Junior surgeon learning curve for performing digital planning of a first-line uncemented total hip prothesis.

PURPOSE: Preoperative digital planning of total hip arthroplasty (THA) anticipates difficulties while increasing implant survival. The objective was to establish the learning curve to produce a reliable and reproducible preoperative planning for THA. We hypothesize that a learning curve exists for planning, and we want to determine the number of procedures required to accomplish it. METHODS: This prospective study included patients for THA from 02/11/2019 to 01/11/2022. Ten junior (Juniors) and senior surgeons (Seniors) had received dedicated training in the use of the software. Modeling was done blindly by Juniors and Senior before surgery on a standardized front pelvis X-ray (mediCAD 2D Classic Hospital software). Statistical analyses to establish the learning curve were done to compare the Juniors and Seniors. RESULTS: 60% of the Juniors achieved competence after 31.5 ± 12.9 [14-54] planning sessions for the acetabular implant, and 80% after 30.3 ± 8.3 [17-40] planning sessions for the femoral implant. Femoral neck size was achieved by all ten Juniors after 23.1 ± 6.8 [17-38] planning. The offset was correctly restored on the plan by 30% of the Juniors after 33.5 ± 11.6 [18-46] planning. CONCLUSION: There is a learning curve for 2D planning of uncemented THA. The different planning items seem to have different learning curves. Compared to Seniors, the completion of 75 planning sessions is not sufficient in totality. The competence of the Juniors for the acetabular implant, the length of the neck and the size of the femoral stem are mostly acquired before 75 sessions. LEVEL OF EVIDENCE: Prospective study-Level II.

Early rehabilitation after reverse total shoulder prosthesis on fracture of proximal humerus in elderly patients provides better functional outcome.

PURPOSE: Reverse total shoulder arthroplasty (RSA) has revolutionized the management of proximal humerus fractures (PHF) in the elderly patients. There is few or no consensus regarding to management of postoperative rehabilitation in elderly patients. An early rehabilitation from D1 allowed better functional results compared to rehabilitation started to D30 independently from tuberosities consolidation. METHODS: 94 patients operated on for PHF were evaluated retrospectively, with a minimum radio-clinical follow-up of 2 years. Clinical evaluation included mobilities and four functional scores: ASES, quick DASH, gross constant, weighted constant. Radiological evaluation was performed on a frontal shoulder X-ray with evaluation of tuberosities' consolidation. RESULTS: The mean follow-up was 45 ± 19 months (24-88 months). Early rehabilitation was significantly associated with a better Constant Score (71.1 ± 17.2 vs. 56.4 ± 15.8; p < 0.001), better adjusted Constant score (92.4 ± 14.2 vs. 80.3 ± 19.5; p < 0.001), better quick DASH (22.8 ± 19.8 vs. 36.7 ± 21.3; p < 0.01), better ASES (78.6 ± 20.2 vs. 63 ± 22; p < 0.001). CONCLUSION: In traumatology, functional result of RSA seems not related in tuberosities' union but in rehabilitation in order to limit postoperative stiffness of operated shoulder. An early rehabilitation is related with better clinical and functional results, independently of tuberosities' union. LEVEL OF EVIDENCE: 3, control-case study.

Osseointegration of two types of titanium cylinders with geometric or trabecular microarchitecture: A nanotomographic and histomorphometric study.

Porous biomaterials promote osseointegration. We have prepared porous titanium cylinders by additive manufacturing from titanium beads. Two types of morphology were tested: cylinders with geometric pores or mimicking trabecular microarchitecture. Cylinders were decontaminated and cleaned by HF/HNO3 to remove unmelted balls. Surgical implantation in ewes was performed under general anesthesia and the animals were housed for 90 and 270days. The femoral condyles were collected and analyzed by nanoCT, embedded in pMMA and analyzed by histomorphometry. No significant difference was found in terms of bone volume or bone/titanium interface between the two types of cylinders. There was no evolution over time except for the mineralization rates which decreased, reflecting the effect of the aging of the animals. The influence of the pores (geometrical or "natural") did not influence osseointegration. HF/HNO3 etching treatments are effective on the outermost surfaces but do not seem to reach the central cavities of the samples. Finally, osseointegration seems to occur only in the few millimeters around the periphery of the implants and does not extend in the center. This is explained by the absence of stress transmission within the very rigid metal cylinders, preventing bone modeling and remodeling.

Wear debris released by hip prosthesis analysed by microcomputed tomography.

Total hip arthroplasty uses commercial devices that combine different types of biomaterials. Among them, metals, ceramics and metal oxides can be used either in the prosthesis itself or in the cement used to anchor them in the bone. Over time, all of these materials can wear out and release particles that accumulate in the periprosthetic tissues or can migrate away. We used histology blocks from 15 patients (5 titanium metallosis, 5 alumina prostheses, 5 with altered methacrylic cement) to perform a microCT study and compare it with conventional histology data. An EDS-SEM analysis was done to characterise the atomic nature of the materials involved. A morphometric analysis was also performed in 3D to count the particles and assess their density and size. The metallic particles appeared to be the largest and the ceramic particles the finest. However, microCT could not reveal the wear particles of radiolucent biomaterials such as polyethylene and the very fine zirconia particles from cement fragmentation. MicroCT analysis can reveal the extent of the accumulation of these debris in the periprosthetic tissues. LAYOUT DESCRIPTION: Hip prostheses progressively degrade in the body by releasing wear debris. They accumulate in the periprosthetic tissues. Microcomputed tomography was used to image three types of radio-opaque wear debris: metal, ceramic and zirconia used in the bone cements.

A patient with single coronary artery, bicuspid aortic valve and sinus of Valsalva aneurysm.

BACKGROUND: We report a rare case of a patient who presented with chest pain and was found to have a constellation of rare cardiac anomalies. CASE PRESENTATION: A 67-year-old patient with no past medical history presented with chest pain. He had mild troponin elevation, but no ischemic changes on ECG. He underwent a CT coronary angiogram for further evaluation. He was found to have a type 0 bicuspid aortic valve, large left sinus of Valsalva aneurysm and type R-III single coronary artery. These findings were confirmed with transesophageal echocardiogram and coronary angiogram. He underwent a successful repair of his aortic root aneurysm with a synthetic patch. CONCLUSIONS: The combination of type R-III single coronary artery, bicuspid aortic valve, and left sinus of Valsalva aneurysm congenital anomalies in one individual is extremely rare and marks our case unique. Given the size of his Sinus of Valsalva aneurysm, the patient underwent surgical repair of his aneurysm and was asymptomatic when seen in follow-up.

Necrosis of the femoral head, X-ray microtomography (microCT) and histology of retrieved human femoral heads.

Aseptic osteonecrosis of the hip (AON) is a rare, but well-known pathology in rheumatology and orthopedic surgery that is a necrosis of the articular cartilage secondary to a necrosis of the subchondral bone. The microscopic aspect is well known, but the microCT aspect has never been reported or correlated with histopathological findings. The objective of this study was to improve the knowledge of the pathophysiology of AON using histochemistry and microCT. One hundred and sixty femoral heads with stage 3 or 4 AON were analyzed: one half of the head was sent for microCT analysis after impregnation with phosphotungstic acid (PTA) and the other half was used for histological analysis without decalcification. The microCT analysis provides relevant information on the cracked articular cartilage and the relationship with the necrotic subchondral trabecular bone well illustrated on three videos. In histology, Goldner's trichrome showed that the articular cartilage remains well preserved for a long time. In addition, toluidine blue staining reveals a modeling process, i.e. the apposition of new bone without prior resorption by osteoclasts. Rhodamine B staining (fluorescence analysis) reveals that the osteonecrotic trabeculae and subchondral bone were devoid of osteocytes. Areas of peri-necrotic osteosclerosis are due to direct bone formation on the surface of pre-existing necrotic trabeculae.

Aseptic osteonecrosis of the shoulder: Etiologies, diagnosis and medical management.

Aseptic osteonecrosis of the humeral head is a multifactorial entity in which the final common pathway results in disrupted blood supply, increased intraosseous pressure, and bone death. It follows a pathologic and radiographic pattern of progression similar to that seen at the hip. Much of the information regarding the disease has been extrapolated from findings in the femoral head. In addition, many treatment modalities have been adapted from techniques used in the hip. The causative underlying factors seem to be multifactorial and can be traumatic or non-traumatic. Although clinical symptoms and the underlying cause of the disease influence the treatment of each patient, staging is the most objective criterion in determining the most appropriate treatment. Earlier identification of osteonecrosis should facilitate the management. MRI is important for asymptomatic humeral head osteonecrosis in patients with poor clinical symptom and risk factor. Conservative treatment can be effective in stages I and II, When symptoms persist and there are signs of collapse despite conservative treatment, surgical intervention is advocated.

Arthroscopic anatomy of the middle glenohumeral ligament. A series of 300 cases.

PURPOSE: The anatomy of the middle glenohumeral ligament (MGHL) is seldomly described during arthroscopy. The aim of this study was to determine the arthroscopic variants concerning the anatomy of the MGHL. METHODS: A prospective, observational, single-center study was conducted between June 2016 and June 2017. All patients undergoing a first-time arthroscopy of the shoulder and with no history of prior surgery or trauma of the same shoulder were consecutively enrolled. The variations of the MGHLs shape and of its glenoid and distal insertions were documented during surgery. RESULTS: A total 300 patients were included. Surgeries included rotator cuff sutures, tenotomy/tenodesis of the long head of the biceps tendon (LHBT) and subacromial decompression in respectively 31%, 32.7% and 35.5% of cases. The MGHL was absent in 12% of cases, presented a flat structure in 72% of cases, a cord-like shape in 14% and a Buford complex was observed in 1%. Its glenoid insertion was located on the labrum between the superior (SGHL) and inferior (IGHL) in 43% of cases, presented a combined insertion with the LHBT in 7%, with the SGHL in 29% and with both the SGHL and LHBT in 9%. The distal insertion was located in 67% of cases on the subscapularis tendon (SCCT) or the capsule covering it, and on the humeral bone in 21%. CONCLUSION: This study confirms and details the anatomic variants of the MGHL, notably describing the lesser-known variants of its distal insertion, yet arises the question of the exact nature and function of this so-called ligament.

Hyaluronic Acid Stimulates Osseointegration of ß-TCP in Young and Old Ewes.

Cross-linked hyaluronic acid (HyAR) increases the local concentration of growth factors. We compared ß-TCP osseointegration in old and young ewes with/without HyAR addition. A blind tunnel was drilled on the medial femoral condyle of each knee in nine young and nine old ewes and was filled with ß-TCP, ß-TCP + HyAR or left unfilled. Double labeling with calcein allowed histodynamic analysis. Ewes were sacrificed at 84 days and the knees were harvested. MicroCT provided histomorphometric parameters: trabecular bone volume, residual volume of biomaterial. Histodynamic parameters were: mineralization rate, mineralized surfaces, bone formation rate. A non-parametric ANOVA and post hoc test analyzed differences between subgroups. Osseointegration of ß-TCP was similar in the aged/young grafted groups. Trabecular bone volume was significantly increased versus ungrafted animals (p < 0.001). There were no significant difference for bone volume, residual volume of biomaterial and histodynamic parameters when a single parameter was considered but additional effects of ß-TCP and HyAR were evidenced by 3D analysis. Addition of HyAR to ß-TCP does not significantly increase bone volume but tends to increase histodynamic parameters. However, considering the reduction of osteoblastic activity in aged animals, ß-TCP, and HyAR boosts osteoblastic activity. HyAR leads to an equivalent response between young and old animals.

Intraosseous metal implants in orthopedics: A review.

Metal implants are biomaterials widely used in orthopedics. They are both used in osteosynthesis and arthroplasty. Their mechanical properties, biocompatibility and resistance to corrosion make them a widely used option in orthopedics. Alloys are the most commonly used metals in orthopedics. As far as physical traumas are concerned, implants such as screws, plates and/or nails are used for osteosynthesis as they ensure the stability of the fractured area and contribute to bone healing. Prostheses are used in arthroplasty to restore joint function for as long as possible. Contact between bone and the prosthesis induces bone remodeling at the interface between metal and bone even if the metal is recognized as biocompatible. Upon time, the interface between the metal implant and the bony tissue is continuously modified and adapted. Hip prosthesis is a typical example of intraosseous metal implant whose bone/implant interface has been extensively studied. Metal can be altered in vivo by different mechanisms including corrosion and fretting. An altered torque friction leads to wear debris that accumulate in the peri-prosthetic tissues causing metallosis.

Sympathetic nervous activity in patients with acute coronary syndrome: a comparative study of inflammatory biomarkers.

Previous studies have shown that both sympathetic hyperactivity and enhanced inflammatory responses are associated with poor outcomes in patients with acute coronary syndrome (ACS). Whether there is a correlation between these two characteristics remains unclear. Thirty-four patients with uncomplicated ACS were evaluated; their mean age was 51.7±7.0 years, 79.4% were male, and 94.1% had myocardial infarction (MI). On the fourth day of hospitalization, they underwent muscle sympathetic nerve activity (MSNA) analysis (microneurography), as well as ultrasensitive C-reactive protein (usCRP), interleukin-6 (IL-6), and lipoprotein-associated phospholipase A2 (Lp-PLA2) activity measurements. These evaluations were repeated at 1, 3, and 6 months after hospitalization. Both MSNA and inflammatory biomarkers were elevated during the acute phase of ACS and then decreased over time. At hospitalization, the median usCRP level was 17.75 (IQR 8.57; 40.15) mg/l, the median IL-6 level was 6.65 (IQR 4.45; 8.20), the mean Lp-PLA2 activity level was 185.8 ±52.2 nmol/min per ml, and mean MSNA was 64.2±19.3 bursts/100 heart beats. All of these variables decreased significantly over 6 months compared with the in-hospital levels. MSNA was independently associated with the peak level of creatine kinase isoenzyme MB (CKMB) in the acute phase (P=0.027) and with left ventricular ejection fraction (LVEF) at 6 months (P=0.026). Despite the increased levels of inflammatory biomarkers and sympathetic hyperactivity in the initial phase of ACS, no significant correlations between them were observed in any of the analyzed phases. Our data suggest that although both sympathetic hyperactivity and inflammation are concomitantly present during the early phase of ACS, these characteristics manifest via distinct pathological pathways.

SmartPilot® view-guided anaesthesia improves postoperative outcomes in hip fracture surgery: a randomized blinded controlled study.

BACKGROUND: Both under-dosage and over-dosage of general anaesthetics can harm frail patients. We hypothesised that computer-assisted anaesthesia using pharmacokinetic/pharmacodynamic models guided by SmartPilot® View (SPV) software could optimise depth of anaesthesia and improve outcomes in patients undergoing hip fracture surgery. METHODS: This prospective, randomized, single-centre, blinded trial included patients undergoing hip fracture surgery under general anaesthesia. In the intervention group, anaesthesia was guided using SPV with predefined targets. In the control group, anaesthesia was delivered by usual practice using the same agents (propofol, sufentanil and desflurane). The primary endpoint was the time spent in the "appropriate anaesthesia zone" defined as bispectral index (BIS) (blinded to the anaesthetist during surgery) of 45-60 and systolic arterial pressure of 80-140 mm Hg. Postoperative complications were recorded for one month in a blinded manner. RESULTS: Of 100 subjects randomised, 97 were analysed (n=47 in SPV and 50 in control group). Anaesthetic drug consumption was reduced in the SPV group (for propofol and desflurane). Intraoperative duration of low BIS (<45) was similar, but cumulative time of low systolic arterial pressure (<80 mm Hg) was significantly shorter in the SPV group (median (Q1-Q3); 3 (0-40) vs 5 (0-116) min, P=0.013). SPV subjects experienced fewer moderate or major postoperative complications at 30-days (8 (17)% vs 18 (36)%, P=0.035) and shorter length of hospitalisation (8 (2-20) vs 8 (2-60) days, P=0.017). CONCLUSIONS: SmartPilot® View-guided anaesthesia reduces intraoperative hypotension duration, occurrence of postoperative complications and length of stay in hip fracture surgery patients. CLINICAL TRIAL REGISTRATION: NCT 02556658.

Phenalenone-type phytoalexins mediate resistance of banana plants (Musa spp.) to the burrowing nematode Radopholus similis.

The global yield of bananas-one of the most important food crops-is severely hampered by parasites, such as nematodes, which cause yield losses up to 75%. Plant-nematode interactions of two banana cultivars differing in susceptibility to Radopholus similis were investigated by combining the conventional and spatially resolved analytical techniques (1)H NMR spectroscopy, matrix-free UV-laser desorption/ionization mass spectrometric imaging, and Raman microspectroscopy. This innovative combination of analytical techniques was applied to isolate, identify, and locate the banana-specific type of phytoalexins, phenylphenalenones, in the R. similis-caused lesions of the plants. The striking antinematode activity of the phenylphenalenone anigorufone, its ingestion by the nematode, and its subsequent localization in lipid droplets within the nematode is reported. The importance of varying local concentrations of these specialized metabolites in infected plant tissues, their involvement in the plant's defense system, and derived strategies for improving banana resistance are highlighted.

Prosopis juliflora as a new cosmetic ingredient: Development and clinical evaluation of a bioactive moisturizing and anti-aging innovative solid core.

Prosopis juliflora is an invasive plant distributed throughout the world and presents metabolites of interest for cosmetology. The aim of this work was to develop a new polysaccharide-based ingredient from P. juliflora and analyze its application in a solid core formulation that upon contact with water instantly forms a gel to improve moisturizing and anti-aging skin properties. Purified extracts by gel chromatography were characterized by NMR and LC-DAD-MS-MS. The in vitro and in vivo safety, antioxidant activity, formulation development and clinical evaluation were performed. The extract was characterized as containing an α-glucan and phenolics. It was non-cytotoxic, non-phototoxic and no skin reactions were observed in vivo. Antioxidant activity were present through different mechanisms. Clinical evaluation reinforced the potential of P. juliflora in skin hydration and microrelief improvement. This innovative form proved to be a prototype of a new product and the first study of an α-glucan as a cosmetic ingredient.

Clinical and radiological outcomes of a cohort of 9 patients with anatomical fractures of the cuboid treated by locking plate fixation.

INTRODUCTION: Cuboid fractures are very rare. Hence, their treatment has not been standardized. Advances in imaging techniques, particularly three-dimensional computed tomography (3D CT), and the introduction of cuboid-specific plates has improved the care of these injuries. The aim of this study was to determine the radiological and clinical outcomes of anatomical reconstruction of comminuted cuboid fractures with a locking plate. HYPOTHESIS: Fixation of comminuted cuboid fractures with a cuboid-specific locking plate leads to stable anatomical reduction and good functional outcomes. MATERIAL AND METHODS: This was a retrospective study of 9 consecutive cases of comminuted cuboid fracture treated at a single hospital between January 2009 and December 2015. A 3D CT scan was performed preoperatively with subtraction of the posterior tarsal bone to allow the articular facets to be viewed and analyzed. Fracture fixation was done with a Locking Cuboid Plate (DePuy Synthes™). Associated lesions in the foot were treated during the same procedure. The patients were reviewed by an independent observer who performed a clinical examination, and determined the AOFAS and Maryland Foot Score. The success of the reconstruction was determined by comparing the parameters on weight-bearing X-rays views between the fixed and non-operated cuboid. RESULTS: The mean follow-up was 4.1 years (range 1-6). The Maryland Foot Score was 93.1 [86-100] and the AOFAS was 91.9 [82-100]. The reconstruction was anatomical and long lasting in all 9 cases. There was no foot misalignment in the frontal plane, based on the radiographs (hindfoot axis 5.5° [0-9]). The mean Djian-Annonier angle was 123.9° [108-130]. CONCLUSION: Cuboid fractures can be treated effectively through appropriate imaging and with a cuboid-specific locking plate as evidenced by very good midterm clinical and radiological outcomes in this study. LEVEL OF EVIDENCE: IV Retrospective study.

Reconstruction of large diaphyseal bone defect by simplified bone transport over nail technique: A 7-case series.

Reconstruction of large diaphyseal bone defect is complex and the complications rate is high. This study aimed to assess a simplified technique of segmental bone transport by monorail external fixator over an intramedullary nail.A prospective study included 7 patients: 2 femoral and 5 tibial defects. Mean age was 31years (range: 16-61years). Mean follow-up was 62 months (range: 46-84months). Defects were post-traumatic, with a mean length of 7.2cm (range: 4 to 9.5cm). For 3 patients, reconstruction followed primary failure. In 4 cases, a covering flap was necessary. Transport used an external fixator guided by an intramedullary nail, at a rate of 1mm per day. One pin was implanted on either side of the distraction zone. The external fixator was removed 1 month after bone contact at the docking site. Mean bone transport time was 11 weeks (range: 7-15 weeks). Mean external fixation time was 5.1months (range: 3.5 to 8months). Full weight-bearing was allowed 5.7months (range: 3.5-13months) after initiation of transport. In one patient, a pin had to be repositioned. In 3 patients, the transported segment re-ascended after external fixatorablation, requiring repeat external fixation and resumption of transport. There was just 1 case of superficial pin infection. Reconstruction quality was considered "excellent" on the Paley-Marr criteria in 6 cases. The present technique provided excellent reconstruction quality in 6 of the 7 cases. External fixation time was shorter and resumption of weight-bearing earlier than with other reconstruction techniques, notably including bone autograft, vascularized bone graft or the induced membrane technique. Nailing facilitated control of limb axis and length. The complications rate was 50%, comparable to other techniques. This study raises the question of systematic internal fixation of the docking site, to avoid any mobilization of the transported segment. The bone quality, axial control and rapidity shown by the present technique make it well-adapted to reconstruction of diaphyseal bone defect. LEVEL OF EVIDENCE: Four-case series.

Percutaneous reduction of proximal radius fracture in adults. A 12-case series.

Fractures of the head or neck of the radius account for 5% of elbow fractures in adults. Treatment varies between authors. We report a retrospective series of 12 cases of percutaneous reduction of Mason II radial head fracture, without internal fixation. All fractures consolidated, without secondary displacement. There were no postoperative complications. Mean ranges of motion were 136° flexion-extension and 175° pronation-supination. Mean QuickDASH score was 11. Results in the present series were at least comparable to those for other techniques, validating percutaneous treatment as a solution for radial head fracture. TYPE OF STUDY: Case series. LEVEL OF EVIDENCE: IV.

Ankle fractures in the elderly: Treatment and results in 477 patients.

INTRODUCTION: In the elderly, ankle fractures are likely to cause specific complications and have a major impact on their autonomy. The goal of this multicentre study was to assess these outcomes in a geriatric population treated operatively. MATERIAL AND METHODS: This retrospective study included 477 patients with ankle fractures treated surgically between 2008 and 2014. The minimum age was 60years for women and 70 for men. Patients with a tibial pilon fracture or less than 3months' follow-up were excluded. Functional (autonomy and comorbidities) and radiological assessments were performed before surgery and at the review. RESULTS: The cohort was 81% female (384 women, 93 men) and had median age of 74years. The preoperative autonomy was 7.8 points on average using the Parker score. Most of the fractures were either Weber type B (n=336) or type C (n=114). At the follow-up, the mean autonomy score was 7.3 points. The fibula was fixed with a plate and screws in 69% of cases (n=325), with additional internal malleolar fixation was carried out in some cases. A satisfactory result, defined as 2 points or less reduction in the Parker score, was found in 89.9% of patients; 71.8% had not lost any autonomy. The main risk factors for loss of autonomy were being more than 80years of age (OR=2.93, P<0.001), poor surgical reduction (OR=2.8, P<0.01), the presence of two or more comorbidities (OR=2.71, P<0.001), being female (OR=2.19, P<0.043) or having a Weber type C fracture (OR=2.05, P=0.023). DISCUSSION: The functional results are satisfactory overall following standard surgical treatment consisting of internal malleolar and fibular fixation for ankle fractures in the elderly. We identified five factors that greatly impact functional recovery. LEVEL OF EVIDENCE: IV.