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.

Results and longevity of total knee arthroplasty depend on the correction of axis of the lower limb and the stability of the prosthesis. Faithful to the principle of dependent cuts, our goal was to obtain two equal correlated, rectangular extension and flexion gaps using a ligament balancing tensor called CORES^® (Stryker^®).

Material and Methods: We retrospectively studied the results of a continuous series of 122 total knee arthroplasties (Jade^®, Stryker^®) implanted by only one operator, between December 1994 and 1997. The mean follow-up is 9,5 years. Tibial plateaus were slip and fixed, with or without conservation of the posterior cruciate ligament. Mean patient age at implantation was 71,2 years. 94% had osteoarthritis and 6% rheumatoid disease. The mean preoperative IKS score was 23,4 and the IKS function score was 42,6. 16% of knees were aligned normally, according to the IKS criteria, 24% presented valgus > 4°, and 60% presented varus > 3°. Patella was centred (AA’ distance < 3mm) in 65% of cases and not tilted (alpha angle< 5°) in 41% of cases. There were 22% antero-medial and 78% antero-lateral with ATT eversion approaches. All tibial and femoral components were cemented. Resurfacing patella was not the rule (5%). Clinical outcome was assessed with the IKS score and radiological outcome with the IKS criteria.

Results: There were no early complications. At follow up, the mean IKS knee score was 90 points with mean motion 109°. Mean IKS function was 85 points. 82% of the knees were aligned (HKA angle between 177° and 183°), 7% in varus, and 11% in valgus. Patella position was centered in 80% of cases, and tilted in 8%. No patellar dislocation was observed. Radiolucent lines were observed in 20% of the tibial components, without aseptic loosening. 3% of the femoral component presented radiolucent line, and one was symptomatic. Four TKA were removed at ten and eleven years, corresponding to three deep haematogenous infections and one aseptic loosening (a young man with haemophilic arthritis). Arthroplasty survival rate was 95% at 9,5 years (Kaplan-Meier method), considering all reasons for removal, and 99,4% for removal for aseptic loosening with 95% confidence interval.

Discussion: Since a well-balanced distribution of medial and lateral contact forces avoids overload of one compartment and thus premature wear, knee imbalance assessment is a key point in TKA. This method allows ongoing intraoperative assessment of the angular and rotational correction, bone defect, as well as bone resection levels.

Conclusion: To our knowledge, our study report the first results at 9,5 years of a TKA based on dependent femoral cuts using a ligament tensor. This confirms the durability and longevity of this model of prosthesis, and the accuracy of the method.

Purpose of the study: The objective of this retrospective analysis was to examine the functional and radiographic results of 33 resvisions for femoral implants using a long locked stem inserted without cement and coated with hydroxyapatite.

Material and methods: Mean follow-up was two years for 33 patient who underwent revison total hip arthroplasty (rTHA) with implantation of a press-fit long locked hydroxyapatite coated femoral stem (Aura or Linea) between 2000 and 2004. The explanted prosthesis was cemented in 23 cases. The reason for revision was femoral loosentng for 60%, femoral fracture for five pateints, and infection for two. According to the SOFCOT 1999 criteria, ten patients had bone defects score grade III or IV. Femorotomy was performed in 21 cases. Patients were reviewed clinically and radiologically. Function was assessed with the Postel-Merle-d’Aubligné (PMA) score and radiographic analysis determined the quality of osteointegration of the implants and the restitution of bone stock.

Results: There were six early complications (one death, one disloction with sciatic paralysis), and six late complications, mainly related to defective locking. The PMA score was less than 3 for only three patients. Twenty-six patients were satisfied or very satisfied and seven patients reported thigh pain which was generally moderate. The locking was released for five prostheses because of failure or pain (relief observed in three cases). Migration was noted in three cases, illustrating their non-integration. For 15 patients, corticalisation around the lower part of the prosthesis suggested implant mobility. This image was observed in all patients who complained of thigh pain (p=0.057). There was a significant increase in the cortical index, reflecting progression of the bone stock favoring the internal cortex.

Conclusion: This type of implant has provided a solution for the difficult problems of explantation and reimplantation of THA. These prostheses provide satisfactory short-term results and a significant improvement in bone stock. There remains the problem of osteointegration of certain implants. Technical factors can contribute to improved clinical results.

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: Free patellar tendon plasty is the most common technique for repairing anterior knee laxity. Functional outcome can be compromised by invalidating knee pain. The purpose of this prospective randomized study was to compare the outcome of plasty procedures using hamstring tendon versus patellar tendon autografts.

Material and methods: From May 1998 through May 2001, 100 patients presenting an isolated grade I anterior cruciate ligament (ACL) tear were included. Exclusion criteria were: history of fracture, advanced-stage laxity (grade II or greater), and contralateral ACL tear. Randomization was performed in the operative theater using the closed envelop method. Two groups of 50 patients were designated: group A: arthroscopic free bone-tendon-bone patellar autograft; group B: arthroscopic free four-strand hamstring autograft. Two metallic interference screws were used for fixation in both groups. The two groups were comparable for demographic features and clinical, radiological, and instrumental laxity variables recorded before surgery. The position of the tunnels was noted according to Aglietti and was the same in the two groups. The same rehabilitation protocol in a dedicated center was used for both groups. All patients (none lost to follow-up) were assess using the IKDC 1993 criteria with objective instrumental measurement of residual laxity. The level of significance was set at 5%.

Results: There was no significant difference between the groups regarding: resumption of sports activity (level and delay), joint motion, ligament examination, the overall IKDC score, and radiological findings ate mean 40±13 months (range 13–69 months) follow-up. Pain at the harvesting site was observed in 34.78% of patients in group A at six months and in 39.5% of those in group B. Conversely, anterior pain was found in 8.5% of patients in group B at six months and 6.6% at one year (p< 0.05). This statistically significant difference disappeared at two years. Instrumental differential laxity was 0.57±1.3 mm in group A and 1.22±1.9 mm in group B (p=0.56, but with power < 80%). There were two cases of repeated traumatic tears in each group. Repeated meniscectomy was performed in one patient in group A and in three in group B (p=0.3074).

Conclusion: The results at 40 months follow-up of this prospective randomized study with no patients lost to follow-up confirmed the minimal morbidity observed at the harvesting site for hamstring plasty. There was no significant difference between the transplants (patellar tendon, hamstring). Anterior pain with the patellar tendon plasty attenuated after two years. Residual laxity was greater when using the hamstring method.

Purpose of the study: The purpose of this retrospective study was to analyze outome at more than one year of 33 anterior cruciate ligament (ACL) ligmanetoplasties performed in subjects aged over 50 years.

Material and methods: Between 1997 and 2002, arthroscopic ACL ligmantoplasty with a free graft was performed for 33 patients aged 50–67 years (mean 55.2 years). All patients were reviewed clinically and radiologically at least one year after surgery (mean follow-up 31 months, range 12–60 months). IKDC criteria and manual KT-1000 measurements were recorded. All subjects were classified C or D before the operation (IKCD 93 criteria). Plain x-rays were considered normal for 21 patients (63.5%) and eight (24%) presented remodeling of the medial femorotibial compartment or the intercondylar eminences. Four knees (12.5%) presented an asymptomatic narrowing of the medial femorotibial space (< 50%). In all patients, the indication for surgery was instability for daily life and/or sports activities, even for patients presenting an asymptomatic narrowing. An inter-articular patellar tendon graft, using two independent tunnels was performed for 29 patients. A hamstring plasty was performed for the others. Mean time from injury to surgery was 18 months. There were 15 lesions of the medial meniscus (45.5%). Six lesions were not repaired because they were considered stable. The lateral meniscus was involved less often (n=11 lesions). The lateral meniscal stock was preserved in nine knees. The rehabilitation protocol was the same as used for ligamentoplasty in young sportive patients.

Results: There were no intraoperative complications. Supplementary fixation of the tibia was required for three knees. All patients resumed their sports activities at the same level. The overall IKDS score was A for eight patients, B for 19 and C for six. For the patients in class C, the poor IKDC score resulted from persistent pain, generally present before the operation. Joint motion was preserved in 30 patients. IKDC laxity was A or B in all patients. At last follow-up, there was no radiological worsening and no meniscal injury left unrepaired required secondary treatment.

Conclusion: The operative technique was joint instability for daily life activities. Stability was improved in all patients, but the surgery did not improve pain relief. Age greater than 50 years is not a contraindication for arthroscopic reconstruction of the central pivot for chronic anterior instability. Fixation of the implant must be precise. The indication for surgery depends on the severity of the instability for daily life activities in a motivated patient.

Purpose of the study: The issue of which graft to choose for anterior cruciate ligament (ACL) reconstruction is still a matter of debate. An analysis of the literature reveals the difficulty encountered when performing comparative trials. It is also difficult to demonstrate significant differences with results obtained with an insufficient number of patients. We propose here a meta-analysis in order to combine the results obtained with different comparative studies.

Material and methods: The literature search (Medline 1990–2005) was based on the following selection criteria: ACL reconstruction, patellar tendon (PT), gracilis and semitendinous (four-strand hamstring) reconstruction and comparative prospective study. Studies were retained with: > 30 patients per group, minimum follow-up 24 months, IKDC score. Evaluation criteria retained were: anterior pain, resumed activity, IKDC score, differential laxity. The relative risk (RR) statistical method with 95% confidence interval (CI) was applied. Means were calculated and the chi-square and z-tests were applied.

Results: Thirteen studies satisfied our inclusion criteria. These studies had included more than 1300 transplants. Mean rate of anterior pain was 23.2% with PR and 17.3% with hamstring reconstructions. The RR was 0.73 with a CI different from 1. The difference was significant. Resumption of sports activities at the same level, subjective assessment, number of failures, and overall IKDC score were not statistically different between the two types of transplants. The IKDC laxity score was not different but the residual maximal manual differential laxity was greater in the hamstring patients than in the patellar patients in 80% of the cases.

Conclusion: At the observed follow-up, free grafting with a four-strand hamstring tendon or a patellar tendon is an effective method for reconstruction of the ACL. Anterior pain is more frequent with the patellar tendon method and residual laxity is greater with the hamstring method. The long-term outcome will determine whether the residual laxity observed with the hamstring graft has a deleterious effect on the meniscocartilaginous structures. This criteria would minimize the advantage of this technique over the patellar tendon technique concerning the initial anterior pain.

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.

Purpose: Free patellar tendon plasty is classically used for the treatment of chronic anterior instability of the knee. Good functional results may however be compromised by invalidating anterior pain. The purpose of this randomised trial was to obtain a prospective comparison of outcome after hamstring plasty or patellar tendon plasty.

Material and methods: One hundred patients with an isolated tear of the anterior cruciate ligament were included in the study between May 1998 and 2001. Exclusion criteria were history of fracture, grade II laxity, and tear of the contralateral ACL. Patients were assigned to one of the treatment arms in random order in the operating room: Group A: arthroscopic free patellar tendon-bone graft; Group B: arthroscopic free four-strand hamstring graft. Two metal interference screws were used for fixation in all cases. The Aglietti method was used to calculate the position of the bore holes in all cases. The same rehabilitation protocol, in the same centre, was applied in all cases. The two groups were comparable for epidemiological, clinical, radiological, and instrumental laxity (KT1000®) data. IKDC criteria, activity level (sports), and instrumental measurement of laxity (KT1000® Medtronic) were used to assess outcome. Differences were considered significant for p < 0.05.

Results: At mean follow-up (24 months, range 6 – 38) groups A and B were not significantly different for delay to resumed sports activity at the initial level, motion, clinical examination of ligaments, IKDC global score, and radiological evolution. At six months, 30% of the patients in group A complained of anterior pain; 20% of the patients still complained of pain at one year. In group B, femoropatellar pain or pain at the harvesting site was reported by 8% of the patients at six months and 4% at one year (p = 0.0005). These differences were no longer present at two years. The instrumental differential laxity was 0.66±1.1 mm in group A and 1±1.5 mm in group B (p =0.20). Two repeated trauma-induced tears were observed in group B.

Conclusion: The preliminary results of this prospective randomised trial confirm the low morbidity of the harvesting site for hamstring grafts and the reliable stability of hamstring repair of isolated ACL laxity. A longer follow-up is however needed for long-term validation, particular concerning secondary distension of hamstring grafts as is frequently reported in the literature and which we have also observed in certain patients treated before this series.