Arthroscopy with partial meniscectomy for degenerative tear does not increase the risk of total knee arthroplasty at five year follow up; however, this population undergoes total knee arthroplasty with a lower threshold of osteoarthritis.

PURPOSE: Degenerative meniscus tears can cause discomfort in some patients, and when medical treatments fail to provide relief, arthroscopy may be considered before resorting to knee prosthesis. However, the benefits of arthroscopy over nonsurgical treatments in patients over 60 years old are limited, and the evidence regarding its overall efficiency and drawbacks remains scarce. Furthermore, there has been no investigation into whether those patients treated with partial meniscectomy, undergo the knee operation at an earlier stage of osteoarthritis. METHODS: This study focused on data from a single Belgian hospital, involving patients over 60 years old with internal meniscal tears. The participants were categorized into two groups based on the treatment they received: arthroscopic partial meniscectomy (APM) or conservative management. The primary outcome assessed was the occurrence of knee arthroplasty within a five year period. Secondary outcomes included evaluating the ICRS cartilage grade and the time taken until total knee arthroplasty (TKA). RESULTS: A total of 194 patients with internal meniscal tears were included in the study. At the 5-year mark, the overall rate of knee arthroplasty was found to be 16.5%, with 11.9% of cases occurring within two years. After the 5-year follow-up, it was observed that 19.2% (24 patients) of the APM group and 11.6% (8 patients) of the conservative management group underwent knee arthroplasty. Notably, patients over 70 years old who underwent APM had a higher risk of eventually requiring TKA compared to those who received conservative management. Additionally, patients who underwent meniscectomy and later underwent TKA showed less wear in the internal compartment of the knee compared to patients in the conservative treatment group who underwent TKA. CONCLUSION: The study suggests that patients who underwent arthroscopy faced a similar risk of knee arthroplasty compared to those who underwent conservative management, excepted for patients over 70 years old. Despite this similar risk of arthroplasty for the whole population, they exhibited lower osteoarthritis severity when compared to the conservative group.

Bone conductivity and spine fluoroscopy, Hand-Eye-Ear dialogue, during pedicle screw positioning: a new human cognitive system for precision and radiation-decrease; better than artificial intelligence and machine learning system?

PURPOSE: There is an increasing need for pedicle screw positioning while decreasing radiation exposure. This study compares intra-operative radiation dose using posterior internal fixation using impedancemetry-guided pedicle positioning by the Pediguard system versus standard free-hand sighting when surgery was performed with a trainee or expert surgeon. MATERIAL AND METHODS: Using the electrical properties of bone, the Pediguard detects iatrogenic penetration of the pedicle wall and gives auditory feedback to the surgeon. A single centre, two surgeons (one experienced and the other novice) conducted a continuous prospective randomized study for one year. Twenty patients were randomized into one group (free-hand control group) receiving pedicle instrumentation without the use of the Pediguard and the second group receiving pedicle instrumentation with the use of the Pediguard. The total screw placement times and fluoroscopic times for each screw was recorded and pedicle screw position was analyzed on post-operative CT scan. RESULTS: Among the 104 screwed pedicles, 22 unrecognized perforations were detected by CT scan, while no perforation signal was observed intra-operatively. Only one perforation was greater than 2 mm. The overall screwing time was 4.33 ± 1.2 minutes per screw for experienced surgeon and 5.84 ± 2.5 minutes per screw for the novice. Pediguard did not increased significantly the time (0.3 mn per screw) for the experienced surgeon, but the time with Pediguard was longer (2 mn more per screw) for the novice surgeon, particularly at the thoracic level. The overall fluoroscopic average time per screw for the experienced surgeon is 5.8 ± 2.3 s and 10.4 ± 4.5 s for the novice surgeon. For the novice surgeon, radiation time reduced from 12 (without Pediguard) to 6 s (with Pediguard). There was no significant difference for the experienced surgeon in terms of improvement in radiation time with the use of Pediguard. CONCLUSION: The overall time was longer for the novice surgeon with the Pediguard system, but allowed to decrease by 50% the fluoroscopy time.

Lateral meniscus with tears or with histologic calcification does not increase the risk of lateral osteoarthritis after medial unicompartmental arthroplasty.

PURPOSE: Meniscal tears or histological meniscal calcifications (in the absence of radiological chondrocalcinosis) are frequent in osteoarthritis. Whether lateral meniscal lesions influence clinical outcomes after medial unicompartmental knee arthroplasty (UKA) is unknown. METHODS: We analyzed 130 patients (130 knees) with medial unicompartmental knee arthroplasties between 2005 and 2015. These 130 knees had full articular cartilage thickness in the lateral compartment and no radiological chondrocalcinosis on preoperative radiographs. The lateral meniscus was analyzed with preoperative MRI and a biopsy of the anterior horn at the time of surgery. Synovial fluid was collected and analyzed for calcium pyrophosphate dihydrate crystal deposition (CPPD crystals). Lateral meniscal tears were untreated when detected on MRI or during surgery, with the hypothesis that these tears on the opposite compartment would remain asymptomatic in medial UKA. At average 10-year follow-up, patients were evaluated with clinical and radiographic outcome, with a focus on the risk of joint space narrowing of the lateral femorotibial compartment. RESULTS: CPPD crystals were present in the synovial fluid of 70 knees. Lateral meniscal tears were seen on MRI in 34 (49%) normal meniscuses of the 60 knees without CPPD crystals and in six other knees without histological meniscal calcification despite CPPD crystals. Histological calcification was present on 61 lateral meniscuses with 53 meniscal tears. The results showed no significant differences in the clinical outcomes between knees with lateral meniscal tears or lateral meniscal histological chondrocalcinosis or both lesions and those without these conditions. Additionally, radiographic progression of osteoarthritis in the opposite femorotibial compartment of the knee was not more frequent in patients with these meniscal issues. The ten year cumulative survival rates, measured by the need for total knee arthroplasty, were 91% for knees without meniscal lesions and 92% for knees with these lesions. CONCLUSION: On this basis, treatment of meniscal tears of the lateral compartment and routine aspiration of the knee to assess for birefringent crystals in the planning of medial UKA do not appear necessary.

Nonoperative and Operative Bone and Cartilage Regeneration and Orthopaedic Biologics of the Hip: An Orthoregeneration Network (ON) Foundation Hip Review.

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the hip, including osteonecrosis (aseptic necrosis) involving bone marrow, bone, and cartilage, and chondral injuries involving articular cartilage, synovium, and bone marrow. Promising and established treatment modalities for osteonecrosis include nonweightbearing; pharmacological treatments including low molecular-weight heparin, prostacyclin, statins, bisphosphonates, and denosumab, a receptor activator of nuclear factor-kB ligand inhibitor; extracorporeal shock wave therapy; pulsed electromagnetic fields; core decompression surgery; cellular therapies including bone marrow aspirate comprising mesenchymal stromal cells (MSCs aka mesenchymal stem cells) and bone marrow autologous concentrate, with or without expanded or cultured cells, and possible addition of bone morphogenetic protein-2, vascular endothelial growth factor, and basic fibroblast growth factor; and arterial perfusion of MSCs that may be combined with addition of carriers or scaffolds including autologous MSCs cultured with beta-tricalcium phosphate ceramics associated with a free vascularized fibula. Promising and established treatment modalities for chondral lesions include autologous platelet-rich plasma; hyaluronic acid; MSCs (in expanded or nonexpanded form) derived from bone marrow or other sources such as fat, placenta, umbilical cord blood, synovial membrane, and cartilage; microfracture or microfracture augmented with membrane containing MSCs, collagen, HA, or synthetic polymer; mosaicplasty; 1-stage autologous cartilage translation (ACT) or 2-stage ACT using 3-dimensional spheroids; and autologous cartilage grafting; chondral flap repair, or flap fixation with fibrin glue. Hip pain is catastrophic in young patients, and promising therapies offer an alternative to premature arthroplasty. This may address both physical and psychological components of pain; the goal is to avoid or postpone an artificial joint. LEVEL OF EVIDENCE: Level V, expert opinion.

Subtalar axis determined by combining digital twins and artificial intelligence: influence of the orientation of this axis for hindfoot compensation of varus and valgus knees.

PURPOSE: Previous studies evaluating hindfoot and knee alignment have suggested compensation between the knee and the hindfoot deformities. However, these studies did not investigate the influence of the orientation of the subtalar axis on the results. MATERIAL AND METHODS: Using computed tomography data of patients without osteoarthritis, digital twins, and artificial intelligence, we identified the orientation of the axis of the subtalar joint. Compensation was evaluated in the subtalar joint according to angular knee deformity and subtalar axis direction. RESULTS: With the inclination angle defined as the angle between the axis and the XY plane (horizontal) and the deviation angle defined as the angle between the projection of axis on the XZ plane, the inclination angle of the subtalar helical axis showed an average angle of 35.3° (range 5° to 48°). The mean deviation angle for the helical axis was 6.4° (range - 4° to + 12°). Our findings indicated that an increase of the inclination angle of the subtalar axis tends to limit adjustment in the hindfoot alignment toward re-balance of the whole lower limb toward a neutral weight-bearing axis when malalignment of the knee occurs. CONCLUSION: Malalignment of the knee and different compensations in the hindfoot contribute to various combined deformities in the population: associated valgus or varus deformities and inverse associations of varus/valgus deformities.

Percutaneous plantar fasciotomy: radiological evolution of medial longitudinal arch and clinical results after one year.

PURPOSE: Plantar fasciitis (PF) is the most common cause of plantar heel pain. Conservative treatment and corrections of risks factors are the first line of care. For the 10% of patients who do not respond to conservative treatment, surgical release can offer relief of symptoms. Due to the critical role of the PF in the function of the foot and its architectural maintenance, its surgical release could cause a collapse of the internal arch of the foot and an alteration of its function. With the hypothesis that an isolated percutaneous PF release may not lead to these alterations of the foot while providing relief to the patients, we evaluated the radiological evolution and clinical results of this surgery after one year. MATERIAL AND METHOD: Between January 2013 and Augustus 2017, we conducted a single arm monocentric prospective study on 22 patients (25 feet) aged from 33 to 84 years, with plantar fasciitis and failure of conservative management who benefited a percutaneous total plantar fasciotomy through a plantar approach. The American Orthopedic Foot and Ankle Score (AOFAS) and the Djian-Annonier's angle were evaluated preoperatively and postoperatively. RESULTS: Among the 22 patients, sixteen patients were female and six patients were male. Three patients (2 females and 1 male) for six feet were operated for bilateral plantar fasciitis. The mean pre-operative Djian-Annonier's angle was 117.6° (range 101-132.9°), and the mean post-operative angle was 119.3° (range 102-137°). There was no statistically significant difference in Djian-Annonier's angle before and after surgery. The mean pre-operative AOFAS was 42.8 (range 32-51). The scores at 15 days, six weeks, and three months show a gradual increase up to 89.9 in the results with significant differences between the groups (p < 0.05). There was no difference between the scores after three months. CONCLUSION: Complete percutaneous plantar fasciotomy is simple and safe and allows a quick recovery to activity without impacting the MLA.

Hip fractures re-operation compared with death at two year in elderly patients: lowest risk of revision with dual mobility total hip arthroplasty than with bipolar hemiarthroplasty or internal fixation of Garden I and II.

PURPOSE: This study determined at two year follow-up the lifetime risk of re-operation for elderly patients with hip fractures undergoing internal fixation, dual mobility total hip arthroplasty, or bipolar hemiarthroplasty, using death of the patient as a competing risk. MATERIALS AND METHODS: With the hypothesis that arthroplasties may have less complications without increasing mortality even for Garden I and Garden II fractures, we retrospectively reviewed 317 hips with femoral neck fractures operated between January 2015 and August 2019. The mean age at time of surgical intervention was 82.4 years (range 65 to 105). Sixty patients presented a nondisplaced hip fracture (Garden I or II) treated by internal fixtion (I-F), and 257 were treated by hip arthroplasty: 118 dual mobility total hip arthroplasty (DM-THA) and 139 with a bipolar hemiarthroplaty (B-H). Demographics, surgical and complications data, and mortality were collected and compared for each group. RESULTS: The overall mortality rate was 22.4% at two years, and similar (p = 0.98) in all groups, respectively 22%, 22%, and 23% for DM-THA, B-H, and I-F groups. With dual mobility THA, the cumulative incidence of re-operations for any reason was (lower (9%) than with internal fixation (22%) or bipolar hemiarthroplasties (19%). CONCLUSION: Using a double mobility total prosthesis does not increase the post-operative mortality of the patients, nor does it increase their survival. But, reducing the risk of complications certainly improves their quality of life during the little time they have left .

Endoscopic fascia lata release for treatment of gluteal tendinopathy: a prospective study with a follow-up of 6 months to 1 year.

Greater trochanteric pain syndrome (GTPS) is clinically defined as greater trochanter pain with mechanical characteristics. The most common diagnosis is gluteal tendinopathy. Most cases of gluteal tendinopathy resolve with conservative management. In case of refractory pain endoscopic surgical treatment can resolved symptoms. This article presents a prospective study of endoscopic proximal fascia lata release associated to trochanteric bursectomy for recalcitrant trochanteric pain syndrome. 33 patients (35 hips) with refractory pain during more than six months were included. All patients were treated by endoscopic iliotibial band release and bursectomy according to Ilizaliturri. Outcomes were assessed by using Harris hip score and Womac hip score. Patients were follow-up until one year after surgery. The mean age was 53.7 years old, there was 9 men and 24 women. There were two bilateral cases in the female group. The average duration of conservative treatment was 20 months (CI95 9 to 31 months). 68% of patients were satisfied of the surgery with disappearance of pain after surgery. WOMAC and Harris hip score significantly improved after surgery until 6 months (respectively from 67 to 29 and from 40 to 76 - p<0.05). No complication was reported. Age, body mass index and duration of conservative treatment did not influence surgical results. This study showed that the endoscopic ilio tibial band (ITB) release and trochanteric bursectomy is simple, safe and easily reproductible but future prospective studies with a larger number of patients are required.

The Dark Age of medieval surgery in France in the first part of Middle Age (500-1000): royal touch, wound suckers, bizarre medieval surgery, monk surgeons, Saint Healers, but foundation of the oldest worldwide still-operating hospital.

PURPOSE: During the Middle Ages, the Christian church established itself as the dominant force over all aspects of medieval life, including the practice of medicine. As the Church's influence expanded across Europe, the role of lay practitioners in medicine declined, and clerics gradually assumed the role of healers in surgical practice as the cure of the soul was felt to take precedence over cure of bodily ills. MATERIAL AND METHODS: A retrospective analysis of hospital foundation, old-school surgical techniques still used today was performed during the first part of the Middle Age. RESULTS: The Hospital Hotel Dieu in Paris was founded and remains the oldest worldwide still-operating hospital. The monastery became a resting place for travelers, as well as a place of refuge for the sick. As this role expanded, monks often developed considerable surgical expertise. This led to fierce competition for saintly relics and pilgrims. Among the myriad of saints to whom powers of healing were ascribed, the names of Damian and Cosmas figure prominently in medical history. Old-school medieval surgery was also performed with some bizarre techniques such as lip service by wound suckers, cautery, blood-letting, leech therapy, and maggot therapy. CONCLUSION: This account of surgery before it became scientific is based on a chronology that runs from the Clovis baptism to the reign of Charlemagne; much of the medicine in this period was based on ancient doctrines; indeed, much of the development of medicine in the period called as "Dark Age" was due to the slow and difficult business of recovering and trying to understand ancient medicine.

Medieval surgery (eleventh-thirteenth century): barber surgeons and warfare surgeons in France.

PURPOSE: From the eleventh to the thirteenth century, three major events marked surgery in France: the appearance of an epidemic linked to ergotism which led to numerous amputations, the emergence of barber surgeons for civilian practice, and the organization of war surgery for the First Crusade. MATERIAL AND METHODS: If a certain separation between medicine and surgery had appeared at the beginning of the Middle Ages, it would have been from 1215 (at the time of the Lateran Council) that the real separation between medicine and surgery was made. Before this date, the surgery was done by the clergy (monks) who had some experience of surgical practice. After the Council de Lateran, the barbers will take charge of the surgery. RESULTS: In the Middle Ages, the first cause of amputation was linked to poisoning by ergot of rye, intoxication due to the ingestion of contaminated bread. Due to ergotamine-related vasoconstriction, many patients will die with a frequency ranging from 10 to 20% in times of starvation. For survivors, gangrenes will lead to amputations made at the beginning by monks, then by the barber surgeons after 1215. With the name of barber surgeon, barbers are initially responsible for small surgical procedures, then for amputations given the epidemics linked to ergotism which led to numerous amputations. By this practice, they will acquire the knowledge of anatomy and the knowledge of the surgery. Apart from this civilian practice of surgery carried out by barber surgeons, the military practice of surgery will appear with the conquests of England and the start of the crusades which will require a more professional organization of surgery. CONCLUSION: After 1371, as only barbers surgeons had some surgical practice, their knowledge surpassed knowledge of the university. This supremacy of the barber surgeon over the surgeons of the university will be demonstrated by Ambroise Paré.

Mesenchymal stem cell therapy improved outcome of early post-traumatic shoulder osteonecrosis: a prospective randomized clinical study of fifty patients with over ten year follow-up.

PURPOSE: Post-traumatic osteonecrosis of the humeral head has a risk of progression to collapse in absence of treatment. The purpose of this study was to evaluate the results of mesenchymal stem cell grafting of the pre-collapse humeral head (study group) in adult patients with osteonecrosis and to compare the results with a simple core decompression without cells (control group). Patients After inclusion and randomization of 50 patients, 26 patients were enrolled in a single-blinded study for the cell therapy group. Twenty-four other patients were treated with simple core decompression without cells (control group). MATERIAL AND METHODS: After a mean of 12-year (range 10 to 15) follow-up, X-ray and MRI were used to evaluate the radiological results, while the Constant score and the visual analog scale were chosen to assess the clinical results. The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow concentration. The average total number of MSCs (counted as the number of colony-forming units-fibroblast) injected in each humeral head was a total injection of average 180,000 ± 35,000 cells (range 74,000 to 460,000). RESULTS: Both the treatment and control groups had a significantly improved clinical score (p < 0.01). At the last follow-up, pain on the visual analog scale and Constant score in the study group had significant improvement (respectively p < 0.001 and p < 0.01) as compared to the control group. Collapse was observed more frequently in the control group (87.5% versus 11.5% for cell therapy, p < 0.0001). The survival rates based on the requirement for further shoulder surgery (arthroplasty) as an endpoint were higher in the cell therapy group in comparison to those in the control group (92% versus 25%; p < 0.0001). CONCLUSION: Core decompression with cell therapy was a safe and effective procedure for treatment in the pre-collapse stages of posttraumatic shoulder osteonecrosis and improved the outcome of the disease as compared with simple core decompression without cells.

Digital twins, artificial intelligence, and machine learning technology to identify a real personalized motion axis of the tibiotalar joint for robotics in total ankle arthroplasty.

PURPOSE: Axial alignment of the talar implant in total ankle arthroplasty remains a major issue, since the real axis of motion of each patient is impossible to determine with usual techniques. Further knowledge regarding individual axis of motion of the ankle is therefore needed. MATERIAL AND METHODS: Therefore, digital twins, artificial intelligence, and machine learning technology were used to identify a real personalized motion axis of the tibiotalar joint. Three-dimensional (3D) models of distal extremities were generated using computed tomography data of normal patients. Digital twins were used to reproduce the mobility of the ankles, and the real ankle of the patients was matched to the digital twin with machine learning technology. RESULTS: The results showed that a personalized axis can be obtained for each patient. When the origin of the axis is the centre of mass of the talus, this axis can be represented in a geodesic system. The mean value of the axis is a line passing in first approximation through the centre of the sphere (with a variation of 3 mm from the centre of the mass of the talus) and through a point with the coordinates 91.6° west and 7.4° north (range 84° to 98° west; - 2° to 12° north). This study improves the understanding of the axis of the ankle, as well as its relationship to the possibility to use the geodesic system for robotic in ankle arthroplasty. CONCLUSION: The consideration of a personalized axis of the ankle might be helpful for better understanding of ankle surgery and particularly total ankle arthroplasty.

Vitamin C prevention of complex regional pain syndrome after foot and ankle surgery: a prospective randomized study of three hundred and twenty nine patients.

PURPOSE: Complex regional pain syndrome (CRPS) after foot and ankle surgery has a significant impact on the ability to walk. As the symptomatic treatment of this disaster complication is poor and has low efficacy, a preventive treatment would be beneficial. Vitamin C has been reported to be efficient in preventing CRPS in elective scheduled surgery. Few authors explored this efficiency in foot and ankle surgery. We, therefore, evaluated the efficacy of vitamin C in preventing this complication after foot and ankle surgeries for both trauma and elective surgery. MATERIAL AND METHODS: Between January 2018 and December 2019, 329 patients were included in the study. We conducted a prospective randomized study on the efficiency of vitamin C (one group with and one without vitamin C) to prevent CRPS risk in patients operated in our institution on foot or ankle surgery. The incidence of CRPS after foot and ankle surgery was evaluated in both groups; the diagnostic of CRPS was made using the Budapest criteria associated with three-phase bone scintigraphy. RESULTS: Among the 329 patients included in the study (232 women and 97 men), 121 patients were included in the vitamin C group and 208 in the control group (without vitamin C). Vitamin C was statistically linked with a decreased risk of CRPS (OR 0.19; CI 95% from 0.05 to 0.8; p = 0.021). Alcoholism and cast immobilization were increased risks factors of CRPS (respectively p = 0.001 and p = 0.034). CONCLUSION: Taking 1 g per day of vitamin C during 40 days after a foot or ankle surgery reduces the risk of CRPS.

Role of Scaffolds, Subchondral, Intra-Articular Injections of Fresh Autologous Bone Marrow Concentrate Regenerative Cells in Treating Human Knee Cartilage Lesions: Different Approaches and Different Results.

The value of bone marrow aspirate concentrates for treatment of human knee cartilage lesions is unclear. Most of the studies were performed with intra-articular injections. However, subchondral bone plays an important role in the progression of osteoarthritis. We investigated by a literature review whether joint, subchondral bone, or/and scaffolds implantation of fresh autologous bone marrow aspirate concentrated (BMAC) containing mesenchymal stem cells (MSCs) would improve osteoarthritis (OA). There is in vivo evidence that suggests that all these different approaches (intra-articular injections, subchondral implantation, scaffolds loaded with BMAC) can improve the patient. This review analyzes the evidence for each different approach to treat OA. We found that the use of intra-articular injections resulted in a significant relief of pain symptoms in the short term and was maintained in 12 months. However, the clinical trials indicate that the application of autologous bone marrow concentrates in combination with scaffolds or in injection in the subchondral bone was superior to intra-articular injection for long-term results. The tendency of MSCs to differentiate into fibrocartilage affecting the outcome was a common issue faced by all the studies when biopsies were performed, except for scaffolds implantation in which some hyaline cartilage was found. The review suggests also that both implantation of subchondral BMAC and scaffolds loaded with BMAC could reduce the need for further surgery.

Role of Matrix-Associated Autologous Chondrocyte Implantation with Spheroids in the Treatment of Large Chondral Defects in the Knee: A Systematic Review.

Autologous chondrocyte implantation (ACI) is a cell therapy for the treatment of focal cartilage defects. The ACI product that is currently approved for use in the European Union (EU) consists of spheroids of autologous matrix-associated chondrocytes. These spheroids are spherical aggregates of ex vivo expanded human autologous chondrocytes and their self-synthesized extracellular matrix. The aim is to provide an overview of the preclinical and nonclinical studies that have been performed to ensure reproducible quality, safety, and efficacy of the cell therapy, and to evaluate the clinical data on ACI with spheroids. A systematic review was performed to include all English publications on self-aggregated spheroids of chondrocytes cultured in autologous serum without other supplements. A total of 20 publications were included, 7 pre- and nonclinical and 13 clinical research publications. The pre- and nonclinical research publications describe the development from concept to in vivo efficacy and quality- and safety-related aspects such as biodistribution, tumorigenicity, genetic stability, and potency. The evaluation of clinical research shows short- to mid-term safety and efficacy for the ACI with spheroid-based treatment of cartilage defects in both randomized clinical trials with selected patients, as well as in routine treatment providing real-world data in more complex patients.

Long-term follow-up of the incisional hernia rate after single-incision laparoscopic cholecystectomy: a prospective observational study.

PURPOSE: To evaluate the long-term occurrence rate of incisional hernias following single-incision laparoscopic cholecystectomy (SILC). BACKGROUND: Since the 90 s, SILC has emerged as a less invasive alternative to standard laparoscopic cholecystectomy in selected patients. But concerns over port-incisional hernias have not been addressed. METHODS: Between February 2009 and February 2011, 142 patients referred for gallstones who agreed to undergo SILC were included in a monocenter prospective observational study. All of the procedures were carried out using a single-port access technique. The occurrence rates of incisional hernias were analyzed with the Kaplan-Meier actuarial method. Statistical significance was set at p < .05. RESULTS: A total of 142 patients with gallbladder pathology were included in the study; 138 of them underwent SILC and 4 were converted to standard multiport cholecystectomy. Twelve patients (8%) were found to have developed a port-site incisional hernia (PSH) by physical examination or by imaging. The Kaplan-Meier curve showed that the rate of PSH development was 83% in the first 2 years after surgery. After 2 years, this risk becomes quite low. CONCLUSIONS: Our results indicate that the SILC procedure is a safe option for treatment of benign gallbladder diseases for selected patients, albeit with a high incisional hernia rate.

Computer Navigation Technique for Simultaneous Total Knee Arthroplasty and Opening Wedge High Tibial Osteotomy in Patients with Large Tibial Varus Deformity.

INTRODUCTION: Total knee arthroplasty (TKA) in patients with established knee osteoarthritis and major varus, mostly due to constitutional proximal deformity, remains a challenging procedure. Orthogonal cuts result in asymmetric bone resection and subsequent bone-related laxity or difficult release. A procedure that combines opening high tibial osteotomy (HTO) and TKA in the same sitting to address such major deformities is possible. But for this combined operation, precise planning and an exact intraoperative transformation of the planning is required. The assumption that the results could be predicted better by means of a navigation system was analyzed. MATERIALS AND METHODS: The precision of surgery with computer-based navigation was compared to conventional surgery. A comparative prospective study was conducted using an expert surgeon. Between 2005 and 2015, we performed 20 procedures on knees with average preoperative 18° (range, 15-25°) varus. Tibial valgus osteotomy plus TKA was performed in one sitting. It allows the surgeon to do a more sparing medial release and to achieve proper realignment with a concomitant well-balanced prothesis. A group of 10 patients had conventional surgery and the other 10 had surgery performed with computer-based navigation for both osteotomy and TKA. By means of this system, the desired mechanical axis is obtained with real-time monitoring of the coronal and sagittal plane on the navigation without intraoperative x-ray control. The positioning of the saw-jigs for the femoral and tibial cuts of the arthroplasty was also performed with the help of the navigation system. RESULTS: Postoperative mean femorotibial varus was 1.5° (range, 0-5°) with better alignment for the computer-based navigation. The mean correction following osteotomy was 16° (range, 12-24°). The intraarticular part of the deformity due to cartilage wear was addressed by the TKA. No release was done during surgery. The patients were mobilized early with limitation in range of motion up to 90° of flexion during the two weeks and were allowed full weight after. No instability and no complications were observed. On assessing radiological coronal alignment of the prostheses, there was better alignment of 0.5° varus (range, 0-3° of varus) in the computer navigation group compared to the traditional group (2.5° varus; range, 1-5° of varus). The navigation group showed better tibial slope maintenance (mean change, + 0.5°, p=0.732), whereas it was increased significantly in the conventional group (mean change, +4.2°, p<0.01). The average number of fluoroscopy shots for the computer navigation group was 2.8 (95% CI, 1.2-6.5) versus 9.4 in the control group (95% CI, 5.3-12.4). This represented a shorter (p<0.001) time of 11.4 seconds of irradiation for the computerized navigation technique compared to 36.2 seconds of irradiation for the traditional technique. CONCLUSIONS: Computer navigation improved precision with less radiation. The findings of this study suggest that computer navigation may be safely used in a complex procedure when combined with total knee arthroplasty and opening wedge high tibial osteotomy in one sitting.

Staying home during "COVID-19" decreased fractures, but trauma did not quarantine in one hundred and twelve adults and twenty eight children and the "tsunami of recommendations" could not lockdown twelve elective operations.

PURPOSE: The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, fractures still need to be treated, as some patients with non-deferrable pathologies. The aim of this paper is to report the early experience of an integrated team of orthopaedic surgeons during this period. MATERIAL AND METHODS: This is a mono-geographic, observational, retrospective, descriptive study. We collected data from the beginning of the epidemic (1 March 2020), during the pandemic lockdown period (declared in the country on March 16, 2020) until the end of our study period on April 15, 2020. All the 140 patients presented to the Emergency Department of the hospital during this period with a diagnosis of fracture, or trauma (sprains, dislocations, wounds) were included in the cohort. In addition, 12 patients needing hospitalization for planning a non-deferrable elective surgical treatment were included. A group of patients from the two same hospitals and treated during the same period (1st March 2018 to April 15, 2018) but previously was used as control. RESULTS: Of these 152 patients (mean age 45.5 years; range 1 to 103), 100 underwent a surgical procedure and 52 were managed non-operatively. Twenty-eight were children and 124 were adults. The COVID-19 diagnosis was confirmed for four patients. The frequency of patients with confirmed COVID-19 diagnosis among this population treated in emergency was ten fold higher (2.6%; 4 among 152) than in the general population (0.30%) of the country. The mortality rate for patients with surgery was 2% (2 of 100 patients) and 50% (2 of 4) for those older than 60 years with COVID-19; it was null for patients who were managed non-operatively. As compared to the year 2018, the number of patients seen with trauma had decreased of 32% during the epidemic. CONCLUSION: Staying home during the COVID-19 pandemic decreased trauma frequency of 32%. The structural organization in our hospital allowed us to reduce the time to surgery and ultimately hospital stay, thereby maximizing the already stretched medical resources available to treat all the patients who needed orthopedic care during this period.

Post-COVID-19 return to elective orthopaedic surgery-is rescheduling just a reboot process? Which timing for tests? Is chest CT scan still useful? Safety of the first hundred elective cases? How to explain the "new normality health organization" to patients?

PURPOSE: The long incubation period and asymptomatic spread of COVID-19 present considerable challenges for health care institutions when patients return to elective surgery. METHODS: A retrospective review of the first adult elective cases performed between May 18, 2020 and June 14, 2020, after the end of lockdown was analysed in Belgium to answer the following questions: (1) for the 236 cancelled patients during the outbreak, how easy was rescheduling? (2) How useful was universal RT-PCR testing and chest CT scan for the 211 orthopaedic and trauma admissions? (3) How were surgical difficulty category, number of operations and complications different when compared to the pre-COVID period? (4) How would patients balance the benefit of surgery against the unknown risk of developing COVID-19? RESULTS: Before surgery, blood tests for anaesthesiology and imaging related to the surgical procedure were scheduled prior to universal testing (COVID-19 PCR and chest CT) performed 72-120 hours before surgery. Among the 211 asymptomatic patients who were tested before surgery, six had positive PCR, while no abnormality was found on the chest CT scan of all the patients. With this timing for tests, the 104 patients included in the current study for elective surgery were free of disease before undergoing surgery and remained without COVID-19 after surgery. Among the 366 cancelled patients during the outbreak, only 12% of the patients accepted to proceed with rescheduling immediately. Therefore, this resulted in a 70% reduction for elective surgery and in a 50% reduction for arthroplasties as compared to pre-COVID period. The rate of complications was not increased during the post-COVID period. A portion of patients have confused idea of screening and have difficulty to perceive the new rules of health organization. CONCLUSIONS: Resumption of elective surgical procedures appears more difficult for patients than for surgeons with a low percentage of cancelled patients accepting to reschedule surgery. Universal testing allowed securing patients; however, surgeons must explore better patient perceptions regarding COVID-19 to facilitate a fully informed decision in the current period.

Thoracic computerised tomography scans in one hundred eighteen orthopaedic patients during the COVID-19 pandemic: identification of chest lesions; added values; help in managing patients; burden on the computerised tomography scan department.

PURPOSE: Based on the recent literature, chest computed tomography (CT) examination could aid for management of patients during COVID-19 pandemic. However, the role of chest CT in management of COVID-19 patients is not exactly the same for medical or surgical specialties. In orthopaedic or trauma emergency, abdomen, pelvis, cervical, dorsal, and lumbar spine CT are performed to investigate patients; the result is a thoracic CT scan incorporating usually the thorax; however, information about lung parenchyma can be obtained on this thorax CT, and manifestations of COVID-19 can be diagnosed. The objective of our study was to evaluate this role in orthopedic patients to familiarize orthopaedists with the value and limits of thoracic CT in orthopaedic surgery. MATERIALS AND METHODS: Among the 1397 chest CT scans performed during the pandemic period from 1 March 2020 to 10 May 2020, in two centres with orthopaedic surgery, we selected all the 118 thoracic or chest CT performed for patients who presented to the Emergency Department of the hospital with a diagnosis of trauma for orthopaedic surgical treatment. Thirty-nine of these 118 patients were tested with PCR for the diagnosis of COVID-19 infection. Depending on clinical status (symptomatic or non-symptomatic), the information useful for the orthopaedist surgeon and obtained from the Chest CT scan according to the result of the PCR (gold standard) was graded from 0 (no or low value) to 3 (high value). The potential risks of chest CT as exposure to radiation, and specific pathway were analyzed and discussed. A group of patients treated during a previous similar period (1 March 2018 to 15 April 2018) was used as control for evaluation of the increase of CT scanning during the COVID-19 pandemic. RESULTS: Among the 118 patients with chest CT, there were 16 patients with positive COVID-19 chest CT findings, and 102 patients with negative chest CT scan. With PCR results as reference, the sensitivity, specificity, positive predictive value of chest CT in indicating COVID-19 infection were 81%, 93%, and 86%, respectively (p = 0.001). A useful information for the orthopaedic surgeon (graded as 1 for 71 cases, as 2 for 5 cases, and as 3 for 11 cases) was obtained from 118 chest CT scans for 87 (74%) patients, while the CT was no value in 30 (25%) cases, and negative value in one (1%) case. Roughly 20% of the total number of CT scanner performed over the pandemic period was dedicated to COVID-19, but only 2% were for orthopaedic or trauma patients. However, this was ten times higher than during the previous control period of comparison. CONCLUSION: Although extremely valuable for surgery management, these results should not be overstated. The CT findings studied are not specific for COVID-19, and the positive predictive value of CT will be low unless disease prevalence is high, which was the case during this period.