Can the number of surgery delays and postponements due to unavailable instrumentation be reduced? Evaluating the benefits of enhanced collaboration between the sterilization and orthopedic surgery units.

INTRODUCTION: The development of outpatient surgery, cost-reduction pressures and instrumentation storage limitations have led to their use "just-in-time". A recent study showed that stoppage of surgical procedures immediately before the incision (No-Go) was often due to the management of supplies and implantable medical devices. To our knowledge, since the development of outpatient surgery and the shortening of hospital stays, managing the flow of instrumentation has not been optimized. At our hospital, we used a two-prong approach consisting of a tool to manage instrumentation and working group from the sterilization and orthopedic surgery units. The aims of this study were to: 1) evaluate whether this approach led to better notification of the risk of supply shortage for instrumentation and 2) determine whether it could reduce by at least half operating room disruptions such as delays or cancellation of surgical procedures. HYPOTHESIS: This approach results in better notification of the risk of supply shortage for instrumentation and reduces by at least half operating room disruptions such as delays or cancellation of surgical procedures. MATERIAL AND METHODS: A tool was developed to manage instrumentation flow based on a retrospective analysis of data from 2015. This tool consisted of: (1) a list of instrumentation needed for each surgical procedure from an analysis of the surgical schedule and verification of traceability labels of the instrumentation actually used, (2) a list of reasons for supply shortage identified from an analysis of non-conformities occurring in the sterilization process of instrumentation kits. These analyses resulted in the development of checklists for instrument sets for each procedure, while identifying those with a high risk of shortage. In 2017, a working group focused on instrumentation was set up with personnel from the sterilization unit and the orthopedic surgery unit. Based on the check-lists and the schedule 24hours before the surgery, the sterilization unit alerted the surgery unit by email of the risk of material shortage; the surgery ward replied with potential changes to the material or the surgery planning. This approach (instrumentation management tool and working group) was named just-in-time (JIT). The main outcome was the number of notifications of potential supply shortage with and without JIT over a 10-week period. The secondary outcomes were the number of notifications resolved in time and the occurrence of operating room disruptions (delay>30min or postponement of surgery) related to unavailable instrumentation. RESULTS: Nine reasons for potential supply shortage were identified such as instrumentation kits used for several types of procedures, those with fast rotation and low stock, or in double pathways (on loan and on deposit). The working group reported 163 potential shortages with JIT versus 41 without (p<10-5), of which 150 (92.5%) were resolved. Thirteen operating room disruptions occurred; only one was not detected by the JIT approach. CONCLUSION: Our JIT approach (instrumentation management tool and working group) is effective at preventing instrumentation supply shortages. LEVEL OF EVIDENCE: III, prospective comparative study.

Treatment of infected non-unions of the femur and tibia in a French referral center for complex bone and joint infections: Outcomes of 55 patients after 2 to 11 years.

INTRODUCTION: An infected non-union is a major complication following bone fracture. While bone union can be obtained in 70% to 100% of cases, treatment of osteomyelitis is less predictable, with reported healing rates ranging from 40% to 100%. The primary aim of this study was to assess the success rate of treating infected non-unions of the tibia and femur by a team specializing in complex bone and joint infections. MATERIAL AND METHODS: This single-center retrospective study included all patients operated between 2002 and 2012 due to an infected non-union of the femur or tibia using standardized surgical methods. The procedure was typically done in two phases: excision of the infected site and stabilization, followed by bone reconstruction after a waiting period. Additional procedures (lavage and/or bone grafting) were performed in some cases. A minimum 6-week course of antibiotic therapy was given. The primary endpoint was successful medical and surgical treatment after a minimum 2 years' follow-up defined as healing of the infection (no local clinical signs of infection, ESR≤20mm and CRP≤10mg/L, no mortality attributed to the infection) and radiological and clinical bone union, with the lower limb spared. RESULTS: Fifty-five patients (39 men, 16 women) were included with an average age of 37±11 years. There were 40 tibial fractures and 15 femur fractures. A polymicrobial infection was present in 47% of cases. Repeat surgery was required in 56.4% of patients. At an average of 4±2 years from the first surgical procedure, the treatment was successful in 49 patients (89%): 36 tibia (90%) and 13 femur (87%). The mean time to union was 9±4 months. There were six failures: 3 amputations at 5, 6 and 16 months; 1 mechanical and infection-related failure; 2 failed union. CONCLUSION: This study found that 89% of patients with an infected tibial or femoral non-union treated by a team specialized in complex bone and joint infections using a standardized surgical protocol had bone union and healing of the infection in an average of 9 months. LEVEL OF EVIDENCE: IV, retrospective study.

Efficacy of vitamin C in preventing complex regional pain syndrome after wrist fracture: A systematic review and meta-analysis.

BACKGROUND: Complex regional pain syndrome type I (CRPS-I), previously known as reflex sympathetic dystrophy, is common after conservatively or surgically treated wrist fractures. Several studies support the efficacy of vitamin C in preventing CRPS-I, although the data are somewhat conflicting. The primary objective of this systematic literature review and meta-analysis was to assess the efficacy of vitamin C therapy in preventing CRPS-I after a wrist fracture. METHODS: Randomised, placebo-controlled trials of vitamin C to prevent CRPS-I after wrist fractures were sought in the three main databases: PubMed (1980 to December 2015), CENTRAL (Central 2015, number 12), and Embase (1980 to December 2015). Two authors worked independently to select articles. Data from selected articles were collected independently. RESULTS: Three randomised placebo-controlled trials in a total of 875 patients were included. Treatment was non-operative in 758/890 (85.1%) fractures and operative in 132 (14.9%) fractures. Vitamin C supplementation was started on the day of the injury and continued for 50 days. In the group given 500mg of vitamin C daily, the risk ratio for CRPS-I was 0.54 (95%CI, 0.33-0.91; P=0.02). Thus, the risk of developing CRPS-I was significantly decreased by prophylactic treatment with 500mg of vitamin C per day. The heterogeneity rate was 65% (non-significant). CONCLUSION: Daily supplementation with 500mg of vitamin C per day for 50 days decreases the 1-year risk of CRPS-I after wrist fracture. LEVEL OF EVIDENCE: II, systematic review of level I and II studies.

Peri-articular local infiltration analgesia versus femoral nerve block for postoperative pain control following anterior cruciate ligament reconstruction: Prospective, comparative, non-inferiority study.

INTRODUCTION: Femoral nerve block (FNB) is considered as a major advance in anterior cruciate ligament (ACL) reconstruction as it reduces the need for parenteral opioids. However, the incidence of transient or even permanent neurological deficits due to the FNB is estimated at 1.94% after knee surgery. The primary objective of this study was to compare local infiltration analgesia (LIA) to FNB during ACL reconstruction procedures. The study hypothesis was that LIA was not less effective than FNB on early postoperative pain. PATIENTS AND METHODS: A retrospective analysis of data collected prospectively in the FAST cohort included a series of continuous patients who underwent primary repair for isolated ACL with a hamstring graft in 2013-2014. Changes in our anesthesia practices over time allowed us to form three successive groups: Group 1 - FNB, Group 2 - FNB+LIA, Group 3 - LIA only. Ultrasound-guided FNB was done pre-operatively. The LIA was done at the end of the procedure by the surgeon with systematic infiltration of all skin incisions and the hamstring donor site; no intra-articular injections were performed. The primary endpoint was the average early postoperative pain (Days 0-3) described by the patient on a visual analogue scale (0-10). Sample size calculation pointed to 36 subjects being needed per group for a non-inferiority study. RESULTS: The study involved 126 patients: G1=42, G2=38, G3=46. The patients were comparable at enrolment. The average early postoperative pain levels were 3.1±2.4, 2.8±2.0 and 2.5±2.2, respectively (P=0.66). A trend toward higher intake of tramadol was noted in the LIA group on D0 to D3, with a significant trend test on Day 1 (P=0.03) and Day 2 (P=0.02). CONCLUSION: After reconstruction of isolated ACL tears with a hamstring graft, FNB is not more effective than LIA on patients' early postoperative pain. Patients who received a FNB consumed significantly less opioid-like analgesics. LEVEL OF EVIDENCE: III - Prospective, comparative, non-randomized study.

Return to recreational sport and clinical outcomes with at least 2years follow-up after arthroscopic repair of rotator cuff tears.

INTRODUCTION: The main objective of the study was to assess return to sports in recreational athletes after arthroscopic repair of rotator cuff tear (RCT). MATERIAL AND METHODS: A retrospective single-center study included all recreational athletes operated between 2008 and 2012 for arthroscopic repair of RCT, with regular sports activity, and aged less than 70 years. All were recontacted at a minimum follow-up of 2 years. The main outcome was return to sports (yes/no). The secondary criteria were return to sports, time to return to sports, number of hours per week of sports activity, and at the last follow-up the subjective assessment of sports level, patient satisfaction, and the Western Ontario Rotator Cuff (WORC) Index. RESULTS: Seventy-six patients (37 females, 39 males) with a mean age of 57.0±7.3 years were included. Of these 76 patients, 53 (69.7%) patients participated in a sport that specifically involved the upper limb. The mean follow-up was 45±14 months. Postoperatively, 67 of 76 (88.2%) patients returned to a sports activity, the same sport for 52 out of 76 (68.4%). The mean time to return to sports was 6±4.9 months. For patients who had taken up their sport again, the mean number of hours a week was not significantly modified (P=0.58). At the last follow-up, the subjective sports level was judged better or identical to the preoperative level by 52 of 67 (77.6%) patients. The factors significantly associated with absence of return to the previous sport were pain symptoms evolving for more than 9 months before surgery (OR=3.6 [1.01-12.5], P=0.04) and preoperative sports intensity less than 2h/week (OR=4.1 [1.4-12.3], P=0.01). At the last follow-up, the functional improvement evaluated by the WORC Index was strongly significant (P<0.00001) and 73 of 76 (96%) patients were satisfied. CONCLUSION: The majority of the recreational athletes returned to sports after arthroscopic rotator cuff repair, most often at the same level and with equivalent intensity compared to before surgery. LEVEL OF EVIDENCE: IV, retrospective study.

Outpatient Latarjet surgery for gleno-humeral instability: Prospective comparative assessment of feasibility and safety.

BACKGROUND: Some surgical procedures are rarely done on an outpatient basis. The primary objective of this study was to assess the safety of outpatient surgical shoulder stabilisation using the Latarjet procedure. HYPOTHESIS: The Latarjet procedure is safe when performed on an outpatient basis provided the patients are managed according to a specifically designed programme starting at the decision to undergo surgery and ending at the end of the early postoperative period. PATIENTS AND METHODS: Consecutive patients with unidirectional anterior shoulder instability managed in 2013-2014 by primary open, minimally invasive surgery involving coracoid process transfer as described by Latarjet was included prospectively. One of the surgeons routinely offered outpatient surgery to patients who met none of the usual exclusion criteria (age>60years, ASA 3-4, and long distance from home to hospital). Standardised protocols were applied for anaesthesia and analgesia. The primary evaluation criterion was failure of the admission modality, defined as inpatient admission of a patient after outpatient surgery either without prior discharge or within 1week after discharge. Secondary evaluation criteria were early postoperative symptoms and functional outcomes after at least 1year. All self-reported criteria were entered online by the patients. RESULTS: Of 46 included patients, 17 had outpatient surgery and 29 inpatient surgery. There were 41 males and 5 females, with a mean age of 25.3±6.4years. No significant baseline differences were found between the two groups. None of the outpatients required inpatient admission or readmission. No postoperative complications were recorded. After a mean follow-up of 18.5±5.2months, the two groups showed no significant differences for return to sports, apprehension, avoidance behaviours, or functional outcomes. Most patients were satisfied with their management and outcomes. CONCLUSION: No serious adverse events were recorded in this first French prospective evaluation of the safety of open, minimally invasive shoulder stabilisation by the Latarjet procedure performed on an outpatient basis. Thus, in selected patients, the risks of outpatient surgery are similar to those of inpatient surgery. LEVEL OF EVIDENCE: III, prospective, comparative, non-randomised study.

Inefficacy of Kinesio-Taping(®) on early postoperative pain after ACL reconstruction: Prospective comparative study.

INTRODUCTION: Kinesio-Taping(®) (K-Tape) is used in sports traumatology with the aim of reducing pain and improving blood and lymph circulation. The main objective of the present study was to assess the efficacy of K-Tape on early postoperative pain after anterior cruciate ligament (ACL) reconstruction. The study hypothesis was that K-Tape significantly decreases pain. METHOD: A prospective non-randomized comparative study was conducted in 2013-2014 and included all patients who underwent primary ACL reconstruction by hamstring graft. Analgesia was standardized. Two groups, "K-Tape" and "controls", were formed according to the days on which the study physiotherapist was present. The K-Tape compression/decompression assembly was applied immediately postoperatively and maintained for 3days. Patients filled out online questionnaires. The main assessment criterion was mean postoperative pain (D0-D3) on a 0-to-10 scale. Secondary criteria were analgesia intake on the three WHO levels, awakening during the night of D0 due to pain, signs of postoperative discomfort, and patient satisfaction. RESULTS: Sixty patients (30 per group) were included, 57 of whom could be assessed: 28 K-Tape, 29 controls; 44 male, 13 female; mean age, 30.9±8.9 years. At inclusion, the two groups were comparable. There was no significant difference in mean (D0-D3) knee pain intensity: 3.8±2.2 for K-Tape, and 3.9±2 for controls (P=0.93). Analysis of variance (ANOVA) found no significant intergroup difference in evolution of pain (P=0.34). There were no other significant differences on the other assessment criteria. CONCLUSION: K-Tape showed no efficacy on early postoperative pain following ACL reconstruction. LEVEL OF EVIDENCE: III; prospective non-randomized comparative study.

Survival and functional results after a mean follow-up of 9 years with the Ceragyr® highly congruent mobile-bearing TKA.

INTRODUCTION: Fixed-bearing total knee arthroplasty (TKA) implants have excellent long-term survival. Mobile-bearing implants were developed to reduce bone-implant interface stresses and polyethylene insert wear. The primary objective of this study was to analyze the survival rate of a highly congruent mobile-bearing TKA implant (Ceragyr(®)) in patients having a minimum follow-up of 7 years. We hypothesized that the survival rate would be 95-100% at that time point. PATIENTS AND METHODS: A single-center prospective study included all the patients operated for a primary TKA procedure with a Ceragyr(®) implant between 2000 and 2003. All the implants were cemented. Patellar resurfacing was not carried out systematically, but could be carried out secondarily in cases of persistent anterior knee pain. Clinical and radiological data were collected before the surgery, at 3 months postoperative, at 1 year and then at a minimum follow-up of 7 years. The primary endpoint was the overall revision-free survival rate. Secondary endpoints were the survival without mechanical failure, IKS scores, knee range of motion and implant positioning. RESULTS: One hundred and thirty-four patients (143 Ceragyr(®) TKA cases) were included; 9 patients (10 TKA) were lost to follow-up (6.7%) and the remaining 125 patients (133 TKA) were contacted. At the final review, 7 of the 133 TKA cases (5.3%) had been revised (6 men, 1 women; P = 0.002), 2 (1.5%) because of mechanical failure and 5 (3.8%) because of an infection. The overall revision-free survival rate was 94.8% [95% CI: 89.3-97.5]; survival was 98.4% [95% CI: 93.8-99.6] with mechanical failure as an endpoint. An in-person assessment was conducted on 76 patients (80 TKA cases) (49 women; 27 men) who had an average age of 70.3 ± 8.4 years at the time of the arthroplasty procedure. The patella had been resurfaced during the initial procedure in 49 cases, and was either not resurfaced or secondarily resurfaced in 31 cases. The average follow-up was 8.7 ± 1.1 years. The IKS score had significantly improved relative to the preoperative values (P < 0.00001). Knee flexion and the IKS knee score remained stable over time (P > 0.05). Patients who underwent patella resurfacing during the initial TKA procedure had better clinical results (P = 0.03). CONCLUSION: After a minimum follow-up of 7years, the overall revision-free survival rate for the Ceragyr(®) was 94.8%; the survival was 98.4% with mechanical failure as an endpoint. The results were stable over time.

Diagnostic value of the GNRB ® in relation to pressure load for complete ACL tears: A prospective case-control study of 118 subjects.

INTRODUCTION: The GNRB(®) is a reliable, validated arthrometer. A pressure pad exerts 0 to 250 Newtons of pressure on the upper calf. The goal of this study was to compare the diagnostic value of the different pressure loads that are usually applied for the diagnosis of complete anterior cruciate ligament (ACL) tears. Our hypothesis was that a load of 200N would be sufficient to diagnose these tears. PATIENTS AND METHODS: A prospective comparative case-control study was performed in 2012. One group included all the male athletes aged 15 to 21 who presented with a complete ACL tear confirmed by arthroscopy (the study group). The control group included male soccer players in a training center aged 15 to 19 with no history of knee injuries (the control group). Anterior laxity was measured in both knees by the same experienced operator using the GNRB(®) system. The main judgment criteria were the diagnostic values of each pressure load evaluated by the area under the curve (AUC), from "Null" (AUC < 0.5) to "Perfect" (AUC = 1). RESULTS: This study included 118 men: 64 in the study group, mean age 18.1 ± 2.3-years-old, who were mainly soccer players (39/64) or rugby men (16/64) and 54 control subjects, mean age 17.3 ± 1.5-years-old. Three hyperalgesic patients could not receive a pressure load of 250N. The mean differential laxity was significantly higher in the control group, whatever the pressure load (P < 10(-5)). The test was "highly informative" for all loads (0.9 ≤ AUC < 1). Analysis of the AUC revealed a diagnostic value in descending order of: 200N(0.97[0.94-1]) > 134N(0.97[0.93-0.99]) > 250N(0.96[0.93-0.99]) > 89N(0.95[0.90-0.99]). CONCLUSION: The GNRB(®) at 200N was shown to be sufficient to diagnose complete ACL tears. Applying a pressure load of 250N does not appear to be useful.

Postoperative discomfort after outpatient anterior cruciate ligament reconstruction: a prospective comparative study.

INTRODUCTION: The principal objective of the present study was to compare rates of postoperative discomfort after anterior cruciate ligament (ACL) reconstruction between inpatient (In) and outpatient (Out) management. PATIENTS AND METHOD: A single-surgeon non-randomized prospective comparative study included patients undergoing primary surgery for isolated ACL tear by short hamstring graft in 2012-13. The Out group comprised patients eligible for and consenting to outpatient surgery and the In group, those not eligible or not consenting. The principal assessment criterion was onset of at least 1 symptom of postoperative discomfort (SPD): anxiety, nausea and vomiting, malaise, vertigo or stomach pain, between postoperative days 0 and 3. Secondary assessment criteria were difficulty in getting to sleep, getting up during the night, regular walking or going out, number of episodes of knee pain and waking because of pain. All criteria were assessed on-line by the patient. RESULTS: One hundred and thirty-three patients filled out the questionnaire, 70 in the Out group and 63 in the In group; 42 females, 91 males; mean age, 30±9 years. Between D0 and D3, the proportion of patients with ≥l SPD was comparable between groups (Out 37% vs In 41%, P=0.62). Out-group patients had significantly less difficulty sleeping the first postoperative night (P=0.01), got up significantly more often during the first night after surgery (P<0.0001), more often walked regularly on day 1 (P=0.03), and were significantly less often woken by pain during the first night (P=0.003). Risk factors for SPD were female gender (OR=4.8±1.9) and postoperative complications (OR=3.8±2.5). CONCLUSION: Patients undergoing ACL reconstruction on an outpatient basis did not show more symptoms of postoperative discomfort than those managed as conventional inpatients. LEVEL OF EVIDENCE: IV; prospective comparative study.

Translation, cross-cultural adaptation and validation of the French version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale.

PURPOSE: The aim of this study was to translate, adapt and validate in French the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), a 12-item English language scale assessing the psychological impact of returning to sports after ACL reconstruction. METHODS: The ACL-RSI scale was forward and back translated, cross-culturally adapted and validated using international guidelines. The study population included all patients who were active in sports and underwent primary arthroscopic ACL reconstruction. The control group included subjects with no history of knee trauma. At the 6-month follow-up, the study population completed the ACL-RSI scale twice within 3-4 days, Knee injury and Osteoarthritis Outcome Score (KOOS) and subjective International Knee Documentation Committee (IKDC) scores. Statistical tests assessed the construct validity, discriminant validity, internal consistency, reliability and feasibility of the ACL-RSI scale. RESULTS: Ninety-one patients with ACL tears and 98 control subjects were included: mean age 31.7 ± 8.1 and 21.8 ± 2, respectively. The ACL-RSI scores were correlated with all KOOS sub-categories (r = 0.22-0.64, p < 0.05) as well as the subjective IKDC score (r = 0.42, p < 0.00001). The mean scores of the study and control groups were significantly different (62.8 ± 19.4 vs. 89.6 ± 11.5, p < 0.00001), and scores were significantly better in patients who returned to the same sport (72.1 ± 21.4 vs. 60.3 ± 18.1, p = 0.008). Internal consistency was high (α = 0.96). Test-retest reproducibility was excellent: ρ = 0.90 (0.86-0.94), p < 0.00001. Administration time was 1.32 ± 0.7 mn, and all items were answered. CONCLUSION: This study showed that the cross-cultural adaptation of the English version of the ACL-RSI was successful and validated in a French-speaking population. The discriminant capacity of the scale between patients who underwent reconstruction and healthy subjects was confirmed. LEVEL OF EVIDENCE: II.

Complete paralysis of the quadriceps secondary to post-traumatic iliopsoas hematoma: a systematic review.

PURPOSE: Paralysis of the femoral nerve secondary to compression by a hematoma of the iliopsoas is rarely post-traumatic. The acute surgical removal of hematoma seems the treatment of choice. The main objective of this systematic review was to determine the optimal delay between the trauma and surgery, to obtain a total functional recovery. METHODS: A search was performed via PubMed. The inclusion criteria were the studies in English language, reporting the results of the treatment of femoral nerve palsy secondary to compression by a post-traumatic hematoma of the iliopsoas. The primary evaluation criterion was the clinical recovery of femoral nerve function. The secondary criteria were the delay of recovery and the delay between the trauma and surgery. RESULTS: Thirteen studies were identified, only case reports. Sixteen patients were included, mean age 16.6 ± 3.4 years, 11 men and 5 women. The injury was associated with the sports practice in 12/16 (75 %) cases. Neurological symptoms developed about 5 days after injury. Femoral palsy was complete in 8 patients and partial in 8 patients. The mean delay between the injury and the diagnosis was 7.3 (2-25) days in conservative group and 17.8 (4-45) days in surgical group. Seven patients were managed conservatively, 6 partial paralysis and 1 total paralysis, and 9 surgically, 7 total paralysis and 2 partial paralysis. The recovery was total in 13/14 patients (seven surgical treatment and six conservative management) and partial in one patient who was managed conservatively despite a total paralysis. The delay of total recovery varied from 1 month to 6 weeks in conservative group and 3 months to 2 years in surgical group. CONCLUSION: This systematic review seems to indicate that whatever the delay, surgery is necessary in case of complete paralysis of the femoral nerve secondary to compression from a post-traumatic hematoma of the iliopsoas muscle.

Tibial tubercle osteotomy hinged on the tibialis anterior muscle and fixed by circumferential cable cerclage in revision total knee arthroplasty.

BACKGROUND: Difficulties in knee exposure during revision total knee arthroplasty (RTKA) may require tibial tubercle osteotomy (TTO). The main objective of this study was to assess union after TTO hinged on the lateral soft tissues and fixed using circumferential cable cerclage during RTKA. HYPOTHESIS: Non-union is uncommon with this technique. PATIENTS AND METHODS: We retrospectively included consecutive patients who underwent RTKA between 2008 and 2010 with TTO. Chevron osteotomy was performed and the fragment was left hinged laterally on the tibialis anterior muscle then fixed using circumferential cerclage with one or two steel cables. The primary evaluation criterion was TTO union as assessed on radiographs. Secondary evaluation criteria were time to union, osteotomy fragment migration, patellar height, and the IKS score at last follow-up. We included 65 patients with a mean age of 72±11.3 years including 39 (60%) undergoing septic revision and 26 (40%) aseptic revision. Mean follow-up was 27.8±10.7 months; there was 1 early death, which was unrelated to the surgery, and another patient was lost to follow-up. RESULTS: TTO union was achieved in 59/63 (93.7%) patients. Fragment migration occurred in 4 (6.3%) patients. Mean time to union was 16.9±5.1 weeks overall, 12.4±2.0 in the aseptic revision group, and 18.9±4.8 in the septic revision group (P=0.0005). Patellar height at last follow-up was not significantly changed compared to the preoperative value (P=0.09). At last follow-up, the mean IKS knee and function scores were significantly improved (P<10-5). CONCLUSION: TTO hinged on the lateral soft tissues and fixed by circumferential cable cerclage ensured union in the vast majority of patients, with a low rate of tubercle migration. LEVEL OF EVIDENCE: IV, retrospective study.

Outpatient surgery feasibility in anterior cruciate ligament reconstruction: a prospective comparative assessment.

INTRODUCTION: The main objective of this study was to assess the feasibility of outpatient surgery in anterior cruciate ligament (ACL) reconstruction. We hypothesized that if the patient underwent the procedure within a dedicated organization, safety would be ensured. PATIENTS AND METHODS: A non-randomized, prospective, comparative, single-operator study conducted in 2012-2013 included all patients undergoing first-line surgery for ACL arthroscopic reconstruction using a short hamstring graft. The outpatient group (OP) included patients who were eligible for outpatient surgery and provided consent; the conventional hospitalization group (CH) comprised those patients not suitable for outpatient surgery and those who refused it. The main evaluation criterion was failure of the admission modality defined as hospitalization of a patient who had undergone outpatient surgery or rehospitalization in the first week after discharge. The secondary evaluation criteria were the rate of postoperative complications, postoperative pain, use of analgesics, and patient satisfaction. A total of 138 patients were included: 71 in the OP group and 67 in the CH group, with a mean age of 29.6±9 years. Twenty-nine percent of the patients refused outpatient surgery. In the CH group, the mean hospital stay lasted 2.7±0.8 days. RESULTS: One patient in the OP group was hospitalized with localized bleeding and there were no rehospitalizations. Six early postoperative complications were noted in each group. The mean postoperative pain on D0-D4 and patient satisfaction were similar in the two groups. CONCLUSION: This prospective study encountered no serious events after outpatient ACL reconstruction surgery. In a selected population, the risks are comparable to those in conventional hospitalization. LEVEL OF EVIDENCE: Level III, comparative study.

Ceramic-on-ceramic total hip arthroplasty: is squeaking related to an inaccurate three-dimensional hip anatomy reconstruction?

Many factors were incriminated in the squeaking generation in ceramic-on-ceramic total hip arthroplasty (THA), including the cup positioning and design. However, the influence of the stem orientation has not been investigated and the true three-dimensional hip anatomy has never been compared to the contralateral healthy hip. Three patients, who underwent unilateral ceramic-on-ceramic THA, complained of squeaking. CT-scans were performed to compare the true three-dimensional hip anatomy to the contralateral healthy hip. All patients presented evidence of posterior neck-rim impingement with a two-fold increase in the global anteversion (above 75°) comparatively to the healthy hip. The excess of anteversion was on the cup side in 2 cases and on the stem side in 1 case. We conclude that squeaking in ceramic-on-ceramic THA could be related to a poor accuracy of 3D hip anatomy reconstruction which generated a posterior impingement and subsequent anterior edge loading because of excessive global anteversion.

Sensitivity and specificity of bell-hammer tear as an indirect sign of partial anterior cruciate ligament rupture on magnetic resonance imaging.

PURPOSE: The main purpose of this study was to evaluate the usefulness of the bell-hammer sign in the diagnosis of partial tears of the anterior cruciate ligament (ACL) of the knee on MRI. METHODS: A retrospective study was performed including all patients who underwent ACL reconstruction for partial or complete tears from 2008 to 2009. The diagnosis of partial or complete ACL tears was based on the appearance of the ligament bundles and the signal quality on MRI. On arthroscopy, which is considered the gold standard, each bundle was classified as normal, partially or completely torn depending on the extent of the rupture and the quality of the remaining fibres. The study included 312 patients, 83 women and 229 men (mean age 33.3 ± 19.6 years). A diagnosis of a tear was made in all patients on preoperative MRI. Arthroscopy did not show any normal ACL, 247/312 (79.2 %) complete tears and 65/312 (20.8%) partial tears, 50/65 (76.9%) on the anteromedial bundle (AM) and 15/65 (23.1%) the posterolateral bundle. RESULTS: The bell-hammer sign was found on MRI in 13/312 patients (4.5%). It involved 9/65 (13.8%) partial tears, all in the AM bundle, and 4/247 (1.6%) complete tears, significantly more frequent in cases of partial rupture (p < 0.0001). MRI diagnosed a partial tear in 15/65 cases without the bell-hammer sign (sensitivity CI 95% = 23.1 ± 10%, specificity CI 95% = 95.9 ± 2.5%) and with the bell-hammer sign in 23/65 cases (sensitivity CI 95% = 35.4 ± 11%, specificity CI 95% = 93.9 ± 3%). The association of the bell-hammer sign with conventional radiological diagnostic criteria has improved diagnosis performance of MRI for partial tears but not significantly (ns). CONCLUSION: The most important interest of the bell-hammer sign in the day-to-day clinical work is to suggest partial tears on MRI. It aids making a diagnosis, but its absence does not exclude partial ACL rupture. LEVEL OF EVIDENCE: Diagnostic study, Level II.

Partial tears of the anterior cruciate ligament: diagnostic performance of isotropic three-dimensional fast spin echo (3D-FSE-Cube) MRI.

PURPOSE: To compare the performance of 3D-FSE-Cube MRI to arthroscopy, the reference test for the diagnosis of partial anterior cruciate ligament (ACL) tears. METHODS: A retrospective study was performed including all patients who underwent surgery for an ACL tear in our Sports Surgery Unit from January 2008 to December 2009. All patients underwent a preoperative MRI, conventional 2D or 3D-Cube. The diagnosis of a partial tear was based on the appearance of the ligament bundles and signal quality on MRI, and on the continuity of the fibers on arthroscopy and the quality of the remaining ligament. Sixty-four of the 312 included patients underwent MRI 3D-Cube and 248 conventional 2D-MRI. The series included 82 women and 223 men, mean age 33.3 ± 19.6 years. Arthroscopy did not reveal any normal ACL, 247/312 (79.2 %) complete tears, and 65/312 (20.8 %) partial tears, with 50/65 (76.9 %) involving the anteromedial bundle and 15/65 (23.1 %) the posterolateral. RESULTS: The results of MRI 3D-Cube were as follows: sensitivity 95 % CI = 62.5 ± 23.7 %, specificity 95 % CI = 93.7 ± 6.9 %, likelihood ratio LR(+) = 9.9, LR(-) = 0.4 and accuracy 85.9 %. Results of conventional 2D-MRI were as follows: sensitivity 95 % CI = 10.2 ± 8.5 %, specificity 95 % CI = 96.5 ± 2.5 %, LR(+) = 2.9, LR(-) = 0.9 and accuracy 79.4 %. The diagnostic performance of MRI 3D-Cube was better than conventional 2D-MRI. CONCLUSION: The diagnostic performance of MRI 3D-Cube in partial ACL tears was good and significantly better than conventional 2D-MRI. The likelihood of having a positive test was 9.9 times higher in a patient with a partial tear. A negative result did not exclude this diagnosis.

Validity of GNRB® arthrometer compared to Telos™ in the assessment of partial anterior cruciate ligament tears.

PURPOSE: The main goal of this study was to compare the results of the GNRB(®) arthrometer to those of Telos™ in the diagnosis of partial thickness tears of the anterior cruciate ligament (ACL). METHODS: A prospective study performed January-December 2011 included all patients presenting with a partial or full-thickness ACL tears without ACL reconstruction and with a healthy contralateral knee. Anterior laxity was measured in all patients by the Telos™ and GNRB(®) devices. This series included 139 patients, mean age 30.7 ± 9.3 years. Arthroscopic reconstruction was performed in 109 patients, 97 for complete tears and 12 single bundle reconstructions for partial thickness tears. Conservative treatment was proposed in 30 patients with a partial thickness tear. The correlation between the two devices was evaluated by the Spearman coefficient. The optimal laxity thresholds were determined with ROC curves, and the diagnostic value of the tests was assessed by the area under the curve (AUC). RESULTS: The differential laxities of full and partial thickness tears were significantly different with the two tests. The correlation between the results of laxity measurement with the two devices was fair, with the strongest correlation between Telos™ 250 N and GNRB(®) 250 N (r = 0.46, p = 0.00001). Evaluation of the AUC showed that the informative value of all tests was fair with the best results with the GNRB(®) 250 N: AUC = 0.89 [95 % CI 0.83-0.94]. The optimal differential laxity threshold with the GNRB(®) 250 N was 2.5 mm (Se = 84 %, Sp = 81 %). CONCLUSION: The diagnostic value of GNRB(®) was better than Telos™ for ACL partial thickness tears.

A new instrument to measure the activity profile of elderly shoulder pathology patients: the Senior Shoulder Activity score (SSA score).

INTRODUCTION: Whether rotator cuff repair is indicated in an elderly subject depends on the patient's activity profile and functional demand. A Senior Shoulder Activity (SSA) score is described, as a support for indications and analysis of clinical results according to activity level. MATERIAL AND METHOD: The SSA score, comprising 4 levels from "sedentary" to "very active", was validated by comparison against a control group of 113 asymptomatic patients. It was included in the protocol of the French Arthroscopy Society's comparative study of repair versus simple decompression in 143 rotator cuff tears. Recovery of activity was assessed according to procedure. RESULTS: At 1-year follow-up, suturing was associated with recovery of previous activity level in 87% of the cases and in 80% for decompression, a non-significant difference. When, however, less active patients (SSA 1 and 2) were contrasted with the more active (SSA 3 and 4), clinical results with suture versus decompression on Constant score showed a greater difference in the SSA 3-4 group. DISCUSSION: The SSA score is not the same as the activity item of the Constant score, as it assesses the patient's usual activity level, before symptom onset, whereas the Constant item assesses activity at a given moment, independently of the patient's normal activity profile. CONCLUSION: The Senior Shoulder Activity score is a simple, reproducible complement to the Constant score, revealing differences in clinical results on the latter, according to activity profile. Rotator cuff repair or simple decompression provided recovery of previous SSA activity level in more than 80% of the cases. The difference in clinical results between the two was significantly greater in more active patients. It would seem to follow that suture is more beneficial for more active subjects while simple decompression may be suitable for those with lower functional demand.

Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee: recurrence rate and functional outcomes after a mean follow-up of seven years.

BACKGROUND: Pigmented villo-nodular synovitis (PVNS) is an uncommon proliferative condition of the synovial membrane that chiefly affects the knee. Arthroscopic synovectomy may carry lower morbidity rates but higher recurrence rates than open synovectomy. Here, our objective was to evaluate recurrence rates and functional outcomes after primary arthroscopic synovectomy for PVNS of the knee. HYPOTHESIS: Primary arthroscopic synovectomy preserves knee function while producing low recurrence and complication rates. MATERIALS AND METHODS: We retrospectively included consecutive patients with histologically documented PVNS managed with primary arthroscopic synovectomy at two centres between 1998 and 2011. Twenty-three patients, 13 men and 10 women with a mean age of 41 ± 12 years, were reviewed including 16 patients with nodular and 7 with diffuse form of this disease. Patients with localized disease underwent partial synovectomy and those with diffuse disease complete synovectomy followed by chemical synovectomy of any residual lesions. The primary outcome measure was recurrence. Secondary outcome measures were the Tegner-Lysholm and Ogilvie-Harris scores. RESULTS: Follow-up data were obtained after a mean of 7 ± 4 years in 21 patients (14 with nodular and 7 with diffuse disease), of whom 2 had recurrences, after 2 and 5 years, respectively. At last follow-up, neither patient had any evidence of recurrence. The mean Tegner-Lysholm score was significantly improved (from 68 ± 10 to 90 ± 8, P=0.0004) and the mean Ogilvie-Harris score indicated excellent function (11 ± 1). DISCUSSION: Primary arthroscopic synovectomy ensures satisfactory control of PVNS while preserving knee function. A full recovery remains possible even in patients with diffuse disease. In the event of a recurrence, open synovectomy can be performed.