Computer-assisted osteotomy for valgus knees: Medium-term results of 29 cases

AbstractIntroductionComputer-assisted surgery has been shown to be beneficial for correcting misaligned lower limbs. The purpose of this study was to analyze the medium-term results of computer-assisted osteotomy for 29 valgus knees. The hypothesis was that computer navigation would allow a valgus deformity to be corrected with similar precision as varus deformity.Material and methodsThe series consisted of 27 patients (29 knees); there were 7 men and 20 women with ages ranging from 15 to 63 years (mean: 42.4±14.3 years). Twenty-four varus osteotomies of the femur (14 medial closing and 10 lateral opening) and five double osteotomies (proximal tibia and distal femur) were performed. The pre-operative functional status was evaluated with the Lysholm-Tegner score. The mean score was 64±20.5 points (range: 18–100). According to Ahlbäck's modified classification for knee osteoarthritis, 12 patients were at stage 1, nine were at stage 2, five at stage 3 and one at stage 4. Two of the knees had no radiological signs of osteoarthritis but had a particularly unsightly deformity; one of these was secondary to high tibial valgus osteotomy. The mean pre-operative hip-knee-angle (HKA) angle was 189.3±3.9°; the mean mechanical medial distal femoral angle (mMDFA) was 97.2±2.6° and mechanical medial proximal tibial angle (mMPTA) was 90.1±2.8°. The goal was to achieve an HKA angle of 179±2° and mMPTA of 90±2° to avoid an oblique joint line. Functional outcomes were evaluated with the Lysholm-Tegner, KOOS and IKS scores.ResultsNo complications other than a transient paralysis of the common fibular nerve were observed. Twenty-three patients (25 knees) were reviewed at a mean follow-up of 50.9±38.8 months (range: 6–144). The mean Lysholm-Tegner score was 92.9±4 points (86–100), the mean KOOS was 89.7±9.3 (range: 68–100), the mean IKS “knee” score was 88.7±11.4 points (range: 60–100) and the “function” score was 90.6±13.3 points (range: 55–100). Twenty-two patients were satisfied or very satisfied. The mean HKA angle was 180.1±1.9°, the mean mMDFA 90.7±2.5° and the mean mMPTA 89.1±1.9°. The pre-operative goal was achieved in 86.2% of cases (25/29) for the HKA angle and 100% of cases of the mMPTA angle. At the follow-up, none of the knees had been revised with a prosthesis.ConclusionComputer-assisted osteotomy for cases of osteoarthritis secondary to valgus knee leads to excellent medium-term results. Navigation provides reliable and accurate deformity correction.Level of evidenceIV. Retrospective study

Standardising the clinical assessment of coronal knee laxity

Clinical laxity tests are used for assessing knee ligament injuries and for soft tissue balancing in total knee arthroplasty. This study reports the development and validation of a quantitative technique of assessing collateral knee laxity through accurate measurement of potential variables during routine clinical examination. The hypothesis was that standardisation of a clinical stress test would result in a repeatable range of laxity measurements.Non- invasive infrared tracking technology with kinematic registration of joint centres gave real-time measurement of both coronal and sagittal mechanical tibiofemoral alignment. Knee flexion, moment arm and magnitude of the applied force were all measured and standardised. Three clinicians then performed six knee laxity examinations on a single volunteer using a target moment of 18Nm. Standardised laxity measurements had small standard deviations (within 1.1°) for each clinician and similar mean values between clinicians, with the valgus laxity assessment (mean of 3°) being slightly more consistent than varus (means of 4° or 5°).The manual technique of coronal knee laxity assessment was successfully quantified and standardised, leading to a narrow range of measurements (within the accuracy of the measurement system). Minimising the subjective variables of clinical examination could improve current knowledge of soft tissue knee behaviour

Is unicompartmental-to-unicompartmental revision knee arthroplasty a reliable option? Case-control study

AbstractBackgroundIn selected patients with failed unicompartmental knee arthroplasty (UKA), revision UKA is a reliable option and may even provide lower morbidity rates and better functional outcomes compared to revision total knee arthroplasty.Material and methodsIn a multicentre retrospective study of 425 knees requiring revision surgery after UKA, 36 knees were managed with revision UKA.ResultsOf the 36 knees, 3 (8.33%) required iterative revision surgery, for aseptic loosening. After a mean follow-up of 8.3 years, the mean IKS knee and function scores were high (93.81/100 and 90.77/100, respectively).DiscussionIn carefully selected patients, UKA-to-UKA revision performed according to a rigorous operative technique deserves a role in the surgical strategy for failed UKA.Level of evidenceIII, multicentre retrospective case-control study

Primary total knee arthroplasty in the management of epiphyseal fracture around the knee

SummaryIntroductionOver the past few years the use of arthroplasty was broadened to treating complex epiphyseal fractures at the shoulder and elbow joints. Similar trends to treat this type of fractures at the knee are less documented. Based on a multicenter retrospective series study, the aims of this work is to evaluate the short term clinical results of total knee prostheses in the management of comminuted epiphyseal fractures around the knee, to identify the technical issues and fine tune the indications.Material and methodsFollowing the initiative of the French Hip and Knee Society (SFHG) and the Traumatology Study Group (GETRAUM), 26 charts from eight different centers in France were included in this multicenter retrospective series. Inclusion criteria were: primary total knee arthroplasty (TKA) in the management of complex articular fractures involving the proximal end of the tibia or distal end of the femur. Surgical features were identified and complications were analyzed. The assessment protocol at last follow-up was standardized and included patient demographic data, analysis of the Parker and IKS scores.ResultsDuring the immediate postoperative period, six patients (23%) reported a general complication and four patients (15%) a local arthroplasty-related complication. At last follow-up (mean 16.2 months), the overall final Parker score was 6.3 (a mean decrease of 1.7) and the mean IKS knee score was 82 points for a mean function score of 54 points.DiscussionPrimary TKA is a suitable management option for complex fractures in autonomous elderly patients suffering from knee osteoarthritis. The key technical details of this procedure should be respected and meticulously planned to achieve optimal results and limit the risk of complications. This risk in these acute complex fractures remains higher than after conventional TKA but comparable to that observed after TKA for post-traumatic arthritis.Level of evidenceIV; retrospective cohort study

Trochanteric locking nail versus arthroplasty in unstable intertrochanteric fracture in patients aged over 75 years

SummaryIntroductionIn trochanteric fracture, whatever its anatomic type, internal fixation is currently the standard attitude, with arthroplasty as a relatively unusual option.HypothesisHip implants are an excellent alternative to osteosynthesis in unstable trochanteric fracture in patients aged over 75 years.Patients and methodsA non-randomised prospective multicenter study compared osteosynthesis by trochanteric nailing (n=113) to hip arthroplasty (n=134) in unstable trochanteric fracture (AO types 31 A2.2 and 3 and A3.3) in 247 patients over the age of 75 years. The series was recruited during 2007 in seven centres, four of which included only arthroplasties, two only osteosyntheses and one both. The two groups were comparable in age, sex, preoperative Parker score, pre-fracture place of residence, fracture type, time to surgery and preoperative comorbidity. The sole difference was in operators, with more senior surgeons in arthroplasty (62% versus 27%).ResultsThree-month mortality was identical in the two groups (21.2% versus 21%). General complications did not differ, although mechanical complications were more frequent in the nailing group (12.5% versus 2.8%). Functional results (Parker and PMA scores) were better in the implant than in the nail group.DiscussionThe present study validated hip arthroplasty in these indications. Cemented stems associated to a dual-mobility acetabular component gave the best results.Type of studyProspective, level of evidence III

Common peroneal nerve palsy complicating knee dislocation and bicruciate ligaments tears

SummaryIntroductionThe occurrence rate of common peroneal nerve (CPN) palsy associated with knee dislocation or bicruciate ligament injury ranges from 10 to 40%. The present study sought first to describe the anatomic lesions encountered and their associated prognoses and second to recommend adequate treatment strategy based on a prospective multicenter observational series of knee ligament trauma cases.Material and methodsTwelve out of 67 knees treated for dislocation or bicruciate lesion presented associated CPN palsy: two females, 10 males; mean age, 32 years. Four sports injuries, three traffic accidents and five other etiologies led to seven complete dislocations and five bicruciate ruptures. Four cases involved associated popliteal artery laceration ischemia; one of the dislocations was open. Paralysis was total in eight cases and partial in four. There were two complete ruptures, three contusions with CPN in continuity stretch lesions and three macroscopically normal aspects.ResultsAt a minimum 1 year's follow-up, regardless of the initial surgical technique performed, recovery was complete in six cases, partial (in terms of motor function) in one and absent in five. Without specific CPN surgery, spontaneous recovery was partial in one case, complete in two and absent in none. Following simple emergency or secondary neurolysis, remission was total in four cases and absent in one. Three nerve grafts were all associated with non-recovery.DiscussionThe present results agree with literature findings. Palsy rates varied with trauma circumstances and departmental recruitment. Neurologic impairment was commensurate to ligamentary damages. The anatomic status of the CPN, subjected to violent traction by dislocation, was the most significant prognostic factor for neurologic recovery. In about 25% of dislocations, contusion-elongation over several centimeters was associated with as poor a prognosis as total rupture. CPN neurolysis is recommended when early clinical and EMG recovery fails to progress and/or in case of lateral ligamentary reconstruction. Possible peripheral nerve impairment needs to be included in the overall functional assessment of treatment for severe ligaments injuries and knee dislocation.Level of evidenceLevel IV, prospective study

Bilateral anterior dislocation of the shoulders at the start of a backstroke competition

Bilateral anterior dislocation of the shoulders is very rare. A 20-year-old man presented with bilateral anterior shoulder dislocation as a result of a diving incident. He complained of pain and restriction of movement in both shoulders with abducted and externally rotated arms. Radiographs revealed that the shoulders were dislocated. The patient was treated with closed reduction and was able to resume swimming 3 months later. To our knowledge, this is the first bilateral anterior dislocation of the shoulders during a backstroke swimming competition that was caused by this mechanism of injury. The rarity of this lesion and its uncommon mechanism prompted us to relate this observation

Quantitative Computed Tomography in COPD: Possibilities and Limitations

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease that is characterized by chronic airflow limitation. Unraveling of this heterogeneity is challenging but important, because it might enable more accurate diagnosis and treatment. Because spirometry cannot distinguish between the different contributing pathways of airflow limitation, and visual scoring is time-consuming and prone to observer variability, other techniques are sought to start this phenotyping process. Quantitative computed tomography (CT) is a promising technique, because current CT technology is able to quantify emphysema, air trapping, and large airway wall dimensions. This review focuses on CT quantification techniques of COPD disease components and their current status and role in phenotyping COPD