Transverse subtrochanteric shortening osteotomy with double tension-band fixation during THA for Crowe III-IV developmental dysplasia: 12-year outcomes.

BACKGROUND: When performing total hip arthroplasty in patients with severe developmental dysplasia, shortening the femur facilitates reduction while also preventing sciatic or crural nerve injury and excessive length of the operated limb. No consensus exists about the optimal type of implant and best internal fixation procedure, two parameters that directly govern the risk of the most common intraoperative and postoperative complications (diaphyseal fractures, dislocation, non-union). To minimise these risks, we developed a technique combining a transverse subtrochanteric shortening osteotomy, a long ovoid-profiled, cementless stem anchored in the metaphysis, and double tension-band wiring for internal fixation. The primary objective of this study was to evaluate the outcomes of this technique with emphasis on (i) complications and femoral implant survival, (ii) clinical outcomes (functional scores and lower-limb length inequality [LLLI]), and time to healing. HYPOTHESIS: Our technique is associated with low rates of intraoperative and postoperative complications. MATERIAL AND METHODS: This single-centre retrospective cohort study included patients who underwent THA with a transverse subtrochanteric shortening osteotomy and fixation using double tension-band wiring to treat severe (Crowe III or IV) developmental hip dysplasia. The femoral implant was a long, ovoid, cementless stem fully coated with hydroxyapatite. We collected the intraoperative and postoperative complications, survival, LLLI, functional scores (Harris Hip Score [HHS] and Forgotten Joint Score [FJS]), patient satisfaction, and radiographic outcomes. RESULTS: The study included 31 hips in 25 patients. Two patients (2/31 hips, 6.5%) were lost to follow-up, leaving 29 hips for the analysis of postoperative outcomes. Mean follow-up was 13.7±4.2 years (range, 5.8-18.3 years). The four intraoperative complications (4/31, 12.9%) consisted fracture of the diaphysis (2/31, 6.5%), fracture of the greater trochanter (1/31, 3.2%), and sciatic nerve injury followed by a full recovery (1/29, 3.4%). The 8 (8/29, 27.5%) postoperative complications consisted of dislocation (2/29, 6.9%), stem subsidence (2/29, 6.9%), and non-union (4/29, 13.8%). Femoral implant survival at last follow-up was 87.1% (95% CI, 76.1-99.7). The mean HHS increased from 39.6±12.0 (range, 14-61) before surgery to 81.7±13.2 (range, 48-100) at last follow-up (p<0.01). The FJS at last follow-up indicated that the joint was forgotten in 14/29 (48.2%) cases and caused only acceptable symptoms in 9/29 (31.0%) of cases. Clinically significant (≥ 1cm) LLLI was present in 8/29 (27.6%) patients postoperatively compared to 19/29 (65.5%) preoperatively. The mean LLLI decreased from 20.8±19.7mm (range, 0-60mm) to 5.0±7.3mm (range, 0-30mm). Mean time to healing was 4.3±2.4 months (range, 2-11 months). CONCLUSION: Regarding these complex procedures, this technique was associated with low rates of intraoperative fractures and early postoperative complications. However, femoral stem survival was shorter than in earlier studies and the non-union rate was high, despite satisfactory functional and clinical outcomes.

Early Evaluation of a New French Surgery Course in the Best Practice of Dealing With Major Incidents and Mass Casualty Events.

OBJECTIVE: The main objective of this study is to evaluate the impact of a nationwide 5-month course aimed to prepare surgeons for Major Incidents through the acquisition of key knowledge and competencies. Learners' satisfaction was also measured as a secondary objective. DESIGN: This course was evaluated thanks to various teaching efficacy metrics, mainly based on Kirkpatrick's hierarchy in medical education. Gain in knowledge of participants was evaluated by multiple-choice tests. Self-reported confidence was measured with 2 detailed pre and post training questionnaires. SETTING: Creation in 2020 of a nationwide, optional and comprehensive Surgical Training in War and Disaster Situation as part of the French surgery residency program. In 2021, data was gathered regarding the impact of the course on participants' knowledge and competencies. PARTICIPANTS: The study included 26 students in the 2021 cohort (13 residents and 13 practitioners). RESULTS: Mean scores were significantly higher in the post-test compared to the pre-test, showing significant increase in participants' knowledge during the course: 73,3% vs. 47,3% respectively (p ≤ 0.001). Average learners' confidence scores to perform technical procedures showed at least a +1-point increase on the Likert scale for 65% of items tested (p ≤ 0.001). 89% of items showed at least a +1-point increase on the Likert scale when it came to average learners' confidence score on dealing with complicated situations (p ≤ 0.001). Our post-training satisfaction survey showed that 92% of all participants have noticed the impact of the course on their daily practice. CONCLUSION: Our study shows that the third level of Kirkpatrick's hierarchy in medical education was reached. This course therefore appears to be meeting the objectives set by the Ministry of Health. Being only 2 years old, it is on the road to gathering momentum and further development.

Survival and complications at a minimum 5years' follow-up of the modular Mark-2 Extreme™ cementless femoral stem: Does the reduced modularity resolve the mechanical issues of the Mark-I stem?

INTRODUCTION: The Extreme™ modular stem was developed for implant revision with metaphyseal-diaphyseal defect. Due to the high breakage rate, a new "reduced modularity" design has been introduced, but without reported results. We therefore conducted a retrospective assessment of (1) overall stem survival, (2) functional results, (3) osseointegration, and (4) the rate of complications, and notably of mechanical failure. HYPOTHESIS: Reduced modularity reduces the risk of revision surgery for mechanical failure. MATERIAL AND METHODS: Forty-five prostheses were implanted between January 2007 and December 2010 in 42 patients with severe bone defect (Paprosky≥III) or periprosthetic shaft fracture. Mean age was 69.6years (range: 44-91years). Minimum follow-up was 5years, for a mean 115.4months (range: 60-156months). The main study endpoint was femoral stem survival, counting all-cause explantation as event. Functional assessment comprised subjective rating of satisfaction, Postel Merle d'Aubigné (PMA) and Harris Hip scores, and Forgotten Joint Score (FJS). Whether the revision assembly was carried out in situ, in the patient's hip, or outside, on the operating table, was not known in 2 cases; in the other 43, assembly was in situ in 15 cases (35%) and on the operating table in 28 (65%). RESULTS: Five-year stem survival was 75.7% (95% CI: 61.9-89.5%), taking all causes of change together. Seventeen patients (45.9%) had complications, 13 (35.1%) requiring revision surgery, including 10 (27.0%) for stem replacement. Five patients (13.5%) had steam breakage at the junction between the metaphysis and the diaphyseal stem, 4 of which occurred within 2 years of implantation or of fixation of a periprosthetic fracture. Mean preoperative Harris score was 48.4 [IQR (25-75% interquartile range): 37-58] and PMA score 11.1 (IQR: 10-12), compared to respectively 74 (IQR: 67-89) and 13.6 (IQR: 12.5-16) at follow-up. Mean FJS at follow-up was 71.5 (IQR: 61-94.5). In the 15 in situ assemblies, there were 3 breakages (20%), compared to 2 (7.1%) in the 28 table assemblies (p=0.21). DISCUSSION: The stem breakage rate was high despite the reduced modularity, which concentrated all stress on a single junction but without reducing the risk of mechanical failure. Surgical technique was faulty in some cases, with in situ assembly of the metaphysis after implanting the diaphyseal stem, which does not respect the manufacturer's recommendations. LEVEL OF EVIDENCE: IV; retrospective study.

Secondary intramedullary nailing for open tibial shaft fractures. Comparison of a one-stage versus two-stage surgical procedure.

INTRODUCTION: The objective of this study was to compare the rates of radiological and clinical complications after sequential treatment of a tibial shaft fracture by external fixation followed by secondary nailing with an early-stage conversion (C1S) versus a two-stage late conversion (C2S). The hypothesis of this work was that treatment with C1S does not increase the risk of surgical site infections compared to C2S, and allows faster healing with a lower malunion rate. MATERIAL AND METHODS: We carried out a retrospective and comparative study based on the files of the traumatology department of the Édouard Herriot University Hospital in Lyon. We reviewed the records of patients who presented with a Gustilo grade 1, 2 or 3a open tibial fracture treated with external fixation with conversion by intramedullary nailing within 6 months from January 2010 to December 2020. We assessed the occurrence of Surgical Site Infections (SSI), consolidation time, time until resumption of weight bearing and the malunion rate. RESULTS: Of the 55 patients included, a C1S procedure was performed in 25 cases (45.5%) versus 30 cases (54.5%) for C2S. No significant difference was found concerning the occurrence of SSI after intramedullary nailing between the two groups (p=0.81). A significant difference was observed in terms of bone healing (p=0.036) and the malunion rate (0.0013) in favor of nailing in one stage. DISCUSSION: The strategy of converting an open leg fracture early, in one stage (C1S), after initial external fixator placement allows for faster healing and weight bearing, while ensuring a lower malunion rate compared to that of a late two-stage conversion. In the absence of a scar at the time of intramedullary nailing, C1S does not increase the risk of surgical site infections. While the choice of a late and sequential two-stage operation is likely related to the surgeon's apprehension around conversion of an open leg fracture by intramedullary nailing, this study could promote the use of C1S in a greater number of situations. LEVEL OF EVIDENCE: IV.

Retired French Military Orthopedic Surgeons' Opinions on Their Careers.

INTRODUCTION: Owing to their professional and personal experiences, retired military orthopedic surgeons' views of their careers are a unique source of inspiration. Reflecting on their experiences allows them to grasp the positive points and those that need to be improved for future generations. The purpose of this study is to gather the opinions of retired surgeons on the career of military orthopedic surgeons. METHODS: We addressed a questionnaire to all retired French military orthopedic surgeons in the database of the Chair of Applied Surgery for the Armed Forces as of December 2020, retrained in the civilian sector. A questionnaire sent by email made it possible to collect demographic, professional, and personal data about their careers. Subjective data were evaluated using a visual analog scale from 0 to 10 or a subjective qualification scale. The main assessment criterion was the average score (out of 10) of the retired surgeons' opinions on their careers. RESULTS: Fifty-two percent of retired surgeons replied (32 out of 61), with the respondents having an average age of 63 years. They had been in military retirement for an average of 14 years and had practiced for approximately 13.5 years. The majority (28 out of 32) had had a civilian activity after leaving the army. The three main reasons for leaving were the unsatisfactory working environment, the high number of deployments, and insufficient pay. Nevertheless, the respondents were satisfied with their activity, their job, and their training. The average score given for the overall opinion on their careers was 8.14/10. The three main disadvantages of the career that were noted were the quality of family life, the conditions of employment, and the financial aspects. The majority were very satisfied with the second half of their civil career. CONCLUSION: Overall, the opinion of retired French military orthopedic surgeons on their careers is very good. Their point of view provides interesting elements for reflection from both a professional point of view and a personal point of view. They were very satisfied with the quality of their training, their job, and their activity. However, the quality of their personal/family life, working conditions, and the financial aspects of the career reduced this satisfaction. The results also have potential application in improving the preparation of young military orthopedic surgeons.

Anterior cruciate ligament reconstruction with short hamstring grafts: the choice of femoral fixation device matters in controlling overall lengthening.

PURPOSE: The purpose was to conduct an independent biomechanical study comparing the main types of femoral fixation adapted to short hamstring grafts in anterior cruciate ligament (ACL) reconstruction surgery and to validate their performance. METHODS: The ACLip® Femoral, ToggleLoc™ Ziploop (TLZ), and Tape Locking Screw (TLS®) implants were tested in tension in the following three different configurations: implant alone, implant fixed on the femur without graft, and implant fixed on the femur with graft. Grafts alone were also tested. The femurs and the 4-strand semi-tendinosus grafts were derived from porcine and human models, respectively. Each set-up was subjected to the same protocol of creep (50 N for 30 s), cycling (1000 cycles between 50 and 250 N, 1 Hz), and load to failure (50 mm/min). RESULTS: A total of 93 tests were performed (30 ACLip®, 30 TLZ, 20 TLS®, and 13 ST4 alone). For the implants tested with femur and graft, the mean ± standard deviation (SD) overall elongation at 250 N after cycling was 5.2 ± 0.2 mm, 8.4 ± 2.1 mm, and 5.3 ± 0.8 mm, the mean ± SD ultimate load to failure was 736 ± 116 N, 830 ± 204 N, and 640 ± 242 N, and the mean ± SD stiffness at the 1000th cycle was 185 ± 15 N/mm, 172 ± 19 N/mm, and 178 ± 21 N/mm for ACLip®, ToggleLoc™, and TLS® devices, respectively. There was no significant difference between the implants except for post-cycling elongation between TLZ and the other two implants (p < 0.05). CONCLUSION: The choice of femoral fixation device plays a decisive role in controlling the overall lengthening of an ACL reconstruction using a short hamstring graft. All implants validated the specifications in terms of ultimate load to failure, the TLS® system had, however, a low performance limit. ToggleLoc™ with adjustable loop should no longer be used on the femur side; instead the other types of fixation should be used to improve the overall elongation control.

Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip.

PURPOSE: This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. METHODS: A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. RESULTS: Eleven patients with a mean age of 27.4 years (range 21-35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180-360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. CONCLUSIONS: Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

Rotating Hinge Knee Arthroplasty for Revision Prosthetic-Knee Infection: Good Functional Outcomes but a Crucial Need for Superinfection Prevention.

Introduction: Management of chronic infection following total knee arthroplasty (TKA) is challenging. Rotating hinged prostheses are often required in this setting due to severe bone loss, ligamentous insufficiency, or a combination of the two. The nature of the mechanical and septic complications occurring in this setting has not been well-described. The aim of this study was to evaluate patient outcomes using a hinge knee prosthesis for prosthetic knee infections and to investigate risk factors for implant removal. Methods: This was a retrospective cohort study that included all patients treated in our tertiary level referral center between January 2009 and December 2016 for prosthetic knee infection with a hinge knee prosthesis. Only patients with a minimum 2-year of follow-up were included. Functional evaluation was performed using international knee society (IKS) "Knee" and "Function" scores. Survival analysis comparing implant removal risks for mechanical and septic causes was performed using Cox univariate analysis and Kaplan-Meier curves. Risk factors for implant removal and septic failure were assessed. Results: Forty-six knees were eligible for inclusion. The majority of patients had satisfactory functional outcomes as determined by mean IKS scores (mean knee score: 70.53, mean function score: 46.53 points, and mean knee flexion: 88.75°). The 2-year implant survival rate was 89% but dropped to 65% at 7 years follow-up. The risk of failure (i.e., implant removal) was higher for septic etiology compared to mechanical causes. Patients with American society of anesthesiologists (ASA) score>1, immunosuppression, or with peripheral arterial diseases had a higher risk for septic failure. Patients with acute infection according to the Tsukayamaclassification had a higher risk of failure. Of the 46 patients included, 19 (41.3%) had atleast one infectious event on the surgical knee and most of these were superinfections (14/19) with new pathogens isolated. Among pathogens responsible for superinfections (i) cefazolin and gentamicin were both active in six of the cases but failed to prevent the superinfection; (ii) cefazolin and/or gentamicin were not active in eight patients, leading to alternative systemic and/or local antimicrobial prophylaxis consideration. Conclusions: Patients with chronic total knee arthroplasty (TKA) infection, requiring revision using rotating hinge implant, had good functional outcomes but experienced a high rate of septic failure, mostly due to bacterial superinfection. These patients may need optimal antimicrobial systemic prophylaxis and innovative approaches to reduce the rate of superinfection.

Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: A cohort study of 184 consecutive patients.

BACKGROUND: Intramedullary nailing is the standard of care for tibial shaft fractures. The risk factors for infectious and/or mechanical complications, notably non-union, remain incompletely understood. The objective of this study was to evaluate risk factors for complications, notably non-union. HYPOTHESIS: Active smoking and an initial open wound are independent risk factors for complications. MATERIALS AND METHODS: We retrospectively included consecutive patients managed for open or closed tibial shaft fractures by primary intramedullary nailing between 2013 and 2018. We collected data on preoperative factors related to the patient and to the mechanism of injury (age, sex, smoking history, energy of the trauma, open wound), on intraoperative factors (residual interfragmentary gap), and on postoperative factors (early or delayed weight-bearing). We evaluated the associations between these factors and the occurrence of complications, notably non-union, by performing a univariate analysis followed by a multivariate analysis. RESULTS: We included 184 patients [mean age, 38.5±17.6 (range, 15-91), 72.2% of males]. One or more complications developed in 28 (15.2%) patients and non-union occurred in 15 (8.1%) patients. There were three significant risk factors for complications: active smoking (OR, 7.93; 95%CI, 2.76-22.7), a residual interfragmentary gap >5mm (OR, 4.92; 95%CI, 1.72-14.02), and an initial open wound (OR,5.16; 95%CI, 1.62-16.43) (p<0.05). The same three factors were significant risk factors for non-union. Energy of the trauma, age, sex, and early or delayed weight bearing were not significantly associated with an excess risk of complications. DISCUSSION: Active smoking, a residual interfragmentary gap >5mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing to treat a tibial shaft fracture. Preventive strategies and specific information could be implemented for these patients. LEVEL OF EVIDENCE: IV; single-centre retrospective cohort study.

How to save time in surveillance without losing quality: comparison of two methods of surgical site infection surveillance in orthopaedic prosthetics in a French university hospital.

Surgical site infection (SSI) surveillance methods are not standardised and are often time-consuming. We compared an active method, based on orthopaedic department staff reporting suspected SSI, with a semi-automated method, based on computerised extraction of surgical revisions, after total hip and knee arthroplasty. Both methods allowed finding the same SSI cases. We found the same sensitivity but higher specificity with a straightforward time gain using the passive method. This represents an added value for the organisation of an effective SSI surveillance, based on existing hospital databases.

Extremity soft tissue coverage in the combat zone: use of pedicled flap transfers by the deployed orthopedic surgeon.

BACKGROUND: In theaters of operation, military orthopedic surgeons have to deal with complex open extremity injuries and perform soft-tissue reconstruction on local patients who cannot be evacuated. Our objective was to evaluate the outcomes and discuss practical issues regarding the use of pedicled flap transfers performed in the combat zone on local national patients. METHODS: A retrospective study was conducted on data from patients treated by a single orthopedic surgeon during four tours in Chad, Afghanistan and Mali between 2010 and 2017. All pedicled flap transfers performed on extremity soft-tissue defects were included, and two groups were analyzed: combat-related injuries (CRIs) and non-combat related injuries (NCRIs). RESULTS: Forty-one patients with a mean age of 25.6 years were included. In total, 46 open injuries required flap coverage: 19 CRIs and 27 NCRIs. Twenty of these injuries were infected. The mean number of prior debridements was significantly higher in the CRIs group. Overall, 63 pedicled flap transfers were carried out: 15 muscle flaps, 35 local fasciocutaneous flaps and 13 distant fasciocutaneous flaps. The flap types used did not differ for CRIs or NCRIs. Complications included one flap failure, one partial flap necrosis and six deep infections. At the mean follow-up time of 71 days, limb salvage had been successful in 38 of the 41 cases. There were no significant differences between CRIs and NCRIs in terms of endpoint assessment. CONCLUSIONS: Satisfying results can be achieved by simple pedicled flaps performed by orthopedic surgeons deployed in forward surgical units. Most complications were related to failure of bone infection treatment. The teaching of such basic reconstructive procedures should be part of the training for any military orthopedic surgeon. TRIAL REGISTRATION: Retrospectively registered on January 2019 (n°2019-090 1-001).

Contribution of the remaining attachment index in the management of Vancouver B1 periprosthetic hip fracture.

INTRODUCTION: Implant fixation assessment following Vancouver B1 periprosthetic hip fracture is a major decision factor for internal fixation and/or implant revision. The main aim of the present study was to assess the correlation between radiographic Remaining Attachment Index (RAI) and risk of implant loosening at last follow-up following internal fixation of Vancouver B1 periprosthetic hip fracture. MATERIAL AND METHOD: A multicentre retrospective study included 50 patients with Vancouver B1 periprosthetic hip fracture with uncemented femoral stem between 2013 and 2019. Preoperative radiographs were analysed independently by 2 senior orthopedic surgeons, distinguishing 2 groups: RAI>2/3 versus<2/3. Postoperative and last follow-up radiographs were then screened for signs of complete femoral component loosening. RESULTS: Median age was 89 years (range: 36-99 years). Two RAI>2/3 patients showed implant loosening (8%) versus 9 RAI<2/3 patients (36%), disclosing a significant correlation between early loosening and RAI<2/3 (p=0.005). Interobserver agreement for both radiographic RAI and radiographic loosening assessment at last follow-up was 98% with kappa correlation coefficient 0.96 [range: 0.88-1]. CONCLUSION: Remaining Attachment Index<2/3 in Vancouver B1 periprosthetic hip fracture was a risk factor for early implant loosening after isolated internal fixation. In these often frail elderly patients, first-line implant exchange is to be considered in the light of the risk/benefit ratio. The present results confirm the need for rigorous preoperative radiographic work-up of the remaining attachment area in Vancouver B1 fracture. LEVEL OF EVIDENCE: IV.

Evaluation of containment measures' effect on orthopaedic trauma surgery during the COVID-19 pandemic: a retrospective comparison between 2019 and 2020.

BACKGROUND: There is no available information about the effect of containment measures on trauma surgery activity. The aim of this study was to analyse and report the containment measures' impact on trauma surgery activity during the COVID-19 pandemic in order to quickly react and adjust in case of a new sanitary crisis and containment. METHODS: An original epidemiological study was performed in our trauma centre in France. Data from trauma surgeries performed during the pre-containment (from March 1 to March 16, 2020), containment (from March 17 to April 17, 2020) and reference (from March 1 to April 17, 2019) periods were compared. The primary outcome was the number of patients operated on daily and the daily operating room time. Clinical data, delay for surgery, mechanism of injury and injury pattern were also reviewed. RESULTS: There was a statistically significant decrease in the number of patients operated upon daily (- 39,8%, p value < 0.001) and daily operating room time (- 35.5%, p value < 0.001) between the reference and containment periods and between the pre-containment and containment periods (respectively, - 35.0%, p value < 0.001 and - 28.7%, p value 0.002). No differences were reported between the reference and pre-containment periods for daily-operated patients (p value 0.359). CONCLUSION: Containment measures had a direct impact on trauma surgery activity with a decrease of a third of trauma surgery activity. Those results could be useful if a new containment occurred.

ACL reconstruction using a quadruple semitendinosus graft with cortical fixations gives suitable isokinetic and clinical outcomes after 2 years.

PURPOSE: The objective of this single-center randomized single-blinded trial was to assess the hypothesis that anterior cruciate ligament reconstruction (ACLR) using a four-strand semitendinosus (ST) graft with adjustable femoral and tibial cortical fixation produced good outcomes compared to an ST/gracilis (ST/G) graft with femoral pin transfixation and tibial bioscrew fixation. Follow-up was 2 years. METHODS: Patients older than 16 years who underwent primary isolated ACLR included for 1 year until August 2017 were eligible. The primary outcome measures were the subjective International Knee Documentation Committee (IKDC) score, isokinetic muscle strength recovery, and return to work within 2 years. The study was approved by the ethics committee. RESULTS: Of 66 eligible patients, 60 completed the study and were included, 33 in the 4ST group and 27 in the ST/G group. Mean age was 30.5 ± 8.9 years in the 4ST group and 30.3 ± 8.5 in the ST/G group (n.s.). No significant between-group differences were found for mean postoperative subjective IKDC (4ST group, 80.2 ± 12.5; ST/G group, 83.6 ± 13.6; n.s.), side-to-side percentage deficits in isokinetic hamstring strength (at 60°/s: ST group, 17% ± 16%; ST/G group, 14% ± 11%; n.s.) or quadriceps strength (at 60°/s: ST group, 14% ± 12%; ST/G group, 19% ± 17%; n.s.), return to work, pain during physical activities, side-to-side differential laxity, balance, loss of flexion/extension, or surgical complications. CONCLUSION: This trial demonstrates that functional outcomes after 4ST for ACLR with cortical fixations could be as good, although not better, than those obtained using ST/G. The 4ST technique spares the gracilis tendon, which thus preserves the medial sided muscle and thereby could improve function and limit donor-side morbidity. LEVEL OF EVIDENCE: Level I.

Influence of loading condition and anatomical location on human cortical bone linear micro-cracks.

Human cortical bone fracture toughness depends on the anatomical locations under quasi-static loading. Recent results also showed that under fall-like loading, cortical bone fracture toughness is similar at different anatomical locations in the same donor. While cortical bone toughening mechanisms are known to be dependent on the tissue architecture under quasi-static loading, the fracture mechanisms during a fall are less studied. In the current study, the structural parameters of eight paired femoral diaphyses, femoral necks and radial diaphyses were mechanically tested under quasi-static and fall-like loading conditions (female donors, 70 ±â€¯14 y.o., [50-91 y.o.]). Synchrotron radiation micro-CT imaging was used to quantify the amount of micro-cracks formed during loading. The volume fraction of these micro-cracks was significantly higher within the specimens loaded under a quasi-static condition than under a loading representative of a fall. Under fall-like loading, there was no difference in crack volume fraction between the different paired anatomical locations. This result shows that the micro-cracking toughening mechanism depends both on the anatomical location and on the loading condition.

Treatment of unstable knee osteochondritis dissecans in the young adult: results and limitations of surgical strategies-The advantages of allografts to address an osteochondral challenge.

Joint surface incongruence resulting from osteochondritis dissecans (OCD) alters the articular physiologic congruence, increasing the contact stress on adjacent joint surfaces and accelerating wear and the cascade of joint degeneration. Accordingly, the restoration of articular surface integrity is of major importance, especially in young adults where, in lesions left untreated or following simple fragment excision, early osteoarthritis can be anticipated. Therefore, the treatment algorithm in unstable knee OCD of the young adult foresees surgical options to restore the articular surface. Several procedures have been proposed, including refixation of the detached fragment bone marrow stimulation, osteochondral autograft implantation, fresh osteochondral allograft transplantation, and cell-based or cell-free regenerative techniques. The aim of this review was to summarize the evidence for these surgical strategies, reporting their results and limitations. The overall evidence documents positive results for each of the assorted surgical procedures applied to treat unstable OCD, thus indicating support for their selected use to treat osteochondral defects paying particular attention to their specific indications for the lesion characteristics. The fixation of a good quality fragment should be pursued as a first option, while unfixable small lesions may benefit from autografts. For large lesions, available cell-based or cell-free osteochondral scaffold are a feasible solution but with limitation in terms of regenerated tissue quality. In this light, fresh allografts may offer articular surface restoration with viable physiologic osteochondral tissue providing a predictably successful outcome, and therefore they may currently represent the most suitable option to treat unstable irreparable OCD lesion in young adults. LEVEL OF EVIDENCE: V.