Should recommended laboratory-test cut-offs allowing surgery be followed for proximal femoral fractures in patients on direct oral anticoagulant therapy?

BACKGROUND: Proximal femoral fractures (PFFs) in elderly patients must receive prompt surgical treatment. Optimal PFF-surgery timing in patients on direct oral anticoagulant (DOA) therapy is a specific but common clinical issue. Recommendations exist about the anti-Xa or anti-IIa levels and creatinine clearance values required to allow surgery. The objectives of this study in patients older than 75 years who required PFF surgery were to evaluate bleeding when the recommendations were versus were not applied and to assess concordance between DOA-activity-assay results and creatinine clearance used to help determine the wait to surgery. HYPOTHESIS: Peri-operative bleeding is more marked when surgery is performed while the DOA is still active. PATIENTS AND METHODS: This single-centre, retrospective, comparative, observational study included 87 patients older than 75 years who required arthroplasty or intra-medullary nailing for PFF and were taking DOA therapy. Surgery was performed after versus before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) versus 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali's formula and the proportion of patients requiring post-operative blood transfusions. RESULTS: Mean blood loss was 287.1mL in the Rec+ group and 411.7mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8g/dL in 11 (16.2%) Rec+ patients and 6 (31.6%) Rec- patients (p=0.2). Concordance was poor between DOA activity and creatinine clearance (Cohen's κ, 0.16; p=0.146). DISCUSSION: Peri-operative bleeding was not significantly more severe when PFF surgery was performed while DOA therapy was still active. These data suggest that PFF surgery within 48h may be appropriate in patients older than 75 years on DOA therapy. LEVEL OF EVIDENCE: IV; retrospective single-centre study.

Assessment and trends in the methodological quality of the top 50 most cited articles in shoulder arthroplasty.

INTRODUCTION: Shoulder arthroplasty is increasingly frequent, and the associated literature is abundant. Citation rate is often considered a good means of assessing impact and scientific value. However, analysis of methodological quality is also essential in evidence-based medicine. OBJECTIVES: (1) To identify the 50 most cited articles on shoulder arthroplasty, and (2) to assess the correlation between citation rate and methodological quality. The study hypothesis was that there is no correlation between citation rate and methodological quality. METHOD: Articles were retrieved from PubMed and Google Scholar, identifying the 50 most cited articles on shoulder arthroplasty via the keywords "shoulder joint replacement", "shoulder arthroplasty", "anatomic shoulder prothesis", "reverse shoulder prothesis", and "glenohumeral arthritis". Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS) were calculated. RESULTS: Mean citation rate for the 50 articles was 312.4±169.5 (range, 151-841.5), with a mean citation density of 18.8±10.6 (range, 4.7-46.7). 56% of the studies (28/50) were retrospective case series with level of evidence IV. There was no correlation between citation rate and methodological quality. DISCUSSION: The 50 most cited articles on shoulder arthroplasty mostly showed low levels of methodological quality. There was no correlation between citation rate and methodological quality: the literature needs to be read with a critical eye. LEVEL OF EVIDENCE: IV.

Can the prognostic score proposed by Elliot serve as an educational tool to shorten the time to surgery for hip fractures in geriatric patients?

INTRODUCTION: Hip fractures require surgical treatment within 48hours to decrease the risk of postoperative complications. Elliott proposed a prognostic score to identify which patients should be prioritized for surgery. This study was designed to answer the following questions: 1- Does using this score shorten the time to surgery? 2- Does shortening the time to surgery reduce mortality at 6 months and 1 year? 3- What factors delay the surgical procedure? We hypothesized that using this score as an educational tool would reduce the time to surgery in patients over 75 years of age who have a hip fracture. MATERIAL AND METHODS: This single-center study involved two populations: 244 patients were included prospectively who had the score applied with the aim of optimizing the time to surgery; 476 patients were included from a historical cohort to serve as a reference group. RESULTS: The mean time to surgery was 2.5 days±1.9 [95% CI: 2.41-2.77] and the median was 2 days (minimum 0, maximum 18 days) in the reference group; the mean was 1.4 days±1.0 [95% CI: 1.46-1.67] and the median was 1 day (min. 0, max 6 days) in the prospective cohort, which was a significant reduction (p<0.001). At 6 months, the mortality rate was 22.5% in the reference population and 23% in the prospective cohort. At 1 year, the mortality rate was 47% and 46%, respectively, with no significant difference. Surgical delays were attributed to lack of OR availability, management of anticoagulants, request for cardiac ultrasound and administrative reasons. DISCUSSION/CONCLUSION: Elliot's prognostic at-risk score for hip fracture can shorten the time to surgery when used an educational tool to raise the medical staff's awareness of the benefits of rapid surgical care. LEVEL OF EVIDENCE: IV; retrospective study without control group.

The use of single-use ancillaries does not increase the cost of osteosynthesis in orthopaedic surgery: A case study of plate osteosynthesis for distal radius fractures.

OBJECTIVE: To compare the cost of using single-use instruments (SUIs) and conventional ancillary instruments (CAIs) during osteosynthesis for distal radius fracture (DRF). MATERIAL AND METHODS: We conducted a prospective, monocentric study of ancillary instruments, including a cost minimisation analysis by micro-costing. DRF reduction and postoperative complications were monitored for 3 months. RESULTS: In 103 procedures, the overall cost and operating times were similar between the two groups. The costs of using unit screws, sterilisation, and operating room and pharmacy staff were superior when using SUIs, compared with CAIs. The postoperative outcomes were comparable between groups. CONCLUSION: In our centre, SUI use was associated with logistical advantages, but it was not associated with increased costs. However, the SUI kit should be optimised in the future.

Femoral shaft fractures treated by antegrade locked intramedullary nailing: EOS stereoradiographic imaging evaluation of rotational malalignment having a functional impact.

INTRODUCTION: The standard treatment of femoral shaft fractures is intramedullary nailing. One of the most frequent complications is femoral malrotation. Our study sought to: 1) use EOS imaging to determine the amount of rotational malalignment after intramedullary nailing that has an impact on 6-month functional results; 2) determine the incidence of femoral malrotation based on EOS imaging; 3) determine the risk factors for postoperative femoral malrotation that impacts the 6-month functional results. The hypothesis was that EOS imaging can be used to determine the amount of femoral malrotation that has a functional impact in patients treated by percutaneous femoral intramedullary nailing. MATERIAL AND METHODS: We performed a prospective, single-center study between September 2017 and February 2020. Patients who had suffered a femoral shaft fracture treated with antegrade intramedullary nailing were included in this study. Femoral anteversion was measured at 6 months with an EOS stereoradiographic imaging system. Patients were assessed at 6 months with the WOMAC, Oxford, Harris and MDP functional scores. The SF-12 quality of life score was also determined. RESULTS: Thirty patients were evaluated at 6 months postoperatively, 15 women (50%) and 15 men (50%) who were 47 years old on average [16; 94]. The average anteversion was 19.9°C [-23°; 75°]. The functional scores (Oxford and Harris) were altered when there was 14° or more difference in femoral torsion between the operated side and the healthy side with a sensitivity of 0.88 and a specificity of 0.77. The risk factors for femoral malrotation were age under 35 years (p=0.01), urgent surgical management (p=0.008), location in middle third of femoral shaft (p=0.05), and short spiral fracture (p=0.02). CONCLUSION: The use of EOS imaging allowed us to demonstrate that functional hip outcomes are altered at 6 months postoperatively when greater than 14° femoral malrotation is present compared to the contralateral side after femoral intramedullary nailing. The risk factors that contributed to intraoperative rotational malalignment were age less than 35 years, urgent surgical management, mid-shaft femoral fracture and short spiroid fractures. LEVEL OF EVIDENCE: II.

User satisfaction with single-use instruments versus reusable instruments for treating distal radius fractures with locking volar plates.

INTRODUCTION: The adoption of single-use instruments (SUI) in orthopedic and trauma surgery continues at a rapid pace. Economics studies on this topic have come to contradictory conclusions about whether these SUI have a cost advantage. The aims of our study were to (1) compare the satisfaction of operating room staff between SUI and reusable instruments (RUI) in the context of distal radius fracture fixation with locking volar plates; (2) compare the immediate postoperative and medium-term radiological outcomes of patients operated these two types of instrument sets. We hypothesized that users will be more satisfied with SUI in the context of distal radius fracture fixation with locking volar plates. MATERIALS AND METHODS: This was a prospective, single-center study performed between April 2019 and July 2020. The inclusion criteria were patients more than 18 years of age who had a distal radius fracture with indication for fixation with volar locking plate, and whose initial treatment and follow-up were completed in our surgery department. Two groups of patients were created: SUI and RUI. The satisfaction of the surgeons and scrub nurses was determined using a 10-item questionnaire. RESULTS: The analysis was done on 91 procedures for which a satisfaction questionnaire was completed by the primary surgeon and the scrub nurse. The satisfaction scores were always significantly better in the RUI group than in the SUI group (p<0.05). DISCUSSION: This study found that surgeons and scrub nurses in our surgery department liked the RUI better than the SUI. At a time when SUI kits become more popular in orthopedic and trauma surgery, based on cost arguments that still need to be confirmed, taking into account the operating room staff's opinion is an important criterion for improving RUI kits. LEVEL OF EVIDENCE: II.

Allograft and autograft provide similar retear rates for the management of large and massive rotator cuff tears: a review and meta-analysis.

PURPOSE: Currently, autografts and allografts are largely used to treat large or massive rotator cuff tear (RCT), without any evidence in favour of one graft or the other. The purpose of this study was to determine the rate of retear of autograft and allograft in the treatment of large or massive posterosuperior RCT. METHOD: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis of the results in the literature as well as the presentation of results. A search of the literature was performed in the electronic databases MEDLINE, Scopus, Embase, and the Cochrane Library. The quality of the included studies was evaluated according to the MINORS (Methodological Index for Nonrandomized Studies) score. Inclusion criteria were studies in English evaluating clinical and radiological results of surgical treatment with autograft or allograft for large or massive RCT since 2008. The main criterion was the retear rate of the graft assessed on MRI or US scan at 1-year minimum follow-up. Partial tear were classified as "tear". RESULTS: The overall retear rate was 23.6% (15.5-32.7) at a mean follow-up of 18.4 ± 7.8 (12-36) months. There was no significant difference between the two kinds of graft, with a retear rate of 27.0% (15.4-40.2) and 20.9% (9.9-34.2) with autograft and allograft respectively (n.s.). Similar improvements of functional scores (+ 28.8 to 38.4 points for the Constant score, + 33.6 to 38.4 points for the ASES, and - 4.0 to - 4.1 points for pain-VAS) were reported in the two groups after at 27.2 ± 11.1 (12-48) months. The rate of complications except retear was 1.8% (0.2, 3.7) with autograft and 0.5% (0.8, 1.8) with allograft (n.s.). CONCLUSION: The use of autograft and allograft for the treatment of large or massive RCT leads to similar retear rate and clinical outcomes at short to medium terms. LEVEL OF EVIDENCE: Level IV.

Trochanteric fractures treated by internal fixation using short intramedullary nails: Does the visual intraoperative estimation of the Tip-Apex Distance (TAD) concur with its digital postoperative measurement?

INTRODUCTION: The tip-apex distance (TAD) is the only predictor for mechanical failure after internal fixation of trochanteric fractures. The main objective of our study was to assess whether the intraoperative visual estimation of the TAD concurred with the measurement taken on postoperative digital X-rays. We hypothesized that there was a good concordance between these 2 different methods of measurement. MATERIALS AND METHODS: Patients with an isolated trochanteric fracture were included in our study. A hardcopy of the intraoperative X-rays were printed, and the TAD was calculated manually. Radiological and clinical follow-ups were scheduled at 6 weeks, 3 months and 6 months during which numerical measurements of the TAD were taken. We also recorded the fracture type (AO/OTA classification), degree of osteoporosis (Singh index), surgeon experience, age and ASA score. RESULTS: A total of 98 patients were included in our study. Of these, 70 had a 6-month follow-up and interpretable postoperative X-rays. The mean age was 87 years, with 77.14% women and a mean ASA score of 3. The coefficient of concordance between the intra and postoperative TAD was 0.7202 (95% CI=0.4905-0.9499). The secondary displacement rate was 3.28%. The univariate analysis showed no statistically significant association between an intraoperative TAD>25mm and fracture type (p=0.7290), degree of osteoporosis (p=0.5701) and surgeon experience (p=1). DISCUSSION/CONCLUSIONS: There was a high degree of concordance between intraoperative visual estimation of the TAD and its measurement on postoperative digital X-rays. The treatment of unstable fractures in osteoporotic bone by junior surgeons was not a risk factor for intraoperative TAD>25mm. It is therefore important to educate young surgeons on the concept of TAD and its intraoperative visual estimation technique as it ensures that the cephalic screw is positioned properly during the fixation of trochanteric fractures. LEVEL OF EVIDENCE: II.

Factors influencing the mid-term radiological and functional outcomes of 41 post-fracture bipolar radial head arthroplasty cases at a mean follow-up of 87 months.

INTRODUCTION: When treating comminuted radial head fractures that cannot be adequately fixed, the next option is arthroplasty (radial head replacement). We hypothesized that the radiological and functional outcomes of bipolar mobile cup radial head arthroplasty is not influenced by the length of follow-up but instead by the correct positioning of the implant intraoperatively and by the presence of associated bone or ligament injuries. PATIENTS AND METHODS: Between May 1998 and December 2016, 82 cases of radial head arthroplasty were performed at our hospital. The mean age of patients at the time of arthroplasty was 53 years (22-81). Ligament or bone injuries complicated the radial head fractures in 70% of patients. RESULTS: For the final assessment, 41 patients were reviewed and included in the statistical analysis with a mean of 82 months (12-228). The mean MEPS at the final assessment was 88.7 (61-100). There were 23 excellent, 9 good, 9 average and 0 poor results. The average DASH score was 18.7 (0-55). The average VAS for pain was 1.0 (0-5). Five patients (12%) required surgical revision, including one implant change. Our statistical analysis found no relationship between follow-up time and functional outcomes. The appearance of periprosthetic radiolucent lines was not affected by the length of follow-up. Associated bone or ligament injuries significantly increased the probability of periprosthetic radiolucent lines, humeroulnar joint degeneration and decentering of the implanted cup. Radiological evidence of a suspended implant was associated with significantly worse functional outcomes. CONCLUSION: This study confirms the long-term stability of the clinical outcomes of radial head arthroplasty. There was no relationship between worsening radiological appearance of the implant and the clinical outcomes. It is critical that this implant not be oversized or suspended, as this can trigger premature capitellar erosion and painful stiffness of the operated elbow. LEVEL OF EVIDENCE: IV; systematic retrospective analysis.

Impact of orthogeriatric management on the average length of stay of patients aged over seventy five years admitted to hospital after hip fractures.

INTRODUCTION: Hip fracture is a frequent and serious condition in the elderly. We conducted a retrospective cohort study to answer the following questions: (1) Could treatment in an orthogeriatric unit help to reduce the average length of stay for patients aged over 75 years admitted to hospital for the treatment of a hip fracture?; and (2) Could such treatment influence the post-operative outcomes of patients with hip fracture? METHODS AND MATERIALS: Our study included 534 patients admitted to hospital between January 2017 and December 2018 for surgical treatment of a hip fracture. We compared 246 patients who received traditional orthopaedic care with 288 patients treated in an orthogeriatric unit. RESULTS: Our cohort included 410 women (77%). The average age was 87.5 ± six years, and 366 patients (68%) were living at home prior to the fracture. A statistically significant difference in median length of stay (from 10 to 9 days) was observed between patients who did and did not receive orthogeriatric unit treatment (groups 1 and 2; 95% CI: 0.64; 2.59; p = 0.001). There was no difference in pre-operative delay, intra-hospital mortality rate, place of recovery, rate of institutionalisation after six months, or the number of new fractures at 6 months between the groups. The mortality rate after six months was 23.6% and 21.3% in groups 1 and 2, respectively; the difference was not significant. DISCUSSION: Orthogeriatric unit treatment reduced the median length of stay by one day, in line with most previous studies. According to Pablos-Hernandez et al., multifaceted orthogeriatric treatment is most effective. In our study, only 38% of the patients received surgical treatment within 48 hours, where early surgery is key for reducing the length of hospital stay. The intrahospital mortality rate was 2.6%, which is comparable to literature data. The discharge rate did not differ by orthogeriatric treatment status, which is also consistent with previous findings (e.g. Gregersen et al.). Lastly, the mortality rate after six months was slightly reduced by orthogeriatric care. In line with this, Boddaert et al. reported a difference in mortality rate after six months between groups who did and did not receive orthogeriatric treatment (15% vs. 24%).

Bibliometric analysis of case report citations and their effect on the impact factor: How does publishing case reports impact journals?

INTRODUCTION: Given their low citation rate, case reports may reduce a journal's impact factor (IF), making a journal less likely to accept them for publication. However, this concept has never been proven in a bibliometric study. This led us to carry out a bibliometric analysis to evaluate (1) the exact number of case reports published in orthopedics over a 2-year period, (2) their citation rate, (3) what the journals' IF would be if they had not published these case reports. HYPOTHESIS: Publishing case reports reduces a journal's IF, bringing into question whether they should be published. MATERIALS AND METHODS: This was a retrospective bibliometric study. We focused on all the articles influencing the year 2017. We looked at all the journals in the "Orthopedics" discipline that had published at least one article in the years n-2 (=2015) or n-1 (=2016). RESULTS: There were 1925 case reports among the 28,903 articles published in all orthopedics journals in 2015-2016, a 6.7% share of publications. Individually, each case report in 2015-2016 was cited an average of 0.86 times±1.4 [0-13] in 2017. Of all the case reports published in 2015-2016, 571 (30%) had not been cited in 2017. When comparing the individual number of each case report citation to the journal's IF, we found 413 instances (21.5%) where the case report was cited more than expected and 1512 (78.5%) where it was cited less than expected based on the journal's IF. The mean IF was 2.013. If the journals had not published any case reports, the mean IF would have been 2.072 (p<0.0001). For all the SIGAPS categories, the mean IF would have been higher if no case reports had been published. On average, the IF was lower by 0.059 points±0.121 [-0.165-0.537], with the difference being statistically significantly only for SIGAPS C and D journals. In 69 instances, the IF would be higher if the journal had not published any case reports. Conversely, the IF improved in 8 instances by publishing case reports: 3 were tier D journals and 5 were tier E journals. DISCUSSION: Our study brings into question whether case reports should be published. Indeed, the publication of case reports lowers the IF of scientific journals. However, we should not completely stop publishing case reports since they can be useful to clinicians caring for patients with rare diseases or medical conditions. LEVEL OF EVIDENCE: IV, systematic retrospective study.

Do bibliometric findings differ between Medline, Google Scholar and Web of Science? Bibliometry of publications after oral presentation to the 2013 and 2014 French Society of Arthroscopy (SFA) Congresses.

INTRODUCTION: Bibliometrics consists in quantitative and qualitative analysis of an individual's or group's communication (volume, visibility), and impacts research funding. There are a number of bibliometric data sources, functioning in different ways and liable to give rise to differing statistics. This point has not been investigated in relation to publication following presentation to a French congress. We therefore conducted a study comparing the main bibliometric instruments, aiming to assess: (1) publication rates following oral presentation to the 2013 and 2014 French Society of Arthroscopy (SFA) Congresses according to the database used, and (2) citation rates for these publications according to database. HYPOTHESIS: Publication and citation rates differ according to database. Material and method All 199 Abstracts of oral presentations to the 2013 and 2014 SFA Congresses were included. Based on author names and key-words, manual search was conducted in the Medline, Web of Science and Google Scholar databases. Publication characteristics (citation rate) were studied using the 3 databases and the French SIGAPS (Système d'Interrogation, de Gestion et d'Analyse des Publications Scientifiques: Scientific Publication Search, Management and Analysis System) website. RESULTS: Publication rates according to Medline and Google Scholar were the same (48.2%: 96 articles for 199 presentations), but significantly lower on Web of Science (44.7%: 89/199; p=0.002). Citation rates differed significantly (p<0.001) between sources, with Google Scholar listing a mean 1.5-3.4-fold more citations per article than the other 2 databases. Citation rates between the 3 databases correlated strongly (r=0.93). DISCUSSION: The example presented in this study illustrates the differences in bibliometrics found between different databases. There was a 4% difference (7/199 articles) in publication rates following oral presentation to an SFA Congress, and even greater differences in citation rates per article, with 1.5-3.4-fold more citations according to Google Scholar. Bibliometric studies need to acknowledge the database(s) being used, which should be as many as possible to enhance exhaustiveness. LEVEL OF EVIDENCE: IV; descriptive epidemiologic study.

Orthogeriatric assessment of patients over 75 years of age with a proximal femur fracture: Predictors of 6-month mortality.

INTRODUCTION: Proximal femur fractures are common and dangerous in older adults, given the high short-term mortality rate. While surgical treatment is vital, medical orthogeriatric care may reduce the 6-month mortality rate; however, this has not been determined on a broad scale in France. This led us to conduct a retrospective study to answer the following questions: (1) Does delayed surgical treatment impact the 6-month mortality rate? (2) Are there correctable medical factors that impact the 6-month mortality? HYPOTHESIS: Delayed surgical treatment is not an isolated risk factor for higher 6-month mortality after proximal femur fracture. METHODS: We included all patients 75 years or older who had suffered a proximal femur fracture requiring surgical treatment. This allowed us to analyze the medical records of 476 patients retrospectively. We documented their comorbidities and pre-, intra- and postoperative characteristics. A univariate then multivariate analysis was done to identify risk factors for mortality at 6 months. RESULTS: In the univariate analysis, time to surgery of more than 48hours increased the risk of dying at 6 months by 1.5 fold (Odds ratio (OR)=1.57/95% CI: 1-2.48/p=0.04). However, this risk factor was not significant in the multivariate analysis since it is not an independent risk factor. In the multivariate analysis, anticoagulants (OR=2/95% CI: 1.13-3.50/p=0.02), dementia (OR=2.2/95% CI: 1.32-3.59/p=0.002), peripheral artery disease (OR=2.9/95% CI: 1.10-7.70/p=0.03), 2-point drop in hemoglobin count from preoperative to postoperative (OR=1.9/95% CI: 1.05-3.12/p=0.04), male sex (OR=1.82/95% CI: 1.05-3.12/p=0.04), age above 85 years (OR=5.26/95% CI: 1.49-5.26/p=0.002) and Charlson comorbidity index≥7 (OR=2.13/95% CI: 1.29-3.52/p=0.003) were statistically associated with mortality at 6 months. DISCUSSION/CONCLUSION: Our study found that the patients most at risk for dying within 6 months of a hip fracture were males, older than 85 and have associated medical conditions (Charlson index≥7). Prior anticoagulant treatment increases the time to surgery in our study and therefore increases the risk of these patients dying within 6 months. Treatment of these at-risk patients should ensure that their underlying medical conditions are not made worse, while providing treatment within 48hours. Patients taking anticoagulants must be monitored carefully to ensure surgical treatment is not delayed. LEVEL OF EVIDENCE: IV, retrospective study without control group.

The human costal cartilage: Anatomical and radiological study of macro-vascularization and micro-vascularization and its clinical relevance regarding vascularized chondrocostal free flap surgery.

INTRODUCTION: Cartilage repair usually involves in non-vascularized osteochondral or chondral grafts with some drawbacks potentially linked to the lack of vascular supply in those grafts. The aim of this study was to describe a surgical approach for harvesting a vascularized chondrocostal graft, to study the vascular supply to the perichondrium and finally to describe the perichondrium micro-vascularization in order to know how such grafts could be used in cartilage repair surgery. MATERIALS AND METHODS: We harvested and studied 18 costal cartilages harvested from 12 fresh anatomical subjects. The anatomic pieces were injected with a radio-opaque tracer, analyzed macroscopically, then a plain X-rays and CT scan analysis with three-dimensional rendering was performed in order to evaluate the characteristics of the different patterns of their vascularization. RESULTS: The surgical approach to harvest a vascularized 5th chondrocostal graft is explained in detail. All of the cartilages were vascularized by the internal thoracic artery and harvested with a pedicle of an average length of 34mm and diameter of 2.14mm. In all specimens, perichondrium vascularization arises from both superior and inferior intercostal branches. Anastomoses between inferior and superior intercostal branches are always found in all specimens at the level of the epichondrium. CONCLUSIONS: The anatomic approach for harvesting a vascularized chondrocostal graft is simple and only slightly differs from the approach described for harvesting a non-vascularized chondrocostal graft. The vascular supply to the perichondrium of such a vascularized chondrocostal graft is sustained by the internal thoracic vessels which have a sufficient diameter and length to allow easy micro-anastomosis. The organization of the micro-vasculature within the perichondrium allows the graft to be tailored to a large cartilage defects and also to small bipolar cartilage defects.

Analysis of the effects of arthrodesis of the hallux metatarsophalangeal joint on gait cycle: results of a GAITRite® treadmill test.

INTRODUCTION: Approximately 80% of patients are satisfied with the outcome of arthrodesis of the hallux metatarsophalangeal (MTP) joint. The hypothesis of this study was that MTP arthrodesis does not influence the walking cycle. The aim of this study was to evaluate the effect of MTP arthrodesis on gait cycle and to measure the functional outcome of MTP arthrodesis after a minimum of two year follow-up. METHOD: This was an observational prospective cohort study performed at a single centre that included 26 patients (32 ft) who underwent unilateral or bilateral MTP arthrodesis during the period 2004-2014. An X-ray assessment based on the American Orthopaedic Foot and Ankle Society score was performed pre-operatively and at the last follow-up (average follow-up duration 8.3 years). The walking cycle was analysed at the final follow-up using a GAITRite® treadmill test. RESULTS: Twenty unilateral and six bilateral MTP arthrodeses were included in this study. The average age of the patients was 70 years. No significant difference was found in the walking cycle between the operated and non-operated sides for unilaterally MTP arthrodesis. However, we observed a non-significant increase in the percentage of contact time after MTP arthrodesis (65% on the operated side vs. 63% on the non-operated side). We also observed a significant decrease in the average walking rate, and a decrease in walking speed, in cases of bilateral MTP arthrodesis compared with normal walking cycle data from a laboratory study. CONCLUSIONS: MTP joint arthrodesis does not appear to have any effect on the walking cycle, but reduced patient pain and increased the walking distance. The patients reported satisfaction with the surgical outcomes and would recommend it to a relative with the same pathology.

Lower-limb Flip-Flap: A simple reliable modification of adipofascial flap for extensive tibial crest cutaneous defect.

INTRODUCTION: Large cutaneous defects exposing the whole tibial crest are difficult to cover and are conventionally best treated with free flaps. This article describes a technical modification of the adipofascial flap in this indication. METHODS: The "flip-flap" is vascularized by the posterior tibial artery perforators harvested on the medial aspect of the leg. The hypodermal and fascial tissue is de-epidermized and elevated from the posterior midline up to the medial edge of the soleus muscle, then folded over the exposed tibial crest like a page of a book. RESULTS: A 27×6cm effect was successfully covered on a 72 year-old patient with vascular status precluding free flap. The flap healed by day 21. DISCUSSION/CONCLUSION: This technical modification is simple and allows coverage of large tibial crest skin defect when a free flap is not possible.

Treatment of cephalotuberosity fractures in elderly patients treated by reverse shoulder prosthesis: a study of functional results in relation to deltoid tension.

INTRODUCTION: The treatment of proximal humerus fractures is a therapeutic challenge in the elderly as the functional demands of these patients are high. We postulated that there may be a relationship between functional results and deltoid tension when these fractures are treated with a reverse prosthesis. This study was performed to determine the optimal tension of the deltoid. The primary outcome was the constant score in relation to humeral length at the final follow-up. MATERIALS AND METHODS: Our retrospective cohort consisted of 45 patients treated with a reverse fracture prosthesis during the period from January 2010 to July 2017. The fractures were all classified as Neer III or IV, 91% of our patients were women and the average age was 82 years. RESULTS: Constant score and antepulsion were improved with humeral elongation between 10 and 25 mm (p < 0.02 and p < 0.05, respectively). External rotation was improved with humeral elongation (p < 0.03). CONCLUSION: Tuberosity reinsertion improves mobility in patients treated surgically for a reverse fracture prosthesis. The recovery of anatomical retroversion seems of fundamental importance, and we confirmed that deltoid tension that must also be taken into account to improve functional results of reverse shoulder prosthesis on fracture. The ideal humeral elongation seems to be between 10 and 25 mm, in relation to the contralateral side, to obtain better functional results.

Are orthopedic surgeons exposed to excessive eye irradiation? A prospective study of lens irradiation in orthopedics and traumatology.

INTRODUCTION: Numerous studies in recent years highlighted an increased risk of pathologies related to ionizing radiation in caregivers. A new French decree was adopted on June 4, 2018, dividing by 7.5 the radiation dose authorized in the lens for exposed workers. HYPOTHESIS: The hypothesis of the present study was that ocular irradiation in orthopedic surgeons was below the new legal threshold. METHOD: The equivalent dose (mSv) received by the lens was prospectively assessed in 10 orthopedic surgeons (5 senior, 5 residents), using 3 passive dosimeters placed at the forehead and either temple. Each intervention of each operator was recorded, with dose per area in the operating room at each use of the fluoroscope. RESULTS: All equivalent doses to the lens at the end of the 4 month study period were well below threshold. Doses were not significantly different between forehead and either temple (p=0.7, p=0.6 for the 2 temples). There was no difference according to side of the head (p=0.3). The dose received in the lens correlated with the dose delivered in the room (p=0.004). There were no significant differences in irradiation according to the surgeon's experience (p=0.2) or trauma activity rate (p=0.4). DISCUSSION: No studies have reported equivalent doses to the lens exceeding the authorized limit. But none previously measured equivalent dose to the lens according to the axis of irradiation in the eyes. The present study showed that orthopedic surgeons received as much eye radiation laterally as frontally. Ocular radiation protection needs therefore to be as effective laterally as frontally. The surgeon's experience did not emerge as a protective factor against ocular irradiation.

Is non-operative treatment still relevant for Garden Type I fractures in elderly patients? The femoral neck impaction angle as a new CT parameter for determining the indications of non-operative treatment.

BACKGROUND: The indications of non-operative treatment of undisplaced femoral neck fractures are controversial. The objective of this study was to assess whether two computed tomography (CT) parameters, the femoral neck impaction angle (IA) and the femoral neck posterior tilt angle (PTA), were effective in predicting the risk of secondary displacement after non-operative treatment of Garden I femoral neck fractures in patients aged 65 years or over. HYPOTHESIS: The working hypotheses were that the IA in the coronal plane and PTA in the axial plane predicted secondary displacement after non-operative treatment of Garden I femoral neck fractures, could be reproducibly and reliably measured on CT scans, and could serve to identify Garden I fractures at risk for secondary displacement after non-operative treatment. METHODS: Forty-nine patients aged 65 years or over with Garden I fractures treated non-operatively were included in a prospective single-centre study. CT images were used to measure the IA as the position of the fracture line relative to the femoral head in the coronal plane and the PTA as the position of the femoral head centre relative to the femoral neck axis in the axial plane. RESULTS: After non-operative treatment, secondary displacement occurred in 22 (45%) patients. The PTA was not significantly different between the groups with vs. without secondary displacement (p=0.62). IA values≤135° were significantly associated with secondary displacement (odds ratio, 11.73; 95% confidence interval [95%CI], 3.04-45.28; p=0.004). An IA≤135° was 72.73% sensitive and 81.48% specific for predicting secondary displacement. IA measurement was reproducible, with intra-class and inter-class Cohen's kappa values of 0.94 (95%CI, 0.90-0.97) and 0.9011 (95%CI, 0.83-0.94), respectively. DISCUSSION: The IA measured on CT images may hold promise for identifying Garden I hip fractures at high risk for secondary displacement after non-operative treatment. IA measurement is reproducible and reliable and may help to determine the indications of non-operative treatment. LEVEL OF EVIDENCE: II, prospective cohort study.