Knee Ligament Sprains: Diagnosing Anterior Cruciate Ligament Injuries by Patient Interview. Development and Evaluation of the Anterior Cruciate Ligament Injury Score (ACLIS).

BACKGROUND: Knee ligament sprains are a common reason for emergency-room visits. Initially, the often difficult physical examination provides limited information, creating a risk of missing cruciate-ligament injuries, which can result in substantial functional impairments. No simple tool is available to emergency and primary-care physicians for decisions regarding specialist referral of patients with knee ligament sprains. An easy to use clinical score for the emergency setting would help identify patients at high risk of anterior cruciate ligament (ACL) tears after knee ligament sprains. The primary objective of this study, in two separate cohorts with acute knee injuries, was to develop, then validate a score for assessing the probability of ACL tear and, therefore, the need for specialist referral. HYPOTHESIS: A score based on patient-interview information with a cut-off associated to good sensitivity and positive predictive value (PPV) for ACL tears can be developed. MATERIAL AND METHODS: A literature review identified seven items to be used in the score: pivoting and contact activity at the time of injury, perceived cracking sound, sensation of dislocation, joint effusion, suggestive mechanism, inability to resume the activity, and immediate sensation of instability upon walking. To select the most relevant items, we recruited a development cohort of 228 patients (127 males and 101 females) with a mean age of 32±9 years who were seen for knee injuries between November 2017 and November 2018 at three healthcare institutions; 183 (80%) had ACL tears. The score was then tested in a validation cohort of 121 patients (79 males and 42 females) with a mean age of 28±2.5 years seen at two healthcare institutions between November 2019 and November 2020; 81 (67%) had ACL tears. In all patients, the diagnosis of ACL tear was confirmed by a specialist examination and magnetic resonance imaging. RESULTS: Four items proved both sensitive and specific for ACL injury and were combined into the score: an immediate sensation of knee instability, an inability to resume the sports activity, a sensation of dislocation, and injury during a pivoting-contact activity. Patient report of two or more of these four criteria had 96% sensitivity and 66% specificity for ACL tear, with a PPV of 91% and an NPV of 83%. Results were similar in the validation cohort, confirming that a cut-off of at least two of the four items strongly suggested an ACL tear, with 94% sensitivity, 56% specificity, a PPV of 82% and an NPV of 82%. CONCLUSION: The ACLIS score performs well for the emergency-room diagnosis of ACL tear, with 95% sensitivity, 62% specificity, an 88% PPV, and an 82% NPV. Patients with ACLIS scores of 2 or more probably require specialist referral with or without magnetic resonance imaging. The ACLIS score could be used routinely in emergency departments to decrease the proportion of patients with undiagnosed ACL tears. LEVEL OF EVIDENCE: III, prospective case-control study of a diagnostic score.

Is the economic and social cost of one-stage bilateral hip resurfacing lower than two-stage procedures? Retrospective case-control study of 260 hips.

BACKGROUND: Studies on the economic impact of medical practices and estimates of intra- and extra-hospital costs have an important role in controlling healthcare spending. But few studies of this nature have been done for bilateral surgery in a single operative session. This led us to carry out a health economics study to determine whether (1) bilateral hip resurfacing arthroplasty (HRA) performed in one stage instead of two stages will reduce the health care expenditures (costs of hospitalization, medical leave, rehabilitation), (2) it is equally safe for the patient. Hypothesis One-stage bilateral HRA is less costly for the health care system than two-stage bilateral resurfacing. METHODS: This was a single-center, single-surgeon retrospective cohort study comparing patients who underwent bilateral HRA in one stage (53 cases) or in two stages (77 cases). We determined the intra-hospital costs based on the French National Cost Scales and the extra-hospital costs (medical leave and rehabilitation), perioperative data (blood loss, operation time, duration of narcotic analgesic use, medical and surgical complications) and the outcomes with a mean follow-up of 4.8 years [1.7-10.1]. RESULTS: The total costs for the one-stage group (€16,840.94±7042.7) were significantly less than those of the two-stage group (€19,335.0±7296.9) (p=0.0101). The two groups were comparable except for the one-stage group having more primary hip osteoarthritis indications (72% (38/53)) than the two-stage group (49% (38/77)) (p=0.0111). The main differences between groups was the cost and duration of hospitalization, with cost of €10,546.06±2049.47 and average length of stay (ALS) of 9.83±2.19 days in the one-stage group and €13,569.49±2186.30, ALS=15.04±3.15 days in the two-stage group (p<0.0001). There was no significant difference in the length of medical leave: 67.15±50.36 (0-180) days for the one-stage group and 97.89±108.39 (0-730) days for the two-stage group (p=0.1933). CONCLUSION: Performing bilateral HRA during a single hospital stay results in lower health care expenditures than performing it during two separate hospital stays. Similar studies on other surgical procedures could help to promote the simultaneous nature of bilateral procedures and reset the current pricing, which is currently too low in the French health care system. LEVEL OF EVIDENCE: III, Retrospective case-control study.

Correlation between groin pain and cup design of hip-resurfacing implants: a prospective study.

PURPOSE: Cup design has been incriminated as the source of groin pain after hip resurfacing but has not been well described; thus, it was assessed in a prospective study looking at three implant types. METHODS: A group-match was done between three groups of hip resurfacing devices according to age, sex, body mass index, activity level, osteoarthritis aetiology and pre-operative scores. RESULTS: The global groin pain rate was 5.7 % at six months and 2.7 % at last follow-up. Groin pain rate was significantly different between the three groups (p = 0.004) and had a strong influence on the subjective results (p = 0.04). No groin pain emerged between six months and last follow-up. No clinical differences were noted in Harris hip score and Merle d'Aubigné-Postel score at last follow-up. However, the Oxford hip score and Devane activity score were significantly lower for cups with macrostructures. CONCLUSION: The low groin pain rate in this prospective cohort was probably secondary to the specific surgical technique used and seems to be correlated with cup design. Macrostructures on the external part of the cup could be significantly harmful.