"One millimetre equals one degree": a simple way to achieve in 92% of cases the desired correction after opening proximal tibial osteotomy for genu varum.

INTRODUCTION: When performing a high tibial osteotomy (HTO) for genu varum deformity, it is not always easy to obtain the correct amount of overcorrection. The aims of this study were to review the results of a simple and reproducible method of correction that we have called "1 mm equals 1°". We have applied this technique to the medial opening wedge osteotomy. Our hypothesis was that one degree of correction corresponded with one degree of opening. METHODS: 97 proximal medial opening wedge osteotomies were measured intraoperatively with a navigation system and at 3 months with long-leg X-rays. The hip-knee-ankle (HKA) angle preoperatively was on average 173.8 ± 2.3° (170°-177°). In most cases, an opening of 4° greater than the initial varus was performed using our formula that one degree varus was equal to 1 mm of opening. In other words, when the varus was 6°, an opening of 10 mm was performed. The void left by the opening wedge was filled with a calcium triphosphate wedge and the construct fixed and held with a locking plate. RESULTS: Aiming for a knee axis of 184 ± 2°, which corresponds to 2°-6° of overcorrection, we obtained the following results: HKA intraoperatively measured angle with navigation was on average 183.5 ± 0.9° (182°-184°) and HKA radiologically postoperatively angle was 182.5° ± 1.6° (179°-189°). We therefore achieved the desired overcorrection of 2°-6° in 92% of cases based on our postoperative radiographs and in 100% cases based on intraoperative measurements with computer navigation. CONCLUSION: The method of "1 mm equals 1°" is a simple, reliable, and reproducible method to achieve in 92% of cases the desired overcorrection (i.e., 184 ± 2°) with valgising proximal medial opening wedge osteotomy in genu varum.

Validity of the lever sign test for the clinical diagnosis of anterior cruciate ligament tears: Assessments in ski resorts.

INTRODUCTION: The clinical diagnosis of an anterior cruciate ligament (ACL) tear is based on 3 tests: anterior drawer, pivot shift and Lachman. The latter is the most commonly used test. The "lever sign" is a new clinical test that was first described by Lelli et al. in 2014. The primary objective of this study was to determine the sensitivity of the lever sign test for the clinical diagnosis of ACL tears, in the primary care setting of patients with acute knee injuries. Primary care being the first point of contact between patients and the healthcare system (general practitioners in this study). The secondary objective was to calculate the positive predictive value (PPV) of the lever sign test, by comparing it to the PPV of the Lachman test and its sensitivity. The working hypothesis was that the sensitivity of the lever sign test was equal to or greater than 80%. METHODS: This prospective cohort study included patients with ski-related knee injuries which occurred in French ski resorts between December 1, 2019, and March 15, 2020. The Lachman test and the lever sign test were performed by 36 mountain physicians and were compared to the magnetic resonance imaging (MRI) findings. The lever sign test involved placing a closed fist under the patient's calf in the supine position and applying downward pressure over the quadriceps. Depending on whether the ACL was intact or not, the patient's heel would either rise off the examination table or remain still. This study included 258 patients: 190 women and 68 men. RESULTS: The MRIs found 219 ACL tears and 36 intact ACLs. Three MRIs were deemed uninterpretable. The sensitivity of the lever sign test was 61.2% and the PPV was 83.8%. The sensitivity of the Lachman test was 99.1% and the PPV was 86.5%. CONCLUSION: This study determined the sensitivity of the lever sign test for the clinical diagnosis of ACL tears during real-life situations encountered by mountain physicians. This sensitivity was lower than expected. The Lachman test, on the other hand, showed a very high sensitivity. It remains the test of choice for the clinical diagnosis of ACL tears in patients with knee injuries. Therefore, the lever sign test can complement the Lachman test but is not a substitute for it. LEVEL OF EVIDENCE: II.

Assessment of morbidity and mortality after periprosthetic hip fracture. Influence of Vancouver stage in a retrospective single-centre study of 88 patients.

BACKGROUND: Peri-prosthetic hip fractures (PPHFs) are serious complications whose treatment is generally difficult due to their predominance in elderly patients with bone frailty and other comorbidities. The Vancouver classification is the most widely used and is helpful for assisting treatment decisions. However, its value for predicting morbidity and mortality has not been assessed. The objective of this retrospective study was to assess post-operative morbidity and mortality according to the fracture type in the Vancouver classification. HYPOTHESIS: Post-operative morbidity and mortality vary across fracture types in the Vancouver classification. METHODS: A single-centre retrospective study was conducted from 1st January 2010 to 31st December 2015. All patients who had surgery for a PPHF were included. There were 88 patients, including 66 (75%) females, and mean age was 82 years. The patients were re-evaluated at least 3 years after surgery. The distribution of the fracture types was as follows: Vancouver (V) A, n=7; VB, n=63 (VB1, n=30; VB2, n=23; and VB3, n=10); and VC, n=18. Data on the pre-operative status (self-sufficiency, comorbidities, ASA score, etc.) were extracted from the admission files. Morbidity and mortality were evaluated globally and according to the Vancouver type, using the patient files and telephone calls to determine self-sufficiency scores (Parker, Katz, and Lawton) and functional scores (Merle d'Aubigné-Postel [MAP] score and Harris Hip Score [HHS]). RESULTS: Post-operative medical complications were very common (33 [37.5%] patients) and correlated with the severity of the fracture. Similarly, the mortality rate at last follow-up varied significantly (p<0.05) with the severity of the fracture, as follows: VA, 28.5%; VB1, 40%; VB2, 47.8%; VC, 55.6%; and VB3, 66.7%). In the overall population, loss of self-sufficiency was 20%, 14%, and 26% according to Parker, Katz, and Lawton, respectively; loss of function was 13.9% and 13.3% according to the MAP score and HHS (p<0.05). All the self-sufficiency scores (Parker, Katz, and Lawton) and functional scores (MAP and HHS) decreased post-operatively in proportion to the severity of the fracture (very small losses for VA and greatest losses for VB3) (p<0.05). CONCLUSION: The short- and medium-term mortality rates in our cohort of patients with PPHFs were high and chiefly dependent on the severity of the fractures. The self-sufficiency and functional scores were better in the group with VA fractures than in the groups with VB1, VB2, VB3, and VC fractures. In any case, early weight-bearing is without doubt a key factor in limiting the impact of PPHFs on the functional outcome and on mortality. LEVEL OF EVIDENCE: IV, retrospective study.

Displaced mid-shaft clavicular fractures: state of the art for athletes and young active people.

INTRODUCTION: Fractures ofthe clavicle are frequent injuries (between 4 and 10% of adult fractures) and mid-shaft diaphyseal fractures represent more than 80% of clavicle fractures. In a recent study from the USA in 2019, an incidence of 22.4 fractures per year per 100,000 people was reported. Multiple injury mechanisms are recognised, with sport accounting for 50 to 85% of these injuries. There is little or no consensus as to the optimal treatment but in recent years multiple studies have suggested operative management should be favoured in athletes and young active patients. OBJECTIVES: These are (1) to present the anatomy and the anatomical-pathology of the fractures of the clavicle as well as the mechanisms of injury, (2), (3) to describe non-operative and operative treatment methods, (4) to review the literature around different treatment modalities and (5) to attempt to describe the best treatment for athletes. METHODS: To collect and analyse the most recent articles of the literature regarding the management of displaced mid-shaft fractures of the clavicle for athletes and young active people. RESULTS: Looking at studies of the general population, the results tend to favour surgical treatment with a smaller incidence of non-union and faster return to function. These results are mirrored in the athlete population where several studies have shown excellent anatomic restoration and functional recovery after plate fixation. CONCLUSION: Based on this analysis, with the exception of patients who refuse operative management after an informed discussion, the treatment of choice in displaced clavicle fractures in athletes seems to be operative treatment with a plate and screws. However, prospective randomised studies comparing non-surgical treatment and plate osteosynthesis are missing and it is not possible to state that the latter is the best treatment.

Deciphering acute shoulder trauma with normal initial X-ray: Contributions of ultrasonography and MRI.

INTRODUCTION: Shoulder trauma with normal radiographs is a frequent emergency presentation. The predominance of pain makes clinical examination unreliable, and complementary imaging is often needed for diagnosis. The aim of the present study was to assess the contribution of ultrasonography (US) and magnetic resonance imaging (MRI) in deciphering such trauma. The study hypothesis was that MRI can confirm most diagnoses and reveal occult lesions. METHODS: 48 patients with a median age of 33 years (IQR, 22-48.75), admitted to the Emergency Department between February and September 2016, were prospectively included. All had normal X-ray and underwent emergency and deferred emergency (D+7-10) clinical examination, and US and MRI at D+7-14. The same examinations were repeated to establish diagnosis and initiate treatment. MRI was considered as gold-standard for definite diagnosis. RESULTS: Diagnoses comprised: 14 shoulder contusions; 13 rotator cuff tears; 8 acromioclavicular sprains; 6 fractures: 3 greater tuberosity, 2 humeral head, 1 lateral quarter of the clavicle; 3 subluxations or anterior dislocations with spontaneous reduction; 1 posterior dislocation with spontaneous reduction; 1 case of resorption of calcification in the pectoralis major tendon; 1 case of coracobrachialis strain; and 1 partial pectoralis major detachment. Concordance with final diagnosis was 42% (20/48) on initial clinical examination and 52% (25/48) on reassessment. On US, concordance was 71% (34/48), with 82% positive predictive value for cuff tear and 0% for instability. MRI was contributive in all cases, revealing 48 abnormal signals in 41 patients, thus establishing 48 diagnoses. CONCLUSION: Except in precise diagnostic situations such as rotator cuff tear, US is not a contributive examination, completely overlooking shoulder instability and bone contusion. MRI should play an increasing role in deciphering these traumas. LEVEL OF EVIDENCE: II; prospective cohort study.

Are Schatzker and AO classifications accurate enough to classify tibial plateau fractures in alpine skiers?

PURPOSE: The aims of this study were (1) to collect prospectively all tibial plateau fractures admitted to our department, over two ski seasons, and to classify them according to the Schatzker and AO classifications; (2) to assess if these classifications are accurate enough to include all types of fractures; and (3) to compare theses fractures with the series found in the literature, which included very few or no skiing accidents. METHODS: During the 2016-2017 and 2017-2018 ski seasons, we prospectively included 116 tibial plateau fractures caused by downhill skiing accidents. All patients underwent standard X-rays and 2D and 3D CT scans. The fractures were classified according to the AO and Schatzker revisited classifications. RESULTS: The full series consisted of 56 males (48%) and 60 females (52%), aged 49 ± 16 years (18-77). There were 60 type B (52%) and 56 type C fractures (48%) for AO classification and 45.5% types I, II and III and 54.5% types IV, V and VI for Schatzker classification. Thirty-five frontal fractures (30%) were not differentiated under the AO classification and, likewise, associated tibial spine fractures (28.5%) were not differentiated in the Schatzker classification. We were also unable to classify anterior tibial tuberosity fractures (14.5%) and fibula head fractures (8%). The anatomo-pathological types were not so different from road traffic accidents. CONCLUSION: Contrary to our hypothesis, the anatomical-pathological damage in tibial plateau fractures resulting from downhill skiing accidents was barely any different from those found in road traffic accidents. However, despite progress in classifications with the emergence of 3D CT scans, it is still not always possible to categorise all fractures within a given classification.

Navigation Improves the Survival Rate of Mobile-Bearing Total Knee Arthroplasty by Severe Preoperative Coronal Deformity: A Propensity Matched Case-Control Comparative Study.

The primary hypothesis of this study was that the survival rate over 10 years of total knee arthroplasties (TKAs) implanted with a navigation system was superior to that of TKAs implanted with a conventional technique. The secondary hypothesis was that the severity of the initial coronal deformity had a negative influence on the survival rate. A national, multicentric, retrospective study was performed in France, including eight university or private centers with high volumes in knee surgery. Cases operated on with either a conventional (control group) or a navigated (study group) technique were matched after calculating the propensity score using the logistic regression technique. All patients were contacted after 10 years or more to determine the survival of the TKA. The need for date and cause of revision were noted. The primary end point of the study was the occurrence of a revision for any mechanical reason. Survival curves were calculated using the Kaplan-Meier's technique, with the primary criterion as end point. The influence of the implantation technique was analyzed by a log-rank test at a 5% level of significance. The influence of severity of the preoperative coronal deformity was analyzed using the same technique. A total of 513 cases were included in each group. The survival rates after 13 years were 96.5% in the study group and 92.9% in the control group (not significant). There was no significant difference between both groups for the survival rates after 13 years for small deformity (96.0 vs. 97.0%), but the difference was significant for large deformity (97.0 vs. 89.0%, p = 0.04). The results suggest that the use of a navigation system, allowing a more consistent correction of the preoperative coronal deformity, thus allows a better long-term prosthetic survival in cases with a large initial coronal deformity. A navigation system should be routinely used in cases of initial coronal deformity greater than or equal to 10 degrees, as conventional techniques do not routinely provide satisfactory axial correction in these difficult cases.

No difference in 13-year survival after medial pivot or central pivot mobile bearing total knee arthroplasty. A propensity matched comparative analysis.

PURPOSE: The present study was designed to evaluate the long-term results (more than 10 years) of mobile bearing total knee arthroplasty (TKA) and to compare the survival of medial pivot axis (MPA) and central pivot axis (CPA) TKAs. The primary hypothesis was that the 10- to 15-year survival rate of MPA TKAs will be better than CPA TKAs. METHODS: A national, multicenter, retrospective study was performed in France. In this case-control design, 1154 TKAs were paired into the CPA group (control group: 577 cases) and MPA group (study group: 577 cases) based on a logistic regression analysis of age, gender, body mass index and severity of the coronal deformity, defining the propensity score for each case. Final survival information follow-up was obtained for 946 cases (82%). RESULTS: There was no significant difference between the control and study groups for any baseline data. Twenty-two prosthetic revisions (2%) were performed for mechanical reasons during the follow-up period. There was no significant difference between the 13-year survival rates of CPA (98%) and MPA (97%) TKAs. There was no significant difference between groups in their final Oxford and Knee Society scores. CONCLUSION: Our findings do not support the assumption that medialization of the pivot axis of a mobile bearing TKA improves clinical results or survival. LEVEL OF EVIDENCE: Level III.

Mid-term results of 119 Taperloc Microplasty™ femoral stems after a mean 61 months (50-82) of follow-up.

INTRODUCTION: Short stems are not all the same and do not meet the same objectives in terms of shape, fixation and biomechanics. The Taperloc Microplasty™ is a shortened stem. In France, no articles have been published on this subject and very few articles are available in the international literature. We therefore decided to analyse results for this stem after a mean follow-up of 61 months, asking the following questions: (1) Is the survival of the Taperloc Microplasty™ at least equivalent to the best conventional cementless prostheses on the market, i.e. with a 10-year revision rate of less than 5% according to NICE criteria? (2) Have the expected benefits of short stems been confirmed? HYPOTHESIS: The Taperloc Microplasty™ prosthesis meets the NICE criteria with a revision rate of less than 5% at 10 years. MATERIALS AND METHODS: This is a retrospective single-surgeon study of 119 prostheses implanted between April 2013 and December 2015. The inclusion criteria were hip arthrosis or avascular necrosis of the femoral head in patients under the age of 70 regardless of height or weight, excluding Dorr type C femurs. The series consisted of 108 patients (11 bilateral total hip arthroplasties (THA)) with a mean age of 58.8±10 years [17-70]; 81 were men and 38 were women. RESULTS: The results were assessed in 110 hips (103 patients since 9 hips (7 patients) were lost to follow-up) at a mean follow-up of 61±8 months [50-82]. At follow-up the Postel-Merle d'Aubigné (PMA) score was 17.8±0.8 [12-18] and the Oxford score 13.1±3.5 [12-41] (p<0.05 versus pre operative). On X-rays, we identified 9 pedestal signs (7.5%) below the distal end of the stem, 6 calcar atrophies (5%), but no cortical hypertrophy greater than 2 mm, no stem subsidence greater than 5mm, and no radiolucent line indicating the absence of integration. The survivorship at 61 months was 100% (95% CI: 0.905; 1.095), taking femoral revision as the end-point and 98.2% (95% CI: 0.887; 1.077) considering revision for any reason. CONCLUSION: The Taperloc Microplasty™ stem is equivalent to the best conventional cementless prostheses on the market in selected surgical indications after a mean follow-up of 61 months. The follow-up is still not sufficient to confirm all the benefits expected from this type of implant. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Risk factors for Staphylococcus aureus surgical site infections after orthopaedic and trauma surgery in a French university hospital.

BACKGROUND: Surgical site infections (SSI) after orthopaedic surgery are responsible for reduced quality of life, increased length of hospital stay and costs. The most commonly identified organism is Staphylococcus aureus but risk factors for S. aureus SSI are not well-known. The aim of this study was to evaluate the incidence rate trend of S. aureus SSI over the years and risk factors of these infections in a French University Hospital. METHODS: SSI rates were expressed as cumulative incidence rates per year. A case-control study nested within a prospective cohort of patients undergoing orthopaedic or trauma surgery from January 1st, 2012 to April 30th, 2015 was performed. Cases were patients with S. aureus SSI; controls were patients without SSI. Risk factors of S. aureus SSI were identified by univariate and multivariable analysis. RESULTS: Of 7438 interventions, 50 (0.7%) S. aureus SSI were identified, without significant increase by years. A total of 46 S. aureus SSI was matched to 91 controls. Risk factors for S. aureus SSI were smoking (odds-ratio (OR) = 8.4, 95%CI 1.2-59.6) and National Nosocomial Infections Surveillance System score (NNISS) ≥1 (OR = 5.8, 95%CI 1.8-19.1). Having 1 or 2 preoperative antiseptic showers (OR = 0.3, 95%CI 0.1-0.7) was a protective factor. CONCLUSION: The rate of S. aureus SSI is not negligible after orthopaedic and trauma surgery. It seems imperative to strengthen smoking cessation recommendations, and to recall the importance of preoperative antiseptic showers. Systematic screening and decolonization for S. aureus carriage before orthopaedic and trauma surgery could be a means to prevent these infections.

Acute instability of the patella: is magnetic resonance imaging mandatory?

PURPOSE: Acute dislocations of the patella represent 2 to 3% of traumatic injuries of the knee. When patients are seen in the emergency department with a dislocated patella clinical diagnosis is often very evident. However, in cases of short-lived subluxation or dislocations that have reduced spontaneously, the diagnosis can be challenging. The aim of this study was to evaluate the utility of MRI in the evaluation of acute patellar instability. METHODS: This was a prospective study of 39 cases of acute patellar instability. The study protocol included a clinical examination by an emergency medicine doctor, a standardised series of radiographs and an MRI scan within 15 days after injury. RESULTS: The series included 15 female and 24 male patients aged on average 23 ± 10.5 years (11-46). Twenty-four cases were following sporting accidents and 15 cases following domestic accidents. In ten cases, a blow to the medial side of the patella led to the injury and in 29 cases, a twisting mechanism with a valgus and external rotation force was responsible. Six patients presented with a clinically dislocated patella and 31 patients were deemed to have a "swollen knee". Nineteen patients described an episode of subluxation of the patella and 14 an odd sensation within the knee without being able to specifically describe what had happened. Radiographs demonstrated trochlear dysplasia in 97.5% of cases and osteochondral lesions in 20.5% of cases. MRI scan confirmed the diagnosis of acute patellar instability in 37 cases giving a sensitivity of 95%. MRI findings included 25 MPFL lesions, 31 patella lesions of which 25 were bone oedema and six medial facet fractures, 31 lateral femoral condyle bone oedema type lesions, 11 chondral lesions of which seven were osteochondral in nature and also three acute associated ACL injuries and two MCL injuries. CONCLUSION: MRI scan is an important tool in the diagnosis and management of acute patellar dislocation and subluxation. When symptoms are subtle, MRI facilitates a diagnosis with relative ease. MRI is particularly useful in identifying the exact nature of lesions most notably chondral lesions which are frequently of significant size and therefore often require expedited surgical treatment.

Intra- and extra-articular proximal tibia malunion.

Extra- and intra-articular proximal tibia malunion is not uncommon. Functional impact is variable but may lead to almost total impotence. The present study aimed to provide a review on malunion, answering 5 questions: (1) How should malunion be classified, and with what pathogenicity? Malunion results from reduction defect and/or secondary displacement in tibial plateau fracture (A2, A3, B, C on the AO classification), but also from previous epiphysiodesis or osteotomy (valgization or varization). (2) How should malunion be assessed? Pre-treatment work-up comprises standard X-ray (AP, lateral, full-length), but also 2D and 3D CT-scan to assess the severity and type of residual depression in old fracture. (3) What conservative treatments are available, and for whom? In under-50 year-olds, correction osteotomy is recommended: intra- or extra-articular or combined. In extra-articular malunion, especially in the absence of osteoarthritis, realignment osteotomy may be indicated even in elderly subjects. (4) What implants are suited to what malunion, and for whom? In over-50 year-olds with intra-or extra-articular or combined malunion, partial or total replacement is recommended, isolated or associated to realignment osteotomy. The open questions concern material removal, surgical approach and type of implant, bearing in mind that these implants raise technical difficulties. (5) What are the complications, and the results? Results with osteotomy and partial prostheses are generally satisfactory. Results in total replacement are poorer than for primary implants in osteoarthritis of the knee, with much more frequent complications. LEVEL OF EVIDENCE: V, expert opinion.

Better functional outcomes for ORIF in tibial eminence fracture treatment: a national comparative multicentric study of ORIF vs ARIF.

PURPOSE: Tibial eminence fractures can occur in adults and are equivalent to an acute ACL rupture. The purpose of this retrospective study was to compare the therapeutic outcomes of ARIF versus ORIF in tibial eminence fractures. Our hypothesis was that ARIF does not offer better results. METHODS: A retrospective national multicentric study was conducted in five university hospitals between 2010 and 2015. A total of 65 consecutive patients were included. 33 patients were treated with ARIF and 32 with ORIF. Clinical functional outcomes were assessed using the Lysholm score and IKDC score. Radiographic findings were recorded, and a statistical analysis carried out. RESULTS: IKDC score at the mean last follow-up of 68.8 ± 11.8 months was significantly higher in the ORIF group with a mean difference of 20.2 points ± 8.9 (p = 0.028). There were early osteoarthritis findings in 12 patients (18.4%). At last follow-up, 7 patients (10.7%) presented complications. CONCLUSION: In this retrospective multicentric study, better functional outcomes were observed in the ORIF group. This difference needs to be carefully interpreted as many confounding factors exist. In terms of complications, the results for both ORIF and ARIF are similar at midterm follow-up. ORIF should remain gold standard for tibial eminence fracture treatment. LEVEL OF EVIDENCE: III.

Inconsistent relationship between body weight/body mass index prior to total knee arthroplasty and the 12-year survival.

BACKGROUND: The primary hypothesis was that body weight (BW) and body mass index (BMI) significantly impact the long-term survival rate after implantation of a mobile bearing total knee arthroplasty (TKA). METHODS: A national, multicentric, retrospective study was performed in France. A total of 1604 TKAs were included. The 10-year follow-up was documented, and the influence of BW and BMI on the survival rate was assessed. RESULTS: There was a significant influence of the BW on the 12-year survival rate for any reason and for infection; but this influence was not proportional to the BW or BMI. There was no significant influence of the BMI on the 12-year survival rate for any reason, for any mechanical reason or for infection. CONCLUSION: Our results suggest that a higher BMI should not be considered as a risk factor for revision for mechanical purpose if a mobile bearing TKA with confirming design is implanted.

Screw-plate fixation for displaced middle-third clavicular fractures with three or more fragments: A report of 172 cases.

BACKGROUND: Although mid-shaft clavicular fractures are generally thought to be non-serious injuries that nearly always heal with non-operative treatment, recent studies found non-union rates of 3%-7% in simple fractures and 20%-33% in complex fractures. The primary objective of this study was to report the functional and anatomical outcomes after screw-plate fixation of displaced mid-shaft clavicular fractures with three or more fragments. HYPOTHESIS: Screw-plate fixation in this indication is an excellent treatment option that minimises the risk of complications. METHODS: A search of our database from 6 January 2012 to 27 December 2016 identified 410 cases of clavicular fracture, of which 250 were managed surgically, including 172 meeting our inclusion criteria and having complete data. These 172 patients were managed using a curved pelvic reconstruction plate with 3.5-mm non-locking screws positioned over the antero-superior aspect of the clavicle. All 172 patients were re-evaluated at least 1 year after surgery by an independent assessor, who determined the UCLA score. RESULTS: We studied 172 patients, 154 (89.5%) males and 18 females with a mean age of 34.5±14.5 years (range, 13-69 years). In 84.5% of cases, the fracture was a sports injury, and the most common sports were skiing (26%), cycling (21%), and mountain biking (18.5%). Of the 172 fractures, all but 1 healed, within a mean of 87 days (range, 45-120 days). After removal of the fixation material, 8 (4.5%) patients experienced a recurrent fracture, within a mean of 90 days (range, 2-210 days); 4 of these recurrent fractures were caused by high-energy traumas occurring 6 months after implant removal. The UCLA score determined at re-evaluation indicated that the outcome was excellent in 164 (95.5%), good in 5 (3%), and fair in 3 patients. CONCLUSION: Internal fixation using a curved pelvic reconstruction plate fixed with 3.5-mm screws provides excellent functional and anatomical outcomes in patients who have displaced mid-shaft clavicular fractures with three or more fragments. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Total femur replacement in non-oncologic indications: Functional and radiological outcomes from a French survey with a mean 6 years' follow-up.

INTRODUCTION: There are few published studies on total femur replacement (TFR) because its indications are rare. Other than malignant diseases, the indications extend to revisions and interprosthetic femur fractures; however, the outcomes of these indications have not been well defined. The aim of this retrospective survey was to analyze the complication rate and functional outcomes of these newer indications. HYPOTHESIS: The morbidity and outcomes after TFR are comparable to those reported in the literature for non-cancer indications. MATERIAL AND METHODS: Between 1997 and 2016, 29 TFR procedures were done at 6 French teaching hospitals in 15 women and 14 men, average age 68±14 years [32-85]. The primary indication was degenerative joint disease in the hip and/or knee in 16 cases, mechanical failure of the implant used after tumor resection in 11 cases and femur fracture in 2 cases. The mean number of surgical procedures before TFR was 3.6 (maximum 5) at the hip and 4.5 (maximum 10) at the knee. Six different models were implanted consisting of a rotational hinge knee (except in one case); 20 patients received a dual mobility system and 9 a standard hip replacement bearing. The femoral shaft was partially conserved 21/29 times and the trochanter 25/29 times. RESULTS: Five patients suffered a general complication and 12 suffered a local complication (including 4 hematomas and 2 hip dislocations). Eight patients (28.6%) suffered a surgical site infection, although three had a prior infection. Among the 12 patients with a history of infection or progressive infection before the TFR, 9 healed and 3 had the infection continue. At a minimum follow-up of 2 years and mean of 6 years, 23 TFR implants were still in place and not infected; the other 6 had been removed or were infected, including one patient who underwent disarticulation. The median survival of the non-infected TFR was 15 years. At 10 years, 70% of TFR implants were still in place and non-infected. Walking was possible with or without a cane in 15 patients (51.7%), with two canes or a walker in 12 patients (41.3%) and impossible in 2 patients. Active knee flexion averaged 79.4°±30.3° [0°-120°]; 17 patients (62.9%) had 90° or more flexion; two patients (7.4%) had no flexion. The extension deficit averaged 3.7°±7°[-20° to 10°] and 20 patients had no flexion deformity. The leg length difference averaged 1.3cm±2.3 [0-10]; 19 patients (67.8%) had no difference in leg length. DISCUSSION: Our starting hypothesis was confirmed for the complication rate and clinical outcomes. The benefits of dual mobility cups are emphasized. While the indications for TFR are rare, they will likely increase in the coming years. LEVEL OF EVIDENCE: IV, Retrospective cohort study….

No Detectable Polyethylene Wear 15 Years After Implantation of a Mobile-Bearing Total Knee Arthroplasty With Electron Beam-Irradiated Polyethylene.

BACKGROUND: The present study was designed to evaluate the risk of significant polyethylene (PE) wear 10 years or more after implantation of a total knee arthroplasty (TKA) using electron beam-irradiated highly cross-linked PE component. METHODS: All patients operated between 2001 and 2004 for implantation of this particular TKA in the two participating centers were eligible for this study. All patients were contacted after the 10-year follow-up for repeat clinical examination and radiological evaluation. The occurrence of a revision prior to the final evaluation and its reason were recorded. The thickness of the PE piece was measured on plain X-rays. RESULTS: Five hundred seventy-eight TKAs were implanted during the study time-frame. One hundred sixteen patients deceased prior to the 10-year follow-up (20%). An additional 121 patients were lost to follow-up prior to the 10-year follow-up (21%). Complete follow-up at 10 years or more (including death or revision) was obtained for 448 cases (78%). Ten prosthetic revisions were performed for mechanical reasons during the follow-up time (2%). One single revision was performed because PE wear after 13 years. No significant PE wear was detected at the final radiographic evaluation for nonrevised cases. The 10-year survival rate for mechanical revision only was 98.0% and decreased to 96.2% at 15 years. CONCLUSION: The use of electron beam-irradiated PE was associated with an extremely low incidence of wear. This technology may be considered as safe regarding PE behavior for TKA after more than 10 years. Further improvement of PE manufacturing may be not required.

Total knee arthroplasties from the origin to navigation: history, rationale, indications.

Since the early 1970s, total knee arthroplasties have undergone many changes in both their design and their surgical instrumentation. It soon became apparent that to improve prosthesis durability, it was essential to have instruments which allowed them to be fitted reliably and consistently. Despite increasingly sophisticated surgical techniques, preoperative objectives were only met in 75% of cases, which led to the development, in the early 1990s, in Grenoble (France), of computer-assisted orthopaedic surgery for knee prosthesis implantation. In the early 2000s, many navigation systems emerged, some including pre-operative imagery ("CT-based"), others using intra-operative imagery ("fluoroscopy-based"), and yet others with no imagery at all ("imageless"), which soon became the navigation "gold standard". They use an optoelectronic tracker, markers which are fixed solidly to the bones and instruments, and a navigation workstation (computer), with a control system (e.g. pedal). Despite numerous studies demonstrating the benefit of computer navigation in meeting preoperative objectives, such systems have not yet achieved the success they warrant, for various reasons we will be covering in this article. If the latest navigation systems prove to be as effective as the older systems, they should give this type of technology a well-deserved boost.

Influence of the post-operative axis on the clinical results of total knee replacement for severe varus deformities: does a slight residual varus improve the results?

PURPOSE: Some recent articles have suggested that in the case of large varus deformity, it may be advantageous to leave some residual post-operative varus as a means of improving functional outcome. The objective of this study is to compare the results of total knee replacement (TKR) performed for significant varus deformity (HKA < 170°) where there is a residual post-operative varus (HKA < 180°) to the results of TKR for significant varus deformity with either neutral post-operative (HKA = 180°) or mild valgus post-operative alignment (HKA > 180°). METHODS: This series was made up of 208 knees. The mean pre-operative HKA angle was 166 ± 3° (154-169°), of which 150 were followed up for a mean 8.5 years (58 lost to follow-up). Based on post-operative radiographs, two groups were formed: group 1 (88 knees) in which post-operative alignment was 177.8 ± 1° (175-179°) and group 2 (62 knees) in which post-operative alignment was 181 ± 1° (180-184°). RESULTS: The mean international knee society (IKS) score for group 1 was 178.8 ± 22 points (113-200) and 181.7 ± 22 points (95-200) for group 2. Oxford knee score was 20.4 ± 9 points (12-45) in group 1 and 19.2 ± 9 (12-50) in group 2. The results were slightly better in group 2 (in slight valgus) but this difference was not statistically significant (p = 0.44 and 0.4). CONCLUSION: The results of knee replacement performed for severe varus deformity are not adversely affected by post-operative valgus alignment. There is in fact a trend towards superior results for neutral or valgus alignment than slight residual varus, but this difference was not statistically significant.

Anterior cruciate ligament reconstruction with the Tape Locking Screw (TLS) and a short hamstring graft: Clinical evaluation of 61 cases with a minimum 12 months' follow-up.

INTRODUCTION: The Tape Locking Screw (TLS®) technique for anterior cruciate ligament (ACL) reconstruction has the advantages of using only one hamstring tendon (semitendinosus) by preparing a short graft secured with screws and braided strips. The theoretical pitfall of this technique is that the graft length is determined arbitrarily. Thus, if the blind tunnels are not long enough, it will be impossible to tension the graft properly upon fixation. The primary objective of this study was to determine the postoperative side-to-side difference in knee laxity. We hypothesized that ACL reconstruction with the TLS(R) system would result in 3mm or less side-to-side difference in knee laxity. MATERIAL AND METHODS: This was a prospective single-center, single-surgeon study performed on patients operated between December 2014 and June 2016 who had a minimum 12 months' follow-up. The pre- and post-operative side-to-side difference in knee laxity was measured with a KT-1000 arthrometer. Secondary outcomes were the pre- and post-operative IKDC, Lysholm and Tegner functional scores. RESULTS: Sixty-one patients were included: 49 men (80%) and 12 women (20%). The average age was 31.6±13.7 years. The average follow-up was 19.3±6.3 months. The average side-to-side difference in laxity went from 6.5mm (min 3; max 12) preoperatively to -0.1mm postoperatively (min -5, max 4) (p<0.01). The average IKDC went from 39.7±12 preoperatively to 94.1±11.2 postoperatively (p<0.005), the average Lysholm score went from 41±12.9 to 95.5±9.8 (p<0.005), and the average Tegner score went from 6.3±1.5 to 4.3±1.4 (p<0.005). Patients were able to return to sports an average of 6.1 months after surgery. In terms of complications, 4.9% of patients developed a cyclops lesion and required surgical revision. DISCUSSION: This study found very good reduction in postoperative laxity after a minimum 12 months' follow-up when ACL reconstruction is performed with the TLS® technique. LEVEL OF EVIDENCE: IV, prospective cohort study.