Higher preoperative range of motion is predictive of good mid-term results in the surgical management of osteochondral lesions of the talus: a prospective multicentric study.

INTRODUCTION: Osteochondral lesions of the talus (OLT) are a frequent cause of pain in young patients and a new CT arthrographic classification system of OLT was recently proposed to help guide the choices of and standardize the indications for surgical treatment. The primary hypothesis was that this algorithm would result in a postoperative AOFAS score of ≥ 80/100. The secondary hypothesis was to identify the preoperative factors of successful surgery. METHODS: This was a prospective observational multicenter study. Eighty-six patients who underwent surgery for OLT after at least 6 months of unsuccessful conservative management were included for a mean follow-up of 15 months (12-36). Forty-nine patients with stage 1 OLT underwent microperforation, 2 patients with stage 2 OLT underwent a lift, drill, fill, and fix graft procedure with screw fixation, and 35 patients with stage 3 OLT were treated with mosaicplasty. RESULTS: After a follow-up of at least 1 year, 56 patients (65%) had an AOFAS score > 80 and the mean AOFAS score was 82 (16-100). A lower BMI (p = 0.038), a higher preoperative range of motion in the ankle (p = 0.033), higher preoperative AOFAS and FAOS scores (p = 0.001 and p = 0.011), and the presence of a preoperative bone bruise on MRI (p = 0.020) were good prognostic factors on univariate analysis. The presence of grade 1 osteoarthritis on the Van Dijk classification was predictive of a poor prognosis (p = 0.044). Multivariate analysis showed that a good preoperative range of motion (OR = 1.080 [1.020-1.150] p = 0.01) was predictive of a positive outcome, while grade 1 osteoarthritis was predictive of a poor outcome (OR = 0.147 [0.036-0.603] p = 0.008). The postoperative AOFAS decreased in six patients and 17 patients had at least one complication: six dysthesias of the superficial fibular nerve, two of the sural nerve, and nine stage 1 complex regional pain syndromes. CONCLUSION: The new algorithm for OLT resulted in a postoperative AOFAS score of ≥ 80/100 in 65% of cases. The positive predictive factors of a successful postoperative outcome were the presence of a good preoperative range of motion and the absence of preoperative osteoarthritis. LEVEL OF EVIDENCE: Level II.

Complications and results of the arthrodesis after total ankle arthroplasty failure: a retrospective monocentric study of 12 cases.

INTRODUCTION: Total ankle arthroplasty (TAA) has the objective to maintain the range of motion of the tibiotarsal joint and to preserve the nearby joints. However, the complication rate and failures remain quite high after TAA. The main objective of the study was to evaluate the improvement in the functional scores of the tibiotarsal arthrodesis after TAA failure. The secondary objective was to assess the specific complications. MATERIALS AND METHODS: This monocentric retrospective series includes 12 patients (nine men, three women, average age 52.5 years) operated between 2003 and 2018. An iliac graft was used in all cases. The arthrodesis was stabilized either by screws or by retrograde nailing. RESULTS: The reoperation was due to painful malleolar conflicts or loosening. The AOFAS score increased from 38/100 to 67/100 (51-86) post-operatively. The fusion was acquired at 3.7 months (3-6) except in two cases. DISCUSSION AND CONCLUSION: The 83% primary fusion rate is in the low average of the literature and 92% fusion rate in the high average after reoperation. All patients were improved even in two non-unions. The results of this study confirm that the arthrodesis after TAA failure is a reliable alternative to the TAA replacement. However, they are lower than those after a first-line arthrodesis.

Value of 3D Preoperative Planning for Primary Total Hip Arthroplasty Based on Biplanar Weightbearing Radiographs.

Two-dimensional (2D) planning on standard radiographs for total hip arthroplasty may not be sufficiently accurate to predict implant sizing or restore leg length and femoral offset, whereas 3D planning avoids magnification and projection errors. Furthermore, weightbearing measures are not available with computed tomography (CT) and leg length and offset are rarely checked postoperatively using any imaging modality. Navigation can usually achieve a surgical plan precisely, but the choice of that plan remains key, which is best guided by preoperative planning. The study objectives were therefore to (1) evaluate the accuracy of stem/cup size prediction using dedicated 3D planning software based on biplanar radiographic imaging under weightbearing and (2) compare the preplanned leg length and femoral offset with the postoperative result. This single-centre, single-surgeon prospective study consisted of a cohort of 33 patients operated on over 24 months. The routine clinical workflow consisted of preoperative biplanar weightbearing imaging, 3D surgical planning, navigated surgery to execute the plan, and postoperative biplanar imaging to verify the radiological outcomes in 3D weightbearing. 3D planning was performed with the dedicated hipEOS® planning software to determine stem and cup size and position, plus 3D anatomical and functional parameters, in particular variations in leg length and femoral offset. Component size planning accuracy was 94% (31/33) within one size for the femoral stem and 100% (33/33) within one size for the acetabular cup. There were no significant differences between planned versus implanted femoral stem size or planned versus measured changes in leg length or offset. Cup size did differ significantly, tending towards implanting one size larger when there was a difference. Biplanar radiographs plus hipEOS planning software showed good reliability for predicting implant size, leg length, and femoral offset and postoperatively provided a check on the navigated surgery. Compared to previous studies, the predictive results were better than 2D planning on conventional radiography and equal to 3D planning on CT images, with lower radiation dose, and in the weightbearing position.

Osteosynthesis of periprosthetic type A and B femoral fractures using an unlocked plate with integrated cerclage cable and trochanteric hook: A multicenter retrospective study of 45 patients with mean follow-up of 20 months.

INTRODUCTION: Femoral periprosthetic fracture (FPF) is a frequent complication in dependent elderly persons, with a limited life expectancy. Their management is difficult and the choice between osteosynthesis and prosthesis is still matter of discussion. To date, there is no study on unlocked plate with integrated cerclage cable and trochanteric hook for this indication. The objectives of this study were to analyze fracture healing, complication rate and functional outcome. Our hypothesis is that this technique allows a high rate of consolidation and a return to the previous state in terms of autonomy and place of residence. MATERIALS AND METHODS: We conducted a retrospective multicenter study between 2010 and 2015. The inclusion criteria were: patients with type A and B FPF according to the classification of Vancouver who received osteosynthesis hook plate. The evaluation focused on the consolidation period, complications and pre and postoperative Parker and Katz scores. Death, nonunion, dislocation, infection and failure of fixation were considered major complications. RESULTS: Forty-five patients met the inclusion criteria and were evaluated at mean 20 months (6-72). All fractures consolidated at a mean 7 weeks (6-10), except one that has not undergone further surgery in the absence of functional impairment. Parker score decreased from 6.4 to 4.9 (p=0.03) and Katz score from 4.8 to 4.3 (p=0.045). Five patients died within the year of the operation. Five patients living at home preoperatively were admitted to an institution, the others returned to their retirement home or nursing home. CONCLUSION: This plate allows for a quick and effective management of patients with FPF. The low rate of complications and the very good consolidation rate lead us to use the same plate even for class B2 or B3 fractures in some patients with precarious health condition who cannot tolerate major revision surgery: Elderly, ASA score >3, loss of autonomy, Katz score <4.

Advantages of external hybrid fixators for treating Schatzker V-VI tibial plateau fractures: A retrospective study of 40 cases.

INTRODUCTION: Proximal tibia fractures make up 1% of all fractures in adults. The fractures classified as Schatzker V and VI fractures can compromise knee structure and function. They are challenging to treat and often have complications. While plate fixation is the gold standard, the resulting infection rate has led us to favor external hybrid fixation. The aims of this study were to assess the radiographic and functional outcomes along with the complication rate when using this method and to compare them to historical plate fixation data. MATERIAL AND METHODS: This was a retrospective study of 40 patients. The complications, quality of reduction, IKS, Lysholm and Rasmussen functional scores at the latest follow-up and factors affecting the functional outcome were evaluated. These parameters were compared to published results from plate fixation studies. RESULTS: The deep infection rate was 2.5%. The union rate was 80%. Satisfactory reduction was obtained in 70% of cases; however, 52% of patients had malunion. The mean IKS score was 73.74, the mean Rasmussen score was 22.85 and the mean Lysholm score was 75.53. Age, reduction at latest follow-up, mechanical axis and anteroposterior laxity had a significant effect on the functional outcome. DISCUSSION: Despite the malunion rate being higher than other studies, the functional outcomes were nearly identical based on the variables measured. There are several advantages associated with using a hybrid external fixator: shorter operative time, less bleeding, shorter hospital stays and lower infection rate. CONCLUSION: Hybrid external fixation is a reliable fracture fixation method that leads to satisfactory functional outcomes, while reducing the infection rate and allowing arthroplasty to be performed in the future if needed.

Is amputation a viable treatment option in lower extremity trauma?

INTRODUCTION: There is currently no consensus on how to treat patients with lower extremity trauma. Should amputation be performed early on to avoid complications or should the limb be saved at any price? The goal of this study was to show that early amputation is a viable treatment option in lower extremity trauma cases. MATERIAL AND METHODS: Twenty patients who underwent early amputation and 16 patients who underwent limb-salvage were included with a minimum follow-up of 1year. The main endpoints were the Mangled Extremity Severity Score (MESS) used to predict amputation, complications, sequelae, bone union and functional outcomes. RESULTS: The amputees had a higher MESS score than those treated conservatively (7.8 vs. 4.9, P<0.00001), had a shorter hospital stay (P<0.022) and had fewer postoperative complications (P<0.003), especially infection-related (P<0.001). The prevalence of infection in limb-salvage patients was 61%. There was no significant difference between the two groups in terms of quality of life. DISCUSSION: In cases of lower extremity trauma, early amputation and limb-sparing treatment each have their advantages and disadvantages. Early amputation seems to be better in cases of complications, despite similar quality of life in the two groups in the long-term. It is a viable treatment option in cases of lower extremity trauma. Amputation must not be considered as a failure, but a deliberate choice due to the functional impact of complications that occur after limb-salvage. LEVEL OF EVIDENCE: Level IV study.

The concept of a waiting period for preoperative patient consent: Prospective study of 51 shoulder arthroscopy cases.

INTRODUCTION: The French Code of Public Health (CSP) does not explicitly require that patients should be given a certain amount of time to think about a procedure, except for cosmetic surgery, where 15 days is required (Art. L 6322-2 CSP). We hypothesized that patients require a waiting period during their decision-making process for scheduled shoulder arthroscopy procedure. MATERIALS AND METHODS: This prospective observational study of 51 patients analysed the concept of a waiting period based on a 10-item questionnaire. A comparative statistical approach was used and the P values were calculated using a paired Wilcoxon rank-sum test. RESULTS: Of the 51 patients, 42 (82%) rejected the concept of a waiting period before the procedure and 37 patients (73%) did not want a mandatory waiting period imposed by law. DISCUSSION: This study looked at the decision-making process during scheduled orthopaedic surgery and differentiated between the conscious and unconscious approach corresponding to an active and passive waiting period. A waiting period does not allow patients to make a conceptually deliberative decision that conforms to the criteria defined by the French Health Authority. This study rejects the need for a mandatory waiting period imposed on surgeons and patients as it does not integrate itself into the informative model of ethical decision-making for scheduled shoulder arthroscopy. TYPE OF STUDY: Prospective, observational; level of evidence IV.

What are the risk factors for dislocation in primary total hip arthroplasty? A multicenter case-control study of 128 unstable and 438 stable hips.

INTRODUCTION: Dislocation after total hip arthroplasty (THA) is a leading reason for surgical revision. The risk factors for dislocation are controversial, particularly those related to the patient and to the surgical procedure itself. The differences in opinion on the impact of these factors stem from the fact they are often evaluated using retrospective studies or in limited patient populations. This led us to carry out a prospective case-control study on a large population to determine: 1) the risk factors for dislocation after THA, 2) the features of these dislocations, and 3) the contribution of patient-related factors and surgery-related factors. HYPOTHESIS: Risk factors for dislocation related to the patient and procedure can be identified using a large case-control study. PATIENTS AND METHODS: A multicenter, prospective case-control study was performed between January 1 and December 31, 2013. Four patients with stable THAs were matched to each patient with a dislocated THA. This led to 566 primary THA cases being included: 128 unstable, 438 stable. The primary matching factors were sex, age, initial diagnosis, surgical approach, implantation date and type of implants (bearing size, standard or dual-mobility cup). RESULTS: The patients with unstable THAs were 67±12 [37-73]years old on average; there were 61 women (48%) and 67 men (52%). Hip osteoarthritis (OA) was the main reason for the THA procedure in 71% (91/128) of the unstable group. The dislocation was posterior in 84 cases and anterior in 44 cases. The dislocation occurred within 3 months of the primary surgery in 48 cases (38%), 3 to 12 months after in 23 cases (18%), 1 to 5years after in 20 cases (16%), 5 to 10years after in 17 cases (13%) and more than 10years later in 20 cases. The dislocation recurred within 6 months of the initial dislocation in 23 of the 128 cases (18%). The risk factors for instability were a high ASA score with an odds ratio (OR) of 1.93 (95% CI: 1.4-2.6), neurological disability (cognitive, motor or psychiatric disorders) with an OR of 3.9 (95% CI: 2.15-7.1), history of spinal disease (lumbar stenosis, spinal fusion, discectomy, scoliosis and injury sequelae) with an OR of 1.89 (95% CI: 1.0-3.6), unrepaired joint capsule (all approaches) with an OR of 4.1 (95% CI: 2.3-7.37), unrepaired joint capsule (posterior approach) with an OR of 6.0 (95% CI: 2.2-15.9), and cup inclination outside Lewinnek's safe zone (30°-50°) with OR of 2.4 (95% CI: 1.4-4.0). DISCUSSION: This large comparative study isolated important patient-related factors for dislocation that surgeons must be aware of. We also found evidence that implanting the cup in 30° to 50° inclination has a major impact on preventing dislocation. LEVEL OF EVIDENCE: Level III; case-control study.

Accuracy and reproducibility of preoperative three-dimensional planning for total hip arthroplasty using biplanar low-dose radiographs : A pilot study.

BACKGROUND: In total hip arthroplasty (THA), the acetabular cup and femoral stem must be correctly sized and positioned to avoid intraoperative and postoperative complications, achieve good functional outcomes and ensure long-term survival. Current two-dimensional (2D) techniques do not provide sufficient accuracy, while low-dose biplanar X-rays (EOS) had not been assessed in this indication. Therefore, we performed a case-control study to : (1) evaluate the prediction of stem and cup size for a new 3D planning technique (stereoradiographic imaging plus 3D modeling) in comparison to 2D templating on film radiographs and (2) evaluate the accuracy and reproducibility of this 3D technique for preoperative THA planning. HYPOTHESIS: Accuracy and reproducibility are better with the 3D vs. 2D method. PATIENTS AND METHODS: Stem and cup sizes were retrospectively determined by two senior surgeons, twice, for a total of 31 unilateral primary THA patients in this pilot study, using 3D preplanning software on low-dose biplanar X-rays and with 2D templating on conventional anteroposterior (AP) film radiographs. Patients with a modular neck or dual-mobility prosthesis were excluded. All patients but one had primary osteoarthritis; one following trauma did not have a cup implanted. The retrospectively planned sizes were compared to the sizes selected during surgery, and intraclass coefficients (ICC) calculated. RESULTS: 3D planning predicted stem size more accurately than 2D templating: stem sizes were planned within one size in 26/31 (84%) of cases in 3D versus 21/31 (68%) in 2D (P=0.04). 3D and 2D planning accuracies were not significantly different for cup size: cup sizes were planned within one size in 28/30 (92%) of cases in 3D versus 26/30 (87%) in 2D (P=0.30). ICC for stem size were 0.88 vs. 0.91 for 3D and 2D, respectively. Inter-operator ICCs for cup size were 0.84 vs. 0.71, respectively. Repetitions of the 3D planning were within one size (except one stem), with the majority predicting the same size. DISCUSSION: Increased accuracy in 3D may be due to the use of actual size (non-magnified) images, and judging fit on AP and lateral images simultaneously. Results for other implant components may differ from those presented. Size selection may improve further with planning experience, based on a feedback loop between planning and surgical execution. LEVEL OF EVIDENCE: Level III. Retrospective case-control study.

Is arthroplasty preferable to internal fixation for the treatment of extracapsular fracture of the upper femur in the elderly?

INTRODUCTION: Although internal fixation is the reference treatment for extracapsular fracture of the upper femur, indications for arthroplasty are broadening, especially in unstable comminutive fracture in fragile bone. The present study hypothesis was that arthroplasty reduces early mortality and morbidity and provides better recovery of autonomy in over-80 year-old patients than does internal fixation. MATERIAL AND METHODS: A prospective multicenter study was conducted on 8 sites. Internal fixation was systematically used in 5 centers; arthroplasty was used systematically in 1 center, and reserved for unstable fracture in 2 centers. A total of 697 patients aged over 80 years (mean age, 85±5 years), presenting with extracapsular fracture, were included; 521 were treated by internal fixation and 176 by arthroplasty. Results were studied on multivariate analysis of ASA score, blood loss, transfusion, and also of treatment modality as an independent factor for early (first 6 months) mortality and morbidity (mechanical, general and nutritional complications) and functional outcome (autonomy and dependence). RESULTS: Overall mortality was 19.2%. Autonomy deteriorated in 56% of patients alive at 6 months and dependence worsened in 44%. Two percent of those managed by internal fixation underwent revision for disassembly (n=8) or infection (n=1). Eight percent of those managed by arthroplasty underwent revision for dislocation (n=4), implant loosening (n=3) or infection (n=7). On univariate analysis, mortality was higher in the arthroplasty group (25%) than with internal fixation (17%; P=0.002), as were blood loss (425±286mL versus 333±223mL; P<0.0001), transfusion rate (61% versus 32%; P<0.0001) and infection (4% versus 0.2%; P<0.001). On multivariate analysis, however, treatment modality no longer showed impact on mortality or on morbidity and autonomy at 6 months. Nutritional status was better conserved at 6 months following arthroplasty, but dependence worsened. Poor preoperative autonomy, ASA score, and nutritional status and time to treatment were independent factors for mortality. Transfusion, associated with onset of mechanical complications, significantly increased dependence. CONCLUSION: Type of treatment had little impact on mortality, morbidity or functional outcome. Differences seemed more related to preoperative functional and nutritional status. LEVEL OF EVIDENCE: III, prospective case-control study.

Developments in imaging methods used in hip arthroplasty: A diagnostic algorithm.

BACKGROUND: Several imaging modalities can be used to diagnose complications of hip prosthesis placement. Despite progress in these imaging techniques, there are, as yet, no guidelines as to their respective indications. METHODS: We formed a panel of experts in fields related to prosthesis imaging (radiology, nuclear medicine, orthopedic surgery) and conducted a review of the literature to determine the value of each modality for diagnosing complications following hip replacement. RESULTS: Few recent studies have investigated the benefits related to the use of the latest technical developments, and studies comparing different methods are extremely rare. CONCLUSIONS: We have developed a diagnostic tree based on the characteristics of each imaging technique and recommend its use. Computed topography was found to be the most versatile and cost-effective imaging solution and therefore a key tool for diagnosing the complications of hip replacement surgery.

Fibroblast Growth Factor 23 drives MMP13 expression in human osteoarthritic chondrocytes in a Klotho-independent manner.

OBJECTIVE: Fibroblast Growth Factor 23 (FGF23) may represent an attractive candidate that could participate to the osteoarthritic (OA)-induced phenotype switch of chondrocytes. To address this hypothesis, we investigated the expression of FGF23, its receptors (FGFRs) and co-receptor (Klotho) in human cartilage and studied the effects of rhFGF23 on OA chondrocytes. METHOD: Gene expression or protein levels were analysed by RT-PCR and immunohistochemistry. Collagenase 3 (MMP13) activity was measured by a fluorescent assay. MAPK signalling pathways were investigated by phosphoprotein array, immunoblotting and the use of selective inhibitors. RNA silencing was performed to confirm the respective contribution of FGFR1 and Klotho. RESULTS: We showed that the expression of FGF23, FGFR1 and Klotho was up-regulated at both mRNA and protein levels in OA chondrocytes when compared to healthy ones. These overexpressions were markedly elevated in the damaged regions of OA cartilage. When stimulated with rhFGF23, OA chondrocytes displayed an extended expression of FGF23 and of markers of hypertrophy such as MMP13, COL10A1, and VEGF. We demonstrated that FGF23 auto-stimulation was both FGFR1-and Klotho-dependent, whereas the expression of markers of hypertrophy was mainly dependent on FGFR1 alone. Finally, we showed that FGF23-induced MMP13 expression was strongly regulated by the MEK/ERK cascade and to a lesser extent, by the PI-3K/AKT pathway. CONCLUSION: These results demonstrate that FGF23 sustains differentiation of OA chondrocytes in a Klotho-independent manner.

A new method for the separation and purification of the osteogenic compounds of nacre Ethanol Soluble Matrix.

Nacre is able to induce bone-forming cells mineralization, and gains widely interest in bone regeneration. While, the osteoinductive compounds are not yet identified. ESM (Ethanol Soluble Matrix), a nacre extract from powder of Pinctada margaritifera pearl oyster shell, has been firstly proven having the capacity to induce mineralization and to restore mineralization defect in vitro. It is suitable to treat ESM as a source of osteoinductive compounds. Herein, we develop a new method for separating and purifying nacre extracts by an ionic approach. At first, cationic ESM (ESMc) and anionic ESM (ESMa) were achieved with ion-exchange resin. Then, ESM was separated and collected on cation exchange HPLC. Scanning Electron Microscopy coupled with Energy Dispersive X-ray Spectrometry (EDS) was used to reveal the concentrated elements in ESM fractions. A coupled cell models were used to test the ESM fractions. Alizarin Red staining was performed and quantified to evaluate the mineralization level. ESMc and 2 HPLC fractions stimulated the mineralization in both cells. EDS demonstrated the abundant presence of calcium and chloride in the osteogenic fractions. To validate, pure CaCl2 was tested and proven having an osteogenic effect in both cells, but less stable than ESM. The mineralization nodules induced by ESM fractions and CaCl2 differed in both cells. In conclusion, a new method was developed for separating and purifying nacre extracts by an ionic approach. By which, the osteoinductive compounds in ESM were proven cationic, and calcium in ESM was demonstrated to play a role in inducing the cell mineralization.

Expression of the semicarbazide-sensitive amine oxidase in articular cartilage: its role in terminal differentiation of chondrocytes in rat and human.

OBJECTIVE: Semicarbazide-sensitive amine oxidase (SSAO) catalyzes the oxidation of primary amines into ammonia and reactive species (hydrogen peroxide, aldehydes). It is highly expressed in mammalian tissues, especially in vascular smooth muscle cells and adipocytes, where it plays a role in cell differentiation and glucose transport. The study aims at characterizing the expression and the activity of SSAO in rat and human articular cartilage of the knee, and to investigate its potential role in chondrocyte terminal differentiation. DESIGN: SSAO expression was examined by immunohistochemistry and western blot. Enzyme activity was measured using radiolabeled benzylamine as a substrate. Primary cell cultures of rat chondrocytes were treated for 21 days by a specific SSAO inhibitor, LJP 1586. Terminal chondrocyte differentiation markers were quantified by RT-qPCR. The basal and IL1ß-stimulated glucose transport was monitored by the entrance of (3)[H]2-deoxyglucose in chondrocytes. RESULTS: SSAO was expressed in chondrocytes of rat and human articular cartilage. SSAO expression was significantly enhanced during the hypertrophic differentiation of chondrocytes characterized by an increase in MMP13 and in alkaline phosphatase (ALP) expressions. SSAO inhibition delayed the late stage of chondrocyte differentiation without cell survival alteration and diminished the basal and IL1ß-stimulated glucose transport. Interestingly, SSAO activity was strongly increased in human osteoarthritic cartilage. CONCLUSIONS: SSAO was expressed as an active form in rat and human cartilage. The results suggest the involvement of SSAO in rat chondrocyte terminal differentiation via a modulation of the glucose transport. In man, the increased SSAO activity detected in osteoarthritic patients may trigger hypertrophy and cartilage degeneration.

Nacre extract restores the mineralization capacity of subchondral osteoarthritis osteoblasts.

Osteoarthritis (OA) is the most common cause of joint chronic pain and involves the entire joints. Subchondral osteoarthritic osteoblasts present a mineralization defect and, to date, only a few molecules (Vitamin D3 and Bone Morphogenetic Protein2) could improve the mineralization potential of this cell type. In this context, we have tested for the first time the effect of nacre extract on the mineralization capacity of osteoblasts from OA patients. Nacre extract is known to contain osteogenic molecules which have demonstrated their activities notably on the MC3T3 pre-osteoblastic cell line. For this goal, molecules were extracted from nacre (ESM, Ethanol Soluble Matrix) and tested on osteoblasts of the subchondral bone from OA patients undergoing total knee replacement and on MC3T3 cells for comparison. We chose to investigate the mineralization with Alizarin Red staining and with the study of extracellular matrix (ECM) structure and composition. In a complementary way the structure of the ECM secreted during the mineralization phase was investigated using second harmonic generation (SHG). Nacre extract was able to induce the early presence (after 7 days) of precipitated calcium in cells. Raman spectroscopy and electron microscopy showed the presence of nanograins of an early crystalline form of calcium phosphate in OA osteoblasts ECM and hydroxyapatite in MC3T3 ECM. SHG collagen fibers signal was present in both cell types but lower for OA osteoblasts. In conclusion, nacre extract was able to rapidly restore the mineralization capacity of osteoarthritis osteoblasts, therefore confirming the potential of nacre as a source of osteogenic compounds.

Outcomes of talar dome osteochondral defect repair using osteocartilaginous autografts: 37 cases of Mosaicplasty®.

BACKGROUND: The indications of osteochondral autograft implantation using the Mosaicplasty(®) technique were only recently extended to osteochondral lesions of the talus (OLT), a site for which no medium- or long-term outcome data are available. Our objective here was to evaluate medium-term outcomes in case-series of patients who underwent Mosaicplasty(®) for OLT repair. HYPOTHESIS: Mosaicplasty(®) provides good medium-term outcomes with low morbidity when used for OLT repair. PATIENTS ET METHODS: We retrospectively reviewed cases of Mosaicplasty(®) for OLT repair, performed in combination with malleolar osteotomy on the side of the OLT, at either of two centres, between 1997 and 2013. Pre-operative clinical data were collected from the medical records and all patients were re-evaluated. We studied 37 patients with a mean age of 33 years. RESULTS: Mean follow-up at re-evaluation was 76 months. Mean AOFAS score at re-evaluation was 83 (range, 9-100). A work-related cause to the OLT was associated with significantly poorer outcomes (P=0.01). AOFAS values were significantly better in patients whose OLT size was 0.5 to 1cm(2). The Ogilvie-Harris score at last follow-up was good or excellent in 78% of patients. No patient experienced morbidity related to the malleolar osteotomy. Persistent patellar syndrome was noted in 6 patients. DISCUSSION: In our case-series, Mosaicplasty(®) for OLT repair provided good medium-term outcomes in 78% of patients. Nevertheless, the donor-site morbidity should be borne in mind. Mosaicplasty(®) deserves to be viewed as a reference standard method for OLT repair. LEVEL OF EVIDENCE: IV, retrospective study.

Locking plate fixation versus antegrade nailing of 3- and 4-part proximal humerus fractures in patients without osteoporosis. Comparative retrospective study of 63 cases.

INTRODUCTION: There is no consensus on the treatment of proximal humeral fractures. The goal of the present retrospective observational study was to compare functional and radiological results and complications of internal fixation using locking plates versus antegrade nailing in the treatment of non-osteoporotic Neer classification 3- and 4-part fractures after a least 1 year of follow-up. MATERIAL AND METHODS: Internal fixation was performed in 67 fractures (1 bilateral): 35 by locking plate (1 lost to follow-up, 1 deceased) and 32 by intramedullary nailing (2 lost to follow-up) between January 1st, 2004 and December 31st, 2010. Thus, the study included 33 plates (21 3-part and 12 4-part fractures) and 30 nails (21 3-part and nine 4-part fractures). Final functional assessment was based on the Oxford, Constant, Relative Constant and QuickDASH scores and percentage of handicap. Radiological follow-up included immediate postoperative, 6 weeks, 3 months and 1 year AP and Lamy lateral views. All complications were recorded prospectively. RESULTS: Mean Oxford, Constant, Relative Constant and QuickDASH scores and percentage of disability for the plate and nail groups respectively were: 23.8 vs. 23.3, 59.7 vs. 60 6, 73.5 vs 79.3, 20.9 vs 21.0, 22.6 vs 22.6. Multivariate analysis did not show any significant difference in functional scores or quality of reduction: final unsatisfactory reduction on AP view, 30.3 vs. 36.7%; lateral view, 3.2 vs. 10.0%; greater tuberosity, 9.1 vs. 16.7%. Four-part fracture (P<0.05), frontal reduction defect at follow-up (P<0.05) or greater tuberosity defect (P>0.05) had negative impacts on functional scores. The complication rates corresponded to those in the literature and did not differ between the techniques (P=0.1901) except for three infections in the plate group. DISCUSSION-CONCLUSION: Internal fixation is the treatment of choice for 3- and 4-part fractures in non-osteoporotic patients. Although no difference was found in the present study between locking plate and intramedullary nailing, the former seems to be less well adapted and more aggressive. TYPE OF STUDY: Retrospective observational study. LEVEL OF EVIDENCE: Level 4.