Introduction: Achieving planned alignment is one of the keys to implant survival and patient satisfaction in total knee arthroplasty (TKA). New technologies have been developed, such as robotics, patient-specific instruments (PSI), and augmented reality (AR). This study evaluated the contribution of AR through the Knee+™ device (PIXEE Medical Company, Besançon, France). This TKA navigation device uses AR to orient the distal femoral and proximal tibial cutting guides in the frontal and sagittal planes. Measurements are independent for the tibia and femur. The device requires no robot, no engineer, and no additional preoperative three-dimensional imaging. There are several papers dedicated to the Knee+™ device; this study is the largest prospective study to date and is independent of the device's promoter, to determine: (1) the accuracy of the Knee+™ device, (2) the existence of a learning effect on operative time and on accuracy, (3) the risk of using the device by reporting the intra-operative events and adverse events occurring within 3 months postoperatively.
Hypothesis: Knee+™ admits an error of less than 1.5 ° between the value announced by the device and post-operative radiographic measurements.
Material and methods: This was a prospective, monocentric study involving 60 patients undergoing TKA with the device under study; mechanical alignment was planned. The accuracy of the procedure was analyzed during the intraoperative cutting inspection stage and then by measuring the Lateral Distal Femoral Angle (LDFA), Medial Proximal Tibial Angle (MPTA), and tibial slope on postoperative radiographs.
Results: There were no intraoperative adverse events and no revision surgery during the 3-month follow-up period. The mean error of the device was 1.23 ° ± 0.94 ° for the LDFA, 1.22 ° ± 1.05 ° for MPTA, and 2.15 ° ± 1.43 ° for the tibial slope. For the femur, no patient had an angle value with an error >3°; for the tibia, one patient (1.7%) had an angle value with an error >3° in the frontal plane, and twelve patients (21%) had an angle value with an error >3° in the sagittal plane. The learning curve showed no effect on accuracy, but operating time was reduced by 20 min after the tenth prosthesis was fitted with the device.
Conclusion: This study showed that the Knee+™ device is a safe, reliable, and reproducible AR tool. It has a rapid learning curve for TKA placement. It can be considered as an alternative or an aid to conventional instrumentation in TKA.
Level of evidence: IV; prospective non-comparative study.
Introduction: To date, no national registry has provided a dedicated report on short femoral stems (SFS) in primary Total Hip Arthroplasty (pTHA). In the historical SOFCOT hip arthroplasty multicentre registry (HAMR, now RENACOT), the first SFS used in pTHA was registered in 2011. Aims of this specific report are: 1) to evaluate the outcome of SFS-pTHAs after 13 years (2011-2023) of monitoring and, 2) to evaluate concerns regarding the increasing use of these femoral implants in older patients.
Hypothesis: This multicentre study indicates that use of SFS in pTHA is safe at mid-term in a French orthopaedic community.
Material & methods: As of December 31, 2023, a total of 5,876 SFS-pTHAs were registered, mostly for primary osteoarthritis (4,866, 82.8%). The mean patient age was 68.7 years (SD, 11.4) with a slight female majority (3,046, 52%). Of the 14 registered SFS brands, only one (489 AMIStem C™/5,876 hips, 8.3%) was cemented. Among 733 revisions linked to a previously registered pTHAs after an average follow-up (FU) of 4.7 years, 64 (8.7%) were SFS-THAs, including 59 cementless and 5 hybrids (stem cemented) constructions. SFS performance was assessed by calculating the revision percent observed component year (Rp100ocy, with an alert threshold if >1.3) and by comparing SFS and conventional femoral stems (CFS) using Kaplan-Meier (KM) cumulative revision risk estimates.
Results: The leading causes of early revision among the 64 SFS-rTHAs were hip dislocation (17/64, 26.6%), periprosthetic fractures (11/64, 17.2%), aseptic loosening (10/64, 15.6%), and acute deep infection (7/64, 10.9%). The Rp100ocy for cementless and cemented SFS-pTHAs was 0.25 (95%CI: 0.19-0.31) at 4.4 years, and 0.24 (95%CI: 0.10-0.57) at 4.2 years, respectively. At 10 years, cumulative revision rates by KM were: 1 (95% CI: 0.4-2.5) for cemented SFS-THA, 1.3 (95% CI: 1.1-1.5) for cemented CFS, 1.4 (95% CI: 1.1-1.9) for cementless SFS, and 1.9 (95% CI: 1.7-2.1) for cementless CFS. The overall Rp100ocy for SFS-pTHAs was 0.246 (CI: 0.193-0.315) at 4.4 years, and 0,245 for CFS-pTHAs (CI: 0.227-0.264) at a 1-year longer follow-up (5.5 years). The revision risk for periprosthetic fracture was 17.2% (11/64) for SFS and 24.5% (164/669) for CFS-pTHAs, that is not significant (p = 0.2).
Discussion: Dislocation was the primary reason for revision in this SFS-pTHA series, despite the use of dual mobility cups (DMC) in 36.7% of primary cases, followed by periprosthetic fracture. Ten-year survival of SFS-pTHAs is comparable to that of CFS-pTHAs. This 13-year multicenter monitoring raises no significant concerns regarding SFS use in pTHA, even with increasing use in older patients.
Level of evidence: III; prospective comparative study.
Introduction: Many factors intrinsic and extrinsic are known to influence the clinical result after rotator cuff repair. Achieving tendon healing is one of the objectives in surgical repair of the rotator cuff, and many factors could influence this healing. After one-year post-op, assessment of tendon healing can guide management if clinical examination reveals persistent pain or unsatisfactory mobility. Despite non-healing being known to be associated with poorer outcome in massive tear, it has not been clearly established that tendon healing has influence on the clinical outcome in the case of isolated distal ruptures. Therefore we performed a retrospective study aiming to determine whether if there is difference in clinical outcomes between healed and non-healed patients at one year follow up after isolated supraspinatus distal repair?
Hypothesis: We hypothesized that tendon healing status at one year has no impact on clinical outcomes.
Materials and methods: A retrospective comparative study was conducted in 203 patients who undergo repair of isolated distal supraspinatus tendon tear. Healing was assessed at 1 year on MRI using the Sugaya classification. Stages I, II and III counting as "healed". Two groups were compared between 186 "healed" (107 females, 79 males) and 17 "non-healed" patients (9 females, 8 males). We analyzed evolution of Constant score and its subscores (pain, activities of daily living, motion and strength components), anterior elevation and lateral rotation at 6 weeks, 3 months, 6 months and results at one year follow up.
Results: There were no significant between the two groups in demographic data and surgical procedures. We found no significative differences during evolution at one year of follow up in global Constant score (healed, 73.7 ± 17.6; non-healed, 72.4 ± 15.6 (p = 0.72)) or its components: pain (11.3 vs 10.9 (p = 0.78)), activities of daily living (8.2 vs 8.3 (p = 0.85)), motion (35.4 vs 32.2 (p = 0.09)), strength (10.8 vs 10.1 (p = 0.59)), and anterior elevation (165.6 ° vs 163.2 ° (p = 0.65)) or lateral rotation (58.6 ° vs 58.7 ° (p = 0.98)).
Discussion: Healing showed no clinical impact in isolated distal supraspinatus tendon repair at one year follow up in Constant score analysis and in pain, activities of daily living, strength or motion. Factors which could influence healing, and the absence of result are not clear. Even so, tendon healing is a prime objective, as it has been shown to prevent lesion extension and long-term clinical deterioration. Many studies have sought to improve intra- or post-operative healing, by improve surgical technique of repair and biological supplements. Further studies are needed to improve these results.
Level of evidence: IV; retrospective study.
Background: Hip osteoarthritis in young patients, particularly when related to developmental dysplasia of the hip or cam-type femoroacetabular impingement, poses complex therapeutic challenges, and while isolated arthroscopic treatments show promising outcomes in borderline cases, the effectiveness of combining arthroscopic shelf acetabuloplasty with femoroplasty and labral repair remains insufficiently documented. Therefore we performed a retrospective investigation aiming to evaluate the functional outcomes of combined treatment using arthroscopic shelf acetabuloplasty based on the Chiron et al. technique and cam-type femoroacetabular impingement correction for patients with mild and borderline hip dysplasia.
Hypothesis: After a mid term follow up combined surgery led to a satisfactory improvement in clinical and radiological parameters.
Patients and methods: This retrospective study involved a continuous cohort of 13 patients undergoing combined surgery for arthroscopic shelf acetabuloplasty and cam-type femoracetabular impingement correction at a minimum of twenty-two months follow up. Clinical and radiographic assessments were made pre- and post-operatively, including validated tools such as the femoral epiphyseal acetabular roof index, Tönnis grading, Cliff sign and iHot-12 scores for functional outcomes. The intraoperative findings were also reported, as well as complications and reoperation.
Results: At a mean follow-up of 27.2 ± 3.7 months (range, 22-34 months), there was a trend toward improvement in iHOT-12 scores, which did not reach statistical significance (mean Δ +27.2/100 (p = 0.084)), and overall patient satisfaction was favorable (6.9 ± 2.9 out of 10). The lateral center-edge angle increased significantly from 17.4 ± 3.4 ° (range, 14-25) to 39.9 ± 3.8 ° (range, 32-45), while the alpha angle decreased significantly from 61.4 ± 10.0 ° (range, 44-78) to 43.0 ± 6.5 ° (range, 34-54). Postoperative complications included one nonunion (7.7%), partial shelf lysis / remodeling in 6 of the 13 patients (46.2%) of patients and hardware discomfort necessitating removal in 12 of the 13 patients (92.3 %).
Discussion: The preliminary findings of this study indicate that the combined approach of arthroscopic shelf acetabuloplasty with cam-type femoroacetabular impingement correction is a promising treatment option for patients with mild and borderline hip dysplasia with concomitant cam-type femoroacetabular impingement. This approach can lead to improvements in functional scores, normalised radiographic parameters, and acceptable patient satisfaction. Nonetheless, there was a high rate of complications and reoperations, mostly due to hardware-related discomfort.
Level of evidence: IV; Retrospective cohort study.
Introduction: Injuries to the posteromedial corner of the knee are common and often require surgical reconstruction. This cadaveric study aimed to compare three reconstruction techniques-Lind, LaPrade, and Versailles-in terms of valgus laxity control, as well as internal and external rotational stability.
Hypothesis: Authors hypothesized that the three posteromedial reconstruction techniques-Versailles, Lind, and LaPrade-would provide comparable restoration of valgus and rotational stability when performed anatomically.
Materials and methods: Fifteen cadaveric knees were tested to compare the three surgical techniques. Valgus laxity in full extension, external rotation at 30 ° (dial test), and internal rotation in extension were measured in three conditions: intact knee, after sectioning of the posteromedial corner and the medial collateral ligament (superficial and deep layers), and after anatomical posteromedial reconstruction using one of each technique.
Results: No significant differences in valgus laxity in full extension were found among the three techniques in the intact, sectioned knees, meaning that the specimens were comparable. After sectioning, valgus laxity increased significantly in all specimens from 6.92 mm to 12.98 mm for Lind, 6.52 mm-12.58 mm for Versailles, and 6.53 mm-12.3 mm for LaPrade. After reconstruction, valgus laxity was restored in all three groups without significant differences compared to the intact knee (p = 0.25), with values of -1.76 mm, -1.35 mm, and -1.16 mm for Lind, LaPrade, and Versailles techniques, respectively. Similarly, no significant differences were observed in external rotation at 30 ° or internal rotation in extension among the three groups: intact knee (p = 0.14, p = 0.47), sectioned state (p = 0.83, p = 0.36), and after reconstruction (p = 0.071, p = 0.17). External and internal rotational stability were restored without significant differences compared to the intact state (p = 0.11, p = 0.15).
Conclusion: Two anatomic reconstructions (Versailles, LaPrade) and one anatomy-aligned technique (Lind) achieved comparable restoration of valgus stability in extension and rotational control.
Level of evidence: IV; cadaver study.
Background: Although surgical correction of hallux valgus (HV) is the most common procedure in foot surgery, nearly one-third of patients express dissatisfaction, primarily due to lack of correction or recurrence. Reported recurrence rates in the literature vary widely, ranging from 2% to 72%. Accurately estimating the prevalence of recurrence is challenging due to the lack of a consensus on its definition and the heterogeneity of the surgical techniques studied. While recurrence can be a slowly progressive phenomenon, most published cohorts have a postoperative follow-up limited to only one or two years. The aims of this study were 1) to assess the radiologic recurrence rate of HV following Scarf osteotomy, with a minimum follow-up of 8 years. 2) to identify factors associated with recurrence.
Hypothesis: At long-term follow up, hallux valgus recurrence is common.
Materials and methods: A retrospective observational study was conducted, including patients who underwent Scarf osteotomy for hallux valgus correction between January 2001 and January 2014. During this period, 3450 patients underwent Scarf osteotomy for HV correction. Among them, 237/3450 (6.9%) had complete medical records and were included in the analysis. The primary outcome was radiologic recurrence, defined as a hallux valgus angle (HVA) exceeding 20 degrees.
Results: At a mean follow-up of 12.2 ± 2.77 years, the recurrence rate was 15.2% (36/237). Mean HVA was 10.53 ± 8 degrees. The identified factors associated with recurrence included the severity of the preoperative deformity (HVA, p < 0.001; sesamoid position, p < 0.001; Intermetatarsal angle, p = 0.018) and the quality of postoperative correction (HVA, p<0.001; sesamoid position, p = 0.0031 and MTP1 joint congruency, p = 0.0037).
Discussion: Over the long term, recurrence of hallux valgus following Scarf osteotomy is a frequent phenomenon, particularly in patients presenting with more severe preoperative deformities. These results may allow for appropriate patient information about long-term recurrence before surgery, even though the recurrence rate is likely underestimated, since only 6.9% of patients benefited from long-term follow-up in this retrospective study.
Level of evidence: III; Retrospective cohort study.
Background: Endoscopic flexor hallucis longus (FHL) tendon transfer is now a common technique for the treatment of chronic Achilles tendon ruptures. In most cases, the FHL is harvested in zones 1-2 and fixed using an interference screw within a vertical calcaneal tunnel. To enhance fixation we developed an original technique involving fixation of the FHL by tenodesis in a horizontal calcaneal tunnel combined with tendon-to-tendon suturing. The aim of this study was to evaluate the outcomes of endoscopic FHL transfer with fixation using a tenodesis screw in a horizontal calcaneal tunnel combined with tendon-to-tendon suturing regarding: (1) iterative rupture and complications, (2) Pain and function according to European Foot and Ankle Society (EFAS) score, (3) return to work and participation is sports.
Hypothesis: This method of FHL transfer would provide satisfactory functional results and enable early return to activities.
Material and methods: Thirty-six patients operated between January 2019 and June 2023 were assessed retrospectively after a mean follow-up of 38 months (range, 12-58 months). The cohort consisted of 30 men and 6 women, with a mean age of 53.6 years (range, 16-76 years) at the time of surgery. Seven cases (19.4%) involved iterative ruptures, and 29 cases (80.6%) involved chronic ruptures. All procedures were performed by the same surgeon using the same FHL transfer technique. The Visual Analog Scale (VAS) for pain and the European Foot and Ankle Society (EFAS) score were used as primary outcome measures.
Results: At the final follow-up, the median VAS decreased from 7 (Inter Quartile Range (IQR), 6-8) preoperatively to 0 (IQR, 0-1.3) (p < 0.001), and the EFAS score improved from 8 (IQR, 4.8-10) to 32 (IQR, 29.5-35,3) (p < 0.001). Three surgical revisions were required for infection (8.3%). Two patients (5.6%) developed complex regional pain syndrome type 1, and three patients (8.3%) reported disabling plantar dysesthesias. No secondary graft rupture was observed. The return-to-work rate among active patients was 100%, with a median time of 3 months. Among athletes, 75.9% (22/29) resumed sports activity, with a mean postoperative Victorian Institute of Sport Assessment - Achilles (VISA-A) score of 69.2/100 (range, 44-100). Only one patient reported dissatisfaction with the surgical outcome.
Discussion: Endoscopic FHL transfer with double fixation appears to be a safe and reliable technique, allowing rapid return to work and sports activities.
Level of evidence: IV; retrospective cohort study.
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