Orthopaedic and trauma surgery in the time of COVID-19 in France: A nationwide survey.

INTRODUCTION: The year 2020 was marked by the COVID-19 pandemic. The entire French health system was mobilized. Surgical services were asked to reschedule all elective procedures. We wondered about the impact of this pandemic on French orthopaedic surgeons. The main objective of this survey was to assess the impact of COVID-19 on emergency and non-emergency orthopaedic surgical activities. The secondary objectives were: to report how orthopaedic surgeons had mobilized and reorganized, and to assess the physical and psychological consequences on their state of health. HYPOTHESIS: The COVID-19 epidemic has led to the suspension of all elective orthopaedic surgeries and has also led to changes in the management of urgent surgeries and traumatology. MATERIAL AND METHODS: This descriptive epidemiological study was conducted in France. A 40-question survey was sent to all French orthopaedic surgeons (senior surgeons and residents) via the mailing lists of the French Society of Orthopaedic and Traumatological Surgery (SoFCOT), the French Society of Pediatric Orthopaedics (SoFOP) and the College of Young Orthopedists (CJO). RESULTS: Over a period of one month, 1098 surgeons; 852 senior surgeons and 246 residents, answered the questionnaire. The complete cessation of all elective interventions was effective in 80% of cases. Urgent and semi-urgent interventions were maintained. Three hundred and twenty-six surgeons (30%) modified their trauma management, among them 55% came from the regions most affected by the pandemic. Sixty percent of surgeons did not receive training to take care of COVID+ patients and 40% took care of these patients. Among the orthopaedic surgeons surveyed, 28% were redeployed to medical services. Teleconsultation was used by 41% of surgeons. Twenty-six (2%) surgeons tested positive for COVID-19 and 54% showed at least one sign of psychological suffering. CONCLUSION: French orthopaedic surgeons reorganized and changed their practices quickly and efficiently to deal with the pandemic. However, progress remains to be seen with training of orthopaedic surgeons in the care of COVID+patients, as well as to democratize the use of telemedicine. LEVEL OF EVIDENCE: IV.

Arthroscopic treatment of diffuse pigmented villonodular synovitis of the elbow.

INTRODUCTION: Pigmented villonodular synovitis (PVNS) is a rare pathology of the elbow, but presents a risk of progression with cartilage destruction. Surgical treatment consists in synovectomy, as complete as possible. Arthroscopy is an excellent tool for the exploration and treatment of intra-articular lesions in the elbow, but the results in PVNS of the elbow have never been evaluated. The aim of this study was to assess the recurrence rate of PVNS of the elbow after arthroscopic synovectomy, and secondarily to assess pain, joint range of motion, functional scores and complication rate. MATERIAL AND METHODS: We performed a retrospective study of a continuous series of 8 patients operated on between February 2012 and February 2019, with a mean age of 43.7 years. The operated side was the dominant side in 75% of cases. Surgery consisted in the most complete synovectomy possible, performed arthroscopically. Recurrence, clinical evaluation, with pain at rest and on mpvement on visual analogue scale (VAS) and joint range of motion, functional MEPS and DASH scores, and any complications were collected. RESULTS: At a mean 66.4 months' follow-up, 2 patients required revision surgery for recurrence. At the last follow-up, VAS for pain at rest was 0.9 and 1.9 for pain on movement. MEPS score was 85.6 and DASH score 82.2. No neurological, vascular or infectious complications of arthroscopic synovectomy were found in our series. DISCUSSION: Arthroscopic synovectomy in the treatment of PVNS of the elbow was a reliable and safe therapeutic alternative, with a low complications rate and 2 cases of recurrence (25%) in our study. This was the first study to report the results of arthroscopic surgical treatment of elbow PVNS. LEVEL OF EVIDENCE: IV Retrospective study without control group.

Tibial pilon fractures treated with a periarticular external fixator: Retrospective study of 47 cases.

INTRODUCTION: Tibial pilon fractures are a treatment challenge, since there is no true gold standard treatment, and because of potential skin complications. Periarticular external fixation (PAEF) appears to produce good results, but the outcomes with the TL-HEX Trauma™ (Orthofix®, Verona, Italy) have not yet been evaluated. We performed a study with the following objectives: 1) evaluate time to union and union rate; 2) determine clinical and radiological results; 3) detect complications. HYPOTHESIS: PAEF will produce comparable fracture union to other external fixator techniques for tibial pilon fractures. METHODS: A single center, retrospective study, was done between June 2016 and December 2018. Patients who had a tibial pilon fracture operated with a PAEF were included if they had a minimum of 12 months' follow-up. Forty-seven patients were included; the mean follow-up was 2.45 years (1.2-3.7). The primary endpoint was the time to union and union rate at the final assessment. The secondary endpoints were the joint range of motion, residual pain (VAS), functional scores (AOFAS and SF12) and complication rate. RESULTS: The union rate was 70% (33/47) and the mean time to union was 201±79 days (89-369). The range of motion was significantly reduced relative to the contralateral side. Twenty patients had residual pain that averaged 2.9 (1-6) on the VAS. The mean AOFAS score was 74 points (51-95). Twenty patients (43%) suffered at least one complication. DISCUSSION: While a PAEF helps to avoid skin complications, in our study, it was associated with a lower union rate and longer time to union than in other published studies. This difference is likely due to a higher rate of open fractures and high-energy trauma in our study, different protocol for return to weightbearing and a different external fixator than other studies. This is the first study reporting the results of the TL-HEX Trauma in this indication. LEVEL OF EVIDENCE: IV, retrospective study.

Revision of failed trapeziometacarpal prothesis by CMI pyrocarbon implant: Retrospective study of 28 patients with a mean follow-up of 7.5 years.

INTRODUCTION: There is no consensus on the best salvage option after a failed trapeziometacarpal prothesis. Conserving the trapezium and inserting a pyrocarbon hemiarthroplasty implant will prevent thumb shortening and preserve the thumb's motion. The aim of this study was to evaluate the clinical and radiological outcomes in the medium term of trapeziometacarpal prothesis revisions done using the CMI pyrocarbon implant. PATIENTS AND METHODS: This was a retrospective study of 28 patients with a mean age of 63.5 years. The mean time to revision was 6.1 years after the initial arthroplasty. The dominant side was operated in 70% of patients. The surgery consisted of removing the existing prosthesis, reconstructing the trapezium with a bone graft, and inserting the CMI pyrocarbon implant. The review consisted of a functional assessment (visual analog scale for pain, QuickDASH score, patient satisfaction), physical assessment (Kapandji, grip strength, key pinch strength, tip pinch strength) and radiological assessment (complications, radiolucent lines, scaphometacarpal height, implant centering, bone remodeling). RESULTS: At a mean follow-up of 7.5 years, no further surgical revisions were needed. The mean QuickDASH score was 1.1 and the mean QuickDASH was 13%. Twenty-five patients (89%) were satisfied with the outcome. The Kapandji score improved significantly from 7.5 to 9.5 on average. Grip strength improved significantly from 16.7kg to 21.5kg on average. The mean postoperative key pinch strength was 93% of the contralateral side. The mean postoperative tip pinch strength was 88% of the contralateral side. There were no fractures or dislocations visible on the radiographs. However, there was bone remodeling in the trapezium related to the pyrocarbon implant's indentation that was well tolerated by patients in the medium term. CONCLUSION: For revision of failed trapeziometacarpal prothesis, inserting the CMI pyrocarbon implant combined with trapezium reconstruction appears to be a good alternative to the more commonly used trapeziectomy procedure. Reconstructing the trapezium and inserting this hemiarthroplasty implant preserves the thumb's projection, length, and stability. The functional improvement experienced by patients makes this a relevant treatment option. LEVEL OF EVIDENCE: IV; retrospective study without control group.

Reconstruction of elbow flexion after sarcoma excision by a unipolar pedicled latissimus dorsi flap.

INTRODUCTION: The latissimus dorsi flap is widely used in plastic surgery for covering the upper limb but also for reconstruction the function of the elbow or shoulder. We describe a case of a sarcoma of the anterior compartment of the arm, the surgical removal then the covering and reconstruction of the elbow flexion. This case was carried out by a unipolar pedicled flap of the latissimus dorsi. MATERIAL AND METHODS: Three steps were performed (excision, flap preparation and flap fixation). The functional results (muscle strength, MRC scale) and range of motion (ROM) were analyzed. We performed a small literature review to compare the results. RESULTS: A complete excision (R0) was carried out with a good vitality of the latissimus dorsi flap. A rapid scarring was obtained, allowing an early start of adjuvant radiotherapy. Muscular strength was 33% less compared to preoperative, MRC scale was classified 4. ROM of the elbow were rated at -10/0/130. One year after the operation, the patient is still in remission. CONCLUSION: Our functional results are comparable to those found in the literature. The muscle strength in our case appears to be superior, probably linked to a brachio-radialis muscle still functional. No difference in function has been found in the literature between a unipolar or a bipolar transfer of the latissimus dorsi. This case report confirms the reliable and effective nature of the latissimus dorsi flap. The use of this flap for reconstruction after sarcoma surgery has only few reports in the literature.

Medium-term evaluation of leg lengthening by ISKD® intramedullary nail in 28 patients: Should we still use this lengthening system?

INTRODUCTION: Lower-limb lengthening presently uses intramedullary nailing. There are motorized systems and mechanical systems, each with their specific complications. The aim of the present study was to assess the efficacy of ISKD® mechanical nails (Orthofix Inc., Texas, USA) on 3D EOS® imaging, and also complications and functional impact. HYPOTHESIS: The study hypothesis was that nail lengthening is effective but should no longer use the ISKD® system, due to the high rate of specific complications. MATERIAL AND METHODS: A single-center retrospective study included 28 patients (14 female, 14 male) undergoing limb-lengthening by ISKD® nail between 2005 and 2018. Mean age was 29 years. Twenty-four procedures were femoral and 4 tibial. Lengthening and consolidation parameters and residual discrepancy were measured on 3D EOS® imaging. Complications and functional scores were collated. RESULTS: Twenty-eight ISKD® nails were implanted in 28 patients. Mean follow-up was 75 months. Planned lengthening was achieved in 78.5% of cases, for a mean lengthening of 34.5mm. Mean lengthening and consolidation indices were respectively 0.94mm/day and 105 days/cm. Length discrepancy showed significant correction, with improvement in functional scores (p<0.01). The overall complications rate was 67.9%, 76% of which were specific to the ISKD® nail. DISCUSSION: The present study confirmed that nail lengthening is an indication of choice in lower-limb length discrepancy, but that the ISKD® system should no longer be used, due to an excessive rate of specific complications. Complications are due to deficient control of lengthening rate, not found with new-generation motorized nails, which show much fewer complications. LEVEL OF EVIDENCE: IV, retrospective study without control group.

ACL reconstruction with lateral extra-articular tenodesis using a continuous graft: 10-year outcomes of 50 cases.

BACKGROUND: Persistence of pivot shift is the main problem after isolated intra-articular anterior cruciate ligament (ACL) reconstruction. Adding lateral extra-articular tenodesis (LET) to the ACL procedure increases the knee's stability by controlling rotational laxity. The aim of this study was to evaluate the long-term clinical and radiological outcomes of combined ACL reconstruction with LET using a continuous hamstring graft as a first-line procedure. MATERIAL AND METHODS: Fifty patients were reviewed at 10 years postoperative. Subjective outcome scores -IKDC, Lysholm, KOOS and Tegner- were collected. A clinical and radiological assessment was done. The knees' anteroposterior laxity was measured with a rollimeter. RESULTS: The mean IKDC subjective score was 85.5, the mean Lysholm score was 90.2 and 80% of patients had a score graded as good or very good. No pivot shift was present in 94% of patients and there was a firm endpoint in the Lachman test in 86% of patients. There was a flexion deficit>5° in 5 patients and an extension deficit of 10° in one patient. Most patients (56%) had resumed their physical activities at the same level as before the surgery. Signs of osteoarthritis were found in 26% of patients (16% were Ahlback stage 1 and 10% were stage 2). There was only one graft failure. These good outcomes are consistent with other published studies on combined ACL-LET. There was neither significant stiffness, nor a higher rate of secondary osteoarthritis relative to ACL reconstruction only, particularly in the lateral tibiofemoral compartment. CONCLUSION: Adding primary LET to ACL reconstruction improves control of rotational laxity over time without increasing the complication rate. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Muscular Hernia of the Leg After Anterior Cruciate Ligament Reconstruction with Hamstring Autograft: A Case Report.

CASE: A 20-year-old woman presented with symptomatic instability secondary to traumatic anterior cruciate ligament (ACL) rupture. Arthroscopic ACL reconstruction was performed using a 4-strand semitendinosus autograft harvested using a posterior approach. At her 2-month follow-up, a painful mass was palpable, and a hernia of the medial gastrocnemius was confirmed by ultrasound. This was treated with fascial closure. The clinical outcome was excellent at final follow-up. CONCLUSION: This is the first case reported in the literature of a muscular hernia after an ACL reconstruction using a posterior harvest of the semitendinosus. Surgeons must be aware of this specific complication and how it may be addressed.

Chromium-Cobalt Intoxication with Intense Systemic Complications following Total Hip Revision after Per-Operative Ceramic Fracture.

INTRODUCTION: Heavy metal intoxication after arthroplasty is extremely rare but could be lethal. Case Report. We report the case of a 69-year-old woman, who presented intense systemic symptoms of chromium-cobalt intoxication after revision of per-operative fractured ceramic components with metal-on-polyethylene. Systemic toxicity occurred a year after surgery and expressed brutally with mostly central neurological symptoms. Chelation associated with revision surgery allowed rapid regression of all symptoms. CONCLUSION: Revision of fractured ceramic, even per-operatively, should not be done with metal-on-polyethylene components, in order to avoid potentially lethal metal intoxication.