Quantitative MRI versus perioperative arthroscopy to measure stage 1 ruptures of the supraspinatus tendon for surgical planning.

BACKGROUND: Accurate preoperative assessment of supraspinatus tendon tear (STT) size is important for surgical planning. Our aims were to evaluate the correlation between stage 1 STT size measured preoperatively by quantitative (q)MRI and size measured perioperatively by arthroscopy. The concordance between preoperative tear size and the surgical plan was also assessed. METHODS: This prospective, non-randomized, non-controlled, interventional study was carried out in patients with a stable stage 1 STT. Three months before surgery, STT size was measured in the sagittal and coronal planes by a radiologist by qMRI (1.5T). Three months later, the surgeon measured the size of the tear again on the same qMRI scans and decided on the most appropriate surgical plan. During arthroscopy, the surgeon measured the size of the tear again using a graduated sensor hook and carried out the repair. STT size measured preoperatively was compared to that measured by arthroscopy and the concordance between preoperative STT size and the surgical plan was determined. RESULTS: Sixty-seven patients were included (mean age: 59.5 ± 8.9 years; 58.2% female). These was good concordance between STT size measured by qMRI vs. arthroscopy in the coronal plane (concordance correlation coefficient (CCC) =0.36 [95%CI: 0.16‒0.53]; Pearson's correlation coefficient =0.42 [95%CI: 0.2‒0.6]; P=0.0004) and in the sagittal plane (CCC =0.51 [95%CI: 0.33‒0.65]; Pearson's correlation coefficient =0.57 [95%CI: 0.38‒0.71]; P<0.0001). Preoperative STT size concurred with the surgical plan in 85% of patients. CONCLUSION: There was good concordance between STT size measured by qMRI and that measured perioperatively by arthroscopy. However, preoperative STT size measured by qMRI did not concur with the surgical plan in 15% of patients and in these patients the surgical procedure had to be revised during surgery.

Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis.

BACKGROUND: There is no consensus about the best choice between all the options available for large and massive rotator cuff tear (mRCTs) management. OBJECTIVE: To determine the comparative effectiveness of current treatment options for management of large and mRCTs. DESIGN: Network meta-analysis. SETTING: We searched the Cochrane systematic reviews, MEDLINE and EMBASE databases for all trials of adults with large and mRCTs that report preoperative and postoperative functional scores after an intervention option. PATIENTS: The network meta-analysis included 20 trials with 1233 patients with 37.24 months follow-up. INTERVENTIONS: Eight treatment options for management of large and mRCTs were compared. MAIN OUTCOME MEASURES: The primary effectiveness outcome was the functional score. RESULTS: This meta-analysis did not show statistically significant differences between conservative, partial repair, patch or platelet rich plasma (PRP) augmentation, reverse total shoulder arthroplasty, and complete repair. Latissimus dorsi (LD) transfer was ranked first for effectiveness [standardized mean difference (SMD): 2.17, 0.28-4.07] and debridement ranked last (SMD: -2.15, -3.13 to -1.17). CONCLUSIONS: Latissimus dorsi transfer seems to be most effective for management of large and mRCTs, although some heterogeneity was observed in this network meta-analysis of full text reports. The choice of the operating technique depends on the patient's general health status and his expectations. When a decision has been reached to perform surgery, a repair, even if partial, should be attempted. Procedures involving biologic augmentation (eg, PRP) seem to convey no additional benefit while introducing more risk. Debridement alone should be avoided.

Divergent Intramedullary Nailing (DIN): A Modified Intramedullary Nailing Technique to Treat Paediatric Distal Tibial Fractures.

INTRODUCTION: Elastic stable intramedullary nailing (ESIN) allows for efficient reduction and stabilization of fractures of the tibial shaft in children and adolescents. However, for fractures of the distal third of the tibia, traditional ESIN could be inappropriate, thus compromising the stability and the healing of the fracture. The aim of this study was to present and to assess a new technique of modified ESIN to treat fracture of the distal third of the tibia, called divergent intramedullary nailing (DIN). METHODS: We performed a retrospective monocentric study. All patients less than 16 years old, managed in our pediatric orthopaedics department, and operated upon according to the DIN technique for a displaced and/or unstable fracture of the distal third of the tibia were included. Demographic and surgical data were collected. X-rays were performed preoperatively, postoperatively, at 6 weeks, and every 6 months. The surgical technique starts as does the classic ESIN. However, nails are not curved, so that they cross only once at the proximal part of the tibia; they are divergent and supported by the medial and lateral distal part of the tibial shaft. This allows for reduction and stabilization of the fracture. RESULTS: A total of 13 patients were included, with a mean age of 10 years and a mean follow-up of 32 months. The size of the nail varied between 2.5 and 4 mm. The mean surgical time was 54 minutes. The DIN technique provided a satisfying reduction (coronal and sagittal angulation <3 degrees) for the 13 fractures. In addition, there was no secondary displacement at 6 weeks. All patients were healed at 6 months, with no clinical torsion or axis malalignment. CONCLUSIONS: The current study confirms the feasibility and the efficiency of the DIN method to treat fracture of the distal third of the tibia.

Surgical repair of large-to-massive rotator cuff tears seems to be a better option than patch augmentation or débridement and biceps tenotomy: a prospective comparative study.

BACKGROUND: This prospective study compared the outcomes after 3 different treatments for large and massive rotator cuff tears. METHODS: Patients with a diagnosis of large-to-massive rotator cuff tears were prospectively included. Patients were allocated in 3 groups: (1) arthroscopic complete repair (repair group), (2) open repair and xenograft patch augmentation (patch group), and (3) arthroscopic débridement and tenotomy of the long head of the biceps (débridement group). Patients were evaluated preoperatively and postoperatively at 3, 6, 12 and 24 months. The primary outcome measure was the Constant-Murley score. RESULTS: The study included 32 consecutive patients. The mean improvement in the Constant-Murley score was +29.1 for the repair group (P < .01), +32.2 for the patch group (P < .01), and +20.1 for the débridement group (P < .01) at the final follow-up examination. No differences were found between the repair and patch groups, but the difference became significant between the débridement group and the patch group (P < .001) and also between the débridement group and the repair group (P < .002) at 12 months and the final follow-up. Moreover, 5 complications occurred in 11 patients in the patch group, whereas there was only 1 complication in the repair group and no complications in the débridement group. CONCLUSION: The use of porcine dermis patches to augment repairs of massive and irreparable rotator cuff tears is not recommended because there is no benefit compared with repair without augmentation and patches result in more complications.

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

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

Double Row Knotted "Trident": 1 Suture Technique for Superior to Posterosuperior Small Cuff Tear.

Many arthroscopy suture techniques have been described for small rotator cuff tears, but there is no consensus. The aim of this study is to describe a double-row knot technique, which we call a "trident point," for the superior and posterosuperior small cuff tear that is easily reproducible and has a fast learning curve. This knot takes into account the excess of tendon tissue on the foot print after a cuff suture, called a "dog-ear deformity." However clinical, ultrasound, and biomechanical evaluation with follow-up remains necessary to validate the sustainability of this arthroscopy technique.

Post-traumatic forearm bone defect reconstruction using the induced membrane technique.

INTRODUCTION: The induced membrane technique, first described by Masquelet, is now well standardized, but little studied in post-traumatic forearm bone defect. The main aim of the present study was to analyze consolidation rates in this indication. The study hypothesis was that the induced membrane technique provides good consolidation results. METHODS: We performed a retrospective assessment of our experience with 10 cases of induced membrane forearm reconstruction. The two main etiologies were acute trauma or treatment for non-union. Functional impact was assessed on range of motion and QuickDASH. The complications rate was also examined. RESULTS: There were 3 cases of post-traumatic bone defect, and 7 of non-union treatment, including 6 septic non-unions. Mean defect size was 4.3cm. Mean interval between induced membrane stages 1 and 2 was 3.3 months. Pure cancellous iliac bone graft was systematic. Nine of the patients showed consolidation, at a mean 9.2 months; there was 1 case of non-consolidation, but no other complications. Range of motion was satisfactory; mean QuickDASH score was 22 at a mean 50.3 months' follow-up. CONCLUSION: The induced membrane technique was reliable, reproducible and technically accessible, with good functional and radiographic results and few complications. LEVEL OF EVIDENCE: IV; retrospective study without control group.

Pyrolytic carbon humeral head in hemi-shoulder arthroplasty: preliminary results at 2-year follow-up.

BACKGROUND: In patients with osteoarthritis (OA) and an intact rotator cuff, hemi-shoulder arthroplasty (HSA) can be a viable option as it offers the advantage of keeping the native glenoid intact. However, glenoid erosion has frequently been reported. The aim of this study was to report preliminary clinical results of HSA with a new pyrolytic carbon (pyrocarbon) humeral head. METHODS: This prospective multicenter study included a continuous series of 65 patients who underwent pyrocarbon HSA in 5 centers. RESULTS: At the time of analysis, 1 patient was lost to follow-up, 3 patients underwent revision, and 61 patients were evaluated at a mean follow-up of 25.9 ± 3.3 months. The mean age at index surgery was 57.9 ± 13.3 years. The indications were primary glenohumeral OA in 37 patients, osteonecrosis in 11, secondary OA in 11, and rheumatoid arthritis in 2. The mean Constant score increased from 31.0 ± 15.8 points at baseline to 74.6 ± 17 points at last follow-up. Radiographic analyses showed that 86% of glenoids remained unchanged whereas 14% evolved slightly. CONCLUSIONS: Pyrocarbon HSA grants improvement in pain and function in patients with primary OA or secondary OA after instability but at a lower level in patients with post-traumatic sequelae (secondary OA or osteonecrosis). These preliminary clinical and radiologic results are encouraging, although they need to be confirmed by longer-term follow-up observations.

Arthroscopy training in France: A resident perception and self-assessment.

BACKGROUND: Arthroscopic surgery is a steadily expanding component of orthopaedic practice that changes continuously as new techniques and indications develop. The many arthroscopy training activities offered to residents include fellowships, practice on cadaver specimens and simulators, and teaching in the operating room. Current practices for arthroscopy training of orthopaedic residents in France have not yet been evaluated. The objectives of this study were to describe current arthroscopy training practices and to assess the perceptions and expectations of residents and junior physicians in France, in order to contribute to the development of a new training strategy for residents. HYPOTHESIS: Residents and junior physicians perceive gaps in their arthroscopy training. METHODS: Between November 2018 and February 2019, the Junior French Arthroscopy Society (Société Francophone d'Arthroscopie Junior, SFAJ) conducted a descriptive epidemiological survey of 918 residents, clinical fellows, and junior physicians in orthopaedic surgery departments in France. The data were collected via an online questionnaire sent by e-mail. The questionnaire had items on demographics; perceptions of, and expectations about, arthroscopy skills training during the residency; and experience in performing arthroscopic procedures. RESULTS: Of the 918 residents, 106 responded to the questionnaire. Most respondents were near the end of their training: 26 (24.8%) were 4th-year residents, 23 (21.6%) were 5th-year residents, 15 (14.3%) were clinical fellows, and 13 (12.4%) were junior physicians. Among respondents, 42 (40%) had performed fewer than 5 simple arthroscopy procedures as the main operator and 73 (69.5%) felt they were not, or would not be, capable of performing arthroscopic procedures without supervision by the end of their residency. CONCLUSION: The survey findings highlighted the challenges encountered by French orthopaedics residents in acquiring satisfactory arthroscopy skills during their residency. They also suggested avenues for improvement such as simulator training or the development of training on cadaver specimens. LEVEL OF EVIDENCE: IV, descriptive survey.