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.

Male sex, revision surgery, low volume of anterior cruciate ligament remnant, and significant instability are risk factors for Posterior Root Tear of the Lateral Meniscus in patients undergoing Anterior Cruciate Ligament Reconstruction.

PURPOSE: This multicenter study aimed to determine the incidence of lateral meniscus posterior root tears (LMPRTs) in patients undergoing ACL reconstruction and identify associated risk factors. METHODS: We conducted a retrospective, multicenter study using data from the Francophone Arthroscopic Society's registry. The study included all the patients in the registry who underwent ACL reconstruction surgery between June 2020 and June 2023, we excluded incomplete data. We compared delay from injury to surgery between LMPRTs group and No LMPRTs group. Variables investigated as potential risk factors for LMPRTs included age, sex, nature of surgery (primary or revision), pivot shift test result, side-to-side laxity under anesthesia, presence of ACL remnant, occurrence of medial meniscal tear, and presence of collateral ligament injury. Risk factors were analyzed using a logistic regression model. RESULTS: Among the 5359 patients analyzed, LMPRTs occurred in 7.0% (n=375) of cases during ACL reconstruction. Mean age at surgery was 29.3 +/- 10.3 years old [11-77]. Concerning delay to surgery, the mean time was 8.4 +/- 23.1 weeks [0.0-347.2] in the No LMPRTs group and 6.5 +/- 10.2 weeks [0.2-61.6] in the LMPRTs group (p = 0.109). Univariate analysis revealed that male sex (p < 0.001), revision surgery (p < 0.001), medial meniscal injury (p = 0.007), ACL remnant (0% vs > 70%, <10% vs > 70%, 10 to 30% vs > 70%, 30 to 50% vs > 70%, 50 to 70% vs > 70%; p < 0.001) and higher pivot shift grade (p = 0.011) were significantly associated with a presence of LMPRTs. Age, side-to-side laxity, and collateral ligament injury were not found to be significant risk factor In multivariate analysis : male sex, revision surgery, pivot shift test result and a low volume of ACL remnant remained significant. Side to side laxity was also a significant factor in multivariate analysis. CONCLUSION: This study identified male sex, revision surgery, low volume of ACL remnant, side to side laxity and higher grade of pivot shift as significant risk factors for LMPRTs during ACL reconstruction.

Risk factors and prevalence of ramp lesions in ACL ruptures: An analysis from the registry of the Francophone Arthroscopic Society.

PURPOSE: The study aimed to estimate the prevalence of ramp lesions among patients undergoing anterior cruciate ligament (ACL) reconstruction and identify risk factors associated with these lesions. METHODS: A retrospective, multicentre cohort study was conducted using data from the Francophone Arthroscopic Society's registry, including 5359 patients who underwent ACL reconstruction (ACLR) from June 2020 to June 2023. Potential risk factors for ramp lesion such as patient demographics, revision surgery, pivot shift, side-to-side anteroposterior laxity, medial collateral ligament (MCL) injury, lateral meniscal tear and the volume of ligament remnant were evaluated using multivariate regression analyses. BMI and delay to surgery were also assessed. RESULTS: Ramp lesions were identified in 822 patients (15.3%). Univariate analysis identified male sex, younger age, revision surgery, lateral meniscal injury, percentage of ACL remnant (all p < 0.0001) and pivot shift (p = 0.0103) as significant risk factors. MCL injury was associated with a lower risk (p < 0.0001). In multivariate analysis, male sex, younger age, revision surgery, lateral meniscal injury and percentage of ACL remnants remained significant risk factors, while MCL injury remained a protective factor. The anteroposterior laxity wasn't a significant predictor in either analysis. In subgroup analysis, there were differences concerning body mass index (n.s) and the delay to surgery (n.s). CONCLUSION: The study identified male sex, younger age, revision surgery, lateral meniscal injury and pourcentage of ACL remnant as significant risk factors for ramp lesions, with MCL injury acting as a protective factor. This will help regarding the suspicion and identification of ramp lesions. LEVEL OF EVIDENCE: Level III.

Dynamic Magnetic Resonance Imaging (MRI) in Inguinal-Related Chronic Groin Pain (CGP): Comparison With Systematic Surgical Assessment.

Objective This study aimed to assess the performance of dynamic MRI in Chronic Groin Pain (CGP) related to the inguinal region, comparing it with surgery as the gold standard. Materials and methods A cohort of 25 consecutive patients exhibiting persistent clinical inguinal-related CGP underwent a pre-surgical pelvis MRI. Imaging encompassed strictly axial Fast Spin Echo (FSE) T1 sequences, both without (static sequence) and with Valsalva Maneuver (VM, dynamic sequence), alongside axial-oblique Proton Density weighted with Fat Saturation (PDFS). Evaluation of these sequences focused on identifying Abdominal Wall (AW) injuries. A consistent surgical approach was employed by the same surgeon across all patients (34 AW injuries in 25 patients). Specificity (Sp), Sensitivity (Se), Negative Predictive Value (NPV), Positive Predictive Value (PPV), and overall accuracy of MRI sequences and their combinations for detecting AW injuries were computed by comparing them to surgical findings. Results Ninety sequences were obtained, revealing that the axial PDFS oblique sequence emerged as the most singularly reliable (Accuracy: 58.82%). The optimal sequence combination was found to be axial T1 combined with axial T1 VM, exhibiting an accuracy of 75.00% (Se: 85.71%, Sp: 70.59%, PPV: 54.55%, NPV: 92.31%, with an average duration of 4 minutes and 31 seconds). Conclusion Based on our findings, we advocate for the adoption of the axial FSE T1 combined with Valsalva Maneuver as a dependable protocol for inguinal-related CGP, characterized by a highly reasonable examination duration.

Better clinical outcomes and faster weight bearing after medial opening-wedge high tibial osteotomy using allogeneic than synthetic graft: A secondary analysis of a Francophone Arthroscopy Society Symposium.

INTRODUCTION: Although an autogenous graft has the highest rate of bone union to fill the void created in medial opening wedge high tibial osteotomy (MOWHTO), it also has some disadvantages, such as prolonged surgical time, donor site pain and morbidity. Two possible candidates for ideal grafts to replace autogenous grafts are allogeneic and synthetic graft, which are free from donor site pain and morbidity. However, previous reports comparing the clinical results of allogeneic to synthetic graft have been limited and controversial. The purpose of this study is to compare radiological findings and clinical outcomes of using synthetic versus allogenic graft to fill the void created in MOWHTO. HYPOTHESIS: The present clinical study hypothesized that allogenic graft to fill the void would allow the higher rate of bone union and better clinical outcomes. MATERIAL AND METHODS: This study compared the clinical and radiological outcomes of 95 patients who received MOWHTO to fill the void with either synthetic or allogenic graft (44 in Syn group, 51 in Allo group). Preoperatively and postoperatively, all patients were clinically evaluated; Return to work, Tegner activity score, and the Western Ontario and Macmaster University scores were reported. Radiographically, osteoarthritis grade and pre- and postoperative parameters were reported, including Hip-knee-ankle angle, mechanical lateral distal femoral angle, medial proximal tibial angle, joint line convergence angle, proximal posterior tibial angle, and limb length discrepancy. Perioperative details and complications were also reported. RESULTS: Mean follow-up (months) were 24.0±1.3 in Syn group and 26.8±1.2 in Allo group (p=0.13). The postoperative improvement of pain and global WOMAC scores in Allo group were significantly better than in Syn group (ΔPain of WOMAC: Syn group 27.8±4.4, Allo group 49.3±3.8, p value <0.001*) (ΔGlobal score of WOMAC: Syn group 16.7±3.2, Allo group 37.4±4.9, p value=0.002*). The risk of hinge fracture in Syn group was significantly higher than in Allo group (Hinge fracture by Takeuchi grade (0/1/2/3): Syn group 37/3/3/1, Allo group 43/8/0/0, p value=0.04*). The timing of full weight bearing in Allo group was significantly earlier than in Syn group (Weight Bearing (1=FWB, 2=PWB 3wk, 3=PWB 6wk): Syn group 2.7±0.1, Allo group 2.3±0.1, p value=0.01*). DISCUSSION: The use of allogenic graft to fill the void in MOWHTO does not show superiority in bone union compared to synthetic graft, however it improves pain, function, decreases the risk of hinge fracture and allows faster weight bearing than synthetic graft. LEVEL OF PROOF: III; Case-control study.

High tibial osteotomy is equally effective for varus malaligned knees with either virgin or wrecked medial meniscus: An age and gender-matched secondary analysis of a Francophone Arthroscopy Society Symposium.

INTRODUCTION: Despite the growing concept of meniscal preservation, partial meniscectomy could be the definitive procedure in specific scenarios. And total meniscectomy was once before a frequent procedure, with current sequelae of degenerate knees. High tibial osteotomy (HTO) is an effective treatment for patients suffering from unicompartmental degenerative changes, and substantial deformities. However, it is yet to be answered, whether HTO is similarly effective in both post-meniscectomy knees and knees with not previously operated meniscus. HYPOTHESIS: Outcomes of HTO is similar with or without previous history of total or subtotal meniscectomy. METHODS: This study compared the clinical and radiological outcomes of 41 patients who received HTO and had no previous history of surgery in the ipsilateral knee (group I), and 41 age, and gender-matched patients who had meniscectomy surgery in the ipsilateral knee (group II). Preoperatively and postoperatively, all patients were clinically evaluated; the visual analogue scale scores, Tegner activity score, and the Western Ontario and Macmaster University scores were reported. Radiographically, osteoarthritis grade and pre- and postoperative parameters were reported, including hip-knee-ankle angle, femoral mechanical angle, medial proximal tibial angle, joint line convergence angle, proximal posterior tibial angle, and limb length discrepancy. Perioperative details and complications were reported. RESULTS: A total of 82 patients were included; group I (n=41) and group II (n=41). The mean age was 51.18±8.64 (27-68) and 90.24% were male. The duration since the onset of symptoms was longer in group II vs. group I, 43.34±41.03 versus 38.07±36.11months respectively. No significant differences in the clinical evaluation between the two groups with a greater proportion of patients demonstrating moderate degenerative changes. Similar preoperative and postoperative radiographic parameters were reported, in group I, Δ HKA was 7.19±4.14 versus 7.65±3.16 in group II. Preoperative pain VAS scores were slightly higher in group II vs. group I, 79.23±26.35 vs. 76.31±24.45, respectively. However, postoperatively, the pain scores significantly improved in group I vs. group II, 22.84±3.65 vs. 41.69±17.33, respectively. Tegner activity scores and WOMAC scores were comparable between both groups preoperatively and postoperatively. Only the WOMAC function scores were better in group I when compared to group II, 26.13±25.84 versus 20.01±17.98. All patients returned to work at an average of 0.82±0.38months. CONCLUSION: Knee preservation with high tibial osteotomy is equally effective in managing unicompartmental degenerative changes in varus malaligned knees with either no previous history of meniscal surgeries or where a meniscal sacrifice was inevitable, either with subtotal or total meniscectomy. LEVEL OF EVIDENCE: III, retrospective case-control study.

Functional scores and prosthetic implant placement are different for navigated medial UKA left in varus alignment.

PURPOSE: The purpose of this study was to analyze the clinical outcomes and radiologic position of the knee in two groups of patients after medial unicompartmental knee arthroplasty (UKA): one group with residual varus axis (RVA) alignment and other one with neutral mechanical axis (NMA) of the lower limb. METHODS: All patients who underwent UKA between January 2015 and January 2018 were evaluated retrospectively. Inclusion criteria were: medial UKA for isolated medial femoro-tibial osteoarthritis, a varus deformity of < 15°, and a minimal follow-up of 2 years. All patients had a preoperative and postoperative clinical examination with functional scores (New International Knee Score (NewIKS) and Knee injury and Osteoarthritis Outcome Score (KOOS) and radiographs. Preoperative and postoperative values for continuous outcomes were compared using the Student's t test for paired data and differences between the groups were compared with the Mann-Whitney U test. p < 0.05 was considered statistically significant. RESULTS: The RVA group consisted of 48 cases of medial UKA in 48 patients (22 females). Mean postoperative hip-knee-ankle (HKA) angle was 174.3° ± 2.8 and the corresponding mean AKI angle (tibial mechanical angle) was 82.9° ± 2.9. The NMA group consisted of 35 cases of medial UKA in 35 patients (14 females). Mean postoperative HKA angle was 178.9° ± 3 and the corresponding mean AKI angle was 85.5° ± 3.1. A significant difference was found between the two groups for the KOOS score and for global NewIKS, with a better score in the RVA group. CONCLUSIONS: RVA alignment after medial UKA results in a significant improvement in functional knee scores at 2-year post-surgery. Return to sport and recreational activities was better than in patients with postoperative NMA. LEVEL OF EVIDENCE: Level 3; retrospective cohort study.

Association of COVID-19 Lockdown With Increased Rate of Cyclops Syndrome in Patients With Unexpected Home-Based Self-Guided Rehabilitation After ACL Reconstruction.

Background: The risk of cyclops syndrome increases significantly after anterior cruciate ligament (ACL) reconstruction (ACLR) if complete extension is not recovered before the sixth postoperative week. The lockdown in France due to the COVID-19 pandemic led to an absence of supervised rehabilitation, requiring unexpected self-rehabilitation in patients who underwent ACLR just before lockdown. Purpose: To determine the rate of cyclops syndrome after ACLR in patients who underwent self-rehabilitation during lockdown. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 75 patients receiving a hamstring graft for ACLR during the COVID-19 pandemic between February 10, 2022, and March 16, 2020, carried out self-rehabilitation during part of their first 6 postoperative weeks using exercise videos on a dedicated website. Clinical examination was performed at a minimum 1-year follow-up with International Knee Documentation Committee (IKDC), Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI) scores. This group was compared with a matched-pair control group of 72 patients who underwent surgery in 2019 and completed postoperative supervised rehabilitation with a physical therapist. Rates and reasons for second surgery (arthrolysis, meniscal procedure) were also recorded. Results: In the COVID group (n = 72; 3 patients were lost to follow-up), the mean follow-up was 14.5 ± 2.1 months (range, 13-21) and rate of reoperation for clinical cyclops syndrome was 11.1% (n = 8). The rate of cyclops syndrome was significantly lower (1.4%) in the control group (P = .01). In the COVID group, 8 patients underwent anterior arthrolysis at a mean of 8.6 months after the primary surgery, and 4 patients underwent another surgical intervention (meniscal procedure [n = 3], device removal [n = 1]). In the COVID group, mean Lysholm was 86.6 ± 14.1 (range, 38-100), Tegner was 5.6 ± 2.3 (range, 1-10), subjective IKDC was 80.3 ± 14.7 (range, 32-100) and ACL-RSI score was 77.3 ± 19.7 (range, 33-100). Conclusion: The rate of cyclops syndrome after ACLR was significantly greater in the COVID group versus the matched controls. The dedicated website was not effective at supporting self-guided rehabilitation and could benefit from interactive improvements so it is at least as effective as supervised rehabilitation.

A predictive score of high tibial osteotomy survivorship to help in surgical decision-making: the SKOOP score.

INTRODUCTION: The high tibial osteotomy (HTO) survival rate is strongly correlated with surgical indications and predictive factors. This study aims to assess HTO survival in the long term, to determine the main predictive factors of this survival, to propose a predictive score for HTO based on those factors. METHODS: This multicentric study included 481 HTO between 2004 and 2015. The inclusion criteria were all primary HTO in patients 70 years old and younger, without previous anterior cruciate ligament injury, and without the limitation of body mass index (BMI). The assessed data were preoperative clinical and radiological parameters, the surgical technique, the complications, the HKA (hip knee ankle angle) correction postoperatively, and the surgical revision at the last follow-up. RESULTS: The mean follow-up was 7.8 ± 2.9 years. The HTO survival was 93.1% at 5 years and 74.1% at 10 years. Age < 55, female sex, BMI < 25 kg/m2 and incomplete narrowing were preoperative factors that positively impacted HTO survival. A postoperative HKA angle greater than 180° was a positive factor for HTO survival. The SKOOP (Sfa Knee OsteOtomy Predictive) score, including age (threshold value of 55 years), BMI (threshold values of 25 and 35 kg/m2), and the presence or absence of complete joint line narrowing, have been described. If the scale was greater than 3, the survival probability was significantly lower (p < 0.001) than if the scale was less than 3. CONCLUSION: A predictive score including age, BMI, and the presence or absence of joint line narrowing can be a helpful in making decisions about HTO, particularly in borderline cases. LEVEL OF EVIDENCE: Retrospective cohort study.

Tibial tunnel expansion does not correlate with four-strand graft maturation after ACL reconstruction using adjustable cortical suspensory fixation.

PURPOSE: Anterior cruciate ligament reconstruction (ACLR) using a short, quadrupled semitendinosus (ST-4) autograft, fixed  with an adjustable suspensory fixation (ASF), has several potential advantages. However, the construct is suspected to generate micromotion, tunnel widening and poor graft maturation. The aim of this study was to evaluate post-operative tibial tunnel expansion, graft maturation and clinical outcomes for this type of ACLR. METHODS: One-hundred and forty-nine patients were reviewed at a minimum of 2 years following 4-ST ACLR, mean 25.6 ± 3.5 months [24-55], with clinical follow-up and MRI scans. Graft maturity of the intra-articular part of the graft and the tibial tunnel portion was assessed using Signal-to-Noise Quotient (SNQ) and Howell score. Tibial tunnel expansion, bone-graft contact and graft volume in the tibial tunnel were calculated from the MRI scans. RESULTS: Mean tibial tunnel expansion was 13 ± 16.5% [12-122]. Mean SNQ for graft within the tibial tunnel was 3.8 ± 7.1 [ - 7.7 to 39] and 2.0 ± 3.5 [ - 14 to 17] for the intra-articular portion of the graft. The Howell score for graft within the tibial tunnel was 41% Grade I, 37% Grade 2, 20% Grade 3, 2% grade 4, and for the intra-articular part 61% Grade 1, 26% Grade 2, 13% Grade 3 and 1% Grade 4. The mean tibial tunnel bone-graft contact was 81 ± 23% [0-100] and mean graft volume was 80 ± 22% [0-100]. No correlation was found between tibial tunnel expansion and graft maturity assessed at both locations. Graft maturity was correlated with higher graft-bone contact and graft volume in the tibial tunnel (p < 0.05). CONCLUSIONS: ST-4 ACLR with ASF had low levels of tunnel enlargement at 2 years. No correlation was found between graft maturation and tibial tunnel expansion. Graft maturity was correlated with graft-bone contact and graft volume in the tibial tunnel. LEVEL OF EVIDENCE: Level III.

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

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

The Mirror Anterolateral Ligament: A Simple Technique to Reconstruct the Deep Medial Collateral Ligament Using the Gracilis Associated With a Four-Strand Semitendinosus for Anterior Cruciate Ligament Reconstruction.

We present a surgical technique to reconstruct the deep portion of the medial collateral ligament (MCL) when associated with an injury of the anterior cruciate ligament (ACL). Patients could benefit from this procedure in cases of ACL reconstruction and persistent laxity at 20° of flexion of the MCL without any laxity in extension. This surgery uses the gracilis to reconstruct the deep portion of the MCL in the same manner described for the anterolateral ligament on the other side of the knee. The procedure is performed percutaneously, graft and tunnels are independent from the ACL, a screw is used on the femoral side, and a cortical device is used on the tibial side.

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

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction is a frequent procedure, with room for improvement by rehabilitation measures and associated peripheral and meniscal surgeries that are currently under assessment, requiring follow-up. Outside France, there have been ACL registries for 20 years now. The French Arthroscopy Society (SFA) decided to set up an ACL tear registry within its SFA DataLake registry platform. MATERIAL AND METHOD: This article presents the methodology underlying the ACL Tear Registry: i.e., identification, definition and coding of essential and relevant data. A test phase comprised an initial assessment to improve data quality and overall coherence, to optimize data-entry time for patients and practitioners, who are the guarantors of the registry's use and efficacy. RESULTS: The SFA DataLake ACL Tear Registry was made available to SFA members in December 2021. It aims to enable a review of practices for surgeons, early detection of failure of procedures and implants, with rates of failure and abnormal complications, and identification of prognostic factors for outcome, especially regarding original items that do not figure in previous registries. CONCLUSION: SFA DataLake strikes a balance between "indispensable" and "original" items. The choice of contents and data quality is founded on a robust methodology with overall coherence, enabling analysis of large cohorts and comparisons with the literature and other registries. However, it remains to assess rates of data entry and item relevance as the Registry progresses. LEVEL OF EVIDENCE: IV.

Combined ACL and ALL reconstruction reduces the rate of reoperation for graft failure or secondary meniscal lesions in young athletes.

PURPOSE: Graft failure and secondary meniscal tears are major concerns after anterior cruciate ligament (ACL) reconstruction in young athletes. The aim was to evaluate the link between ACL reconstruction with and without anterolateral ligament (ALL) reconstruction and outcomes in young patients participating in pivoting sports. METHODS: This was a retrospective study of data collected prospectively. Patients less than 20 years, involved in pivoting sports and undergoing primary ACL reconstruction with a quadruple hamstring tendon (4HT) graft or 4HT graft combined with anterolateral ligament reconstruction (4HT + ALL) were included. Survival analysis was performed to identify the prognostic indicators for reoperation due to graft failure or secondary meniscal lesions. Knee laxity was assessed and patient reported outcome measures (PROMs) were collected. RESULTS: A total of 203 patients (mean (± SD) age: 16.3 ± 2 years) with a mean follow-up of 4.8 ± 0.9 (range: 3.3‒6.8) years were included. There were 101 4HT and 102 4HT + ALL grafts. Graft rupture rates were 11.9% for 4HT grafts and 5.8% for 4HT + ALL grafts (n.s.). There were 9.9% secondary meniscal procedures for 4HT grafts vs. 1.9% for 4HT + ALL grafts (p = 0.02). With reoperation for graft failure or secondary meniscal lesions at final follow-up as the endpoint, survival was better in the 4HT + ALL group (91.4% vs. 77.8%, respectively; p = 0.03). Absence of ALL reconstruction (HR = 4.9 [95%CI: 1.4-17.9]; p = 0.01) and preoperative side-to-side laxity > 3 mm (HR = 3.1 [95%CI: 1.03-9.1]; p = 0.04) were independently associated with an increased rate of reoperations. Mean (± SD) side-to-side laxity was 1.3 ± 1.3 mm (range: - 2 to 5) for 4HT grafts vs. 0.9 ± 1.3 mm (range: - 6 to 4.8) for 4HT + ALL grafts (n.s.) 6 months post-surgery. The rate of return to the same sport at the same level was 42.2% for 4HT grafts vs. 52% for 4HT + ALL grafts (n.s.). There was no significant difference in subjective outcomes including PROMs between the two groups. CONCLUSION: Combined ALL + ACL reconstruction reduced the rate of graft failure and secondary meniscal injury in young athletes when compared to ACL reconstruction alone. Subjective results were comparable, with a similar rate of complications. Combined reconstruction should be preferred in this young population. LEVEL OF EVIDENCE: Level IV.

Two-year postoperative MRI appearances of anterior cruciate ligament hamstrings autografts are not correlated with functional outcomes, anterior laxity, or patient age.

AIMS: MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft "ligamentization" after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation. METHODS: A consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity differential laxity testing. RESULTS: Two-year postoperative mean outcome scores were: Tegner 6.5 (2 to 10); Lysholm 89.8 (SD 10.4; 52 to 100); and IKDC subjective 86.8 (SD 11.8; 51 to 100). The objective IKDC score was 86% A (128 patients), 13% B (19 patients), and 1% C (two patients). Mean side-to-side anterior laxity difference (134 N force) was 0.6 mm (SD 1.8; -4.1 to 5.6). Mean graft SNQ was 2.0 (SD 3.5; -14 to 17). Graft Howell scores were I (61%, 91 patients), II (25%, 37 patients), III (13%, 19 patients), and IV (1%, two patients). There was no correlation between either Howell score or SNQ with instrumented anterior or Lysholm, Tegner, and IKDC scores, nor was any correlation found between patient age and ACL graft SNQ or Howell score. CONCLUSION: The two-year postoperative MRI appearances of four-strand, semitendinosus ACL autografts (as measured by SNQ and Howell score) do not appear to have a relationship with postoperative functional scores, instrumented anterior laxity, or patient age at surgery. Other tools for analysis of graft maturity should be developed. Cite this article: Bone Jt Open 2021;2(8):569-575.

Medium-term survival and clinical and radiological results in high tibial osteotomy: Factors for failure and comparison with unicompartmental arthroplasty.

INTRODUCTION: High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are two surgical solutions for isolated medial tibiofemoral osteoarthritis. Results depend on preoperative criteria and patient selection, but also on postoperative factors: implant positioning, limb alignment. Factors for HTO survival need identifying to reduce risk of failure requiring total knee arthroplasty (TKA). HYPOTHESIS: Age, gender, weight, osteoarthritis grade, degree of correction, type of osteotomy, technique and intraoperative complications impact HTO survival. MATERIAL AND METHOD: As part of a symposium of the French Society of Arthroscopy (SFA), a multicenter retrospective study compared 2 series. The HTO series comprised 488 patients: 153 female (31.4%); mean age, 55.1 years; mean weight, 83.1kg; mean body-mass index (BMI), 28.6. The UKA series comprised 284 patients: 172 female (60.6%); mean age, 64.1 years; mean weight, 75.3kg; mean BMI, 27.6. The main endpoint was comparative survival at 5, 8 and 10 years; secondary endpoints comprised pre- and post-operative hip-knee-ankle (HKA) angle, mechanical femoral angle (mFA) and mechanical tibial angle (mTA), surgical technique, satisfaction, time to and level of return to work, WOMAC and Tegner scores and complications rates. The significance threshold was set at p<0.05; 95% confidence intervals were calculated. RESULTS: Age>54 years, male gender, BMI>25, medial tibiofemoral wear severity Ahlback ≥3, ≥0.9° varus joint component, HKA correction<8°, postoperative HKA<180° and hinge fracture were significantly associated with poorer survival. There was no impact of type of osteotomy, navigation assistance or postoperative HKA 183-186°. Ten-year survival was 74.3% for HTO and 71% for UKA (non-significant); however, survival curves crossed at 6 years. CONCLUSION: HTO showed survival and functional results comparable to those of UKA in selected patients when target limb alignment correction was achieved. The present study determined selection criteria. A predictive score for results of either procedure would facilitate decision-making. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Is patient-specific instrumentation more precise than conventional techniques and navigation in achieving planned correction in high tibial osteotomy?

INTRODUCTION: Preoperative planning in high tibial osteotomy (HTO) is a critical step for achieving the desired correction and a clinically satisfactory outcome. Conventional radiography, navigation assistance and patient-specific instrumentation (PSI) are the 3 means of planning, but no prospective studies have compared precision between the 3. The aims of the present study were: (1) to analyze and compare correction precision between the 3 planning approaches at 1 year's follow-up; (2) to compare results to those reported in the literature; and (3) to analyze factors influencing the achievement of planned correction. HYPOTHESIS: The study hypothesis was that PSI provides more precise and reproducible planned correction than conventional methods or navigation. MATERIAL AND METHOD: Between June 2017 and June 2018, a multicenter non-randomized prospective observational study was conducted in 11 centers. One hundred and twenty-six patients with Ahlbäck grade I, II or III idiopathic medial tibiofemoral osteoarthritis with stable knee were included and allocated to 3 preoperative planning groups: conventional (group 1), navigation (group 2) and PSI (group 3). Mean age at surgery was 51.2 years (range, 19-69 years; median, 53.2 years); 100 male, 26 female. Complete weight-bearing radiographic work-up was performed preoperatively and at 1 year's follow-up. The PSI group also underwent CT as part of guide production. Target angular correction and mechanical Hip-Knee-Ankle (HKA) axis were set preoperatively. The main endpoint was the difference between planned HKA and HKA at a minimum 12 months. RESULTS: Mean HKA difference was 1.1±3 in group 1, 2.1±2.6 in group 2 and 0.3±3.1 in group 3. Precision was better with PSI, but not significantly when comparing all 3 groups together. On pairwise intergroup comparison, there was a significant difference only between groups 2 and 3, in favor of PSI (P=0.011). DISCUSSION: None of the 3 techniques demonstrated superiority in achieving target correction at 1 year. The study hypothesis was thus not confirmed. All 3 techniques proved reliable and precise in HTO planning. LEVEL OF EVIDENCE: III, prospective non-randomized comparative study.

Arthroscopic anterior cruciate ligament reconstruction is a reliable option to treat knee instability in patients over 50 years old.

PURPOSE: To evaluate return to sport and clinical outcomes with at least 2 years followup after arthroscopic reconstruction ACL in population over 50 years-old. METHODS: eighty-one patients aged 50 years or older underwent isolated, primary ACL reconstruction with hamstring autograft between 2014 and 2016. In all patients, a period of conservative treatment had failed (minimum 6 months), and they complained of functional instability and/or limitation during daily activity. Patients were assessed preoperatively and at the latest follow-up with a physical examination, return to sports activity, the Lysholm score, the International Knee Documentation Committee scoring system, the Knee injury and Osteoarthritis Outcome Score, and the Tegner activity scale. Data regarding complications and revision surgeries were collected at 2-year follow-up. RESULTS: At the last follow-up, significant improvement in outcome scores from pre- to postoperative assessments was found. The mean overall IKDC score increased from a preoperative mean of 54.4-82.9 (p < 0.001). Mean preoperative Lysholm score increased from a preoperative mean of 67.4-90.4 (p < 0.001). The mean overall KOOS score increased from a preoperative mean (p < 0.001). Median preoperative Tegner score was 5 (range 2-8) and median postoperative score was 5 (range 1-7). 86% of patients returned to the sport, 51% to their preinjury sports level. Tegner score, before accident, was the only positive influencing factor a return to pre-injury level of the sport. CONCLUSION: Arthroscopic reconstruction ACL in patients over 50 years-old resulted in excellent functional outcomes, with most patients returning to sport and at the same level they had before the injury. LEVEL OF EVIDENCE: Level IV.

ACL injuries before 15 years of age: could the young become an athlete?

PURPOSE: The purpose of this study was to systematically assess the possibility for a patient younger than 15 to return to a competitive level of sport following an ACL injury. METHODS: Four databases were analyzed (PubMed, MedLine, Cinahl, Cochrane Library and LISTA). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to guide the screening of the literature. Studies about functional and surgical treatments were included with a minimum of 5 years of mean follow-up. Methodological quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale. RESULTS: Ten studies were included, corresponding to a total of 217 patients. All studies were retrospective with level 4 evidence. Seven studies reported results of a transphyseal technique reconstruction, two studies a physeal-sparing reconstruction, and one studied the results of a repair (« healing response ¼). Only one study compared functional treatment and surgery. The mean age of patients at the time of surgery was 12.29 years (range 2-16) with a mean follow-up of 7.9 years (range 5.5-18.3). Return to sport was possible for 80 to 100% of patients (average of 91.7%) at the final follow-up but the level for return to sport was reported in only four studies and found between 61 and 89% for return to the same level and at 42% for return to a competitive level. Evolution of the Tegner score was analyzed in five studies and was reported to decrease at the follow-up in three studies. ACL re-ruptures can be considered as failure of the graft (nine studies with surgical technique) and occurred with an average of 16%. CONCLUSION: This review demonstrate that ACL reconstruction is superior to conservative treatment and 'healing response' in terms of revision rates and knee laxity. Return to sport is possible for more than 4/5 of patients but only two thirds of them were able to return to the same level or to competitive level, and failure rates of the graft were not superior to global population. However, qualities of included studies and variability of treatment limited the clinical application of results. Despite this, patients and parents should be informed that ACL injuries are lesions that may influence the level of sport at a 5-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review.