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

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

Efficacy of arthroscopic treatment for resolving infection in septic arthritis of native joints.

BACKGROUND: Septic arthritis is a diagnostic and therapeutic emergency that threatens both life and function. The primary objective of this study was to assess the efficacy on the infectious process of arthroscopic treatment in patients with septic arthritis of native joints. The secondary objective was to identify factors predicting failure to achieve infection resolution after arthroscopic treatment. We hypothesised that arthroscopy was the appropriate treatment strategy. MATERIAL AND METHODS: Forty-six cases of septic arthritis in 46 patients with a mean age of 46 years (range, 18-72 years) were retrospectively reviewed. The cause of the septic arthritis was haematogenous dissemination in 39.1% of patients, surgery in 34.8%, a local injection in 19.6%, and trauma in 6.5%. The involved joint was the knee in 32 patients, the shoulder in 6, the hip in 3, the ankle in 3, and the elbow in 2. All patients underwent arthroscopic joint lavage, with or without synovectomy depending on the Gächter stage. Dual antibiotic therapy was given routinely after the procedure. For each patient, we assessed time to treatment, intraoperative findings according to the Gächter classification, cultures of drainage-fluids, and whether repeat arthroscopic lavage was required. Recovery of the infection was defined as absence of clinical or laboratory signs of infection at last follow-up. RESULTS: Mean follow-up was 42 months (range, 1-120). Mean time from symptom onset to arthroscopic treatment was 7.5 days. Full recovery of the infection was achieved in 93% of patients, although 25% required more than one arthroscopic lavage. Factors significantly associated with arthroscopic treatment failure were Gächter stage III or IV and positive drainage-fluid cultures after 24h. CONCLUSION: Arthroscopic treatment is indicated in all patients with septic arthritis on native joints. The procedure should be repeated if the initial course is unfavourable. LEVEL OF EVIDENCE: IV. Retrospective study.

Contribution of MRI and CT arthrography to the diagnosis of intra-articular tendinopathy of the long head of the biceps.

INTRODUCTION: Clinical diagnosis of biceps tendinopathy is difficult to make because of the poor sensitivity of existing clinical tests. The goal of this study was to determine whether MRI or CT arthrogram could contribute to the diagnosis of tendinopathy in the intra-articular portion of the long head of biceps (LHB), while using macroscopic findings during shoulder arthroscopy as a reference. MATERIAL AND METHODS: A prospective, single-centre study was performed over a 4-month period. The radiology part of the study was carried out by a radiologist experienced in shoulder imaging. The arthroscopy part of the study was conducted while the biceps was being evaluated for treatment purposes. The study included 87 patients having an average age of 45.7 years (range 17-78). Fifty-eight patients underwent CT arthrography and 38 underwent an MRI. Seven patients underwent both imaging exams. One patient was removed from the study because of a spontaneous LHB rupture. The demographics of the two study populations were equivalent. RESULTS: For the diagnosis of tendinopathy of the intra-articular portion of the long head of biceps, the CT arthrogram had a sensitivity of 71.43%, specificity of 100%, positive predictive value of 100% but a negative predictive value of 67.74%. For the diagnosis of tendinopathy of the intra-articular portion of the long head of biceps, the MRI had a sensitivity of 42.85%, specificity of 75%, positive predictive value of 50% but a negative predictive value of 69.23%. CONCLUSION: This study showed that radiological diagnosis of tendinopathy of the long head of biceps remains challenging. Nevertheless, CT arthrography is more sensitive and specific than MRI in identifying this disorder. LEVEL OF EVIDENCE: III (case-control study).

Optimization of bone-block positioning in the Bristow-Latarjet procedure: a biomechanical study.

BACKGROUND: In the Bristow-Latarjet procedure, optimal positioning of the coracoid bone-block on the anterior aspect of the glenoid (standing or lying on the glenoid rim) remains debated. A biomechanical study assessed the effect of the position of the bone-block with its attached conjoint tendon on anterior and inferior stabilization of the humeral head. MATERIALS AND METHODS: The Bristow-Latarjet procedure was performed on 8 fresh cadaveric shoulders. The bone-block size was systematically at 2.5×1×1 cm. Anterior translation of the humeral head was stress induced under 30-N traction, in maximum external rotation at 0° and at 90° abduction: respectively, adduction and external rotation (ADER), and abduction and external rotation (ABER). Under radiological control, displacement of the center of the humeral head was compared with the glenoid surface at the 3, 4 and 5 o'clock (medial, antero-inferior and inferior) positions for the 2 bone-block positionings. RESULTS: The lying position at 4 o'clock substantially decreased anterior and inferior displacement of the humeral head respectively in ADER and ABER; and in ABER it also tended to decrease anterior translation, but not significantly. The standing bone-block position did not affect translation. CONCLUSIONS: Positioning the bone-block so that it lies on the anterior aspect of the glenoid in the middle of the antero-inferior quarter of the rim at 4 o'clock can decrease anterior displacement of the humeral head and inferior glenohumeral translation, especially in ADER for anterior displacement and in ABER for inferior displacement. STUDY DESIGN: Laboratory study.

Arthroscopic classification of posterior labrum glenoid insertion.

PURPOSE: We performed a prospective arthroscopic study to explore the variability of the posterior labrum glenoid insertion. We aimed to classify the insertions and to explore whether these insertions can be identified by pre-operative arthro-CT scan. PATIENTS AND METHODS: From January to December 2011, 86 patients were prospectively included in the current study. During arthroscopy, anterior labrum was evaluated and posterior labrum was assessed in 3 different locations: superior, medial, and inferior. For each segment, the labrum was considered normally inserted (directly to the glenoid cartilage), medialized (inserted at the posterior part of the glenoid bone, without direct contact with the cartilage), torn (macroscopic degenerative changes, tears, fragments) or absent (agenesis). Imaging was analyzed segment by segment by an experienced osteoarticular radiologist, using the same classification. RESULTS: Four types of posterior labrum insertions were identified. Type 1, 60% of the cases, corresponded to a posterior labrum totally inserted in the glenoid, with direct contact with the cartilage. Type 2, 20% of the cases, represented medialized insertion of the superior segment. Type 3, 15% of the cases, represented an associated medialization of the superior and medial segment of the posterior labrum. Type 4 is a medialized insertion of the all-posterior labrum. Fifty-six shoulders were used for arthro-CT and arthroscopy correlation: for the superior segment (n=22/56), the sensitivity of arthro-CT to identify an abnormal insertion when the labrum is medialized was 68.18%, specificity 70.59%, positive predictive value (PPV) 60%, and negative predictive value (NPV) 77.42%. For the medial segment (n=16/56), the sensitivity of arthro-CT to identify an abnormal insertion when the labrum is medialized was 81.25%, specificity 57.50%, PPV 43.33% and NPV 88.46%. For the inferior segment (n=5/56), the sensitivity was 100%, specificity 47.60%, PPV 15.63% and NPV 100%. CONCLUSION: The current study points out the high variability of shoulder posterior labrum glenoid insertion, and thus the risk of misdiagnosis with posterior labral tears, especially in posterior instability and also the risk of considering as labral lesions some non-pathological aspects. LEVEL OF EVIDENCE: Level III. Anatomic prospective study.

Influence of prolonged immersion on the resistance of arthroscopy knots in biological media.

INTRODUCTION: Biomechanical studies of arthroscopic knots have been performed on sutures that were tied manually and tested immediately after tying. We performed this study to evaluate the knot and the suture during the healing phase, which was not evaluated in these previous studies. Our hypothesis was that the biomechanics features of arthroscopic knots may change in relation to the duration of incubation in biological media simulating synovial fluid. Thus our goal was to study the influence of incubation for 30 days in biological media simulating body fluid using a device to standardize knot tying and allow comparison of arthroscopic sutures. MATERIALS AND METHODS: Three Ultra-High Molecular Weight PolyEthylene (UHMPWE) sutures (Fiberwire, Orthocord and Maxbraid) were tested with a self-locking slip knot (SMC knot). Sixty identical knots were tied using a standardized device, and divided into two groups: the control group « D0 ¼ and the group « D30 ¼ where the knots were soaked in biological media simulating body fluid for 30 days. Cyclic loading tests were then performed on the knots in each group using a machine to define four variables: clinical failure, ultimate failure, knot slippage and the characteristics of failure. RESULTS: There was no significant difference between the two groups for knot resistance at clinical failure or ultimate failure, without regard to the suture, (P<0.05). After cyclic loading, the most slippage occurred in the Orthocord (≈5.6mm) then the Maxbraid (≈3.55mm) and the Fiberwire (≈2.51mm). The only suture whose slippage was influenced by the duration of incubation was Orthocord. At clinical failure, the loop that slipped the most was the Orthocord suture (≈5.45mm) then the Fiberwire (≈4.8mm) and the Maxbraid (≈4.1mm). In the Orthocord and Maxbraid sutures, knot slippage after clinical failure significantly increased with the duration of suture incubation (P<0.05). The reason for failure was breakage from tearing of suture fibers in all cases. CONCLUSION: Prolonged incubation of arthroscopic suture knots influences slippage, which could result in unsuccessful primary attachment of the tendon during the healing phase. LEVEL OF EVIDENCE: Level IV. Biomechanical study.

Reliability of a new method for lower-extremity measurements based on stereoradiographic three-dimensional reconstruction.

INTRODUCTION: Several clinical and radiological techniques have been described to assess lower limb length and angle measurements. None of them has yet met the ideal criteria for a reliable, reproducible, safe, and inexpensive system. In this context, a new biplanar X-ray system (EOS™, EOS imaging, Paris, France) makes it possible to obtain a 3D reconstruction of the lower extremities from two 2D orthogonal radiographic images, with associated calculation of 3D measurements. The reliability of this technique has never been documented on adults. HYPOTHESIS: Lower limb measurements produced by the 3D EOS™ reconstruction system are reproducible regarding inter- and intraobserver assessment and more reliable with this 3D technique than when they are obtained from 2D measurements. MATERIALS AND METHODS: This study included 25 patients awaiting total hip arthroplasty (50 lower limbs). Two independent observers made all measurements twice, both on the 2D frontal radiograph and using 3D reconstructions (femoral measurements of length, offset, neck shaft angle, neck length, and head diameter, as well as the tibia length, limb length, HKA and HKS). Reproducibility was estimated by intraclass correlation coefficients. RESULTS: Both the inter- and intraobserver reproducibility of the EOS™ measurements was excellent; more specifically inter- and intraobserver reproducibility was 0.997 and 0.997 for femoral length, 0.996 and 0.995 for tibial length, 0.999 and 0.999 for limb length, 0.894 and 0.891 for HKS, 0.993 and 0.994 for HKA, 0.870 and 0.845 for femoral offset, and 0.765 and 0.851 for neck shaft angle. For most of the variables, the interobserver correlations were statistically better with the EOS™ 3D reconstruction. DISCUSSION: Our results show that the EOS™ systems allow reproducible lower limb measurements. Furthermore, 3D EOS™ reconstructions offer better reproducible measures for most of the parameters than radiographic 2D projection. Its use before deciding on surgery and during planning for lower limb arthroplasty appears essential to us. LEVEL OF EVIDENCE: Level III: diagnostic prospective study on consecutive patients.

Isolated Kaposi sarcoma of the finger pulp in an AIDS patient.

A 63-year-old woman with long-standing AIDS and previous Kaposi sarcomas of the lower limb presented to our consultation complaining of a painful left ring finger with pulp enlargement. X-rays revealed an osteolytic lesion of the distal phalanx. We suspected an isolated osseous Kaposi sarcoma and at surgery we found a hemorrhagic lesion with bone extension into the phalanx. Bone involvement is rare in Kaposi sarcoma and even rarer in patients without a cutaneous location.