Is sequential bilateral robotic total knee arthroplasty a safe procedure? A matched comparative pilot study.

INTRODUCTION: To our knowledge, no papers have reported the results of robotic-assisted surgery for sequential bilateral Total Knee Arthroplasty (TKA). Indeed, sequential bilateral TKA present several benefits, as one single anesthesia, surgical episode, hospitalization, and rehabilitation. The purpose of our study was to evaluate peri-operative outcomes and compare the complication rates, clinical outcomes, and implant positioning of sequential bilateral TKA performed with a robotic-assisted system versus a conventional technique. MATERIALS AND METHODS: All patients who underwent a sequential bilateral robotic-assisted primary TKA (raTKA) in our institution between November 2019 and February 2021 were included. Twenty patients met the inclusion criteria and were matched with 20 sequential bilateral TKA performed with a conventional technique. The two groups were comparable for the demographic data and the preoperative parameters, including preoperative anticoagulation and ASA score. The minimum follow-up was 6 months. RESULTS: The operative time was significantly longer in the robotic group (< 0.0001), with a mean additional time of 29 min. There was no significant difference between both groups for postoperative blood loss, rate of blood transfusion, or postoperative pain. The average length of stay was 5 days. There was one early complication in the robotic group due to the tibial trackers. The functional outcomes were similar between both groups, except for the functional KSS score, which was better at 6 months in the robotic group (p < 0.0001). The restoration of the knee alignment and the distal femoral anatomy were significantly better in the robotic group than in the conventional group. CONCLUSIONS: Despite a longer operative time, the peri-operative parameters of sequential bilateral TKA were similar between robotic and conventional techniques. Further, sequential bilateral raTKA was at least as safe as a conventional technique, without additional risk of medical complications.

Highly Crosslinked Polyethylene Can Reduce Wear Rate in THA for High-Demand Patients: A Matched-Paired Controlled Study.

BACKGROUND: The average age of patients benefiting from total hip arthroplasty (THA) has been declining. In addition to pain relief, patients seek to return to physical activity. However, the latter may increase polyethylene wear and therefore the potential risk of early aseptic loosening. The introduction of highly crosslinked polyethylene (HXLPE) has reduced wear rates in the general patient population. The objective of this study was to evaluate the influence of impact sports in patients operated with THA using ceramic-on-conventional polyethylene (cPE) versus ceramic-on-HXLPE, in terms of wear and function, with a minimum of five year follow-up. METHODS: Sixty-eight patients practicing an impact sport (University of California Los Angeles score ≥8) who underwent a primary THA were included: 34 with a ceramic-on-cPE versus 34 with a ceramic-on-HXLPE using the same cementless acetabular and femoral component. Patients were matched-paired by age, sex, BMI, and University of California Los Angeles score. The wear analysis was performed using the IMAGIKA software. The Harris hip score and hip and osteoarthritis outcome score were collected. RESULTS: The linear wear rate was statistically higher (P < .0001) in the cPE group (0.13503 ± 0.0630 mm/year) than in the HXLPE group (0.03059 ± 0.0084 mm/year). Postoperatively, the increase in Harris hip score was calculated at 37.64 for the entire cohort and was comparable in both groups (P = .3674). The hip and osteoarthritis outcome score for pain (P = .0009), daily life activities (P = .0016), and quality of life (P = .0179) were significantly higher in the HXLPE group, with, between groups, a difference inferior to the reported minimal clinical important difference. Three patients exhibited signs of periprosthetic osteolysis in the cPE group, one on the femoral side and two on the acetabular side. None were observed in the HXLPE group. No revision for aseptic loosening was reported in both cohorts. CONCLUSION: Patients partaking in impact sports and receiving a ceramic-on-HXLPE THA demonstrated lower wear and osteolysis rates than those having a ceramic-on-cPE THA, with similar functional results.

A Case-Control Comparison of Single-Stage Bilateral vs Unilateral Medial Unicompartmental Knee Arthroplasty.

BACKGROUND: We aimed to compare postoperative pain, functional recovery, and patient satisfaction among patients receiving one-stage medial bilateral or medial unilateral UKA (unicompartmental knee arthroplasty). Our main hypothesis was that during the first 72 postoperative hours, patients who underwent medial bilateral UKA did not consume more analgesics than those who underwent medial unilateral UKA. METHODS: A prospective case-control study was undertaken involving 148 patients (74 one-stage medial bilateral vs 74 medial unilateral Oxford UKA). The primary outcome was evaluation of the postoperative total consumption of analgesics from 0 to 72 hours. Next, the postoperative evolution of pain scores and functional recovery were assessed. Oxford Knee Scores were assessed preoperatively at 6 and 12 months with the occurrence of clinical or radiological complications. Finally, patient satisfaction was evaluated at the final follow-up. RESULTS: The cumulative sums of analgesic consumption (0-72 hours) calculated in the morphine equivalent dose were 21.61 ± 3.70 and 19.11 ± 3.12 mg in the patient and control groups, respectively (P = .30). Moreover, there were no significant differences in terms of pain scores (P = .45), functional recovery (P = .59, .34), length of stay (P = .18), Oxford Knee Scores (P = .68, .60), complications (P = .50), patient satisfaction (P = .66), or recommendations for intervention (P = .64). CONCLUSION: Patients who undergo one-stage medial bilateral UKA do not experience more pain and do not consume more analgesics than those who undergo medial unilateral UKA. A bilateral procedure is not associated with a lower recovery or a higher rate of complications, as functional outcomes at 6 and 12 months are similar to those of unilateral management.

Short Leukocyte Telomere Length Precedes Clinical Expression of Atherosclerosis: The Blood-and-Muscle Model.

RATIONALE: Short telomere length (TL) in leukocytes is associated with atherosclerotic cardiovascular disease (ASCVD). It is unknown whether this relationship stems from having inherently short leukocyte TL (LTL) at birth or a faster LTL attrition thereafter. LTL represents TL in the highly proliferative hematopoietic system, whereas TL in skeletal muscle represents a minimally replicative tissue. OBJECTIVE: We measured LTL and muscle TL (MTL) in the same individuals with a view to obtain comparative metrics for lifelong LTL attrition and learn about the temporal association of LTL with ASCVD. METHODS AND RESULTS: Our Discovery Cohort comprised 259 individuals aged 63±14 years (mean±SD), undergoing surgery with (n=131) or without (n=128) clinical manifestation of ASCVD. In all subjects, MTL adjusted for muscle biopsy site (MTLA) was longer than LTL and the LTL-MTLA gap similarly widened with age in ASCVD patients and controls. Age- and sex-adjusted LTL (P=0.005), but not MTLA (P=0.90), was shorter in patients with ASCVD than controls. The TL gap between leukocytes and muscle (LTL-MTLA) was wider (P=0.0003), and the TL ratio between leukocytes and muscle (LTL/MTLA) was smaller (P=0.0001) in ASCVD than in controls. Findings were replicated in a cohort comprising 143 individuals. CONCLUSIONS: This first study to apply the blood-and-muscle TL model shows more pronounced LTL attrition in ASCVD patients than controls. The difference in LTL attrition was not associated with age during adulthood suggesting that increased attrition in early life is more likely to be a major explanation of the shorter LTL in ASCVD patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02176941.

Better functional outcomes for ORIF in tibial eminence fracture treatment: a national comparative multicentric study of ORIF vs ARIF.

PURPOSE: Tibial eminence fractures can occur in adults and are equivalent to an acute ACL rupture. The purpose of this retrospective study was to compare the therapeutic outcomes of ARIF versus ORIF in tibial eminence fractures. Our hypothesis was that ARIF does not offer better results. METHODS: A retrospective national multicentric study was conducted in five university hospitals between 2010 and 2015. A total of 65 consecutive patients were included. 33 patients were treated with ARIF and 32 with ORIF. Clinical functional outcomes were assessed using the Lysholm score and IKDC score. Radiographic findings were recorded, and a statistical analysis carried out. RESULTS: IKDC score at the mean last follow-up of 68.8 ± 11.8 months was significantly higher in the ORIF group with a mean difference of 20.2 points ± 8.9 (p = 0.028). There were early osteoarthritis findings in 12 patients (18.4%). At last follow-up, 7 patients (10.7%) presented complications. CONCLUSION: In this retrospective multicentric study, better functional outcomes were observed in the ORIF group. This difference needs to be carefully interpreted as many confounding factors exist. In terms of complications, the results for both ORIF and ARIF are similar at midterm follow-up. ORIF should remain gold standard for tibial eminence fracture treatment. LEVEL OF EVIDENCE: III.

Long-term results of custom-made femoral stems.

BACKGROUND: The progress of 3D imaging and manufacturing of implants has made it possible to achieve a custom-made concept in THA. The custom-made cementless femoral stem provides optimal implant stability combined with restoration of the native hip mechanics. OBJECTIVE: The purpose of this study was to evaluate the long-term survivorship of custom-made hip femoral stems in two populations of patients undergoing THA: patients under 50 years old (young patients group) and patients with high-grade developmental dysplasia of the hip (DDH group). METHODS: A series of 232 primary custom-made cementless THA stems were retrospectively evaluated in patients less than 50 years old at the time of surgery and at follow-up after an average of 20 years. A second series of 26 custom-made cementless stem THAs for late DDH (21 patients) including only Crowe grade III and grade IV were also retrospectively evaluated with an average follow-up of 16 years. The clinical and radiological evaluations were performed preoperatively and at yearly intervals. RESULTS: For the young patient group, the follow-up ranged from 14 to 27 years. The HHS and the Merle D'Aubigne-Postel score significantly improved from preoperatively to a mean of 94.1 (range 48-100) and 15.9 (range 9-18), respectively. Taking stem revision for aseptic loosening as an endpoint, survivorship was 96.8% at 20 years (95% confidence interval, CI 95.1-98.5). For the DDH group, the follow-up ranged from 10 to 22 years. The mean HHS increased significantly from preoperative 49 ± 22 points to the most recent follow-up examination with 86 13 points and survivorship was 96.1% (95% CI, 92.7-99.9). CONCLUSION: Custom-made femoral stems provide good functional outcome and long-term survivorship in two specific populations of patients undergoing THAs: patients under 50 years old with high expectations and patients with high-grade DDH.

Better Implant Positioning and Clinical Outcomes With a Morphometric Unicompartmental Knee Arthroplasty. Results of a Retrospective, Matched-Controlled Study.

BACKGROUND: During medial unicompartmental knee arthroplasty (UKA), tibial tray implantation requires compromise between bone coverage and rotational position. It was hypothesized that morphometric tibial tray (MTT) would improve implant positioning and subsequently clinical outcomes as compared to symmetric tibial tray (STT). METHODS: A total of 106 patients who underwent medial UKA in our department between January 2017 and March 2018 were included matched on gender and age (53 in each group). Inclusion criteria were symptomatic medial femorotibial osteoarthritis, functional anterior cruciate ligament, primary arthritis, or osteonecrosis. Rotation of the tibial implant, tibial bone coverage, medial and posterior overhang were assessed with a postoperative computed tomography scan. The Knee Society Score (KSS), the Knee injury and Osteoarthritis Outcome Score Short Form (KOOS SF), and the quality of life score EuroQoL 5-Dimensions 3-Levels (EQ5D3L) were assessed at a minimum of 1-year follow-up. RESULTS: Implants of the STT group exhibited more external rotation (6.3° ± 4.02° vs 4.6° ± 3.59°; P = .04), and medial and posterior overhang >3 mm (35% vs 0% and 22% vs 0%; P < .0001) but no difference for tibial bone coverage (97.3% ± 11.35% vs 94.7% ± 10.89%; P = .23). Global KSS (188.6 ± 6.6 vs 175.2 ± 31.7; P < .01), KOOS SF (16.9 ± 6.1 vs 22.5 ± 11.8; P < .003), and EQ5D3L (1 ± 0.1 vs 0.9 ± 0.2; P < .001) were higher in MTT group. According to the multivariate analysis, MTT had a positive independent effect on the KSS, KOOS SF, and EQ5D3L. CONCLUSION: The use of an MTT in medial UKA allowed better implant positioning when decreasing the rate of overhang; superior short-term clinical outcomes were found as compared to STT.

Treatment of infection following intramedullary nailing of tibial shaft fractures-results of the ORS/ISFR expert group survey.

OBJECTIVE: The lack of universally accepted treatment principles and protocols to manage infected intramedullary (IM) nails following tibial fractures continues to challenge us, eliciting a demand for clear guidelines. Our response to this problem was to create an ORS/ISFR taskforce to identify potential solutions and trends based on published evidence and practices globally. MATERIALS AND METHODS: A questionnaire of reported treatment methods was created based on a published meta-analysis on the topic. Treatment methods were divided in two groups: A (retained nail) and B (nail removed). Experts scored the questionnaire items on a scale of 1-4 twice, before and after revealing the success rates for each stage of infection. Inter- and intra-observer variability analysis among experts' personal scores and between experts' scores was performed. An agreement mean and correlation degree between experts' scores was calculated. Finally, a success rate report between groups was performed. RESULTS: Experts underestimated success rate of an individual treatment method compared to published data. The mean difference between experts' scores and published results was + 26.3 ± 46 percentage points. Inter-observer agreement mean was poor (< 0.2) for both rounds. Intra-observer agreement mean across different treatment methods showed a wide variability (18.3 to 64.8%). Experts agree more with published results for nail removal on stage 2 and 3 infections. CONCLUSIONS: Experts' and published data strongly agree to retain the implant for stage 1 infections. A more aggressive approach (nail removal) favoured for infection stages 2 and 3. However, literature supports both treatment strategies. EVIDENCE: Clinical Question.

No Benefit of Computer-assisted TKA: 10-year Results of a Prospective Randomized Study.

BACKGROUND: Previously published studies reported benefits of computer-assisted surgery (CAS) in terms of radiographic implant position in TKA, but whether these improvements result in clinically important survival differences or functional differences that a patient might perceive at a minimum 10-year followup remains largely unknown. QUESTIONS/PURPOSES: We performed a prospective randomized trial and asked whether CAS (1) improved survival free from aseptic loosening; and (2) demonstrated any clear difference in patient-reported outcomes at latest followup using validated outcome measures at minimum 10-year followup. METHODS: Between January 2004 and December 2005, 80 patients scheduled for TKA were randomly assigned either to the CAS group or to the conventional technique group by the Hospital Informatics Department. The patient inclusion criteria were age 20 to 80 years old, weight < 100 kg, and consent to receive a primary knee arthroplasty performed through a medial parapatellar approach by the senior author. The exclusion criteria were a history of prior knee surgery, TKA performed for a posttraumatic indication, or revision knee surgery. The first 80 patients meeting these criteria were included in the study. There were 21 women and 19 men and in each group; mean age was 66 years (range, 58-77 years), and mean body mass index was 27 ± 4 kg/m. An initial published study using this patient group investigated only differences regarding implant positioning in the coronal and sagittal planes. This is a secondary analysis of patients from the earlier study protocol at a minimum of 10-year followup with different endpoints. Kaplan-Meier survivorship was compared between groups, and functional patient-reported outcome measures (PROMs) were evaluated using the SF-12, Knee Injury and Osteoarthritis Outcome Score (KOOS), Forgotten Joint Score, and the new Knee Society Score. Those PROMs were not available at the time of the original randomized controlled trial and we therefore do not have baseline preoperative values demonstrating that our two groups were comparable. However, our groups were created using strict randomization and were similar in terms of demographic parameters and knee deformities. Our secondary analysis was not powered for survival analysis but had 80% power to detect a difference > 6 points on the SF-12 components and > 6 points out of 100 on the KOOS subscores (published minimal clinically important difference: 8 points) at the p < 0.05 level. RESULTS: With the numbers available, there was no difference between the CAS group and the conventional TKA group in terms of survivorship free from aseptic loosening 10 years after TKA (97%, 95% confidence interval [CI], 95%-99% versus 97%, 95% CI, 95%-99%; p = 0.98). Investigation of the latest followup PROM scores showed no difference between SF-12 scores (respectively, for CAS and control patients, physical SF-12: 72 ± 12 versus 73 ± 13 mean difference 0, 95% CI -3 to 3, p = 0.9; mental SF-12: 75 ± 8 versus 73 ± 10, mean difference 2, 95% CI 0-4, p = 0.3) as well as for all KOOS subscores (all p > 0.1). Forgotten Joint Scores were similar in both groups with 83 ± 4 for CAS and 82 ± 5 for control patients (mean difference 1, 95% CI 0-2, p = 0.2). Finally, the new Knee Society Scores were not statistically different between groups with a mean objective score of 82 ± 13 for CAS patients versus 79 ± 12 for control patients (mean difference 2, 95% CI 0-5, p = 0.5) and a mean subjective score of 83 ± 11 versus 85 ± 12, respectively (mean difference 2, 95% CI 0-5, p = 0.5). CONCLUSIONS: Our observations suggest that CAS used for TKA alignment with restoration of a neutral mechanical axis as the goal did not confer any substantial advantage in survivorship, function, or quality of life at 10 years after TKA. Larger studies with longitudinal collection of PROMs for functional assessment and greater numbers to assess survivorship are needed to confirm these findings. LEVEL OF EVIDENCE: Level III, therapeutic study.

Minimum 10-Year Outcome of One-Stage Total Hip Arthroplasty Without Subtrochanteric Osteotomy Using a Cementless Custom Stem for Crowe III and IV Hip Dislocation.

BACKGROUND: Options for total hip arthroplasty (THA) in high dislocated hips include subtrochanteric osteotomy (STO), high hip center positioning, and 2-stage surgery with progressive lowering using an external fixator before THA. We described the long-term results of 1-stage THA performed without STO, using a cementless customized stem associated if necessary with sequential tenotomies and/or greater trochanteric osteotomy. METHODS: Ninety-eight consecutive THA without STO were performed using this technique. Of those 98 hips, 26 hips with high dislocation (12 class III and 14 class IV according to the Crowe classification) were evaluated at an average follow-up of 16 (10-22) years. RESULTS: At the time of last follow-up, the mean Harris Hip Score was 86 points (37-100). The mean leg-length discrepancy was 7 ± 5 mm (0-17). Two transient (7.7%) nerve palsies (1 sciatic and 1 femoral) were notified. A revision was required for 6 hips (23.1%). Kaplan-Meier survivorship analysis at 15 years regarding aseptic loosening of the femoral component was 87.5% (95% confidence interval, 76.5-99.1). During the same period, acetabular implant survivorship free from revision for aseptic loosening was 96.1% (95% confidence interval, 92.7-99.9). CONCLUSION: The combination of intramedullary fit and extramedullary adaptation for offset and anteversion provided by the custom stem can avoid additional procedures associated to THA in high developmental dysplasia of the hip. The clinical function and long-term survival reported in this series is encouraging for THA performed in case of high hip dislocation.

Morphometric Tibial Implant Decreases Posterior Overhang Rate and Improves Clinical Outcomes: Results of a Prospective, Matched Controlled Study.

BACKGROUND: Tibial implant's positioning in total knee arthroplasty (TKA) requires a compromise between implant's rotation and bone coverage. We hypothesized that morphometric tibial trays (MTTs) would improve implant positioning and clinical outcomes as compared with symmetrical tibial trays. METHODS: Thirty-three patients were included prospectively according to the following criteria: age from 18 to 85 years, body mass index <35 kg/m2, and posterostabilized cemented TKA performed for primary arthritis. Patients were matched for age, gender, body mass index, and preoperative international knee society (IKS) scoring system and Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score, in a 1:1 fashion with patients from a prospectively collected database receiving a symmetrical tibial tray TKA. Tibial implant's rotation, bone coverage, and the percentage of patients with a posterior overhang (PO) >3 mm were assessed using computerized tomography. The IKS and the KOOS were compared at 3-year follow-up. RESULTS: Bone coverage (90% vs 88%, P = .07) and rotation (mean difference 0.7 ± 3°; P = .69) were not different between the 2 groups. The percentage of patient with a PO was lower in the morphologic group (2/33 vs 14/33, P = .01, odds ratio = 10.3 [2.12-50.24]). Functional scores were superior in the morphometric group: IKS (mean difference 20 ± 21 points; P = .0005), mainly due to a difference in the IKS pain subscore (mean difference 11 ± 15 points; P = .0002). According to the multivariate analysis, an MTT had a positive, independent effect on IKS pain (P = .006) and KOOS pain subscores (P = .03) at the last follow-up. CONCLUSION: The use of an MTT in TKA did not modify the tibial implant position in the axial plane; however, it decreased implant's posterior overhang and improved functional scores. The clinical improvement was mainly found on pain scores.

Long-term results of custom cementless-stem total hip arthroplasty performed in hip fusion.

INTRODUCTION: Due to complex anatomical considerations, results of cementless-stem total hip arthroplasty (THA) in hip fusion remain controversial compared with conventional THA. We therefore aimed to analyse 3D anatomy of the fused hip based on pre-operative computed tomography (CT) scans, functional outcomes based on the Harris Hip Score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS), modifications of hip anatomy based on post-operative standardised radiography, and determine complication rate and long-term survival based on Kaplan-Meier analysis. METHODS: We retrospectively studied 23 hips that underwent conversion of a fused hip to THA using a 3D CT scan-based custom titanium (Ti alloy hypoxyapetite (HA)-coated stem. The mean follow-up was 15 (9-22) years. Femur anteversion ranged from -29° to 80°. RESULTS: HHS improved from 59 to 89 points and average range of motion (ROM) was 88° for flexion. Back pain decreased in 62%, and knee pain decreased in 42%. The mean post-operative leg-length discrepancy was 7.8 mm. No intra-operative complications occurred. One aseptic stem loosening for mechanical failure was observed. The Kaplan-Meier survivorship considering revision for any reasons as the end point was 95.6% [95% confidence interval (CI) 92.4-98.8] at 15 years. CONCLUSION: Custom cementless stems may be an interesting solution to address the particular anatomical features of hip fusion at the time of THA, with an excellent survival rate at 15 years.

Use of porous tantalum components in Paprosky two and three acetabular revision. A minimum five-year follow-up of fifty one hips.

INTRODUCTION: Recent studies have reported short-term favourable results of tantalum-made components in acetabular revisions with bone loss. However, there is a lack of information regarding the mid to long-term results of such components. OBJECTIVES: The objective of this study was to analyse the outcome and survivorship of acetabular revision hip arthroplasty using tantalum components for loosening associated with bone loss at a minimum of five-year follow-up. METHODS: We retrospectively reviewed 51 consecutive patients (51 hips) who had an acetabular revision using porous tantalum components at a minimum follow-up of five years. The mean age was 64 years (range, 31-87). There were 27 males and 24 females, 47 right hips and four left hips. Twenty-five (49 %) included a femoral revision. According to Paprosky's classification 18 hips were classified type 2A, 11 type 2B, ten type 2C, seven type 3A and five type 3B. No bone grafting was performed. Sixteen hips (31.3 %) required the use of additional tantalum-made augments stabilized by screws and cement at the cup-augment interface. RESULTS: At a mean followup of 6.8 years (range, 5.1-10 years), the Harris hip score improved from 44 pre- operatively (range, 23-72) to 84 post-operatively (range, 33-98). The mean post-operative hip centre position in relation to the teardrop was 29 mm (range, 20-43 mm) horizontally and 21 mm (range, 8-36 mm) vertically. The mean acetabular inclination was 42° (range, 17-60°). Six hips (11.7 %) required a re-operation without component revision (two for chronic instability, one ossification removal, one haematoma, one deep infection and one periprosthetic femoral fracture). One patient required a cup re-revision for septic loosening. No aseptic loosening occurred. At last followup the radiological analysis showed one evolutive osteolysis and one screw breakage. The global survivorship was 92.3 % at 64 months. If only aseptic loosening was defined as the end-point the survivorship was 100 % at 64 months. CONCLUSIONS: When facing an acetabular revision with severe bone loss, tantalum-made components can provide a stable fixation. This study at a minimum five-year follow-up compares favourably with other reconstruction techniques, but longer follow-up is still required.

No Benefit After THA Performed With Computer-assisted Cup Placement: 10-year Results of a Randomized Controlled Study.

BACKGROUND: Computer-assisted surgery (CAS) for cup placement has been developed to improve the functional results and to reduce the dislocation rate and wear after total hip arthroplasty (THA). Previously published studies demonstrated radiographic benefits of CAS in terms of implant position, but whether these improvements result in clinically important differences that patients might perceive remains largely unknown. QUESTIONS/PURPOSES: We hypothesized that THA performed with CAS would improve 10-year patient-reported outcomes measured by validated scoring tools, reduce acetabular polyethylene wear as measured using a validated radiological method, and increase survivorship. METHODS: Sixty patients operated on for a THA between April 2004 and April 2005 were randomized into two groups using either the CAS technique or a conventional technique for cup placement. All patient candidates for a THA with the diagnosis of primary arthritis or avascular necrosis were eligible for the CAS procedure and randomly assigned to the CAS group by the Hospital Informatics Department with use of a systematic sampling method. The patients assigned to the freehand cup placement group were matched for sex, age within 5 years, pathological condition, operatively treated side, and body mass index within 3 points. All patients were operated on through an anterolateral approach (patient in the supine position) using cementless implants. In the CAS group, a specific surgical procedure using an imageless cup positioning computer-based navigation system was performed. There were 16 men and 14 women in each group; mean age was 62 years (range, 24-80 years), and mean body mass index was 25 ± 3 kg/m(2). No patient was lost to followup at 10 years, but five patients have died (two in the CAS group and three in the control group). At the 10-year followup, an independent observer blinded to the type of technique performed patients' evaluation. Cup positioning was evaluated postoperatively using a CT scan in the two groups with results previously published. At 10 years, we assessed subjective functional outcome and quality of life using validated questionnaires (SF-12, Harris hip score [HHS], Hip injury and Osteoarthritis Outcome Score). Wear rate was then evaluated on standardized radiographs using a previously validated semiautomated computer analogic measurement method (dual circle method). Complications and survivorship were compared between groups. With our available sample size, this study had 80% power to detect a difference of 4 points out of 100 on the HHS at the p < 0.05 level. RESULTS: With the numbers available, we found we found no differences between groups regarding HSS at last followup 95.3 ± 5.9 points (CAS group) versus 96.2 ± 4.5 points, a mean difference of 0.9 points (95% confidence interval [CI], -4.3 to 4.6; p = 0.6). There was no difference between the groups in terms of the mean (± SD) acetabular linear wear at 10 years. The mean wear was 0.71 ± 0.6 mm in the CAS group versus 0.77 ± 0.52 mm in the control group, a mean difference of 0.06 mm (95% CI, -0.1 to 0.2; p = 0.54). With the numbers available, there was no difference between the CAS group and the conventional THA groups in terms of survivorship free from aseptic loosening (100%; 95% CI, 100%-95%, versus 100%; 95% CI, 100%-94%; p = 0.3). CONCLUSIONS: Our observations suggest that CAS used for cup placement does not confer any substantial advantage in function, wear rate, or survivorship at 10 years after THA. Because CAS is associated with added costs and surgical time, future studies need to identify what clinically relevant advantages it offers, if any, to justify its continued use in THA. LEVEL OF EVIDENCE: Level II, therapeutic study.

Minimally invasive surgery of femoral periprosthetic fractures increases the rate of consolidation and decreases time to bone healing without a higher rate of complications.

BACKGROUND: Knee periprosthetic femoral fractures (KPPFF) are becoming more frequent due to the increasing number of arthroplasties and the aging population, for whom maintaining autonomy and function remains a challenge. The use of locking plates has improved functional results and promoted the development of "minimally invasive" surgical (MIS) approaches. Despite the availability of literature comparing between different types of osteosynthesis for KPPFF, there is a paucity of information available on the complications of osteosynthesis using locking plates, depending on the approach. We therefore carried out a retrospective multicenter study (nine centers: Dijon, Grenoble, Lille, Marseille, Nice, Paris, Saint-Étienne, Strasbourg, Colmar) as part of a Symposium of the French Society of Orthopedic Surgery and Traumatology (SOFCOT). Following osteosynthesis of KPPFF by locking plates carried out by a standard approach or by a minimally invasive approach (MIS), the objectives were: (1) to compare the complications, (2) to evaluate whether the radiological and clinical results (rate and time of consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy) were comparable in the two groups. HYPOTHESIS: The hypothesis was that performing an MIS approach in these indications does not confer more complications than a standard approach, and rather, the MIS approach offers better functional and radiological results. MATERIAL AND METHOD: Five hundred and seventy-three patients presented with KPPFF over the periods studied (retrospective series from January 2012 to December 2016, then prospective series from January to December 2019). After applying the inclusion criteria (KPPFF by locking plate) and exclusion criteria (tumor context, infectious, intraoperative fractures, fractures on loose prostheses, other osteosynthesis methods, treatment by prosthetic revision, patients under the age of 18, follow-up less than 1-year, incomplete files), a global series of 306 patients was retained. Two groups were created according to the approach performed: a standard approach group (S, n=228) and a minimally invasive approach group (MIS, n=78). The demographic data of the population were recorded, as was the criteria for autonomy (Parker score, place of living). Postoperative complications were sought (infection, mechanical complication, surgical revision). Finally, the radiological and clinical results were evaluated (rate of, and time to consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy). RESULTS: The comparison of the two subgroups, S and MIS, found complication rates are comparable in the two groups in terms of infections [S group: n=18 (7.9%), MIS group: n=2 (2.6%)], mechanical complications [S: n=23 (10.1%), MIS: n=2 (2.6%)], and surgical revision [S: n=33 (14.5%), MIS: n=7 (8.9%)], and a lack of difference in postoperative autonomy [Parker; S group: 4.7±2.4 (0-9) vs. MIS group: 5±2, 7 (0-9)]. On the other hand, the time to return to weight bearing was shorter in the MIS group [4.3±3.5weeks (0-12) versus 10.1±10.1weeks (0-110), p<0.001]. The rate of nonunion was lower in the MIS group [n=1 vs. n=20, i.e. 1.7% vs. 11.1% (p=0.031)] and the time to consolidation was shorter [7.5±4.3weeks (6-30) versus 15.2±9.4weeks (5-78) (p<0.001)]. CONCLUSION: Performing an MIS approach in the management of KPPFF by locking plate osteosynthesis does not cause any more complications than a standard approach. In addition, higher consolidation rates can be obtained in shorter periods of time. This study suggests that it proposing osteosynthesis using the MIS approach as a primary surgery is a reasonable choice when treatment using locking plates is chosen for a KPPFF, subject to technical expertise. LEVEL OF EVIDENCE: III; observational study.

Revision total knee arthroplasty with periprosthetic distal femoral fracture.

Treatment strategies for periprosthetic distal femoral fracture depend on the type of fracture, level with respect to the prosthesis, and prosthesis fixation. The usual treatment is internal fixation by nail or locking plate. This can be more difficult when the fracture is close to the joint, is destabilizing the prosthesis or is associated with reduced bone stock, and implant exchange should be considered, depending on the patient's health status. The aim is to obtain the fastest possible recovery while limiting complications and minimizing surgery time for often frail and elderly patients. The present study details the implant revision technique in periprosthetic distal femoral fracture, which requires experience in traumatology and prosthetic revision and material adapted to the situation. LEVEL OF EVIDENCE: V, expert opinion.

Bicondylar tibial plateau fracture osteosynthesis with double-plate fixation: Similar complication rates and clinical results but improved radiographic outcomes with dual compared to single approach.

INTRODUCTION: Associating posteromedial and anterolateral approaches should improve fracture line visualization and optimize bicondylar tibial plateau fracture reduction compared to a single midline approach. The present study aimed to compare postoperative complications rates and functional and radiographic results after double-plate fixation via either a single or a dual approach. The study hypothesis was that double-plate fixation using a dual approach provides equivalent complications rates with improved radiographic results compared to a single approach. MATERIAL AND METHODS: A retrospective 2-center study compared bicondylar tibial plateau fractures treated by double-plate fixation on a single versus a dual approach between January 2016 and December 2020. Comparison focused on major complications requiring surgical revision, radiographic measurements of medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA); change from their respective baseline values of 87° and 83° (deltaMPTA and deltaPPTA), and functional results on KOOS, SF12 and EQ5D-3L self-reported questionnaires. RESULTS: Major complications occurred in 2 of the 20 single approach group patients (10%) [1 surgical site infection (SSI) (5%), and 1 skin complication (5%)], and in 3 of the 39 dual approach group patients (7.69%) (p=0.763), at an average 29 months' follow-up. In the sagittal plane, deltaPPTA was significantly lower with dual than single approach (respectively, 4.67° versus 7.43°; p=0.0104). There were no significant intergroup differences in deltaMPTA or functional results at last follow-up. CONCLUSION: The present study suggests an absence of significant difference in major complications, between single and dual approach for double-plate osteosynthesis of bicondylar tibial plateau fractures. Using a dual approach enabled improved anatomic restoration in the sagittal plane, without significant differences observed in the frontal plane or functional scores at an average 29months' follow-up. LEVEL OF EVIDENCE: III; case-control study.

Use of dual mobility cup cemented into a tantalum acetabular shell for hip revision with large bone loss can decrease dislocation risk without increasing the risk of mechanical failure.

BACKGROUND: Porous tantalum components and augments have demonstrated short to midterm fixation stability in acetabular total hip arthroplasty (THA) revision but do not offer a novel option to decrease the postoperative dislocation rate. Recently, dual mobility (DM) cups have gained interest to decrease the prevalence of recurrent hip instability after revision hip arthroplasty, but this issue was not confirmed combined with use of tantalum reconstruction devices. Therefore, we did a retrospective study aiming to: (1) evaluate at a 5-year minimum follow-up period the dislocation rate (and other intra- and postoperative complications), (2) assess radiographic results specifically looking at osseointegration and restoration of the hip center, (3) and also clinical results in a cohort of patients who underwent complex acetabular reconstruction with trabecular metal revision components associated with a cemented DM socket. HYPOTHESIS: Using a DM socket cemented in porous tantalum components can reach the low risk of hip dislocation reported with DM components in revision setting without increasing the risk of a mechanical failure. METHODS: A cross-sectional study identified 174 THA revision including an acetabular revision. Were excluded 118 revisions with acetabular defects Type 1, 2a or 2B according to Paprosky's classification, as well as 18 hips revised without a dual mobility and 3 patients (3 hips) lost to follow-up. Were thus included in this study 35 hips (35 patients) implanted with uncemented total hip arthroplasty revision using both trabecular metal acetabular cup-cage reconstruction and a cemented DM cup. Seven hips were classified Paprosky types 2C, 15 type 3A and 13 types 3B. Patients were followed with clinical and radiological evaluation regarding dislocation rate, infection, reoperation or re-revision, osseointegration and restoration of the hip center, and functional results according to the Harris hip score and psoas impingement presence. RESULTS: At a mean follow-up of 8.1±1.8 years (5.1-12.6), one dislocation was recorded, and one acute deep infection. No patient required a cup re-revision for septic or aseptic loosening. The survivorship at 8years regarding revision for any cause as an endpoint was 96.5% (CI95%: 92-99). Osseointegration of TM implants was analyzed and found no acetabular migration at the last follow-up in the cohort. The mean hip center position was optimized from 48±7mm (37-58) to 34±5mm (29-39) vertically and from 26±5mm (-18-36) to 24±8mm (7-31) horizontally without reaching significance (p=0.1). On the last follow-up X-rays, the mean acetabular inclination was 47̊±9̊ (32̊-61̊). According to the criteria of Hirakawa, 97.1% (34/35) of the hip centers were restored. One cup (2.9%) was more than 5mm proximally from the hip center, and none more than 10mm. Clinical results assessed a Harris Hip Score improved from 36±17 (23-62) preoperatively to 82±15 (69-93) at last follow-up (p<0.0001). Two patients (2/35, 5.7%) complained of psoas impingement. CONCLUSION: This study suggests effectiveness of DM cups in association with a tantalum-made acetabular shell for reconstruction of large bone defect in THRs for both solving postoperative instability and aseptic loosening without increasing the re-revision rate for any reason in a midterm follow-up. LEVEL OF EVIDENCE: IV; observational study.

Management of periprosthetic femoral fractures following total knee arthroplasties using locking plates or intramedullary nailing. Comparative study of 567 cases.

INTRODUCTION: Proximal femur fractures in elderly patients pose a common problem that requires surgical management. The main objective of this study was to compare the results of treatment by locked plate (LP) and by anterograde (AIN) or retrograde (RIN) intramedullary nailing. The secondary objective was to analyze the complications related to each group. The hypothesis of this study was that the radiological and clinical results of each group were comparable. MATERIALS AND METHODS: The data of 438 patients from 8 centers were studied retrospectively with 365 LP and 69 cases of intramedullary nailing (49 AIN and 20 RIN). The groups were comparable in terms of mean age (75±2years), mean preoperative Parker score (5.3±0.5) and mean KOOS score (74±2). Most patients lived at home before their fracture [n=375 (86%)]. At follow-up, the joint range of motion, the KOOS and Parker scores, living premises, the time required to regain full weight-bearing, the time required for consolidation as well as the reduction alignment: frontal, sagittal, horizontal. RESULTS: The average follow-up was: 79±2weeks (65 to 82). The functional and radiological results were comparable, although nailing allowed a faster return to weight-bearing (1±2weeks for nailing versus 7±2weeks for LP, p=0.048) and a better postoperative Parker score (5.5±0.5 for nailing versus 4.7±0.2 for LP, p=0.045). Rotational malalignment in femoral nailing was often in the direction of internal rotation, compared to the LP (p=0.045). Complications were comparable with the exception of mortality, which was more frequent for LP [22.5% in the LP group versus 13% in the nailing group (p=0.045)]. Complications were categorized as: mechanical complications 6.8% of LP, 5.7% of nailing (p>0.05), infections [11% of LP, 5.8% of nailing (p>0.05)], surgical revisions [2% of LP, 10% of nailing (p>0.05)]. DISCUSSION AND CONCLUSION: The hypothesis was refuted. These results show that nailing conferred a faster recovery of weight-bearing, a better Parker score, and is associated with a lower mortality rate. The morbidity rate is comparable between the two techniques. Indeed, when the indication for osteosynthesis by LP or by nailing is made, and both choices are technically justifiable, it would be prudent to favor the technique, which carries the least risk, which in this case is nailing. This conclusion must, however, be taken in to consideration with regard to the reduced number of nailing. A larger series of nailing, particularly retrograde, would be necessary to be able to confirm this last difference between the 2 groups. LEVEL OF EVIDENCE: IV; comparative retrospective study.

No benefit of direct anterior over posterolateral approach in total hip arthroplasty using dual-mobility acetabular component for femoral neck fracture.

Aims: Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA. Methods: A prospective continuous cohort study was conducted on patients undergoing operation for FNF using DMC by DAA or PLA. Functional outcome was evaluated using the Harris Hip Score (HHS) and Parker score at three months and one year. Perioperative complications were recorded, and radiological component positioning evaluated. Results: There were 50 patients in the DAA group and 54 in the PLA group. The mean HHS was 85.5 (SD 8.8) for the DAA group and 81.8 (SD 11.9) for the PLA group (p = 0.064). In all, 35 patients in the DAA group and 40 in the PLA group returned to their pre-fracture Parker score (p = 0.641) in both groups. No statistically significant differences between groups were found at one year regarding these two scores (p = 0.062 and p = 0.723, respectively). The DAA was associated with more intraoperative complications (p = 0.013). There was one dislocation in each group, and four revisions for DAA and one for PLA, but this difference was not statistically significant. There were also no significant differences regarding blood loss, length of stay, or operating time. Conclusion: In DMC-THA for FNF, DAA did not achieve better functional results than PLA, either at three months or at one year. Moreover, DAA presented an increased risk of intra-operative complications.