Navigation and 3D-imaging in pelvic ring surgery: a systematic review of prospective comparative studies.

BACKGROUND: Few literature reviews have been published focusing on navigation, robotic or pre-operative planning using 3D-imaging technology (3D-printing, 3D-planning). To our knowledge, no reviews have been performed to assess and compare all these modalities together versus control groups (conventional fluoroscopy) through high Randomized Control Trials (RCTs) and Prospective Control Studies (PCSs). The aim of this study was to assess and compare 3D-imaging technologies from pre-operative planning to per-operative navigation and robotic in the management of pelvic ring fractures through high level studies. METHODS: A literature search was performed using PubMed, the Cochrane library and Google scholar using keywords up to December 2023. Only prospective comparative studies (RCT and PCS) were included. A total of 341 articles were identified, 39 articles were selected for full-text analysis leaving 7 articles included in this literature systematic review. RESULTS: A trend towards improved precision in screw placement and reduction of radiation exposure without consequences in term of functional outcomes have been identified. No conclusions can be extrapolated regarding operative time and blood loss except for robotic which improve these parameters because robotic arm assistance help surgeons to correctly follow the planning based on 2D-fluoroscopy. Surgery duration and radiation dose are significantly reduced with robotic-arm assistance for the same reasons. With navigation the results have to be nuanced according to the experience of the surgical team. Interest of navigation is emphasized in sacral dysmorphism in comparison with conventional fluoroscopy. This highlights the benefits of navigation for ilio-sacral screw placement in difficult cases and less experimented teams. CONCLUSION: High level studies which assess and compare 3D-imaging technologies from pre-operative planning to per-operative navigation and robotic in the management of pelvic ring fractures are low. To date and according to the present high level literature, navigation and 3D-technologies in pelvic ring surgery should be recommended for difficult cases. LEVEL OF EVIDENCE, II: Systematic review of Level II studies.

Internal fixation of radiation-induced fragility fractures of the pelvis: a case series.

BACKGROUND: The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition. PURPOSE: The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation. METHODS: A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented. RESULTS: Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale. CONCLUSION: RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery. LEVEL OF EVIDENCE: III, retrospective study.

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.

Part 1: Outcome of Posterior Pelvic Ring Injuries and Associated Prognostic Factors - A Five-Year Retrospective Study of One Hundred and Sixty Five Operated Cases with Closed Reduction and Percutaneous Fixation.

PURPOSES: The aim of this study was to evaluate: 1. the outcome of pelvic ring fractures treated by closed reduction and percutaneous fixation, 2. the prognostic factors associated with a poor quality reduction, 3. the prognostic factors associated with ilio-sacral screws misplacement and 4. the prognostic factors associated with nonunion. METHODS: Data from medical charts for all patients admitted with unstable posterior pelvic ring injuries from 2009 to 2013 were extracted. A total of 165 patients with a mean age of 40 years were included. One hundred and five patients were reviewed at a mean of 32 months of follow-up. The prognostic factors analyzed were clinical and radiological factors. Tile B and Tile C pelvic ring fractures were compared and analyzed separately. Then specific statistical analysis was performed using a logistic regression model to eliminate confusion factors. RESULTS: An excellent or good clinical result was achieved for 94 patients (90%). An excellent or good reduction was achieved for 141 patients (85%). Nonunion rate, smoking patients, bad reductions, age of patients and ISS score were significantly higher in Tile C group. To eliminate confusion factors we used a multivariate analysis logistic regression model. Only unstable vertical bilateral posterior injuries (Tile C2 and C3) were independent prognostic factors for unsatisfactory reduction (p = 0.001; OR = 4.72; CI 95% [2.08-16.72]). Screw misplacement was recorded for 30 patients (16%) and sacral dysmorphia was an associated prognostic factor (p = 0.0001; OR = 15.6; CI95% [3.41-98.11]). Nonunion was recorded for ten patients (6%) and smoking was an associated prognostic factor (p = 0.01, OR = 5.12; CI95% [1.1-24.1]). CONCLUSIONS: Posterior pelvic ring fractures treated by closed reduction and percutaneous fixation are associated with excellent/good clinical results if excellent/good reduction and bone healing are achieved without screw misplacement. Bilateral unstable vertical posterior pelvic ring injuries, and sacral dysmorphia are risk factors for bad quality reduction and screw misplacement respectively.

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.

Results of the Latarjet coracoid bone block procedure performed by mini invasive approach.

INTRODUCTION: The coracoid block technique described by Latarjet was modified by Patte and Walch in order to increase the glenoid surface. Saragaglia further modified this technique and described a minimally invasive approach which allows faster post-operative recovery. The aim of this study was to evaluate the medium-term functional and radiological results of this technique. METHODS: This is a single surgeon cohort of 40 shoulders in 38 patients (32 men, 6 women) with an average age of 34.5 years operated on between January and December 2014. The skin incision was 3 to 6 cm long allowing the bony block to be passed under the subscapularis tendon without sectioning it and to be placed in lying position. The bone block was fixed with a 6.5 cancellous screw or a 7.0 cannulated screw. RESULTS: At an average follow-up of 48 months, there were no recurrent dislocations. The average WOSI score was 42, the average Constant score was 95 corrected to 97% and the average SSV was 97. Visual analogue scores were 0 at rest and 0.6 with activity. The bone block healed in 92.5% of cases. It was flush with the edge of the glenoid in 84% of cases, lateralised in 10% and medialised in 6% of cases. Mean internal rotation power was 12 kg in the operated shoulder compared with 9 kg in the non-operated shoulder. CONCLUSION: The treatment of recurrent anterior shoulder instability by mini invasive Latarjet gives excellent medium-term functional results. The rate of recurrent dislocation in this series was zero and internal rotation power was well preserved. This is an excellent alternative to arthroscopic procedures which are yet to demonstrate their superiority over open surgery.

Ganglion cysts of the proximal tibiofibular articulation: the role of arthrodesis and combined partial fibula excision.

PURPOSE: Cysts of the proximal tibiofibular articulation are rare and their optimal treatment remains unclear. The objective of this study was to evaluate the results and complications of the treatment of synovial ganglion cysts of the proximal tibiofibular articulation by simple excision or by excision and fusion of the proximal tibiofibular joint with a limited fibula excision. METHODS: Between January 2005 and December 2016, seven male patients with an average age of 46 years were treated for a ganglion cyst of the proximal tibiofibular articulation. Nine procedures were performed in total. Four patients underwent primary cyst excision, two underwent revision cyst excision and three underwent revision cyst excision with arthrodesis of the proximal tibiofibular joint and partial excision of the fibula (two patients underwent two procedures). RESULTS: Average follow-up was 79 months. The recurrence rate was 25% for simple cyst excision, 100% for revision cyst excision and 0% for cyst excision with arthrodesis. Average kitaoka score was 98 for simple cyst excision and 100 for cyst excision with arthrodesis (P = 0.34); resting visual analogue scores (VAS) were zero in both groups. With activity VAS was 0 for simple cyst excision and 1.6 in the arthrodesis group (P = 0.33). Two of the three arthrodesis patients went on to successful fusion. The third patient has an asymptomatic pseudarthrosis. CONCLUSION: Simple primary cyst excision has a high failure rate at 25%. Revision cyst excision without fusion failed in all cases. We therefore recommend arthrodesis with limited fibula excision.

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.

[Surgery for chronic low back pain: good option? Better than conservative treatment?]

The goal of this article is to assess, using the literature and our own experience, whether surgery is a reasonable option in the management of non-specific or degenerative chronic low back pain. The usual starting points for low back pain are without doubt the intervertebral disc and the facet joints, but the actual etiology is often difficult to determine. Moreover, psychogenic factors may amplify clinical symptoms. In our experience, thorough clinical, psychological, and socioprofessional assessment along with relevant imaging studies, parti- cularly MRI to look for inflammatory disc disease and EOS system to evaluate sagittal balance, leads to surgical indication in only 5 % of the patients with chronic low back pain. In these cases, surgery is aimed at short-circuiting ideally one, but sometimes two, interver- tebral segment by a conventional rigid fixation (arthrodesis), or by more recent non-rigid fixation techniques (disc replacement or interspinous dynamic stabilization). Their preven- tive effect on accelerated degeneration of adjacent segment appears to be moderate at best. The problem is to compare the results of surgical and conservative treatment: The analysis of publications concerning comparative randomized studies and personal studies shows that surgery is useful in only a small proportion of well selected patients with chronic low back pain, compared with physical and cognitive-behavioral management techniques.

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.

Managing periprosthetic fractures: perspectives on periprosthetic pelvic fractures.

Periacetabular periprosthetic fractures are rare but potentially disastrous for the longevity of the adjacent implants, leading to multiple revision surgeries. It is of paramount importance to identify and treat intraoperative fractures, which will lead to satisfactory results. Postoperative fractures may be managed operatively or nonoperatively depending on the patient's pain and function, the fracture pattern, and the stability of the acetabular component.

Plate fixation of the anterior pelvic ring in patients with fragility fractures of the pelvis.

INTRODUCTION: In fragility fractures of the pelvis (FFP), fractures of the posterior pelvic ring are nearly always combined with fractures of the anterior pelvic ring. When a surgical stabilization of the posterior pelvis is performed, a stabilization of the anterior pelvis is recommended as well. In this study, we aim at finding out whether conventional plate osteosynthesis is a valid option in patients with osteoporotic bone. MATERIALS AND METHODS: We retrospectively reviewed medical charts and radiographs of all patients with a FFP, who underwent a plate osteosynthesis of the anterior pelvic ring between 2009 and 2019. Patient demographics, fracture characteristics, properties of the osteosynthesis, complications and revision surgeries were documented. Single plate osteosynthesis (SPO) at the pelvic brim was compared with double plate osteosynthesis (DPO) with one plate at the pelvic brim and one plate anteriorly. We hypothesized that the number and severity of screw loosening (SL) or plate breakage in DPO are lower than in SPO. RESULTS: 48 patients with a mean age of 76.8 years were reviewed. In 37 cases, SPO was performed, in 11 cases DPO. Eight out of 11 DPO were performed in patients with FFP type III or FFP type IV. We performed significantly more DPO when the instability was located at the level of the pubic symphysis (p = 0.025). More patients with a chronic FFP (surgery more than one month after diagnosis) were treated with DPO (p = 0.07). Infra-acetabular screws were more often inserted in DPO (p = 0.056). Screw loosening (SL) was seen in the superior plate in 45% of patients. There was no SL in the anterior plate. There was SL in 19 of 37 patients with SPO and in 3 of 11 patients with DPO (p = 0.16). SL was localized near to the pubic symphysis in 19 of 22 patients after SPO and in all three patients after DPO. There was no SL in DPO within the first month postoperatively. We performed revision osteosynthesis in six patients (6/48), all belonged to the SPO group (6/37). The presence of a bone defect, unilateral or bilateral anterior pelvic ring fracture, post-operative weight-bearing restrictions, osteosynthesis of the posterior pelvic ring, and the presence of infra- or supra-acetabular screws did not significantly influence screw loosening in SPO or DPO. CONCLUSION: There is a high rate of SL in plate fixation of the anterior pelvic ring in FFP. In the vast majority, SL is located near to the pubic symphysis. DPO is associated with a lower rate of SL, less severe SL and a later onset of SL. Revision surgery is less likely in DPO. In FFP, we recommend DPO instead of SPO for fixation of fractures of the anterior pelvic ring, which are located in or near to the pubic symphysis.