Poor clinical outcomes and high rates of dislocation after modular reverse shoulder arthroplasty for proximal humeral oncologic resection.

PURPOSE: The shoulder is the most common site for upper extremity tumors. The aim of the study was to analyze the outcomes and the complications of modular reverse shoulder arthroplasty (RSA) after proximal humerus resection. METHODS: We retrospectively included 15 consecutive patients who underwent a modular MUTARS™ RSA reconstruction after proximal humerus tumour resection between 2017 and 2020. The mean age was 52 years. Their clinical outcomes were assessed using the Constant-Murley score and the MSTS shoulder. Radiological outcomes were assessed based on the presence of loosening, osteolysis, and scapular notching. Complications such as dislocation, oncological recurrence, and infection were assessed. Mean follow-up time was 32.9 months (24 to 45). RESULTS: The mean adjusted Constant score was 50.7% (min 22, max 81), and the mean MSTS score was 15.6 (min 4, max 26). We had no loosening, osteolysis, or scapular notching on the radiographs at last follow-up. We had a high complication rate of 53%: one infection, one oncological recurrence, and six dislocations (40%), of which five were re-operated. CONCLUSION: In our experience, the MUTARS™ Implantcast™ modular RSA has poor functional results and a high rate of dislocation in the case of large proximal humerus resections below the distal insertion of the deltoid.

Presurgical Perspective and Postsurgical Evaluation of Non-Achilles Tendons of the Ankle and Retinaculum.

The vast majority of non-Achilles ankle tendinopathies are related to overuse. This article discusses the clinical aspect, imaging appearance, and management of tendinopathies of the lateral, medial, and the anterior compartments with a focus on presurgical perspective and postsurgical evaluation.

Sarcomas in patients over 90: Natural history and treatment-A nationwide study over 6 years.

Soft tissue sarcomas (STS) are rare tumors accounting for less than 1% of human cancers. While the highest incidence of sarcomas is observed in elderly, this population is often excluded or poorly represented in clinical trials. The present study reports on clinicopathological presentation, and outcome of sarcoma patients over 90 recorded in the Netsarc.org French national database. NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor board (MDTB), funded by the French National Cancer Institute to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB, second pathological review, and collection of sarcoma patient characteristics and follow-up are collected in a database Information of patients registered from January 1, 2010, to December 31, 2016, in NETSARC were collected, analyzed and compared to the younger population. Patients with sarcomas aged >90 have almost exclusively sarcomas with complex genomics (92.0% vs. 66.3%), are less frequently metastatic (5.3% vs. 14·7%) at diagnosis, have more often superficial tumors (39.8% vs. 14.7%), as well as limbs and head and neck sites (75.2% vs. 38.7%) (all p < 0.001). Optimal diagnostic procedures and surgery were less frequently performed in patients over 90 (p < 0.001). These patients were less frequently operated in NETSARC centers, as compared to those of younger age groups including aged 80-90. However, local relapse-free survival, metastatic relapse-free survival and relapse-free survival were not significantly different from those of younger patients, in the whole cohort, as well as in the subgroup of operated patients. As expected overall survival was worse in patients over 90 (p < 0.001). Patients over 90 who were not operated had worse overall survival than younger patients (9.9 vs. 27.3 months, p < 0.001). Patients with STS diagnosed after 90 have distinct clinicopathological features, but comparable relapse-free survival, unless clinical practice guidelines recommendations are not applied. Standard management should be proposed to these patients if oncogeriatric status allows.

Improvement of the initial management of sarcomas after the dissemination of evidence-based guidelines depends on the primary sarcoma location: a population-based study.

BACKGROUND: Improvement of the initial management of sarcomas after the dissemination of evidence-based guidelines depends on the primary sarcoma location: a population-based study. To improve the initial management of adult sarcomas, a regional expert team in Northern France performed two actions: dissemination of evidence-based guidelines (EBG) for the management of soft tissue/visceral sarcoma and yearly educational symposia. The aim of this study was to measure the impact of the dissemination of EBG on the key-indicators of adult sarcoma management. METHODS: We conducted a before-after population-based study (before: 2005 with 63 cases, after: 2008-2009 with 86 cases) in the Lille area (Northern France urban/sub-urban area with 800,000 inhabitants). The following were the key-indicators of adult sarcoma management: pre-therapeutic biopsy, appropriate tumour and chest imaging, expert interdisciplinary discussion, expert interdisciplinary discussion before the first treatment and in operated cases, the rate of R0 resection. RESULTS: There was no statistically significant difference in patient and tumour characteristics for the two time periods in terms of gender, prior cancer, primary location, histological subtype, grade, size, metastasis and lymph node involvement. There was no statistically significant improvement in primary tumour imaging (83 versus 87%), chest imaging (67 vs 71%), pre-therapeutic biopsy (57 vs 58%). There was an improvement in expert multidisciplinary discussion (37 vs 45%) or discussion before the first treatment (26 vs 44%) but no statistically significant. However, when soft tissue and bone sarcomas were analysed separately, we observed statistically significant improvements in expert multidisciplinary discussion (50 vs 74%, p = 0.02) and R0 resection rate (58 vs 91%, p = 0.002). In contrast, in cases of visceral sarcoma, there was no improvement in expert multidisciplinary discussion (10 vs 16%, p = 0.7) or in R0 resection (88 vs 81%, p = 0.7). CONCLUSIONS: The dissemination of EBG was associated with a limited improvement in sarcoma management when measured in this before-after population-based study, and this improvement was dependent on the primary location of the tumour. Efforts to implement these guidelines by all surgical teams that could treat sarcoma, including visceral sarcoma, need to be made.

Limb schwannoma: Factors for postoperative neurologic deficit and poor functional results.

INTRODUCTION: Neurologic complications after limb schwannoma resection are not unusual, but there is no consensus on risk factors for neurologic deficit or poor functional results. We therefore conducted a retrospective study, to screen for factors predicting, firstly, postoperative neurologic deficit and, secondly, poor functional results. HYPOTHESIS: Certain pre- and intraoperative features predict risk of failure, poor results or aggravation. PATIENTS AND METHODS: A single-center retrospective study was conducted in the University Hospital of Lille, France, for the period January 2004 to March 2020, including 71 patients. Preoperative variables (gender, age, symptoms, progression, tumor location and size) and operative data (type of surgery) were collected as possible risk factors for postoperative sensory deficit (Weber) and/or motor deficit [Medical Research Council (MRC)] and poor functional result [Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH); Lower Extremity Functional Scale (LEFS) and douleur neuropathique (neuropathic pain) 4 (DN4)]. RESULTS: Results were assessed a mean 69.4±38.5 months' follow-up (range, 6-180 months). In total, 21 patients (29.6%) had deficits (21 sensory, 1 motor) preoperatively and 25 patients (35.2%) postoperatively (20 sensory, 9 motor) (p=0.689). Fourteen patients (19.7%) showed functional aggravation. Fascicular resection was associated with risk of postoperative deficit [OR = 4.65 (95% CI: 1.485-15.543); p=0.004] and functional deterioration [OR = 3.9 (95% CI: 1.143-13.311); p=0.042]. Thirteen patients (18.3%) showed no improvement on DN4. Preoperative pain was a factor for improvement on DN4 [OR = 3.667 (95% CI: 1.055-12.738); p=0.0409]. DISCUSSION: The study identified fascicular resection as a risk factor for postoperative deficit and functional deterioration after limb schwannoma resection. Patients with preoperative neuropathic pain showed alleviation. Resection should be precise, under magnification, avoiding fascicular resection. Preoperative patient information is essential. LEVEL OF EVIDENCE: IV; retrospective series.

Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year.

OBJECTIVE: The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results. HYPOTHESES: There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols. METHODS: This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review. RESULTS: Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07). CONCLUSIONS: This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes. LEVEL OF EVIDENCE: III; retrospective comparative, non-randomized.

Portable device for measuring isometric plantar-flexion force after open Achilles repair: Retrospective cohort of 30 recreational athletes with one-year minimum follow-up.

BACKGROUND: Plantar flexion force in recreational athletes after repair of Achilles tendon tears has rarely been reported, due to the lack of a widely available and fast measurement method. Knowledge of this parameter would allow optimisation of muscular and sports recovery. The main objective of this study was to measure the isometric force of the triceps surae at least 1 year after unilateral Achilles-tendon repair, comparatively to the unaffected side, using a portable device. The secondary objectives were to compare Achilles tendon and calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test versus the normal side and to assess functional scores at last follow-up. HYPOTHESES: (i) Plantar flexion force does not differ significantly between the operated and contralateral sides. (ii) Calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test do not differ significantly between the operated and contralateral sides. PATIENTS AND METHODS: This single-centre retrospective study included patients aged 18 to 65 years with a history of open repair of an acute unilateral Achilles tear at least 1 year earlier. Plantar flexion force, calf-muscle trophicity, dorsiflexion, and the heel-to-floor distance were measured on both sides and compared. The ATRS, VISA-A score, and EFAS score were determined. All complications were recorded. RESULTS: The study included 30 patients with a mean follow-up of 20.3 months (range, 12-28 months). The operated side had significantly lower values for isometric triceps surae force, calf circumference, and heel-to-floor distance compared to the contralateral side (p<0.0001). Tendon width was significantly greater on the operated side (p<0.0001). Dorsiflexion did not differ significantly between sides (p=0.106). Mean functional score values were 91.5±6 for the ATRS (maximum, 100), 85±12 for the VISA-A score (maximum, 100), and 19.5±4 for the EFAS score (maximum, 24). DISCUSSION: Isometric triceps-surae force measured using a portable device at least 1 year after open surgical Achilles-tendon repair was significantly decreased compared to the contralateral side. Calf circumference and heel-to-floor distance were also significantly lower. These data indicate a need for improved monitoring of triceps surae recovery to optimise rehabilitation and sports resumption. LEVEL OF EVIDENCE: IV, retrospective comparative cohort study.

Long-term prevalence and impact of glenohumeral osteoarthritis after Latarjet-Patte procedure for anterior instability.

INTRODUCTION: The Latarjet procedure provides satisfactory functional results, with low rates of recurrence. It is, however, sometimes claimed to induce osteoarthritis due to the positioning of the bone-block and hardware. The aims of the present study were to assess the long-term prevalence of osteoarthritis following the procedure, to determine risk factors and assess clinical impact. The study hypothesis was that osteoarthritis risk can be reduced by good bone-block positioning. The secondary objective was to assess long-term recurrence of instability. MATERIALS AND METHODS: Out of a cohort of 102 patients (106 shoulders) operated on between 1984 and 1998, 77 had complete radiology files for analysis in a previous study published in 2003. Forty-four of these patients were seen again for clinical and radiological assessment at a mean 22 years' follow-up, to be compared to results previously reported at 8 years. Clinical assessment comprised range of motion and Constant and Walch-Duplay scores. X-rays were taken systematically to determine Samilson osteoarthritis stage; 31 patients also underwent CT. RESULTS: In the 44 patients, the rate of osteoarthritis was 34.1%. 90.9% of patients were satisfied. Mean Constant score was 83.5±14 and mean Walch-Duplay score was 71.6±23.4. Advanced age at surgery and at assessment, length of follow-up and age >30 years at first episode of instability were the main factors for onset of osteoarthritis, independently of surgery. Lateral bone-block overhang correlated with onset of osteoarthritis: 71.4%, versus 16.7% in medial or flush bone-block (p=0.0004). Humeral notch, glenoid bone defect and number of preoperative episodes of instability were unrelated to onset of osteoarthritis. Lateral bone-block overhang was the only risk factor related to surgery. The clinical impact of the osteoarthritis was significant only in advanced stages (Samilson 3 and 4). CONCLUSION: Lateral bone-block overhang was the only surgical risk factor for osteoarthritis in the long-term. Strict coracoid positioning is therefore essential, and could be facilitated by specific instrumentation and by arthroscopy. LEVEL OF EVIDENCE: IV; retrospective study.

Recovery of leg strength based on isokinetic testing after tumor resection and reconstruction with a modular rotating hinge knee system: Prospective cross-sectional study with a minimum follow-up of 24 months.

BACKGROUND: While modular reconstruction implants can be used to replace the bone lost after bone tumor resection, tumor excision from the neighboring soft tissues can lead to loss of strength and joint range of motion (ROM), which results in worse knee function. Functional recovery after total knee arthroplasty for osteoarthritis has been extensively documented. But few studies have evaluated the recovery after total knee reconstruction following tumor excision despite the fact that most of these patients are young and have high functional demands. We did a prospective cross-sectional study to: 1) compare muscle strength recovery around the knee with an isokinetic dynamometer after tumor excision and reconstruction with a modular implant to the healthy contralateral knee; 2) determine if the differences in peak torque (PT) in the knee extensors and flexors had a clinical impact. HYPOTHESIS: Resection of soft tissues during tumor excision around the knee causes strength loss that cannot be fully recovered. METHODS: The 36 patients who underwent extra- or intra-articular resection of a primary or secondary bone tumor in the knee area followed by reconstruction with a rotating hinge knee system between 2009 and 2021 were eligible for this study. The primary outcome was the ability to actively lock the operated knee. The secondary outcomes were the concentric PT during isokinetic testing at slow (90°/sec) and fast (180°/sec) speeds, flexion-extension ROM, Musculoskeletal Tumor Society (MSTS) score, the IKS, Oxford Knee Score (OKS) and KOOS. RESULTS: Nine patients agreed to participate in the study, all of whom had regained the ability to lock their knee postoperatively. PT in flexion and extension on the operated knee was less than the healthy knee. The PT ratio for the operated/healthy knee at 60°/sec and 180°/sec in flexion was 56.3%±16.2 [23.2-80.1] and 57.8%±12.3 [37.7-77.4], respectively, which corresponded to a slow-speed strength deficit of 43.7% in the knee flexors. The PT ratio for the operated/healthy knee at 60°/sec and 180°/sec in extension was 34.3%±24.6 [8.6-76.5] and 43%±27.2 [13.1-93.4], respectively, which corresponded to a slow-speed strength deficit of 65.7% in the knee extensors. The mean MSTS was 70%±20 [63-86]. The OKS was 29.9/48±11 [15-45], the mean IKS knee was 149.6±36 [80-178] and the mean KOOS was 67.43±18.5 [35-88.7]. DISCUSSION: Despite all patients having the ability to lock out their knee, there was an imbalance in the strength between opposite muscle groups: 43.7% strength deficit at slow-speed and 42.2% at fast speed for the hamstring muscles, and 65.7% at slow-speed and 57% at fast speed for the quadriceps muscles. This difference is considered pathological with an increased risk of knee injury. Despite this strength deficit, this joint replacement technique, which is free of complications, can preserve good knee function with acceptable knee joint ROM and satisfactory quality of life. LEVEL OF EVIDENCE: III; prospective cross-sectional case-control study.

Ankle surgery in 2022: What do the scientific articles say, and what do the patients?

LEVEL OF EVIDENCE: V.

Average 4-Year Outcomes of Distal Oblique First Metatarsal Osteotomy for Stage 1 to 3 Hallux Rigidus.

BACKGROUND: Hallux rigidus is the second most frequent pathology of the first ray. Surgical options for degenerative metatarsophalangeal joint disease are either joint destructive or conservative procedures. The hypothesis was that oblique distal shortening osteotomy of the first metatarsal is an effective conservative technique for the management of stage 1 to 3 hallux rigidus. METHODS: We conducted a retrospective cohort study of 87 feet with Coughlin and Shurnas's stage 1-3 hallux rigidus, operated between 2009 and 2019. The cohort consisted in 72 patients (87 feet) with an average age of 57±9 (30/79) years; 22 of 87 (25.3%) feet had the first metatarsal surgery performed in isolation; 65 of 87 (74.7%) had concomitant forefoot procedures, including 31 of 87 (35.6%) with Akin phalangeal osteotomies and 34 of 87 (39.1%) with Moberg phalangeal osteotomies.We evaluated the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, subjective satisfaction, joint amplitudes, shortening rate, and occurrence of postoperative complications with a mean follow-up of 51 months (16/134). RESULTS: The AOFAS score increased from 54.2±11.3 (25/70) preoperatively to 92.2±7.8 (62/100) postoperatively (P < .001). Patients reported excellent or good outcome in 95.4% of cases. The 40-point self-reported pain subscale score improved from 19.6 (± 10.0) to 37.4 (± 5.4), P < .001.The overall range of motion increased from 61±21 (20/110) degrees to 69±17 (35/120) degrees (P < .001). The mean first metatarsal shortening rate (SRpo) was 9.6%. Neither the Coughlin grade, the metatarsal index, or the SRpo influenced the AOFAS score. At 6-month follow-up, 15 patients had transfer metatarsalgia compared with 5 at last follow-up without requiring another surgical procedure. The risk was not significantly different according to Coughlin's stage, preoperative metatarsal index, or SRpo. CONCLUSION: Oblique distal osteotomy of the first metatarsal for stage 1-3 hallux rigidus, often in combination with other first ray procedures, performed well during our follow-up time period, with a high subjective satisfaction rate and few complications. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Outcome and predictors of treatment failure in total hip/knee prosthetic joint infections due to Staphylococcus aureus.

BACKGROUND: Variables associated with the outcome of patients treated for prosthetic joint infections (PJIs) due to Staphylococcus aureus are not well known. METHODS: The medical records of patients treated surgically for total hip or knee prosthesis infection due to S. aureus were reviewed. Remission was defined by the absence of local or systemic signs of implant-related infection assessed during the most recent contact with the patient. RESULTS: After a mean posttreatment follow-up period of 43.6 ± 32.1 months, 77 (78.6%) of 98 patients were in remission. Retention of the infected implants was not associated with a worse outcome than was their removal. Methicillin-resistant S. aureus (MRSA)-related PJIs were not associated with worse outcome, compared with methicillin-susceptible S. aureus (MSSA)-related PJIs. Pathogens identified during revision for failure exhibited no acquired resistance to antibiotics used as definitive therapy, in particular rifampin. In univariate analysis, parameters that differed between patients whose treatment did or did not fail were: American Society of Anesthesiologists (ASA) score, prescription of adequate empirical postsurgical antibiotic therapy, and use of rifampin combination therapy upon discharge from hospital. In multivariate analysis, ASA score ≤2 (odds ratio [OR], 6.87 [95% confidence interval {CI}, 1.45-32.45]; P = .04) and rifampin-fluoroquinolone combination therapy (OR, 0.40 [95% CI, 0.17-0.97]; P = .01) were 2 independent variables associated with remission. CONCLUSIONS: The results of the present study suggest that the ASA score significantly affects the outcome of patients treated for total hip and knee prosthetic infections due to MSSA or MRSA and that rifampin combination therapy is associated with a better outcome for these patients when compared with other antibiotic regimens.

A low teres minor index of trophicity negatively impacts the functional outcomes of reverse shoulder arthroplasty.

INTRODUCTION: The teres minor (TM) participates in active external rotation (ER) after reverse shoulder arthroplasty (RSA). The TM index of trophicity (T2/G) measured on CT scan is a predictor of poor results in patients who have irreparable rotator cuff tears. The aim of this study was to evaluate how T2/G impacts the functional outcomes of RSA in the context of massive rotator cuff tears. We hypothesized that a T2/G less than 0.75 is a predictor of worse functional outcomes. MATERIALS AND METHODS: This study involved 32 shoulders in 26 patients (mean age 71 years) who underwent RSA for cuff tear arthropathy and had a minimum follow-up of 1 year (mean 3 years). T2/G is the ratio between T2 (TM thickness) and G (maximum glenoid cavity thickness) on preoperative axial CT slices. Clinical examination at the final assessment involved determining the Constant score, the shoulder joint's range of motion and the Subjective Shoulder Value (SSV). RESULTS: Eight shoulders had a T2/G of less than 0.75 (group 1) while 24 shoulders had an index above 0.75 (group 2). These two groups were similar preoperatively. The Constant-Murley score in group 1 was significantly lower than in group 2 (50.2 points versus 59.7 points, p<0.05). Group 1 had a postoperative improvement of 1̊ in their ER with elbow at side while group 2 had a 16.5̊ improvement (p=0.002). Group 1 had a postoperative loss of 6.3̊ in their ER in 90̊ abduction while group 2 had a 21.7̊ improvement (p=0.001). The SSV at the final assessment was 69% in group 1 versus 79% in group 2 (p=0.094). CONCLUSION: Having a TM index of trophicity below 0.75 is a negative predictor of clinical outcomes due to lack of ER after RSA. LEVEL OF EVIDENCE: IV.

Arthroscopic Bankart Repair Versus Immobilization for First Episode of Anterior Shoulder Dislocation Before the Age of 25: A Randomized Controlled Trial.

BACKGROUND: The risk of recurrence after the first episode of anterior shoulder dislocation is high with nonoperative treatment in younger patients. PURPOSE/HYPOTHESIS: The aim of this study was to compare the results of arthroscopic Bankart repair and nonoperative treatment for shoulder dislocation in patients younger than 25 years, with a minimum of 2 years of follow-up. The hypothesis was that surgery would decrease the risk of recurrence. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: We included patients aged between 18 and 25 years after a first episode of anterior shoulder dislocation and divided them into 2 groups. The first group was treated surgically with an arthroscopic Bankart repair within 2 weeks after the dislocation; the second group was treated nonoperatively. Both groups were immobilized for 3 weeks in internal rotation and followed the same physical therapy protocol. Standard radiography and computed tomography were performed immediately after reduction of the dislocation, and follow-up was performed at 3, 6, 12, and 24 months. The primary outcome measure was instability recurrence, defined as another anterior shoulder dislocation requiring closed reduction by another person (the patient was unable to reduce the dislocated joint themselves), a subluxation, or a positive apprehension test. Secondary outcome measures included range of motion, return to sport, and functional scores such as the short version of the Disabilities of the Arm, Shoulder and Hand score the Walch-Duplay score, and the Western Ontario Shoulder Instability Index (WOSI). RESULTS: A total of 20 patients were included in each group. The mean ± SD age was 21 ± 1.8 years, and there were 33 men (82.5%) and 7 women (17.5%) in the total sample. Recurrence of instability was significantly decreased in the surgical treatment group compared with the nonoperative group (2 [10%] vs 14 [70%], respectively; P = .0001). Fewer patients in the surgical treatment group versus the nonoperative group had another episode of dislocation (0 vs 6 [30%], respectively), subluxation (2 [10%] vs 13 [65%], respectively; P = .003), or a positive apprehension test (1 [5%] vs 11 [58%], respectively; P = .0005). The Walch-Duplay score (88.4 vs 70.3 points; P = .046) and WOSI (11.5 vs 17.7 points; P = .035) were significantly better in the surgical group versus the nonoperative group after a 2-year follow-up. Level of sport was the same or better in 89% of the surgical treatment group vs 53% of the nonoperative treatment group (P = .012). No surgical complication was recorded. We did not find any significant difference in range of motion. CONCLUSION: In patients with first-time shoulder dislocations, arthroscopic labral repair (Bankart procedure) reduced the risk of secondary shoulder dislocation and improved functional outcome versus nonoperative treatment after a 2-year follow-up. Surgical treatment after a first episode of shoulder dislocation could be offered as a primary treatment option in a younger population if these results are confirmed by larger studies with a longer follow-up. REGISTRATION: NCT03315819 (ClinicalTrials.gov identifier).

Long-term outcome for repair of osteochondral lesions of the talus by osteochondral autograft: A series of 56 Mosaicplasties®.

INTRODUCTION: The present study analyzed results in 56 osteochondral Mosaicplasty® autografts for osteochondral lesion of the talus (OLT) at more than 5 years' follow-up. HYPOTHESIS: Mosaicplasty® shows long-term efficacy and low morbidity in the treatment of OLT. PATIENTS AND METHODS: A multicenter retrospective study included patients treated by Mosaicplasty® with more than 5 years' follow-up. Preoperative data were collected from medical files, and all patients were reassessed. AOFAS scores and FAOS were calculated at last follow-up. Imaging comprised standard radiographs and MRI or CT arthrography of the ankle. RESULTS: Fifty-six patients were included, with a mean age of 34 years (range, 18-60 years). Seventeen involved work accidents. Mean follow-up was 8.5 years (range, 5-20 years). Mean AOFAS score at follow-up was 80.6±19.4 and mean FAOS 77.8±21.5. Work accident, preoperative osteoarthritis and untreated laxity correlated significantly with poorer results. At last follow-up, 22 patients (39%) showed signs of osteoarthritis. There was no morbidity implicating the malleolar osteotomy. There were 11 cases (20%) of persistent patellar syndrome at the donor site. DISCUSSION: The present results were comparable to those reported elsewhere, showing that functional results of Mosaicplasty® autograft for OLT do not deteriorate over the long term. Work accidents correlated significantly with poorer functional outcome. Any associated instability must always be treated. Malleolar osteotomy provides good exposure without additional morbidity. LEVEL OF EVIDENCE: IV; retrospective study.

Osteochondral lesion of the talus: What are we talking about?

INTRODUCTION: The analysis of osteochondral lesions of talus (OLT) is currently mostly descriptive, not permitting an understanding of the different nosological frameworks of these lesions. Better knowledge of the characteristics of patients with OLT should make it possible to optimize the surgical indications and anticipate the associated lesions, which should not be overlooked. The main objective of this study was, therefore, to assess the characteristics of patients with OLT, and to analyze the lesions encountered. HYPOTHESIS: OLTs correspond to variable entities responding to specific treatments. MATERIAL AND METHOD: This was a prospective multicenter descriptive study including all patients operated on for an OLT, aged between 15 and 65 years, across 10 French specialist centers. The demographic, clinical and radiological data of the patients were analyzed. RESULTS: OLTs predominantly affect males and patients in their thirties. Two types of OLT should be distinguished: a lateral OLT; smaller and more superficial, most often presenting with painful instability, in the context of trauma, and a medial OLT; more frequent, wider and deeper. DISCUSSION: Two nosological frameworks exist for OLTs, and correspond to precise surgical indications: medial lesions of more than 10mm2 and more than 5mm in depth, with isolated anteromedial pain and significant functional impairment, most often idiopathic, generally requiring treatment by osteochondral autografts. Lateral lesions less than 5mm in depth and less than 10mm2, often superficial, following trauma or ankle laxity, associated with lateral ligament damage in one-third of cases, and a clinical presentation associated to instability and pain, requiring treatment most often by microfracture with associated ligament repair. LEVEL OF EVIDENCE: III.

Safety of malleolar osteotomies in surgery for osteochondral lesions of the talus.

The talus is a central bone in the hindfoot that is difficult to access surgically. Performing a medial or lateral malleolar osteotomy in the management of an osteochondral lesion of the talus (OLT) is a feared procedure amongst surgeons and their patients. The objective of this study was to assess the complications inherent to malleolar osteotomies in the treatment of OLTs. HYPOTHESIS: The use of a standardized protocol concerning the technical performance and osteosynthesis of malleolar osteotomies results in fewer postoperative complications than a non-standardized protocol. MATERIALS AND METHOD: This is a comparative study comprising a prospective multicenter non-randomized series with a standardized protocol for performing malleolar osteotomies, and a multicenter retrospective series without a standardized protocol. We included all patients aged 16 to 65 years with symptomatic OLTs, resistant to more than 6-months of well-conducted medical treatment, for whom surgery was considered. The minimum follow-up was 1 year for the prospective study, and 5 years for the retrospective study. A total of 86 and 97 patients were included in the prospective and retrospective studies, respectively. Of these 183 patients, 86 patients (33 prospective and 53 retrospective) underwent medial or lateral malleolar osteotomies as part of their surgery for OLT. Complications specific to the osteotomy procedures such as scar tissue, surgical site infection, non-union, articular malunion, neurological lesions or surgical revision, were investigated. RESULTS: No specific complication was found to be associated to the malleolar osteotomy. No surgical revision was directly linked to the osteotomy procedure. No significant difference was found between the two series. DISCUSSION: There was no evidence of morbidity related specifically to medial or lateral malleolar osteotomies. A standardized protocol, subject to rigorous technical implementation, does not improve results after malleolar osteotomy. The fear associated with this malleolar osteotomy procedure seems unfounded. LEVEL OF EVIDENCE: IV.

Clinical and radiological outcomes of 17 reverse shoulder arthroplasty cases performed after failed humeral head resurfacing.

INTRODUCTION: Despite the good outcomes with shoulder resurfacing procedures reported by some authors, our team has documented several failures caused by glenoid erosion and rotator cuff rupture, likely due to implant overstuffing. The aim of this study was to evaluate the clinical and radiological outcomes of reverse shoulder arthroplasty (RSA) performed after failed humeral head resurfacing (HHR). MATERIAL AND METHODS: This was a retrospective, single-center study of 17 patients who underwent RSA after failed HHR between January 2011 and February 2016. The mean patient age was 69.4 years and the mean time between HHR and surgical revision was 41 months (14.7-73.5±18.8). Preoperative ultrasonography and CT were used to evaluate the condition of the rotator cuff, extent of glenoid erosion and to look for signs of humeral cup loosening. The clinical outcomes were evaluated pre- and postoperatively using the simple shoulder test (SST), DASH (Disabilities of the Arm, Shoulder and Hand) and the Constant-Murley score. Pain was estimated using a visual analog scale (VAS). The range of motion (ROM) was determined pre- and postoperatively. All patients had standard AP and lateral X-ray views of the shoulder taken as part of their postoperative follow-up protocol to look for implant loosening. RESULTS: The mean follow-up was 35.9 months (24-59±10.7). There were no intraoperative or postoperative complications. All the functional scores were improved after RSA. The median weighted Constant score preoperatively was 46% (36; 62) while it was 92% postoperatively (78; 100) (p<0.0001). The active ROM improved by 65° in forward flexion (p=0.0003) and by 30° in external rotation (p=0.002). On X-rays, we identified one patient with Sirveaux stage 4 glenoid notching and one patient with a humeral periprosthetic radiolucent line less than 2mm thick in zone 6, with no clinical consequences. CONCLUSION: The excellent outcomes after RSA for failed HHR in our study are similar to the ones reported when RSA is performed for cuff tear arthropathy.