Outcomes of acute versus delayed total hip arthroplasty following acetabular fracture.

PURPOSE: Post-traumatic arthritis is known complication following acetabular fracture. The aim was to compare mid- to long-term outcomes of acute THA (aTHA) for acetabular fracture and delayed THA (dTHA) following failure of ORIF or conservative management. METHODS: We retrospectively analysed 60 THA (21 aTHA; 39 dTHA) performed for acetabular fracture between 2004 and 2014 in 60 patients with a mean age of 59 years (20-94). Functional and Radiographic outcomes were assessed at a mean follow-up of 5 years (2-13) utilizing Oxford, Harris Hip (HHS), and Postel Merle d'Aubigné (PMA) scores and Brooker classification. RESULTS: The mean HHS (73), Oxford (32) and PMA (12) scores were significantly lower in the aTHA group. Acute THA was significantly associated with lower postoperative Oxford (ß = -4.2), HHS (ß = -7.8), and PMA (ß = -2.2) scores at mean 5 years (2-13). Eleven patients returned to the operating room. There were no significant differences between THA performed in acute or delayed fashion. The two primary reasons for revision were periprosthetic joint infection (n = 5) and aseptic loosening (n = 4). Survivorship free from reoperation at 10 years was 91% and 82% for aTHA and dTHA, respectively (p = 0.24). Increased PMA scores were associated with decreased overall survival of the THA free from reoperation (HR = 0.60). The degree of heterotopic ossification was significantly higher in the aTHA group (p < 0.001). CONCLUSION: Acute THA in the setting of acetabular fracture is a technically challenging procedure. However, in the present series, aTHA provided satisfactory immediate stability and good survivorship at 10 years in a medically vulnerable patient population. LEVEL OF EVIDENCE: Level 3; Therapeutic study.

[Place of preperitoneal pelvic packing in severe pelvic traumatisms: 20 cases in a French level 1 trauma center]. / Place du packing pré-péritonéal pelvien dans les traumatismes graves du bassin : étude à partir de 20 cas réalisés dans un trauma center de niveau 1 français.

BACKGROUND: The overall mortality of hemodynamically unstable patients with pelvic trauma is high. Their management is controversial concerning places of arterioembolization and pelvic packing associated with pelvic stabilization. The aim of this study was to collect the pre-peritoneal pelvic packing (PPP) performed in our institution over 10years in order to propose a management algorithm. METHOD: From January 2010 to December 2020, all patients with a hemodynamically unstable pelvic fracture who had PPP combined with pelvic stabilization were included. Data were collected prospectively and analyzed retrospectively. The main judgement criteria were early hemorrhage-induced mortality (<24h) and overall mortality (<30d). RESULTS: Twenty patients had PPP out of 287 polytrauma patients with pelvic fracture. The first-line PPP proposed in our algorithm significantly reduced the number of red blood cells (RBCs) (P=0.0231) and improved systolic blood pressure (SBP) (P<0.001) within 24hours of first-line PPP (compared with preoperative). Six patients (30%) were embolized postoperatively for active bleeding not necessarily pelvic. The overall mortality at 30days was 50% (10/20). CONCLUSION: PPP is a fast, easy, effective and safe procedure for venous, bone and sometimes arterial bleeding. PPP is part of damage control surgery and we propose it as a first-line procedure. AE remains complementary in a second step.

[Late complications after blunt renal trauma: A French multicenter study]. / Complications tardives après traumatisme fermé du rein : résultats de l'étude observationnelle nationale multicentrique TraumAFUF.

INTRODUCTION: Among genitourinary traumas, blunt trauma to the kidney are the most frequent: their initial management has been well studied but their development at a distance is poorly documented. The objective of this study was to assess the late complications of blunt renal trauma, and to investigate their predictive factors for occurrence. MATERIALS AND METHODS: A retrospective observational study of the TraumAFUF project was conducted, including, between 2005 and 2018, all blunt renal trauma treated in 18 French hospitals and followed for more than 3 months. The characteristics of the initial trauma, as well as any complications occurring after three months, were identified. The patients were divided into two groups: onset of a late complication (LC) or uncomplicated (UC). The groups were compared in univariate and multivariate analyses to identify the risk factors for the occurrence of these complications. RESULTS: Among the 454 patients included, 50 presented with LC (11%), as symptomatic morphologically altered kidney (2.9%), secondarily impaired biological renal function (2.9%), or secondary arterial hypertension (2.4%). The risk factors identified were, during initial medical care, a high-grade renal trauma≥IV (OR=2.4, P=0.025), active bleeding (OR=2.6, P=0.007), the need for transfusion (OR=2.3, P=0.001), or interventional (R=1.7, P=0.09) or endoscopic treatment (OR=2.0, P=0.035). CONCLUSION: In this study, late complications occurred in 11% of cases after blunt renal trauma. The risk factors identified make it possible to draw up a patient profile who would benefit from prolonged follow-up to detect these complications.

[Non-infectious emergencies of the lower urinary tract and genitals]. / Urgences non infectieuses du bas appareil urinaire et des organes génitaux.

INTRODUCTION: The objective of this narrative review was to report the most relevant data on the contemporary management of the main non-infectious emergencies of the lower urinary tract and genital organs. METHODS: A narrative synthesis of the articles (French, English) available on the Pubmed database was carried out in June 2021. A request to the health surveillance network for emergencies and deaths (SurSaUD®, Santé Publique France) revealed original data on the epidemiology of non-infectious lower urinary tract and genital organs emergencies. RESULTS: Non-infectious emergencies of the low urinary tract and genital organs represent a large panel of traumatic and non-traumatic situations, which constitute the 3rd reasons in urology for a consultation at the emergency department after, infectious disease (1st) and non-traumatic/non-infectious emergencies of the upper urinary tract (2nd). Hematuria is the 3rd urological reason for men for a consultation at the emergency department. Globally, pelvic trauma and genital traumatism mainly concern men. These emergencies rarely affect the prognosis but can be integrated into more complete situations which are likely to impact their treatment, particularly in multiple traumas. CONCLUSIONS: In this article we report the epidemiology and the principles of management of non-infectious emergencies of the lower urinary tract and genital organs.

[The urologist confronted with a mass killing]. / Le chirurgien urologue face à une tuerie de masse.

INTRODUCTION: Following the Paris attacks in 2015, the French hospital system has had to organize itself in mass casualties of serious injuries, especially hemorrhagic shock. Recent experience shows that the first flow of casualties is spontaneously directed to the structure closest to the events, whether it is suitable or not. Any surgeon can face such a crisis regardless of their practice structure, because terrorist attacks are unpredictable. The urologist must anticipate the responsibilities that they might be forced to shoulder in such a situation. MATERIAL AND METHOD: A systematic literature review based on PubMed, Embase and Google Scholar was conducted between January 2000 and June 2021. RESULTS: In addition to a coordinator role, reserved for the most experienced, his visceral surgical expertise would allow a urologist to apply damage control (DC) at each stage. We describe here the principles of DC, in particular the DC laparotomy including its strategy concerning genitourinary lesions. DISCUSSION: Whatever his role (sorter, organizer, technician) in the management of a mass casualties of hemorrhagic injuries, an urologist has to know the principles of DC. A damage control laparotomy (stage 1 of DC) requires the urologist surgeon to never seek to perform a primary reconstruction procedure but to favor speed and efficiency (both on the hemostatic and urostatic side) to lead the injured patient stabilized to faster in intensive care unit (stage 2). Revision surgery called "definitive surgical management" (stage 3) will be performed anyway at the end of this period.

[Rare emergencies in urology]. / Les urgences rares en urologie.

INTRODUCTION: The aim of this article was to cite rare but sometimes serious emergencies that may be encountered by any urologist during their practice, and to outline the main principles of their management. MATERIAL AND METHOD: A systematic review of the literature using PubMed, Embase and Google Scholar was carried out between January 2000 and June 2021. The articles obtained were selected according to their age and type. The original articles, meta-analyses, recommendations and the most recent journal articles published in French and English have been retained. A total of 312 articles were identified and 58 selected from their abstracts. The articles were then analysed exhaustively by the authors, and 24 references were finally selected. RESULTS: Several rare emergencies of an infectious nature (xanthogranulomatous pyelonephritis, emphysematous cystitis and pyelonephritis, malacoplasia, hydatiduria), ischemic nature (Fournier's gangrene, penile calciphylaxis), or hemorrhagic nature (hemospermia, hemorrhages of the upper urinary tract or adrenal gland spontaneous hematoma), or at the origin of painful manifestations (spermatic colic, venous thrombosis of the penis), can pose diagnostic and therapeutic difficulties, in the absence of consensus concerning their management. CONCLUSION: These pathologies, rare but sometimes serious, must be recognized in order to not delay the treatment and to be able to reduce their morbidity and mortality. Combined with the constant improvement of our diagnostic and therapeutic arsenal, a better knowledge of these rare emergencies will help to preserve the functional and vital prognosis of patients.

Radiation dose and magnification in pelvic X-ray: EOS™ imaging system versus plain radiographs.

BACKGROUND: In plain pelvic X-ray, magnification makes measurement unreliable. The EOS™ (EOS Imaging, Paris France) imaging system is reputed to reproduce patient anatomy exactly, with a lower radiation dose. This, however, has not been assessed according to patient weight, although both magnification and irradiation are known to vary with weight. We therefore conducted a prospective comparative study, to compare: (1) image magnification and (2) radiation dose between the EOS imaging system and plain X-ray. HYPOTHESIS: The EOS imaging system reproduces patient anatomy exactly, regardless of weight, unlike plain X-ray. MATERIAL AND METHOD: A single-center comparative study of plain pelvic X-ray and 2D EOS radiography was performed in 183 patients: 186 arthroplasties; 104 male, 81 female; mean age 61.3±13.7years (range, 24-87years). Magnification and radiation dose (dose-area product [DAP]) were compared between the two systems in 186 hips in patients with a mean body-mass index (BMI) of 27.1±5.3kg/m2 (range, 17.6-42.3kg/m2), including 7 with morbid obesity. RESULTS: Mean magnification was zero using the EOS system, regardless of patient weight, compared to 1.15±0.05 (range, 1-1.32) on plain X-ray (P<10-5). In patients with BMI<25, mean magnification on plain X-ray was 1.15±0.05 (range, 1-1.25) and, in patients with morbid obesity, 1.22±0.06 (range, 1.18-1.32). The mean radiation dose was 8.19±2.63dGy/cm2 (range, 1.77-14.24) with the EOS system, versus 19.38±12.37dGy/cm2 (range, 4.77-81.75) with plain X-ray (P<10-4). For BMI >40, mean radiation dose was 9.36±2.57dGy/cm2 (range, 7.4-14.2) with the EOS system, versus 44.76±22.21 (range, 25.2-81.7) with plain X-ray. Radiation dose increased by 0.20dGy with each extra BMI point for the EOS system, versus 0.74dGy for plain X-ray. CONCLUSION: Magnification did not vary with patient weight using the EOS system, unlike plain X-ray, and radiation dose was 2.5-fold lower. LEVEL OF EVIDENCE: 3, prospective case-control study.

Can a target zone safer than Lewinnek's safe zone be defined to prevent instability of total hip arthroplasties? Case-control study of 56 dislocated THA and 93 matched controls.

BACKGROUND: Various factors contribute to instability of total hip arthroplasty (THA), with implant orientation being a major contributor. We performed a case-control study with computed tomography (CT) data to determine whether: 1) orientation contributes to THA instability and 2) a safer target zone for stability than Lewinnek's classic safe zone can be defined. MATERIAL AND METHODS: We included prospectively 363 cases of THA dislocation that occurred during the calendar 2013 year in 24 participating hospitals. Of the 128 dislocations that occurred in patients who underwent THA at these centers, 56 (24 anterior, 32 posterior) had CT scans, thus were included in the analysis. The control group was matched 4:1 based on implant type, year of implantation, age, sex, bearing types and THA indication. Of the 428 matched control THA cases, 93 had CT scans. In all, the CT scans from 149 cases (56 unstable, 93 stable) were analyzed to determine the acetabular cup's inclination and anteversion, and the femoral stem's anteversion. RESULTS: In the unstable THA group, cup inclination was 46.9°±7.4°, cup anteversion was 20.4°±10.8° and stem anteversion was 14.2°±9.9°. In the stable THA group, cup inclination was 44.9°±5.3° (P=0.057), cup anteversion was 22.1°±5.1° (P=0.009) and stem anteversion was 13.4°±4.4° (P=0.362). The optimal total anteversion (cup+stem) of 40-60° was achieved in 16.5% of unstable THA cases and 13.9% of stable THA cases, thus this parameter does not predict stability (odds ratio [OR] of 0.40, P=0.144). The cup was positioned in Lewinnek's safe zone in 44.6% of patients in the unstable group and 68.2% of those in the stable group (OR 3.74, P=0.003). A target zone defined as 40-50° inclination and 15-30° anteversion was better able to distinguish between unstable cases (23.2%) and stable cases (71.6%) resulting in an OR of 13.91 (P<0.001). DISCUSSION: Implant positioning was the only risk factor for instability found in this study. Moreover, our findings reinforce the theory put forward by other authors that Lewinnek's safe zone is not specific enough to differentiate between stable and unstable THA implantations. The target zone for acetabular cups proposed here (40-50° inclination and 15°-30° anteversion) is related to a lower risk of instability. This orientation can be used as a guide, but must be combined with other technical elements to optimize stability. By balancing stability and biomechanics, the 40-50° inclination and 15°-30° anteversion target zone redefines the optimal positioning window. LEVEL OF EVIDENCE: III case-control study.

Cryotherapy With Dynamic Intermittent Compression Improves Recovery From Revision Total Knee Arthroplasty.

BACKGROUND: The goal of this study was to assess the efficacy of cryotherapy with dynamic intermittent compression (CDIC) in relieving postoperative pain, decreasing blood loss, and improving functional scores after revision total knee arthroplasty (rTKA). METHODS: We conducted a prospective case-control study (level of evidence: I) to evaluate the efficacy of CDIC on postoperative bleeding, pain, and functional outcomes after rTKA. Forty-three cases were included at a single institution and divided in 2 groups: a control group without CDIC (n = 19) and an experimental group with CDIC (n = 24). Bleeding was evaluated by calculating total blood loss, pain at rest was evaluated with a visual analog scale on postoperative day 3, and function was assessed using the Oxford score at 6 months postoperatively. The comparative analysis was performed using the Fisher exact test. RESULTS: The CDIC group had significantly lower total blood loss (260 vs 465 mL; P < .05), significantly less pain on day 3 (1 vs 3; P < .05), and a significantly higher functional score (42 vs 40; P < .05) than the control group. CONCLUSION: This is the first report dealing with the use of CDIC after rTKA. According to our results, it improves the recovery of patients who underwent rTKA; thus, it should be integrated into our daily practice.

Microbial flora on cell-phones in an orthopedic surgery room before and after decontamination.

INTRODUCTION: Cell-phones are the typical kind of object brought into the operating room from outside by hospital staff. A great effort is made to reduce the level of potentially contaminating bacteria in the operating room, and introducing these devices may run counter to good practice. The study hypothesis was that cell-phones are colonized by several strains of bacteria and may constitute a source of nosocomial contamination. The main study objective was to screen for bacterial colonies on the surfaces of cell-phones introduced in an orthopedic surgery room. The secondary objective was to assess the efficacy of decontamination. MATERIAL AND METHOD: Samples were taken from the cell-phones of hospital staff (surgeons, anaesthetists, nurses, radiology operators, and external medical representatives) entering the operating room of the university hospital center orthopedic surgery department, Toulouse (France). Sampling used Count Tact® contact gel, without wiping the phone down in advance. Both sides of the phone were sampled, before and after decontamination with a pad imbibed with 0.25% Surfanios® Premium disinfectant. A nasal sample was also taken to investigate the correlation between Staphylococcus aureus in the nasal cavities and on the cell-phone. RESULTS: Fifty-two cell-phones were sampled. Before decontamination, the mean number of colony-forming units (CFU) was 258 per phone (range, 0-1,664). After decontamination, it was 127 (range, 0-800) (P=0.0001). Forty-nine cell-phones bore CFUs before decontamination (94%), and 39 after (75%) (P=0.02). DISCUSSION: Cell-phones are CFU carriers and may thus lead to contamination. Guidelines should be drawn up to encourage cleaning phones regularly and to reduce levels of use within the operating room.

Is the prognosis the same for periprosthetic joint infections due to Staphylococcus aureus versus coagulase-negative staphylococci? A retrospective study of 101 patients with 2-year minimum follow-up.

BACKGROUND: Staphylococcus aureus (SA) and Coagulase-negative staphylococci (CoNS) are often responsible for infections of total hip arthroplasty (THA) and total knee arthroplasty (TKA). One of the main differences between these two microorganisms is their virulence, with SA presumed to be more virulent; however, few studies have specifically investigated the impact of this virulence. This inspired us to carry out a retrospective study to evaluate whether the healing rate differed between SA and CoNS infections. HYPOTHESIS: We hypothesised that the healing rate is lower for SA prosthetic joint infections. MATERIALS AND METHODS: This was a retrospective study of 101 consecutive Staphylococcus infection cases that occurred between 2007 and 2011. There were 56 men and 45 women with an average age of 69 years (range 23-95). The infection was associated with TKA in 38 cases and THA in 63 cases. Thirty-two percent of patients had one or more comorbidities with infectious potential. In our cohort, there were 32 SA infections (31.7 %) and 69 CoNS infections (68.3 %) with 58 of the infections being methicillin-resistant (15 SA and 43 CoNS); there were 27 polymicrobial infections (26.7 %). RESULTS: With a minimum 24-month follow-up after the end of antibiotic treatment, the healing rate was 70.3 % overall (71 patients). The healing rate was 75 % in the SA group (24 patients) versus 68.1 % (47 patients) in the CoNS group (P = 0.42). CONCLUSION: Our hypothesis was not confirmed: the healing rate of SA prosthetic joint infections was not lower than that of CoNS infections. LEVEL OF EVIDENCE: III, retrospective case-control study.

Penetrating pelvic trauma: Initial assessment and surgical management in emergency.

Penetrating pelvic trauma (PPT) is defined as a wound extending within the bony confines of the pelvis to involve the vascular, intestinal or urinary pelvic organs. The gravity of PPT is related to initial hemorrhage and the high risk of late infection. If the patient is hemodynamically unstable and in hemorrhagic shock, the urgent treatment goal is rapid achievement of hemostasis. Initial strategy relies on insertion of an intra-aortic occlusion balloon and/or extraperitoneal pelvic packing, performed while damage control resuscitation is ongoing before proceeding to arteriography. If hemodynamic instability persists, a laparotomy for hemostasis is performed without delay. In a hemodynamically stable patient, contrast-enhanced CT is systematically performed to obtain a comprehensive assessment of the lesions prior to surgery. At surgery, damage control principles should be applied to all involved systems (digestive, vascular, urinary and bone), with exteriorization of digestive and urinary channels, arterial revascularization, and wide drainage of peri-rectal and pelvic soft tissues. When immediate definitive surgery is performed, management must address the frequent associated lesions in order to reduce the risk of postoperative sepsis and fistula.

Grade IV renal trauma management. A revision of the AAST renal injury grading scale is mandatory.

INTRODUCTION: The AAST renal injury grading scale is currently the most important variable predicting the need for kidney repair or removal, morbidity and mortality after blunt or penetrating kidney injuries. The 2011 revised version included renal pelvis, uretero-pelvic junction and segmental vascular injuries as grade IV, limiting grade V to severe hilar injuries. However, patients requiring surgery cannot be properly identified because of hemodynamic instability due to grade IV renal injuries. This study proposes an add-on for the AAST grade IV renal injury scale to improve the management of these patients. METHOD: We searched the Medline and Scopus databases up to September 2014. Searches were not restricted by date, language or publication status. Pediatric studies were excluded. RESULTS: 71 articles were found, 57 were pertinent, including 6 directly related to the topic. 3 risk factors were identified to be associated with surgery for hemodynamic instability: perirenal hematoma >3.5 cm, intravascular contrast extravasation and medial renal laceration. Presence of two or more of these criteria has been validated in two other studies to predict the need for intervention. Patients with >25 % devascularized fragments also have poor prognosis and should be treated more aggressively. CONCLUSION: These elements should be included in future classification reassessment to efficiently determine the time for surgery in grade IV renal traumas, generally leading to nephrectomy.

Total hip arthroplasty survival in femoral head avascular necrosis versus primary hip osteoarthritis: Case-control study with a mean 10-year follow-up after anatomical cementless metal-on-metal 28-mm replacement.

BACKGROUND: Total hip arthroplasty is the most widely used procedure to treat avascular necrosis (AVN) of the femoral head. Few studies have compared the outcomes of THA in femoral head AVN and primary hip osteoarthritis. Therefore we performed a case-control study to compare THA for femoral head AVN vs. primary hip osteoarthritis in terms of: (1) prosthesis survival, (2) complication rates, (3) functional outcomes and radiographic outcomes, (4) and to determine whether specific risk factors for THA failure exist in femoral head AVN. HYPOTHESIS: THA survival is similar in femoral head AVN and primary hip osteoarthritis. MATERIAL AND METHODS: We compared two prospective cohorts of patients who underwent THA before 65 years of age, one composed of cases with femoral head AVN and the other of controls with primary hip osteoarthritis. In both cohorts, a cementless metal-on-metal prosthesis with a 28-mm cup and an anatomical stem was used. Exclusion criteria were THA with other types of prosthesis, posttraumatic AVN, and secondary osteoarthritis. With α set at 5%, to obtain 80% power, 246 patients were required in all. Prosthesis survival was assessed based on time to major revision (defined as replacement of at least one implant fixed to bone) and time to aseptic loosening. The other evaluation criteria were complications, Postel-Merle d'Aubigné (PMA) score, and the Engh and Agora Radiographic Assessment (ARA) scores for implant osseointegration. RESULTS: The study included 282 patients, 149 with AVN and 133 with osteoarthritis. Mean age was 47.8±10.2 years (range, 18.5-65) and mean follow-up was 11.4±2.8 years (range, 4.5-18.3 years). The 10-year survival rates were similar in the two groups: for major revision, AVN group, 92.5% (95% confidence interval [95% CI], 90.2-94.8) and osteoarthritis group, 95.3% (95% CI, 92.9-97.7); for aseptic loosening, AVN group, 98.6% (95% CI, 97.6-98.6) and osteoarthritis, 99.2% (95% CI, 98.4-100). The AVN group had higher numbers of revision for any reason (19 vs. 6, P=0.018) and for dislocation (8 vs. 1, P=0.031). Mean PMA scores at last follow-up were comparable in the AVN group (17.65±1.27 [range, 10-18]) and osteoarthritis group (17.59±1.32 [range, 14-18]) (P=0.139). Osseointegration was also similar in the two groups: global Engh score, 26.51±1.81 (range, 14-27) for AVN and 26.84±0.91 (range, 19.5-27) for osteoarthritis (P=0.065); femoral ARA score, 5.83±0.46 (range, 3-6) for AVN and 5.90±0.42 (range, 3-6) for osteoarthritis (P=0.064); and cup ARA score, 5.74±0.67 (range, 3-6) for AVN and 5.78±0.66 (range, 3-6) for osteoarthritis (P=0.344). DISCUSSION: Survival in this study was good and consistent with recent data on AVN, with no difference between AVN and osteoarthritis. Revisions for any cause or for dislocation were more common after THA for AVN. Functional outcomes were similar in the AVN and osteoarthritis groups. An anatomical cementless prosthesis combined with metal-on-metal 28-mm bearing provides durable good outcomes. LEVEL OF EVIDENCE: III, non-randomized comparison of two prospective cohorts.

[Use of French version of Ureteral Stent Symptom Questionnaire for tolerance evaluation of ureteral double J-stent]. / Évaluation de la tolérance de la sonde JJ par l'utilisation de l'autoquestionnaire USSQ.

OBJECTIVES: To evaluate the quality of life of the holders of a ureteral double J stent (US) using the USSQ questionnaire (Ureteral Stent Symptom Questionnaire), validated in French in 2010. METHODS: Between January 2009 and December 2011, 249 patients underwent flexible ureteroscopy for urolithiais in our service. Among them, 160 received a US in perioperative, and they were sent self-questionnaire USSQ-FR retrospectively. The questionnaire includes 38 questions, concerning the perioperative period with US, and 4 weeks after its removal, grouped into 6 sections: urinary symptoms, pain, general health, professional resounding, sexual resounding, and other problems. A subgroup analysis was performed, comparing US used in emergency and planned US, active patients or retired, male or female. Statistical analysis used the Chi(2) test for paired data, the Fisher exact test and the Kruskal Wallis test. RESULTS: Of the 157 questionnaires sent (two patients who died, one mentally retarded), we obtained 80 responses. Quality of life appears to be significantly altered in all areas explored by the questionnaire. Urinary symptoms: 26.9 versus 19.9 score (P<0.0001), pain: 16.1 versus 10.7 (P=0.003), general health: 13.9 versus 9.1 (P<0.0001), professional practice: 6.1 versus 3.6 (P=0.0002), female: 3.3 versus 1.8 (P=0.001). There was no significant difference if the US was placed in emergency or programmatically, if patients were professionally active or retired. In addition, women had a significantly impaired quality of life compared to men for urinary symptoms, general health and professional practice. CONCLUSION: US are responsible for a significant impairment of quality of life for patients. The validated, self-administered, USSQ-FR questionnaire is a reliable tool for this evaluation. LEVEL OF EVIDENCE: 5.

45°-45°-30°Frog-leg radiograph for diagnosing cam-type anterior femoroacetabular impingement: Reproducibility and thresholds.

BACKGROUND: The many radiographic views suggested for evaluating anterior femoroacetabular impingement (FAI), due to a cam effect, are not specific for this condition and have not been proven of diagnostic value in studies, including control groups. Using a new and specific radiographic view, we evaluated the reproducibility of the main radiographic criteria for FAI, determined normal values for these criteria in a control group, and established diagnostic threshold values. HYPOTHESIS: This specific view offers good reproducibility and effectively detects abnormal values of criteria for FAI. MATERIALS AND METHODS: Inter-observer and intra-observer reproducibility of specific radiographic criteria (αangle and modified head-neck offset [HNO]) were computed from preoperative and postoperative radiographs of 96 hips (75 patients, 61 males and 14 females) using the specific 45°-45°-30° frog-leg view (F45 view). Values in the group with FAI were compared to those in a control group of asymptomatic volunteers (100 hips, 27 males and 23 females). RESULTS: Inter-observer and intra-observer reproducibility was very good, with intra-class correlation coefficients of 0.955and 0.987, respectively, for the α angle and of 0.895 and 0.984, respectively, for the HNO. Mean values of both parameters differed significantly between the FAI and control groups: 73.9° (53° to 96°) vs. 49.3° (35° to 69°) for the αangle, respectively; and 2.5mm (-4.6 to 9.4) vs. 7.6mm (1.7 to 11.8) for HNO, respectively. The normal values defined as the boundary of the 95% reference interval in the control group were<60.2° for the α angle, and>4.6mm for the HNO. DISCUSSION: The45°-45°-30° frog-leg view is useful for diagnosing FAI due to a cam effect. This view is easy to perform, and the thresholds determined in our study assist in its interpretation: α angle values>58° in females and>63° in males indicate cam-type femoral geometry. In both genders, HNO values<5mm support a diagnosis of anterior FAI. LEVEL OF EVIDENCE: Level III, case-control study.

Recurring intraprosthetic dislocation of rotating-hinge total knee prosthesis. Effect of implant design on intrinsic stability.

During total knee replacement, hinged total knee implants are used in cases where ligament balancing cannot be achieved with less-constrained implants. The case of a patient who experienced two episodes of intraprosthetic dislocation of his rotating-hinge total knee prosthesis is described. There are very few reports of this type of dislocation with these implants. The implant's design, particularly of the hinge, plays an important role in stability. The balance between the flexion and extension spaces is very important even when using a hinged total knee implant. The role of the extensor mechanism in anteroposterior stability is reviewed, along with simple ways to augment it.

Minimally invasive medial hip approach.

The medial approach to the hip via the adductors, as described by Ludloff or Ferguson, provides restricted visualization and incurs a risk of neurovascular lesion. We describe a minimally invasive medial hip approach providing broader exposure of extra- and intra-articular elements in a space free of neurovascular structures. With the lower limb in a "frog-leg" position, the skin incision follows the adductor longus for 6cm and then the aponeurosis is incised. A slide plane between all the adductors and the aponeurosis is easily released by blunt dissection, with no interposed neurovascular elements. This gives access to the lesser trochanter, psoas tendon and inferior sides of the femoral neck and head, anterior wall of the acetabulum and labrum. We report a series of 56 cases, with no major complications: this approach allows treatment of iliopsoas muscle lesions and resection or filling of benign tumors of the cervical region and enables intra-articular surgery (arthrolysis, resection of osteophytes or foreign bodies, labral suture).

The frequency of sequelae of slipped upper femoral epiphysis in cam-type femoroacetabular impingement.

Slipped upper femoral epiphysis (SUFE) is one of the known causes of cam-type femoroacetabular impingement (FAI). The aim of this study was to determine the proportion of FAI cases considered to be secondary to SUFE-like deformities. We performed a case-control study on 96 hips (75 patients: mean age 38 years (15.4 to 63.5)) that had been surgically treated for FAI between July 2005 and May 2011. Three independent observers measured the lateral view head-neck index (LVHNI) to detect any SUFE-like deformity on lateral hip radiographs taken in 45° flexion, 45° abduction and 30° external rotation. A control group of 108 healthy hips in 54 patients was included for comparison (mean age 36.5 years (24.3 to 53.9). The impingement group had a mean LVHNI of 7.6% (16.7% to -2%) versus 3.2% in the control group (10.8% to -3%) (p < 0.001). A total of 42 hips (43.7%) had an index value > 9% in the impingement group versus only six hips (5.5%) in the control group (p < 0.001). The impingement group had a mean α angle of 73.9° (96.2° to 53.4°) versus 48.2° (65° to 37°) in the control group (p < 0.001). Our results suggest that SUFE is one of the primary aetiological factors for cam-type FAI.