Operative versus non-operative treatment of displaced acetabular fractures in elderly patients.

BACKGROUND: Acetabular fracture treatments in elderly patients are not well codified. PURPOSE: The aim of the study was to determine if, for active elderly patients, the clinical results after surgical treatment of displaced acetabular fractures are better than for non-operative treatment. METHODS: All active patients over 60 years with a Parker score higher than 6, managed for displaced acetabular fracture between 2005 and 2014, were included in this single-center retrospective study. Clinical outcomes were compared according to the therapeutic option (operative or non-operative) and the fracture pattern (anterior fracture that requires open reduction and internal fixation or posterior fracture that requires total hip arthroplasty). RESULTS: Among the 82 patients with Parker score higher than 6, 44 were treated non-operatively and 38 were operated. Forty-seven had anterior fracture (AF) and 35 had posterior fracture (PF). In the AF group, the autonomy scores were better for operative than non-operative patients (p < 0.05) with a PARKER score 7.8 (7-8) versus 5.4 (1-9); ADL score 5.7 (4-6) versus 4.4 (1-6) and IADL score 7.6 (6-8) versus 4.2 (0-8). In the PF group, the autonomy scores were better for operative than non-operative patients (p < 0.05) with a PARKER score 7.3 (4-9) versus 5.6 (2-9), ADL score 5.3 (2-6) versus 4.4 (1-6) and IADL score 5.6 (2-8) versus 4.1 (1-7). Regarding clinical outcomes, the HARRIS and PMA scores were better for operative patients (p < 0.05). CONCLUSION: Surgical treatment in elderly patients with displaced acetabular fractures is associated with better clinical outcomes than non-operative treatment when the autonomy level is comparable.

Total Talar Prosthesis Replacement after Talar Extrusion.

Dislocation of the talus is a serious and extremely rare injury, with 86 cases reported in the published data in 20 years. The reference standard for case management involves replacement of the dislocated talus to restore the height and function of the tibiotalar joint. The risk of avascular necrosis remains very high, and the standard treatment in such cases is tibiotalar arthrodesis. We report the case of total dislocation of the talus, which was treated with the insertion of a custom total talar prosthesis affixed directly to the tibial cartilage at 6 months after injury. At the 2-year follow-up point, the preliminary results were rather encouraging, with well-functioning activity and an improved American Orthopaedic Foot and Ankle Society foot function scale score increasing from 11 to 77 of 100 and a Short-Form 36-item Health Survey score increasing from 17 to 82. Much longer follow-up periods are necessary to evaluate longer term trends.

Part 2: outcome of acetabular fractures and associated prognostic factors-a ten-year retrospective study of one hundred and fifty six operated cases with open reduction and internal fixation.

QUESTIONS/PURPOSES: The aim of this study was to identify prognostic factors associated with a poor quality of reduction and their relationships. METHODS: Data from medical charts for all patients admitted with acetabular fractures operated by open reduction and internal fixation (ORIF) from 2005 to 2014 were extracted. A total of 156 patients with a mean age of 40.3 years were included. All patients were reviewed at six months of follow-up. The prognostic factors analyzed were clinical and radiological factors. A new radiological parameter was also studied: the scanographic roof-arc angle. Specific statistical analysis was performed using a logistic regression model. RESULTS: Using a multivariate analysis logistic regression model: roof impaction (p = 0.001; OR = 6.59; CI 95% [2.01-20.97]), transverse + posterior wall (p = 0.03, OR = 2.52; CI 95% [1.46-13.65]) and surgeons in training (p = 0.02; OR = 1.24; CI 95% [1.07-3.32]) were three independent prognostic factors. Lower values of medial and posterior scanographic roof-arc angle were associated with unsatisfactory reduction. A significant association between unsatisfactory reduction and posterior roof arc angle < 61° was found. CONCLUSIONS: Three independent prognostic factors associated with a risk of unsatisfactory reduction in ORIF for acetabular fractures were identified: roof impaction, transverse + posterior wall fracture and surgeons in training. Scanographic roof-arc angle seems to be a new prognostic factor. Level of Evidence Level 4 retrospective study.

[One-year mortality after a hip fracture: prospective study of a cohort of patients aged over 75 years old]. / Mortalité des 75 ans et plus après une fracture de l'extrémité supérieure du fémur : suivi d'une cohorte prospective.

Hip fracture (HF) is a serious complication of the elderly who have suffered a fall. Studies focused on patients over 75 years old without excluding the most vulnerable are not frequent. Before we can think about the creation of an orthogeriatric unit, we evaluated the mortality rate one year after a HF only of patients over 75 years old and we identified associated factors with mortality, functional status and living. METHODS: Prospective observational study of 75 years and older hospitalized for a HF in a conventional orthopaedic unit. Surgical and geriatric data collected was: instrumental activities of daily life ADL (IADL), comorbidity (cumulative illness rating scale-geriatric (CIRS-G)), mini nutritional assessment (MNA), severity, preoperative delay. A phone assessment one year after HF was about: vital and functional status, living place. RESULTS: The mean age of 113 patients included was 87 years (76-100). The mortality rate was 35%. It was associated with low IADL day -15 (p< 0.01), elevated CIRS-G (p< 0.01), severity (p=0.05) and malnutrition (p=0.05). Preoperative delay average was 70.7 h (+/- 59) and 48.6% had surgery within 48 hours. Among survivors and from the data available, 45% had a functional decline one year after the HF and 11% were admitted in a nursing home. CONCLUSION: Without any exclusion of frailty patients, the one-year mortality rate of HF of people aged 75 years and older was 35%. HF is a public health challenge due to its high prevalence, poor prognosis with considerable expense. The associated factors help to explain why geriatricians are required and support the project of creating an orthogeriatric unit. Nevertheless, geriatric care will not likely change prognosis of the most vulnerable patients but could improve the level of care.

Image-free cup navigation inaccuracy: a two-study approach.

The present study tested the accuracy of an image-free navigation system used for total hip arthroplasty (THA). Two parallel, prospective studies were performed: one on real patients and the other on pelvic phantoms. We used a comparison between the intra-operative cup orientation, as displayed by the navigation system, and the post-operative cup position, as measured on CT data. The mean intrinsic overall error (+/- standard deviation) found in the phantom study was 2.6 +/- 1.1 degrees (range: 1.5-4.4 degrees ) for cup abduction, and 0.9 +/- 0.7 degrees (range: 0-2.5 degrees ) for cup anteversion. The system was less accurate in the clinical operative setting. The evaluation model was able to identify, and more importantly quantify, the clinically induced error. Ameliorating this would improve the clinical accuracy of the system.

Anterior cruciate ligament reconstruction using navigation: a comparative study on 60 patients.

BACKGROUND: Poor outcome in anterior cruciate ligament reconstruction is often related to tunnel position. HYPOTHESIS: Improving accuracy of the tunnel position will lead to improved outcome. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Sixty patients were randomized to either standard instrumentation or computer-assisted guides to position the tibial and femoral tunnels. The results were evaluated on clinical outcome based on International Knee Documentation Committee form (laxity) and radiologic assessment: radiologic Lachman (Telos at 150 and 200 N) and analysis of the tunnel positions. RESULTS: International Knee Documentation Committee laxity was level A in 22 knees in the conventional group (mean, 1.5 mm at 200 N) compared with 26 navigated knees (mean laxity, 1.3 mm; P = .49). Laxity was less than 2 mm in 96.7% of the navigated group and 83% of the conventional group (P = .292). The variability of laxity in the navigated group was significantly less than in the conventional group, with the standard deviation of the navigated group being smaller than that in the conventional group (P = .0003 at 150 N and .0005 at 200 N Telos). A significant difference (P = .03) was found between the groups in the ATB value (distance between the projection of the Blumensaat line on the tibial plateau and the anterior edge of the tibial tunnel), characterizing the sagittal position of the tibial tunnel (negative ATB values imply graft impingement in extension). In the conventional group, mean ATB was -0.2 (-5 to +4), whereas it was 0.4 (0 to 3) in the navigated patients. There were no negative ATB values in the navigated group. CONCLUSION: This study confirms that the accuracy and consistency of tibial tunnel position can be improved by the use of computer-assisted navigation and that the clinical result in terms of laxity is more reliable.

Detection of the center of the hip joint in computer-assisted surgery: an evaluation study of the Surgetics algorithm.

OBJECTIVE: The aim of this paper is to assess the accuracy of an algorithm implemented by PRAXIM in the SURGETICS navigation station for detection of the hip center. This study will assess the robustness and accuracy of the algorithm in various clinical situations such as those involving non-sphericity of the femoral head, motion of the pelvis during hip center detection, and restricted range of motion. MATERIALS AND METHODS: The localization of the hip center, based on kinematics, relies on the recording of n successive positions of the femoral rigid body in the localizer reference system during a passive circumduction motion of the hip joint. Therefore, the shape of the clouds of points acquired may vary from one acquisition to the next. To allow a comprehensive study of the consequences of these variations for hip center detection, we developed a simulator to generate numerous clouds of points. Results given subsequently for each test are the values of the difference between the femoral mechanical axis computed with C(c), the computed hip center, and the same axis computed with C(o), the reference hip center. RESULTS: Test 1: Sensitivity to noise. The errors ranged from 3.33 E - 12 (SD 3.29E - 12) for a noise of 0 mm to 8.18E - 1 (SD - 7.05E - 1) for a noise of 15 mm. Test 2: Sensitivity to the shape of the acquisition motion. All trajectories gave an error < 1 degrees . Test 3: Sensitivity to restricted range of motion. No value > 1 degrees was found during this test. Test 4: Sensitivity to the distance between two points of the cloud. No value > 0.5 degrees was found during this test. Test 5: Sensitivity to the number of points included in the cloud. No value > 1 degrees was found during this test. CONCLUSIONS: The Surgetics algorithm is robust to noise, can compensate for pelvic motion, and can be used even in the case of restricted range of motion.

Compliance with guidelines on antibiotic prophylaxis in total hip replacement surgery: results of a retrospective study of 416 patients in a teaching hospital.

OBJECTIVE: To assess compliance of anesthesiologist practices in antibiotic prophylaxis during total hip replacement (THR) surgery with the French Society of Anesthesiology and Intensive Care consensus-based guidelines. DESIGN: Retrospective review of medical records. Compliance of anesthesiologist practices with the guidelines was assessed according to antibiotic prophylaxis use, antimicrobial agent, dosage of first injection, time from first dose to incision, and total duration of antibiotic prophylaxis. SETTING: Orthopedic surgery wards in a 2,200-bed French teaching hospital. PATIENTS: A random sample of 416 patients undergoing THR from January 1999 to December 2000. RESULTS: Three hundred eighty-six (93%) of the sampled medical records were usable. Antibiotic prophylaxis was used for 366 (95%) of the patients. Total duration of prophylaxis did not exceed 48 hours in 98% (359 of 366) of the patients. Drug selection complied with national guidelines in 259 (71%) of the patients. Dosage and timing of the first injection were appropriate in 98% (290 of 296) and 80% (236 of 296) of the patients, respectively, who received one of the recommended antibiotics. Overall, 53% (203 of 386) of the patients met all five criteria. In multivariate analysis, there was a significant anesthesiologist effect on overall compliance with the guidelines (likelihood ratio chi-square with 9 degrees of freedom, 25.7; P < .01). Undergoing surgery during 2000 was the only patient characteristic associated with an increased rate of appropriate practices (adjusted OR, 1.56; CI95 1.02-2.38). CONCLUSION: The overall compliance rate should be improved by disseminating the guidelines and the results of this study following audit and feedback.

Epiphyseal stapling of the proximal tibia for idiopathic genu valgum.

PURPOSE: The purpose of this study is to evaluate the clinical and radiological outcomes of hemiepiphysiodesis with a single medial staple of the proximal tibia in idiopathic genu valgum angular correction. METHODS: A retrospective review was performed identifying nine adolescents (18 knees) treated for idiopathic adolescent genu valgum by means of a bilateral hemiepiphysiodesis with a single staple of the proximal tibia. The intermalleolar distance (IMD) and hip-knee-ankle angle were measured at skeletal maturity. RESULTS: The IMD and hip-knee-ankle angle were reduced in all patients at skeletal maturity. CONCLUSION: Hemiepiphysiodesis with a single medial staple of the proximal tibia seems to be a reliable and safe alternative method to achieve correction of an idiopathic genu valgum.

[Computer assisted systems for arthroscopic reconstruction of anterior cruciate].

OBJECTIVE: To introduce several navigation systems in anterior cruciate ligament reconstruction and to investigate the application of navigation systems for the improvement in reconstruction of the anterior cruciate ligament. METHODS: The related literature was reviewed extensively, and the main current computer assisted surgery systems (OthoPilot system, Bone Morphing system, Fluoroscopic-based system, etc) for utilization in the anterior cruciate ligament reconstruction were analyzed. RESULTS: The computer-assisted systems can enhance the accurate placement of tunnels. According to the anatomical and isometric parameters, graft impingement on the intercondylar notch could be avoided, and individual ideal implantation using 3D visualization localisers was achieved. CONCLUSION: It is possible that computer-assisted systems will enable surgeons to better acquire the accuracy and reliability of the various operative techniques, to meet the demand of surgeon's surgical optimisation and to improve the clinical results.

[Modified robotized hydraulic tensor for ligament balance in total knee arthroplasty].

OBJECTIVE: To investigate a modified robotized hydraulic tensor for management of the ligament balance in the total knee arthroplasty. METHODS: The effect of the modified robotized hydraulic tensor on the mechanical behaviour of the ligament system balance in the total knee arthroplasty was analyzed and the related information was obtained. RESULTS: The robotized hydraulic tensor acted as a tensor-sensor system, which could assist the surgeon by providing the quantitative information to align the lower limb in extension, equalize the articular spaces in extension and flexion, balance the internal and external forces, and define the femoral component rotation, and by providing the information to plan the releasing of the soft tissues and the rotating of the femoral component. CONCLUSION: The modified robotized hydraulic tensor can enable the surgeon to properly manage the ligament balance in the total knee arthroplasty.

[Basic concept in computer assisted surgery].

OBJECTIVE: To investigate application of medical digital imaging systems and computer technologies in orthopedics. METHODS: The main computer-assisted surgery systems comprise the four following subcategories. RESULTS: (1) A collection and recording process for digital data on each patient, including preoperative images (CT scans, MRI, standard X-rays), intraoperative visualization (fluoroscopy, ultrasound), and intraoperative position and orientation of surgical instruments or bone sections (using 3D localises). Data merging based on the matching of preoperative imaging (CT scans, MRI, standard X-rays) and intraoperative visualization (anatomical landmarks, or bone surfaces digitized intraoperatively via 3D localiser; intraoperative ultrasound images processed for delineation of bone contours). (2) In cases where only intraoperative images are used for computer-assisted surgical navigation, the calibration of the intraoperative imaging system replaces the merged data system, which is then no longer necessary. (3) A system that provides aid in decision-making, so that the surgical approach is planned on basis of multimodal information: the interactive positioning of surgical instruments or bone sections transmitted via pre- or intraoperative images, display of elements to guide surgical navigation (direction, axis, orientation, length and diameter of a surgical instrument, impingement, etc. ). And (4) A system that monitors the surgical procedure, thereby ensuring that the optimal strategy defined at the preoperative stage is taken into account. CONCLUSION: It is possible that computer-assisted orthopedic surgery systems will enable surgeons to better assess the accuracy and reliability of the various operative techniques, an indispensable stage in the optimization of surgery.

Femoral nerve palsy following mini-open extraperitoneal lumbar approach: report of three cases and cadaveric mechanical study.

Anterior extraperitoneal exposures to the lumbar spine are being increasingly used owing to the expanding use of novel technologies to treat degenerative disc disease. Lumbar plexus injuries are potential, albeit uncommon, complications of such exposures and can lead to significant perioperative morbidity. In this report, we present three patients with thoracolumbar fractures who sustained isolated femoral nerve palsies after a mini-open extraperitoneal approach to the midlumbar spine was undertaken to perform a partial corpectomy. To further understand the pathophysiology of this nerve injury, we conducted a cadaveric experiment to evaluate the effect of performing this approach and the effect of hip positioning on linear displacement of the femoral nerve. The displacement of the femoral nerve during the anterolateral extraperitoneal exposure through a 4- to 6-cm incision was equal to 6.6% of the full femoral nerve length. Relaxation of the femoral nerve was equal to 25% of the full nerve length when the hip was flexed to 90 degrees in neutral abduction-adduction. We conclude that the anterolateral extraperitoneal exposure of the midlumbar spine can potentially stretch the femoral nerve beyond its physiologic limits, particularly in trauma cases where exposure of the lateral vertebral body necessitates substantial retraction of the psoas muscle. The avoidance of self-retaining retractors for prolonged periods of time and the positioning of the hip in flexion may help to avoid such nerve injuries.