Reliability of the Harris Hip limping sub-score in patients undergoing total hip arthroplasty.

PURPOSE: In patients undergoing total hip arthroplasty, limping is a significant symptom, often assessed with the limping sub-score of the Harris Hip Score. However, the reliability of this sub-score has not been specifically investigated. The purpose of this study is to investigate the intra- and inter-rater reliability of this sub-score. METHODS: Thirty patients undergoing THA were recruited and performed a gait analysis before surgery and three months after surgery. In addition, 30 asymptomatic participants were included. In total, 90 visits were analysed in this study. The HHS limping sub-score was assessed for each visit using a video (front and back view side-by-side) of a ten metre walk at a self-selected speed. Two orthopaedic surgeons evaluated the limping of each video in two different grading sessions with a one week delay. To avoid recall bias, the patient's number identity was randomized and different for each grading session and each rater. The weighted Cohen's Kappa coefficient was used to quantify the intra- and inter-reliability. The reliability of three components was studied: the presence of limping, its severity, and the compensation type. RESULTS: For all components, the agreement for intra-rater reliability ranged from moderate to strong and from none to moderate for the inter-rater reliability. CONCLUSION: These results do not encourage the use of HHS-limping sub-score for data involving different raters in both clinical and research contexts. It calls for improved consensus on limping definitions or the creation of objective measures.

Rehabilitation protocol after suturing the medial meniscus of a stable knee, a retrospective series of the Francophone Arthroscopy Society.

INTRODUCTION: Surgical meniscal lesions are common and 80% of cases involve the medial meniscus of a stable knee. There is a lack of consensus regarding postoperative rehabilitation protocols and a wide variation between restrictive and accelerated rehabilitation protocols exists. The main objective of this study was to report the functional results and the failure rate of the various rehabilitation protocols of the retrospective series of the French Society of Arthroscopy (SFA) after suturing the medial meniscus of a stable knee, considering whether the tear is stable or unstable. HYPOTHESIS: Our hypothesis was that accelerated rehabilitation was not associated with an increased risk of failure. MATERIALS AND METHODS: This retrospective, multicenter study was conducted across 10 centers (6 private hospitals and 4 public hospitals) including all patients tested for a medial meniscus suture in a stable knee between January 1, 2005 and November 31, 2017 for a minimum follow-up of 5years. Demographic, imaging, suturing, rehabilitation protocol, and functional TEGNER and KOOS scores were collected. Failure was defined as performing a secondary meniscectomy. RESULTS: Three hundred and sixty-seven patients were analyzed with an average follow-up of 82months. Immediate weight bearing was allowed in 85% of cases, the wearing of a brace was present in almost 74% of cases and flexion was limited in 97% of cases. Inter-group comparisons found a higher suture failure rate in the group with immediate weight bearing (35.6% vs. 20%, p=0.011) and in the group with a brace (36.9% vs. 22.4%, p<0.001). There was no difference in the 90° flexion group. The TEGNER score was higher in the non-weight bearing group (6.5 vs. 5.4, p=0.028) and the KOOS QOL score was higher in the group without a brace (82.2 vs. 66.8, p=0.025). According to a multivariate analysis, immediate weight bearing (OR=3.6, [1.62; 7.98], p=0.0016) and wearing a brace (OR=2.83, [1.54; 5.02], p<0.001) were associated with a higher failure rate. In the group of stable lesions, the use of a brace (OR=3.73, [1.62; 8.56], p=0.0019) was associated with a higher failure rate. CONCLUSION: No consensus regarding rehabilitation protocols has been established to date and the results of this retrospective series of the SFA affirm the great variability of practices at a national level. Although accelerated rehabilitation protocols are presently favored, the resumption of immediate full weight bearing should be considered with caution, being associated with a higher risk of failure in this series. Deferring weight bearing for 1 month can be considered in the event of a large tear or in the event of damage to the circumferential fibers. Wearing a brace does not seem to have any influence, while limited flexion achieved a consensus. LEVEL OF EVIDENCE: IV, retrospective study.

[Dislocation after total hip arthroplasty : how to avoid it ?] / Luxations de prothèse de hanche : comment les éviter ?

Dislocation after hip replacement is a complication that can have dramatic consequences for the patient. The purpose of this article is to review the different parameters influencing stability and how to reduce this risk. The approach, the diameter of the femoral head, and the use of dual-mobility acetabular cups have led to a drastic reduction in the rate of dislocation, particularly in patients at risk, in cases of imbalance of the spino-pelvic complex, or in cases of revision surgery. The inclusion of patients in dedicated clinical pathways and participation in preoperative education sessions also contribute to the reduction of dislocation risk.

La luxation après prothèse de hanche est une complication qui peut avoir des conséquences dramatiques pour le patient. Cet article a pour but de revoir les différents paramètres influençant la stabilité prothétique et pouvant diminuer ce risque. La voie d'abord, le diamètre de la tête fémorale et l'usage de cotyles à double mobilité ont permis une diminution drastique du taux de luxation, en particulier chez les patients à risque, en cas de déséquilibre du complexe spino-pelvien ou en cas de reprise chirurgicale. L'inclusion des patients dans des itinéraires cliniques dédiés et la participation à des séances d'information préopératoire participent également à la réduction du risque de luxation.

Acetabular Peri-Prosthetic Fractures-A Narrative Review.

Acetabular peri-prosthetic fractures are rare but their incidence is rising due to the increased prevalence of total hip arthroplasty, the increasing life expectancy and the growing functional demand of an ageing population, the incidence of primary total hip arthroplasty is increasing. They are either intra-operative or post-operative and have various aetiologies. Several factors such as implant stability, bone loss, remaining bone stock, fracture pattern, timing, age and co-morbidities of the patients must be considered for adequate treatment. To date, the literature on this subject has been sparse and no universally recognized treatment algorithm exists. Their rarity makes them a little-known entity and their surgical management represents a challenge for most orthopaedic surgeons. This review aims to present an update on epidemiology, the diagnostic work up, existing classification systems, surgical approaches and therapeutic options for acetabular peri-prosthetic fractures.

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.

Long-term functional outcomes of multiligament knee reconstructions with lateral injuries.

INTRODUCTION: Multiligament knee injuries are a rare but serious injury, affecting functional prognosis. The objective of this study was to assess the long-term clinical and laximetric outcomes of acute or chronic multiligament knee reconstructions, with lateral impairment, using autografts. HYPOTHESIS: Autograft reconstructions give good long-term clinical and laximetric results. MATERIAL AND METHOD: A retrospective monocentric consecutive study was conducted in patients who had multiligament knee reconstructions. The criteria for inclusions were cruciate ligament lesions associated with lateral injuries, reconstructed using autografts, regardless of the time to surgery. A minimum follow-up of 5-years was required. Twenty-nine patients were analysed. The average age at surgery was 30.2±13 years. The patients were clinically reviewed at the last follow-up. Differential residual laxity was objectively assessed with comparative dynamic X-rays. Functional IKDC, Lysholm and KOOS scores were analyzed. RESULTS: The average follow-up was 7.5±1.7 years. The lesions were divided into 12 KD-I, 16 KD-IIIL and 1 KD-IV, including 16 acute lesions (time to surgery <30-day) and 13 chronic lesions. At the last follow-up, the objective IKDC identified: 3 stage A, 15 stage B and 11 stage C. The average scores were: subjective IKDC 70.1±16, Lysholm 76.8±14 and KOOS: pain 71.6±20, symptoms 83.6±22, activity 90.6±20, sport 58.8±23, quality of life 60.0±30. Dynamic X-rays showed an average differential laxity of 2.8±2.6mm anteriorly, 5.0±2.2mm posteriorly, and 2.0±2.5mm in varus. Four cases required surgery: 3 arthrolysis procedures for stiffness and 1 joint lavage for sepsis. DISCUSSION: With an average follow-up of 7.5 years, multiligament knee reconstructions using autografts with lateral involvement provide good long-term control of frontal and sagittal laxities. A comparison with allograft reconstructions is necessary to be able to potentially overcome the morbidity associated to donor sites. LEVEL OF EVIDENCE: IV; monocentric retrospective descriptive study.

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.

[Nailing of long bone fractures in precarious situations: focus on the Surgical Implant Generation Network (SIGN) nail]. / Enclouage des os longs en situation précaire: intérêt du clou SIGN (Surgical Implant Generation Network).

Economic development in low-income countries has led to a considerable increase in motor vehicles, in particular motorcycles. Traffic accident-related fractures are therefore increasing. The treatment of long bone fractures is, in the majority of cases, based on locked intramedullary nailing, a procedure which is rarely available in countries with poor sanitary conditions. To provide optimal treatment to these countries, the SIGN (Surgical Implant Generation Network) nail was developed in 1999 by Lewis Zirkle. It is currently used free of charge in 53 countries. In return, an international database must be completed in order to assess and develop it. In the light of our experiences in Haiti and Burundi and on the basis of a literature review, we here highlight the conceptual and technical features of SIGN nail whose implant in French-speaking countries is still limited.

Use of chest CT-scan images to differentiate between SARS-CoV-2 infection and fat embolism: A clinical case.

The authors present the case of a young man victim of a traffic accident during the SARS-CoV-2 confinement, having presented a fracture of the femoral shaft that was soon complicated by respiratory failure with oxygen desaturation. In this pandemic context, Covid-19 RT-PCR tests were carried out but returned negative. The CT images could suggest either a fatty embolism, a SARS-CoV-2 infection or both. The patient's condition improved significantly after going into intensive care and only symptomatic treatment. This case demonstrates the difficulty of differential interpretation of CT images between fatty embolism and SARS-CoV-2 infection.

Risk factors and mortality of patients undergoing hip fracture surgery: a one-year follow-up study.

Hip fracture (HF) remains a main issue in the elderly patient. About 1.6 million patients a year worldwide are victims of a HF. Their incidence is expected to rise with the aging of the world's population. Identifying risk factors is mandatory in order to reduce mortality and morbidity. The aim of the study was to identify risk factors of 1-year mortality after HF surgery. We performed an observational, prospective, single-center study at Amiens University Hospital (Amiens, France). After ethical approval, we consecutively included all patients with a HF who underwent surgery between June 2016 and June 2017. Perioperative data were collected from medical charts and by interviews. Mortality rate at 12 months was recorded. Univariate analysis was performed and mortality risk factors were investigated using a Cox model. 309 patients were analyzed during this follow-up. Mortality at 1 year was 23.9%. Time to surgery over 48 hours involved 181 patients (58.6%) while 128 patients (41.4%) had surgery within the 48 hours following the hospital admission. Independent factors associated with 1-year mortality were: age (HR at 1.059 (95%CI [1.005-1.116], p = 0,032), Lee score ≥ 3 (HR at 1,52 (95% CI [1,052-2,198], p = 0.026) and time to surgery over 48 hours (HR of 1.057 (95% CI [1.007-1.108], p = 0.024). Age, delayed surgical (over 48 hours) management and medical history are important risk factors of 1-year mortality in this French cohort.

Functional Validation of a New Alginate-based Hydrogel Scaffold Combined with Mesenchymal Stem Cells in a Rat Hard Palate Cleft Model.

BACKGROUND: One of the major difficulties in cleft palate repair is the requirement for several surgical procedures and autologous bone grafting to form a bony bridge across the cleft defect. Engineered tissue, composed of a biomaterial scaffold and multipotent stem cells, may be a useful alternative for minimizing the non-negligible risk of donor site morbidity. The present study was designed to confirm the healing and osteogenic properties of a novel alginate-based hydrogel in palate repair. METHODS: Matrix constructs, seeded with allogeneic bone marrow-derived mesenchymal stem cells (BM-MSCs) or not, were incorporated into a surgically created, critical-sized cleft palate defect in the rat. Control with no scaffold was also tested. Bone formation was assessed using microcomputed tomography at weeks 2, 4, 8, and 12 and a histologic analysis at week 12. RESULTS: At 12 weeks, the proportion of bone filling associated with the use of hydrogel scaffold alone did not differ significantly from the values observed in the scaffold-free experiment (61.01% ± 5.288% versus 36.91% ± 5.132%; p = 0.1620). The addition of BM-MSCs stimulated bone formation not only at the margin of the defect but also in the center of the implant. CONCLUSIONS: In a relevant in vivo model of cleft palate in the rat, we confirmed the alginate-based hydrogel's biocompatibility and real advantages for tissue healing. Addition of BM-MSCs stimulated bone formation in the center of the implant, demonstrating the new biomaterial's potential for use as a bone substitute grafting material for cleft palate repair.

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.

Resection of a Rare Metacarpal Distal Condyle Osteoid Osteoma.

INTRODUCTION: Osteoid osteoma is a benign bone-forming tumor with young male predilection. It occurs predominantly in the long bones. In the hand, osteoid osteoma is more commonly located in the phalanges and carpal bones. The metacarpals are the least common site for osteoid osteoma. Pain is the most common symptom. It usually increases at night and responds to nonsteroidal anti-inflammatory drugs. CASE PRESENTATION: The authors report the excision of an osteoid osteoma lying at the distal condyle of a metacarpal bone of the left hand. The clinical and radiological findings are exposed as well as the surgical management of the lesion. Pain and swelling disappeared after surgery, and there was no evidence of recurrence at follow-up. DISCUSSION: They discuss this rare location and further radiological examination that was used leading to the diagnosis. The imputation of the traumatic factor has been discussed, along with the different therapeutic possibilities and the advantages of a total excision while preserving the integrity of the adjacent ligament and joint space. CONCLUSION: The surgical alternative appears to be a satisfying treatment for osteoid osteoma in this particular superficial location. Both the exact pathogenesis and the contribution of the traumatic factor remain unclear.

A Misdiagnosed Complication of a Metal-on-Metal Total Hip Arthroplasty.

INTRODUCTION: The enterobacterial genus Yersinia includes a number of human pathogens. Large-diameter, metal-on-metal prostheses are no longer used because of their high failure rate. Here, we describe the first case of Yersinia enterocolitica infection of a metal-on-metal total hip arthroplasty. CLINICAL EXAMINATION: A metal-on-metal prosthesis failed ten years after implantation. After surgical revision, bacteriological testing revealed the presence of a pathogenic strain of Yersinia enterocolitica. Combination antibiotic therapy resulted in a favorable clinical outcome. DISCUSSION: Three cases of hip arthroplasty infected with Yersinia enterocolitica have been described in the literature. The present case is the first infection of a metal-on-metal total hip arthroplasty. We suggest that the risk of infection is increased by the release of metal wear particles and their influence on the surrounding tissue. CONCLUSION: When a large-diameter, metal-on-metal total hip arthroplasty fails, the known complications associated with this type of prosthesis should not deter the physician from screening for an infectious process that requires specific treatment.