Publications by authors named "Elvire Servien"

133 Publications

Kinematic alignment fails to achieve balancing in 50% of varus knees and resects more bone compared to functional alignment.

Knee Surg Sports Traumatol Arthrosc 2022 Aug 13. Epub 2022 Aug 13.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.

Purpose: Evidence is emerging that tibio-femoral compartmental balancing is related to clinical outcomes after total knee arthroplasty (TKA). The purpose of this study was to assess if kinematic alignment (KA) delivered a balanced knee in flexion and extension after TKA on varus deformity, compared to functional alignment (FA).

Methods: This single-centre retrospective cohort study assessed 110 consecutive TKAs performed with an image-based robotic system for pre-operative varus deformity. The ligament balancing in the medial and lateral femorotibial compartments was assessed intra-operatively with a robotic system to evaluate if a KA plan would deliver a balanced knee. Balance was considered achieved if tibio-femoral compartments (medial/lateral) were equal to or less than 1.5 mm, or if the estimated final gap position more than 2 mm from the global implant thickness (17 mm). Implant positioning was modified within limits previously defined for a FA philosophy to achieve balancing. Resection thickness and implant positioning were compared with the KA plan and after the FA adjustments; and also, between the patients with a final balanced knee in extension and at 90° of flexion.

Results: A total of 102 patients were eligible for final analysis. Mean age was 67.3 ± 8.2 years, average BMI was 29.1 ± 5.2 kg/m, mean pre-operative coronal alignment was 174.0° ± 3.3° and sagittal alignment 3.4° ± 5.9°. Mean post-operative coronal alignment was 177.7° ± 1.0° and sagittal alignment 0.8° ± 1.9°. A KA plan delivered medial-lateral tibio-femoral compartment balancing in 67 cases (65.7%) for the extension gap and in 50 cases (49.1%) for the flexion gap. All measured bone resection depths were significantly less for FA compared to KA. To achieve balancing targets, final femoral component position was more externally rotated relative to the posterior condylar axis, (0.5° with KA compared to 1.7° with FA (p < 0.0001), and the tibia in more varus (3.0° KA vs. 3.5° FA p = 0.0024). Only one soft tissue release was required.

Conclusion: KA failed to deliver a balanced TKA in more than 50% of cases, especially regarding the flexion gap. Consideration of soft tissue laxity led to significantly less bone resection, with more externally rotated femoral component and more varus tibial component.
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http://dx.doi.org/10.1007/s00167-022-07073-5DOI Listing
August 2022

Is combined robotically assisted unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction a good solution for the young arthritic knee?

Int Orthop 2022 Aug 13. Epub 2022 Aug 13.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France.

Purpose: Anterior cruciate ligament (ACL) deficiency can be a consequence or a cause of femoro-tibial osteoarthritis (OA). Several studies have published satisfactory outcomes of unicompartimental knee arthroplasty (UKA) and combined ACL reconstruction despite its absence classically being considered a contraindication. A major challenge in the ACL deficient knee is obtaining appropriate gap balancing and limb axis. Robotically assisted UKA allows for precise control of these factors; however, it's utilisation as a tool with combined ACL reconstruction and UKA has not been described. The purpose of this study was to evaluate the clinical and radiological outcomes of robotically assisted UKA with combined ACL reconstruction.

Methods: This was a retrospective single-centre study of ten patients operated by a single surgeon from 2016 to 2020. All surgery was performed using a cemented fixed bearing UKA prosthesis (Journey uni, Smith and Nephew®) (8 medial, 2 lateral) inserted with the assistance of an image-free robotic-assisted system (BlueBelt, Navio, Smith and Nephew®). All ACL reconstructions were performed using hamstring autograft. Clinical assessment included International Knee Score (IKS) score, Tegner score and patient satisfaction. Radiological assessment was performed to assess radiolucent lines, progression of OA in the other compartments, Hip-Knee-Ankle angle and Posterior Tibial Slope.

Results: There were eight females (80%), mean age was 57 ± 7 [48-70], mean BMI was 26 ± 3 [22-31]. The mean follow-up was 45 months ± 13 months [24-66]. Mean post-operative IKS knee and function score were respectively 96 ± 4.5 [88-100] and 93 ± 8.2 [74-100], mean Tegner score was 4.5 ± 1.4 [3-6]. Nine patients (90%) returned to sport; one patient (10%) was dissatisfied because of residual pain preventing a return to a desired level of sport. 100% of the radiological objectives were achieved. No radiolucent lines were seen at the last follow-up. There were two re-operations (20%) for stiffness requiring arthroscopic arthrolysis at two and three months respectively following surgery, with full recovery of the flexion at the last follow-up in both cases. No other complications were observed.

Conclusion: Robotic UKA associated with ACL reconstruction provides satisfactory early patient outcomes and accurate implant positioning. The first results in terms of return to sports were promising.
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http://dx.doi.org/10.1007/s00264-022-05544-5DOI Listing
August 2022

The Dynamic Effect of Anterior Cruciate Ligament Deficiency on Patellar Height.

Indian J Orthop 2022 Aug 20;56(8):1403-1409. Epub 2022 Jun 20.

FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, 103 Boulevard de la Croix Rousse, 69004 Lyon, France.

Background: The anterior tibial translation (ATT) in case of Anterior Cruciate Ligament (ACL) tear can lead to dynamic alterations of the extensor apparatus biomechanics. The aim of this study is to evaluate the dynamic effect of isolated ACL deficiency on patellar height. The hypothesis is that the ATT of ACL-insufficient knees dynamically reduces patellar height.

Methods: Skeletally mature patients who underwent ACL reconstruction using hamstring graft between January and December 2018 were included in this study. The Posterior Tibial Slope (PTS), Caton-Deschamps (CDI), modified Insall-Salvati (MISI), and Blackburne-Peel (BPI) indices were calculated in standard lateral and TELOS X-rays. The mean of the measurements calculated between two observers was used to compare these parameters.

Results: 95 patients (M: 57; F: 38; 95 knees) were included in the study with a mean age of 31.8 years (16-56 years old). Significant patellar height reduction (CDI: 0.11 [- 0.32; 0.31]; MISI: 0.09 [- 0.66; 0.30]) was reported in TELOS compared with standard lateral knee radiography ( < 0.001). 20.0% of the study knees reported an abnormal CDI and 84.2% (16/19 knees) of them reduced this index to within normal limits in TELOS. 20.0% of the knees with mild patella alta reduced CDI in TELOS but always remained above 1.2.

Conclusions: The abnormal ATT in case of ACL-deficient knees results in a lowering effect of the patella in TELOS X-rays. In patients with ACL tear and anterior pain the reconstructive ligament surgery should be performed to avoid also chronic anterior knee pain.

Level Of Evidence: Basic Science Study (Case Series).

Clinical Relevance: The decrease in patellar height in stress-X-rays compared with standard lateral knee radiography in ACL deficient knees, should be considered as a possible contributing cause of anterior pain in these patients.
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http://dx.doi.org/10.1007/s43465-022-00632-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9283625PMC
August 2022

Tibial tuberosity osteotomy and medial patellofemoral ligament reconstruction for patella dislocation following total knee arthroplasty: A double fixation technique.

SICOT J 2022 14;8:23. Epub 2022 Jun 14.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France - Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 69622 Lyon, France.

Introduction: Patella instability post total knee arthroplasty (TKA) is a rare complication. Tibial tubercle osteotomy (TTO) with medial patellofemoral ligament reconstruction (MPFLr) has not been well described for this indication. This paper describes a surgical technique to address the unique challenges faced when performing TTO and MPFLr in the prosthetic knee.

Technique: This technique and video describe a TTO and MPFLr via an extensile incision and medial sub-vastus approach. A 6 cm long TTO is performed, if indicated, to medialise the extensor mechanism up to 1 cm and fixed with ×2 4.5 mm cortical screws. For the MPFLr, a quadriceps tendon autograft is utilized, with the natural insertion to the superior pole of the patella being left undisturbed. The graft is first attached with an interference screw and then reinforced with an endobutton to provide crucial cortical fixation to overcome the problem of low bone mineral density encountered in this area of the femur following TKA.

Results: Five patients underwent MPFLr using the described technique. No failures or recurrence of instability occurred at the last follow-up. Pre-operative mean patella tilt and shift were 44° and 3.5 cm, respectively. Post-operatively, mean tilt and shift were 4.1° and 0.4 cm, respectively. There was one wound dehiscence requiring surgical debridement and closure.

Conclusion: This paper describes a surgical technique to perform a TTO and MPFLr for patella instability post-TKA. The described method highlights key adaptations to address the unique challenges in this patient population.
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http://dx.doi.org/10.1051/sicotj/2022023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9196027PMC
June 2022

Can Patella Instability After Total Knee Arthroplasty be Treated With Medial Patellofemoral Ligament Reconstruction?

Arthroplast Today 2022 Aug 4;16:130-139. Epub 2022 Jun 4.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.

Background: The aim of this study was to describe outcomes of patients who had undergone medial patellofemoral ligament reconstruction (MPFLr) to treat patellofemoral instability (PFI) following total knee arthroplasty (TKA).

Material And Methods: This is a retrospective case series of consecutive patients treated for PFI after TKA. Patients were included if they had radiographic documentation of patella dislocation or subluxation and component position was adequate. MPFLr was performed using a quadriceps tendon autograft. The graft was fixed with either an interference or additional suspensory fixation. A tibial tubercle osteotomy was performed in select indications. Patients were assessed with Kujala and International Knee Score (IKS) at a minimum 12-month follow-up and radiographically with plain radiographs.

Results: A total of 22 patients (23 procedures) were included. The mean follow-up period was 38 months (range 12-72). Average preoperative femoral component rotation on computed tomography was 0.10° external rotation (range 3° internal rotation to 3° external rotation). All patients had improved clinical and radiographic outcomes postoperatively. At the last follow-up, the mean IKS knee score was 77.6 ± 13.1, mean IKS function score was 75.2 ± 23.3, and mean Kujala score was 60.2/100 ± 10.9. There was 1 mechanical failure, which occurred following MPFLr with interference fixation. There were 6 complications (28.1%) postoperatively. Patients receiving double fixation of the MPFLr graft had higher clinical and radiographic scores; however, this difference was not statistically significant. MPFLr had a patella-lowering effect, 0.97 preoperatively to 0.74 postoperatively ( = .069).

Conclusion: MPFLr in appropriately selected patients is a satisfactory option to treat PFI following TKA.
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http://dx.doi.org/10.1016/j.artd.2022.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9168055PMC
August 2022

Correction Notice to: Functional Alignment Philosophy in Total Knee Arthroplasty - Rationale and technique for the varus morphotype using a CT based robotic platform and individualized planning.

SICOT J 2022 20;8:18. Epub 2022 May 20.

Department of Orthopaedics, Croix Rousse Hospital, University of Lyon 1, 69004 Lyon, France - Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 69622 Lyon, France.

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http://dx.doi.org/10.1051/sicotj/2022017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9121852PMC
May 2022

Does meniscal repair impact muscle strength following ACL reconstruction?

SICOT J 2022 16;8:16. Epub 2022 May 16.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 69004 Lyon, France - LIBM - EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, 69100 Lyon, France.

Purpose: Meniscal lesions are commonly associated with anterior cruciate ligament (ACL) rupture. Meniscal repair, when possible, is widely accepted as the standard of care. Despite advancements in surgical and rehabilitation techniques, meniscal repair may impact muscle recovery when performed in conjunction with ACL reconstruction. The objective of this study was to explore if meniscal repairs in the context of ACL reconstruction affected muscle recovery compared to isolated ACL reconstruction.

Methods: Fifty-nine patients with isolated ACL reconstruction were compared to 35 patients with ACL reconstruction with an associated meniscal repair. All ACL reconstructions were performed using hamstring grafts with screw-interference graft fixation. Isokinetic muscle testing was performed between six and eight months of follow-up. Muscle recovery between both groups was compared. A further subgroup analysis was performed to compare muscle recovery function of gender and meniscal tear location. Tegner scores were assessed at six months' follow-up.

Results: No significant differences were found between the two groups regarding muscle recovery. No difference in muscle recovery was found concerning gender. Lesion of both menisci significantly increased the deficit of hamstrings muscular strength at 60°/s compared to a lesion of one meniscus (26.7% ± 15.2 vs. 18.1% ± 13.5, p = 0.018) and in eccentric test (32.4% ± 26.2 vs. 18.1% ± 13.5, p = 0.040). No significant differences were found concerning the Tegner score.

Conclusion: Meniscal repairs performed during an ACL reconstruction do not impact muscle recovery at 6-8 months post-operatively compared to an isolated ACL reconstruction. However, reparations of both menisci appear to impact hamstring muscle recovery negatively.

Level Of Evidence: III, Retrospective cohort study.
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http://dx.doi.org/10.1051/sicotj/2022016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9112909PMC
May 2022

Using standard-length compactors to implant short humeral stems in total shoulder arthroplasty: A cadaver study of humeral stem alignment.

PLoS One 2022 5;17(5):e0268075. Epub 2022 May 5.

Ramsay Générale de Santé, Jean Mermoz Private Hospital, Centre Orthopédique Santy, Lyon, France.

Background: Short-stem implants in shoulder arthroplasty were recently developed and reported clinical outcomes are good. However, radiological analysis often reveals humeral stem misalignment in the frontal plane, along with high filling ratios that can lead to proximal bone remodeling under stress shielding. The aim of this cadaveric study was to test whether using compactors for standard-length (> 100 mm) stems to implant short (< 100 mm) stems reduces the risk of stem misalignment without compromising in terms of a higher filling ratio.

Methods: In a cadaveric study, twenty short stems were implanted using instrumentation for standard-length stems. Alignment and filling ratios were evaluated on anteroposterior radiographs for both the compactors and the stems. The angular deviations (α) from the humeral axis of the compactors and the short stems were measured. Misalignment was defined as |α| > 5°. Metaphyseal and diaphyseal filling ratios were calculated and defined as either high (≥ 0.7) or low (< 0.7).

Results: The median angular deviations of the compactors and the short stems were respectively 1.6° (range, 0.03 to 5.9°) and 1.3° (range, 0.3 to 9.6°). Nineteen of the 20 compactors (95%) and 17/20 short stems (85%) were correctly aligned. The proportions of correctly aligned compactors and stems were not significantly different (95% CI, -0.33 to 0.11; Z-test of proportions p = .60), and the respective angular deviations were significantly correlated (Spearman ρ = .60, p = 0.006). The diaphyseal and metaphyseal filling ratios of the compactors and the stems were all low.

Conclusions: In this series of 20 implants in cadavers, the narrow short humeral stems implanted with compactors for standard-length stems were correctly aligned with the humeral axis. This approach may be a way to achieve both correct frontal alignment and low filling ratios.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0268075PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9070928PMC
May 2022

Artificial intelligence in knee arthroplasty: current concept of the available clinical applications.

Arthroplasty 2022 May 2;4(1):17. Epub 2022 May 2.

Orthopaedic Surgery and Sports Medicine Department, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.

Background: Artificial intelligence (AI) is defined as the study of algorithms that allow machines to reason and perform cognitive functions such as problem-solving, objects, images, word recognition, and decision-making. This study aimed to review the published articles and the comprehensive clinical relevance of AI-based tools used before, during, and after knee arthroplasty.

Methods: The search was conducted through PubMed, EMBASE, and MEDLINE databases from 2000 to 2021 using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA).

Results: A total of 731 potential articles were reviewed, and 132 were included based on the inclusion criteria and exclusion criteria. Some steps of the knee arthroplasty procedure were assisted and improved by using AI-based tools. Before surgery, machine learning was used to aid surgeons in optimizing decision-making. During surgery, the robotic-assisted systems improved the accuracy of knee alignment, implant positioning, and ligamentous balance. After surgery, remote patient monitoring platforms helped to capture patients' functional data.

Conclusion: In knee arthroplasty, the AI-based tools improve the decision-making process, surgical planning, accuracy, and repeatability of surgical procedures.
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http://dx.doi.org/10.1186/s42836-022-00119-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9059406PMC
May 2022

Satisfactory Outcomes of All-Poly Fixed Bearing Unicompartmental Knee Arthroplasty for Avascular Osteonecrosis Versus Osteoarthritis: A Comparative Study With 10 to 22 Years of Follow-up.

J Arthroplasty 2022 Apr 6. Epub 2022 Apr 6.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France; University Lyon, Claude Bernard Lyon 1 University, IFSTTAR, Lyon, France.

Background: While good mid-term results for treating spontaneous knee osteonecrosis (SPONK) with unicompartmental knee arthroplasty (UKA) have been reported, concerns remain about implant survival at long-term. This study aimed to compare outcomes and survivorship of UKA for SPONK vs osteoarthritis at a minimum of 10 years.

Methods: This case-control study included medial UKA for femoral SPONK operated between 1996 and 2010 with a minimum 10-year follow-up (n = 47). Each case was matched with a medial UKA for osteoarthritis based on body mass index (BMI), gender, and age. Knee Society Score (KSS), complications and radiological (loosening) data were collected at the last follow-up. Kaplan-Meier survivorship analysis was performed using revision implant removal as endpoint.

Results: The mean follow-up was 13.2 years (range 10 to 21 years). Mean age and BMI were 72.9 ± 8.4 years and 25.5 ± 3.6 Kg/m in SPONK group. At last follow-up, knee and function KSS were 89.5 ± 12 and 79 ± 18 in SPONK group vs 90 ± 15 (P = .85) and 81.7 ± 17 (P = .47) in control group. Complications and radiological results showed no significant differences. The survival rate free from any revision was 85.1% at last follow-up in SPONK group and 93.6% in control group (P = .23). The leading cause for revision was aseptic tibial loosening (57.1%) in SPONK group. The 15-year survival estimate was 83% in SPONK group.

Conclusion: Satisfactory clinical outcomes at long-term after UKA for femoral SPONK were observed, similar to those after UKA for osteoarthritis, despite a higher risk of tibial loosening in the SPONK group. No symptomatic femoral loosening leading to a revision was observed.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.arth.2022.03.089DOI Listing
April 2022

Functional Alignment Philosophy in Total Knee Arthroplasty - Rationale and technique for the varus morphotype using a CT based robotic platform and individualized planning.

SICOT J 2022 1;8:11. Epub 2022 Apr 1.

Department of Orthopaedics, Croix Rousse Hospital, University of Lyon 1, 69004 Lyon, France - Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 69622 Lyon, France.

Introduction: Alignment techniques in total knee arthroplasty (TKA) continue to evolve. Functional alignment (FA) is a novel technique that utilizes robotic tools to deliver TKA with the aim of respecting individual anatomical variations. The purpose of this paper is to describe the rationale and technique of FA in the varus morphotype with the use of a robotic platform.

Rationale: FA reproduces constitutional knee anatomy within quantifiable target ranges. The principles are founded on a comprehensive assessment and understanding of individual anatomical variations with the aim of delivering personalized TKA. The principles are functional pre-operative planning, reconstitution of native coronal alignment, restoration of dynamic sagittal alignment within 5° of neutral, maintenance of joint-line-obliquity and height, implant sizing to match anatomy and a joint that is balanced in flexion and extension through manipulation of implant positioning rather than soft tissue releases.

Technique: An individualized plan is created from pre-operative imaging. Next, a reproducible and quantifiable method of soft tissue laxity assessment is performed in extension and flexion that accounts for individual variation in soft tissue laxity. A dynamic virtual 3D model of the joint and implant position that can be manipulated in all three planes is modified to achieve target gap measurements while maintaining the joint line phenotype and a final limb position within a defined coronal and sagittal range.

Conclusion: Functional alignment is a novel knee arthroplasty technique that aims to restore constitutional bony alignment and balance the laxity of the soft tissues by placing and sizing implants in a manner that it respects the variations in individual anatomy. This paper presents the approach for the varus morphotype.
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http://dx.doi.org/10.1051/sicotj/2022010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8973302PMC
April 2022

Optimal Combination of Femoral Tunnel Orientation in Anterior Cruciate Ligament Reconstruction Using an Inside-out Femoral Technique Combined With an Anterolateral Extra-articular Reconstruction.

Am J Sports Med 2022 04 4;50(5):1205-1214. Epub 2022 Mar 4.

Department of Orthopaedic Surgery, University Hospital of Saint-Etienne, Saint-Etienne, France.

Background: The optimal orientation of the anterolateral extra-articular reconstruction (ALLR) femoral tunnel to avoid collision with the anterior cruciate ligament reconstruction (ACLR) femoral tunnel is not clearly defined in the literature.

Purpose: To define the optimal combination of orientations of the ALLR femoral tunnel and the ACLR femoral tunnel using an inside-out technique to minimize risk of collision between these tunnels.

Study Design: Descriptive laboratory study.

Methods: Three-dimensional reconstruction of magnetic resonance imaging scans of 40 knees after an isolated ACLR with an inside-out femoral technique was used to assess the collision risk between ACLR and virtual ALLR tunnels. The optimal ACLR tunnel orientation was defined as having the safest distance from the ALLR tunnel. A second collision analysis was performed on all patients presenting with an optimal orientation of the ACLR tunnel to then define the optimal ALLR tunnel orientation. The potential for trochlear damage was also studied. A collision risk of 0% to 5% was considered acceptable and referred to as "low risk."

Results: The only ALLR tunnel orientation presenting a low risk of collision with the ACLR tunnel was with an axial angle of 40° anteriorly and a coronal angle of 0°. This orientation presented a 48% risk of trochlear damage with the guide wire of the ALLR tunnel. The more posterior the orientation of the ACLR, the larger the distance from the ALLR tunnel. Among the 22 patients presenting with an optimal ACLR tunnel (alpha angle superior to 40°), the ALLR tunnels aimed with 1 of these 3 orientations presented a low risk of tunnel collision and trochlear damage: 40° axial and 10° coronal, 35° axial and 5° coronal, or 30° axial and 0° coronal.

Conclusion/clinical Relevance: To minimize risk of tunnel collision or trochlear damage when combining an inside-out ACLR with an ALLR, the ACLR tunnel should be performed with a posterior orientation (alpha angle >40°), and the ALLR tunnel should be aimed with 1 of 3 orientations: 40° axial and 10° coronal, 35° axial and 5° coronal, or 30° axial and 0° coronal.
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http://dx.doi.org/10.1177/03635465221078326DOI Listing
April 2022

Combined procedures with unicompartmental knee arthroplasty: High risk of stiffness but promising concept in selected indications.

SICOT J 2022 22;8. Epub 2022 Feb 22.

FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, Hospices Civils de Lyon, 103 Grande rue de la Croix Rousse, 69004 Lyon, France - Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 25 Avenue François Mitterand, 69500 Lyon, France.

Introduction: Unicompartmental knee arthroplasty (UKA) has traditionally been contraindicated in the presence of an ACL deficient knee, bi-compartmental disease, or significant coronal deformity due to concerns regarding increased risk of persisted pain, knee instability, tibial loosening, or progression of osteoarthritis. The aim of this study was to evaluate the outcomes of patients undergoing UKA with an associated surgical procedure in these specific indications.

Method: This was a retrospective cohort study of patients undergoing UKA between December 2015 and October 2020. Patients were categorized into groups based on associated procedures: UKA + ACL, UKA + HTO, and bicompartmental arthroplasty. Outcomes were assessed using the Knee Society Score (KSS) knee and function scores and the Forgotten Joint Score. Radiological and complication analysis was performed at the last clinical follow-up.

Results: Thirty-two patients (13 men and 19 women) were included. The mean age was 56.2 years ± 11.1 (range, 33-84) with a mean follow-up of 26.3 months ± 15 (7.3-61.1). There was a significant improvement between the pre-and postoperative KSS Knee (+34.3 ± 16.5 [12-69]), Function (+34.3 ± 18.6 [0-75]), and Total scores (+68.5 ± 29.4 [24-129]) (p = 0.001). Seven patients (21.8%) required an arthroscopic arthrolysis for persistent stiffness. Two patients (UKA + PFA and UKA + ACL) underwent revision to TKA. Patient satisfaction was 90%, and mean flexion at last follow-up was 122° ± 6 (120-140). The implant survival rate was 94%.

Discussion: This study found performing UKA with an additional procedure to address relative contraindications to the arthroplasty in physically active patients with monocompartmental knee arthritis is an efficient strategy with good results at short-term follow-up. It should be reserved for patients where TKA is likely to have unsatisfactory results, and the patient has been fully counseled regarding the management options. Even if there is a high rate of complications with stiffness requiring a re-intervention, the final results are very satisfying with no impact of the reintervention on the clinical result in the short term.
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http://dx.doi.org/10.1051/sicotj/2022002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8862640PMC
February 2022

Significant risk of arthrolysis after simultaneous anterior cruciate ligament reconstruction and treatment of dislocated bucket-handle meniscal tear.

Orthop Traumatol Surg Res 2022 05 17;108(3):103252. Epub 2022 Feb 17.

Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France; LIBM-EA 7424, Laboratoire Interuniversitaire de la Biologie du Mouvement, Université Claude Bernard Lyon 1, Lyon, France.

Introduction: Postoperative stiffness is a feared complication after anterior cruciate ligament (ACL) reconstruction. In case of associated dislocated bucket-handle meniscal tear (BHMT), reduction is urgent, with ligament reconstruction in the same surgical step.

Hypothesis: Treatment of associated dislocated BHMT in ACL reconstruction incurs increased risk of arthrolysis for stiffness in flexion and/or extension.

Material And Methods: A retrospective exposure/non-exposure study included 208 patients undergoing ACL reconstruction between January 2009 and December 2018. Those showing dislocated medial or lateral BHMT at surgery (group A) were compared versus those free of meniscal lesions (group B). The main objective was to assess the risk of surgical revision for arthrolysis within 12 months. Group A included 69 patients: 40 male (58%), 29 female (42%); mean age, 29.0±11.2 years. Group B included 139 patients: 68 male (49%), 71 female (51%); mean age, 30.0±10.4 years. Patients were classified according to age of ACL tear, as acute (<6 weeks), subacute (6 weeks to 6 months), or chronic (>6 months).

Results: Risk of revision surgery for arthrolysis was greater in Group A than in Group B, with 7 (10.1%) and 4 (2.9%) cases respectively (p=0.044), with 12-month arthrolysis-free survival of 89.7% (95% CI, 82.7-97.2) and 97.1% (95% CI, 94.3-99.9) respectively (p=0.023). Stiffness in flexion and extension was more frequent in Group A at 6 weeks and at 6 months (p>0.05). Risk of arthrolysis did not significantly differ according to accident-to-surgery time in the overall series (p=0.421) or specifically in Group A (p=0.887). The BHMT was sutured in 39 cases (56.5%), including 3 failures (7.7%) at 12 months' follow-up. Arthrolysis was required in 6 patients treated by meniscal suture (15.4%) and just 1 patient treated by meniscectomy (3.3%) (p=0.128).

Conclusion: The present study confirmed increased risk of surgical revision for arthrolysis after ACL reconstruction in case of dislocated BHMT treated in the same surgical step. Age of ACL tear and type of BHMT treatment (suture or meniscectomy) showed no impact on postoperative stiffness.

Level Of Evidence: IV, retrospective exposure/non-exposure cohort study.
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http://dx.doi.org/10.1016/j.otsr.2022.103252DOI Listing
May 2022

Similar outcomes including maximum knee flexion between mobile bearing condylar-stabilised and fixed bearing posterior-stabilised prosthesis: a case control study.

J Exp Orthop 2022 Feb 15;9(1):17. Epub 2022 Feb 15.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.

Purpose: Prosthesis design influences stability in total knee arthroplasty and may affect maximum knee flexion. Posterior-stabilised (PS) and condylar-stabilised (CS) designed prosthesis do not require a posterior-cruciate ligament to provide stability. The aim of the current study was to compare the range of motion (ROM) and clinical outcomes of patients undergoing cemented total knee arthroplasty (TKA) using either a PS or CS design prosthesis.

Methods: A total of 167 consecutive primary TKAs with a CS bearing (mobile deep-dish polyethylene) were retrospectively identified and compared to 332 primary TKA with a PS constraint, with similar design components from the same manufacturer. Passive ROM was assessed at last follow-up with use of a handheld goniometer. Clinical scores were assessed using Patient-Reported Outcome Measures (PROMs); International Knee Society (IKS) knee and function scores and satisfaction score. Radiographic assessment was performed pre and post operatively consisting of mechanical femorotibial angle (mFTA), femoral and tibial mechanical angles measured medially (FMA and TMA, respectively) on long leg radiographs, tibial slope and patella height as measured by the Blackburne-Peel index (BPI).

Results: Both groups had a mean follow-up of 3 years (range 2-3.7 years). Mean post-operative maximum knee flexion was 117° ± 4.9° in the PS group and 119° ± 5.2° in the CS group (p = 0.29). Postoperative IKS scores were significantly improved in both groups compared to preoperative scores (p < 0.01). The mean IKS score in the PS group was 170.9 ± 24.1 compared to 170.3 ± 22.5 in the CS group (p = 0.3). Both groups had similar radiographic outcomes as determined by coronal and sagittal alignment, tibial slope and posterior condylar offset ratio measurements. When considering the size of tibial slope change and posterior-condylar offset ratio, there was no differences between groups (p = 0.4 and 0.59 respectively). The PS group had more interventions for post-operative stiffness (arthrolysis or manipulation under anaesthesia) 8 (2.7%) compared to 1 (0.6%) in the CS group (p = 0.17).

Conclusion: Condylar-stabilised TKA have similar patient outcomes and ROM at a mean follow-up of 3 years compared to PS TKA. Highly congruent inserts could be used without compromising results in TKA at short term.

Level Of Evidence: Level IV, retrospective case control study.
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http://dx.doi.org/10.1186/s40634-022-00456-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8847635PMC
February 2022

Sex differences in semitendinosus muscle fiber-type composition.

Scand J Med Sci Sports 2022 Apr 20;32(4):720-727. Epub 2022 Jan 20.

Department of Orthopedic Surgery and Sport Medicine, FIFA medical center of excellence, Hôpital de la Croix-Rousse, University Lyon 1, Lyon, France.

Sex differences in muscle fiber-type composition have been documented in several muscle groups while the hamstring muscle fiber-type composition has been poorly characterized. This study aimed to compare the semitendinosus muscle composition between men and women. Biopsy samples were obtained from the semitendinosus muscle of twelve men and twelve women during an anterior cruciate ligament reconstruction. SDH and ATPase activities as well as the size and the proportion of muscle fibers expressing myosin heavy chain (MyHC) isoforms were used to compare muscle composition between men and women. The proportion of SDH-positive muscle fibers was significantly lower (37.4 ± 11.2% vs. 49.3 ± 10.6%, p < 0.05), and the percentage of fast muscle fibers (i.e., based on ATPase activity) was significantly higher (65.8 ± 10.1% vs. 54.8 ± 8.3%, p < 0.05) in men versus women. Likewise, men muscles exhibited a lower percentage of the area that was occupied by MyHC-I labeling (35.6 ± 10.1% vs. 48.7 ± 8.9%; p < 0.05) and a higher percentage of the area that was occupied by MyHC-IIA (38.3 ± 6.7% vs. 32.5 ± 6.5%; p < 0.05) and MyHC-IIX labeling (26.1 ± 9.6% vs. 18.8 ± 8.5%; p = 0.06) as compared with women muscles. The cross-sectional area of MyHC-I, MyHC-IIA, and MyHC-IIX muscle fibers was 31%, 43%, and 50% larger in men as compared with women, respectively. We identified sex differences in semitendinosus muscle composition as illustrated by a faster phenotype and larger muscle size in men as compared with women. This sexual dimorphism might have functional consequences.
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http://dx.doi.org/10.1111/sms.14127DOI Listing
April 2022

Medial patellofemoral ligament reconstruction for recurrent patellar dislocation allows a good rate to return to sport.

Knee Surg Sports Traumatol Arthrosc 2022 Jun 30;30(6):1865-1870. Epub 2021 Nov 30.

Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France.

Purpose: Recurrent patellar dislocation is a frequent knee disorders in young, active patients. Medial patellofemoral ligament reconstruction (MPFLR) can restore knee stability and function, but the rate of return to sports is less clear. The aim of this study was to evaluate rate of return to sport following treatment of recurrent patellar dislocation with isolated MPFLR.

Methods: Between 2011 and 2018, 113 patients with recurrent patellar dislocation were treated with isolated MPFLR at an academic center. Pre-injury sports participation and Tegner score, pre-operative subjective IKDC score, time to return to sports, and post-operative Tegner and subjective IKDC scores were collected, with a minimum of follow-up of 2 years.

Results: One hundred and three patients (91%) were evaluated at a mean of 4.5 ± 2.5-year post-operative. 92 patients (89%) participated in sports prior to onset of patellar instability. At final follow-up, 84 of these 92 patients (91%) were able to return to sports. The mean time from surgery to return to sports was 10.4 ± 8.6 months (range: 2-48 months). 62 patients (67%) returned to the same (50 patients) or higher (12 patients) level. 22 patients (26%) returned at a lower level. 19 of these patients attributed this decreased participation to ongoing knee problems. The median Tegner score was noted to decrease from 5 pre-injury to 4 post-operatively (p = 0.02).

Conclusion: Isolated MPFL reconstruction allowed return to pre-injury sports in 91% of patients, with 67% of patients returning to the same or higher level than pre-injury. Mean time to return to sports was 10 months and post-operative Tegner score was noted to be modestly decreased from pre-injury level.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-021-06815-1DOI Listing
June 2022

Similar stress repartition for a standard uncemented collared femoral stem versus a shortened collared femoral stem.

SICOT J 2021 19;7:58. Epub 2021 Nov 19.

Department of Orthopaedic surgery and Sports Medicine, Croix-Rousse Hospital, Lyon University Hospital, 103 grande rue de la Croix Rousse, 69004, Lyon, France - Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 69622 Lyon, France.

Introduction: The design of uncemented femoral stems for use in total hip arthroplasty has evolved. Several uncemented short stems have been developed with different bone fixations, shapes, or stem lengths. The literature analyzing the biomechanical performance of short to standard stem lengths is limited. The aim was to compare the stress repartition on a standard uncemented stem and a shortened uncemented femoral stem with the same design features.

Material And Methods: This finite element analysis assessed the stress repartition on two femoral components with the same design (uncemented, collared, proximal trapezoidal cross-section, and a tapered quadrangular distal stem) but with two different lengths. The shortened stem was shorter by 40 mm compared to the standard stem. The stress repartition was analysed according to the Von Mises criterion.

Results: The stress repartition was similar for the standard and shorter stem without significant difference (p = 0.94). The mean Von Mises stress was 58.1 MPa [0.2; 154.1] for the standard stem and 57.2 MPa [0.03; 160.2] for the short stem. The distal part of the standard stem, which was removed in the short stem, had mean stress of 3.7 MPa [0.2; 7.0].

Conclusion: The finite element analysis found similar stress repartitions between a standard uncemented collared stem and a short, collared stem with the same design. A clinical study assessing the clinical outcomes and the bone remodelling with a collared short stem would be interesting to confirm these first promising results.
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http://dx.doi.org/10.1051/sicotj/2021061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8603923PMC
November 2021

The modifying factors that help improve anterior cruciate ligament reconstruction rehabilitation: A narrative review.

Ann Phys Rehabil Med 2022 Jun 20;65(4):101601. Epub 2021 Nov 20.

Univ Lyon, UJM-Saint-Etienne, Laboratoire Interuniversitaire de Biologie de la Motricité, EA 7424, F-42023 Saint-Etienne, France; Department of Clinical and Exercise Physiology, Sports Medicine Unity, University Hospital of Saint-Etienne, Faculty of medicine, Saint-Etienne. France.

Background: The goal of a rehabilitation programme after anterior cruciate ligament (ACL) reconstruction is to manage a patient's goals and expectations (i.e., returning to physical activities and sports) while minimizing the risk of new injury, particularly a new ACL injury. Although general rehabilitation programmes have been proposed, some factors can lead to adapting each programme to each patient.

Objective: To describe how different variables, including surgical techniques, sports participation, psycho-social and contextual factors can modify the rehabilitation programme.

Methods: We performed a narrative review with input from experts in the field (level of evidence 5).

Conclusions: Modifying factors of the ACL rehabilitation programme are related to the initial lesion or surgery, to sports, or to psychological or social aspects. Regarding the type of graft, the rehabilitation is mainly different in the early postoperative phase; the other phases are not graft-based but rather goal-based rehabilitation. Depending on the meniscal or cartilage repair, the rehabilitation protocol will initially take priority over the anterior cruciate ligament reconstruction protocol. The ACL reconstruction rehabilitation programme should meet the requirements of the anticipated sports, to optimize the athlete's ability to return to the expected level and minimize the risk of reinjury. Psycho-social and contextual factors must also be considered in rehabilitation care to individualize and optimize each patient's programme.
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http://dx.doi.org/10.1016/j.rehab.2021.101601DOI Listing
June 2022

Autologous osteochondral transplantation for focal femoral condyle defects: Comparison of mosaicplasty by arthrotomy vs. arthroscopy.

Orthop Traumatol Surg Res 2022 05 7;108(3):103102. Epub 2021 Oct 7.

Orthopaedics surgery and sports medicine department, FIFA Medical Centre of Excellence, Croix-Rousse hospital, Lyon university hospital, 69004 Lyon, France; LIBM - EA 7424, interuniversity laboratory of biology of mobility, Claude Bernard Lyon 1 university, Lyon, France.

Background: While many studies have reported the outcomes of open mosaicplasty, data on arthroscopic mosaicplasty are scarce. Only two cadaver studies have compared arthrotomy and arthroscopy. Moreover, the patello-femoral joint, which is the main donor site, has never been assessed using a specific functional score. The objective of this in vivo study was to compare arthrotomy and arthroscopy for mosaicplasty using both a global functional knee score and a specific score of the patello-femoral joint.

Hypothesis: The arthroscopic technique results in better functional patello-femoral outcomes.

Material And Methods: We retrospectively compared two groups of 17 patients who underwent mosaicplasty for focal condylar cartilage defects, at our department between 2009 and 2019. Functional outcomes were assessed using the Kujala score and the Lysholm score, at least 1 year after surgery. The return to sports was assessed using the Tegner score.

Results: Mean follow-up was 67.4±15.9 months in the arthrotomy group and 45.2±35.1 months in the arthroscopy group (p<0.01). Cartilage defect size was similar in the two groups (arthrotomy: 1.21±0.91cm; arthroscopy: 0.92±1.23cm; p=0.052). The mean Kujala score was 85±21.3 in the arthrotomy group and 91.9±13.7 in the arthroscopy group (p=0.064). The mean Lysholm score was 83.9±19.8 with arthrotomy and 89.5±14.9 with arthroscopy (p=0.1). The Kujala score was greater than 95 in 4 (26%) arthrotomy patients and 13 (81%) arthroscopy patients (p=0.003). The Lysholm score was higher than 95 in 4 (26%) arthrotomy patients and 12 (75%) arthroscopy patients (p=0.012). No patient underwent surgical revision for autograft failure.

Discussion: This is the first clinical study comparing arthrotomy and arthroscopy for mosaicplasty. Clinical outcomes were good with both techniques. The proportion of patients with excellent Lysholm and Kujala functional scores was significantly higher in the arthroscopy group than in the arthrotomy group. This result may be ascribable to decreased donor-site morbidity obtained with arthroscopy.

Level Of Evidence: IV, retrospective observational comparative study.
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http://dx.doi.org/10.1016/j.otsr.2021.103102DOI Listing
May 2022

Rotating Hinge Knee Arthroplasty for Revision Prosthetic-Knee Infection: Good Functional Outcomes but a Crucial Need for Superinfection Prevention.

Front Surg 2021 20;8:551814. Epub 2021 Sep 20.

Université Claude Bernard Lyon 1, Lyon, France.

Management of chronic infection following total knee arthroplasty (TKA) is challenging. Rotating hinged prostheses are often required in this setting due to severe bone loss, ligamentous insufficiency, or a combination of the two. The nature of the mechanical and septic complications occurring in this setting has not been well-described. The aim of this study was to evaluate patient outcomes using a hinge knee prosthesis for prosthetic knee infections and to investigate risk factors for implant removal. This was a retrospective cohort study that included all patients treated in our tertiary level referral center between January 2009 and December 2016 for prosthetic knee infection with a hinge knee prosthesis. Only patients with a minimum 2-year of follow-up were included. Functional evaluation was performed using international knee society (IKS) "Knee" and "Function" scores. Survival analysis comparing implant removal risks for mechanical and septic causes was performed using Cox univariate analysis and Kaplan-Meier curves. Risk factors for implant removal and septic failure were assessed. Forty-six knees were eligible for inclusion. The majority of patients had satisfactory functional outcomes as determined by mean IKS scores (mean knee score: 70.53, mean function score: 46.53 points, and mean knee flexion: 88.75°). The 2-year implant survival rate was 89% but dropped to 65% at 7 years follow-up. The risk of failure (i.e., implant removal) was higher for septic etiology compared to mechanical causes. Patients with American society of anesthesiologists (ASA) score>1, immunosuppression, or with peripheral arterial diseases had a higher risk for septic failure. Patients with acute infection according to the Tsukayamaclassification had a higher risk of failure. Of the 46 patients included, 19 (41.3%) had atleast one infectious event on the surgical knee and most of these were superinfections (14/19) with new pathogens isolated. Among pathogens responsible for superinfections (i) cefazolin and gentamicin were both active in six of the cases but failed to prevent the superinfection; (ii) cefazolin and/or gentamicin were not active in eight patients, leading to alternative systemic and/or local antimicrobial prophylaxis consideration. Patients with chronic total knee arthroplasty (TKA) infection, requiring revision using rotating hinge implant, had good functional outcomes but experienced a high rate of septic failure, mostly due to bacterial superinfection. These patients may need optimal antimicrobial systemic prophylaxis and innovative approaches to reduce the rate of superinfection.
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http://dx.doi.org/10.3389/fsurg.2021.551814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8488173PMC
September 2021

Condylar constrained knee prosthesis and rotating hinge prosthesis for revision total knee arthroplasty for mechanical failure have not the same indications and same results.

SICOT J 2021 10;7:45. Epub 2021 Sep 10.

FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, Hospices Civils de Lyon, 103 grande rue de la croix rousse, 69004 Lyon, France - Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 25 Avenue François Mitterand, Lyon, France.

Purpose: This study aimed to evaluate whether there are any differences in outcomes and complication rates between condylar constrained knee (CCK) and rotating hinge knee (RHK) prostheses used for the first revision of total knee arthroplasty (rTKA) after mechanical failure.

Methods: Sixty-three consecutive non-septic revisions of posterior stabilized implants using 33 CCK and 30 RHK prostheses were included. Clinical evaluation and revision rate were compared between the two groups at two years minimum follow-up.

Results: The CCK group had significantly better clinical outcomes and satisfaction rates compared to patients with RHK (KSS-knee 70.5 versus 60.7 (p < 0.003) and KSS-function 74.9 versus 47.7 (p < 0.004) at 3.7 (2.0-9.4) years mean follow-up. Moreover, the clinical improvement was significantly higher for the CCK group concerning the KSS-Knee (+23.9 vs. +15.2 points, p = 0.03). The postoperative flexion was significantly better in the CCK group compared to the RHK group (115° vs. 103°, p = 0.01). The prosthesis-related complications and the re-revision rate were higher in the RHK group, especially due to patellofemoral complications and mechanical failures.

Conclusions: CCK prostheses provided better clinical and functional outcomes and fewer complications than RHK prostheses when used for the first non-septic rTKA. CCK is a safe and effective implant for selected patients, while RHK should be used with caution as a salvage device for complex knee conditions, with particular attention to the balance of the extensor mechanism.
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http://dx.doi.org/10.1051/sicotj/2021046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436950PMC
September 2021

Current role of intraoperative sensing technology in total knee arthroplasty.

Arch Orthop Trauma Surg 2021 Dec 24;141(12):2255-2265. Epub 2021 Aug 24.

Department of Orthopedic Surgery and Sport Medicine, Croix-Rousse Hospital, 103 grande rue de la Croix-Rousse, 69004, Lyon, France.

Purpose: Sensors have been introduced within the last 10 years to quantify soft tissue balancing during total knee arthroplasty (TKA) and to give the surgeon objective data. These devices are fairly new and their impact on patient outcome remains uncertain. The aim of this systematic review was to summarize all the relevant surgical and clinical results of sensors for TKA.

Methods: A PRISMA systematic review was conducted using five databases (PubMed, EMBASE, MEDLINE, GOOGLE SCHOLAR, and the COCHRANE LIBRARY) to identify all available literature that described the surgical and clinical results of sensors for TKA between 2000 and 2021. The main investigated outcome criteria were intraoperative data, postoperative functional and clinical outcome, knee range of motion, complications and revision rates.

Results: Twenty-seven articles were finally included. The maximum reported follow-up was 26 months. A balanced knee with sensor corresponded to a mediolateral difference inferior to 15 lb and a stable posterior drawer test. The standard assessment of knee balance was a poor predictor of the true soft tissue balance when compared to sensor data. At least 60% of TKA needed an additional rebalancing procedure with the sensor, after conventional gap balancing. Achieving a quantitatively balanced knee resulted in a significantly higher patient satisfaction score. But the prospective comparative studies found no demonstrable improvement in clinical outcome, range of motion or complication rate at one year postoperatively for patients undergoing TKA using sensor-guided balancing compared with routine techniques.

Conclusion: Even though the use of the intraoperative sensing technology was not related to an improvement in clinical outcome, the current studies showed that using sensors facilitates the reproduction of natural joint stability, and improves the rate of achieving a balanced knee. Sensor use in complex cases could be particularly valuable, but their use in standard practice remains to be defined.
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http://dx.doi.org/10.1007/s00402-021-04130-5DOI Listing
December 2021

Restricted kinematic alignment may be associated with increased risk of aseptic loosening for posterior-stabilized TKA: a case-control study.

Knee Surg Sports Traumatol Arthrosc 2022 Aug 23;30(8):2838-2845. Epub 2021 Aug 23.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France.

Purpose: The purpose of the study was to compare clinical and radiological results between kinematic alignment (KA) and mechanical alignment (MA) with a posterior-stabilized (PS) total knee arthroplasty (TKA) with a post-cam mechanism at a minimum follow-up of 3 years. The authors hypothesized a higher risk of aseptic loosening when performing KA using PS TKA.

Methods: A retrospective monocentric single surgeon case control study was performed comparing 100 matched patients who had TKA performed using a MA philosophy to 50 patients receiving TKA with a KA technique between January 2016 and October 2017. All patients had the same knee prosthesis (GMK primary posterior-stabilized, Medacta, Switzerland). Patient specific cutting blocks were used in both groups and a restricted KA (rKA) was aimed in the KA group. A hybrid cementation technique was performed. The new Knee Society Score (KSS) and radiological assessment were collected preoperatively and at the final follow-up. Comparisons between groups were done with the T test or Fisher exact test. Global survival curves were estimated with Kaplan-Meier model. Significance was set at p < 0.05.

Results: Mean follow-up was 42.9 months ± 3.6 (range 37.6-46.7) and 53.3 months ± 4.1 (range 45.5-59.8) for rKA and MA groups. Postoperatively, no significant differences were found for clinical scores between both groups. Radiological assessment found similar postoperative Hip-Knee-Ankle angle for rKA and MA groups (178° versus 179° respectively, NS). At last follow-up, a significant higher survivorship was found for the MA group compared to the rKA group (97 versus 84%; p < 0.001) for aseptic loosening revision as the endpoint.

Conclusion: An increased risk of tibial implant loosening was found with rKA compared to MA using a posterior-stabilized TKA with a post-cam system at short-term follow-up. Caution should be taken when choosing the TKA design while performing rKA.

Level Of Evidence: Retrospective case-control study, Level IV.
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http://dx.doi.org/10.1007/s00167-021-06714-5DOI Listing
August 2022

Mechanical alignment for primary TKA may change both knee phenotype and joint line obliquity without influencing clinical outcomes: a study comparing restored and unrestored joint line obliquity.

Knee Surg Sports Traumatol Arthrosc 2022 Aug 22;30(8):2806-2814. Epub 2021 Jul 22.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 grande rue de la croix rousse, Hopital de La Croix Rousse, 69004, Lyon, France.

Purpose: In total knee arthroplasty (TKA), knee phenotypes including joint line obliquity are of interest regarding surgical realignment strategies. The hypothesis of this study is that better clinical results, including decreased postoperative knee pain, will be observed for patients with a restored knee phenotype.

Methods: A retrospective analysis was performed on prospective data, including 1078 primary osteoarthritic knees in 936 patients. The male:female ratio was 780:298, mean age at surgery was 71.3 years ± 8.0. International Knee Society Scores and standardized long-leg radiographs (LLR) were collected preoperatively and at 2 years follow-up after TKA. Patients were categorized using the Coronal Plane Alignment of the Knee (CPAK) classification including the lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) measured on LLR by a single observer, allowing knee phenotypes to be categorized considering the arithmetic hip-knee-ankle (aHKA) angle (MPTA-LDFA) as measure of constitutional alignment, and joint line obliquity (JLO) (MPTA + LDFA). Clinical results were compared between patients with surgically restored preoperative constitutional knee phenotype to patients without restored constitutional knee phenotypes. Descriptive data analysis such as means, standard deviations and ranges were performed. T tests for independent samples were performed to compare group differences. Comparisons of categorical data were performed using the χ test. Significance was set at p < 0.05.

Results: A third of patients (33.4%) had constitutional knee varus with apex distal JLO. 63.5% of patients had preoperative apex distal JLO. Postoperatively, 57.8% of patients had a neutral HKA (- 2° to 2°) and a neutral JLO (- 3° and 3°), with only 18% of patients with restored constitutional knee phenotype. Of these patients, statistically less postoperative pain was observed in patients where apex distal JLO was restored compared to non-restored apex distal JLO (pain score 46.7 vs. 44.6; p = 0.02) without clinical relevance. Other categories of restored JLO or arithmetic HKA angle were not associated with improved outcomes.

Conclusion: This study showed that performing mechanical alignment for primary TKA resulted in most cases in a change of the preoperative knee phenotype. These results emphasize the relevance of considering joint line obliquity to better understand preoperative knee deformity and better restore knee phenotypes with a more personalized realignment strategy to potentially improve TKA postoperative results.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-021-06674-wDOI Listing
August 2022

Health economic value of CT scan based robotic assisted UKA: a systematic review of comparative studies.

Arch Orthop Trauma Surg 2021 Dec 18;141(12):2129-2138. Epub 2021 Jul 18.

FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.

Purpose: The aim of this systematic review was to compare relevant health economic consequences of the CT-based robotic-arm-assisted system versus conventional Uni-compartmental Knee Arthroplasty (UKA).

Methods: In November 2020, A PRISMA systematic review was conducted using four databases (Pubmed, Scopus, Cochrane and Google Scholar) to identify all comparative studies reporting health economic assessments, such as robotic system costs, consumable costs, surgical revision rate, operating time, length of stay, and inpatient care costs.

Results: A total of nine comparative studies published between 2014 and 2020 were included in this systematic review. There was a moderate risk of bias as assessed using the ROBINS-I Tool. The CT-based robotic-arm-assisted system seemed to be associated with a lower risk of revision, decreased analgesia requirements during hospitalization, a shorter length of stay, and lower inpatient care costs compared to a conventional technique.

Conclusion: CT-based robotic-arm-assisted system for UKA appears to be an economically viable solution with a positive health economic impact as it tends to decrease revision rate compared to conventional UKA, improve post-operative rehabilitation and analgesia management. Post-operative inpatient care costs seem lower with the robotic-assisted system but depend on institutional case volume and differ among health systems. More studies are needed to confirm cost-effectiveness of CT-based robotic-arm-assisted system based on different health systems.

Level Of Evidence: Systematic review, Level IV.
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http://dx.doi.org/10.1007/s00402-021-04066-wDOI Listing
December 2021

Femorotibial alignment measured during robotic assisted knee surgery is reliable: radiologic and gait analysis.

Arch Orthop Trauma Surg 2022 Jul 3;142(7):1645-1651. Epub 2021 Jul 3.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.

Purpose: Femorotibial alignment is crucial for the outcome of unicompartmental knee arthroplasty (UKA). Robotic-assisted systems are useful to increase the accuracy of alignment in UKA. However, no study has assessed if the femorotibial alignment measured by the image-free robotic system is reliable. The aim of this study was to determine whether measurement of the mechanical femorotibial axis (mFTA) in the coronal plane with handheld robotic assistance during surgery is equivalent to a static measurement on radiographs and to a dynamic measurement during walking.

Methods: Twenty patients scheduled for robotic-assisted medial UKA using handheld technology were included in this prospective study. Three measurements of the frontal femorotibial axis were compared: intra-operative acquisition by computer assistance (dynamic, non-weightbearing position), radiographic measurements on long leg X-ray (static, weightbearing position), and by gait analysis during walking (dynamic, weightbearing position).

Results: There was no significant difference in the mFTA between computer (174.4 ± 3.4°), radiological (173.9 ± 3.3°), and gait analysis (172.9 ± 5.1°) measurements (p = 0.5). There was a strong positive correlation (r = 0.6577355, p = 0.0016) between robotic-assisted measurements and gait analysis.

Conclusion: There was no significant difference in the femorotibial axis measured by the image-free robotic assistance, from the preoperative radiographs or by gait analysis. The reliability of intra-operative measurements of the frontal femorotibial axis by these robotic-assisted systems is acceptable.
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http://dx.doi.org/10.1007/s00402-021-04033-5DOI Listing
July 2022

Stiffness after unicompartmental knee arthroplasty: Risk factors and arthroscopic treatment.

SICOT J 2021 19;7:35. Epub 2021 May 19.

Department of Orthopedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence, 69004 Lyon, France - EA 7424 - Interuniversity Laboratory of Human Movement Science, Université Lyon 1, Lyon, France.

Introduction: One of the principal complications after total knee arthroplasty (TKA) is stiffness. There are no publications concerning stiffness after unicompartmental knee arthroplasty (UKA). Study objectives were to describe the incidence of stiffness after UKA, to look for risk factors, and to describe safe and effective arthroscopic treatment.

Methods: There were 240 UKA performed between March 2016 and January 2019 included. Robotic-assisted surgery was performed in 164 patients and mechanical instrumentation in 76 patients. Stiffness was defined as flexion < 90° or a flexion contracture > 10° during the first 45 post-operative days. Patients with stiffness were treated with arthroscopic arthrolysis. Several factors were studied to look for risk factors of stiffness: body mass index, gender, age, mechanical or robotic instrumentation, preoperative flexion, previous meniscectomy, and anticoagulant treatment. Arthrolysis effectiveness was evaluated by flexion improvement and UKA revision rate.

Results: 22 patients (9%) developed stiffness. Mechanical instrumentation significantly increased the risk of stiffness with OR = 0.26 and p = 0.005. Robotic-assisted surgery decreased the risk of stiffness by five-fold. Before arthrolysis, mean knee flexion was 79°, versus 121° (53% improvement) after arthroscopic arthrolysis. Only 2 patients (9%) underwent UKA revision after arthrolysis.

Discussion: Stiffness after UKA is an important complication with an incidence of 9% in this study. Arthroscopic arthrolysis is a safe and effective treatment with a range of motion improvement of > 50%. Robotic-assisted surgery significantly decreases the risk of postoperative stiffness.

Level Of Evidence: Level III, therapeutic study, retrospective cohort study.
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http://dx.doi.org/10.1051/sicotj/2021034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132602PMC
May 2021

Posterior-Stabilized TKA in Patients With Severe Genu Recurvatum Achieves Good Clinical and Radiological Results at 5-year Minimum Follow-Up: A Case-Controlled Study.

J Arthroplasty 2021 09 24;36(9):3154-3160. Epub 2021 Apr 24.

Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France; Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France.

Background: Genu recurvatum is a rare knee deformity. Total knee arthroplasty (TKA) in severe preoperative recurvatum requires surgical adjustments. Few studies have assessed the clinical and radiological results of TKA in recurvatum. The aim was to compare the clinical and radiological outcomes, complications, and revision rates after posterior-stabilized TKA in severe recurvatum with those without recurvatum.

Methods: Between 1987 and 2015, 32 primary posterior-stabilized TKA were performed with a preoperative genu recurvatum greater than 10° and minimum follow-up of 60 months. In severe genu recurvatum, the extension gap needs to be decreased compared with flexion gap. To achieve this, the distal femoral cut is distalized, whereas the posterior femoral and tibial cuts are performed as usual. They were compared with 64 matched posterior-stabilized TKAs without recurvatum. The demographic data were similar between groups. The clinical and radiological outcomes, complications, and revision rates were assessed at the last follow-up.

Results: At a mean follow-up of 7.4 years ± 1.9, there was no significant difference in International Knee Score functional score (77.5 vs. 73.4; P = .50) and knee score (86.6 vs. 89.5; P = .37) between the recurvatum group and the control group, respectively. 6 patients had a postoperative recurvatum equal or superior to 10° in the recurvatum group (18.8%). There was no difference between both groups in radiological outcomes, complication, or revision rates. No instability was found in the recurvatum group.

Conclusion: Posterior-stabilized TKA with controlled distalization of the femoral component in the setting of severe preoperative genu recurvatum achieves good clinical and radiological outcomes at a minimum follow-up of 5 years and similar to TKA without preoperative recurvatum.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.arth.2021.04.020DOI Listing
September 2021

Similar kinematic patterns between revision total stabilized (TS) and primary posterior stabilized (PS) knee prostheses: a prospective case-controlled study with gait assessment.

Knee Surg Sports Traumatol Arthrosc 2022 Aug 4;30(8):2714-2722. Epub 2021 May 4.

Orthopaedic Department, Lyon North University Hospital, Hôpital de La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.

Purpose: There are increased surgical considerations when revising total knee arthroplasty (TKA) in active patients. Few studies have assessed if a semi-constrained [Total Stabilized (TS)] prostheses has similar knee biomechanics to a primary posterior stabilized (PS) prosthesis. The aim was to compare the gait parameters in patients with PS or TS TKA and normal controls.

Methods: 32 patients with TKA were prospectively included with either a primary PS (n = 15) or a revision TS (n = 17) prosthesis. Gait analysis was performed at 6 months postoperatively for each patient, with an optoelectronic knee assessment device (KneeKG®) assessing the displacement of the tibia relative to the femur during the different gait phases (flexion/extension, anterior/posterior translation, adduction/abduction, internal/external rotation). A control group (n = 12) of healthy knees was compared with the TKA groups.

Results: There were no significant kinematic differences between PS and TS groups. The maximum knee flexion during gait was 53° ± 8.1° in the PS group vs 52° ± 8.7° in the TS group. The antero-posterior translation was similar in both group (2.3 ± 0.5 mm vs 2.6 ± 0.9 mm, respectively). Peak varus angle during loading and swing phase was slightly higher in the TS group (2.7° ± 0.7° and 5.2° ± 0.9°) than in the PS group (2.9° ± 0.6° and 5.6° ± 1.2°), without significant difference. The ranges in internal/external rotation were similar between PS and TS TKA (3.7° ± 0.5° vs 3.3° ± 0.6°, respectively). Both designs approached closely the normal gait patterns of the control group except in the frontal plane.

Conclusion: Single radius TS TKA has gait parameters similar to single radius PS TKA. Use of a single radius TS TKA in revision TKA is not detrimental to a patient's gait pattern. Both designs approached closely the normal gait patterns of the control group.

Level Of Evidence: Prospective, case-control study; Level III.
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http://dx.doi.org/10.1007/s00167-021-06591-yDOI Listing
August 2022
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