Restoring the Preoperative Phenotype According to the Coronal Plane Alignment of the Knee Classification After Total Knee Arthroplasty Leads to Better Functional Results.

BACKGROUND: Mechanical alignment after total knee arthroplasty (TKA) is still widely used in the surgical community, but the alignment finally obtained by conventional techniques remains uncertain. The recent Coronal Plane Alignment of the Knee (CPAK) classification distinguishes 9 knee phenotypes according to constitutional alignment and joint line obliquity (JLO). The aim of this study was to assess the phenotypes of osteoarthritic patients before and after TKA using mechanical alignment and to analyze the influence of CPAK restoration on functional outcomes. METHODS: This retrospective multicenter study included 178 TKAs with a minimum follow-up of 2 years. Patients were operated on using a conventional technique with the goal of neutral mechanical alignment. The CPAK grade (1 to 9), considering the arithmetic Hip-Knee-Ankle angle (aHKA) and the JLO, was determined before and after TKA. Functional results were assessed using the following patient-reported outcome measures: Knee Injury and Osteoarthritis Outcome Score, the Simple Knee Value, and the Forgotten Joint Score. RESULTS: A true neutral mechanical alignment was obtained in only 37.1%. Isolated restoration of JLO was found in 31.4%, and isolated restoration of the aHKA in 44.9%. Exact restoration of the CPAK phenotype was found in 14.6%. Restoration of the CPAK grade was associated with an improvement in the "daily living": 79.2 ± 5.3 versus 62.5 ± 2.3 (R2 = 0.05, P < .05) and "Quality of life" Knee Injury and Osteoarthritis Outcome Score subscales: 73.8 ± 5.0 versus 62.9 ± 2.2 (R2 = 0.02, P < .05). CONCLUSIONS: This study shows that few neutral mechanical alignments are finally obtained after TKA by conventional technique. A major number of patients present a postoperative modification of their constitutional phenotype. Functional results at 2 years of follow-up appear to be improved by the restoration of the CPAK phenotype, JLO, and aHKA. LEVEL OF CLINICAL ART EVIDENCE: III, Retrospective Cohort Study.

Early morbidity and mortality after one-stage bilateral shoulder arthroplasty.

PURPOSE: One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high. METHODS: A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders. RESULTS: There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction. CONCLUSIONS: One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation.

A significant rate of tibial overcorrection with an increased JLO occurred after isolated high tibial osteotomy without considering international consensus.

PURPOSE: The recent ESSKA consensus recommendations defined indications and outlined parameters for osteotomies around a degenerative varus knee. The consensus collated these guidelines based on the published literature available to answer commonly asked questions including the importance of identifying the site and degree of the lower limb deformity. In the consensus, the authors suggest that a knee joint line obliquity (JLO) greater than 5° or a planned medial proximal tibial angle (MPTA) > 94° preferentially indicates a double level osteotomy (DLO) compared to an isolated opening wedge high tibial osteotomy (OWHTO). This study aimed to analyze the corrections performed on a cohort of isolated opening wedge high tibial osteotomies (OWHTOs) prior to the recent ESSKA recommendations, with a focus on the impact of knee joint line obliquity (JLO) and medial proximal tibial angle (MPTA) on the choice of osteotomy procedure. METHODS: This monocentric, retrospective study included 129 patients undergoing medial OWHTO for symptomatic isolated medial knee osteoarthritis (Ahlbäck grade I or II) and a global varus malalignment (hip-knee-ankle angle ≤ 177°). An automated software trained to automatically detect lower limb deformity was implemented using patients preoperative long leg alignment X-rays to identify suitability for an isolated HTO in knee varus deformity. Based on the ESSKA recommendations, the site of the osteotomy was identified as well as the degree of correction required. The ESSKA consensus considers avoiding an isolated high tibial osteotomy if the planned resultant knee joint line orientation exceeds 5 ̊ or MPTA exceeds 94°. A preoperative abnormal MPTA was defined by a value lower than 85° and a preoperative abnormal LDFA by a value greater than 90°. The cases of DLO or DFO suggested by the software and the number of extra-tibial anomalies were collected. Multiple linear regression models were developed to establish a relationship between preoperative values and the risk of being outside of ESSKA recommendations postoperatively. RESULTS: Based on ESSKA recommendations and on threshold values considered abnormal, the software suggested a DLO in 17.8% (n = 23/129) of cases, a distal femoral osteotomy in 27.9% (n = 36/129) of cases and advised against an osteotomy procedure in 24% (n = 31/129) of cases. The software detected a femoral anomaly in 34.9% (n = 45/129) of cases and an JLCA > 6° in 9.3% (n = 12/129). Postoperatively, the MPTA exceeds 94° in 41.1% (n = 53/129) and the JLO exceeds 5° in 29.4% (n = 38/129). On multivariate analysis, a high preoperative MPTA was associated with higher risk of postoperative MPTA > 94° (R2 = 0.36; p < 0.001). Similarly, the probability of the software advising a DLO or DFO was associated with the presence of an "normal" preoperative MPTA (R2 = 0.42; p < 0.001) or an abnormal preoperative LDFA (R2 = 0.48; p < 0.001) or a planned JLO > 5° (R2 = 0.27; p < 0.001). CONCLUSIONS: Analysis of patients who underwent an isolated OWHTO prior to the ESSKA guidelines, demonstrated a significant rate of post-operative tibial overcorrection and a resultant increased JLO. Pre-operative planning that considers the ESSKA guidelines, allows for better identification of those patients requiring a DFO or DLO and avoidance of resultant post-operative deformities. LEVEL OF EVIDENCE: IV, case-series.

Normo-or slightly overcorrection show better results after medial closing wedge high tibial osteotomy.

PURPOSE: The objectives of this study were to evaluate functional results, revision-free survival, and the influence of postoperative alignment on outcomes after MCWHTO. METHODS: This retrospective study included 27 MCWHTO operated on from 2009 to 2021. Radiographic measurements were performed pre- and postoperatively. The HKA (Hip-Knee-Ankle angle), MPTA (Medial Proximal Tibial angle), LDFA (Lateral Distal Femoral Angle), JLO (Joint Line Obliquity), and JLCA (Joint Line Convergence Angle) were evaluated. The Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Society (IKS) Function and Knee Score, and the Subjective Knee Value (SKV) as well as revision-free survival were evaluated. Postoperative alignment and its influence on clinical outcomes were also analysed. RESULTS: The mean follow-up was 61.9 months ± 31.4 (13-124). The HKA, MPTA, and JLCA angles were decreased post-operatively (respectively, Δ = 5.9° ± 2.6, p < 0.001; Δ = 6.1° ± 3.2, p < 0.001 and Δ = 2.5° ± 1.9, p < 0.001). LDFA and JLO were unchanged, post-operatively (respectively, Δ = 0.1° ± 2.2, p = 0.93 and Δ = 1.2° ± 3.3, p = 0.23). Postoperative HKA correlated with knee IKS (R = - 0.15, p = 0.04) and function IKS (R = - 0.44, p = 0.03). Postoperative LDFA correlated with knee IKS(R = 0.8, p < 0.01). Patients with postoperative HKA ≤ 180° had better KOOS (Δ = 12.3, p = 0.04) and IKS function (Δ = 28.1, p < 0.01) than those with HKA > 180°. CONCLUSION: Functional results and revision-free survival after MCWHTO are satisfactory when the deformity is located in the proximal tibia. The joint line obliquity is not significantly altered with small tibial correction and, obtaining an overall neutral or slightly varus alignment under the conditions of this study allowed an improvement in the postoperative clinical scores. The literature is still inconclusive on the ideal alignment for valgus deformities and larger series are needed to draw definitive conclusions. LEVEL OF EVIDENCE: IV, case series.

Restoration of preoperative tibial alignment improves functional results after medial unicompartmental knee arthroplasty.

PURPOSE: The alignment obtained after unicompartmental knee arthroplasty (UKA) influences the risk of failure. Kinematic alignment after UKA based on Cartier angle restauration is likely to improve clinical outcomes compared with mechanical alignment. The purpose of this study is to analyze the influence of implant alignment and native knee restoration after UKA using the conventional techniques on clinical outcomes. METHODS: This retrospective study included 144 medial UKA patients from 2015 to 2020. Radiographic measurements were performed pre- and postoperatively. Outliers were defined as follows: Δ Cartier > 3° (difference between the preoperative and postoperative Cartier angle); Δ MPTA (Medial Proximal Tibial angle) and postoperative TCA (Tibial Coronal component Angle) > 3° (difference between the positioning of the tibial implant and the preoperative proximal tibial deformity). The Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Society (IKS) Function and Knee score, the Forgotten Joint Score (FJS), and the Subjective Knee Value (SKV) were evaluated. A Student t test or a non-parametric Wilcoxon test was used for non-normal data to compare pre- and postoperative values for functional scores and angular measurements. The correlation of postoperative angles with functional outcomes was assessed by the Spearman's rank correlation coefficient. RESULTS: During the inclusion period, 214 patients underwent medial UKA, 71 patients were excluded, and 19 were lost to follow-up leaving 124 patients with 144 knees (20 bilateral UKA) included for analysis with a mean follow-up of 54.7 months ± 22.1 (24-95). The Δ Cartier was significantly correlated with IKS function (R2 = 0.06, p < 0.001) and FJS (R2 = 0.05, p < 0.01) scores. The Δ preoperative MPTA-TCA was significantly correlated (p < 0.001) with KOOS (R2 = 0.38), IKS Knee (R2 = 0.17), IKS function (R2 = 0.34), SKV (R2 = 0.08), and FJS (R2 = 0.37) scores. In subgroup analysis, non-outliers (< 3°) for Δ preoperative MPTA-TCA had better KOOS score (Δ = 23.5, p < 0.001) and IKS Function (Δ = 17.7, p < 0.001) compared to outliers (> 3°) patients. CONCLUSION: Functional results after medial UKA can be influenced by implant alignment in the coronal plane with slight clinical improvement when positioning the tibial implant close to the preoperative tibial deformity, rather than by restoring the Cartier angle. This series suggests the interest of a more personalized alignment strategy, but these results will have to be confirmed by other controlled studies. LEVEL OF EVIDENCE: IV, retrospective case series.

Global varus malalignment increase from double-leg to single-leg stance due to intra-articular changes.

PURPOSE: Preoperatively planned correction for tibial osteotomy surgery is usually based on weightbearing long-leg Xrays, while the surgery is performed in a supine non-weightbearing position. The purpose of this study was to assess the differences in lower limb alignment in three different weightbearing conditions: supine position, double-leg (DL) stance and single-sleg (SL) stance prior to performing a medial opening wedge high tibial osteotomy (MOWHTO) for varus malalignment. The hypothesis of this study was that progressive limb-loading would lead to an increased preoperative varus deformity. MATERIAL AND METHODS: This retrospective study included 89 patients (96 knees) with isolated medial knee osteoarthritis (Ahlbäck grade I or II) and significant metaphyseal tibial vara (> 6°). The differences between supine position, DL stance and SL stance were analysed for the hip-knee-ankle angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), weight-bearing line ratio (WBL) and joint line convergence angle (JLCA). RESULTS: From a supine position to DL stance, the HKA angle slightly increased from 175.5° ± 1.1° to 176.3° ± 1.1° and JLCA changed from 2.0° ± 0.3° to 1.8° ± 0.3° without a statistically significant difference. From DL to SL stances, the HKA angle decreased from 176.3° ± 1.1° to 174.4° ± 1.1° (p < 0.05) and the JLCA increased from 1.8° ± 0.3° to 2.6° ± 0.3° (p < 0.05). A significant correlation was found between ΔHKA and ΔJLCA between the DL and the SL stances (R2 = 0.46; p = 0.01). CONCLUSION: Varus malalignment increases with weight-bearing loading from double-leg to single-leg stances with an associated JLCA increase. Thus, single-leg stance radiographs may be useful to correct preoperative planning considering patient-specific changes in JLCA. LEVEL OF CLINICAL EVIDENCE: III, retrospective comparative study.

Patients with varus knee osteoarthritis undergoing high tibial osteotomy exhibit more femoral varus but similar tibial morphology compared to non-arthritic varus knees.

PURPOSE: The aim of this study was to compare alignment parameters between patients undergoing high tibial osteotomy (HTO) for knee osteoarthritis (OA) and non-arthritic controls. METHODS: Pre-operative computed tomography images from 194 patients undergoing HTO for medial knee OA and 118 non-arthritic controls were utilized. All patients had varus knee alignment (mean age: 57 ± 11 years; 45% female). The hip-knee-ankle (HKA) angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA) and non-weight-bearing joint line convergence angle (nwJLCA) were compared between "control group" and "HTO group". Femoral and tibial phenotypes were also assessed and compared between groups. Variables found on univariate analysis to be different between the groups were entered into a binary logistic regression model. RESULTS: The mean age was lower (Δ = 4 ± 6 years, p = 0.024), body mass index (BMI) was higher (Δ = 1.1 ± 2.8 kg/m2, p = 0.032) and there were more females (Δ = 14%, p = 0.020) in the HTO group. The HTO group had more overall varus (7° ± 4.7° vs 4.8° ± 1.3°, p < 0.001). There was a significant difference in the mean mLDFA between the two groups with the HTO group having more femoral varus (88.7 ± 3.2° vs 87.3 ± 1.8°, p < 0.001). MPTA was similar between the groups (p = 0.881). Age was found to be a strong determinant for femoral varus (p = 0.03). CONCLUSION: Patients undergoing HTO for medial knee OA have more femoral varus compared to non-arthritic controls while tibial morphology was similar. This will be an important consideration in pre-operating planning for realignment osteotomy in patients presenting with medial knee OA and warrants further investigation. LEVEL OF EVIDENCE: III, retrospective comparative study.

Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: a prospective analysis of a cohort of twenty-two continuous patients.

PURPOSE: Double level osteotomy (DLO) (femoral and tibial) is a technically demanding procedure for which pre-operative planning accuracy and intraoperative correction are key factors. The aim of this study was to assess the accuracy of the achieved correction using patient-specific cutting guides (PSCGs) compared to the planned correction, its ability to maintain joint line obliquity (JLO), and to evaluate clinical outcomes and level of patient satisfaction at a follow-up of two years. METHODS: A single-centre, prospective observational study including 22 patients who underwent DLO by PSCGs between 2014 and 2018 was performed. Post-operative alignment was evaluated and compared with the target angular values to define the accuracy of the correction for the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), lateral distal femoral angle (ΔLDFA), and posterior proximal tibial angle (ΔPPTA). Pre- and post-operative JLO was also evaluated. At two year follow-up, changes in the KOOS sub-scores and patient satisfaction were recorded. The Mann-Whitney U test with 95% confidence interval (95% CI) was used to evaluate the differences between two variables; the paired Student's t test was used to estimate evolution of functional outcomes. RESULTS: The mean ΔHKA was 1.3 ± 0.5°; the mean ΔMPTA was 0.98 ± 0.3°; the mean ΔLDFA was 0.94 ± 0.2°; ΔPPTA was 0.45 ± 0.4°. The orientation of the joint line was preserved with a mean difference in the JLO of 0.4 ± 0.2. At last follow-up, it was recorded a significant improvement in all KOOS scores, and 19 patients were enthusiastic, two satisfied, and one moderately satisfied. CONCLUSION: Performing a DLO using PSCGs produces an accurate correction, without modification of the joint line orientation and with good functional outcomes at two year follow-up.

Neutral alignment resulting from tibial vara and opposite femoral valgus is the main morphologic pattern in healthy middle-aged patients: an exploration of a 3D-CT database.

PURPOSE: Given the goal of achieving optimal correction and alignment after knee arthroplasty or high tibial osteotomy, literature focusing on the inter-individual variability of the native knee, tibia and femur with regards to the coronal or sagittal alignment is lacking. The aim of this study was to analyse normal angular values in the healthy middle-aged population and determine differences of angular values according to inter-individual features. The first hypothesis was that common morphological patterns may be identified in the healthy middle-aged non-osteoarthritic population. The second hypothesis was that high inter-individual variability exists with regards to gender, ethnicity and alignment phenotype. METHODS: A CT scan-based modelling and analysis system was used to examine the lower limb of 758 normal healthy patients (390 men, 368 women; mean age 58.5 ± 16.4 years) with available data concerning angular values and retrieved from the SOMA database. The hip-knee-ankle angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), posterior distal femoral angle (PDFA), posterior proximal tibial angle (PPTA) and non weight-bearing joint line convergence angle (nwJLCA) were then measured for each patient. Results were analysed for the entire cohort and based on gender, ethnicity and phenotype. RESULTS: The mean HKA was 179.4° ± 2.6°, LDFA: 85.8° ± 2.0°, MPTA: 85.6° ± 2.4°, PDFA: 85.2° ± 1.5°, PPTA: 83.8° ± 2.9° and nwJLCA: 1.09° ± 0.9°. Gender was associated with higher LDFA and lower HKA for men. Ethnicity was associated with greater proximal tibial vara and distal femoral valgus for Asian patients. Patients with an overall global varus alignment had more tibia vara and less femoral valgus than patients with an overall valgus alignment. CONCLUSION: Even if significant differences were found based on subgroup analysis (gender, ethnicity or phenotype), this study demonstrated that neutral alignment is the main morphological pattern in the healthy middle-aged population. This neutrality is the result from tibia vara compensated by an ipsilateral femoral valgus. LEVEL OF CLINICAL EVIDENCE: III, retrospective cohort study.

Accuracy of the correction obtained after tibial valgus osteotomy. Comparison of the use of the Hernigou table and the so-called classical method.

INTRODUCTION: Medial valgus-producing tibial osteotomy (MVTO) is classically used to treat early medial femorotibial osteoarthritis. Long-term results depend on the mechanical femorotibial angle (HKA) obtained at the end of the procedure. A correction goal between 3 and 6° valgus is commonly accepted. Several planning methods are described to achieve this goal, but none is superior to the other. OBJECTIVE: The main objective was to compare the accuracy of the correction obtained using either the Hernigou table (HT) or a so-called conventional method (CM) for which 1° of correction corresponds to 1° of osteotomy opening. The secondary objective was to analyze the variations observed in the sagittal plane on the tibial slope and on the patellar height. The working hypothesis was that the HT allowed a more accurate correction and that the tibial slope and patellar height were modified in both groups. MATERIAL AND METHOD: In this monocentric and retrospective study, two senior surgeons operated on 39 knees (18 in the CM group, 21 in the HT group) between January 1, 2009 and December 31, 2014. The operator was unique for each group and expert in the technique used. The correction objective chosen for each patient, and written in the operative report, was considered as the one to be achieved. The surgical correction was the difference between the pre-operative and immediate post-operative data (< 5 J) for the mechanical tibial angle (MTA) and the hip-knee-ankle (HKA) angle. Surgical accuracy, where a value close to 0 is optimal, was the absolute value of the difference between the surgical correction performed and the goal set by the surgeon. RESULTS: The median surgical accuracy on the MTA was 3.5° [0.2-7.4] versus 1.4° [0-4.1] in the CM and HT groups, respectively (p = 0.006). In multivariate analysis, with the same objective, the CM had a significantly lower accuracy of 1.9° ± 0.8 (p = 0.02). For HKA, the median accuracy was 3.1° [0.3-7.3] versus 0.8° [0-5] in the CM and HT groups, respectively (p = 0.006). Five (5/18, 28%) and 16 (16/21, 76%) knees were within 3° of the target in the CM and HT groups, respectively (p = 0.004). The median tibial slope increased in both groups. This increase was significantly greater in the CM group compared with the HT group, with 5.5° [- 0.3-13] versus 0.5 [- 5.2-5.6], respectively (p < 0.001). The median Caton-Deschamps index decreased (patella lowered) in both groups after surgery, by - 0.21 [- 1.03; - 0.05] and - 0.14 [- 0.4-0.16], but without significant difference (p = 0.19). In univariate analysis, changes in tibial slope and patellar height were not significantly related to frontal surgical correction performed according to ΔMTA (R2 = 0.07; p = 0.055) and (R2 = - 0.02; p = 0.54) respectively. DISCUSSION: The correction set by the surgeons was achieved with greater accuracy and more frequently in the HT group, confirming the working hypothesis. The HT is therefore recommended as a simple way of achieving the set objective; the tibial slope and patellar height were modified unaffected by the frontal correction performed.

Acute compartment syndrome of the lower limbs: Fasciotomy or dermofasciotomy? A cadaver study of compartment pressures.

BACKGROUND: Acute compartment syndrome (ACS) of the lower limbs is a function-threatening event usually managed by extended dermofasciotomy. Closure of the skin may be delayed, creating a risk of complications when there is an underlying fracture. Early treatment at the pre-ACS stage might allow isolated fasciotomy with no skin incision. The primary objective of this study was to compare intracompartmental pressure (ICP) changes after fasciotomy and after dermofasciotomy. The secondary objectives were to evaluate potential associations linking the starting ICP to achievement of an ICP below the physiological cut-off of 10mm Hg and to determine whether the ICP changes after fasciotomy and dermofasciotomy varied across muscle compartments. HYPOTHESIS: Fasciotomy with no skin incision may not provide a sufficient ICP decrease, depending on the initial ICP value. MATERIAL AND METHODS: A previously validated model of cadaver ACS of the lower limbs was used. Saline was injected gradually to raise the ICP to>15mmHg (ICP15), >30mmHg (ICP30), and >50mmHg (ICP50). We studied 70 leg compartments (anterior, lateral, and superficial posterior) in 13 cadavers (mean age, 89.1±4.6years). ICP was monitored continuously. Percutaneous, minimally invasive fasciotomy consisting in one to three 1-cm incisions was performed in each compartment. ICP was measured before and after fasciotomy then after subsequent skin incision. The objective was to decrease the ICP below 10mmHg after fasciotomy or dermofasciotomy. RESULTS: Overall, mean ICP was 37.8±19.1mmHg after the injection of 184.0±133.01mL of saline. In the ICP15 group, the mean ICP of 16.1mmHg fell to 1.4mmHg after fasciotomy (ΔF=14.7) and 0.3mmHg after dermofasciotomy (ΔDF=1.1). Corresponding values in the ICP30 group were 33.9mmHg, 4.7mmHg (ΔF=29.2), and 1.2mmHg (ΔDF=3.5); and in the ICP50 group, 63.7mmHg, 17.0mmHg (ΔF=46.7), and 1.2mmHg (ΔDF=15.8). Thus, in the group with initial pressures >50mmHg, the ICP decrease was greater after both procedures, but fasciotomy alone nonetheless failed to achieve physiological values (<10mmHg). The pressure changes were not significantly associated with the compartment involved (anterior, lateral, or superficial posterior) (p<0.05). CONCLUSION: Under the conditions of this study, higher baseline ICPs were associated with larger ICP drops after fasciotomy and dermofasciotomy. Nevertheless, when the baseline ICP exceeded 50mmHg, fasciotomy alone failed to decrease the ICP below 10mmHg. Adding a skin incision achieved this goal. LEVEL OF EVIDENCE: IV, experimental study.

Osteotomies for genu varum: Should we always correct at the tibia? A multicenter analysis of practices in France.

INTRODUCTION: Tibial correction is often performed during a valgus-producing osteotomy for genu varum. However, overcorrection and the creation of a joint line obliquity (JLO) have been associated with unfavorable functional outcomes after high tibial osteotomy (HTO). The aims of this study were to analyze: 1) the corrections obtained after HTO; 2) the rationale behind the indication per the European Society for Sports Traumatology Surgery and Arthroscopy (ESSKA) recommendations; and 3) the correlation between the postoperative corrections obtained and functional outcomes. HYPOTHESIS: A significant number of patients who underwent an isolated HTO did not present an "ideal" theoretical indication based on the preoperative angles and correction targets to be performed. MATERIALS AND METHODS: This multicenter study included 289 isolated HTOs. Demographic and morphometric data were anonymized and compiled in a database. Preoperative radiographic parameters were compared with the ESSKA consensus recommendations on osteotomies for genu varum. The consensus defined the "ideal" indication for performing an HTO as medial tibiofemoral compartment pain with significant tibial varus deformity (medial proximal tibial angle [MPTA]<85°), no significant femoral varus deformity (lateral distal femoral angle [LDFA]<90°), an expected postoperative obliquity of less than 5°, and a correction resulting in moderate tibial valgus (postoperative MPTA<94°). The incidence of patients with an "ideal" theoretical indication for isolated HTO and those with a theoretical indication not perfectly justified by the radiographic data and preoperative planning were recorded. RESULTS: Under the ESSKA consensus criteria, 25.3% (n=73) of isolated HTOs, 15.6% (n=45) of isolated femoral osteotomies, 9.3% (n=27) of double-level osteotomies, and 49.9% (n=144) of cases where no osteotomy was performed due to the lack of significant extra-articular tibial and/or femoral deformity were deemed justified. The presence of a preoperative femoral deformity and the absence of an "ideal" indication for HTO did not affect the postoperative Tegner Activity Scale or the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (p>0.05). A high preoperative hip-knee-ankle (HKA) angle and MPTA, which indicated less varus, were associated with a greater risk of there being no "ideal" theoretical indication for an HTO (coefficient of determination [R2]=0.19 and R2=1, respectively; p<0.001). CONCLUSION: This study showed that isolated HTOs in current practice were not justified in a significant number of patients, even though they could lead to tibial overcorrection and excessive JLO. This did not impact the functional results of this series, but it might complicate the performance of a secondary knee arthroplasty. Nevertheless, some young patients in this series underwent a salvage osteotomy outside the "ideal" indications of the European recommendations. LEVEL OF EVIDENCE: IV; case series.

Trans-medial gastrocnemius approach (Badet approach) for displaced posterior cruciate ligament tibial avulsion.

Avulsions of the retrospinal surface are rare injuries resulting from high-energy trauma. Displacement of this fracture frequently indicates a surgical treatment to restore posterior cruciate ligament function. Several approaches have been proposed in the literature, either open or arthroscopic, which can be tricky due to the fracture's proximity to the popliteal vascular-nervous elements. Badet's open approach is a medial trans-gastrocnemius approach, providing a direct access to the retro-spinal surface for osteosynthesis. In this technique, an L-shaped incision is made along precise skin lines, followed by discision of the muscle fibers. The capsule is then approached, allowing a view of the retro-spinal surface protected from the popliteal vasculo-nervous elements by the muscular lateral lip of the gastrocnemius. A reduction followed by screw osteosynthesis is usually performed, allowing early mobilization of the patient. In this technical note, we describe the Badet approach supporting by video and case series. LEVEL OF EVIDENCE: IV.

Double-level osteotomy for varus knees using patient-specific cutting guides allow more accurate correction but similar clinical outcomes as compared to conventional techniques.

PURPOSE: Patient-specific cutting guides are increasingly used in the field of osteotomies around the knee and can improve the accuracy of planned correction and more specifically in the case of double-level osteotomy (DLO). The purpose of this study was to analyse the accuracy of postoperative coronal alignment after DLO using patient-specific cutting guides techniques (PSI) compared to conventional techniques. The secondary objective was to compare the functional results between the two groups at short-term follow-up. HYPOTHESIS: The accuracy of global correction (HKA angle) is better with patient-specific cutting guides compared to conventional techniques for double-level osteotomy METHODS: This multicentric comparative retrospective study included 53 patients (mean age: 53.8 ± 5.2 years, male/female: 44/9) who underwent a DLO for knee varus malalignment. The coronal correction accuracy (as expressed by the difference between postoperative angular values and preoperative targeted correction) was compared between techniques using patient-specific cutting guides (PSI group, n = 27) or conventional techniques (n = 26) for the medial proximal tibial angle (MPTA) and the lateral distal femoral angle (LDFA). Postoperatively, the global alignment expressed by the hip-knee-ankle angle and the joint line obliquity were compared between groups. The postoperative functional results for KOOS and UCLA activity scale score were also compared at a mean follow-up of 1.7 years (1.0-3.1 years). RESULTS: No difference was observed for the postoperative global alignment between the PSI and the conventional groups (Δ = 0.6 °, p = 0.11) neither for the postoperative posterior proximal tibial angle (Δ = 1.6°, p = 0,99) or the joint line obliquity (Δ = 0.3°, p = 0,17). In the coronal plane, the postoperative MPTA was lower in the PSI group (Δ = 2.3°, p < 0.001) as well as the postoperative LDFA (Δ = 0.9°, p = 0.01). Concerning correction accuracy in the coronal plane, the results showed a significant higher accuracy of the planned correction in the PSI group compared to the conventional group for MPTA (2.2 ± 0.2 versus 0.8 ± 0.7, Δ = 1.5 °, p < 0.001) and LDFA (1.3 ± 1.0 versus 0.6 ± 0.9, Δ = 0.7°, p < 0.001). No improvement difference was observed between the conventional group and the PSI group respectively for the KOOS symptoms (p = 0.12), the KOOS Pain (p = 0,57), the KOOS activities of daily living (p = 0.61), the KOOS sport/rec (p = 0.65), or for the KOOS Quality of Life (p = 0.99) neither for the UCLA (p = 0.97). CONCLUSIONS: This study suggests that the use of custom-made cutting guides improves the accuracy of planned correction in double-level osteotomy compared with conventional techniques, which may have implications particularly in centers not performing a large volume of osteotomies. This improved accuracy is not associated with any difference in joint line obliquity or functional results but these results need to be confirmed by a randomized prospective study. LEVEL OF EVIDENCE: III; Retrospective comparative study.

Can hip function be assessed with self-report questionnaires? Feasibility study of a French self-report version of the Harris Hip and Merle d'Aubigné scores.

INTRODUCTION: The Harris Hip Score (HHS) and the Merle D'Aubigné Postel (MDP) score both provide an objective and subjective evaluation of hip function. These scores are collected during the follow-up of patients who have a hip disease. The objectives of this prospective study were (1) to analyze the differences between the two new French self-report versions of the HHS and MDP, and the traditional surgeon-assessed HHS and MDP; (2) to analyze the correlation between the self-report HHS and MDP and the surgeon-assessed HHS and MDP; (3) to analyze the floor and ceiling effects of the two self-report scores and the reliability of these self-report scores in operated and non-operated patients. HYPOTHESIS: The French self-report HHS and MDP are sufficiently reliable to accurately estimate the patient's objective and subjective outcomes compared to the clinical examination done by a surgeon. METHODS: A prospective multicenter study was done with patients who had a hip disease. Two self-report questionnaires were completed by the patient, independently of the clinical examination done by the surgeon. The questionnaires were in French and consisted solely of checkboxes, with sample photos that corresponded to the various range of motion items in the HHS and MDP. The agreement between the self-report scores and the surgeon-assessed scores were evaluated using the intraclass correlation coefficient (ICC). Differences in the mean values were evaluated with a paired t test. RESULTS: The analysis involved 89 patients. The self-report HHS was 2.7±3.7 points (/100) lower than the surgeon-assessed HHS, but this difference was not statistically significant (p=0.34). The self-report MDP was significantly less by 1.2±2.9 points (/18) than the surgeon-assessed MDP (p=0.01). The agreement between the self-report HSS and the surgeon-assessed HSS was excellent (ICC=0.86) as was the one between the self-report MDP and the surgeon-assessed MDP (ICC=0.75). There was a strong positive correlation between the surgeon-assessed and self-report HHS in operated patients (ICC= 0.84; R=0.75; p<0.001) and in non-operated patients (ICC=0.96; R=0.89; p<0.001). This positive correlation was also found between the surgeon-assessed and self-report MDP for operated patients (ICC=0.73; R=0.62; p<0.001) and non-operated patients (ICC=0.79; R=0.64; p<0.001). A ceiling effect (maximum of 100 points) was found in 22% of patients (20/89) for the self-report HHS and in 34% of patients (30/89) for the self-report MDP (maximum of 18 points). No floor effect was observed for either questionnaire. CONCLUSION: The French version of the HHS self-report questionnaire is an excellent overall estimator of the HHS score for patients with hip osteoarthritis or fracture, whether operated or not. The addition of the MDP, whose self-report version is less accurate, is also a reliable tool. These self-report questionnaires, when validated on a larger scale, will be useful for the long-term follow-up of patients undergoing hip arthroplasty. LEVEL OF EVIDENCE: III; prospective diagnostic study.

Total blood loss after hip hemiarthroplasty for femoral neck fracture: Anterior versus posterior approach.

INTRODUCTION: Femoral neck fractures constitute a public health problem due to significant associated morbidity and mortality amongst the ageing population. Perioperative blood loss can increase this morbidity. Blood loss, as well as the influence that the surgical approach exerts on it, remains poorly evaluated. We therefore conducted a retrospective comparative study in order to: (1) compare total blood loss depending on whether the patients were operated on using an anterior or posterior approach, (2) compare the transfusion rates, operating times and hospital stays between these two groups and, (3) analyze dislocation rates. HYPOTHESIS: Total blood loss is greater from an anterior approach following a hip hemiarthroplasty for femoral neck fracture, compared to the posterior approach. MATERIAL AND METHODS: This retrospective single-center comparative study included 137 patients operated on by hip hemiarthroplasty between December 2020 and June 2021, and seven patients were excluded. One hundred and thirty patients were analyzed: 69 (53.1%) had been operated on via the anterior Hueter approach (AA) and 61 (46.9%) via the posterior Moore approach (PA). The analysis of total blood loss was based on the OSTHEO formula to collect perioperative "hidden" blood loss. The risk of early dislocation (less than 6 months) was also analyzed. RESULTS: Total blood loss was similar between the two groups, AA: 1626±506mL versus PA: 1746±692mL (p=0.27). The transfusion rates were also similar between the two groups, AA: 23.2% versus PA: 31.1% (p=0.31) as well as the duration of hospitalization, AA: 8.5±3.2 versus PA: 8.2±3.3 days (p=0.54). The operating time was shorter in the PA group (Δ=10.3±14.1minutes [p<0.001]) with a greater risk of early dislocation when the patient was operated on by PA with AA: 9.8% versus PA: 1.4% (p=0.03). CONCLUSION: This study does not demonstrate any influence of the approach (anterior or posterior) on total blood loss. Transfusion rates and length of hospitalization were similar between the groups with a slightly shorter operating time but a greater risk of early dislocations after posterior hemiarthroplasty in a population at high anesthesia-related risk. LEVEL OF PROOF: III, comparative study of continuous series.

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.

Slope-decreasing anterior closing wedge proximal tibial osteotomies using the freehand technique are accurate to within 2̊.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction requires a detailed analysis of the posterior tibial slope (PTS) as excessive values may cause the reconstruction to fail and require a slope-decreasing anterior closing wedge tibial osteotomy combined with revision of the failed ACL reconstruction. The main purpose of this study was to assess the accuracy of correction after slope-decreasing anterior closing wedge tibial osteotomy in cases of chronic anterior instability caused by ACL rerupture. MATERIALS AND METHODS: This single-center retrospective study included 19 patients (20 knees) operated on by slope-decreasing anterior closing wedge tibial osteotomy combined with a second revision ACL reconstruction. The mean age was 22.4±3.3 years and the mean follow-up was 12.7±4.4 months. The preoperative planning was based on lateral calibrated X-rays of the entire tibia. The height of the closing wedge, which corresponded to the base of the osteotomy, was measured in millimeters. The procedure was performed using the freehand technique. The accuracy of the correction was defined as the difference between the desired preoperative PTS and the postoperative PTS achieved. An inter- and intraobserver analysis was performed. RESULTS: The mean preoperative PTS was 13.9±2̊ and the mean postoperative PTS was 4.0±1.7̊. The mean PTS correction was 10.1±2.1̊ with a planned target of 5.4±1.8̊. The accuracy obtained between the planned target and the postoperative corrections was 1.7±1.1̊. The regression analysis showed that the accuracy of the PTS correction was not influenced by the patient's age, BMI, excessive preoperative PTS, or degree of correction achieved (p>0.05). CONCLUSION: Slope-decreasing anterior closing wedge tibial osteotomies performed using the freehand technique for ACL graft rerupture can correct an excessive PTS within 2̊ of the planned slope correction. This accuracy is not determined by demographic factors, excessive preoperative PTS or degree of correction achieved. LEVEL OF EVIDENCE: IV; retrospective cohort study.

Comparative study of bilateral total hip arthroplasty in one or two stages.

INTRODUCTION: Bilateral total hip arthroplasty (Bi THA) for disabling bilateral hip osteoarthritis can be performed in one or two operative sessions. The objective of this study was to compare the complication rates of a group of patients who had bilateral THA in one operating session (Bi-1S THA) to a matched group of patients who had bilateral THA in two separate operating sessions (Bi-2S THA). MATERIALS AND METHODS: This retrospective case-control study compared 84 Bi-1S THA matched to 84 Bi-2S THA by age, gender, diagnosis, ASA score (1-2) and surgical approach. The minimum follow-up was 12 months. Complication rates, total blood loss, number of blood transfusion units, and functional outcomes were assessed. RESULTS: Twelve patients (14.3%) in the Bi-1S THA group had minor or major complications, compared to twenty-one (25%) in the Bi-2S THA group (p=0.08): there were fewer minor complications in the Bi-1S THA group and a similar rate of major complications amongst the two groups. Total blood loss estimated using the OSTHEO formula was significantly lower in patients operated on by Bi-1S THA (1853±753mL versus 2804±1012mL, p <0.0001). The number of blood transfusion units was similar between the groups (0.5±0.8 versus 0.3±1.4 respectively, p=0.55). No significant difference was found regarding the functional results. CONCLUSION: Under the conditions of this study, bilateral total hip arthroplasty in one operative session leads to fewer minor complications, and a similar rate of major complications, when compared to bilateral total hip arthroplasty in two separate sessions. This strategy can therefore be recommended for ASA 1 and 2 patients, under the age of 80 with disabling bilateral osteoarthritis. LEVEL OF EVIDENCE: III, retrospective comparative study.

Patient specific instrumentation allow precise derotational correction of femoral and tibial torsional deformities.

BACKGROUND: Rotational malalignment deformities of the lower limb in adults mostly arise from excessive femoral anteversion and/or excessive external tibial torsion. The aim of this study was to assess the correction accuracy of a patient specific cutting guides (PSCG) used in tibial and femoral correction for lower-limb torsional deformities. METHODS: Forty knees (32 patients) were included prospectively. All patients had patellofemoral pain or instability with torsional malalignment for which a proximal tibial (HTO) or distal femoral (DFO) or a double-level osteotomy (DLO) had been performed. Accuracy of the correction between the planned and the postoperative angular values including femoral anteversion, tibial torsion, coronal and sagittal alignment were assessed after tibial and/or femoral osteotomy. RESULTS: Forty knees were included in this study. In cases of HTO, the correction accuracy obtained with PSCG was 1.3 ± 1.1° for tibial torsion (axial plane), 0.8 ± 0.7° for MPTA (coronal plane) and 0.8 ± 0.6° for PPTA (sagittal plane). In cases of DFO, the correction accuracy obtained with PSCG was 1.5 ± 1.4° for femoral anteversion (axial plane), 0.9 ± 0.9° for LDFA (coronal plane) and 0.9 ± 0.9° for PDFA (sagittal plane). The IKSG was improved from 58.0 ± 13.2° to 71.4 ± 10.9 (p = 0.04) and the IKSF from 50.2 ± 14.3 to 87.0 ± 6.9 (p < 0.001). CONCLUSIONS: Using the PSCG for derotational osteotomy allows excellent correction accuracy in all the three planes for femoral and tibial torsional deformities associated with patellofemoral instability. Level of clinical evidence II, prospective cohort study.