Predictors of Early Return to Sport After Surgical Repair of Proximal Hamstring Complex Injuries in Professional Athletes: A Prospective Study.

BACKGROUND: Proximal hamstring complex injury (PHCI) is a common injury among professional athletes, particularly those participating in pivot contact sports. Previous studies have suggested that surgery can be effective in restoring function and allowing athletes to return to sport (RTS), but the factors influencing successful RTS have been less clear. PURPOSE: To assess RTS capabilities after surgical treatment of PHCI in professional athletes and to identify favorable predictors of RTS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study (2002-2022) was conducted on professional athletes who underwent surgical treatment for PHCI at a sports surgery center. The primary outcome of the study was the RTS capability, evaluated based on the rate of athletes' return to their preinjury level of competition, time delay to RTS, and quality of RTS as measured using their level of performance and progression of scores on activity scales such as the Tegner Activity Scale (TAS) and University of California, Los Angeles (UCLA), scale. "Maintained performance" was defined as athletes returning to the same preinjury activity level (per the TAS and UCLA scale) and perceiving themselves to have maintained their performance. Secondary outcomes covered the potential RTS predictors and complication rate. The study distinguished 2 types of PHCI: proximal hamstring tendon avulsion injury (proximal rupture with empty footprint, or having a "positive dropped ice cream sign") and complete proximal hamstring free tendon rupture (PHTR; proximal rupture without empty footprint, or having a "negative dropped ice cream sign"). RESULTS: The study examined 64 professional athletes (mean age, 27.3 years; 82.8% male) undergoing surgery for PHCI. The RTS rate was 98.4%, with 78.1% of the athletes returning to their preinjury level of competition at 6.2 months (SD, 2.5 months). Twelve (19%) patients had returned to sport at an inferior level of competition, and 2 (3.1%) were unable to continue in their preinjury sport. Subgroup analysis revealed variation in RTS based on sport type, with the highest rate of return to preinjury performance found in athletes in handball and sports with splits (fencing, squash, and escalade; 100%) and soccer (95.2%). In the univariate analysis, male sex (hazard ratio [HR], 4.05; 95% CI, 1.45-11.3; P = .008), higher preinjury TAS score (HR, 1.27; 95% CI, 1.06-1.52; P = .011), injury involving the semimembranosus (HR, 4.84; 95% CI, 2.31-10.2; P < .001) or conjoint tendon (HR, 3.12; 95% CI, 1.55-6.25; P = .001), and PHTR (HR, 7.77; 95% CI, 3.54-17.0; P < .001) were significantly associated with a better postoperative level of competition. Multivariate analysis identified 3 favorable predictors of RTS with HRs of 2.91 (95% CI, 1.01-8.35; P = .047) for male sex, 3.86 (95% CI, 1.78-8.37; P < .001) for isolated semimembranosus injury, and 5.18 (95% CI, 2.24-12.0; P < .001) for PHTR. The complication rate was 4.7%. CONCLUSION: Favorable predictors of early RTS were male sex, isolated semimembranosus injury, and PHTR injuries. REGISTRATION: NCT02906865 (ClinicalTrials.gov identifier).

Customized-individually-made origin® implants in total knee arthroplasty allow a reliable solution for accurate reproduction of planned implant positioning.

PURPOSE: To evaluate the accuracy and reproducibility of a patient-specific, customized individually made (CIM) total knee replacement (TKR) using the ORIGIN® prosthesis. METHODS: This was a prospective study conducted at a University Hospital from January 15, 2019, to April 30, 2021. The study included patients planned for an ORIGIN® CIM TKR procedure. Exclusion criteria included revision surgery, severe deformity, stiffness, or laxity. Evaluations were carried out using computed tomography scans performed 8 weeks preoperatively and 6 weeks postoperatively. The primary outcome measurements were the preoperative, planned, and postoperative CT scan alignment measurements including the Hip-Knee-Ankle (HKA) angle, mechanical Medial Distal Femoral articular surface Angle (mMDFA, distal alpha angle), Posterior Distal femoral articular surface angle (PDFA, posterior alpha angle), mechanical Medial Proximal Tibial articular surface Angle (mMPTA, beta angle) and posterior proximal tibial angle (PPTA). Secondary outcomes included the accuracy of implant positioning with percentage of outliers at 2° and 3° RESULTS: The study encompassed 51 knees from 50 patients with mean age of 68.1 (SD = 8.89). The overall HKA angle deviated by -0.93° [95% CI: -1.45; -0.43], and the PDFA angle by -0.61° [95% CI: -1.07; -0.15], while the mMPTA exceeded planned values by 1.00° [95% CI: 0.57; 1.43]. The 3° outliers rate ranged from 3.9% for the mMPTA to 7.8% for the HKA alignment, with no outliers in mMDFA and PPTA. Similarly, the 2° outliers rate ranged from 15.7% for both the PDFA angle and mMPTA to 19.6% for the HKA alignment. The Bland-Altman plots further emphasized the precision of planned and post-operative angles across all measurements. CONCLUSION: The CIM TKR showed high accuracy and reproducibility, closely matching preoperative planning. The weakest accuracy at 3°-outliers is in the reproduction of the HKA alignment at 92.2% (range for all angle: 92.2-100%). Similarly, the weakest accuracy at 2°-outliers is in the reproduction of the HKA alignment at 80.4% (range for all angles: 80.4-92.2%).

Dynamic intermittent compression cryotherapy with intravenous nefopam results in faster pain recovery than static compression cryotherapy with oral nefopam: post-anterior cruciate ligament reconstruction.

PURPOSE: To evaluate the effectiveness of dynamic intermittent compression cryotherapy (DICC) (CryoNov®) with an intravenous nefopam-based pain management protocol (DCIVNPP) in reducing post-operative pain following anterior cruciate ligament reconstruction (ACLR) compared to static compression cryotherapy (SCC) (Igloo®) and oral Nefopam. METHODS: This was a retrospective analysis of prospectively collected data including 676 patients who underwent primary ACLR in 2022. Patients were either in the DCIVNPP group or in the SCC (control group), and were matched for age, sex, and Lysholm and Tegner scores (338 per arm). The primary outcome was pain on the visual analogue scale (VAS), analyzed in relation to the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds for VAS. The secondary outcome was side effects. RESULTS: Postoperative pain in the DCIVNPP group was less severe on the VAS than in the control group (p < 0.05). The maximum difference in the VAS between groups was 0.57, which is less than the MCID threshold for VAS. The DCIVNPP group crossed the PASS threshold for VAS on Day 3, sooner than the control group. The side effect profiles were similar in both groups except for higher rates of dizziness and malaise in the DCIVNPP group, and higher rates of abdominal pain in the control group. Most of the side effects decreased over time in both groups, with no significant side effects after Day 3. CONCLUSION: DCIVNPP effectively allows for faster pain recovery than in the control group. The difference in side effects between the protocols may be due to mode of administration of nefopam. LEVEL OF EVIDENCE: III.

Release-reinsertion of the biceps femoris tendon onto the fibula in biceps femoris impingement on the knee with or without snap.

Ectopic insertions of the biceps femoris tendon at the knee can cause impingement with the fibular head, leading to pain with or without snap. There are several variant insertions that have recently been described and classified. Pain syndrome primarily affects athletic patients, often cyclists, disrupting sports practice. Diagnosis is difficult and often late. Medical treatment is often disappointing, leading to surgery. The aim of surgery is to remove the impingement between the ectopic insertion of the biceps tendon and the fibular head, by releasing the unduly anterior tendon, sometimes from the tibia and reinserting it in an anteroposterior tunnel in the fibular head. This reinsertion in a physiological zone without impingement is then fixed by an interference screw.

Anterior cruciate ligament arthroscopic reconstruction and lateral tenodesis with iliotibial band and gracilis tendon: Technical note.

While anterior cruciate ligament reconstruction using the iliotibial band is not a new technique, it still remains underdeveloped. The iliotibial band has historically been described as a thin and less resistant structure. Its harvesting has been associated with a risk of complications (hematoma, muscle hernia) and its small graft diameter increases the risk of rerupture. The addition of the gracilis tendon could potentially produce a graft with an increased diameter. In this technical note, we present a modification to the traditional technique performed on 50 patients, describing the surgical steps, graft diameter, clinical outcomes and complications at the 2-year follow-up. The mean graft diameter was 8.9±0.9 mm at the femur and 7.7±0.7 mm at the tibia. No rerupture was reported at the 2-year follow-up. LEVEL OF EVIDENCE: IV.

Femoral intercondylar notch: Accuracy of a novel MRI measurement protocol.

OBJECTIVE: The most common mechanical complication following an anterior cruciate ligament (ACL) reconstruction is joint stiffness, due in part to cyclops syndrome. A narrow intercondylar notch is an anatomical risk factor. A reliable preoperative notch measurement would help anticipate proper graft size, or plan a notchplasty during the ligament reconstruction, if necessary. No study has yet assessed the accuracy of the methods used to measure notch size. HYPOTHESIS: The novel measurement protocol proposed in this study would be more reproducible than the reference technique. METHODS: A total of 20 preoperative knee MRIs performed during the assessment of an ACL rupture were randomly selected. The notch size was measured using 2 methods: traditional (ratio of the notch and metaphyseal widths measured on a line drawn through the popliteal groove) and novel. The latter was measured using the same ratio but took into account the notch width in its proximal third, according to a coronal slice that passes through the ACL tibial attachment. Three orthopedic surgeons with different levels of experience (senior surgeon, junior surgeon and surgical resident) performed these measurement protocols twice on anonymized MRI scans, 10days apart. Spearman's rank correlation coefficient was used to assess the intraobserver correlations and a concordance index was used to assess the interobserver correlations. The influence of the second MRI reading was analyzed with a bootstrap test. RESULTS: The mean intraobserver reliability was 0.73 for the reference method and 0.83 for the proposed method. The values of the bootstrap tests were higher for the proposed method (0.45 vs. 0.45 and 0.70; p<05 for interobserver; 0.49 vs. 0.69 and 0.62; p<05 for intraobserver). CONCLUSION: The proposed measurement protocol showed a higher reproducibility in assessing notch size than the traditional method. This technique therefore provides a reliable assessment of the intercondylar notch width. LEVEL OF EVIDENCE: IV; retrospective study.

Biceps femoris snapping and friction on the fibular head secondary to abnormal distal tendon insertion: 15 cases and a literature review.

INTRODUCTION: Abnormal biceps femoris distal tendon insertion can cause tendon snapping, as is well-known in the literature. The presenting symptom is lateral knee pain, often during sports activities and cycling in particular. The present study tested two hypotheses: abnormal biceps femoris insertion on the fibular head may cause painful friction without clinical snapping, whether visible, audible or palpable; surgical correction achieves good results for pain and return to sport, regarding both snapping and friction. MATERIAL AND METHODS: Between 2006 and 2017, 11 patients were managed for pain secondary to abnormal biceps femoris insertion. In 4 cases, pain was bilateral, resulting in a total of 15 knees: 9 with snapping (in 6 patients), and 6 with friction syndrome without snapping (in 5 patients). All 6 patients with snapping were male, with a mean age of 29 years. Friction without snapping concerned 3 female and 2 male patients, with a mean age of 30 years. Study data included type and level of sport, clinical signs, imaging, type and results of treatment, and type of abnormality. RESULTS: The insertion abnormality consisted in excessively anterior insertion in the fibular arm in 6 cases, in predominantly tibial insertion in 2 cases, and in isolated tibial insertion in 4 cases. Surgery mainly consisted inrelease and reinsertion of the distal biceps femoris tendon (in 7 cases). All patients were able to return to sport. The mechanism underlying snapping and friction was the same: distal biceps tendon friction on the fibular head secondary to unduly anterior fibular or predominantly or exclusively tibial insertion. DISCUSSION: The literature reports 24 cases, all of snapping, with between 1 and 3 cases per author. These findings were compared with the present results. With or without snap, symptoms are secondary to abnormal tendon insertion and to activity or sport requiring repeated knee flexion greater than 90°. CONCLUSIONS: (1) Case studies show that lateral knee pain by friction on the fibular head is not systematically accompanied by snapping. (2) In all reports and in the present series, surgery was highly effective on snapping and pain, and patients returned to sport at their previous level. LEVEL OF EVIDENCE: IV.

Should proximal ruptures of the anterior rectus femoris muscle be treated surgically?

PURPOSE: No therapeutic consensus has been established about proximal ruptures of the rectus femoris muscle. The objective of this literature review is to determine a therapeutic course of action. METHODS: We conducted a literature review on the PubMed database using the following keywords (in French and English, respectively): "quadriceps/quadriceps", "droit antérieur/rectus femoris", "proximal/proximal", "chirurgie/surgical", "avulsion/avulsion". We collected 266 articles, 36 of them were selected, which were related to our topic: proximal rupture of the anterior rectus femoris. Patients with a proximal rupture of the rectus femoris, minor or major patient of traumatic origin were included in this study. Patients injured at another lesion level, or non-traumatic lesions of the proximal rectus femoris (tendinitis without ruptures, tumor or others) were excluded. For each patient, the indications, the type of treatment and the functional result were analyzed, with the time to recovery and the level of recovery from sports and professional activities (same sport/profession or not, same level or not) as the main criterion of judgment. Fisher exact test was used for statistical comparison. RESULTS: The aims of conservative treatment are to be pain free for the patient, to fight hematoma and to rehabilitate the injury as quickly as possible. The surgical techniques are varied, with most consisting of either a reinsertion of the musculo-tendon stump or a resection of the scar tissue with myo-tendino-aponeurotic suture in place. The functional results are good for the majority of the treatments proposed, but the conservative treatment has a shorter recovery time (3 months vs. 4 months for the best surgical results). Highly displaced bone avulsion is the only indication for first-line surgical treatment. CONSLUSION: The main disadvantage of conservative treatment is the risk of residual pain beyond 3 months (10%), justifying an MRI to guide secondary surgical treatment. We propose a treatment plan for proximal rupture of the proximal rectus femoris rupture.

Cementation of proximal femoral nails of the very elderly subject in per-trochanteric fractures.

The management of pertrochanteric fractures (PTF) in the very elderly relies on early verticalisation to limit complications of the decubitus and this requires stable osteosynthesis allowing immediate full support without risk of mechanical failure. The aim of the study was to analyse the value of cementing the cervicocephalic blade during osteosynthesis with a proximal femoral nail. A prospective bicentric comparative study was con- ducted. Patients over 90 years of age with PTF were included. Centre A used a PFNA (Proximal Femoral Nail Antirotation) nail without blade cementing and Centre B used the same nail with blade cementing. The primary endpoint was the occurrence of disassembly of the osteosynthesis requiring revision surgery. Secondary endpoints were functional out- come (resumption of walking), postoperative pain and duration of surgery. Sixty-four patients were included in Centre A and 23 patients were included in Centre B. Mean age, gender, functional abilities before fracture, fracture type and tip-apex distance were comparable between the groups. Postoperative pain and duration of surgery did not show significant differences between the groups. Four patients operated on with an uncemented PFNA (6.25%) and one patient operated on with a cemented PFNA nail (4.35%) showed early dismantling. The rate of patients returning to walking was significantly higher in the cemented group (p=0.00005). No significant differences in the rate of dismantling were observed between the two groups. However, the group operated on with a cemented PFNA showed better functional recovery with a significantly higher rate of walking recovery.

Case Report: Stress Fracture in an International Triple Jumper: Importance of an Integrated Care Approach Which Also Incorporates Biomechanics.

Athletes fear stress fracture (SF) injuries as they can put a premature end to their athletic careers. Understanding any mechanical constraints can suggest preventive management approach. Specifically, for the triple jump, the mechanical stresses that occur during the event appear to be the main factors for risk of injury. This clinical case describes three successive episodes of anterior tibial fracture in an international triple jumper between 2011 and 2013. The first fracture received surgical treatment involving intramedullary nailing. The second fracture occurred in the same location and was considered a recurrence requiring medical treatment, whilst the third was a complete fracture of the surgical material and required surgical revision. These recurrent fractures can be explained by the fatigue of materials (bone and nail) induced by triple jump practice and emphasize the importance of integrating biomechanics into an assessment of the case. The use of biomechanical modelization to identify these weaknesses could be an approach for clinical management of such patients. Observation of the intrinsic mechanical stresses during high-level triple jump may lead to identification of modifiable risk factors for bone fragility.

Hip Fracture Leads to Transitory Immune Imprint in Older Patients.

Background: Hip fracture (HF) is common in the geriatric population and is associated with a poor vital and functional prognosis which could be impacted by immunological changes. The objective here is to decipher immune changes occurring in the 1st days following HF and determine how phenotype, function, and regulation of innate and adaptive compartments adapt during acute stress event. Methods: We included HF patients, aged over 75 years. For each patient, blood samples were taken at five different timepoints: four in the perioperative period (day 0 to hospital discharge) and one at long term (6-12 months). Phenotypical and functional analysis were performed longitudinally on fresh blood or cryopreserved PBMCs. Clinical data were prospectively collected. Results: One-hundred HF patients and 60 age-matched controls were included. Innate compartment exhibits pro-inflammatory phenotypes (hyperleukocytosis, increase of CD14+ CD16+ proportion and CCR2 expression), maintaining its ability to produce pro-inflammatory cytokines. Adaptive compartment extends toward a transitory immunosuppressive profile (leucopenia) associated with an active T-cell proliferation. Furthermore, increases of LAG-3 and PD-1 and a decrease of 2-B4 expression are observed on T-cells, reinforcing their transitory suppressive status. Of note, these immune changes are transitory and sequential but may participate to a regulation loop necessary for homeostatic immune control at long term. Conclusion: HF is associated with several transitory immunological changes including pro-inflammatory phenotype in innate compartment and immunosuppressive profile in adaptive compartment. A comprehensive assessment of immune mechanisms implicated in the patient's prognosis after HF could pave the way to develop new immune therapeutics strategies.

Attributable Mortality of Hip Fracture in Older Patients: A Retrospective Observational Study.

Hip fracture (HF) in older patients is associated with a high six-month mortality rate. Several clinical conditions may affect outcome, including baseline characteristics, co-existing acute illnesses, perioperative factors, and postoperative complications. Our primary objective was to estimate the respective effect of these four domains on six-month mortality after HF. A retrospective observational study using a monocentric cohort of older patients was conducted. All patients ≥ 70 years old admitted to the emergency department for HF and hospitalized in our perioperative geriatric care unit from June 2009 to September 2018 were included. Among 1015 included patients, five (0.5%) were lost to follow-up, and 1010 were retained in the final analysis (mean age 86 ± 6 years). The six-month mortality rate was 14.8%. The six-month attributable mortality estimates were as follows: baseline characteristics (including age, gender, comorbidities, autonomy, type of fracture): 62.4%; co-existing acute illnesses (including acute events present before surgery that could result from the fracture or cause it): 0% (not significantly associated with six-month mortality); perioperative factors (including blood transfusion and delayed surgery): 12.3%; severe postoperative complications: 11.9%. Baseline characteristics explained less than two-thirds of the six-month mortality after HF. Optimizing patients care by improving management of perioperative factors and thus decreasing postoperative complications, could reduce by a maximum of one quarter of the six-month mortality rate after HF.

How tibial tubercle torsion impacts patellar stability: A biomechanics study.

INTRODUCTION: A new factor for patellofemoral instability-external torsion of the tibial tubercle-has recently been described. The primary aim of this biomechanics study was to analyze the consequences of internal torsion tibial tubercle osteotomy (TTO) on an experimentally unstable patella. We hypothesized that internal TTO can stabilize an experimental patellar instability. MATERIALS AND METHODS: This in vitro study was conducted on six fresh anatomical specimens. The knees were flexed to 25°. The patella was destabilized by transecting the patellar retinaculae and the vastus medialis tendon and by applying continuous oblique traction on the quadriceps tendon. A 3D stereovision system was used to record patellar displacement and tilt and to determine whether patellar dislocation occurred. The measurements were done before the osteotomy then repeated on the same knee after a triangular internal torsion 30° TTO was completed, without medialization. RESULTS: There was a significant difference in the patellar displacement and tilt before and after the osteotomy (p<0.05). Patellar dislocation, which was induced by traction on all the knees before osteotomy, did not occur after the osteotomy was performed. DISCUSSION: Internal torsion of the tibial tubercle improves patellar stability, confirming our hypothesis. These findings confirm the stabilizing effect of placing the tibial tuberosity in internal torsion. Although a knee without instability factors is not the perfect model for patellar instability, our findings suggest that tibial tubercle torsion influences patellar stability. Internal TTO may be justified as a surgical treatment of patellofemoral instability.

Return to sport after early surgical repair of acute patellar tendon ruptures.

INTRODUCTION: Patellar tendon ruptures make up about 5% of all extensor mechanism injuries. They mainly occur in young, athletic men who have contributing risk factors such as chronic tendinopathy. The aim of this study was to evaluate the return to sport after repair of an acute patellar tendon rupture. We hypothesized that surgical repair yields good functional outcomes with a high rate of return to competitive sports in patients treated with the same surgical technique. METHODS: This retrospective study involved 23 cases of patellar tendon rupture in 20 patients (2 women, 18 men). The average age was 42.0±13.8 years (24-68). Eighteen ruptures occurred at the patellar attachment and five were mid-substance. Either transosseous reattachment or direct suture repair was carried out within 21 days; all tendons were augmented with a non-metallic tibiopatellar suture. At the final assessment, a clinical examination was carried out (extensor mechanism testing and range of motion) with collection of functional scores (pain, VISA-P, Lysholm and satisfaction), date of return to sport and final radiographs. RESULTS: At a mean follow-up of 47.7 months (15-120), there were no cases of significant knee stiffness. Seventeen patients (94.4%) had returned to sport, 15 at their pre-injury level (83%). The mean time before running could be restarted was 9 months (6-15 months) and 17 months for sports at the same pre-injury level (8-18 months). The mean VISA score and the mean Lysholm score were 85.5 (62-99) and 67.3 (35-97) respectively; 85% of patients were satisfied or very satisfied. The prognosis was worse when the patient was older than 40 and had a BMI above 25. Early surgical repair of patellar tendon rupture yields good functional outcomes with return to sport possible at high levels. LEVEL OF EVIDENCE: IV, Retrospective cohort study.

Procalcitonin and C-Reactive Protein for Bacterial Infection Diagnosis in Elderly Patients After Traumatic Orthopedic Surgery.

BACKGROUND: Biomarkers prove valuable for diagnosing postoperative bacterial infection, but data in elderly patients are scarce. Here we analyze how procalcitonin and C-reactive protein (CRP) perform for bacterial infection diagnosis after traumatic orthopedic surgery in elderly patients. METHODS: We included all patients admitted to our perioperative geriatrics unit after traumatic orthopedic surgery. Patients on antibiotics, presenting preoperative bacterial infection, or without procalcitonin measurement were excluded. Clinical and biological data were collected prospectively. Medical charts were reviewed by three experts blinded to biomarker results to assess bacterial infection diagnosis. Areas under the curve and 90%-specificity thresholds were analyzed for baseline procalcitonin and CRP levels and relative variations. RESULTS: Analysis included 229 patients (median age 86 years, hip fracture 83%), of which 40 had bacterial infection (pneumonia [n = 23], urinary tract infection [n = 8]; median delay to onset: 2 days post-admission). For bacterial infection diagnosis, the computed areas under the curve were not significantly different (procalcitonin-baseline 0.64 [95% confidence interval: 0.57-0.70]; procalcitonin-relative variation 0.65 [0.59-0.71]; CRP-baseline 0.68 [0.61-0.74]; CRP-relative variation 0.70 [0.64-0.76]). The 90%-specificity thresholds were 0.75 µg/L for procalcitonin-baseline, +62% for procalcitonin-variation, 222 mg/L for CRP-baseline, +111% for CRP-variation. CONCLUSIONS: Diagnostic performances of procalcitonin and CRP were not significantly different. Baseline levels and relative variations of these biomarkers showed little diagnostic value after traumatic orthopedic surgery in elderly patients.

Comparative evaluation of minimally invasive 'tibial tuberoplasty' surgical technique versus conventional open surgery for Schatzker II-III tibial plateau fractures: design of a multicentre, randomised, controlled and blinded trial (TUBERIMPACT study).

INTRODUCTION: Fractures of the tibial plateau are in constant progression. They affect an elderly population suffering from a number of comorbidities, but also a young population increasingly practicing high-risk sports. The conventional open surgical technique used for tibial plateau fractures has several pitfalls: bone and skin devascularisation, increased risks of infection and functional rehabilitation difficulties. Since 2011, Poitiers University Hospital is offering to its patients a new minimally invasive technique for the reduction and stabilisation of tibial plateau fractures, named 'tibial tuberoplasty'. This technique involves expansion of the tibial plateau through inflation using a kyphoplasty balloon, filling of the fracture cavity with cement and percutaneous screw fixation. We designed a study to evaluate the quality of fracture reduction offered by percutaneous tuberoplasty versus conventional open surgery for tibial plateau fracture and its impact on clinical outcome. METHODS AND ANALYSIS: This is a multicentre randomised controlled trial comparing two surgical techniques in the treatment of tibial plateau fractures. 140 patients with a Schatzker II or III tibial plateau fracture will be recruited in France. They will be randomised either in tibial tuberoplasty arm or in conventional surgery arm. The primary outcome is the postoperative radiological step-off reduction blindly measured on CT scan (within 48 hours post-op). Additional outcomes include other radiological endpoints, pain, functional abilities, quality of life assessment and health-economic endpoints. Outcomes assessment will be performed at baseline (before surgery), at day 0 (surgery), at 2, 21, 45 days, 3, 6, 12 and 24 months postsurgery. ETHICS AND DISSEMINATION: This study has been approved by the ethics committee Ile-De-France X and will be conducted in accordance with current Good Clinical Practice (GCP) guidelines, Declaration of Helsinki and standard operating procedures. The results will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: Clinicaltrial.gov:NCT03444779.

Same-stage total knee arthroplasty and osteotomy for osteoarthritis with extra-articular deformity. Part I: Tibial osteotomy, prospective study of 26 cases.

BACKGROUND: In patients with advanced knee osteoarthritis and extra-articular knee deformity (EKD), ligament balance may be difficult to achieve during total knee arthroplasty (TKA). Treatment options include two-stage surgery with the first stage involving correction of the EKD and same-stage TKA and tibial osteotomy (1S-TKA-TO). The objective of this study was to assess outcomes in 26 patients managed with 1S-TKA-TO. HYPOTHESIS: 1S-TKA-TO produces satisfactory clinical and anatomical outcomes and is not associated with higher morbidity rates compared to TKA alone or two-stage TKA-TO. MATERIAL AND METHODS: A prospective study was conducted in 25 patients (26 knees) managed with 1S-TKA-TO between 1995 and 2014. There were 16 males and 9 females with a mean age of 64 years (range, 29-80 years) and a mean body mass index of 29.6 (range, 24-49). The EKD was constitutional in 14 knees, post-traumatic in 5 knees, and induced by TO in 7 knees. None of the patients received a hinged knee implant. In each patient, the clinical International Knee Society (IKS score) was assessed and the hip-knee-ankle angle (HKA), tibial mechanical angle (TMA), and femoral mechanical angle (FMA) were measured on radiographs before surgery and at last follow-up. RESULTS: The mean IKS score increased significantly, from 70 before surgery to 170 at the end of the mean 9-year follow-up. Mean flexion range increased from 98° to 107°. The clinical and anatomical outcomes were satisfactory in 25 patients. In the remaining patient, who had a history of multiple surgeries for Blount disease and a body mass index of 49, a severe complication consisting in massive skin necrosis followed by infection occurred; this was the only patient who required revision surgery with implant removal. DISCUSSION: These findings are consistent with the satisfactory outcomes observed in earlier studies, most of which included small numbers of patients. The alternatives to 1S-TKA-TO are under evaluation. The best indication for 1S-TKA-TO may be knee osteoarthritis with a greater than 10° intra-osseous deformity. LEVEL OF EVIDENCE: IV, prospective observational cohort study.

Same-stage total knee arthroplasty and osteotomy for osteoarthritis with extra-articular deformity. Part II: Femoral osteotomy, prospective study of 6 cases.

BACKGROUND: Same-stage (1S) total knee arthroplasty (TKA) and femoral osteotomy (FO) may deserve consideration in patients with both knee osteoarthritis and severe extra-articular knee deformity (EKD). The objective of this study was to assess clinical and radiological outcomes and morbidity (complications and revisions) in 6 patients managed with S1-TKA-FO. HYPOTHESIS: 1S-TKA-FO produces satisfactory outcomes and is not associated with higher morbidity rates compared to two-stage TKA-TO or TKA with intra-articular EKD correction, while also significantly shortening total treatment duration. MATERIAL AND METHODS: A prospective study was performed in 6 patients managed with 1S-TKA-FO between 1999 and 2011; mean age was 64 years (range, 59-72 years) and mean body mass index was 29.5 (range, 26-35). The EKD was consistently greater than 10°. The cause was post-traumatic mal-union in 4 patients, constitutional EKD in 1 patient, and FO in 1 patient. In each patient, the clinical International Knee Society (IKS) score and the hip-knee-ankle angle (HKA), femoral mechanical angle (FMA) and tibial mechanical angle (TMA), were recorded prospectively before and after surgery. RESULTS: A long uncemented extension stem was used in all 6 patients and a posterior-stabilised implant in 5 patients. No hinged implants were used. In 4 patients, internal fixation of the FO was performed. Mean follow-up was 10 years (range, 4-15 years). From baseline to last follow-up, the mean IKS score increased from 46 to 161 and mean flexion from 95° (range, 70-110°) to 107° (range, 90-120°). The HKA measured radiographically was between 178° and 182° in all 6 patients. The complications consisted of deep vein thrombosis in 1 patient and knee stiffness requiring manipulation under general anaesthesia in 1 patient. No patient experienced mal-union or required revision surgery. DISCUSSION: Apart from a case-series study of 11 patients, very few data are available on 1S-TKA-FO. In our small population, no major complications were recorded. The encouraging long-term outcomes warrant a recommendation to perform 1S-TKA-FO in patients with knee osteoarthritis and an intra-femoral deformity greater than 10°. LEVEL OF EVIDENCE: IV, prospective observational cohort study.

Long-Term Results for Treatment of Chronic Ankle Instability With Fibular Periosteum Ligamentoplasty and Extensor Retinaculum Flap.

Long-term results of anatomic reconstruction for chronic ankle instability are good, but no study has shown the results of fibular periosteum ligamentoplasty associated with extensor retinaculum flap at long-term follow-up. To demonstrate the efficacy of fibular periosteum ligamentoplasty and extensor retinaculum flap in chronic lateral instability, 40 patients underwent surgery for ankle instability. Thirty-three (82.5%) patients were reviewed, with a median follow-up duration of 8.2 (range 4 to 13) years. Functional results were assessed using the Karlsson score. Static and dynamic x-ray images were realized to measure varus tilt and anterior drawer, and osteoarthritis was evaluated with the van Dijk classification. The median Karlsson score was 95 (range 80 to 100). The mean decrease in varus laxity was 11° (range 0 to 18) and in anterior drawer was 1 (range -8 to 4) mm. At the last follow-up visit, 3 (7.5%) patients showed an evidence of osteoarthritis according to the preoperative criteria of the van Dijk classification (grade 2) and 6 (15%) patients had radiologic changes, without narrowing of the joint space (grade 1). Studies that have a follow-up time >5 years are rare. This study shows that despite the excellent control of ankle laxity, severe radiographic changes (grade 2) continue to evolve in the long term. This study indicates a good long-term outcome but suggests the need to monitor the occurrence of osteoarthritis over the long term.