Results of a French multicentre retrospective experience with four hundred and eighteen failed unicondylar knee arthroplasties

Purpose

By means of a multicentre retrospective study based on the failure of 418 aseptic unicondylar knee arthroplasties (UKA) our aims were to present the different types of revision procedure used in failed UKAs, to establish a clear operative strategy for each type of revision and to better define the indications for each type of revision.

Methods

Aseptic loosening was the principal cause of failure (n = 184, 44 %) of which 99 cases were isolated tibial loosening (23.5 % of the whole series and 54 % of all loosening), 25 were isolated femoral loosening (six and 13.6 %) and 60 were both femoral and tibial loosening (14.3 and 32.6 %). The next most common causes of failure were progression of arthritis (n = 56, 13.4 %), polyethylene wear (n = 53, 12.7 %), implant positioning errors (n = 26), technical difficulties (n = six) and implant failure (n = 16, 3.8 % of cases). Data collection was performed online using OrthoWave™ software (Aria, Bruay Labuissiere, France), which allows collection of all details of the primary and revision surgery to be recorded.

Results

A total of 426 revisions were performed; 371 patients underwent revision to a total knee arthroplasty (TKA) (87 %), 33 patients (7.7 %) were revised to an ipsilateral UKA, 11 (2.6 %) patients underwent contralateral UKA (ten) or patellofemoral arthroplasty (one) and 11 patients (2.6 %) underwent revision without any change in implants.

Conclusions

Before considering a revision procedure it is important to establish a definite cause of failure in order to select the most appropriate revision strategy. Revision to a TKA is by far the most common strategy for revision of failed UKA but by no means the only available option. Partial revisions either to an alternative ipsilateral UKA or contralateral UKA are viable less invasive techniques, which in carefully selected patients and in experienced hands warrant consideration.     

Indications for and results of arthroscopy in the arthritic knee: a European survey

Purpose

The place of arthroscopic treatment in osteoarthritis of the knee has generated much controversy. A survey was initiated to collect the opinion of experienced surgeons.

Methods

Of the 211 surgeons interviewed, 170 (80.6 %) replied to the electronic questionnaire. Respondents had at least ten years of experience in arthroscopy and currently perform more than 100 arthroscopies per year. Various indications and treatment modalities for arthroscopy in osteoarthritis of the knee had to be evaluated on a scale from “excellent” to “no indication”.

Results

The respondents generally believe that an improvement is more likely in low-grade osteoarthritis (p < 0.001) and in neutral leg axis (p < 0.001). The outcome was rated better if symptoms had persisted for less than six months (p < 0.001) and for patients that were younger than 60 years (p < 0.001). Partial meniscectomy and notchplasty in cases of extension deficit were considered as successful treatment options. Debridement was an accepted indication, with an outcome mainly rated as fair. A majority saw no indication for joint lavage, arthroscopic treatment of arthrofibrosis and removal of osteophytes. The outcome appears to be poor if a bone edema is diagnosed on magnetic resonance imaging prior to arthroscopy. Only 55.9 % of respondents were comfortable with the current definition of osteoarthritis.

Conclusions

Experienced arthroscopic surgeons all over Europe believe arthroscopy in osteoarthritis is appropriate, under certain conditions. The major task for surgeons is to select the right patients who are likely to benefit from this intervention.     

The incidence of trochlear dysplasia in anterior cruciate ligament tears

Purpose

The purpose of the present epidemiologic study is to record the radiographic presence of trochlear dysplasia and patella alta in patients who undergo anterior cruciate ligament (ACL) reconstruction as a potential underlying factor for post-operative anterior knee pain (AKP).

Methods

All consecutive cases of skeletally-mature ACL-deficient knees that would undergo ACL reconstruction in three different hospitals were prospectively included during a six-month period. Inclusion criteria were acute and sub-acute ACL injury with no previous ipsilateral knee operation. Patients with chronic ACL tears, prior-to-ACL-injury history of patellar instability or other PF disorders were excluded from the study.

Results

A total of 299 knees were included (mean age 32 ± ten years). Forty-four (14.7 %) knees had a positive ‘crossing sign’ in the lateral X-rays and 255 (85.3 %) had no sign of trochlear dysplasia (p < 0.01). Among the cases with trochlear dysplasia, 41 (93 %) had type A trochlear dysplasia with the presence only of the ‘crossing sign’ and three (7 %) had type C trochlear dysplasia. Patellar height results included a mean Caton-Deschamps index of 1.0 ± 0.14 (0.5–1.4). Twenty (6.6 %) knees had an index of less than 0.8, and two (0.6 %) knees had an index less than 0.6. In contrast, 15 (5.0 %) knees had an abnormal value of more than 1.2, indicating patella alta.

Conclusions

The most important finding of the study is the increased prevalence of trochlear dysplasia and patella alta in patients with ACL injury, when compared to the incidence of trochlear dysplasia and patella alta in the general population in the literature. This finding could sound as an alert of a possible additional risk factor for post-operative anterior knee pain after ACL reconstruction.     

Définition clinique, laximétrique, vidéo arthroscopie des ruptures du LCA. Étude prospective multicentrique

This prospective multicentric study of 418 anterior cruciate ligament (ACL) rupture has been done to investigate the correlation existing between the various aspects of the anterior cruciate ligament recognized at the time of surgery and data from clinical examination, radiographic examination of the standard and anterior drawer, and MRI. Four types of ACL injuries have been identified: completely disappeared, conservation posterolateral bundle, scarring on the posterior cruciate ligament, and scarring in the notch. Different correlations have shown a greater laxity in the group disappeared completely with a greater frequency soft Lachman and explosive pivot shift. All these findings were also correlated with the time to “injury surgery” higher in the group disappeared completely from conservation groups “posterolateral.” This study showed the different criteria for ACL ruptures, and this may help the surgeon to make the best surgical choice.     

A European workshop to investigate technical problems of using HLA monoclonal antibodies in microcytotoxicity assays

Various methods for controlling carryover from monoclonal antibodies (MCA) used in the microcytotoxicity assay to detect HLA antigens were investigated by 45 European laboratories. Carryover was demonstrated in most laboratories when using standard techniques (i.e. as for allo-antisera). Taking into consideration factors such as technical ease, time, accuracy and reagent availability, nearly half the participants selected the "no-touch" technique for adding cells and complement as being the best method for controlling carryover in their laboratory. (This method allows the needle of the Hamilton syringe to touch the oil but not the antibody in each well). Most participants (75%) thought that at least one diluent well was still necessary between each MCA well, even when using their preferred technique.     

Ossäre und chondrale Anatomie des patellofemoralen Gelenks

Zusammenfassung Chronische Schmerzen im vorderen Kniegelenkbereich sowie Instabilitäten des patellofemoralen Gelenks sind im klinischen Alltag häufig beobachtete Probleme. Morphologische Besonderheiten wie eine Dysplasie der Trochlea femoris oder Form- und Positionsabweichungen der Kniescheibe beeinträchtigen dabei die Funktion des patellofemoralen Gelenks als integralen Bestandteil des Kniegelenks.Die Patella bildet in ihrer Funktion als Sesambein einerseits einen wichtigen Hebelarm für die Kraftübertragung der Quadrizepsmuskulatur bei der Streckung im Kniegelenk, andererseits muss das Gelenk zwischen Trochlea und Patella großen Druck- und Zugkräften widerstehen.In dieser Arbeit versuchen wir sowohl einen Überblick über die knöcherne Anatomie des Patellofemoralgelenks zu geben als auch unter Berücksichtigung des Knorpelaufbaus die Eigenschaften des patellofemoralen Gleitlagers zu erläutern.     

Chronic posterior instabilities

As an introduction, isolated posterior, posterolateral, posteromedial, as well as combined posterior stability are defined. Rupture of the posterior cruciate ligament leads to pathological patterns for both concentric and eccentric quadriceps movements. Special attention is drawn to the significance of the peripheral stabilizers and their influence on instability. Ruptures of the posterior cruciate ligament are commonly followed by a phase of functional adaptation, functional tolerance, and arthrotic decompensation. Diagnosis should not only be based on the posterior drawer test, but also consider stability tests in the frontal plane and eventual rotational instabilities. What constitutes adequate therapy is still a subject of controversy today. Among the operative procedures, the most common are the pes anserinus graft according to Hey-Groves and Lindemann, the gastrocnemius graft of Hughston and Insall, the free patellar ligament graft, and synthetic replacement. The decision about indications for surgery should not be made earlier than 18 months after the accident, when the phase of functional adaptation has been completed.     

The pathophysiology of patellofemoral arthritis

Faced with a patient suffering from patellofemoral arthritis, the surgeon must determine the pathophysiology of the condition, because different causes demand different treatments. Possible causes include malalignment, patellofemoral dysplasia, patellofemoral instability, patellofemoral trauma, obesity, osteoarthritis, inflammatory arthritis, and a genetic predisposition. Arthritis secondary to malalignment, dysplasia, instability, or trauma is less likely than arthritis secondary to the other causes to progress to femorotibial arthritis.