Clinical outcomes after multiligament injured knees: medial versus lateral reconstructions.

PURPOSE: The purpose of this study was to analyse the clinical outcomes of multiligament injured knees with respect to the medial collateral ligament and posteromedial corner (PMC) repair or reconstruction versus the posterolateral corner (PLC) reconstruction in patients operated according to a codified surgical protocol. METHODS: Patients were divided into two groups depending on whether PMC or PLC was injured. Cruciate ligaments as well as PMC or PLC were reconstructed/repaired in a one-stage procedure. At minimum of 1-year follow-up, objective and subjective International Knee Documentation Committee (IKDC) forms, Lysholm score and sports activity level were recorded. RESULTS: Thirty-nine patients with a median follow-up time of 57 months (range 12-129) were reviewed. No significant difference was found for functional scores between acute PMC and PLC subgroups. In Group PLC, subjective outcomes tend to be better in the acute than in chronic reconstruction subgroup. CONCLUSIONS: A one-stage protocol with early surgery rather than delayed reconstruction produced better clinical outcomes whatever the injured collateral ligament, medial or lateral. In the future, early and chronic reconstructions as well as each injury pattern should be considered as separate entities in studies on multiple ligament injured knees to reach a better level of evidence. LEVEL OF EVIDENCE: IV.

Abnormal rate of intraoperative and postoperative implant positioning outliers using "MRI-based patient-specific" compared to "computer assisted" instrumentation in total knee replacement.

PURPOSE: The aim of this study was to analyze first intraoperative alignment and reason to abandon the use of patient-specific instrumentation using intraoperative CAS measurement, secondly assess by postoperative CT analysis if CI, based on preoperative 3D-MRI data, improved postoperative component positioning (including femoral rotation) and lower limb alignment as compared with results obtained with CAS. METHODS: In this randomized controlled trial, 80 consecutive patients scheduled to undergo TKA were enrolled. Eligible knees were randomized to the group of PSI-TKAs (n = 40) or to the group of CAS-TKAs (n = 40). In the CAS group, CAS determined and controlled cutting block positioning in each plane. In the PSI group, CAS allowed to measure adequacy of intraoperative alignment including femoral component rotation. At 3 months after surgery, implants position were measured and analyzed with full-weight bearing plain radiographs and CT scan. RESULTS: Intraoperatively, there was a significant difference concerning Sagittal Femoral mechanical, Frontal tibial mechanical angle and tibial slope between the two groups (respectively p = 0.01, p = 0.02, p = 0.046). Custom instrumentation was abandoned intraoperatively in seven knees (17.5 %). Abnormal tibial cuts were responsible of the abandon in three out of seven cases, femoral cut in 1/7 and dual abnormalities in 3/7. Postoperatively, tibial slope outliers percentage was higher in the patient specific instrumentation group with six patients (18.18 %) versus one patient (2.5 %) in the CAS group (p = 0.041). CONCLUSION: Patient specific instrumentation was associated with an important number of hazardous cut and a higher rate of outliers in our series and thus should be used with caution as related to. This study is the first to our acknowledgement to compare intra-operative ancillary and implant positioning of PSI-TKA and CAS-TKA. High rate of malposition are sustained by our findings, as such PSI-TKA should be used with caution, by surgeons capable to switch to conventional instrumentation intra-operatively. LEVEL OF EVIDENCE: Randomized control trial, Level I.

Toxigenic Corynebacterium ulcerans in a fatal human case and her feline contacts, France, March 2014.

In March 2014, a person in their eighties who was diagnosed with extensive cellulitis due to toxigenic Corynebacterium ulcerans died from multiple organ failure. Environmental investigation also isolated C. ulcerans in biological samples from two stray cats in contact with the case. This finding provides further evidence that pets can carry toxigenic C. ulcerans and may be a source of the infection in humans.

[Distal femoral torsion: comparison of CT scan and intra operative navigation measurements during total knee arthroplasty. A report of 70 cases]. / Torsion distale fémorale du genou : comparaison de la mesure par tomodensitométrie et par navigation peropératoire au cours des arthroplasties totales de genou. A propos de 70 cas.

INTRODUCTION: Proper positioning of the prosthesis components in total knee arthroplasty is an important factor for satisfactory outcomes such as mobility, pain and wear. If an independent cutting technique is performed, rotational alignment of the femoral component should adapt patient's specific anatomy. The distal epiphyseal femoral torsion (DEFT) is adjusted in order to align the prosthetic posterior condylar axis along the bone transepicondylar axis. The DEFT presents a high rate of interindividual variations. Computed tomography scanning produces reliable and reproducible measurement of the epiphyseal torsion, but this requires additional procedure. We therefore used intraoperative computed navigation for DEFT measurement, thus accurately adapting each patient's epiphyseal torsion during the procedure, without resorting to the preoperative CT scan. MATERIAL AND METHODS: This prospective study included 70 patients with arthritic knees who underwent TKA. Mean patient age was 74 years old. There were 52 women, 35 right knees, 33 genu varum, 19 genu valgum, 18 normal knees. DEFT was determined by preoperative CT scan, using the Yoshioka angle referencing. Distal epiphyseal femoral torsion measurement was carried out using the Navitrack system (Orthosoft). The DEFT was the navigated measured angle between the transepicondylar axis and the posterior condylar axis manually located and digitized with an optically tracked stylus. The navigation system was therefore used as a simple digital measurement device to evaluate the distal epiphyseal femoral torsion. We had established the reference transepicondylar axis as the line connecting the prominence of the medial and lateral epicondyles. During the procedure, we also carried out computer-assisted measurement of HKA axis in full extension and at 90 degrees of knee flexion. Correlation between the navigated HKA in full extension and HKA measured on the preoperative pangonogram (R(2)=0.621) demonstrated a high reliability of the navigation system in the frontal plane. RESULTS: There was no correlation between the mean epiphyseal torsion determined with computer navigation and the epiphyseal torsion measured on the CT scan (R(2)=0.09). Significant interindividual variations were reported. Navigated HKA at 90 degrees of knee flexion was not correlated with navigated HKA in full extension (R(2)=0.398) nor with epiphyseal torsion measured on the CT scan (R(2)=0.063). Results demonstrated a major interindividual variation. DISCUSSION: Our results report a large variability in distal epiphyseal femoral torsion measured with CT scan. Moreover, computed navigation does not provide a reliable and reproducible evaluation of the epiphyseal torsion. Due to inaccurate identification of femoral epicondyles, the related navigated measurement is not considered to be reliable and reproducible. Navigated HKA at 90 degrees of knee flexion is not a fair indirect reflection of epiphyseal torsion. Computer-assisted navigation fails to provide direct or indirect, reliable and reproducible intraoperative measurement of distal epiphyseal femoral torsion. Preoperative CT scan is the only reliable method to produce accurate measurement of distal epiphyseal femoral torsion.

[Rotational alignment of femoral component with computed-assisted surgery (CAS) during total knee arthroplasty]. / Rotation fémorale par navigation sur la base d'un scanner préopératoire dans l'arthroplastie totale de genou : à propos de 70 cas.

INTRODUCTION: Accurate implantation of the prosthesis components is a prognostic factor for long-term total knee arthroplasty survival as it reduces wear and loosening failure. Computer-assisted navigation systems have proved to produce accurate bone cuts orthogonal to the mechanical axis. Proper rotational alignment of the femoral component is one of the requirements for optimal positioning of the femoral prosthesis. The posterior bicondylar axis of the femoral prosthesis should therefore be parallel to the transepicondylar axis. The purpose of the present study was to determine whether computer-assisted navigation provides an accurate rotational alignment of the femoral implant, when preoperatively defined with CT scan. MATERIAL AND METHODS: This prospective study, carried out between December 2003 and June 2005, included 70 patients of average age 74 years old (range 57-85) who underwent primary total knee arthroplasty, with a SAL prosthesis (Zimmer). Preoperative investigations with computed tomography scanning produced accurate measurements of distal epiphyseal femoral torsion (DEFT). The posterior bicondylar axis was found to be a reliable landmark for the rotational orientation of the femoral cutting-guide during bone-cuts. The rotational orientation of the cutting-guide was based on the preoperative CT data. A three-month follow-up CT scan was carried out to evaluate final rotational position of the femoral component. RESULTS: The mean DEFT evaluated on the preoperative CT scan was 6.9+/-2.9 degrees . The mean rotational orientation of the cutting guide was 4.8+/-2 degrees . The mean postoperative measurement of DEFT was 1.56+/-2.7 degrees . The mean adjustment of DEFT was 5.34 degrees . Adopting a +/- 2 degrees cutoff, 77 % of patients achieved acceptable alignment within +/- 2 degrees compared with our objectives. These findings were compared to a previous series of 34 cases using an arbitrary 3 degrees standardized rotation of the femoral component and following an identical radiological protocol. Among the knees, 44% reported alignment within +/- 2 degrees . DISCUSSION: When femoral and tibial bone cuts are performed independently, conventional instrumentation techniques seem insufficient to adapt patient's specific anatomy and prove inadequate to provide precise rotational alignment of the femoral component. Computed tomography scan is a reliable mean to produce precise preoperative measurements for proper DEFT. Moreover, it allows accurate postoperative control of the implant positioning. Other studies have documented a higher degree of precision in the rotational alignment of the femoral component with computed navigation systems in comparison to conventional instrumentation. However, in such studies, rotational alignment was always determined by computer navigation, and based on a controversial intraoperative identification (epicondyles and Whiteside's line referencing). We believe that preoperative CT scanning is a more favourable method. Actually, 77% of the cases reported satisfactory rotational alignment of the femoral component using this technique.

Cutibacterium acnes prosthetic joint infection: Diagnosis and treatment.

Cutibacterium acnes is a commensal skin bacterium, regularly implicated in prosthetic joint infection, particularly of the shoulder. Diagnosis has been improved by progress in bacteriological techniques: longer culture time, liquid medium culture, MALDI-TOF mass spectrography, and universal 16S rRNA PCR, associated by some authors to sonication of ablated implants. C. acnes pathogenicity involves many virulence factors, notably including biofilm formation. C. acnes may lead to infection that is clinically evident or, frequently, relatively asymptomatic. C. acnes is an anaerobic Gram-positive bacterium, susceptible to many antibiotics that are regularly used in bone and joint infection: beta-lactams, quinolone, rifampicin and clindamycin. It shows increasing resistance to clindamycin and natural resistance to metronidazole. Treatment is medical and surgical, associating synovectomy or complete 1- or 2-step revision depending on time to treatment, and antibiotic therapy. Antibiotic therapy is typically for three months with an initial 2-6 weeks' intravenous phase. Prognosis is generally favorable with well-conducted treatment. Late discovery of positive samples after apparently aseptic implant change is an at-risk situation, usually managed by antibiotic therapy, but with late initiation and hence increased risk of failure. Adverse secondary progression requires repeat revision under good conditions.

Meniscal sizing before allograft: Comparison of three imaging techniques.

BACKGROUND: Accuracy of meniscal sizing is an important issue before allograft transplantation. To date, there is no consensus on the best imaging method. The purpose of this study was to compare plain radiographs, magnetic resonance imaging (MRI) and computed tomography (CT) arthrography in the assessment of meniscal size. We hypothesized that MRI and CT arthrography had better correlations than plain radiographs. METHODS: All patients operated on by meniscal allograft between January 2005 and May 2015 were screened. Among them, 32 patients had both preoperative radiographs, MRI and CT arthrography of the affected knee. The meniscal dimensions were evaluated, blindly and randomly, using three imaging methods. A correlation analysis between each technique was made. For radiographic methods, an additional comparison was made between original Pollard's method and the modified method (Yoon). Bone dimensions (tibial metaphysis) were also collected, using radiographs and MRI, in order to build new equations allowing determination of meniscal dimensions from those bone measurements. RESULTS: The radiographic methods offered satisfying evaluations of the meniscal dimensions in the sagittal plane, without significant difference when compared with CT arthrography or MRI. In the frontal plane, the radiograph methods were less effective. With new equations, allowing determination of meniscal dimensions from tibial plateau dimensions, the mean correlation coefficient was 0.39 (0.14-0.71). CONCLUSIONS: The correlation between radiographic methods and MRI depended on which parameter (frontal or sagittal) was measured. Thus, we proposed a new method for sizing of meniscus, easily measurable from bony landmarks, aiming to improve the accuracy of graft selection.

Hybrid fixation in adult osteochondritis dissecans of the knee.

Osteochondritis dissecans progresses to osteoarthritis if integration of the fragment is not obtained. The prognosis of osteochondritis dissecans is more severe in adults, as spontaneous integration due to physeal closure does not occur. Hybrid fixation consists in combining screw fixation of the fragment with mosaicplasty through the fragment to promote integration into the native condyle. We describe this technique with reference to 17 patients.

Opening-wedge high tibial osteotomy without bone grafting in severe varus osteoarthritic knee. Rate and risk factors of non-union in 41 cases.

INTRODUCTION: Using locking plates in opening-wedge high tibial osteotomy (OWHTO) via a medial opening theoretically allows early weight-bearing without need for bone or bone-substitute grafting. It incurs a risk of non-consolidation in case of large correction (>10°), although rates and risk factors of non-union are not known. The present retrospective study compared OWHTO with correction <10° versus >10°, with a view to determining: (1) complications rates (non-union) according to degree of correction, and (2) risk factors for such complications. HYPOTHESIS: OWHTO with correction greater than 10° without graft shows normal consolidation and allows early weight-bearing. MATERIAL AND METHOD: Forty-one patients treated by OWHTO for medial osteoarthritis of the knee between January 2101 and November 2015 were included in a retrospective study. HKA angle was assessed by long-leg axis radiographs, preoperatively and at 3 months. Clinical and radiological follow-up at 6 weeks, 3 months and 6 months assessed consolidation in terms of >40% filling of the osteotomy site. Partial (contact) weight-bearing was allowed from the first postoperative day, with full weight-bearing at 6 weeks. RESULTS: Mean patient age was 59±5 years. Mean body-mass index (BMI) was 30.3±5.2; 17 patients (41.5%) had BMI >30. Mean initial HKA angle was 173.5°±3° (range, 167-178°) and mean correction was 10.7°±2.7° (range, 5-15°). There were 27 corrections of 10° or more, and 14 less than 10°. At 3 months, mean HKA was 182.9°±2.5° (range, 178-187°). Twelve cases showed lateral tibial cortex fracture after opening. Thirty-six patients (87.8%) showed consolidation, at a mean 5±3 months. Five patients showed osteotomy site non-union; in all these cases, the lateral cortex was broken initially (P=0.003); all had BMI >30 (mean, 37.2±3.8; P<0.03); none were smokers. On univariate analysis, lateral tibial cortex fracture (OR=10; 95% CI, (1.59-196.30)), BMI >30 (OR=1.18; 95% CI, (1.03-1.41)) and correction ≥10° (OR=10.50; 95% CI, (2.49-53.86)) were associated with delayed consolidation. On multivariate analysis, only degree of osteotomy was significantly associated with delayed consolidation (OR=11.51; 95% CI, (2.13-95.74)). DISCUSSION/CONCLUSION: Obesity and initial lateral cortex fracture appeared as risk factors for non-consolidation of OWHTO with large correction. Systematic bone or bone-substitute grafting may therefore be considered in this population in case of >10° correction. LEVEL OF EVIDENCE: IV, prospective cohort study.

Anterior tibial laxity using the GNRB® device in healthy knees.

BACKGROUND: GRNB® is a non-radiating power tool that allows the evaluation of the anterior tibial translation. HYPOTHESIS: The pressure exerted by the system against the patella and the body mass index (BMI) could affect the anterior tibial translation when we repeat the measurements in healthy knees. MATERIALS AND METHODS: We retrospectively evaluated the measurements of anterior knee laxity in healthy knees carried out by the GNRB® in 69 consecutive patients who underwent anterior cruciate ligament (ACL) repair in the contralateral knee. Two measurements were carried out, the initial measurements (M1), and then repeated at a mean of seven months (M2) (4.9 to 13months). RESULTS: There were 38 women and 31 men with an average age of 31years. In healthy knees, the Mean average anterior translation was 5.4±4mm with an average patellar force of 35.8 at time M1. The average anterior translation was 4.9±4mm with an average patellar force of 47 at time M2. There was a significant difference between the measurements M1 and M2 (P<0.03). The tightening force was significantly different between the two sets of measurements (P<10-7). There was a negative correlation between the pressure applied on the patella and anterior knee laxity (P<0.01). CONCLUSION: The pressure force exerted on the patella during GNRB® affects the measurement of anterior laxity in healthy knees. This raises the problem of the reproducibility of the measurements during repeated examinations at different times.

Is distal femoral torsion the same in both of a patient's legs? Morphometric CT study.

INTRODUCTION: The rotational position of the femoral component is a primary driver of success in total knee arthroplasty. However, distal femoral torsion (DFT) varies greatly between individuals. Measuring DFT preoperatively by CT in combination with computer-assisted surgery can significantly improve the rotational positioning of the femoral component. However, a preoperative CT scan is costly and exposes the patient to radiation. These are doubled when the patient is undergoing bilateral arthroplasty. The aim of this study was to determine the DFT in both knees of a patient undergoing bilateral arthroplasty. We hypothesized that DFT was symmetric between a patient's two knees and was independent of frontal alignment. MATERIAL AND METHODS: In this retrospective study of TKA cases performed between December 2008 and March 2015, 82 patients (mean age 73years) who underwent two-stage bilateral TKA (164 knees) were included. A preoperative CT scan of each knee was performed to measure the DFT using the surgical posterior condylar angle (PCA) described by Yoshioka. Two observers performed the measurements twice each, to allow calculation of the intraclass and interclass correlation coefficients. RESULTS: The mean PCA was 5.4° (±1.48) in the right knee and 5.4° (±1.45) in the left knee, with a left/right difference ranging from 0 to 2.2° (p=0.8). In the entire cohort, 84.6% of patients had a left/right difference of less than 1°. We found no significant differences in DFT in knees with large or small frontal deformity (deformity<10°, p=0.7; deformity>10°, p=0.5) or the presence of varus or valgus (p=0.9). The intraclass correlation coefficient was excellent (94%) and the interclass correlation coefficient was moderate to good (60% for left knees, 53% for right knees). DISCUSSION: Based on CT scan measurements, the DFT in both knees of an arthritic patient is comparable and this measurement is reproducible. This means that a single, unilateral preoperative CT scan is sufficient for planning purposes. LEVEL OF EVIDENCE: IV (retrospective cohort study).

[Mini-invasive double-incision for patellar tendon harvesting in anterior cruciate ligament reconstruction]. / Prélèvement du transplant patellaire par double voie mini invasive dans la reconstruction du ligament croisé antérieur.

PURPOSE OF THE STUDY: Injury to infrapatellar branches of the medial saphenous nerve are incriminated in disorders of the anterior aspect of the knee, particularly following bone-tendon-bone reconstruction. We demonstrated in prior anatomic work the usefulness of using a double-incision minimal approach for harvesting the patellar transplant in order to spare the nerve branches. MATERIAL AND METHODS: The patellar transplant is harvested via two vertical incisions, one on the apex of the patella and the other along the protrusion of the anterior tibial tubercle. After harvesting the bony transplant from the patella, discision of the patellar tendon fibers is advanced subcutaneously towards the anterior tibial tubercle, allowing extraction of the patellar graft via the tibial incision using a small forceps and respecting the peritendon. The tibial bone is then harvested. The standard anterolateral and anteromedial approaches are used for the ligament reconstruction. RESULTS: We have conducted a case control study between this harvesting technique using the double-incision technique (42 knees) versus the conventional single incision harvesting technique. We studied the influence of the harvesting technique on anterior knee pain, the surface area of the sensorial disorders involving the anterior aspect of the knee, and kneeling problems. DISCUSSION: Our technique has enabled a significant decrease in the surface area of sensorial disorders (7.4 cm2 versus 17.4 cm2) and problems kneeling compared with the conventional method.

Anatomical knee postero-lateral corner reconstruction: The "Versailles" technique.

Postero-lateral knee instability raises surgical challenges. Of the many available reconstruction techniques, few ensure anatomical reconstruction of the postero-lateral corner (PLC). The "Versailles" technique ensures the anatomical reconstruction of the three main PLC stabilisers (lateral collateral ligament, popliteus tendon, and popliteo-fibular ligament) by using either a hamstring autograft or a tendon allograft.

Actifit® polyurethane meniscal scaffold: MRI and functional outcomes after a minimum follow-up of 5 years.

BACKGROUND: Implantation of the Actifit® polyurethane meniscal scaffold in patients who have pain after partial meniscectomy provides short-term pain relief and better function. But there is a lack of information about medium-term outcomes. The objective of this longitudinal study was to evaluate the MRI and functional outcomes after a minimum follow-up of 5 years. It was hypothesized that the results are stable over time. MATERIAL AND METHODS: Fifteen consecutive patients (8 men, 7 women; mean age 30 years, range 19-47, mean BMI 25) were enrolled in the study between February 2008 and January 2011. Five patients also underwent ACL reconstruction and one underwent mosaicplasty. Nine lateral and six medial Actifit® implants were evaluated prospectively before the surgery and at a minimum of 12, 24 and 60 months' follow-up using a visual analogue scale (VAS) for pain, the objective and subjective IKDC scores, radiological and MRI analysis with measurement of the ICRS score, Genovese score and extrusion. RESULTS: The mean follow-up was 6 years (range 5-8.1). Two patients were lost to follow-up. Three patients were re-operated at 7, 19 and 30 months because they had not improved functionally and the implant appeared damaged on MRI. Partial removal of the implant did not improve the functional outcomes (mean subjective IKDC pre- and post-revision: 37.0 vs. 34.9). Two patients were lost to follow-up. In intention to treat (13 cases), the pain (VAS) and subjective IKDC score were improved between the preoperative period and the last follow-up (5.46 vs. 2.92, P=0.007 and 51.2 vs. 66.1, P=0.05). In per protocol (10 cases, failures excluded), the pain (VAS) and subjective IKDC score were improved (5.3 vs. 1.9, P=0.0009; 49.6 vs. 75.4, P=0.002) along with the pain, daily activities and quality of life components of the KOOS (60.6 vs. 86.0, P=0.0008; 70.3 vs. 90.2, P=0.001; 42.7 vs. 71.0, P=0.0058). The functional scores were stable between months 12, 24 and 60. ICRS cartilage score and mean meniscal extrusion were unchanged at the last follow-up (1.6 vs. 1.6 and 2.41 vs. 2.79). In all patients, the meniscal implant had an intermediate signal and reduced size on MRI. DISCUSSION: Despite an abnormal MRI appearance suggesting the meniscal scaffold is not fully mature after 5 years, the functional scores and cartilage status are stable at this time point. However, the failure rate is still high and removing the implant in patients with poor function does not improve the outcome. TYPE OF STUDY: Prospective cohort study Level IV.

Long-term assessment of meniscal extrusion after meniscal repair.

BACKGROUND: Arthroscopic meniscal repair limits the medium-term risk of radiological osteoarthritis. Magnetic resonance imaging (MRI) cannot provide an accurate assessment of meniscal healing but may show harbingers of osteoarthritis such as meniscal extrusion. The objective of this study was to assess long-term meniscal extrusion after meniscal repair. HYPOTHESIS: Arthroscopic meniscal suture is not followed by meniscal extrusion and can, therefore, provide good knee function in the long-term. METHODS: Consecutive patients who underwent arthroscopic meniscal suture on a stable or stabilised knee were included retrospectively. MRI was performed to measure absolute meniscal extrusion (AME), relative meniscal extrusion (RME), anterior sagittal extrusion (ASE), posterior sagittal extrusion (PSE), coronal cartilage coverage index (cCCI), and sagittal cartilage coverage index (sCCI). RESULTS: After a mean follow-up of 8.8±0.87 years, there was no evidence of meniscal extrusion in these patients with stable or stabilised knees: AME, 1.7±1.03 and 2.3±0.93mm, RME, 17±0.10% and 28±0.12%, ASE, 2.52±1.43 and 1.71±2.42mm, PSE, 0.29±3.49 and 0.22±2.35mm, cCCI, 23±0.08% and 20±0.09%, and sCCI, 49±0,10% and 53±0.09%. CONCLUSION: In the long-term after meniscal repair, osteoarthritis is limited and meniscal function seems preserved. LEVEL OF EVIDENCE: IV, retrospective study.

High failure rate of anterior cruciate ligament reconstruction with bimeniscal repair: A case-control study.

BACKGROUND: Bimeniscal lesions are common in patients with anterior cruciate ligament (ACL) tears. However, bimeniscal repair is rarely performed during ACL reconstruction. OBJECTIVE: To assess outcomes after ACL reconstruction with bimeniscal repair. HYPOTHESIS: Bimeniscal lesions, even when repaired, are associated with poorer outcomes of ACL reconstruction. MATERIAL AND METHODS: A retrospective case-control design was used. The cases were 15 patients who underwent ACL reconstruction, without procedures on any other ligaments, combined with bimeniscal repair, between May 2009 and May 2013 (3.2% of all ACL reconstructions during the study period). This group (2-Mc group) was matched on age, gender, body mass index, and time to surgery to 30 patients who underwent ACL reconstruction and had no meniscal lesions (0-Mc group) and to 30 patients who underwent ACL reconstruction and repair of the medial meniscus (1-Mc group). After a mean follow-up of 3.6 years, clinical outcomes were assessed based on the KOOS, Lysholm, and IKDC scores and knee laxity based on TELOS and GNRB measurements. The primary outcome measure was the rate of ACL re-rupture. Secondary outcome measures were functional outcomes and rate of delayed meniscectomy. RESULTS: The ACL re-rupture rate was significantly higher in the 2-Mc group than in the 0-Mc and 1-Mc groups pooled (20%, vs. 1.7%; P=0.02). The functional scores showed no significant differences across groups. Post-operative differential laxity was significantly greater in the 2-Mc group (3.3mm by TELOS, P=0.02; and 2.5mm by GNRB, P=0.03) than in the 0-Mc and 1-Mc groups pooled. Delayed meniscectomy was performed in none of the 2-Mc group patients and in 2 of the 1-Mc group patients. CONCLUSION: ACL reconstruction combined with bimeniscal repair is a rarely performed procedure. It is associated with a high ACL re-rupture rate and greater differential laxity. Meniscal outcomes of bimeniscal repair, in contrast, are good. LEVEL OF EVIDENCE: III, matched case-control study.

[Knee septic arthritis]. / L'arthrite septique du genou.

The development of antibiotics and arthroscopic treatment have been two major turning points in the management of septic arthritis of the knee joint. We report a retrospective review of 78 patients managed in three surgery units and one rheumatology unit. Management practices varied between the units. Joint aspiration was proposed for all patients seen by rheumatologists. Certain surgeons proposed arthroscopy systematically at admission while others preferred a more selective approach. Arthroscopic wash-out was proposed as the first-line procedure for only 33 patients. All were given systemic antibiotics using a variety of protocols. The course under antibiotic treatment confirmed the potential gravity of septic arthritis of the knee joint since two patients died and 34 required surgery, half of which had more than one operation. The functional outcome at mean 19 months was rather poor. Only 65 knees were free of any implant and only 40 (62%) were pain free. Mean flexion was 116 degrees and 11 patients (17%) had significant flexion contracture. Factors of poor prognosis were initially high sedimentation rate, advanced stage according to Gächter, presence of specific germs (meti-R S. aureus, Gram-negative bacilli), and failure of first-line treatment. A management algorithm was proposed: initial aspiration for evacuation, medical treatment alone if there is no synovitis, and reduction synovectomy otherwise. The key to success is early well adapted treatment.

[Endoscopic treatment of snapping scapula]. / Traitement endoscopique des accrochages scapulothoraciques.

We describe an endoscopic method for resection of the superomedial comer of the scapula in cases of painful snapping scapula. A preoperative computed tomography may be useful to show narrowing between the superomedial comer and the chest wall. Endoscopic technique gives the same goods results than open surgery with in cosmetic advantage and early rehabilitation. Avoided neurological lesion need to perform a precise portal placement.

Mid-term survivorship of Mini-keel™ versus Standard keel in total knee replacements: Differences in the rate of revision for aseptic loosening.

INTRODUCTION: To reduce the size of the surgical incision, modular mini-keel tibial components have been developed with or without extensions for the Nexgen™ MIS Tibial Component. Although a smaller component could theoretically result in defective fixation, this has never been evaluated in a large comparative series. Thus, we performed the following case control study to: (1) evaluate intermediate-term survival of a modular "mini-keel" tibial component compared to a reference standard keel component from the same line of products (Nexgen LPS-Flex Tibial Component, Zimmer); (2) to identify any eventual associated factors if the frequency of loosening was increased. HYPOTHESIS: The rate of revision for aseptic tibial loosening is comparable for both components. MATERIALS AND METHODS: This comparative, retrospective, single center series of 459 consecutive total knee arthroplasties (TKA) was performed between 2007 and 2010: with 212 modular "mini-keel" (MK) tibial components and 247 "standard" (S) components. Survival, rate of revision for aseptic tibial loosening and identification of a radiolucent line were analyzed at the final follow-up. RESULTS: After a median follow-up of 5years, the rate of revision for tibial aseptic loosing was significantly higher in the MK group with 12 cases (5.7%) and 4 cases in the S group (1.6%) (P=0.036). The use of the MK component appears to be a prognostic factor for surgical revision (hazard ratio=3.86 (1.23-11.88), P=0.02) but not for the development of a radiolucent line (HR=1.75 (0.9-3.4), P=0.097). The mean delay before revision was 38months (8-64) in the MK group and 15.2months (8-22) in the S group (P=0.006). Individual factors, such as gender, body mass index (BMI) and pre- or postoperative alignment were not prognostic factors for revision or radiolucent lines. CONCLUSION: The modular "mini-keel" tibial component was associated with a greater risk of revision for tibial component loosening. LEVEL OF EVIDENCE: Case control study, III.

[Reconstruction of acute posterior cruciate ligament tears using a synthetic ligament]. / Cicatrisation sur tuteur synthétique dans les ruptures récentes du ligament croisé postérieur.

PURPOSE OF THE STUDY: Treatment of recent laxity of the posterior cruciate ligament is not standardized. The purpose of this work was to analyze results of reconstruction with adjunction of a synthetic ligament for major recent isolated or combined laxity of the posterior cruciate ligament (triades, pentades or dislocations). Our hypothesis was that the synthetic ligament acts like a tutor for healing of the torn ligament. MATERIAL AND METHODS: This retrospective analysis included 14 patients (1 woman and 13 men), mean age 27 years. All were competition athletes except one who did not practice sports. Three quarters of the patients were traffic accident victims. The series included three isolated posterior ligament tears, six combined laxities, and five knee dislocations. Average posterior laxity was 24 mm preoperatively. The procedure was performed 7 to 53 days after the accident. Arthroscopic reconstruction was performed for six patients and arthrotomy for eight. All associated lesions were repaired during the same procedure except for two cases (one anterior cruciate ligament and one popliteal tendon). Posterior cruciate ligament repair was achieved with the adjunction of a polyester ligament (LARS) using a one or two strand technique. Patients were reviewed at 36 months mean follow-up (10 - 88 months). The IKDC score was determined. A posterior drawer was measured manually with Telos at 70 degrees. RESULTS: Five stiff knees required either mobilization under anesthesia or arthrolysis. One tear occurred late after the accident during a new trauma. Subjectively, two patients were very satisfied, eight satisfied and three disappointed. Mean knee motion measurements were 6/0/130 degrees . A differential posterior drawer persisted in twelve knees. The Telos measurement of posterior drawer changed from a mean 24 mm to a mean 8 mm. The overall IKDC score was A: 0, B: 7, C: 3, and D: 2. Persistent posterior laxity was the predominant cause of poor scores. Outcome was less satisfactory for all items of posterolateral laxity. There was no difference between the 2- and 4-strand techniques. There were no cases of morbidity (synovitis, spontaneous tear) directly related to the synthetic ligament. DISCUSSION: The gain in posterior laxity was substantial. Results depended on associated lesions, particularly lateral involvement (stiffness, IKDC score) rather than the repair technique. The synthetic ligament appeared to play the role of a tutor: a single strand measuring 6 mm in diameter is sufficient. This technique spares tendon stock and could be proposed for major posterior cruciate ligament laxity. A longer follow-up will be necessary to confirm the durable stability.