Can hip function be assessed with self-report questionnaires? Feasibility study of a French self-report version of the Harris Hip and Merle d'Aubigné scores.

INTRODUCTION: The Harris Hip Score (HHS) and the Merle D'Aubigné Postel (MDP) score both provide an objective and subjective evaluation of hip function. These scores are collected during the follow-up of patients who have a hip disease. The objectives of this prospective study were (1) to analyze the differences between the two new French self-report versions of the HHS and MDP, and the traditional surgeon-assessed HHS and MDP; (2) to analyze the correlation between the self-report HHS and MDP and the surgeon-assessed HHS and MDP; (3) to analyze the floor and ceiling effects of the two self-report scores and the reliability of these self-report scores in operated and non-operated patients. HYPOTHESIS: The French self-report HHS and MDP are sufficiently reliable to accurately estimate the patient's objective and subjective outcomes compared to the clinical examination done by a surgeon. METHODS: A prospective multicenter study was done with patients who had a hip disease. Two self-report questionnaires were completed by the patient, independently of the clinical examination done by the surgeon. The questionnaires were in French and consisted solely of checkboxes, with sample photos that corresponded to the various range of motion items in the HHS and MDP. The agreement between the self-report scores and the surgeon-assessed scores were evaluated using the intraclass correlation coefficient (ICC). Differences in the mean values were evaluated with a paired t test. RESULTS: The analysis involved 89 patients. The self-report HHS was 2.7±3.7 points (/100) lower than the surgeon-assessed HHS, but this difference was not statistically significant (p=0.34). The self-report MDP was significantly less by 1.2±2.9 points (/18) than the surgeon-assessed MDP (p=0.01). The agreement between the self-report HSS and the surgeon-assessed HSS was excellent (ICC=0.86) as was the one between the self-report MDP and the surgeon-assessed MDP (ICC=0.75). There was a strong positive correlation between the surgeon-assessed and self-report HHS in operated patients (ICC= 0.84; R=0.75; p<0.001) and in non-operated patients (ICC=0.96; R=0.89; p<0.001). This positive correlation was also found between the surgeon-assessed and self-report MDP for operated patients (ICC=0.73; R=0.62; p<0.001) and non-operated patients (ICC=0.79; R=0.64; p<0.001). A ceiling effect (maximum of 100 points) was found in 22% of patients (20/89) for the self-report HHS and in 34% of patients (30/89) for the self-report MDP (maximum of 18 points). No floor effect was observed for either questionnaire. CONCLUSION: The French version of the HHS self-report questionnaire is an excellent overall estimator of the HHS score for patients with hip osteoarthritis or fracture, whether operated or not. The addition of the MDP, whose self-report version is less accurate, is also a reliable tool. These self-report questionnaires, when validated on a larger scale, will be useful for the long-term follow-up of patients undergoing hip arthroplasty. LEVEL OF EVIDENCE: III; prospective diagnostic study.

Anterior Cruciate Ligament Reconstruction in French Army: Return to Prior Level of Running on Selected Military Tests.

INTRODUCTION: Anterior cruciate ligament (ACL) rupture is frequently encountered in athletes as well as in military personnel. In civilian population, many studies have looked at the return to sport, but return to duty in Army is a topic that requires further research.The purpose of this study was to determine through annual military fitness tests in real conditions, the return to sport in soldiers after ACL reconstruction and factors influencing failure. MATERIALS AND METHODS: This was a retrospective comparative study. Patients were all soldiers and had followed up in a Military Hospital. The SUCCESS group was military personnel who obtained a result of the specific aptitude test greater than or equal to this same test carried out before reconstruction of the ACL, the FAILURE group comprised the others. Results of the annual specific aerobic fitness tests were collected before and after ACL reconstruction. Preoperative epidemiological data, intraoperative information, and isokinetic test results were collected. RESULTS: One hundred forty four soldiers were included between January 2011 and December 2017 (94.9% of men with a median age of 27.6 years); 40.3% obtained a result greater than or equal to the preoperative fitness test after ACL reconstruction. Among the soldiers who did not regain their performance, 24.3% were declared unfit or discharged. In the FAILURE group, we found patients with a higher body mass index (25.5 vs. 24.4; P = .04), less patients with isokinetic deficit < 30% on the knee flexors and extensors (26.6% vs. 62.9%; P < .01), more long sick leave (39.5% vs. 13.7%; P < .01), and late resumption of military activities (10.5 vs. 8.9 months; P < .01). CONCLUSION: Rupture of ACL has a significant impact on the operational capacity of the French army. The proportion of return to the same level in annual specific fitness tests after ACL reconstruction is 40% among soldiers. Several variables are important to consider in the follow-up of these patients to optimize their recovery of sports performance and therefore their operational capacity.

Relevance of a Simulation Model to Microvascular Surgery for Military Surgical Residents.

Introduction: Microsurgical training is an asset for deployed military orthopaedic surgeons who frequently treat hand or nerve injuries in the field. The objective of this study was to evaluate a microvascular surgery simulation model intended to prepare residents prior to their enrolment in conventional microsurgery degree training. Methods: An experimental study was conducted to evaluate technical progress and satisfaction of military surgical residents using a model based on Japanese noodles with four tests of increasing difficulty. Objective endpoints included instruments handling, distribution, and quality of stitches, as well as anastomoses duration. Responses to the Structured Assessment of Microsurgery Skill self-assessment questionnaire were also analyzed. Results: Nine residents from different specialties participated in the study. Their anastomoses quality and average satisfaction significantly increased between the first and the last session (p < 0.05). Conversely, the average operating time decreased significantly over the sessions (p < 0.001). Conclusion: This simulation model seems to constitute a satisfactory initiation to microsurgery and could limit the use of animal models. It could also be included in the continuing education of military surgeons who have an occasional microsurgical practice during deployments.

Surgical Experiences From a French Forward Surgical Team on Board of the Landing Helicopter Deck MISTRAL.

INTRODUCTION: Onboard surface ships like destroyers and frigates, there is ROLE 1, whereas on a three-landing helicopter deck (LHD) and aircraft carrier, there is ROLE 2, with a surgical team. At sea, evacuation takes more time than on any other theater of operation. It also costs more money, so we wanted to analyze how many patients have been maintained onboard, thanks to ROLE 2. Moreover, we wanted to analyze the surgical activities on the LHD MISTRAL ROLE 2. METHODS: We performed a retrospective observational study. We retrospectively analyzed all surgery cases performed on the MISTRAL between January 1, 2011, and June 30, 2022. During this period, there were only 21 months with a surgical team ROLE 2 onboard. We included all consecutive patients who underwent minor or major surgery onboard. RESULTS: A total of 57 procedures were performed during the period, involving 54 patients (52 males and 2 females) with an average age of 24.4 ± 1.9 years. The most frequent pathology was abscess (pilonidal sinus abscess, axillary abscess, or perineal abscess) (n = 32; 59.2%). Only two Medical Evacuations were conducted because of surgery; the other patients who underwent surgery were maintained onboard. CONCLUSIONS: We have shown that using ROLE 2 aboard the LHD MISTRAL decreases the use of Medical Evacuation. It also helps to perform surgery under better conditions for our sailors. Doing everything to keep sailors onboard seems to be an important point.

Return to duty in military personnel after ACL reconstruction: STG versus ST4 double adjustable-loop device.

INTRODUCTION: ACL ligamentoplasty with a quadruple semitindosus graft (ST4) and double adjustable endobutton (ST4E) allow the preservation of the gracilis, which should allow more rapid recovery of soldiers following ACL reconstruction. However, the literature does not report any superiority of this technique over others in terms of return to duty and sport. HYPOTHESIS: The ST4E system allows a return to military duty at least equivalent to the semitendinosus and gracilis graft (STG) with screw fixation. MATERIAL AND METHOD: A total of 133 soldiers operated on for ACL were included, 64 by the STG technique and 69 by ST4E, with an average follow-up of 4 years. The return to duty was assessed, with recovery of skills between the first and second postoperative year, as well as the medico-administrative status at the last follow-up, muscle recovery through isokinetic tests, the sports level before/after surgery, and the failure rate. RESULTS: No difference was found in the return to the soldier's previous post between the STG (64%) and the ST4E (64%) (p=0.97). No difference was found for the medico-administrative status at the last follow-up, but the short-term muscle recovery, the return to sport, and the failure rate were in favor of the ST4E group. DISCUSSION: The ST4E, adjustable double endobutton system, is comparable to the STG technique in terms of return to military duty. On the other hand, it offers faster muscle recovery with better sports results and fewer patients on prolonged sick leave (PSL). This study demonstrated that two-thirds of soldiers operated on for anterior cruciate ligamentoplasty regained their initial aptitude regardless of the technique used, which influences the army's operational capacity and on disability pension requests after service. LEVEL OF EVIDENCE: III, single center retrospective comparative study.

How do patients choose their surgeon? Example of anterior cruciate ligament reconstruction.

INTRODUCTION: In this age of social media, with an ever-higher profile for surgery and rankings for the general public, patients' criteria for choosing a surgeon or team are not precisely known, especially in France. We therefore conducted a prospective study concerning anterior cruciate ligament reconstruction: (1) to determine how patients came to know their surgeon; (2) to identify factors affecting final choice. HYPOTHESIS: Patients' choice of surgeon is affected by scores found in social media and rankings found in the press. MATERIAL AND METHOD: A prospective continuous study included all patients operated on, without standardization of technique, in 3 hospitals (public and private sector). An anonymous questionnaire on surgeon selection criteria, scored 0 to 10, was distributed on a voluntary basis on the day of surgery scheduling. RESULTS: One hundred and five patients were included. They had come to know of their surgeon via family or friends or their personal physician in more than two-thirds of cases. The essential criterion of final choice was the clarity of the written and oral information provided in consultation (mean score, 8.09±1.83). Other factors included wait-time to surgery (7.39±2.25) and to first consultation (7.26±2.01) and the surgeon's reputation (7.42/10±2.43). CONCLUSION: "Word of mouth" and the quality if information provided in consultation motivated final choice, more than any influence of social media or press hospital rankings. LEVEL OF EVIDENCE: IV; prospective observational study without control group.

Direct Suturing of Sciatic Nerve Defects in High-degree Knee Flexion: An Experimental Study.

OBJECTIVE: We sought to elucidate the conditions of direct suturing of sciatic nerve defects in high-degree knee flexion. We aimed to establish a correlation among the defect length, defect location, degree of knee flexion, and eventual need for hip immobilization in extension. METHODS: We performed an experimental study by completing bilateral dissection of the sciatic nerve in 6 cadavers. Three groups of lesions were identified: at the buttock (BG), in the thigh (TG), and in the popliteal fossa (PG). For each defect, a direct, tensionless suture was performed with minimal knee flexion. Next, the hip was progressively flexed until rupture. The nerve defect length correlated with the degree of knee flexion and hip extension required to perform and protect the installed sutures. RESULTS: A 30° knee flexion allowed for direct suturing of defects >2 cm in the 3 groups. The largest suturable nerve defects measured 7 cm in the TG and PG and 6 cm in the BG. When considering the same-size defects, the required knee flexion tended to be significantly greater in the BG. A bowstringing effect was noted at the buttock and popliteal levels. Hip flexion placed tension on the nerve suture at all locations. CONCLUSIONS: The middle third of the thigh was the most compliant level, because the largest defects will be suturable without a visible bowstringing effect. Hip immobilization should be considered as soon as the defect has exceeded 2 cm, regardless of the location.

Sequential management of tibial fractures using a temporary unicortical external fixator.

INTRODUCTION: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation. METHODS: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO® - Orthofix®) followed by an early conversion to intramedullary nailing. RESULTS: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with "fixator in place" in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications. DISCUSSION: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries.