Brain MRI in status epilepticus: Relevance of findings.

Status epilepticus (SE) represents one of the most common neurological emergencies, associated with high mortality and an important risk of functional sequelae in survivors. Magnetic resonance imaging (MRI) offers the possibility of early and noninvasive observation of seizure-induced parenchymal disturbances secondary to the epileptic process. In the present review, we propose a descriptive and comprehensive understanding of current knowledge concerning seizure-induced MRI abnormalities in SE, also called peri-ictal MRI abnormalities (PMAs). We then discuss how PMAs, as a noninvasive biomarker, could be helpful to optimize patient prognostication in SE management. Finally, we discuss alternative promising MRI approaches, including arterial spin labeling (ASL), susceptibility-weighted imaging (SWI), dynamic contrast-enhanced (DCE) MRI and dynamic susceptibility contrast (DSC) MRI that could refine our understanding of SE, particularly in non-convulsive form.

Multi-locus sequence typing and phylogenetics of Cryptococcus neoformans AD hybrids.

Hybrid AD strains of the human pathogenic Cryptococcus neoformans species complex have been reported from many parts of the world. However, their origin, diversity, and evolution are incompletely understood. In this study, we analyzed 102 AD hybrid strains representing 21 countries on five continents. For each strain, we obtained its mating type and its allelic sequences at each of the seven loci that have been used for genotyping haploid serotypes A and D strains of the species complex by the Cryptococcus research community. Our results showed that most AD hybrids exhibited loss of heterozygosity at one or more of the seven analyzed loci. Phylogenetic and population genetic analyses of the allelic sequences revealed multiple origins of the hybrids within each continent, dating back to one million years ago in Africa and up to the present in other continents. We found evidence for clonal reproduction and long-distance dispersal of these hybrids in nature. Comparisons with the global haploid serotypes A and D strains identified new alleles and new haploid multi-locus genotypes in AD hybrids, consistent with the presence of yet-to-be discovered genetic diversity in haploid populations of this species complex in nature. Together, our results indicate that AD hybrids can be effectively genotyped using the same multi-locus sequencing type approach as that established for serotypes A and D strains. Our comparisons of the AD hybrids among each other as well as with the global haploid serotypes A and D strains revealed novel genetic diversity as well as evidence for multiple origins and dynamic evolution of these hybrids in nature.

ACL surgical trends evolve in the last five years for young European surgeons: results of the survey among the U45 ESSKA members.

PURPOSE: Although the outcomes of ACL reconstruction are generally satisfying, there are several patients who do not regain their pre-injury sporting level and suffer persistent symptoms. Orthopaedic practice has evolved significantly over the last five years to address these drawbacks. The aim of the present survey was to analyze the changes in the approach to ACL reconstruction among a population of young ESSKA surgeons dedicated to ACL surgery. METHODS: The survey was uploaded on the ESSKA website and was accessible to members under the age of 45. The ESSKA society has 1035 U45 members involved in multiple aspects of Orthopaedic practice. One hundred and forty questionnaires were returned. Several aspects of ACL surgery were investigated at baseline and 5 years prior. They included general details such as the volume of ACL reconstructions per surgeon per year, the graft choice in cases of low and high demanding patients, the technique for femoral tunnel drilling and the preferred device for femoral fixation. The approach to the management of damage to peripheral structures, as well as meniscal ramp and root tears were also investigated. RESULTS: Hamstrings and quadrupled semitendinosus were the preferred graft choice in low-demanding patients (92.9%) while quadriceps tendon is gaining popularity in contact sport practitioners (from 4.3 to 10.7%). The percentage of surgeons using femoral screws had decreased from 37.9 to 29.3 while the percentage of those who used buttons increased from 52.9 to 69.3%. Extra-articular procedures (antero-lateral ligament (ALL) or lateral tenodesis have become popular. The percentage of surgeons who perform an additional peripheral reconstruction rose from 28.5 to 71.5%. Of those who perform the meniscal repair more than 50% of patients rose from 14.3 to 27.9%. Similarly, the percentage of surgeons who performed a medial meniscus ramp lesion repair rose from 29.4 to 54.7%. While the percentage of those who choose to perform a transtibial pull-out repair of lateral meniscus root tears significantly rose from 17.9 to 59.3%. CONCLUSIONS: The present survey among under 45 years old ESSKA surgeons yields some notable findings. The new evidence on the impact of injuries on peripheral structures and menisci is stimulating surgeons towards a more anatomic approach if identified at the time of ACL reconstruction. This evidence will probably influence future research and decision-making. LEVEL OF EVIDENCE: IV.

CAS and PSI increase coronal alignment accuracy and reduce outliers when compared to traditional technique of medial open wedge high tibial osteotomy: a meta-analysis.

PURPOSE: Medial open-wedge high tibial osteotomy (MOWHTO) is an accepted option in the treatment of medial compartment osteoarthritis of the knee in young and active patients. Functional results are closely correlated to the correction of the mechanical axis of the lower limb. Although several angular and geometrical methods and values have been proposed in the past, the ideal target is still debated. In addition, it is important to have a deep correlation between the planned correction and the achieved correction after surgery. The aim of the present systematic review was to identify the ideal coronal correction after MOWHTO and the most accurate method to achieve it. METHODS: A systematic review of the literature was completed on July 3rd 2020 in the Pubmed, Medline, Cochrane Reviews, and Google Scholar databases using the Medical Subject Headings (MeSH) terms: "high tibial osteotomy" AND "accuracy" OR "planning". RESULTS: 28 studies were included; 18 were focused on computer-assisted surgery (CAS) and 10 on patient-specific instrumentation (PSI). There were 598 patients in the CAS group and 501 in the control group; the rate of outliers was 16% and 38.2% respectively (P = 0.04), while there was no significant difference between the two groups (SMD = - 0.10; 95% CI 1.31 to 1.12; P = n.s.) in terms of coronal accuracy. Likewise, there were 318 patients in the PSI group and 40 in the control group; the rate of outliers was 15% and 40% respectively (P = 0.98), while there was no significant difference between the two groups (SMD = 0.01; 95% CI 0.58 to 0.59; P = 0.98). CONCLUSIONS: A statistically significant reduced outlier rate and a non-significant increased accuracy emerged with the use of CAS when compared to the traditional surgical technique, whereas the results of PSI were still inconclusive. In addition, it emerged clearly that no consensus still exists on the ideal correction target to be achieved after surgery. LEVEL OF EVIDENCE: III.

Comparison of knee extensor strength after anterior cruciate ligament reconstruction using either quadriceps tendon or hamstring tendon autografts.

PURPOSE: The aim was to assess the consequences of quadriceps tendon (QT) harvest on knee extensor strength after anterior cruciate ligament reconstruction (ACL-R) compared to hamstring tendon (HT) autograft. Secondary objectives were to evaluate flexor strength recovery and search for correlation between strength status and functional outcome. METHODS: This a retrospective cohort of 44 patients who underwent ACL-R using either QT (25) or HT (19). Median age was 31.1 years. We assessed thigh muscle strength thanks to concentric iso kinetic evaluation (peak torque) at 60°.s-1, 180°.s-1, 240°.s-1 and eccentric at 30°.s-1, 7 months on average after surgery. Muscle strength values were compared to the uninjured leg in order to calculate a percentage of deficit as well as unilateral hamstring/quadriceps (H/Q) ratios. KOOS score was obtained at a mean follow-up of 18 months. RESULTS: Extensor strength deficit (concentric 60°.s-1) was one average 33.1% in the QT group and 28.2% in the HT group (p = 0.42). Difference of flexor strength deficit (concentric 60°.s-1) was close to be significant with 5% and 12% of deficit in the QT and HT group, respectively (p = 0.1), and statistically significant for high angular velocity (14% versus 3% at 240°.s-1, p = 0.04). H/Q ratios were comparable in both groups ranging from 0.62 to 0.78. Quadriceps muscle strength deficit was negatively correlated with the KOOS score (Pearson coefficient = -0.4; p = 0.005). CONCLUSION: QT autograft harvest does not yield significant quadriceps muscle weakness after ACL-R, which appear to be a pejorative factor for functional outcome. LEVEL OF EVIDENCE: IV, Retrospective study.

Intraoperative virtual reality distraction in TKA under spinal anesthesia: a preliminary study.

INTRODUCTION: The effect of patient anxiety during the perioperative period has been shown to be of great importance in its influence on post-operative recovery. Over the last 10 years, virtual reality (VR) has been developed in anesthesia for patient's distraction by immersion. The aim of this study was to evaluate post-operative patient anxiety the day after TKA surgery under spinal anesthesia (SA) with or without VR distraction. MATERIALS AND METHODS: A single-center, prospective cohort study was performed looking at patients undergoing TKA surgery under SA with a VR headset (group 1) compared with those undergoing the same procedure with standard protocol (group 2). Data using a validated scoring system looking at patient anxiety (STAI Y-1) were collected. Secondary endpoints were need for sedation during surgery, intraoperative complications (hypotension and oxygen need), postoperative pain and comfort scores (VAS) and patient satisfaction. RESULTS: Ten patients (group 1) received the VR headset during surgery and 10 (group 2) received the standard protocol established in our center. Average age was 73 years old. No difference was found in post-operative patient anxiety regarding to STAI Y-1 score (95% CI - 7 to 10, p = 0.71. There was a decrease of sedation and intra-operative adverse event as hypotension and oxygen requirement in group 1 (p < 0.0001, p = 0.015, p = 0.0054), and a significant increase in comfort score (p = 0.002). No difference in patient satisfaction was found. CONCLUSION: Using VR for immersive distraction seemed to lead to no difference in patient anxiety in TKA under SA. Intra-operative adverse events were decreased, and post-operative comfort was increased. Patient satisfaction was not modified. This preliminary study is encouraging and gives us arguments to involve larger number of patients while exploring the various possibilities offered by VR.

Communicating chronic hydrocephalus: A review.

Formerly called normal pressure hydrocephalus, communicating chronic hydrocephalus (CCH) is a condition affecting 0.1 to 0.5% of patients over 60years of age. The pathophysiology of this disease is poorly understood, but a defect in cerebrospinal fluid (CSF) resorption appears to be commonly defined as the cause of the neurological disorders. The last important discovery is the description of the glymphatic system and its implication in CCH and CSF resorption. Comorbidities (Alzheimer's disease, microangiopathy, parkinsonism) are very frequent, and involve a diagnostic challenge. The clinical presentation is based on the Hakim and Adams triad, comprising gait disorders, mainly impairing walking, cognitive disorders, affecting executive functions, episodic memory, visuospatial cognition, and sphincter disorders as urinary incontinence (detrusor hyperactivity). The diagnosis is suspected through a set of arguments, combining the clinical presentation, the radiological data of the magnetic resonance imaging (MRI) showing a ventriculomegaly associated with signs of transependymomous resorption of the CSF and disappearance of the cortical sulci, and the clinical response to the depletion of CSF. In the presence of all these elements, or a strong clinical suspicion, the standard treatment will be of a permanent CSF shunt, using a ventriculoatrial or ventriculoperitoneal shunt. The effectiveness of this treatment defines the diagnosis. The clinical improvement is better when treatment occurs early after the onset of the disorders, reaching 75 to 90% of motor improvement.

Advanced multiparametric magnetic resonance imaging of multinodular and vacuolating neuronal tumor.

BACKGROUND AND PURPOSE: Multinodular and vacuolating neuronal tumor (MVNT) of the cerebrum is a rare brain lesion with suggestive imaging features. The aim of our study was to report the largest series of MVNTs so far and to evaluate the utility of advanced multiparametric magnetic resonance (MR) techniques. METHODS: This multicenter retrospective study was approved by our institutional research ethics board. From July 2014 to May 2019, two radiologists read in consensus the MR examinations of patients presenting with a lesion suggestive of an MVNT. They analyzed the lesions' MR characteristics on structural images and advanced multiparametric MR imaging. RESULTS: A total of 64 patients (29 women and 35 men, mean age 44.2 ± 15.1 years) from 25 centers were included. Lesions were all hyperintense on fluid-attenuated inversion recovery and T2-weighted imaging without post-contrast enhancement. The median relative apparent diffusion coefficient on diffusion-weighted imaging was 1.13 [interquartile range (IQR), 0.2]. Perfusion-weighted imaging showed no increase in perfusion, with a relative cerebral blood volume of 1.02 (IQR, 0.05) and a relative cerebral blood flow of 1.01 (IQR, 0.08). MR spectroscopy showed no abnormal peaks. Median follow-up was 2 (IQR, 1.2) years, without any changes in size. CONCLUSIONS: A comprehensive characterization protocol including advanced multiparametric magnetic resonance imaging sequences showed no imaging patterns suggestive of malignancy in MVNTs. It might be useful to better characterize MVNTs.

Diagnostic implications of mycetoma derived from Madurella pseudomycetomatis isolates from Mexico.

BACKGROUND: At the dermatology service of the General Hospital of Mexico City, Mexico, two patients, father and son, with black-grain mycetoma were seen. The grains were isolated, and the cultured fungi were identified as Madurella mycetomatis based on morphology. Using the M. mycetomatis specific PCR, amplicons of a different size than that of the M. mycetomatis type strain were obtained. OBJECTIVE: To determine the causative agent of the two black-grain mycetoma cases and develop non-culture-based diagnostic tools to identify them to the species level. METHODS: The M. mycetomatis specific, the internal transcribed spacer (ITS) region, ß-tubulin (BT) and ribosomal binding protein 2 (RBP2) PCRs were used to confirm the identity of the isolates. Genetic variation was established by amplification fragment length polymorphisms. To determine the antifungal susceptibility profile, the Sensititre™ YeastOne™ assay was used. To develop a species-specific PCR primers were designed on the sequenced PCR amplicon from the M. mycetomatis specific PCR. RESULTS: By analyzing the ITS, BT and RBP2 regions the isolates were identified as Madurella pseudomycetomatis. The isolates from father and son were similar but not identical to M. pseudomycetomatis from Venezuela and one from an unknown origin. Madurella pseudomycetomatis isolates were inhibited by itraconazole, posaconazole and voriconazole but showed increased MIC values for amphotericin B and fluconazole. They were not inhibited by the echinocandins and five flucytosine. The two patients were treated with itraconazole resulting in cure for the father while the son was lost to follow-up. The species-specific PCR developed for M. pseudomyceotmatis was discriminative and specific. CONCLUSION: Madurella pseudomycetomatis is genetically diverse with same susceptibility profile as M. mycetomatis and causes eumycetoma in Latin America. The M. pseudomycetomatis specific PCR can be used to identify this causative agent to the species level; however, this needs to be validated in an endemic setting.

Treatment of degenerative meniscal tear with intrameniscal injection of platelets rich plasma.

PURPOSE: The purpose of this retrospective study was to describe our preliminary results of intra-meniscal administration of platelet rich plasma (PRP) in patients with degenerative meniscal tears of the knee. MATERIAL AND METHOD: Ten patients with degenerative meniscal tears according to the Stoller classification and without knee osteoarthritis were included. There were 7 men and 3 women with a mean age of 40.4±13.6 [SD] years (range: 18-59 years). Patients were prospectively assessed at baseline and 3- and 6-months after intra meniscal PRP administration. Evaluation included the knee injury and osteoarthritis outcome score (KOOS), pain visual analog scale, and return to competition and training. MRI follow-up was performed 6 months after PRP administration. Adverse events were recorded. RESULTS: Volume of injected PRP was standardized to 4.0mL. Adverse events during PRP administration was moderate pain in 8 patients (8/10; 80%). Mean KOOS total score significantly improved from 56.6±15.7 (SD) to 72.7±18.5 (SD) (P=0.0007). All six patients practicing sports regularly were able to recover competition or training. In seven patients who underwent MRI follow-up at 6 months, MRI showed stability of the meniscal tears and similar Stoller grades. CONCLUSION: Intra-meniscal administration of PRP under ultrasound guidance directly into meniscal degenerative lesions is feasible and safe. Further randomized controlled studies are needed to definitely confirm the effectiveness of this procedure.

Multinodular and Vacuolating Posterior Fossa Lesions of Unknown Significance.

Multinodular and vacuolating neuronal tumor of the cerebrum is a rare supratentorial brain tumor described for the first time in 2013. Here, we report 11 cases of infratentorial lesions showing similar striking imaging features consisting of a cluster of low T1-weighted imaging and high T2-FLAIR signal intensity nodules, which we referred to as multinodular and vacuolating posterior fossa lesions of unknown significance. No relationship was found between the location of the lesion and clinical symptoms. A T2-FLAIR hypointense central dot sign was present in images of 9/11 (82%) patients. Cortical involvement was present in 2/11 (18%) of patients. Only 1 nodule of 1 multinodular and vacuolating posterior fossa lesion of unknown significance showed enhancement on postcontrast T1WI. DWI, SWI, MRS, and PWI showed no malignant pattern. Lesions did not change in size or signal during a median follow-up of 3 years, suggesting that multinodular and vacuolating posterior fossa lesions of unknown significance are benign malformative lesions that do not require surgical intervention or removal.

Antibiotic-loaded tantalum may serve as an antimicrobial delivery agent.

AIMS: The aims of this study were to compare the mean duration of antibiotic release and the mean zone of inhibition between vancomycin-loaded porous tantalum cylinders and antibiotic-loaded bone cement at intervals, and to evaluate potential intrinsic antimicrobial properties of tantalum in an in vitro medium environment against methicillin-sensitive Staphylococcus aureus (MSSA). MATERIALS AND METHODS: Ten porous tantalum cylinders and ten cylinders of cement were used. The tantalum cylinders were impregnated with vancomycin, which was also added during preparation of the cylinders of cement. The cylinders were then placed on agar plates inoculated with MSSA. The diameter of the inhibition zone was measured each day, and the cylinders were transferred to a new inoculated plate. Inhibition zones were measured with a Vernier caliper and using an automated computed evaluation, and the intra- and interobserver reproducibility were measured. The mean inhibition zones between the two groups were compared with Wilcoxon's test. RESULTS: MSSA was inhibited for 12 days by the tantalum cylinders and for nine days by the cement cylinders. At day one, the mean zone of inhibition was 28.6 mm for the tantalum and 19.8 mm for the cement group (p < 0.001). At day ten, the mean zone of inhibition was 3.8 mm for the tantalum and 0 mm for the cement group (p < 0.001). The porous tantalum cylinders soaked only with phosphate buffered solution showed no zone of inhibition. CONCLUSION: Compared with cement, tantalum could release antibiotics for longer. Further studies should assess the advantages of using antibiotic-loaded porous tantalum implants at revision arthroplasty. Cite this article: Bone Joint J 2019;101-B:848-851.

Isavuconazole MIC distribution of 29 yeast species responsible for invasive infections (2015-2017).

OBJECTIVES: Isavuconazole is a recent extended-spectrum triazole with activity against yeasts. However, few data are available about the in vitro activity of rare yeast species. We report the MIC distribution of isavuconazole compared with fluconazole for a large collection of common or rare yeasts. METHODS: Isavuconazole and fluconazole MICs were determined using the EUCAST method for 1457 clinical isolates, mainly recovered from invasive infections, belonging to 29 species. They were sent to the National Reference Centre for Invasive Mycoses & Antifungals between January 2015 and October 2017 and species identification was performed using a polyphasic approach (matrix-assisted laser desorption/ionization time of flight analysis and a molecular method). RESULTS: Isavuconazole had effective in vitro activity against Cryptococcus neoformans (MIC90 < 0.25 mg/L), the five most common Candida spp. (MIC90 ≤ 0.5 mg/L for Candida albicans, Candida glabrata, Candida tropicalis, Candida parapsilosis, and Candida krusei) and also against the majority of rare species, including Candida kefyr and Candida lusitaniae. A few isolates of C. albicans (0.7%, 3/404), C. glabrata (2.7%, 5/184), C. tropicalis (1.0%, 1/96) and C. parapsilosis (0.8%, 1/127) exhibited MIC ≥4 mg/L. All were also resistant to fluconazole according to the EUCAST breakpoints. Some isolates with isavuconazole MIC ≥4 mg/L were also observed among rarer species: Meyerozyma guilliermondii (8.7%, 2/23), Wickerhamomyces anomalus (10.0%, 1/10). Other rare species Saprochaete clavata, Magnusiomyces capitatus, and Rhodotorula mucilaginosa had high MIC50 (≥1 mg/L) and MIC90 (≥4 mg/L) and could be considered as resistant to isavuconazole. CONCLUSIONS: We confirmed the good in vitro activity of isavuconazole against common Candida, Cryptococcus species and the majority of the rare yeast species studied.

Repeat two-stage exchange arthroplasty for prosthetic hip re-infection.

Aims: Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure. Patients and Methods: We retrospectively identified 19 hips (19 patients) that had undergone repeat two-stage revision THA for infection between 2000 to 2013. There were seven female patients (37%) and the mean age was 60 years (30 to 85). Survival free from revision was assessed via Kaplan-Meier analysis. The patients were classified according to the Musculoskeletal Infection Society (MSIS) system, and risk factors for failure were identified. Mean follow-up was four years (2 to 11). Results: Gram-positive bacteria were responsible for 16/17 (94%) of the re-infections where microbes were identified. Following the repeat two-stage exchange arthroplasty, survival free from any revision was 74% (95% confidence interval (CI) 56% to 96%, 14 at risk) at two years and 45% (95% CI 25% to 75%, five at risk) at five years. Failure to control infection resulted in re-operation or revision in 42%A of patients (8/19). Survival free from revision was not dependent on host grade. Conclusion: Re-infection after two-stage exchange hip arthroplasty for PJI presents a challenging scenario. Repeat two-stage exchange arthroplasty has a low survival free from revision at five years (45%) and a high rate of re-infection (42%). Cite this article: Bone Joint J 2018;100-B:1157-61.

Which factors influence proximal femoral asymmetry?: a 3D CT analysis of 345 femoral pairs.

Aims: In patients where the proximal femur shows gross deformity due to degenerative changes or fracture, the contralateral femur is often used to perform preoperative templating for hip arthroplasty. However, femurs may not be symmetrical: the aim of this study was to determine the degree of variation between hips in healthy individuals and to determine whether it is affected by demographic parameters. Materials and Methods: CT-scan based modelling was used to examine the pelvis and bilateral femurs of 345 patients (211 males, 134 women; mean age 62 years (standard deviation (sd) 17), mean body mass index 27 kg/m2 (sd 5)) representing a range of ethnicities. The femoral neck-shaft angle (NSA), femoral offset (FO), femoral neck version (FNV), femoral length (FL), femoral canal flare index (fCFI), and femoral head radius (FHr) were then determined for each patient. All measurements were constructed using algorithm-calculated landmarks, resulting in reproducible and consistent constructs for each specimen. We then analyzed femoral symmetry based on absolute differences (AD) and percentage asymmetry (%AS) following a previously validated method. Results: We found an asymmetry > 2% for NSA (mean AD 2.9°, mean %AS 2.3; p = 0.03), FO (AD 3.8 mm, %AS 9.1 ; p = 0.01), FNV (AD 5.1°, %AS 46.7 ; p = 0.001) and fCFI (AD 0.2 mm, %AS 5.4 ; p = 0.7). Significant relationships were found for AD regarding NSA and ethnicity (p = 0.037), FL and height (R2 = 0.22), and fCFI and gender (R2 = 0.34). Conclusion: Our data confirm the presence of asymmetry of proximal femurs, which is mostly independent of demographic parameters. In cases where contralateral templating is used, such asymmetry may lead to inaccurate anatomical restoration of the hip if the templated sizes are routinely implanted. However, the clinical impact cannot be determined from our investigation. Cite this article: Bone Joint J 2018;100-B:839-44.

The CJOrtho app: A mobile clinical and educational tool for orthopedics.

The need for modern patient evaluation tools continues to grow. A dependable and reproducible assessment provides objective follow-up and increases the validity of collected data. This is where mobile apps come into play, as they provide a link between surgeons and patients. They also open the possibility of interacting with other healthcare staff to exchange common scientific reference systems and databases. The CJOrtho app provides fast access to 65 classification systems in orthopedics or trauma surgery, 20 clinical outcome scores and a digital goniometer. The development of free mobile apps is an opportunity for education and better follow-up, while meeting the demands of patients.

Influence of treatment modality on morbidity and mortality in periprosthetic femoral fracture. A comparative study of 71 fractures treated by internal fixation or femoral implant revision.

INTRODUCTION: The incidence of periprosthetic femoral fracture is constantly increasing, with high associated morbidity and mortality. Surgical treatment is guided by the Vancouver classification, but the influence of type of treatment on morbidity and mortality has been little analyzed. The theoretical advantage of implant revision over internal fixation is that it should allow earlier weight-bearing, although the impact of this on morbidity and mortality and autonomy has not been demonstrated. We conducted a case-control study, to assess the influence of type of treatment (implant revision or internal fixation) (1) on mobility and autonomy and (2) on morbidity and mortality. HYPOTHESIS: The study hypothesis was that clinical results and morbidity and mortality do not differ between these two types of treatment. METHODS: A retrospective study included 70 patients with a total of 71 femoral periprosthetic fractures treated between 2007 and 2014. Two treatment groups, comparable for mean age, gender and ASA and Parker scores, were studied. Mean age was 78±13.5years (range, 23-95years). Thirty-six fractures (50.7%) were treated by implant revision via a posterolateral approach, using a revision stem with (n=11) or without cement (n=25) (REVISION group); immediate postoperative weight-bearing was authorized. Thirty-five fractures (49.3%) were treated by open reduction and internal fixation, using a locking plate (ORIF group); weight-bearing was authorized only in the third month. Mean follow-up was 43±27months (range, 0.75-107months). RESULTS: Autonomy on Parker score was reduced by 2 points at 1year's follow-up. Mean preoperative scores were 7.32±1.79 (range, 3-9) and 7.43±1.79 (range, 4-9) in the REVISION and ORIF group, respectively, (p=0.8), falling to 5.06±2.6 (range, 0-9) and 4.5±2.01 (range, 0-9) respectively at follow-up (p=0.349). Sixteen patients in the REVISION group versus 13 in the ORIF group had made adaptations in their home or changed place of residence (p=0.2). At last follow-up, 18 patients (28.6%) had died: 12 (37.5%) in the ORIF and 6 (19.3%) in the REVISION group (p<0.05). Survival with death as endpoint at a mean 3.5years was 88±11% in the REVISION group versus 51±11% in the ORIF group (p=0.02). Three implant replacements were performed in each group (p=0.83). Twelve medical or surgical complications occurred in the ORIF group (37.5%) and 11 in the REVISION group (34%) (p=0.9). CONCLUSION: Implant revision for periprosthetic femoral fracture showed significantly lower overall mortality than internal fixation, without difference in terms of treatment failure or complications requiring revision surgery. LEVEL OF EVIDENCE: Level III, case-control study.

Pull-out strength of four tibial fixation devices used in anterior cruciate ligament reconstruction.

INTRODUCTION: In reconstructions of the anterior cruciate ligament (ACL), tibial fixation can be the weak point in the assembly during the early postoperative period. The present study sought to compare pull-out strength between four tibial fixation systems used in ACL reconstruction. HYPOTHESIS: The study hypothesis was that all four devices show ≥450N pull-out strength with comparable biomechanical breakage characteristics. MATERIAL AND METHODS: An experimental study used a mechanical model to perform axial traction on a synthetic ligament (polypropylene cord folded in four) implanted in an artificial tibia (Sawbones Proximal Tibia # 1116-2: model: normal anatomy; solid foam; size: medium) using four tibial fixation systems: Ligafix® interference screw (SBM™); Bio-Intrafix® (Mitek™); Translig® (SBM™); RIGIDfix® (SBM™). For each system, four models were tested using an Instron 5566® traction machine, allowing 100mm/min stretching up to breakage. Study parameters comprised: pull-out strength, maximal whole assembly slippage, stiffness at breaking point, and type of break. RESULTS: Mean pull-out strength was 450±24N (range, 421-488N) for Ligafix®, 415±60N (327-454N) for Bio-Intrafix®, 539±66N (449-636N) for RigidFix and 1067±211N (736-1301N) for Translig®, and was significantly greater for Translig® than for the other devices (p=0.02), which did not significantly differ from one another. The expected maximal load of 450N was reached in 100% of cases with Translig® and RIGIDfix® and in 50% of cases with Bio-Intrafix® and Ligafix®. There were no significant differences regarding stiffness. Ligafix® showed significantly less slippage than the others (p=0.006), with breakage caused by the ligament sliding between bone and implant. DISCUSSION: In this in-vitro study, the Translig® fixation device showed better pull-out strength than the other three devices tested. TYPE OF STUDY AND LEVEL OF EVIDENCE: Comparative laboratory study. Level II.