Zoledronic Acid Contraindications Prevalence among Hip-Fractured Patients Aged 75 Years or Over Hospitalized in an Orthogeriatric Unit.

OBJECTIVE: Zoledronic acid (ZA) is an antiosteoporotic drug that has been proven to reduce mortality after a hip fracture (HF). ZA is however underused with older HF patients. One possible cause may be the high prevalence of severe renal failure and hypocalcemia which contraindicate ZA administration. The aim of this study was to assess the prevalence of these 2 contraindications in patients aged 75 years or older admitted into an orthogeriatric (OG) unit after a low-energy HF. The secondary objective was to assess the prevalence of situations in which ZA must be used with caution. METHODS: Our retrospective descriptive monocentric study was performed in an OG unit on a cohort of elderly patients hospitalized for HF from August 2015 to August 2017. Prevalence of hypocalcemia lower than 2 mmol/L and Cockcroft creatinine clearance lower than 35 mL/min was recorded. RESULTS: Among the 194 patients admitted for HF, 136 patients (mean age 86 ± 5.6 years; 101 women) were included. The mean length of hospital stay was 15 ± 9 days. 111 (81.5%) had no contraindications to ZA administration. More than 80% presented situations in which ZA had to be used with caution, including 25(OH)D deficiency (20%). CONCLUSION: The majority of subjects aged 75 years or older admitted to hospital after an HF seem to have no contraindication for ZA administration during their immediate postoperative hospital stay. The hospitalization period after HF repair gives the opportunity to give most of them this treatment to improve their prognosis, taking into account situations in which ZA must be used with caution.

Management of preoperative pain in elderly patients with moderate to severe cognitive deficits and hip fracture: a retrospective, monocentric study in an orthogeriatric unit.

BACKGROUND: Patients with cognitive deficits are 3 times more likely to suffer a hip fracture than geriatric patients of the same age group without cognitive deficits. The persistence of perioperative pain following hip fracture is a risk factor for the occurrence of delirium, poor functional prognosis, and the development of secondary chronic pain. Patients with cognitive deficits receive 20 to 60% less analgesics than those without cognitive deficits. Our retrospective descriptive monocentric study was performed in an orthogeriatric unit on a cohort of elderly patients hospitalized for hip fracture. The aim of the study was to compare the quantity of strong opioids delivered in a morphine sulfate equivalent daily during the preoperative period after a hip fracture between cognitively intact patients and those with cognitive deficits. RESULTS: Our total population of 69 patients had a median age of 90 years old, and 46% of these patients had moderate or severe cognitive deficits. During the preoperative period, the same quantity of strong opioids was administered to both groups of patients (13.1 mg/d versus 10.8 mg/d (p = 0.38)). Patients with moderate to severe cognitive deficits more often experienced delirium during their hospitalization (p < 0.01) and received more psychotropic drugs in the first 3 postoperative days (p = 0.025). CONCLUSIONS: We reported that with standardized pain management in an orthogeriatric unit, patients aged 75 years and older received the same daily average quantity of strong opioids during the preoperative period regardless of the presence of cognitive deficits.

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.

Clinical and radiological outcomes in thoracolumbar fractures using the SpineJack device. A prospective study of seventy-four patients with a two point three year mean of follow-up.

PURPOSE: The aim of this study was to assess clinical and radiological results of SpineJack on the treatment of vertebral body fractures in a continuous prospective series of patients. MATERIAL AND METHODS: Between May 2012 and April 2015, all patients operated using the SpineJack device were prospectively included in this monocentric study. Demographic data, clinical, and radiological results were recorded. Complications and surgical managements were recorded. RESULTS: At a mean follow-up of 2.3 years, 74 patients with 77 fractured vertebrae were included. The stand-alone SpineJack group comprised 60 patients with 63 fractured vertebrae (group 1) and the group with additional posterior fixation 14 patients with 14 fractured vertebrae (group 2). The average initial vertebral wedge angle was 13.3 ± 6.1 degrees for group 1 and 15.3 ± 5.7 degrees for group 2 (p = 0.25). Post-operative values were 6.5 ± 4.6 degrees for group 1 and 5.1 ± 3.9 degrees for group 2 (p = 0.31). The differences within the same group were highly significant (p < 0.0005). The loss of reduction at last follow-up was 0.8 ± 1.6 degrees in group 1 and 0.6 ± 2.0 degrees in group 2 (p = 0.77). Subjective results were considered as very good or good for 57 patients (95%) in group 1 and for 11 patients (79%) in group 2, p = 0.07. CONCLUSION: The SpineJack seems to be a promising tool in the treatment of traumatic vertebral fractures with a correction in the sagittal plane comparable with what can be found in the literature.

Outcomes of acetabular fractures in the elderly: a five year retrospective study of twenty seven patients with primary total hip replacement.

PURPOSES: Open reduction and internal fixation (ORIF) in osteoporotic acetabular fractures is quite difficult with high risk of implant failure. Total hip arthroplasty (THA) may be an effective option for treating acetabular fractures in appropriately selected patients, with immediate full weightbearing. The aim of the study was to evaluate the functional outcomes of primary THA for acetabular fractures in elderly patients. METHODS: Between 2010 and 2015, 27 elderly patients operated for acetabular fractures by primary THA were included. The surgical technique associated plate stabilization of both acetabular columns with THA using an acetabular reinforcement cross-plate. Mean age was 68.5 years (57-84) and mean ASA was 2 (1-3). The mean follow-up was four years. RESULTS: The mean Harris score was 70.4 ± 23 (24-90), and the mean Postel-Merle Aubigné (PMA) score was 14.3 ± 4 (7-18). For 17 patients with rank of pre-operative Devane 4, the post-operative rank was unchanged (p < 0.05). Twenty patients (74%) were satisfied by the surgical treatment. Twenty post-operative complications (74%) were found. Two patients died during follow-up (7%). CONCLUSIONS: Primary THA for acetabular fracture in the elderly population might be a good therapeutic option that allows return to the previous daily life activity. Three patients (11%) became bedridden, and four patient's skiers (15%) returned to skiing. However, this surgery is difficult and selection of elderly patients, i.e., with acetabular fractures who are expected to get a poor result with ORIF, i.e., fracture patterns with posterior wall lesion and marginal impaction, for primary THA in an experienced centre provides satisfactory clinical results.

Does continuous wound infiltration enhance baseline intravenous multimodal analgesia after posterior spinal fusion surgery? A randomized, double-blinded, placebo-controlled study.

PURPOSE: There has been a growing interest in continuous local anaesthetic wound infiltration as a non-opioid technique for postoperative pain relief. The impact of this modality on baseline analgesia after spinal fusion surgery has however been inconclusive. We tested whether continuous wound infiltration with ropivacaine can enhance postoperative analgesia compared to a baseline intravenous multimodal analgesia protocol after spinal fusion surgery. METHODS: In this randomized, double-blinded, placebo-controlled study, a multiholed 19-gauge catheter was placed at the end of the surgical procedure through the wound to permit the continuous administration (8 ml/h) of ropivacaine 0.2 % (ropivacaine group; n = 19 patients) or saline (control group; n = 20 patients) during the first 48 postoperative hours (H48). Both groups received intraoperative low-dose ketamine, a combination of acetaminophen, non-steroidal anti-inflammatory drug, and nefopam over the same postoperative period, and morphine delivered by a patient-controlled analgesia (PCA) device. RESULTS: Morphine consumption was comparable between the two groups both at H48, 38 mg (26:52) (median, 25th:75th percentile) (control group) versus 43 mg (19:74) (ropivacaine group), and at H24, 18 mg (16:22) versus 22 mg (9:35) respectively. Pain scores at rest and during mobilization, quality of postoperative sleep, and morphine-related side effects were comparable between the two groups at H24 and H48. CONCLUSION: Our findings indicate that no additional analgesia was provided with continuous wound infiltration of ropivacaine compared to a baseline intravenous multimodal analgesia protocol after spinal fusion surgery. TRIAL REGISTRATION: Clinicaltrials.gov #NCT01743794.

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.

Are normal hips being labeled as pathologic? A CT-based method for defining normal acetabular coverage.

BACKGROUND: Plain radiographic measures of the acetabulum may fail to accurately define coverage or pathomorphology such as impingement or dysplasia. CT scans might provide more precise measurements for overcoverage and undercoverage. However, a well-defined method for such CT-based measurements and normative data regarding CT-based acetabular coverage is lacking. QUESTIONS/PURPOSES: The purposes of the study were (1) to develop a method for evaluation of percent coverage of the femoral head by the acetabulum; and (2) to define normative data using a cohort of asymptomatic patient hip and pelvic CT scans and evaluate the variability in acetabular version for asymptomatic patients with normal lateral coverage (lateral center-edge angle [LCEA] 20°-40°) that has previously been defined as abnormal based on radiographic parameters. METHODS: Two-hundred thirty-seven patients (474 hips) with hip CT scans obtained for reasons other than hip-related pain were evaluated. The scans were obtained from a hospital database of patients who underwent CT evaluation of abdominal trauma or pain. In addition, hips with obvious dysplasia (LCEA < 20°) or profunda (LCE > 40°) were excluded resulting in a final cohort of 222 patients (409 hips [115 men, 107 women]) with CT scans and a mean age of 25 ± 3 years. CT scan alignment was corrected along the horizontal and vertical axis and percent acetabular coverage around the clockface (3 o'clock = anterior), and regional (anterior, superior, posterior) and global surface area coverage was determined. Percent coverage laterally was correlated with the LCEA and the presence and prevalence of cranial retroversion (crossover sign) and a positive posterior wall sign were determined. RESULTS: The mean regional percent femoral head surface area coverage for the asymptomatic cohort was 40% ± 2% anteriorly, 61% ± 3% superiorly, and 48% ± 3% posteriorly. Mean global coverage of the femoral head was 40% ± 2%. The local coverage anteriorly (3 o'clock) was 38% ± 3%, laterally (12 o'clock) was 67% ± 2%, and posteriorly (9 o'clock) was 52% ± 3%. The mean lateral coverage represented a mean LCEA of 31° (± 1 SD). Fifteen percent of hips demonstrated cranial retroversion that would correlate with a crossover sign, and 30% had < 50% posterior coverage that would correlate with a positive posterior wall sign on an anteroposterior pelvis radiograph. In addition, male hips had a higher prevalence of a crossover sign (19%; 95% confidence interval [CI], 14%-25% versus 11%; 95% CI, 7%-16%; p = 0.03) and posterior wall sign (46%; 95% CI. 39%-53% versus 13%; 95% CI, 9%-19%; p < 0.001) compared with women. A positive crossover sign or posterior wall sign was present for 113 male hips (53%; 95% CI, 46%-60%) compared with 39 female hips (20%; 95% CI, 15%-26%; p < 0.001). CONCLUSIONS: This study provides normative coverage data and a reproducible method for evaluating acetabular coverage. Cranial acetabular retroversion (crossover sign) and a positive posterior wall sign were frequent findings in a young asymptomatic cohort and might be a normal variant rather than pathologic in a significant number of cases.

Navigated pedicle screw insertion with the Surgivisio system: Malposition rate and risk factors - about 648 screws.

PURPOSE: Pedicle screw malposition rates vary greatly in scientific literature depending on the chosen criteria. Different techniques have been developed to lower the risk of screw malposition. Our primary objective is to evaluate the malposition rate associated with the use of the Surgivisio navigation system and to identify risk factors for screw malposition. The secondary objectives are to assess operating time and radiation data. MATERIALS AND METHODS: We performed a monocentric retrospective consecutive case series. All patients operated for pedicle screw implantation using the Surgivisio system between September 2017 and June 2020 were included. Screw positioning was evaluated on postoperative CT scans using Heary and Gertzbein classifications. Thirteen potential risk factors for screw malposition were hypothesized and tested with a univariate and multivariate analysis. RESULTS: Six hundred and forty-eight screws could be evaluated in 97 patients. Our study reported a 92.4% satisfactory screw implantation rate with a mean operative time per screw of 14.5±6.7minutes and a patient effective dose of 0.47±0.31 mSv per screw. One screw was neurotoxic and required an early revision (0.15%). Three risk factors for screw malposition have been identified in a multivariate analysis: female gender (OR=2.13 [1.11; 4], p=0.0219), an implantation level above D10 (OR=2.17 [1.13; 4.16], p=0.0197), and an "open" surgery (as opposed to percutaneous) (OR=3.47 [1.83; 6.56], p=0.0002). CONCLUSION: Pedicle screw malposition rate and operative time with the Surgivisio navigation system are comparable with those reported in scientific literature. We theorized that intraoperative patient reference displacement could be a major cause of navigation failure. LEVEL OF EVIDENCE: IV.

Fragility fractures of the pelvis: First 48 cases of surgical treatment at a level 1 trauma center in France.

INTRODUCTION: Longer life expectancy is accompanied by a higher incidence of fragility fractures of the pelvis (FFP), which has repercussions on mortality and nursing home admissions. Given the paucity of data at French healthcare facilities, we carried out a retrospective study to (1) evaluate how surgical treatment of FFP with posterior displacement (type III and IV according to Rommens and Hofmann) affects a patient's pain, functional status and ability to stay at home and (2) evaluate the postoperative complications and mortality rate. HYPOTHESIS: Surgery for posteriorly displaced FFP will relieve pain and preserve the patient's independence. METHODS: All the patients over 65 years of age who were operated on for a posterior FFP between January 2015 and August 2020 were included in this prospective, single-center study. The demographics, fracture type, details of the surgical treatment, complications and mortality were analyzed. Pain (visual analog scale, VAS), functional status (Activity of Daily Living [ADL] and Instrumental Activity of Daily Living [IADL]), mobility (Parker score) and rates of nursing home admissions were compared before the fracture, after surgery and at a mean follow-up of 28 months (minimum follow-up of 1 year). RESULTS: Forty-eight patients with a mean age of 75 years were included. Twenty-four of these patients (50%) had at least two comorbidities. The FFPs were either type IV (31/48; 65%) or type III (17/48; 35%). The mean VAS for pain was significantly lower on the first day postoperative (3.5 versus 4.8; p=0.02). This significant reduction continued upon discharge from the hospital (1.95; p=0.003) and persisted at the mean follow-up of 28 months (2.2; p=0.64). The complication rate was 15% (7/48) and the mortality rate at the final review was 15% (7/48). Among the surviving patients, 81% (29/36) returned to living at home. The ADL (5.1 versus 5.8; p=0.09), IADL (5.9 versus 6.9; p=0.15) and Parker score (6.8 versus 8.2; p=0.08) at the final review were not significantly different from the values before the fracture. CONCLUSION: This is the first French study of patients operated on for an FPP. Fixation of posteriorly displaced fractures allows surviving patients to retain their mobility. Pain relief is achieved quickly and maintained during the follow-up period. Thus, our initial hypothesis is affirmed. The complication rate is not insignificant; given the complexity of this surgery, percutaneous treatment is preferable. LEVEL OF EVIDENCE: IV; retrospective study.

Functional outcomes and center of rotation restoration in total hip arthroplasty after acetabular fracture: A review of 367 hips.

BACKGROUND: Total hip arthroplasty (THA) after acetabular fracture is typically performed months or years later for posttraumatic arthritis after initial conservative treatment. But THA can be performed earlier after open reduction and internal fixation (ORIF) of the fracture. The aim of this study was to determine which strategy is best. The primary outcome measure was the radiological restoration of the hip's center of rotation (COR). The secondary outcome measures were the incidence of complications and the hip's functional scores. MATERIALS AND METHODS: A multicenter cohort was analyzed by splitting patients into three groups: group A (THA within 3weeks of fracture); group B (THA deferred after early ORIF); group C (THA more than 3weeks after fracture, without ORIF). Group B was separated into two subgroups: B- (THA less than 1year after ORIF) and B+ (THA more than 1year after ORIF). The demographics, surgical techniques, COR superior and lateral migration coefficient and functional scores (HHS, HOOS-PS and FJS) were recorded. The functional scores were gathered using PROMs. RESULTS: In all, 367 patients were included: 108 in group A, 69 in group B-, 113 in group B+ and 77 in group C. The mean follow-up was 5.8years [3.4 months-35years]. The mean age of the patients was 69.2years [SD 15; 26-101], 52years [SD 16; 19-83], 49years [SD 16; 16-85] and 58.1years [SD 17; 13-94], respectively (p<0.01). The mean ASA score was 2.13 [SD 0.70], 1.84 [SD 0.65], 1.67 [SD 0.63] and 1.79 [SD 0.60], respectively (p<0.01). A complex Letournel fracture was present in 63 patients (61%), 46 patients (71%), 48 patients (49%) and 38 patients (62%), respectively (p<0.01). A reinforcement cage was implanted in 38 patients (69%), 16 patients (62%), 5 patients (12%) and 19 patients (66%), respectively (p<0.01). Cement was used in 45 patients (45%), 23 patients (35%), 19 patients (18%) and 21 patients (32%), respectively (p<0.01). A graft was needed in 46 patients (46%), 35 patients (53%), 17 patients (16%) and 21 patients (48%), respectively (p<0.01). Posterior ORIF was done in 40 patients (46%), 32 patients (55%), 64 patients (61%) and 9 patients (82%), respectively (p<0.01). The COR lateral migration coefficient was significantly higher in group C with a mean of +0.17 (SD 0.85) [-0.27 to +6] compared to the other groups (p=0.02). The COR superior migration coefficient was comparable between groups, with a mean of +0.77 (SD 2.26) [-0.99 to 27], p>0.05. There were complications in 10 patients (9.2%), 6 patients (8.7%), 6 patients (5.3%) and 3 patients (3.9%), respectively, with no significant difference between groups. The PROMs were completed by 51% of patients. At the final review, the mean HHS was 79.2 (SD 21.8) and the mean HOOS-PS was 77.7 (SD 20.1) in the entire cohort, p>0.05. The mean FJS by group was 55.9 (30.2), 47.7 (SD 36.4), 66.1 (SD 30.4) and 65.8 (SD 30.3), respectively (p=0.02). DISCUSSION AND CONCLUSION: The B strategy (B+) yielded good outcomes in terms of function and COR restoration. When using this strategy, anterior ORIF preserves the native hip for a subsequent THA through a posterior approach. Strategy C also produces good functional outcomes but shifts the COR laterally. This study confirms the poor results of strategy A in previous publications. When the prognosis is poor, immediate mobilization after anterior ORIF followed by THA within 1year appears to be a good strategy (group B-). LEVEL OF EVIDENCE: IV, observational study.

Simulation Software to Plan the Treatment of Acetabular Fractures: The Patient-Specific Biomechanical Model.

OBJECTIVES: The objective of this study was to assess the impact of using simulation software for preoperative planning: a patient-specific biomechanical model (PSBM) in acetabular surgery. The secondary objectives were to assess operating time, intraoperative bleeding, and peroperative complications. DESIGN: This is a prospective control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between January 2019 and December 2022, patients with operative acetabular fracture treated by the first author were prospectively enrolled. INTERVENTION: Patients were divided into 2 groups according to the use or not of PSBM for preoperative planning. When PSBM was used, data were extracted from the preoperative high-resolution computed tomography scans to build a biomechanical model implemented in a custom software [simulation (SIM group)]. When computed tomography scans were not performed in our hospital, PSBM was not feasible (non-SIM group). MAIN OUTCOME MEASUREMENTS: Radiological results, surgery duration, blood loss, and peroperative complications were recorded. RESULTS: Sixty-six patients were included; 26 in the PSBM group and 40 in the standard group. The 2 groups were comparable regarding fracture patterns and epidemiological data. After simulation, in the SIM group, a poor reduction (>3 mm) was found in 2 of 26 patients (7.7%) versus 11 of 40 patients (27.5%) in the non-SIM group, P = 0.048. The mean operative time was shorter after simulation (110 minutes vs. 155 minutes, P = 0.01), and the mean blood loss was reduced (420 vs. 670 mL, P = 0.01). CONCLUSIONS: By reducing the peroperative trials for reduction, PSBM allows better reduction in a shorter operative time and with less blood loss. LEVEL OF EVIDENCE: Level II: prospective study.

Surgical treatment of terrible triad of the elbow: Retrospective continuous 50-patient series at 2 years' follow-up.

INTRODUCTION: Terrible triad (TT) of the elbow is an association at high risk of instability. Treatment aims to restore joint stability. Lateral collateral ligament (LCL) repair is systematic, whereas medial collateral ligament (MCL) repair is only exceptionally necessary. The main aim of the present study was to assess clinical results in TT surgery. The secondary objective was to compare clinical progression with versus without MCL repair. MATERIAL AND METHODS: A retrospective study included 50 TTs operated on via an isolated lateral or combined medial-lateral approach. Clinical assessment comprised MEPS, QuickDASH, VAS, flexion-extension and pronation-supination, and return to work and sport. Subgroup analysis was made according to associated MCL repair. RESULTS: Fifty patients (19 female, 31 male) were operated on between January 2006 and January 2017. Mean follow-up was 24 months. At last follow-up, mean MEPS was 89.1, VAS 0.7, QuickDASH 16, flexion-extension 114°, and pronation-supination 137°. Only MEPS was significantly improved by MCL repair (p=0.02), with no significant difference in complications. DISCUSSION: TT surgery with immediate mobilization gave good long-term functional results, not significantly improved by MCL repair. The lateral approach should be adopted in first line, with the medial approach in second line in case of persistent instability after lateral osteo-ligamentous repair. LEVEL OF EVIDENCE: IV; retrospective study.

[Trends in the treatment of spinal osteoporic fractures: vertebroplasty and kyphoplasty]. / Nouveautés dans la prise en charge des fractures vertébrales ostéoporotiques: place de la vertébroplastie et de la kyphoplastie.

Vertebral osteoporotic fracture (VOF) is a major problem of public health. Surgical treatments such as vertebroplasty and kyphoplasty are interesting adjuvant treatments for the management of osteoporosis. A consensus proposed by the principal contributors of this management is important. Regarding the actual data, we propose a vertebroplasty or a kyphoplasty for all patients suffering of an acute VOF. If a previous kyphosis or an important local kyphosis exists, secondary to the acute VOF or others, we propose a kyphoplasty. If the VOF is older and the conservative treatment is inefficient, we propose a vertebroplasty. In all cases, a specific management and treatment of osteoporosis is proposed.

Screw misplacement in percutaneous posterior pelvic iliosacral screwing with and without navigation: A prospective clinical study of 174 screws in 127 patients.

BACKGROUND: Recent studies of iliosacral screw fixation performed using intraoperative navigation systems have shown promising results. The Surgivisio Platform is a new-generation three-dimensional intraoperative navigation tool that has been used at our institution for 2years. The aim of this prospective study was to assess the contribution of navigation in terms of iliosacral screw positioning accuracy and of radiation exposure, by comparing outcomes with vs. without navigation. HYPOTHESIS: Navigation allows more accurate percutaneous iliosacral screw positioning regardless of the type of screw fixation (with sacral dysmorphism and/or cemented screw fixation and/or multiple screw fixation). MATERIALS AND METHODS: Between January 2018 and December 2019, consecutive patients who underwent percutaneous iliosacral screw fixation of pelvic ring fractures without vertical instability were included in this single-centre prospective study. Screw position accuracy was evaluated by postoperative high-resolution computed tomography (HRCT). Operative time, radiation dose, and complications were recorded. RESULTS: We included 127 patients with 174 iliosacral screws, of which 129 were positioned under fluoroscopic guidance and 45 using navigation. According to the modified Gras classification, 7% (12/174) of the screws were incorrectly positioned and 2% (4/174) required repositioning. The frequency of screw malposition was not significantly different between the fluoroscopy and navigation groups (8.5%, 11/129 vs. 2.2%, 1/45, respectively; p=0.19). However, screw position in dysmorphic sacra was significantly better with navigation (p=0.04), whereas no significant difference in final screw position was found for cemented or multiple screw implantations. In the navigation group, the operative time was significantly longer (28.2min vs. 21.6min, p=0.003), and the mean dose-area product significantly greater (6.6Gy·cm2 vs. 4.9Gy·cm2, p=0.02). The complication rates were not different between the two groups. CONCLUSION: In patients who have pelvic ring fractures without vertical instability, navigation of percutaneous iliosacral screw placement using the Surgivisio Platform improves screw positioning in dysmorphic sacra, at the cost of a longer operative time and greater radiation exposure of the patient. LEVEL OF EVIDENCE: II, prospective study.

Clinical and radiological outcomes of antegrade posterior column screw fixation of the acetabulum.

INTRODUCTION: Antegrade posterior column screw fixation (APCS) provides stable fixation while reducing the complications related to dual acetabular approaches. The objective of this study was to present the radiological and clinical outcomes of fixation of the posterior column of the acetabulum through a single anterior approach. HYPOTHESIS: APCS will produce better clinical and radiological outcomes relative to not placing any screws in the posterior column. PATIENTS AND METHODS: This was a retrospective single-center study of 69 patients operated through a single anterior approach for a both-column fracture of the acetabulum between 2014 and 2018. Patients were divided into two groups (APCS+, n=24 and APCS-, n=45) depending on whether the posterior column was fixed with an antegrade lag screw or not. The radiological outcomes were defined by the quality of the reduction according to Matta. The clinical outcomes were evaluated using the Harris Hip score and Merle Postel D'Aubigné (MDP) score at the final assessment. A sequential hierarchical analysis was done with a Chi2 test for the radiological criterion and Student's t test for the clinical outcomes. RESULTS: In the APCS+ group, the reduction was anatomical in 71% (17/24) of patients, imperfect in 12% (3/24) and poor in 17% (4/24). In the APCS- group, the reduction was anatomical in 33% (15/45) of patients, imperfect in 31% (14/45) and poor in 35% (16/45). This difference between groups was statistically significant (p=.012). The differences between groups in the Harris (p=.201) and MDP (p>.05) scores were not significant. Mean irradiation in the APCS+ group was significantly higher (114.8 cGy.cm-2) relative to the APCS- group (39.8 cGy.cm-2) (p<.001). None of the patients in the APCS+ group underwent a subsequent total hip arthroplasty, while 8 patients from the APCS- group did (p=.031). The differences in the postoperative complications were not statistically significant. DISCUSSION: APCS yields satisfactory radiological and clinical outcomes without increasing the complication rate; this must be balanced out against the additional irradiation. LEVEL OF EVIDENCE: III.

Navigated Cementoplasty With O-Arm and Surgivisio: An Ambispective Comparison With Radiation Exposure.

BACKGROUND: Vertebral compression fractures (VCF) are usually treated by cementoplasty. Computerized navigation allows more accurate surgery without additional imaging acquisition for guidance and related radiation exposure. New technologies trend to optimize the irradiation for patients and surgeons. The objective was to investigate the radiological results and radiation exposure of O-arm navigation compared with the all-in-one 2-dimensional/3-dimensional (2D/3D) Surgivisio device in navigated cementoplasty procedures. METHODS: Patients in the O-arm group comprised an O-arm prospective cohort as well as previous patients. Operations for VCF by navigated cementoplasty took place over 18 months. Patients in the Surgivisio group were the first patients operated on using Surgivisio and were prospectively recruited. Demographic, operative, and irradiation data were collected, as well as the image quality subjectively evaluated by the surgeon. The vertebal filling was evaluated using the Garnier classification and quoted as satisfactory, acceptable, or poor. The effective dose in millisievert (mSv) was calculated for radiation exposure estimation, and the absolute risk of cancer (AR) in percent equivalent to a whole-body irradiation was also calculated. RESULTS: A total of 123 patients were included: 62 in the O-arm group and 61 in the Surgivisio group. A total of 166 vertebrae were analyzed. Compared with the Surgivisio group, the effective dose was significantly higher in the O-arm group, with a mean of 11.47 vs 1.14 mSv, respectively (P < 0.001). The 2D part of the effective dose received by the surgeon was significantly higher in the O-arm group, with an average of 2.25 vs 0.47 mSv, respectively (P < 0.001). Overall AR followed the same trend, with a mean of 4.9 × 10-4% in the O-arm group and 5.7 × 10-5% in the Surgivisio group (P < 0.001). Operative time was significantly higher in the O-arm group (34.52 vs 30.12 minutes respectively, P = 0.03). Image quality was similarly sufficient in 3D, but in 2D, image quality was significantly better in the O-arm group (P = 0.01). Vertebral filling was significantly better in the O-arm group, with 100% of results reported as satisfactory and acceptable versus 85% in the Surgivisio group (P < 0.001). CONCLUSIONS: The O-arm delivered a 10-times higher effective dose during navigated cementoplasty in comparison with the Surgivisio device. The O-arm also had a longer operative time, but it had better image quality and radiological results.

Design and implementation of a visual and haptic simulator in a platform for a TEL system in percutaneuos orthopedic surgery.

Within a research project whose aim is to promote the learning of percutaneous operation in orthopedic surgery we design a Technological Enhanced Learning (TEL) system. This project belongs to a multidisciplinary field including computer, orthopedic surgery, medical imaging, didactic and cognitive sciences. The article presents the design principles of TEL with a particular interest in the development of a simulator. This simulator allows a virtual exercise interacting with the learner in visual, temporal and haptic dimension.

Virtual preoperative planning of acetabular fractures using patient-specific biomechanical simulation: A case-control study.

INTRODUCTION: The first patient-specific biomechanical model for planning the surgical reduction of acetabular fractures was developed in our institution and validated retrospectively. There are no prior studies showing its effectiveness in terms of reduction quality, operative duration and intraoperative bleeding. Therefore, we performed a case control study aiming to: 1) evaluate the effect of preoperative simulation by patient-specific biomechanical simulator on the operating time and intraoperative bleeding; 2) evaluate the effect of preoperative simulation by patient-specific biomechanical simulator on the quality of reduction. METHOD: All patients operated on between January 2019 and June 2019 after planning by biomechanical simulation were included in this case-control study. Each patient included was matched to 2 controls from our database (2015-2018) according to age and fracture-type. DICOM data were extracted from the preoperative high-resolution scanners to build a three-dimensional model of the fracture by semi-automatic segmentation. A biomechanical model was built to virtually simulate the different stages of surgical reduction. Surgery was then performed according to simulation data. Surgical duration, blood loss, radiological findings and intraoperative complications were recorded, analysed and compared. RESULTS: Thirty patients were included, 10 in the simulation group and 20 in the control group. The two groups were comparable in terms of age, time from accident to surgery, fracture-type and surgical approach. The mean operative time was significantly reduced in the simulation group: 113min±33 (60-180) versus 196min±32 (60-260) (p=0.01). Mean blood loss was significantly reduced in the simulation group: 505mL±189 (100-750) versus 745mL±130 (200-850) (p<0.01). However, no significant difference was found in the radiological results according to Matta's criteria, although an anatomical reduction was obtained for 9 patients in the simulation group (90%) versus 12 patients in the control group (60%) (p=0.26). A postoperative neurological complication was recorded in the control group (sensory deficit of the lateral cutaneous nerve of thigh). CONCLUSION: This study confirms the promising results of preoperative planning in acetabular trauma surgery based on patient-specific biomechanical simulation as well as its feasibility in routine clinical practice. By providing a better understanding of the fracture and its behavior, a reduction in intraoperative bleeding and in operative duration is achieved. LEVEL OF EVIDENCE: III; case-control study.