Arthroscopic suture-fixation of anterior tibial intercondylar eminence fractures by retensioning of the ACL and hollowing of the tibial footprint: Objective and subjective clinical results in a paediatric population.

INTRODUCTION: Anterior tibial intercondylar eminence fractures (ATIEF) of the knee are rare in children. They are associated with prefracture intraligamental distention of the anterior cruciate ligament (ACL). OBJECTIVE: The objective of this study was to evaluate the subjective and objective clinical results of an arthroscopic surgical technique by suture-fixation of the fracture and tensioning of the ACL through hollowing of the tibial footprint. HYPOTHESIS: Suture-tensioning of ATIEF arthroscopically helps to achieve treatment objectives by leaving the knee joint free of any hardware. MATERIALS AND METHODS: This single-operator monocentric retrospective study involved twenty children operated on over a period of 2-years and 10 months, from March 2013, and with a minimum of one-year follow-up. Surgery was indicated for Stage II to IV fractures according to the Meyers and McKeever classification. Type I fractures were excluded. Seventeen out of 20 patients were reviewed. The median age was 12 years at the time of surgery and the mean follow-up was 28 months. The fractures were 5 of stage II, 9 of III and 3 of IV. The scores of Lysholm, objective and subjective IKDC were collected. Residual objective laxity was measured using the GNRB arthrometer at 150N. A standard X-ray evaluation permitted detection of possible growth disorders. RESULTS: At 28 months of mean follow-up, the mean scores of Lysholm and subjective IKDC were 99 (95; 100) and 97 (92; 100), respectively. As for the objective IKDC, 14 knees were rated A and 3 were rated B. The mean differential residual laxity via GNRB was 0.94mm (0; 2.4). No radiological growth disorder was observed at the last follow-up. CONCLUSION: The ACL suture-tensioning technique is simple and reliable. It also preserves the joint of the adult to remain free of any residual hardware. LEVEL OF EVIDENCE: IV; retrospective cohort study.

Outcomes of Cemented Distal Femoral Replacement Using "Line to Line" Technique With All-Polyethylene Tibial Implant for Tumors.

BACKGROUND: Both cemented and cementless stemmed endoprosthetic implants have been used to reconstruct large skeletal defects after tumor resection with similar outcomes. In this study, we examined the oncologic, clinical, and functional outcomes in patients undergoing distal femur replacement using the French paradox technique. METHODS: A total of 125 patients who underwent distal femur replacement between 1990 and 2019 using the line-to-line cementation technique were reviewed. Implant failure was recorded as per Henderson's classification. Functional outcomes were analyzed using the Musculoskeletal Tumor Society and Toronto Extremity Salvage Score scoring systems. The mean follow-up was 84 (1-350) months. RESULTS: Aseptic loosening of the femoral stem was recorded in one patient at 21-years of follow-up. Twenty of 125 patients required bushing exchange for polyethylene wear, all after 10 years. Six tibial bearing component fractures were recorded in four patients while one femoral stem component Morse taper fractured. Two all-polyethylene cemented tibial implants were revised for polyethylene granuloma. Deep surgical site infection occurred in 13 patients, while six patients experienced local recurrence. Kaplan-Meier estimates for implant survival for all-cause revision were 85% at 1 year and 70% at 5 years. These estimates for femur or tibia loosening as an end point were 96% at 10 years and 90% at 15 years. The mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Score scores at the last follow-up were 76% and 74%, respectively. Thirty-five patients died of disease progression. CONCLUSION: The line-to-line cementation technique, used with all-polyethylene tibial implants, demonstrates low incidence of aseptic loosening at medium and long-term follow-ups. LEVEL OF EVIDENCE: III.

Epidemiology of spinal fractures in children: Cross-sectional study.

INTRODUCTION: Epidemiological studies of fractures of the spine in children are all old, mostly single-centre, with series spanning periods of 5 to 20 years. HYPOTHESIS: As lifestyle is constantly changing, notably with an increase in sports activities and improvements in the prevention of road and household accidents, epidemiology has likely changed. OBJECTIVE: To update the description of spinal trauma in children and adolescents compared to the existing literature. MATERIAL AND METHOD: A multicentre cross-sectional study of spinal fracture, dislocation and spinal cord injury without radiological abnormality (SCIWORA) in children was carried out in 15 French university hospital centres, for a period of one year (2016). RESULTS: One hundred and sixty-five children were identified: 85 girls, 80 boys; mean age 11 years (range, 10 months-17 years); median, 12 years 6 months. One hundred and fifty-two children (92%) had fracture, 8 (5%) dislocation (including 7 C1-C2 rotary dislocations), and 5 (3%) SCIWORA. Fractures were multiple in 80 cases (49%), contiguous in 73 cases (91%) and non-contiguous in 7 (9%). Locations were cervical in 25 cases (15%), thoracic in 85 (52%), lumbar in 75 and sacral in 4 (2%). Fracture types comprised 234 vertebral compactions (78%), 25 burst fractures (8%), 5 chance fractures (2%), 2 odontoid fractures, and 33 other lesions. Causes comprised fall in 77 cases (47%), sports accidents in 56 (34%), road accidents in 29 (18%), and others in 3. In 52 cases (32%), there was ≥1 associated lesion: appendicular in 35 cases (67%), thoracic or abdominal in 31 (60%), and head in 16 (31%). Twenty-one cases had multiple lesions (40%). Eighteen cases showed neurological involvement (11%) including 5 SCIWORAs. Neurological complications were more frequent before 9 years of age. CONCLUSION: The epidemiology of spine fractures in children has slightly changed. There are now fewer cervical lesions. Causes are less often road accidents and more often sports accidents. Multi-level lesions remain frequent and the rate of neurological complications is around 10%. Compaction fracture is the most common type.

Can the TrueLok Hexapod System™ be used to accurately correct lower limb deformity in children?

INTRODUCTION: Progressive bone lengthening in children can be done using an external fixator, a lengthening nail, or plate with screws. The TrueLok Hexapod System™ (TL-HEX™) is the newest hexapod external fixator on the market. We hypothesized that the TL-HEX™ can accurately correct lower limb deformities in children. The goal of this study was to evaluate the clinical and radiographic outcomes after correcting lower limb deformities in children using the TL-HEX™ system. MATERIAL AND METHODS: Data from 58 limbs that underwent bone lengthening with the TL-HEX™ were analyzed for this retrospective, single-center study. The average patient age was 11.4 years. The femur was lengthened in 23 limbs and the tibia in 35. The outcomes were evaluated using long leg standing radiographs preoperatively and at the final assessment. The variables of interest were the mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), mechanical lateral proximal tibia angle (mMPTA), healing index (HI) and accuracy of the correction. The complications were graded on a 4-point scale summarizing three broad goals: planned correction, duration of treatment and sequelae. The accuracy of the correction was defined as the difference between the planned correction and the actual correction achieved. RESULTS: The mean HI was 37 days/cm. Significant correction was achieved for leg length discrepancy (LLD) (60 mm vs. 20 mm; p<0.01) and mLDFA (88.6° vs. 89.9°; p=0.04) but not the MAD (17.7 vs. 14.7; p= 0.17) or mMPTA (87.3 vs. 88.1; p=0.08). In the entire cohort, the difference from planned was 12.5 mm (p<0.01) for lengthening, 1.3° for the mLDFA (p=0.5) and 3° for the mMPTA (p=0.02). Relative to the initial goal, the mean lengthening achieved was 118%. In the sub-group where the plan did not need to be modified, the accuracy of the correction was better. There were 40 complications (69%). CONCLUSION: The TL-HEX™ is an effective and accurate system. The complication rate associated with its use is the same as other hexapod external fixators. Surgeons and patients must be aware of the high complication rate, which may require the plan to be modified and could potentially compromise the outcome.

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

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.

Descriptive and dynamic study of the medial patellofemoral ligament (MPFL).

PURPOSE: The goal of this study was to evaluate the anatomy of the medial patellar retinaculum and the medial patellofemoral ligament (MPFL) to provide an anatomical validation of a pediatric reconstruction technique. METHODS: Fifteen knees were dissected to study the MPFL and its relationship with the medial patellar retinaculum and the femoral insertion of the medial collateral ligament (MCL). The distances between the insertions of the MPFL of eight knees, and the patellar insertion of the MPFL and the femoral insertion of the MCL of four knees, were measured during the flexion to evaluate the isometricity of the native and reconstructed MPFL. RESULTS: The medial patellar retinaculum includes four structures: the fascia, fibrous expansions of the vastus muscles, the MPFL and the medial patellomeniscal ligament. The femoral insertion of the MPFL was located just behind the femoral insertion of the MCL in 12 knees. During flexion, the distance between the insertion on the upper patella and the femoral insertion of the MPFL increased while the distance between the insertion on the lower patella and the femoral insertion of the MPFL decreased. The variation in the distances measured during the flexion was greater between the MPFL insertions (nsup = 6.5 mm, ninf = 6.5 mm) than between the patellar insertion of the MPFL and the femoral insertion of the MCL (n'sup = 2.5 mm, n'inf = 5.75 mm). CONCLUSION: The MPFL is not isometric. Even though the results were obtained from knees of elderly specimens, this study demonstrates reconstruction of the MPFL should take into account its anatomy and biomechanical role in the knee.

Isolation of circulating tumor cells in a preclinical model of osteosarcoma: Effect of chemotherapy.

Osteosarcoma is a rare primary bone tumor, which mainly affects children and adolescents and has a poor prognosis, especially for patients with metastatic disease. A poor therapeutic response to the conventional chemotherapy is observed with the development of lung metastases, highlighting the need for improving the current regimens and the identification of early markers of the recurrent and metastatic disease. Circulating Tumour Cells (CTCs) play a key role in the metastatic process and could be powerful biomarkers of the progressive disease. The present study aimed to isolate CTCs by using a pre-clinical model of human osteosarcoma and to monitor their kinetic of release and their modulation by ifosfamide. CTCs were detectable into the bloodstream before any palpable primary tumors. Ifosfamide increased CTCs count and in contrast decreased the number of lung tumor nodules. On established tumors, ifosfamide slowed down the tumour growth and did not modulate CTC count that could be explained by a release of cancer cells from the primary tumour with reduced properties for inducing lung metastases. This report highlights the biological interest of CTCs in osteosarcoma.

How Sublaminar Bands Affect Postoperative Sagittal Alignment in AIS Patients with Preoperative Hypokyphosis? Results of a Series of 34 Patients with 2-Year Follow-Up.

Hypokyphosis is currently observed in thoracic idiopathic scoliosis. The use of sublaminar bands allows a good restoration of sagittal balance of the spine. The aim of the study was to provide a middle-term radiographic analysis of patients with adolescent idiopathic scoliosis with preoperative hypokyphosis treated by posterior arthrodesis with sublaminar bands. This retrospective study included 34 patients with Lenke 1 scoliosis associated with hypokyphosis (TK < 20°). A radiographic evaluation was performed with a 2-year follow-up. Cobb angle, cervical lordosis, thoracic kyphosis, lumbar lordosis, and pelvic parameters were measured preoperatively, postoperatively, and at 6-month and 2-year follow-up. The mean preoperative thoracic kyphosis was 10.5° versus 24.1° postoperatively (p < 0.001), representing a mean gain of 13°. Cobb angle ranged from 59.3° to 17.9° postoperatively (mean correction 69%, p < 0.001). Cobb angle increased between the immediate postoperative measurement and the 6-month follow-up (17.9 versus 19.9, p = 0.03). Cervical curvature changed from a 5.6° kyphosis to a 3.5° lordosis (p = 0.001). Concerning lumbar lordosis, preoperative measurement was 39.7° versus 41.3° postoperatively (p = 0.27). At 6-month follow-up, lumbar lordosis significantly increased to 43.6° (p = 0.03). All parameters were stable at final follow-up. Correction performed by sublaminar bands is efficient for both fontal and sagittal planes. Moreover, the restoration of normal thoracic kyphosis is followed by an adaptation of the adjacent curvatures with improved cervical lordosis and lumbar lordosis.

Circulating Tumor Cells: A Review of Non-EpCAM-Based Approaches for Cell Enrichment and Isolation.

BACKGROUND: Circulating tumor cells (CTCs) are biomarkers for noninvasively measuring the evolution of tumor genotypes during treatment and disease progression. Recent technical progress has made it possible to detect and characterize CTCs at the single-cell level in blood. CONTENT: Most current methods are based on epithelial cell adhesion molecule (EpCAM) detection, but numerous studies have demonstrated that EpCAM is not a universal marker for CTC detection because it fails to detect both carcinoma cells that undergo epithelial-mesenchymal transition (EMT) and CTCs of mesenchymal origin. Moreover, EpCAM expression has been found in patients with benign diseases. A large proportion of the current studies and reviews about CTCs describe EpCAM-based methods, but there is evidence that not all tumor cells can be detected using this marker. Here we describe the most recent EpCAM-independent methods for enriching, isolating, and characterizing CTCs on the basis of physical and biological characteristics and point out the main advantages and disadvantages of these methods. SUMMARY: CTCs offer an opportunity to obtain key biological information required for the development of personalized medicine. However, there is no universal marker of these cells. To strengthen the clinical utility of CTCs, it is important to improve existing technologies and develop new, non-EpCAM-based systems to enrich and isolate CTCs.

What are the risk factors for post-operative infection after hip hemiarthroplasty? Systematic review of literature.

BACKGROUND: Femoral neck fractures are frequent in the elderly population and lead to high morbidity and mortality. Hemiarthroplasty is an established surgical procedure for displaced intracapsular femoral neck fractures. Post-operative infection is frequent and is potentially devastating for the patient and the healthcare services. The goal of this study was to identify the risk factors of infection after hemiarthroplasty and help adapt our surgical practice. METHODS: A systematic review of the literature was performed in July 2015 by two authors using the MedLine, PubMed and Cochrane databases. We used the MeSH keywords "hip hemiarthroplasty" AND "infection" to identify risk factors and methods of prevention for surgical site infection after hemiarthroplasty. Following the search, two authors independently performed the first stage based on titles and abstracts. RESULTS: Thirty-seven articles were selected. Review and analysis of the references was performed to find other articles of interest. Thirteen articles were selected to analyse. According to literature, the surgical site infection (SSI) rate after hip hemiarthroplasty (HHA) is between 1.7 and 7.3 %. Pre-operative comorbidities (obesity, liver disease, advanced age), operative conditions (junior surgeon, uncemented stems, time of surgery) and post-operative management (length of hospitalisation, haematoma, prolonged wound drainage and two urinary catheterisations) were identified as risk factors of surgical site infection. Authors describe conditions to decrease the incidence of these complications and underline the importance of "a specialised hip team" that provides fast care and helps decrease the duration of hospitalisation. CONCLUSIONS: Careful patient management for hemiarthroplasty is vital and may decrease the incidence of surgical site infection, which is associated with high morbidity and high procedure cost. Our review suggests that there are specific correctable risk factors for SSIs after HHA. Being able to identify these risk factors leads to better care because of SSI prevention in patients undergoing HHAs after femoral neck fractures. To improve the outcomes, some methods of prevention of surgical site infection are available: before, during and after the operation. STUDY DESIGN: Review of literature. LEVEL OF EVIDENCE: IV.