Vitamin E-enriched medium cross-linked polyethylene in total knee arthroplasty (VIKEP): clinical outcome, oxidation profile, and wear analysis in comparison to standard polyethylene-study protocol for a randomized controlled trial.

BACKGROUND: The gliding surface of total knee endoprostheses is exposed to high loads due to patient weight and activity. These implant components are typically manufactured from ultra-high molecular weight polyethylene (UHMWPE). Crosslinking of UHMWPE by ionizing radiation results in higher wear resistance but induces the formation of free radicals which impair mechanical properties after contact with oxygen. Medium-crosslinked UHMWPE enriched with vitamin E (MXE) provides a balance between the parameters for a sustainable gliding surface, i.e., mechanical strength, wear resistance, particle size, and oxidation stability. Therefore, a gliding surface for knee endoprostheses made up from this material was developed, certified, and launched. The aim of this study is to compare this new gliding surface to the established predecessor in a non-inferiority design. METHODS: This multicenter, binational randomized controlled trial will enroll patients with knee osteoarthritis eligible for knee arthroplasty with the index device. Patients will be treated with a knee endoprosthesis with either MXE or a standard gliding surface. Patients will be blinded regarding their treatment. After implantation of the devices, patients will be followed up for 10 years. Besides clinical and patient-related outcomes, radiological data will be collected. In case of revision, the gliding surface will be analyzed biomechanically and regarding the oxidative profile. DISCUSSION: The comparison between MXE and the standard gliding surface in this study will provide clinical data to confirm preceding biomechanical results in vivo. It is assumed that material-related differences will be identified, i.e., that the new material will be less sensitive to wear and creep. This may become obvious in biomechanical analyses of retrieved implants from revised patients and in radiologic analyses. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04618016. Registered 27 October 2020, https://clinicaltrials.gov/study/NCT04618016?term=vikep&checkSpell=false&rank=1 . All items from the World Health Organization Trial Registration Data Set can be found in Additional file 1.

Perioperative Iron Deficiency in Patients Scheduled for Major Elective Surgeries: A French Prospective Multicenter Cross-Sectional Study.

BACKGROUND: The management of perioperative iron deficiency is a component of the concept of patient blood management. The objective of this study was to update French data on the prevalence of iron deficiency in patients scheduled for major surgery. METHODS: The CARENFER PBM study was a prospective cross-sectional study in 46 centers specialized in orthopedic, cardiac, urologic/abdominal, or gynecological surgery. The primary end point was the prevalence of iron deficiency at the time of surgery (D-1/D0) defined as serum ferritin <100 µg/L and/or transferrin saturation (TSAT) <20%. RESULTS: A total of 1494 patients (mean age, 65.7 years; women, 49.3%) were included from July 20, 2021 to January 3, 2022. The prevalence of iron deficiency in the 1494 patients at D-1/D0 was 47.0% (95% confidence interval [CI], 44.5-49.5). At 30 days after surgery, the prevalence of iron deficiency was 45.0% (95% CI, 42.0-48.0) in the 1085 patients with available data. The percentage of patients with anemia and/or iron deficiency increased from 53.6% at D-1/D0 to 71.3% at D30 ( P < .0001), mainly due to the increase of patients with both anemia and iron deficiency (from 12.2% at D-1/D0 to 32.4% at D30; P < .0001). However, a treatment of anemia and/or iron deficiency was administered preoperatively to only 7.7% of patients and postoperatively to 21.7% (intravenous iron, 14.2%). CONCLUSIONS: Iron deficiency was present in half of patients scheduled for major surgery. However, few treatments to correct iron deficiency were implemented preoperatively or postoperatively. There is an urgent need for action to improve these outcomes, including better patient blood management.

A predictive score of high tibial osteotomy survivorship to help in surgical decision-making: the SKOOP score.

INTRODUCTION: The high tibial osteotomy (HTO) survival rate is strongly correlated with surgical indications and predictive factors. This study aims to assess HTO survival in the long term, to determine the main predictive factors of this survival, to propose a predictive score for HTO based on those factors. METHODS: This multicentric study included 481 HTO between 2004 and 2015. The inclusion criteria were all primary HTO in patients 70 years old and younger, without previous anterior cruciate ligament injury, and without the limitation of body mass index (BMI). The assessed data were preoperative clinical and radiological parameters, the surgical technique, the complications, the HKA (hip knee ankle angle) correction postoperatively, and the surgical revision at the last follow-up. RESULTS: The mean follow-up was 7.8 ± 2.9 years. The HTO survival was 93.1% at 5 years and 74.1% at 10 years. Age < 55, female sex, BMI < 25 kg/m2 and incomplete narrowing were preoperative factors that positively impacted HTO survival. A postoperative HKA angle greater than 180° was a positive factor for HTO survival. The SKOOP (Sfa Knee OsteOtomy Predictive) score, including age (threshold value of 55 years), BMI (threshold values of 25 and 35 kg/m2), and the presence or absence of complete joint line narrowing, have been described. If the scale was greater than 3, the survival probability was significantly lower (p < 0.001) than if the scale was less than 3. CONCLUSION: A predictive score including age, BMI, and the presence or absence of joint line narrowing can be a helpful in making decisions about HTO, particularly in borderline cases. LEVEL OF EVIDENCE: Retrospective cohort study.

Survival and radioclinical evaluation of the Optimys™ short stem at more than 6years' mean follow-up: A retrospective study of 108 cases.

INTRODUCTION: The short stems developed in recent years offer an interesting alternative to standard long stems. The Optimys™ short stem has been widely studied, but not according to the National Institute for Health and Care Excellence (NICE) criteria. We therefore conducted a retrospective study of Optimys™ at a minimum 5years' follow-up, to assess: (1) survival on NICE criteria, (2) complications, (3) functional results, and (4) subsidence, restoration of offset and bone remodeling. HYPOTHESIS: Optimys™ shows survival comparable to that of other non-cemented standard and short stems, with a<0.5% per year revision rate or<2.5% at 5years on NICE criteria. MATERIAL AND METHODS: A single-center retrospective study included 108 Optimys™ stems at a mean 76.5months' follow-up (range: 60-112months). Clinical [Harris, Oxford-12 and forgotten hip (French version: SHO-12) scores] and radiologic data were collected pre- and postoperatively. Analysis focused on implant survival, complications, functional results and radiological results (restoration of offset, bone remodeling, subsidence and osseointegration) and risk factors for stem migration. RESULTS: At a mean 76.5months' follow-up (range: 60-112months), Optimys™ survival was 97.7% (95% CI: 0.945-1). Oxford and Harris scores improved significantly: respectively, 16.1 vs. 44.7 [Δ=28.598; 95% CI: 27.410-29.785 (p<0.001)] and 45.3 vs. 95 [Δ=49.662; 95% CI: 47.442-51.882 (p<0.001)]. Mean forgotten hip score (SHO-12) at last follow-up was 82.7±19.6 (range: 35.4-100.0). There was 1 case of aseptic revision at 11months for femoral osseointegration defect. Mean subsidence was 1.64mm (range: 0-20.63mm); no predisposing factors could be identified. Femoral offset increased by a mean 2.41±4.53mm (range: -10.10 to 14.70mm). CONCLUSION: The present study reports good survival for the Optimys™ stem, which meets NICE criteria. Radiologic and clinical results were encouraging, with a low rate of subsidence, comparable to other series, but with increased femoral offset. LEVEL OF EVIDENCE: IV; retrospective cohort study.

Beneficial effect of a zirconium-nitride-coated implant in total knee arthroplasty revision for suspected metal hypersensitivity.

INTRODUCTION: Revision of total knee arthroplasty (rTKA) for suspicion of metal hypersensitivity (MHS) may require hypoallergenic implants. Results for coated implants have not been reported. The aim of the present study was to assess short-term results and survival of rTKA for MHS using a multilayer implant coating. HYPOTHESIS: Multilayer implant coating improves functional results in rTKA, with survival comparable to primary coated implants. MATERIAL AND METHODS: A single-center retrospective observational study included 28 patients (30 knees) undergoing rTKA for MHS using a coated implant between May 2011 and November 2016. Exclusion criteria comprised implant malpositioning and history of infection in the affected knee. Clinical and radiological results were assessed on the International Knee Society (IKS) and SF-36 functional scores and Ewald radiological score. Survival was calculated on Kaplan-Meier estimation. RESULTS: Mean follow-up was 3.8 years. Mean IKS score increased by 40.2 points (40%) [range, 28.1-52.3] (p<0.05). Mean range of motion increased by 17° [range, 9.5-24.5°] (p<0.05). Mean physical and mental SF-36 components were respectively 44.7 and 46.1. Survivorship was 93%. DISCUSSION: There was significant functional improvement after rTKA for MHS. There were no short-term complications related to the zirconium nitrate coating. However, studies with longer follow-up will be needed for confirmation. LEVEL OF EVIDENCE: IV; retrospective study.

Clinical and radiological results after revision THA with distal locking stem: A cohort study of 44 patients.

BACKGROUND: Distal locking stems were developed in response to some complex revision procedures in total hip arthroplasty (THA), providing better axial and rotational stability. The aim of the present study was to assess medium-term clinical and radiological results of treatment with last-generation distal locking stem. HYPOTHESIS: Our hypothesis was that this implant provided a high survival rate. MATERIAL AND METHODS: A single-center retrospective observational study included all patients who underwent THA revision with distal locking stem between April 2013 and January 2015 in our university hospital. The implant was a curved distal-locking stem fully coated in grit-blasted titanium alloy and hydroxyapatite (HA) with a collar made of TiAlV. This concept is based on primary distal fixation by interlocking screws. The primary endpoint was surgical revision for implant exchange. RESULTS: A total of 47 procedures with distal locking stem were performed, 44 of which were included. Minimum follow-up was 5 years. Etiologies of revision comprised 25 femoral loosenings, 13 periprosthetic fractures, 3 infections, and 3 modular taper breakages. Six patients underwent re-revision (13%), with only 1 implant change (98% survival rate). Mean Harris and Oxford Hip scores at last follow-up were respectively 81±13.5 [range, 67.4-94.5] and 26±9⋅2 [range, 16.7-35.2]. Radiologically, no stem subsidence occurred, and bone ingrowth was obtained in all cases. DISCUSSION: Fully-coated distal locking stems showed a high survival rate. They provided strong initial fixation, allowing early full weight-bearing in these frail patients. LEVEL OF EVIDENCE: IV; retrospective series.

French Hip & Knee Society classification of short-stem hip prostheses: Inter- and intra-observer reproducibility.

INTRODUCTION: In total hip replacement (THR), a short stem theoretically provides more physiological force transfer to the proximal femur, conserves bone stock and facilitates minimally invasive surgery. On the other hand, such implants involve a learning curve and incur risk of malpositioning or fracture and of secondary mobilization. There are several types of short stem, and classification is needed. Classifications exist, but are based more on implant length than on anchorage zone, and most have not been tested for reproducibility. The French Hip & Knee Society (SFHG) developed a short-stem classification based on anchorage zone inside the femur. The objectives of the present study were: (1) to present the classification, (2) to apply it to the short-stem models available in France and those widely used worldwide, and (3) to assess reproducibility. HYPOTHESIS: The SFHG short-stem classification enables reproducible comparison. MATERIAL AND METHOD: A short-stem classification according to anchorage zone was drawn up by an expert group. The stems and the classification were presented to 12 surgeons performing THR, who classified the stems according to the classification; a retest was performed 2 months later. RESULTS: The classification is based on femoral stem anchorage site, in 5 types: type 1, cephalic; type 2, isolated cervical; type 3, Calcar femorale; type 4, metaphyseal; and type 5, conventional metaphyseal-diaphyseal, with shortened stems. Inter-observer reproducibility was 92.7% [95%CI: 91.7%-93.6%], with kappa 0.785 [95%CI: 0.755-0.814], and Lin test-rest concordance correlation coefficient 0.852 [95%CI: 0.836-0.869]. Intra-observer reproducibility was 94.0% [95%CI: 91.9%-96.1%], with kappa 0.820 [95%CI: 0.759-0.882], and Lin test-retest concordance correlation coefficient 0.820 [95%CI: 0.792-0.849]. DISCUSSION: This new classification enables femoral implants to be reproducibly compared according to anchorage zone. LEVEL OF EVIDENCE: IV; retrospective study without control group.

Comparison of periprosthetic bone mineral density between two types of short-stems in total hip arthroplasty with a mean follow-up of 4 years.

INTRODUCTION: The use of short stems in primary hip arthroplasty has grown considerably in recent years, with a large variety of designs and stabilization methods available. Few studies have directly compared how these designs and fixation modes influence the bone mineral density (BMD) that is said to be better preserved with shorter implants. This led us to carry out a medium-term retrospective comparative study to (1) specify how the design of two different types of short stems influences the periprosthetic BMD, (2) compare the radiological and clinical outcomes of these stems. HYPOTHESIS: The periprosthetic BMD of a short stem varies based on the implant's design. MATERIALS AND METHODS: Ninety-three patients underwent total hip arthroplasty (THA) with a short stem between July 2012 and July 2014. Two groups of patients were formed: Vitae™ short stem (Adler Ortho, Milan, France), Optimys™ short stem (Mathys, Bettlach, Switzerland). The Vitae group consisted of 46 patients, while the Optimys group consisted of 47 patients. The mean age was 66 years, and the mean body mass index (BMI) was 26 kg/m2. The groups had comparable age, BMI, sex, Harris Hip score and preoperative radiological features. Periprosthetic BMD of the two types of implants was determined between the 1st and 4th year postoperative using dual-energy x-ray absorptiometry (DEXA) in the Gruen zones. The radiological and clinical outcomes were also determined. RESULTS: There was a significant decrease in BMD in zone 7(-5.8%±0.1 CI95%[-0.09; -0.02] (p=0.003)), zone 2 (-4.8% ±0.1 CI95%[-0.093; -0.003] (p=0.038)) and zone 6 (-11% ±0.2 CI95%[-0.19; -0.03] (p=0.009)) in the patients with Vitae stems and in zone 2 (-13.7%±0.3 CI95%[-0.25; -0.03] (p=0.018)) in the patients with Optimys stems. A significant difference in BMD in zone 7 at 1 year (p=0.014) and 4 years (p=0.001) postoperative and in zone 6 (p=0.011) at 4 years postoperative existed between groups, with the Optimys group having higher BMD. There was a significant increase in femoral offset in the Optimys group but not the Vitae group: Δoffset=-0.50 mm±5.2 CI95%[-2.05; 1.05] (p=0.522) and Δoffset=2.79 mm±4.2 CI95%[1.21; 4.37] (p=0.001). The Harris Hip score was not significantly different between the two groups at 4 years postoperative (95.3±2.5 [88; 99] vs. 95.2±2.6 [88; 99] (p=0.991)). DISCUSSION: The design of short stems appears to influence the distribution of loads and the periprosthetic BMD. These stems are associated with very good radiological and clinical results in the medium term. Bone remodeling appears to continue beyond 1 year after the THA procedure. LEVEL OF EVIDENCE: III; Retrospective case-control study.

Sleep Deprivation Adversely Impacts Resident Performance for Simulated Arthroscopy.

PURPOSE: The purpose of the study was to assess the performance of residents in orthopaedics before and after a 24-hour shift on a shoulder arthroscopy simulator. The primary study endpoint was an overall performance score (OPS) generated by the simulator. METHODS: A prospective, comparative study of 120 simulator trials by 10 resident junior surgeons was performed in our university hospital's simulation center between May and November 2018. To avoid memorization bias, all participants performed the same exercise 10 times on a VirtaMed ArthroS simulator prior to the study. Each resident's performance (the OPS, the operating time, the proportion of procedures with iatrogenic lesions, the camera path length and the hook path length) in two different simulated arthroscopy exercise tasks was assessed once before and once after a 24-hour shift. This sequence was performed three times during the semester, and the change over time in performance was also evaluated. RESULTS: The OPS was significantly lower after the night shift (P = 0.035 for the first exercise, and P = 0.025 for the second). CONCLUSION: In a group of previously trained resident junior surgeons, overall performance with an arthroscopy simulator was significantly worse after a 24-hour shift. The study of secondary parameters of the OPS and the subgroup analysis based on the sleep time and Epworth score vary depending on the type of exercise performed arthroscopically. However, the use of a simulator after a night shift did not prevent the trainee from improving his/her level of performance over time. LEVEL OF EVIDENCE: II, a prospective, comparative study.

Diagnostic value of the hourglass biceps test for the detection of intra-articular long head of the biceps hypertrophy.

BACKGROUND: Shoulder surgeons performing tenodesis note a great variability in morphology of the proximal biceps. The hourglass biceps test measures the integrity of the intra-articular biceps tendon. The hourglass maneuver (HM) is positive when there is a passive flexion deficit compared to the contralateral shoulder in a relaxed patient in the supine position. HYPOTHESIS: Preoperative HM is correlated with an increased width of the biceps portion resected during tenodesis. METHODS: This prospective study evaluated all patients (N = 58) who underwent biceps tenodesis between January and September 2019. Two groups of patients were compared: group 1 (n = 20) had a positive HM and group 2 had a negative HM (n = 38). The smallest (s) and largest (L) width of the tendon were measured intraoperatively, and the L/s ratio was calculated. The HM was then evaluated as a diagnostic test by creating a contingency table and determining the sensitivity and specificity of the test for different L/s ratios. A receiver operating characteristic curve was created and the area under the curve (AUC) was calculated. RESULTS: A nonsignificant difference was found between the mean largest biceps width in group 1 compared to group 2 (11.65 mm [range: 5-21] vs. 9.71 mm [range: 6-20], respectively; P < .05). The AUC was 0.81; the sensitivity was 68.9% and specificity, 80.8%. CONCLUSION: Preoperative positivity of the HM is linked to the increased width of the biceps portion resected during tenodesis. The hourglass biceps test should be predictive of intraoperative hourglass biceps according to our definition.

Fast track protocol for primary total hip arthroplasty in non-trauma cases reduces the length of hospital stay: Prospective French multicenter study.

BACKGROUND: Fast-track (FT) procedures continue to evolve; however, their benefits are still controversial. This led us to conduct a prospective study of FT procedures for total hip arthroplasty (THA) on a national scale in France with historical control data. The aims were to (1) evaluate the effectiveness of FT procedures after THA on the length of hospital stay (LOS) in a multicenter analysis, (2) measure the immediate return to home, rehospitalization and reoperation rates. HYPOTHESIS: FT procedures reduce the LOS after primary THA for non-traumatic indications relative to national historical data. METHODS: A prospective observational study was done at 11 hospital facilities throughout France. Patients who underwent primary THA for a non-traumatic condition and FT procedures were followed for 3 months. The average LOS, discharge to home, unexpected readmissions, and reoperation rate were compared to 2016 figures from the French national database of 104,745 procedures on the same population. RESULTS: The study included 1,110 patients, 499 men (45%) and 611 women (55%), with a mean age of 67.5±11.9 years. The average LOS was 3.3±2.9 days versus 7.5±5.3 days in the national database (p<0.001). Eight hundred eighty patients (79%) were discharged directly to home versus 72,577 (69%) in the national database (p<0.001). Forty-two patients (4%) were readmitted to the hospital within 90 days of the THA versus 11,092 (11%) in the national database (p<0.001). Eighteen patients (1.6%) were reoperated within 90 days of the THA procedure versus 2100 (2.0%) in the national database (p=0.72). DISCUSSION: FT procedures help to significantly reduce the average LOS and rehospitalization rate after primary THA for non-traumatic conditions and significantly increased the percentage of patients being discharged directly to home relative to national historical data, without altering the risk of reoperation. FT procedures should become the standard of care after THA. LEVEL OF EVIDENCE: III; prospective case-control study.

Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program.

INTRODUCTION: Prevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol. HYPOTHESIS: The risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol. METHODS: This was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months. RESULTS: Of the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA. DISCUSSION: The primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed. LEVEL OF EVIDENCE: IV; Prospective cohort study without control group.

Is patient-specific instrumentation more precise than conventional techniques and navigation in achieving planned correction in high tibial osteotomy?

INTRODUCTION: Preoperative planning in high tibial osteotomy (HTO) is a critical step for achieving the desired correction and a clinically satisfactory outcome. Conventional radiography, navigation assistance and patient-specific instrumentation (PSI) are the 3 means of planning, but no prospective studies have compared precision between the 3. The aims of the present study were: (1) to analyze and compare correction precision between the 3 planning approaches at 1 year's follow-up; (2) to compare results to those reported in the literature; and (3) to analyze factors influencing the achievement of planned correction. HYPOTHESIS: The study hypothesis was that PSI provides more precise and reproducible planned correction than conventional methods or navigation. MATERIAL AND METHOD: Between June 2017 and June 2018, a multicenter non-randomized prospective observational study was conducted in 11 centers. One hundred and twenty-six patients with Ahlbäck grade I, II or III idiopathic medial tibiofemoral osteoarthritis with stable knee were included and allocated to 3 preoperative planning groups: conventional (group 1), navigation (group 2) and PSI (group 3). Mean age at surgery was 51.2 years (range, 19-69 years; median, 53.2 years); 100 male, 26 female. Complete weight-bearing radiographic work-up was performed preoperatively and at 1 year's follow-up. The PSI group also underwent CT as part of guide production. Target angular correction and mechanical Hip-Knee-Ankle (HKA) axis were set preoperatively. The main endpoint was the difference between planned HKA and HKA at a minimum 12 months. RESULTS: Mean HKA difference was 1.1±3 in group 1, 2.1±2.6 in group 2 and 0.3±3.1 in group 3. Precision was better with PSI, but not significantly when comparing all 3 groups together. On pairwise intergroup comparison, there was a significant difference only between groups 2 and 3, in favor of PSI (P=0.011). DISCUSSION: None of the 3 techniques demonstrated superiority in achieving target correction at 1 year. The study hypothesis was thus not confirmed. All 3 techniques proved reliable and precise in HTO planning. LEVEL OF EVIDENCE: III, prospective non-randomized comparative study.

The Lefèvre retentive cup compared with the dual mobility cup in total hip arthroplasty revision for dislocation.

BACKGROUND: Limiting the risk of dislocation is one of the main aims of both dual mobility and Lefèvre retentive cups. However, these devices have never been compared. The goal of our study was to compare these devices in total hip arthroplasty revisions for instability. The judgement criterion was non-recurrence of dislocation in a follow-up period of eight years. METHODS: This retrospective case-control study compared two continuous paired series of total hip arthroplasty revisions for instability. These series included 63 patients and 159 patients with implantation of a Lefèvre retentive cup and a dual mobility cup, respectively. RESULTS: The success rate at eight years (i.e., no recurrence) was 91 ± 0.05% and 95 ± 0.02% in the Lefèvre retentive cup and dual mobility groups, respectively. The difference was not statistically significant (p = 0.6). CONCLUSION: It seems that the Lefèvre retentive cup provides comparable outcomes with the dual mobility cup in the total hip arthroplasty revisions for instability, avoiding recurrence in long term.

Femoral stem modularity.

Femoral stem modularity in hip replacement was first developed to connect a ceramic head to the stem, then extended to metal heads using the Morse taper principle. Is it a good thing, or a necessary evil? It contributes to improving lower limb length and lateralization setting, at the cost of fairly rare complications such as dissociation and fretting corrosion, which can exceptionally lead to ARMD (Adverse Reaction to Metal Debris). Modular necks were later recommended, with a double Morse taper: cylindrical for the head junction, and more or less flattened for the stem. Is this one modularity too far? Dual modularity in theory perfectly reproduces the biomechanical parameters of the hip, but is unfortunately associated with fractures and severe corrosion, leading to ARMD and pseudotumor, especially in Cr-Co necks. Moreover, it provides no functional advantage, and no longer has a role outside dysplasia and other femoral deformities. Metaphyseal-diaphyseal modularity is not widespread in primary implants, and is it really necessary? Only one model has been widely studied: S-Rom™ (Depuy®). It features a metaphyseal sleeve adapting to the anatomy of the proximal femur, with a stem fitted via an inverse Morse taper. Its only interest is in case of congenital dislocation; like all metal connections, it incurs a risk of fracture and corrosion. On the other hand, modularity is widely employed in revision implants. Does it really help these procedures? The connection between a proximal femoral component of variable geometry and a diaphyseal stem with press-fit distal fixation provides a real solution to problems of length, lateralization and anteversion. Early models encountered high rates of fracture, but current implants and rigorous surgical technique have reduced this risk. Corrosion is a less serious problem, as the Morse taper undergoes only axial stress, without the friction undergone by other models subject to varus stress.

A comparison of bone union and complication rates between locking and non-locking plates in distal fibular fracture: Retrospective study of 106 cases.

BACKGROUND: Ankle fractures represents the third most frequent fracture in elderly patients. There is a current tendency to fix long bones fractures with locking plates. However, we rarely find published accounts about the use of locking plates in distal fibula fractures, except for biomechanical ones, studying human cadaveric fibula. OBJECTIVES: The main objective was to compare radiographic bone union rates at 6 and 12 weeks of follow up, then wound complications and hardware removal rates, and construct cost. STUDY DESIGN & METHODS: We retrospectively analyzed 105 patients who underwent surgery with locking plates or non-locking plates over a two-year period, out of which 42 patients were treated with non-locking plates (VIVES™ - StrykerⓇ) and 63 with locking plates (VariAx™ - StrykerⓇ,). We analyzed bone union on anterior posterior and lateral X-rays of the ankle. We collected data of wound complications and hardware removal from patient records. Multiple linear regression techniques were performed after identifying dependent variables. RESULTS: There was no significant difference between non-locking and locking plates in the radiographic bone union rate of distal fibula, respectively at 6 and 12 post-operative weeks (85.71% vs. 81%; p = 0.525 and 97.62% vs. 96.83%; p = 1). No significant difference was found in the wound complication rate between the two groups (11.9% vs. 11.12%; p = 0.9). No significant differences were found in the hardware removal rate, either with or without operative site's infection (respectively: 30.95% vs. 39.68%; p = 0.361 and 21.42% vs. 38.09%; p = 0.071). Cost efficiency is in the favor of non-locking plates. CONCLUSION: Non-locking constructs are as effective as locking constructs in the treatment of displaced distal fibula fractures at a substantially lower cost. High-quality randomized controlled trials are needed in the future to verify the finding of this study.

Factors associated with hospital stay length, discharge destination, and 30-day readmission rate after primary hip or knee arthroplasty: Retrospective Cohort Study.

BACKGROUND: In France and in the US, predictions for 2030 include an increased number of total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures together with an overall trend towards shorter hospital stays. Predictors of hospital length of stay (LOS) include the day of surgery, discharge destination, and patient comorbidities. Available data are conflicting, however, and to our knowledge predictors of LOS after THA or TKA have not been evaluated in France. Improved knowledge of these predictors would be expected to increase patient care efficiency. The objectives of this study were: (1) to determine whether the above-listed factors predict LOS after THA or TKA, (2) to identify predictors of discharge to a rehabilitation unit and of readmission within 30 days after surgery. HYPOTHESIS: Both patient-related factors unamenable to modification and modifiable organisational factors are associated with LOS after THA or TKA. MATERIAL AND METHODS: This large single-centre retrospective cohort study included all adults who underwent primary THA or TKA at our university hospital between 1 January 2015 and 31 December 2016. Non-inclusion criteria were revision arthroplasty, THA with femoral or acetabular reconstruction, TKA using a constrained hinged implant, and fracture as the reason for arthroplasty. Preoperative parameters, type of arthroplasty, and postoperative care were recorded. RESULTS: We included 938 patients with THA and 725 patients with TKA. By multivariate analysis, the likelihood of being discharged by day 5 decreased with older age (HR, 0.986; 95%CI: 0.98-0.99) and was lower by 13% in females (HR, 0,871; 95%CI: 0.77-0.986), by 39% in patients with diabetes (HR, 0.606; 95%CI: 0.5-0.73), by 68% in patients discharged to rehabilitation units (HR, 0.322; 95%CI: 0.267-0.389), and by 27% in patients who had arthroplasty on a Friday (HR, 0.733; 95%CI: 0.631-0.852). Factors predicting discharge to rehabilitation unit were older age, female gender, chronic obstructive pulmonary disease, anxiety-depressive disorder, and a history of stroke. Risk factors for 30-day readmission were male gender, obesity, and discharge to rehabilitation unit. DISCUSSION: In this study, predictors of LOS were identified using a survival model that considered age as a continuous variable, separate comorbidities, and the discharge destination. Our findings are consistent with earlier reports and confirm the strong associations linking LOS to diabetes, day of surgery, and discharge destination in France. We also identified predictors of discharge to rehabilitation and of readmission within 30 days. LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

Does the direct anterior approach allow earlier recovery of walking following total hip arthroplasty? A randomized prospective trial using accelerometry.

INTRODUCTION: In total hip arthroplasty (THA), the anterior approach is attractive, being intermuscular, with theoretic functional benefit. Such benefit has been frequently claimed, but there are few data from randomized comparative studies using more precise metrics than patient satisfaction. We therefore conducted a randomized trial comparing early functional results between anterior and posterior approaches on gait analysis and functional scores. HYPOTHESIS: The study hypothesis was that there is no difference between the two approaches in terms of early recovery of walking. MATERIALS AND METHOD: A single-center single-surgeon prospective randomized study was conducted between February 2017 and April 2018. Inclusion criteria comprised: age<85 years, body-mass index (BMI)<32, and hip osteoarthritis with indication for THA. Preoperatively, the 2 groups were comparable for age, gender, BMI, Charnley, Harris, Postel-Merle-d'Aubigné and Oxford-12 scores and locomotor parameters (triaxial acceleration, step regularity and walking power). Preoperative and 3-, 6- and 12-week assessment comprised triaxial acceleration in walking and Postel-Merle-d'Aubigné, Harris and Oxford SF-12 scores. RESULTS: One hundred patients were randomized to the anterior approach (AA: n=50) and posterior approach (PA: n=50) groups. Hospital stay was comparable between groups: PA, 2.8±1.78 days [range, 2.29-3.31 days]; AA, 2.84±1.25 days [range, 2.48-3.2 days] (p=0.8). Operative time was significantly longer in AA: 70.1±11 minutes vs. 56.7±11.79 (p<0.0001). There were no significant differences in locomotor parameters (p 0.122 to 0.987) or functional scores (p 0.052 to 0.968) over the 3-month follow-up. There was no difference in cup inclination: PA, 39.6±6.87° [range, 37.65-41.55°] vs. AA, 37.74±4.2° [range, 36.55-38.93°] (p=0.09). There were 8/50 cases (16%) of neurapraxia of the lateral cutaneous nerve of the thigh in the AA group; rates for other complications did not differ between groups. CONCLUSION: Early functional results and especially objective locomotor parameters following THA were comparable between anterior and posterior approaches at 3 to 12 weeks. The approach should be chosen according to the surgeon's experience. LEVEL OF EVIDENCE: II, low-power prospective randomized study.