No benefit of direct anterior over posterolateral approach in total hip arthroplasty using dual-mobility acetabular component for femoral neck fracture.

Aims: Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA. Methods: A prospective continuous cohort study was conducted on patients undergoing operation for FNF using DMC by DAA or PLA. Functional outcome was evaluated using the Harris Hip Score (HHS) and Parker score at three months and one year. Perioperative complications were recorded, and radiological component positioning evaluated. Results: There were 50 patients in the DAA group and 54 in the PLA group. The mean HHS was 85.5 (SD 8.8) for the DAA group and 81.8 (SD 11.9) for the PLA group (p = 0.064). In all, 35 patients in the DAA group and 40 in the PLA group returned to their pre-fracture Parker score (p = 0.641) in both groups. No statistically significant differences between groups were found at one year regarding these two scores (p = 0.062 and p = 0.723, respectively). The DAA was associated with more intraoperative complications (p = 0.013). There was one dislocation in each group, and four revisions for DAA and one for PLA, but this difference was not statistically significant. There were also no significant differences regarding blood loss, length of stay, or operating time. Conclusion: In DMC-THA for FNF, DAA did not achieve better functional results than PLA, either at three months or at one year. Moreover, DAA presented an increased risk of intra-operative complications.

CPAK classification cannot be used to determine segmental coronal extra-articular knee deformity.

PURPOSE: While the coronal plane alignment of the knee (CPAK) classification serves as a useful guide in personalising total knee arthroplasty (TKA), the extent of its correlation with segmental coronal extra-articular knee deformities remains uncertain. This study aims to investigate the potential correlation between CPAK matrix groups and segmental coronal extra-articular deformities in prearthritic knees, shedding light on the relationship between these two factors that seems to be both essential to perform personalised TKA. MATERIALS AND METHODS: A radiological assessment of 1240 nonarthritic knees was performed by evaluating lower limb measurements following the protocol established by Paley et al. Subsequently, all knees were classified into their respective CPAK matrix groups. In our quest to discern any correlation between the CPAK matrix groups and the presence of segmental coronal extra-articular knee deformities, nine potential coronal extra-articular deformity phenotype (CEDP) groupswere identified based on medial proximal tibial angle (MPTA) and mechanical lateral distal femoral angle (mLDFA). Neutral values for MPTA and mLDFA were set at 90.0° ± 3.0° and then at 87.0° ± 2.0°. Each CPAK matrix group underwent detailed coronal morphology analysis and then, segmental coronal extra-articular deformities were assessed by comparing them with the CEDP groups. RESULTS: The study revealed a mean hip-knee-ankle angle (HKA) of 178.6° ± 4.4°, mLDFA of 86.9° ± 2.5°, MPTA of 85.4° ± 2.4°, arithmetic HKA of -1.4° ± 3.2° and joint line obliquity of 172.5° ± 3.7°. The varus CPAK groups (I/IV/VII) included 435 patients, the neutral groups (II/V/VIII) comprised 630 patients and the valgus groups (III/VI/IX) had 175 patients. Notably, CPAK matrix groups were not distinctly associated with specific coronal extra-articular deformity phenotype (CEDP) groups. Particularly among the most common CPAK matrix groups (I/II/III/IV/V), there was a significant variation in segmental coronal extra-articular deformity patterns. Moreover, when neutral MPTA/mLDFA values were set at 87.0° ± 2.0°, the CPAK matrix groups exhibited even greater variability in coronal extra-articular deformities. CONCLUSION: The CPAK matrix groups do not exhibit a direct correlation with a specific extra-articular deformity pattern (CEDP), thus rendering them unsuitable for determining segmental coronal extra-articular knee deformities. LEVEL OF EVIDENCE: Level III, retrospective diagnostic study.

The tipping point in medial opening wedge high tibial osteotomy relates to the shape of the proximal tibia more than to lower limb alignment correction.

PURPOSE: The tipping point (TP) of the knee joint is the centre of rotation of the joint in the coronal plane. This study aimed to define the TP in medial opening wedge high tibial osteotomy (MOWHTO). METHODS: Data from 154 consecutive patients with varus knee malalignment, who underwent MOWHTO between 2017 and 2021, was retrospectively reviewed. The degree of preoperative osteoarthritis (OA), using the Kellgren-Lawrence (KL) grading system, was recorded. Long-leg standing radiographs were used to record the alignment parameters, including the hip-knee-ankle angle (HKA), the mechanical lateral distal femoral angle (mLDFA), the medial proximal tibial angle (MPTA), the joint line convergence angle (JLCA) and the joint line obliquity (JLO) angle. Postoperative Tegner activity scores, Western Ontario and McMaster University Scores and patients' satisfaction were recorded. To define the TP, the relationship of all variables to Δ JLCA (absolute difference between preoperative to postoperative JLCA values) was analysed. Linear regression was employed for Δ JLCA to preoperative JLCA and postoperative and Δ MPTA (absolute difference between preoperative and postoperative values). K-means clustering was used to partition observations into clusters, in which each observation belongs to the cluster with the nearest mean serving as a prototype of the cluster, and analysed if there was any specific threshold influencing Δ JLCA. After defining the TP, further subanalysis of the TP based on the preoperative KL OA grade and analysis of variance of this TP to the KL OA grade was performed. RESULTS: A total of 154 patients (77.9% males and 22.1% females) were included. The mean age was 48.2 ± 11 years, and the mean body mass index was 27.1 ± 4 kg/m2. Preoperatively, 26 (16.9%) patients had KL grade IV OA. The mean preoperative and postoperative JLCA and the significance of their relation to Δ JLCA were 2.6° ± 1.8° (p < 0.0001) and 1.9° ± 1.8° (p = 0.6), respectively. The mean Δ JLCA was 1.4° ± 1.5°. The mean pre- and postoperative MPTA and the significance of their relation to Δ JLCA were 84.6 ± 2.2 (p = 0.005) and 91.8 ± 2.5 (p < 0.0007), respectively. The mean Δ MPTA was 7.2 ± 2.3 (p = 0.3). The mean preoperative and postoperative HKA and the significance of their relation to Δ JLCA were 174.6 ± 2.5 (p = 0.2) and 181.9 ± 2.4 (p = 0.7), respectively. The overall linear regression for Δ JLCA was statistically significant for preoperative JLCA (R2 = 0.3, p < 0.0001) and postoperative MPTA (R2 = 0.09, p = 0.0001) and statistically insignificant for Δ MPTA (R2 = 0.01, p = 0.2) and postoperative HKA (R2 = 0.04, p = 0.7). MPTA > 91.5° was the optimal threshold dividing this series data set between substantial and nonsignificant Δ JLCA. CONCLUSION: In this study, the main predictive factors for intra-articular correction (Δ JLCA) after MOWHTO were the preoperative value of JLCA and the postoperative value of MPTA. A value of 92° for postoperative MPTA is potentially the optimal threshold to predict intra-articular correction. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Deformity in valgus knee malalignment is not only in the femur but also in tibia or both, based on demographic and morphological analysis before and after knee osteotomies.

PURPOSE: This study aims to identify the demographic and morphological features of valgus knee deformity with unilateral osteoarthritic knee in the coronal plane. A secondary aim was to identify the distinct phenotypes of valgus knees in Hirschmann's phenotype and the coronal plane alignment of the knee (CPAK) classifications before and after a knee osteotomy (KO). METHODS: A total of 107 patients (57 female and 50 male) with a mean age of 42.4 ± 17.2 years, who underwent varisation osteotomy for symptomatic unilateral knee osteoarthritis (OA) and constitutional valgus deformity, were enrolled in the study, and the mean follow-up period was 29.1 ± 7.3 months. The included cases comprised 60 cases of distal femoral osteotomy, 10 cases of double-level osteotomy and 33 cases of high tibial osteotomy. All patients underwent preoperative and postoperative clinical, functional and radiological evaluations, analysed by analysis of variance tests. RESULTS: An analysis of the location of the valgus deformities demonstrated that 56 cases (52.3%) were femoral based, 18 cases (16.8%) were both femoral and tibial based and 33 cases (30.9%) were tibial based. Twelve preosteotomy cases (11.2%) and 38 postosteotomy cases (35.5%) matched the most common eight Hirschmann's phenotypes, phenotyping the coronal lower limb alignment based on the native alignment in young patients without OA. Four (3.7%) preosteotomy cases and 89 postosteotomy cases (83.1%) matched the most common three CPAK phenotypes (Ⅰ, Ⅱ, Ⅴ) based on constitutional alignment and joint line obliquity in healthy and osteoarthritic knees. CONCLUSION: In valgus knee malalignment, the location of the deformity is not only solely femoral-based but also solely tibial-based or combined femoral and tibial-based. An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. Hirschmann's and CPAK classification would not be relevant when KO is considered. LEVEL OF EVIDENCE: Level Ⅳ, retrospective case-control study.

Outcomes of Short and Long Tibial Stems for Primary Total Knee Arthroplasty in a Population of Obese Patients at Two-Year Follow-Up: A Clinical and Biomechanical Study.

BACKGROUND: Obesity can be a source of higher failure rates and inferior clinical outcomes after total knee arthroplasty (TKA). The aim of this study was to compare outcomes, failure rates, and stress distributions of TKA in obese patients using a short, long, or no tibial stem. METHODS: A matching process based on the type of stem used and the age allowed included 180 patients who had a body mass index (BMI) > 30 and underwent a TKA between January 2010 and December 2019, with a minimum follow-up of 2 years. They were classified as moderately obese (MO: 30 < BMI < 35, N = 90) and severely obese (SO: BMI > 35, N = 90). For each, 3 subgroups were defined: thirty patients received a 30 mm short stem (SS), thirty received a 100 mm long stem (LS), and thirty received no stem (NS). Patients were assessed preoperatively and postoperatively using the Knee Society Score (KSS). A finite element model was developed to evaluate the biomechanical effects of the tibial stem on stress distribution in the subchondral bone based on BMI. RESULTS: The SS patients had significantly higher postoperative KSS knee score [MO: 88.9 (SS) versus 79 (LS) versus 80.6 (NS); SO: 84.5 versus 72.4 versus 78.2] (P < .0001) and function score [MO: 90.4 (SS) versus 78.4 (LS) versus 68.5 (NS); SO: 85.5 versus 73 versus 61.8] (P < .0001) compared to LS and NS patients. The biomechanical study demonstrated a BMI-dependent increase in stress in the subchondral bone in contact with the tibial components. These stresses were mainly distributed at the tibial cut for NS and along the stem for SS and LS. CONCLUSIONS: A short, cemented tibial stem offers better functional outcomes without increasing failure rates compared to a longer stem during primary TKA in a population of obese patients at two-year follow-up. A short tibial stem does not lead to increased stress compared to an LS, at least for certain BMI categories.

The unintentional effect of unicompartmental knee arthroplasty on extraarticular deformity and of high tibial osteotomy on intraarticular deformity for the treatment of anteromedial osteoarthritis.

INTRODUCTION: Unicompartmental Knee Arthroplasty (UKA) and High Tibial Osteotomy (HTO) are two valid options in the treatment of Anteromedial Osteoarthritis (AMOA) of the knee with UKA being mainly performed in cases of Intraarticular deformity (IA) and HTO in cases of Extraarticular deformity (EA). The exact unintentional effect of UKA on EA deformity and HTO on IA deformity is still not well understood. The aim of this study was to assess this unintentional effect of UKA on EA and HTO on IA deformities respectively. MATERIALS AND METHODS: This a single-center retrospective study in which 50 patients who underwent UKA and 50 patients who underwent medial opening wedge HTO (MWOHTO) for the treatment of AMOA were included. Overall, 35 males and 15 females underwent HTO with a mean age of 44.3 ± 11.2 years while the mean age of the UKA group was 71.8 ± 7.9 years in 23 males and 27 females. The radiological effect of UKA and HTO on each of the following angles: Hip-Knee-Ankle angle (HKA), Medial Proximal Tibial Angle (MPTA), mechanical Lateral Distal Femoral Angle (mLDFA) and Joint Line Convergence Angle (JLCA) on long film radiographs both pre- and postoperatively was measured. The postoperative values were compared to the preoperative values to detect the expected and unintended effects of each technique on IA and EA deformities. RESULTS: In the HTO group, the MPTA has changed significantly as expected from 83.1 ± 4.5 preoperatively to 88.9 ± 3.9 postoperatively (p value < 0.001) correcting the existing preoperative EA varus without overcorrection. Similarly in the UKA group, the JLCA has also changed significantly as expected to correct the IA varus from 3.8 ± 1.7 preoperatively to 0.9 ± 1 postoperatively (p value < 0.001). On the other hand, the JLCA was unintentionally changed in the HTO group from 2.6 ± 2.1 preoperatively to 1.6 ± 2.4 postoperatively (p value = 0.03) partly correcting the IA varus deformity. Similarly, the MPTA showed a significant change that occurred inadvertently in the UKA group from 84.8 ± 2.1 to 86.3 ± 1.6 postoperatively (p value < 0.001). This unintentional increase in the MPTA also partly corrected the preexisting EA varus deformity. The mLDFA did not show a significant change neither in the HTO group (p value = 0.96) nor in the UKA group (p value = 0.94). CONCLUSION: In addition to intraarticular varus correction, UKA can partly correct the extraarticular varus deformity in AMOA even when resurfacing is exclusively attempted. Additionally, intraarticular deformity can be also partially managed by HTO along with the extraarticular varus correction even without performing overcorrection.

Massive traumatic articular bone loss of the capitulum humeri treated by costal osteochondral autograft reconstruction: A case report.

INTRODUCTION: Articular traumatic bone loss is a severe condition with heterogeneous outcomes, often necessitating complex technical solutions and posing challenges in managing both bone and cartilage loss. Thus, some surgeons have used a technique of osteochondral autograft using a rib to fix an articular bone loss to manage both of these tissue losses. PRESENTATION OF CASE: We present the case of a 25-years-old patient, who had a complex open elbow injury. He presented an association of a terrible triad of the elbow injury with an open traumatic bone loss of the capitulum humeri and unfixable lesion of the lateral collateral ligament complex of the elbow. We initially managed these lesions with an external fixator for 2 months followed by a reconstruction of the capitulum humeri using a costal osteochondral autograft. Unfortunately, the patient was lost to follow-up after the 1 month post-operative consultation but he had some encouraging results. DISCUSSION: In this case report, we describe our technique using an osteochondral autograft to address complex bone and cartilaginous losses, thereby expanding the treatment options available to trauma surgeons. CONCLUSION: This case report shows that a reconstruction of the capitellum humeri for a traumatic bone loss with an osteochondral autograft using the eighth rib can be easily performed. More generally, this technique could even help to manage complex traumatic substance loss of both bone and cartilage in other locations.

Bicondylar tibial plateau fracture osteosynthesis with double-plate fixation: Similar complication rates and clinical results but improved radiographic outcomes with dual compared to single approach.

INTRODUCTION: Associating posteromedial and anterolateral approaches should improve fracture line visualization and optimize bicondylar tibial plateau fracture reduction compared to a single midline approach. The present study aimed to compare postoperative complications rates and functional and radiographic results after double-plate fixation via either a single or a dual approach. The study hypothesis was that double-plate fixation using a dual approach provides equivalent complications rates with improved radiographic results compared to a single approach. MATERIAL AND METHODS: A retrospective 2-center study compared bicondylar tibial plateau fractures treated by double-plate fixation on a single versus a dual approach between January 2016 and December 2020. Comparison focused on major complications requiring surgical revision, radiographic measurements of medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA); change from their respective baseline values of 87° and 83° (deltaMPTA and deltaPPTA), and functional results on KOOS, SF12 and EQ5D-3L self-reported questionnaires. RESULTS: Major complications occurred in 2 of the 20 single approach group patients (10%) [1 surgical site infection (SSI) (5%), and 1 skin complication (5%)], and in 3 of the 39 dual approach group patients (7.69%) (p=0.763), at an average 29 months' follow-up. In the sagittal plane, deltaPPTA was significantly lower with dual than single approach (respectively, 4.67° versus 7.43°; p=0.0104). There were no significant intergroup differences in deltaMPTA or functional results at last follow-up. CONCLUSION: The present study suggests an absence of significant difference in major complications, between single and dual approach for double-plate osteosynthesis of bicondylar tibial plateau fractures. Using a dual approach enabled improved anatomic restoration in the sagittal plane, without significant differences observed in the frontal plane or functional scores at an average 29months' follow-up. LEVEL OF EVIDENCE: III; case-control study.

Distal femoral osteotomy planning: Reversed Miniaci's method is more accurate than Dugdale and Paley methods.

PURPOSES: The purpose of this study was to validate the reversed Miniaci method for distal femoral osteotomies and to compare the accuracy with Dugdale and Paley methods. METHODS: Between January 2019 and October 2021, 59 DFO were performed in a single center. Following application of the eligibility and exclusion criteria, radiographic measurements and analysis was performed for 24 patients by two independent observers, then repeated after one month. Medical planning software: PeekMed v2.3.7.6® was used. For all patients the following measurements were performed: Hip-Knee-Ankle (HKA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), joint line obliquity (JLO), width of the proximal tibia and the weight-bearing line (WBL). Each image was then analysed using the following planning methods for realignment surgery: Reversed Miniaci, Dugdale and Paley. Measurements were recorded post deformity correction. Difference between target and post-correction WBL was evaluated. This difference was adjusted by the objective in order to limit biases related to the different objectives according to the method. RESULTS: Eighteen patients were managed for a varus osteotomy and 6 for a valgus osteotomy. Preoperative data was, HKA at 176.7±6.3, mLDFA at 90.6±5.4, MPTA 88.9±1.1, a WBL for valgus 80.9%±9.1 and for varus deformity 23.5%±11.7. Inter- and intra-rater reliability was>0.8 for every method. After normalizing reported precision on the amount of correction expected, reversed Miniaci method was the most accurate with a mean deviation from the target of 3%, compared to the Dugdale's method with 9% (p<0.001) and to Paley's method with 8.6% (p<0.001). CONCLUSION: The reversed Miniaci method is effective and reliable for planning distal femoral osteotomies. Compared to other planning methods, it is the most accurate approach for achieving a correction goal. LEVEL OF EVIDENCE: IV; retrospective cohort study.

Use of dual mobility cup cemented into a tantalum acetabular shell for hip revision with large bone loss can decrease dislocation risk without increasing the risk of mechanical failure.

BACKGROUND: Porous tantalum components and augments have demonstrated short to midterm fixation stability in acetabular total hip arthroplasty (THA) revision but do not offer a novel option to decrease the postoperative dislocation rate. Recently, dual mobility (DM) cups have gained interest to decrease the prevalence of recurrent hip instability after revision hip arthroplasty, but this issue was not confirmed combined with use of tantalum reconstruction devices. Therefore, we did a retrospective study aiming to: (1) evaluate at a 5-year minimum follow-up period the dislocation rate (and other intra- and postoperative complications), (2) assess radiographic results specifically looking at osseointegration and restoration of the hip center, (3) and also clinical results in a cohort of patients who underwent complex acetabular reconstruction with trabecular metal revision components associated with a cemented DM socket. HYPOTHESIS: Using a DM socket cemented in porous tantalum components can reach the low risk of hip dislocation reported with DM components in revision setting without increasing the risk of a mechanical failure. METHODS: A cross-sectional study identified 174 THA revision including an acetabular revision. Were excluded 118 revisions with acetabular defects Type 1, 2a or 2B according to Paprosky's classification, as well as 18 hips revised without a dual mobility and 3 patients (3 hips) lost to follow-up. Were thus included in this study 35 hips (35 patients) implanted with uncemented total hip arthroplasty revision using both trabecular metal acetabular cup-cage reconstruction and a cemented DM cup. Seven hips were classified Paprosky types 2C, 15 type 3A and 13 types 3B. Patients were followed with clinical and radiological evaluation regarding dislocation rate, infection, reoperation or re-revision, osseointegration and restoration of the hip center, and functional results according to the Harris hip score and psoas impingement presence. RESULTS: At a mean follow-up of 8.1±1.8 years (5.1-12.6), one dislocation was recorded, and one acute deep infection. No patient required a cup re-revision for septic or aseptic loosening. The survivorship at 8years regarding revision for any cause as an endpoint was 96.5% (CI95%: 92-99). Osseointegration of TM implants was analyzed and found no acetabular migration at the last follow-up in the cohort. The mean hip center position was optimized from 48±7mm (37-58) to 34±5mm (29-39) vertically and from 26±5mm (-18-36) to 24±8mm (7-31) horizontally without reaching significance (p=0.1). On the last follow-up X-rays, the mean acetabular inclination was 47̊±9̊ (32̊-61̊). According to the criteria of Hirakawa, 97.1% (34/35) of the hip centers were restored. One cup (2.9%) was more than 5mm proximally from the hip center, and none more than 10mm. Clinical results assessed a Harris Hip Score improved from 36±17 (23-62) preoperatively to 82±15 (69-93) at last follow-up (p<0.0001). Two patients (2/35, 5.7%) complained of psoas impingement. CONCLUSION: This study suggests effectiveness of DM cups in association with a tantalum-made acetabular shell for reconstruction of large bone defect in THRs for both solving postoperative instability and aseptic loosening without increasing the re-revision rate for any reason in a midterm follow-up. LEVEL OF EVIDENCE: IV; observational study.

Immunobiodiversity: Conserved and specific immunity across land plants and beyond.

Angiosperms represent most plants that humans cultivate, grow, and eat. However, angiosperms are only one of five major land plant lineages. As a whole lineage, plants also include algal groups. All these clades represent a tremendous genetic diversity that can be investigated to reveal the evolutionary history of any given mechanism. In this review, we describe the current model of the plant immune system, discuss its evolution based on the recent literature, and propose future directions for the field. In angiosperms, plant-microbe interactions have been intensively studied, revealing essential cell surface and intracellular immune receptors, as well as metabolic and hormonal defense pathways. Exploring diversity at the genomic and functional levels demonstrates the conservation of these pathways across land plants, some of which are beyond plants. On basis of the conserved mechanisms, lineage-specific variations have occurred, leading to diversified reservoirs of immune mechanisms. In rare cases, this diversity has been harnessed and successfully transferred to other species by integration of wild immune receptors or engineering of novel forms of receptors for improved resistance to pathogens. We propose that exploring further the diversity of immune mechanisms in the whole plant lineage will reveal completely novel sources of resistance to be deployed in crops.

Maintaining Posterior Tibial Slope and Patellar Height During Medial Opening Wedge High Tibial Osteotomy.

Background: Increased posterior tibial slope (PTS) and decreased patellar height (PH) after medial opening wedge high tibial osteotomy (MOWHTO) have been repeatedly reported in the literature. However, this has been disputed in more recent biomechanical studies. Hypothesis: No change in PTS or PH would result after MOWHTO with the freehand technique, regardless of the degree of the coronal plane correction. Study Design: Case series. Methods: A total of 62 patients who underwent MOWHTO between 2018 and 2020 were included. Surgery was performed using a dedicated step-by-step protocol to reduce the risk of unintentional slope changes. All patients were evaluated preoperatively and at a 2-year follow-up with the Knee injury and Osteoarthritis Outcome Score and the University of California, Los Angeles physical activity scale. Pre- and postoperative radiographic lower limb alignment parameters-including hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle, proximal posterior tibial angle (PPTA), joint line convergence angle, and joint line obliquity-were measured on full-length lower limb radiographs. PH measurements assessed on lateral and anteroposterior knee radiographs included the Caton-Deschamps, Insall-Salvati, and Schröter indices. Results: A significant change was observed in the coronal plane alignment, with an increase in the MPTA from 84.38° to 90.39° (P < .001) and a consequent increase in the HKA from 172.19° to 180.15° (P < .001). No significant changes were observed in the PTS, as evidenced by a postoperative PPTA of 80.6° versus a preoperative value of 80.4° (P = .2). No significant changes were detected in the mean PH on all 3 indices used-pre- versus postoperative Caton-Deschamps, Insall-Salvati, and Schröter indices measured 0.95 versus 0.93 (P = .2), 1.03 versus 1.03 (P = .5), and 1.56 versus 1.54 (P = .3), respectively. Conclusion: In this study, MOWHTO did not result in significant changes in the PTS or PH when accurate preoperative planning and precise intraoperative freehand technique were adopted..

Outcomes of Slope-Reducing Proximal Tibial Osteotomy Combined With a Third Anterior Cruciate Ligament Reconstruction Procedure With a Focus on Return to Impact Sports.

BACKGROUND: An increased posterior tibial slope (PTS) is a proven risk factor for both native anterior cruciate ligament (ACL) and ACL graft insufficiency. Anterior closing wedge high tibial osteotomy (ACW-HTO) for PTS correction is a validated procedure in revision ACL reconstruction (ACLR). PURPOSE/HYPOTHESIS: The aim of this study was to evaluate the effect of combined ACW-HTO and at least a second revision ACLR procedure on knee stability, function, and sports performance in a large series of patients. The hypothesis was that patients would return to impact sports after ACW-HTO combined with a second or third revision ACLR procedure. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 64 patients who underwent a second (or more) revision ACLR procedure and ACW-HTO between June 1, 2015, and June 1, 2019, and had a PTS >12° were included. The mean age was 29.60 ± 6.31 years, and the mean preoperative PTS was 13.79°± 1.50°. The cases were analyzed at a mean follow-up of 2.96 ± 0.83 years (range, 2-5 years). At the last follow-up, the rate of patients returning to impact sports (based on the University of California, Los Angeles [UCLA], activity scale), ACL graft status (per magnetic resonance imaging), International Knee Documentation Committee (IKDC) scores, Lysholm scores, and laxity measurements using a knee arthrometer were recorded. RESULTS: The total number of patients participating in impact sports and high-impact sports was as follows: 43 and 30, respectively, before the injury; 0 and 0, respectively, preoperatively; and 31 and 12, respectively, postoperatively. At the last follow-up, the UCLA score was ≥8 in 48.44% of the patients, and only 16 patients returned to their preinjury level of activity. At a minimum of 2 years of follow-up, there was clinical improvement in the IKDC score from 37.98 ± 12.48 preoperatively to 69.06 ± 12.30 postoperatively (P < .0001), in the Lysholm score from 51.94 ± 14.03 preoperatively to 74.45 ± 11.44 postoperatively (P < .001), and in the UCLA score. However, this clinical improvement did not equate to preinjury values for all outcome scores (P < .001). The preinjury IKDC and Lysholm scores were 76.98 ± 11.71 and 89.26 ± 8.91, respectively. The mean change in anterior knee laxity using a knee arthrometer at 134 and 250 N was -4.03 ± 0.18 mm and -3.63 ± 0.16, respectively. There were 3 cases of a rerupture with a severe pivot shift on the clinical examination. None of these patients underwent revision per the patient's preference. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. CONCLUSION: In the setting of chronic ACL-deficient knees, PTS reduction (ACW-HTO) with revision ACLR restored knee stability and improved function with an acceptable rate of specific complications. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Also, approximately half of the patients were able to return to impact sports.

Reduced mortality associated to cementless total hip arthroplasty in femoral neck fracture.

Mortality related to femoral neck fractures remains a challenging health issue, with a high mortality rate at 1 year of follow-up. Three modifiable factors appear to be under control of the surgeon: the choice of the implant, the use of cement and the timing before surgery. The aim of this research project was to study the impact on mortality each of these risk factors play during the management of femoral neck fractures. A large retrospective epidemiological study was performed using a national database of the public healthcare system. The inclusion criteria were patients who underwent joint replacement surgery after femoral neck fracture during the years 2015 to 2017. All data points were available for at least 2 years after the fracture. The primary outcome was mortality within 2 years following the surgery. We evaluated the association between mortality and the type of the implant hemiarthroplasty (HA) versus total hip arthroplasty (THA), cemented versus non cemented femoral stem as well as the timing from fracture to surgical procedure. A multivariate analysis was performed including age, gender, comorbidities/autonomy scores, social category, and obesity. We identified 96,184 patients who matched the inclusion criteria between 2015 and 2017. 64,106 (66%) patients underwent HA and 32,078 (33.4%) underwent THA. After multivariate analysis including age and comorbidities, patients who underwent surgery after 72 h intra-hospital had a higher risk of mortality: Hazard Ratio (HR) = 1.119 (1.056-1.185) p = 0.0001 compared to the group who underwent surgery within 24 h. THA was found to be a protective factor HR = 0.762 (0.731-0.795) p < 0.0001. The use of cement was correlated with higher mortality rate: HR = 1.107 (1.067-1.149) p < 0.0001. Three key points are highlighted by our study in the reduction of mortality related to femoral neck fracture: the use of hemiarthroplasty a surgery performed after 48 h and the use of cement for femoral stem fixation adversely affect mortality risk.

Ecological Burden of Modern Surgery: An Analysis of Total Knee Replacement's Life Cycle.

Background: It is estimated that surgical procedures account for 20%-30% of the greenhouse gases emissions from health-care systems. Total knee replacements (TKR) are one of the most frequently performed procedures in orthopaedics. The aim of this study was to identify and quantify the environmental impacts generated by TKRs, the factors that generate the most emissions, and those that can be easily modified. Methods: To calculate the life cycle carbon footprint of a posterior stabilized cemented TKR performed in a single orthopaedic surgery department, 17 TKRs performed between October 12 and 20, 2020 by 4 senior surgeons were analysed. The analysis of the life cycle included the manufacture of the implant, from raw materials to distribution; the journey made by patients and staff; and the surgery including all consumables required to facilitate the procedure. Results: The overall life cycle carbon footprint of a single TKR was 190.5 kg of CO2. This consisted of 53.7 kg CO2 (28%) for the manufacture of the prosthesis, 50.9 kg CO2 (27%) for travel, 57.1 kg CO2 (30%) for surgery, and 28.8 kg CO2 (15%) for waste management. This is comparable to a New York-Detroit direct flight. Conclusions: The production of a total knee prosthesis, throughout its life cycle, generates emissions with important consequences on the environment and therefore on our health. Although much data are currently missing to make precise estimates, and especially regarding benefits in terms of patient function and its impact on carbon emissions, these data serve as a starting point for other more detailed or comparative studies.

Quad Tendon Autograft for Posterior Cruciate Ligament Reconstruction Using Transseptal and Posteromedial Portals.

We describe a surgical technique for reconstruction of the posterior cruciate ligament with quad tendon autograft using transseptal portal. We place the guide for the tibial socket through the posteromedial portal instead of transnotch, which is the most common practice. The use of the transseptal portal allows good visualization during the drilling of the tibial socket to protect the neurovascular bundle while avoiding the use of fluoroscopy. The advantage of using the posteromedial approach is the easy placement of the drill guide and to option to pull the graft once through the posteromedial portal and a second time through the notch, which helps passing the "killer turn." The quad tendon is harvested with a bone block that is placed in the tibial socket and fixed with screws in the tibial and femoral side.

Assessment of return to sport and functional outcomes following distal femoral, double level and high tibial osteotomies for active patients with symptomatic varus malalignment.

PURPOSE: This study indicated the outcomes of three surgical techniques for the treatment of symptomatic unicompartmental knee osteoarthritis (UKOA) with varus malalignment in younger, active patients: distal femoral osteotomy (DFO), double-level osteotomy (DLO) and high tibial osteotomy (HTO). The outcomes measured included the return to sport, sport activity and functional scores. METHODS: A total of 103 patients (19 DFO, 43 DLO, 41 HTO) were enrolled in the study and were divided into three groups based on their oriented deformity, each undergoing one of the three surgical techniques. All patients underwent pre- and post-operative evaluations including X-rays, physical exams and functional assessments. RESULTS: All three surgical techniques were effective in treating UKOA with constitutional malalignment. The average time to return to sport was similar among the three groups (DFO: 6.4 ± 0.3 [5.8-7] months, DLO: 4.9 ± 0.2 [4.5-5.3] months, HTO: 5.6 ± 0.2 [5.2-6] months). The sport activity and functional scores improved significantly for all three groups, with no significant differences observed among the groups. CONCLUSION: Various knee osteotomy procedures, DFO, DLO, and HTO, result in high RTS rates and quick RTS times with satisfactory functional scores. Despite pre- to post-operative improvements in sport activities following DFO and DLO, pre-symptom levels were not reached following all evaluated procedures. LEVEL OF EVIDENCE: Retrospective case-control study, Level III.

Ramp Lesions of the Medial Meniscus.

PURPOSE OF REVIEW: To provide an overview of the recent scientific literature about ramp lesions of the medial meniscus and to summarise the current evidence on their prevalence, classification, biomechanics, surgical techniques and clinical outcomes. RECENT FINDINGS: Ramp lesions may be present in more than 1 patient undergoing ACL reconstruction out of 5 and almost half of the medial meniscal tears observed in this population. Due to the risk of persistent anterior and rotational laxity after ACL reconstruction, their repair has been advocated. There is no general agreement to date on whether and when ramp lesions should be treated surgically. Comparative studies have failed to show that the repair of stable lesions was superior in comparison to nonoperative approaches. A lower failure rate and secondary meniscectomy has been reported with a suture hook repair through the posteromedial portal in comparison with an all-inside technique. Furthermore, reconstructions of the anterolateral complex in association with ACL reconstruction may have a protective effect on ramp repair. Ramp lesions of the medial meniscus in ACL-injured knees cannot be neglected anymore. Given their novelty, their clinical impact has not been fully assessed yet, but the evidence is growing that they need to be systematically identified and eventually repaired, for which they require advanced surgical knowledge. There is, to date, no consensus on whether and when ramp lesions should be treated surgically. Their subtypes, size and stability may influence the decision-making process.

Clinical and Radiological Outcomes of Double-Level Osteotomy Versus Open-Wedge High Tibial Osteotomy for Bifocal Varus Deformity.

Background: In bifocal varus deformity, double-level osteotomy (DLO) is advocated to treat lower limb alignment to prevent an adverse increase in joint line obliquity. Purpose/Hypothesis: The purpose of this study was to compare the clinical and radiological results after DLO and open-wedge high tibial osteotomy (OWHTO) in patients with combined varus deformity. It was hypothesized that DLO would improve clinical results without increasing the complication rate compared with OWHTO. Study Design: Cohort study; Level of evidence, 3. Methods: Inclusion criteria were medial tibiofemoral compartment pain, varus knee deformity with an abnormal medial proximal tibial angle <84° and a lateral distal femoral angle >90°, a functional anterior cruciate ligament, failure of nonoperative treatment, and a minimum 2-year follow-up with all clinical and radiological data. The rate of return to work or sports; the Knee injury and Osteoarthritis Outcome Score (KOOS); the University of California, Los Angeles (UCLA) activity score; and patient satisfaction were assessed at a minimum of 2 years of follow-up. Statistical comparison of the 2 groups was made using the chi-square or Student t test. Results: A total of 69 consecutive patients were analyzed, of whom 38 underwent OWHTO and 31 underwent DLO surgery. A significant between-group difference was found for all radiological parameters; in particular, there was less joint line obliquity after DLO compared with OWHTO (1.7° vs 5.6°; P < .001). DLO provided better outcomes compared with OWHTO regarding the UCLA score (4.3 vs 6.7; P < .001) and patient satisfaction (2.6 vs 3.9; P < .001), but no significant difference in KOOS or return to work or sports was observed. The OWHTO group had more hinge fractures than the DLO group (34.2% vs 12.9%; P < .001). Conclusion: For combined tibial and femoral varus deformity, DLO produced more physiologic joint line obliquity with slightly improved UCLA and patient satisfaction scores. A greater incidence of hinge fracture was observed after isolated OWHTO compared with DLO due to a larger tibial correction; however, this had little effect on clinical results at the 2-year follow-up.

Retrospective analysis of return to impact sport after medial unicompartmental knee arthroplasty based on a cohort of 92 patients.

BACKGROUND: Return to sport after Knee Arthroplasty has been investigated reporting modifications in the physical activities with a trend towards to lower impact sports after Unicompartemental Knee Arthroplasty. The purpose of this study was to analyze the return to sport level after medial unicompartmental knee arthroplasty (MUKA) in a population of osteoarthritic patients having practiced impact sport, defined with a University of California at Los Angeles activity scale (UCLA)≥9 in their pre-symptomatic arthritic period. HYPOTHESIS: Return to an impact sport after MUKA was possible for a population of osteoarthritic patients having practiced impact sport in their pre-symptomatic arthritic period. METHODS: Ninety-two MUKA with a pre-symptomatic arthritic UCLA score≥9, including 60 men (65.2%) and operated between January 2009 and September 2014, were evaluated by a dedicated survey. Informations were obtained concerning the physical activities (intensity, frequency, kind of sport, reasons to decrease or stop the physical activities in the pre- and the postoperative period). The average age was 64.9 years±6.4 (range 49-74.4). Three different periods were compared: pre-symptomatic arthritic, preoperative and postoperative period. The mean follow-up was 7.3±1.7 years. RESULTS: The mean pre-symptomatic arthritic UCLA score was 9.9±0.3, the mean preoperative UCLA score was 7.0±2.5 (2-10) and the mean postoperative UCLA score was 7.2±2.0 (3-10). There were significant differences for the mean UCLA score values between pre-symptomatic arthritis and postoperative UCLA scores (p=0.034), however no difference was detected in mean score values before and after surgery (p=0.09). Only 32.6% (30/92) of patients had a postoperative UCLA score≥9. For patients practicing an impact sport activity (UCLA≥9) in the preoperative period (23/92; 25%), the postoperative UCLA score was at 8±1.1 (range 4-10). In this subgroup, 47.8% (11/23) of patients had a postoperative UCLA score≥9. The decline in sports in postoperative was predominantly explained by residual pain of the operated knee (31/92; 34%), precaution to not damage the prosthesis (25/92; 27%) and restrictions due to another joint (19/92; 21%). DISCUSSION: Return to impact sport after MUKA seems to be limited to a restrained number of patients. The main reasons to the decline in sporting activity level are linked to the residual pain of the operated knee and the precaution to not damage the prosthesis. LEVEL OF EVIDENCE: IV, retrospective cohort study.