Is there a femoral morphology at risk of a cervical or pertrochanteric fracture? Description and validation of the "Neck shaft ratio" and the "Intertrochanteric distal ratio" after analyzing a continuous cohort of 126 bilateral fractures of the proximal femur.

BACKGROUND: Proximal femur fractures constitute a public health concern given their high frequency and the aging population. The frequency of a contralateral fracture occurring can reach up to 15% of cases. Certain historical or demographic factors constitute risk factors for refracture, but the type of fracture, either of the femoral neck (FN) or pertrochanteric (PT), cannot be predicted. The objectives of this retrospective study were: firstly, to analyze several anatomical markers in order to determine whether they predispose to a certain type of fracture in the event of contralateral refracture, and secondly, to determine the predictive power of these possible radiological markers for the type of contralateral fracture. HYPOTHESIS: The hypothesis was that the "Neck shaft ratio" (NSR) and the "Intertrochanteric distal ratio" (ITDR) made it possible to determine a proximal femoral morphology at risk of FN and/or PT fracture in the event of a second fracture. MATERIAL AND METHODS: This continuous retrospective single-center series from January 2011 to December 2019 of patients who presented with bilateral fractures of the proximal femurs was analyzed. Radiographs, taken after the first fracture, of the contralateral femur were studied. Morphological measurements previously described in the literature were carried out as well as the NSR (ratio of the medial cortical thicknesses of the femoral neck at its narrowest and basicervical level) and the ITDR (ratio of the medial diaphyseal cortical thicknesses at 5mm and 20mm from the distal portion of the lesser trochanter). One hundred and twenty-six patients were included: 46/126 (36.5%) had bilateral FN, 50/126 (39.7%) bilateral PT and 30/126 (23.8%) one of each. RESULTS: Only NSR and ITDR were significant predictive measures for FN or PT fracture type [0.54±0.11 vs. 0.81±0.16 (p<0.0001) and 0. 85±0.1 vs. 0.68±0.1 (p<0.0001), respectively]. These two ratios had an excellent predictive value for the type of fracture occurring on the contralateral side [NSR: AUC ROC = 0.91 (95% CI; 0.86-0.96); ITDR: AUC ROC = 0.81 (95% CI; %, 0.74-0.89)]. The NSR had excellent intra- and inter-observer reproducibility with an interclass correlation coefficient of 0.93 [95% CI: 0.86-0.97] and 0.91 [95% CI: 0.82-0.96] respectively, the same also applied for the ITDR with interclass correlation coefficient values of 0.93 [95% CI: 0.87-0.97] and 0.86 [95% CI: 0.73-0.93] respectively. DISCUSSION: The NSR and ITDR ratios offer a simple and reproducible means to predict a morphological predisposition to a certain fracture type, respectively an FN and PT on the side contralateral to an initial osteoporotic proximal femur fracture. A prospective cohort study would be useful in defining a possible prognostic nature on the occurrence and/or time until refracture. LEVEL OF EVIDENCE: III; retrospective control case.

Anatomic reconstruction of the posteromedial corner of the knee: The Versailles technique.

INTRODUCTION: Multiligament knee injury with posteromedial laxity is serious and usually requires surgery. Reconstruction is preferable to repair. The main aim of the present study was to report clinical results and laximetry for an original posteromedial corner (PMC) allograft reconstruction technique known as The Versailles Technique. The secondary aim was to determine prognostic factors for surgery. The study hypothesis was that anatomic PMC reconstruction by tendon allograft provides satisfactory medium-term clinical and laximetric results. METHODS: A retrospective study assessed postoperative clinical and laximetric results after PMC allograft reconstruction at a minimum 12 months' follow-up. Laxity was assessed on comparative bilateral stress X-rays, and functional results on the International Knee Documentation Committee (IKDC) score, the Lysholm score and the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Twenty-six patients were included between 2013 and 2019. Mean follow-up was 27.4±9 months. Mean subjective IKDC score was 69.21±17.36, mean Lysholm score 77.78±14.98 and mean KOOS 66.44±18.52. OBJECTIVE: IKDC results were 77% grade A, 22% grade B, and 0% grade C or D. Mean medial differential laxity in forced varus was 0.83±1.26mm. Mean subjective IKDC scores were poorer in Schenck KD-III than KD-I (p=0.03). Functional results were comparable with acute and with chronic laxity. Age correlated inversely with median KOOS (p=0.009). There was no correlation between postoperative radiologic laxity in forced varus and functional results. DISCUSSION: Versailles anatomic PMC allograft reconstruction for acute or chronic posteromedial knee laxity showed medium-term efficacy in restoring good objective and subjective stability. LEVEL OF EVIDENCE: IV; retrospective observational study.

Femoral condyle bone mineral density in osteoarthritis differs significantly between knees with valgus vs. varus deformity.

BACKGROUND: The objective of this study was to measure bone mineral density (BMD) of the cancellous bone in both femoral condyles and to compare the results according to the hip-knee-ankle (HKA) angle in patients with knee osteoarthritis. HYPOTHESIS: BMD of cancellous bone in the medial condyle is markedly lower in valgus knees compared to that in the lateral condyle in varus knees. METHODS: Consecutive patients with computed tomography (CT) of the knee and long-leg radiographs obtained in preparation for total knee arthroplasty were included. The 189 knees were divided into five groups based on whether the hip-knee-ankle angle was<170° (major varus deformity), 171°-177° (varus deformity), 178°-182° (normal alignment), 183°-189° (valgus deformity), and>190° (major valgus deformity). A protocol for CT measurement of BMD values at the femoral condyles was developed. Correlations between the HKA angle and BMD were assessed using the ratio of medial-to-lateral condyle BMD values (M/L). RESULTS: M/L was lower for knees with valgus deformity than for normally aligned knees (0.7 vs. 1, p<0.001). This difference was larger in the group with major valgus deformity, with a mean M/L value of 0.5 (p<0.001). M/L was higher for knees with major varus (mean, 1.2; p=0.035). The correlation coefficients showed excellent intra-observer and inter-observer agreement for the BMD measurements. CONCLUSION: The BMD values of the femoral condyles correlate with the HKA angle. BMD is lower at the medial femoral condyle of valgus knees, particularly when the deformity exceeds 10°. This finding may deserve consideration when planning total knee arthroplasty. LEVEL OF EVIDENCE: IV; retrospective study.

Is lateral femoral condyle hypoplasia a feature of genu valgum? A morphological computed tomography study of 200 knees.

BACKGROUND: Young surgeons are taught that genu valgum deformity is associated with hypoplasia of the lateral femoral condyle, despite the absence of supporting evidence. The objective of this study was to determine whether the lateral condyle was hypoplastic in genu valgum, by assessing the morphological features of the distal femur and their variations according to the severity of the coronal deformity. HYPOTHESIS: The lateral femoral condyle is not hypoplastic in genu valgum deformity. MATERIAL AND METHODS: The 200 included patients treated by unilateral total knee arthroplasty were divided into five groups based on their preoperative hip-knee-ankle (HKA) angle. The HKA angle, valgus cut angle (VCA), and anatomical lateral distal femoral angle (aLDFA) were measured on long-leg radiographs. Computed tomography images were then used to measure the medial and lateral anterior-posterior condylar lengths (mAPCL and lAPCL) and condylar thicknesses (mCT and lCT), distal femoral torsion (DFT), medial and lateral posterior condylar heights (mPCH and lPCH), and medial and lateral condylar volumes (mCV and lCV). RESULTS: No significant differences were demonstrated across the five mechanical-axis groups for mAPCL, lAPCL, mCT, lCT, mPCH, or lPCH. The groups differed significantly regarding the VCA (p<0.0001), aLDFA (p<0.0001), DFT (p<0.0001), and mCV/lCV ratio (p<0.0001). VCA and aLDFA were smaller when the valgus exceeded 10°. DFT was similar in all varus knees (2.2°-2.6°) but significantly greater for knees with moderate (4.0°) or severe (6.2°) valgus. Finally, lCV was greater than mCV in valgus knees compared to varus knees. CONCLUSION: The presence of lateral condyle hypoplasia in knees with genu valgum seems open to question. Apparent hypoplasia noted during the standard physical examination may be chiefly ascribable to distal valgus of the femoral epiphysis in the coronal plane and, with the knee flexed, to distal epiphyseal torsion, whose severity increases with the degree of valgus deformity. These considerations should be taken into account when performing distal femoral cuts for TKA, to ensure the restoration of normal anatomy in patients with genu valgus. LEVEL OF EVIDENCE: IV.

Proximal femoral fracture and female gender are risk factors for recurrent fracture: Cohort study of 292 patients over 75 years-old with iterative osteoporotic fractures.

PURPOSE: The purpose of this study was to: 1/ describe the characteristics of a cohort of patients over 75 years of age hospitalized in perioperative geriatric units (UPOG) for iterative fractures; 2/ investigate the risks of institutionalization related to the first fracture; and 3/ search for potential risk factors for iterative fracture. METHODS: This is a retrospective single-center study analyzing patients over 75 years old, hospitalized in UPOG. RESULTS: Of the 3207 patients hospitalized, 292 patients had a refracture (9.1%), with a mean age of 85.4+/-5.8 years. Initial fractures were mainly intertrochanteric (43.2%) and the femoral neck (32.9%). Refractures occurred mainly in the first year (55.5%), with a median delay of 9.6 months. Refractures were mainly intertrochanteric (29.5%), peri­implant (prosthesis, osteosynthesis) (28.8%), and femoral neck (26.7%). Dementia was the only factor for institutionalization after the first fracture episode (p = 0.0002). Proximal femoral fracture (PFF) and female gender were risk factors for iterative fracture (10.2% vs. 6.8%, p = 0.003; 10.7% vs. 6.8%, p = 0.005 respectively), but not age (85.4 vs. 85.8 years, p = 0.24). PFF were more likely to result in the same fracture type in the second episode (58.1% vs 7.1%, p<0.0001). The time to refracture was shorter in case of peri­implant fracture (p = 0.0002), or discharge directly to home (p = 0.04). CONCLUSION: PFF and female gender are risk factors for recurrent fracture, which is even more likely to occur early in case of home discharge or peri­implant fracture.

Malpractice litigation after spinal surgery: A review of allegations in France in 1990-2020.

OBJECTIVE: Spinal surgery is among the specialities with the highest rates of complications and of peri-operative morbidity and mortality. The number of spinal surgeries performed is rising year on year in France. The objectives of this study were to identify the main reasons for malpractice claims after spinal surgery in France, to evaluate the impact of avoidable errors, and to examine differences between civil lawsuits (private institutions) and administrative lawsuits (public institutions). HYPOTHESIS: The leading reasons for malpractice litigation are avoidable errors such as inadequate patient information, errors in indications, and inadequate post-operative monitoring. MATERIAL AND METHODS: We reviewed malpractice claims related to spinal surgery and recorded in two French databases (Legifrance and Doctrine) in 1990-2020. We combined the indexing term "surgery" with any of the following terms: "disc", "spine", "cervical", "vertebral", "lumbar", "scoliosis", "disc replacement", and "fusion". The search was performed by three orthopaedic surgeons who were blind to patient data and recorded the allegations, verdicts, and pay-outs. RESULTS: We included 275 claims. The main plaintiff allegations were inadequate information (34.5%), infection (22%), spinal-cord injury (17%), and errors in indication (13%). Among these reasons, 56.7% may have been partly avoidable. In private institutions, claims for infection and for erroneous indication were significantly more common than in public institutions (p=0.02 for both), whereas the opposite was true for spinal-cord injury (p<0.001). CONCLUSION: After spinal surgery in France, the most common malpractice allegation was inadequate information. Over half the claims were related to potentially avoidable factors. Among allegations, errors in indication were significantly more common in civil than in administrative lawsuits. LEVEL OF PROOF: IV, retrospective observational database study.

Microbiological Diagnosis of Osteoarticular Infections: Comparison between BacT/Alert Bottles and Schaedler Broth.

Microbiological diagnosis of osteoarticular infections (OAIs) is based on culture on several media. Experts recommend the use of liquid media, such as Schaedler broth, but many laboratories use blood culture media with automated detection instead for convenience. We aimed to evaluate the performance of culturing in BacT/Alert (bioMérieux) bottles for the microbiological diagnosis of OAI versus culturing in Schaedler broth. This prospective study was conducted on all osteoarticular specimens sent to the microbiology laboratories of the Versailles and Diaconesses Croix Saint-Simon hospitals between October 2016 and February 2017. Each sample was inoculated onto solid agar, into BacT/Alert bottles incubated for 14 days, and into a Schaedler broth incubated for 14 days with daily reading. The gold standard was defined as follow: OAI was diagnosed for a patient if at least two samples were positive for a nonskin microorganism and at least three for a cutaneous species. The times to detection were compared. A total of 1,616 specimens from 349 patients were collected. BacT/Alert bottles were significantly more sensitive than the Schaedler process for OAI diagnosis (114/135 OAI detected by BacT/Alert bottles; 91/135 OAI detected by Schaedler broth; +17.0% [95% confidence interval {CI}, 6.8%, 27.3%]; P = 0.0004). The time to detection was significantly shorter using BacT/Alert bottles (2.0 ± 2.2 days) than using Schaedler broth (4.6 ± 3.6 days, P < 0.0001). The culture of osteoarticular specimens in BacT/Alert bottles allows bacterial enrichment with an automated detection of positivity. Their use decreased detection time and increased sensitivity, making it a useful tool for the diagnosis of OAI that should be included among the recommended media. IMPORTANCE Microbiological diagnosis of OAI is based on culture on several media. French experts recommend the use of liquid media such as Schaedler broth, but many laboratories use blood culture media with automated detection in substitution because it is more convenient. We report here a prospective multicentric study evaluating the performance of culture in BacT/Alert (bioMérieux) bottles for microbiological diagnosis of OAI in comparison with culture in Schaedler broth. A total of 1,616 osteoarticular specimens from 349 patients were collected and inoculated onto agar, into BacT/Alert aerobic and anaerobic bottles, and into a Schaedler broth. BacT/Alert bottles were significantly more sensitive than the Schaedler process for OAI diagnosis (+17.0% [95% CI, 6.8%, 27.3%], P = 0.0004). The time to detection was significantly shorter for the BacT/Alert bottles (2.0 ± 2.2 days) than for Schaedler broth (4.6 ± 3.6 days, P < 0.0001). This study suggests that the use of BacT/Alert bottles should be recommended in microbiological diagnosis of OAI.

The severity of patellar and trochlear dysplasia are correlated.

PURPOSE: Patellar instability is a frequent clinical situation in adolescents and young adults. One of the most important risk factors of this condition is trochlea dysplasia. Few studies have analyzed the role of patellar dysplasia. The objective of this paper was to assess the correlation between trochlear and patellar dysplasia. The hypothesis is that patellar dysplasia increased in parallel with femoral trochlear dysplasia. METHODS: The study included patients operated on at least one knee for patellar instability between 2008 and 2020. For these patients, symptomatic knees (operated or not) were included if they had lateral and patellofemoral skyline radiographs. Two blinded observers categorized each trochlear and patellar dysplasia according to the Dejour and Wiberg classifications. Patellar height was also measured by applying the Caton-Deschamps index. RESULTS: A total of 100 patients were selected, involving 149 symptomatic knees. A significant correlation between trochlear and patellar dysplasia types was found (0.82; p < 0.0001). Dejour types B and C of trochlear dysplasia were significantly more often associated with patellar dysplasia than Dejour type A (p = 0.033 and p = 0.019, respectively). Moreover, severe Wiberg 3 patellar dysplasia was significantly associated with type D Dejour trochlear dysplasia than with the sum of all other Dejour types taken together (p < 0.0001). CONCLUSION: This study confirms a linear correlation between the severity of patellar and trochlear dysplasia. Further studies are needed to evaluate the place of patellar dysplasia in the therapeutic strategy. LEVEL OF EVIDENCE: Level IV.

Litigation after hallux valgus surgery in France between 2000 and 2020: A review of the two national legal research databases.

BACKGROUND: The objectives of this review were to: 1) describe reasons for lawsuits following primary hallux valgus surgery in France from 2000 to 2020; 2) to compare private and public practice. METHODS: Civil (private practice) and administrative (public practice) court decisions in France between 2000 and 2020 were collected using the two leading legal data sources (Legifrance, Doctrine). RESULTS: Seventy-two court decisions related to hallux valgus surgery were included. An appeal was filed in 93% of cases. Finally, 70.8% of the verdicts were in favor of the complainants. The average compensation awarded to a plaintiff was €55,333. The main reasons for complaint after hallux valgus surgery were: a failure to provide preoperative information (47.2%), post-operative pain/stiffness (38.9%), and infection (30.6%). A proven lack of information increased the risk of recognizing the occurrence of post-operative pain and stiffness as faulty from 13.3% to 61.5% (p = 0.01), and the average compensation from €25,330 to €76,716 (p = 0.04). The duration of the procedure was about 1.5 years longer in civil proceedings (p = 0.04). There was no significant difference between private and public activity litigation. CONCLUSION: Clear and adapted patient information and its traceability could be a way to reduce the number of complaints and their consequences in case of disappointing results.

Litigation after primary total hip and knee arthroplasties in France: review of legal actions over the past 30 years.

INTRODUCTION: Since the law of March 4, 2002, several modifications have impacted medical practices and their medico-legal implications. In case of an infectious complication not related to a fault of the practitioners (surgeons, anesthetists), the patient has the right to compensation assumed by the care structures. Moreover, the lack of preoperative information is no longer just a failing of the ethical standards but a breach of medical and legal obligations. Then, aims of this study were: (1) to describe the reasons for a lawsuit in France following total primary hip (THA) and total knee (TKA) arthroplasties and (2) to compare litigation characteristics of private and public practices. MATERIALS AND METHODS: Civil (private practice) and administrative (public practice) court decisions in France between 1990 and 2020 were collected using the two main legal data sources (Legifrance, Doctrine). RESULTS: Eighty-three TKA and 173 THA cases were identified. Reasons for complaint in primary THA were mainly infection (29%), prosthetic failures (18%), nerves injuries (17%), and leg length discrepancies (11%). The main grounds for complaint in favor of the plaintiff were diagnostic or indication mistakes (100%), infections (80%), especially if a lack of information was recognized (88%). Reasons for complaint following primary TKA were mainly infections (65%) and persistent pain or stiffness (12%). Whatever the reason, the verdict was in favor of the plaintiff in about 2/3 of the cases. THAs were more at risk of appeal in administrative procedures than in civil (p = 0.008). There were more cases of implant failure in civil proceedings (p = 0.008). Indemnities after primary THA was higher in public activity litigation (p = 0.04). There were no differences in verdicts, grounds for complaints, and compensation between public and private practices for primary TKA. CONCLUSION: The main complaint about all the arthroplasties in France was a septic complication. The lack of information could be an added pejorative element for the final verdict.

Fast-track procedures after primary total knee arthroplasty reduce hospital stay by unselected patients: a prospective national multi-centre study.

PURPOSE: The aim of this study was to evaluate the impact of fast-track procedures (FTPs) on length of hospital stay after primary total knee arthroplasty (TKA) in a prospective, national, multicentric analysis. The innovative point was that no patient selection was used. The hypothesis was that FTPs reduce hospital stay after primary TKA for non-traumatic conditions compared with the national database. METHODS: An observational prospective study was conducted in ten centres throughout France. A total of 839 patients included in FTPs were followed up for three months. The average LOS, direct return home rate, unscheduled re-admission rate, and re-intervention rate were compared with those in the national database (93,329 TKAs). Knee society and Oxford score were collected. RESULTS: The mean LOS was 4.4 ± 3.3 days, while the national base LOS was 6.4 ± 3.1 days (p < 0.001). A total of 560 patients (66.7%) were able to return home, compared with 47,617 (49.6%) in the national database (p < 0.001). Thirty-five patients (4.2%) were re-admitted within 90 days of the intervention, compared with 10,399 (10.8%) in the national database (p < 0.001). Seventeen patients (2.0%) were re-operated upon within 90 days after the TKA, compared with 529 (0.5%) in the national database (p < 0.05). CONCLUSION: The FTPs used by unselected patients allowed a significant decrease in the mean LOS and in the rate of re-admission and a significant increase of the rate of direct home return after primary TKA compared with the national database. The significant increase in the re-operation rate warrants further investigation. However, FTP should become the standard of care after this intervention.

Litigation in arthroscopic surgery: a 20-year analysis of legal actions in France.

PURPOSE: The main objective of this study was to identify the epidemiological characteristics of litigation following arthroscopic procedures, performed in private practice and public hospitals in France. The secondary objective was to establish a risk profile for medical malpractice lawsuits after arthroscopic surgery. METHODS: All court decisions related to arthroscopic surgery between 1994 and 2020 were collected and reviewed cases from the two main French legal databases (Legifrance and Doctrine). Data were retrospectively collected and included: gender, joint and defendant's specialty involved, reason behind the lawsuit, initial indication and the type of arthroscopic procedure performed. The final verdicts as well as the indemnity awarded to the plaintiff (if any) were recorded. RESULTS: One-hundred eighty cases met the inclusion criteria of the study and were analyzed: 58 cases were before administrative courts and 122 were before civil courts. An orthopaedic surgeon was involved alone or in solidum in 45.6% of cases (82/180), followed by anesthesiologists in 5.6% (10/180). The private surgery center or public hospital were implicated in 63.9% (115/180) of cases. The 2 most common joints involved in litigation following arthroscopic surgery were the knee (82.2%, n = 148) and the shoulder (11.1%, n = 20). The main reasons behind the lawsuit were related to postoperative infection in 78/180 cases and to a musculoskeletal complication in 45/180 cases (25%). A failure to inform was also reported in 34/180 cases (18.9%). Of the 180 cases, 122 cases (67.8%) resulted in a verdict for the plaintiff. The average indemnity award for the plaintiff was 77.984 euros [2.282-1.117.667]. A verdict for the plaintiff was significantly associated with postoperative infection or a wrong-side surgery, while technical error and musculoskeletal complications were more significantly likely to result in a verdict in favor of the defendant (p = 0.003). CONCLUSION: This study evaluated and mapped lawsuits following after arthroscopic surgery in France over a period of more than 20 years. The main joint involved in lawsuits was knee. The main causes of lawsuits following arthroscopic surgery were related to postoperative infection, musculoskeletal complications and failure to inform. LEVEL OF EVIDENCE: Level IV.

Functional outcome of osteochondral autograft is equivalent in stable knee and in anterior cruciate ligament reconstruction.

INTRODUCTION: Anterior cruciate ligament (ACL) tears are associated in 10% to 20% of cases with extensive traumatic focal osteochondral damage. Ligament reconstruction may require osteochondral autograft for symptomatic osteochondral lesions. Combined ACL and chondral or osteochondral reconstruction is poorly evaluated in the literature; osteochondral reconstruction in stable knee better documented. The objective of this study was to compare functional results after osteochondral autograft transfer (OAT) for significant symptomatic femoral condyle defect, in stable or stabilised knees (concomitant ACL reconstruction). The hypothesis was that functional results are equivalent in both groups. MATERIAL & METHOD: This was a single-centre retrospective comparative observational study of patients consecutively operated on between 2000 and 2018. Fifty patients met the inclusion criteria and were divided into two groups: Group 1 (OAT+ACL, n=13) and group 2 (OAT on stable knee, n=37). The following criteria were recorded at follow-up: pain (VAS), KOOS, IKDC and Lysholm scores and Hughston radiologic score, and time to return to sport. Mean follow-up was 79.7±60 months in group 1 and 86.4±62 months in group 2. RESULTS: Ten patients were included for analysis in group 1 and 30 in group 2. Cartilage lesion size was comparable between groups: 1.6±1.20 cm2 for group 1 and 2.3±1.3 cm2 for group 2 (ns). One complication (infection with favourable course) was observed in group 2. Sport was resumed at 8.7±2.7 vs. 8.4±3.3 months, respectively. Mean subjective scores were respectively 83.3±7.4 and 75.4±14 for Lysholm, 89.7±7.8 and 89.7±19.6 for KOOS, 78±13.7 and 72.2±12.9 for subjective IKDC, 0.5±0.5 and 0.8±0.9 for pain on VAS and 3 and 3 for radiological Hughston radiologic score, with no significant differences between groups. CONCLUSION: Symptomatic focal osteochondral lesions treated by osteochondral autograft transfer gives the same outcome on stable or stabilised knee. LEVEL OF EVIDENCE: IV; retrospective study.

Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program.

INTRODUCTION: Prevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol. HYPOTHESIS: The risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol. METHODS: This was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months. RESULTS: Of the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA. DISCUSSION: The primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed. LEVEL OF EVIDENCE: IV; Prospective cohort study without control group.

Multiligament knee injuries treated by one-stage reconstruction using allograft: Postoperative laxity assessment using stress radiography and clinical outcomes.

BACKGROUND: Surgical treatment of multiligament knee injuries (MLKIs) leads to better outcomes but there are controversies about optimal surgical strategies. Debates remain about timing of surgery: acute, staged or delayed and about graft choice: autograft, allograft or a combination of both. Therefore, we performed a retrospective study aiming to evaluate postoperative laxity using stress radiographs and clinical outcomes after one-stage reconstructions of injured ligaments using non-irradiated, fresh-frozen allografts. HYPOTHESIS: MLKIs treated by one-stage reconstructions using non-irradiated, fresh-frozen allograft may lead to satisfactorily postoperative laxity and clinical outcomes. METHODS: Between November 2013 and July 2015, 23 patients with MLKIs underwent one-stage reconstruction using allograft. Knee injuries were defined according Schenk classification of Knee Dislocation (KD). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, and the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form at a minimum follow-up of 24 months. Postoperative anterior, posterior, varus, and valgus laxities were assessed using stress radiographs and expressed as side-to-side differences (SSD) in millimeters. RESULTS: Three of 23 patients were lost to follow-up. There were 6 KD-I, 12 KD-III, and 2 KD-IV lesions, 12 lateral-side and 10 medial-side lesions, and 13 acute and 7 chronic cases. Three patients had associated neurovascular injuries. Mean follow-up was at 29.4±6.1 months. Mean valgus SSD was 0.2mm±1.4mm (range, -2.1-2.2mm), mean varus SSD was 1.4mm±2.5mm (range, -1.7-6.0mm), mean posterior SSD was 7.2mm±3.9mm (range, 1.2-16.0mm), mean anterior SSD was 3.6mm±5.1mm (range, -4.8-16.8mm). Overall IKDC ratings were: 4 grade A, 3B, 7C, and 6D. Three patients complained of postoperative instability, with an IKDC rating of D. The mean subjective IKDC score was 67.2±19.6, the mean Lysholm Knee Scoring Scale was 77.3±16.5, and the mean KOOS results were 78.5±16.6 for pain, 67.7±17.4 for symptoms, 86.5±14.2 for daily activities, 56±25.4 for sports, and 47.2±28.6 for quality of life. Nineteen of 20 patients returned to sport-6 to the same level. One patient underwent an arthroscopic arthrolysis due to postoperative arthrofibrosis. CONCLUSIONS: Using non-irradiated allografts for one-stage reconstructions of all the injured ligaments in MLKIs is effective and safe. Anteroposterior stability was difficult to restore, but patients returned to their daily activities and sometimes to their sports activity at the same preinjury level. LEVEL OF EVIDENCE: Level IV, case series.

Correction to: Rotational profile alterations after anatomic posterolateral corner reconstructions in multiligament injured knees.

The original article can be found online.

Sectioning of the Anterior Intermeniscal Ligament Changes Knee Loading Mechanics.

PURPOSE: The purpose of this cadaver research project was to describe the biomechanical consequences of anterior intermeniscal ligament (AIML) resection on menisci function under load conditions in full extension and 60° of flexion. METHODS: Ten unpaired fresh frozen cadaveric knees were dissected leaving the knee joint intact with its capsular and ligamentous attachments. The femur and tibia were sectioned 15 cm from the joint line and mounted onto the loading platform. A linear motion x-y table allows the tibial part of the joint to freely translate in the anterior-posterior direction. K-scan sensors were used to define contact area, contact pressure, and position of pressure center of application (PCOA). Two series of analysis were planned: before and after AIML resection, mechanical testing was performed with specimens in full extension (1,400 N load) and in 60° of flexion (700 N load) to approximate heel strike and foot impulsion during the gait. RESULTS: Sectioning of the AIML produced mechanical variations below the 2 menisci when specimens were at full extension and loaded to 1,400 N: increasing the mean contact pressure (delta 0.4 ± 0.2 MPa, +15% variation P = .008) and maximum contact pressure (delta 1.50 ± 0.8 MPa, 15% variation P < .0001) and decreasing of tibiofemoral contact area (delta 71 ± 51 mm2, -15% variation P < .0001) and PCOA (delta 2.1 ± 0.8 mm). At 60° flexion, significant differences regarding lateral meniscus mechanical parameters were observed before and after AIML resection: mean contact pressure increasing (delta 0.06 ± 0.1 MPa, +21% variation P = .001), maximal contact-pressure increasing (delta 0.17 ± 0.9 MPa, +28% variation P = .001), mean contact area decreasing (delta 1.84 ± 8 mm2, 4% variation P = .3), and PCOA displacement to the joint center (mean displacement 0.6 ± 0.5 mm). CONCLUSIONS: The section of the intermeniscal ligament leads to substantial changes in knee biomechanics, increasing femorotibial contact pressures, decreasing contact areas, and finally moving force center of application, which becomes more central inside the joint. CLINICAL RELEVANCE: AIML resection performed ex vivo in this study, might potentially be deleterious in vivo. Clinical studies focusing on preserving or even repairing the AIML are needed to evaluate those ex vivo elements.

Prospective comparative study of knee laxity with four different methods in anterior cruciate ligament tears.

BACKGROUND AND PURPOSE: Anterior knee laxity can be evaluated using different devices, the most commonly used being the Telos®, KT1000®, Rolimeter®, and GNRB®. However, the laxity values obtained with these devices have never been compared to one another. As such, the outcomes of studies using these different knee laxity measurement devices may not be comparable. The primary purpose of this study was to determine the side-to-side laxity difference in patients with one ACL-injured knee, using each of these devices, and to compare the values obtained from each. We hypothesized that the measurements of laxity would vary depending on the device used. METHODS: This was a prospective study. All patients with an ACL injury, in which surgical reconstruction was planned, underwent pre-operative knee laxity measurements using four different devices. The concordance correlation coefficient (CCC) of the results was compared between the four devices. RESULTS: The study enrolled 52 patients. With regard to the values of the side-to-side differences, the KT1000® and the GNRB® obtained the most similar values (CCC = 0.51, 95% CI 0.37-0.63). The two devices with the lowest correlation were the Telos® and the Rolimeter® (CCC = 0.04, 95% CI - 0.14-0.23). The comparability was considered average for the KT1000® and GNRB® and poor for the other devices. CONCLUSIONS: The knee laxity devices used in regular practice are not comparable to one another. As a result, caution must be taken when comparing results from studies using these different devices.

Torsional Appearance of the Anterior Cruciate Ligament Explaining "Ribbon" and Double-Bundle Concepts: A Cadaver-based Study.

PURPOSE: To investigate the effect of the anterior cruciate ligament (ACL) torsion in 90° knee flexion on the morphological appearance of the ACL. METHODS: Sixty knees from fresh frozen anatomical specimens were dissected. Eighteen knees were excluded according to selection criteria (torn ACL, mucoid degeneration of the ACL, arthritic lesions of the notch, or knees harboring synovial inflammatory pathologies). After the removal of the synovial membrane, the morphology of the ligamentous fibers of the ACL and the twist were analyzed. Twisting of the ACL was measured using a goniometer in 90° knee flexion and defined by the angle of external rotation of the femur on the axis of the tibia required to visualize a flat ACL. The orientation of tibial and femoral footprint was described in a coronal plane for the tibia and a sagittal plane for the femur. RESULTS: In the 42 knees that were finally included, the ACL was always displayed as a single ribbon-like structure. The torsion of the fibers was on average 83.6° (± 9.4°) in 90° knee flexion. The twisting could be explained by the different orientations of the femoral (vertical in a sagittal plane) and tibial (horizontal in a coronal plane) footprints. An intraligamentous proximal cleavage area was encountered in 11 cases (i.e., 26%). CONCLUSIONS: The ACL is a twisted structure with 83.6° of external torsion of fibers in 90° knee flexion. It is the torsion in the fibers, due to the relative position of bone insertions, which gives the ACL the appearance of being double bundle. CLINICAL RELEVANCE: The concept of the torsional flat structure of the native ACL may be of importance during ACL reconstruction, both in terms of graft choice (flat rather than cylindrical) and of technical positioning (torsion).

Biomechanical evaluation of four femoral fixation configurations in a simulated anterior cruciate ligament replacement using a new generation of Ligament Advanced Reinforcement System (LARS™ AC).

BACKGROUND: Recent improvements in manufacturing of biomaterials have made available a new generation of artificial ligaments with better biocompatibility and design that have led to a new interest in using them for ACL reconstructions. PURPOSE: To evaluate the biomechanical characteristics of four femoral fixations using a Ligament Advanced Reinforcement System (LARS™ AC; LARS, Arc sur Tille, France) for anterior cruciate ligament replacement. METHOD: Six femoral ACL fixations in four configurations using fresh calf femurs with an interference titanium screw inserted inside to outside, an interference titanium screw inserted outside to inside, an interference titanium screw inserted inside to outside with a staple and a new transversal cortical suspension device developed by LARS™ were compared in a static loading and failure test. Output values were ultimate strength, graft slippage, mode of failure, energy to failure and stiffness. RESULTS: The transversal fixation performed with a significantly higher failure load than others (1804 N) (p < 0.001), whereas there were no significant differences between the three fixations with interference screws. There were no significant differences of stiffness between all fixations, and the transversal device had a significantly higher graft slippage (13.1 mm) than others (all p < 0.01). CONCLUSIONS: In this in vitro evaluation, the transversal fixation exhibited better biomechanical performance under static solicitations than others. The transversal device is expected to provide better clinical results than the well-established screw system fixations for femoral ACL fixation. CLINICAL RELEVANCE: Laboratory investigation (Level 2).