Balancing the flexion gap first in total knee arthroplasty leads to better preservation of posterior condylar offset resulting in better knee flexion.

PURPOSE: The purpose of this study is to determine whether the flexion first balancing technique, developed in an attempt to solve the dissatisfaction due to instability in total knee arthroplasties, leads to better restoration of joint line height and medial posterior condylar offset. This might result in better knee flexion, compared to the classic extension first gap balancing technique. The secondary objective is to show non-inferiority of the flexion first balancing technique in terms of clinical outcomes as measured by the Patient Reported Outcome Measurements. METHODS: A cohort of 40 patients (46 knee replacements) operated using the flexion first balancing technique was retrospectively analyzed and compared with a cohort of 51 patients (52 knee replacements) operated using the classic gap balancing technique. Radiographic analysis of the coronal alignment, joint line height and posterior condylar offset was performed. Clinical and functional outcome data were analyzed pre- and postoperatively and compared between both groups. The two sample t test, Mann-Whitney U test, Chi-square test and a linear mixed model were used for performing statistical analyses, after normality analyses were executed. RESULTS: Radiologic evaluation showed a decrease in posterior condylar offset using the classic gap balancing technique (p = 0.040) versus no change using the flexion first balancing technique (p = n.s.). No statistically significant differences were noted for joint line height and coronal alignment. Using the flexion first balancer technique leads to a greater postoperative range of motion with deeper flexion (p = 0.002) and a better Knee injury and Osteoarthritis Outcome Score (KOOS) (p = 0.025). CONCLUSION: The Flexion First Balancing technique is a valid and safe technique for TKA, resulting in better preservation of PCO with consequently greater postoperative flexion and better KOOS scores. LEVEL OF EVIDENCE: III.

Medium-term outcome with contemporary mobile-bearing implants : results from a retrospective multicentre study.

Previous studies report good clinical outcomes with the initial mobile-bearing implant design in TKA. Nevertheless clinical data on the subject system are scant and information is lacking to fully appraise the safety and performance of the subject device. A population of 283 consecutive patients who received 307 primary Vanguard ROCC TKAs over a 5.5-year period was retrospectively assessed. At follow-up, Knee Society Scores, Forgotten Joint Scores and Knee injury and Osteoarthritis Outcome Scores were obtained, and patients underwent radiographic evaluation at 4.9 ± 1.0 years post-implantation. Survival analyses included the following endpoints : revision of the tibial or femoral component for any reason, and revision of any component for any reason. At a mean follow-up time of 5.0 (range, 3.0-8.2) years, 166 patients (183 TKAs) were available for clinical assessment. All postoperative clinical scores were deemed satisfactory. Survival with revision of the tibial and/or femoral component for any reason was 97.3% (95%, 94.5-98.7%) at 6 years. Radiolucent lines were observed in 32 (17.7%) out of 181 knees. The present study showed that the Vanguard ROCC system demonstrates favourable clinical outcome with satisfactory medium-term survival.

Vitamin D, calcium and albumin bloodserum levels in Belgian orthopedic patients - is systematic screening justified?

In the setting of fracture care, orthopedic surgeons are primarily focused on treating the fracture itself, but more and more attention is being paid to prevention of such fractures and identifying risk factors associated with worse postoperative prognoses. In our study we collected postoperative vitamin D, calcium and albumin bloodserum levels from 163 patients who were admitted with a femur fracture and from 233 patients who were admitted for an elective hip arthroplasty during the period of 365 days. Results : 84.21% of the fracture population had a vitamin D deficiency (< 20 ng/mL) as well as 77.30% of the elective hip arthroplasty population. There were no significant seasonal differences in the fracture population. 80.27% of the fracture population had an albumin deficiency (< 29 g/L) compared to 38.75% of the reference population. There were no significant statistical differences in vitamin D and albumin bloodserum levels between the under 75 years old age group and the over 75 years old age group. We can make the tentative assumption that systematic screening for all hip fracture patients and all elective hip arthroplasty patients admitted to our orthopedic ward - independent of their age, season or pathology - is justified and we advise other hospitals to implement this as well.

Surgical Indications and Technique for Anterior Cruciate Ligament Reconstruction Combined with Lateral Extra-articular Tenodesis or Anterolateral Ligament Reconstruction.

After anterior cruciate ligament (ACL) rupture, anteroposterior and rotational laxity in the knee causes instability, functional symptoms, and damage to other intra-articular structures. Surgical reconstruction aims to restore the stability in the knee, and to improve function and ability to participate in sports. It also protects cartilage and menisci from secondary injuries. Because of persistent rotational instability after ACL reconstruction, combined intra-articular and extra-articular procedures are more commonly performed. In this article, an overview of anatomy, biomechanical studies, current gold standard procedures, techniques, and research topics are summarized.

Long-term Subjective, Clinical, and Radiographic Outcome Evaluation of Meniscal Allograft Transplantation in the Knee.

BACKGROUND: Although meniscal allograft transplantation (MAT) has been performed for nearly 30 years, there are few long-term published studies of the technique. HYPOTHESIS/PURPOSE: The goal of this study was to report the long-term results of a patient cohort whose medium-term results have been reported and to evaluate whether the results are maintained in the long term or deteriorate after a certain period. The hypothesis was that the subjective, clinical, and radiographic results are consistent in the long term without significant deterioration. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty patients from the original cohort of 49 patients (50 MATs) who underwent MAT at least 9 years before this study were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS); Lysholm, Tegner, and Short Form-36 scores; and a visual analog score for pain. A standardized clinical examination was performed to objectively evaluate knee-related symptoms. Standard weightbearing radiographs, including a full-leg standing radiograph, were performed to evaluate joint space narrowing and any progression of osteoarthritis and malalignment. These results, at a mean follow-up time of 12 years and 8 months (152 months; range, 112-216 months), were compared with the preoperative data and the outcome results at medium-term follow-up (mean, 8 years and 9 months). RESULTS: Of the original 49 patients, 6 (12.2%) required conversion to a total knee arthroplasty during the study period and were considered failures, and 17 (34.7%) required a second surgical procedure during the study period. Excluding the 6 total knee arthroplasty cases, 90% of patients reported being very satisfied or satisfied and would undergo the procedure again. Only 1 patient reported not wanting to undergo the procedure again. Results of the visual analog score, KOOS and all KOOS subscales, Lysholm, and Short Form-36 all showed a statistically significant improvement at estimated follow-up periods of 7.5 and 12.5 years compared with preoperative scores. There was no statistically significant difference for these scores between 7.5 and 12.5 years postoperatively. Despite the improvement in outcome scores, the Tegner activity level score remained unchanged during the entire follow-up period. Regarding radiographic outcomes, there was a progressive increase in the Kellgren-Lawrence rating over the study period. There was a statistically significant (P = .0208) progressive joint space narrowing between estimates at the 7.5-year (5.45 mm) and 12.5-year (4.95 mm) follow-up. However, there was no statistically significant (P = .6724) difference in absolute value of alignment deviation from the 0° mechanical axis between 7.5 years (2.32°) and 12.5 years (2.51°) postoperatively. There was no difference between medial and lateral transplants. CONCLUSION: Despite an increase in joint space narrowing, MAT resulted in significant improvements in pain and functional outcomes over the study period. There was no change in these improvements between the medium- and long-term follow-up period. This study confirms the good and consistent results found in the literature concerning satisfaction, pain resolution, and functional scores at long-term follow-up.

Taper corrosion in modular hip prostheses: analysis of serum metal ions in 19 patients.

Recently, concerns have been raised about the use of metal-on-metal (MoM) implants. This has led to the recall of several resurfacing and large-diameter total hip arthroplasties (THA). Any MoM interface can be the cause of metal debris and adverse tissue reactions. We analyzed serum metal ions and HOOS scores in 19 of 306 patients treated with a THA with modular neck section. The only MoM interface in this particular implant is the taper between the neck and the stem. The articulating surface consists of a ceramic-on-polyethylene or ceramic-on-ceramic interface. As such, this study looks at the metal ion production from the modular neck section. One of 306 implants needed revision at 52-month follow-up because of an adverse reaction to metal debris (ARMD).

Functional and radiographic short-term outcome evaluation of the Visionaire system, a patient-matched instrumentation system for total knee arthroplasty.

Patient matched instrumentation is a new operative tool in the field of total knee arthroplasty. Custom made cutting blocks are designed to perform distal femoral and tibial bone cuts according to a pre-operative planning. This study evaluates the Visionaire system of Smith & Nephew. Thirty-one patients, operated with the Visionaire technique, were compared to an equal control group for different clinical and radiographic outcome parameters. Between both groups, no statistical significant difference could be found in post-operative pain, satisfaction, functional outcome, hospital stay, blood loss, radiographic alignment and precision of bone cuts. Only tibial plateau backslope can be created with more precision in the Visionaire group. But there was a statistical significant difference for residual flexion deformity after a mean follow-up time of 200 days.

Osteochondral defect in femoral head: Trufit implantation under fluoroscopic and arthroscopic control.

Under arthroscopic control and guided by fluoroscopy, a Trufit Plug was successfully implanted to repair an osteochondral lesion of the head of the femur. The procedure was evaluated clinically using the HOOS score and Magnetic Resonance Imaging (MRI) of the hip. The short-term (6 months) clinical results are encouraging: the HOOS score improved clearly and the patient was satisfied. Interpretation of MRI images in the early post-operative period is very difficult: in the early months history and clinical examination prevail in the evaluation.

Functional and radiographic medium-term outcome evaluation of the Humerus Block, a minimally invasive operative technique for proximal humeral fractures.

BACKGROUND: Conservative treatment of severe displacement of proximal humeral fracture fragments yields bad functional results, but open operative techniques have a high risk of avascular necrosis of the humeral head. We performed a medium-term outcome evaluation of the Humerus Block (Synthes, Oberdorf, Switzerland), a minimally invasive technique used in selected patients with proximal humeral fractures, to investigate the functional and radiographic outcome. MATERIALS AND METHODS: Of 47 patients operated on with the Humerus Block, 34 with a minimum follow-up of 30 months and a mean follow-up of 4 years and 4 months, were invited for interview, radiographic evaluation, and functional analysis by the Constant, Disabilities of Arm, Shoulder and Hand (DASH) and the University of California, Los Angeles (UCLA) scorings. Paired t test was used to investigate equivalence of the geometric mean scores of the trauma and control arm, for the scores of the functional analyses, and for the scores for mobility of the shoulder. RESULTS: Scorings and clinical examination showed that 85% of shoulder function and motion were preserved compared with the control arm. Radiographic evaluation showed very good healing and positioning of the fracture fragments, and only 10% developed avascular necrosis of the humeral head. CONCLUSIONS: With very satisfied patients; good clinical, functional, and radiographic outcomes; a short hospital stay; few complications; a reduced cost of implant; and a low incidence of avascular necrosis, this technique is a valuable alternative for operative treatment of proximal humeral fractures.

Arthroscopically assisted meniscal allograft transplantation in the knee: a medium-term subjective, clinical, and radiographical outcome evaluation.

BACKGROUND: Allograft meniscal transplantation is known as a possible procedure to solve pain and loss of function in the knee of patients with a history of subtotal or total meniscectomy. PURPOSE: This work was undertaken to evaluate, using subjective questionnaires and clinical and radiographical scores, patients who underwent an arthroscopically assisted meniscal allograft transplantation with a minimum follow-up between 5 and 15 years (range, 62-169 months). STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Demographic data of 49 patients (50 meniscal allograft transplantations) were collected. At the latest follow-up visit, the authors collected preoperative and follow-up Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and Short Form 36 (SF-36) scores, and visual analog scale (VAS) scores for pain for comparison. Patients were also evaluated with a standardized clinical examination of the knee to objectively evaluate knee-related symptoms. Standard weightbearing radiographs and a full-leg standing radiograph were performed to evaluate the progression of osteoarthritis and malalignment. RESULTS: Five patients underwent total knee replacement and were considered failures, 8 patients could only be contacted by phone, and 2 patients were lost to follow-up, so 34 patients underwent the complete study protocol (except for 1 patient who did not have a radiographical evaluation because of pregnancy). The study group consisted of 18 men and 16 women, with a mean age of 33 years at the moment of transplantation and with an average follow-up of 8 years and 9 months. There were only a few concomitant procedures. There was a significant (P < .001) and clinically relevant decrease in the VAS (7 to 3.4) and increase in KOOS (35.8 to 60.2), Lysholm (39.7 to 71.8), and total SF-36 (51.5 to 75.2) from preoperative mean score to postoperative mean score. This improvement stayed consistent during the follow-up period. Despite this improvement, there was no increase in Tegner activity level (P = .604). The more severe the osteoarthritis, the less the improvement. There was a significant (P < .001) increase in osteoarthritis in 42% of the patients (14 of 33), as scored following the Kellgren-Lawrence classification. When strictly respecting the indications, there was no significant correlation between preoperative cartilage damage, preoperative osteoarthritis, alignment deviation, gender, and body mass index and the outcome scores or improvement. In this series, with few concomitant procedures, there was no difference in outcome between medial and lateral transplants. CONCLUSION: Meniscal allograft transplantation may result in important pain relief and functional improvement in patients with a history of (sub)total meniscectomy and pain localized in the affected compartment. Strictly following the indications, meniscal transplantation can give good and predictable results. In 58% of patients, there was no increase in osteoarthritis according to the Kellgren-Lawrence classification. In 42%, there was a slight or moderate increase in osteoarthritis. No severe increase was noted.