Average total weight of surgical waste and CO2 carbon footprint of orthopedic surgery in France, estimated on the basis of a representative panel.

BACKGROUND: Reduction of waste and carbon footprint can be optimized. Awareness of carbon sources and quantification of the waste are two key parameters. To our knowledge, there is no study in France on waste production by the surgical team during the operation in orthopedic surgery, in a global scope. Therefore, we performed an observational investigation aiming to: (1) quantify and characterize the weight of the wastes generated after a panel of orthopedic procedures, (2) calculate the CO2 footprint generated by these wastes and extrapolate the figure at the national scale. HYPOTHESIS: Waste production is highly variable according to the types of procedures and infectious clinical waste is still a predominant source of waste and CO2 emission. MATERIALS AND METHODS: It is a comparative and prospective study in which a total of 14 procedures were selected as a representative panel: arthroplasties (hip, knee), spine fusions, arthroscopic procedures (shoulder, knee), nerve release, forefoot osteotomies, trauma procedures. The main outcome was the average total weight of waste for each of the fourteen categories (280 measurements: 140 times 2, at the end of each procedure), expressed in kilograms (kg), and the proportions of infectious clinical waste (ICW) and household wastes (HW), expressed in percentages. Ten measures were prospectively recorded for each type of procedure in a single teaching hospital from January to September 2022. The theoretical carbon footprint generated by the treatment of the wastes was estimated in kilograms of CO2 equivalent (KgEqCO2). The national extrapolation of the carbon footprint was performed by collecting the total number of procedures in France in 2021 using the VisuChir tool. RESULTS: A total of 937kg of waste were produced for the 140 procedures, amongst which 514kg of ICW (54.8%) and 423kg of HW (45.2%). The overall median waste weight was 5.9kg (Q1: 4.4, Q3: 8.1), ranging from 1.8kg to 18.3kg. The overall median waste weight for HW was 2.8kg (Q1: 2.5, Q3: 3.4), ranging from 1.8kg to 17.8kg. The overall median waste weight for ICW was 3.8kg (Q1: 2.7, Q3: 4.8), ranging from 0.8kg to 7.2kg. The knee surgeries were responsible for the heaviest waste weight; the least waste-productive procedures were the foot and the carpal tunnel release. The median proportions of ICW varied from 39% for the total knee replacements to 72% for the femoral nails. There was a significant inverse correlation between the total waste weight and the proportion of ICW: r=-0.47, p<10-4. The total median estimated carbon footprint was 4.3KgCO2Eq (Q1: 3.1, Q3: 5.8), ranging from 1.59KgCO2Eq (Q1: 1.5, Q3: 1.8) and 7.07KgCO2Eq (Q1: 6.7, Q3: 8.17). The total median estimated carbon footprint was 3.5KgCO2Eq for ICW (Q1: 2.5, Q3: 4.5) and 0.76KgCO2Eq (Q1: 0.54, Q3: 1.3) for HW. The national median estimated carbon footprint was 10.1 million KgEqCO2 in 2021 for orthopedic surgery. CONCLUSION: Our study revealed that in most cases more than half of the wastes were ICW. The total estimated national carbon footprint for orthopedic procedures was 10 million kilograms. The reduction of the ICW constitutes a cornerstone, as they are responsible for more carbon emissions. LEVEL OF EVIDENCE: III; prospective comparative observational in vivo study.

Comparison of Three Grafting Options for Anterior Cervical Corpectomy and Fusion: A Retrospective 3-Arms Case Control Study.

BACKGROUND: Anterior cervical corpectomy and fusion achieves foraminal radicular and central medullary decompression and spinal stabilization in staged lesions. Many bone graft materials have been developed for the reconstruction of cervical lordosis and the restoration of intervertebral height after corpectomy. The PolyEtherKetoneEtherKetoneKetone (PEKEKK) is a semicrystalline thermoplastic polymer that can be reinforced with carbon fibers to create long and highly fenestrated rectangular cervical cages for corpectomy. This study aimed to evaluate the radiological outcomes of an innovative PEKEEKK cage compared with others grafting options. METHODS: Forty-five consecutive patients who underwent surgery with PEKEKK cages between 2017 and 2019 at a spine institution, were matched with 15 patients with a titanium mesh cylindrical cage (TMC) and 15 patients with a tricortical structural iliac bone graft. The restoration of vertebral height and cervical lordosis postoperatively, and subsidence of the construct were evaluated. Complications were reported. RESULTS: The minimal follow-up was 5.1±2years. A better, but nonsignificant, postoperative gain in height was observed for PEKEKK (+8.1 ± 20%) and TMC cages (+8.2 ± 16%) than for iliac crest autograft reconstruction (+2.3 ± 15%, P = 0.119). The mean subsidence at the last follow-up was greater for TMC cages (-10.2 ± 13%), but was not significant, with -6.1 ± 10% for PEKEKK cages and -4.1 ± 7% for iliac crest autografts (P = 0.223). The gain in segmental cervical lordosis was significant (P < 0.001) and remained stable in all the groups. CONCLUSIONS: Although an improvement in radiologic anatomical parameters can be achieved with all cage groups, the PEKEKK cage can be considered as a safe alternative for reducing subsidence.

Faster strength recovery and better strength ratio with arthroscopic Latarjet compared to the open technique: An observational study.

INTRODUCTION: The arthroscopic bone block has shown reliability and reproducibility regarding functional scores and shoulder mobility compared to the open bone block technique. The recovery of muscle strength, especially the strength ratio external rotator/internal rotator (ER/IR), is crucial to recovering satisfactory function. This ratio should be as near to 1 as possible, meaning a good strength balance. Little is known about the difference in strength recovery between the open and arthroscopic techniques. HYPOTHESIS: Arthroscopic Latarjet reduces surgical stress and improves the strength recovery and strength ratio. OBJECTIVES: To compare arthroscopic and open Latarjet procedures for shoulder muscle strength and functional outcomes. MATERIAL AND METHODS: It was an observational longitudinal and prospective cohort follow-up. Two groups of patients were accessible for comparison: 35 in an arthroscopy group and 38 in an open group. The main outcome was the muscle strength of shoulder muscles measured with a dynamometer and expressed in Newton (N) at day 21 (D21), D45, D90, D180, and D365 in the operated and contralateral shoulders. The measurements were made for the pectoralis major, the three deltoid fascicles, and the subscapularis. The shoulder ER/IR strength ratio was calculated. Other variables were the range of motion (ROM), the Walch-Duplay (WD), the Western Ontario Shoulder Instability score (WOSI), and the Visual Analogic Scale for pain assessment. The strength, ROM, and functional scores were compared between open and arthroscopy with linear mixed models. RESULTS: The median strengths at 52 weeks were significantly higher than at 3 weeks (P<10-4): anterior deltoid (AD) 8N (Q1:7, Q3: 9) versus 4N (Q1:2, Q3: 5), lateral deltoid (LD) 9N (Q1:9, Q3: 11) versus 6N (Q1:4, Q3: 7), posterior deltoid (PD) 14N (Q1:12, Q3: 15) versus 9N (Q1:8, Q3: 10), subscapularis 10N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 8), and pectoralis major (PM) 11N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 10). The overall strengths were lower in the open group compared to the arthroscopy group: AD -2.1N (CI95%[-3.1--1.2], p=0.0005), LD -1.3N (CI95% [-2.4--0.15], p=0.03), PD -0.35N (CI95% [-1-0.9], p=0.52), subscapularis -2.1N (CI95% [-3.3--0.7], p=0.006), and PM -1.4N (CI95% [-2.2--0.02], p=0.03). The ER/IR ratio was stable throughout the follow-up for both the operated and contralateral shoulders (p>0.5). The overall mean ratio was 1.3 (median 1.2, Q1: 1, Q3:1.45) for the operated shoulder and 1.1 (median 1, Q1: 0.9, Q3:1.3) for the contralateral shoulder (p=0.0004). The average ER/IR ratio was 0.27 points higher in the open group (CI95% [0.1-0.46], p=0.003). The ROM was similar between the two groups, and there was no correlation between the ER/IR ratio and the ROM (p>0.5). The VAS < 3 weeks and WD > 12 weeks were significantly poorer in the open group: +0.61 (CI95% [0.03-1.16] p=0.02), and -7.3 points (CI95% [-13--0.01], p=0.05), on average, respectively. CONCLUSION: The patients in the arthroscopy group had a better ER/IR strength ratio (closer to 1) and better WOSI after 12 weeks. The strength and the ROM were not correlated with each other. LEVEL OF EVIDENCE: III.

AtoG: A simple score to predict complications and death after hip fractures, in line with the comprehensive geriatric assessment.

INTRODUCTION: Proximal Femur Fractures (PFFs) are a significant public health issue and occur in the context of global frailty and aging. Recent literature identifies new patient-related prognostic factors that focus on socioeconomic environment, patient well-being, or nutrition status. Specific scores have been developed, but in most cases, they fail to be in line with the comprehensive geriatric assessment, or do not assess the newly identified prognostic factors, contain multitude collinearities, or are too complex to be used in the daily practice. Hypothesis A comprehensive score with equal representation of the patient's dimensions does at least as good as the Charlson score (CCI), to predict complications and mortality. OBJECTIVE: To develop a new comprehensive prognostic score, predicting inpatient complications and mortality up to 5-year after PFF. MATERIAL AND METHODS: The patients treated surgically for PFF on a native hip, between 2005 and 2017 were selected from a French national database. The variables were the gender, age, the type of treatment (osteosynthesis or arthroplasty), and the CCI. The outcomes were the medical and surgical complications as inpatient and the mortality (up to 5-year). Variables were grouped into dimensions with similar clinical significance, using a Principal Component Analysis, for instance, bedsores and malnutrition. The dimensions were tested for 90-day mortality and complications, in regressions models. Two scores were derived from the coefficients: SCOREpond (strict ponderation), and SCORE (with loose ponderation: 1 point/risk factors, -1 point/protective factors). Calibration, discrimination (ROC curves with Area Under Curves AUC), and cross-validation were assessed for SCOREpond, SCORE, and CCI. RESULTS: Analyses were performed on 7756 fractures. The factorial analysis identified seven dimensions: age; brain-related conditions (including dementia): 1738/7756; severe chronic conditions (for instance, organ failures) 914/7756; undernutrition: 764/7756; environment, including social issues or housing difficulties: 659/7756; associated trauma: 814/7756; and gender. The seven dimensions were selected for the prognostic score named AtoG (ABCDEFG, standing for Age, Brain, Comorbidities, unDernutrition, Environment, other Fractures, Gender). The median survival rate was 50.8 months 95% CI [49-53]. Anaemia and urologic complications were the most prevalent medical complications (1674/7756, 21%, and 1109/7756, 14.2%). A total of 149/7756 patients (1.9%) developed a mechanical inpatient complication (fractures or dislocations), with a slightly higher risk for arthroplasties. The AUCs were 0.69, 0.68, and 0.67 for AtoGpond, AtoG, and CCI, respectively, for 90-day mortality, and 0.64, 0.63, and 0.56 for complications. Compared to patients with AtoG=0, Hazard Ratios for 90-day mortality were 2.3 95% CI [1.7-2.9], 4.2 95% CI [3.1-5.4], 6 95% CI [4.5-8.1], 8.3 95% CI [6.5-12.9], and 13.7 95% CI [8-24], from AtoG=1 to AtoG≥5, respectively (p<10-4); the 90-day survival decreased by 5%/point, roughly. The sur-risk of mortality associated with AtoG was up to 5-year: HR=1.51 (95% CI [1.46-1.55], p<10-4). Compared to AtoG=0, from AtoG=1 to AtoG≥5, the pooled Odd Ratios were 1.14 95% CI [1.06-1.2], 1.53 95% CI [1.4-1.7], 2.17 95% CI [1.9-2.4], 2.9 95% CI [2.4-3.4], and 4.9 95% CI [3.3-7.4] for any complication (p<10-4). CONCLUSION: AtoG is a multidimensional score in line with the concept of comprehensive geriatric assessment. It had good discrimination and performance in predicting 90-day mortality and complications. Performances were as good as CCI for 90-day mortality, and better than it for the complications. LEVEL OF PROOF: IV; retrospective cohort study.

External Validation of the Spinal Orthopedic Research Group Index for Spinal Epidural Abscess 90-day Mortality in a Geographically Remote Population.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To externally validate the Spinal Orthopaedic Research Group (SORG) index for predicting 90-day mortality from Spinal Epidural Abscess (SEA) and compare its utility to the 11-item modified frailty index (mFI-11) and Charlson Comorbidity Index (CCI). SUMMARY OF BACKGROUND DATA: Providing a mortality estimate may guide informed patient and clinician decision-making. A number of prognostic tools and calculators are available to help predict the risk of mortality from SEA, including the SORG index, which estimates ninety-day post discharge mortality. External validation is essential before wider use of any clinical prediction tool. METHODS: Patients were identified using hospital coding. Medical and radiological records were used to confirm the diagnosis. Mortality data, and data to calculate the SORG index, mFI-11 and CCI was collected. Area under the curve (AUC) and calibration plots were used to analyse. RESULTS: 150 patients were included: 58 female (39%), with median age 63 years. Fifteen deaths (10%) at 90-days post discharge and 20 (13%) at one-year. The mean SORG index was 13.6%, mean CCI 2.75, and mean mFI-11 was 1.34. The SORG index (P=0.0006) and mFI-11 (P<0.0001) were associated with 90-day mortality. AUC for SORG, mFI-11, and CCI were 0.81, 0.84, and 0.49, respectively. The calibration slope for the SORG index showed slight overestimation in the middle ranges of the predicted probability, more so than mFI-11, and was not well-calibrated over the higher ranges of predicted probability. CONCLUSIONS: This study externally validated the SORG index, demonstrating its utility in our population at predicting 90-day mortality, however, it was less well calibrated than the mFI-11. Variations in algorithm performance may be a result of difference in socioethnic composition and health resource between development and validation centres. Continued multicentre data input may help improve such algorithms and improve their generalisability.

Keeping It Simple: Developing a Prognostic Tool for Spinal Epidural Abscess.

STUDY DESIGN: A retrospective study. OBJECTIVE: To develop a prognostic score for mortality and treatment failure in Spinal epidural abscess (SEA), based on simplicity and multidimensional assessment principles. METHODS: One-hundred-fifty patients were reviewed. Variables assessed included comorbidities, functional status, clinical presentation, Frankel classification, and biochemical and radiological parameters. The main outcomes were the 90-day mortality and treatment failure, corresponding to any intensification of the initial treatment plan. Variables were sorted out with a factorial analysis. Logistic regressions were performed, and the new score was derived from the coefficients. ROC curves with Area Under Curve, calibration plots, and cross-validation were performed. RESULTS: Forty-three patients (29%) had treatment failure, and 15 died (10%) by 90 days. Factorization created 3 groups: Comorbidities (C), Severity (S), and Function (F). For 90-day mortality, Odds ratios were 1.20 (P = .0002), 1.15, (P = .03), 1.36, (P < 10-4) for C, S, F, respectively. The new score 'CSF' had 1 point per item, ranging from zero to 3. OR increased by 1.2/point for 90-day mortality (P < 10-4), AUC was .86. For failures OR increased by 1.15/point (P = .014), AUC was .58, and increased to .64 for patients who survived after 90 days, probably due to competing risks. CONCLUSIONS: Comorbidities, Severity, and Function is a new simplistic tool, easy to use in daily practice; its performances were excellent for 90-day mortality, and acceptable for failures. Simple tools are more likely to be adopted into practice. External validation of this technique is desirable.

The Anteroposterior Positioning of Viscoelastic Cervical Disc Prosthesis Does Not Alter the Outcomes.

BACKGROUND: While first-generation articulated disc prostheses had an ideal positioning schematically as posterior as possible because of their geometrically determined center of rotation, the dogma may change for viscoelastic implants, whose center of rotation is free. Our hypothesis was to assess whether the anteroposterior positioning (APP) of a viscoelastic implant may influence the clinical or radiological outcomes at follow-up. METHODS: Twenty-five patients (mean age 47 years) were evaluated, with an average follow-up of 25.9 months. The primary outcome was the implants' APP on lateral radiographs. APP between 0% and 49% meant anterior centering, 50% perfect centering, and 51% to 100% posterior centering. The cohort was divided into 2 groups: anterior positioning and posterior positioning. Measurements were performed blindly to the functional outcomes. Visual analog scale for neck pain and radicular pain and the Neck Disability Index were assessed. Range of motion was measured at the last follow-up. The C2 to C7 Cobb angle and the spinocranial angle were also measured. RESULTS: The median crude offset from the vertebral endplate center was 0.4 mm (mean: 0.3 mm, Q1: -1.5 mm, Q3: 2 mm; range, -2.9 to 4 mm). The mean overall APP was 49%, 45.2% (95% CI, 43.2%-47.1%) in the anterior group, and 54.1% (95% CI, 51.4%-55.3%) in the posterior group. Fifteen patients were in the group anterior positioning and 10 in the group posterior positioning. The mean spinocranial angle was 79° preoperatively and 74° preoperatively (P = 0.04). Functional outcomes were significantly improved at the last follow-up (P < 10-4). There was no significant correlation between the APP, functional outcomes, and range of motion. CONCLUSION: The APP of the CP-ESP viscoelastic disc arthroplasty does not significantly influence the clinical or radiological outcomes at follow-up. This study suggests that this type of implant tolerates greater variability in its implantation technique.

Hip fractures after 60 years of age in France in 2005-2017: Nationwide sample of statutory-health-insurance beneficiaries.

BACKGROUND: Proximal femoral factures (PFFs) constitute a heavy medical, social, and economic burden. Overall, orthopaedic conditions vary widely in France regarding the patients involved and treatments applied. For PFFs specifically, data are limited. Moreover, the ongoing expansion of geriatric orthopaedics holds promise for improving overall postoperative survival. The objectives of this retrospective study of a nationwide French database were: 1) to describe the pathway of patients with PFFs regarding access to care, healthcare institutions involved, and times to management; 2) to look for associations linking these parameters to post-operative mortality. HYPOTHESIS: Across France, variations exist in healthcare service availability and time to management for patients with PFFs. MATERIAL AND METHODS: A retrospective analysis of data in a de-identified representative sample of statutory-health-insurance beneficiaries in France (Échantillon généraliste des bénéficiaires, EGB, containing data for 1/97 beneficiaries) was conducted. All patients older than 60 years of age who were managed for PFFs between 2005 and 2017 were included. The following data were collected for each patient: age, management method, Charlson's Comorbidity Index (CCI), home-to-hospital distance by road, and type of hospital (public, non-profit private, or for-profit private), and time to surgery were collected. The study outcomes were the incidence of PFF, mortality during the first postoperative year, changes in mortality between 2005 and 2017, and prognostic factors. RESULTS: In total 8026 fractures were included. The 7561 patients had a median age of 83.8 years and a mean CCI of 4.6; both parameters increased steadily over time, by 0.18 years and 0.06 points per year, respectively (p<10-4 for both comparisons). Management was by total hip replacement in 3299 cases and internal fixation in 4262 cases; this information was not available for 465 fractures. The overall incidence increased from 90/100,000 in 2008 to 116/100,000 in 2017 (p=0.03). Of the 8026 fractures, 5865 (73.1%) were managed in public hospitals (and this proportion increased significantly over time), 1629 (20.3%) in non-profit private hospitals (decrease over time), and 264 (3.3%) in for-profit private hospitals. The home-to-hospital distance ranged from 7.5 to 38.5km and increased over time by 0.26km/year (95% confidence interval [95%CI]: 0.15-0.38) (p<10-4). Median time to surgery was 1 day [1-3 days], with no significant difference across hospital types. Mortality rates at 90 days and 1 year were 10.5% (843/8026) and 20.8% (1673/8026), respectively. Two factors were significantly associated with day-90 mortality: the CCI (hazard ratio [HR], 1.087 [95%CI: 1.07-1.10] [p<10-4]) and time to surgery>1 day (HR 1.35 [95%CI: 1.15-1.50] [p<0.0001]). Day-90 mortality decreased significantly from 2005 to 2017 (HR 0.95 [95%CI: 0.92-0.97] [p<10-4]), with no centre effect. CONCLUSION: The management of PFF in patients older than 60 varied widely across France. Time to surgery longer than 1 day was a major adverse prognostic factor whose effects persisted throughout the first year. This factor was present in over half the patients. Day-90 mortality decreased significantly from 2005 to 2017 despite increases in age and comorbidities. LEVEL OF EVIDENCE: IV Retrospective cohort study.

What to improve: Results of fixed-hinge knee endoprosthesis reconstructions over 40 years in a single tumor center.

INTRODUCTION: Over the past decades, numerous structural changes in implants, medical treatments, and surgical techniques have been made for Malignant Bone Tumors (MBT) around the knee. However, the overall care improvement is still unclear. The method is crucial when analyzing outcomes in surveys involving tumors, and a thorough assessment of the mortality is mandatory because death acts as competing event. The aims of this study were: 1) a comprehensive and longitudinal assessment of the revisions with an extensive follow-up and adequate methods; 2) a complete mortality review to consider competing risks. HYPOTHESIS: The hypothesis was that some prosthesis's structural improvements were made while the surgical toll increased as well as an improvement of mortality was also expected. MATERIAL AND METHODS: Analyses were performed on 248 patients with MBT (mean follow-up was 8.7 years, surgeries between 1972 and 2017). Three prosthesis models were successively used over time: 120 Guepar (older model), 42 Tornier, and 86 Stanmore (more recent model). The primary outcome was the assessment of revisions sorted out according to Henderson: type-1 soft-tissue failures or instability, type-2 aseptic loosening, type-3 structural failures, type-4 periprosthetic infections, type-5 tumoral progression. Death and amputations were considered as competing events. An extensive assessment of mortality was performed by merging the dataset with the French register of Deaths (INSEE). Cumulative probabilities were computed at 2, 5, 10, and 15 years and compared with Gray's tests. RESULTS: The overall 5-year survival was, 80% (95% CI: 73-87) for Guepar, 69% (95% CI: 56-84) for Tornier, and 71% (95% CI: 62-82) for Stanmore (p=0.4). The 5-year cumulative risks for type-1 were 5% (95% CI: 1-9), 9% (95% CI: 0-18), and 17% (95% CI: 9-25) for Guepar, Tornier, and Stanmore, respectively (p=0.01). The 15-year cumulative risks for type-2 were 22% (95% CI: 15-39), 8% (95% CI: 0-17) and 8% (95% CI: 2-14) for Guepar, Tornier, and Stanmore, respectively (p=0.10). Ten patients had an implant failure, nine Guepar, and one Tornier. The 5-year cumulative risks for type-4 were 7% (95% CI: 2-12), 19% (95% CI: 7-31), and 12% (95% CI: 5-18) for Guepar, Tornier, and Stanmore, respectively (p=0.08). There were 29 tumoral progressions; the 15-year risks were 16% (95% CI: 2-22), 2% (95% CI: 0-7%), and 12% (95% CI: 4-19%) for Guepar, Tornier, and Stanmore, respectively (p=0.08). No difference whatsoever was found between the proximal tibial and distal femur. CONCLUSION: There were some improvements in prosthesis design (forged steel instead of cast steel) and probably also in cemented stem fixation, but not in prosthetic joint infection and local recurrence over forty years. The overall mortality did not change significantly over the last 40 years amongst this specific cohort of patients who benefited from a hinge reconstruction prosthesis. LEVEL OF EVIDENCE: III; comparative case series with sensibility analysis.

The Associative Pattern Between Segmental Arterial Damage and Complete Neurological Disorder After Spinal Cord Injury: A Case-Control Study.

INTRODUCTION: The prevalence of vascular trauma surrounding the thoracic spine following Spinal Cord Injury (SCI) is unknown. The potential for neurologic recovery is uncertain in many cases; in some cases, neurologic assessment is not possible, for example, in severe head injury or early intubation, and detection of segmental artery injury may help as a predictive factor. OBJECTIVE: To assess the prevalence of segmental vessel disruption in two groups, with and without neurologic deficit. MATERIAL AND METHODS: This is a retrospective cohort study, with a group SCI American Spinal Injury Association (ASIA) E and a group SCI ASIA A. All patients had a high-energy thoracic or thoracolumbar fracture from T1 to L1. Patients were matched 1:1 (one ASIA A matched with one ASIA E) according to the fracture type, age, and level. The primary variable was the assessment of the presence/disruption of the segmental arteries, bilaterally, around the fracture. Analysis was performed twice by two independent surgeons in a blinded fashion. RESULTS: Both groups had 2 type A, 8 type B, and 4 type C fractures. The right segmental artery was detected in 14/14 (100%) of the patients with ASIA E and in 3/14 (21%) or 2/14 (14%) of the patients with ASIA A, according to the observers, p=0.001. The left segmental artery was detectable in 13/14 (93%) or 14/14 (100%) of the patients ASIA E and in 3/14 (21%) of the patients ASIA A for both observers. All in all, 13/14 of the patients with ASIA A had at least one segmental artery undetectable. The sensibility varied between 78%to 92%, and the specificity from 82% to 100%. The Kappa Score varied between 0.55 and 0.78. CONCLUSION: Segmental arteries disruption was common in the group ASIA A. This may help to predict the neurological status of patients with no complete neurological assessment or potential for recovery post-injury.

Septic arthritis of the native hip joint: a multi-pattern, multi-outcome disease.

PURPOSE: Septic arthritis of the native hip joint (SANH) is an uncommon surgical and medical emergency with few reports. The aim of this study was to determine predictors of return to theatre (RTT), complications and mortality. METHODS: Patients with SANH were identified from January 2009 to June 2022; 50 patients and three subgroups were identified: Pyogenic (surgical washout without systemic inflammatory disease), Systemic (surgical washout with SIDs) and patients managed non-surgically. Patterns of these groups were assessed with a principal component analysis. The cumulative incidences for death, any complication and RTT for repeat washout were calculated. The predictive variables associated with outcomes were selected with univariable models and then incorporated in multivariable CoxPH regressions. RESULTS: The 1-year cumulative incidence was 14% for mortality and 48.5% for any complication. Amongst patients managed surgically, 1-year risk of RTT was 46% in Pyogenic subgroup and 21% in Systemic subgroup. Systemic subgroup had lower complications and RTT and higher rate of sterile aspirate, compared to Pyogenic. Charlson comorbidity index (CCI) (HR = 1.41, P value = 0.03), preoperative albumin (HR = 0.81, P value = 0.009) and preoperative haemoglobin (HR = 0.95, P value = 0.02) were significantly associated with 1-year mortality. Time between symptom onset and admission > 7 days (HR = 3.15, P value = 0.042), preoperative Hb (HR = 1.05, P value = 0.016), socioeconomic deprivation (HR = 1.18, P value = 0.04) and Systemic subgroup (HR = 0.25, P value = 0.04) were significantly associated with RTT. CONCLUSION: Mortality was well predicted by the usual parameters including CCI, albumin, but also low haemoglobin. Patients presenting in a delayed fashion were more likely to have multiple lavages.

Wide awake local anesthesia no tourniquet (WALANT) versus axillary brachial plexus block for carpal tunnel release in a French public university hospital: Care pathways and operating room costs.

INTRODUCTION: The wide awake local anesthesia no tourniquet (WALANT) is a local anesthetic technique that theoretically cuts costs and shortens surgical waiting times, but this has yet to be demonstrated in France. The main objective of this study was to assess and compare the comprehensive care pathways and costs of performing carpal tunnel release (CTR) procedures in the ambulatory surgery unit using WALANT and axillary brachial plexus block (ABPB). METHODS: A total of 72 CTRs in 66 patients were reviewed after a minimum follow-up of 6 months. The anesthesia was performed by an anesthesiologist after a preoperative consultation. The surgical waiting time, operating room occupancy time, total time taken off work (TOW) and the return to work rate were recorded. The estimated total direct cost per patient (TDCPP) was the sum of the specialist consultation fees, the French diagnosis-related group (DRG) rates and the minimum daily cost of TOW (€27.30/day). RESULTS: Only the total operating room occupancy time differed significantly: 27minutes for the WALANT versus 37minutes for the ABPB (p=0.004). There were no complications or reoperations in either group. The total cost for the cohort was estimated at €190,970. The mean estimated TDCPP was €2,870 for the entire cohort, €2,543 for the ABPB and €2,713 for the WALANT (p=0.791). Twenty-seven of the 45 patients returned to work after a mean TOW of 3.1 months. Fourteen CTRs were preceded by a mean preoperative TOW of 27 days, which resulted in a cost of €24,948 (13% of the total cost). There were no significant differences in TOW or revision rate between WALANT and ABPB. CONCLUSION: Although WALANT significantly reduced operating room occupancy times in our public hospital, the societal costs were the same regardless of the anesthesia technique. Reducing surgical waiting times in France could result in a theoretical saving of nearly €14 million annually. LEVEL OF EVIDENCE: IV.

Do web-based follow-up surveys have a better response rate than traditional paper-based questionnaires following outpatient arthroscopic rotator cuff repair? A randomized controlled trial.

INTRODUCTION: Considering the extensive use of smartphones in current societies, web-based applications could be considered as a new option for patient follow-up in surgery. By means of such tool, automated and periodic questionnaires could improve the rigor, accuracy and the comprehensiveness of postoperative monitoring, as well as early detection of complications, especially in the current context of evolving ambulatory surgery. HYPOTHESIS: The web-based surveys would improve the quality of immediate postoperative monitoring. MATERIAL AND METHODS: For 7 months, we included all patients who underwent outpatient arthroscopic rotator cuff repair. After preoperative randomization, each patient was asked postoperatively to complete either paper-based forms or digital questionnaires via a website (Orthense.com®, Digikare Inc. Blagnac, France). Both media (i.e. paper and digital) followed the same postoperative agenda (i.e., D+3, D+14, D+28, D+45, D+90) and had the same content, including pain and discomfort assessments, functional scores (i.e. Shoulder subjective value, simple shoulder test and auto-constant scores). The main objective was to investigate the quality of postoperative follow-up after outpatient arthroscopic rotator cuff surgery, using either printed questionnaires or web-based surveys. The hypothesis was that using a web-based survey would result in greater response rates and increased patient satisfaction regarding follow-up. Primary outcomes were questionnaire response rates at D+45 and D+90, while secondary outcomes were overall response rates, patient recommendation for the monitoring medium and overall patient satisfaction regarding their follow-up using the net promoter score (NPS). RESULTS: Among the 59 consecutive patients who were included, there were 27 females and 26 males with a mean age of 57±10.2 years; 27 patients completed the web-based survey (Group A) and 26 patients answered paper-based questionnaires (Group B). Regarding the D+45 questionnaire, response rates were 85.2% (n=23) in group A and 42.3% (n=11) in group B (p=.005); a similar significant difference was observed regarding the D+90 questionnaire, with response rates of 70.4% and 34.6%, respectively (p=.027). The mean NPS for the survey was 10 in Group A and 8.29 in Group B (p=.016). Overall, satisfaction regarding postoperative care did not differ between the two groups. DISCUSSION: Compared to traditional paper-based forms, web-based surveys appear to increase patient adherence to short-term postoperative monitoring. If these findings were to be confirmed in long-term follow-up, such straightforward and cost-effective tool could be of great use in clinical care and research. LEVEL OF EVIDENCE: I; Randomized controlled clinical trial.

Readability of online patient educational materials for common orthopaedic paediatric conditions within Australasia.

BACKGROUND: The role of patient educational materials for paediatric patients is increasing. A reading grade level of eighth-grade (USA) or year nine (Australia and New Zealand) is recommended as acceptable. The aim of this paper was to assess the reading grade levels of paediatric online patient educational materials, within Australasia. METHODS: The online Google® search engine was used with a variety of keyword combinations, filtered to the location of Australia and New Zealand. Suitable websites were explored for webpages related to slipped upper femoral epiphysis, septic arthritis, osteomyelitis, talipes equinovarus and developmental dysplasia of the hip. Readability was assessed using the online readability software WEB FX®. RESULTS: Seventy-six patient educational webpages were analysed: 66 from Australia and 10 from New Zealand. Only eight of the 76 webpages (10.5%) had reading grade levels below the recommended eighth-grade (US)/year nine (AUS/NZ) level. Webpages from private healthcare providers and pages related to septic arthritis had the significantly highest reading grades. CONCLUSIONS: Australasian families have limited online patient educational materials available to them, which are mostly set at reading grade levels above recommended standards. Healthcare providers should be incentivized to improve the readability of their patient educational materials to reduce health disparities and improve health literacy moving forward.

Excess mortality after hip fracture during COVID-19 pandemic: More about disruption, less about virulence-Lesson from a trauma center.

To date, literature has depicted an increase in mortality among patients with hip fractures, directly related to acute coronavirus disease 2019 (COVID-19) infection and not due to underlying comorbidities. Usual orthogeriatric pathway in our Department was disrupted during the pandemic. This study aimed to evaluate early mortality within 30 days, in 2019 and 2020 in our Level 1 trauma-center. We compared two groups of patients aged >60 years, with osteoporotic upper hip fractures, in February/March/April 2020 and February/March/April 2019, in our level 1 trauma center. A total of 102 and 79 patients met the eligibility criteria in 2019 and 2020, respectively. Mortality was evaluated, merging our database with the French open database for death from the INSEE, which is prospectively updated each month. Causes of death were recorded. Charlson Comorbidity Index was evaluated for comorbidities, Instrumental Activity of Daily Living (IADL), and Activity of Daily Living (ADL) scores were assessed for autonomy. There were no differences in age, sex, fracture type, Charlson Comorbidity Index, IADL, and ADL. 19 patients developed COVID-19 infection. The 30-day survival was 97% (95% CI, 94%-100%) in 2019 and 86% (95% CI, 79%-94%) in 2020 (HR = 5, 95%CI, 1.4-18.2, p = 0.013). In multivariable Cox'PH model, the period (2019/2020) was significantly associated to the 30-day mortality (HR = 6.4, 95%CI, 1.7-23, p = 0.005) and 6-month mortality (HR = 3.4, 95%CI, 1.2-9.2, p = 0.01). COVID infection did not modify significantly the 30-day and 6-month mortality. This series brought new important information, early mortality significantly increased because of underlying disease decompensation. Minimal comprehensive care should be maintained in all circumstances in order to avoid excess of mortality among elderly population with hip fractures.

Efficiency of fine scale and spatial regression in modelling associations between healthcare service spatial accessibility and their utilization.

BACKGROUND: Healthcare accessibility, a key public health issue, includes potential (spatial accessibility) and realized access (healthcare utilization) dimensions. Moreover, the assessment of healthcare service potential access and utilization should take into account the care provided by primary and secondary services. Previous studies on the relationship between healthcare spatial accessibility and utilization often used conventional statistical methods without addressing the scale effect and spatial processes. This study investigated the impact of spatial accessibility to primary and secondary healthcare services on length of hospital stay (LOS), and the efficiency of using a geospatial approach to model this relationship. METHODS: This study focused on the ≥ 75-year-old population of the Nord administrative region of France. Inpatient hospital spatial accessibility was computed with the E2SFCA method, and then the LOS was calculated from the French national hospital activity and patient discharge database. Ordinary least squares (OLS), spatial autoregressive (SAR), and geographically weighted regression (GWR) were used to analyse the relationship between LOS and spatial accessibility to inpatient hospital care and to three primary care service types (general practitioners, physiotherapists, and home-visiting nurses). Each model performance was assessed with measures of goodness of fit. Spatial statistical methods to reduce or eliminate spatial autocorrelation in the residuals were also explored. RESULTS: GWR performed best (highest R2 and lowest Akaike information criterion). Depending on global model (OLS and SAR), LOS was negatively associated with spatial accessibility to general practitioners and physiotherapists. GWR highlighted local patterns of spatial variation in LOS estimates. The distribution of areas in which LOS was positively or negatively associated with spatial accessibility varied when considering accessibility to general practitioners and physiotherapists. CONCLUSIONS: Our findings suggest that spatial regressions could be useful for analysing the relationship between healthcare spatial accessibility and utilization. In our case study, hospitalization of elderly people was shorter in areas with better accessibility to general practitioners and physiotherapists. This may be related to the presence of effective community healthcare services. GWR performed better than LOS and SAR. The identification by GWR of how these relationships vary spatially could bring important information for public healthcare policies, hospital decision-making, and healthcare resource allocation.

Influence of positioning of L4-5 disc prostheses on functional outcomes and sagittal balance: 2-year follow-up of a cohort of 38 patients.

OBJECTIVE: The main objective of this study was to evaluate the influence of L4-5 total disc replacement (TDR) positioning on functional outcome at the 2-year follow-up. The secondary objective was to assess its influence on sagittal balance. METHODS: Prospective data were compiled for 38 single-level L4-5 ProDisc-O TDRs. Anteroposterior placement (APP) was the distance between the center of the implant and the center of the L5 endplate divided by the total length of the L5 endplate. This ratio was expressed as a percentage (APP 0%-49%, anterior off-centering; 50%, perfect centering; and 51%-100%, posterior off-centering). The patients were divided into 3 groups depending on the APP and using quartile values: group 1, anterior placement (APP 0%-46%); group 2, central placement (APP 46.1%-52%, the 2 central quartiles); and group 3, posterior placement (APP 52.1%-100%). The sagittal balance parameters assessed were overall lordosis, segmental lordosis, and pelvic incidence. Adequate lordosis was defined for each patient according to their pelvic incidence. The Oswestry Disability Index and visual analog scale (VAS) scores for back and leg pain were assessed. RESULTS: The average APP was 48% (range 40%-64%). There were 10 patients in group 1, 18 in group 2, and 10 in group 3. There was a significant difference in functional outcomes among the 3 groups. APP influenced the VAS back (p = 0.04) and VAS leg (p = 0.05) scores. Group 1 consistently showed the highest performance scores. No significant association between APP and the sagittal balance parameters was found. Patients who had preoperative sagittal imbalance or those who significantly modified their balance after the surgery had the poorest outcomes. CONCLUSIONS: Disc prostheses at L4-5 seem to provide better functional outcome when they are positioned anteriorly to the center of the vertebral body.

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.