Reproducibility of the Mayo and Schatzker classification systems in proximal ulna fractures.

INTRODUCTION: A fracture classification system should provide a reliable and reproducible means of communication between different parties. It should be logical and understandable, with few categories to memorize. The aim of this study was to determine the intra- and interobserver reliability of the Schatzker and Mayo classification systems for the assessment of proximal ulna fractures. MATERIALS AND METHODS: Intra- and interobserver reliability studies were conducted on 39 X-rays of injured elbows drawn randomly from 74 cases previously used in a series on predictors of ulnohumeral osteoarthritis in proximal ulna fractures. Ten observers independently reviewed these X-rays on 2 separate occasions 3 months apart. The fracture type was assessed according to the Schatzker and Mayo classification systems during each reading session. Cohen's and Fleiss' kappa were used to measure the intra- and interobserver reliability. RESULTS: The Schatzker classification had a fair interobserver reliability for the first (Schatzker R1, Fleiss' κ: 0.394) and second (Schatzker R2, Fleiss' κ: 0.351) readings. The mean intraobserver reliability value between the 10 reviewers for the Schatzker classification was rated as substantial (0.61). The Mayo classification had a fair interobserver reliability for the first (Mayo R1, Fleiss' κ: 0.278) and second (Mayo R2, Fleiss' κ: 0.292) readings. The mean intraobserver reliability value between the 10 reviewers for the Mayo classification was rated as fair (0.52). DISCUSSION: The classification systems for proximal ulna fractures showed poor reproducibility between the different observers since they had low interobserver agreement values. Nevertheless, their use remained reliable since the measured intraobserver agreement value was deemed substantial. LEVEL OF EVIDENCE: IV; retrospective.

One-stage revision hip arthroplasty for infection using primary cementless stems as first-line implants: About 35 cases.

INTRODUCTION: During infected total hip arthroplasty revisions (THAR), the need for systematic antibiotic cementation remains undefined. HYPOTHESIS: Implantation of a primary cementless stem as first-line implant in 1-stage septic THAR provides results as good as those from a stem cemented with antibiotics in terms of infection resolution. MATERIALS AND METHODS: We retrospectively examined 35 patients operated on for septic THAR with Avenir® cementless stem placement - between 2008 and 2018 at Besançon University Hospital - with a minimum follow-up of 2 years to define healing in the absence of infectious recurrence. Clinical outcomes were assessed using the Harris, Oxford, and Merle D'Aubigné scores. Osseointegration was analyzed by the Engh radiographic score. RESULTS: The median follow-up was 5±2.6 years (2-11). The infection was cured in 32 of 35 (91.4%) patients. The median scores of the following were: Harris 77/100, Oxford 47.5/60 and Merle d'Aubigné 15/18. Of 32 femoral stems, 31 (96.8%) had radiographically stable osseointegration. Age greater than 80 years was a risk factor for failure to cure the infection during septic THAR. DISCUSSION: A primary cementless stem as first-line implant plays a role in 1-stage septic THAR. It confers good results in terms of infection resolution and stem integration in the setting of loss of femoral bone substances rated Paprosky 1. LEVEL OF EVIDENCE: IV; retrospective case series.

Has the COVID lockdown altered the incidence and management of fragility fractures in older adults? Case-control study at a French University Hospital.

INTRODUCTION: In France, a national lockdown related to the COVID-19 pandemic was imposed from March 17 to May 11, 2020, drastically changing our professional and organizational practices. We were interested on the impact of the lockdown on fragility fractures in older adults (65 years and older). The primary objective of this study was to evaluate the incidence of peripheral and pelvic fragility fractures during the lockdown. The secondary objectives were to carry out an epidemiological analysis of the fractures, treatments and hospitalization data. HYPOTHESIS: The main hypothesis was that the number of peripheral and pelvic fragility fractures was lower during the lockdown in 2020 than in the same (non-lockdown) period in 2019. MATERIALS AND METHODS: We retrospectively collected epidemiological (age, sex), clinical (type of fracture, treatment) and hospitalization data from patients 65 years and older who came to the emergency room because of a peripheral and/or pelvic fracture between March 17 and May 11 of the years 2019 and 2020. RESULTS: We included 192 patients in 2019 and 157 patients in 2020. The mean age and sex ratio were not statistically different. The number of peripheral and/or pelvic fragility fractures decreased by 16%. The share of patients treated surgically was similar in both years (46% in 2019; 51% in 2020 (p=0.47)). The number of proximal femur fractures dropped by 21%. The mean time to surgery for these fractures was shorter in 2020 (p=0.02) although the mean length of hospital stay was unchanged (p=0.72) The mortality rate of patients hospitalized for fragility fractures did not increase significantly (p=0.51). DISCUSSION: We observed a reduction in the number of peripheral and pelvic fragility fractures in patients 65 years and older during the lockdown. To ensure that we met our goals of optimal care for proximal femur fractures, a general reorganization of the operating room was necessary. The continued availability of fully functional technical facilities despite this health crisis was crucial to being able to treat these fractures and to prevent increased mortality. LEVEL OF EVIDENCE: III, case-control study.

Prone Positioning for Severe Acute Respiratory Distress Syndrome in COVID-19 Patients by a Dedicated Team: A Safe and Pragmatic Reallocation of Medical and Surgical Work Force in Response to the Outbreak.

OBJECTIVE: The aim of this study was to define whether rapidly reallocating health care workers not experienced with PP for performing PP in ICU is feasible and safe. SUMMARY BACKGROUND DATA: In the setting of severe acute respiratory distress syndrome (ARDS), the use of prone and supine positioning procedures (PP) has been associated with improved oxygenation resulting in decreased mortality. Nevertheless, applying PP is time consuming for ICU staffs that are at risk of mental of physical exhaustion, especially with the constant surge of admitted COVID-19 patients with severe ARDS. METHODS: This prospective cohort study conducted at a single regional university hospital between March 27 and April 15, 2020. Among 117 patients admitted to ICU, 67 patients (57.3%) presented with proven SARS-CoV-2 infection with severe ARDS requiring PP. After accelerated simulation training, 109 volunteers including surgeons, physicians, nurses and physiotherapists, multiple dedicated teams performed daily multiple PP following a systematic checklist. Patient demographics and PP data were collected. Patient safety and health care workers safety were assessed. RESULTS: Among 117 patients admitted to ICU, 67 patients (57.3%) required PP. Overall, 53 (79%) were male, with a median age of 68.5 years and median body mass index of 29.3 kg/m. A total of 384 PP were performed. Overall, complication occurred in 34 PP (8.8%) and led to PP cancelation in 4 patients (1%). Regarding health care workers safety, four health care workers presented with potential COVID-19 related symptoms and none was positive. CONCLUSIONS: To overcome the surge of critically ill COVID-19 patients, reallocating health care workers to targeted medical tasks beyond their respective expertise such as PP was safe.

Plate fixation of distal radius fracture and related complications.

INTRODUCTION: Distal radius fractures are common. In cases where surgical treatment is needed, volar plates can be used to obtain stable, long-lasting fixation. The design of these plates has continually improved over the years, but complications remain a problem. PURPOSE: The goal of this study was to evaluate the types of complications that occur with different types of volar plates with a view towards preventing them. MATERIALS AND METHODS: The emergency department at our hospital saw 524 patients with distal radius fractures between 2006 and 2008. Some of these were treated surgically with a volar plate. All of the post-operative complications were documented. RESULTS: With a minimum follow-up of 6 months, 152 patients who had undergone plate fixation were reviewed: 31 had received plates with non-locking screws or uniaxial locking screws and 121 had received plates with polyaxial locking screws. The complication rate was similar in these two groups (16.1 and 16.5%, respectively). The main complications were tendon ruptures and problems related to the plate itself. DISCUSSION: Plate-related complications have been described in published studies, but few of these studies link them to the plate design or surgical technique. Manufacturers must continue to refine these plates to minimise their thickness while keeping their strength. Surgeons must be sure to use a highly exacting technique.

Can preoperative CRP levels predict infections of bipolar hemiarthroplasty performed for femoral neck fracture? A retrospective, multicenter study.

INTRODUCTION: Current recommendations urge us to operate quickly on femoral neck fractures to reduce the risk of comorbidity decompensation. In some cases, this leads us to operate when an underlying infection is present. In this study, we evaluated the infection rate of bipolar hemiarthroplasty after femoral neck fracture and attempted to relate it to preoperative C-reactive protein (CRP) levels. MATERIALS AND METHODS: The infection rate of bipolar hemiarthroplasty was evaluated in a dual-center, retrospective study of 260 patients over a 2-year period. During the first year, the preoperative CRP levels were not taken into account when scheduling the procedure. During the second year, if preoperative CRP levels were above 50 mg/L, the procedure was delayed to look for and treat any ongoing infections. RESULTS: The overall periprosthetic infection rate in this study was 4.85 % (range 4.8-4.9), with 33 % of patients passing within 1 year due to the infection. In the group where CRP was not taken into consideration, 59 of the 143 operated away patients (41 %) had their preoperative CRP levels measured. Twenty-nine of these patients had CRP > 50 mg/L when they were operated. Of the seven infections in the group, one patient had CRP > 50 mg/L, two had CRP < 50 mg/L, and four patients did not have preoperative CRP levels measured. In the group where CRP was taken into consideration, 104 of the 117 patients (89 %) had their preoperative CRP assessment. Thirty of these patients had CRP > 50 mg/L upon admission; their procedure was delayed to determine the etiology of this CRP elevation. No cause was found in 16 of these 30 patients, and they were operated despite having CRP > 50 mg/L. There were five infections in this group: four patients had CRP > 50 mg/L and were treated accordingly; one patient had preoperative CRP < 50 mg/L. In patients where the preoperative CRP levels were taken into account, the delay before surgery was twice as long as those where CRP levels were not considered. DISCUSSION: C-reactive protein (CRP) level alone is not a good preoperative predictive factor for periprosthetic joint infection, although 80 % of the patient with an infected bipolar hemiarthroplasty had CRP > 50 mg/L upon admission. The increased delay due to the CRP analysis is not without consequence for this cohort. Two previous studies have looked into the predictive ability of CRP levels, but these involved scheduled surgical procedures. CONCLUSION: This study could not validate the use of CRP levels, nor a 50 mg/L threshold, as predictive factors for a preexisting infection during bipolar hemiarthroplasty for femoral neck fracture. As a consequence, new infection screening tools must be developed and validated.

Cementless total knee arthroplasty in chronic inflammatory rheumatism.

INTRODUCTION: We report a short-term monocentric retrospective evaluation of cementless total knee arthroplasty (TKA) in a population suffering from chronic inflammatory rheumatism. MATERIALS AND METHODS: We have reviewed 23 patients (34 knees) with an average age of 55 years (range 26-78), bearing a TKA for chronic inflammatory rheumatisms with a 6-year follow-up (range 3-12); 78% suffered from rheumatoid arthritis and 15% from juvenile rheumatoid arthritis. We used a cementless total prosthesis sacrificing the posterior cruciate ligament and bearing an ultra-congruent rotational tibial insert, the Natural Knee (NK2™) (Zimmer(®), Warsaw, IN, USA). At last follow-up, an independent surgeon performed a clinical assessment for pain, function and quality of life using International Knee Documentation Committee score, International Knee Society (IKS) score and Devane's score. A radiographic study evaluated secondary fixation according to the radiographic index of the Knee Society and according to Ewald's score. RESULTS: The mean postoperative IKS score was 83 points (range 40-100) for the knee score and 74 points (range 20-100) for the function score. Radiographic assessment came across only one case of loosening, concerning the tibial component on an asymptomatic patient. We came across the following complications: 1 early infection, 2 important postoperative flessum deformity having needed an arthrolysis, 1 supracondylar fracture of the femur and 1 fracture of the patellar component. Survival rate at 6-year follow-up is 97% taking into account one case of revision. CONCLUSION: Non-cementation of this implant in chronic inflammatory rheumatism does not result in a higher rate of loosening. In this series, patients own satisfaction, function of the knee and survival rate are rather good. LEVEL OF EVIDENCE: Retrospective, no control group, Level IV.

[Articular reconstructions by a costochondral grafting (or osteochondral costal grafting)]. / Utilisation du greffon cartilagineux (ou ostéocartilagineux) costal en reconstruction articulaire.

We describe a novel technique of costochondral autografting for the treatment of trapeziometacarpal arthritis, radioscaphoid osteoarthritis, malunion of the distal end of the radius, and osteoarticular loss of the MP joints of long fingers. The costal graft harvest technique is always the same. A 5-cm horizontal incision is made over the 9th rib, and the rib is exposed at the osteocartilaginous junction. Cartilaginous grafts are harvested with a scalpel, and osteocartilaginous grafts with a saw. Since 1992, 116 patients with trapezio-metacarpal arthritis have been treated by partial trapeziectomy and autologous rib cartilage grafting. One hundred patients were reviewed with an average follow-up of 5.6 years. The results were better than those of trapeziectomy with tendon interposition or ligamentous reconstruction, owing to good stability of the thumb ray height. For the treatment of radioscaphoid osteoarthritis following scaphoid non union or chronic scapholunate instability, partial carpal arthrodesis and resection of the first row are the classical techniques. As an alternative to these procedures, 18 patients were treated by resection of the proximal portion of the scaphoid and insertion of an osteochondral costal autograft. Mean follow-up is 4.1 years. The results are excellent or good in 15 cases, fair in 2 cases, and poor in 1 case (luxation of the graft). Four patients with articular malunion of the distal radius received an osteocartilaginous costal graft to reconstruct the articular surface of the radius while avoiding partial or total arthrodesis of the wrist. Four patients with segmental osteoarticular loss of the longfingers were treated with the same technique, thereby avoiding silicone arthroplasty. We review the literature on cartilaginous rib grafts in maxillofajcial and orthopaedic surgery. In our experience, MRI and biopsy show viable cartilage but also histologic changes such as revascularization, fibrous transformation and bone metaplasia.