Dedicated locking plate reduces non-union risk in open ankle fusion in obese patients.

INTRODUCTION: Obesity is a growing public health concern. In ankle osteoarthritis, non-conservative treatment in advanced stages consists in ankle fusion, or else total ankle replacement, for which obesity is a relative contraindication. One of main complications of ankle fusion is non-union. Devascularization, obesity and fixation material are all factors involved in postoperative non-union, and have to be taken into account in surgical strategy for reliable results. The objective of this study was to compare the rate of ankle non-union in obese patients using quadruple screwing or a dedicated locking plate. The hypothesis was that the locking plate limits the risk of non-union in this population. METHODS: All patients were obese (BMI>30kg/m2) and presented ankle osteoarthritis with>10° intra-articular deformity. The approach and joint preparation were performed via an anteromedial approach. Group S was composed of 32 patients, operated on by quadruple screwing; group P comprised 10 patients operated on using a dedicated locking plate. The main endpoint was a significant difference in the rate of non-union between the 2 groups. The secondary endpoint was improvement in pre- and 6-month postoperative AOFAS score. RESULTS: Group S presented 31% non-union (10/32) and group P 0% (0/10) (p<0.05). Postoperative AOFAS score was significantly higher in group P: 67.8±10.4 [range, 40-92] vs. 83.1±8.0 [range, 64-92] (p<0.05). CONCLUSION: The dedicated anterior locking plate is a technique of choice for ankle fusion in obese patients with intra-articular deformity>10°, to limit the risk of non-union. LEVEL OF EVIDENCE: IV; retrospective study.

The "Metaizeau trick" to facilitate medullary pubic ramus screw insertion: A technical note.

Minimally invasive procedures have recently seen an increase in the treatment of pelvic ring disruptions and select acetabular fractures. Similar to ilio-sacral screws, the superior pubic ramus screw is becoming a preferred method for treating unstable pelvic ring fractures. While the osteology of the superior pubic ramus is well understood and has inherent variability, standard screw insertion techniques work effectively in most cases. If the anatomy prevents the standard approach, there are alternative methods that can be employed for successful screw placement, or there might be a need for an open reduction and internal fixation with plates. Such techniques can be material-intensive and time-consuming. In this paper, we introduce a straightforward method that utilizes the Metaizeau nail as a guide wire to facilitate screw insertion in most instances, termed the "Metaizeau trick". Metaizeau nails, commonly found in trauma centers, are designed to locate a pathway effortlessly using this method. LEVEL OF EVIDENCE: IV.

Validation of the postoperative Quality of Recovery-15 questionnaire after emergency surgery and association with quality of life at three months.

PURPOSE: The Quality of Recovery-15 (QoR-15) tool, validated for measuring postoperative recovery following scheduled surgeries, has not been psychometrically assessed in emergency contexts. Moreover, the QoR-15's associations with long-term outcomes remain underexplored. This study aimed to confirm the validity and reliability of the QoR-15 following emergency surgery and assess its association with three-month postoperative quality of life. METHODS: We conducted a prospective cohort study (August 2021-April 2022) on adult patients who underwent emergency surgery. The QoR-15 questionnaire was administered before surgery (H0) and at 24 hr (H24) and 48 hr (H48) after surgery. We examined the H24 score's associations with both the three-month quality of life, as assessed by the EQ-5D scale, and the number of days spent at home at 30 (DAH30) and 90 (DAH90) days. RESULTS: Of the 375 included patients, 352 (94%) completed the QoR-15 at H24 and 338 (90%) were followed up at three months. The population represented the following diverse surgical specialties: orthopedic (51%), gastrointestinal (27%), urologic (13%), and others (9%). The QoR-15 questionnaire confirmed all psychometric qualities (internal consistency, reproducibility, responsiveness, acceptability, construct, and convergent validities) in the emergency context. The average minimum clinical difference was 8.0 at H24. There was an association between QoR-15 at H24 and the three-month quality of life (r = 0.24; 95% confidence interval [CI], 0.14 to 0.34; P < 0.001), DAH30 (r = 0.33; 95% CI, 0.23 to 0.41; P < 0.001), and DAH90 (r = 0.31; 95% CI, 0.22 to 0.40; P < 0.001). CONCLUSION: The QoR-15 score is valid for measuring early postoperative recovery after emergency surgery. The H24 score significantly correlated with both the three-month quality of life and the number of days at home. STUDY REGISTRATION: ClinicalTrials.gov (NCT04845763); first submitted 11 April 2021.

RéSUMé: OBJECTIF: L'outil Quality of Recovery-15 (QoR-15), validé pour mesurer la récupération postopératoire après des chirurgies programmées, n'a pas fait l'objet d'une évaluation psychométrique dans des contextes d'urgence. De plus, l'association entre les réponses au QoR-15 et les devenirs à long terme demeure peu explorée. Cette étude visait à confirmer la validité et la fiabilité du QoR-15 après une chirurgie d'urgence et à évaluer son association avec la qualité de vie postopératoire à trois mois. MéTHODE: Nous avons mené une étude de cohorte prospective (août 2021-avril 2022) auprès de patient·es adultes ayant bénéficié d'une intervention chirurgicale d'urgence. Le questionnaire QoR-15 a été administré avant la chirurgie (H0), ainsi que 24 (H24) et 48 heures (H48) après la chirurgie. Nous avons examiné les associations du score à H24 avec la qualité de vie à trois mois, telle qu'évaluée par l'échelle EQ-5D, et le nombre de jours passés à la maison à 30 (DAH30) et 90 (DAH90) jours. RéSULTATS: Sur les 375 patient·es inclus·es, 352 (94 %) ont complété le QoR-15 à H24 et 338 (90 %) ont bénéficié d'un suivi à trois mois. La population représentait les diverses spécialités chirurgicales suivantes : orthopédique (51 %), gastro-intestinale (27 %), urologique (13 %) et autres (9 %). Le questionnaire QoR-15 a confirmé toutes les qualités psychométriques (cohérence interne, reproductibilité, réactivité, acceptabilité, construit et validités convergentes) dans le contexte de l'urgence. La différence clinique minimale moyenne était de 8,0 à H24. Il y avait une association entre le QoR-15 à H24 et la qualité de vie à trois mois (r = 0,24; intervalle de confiance à 95 % [IC], 0,14 à 0,34; P < 0,001), le DAH30 (r = 0,33; IC 95 %, 0,23 à 0,41; P < 0,001) et le DAH90 (r = 0,31; IC 95 %, 0,22 à 0,40; P < 0,001). CONCLUSION: Le score QoR-15 est valable pour mesurer la récupération postopératoire précoce après une intervention chirurgicale d'urgence. Le score à H24 était significativement corrélé à la fois à la qualité de vie à trois mois et au nombre de jours passés à la maison. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT04845763); soumis pour la première fois le 11 avril 2021.

In vitro comparative study of deformation of 3D-printed models using different polylactic acids treated by steam sterilization.

INTRODUCTION: 3D printing, which is becoming ever more widespread in orthopedic surgery, requires specific materials. Polylactic acid (PLA) is the most widely used in general-purpose 3D printing, but its thermosensitivity can be incompatible with sterilization. Even so, it is easy to use, inexpensive, non-toxic and biodegradable. Controversy surrounds its use. 3D printing of directly sterilizable PLA parts according to surgeons' needs would be highly advantageous, but doubts remain. We therefore performed an in vitro study to determine which PLAs resist steam sterilization regarding deformation. HYPOTHESIS: The study hypothesis was that, depending on make and shape, 3D-printed PLA parts can retain their properties after steam sterilization. MATERIAL AND METHODS: We selected 4 makes of PLA and used each to print 4 simple cubes and 4 complex shapes corresponding to cuboid bones. They were subjected to steam sterilization under normal French hospital conditions. The size of the cubes was measured before and after sterilization, using a digital caliper. RESULTS: Cuboid parts in HT-PLA and PLA-WANAO showed mean deformation of -0.02mm and -0.4mm, respectively after sterilization, the differences being non-significant (p=0.679 and p=0.241, respectively). Cuboid parts in PLA-SUNLU and PLA-G3D showed significant mean deformation: respectively, -1.37mm (p=0.026) and -35.03mm (p>0.001). Cubes in all types of PLA showed significant mean deformation: HT-PLA, -0.61mm (p=0.004); PLA-SUNLU, -2.70mm (p=0.002); PLA-G3D, -28.64mm (p>0.001); and PLA-WANAO, -1.33mm (p=0.010). DISCUSSION: The study confirmed recent findings that steam sterilization is feasible with certain PLA-printed parts, with deformations less than 1mm, and that choice of PLA is crucial for success. Computer-designed objects (here, cubes) did not resist sterilization without significant deformation. Analysis of resistance to various stresses was not performed, and therefore it cannot be claimed that the process could be used other than for printing anatomic parts. Use of 3D printing in French hospitals is probably a real source of innovation and improvement in care quality; however, a legal framework needs establishing for the use of 3D-printed parts, to ensure patient safety and promote research in this field. LEVEL OF EVIDENCE: III; prospective in vitro study.

Management of acute grade IV and greater acromioclavicular dislocations: Open acromioclavicular brace versus arthroscopic double DogBone® endobutton.

INTRODUCTION: Several surgical techniques exist to manage grade IV acute acromioclavicular dislocation (ACD). However, the conventional acromioclavicular brace technique (ACB) has never been compared to the arthroscopic DogBone® (DB) double endobutton technique. The aim of this work was to compare the functional and radiological results of DB stabilization with those of ACB. HYPOTHESIS: DB stabilization provides similar functional results with a low rate of radiological recurrences compared to ACB. MATERIAL AND METHODS: This is a case-control study comparing 17 cases of ACD operated by DB (DB group) between January 2016 and January 2021 with 31 cases of ACD operated by ACB (ACB group) between January 2008 and January 2016. The primary outcome was the difference in the D/A ratio (reflecting vertical displacement) measured on an anteroposterior acromioclavicular (AC) X-ray compared between the 2 groups at one-year after surgery. The secondary outcome was a clinical evaluation at one-year using the Constant score and clinical AC instability. RESULTS: At revision, the mean D/A ratio in the DB and ACB groups was 0.4±0.5 [-0.4-1.6] and 1.6±0.3 [0.8-3.1] respectively (p>0.05). Two patients (11.7%) in the DB group had implant migration with radiological recurrence while 14 patients (33%) had radiological recurrence in the ACB group (p<0.05). CONCLUSION: The DB technique limits the radiographic recurrence of acute ACD with an equivalent functional result at 1-year postoperatively compared to the conventional ACB technique, which implicitly requires a second operation for hardware removal. The DB technique has become the technique of choice in first-line treatment of acute grade IV ACD. LEVEL OF EVIDENCE: III; retrospective case-control series.

Corona mortis and pelvic dissection: Understanding the relationship between anatomical structures and bone areas.

Pelvic fractures are becoming increasingly frequent. The gold standard for surgical managements remains open procedures. Despite its excellent biomechanically results, it can lead to many complications. Minimally invasive surgery could reduce these complications. For complex pelvic trauma, extraperitoneal endoscopic technique has never been described. The aim of this study is to determine anatomical landmarks which are useful for endoscopic pelvic ring surgery using an extraperitoneal approach. The second objective is to compare this minimally invasive procedure to expose the bone versus a traditional open approach. After preparing the vessels with latex injections, 10 specimens are dissected alternately, using an endoscopic method (MIS) on one side and an open method on the other side. Both procedures are performed on the same subject. The visualized bone areas are drilled with burr holes. The marked surfaces are measured with photogrammetry. Finally, the data are processed (surface analysis). An extraperitoneal endoscopic dissection that follows anatomical landmarks can be performed. Bone area (mm2 ) visualized by endoscopy was 74 ± 14 (59-94) compared to 71 ± 16 (48-94) by open method. Paired t-test was performed with no significant difference between the two methods. Skin and muscular incisions were significantly lower in the MIS group (5.1, IC95% [4.1; 6.1], p < 0.001). An extraperitoneal endoscopic dissection of the pelvis can be performed. We also find no significant difference between our method and an open traditional approach concerning bone exposure. We offer a holistic approach to treat pelvic fractures by identifying key anatomical structures.

Total Ankle Replacement in Cavovarus Deformity: How Far Can We Go?

Because of the good functional results and satisfactory implant survival achieved with modern models, total ankle replacement (TAR) has become a legitimate alternative to ankle fusion. However, alignment and balance are mandatory for implant survival. Satisfactory results can be achieved in patients with significant preoperative deformity if alignment and balance were obtained. If not, a staged procedure involving deformity correction and secondary TAR is possible. The authors describe the principal aspects of this concept and illustrate their current approach to TAR in cavovarus deformity.

Ferric derisomaltose and tranexamic acid, combined or alone, for reducing blood transfusion in patients with hip fracture (the HiFIT trial): a multicentre, 2 × 2 factorial, randomised, double-blind, controlled trial.

BACKGROUND: Anaemia and blood transfusion are associated with poor outcomes after hip fracture. We evaluated the efficacy of intravenous iron and tranexamic acid in reducing blood transfusions after hip fracture surgery. METHODS: In this double-blind, randomised, 2 × 2 factorial trial, we recruited adults hospitalised for hip fractures in 12 medical centres in France who had preoperative haemoglobin concentrations between 9·5 and 13·0 g/dL. We randomly allocated participants (1:1:1:1), via a secure web-based service, to ferric derisomaltose (20 mg/kg intravenously) and tranexamic acid (1 g bolus followed by 1 g over 8 h intravenously at inclusion and 3 g topically during surgery), iron plus placebo (normal saline), tranexamic acid plus placebo, or double placebo. Unmasked nurses administered study drugs; participants and other clinical and research staff remained masked to treatment allocation. The primary outcome was the percentage of patients transfused during hospitalisation (or by day 30). The primary analysis included all randomised patients. This study is registered on ClinicalTrials.gov (NCT02972294) and is closed to new participants. FINDINGS: Of 413 patients (51-104 years old, median [IQR] 86 [78-91], 312 [76%] women, 101 [24%] men), 104 received iron plus tranexamic acid, 103 iron plus placebo, 103 tranexamic acid plus placebo, and 103 double placebo between March 31, 2017 and June 18, 2021 (study stopped early for efficacy after the planned interim analysis done on the first 390 patients included on May 25, 2021). Data for the primary outcome were available for all participants. Among patients on double placebo, 31 (30%) were transfused versus 16 (15%) on both drugs (relative risk 0·51 [98·3% CI 0·27-0·97]; p=0·012). 27 (26%) participants on iron (0·81 [0·50-1·29]; p=0·28) and 28 (27%) on tranexamic acid (0·85 [0·54-1·33]; p=0·39) were transfused. 487 adverse events were reported with similar event rates among the groups; among prespecified safety endpoints, severe postoperative anaemia (haemoglobin <8 g/dL) was more frequent in the double placebo group. Main common adverse event were sepsis, pneumonia, and urinary infection, with similar rates among all groups. INTERPRETATION: In patients hospitalised for hip fracture surgery with a haemoglobin concentration 9·5-13·0 g/dL, preoperative infusion of ferric derisomaltose plus tranexamic acid reduced the risk of blood transfusion by 50%. Our results suggest that combining treatments from two different pillars improves patient blood-management programmes. Either treatment alone did not reduce transfusion rates, but we might not have had the power to detect it. FUNDING: French Ministry of Health, HiFIT trial.

In France, distance from hospital and health care structure impact on outcome after arthroplasty of the hip for proximal fractures of the femur.

BACKGROUND: Hip arthroplasty is a frequently performed procedure in orthopedic surgery, carried out in almost all health structures for two main issues: fracture and coxarthrosis. Even if volume-outcome relationship appeared associated in many surgeries recently, data provided are not sufficient to set surgical thresholds neither than closing down low-volumes centers. QUESTION: With this study, we wanted to identify surgical, health care-related and territorial factors influencing patient' mortality and readmission after a HA for a femoral fracture in 2018 in France. PATIENTS AND METHODS: Data were anonymously collected from French nationwide administrative databases. All patients who underwent a hip arthroplasty for a femoral fracture through 2018 were included. Patient outcome was 90-day mortality and 90-day readmission rate after surgery. RESULTS: Of the 36,252 patients that underwent a HA for fracture in France in 2018, 0.7% died within 90-day year and 1.2% were readmitted. Male and Charlson comorbidity index were associated with a higher 90-day mortality and readmission rate in multivariate analysis. High volume was associated with a lower mortality rate. Neither time of travel nor distance upon health facility were associated with mortality nor with readmission rate in the analysis. CONCLUSION: Even if volume appears to be associated with lower mortality rate even for longer distance and time of travel, the persistence of exogenous factors not documented in the French databases suggests that regionalization of hip arthroplasty should be organized with caution. CLINICAL RELEVANCE: As volume-outcome relationship must be interpreted with caution, policy makers should not regionalize such surgery without further investigation.

C-Nail® locking nail versus conventional plate for thalamic calcaneal fractures.

BACKGROUND: Surgery for displaced intra-articular calcaneal fractures (DIACFs) is often followed by skin complications that adversely impacts the functional outcomes. Minimally invasive techniques have been developed to decrease the risk of skin complications. The objective of this study was to compare C-Nail® locking-nail fixation to conventional plate fixation for DIACFs. HYPOTHESIS: C-Nail® fixation restores calcaneal anatomy similarly to conventional plate fixation and decreases the frequency of skin complications compared to conventional plate fixation, while providing satisfactory functional outcomes. MATERIAL AND METHODS: In this case-control study of DIACFs, fixation was with a non-locking plate in 30 patients treated between January 2016 and June 2017 and with the C-Nail® in 25 patients treated between April 2017 and April 2018. Computed tomography was performed before surgery then bilaterally after surgery for measurements of the following calcaneal parameters: height, length, width, joint-surface step-off and inter-fragmentary distance. The values of these parameters were compared between the two groups. Postoperative skin complications were recorded. The functional outcome was assessed by determining the AOFAS score 1 year after the injury. RESULTS: The two groups showed no significant differences for age, sex or fracture type. Wound healing was delayed in 3 patients in the plate group. The mean postoperative values of the calcaneal parameters were not significantly different between the two groups. The mean AOFAS score was 85.3±10.4 (range, 50-100) in the plate group and 87.0±12.0 (range, 64-100) in the C-Nail® group (p>0.05). DISCUSSION: Minimally invasive C-Nail® fixation provides similar restoration of calcaneal anatomy as does conventional plate fixation. LEVEL OF EVIDENCE: III, retrospective case-control study.

Clinical and radiological outcomes of internal fixation of complex talar neck and body fractures with locking plates through a dual approach.

INTRODUCTION: Talar fractures are rare and surgical treatment has not been standardized. The literature is rather poor on preserving talar vascularization in single or dual approaches. A dual approach allows better exposure and should limit devascularization. Locking plates are one of the modern solutions for challenging comminuted fractures. The aim of this study was to determine clinical and radiological outcomes in complex talar fracture (CTF) of the neck and body, fixed by locking plates through a dual approach with at least one locking plate. HYPOTHESIS: Locking-plate fixation of CTF through a dual approach leads to good clinical outcome. MATERIAL AND METHODS: A single-center retrospective study included 12 cases of CTF treated between January 2007 and May 2019. 3D CT was systematically performed to plan surgery. A dual approach and at least one locking plate were used for fixation. Clinical outcome was evaluated on AOFAS score. Reduction quality and correlation to clinical results were evaluated, reduction with<2mm joint step being considered satisfactory. Consolidation rate and occurrence of avascular necrosis of the talus (ANT), post-traumatic arthritis (PTA) and postoperative complications were analyzed. RESULTS: Mean follow-up was 27 months (range, 15-47). Mean AOFAS score was 70±18 (range, 30-97). Inframillimetric reduction was achieved in 67% of cases, without significant correlation with clinical results. The consolidation rate was 91.6%, ANT rate 18.2% and PTA rate 45.5%. One patient presented septic osteoarthritis secondary to scar necrosis. CONCLUSION: Locking plate fixation of CTF through a dual approach provided acceptable clinical outcomes. LEVEL OF EVIDENCE: IV; retrospective study.

Does isolated arthroscopic anterior acromioplasty modify critical shoulder angle?

INTRODUCTION: Critical shoulder angle (CSA)>35° correlates significantly with primary rotator cuff tear and re-tear after repair. Acromial axial orientation varies between individuals. The present study aimed to assess the impact of strictly anterior acromioplasty on CSA. HYPOTHESIS: CSA is reduced by arthroscopic anterior acromioplasty. MATERIAL AND METHODS: A single-center retrospective study included patients receiving isolated arthroscopic acromioplasty between January 2016 and December 2017. Exclusion criteria comprised history of surgery and fracture or dislocation of the shoulder. Pre- and post-operative AP shoulder radiographs were taken. The angle subtended by a line between the inferior and superior edges of the glenoid and a line between the inferior edge of the glenoid and the most lateral point on the acromion was measured. RESULTS: One hundred and two patients were included: mean age, 50.5±10.1 years (range, 23-82 years). Mean CSA was 34.7±4.4° (range, 26-48°) preoperatively and 31.7±3.7° (range, 23-40°) postoperatively (p<0.001). In the group with CSA >35°, the decrease was significant: 34.4±3.2° (range, 28-40°) versus 38.9±2.8° (range, 36-48°) (p<0.001), with 64% CSA <35° after isolated anterior acromioplasty. DISCUSSION: CSA was decreased by arthroscopic acromioplasty. However, in 36% of cases with preoperative CSA >35°, CSA was not normalized. CONCLUSION: Anterior arthroscopic acromioplasty significantly reduced CSA in the overall population, and especially in case of high CSA. LEVEL OF EVIDENCE: IV; retrospective study.

Pediatric fracture reduction in the emergency department.

Limb fractures are a large part of pediatric trauma activity. Conservative treatment is possible because of children's bone remodeling potential. In case of displaced fractures, when a closed reduction can be done in the emergency room (ER), this avoids general anesthesia, hospitalization and the associated costs. In well-defined situations, there is a consensus about the indication for fracture reduction in the ER. Some complex fracture cases require immediate treatment in the operating room: intra-articular fractures, pathological fractures, fractures with associated skin, nerve or vascular injuries and/or early signs of compartment syndrome. And last, there is another set of fractures where the indication is not so clear. To specify the indications and technical implementation of these treatments in ER, we did a non-systematic narrative review of literature in the MEDLINE® database using the PubMed search engine to query "emergency room AND children AND fracture AND reduction". We retained the most recent articles addressing the questions related to indications and their care, sedation protocol and complications. The sedation protocol for the ER is established collaboratively by surgical, ER and anesthesia teams. The residual angulation that can be tolerated after reduction depends on the patient's age, remaining growth potential and location of the fracture line. When reduction is done in the ER, the complication and secondary displacement rates are not higher, although surgeon experience and specific procedural training appear to be crucial.

Microarchitecture of titanium cylinders obtained by additive manufacturing does not influence osseointegration in the sheep.

Large bone defects are a challenge for orthopedic surgery. Natural (bone grafts) and synthetic biomaterials have been proposed but several problems arise such as biomechanical resistance or viral/bacterial safety. The use of metallic foams could be a solution to improve mechanical resistance and promote osseointegration of large porous metal devices. Titanium cylinders have been prepared by additive manufacturing (3D printing/rapid prototyping) with a geometric or trabecular microarchitecture. They were implanted in the femoral condyles of aged ewes; the animals were left in stabling for 90 and 270 days. A double calcein labeling was done before sacrifice; bones were analyzed by histomorphometry. Neither bone volume, bone/titanium interface nor mineralization rate were influenced by the cylinder's microarchitecture; the morphometric parameters did not significantly increase over time. Bone anchoring occurred on the margins of the cylinders and some trabeculae extended in the core of the cylinders but the amount of bone inside the cylinders remained low. The rigid titanium cylinders preserved bone cells from strains in the core of the cylinders. Additive manufacturing is an interesting tool to prepare 3D metallic scaffolds, but microarchitecture does not seem as crucial as expected and anchoring seems limited to the first millimeters of the graft.

Does anterior arthroscopic acromioplasty modify critical shoulder angle?

INTRODUCTION: Critical shoulder angle (CSA) is measured on AP view in neutral rotation as the angle subtended by the tangent to the glenoid and the lateral edge of the acromion. CSA >35° is a risk factor for primary rotator cuff tear and iterative tear after cuff repair. The aim of the present study was to assess change in CSA following arthroscopic anterior acromioplasty. HYPOTHESIS: CSA is decreased by arthroscopic anterior acromioplasty. MATERIAL AND METHOD: A single-center retrospective descriptive observational study included patients undergoing arthroscopic acromioplasty between January 2016 and December 2017, for whom strictly AP pre- and post-operative radiographs were available. Patients with history of surgery, fracture or dislocation in the same shoulder were excluded. RESULTS: 102 patients were included; mean age, 50.5 years (range, 23-82 years). Mean preoperative CSA was 34.7±4.4° (range, 26-48°) and postoperative CSA 31.7±3.7° (range, 23-40°) (p<0.001). In the pathological CSA group (>35°), the values were 38.9±2.8° (36-48°) and 34.4±3.2° (28-40°) (p<0.001), with a 64.3% rate of correction after acromioplasty. DISCUSSION: CSA decreased after arthroscopic acromioplasty. Even so, 36.7% of pathological CSAs (>35°) were not corrected, with risk of rotator cuff tear. CONCLUSION: Anterior arthroscopic acromioplasty significantly reduced CSA overall, notably in case of high CSA. LEVEL OF EVIDENCE: IV, retrospective study.

Does the retention of osseointegrated prosthetic implants during the surgical management of chronic infections following reverse total shoulder arthroplasty (RTSA) influence functional outcomes without impacting the efficacy of the infection treatment?

INTRODUCTION: The gold standard (GS) for treating chronic infections following reverse total shoulder arthroplasty (RTSA) is a complete exchange of the prosthesis carried out in one or two stages. This surgical procedure, which may damage the bone stock, can result in poor functional outcomes due to intraoperative complications. The purpose of this study was to compare the GS to a surgical technique that retained osseointegrated implants: the partial one-stage exchange. HYPOTHESIS: Partial one-stage exchange was effective in treating chronic infections after RTSA (no recurrent infection) and resulted in better functional outcomes than the GS. MATERIALS AND METHODS: This retrospective single-center study included 18 patients with chronic infection after a primary RTSA. Two treatments were compared in a non-randomized fashion. The first included 11 patients who underwent a partial one-stage exchange with implant retention in case of macroscopic osseointegration. The second included seven patients who were treated with the GS: six patients with a complete one-stage exchange and one patient with a two-stage surgical approach. The absence of recurrent infection and functional outcomes were assessed after a minimum of two years. RESULTS: There were no statistically significant differences in treatment efficacy between the two strategies: 91% vs. 100%, respectively. The partial one-stage exchange resulted in a significantly improved shoulder function compared to the GS with postoperative Constant scores of 55±14.58 vs. 44±14.45, respectively (p=.03). In the partial one-stage exchange group, there was a significantly improved shoulder function with a preoperative Constant score of 40 [28-55]±9.04 preoperatively vs. 55 [25-75]±14.58 postoperatively (p=.01). The GS treatment did not significantly improve the postoperative function (p=.09). DISCUSSION: Partial one-stage exchange does not compromise treatment efficacy of chronic infections after RTSA. This technique resulted in better shoulder function than a conventional GS-type management. A study with greater statistical power is required. LEVEL OF EVIDENCE: III; clinical series, retrospective, single-center.

Comparison of double screw fixation versus tension-band fixation after olecranon osteotomy for complex distal humerus fractures.

INTRODUCTION: Supra- and intercondylar elbow fractures are surgically challenging given the intra-articular comminution. Various surgical approaches have been described. Among these-olecranon osteotomy-provides optimal joint exposure but is associated with several complications. Tension band wiring (TBW) is the most commonly used fixation method. We hypothesized that double screw fixation would lead to fewer surgical revisions than TBW (all causes included) after olecranon osteotomy. METHODS: We carried out a single-center retrospective study of 39 patients, treated between January 2007 and April 2016, for a supra- or intercondylar elbow fracture using the transolecranon exposure. There were 34 type C fractures (13 C1, 6 C2 and 15 C3), 3 type B fractures and 2 type A fractures, based on the AO classification. Fourteen patients received double screw fixation and 25 received TBW. The primary outcome measure was the number of surgical revisions, regardless of cause. Secondary outcome measures were the number of surgical revisions for olecranon nonunion, fixation failure or fixation device removal due to pain. RESULTS: There were significantly more surgical revisions in the TBW group than in the double screw fixation group: 3 (21%) versus 14 (56%) (p=0.049, Fisher test). The three main reasons for revision in the TBW and double screw fixation groups were removal of the fixation device due to soft tissue impingement (11 [44%] versus 2 [14%]; p=0.08), failure of the olecranon fixation (6 [24%] versus 1 [7%] p=0.38), and olecranon nonunion (4 [16%] versus 0 [0%] p=0.27). DISCUSSION: There are no published studies on the outcomes of this surgical technique. The posterior transolecranon approach provides the best exposure at the elbow joint. TBW fixation is associated with multiple complications. Double screw fixation for olecranon fractures yields good clinical and radiological outcomes. CONCLUSION: Based on our findings, double screw fixation of the olecranon results in fewer surgical revisions (all causes combined) than TBW in supra- and intercondylar elbow fractures operated by a transolecranon approach. LEVEL OF EVIDENCE: IV.

Histochemical identification of wear debris released by alumina-on-alumina hip prostheses in the periprosthetic tissues.

BACKGROUND: Tribological studies have shown that the most used couples for hip prostheses consist of metal-on-polyethylene and alumina-on-alumina prostheses. Over time, wear products accumulate in the joint cavity and in the periprosthetic tissues. Although polyethylene and metal are easily identifiable by microscopy in periprosthetic tissues, alumina particles are very difficult to identify. HYPOTHESIS: The fluorescent azo-dye lumogallion was evaluated as a suitable histochemical stain for alumina particles in periprosthetic tissues. MATERIAL AND METHOD: In 28 patients who had a prosthetic revision of an alumina-on-alumina prosthesis, periprosthetic tissues were removed and embedded in paraffin; sections were stained with HPS (for conventional diagnosis) or with lumogallion. Sections were examined for wear particles in light and fluorescence microscopy. Some sections were counter-stained using DAPI for visualization of cell nuclei. RESULTS: The wear particles of the alumina-alumina prostheses were very difficult to identify on the HPS stained sections; they were clearly evidenced by lumogallion staining with a bright orange fluorescence. The stain revealed large quantities of particles (of the order of several thousand per section). Only two patients had no particles. The staining technique identified numerous particles that were not visible on HPS-stained sections in macrophages, synoviocytes and fibroblasts. CONCLUSION: This staining, which has been validated in neuromuscular pathology for the identification of alumina used as a vaccine adjuvant, gave successful results in the present study. Alumina particles are modified when they are phagocytized by macrophages. lumogallion staining easily shows the presence of thousands of wear particles released by alumina-on-alumina prostheses in periprosthetic tissues. LEVEL OF EVIDENCE: V expert opinion study.