The Influence of Tibial Tubercle-Sparing Slope-Reducing Osteotomy on Patellar Height in Patients Undergoing Revision ACL Reconstruction.

BACKGROUND: A posterior tibial slope (PTS) >12° is an independent risk factor for anterior cruciate ligament (ACL) graft rupture, and a high tibial osteotomy (HTO) for slope correction can help avoid it. Management of patellar height is of major concern when performing HTO. PURPOSE: To evaluate the effect of tibial tubercle-sparing anterior closing-wedge osteotomy on patellar height in revision ACL reconstruction (ACLR). STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent arthroscopic revision ACLR combined with retro-tibial tubercle anterior closing-wedge HTO (ACW-HTO) between January 1, 2016, and March 31, 2021, were assessed for eligibility. Patellar height was measured on full weightbearing lateral radiographs according to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) or frontal radiographs using the femoral patellar height index. The PTS was evaluated using the proximal anatomic axis of the tibia on standard short lateral radiographs. The delta (postoperative - preoperative) and the ratio (preoperative/postoperative) of the 3 patellar height indices and PTS were calculated. Preoperative and postoperative patellar heights were compared using independent t tests for each index. Also investigated was whether patients changed patellar height category (baja, normal, or alta) after slope osteotomy. RESULTS: Among 475 revision ACLRs, 47 tibial tubercle-sparing ACW-HTOs were retained for analysis. No significant difference in patellar height was found between pre- and postoperative radiographs regardless of the index (preoperative - postoperative) (ISI: 1.0 ± 0.2 - 0.9 ± 0.2, P = .1729; CDI: 1.0 ± 0.2 - 1.0 ± 0.2, P = .4034; femoral patellar height index: 1.5 ± 0.2 - 1.5 ± 0.2; P = .5130). Fifteen patients (31.9%) exhibited a postoperative change in their patellar height category when measured by the ISI (6 moved up a category, 9 moved down one), and 18 patients (38.3%) changed category according to the CDI (10 moved up a category, 8 moved down one). No significant difference was found between pre- and postoperative patellar height among these patients (ISI: P = .2418; CDI: P = .3005). CONCLUSION: Changes in patellar height ratio are common after tibial tubercle-sparing ACW-HTO in patients undergoing revision ACLR. The clinical effect of these changes is unknown, and further study is needed to investigate whether they may result in patellofemoral symptoms.

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

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

No significant differences in 60-day postoperative complication rates between conventional and shortened stems.

PURPOSE: To compare 60-day complication rates, radiographic outcomes, and clinical outcomes following primary THA with conventional versus shortened stems, in a large cohort study. METHODS: The authors reviewed a consecutive series of 800 primary THAs, of which 781 met the inclusion/exclusion criteria: 395 received a conventional stem and 386 received a shortened stem. Intraoperative and postoperative complications were noted. Radiographic and clinical assessments were performed preoperatively and 60 days after surgery. RESULTS: Compared to conventional stems, shortened stems had significantly less intraoperative complications (2.8% vs 0.3%, p = 0.006), but no significant differences in complications that did not require reoperation (1.0% vs 1.3%, p = 0.620), complications that required reoperation without stem revision (2.0% vs 1.0%, p = 0.384), and complications that required stem revision (0.5% vs 0.5%, p = 1.000). Four hips (two from each group) required stem revision and were thus excluded from 60-day assessment. There were no significant differences between groups in subsidence ≥ 3 mm (1.0% vs 0.5%, p = 0.686), alignment (90.3%vs 86.7%, p = 0.192), net change in offset (within 3 mm, 32.3% vs 30.5%, p = 0.097), and limb length discrepancy (3.0 ± 2.6 mm vs 2.9 ± 2.4 mm, p = 0.695). Compared to conventional stems, shortened stems had significantly better preoperative mHHS (56.5 ± 18.5 vs 64.5 ± 13.5, p < 0.001), and significantly lower net improvement in mHHS (29.9 ± 17.1 vs 24.4 ± 15.0, p < 0.001), but no significant differences in postoperative mHHS (87.3 ± 11.9 vs 89.4 ± 9.6, p = 0.109). CONCLUSIONS: There were no significant differences between conventional and shortened stems in terms of postoperative complication rates, radiographic outcomes, and postoperative mHHS. However, patients implanted with shortened stems had less intraoperative complications, but lower net improvement in mHHS. LEVEL OF EVIDENCE: Level IV, Retrospective comparative cohort study.

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

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

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

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

Clinical Outcomes of Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis Procedures in Skeletally Immature Patients: A Systematic Review From the SANTI Study Group.

BACKGROUND: The treatment of anterior cruciate ligament (ACL) tears in the pediatric population has changed significantly in the past few decades. Pediatric patients who underwent ACL reconstruction (ACLR) have a high risk of rerupture of up to 32%. The addition of lateral extra-articular procedures [lateral extra-articular tenodesis (LET)], already shown to be effective in reducing the risk of rerupture in adults, may also be effective in pediatric patients. The purpose of this study was to systematically review the clinical outcomes of ACLR+LET tenodesis in pediatric patients. METHODS: Data were collected from Pubmed, MEDLINE, Cochrane, and Scopus Databases according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies reporting the clinical outcomes of ACLR+LET in the pediatric population using autograft, return to play, growth disturbances, failure rate, and surgical complications were included. RESULTS: A total of 5 studies comprising 381 pediatric patients were included. Three main surgical techniques with common features were used. The mean age of all pediatric patients in the included studies was 11.73 years (range, 5.6 to 16) with a mean follow-up of 50.1 months. The overall graft failure rate of the included studies was 4.65%. The return to play was 95.11%. The mean Lysholm score was 94.51 and the mean Pediatric International Knee Documentation Committee (Pedi-IKDC) was 93.39. In all, 1.9% of the patients had a coronal plane deformity and 0.8% had a limb length discrepancy. 4.6% of the patients had a contralateral ACL tear. CONCLUSIONS: A combined ACLR+LET in pediatric patients showed a graft failure ranging from 0% to 13.6% at a mean follow-up of 50.1 months. This low graft failure rate is consistent with ACLR+LET in adults. Further investigations are needed to validate these findings and the potential role of LET in reducing graft rupture rates in this population. LEVEL OF EVIDENCE: Level IV-systematic review of level IV studies.

The Minimal Clinically Important Difference, Patient Acceptable Symptom State, and Clinical Outcomes of Anterior Cruciate Ligament Repair Versus Reconstruction: A Matched-Pair Analysis From the SANTI Study Group.

BACKGROUND: There has been increasing interest in anterior cruciate ligament (ACL) repair because of theoretical advantages over ACL reconstruction; however, the contemporary literature has failed to provide high-quality evidence to demonstrate these advantages. PURPOSE: To compare the clinical and functional outcomes of ACL repair versus ACL reconstruction at a minimum follow-up of 2 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent ACL repair were propensity matched (based on demographics, time between injury and surgery, knee laxity parameters, presence of meniscal lesions, preoperative activity level, and sport participation), in a 1:1 ratio, to those who underwent ACL reconstruction during the same period. Isokinetic testing was used to evaluate strength deficits at 6 months postoperatively. Knee laxity parameters were evaluated at 12 months. Complications, return to sport, and patient-reported outcome scores were recorded at final follow-up. RESULTS: In total, 75 matched pairs (150 patients) were evaluated. The repair group had significantly better mean hamstring muscle strength at 6 months compared with the reconstruction group (1.7% ± 12.2% vs -10.0% ± 12.8%, respectively; P < .0001). At a mean final follow-up of 30.0 ± 4.8 months, the repair group had a significantly better mean Forgotten Joint Score-12 (FJS-12) score compared with the reconstruction group (82.0 ± 15.1 vs 74.2 ± 21.7, respectively; P = .017). Noninferiority criteria were met for ACL repair, compared with ACL reconstruction, with respect to the subjective International Knee Documentation Committee score (86.8 ± 9.0 vs 86.7 ± 10.1, respectively; P < .0001) and side-to-side anteroposterior laxity difference (1.1 ± 1.4 vs 0.6 ± 1.0 mm, respectively; P < .0001). No significant differences were found for other functional outcomes or the pivot-shift grade. There were no significant differences in the rate of return to the preinjury level of sport (repair group: 74.7%; reconstruction group: 60.0%; P = .078). A significant difference was observed regarding the occurrence of ACL reruptures (repair group: 5.3%; reconstruction group: 0.0%; P = .045). Patients who experienced a failure of ACL repair were significantly younger than those who did not (26.8 vs 40.7 years, respectively; P = .013). There was no significant difference in rupture rates between the repair and reconstruction groups when only patients aged >21 years were considered (2.9% vs 0.0%, respectively; P = .157). The minimal clinically important difference and Patient Acceptable Symptom State (PASS) thresholds were defined for the ACL repair group. A significantly greater proportion of patients in the repair group achieved the PASS for the FJS-12 compared with their counterparts in the reconstruction group (77.3% vs 60.0%, respectively; P = .034). CONCLUSION: ACL repair was associated with some advantages over ACL reconstruction including superior hamstring muscle strength at 6 months and significantly better FJS-12 scores. However, the failure rate was significantly higher after ACL repair, and younger patients were particularly at risk.

Anterior Closing-Wedge High Tibial Osteotomy Using Patient-Specific Cutting Guide in Chronic Anterior Cruciate Ligament-Deficient Knees.

An increased posterior tibial slope has been identified as an independent risk factor for anterior cruciate ligament (ACL) graft rupture, with a critical threshold of 12°. Surgical slope correction by anterior closing wedge (ACW)-high tibial osteotomy (HTO) can reduce ACL force and anterior tibial translation with good clinical outcomes when combined with revision ACL reconstruction. Performing ACW-HTO preserving the tibial tubercule can be challenging for inexperienced surgeons. Patient-specific cutting guides have been shown to be effective in facilitating the surgeon's learning curve in medial opening wedge-HTO by reducing operative time and the use of fluoroscopy as well as decreasing anxiety. The present technique describes a retro-tibial tubercule ACW-HTO using a patient-specific cutting guide.

Arthroscopic Medial Compartment Drive-Through Sign for Knee Medial Collateral Ligament Complex Injuries.

Acute injuries of the knee medial collateral ligament complex concomitant with anterior cruciate ligament injuries are common. The exact site of the injury may be difficult to diagnose preoperatively on magnetic resonance imaging. This study describes an arthroscopic sign that helps determine the site of the knee medial collateral ligament complex injury. The "medial compartment drive-through sign," visualized during arthroscopy, is described as an excessive opening of the medial compartment. If this excessive opening is above the meniscus, it corresponds to a femoral-sided injury; conversely, if the excessive opening is below the meniscus, then it is a tibial-sided injury. This allows a precise surgical incision to be made, thereby avoiding extensive approaches and possible wound-related complications.

Risk of Graft Rupture After Adding a Lateral Extra-articular Procedure at the Time of ACL Reconstruction: A Retrospective Comparative Study of Elite Alpine Skiers From the French National Team.

BACKGROUND: Elite alpine skiing is associated with a particularly high risk of anterior cruciate ligament (ACL) injuries, including graft ruptures. Despite a considerable focus on prevention, a reduction in injury rates has not been observed since the 1980s. PURPOSE: To determine whether elite alpine skiers undergoing ACL reconstruction (ACLR) with a lateral extra-articular procedure (LEAP) had a lower rate of ACL graft rupture when compared with those who underwent isolated ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Elite skiers from the French ski team who had undergone ACLR, with or without a LEAP, and had a minimum follow-up of 2 years were identified from the national ski team database. Rates of secondary ACL injury were determined via interrogation of the database, review of medical notes, and a final telemedicine interview. A multivariable analysis using the penalized Cox model was performed to explore the relationship among graft rupture, surgical procedure type, and any potential explanatory variables. RESULTS: Among 81 ACLR procedures analyzed, 50 were isolated and 31 were combined with a LEAP, which was performed using modified Lemaire or anterolateral ligament reconstruction. Graft rupture rates were 34.0% in the isolated ACLR group and 6.5% in the ACLR + LEAP group. Multivariable analysis demonstrated that adding a LEAP was associated with a significant reduction in risk of ACL graft rupture when compared with isolated ACLR (hazard ratio [HR], 5.286 [95% CI, 1.068-26.149]; P = .0412). Age (HR, 1.114; P = .1157), sex (HR, 1.573; P = .3743), and ACL graft type (HR, 1.417; P = .5394) were not significant risk factors. CONCLUSION: Combined ACLR and LEAP were associated with a significant reduction in the rate of ACL graft rupture in elite alpine ski athletes. Those treated with isolated ACLR remain at extremely high risk of a second ACL injury.

Qualitative Comparison of Image Stitching Algorithms for Multi-Camera Systems in Laparoscopy.

Multi-camera systems were recently introduced into laparoscopy to increase the narrow field of view of the surgeon. The video streams are stitched together to create a panorama that is easier for the surgeon to comprehend. Multi-camera prototypes for laparoscopy use quite basic algorithms and have only been evaluated on simple laparoscopic scenarios. The more recent state-of-the-art algorithms, mainly designed for the smartphone industry, have not yet been evaluated in laparoscopic conditions. We developed a simulated environment to generate a dataset of multi-view images displaying a wide range of laparoscopic situations, which is adaptable to any multi-camera system. We evaluated classical and state-of-the-art image stitching techniques used in non-medical applications on this dataset, including one unsupervised deep learning approach. We show that classical techniques that use global homography fail to provide a clinically satisfactory rendering and that even the most recent techniques, despite providing high quality panorama images in non-medical situations, may suffer from poor alignment or severe distortions in simulated laparoscopic scenarios. We highlight the main advantages and flaws of each algorithm within a laparoscopic context, identify the main remaining challenges that are specific to laparoscopy, and propose methods to improve these approaches. We provide public access to the simulated environment and dataset.

Isolated Meniscotibial Ligament Rupture: The Medial Meniscus "Belt Lesion".

Ramp lesions play a major role in both anteroposterior and rotational instability following anterior cruciate ligament rupture. The meniscotibial ligament (MTL) is the most important structure to repair and is the primary stabilizer of the posterior horn of the medial meniscus. The posteroinferior insertion of the MTL on the posterior horn of the medial has been described, forming a posterior "belt." Isolated MTL lesion diagnosis can be challenging, as the absence of a meniscocapsular ligament lesion prevents its correct visualization through transnotch vision. This article details a technique to diagnose and repair the "belt lesion" of the medial meniscus.

Presoaking ACL Grafts in Vancomycin Decreases the Frequency of Postoperative Septic Arthritis: A Cohort Study of 29,659 Patients, Systematic Review, and Meta-analysis From the SANTI Study Group.

BACKGROUND: Presoaking anterior cruciate ligament (ACL) grafts in vancomycin has been reported to reduce the occurrence of septic arthritis (SA). However, strong recommendations for its universal use have been precluded by concerns regarding the fragility of previous meta-analyses. PURPOSE: The primary objective was to investigate whether presoaking ACL grafts in vancomycin was associated with a reduction in the rate of SA in a large series of patients. The secondary objective was to perform an updated systematic review and meta-analysis to determine the efficacy of vancomycin in reducing the rate of SA. STUDY DESIGN: Cohort study and systematic review; Level of evidence, 3. METHODS: A retrospective analysis of patients who underwent primary ACL reconstruction (ACLR) at our institution was undertaken. Rates of postoperative SA were determined and analyzed according to whether patients had received grafts presoaked in vancomycin. A systematic review of the literature and meta-analysis was performed. Odds ratios (ORs) for the risk of SA were calculated according to the inverse variance approach. Results were presented using forest plots, funnel plots, and the fragility index. RESULTS: A total of 5300 patients underwent primary ACLR during the study period. The rate of SA was 0.34% (11/3228) in the control group and 0.05% (1/2072) in the presoaked group. There was a 5-fold greater risk of SA in patients who did not receive grafts presoaked in vancomycin (OR, 5.13 [95% CI, 1.16-48.30]; P = .04). Overall, 11 studies were included in the systematic review (29,659 ACLR procedures). The meta-analysis demonstrated a significantly greater risk of SA in those patients who did not receive grafts presoaked in vancomycin (OR, 14.39 [95% CI, 5.90-35.10]; fragility index = 23). This finding held true for the subpopulation receiving hamstring tendon grafts (fragility index = 16), but only a trend was demonstrated for bone-patellar tendon-bone grafts. CONCLUSION: The meta-analysis demonstrated that presoaking ACL grafts in vancomycin was associated with significant reductions in the rates of SA when all graft types were analyzed together. This finding held true specifically for hamstring tendon autografts. The fragility index of these findings allows for a strong recommendation for the universal use of vancomycin presoaking. However, it should be noted that only a trend toward reduced SA rates was demonstrated with presoaking bone-patellar tendon-bone autografts in vancomycin.

Arthroscopic confirmation of femoral button deployment prevents soft tissue interposition in ACL reconstruction.

PURPOSE: The purpose of this study was to determine whether direct arthroscopic control of femoral buttons can prevent improper deployment and soft tissue interposition in anterior cruciate ligament (ACL) reconstruction. METHODS: A retrospective analysis of prospectively collected data from the SANTI study group database was performed. All patients who underwent ACL reconstruction using suspensive femoral fixation between 01/01/2017 and 31/12/2019 were included. Patient assessment included demographics, sports metrics, reoperations performed and femoral button-related specific complications such as iliotibial band (ITB) irritation and/or septic arthritis. Proper deployment of the button and soft tissue interposition were assessed on postoperative radiographs. RESULTS: A total of 307 patients underwent ACL reconstruction using adjustable femoral button fixation and were analyzed after a mean follow-up of 35.2 ± 11.0 months (14.3-50.2). The mean age was 39.5 ± 10.9-years old (range 13.3-70.6). Postoperative radiographs showed a correctly deployed femoral button without soft tissue interposition for all patients. No septic arthritis was reported. Nine patients (2.9%) suffered from lateral pain related to ITB irritation due to the button. Five of them had their symptoms resolve during rehabilitation. Ultrasound-guided corticosteroid infiltration was necessary for four patients after an average delay of 14.5 ± 4.8 months (11.7-21.7). Three patients were then symptom-free, but one required surgical removal of the implant 27.5 months after the surgery. Regarding unrelated femoral button complications, 15 patients (4.9%) underwent secondary arthroscopic procedures, including meniscectomy (1.6%), surgery for cyclops syndrome (2.6%) and revision ACLR (0.7%). CONCLUSION: Arthroscopic confirmation of femoral button deployment prevents soft tissue interposition without specific complications. LEVEL OF EVIDENCE: Level IV.

Osteochondritis Dissecans of the Knee: Pearls and Pitfalls of Anatomical Reduction and Secure Fixation.

Osteochondritis dissecans of the knee is characterized by sterile necrosis of the subchondral bone and typically affects skeletally immature patients. When left untreated, osteochondritis dissecans can lead to early-onset osteoarthritis, resulting in pain and disability. This study shows the pearls and pitfalls of an arthroscopic technique of fixation performed successfully using a bioabsorbable nail for unstable osteochondritis dissecans lesions located in the medial femoral condyle of the knee.

Highly Crosslinked Polyethylene Can Reduce Wear Rate in THA for High-Demand Patients: A Matched-Paired Controlled Study.

BACKGROUND: The average age of patients benefiting from total hip arthroplasty (THA) has been declining. In addition to pain relief, patients seek to return to physical activity. However, the latter may increase polyethylene wear and therefore the potential risk of early aseptic loosening. The introduction of highly crosslinked polyethylene (HXLPE) has reduced wear rates in the general patient population. The objective of this study was to evaluate the influence of impact sports in patients operated with THA using ceramic-on-conventional polyethylene (cPE) versus ceramic-on-HXLPE, in terms of wear and function, with a minimum of five year follow-up. METHODS: Sixty-eight patients practicing an impact sport (University of California Los Angeles score ≥8) who underwent a primary THA were included: 34 with a ceramic-on-cPE versus 34 with a ceramic-on-HXLPE using the same cementless acetabular and femoral component. Patients were matched-paired by age, sex, BMI, and University of California Los Angeles score. The wear analysis was performed using the IMAGIKA software. The Harris hip score and hip and osteoarthritis outcome score were collected. RESULTS: The linear wear rate was statistically higher (P < .0001) in the cPE group (0.13503 ± 0.0630 mm/year) than in the HXLPE group (0.03059 ± 0.0084 mm/year). Postoperatively, the increase in Harris hip score was calculated at 37.64 for the entire cohort and was comparable in both groups (P = .3674). The hip and osteoarthritis outcome score for pain (P = .0009), daily life activities (P = .0016), and quality of life (P = .0179) were significantly higher in the HXLPE group, with, between groups, a difference inferior to the reported minimal clinical important difference. Three patients exhibited signs of periprosthetic osteolysis in the cPE group, one on the femoral side and two on the acetabular side. None were observed in the HXLPE group. No revision for aseptic loosening was reported in both cohorts. CONCLUSION: Patients partaking in impact sports and receiving a ceramic-on-HXLPE THA demonstrated lower wear and osteolysis rates than those having a ceramic-on-cPE THA, with similar functional results.

Deep learning for the radiographic diagnosis of proximal femur fractures: Limitations and programming issues.

INTRODUCTION: Radiology is one of the domains where artificial intelligence (AI) yields encouraging results, with diagnostic accuracy that approaches that of experienced radiologists and physicians. Diagnostic errors in traumatology are rare but can have serious functional consequences. Using AI as a radiological diagnostic aid may be beneficial in the emergency room. Thus, an effective, low-cost software that helps with making radiographic diagnoses would be a relevant tool for current clinical practice, although this concept has rarely been evaluated in orthopedics for proximal femur fractures (PFF). This led us to conduct a prospective study with the goals of: 1) programming deep learning software to help make the diagnosis of PFF on radiographs and 2) to evaluate its performance. HYPOTHESIS: It is possible to program an effective deep learning software to help make the diagnosis of PFF based on a limited number of radiographs. METHODS: Our database consisted of 1309 radiographs: 963 had a PFF, while 346 did not. The sample size was increased 8-fold (resulting in 10,472 radiographs) using a validated technique. Each radiograph was evaluated by an orthopedic surgeon using RectLabel™ software (https://rectlabel.com), by differentiating between healthy and fractured zones. Fractures were classified according to the AO system. The deep learning algorithm was programmed on Tensorflow™ software (Google Brain, Santa Clara, Ca, USA, tensorflow.org). In all, 9425 annotated radiographs (90%) were used for the training phase and 1074 (10%) for the test phase. RESULTS: The sensitivity of the algorithm was 61% for femoral neck fractures and 67% for trochanteric fractures. The specificity was 67% and 69%, the positive predictive value was 55% and 56%, while the negative predictive value was 74% and 78%, respectively. CONCLUSION: Our results are not good enough for our algorithm to be used in current clinical practice. Programming of deep learning software with sufficient diagnostic accuracy can only be done with several tens of thousands of radiographs, or by using transfer learning. LEVEL OF EVIDENCE: III; Diagnostic studies, Study of nonconsecutive patients, without consistently applied reference "gold" standard.

Trabecular Metal Cones Combined With Short Cemented Stem Allow Favorable Outcomes in Aseptic Revision Total Knee Arthroplasty.

BACKGROUND: The purpose of this study was to compare the functional outcomes and implant survivorship at a minimum of 5 years of follow-up of several reconstruction techniques with or without metaphyseal cone and stems of variable length. METHODS: A retrospective comparative matched analysis was performed from 2 prospectively collected databases. Only patients who underwent revision total knee arthroplasty procedures for aseptic causes using a single design of rotating hinge knee with a minimum of 5 years of follow-up were analyzed. Patients were separated into 3 groups: trabecular metal (TM) cones + short cemented stems (TM + short stem [SS]), TM cones + long uncemented stems (TM + long stem [LS]), and no cone (NC) + long uncemented stems (NC + LS). A matching process based on age (±5 years) was realized. RESULTS: About 99 patients were included; 33 in the TM + SS group, 33 in the TM + LS group, and 33 in the NC + LS group. The mean time of follow-up was 9.3 years. A significant difference of the improvement of subscale pain, symptom, activities of daily living, quality of life of the Knee Injury and Osteoarthritis Outcome score and knee, function of the Knee Society Score was observed in favor of TM + SS group compared with the 2 other groups. At 8 years of survivorship, the components free of revision for any cause were 90.9% for the TM + SS group, 84.9% for the TM + LS group, and 90.6% for the NC + LS group. CONCLUSION: The use of a short cemented tibial stem combined with a TM cone in revision total knee arthroplasty offers identical survival rate with better functional outcome compared with the use of a long uncemented stem associated with TM cones or metallic augments at a minimum of 5 years of follow-up.