Publications by authors named "Gilles Pasquier"

29 Publications

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Does the alpha-defensin lateral flow test conserve its diagnostic properties in a larger population of chronic complex periprosthetic infections? Enlargement to 112 tests, from 42 tests in a preliminary study, in a reference center.

Orthop Traumatol Surg Res 2021 Mar 31:102912. Epub 2021 Mar 31.

Centre de Référence pour le Traitement des Infections Ostéo-Articulaires Complexes (CRIOAC), Avenue du Professeur-Émile-Laine, 59037 Lille, France; Univ. Lille, CHU Lille, ULR 4490, Département Universitaire de Chirurgie Orthopédique et Traumatologique, F-59000 Lille, France; Service d'Orthopédie, Hôpital Salengro, Place de Verdun, CHU Lille, F-59000 Lille, France.

Background: Diagnosis of periprosthetic infection (PPI) is crucial for management of bone and joint infection. The preoperative gold-standard is joint aspiration, providing results after 2-14 days' culture, with non-negligible false negative rates due to the fragility of certain micro-organisms and/or prior antibiotic treatment. The Synovasure alpha-defensin lateral flow test (Zimmer, Warsaw, IN, USA) contributes within minutes to joint fluid diagnosis of almost all infectious agents, including in case of concomitant antibiotic therapy. Validity remains controversial, notably in complex microbiological situations: multi-operated patients, diagnostic doubt despite iterative sterile culture, long-course antibiotic therapy. We extended a prospective study reported in 2018, to determine whether the test maintained diagnostic value in a larger population, assessing 1) negative (NPV) and positive (PPV) predictive value, and 2) sensitivity and specificity.

Hypothesis: Synovasure maintains NPV above 95% in a broader population of microbiologically complex suspected PPI.

Material And Methods: Synovasure's performance was assessed between October 2015 and October 2019 in 106 patients (112 tests) in complex diagnostic situations: 37 discordant cultures (discordant findings between 2 samples), 65 cases with clinically or biologically suspected infection but iterative sterile culture, 10 emergencies (requiring surgery, precluding antibiotic window, or mechanical failure in suspected infection), including 5 with ongoing antibiotic therapy for infection in another organ. Six tests were repeated in the same patient and same joint at >6 months' interval for strong clinical suspicion of infection. The main endpoint was the MSIS score (MusculoSkeletal Infection Society, 2018).

Results: NPV was 98.8%, PPV 72.4%, sensitivity 95.5% and specificity 91%. Prevalence of infection was 19.6%. Only 1 of the 22 infected patients had negative Synovasure™ tests, compared to 81 of the 84 non-infected patients.

Conclusion: Synovasure™ is a reliable novel diagnostic test, contributing mainly to ruling out infection thanks to its strong NPV. The cost imposes sparing use, but medico-economic assessment would be worthwhile.

Level Of Evidence: III; prospective of diagnostic performance.
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http://dx.doi.org/10.1016/j.otsr.2021.102912DOI Listing
March 2021

Above-the-knee amputation versus knee arthrodesis for revision of infected total knee arthroplasty: recurrent infection rates and functional outcomes of 43 patients at a mean follow-up of 6.7 years.

Orthop Traumatol Surg Res 2021 Mar 31:102914. Epub 2021 Mar 31.

Univ Lille, Hauts de France, F-59000 Lille, France; Service d'orthopédie, Hôpital Salengro, Place de Verdun, CHU Lille, F-59000 Lille, France; CRIOAC, Centre de Référence pour le traitement des Infections Ostéo-Articulaires Complexes Lille-Tourcoing, rue Emile Laine, F-59000 Lille, France.

Introduction: In cases of repeated treatment failure of periprosthetic joint infections (PJI) of the knee, above-the-knee amputation (AKA) or knee arthrodesis can be proposed to reduce the risk of recurrent infection, especially in cases with major bone defects or irreparable damage to the extensor mechanism of the knee. Since AKA versus knee arthrodesis results have been rarely assessed for these indications, we conducted a retrospective case-control study to compare both the rates of recurrent infection and functional outcomes.

Hypothesis: Patients who underwent AKA had fewer recurrent infections than those who had arthrodesis.

Materials And Methods: Twenty patients who underwent AKA and 23 patients who had knee arthrodesis, between 2003 and 2019, were retrospectively included in this study. These two groups were comparable in age (73.8 versus 77.7 years (P = .31)) and sex (10 women and 10 men versus 16 women and seven men (P = .19)). Each group was analyzed individually and then compared in terms of survival (recurrent infection) and functional outcomes using clinical assessment scores (visual analog scale (VAS), French neuropathic pain questionnaire (DN4), Parker and Palmer mobility score and the 36-item short-form survey (SF-36)).

Results: The rate of recurrent infection was 10% (two out of 20 patients) for the AKA group and 21.75% (five out of 23 patients) for the arthrodesis group (P = .69). The mean follow-up for the AKA group was 4.18 years (1.2-11.8) and 9.7 years (1.1-14.33) for the arthrodesis group (P = .002). The number of previous revisions (three (1.5-4) for AKA and two (2-3) for arthrodesis) and the time between the primary arthroplasty and surgical procedure were significantly greater in the AKA group (48.0 (12.0-102.0) months) than the arthrodesis group (48.0 (24.0-87.0) months) (P <.001). The AKA group had significantly better clinical results for VAS (2.7 ± 2.2 vs. 3.1 ± 3.3), DN4 (1.5 ± 2.1 vs. 2.6 ± 2.9), Parker and Palmer (5.2 ± 1.7 vs. 4.6 ± 1.4), and SF-36 (30.9 ± 15.6 vs. 26.9 ± 17.0) (P <.001).

Conclusion: Above-the-knee amputation and knee arthrodesis showed no differences in the rate of recurrent sepsis. However, the comparison of the two groups demonstrated that patients who underwent an AKA had less pain, were more autonomous and had a better quality of life.

Level Of Evidence: III; retrospective case-control.
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http://dx.doi.org/10.1016/j.otsr.2021.102914DOI Listing
March 2021

Complications and failures of non-tumoral hinged total knee arthroplasty in primary and aseptic revision surgery: A review of 290 cases.

Orthop Traumatol Surg Res 2021 Feb 27:102875. Epub 2021 Feb 27.

56, rue Boissonade, 75014 Paris, France.

Introduction: Hinged total knee arthroplasty (TKA) implants are a commonly used option during revision or even primary surgery, but their complications are not as well known, due to the rapid adoption of gliding implants. The literature is inconsistent on this topic, with studies having a small sample size, varied follow-up duration and very different indications. This led us to carry out a large multicentre study with a minimum follow-up of 5 years to evaluate the complications after hinged TKA in a non-tumoral context based on the indications of primary arthroplasty, aseptic surgical revision or fracture treatment around the knee.

Hypothesis: Hinged TKA was associated with a high complication rate, no matter the indication.

Material And Methods: Two hundred and ninety patients (290 knees) were included retrospectively between January 2006 and December 2011 at 17 sites, with a minimum follow-up of 5 years. The patients were separated into three groups: primary surgery (111 patients), aseptic revision surgery (127 patients) and surgery following a recent (<3 months) fracture (52 patients: 13 around the TKA and 39 around the knee treated by hinged TKA). Patients who had an active infection the knee of interest were excluded. All the patients were reviewed based on a standardised computer questionnaire validated by the SOFCOT.

Results: The mean follow-up was 71±39 months [range, 0 to 188]. Of the 290 patients included in the study, 108 patients (37%) suffered at least one complication and 55 patients (19%) had to undergo revision surgery: 16 in the primary TKA group (16/111, 14% of primary TKA), 28 in the revision surgery group (28/127, 22% of revision TKA) and 11 in the fracture treatment group (11/52, 21% of fracture TKA). The complications due to the hinged TKA for the entire cohort from most to least common were stiffness (41/290, 14%), chronic postoperative pain (37/290, 13%), infection (32/290, 11%), aseptic loosening (23/290, 8%), general complications (20/290, 7%), extensor mechanism complications (19/290, 6%), periprosthetic fracture (9/290, 3%), mechanical failure (2/290, 0.7%). In the primary TKA group, the main complication leading to re-operation was infection (12/111, 11%), while it was loosening for the revision TKA group (15/127, 12%) and infection (8/52, 15%) for the fracture TKA group.

Discussion: The 37% complication rate for hinged TKA implants is high, with 19% of them requiring re-operation. The frequency of complications differed depending on the context in which the hinged implant was used (primary, revision, fracture). The complications requiring revision surgery were major ones that prevented patients from preserving their autonomy (infection, symptomatic loosening, fracture, implant failure). The most found complications - stiffness and chronic pain - rarely led to revision.

Level Of Evidence: IV; retrospective cohort study.
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http://dx.doi.org/10.1016/j.otsr.2021.102875DOI Listing
February 2021

The advantages of cone-beam computerised tomography (CT) in pain management following total knee arthroplasty, in comparison with conventional multi-detector CT.

Orthop Traumatol Surg Res 2021 Feb 26:102874. Epub 2021 Feb 26.

Département universitaire de chirurgie orthopédique et traumatologique, Université de Lille, CHU de Lille, ULR 4490, 59000 Lille, France; Service de chirurgie orthopédique, CHU de Lille, Hôpital Roger-Salengro, 59000 Lille, France.

Background: Revision of total knee arthroplasty (TKA) requires preoperative assessment to identify the causes of failure. Multidetector computerised tomography (MDCT) is a commonly used imaging technique, but is sensitive to certain artifacts, such as metal implants, limiting its use. Cone-beam CT (CBCT) is a new technique dedicated to musculoskeletal imaging that is less sensitive to artifacts and could be utilised in knee implantation surgery. CBCT has not yet been validated for this indication, and we therefore undertook a retrospective assessment of MDCT versus CBCT, comparing: 1) image quality; 2) reproducibility of angle measurements; 3) effectiveness in screening for periprosthetic radiolucency and implant loosening; and 4) radiation dose.

Hypothesis: This study hypothesised that CBCT provides better image quality, angle measurement reproducibility, and screening for radiolucency and implant loosening at lower doses of radiation than MDCT.

Patients And Method: Between October 2017 and March 2018, 28 patients, with a mean age of 61±11.6 years [range, 45-85 years] underwent both MDCT and CBCT for pain following TKA. Two radiologists performed angle measurements on both devices: patellofemoral tilt (PFT), rotation angle of the femoral component (RAFC) and rotation angle of the tibial component (RATC). They also screened for pathological radiolucency and/or implant loosening, and assessed image quality at the various bone/implant interfaces. The mean CT dose index per examination was recorded.

Results: Intraclass correlation coefficients for angles and radiolucency screening on MDCT and on CBCT were respectively good (0.73) and excellent (0.82) for PFT, borderline (0.28) and moderate (0.44) for RAFC, excellent (0.82) and excellent (0.96) for RATC, and moderate (0.45) and excellent (0.84) for radiolucency screening. The inter-observer kappa correlation coefficients for diagnosis of implant loosening and image quality assessment for MDCT and CBCT were respectively moderate (0.45) and excellent (0.93) for tibial loosening and low (0.19) and borderline (0.38) for femoral loosening. The mean image quality at the various interfaces for MDCT and CBCT was respectively 2.2/3 and 2.75/3 at the tibia/tibial implant interface, 1/3 and 2.3/3 at the trochlear region/femoral implant interface, 0.9/3 and 2/3 at the femoral condyle/femoral implant interface, and 1.25/3 and 2.1/3 at the patella/patellar medallion interface. The mean CT dose index was significantly lower, by a factor of 1.24, on CBCT (4.138 mGy) than MDCT (5.125 mGy) (p<00396).

Conclusion: The results of the present study revealed added value for CBCT in the etiological work-up for pain following a TKA. It was reliable and reproducible for the rotation measurement and diagnosis of implant loosening, due to enhanced image quality despite a lower radiation dose than conventional MDCT.

Level Of Evidence: III; retrospective comparative study.
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http://dx.doi.org/10.1016/j.otsr.2021.102874DOI Listing
February 2021

A retrospective comparison of central and posterior hinge joints in 53 total knee arthroplasties.

Orthop Traumatol Surg Res 2021 Feb 23:102868. Epub 2021 Feb 23.

Service de chirurgie orthopédique et traumatologique, Hôpital Pierre-Paul-Riquet, 1, place du Dr-Baylac, TSA 40 031, 31059 Toulouse cedex 9, France.

Introduction: The number of hinged total knee arthroplasty (HTKA) procedures is constantly increasing. There are two hinge types: central (CHTKA) and posterior (PHTKA). The primary purpose of the study was to compare implant survival in patients with CHTKA versus PHTKA. The secondary purpose was to analyse the radiological and clinical results of the implants.

Hypothesis: There is no difference between the two groups.

Materials And Methods: This study involved 53 patients who received a HTKA for either primary, trauma or revision surgery, of these 32 were in the CHTKA group and 21 in the PHTKA group, with a mean age of 69 years (38-89). The exclusion criteria were: etiology of sepsis, incomplete records and refusal to use data. The revision rate, with the replacement of prosthetic components, was the primary endpoint. The secondary outcomes were: mobility, complications, VAS, IKS, Devane, Charnley and Oxford knee scores, and radiological progression.

Results: The mean follow-up was 51 months (1-139). At 60 months, overall survival rate of the HTKA was 81%, with a confidence interval (CI) of 95% (71-93.2), and there was no difference between CHTKA and PHTKA, 77.7% (95% CI, 63.3-95.4) versus 85.7% (95% CI, 72-100), p=0.625, respectively. Flexion was 101°±15 (80-140) for CHTKA versus 98°±12 (30-130) for PHTKA, p=0.006. VAS was 0.5±16 (0-6) for CHTKA versus 1.6±14 (0-4) for PHTKA, p=0.000008. The IKS was 103±39 (15-180) for CHTKA versus 81±51 (9-200) for PHTKA, p=0.03. There were no differences in either radiological progression, complications or other functional scores.

Discussion: No significant difference was observed between the survival of CHTKA and PHTKA. CHTKA had better flexion, reduced VAS and increased IKS. Surgeons should be aware of these findings and apply careful consideration to their choice of hinge.

Level Of Evidence: IV; retrospective single-centre study.
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http://dx.doi.org/10.1016/j.otsr.2021.102868DOI Listing
February 2021

Rotating-Hinge Prosthesis for Aseptic Revision Knee Arthroplasty: A Multicentre Retrospective Study of 127 Cases with a Mean Follow-up of Five Years.

Orthop Traumatol Surg Res 2021 Feb 10:102855. Epub 2021 Feb 10.

Service de Chirurgie Orthopédique et de Traumatologie, CHU de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098 Strasbourg cedex, France.

Background: The use of third-generation rotating-hinge knee prostheses has increased considerably in recent years. The more anatomical design of these prostheses, together with their controlled rotation system that reduces constraints generated by the single degree of liberty, have produced better outcomes. The objective of this study was to evaluate the clinical and radiological outcomes of revision knee arthroplasty for aseptic failure using rotating-hinge prostheses.

Hypothesis: The rotating-hinge knee prostheses currently used in France provide significant improvements in function and self-sufficiency of patients undergoing revision knee arthroplasty, with outcomes comparable to those reported with constrained condylar knees.

Material And Methods: A multicentre retrospective study was conducted in 17 centres, under the auspices of the SoFCOT. The cohort consisted of 127 patients (127 knees) operated on before 2013. The main reasons for knee revision were aseptic loosening, major instability, mechanical failure, and extensor apparatus failure. Function and self-sufficiency were assessed using the International Knee Society (IKS) score and the Devane score, respectively. Survival was defined with all-cause surgical revision as the end point.

Results: Mean follow-up was 67.3±11.8 months (range, 13-180 months). Significant improvements (p<0.001) were seen in the total IKS score (+42 points), the IKS function score (+12 points), and the knee IKS score (+30 points). Paradoxically, the Devane score decreased by 0.44 point. The 5-year survival rate was 77% (95% confidence interval, 0.70-0.85). Post-operative complications developed in 29% of patients (infection, n=12; aseptic loosening, n=11; and fracture, n=7).

Discussion: Rotating-hinge prostheses provide satisfactory outcomes of knee arthroplasty revision and remain an effective option for complex cases, confirming our working hypothesis. Self-sufficiency diminished slightly. The long-term outcomes obtained using rotating-hinge prostheses were, however, less good than those seen with constrained condylar knees for aseptic TKA revision, and the complication rate was higher, although the population and local circumstances were different. Discernment is therefore in order when determining the indications of rotating-hinge prostheses.

Level Of Evidence: IV; retrospective cohort study.
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http://dx.doi.org/10.1016/j.otsr.2021.102855DOI Listing
February 2021

Can the minimal clinically important difference be determined in a French-speaking population with primary hip replacement using one PROM item and the Anchor strategy?

Orthop Traumatol Surg Res 2021 Jan 29:102830. Epub 2021 Jan 29.

Université de Lille, 59000 Lille, France; University of Lille, CHU of Lille, ULR2694-METRICS: évaluation des technologies de santé et des pratiques médicales, 59000 Lille, France; Department of biostatistics, CHU Lille, 59000 Lille, France.

Background: The impact of surgery on the patient is classically assessed on pre- and post-treatment scores. However, it is increasingly recommended to rank these results according to the minimal clinically important difference (MCID), using either the data distribution method or the anchor method, latter consisting in an extra question specifically targeting the patient's improvement. MCIDs vary between populations and, to the best of our knowledge; there have been no investigations in France regarding this in the context of total hip replacement (THR). Therefore, we conducted a prospective study in a population with THR to determine: 1) whether MCID scores in France were comparable to those reported in the data from the international literature; 2) whether a general item taken from a different score could serve as an anchor; and 3) whether an item from the actual questionnaire itself could serve as an anchor.

Hypothesis: When pre- and post-treatment scores are available, an item from the questionnaire itself can serve as an anchor for MCID.

Material And Methods: In a prospective observational study, 123 primary THR patients (69 male, 54 female), out of 150 initially included, completed the 5 domains of the HOOS hip disability and osteoarthritis outcome score and the Oxford-12 questionnaire, preoperatively and at 6-12 months. The MCID was calculated via the distribution-based and the anchor-based methods. Two Oxford items (questions 1 and 2) and 2 HOOS items (questions S1 and Q4) were used as anchors, as well as a supplementary question on improvement and the Forgotten Joint Score (FJS).

Results: At a mean 10.12±1.2 months' follow-up [range, 6.5-11.9 months], the Oxford-12 score increased from 19±8 [3-35] to 40±10 [8-48] (p<0.001), all HOOS components demonstrated improvement, and the FJS at the final follow-up was 71±29 [0-100]. The general items (Oxford question 1 and HOOS question Q4) were more discriminating than the joint-specific items (Oxford question 2 and HOOS question S1). Based on results from the 3 anchors (improvement rated 1 to 5, Oxford question 1 and HOOS question Q4), 3 to 5 patients showed deterioration, 5 to 6 were unchanged, 30 to 40 were slightly improved, and 73 to 80 were improved by THR. The mean MCID on both distribution and anchor methods was 9 [5.5-12] for Oxford-12, 20 [12-27] for HOOS symptoms, 26 [10-36] for HOOS pain, 22 [11.5-28] for HOOS function, 26 [13-34] for HOOS sport and 22 [14-28] for HOOS quality of life.

Discussion: The MCID for the Oxford-12 and HOOS scores in a French population was comparable to data from the past literature. Using a score item as an anchor to define improvement is possible, but only if a general item is used.

Level Of Evidence: IV; prospective study without control group.

Clinical Trials Registration: NCT04057651.
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http://dx.doi.org/10.1016/j.otsr.2021.102830DOI Listing
January 2021

Does change in language change the properties of a shortened score previously validated in its complete version? Validation of the French versions of the HOOS-12 and KOOS-12 scores in primary knee and hip arthroplasties.

Orthop Traumatol Surg Res 2021 Jan 22:102824. Epub 2021 Jan 22.

Université de Lille, CHU de Lille, EA 2694-Metrics: évaluation des technologies de santé et des pratiques médicales, 59000 Lille, France; CHU de Lille, unité de methodologie et biostatistiques, 59000 Lille, France.

Background: The HOOS and KOOS scoring questionnaires comprise respectively 40 and 42 items; a shorter 12-item version was recently developed, but remains to be validated in a French-speaking population. We therefore conducted a prospective study: 1) to determine whether the new 12-item versions in French are equivalent to the longer HOOS and KOOS versions, and 2) to validate the French-language HOOS-12 and KOOS-12 patient-reported outcome measures in a population of primary total hip and knee arthroplasty: validity, reliability, and responsiveness.

Hypothesis: The change in language in a score already validated in its long version does not alter its properties in the short version.

Material And Methods: One hundred patients (59 males, 41 females) undergoing primary total hip arthroplasty and 100 patients (43 males, 57 females) undergoing primary total knee arthroplasty were prospectively included. They filled out the original HOOS or KOOS questionnaires, their simplified versions (PS: Physical function Short form; JR: Joint Replacement) and the short HOOS-12 and KOOS-12 versions, and also the Oxford-12 score assessing the affected joint, preoperatively, then at 6-12 months.

Results: The 100% response rate confirmed ease of use. There were no redundant items. There were strong correlations between the 12-item and longer versions (>0.9). The HOOS-12 and KOOS-12 scores were reliable and valid: 1) there were no ceiling or floor effects for pre- or postoperative KOOS-12 scores, although a ceiling effect was found for HOOS-12 postoperatively (20% of patients having maximum scores of 100); 2) internal consistency was confirmed, with Cronbach alpha>0.8; 3) external consistency between Oxford-12 and HOOS-12/KOOS-12 was excellent, with Pearson correlation coefficient>0.8. Sensitivity to pre-/postoperative change was confirmed, with effect size>0.8.

Discussion: The present study confirmed the usefulness of this new 12-item form for HOOS and KOOS. Properties were identical between the French- and English-language versions, authorising everyday use of these simpler versions.

Level Of Evidence: IV; prospective study without control group.
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http://dx.doi.org/10.1016/j.otsr.2021.102824DOI Listing
January 2021

Techniques for filling tibiofemoral bone defects during revision total knee arthroplasty.

Orthop Traumatol Surg Res 2021 Feb 13;107(1S):102776. Epub 2020 Dec 13.

Service de chirurgie orthopédique et réparatrice, hôpital Pontchaillou, 2, rue H-Le-Guilloux, 35000 Rennes, France.

There are a variety of options for filling defects during revision total knee arthroplasty: cement with or without screws, structural or morselized allograft, highly porous cones and sleeves, massive bone allograft or megaprostheses. Our goal is to describe the techniques for these procedures and their indications. Any necrotic bone, fibrous tissue or granulomas must be excised, and the bone freshened. The height of the joint line must be restored using trial components stabilized by stems. The defect is the space between the bone and each of the two components. Whether contained or not, it can be evaluated using the AORI classification. Cement alone or supplemented with screws, which is pressurized to penetrate the bone, is now only used in small defects less than 10mm in diameter, especially contained one. It is preferable to use morselized compacted bone graft instead. Augments are used to fill AORI type 2 defects less than 10 mm deep in a condyle. They can also be used to position the femoral component and sometimes the tibial one. For type 2 and 3 defects, bone allografts aim to reconstruct the skeleton. They can be used as trimmed fragments, as described by Engh who did hemispheric reaming to embed a femoral head into the defect. One can also compact or pack morselized bone graft around a stem. These reconstruction procedures are long and difficult. They are being done less and less since porous cones and sleeves were introduced, which are impacted after bone preparation. These sterile components are secured to the stem either mechanically or with cement, saving time. Once in place, bone grows into them. They provide metaphyseal anchoring that helps to reduce the stem's length. When the epiphysis is nearly all gone, the choices are a massive bone allograft or a megaprosthesis, although both have a high risk of infection and mechanical failure. The allograft must be trimmed to restore the height of the joint line and achieve a stable connection with the host bone. A long stem, always cemented into the allograft, is essential. In older patients, a megaprothesis is simpler to use and faster. The femur is better suited to massive reconstruction than the tibia, where coverage must be ensured along with extensor mechanism continuity. LEVEL OF EVIDENCE: V; expert opinion.
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http://dx.doi.org/10.1016/j.otsr.2020.102776DOI Listing
February 2021

Survival and complications in hinged knee reconstruction prostheses after distal femoral or proximal tibial tumor resection: A retrospective study of 161 cases.

Orthop Traumatol Surg Res 2020 05 8;106(3):403-407. Epub 2020 Apr 8.

SoFCOT, 56, rue Boissonade, 75014 Paris, France.

Introduction: Hinged knee megaprostheses are mainly used for reconstruction after tumor resection. They may incur complications, but this has not been assessed in the French literature, except in small series at short follow-up. We therefore conducted a large-scale nationwide multicenter retrospective study with a minimum 5 years' follow-up. The objectives were (1) to compare survival between distal femoral and proximal tibial reconstruction prostheses, and (2) to analyze complications and failure.

Hypothesis: Distal femoral hinged reconstruction prostheses show longer survival with fewer complications than proximal tibial prostheses.

Material And Methods: One hundred sixty-one patients were included: 118 in the distal femoral group, and 43 in the proximal tibial group. Tumors were mostly osteosarcomas (90 cases) or chondrosarcomas (31 cases). Mean age was 37 years (range, 12-86 years). Complications were assessed on the Henderson classification. Failure was defined by prosthesis anchor exchange or amputation.

Results: At a mean 9 years' follow-up (range, 5-23 years), implant survival was longer in the distal femoral group: 5- and 10-year survival, 84% [95% CI, 75-89] and 70% [95% CI, 59-79] versus 74% [95% CI, 69-85] and 43% [95% CI, 23-61] (p=0.02). Revision surgery for complications mainly concerned aseptic loosening (19%, 30 cases) or deep infection (16%, 25 cases) and more often involved the proximal tibia (65% vs. 43%, 28 vs. 51 cases; OR 2.4 [95% CI, 1.2-5.1]; p=0.02).

Discussion: Hinged knee reconstruction prosthesis is a solution in tumoral pathology, but with a high risk of complications (loosening and infection) and a higher failure rate in the proximal tibial reconstruction prosthesis.

Level Of Evidence: IV, case series.
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http://dx.doi.org/10.1016/j.otsr.2019.11.027DOI Listing
May 2020

Hinged total knee arthroplasty for fracture cases: Retrospective study of 52 patients with a mean follow-up of 5 years.

Orthop Traumatol Surg Res 2020 05 4;106(3):389-395. Epub 2020 Apr 4.

56, rue Boissonade, 75014 Paris, France.

Introduction: Hinged total knee arthroplasty (hTKA) is one of the treatment options available for complex fractures around an intact knee or an existing implant. The primary objective of this multicenter study was to evaluate the medium-term outcomes of hTKA for fractures. The secondary objective was to analyze the complications and risk factors based on fracture type, predisposition and time to surgery. We hypothesized that outcomes would be satisfactory, despite the context, and comparable to published data although impacted by significant mortality and morbidity.

Materials And Methods: Within the framework of a symposium organized by the French Society of Orthopedic and Traumatology Surgery (SOFCOT), 52 patients from 11 hospitals were included retrospectively. All had undergone hTKA following a fracture event: recent fracture, postoperative course after a complex epiphyseal fracture on an intact knee, or periprosthetic fracture. Clinical outcomes (demographics, IKS score, Parker score, Devane score, time to surgery) and radiographic outcomes, along with complications were analyzed.

Results: Of the 52 patients included, 3 were lost to follow-up and 1 died early on. Thus, 48 patients with a mean age of 72 years (range, 31-95) were available for analysis at a mean follow-up of 59 months (range, 3-162). Forty of these patients (78%) had suffered a fracture to an intact knee and 12 (22%) had suffered a periprosthetic fracture. Of the 52 initial patients, 21 (40%) had early complications with 7 patients (19%) requiring surgical revision (5 surgical site infections, 1 extensor mechanism tear, 1 patellar dislocation). Sixteen patients (31%) developed late complications an average of 57 months after the hTKA implantation. All required surgical revision. There were 8 implant infections (15%), 3 cases of stiffness (6%), 2 extensor mechanism tears (4%) and 3 cases of loosening (6%). At a mean follow-up of 59 months, there was a 24-point improvement on the IKS pain scale (p=0.032). The postoperative activity level was unchanged in the patients who did not suffer a complication. The mortality rate was high (7/48; 15%).

Conclusion: Our hypothesis was confirmed since the outcomes were satisfactory, but mortality and morbidity were high. Performing hTKA remains an option in the post-fracture context, although surgeons must carefully consider the indications.

Level Of Evidence: IV, retrospective study.
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http://dx.doi.org/10.1016/j.otsr.2019.11.029DOI Listing
May 2020

Hinged knee prostheses: To be used with due consideration, but indispensable in complex situations.

Orthop Traumatol Surg Res 2020 05 17;106(3):385-387. Epub 2020 Mar 17.

Département Universitaire de Chirurgie Orthopédique et de Traumatologie, Hôpital Roger Salengro, rue Emile-Laine, 59037 Lille, France.

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http://dx.doi.org/10.1016/j.otsr.2020.03.001DOI Listing
May 2020

Prospective randomized study using EBRA-FCA to compare bone fixation between cementless SL-PLUS Zweymüller versus SL-PLUS MIA femoral implants in primary total hip arthroplasty with clinical assessment at a minimum 5years' follow-up.

Orthop Traumatol Surg Res 2020 05 3;106(3):519-525. Epub 2020 Feb 3.

Université Lille Nord de France, 59000 Lille, France; Service d'Orthopédie, Hôpital Salengro, CHRU de Lille, Place de Verdun, 59037 Lille cedex, France.

Introduction: Sometimes the slightest changes in implant design can lead to failure, even for a validated prosthesis. A minimally invasive cementless model, the SL-PLUS MIA™, in which the lateral shoulder is eliminated, was developed from the Zweymüller SL-PLUS™ implant. After satisfactory in-vitro tests, it required in-vivo assessment to ensure that bone fixation is good. We therefore conducted a prospective randomized study comparing the two versions of the Zweymüller femoral stem, with the aim of (1) comparing bone fixation up to 2 years' follow-up on EBRA-FCA radiography; and (2) assessing any difference in clinical or radiographic performance.

Hypothesis: Primary stability assessed on EBRA-FCA does not significantly differ between the SL-PLUS MIA™ and SL-PLUS™ implants.

Patients And Method: A single-center multi-surgeon prospective randomized study included 80 patients (79 were operated on) between April 2009 and October 2012, with a mean 6 years' follow-up. Radiographic assessment used the EBRA-FCA application up to 2 years' follow-up; clinical assessment, with a minimum 5 years' follow-up, was performed by a single observer, using the Harris and Oxford-12 scores. The two groups, SL-PLUS™ (n=38) and SL-PLUS MIA™ (n=41), were comparable in gender, age, indications, body-mass index and preoperative functional status.

Results: At a minimum 2 years' follow-up, 24 SL-PLUS™ and 27 SL-PLUS MIA™ implants were analyzed on EBRA-FCA. Mean migration was respectively -0.3mm±0.8 [range, -1.6 to 1.3] and -0.5mm±0.7 [range, -2.2 to 0.5] (p=0.21). There was likewise no significant difference in varus tilt. The number of ectopic ossifications did not differ, despite the absence of shoulder: 7 with SL-PLUS™ (23%), and 10 with SL-PLUS MIA™ (32%), without clinical impact. Oxford score improved from 43±6.8 to 19±7 at 5 years' follow-up with SL-PLUS ™ and from 44±8.8 to 20±7.4 with SL-PLUS MIA™: i.e., no significant inter-group difference. Likewise, Harris score at 2 years' follow-up did not differ: 91.6±8.7 and 89.7±10.2, respectively. Implant survival did not differ: SL-PLUS MIA™, 41/41 (100%); SL-PLUS™, 36/38 (94.7%) (p=0.13).

Conclusion: There was no significant difference in fixation quality between the SL-PLUS™ and SL-PLUS MIA™ implants. Elimination of the shoulder did not jeopardize primary or secondary fixation, but neither did it reduce the rate of ossification. The modified Zweymüller implant appeared risk-free at 6 years' follow-up.

Level Of Evidence: II, low-power prospective randomized study.
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http://dx.doi.org/10.1016/j.otsr.2019.10.011DOI Listing
May 2020

Extraction of total knee arthroplasty intramedullary stem extensions.

Orthop Traumatol Surg Res 2020 02 4;106(1S):S135-S147. Epub 2019 Dec 4.

Service de chirurgie orthopédique, hôpital Roger-Salengro, rue Emile-Laine, 59037 Lille, France.

Intramedullary stem extensions will need to be extracted during total knee arthroplasty (TKA) revisions, especially repeated ones. These stems have various designs and lengths, can be straight or offset, cemented (partially or totally) or cementless, smooth or rough. This diversity adds to the difficult of extracting them, which the surgeon must anticipate before starting the revision procedure. Porous metaphyseal metal components (cones, sleeves) are being used increasingly during revision TKA. They pose specific extraction challenges and complicate the extraction of the stems with which they are often associated. The maneuvers used during extraction have a direct impact on the subsequent joint reconstruction methods. These procedures are always long and difficult, with an increased risk of bone-related complications (perforation, fracture) or infection. They must always be carried out at specialized centers by experienced surgeons. The reasons for re-revision are the same as those for TKA revision, mainly aseptic loosening, instability and infection-only the latter requires that all components be removed. The local conditions are often unfavorable: epiphyseal-metaphyseal bone defect, thin cortices, osteoporosis, and in some cases, stiffness. The type of implant to extract and its characteristics must be identified beforehand in case special instruments are needed. An imaging workup is done to specify the relationship of the stem with bone, quality of its fixation, bone lesions and gaps between stem and bone, knowing that extraction is harder when the gaps are smaller. A combination of extended radiolucent lines, purely metaphyseal fixation, and a thin smooth stem may mean that intramedullary extraction is feasible. The extensor mechanism must be released to achieve sufficient exposure. If a tibial tubercle osteotomy is needed, it must be sized to match the extraction. After disassembly of femoral and tibial components-which can be challenging-the epiphyseal components must be released. High performance instruments for cement extraction and metal cutting are essential. Other than simple cases (loosened or partially fixed implants), intramedullary extraction can be dangerous especially when the stem extension is well-fixed, whether cemented or not. A diaphyseal window may be sufficient, but in most cases, an extended osteotomy is needed. This includes detaching the tibial tubercle at the tibia. At the femur, this may require an anterior midline window, an anterior extended ostéotomy or an anterolateral oblique distal femoral osteotomy with fibrous hinge. The extraction of metaphyseal porous components is difficult. Their connection with the bone must be broken - which can be long and risky - before the associated stem is removed. While it is easier to extract when the stem can be removed first, it is not always feasible. Reconstruction depends intimately on the methods used to extract the existing implants. Any diaphyseal discontinuity must be bridged (long stem or plate). The extent of the resulting bone defect after extraction drives the revision methods, which are simplified by using porous metaphyseal metal components and shorter stems when possible.
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http://dx.doi.org/10.1016/j.otsr.2019.05.025DOI Listing
February 2020

Compared outcomes 16 and 25 years after lateral wedge augmentation trochleoplasty: Rate of recurrent dislocation and progression to osteoarthritis.

Orthop Traumatol Surg Res 2019 11 15;105(7):1361-1367. Epub 2019 Oct 15.

Département universitaire de chirurgie orthopédique et de traumatologie, hôpital Roger-Salengro, rue Emile-Laine, 59037 Lille cedex, France; Université Lille-Nord de France, 59000 Lille, France.

Background: Lateral wedge augmentation trochleoplasty (LWAT) was the earliest described trochleoplasty technique but was gradually replaced by other methods for the treatment of patello-femoral instability with trochlear dysplasia. Data on the outcomes of this procedure in adults are limited. We therefore performed a retrospective study in patients managed by LWAT to assess (1) clinical (recurrent instability and functional scores), (2) and radiological (patello-femoral osteoarthritis) outcomes.

Hypothesis: LWAT is associated with a low long-term rate of recurrent patello-femoral dislocation and with no risk of progression to severe patello-femoral osteoarthritis.

Material And Methods: Between 1988 and 1995, LWAT was performed on 66 knees in 58 patients to treat patello-femoral instability with trochlear dysplasia. Among them, 17 knees in 13 patients were re-evaluated 16 then 25 years after surgery and were included in the study. At both time points, the following were recorded: stability, pain, the Lille patello-femoral function score, and changes in radiographic and computed tomography findings. In addition to LWAT, Insall's realignment vastus medialis advancement was performed in 4 cases, sartorius muscle transposition in 9 cases, and anterior tibial tubercle osteotomy in 10 cases.

Results: No episodes of patello-femoral dislocation were recorded during the 25-year follow-up. The mean Lille patello-femoral function score (0 worst to 100 highest) was 90±15 (range, 48-99) after 16 years and 86±23 (range, 33-94) after 25 years. After 16 years, 8/17 knees had evidence of patello-femoral osteoarthritis, which was Iwano stage 1 in 7 cases and Iwano stage 2 in 1 case. Patello-femoral osteoarthritis was noted in 12 of 13 knees after 25 years but was mild (Iwano stage 1 or 2) in 8 cases. After 25 years, arthroplasty had been performed for 4 of the 17 knees, with 2 cases each of patello-femoral arthroplasty and total knee arthroplasty.

Conclusion: LWAT is a reliable procedure that provides sustained protection against patello-femoral dislocation and good functional scores when used to treat patello-femoral instability due to trochlear dysplasia. Our results do not support claims that LWAT may be associated with high rates of severe osteoarthritis even after more than 20 years.

Level Of Evidence: IV, retrospective observational study with no control group.
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http://dx.doi.org/10.1016/j.otsr.2019.08.008DOI Listing
November 2019

Contemporary rotating hinge arthroplasty can safely be recommended in complex primary surgery.

Knee Surg Sports Traumatol Arthrosc 2020 Jun 1;28(6):1780-1788. Epub 2019 Jul 1.

Service de Chirurgie Orthopedique, Centre-Hospitalo-Universitaire de Lille, Lille, France.

Purpose: The objective was to evaluate clinical and radiological outcomes, survival rate and complications of primary contemporary rotating hinged total knee arthroplasty (CRH-TKA).

Methods: Through a national multicenter retrospective study (14 centers), 112 primary CRH-TKA performed between 2006 and 2011 were included. Indications were: severe frontal plane deformity (55%), inflammatory, constitutional, congenital or post-trauma arthritis (26%), ligament laxity (10%), primary osteoarthritis (9%). Population was elderly (68 ± 13), sedentary (37.5% with a Devane score ≥ 3) and with important comorbidities (87% with ASA score ≥ 2). A clinical (KSS, Oxford scores) and radiological evaluation (implant loosening), as well as survival and reoperation rates assessment, were performed.

Results: At last follow-up (7 ± 3 years), KSS and Oxford scores were 64 ± 43 and 33 ± 10 each with a significant improvement of both scores overtime (respectively, p = 0.047 and p < 0.001). Twenty-eight complications (25%) were reported: 12 infections, 6 stiffness, 5 aseptic loosening and 5 patellofemoral instabilities. All in all, 91% (n = 102) of implants were still sealed and in place, 6% (n = 7) required revision and 3% (n = 3) were loose but could not undergo revision due to weak general health status. Mortality rate (18%, n = 20), linked to comorbidities, was high.

Conclusion: Clinical outcomes and survival of primary CRH-TKA are acceptable given the difficult and complex clinical situations it faced, but with high infection rate. In primary surgery, for patients with severe deformity, bone loss or ligament laxity, the use of CRH-TKA can be recommended. The choice of these implants must remain cautious and limited to situations not allowing the use of less constrained implants.

Level Of Evidence: Retrospective therapeutic and cohort study, Level III; retrospective case series, Level IV.
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http://dx.doi.org/10.1007/s00167-019-05589-xDOI Listing
June 2020

Ten-year outcomes of cementless anatomical femoral implants after 3D computed tomography planning. Follow-up note.

Orthop Traumatol Surg Res 2019 09 26;105(5):937-942. Epub 2019 Jun 26.

Service d'orthopédie, département universitaire de chirurgie orthopédique et de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, Lille 59037, France; Faculté de médecine, université Lille-Nord-de-France, Lille 59000, France.

Background: Pre-operative 3D planning based on computed tomography (CT) imaging is used to optimise the restitution of normal hip anatomy during primary total hip arthroplasty (THA). Although CT planning has been proven effective and reproducible, its influence on long-term THA outcomes is unknown. In this 10-year follow-up study of patients managed with the same technique of CT-planned primary anatomical THA, the objectives were to assess femoral implant survival, long-term functional outcomes, 10-year outcomes of titanium modular femoral necks, and associations with the dislocation rate. Hypothesis Pre-operative CT planning of primary THA ensures achievement of the NICE criterion of a lower than 5% femoral revision rate within 10 years.

Material And Methods: The study included 61 patients (61 hips) managed between 2004 and 2007 by CT-planned primary THA via the posterior approach, with an uncemented anatomical femoral component (SPS, Symbios); when deemed necessary by the surgeon to restore normal anatomy, a titanium modular femoral neck was used (35/61 patients). After 10 years, 17 patients had died and 3 were lost to follow-up, leaving 41 patients with a mean age of 76 years (range, 60-91 years) for re-evaluation. Clinical outcomes were assessed by determining the Harris Hip Score (HHS) and the Postel-Merle d'Aubigné (PMA) score, which were compared to baseline values. Radiographs were evaluated using the AGORA Roentgenographic Assessment system (ARA).

Results: The 10-year femoral component survival rate was 96% (95%CI, 88;99%). Revision was required in 4 patients, to treat delayed peri-prosthetic fractures (n=2) or to correct initial cup malposition (n=2). No changes occurred from 2010 to last follow-up in the mean HHS (90 [95%CI, 84;95] and 91 [95%CI, 77;96], respectively) or mean PMA score (16 [95%CI, 14;17] and 15.5 [95%CI, 14;16.5], respectively). The mean ARA score was 5.2 (range, 3-6) at last follow-up. No complications related to the use of modular femoral necks were recorded. Dislocation occurred in 2 patients, but in neither was the pre-operative plan followed during surgery.

Discussion: The SPS stem produced good 10-year clinical and radiographic outcomes. No patients experienced complications related to use of a titanium modular femoral neck. The restoration of anatomical hip geometry made possible by pre-operative CT planning provided sustained clinical improvements with a low complication rate.

Level Of Evidence: IV, retrospective observational cohort study.
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http://dx.doi.org/10.1016/j.otsr.2019.04.019DOI Listing
September 2019

The role of rotating hinge implants in revision total knee arthroplasty.

EFORT Open Rev 2019 Jun 3;4(6):269-278. Epub 2019 Jun 3.

Service de Chirurgie Orthopédique, Cente Hospitalo-Universitaire de Nancy, Centre Hospitalo-Universitaire de Nancy, France.

Hinged implants are the most constrained knee replacement prostheses. They are very useful in complex cases of total knee arthroplasty (TKA) revision.Hinged implants have evolved with rotating bearings and modularity that allows local joint reconstruction or segmental bone replacement.They are required when significant instability persists in cases with inadequate collateral ligaments and significant flexion laxity.They are now used when a large bone defect is reconstructed, or when bone fixation of the implant is questionable especially in the metaphyseal zone.The use of hinged implants in TKA revision is associated with high complication rates. Published outcomes differ based on the patients' aetiology.The outcomes of rotating-hinged implants used in septic revisions or salvage situations are poorer than other types of revision and have a higher complication rate.The poor general health of these patients is often a limitation.Despite these relatively poor results, hinged implants continue to have a place in revision surgery to solve major instability or to obtain stable bone fixation of an implant when the metaphysis is filled with bone grafts or porous devices. Cite this article: 2019;4 DOI: 10.1302/2058-5241.4.180070.
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http://dx.doi.org/10.1302/2058-5241.4.180070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549216PMC
June 2019

Long-term comparative study of large-diameter metal-on-metal bearings: Resurfacing versus total arthroplasty with large-diameter Durom™ bearing.

Orthop Traumatol Surg Res 2019 09 11;105(5):943-948. Epub 2019 Jun 11.

Université de Lille Nord de France, 59000 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, Centre Hospitalier et Universitaire de Lille, place de Verdun, 59037 Lille, France.

Introduction: Short-term results in total hip arthroplasty (THA) with large-diameter metal-on-metal (MoM) bearings were encouraging, but high failure rates have been reported in the long term, notably implicating corrosion due to modularity. Several studies compared resurfacing (to which modularity does not apply) versus large-diameter MoM THA; but, to our knowledge, none compared the same bearing in the two situations with more than 10 years' follow-up. We therefore conducted a retrospective case-control study, using a single cup model (Durom™, Zimmer, Warsaw, USA) for both resurfacing (R) and large-diameter THA, to determine the role of modularity in failure of large-diameter MoM bearings. The study compared (1) metallic ion levels, and (2) survival, functional scores and complications rates between R and THA.

Hypothesis: Large-diameter MoM bearing failure implicates not bearing wear but head-neck junction modularity in larger-diameter MoM THA.

Material And Method: Eighty-three THAs and 90 Rs were included between February 2004 and March 2006. All patients had clinical and radiologic follow-up with chromium (Cr) and cobalt (Co) ion blood assay.

Results: In the THA group, 24 of the 83 patients (28.9%) underwent revision for adverse reaction to metal debris (ARMD), versus none in the R group. Ten-year all-cause survival was significantly better in R (97.7%; 95% CI, 96.2-99.2) than THA (67.1%; 95% CI, 60.9-73.3). Median blood ion level was higher in THA (with a difference between Co and Cr: 5.75μg/L (range, 3.82-19.2) versus 1.75μg/L (range, 1.34-2.94) respectively) than in R (no difference: 0.89μg/L (range, 0.67-2.89) and 1.07μg/L (range, 0.67-1.65) respectively). In the THA group, there were positive correlations between Co and Cr elevation and implant revision (both p<0.0001). Co/Cr ratio was significantly higher in THA (2.57) than R (0.88) (p<0.0001), and higher again in the 24 cases of THA revision (4.67). There was no significant difference in mean PMA score (THA: 17.08±1.82 (range, 7-18); R: 17.50±0.74 (range, 15-18)), whereas mean Oxford score was better in R (14.32±2.5 (range, 12-24)) than THA (18.17±8.05 (range, 12-42)) (p=0.02).

Discussion: The present study confirmed the incontrovertible implication of modularity in failure of large-diameter MoM THA, by analyzing the same bearing in THA and in resurfacing. Trunnionosis was observed in the 24 cases of revision, with the THA adaptation ring inducing serious metallic ion release (with dissociated Co/Cr ratio), accounting for the high rate of revision.

Level Of Evidence: III, case-control study.
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http://dx.doi.org/10.1016/j.otsr.2019.04.006DOI Listing
September 2019

Have the frequency of and reasons for revision total knee arthroplasty changed since 2000? Comparison of two cohorts from the same hospital: 255 cases (2013-2016) and 68 cases (1991-1998).

Orthop Traumatol Surg Res 2019 06 11;105(4):639-645. Epub 2019 May 11.

Université Lille Nord de France, 59000 Lille, France; Service d'orthopédie, Hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France.

Introduction: The number of total knee arthroplasty (TKA) revisions is expected to increase 601% in the United States between 2005 and 2030. This type of information is not available in France, and the last national study on this topic was done in 2000. This led us to perform a comparative study to determine if 1) the frequency of TKA revisions has increased and 2) the reasons for reoperation have changed relative to data gathered in 2000 at a single hospital in France.

Hypothesis: The frequency of TKA revision has increased between the two studies, performed 15 years apart.

Material And Methods: In this retrospective observational single-center study (January 2013 to December 2016), all patients with a TKA who were reoperated with or without any component change were included. This cohort was compared to our historical cohort defined in 2000 of 68 TKA reoperations between January 1991 and January 1998. The reasons for revision were determined by consulting computerized patient records to find the disease history, clinical examinations, imaging findings, laboratory tests and the surgery report. Cases due to periprosthetic fractures, infection and skin-related complications were excluded in order to be consistent with the indications of the historical cohort.

Results: Between 2013 and 2016, 349 TKA revisions were performed, and 255 met the inclusion criteria. Note that the historical cohort had 68 cases. The mean time elapsed between the primary TKA and revision procedure was 5.3 years [34 days to 31 years]. Eight reasons for reoperation were identified. Aseptic loosening (85 cases (33.3%)), stiffness (70 cases (27.5%)), tibiofemoral laxity (39 cases (15.3%)) and patellar complications (34 cases (13.3%)) were the four most common reasons for reoperation. The frequency has changed over time: relative to 2000, the annual frequency increased by a factor of 6.5. The reasons have also changed over time: there was an increase in revisions for aseptic loosening (33.3% vs. 23.5%), stiffness (27.5% vs. 20.6%) and knee joint laxity (15.3% vs. 10.3%). Conversely, there was a reduction in revisions for patellar complications (13.3% vs. 26.5%), unexplained pain (0.4% vs. 8.8%) and patellar clunk syndrome (1.2% vs. 4.4%).

Discussion: The number of TKA revisions has increased by a factor of 6.5, with aseptic loosening still being the most common reason. The number of revisions performed for stiffness and knee joint laxity have increased. Fewer revisions are being done for unexplained pain because surgeons are now better able to determine the cause of TKA-related pain. There were fewer patella-related complications because of technical progress. The data generated from our single-center study are consistent with current published data.

Level Of Evidence: II, comparative study.
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http://dx.doi.org/10.1016/j.otsr.2019.01.025DOI Listing
June 2019

Total knee replacement on more than 20° valgus: A case control study.

Orthop Traumatol Surg Res 2019 06 28;105(4):613-617. Epub 2019 Mar 28.

Société française de chirurgie de la hanche et du genou (SFHG), 56, rue Boissonade, 75014 Paris cedex, France.

Introduction: Lower-limb valgus deformity exceeding 20° is a particular case, with few publications assessing the impact of the severity of the valgus. The present retrospective case control study compared a series of>20° valgus versus a series of 10-20° valgus, assessing (1) operative data [approach, type of total knee replacement (TKR)], (2) complications and implant survival, and (3) clinical and radiological results.

Hypothesis: Severe valgus deformity requires TKR with greater constraint, incurring a higher rate of complications and poorer implant survival.

Material And Method: A multicenter retrospective study for the period January 2006 to December 2010 included 53 patients, with a mean age of 72±10 years, presenting>20° valgus. The study series was matched for age and gender with a series of 53 cases of 10-20° valgus. Convexity laxity was greater in the>20° group (p=0.004).

Results: There was no significant inter-group difference in approach (p=0.13). Greater constraint was more frequent in the>20° group (7/53 versus 1/53; p=0.03), independently of convexity laxity or Krackow grade (p=0.14). There were 7 complications (13.2%) in the>20° group and 7 in the 10-20° group (NS). Eight-year survivorship was 95.12% in the>20° group and 94.9% in the 10-20° group (p=0.63). There were no significant differences in Oxford score (p=0.30) or HKA angle (p=0.78) at last follow-up.

Conclusion: The study hypothesis was partially confirmed: greater constraint was more frequent in>20° valgus. The number of complications was low, and survival was identical to that of a control group with less severe deformity.

Level Of Evidence: III, retrospectivecase controlstudy.
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http://dx.doi.org/10.1016/j.otsr.2018.12.014DOI Listing
June 2019

Patellofemoral design enhancements reduce long-term complications of postero-stabilized total knee arthroplasty.

Knee Surg Sports Traumatol Arthrosc 2019 Apr 10;27(4):1241-1250. Epub 2018 Sep 10.

Université de Lille Nord de France, Lille, France.

Purpose: Few studies investigated whether trochlear and patellar design enhancements improve long-term outcomes of total knee arthroplasty (TKA). This study aimed to compare the long-term survival and complication rates of two consecutive generations of the same TKA system with identical tibiofemoral geometry, but different patellofemoral designs.

Methods: The authors retrieved the records of 93 patients (104 knees) operated with the HLS II system and 116 patients (122 knees) operated with HLS Evolution system. Patients were evaluated preoperatively and at a minimum of 10 years noting all complications. Kaplan-Meier (KM) survival was compared for two endpoints: (1) revision of all components and (2) revision of any component.

Results: From the HLS II series, the incidence of revision of all components was 6.4%, and of any component was 9.8%. From the HLS Evolution series, the incidence of revision of all components was 4.1%, and of any component was 5.1%. Comparing the survival at equivalent follow-up of 14 years, considering revision of all components, the HLS II had higher survival than the HLS Evolution (98.9% vs 95.9%), while considering revision of any component, the HLS II had lower survival than the HLS Evolution (93.0% vs 94.9%). The differences in survival of the two implants were not significant, neither at equivalent follow-up of 14 years (n.s.), nor at maximum follow-up of each cohort (n.s.). The complication rate was higher for the HLS II series compared to the HLS Evolution (28% vs 12%, p = 0.009), but patellofemoral complications were not more frequent (8% vs 6%, n.s.).

Conclusions: Though the differences in survival of the two implants were not significant, conflicting findings are observed due to partial revisions for patellar fractures (5 in the HLS II series and 1 in the HLS Evolution series) which could be related to patellofemoral design enhancements. This study highlights the importance of patello-femoral geometry, which is often overlooked in TKA.

Level Of Evidence: Retrospective comparative study, Level III.
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http://dx.doi.org/10.1007/s00167-018-5137-6DOI Listing
April 2019

Patellar complications after total knee arthroplasty.

Orthop Traumatol Surg Res 2019 02 7;105(1S):S43-S51. Epub 2018 Jul 7.

Université de Lille Nord de France, 59037 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, place de Verdun, 59037 Lille, France.

Patellar complications are a source of poor total knee arthroplasty (TKA) outcomes that can require re-operation or prosthetic revision. Complications can occur with or without patellar resurfacing. The objective of this work is to answer six questions. (1) Have risk factors been identified, and can they help to prevent patellar complications? Patellar complications are associated with valgus, obesity, lateral retinacular release, and a thin patella. Selecting a prosthetic trochlea that will ensure proper patellar tracking is important. Resurfacing is an option if patellar thickness is greater than 12mm. (2) What is the best management of patellar fracture? The answer depends on two factors: (a) is the extensor apparatus disrupted? and (b) is the patellar implant loose? When either factor is present, revision surgery is needed (extensor apparatus reconstruction, prosthetic implant removal). When neither factor is present, non-operative treatment is the rule. (3) What is the best management of patellar instability? Rotational malalignment should be sought. In the event of femoral and/or tibial rotational malalignment, revision surgery should be considered. If not performed, options consist of medial patello-femoral ligament reconstruction and/or medialization tibial tuberosity osteotomy. (4) What is the best management of patellar clunk syndrome? When physiotherapy fails, arthroscopic resection can be considered. Recurrence can be treated by open resection, despite the higher risk of complications with this method. (5) What is the best management of anterior knee pain? The patient should be evaluated for causes amenable to treatment (fracture, instability, clunk, osteonecrosis, bony impingement on the prosthetic trochlea). If patellar resurfacing was performed, loosening should be considered. Otherwise, secondary resurfacing is appropriate only after convincingly ruling out other causes of pain. A painstaking evaluation is mandatory before repeat surgery for anterior knee pain: surgery is not in order in the 10% to 15% of cases that have no identifiable explanation. (6) What can be done to treat patellar defects? Available options include re-implantation (with bone grafting, cement, a biconvex implant, or a metallic frame), bone grafting without re-implantation, patellar reconstruction, patellectomy (best avoided due to the resulting loss of strength), osteotomy, and extensor apparatus allograft reconstruction. LEVEL OF EVIDENCE: V, expert opinion.
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http://dx.doi.org/10.1016/j.otsr.2018.04.028DOI Listing
February 2019

Does medial collateral ligament pie-crusting induce residual laxity in arthroscopic management of medial meniscus tears? A prospective study of 40 cases.

Orthop Traumatol Surg Res 2018 09 19;104(5):707-711. Epub 2018 Jun 19.

Service d'orthopédie D, CHRU de Lille, hôpital Salengro, place de Verdun, 59037 Lille cedex, France; Université de Lille, Hauts de France, 59000 Lille, France.

Introduction: Arthroscopic meniscectomy and medial meniscal repair are frequent procedures, liable to be complicated by iatrogenic cartilage lesions, especially in tight knee. Medial collateral ligament pie-crusting was developed to counter this, but, although the technique is employed, its impact on medial laxity has not been precisely determined. We therefore conducted a prospective observational study to compare radiographic laxity preoperatively versus 6 weeks following pie-crusting.

Hypothesis: Medial collateral ligament pie-crusting alters radiographic laxity at 6 weeks.

Material And Methods: Between December 2015 and February 2017, 40 patients (33 male, 7 female) underwent surgery with pie-crusting for isolated medial meniscal lesion. Mean age was 39 years (range, 20-54 years). Meniscectomy was performed in 33 cases (82.5%) and repair in 7 (17.5%). Pie-crusting used an intramuscular needle under arthroscopic control, adjacent to the medial meniscus at the posterior two-thirds junction of the compartment, until opening was deemed satisfactory. Laxity was compared on preoperative versus 6 weeks stress valgus views (Telos ™), by 2 independent observers, on 2 measurements: opening angle, and medial tibiofemoral joint space height. Each measurement was taken twice at a 2-week interval by each observer.

Results: Inter- and intra-observer concordance was excellent on both measurements: intraclass correlation coefficient was 0.82 (95% CI, 0.73-0.89) and 0.91 (95% CI, 0.86-0.94) pre- and post-operatively for opening angle, and 0.87 (95% CI, 0.79-0.92) and 0.88 (95% CI, 0.82-0.92) for joint space height. Tibiofemoral joint space opening was significantly greater at 6 weeks on both measurements: 0.9±1° [range, -1° to 4°] (p<0.0001) and 1.1±1mm [range, -0.6 to 3.2mm] (p<0.0001).

Discussion: Medial collateral ligament pie-crusting led to a moderate but significant increase in medial laxity at 6 weeks. A longer-term study is needed to assess progression.

Level Of Evidence: IV, prospective study without control group.
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http://dx.doi.org/10.1016/j.otsr.2018.05.007DOI Listing
September 2018

Under-corrected knees do not fail more than aligned knees at 8 years in fixed severe valgus total knee replacement.

Knee Surg Sports Traumatol Arthrosc 2018 Nov 28;26(11):3386-3394. Epub 2018 Mar 28.

Université de Lille, Hauts de France, Lille, France.

Purposes: A fixed severe valgus knee is a surgical challenge. A safe post-operative Hip-Knee-Ankle angle (HKA) range of 180° ± 4 was recommended, but recent studies mentioned equal results from outliers of this range. Nevertheless, no distinction was made between varus and valgus knees, as well as over-corrected or under-corrected knees. Did post-operative nonaligned total knee replacements (TKR) from fixed severe valgus knees behave differently from the properly aligned population? Did over-corrected knees behave differently from under-corrected knees?

Methods: Through a multi-center retrospective cohort study, we provided 557 knees of at least 10° of minimal pre-operative valgus; in this population 75 presented a post-operative Hip-Knee-Ankle angle (HKA) outside of the 180° ± 4 range; 23 of them had at least 5° of varus; 52 of them had at least 5° of valgus. Median pre-operative HKA of the entire cohort was 194° (range 190-198). Median follow-up was 8 years (range 5-11); Knee Society Score (KSS) results, HKA, Femoral and Tibial Mechanical Angles (FMA, TMA) and complication rates were obtained. The outlier group (HKA ≤ 175 or ≥ 185) was compared to the control group (HKA 180 ± 4); over-corrected (HKA ≤ 175) and under-corrected (HKA ≥ 185) sub-groups were individually tested against the control group.

Results: The outlier group had a lower Final Knee Score than the aligned group (p = 0.023). In the over-corrected sub-group, median post-operative FMA was 88° (SD 4°) and median TMA was 87° (SD 4°). The complication rate was higher (p = 0.019). Knee (p = 0.018), Function (p = 0.034) and Final Knee Scores (p = 0.03) were statistically lower than in the control group. In the under-corrected sub-group, mean post-operative FMA was 93° (SD 2°) and mean TMA was 91° (SD 2°). The complication rate was lower (p = 0.019) and there was no difference with the control group concerning KSS.

Conclusions: In case of pre-operative fixed severe valgus knee, one should avoid over-correcting HKA angle and especially the TMA. Over-correction of a severe preoperative valgus in a post-operative varus was prejudicial for TKA survival. Keeping a severe valgus knee in low valgus to avoid using a more constrained implant and/or ligament releases will not decrease the 5-10 year implant survival and functional scores.

Level Of Evidence: Level IV-Case series.
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http://dx.doi.org/10.1007/s00167-018-4906-6DOI Listing
November 2018

Metallic ion release after knee prosthesis implantation: a prospective study.

Int Orthop 2017 12 14;41(12):2503-2508. Epub 2017 Jun 14.

Université de Lille Nord de France, F-59000, Lille, France.

Introduction: Metal-on-metal (MoM) hip replacement bearings produce metallic ions that can cause health complications. Metallic release also occurs with other materials, but data on metallic ion levels after knee arthroplasty are sparse. We postulate that knee replacement generates elevating metallic ions (chromium (Cr), cobalt (Co) and titanium (Ti)) during the first year after implantation.

Patients And Methods: This ongoing prospective study included all patients who underwent the same type of knee arthroplasty between May and December 2013. Cr, Co and Ti levels were measured in whole blood at pre-operation and one-year follow-up (6 and 12 months). Clinical and radiographic data (range of motion, Oxford, International Knee Society (IKS) and satisfaction scores) were recorded.

Results: In 90 patients, preoperative Cr, Co and Ti metallic ion levels were respectively 0.45 μg/l, 0.22 μg/l, 2.94 μg/l and increased to 1.27 μg/l, 1.41 μg/l, 4.08 μg/l (p < 0.0001) at last one-year follow-up. Mean Oxford and IKS scores rose, respectively, from 45.9 (30-58) and 24.9 (12-52) to 88.3 (0-168) and 160.8 (93-200) (p < 0.001).

Conclusion: After the implantation of knee arthroplasty, we found significant blood elevation of Cr, Co and Ti levels one year after implantation exceeding the normal values. This metallic ion release could lead to numerous effects: allergy, hypersensitivity, etc.
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http://dx.doi.org/10.1007/s00264-017-3528-9DOI Listing
December 2017

Recurrent posterior knee laxity: diagnosis, technical aspects and treatment algorithm.

Knee Surg Sports Traumatol Arthrosc 2017 Oct 29;25(10):3046-3052. Epub 2016 Mar 29.

Cabinet Goethe, 23 Avenue Niel, 75017, Paris, France.

Purpose: Aim of this study was to determine the characteristics, clinical and radiological diagnostic methods of PCL isolated and combined knee injuries.

Methods: One hundred and twelve patients with a recurrent posterior knee laxity were surgically treated. Clinical examination, MRI, Telos™ stress dynamic X-rays, KT-1000 measurements and the IKDC questionnaire were used to diagnose and evaluate these injuries.

Results: Median follow-up was 4.5 years (2-11 years). Thirty-two patients (28.6 %) had an isolated posterior laxity, 53 (47.3 %) a posterior posterolateral laxity, 21 (18.7 %) a posterior posteromedial laxity and six (5.4 %) patients had a complex posterior and mediolateral laxity. Road traffic accidents and sports injuries were the main causes of trauma. The mean preoperative value of posterior tibial translation was 13.5 mm (SD 1.4) and the mean postoperative value was 4.4 mm (SD 1.7) as measured with the Telos device. In the cases with a concomitant ACL rupture, the mean preoperative value of anterior tibial translation was 6.5 mm (SD 1.3) and the mean postoperative value was 1.7 mm (SD 0.8). The mean pre- and postoperative IKDC scores were 74.5 (SD 4.2) and 87.9 (SD 3.1), respectively. Meniscal and/or cartilage injuries were found in 80 patients (71.4 %).

Conclusions: Recurrent posterior knee laxity can be restored with the one-stage PCL reconstruction using a quadriceps graft and reconstruction of the posteromedial-posterolateral lesions using the LaPrade techniques. The benefits of this study include enabling surgeons to accurately manage these injuries from a clinical perspective, and treating them with a specific surgical algorithm.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-016-4085-2DOI Listing
October 2017

Comparison of two-dimensional fast Raman imaging versus point-by-point acquisition mode for human bone characterization.

Anal Chem 2012 Nov 11;84(21):9116-23. Epub 2012 Oct 11.

Univ Lille Nord de France, F-59000 Lille, France.

Recent technical developments gave rise to a new technology for two-dimensional fast Raman imaging: the DuoScan averaging mode (DS-Avg). This technology allows the acquisition of a Raman spectrum over a rastered macro spot. The aim of this study was to evaluate the interest of the DS-Avg applied on trabecular human bone. The evaluation was based on the comparison of the DS-Avg versus the point-by-point mapping mode in real usage conditions. The signal-to-noise ratio, the spectral difference, and the physicochemical parameters were estimated for comparison of the efficiency of both modes. Principal component analysis was performed to explore the capacity of both modes to detect compositional variations. Results showed that the DS-Avg spectrum was equivalent to the average spectrum of individual spectra acquired with the point-by-point mode for the same sample area. The physicochemical parameters can be also determined from DS-Avg acquisition. The DS-Avg combined with an objective ×50 allows a drastic decrease of the acquisition time, but the information about the micrometric composition is lost. The combination of the DS-Avg with an objective ×100 is a good compromise between acquisition time and resolution. The DS-Avg is a useful technology for imaging mineral and organic phases of bones and for assessing their spatial distribution on large samples. The point-by-point imaging mode is more appropriate to assess the heterogeneous composition of bone within the micrometer scale. For the first time, this study compares the DuoScan averaging mode to the point-by-point imaging mode on a trabecular human bone.
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http://dx.doi.org/10.1021/ac301758yDOI Listing
November 2012

Three-dimensional hip anatomy in osteoarthritis. Analysis of the femoral offset.

J Arthroplasty 2009 Sep 30;24(6):990-7. Epub 2008 Aug 30.

Medical Engineering Department, Leeds University, United Kingdom; Hopítal Pitié Salpétrière, Paris, France.

Two hundred twenty-three patients with osteoarthritic hips were analyzed using computed tomography and a specific image processing software (HIP-PLAN) to determine 3-dimensional morphological data of the hip focusing on femoral offset (FO). Mean FO was found to be 42.2 +/- 5.1 mm, 2.2 mm greater than the 2-dimensional FO values reported in the literature. The FO was found to be above 45 mm in 31% of patients and greater than 50 mm in 12%. The error associated with the use of conventional plane x-rays to measure FO was found to be 3.5 +/- 2.5 mm, the x-ray technique generally underestimating the measure of FO. The sum of acetabular and femoral anteversion was found to be out of the safe zone regarding dislocation risk in 47% of patients.
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http://dx.doi.org/10.1016/j.arth.2008.04.031DOI Listing
September 2009