The Saint-Joseph Acetabular score: a reproducible and accurate prediction of the outcome of open reduction and internal fixation of acetabular fractures.

PURPOSE: Acetabular fractures are associated to an increased risk of subsequent hip osteoarthritis. The only available score for post-operative reduction assessment in acetabular fractures (Matta's score) is x-ray based. CT-scan was shown superior to X-rays in post-operative reduction assessment. We aim to describe a CT-scan-based post-operative reduction score in acetabular fractures and evaluate its accuracy and reproducibility. METHODS: This is a retrospective study that includes 138 patients who underwent surgery for an acetabular fracture in our tertiary referral centre with a mean follow-up of 104.39±42.2 months. The post-operative CT-scan was reviewed and residual displacement (maximum gap and step) measured by three independent observers. The association between the occurrence of THA and the CT-scan measurements was evaluated. This led to a new prognostic score. The interobserver reliability and accuracy of this score were calculated. RESULTS: Interobserver reproducibility for the residual maximal gap was 0.82 (95% CI [0.70-0.89]) and 0.61 (95% CI [0.52-0.70]) for the residual maximal step displacement measurements. We created a score from a logistic regression model, attributing 1 point for every 1 mm of residual maximal step displacement and 1 point for every 2 mm of residual maximal gap displacement. The interobserver reproducibility of this score was 0.78 (95% CI [0.71-0.84]), and its AUC was 0.79 (95% CI [0.69-0.88]). CONCLUSION: This is the first CT-scan-based score for the assessment of residual displacement of a surgically treated acetabular fracture. It shows good interobserver reproducibility and accuracy in predicting the risk for secondary THA. It should be regularly used per-operatively (if per-operative 3D imaging is available) and post-operatively to predict the prognosis.

Knee injuries concomitant to posterior acetabular fractures: an association to look for.

PURPOSE: Acetabular fractures are frequently associated with other skeletal injuries, particularly knee injuries. This study aims to evaluate the relationship between posterior acetabular fractures and knee injury, analyzing its patterns and association with other injuries. METHODS: This is a retrospective monocentric study in a tertiary referral centre. We reviewed the data (age, sex, type of fracture, and concomitant injury) of patients hospitalized for a posterior acetabular fracture. We recorded concomitant knee injury diagnosed up to one year following acetabular fracture. RESULTS: Two-hundred-seventeen patients (177 males/40 females) were included. The mean age was 40.5 years. Eighty-five patients (39%) had a concomitant hip dislocation, nine (4.1%) had sciatic nerve palsy, 17 (7.8%) had upper extremity injury, and 18 (8.3%) had lower extremity injury (other than the knee). Eight (3.7%) patients had spine injury, 11 (5.1%) had severe thoracic injury, nine (4.1%) had an abdominal injury, and four (1.8%) had a head injury. There were 33 (15.21%, 95% CI 10.80-20.8%) patients (30 M/3 F) (group 1) with a concomitant knee injury and 184 patients without a concomitant knee injury(group 2). The mean age in group 1 was 34.3 compared to 45.4 in group 2(p = 0.021). The pattern analysis revealed five fractures, 14 ligamentous injuries (PCL injuries = 68%), and 14 soft tissue injuries. Sixteen (48.48%) injuries were identified during hospitalization and 17 (51.51%) during follow-up. There were an association between knee injury and upper extremity injury (OR = 3.49 95% CI 1.12-10.00,p = 0.022) and other lower extremity injury (OR = 3.18 95% CI 1.03-8.95,p = 0.032). DISCUSSION: Knee injury is the second most frequent lesion associated with posterior acetabular fractures. Being missed in half of cases, we recommend a systematic examination of ipsilateral knees under general anaesthesia, keeping a high index of suspicion and a low threshold for complementary knee imaging. Knee injury should be mainly looked for in patients younger than 60 years and in those with upper and/or lower extremities injuries.

French Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Development and Validation.

Background: The 12-item Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale was developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR). A short (6-item) English version was also developed, which has shown to have good reliability and validity. Purpose/Hypothesis: We aimed to develop and validate a French version of the short ACL-RSI scale. We hypothesized that the same questions would remain in the selection as the English version and that the French version of the scale would have the same psychometric properties. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The full 12-item French ACL-RSI scale was administered to 1000 patients who had undergone ACLR surgery. Reliability (Cronbach alpha) and factor analysis of the full scale were determined. Item selection and elimination process was conducted to develop a short (6-item) version. The same methodology was used to develop the English short ACL-RSI scale. A minimal (3-item) version was also developed and assessed. Results: Internal consistency of the full version of the French ACL-RSI was found to be high (Cronbach alpha = .95), suggesting item redundancy. The short (6-item) version was also found to have high internal consistency (Cronbach alpha = .92) and was strongly correlated with the full version (r = 0.98). The minimal (3-item) version was also found to have high internal consistency, as well as a strong correlation with the full version (r = 0.94). Conclusion: The French version of the short (6-item) ACL-RSI scale was valid, discriminant, consistent, and reproducible. The minimal (3-item) version was also found to be useful and more efficient to collect the information provided by the full ACL-RSI in a French-speaking population.

Patient-specific cutting guides increase accuracy of medial opening wedge high tibial osteotomy procedure: A retrospective case-control study.

Purpose: To compare the accuracy of patient-specific guides (PSCG) to the standard technique in medial open-wedge high tibial osteotomy (OWHTO). Secondary objectives were to evaluate factors that could influence accuracy and to compare the complication rate and operating time for both procedures. Methods: A retrospective analysis of prospective collected data was performed. Between March 2011 and May 2018, 49 patients with isolated medial knee osteoarthritis who were operated for OWHTO using PSCG and 38 patients using the standard technique were included. Preoperative and postoperative deformities were evaluated on long leg radiographs by measuring the mechanical medial proximal tibial angle, mechanical lateral distal femoral angle, hip knee ankle angle (HKA), and joint line convergence angle. Pre- and postoperative posterior tibial slope was also evaluated. Accuracy was evaluated by analysing the difference between the preoperative planned and the actual postoperative HKA. Operating time and complication rate were also recorded in both groups. Results: The mean preoperative HKA was 173.4° (±3.1°) in the PSCG group and 173.3° (±2.4°) in the standard group (p = 0.8416). Mean planned HKA were 182.8° (±1.1°) and 184.0° (±0°) respectively for the PSCG and the standard group. Mean postoperative HKA were 181.9° (±1.9°) and 182.6° (±3.1°) respectively for the PSCG and the standard group. An accuracy of ±2° in the HKA was achieved in 44 (90%) in the PSCG group and 24 (65%) in the standard group (p = 0.006). The probability of achieving a HKA accuracy was four times higher for patients in the PSCG group (odds ratio [OR] = 4.06, [1.1; 15.3], p = 0.038). Also, higher preoperative Ahlback grade was associated with precision, all other parameters being equal (OR = 4.2, [0.13; 0.97], p = 0.04). Conclusion: In this study, the PSCG technique was significantly more accurate for achieving the planned HKA in OWHTO. Complication rates and operating times were comparable between groups. Level of Evidence: Level IV, case-control study.

Predictive radiological parameters of failure following surgical management of femoroacetabular impingement associated with borderline acetabular dysplasia.

INTRODUCTION: The role of arthroscopic treatment of femoroacetabular impingement (FAI) in mild or borderline hip dysplasia (lateral center edge angle=18-25) is controversial. It is recommended to combine capsular plication with femoral neck osteoplasty and suture repair of the labrum. Few studies have investigated which radiological parameters are associated with failure of this procedure. HYPOTHESIS: A larger number of radiological signs of mild or borderline hip dysplasia than radiological signs of FAI negatively influence the outcomes of arthroscopic treatment. METHODS: This was a retrospective study done with data collected prospectively after a minimum of 2 years' follow-up in patients who underwent arthroscopic treatment of FAI due to cam impingement combined with mild to moderate hip dysplasia. Patients with hip osteoarthritis graded as ≥ Tönnis 2 were excluded. Functional outcome scores (mHHS and NAHS) were determined along with the need for reoperation. Three groups were defined based on the outcomes: success (mHHS ≥ Patient Acceptable Symptomatic State [PASS]); moderate improvement (improvement in mHHS + mHHS

Postoperative regular use of a self-rehabilitation mobile application for more than two weeks reduces extension deficit and cyclop syndrome after anterior cruciate ligament reconstruction.

PURPOSE: To investigate the minimum use that correlates with the best outcomes in term of complications associated with self-directed rehabilitation mobile application and to explore the user profile and usage habits. METHODS: This was a single-center retrospective study of 356 patients who underwent ACL reconstruction surgery between November 2019 and August 2020. Complications were defined as the presence of an extension deficit ≥ 5° after 6 weeks and/or the presence of cyclops syndrome. The demographics, sports competition level and number of connections were collected by the application. RESULTS: The complication rate was reduced 4.2-fold with at least 2 weeks of use (2.4% (3/123) (with 0.8% (1/123) of cyclops syndrome) versus 10.8% (23/212) (with 3.3% (7/212) cyclops syndrome), p = .04). The mean duration of use was 20 ± 23 days with a frequency of 2.1 ± 2.3 connections per day. The usage rate was 50% in week 1, 35% in week 2, and 24% in week 3. There was one peak in the abandon rate during the first few days of use and a second peak at Day 10 when physiotherapy sessions started. There were two dips in the abandon rate associated with the follow-up visits at Days 21 and 45. Greater use was found in older patients (p = .0001) and female patients (p = .04). CONCLUSIONS: When using the application for a minimum of 2 weeks, the risk of complications was reduced 4.2-fold. The typical users of a self-directed rehabilitation application after ACL surgery in this study were women and patients over 30 years of age. LEVEL OF EVIDENCE: IV, retrospective.

Return to Sports After ACL Augmentation With Anterolateral Reconstruction (ALR) Harvesting Gracilis Only Compared With ACL Reconstruction With ALR Harvesting Both Hamstring Tendons.

BACKGROUND: Anterior cruciate ligament (ACL) repair (ACL-Rp) is known to be a valuable alternative to ACL reconstruction (ACL-Rc) in selected indications. The majority of the ACL-Rp techniques recommend the use of a synthetic brace. The use of the gracilis allows both a biological internal brace and anterolateral ligament reconstruction (ALR). PURPOSE: The primary objective was to compare the early ability to return to sports between patients who underwent ACL-Rp using a gracilis autograft as an internal brace augmentation with ALR and patients who underwent the conventional ACL-Rc with ALR technique sacrificing both the gracilis and the semitendinosus. The secondary objective was to compare the failure rate, clinical scores, and return to sports at a minimum follow-up of 2 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis was undertaken. A total of 49 patients who underwent ACL-Rp with ALR between December 2018 and May 2019 were propensity matched at a 1:1 ratio to those who underwent ACL-Rc with ALR during the same period. The decision to perform ACL-Rp with ALR was based on preoperative selection and intraoperative arthroscopic findings: proximal avulsion tear, partial ACL tear, low- to midlevel sports participation, and good tissue quality. The ability to return to sports was assessed using isokinetic tests and the Knee Santy Athletic Return to Sport test functional test at 6 months postoperatively. At the final follow-up, knee laxity parameters, return to sports, and clinical outcome (Lysholm score, Tegner Activity Scale score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Anterior Cruciate Ligament-Return to Sport after Injury score) were recorded. RESULTS: The ACL-Rp group had significantly less hamstring strength deficit when compared with their counterparts who underwent ACL-Rc (0.2% vs 10.2% in concentric, P < .001; 2.5% vs 14% in eccentric, P < .001). The mean Knee Santy Athletic Return to Sport test score was significantly higher in the ACL-Rc group (69.7% ± 16.6% [range, 19%-100%] vs 61% ± 16.8% [range, 19%-100%]; P = .001). In the ACL-Rp group, 61% (30/49) of the patients were authorized to return to pivot sports versus 41% (20/49) in the ACL-Rc group (P = .04). At a mean final follow-up of 31.4 ± 3.5 months, no significant differences were demonstrated between groups with respect to clinical scores and knee laxity parameters. There was a trend for a higher failure rate in the ACL-Rp group without any significance (ACL-Rp: 6.1% [3/49] vs ACL-Rc: 0%; P = .08). CONCLUSION: At 6 months after operation, harvesting only the gracilis with this ACL-Rp and augmentation with ALR technique was linked to a better early ability to return to sports compared with the ACL-Rc with ALR technique harvesting both the gracilis and semitendinosus. This technique had a limited effect on early flexion strength and provided a satisfactory rerupture rate.

Evaluation of a smartphone application for self-rehabilitation after anterior cruciate ligament reconstruction during a COVID-19 lockdown.

BACKGROUND: Rehabilitation after surgery is a crucial process that governs the final functional outcome. The self-rehabilitation smartphone application Doct'up (Healing SAS, Lyon, France) is designed for patients who have had anterior cruciate ligament (ACL) reconstruction surgery. In France in the spring of 2020, the lockdown mandated due to the COVID-19 pandemic prevented patients from seeing their physiotherapists for 2 months. The objective of this study was to compare the clinical outcomes in two groups of patients who underwent ACL reconstruction surgery: in one group, surgery performed before the lockdown was followed by standard in-person physiotherapy while, in the other, surgery was done just before the lockdown and rehabilitation was performed by the patients themselves using the phone application. HYPOTHESIS: Using a self-rehabilitation smartphone app limits the negative effects of not receiving physiotherapist rehabilitation after ACL reconstruction. MATERIAL AND METHODS: We performed a case-control study involving the retrospective analysis of prospectively collected data from two groups of patients who had undergone ACL reconstruction surgery. Patients in the App group had surgery just before the 2-month COVID-19-related lockdown that started in France on March 17, 2020,and used only the smartphone app for rehabilitation. The standard-care group was composed of matched controls who had surgery 1 year before the cases and received rehabilitation therapy during in-person physiotherapist visits. The ACL reconstruction technique was the same in the two groups. The primary outcome measure was extension lag 6 weeks after surgery. The secondary outcome measures were extension lag 3 weeks and 6 months after surgery, quadriceps muscle activation, knee extension locking 3 and 6 weeks after surgery, and the 6-month rate of surgical revision for cyclops syndrome. RESULTS: We included 32 cases managed using only self-rehabilitation guided by the phone app, and we identified 101 matched controls managed using standard care. We found no significant between-group difference in extension lag after 6 weeks: 9.4% (28/32) vs. 4.6% (87/101), p=0.39. After 3 weeks, the App group had a higher proportions of patients with quadriceps activation (94% [30/32] vs. 73% [74/101], p=0.015) and extension control using canes (78.1% [25/32] vs. 40.6% [41/101], p=0.0002). None of the other measured outcomes differed significantly between the two groups (extension lag after 3 weeks: 12.5% [4/32] vs. 13.8% 14/101]; extension lag after 6 months: 3.2% [1/32] vs. 1% [1/101]; quadriceps activation after 6 weeks: 97% [31/32] vs. 99% [100/101]; extension locking with canes after 6 weeks: 96.9% [31/32] vs. 93.1% [94/101]; extension locking without canes after 3 weeks: 53.2% [17/32] vs. 47.5% [48/101]; extension locking without canes after 6 weeks: 93.7% [30/32] vs. 82.2% [83/101]; and surgery for cyclops syndrome (3.1% [1/32] vs. 1% [1/101]). DISCUSSION: The use of a self-rehabilitation phone app after ACL reconstruction during a COVID-19 lockdown limited the adverse effects of not receiving in-person physiotherapy. The 6-month outcomes were similar to those seen with standard rehabilitation. The study results demonstrate the usefulness of self-rehabilitation after ACL reconstruction surgery. Self-rehabilitation guided by a phone app could be used as a complement to the protocols generally applied by physiotherapists. LEVEL OF EVIDENCE: IV, single-centre retrospective case-control study.

Bone metastases from renal cell carcinoma: 4 years after aggressive surgeries and anti-angiogenic therapy.

Management of bone metastases from renal cell carcinoma (RCC) has significantly changed after the era of targeted therapy that improved the overall survival (OS). Surgical decision-making remains a subject of controversy. We report a case of pelvic bone metastasis from RCC, 2 months after nephrectomy and surgery of a revealing clavicular metastasis.

Arthroscopic treatment of type I and II greater trochanteric pain syndrome.

The goal of this study was to describe and evaluate endoscopic bursectomy combined with fascia lata lengthening in the treatment of type I and II greater trochanteric pain syndrome recalcitrant to conservative management. This was a retrospective study of 20 patients (7 type I, 13 type II) reviewed with a minimum follow-up of 2 years. The mean follow-up was 44±11 [26-65] months. While significant improvements in pain, mHHS and NAHS were found, 80% of patients still had hip pain graded at≥3 on VAS. The satisfaction rate was 7/10±2 [3-10]. Snapping in the hip had been eliminated in 100% of cases. No complications were observed. This is a minimally invasive surgery that is feasible in patients who have failed an optimal course of conservative treatment. But patients must be informed that pain might not be completely eliminated by this procedure. LEVEL OF EVIDENCE: IV; retrospective, case series.

Modified Stoppa Approach: Beyond Acetabular Fractures: A Report of 2 Cases.

CASES: We used the modified Stoppa approach in a 17-year-old man with a retained bullet in his acetabular fossa. The acetabular hole was used to irrigate the hip joint. We also used this approach in a 29-year-old woman with right hip pain and limping to remove an isolated tenosynovial giant cell tumor ("localized pigmented villonodular synovitis") in the acetabular fossa expanding through the acetabulum. DISCUSSION: We believe that this approach should become more familiar because it offers a simple alternative for treating acetabular pathologies mainly involving the acetabular fossa, sparing patients the hazards of capsulotomy, trochanteric osteotomy, dislocation, and traction and fluid pressure in hip arthroscopy.