthritis. Both tibial (p<0.001) and femoral (p<0.001) component sizes were significantly larger in the male group than the female group. For males, the size of both the femoral (r2=0.12, p=0.033) and tibial (r2=0.29, p=0.0005) components correlated with patient height. For females, the size of neither the femoral (r2=0.000082, p=0.96) nor tibial (r2=0.0065, p=0.63) components correlated with patient height.

The key finding in this study is that when patients are selected for UKA according to specific selection criteria (including avoiding performance of UKA in younger patients and patients over 85 kg), gender is not a predictor of outcome based on IKS scores. When using these selection criteria, gender should not be considered when determining whether to perform a UKA.

Introduction

Microbiological diagnosis of bone and joint infections (BJIs) currently relies on standard cultures which are time consuming and lack sensitivity. Various molecular approaches have been described and allowed improvement of BJI diagnosis. This study evaluated for the first time the performance of a DNA microarray-based assay (Prove-it™ Sepsis assay, PISA) for the rapid (<6 hours) detection and identification of 50 different species involved in BJI directly from clinical samples.

To our knowledge in medial unicompartmental knee arthroplasty (UKA) no study has specifically assessed the difference in outcome between matched gender groups. Previous unmatched gender studies have indicated more favourable results for women.

Introduction

Rapid identification of bacteria from extemporaneous samples would greatly help management of prosthesis joint infection. The aim of the present retrospective study was to evaluate a new molecular assay (GeneXpert MRSA-SA SSTI (Cepheid)) for detecting Staphylococcus aureus (SA) and methicillin resistance directly from bone and joint samples in less an hour (58 minutes).

Introduction

It is documented in the literature the very good results of lateral unicompartmental knee arthroplasty (UKA) when the standard accepted indications are followed. In our experience these indications can be extended to include post-traumatic osteoarthritis (OA) with malunion secondary to tibial plateau fracture. We report our results concerning 15 UKAs in these particular situations.

Purpose of the study: Transposition of the anterior tibial tuberosisty (ATT) is often performed during the treatment of periodic dislocation of the patella. The purpose of this retrospective study was to evaluate the rate of medial femorotibial osteoarthritis and medial patellofemoral osteoarthritis after ATT transfer.

Material and method: We reviewed 129 knees in 106 patients who underwent surgery from 1988 to 2004. The patients were reviewed at mean 9 years follow-up, minimum 2 years. Three groups were defined:

isolated descent (n=15),

The degree of the medial shift and the descent depended on the distance from the tibial tuberosity to the trochlear notch and the Caton-Deschamps index measured preoperatively. Patients who underwent surgery for chronic anterior laxity and/or meniscal lesions were excluded (n=3). All patients were free of osteoarthritis before surgery. A complete radiographic series was available for 102 knees. Unilateral periodic dislocation of the patella was present in 60 patients whose knee x-rays were obtained bilaterally.

Results: All patients in group 2 were free of osteoarthritis. In group 2, the rate of medial femorotibial osteoarthritis was 10.5%; the rate of medial patellofemoral osteoarthritis was 21%. In group 3, the rate of medial femorotibial osteoarthritis was 7% and that of medial patellofemoral osteoarthritis 14%. For patients with unilateral periodic patellar dislocation, only the operated knees exhibited medial patellofemoral osteoarthritis (12%). The rate of medial patellofemoral osteoarthritis was significantly greater for knees with a medial shift of the ATT. The rate of medial femorotibial osteoarthritis was 6.8% for knees with medial shift versus 8.3% for the index knees. There was no significant difference between the medial shift knees and the index knees for medial femorotibial osteoarthritis.

Discussion: Biomechanical studies have shown increased stress forces on the medial compartment after medial shift of the ATT. However, these studies were performed with normal knees free of the morphological anomalies generally present in knees exhibiting periodic patellar dislocation (abnormally high tibial tuberosity femoral notch distance, trochlear dysplasia. In our series, regarding the rate of medial femorotibial osteoarthritis, there was no significant difference between the knees which underwent a medial shift of the ATT and healthy knees. Consequently, medial shift of the ATT should be avoided when unnecessary; the morphology of the trochlea (depth, morphology of the medial component) can induce increased medial stress on the patellofemoral joint.

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).

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique.

The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

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: Increasing popularity of unicompartmental knee arthroplasty (UKA) brings greater relevance for possibilities and outcome of revision surgery. UKA is less aggressive, allows earlier rehabilitation and better kinematics comparing to total knee arthroplasty (TKA). It is tempting to apply such advantages in cases with secondary degenerative changes in the opposite compartment after an UKA with satisfactory results by implanting a contralateral UKA (BiUni). Absence of loosening or wear with overcorrection under 5° after first prosthesis and patient selection criteria for UKA in the opposite compartment are required.

Material and Methods: From June 2004 to January 2007 six BiUni were done, out of ten secondary surgeries following UKA (six BiUni, three arthroscopies and one TKA conversion). Four consisted in external UKA after medial and two others the opposite. All have been submitted to prospective radiologic and clinical evaluation (International Knee Society Score-IKSS) with 25.5 months mean follow-up (12 to 42).

Results: Identified causes for secondary arthritic changes included: “hypercorrection” (n=3), partial lateral meniscectomy (n=2) and femoral condyle osteonecrosis (n=1). Before BiUni the mean IKSS knee was 62.5 (60 to 70) and IKSS function 65.0 (60 to 70). At latest revision, mean IKSS knee was 92.5 (80 to 100) and function 87.5 (70 to 100). No radiologic signs of wear or migration were noticed.

Discussion: There are only few papers in literature regarding this concept. BiUni is not about revising failed UKA neither is a bycondilar knee arthroplasty. These results encourage further evaluation about possible long-term advantages for strictly selected cases particularly those at higher risk for TKA.

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.

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.

Introduction: The degenerative changes in the patello-femoral joint after an autologous bone-tendon-bone anterior cruciate ligament reconstruction were studied using plain radiology more than 24 years after the surgical procedure.

Material and Methods: One hundred patients out of a total of 148 patients could be reviewed at 24.5 years follow-up. Radiological analysis included joint space width narrowing classification of the medial and lateral facet according to IKDC and patellar height according to Caton-Deschamps index (CDI).

Results: Fifty four percent of patients had medial femorotibial moderate or severe degenerative changes.

Medial patello-femoral degenerative changes were found more frequently and these lesions were more pronounced: 20% had narrowing < 50% (IKDC C) and 4% had narrowing > 50% (IKDC D). Onset of medial patellofemoral osteoarthritis was correlated with medial femorotibial osteoarthritis (p< 0,001).

Patellar height was statistically different between the operated and controlateral knee (CDI = 0.92 and 0.96, p< 0.001). Patella baja (CDI< 0.8, frequency 9.9%) was correlated with medial femoro-patellar osteoarthritis (< 0.001) and postoperative cast immobilisation (p=0.047).

Discussion: Patello-femoral degenerative changes observed 24.5 years after ACL reconstruction are part of the global degenerative changes of the knee joint. Harvesting of the patellar tendon for anterior cruciate ligament reconstruction results in a only 0.04 point decrease of the Caton-Deschamps index 24.5 years after surgery.

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.

Purpose of the study: Cysts are rarely identified in the anterior cruciate ligament; the pathogenic mechanisms involved are poorly understood. We investigated the anatomic and clinical presentation.

Material and methods: This retrospective analysis included 24 patients, seven women and seventeen men managed in a single center from 1998 to 2004. Mean patient age was 45 years (range 25–74 years). All patients complained of pain. A preoperative MRI was available for all patients. Mean follow-up was 25 months (range 6–48 months). Arthroscopic procedures were used for 17 patients and the IKDC subjective score was determined preoperatively in all. Radioguided (US or CT) puncture was performed for seven patients associated with corticosteroid injections.

Results: On the MRI, there were 16 infiltrating cysts and eight cystic formations. Surgical treatment (n=17) was performed for 13 infiltrative cysts and for four cystic formations. There were two cases of recurrence. Outcome was poor after puncture (two puncture failures, three recurrences and one vascular complication).

Discussion: Two forms of cysts of the ACL can be demonstrated by MRI. The clinical presentation may not be different but the therapeutic management should be. The cystic formation is an indication for puncture, with arthroscopic treatment in the event of failure. For infiltrating cysts, complete resection of the cyst during an arthroscopic procedure is indicated, sometimes associated with resection of the ACL. Puncture yields poor results.

Purpose of the study: The purpose of this retrospective study was to analyze clinical datao n pigmented villon-odular synovitis (PVSN) of the knee as well as outcome after treatment in order to define the diagnostic stages, the surgical treatment, and follow-up modalities for this rare benign proliferative disease of the synovial which predominantly affects the knee joint.

Material and methods: Between 1996 and 2004, 28 patients were managed in our department, 13 men and 15 women, diffuse PVNS in 20 and localized PVNS in 8. IN the localized forms, symptoms were similar to those observed in knees with intra-articular foreign bodies or a meniscal lesion (75%) was present for 14 months on average at the first consultation. Mean age at onset of therapeutic management was 40 years (range 20–62). Localized arthroscopic or open resection was performed. For the diffuse forms, symptoms had been present for 15 months on average at the first consultation. Patients sought medical care because of spontaneous hemarthrosis or diffuse knee pain with no specific signs. Mean age at onset of therapeutic management was 38 years (range 15–59). Bony lesions were observed in 20%. Synoviorthesis or surgical synovectomy were performed. Mean follow-up was 97 months (range 12–309). Outcome was analyzed separately for the localized and diffuse forms.

Results: For the localized PVNS, there were no complications after surgical treatment but the relapse rate reached 12.5%. For diffuse PVNS, the cumulative rate of relapse was 50%, recurrence being noted on average 37 months after treatment. A stiff joint developed in 14% after open synovectomy. Surgical treatment was necessary in four cases (total arthroplasty in three) seen late after development of bony lesions; the clinical outcome was good with good gain in flexion.

Discussion: MRI is essential for the topographic diagnosis and to guide surgery. For diffuse PVNS seen at an advanced stage or after several recurrences, adjuvant synoviorthesis can be useful 4 to 8 months after surgery.

Conclusion: Appropriate treatment of PVNS of the knee depends on the presentation but usually involves a surgical procedure. The risk of recurrence for diffuse PVNS warrants annual MRI for four years.

Purpose of the study: The objective of this study was to compare outcome after total knee arthroplasty (TKA) with a metallic tibial base versus full poly prostheses.

Material and methods: This monocentric retrospective study compared 169 Tornier full poly HLS TKA (group A) with 169 TKA with a fixed metallic tibial base (group B). The two series were matched for age, gender and etiology. Mean age was 71 years and female gender predominated, 80%. Mean follow-up was 66 months. Clinical (IKS score) and radiological outcome was assessed. Statview 5.0™ was used for the statistical analysis, Student’s t test for quantitative variables and chi-square test for qualitative variables. Differences were considered significant for p< 0.05. The beta factor was 0.2.

Results: The main intraoperative incidents were, weakening of the popliteal tendon (n=1) and supra and inter-condylar fracture of the femur (n=1) in group A patients and weakening of the popliteal tendon (n=2) and secondary fracture line of the medial tibial plateau (n=2) in group B patients. For group A, the knee score was 89±10.82 (mean±SD) and for group B 88.28±11.94. The function score was 68±23.75 for group A and 71±24.05 for group B. Mean flexion in both groups was 113°. Non-progressive tibial lucent lines were observed in 27 patients in group A and in 23 in group B. There were 7 replacements of the TKA in group A and 6 in group B. Survival for group A was 94.5% and 93.64% for group B.

Discussion: There were no significant differences concerning function and knee scores, presence of lucent lines and prosthesis replacement between the two series (p> 0.05).

Conclusion: This study did not demonstrate a superiority of the metallic tibial base TKA at five years follow-up. Use of a full poly TKA could decrease the medical cost by more than 30%.

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.