Estimation of the carbon footprint of arthroscopic rotator cuff repairs in France.

AIM: The main objective of this study was to estimate the carbon impact of arthroscopic rotator cuff repairs in France. The secondary objective was to assess the effectiveness of the following measures in reducing the carbon footprint associated with this technique: outpatient treatment, arthroscopic water filtration, surgery under locoregional anesthesia. HYPOTHESIS: The hypothesis was that the carbon footprint could be significantly improved with the implementation of these three procedures. METHODS: A continuous series of 26 patients who underwent surgery for a rotator cuff tear involving only one tendon between November 2020 and April 2021 were included. The evaluation protocol consisted of three parts: 1/ use of volatile anesthetic agents; 2/ electrical consumption linked to the procedure; 3/ emissions related to patient and staff travel, delivery of implants and waste management. Another series of 26 patients operated between November 2018 and April 2019 who had none of these three factors were matched. RESULTS: The carbon impact of arthroscopic repair of the rotator cuff was estimated at 334.61±18.82kgCO2eq. The implementation of the three methods for improvement made it possible to significantly reduce emissions by 40.9±1.71kgCO2eq (12.2%) (p<0.001). CONCLUSION: Performing surgery under locoregional anesthesia, on an outpatient basis with water purification, reduces the carbon impact of arthroscopic rotator cuff repair by more than 12%. LEVEL OF EVIDENCE: III, retrospective case control.

Surgical solutions for preoperative skin preparation in total hip arthroplasty: A cost-effectiveness analysis of Betadine® and Chloraprep™.

OBJECTIVE: The purpose of our study was to compare the cost of surgical site skin preparation using ChloraPrep™ (2% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) with skin cleansing using Betadine® Surgical Scrub and Betadine® 5% solution (povidone-iodine [PVI]) in total hip arthroplasty (THA). HYPOTHESIS: The hypothesis was that the ChloraPrep™ skin disinfection protocol reduces the cost of perioperative antisepsis. METHODS: A prospective database was created for all THAs performed at our university hospital between November 1st, 2020, and December 31st, 2020. Each surgeon was randomly assigned one type of antiseptic prior to the start of the study: one surgeon to the ChloraPrep™ group and one to the Betadine® group. In both groups, the enrollment stopped at the 15th patient. The costs related to consumables, waste disposal, and operating room occupancy time of each protocol were then assessed for each patient. RESULTS: The mean duration of the ChloraPrep™ protocol was 3.5±0.3minutes compared to 13.5±0.9minutes for the Betadine® protocol. The overall cost of a surgical site skin preparation involving all three steps was on average €46.8±4.2 for the ChloraPrep™ group compared to €155±10.9 for the Betadine® group (p<0.0001). DISCUSSION: Not only is the effectiveness of ChloraPrep™ already recognized but it also appears to have health economic benefits. However, further studies are needed to confirm this finding. LEVEL OF EVIDENCE: III, case control study.

Aerodynamic analysis of hospital ventilation according to seasonal variations. A simulation approach to prevent airborne viral transmission pathway during Covid-19 pandemic.

During the Covid-19 pandemic, location of the SARS-CoV-2 infected patients inside the hospital is a major issue to prevent viral cross-transmission. The objective of this study was to evaluate the risk of contamination through aerosol by using a global approach of the multiple environmental parameters to simulate, including seasonal context. A computational fluid dynamic (CFD) simulation based on the Lattice Boltzmann Method approach was used to predict airflow on the entire floor of a private hospital in Paris. The risk of contamination outside the rooms was evaluated by using a water vapor mass fraction tracker. Finally, the air contamination was estimated by a "cough model" producing several punctual emissions of contaminated air from potentially infected patients. In a winter configuration, the simulation showed a well-balanced ventilation on the floor and especially inside the rooms. After cough emissions from COVID-positive rooms, no significant contamination was observed in the circulation area, public waiting space and nurse office. On the contrary, in a summer configuration, the temperature difference due to the impact of the sun radiation between both sides of the building created additional air transport increasing the contamination risk in neighboring rooms and public spaces. Airborne spread was limited to rooms during winter conditions. On the contrary, during summer conditions, market airflow with potentially contaminated air coming from rooms located on the side of the building exposed to solar radiation was evidenced. These observations have implications to locate infected patients inside the building and for the conception of future health care structures.

Postoperative pain and infection are the most frequent reasons for legal action after knee arthroscopy: a 5-year review based on two private insurance French companies after arthroscopy.

PURPOSE: The objective of this study was to determine the reasons for complaints and describe the judicial means upstream of France's courts following arthroscopy. METHODS: This is a retrospective observational study including all compensation records related to arthroscopic surgery, collected from the two leading French insurance organizations: MACSF and Branchet companies, from 2014 to 2018. Three medical experts performed the protocol and analysis. RESULTS: Finally, 247 procedures were included. The most common motives were: the appearance or persistence of pain (43.7%), postoperative infection (29.1%), technical errors (10.5%), nerve damage (5.7%), arterial lesions (2.8%), side errors (2.4%). Knee arthroscopies were more at risk of legal action for infection (p = 0.0006), and for disappointing results or persistent pain (p = 0.001). The first recourse was the conciliation and compensation commission (CCI) in 136 cases (55.1%), the civil court (TGI) in 88 cases (35.6%) and amicable settlement in 23 cases (9.3%). The mean time between surgery and the complaint was 32.8 ± 25.7 months, and was shorter in the case of an amicable procedure (p < 0.001). The lawsuit's mean duration was 15.6 ± 11.2 months, but longer in case of civil proceedings (p < 0.0001). The experts found no negligence in 81.8% of cases (n = 202). Infections were the leading cause of recourse to the conciliation and compensation commission (p < 0.0001), while technical errors were the main reason for complaints settled in an amicable procedure (p = 0.035). It was found more proven negligence in case of amicable procedures (p < 0.0001). The mean amount of compensation was 60,968.45€. No significant difference could be found regarding the median values of compensation between the reason of complaint. The amount of compensation was higher in civil court proceedings than in any others (p = 0.02). CONCLUSION: The main reasons for arthroscopy litigation in France are reported in this study, specifying how they are managed upstream of possible legal proceedings. The knee is the main joint involved. Patient information, close follow-up associated with early and appropriate management of complications are the main ways to reduce complaints. LEVEL OF EVIDENCE: IV.

Dynesys® dynamic stabilization outcomes in degenerative spine surgery.

Dynesys® is a dynamic device used for posterior stabilization of the lumbar spine. The objective of this study was to analyze the clinical and radiological outcomes at a 2-year minimum follow-up. In this retrospective study, patients operated between 2009 and 2016 with Dynesys® stabilization were included. 5 different etiologies were included: disc herniation, lumbar stenosis, revision for adjacent seg- ment disease (ASD), spondylolisthesis, and scoliosis. Clinical and radiological evaluations were performed. Postoperative complications and revisions were recorded. 136 patients were included: 34 for lumbar spinal stenosis, 19 for disc herniation, 29 degenerative spon- dylolisthesis, 41 revisions for ASD, and 13 scoliosis. Mean age was 64.8. Average clinical follow-up was 46 months. Postoperative clinical results showed a mean lumbar VAS of 3.07, a mean radicular VAS of 3.01 and an ODI score of 31.8%. The ASD rate was 16.2%, and overall revision rate was 11.8%. 2 cases (1.5%) of screw loosening were identified. Clinical outcomes, ASD rate and revision rate were more favorable in the spondylolisthesis and disc herniation groups. This study has one of the largest Dynesys® cohort in literature. Spinal dynamic stabilization by Dynesys® presents good long-term clinical and radiological out- comes with a lower rate of complications than pre- viously published cohorts and lumbar fusions. Best indications seem to be degenerative spondylolisthesis.

Ceramic-on-ceramic THA Implants in Patients Younger Than 20 Years.

BACKGROUND: Poor survival of THA implants in very young patients has been attributed to use of cemented implants, wear of conventional polyethylene, and the presence of morphologic deformities in the proximal femur or in the acetabulum. Few studies have reported the long-term results of ceramic-on-ceramic implants in THAs in patients younger than 20 years. QUESTION/PURPOSES: We determined: (1) the proportion of patients who experienced complications related to the ceramic bearing (squeaking, fracture); (2) the survivorship free from loosening and free from revision for any reason; (3) whether patients with osteonecrosis had inferior survivorship compared with patients whose surgical indication was all other diagnoses including sequelae of pediatric hip disorders (developmental dysplasia of the hip, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis); and (4) clinical function. METHODS: Between 1979 and 2013, we performed 113 primary THAs in 91 patients younger than 20 years at the time of surgery. Of those, 105 THAs (83 patients) were done with ceramic-on-ceramic bearings (91% of the 91 patients); during that period, a ceramic-on-ceramic bearing couple was indicated in all patients younger than 20 years. In eight patients (eight hips), a cemented polyethylene cup was implanted because the diameter of the acetabulum was smaller than the smallest available ceramic cup (46 mm), or because adequate fixation of a ceramic press-fit cup could not be achieved despite careful reaming of the acetabulum. The most common diagnosis indicating THA was avascular necrosis of the femoral head (56.2%; 59 hips). Thirty-five patients (40 hips) had undergone previous operations before the replacement. Three patients (4%; four hips) died from unrelated causes, nine patients (11%; 13 hips) were lost to followup, and four patients (five hips) had a followup greater than 8.5 years but have not been seen in the last 5 years. Patients were assessed clinically (using the Merle d'Aubigne-Postel score, Hip disability and Osteoarthritis Outcome score (HOOS), and the SF-12(®) Health Survey, and radiographically for signs of radiolucencies, subsidence, or osteolysis on plain films. The mean followup was 8.8 ± 6.1 years (range, 2-34.4 years). RESULTS: Five patients experienced transient noise generation, defined as a snap in four patients and squeaking in one. Seventeen hips underwent revision surgery-16 for aseptic loosening and one for septic loosening. The implant survival rate at 10 years with aseptic loosening as the endpoint was 90.3% (95% CI, 82.4%-98.9%). No hip had acetabular or femoral osteolysis. Survivorship in patients with osteonecrosis did not differ from survivorship in patients with other diagnoses. The Merle d'Aubigne-Postel score increased from 10.1 ± 4.0 to 17.6 ± 1.1 (p < 0.01); the mean HOOS score was 79.3 ± 13.8 (range, 50.6-100); the mean SF-12(®) physical and mental component scores were 48.1 ± 7.9 (range, 21.4-57.6), and 47.4 ± 12.2 (range, 24.5-99.4), respectively. CONCLUSIONS: We found that patient-reported outcomes scores improved in most patients undergoing THA in this very young study group. Underlying diagnosis did not affect long-term survivorship. However, the revision-free survival rate at 10 years is lower than published estimates in older patients, and with 11% of patients lost to followup, our estimates may represent a best-case scenario. Therefore, we believe THA should be performed as a last resort in this population. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Anterior cruciate ligament surgery in the rabbit.

BACKGROUND: Various methods regarding allograft knee replacements have been described. The animal models, which are generally used for this purpose include sheep, dogs, goats, and pigs, and accrue significant costs for study protocols. The authors herein describe an efficient and cost-effective model to study either native or tissue-engineered allografts for anterior cruciate ligament (ACL) replacement in a New Zealand rabbit model with the potential for transgenic and cell migration studies. METHODS: ACL reconstructions were performed in rabbits under general anesthesia. For fresh allograft implantations, two animals were operated in parallel. Each right extensor digitorum longus tendon was harvested and prepared for implantation. After excision of the ACL, tibial and femoral bone tunnels were created to implant each graft in the native ACL position. RESULTS: During a 2-year period, the authors have successfully undertaken this surgery in 61 rabbits and have not noticed any major complications attributed to this surgical technique. In addition, the authors have observed fast recovery in the animals postoperatively. CONCLUSION: The authors recommend this surgical procedure as an excellent model for the study of knee surgery.

Can patients really participate in sport after high tibial osteotomy?

PURPOSE: The possibility to return to sporting activity can be an important consideration in the decision-making process in femorotibial osteoarthritis. We analyzed functional outcomes and sport participation in a continuous series of HTO and asked whether this procedure could match expectations in active and motivated patients. METHODS: We retrospectively investigated activities, sports participation, and the level of satisfaction in 139 patients with unilateral noncomplicated HTO. The study included 41 women and 98 men with a mean age of 59 years and a mean 50 months of follow-up. RESULTS: Eighty-seven patients (63%) reported that their knee was "normal," and eighty-six patients (62%) felt that their activities were limited by their knee. A total of 78 patients (56%) reported that they were as active as they expected to be before the intervention. Of these patients, 98% were satisfied. Of the patients who were not as active as they thought they would be, 51% were satisfied (P < 0.0001). The duration of preoperative pain, the age at evaluation, and the number of previous surgeries did not influence the subjective result. Among patients under 75 years, 28% regularly participated in strenuous sports, but 40% were motivated for these activities. 66% of the motivated patients regularly participated in at least one impact sport. CONCLUSION: This study shows that young motivated patients are able to resume strenuous activities following HTO. However, patients must be informed that they will typically not recover their pre-pathology level and that residual pain during strenuous sports is not exceptional. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Is there a risk in placing a ceramic head on a previously implanted trunion?

BACKGROUND: Strategies for revising a ceramic-on-ceramic total hip prosthesis are controversial. Some consider reimplantation of a ceramic head on a well-fixed femoral stem inadvisable as it may lead to a fracture of the newly implanted head. QUESTIONS/PURPOSES: We assessed (1) the risk of fracture when a new ceramic head was placed on a previously implanted trunion; (2) the survival rate of the revised hips; and (3) hip function and acetabular and femoral component loosening at midterm followup. PATIENTS AND METHODS: We retrospectively reviewed all 126 patients (139 hips) who had revision of alumina-alumina hip arthroplasties between January 1977 and December 2005. Of these, 99 patients (110 hips) had revision of the socket only with retention of the femoral component. The femoral head was left in place in 33 hips, the same alumina head was re-implanted in seven hips, a new alumina head was implanted in 45 hips, a metallic head in 16, and a zirconia head in nine. Twenty-six patients (29 hips) died and nine (10 hips) were lost to followup before 5 years; this left 71 hips for review. Minimum followup was 60 months (mean, 112 months; range, 60-319 months). RESULTS: Eighteen hips required rerevision surgery, 11 for aseptic loosening, two for septic loosening, two for fracture of a ceramic liner, one for recurrent dislocation, one for ipsilateral femoral fracture, and one for unexplained pain. Among the 61 ceramic heads implanted on a well-fixed stem, no fracture of the head occurred at a mean 88 months' followup. The survival rate at 10 years with mechanical failure as the end point was 81.6%. CONCLUSIONS: We observed no fractures of the ceramic heads implanted on a previous titanium trunion. This approach is possible if inspection shows no major imperfection of the Morse taper.

Osteonecrosis after allogeneic bone marrow transplantation.

UNLABELLED: Osteonecrosis after bone marrow transplantation is usually severe. Most patients develop acute and chronic graft-versus-host disease requiring a high dose of steroids for a long period of time. Generally ineffective nonoperative treatment in the past has resulted in treatment primarily with total hip arthroplasty (THA). We asked whether THA (1) reliably improved functional status, (2) led to more complications, and (3) THA after bone marrow transplantation was as durable as THA for idiopathic ON. We retrospectively reviewed 77 patients (123 hips) with osteonecrosis. The mean age at surgery was 33 years (range, 15.7-56 years). We performed all arthroplasties with an alumina ceramic bearing coupled with an alumina head 32 mm in diameter. The minimum followup was 2 years (mean, 9.2 years; range, 2-26 years). We documented seven revisions: three for late septic loosening, four for late aseptic loosening. Considering loosening of any component as the end point, the survivorship was 74.8% (range, 58.7%-90.9%) at 10 years. In this difficult situation, we believe the results acceptable. Septic loosening affecting this specific population has to be considered a serious event. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.