Showing papers in "Orthopaedics & Traumatology-surgery & Research in 2019"

Hemiarthroplasty or total hip arthroplasty in recent femoral neck fractures

Abstract: The optimal treatment of recent femoral neck fractures remains debated. The available options are internal fixation, hemiarthroplasty (HA) and total hip arthroplasty (THA). There is a consensus in favour of internal fixation in younger patients. In elderly individuals who are institutionalised and have limited physical activity, HA is usually performed when the joint line is intact. Whether HA or THA deserves preference in patients aged 60 years or over is unclear. In addition, there are two types of HA, unipolar and bipolar, and two types of THA, conventional and dual-mobility. Both HA types provide similar outcomes with satisfactory stability but a risk of acetabular wear that may eventually require conversion to THA. THA is associated with better functional outcomes and a lower risk of revision surgery in self-sufficient, physically active patients. Instability is the leading complication of conventional THA and occurs with a higher incidence compared to HA. With all implant types, preoperative factors associated with mortality and complications include walking ability and level of self-sufficiency, nutritional status, and haematocrit. An evaluation of these factors before surgery is of paramount importance. Factors amenable to treatment should be corrected by working jointly with geriatricians to develop a preoperative management strategy. In patients who are self-sufficient, physically active, and free of risk factors, THA remains the option of choice, as it provides better functional outcomes. A dual-mobility implant deserves preference to prevent instability. HA is indicated in patients whose self-sufficiency and physical activity are limited. A unipolar implant should be used, as no evidence exists that bipolar implants provide additional benefits. When performing HA, the posterior approach should be avoided given the risk of instability. For THA, in contrast, the posterior approach is a reliable option in the hands of an experienced surgeon using a dual-mobility cup. Cement fixation of the stem is recommended to minimise the risk of peri-prosthetic fracture.

Factors associated with hospital stay length, discharge destination, and 30-day readmission rate after primary hip or knee arthroplasty: Retrospective Cohort Study.

Abstract: Background In France and in the US, predictions for 2030 include an increased number of total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures together with an overall trend towards shorter hospital stays. Predictors of hospital length of stay (LOS) include the day of surgery, discharge destination, and patient comorbidities. Available data are conflicting, however, and to our knowledge predictors of LOS after THA or TKA have not been evaluated in France. Improved knowledge of these predictors would be expected to increase patient care efficiency. The objectives of this study were: (1) to determine whether the above-listed factors predict LOS after THA or TKA, (2) to identify predictors of discharge to a rehabilitation unit and of readmission within 30 days after surgery. Hypothesis Both patient-related factors unamenable to modification and modifiable organisational factors are associated with LOS after THA or TKA. Material and methods This large single-centre retrospective cohort study included all adults who underwent primary THA or TKA at our university hospital between 1 January 2015 and 31 December 2016. Non-inclusion criteria were revision arthroplasty, THA with femoral or acetabular reconstruction, TKA using a constrained hinged implant, and fracture as the reason for arthroplasty. Preoperative parameters, type of arthroplasty, and postoperative care were recorded. Results We included 938 patients with THA and 725 patients with TKA. By multivariate analysis, the likelihood of being discharged by day 5 decreased with older age (HR, 0.986; 95%CI: 0.98–0.99) and was lower by 13% in females (HR, 0,871; 95%CI: 0.77–0.986), by 39% in patients with diabetes (HR, 0.606; 95%CI: 0.5–0.73), by 68% in patients discharged to rehabilitation units (HR, 0.322; 95%CI: 0.267–0.389), and by 27% in patients who had arthroplasty on a Friday (HR, 0.733; 95%CI: 0.631–0.852). Factors predicting discharge to rehabilitation unit were older age, female gender, chronic obstructive pulmonary disease, anxiety-depressive disorder, and a history of stroke. Risk factors for 30-day readmission were male gender, obesity, and discharge to rehabilitation unit. Discussion In this study, predictors of LOS were identified using a survival model that considered age as a continuous variable, separate comorbidities, and the discharge destination. Our findings are consistent with earlier reports and confirm the strong associations linking LOS to diabetes, day of surgery, and discharge destination in France. We also identified predictors of discharge to rehabilitation and of readmission within 30 days. Level of evidence IV, retrospective observational cohort study.

Progression and projection for hip surgery in France, 2008-2070: Epidemiologic study with trend and projection analysis.

Abstract: Introduction Hip replacement was declared “operation of the century” in tribute to the functional improvement it provides. Frequency is increasing, but it is difficult to estimate the actual number of procedures performed and the expected progression, because of changes in indications and lengthening life-expectancy, and also, in France, because there is no registry. As data are lacking in France, we conducted an investigation 1) to update the number of hip surgeries in France, and 2) to forecast progression over the coming decades, considering extreme scenarios. Hypothesis The number of hip procedures can be expected to increase considerably over the coming 50 years. Material and method A study was conducted to analyze national coding data for the number of hip surgeries performed in France. Two scenarios were defined: one taking account of population progression and age structure, the other also extrapolating trends observed over recent years. Current hip surgery activity in France was measured, and progression estimated according to population changes. Results In 2018 in France, 183,139 procedures were coded as principally concerning the hip. There was a clear predominance of reconstruction procedures, with 148,965 primary hip replacements, 124,251 of which were total. There were 19,304 hip replacement revision procedures. There were strong regional differences in revision according to the type of center performing surgery (p Discussion The present results are subject to future technological breakthroughs and medical discoveries, but forecast a major increase in hip surgery requirements. These results extend the present state of medical knowledge. Level of evidence IV, descriptive epidemiological study.

Very long-term results of post-traumatic bone defect reconstruction by the induced membrane technique.

Abstract: Introduction The induced membrane technique for bone defect reconstruction is now well recognized, and short-term results for bone healing are consistent between published reports. Objectives To assess very long-term functional results in post-traumatic reconstruction using the induced membrane technique. Method Results for 18 patients undergoing bone defect reconstruction by induced membrane were retrospectively analyzed at 10 to 22 years’ follow-up. Initial lesions were multitissue with infection in 14 cases. Reconstruction concerned the tibia in 14 cases, and the humerus, elbow, radius or ulna in 1 case each. Soft-tissue reconstruction was performed in 17 cases, by free flap (n = 8) or pedicle flap (n = 9). Fixation used a single-plane external fixator in 15 cases, screwed plate in 1 case (humerus), or intramedullary nail in 1 case (ulna). There was 1 crossover from external fixator to internal plate fixation (radius). Assessment comprised radiology, functional assessment, clinical examination and patient satisfaction. All patients were followed up in individual consultation. Results Eight of the 14 patients with lower limb lesions had unrestricted walking distance; 4 resumed leisure sports. Limb shortening ranged from 0.5 to 4 cm and was well-tolerated, although dorsiflexion was abolished or limited in most cases. Several patients underwent second procedures to improve limb function: ankle fusion, Achilles lengthening, tendon transfer, or realignment osteotomy. Radiology found a neotubular aspect, indicating peripheral densification and central resorption. Despite the multiple procedures, no patients regretted the original limb-conserving surgery. All reported that it took 2 to 3 years after consolidation and resumption of walking to achieve stable final functional improvement. No recurrent sepsis in the reconstruction zone was found. Conclusion The present results encourage implementing limb-conserving strategies in young patients after severe multitissue limb trauma, on condition that lesions are properly assessed, notably in terms of infection, and that the reconstruction protocol is feasible and has the patient's consent. Level of evidence IV, retrospective series.

Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs.

Abstract: Introduction An attractive option to reduce hospital length of stay (LOS) after hip or knee joint replacement (THA, TKA) is to follow the Enhanced Recovery After Surgery principles (ERAS) to improve patient experience to a level where they will feel confident to leave for home earlier. The objective of this study was to evaluate the implementation of short-stay protocol following the ERAS principles. Hypothesis We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital LOS and reduced direct health care costs compared to our standard procedure. Material and methods We compared the complications rated according to Clavien-Dindo scale, hospital LOS and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. Results Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p Discussion In many short-stay protocols, focus has shifted from ERAS goals of a reduction in complications and improved recuperation to use length of stay as the main factor of success. Implementation of an ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital LOS, but also in improved patient care and reduced direct health care costs. Level of evidence Level II.

Reverse shoulder arthroplasty for recent proximal humerus fractures: Outcomes in 422 cases.

Abstract: Background The ageing of the population is steadily increasing the frequency of displaced proximal humerus fractures (PHFs) in elderly patients. The last decade has seen a shift from hemi-arthroplasty (HA) to reverse shoulder arthroplasty (RSA) in these patients. The primary objective of this study was to assess short- and long-term outcomes of RSA in a large cohort of elderly patients with recent PHFs. The secondary objectives were to evaluate radiological outcomes and short- and long-term morbidity and mortality rates. Hypothesis Outcomes of RSA to treat PHFs in older patients are satisfactory, reliable, and sustained over time. Material and methods This retrospective multi-centre study included 898 patients with a mean age of 79 years, among whom 422 underwent a standardised clinical and radiological evaluation at least 1 year after RSA. Some patients were re-evaluated twice. An evaluation within the first 5 years was available for 420 patients (≤ 5-Y group), whereas 119 patients were re-evaluated more than 5 years after RSA (> 5-Y group). Some patients had one re-evaluation either within or after 5 years and others had both an early and a late re-evaluation; thus the total number of re-evaluation was greater than the number of patients. Results Mean active forward elevation was 115° ± 29°, mean external rotation with the elbow by the side was 17° ± 19°, mean internal rotation (hand-to-back) was 4.3 ± 2.5 points, mean absolute Constant score was 57 ± 15, and mean Subjective Shoulder Value was 70% ± 18%. Re-implantation of the tuberosities followed by healing in the anatomical position was associated with significantly better outcomes, notably regarding rotations. Even in the absence of healing in the anatomical position, tuberosity repair was associated with better clinical outcomes compared to tuberosity excision. Humeral loosening occurred in 3.5% of patients and was associated with tuberosity excision. Glenoid loosening was seen in 3.5% of patients and was associated with superior tilt of the glenoid component. The main complication was prosthesis instability, which occurred in 2.5% of patients, a proportion similar to that seen in the general population. Post-operative patient survival was not significantly different from that in the general population of the same age. Prosthesis survival was 91% after 20 years. Conclusion Clinical outcomes of RSA for PHF in elderly patients were not only satisfactory but also reproducible and sustained over time. Tuberosity re-implantation around the prosthesis is the key step for optimising the functional outcomes, notably by restoring rotations and decreasing the risk of complications (prosthesis instability and humeral loosening). Level of evidence IV, retrospective observational study.

The CRIOAc healthcare network in France: A nationwide Health Ministry program to improve the management of bone and joint infection

Abstract: Background Bone and joint infections (BJIs) have a major clinical and economic impact in industrialized countries. Its management requires a multidisciplinary approach, and a great experience for the most complicated cases to limit treatment failure, motor disability and amputation risk. To our best knowledge there is not currently national specific organization dedicated to manage BJI. Is it possible to build at a national level, a network involving orthopaedic surgeons, infectiologists and microbiologists performing locally multidisciplinary meetings to facilitate the recruitment and the management of patients with complex bone and joint infection in regional centers? Hypothesis A national healthcare network with regional labeled centers creates a dynamic that improves the recruitment, the management, the education, and the clinical research in the field of complex BJI. Patients and methods We describe the history of this unique national healthcare network and how it works, specify the missions confided to the CRIOAcs, evaluate the activity of the network over the first decade, and finally discuss perspectives. Results The labelling of 24 centers in the CRIOAc network allowed for a meshing of the territory, with the possibility of management of complex BJI in each region of France. A dedicated secure national online information system was designed and used to facilitate decision-making during multidisciplinary consultation meetings. Since October 2012 to June 2017, 4553 multidisciplinary consultation meetings have been performed in the structures belonging to the network, with 34,607 cases discussed in 19,961 individual. Prosthetic joint infections represented 38% (7585/19,961) of all BJIs. Among all the cases discussed, the rate of complexity was of 61% (21,110/34,607) (related to antibiotic resistance, infection recurrence, patient co morbidities). A national scientific meeting was created and a national postgraduate diploma in the field of BJI was launched in 2014. The promotion of education, clinical research and interactivity between each academic discipline and between each labeled centers across the country has synergized the strengths and have greatly facilitated the management of patients with BJI. Discussion The setting up of the CRIOAc network in France took time, and has a cost for the French Ministry of Health. However, this network has greatly facilitated the management of BJI in France, and allowed to concentrate the management of complex BJI in centers that have significantly gained skills. There is, to our knowledge, no other exemple of such nationwide network in the field of BJI. Level of evidence IV, case series without control group.

Patellar complications after total knee arthroplasty.

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

Hamstring tendons or bone-patellar tendon-bone graft for anterior cruciate ligament reconstruction?

Abstract: In anterior cruciate ligament (ACL) reconstruction, success depends on several factors: patient selection; surgical technique, taking account of associated meniscal and ligamentous lesions; and postoperative rehabilitation. Improved hamstring-tendon graft preparation and fixation techniques now provide results in terms of laxity and retear comparable to patellar tendon graft, which has long been the gold-standard for patients with strong functional demand, despite its higher risk of extension stiffness and anterior pain. Apart from a few exceptional preferential indications, such as hamstring tendon in growing children and patients whose lifestyle or occupation involves frequent kneeling and patellar tendon in case of severe medial laxity associated with ACL tear, either graft may be used for ACL reconstruction. The keypoints in the procedure are good tunnel positioning and hence good mastery of the surgical technique, and treatment of all associated lesions, and especially of occult meniscal lesions and rotational laxity due to anterolateral ligament deficiency, which requires associated extra-articular plasty. Graft choice is secondary and not a key to success.

Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017.

Abstract: Introduction In 2008, the French National Authority for Health (HAS) recommended that “conservative” treatments be adopted for meniscal lesions. This recommendation and the lack of superiority of meniscectomy over non-operative treatment for meniscus degeneration have modified the treatment pathway. However, the impact of these findings on French clinical practice is not known. The objective of this study was to evaluate the change over time in the number of alternative surgical procedures (meniscectomy and meniscus repair) and regional variation in France using data from the French agency for information on hospital care (ATIH). Hypothesis We hypothesized that the number of meniscectomy procedures will decrease, and the number of repair procedures will increase over time at various healthcare facilities. Patients and methods Between 2005 and 2017, the number of hospitalizations in the Medicine-Surgery-Obstetrics wards for meniscectomy (NFFC003 and NFCC004) or meniscus repair (NFEC001 and NFEC002) was evaluated overall and then based on whether the stay occurred in public or private sector hospitals in France. Data were extracted from the ATIH database and the findings were (1) related to French demographics during the period in question; (2) separated into public or private sector hospitals; (3) distributed into various regions in France and; (4) stratified by patient age. Results Between 2005 and 2017, 1,564,461 meniscectomy and 63,142 meniscus repair procedures were done in France. Over this period in the entire country, the meniscectomy rate gradually decreased from 19.80/10,000 inhabitants in 2005 to 15.77/10,000 inhabitants in 2017 (21.4% reduction) (p Conclusion These findings suggest there has been a significant shift in the surgical management of meniscal injuries towards more conservative treatments. But the large variations between regions in France is evidence of a continued disparity in clinical practices. Level of evidence IV, retrospective study without control group.

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

Abstract: Introduction The number of total knee arthroplasty (TKA) revisions is expected to increase 601% in the United States between 2005 and 2030. This type of information is not available in France, and the last national study on this topic was done in 2000. This led us to perform a comparative study to determine if 1) the frequency of TKA revisions has increased and 2) the reasons for reoperation have changed relative to data gathered in 2000 at a single hospital in France. Hypothesis The frequency of TKA revision has increased between the two studies, performed 15 years apart. Material and methods In this retrospective observational single-center study (January 2013 to December 2016), all patients with a TKA who were reoperated with or without any component change were included. This cohort was compared to our historical cohort defined in 2000 of 68 TKA reoperations between January 1991 and January 1998. The reasons for revision were determined by consulting computerized patient records to find the disease history, clinical examinations, imaging findings, laboratory tests and the surgery report. Cases due to periprosthetic fractures, infection and skin-related complications were excluded in order to be consistent with the indications of the historical cohort. Results Between 2013 and 2016, 349 TKA revisions were performed, and 255 met the inclusion criteria. Note that the historical cohort had 68 cases. The mean time elapsed between the primary TKA and revision procedure was 5.3 years [34 days to 31 years]. Eight reasons for reoperation were identified. Aseptic loosening (85 cases (33.3%)), stiffness (70 cases (27.5%)), tibiofemoral laxity (39 cases (15.3%)) and patellar complications (34 cases (13.3%)) were the four most common reasons for reoperation. The frequency has changed over time: relative to 2000, the annual frequency increased by a factor of 6.5. The reasons have also changed over time: there was an increase in revisions for aseptic loosening (33.3% vs. 23.5%), stiffness (27.5% vs. 20.6%) and knee joint laxity (15.3% vs. 10.3%). Conversely, there was a reduction in revisions for patellar complications (13.3% vs. 26.5%), unexplained pain (0.4% vs. 8.8%) and patellar clunk syndrome (1.2% vs. 4.4%). Discussion The number of TKA revisions has increased by a factor of 6.5, with aseptic loosening still being the most common reason. The number of revisions performed for stiffness and knee joint laxity have increased. Fewer revisions are being done for unexplained pain because surgeons are now better able to determine the cause of TKA-related pain. There were fewer patella-related complications because of technical progress. The data generated from our single-center study are consistent with current published data. Level of evidence II, comparative study.

Superior capsular reconstruction for irreparable supraspinatus tendon tears using the long head of biceps: A biomechanical study on cadavers.

Abstract: Introduction The superior articular capsule complements the rotator cuff's function in shoulder stability. With irreparable rotator cuff tears, superior capsular reconstruction (SCR) improves dynamic glenohumeral (GH) joint kinematics. We present a novel method of SCR in cadaveric shoulders using the long head of bicep (LHB) tendon instead of previously explored fascia lata autograft, thereby reducing harvest site and suture anchor associated complications. Hypothesis This novel method of SCR using the LHB is feasible biomechanically in restoring shoulder stability in irreparable supraspinatus tendon tear. Materials and methods Seven cadaveric shoulders were tested in a custom shoulder testing system. Superior translation of the humerus, subacromial contact pressure and area, and glenohumeral range of motion were tested at 0°, 30°, and 60° of glenohumeral abduction in the following conditions: (1) intact shoulder, (2) simulated complete supraspinatus tendon tear, (3) modified SCR using LHB, (4) and modified SCR using LHB and side-to-side repair augmentation. Results The complete cuff tear shifted the humeral head superiorly as compared to the intact shoulder. Subacromial peak contact pressure was also increased at 30° and 60° while contact area was increased at 0° and 30°. The modified SCR both with and without side-to-side repair shifted the humeral head inferiorly at 30° and 60°, with contact area further reduced at 60°. Both techniques had comparable results for contact pressure and total rotational range of motion. Conclusion The LHB with appropriate distal insertion on the greater tuberosity restores shoulder stability in irreparable rotator cuff tears by re-centering the humeral head on the glenoid. Level of evidence Basic science study, biomechanical testing.

Tarsal coalition in paediatric patients.

Abstract: Tarsal coalition is due to failure of segmentation between two or more foot bones during embryological development at a site where the joint cleft fails to develop. Depending on the nature of the tissue connecting the bones, the abnormality is a syndesmosis, synchondrosis, or synostosis. Although the coalition exists at birth, synostosis usually develops only late during growth. Talo-calcaneal and calcaneo-navicular coalitions account for over 90% of all cases of tarsal coalition. The joint at the site of the coalition is stiff. Pain during physical activity is the main symptom, although recurrent ankle sprain is another possible presenting manifestation. During the physical examination, range-of-motion limitation at the hindfoot or midfoot should be sought, as well as varus or valgus malalignment of the hindfoot. Either pes planus or pes cavus may be seen. Calcaneo-navicular coalition may be visible on the standard radiograph, whereas talo-calcaneal coalition is best visualised by computed tomography or magnetic resonance imaging. As growth proceeds, the coalition becomes ossified and range-of-motion diminishes. Onset of the pain is often in the second decade of life or later. In patients with symptomatic tarsal coalition, the initial management should always consist in non-operative treatment for at least 6 months. A consensus exists that surgery should be offered when non-operative treatment fails. Open resection of the coalition is the treatment of choice, although endoscopic resection is also an option. Sound evidence exists that resection of the coalition can produce favourable outcomes even in the long-term. Fusion should be reserved for failure of resection, extensive coalitions, multiple coalitions, and patients with advanced osteoarthritis.

Predictive factors for satisfaction after contemporary unicompartmental knee arthroplasty and high tibial osteotomy in isolated medial femorotibial osteoarthritis

Abstract: Introduction Both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are viable treatment options for early osteoarthritis (OA). Although a substantial proportion of the patient selection criteria for HTO and UKA are now shared, the factors related to satisfaction following each procedure remain unclear. Hypothesis We hypothesized that patient factors associated with satisfaction following contemporary HTO and UKA would be different. Material and methods We retrospectively reviewed the records of consecutively enrolled medial opening-wedge HTOs (n = 123) and Oxford mobile-bearing UKAs (n = 118) with satisfactory postoperative alignment. Preoperative demographics, physical activity levels, varus deformity status, and degree of OA were recorded. Postoperative radiographs, frequency of combined procedures and patient-reported outcomes (PROs) including pain, Western Ontario and McMaster Universities Osteoarthritis Index score, and patient satisfaction were assessed. Results Severe OA (p Conclusion Despite the shared patient selection criteria for contemporary HTO and UKA, severe OA was associated with dissatisfaction following HTO, whereas young age and varus deformity were associated with dissatisfaction following UKA. Age, varus deformity and OA severity should be considered when deciding whether to perform HTO or UKA. Type of study and level of proof Retrospective cohort study, Level III.

Dual mobility device reduces the risk of prosthetic hip instability for patients with degenerated spine: A case-control study

Abstract: Introduction: The pelvic incidence is an anatomical and biomechanical pelvic parameter determining spine sagittal morphology and kinematics. Stiffening of the lumbo-pelvic complex, a result of degeneration, affects the functional cup positioning, putting prosthetic hip patients at risk of instability. The anti-dislocation dual mobility (DM) device may be clinically advantageous by reducing the risk of prosthetic instability for older patients with spine ageing. Our study aims to answer the following questions: (1) is there a relationship between prosthetic hip instability and the standing cup position, (2) is there a relationships between prosthetic hip instability and the pelvic incidence, (3) is there a relationships between prosthetic hip instability and the severity of the spine degeneration?, (4) is the DM cup device an effective option for reducing the risk of prosthetic instability related to spine degeneration?Hypothesis: There is a relationship between prosthetic hip instability and the standing cup position and pelvic parameters.Methods: Case-control study on prospectively collected data since 2009. From 1672 conventional total hip replacements (THR-5.4% dislocation rate) and 1056 DM-THRs (1.1% dislocation rate) performed at our institute since 2009, we created three groups: 33 patients with unstable THR (group 1-case), 41 patients with stable THR (group 2-control), and 42 patients with stable DM-THR (group 3-control). The cup orientation was measured on standing pelvic radiographs and the spino-pelvic parameters were measured on standing EOS™ biplanar images or lateral full spine radiographs.Results: By comparing patients from group 1 with those of group 2 we found they had similar cup position (57% versus 51% fitting the safe zone, p=0.58), higher pelvic incidence (58° versus 51°, p=0.01), and more severe spine degeneration (smaller anterior pelvic plane Tilt (2° versus 7° [p=0.002]), a larger pelvic incidence-lumbar lordosis mismatch (17° versus 8° [p=0.005]), and a higher proportion of spino-sacral angle<127° (70% versus 43%, (p=0.02)). Patients from group 3 had similar cup position, pelvic incidence, and spine degeneration compared to patients from group 1.Discussion/conclusion: Patients with spine-hip relation type 2C/D (high pelvic incidence and severe spine degeneration) have an increased risk of instability that is partly compensated for by the use of a DM device. Preoperative screening of patients with abnormal spine-hip relation would improve THR planning and reduce the risk of prosthetic hip instability. The use of a DM device on spine-degenerated elderly patients is probably sound.

Resection Margins Obtained With Patient-Specific Instruments for Resecting Primary Pelvic Bone Sarcomas: A Case-Control Study

Abstract: Background Limb salvage surgery for pelvic bone sarcoma carries a very high risk of local recurrence. Patient-specific instruments (PSIs) have shown promise for obtaining tumour-free resection margins. However, no data are available on medium-term outcomes including local recurrence rates after PSI-guided resection. The objectives of this case-control study were to determine whether PSI-guided resection: 1) was associated with a lower local recurrence rate, 2) allowed a shorter operative time, 3) was associated with better-quality allograft reconstruction. Hypothesis PSI-guided resection decreases the local recurrence rate by improving the resection margins in patients with primary pelvic bone sarcomas. Patients and methods PSI-guided resection was performed in 9 consecutive patients (cases) with primary pelvic sarcomas (chondrosarcoma, n = 3; Ewing's sarcoma, n = 3; osteosarcoma, n = 1; fibrosarcoma, n = 1; and radiation-induced sarcoma, n = 1). Age ranged from 11 to 63 years. Outcomes were compared to those in a historical control group of 19 patients with primary bone sarcomas who underwent resection surgery in the same hospital without PSI guidance. The case and control groups were similar regarding age, sex distribution, and follow-up duration. The local recurrence rate and operative time were compared between the two groups. Resection margins were classified as R0, R1, or R2. The quality of allograft reconstruction, which was performed in 7 of the 9 cases, was assessed. Results After a mean follow-up of 52 months (range, 30–90 months), none of the cases had experienced local bone or soft-tissue recurrences, compared to 7 of the 19 controls (p = 0.03), in whom mean follow-up was 62 months (range, 24–134 months). Bone resection margins were R0 in 8 cases; in the remaining patient, R1 resection was performed deliberately to preserve an S1 root. All 9 cases had R0 soft-tissue resection margins. In the control group, bone resection margins were R0 in 13 patients, R1 in 5 patients, and R2 in 1 patient (p = 0.47). Mean operative time was similar in the cases (612 minutes [range, 435–854 minutes]) and controls (633 minutes [range, 420–990 minutes]) (p = 0.87). In the 7 patients who underwent pelvic allograft reconstruction, allograft contact in the defect and osteosynthesis stability were deemed satisfactory by the surgeon. Discussion The lower local recurrence rate in the cases demonstrates that the improved resection accuracy provided by PSIs directly influences the risk of local recurrence. In addition, the R0 bone margins in 8 cases establishes that PSIs are effective in improving resection accuracy. Level of evidence III, case-control study.

Acetabular reconstruction using porous metallic material in complex revision total hip arthroplasty: A systematic review.

Abstract: Bone defects during acetabular revision of total hip arthroplasty raise a problem of primary fixation and of durable reconstruction. Bone graft with direct cemented fixation or in a reinforcement cage was long considered to be the gold standard; however, failures were reported after 10 years' follow-up, especially in segmental defect of the roof or pelvic discontinuity. In such cases, metallic materials were proposed, to ensure primary fixation by a roughness effect with added screws, and especially to avoid failure due to bone resorption in the medium term. We report a systematic literature analysis, addressing the following questions: (1) What materials are available and can be used with dual mobility (DM) designs? Apart from Trabecular Metal™ (TM), in which a DM cup can be cemented for sizes≥56mm, 4 other porous metals are available (Tritanium™, Trabecular Titanium™, Conceloc™, Regenerex™ and Gription™) although only the first 3 can be associated to DM. (2) Can the cost of these materials be estimated and compared to allograft with reinforcement cage? Considering simply the cost of the implant itself, compared to reconstruction by graft+cage+cemented cup (€2100), TM incurs an extra cost of €534, but with €1434 not covered by the French healthcare insurance. The cost of custom implants (apart from hemi-pelvis) ranges between €4200 and €8500, with only €4749 cover. (3) Do metallic materials ensure better survival than allograft+cage, according to severity of bone loss? Metallic reconstruction is claimed (with a low level of evidence) to reduce the risk of iterative loosening, but with a higher rate of dislocation, probably due to the lack of DM in many series. (4) What are the advantages and drawbacks of modular and custom metallic reconstructions? Modular reconstructions do not require 3D preoperative planning, but incur the risks of complications inherent to modularity. Custom implants can deal with more extensive defects, but require 5 to 8 weeks' production and are difficult to implant for the larger ones and/or when revision is limited to the acetabulum. (5) In what indications are these materials irreplaceable? Prior failure of allograft+cage in Paprosky type III defect with or without pelvic discontinuity shows the greatest benefit from metallic reconstruction, conditional on certain technical tricks. Only reconstructions using TM have more than 10 years' follow-up; other materials will need close monitoring. Failures in allograft with reinforcement cages occurred after about 10 years, and TM will need longer follow-up to prove its effectiveness. The high risk of dislocation should enable DM to be used, especially for small-diameter metallic reconstructions.

Diagnosis and treatment of tibiofibular syndesmosis lesions.

Abstract: The tibiofibular syndesmosis is a fibrous joint essential for ankle stability, whence the classical comparison with a mortise. Syndesmosis lesions are quite frequent in ankle trauma. This is a key element in ankle stability and lesions may cause pain or instability and, in the longer term, osteoarthritis. The lesions are often overlooked due to diagnostic difficulties, but collision sport with strong contact is the main culprit. Diagnosis, whether in the acute or the chronic phase, is founded on an association of clinical and paraclinical signs. Cross-sectional imaging such as MRI is fundamental to confirming clinical suspicion. Absence of tibiofibular diastasis no longer rules out the diagnosis. Stress CT and the introduction of weight-bearing CT are promising future diagnostic tools. Exhaustive osteo-ligamentous ankle assessment is necessary, as syndesmosis lesions may be just one component in more complex rotational instability. Therapeutically, arthroscopy and new fixation techniques, such as suture buttons, are opening up new perspectives, especially for chronic lesions (>6months). The present anatomic, epidemiological, diagnostic and therapeutic review does not preclude further clinical studies of rotational ankle instability with its strong risk of osteoarthritis.

Kinematically aligned total knee arthroplasty reproduces more native rollback and laxity than mechanically aligned total knee arthroplasty: A matched pair cadaveric study.

Abstract: Background A growing body of evidence supports that kinematically aligned (KA) total knee arthroplasty (TKA) provides superior clinical outcomes and satisfaction than mechanically aligned (MA) TKA. In theory, KA TKA would restore knee kinematics closer to the native condition than MA TKA, but the current biomechanical evidence is lacking. Hypothesis KA TKA would restore knee biomechanics to the native condition better than MA TKA. Methods Seven pairs of cadavers were tested. For each pair, one knee was randomly assigned to KA TKA and the other to MA TKA. During KA TKA, the sizes of femur and tibia resections were equivalent to implant thickness to align with the patient-specific joint line. MA TKA was performed using conventional measured resection techniques. All specimens were mounted on a customized knee-testing system and digitized. Knee motions measured during flexion included rollback, axial tibiofemoral rotation, and laxities, specifically varus-valgus laxity, anterior-posterior translation, and internal-external rotation. Results The pattern of knee motion following KA TKA was similar to the native knee. However, following MA TKA, both medial and lateral rollback and tibiofemoral axial rotation were decreased relative to those of the native knee. Valgus laxity was restored only after KA TKA, whereas varus laxity was restored only after MA TKA. Anterior translation was increased regardless of the alignment strategy. In addition, rotational laxities were restored after KA TKA, but external rotation laxity increased after MA TKA. Conclusion KA TKA restores femoral rollback and laxity to the native condition better than MA TKA. KA TKA may enhance functional performance and provide a more normal knee sensation. Level of evidence II, Controlled laboratory study.

Can the Reamer/Irrigator/Aspirator System replace anterior iliac crest grafting when treating long bone nonunion?

Abstract: INTRODUCTION Autologous bone graft is the gold standard for filling bone defects associated with diaphyseal nonunions. It is typically harvested from the anterior iliac crest (AIC) despite the high complication rate. The Reamer/Irrigator/Aspirator System (RIA) was developed to recover the reaming aspirate and use it as autograft. Initially described for harvesting bone from the femur, the bone volume available is similar to the AIC site; however, its use directly at nonunion sites has been studied very little. HYPOTHESES Compared to AIC harvesting, RIA at a non-union site will result in (1) sufficient bone volume, (2) similar time to union and union rate, (3) lower morbidity. RESULTS Two groups of patients received an autograft for aseptic nonunion of the tibia or femur for a bone defect up to 2cm: the RIA group (n=30) was followed prospectively and received an autograft by RIA while the AIC group (n=29) was reviewed retrospectively and received an autograft by AIC. We compared the time to union and union rate, operative time, intake of analgesics, duration of hospital stay and complication rate between groups. The RIA provided sufficient bone, 60cm3 on average in a reliable manner. The union rate was similar between groups: 90% (RIA) and 89.7% (CIA) (p=0.965), while the time to union was shorter in the RIA group (8.63±1.47months vs. 10.08±1.7 months) (p=0.006). The operative time (p<0.0001), analgesic intake (p=0.013), length of stay (p<0.0001) and immediate complication rate (p=0.0195) were higher in the AIC group. DISCUSSION For the treatment of aseptic long bone nonunion, autograft harvested by the RIA from the nonunion site results in similar union rate and time to union as AIC grafts without additional complications. LEVEL OF EVIDENCE IV, comparative retrospective study.

Management of lateral epicondylitis.

Abstract: Lateral epicondylitis is the most common cause of lateral elbow pain. Although also known as tennis elbow, lateral epicondylitis often develops as a work-related condition and therefore constitutes a major public health issue. This article reviews the pathophysiological factors involved in lateral epicondylitis, as well as the tools available for establishing the diagnosis and ruling out other causes of lateral elbow pain. Finally, the non-operative and surgical treatment options are discussed in detail.

Incidence and risk factors for cyclops syndrome after anterior cruciate ligament reconstruction: A systematic literature review.

Abstract: Background Cyclops syndrome after anterior cruciate ligament (ACL) reconstruction is due to a fibrous nodule that develops in the anterior part of the intercondylar notch and prevents full knee extension. The primary objective of this systematic literature review was to evaluate the incidence of symptomatic cyclops lesion after ACL reconstruction. The secondary objective was to identify risk factors for cyclops syndrome. Hypothesis Cyclops syndrome is common after ACL reconstruction and has several risk factors reported in the literature. Methods A systematic literature review was performed by searching the PubMed, Medline, CINAHL, Cochrane, and Embase databases with the key terms ‘cyclops’ and ‘ACL reconstruction’. The data thus retrieved were evaluated independently by two investigators. All articles in English or French that reported the incidence and risk factors of cyclops syndrome after ACL reconstruction were included. Results The search retrieved the titles and abstracts of 79 articles, of which 20 were selected to be read in full; among these, 10 were included in the study. The incidence of symptomatic cyclops lesion ranged from 1.9% to 10.9%. Identified risk factors were as follows: pre-operatively, knee inflammation and/or motion restriction at the time of ACL reconstruction; intra-operatively, narrow intercondylar notch and excessively anterior position of the tibial tunnel; and post-operatively, persistent hamstring muscle spasm. Discussion Development of a cyclops lesion is common after ACL reconstruction, occurs early, and may require further surgery. The knowledge of the risk factors provided by this study may improve the ability to devise effective preventive measures. Level of evidence II, systematic literature review.

Reconstruction techniques after proximal humerus tumour resection.

Abstract: Reconstruction of the proximal humerus after tumour resection is a surgical challenge. The goal consists not only in reconstructing the resected bone segment, but also in restoring a stable and mobile shoulder. The choice of the technique depends on the status of the soft-tissues at the end of the resection. The preoperative work-up must determine the oncological goals of the resection and identify the structures that can be spared. When deltoid muscle function is preserved, a reverse prosthesis offers the best stability and mobility outcomes. The objective of this work is to describe the indications and techniques used in the various available reconstruction methods. Shoulder mobilities are restored using some of these methods and lost with others. Emphasis is put on the reverse shoulder prosthesis, with a description of its variants (standard prosthesis, cement sleeve, allograft-prosthesis composite, and massive prosthesis) and a discussion of the management of its early complications. When performing reverse shoulder arthroplasty, glenoid implant preparation and positioning are crucial to achieve stability, and humeral length restoration will govern soft-tissue tension. Latissimus dorsi tendon transfer is required to restore active external rotation if the posterior rotator cuff tendons have been removed. Allograft-anatomic prosthesis composites, osteo-cartilaginous allografts, arthrodesis, and spacer prostheses are proposed for patients in whom the local conditions preclude implantation of a reverse shoulder prosthesis.

Application of computer-assisted virtual surgical procedures and three-dimensional printing of patient-specific pre-contoured plates in bicolumnar acetabular fracture fixation.

Abstract: Introduction With the rapid development of three-dimensional (3D) printing and computer technology, adopting computer-assisted virtual surgical procedures and 3D printing of patient-specific pre-contoured plates can greatly reduce surgical invasiveness and operative time and simplify the procedure. Hypothesis Use of computer-assisted virtual surgical procedures and 3D printing of patient-specific pre-contoured plates reduce the operative time and blood loss in bicolumnar acetabular fracture fixation. Methods A retrospective analysis was performed for 52 bicolumnar acetabular fracture cases treated surgically in our department from January 2013 to January 2017. According to the patients’ willingness to accept 3D printing services, 52 patients were divided into groups A and B. In group A (28 patients), computer-assisted virtual surgical procedures and 3D printing of patient-specific pre-contoured plates were adopted. In group B (24 patients), the conventional method was adopted. Fracture type, operative blood loss, surgical time, complications, radiographic quality of reduction, and hip function were compared between groups. All patients were operated by the same surgeon. Results The real surgical procedure of all patients in group A was almost identical to the preoperative virtual operation. Operative time and intraoperative blood loss were significantly reduced in group A than in group B ( p Conclusions Computer-assisted virtual surgical procedures, 3D printing technology and patient-specific pre-contoured plates can reduce the operative time and blood loss with less surgical invasiveness and ensure completely satisfactory clinical outcomes. However, promotion of this technology requires additional work. Level of evidence III, therapeutic study.

The third dimension of scoliosis: The forgotten axial plane.

Abstract: Idiopathic scoliosis is a three-dimensional (3D) deformity of the spine. In clinical practice, however, the diagnosis and treatment of scoliosis consider only two dimensions (2D) as they rely solely on postero-anterior (PA) and lateral radiographs. Thus, the projections of the deformity are evaluated in only the coronal and sagittal planes, whereas those in the axial plane are disregarded, precluding an accurate assessment of the 3D deformity. A universal dogma in engineering is that designing a 3D object requires drawing projections of the object in all three planes. Similarly, when dealing with a 3D deformity, knowledge of the abnormalities in all three planes is crucial, as each plane is as important as the other two planes. This article reviews the chronological development of axial plane imaging and spinal deformity measurement.

Injury patterns of medial meniscus posterior root tears.

Abstract: INTRODUCTION: Medial meniscus posterior root tear (MMPRT) can occur in middle-aged patients who have a posteromedial painful popping during light activities. MMPRTs are more common in patients with increased age, female gender, sedentary lifestyle, obesity, and varus knee alignment. However, injury mechanisms of minor traumatic MMPRTs are still unclear. We hypothesized that high flexion activities are the major cause of MMPRTs. The aim of this study was to clarify injury patterns of MMPRTs. MATERIALS AND METHODS: One hundred patients were diagnosed having MMPRTs after posteromedial painful popping episodes. Details of posteromedial painful popping episode, situation of injury, and position of injured leg were obtained from the patients by careful interviews. Injury patterns were divided into 8 groups: descending knee motion, walking, squatting, standing up action, falling down, twisting, light exercise, and minor automobile accident. RESULTS: A descending knee motion was the most common cause of MMPRTs (38%) followed by a walking injury pattern (18%) and a squatting action related to high flexion activities of the knee (13%). The other injury patterns were less than 10%. DISCUSSION: Descending knee motions associated with descending stairs, step, and downhill slope are the most common injury pattern of MMPRTs. High flexion activities of the knee are not the greatest cause of MMPRTs. Our results suggest that the descending action with a low knee flexion angle may trigger minor traumatic MMPRTs.

What are the influencing factors on hip and knee arthroplasty survival? Prospective cohort study on 63619 arthroplasties

Abstract: Background Body mass index is used by the World Health Organization to classify obesity. While obesity influences the onset of arthritis and type-2 diabetes, its effect on implant survival is still open to debate, with conflicting results from clinical and registry studies, as well as meta-analyses. Other known factors such as gender or diabetes status could ponderate or mask the effect of BMI on implant survival. Hypothesis Our hypothesis was BMI influenced hip and knee arthroplasty survival, when results were made independent of gender and diabetes status. Patient and methods A registry study was designed on 30733 Total Hip Arthroplasties (THA), 28483 Total Knee Arthroplasties (TKA), 3754 Uni compartmental Knee Arthroplasties (UKA) and 649 Hinged Knee arthroplasties (HK), from 01/01/2003 to 31/12/2015. Mean follow-up was 5.5 years. Diabetes status was added to the model. Each arthroplasty survival was tested for age at implantation, gender, diabetes status, implant characteristics and specifically BMI, taking into account gender and diabetes status. Results Gender had a strong influence on arthroplasty results. Age also influenced arthroplasty survival, especially aseptic loosening; a young age would lower implant survival. Diabetes had an influence in hip survival, but its influence on septic loosenings in TKA wasn’t proven (p = 0.065). A mobile liner and/or a cruciate retaining knee were factors increasing the risk of revision. Weight influenced THA survival, especially aseptic loosening, but didn’t have a measurable effect in any other arthroplasty. BMI was not found to influence any arthroplasty survival, whatever the endpoint, when diabetes and gender were taken into account. Discussion Gender, age and diabetes influenced survival of the lower limb arthroplasties, whereas BMI did not. Only weight did influence THA results and should be used instead of BMI. Conclusion Studies on arthroplasty survival should systematically mention gender and diabetes status and beware of potential group incomparability. Level of evidence III, cohort study.

Pitfalls and limits of locking plates

Abstract: The use of locking plates relies on novel mechanical and biological concepts: the bone healing is endochondral because of the elasticity of the constructs. Preoperative planning is required to determine the fracture reduction strategy and select the implants. The type of plate and the type of screws and their position determine the mechanical properties of the construct. Failure of locking plate fixation is a new phenomenon that differs from conventional plate fixation. These are brought on by inadequate planning, which is made worse when minimally invasive surgery is performed. Often, the fracture is not reduced correctly (leading to malunion), the implant length is incorrect, or the screw type, number, location and implantation sequence are inappropriate. Together these can result in an overly rigid construct with poor healing and implant failure or the opposite, an overly flexible construct that can compromise healing. The return to weight bearing after fracture fixation must be adapted to the type of fracture and construct. While locking plates provide better bone purchase, especially in osteoporotic bone, "en bloc" pulling out of the implant is possible. Delayed fractures at the end of the plates are also possible but can be avoided by making the correct biomechanical choices during fixation. For epiphyseal fractures, there are risks of cut-out and impaction of locking screws in cancellous bone related to the fracture pathology. In the long-term, locking plates can be difficult to remove; however, specialized instrumentation can make this easier.

Does the direct anterior approach allow earlier recovery of walking following total hip arthroplasty? A randomized prospective trial using accelerometry.

Abstract: Introduction In total hip arthroplasty (THA), the anterior approach is attractive, being intermuscular, with theoretic functional benefit. Such benefit has been frequently claimed, but there are few data from randomized comparative studies using more precise metrics than patient satisfaction. We therefore conducted a randomized trial comparing early functional results between anterior and posterior approaches on gait analysis and functional scores. Hypothesis The study hypothesis was that there is no difference between the two approaches in terms of early recovery of walking. Materials and method A single-center single-surgeon prospective randomized study was conducted between February 2017 and April 2018. Inclusion criteria comprised: age Results One hundred patients were randomized to the anterior approach (AA: n = 50) and posterior approach (PA: n = 50) groups. Hospital stay was comparable between groups: PA, 2.8 ± 1.78 days [range, 2.29-3.31 days]; AA, 2.84 ± 1.25 days [range, 2.48-3.2 days] (p = 0.8). Operative time was significantly longer in AA: 70.1 ± 11 minutes vs. 56.7 ± 11.79 (p Conclusion Early functional results and especially objective locomotor parameters following THA were comparable between anterior and posterior approaches at 3 to 12 weeks. The approach should be chosen according to the surgeon's experience. Level of evidence II, low-power prospective randomized study.

Failed rotator cuff repair.

Abstract: After rotator cuff repair, few patients require revision surgery, and failure to heal does not always translate into clinical failure, although healing is associated with better outcomes. Failure of rotator cuff repair is perceived differently by the patient, by the surgeon, and in terms of social and occupational abilities. The work-up of failed cuff repair differs little from the standard work-up of cuff tears. Information must be obtained about the circumstances of the first repair procedure, a possible diagnostic inadequacy and/or technical error, and early or delayed trauma such as an aggressive rehabilitation programme. Most cuff retears do not require surgery, given their good clinical tolerance and stable outcomes over time. Repeat cuff repair, when indicated by pain and/or functional impairment, can improve pain and function. The quality of the tissues and time from initial to repeat surgery will influence the outcomes. The ideal candidate for repeat repair is a male, younger than 70 years of age, who is not seeking compensation, shows more than 90 of forwards elevation, and in whom the first repair consisted only in tendon suturing or reattachment. In addition to patient-related factors, the local conditions are of paramount importance in the decision to perform repeat surgery, notably repeat suturing. The most favourable scenario is a small retear with good-quality muscles and tendons and no osteoarthritis. When these criteria are not all present, several options deserve consideration as potentially capable of relieving the pain and, to a lesser extent, the functional impairments. They include the implantation of material (autograft, allograft, or substitute), a muscle transfer procedure, or reverse shoulder arthroplasty. However, the outcomes are poorer than when these options are used as the primary procedure. Prevention is the best treatment of cuff repair failure and involves careful patient selection and a routine analysis of the treatments that may be required by concomitant lesions. Biceps tenotomy should be considered on a case-by-case basis. Smoking cessation should be strongly encouraged and any metabolic disorders associated with repair failure should be brought under control.