Does AMIC® provide improvements at least two years after surgery for knee osteochondral lesions? A multicentre retrospective study of 101 patients.

BACKGROUND: Osteochondral defects of the knee due to trauma or osteochondritis are associated with osteoarthritis in the medium term. Defects 2 to 8cm2 in size can be managed by autologous matrix-induced chondrogenesis (AMIC®), in which sub-chondral micro-fractures are created within the lesion and the defect is then covered by a matrix of type I and type III collagen to induce de novo cartilage formation. Although promising outcomes have been observed in small single-centre cohorts, the medium-term clinical and radiological effectiveness of AMIC® remains to be demonstrated in larger populations. The objective of this study was to evaluate outcomes of patients at least 2 years after AMIC® for knee osteochondral defects. HYPOTHESIS: AMIC® is associated with clinical and radiological improvements after at least 2 years. MATERIAL AND METHOD: This multicentre (16 centres), multisurgeon (18 senior orthopaedic surgeons), retrospective study included consecutive patients who underwent AMIC® with Chondro-Gide® membrane implantation between September 2011 and January 2020. The 36-item Short Form quality-of-life (SF-36) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) score were determined before the procedure and during follow-up. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed by magnetic resonance imaging 2 years after the procedure. RESULTS: In total, 101 patients aged 12 to 60 years were included. Mean follow-up was 30 months. Mean defect size was 3.44cm2 (range, 2-8cm2). Significant improvements were documented in the SF-36 score, KOOS, and IKDC score. The mean MOCART score at 2 years was 75% (range, 20-100). DISCUSSION: The AMIC® procedure was associated with significant improvements at 2.5 years in patients treated for knee osteochondral defects measuring 2 to 8cm2. This method seems to provide similar outcomes to those of other available methods with the advantages of single-step surgery and elimination of osteochondral graft donor-site complications. LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

How do patients choose their surgeon? Example of anterior cruciate ligament reconstruction.

INTRODUCTION: In this age of social media, with an ever-higher profile for surgery and rankings for the general public, patients' criteria for choosing a surgeon or team are not precisely known, especially in France. We therefore conducted a prospective study concerning anterior cruciate ligament reconstruction: (1) to determine how patients came to know their surgeon; (2) to identify factors affecting final choice. HYPOTHESIS: Patients' choice of surgeon is affected by scores found in social media and rankings found in the press. MATERIAL AND METHOD: A prospective continuous study included all patients operated on, without standardization of technique, in 3 hospitals (public and private sector). An anonymous questionnaire on surgeon selection criteria, scored 0 to 10, was distributed on a voluntary basis on the day of surgery scheduling. RESULTS: One hundred and five patients were included. They had come to know of their surgeon via family or friends or their personal physician in more than two-thirds of cases. The essential criterion of final choice was the clarity of the written and oral information provided in consultation (mean score, 8.09±1.83). Other factors included wait-time to surgery (7.39±2.25) and to first consultation (7.26±2.01) and the surgeon's reputation (7.42/10±2.43). CONCLUSION: "Word of mouth" and the quality if information provided in consultation motivated final choice, more than any influence of social media or press hospital rankings. LEVEL OF EVIDENCE: IV; prospective observational study without control group.

Long-Term Results of a Monocentric Series of Soldiers After Latarjet Procedure for Anterior Shoulder Instability. Implications for the Assessment of Soldiers' Medical Ability.

Introduction: Stabilizing surgery of the shoulder with a coracoid graft according to Latarjet is a recognized surgical treatment for anterior instability of the shoulder. This pathology frequently affects soldiers. Postoperatively, the potential risk of recurrence or of secondary shoulder arthritis can limit the practitioner in their ability assessment. The aim of this study is to analyze the long-term outcomes of this surgery in a military population, in order to assess the possible implications for French soldiers' medical ability. Material and Methods: Twenty soldiers operated on the shoulder by Latarjet procedure by the same surgeon were retrospectively reviewed after more than 15 yr. All of them did regular physical activity for leisure or competitions. None had preoperative osteoarthritis injuries. The number of dislocation recurrences, the functional score, and the rate of radiographic osteoarthritis were assessed. Results: After more than 16.3 yr (extremes: 15-24 yr), none displayed a dislocation recurrence. The average Rowe's score was 91.8 ± 9.9. The average subjective shoulder value was 89.2 ± 9.7. All patients had resumed sport. Three of them developed level 1 or 2 radiological signs of osteoarthritis according to Samilson. No level 3 or 4 osteoarthritis was found. Among all the patients, 14 still did regular physical activity. Discussion: In view of our results and of those from the literature, the results of treatment for anterior shoulder instability with the Latarjet procedure are good, even very good in the long term. These data must be considered to favor this procedure for soldiers with shoulder instability and from a medico-administrative viewpoint for military patients in order to pursue their careers without any job restrictions.

A growing stake in orthopaedic surgery and traumatology for the future management of obese patients.

The prevalence of obesity is increasing. In orthopaedic surgery, the impact of obesity is felt. The aim is to take stock of the consequences of obesity for patients at each stage of management. In this mini-review, we identify the main pathophysiological factors, specific orthopaedic complications and consequences to consider at each stage of management. Obese patients are subjected to a chronic inflammatory state and biomechanical stress. This augments the risk of sepsis and trauma, musculoskeletal damage, the frequency of organ failure and thus, morbidity and mortality. This results in more complex and longer supportive care. At each stage of care, surgeons and doctors have to adapt to optimize care. It is necessary to obtain timely and accurate information from the patient. Patient information is necessary. Being obese in orthopaedics is a factor in poor prognosis. Treatments need to be adapted. This requires specific preparation at each step.

Surgical support during the terrorist attacks in Paris, November 13, 2015: Experience at Bégin Military Teaching Hospital.

BACKGROUND: Recent conflicts have allowed the French Army Health Service to improve management quality for wartime-injured people during military operations. On November 13, 2015, it was in Paris that France was directly attacked and Bégin Military Teaching Hospital, like several hospitals in Paris, had to face a large number of gunshot victims. Thanks to our operational experience, injured people hospitalized in military hospitals benefited from a management based on triage and damage control (DC) principles. METHODS: Forty-five patients were taken care of in our hospital with an average age of 32 years. During triage, eight patients were categorized T1 (with four extreme emergencies) and 10 were classified T2 and 27 as T3. Twenty-two patients underwent emergency surgery, 15 for soft tissue lesions of limbs, 8 for ballistic fractures (one of which was a cervical wound), and 5 for abdominal wounds. Two patients classified T1 died early. RESULTS: In total, more than 50 operations were performed including iterative debridements, bone fixation, three amputations, and two flaps. After 9 months, all of the patients had healed. One woman with limb stiffness required an arthrolysis. CONCLUSION: This event showed that terrorist attacks and mass casualties with war wounds can occur in France. Acquired experience regarding war wounds by the French Army Health Service is precious. Everyone must understand the importance of triage and the principles of damage control. Every hospital must be ready to face this type of massive influx of injured people (white plan). LEVEL OF EVIDENCE: Epidemiological study, level V.

Wartime paediatric extremity injuries: experience from the Kabul International Airport Combat support hospital.

Since the beginning of Operation Enduring Freedom, management of Afghan military or civilian casualties including children is a priority of the battlefield medical support. The aim of this study is to describe the features of paediatric wartime extremities injuries and to analyse their management in the Kabul International Airport Combat Support Hospital. A retrospective review was carried out using the French surgical database OPEX (Service de Santé des Armées) from June 2009 to January 2013. Paediatric patients were defined as those younger than 16 years old. Of the 220 injured children operated on, 155 (70%) sustained an extremity injury and were included. The mean age of the children was 9.1 ± 3.8 years. Among these children, 77 sustained combat-related injuries (CRIs) and 78 sustained noncombat-related injuries (NCRIs), with a total of 212 extremities injuries analysed. All CRIs were open injuries, whereas NCRIs were dominated by blunt injuries. Multiple extremities injuries and associated injuries were significantly more frequent in children with CRIs, whose median Injury Severity Score was higher than those with NCRIs. Debridement and irrigation was significantly predominant in the CRIs group, as well as internal fracture fixation in the NCRIs group. There were four deaths, yielding a global mortality rate of 2.6%. This study is the first to analyse specifically paediatric extremities trauma and their management at level 3 of battlefield medical facilities in recent conflicts. Except for severe burns and polytrauma, treatment of paediatric extremities injuries can be readily performed in Combat Support Hospitals by orthopaedic surgeons trained in paediatric trauma.

Are gender-specific femoral implants for total knee arthroplasty necessary?

The purpose of this study was to determine the effect of gender on epiphyseal morphology and using this information to determine if an implant product line with a single width provides sufficient bone coverage for the entire population of knees being replaced. Morphology of the distal femoral epiphysis from 420 continuous knees was acquired with a surgical navigation system during primary TKA. A three-dimensional model of the distal femur was generated and used to determine the anterioposterior (AP) and mediolateral (ML) dimensions on 19 different virtual knee sections. Female knees had smaller AP and ML dimensions than male knees. The ML width of the distal femoral epiphysis was associated with femur length, not gender. Measurements derived from surgical navigation confirm that distal femoral epiphysis dimensions are related to femur length only independently of gender.

Can hip anatomy be reconstructed with femoral components having only one neck morphology? A study on 466 hips.

This extensive radiographic study asks if there is a statistical relationship between the size of the stem that will best fit the femur and the vertical and lateral offsets of the reconstructed acetabular center, what is the distribution of vertical and lateral offsets in this large and if there is a statistical difference among surgeons in the planned location of the reconstructed acetabular center. On 466 radiographs, five surgeons separately templated stem size and acetabular cup location. The vertical and horizontal coordinates of the reconstructed acetabulum center were measured relative to the planned position of the stem. We found a strong correlation between the stem size and the average lateral and vertical offsets. Acetabular reaming associated with the anatomic variability of native femoral necks, leads to a span of 36 mm in lateral offset, and a span of 39 mm in vertical offset. Statistically significant differences were also found in the way surgeons plan acetabular reaming.

Vascular complications following total hip arthroplasty: a case study and a review of the literature.

Vascular complications after total hip arthroplasty (THA) are rare but represent a real risk. The diversity of clinical presentations can make diagnosis difficult. They could manifest as an immediate and acute hemorrhage or subsequent ischemia. We report the case of a patient who presented a thrombosis of the femoral artery associated with a sciatic palsy after THA for a coxa profunda. The diagnosis was actually made 3 years after surgery because of atypical symptoms. The mechanism involved was either a crash of the artery by a retractor on the anterior wall of the acetabulum, or a stretching of the artery. A review of the literature of vascular complications occurring after THA recalls the multiplicity of clinical presentations and the diagnostic difficulties. They could manifest as an immediate and acute hemorrhage or deferred ischemia, as in our case. Knowledge of these complications should help prevent them, and the diagnosis should be considered in atypical sequences after THA.

How to Cover Soft-Tissue Defects After Injuries to the Leg in Precarious Conditions.

BACKGROUND: In precarious conditions, bone exposure on the leg is synonymous with amputation. The authors describe their experiences with such injuries in 15 patients. MATERIALS AND METHODS: Fifteen patients were operated by the same surgeon in Afghanistan and Ivory Coast for bone exposure on the leg after war or roadcrash injuries. A flap was performed after an initial debridement and external fixation. The delay between the flap and the first injury was about 42 days. RESULTS: The duration of hospitalization following the flap was about eight days. Cicatrization was complete after 25 days. Three patients had complications: one partial necrosis of the skin, one sepsis, and one patient had a leg amputation. DISCUSSION: In precarious conditions, the management of bone exposure in local civilians and soldiers is limited by the conditions in their country or the conditions at the field hospital. The treatment must be simple and reliable because it may be difficult to perform patient follow-up. A pedicled flap provides new vascularized tissue with anti-infectious properties. Classical indications are: muscular flaps for the proximal and the middle part of the leg; sural flaps for the middle and the distal-third part. In substantial soft-tissue defects, amputation must be discussed. CONCLUSION: The pedicled flap is an essential technique for fighting against infection, especially in cases where only poor technical and medicinal resources are available. This simple and reliable technique allows most tissue defects on the leg to be covered.