Improved Metastatic-Free Survival after Systematic Re-Excision Following Complete Macroscopic Unplanned Excision of Limb or Trunk Soft Tissue Sarcoma.

BACKGROUND: Whether re-excision (RE) of a soft tissue sarcoma (STS) of limb or trunk should be systematized as adjuvant care and if it would improve metastatic free survival (MFS) are still debated. The impact of resection margins after unplanned macroscopically complete excision (UE) performed out of a NETSARC reference center or after second resection was further investigated. METHODS: This large nationwide series used data from patients having experienced UE outside of a reference center from 2010 to 2019, collected in a French nationwide exhaustive prospective cohort NETSARC. Patient characteristics and survival distributions in patients reexcised (RE) or not (No-RE) are reported. Multivariate Cox proportional hazard model was conducted to adjust for classical prognosis factors. Subgroup analysis were performed to identify which patients may benefit from RE. RESULTS: Out of 2371 patients with UE for STS performed outside NETSARC reference centers, 1692 patients were not reviewed by multidisciplinary board before treatment decision and had a second operation documented. Among them, 913 patients experienced re-excision, and 779 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, size, depth, grade and histotype in patients re-excised (RE) or not (No-RE). In univariate analysis, final R0 margins are associated with a better MFS, patients with R1 margins documented at first surgery had a better MFS as compared to patients with first R0 resection. The study identified RE as an independent favorable factor for MFS (HR 0.7, 95% CI 0.53-0.93; p = 0.013). All subgroups except older patients (>70 years) and patients with large tumors (>10 cm) had superior MFS with RE. CONCLUSIONS: RE might be considered in patients with STS of limb or trunk, with UE with macroscopic complete resection performed out of a reference center, and also in originally defined R0 margin resections, to improve LRFS and MFS. Systematic RE should not be advocated for patients older than 70 years, or with tumors greater than 10 cm.

Economic impact of a clinical pharmacist in the orthopaedic sector: a review of the literature.

OBJECTIVES: This review of the literature aimed to evaluate the economic impact of a clinical pharmacist in the orthopaedic sector. METHODS: The review followed the PRISMA recommendations. A bibliographic search was conducted on 23 June 2023 using PubMed, Cochrane Library and Web of Science. All articles in French or English with economic data on clinical pharmacy activities in orthopaedics were included. Articles not mentioning the term 'orthopaedics' and those published prior to 1990 were excluded. Data from the studies were compiled in an Excel table. A bias analysis using the ROBINS-I Cochrane tool was performed. The methodology of the studies was compared and weighted using the CHEERS and STROBE checklists. RESULTS: Among 529 articles initially identified, 10 were included in the review. The cost-benefit ratio of a clinical pharmacist in orthopaedics ranged from 0.47:1 to 28:1. The maximum savings reached US$73 410 /year in the American study and €1 42 356 /year in the French study. For three studies, the cost of a clinical pharmacist was not evaluated. Eight studies showed a positive economic impact. The Dutch study showed a balance and the Danish study showed a negative economic impact of €3442/month. CONCLUSIONS: This literature review has shown an economic benefit of a clinical pharmacist in the orthopaedic sector despite several biases and methodological limitations. The two studies that did not confirm this benefit only evaluated a limited number of expected benefits. Nevertheless, the economic impact of the clinical pharmacist in the orthopaedic sector seems positive and undervalued.

Reliability of a new computerized equinometer based on Silfverskiöld test to measure gastrocnemius tightness.

BACKGROUND: Several tools exist to measure tightness of the gastrocnemius muscles; however, few of them are reliable enough to be used routinely in the clinic. The primary objective of this study was to evaluate the intra- and inter-rater reliability of a new equinometer. The secondary objective was to determine the load to apply on the plantar surface of the metatarsal heads to achieve the highest reliability when measuring gastrocnemius tightness. METHODS: The equinometer consisted of a goniometer and an electronic dynamometer, hooked up to a computer. Three raters carried out three trials of passive dorsiflexion by applying controlled pressure to the metatarsal heads of both ankles in 29 healthy subjects under two experimental conditions: knee extended (KE) and knee flexed at 30 degrees (KF). The equinometer continuously recorded the ankle dorsiflexion values (in °) corresponding to each 1 N interval of plantar pressure between 4 N and 20 N. The intra- and inter-rater reliability of the ankle dorsiflexion were evaluated through the intra-class correlation (ICC) coefficients in each of the pressure intervals. RESULTS: The intra-rater ICC in KE and KF was between 0.84 and 0.98. The inter-rater ICC in KE and KF was between 0.59 and 0.92. The pressure interval between 14 N and 15 N had the highest intra-rater (ICC = 1) and inter-rater reliability (0.87≤ICC≤0.99). A more refined analysis of this interval found that a load of 14.5 N yielded the best reliability. CONCLUSIONS: This compact equinometer has excellent intra-rater reliability and moderate to good inter-rater reliability. Since this reliability is optimal in the 14-15 N range, this load should be used going forward in clinical practice, especially when aiming to define a pathological threshold for tightness of the gastrocnemius muscles.

Thoracogenic scoliosis: coronal deformity progression in paediatric patients.

PURPOSE: To assess the risk of developing thoracogenic scoliosis (THS) in paediatric patients, depending on the side of lateral thoracotomy (LT) and of spine deviation in the coronal plane by means of logistic regression and scoliosis-free survival analyses. METHODS: A total of 307 consecutive patients undergoing LT were retrospectively reviewed; 32 patients met the inclusion criteria: 1) underwent LT and developed THS; 2) age < 15 years at LT; 3) clinical and radiographic follow-up ≥ 5 years. Patients were divided into ipsilateral group (convexity ipsilateral to LT) and contralateral group (convexity contralateral to LT). RESULTS: The mean follow-up was 10 ± 4.7 in the ipsilateral group (n = 13) and 12 ± 4.8 years in the contralateral group (n = 19). The contralateral group underwent LT at a younger age (4.4 vs 6.4 years, p = 0.55), developed more severe coronal deformity (27.8° vs 18.9°, p = 0.15), had higher rate of THS > 20° (47.5% vs 38.4%; p = 0.34) and > 45° (21.1% vs 0%; p = 0.99). The mean time from LT to THS diagnosis was 4.2 ± 2.9 in ipsilateral group and 5.5 ± 4.2 years in contralateral group. Left-side LT (p = 0.03) and age > 5 years (p = 0.01) showed a lower risk of THS diagnosis. The group variable had a statistically significant effect on the risk of developing THS > 45° (p = 0.03). CONCLUSION: In this series, children that developed THS with a convexity contralateral to the side of LT had more severe and progressive coronal spine deformity. LEVEL OF EVIDENCE: III.

Soft tissue sarcomas of the buttock: A systematic review and meta-analysis.

BACKGROUND: Soft tissue sarcomas of the buttock (BSTS) are historically associated with a poor prognosis. The literature includes retrospective studies with small sample size. It is difficult to estimate the rate of local recurrence (LR), distant metastasis (DM) and overall survival (OS). A systematic review and meta-analysis was deployed to summarize the available information on BSTS patients that underwent surgical treatment. METHODS: The PubMed, EMBASE, Scopus and Google Scholar databases were reviewed for eligible studies following PRISMA guidelines. INCLUSION CRITERIA: (1) primary BSTS confirmed by pathological biopsy (2) indication for surgical treatment (3) reporting either the rate of LR, DM, or OS at 5-year (4) articles published up to December 2021 (5) english language. The Methodological Index for Non-Randomized Studies (MINORS) was applied for the quality appraisal. RESULTS: Six eligible studies with 216 BSTS patients were identified. Most patients underwent surgical resection, associated with radiation therapy. The most represented histological types were liposarcoma (n = 43, 19,9%), rhabdomyosarcoma (n = 27, 12.5%), and undifferentiated pleomorphic sarcoma (n = 23, 10.6%). High-grade tumor rates ranged from 37% to 88.2%, marginal resection rates from 20.3% to 50%, LR rates from 0% to 62.5%, DM rates from 37.5% to 62.5%. The pooled 5-year OS from 1941 to 2002 was 41% (IC95%: 33%-49%). The average MINORS score was 9.3 (range: 6 to 11). CONCLUSIONS: Surgical resection of BSTS had on average dissatisfactory outcomes, and the 5-year overall survival was poor, with high rates of local recurrence and distant metastasis. An effort to collect new data with a higher level of evidence is warranted.

Overall survival in patients with re-excision of positive microscopic margins of limb and trunk wall soft tissue sarcoma operated outside of a reference center: a nationwide cohort analysis.

BACKGROUND: This French nationwide NETSARC exhaustive prospective cohort aims to explore the impact of systematic re-excision (RE) as adjuvant care on overall survival (OS), local recurrence free survival (LRFS), and local and distant control (RFS) in patients with soft tissue sarcoma (STS) with positive microscopic margins (R1) after initial resection performed outside of a reference center. METHODS: Eligible patients had experienced STS surgery outside a reference center from 2010 to 2017, and had R1 margins after initial surgery. Characteristics and treatment comparisons used chi-square for categorical variables and Kruskall-Wallis test for continuous data. Survival distributions were compared in patients reexcised (RE) or not (No-RE) using a log-rank test. A Cox proportional hazard model was used for subgroup analysis. RESULTS: A total of 1,284 patients had experienced initial STS surgery outside NETSARC with R1 margins, including 1,029 patients with second operation documented. Among the latter, 698 patients experienced re-excision, and 331 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, tumor size, tumor depth, and histotype in the population of patients re-excised (RE) or not (No-RE). The study identified RE as an independent favorable factor for OS (HR 0.36, 95%CI 0.23-0.56, p<0.0001), for LRFS (HR 0.45, 95%CI 0.36-0.56, p<0.0001), and for RFS (HR 0.35, 95%CI 0.26-0.46, p<0.0001). CONCLUSION: This large nationwide series shows that RE improved overall survival in patients with STS of extremities and trunk wall, with prior R1 resection performed outside of a reference center. RE as part of adjuvant care should be systematically considered.

La douche préopératoire chez les patients obèses : ce qu'en disent les patients et les soignants.

Introduction : At least one preoperative shower is recommended to avoid surgical site infection. Caregivers must explain the showering technique, help the patient if necessary, and assess skin cleanliness after showering.Context : Showering may be more difficult for obese patients because of inadequate equipment and difficulties moving, as well as insufficient explanation regarding the showering technique and an insufficient skin cleanliness assessment from caregivers.Objective : to assess whether patients and/or caregivers report difficulties in the preoperative shower process that could be linked to patient obesity. Methods : pilot qualitative survey with semi-structured interviews conducted with 9 obese surgery patients and 11 surgery caregivers.Results : Patients did not report feelings of discrimination. They described no problem with equipment, but declared having received little explanation on the showering technique and no visual skin cleanliness assessment. Caregivers reported equipment as inadequate, they stated having delivered detailed information, but found the skin cleanliness assessment difficult.Discussion : The lack of skin cleanliness assessment by caregivers after preoperative showering is new information. Limits : preliminary study with a small number of interviews and no non-obese patients.Conclusion : the subject warrants additional work with both quantitative and qualitative surveys to better understand the difficulties with preoperative showering.

Posterior hinge fixation for the treatment of unstable traumatic sacroiliac joint injuries.

INTRODUCTION: Posterior hinge fixation (PHF) is a sacroiliac joint fixation method indicated for the surgical treatment of unstable pelvic ring fractures (tile C). HYPOTHESIS: PHF yields good functional outcomes based on the Majeed score at more than 1 year of follow-up. METHODS: A single-center, retrospective study of patients who had a Tile C pelvic ring fracture, who were operated by PHF and who were evaluated at a minimum follow-up of 1 year. The functional outcome was determined using the Majeed score and pain was evaluated by the patients using a visual analog scale (VAS). The preoperative, intraoperative and postoperative data, complications and sequelae were documented. A CT-scan was done at least 1 year after the surgical treatment to determine the SI joint's reduction and fusion. RESULTS: Included were 22 patients (59% men) who had a mean age of 37.3±11.9 years; 21 of these patients were reviewed at a mean of 4.8±4 years. The mean Majeed score at the final assessment was 76.4 points±15.3, with 24% of patients having excellent results (n=5), 53% having good results (n=11), 19% having average results (n=4) and 5% having poor results (n=1). The mean pain level on VAS was 28±23mm. Of the eight surgical site infections, seven occurred in the PHF (88%). CT-scans taken at 1 year postoperative were compared to the preoperative scans. The pelvic opening was reduced by -9±6 (p<0.01), SI diastasis by -11mm±9 (p<0.001), vertical displacement by-7mm±8 (p<0.001), symphysis opening by -15mm±15 (p<0.001), median transverse diameter by -10mm±9 (p<0.001) and bispinal diameter by -5mm±7 (p<0.001). SI fusion was confirmed in 43% of patients (n=9). CONCLUSION: PHF is a surgical instrumentation method that provides satisfactory long-term reduction of Tile C pelvic ring fractures. The clinical outcomes are good or excellent in 77% of cases. The perioperative morbidity is marked by surgical site infections, all of which healed. LEVEL OF EVIDENCE: IV; retrospective, non-comparative cohort study.

Optoelectronic Study of Gait Kinematics in Sagittal Spinopelvic Imbalance.

OBJECTIVE: Degenerative processes induce loss of lumbar lordosis and anterior sagittal imbalance (ASI). Optoelectronic study provides kinematic analysis of movement and can also detect ASI. The aim of the present study was to assess gait kinematic modifications induced by ASI. METHODS: Thirty-five healthy male volunteers were subjected to reversible ASI induced by wearing a kyphotic thermoformed thoracolumbar corset. The deformation was assessed by C7 tilt on EOS (EOS Imaging, Paris, France) full-spine views. Ten optoelectronic gait recordings were made with corset and 10 without. Gait kinematic parameters (stride length, walking speed, rhythm), gait balance parameters (center of mass braking index, stride width, double support time) and spinal sagittal balance parameters (C7T10S1, C7´S1' and spinal angles) were averaged. Adjusted analysis distinguished direct ASI impact from locomotor factors. RESULTS: The corset-induced ASI produced +15° change in C7 tilt (P < 0.0001), -7.4° in C7T10S1 (P < 0.0001), +66.2 mm in C7´S1' (P < 0.0001), and +13.1° in spinal angle (P < 0.0001). Radiographic and optoelectronic data correlated significantly. Stride length (P < 0.0001) and rhythm (P = 0.0003) were significantly reduced, contributing to a reduction in walking speed (P < 0.0001), and strongly influencing double support time (ß = -0.38; 95% confidence interval [CI]: -0.69; -0.06). Center of mass braking index was significantly reduced (P < 0.0001) and significantly influenced by ASI (ß = -0.51; 95% CI: -0.78; -0.28). Stride width was significantly increased by ASI (P < 0.0001), independently of rhythm and stride length. CONCLUSIONS: ASI induced by a kyphotic corset was detectable on the optoelectronic system, leading to significant changes in gait kinematics. Locomotor parameters were significantly reduced. Balance parameters were significantly and directly altered by ASI.

Arthroscopic management of unexplained pain following total knee arthroplasty.

INTRODUCTION: Arthrofibrosis develops in 3-10% of knees after total knee arthroplasty (TKA), which may result in pain and restricted range-of-motion. Treatment options include manipulation under anaesthesia, arthroscopic debridement, and quadricepsplasty, but there is little consensus on their efficacy for treatment of unexplained pain after TKA. The purpose of this study was to report the prevalence and characteristics of unexplained pain after TKA as revealed by arthroscopic exploration, and assess the efficacy of arthroscopic procedures to relieve pain. MATERIALS AND METHODS: From a consecutive series of 684 TKAs, 11 patients (1.6%) had unexplained pain at 7-48 months after TKA. Causes of pain remained unidentified after systematic and differential assessment, but arthroscopic exploration revealed fibrotic tissues, which were debrided during the same procedure. Patients were assessed first at 6-61 months and last at 90-148 months, with pain on a visual analog scale (pVAS) and range-of-motion recorded during both assessments, but Oxford Knee Score (OKS) and Forgotten Joint Score (FJS) only during the last assessment. Residual pain was classified as little or no pain (pVAS, 0-1), moderate pain (pVAS, 2-4), and severe pain (pVAS, 5-10). RESULTS: At first follow-up (n = 11) pVAS improved by 4.1 ± 1.1 (p < 0.001), and range-of-motion improved by 5.0° ± 7.1° (p = 0.041). Seven patients (64%) had little or no residual pain, while four (36%) had moderate residual pain. At final follow-up (n = 9) pVAS improved by 3.2 ± 2.9 (p < 0.001), and range-of-motion improved by 4.4° ± 8.5° (p = 0.154). Six patients (67%) had little or no residual pain, while one (11%) had moderate and two (22%) had severe residual pain. CONCLUSION: Arthroscopic exploration revealed that all 11 knees with unexplained pain had fibrotic tissues, the removal of which alleviated pain in only 67%, while moderate to severe pain persisted in 33% which merits further scrutiny.

Static and dynamic stabilometric force platform study of spinopelvic anterior sagittal imbalance.

BACKGROUND DATA: Anterior sagittal imbalance (ASI) is a severity factor in spinal pathology. Stabilometric study of the dynamic position of the center of pressure (CoP) assesses orthostatic control. These analyses provide the energy expenditure used for this control. HYPOTHESIS: Stabilometric signs are associated with ASI indicate increased energy expenditure. PATIENTS AND METHODS: Healthy male volunteers were subjected to reversible ASI induced by wearing a kyphotic thermoformed thoracolumbar corset. The deformation was assessed by C7 tilt on EOS whole-spine views. Static and dynamic posturographic force platform study was performed under conditions of anteroposterior and mediolateral instability. Mean CoP position (Xmean, Ymean) was studied on statokinesigram, with scatter assessed as confidence ellipse (CE). Path length according to CE surface (LAS) indicated energy expenditure. The stabilogram quantified displacement over time as lengths (Lx, Ly) and amplitudes (Ax, Ay). RESULTS: The corset significantly increased C7 tilt (p<0.0001). This did not significantly change mean CoP positions (Xmean and Ymean), but LAS was significantly increased (p=0.003). Static tests showed changes in Ly (p=0.0008) and Ax (p=0.003), and dynamic tests showed changes in Ly (p<0.0001), Lx (p<0.0001), Ax (p<0.0001), Ay (p<0.05) and CE (p<0.004). DISCUSSION: Posturographic parameters were impacted by inducing ASI in healthy subjects. Significant differences were seen in stabilography, CE and LAS, were greater on dynamic testing, and correlated with radiologic sagittal balance. Force platforms can reveal increased energy expenditure in maintaining posture. LEVEL OF EVIDENCE: II; Single-center prospective study involving healthy volunteers.

Massive Rotator Cuff Repair: Banana SutureLasso Double-Row Fixation.

Massive rotator cuff tears have always been a worrisome situation to every orthopaedic surgeon. Patients' functional demands are increasing with time, and this is why we aim to offer them the best options to preserve their quality of life. We found that using the Banana SutureLasso (Arthrex) has made this type of surgery much easier. We think that with the Banana SutureLasso (Arthrex) we have more access to the medial part of the rotator cuff, and that we can grab both the deep and superficial layers of the tendons while diminishing the risk of laceration. We combined an X-suture with a double-row fixation using a Corkscrew (Arthrex) on the humeral tuberosity and a SwiveLock (Arthrex) screw on lateral side of the humerus. We used only 3 portals with an extra parking portal. Another advantage is that we can adjust the sutures so they would be perpendicular to both ends of the tear. Our technique is simple, safe, and reproducible.

Arthroscopic Side-to-Side Repair of Massive Rotator Cuff Tears Maintains Adequate Functional Improvement at 12 to 14 Years' Follow-up.

BACKGROUND: Rotator cuff tears are common shoulder injuries that often cause pain and loss of function. Nonanatomic side-to-side techniques facilitate repair by minimizing tensions within tendons to improve healing and optimize the thickness of sutured tissues. PURPOSE/HYPOTHESIS: The purpose was to evaluate long-term clinical and radiographic outcomes of arthroscopic side-to-side repair of massive rotator cuff tears (mRCTs). The hypothesis was that, at a minimum follow-up of 12 years, arthroscopic side-to-side repair maintains clinically important improvements. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors reviewed records of all patients who underwent arthroscopic repair of mRCTs over 2 consecutive years. A total of 30 adult patients met the eligibility criteria and underwent side-to-side repair. Patients were evaluated clinically using the Constant score (CS) and ultrasound to assess retears at 3 timepoints after surgery: 2 to 4 years, 5 to 7 years, and 12 to 14 years. RESULTS: At first follow-up (3.2 ± 0.5 years), all 30 patients had clinical and ultrasound assessment, which revealed 13 retears (43%). At second follow-up (6.2 ± 0.5 years), all 30 patients had clinical and ultrasound assessment, which revealed 2 new retears (total 50%). At final follow-up (13.0 ± 0.7 years), only 21 patients had clinical assessment (1 died and 8 could not be reached), and only 19 patients had ultrasound assessment, which revealed 6 new retears (total 79%). Both absolute CS and age-/sex-adjusted CS improved significantly from baseline values at first follow-up (73.5 and 96.6, respectively), and remained stable at second follow-up (69.0 and 91.9, respectively), and final follow-up (64.4 and 87.0, respectively). Compared to shoulders with intact repairs, those with retears tended to have lower absolute CS at all follow-up visits, although differences were not statistically significant. CONCLUSION: Patients with mRCTs maintain satisfactory clinical scores at 12 to 14 years after arthroscopic side-to-side repair despite a high incidence of retears. Repair is a safe and effective treatment for mRCTs, providing a less invasive and less complex alternative to reverse shoulder arthroplasty and tendon transfer procedures.

A comparative study between isolated gastrocnemius tightness patients and controls by quantitative Gait analysis and baropodometry.

BACKGROUND: Isolated gastrocnemius tightness (IGT) has been suggested as an etiologic factor in mechanical disorders of the foot and ankle without a clear pathophysiological mechanism in the literature. We hypothesized that restricted ankle dorsiflexion inducing increased forefoot pressure in IGT patients could be this pathophysiological mechanism. METHODS: Case/control experimental observational investigation. Forty lower limbs in 20 asymptomatic IGT patients were included and compared to controls. Quantitative gait analyses coupled with dynamic baropodometry were used for comparison between groups. The primary outcome was maximum ankle dorsiflexion during stance phase. Secondary outcomes were knee flexion and forefoot pressure. RESULTS: Maximum ankle dorsiflexion and maximum forefoot pressure were similar between groups. Increased knee flexion was found in the asymptomatic IGT group. CONCLUSIONS: IGT induced compensatory knee flexion during stance phase, which probably prevents increased pressure on the forefoot by allowing ankle dorsiflexion. LEVEL OF EVIDENCE: Level IV, Case/control experimental observational investigation.

Castleman's disease in two patients with spondyloarthritis treated by Tumor Necrosis Factor-alpha antagonists.

Castleman's disease is a rare lymphoproliferative syndrome involving several anatomical and clinical entities. We report two cases of Castleman's disease in patients with spondyloarthritis (with and without psoriasis) treated with Tumor Necrosis Factor-alpha blockers. During follow-up, imaging examinations, carried out for disease assessment, fortuitously revealed a pelvic mass close to the psoas or an atypical cervical adenopathy. Both lesions were in moderate hypermetabolism on Positron emission tomography-computed tomography. After surgical excision and histological analysis, Castleman's disease was diagnosed without signs of malignancy. To the best of our knowledge, these are the first cases of Castleman's disease diagnosed in a context of spondyloarthritis treated with Tumor Necrosis Factor-alpha blockers. The relationship between these two pathologies and the link with Tumor Necrosis Factor-alpha blockers agents has not been explored in the literature until now.

Extended anterolateral transiliac approach to the sacral plexus.

The approach to the sciatic plexus and lateral part of the sacrum is difficult. A subperitoneal anterolateral approach can be extended by sectioning the iliac bone above the acetabulum and lowering it toward the external part of the iliac wing and buttock. This transiliac anterolateral approach exposes the lumbosacral trunk, first sacral foramina and sciatic plexus to the origin of the sciatic trunk. Exposure can be extended upward by subperitoneal lumbotomy, downward by opening the ischiorectal fossa, or outward by trochanterotomy. This approach was used 18 times by one of the authors (FHD) for resection of 13 malignant tumors and 5 plexus releases. Procedure time was 3-6hours, with 500-4,000ml blood loss. The approach systematically enabled surgical objectives to be met. There was 1 septic complication that healed after debridement.

[Intraoperative hypotension and delirium in patients with hip fracture]. / Hypotension per-opératoire et syndrome confusionnel chez les patients présentant une fracture de l'extrémité supérieure du fémur.

Postoperative delirium is common after hip fracture surgery in elderly patients and is associated with poor outcome (higher risk of mortality, institutionalization and length of stay). The relationship between modifiable intra-operative risk factors, such as intra-operative hypotension, and postoperative delirium is unclear. The main objective of this study was to evaluate the association between intra-operative hypotension and the development of a postoperative delirium in older patients with hip fracture. A secondary aim was to assess the impact of other pre- and intra-operative predisposing factors (anaesthetic approaches or specific anaesthetic drugs, surgery duration, timing of surgery, type of implants used as primary treatment, intra-operative blood loss) on developing postoperative delirium in this elderly population. This retrospective monocentric study included 100 consecutive hip fracture patients, aged 75 years and older, admitted to a dedicated ortho-geriatric unit. All patients were screened for post-operative delirium using the confusion assessment method performed by a geriatrician. Intra-operative hypotension was defined as a decrease of more than 30% below the preoperative baseline for systolic blood pressure or a decrease in mean arterial pressure (MAP) below 60 mmHg. Post-operative delirium (n = 37; 37.8%) and intra-operative hypotension (n = 80; 81.6%) are both common in old patients but we did not demonstrate a significant association regardless of the chosen definition. The following risk factors were significantly associated with postoperative delirium: surgical delay (OR 1.47[1.01-2.02]; p = 0.02), institutionalisation (OR 2.25[1.33-3.8]; p = 0.02) and postoperative acute kidney injury (OR 2.34[1.32-4.15]; p = 0.02). Postoperative delirium is common in old patients with hip fracture and is associated with postoperative complications, institutionalisation and surgical delay but not with intra-operative risk factors.

Total femur replacement in non-oncologic indications: Functional and radiological outcomes from a French survey with a mean 6 years' follow-up.

INTRODUCTION: There are few published studies on total femur replacement (TFR) because its indications are rare. Other than malignant diseases, the indications extend to revisions and interprosthetic femur fractures; however, the outcomes of these indications have not been well defined. The aim of this retrospective survey was to analyze the complication rate and functional outcomes of these newer indications. HYPOTHESIS: The morbidity and outcomes after TFR are comparable to those reported in the literature for non-cancer indications. MATERIAL AND METHODS: Between 1997 and 2016, 29 TFR procedures were done at 6 French teaching hospitals in 15 women and 14 men, average age 68±14 years [32-85]. The primary indication was degenerative joint disease in the hip and/or knee in 16 cases, mechanical failure of the implant used after tumor resection in 11 cases and femur fracture in 2 cases. The mean number of surgical procedures before TFR was 3.6 (maximum 5) at the hip and 4.5 (maximum 10) at the knee. Six different models were implanted consisting of a rotational hinge knee (except in one case); 20 patients received a dual mobility system and 9 a standard hip replacement bearing. The femoral shaft was partially conserved 21/29 times and the trochanter 25/29 times. RESULTS: Five patients suffered a general complication and 12 suffered a local complication (including 4 hematomas and 2 hip dislocations). Eight patients (28.6%) suffered a surgical site infection, although three had a prior infection. Among the 12 patients with a history of infection or progressive infection before the TFR, 9 healed and 3 had the infection continue. At a minimum follow-up of 2 years and mean of 6 years, 23 TFR implants were still in place and not infected; the other 6 had been removed or were infected, including one patient who underwent disarticulation. The median survival of the non-infected TFR was 15 years. At 10 years, 70% of TFR implants were still in place and non-infected. Walking was possible with or without a cane in 15 patients (51.7%), with two canes or a walker in 12 patients (41.3%) and impossible in 2 patients. Active knee flexion averaged 79.4°±30.3° [0°-120°]; 17 patients (62.9%) had 90° or more flexion; two patients (7.4%) had no flexion. The extension deficit averaged 3.7°±7°[-20° to 10°] and 20 patients had no flexion deformity. The leg length difference averaged 1.3cm±2.3 [0-10]; 19 patients (67.8%) had no difference in leg length. DISCUSSION: Our starting hypothesis was confirmed for the complication rate and clinical outcomes. The benefits of dual mobility cups are emphasized. While the indications for TFR are rare, they will likely increase in the coming years. LEVEL OF EVIDENCE: IV, Retrospective cohort study….