Distal femoral megaprosthesis fracture treated by RescueSleeve MEGASYSTEM-C.

Escalating revision surgery after megaprosthesis knee replacement sometimes raises the question of "limb salvage". Here we present a salvage technique for megaprosthesis fracture at the junction between the stem and the metaphyseal component. In this young active patient, the short residual proximal femur was not loose and was difficult to extract without prosthetic escalation. The technique described here conserved the well-fixed primary stem and used a custom-made RescueSleeve MEGASYSTEM-C connection sleeve (Link, Hamburg, Germany) plus spacer and a standard epiphyseal implant. This semi-conservative procedure avoided femorotomy or larger morbid segmental femoral resection. It conserved maximal bone stock and achieved rapid functional recovery. To our knowledge, this is the first reported case of this technique using a custom-made connecting part to manage megaprosthesis fracture. LEVEL OF EVIDENCE: IV.

Implant breakage and revision factors for modular fluted tapered stems in revision total hip arthroplasty.

PURPOSE: Modular stems in revision total hip arthroplasties allow diaphyseal fixation and optimal restoration of the architecture of the proximal femur. Several studies report metaphyseal implant breakage having a negative impact on survivorship. The aim of the study was to evaluate the outcome of an uncemented modular fluted tapered stem (MFT) in revision surgery. METHODS: In a retrospective study, 316 patients who had revision surgery using the same design of MFT implant (Modular Revision Stem [MRS], Lima Corporate, Italy) between 2012 and 2017 were identified. Patients were male in 51% of cases and mean age was 74 years. Indications were 110 periprosthetic fractures, 98 periprosthetic joint infection, 97 aseptic loosening, 10 instability and 1 other cause. Survivorship, complications, clinical and radiographic outcomes, were assessed. Mean follow-up was 5 years. RESULTS: There was no implant breakage. At 5-year follow-up, the survivorship, free from revision for aseptic loosening and free of revision for any reason were 96% and 87%, respectively. At last follow-up (8 years), these figures were 92% and 71%, respectively. 31 implants were revised. The risk of revision for any cause was higher for extreme length metaphyseal implants, hazard ratio was 3.7 (95% CI, 1.82-7.52). A mean stem subsidence of 9 mm was noted in 37 cases; 4 were revised for aseptic loosening. The Harris Hip Score at final follow-up was 82. CONCLUSIONS: At 5-year follow-up, the MFT implant showed a good survivorship and outcomes with no specific complications. Unlike literature reports, no specific complications occurred with this design. Stem junction positioning and therefore metaphyseal length may be key to optimise long-term survivorship. However, a longer follow-up is needed as implant breakage is more often seen after long implantation times.

Management of tumor volume changes during preoperative radiotherapy for extremity soft tissue sarcoma: a new strategy of adaptive radiotherapy.

BACKGROUND: Using adaptive radiotherapy (ART), to determine objective clinical criteria that identify extremity soft tissue sarcoma (ESTS) patients requiring adaptation of their preoperative radiotherapy (RT) plan. PATIENTS AND METHODS: We included 17 patients with a lower extremity ESTS treated between 2019 and 2021 with preoperative RT, using helicoidal intensity-modulated RT (IMRT) tomotherapy, before surgical resection. We collected clinical, tumor parameters and treatment data. Repositioning was ascertained by daily Megavoltage computed tomography (MVCT) imaging. Using the PreciseART technology we retrospectively manually delineated at least one MVCT for each patient per week and recorded volume and dosimetric parameters. A greater than 5% change between target volume and planned target volume (PTV) dosimetric coverage from the initial planning CT scan to at least one MVCT was defined as clinically significant. RESULTS: All 17 patients experienced significant tumor volume changes during treatment; 7 tumors grew (41%) and 10 shrank (59%). Three patients (18%), all undifferentiated pleomorphic sarcomas (UPS) with increased volume changes, experienced significant reductions in tumor dose coverage. Seven patients required a plan adaptation, as determined by practical criteria applied in our departmental practice. Among these patients, only one ultimately experienced a significant change in PTV coverage. Three patients had a PTV decrease of coverage. Among them, 2 did not receive plan adaptation according our criteria. None of the patients with decreased tumor volumes had reduced target volume coverage. Monitoring volume variations by estimating gross tumor volume (GTV) on MVCT, in addition to axial and sagittal linear tumor dimensions, appeared to be most effective for detecting reductions in PTV coverage throughout treatment. CONCLUSIONS: Variations in ESTS volume are evident during preoperative RT, but significant dosimetric variations are rare. Specific attention should be paid to grade 2-3 UPSs during the first 2 weeks of treatment. In the absence of dedicated software in routine clinical practice, monitoring of tumor volume changes by estimating GTV may represent a useful strategy for identifying patients whose treatment needs to be replanned.

One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior.

Revision of an anterior cruciate ligament (ACL) reconstruction can be performed as a one-stage or two-stage surgery. Several factors must be taken into consideration when making this choice, especially the size and position of the existing tunnels. When the tibial tunnel is semianatomic, it is difficult to make a new tunnel in the correct position without overlapping the existing tunnel. For this reason, we have developed a one-stage ACL revision surgery that uses a bone allograft plug. When it comes to choosing a reconstruction technique, we believe that combined intra-articular and extra-articular reconstruction with the iliotibial band is suitable when the hamstring tendons are not available, combined with clinical findings of translational and rotational instability. Because the existing tunnels require reorientation, a new femoral tunnel can be created by outside-in drilling to eliminate the risk of overlap, while an allograft bone plug can be used to fill the overly anterior tibial tunnel and allow us to drill the correct tibial tunnel right away. In our hands, this is a safe and effective technique, but longer follow-up is needed to validate its indications.

Iliotibial band autograft is a suitable alternative graft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes.

PURPOSE: Despite encouraging clinical, biomechanical and histological results, ACL reconstruction using the ITB was slowly abandoned. The hypothesis was that the current literature supports the use of ITB as the graft of choice for ACL reconstruction because of its good outcomes. METHODS: A systematic search of the literature was performed in the PubMed, MEDLINE, Cochrane, and Ovid databases to identify published clinical studies relevant to ACL reconstruction with ITB autograft and studies comparing ITB autograft with bone-patellar tendon-bone (BPTB) and hamstring (HT) autografts (none were found). The results of the eligible studies were analyzed in terms of graft failure, instrumented knee laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, Tegner activity score, return to sports rate, return to sports at pre-injury level and complications. RESULTS: Nineteen clinical studies including 1,210 patients with ACL reconstruction met the inclusion criteria. Graft failure occurred after ITB autograft in 4.2% of patients. Postoperative mean side-to-side laxity was 1.41 mm with 21% of patients having greater than 3 mm side-to-side difference. Lachman test and pivot-shift test were negative (grade 0) in 57% and 85%, respectively, and were grade 0 or 1 in 95% and 97%, respectively. Functional outcomes were satisfactory in 84% of patients with good to excellent results (Lysholm score > 84). Mean postoperative Lysholm score was 93.3 and 84% of patients had an objective IKDC grade of A or B. Mean postoperative Tegner score was 6.8. The return to sports rate was 89% and 61% of patients returned to their pre-injury level. A comparison of 89 ITB versus 80 BPTB autografts revealed no significant differences in graft failure (n.s.), instrumented mean side-to-side knee laxity difference (n.s.) or Tegner score (n.s.). CONCLUSION: The graft survival rate and clinical and functional outcomes for ITB autograft are satisfactory. By allowing ACL reconstruction and lateral tenodesis to be done with a single, continuous, pedicled graft through an outside-in femoral tunnel, this technique may become the preferred alternative for primary or secondary ACL surgery. LEVEL OF EVIDENCE: Level IV.

Outside-In Anterior Cruciate Ligament Revision With Lateral Tenodesis and High-Strength Suture Augmentation Is Easy to Perform With the Iliotibial Band.

We describe a technique for revision anterior cruciate ligament (ACL) surgery using a 15-cm strip of the iliotibial band as a graft and the gracilis tendon if available. An internal brace is added to augment the graft. The graft is passed through the femur by drilling an outside-in tunnel from the isometric point F9 of Krackow toward the ACL's footprint and is then double fixed at the tibia using an interference screw and a cortical button. This technique makes it possible to perform simultaneous ACL reconstruction and lateral tenodesis with a continuous, rigid, good-diameter graft that is pedicled to the Gerdy tubercle. Good rotational control is achieved, and all the factors that contribute to ligamentization are present.

Patient Participation During Anterior Cruciate Ligament Reconstruction Improves Comprehension, Satisfaction, and Functional Outcomes: A Simple Way to Improve Our Practices.

BACKGROUND: It is estimated that 28% of patients are dissatisfied after anterior cruciate ligament (ACL) reconstruction, in part because they do not understand the procedure well enough. PURPOSE: To assess the postoperative comprehension, satisfaction, and functional outcomes of 2 patient groups: 1 undergoing a standard surgical procedure (standard group) and 1 involved in their surgery (participation group). STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Over a 4-month period, 62 patients were included: 31 in the standard group and 31 in the participation group. The preoperative information, surgical technique, anesthesia, and postoperative course were identical in both groups. Patients in the participation group were allowed to watch the arthroscopic portion of their surgery live on a video screen, and standardized information was given to these patients during the arthroscopic phase. Self-administered questionnaires were given to assess comprehension (Matava score), satisfaction (visual analog scale [VAS] for satisfaction, Net Promoter Score [NPS], and Evaluation du Vécu de l'Anesthésie LocoRégionale [EVAN-LR]), and outcomes (International Knee Documentation Committee [IKDC] form and Anterior Cruciate Ligament-Return to Sport after Injury [ACL-RSI] scale) between groups. RESULTS: Postoperative comprehension was significantly improved in the participation group, as the Matava score increased by a mean of 7.1 ± 5.3 points versus 2.7 ± 5.6 points in the standard group (P = .0024). The mean VAS satisfaction score immediately after surgery was 9.8 ± 0.6 in the participation group versus 8.9 ± 1.9 in the standard group (P = .0033); this difference was still present at 1 year postoperatively (9.8 ± 0.6 vs 9.1 ± 1.7, respectively; P = .0145). The NPS was 96.8% in the participation group versus 64.5% in the standard group (P = .0057) in the immediate postoperative period and 100.0% in the participation group versus 71.0% in the standard group at 1 year postoperatively (P = .0046). The mean total EVAN-LR score was 89.1 ± 6.5 in the participation group and 84.6 ± 9.9 in the standard group (P = .0416). At 1 year postoperatively, the mean IKDC score was 86.0 ± 7.5 in the participation group versus 80.0 ± 7.4 in the standard group (P = .0023). The mean ACL-RSI score was 80.9 ± 7.7 in the participation group versus 74.3 ± 8.4 in the standard group (P = .0019). CONCLUSION: Involving patients in their ACL reconstruction surgery improves their understanding of the procedure and their satisfaction with their care, which results in better outcomes at 1 year postoperatively.