Showing papers in "Orthopaedics & Traumatology-surgery & Research in 2012"

Treatment of posttraumatic bone defects by the induced membrane technique

Abstract: Summary Introduction Among bone reconstruction techniques, the induced membrane technique, proposed in 1986 by Masquelet, has rarely been studied or evaluated in the surgical literature until recently. The 2010 French Society of Orthopaedic Surgery and Traumatology (SoFCOT) Annual Convention symposium was the occasion to evaluate a large cases series having used this technique. Patients and methods This retrospective study included 84 posttraumatic diaphyseal long bone reconstructions using the induced membrane technique (1988–2009). The series included 79 men and five women (mean age 32-year-old). In 89% of cases, the initial trauma was an open fracture. The leg was involved in 70% of cases. The mean delay between the accident and treatment of bone defects (BD) was 8 months. In 50% of the cases, infection was present. Bone defects were larger than 5 cm in 57% of the cases. Results Union was obtained in 90% of cases, a mean 14.4 months after the first stage of the reconstruction. A mean 6.11 interventions were necessary to obtain union. Malalignment was present in 17% of cases. Delayed interventions to correct deformities mostly of the foot were necessary in 16% of the cases. Eight failures (10%) involved severe leg traumas associating extensive bone defects, soft tissue lesions and infection and required amputation in six cases. Discussion This series emphasizes the severity of open fractures of the leg, especially those with primary or secondary infection. The induced membrane technique has been shown to be effective in treating bone defects, regardless of their magnitude. In a two-step procedure, this simple but demanding technique, which may be more complicated when repair of soft tissue is necessary, provides successful treatment in case of initial infection and fulfills the goal of controlling infection before bone reconstruction. Moreover, the induced membrane technique can be integrated in hybrid reconstruction procedures. Level of evidence Level IV. Retrospective study.

Epidemiology of proximal humerus fractures managed in a trauma center

Abstract: Proximal humerus fractures (PHF) are osteoporotic fractures that affect women over 70 years of age. Like fractures of the femoral neck they have become a public health concern. As the population ages there is an increase in the number of people in poor general condition with an increased risk of falls on fragile bones. The incidence of these fractures has increased by 15% per year. All patients managed for PHF in our center in the past year were included in this prospective study (prospective cohort study; level 2). Three hundred and twenty-five patients were included with 329 fractures. There was a ratio of two women to one man. At the final follow-up 50 patients had died (15%) and 25 patients were lost to follow-up. The mean age was 70 years old. There were two types of risk factors. The first was fragile bones, and the second was patient specific risk of falls. The severity of the fracture increased with the age of the population. In the study by Charles S. Neer in 1970, 85% of PHF were not or were only slightly displaced, while this category percentage was only 42% in our study. Hospitalization was necessary in 43% of the cases in our study. Surgical management was necessary in 21%. This lack of relationship between the percentage of displaced fractures (58%) and the percentage of surgically treated fractures is a sign of the difficulties of managing this population, which is usually in poor general condition.

Unicompartmental knee arthroplasty modes of failure: Wear is not the main reason for failure: A multicentre study of 418 failed knees

Abstract: Summary Background This study originated from a symposium held by the French Hip and Knee Society (Societe francaise de la hanche et du genou [SFHG]) and was carried out to better assess the distribution of causes of unicompartmental knee arthroplasty (UKA) failures, as well as cause-specific delay to onset. Hypothesis Our working hypothesis was that most failures were traceable to wear occurring over a period of many years. Materials and methods A multicentre retrospective study (25 centres) was conducted in 418 failed UKAs performed between 1978 and 2009. We determined the prevalence and time to onset of the main reasons for revision surgery based upon available preoperative findings. Additional intraoperative findings were analysed. The results were compared to those of nation wide registries to evaluate the representativeness of our study population. Results Times to revision surgery were short: 19% of revisions occurred within the first year and 48.5% within the first 5 years. Loosening was the main reason for failure (45%), followed by osteoarthritis progression (15%) and, finally, by wear (12%). Other reasons were technical problems in 11.5% of cases, unexplained pain in 5.5%, and failure of the supporting bone in 3.6%. The infection rate was 1.9%. Our results were consistent with those of Swedish and Australian registries. Discussion Our hypothesis was not confirmed. The short time to failure in most cases suggests a major role for surgical technique issues. Morbidity related to the implant per se may be seen as moderate and not greater than with total knee prostheses. The good agreement between our data and those of nationwide registries indicates that our population was representative. A finer analysis is needed, indicating that the establishment of a French registry would be of interest. Level of evidence Level IV, retrospective study.

Accuracy of the preoperative planning for cementless total hip arthroplasty. A randomised comparison between three-dimensional computerised planning and conventional templating

Abstract: Summary Introduction A high accuracy was recently reported for the three-dimensional (3D) computerised planning of total hip arthroplasty (THA), comparing well with navigation regarding leg length and femoral offset. However, there is no randomised study comparing 3D preoperative planning with conventional 2D templating in terms of accuracy and clinical relevance. Hypothesis The 3D preoperative planning has a higher accuracy than the conventional 2D preoperative templating regarding the implants size and their positioning. Patients and methods A prospective comparative randomised study was carried out from 2008 to 2009, including two groups of 30 patients who underwent THA for primary osteoarthritis. One surgeon performed all the surgical procedures using a minimally invasive direct anterior approach. In one group, the planning was made on calibrated X-rays using 2D templates. In the other group, a CT-scan based 3D computerised planning was performed with dedicated software. The reconstructed hip final anatomy was compared postoperatively to the preoperative planning and the accuracy was expressed as the mean difference (± SD) between the planned positioning and the final positioning of the implants. Results The prediction rate for the stem and the cup sizes were respectively of 100% and 96% in the 3D group versus 43% for both components in the 2D group. When combining both components, the prediction rate was 96% in the 3D group versus 16% in the 2D group. In the 3D group, a high accuracy was achieved for the planning of the leg length (−1.8 ± 3.6 mm ranging from −8 to + 4 mm) and the femoral offset (−0.07 ± 2.7 mm ranging from −5 to + 4 mm) versus 1.37 ± 6.4 mm ranging from −9 to 13 mm and 0.33 ± 5.7 mm (−16 to 11 mm) in the 2D templating group (P Discussion The 3D planning gives a higher accuracy than conventional 2D templating in forecasting the size of cup and the stem. This contributes to the prediction for leg length and offset that is more reliable with the 3D technique. This study suggests that 3D planning CT-scan data is an attractive alternative to navigation to restore these parameters. The high accuracy achieved by a low-experience surgeon suggests that 3D planning may help shorten the learning curve when using the minimally invasive direct anterior approach. Level of evidence Level III low-powered prospective randomized trial.

Dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. A prospective, systematic, multicenter study with specific focus on postoperative dislocation

Abstract: Summary Introduction Displaced fractures of the femoral neck in the elderly are best treated with arthroplasty. The type of arthroplasty to be used, either hemi- or total hip arthroplasty, remains controversial as total hip replacements potentially have a higher rate of dislocation. Hypothesis Dual mobility cups have a low dislocation rate when used to manage acute fractures of the femoral neck. Patients and methods In a multicenter prospective study conducted in France over an inclusion time of 3 months, all displaced fractures of the femoral neck treated with arthroplasty were operated on with insertion of a dual mobility cup. Patients had clinical and radiological assessment at 3, 6, and 9 months postoperative. Results Two hundred and fourteen hips in 214 patients with a mean age of 83 years (range, 70–103 years) were included. None of the patients was lost to follow-up. The mortality rate after 9 months was 19%. Two patients (1%) had early postoperative infection successfully treated with lavage and antibiotics. Three patients (1.4%), operated through a posterior approach, presented one postoperative dislocation, all of which were posterior. Reduction was performed through closed external manipulation under general anesthesia. There was no recurrence of dislocation. Discussion This low rate of dislocation after acute total hip replacement using dual mobility design cups favorably compares with hemiarthroplasties. Dual mobility cups might therefore be considered a valuable option to prevent postoperative dislocation when treating displaced intracapsular fractures of the proximal femur in elderly patients if a total hip replacement is recommended. Further study is needed before extending the indications for total hip arthroplasty following a fracture of the femoral neck, to assess the potential cost and complications of a longer procedure with its potential acetabular complication, and weigh them against the potential benefits. Level of evidence Level III prospective, case study.

Infected total hip arthroplasty revision: one- or two-stage procedure?

Abstract: Summary Introduction Better outcomes have been reported for two-stage total hip arthroplasty (THA) revision for infection. However, one-stage revision arthroplasty remains an attractive alternative option since it requires only one operation. A decision tree has been developed by the authors in order to determine which type of surgical procedure can be performed safely. The goal of this study was to assess this decision tree for THA replacement in the case of a peri-prosthetic infection. Hypothesis A one-stage procedure may be as successful as a two-stage procedure provided some criteria are fulfilled. Methods A prospective study included 84 patients, all diagnosed with infected THA who had prosthesis replacement. A one-stage exchange was performed in 38 cases and a two-stage procedure in 46 cases. A two-stage procedure was decided in the case of important bone loss or unidentified germ. Postoperatively, patients received intravenous antibiotics (six weeks), then oral antibiotics (six weeks). The main evaluation criterion was the rate of infection eradication at 2 years minimal follow-up since surgery. If new infection was suspected, a hip aspiration was performed to determine whether it was non-eradication (same germ) or a new re-infection (other germ), which was not considered as a failure. Results The initial infection was cured in 83 out of 84 patients (98.8%), 38 (100%) for the one-stage group and 45 (97.8%) for the two-stage group. Three patients were re-infected with different germs in the two-stage group. Eighty out of 84 (95.2%) patients were infection free, all patients (100%) of the one-stage group and 42 patients (91.3%) of two-stage group. Discussion If some selection criteria were respected, a high success rate in THA replacement for infection may be achieved with a one-stage procedure. It permits to reduce the costs with no loss of chance for the patients. The decision tree was validated. Level of evidence Level III; prospective case control study.

Bone transport techniques in posttraumatic bone defects

Abstract: Summary Introduction The treatment of posttraumatic diaphyseal bone defects (BD) calls on a number of techniques including bone transport techniques: isolated shortening, compression-distraction at the fracture site, shortening followed by lengthening in a corticotomy distant from the site and segmental bone transport. Patients and methods The multicenter retrospective study combined 38 cases: 22 cases of initial diaphyseal bone defect and 16 cases of secondary diaphyseal BD, sometimes associated with metaphyseal or metaphyseal-epiphyseal BD, involving the humerus, the forearm, the femur and the tibia. These techniques were mainly used on the lower extremity (33 cases), for the most part on the tibia (22 cases) in young men. Results Bone healing was acquired in 37 cases out of 38 after a mean 14.9 months (range, 6–62 months). A mean 4.3 secondary interventions were required to obtain final union; most notably, a bone graft was necessary at the docking site for the segmental bone transport procedures. Discussion Many reconstruction techniques can be proposed to treat posttraumatic BD. None responds to all situations. Bone transport techniques have their place and their indications. Isolated shortening is intended for bone loss not exceeding 3 cm, notably in the humerus and to a lesser degree in the lower extremity. Shortening associated with lengthening is valuable in the femur and the tibia for bone loss up to 6 cm. Segmental bone transport is the only technique that can treat bone defects associated with shortening in the lower limb. For substantial bone loss beyond 10 cm, segmental bone transport is particularly indicated. However, these cases of substantial bone loss tend to be resolved by a hybridization of the procedures. The distraction gap of a bone segment can, for example, be prepared using an induced-membrane technique. Level of evidence Level IV. Retrospective study.

Reliability of a new method for lower-extremity measurements based on stereoradiographic three-dimensional reconstruction.

Abstract: Summary Introduction Several clinical and radiological techniques have been described to assess lower limb length and angle measurements. None of them has yet met the ideal criteria for a reliable, reproducible, safe, and inexpensive system. In this context, a new biplanar X-ray system (EOS™, EOS imaging, Paris, France) makes it possible to obtain a 3D reconstruction of the lower extremities from two 2D orthogonal radiographic images, with associated calculation of 3D measurements. The reliability of this technique has never been documented on adults. Hypothesis Lower limb measurements produced by the 3D EOS™ reconstruction system are reproducible regarding inter- and intraobserver assessment and more reliable with this 3D technique than when they are obtained from 2D measurements. Materials and methods This study included 25 patients awaiting total hip arthroplasty (50 lower limbs). Two independent observers made all measurements twice, both on the 2D frontal radiograph and using 3D reconstructions (femoral measurements of length, offset, neck shaft angle, neck length, and head diameter, as well as the tibia length, limb length, HKA and HKS). Reproducibility was estimated by intraclass correlation coefficients. Results Both the inter- and intraobserver reproducibility of the EOS™ measurements was excellent; more specifically inter- and intraobserver reproducibility was 0.997 and 0.997 for femoral length, 0.996 and 0.995 for tibial length, 0.999 and 0.999 for limb length, 0.894 and 0.891 for HKS, 0.993 and 0.994 for HKA, 0.870 and 0.845 for femoral offset, and 0.765 and 0.851 for neck shaft angle. For most of the variables, the interobserver correlations were statistically better with the EOS™ 3D reconstruction. Discussion Our results show that the EOS™ systems allow reproducible lower limb measurements. Furthermore, 3D EOS™ reconstructions offer better reproducible measures for most of the parameters than radiographic 2D projection. Its use before deciding on surgery and during planning for lower limb arthroplasty appears essential to us. Level of evidence Level III: diagnostic prospective study on consecutive patients.

Three-dimensional measurement method of arthritic glenoid cavity morphology: feasibility and reproducibility.

Abstract: Summary Introduction Glenoid component loosening is the main complication of total shoulder arthroplasty. Better knowledge of the arthritic glenoid cavity anatomy can help in developing new implants and techniques. The goal of this study was to describe and validate the reproducibility of a CT scan-based, 3D measurement method used to describe various parameters characterizing arthritic glenoid cavity morphology. Materials and methods Twelve CT scans and 29 CT arthrogram were evaluated. These scans were taken from 41 patients with glenohumeral osteoarthritis who received an anatomical shoulder prosthesis. A 3D reconstruction of the scapula was performed based on the DICOM files. Following the 3D volume acquisition, points on the glenoid articular surface were manually extracted by three observers, each one three times, allowing one week between readings, to determine the inter- and intra-observer reproducibility. The intraclass correlation coefficient (ICC) was calculated on five 3D parameters that were automatically calculated: glenoid height, glenoid width, height at maximum width glenoid version and radius of the articular surface best-fit sphere. Results The intra-observer and inter-observer ICC were 0.91 to 0.99, and 0.95 to 0.99, respectively. Discussion This study is the first to report on a reproducible 3D measurement method, based on CT scans, for the arthritic glenoid cavity, which derives the joint radius of curvature among other morphology parameters. These 3D measurements are advantageous because they are free of problems related to patient positioning in the CT scanner and to the choice of slices, which limits the accuracy of measurements made on slices from 2D CT scans. Three-dimensional methodology similar to ours has been validated on healthy glenoids. Conclusion This study confirms the reliability and good reproducibility of our method, which allows us to extend this method to a larger patient cohort and adapt this automated technology to preoperative planning software. Level of evidence Level 4 study.

Posterior tibial slope changes after opening- and closing-wedge high tibial osteotomy: a comparative prospective multicenter study.

Abstract: Summary Introduction: Valgus high tibial osteotomy is considered to be an effective treatment for uni- compartmental medial osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. However, the effects on posterior tibial slope of closing- or opening-wedge osteotomies remain controversial. Hypothesis: We analyzed the modifications of tibial slope after opening- and closing-wedge high tibial osteotomies and compared the results of these two procedures. We hypothesized that there was no difference in postoperative tibial slope between opening and closing-wedge osteotomies.

Axial rotation of the first metatarsal head in a normal population and hallux valgus patients.

Abstract: Summary Hypothesis Does metatarsal pronation exist and, if so, what is its impact? Introduction Hallux valgus is a deformity associating angulation and a rotational component. The present study sought to investigate the nature and origin of the coronal plane displacement. Materials and methods A prospective single-center radiological and anatomic study was conducted on 100 feet operated on for hallux valgus. Baseline X-ray determined the preoperative position of the 1st metatarsal head in the coronal plane. The range of motion (ROM) of the cuneometatarsal joint in pronation–supination was measured peroperatively. An anatomic study investigated possible diaphyseal torsion. Results Mean radiologic pronation in hallux valgus was 12.7° (range, 0°–40°). Cuneometatarsal rotational ROM was determined by adding peroperative ROM in pronation (mean, 9.3°; range, 0°–30°) and in supination (mean, 8.7°; range, 0°–20°). Intermetatarsal divergence showed no correlation with radiologic pronation or ROM in pronation. Radiologic pronation showed no correlation with peroperative ROM in pronation. Pronation of the metatarsal head was never observed without associated sesamoid pronation; the latter, however, was in some cases observed without the former. Twenty randomly selected metatarsal cadaver specimens from the anatomy laboratory of the University of Nice (France) showed diaphyseal torsion in 80% of cases, with the metatarsal head in neutral position or in supination with respect to the base. Discussion In hallux valgus, 1st ray pronation appears to be systematic, in contrast to the typical supination found in the general population. Metatarsal rotation is always associated with sesamoid rotation, whereas the converse is not the case: displacement of the sesamoids appears to displace the metatarsal head via the metatarsosesamoid ligaments. This “drive-belt” effect, however, varies in its mechanical properties and the transmission is imperfect and likely subject to progressive ligament stretching, so that head rotation does not exactly follow and may even become independent of the sesamoid displacement. Radiologic and clinical rotation thus do not match any longer. The anatomic study showed that, while diaphyseal torsion cannot be ruled out, the metatarsal pronation mainly derives from cuneometatarsal joint rotational instability, the evolution of which does not parallel lateral instability, no correlation being found between degree of varus and rotational instability. Conclusion The present study found metatarsal pronation to be associated with hallux valgus, making a preoperative AP view useful; the underlying mechanism was generally cuneometatarsal instability. Although difficult to specify exactly without correlation between radiological and clinical data, any such pronation raises the question of whether replacing the metatarsal head on its sesamoid supports is sufficient to achieve stability in all planes, or whether on the contrary derotation should be associated to metatarsal valgization osteotomy to restore horizontal support. Level of evidence Level IV.

Tranexamic acid reduces blood loss and financial cost in primary total hip and knee replacement surgery.

Abstract: Summary Background Blood conservation strategies have been developed to diminish blood transfusion requirements in patients undergoing hip or knee replacement surgery. Tranexamic acid (TA) is an inexpensive antifibrinolytic agent that is little used in orthopaedic surgery due to the absence of standardised optimal administration regimens. Hypothesis Blood transfusion requirements and induced costs can be diminished by using TA according to a standardised administration protocol in a large cohort of patients. Materials and methods A retrospective study in patients who underwent joint replacement surgery by a single surgeon compared two periods, 2007–2008 without TA and 2008–2009 with TA. The 451 included patients underwent primary unilateral hip ( n = 261) or knee ( n = 190) replacement for osteoarthritis. Standardised protocols were used for surgery and anaesthesia. TA was given intravenously in a dose of 1 g (i.e., 15 mg/kg) at incision and wound closure then at 6-hour intervals for 24 hours. Blood losses were estimated using the Mercuriali formula. Haemoglobin on D –1 and D 8 and the number and volume of autologous (from intra-operative blood salvage) and homologous blood transfusions were collected. The costs of TA, blood salvage systems, and homologous blood units were recorded. The two groups were compared using Student's test, Wilcoxon's test, and the Khi 2 test, and multivariate analyses were performed. Values of p less than 0.05 were considered significant. Results TA use was associated with a significant decrease in the homologous blood transfusion rate (from 4% to 0%) and with 38% and 68% reductions in the rate and volume of autologous blood transfusions, respectively, due to a 34% decrease in blood losses. After taking into account the additional cost of TA therapy, there was a 25% reduction in the cost of the blood conservation strategy. Conclusion TA therapy abolished the need for homologous blood transfusion and induced no notable side effects. TA therapy decreased the amount of blood salvaged intra-operatively, allowing a more rational use of the blood salvage system and decreasing the cost of anaesthesia. Level of evidence IV. Retrospective case-control.

Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: a prospective randomized study.

Abstract: Summary Introduction Rehabilitation programs after rotator cuff repair should allow recovery of shoulder function without preventing tendon healing. The aim of this randomized prospective study was to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization. Patients and methods We followed 100 patients, mean age 55 years old, who underwent arthroscopic repair of a non-retracted supraspinatus tear. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks. A clinical evaluation was performed in 92 patients, and CT arthrography in 82. Mean follow-up was 15 months. Results The mean preoperative Constant score improved significantly from 46.1 points to 73.9 at the final follow-up. The rate of intact cuffs was 58.5%. Functional results were statistically better after immediate passive motion with a mean passive external rotation of 58.7° at the final follow-up versus 49.1° after immobilization (P = 0.011), a passive anterior elevation of 172.4° versus 163.3° (P = 0.094) respectively, a Constant score of 77.6 points versus 69.7 (P = 0.045) respectively, and a lower rate of adhesive capsulitis and complex regional pain syndrome. Results for healing seemed to be slightly better with immobilization, but this was not statistically significant: the cuff had a normal appearance in 35.9% of cases after immobilization compared to 25.6% after passive motion, an image of intratendinous addition was found in 25.6% versus 30.2%, punctiform leaks in 23.1% versus 20.9%, and recurrent tears in 15.4% versus 23.3% respectively. Discussion The rehabilitation program that results in better tendon healing by preventing postoperative stiffness has not yet been identified. Our results suggest that early passive motion should be authorized: the functional results were better with no significant difference in healing. Level of evidence Level II. Randomized prospective study.

Surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: when gloves should be changed

Abstract: Summary Introduction Double gloving is recommended in orthopedic surgery, notably in total hip arthroplasties (THA) to prevent contamination of the surgical site. Hypothesis Systematic glove changes during the key phases of hip prosthesis implantation reduce the frequency of occult perforations and bacterial loading of glove surfaces. Patients and methods During 29 THA implantation procedures, we evaluated the bacterial contamination of the outer glove surface and its perforation rate. Contaminations were sought by placing the gloved fingertips on blood geloses (incubation, 48 h at 37 °C), and perforations were sought using a water test (NF EN 455-1). Results One intervention was excluded from the study because an initial contamination was detected, leaving 28 cases analyzed. Fifteen interventions (53.6%) presented contaminated geloses (26 contaminated glove changes for 3.38% of the gloves used). These contaminations were found on the gloves of all of the gloved personnel, with no distinction as to the right or left side. Thirty-eight percent of the contaminations occurred during joint reduction, whereas the other surgical stages grouped 15–26% of the contaminations ( P P Discussion Increasing the number of outer glove renewals, notably during certain surgical stages at risk for contamination (prosthesis reduction) or perforation (surgical incision/femoral cementing) can reduce the risk of contamination and perforation. The bacteria isolated suggest a cutaneous origin. Regularly changing gloves has resulted in a sterile state in 80% of cases. Level of evidence and type of study Level III prospective diagnostic study.

Total shoulder arthroplasty – Arthroplasty for glenohumeral arthropathies: Results and complications after a minimum follow-up of 8 years according to the type of arthroplasty and etiology

Abstract: Introduction Arthroplasty for glenohumeral arthropathies have specific complications and the final results are sometimes more dependent upon the type of shoulder arthroplasty than the initial etiology. The aim of our study was to evaluate the rate of complications and the functional improvement with different types of shoulder arthroplasties after a minimum follow-up of 8 years. Materials and methods This was a multicenter retrospective study of 198 shoulders including 85 primary osteoarthritis of the shoulder, 76 cuff tear arthropathies, 19 avascular necrosis and 18 rheumatoid arthritis. Arthroplasties included 104 anatomic total shoulder arthroplasties (TSA), 77 reverse arthroplasties and 17 hemiarthroplasties. Ten patients had their arthroplasty revised, and 134 patients with TSA were able to be present at the final follow-up or provide information on their case. Function was evaluated by the Constant-Murley score and loosening by standard radiographs. Results In the group with primary osteoarthritis of the shoulder, there were eight complications (11%) including six (8.3%) requiring implant revision. In the group of rotator cuff arthropathies, there were nine (14.7%) complications including four (6.5%) requiring implant revision. In the group with rheumatoid arthritis, there was one complication, and no surgical revision was necessary. There were no complications in the group with avascular necrosis. Glenoid migration occurred in 28.5% of anatomic TSA, and 3.4% of reverse arthroplasties. This difference was significant (P < 0.001). The Constant-Murley score was significantly improved in all etiologies. Conclusions Glenohumeral arthropathies can be successfully treated by arthroplasty. Anatomic TSA was shown to be associated with a high risk of glenoid loosening at radiographic follow-up, which makes us hesitate to use the cemented polyethylene implant, especially in young patients. Level of evidence IV – Retrospective study.

Percutaneous fixation of thoracolumbar fractures: current concepts.

Abstract: Numerous improvements in minimally invasive spine surgery (MISS) have been made during the last decade. MISS in thoracolumbar spine trauma management must achieve the same results as conventional treatment but with less morbidity. The increased use of MISS technologies in spine trauma has been correlated to the availability of more versatile instrumentation, which makes the fixation of all thoracic and lumbar levels possible. Balloon-assisted techniques have been used to support the anterior column in a stand-alone manner or in combination with open or percutaneous pedicle screw fixation. Fluoroscopy-assisted pedicle screw insertion is associated with less pedicle wall violation when compared to open surgery, but with increased radiation exposure for the surgeon and patient. Surgeons must be aware of this issue and new technologies are available to decrease irradiation. The advantages of percutaneous pedicle screw fixation relative to open surgery are discussed: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter rehabilitation time as well as shorter hospital stay. Limitations of percutaneous fixation include the inability to achieve direct spinal canal decompression and not having the option to perform a fusion. Nevertheless, these limitations can be addressed by combining MISS with open techniques. Indications for percutaneous spine fixation alone or in combination with MISS or open techniques are discussed based on the AO classification. The benefits of percutaneous spinal fixation for unstable spine fractures in polytrauma patients are also discussed. Posterior instrumentation can be easily removed after bone union to allow young patients to regain their mobility. Large well-controlled prospective studies are needed to draw up guidelines for less invasive procedures in spine trauma. In the future, development of new technologies can expand the scope of indications and treatment possibilities using MISS techniques in spine trauma.

The reliability of a simplified Garden classification for intracapsular hip fractures

Abstract: Summary Background The Garden classification is used to classify intracapsular proximal femur fractures. The reliability of this classification is poor and several authors advise a simplified classification of intracapsular hip fractures into non-displaced and displaced fractures. However, this proposed simplified classification has never been tested for its reliability. Hypothesis We estimate simplifying the classification of femoral neck fractures will lead to a higher inter-observer agreement. Materials and methods Ten observers, trauma surgeons and residents, from two different institutes classified 100 intracapsular femoral neck fractures. The inter-observer agreements were calculated using the multi-rater Fleiss’ kappa. Results The inter-observer kappa for the Garden classification was 0.31. An agreement of κ0.52 was observed if the Garden classification was simplified and the fractures were classified by our observers as ‘non-displaced’ or ‘displaced’. No difference in reliability was seen for the use of the four-grade Garden classification as well as the simplified classification between trauma surgeons and residents. Discussion Classification of intracapsular hip fractures according to the four-grade Garden classification is unreliable. The reliability of classification improves when the Garden classification is simplified in a classification using the terms: ‘non-displaced’ or ‘displaced’. Level of evidence Level IV. Diagnostic retrospective study.

Effects of a preoperative simplified home rehabilitation education program on length of stay of total knee arthroplasty patients

Abstract: Summary In patients with severe knee osteoarthritis (OA), total knee arthroplasty (TKA) is performed for both symptom relief and to achieve better function in daily life. Implementation of efficient TKA rehabilitation programs with shorter length of stay (LOS) and reduced medical expenditures is an important issue in clinical practice. However, the effectiveness of preoperative rehabilitation programs is still under debate. Most preoperative rehabilitation programs last many weeks and may be more expensive than TKA. The purpose of this study was to investigate the effects of a simplified, easy-to-learn, and less time-consuming preoperative rehabilitation education program on TKA patients. Patients and methods In this randomized controlled study, we allocated all the patients into study and control group according to chart number. The study group, which comprised 126 patients, participated in a 40-min preoperative home rehabilitation education program 4 weeks prior to TKA. One hundred seventeen patients in the control group did not participate in this preoperative program. Results The study group required a shorter hospital LOS (mean: 7.12 days; P = 0.027) and had less hospitalization-related medical expenditures (mean: 123726 New Taiwan dollars [NTD], equivalent to 4266.4 United States dollars [USD] or 3022.1 [Euros]), ( P = 0.001) than the control group. However, the study group showed no significant improvement in function when compared to the control group. Discussion Our study demonstrates that a simplified preoperative rehabilitation program can reduce LOS and increase cost savings. This program was recommended as a routine protocol for OA patients before admission for TKA. Level of evidence Level II. Prospective randomized study.

Plating of humeral shaft fractures: comparison of standard conventional plating versus minimally invasive plating.

Abstract: Summary Purpose This study compared clinical outcomes and complications in patients with humeral shaft fractures treated using two methods of fixation by plating. Methods Minimally invasive plate osteosynthesis (MIPO, n = 29) was prospectively performed from around the middle of the study period, while open reduction and plate osteosynthesis (ORPO, n = 30) had been the original standard method. Locking compression plate was used in these two groups. Major characteristics of the two groups were similar in terms of fracture type, fracture location, age, associated injuries and numbers of open fractures. Results Primary union was achieved in 28 of 29 in the MIPO and in 27 of 30 in the ORPO. Mean time to union was similar in the two groups. Mean operation time in the MIPO (110 min) was shorter than in the ORPO (169 min) (P Conclusions Minimally invasive plate osteosynthesis may achieve comparable results with the open plate osteosynthesis method in simple as well as complex fractures of humeral shaft. Although MIPO potentially has the radiation hazard, it may reduce the perioperative complications with a shortened operation time. Level of evidence Level III. Case-control study.

Cavus foot, from neonates to adolescents

Abstract: Pes cavus, defined as a high arch in the sagittal plane, occurs in various clinical situations. A cavus foot may be a variant of normal, a simple morphological characteristic, seen in healthy individuals. Alternatively, cavus may occur as a component of a foot deformity. When it is the main abnormality, direct pes cavus should be distinguished from pes cavovarus. In direct pes cavus, the deformity occurs only in the sagittal plane (in the forefoot, hindfoot, or both). Direct pes cavus may be related to a variety of causes, although neurological diseases predominate in posterior pes cavus. Pes cavovarus is a three-dimensional deformity characterized by rotation of the calcaneopedal unit (the foot minus the talus). This deformity is caused by palsy of the intrinsic foot muscles, usually related to Charcot-Marie-Tooth disease. The risk of progression during childhood can be eliminated by appropriate conservative treatment (orthosis to realign the foot). Extra-articular surgery is indicated when the response to orthotic treatment is inadequate. Muscle transfers have not been proven effective. Triple arthrodesis (talocalcanear, talonavicular, and calcaneocuboid) accelerates the mid-term development of osteoarthritis in the adjacent joints and should be avoided.

The Oxford Knee Score: Compared performance before and after knee replacement

Abstract: Summary Background Self-administered quality-of-life questionnaires are now crucial to the evaluation of orthopaedic surgical patient-reported outcomes, as they reflect patient satisfaction. The Oxford Knee Score (OKS) is a validated instrument that is widely used to assess outcomes of knee osteoarthritis surgery. Hypothesis The relevance of the OKS (comprehension and relevance of the items and responses, and internal and external validity) and its discriminating performance measured based on the ceiling and floor threshold effects are better before than after knee replacement surgery. Materials and methods We included 200 patients (100 scheduled for knee replacement and 100 having had knee replacement more than 1 year earlier). The OKS questionnaire was handed to each patient during the first surgeon visit or during a follow-up visit. The American Knee Society (AKS) score was determined simultaneously. Results The mean OKS was 43.7 (range, 21–56; SD, 6.9) before surgery and 20.5 (range, 12–45; SD, 5.6) after surgery. The floor effect was absent (0%) before surgery and substantial (33%) after surgery; a weak ceiling effect (7%) was noted before surgery and no ceiling effect after surgery. Internal consistency of the OKS was excellent. The OKS correlated negatively with the AKS knee and functional scores, both before and after surgery. Discussion The OKS is well-suited to the evaluation of knee function both before and after knee replacement surgery. Before surgery, the absence of substantial floor and ceiling effects lead to excellent discrimination. After surgery, the substantial floor effect limits the ability to discriminate among the best results. Efforts should be made to develop more demanding scoring systems. Level of evidence Level 2. Exploratory cohort study with universally applied reference standards.

Induced membrane technique for reconstruction after bone tumor resection in children: a preliminary study.

Abstract: Summary Aim Segmental long-bone defect due to tumor resection remains a challenge to treat. The induced membrane technique is a new alternative for biological reconstruction. During the first stage, a cement spacer is inserted after bone resection and stabilisation. The cement spacer is removed during a second stage procedure performed after chemotherapy, and cortico-cancellous bone autograft was placed in the biological induced chamber. The aim of this study was to assess preliminary results in eight children. Patients and methods This prospective study included six girls and two boys, with a mean age of 12.1 years (range 9.5 to 18) and treated for a mean 15 cm defect (range 10 to 22 cms) due to resection of osteosarcoma (n = 4), Ewing sarcoma (n = 3) and low grade sarcoma. All patients except one, were given pre- and postoperative chemotherapy. Surgery was performed for three patients with a distal femur tumor, two patients with a proximal tibial tumor and three patients who had proximal humerus, shaft of humerus and fibular tumors. Fixation was mainly performed with locking compression plate (n = 4) and locked nail (n = 2). The mean operating times for first and second step procedures were 4.8 and 4 h respectively. The healing process was radiologically assessed. Results After a mean follow-up of 21.6 months (15 to 30), all patients were free of disease and seven had bony union. For the lower limb reconstructions, full weight bearing was possible after a mean of 116 days (range90 to 150) following the second stage. Mean time to bone union was 4.8 months (1.5 to 10). The early Musculoskeletal Tumor Society (MSTS) score was 25.2/30 (range 20–30). Complications were: non-union (n = 1), paradoxical graft resorption (n = 1) requiring graft revision. Conclusion This two stage procedure reduces the operating time during the first stage and it also reduces early complications. Rapid bone union is objectively obtained despite major bone resection and the patients receiving chemotherapy. Significance The induced membrane technique could be an excellent alternative for biological reconstruction after tumor resection in children.

Efficacy of tranexamic acid on blood loss after primary cementless total hip replacement with rivaroxaban thromboprophylaxis: A case-control study in 70 patients.

Abstract: Summary Introduction Perioperative blood loss is a frequent cause of complications in total hip replacement (THR). The present prospective study assessed the efficacy of tranexamic acid (Exacyl®) in reducing blood loss in primary THR associated to rivaroxaban (Xarelto®) thromboprophylaxis. Hypothesis Tranexamic acid associated to rivaroxaban reduces blood loss. Material and method A prospective case-control study included 70 primary cementless THRs performed by a single surgeon on a standardized technique, between September 2009 and September 2010. Thirty-seven patients received perioperative tranexamic acid; all patients received rivaroxaban thromboprophylaxis. Results There was no significant difference between the two groups in terms of peroperative blood-loss volume or rates of thromboembolic or ischemic events or hematoma. Postoperative blood loss, D0-5 differential hemoglobinemia and real blood loss (in mL 100% hematocrit) were significantly lower in the tranexamic acid group. No transfusions were required in the tranexamic acid group, versus four in the control group. Discussion Tranexamic acid associated to direct anti-Xa (antithrombin-independent) oral anticoagulants was effective in reducing postoperative blood loss, improving hemoglobinemia at 5 days and reducing transfusion rates. The results also confirmed the efficacy of and tolerance for rivaroxaban thromboprophylaxis in primary THR, with no clinical thrombotic events induced by the association of tranexamic acid with rivaroxaban. Conclusions Tranexamic acid is a simple means of reducing postoperative blood loss in THR, without increased risk of thromboembolism when associated to rivaroxaban thromboprophylaxis. Level of evidence Level III prospective case-control study.

Joint perception after hip or knee replacement surgery

Abstract: Summary Introduction Knee and hip arthroplasties are recognized as being effective. However, subjects with a prosthetic joint rarely report returned sensation comparable to their native joint. Hypothesis Joint perception by patients following hip joint replacement is better than following knee replacement and in both cases this perception is directly related to the clinical results measured with currently validated scores. Patients and methods Patient joint perception in prosthetic reconstruction was evaluated in 347 patients, 46 who underwent unicompartmental knee arthroplasty (UKA), 119 tricompartmental knee arthroplasty (TKA), 93 hip resurfacing (HR), and 89 total hip arthroplasty (THA). The subjects’ joint perception, their satisfaction, and the WOMAC clinical score were recorded and compared. Results Joint perception was significantly worse for knee arthroplasties (TKA and UKA) compared to hip arthroplasties (THA or HR) ( P P R 2 = 0.951). Discussion No difference was found after more conservative surgeries such as HR or UKA compared to traditional arthroplasty procedures (THA or TKA). Demonstrating inferior results in comparison to the hip, knee arthroplasties deserve particular attention and can still be improved. The assessment of joint perception used in this study can be considered a valuable clinical tool that is strongly correlated to validated, but more complex to apply, clinical scores. Level of evidence Level III prospective case – control study.

Indications and results for the Exogen™ ultrasound system in the management of non-union: A 59-case pilot study

Abstract: Summary Introduction This pilot series sought to assess the use of external ultrasound stimulation (Exogen™) in the treatment of femoral or tibial non-union. Materials and methods A continuous retrospective study was conducted from 2004 to 2009. It included patients with a non-united fracture or osteotomy at 6 months or more post-surgery, with less than 10 mm inter-fragment gap. Daily 20-min ultrasound sessions were continued until bone healing was achieved or for a maximum 6-month duration. Radio-clinical control was performed at months 3 and 6; treatment compliance and transmitter positioning were checked at each follow-up visit. Results Sixty non-unions were included in the series. One patient was excluded for early material breakage. Mean fracture-to-surgery interval was 271 days. The 6-month consolidation rate was 88%. There was no loss to follow-up. Mean ultrasound treatment duration was 151 days (range, 90–240 days). Bone healing correlated significantly with stability of the internal fixation assembly ( P = 0.01). The seven cases of failure included four fixations,considered unstable at inclusion, one femoral non-union associated with BMI 45 and one inadequate subchondral roughening (at the time of arthrodesis). There was a significant difference in delay to non-union treatment start between the groups with (251 days) and without (420 days) bone healing. Discussion The present results are in line with the literature. The main prognostic factors were fracture fixation stability, short time to treatment, and inter-fragment gap less than 10 mm. Bone healing rates in the literature are around 80% for non-union treated at around 6 months, versus 60% for more than 12 months’ delay. Factors such as gender, bone site, smoking, numbers of previous operations or type of osteosynthesis do not impact consolidation. External treatment offers an alternative to traditional surgery (graft, or bone-marrow concentrate or bone morphogenetic protein injection), provided that the fracture fixation is stable. Bone healing rates are better, and the procedure is non-invasive. External treatment results using ultrasound are similar to those using electromagnetic fields; the main difference lies in treatment session duration, which is 20 min for ultrasound, versus 3 hours for electromagnetic fields. Active patient commitment is vital, as the treatment is delivered at home, although the machine is equipped with a monitor to count treatment cycles. Conclusion The 88% bone healing rate supports advocating first-line implementation in non-union of less than 10 mm with stable osteosynthesis. This rate is higher than in traditional surgery, with a unit cost at least 60% lower: € 1772 for external therapy, versus € 4480 for decortication with or without fracture fixation exchange (itemized 08c50 under the French healthcare treatment coding system). Level of evidence Level IV. Retrospective therapeutic study.

Shoulder hemiarthroplasty: Outcomes and long-term survival analysis according to etiology

Abstract: Summary Background The indications for hemiarthroplasty in glenohumeral joint diseases remain controversial and depend mainly on the original underlying diagnosis. Our objective was to investigate the influence of the primitive aetiology on long-term prosthesis survival and on the Constant-Murley score. Materials and methods We studied 272 shoulders with the following diagnoses: fracture sequelae (n = 73), primary osteoarthritis (n = 67), cuff tear arthropathy (n = 43), avascular necrosis (n = 40), rheumatoid arthritis (n = 31), and other (n = 18). Of the 272 shoulders, 139 were evaluated after at least 8 years (mean follow-up, 134 months). In all, 30 prostheses required removal. Functional status was evaluated using the Constant-Murley score and survival rate using the Kaplan-Meier method with prosthesis removal or conversion to total arthroplasty as the endpoint. Results Ten-year prosthesis survival was 88.13% overall, 100% in the rheumatoid arthritis group, 94.9% in the avascular necrosis group, 94.2% in the primary osteoarthritis group, 81.5% in the cuff tear arthropathy group, and 76.8% in the fracture sequelae (P = 0.05). The mean Constant-Murley score after 8 years or more was 70.1 in avascular necrosis, 60.7 in primary osteoarthritis, 57.7 in fracture sequelae, 55.3 in rheumatoid arthritis, and 46.2 in cuff tear arthropathy (P = 0.0006). The complication rate with the initial population as the denominator was 24.7% in fracture sequelae, 18.6% in cuff tear arthropathy, 15% in avascular necrosis, 8.9% in primary osteoarthritis, and 3.2% in rheumatoid arthritis. Conclusions The best indication for shoulder hemiarthroplasty is avascular necrosis and the worst indications are cuff tear and post-traumatic fracture sequellae. Rheumatoid arthritis and primary glenohumeral osteoarthritis are good indications in patients younger than 50 years of age. Level of evidence Level IV, retrospective study.

Proximal femoral nail antirotation (PFN-ATM) fixation of extra-capsular proximal femoral fractures in the elderly: retrospective study in 102 patients.

Abstract: Summary Background The best surgical strategy for extra-capsular proximal femoral fractures (PFFs) is controversial in the elderly. Poor bone quality and neck screw instability can adversely affect the results with currently available fixation devices, which predominantly consist in dynamic hip screw-plates and proximal reconstruction nails. Hypothesis The helical blade of the proximal femoral nail antirotation (PFN-A™) achieves better cancellous bone compaction in the femoral neck, thereby decreasing the risk of secondary displacement. Materials and Methods We retrospectively reviewed consecutive cases of PFN-A™ fixation performed between 2006 and 2008 in 102 patients (75 females and 27 males) with a mean age of 84.9 ± 9.5 years (range, 70–100 years). Functional outcomes were assessed using the Parker Mobility Score. Results Mean follow-up in the 102 patients was 21.3 ± 17.5 months (4–51 months). Fracture distribution in the AO classification scheme was A1, n = 45; A2, n = 41; and A3, n = 16. At last follow-up, Parker Mobility Score values in the 65 survivors were 0–3, n = 35; 4–6, n = 11; and 7–9, n = 19. Fracture union was consistently achieved, after a mean of 10.3 ± 3 weeks. Blade back-out allowed by the device design occurred in 16 (15.7%) patients but caused pain due to screw impingement on the fascia lata in only five patients (of whom two underwent reoperation). Cephalic blade cut-out was noted in three (2.9%) patients, of whom one required reoperation because of acetabular penetration. Two hardware-related fractures were recorded. Discussion The new PFN-A™ device ensures reliable fixation with low mechanical complication rates. Although our data do not constitute proof that a helical blade is superior over a neck screw, they suggest a decreased rate of construct failure and may serve as a basis for a comparative study. Level of evidence Level IV, retrospective study.

Early surgical site infections in adult spinal trauma: a prospective, multicentre study of infection rates and risk factors.

Abstract: Summary Introduction Spine surgery is known to have a high risk of surgical site infection (SSI). Multiple studies have looked into the risk factors and incidence of SSI during elective surgery, but only two retrospective studies have specifically evaluated SSI during surgery following spine trauma. Materials and methods This work was based on a prospective cohort study that included all the patients operated on for spinal trauma at 13 French hospitals over a three-month period. The main endpoint was the occurrence of a SSI during the three-month period. Patients with multiple trauma or open fractures were excluded from the study. Results Of the 169 patients re-examined after a minimum of three months, six had had an acute SSI (3.55%). The following factors were significantly related to a SSI: age, ASA score, diabetes, procedure duration, delay elapsed between accident and procedure, number of levels fused, bleeding and prolonged presence of urinary catheter. Discussion Our results were consistent with the published infection rates of 2 to 10%. The risk factors identified have all been described in previous studies on elective spine surgery. Level of evidence Level IV, prospective cohort study.

Total talar fracture - long-term results of internal fixation of talar fractures. A multicentric study of 114 cases.

Abstract: Summary Introduction Displaced talar neck and body fractures are rare and challenging for the surgeon. Results are often disappointing due to inadequate reduction or internal fixation and high rates of osteoarthritis and osteonecrosis. Very few published series describe the long-term results after internal fixation of talar factures. One of the goals of the 2011 SOO meeting symposium was to specifically evaluate the long-term results after internal fixation of talar fractures. This study included only central fractures. Material and methods We reviewed the results of 114 central talar fractures that had been treated by internal fixation between 1982 and 2006 in nine hospitals in the Western part of France. The clinical and radiological follow-up was 111 months on average. All the patients with a radiological assessment had at least 5 years of follow-up. Results Poor reduction was apparent in 33% of cases. The average Kitaoka score was 70/100, which corresponds to an average functional level. At the last follow-up evaluation, 34% of cases had osteonecrosis and 74% had peritalar osteoarthritis. Secondary fusion was required in 25% of cases with an average follow-up of 24 months. Discussion The complication rate for talar fractures was high, mostly due to osteonecrosis and osteoarthritis; these conditions had an impact on the final outcome. The outcome could be improved by better evaluating these fractures with a CT scan, developing dual surgical approaches to best preserve the bone vascular supply and achieve better reduction, and improving the internal fixation hardware, especially the use of plates for comminuted fractures.

Patellar denervation in total knee arthroplasty without patellar resurfacing: A prospective, randomized controlled study

Abstract: Summary Background Anterior knee pain is still a major problem in total knee arthroplasty (TKA). Although the most widely accepted opinion is that anterior knee pain is often associated with a patellofemoral etiology, there is no clear consensus as to etiology or treatment. Disabling pain receptors by electrocautery could theoretically achieve denervation of the anterior knee region. The present prospective randomized controlled study aimed to evaluate results after patellar denervation with electrocautery in TKA at a minimum follow-up of 2 years. Hypothesis Patellar denervation provides some benefit in terms of pain and clinical outcomes after TKA without patellar resurfacing. Patients and methods Clinical and radiological results for 35 patients with single-stage bilateral TKA (70 knees; 26 women, nine men; mean age, 68 years [range, 58 to 77 years]) were reviewed. In addition to removal of all osteophytes, patellar denervation by electrocautery was performed on one patella; and debridement alone, removing all osteophytes, was performed on the contralateral patella, as a control. KSS score and a visual analog scale (VAS) were used to assess pre- and postoperative anterior knee pain. Results Mean follow-up was 36 months (24 to 60 months). No revisions or re-operations were performed. There were no patellar fractures. On all parameters (KSS score, range of motion and VAS), there was a statistically significant pre- to postoperative difference in favor of the denervation group. Discussion Patellar denervation with electrocautery can reduce anterior knee pain, with satisfactory clinical and radiological outcome, in TKA without patellar resurfacing. Level of evidence Level II: low-powered prospective randomized trial.