Systematic alignments yield balanced knees without additional releases in only 11% of knee arthroplasties: a prospective study.

PURPOSE: The literature suggests that "forgotten" knees are the most stable knees postoperatively. The main objective of our study was to determine whether a systematic alignment (mechanical, anatomical or kinematic) makes it possible to stabilise the operated joint in extension and in flexion. METHODS: This monocentric prospective cohort study was conducted between May 1st, 2021 and October 31st, 2021. A total of 132 consecutive patients undergoing primary navigated total knee arthroplasty were included, with a mean age of 72.4 years (7.9; 48.8-91.2 years), a mean body mass index (BMI) of 28.6 kg/m2 (4.6; 17.6-41.6) and 71.2% (94/132) women. Mechanical, anatomical and kinematic knee alignments were simulated using Kick software for each patient. The primary outcome was the targeted rate of balanced knees for each type of alignment, based on a three-point score, aiming for a 3/3 score for each knee. Our secondary outcome was to characterise the specific implantation finally achieved by the surgeon. RESULTS: The targeted balance was reached in 10.6% (14/132), 10.6% (14/132) and 12.9% (17/132) of knees with mechanical, anatomical and kinematic alignment simulations, respectively. None of these simulations provided a superior number of balanced knees (p = 0.87). When simulating a patient-specific implantation, the highest score was reached in 89.1% (115/132) of cases. CONCLUSION: Systematic alignment simulations achieved knee balance in only 11% of cases. Patient-specific implantation, favouring knee balancing over alignment, allowed an 89% perfect score rate without having to perform any collateral release. LEVEL OF EVIDENCE: Case series. Level 4.

Use of a locking stem for reverse shoulder arthroplasty is a rare but reliable option.

INTRODUCTION: RSA is widely used in the treatment of complex trauma or degenerative changes of the shoulder. Strong primary fixation of the stem is necessary to prevent any loosening of the stem and subsequent revision. Presently, cement fixation or press-fit fixation are two options for humeral fixation, though each has its own limitations and risks. The aim of the current study is to evaluate the effectiveness of an alternative option involving a distal screw interlocking system for fixation of the humeral stem from initial implantation. METHODS: We performed a retrospective multicenter study of patients implanted with the Humelock Reversed® stem RSA that can be locked with distal humeral screws in cases of operative poor press fit or to modulate the lengthening of the arm via prosthetic humeral height. Seventy-two patients with a minimum two year follow-up were included, 13 for acute trauma, 42 for degenerative changes, and 17 for revision surgery. RESULTS: No difference was seen in radiological or clinical results for patients with or without interlocking screw primary stabilization. For non-trauma patients, the mean raw Constant score improved significantly from 31 (± 12) to 71 (± 12). For trauma patients, the mean raw Constant score for trauma (63.4) was significantly lower than for non-trauma cases (72.1) (p < 0.001). Analysis of the filling ratio demonstrated that interlocking screws were not used for lower filling ratios and that midterm fixation of the stem is not negatively impacted by distal interlocking screw fixation. DISCUSSION: Even if use of a distal interlocking screw fixation system is rare, it can be useful for patients with poor quality fixation of stemmed RSA. CONCLUSION: Use of an interlocking screw system to stabilize the stem in RSA provides good immediate and midterm stability of the implant allowing for clinical and radiological outcomes comparable to those obtained with press-fit fixation alone.

Ankle CT scan allows better management of posterior malleolus fractures than X-rays.

PURPOSE: Undiagnosed and undertreated posterior malleolus fractures lead to early ankle instability and arthritis. A preoperative CT scan could improve the management of those fractures. This study assessed the benefits of a systematic ankle CT scanner to diagnose and manage posterior malleolus fracture. METHODS: A monocentric retrospective cohort study was conducted. Sixty consecutive patients with bimalleolar fractures were operated and underwent a preoperative CT scan. The mean age was 50.0 years old (18.6 years old) with a mean body mass index of 20.3 (kg/m2) (11.4 kg/m2) and 71.7% (43/60) of women. The primary outcome was the rate of posterior malleolus fragment diagnosed on X-rays and on CT scan. Secondly, interobserver and interobserver's agreement were compared between conventional X-rays and CT scan. RESULTS: Thirty-five (58.3%) posterior fragment fractures were observed on X-rays and 53 (88.3%) on the preoperative CT scan (p < 0.01). The intraobserver reproducibility for X-rays was low (0.02 [- 0.23; 0.27]) and moderate for CT scan (0.45 [0.0; 0.84]). The interobserver reproducibility for X-rays was moderate (0.39 [0.15; 0.60]) and excellent for CT scan (0.78 [0.0; 1.0]). CONCLUSION: A wide proportion of bimalleolar fractures are associated with posterior malleolus fractures and undiagnosed with standard X-rays. We advocate a systematic preoperative CT scan in the management of bimalleolar fractures. LEVEL OF EVIDENCE: Level IV, retrospective cohort study. TRIAL REGISTRATION NUMBER: 2218999v0, date of registration: 11/08/2020 (retrospectively registered).

Comparative Efficacy of the Different Surgical Approaches in Total Knee Arthroplasty: A Systematic-Review and Network Meta-Analysis.

BACKGROUND: Several surgical approaches including midvastus, subvastus, mini-parapatellar, quadriceps-sparring (QS) and parapatellar are currently used to perform total knee arthroplasty (TKA). Since none of published study exhibited a simultaneous comparison of all of them, a network meta-analysis has been conducted to compare the most widely used knee surgical approaches regarding the improvement of functional outcomes and the range of motion (ROM). METHODS: Randomised controlled trials (RCTs) comparing TKA approaches were searched in electronic databases, major orthopedics journals, and oral communications, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform until May 1st, 2020. Two reviewers independently selected trials and extracted data. The primary outcomes were functional scores at 6 months post-surgeryevaluated by KSS and WOMAC, and the ROM. RESULTS: Sixty RCTs involving 5042 patients with 5107 TKA were included. No significant differences between different approaches were found for the KSS assessment or the WOMAC at 6 months. The mean of ROM at 6 months post-surgery were higher in the subvastus group than in all the others surgical approaches. The difference of ROM with subvastus approach was 7.3° (95% CI -14.1 to -0.1) with the midvastus approach, 11.1° (95% CI -18.7 to -2.8) with mini-parapatellar, 8.9° (95% CI -14.2 to -3.1) with standard parapatellar, and 9.2° (95% CI -16.1 to -1.8) with QS. CONCLUSION: No differences were found in functional outcomes over short or medium terms but subvastus seemed to increase the ROM at 6 months post-surgery. Until or unless future studies can demonstrate a long-term benefit, based on these results all studied surgical approaches to perform a TKA are equal. LEVEL OF EVIDENCE: Network meta-analysis. Level 1.

Are There Differences in Accuracy or Outcomes Scores Among Navigated, Robotic, Patient-specific Instruments or Standard Cutting Guides in TKA? A Network Meta-analysis.

BACKGROUND: Several kinds of cutting guides, including patient-specific instrumentation, navigation, standard cutting guides, accelerometer-based navigation, and robotic guidance, are available to restore a planned alignment during TKA. No previous study has simultaneously compared all of these devices; a network meta-analysis is an especially appealing method because it allows comparisons across approaches that were not compared head-to-head in individual randomized controlled trials. QUESTIONS/PURPOSES: We performed a network meta-analysis to determine whether novel approaches to achieving implant alignment, such as patient-specific instrumentation, navigation, accelerometer-based navigation, and robotic guidance, provide any advantage over standard cutting guides in terms of: (1) hip-knee-ankle (HKA) alignment outliers greater than ± 3°, (2) outcome scores (1989 - Knee Society Score and WOMAC score) measured 6 months after surgery, or (3) femoral and tibial implant malalignment (greater than ± 3°), taken separately, in the frontal and sagittal plane, as well as other secondary outcomes including validated outcome scores 1 and 2 years after surgery. METHODS: In our network meta-analysis, we included randomized controlled trials comparing the different cutting guides by using at least one of the previously specified criteria, without limitation on language or date of publication. We searched electronic databases, major orthopaedic journals, proceedings of major orthopaedic meetings, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform until October 1, 2018. This led to the inclusion of 90 randomized controlled trials involving 9389 patients (mean age 68.8 years) with 10,336 TKAs. Two reviewers independently selected trials and extracted data. The primary outcomes were the proportion patients with malalignment of the HKA angle (defined as HKA > 3° from neutral) and the Knee Society Score and WOMAC scores at 6 months postoperatively. We combined direct and indirect comparisons using a Bayesian network meta-analysis framework to assess and compare the effect of different cutting guides on outcomes. Bayesian estimates are based on the posterior distribution of an endpoint and are called credible intervals. Usually the 95% credible interval, corresponding to a posterior probability of 0.95 that the endpoint lies in the interval, is computed. Unlike the frequentist approach, the Bayesian approach does not allow the calculation of the p value. RESULTS: The proportion of HKA outliers was lower with navigation than with patient-specific instrumentation (risk ratio 0.46 [95% credible interval (CI) 0.34 to 0.63]) and standard cutting guides (risk ratio 0.45 [95% CI 0.37 to 0.53]); however, this corresponded to an actual difference of only 12% of patients for navigation versus 21% of patients for patient-specific instrumentation, and 12% of patients for navigation versus 25% for standard cutting guides. We found no differences for other comparisons between different cutting guides, including robotics and the accelerometer. We found no differences in the Knee Society Score or WOMAC score between the different cutting guides at 6 months. Regarding secondary outcomes, navigation reduced the risk of frontal and sagittal malalignments for femoral and tibial components compared with the standard cutting guides, but none of the other cutting guides showed superiority for the other secondary outcomes. CONCLUSIONS: Navigation resulted in approximately 10% fewer patients having HKA outliers of more than 3°, without any corresponding improvement in validated outcomes scores. It is unknown whether this incremental reduction in the proportion of patients who have alignment outside a window that itself has been called into question will justify the increased costs and surgical time associated with the approach. We believe that until or unless these new approaches either (1) convincingly demonstrate superior survivorship, or (2) convincingly demonstrate superior outcomes, surgeons and hospitals should not use these approaches since they add cost, have a learning curve (during which some patients may be harmed), and have the risks associated with uncertainty of novel surgical approaches. LEVEL OF EVIDENCE: Level I, therapeutic study.

Is the position of dual-mobility cup in THA for femoral neck fractures optimal? A retrospective study.

INTRODUCTION: Few studies have examined the relationship between the indication of total hip arthroplasty (THA) and the quality of its technical achievement. Implants mispositioning could happen more frequently while THA is performed on acute proximal femur fracture cases. The purpose of this study was to compare the frontal inclination (FTA) of double-mobility cups (DMC) in patients undergoing THA for hip osteoarthritis or fracture. MATERIALS AND METHODS: This retrospective study included all patients undergoing THA for hip fracture or hip osteoarthritis. The surgical protocol was identical in all patients and included a systematic DMC implantation. In the postoperative period, the FTA was measured on anteroposterior pelvic radiographs and compared between groups. Malposition was defined for FTA values outside the 35°-55° range. RESULTS: The study included 97 patients: 33 men, mean age: 78.8 years, 45 fractures. The misalignment rate was 55% after THA for fracture versus 33% for hip osteoarthritis (p = 0.02). The mean FTA value was 39° for "fracture" and 43° for "hip osteoarthritis" groups (p = 0.052). The risk for hip dislocation, surgical revision for mechanical or infectious cause was identical in both groups. DISCUSSION: Misalignment was more frequent when THA was achieved for an acute proximal femur fracture. Several explanations can be proposed: lesser bone quality, incomplete removal of upper acetabular osteophytes which can lead to excessive horizontalization of the cup and surgical procedure performed by younger surgeons in "fracture group". These misalignments don't cause more mechanical complications in the first months after surgery.

High Rates of Return to Play and Low Recurrence Rate After Arthroscopic Latarjet Procedure for Anterior Shoulder Instability in Rugby Players.

Purpose: To analyze the rate of return to play, changes in athletic level, and recurrence rate and to report subjective outcomes in a series of rugby players with anterior shoulder instability who underwent an arthroscopic Latarjet procedure. Methods: A multicenter retrospective study done in 2 centers on rugby players who were operated on between January 2011 and December 2020 was performed. Rugby players who underwent arthroscopic Latarjet procedure for anterior shoulder stabilization with a minimum follow-up period of 2 years were included. Rugby players were grouped according to their competitive level in their country (recreational, regional, national, and international). Data collected included return to sport after surgery, time to return to rugby, athletic level before and after surgery, patient satisfaction, and subjective scores. Recurrence and apprehension rates were also evaluated. Results: A total of 73 subjects were included. Mean age at time of surgery was 23 ± 5 years. Mean duration of follow-up was 5 ± 2.6 years. Eighty-four percent of rugby players returned to rugby within a mean period of 6.6 months. Initial athletic level was a significant factor (P = .012) for not returning to sport, with 67% of patients who initially played at a recreational level not returning to rugby and 33% of patients who initially played at a regional league level not returning. All national and international players returned to play. Of the 12 non-returning rugby players, only 30% did not return because of their shoulder. Mean Subjective Shoulder Value was 90 ± 9%. Recurrence rate was 7%. Conclusions: Arthroscopic Latarjet procedure proved its efficacy in managing recurrent anterior shoulder instability in rugby players. Return to play was achieved in almost all cases, with low recurrence rates. Despite high global return to the same level of sport, the higher the level of competition, the harder it is for rugby players to resume sport at the same level. Level of Evidence: Level IV, therapeutic case series.

Comparative efficacy of the different cutting guides in unicompartmental knee arthroplasty: A systematic-review and network meta-analysis.

BACKGROUND: Several cutting guides including conventional, navigation, patient specific instrumentation (PSI) and robotic are currently used in unicompartmental knee arthroplasty (UKA). A network meta-analysis was conducted to compare the most widely used cutting guides regarding the improvement of radiological, functional outcomes and the rate of complications. METHODS: Randomised controlled trials (RCTs) comparing UKA cutting guides were searched in electronic databases, major orthopaedics journals, and oral communications in major orthopaedics meetings, until May 1st, 2022. The primary outcomes were the rate of outliers for the tibial and femoral components in the frontal plane, KSS score and the complication rate. RESULTS: Eighteen RCTs involving 1562 patients with 1564 UKA were included Regarding the prosthetic components' positions, we found a significant increase of the outliers rate using PSI for the femoral component, compared to robotic surgery (risk ratio 0.00 [95% CI 0.00 to 0.55]) and navigated surgery (risk ratio 305.1 [95% CI 1.50 to 1,27e + 07]). We didn't emphasize any difference regarding the tibial component's position, the KSS value at 24 months postoperatively, and the complication rate. Regarding secondary outcomes, robotics provided a better precision in bone cuts in the sagittal plane for the tibial component and the lower limb alignment. No other differences were observed. CONCLUSION: In the light of these results, the robot seems to be the most precise cutting instrument to perform UKA. However, this did not demonstrate any difference in functional or clinical outcome. The cost of this technology can be a major economic brake, especially in surgical centers that do not have an exclusive prosthetic activity. Further outcome and survivorship data is needed to recommend one cutting instrument over the other.

Mid- to long-term clinical outcomes after press-fit short stem reverse shoulder arthroplasty.

Background: To date, a limited number of studies report mid- to long-term outcomes of press-fit short stem shoulder arthroplasty. The purpose of this study was to report and analyze mid- to long-term outcomes in a series of patients that received press-fit short stem reverse shoulder arthroplasty (RSA). The hypothesis was that press-fit short stem RSA would be a safe and effective treatment with satisfactory mid- to long-term outcomes. Methods: The authors retrospectively reviewed the records of 60 patients that received RSA using press-fit uncemented short humeral stems by two surgeons between March 2014 and December 2015. The absolute Constant Score (CS), age-/sex-adjusted CS, and the American Shoulder and Elbow Surgeons (ASES) score were recorded preoperatively and postoperatively at a minimum follow-up of 6 years. The proportions of patients that achieved a satisfactory outcome after RSA were based on the substantial clinical benefit, as proposed for the absolute CS (net improvement ≥19.1). Results: Of the initial cohort of 60 patients, 9 (15%) died of causes unrelated to RSA, 5 (8%) were revised with partial implant removal, and 4 (7%) were lost to follow-up. This left a final cohort of 42 patients (70%) with complete postoperative CS (absolute and age-/sex-adjusted) and ASES scores at a mean follow-up of 6.7 ± 0.5 years (range, 6.1-7.8). Of the final cohort, 11 (18%) had complications, of which 9 (15%) were treated conservatively, and 2 (3%) required reoperations without implant removal. Net improvements in functional outcomes were 34.7 ± 21.2 for the absolute CS, 54% ± 32% for the age-/sex-adjusted CS, and postoperative ASES scores were 87.9 ± 13.7. Of the 29 patients who had complete records for absolute CS, 22 (76%) received a substantial clinical benefit (net improvement ≥19.1). Conclusions: Mean net improvements of absolute CS exceeded the substantial clinical benefit after press-fit short stem RSA at a follow-up of 6.1 to 8.6 years. While 5 patients (8%) experienced postoperative instability, none had fracture sequelae, which indicates that offset or angular adjustments may be required even in patients with normal bony anatomy. Press-fit short stem RSA is a safe and effective treatment with satisfactory mid- to long-term outcomes, with no stem revisions for aseptic reasons, which compares favorably to the literature that reports high rates of osteolysis and subsequent stem loosening.

Resection and extemporaneous coverage of a soft tissue sarcoma with a pedicled groin flap in the trochanteric region: Technical note.

The main issues pertaining to oncological surgery of the musculoskeletal system are tumour resection with sufficient margins, and the coverage of inherent defects. We report the use of a pedicled cutaneous groin flap as coverage for a trochanteric defect following an oncological resection of a grade III pleomorphic soft tissue sarcoma in a 75-year-old patient. This flap is not routinely used in the coverage of a defect in this region. The interest of this original process lies in its technical ease, and in the possibility of lifting the flap directly after resection, without changing the set-up.

Specific Design of a Press Fit Humeral Stem Provides low Stress Shielding in Reverse Shoulder Arthroplasty at minimum 5 Years FU.

Press fit fixation is becoming more popular in RSA to preserve, in theory, bone capital. Several studies report that bone resorption can be very high around humeral stems depending on their size, shape and mode of fixation. The aim of the current study is to mid-term follow-up clinical and radiological result of a press fit ovoid regular stem RSA in non acute trauma cases. Materials and Methods: We performed a retrospective monocentric study of patients continuously implanted with the Humeris® stem RSA for degenerative change of the shoulder. Nineteen shoulders, in eighteen patients (74.6 y.o (from 69 to 81)), were available at minimum five years follow-up. Results: The mean final adjusted Constant score was 111.9 (65 to 130), and the mean ASES score was 49.82 (10 to 60). Humeral resorption was observed in 21% of cases. We found a statistically significant (p = .014) lower adjusted Constant score in patients presenting with resorption on post-operative X-rays compared to those without resorption (115.6 vs. 98.25). Half cases of patients presenting a resorption underwent L'Episcopo procedure during surgery. Humeral resorption occurs the first year after surgery and do not increase even 8 years after surgery. Analysis demonstrated no correlation between the value of filling ratios and bone resorption. Conclusion: The current study confirms a low rate of stress shielding around the studied stem, with rare bony resorption and no osteopenia around the humeral stem. This study highlights the importance of choosing the appropriate proximal shape and length of the humeral stem for press fit fixation in RSA.

Does delayed weight bearing in the surgical management of fractures of the upper end of the femur in the elderly lead to more complications? A prospective study.

INTRODUCTION: Fractures of the upper end of the femur (FUEF) lead to increased mortality and dependence in the elderly. However, mechanical complications after surgery persist in up to 20% of cases, which may justify a delayed resumption of full weight bearing to protect the osteosynthesis during consolidation. HYPOTHESIS: Our hypothesis was that the late resumption of weight bearing in an elderly population after a FUEF would be limited by a higher frequency of medical complications. METHODS: This was a prospective monocentric study including patients aged 80 or over with an isolated FUEF requiring osteosynthesis. The operator decided on the discharge. The primary endpoint was to show a difference in a medical complication score created for this study (APRETAR), between a group with, and a group without, weight bearing delayed by 45 days. RESULTS: Between 2016 and 2019, 254 patients (88±5.6 years, 77.6% women) were included, and of these, 70 (27.6%) had delayed weight bearing. The mean APRETAR at 45 days was greater in the delayed weight bearing group (5.9±8.6 vs. 5.7±11.0; p<0.001). One-year mortality was 12.6% (32 patients), with no difference between the two groups (p=0.51). The level of dependence was significant (IADL at 2.2±1.7), with some comorbidities (Charlson at 2.9±2.2 and CIRS-G at 6.5±4.3) and all comparable across the two groups but with low cognitive levels, especially in the group with delayed weight bearing (MMSE 15.9±10.7 vs. 21±6.9; p<0.001). CONCLUSION: This prospective study shows that delaying weight bearing in the elderly population, even for mechanical problems with FUEF, statistically increases medical complications but in a clinically acceptable manner. LEVEL OF EVIDENCE: II, Prospective cohort study.

Custom-made macroporous bioceramic implants based on triply-periodic minimal surfaces for bone defects in load-bearing sites.

The architectural features of synthetic bone grafts are key parameters for regulating cell functions and tissue formation for the successful repair of bone defects. In this regard, macroporous structures based on triply-periodic minimal surfaces (TPMS) are considered to have untapped potential. In the present study, custom-made implants based on a gyroid structure, with (GPRC) and without (GP) a cortical-like reinforcement, were specifically designed to fit an intended bone defect in rat femurs. Sintered hydroxyapatite implants were produced using a dedicated additive manufacturing technology and their morphological, physico-chemical and mechanical features were characterized. The implants' integrity and ability to support bone ingrowth were assessed after 4, 6 and 8 weeks of implantation in a 3-mm-long, femoral defect in Lewis rats. GP and GPRC implants were manufactured with comparable macro- to nano-architectures. Cortical-like reinforcement significantly improved implant effective stiffness and resistance to fracture after implantation. This cortical-like reinforcement also concentrated new bone formation in the core of the GPRC implants, without affecting newly formed bone quantity or maturity. This study showed, for the first time, that custom-made TPMS-based bioceramic implants could be produced and successfully implanted in load-bearing sites. Adding a cortical-like reinforcement (GPRC implants) was a relevant solution to improve implant mechanical resistance, and changed osteogenic mechanism compared to the GP implants. STATEMENT OF SIGNIFICANCE: Architectural features are known to be key parameters for successful bone repair using synthetic bioceramic bone graft. So far, conventional manufacturing techniques, lacking reproducibility and complete control of the implant macro-architecture, impeded the exploration of complex architectures, such as triply periodic minimal surfaces (TPMS), which are foreseen to have an unrivaled potential for bone repair. Using a new additive manufacturing process, macroporous TPMS-based bioceramics implants were produced in calcium phosphate, characterized and implanted in a femoral defect in rats. The results showed, for the first time, that such macroporous implants can be successfully implanted in anatomical load-bearing sites when a cortical-like outer shell is added. This outer shell also concentrated new bone formation in the implant center, without affecting new bone quantity or maturity.