Revision of total hip arthroplasty by long locking stem with fully hydroxyapatite-coated modular metaphysis (Reef™): A continuous series of 78 cases at a minimum 2-year follow-up.

INTRODUCTION: Since the Wagner and Vives stems were introduced in the 1980s, the range of uncemented implants for femoral revision has grown with increasing demand. Cementless modular implants with a wide range of lengths and diameters improved adaptation to the bone and secondary metaphyseal integration. Data are sparse for the Reef™ locking stem (Depuy-Synthes, Saint-Priest, France) and we therefore conducted a retrospective study at more than 2 years' follow-up, in a continuous series of total hip arthroplasty (THR) revision procedures using this long fully-hydroxyapatite-coated modular locking stem, assessing (1) implant survival, (2) clinical and functional results, and (3) radiographic results. HYPOTHESIS: The study hypothesis was that all-cause≥2-year survival is>90%. PATIENTS AND METHODS: Between 2007 and 2018, 413 femoral stem exchanges were performed in our center, a Reef™ model being needed in 93 cases. Etiologies comprised: Vancouver B2 or B3 periprosthetic fracture (57%, n=53), aseptic loosening (33%, n=30), septic loosening (10%, n=9) and 1 case of aseptic non-union under the stem (1%, n=1). Clinical and functional assessment used Harris Hip Score (HHS), Postel Merle d'Aubigné score (PMA) and Oxford-12 Hip Score (OHS). Radiographic assessment used immediate postoperative views and last follow-up radiographs, assessing osseointegration, filling index and stress shielding. Implant survival was estimated following Kaplan-Meier with 95% confidence intervals. RESULTS: Mean follow-up was 6±3 years (range, 2-12). Last follow-up included 78 cases for analysis (12 deaths [13%] and 3 patients lost to follow-up before 2 years [3%]). Ten-year Reef™ implant survival was 98.7% (95% CI: 96.3-100) free of aseptic loosening (n=1) and 94% (95% CI: 87-100) for all causes (n=3). The failures related to aseptic loosening involved femoral stem fracture away from the modular part; the 2 cases of septic loosening did not undergo reimplantation for medical reasons. Preoperatively (scheduled surgeries, excluding periprosthetic fractures: n=40), mean HHS was 43±12 and 77±12 at last follow-up (81±13 in scheduled surgery [n=40] and 73±11 in emergency surgery for periprosthetic fracture [n=53]), mean PMA score was 13±2 and mean OHS was 26±9. The infection rate was 11% (n=9) including 7.6% new infection (n=6). The dislocation rate was 6% (n=5). The radiographic stress shielding rate was 11% (n=9) and significantly associated with low metaphyseal filling index (76±7% vs. 83±8% [p=0.009]). DISCUSSION: Like other recent data, the present good survival results support the trend for uncemented stems in femoral revision, as encouraged by the 1999 symposium of the French Society of Orthopedic Surgery and Traumatology (SoFCOT). Primary diaphyseal fixation enables secondary metaphyseal integration on an implant with modularity ensuring good bone adaptation. Close contact between the bone and hydroxyapatite surfaces is a key-point in the surgical strategy. LEVEL OF EVIDENCE: IV, retrospective study.

Kinetics of functional recovery after foot and ankle surgery. Comparison of EFAS and SF36 scores.

INTRODUCTION: The EFAS score is a new recently validated European quality of life score for foot and ankle surgery, comprising 6 questions on activities of daily living (ADL) and 4 on sport. The aim of the present study was to assess the kinetics of functional recovery on the EFAS and SF36 scores, and to assess correlations between the two at 0 to 6 months then 6 months to 1 year in a population of foot and ankle surgery patients, globally and per pathology. HYPOTHESIS: Hindfoot and ankle surgery requires at least 1 year's follow-up for assessment of recovery, whereas 6 months is sufficient to assess forefoot recovery. MATERIAL AND METHODS: A multicenter prospective cohort study included all patients undergoing surgery for foot and ankle pathology between December 2015 and July 2016. Statistical analysis, global and per pathology, was performed preoperatively and at 6 months and 1 year. RESULTS: In total, 98 patients were assessed at 1 year. In the global population, EFAS ADL score improved by 17.1±22.1 points (hindfoot, 16.9±24.6; forefoot, 19.7±21.4) and global SF36 score by 8.7±17.1 points (hindfoot, 10.2±19.1; forefoot, 9.6±15.9). Both scores progressed between 6 months and 1 year for hindfoot pathologies, whereas they remained constant after 6 months for the forefoot. The EFAS score showed weak correlation with SF36. CONCLUSION: Recovery kinetics differs according to type of foot and ankle pathology. The EFAS score is more suitable than the SF36. LEVEL OF EVIDENCE: II.

Active or passive maternal smoking increases the risk of low birth weight or preterm delivery: Benefits of cessation and tobacco control policies.

In France, maternal smoking, active or passive, remains one of the highest in Europe. At the same time, there is an increase in the number of low birth weight (<2500 g) and premature (<37 weeks of amenorrhea) newborns. The objective of this narrative review is to examine the impact of active or passive maternal smoking on birth weight or prematurity rates, and to consider the benefits of policies to stop or control smoking. This is a narrative review that analyzes and discusses the major articles published over the past 20 years regarding the role of active or passive maternal smoking on the risk of low birth weight or preterm delivery. Articles were selected using the following keywords: maternal smoking, low birth weight, preterm birth, smoking cessation, passive smoking, exhaled carbon monoxide, tobacco control policies. Active smoking is associated, in a dose-response relationship, with increased risks of low birth weight and preterm delivery. Passive smoking, mainly related to the presence of a smoking spouse, increases the risk of low birth weight and preterm birth. Our review confirmed also the benefits of smoking cessation, even in the third trimester, in reducing the risk of small for gestation age or fetal growth restriction and preterm birth. Several studies of tobacco control policies have been shown to be effective in significantly reducing maternal smoking. There is sufficient evidence to infer a causal link between active or passive maternal smoking and low birth weight or preterm delivery. This causal link is compelling and sufficient to justify intensifying efforts to promote rapid progress in tobacco control policies, with the vision of a tobacco-free generation, and smoking cessation with best practices during preconception or pregnancy.

Analysis of an explanted dual mobility cup after 21 years, parabolic wear pattern: A case report.

CASE: A dual mobility cup was implanted in 1983 in a 43-year woman. After 31 years of normal function, we analysed the explanted materials with modern techniques. CONCLUSION: Volumetric wears of the small and large articulations of the dual-mobility construct were similar. For the first time, we demonstrated that the dual-mobility liner underwent parabolic (not linear) wear during the period of implantation.

Talo-navicular and calcaneo-cuboid fusion with PEEK H-pode™ vs. Titanium Maxlock™ locking plates: Comparison of functional and radiographic outcomes.

BACKGROUND: Locking plates are increasingly used to achieve hindfoot fusion. The objective of this study was to compare hindfoot fusion outcomes with the PEEK H-pode™ (Biotech™) locking plate and the titanium Maxlock™ (Tornier-Wright™) locking plate. HYPOTHESIS: A polyetheretherketone (PEEK) H-pode™ locking plate provides similar fusion rates to a titanium Maxlock™ locking plate for talo-navicular and calcaneo-cuboid arthrodesis. METHODS: We conducted a retrospective comparative study in 39 patients (including 21 [54%] with pes planovalgus and 11 [28%] with neurological equinovarus deformities) who underwent talo-navicular and/or calcaneo-cuboid fusion, usually combined with subtalar fusion. The first 17 patients (January 2014-February 2016) were managed with Maxlock™ locking plates and the next 22 patients (March 2016-August 2018) with H-pode™ locking plates. These two cohorts of consecutive patients were comparable regarding age, sex distribution, body mass index, and comorbidities. At last follow-up more than 1year after surgery, we compared functional scores, pain intensity, and fusion assessed by radiographs and computed tomography (CT) (threshold set at 33%). RESULTS: Mean follow-up was 42months (range: 34-63months) in the Maxlock™ group and 25months (range: 12-36months) in the H-pode™ group. At last follow-up, the two groups were not significantly different for the mean values of the American Orthopedic Foot & Ankle Society score, European Foot & Ankle Society score, and visual analogue scale pain score. Neither were the two groups significantly different for talo-navicular and calcaneo-cuboid fusion by CT. In the Maxlock™ group, we found non-significant trends towards a higher proportion of patients with talo-navicular nonunion (18% vs. 5% in the H-pode™ group) and weaker talo-navicular fusion in patients with pes planovalgus (60.8% vs. 82.0%, respectively). Radiographic results overestimated the fusion rates. DISCUSSION: Talo-navicular and calcaneo-cuboid fusion was not significantly different with H-pode™ and Maxlock™ locking plates. CT was more accurate than standard radiography to assess fusion. These results underline the usefulness of PEEK locking plates for talo-navicular and calcaneo-cuboid fusion; moreover, the radiolucency of PEEK facilitates the interpretation of radiographs. LEVEL OF EVIDENCE: IV.

Accuracy and precision of the measurement of liner orientation of dual mobility cup total hip arthroplasty using ultrasound imaging.

The Dual Mobility Cup (DMC) was created in 1974 to prevent dislocation and decrease wear. However, the movement of the polyethylene liner in vivo remains unclear. The aims of this study were to visualise liner positions and quantify the accuracy of the liner plane orientation for static positions, using ultrasound imaging. DMC reconstruction and angle between cup and liner were evaluated on isolated submerged DMCs by comparing 3D laser scans and ultrasound imaging. Moreover, the abduction and anteversion angles of the liner plane relative to the pelvis orientation were calculated via combined motion analysis and 3D ultrasound imaging on four fresh post-mortem human subjects with implanted DMC. On submerged DMC, the mean angle error between ultrasound imaging and 3D scan was 1.2°. In cadaveric experiments, intra-operator repeatability proved satisfactory, with low range value (lower than 2°) and standard deviation (lower than 1°). The study demonstrates the feasibility of measuring liner orientation on submerged and ex vivo experiments using ultrasound imaging, and is a first step towards in vivo analysis of DMC movement.

Fetal growth restriction, low birth weight, and preterm birth: Effects of active or passive smoking evaluated by maternal expired CO at delivery, impacts of cessation at different trimesters.

INTRODUCTION: The objectives of this study were to evaluate the effect of cessation of active smoking during the 1st, 2nd, and 3rd trimesters of pregnancy on the risk of reduced birth weight and prematurity using an exhaled carbon monoxide biomarker with a cut-off value ≥3 ppm as well as the effects of passive smoking. METHODS: This was a multicenter prospective cohort study involving pregnant smokers and non-smokers. Pregnant smokers were identified at the first prenatal visit before 15 weeks of amenorrhea by the number of cigarettes smoked per day and by the carbon monoxide breath test. Women were classified into 6 groups: non-smokers, passive smokers, first trimester cessation, second trimester cessation, third trimester cessation, and smoking throughout pregnancy. Smoking cessation was defined if the pregnant woman reported quitting smoking and if she achieved an exhaled CO level of <3 ppm. The association between smoking cessation and fetal growth restriction or prematurity was assessed by multivariate logistic regression. Passive smoking was defined for non-smoking women on declarative smoking status and exhaled CO ≥3 ppm. The association between passive smoking and fetal growth restriction or prematurity was assessed by multivariate logistic regression. RESULTS: The number of patients included was 5244. The incidence of fetal growth restriction below the 10th percentile was 10.6%, 12.1%, 8.5%, 9.1%, 21.1%, and 22.9%, respectively, for the non-smoking, passive smoking, first, second, third trimester cessation, and full-pregnancy smoking, groups. The risk of FGR compared to non-smokers was OR=2.3 (95% CI: 1.18-4.30, p=0.014) for patients who quit smoking in the third trimester, OR=2.5 (95% CI: 2.03-3.12, p<0.001) for women who smoked throughout pregnancy. After logistic regression, FGR (AOR=1.9; 95% CI: 0.96-3.82) for women who quit smoking in the 3rd trimester (AOR=1.8; 95% CI: 1.38-2.31, p<0.001). The risk of FGR <5th percentile was AOR=1.96 (95% CI: 1.36-2.48, p<0.001). CONCLUSIONS: Active or passive smoking during pregnancy is associated with an increased risk of intrauterine growth restriction and low birth weight. Cessation in the 1st and 2nd trimester reduces the risk of intrauterine growth restriction or low birth weight. Passive smoking has a deleterious impact on fetal development, intermediate to that of active smoking.

An anatomical study of the meniscal roots of the knee: landmarks for its surgical reconstruction and implications for knee surgeons.

PURPOSE: The aim of this anatomical study was to describe the anatomy of the meniscal roots and their relationships with respect to the main adjacent structures in order to improve their surgical reconstruction. METHODS: Fourteen knees were included. The mean age of the donors was 92 years (range 89-96). We studied the general characteristics of the anterior and posterior roots of the medial meniscus and lateral meniscus by measuring their widths at their base and area. We investigated the relations between anterior and posterior roots of the medial and lateral menisci with respect to the anterior and posterior cruciate ligaments (ACL and PCL). RESULTS: The mean width of the anterior root of the lateral meniscus was 10.5 ± 1.4 mm. The mean width of the anterior root of the medial meniscus was 10 ± 1.5 mm. The mean width of the posterior root of lateral meniscus was 11.4 ± 1.4 mm. The mean width of the posterior root of medial meniscus was 10.5 ± 1.0 mm. The mean distance between the anterior cruciate ligament and the anterior root of lateral meniscus was 9.8 ± 2.9 mm, for the medial meniscus it was 15.9 ± 3.4 mm. The mean distance between the posterior cruciate ligament and the posterior root of the lateral meniscus was 11.5 ± 2.7 mm, for the medial meniscus, it was 11 ± 2.6 mm. CONCLUSION: The anterior and posterior meniscal roots have precise landmarks, and this article contributes to define the location of the meniscal roots with respect to their adjacent anatomical structures: ACL, PCL and intercondylar tubercle. Having precise measures of the distances between the meniscus roots and these structures allows knee surgeons to perform ACL reconstruction, meniscal root repair and meniscal allograft transplantation.

Impact of smoking cessation on healing after foot and ankle surgery.

INTRODUCTION: Perioperative smoking is the main risk factor for the development of postoperative cutaneous wound healing complications. We require that all patients undergoing elective foot and ankle surgery stop smoking (6 weeks before and 3 months after) and this abstinence is monitored with a preoperative cotinine test. We therefore wanted to understand how this impacted wound healing in elective foot and ankle surgery: do wounds heal differently in patients who quit smoking for surgery, former smokers and nonsmokers? HYPOTHESIS: Our hypothesis was that patients who stopped smoking for an upcoming surgery had the same wound healing complications as nonsmokers and former smokers. MATERIALS AND METHODS: This was a historical, single-center, single-surgeon cohort study of adult patients who underwent an elective ankle or foot surgery between June 2016 and July 2017. Patients were divided into 3 groups: group 1 smokers who stopped for surgery, group 2 former smokers, and group 3 nonsmokers. The primary endpoint was the occurrence of wound healing complications during the wound care consult scheduled 3 weeks after surgery. RESULTS: A total of 256 patients with a mean age of 58±14.2 years (range, 18-88) were included. Group 3 had more women and a lower BMI than the other groups, but all the other demographic characteristics were similar. Smoking cessation was achieved in group 1 on average 2.5±1.3 months (range, 1-6) before surgery. There were a total of 20 wound healing complications or 7.5% of the cohort: 13% in group 1, 11.1% in group 2 and 6.4% in group 3. The univariate analysis found that the odds ratio was 2.3 when comparing Group 1 to Group 3 and 1.85 when comparing group 2 to group 3 (p=413). No significant risk factors for wound healing complications were found. DISCUSSION/CONCLUSION: Smoking cessation for foot and ankle surgery seems to limit the risk of wound healing complications, with results close to those of former smokers and nonsmokers. Mandatory smoking cessation before surgery could be one of the solutions to prevent this frequent complication. LEVEL OF EVIDENCE: III.

97 HINTEGRA ankle prostheses: Results and survival at more than 5 years' follow-up.

BACKGROUND: In Europe, fixed-bearing implants predominate again in total ankle replacement (TAR). The present single-center single-surgeon study assesses the Hintegra® mobile-bearing implant (NEWDEAL). METHODS: Between November 2008 and November 2015, 97 Hintegra® were implanted in 94 patients: mean age, 62.4±10.9 years (26-83); 59% (57/97) male; normal mean body-mass index (BMI), 27.5 ± 4.3 kg/m2. Indications mainly comprised posttraumatic (40.2%), instability (29.9%) and primary osteoarthritis (16.5%). 17.5% of patients had prior surgery during the previous 6 months (9 fusions, 8 ligament reconstructions, and 4 osteotomies); in 59.8%, other procedures were associated to TAR. Functional, clinical and radiological follow-up was conducted at 1 year, 2 years and last follow-up (>5 years). RESULTS: Ninety-four TARs were analyzed at a mean 81 ± 21.6 months (19-124). Revision-free survival was 76% (95% confidence interval (95%CI): 0.66-0.8), and explantation-free survival 92% (95%CI: 0.85-1) with 10 cases of curettage and 5 explantations. Mean AOFAS score improved from 41.8 ± 12.5 (21-69) to 77.5 ± 16.5 (24-100) up (p < 0.001); 75% of patients had no or only mild pain (p < 0.001). Clinical ranges of motion were 8.0 ± 7.1° dorsiflexion (p < 0.001) and 35.1 ± 9.4° plantar flexion (preoperatively, 34.1 ± 7.9°) (p = 0.71). Radiologically, tibial components were well-positioned; 87% of talar components were well-centered. Global ankle range of motion was 23.5 ± 10.2° (5-48) (p = 0.17). 54.6% of TARs showed posterior tibial calcification at follow-up. Risk of severe cyst (>1 cm) on CT was 36% (95%CI: 23-47) at a mean 77 ± 21.9 months (18-123). CONCLUSION: Hintegra® TAR incurred a low risk of revision, and is a reliable option for ankle osteoarthritis. LEVEL OF EVIDENCE: IV.

Relationships of the superficial fibular nerve and sural nerve with respect to the lateral malleolus: implications for ankle surgeons.

PURPOSE: Superficial fibular nerve (SFN) and sural nerve are at risk during osteosynthesis of the lateral malleolus. The aim of this anatomical study was to describe the relationships of the superficial fibular and sural nerves with respect to the lateral malleolus. METHODS: Nine corpses (18 ankles) were dissected, using a direct lateral approach. Measurements were recorded between the fibula and the nerves, and the pattern variations of the SFN were recorded for both right and left side to assess intra-individual variability. RESULTS: Distance between the tip of the lateral malleolus and the piercing of fascia cruris was 111 ± 26 mm for type 1 pattern, and range was 46-161 mm all types included. 78% (14 SFN) were type 1 pattern, 17% (3 SFN) were type 2 pattern, and 5% (1 SFN) were type 3 pattern. 44% (4 specimen) had a type 1 pattern SFN on one ankle and another pattern on the other ankle. The sural nerve was always observed just posterior to the lateral malleolus. CONCLUSION: This study demonstrated a great inter-individual variability especially for the SFN, but also an intra-individual variability with frequent different patterns between right and left leg. It is important to know the anatomical variations of the SFN and sural nerve to decrease the risk of intra operative nerve injury during direct lateral approach of lateral malleolus.

Cementless hydroxyapatite-coated stem with dual mobility and posterior approach in over-80 year-old patients with osteoarthritis: Rates of dislocation and periprosthetic fracture at a mean 8 years' follow-up.

BACKGROUND: Straight cementless stems are common in primary total hip arthroplasty (THA) in the elderly, but controversial due to higher risk of loosening and periprosthetic fracture (PPF). Apart from registries, results for the Corail implant and dual mobility (DM) in over-80 years-old are not known, notably in case of systematic association to a DM cup. We therefore performed a retrospective analysis of Corail implants in patients aged≥80years at implantation for osteoarthritis of the hip, assessing 1) PPF rate and survival for cementless straight stems associated to DM cups, 2) complications, and dislocation in particular, and 3) clinical scores. HYPOTHESIS: PPF and dislocation rates are low in THA with cementless straight stem associated to DM cup in patients aged≥80years. PATIENTS METHODS: A retrospective study was conducted in our department for the period July 2007 to December 2012. Inclusion criteria were age≥80years, with primary THA for osteoarthritis. Exclusion criteria were revision procedure and femoral neck fracture. One hundred and twenty-eight consecutive THAs were included, in 120 patients, with a minimum 5years' follow-up. Clinical results were assessed on Harris Hip Score (HHS) and Oxford Hip Score (OHS). Data were collected for PPF or dislocation and other complications. RESULTS: At a mean 8±1 years' follow-up (range, 5-10 years), 66 patients (55%, for 68 hips) were alive, 48 (40%, for 54 hips) had died, and 6 (5%, for 6 hips) were lost to follow-up. Median age at surgery was 83years (range, 80-93years). Mean OHS at last follow-up was 41±6 (range, 21-48) and HHS 83±14 (range, 23-100) with mean gain of 32 points (95% CI, [28-36]; p<0.001)). There were 2 cases (1.6%) of PPF, at 2 and 65months, and no dislocations or cases of aseptic loosening. There were 2 cases (1.6%) of intraoperative calcar fracture, treated by wire cerclage with immediate complete weight-bearing, without further complications. With death as a competing risk, cumulative 10-year incidence of femoral stem revision was 1.6% [95% CI: 0.4-6.5], and cumulative incidence of all-cause revision was 4.1% [95% CI: 1.7-9.7]. DISCUSSION: In an over-80 year-old population, primary THA with straight cementless stem and 2nd generation dual mobility cup was an effective option with low risk of PPF or dislocation after a minimum 5-year of follow-up. LEVEL OF EVIDENCE: IV; retrospective study.

Outcomes and survival of a modern dual mobility cup and uncemented collared stem in displaced femoral neck fractures at a minimum 5-year follow-up.

INTRODUCTION: The choice of implant type for total hip replacement in the treatment of femoral neck fractures remains debated. Some authors advocate for the systematic use of cemented stems, while others do not use dual mobility first-line. We therefore conducted a retrospective study using a dual mobility cup (DMC) and an uncemented collared stem (UCS) in order to: (1) confirm the low dislocation rate in this indication, (2) assess other surgical complications, in particular periprosthetic fractures, (3) ensure that these benefits are maintained over time, at a minimum follow-up of 5 years and, (4) assess the rate of revision of the implants. HYPOTHESIS: Our hypothesis was that the dual mobility dislocation rate for the treatment of femoral neck fractures was lower than for bipolar hemiarthroplasties or single mobility hip prostheses. PATIENTS AND METHODS: A retrospective study of 244 femoral neck fractures (242 patients) treated with DMC and UCS was conducted, between 2013 and 2014. The mean age was 83±10 years (60-104). The occurrence of dislocation, periprosthetic fracture, infection of the surgical site, loosening, reoperation and revision were investigated. The HOOS Joint Replacement (JR) score was collected. The cumulative incidence with mortality was used as a competing risk. RESULTS: The mean follow-up was 6 years±0.5 (5-7). At the last follow-up, 108 patients (50%) had died. Twenty-three patients (9.5%) were lost to follow-up. One case of symptomatic aseptic loosening of DMC was observed. The cumulative incidence of dislocations and periprosthetic fractures at 5 years were 2% (95% CI: 0.9-5.4) and 3% (95% CI: 1.2-6), respectively. The 5-year cumulative incidence of surgical site infections was 3.5% (95% CI: 1.8-7). The cumulative incidence of reoperations at 5 years was 7% (95% CI: 4.5-11). The causes of reoperation were periprosthetic fracture (n=6), infection (n=8), postoperative hematoma (n=2) and cup malposition (n=2). The cumulative incidence of a revision at 5 years was 2.7% (95% CI: 1.2-6). The cumulative incidence of a surgical complication from any cause at 5 years was 9% (95% CI: 6.7-14.8). The mean HOOS JR score was 79±5 (52-92). DISCUSSION: The cumulative incidence of dislocation at 5 years is low and other surgical complications (including periprosthetic fractures) do not increase during this period for DMC associated with UCS, in femoral neck fractures. The use of this type of implant is reliable in the treatment of femoral neck fractures. LEVEL OF EVIDENCE: IV; retrospective study without control group.

Incidence and risk factors for bilateral proximal femoral fractures.

BACKGROUND: Proximal femoral fractures (PFFs) are a public health issue due to their high frequency. The frequency of a second PFF on the other side is estimated at 10%. This estimation is controversial, however, and the risk factors have not been evaluated in a large population of French patients. The objective of this retrospective case-control study was to determine: (1) the incidence of second PFFs and (2) their risk factors. HYPOTHESIS: The incidence of second PFFs is >2% after 1 year and >5% after 3 years. MATERIAL AND METHODS: We conducted a case-control study in a population of consecutive patients managed surgically for PPF at the Lyon Sud Hospital between 2013 and 2014. We analysed the following clinical factors: age, sex, body mass index (BMI), institutionalisation, the Parker score, the American Society of Anesthesiologists score (ASA), comorbidities, and the use of psychoactive drugs. RESULTS: We included 474 PFFs (trochanter, n=240 and neck, n=234) of which 36 were bilateral. The contralateral fracture occurred within 1 year of the first fracture in 6/474 (1.3%) cases and within 3 years in all 36 cases (7.6%). The case-control study comprised 49 cases with bilateral PFF and 161 controls with no second hip fracture within 3 years. Risk factors for a second hip fracture were age older than 90 years (odds ratio [OR]=5.44; 95% confidence interval [95%CI], 112-2642 (p=0.002)) and a history of heart disease (OR, 2.18; 95%CI, 1.06-4.47 [p=0.03]). A Parker score≥6 was protective (OR, 0.84; 95%CI, 0.71-0.99 [p=0.03]). Mortality after 3 years was 42% (201/474), and 13% (63/474) of patients were lost to follow-up. DISCUSSION: Age older than 90 years, a Parker score below 6, and a history of heart disease are risk factors for a second PFF within 3 years after the first PFF. LEVEL OF EVIDENCE: III; case-control study.

Prospective analysis of intraoperative radiation dose in foot and ankle surgery using mini-C-arm fluoroscopy. Continuous series of 1064 procedures.

INTRODUCTION: Foot and ankle surgeons make daily use of mini-C-arm fluoroscopes. The present study aimed to quantify associated radiation doses. HYPOTHESIS: X-ray exposure for foot and ankle surgeons using a mini-C-arm fluoroscope is below the nuclear safety authority authorized doses of 20 mSv/year for the whole body and crystalline lens, 150 mSv/year for the thyroid and 500 mSv/year for the skin and limbs. MATERIAL AND METHODS: A single-center, single-surgeon prospective series was treated between February 2014 and December 2017. Doses emitted by the mini-C-arm (15cm field) were recorded during 1,064 operations. Doses received by the surgeon were recorded by 3 passive dosimeters (thorax, eyes and hands) and 1 active dosimeter. The significance threshold was set at p<0.05. RESULTS: A total of 64.4% of procedures concerned the forefoot, 35.3% the hindfoot and ankle, and 0.3% were strictly percutaneous. Mean dose-area product (DAP) per procedure was 3.9 cGy/cm2±7: in forefoot surgery, 1.1 cGy/cm2±0.9, and in hindfoot and ankle surgery 8.7 cGy/cm2±9.7 (p<0.05), for mean irradiation times of 7.6s±5.3 and 36.7s±35.5 respectively and image numbers 4.1±2.7 and 18.7±20.5. Total ankle replacement was associated with the highest doses: 20.1 cGy/cm2±14.7. Mean daily active dosimetry was 2.2µSv±1.4. Mean annual dose to the hand, crystalline lens and deep (Hp(10)) and shallow (Hp(0.07)) whole body was respectively 1.28 mSv, 0.6 mSv, 0.31 mSv and 0.19 mSv. The highest annual exposure was recorded for the hands: 2.68 mSv in 2015. There was a significant linear relationship between daily active dosimetry and daily emission: daily active dosimetry=(DAP×0.11)+0.54, for a correlation coefficient of 0.77. DISCUSSION/CONCLUSION: The exposure of foot and ankle surgeons using mini-C-arms was well below threshold, and also lower than in the literature. LEVEL OF EVIDENCE: IV.

Rheumatoid Forefoot Reconstruction in Nonrheumatic Patients: Lesser Metatarsal Head Resection versus Osteotomy.

In the literature, first metatarsophalangeal joint arthrodesis with lesser metatarsal head resection seems to be a reliable procedure in rheumatoid foot deformity. Maybe this procedure could be proposed in nonrheumatoid severe forefoot deformity (hallux valgus angle >40° and lesser metatarsophalangeal dislocation). The aim of this study was to compare radiological and clinical outcomes between lesser metatarsal head resection and lesser metatarsal head osteotomy in nonrheumatoid patients. Thirty-nine patients (56 feet) suffering from well-defined nonrheumatoid severe forefoot deformity were retrospectively enrolled in our institution between 2009 and 2015. Metatarsal head resection and metatarsal head osteotomy represented 13 patients (20 feet) and 26 patients (36 feet), respectively. In this observational study, a rheumatoid population (21 patients) was included as the control. The clinical outcome measures consisted of American Orthopaedic Foot and Ankle Society score, Foot and Ankle Ability Measurement, and Short Form-36. The radiological outcomes were: intermetatarsal angle, hallux valgus angle, and metatarsophalangeal alignment. Mean follow-up was 24 months. Satisfaction rate was, respectively, 92% for resection, 91% for osteotomy procedure, and 80% for surgery in rheumatoid patients. Short Form-36 global score was, respectively, 80.7 (52.5-96.4), 76 (57.7-93), and 68.3 (22.6-86). No functional outcome difference was found between resection and osteotomy procedures, except that the metatarsal head resection group had poorer results in sports activities than the osteotomy group. Complications were similar between osteotomy and resection (p > .05). The radiological outcomes were improved significantly from preoperative to postoperative. First metatarsophalangeal joint arthrodesis with lesser metatarsal head resection in nonrheumatoid severe forefoot deformity might be a good therapeutic option.

Articular Noise After THA Using Delta CoC Bearings Has Little Impact on Quality of Life.

BACKGROUND: To report clinical outcomes and survival at a minimum of 10 years of a consecutive series of uncemented total hip arthroplasty (THA) with fourth-generation ceramic-on-ceramic (CoC) bearings and determine the incidence of articular noises, their risk factors, and impact on quality of life (QoL). METHODS: From a series of 456 CoC THAs, there were 25 revisions, 38 deceased, and 36 lost to follow-up. The remaining 357 hips were assessed at 11.1 ± 0.7 years (range, 10-14) using the Forgotten Joint Score, Oxford Hip Score, and a questionnaire on articular noises. Kaplan-Meier survival was calculated, and multivariable analysis was performed to determine associations between articular noise and patient/surgical factors. RESULTS: The 10-year survival was 96.3% for the cup, 96.5% for the stem, and 94.2% for all components. The Forgotten Joint Score was 79 ± 26 (range, 0-100), and Oxford Hip Score was 16 ± 7 (range, 12-60). The mean impact of articular noises on QoL was 1.8 ± 2.9 (range, 0-9): considered negligible in 60 hips (16%), moderate in 27 hips (7%), and severe in only 13 hips (4%). Multivariable analyses revealed that the incidence of articular noise decreased with age (odds ratio [OR], 0.94; P = .001), body mass index (OR, 0.85; P = .001), and in hips implanted with 32-mm (vs 36 mm) heads (OR, 0.18; P = .030). CONCLUSION: Of 100 hips (28%) that reported some articular noises 10 years after CoC THA, the impact of articular noises on QoL was negligible for most patients. Although larger heads can improve mobility and reduce risks of dislocations, surgeons must be aware that increasing head size could also increase risks of articular noises, notably in young and active patients.

Mid-Term Clinical and Radiographic Outcomes of a Long Cementless Monobloc Stem for Revision Total Hip Arthroplasty.

BACKGROUND: For the past 2 decades, the authors have been using a long tapered cementless stem made of titanium and fully coated with hydroxyapatite for revision total hip arthroplasty. The purpose of this multicentric study is to assess clinical outcomes, radiographic outcomes, re-revision rates, and survival rates of this revision stem at a minimum 5-year follow-up. METHODS: The records of a multicentric continuous series of 335 adults undergoing revision total hip arthroplasty using the Corail revision stem (DePuy, Leeds, UK) between 2000 and 2012 were retrospectively reviewed. The Harris Hip Score, Oxford Hip Score, and Engh score were recorded. Survival was assessed using the Kaplan-Meier method and cumulative incidence function. RESULTS: Seventy-seven patients died with their revision stem in place, 47 could not be contacted, and 22 had stem re-revisions. This left a final cohort of 201 patients, aged 70 ± 12 years at revision surgery, with a body mass index of 26 ± 4. The Kaplan-Meier survival was 93.9% for re-revision of any component for any reason, 96.7% for re-revision of the stem for any reason, and 99.3% for re-revision of the stem for aseptic reasons. At last follow-up, the Harris Hip Score was 84.8 ± 13.1, the Oxford Hip Score was 21.0 ± 7.8, and the Engh score was 16.4 ± 6.7. CONCLUSION: The long tapered cementless revision stem had excellent clinical and radiographic outcomes at a minimum follow-up of 5 years. The revision stem enabled restoration of bone stock in femurs with pre-revision bone defects, confirming that the hydroxyapatite coating promotes osseointegration, even in femurs with extensive bone loss. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Pseudomonas aeruginosa Implant-Associated Bone and Joint Infections: Experience in a Regional Reference Center in France.

Background: P. aeruginosa implant-associated bone and joint infections (BJI) is considered to be one of the most difficult to treat BJI. The data focusing specifically on this pathogen are sparse, and it seems difficult to extrapolate the results obtained with Enterobacteriaceae. Methods: We performed a retrospective observation study of all P. aeruginosa implant-associated BJI diagnosed at our institution from 2011 to 2018. We defined failure as any type of relapse, including persistence of the same P. aeruginosa, superinfection by another organism(s) or any other cause of relapse such as the need for a subsequent surgery. Nonparametric statistical methods were used to compare the study groups and Kaplan-Meier curves and multivariate Cox analysis and were used to detect determinants associated with treatment failure. Results: A total of 90 patients (62% men, median age 60 years IQR 47-72) including 30 (33%) prosthetic-joint infections and 60 (66%) other implant-associated BJIs were studied. Most of them were acute (62%). During the prolonged follow-up, (median 20 months; IQR 9-37), 23 patients (26%) experienced treatment failure. Optimal surgical treatment (DAIR for acute forms, explantation, 1-stage or 2-stage exchange for others) was significantly associated with a higher success rate in the univariate analysis (p = 0.003). Sixty-four (71%) patients received effective initial treatment against P. aeruginosa administered and 81 of them (90%) did for at least 3 weeks: both these parameters correlated with a higher success rate. In the multivariate Cox-analysis optimal surgical treatment, IV effective treatment of at least 3 weeks and treatment with ciprofloxacin for at least 3 months proved to be independently associated to a better outcome in patients with P. aeruginosa implant-associated BJI. Conclusion: P. aeruginosa implant-associated BJI is one of the most difficult-to-treat BJI, with a strong impact on the prognosis of the surgical strategy. An effective initial IV antibiotic treatment for at least 3 weeks seems to be required, followed by oral ciprofloxacin for a total duration of 3 months.

Metasul vs Cerasul bearings: a prospective, randomized study at a mean eighteen years.

BACKGROUND: The aims of our study were to compare the clinical, radiographic outcomes and survivals between second-generation metal-on-metal (Metasul) and ceramic-on-ceramic (Cerasul) bearings at a very long-term follow-up. METHODS: A prospective, randomized study was originally performed on a consecutive series of 250 cementless, 28-mm head and primary total hip arthroplasties between 1999 and 2002. For each bearing (Metasul or Cerasul), 125 THAs were initially included. All cases were evaluated both clinically and radiographically, and survival was assessed, considering revisions for aseptic loosening or for any reason as the end points for failure. RESULTS: At a mean 18-year follow-up, clinical and radiographic outcomes were similar. Harris Hip Score increased 30% in the Metasul group and 32% in the Cerasul group (p = 0.6). Survival free of aseptic loosening was higher for Cerasul (100%), than for Metasul (94% [CI 88-99.9]) (p = 0.04). Survival free of any revision was 91% ([CI 84-98%]) for Cerasul and 91% ([CI 84-98%]) for Metasul. Fractures of Cerasul insert occurred in four cases (3%) at a mean 12.5 ± 3.3 years (range, 6 to 17 years). CONCLUSION: At 18 years, Cerasul demonstrated higher survivorship than Metasul considering aseptic loosening as an end point. However, Cerasul liners had high rate of fracture because of its sandwich design (thin ceramic liner into polyethylene). These implants are no more available on the market.