Infection recurrence factors in one- and two-stage total knee prosthesis exchanges.

PURPOSE: Revision of infected total knee replacements (TKR) is usually delayed for a period in which the joint space is filled with an antibiotic-loaded acrylic spacer. In contrast, one-stage re-implantation supposes immediate re-implantation. Formal comparisons between the two methods are scarce. A retrospective multi-centre study was conducted to investigate the effects of surgery type (one-stage vs. two-stage) on cure rates. It was hypothesised that this parameter would not influence the results. METHOD: All infected TKR, treated consecutively between 2005 and 2010 by senior surgeons working in six referral hospitals, were included retrospectively. Two hundred and eighty-five patients, undergoing one-stage or two-stage TKR, with more than 2-year follow-up (clinical and radiological) were eligible for data collection and analysis. Of them, 108 underwent one-stage and 177 received two-stage TKR. Failure was defined as infection recurrence or persistence of the same or unknown pathogens. Factors linked with infection recurrence were analysed by uni- and multi-variate logistic regression with random intercept. RESULTS: Factors associated with infection recurrence were fistulae (odds ratio (OR) 3.4 [1.2-10.2], p = 0.03), infection by gram-negative bacteria (OR 3.3 [1.0-10.6], p = 0.05), and two-stage surgery with static spacers (OR 4.4 [1.1-17.9], p = 0.04). Gender and type of surgery interacted (p = 0.05). In men (133 patients), type of surgery showed no significant linkage with infection recurrence. In women (152 patients), two-stage surgery with static spacers was associated independently with infection recurrence (OR 5.9 [1.5-23.6], p = 0.01). Among patients without infection recurrence, International Knee Society scores were similar between those undergoing one-stage or two-stage exchanges. CONCLUSION: Two-stage procedures offered less benefit to female patients. It suggests that one-stage procedures are preferable, because they offer greater comfort without increasing the risk of recurrence. Routine one-stage procedures may be a reasonable option in the treatment of infected TKR. LEVEL OF EVIDENCE: III.

[Hemophagocytic lymphohistiocytosis: A retrospective analysis of 66 patients]. / Lymphohistiocytose hémophagocytaire : analyse rétrospective de 66 patients.

CONTEXT: Hemophagocytic lymphohistiocytosis is a rare syndrome with a poor prognosis, characterized by an uncontrolled dysregulation of the immune system. The rarity of this disease makes it difficult to obtain large cohorts. In this study, we analyzed the data of 66 patients: the objective was to describe the epidemiological, clinical, biological and therapeutic characteristics and to compare our results with those already published. METHODS: We conducted a retrospective study at the University Hospital of Montpellier from 2015 to 2021. Patients were included when the diagnosis of HLH was mentioned on the hospitalization report and when the HSCORE was higher than 50% (169). Prognostic analyses were performed by comparing the patients who died from HMH to those who didn't. RESULTS: The mean age the 66 patients included was 49.2 years, 62% were men. The percentage of deaths was 45.9%. Lymphoma was the main etiology, followed by infections, then autoimmune/autoinflammatory diseases. Fever, splenomegaly, hepatomegaly and organ failure were the main clinical manifestations. Pancytopenia was present in 62% of cases. Ferritin, triglycerides, LDH and AST were highly increased. Advanced age, associated lymphoma, and the severity of cytopenias were linked to a poor prognosis. DISCUSSION: The study of the clinico-biological, epidemiological and survival data of the patients in our cohort allowed us to confirm previously published data but also to discuss some of them.

[Comparison of oestradiol and testosterone levels in peripheral blood and spermatic cord blood in patients with secretory azoospermia]. / Comparaison des taux d'estradiol et de testostérone dans le sang périphérique et dans le sang spermatique chez les patients avec azoospermie sécrétoire.

OBJECTIVE: Comparison of testosterone and oestradiol levels in spermatic cord blood and peripheral blood as a function of the results of testicular sperm extraction by surgical biopsy in a population of patients with nonobstructive azoospermia (NOA). MATERIAL AND METHODS: Prospective, comparative, teaching hospital-sponsored, ethics committee-approved study of 30 patients with NOA. Plasma testosterone and oestradiol assays in peripheral blood and blood taken from the spermatic vein during testicular biopsy were performed simultaneously for each patient. Statistical analyses were performed with Mann-Whitney test and Spearman's correlation coefficient by univariate and multivariate analysis of variance (p<0.05). RESULTS: No significant correlation was demonstrated between spermatic and peripheral blood levels of testosterone and oestradiol, regardless of the biopsy results. The spermatic oestradiol/testosterone ratio was significantly increased when testicular sperm extraction was negative (p=0.018). CONCLUSION: The increase of the oestradiol/testosterone ratio in spermatic cord blood in the case of negative testicular sperm extraction suggests the hypothesis of greater conversion of testosterone to oestradiol in the testes. This could reflect increased aromatase activity in the absence of germ cells. Further studies using tissue markers of spermatogenesis should provide a better understanding of the physiological role of oestrogens in spermatogenesis and to refine the indications for testicular biopsy in patients with NOA.

Opening-wedge high tibial osteotomy performed with locking plate fixation (TomoFix) and early weight-bearing but without filling the defect. A concise follow-up note of 48 cases at 10 years' follow-up.

INTRODUCTION: Use of a locking plate during medial opening high tibial osteotomy (HTO) eliminates the need to fill the defect and its associated complications. It also allows early weight-bearing. Since long-term data with this type of construct are rare, we wanted to report the outcomes of a 51-patient cohort evaluated after a mean follow-up of 10.2years. The goals were to determine (1) the HTO survival and whether the correction was maintained between 2 and 10years later, (2) the stability of the functional outcomes, (3) the complication rate related to use of locking plates. HYPOTHESIS: The correction following medial opening HTO with a Tomofix™ plate without void filling is maintained after 10years' follow-up. MATERIAL AND METHODS: Fifty-one patients ranging from 37 to 72years of age at the time of surgery between 2003 and 2005 underwent a medial opening HTO that was stabilized with a Tomofix™ locking plate (Synthes, Oberdorf, Switzerland) without void filling. Forty-eight patients were reviewed between March and September 2014; 1 patient had died and 2 were lost to follow-up. RESULTS: The mean HKA angle went from 172±3.18° (165-178°) preoperatively to 181±1.18° (176-185°) postoperatively, to 181±1.60° (176-185°) at 2years, and 180.8±2.4° (175-184°) at 10years' follow-up. This equates to a loss of correction of 0.71±1.9° (0-6°) (p=0.02) between 2 and 10years after the surgery. Five patients underwent total knee arthroplasty (TKA), thus the 10-year survival of the HTO procedure was 88% (95% CI: 81-98%). If the five TKA procedures are excluded, the mean IKS knee score went from 90±7.4 (66-98) at 2years' follow-up to 77±15.3 (43-97) at 10years (p>0.05). There were four complications in all (8%), of which three occurred within 2years (2 cases of nonunion and 1 surgical site infection) and one occurred later (infection after 118months that resolved once the hardware was removed and the patient given appropriate antibiotics). There were no complications related to the five subsequent TKA procedure and no bone grafting was required. DISCUSSION: There was a small (less than 1 degree) but statistically significant loss of correction and non-significant deterioration in the functional outcomes. Conversely, the complication rate did not increase over time, despite the lack of void filling, particularly in patients who subsequently underwent TKA. The 10-year survival was similar to other HTO procedures. This locking plate construct without void filling is reliable after 10years. LEVEL OF EVIDENCE: Level IV, prospective study without control group.

Course of dislocated posterior hip arthroplasty: A continuous 232-patient series at a mean 10 years' follow up (range, 1-22 years).

BACKGROUND: Dislocation rates in posterior total hip arthroplasty (THA) range between 2% and 5%, but long-term course (recurrence of dislocation or revision surgery) is not known, most series having short follow-up or small populations. We therefore conducted a retrospective study on a large series, to determine long-term rates of recurrence and surgical revision and recurrence risk factors. HYPOTHESIS: Long-term follow-up of a large cohort of THA dislocations enables recurrence rate and factors to be determined. MATERIAL AND METHOD: Five hundred and nine cases of THA dislocation were admitted to our center between 1994 and 2008. A hundred and twenty seven incomplete files and 150 patients who had received their THA elsewhere were excluded, leaving 232 patients: 150 female, 82 male. Mean age at THA (163 primary, 69 revision) was 63 years (range, 15-90 years), and 65 years (range 20-90 years) at first dislocation, with a mean interval to dislocation of 25 months. Minimum follow-up was 8 years up to 2016, or 1 year taking account of deaths (111 deaths). There were 46 anterior, 185 posterior and 1 multidirectional dislocations. The following potential recurrence factors were assessed: gander, age, body-mass index (BMI), etiology, surgical history, bearing diameter and type, component fixation means, dislocation direction, and time to dislocation. RESULTS: A hundred and thirty three of the 232 patients (57%) showed at least 1 recurrence, at a mean 38 months (range, 0.5-252 months); 78 experienced a second and 32 a third recurrence. Ninety-nine (43%) had only 1 dislocation, without recurrence, but 17 of these (17%) underwent reoperation for other causes. The reoperation rate was 17/232 (7%) excluding recurrent instability, and 84/232 (36%) for instability. Fourty-eight months after the first dislocation, 84/133 cases of recurrence (63%) had been reoperated on: 16 complete replacements, 18 bearing replacements, 42 dual mobility cups, one large diameter cup, seven Lefèvre retentive cups. The rate of revision surgery for instability was high, at 84/232 (36%), and higher again in relation to recurrence (84/133: 63%). Only posterior dislocation emerged as a factor for recurrence (HR=1.774, 95% CI [1.020-3.083]), the other tested factors showing no correlation.14 of the 84 revision surgeries for instability (16.6%) were followed by recurrence, without identifiable risk factors. CONCLUSION/DISCUSSION: The recurrence rate was 57%, with posterior dislocation as the only risk factor. The rate of revision surgery for recurrence was 84/232 (36%), with 14/84 revision procedures (16.6%) followed by further recurrence. LEVEL OF EVIDENCE: IV, retrospective, without control group.

Diagnostic accuracy of the alpha defensin lateral flow device (Synovasure) for periprosthetic infections in microbiologically complex situations: A study of 42 cases in a French referral centre.

BACKGROUND: Joint aspiration is currently the reference standard test for diagnosing periprosthetic joint infection (PJI) despite the high rate of false-negative results, of which a major cause is the fastidious nature of some microorganisms. A rapid diagnostic test that detects alpha defensin (Synovasure™, Zimmer, Warsaw, IN, USA) in joint fluid can provide the diagnosis of PJI within a few minutes across the full spectrum of causative organisms (including mycobacteria and yeasts). Its performance in detecting bacterial infections is unaltered by concomitant antibiotic therapy. Few studies of Synovasure™ have been conducted by groups that were involved in designing the test, which has not been validated in France. Assessments in referral centres where complex microbiological situations are common hold considerable interest. The objective of this prospective study was to determine the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and causes of error of Synovasure™ used to diagnose periprosthetic infection in complex microbiological situations. HYPOTHESIS: The rapid diagnostic test Synovasure™ has greater than 90% NPV for detecting periprosthetic infections in complex microbiological infections. MATERIAL AND METHODS: Synovasure™ was used 42 times in 39 patients between October 2015 and October 2017 in challenging microbiological situations [discordant joint aspiration results (n=20), negative cultures with clinical or laboratory evidence of infection, (n=21), and concomitant antibiotic therapy (n=1)]. Of the 39 patients, 23 had total knee prostheses, 13 total hip prostheses, and 3 total femoral prostheses. The reference standard to which the Synovasure™ results were compared was the PJI criteria set developed by the Musculoskeletal Infection Society (MSIS). RESULTS: Synovasure™ was negative in 30 cases with negative joint fluid cultures (30/42, 71.4%). Of the 12 (28.6%) cases with positive Synovasure™ results, only 7 (7/12, 58.3%) had positive joint fluid cultures. According to the MSIS criteria 9 cases were infected, including 8 with positive and 1 with negative Synovasure™ results. Of the 33 cases that were not infected according to MSIS criteria, 29 had negative and 3 positive Synovasure™ results; the remaining case had a positive Synovasure™ result but was excluded when metallosis was found intra-operatively. NPV was 96.7%, PPV 72.7%, sensitivity 88.9%, and specificity 90.6%. DISCUSSION: The high NPV of Synovasure™ suggests a role for this test in microbiologically complex situations as a new tool for ruling in and, most importantly, ruling out infection in doubtful cases. LEVEL OF EVIDENCE: III, prospective study of diagnostic accuracy.

Prospective assessment of patients' knowledge and informational needs and of surgeon-to-patient information transfer before and after knee or hip arthroplasty.

BACKGROUND: Patients are playing an increasingly large role in their own management and must therefore receive clear, complete, and comprehensible information. In the field of hip and knee arthroplasty, little is known about the level of patient knowledge and effectiveness of surgeon-to-patient information transfer. We therefore designed a prospective observational study with the objective of assessing four factors: patient knowledge during management, quality of information transfer, informational needs, and factors associated with the level of knowledge. HYPOTHESIS: The level of patient knowledge changes during the management process. PATIENTS AND METHODS: A prospective single-centre study was conducted between January 2014 and March 2015 during the outpatient visits and inpatient stays of 63 patients who underwent arthroplasty of the hip (n=36) or knee (n=27). A single observer attended all patient visits and recorded the information provided by the surgeon. Each patient completed a self-questionnaire after the outpatient visit (T1), at admission (T2), and at discharge after surgery (T3). Semi-quantitative scores were used to assess knowledge and informational needs. The effectiveness of information transfer was evaluated by comparing the information provided by the surgeon to the replies made by the patients. RESULTS: The mean overall knowledge score (on a 0-42 scale) increased from 17.22±6.33 at T1 to 19.44±6.89 at T3 (P=0.0028). In contrast, knowledge about complications was better at T1 than at T3 (2.67±1.98 vs. 2.19±1.91; P<0.05). Agreement between information given by the surgeon and replies made by patients varied across items from 23% to 100%. The mean informational needs score (on a scale from 0 to 21) ranged from 3.67 to 4.83 and was higher at T3 than at T2 (4.83±3.77 vs. 3.67±4.86; P=0.03). The proportion of patients who wanted written information was higher at T3. Most patients sought information before the outpatient visit. At each step of the management process, the main areas about which the patients wanted information were the surgical procedure, the rehabilitation programme, and the prosthesis. Several socio-demographic or management-related factors influenced the level of knowledge. Thus, older age and lower educational attainment were associated with lower knowledge scores, whereas previous lower-limb orthopaedic surgery and amount of information provided by the surgeon were associated with higher knowledge scores. Knowledge scores were not associated with being employed vs. retired, gender, replacement of a hip vs. a knee, the surgeon, or being accompanied by another person. DISCUSSION: Our study is original in that we assessed changes in patient knowledge during the management process for hip or knee arthroplasty. The level of patient knowledge was fairly low and varied considerably across individuals and time points in the management process. These data highlight the importance of providing patients with information throughout their management and particularly at discharge, when the desire for information seems greatest. LEVEL OF EVIDENCE: IV, prospective observational study with no control group.

Validation of a French patient-reported outcome measure for patello-femoral disorders: The Lille Patello-Femoral Score.

BACKGROUND: The diagnosis of patello-femoral instability (PFI) relies chiefly on the patient's clinical findings. Nevertheless, few clinical scores specifically designed to evaluate the patello-femoral joint are available. The Lille scoring system is a 12-item self-questionnaire yielding a score from 0 to 100 that is used in France but has not been validated. We therefore conducted a validation study in a population of younger patients with PFI. HYPOTHESIS: The Lille scoring system meets validation criteria for patient-reported outcome measures (PROMs). MATERIAL AND METHOD: A retrospective study done in two centres identified 136 patients with objective (n=109) or potential (n=27) PFI. Before and after surgery, the Lille score was determined by all patients and the Kujala score in 61 patients. The Lille score was also determined by 30 controls free of patello-femoral disorders to allow an evaluation of discrimination between PFI and other knee disorders in individuals of similar age. RESULTS: The response rate was 100%, indicating that the Lille questionnaire was easy to complete. Consistency was established: (a) the global score showed no floor or ceiling effect (in no questionnaires were over 85% of items given the highest or lowest possible score), and saturation occurred neither for the global score nor for the item sub-scores (fewer than 85% of patients had the lowest or highest possible score); (b) a single redundancy was found, between the items 'pain' and 'locking', for which the correlation coefficient was≥0.7 (P<0.0001). Discriminating performance was assessed by comparing the mean Lille score values in the controls (67.8±9.2) and patients (38.1±10.4); the difference was significant (P<0.05) and the estimated effect size was>0.8, indicating strong discrimination by the Lille scoring system. Item uniformity, with all items measuring the same phenomenon, was established by the Cronbach alpha coefficient value>0.7. External consistency between the Lille and Kujala scoring systems was confirmed in the 61 patients for whom both scores were available (Pearson correlation coefficient, 0.5). Sensitivity to change was established by the>0.8 effect size of surgical treatment. DISCUSSION: The Lille scoring system deserves to be used routinely in clinical practice as a patient-reported outcome measure. A prospective study will assess intra-observer reproducibility and sensitivity to change in patients treated non-operatively. Although confined to retrospective data, this study based on methods designed to assess PROMs establishes the validity of the Lille scoring system and supports its use in PFI. LEVEL OF EVIDENCE: III, case-control design.

Reproducibility of digital measurements of lower-limb deformity on plain radiographs and agreement with CT measurements.

INTRODUCTION: Five angles (HKA, HKS, alpha, beta, tibial slope) are used for goniometry in total knee arthroplasty. The reproducibility of the measurement of these angles has been assessed on plain and digitized x-rays, but to our knowledge, this has not been confirmed on x-rays taken on the PACS system and they have not been compared to computed tomography (CT) measurements, the reference for angle measurement. This prospective study aimed to: (1) evaluate the inter- and intrarater reliability of the measurement of these angles on digital x-rays taken on a PACS; (2) determine the agreement of these measurements with those obtained using a CT protocol. HYPOTHESIS: The measurements of these five angles on digitized radiographs are reproducible and in agreement with CT values. MATERIAL AND METHODS: Forty-two patients suffering from knee osteoarthritis and scheduled for total knee arthroplasty were included in the study. Each patient had a PACS digitized x-ray and a CT intended to produce patient-specific instrumentation (Symbios, Yverdon, Switzerland) including measurements of the angles evaluated. Four senior orthopaedic surgeon-raters measured all the angles twice. Inter- and intrarater reliability was then calculated as well as the agreement between the second measurement of each rater and the CT measurement using interclass correlation and kappa coefficients (data provided as means and 95% confidence intervals). RESULTS: The inter- and intrarater reliability values were excellent for the HKA, alpha, and beta angles (with, respectively, a coefficient of 0.99 [0.97-0.99], 0.84 [0.76-0.9], and 0.94 [0.86-0.96] interrater reliability and 0.98 [0.96-0.99], 0.86 [0.75-0.92], and 0.65 [0.44-0.8] intrarater reliability). Interrater reliability was low for HKS and tibial slope angles (coefficients all<0.4 for interrater reliability and <0.7 for intrarater reliability). The x-ray/CT agreement was very good for the HKA, alpha, and beta angles (0.81 [0.67-0.99], 0.74 [0.56-0.91], and 0.74 [0.45-0.92], respectively) and low for the HKS and tibial slope angles (all<0.45). DISCUSSION/CONCLUSION: The HKA, alpha, and beta angles were reproducible for digital radiographs and showed good agreement with CT measurements. HKS and tibial slope angles should be used with greater caution, and other navigation methods or patient-specific instrumentation should be explored. LEVEL OF EVIDENCE: Level III, prospective, comparative diagnostic case-control study.

Epidemiology of patients with MSSA versus MRSA infections of orthopedic implants: Retrospective study of 115 patients.

Factors that predict the occurrence of a surgical site infection due to methicillin-resistant Staphylococcus aureus (MRSA) are not well known; however this information could be used to modify the recommended antimicrobial prophylaxis. We carried out a retrospective study of S. aureus infections on orthopedic implants to determine: (1) whether epidemiological factors can be identified that predict a MRSA infection, (2) the impact of these factors as evidenced by the odds ratio (OR). HYPOTHESIS: Risk factors for a MRSA infection can be identified from a cohort of patients with S. aureus infections. MATERIALS AND METHODS: We identified 244 patients who experienced a S. aureus surgical site infection (SSI) in 2011-2012 documented by intraoperative sample collection. Of these 244 patients, those who had a previous SSI (n=44), those with a SSI but no orthopedic implant (n=80) or those who had the infection more than 1-year after the initial surgery (n=5) were excluded. This resulted in 115 patients (53 arthroplasty, 62 bone fixation) being analyzed for this study. There were 24 MRSA infections and 91 MSSA infections. The following factors were evaluated in bivariate and multifactorial analysis: age, sex, type of device (prosthesis/bone fixation), predisposition (diabetes, obesity, kidney failure), and environmental factors (hospitalization in intensive care unit within past 5 years, nursing home stay). RESULTS: Two factors were correlated with the occurrence of MRSA infections. (1) Nursing home patients had a higher rate of MRSA infections (67% vs. 18%, P=0.017) with an OR of 8.42 (95% CI: 1.06-66.43). (2) Patients who had undergone bone fixation had a lower rate of MRSA infections than patients who had undergone arthroplasty (13% vs. 30%, P=0.023), OR 0.11 (95% CI: 0.02-0.56). Although the sample size was too small to be statistically significant, all of the patients with kidney failure (n=4) had a MRSA infection. DISCUSSION: Since these MRSA infection risk factors are easy to identify, the antimicrobial prophylaxis could be adapted in these specific patient groups.

Total knee arthroplasty revision with trabecular tantalum cones: Preliminary retrospective study of 51 patients from two centres with a minimal 2-year follow-up.

BACKGROUND: Successful management of large bone defects is of crucial importance when performing revision total knee arthroplasty (TKA). Trabecular tantalum cones may improve prosthesis fixation via their potential for reconstructing a stable metaphyseal support. The objective of this study was to evaluate the clinical and radiological outcomes and the complications of tantalum cones in revision TKA. HYPOTHESIS: Trabecular tantalum cones provide stable and durable metaphyseal reconstruction when used during revision TKA. MATERIAL AND METHODS: Trabecular Metal™ cones (Zimmer, Warsaw, IN, USA) were used for 52 revision TKAs in 51 patients (mean age, 68±9 years) managed in two centres between 2008 and 2013. A rotating hinge prosthesis was chosen for 38 (73%) knees and a condylar constrained knee prosthesis for 14 (27%) knees, with 37 tibial and 34 femoral cones. The two most common reasons for revision surgery were aseptic loosening (n=22, 42%) and infection (n=19, 37%). The bone loss was severe in most cases. At each centre, after a mean follow-up of 34 months (range, 24-52 months), two independent observers assessed the Knee Society Score (KSS), range of motion, mechanical axis, and osteo-integration for each patient. RESULTS: Mean KSS increased from 46 preoperatively to 77 (P=0.001) at last follow-up and the mean KSS function from 39 to 57 (P=0.007). Mean range of motion improved from 93° (45°-120°) to 110° (65°-130°) (P=0.001). Mean postoperative mechanical axis was 180° (172°-190°). Radiographic evaluation showed evidence of osteo-integration for all cones. Four revisions were performed for recurrence of infection but none for mechanical failure. DISCUSSION: The findings of our study confirm the biomechanical and biological reliability of Trabecular Metal™ cones used to fill metaphyseal bone defects during revision TKA. LEVEL OF EVIDENCE: IV, retrospective therapeutic study.

Technique to treat iliopsoas irritation after total hip replacement: Thickening of articular hip capsule through an abridged direct anterior approach.

Iliopsoas irritation due to acetabular cup component impingement following total hip arthroplasty (THA) is usually treated by infiltration or by distal iliopsoas tenotomy in case of recurrence; however, this can result in an active flexion deficit of the thigh. To prevent this complication, we developed an original technique that we performed between 2012 and 2014 in patients with recurrent impingement following extraarticular corticosteroid injections. This included 5 patients (mean age: 64 [53-75] years old) in whom we performed an ambulatory bursectomy by the Hueter approach and placed a polyglactin 910 (Vicryl™) mesh plate on the entire anterior hip capsule. After a mean follow-up of 12months (9-29months), anterior pain had decreased in all patients with improvement and an increase in the Oxford-12 (mean: 15 points [10-19]), Merle d'Aubigné (mean: 2.5 points [1-5]) and Harris (mean: 18 points [10-29]) scores. No flexion deficits were observed. An infected postoperative hematoma had to be drained but was cured at follow-up. This simple procedure provides satisfactory results and preserves THA function. It does not jeopardize future procedures and is an alternative option in case of unsuccessful conservative treatment.

Does severity of femoral trochlear dysplasia affect outcome in patellofemoral instability treated by medial patellofemoral ligament reconstruction and anterior tibial tuberosity transfer?

INTRODUCTION: Medial patellofemoral ligament (MPFL) reconstruction associated to anterior tibial tuberosity transfer (ATTT) is recommended in objective patellofemoral instability (PFI). Efficacy, however, has not been precisely determined in trochlear dysplasia with spur. A case-control study was performed in a PFI population, comparing groups with trochlear dysplasia with and without spur (S+ vs. S-) to assess the impact of trochlear dysplasia on (1) patellofemoral stability, (2) functional results and complications, and (3) patellofemoral cartilage status on MRI. HYPOTHESIS: Trochlear spur does not affect outcome in PFI managed by MPFL reconstruction and ATTT. MATERIAL AND METHODS: Twenty-eight knees (26 patients) with PFI were analyzed retrospectively and divided into 2 groups of 14 knees each according to presence of trochlear spur (S+ vs. S-). All 28 knees had undergone ATTT and MPFL reconstruction by semitendinosus autograft. Results were assessed on Lille and IKDC functional scores, and cartilage status was determined on MRI at last follow-up. RESULTS: At a mean 24 months' follow-up (range, 12-52 months), there was no recurrence of dislocation. IKDC and Lille scores tended to improve in both groups, although the only significant improvement was in IKDC score (S- gain, 21.3±16; S+ gain, 18.1±14) (P=0.01). IKDC scores at last follow-up were better in the S+ than S- group (79±19 [range, 21-92] vs. 68±13 [range, 35-84], respectively; P=0.012). Lille scores showed no significant inter-group differences in mean gain (P=0.492) or mean value (P=0.381). The S+ group showed more cartilage lesions (n=14/14 knees, including 12/14 with grade≥2 lesions) than the S- group (n=9/14 knees, all grade≤2). CONCLUSION: MPFL reconstruction with ATTT provided good short-term patellofemoral stability independently of the severity of trochlear dysplasia. Functional results and gain on IKDC, however, were poorer in case of dysplasia with trochlear spur. This is probably due to cartilage lesions, observed more frequently pre- and post-operatively in the spur group, especially as there was no significant difference in Lille Score, which highlights stability. LEVEL OF EVIDENCE: III, retrospective case-control study.

Long-term outcomes of primary constrained condylar knee arthroplasty.

BACKGROUND: Although constrained condylar knee (CCK) inserts are widely used for total knee arthroplasty (TKA), their long-term outcomes remain unclear. We sought to evaluate patients with at least 10 years' follow-up after CCK TKA to identify potential adverse events (osteolysis, loosening, constraint-mechanism failure), assess functional outcomes with special emphasis on range of motion, and determine prosthesis survival. HYPOTHESIS: Increasing constraint by implantation of a CCK insert does not increase the long-term frequencies of osteolysis or mechanical loosening. MATERIAL AND METHODS: We studied 43 knees after Legacy(®) CCK TKA. The indication was severe deformity (n=20), pre-operative laxity (n=6), or failure to achieve intra-operative balancing (n=17). There were 41 patients with a mean age of 66 years (21-88). A history of one or more surgical procedures was noted for 27 (63%) knees. Outcome measures were the Hospital for Special Surgery (HSS) knee score, Knee Society Score (KSS), and change in the hip-knee-ankle (HKA) angle. Prosthesis survival was assessed using revision surgery for any reason or for reasons other than infection as the censoring criterion. RESULTS: Complications other than venous thrombosis occurred in 16% of patients, including 3 who required revision surgery (septic loosening, n=2; and major instability in a patient with ipsilateral hip arthrodesis). No cases of osteolysis or aseptic loosening were recorded. Mean follow-up was 12.7 years (range, 10-14). At last follow-up, the HSS score had improved from 53 (26-83) pre-operatively to 80 (55-93), the KSS knee component from 42 (16-77) to 90 (77-99), and the KSS function component from 31 (0-80) to 61 (10-90) (P<0.001). Mean range of flexion increased from 109° (50°-140°) to 112° (90°-130°) (P=0.12). The HKA angle changed from 182°±15.5° (150°-210°) to 179.5°±2.5° (174°-184°) (P=0.5). The 11-year prosthesis survival rate was 88.5% (95% confidence interval, 0.69-0.94) overall and 97.7% (0.76-0.99) after excluding the cases of infection. DISCUSSION: Long-term functional gains after CCK TKA were similar to those reported after standard posterior-stabilised TKA, with no cases of constraint-mechanism failure or osteolysis. The complication rate was higher, with decreased survival compared to standard TKA, but the knee deformities and/or instability were particularly severe and two-thirds of knees had a history of one or more surgical procedures.

Sulcus deepening trochleoplasty for patellofemoral instability: A series of 34 cases after 15 years postoperative follow-up.

INTRODUCTION: Trochlear dysplasia is one of the main elements of patellofemoral instability. Although correction by trochleoplasty seems logical, the long-term outcome of this procedure is unknown and the progression to osteoarthritis has not been clarified. Thus, we performed a retrospective study of a series of sulcus deepening trochleoplasties with a 15-year follow-up whose goal was to (1) evaluate the long-term clinical outcome and radiological rate of osteoarthritis, and (2) define the results in relation to the type of instability and the grade of dysplasia. HYPOTHESIS: Sulcus deepening trochleoplasty is an effective procedure to stabilize the patellofemoral joint that does not increase the risk of osteoarthritis. PATIENTS AND METHODS: This retrospective study analyzed 34 sulcus deepening trochleoplasties based on clinical scores (IKS, Lille, Kujala and Oxford scores) and radiological results (stage of osteoarthritis according to the Iwano score) after a mean follow-up of 15 years (12-19 years). An Insall procedure was systematically associated with an anterior tibial tubercle transfer in 17 cases (7 prior tibial transfers). RESULTS: No recurrent objective instability was observed. Seven knees had additional surgery after a mean follow-up of 7 years (2-16): 7 underwent conversion to total knee arthroplasty because of progression of osteoarthritis and one knee had tibial tubercle transfer for pain and episodes of the knee giving way. The mean Lille, Kujala and IKS scores increased from 53.3 (30-92), 55 (13-75) and 127 (54-184) to 61.5 (25-93), 76 (51-94) and 152.4 (66-200) respectively between preoperative and follow-up assessment (P<0.05) (revisions included). Functional outcome was significantly better for dysplasia with supratrochlear spurs (IKS score 168 [127-200] versus 153 [98-198] and Kujula score 81.5 [51-98] versus 76 [51-94] [P<0.05]). Patients were satisfied in 65% of the cases and the total mean Oxford score was 24.1/60 (12-45 points). Occasional pain was present in 53% of the cases. The trochlear prominence decreased from 4.9 mm (3-9 mm) to -1.2mm (-7-4mm). Ten cases of preoperative patellofemoral osteoarthritis were identified, but none with>Iwano 2, while osteoarthritis was present in 33/34 cases at the final follow-up with 20 cases>Iwano 2 (65%). DISCUSSION: Sulcus deepening trochleoplasty corrects patellofemoral stability even in patients with severe dysplasia and the long-term functional outcome is better in this group. It does not prevent patellofemoral osteoarthritis. It should be limited to severe dysplasia with supratrochlear spurs and associated with procedures to realign the extensor apparatus.

Femoral lengthening during hip resurfacing arthroplasty: a new surgical procedure.

Correction of leg length discrepancy during hip arthroplasty is a technical challenge. Although resurfacing proposed to young subjects presents a number of advantages (stability, bone stock, etc.), it does not correct leg length discrepancy. We propose an original femoral lengthening technique concomitant to resurfacing performed through the same approach, consisting in a Z-shaped subtrochanteric osteotomy. Resurfacing was performed first and the femoral and acetabular reaming material was used for autografting. The series comprised five cases followed for a mean 42.2 months (range, 33-64 months). The mean surgical time was 100 min (range, 76-124 min). Weightbearing was authorized in all cases at the 8th week. The mean lengthening was 32 mm (range, 25-40 mm). Healing was observed in all cases. This surgical technique, reserved for very young subjects who accept an 8-week postoperative period without weightbearing, can be proposed in cases with substantial preoperative leg length discrepancy.

Tantalum cones and bone defects in revision total knee arthroplasty.

Management of bone loss is a major challenge in revision total knee arthroplasty (TKA). The development of preformed porous tantalum cones offers new possibilities, because they seem to have biological and mechanical qualities that facilitate osseointegration. Compared to the original procedure, when metaphyseal bone defects are too severe, a single tantalum cone may not be enough and we have developed a technique that could extend the indications for this cone in these cases. We used 2 cones to fill femoral bone defects in 7 patients. There were no complications due to wear of the tantalum cones. Radiological follow-up did show any migration or loosening. The short-term results confirm the interest of porous tantalum cones and suggest that they can be an alternative to allografts or megaprostheses in case of massive bone defects.

Computed tomography evaluation of hip geometry restoration after total hip resurfacing.

BACKGROUND: Anatomic reconstruction of the hip is among the main requirements for hip arthroplasty to be successful. Resurfacing arthroplasty may improve replication of the native joint geometry but has been evaluated only using standard radiographs. We therefore performed a computed tomography (CT) study to assess restoration of hip geometry after total hip resurfacing (HR), comparatively with the non-operated side. HYPOTHESIS: HR does not change native extra-medullary hip geometry by more than 5mm and/or 5°. PATIENTS AND METHODS: CT was used to evaluate unilateral HR in 75 patients with a mean age of 52.2years (range, 22-67years). The normal non-operated side served as the control in each patient. Mean follow-up was 2.5years (range, 1.9-3.1years). The primary evaluation criteria were femoral offset (FO) and femoral neck anteversion (FNA) and the secondary criteria were cup inclination angle, cup anteversion angle, and lower-limb length. RESULTS: FO showed a non-significant decrease (mean, -2.2mm; range, -4.5 to +3.7mm). FNA was preserved, with a difference of less than 2° at last follow-up versus the preoperative value. Cup measurements showed a mean anteversion angle of 24.8° (0.9-48.6) and mean inclination angle of 44.1° (32.1-56.3); corresponding values for the native acetabulum were 38.9° (20.5-54.8) and 24.8° (4.8-33.6). The residual lower-limb length discrepancy was less than 1mm (mean, -0.04mm [-1.2 to +1.6mm]). The mean angle between the femoral implant and the femoral neck axis was 5.4° of valgus. DISCUSSION: Our results show that HR accurately restored the native extra-medullary hip geometry. LEVEL OF EVIDENCE: III, prospective diagnostic case-control study.

Influence of preoperative factors on the gain in flexion after total knee arthroplasty.

UNLABELLED: Final flexion mobility after a total knee arthroplasty is an important factor in patient comfort. Some patients gain in flexion mobility, others do not. Is it possible to identify the clinical factors related to the patient that predicted the final gain in flexion? MATERIALS AND METHODS: A multicenter retrospective study directed by the Société française de la hanche et du genou (SFHG) was conducted on 1601 cases of total knee arthroplasty that had presented no complications and a minimal follow-up of 2 years. The gain in flexion was assessed by the difference between the preoperative and the final range of flexion. The range of the gain in flexion was tested based on eight factors: age, gender, etiology, body mass index, frontal deformity, preoperative flexum deformity and four levels of preoperative mobility: < 90°, 90°-109°, 110°-129°, and ≥ 130°. RESULTS: A mean gain in flexion of 8.4°±14° was found for the overall series. In 66% of cases, we found an increase of flexion and in 19% a loss of flexion. In cases with BMI higher than 35, varus deformity with an HKA angle<166°, or flessum greater than 5°, the gain in flexion was significantly higher. A significantly different gain in flexion (P<0.0001) was found in the four levels of preoperative flexion: the greatest gain in flexion was found in the "<90°" group, then this gain was less in the next two groups, to become a significant decrease in the "≥130°" group. A decrease in flexion was noted in 51% of the cases in the latter group. Other factors such as age, sex, and etiology had no influence on the gain in flexion. DISCUSSION: After TKA, a gain in flexion was often noted. The amount of gain depended on the preoperative range of flexion: the lower this level was, the more flexion increased. The presence of a varus deformity, morbid obesity, or flessum was associated with greater gain in flexion, even if the final flexion was lower than the mean flexion in the overall population. The search for these factors made it possible to predict a gain in flexion and discuss this with the patient. LEVEL OF EVIDENCE: Level IV. Multicenter retrospective study.

Angiofollicular and plasmacytic polyadenopathy: a pseudotumourous syndrome with dysimmunity.

Two cases are reported of an apparently distinct type of immune disorder. Beginning with mild anaemia and widespread massive lymphadenopathy, the disease progressed to a fatal autoimmune type haemolytic anaemia. Serum investigation showed polyclonal hypergamma-globulinaemia and some autoantibodies. Repeat lymph node biopsies in each case showed hyperplasia within B lymphocyte territory (follicular hyperplasia and polyclonal plasmacytosis with IgG predominance) and atrophy of T dependent areas. Dilatation of lymph sinuses, vascular proliferation, and sclerosis were striking features. This appears to be a new entity, and reasons are given for separating this disease from other pseudotumourous lymph node disorders associated with dysimmunity.