Knowledge-based, computerized, patient clinical decision support system for perioperative pain, nausea and constipation management: a clinical feasibility study.

Opioid administration is particularly challenging in the perioperative period. Computerized-based Clinical Decision Support Systems (CDSS) are a promising innovation that might improve perioperative pain control. We report the development and feasibility validation of a knowledge-based CDSS aiming at optimizing the management of perioperative pain, postoperative nausea and vomiting (PONV), and laxative medications. This novel CDSS uses patient adaptive testing through a smartphone display, literature-based rules, and individual medical prescriptions to produce direct medical advice for the patient user. Our objective was to test the feasibility of the clinical use of our CDSS in the perioperative setting. This was a prospective single arm, single center, cohort study conducted in Strasbourg University Hospital. The primary outcome was the agreement between the recommendation provided by the experimental device and the recommendation provided by study personnel who interpreted the same care algorithm (control). Thirty-seven patients were included in the study of which 30 (81%) used the experimental device. Agreement between these two care recommendations (computer driven vs. clinician driven) was observed in 51 out 54 uses of the device (94.2% [95% CI 85.9-98.4%]). The agreement level had a probability of 86.6% to exceed the 90% clinically relevant agreement threshold. The knowledge-based, patient CDSS we developed was feasible at providing recommendations for the treatment of pain, PONV and constipation in a perioperative clinical setting.Trial registration number & date The study protocol was registered in ClinicalTrial.gov before enrollment began (NCT05707247 on January 26th, 2023).

Early perioperative quality of recovery after hip and knee arthroplasty: a retrospective comparative cohort study.

PURPOSE: Increasing our knowledge about postoperative global Quality-Of-Recovery (QoR) after THA and TKA is important to improve perioperative medicine, in particular for preoperative patient information and benchmarking of postoperative patient status. METHODS: This study is a single centre, retrospective cohort study of prospectively collected data, conducted in Strasbourg University Hospital, Strasbourg, France. The main outcome was the modified French version of the QoR-15 (mQoR-15F) score monitored preoperatively, at postoperative day one, three, 14 and 28. We questioned the hypothesis: would THA and TKA recovery patterns differ and would postoperative health status eventually overreach the preoperative reference? RESULTS: The mQoR-15F was statistically higher in the THA group compared to the TKA group in POD 1 and 28 (112 ± 17 vs. 107 ± 17; p < 0.01 and 131 ± 12 vs. 127 ± 15; p = 0.02, respectively). The mean postoperative time delay to reach preoperative mQoR-15F was seven and 16 days for THA and TKA patients, respectively. CONCLUSION: Early postoperative health status after THA and TKA differs significantly; TKA being associated with a larger early decrease of global health status compared to THA. Both THA and TKA groups global health status overreached preoperative levels after one and two weeks postoperatively. These surgery-specific recovery profiles may favor improved patient information to steer advised operative decision and set specific recovery goals as part of enhanced recovery pathways.

The distal fibular perforating axial flap for lateral malleolus coverage: an anatomical description and surgical technique.

PURPOSE: Skin closure disorders in ankle surgery are a recurrent problem not only in traumatology but also in elective surgery. The aim of the study was to describe the anatomical basis of the fasciocutaneous vascularization of the lateral malleolus region to develop a posterior cover flap for the region. METHODS: We dissected ten fresh frozen specimens after arterial injection of an Indian ink preparation and individualized the perforating arteries. Their positions and diameters were collated. Then, the surgical technique was clinically applied for two different cases by transferring the fasciocutaneous flap posterior to the lateral malleolus to cover a loss of skin substance. RESULTS: There were in average 5 fibular perforators over the last 100 mm of the fibula. The average diameter of the first two perforating arteries was 0.6 ± 0.12 mm and 0.9 ± 0.25 mm, respectively, and the consistency of the latter makes it possible to produce a skin flap with anterior translation. This is an axial flap. Two patients were operated on using this technique. There was no necrosis of the posterior fibular flap and healing was achieved by the third post-operative week. CONCLUSION: This study showed the presence of fibular perforating arteries with a high reproducibility of their dissection. This anatomical description served as the basis for the description of a new distal fibular perforating flap.

Accuracy of the correction obtained after tibial valgus osteotomy. Comparison of the use of the Hernigou table and the so-called classical method.

INTRODUCTION: Medial valgus-producing tibial osteotomy (MVTO) is classically used to treat early medial femorotibial osteoarthritis. Long-term results depend on the mechanical femorotibial angle (HKA) obtained at the end of the procedure. A correction goal between 3 and 6° valgus is commonly accepted. Several planning methods are described to achieve this goal, but none is superior to the other. OBJECTIVE: The main objective was to compare the accuracy of the correction obtained using either the Hernigou table (HT) or a so-called conventional method (CM) for which 1° of correction corresponds to 1° of osteotomy opening. The secondary objective was to analyze the variations observed in the sagittal plane on the tibial slope and on the patellar height. The working hypothesis was that the HT allowed a more accurate correction and that the tibial slope and patellar height were modified in both groups. MATERIAL AND METHOD: In this monocentric and retrospective study, two senior surgeons operated on 39 knees (18 in the CM group, 21 in the HT group) between January 1, 2009 and December 31, 2014. The operator was unique for each group and expert in the technique used. The correction objective chosen for each patient, and written in the operative report, was considered as the one to be achieved. The surgical correction was the difference between the pre-operative and immediate post-operative data (< 5 J) for the mechanical tibial angle (MTA) and the hip-knee-ankle (HKA) angle. Surgical accuracy, where a value close to 0 is optimal, was the absolute value of the difference between the surgical correction performed and the goal set by the surgeon. RESULTS: The median surgical accuracy on the MTA was 3.5° [0.2-7.4] versus 1.4° [0-4.1] in the CM and HT groups, respectively (p = 0.006). In multivariate analysis, with the same objective, the CM had a significantly lower accuracy of 1.9° ± 0.8 (p = 0.02). For HKA, the median accuracy was 3.1° [0.3-7.3] versus 0.8° [0-5] in the CM and HT groups, respectively (p = 0.006). Five (5/18, 28%) and 16 (16/21, 76%) knees were within 3° of the target in the CM and HT groups, respectively (p = 0.004). The median tibial slope increased in both groups. This increase was significantly greater in the CM group compared with the HT group, with 5.5° [- 0.3-13] versus 0.5 [- 5.2-5.6], respectively (p < 0.001). The median Caton-Deschamps index decreased (patella lowered) in both groups after surgery, by - 0.21 [- 1.03; - 0.05] and - 0.14 [- 0.4-0.16], but without significant difference (p = 0.19). In univariate analysis, changes in tibial slope and patellar height were not significantly related to frontal surgical correction performed according to ΔMTA (R2 = 0.07; p = 0.055) and (R2 = - 0.02; p = 0.54) respectively. DISCUSSION: The correction set by the surgeons was achieved with greater accuracy and more frequently in the HT group, confirming the working hypothesis. The HT is therefore recommended as a simple way of achieving the set objective; the tibial slope and patellar height were modified unaffected by the frontal correction performed.

Meniscus sutures by arthrotomy for a non-transfixing horizontal lesion associated with a cyst.

INTRODUCTION: Meniscal cysts are rare in Stoller grade II horizontal lesions. Several techniques are described in the literature for their management, without any real gold standard. The objective of this work was to report a series of meniscal sutures associated with cyst resection by arthrotomy. The hypothesis was that the results were satisfactory and comparable with the data in the literature regardless of the technique reported without morbidity added by arthrotomy. MATERIALS AND METHODS: This was a monocentric retrospective study on 13 patients, aged 33 on average with a grade II meniscus lesion associated with a cyst (9 lateral and 4 medial menisci). Pre-operative data available was the VAS (5.7/10) and the Lysholm score (61/100). Primary endpoints were as follows: pain (visual analogue scale), global satisfaction, Lysholm functional score, and return to sports and professional activities at a minimum of two years. Secondary endpoints were complications, possible recurrence, and/or surgical revision. Recurrences, complications, and surgical recovery were gathered. RESULTS: Patients were evaluated with an average follow-up of 32 months. All patients were satisfied or very satisfied. The VAS significantly improved (0.2/10, p < 0.05) as well as the Lysholm score (97/100, p < 0.05). All patients returned to their professional activity: 11 within two months, one within six weeks, and one in the first post-operative week (this patient being a student). Only one patient did not resume pre-operative sport level due to a femoropatellar syndrome, not linked to the meniscal surgery performed. However, only 11 patients resumed their previous sport level (84.6%). No recurrence or surgical revision occurred. DISCUSSION: The results are good and similar to the literature, confirming the working hypothesis. These results are equivalent to partial meniscectomies and arthroscopic sutures associated with a procedure on the cyst by arthroscopy or arthrotomy. The literature is in favour of a procedure on the cyst. CONCLUSION: The results confirm the effectiveness of a direct approach suture of non-transfixing meniscal lesions associated with a cyst resection with a good functional recovery, without additional morbidity. The hypothesis was confirmed.

Revision of anterior cruciate ligament reconstruction with a pedicled quadruple hamstring autograft.

INTRODUCTION: Results of iterative ACL reconstructions are lower than after primary reconstructions. Our aim was to report the results of a retrospective series of revision using pedicled quadruple hamstring autograft. The hypothesis was that the results were satisfactory and comparable to the literature. METHODS: The study period was from January 2012 to December 2014. Fourteen patients (average age 26) were included. A fascia lata graft was used 12 times for primary reconstruction. Trauma was the cause of failure 12 times. The time interval between primary reconstruction and revision was 6.2 years. Preoperative scores used were LYSHOLM, TEGNER and IKDC. Sagittal stability was measured using the KT-1000 device. X-rays and MRI were performed to confirm the diagnosis, look for preoperative osteoarthritis and evaluate the position of the bony tunnels (Bernard and Hertel). Bone tunnels were in a proper position 14 times. RESULTS: At 45-month follow-up, improvement of objective IKDC score was significant (85.7% A/B, p < 0.0002) as well as subjective IKDC score (85.5, p < 0.0004). A significant improvement was established for the LYSHOLM score (91.8, p = 0.001) using the Wilcoxon test. The average LYSHOLM score was 92% (p > 0.5), and the average TEGNER score was 5.5 (p = 0.003). The Lachman test found a hard stop in all patients. The pivot shift test was negative for 78.5% of the cases. The laxity measurement found 12 cases with less than 3 mm. One persistent distal hypoesthesia at 2-year follow-up was observed. CONCLUSION: The hypothesis was confirmed. This series differs by the cause of failure, which was essentially traumatic, and the initial predominance of a fascia lata graft. These results remain to be confirmed. LEVEL OF EVIDENCE: Retrospective case series, level IV.

Clinical, functional, and isokinetic study of a prospective series of anterior cruciate ligament ligamentoplasty with pedicular hamstrings.

PURPOSE: Few studies describe the specific results of anterior cruciate ligament reconstruction with pedicled hamstring graft (HG). Our goal was to report the isokinetic, clinical, and functional outcomes over the post-operative year following pedicled hamstring ligamentoplasty. METHODS: Twenty-four patients with ACL rupture (mean age 27.4 years) were included prospectively. The technique used a four-stranded HG transplant pedicled to the tibia. The functional result (Lysholm knee score and subjective IKDC score), clinical result (KT-1000, Lachman test, joint amplitudes, objective IKDC score), and isokinetic complication occurrence were analyzed at six months and 12 months follow-up. The functional results, clinical parameters, and complications were analyzed at 30 months follow-up. The comparison of the variables with the various regressions was carried out by a Wilcoxon sign test. RESULTS: Twenty-one patients were reviewed at six, nine, 12, and 30 months. The mean Lysholm knee score was 90/100 at six months, 96/100 at one year, and 95/100 at 30 months. The mean subjective IKDC score was 77/100 and 89/100 at six and 12 months, and 91/100 at 30 months. The mean difference in laxity compared with the healthy knee was 1.4 mm at six months, 1.9 mm at 12 months, and 2 mm at 30 months. The objective IKDC score was A or B for all patients at 12 and 30 months. The average quadriceps strength deficit decreased from 27 to 16% between six and 12 months post-operative (p = 0.0091) and the average flexor deficit from 23 to 12% (p = 0.0084). No complications were identified. CONCLUSION: The abovementioned technique allows reaching functional, clinical, and isokinetic results comparable with the standard techniques while preserving the mechanical and biological interest of tibial insertion.

Total knee arthroplasty in patients with varus deformities greater than ten degrees: survival analysis at a mean ten year follow-up.

INTRODUCTION: Total knee arthoplasty (TKA) is a secure procedure with more than 90% survival at ten years. The purpose of this study was to report both clinical and radiological outcomes of TKA with a varus > 10°. The second objective was to identify risk factors for failure or bad clinical results. Our hypothesis was that results and survey are comparable to TKA with lesser deformities. METHODS: Eighty-two TKA (69 patients) between January 2004 and December 2008 with a varus > 10° were reviewed retrospectively. The endpoints were clinical (range of motion, IKS knee score, Oxford, and SF-12) and radiological (HKA post-operative and the existence of radiolucent lines or loosening at last follow-up). RESULTS: Sixty-three TKA (55 patients) were assessed with a mean follow-up of 10.9 years. The global IKS score significantly increased (p = 0.04). Seven TKA needed a revision: two for sepsis, four for aseptic loosening, and one for polyethylene wear, with an overall survival of 91.6% at ten years. For aseptic loosening, the survival rate was 94.7% at ten years. Risk factors for failure were age (p = 0.001), weight (p = 0.04), and a post-operative HKA lesser than 175° (p = 0.05) for aseptic loosening. DISCUSSION: The hypothesis was confirmed: the results showed a significant improvement of function and quality of life with a survival rate comparable to those found in the literature for greater varus but also inferior to 10°. Three risk factors have been identified suggesting increased surveillance in these cases. CONCLUSION: The results of this survey confirm the work hypothesis. Total knee arthroplasty in patients with important axial deformities is a confirmed, reliable, patient-friendly and predictable good outcome procedure.

Global radiological score for femoral cementless revision stem.

PURPOSE: The purpose of this study was to evaluate the outcomes of total hip arthroplasty (THA) revision with cementless stems using a numeric global radiological score (GRxS) that summarizes two previously validated scores: secondary bone stock (SBS) and osseointegration-secondary stability (O-SS). METHOD: One hundred fifty cases of THA were evaluated at a mean follow-up of 6.5 ± 3.7 years. The GRxS combines the SBS, which evaluated cortical bone thickness, bone density and bone defects in each Gruen zone and the O-SS, which evaluated the location and extent of a single radiolucent line. To calculate the GRxS, the SBS and O-SS were each expressed on a 10-point scale and given equal weighing. The final result was a number out of 20. The GRxS was used to assign a radiological grade to each THA case: very good (20), good (18-15), average (13-12), or poor (≤ 10). The numerical mean (Nm) was calculated for each grade. The inter- and intra-observer reproducibility was evaluated. RESULTS: The inter-observer reproducibility was good (0.8) and the intra-observer reproducibility was very good (0.9). The GRxS was considered very good in 46 cases (Nm 20), good in 57 cases (Nm 16.6), average in 25 cases and poor in 22 cases. There was a significant relationship between the GRxS and the Harris Hip and Postel Merle d'Aubigné scores (p < 0.0001), and the initial bone stock (p = 0.0001). CONCLUSIONS: The GRxS is reliable and reproducible. This information can be used by surgeons to adapt the surgical technique to bone characteristics (especially during revision cases) and to compare the outcomes of different implant designs.

Cementless Total Hip Arthroplasty With Metasul Bearings Provides Good Results in Active Young Patients: A Concise Followup.

BACKGROUND: A primary concern of younger, more active patients who have undergone total hip arthroplasty (THA) is the longevity of the implant. Cementless fixation and hard-on-hard bearings are recognized as options to enhance THA durability. Earlier, we published a series of 83 cementless primary THAs using 28-mm metal-on-metal (MoM) bearings in patients aged 50 years or younger; here we provide concise followup on that same group after an additional 8-year survey period. QUESTIONS/PURPOSES: (1) What is the long-term survivorship of cementless primary THA using 28-mm MoM bearings in patients aged 50 years or younger? (2) What are the clinical and radiographic results of cementless THA in this active patient population? (3) Can any of the observed implant failures or adverse events be attributed to the metallic nature of the bearing couple? METHODS: We retrospectively reviewed 83 cementless THAs performed in three institutions over a decade (1995-2004) in 68 patients with 28-mm MoM articulation. All patients (15 bilateral) had a median age of 42 years (range, 24-50 years) at the time of the index procedure and 56 of them (82% [70 hips]) had activity level graded Devane 4 or 5 before significant hip pain. A 28-mm Metasul™ articulation was used with an Alloclassic-SL™ cementless stem in all cases paired with three different cementless titanium acetabular components (one threaded and two press-fit cups) from the same manufacturer. Survivorship analysis was calculated according to Dobbs life table, patient clinical results were evaluated with use of the Postel-Merle d'Aubigné scoring system, radiographic analysis was performed by independent observers, and cobalt level was determined in whole blood. RESULTS: The 15-year survivorship (33 hips at risk) for revision for any reasons (four hips) and for aseptic loosening (one hip) was 96% (95% confidence interval [CI], 81%-99%) and 99% (95% CI, 85%-99.9%), respectively. The median Merle d'Aubigné-Postel score remained stable at 17 points (range, 10-18). Thus far, we have not observed pseudotumors or other adverse reactions to metallic debris. Eight hips have undergone reoperation: trochanteric suture removal (one), psoas tendon impingement (two), and five revisions for periprosthetic fracture (one), late infection (two), acetabular osteolysis (one, as a result of polyethylene backside wear), and one hydroxyapatite-coated cup for aseptic loosening. None of the complications, failures, or revisions observed so far could directly be related to the metallic nature of the 28-mm Metasul bearings used in this selected group of patients. CONCLUSIONS: The current survey at 13-year median followup has not yet indicated any long-term deleterious effects related to dissemination of metallic ions. Two senior authors continue to use 28- or 32-mm Metasul™ bearings with cementless THA components in young and active patient populations. Longer followup with a more sophisticated imaging study is necessary to confirm this so far positive report. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Assessment of fixation in cementless femoral revision of total hip arthroplasty: comparison of the Engh score versus radiolucent line measurement.

PURPOSE: To assess osseointegration and stability of a primary cementless femoral stem, many scoring systems have been developed, but none of them have taken into account only the radiolucent line. The purposes of this study were (1) to compare the results between the Engh score to assess osseointegration and stability of the cementless stem with results of a score called the O-SS score (osseointegration-secondary stability), which takes into account the radiolucent line, (2) to verify the relationship between these two scores and the functional results, and (3) to verify if there is a relationship between the O-SS score and secondary subsidence or a pedestal. METHODS: A clinical and radiological evaluation was performed in a group of 100 hip prosthesis revisions comparing the results obtained by Engh score and O-SS score for which reproducibility was analysed. RESULTS: Inter-observer reproducibility was estimated to be average at 0.5 and intra-observer reproducibility good at 0.7. The correlation with the Engh score was good at r = 0.59 (p < 0.0001). For the 80 cases assessed O-SS score as very good/good, Harris hip score was at 83.7 versus 78.25 for the 20 cases assessed as average/poor (p = 0.07). For the 73 cases with assessed Engh score as very good/good, this score was at 82.8 versus 82.14 for the 27 cases assessed as average/poor. No correlation between the O-SS score and secondary subsidence (p = 0.2) or pedestal (p = 0.2) was noticed. CONCLUSION: The evaluation of the clear radiolucent line alone, extent and location, is a sufficient condition to assess osseointegration and secondary stability of a cementless femoral stem.

Has a patient type with peri-prosthetic femoral fractures evolved?

PURPOSE: Peri-prosthetic fractures (PPF) have been showing a constant increase. The typical patient described in the SOFCOT symposium in 2005 with PPF was an elderly 77-year-old woman with hip athroplasty (HA). The purpose of this study was to actualize the characteristics of this population. Our hypothesis is that patient type remains a female, but much older, with an equal distribution between HA and knee arthroplasty (KA). METHODS: All cases of PPF were retrospectively gathered during an 18 month period. Besides regular epidemiologic data, we noted autonomy level (Parker, Devane), residence and dependence (Katz), the type of implant, of fracture, the severity of fracture, the onset and the state of solidity of the prosthesis. RESULTS: The series consisted of 81 patients (58 F, 23 M) (81 fractures), mean age of 82.2 years; 3.5% of them were admits from the emergency admits; and 69.1% lived at home. Parker's mean score was 4.6, Devane's mean score was 1.8 and Katz's mean score was 4.2. There were totals of 46 HA fractures and 39 total knee arthroplasty (TKA) of which four were inter-prosthetic and three were either KA or proximal osteosynthesis. Onset before fracture for HA was 12.1 years, 7.9 years for KA, and 10.2 years for all series. Patients were younger for HA (80.8 years) than for KA (84.1 years). The fracture was mostly noticed in the third proximal (49.4%), spiral segment (44.5%) and around the implant, while 34.8% of loosening was observed for HA versus 7.7% for KA. DISCUSSION-CONCLUSION: The patient type has evolved confirming our hypothesis: they are always a female more than 82 years old with a number of fractures on KA similar to that of HA. The patients lived at home, had some autonomy, were somewhat independent in their daily activities but sedentary. Fractures were mostly on the third proximal femur, spiral segment and around the implant. PPF remains rare and a theoretical increase is yet to be confirmed. LEVEL OF EVIDENCE: prospective study type IV, cohort study.

Comparison of the pre-shaped anatomical locking plate of 3.5 mm versus 4.5 mm for the treatment of tibial plateau fractures.

PURPOSE: Treatment of tibial plateau fractures is discussed. A retrospective comparative study of fractures treated with an anatomical locking plate of 4.5 mm or 3.5 mm. Our hypothesis is that the 3.5 mm plates give an equivalent hold of fractures with comparable results and better clinical tolerance. METHODS: From May 2010 to October 2011, 18 patients were operated on using a 4.5-mm LCP™ anatomical plate (group A) and 20 patients received a3.5-mm LCP™ anatomical plate (group B). Groups were comparable. One fracture was open. RESULTS: For the Group A, 14 patients had a follow up of 35.3 months and for the Group B, 16 patients had a follow up of 27 months. Mobility was comparable in both groups. The Hospital for Special Surgery (HSS) score was 86.4 versus 80.6, the Lysholm score was 83.6 versus 77 for groups A and B respectively. Consolidation was 3.25 months versus 3.35 months and mean axis was 183.1° versus 181.6° for groups A and B. Mechanical axes during revision were statistically different to the controlateral axes. One secondary displacement was noted in group A and one secondary displacement in group B. Group A had eight patients reporting discomfort with the material versus three in group B (p < 0.05). CONCLUSION: The hypothesis is proven. In regards to the results, there is no significant difference between the two groups but the clinical tolerance was better in group B. More time is needed in the long term to better evaluate these severe fractures.

Minimally invasive surgery with locking plate for periprosthetic femoral fractures: technical note.

PURPOSE: Periprosthetic fractures of the femur are increasing due to the increase of arthroplasties and the aging population. They concern a population that is often elderly and with important comorbidities that complicate managing this already complex pathology. Usual complications of classic osteosynthesis are numerous, including infections and nonunions and the need for delayed weight bearing after surgery. METHODS-RESULTS: The development of locking plates has allowed complication avoidance. When used in minimally invasive surgery, they combine the biological advantages of closed-wound surgery to the mechanical advantages of locking plates, which have better stability in fragile bones. We propose a technical update on handling such fractures by using locking plates under minimally invasive surgery. DISCUSSION-CONCLUSION: In our experience, under certain guidelines, this allows for immediate post-operative full weight bearing, which is beneficial to these often elderly patients.

Bone stock in revision femoral arthroplasty: a new evaluation.

PURPOSE: The purpose of this study was to finalize a method allowing a qualitative and numerical evaluation of the bone stock and to confirm its reproducibility, to verify the relationship between the secondary bone stock value and the functional results, and to determine the main factors influencing the value of the bone stock. METHODS: A clinical and radiological evaluation was performed in a group of 150 revisions of total hip replacements according to a new method taking into account cortical bone thickness, bone density and bone defects. RESULTS: Interobserver reproducibility was evaluated at an average of 0.6 and intra-observer reproducibility was considered good at 0.8. Between the initial bone stock and at the last follow-up, no significant difference was noticed. For secondary bone stock considered as "very good or good", the gain was +38.1 points versus +29.9 points for patients evaluated as "average or poor" (p < 0.0001). Between the initial bone stock assessment and at last follow-up, a significant relation was found in numerical values for the global type of primary fixation and in the presence of osteopenia (p < 0.0001). CONCLUSIONS: Deficient secondary bone stock can result in less favourable functional results. The numerical scores confirm the importance of strategic choices during surgery in order to manage bone stock preservation.

Osteosynthesis by locking plate for proximal tibial fractures.

INTRODUCTION: Treatment of proximal tibial fractures is known to be difficult. We report our own experience of the treatment of these fractures and evaluate our results. The hypothesis was that the clinical and radiological results were good. MATERIAL AND METHOD: From January 2004 to October 2008, fourteen AO-type 41A2-3 and C1 fractures have been treated with a LCP locking plate (8 women and 6 men, average age 60.42). Plating was performed either with an open approach or a minimal invasive approach. Clinical and radiological follow-up was carried out looking for range of motion of the knee joint and autonomy level. RESULTS: Mean follow-up was 32.63 months (12-70). Range of motion was maintained with a mean arch of 117.5° Autonomy was maintained in all cases. Professional, domestic and sports activities were unchanged. No infection or general complication occurred. Bone fusion was obtained in all cases after an average of 13.28 weeks. 6° of valgus deformation, already seen immediately postoperatively was observed once. Secondary displacement was observed in 6 cases, with an average of 2.83° DISCUSSION-CONCLUSION: We report good radiological results, with only one initial malalignment. The hypothesis was confirmed. However, X-ray analysis at consolidation shows 6 secondary displacements, without any satisfactory explanation. Though the clinical consequences of these malunions are minimal. Osteosynthesis with plate, in the sight of this study, yields good clinical results. Radiological evolution concerning the evolution of bone axes puts the emphasis on careful operative technique and adequate time to weight bearing. LEVEL OF EVIDENCE: retrospective study, IV.

Hip and knee arthroplasty in one surgical session: early morbi-mortality study.

INTRODUCTION: Bilateral prosthetic hip or knee replacement in one surgical session is a procedure that has been widely validated in the literature, whereas hip and knee replacement in one surgical session remains poorly documented. This study reports on the results of these procedures by analyzing early post-operative complications in a retrospective multicenter study. MATERIAL AND METHODS: Between 2009 and 2023, 51 patients underwent hip and knee replacement surgery in a single surgical session at 4 French centers. They were 24 men and 27 women, with a mean age of 68.8 years (36 - 87); 7 patients were ASA 1, 30 were ASA 2 and 14 ASA 3. Prosthetic hip replacement was always performed first, associated 33 times with the ipsi-lateral knee and 18 times with the contralateral knee. All early complications, within the first 90 days post-operatively, were recorded: death, phlebitis, pulmonary embolism, myocardial infarction, surgical site infection (SSI), knee stiffness treated by mobilization under general anesthesia, urinary tract infection, acute urine retention or any other adverse event related to care. Transfusion rates were also reported. RESULTS: The rate of early complications was 9.8% (5/51). No deaths, no phlebitis, no pulmonary embolism and no SSI were observed. Complications included one myocardial infarction, one urinary tract infection, one superficial infection, one haematoma treated by surgical evacuation and one recurrent instability requiring revision surgery (hip arthroplasty). The transfusion rate was 17.6% (9/51). The complication rate of ASA 3 patients was higher than that of ASA 1 and 2 patients, while there was no difference related to age or BMI. DISCUSSION: Our results confirm the feasibility of single-stage hip and knee replacement, with a low complication rate in ASA 1 and 2 patients. This study adds to the few published works on the subject and reports comparable results. The small sample size and the heterogeneity of patients and centers limit the scope of the results, these limitations being relative to the volume expected for a rare procedure. CONCLUSION: Single-session hip and knee arthroplasty should be reserved for patients selected according to comorbidities: ASA score, age and body mass index. ASA 3 patients have a higher risk of complications. LEVEL OF EVIDENCE: IV; retrospective.

Experimental study of risk of medial hinge fracture during distal femoral varus osteotomy.

INTRODUCTION: Lateral opening wedge distal femoral osteotomy (LOWDFO) is indicated for isolated lateral osteoarthritis in the valgus morphotype. Medial hinge fracture is a factor for poor prognosis. The present study had two aims: (1) to assess the impact of a temporary K-wire on hinge fracture risk; and (2) to assess the impact of LOWDFO opening speed. HYPOTHESIS: The main study hypothesis was that a temporary hinge K-wire reduces hinge fracture risk. The second hypothesis was that faster opening speed increases fracture risk. MATERIAL AND METHOD: Twenty femurs were produced by 3D printing from a CT database, reproducing LOWDFO anatomy. The ABS® polymer showed the same breaking-point behavior as human bone. Ten specimens were included in the "K-wire" group (KW+) and 10 in the "No K-wire" group (KW-). To determine high and low speed, a motion-capture glove was used by 2 operators, providing 3D modeling of the surgeon's hand. High speed was defined as 152mm/min and low speed as 38mm/min. The KW+ and KW- groups were subdivided into high- and low-speed subgroups (HS, LS) of 5 each. Compression tests were conducted using an Instron® mechanical test machine up to hinge fracture. The main endpoint was maximum breaking-point force (N); the secondary endpoints were maximum displacement (mm) and maximum speed (min) at breaking point. RESULTS: The K-wire significantly increased maximum breaking-point force (LS, 143.08N vs. 93.71N, p<0.01; and HS, 186.98N vs. 95.22N, p<0.01), but not maximum displacement (LS, 26.17mm vs. 24.11mm, p=0.31; and HS 26.18mm vs. 23.66mm, p=0.14) or maximum time (LS, 27.07s vs. 24.94s, p=0.31; and HS, 5.24s vs. 4.73s, p=0.14). Speed did not affect maximum force (KW+, 143.08N vs. 186.98N, p=0.06; and KW-, 93.71N vs. 95.22N, p=0.42) or maximum displacement (KW+, 26.17mm vs. 26.18mm, p=1; and KW-, 24.11mm vs. 23.66mm, p=0.69). Only maximum time was greater at low speed (KW+, 27.07s vs. 5.24s, p>0.01; and KW-, 24.94s vs. 4.73s, p<0.01), which is obvious for constant distance. DISCUSSION: The first study hypothesis was confirmed, with significantly lower hinge fracture risk with the K-wire, independently of opening speed. The second hypothesis was not confirmed. The study was performed under strict experimental conditions, unprecedented to our knowledge in the literature. However, complementary clinical studies are needed to confirm the present findings. LEVEL OF EVIDENCE: IV, experimental study.

Interimplant femoral fractures.

The number of hip or knee arthroplasties, and internal fixations of the proximal and distal femur, is increasing in proportion to the growing and ageing population, whose life expectancy is lengthening. Thus, fractures of the femur between proximal and distal implants, although rare, are becoming more frequent. Women over the age of 70, with fragile bones and whose ends of the two implants are close to each other ("kissing implants") are particularly vulnerable to them. Reliable and reproducible fracture classifications exist when it comes to 2 prostheses, but they are less well established in the presence of one, or even two, non-prosthetic implants. Their treatment is difficult and must consider the possibility of fracture consolidation while ensuring or restoring the stability and role of the implants. Whether it is the main element of treatment or a complement to prosthesis revision, locked plating forms the basis of the treatment but it must be rigorous, considering that failures are mainly the result of technical errors. Other more invasive treatments (total femoral arthroplasty, cortical sleeves) are offered more rarely if consolidation appears compromised.

Accuracy of the correction achieved after a valgus high tibial osteotomy: Comparison of the Hernigou table and navigation.

INTRODUCTION: The outcome of a medial opening wedge valgus high tibial osteotomy indicated for the treatment of isolated medial tibiofemoral osteoarthritis depends mainly on the accuracy of the correction of the hip-knee-ankle angle (HKAA) and the mechanical medial proximal tibial angle (mMPTA). Most authors aim for a desired correction target between 2° and 4° of valgus. Several planning and surgical techniques have been described to achieve this target value that is specific to each surgeon. OBJECTIVE: The purpose of this study was to compare the accuracy of the correction achieved using either the Hernigou table (HT) planning method or a computer-assisted navigation system (CAS). It was hypothesized that no difference would be found between these 2 techniques. MATERIALS AND METHODS: This retrospective single-center study involved 43 knees: 21 in the HT group and 22 in the CAS group. Two surgeons (ME, JYJ), who were experts in 1 of the 2 planning methods performed these procedures, with a single surgeon assigned to each group. The correction was noted in the operative report and was considered to be the desired correction target. The surgical correction was calculated by comparing preoperative and immediate postoperative mMPTA measurements. The surgical accuracy, where a value close to 0 represented optimal accuracy, was defined as the absolute value of the difference between the correction target set by the surgeon and the surgical correction achieved. The median accuracy between the 2 groups was compared by a Mann-Whitney U test (significance level at 5%). The number of patients deviating from the target by>3° was analyzed with a Fisher exact test (significance level at 5%). Pre- and postoperative comparisons of the HKAA measurements could not be used because the measurement was not performed postoperatively for the CAS group. RESULTS: The median surgical accuracy on the mMPTA was 1.4° (0-4.1) for the HT group versus 1.9° (0.2-6.7) for the CAS group (p=0.85). Sixteen procedures (76%) were performed with an accuracy of<3° in the HT group versus 15 in the CAS group (68%) (p=0.73). DISCUSSION-CONCLUSION: The working hypothesis was confirmed: no differences were found between the HT and CAS groups regarding the surgical accuracy in achieving the corrections set in this series. We therefore demonstrated that HT was a highly accessible, simple and reliable technique for achieving the planned target. It can be used widely. LEVEL OF EVIDENCE: III; comparative retrospective series.