Is there a femoral morphology at risk of a cervical or pertrochanteric fracture? Description and validation of the "Neck shaft ratio" and the "Intertrochanteric distal ratio" after analyzing a continuous cohort of 126 bilateral fractures of the proximal femur

BACKGROUND

Proximal femur fractures constitute a public health concern given their high frequency and the aging population. The frequency of a contralateral fracture occurring can reach up to 15% of cases. Certain historical or demographic factors constitute risk factors for refracture, but the type of fracture, either of the femoral neck (FN) or pertrochanteric (PT), cannot be predicted. The objectives of this retrospective study were: 1) to analyze several anatomical markers in order to determine whether they predispose to a certain type of fracture in the event of contralateral refracture, 2) to determine the predictive power of these possible radiological markers for the type of contralateral fracture.

HYPOTHESIS

The hypothesis was that the "Neck shaft ratio" (NSR) and the "Intertrochanteric distal ratio" (ITDR) made it possible to determine a proximal femoral morphology at risk of FN and/or PT fracture in the event of a second fracture.

MATERIAL AND METHODS

This continuous retrospective single-center series from January 2011 to December 2019 of patients who presented with bilateral fractures of the proximal femurs was analyzed. Radiographs, taken after the first fracture, of the contralateral femur were studied. Morphological measurements previously described in the literature were carried out as well as the NSR (ratio of the medial cortical thicknesses of the femoral neck at its narrowest and basicervical level) and the ITDR (ratio of the medial diaphyseal cortical thicknesses at 5 mm and 20 mm from the distal portion of the lesser trochanter). One hundred and twenty-six patients were included: 46/126 (36.5%) had bilateral FN, 50/126 (39.7%) bilateral PT and 30/126 (23.8%) one of each.

RESULTS

Only NSR and ITDR were significant predictive measures for FN or PT fracture type (0.54 ± 0.11 vs 0.81 ± 0.16 (p<0.0001) and 0. 85 ± 0.1 vs 0.68 ± 0.1 (p<0.0001), respectively). These two ratios had an excellent predictive value for the type of fracture occurring on the contralateral side (NSR: AUC ROC= 0.91 [95% CI; 0.86-0.96]; ITDR: AUC ROC= 0.81 [95% CI; %, 0.74-0.89]). The NSR had excellent intra- and inter-observer reproducibility with an Interclass Correlation Coefficient of 0.93 [95% CI: 0.86-0.97] and 0.91 [95% CI: 0.82-0.96] respectively, the same also applied for the ITDR with Interclass Correlation Coefficient values of 0.93 [95% CI: 0.87-0.97] and 0.86 [95% CI: 0.73-0.93] respectively.

DISCUSSION

The NSR and ITDR ratios offer a simple and reproducible means to predict a morphological predisposition to a certain fracture type, respectively an FN and PT on the side contralateral to an initial osteoporotic proximal femur fracture. A prospective cohort study would be useful in defining a possible prognostic nature on the occurrence and/or time until refracture.

LEVEL OF EVIDENCE

III; retrospective control case.

Patellar resurfacing might not be mandatory in contralateral second total knee replacement even if performed during replacement of the first knee

INTRODUCTION

The appropriateness or necessity of patellar resurfacing in total knee arthroplasty (TKA) is not clearly established. The objective of the present study was to compare the clinical and functional results of patients with bilateral involvement, operated on in one knee by TKA with patellar resurfacing and in the other knee by TKA without resurfacing. The hypothesis was that there was no difference in results between the two sides.

METHOD

This was a retrospective cohort of patients operated on by TKA without patellar resurfacing in a second osteoarthritic knee after contralateral TKA with patellar resurfacing. Twenty consecutive patients who underwent second primary TKA constituted their own control group (40 knees). Iwano scores were comparable. Mean age was 75.9 ± 6.2 years. Mean time between the two procedures was 20.6 ± 11.9 months.

RESULTS

There were no differences in SF-36, KOOS or Lille patellofemoral scores between the right and left knees. Sixty-five percent of patients were unable to differentiate the performance of their knees in activities of daily living.

CONCLUSION

The present study did not differentiate results according to patellar resurfacing, showing the limitations of resurfacing for early functional gain after primary TKA. Resurfacing might thus not be essential, even if it was performed in replacement of the first knee.

LEVEL OF EVIDENCE

IV; retrospective cohort study.

Anatomic reconstruction of the posteromedial corner of the knee: The Versailles technique

INTRODUCTION

Multiligament knee injury with posteromedial laxity is serious and usually requires surgery. Reconstruction is preferable to repair. The main aim of the present study was to report clinical results and laximetry for an original posteromedial corner (PMC) allograft reconstruction technique known as The Versailles Technique. The secondary aim was to determine prognostic factors for surgery. The study hypothesis was that anatomic PMC reconstruction by tendon allograft provides satisfactory medium-term clinical and laximetric results.

METHODS

A retrospective study assessed postoperative clinical and laximetric results after PMC allograft reconstruction at a minimum 12 months' follow-up. Laxity was assessed on comparative bilateral stress X-rays, and functional results on the International Knee Documentation Committee (IKDC) score, the Lysholm score and the Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Twenty-six patients were included between 2013 and 2019. Mean follow-up was 27.4±9 months. Mean subjective IKDC score was 69.21±17.36, mean Lysholm score 77.78±14.98 and mean KOOS 66.44±18.52.

OBJECTIVE

IKDC results were 77% grade A, 22% grade B, and 0% grade C or D. Mean medial differential laxity in forced varus was 0.83±1.26mm. Mean subjective IKDC scores were poorer in Schenck KD-III than KD-I (p=0.03). Functional results were comparable with acute and with chronic laxity. Age correlated inversely with median KOOS (p=0.009). There was no correlation between postoperative radiologic laxity in forced varus and functional results.

DISCUSSION

Versailles anatomic PMC allograft reconstruction for acute or chronic posteromedial knee laxity showed medium-term efficacy in restoring good objective and subjective stability.

LEVEL OF EVIDENCE

IV; retrospective observational study.

Evolution of body mass index and complications rate in severely or morbidly obese patients undergoing total knee arthroplasty

INTRODUCTION

Associations between obesity and knee osteoarthritis or complications after total knee arthroplasty (TKA) are well established. The procedure can significantly improve knee function, favoring weight loss, despite the risk of surgical complications. The main objective of the present study was to assess change in body mass index (BMI) after TKA in patients with severe or morbid obesity (BMI≥35kg/m2). The secondary endpoint was the rate of surgical revision. The hypotheses were that there is no significant change in BMI after TKA and that there is a significant rate of revision.

METHODS

This retrospective descriptive study was conducted for the period June 2009 to December 2019. Thirty-three patients (48 knees) were included: 27 women, 6 men; mean age, 66.5 years (range, 55-80). Preoperatively, 11 patients had BMI 35-39.9kg/m2 and 22 BMI≥40 (including 11 with BMI≥45kg/m2). The preoperative axis was in varus for 35 patients (73%, including 54%≥10°) and in valgus for 13 (27% including 33%≥10°). Radiological and clinical evaluation was carried out at 3 months and 1 year postoperatively. At≥2 years, change in BMI and EQ5D functional score were established by telephone survey; >5% change in BMI was considered significant.

RESULTS

Mean follow-up was 6.9±2.3 years (range, 2.9-10.5). Twenty-five patients (38 knees) were included for analysis. Mean postoperative BMI was 41±5kg/m2, with a mean decrease of 1.2±3.6kg/m2. At the last follow-up, BMI had increased in 8 patients (32%), including 3 by >5% (12%), and decreased in 16 (64%), including 7 by >5% (28%). The higher the baseline BMI, the greater the decrease: for BMI [35-39.9], -0.81 (range, -6.8; +4.3); for BMI [40-44.5],-1 (range, -9; +5.22); and for BMI>45, -1.54 (range, -3.97; +1.3). EQ5D averaged 0.75 at last follow-up. The higher the preoperative BMI, the more satisfactory the postoperative EQ5D: EQ5D for BMI [35-39.9]=0.71 (range, 0.36; 1); for BMI [40-44.5]=0.75 (range, 0.45; 1); and for BMI>45=0.80 (range, 0.48; 1). Four early surgical site infections (10.5%) and 2 isolated changes of the tibial component for early loosening (5.2%) required surgical revision.

CONCLUSION

Patients with severe or morbid obesity had a low tendency to lose weight after TKA, but this does not appear to us to be clinically relevant: the functional results were good. Nevertheless, this series showed a significant rate of revision (15%). TKA was feasible in patients with BMI≥35kg/m2, but requires appropriate patient information.

LEVEL OF EVIDENCE

IV.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision.

METHODS

Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document.

RESULTS

The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article.

CONCLUSION

ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults.

LEVEL OF EVIDENCE

Level II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision.

METHODS

The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document.

RESULTS

The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below.

CONCLUSION

ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance.

LEVEL OF EVIDENCE

II.

Is the popliteal tendon sufficient for all-inside suture in lateral meniscus repair? A 22-case cadaver study

INTRODUCTION

Arthroscopic lateral meniscus repair is performed in the "figure-of-4 position" (supine, with the affected knee flexed and the lower leg crossed over the extended contralateral leg), and anchorage is often on the popliteal tendon. Extending the limb at the end of the procedure alters the relations between the popliteal tendon and the repaired meniscus. The present study aimed to assess lateral meniscal suture fixation on the popliteal tendon after a cycle of flexion-extension.

HYPOTHESIS

Extending the knee can induce suture release.

TYPE OF STUDY

Cadaver study.

MATERIALS AND METHODS

Twenty-two fresh adult human cadaver knee specimens were used. Under arthroscopy with all-inside implants, a vertical suture onto the popliteal tendon was performed through the lateral meniscus. Suture status was assessed under arthroscopy after a cycle of flexion-extension, and deemed defective if the suture was sufficiently loose for the arthroscope to be able to be passed through the popliteal hiatus, if the stitch had passed through the meniscus, or if the suture was broken.

RESULTS

Thirteen sutures (59.1%) remained well fixed, and 9 (40.1%) were defective: 4 (18.2%) were loose, in 4 (18.2%) the stitch had passed through the meniscus, and in 1 (4.5%) the suture had broken.

CONCLUSION

In a population of elderly cadaver knee specimens, arthroscopic suture of the lateral meniscus to the popliteal tendon was defective after flexion-extension in 40% of cases. Stress seems to be exerted on the suture when extension is resumed. Thus, a single stitch seems insufficient for stable lateral meniscus repair.

CLINICAL IMPLICATIONS

Suture of the lateral meniscus to the popliteal tendon undergoes stress when extension is resumed, potentially causing failure of lateral meniscus repair.

LEVEL OF EVIDENCE

IV.

Femoral condyle bone mineral density in osteoarthritis differs significantly between knees with valgus vs. varus deformity

BACKGROUND

The objective of this study was to measure bone mineral density (BMD) of the cancellous bone in both femoral condyles and to compare the results according to the hip-knee-ankle (HKA) angle in patients with knee osteoarthritis.

HYPOTHESIS

BMD of cancellous bone in the medial condyle is markedly lower in valgus knees compared to that in the lateral condyle in varus knees.

METHODS

Consecutive patients with computed tomography (CT) of the knee and long-leg radiographs obtained in preparation for total knee arthroplasty were included. The 189 knees were divided into five groups based on whether the hip-knee-ankle angle was<170° (major varus deformity), 171°-177° (varus deformity), 178°-182° (normal alignment), 183°-189° (valgus deformity), and>190° (major valgus deformity). A protocol for CT measurement of BMD values at the femoral condyles was developed. Correlations between the HKA angle and BMD were assessed using the ratio of medial-to-lateral condyle BMD values (M/L).

RESULTS

M/L was lower for knees with valgus deformity than for normally aligned knees (0.7 vs. 1, p<0.001). This difference was larger in the group with major valgus deformity, with a mean M/L value of 0.5 (p<0.001). M/L was higher for knees with major varus (mean, 1.2; p=0.035). The correlation coefficients showed excellent intra-observer and inter-observer agreement for the BMD measurements.

CONCLUSION

The BMD values of the femoral condyles correlate with the HKA angle. BMD is lower at the medial femoral condyle of valgus knees, particularly when the deformity exceeds 10°. This finding may deserve consideration when planning total knee arthroplasty.

LEVEL OF EVIDENCE

IV; retrospective study.

Unplanned return to the operating room after arthroscopic procedures: a need to consider 12 months after the initial surgery

INTRODUCTION

The purpose of this study was to report the proportion and cause of unplanned revision surgery rates within 1 year following arthroscopic procedures. Our hypothesis was that there is a significant rate of unplanned returns (URs) occurring between 3 and 12 months after the initial procedure and that causes of revision are different when considering the delay after the index surgery.

MATERIALS AND METHODS

Among 4142 consecutive patients who underwent an arthroscopic procedure in a single department of orthopedics and traumatology, patients undergoing revision surgery for any reasons directly related to the primary procedure were included. Cause for revision, surgical site, delay from index procedure, and number of revisions were screened.

RESULTS

Seventy-eight patients underwent 97 revision surgeries (2.3%) for reasons directly related to the primary procedure. Most revision surgeries were performed after month 3 following index surgery (59 patients, 60.8%). Mean time to revision surgery was 5.3 ± 4.3 months (range 0-365 days). Usual early-onset (< 3 months) reasons for unplanned revision were surgical site infection (17 patients, 0.41%), wound-healing defect (12 patients, 0.29%), and hemorrhagic complication (7 patients, 0.17%). Reasons for delayed unplanned revision (> 3 months) were index procedure failure (21 patients, 0.51%), stiffness (18 patients, 0.43%), and removal of hardware (16 patients, 0.41%).

CONCLUSIONS

Reasons for return to the operating room (OR) are different depending on the timepoint from index procedure. Patients should receive relevant information accordingly when scheduling any arthroscopic procedure, including up to 1-year potential complications.

LEVEL OF EVIDENCE

Prognostic study, Case series, Level IV.

Incidence and risk factors of prolonged grief in relatives of patients with terminal cancer in French palliative care units: The Fami-Life multicenter cohort study

OBJECTIVES

Psychological consequences of grief among relatives are insufficiently known. We reported incidence of prolonged grief among relatives of deceased patients with cancer.

METHODS

Prospective cohort study of 611 relatives of 531 patients with cancer hospitalized for more than 72 hours and who died in 26 palliative care units was conducted. The primary outcome was prolonged grief in relatives 6 months after patient death, measured with the Inventory Complicated Grief (ICG > 25, range 0-76, a higher score indicates more severe symptoms) score. Secondary outcomes in relatives 6 months after patient death were anxiety and depression symptoms based on Hospital Anxiety and Depression Scale (HADS) score (range 0 [best]-42 [worst]), higher scores indicate more severe symptoms, minimally important difference 2.5. Post-traumatic stress disorder symptoms were defined by an Impact Event Scale-Revised score >22 (range 0-88, a higher score indicates more severe symptoms).

RESULTS

Among 611 included relatives, 608 (99.5%) completed the trial. At 6 months, significant ICG scores were reported by 32.7% relatives (199/608, 95% CI, 29.0-36.4). The median (interquartile range ICG score) was 20.0 (11.5-29.0). The incidence of HADS symptoms was 87.5% (95% CI, 84.8-90.2%) at Days 3-5 and 68.7% (95% CI, 65.0-72.4) 6 months after patient's death, with a median (interquartile range) difference of -4 (-10 to 0) between these 2 time points. Improvement in HADS anxiety and depression scores were reported by 62.5% (362/579) relatives.

SIGNIFICANCE OF RESULTS

These findings support the importance of screening relatives having risk factors of developing prolonged grief in the palliative unit and 6 months after patient's death.

Is lateral femoral condyle hypoplasia a feature of genu valgum? A morphological computed tomography study of 200 knees

BACKGROUND

Young surgeons are taught that genu valgum deformity is associated with hypoplasia of the lateral femoral condyle, despite the absence of supporting evidence. The objective of this study was to determine whether the lateral condyle was hypoplastic in genu valgum, by assessing the morphological features of the distal femur and their variations according to the severity of the coronal deformity.

HYPOTHESIS

The lateral femoral condyle is not hypoplastic in genu valgum deformity.

MATERIAL AND METHODS

The 200 included patients treated by unilateral total knee arthroplasty were divided into five groups based on their preoperative hip-knee-ankle (HKA) angle. The HKA angle, valgus cut angle (VCA), and anatomical lateral distal femoral angle (aLDFA) were measured on long-leg radiographs. Computed tomography images were then used to measure the medial and lateral anterior-posterior condylar lengths (mAPCL and lAPCL) and condylar thicknesses (mCT and lCT), distal femoral torsion (DFT), medial and lateral posterior condylar heights (mPCH and lPCH), and medial and lateral condylar volumes (mCV and lCV).

RESULTS

No significant differences were demonstrated across the five mechanical-axis groups for mAPCL, lAPCL, mCT, lCT, mPCH, or lPCH. The groups differed significantly regarding the VCA (p<0.0001), aLDFA (p<0.0001), DFT (p<0.0001), and mCV/lCV ratio (p<0.0001). VCA and aLDFA were smaller when the valgus exceeded 10°. DFT was similar in all varus knees (2.2°-2.6°) but significantly greater for knees with moderate (4.0°) or severe (6.2°) valgus. Finally, lCV was greater than mCV in valgus knees compared to varus knees.

CONCLUSION

The presence of lateral condyle hypoplasia in knees with genu valgum seems open to question. Apparent hypoplasia noted during the standard physical examination may be chiefly ascribable to distal valgus of the femoral epiphysis in the coronal plane and, with the knee flexed, to distal epiphyseal torsion, whose severity increases with the degree of valgus deformity. These considerations should be taken into account when performing distal femoral cuts for TKA, to ensure the restoration of normal anatomy in patients with genu valgus.

LEVEL OF EVIDENCE

IV.

Combined Lateral Extra-Articular Tenodesis or Combined Anterolateral Ligament Reconstruction and Anterior Cruciate Ligament Reconstruction Improves Outcomes Compared to Isolated Reconstruction for Anterior Cruciate Ligament Tear: A Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To conduct a network meta-analysis (NMA) comparing the results of randomized controlled trials (RCTs) among patients who underwent either isolated anterior cruciate ligament (ACL) reconstruction or combined lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR).

METHODS

RCTs that compared isolated ACL reconstruction and combined LET or ALLR were included with minimum 12 months follow-up. Studies that used the double-bundle technique were excluded. Outcome assessment included the number of positive pivot shifts, amount of anterior tibial translation, and International Knee Documentation Committee (IKDC) subjective, Tegner, and Lysholm scores. Bayesian NMA and the surface under the cumulative ranking area (SUCRA) were evaluated.

RESULTS

A total of 1,077 patients from 11 RCTs were enrolled in this study. In NMA, the odds ratios (ORs) of positive pivot shift were significantly lower in ACL + ALLR (OR: 0.17; 95% CI: 0.027-0.67) than isolated ACL reconstruction, but no difference between ACL + ALLR and ACL + LET. There were no significant differences in anterior tibial translation among the techniques, but the IKDC subjective and Lysholm scores of ACL + ALLR and ACL + LET were significantly higher than isolated ACL reconstruction. ACL + ALLR were the most preferred in terms of residual pivot shift, anterior tibial translation, and IKDC subjective scores (SUCRA = 88.2%, 86.4%, and 93.1%, respectively). Additional lateral procedures resulted in significantly lower risk of graft failure (OR: 0.27; 95% CI: 0.1-0.71) than isolated ACL reconstruction.

CONCLUSIONS

ACL + ALLR were found to have significantly better outcomes in terms of knee rotational stability and graft failure rate than isolated ACL reconstructions, but the clinical outcomes were uncertain after a minimum 12 months follow-up. Considering the greatest probability of obtaining better knee rotational stability in this NMA, ACL + ALLR was found to be the most preferred technique for patients with ACL injury.

LEVEL OF EVIDENCE

Level II, network meta-analysis and systematic review of Level I and II studies.

Proximal femoral fracture and female gender are risk factors for recurrent fracture: Cohort study of 292 patients over 75 years-old with iterative osteoporotic fractures

PURPOSE

The purpose of this study was to: 1/ describe the characteristics of a cohort of patients over 75 years of age hospitalized in perioperative geriatric units (UPOG) for iterative fractures; 2/ investigate the risks of institutionalization related to the first fracture; and 3/ search for potential risk factors for iterative fracture.

METHODS

This is a retrospective single-center study analyzing patients over 75 years old, hospitalized in UPOG.

RESULTS

Of the 3207 patients hospitalized, 292 patients had a refracture (9.1%), with a mean age of 85.4+/-5.8 years. Initial fractures were mainly intertrochanteric (43.2%) and the femoral neck (32.9%). Refractures occurred mainly in the first year (55.5%), with a median delay of 9.6 months. Refractures were mainly intertrochanteric (29.5%), peri‑implant (prosthesis, osteosynthesis) (28.8%), and femoral neck (26.7%). Dementia was the only factor for institutionalization after the first fracture episode (p = 0.0002). Proximal femoral fracture (PFF) and female gender were risk factors for iterative fracture (10.2% vs. 6.8%, p = 0.003; 10.7% vs. 6.8%, p = 0.005 respectively), but not age (85.4 vs. 85.8 years, p = 0.24). PFF were more likely to result in the same fracture type in the second episode (58.1% vs 7.1%, p<0.0001). The time to refracture was shorter in case of peri‑implant fracture (p = 0.0002), or discharge directly to home (p = 0.04).

CONCLUSION

PFF and female gender are risk factors for recurrent fracture, which is even more likely to occur early in case of home discharge or peri‑implant fracture.

Incidence and type of meniscal tears in multilligament injured knees

PURPOSE

Meniscal injuries occurring during multi-ligament knee injuries (MLKI) are underreported. The purpose of this study was to compare the incidence and type of meniscal tears seen at the time of multi-ligament reconstruction surgery compared to those occurring during isolated anterior cruciate ligament (ACL) surgery.

METHODS

Patients undergoing surgical treatment for MLKI and ACL-only injuries between 2010 and 2020 were reviewed. Two-hundred and thirty-five patients were included in the MLKI group. There were 131 chronic injuries and 104 acute injuries. Two-hundred and twenty-two ACL-only chronic injuries were used as a control group for comparison with the chronic MLKI group. Demographic data, type of meniscal tears, ligament injury patterns (Schenck classification) and time from injury to surgery were recorded. A delayed procedure was defined by a 4-week interval after the knee injury.

RESULTS

A meniscus was torn in 69 knees (29.4%): 36 knees (15.3%) with an isolated medial meniscus tear, 33 knees (17.9%) with an isolated lateral meniscus tear,.Nine knees (3.8%) had both menisci torn. MLKI with medial or lateral-sided bicruciate ligament injuries (KDIIIM-KDIIIL) were significantly associated with a lower rate of meniscal tears than knee injuries involving the ACL-only and medial/lateral-sided ligament injuries (KDI) (medial-sided injuries p = 0.025; lateral-sided injuries p = 0.049). Lateral-sided injuries had significantly less meniscal damage than medial-sided injuries: 22/124 (17.7%) vs. 41/100 (41%); (p < 0.001). No significant differences were found for frequency, type and distribution of meniscal tears between acute and chronic MLKI surgery. ACL-only chronic injuries were associated with a higher rate of meniscal tears: 123/222 knees (55.4%) vs. 35/131 (26.9%) chronic MLKI; (p < 0.001), mainly involving the medial meniscus: 102/222 (46%) vs. 18/131 (13.7%); (p < 0.001).

CONCLUSIONS

Meniscal tears were less common in the MLKI group than in the isolated ACL injury group. The degree of ligament injury patterns and the side of the injured collateral ligament influenced the type and incidence of meniscal damage. Contrary to isolated ACL injuries, a delayed procedure was not associated with a higher rate of meniscal lesions but did influence the type of treatment. Understanding of meniscal tears patterns in MLKI helps to improve the treatment management of these complex injuries.

Comparison of three surgical techniques of posterolateral knee reconstruction: A cadaver study

BACKGROUND

Injuries to the posterolateral corner (PLC) of the knee are often overlooked but, require reconstruction in order to restore stability in varus and external rotation. Among the many anatomic and non-anatomic PLC reconstruction techniques available, the modified Larson (mLR), LaPrade (LPR) and Versailles reconstruction (VR) procedures are widely used.

HYPOTHESIS

The hypothesis was that anatomic PLC reconstruction (VR and LPR procedures) provides better restoration and control of external rotation.

PATIENTS AND METHODS

Fifteen fresh-frozen cadaveric knees were tested to compare the 3 procedures. Varus laxity on stress radiographs in full knee extension and external rotatory laxity on dial test at 30° flexion were quantified at 3 phases: intact knee, PLC sectioned and PLC reconstructed.

RESULTS

Mean varus laxity did not differ significantly between techniques in intact knees (p=.14), after PLC sectioning (p=.14) or after PLC reconstruction (p=.17). After PLC reconstruction, varus laxity was restored, with no statistical difference between mLR, VR and LPR compared to intact test values (respectively, -1.0, -1.3 and -1.5; p=.98). In all 3 groups, mean external rotation laxity on dial test at 30° flexion did not significantly differ between intact knees (p=.32) and after PLC sectioning (p=.15). After PLC reconstruction, the mLR technique was significantly less effective in restoring rotational stability than the VR and LPR techniques (p=.025).

DISCUSSION

The VR technique provided similar outcomes to LPR for restoring stability in varus and external rotation. The 2 "anatomic" reconstruction procedures (VR and LPR) were significantly more effective than the modified Larson technique for external rotation control, confirming the study hypothesis. Consequently, it remains preferable to use anatomic techniques in multiligament injuries involving the PLC.

LEVEL OF EVIDENCE

IV, cadaver study.

Consensus statement on data to be entered in the ACL tear registry: SFA-DataLake

INTRODUCTION

Anterior cruciate ligament (ACL) reconstruction is a frequent procedure, with room for improvement by rehabilitation measures and associated peripheral and meniscal surgeries that are currently under assessment, requiring follow-up. Outside France, there have been ACL registries for 20 years now. The French Arthroscopy Society (SFA) decided to set up an ACL tear registry within its SFA DataLake registry platform.

MATERIAL AND METHOD

This article presents the methodology underlying the ACL Tear Registry: i.e., identification, definition and coding of essential and relevant data. A test phase comprised an initial assessment to improve data quality and overall coherence, to optimize data-entry time for patients and practitioners, who are the guarantors of the registry's use and efficacy.

RESULTS

The SFA DataLake ACL Tear Registry was made available to SFA members in December 2021. It aims to enable a review of practices for surgeons, early detection of failure of procedures and implants, with rates of failure and abnormal complications, and identification of prognostic factors for outcome, especially regarding original items that do not figure in previous registries.

CONCLUSION

SFA DataLake strikes a balance between "indispensable" and "original" items. The choice of contents and data quality is founded on a robust methodology with overall coherence, enabling analysis of large cohorts and comparisons with the literature and other registries. However, it remains to assess rates of data entry and item relevance as the Registry progresses.

LEVEL OF EVIDENCE

IV.

The SFA datalake platform and anterior cruciate ligament tear registry of the French Society of Arthroscopy (SFA): Rationale, statutes and plans

SFA Datalake is the registry platform of the French Society of Arthroscopy (SFA). It was designed to collect and store data on arthroscopic orthopedic surgery and joint-sparing surgery in French-speaking countries. The anterior cruciate ligament (ACL) tear registry is the first registry to be set up based on SFA Datalake. Registries are intended to enable systematic standardized data collection, and provide information for surgeons to improve clinical practice and results. The ACL tear registry was designed in the light of guidelines, the literature and existing registries. Data are collected prospectively on a secure on-line application accessible via a computer or smartphone. Data collection is organized according to clinical examination results, preoperative findings, and follow-up data based on patient-administered subjective quality of life questionnaires. The pilot committee consists of 5 SFA board members, appointed for 2 years. LEVEL OF EVIDENCE: IV.

Survey of practices in surgical management of trapeziometacarpal osteoarthritis in France in 2020

The purpose of this study was to obtain an overview of French surgical practices for treating trapeziometacarpal osteoarthritis in 2020. An online survey was sent to 64 French hand surgeons: 32 authors of articles on carpometacarpal osteoarthritis of the thumb and 32 other surgeons randomly selected from the membership of the French Society of Hand Surgery (SFCM). The questions concerned demographic data, surgical practice, operative indications, choices for revision surgery, and eight clinical cases. The response rate was 56.2%. The most popular technique was trapeziometacarpal replacement (63.9%). During the previous 5 years, 31.6% of respondents had changed their practices, 69.2% of whom had adopted total joint replacement. Total trapeziectomy with ligamentoplasty and interposition was the second most frequent method. Most surgeons (77.8%) implemented medical treatment for 6 months to 1 year before resorting to surgery. In the clinical cases, agreement between surgeons was very low, with an overall inter-rater concordance coefficient of 0.182. Except for two cases (a young manual worker and a patient with a flattened trapezium) where no technique was significantly preferred, trapeziometacarpal replacement was chosen by a majority of respondents (p &lt; 0.001). It was the most frequently performed surgical technique in France in 2020. However, there is no real consensus on choice of technique, which reflects the absence of guidelines.

Coronal knee alignment measurements differ on long-standing radiographs vs. by navigation

BACKGROUND

The long-standing radiograph (LSR) is the reference tool for assessing knee alignment after total knee arthroplasty (TKA). However, its value is debatable, as many factors can influence measurement accuracy. Computer-assisted surgery (CAS) provides accurate measurements. Few studies have compared LSR and computer-assisted measurements of knee alignment. The objective of this study was to compare hip-knee-ankle (HKA) angle values obtained before and after TKA on LSRs to those obtained during CAS.

HYPOTHESIS

The HKA angle values measured on LSRs before and after surgery are identical to those measured during CAS.

MATERIAL AND METHODS

The HKA angles of 126 knees were measured on bipedal full-weight-bearing LSRs obtained before and 3 months after TKA. The results were compared to the values obtained during CAS.

RESULTS

Before surgery, the standard deviation was 2.672, with limits of agreement of {-5.391; + 5.082}. The intra-class coefficients were good for the overall measurements (0.9), good for detecting>10° varus (0.89), fair for<10° varus and valgus (0.66 and 0.71, respectively), poor for>10° valgus (0.43) and poor for normal alignment (0). Post-operatively, the standard deviation was 3.113, with limits of agreement of {-6.426; +5.776}. The intra-class coefficient was poor for the overall measurements (0.20), negative for normal alignment (-0.05) and<10° valgus (-0.05), and positive for<10° varus (0.017) and for>10° varus and valgus (0.33).

CONCLUSION

Before TKA, the LSR overestimates the deformity compared to CAS. After surgery, the two methods are not comparable. These findings underline the relevance of routinely obtaining LSRs and for using LSR results to estimate costs for healthcare insurance reimbursement purposes.

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

Coronal knee alignment measurements differ on long-standing radiographs vs. by navigation

BACKGROUND

The long-standing radiograph (LSR) is the reference tool for assessing knee alignment after total knee arthroplasty (TKA). However, its value is debatable, as many factors can influence measurement accuracy. Computer-assisted surgery (CAS) provides accurate measurements. Few studies have compared LSR and computer-assisted measurements of knee alignment. The objective of this study was to compare hip-knee-ankle (HKA) angle values obtained before and after TKA on LSRs to those obtained during CAS.

HYPOTHESIS

The HKA angle values measured on LSRs before and after surgery are identical to those measured during CAS.

MATERIAL AND METHODS

The HKA angles of 126 knees were measured on bipedal full-weight-bearing LSRs obtained before and 3 months after TKA. The results were compared to the values obtained during CAS.

RESULTS

Before surgery, the standard deviation was 2.672, with limits of agreement of {-5.391; + 5.082}. The intra-class coefficients were good for the overall measurements (0.9), good for detecting>10° varus (0.89), fair for<10° varus and valgus (0.66 and 0.71, respectively), poor for>10° valgus (0.43) and poor for normal alignment (0). Post-operatively, the standard deviation was 3.113, with limits of agreement of {-6.426; +5.776}. The intra-class coefficient was poor for the overall measurements (0.20), negative for normal alignment (-0.05) and<10° valgus (-0.05), and positive for<10° varus (0.017) and for>10° varus and valgus (0.33).

CONCLUSION

Before TKA, the LSR overestimates the deformity compared to CAS. After surgery, the two methods are not comparable. These findings underline the relevance of routinely obtaining LSRs and for using LSR results to estimate costs for healthcare insurance reimbursement purposes.

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

No Differences In Clinical Outcomes Between Rectangular and Round Tunnel Techniques For Anterior Crucial Ligament Reconstruction

PURPOSE

To compare the clinical outcomes between conventional round tunnel and rectangular tunnel in anatomic anterior cruciate ligament (ACL) reconstruction.

METHODS

This was a retrospective comparative cohort study between March 2015 and September 2018. The primary ACL reconstructions using anteromedial portal technique with minimum of 2 years follow-up were enrolled for this study. The exclusion criteria were patients with revision ACL reconstruction, high tibial osteotomy, multiligament injuries, and associated fractures around the knee. Outcome measures included the subjective International Knee Documentation Committee score, Tegner activity score, knee laxity testing, and measurement of the centers of the femoral and tibial tunnels on postoperative computed tomography (CT) images.

RESULTS

Forty-seven patients with ACL reconstruction with rectangular tunnel (group 1) and 108 patients with ACL reconstructions with conventional rounded tunnel (group 2) were included consecutively. There were no significant differences between groups in terms of clinical scores or knee laxity, as well as femoral and tibial tunnel positions on CT. One patient in group 2 had ACL failure because of trauma and was treated with revision surgery. Two patients had incomplete tibial fracture, but they healed spontaneously and showed no residual laxity at final follow-up. The intraobserver and interobserver reliability for the radiological measurements ranged from 0.78 to 0.86.

CONCLUSIONS

There were no differences in radiological and clinical results between rectangular tunnel group and conventional round tunnel group for arthroscopic ACL reconstruction. ACL reconstruction with a rectangular tunnel could be considered as a reliable technique, but care should be taken during tunnel establishment because of risk of fractures and malposition of rectangular tunnel.

Good medium-term functional results in reconstruction of lateral femoral condyle osteochondral lesions

INTRODUCTION

Results of autologous osteochondral graft (mosaicplasty) are well-reported for the medial femoral condyle but much less for the lateral femoral condyle. The main aim of the present study was to assess results specifically for lateral condyle reconstruction. The secondary objective was to compare results according to the two main etiologies: osteochondritis dissecans (OCD) and osteochondral fracture (OCF).

HYPOTHESIS

The study hypothesis was that medium-term functional and radiological results of lateral femoral condyle autologous osteochondral graft are good.

MATERIAL AND METHODS

A single-center retrospective continuous study included 24 patients with symptomatic focal lateral femoral condyle osteochondral lesion treated by osteochondral autograft, at a minimum 24 months' follow-up. Mosaicplasty was performed for lesions <200 mm², with associated fixation for lesions >200 mm² with viable osteochondral fragments. IKDC, Lysholm and KOOS functional scores and pain on visual analog scale (VAS) were collected at last follow-up. Progression toward osteoarthritis was assessed on comparative X-ray.

RESULTS

Twenty patients were analyzed (11 OCD, 9 OCF) at a mean of 66.4±44 months. Mean pain on VAS was 1.8±2 out of 10. Mean subjective IKDC, Lysholm and global KOOS scores were respectively 68.1±26, 76.5±22 and 73.9±21. Two patients showed Ahlbäck grade 2 lateral femorotibial osteoarthritis. Functional results were comparable between OCD and OCF.

CONCLUSION

Reconstruction of lateral femoral condyle osteochondral lesion by osteochondral autograft gave good medium-term functional results, whatever the etiology. Longer-term studies are needed to assess progression toward osteoarthritis and functional deterioration over time.

LEVEL OF EVIDENCE

IV; retrospective study.

Long-term functional outcomes of multiligament knee reconstructions with lateral injuries

INTRODUCTION

Multiligament knee injuries are a rare but serious injury, affecting functional prognosis. The objective of this study was to assess the long-term clinical and laximetric outcomes of acute or chronic multiligament knee reconstructions, with lateral impairment, using autografts.

HYPOTHESIS

Autograft reconstructions give good long-term clinical and laximetric results.

MATERIAL AND METHOD

A retrospective monocentric consecutive study was conducted in patients who had multiligament knee reconstructions. The criteria for inclusions were cruciate ligament lesions associated with lateral injuries, reconstructed using autografts, regardless of the time to surgery. A minimum follow-up of 5-years was required. Twenty-nine patients were analysed. The average age at surgery was 30.2±13 years. The patients were clinically reviewed at the last follow-up. Differential residual laxity was objectively assessed with comparative dynamic X-rays. Functional IKDC, Lysholm and KOOS scores were analyzed.

RESULTS

The average follow-up was 7.5±1.7 years. The lesions were divided into 12 KD-I, 16 KD-IIIL and 1 KD-IV, including 16 acute lesions (time to surgery <30-day) and 13 chronic lesions. At the last follow-up, the objective IKDC identified: 3 stage A, 15 stage B and 11 stage C. The average scores were: subjective IKDC 70.1±16, Lysholm 76.8±14 and KOOS: pain 71.6±20, symptoms 83.6±22, activity 90.6±20, sport 58.8±23, quality of life 60.0±30. Dynamic X-rays showed an average differential laxity of 2.8±2.6mm anteriorly, 5.0±2.2mm posteriorly, and 2.0±2.5mm in varus. Four cases required surgery: 3 arthrolysis procedures for stiffness and 1 joint lavage for sepsis.

DISCUSSION

With an average follow-up of 7.5 years, multiligament knee reconstructions using autografts with lateral involvement provide good long-term control of frontal and sagittal laxities. A comparison with allograft reconstructions is necessary to be able to potentially overcome the morbidity associated to donor sites.

LEVEL OF EVIDENCE

IV; monocentric retrospective descriptive study.

Total Knee Arthroplasty after Previous Ipsilateral Hip Arthroplasty Showed Lower Clinical Outcomes and Higher Leg Length Discrepancy Perception

The purpose of this study is to compare perception of leg length discrepancy (LLD) and clinical results of total knee arthroplasties (TKA) in patients with or without previous ipsilateral hip arthroplasty. Between 2008 and 2015, navigation-assisted TKA was performed in 43 patients with previous hip arthroplasty after hip fracture. After 1:3 propensity score matching was performed, 108 patients of primary navigation-assisted TKA (group 1) and 36 patients with hip arthroplasty (group 2) were included. Knee Society (KS) scores, Western Ontario and McMaster Universities Index (WOMAC) scores, and patients' satisfaction including perception of LLD were evaluated. Radiographic evaluation included mechanical axis, component position, and LLD. Logistic regression analysis was performed to find the factors that affect the clinical outcomes. No significant differences in radiologic and clinical evaluations, except for KS function score, patient's satisfaction and LLD (p< 0.001), were detected between the groups. LLD and its perception were significantly higher in group 2 (1.8 ± 3.4 mm in group 1 and 9.7 ± 4.1 mm in group 2, p = 0.000). Risk factors for the low KS function score were found as LLD (odds ratio [OR]: 1.403, p = 0.008) and previous hip arthroplasty itself (OR: 15.755, p = 0.002), but much higher OR was found in previous hip arthroplasty. Although the outcomes of TKA in patients with ipsilateral hip arthroplasty are comparable to those of primary TKA, LLD was high and patient's satisfaction and functional outcomes were low in patients with previous ipsilateral hip arthroplasty. Care should be taken when considering TKA in patients with previous hip arthroplasty. This is a Level III, case control study.

Management of acute knee dislocation with vascular injury: the use of the external fixator. A systematic review

INTRODUCTION

Vascular injuries after traumatic knee dislocation pose a potential limb threat for the patient. The benefits of external fixation have been described by many authors. However, the usefulness of the external fixator during acute management of knee dislocations with vascular injuries is a controversial aspect that has no consensus in the literature. The purpose of the present study was to provide data from the current literature on the utility of the external fixator and to investigate the percentage of knee dislocations with vascular injuries treated with an external fixator, the timing between external fixator and vascular repair, and the total time of external fixator.

MATERIAL AND METHODS

The present systematic review was conducted according to the PRISMA checklist. MEDLINE (Pubmed), Web of Science, and SCOPUS databases were searched for articles from 1 January 2000 to 6 February 2019. Studies reporting outcomes of treatment of knee dislocations with vascular injuries were included. Exclusion criteria included studies investigating chronic knee dislocations, knee arthroplasties, editorials, case reports, and expert opinions. Two authors independently extracted data and appraised the quality of evidence and risk of bias using the Methodological quality and synthesis of case series and case reports.

RESULTS

Descriptive statistics were used to report the outcome of our findings. Seven studies related to the usefulness of the external fixator during acute management of knee dislocations with vascular injuries were included. The external fixator had been used in the majority of knee dislocations with vascular lesions (72%). Timing between external fixator and vascular repair was reported on four studies (57%), two studies performed external fixation before vascular repair, and two studies performed external fixation after vascular repair. Total time of external fixator was only reported on three studies, ranging from 3 weeks to 3 months. These studies reported acute management, without referring to long-term results and without comparative groups.

CONCLUSIONS

External fixator was used in the majority of knee dislocations with vascular injuries but the justification for its use remained unclear. Larger studies are needed to fully understand the merit of the external fixator in knee dislocations with vascular injuries. Joint protocols between vascular surgeons and trauma surgeons are necessary to agree on the aspects related to the management of knee dislocations with vascular injuries.

LEVEL OF EVIDENCE

IV.

Méthodologies de la recherche en soins palliatifs : les défis de l’interdisciplinarité

AIM

This article aims to set some theoretical and practical milestones to better understand the challenges of interdisciplinary research in palliative care.

METHOD

A theoretical perspective of the main challenges of interdisciplinary research is provided through a review of existing literature, supported by practical experiences learnt from the implementation of two research projects on the improvement of the organization of healthcare services in palliative care in France.

RESULTS

Palliative care is historically and philosophically grounded in interdisciplinary culture. Implementation of interdisciplinary research in palliative care is particularly challenging as it implies engaging in a &#8220;paradigm dialogue&#8221; with different disciplines involved. Beyond the relational skills inherent in and required for actual interdisciplinary practice, interdisciplinary research calls for metacognitive skills such as the ability to search, identify, understand, connect and integrate theoretical and methodological perspectives of different disciplines.

CONCLUSION

Addressing the challenges of interdisciplinary research in palliative care requires an educational program that integrates an interdisciplinary approach at the early stage of the medical and healthcare curriculum. Paradigm dialogue should also be encouraged in national research and innovation programs.

Incidence of Associated Lesions of Multiligament Knee Injuries: A Systematic Review and Meta-analysis

Background:

The incidence of concomitant injuries, including meniscal and cartilage injuries, has not been adequately reported in previous studies on multiligament knee injury (MLKI) because their primary focal points have been the degree of ligament injury, treatment strategy, involvement of other soft tissues, and neurovascular injury.

Purpose:

To analyze the incidence of associated lesions in MLKIs, including medial and lateral meniscal injuries, cartilage lesions, and complications.

Study Design:

Systemic review; Level of evidence, 4.

Methods:

The PubMed, Embase, Cochrane Library, CINAHL, and Scopus databases were searched between inception and April 30, 2020. Studies were included if they reported the incidence rates of medial and/or lateral meniscal tears and cartilage injuries in cases of MLKIs. For the meta-analysis, data were extracted on clinical outcomes measured according to the number of medial and/or lateral meniscal tears, cartilage injuries, and complications.

Results:

A total of 45 studies were included in the MLKI analysis (3391 patients). The pooled rate of medial meniscal tears was 30.4% (95% CI, 24.1%-37.1%; P < .0001; I² = 85.8%). The pooled rate of lateral meniscal tears was 27.5% (95% CI, 20.3%-35.3%; P < .0001; I² = 89.6%). The pooled rate of cartilage injuries was 27.5% (95% CI, 22.1%-33.3%; P < .0001; I² = 86.8%). The pooled rates of peroneal nerve injuries, vascular injuries, and arthrofibrosis were 19.2% (95% CI, 14.2%-24.7%; P < .001; I² = 81.3%), 18.4% (95% CI, 13.2%-24.3%; P < .0001; I² = 81.0%), and 11.2% (95% CI, 8.1%-14.7%; P = .0018; I² = 54.0%), respectively.

Conclusion:

The pooled rates of meniscal tears and cartilage injuries concomitant with MLKIs were high, ranging from 27% to 30%, and the pooled rates of peroneal nerve injury, vascular injury, and arthrofibrosis were considerable, ranging from 11% to 19%. The influence of these associated lesions on clinical results should be evaluated in future clinical studies.

Incidence and Risk Factors for Residual High-Grade Pivot Shift After ACL Reconstruction With or Without a Lateral Extra-articular Tenodesis

Background

Residual rotatory knee laxity at midterm follow-up after isolated anterior cruciate ligament reconstruction (ACLR) versus ACLR with lateral extra-articular tenodesis (LET) remains an issue.

Purpose/Hypothesis

To evaluate the outcomes of ACLR with or without additional LET at a minimum 2-year follow-up in patients with preoperative high-grade pivot shift (PS). Our hypothesis was that the addition of LET would decrease the risk of secondary meniscal injury and the presence of residual high-grade PS at follow-up.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective analysis performed at 3 sports medicine centers identified 266 study patients; all had a high-grade PS (grade 2 or 3) preoperatively and underwent isolated ACLR with or without LET. Four different ACLR techniques were used: single-strand quadrupled semitendinosus (ST4) ACLR without LET (ST4 group; n = 55), ST4 with anatomic LET (ST4+LET group; n = 77), bone-patellar tendon and modified Lemaire LET (BTB+LET group; n = 43), and quadriceps tendon and modified Lemaire LET (QT+LET group; n = 91). At follow-up, we evaluated for the presence of high-grade (grade ≥2) PS. Preoperative meniscal tears and their treatment were recorded.

Results

Overall, 185 (69.5%) patients had at least 1 meniscal tear at index surgery. The mean follow-up period was 44.3 months; 47 (17.7%) patients had a new meniscal tear and 64 (24%) patients had a high-grade PS at follow-up. Compared with meniscal repair, significant predictors for high-grade PS at follow-up were meniscectomy (odds ratio [OR] = 2.65 [95% CI, 1.19-5.63]; P = .02) and nonrepair of preoperative meniscal tear (OR = 3.26 [95% CI, 1.27-9.43]; P = .007). The appearance of a new symptomatic meniscal tear was the strongest significant predictor of high-grade PS at follow-up (OR = 4.31 [95% CI, 2.31-8.06]; P < .001). No significant correlation was observed between the addition of LET and the presence of high-grade PS at follow-up.

Conclusion

In the current study, 1 in 4 patients with high-grade PS before ACLR with or without LET was at risk of residual rotatory knee laxity at mean 44-month follow-up, regardless of the technique used. Repairing a pre-existing meniscal lesion was more effective than performing LET to decrease the presence of a high-grade PS at follow-up.

Litigation in arthroscopic surgery: a 20-year analysis of legal actions in France

PURPOSE

The main objective of this study was to identify the epidemiological characteristics of litigation following arthroscopic procedures, performed in private practice and public hospitals in France. The secondary objective was to establish a risk profile for medical malpractice lawsuits after arthroscopic surgery.

METHODS

All court decisions related to arthroscopic surgery between 1994 and 2020 were collected and reviewed cases from the two main French legal databases (Legifrance and Doctrine). Data were retrospectively collected and included: gender, joint and defendant's specialty involved, reason behind the lawsuit, initial indication and the type of arthroscopic procedure performed. The final verdicts as well as the indemnity awarded to the plaintiff (if any) were recorded.

RESULTS

One-hundred eighty cases met the inclusion criteria of the study and were analyzed: 58 cases were before administrative courts and 122 were before civil courts. An orthopaedic surgeon was involved alone or in solidum in 45.6% of cases (82/180), followed by anesthesiologists in 5.6% (10/180). The private surgery center or public hospital were implicated in 63.9% (115/180) of cases. The 2 most common joints involved in litigation following arthroscopic surgery were the knee (82.2%, n = 148) and the shoulder (11.1%, n = 20). The main reasons behind the lawsuit were related to postoperative infection in 78/180 cases and to a musculoskeletal complication in 45/180 cases (25%). A failure to inform was also reported in 34/180 cases (18.9%). Of the 180 cases, 122 cases (67.8%) resulted in a verdict for the plaintiff. The average indemnity award for the plaintiff was 77.984 euros [2.282-1.117.667]. A verdict for the plaintiff was significantly associated with postoperative infection or a wrong-side surgery, while technical error and musculoskeletal complications were more significantly likely to result in a verdict in favor of the defendant (p = 0.003).

CONCLUSION

This study evaluated and mapped lawsuits following after arthroscopic surgery in France over a period of more than 20 years. The main joint involved in lawsuits was knee. The main causes of lawsuits following arthroscopic surgery were related to postoperative infection, musculoskeletal complications and failure to inform.

LEVEL OF EVIDENCE

Level IV.

Does intermeniscal ligament tenodesis affect meniscal allograft extrusion? Retrospective comparative study at a minimum follow-up of 2 years

INTRODUCTION

Meniscal allograft transplantation (MAT) is indicated for the treatment of post-meniscectomy syndrome in young patients who do not have severe cartilage loss. While its clinical effectiveness is well established in the short- and mid-term, it does not appear to stop the progression of osteoarthritis. Meniscal extrusion often occurs early on and is irreversible. The aim of this study was to evaluate results of arthroscopic MAT combined with reconstruction of the intermeniscal ligament (IML).

HYPOTHESIS

Concurrent reconstruction of the IML decreases the incidence of early allograft extrusion when compared to conventional soft-tissue techniques.

MATERIALS AND METHODS

This was a retrospective single-centre comparative study of 55 patients operated between 2011 and 2018. The 34 patients who met the inclusion criteria were divided into two subgroups: the IML group (MAT with IML repair, n=14) and the non-IML group (MAT without IML repair, n=20). Clinical outcomes consisted of the KOOS at the last follow-up visit and the surgical revision rate. MRI was performed at a minimum of 12 months (mean 34±25 months) to determine absolute and relative meniscal extrusion, sagittal anterior and posterior extrusion, and cartilage coverage in the frontal and sagittal planes.

RESULTS

The KOOS score was not significantly different between the two groups. There were no reoperations in the IML group, but there were four in the non-IML group (13%) (p=0.13). Meniscal extrusion of the allograft occurred in 43% of patients (6/14) in the IML group versus 85% (17/20) in the non-IML group (p<0.03). Absolute meniscal extrusion was 2.9mm ([2.2-3.6] SD=1.2) in the ILM group versus 5.4 mm ([4.1-6.7] SD=2.9) (p=0.004) in the non-ILM group.

DISCUSSION

Adding ILM tenodesis or reconstruction can significantly limit early extrusion of the meniscal allograft. Clinical outcomes at a mean of 34 months are not different when compared to standard procedure. These patients should be re-evaluated in the long term to determine whether the incidence of osteoarthritis is lower with ILM tenodesis.

LEVEL OF EVIDENCE

III; case-control study.

Functional outcome of osteochondral autograft is equivalent in stable knee and in anterior cruciate ligament reconstruction

INTRODUCTION

Anterior cruciate ligament (ACL) tears are associated in 10% to 20% of cases with extensive traumatic focal osteochondral damage. Ligament reconstruction may require osteochondral autograft for symptomatic osteochondral lesions. Combined ACL and chondral or osteochondral reconstruction is poorly evaluated in the literature; osteochondral reconstruction in stable knee better documented. The objective of this study was to compare functional results after osteochondral autograft transfer (OAT) for significant symptomatic femoral condyle defect, in stable or stabilised knees (concomitant ACL reconstruction). The hypothesis was that functional results are equivalent in both groups.

MATERIAL & METHOD

This was a single-centre retrospective comparative observational study of patients consecutively operated on between 2000 and 2018. Fifty patients met the inclusion criteria and were divided into two groups: Group 1 (OAT+ACL, n=13) and group 2 (OAT on stable knee, n=37). The following criteria were recorded at follow-up: pain (VAS), KOOS, IKDC and Lysholm scores and Hughston radiologic score, and time to return to sport. Mean follow-up was 79.7±60 months in group 1 and 86.4±62 months in group 2.

RESULTS

Ten patients were included for analysis in group 1 and 30 in group 2. Cartilage lesion size was comparable between groups: 1.6±1.20 cm² for group 1 and 2.3±1.3 cm² for group 2 (ns). One complication (infection with favourable course) was observed in group 2. Sport was resumed at 8.7±2.7 vs. 8.4±3.3 months, respectively. Mean subjective scores were respectively 83.3±7.4 and 75.4±14 for Lysholm, 89.7±7.8 and 89.7±19.6 for KOOS, 78±13.7 and 72.2±12.9 for subjective IKDC, 0.5±0.5 and 0.8±0.9 for pain on VAS and 3 and 3 for radiological Hughston radiologic score, with no significant differences between groups.

CONCLUSION

Symptomatic focal osteochondral lesions treated by osteochondral autograft transfer gives the same outcome on stable or stabilised knee.

LEVEL OF EVIDENCE

IV; retrospective study.

Evaluation of the "Minimal Clinically Important Difference" (MCID) of the KOOS, KSS and SF-12 scores after open-wedge high tibial osteotomy

PURPOSE

Defining a Minimal Clinically Important Difference (MCID) value for Patient-Reported Outcome Measures (PROMs) is crucial for determining the effectiveness of a procedure and calculating the sample size for trial planning. The purpose of this study was to determine the MCID of several PROMs (Knee injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) and the SF-12) in patients who underwent medial opening-wedge High-Tibial Osteotomy (owHTO) with Patient-Specific Cutting Guides (PSCGs), using anchor-based methods.

METHODS

Patients undergoing isolated medial owHTO with PSCGs between January 2013 and January 2017 were enrolled in this single-center, prospective, observational study. Three outcome scores were collected pre-operatively and at the 2 years follow-up evaluation: KOOS, KSS and SF-12. The MCIDs were calculated using anchor-based method: at 2 years postoperatively: "Compared with before surgery, how would you rate operated joint now?" The responses were recorded using a five-point scale. Patients who answered "about the same" or "somewhat worse" were classified into the no change group, while those who answered "somewhat better" were classified into the minimal change group. A receiver operating characteristic (ROC) curve was used to define the cutoff point that best discriminated between the minimal change and no change groups for each PROMs RESULTS: 196 patients were included, 75 (somewhat better) and 24 patients (about the same and somewhat worse) were, respectively, assigned to the "no change" and "minimal change" groups. There was no significant difference between the two groups in terms of baseline characteristics and postoperative complications. At 24 months follow-up all the PROMs (KOOS, KSS and SF-12) were significantly better for the "minimal change" group compared to the "no change" group. MCID was 15.4 for KOOS pain, 15.1 for KOOS symptoms, 17 for KOOS ADL, 11.2 for KOOS sports/recreation, 16.5 for KOOS QQL, 3 for KSS symptoms, 5.6 for KSS activity, 7.2 for SF-12 physical component and 6.3 for PCS mental component.

CONCLUSION

This study determined the MCIDs of common used PROMs in patients undergoing owHTO.

LEVEL OF EVIDENCE

Prospective Cohort Study, Level II.

Feasibility of arthroscopic decompression of the axillary nerve in the quadrilateral space: Cadaver study

INTRODUCTION

Axillary nerve compression is a rare, but disabling condition. The three main causes are quadrilateral space syndrome among young athletes, compression due to an inferior glenohumeral osteophyte in early osteoarthritis and isolated teres minor atrophy secondary to triceps hypertrophy. The diagnosis is clinical, but may be reinforced by an electromyogram or corticosteroid injection. The usual surgical treatment is open nerve decompression using a posterior approach. Arthroscopy is a less invasive approach that should be useful in theory.

HYPOTHESIS

Arthroscopic decompression of the axillary nerve is safe and less invasive than open techniques.

MATERIAL AND METHODS

Arthroscopic nerve decompression was performed as described by PJ Millet and TR Gaskill on 10 shoulders from 6 frozen cadavers. An open posterior approach was then made to verify the effectiveness of the nerve decompression.

RESULTS

The axillary nerve and its branches, the circumflex artery and the triceps were always sufficiently released in the space below the joint capsule. When the joints were subsequently opened by a posterior approach, complete nerve decompression was confirmed in all cases with no iatrogenic lesions.

DISCUSSION

The good results of this study are encouraging, but should be supplemented with a comparative study in patients of open versus arthroscopic axillary nerve release.

CONCLUSION

We think this arthroscopic technique is a good option for treating axillary nerve compressions. The complication risk is expected to be low.

LEVEL OF EVIDENCE

IV.

A systematic review comparing the results of early vs delayed ligament surgeries in single anterior cruciate ligament and multiligament knee injuries

PURPOSE

The purpose of this study was to compare clinical outcomes and incidence of concomitant injuries in patients undergoing early vs delayed surgical treatment of single anterior cruciate ligament (ACL) injury and multiligament knee injury (MLKI).

METHODS

A literature search using PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health, and Scopus from their inception to April 30, 2020 was conducted. Studies with levels I to IV evidence reporting the incidence of meniscus or cartilage injury according to early vs delayed surgery in single ACL injuries and MLKIs were included. In the meta-analysis, data based on the number of meniscus and cartilage injuries were extracted and pooled. Lysholm and Tegner scores were analyzed using two-sample Z-tests to calculate the non-weighted mean difference (NMD). A meta-regression analysis was also performed to determine the effect of single ACL injury and MLKI/study design.

RESULTS

Sixteen studies on single ACL injury and 14 studies on MLKI were included in this analysis. In the analysis, there were significant decreases in Lysholm score (NMD - 5.3 [95% confidence interval (CI) - 7.37 to - 3.23]) and Tegner score (NMD - 0.25 [95% CI - 0.45 to - 0.05]) and increases in risk of meniscus tear (odds ratio [OR] 1.73 [95% CI 1.1-2.73], p = 0.01) and cartilage injury (OR 2.48 [95% CI 1.46-4.2], p = 0.0007) in the delayed surgery group regardless of single ACL injury or MLKI. The result of the meta-regression analysis indicated that single ACL injury and MLKI/study design were not significant moderators of overall heterogeneity (p > 0.05).

CONCLUSIONS

Our study suggests that delayed ACL surgery significantly resulted in a higher risk of meniscus tear and cartilage injury and decreased Lysholm and Tegner scores compared to early ACL surgery. The Lysholm scores in the delayed MLKI surgery group were significantly decreased, but the risks of meniscus tear and cartilage injury in the delayed MLKI surgery group remained unclear.

LEVEL OF EVIDENCE

Level III, meta-analysis.

The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation

PURPOSE

To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique.

METHODS

A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three.

RESULTS

Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction.

CONCLUSION

A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification.

LEVEL OF EVIDENCE

Level V.

The use of an asymmetrical tibial tray in TKA optimises tibial rotation when fitted to the posterior tibial plateau border

PURPOSE

The aim of this study was to evaluate the suitability of positioning an asymmetrical tibial tray relative to the posterior tibial edge and to analyse the relationship between the posterior fit and tibial rotation after computer-assisted total knee arthroplasty (TKA). It was hypothesised that an asymmetrical tray would adjust to the posterior border of the tibial plateau with proper tibial rotation.

METHODS

Ninety-three consecutive knees underwent total knee arthroplasty using a Persona fixed-bearing system (63 varus deformities and 30 valgus deformities) and a 3-month follow-up CT scan. An independent examiner measured different variables: the femoral angle between the clinical epicondylar axis and the posterior condylar line of the femoral component, the tibial angle between the posterior borders of the tibial tray and the tibial plateau, and the tibial rotation with respect to the femoral component. These measurements were also compared between varus and valgus subgroups.

RESULTS

For the varus and valgus subgroups, the mean postoperative femoral angle was 2.1º ± 1.2º and 2.5º ± 1.0º, respectively (n.s.). The mean posterior fitting angle of the tibial tray was 0.1º ± 2.4º and 1.4º ± 3.2º for the varus and valgus subgroups, respectively, with a significant difference between groups (p = 0.03). The tibial rotations with respect to the femoral component for the varus and valgus groups were 0.9º ± 3.3º and 2.2º ± 3.1º of external rotation, respectively (n.s.).

CONCLUSIONS

This study demonstrated that fitting an asymmetrical tibial tray to the posterior border of the tibial plateau could optimise tibial rotation. The posterior border was considered to be a reliable and easily identifiable landmark for proper tibial rotation and coverage during a primary TKA.

LEVEL OF EVIDENCE

IV.

Predictive factors for failure of anterior cruciate ligament reconstruction via the trans-tibial technique

INTRODUCTION

Factors for graft failure after trans-tibial (TT) ACL reconstruction, including anterolateral ligament (ALL) injury and degree of synovialization, remain unclear. This study is to evaluate the risk factors for graft failures after TT ACL reconstruction including ALL injury and synovialization.

MATERIALS AND METHODS

A total 391 patients who underwent primary TT ACL reconstruction were included. Failure was defined as greater than grade 2 laxity on the Lachman or pivot shift tests or 5 mm of anterior translation on stress radiograph. After applying inclusion/exclusion criteria, 31 patients with failure were categorized as group 1 and 89 patients without failure were categorized as group 2. Chi-square test and Cox proportional hazard analyses were performed.

RESULTS

Preoperatively, 64 patients had ALL injuries (53.3%), 58 had medial meniscal (MM) tears (48.3%), and 62 had lateral meniscal (LM) tears (51.6%). Ninety-three patients (77.5%) had acute injuries and 27 had chronic injuries as per 6-weeks duration. Significant risk factors for failure were LM tear (hazard ratio [HR], 4.018; 95% confidence interval [CI] 1.677-9.629; p = 0.002), chronicity (HR, 6.812; 95% CI 2.758-16.824; p = 0.000), presence of ALL injury (HR, 3.655; 95% CI 1.442-9.265; p = 0.006), and poor synovialization (HR, 3.134; 95% CI 1.298-7.566; p = 0.011) in Cox proportional hazard analysis. If combined MM and LM tears were found, an increased risk of failure was also identified (combined tears: HR, 3.951; 95% CI 1.754-8.901; p = 0.001/preoperative high-grade laxity: HR, 4.546; 95% CI 1.875-11.02; p = 0.001).

CONCLUSION

Chronic ACL injuries, meniscus tear, preoperative ALL injuries, preoperative high-grade laxity and poor synovialization are significant risk factors. Therefore, these factors should be carefully assessed and properly treated in TT ACL reconstruction.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Multiligament knee injuries treated by one-stage reconstruction using allograft: Postoperative laxity assessment using stress radiography and clinical outcomes

BACKGROUND

Surgical treatment of multiligament knee injuries (MLKIs) leads to better outcomes but there are controversies about optimal surgical strategies. Debates remain about timing of surgery: acute, staged or delayed and about graft choice: autograft, allograft or a combination of both. Therefore, we performed a retrospective study aiming to evaluate postoperative laxity using stress radiographs and clinical outcomes after one-stage reconstructions of injured ligaments using non-irradiated, fresh-frozen allografts.

HYPOTHESIS

MLKIs treated by one-stage reconstructions using non-irradiated, fresh-frozen allograft may lead to satisfactorily postoperative laxity and clinical outcomes.

METHODS

Between November 2013 and July 2015, 23 patients with MLKIs underwent one-stage reconstruction using allograft. Knee injuries were defined according Schenk classification of Knee Dislocation (KD). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, and the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form at a minimum follow-up of 24 months. Postoperative anterior, posterior, varus, and valgus laxities were assessed using stress radiographs and expressed as side-to-side differences (SSD) in millimeters.

RESULTS

Three of 23 patients were lost to follow-up. There were 6 KD-I, 12 KD-III, and 2 KD-IV lesions, 12 lateral-side and 10 medial-side lesions, and 13 acute and 7 chronic cases. Three patients had associated neurovascular injuries. Mean follow-up was at 29.4±6.1 months. Mean valgus SSD was 0.2mm±1.4mm (range, -2.1-2.2mm), mean varus SSD was 1.4mm±2.5mm (range, -1.7-6.0mm), mean posterior SSD was 7.2mm±3.9mm (range, 1.2-16.0mm), mean anterior SSD was 3.6mm±5.1mm (range, -4.8-16.8mm). Overall IKDC ratings were: 4 grade A, 3B, 7C, and 6D. Three patients complained of postoperative instability, with an IKDC rating of D. The mean subjective IKDC score was 67.2±19.6, the mean Lysholm Knee Scoring Scale was 77.3±16.5, and the mean KOOS results were 78.5±16.6 for pain, 67.7±17.4 for symptoms, 86.5±14.2 for daily activities, 56±25.4 for sports, and 47.2±28.6 for quality of life. Nineteen of 20 patients returned to sport-6 to the same level. One patient underwent an arthroscopic arthrolysis due to postoperative arthrofibrosis.

CONCLUSIONS

Using non-irradiated allografts for one-stage reconstructions of all the injured ligaments in MLKIs is effective and safe. Anteroposterior stability was difficult to restore, but patients returned to their daily activities and sometimes to their sports activity at the same preinjury level.

LEVEL OF EVIDENCE

Level IV, case series.

Polyurethane Meniscal Scaffold for the Treatment of Partial Meniscal Deficiency: 5-Year Follow-up Outcomes: A European Multicentric Study

BACKGROUND

A biodegradable polyurethane scaffold was developed to treat patients with the challenging clinical condition of painful partial meniscal defects.

HYPOTHESIS

The use of an acellular polyurethane scaffold in patients with symptomatic partial meniscal defects would result in both midterm pain relief and improved function.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 155 patients with symptomatic partial meniscal defects (101 medial and 54 lateral) were implanted with a polyurethane scaffold in a prospective, single-arm, multicentric study with a minimum 5-year follow-up. Clinical outcomes were measured with the visual analog scale for pain, International Knee Documentation Committee subjective knee evaluation form, Lysholm knee scale, and Knee injury and Osteoarthritis Outcome Score at baseline and at 2- and 5-year follow-ups. Magnetic resonance imaging (MRI) was used to evaluate the knee joint, meniscal implant, and meniscal extrusion. Kaplan-Meier survival analysis was also performed. Removal of the scaffold, conversion to a meniscal transplant, and unicompartmental/total knee arthroplasty were used as endpoints.

RESULTS

Eighteen patients were lost to follow-up (11.6%). The patients who were included in this study showed significant clinical improvement after surgery as indicated by the different outcome measures (P = .01). However, the clinical improvement tended to stabilize between 2 and 5 years of follow-up. MRI scans of the scaffolds in 56 patients showed a smaller-sized implant in the majority of the cases when compared with the native meniscus with an irregular surface at the 5-year follow-up. During the follow-up period, 87.6% of the implants survived in this study. At 5 years of follow-up, 87.9% of the medial scaffolds were still functioning versus 86.9% of the lateral scaffolds. In total, 23 treatments had failed: 10 removed scaffolds because of breakage, 7 conversions to meniscal allograft transplantation, 4 conversions to unicompartmental knee arthroplasty, and 2 conversions to total knee arthroplasty.

CONCLUSION

The polyurethane meniscal implant was able to improve knee joint function and reduce pain in patients with segmental meniscal deficiency over 5 years after implantation. The MRI appearance of this scaffold was different from the original meniscal tissue at the midterm follow-up. The treatment survival rates of 87.9% of the medial scaffolds and 86.9% of the lateral scaffolds in the present study compared favorably with those published concerning meniscal allograft transplantation after total meniscectomy.

Very long-term osteoarthritis rate after anterior cruciate ligament reconstruction: 182 cases with 22-year' follow-up

BACKGROUND

Few data are available on the 20-year outcomes of anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to assess the prevalence and risk factors of knee osteoarthritis at least 20 years after ACL reconstruction.

HYPOTHESIS

Factors associated with progression to knee osteoarthritis include meniscal lesions, level of physical activity, injury-to-surgery time, body mass index, residual laxity, tunnel position and cartilage injury.

MATERIAL AND METHODS

One hundred and eighty two patients were included in a multicentre retrospective study conducted in the setting of a SoFCOT symposium. Females contributed two-thirds of the study population. ACL reconstruction was performed arthroscopically in 82% of cases, and a bone-patellar tendon-bone transplant was used in 92.8% of cases. Mean age at surgery was 26±7years. Clinical outcomes were assessed based on the objective and subjective IKDC scores and on the KOOS. Radiographic evidence of osteoarthritis was classified according to the IKDC. Factors evaluated for their ability to predict progression to osteoarthritis included age, sex, body mass index, level of physical activity, injury-to-surgery time, meniscectomy, cartilage injury, tunnel position and residual laxity.

RESULTS

At last follow-up, the objective IKDC score was A (normal) for 48%, B for 35%, and C or D for 17% of the knees. The mean subjective IKDC score was 82.7±13.1. Moderate-to-severe osteoarthritis was present in 29% of cases. The following risk factors for osteoarthritis were identified: medial or lateral meniscectomy, residual laxity, age >30years at surgery, and engaging in a pivoting sport. Meniscectomy was a major contributor to the development of osteoarthritis (17% of knees without vs. 46% with meniscectomy). Finally, the ACL re-tear rate was 13%.

CONCLUSION

ACL reconstruction provides satisfactory knee stability. The risk of subsequent osteoarthritis depends chiefly on the status of the menisci. Residual laxity is also associated with the development of osteoarthritis.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Repair of large condylar osteochondral defects of the knee by collagen scaffold. Minimum two-year outcomes

INTRODUCTION

Collagen scaffolds are a good surgical option for covering large focal osteochondral defects in the knee. In the recent literature there is a wide range of patient profiles and chondral defect treatments (chondral and osteochondral defects, associated procedures, etc.). The aim of the present study was to evaluate clinical and imaging outcomes with collagen scaffolds and to assess any correlation between medium-term clinical outcome and MRI features. The hypothesis was that there is no correlation between clinical outcome and MRI after 2 years postoperatively.

MATERIAL AND METHODS

A single-center retrospective observational study included all patients receiving a MaioRegen® scaffold for large painful focal osteochondral defect of the femoral condyle. There were 17 patients, with a mean age of 28±9 years. Defect locations comprised 12 medial femoral condyles, 4 lateral femoral condyles and 1 lateral tibial plateau. Mean defect area was 4.5±1.4cm². All patients were evaluated clinically and on KOOS and objective and subjective IKDC scales, with MRI at last follow-up.

RESULTS

At a mean follow-up of 46±17 months, mean subjective IKDC was 67.8±23; KOOS scores were: symptoms, 78±22; pain, 78±23; function, 85±20; sports, 66±27; and activities of daily living, 59±25. MRI MOCART score revealed incomplete scaffold healing in 21.4% of cases, with variable signal intensity within regenerated tissue. Functional scores did not correlate with reconstruction aspect on MRI.

DISCUSSION/CONCLUSION

3D collagen scaffolds yield good medium-term clinical outcomes in large osteochondral defects of the knee. There is, however, a discrepancy between MRI features of the recipient site and objective and subjective clinical scores. These scaffolds may be a good option for treating large focal osteochondral defects in knees of young patients, but MRI does not provide satisfactory medium-term assessment.

Meniscal Allograft Transplantation With Soft-Tissue Fixation Including the Anterior Intermeniscal Ligament

Meniscal allograft transplantation has been introduced as a treatment for symptomatic meniscus-deficient patients to improve clinical outcomes. We describe an arthroscopic technique for meniscal allograft with soft-tissue fixation including the anterior intermeniscal ligament (AIML): arthroscopic double soft-tissue fixation technique. The AIML and anterior and posterior roots are detached and sutured using running locked Krackow stitches. After preparation of the meniscal bed, the meniscus is passed into the knee and the posterior meniscal horn is fixed with sutures through bone tunnels. The body of the meniscus is fixed with all-inside sutures. Then, the anterior meniscal suture is fixed on the anatomic point of the anterior root with an anchor. The AIML suture is fixed with an anchor to the bare area of the proximal tibia, anterior to the anterior cruciate ligament insertion. This reliable and reproducible technique is less complex than bone plug methods; it is less invasive but still provides stable and secure graft fixation. It will help surgeons to improve clinical results and to limit early secondary extrusion of the graft.

Functional and anatomical outcomes of single-stage arthroscopic bimeniscal replacement

BACKGROUND

Meniscal replacement by an allograft or scaffold has been proven effective in patients with post-meniscectomy pain syndrome. Replacement of both menisci is a rarely performed procedure about which little is known. The primary objective of this work was to assess the functional outcomes of arthroscopic bimeniscal replacement. The secondary objectives were to evaluate meniscal healing and the time-course of cartilage lesions.

HYPOTHESIS

Single-stage arthroscopic bimeniscal replacement provides good functional and anatomical outcomes, similar to those seen after replacement of a single meniscus, in adults with post-meniscectomy pain syndrome.

MATERIAL AND METHODS

Five patients received regular follow-up after single-stage arthroscopic bimeniscal replacement by an allograft and/or substitute, with or without concomitant anterior cruciate ligament reconstruction. Median follow-up was 30 months (range, 24-68 months). Radiographs and magnetic resonance imaging scans of the knee obtained before surgery and at last follow-up were evaluated. The following parameters were recorded: KOOS and IKDC score, knee osteoarthritis, knee alignment, condition of the cartilage, healing of the meniscal replacement material, meniscal extrusion, and other complications.

RESULTS

Allografts were used to replace both menisci in 3 patients, whereas 2 patients received a lateral allograft and a medial scaffold. The median subjective IKDC score was 83.9 (range, 55.1-94.3) and the median objective IKDC score was B (range, A-C). The median global KOOS was 85.7 (range, 65.7-92.3). Extrusion occurred for one medial and two lateral menisci.

CONCLUSION

Bimeniscal replacement by an allograft and/or substitute provides good short-term functional and anatomical outcomes. Nevertheless, this procedure is warranted only in highly selected patients.

LEVEL OF EVIDENCE

IV, retrospective study.

Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017

INTRODUCTION

In 2008, the French National Authority for Health (HAS) recommended that "conservative" treatments be adopted for meniscal lesions. This recommendation and the lack of superiority of meniscectomy over non-operative treatment for meniscus degeneration have modified the treatment pathway. However, the impact of these findings on French clinical practice is not known. The objective of this study was to evaluate the change over time in the number of alternative surgical procedures (meniscectomy and meniscus repair) and regional variation in France using data from the French agency for information on hospital care (ATIH).

HYPOTHESIS

We hypothesized that the number of meniscectomy procedures will decrease, and the number of repair procedures will increase over time at various healthcare facilities.

PATIENTS AND METHODS

Between 2005 and 2017, the number of hospitalizations in the Medicine-Surgery-Obstetrics wards for meniscectomy (NFFC003 and NFCC004) or meniscus repair (NFEC001 and NFEC002) was evaluated overall and then based on whether the stay occurred in public or private sector hospitals in France. Data were extracted from the ATIH database and the findings were (1) related to French demographics during the period in question; (2) separated into public or private sector hospitals; (3) distributed into various regions in France and; (4) stratified by patient age.

RESULTS

Between 2005 and 2017, 1,564,461 meniscectomy and 63,142 meniscus repair procedures were done in France. Over this period in the entire country, the meniscectomy rate gradually decreased from 19.80/10,000 inhabitants in 2005 to 15.77/10,000 inhabitants in 2017 (21.4% reduction) (p<0.0001) while the meniscus repair rate increased from 0.42/10,000 inhabitants in 2005 to 1.36/10,000 inhabitants in 2017 (320% increase) (p<0.0001). The largest meniscectomy reduction effort occurred in private sector hospitals, going from 15.79 to 12.01/10,000 inhabitants in 12 years; the decrease was smaller in public hospitals (going from 4.01 to 3.77/10,000 inhabitants) (p<0.0001 in both cases). The change in the procedure ratio between private and public hospitals was asymmetric, with the meniscus repair/meniscectomy ratio clearly increasing more in public hospitals (4% to 12.6%) between 2005 and 2017 than in private hospitals (1.6% to 6.6%) (p<0.0001). We found large regional differences: regions in Eastern France had higher meniscectomy rates, while regions in Western France had higher meniscus repair rates. When the analysis of procedures between 2008 and 2017 was stratified by age, a similar increase in repair procedures was found in all age brackets. Conversely, the reduction in meniscectomy was most apparent before 40 years of age, and the number of meniscectomy procedures was stable after 60 years of age.

CONCLUSION

These findings suggest there has been a significant shift in the surgical management of meniscal injuries towards more conservative treatments. But the large variations between regions in France is evidence of a continued disparity in clinical practices.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

A model of guided cell self-organization for rapid and spontaneous formation of functional vessels

Most achievements to engineer blood vessels are based on multiple-step manipulations such as manual sheet rolling or sequential cell seeding followed by scaffold degradation. Here, we propose a one-step strategy using a microfluidic coextrusion device to produce mature functional blood vessels. A hollow alginate hydrogel tube is internally coated with extracellular matrix to direct the self-assembly of a mixture of endothelial cells (ECs) and smooth muscle cells (SMCs). The resulting vascular structure has the correct configuration of lumen, an inner lining of ECs, and outer sheath of SMCs. These "vesseloids" reach homeostasis within a day and exhibit the following properties expected for functional vessels (i) quiescence, (ii) perfusability, and (iii) contractility in response to vasoconstrictor agents. Together, these findings provide an original and simple strategy to generate functional artificial vessels and pave the way for further developments in vascular graft and tissue engineering and for deciphering the angiogenesis process.

Neither significant osteoarthritic changes nor deteriorating subjective outcomes occur after hybrid fixation of osteochondritis dissecans in the young adult

PURPOSE

The goal of the fixation of painful osteochondritis dissecans of the femoral condyles in adults is to integrate the osteochondral fragment and thus achieve a normal hyaline cartilaginous coverage. The addition of a biological process to primary fixation may result in improved fragment integration (hybrid fixation). Osteochondral plugs may fulfil this role. The aim of this study was to evaluate long-term clinical and radiological results after hybrid fixation of unstable osteochondritis dissecans. The hypothesis was that the rate of secondary osteoarthritis would be low.

METHODS

Nine patients treated by hybrid fixation were retrospectively reviewed at a median follow-up of 10.1 years (range 7-14). The median age at surgery was 21 (range 17-28). Six of them were evaluated as ICRS grade II and three, as ICRS grade III. The mean surface of the lesion was 4.5 cm². All patients were followed up clinically (IKDC, KOOS, Lysholm) and radiologically [Kellgren-Lawrence score (KL)].

RESULTS

During arthroscopic assessment at the time of screw removal (3 months after surgery), the fragments were stable, and autograft plugs were all well integrated. At the most recent follow-up visit, the median IKDC score was 85.8 (range 51.72-100), the KOOS score was 87.7 (52.4-100), and the Lysholm scale score was 89.8 (77-100). In 7 out of 9 patients, radiographs showed a joint space KL grade of 0 or 1.

CONCLUSION

Hybrid fixation for treating osteochondritis dissecans lesions of the femoral condyles using mechanical and biological fixation provides healing of the osteochondral fragments with good long-term outcomes. No significant osteoarthritic change was seen with this technique at a mid-term follow-up.

LEVEL OF EVIDENCE

IV-case series.

Experimental study of the susceptibility of a European Aedes albopictus strain to dengue virus under a simulated Mediterranean temperature regime

Dengue virus (DENV) has re-emerged in Europe driven by the geographic expansion of the mosquito species Aedes albopictus and Aedes aegypti (Diptera: Culicidae) and the introduction of the virus by viraemic travellers. In the present study, the vector competence (VC) of Ae. albopictus collected in Catalonia (northeast Spain) was evaluated for two different DENV strains, DENV-1 and DENV-2, the serotypes responsible for all outbreaks of dengue that have occurred in Europe. Mosquitoes were reared under environmental conditions mimicking the mean temperature and humidity recorded in July on the Mediterranean coast of Catalonia. Mosquitoes were fed on an artificial infectious bloodmeal and, at 14 days post-exposure, infection, disseminated infection and transmission rates (IR, DIR, TR) and transmission efficiency (TE) were determined by testing the virus in the body, legs and saliva. The tested Ae. albopictus strain was found to be susceptible to both DENV-1 and DENV-2 and to be able to transmit DENV-1. This is the first time that the VC of Ae. albopictus for DENV has been tested in Europe in this specific context (i.e. mimicking the Mediterranean temperature and humidity recorded in Catalonia in July). This study confirms the potential of Ae. albopictus to start autochthonous DENV transmission cycles in the Mediterranean basin.