Cementless, modular, titanium stem in Vancouver B2 and B3 periprosthetic femoral fractures.

INTRODUCTION: The periprosthetic femoral fracture (PFF) is a serious complication after primary total hip arthroplasty. We conducted a retrospective study to determine whether the PRIUS® system presented similar survival to other existing implants for the treatment of Vancouver B2 or B3 PFFs. Bone consolidation rate, functional results and complications were analysed. METHOD: This is a bi-centric retrospective study between 2012 and 2017 including 39 patients with (B2/B3) PFFs treated by senior surgeons using a PRIUS® femoral implant. Implant survival, radiological outcome (fracture healing) and clinical scores (Oxford-OHS, Harris Hip Score-HHS, Postel Merle d'Aubigné-PMA, Devane and Charnley) were analysed. 10 patients had died before data collection and 5 patients were lost to follow-up. A total of 21 patients were able to undergo a clinical and radiological evaluation. The mean follow-up period was 3 years. RESULTS: The 3-year PRIUS® stem survival rate was 88.6% [95% CI, 77.2-100]. The consolidation rate was 81% (17/21). The rate of satisfied or very satisfied patients was 85.6% (18/21). Regarding the Devane score, activity level was maintained in 70.6% of cases (12/17) and decreased in 29.4% of cases (5/17), the Charnley score was stable in 94% of cases (16/17) and decreased in 6% of cases (1/17). The mean Oxford score was 28.8/48 (9.3; 16-48), the mean HHS was 67/100 (16.4; 46-91) and the mean PMA score was 12.6/18 (4.5; 2-18). CONCLUSION: The results in terms of survival rate and bone consolidation are comparable to other literature series. The PRIUS® System can be added to the surgical arsenal in the treatment of (B2/B3) PFF, subject to confirmation of these results in the longer term.

Results of isolated ulnar shaft shortening osteotomy in the treatment of idiopathic ulnocarpal impaction syndrome.

The objective of this study was to evaluate the results of isolated ulnar shaft shortening osteotomy (USSO) in the treatment of idiopathic ulnocarpal impingement syndrome. This was a two-center retrospective study. All patients older than 18 years who underwent isolated USSO for idiopathic ulnocarpal impingement syndrome between 2006 and 2016 were included. The outcome measures were: patient satisfaction, decrease in pain intensity, change in occupation, QuickDASH and PRWE functional scores, secondary palliative surgery suggesting failure of the ulnar shaft shortening osteotomy, and postoperative ulnar variance. The main complications were analyzed. Thirty-one patients were included. Twenty-six (84%) were satisfied with the procedure. At an average follow-up of 62 months, there was no secondary palliative surgery. Mean pain intensity on VAS was 7/10 (range, 2-10) and 1.7/10 (range, 0-6) preoperatively and postoperatively, respectively, for a mean decrease of 5.3 ± 2.6 points; this decrease was statistically significant (p < 0.001). None of the manual workers had to alter their work. Mean postoperative QuickDASH score was 19.6/100 (range, 0-79.55) and mean postoperative PRWE score was 23/100 (range, 1-85). Mean postoperative ulnar variance was -0.5 mm. As for complications, 61% of patients (n = 19/31) had discomfort related to the plate; 9.7% (n = 3/31) had distal radioulnar osteoarthritis; 4% (n = 1/19) had a fracture after hardware removal; 13% (n = 4/31) had non-union. Despite a high rate of complications, the study confirmed the effectiveness, in terms of pain, of isolated USSO in the treatment of idiopathic ulnocarpal impingement syndrome. LEVEL OF EVIDENCE: IV; retrospective cohort.

Monogenic diabetes in adults: A multi-ancestry study reveals strong disparities in diagnosis rates and clinical presentation.

AIM: Identification of monogenic diabetes (MgD) conveys benefits for patients' care. Algorithms for selecting the patients to be genetically tested have been established in EuroCaucasians, but not in non-EuroCaucasian individuals. We assessed the diagnosis rate, the phenotype of MgD, and the relevance of selection criteria, according to ancestry in patients referred for a suspected MgD. METHODS: Seven genes (GCK, HNF1A, HNF4A, HNF1B, ABCC8, KCNJ11, INS) were analyzed in 1975 adult probands (42% non-EuroCaucasians), selected on the absence of diabetes autoantibodies and ≥2 of the following criteria: age ≤40 years and body mass index <30 kg/m2 at diagnosis, and a family history of diabetes in ≥2 generations. RESULTS: Pathogenic/likely pathogenic variants were identified in 6.2% of non-EuroCaucasian and 23.6% of EuroCaucasian patients (OR 0.21, [0.16-0.29]). Diagnosis rate was low in all non-EuroCaucasian subgroups (4.1-11.8%). Common causes of MgD (GCK, HNF1A, HNF4A), but not rare causes, were less frequent in non-EuroCaucasians than in EuroCaucasians (4.1%, vs. 21.1%, OR 0.16 [0.11-0.23]). Using ethnicity-specific body mass index cutoffs increased the diagnosis rate in several non-EuroCaucasian subgroups. CONCLUSION: The diagnosis rate of MgD is low in non-EuroCaucasian patients, but may be improved by tailoring selection criteria according to patients'ancestry.

The interest of "ortho-plastic" collaboration in management of complex limb injury.

Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.

Predictive factors of postoperative deficit and functional outcome after surgery for upper limb schwannomas: Retrospective study of 21 patients.

Schwannomas are the most frequent benign tumors of the peripheral nerves. Tumor enucleation is the traditional surgical treatment. The incidence of neurological complications after surgery varies and predictive factors for these complications are not clearly defined. The aim of this study was to find predictive factors of postoperative neurological deficit after surgical treatment of schwannomas of the upper limb. Twenty-four schwannomas removed from 21 patients were analyzed retrospectively. The patients' mean age was 45.4years and the mean follow-up was 64.4months. Clinical parameters studied were age, gender, nature of preoperative symptoms, duration of symptoms, type of surgery performed, tumor location and size, nerve involved, QuickDASH and DN4 scores. Postoperative neurological deficits occurred in 14 patients (67%), with 11 having a sensory deficit and 7 a motor weakness. Eleven did not exist before surgery (6 sensory, 5 motor). In the postoperative deficit subgroup, 6 schwannomas involved the brachial plexus, 4 the ulnar nerve, and 4 the median nerve. All patients who had a fascicular resection because tumor enucleation was not feasible were in the postoperative deficit subgroup. Ten patients had either unchanged or worse QuickDASH and/or DN4 scores after surgery. Surgical treatment of schwannomas can lead to postoperative complications. Although none of our findings were statistically significant, advanced age, large tumor size, more than 16months between the first symptoms and surgery, and brachial plexus location seem to be more frequently observed in those with a postoperative neurological deficit.

Correction to: Secondary prevention of osteoporotic fractures: evaluation of the Lille University Hospital's Fracture Liaison Service between January 2016 and January 2018.

The original version of this article, published on 5 June 2019, an author's name was misspelled.

Secondary prevention of osteoporotic fractures: evaluation of the Lille University Hospital's Fracture Liaison Service between January 2016 and January 2018.

The purpose of this study was to assess the performance of our Fracture Liaison Service (FLS) over a period of 2 years. Osteoporosis medication was prescribed for 243 patients, and zoledronic acid was the main drug prescribed (60.2%). INTRODUCTION: A Fracture Liaison Service (FLS) was implemented at Lille University Hospital in 2016. The main purpose of this study was to assess the performance of the FLS using criteria proposed by the International Osteoporosis Foundation (IOF). METHODS: The criteria used were patient identification, patient evaluation, post-fracture assessment timing, vertebral-fracture identification, blood and bone mineral density (BMD) testing, falls prevention, multifaceted health and lifestyle risk-factor assessment, and medication initiation and review. RESULTS: Between January 2016 and January 2018, 736 patients (≥ 50 years old) with a recent history of fragility fracture (≤ 12 months) were identified. The identification rate for hip fractures was 74.2%. However, patient evaluation for all type of fractures was quite low (30.3%) since many patients failed to attend the FLS unit. The reasons for non-attendance were refusal, agreed but subsequently failed to attend, and still waiting to be seen. In all, 256 patients (76.6% female, mean (SD) age 74.3 (11.0) years) were seen at the FLS. Mean (SD) post-fracture assessment timing was 13.3 (9.3) weeks. Of the 139 patients seen for a non-vertebral fracture, 103 were assessed for vertebral fractures, and at least one new vertebral fracture was found in 45 of them (43.7%). Osteoporosis medication was prescribed for 243 (94.9%) patients. The main osteoporosis drug prescribed was zoledronic acid (60.2%). CONCLUSIONS: Secondary prevention of osteoporotic fractures has improved since the implementation of the FLS. However, patient identification, patient evaluation, and post-fracture assessment timing still need to be improved.

Does arthroscopic assistance improve reduction in distal articular radius fracture? A retrospective comparative study using a blind CT assessment.

INTRODUCTION: The objective of this study was to compare the articular reduction in two groups of patients with a distal articular radius fracture who underwent surgery with versus without arthroscopic assistance. The initial hypothesis of this study is that arthroscopic assistance does not improve reduction in distal articular radius fractures. METHODS: The study was retrospective (1/04/2014-01/04/2017) and included 41 patients: 23 had arthroscopically assisted osteosynthesis, and 18 had not. All patients included had CT before and 3 months after surgery. All radiographic and CT measurements were retrospectively taken by an independent radiologist who did not know which operative technique was performed. Secondary judgement criteria were clinical analysis at 1-year follow-up and tourniquet time. We also reported all soft tissue injuries diagnosed and repaired and postoperative complications. RESULTS: At the third month, articular step was 0.91 ± 1.25 mm (arthroscopy) and 1.41 ± 1.68 mm (no arthroscopy), without statistical difference (p = 0.3756). No difference was found for articular gap between the two groups [arthroscopy (0.55 ± 1.04 mm), (no arthroscopy (0.82 ± 1.54 mm)] (p = 0.8574). Except for the tourniquet time, clinical results at 1-year follow-up were not different. One patient of each group had a scapholunate pinning, and 6 patients of the arthroscopy group had a TFCC 1B injury, which was repaired. CONCLUSION: This study did not demonstrate that arthroscopic assistance improves step and gap reduction of articular distal radius fracture, confirming initial hypothesis and recent literature data. LEVEL OF EVIDENCE: Retrospective, III.

What happens to the posterior comminution in extra-articular fractures of the distal radius treated with volar locking plates?

Extra-articular fractures of the distal radius with posterior displacement are typically treated with volar locking plates. However, this fixation method does not address the posterior comminution, which seems to have no impact on the final result. The purpose of this study was to determine the fate of the posterior comminution. This was a retrospective study of 22 patients over 50 years old with a distal radius fracture. A preoperative computed tomography (CT) scan was performed to evaluate the comminution. All fractures were fixed with a volar locking plate. All patients underwent a bone density scan. Patients were reviewed at 6 months post-operative to determine their clinical, radiological and functional outcomes. The CT scan was performed again to determine the fate of the comminution. At 6 months post-operative, 82% of patients had an oval metaphyseal defect. The mean volume of this defect was 1.86 mL. The contents of this defect most closely resembled fat. There was no statistical link between the defect's volume and the various parameters studied. On the other hand, the defect's density was positively related to the functional outcome and negatively related to the patients' body mass index. Because of the compression experienced by the cancellous bone, a distal metaphyseal defect often persists after consolidation in dorsally displaced distal radius fractures. The posterior comminution is ultimately of little consequence.

The benefit of the systematic revision of the acetabular implant in favor of a dual mobility articulation during the treatment of periprosthetic fractures of the femur: a 49 cases prospective comparative study.

INTRODUCTION: The SOFCOT symposium (2005) on periprosthetic fractures of the femur (PFFs) highlighted a high rate of dislocation (15.6% at 6 months) after change of prosthesis. So far, no study has ever proved the benefit of dual-mobility articulation during PFFs revisions. We conducted a comparative study on two prospective cohorts in order to (1) assess the influence of systematic acetabular revision in favor of a double mobility on dislocation rate (2) and in order to evaluate the rate of morbidity associated with this extra surgical procedure. HYPOTHESIS: A systematic replacement of the cup in favor of a dual-mobility articulation enables to reduce the dislocation rate in PFFs revisions without increasing morbidity. METHODOLOGY: We compared two prospective multicenter cohorts over a year (2005 and 2015) using the same methodology. Any fracture around hip prosthesis which occurred 3 months at least after surgery was included. Data collection was clinical and radiological on preoperative, intraoperative and 6 months after surgery. The 2015 "bipolar" group (n = 24) included patients who had a bipolar revision (both femoral and dual-mobility articulation). The 2005 "unipolar" group (n = 25) included patients who had only a femoral implant revision. Patients were comparable by age (p = 0.36), sex (p = 0.91), ASA score (p = 0.36), history of prosthetic revision (p = 1.00), Katz score (p = 0.50) and the type of fracture according to the Vancouver classification (p = 0.55). RESULTS: There was a 4% rate of dislocation in the "bipolar group" while there was 21% rate of dislocation in the "unipolar group" (8% of recurrent dislocation) (p = 0.19). The rate of all-cause complications 6 months after surgery was not significantly different (p = 0.07): 12.5% in the 2015 "bipolar" cohort (one dislocation, one non-symptomatic cup migration and one pseudarthrosis of the major trochanter) versus 35% in the "unipolar" cohort (5 dislocations, 1 major trochanter fracture and 1 femur pseudarthrosis, 1 secondary displacement associated with a superficial infection). The surgical revision after 6 months was not significantly different (1/23 or 4% vs. 4/25 or 16%, p = 0.35). CONCLUSION: We confirm the low rate of dislocations after fitting a dual-mobility cup in case of revision of the femoral side in case of periprosthetic femoral fracture, as well as the need for additional cases to be carried out upon further studies to significantly confirm the interest of preventing instability after femoral revision.

Contribution of arthroscopy to the treatment of intraarticular fracture of the distal radius: Retrospective study of 40 cases.

Our study aimed to compare the anatomical result after treatment of intraarticular distal radius fracture with locking volar plates with and without arthroscopy. This was a retrospective, single-center study of intraarticular fractures. A volar locked plate was used for fracture fixation in all patients. Twenty patients were operated on with fluoroscopy only ("plate" group) and 20 operated using arthroscopy assistance ("arthroscopy" group). All patients underwent a CT scan before surgery and at 3 months postoperative. The main outcome measure was the residual intraarticular step-off (measured in millimeters). Other studied outcomes were the residual gap between fragments and extra-articular reduction. The two groups were similar preoperatively in all aspects except the size of the gap between fragments. The residual step-off was significantly less in the arthroscopy group: 1.9mm (Q1 1.7; Q3 2.25) for plate versus 0.8mm (Q1 0.7; Q3 1.5) for arthroscopy (P=0.001). The change from the preoperative to the postoperative measurement was significantly greater in the arthroscopy group: 0.1 mm (Q1 -0.5; Q3 0.8) for plate and -1mm (Q1 -1.9; Q3 -0.6) for arthroscopy (P=0.0002). The residual gap was similar between both groups: 2.4mm (Q1 1.9; Q3 3.5) for plate vs. 2.3mm (Q1 1.1; Q3 2.8) for arthroscopy (P=0.37). The change in gap was not significantly different between the two groups: -0.9mm (Q1 -1.8; Q3 -0.1) for plate vs. -2.9mm (Q1 -4.4; Q3 -1.7) for arthroscopy (P=0.32). There was no difference in the extra-articular reduction. Damage was found to the scapholunate ligament in 30% and the TFCC in 30% of arthroscopy cases. Arthroscopy improves intraarticular reduction without altering extra-articular reduction in patients with intraarticular fractures of the distal radius, and it allows for assessment and treatment of any injuries discovered. We must now follow these patients over the long-term to assess the clinical benefit. LEVEL OF EVIDENCE: 3.

Predictors of radial nerve palsy recovery in humeral shaft fractures: A retrospective review of 17 patients.

BACKGROUND: Radial nerve injury is common in humeral shaft fractures and fails to recover spontaneously in 30% of cases. Few studies have evaluated predictors of recovery. The objectives of this study were to identify predictors of radial nerve palsy recovery and to assess the usefulness of surgical radial nerve exploration in patients with preoperative radial nerve palsy. HYPOTHESIS: Factors predicting the outcome of radial nerve palsy can be identified. METHODS: Of 373 patients with humeral shaft fractures between 2005 and 2012, 43 had radial nerve palsy, including 23 who were lost to follow-up and 17 who were evaluated retrospectively at a mean of 26 months (range, 12-84 months) after internal fixation. The following were studied: age, smoking history, energy of the trauma, fracture type and displacement, skin integrity and intra-operative appearance of the radial nerve. RESULTS: Of the 17 palsies, 13 were present preoperatively, including 10 that recovered (PreR group) and 3 that did not recover (PreNR group). Plate fixation and radial nerve exploration were performed in all patients. Of the 10 PreR patients, 6 had nerve contusion and 2-nerve entrapment. Of the 3 PreNR patients, 2 had gross nerve damage and 1 nerve contusion and a history of spinal muscular atrophy. Only age and presence of gross nerve damage differed significantly between the PreR and PreNR groups; trends towards significant differences were noted for skin breach and fracture displacement. Of the 4 postoperative radial nerve palsies, 2 recovered fully and 2 partially; mean age was higher in the 2 patients with partial recovery. DISCUSSION: These findings are consistent with the few previous studies of outcome predictors in radial nerve palsy. Factors such as major fracture displacement and high-grade skin wounds probably promote the occurrence of gross nerve lesions. The high incidence of nerve entrapment and stretching supports routine nerve exploration during internal fixation in patients with preoperative radial nerve palsy. LEVEL OF EVIDENCE: IV, retrospective study with no control group.

Epidemiology of patients with MSSA versus MRSA infections of orthopedic implants: Retrospective study of 115 patients.

Factors that predict the occurrence of a surgical site infection due to methicillin-resistant Staphylococcus aureus (MRSA) are not well known; however this information could be used to modify the recommended antimicrobial prophylaxis. We carried out a retrospective study of S. aureus infections on orthopedic implants to determine: (1) whether epidemiological factors can be identified that predict a MRSA infection, (2) the impact of these factors as evidenced by the odds ratio (OR). HYPOTHESIS: Risk factors for a MRSA infection can be identified from a cohort of patients with S. aureus infections. MATERIALS AND METHODS: We identified 244 patients who experienced a S. aureus surgical site infection (SSI) in 2011-2012 documented by intraoperative sample collection. Of these 244 patients, those who had a previous SSI (n=44), those with a SSI but no orthopedic implant (n=80) or those who had the infection more than 1-year after the initial surgery (n=5) were excluded. This resulted in 115 patients (53 arthroplasty, 62 bone fixation) being analyzed for this study. There were 24 MRSA infections and 91 MSSA infections. The following factors were evaluated in bivariate and multifactorial analysis: age, sex, type of device (prosthesis/bone fixation), predisposition (diabetes, obesity, kidney failure), and environmental factors (hospitalization in intensive care unit within past 5 years, nursing home stay). RESULTS: Two factors were correlated with the occurrence of MRSA infections. (1) Nursing home patients had a higher rate of MRSA infections (67% vs. 18%, P=0.017) with an OR of 8.42 (95% CI: 1.06-66.43). (2) Patients who had undergone bone fixation had a lower rate of MRSA infections than patients who had undergone arthroplasty (13% vs. 30%, P=0.023), OR 0.11 (95% CI: 0.02-0.56). Although the sample size was too small to be statistically significant, all of the patients with kidney failure (n=4) had a MRSA infection. DISCUSSION: Since these MRSA infection risk factors are easy to identify, the antimicrobial prophylaxis could be adapted in these specific patient groups.

Is arthroplasty preferable to internal fixation for the treatment of extracapsular fracture of the upper femur in the elderly?

INTRODUCTION: Although internal fixation is the reference treatment for extracapsular fracture of the upper femur, indications for arthroplasty are broadening, especially in unstable comminutive fracture in fragile bone. The present study hypothesis was that arthroplasty reduces early mortality and morbidity and provides better recovery of autonomy in over-80 year-old patients than does internal fixation. MATERIAL AND METHODS: A prospective multicenter study was conducted on 8 sites. Internal fixation was systematically used in 5 centers; arthroplasty was used systematically in 1 center, and reserved for unstable fracture in 2 centers. A total of 697 patients aged over 80 years (mean age, 85±5 years), presenting with extracapsular fracture, were included; 521 were treated by internal fixation and 176 by arthroplasty. Results were studied on multivariate analysis of ASA score, blood loss, transfusion, and also of treatment modality as an independent factor for early (first 6 months) mortality and morbidity (mechanical, general and nutritional complications) and functional outcome (autonomy and dependence). RESULTS: Overall mortality was 19.2%. Autonomy deteriorated in 56% of patients alive at 6 months and dependence worsened in 44%. Two percent of those managed by internal fixation underwent revision for disassembly (n=8) or infection (n=1). Eight percent of those managed by arthroplasty underwent revision for dislocation (n=4), implant loosening (n=3) or infection (n=7). On univariate analysis, mortality was higher in the arthroplasty group (25%) than with internal fixation (17%; P=0.002), as were blood loss (425±286mL versus 333±223mL; P<0.0001), transfusion rate (61% versus 32%; P<0.0001) and infection (4% versus 0.2%; P<0.001). On multivariate analysis, however, treatment modality no longer showed impact on mortality or on morbidity and autonomy at 6 months. Nutritional status was better conserved at 6 months following arthroplasty, but dependence worsened. Poor preoperative autonomy, ASA score, and nutritional status and time to treatment were independent factors for mortality. Transfusion, associated with onset of mechanical complications, significantly increased dependence. CONCLUSION: Type of treatment had little impact on mortality, morbidity or functional outcome. Differences seemed more related to preoperative functional and nutritional status. LEVEL OF EVIDENCE: III, prospective case-control study.

High-sensitivity C-reactive protein does not improve the differential diagnosis of HNF1A-MODY and familial young-onset type 2 diabetes: A grey zone analysis.

AIM: Low plasma levels of high-sensitivity C-reactive protein (hs-CRP) have been suggested to differentiate hepatocyte nuclear factor 1 alpha-maturity-onset diabetes of the young (HNF1A-MODY) from type 2 diabetes (T2D). Yet, differential diagnosis of HNF1A-MODY and familial young-onset type 2 diabetes (F-YT2D) remains a difficult challenge. Thus, this study assessed the added value of hs-CRP to distinguish between the two conditions. METHODS: This prospective multicentre study included 143 HNF1A-MODY patients, 310 patients with a clinical history suggestive of HNF1A-MODY, but not confirmed genetically (F-YT2D), and 215 patients with T2D. The ability of models, including clinical characteristics and hs-CRP to predict HNF1A-MODY was analyzed, using the area of the receiver operating characteristic (AUROC) curve, and a grey zone approach was used to evaluate these models in clinical practice. RESULTS: Median hs-CRP values were lower in HNF1A-MODY (0.25mg/L) than in F-YT2D (1.14mg/L) and T2D (1.70mg/L) patients. Clinical parameters were sufficient to differentiate HNF1A-MODY from classical T2D (AUROC: 0.99). AUROC analyses to distinguish HNF1A-MODY from F-YT2D were 0.82 for clinical features and 0.87 after including hs-CRP. For the grey zone analysis, the lower boundary was set to miss<1.5% of true positives in non-tested subjects, while the upper boundary was set to perform 50% of genetic tests in individuals with no HNF1A mutation. On comparing HNF1A-MODY with F-YT2D, 65% of patients were classified in between these categories - in the zone of diagnostic uncertainty - even after adding hs-CRP to clinical parameters. CONCLUSION: hs-CRP does not improve the differential diagnosis of HNF1A-MODY and F-YT2D.

Does primary total knee arthroplasty for acute knee joint fracture maintain autonomy in the elderly? A retrospective study of 21 cases.

INTRODUCTION: Due to poor results and failure encountered in osteosynthesis of peri-articular fracture of the knee, arthroplasty may be suggested to osteopenic elderly subjects. All osteosynthesis techniques entail loss of independence and are associated with elevated mortality. No studies definitively establish better management of such fractures. HYPOTHESIS: Total arthroplasty provides better autonomy after peri-articular fracture of the knee. MATERIAL AND METHOD: Seventy-nine patients aged over 65years were operated on for peri-articular fracture of the knee between April 2008 and March 2013. In 21 cases, treated by a single surgeon, total knee arthroplasty was performed in view of osteopenia or osteoarthritis. Mean age was 79years (range, 68-96years). There were 10 distal femoral and 11 proximal tibial fractures. Mean follow-up was 31months (range, 9-68months). Cases of pathologic fracture, failed osteosynthesis and non-operative management were excluded. All patients showed severe osteopenia on radiology and half already had advanced osteoarthritis. RESULTS: One-year mortality was 14%. At last follow-up, the revision rate was 9.5%. Fifteen patients were followed up. Mean Parker score fell from 7.2 (range, 2-9) preoperatively to 4.6 (range, 0-9) at last follow-up, indicating loss of independence. At follow-up, mean IKS score was 116.6 (range, 0-192) with mean IKS knee score of 78.4 (range, 0-100) and IKS function score of 38.2 (range, 0-100). Mean Oxford score was 36/60 (range, 18-53). Global IKS and IKS function scores were significantly better in case of ASA-2 than ASA-3 (P<0.05). There was no difference between femoral and tibial fractures in terms of IKS or Oxford score or loss of independence. DISCUSSION: Total knee arthroplasty can be considered for peri-articular fracture of the knee in osteopenic geriatric patients. Although surgical revision was less frequent than after osteosynthesis and resumption of weight-bearing was immediate, autonomy was still impaired. Mortality was comparable to other reports. LEVEL OF EVIDENCE: IV, retrospective study.

Monoallelic ABCC8 mutations are a common cause of diazoxide-unresponsive diffuse form of congenital hyperinsulinism.

ABCC8 encodes a subunit of the ß-cell potassium channel (KATP ) whose loss of function is responsible for congenital hyperinsulinism (CHI). Patients with two recessive mutations of ABCC8 typically have severe diffuse forms of CHI unresponsive to diazoxide. Some dominant ABCC8 mutations are responsible for a subset of diffuse diazoxide-unresponsive forms of CHI. We report the analysis of 21 different ABCC8 mutations identified in 25 probands with diazoxide-unresponsive diffuse CHI and carrying a single mutation in ABCC8. Nine missense ABCC8 mutations were subjected to in vitro expression studies testing traffic efficiency and responses of mutant channels to activation by MgADP and diazoxide. Eight of the 9 missense mutations exhibited normal trafficking. Seven of the 8 mutants reaching the plasma membrane had dramatically reduced response to MgADP or to diazoxide (<10% of wild-type response). In our cohort, dominant KATP mutations account for 22% of the children with diffuse unresponsive-diazoxide CHI. Their clinical phenotype being indistinguishable from that of children with focal CHI and diffuse CHI forms due to two recessive KATP mutations, we show that functional testing is essential to make the most reliable diagnosis and offer appropriate genetic counseling.

Unicondylar fractures of the distal femur.

BACKGROUND: Unicondylar fractures of the distal femur are rare, complex, intra-articular fractures. The objective of this multicentre study was to assess the reduction and fixation of unicondylar fractures. HYPOTHESIS: Anatomic reduction followed by strong fixation allows early rehabilitation therapy and provides good long-term outcomes. MATERIAL AND METHODS: We studied 163 fractures included in two multicentre studies, of which one was retrospective (n=134) and the other prospective (n=29). Follow-up of at least 1 year was required for inclusion. The treatment was at the discretion of the surgeon. Outcome measures were the clinical results assessed using the International Knee Society (IKS) scores and presence after fracture healing of malunion with angulation, an articular surface step-off, and/or tibio-femoral malalignment. RESULTS: Mean age of the study patients was 50.9 ± 24 years, and most patients were males with no previous history of knee disorders. The fracture was due to a high-energy trauma in 51% of cases; 17% of patients had compound fractures and 44% multiple fractures or injuries. The lateral and medial condyles were equally affected. The fracture line was sagittal in 82% of cases and coronal (Hoffa fracture) in 18% of cases. Non-operative treatment was used in 5% of cases and internal fixation in 95% of cases, with either direct screw or buttress-plate fixation for the sagittal fractures and either direct or indirect screw fixation for the coronal fractures. After treatment of the fracture, 15% of patients had articular malunion due to insufficient reduction, with either valgus-varus (10%) or flexion-recurvatum (5%) deformity; and 12% of patients had an articular step-off visible on the antero-posterior or lateral radiograph. Rehabilitation therapy was started immediately in 65% of patients. Time to full weight bearing was 90 days and time to fracture healing 120 days. Complications consisted of disassembly of the construct (2%), avascular necrosis of the condyle (2%), and arthrolysis (5%). The material was removed in 11% of patients. At last follow-up, the IKS knee score was 71 ± 20 and the IKS function score 64 ± 7; flexion range was 106 ± 28° (<90° in 27% of patients); and 12% of patients had knee osteoarthritis. CONCLUSION: Anatomic reduction of unicondylar distal femoral fractures via an appropriate surgical approach, followed by stable internal fixation using either multiple large-diameter screws or a buttress-plate, allows immediate mobilisation, which in turn ensures good long-term outcomes. LEVEL OF EVIDENCE: IV, cohort study.