Patient satisfaction after distal upper limb surgery under WALANT versus axillary block: A propensity-matched comparative cohort study.

Distal upper limb surgery is performed under WALANT (Wide Awake Local Anesthesia No Tourniquet) in many outpatient centers because the benefits are numerous: simple, low-cost technique, with fast turnover and short length of stay. In view of a paucity of data concerning patient satisfaction, this non-randomized cohort study was designed to compare EVAN-LR anesthesia satisfaction questionnaire results (information, pain, expectation, attention, discomfort: 0-100 points) between patients receiving WALANT or axillary nerve block (AxB). After IRB approval, patients (>18 years, stable ASA 1-3) scheduled for outpatient distal upper limb surgery were prospectively enrolled in the two groups. At discharge, patients in both groups received standard information on postoperative recovery and care, with a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The primary endpoint was EVAN-LR score before discharge. Secondary endpoints were pain relief and side-effects over a 7-day period. Results were recorded as median and 25-75% interquartile range. Propensity-score-matched analysis was performed. Over the study period, from October 2019 to November 2020, 183 patients were included; 48 WALANT patients were propensity-score matched to 48 AxB patients. Pre-procedural APAIS anxiety score was lower in the WALANT than the AxB group: 9 (IQR, 6-12) vs 12 (IQR, 8-14) (p = 0.01). EVAN-LR scores were similar between the WALANT (78 [72-82]) and the AxB group (73 [67-80]). Incidences of paresthesia and of pain (NRS pain score, opioid rescue) were similar. WALANT patients had shorter length of stay: 135 (110-175) min vs 170 (110-250) min (p = 0.01). The present study demonstrated that WALANT was associated with a high level of patient satisfaction. For clinical relevance and quality of care, WALANT should be proposed in first line for distal limb surgery.

Analysis of apex and transitional vertebra of the spine according to pelvic incidence using orientation and position parameters.

OBJECTIVE: To identify the different apex and transitional vertebra according to the shape of the pelvis of individuals despite their difference in sagittal alignment using our measurement system. METHODS: Full-spine X-rays using EOS in standard stand-position of 99 volunteers were selected (47 women, 52 men, mean age 31 years old). Validated 3D reconstruction technique allows extraction of spinopelvic parameters, and position and rotation of each vertebra and lumbar disks. Subjects were divided into three groups: low PI (lowPI, n = 37), moderate PI (midPI, n = 52), high PI (highPI, n = 10), with, respectively, a PI below 45°, between 45° and 60° and above 60°. Occurrence of specific position and rotation values of apex and transitional vertebra were assessed in each group. RESULTS: Frequency curves tend to move cranially when the incidence increases except in cervicothoracic where T1 is a constant for all shapes of spine with occurrence approaching 90%. Angulation value of relevant vertebra and lumbar lordosis are significantly positively correlated for the whole population. CONCLUSIONS: Our study allowed the assessment of the distribution of spine curvatures according to the pelvic incidence. It describes the occurrence of localization of the apex and transitional vertebrae according to pelvic incidence. These results should be taken into account during the analysis of the sagittal balance, especially when planning deformity surgery in adults.

Trapeziometacarpal (TMC) arthroplasty under Wide Awake Local Anesthesia with No Tourniquet (WALANT) versus Local Anesthesia with peripheral nerve blocks (LAPNV): Perioperative pain and early functional results in 30 patients.

We hypothesized that WALANT would provide similar perioperative analgesic comfort compared to local anesthesia with peripheral nerve blocks (LAPNV). We analyzed whether the patient's active participation during surgery would improve its early functional results. We did a retrospective, single study in an outpatient surgery unit, comparing two types of surgery: trapeziometacarpal arthroplasty (TMCA) under LAPNV and TMCA under WALANT. Fifteen patients were included per group. Pain levels were determined during anesthesia induction, intraoperatively, postoperatively, at rest and during activity at the last follow-up visit. The overall satisfaction with the surgery and time to resume daily activities and work were documented. The statistical analysis was performed on SAS software with an ANOVA. The significance threshold was set at 0.05. The groups were comparable on age, sex, dominant side, and operated side. No patients were lost to follow-up. The mean follow-up was 4 months (2.3-11). The QuickDASH score was 4.93 for TMCA under WALANT vs. 13.47 for TMCA under LAPNV (p = 0.01). There was no loosening, dislocation, or major complication. Our study showed that TMCA performed with WALANT yields similar results to the same procedure with LAPNV for perioperative pain relief without additional complications. Functional scores seem to be slightly improved with WALANT compared to LAPNV, but these results should be confirmed with longer follow up.

C1-C2 Injury: Factors influencing mortality, outcome, and fracture healing.

BACKGROUND: C1-C2 injury represents 25-40% of cervical injuries and predominantly occurs in the geriatric population. METHODS: A prospective multicentre study was conducted under the aegis of the french spine surgery society (SFCR) investigating the impact of age, comorbidities, lesion type, and treatment option on mortality, complications, and fusion rates. RESULTS: A total of 417 patients were recruited from 11 participating centres. The mean ± SD age was 66.6 ± 22 years, and there were 228 men (55%); 5.4% presented a neurological deficit at initial presentation. The most frequent traumatic lesion was C2 fracture (n = 308). Overall mortality was 8.4%; it was 2.3% among those aged ≤ 60 years, 5.0% 61-80 years, and 16.0% > 80 years (p < 0.001). Regarding complications, 17.8% of patients ≤ 70 years of age presented with ≥ 1 complication versus 32.3% > 70 years (p = 0.0009). The type of fracture did not condition the onset of complications and/or mortality (p > 0.05). The presence of a comorbidity was associated with a risk factor for both death (p = 0.0001) and general complication (p = 0.008). Age and comorbidities were found to be independently associated with death (p < 0.005). The frequency of pseudoarthrosis ranged from 0 to 12.5% up to 70 years of age and then constantly and progressively increased to reach 58.6% after 90 years of age. CONCLUSIONS: C1-C2 injury represents a serious concern, possibly life-threatening, especially in the elderly. We found a major impact of age and comorbidities on mortality, complications, and pseudarthrosis; injury pattern or treatment option seem to have a minimal effect.

Bilateral simultaneous endoscopic carpal tunnel release: Mean time to resume activities of daily living and return to work.

The purpose of this study was to determine the time needed to return to personal and professional activities after bilateral simultaneous endoscopic carpal tunnel release. During a retrospective, single-center study, we included a cohort of 30 patients (60 wrists). Patients were evaluated clinically (pain, paresthesia) and functionally (QuickDASH score) pre- and postoperatively. At the last follow-up, patients completed a questionnaire regarding the time needed to resume personal activities using the ADL scale (feeding, personal hygiene and dressing) and return to work. We also evaluated procedure satisfaction and willingness to undergo the surgery again. The average patient age was 60.5 years (range 39-86). At the last follow-up, average time to resume personal activities was 2.2 days (0-14) for feeding, 4.4 days (0-15) for personal hygiene and 3.9 days (0-14) for dressing. Average time to return to recreational activities was 11.7 days (1-60). Average time to return to work was 36.6 days (15-60). Overall, 97% of patients were satisfied or very satisfied with the outcome. All patients would have the bilateral simultaneous surgery again. Bilateral simultaneous endoscopic carpal tunnel release is rarely performed. For mild conditions, contralateral symptom improvement is common after unilateral surgery. Bilateral simultaneous endoscopic carpal tunnel release appears to be disabling right after surgery, but clinical and functional scores are similar after the third postoperative day. These data can be used for patient education and decision making when considering surgery bilateral carpal tunnel syndrome. Bilateral simultaneous endoscopic carpal tunnel release is a feasible and safe procedure. LEVEL OF EVIDENCE: Level IV, case series.

[Surgical exposures for distal radius fractures]. / Les voies d'abord des fractures du radius distal : une mise au point.

This is a review of the various approaches that can be used for open reduction and internal fixation (ORIF) of distal radius fractures. The main dissection steps are exposed and the specific indications for each approach are described. The anterior approach is discussed extensively as it is now the gold standard for ORIF of distal radius fractures. The lateral and posterior approaches are also described as they are sometimes needed for complex fractures.

Periprosthetic fracture in the elderly with anatomic modular cementless hemiarthroplasty.

BACKGROUND: The use of an anatomic cementless stem in hemiarthroplasties for femoral intracapsular proximal fracture has been debated, notably because of bone weakness and/or morphological defects related to osteoporosis. We therefore conducted a retrospective study in subjects over 75 years of age who had received an anatomic stem partially coated with hydroxyapatite. The objectives were to determine: 1) the incidence of periprosthetic fractures (PPFs) and, 2) the influence of anatomic factors, including the Cortical Bone Ratio (CBR) (the relation between the endosteal and external diameter of the femoral diaphysis 10cm below the lesser trochanter). HYPOTHESIS: The risk of PPF with an anatomic cementless implant is greater than with cemented stems. MATERIAL AND METHODS: We retrospectively analyzed 233 patients followed up for 5 years after their surgery. The stem used was an anatomic stem with a modular neck partially coated with hydroxyapatite. The risk factors examined were age, gender, history of osteoporotic fractures, diverse causes of secondary osteoporosis, and proximal bone stock according to various referenced radiological indices such as the CBR. RESULTS: Twenty patients (15%) were lost to follow-up, 74 had died (32%) but did not undergo revision for PPF, 15 of the 139 survivors at the last follow-up (10.8%) had had a PPF, five (3.6%; four females, one male) were early fractures (≤2 months after implantation), ten (7.2%; two females, eight males) were late fractures (>2 months). Male gender was protective for PPF occurrence (RR=0.129; 95%CI (0.04-0.39); P=0.0003), whereas secondary factors of osteoporosis (RR=2.035; 95%CI (1.11-3.72); P=0.0211), and CBR>0.49 (RR=227.42; 95%CI (1.072-48,226.76); P=0.0471) were found as risk factors of PPF. DISCUSSION: The PPF rate was greater than that related to cemented stems, requiring that morphological and clinical factors of bone weakness (collected with the patient history and related to osteoporosis) be taken into account. A CBR>0.49 requires caution on the use of this type of stem. LEVEL OF EVIDENCE: Level 4. Retrospective study.

Clinical results of endoscopic treatment without repair for partial thickness gluteal tears.

INTRODUCTION: Various surgical treatments have been proposed for greater trochanteric pain syndrome (GTPS) related to gluteal tendinopathy with partial thickness tears. The clinical results of endoscopic debridement without repair of these gluteal tears are not well known. The objectives of this study were to determine if this procedure leads to: (1) reduction of pain, (2) functional improvement, (3) patient satisfaction (on scale of 0 to 10). HYPOTHESIS: Endoscopic treatment without tendon repair provides short-term pain relief in patients with GTPS due to partial thickness gluteal tears. MATERIAL AND METHODS: Seventeen patients (16 women, 1 man) with GTPS due to partial thickness gluteal tears that was present for at least 6 months and was refractory to conservative treatment were included in the analysis. The average age at the time of the procedure was 53.5years (17-71). Pain was evaluated with a visual analogue scale (VAS). Functional outcomes were defined using the Harris Hip Score and the UCLA activity score. Satisfaction was evaluated using a VAS and Odom's criteria. RESULTS: The average follow-up was 37.6months (12-48). The average preoperative and follow-up values were respectively: (1) Pain: 7.2±1.1 (5-9) versus 3.3±1.9 (1-7) (P<0.001), (2) Harris score: 53.5±8.4 (36-68) versus 79.8±14.7 (45-96) (P<0.001). Seven patients (41.2%) were able to resume sports activities. The average satisfaction score for the surgery was 6.2±2.4 (0-9) at follow-up. Five patients had a poor outcome at the review: four still had pain and one had recurrence of the lateral snapping hip. CONCLUSION: Endoscopic treatment without repair of partial thickness gluteal tears is a treatment option with modest clinical results for GTPS patients refractory to conservative treatment. LEVEL OF EVIDENCE: IV, retrospective study.

Fracture of the lower cervical spine in patients with ankylosing spondylitis: Retrospective study of 19 cases.

INTRODUCTION: Controversy exists surrounding optimal treatment of cervical spine fractures secondary to ankylosing spondylitis (AS). HYPOTHESIS: The anterior approach is an effective surgical technique for these fractures and can be used to correct the AS-induced cervical-thoracic kyphosis. MATERIALS AND METHODS: This continuous, retrospective series between 1990 and 2010 included 19 patients aged 33 to 84 years who presented with a lower cervical spine fracture in the context of AS. The average follow-up was 45 months. Sixteen of these patients were surgically treated using an anterior approach and anterior fixation. In five patients without any neurological deficit, their cervical-thoracic kyphosis was corrected during the same surgery. Regional kyphosis was measured before the surgery, immediately after the surgery and at the last follow-up. RESULTS: Five deaths occurred; these were all patients with post-traumatic complete quadriplegia. Most the incomplete neurological problems improved (66%). In no cases did the neurological condition worsen. Among the 16 patients operated with the anterior approach, two patients also required an additional procedure with a posterior approach because of a persistent neurological deficit. The fractures in the operated patients who survived (14 patients) had healed within an average 4-month delay (range 3-7 months), without worsening of the kyphosis at final follow-up. In the five cases where the kyphosis was corrected, the correction averaged 26° (range 18-36°); there were no neurological complications. DISCUSSION: Based on these results, we suggest using the anterior approach to perform internal fixation as a treatment for cervical fractures secondary to AS and to correct the cervical-thoracic kyphosis in patients without neurological deficits. LEVEL OF EVIDENCE: Level IV - retrospective study.

Clinical evaluation of hip joint rotation range of motion in adults.

INTRODUCTION: Data on hip joint rotation range of motion (ROM) are rare; the methods of measurement vary and reproducibility has not been evaluated, in particular in relation to the subject's position (prone or supine, seated). HYPOTHESIS: Hip joint rotation ROM is symmetrical, and ROM is not modified by the patient's position when data is obtained. PATIENTS AND METHODS: This series included 120 adults between 20 and 60 years old (71 women, 49 men), who had no hip, spine or lower extremity disorders. External (ER) and internal (IR) rotation ROM was obtained using a photographic method by two observers. Measurements were obtained with the patient in three positions: the dorsal decubitus (supine) (P1), and ventral decubitus (prone) (P2) with the hip in extension and seated with the hip in flexion (P3). RESULTS: Hip rotation ROM was P1: 68.1° (ER=38.5°; IR=29.6°); P2: 77.1°(ER=41.8°; IR=35.2°); P3: 78.5° (ER=78.5°; IR=37.9°) with no significant difference among the three positions. Interobserver reproducibility was satisfactory (concordance correlation coefficient (ccc) 0.7) and was comparable in the three positions with a ccc of 0.7072 (P1), 0.7426 (P2) and 0.7332 (P3), respectively. Hip rotation ROM balance was ER predominant in 47.5%, neutral in 39.5% and IR predominant in 13%. Hip rotation ROM balance was symmetric in both hips in 73 subjects (61%). Hip rotation ROM was reduced with age (P<0.0001), and was 4.7° less in men (P=0.0078), and in overweight subjects (P<0.0006). DISCUSSION: Our values are probably lower than those in the literature because of the difference in study population. In our series, age, BMI and gender seemed to be determining factors. Hip rotation ROM balance is usually ER predominant or neutral. Hip rotation ROM can be measured in the three positions with no significant difference, with satisfactory interobserver reproducibility for each. TYPE OF STUDY: Diagnostic prospective study: level III.

Total ankle arthroplasty and coronal plane deformities.

INTRODUCTION: There is no consensus regarding total ankle replacement (TAR) in case of arthritis associated with coronal plane deformities. The purpose of this study was to determine, based on clinical and radiographic outcomes, the technical requirements and additional procedures that should be performed in such indications. HYPOTHESIS: Coronal deformities greater than 10° are not a contraindication to TAR if a stable and aligned ankle can be obtained after surgery. MATERIALS AND METHODS: Of a total of 131 TAR, 21 were performed on coronal plane deformities greater than 10°. Only cases of osteoarthritis secondary to fracture or chronic instability were included. Inflammatory ankles were excluded. Twenty-one patients (15 men and 6 women), mean age 57 years old (±12) were reviewed retrospectively with a mean follow-up of 38 months (±26). Patients were divided into four groups, categorizing first, congruent and incongruent ankles, and second varus and valgus deformities. Associated procedures were performed from proximal to distal, correcting periarticular malunions first, ligament imbalances, associated deformities of the foot and equinus deformity. Revision arthrodesis and implant changes due to loosening or progressive instability were considered to be failures. RESULTS: Surgery resulted in improved functional outcome and durable correction of the deformity, passing from 16.5° (±4.9) to 2.5° (±3.9) for varus, and from 16.7° (±5.6) to 1.4° (±2.1) for valgus. Six varus ankles required revision surgery for further corrections. Three incongruent ankles failed. DISCUSSION: Correction of osteoarticular deformities and ligament imbalance in case of frontal deformities requires a significant number of associated procedures. Residual defects are detrimental to implant longevity and warrant further correction. Short-term results are satisfactory even for severe deformities, but require longer-term monitoring. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Long-term results of the ABG-1 hydroxyapatite coated total hip arthroplasty: analysis of 111 cases with a minimum follow-up of 10 years.

INTRODUCTION: Medium-term studies of ABG-1 cementless total hip arthroplasty have shown favorable functional results with excellent femoral component fixation but an abnormally high rate of periacetabular component osteolysis, which may require early revision. HYPOTHESIS: The periacetabular osteolysis rate increases with time with the ABG-1 implant, leading to a high revision rate. OBJECTIVE: The objective of this study was to test this hypothesis with a minimum follow-up of 10 years and evaluate the progression of periacetabular osteolysis and its consequences on implant fixation. MATERIAL AND METHODS: A continuous series of 111 ABG-1 cementless prostheses implanted by a single operator with a theoretical minimum follow-up of 10 years. Seventy-five implants were analyzed with a mean follow-up of 13 years. All the prostheses had been implanted via a posterolateral approach and consisted of a 28 mm cup matching a head in zirconia and an antidislocation rim design high-density polyethylene insert. RESULTS: Twelve cups were revised because of progressive retroacetabular osteolysis. The revisions were performed systematically although there was no pain or gross cup loosening. The revisions included resection of the granuloma, cavity filling with morselized bone grafts, and implantation of new uncemented ABG-2 cups in eight cases or cemented cups associated with a support ring in the four other cases. Thirty-two (48.5%) of the cups still in place at the end of the follow-up evaluation presented moderate and asymptomatic radiographic osteolysis, inciting close subsequent observation. No predictive factor of osteolysis onset was identified (age, body mass index, polyethylene wear, or cup orientation). None of the femoral stems was changed because of osteolysis: the only two femoral revisions resulted from periprosthetic fracture and one case of bipolar loosening. The femoral osteolysis images were small and all limited to zones 7a (18.8% of cases), 1a, and 1b (65.2% of cases). The overall survival rate of the series at 13 years of follow-up was 80.5%; the cup survival rate was 83.2%; the femoral implant, 94.3%; and failure of the femoral stem secondary to aseptic loosening was only 1.3%. DISCUSSION, CONCLUSION: This long-term study confirms the high frequency of retroacetabular osteolysis of ABG-1 prostheses surpassing the osteolysis rate of other uncemented cups with a polyethylene insert. The absence of predictive criteria of osteolysis occurrence and the lack of symptoms warrants periodic follow-up of patients with ABG-1 cups and, if necessary, early repair of bone stock loss with grafts combined with acetabular cup revision. This procedure remains simple as long as performed before the onset of massive bone destruction, confirming the proposed revisions in this series were judicious. This study also confirms the excellent long-term fixation of the ABG-1 femoral stems derived from the osteointegration and proximal seal around the hydroxyapatite coating.