Pelvic floor muscle training: mechanisms of action for the improvement of genitourinary syndrome of menopause.

Objective: This study aims to investigate the mechanism of action of pelvic floor muscle training (PFMT) for the improvement of the signs and symptoms of genitourinary syndrome of menopause (GSM) in postmenopausal women with GSM and urinary incontinence (UI).Methods: Twenty-nine women were included in the secondary analysis of a single-arm feasibility study. Using color Doppler ultrasound, the peak systolic velocity, time-averaged maximum velocity, and pulsatility index of the internal pudendal and dorsal clitoral arteries were measured at rest and after a pelvic floor muscle (PFM) contraction task. PFM function was assessed by dynamometry, and vulvovaginal tissue elasticity was measured using the Vaginal Atrophy Index.Results: PFMT significantly improved blood flow parameters in both arteries (p < 0.05) and significantly increased the speed of PFM relaxation after a contraction (p = 0.003). After the intervention, a marginally significant decrease in PFM tone was observed, as well as an increase in PFM strength (p = 0.060 and p = 0.051, respectively). Finally, improvements in skin elasticity and introitus width were observed as measured by the Vaginal Atrophy Index (p < 0.007).Conclusion: Our findings suggest that PFMT improves blood flow in vulvovaginal tissues, PFM relaxation capacity, and vulvovaginal tissue elasticity in postmenopausal women with GSM and UI.

Validation of a French patient-reported outcome measure for patello-femoral disorders: The Lille Patello-Femoral Score.

BACKGROUND: The diagnosis of patello-femoral instability (PFI) relies chiefly on the patient's clinical findings. Nevertheless, few clinical scores specifically designed to evaluate the patello-femoral joint are available. The Lille scoring system is a 12-item self-questionnaire yielding a score from 0 to 100 that is used in France but has not been validated. We therefore conducted a validation study in a population of younger patients with PFI. HYPOTHESIS: The Lille scoring system meets validation criteria for patient-reported outcome measures (PROMs). MATERIAL AND METHOD: A retrospective study done in two centres identified 136 patients with objective (n=109) or potential (n=27) PFI. Before and after surgery, the Lille score was determined by all patients and the Kujala score in 61 patients. The Lille score was also determined by 30 controls free of patello-femoral disorders to allow an evaluation of discrimination between PFI and other knee disorders in individuals of similar age. RESULTS: The response rate was 100%, indicating that the Lille questionnaire was easy to complete. Consistency was established: (a) the global score showed no floor or ceiling effect (in no questionnaires were over 85% of items given the highest or lowest possible score), and saturation occurred neither for the global score nor for the item sub-scores (fewer than 85% of patients had the lowest or highest possible score); (b) a single redundancy was found, between the items 'pain' and 'locking', for which the correlation coefficient was≥0.7 (P<0.0001). Discriminating performance was assessed by comparing the mean Lille score values in the controls (67.8±9.2) and patients (38.1±10.4); the difference was significant (P<0.05) and the estimated effect size was>0.8, indicating strong discrimination by the Lille scoring system. Item uniformity, with all items measuring the same phenomenon, was established by the Cronbach alpha coefficient value>0.7. External consistency between the Lille and Kujala scoring systems was confirmed in the 61 patients for whom both scores were available (Pearson correlation coefficient, 0.5). Sensitivity to change was established by the>0.8 effect size of surgical treatment. DISCUSSION: The Lille scoring system deserves to be used routinely in clinical practice as a patient-reported outcome measure. A prospective study will assess intra-observer reproducibility and sensitivity to change in patients treated non-operatively. Although confined to retrospective data, this study based on methods designed to assess PROMs establishes the validity of the Lille scoring system and supports its use in PFI. LEVEL OF EVIDENCE: III, case-control design.

Sulcus deepening trochleoplasty for patellofemoral instability: A series of 34 cases after 15 years postoperative follow-up.

INTRODUCTION: Trochlear dysplasia is one of the main elements of patellofemoral instability. Although correction by trochleoplasty seems logical, the long-term outcome of this procedure is unknown and the progression to osteoarthritis has not been clarified. Thus, we performed a retrospective study of a series of sulcus deepening trochleoplasties with a 15-year follow-up whose goal was to (1) evaluate the long-term clinical outcome and radiological rate of osteoarthritis, and (2) define the results in relation to the type of instability and the grade of dysplasia. HYPOTHESIS: Sulcus deepening trochleoplasty is an effective procedure to stabilize the patellofemoral joint that does not increase the risk of osteoarthritis. PATIENTS AND METHODS: This retrospective study analyzed 34 sulcus deepening trochleoplasties based on clinical scores (IKS, Lille, Kujala and Oxford scores) and radiological results (stage of osteoarthritis according to the Iwano score) after a mean follow-up of 15 years (12-19 years). An Insall procedure was systematically associated with an anterior tibial tubercle transfer in 17 cases (7 prior tibial transfers). RESULTS: No recurrent objective instability was observed. Seven knees had additional surgery after a mean follow-up of 7 years (2-16): 7 underwent conversion to total knee arthroplasty because of progression of osteoarthritis and one knee had tibial tubercle transfer for pain and episodes of the knee giving way. The mean Lille, Kujala and IKS scores increased from 53.3 (30-92), 55 (13-75) and 127 (54-184) to 61.5 (25-93), 76 (51-94) and 152.4 (66-200) respectively between preoperative and follow-up assessment (P<0.05) (revisions included). Functional outcome was significantly better for dysplasia with supratrochlear spurs (IKS score 168 [127-200] versus 153 [98-198] and Kujula score 81.5 [51-98] versus 76 [51-94] [P<0.05]). Patients were satisfied in 65% of the cases and the total mean Oxford score was 24.1/60 (12-45 points). Occasional pain was present in 53% of the cases. The trochlear prominence decreased from 4.9 mm (3-9 mm) to -1.2mm (-7-4mm). Ten cases of preoperative patellofemoral osteoarthritis were identified, but none with>Iwano 2, while osteoarthritis was present in 33/34 cases at the final follow-up with 20 cases>Iwano 2 (65%). DISCUSSION: Sulcus deepening trochleoplasty corrects patellofemoral stability even in patients with severe dysplasia and the long-term functional outcome is better in this group. It does not prevent patellofemoral osteoarthritis. It should be limited to severe dysplasia with supratrochlear spurs and associated with procedures to realign the extensor apparatus.

Opening wedge high tibial osteotomy performed without filling the defect but with locking plate fixation (TomoFix™) and early weight-bearing: prospective evaluation of bone union, precision and maintenance of correction in 51 cases.

INTRODUCTION: A medial opening wedge high tibial osteotomy (HTO), where the osteotomy site is filled, is often preferred to a lateral closing osteotomy, but filling the defect can lead to certain complications. HYPOTHESIS: A medial opening HTO can be performed without filling the bone defect if fixation is carried out with a specially-designed stiff locking plate. PATIENTS AND METHODS: Fifty-one patients, 37 to 72 years of age where followed prospectively and continuously from 2003 to 2006. A single surgical technique was used: medial opening HTO with locked plate fixation (TomoFix™, Synthes) but without filling the defect. The preoperative genu varum could not exceed 15°. The following were evaluated: time to return to weight-bearing, IKS functional score, long-leg standing film performed preoperative, postoperative and at follow-up to evaluate limb alignment and validate the precision of the correction and its stability over time. A measurement of the area of bone union in the osteotomy site was used to quantify the rate of union. RESULTS: Bone union occurred at 4.5 months on average; two cases of incomplete union (7%) were found and revised with an autograft at 7 and 9 months. Lower-limb alignment was 7.5° of varus on average before surgery (3° to 15° varus, SD=2.85) and 1.2° of valgus on average after the surgery (4° varus to 5° valgus, SD=1.78). The correction was maintained at 1 year post-surgery. The average IKS knee score went from 69±15.5 (range 25 to 96) before surgery to 90±7.4 (range 66 to 98) at follow-up (P=0.0001). Full weight-bearing without assistance was possible after 3 months on average (range 1.5 to 8, SD=1.21). Forty-seven patients (92%) were fully weight-bearing after 2 months. Forty-eight patients were able to return to work and sporting activities at the same or a higher level than before the procedure. DISCUSSION: Bone union seems to happen more slowly when the defect is filled; however, there are doubts about radiological evaluation of bone union in different published studies. When osteotomy defect was left unfilled in this study, union and filling of 4/5 of the osteotomy site was obtained in 4.2 months for 49 of the 51 cases. Fixation with the locking plate is reliable and provides stable correction and the option for early weight-bearing.

Proximal tibial derotation osteotomy for torsional tibial deformities generating patello-femoral disorders.

INTRODUCTION: Torsional abnormalities of the leg may cause instability and pain in the patellofemoral joint. Although derotation osteotomies seem logical to address these conditions, there are very few surgical results reported in the literature. HYPOTHESIS: Isolated tibial derotation osteotomies relieve patellofemoral pain and instability even in the event of combined femoral and tibial torsion abnormalities. AIM: Test this hypothesis in a retrospective and continuous series of thirty-six tibial derotation osteotomies and define the factors of success and failure. PATIENTS AND METHODS: Thirty-six derotation osteotomies of the proximal tibial metaphysis were performed between 1995 and 2006 in 29 patients (five men and 24 women, an average of 26.5 years old±7.4 (18-44)) followed-up for a mean 4.7 years. There was confirmed patellar instability in five knees, and patellofemoral pain without instability in 31. A proximal metaphyseal osteotomy was performed to correct excessive external tibial rotation as well as to recenter the tibial tubercle after anterior tibial cortex elevation. All patients were followed-up and the clinical data were analysed according to criteria from the Lille score [specifically designed for patellofemoral joints (100 point score)] and the IKS score. All patients had a preoperative radiological evaluation [(including measurement of torsion abnormalities in 32 cases by computed tomodensitometry (CT scan))]. The mean preoperative external tibial torsion measured on CT scan was 36.2°±9.48 (26-51°) and the mean femoral anteversion was 19.4°±9.5 (8-36°). RESULTS: Twenty-seven patients (94%) were satisfied or very satisfied. The Lille score increased from 54.8±16.9 (30-92) preoperatively to 85.2±14.2 (36-100) at follow-up. The mean IKS knee scores and function increased from 56±14.8 (45-94) to 94±12.1 (60-100) and from 71±18.4 (30-100)-96±11.9 (50-100). Patellofemoral dislocations did not occur in any of the five cases with instability. Mean derotation was 25° measured with a mean tibial torsion measured clinically at follow-up 8.6°±7.2 (0-30). Two reoperations were necessary, (one knee manipulation under general anesthesia, and in another the fibular fibrous arch had to be released). One case of regressive palsy of the common fibular nerve was observed. Union of the osteotomy was obtained in all patients. DISCUSSION: This series is one of the largest series published to date. Isolated medialization of the anterior tibial tubercle only partially corrects these morphological abnormalities. In cases of associated excessive femoral anteversion we recommend surgery to the tibia alone because results were comparable in groups with and without excessive anteversion of the femoral neck. LEVEL OF EVIDENCE: level IV. Retrospective study.

Knee arthodesis using a modular customized intramedullary nail.

INTRODUCTION: Arthrodesis of the knee, particularly in infectious situations, can be achieved using either an external fixator or an intramedullary device. The objective of this study is to report the clinical, functional, and radiographic outcomes of a continuous series of 19 cases of knee arthrodesis using a customized modular intramedullary nailing system. HYPOTHESIS: The modular intramedullary nail offers a satisfactory functional result while maintaining limb length, in spite of a nonunion risk, since acting like a true endoprosthesis. MATERIAL AND METHODS: In our retrospective series of 19 patients, the main source of patients were infected total knee replacements. The nail was customized from assembling a dual surface-sanded titanium component (femoral and tibial). The Lequesne Algofunctional score and the WOMAC score were recorded, as well as the length discrepancy between the lower extremities. Arthrodesis consolidation and the nail's fit in the shaft were verified on anterior-posterior (AP) and lateral radiographs. RESULTS: Five complications were observed: one anterior cortical break, one excessive tibial rotation, two cases of delayed union, and one nail revision due to residual nail instability. The postoperative Lequesne Algofunctional score was 13/24 and the WOMAC score 57/100. The nonunion rate was 32%. From a functional point of view, the patients who did not achieve complete union and those who did had similar scores. The subjective results were not as good in patients who did not achieve final consolidation. DISCUSSION: Modular intramedullary nailing simplifies the technique, shortens the procedure, and reduces the amount of blood loss at surgery. Our nonunion rate was high, although the functional result did not seem compromised by such nonunion. The risk of long-term implant failure was not studied and requires longer follow-up studies. LEVEL OF EVIDENCE: Level IV therapeutic study.

Total knee arthroplasty in valgus knees: predictive preoperative parameters influencing a constrained design selection.

INTRODUCTION: In valgus knees, ligament balance might remain a challenge at total knee prostheses implantation; this leads some authors to systematically propose the use of constrained devices (constrained condylar knee or hinge types...). It is possible to adapt the selected level of constraints, by reserving higher constraints to cases where it is not possible to obtain final satisfactory balance: less than 5 degrees of residual frontal laxity in extension in each compartment, and a tibiofemoral gap difference not in excess to 3 mm between flexion and extension. HYPOTHESIS: It is possible to establish preoperative criteria that can predict a constrained design prosthetic implantation at surgery. MATERIALS AND METHODS: A consecutive series of 93 total knee prostheses, implanted to treat a valgus deformity of more than 5 degrees was retrospectively analysed. Preoperatively, full weight bearing long axis AP views A-P were performed: hip knee angle (HKA) averaged 195 degrees (186 degrees to 226 degrees), 36 knees had more than 15 degrees of valgus, and 19 others more than 20 degrees of valgus. Laxity was measured by stress radiographies with a Telos system at 100 N. Fifty-two knees had preoperative laxity in the coronal plane of more than 10 degrees. Fourteen knees had more than 5 degrees laxity on the convex (medial) side, 21 knees had more than 10 degrees laxity on the concave (lateral) side. Statistical assessment, using univariate analysis, identified the factors that led, at surgery, to an elevated constraint selection level; these factors of independence were tested by multivariate analysis. Logistical regression permitted the classification of the said factors by their odds ratios (OR). RESULTS: High-constraints prostheses (CCK type) numbered 26 out of 93 implantations; the other total knee prostheses were regular posterostabilized (PS) prostheses. Statistically, the preoperative factors that led to the choice of a constrained prosthesis were: (1) valgus severity as measured by HKA (PS=193 degrees, CCK=198 degrees), (2) increased posterior tibial slope (PS=4.8 degrees, CCK=6.5 degrees), (3) low patellar height (using Blackburne and Peel index PS=0.89, CCK=0.77), (4) severity of laxity in valgus (PS=2.3 degrees, CCK=4.3 degrees). Among all these factors, the only independent one was laxity in valgus (convex side laxity) (p=0.0008). OR analysis showed a two-fold increased probability of implanting an elevated constraints prosthesis for each one degree increment of laxity in valgus. DISCUSSION: This study demonstrated that it was not the valgus angle severity but rather the convex medial side laxity that increased the frequency of constrained prostheses implantation. Other factors, as a low patellar height or an elevated posterior tibial slope, when associated, potentiate this possible prosthetic switch (to higher constraints) and should make surgeons aware, in these situations, of encountering difficulties when establishing ligament balance. LEVEL OF EVIDENCE IV: Therapeutic retrospective study.

What is the role of the physical medicine and rehabilitation unit after total knee arthroplasty? Clinical practice recommendations.

OBJECTIVES: To develop clinical practice guidelines concerning the interest of post-operative rehabilitation in physical medicine and functional rehabilitation (PMR) ward after total knee arthroplasty (TKA). METHOD: The SOFMER (French Physical Medicine and Rehabilitation Society) methodology, associating a systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, was used. Main outcomes were impairment, disability, medico-economic implications and postoperative complications. RESULTS: Post-operative rehabilitation in a PMR ward after TKA is recommended for patients because of preoperative joint stiffness, and/or associated co-morbidities. The other parameters used by French physician for post-operative rehabilitation in a PMR ward after TKA are: the self-governing of the patient at home, the wishes of the patient and the opinion of the surgeon on the post-operative functional evolution of the patients. For patients in whom sustained rehabilitation is not necessary but who cannot return home, a stay in a non-specific (non-PMR) post-operative centre could be recommended. Post-operative rehabilitation in a PMR ward after TKA could reduce the length of stay in a surgical ward and increase the functional status of patients with co-morbidities. Studies with good methodological quality are needed to evaluate the cost/benefit ratio in the French health care system. CONCLUSION: This study suggests a value of rehabilitation in a PMR ward after TKA, but good methodological quality studies are needed to evaluate the cost/benefit ratio of rehabilitation in a PMR ward after TKA in the French health care system.

[Patellar reconstruction during total knee arthroplasty after previous patellectomy]. / Reconstruction patellaire au cours d'une arthroplastie totale sur genou patellectomisé

PURPOSE OF THE STUDY: In order to limit the consequences of prior total patellectomy on knee function after total knee arthroplasty, we propose an original technique using an en bloc patellar graft to reconstruct the quadriceps lever arm. The purpose of this work was to describe the technique and present preliminary results obtained in seven patients. PATIENTS AND METHODS: Seven en bloc patellar grafts were performed in seven patients (6 women and 1 man) during total knee arthroplasty procedures for femorotibial degenerative joint disease after prior patellectectomy (mean 13 years before arthroplasty, range 5-20 years). We implanted three posterior stabilized prostheses, one ultracongruent prosthesis, two prostheses preserving the posterior cruciate ligament, and one bi-cruciate prosthesis. The patella was reconstructed with an autologous bone graft fashioned from the tibial plateau in six cases, and with a homologous graft fashioned from a bone-bank femoral head in one. Transosseous sutures were used to fix the graft to the extensor system. A polyethylene button was cemented on five of the grafts. RESULTS: Active extension was defective in five knees prior to the patellar graft and in only one knee after patellar reconstruction. The IKS knee score improved from 41 points (range 35-45) before surgery to 78 points (range 55-95) after grafting and the IKS function score from 35 (range 5-50) to 72 (range 40-100). Four of the seven grafts were removed (eight weeks to five years after implantation, mean two years) mainly due to failure of fixation leading to progressive migration. Follow-up varied from eight weeks to six years. Mean follow-up for the three grafts still in place was 4.6 years (4-6 years). After removing the patellar graft (4 knees) the IKS knee score decreased to 68 points (20-95) and the IKS function score to 62 points (30-100). Lack of active extension reappeared in three of the knees after removing the patellar graft but was not observed in the three knees with the patellar graft in place (and flexion was at least 110 degrees ). Microradiography of the patellar graft explanted after two years revealed peripheral corticalization with areas of living bone tissue seen on the pathology specimens. Inversely, the autografts explanted at eight weeks and at five years exhibited bone necrosis. CONCLUSION: This preliminary study shows that patellar autograft can improve the performance of total knee arthroplasty on patellectomized knees. The fixation technique must be improved using transosseous transverse sutures in addition to peripheral sutures in order to limit secondary migration of the graft. A patellar autograft fixed into the extensor system can remain viable two years after implantation. This technique can be proposed when total knee arthroplasty is indicated for a patellectomized knee, particularly in patients with lack of active extension.

[Management of stiffness after total knee arthroplasty: indication for different mobility management in 62 cases]. / Traitement des raideurs sur prothèse totale du genou: indication des différents gestes mobilisateurs à propos de 62 cas.

PURPOSE OF THE STUDY: Stiffness of the knee is a common reason for revision of total knee arthroplasty. Three methods are currently used to mobilize the knee: manipulation under general anesthesia, arthroscopic release, open surgical release. The purpose of the present work was to determine the respective indications of these three procedures in a large single-center study. MATERIAL AND METHODS: We retrospectively assessed all revision procedures without component exchange in patients with a stiff total knee prosthesis. Sixty-two procedures were performed in our institution between 1989 and 2001. All patients were followed for at least one year. There were 34 manipulations under general anesthesia, 18 arthroscopic release procedures, and 10 open surgical release procedures. The three groups were not different for all parameters studied except time interval between implantation of the prosthesis and the mobilization procedure: 17 weeks for manipulation under general anesthesia, 46 weeks for arthroscopic release, 97 weeks for surgical release. A comparable postoperative analgesia and rehabilitation program was instituted for all patients. RESULTS: Range of flexion improved after all 62 procedures: mean 58.4 degrees before the procedure, mean 94.6 degrees at one-year follow-up. Flexion deformity also improved from 7.6 degrees to 2.5 degrees at one year (p=0.001). From surgery to one-year follow-up, there was a decrease in flexion (104.6 degrees to 94.6 degrees ) and an increase in flexion deformity (1.3 degrees to 2.5 degrees ) (NS). The worst postoperative ranges of motion were observed at six weeks after the procedure. Improvement was then observed up to six months but was not significant. There was no improvement in flexion beyond six months after the mobilization procedure. The results of the three techniques were not significantly different. Failures were however more frequent when manipulation under anesthesia was performed more than eight weeks after prosthetic insertion, and when arthroscopic release was performed more than six months after prosthetic insertion (p<0.01). DISCUSSION AND CONCLUSION: We recommend treatment of stiff total knee prosthesis by manipulation under general anesthesis if the procedure is performed less than eight weeks after implantation; a delay of six weeks is even better because intraoperative complications were observed for patients treated between six and eight weeks. Between eight weeks and six months, arthroscopic release should be advised, surgical release thereafter. Whatever the delay, this protocol is appropriate for stiff knee prostheses without infection and without component malposition. Whatever procedure is applied, the definite range of motion is reached six months after the intervention.

MR imaging of the knee at 0.2 and 1.5 T: correlation with surgery.

OBJECTIVE: The purpose of this study was to compare the diagnostic efficacy of low- and high-field-strength MR imagers in the diagnosis of anterior cruciate ligament tears and meniscus tears. SUBJECTS AND METHODS: In 219 patients with suspected internal derangement of the knee, MR imaging at 0.2 and 1.5 T was performed with similar sequences. Only patients with surgically confirmed diagnosis (n = 90) were included in the statistical analysis. Radiologists were unaware of diagnosis and field strength. Sensitivity, specificity, diagnostic accuracy, and inter- and intraobserver variability were determined. RESULTS: There was excellent correlation between the field strengths in accuracy, sensitivity, and specificity for anterior cruciate ligament and meniscus tears. Accuracy for medial meniscus, lateral meniscus, and anterior cruciate ligament tears was 91-93%, 88-90%, and 93-96%, respectively, at 0.2 T and 91-94%, 91-93%, and 97-98%, respectively, at 1.5 T. Inter- and intraobserver variability values showed excellent correlation (kappa > 0.8). CONCLUSION: The level of diagnostic accuracy in anterior cruciate ligament tears and meniscus tears is comparable for low- and high-field-strength MR imagers.

[Reliability of the KT-1000 arthrometer in measuring anterior laxity of the knee: comparative analysis with Telos of 48 reconstructions of the anterior cruciate ligament and intra- and interobserver reproducibility]. / Fiabilité de l'arthromètre KT-1000 pour la mesure de la laxité antérieure du genou: analyse comparative avec le Telos de 48 reconstructions du ligament croisé antérieur et reproductibilité intra- et interobservateurs.

PURPOSE OF THE STUDY: The goal of this study was to compare KT-1000 and Telos measurements after anterior cruciate ligament reconstruction (ACLR). MATERIAL AND METHOD: Forty eight patients with asymptomatic ACLR (4 failures with positive pivot shift and 12 knees with positive (+) Lachman test) were assessed (mean 2.5 years after surgery) by the same examiner by means of: 1) Lachman radiographic with Telos at 150 N, 2) MEDmetric KT-1000 at 69 N, 89 N and maxi-manuel (MM). The examiner tested more than 200 patients each year. Measurements were performed for KT-1000 according to the manufacturers' recommendations and for Telos according to Staübli. Only side to side differences in millimeters are reported. Reproducibility of KT-1000 measurements were also evaluated: interobserver reproducibility was assessed by 16 examiners on a healthy patient, and the experienced examiner tested 20 times a healthy patient. RESULTS: An Interobserver error of 4 mm range (+/- 2 mm related to 0) was observed by 12 to 44 p. 100 of the examiners, respectively at 69 N to MM. An intraobserver error of 4 mm range (+/- 2 mm related to 0) was observed in 10 p. 100 at MM and in 20 p. 100 at 89 N. Mean side to side laxity with KT-1000 was 0.93 mm +/- 1.1 [-1 to 5] at 69 N, 1.3 mm +/- 1.6 [-2 to 6] at 89 N, and 1.41 +/- 1.8 [-2 to 6] at MM. With Telos the mean side to side laxity was 3.95 mm +/- 3.84 [0 to 15]. Significant differences (p = 0.0001) were found between measurements obtained by the two methods. No statistical correlation could be detected between values observed by Telos and KT-1000 (R < 0.1). If we consider a 3 mm side to side difference 23 knees (48 p. 100) had abnormal anterior laxity with Telos and with KT-1000 only 3 (6.2 p. 100) at 89 N and 6 (12.5 p. 100) at MM (1 (2 p. 100) at 69 N). With a 5 mm side to side difference, 12 knees (25 p. 100) had abnormal anterior laxity with Telos and with KT-1000 only 1 (2 p. 100) at 89 N and 1 (2 p. 100) at MM (0 at 69 N). Only Telos measurements were correlated to positive pivot shift (p = 0.007) and positive Lachman test (p = 0.01). CONCLUSION: Interobserver reproducibility of KT-1000 measurements was low, but improved for intraobserver agreement. However, even for a unique KT-1000 experienced examiner, reliability of KT-1000 was poor when comparing Telos and KT-1000 predicitive value to diagnose ACLR failure. Telos results were much more pejorative but the only ones corelated with ACLR failures. We recommand Telos instead of KT-1000 to assess laxity after ACLR.

[Laxity and functional results of Miller-Galante total knee prosthesis with posterior cruciate ligament sparing after a 6-year follow-up]. / Laxité et résultat fonctionnel des prothèses totales de genou Miller-Galante conservant le ligament croisé postérieur après 6 ans de recul.

PURPOSE OF THE STUDY: The preservation of the posterior cruciate ligament (PCL) was introduced in total knee arthroplasty to improve the quadriceps efficiency and the range of flexion in stairs. The purpose of this study was to determine if these goals were achieved with the Miller-Galante total knee prothesis and to assess the relation between knee laxity and function. MATERIALS AND METHOD: We assessed retrospectively the results of 48 consecutive Miller-Galante with PCL retaining. Four patients were excluded: 2 died, 2 lost to follow-up. Forty-four prostheses were evaluated in 38 patients mean aged 65 (33-79). The preoperative HSS score was 41 +/- 12.4 [21-63]. All the components were cemented with patellar resurfacing (25 metal-backed, 19 polyethylene). Stressed X-rays with Telos device were performed to assess frontal and antero-posterior laxity. All radiographic measurements were carried out with a digitizer (Orthographics). RESULTS: After 6 years of follow-up, 8 prostheses (18.1 p. 100) were already revised because of: 1) 3 excessive anterior tibial translations and severe polyethylene wear; 2) 5 femoro-patellar disorders. These last 5 knees (4 patellar metal-backed) had a greater patellar thickness [(25 mm +/- 1.2) (p = 0.01)]. The mean HSS knee score for the 36 remaining prostheses was 73.8 +/- 11.3 (35-92). Only 5 patients were able to climb stairs without support. The mean mechanical axis was 2.3 degrees in varus, but 81 percent of the knees were at 5 degrees around neutral position. The mean laxity in valgus was 4 degrees +/- 2.3 degrees [1-10], and 4.1 degrees +/- 2.1 degrees [1-9] in varus. The mean anterior tibial translation was 5.3 mm +/- 5 [1-17] and posterior laxity was 4.7 mm +/- 2.5 [1-10]. HSS knee score was lowered by 9 points when frontal laxity (valgus + varus) was greater than 5 degrees (p = 0.01), and by 9.8 points when posterior laxity was 5 mm or more (p = 0.02). The mean thickness of the patella was 22 mm +/- 2.3 [16-27]. DISCUSSION: These results were unsatisfactory considering the high revision rate and the low functional score observed despite of a correct implant positioning. The major challenge for PCL retaining (i.e. free stair climbing) was achieved in few cases. The wide range of posterior laxity underlined the difficulties to control PCL tension. On the other hand, PCL tension has to be controlled as it could influence knee function. Patello-femoral disorders was the main reason for revision surgery and an insufficient patellar bone resection may be contributive. Sagittal anterior laxity was the second reason for revision and it should be carefully detected as it could drive to catastrophic polyethylene wear. CONCLUSION: The advantages of PCL retaining were not demonstrated with this low constrained design. Surgical control of PCL tension could give a wide range of posterior laxity. Sagittal femoral-tibial laxity and femoro-patellar disorders should be detected before severe polyethylene wear. These results advocates for: 1) more congruent designs with PCL retaining or for PCL substituting designs, 2) improvement of patello-femoral design.

Inter- and intraobserver reproducibility in radiographic diagnosis and classification of femoral trochlear dysplasia.

Dejour's radiographic criteria are commonly used to diagnose and assess femoral trochlear dysplasia in case of patello-femoral instability. The aim of this study was to establish the intra- and interobserver reliability of these radiographic criteria. Sixty-eight lateral knee radiographs were examined independently by 7 observers (2 juniors, 5 seniors) to assess interobserver agreement, and the 2 juniors repeated the observations to test intraobserver agreement. These 68 true lateral views were harvested from clinical records of 64 patients who underwent a trochleoplasty because of patellofemoral instability. To evaluate the agreement on analytic data (morphologic type of trochlea) we used the kappa statistical method, and to evaluate the agreement on numerical data (depth and prominence of the trochlear groove) we used interclass correlation analysis. The "crossing sign" (between the trochlear groove and the anterior aspect of both condyles) was reliable since the probability of rating as normal a pathologic trochlea was only 3.1% (0 to 8.8%). In classifying trochlear morphology interobserver agreement was slight (kappa = 0.17) and intraobserver agreement was fair (kappa = 0.3). On the other hand, the measurements of the depth and prominence of the trochlear groove were more reliable since the interclass coefficients between observers were 0.62 and 0.38 respectively. The most frequent interobserver error was related to misdiagnosis of type II. To clarify Dejour's criteria we propose a diagnosis of type II only when 5 mm or more are measured between the intersections with the medial and lateral femoral condyles. We recommend the use of the prominence of the trochlear groove to evaluate the grade of bony trochlear dysplasia.

[Malignant melanoma of soft tissues. Apropos of a case]. / Le mélanome malin des tissus mous. A propos d'une observation.

A case of malignant melanoma of the quadriceps tendon is reported. This is an uncommon soft tissue sarcoma of melanocytic origin. The appearance on MRI depends on its melanin content. The microscopic appearance is distinctive and prognosis is poor. This tumor should be kept in mind when a nodular lesion is detected in specific tendon or aponeurosis.

[Reproducibility of the radiographic analysis of dysplasia of the femoral trochlea. Intra- and interobserver analysis of 68 knees]. / Reproductibilité de l'analyse radiographique de la dysplasie de la trochlée fémorale. Analyse intra- et interobservateur sur 68 genoux.

PURPOSE OF THE STUDY: The relation between patello-femoral instability and trochlear dysplasia was identified by Dejour. Trochlear dysplasia, diagnosed on knee lateral Xray when the trochlear groove crosses both femoral condyles (the so-called "crossing sign"), must be corrected to improve patello-femoral stability. However surgery should be related to the severity and the shape of trochlear dysplasia, underlining the importance of a reproducible classification. The aim of this study was to establish intra and inter-observer reliability of Dejour's radiographic criteria. MATERIAL: 68 preoperative exact knee profile radiographs were harvested from clinical records of 64 patients who underwent trochleoplasty because of patello-femoral instability and trochlear dysplasia. On these 68 views, the crossing sign was identified by the senior surgeon (F.G.) who performed or supervised surgery. METHOD: The 68 radiographs were examined independently by 7 observers (2 juniors, 5 seniors) in order to assess interobserver agreement. Two juniors repeated the observation to test intraobserver agreement. Reproducibility for categorical data (7 shapes of trochlea according to Dejour (3 for dysplasia)) was evaluated by Kappa statistics, and for numerical data (depth and anterior projection of the trochlear groove with respect to anterior femoral cortex) we used the interclass correlation analysis. RESULTS: Two out of the 7 observers rated all the 68 trochleas as dysplastics. The 5 others rated as normal 1 to 6 trochleas out of the 68. None of the 68 trochleas were recognized with the same shape by the 7 examiners. At best, 6 observers agreed on the same shape and for only 12 trochleas. Disagreement was mostly related to mistakes between type I and type II of dysplasia. For trochlear morphology interobserver agreement was slight (Kappa = 0.17) and intraobserver agreement was fair (Kappa = 0.3). The mean prominence of the trochlea was 3 +/- 2.1 mm [-6 to 10], and the mean trochlea depth was 1 +/- 1.9 mm [0 to 11]. These measurements were more reliable since the interclass correlation coefficients were respectively 0.62 and 0.38. The level of experience of the observers had no influence for categorical or numerical data. DISCUSSION: Our results indicated a low interobserver agreement for trochlear shape identification according to Dejour. The most reliable criteria was measurement of the trochlear prominence which was mostly pathological in our series. The "crossing sign" was reliable to diagnose dysplasia since the probability to rate as normal a true dysplastic trochlea was only 3.1 per cent. However, once the dysplasia diagnosed, this classification gave inconsistent results to select the trochlear shape, particularly for type II. To improve reproducibility we propose to diagnose a type II only when 5 millimeters separate the crossings between the medial and lateral condyles. CONCLUSION: We recommend to use anterior projection of the trochlear groove to rate trochlear dysplasia and to determine the adequate type of trochleoplasty: elevating of the lateral facet if non prominent or deepening of the groove when prominent.

[Temporary antibiotic-loaded cemented prosthesis for two-stage septic hip arthroplasty]. / Prothèse temporaire en ciment imprégné d'antibiotiques au cours des arthroplasties en deux temps sur hanche infectée.

PURPOSE OF THE STUDY: During the excision period of a two-stage revision arthroplasty, the hip has a low function and an unacceptable leg length discrepancy. The goal of this study was to expose technical details in order to perform a simple articulated cement spacer which could be implanted during this period to improve hip function, to authorize partial weight bearing and to avoid leg length discrepancy. MATERIAL: This method was applied in three two-stage procedures justified because of particular immunodeficiency conditions: a 43 years old man who had bone marrow allograft and immunosuppressive therapy because of leukemia suffering of subacute septic hip arthritis; a 58 years old man suffering of diabetes and active C-hepatitis who had a septic loosening of a total hip arthroplasty (THA); a 76 years old woman suffering of diabetes who had a third septic loosening of THA. METHOD: The prosthesis was made of antibiotic-impregnated cement according to organisms antibiotic resistance. The prosthetic junction between head and diaphysis was reinforced with a tibial plate. Prosthetic shape was identical to the one of femoral broaches inserted in the femur after prosthetic and cement removal. The broach size was chosen when mechanical stability in the femur was obtained, and avoided leg length discrepancy after trials with cups. The tibial plate was bent in order to reinforce the junction with regard to the shape of the determined broach. Two doses of antibiotic-impregnated cement were mixed and molded with hands, then the plate was incorporated at the appropriate location, finally the broach was applied on this composite and cement in excess was removed before polymerisation. For prosthetic head, two options were available: to mold the cephalic zone of the cement at the patient acetabulum diameter with a soft aluminium cup previously molded in the acetabulum; to mold the cement cephalic zone with a trial cup in order to obtain a 22 or 28 ball. For this last option, a third dose of antibiotic-impregnated cement was prepared and placed in the acetabulum, a trial femoral head was applied in it to mold the location for the 22 or 28 prosthetic head. Before insertion, a collar was applied on the stem to prevent migration. Active mobilization was encouraged, and partial weight-bearing authorized. RESULTS: The mean range of hip flexion during period was 60 degrees. The patients were discharged approximatively 12 days after the first stage. Two patients had effective painless partial weight-bearing. The second stage was performed six weeks later on the average. The second procedure was easier than the second stage of a conventional two-stage procedure because of: easy and low hemorrhagic dissection authorized by the prosthesis; low difficulties with soft tissue tension as the prosthesis prevents leg length discrepancy; preservation of the articular space which prevents soft tissue sacrifice during the second stage. CONCLUSION: This simple technique is effective to prevent complications related to the excision period of a two-stage hip revision arthroplasty. Likewise, the economical aspect (short delay of hospitalisation, quick functional recovery) should be considered when compared with the excision period of a conventional two-stage procedure.

[Malignant synovial "chondromatosis" or chondrosarcomatous transformation of synovial chondromatosis of the knee?]. / "Chondromatose" synoviale maligne d'emblée ou évolution chondrosarcomateuse d'une chondromatose synoviale du genou?

A case of chondrosarcoma of the knee with clinical and histopathological features of malignant chondromatosis in a 40-year-old white man is reported. Malignant transformation of true chondromatosis is uncommon and has important implication of diagnosis and surgical treatment.

Effect of graft position on laxity after anterior cruciate ligament reconstruction. Stress radiography in 90 knees 2 to 5 years after autograft.

The effect of tibial and femoral graft placement on radiographic laxity after anterior cruciate ligament reconstruction was studied in 90 knees. All the knees were operated according to the Marshall-MacIntosh procedure with a through-the-condyle technique. Graft position and laxity were determined on lateral x-rays (static and mechanically assisted 200 Newtons anterior drawer strain). No relation was observed between tibial tunnel position and radiographic laxity. In fact few variations in placement were recorded. Femoral tunnel placement was more dispersed, and it strongly influenced the radiographic laxity (p = 0.0001). Laxity was minimal when the center of the femoral tunnel was 6 mm below the intercondylar notch roof and 2.5 mm behind the posterior margin of the notch. No correlations were observed between tunnel positions and function evaluated with the ARPEGE score. These results stressed the importance of the femoral graft placement to control laxity after anterior cruciate ligament reconstruction, and allowed determination in vivo of a position for which minimal laxity could be expected. Since the method determining the femoral graft placement in the present study was not precise, we now use fluoroscopic control to determine drill-guide position.