Glenoid erosion is a risk factor for recurrent instability after Hill-Sachs remplissage.

AIMS: The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR). METHODS: This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport. RESULTS: At a mean follow-up of four years (1.0 to 8.25), ten patients (7.5%) had recurrent instability. Patients in group B had a significantly higher recurrence rate than those in group A (p = 0.001). Using a multivariate logistic regression, the presence of glenoid erosion of > 10% (odds ratio (OR) = 35.13 (95% confidence interval (CI) 8 to 149); p = 0.001) and age < 23 years (OR = 0.89 (0.79 to 0.99); p = 0.038) were associated with a higher risk of recurrent instability. A total of 80 patients (78%) could return to sport, but only 11 athletes (65%) who practiced high-risk (collision or contact-overhead) sports. All seven shoulders which were revised using a Latarjet procedure were stable at a mean final follow-up of 36 months (11 to 57) and returned to sports at the same level. CONCLUSION: Patients with subcritical glenoid bone loss (> 10%) and younger age (≤ 23 years) are at risk of failure and reoperation after ABR-HSR. Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. Cite this article: Bone Joint J 2021;103-B(4):718-724.

Outpatient shoulder prostheses: Feasibility, acceptance and safety.

INTRODUCTION: Outpatient surgery in France is defined by the national authority for health (HAS) as a scheduled surgery enabling same-day discharge without any increased risk to the patient. With the advent of enhanced recovery after surgery, outpatient lower limb arthroplasty has become a common procedure. However, only 1.1% of knee arthroplasties in France were performed on an outpatient basis in 2017. OBJECTIVES: 1) assess early morbidity and mortality after outpatient shoulder arthroplasties to validate eligibility and safety criteria; and 2) assess patient acceptance of outpatient surgery. METHODS: A single-center study with the following inclusion criteria: primary shoulder arthroplasty, American Society of Anesthesiology (ASA) score I or II, no cognitive impairment, and no coronary artery or thromboembolic diseases. Analgesia was provided by bupivacaine via a peripheral nerve catheter in the first 72 hours followed by oral analgesics. Patients were discharged if the post-anesthetic discharge scoring system (PADSS) was>9/10 and the visual analog scale (VAS) was<5/10. Postoperative telephone interviews were carried out on D1, D2 and D3 to assess pain with the numerical rating scale and to collect data on their analgesic consumption. All patients were seen by an independent observer at one and six months for a clinical and radiologic follow-up and at 90 days during a consultation with the senior surgeon. The primary endpoint was the 90-day morbidity and mortality rate (readmissions, rehospitalizations, and minor and major complications). A satisfaction questionnaire was collected at one and six months. RESULTS: Thirty-six patients were offered an outpatient shoulder arthroplasty between February 2016 and February 2018: 12 (33%) refused with no valid reasons and 24 patients agreed to the procedure (seven hemiarthroplasties, nine anatomic shoulder arthroplasties and eight reverse shoulder arthroplasties). The mean age at surgery was 70 years (55-82), mean body mass index (BMI) was 26 (21-32) and 14 patients were ASA II (66%). Three patients (12%) refused same-day discharge despite a PADSS score>9/10 and adequate pain management. Two patients (8%) were not discharged home on the same day as the surgery for medical reasons (one for pain and one for high blood pressure). No readmissions or complications were reported for the 19 outpatient arthroplasties. None of the outpatients used opioids. All patients were satisfied with their functional outcome, 84% were satisfied with the outpatient management and 17% felt they were insufficiently monitored and regretted that they were not hospitalized. CONCLUSIONS: 1) outpatient shoulder arthroplasty can be safely proposed to selected patients with low comorbidities, regardless of their age and type of implant; 2) the acceptance rate for outpatient shoulder arthroplasty remained low among our patient population. These results should incite us to better educate patients about outpatient surgery. LEVEL OF EVIDENCE: IV; retrospective study.

Long-Term Efficacy of Occipital Nerve Stimulation for Medically Intractable Cluster Headache.

BACKGROUND: Occipital nerve stimulation (ONS) has been proposed to treat refractory chronic cluster headache (rCCH) but its efficacy has only been showed in small short-term series. OBJECTIVE: To evaluate ONS long-term efficacy in rCCH. METHODS: We studied 105 patients with rCCH, treated by ONS within a multicenter ONS prospective registry. Efficacy was evaluated by frequency, intensity of pain attacks, quality of life (QoL) EuroQol 5 dimensions (EQ5D), functional (Headache Impact Test-6, Migraine Disability Assessment) and emotional (Hospital Anxiety Depression Scale [HAD]) impacts, and medication consumption. RESULTS: At last follow-up (mean 43.8 mo), attack frequency was reduced >50% in 69% of the patients. Mean weekly attack frequency decreased from 22.5 at baseline to 9.9 (P < .001) after ONS. Preventive and abortive medications were significantly decreased. Functional impact, anxiety, and QoL significantly improved after ONS. In excellent responders (59% of the patients), attack frequency decreased by 80% and QoL (EQ5D visual analog scale) dramatically improved from 37.8/100 to 73.2/100. When comparing baseline and 1-yr and last follow-up outcomes, efficacy was sustained over time. In multivariable analysis, low preoperative HAD-depression score was correlated to a higher risk of ONS failure. During the follow-up, 67 patients experienced at least one complication, 29 requiring an additional surgery: infection (6%), lead migration (12%) or fracture (4.5%), hardware dysfunction (8.2%), and local pain (20%). CONCLUSION: Our results showed that long-term efficacy of ONS in CCH was maintained over time. In responders, ONS induced a major reduction of functional and emotional headache-related impacts and a dramatic improvement of QoL. These results obtained in real-life conditions support its use and dissemination in rCCH patients.

One-session bilateral total knee replacement: Late complications and survivorship.

INTRODUCTION: The early morbidity and mortality of one-session bilateral total knee arthroplasty (1-session BTKA) has been reported in the medical literature. However, there is less information about the long-term clinical impact of this strategy. The aim of this study was to report on the late complications (>90 days), clinical outcomes (KOOS and new KSS) along with the survivorship of 1-session BTKA. We hypothesised that 1-session BTKA will cause few late complications and that the implant survival will meet the criteria of the National Institute for Health and Clinical Excellence (NICE). METHODS: This single-centre retrospective study analysed a cohort of ASA-1 and ASA-2 patients who underwent 1-session BTKR over an 8-year period (2009 to 2016). The cohort consisted of 116 patients (66% women, 34% men) with mean age at inclusion of 69 years (32-85 years); 22% of patients were ASA-1 and 78% were ASA-2. The implant-related, infection-related or mechanical complications that occurred more than 90 days after the operation, the clinical outcomes (KOOS and New KSS) and radiological outcomes, along with the survivorship were determined during the scheduled follow-up visits at 3 months, 6 months and 1 year postoperative and during the long-term follow-up or during an intercurrent event. RESULTS: No patients were lost to follow-up. Fifteen complications occurred (6.5%): four infections, four patellar problems (three cases of clunk syndrome and one of patellofemoral pain), four cases of stiffness, two of unexplained pain and one femoral periprosthetic fracture. Eight patients were readmitted to the hospital (7%); seven were reoperated (3%) and two implants were revised (1%). The functional outcomes (KOOS and New KSS) were significantly improved and 87% of patients were satisfied or very satisfied with this procedure. At a mean follow-up of 5 years, the survivorship estimated using the Kaplan-Meier method was 98.4% (95% CI: 0.933-0.996). CONCLUSION: Performing 1-session BTKA is a reliable strategy as it produces a low rate of late complications, excellent medium-term functional outcomes and survivorship that meets NICE criteria, thus confirming our hypothesis. LEVEL OF EVIDENCE: IV, retrospective case series.

One-stage bilateral total hip arthroplasty versus unilateral total hip arthroplasty: A retrospective case-matched study.

BACKGROUND: One-stage bilateral hip replacement has the advantage of involving a single anesthesia, single hospital admission and single rehabilitation program. The theoretic drawback is increased surgical risk. Few French series have been reported, and none with comparison versus unilateral arthroplasty. We therefore conducted a comparative case-control study between 1-stage bilateral (1B-THA) and unilateral total hip arthroplasty (U-THA), assessing (1) morbidity/mortality, (2) survival, and (3) functional scores and forgotten hip rates. HYPOTHESIS: In a selected ASA 1 or 2 population, 1B-THA shows complications rates and implant survival comparable to U-THA. MATERIAL AND METHOD: Between 2004 and 2018, 327 patients were included: 109 with 1B-THA, 218 with U-THA. One 1B-THA patient was matched to 2 U-THA patients on age, gender, diagnosis, ASA score 1 or 2, and anterior or posterior approach. Minimum follow-up was 12 months. Complications were collected for all patients in both groups. Early (≤90 days) or late (>90 days) morbidity/mortality and implant survival were recorded for both groups. Secondary endpoints concerned blood-sparing strategy and blood loss, functional scores, and patient satisfaction. RESULTS: Mortality was zero in both groups. There was no significant difference in complications rates (1B-THA 38.5%, U-THA 40.8%) (p=0.69), whether early (8.3% [9/109] and 7.8% [17/218] respectively [p=0.89]) or late (30.3% [33/109] and 33.0% [72/218] respectively [p=0.61]). Limb-length discrepancy was significantly less frequent in 1B-THA (5.5% [6/109] versus 13.3% [29/218] [p=0.03]). Forgotten hip rate was significantly more frequent in 1B-THA (86% [94/109] versus 70% [152/218] [p=0.01]). Five-year Kaplan-Meier implant survival was 97.2% (95% CI [91.9-99.1]) in 1B-THA and 96.6% (95% CI [93.0-98.4]) in U-THA (p=0.08). DISCUSSION: One-stage bilateral total hip arthroplasty gave acceptable results in disabling bilateral osteoarthritis of the hip with low surgical risk in selected patients (ASA 1 or 2). Mortality, complications and implant survival were unaffected, but the 1-stage bilateral procedure allowed better control of limb-length and provided a higher rate of forgotten hip. LEVEL OF EVIDENCE: III, matched case-control study.

Pyrocarbon interposition shoulder arthroplasty in young arthritic patients: a prospective observational study.

BACKGROUND: We evaluated survival and midterm results of pyrocarbon interposition shoulder arthroplasty (PISA) in arthritic patients younger than 65 years. METHODS: Fifty-eight PISAs (InSpyre; Tornier-Wright, Bloomington, MN, USA), implanted in 56 patients between 2010 and 2015, were prospectively observed. The mean age at surgery was 52 ± 13 years. The cause was primary osteoarthritis (18), fracture sequelae (16), post-instability arthritis (15), aseptic necrosis (3), inflammatory disease (2), and failed hemiarthroplasty (4); 34 shoulders (61%) had previously undergone surgery. Glenoid erosion was assessed in 4 grades according to the Sperling classification. Humeral erosion was also assessed in 4 grades. Multivariate analysis was used to determine predisposing risk factors for both humeral and glenoid erosion. RESULTS: At a mean follow-up of 47 ± 15 months, survival rate was 90%. Six patients (10%) required conversion to reverse total shoulder prosthesis for painful glenoid erosion (n = 2) and humeral erosion with greater tuberosity stress fractures (n = 4). The mean Constant score and subjective shoulder value significantly increased from 36 ± 14 points to 70 ± 15 points and 32% ± 14% to 75% ± 19%, respectively (P < .001). Humeral medialization was observed in 78% of the cases with increased pain score. Uncorrected anteroposterior implant subluxation (12 cases) was associated with lower Constant score (50 points vs. 72 points; P = .02) and lower subjective shoulder value (53% vs. 78%; P = .002). On multivariate analysis, no risk factors for glenoid or humeral erosion were found. CONCLUSION: At midterm follow-up, PISA does not protect from progressive glenoid erosion and can lead to greater tuberosity erosion and stress fractures. Longer follow-up is required to see whether PISA survival will be superior to that of hemiarthroplasty.

Early morbidity and mortality after one-stage bilateral THA: Anterior versus posterior approach.

BACKGROUND: Advantages of performing bilateral total hip arthroplasty (THA) in one stage include a single hospital stay, a single exposure to anaesthesia risks, and expedited rehabilitation. Controversy persists however, regarding safety, notably morbidity and mortality rates. Importantly, few studies have compared the anterior to the posterior approach for single-stage bilateral THA (1B-THA). The objective of this retrospective study in a uniform patient population was to compare the anterior and posterior approaches for 1B-THA in terms of: 1) early mortality rates, 2) early complications, 3) and 90-day re-admission rates, hospital stay lengths, and blood loss. HYPOTHESIS: 1B-THA in patients younger than 80 years who have an ASA score of 1 or 2 is associated with no early mortality and with low early morbidity rates regardless of whether the anterior or posterior approach is used. MATERIAL AND METHODS: A single-centre retrospective comparative design was used to assess 90-day mortality and morbidity rates in consecutive patients who underwent 1B-THA between 2004 and 2018. The groups managed with the anterior approach (AA) without traction table and posterior approach (PA) were compared. The ASA score was ≤2 and age ≤80 years in all patients. The groups were comparable for age, sex distribution, ASA score, pre-operative haemoglobin level, and reason for THA. RESULTS: We included 55 patients managed via the AA and 82 managed via the PA. No patients died in either group. Early complications occurred in 3 patients in the AA group and 6 in the AP group (p=0.74). No differences were noted between the two groups for each type of complication. In the AA group, 3 patients experienced major complications (p=0.06) (2 cerebrovascular events and 1 peri-prosthetic fracture). In the PA group, 6 patients experienced minor complications (1 case each of dislocation, piriformis syndrome, sacral pressure sore, and deep vein thrombosis and 2 cases of ilio-psoas irritation; p=0.08). Operative time was 144minutes (range, 110-195minutes) in the AA group and 171minutes (range, 108-255minutes) in the PA group (p<0.001). Mean hospital stay length was 7.6 days (range, 3-13 days) overall, 6.7 days (range, 5-11 days) in the AA group, and 8.2 days (range, 3-13 days) in the PA group (p<0.001). The early re-admission rate was 2.9% overall, with no difference between the AA group (3.6% [2/55]) and the PA group (2.4% [2/82]) A post-operative blood transfusion was required by 34/137 (24.8%) patients overall, 15/55(27.3%) patients in the AA group and 19/82 (23.2%) patients in the PA group (p=0.58). DISCUSSION: In selected patients (ASA score 1 or 2 and age ≤80 years), 1B-THA was not followed by any early deaths in the patients managed using the anterior or posterior approach. Total early morbidity rates were low. Neither the types of complications nor the early re-admission rates differed between the AA and PA groups. The shorter operative time in the AA group is ascribable to change in patient installation between the two arthroplasties when the PA is used. LEVEL OF EVIDENCE: III, comparative study of consecutive patients.

Sciatic nerve block or not for outpatient total knee arthroplasty? Study protocol for a randomized controlled trial.

BACKGROUND: The number of patients operated on for total knee arthroplasty (TKA) is growing worldwide. Outpatient surgery is defined by a length of stay (LOS) in the hospital of less than 12 h. This can be limited for TKA, with the efficient management of pain and perioperative complications, such as blood loss, affecting a safe hospital discharge. Outpatient TKA with a suitable protocol, including multimodal measures, could improve the success rate of this procedure. Among the main measures, single-shot sciatic nerve block in association with continuous femoral nerve block for pain control needs to be evaluated in outpatient TKA. Furthermore, to promote the safety of the postoperative period and to accelerate rehabilitation, patients who undergo ambulatory TKA could be discharged to a rehabilitation center on the day of surgery to screen adverse events and to optimize the rehabilitation process. This study is designed to assess the benefits of sciatic nerve block in postoperative pain relief for outpatient TKA. METHODS/DESIGN: This randomized prospective controlled study will be conducted in the knee unit of the teaching hospital of the Nice university and will include 40 patients undergoing primary unilateral outpatient TKA, discharged the day of surgery to a private rehabilitation center for enhanced recovery after surgery, after a hospital stay of less than 12 h. Before surgery, all patients will receive a continuous femoral nerve block with 2 mg/ml ropivacaine 20 ml, and then patients will be randomly assigned to receive or not receive a single-shot sciatic nerve block with 2 mg/ml ropivacaine, 20 ml. The primary outcome measure is the success rate of outpatient TKA. This rate is defined by patients discharged from the hospital to a rehabilitation center the day of surgery with no re-hospitalization due to insufficient pain control before the fifth postoperative day. Secondary outcomes include the incidence of major and minor adverse events during the first five postoperative days and measurement of the quality of recovery using the Knee injury and Osteoarthritis Outcome Score and the new International Knee Society scores plus the Quality of Recovery-40 questionnaire. DISCUSSION: The assessment of anesthesia and rehabilitation protocols enabling major orthopedic surgery, such as TKA, is necessary. This randomized controlled study will address the hypothesis that a suitable multimodal protocol including sciatic nerve block could improve pain control and thus improve the success rate of outpatient TKA. TRIAL REGISTRATION: EudraCT, 2016-000226-19. Registered on 15 April 2016.

Early morbidity and mortality after single-stage bilateral total knee replacement.

INTRODUCTION: Single-stage bilateral total knee replacement (TKR) has the advantages of requiring only one hospital stay and one anesthesia session, having a shorter rehabilitation period, and reducing the cost of patient care. However, this strategy is controversial because of the perioperative risk. We hypothesized that this strategy did not cause early perioperative mortality and that the early morbidity and readmission rates would be low when patients are selected based on their ASA score. METHODS: This single-center retrospective study analyzed a cohort of ASA-1 and ASA-2 patients who underwent single-stage bilateral TKR over an 8-year period (2009 to 2016). The study cohort consisted of 116 patients, mainly women with mean age of 69 years at inclusion; 22.4% of patients were ASA-1 and 77.6% were ASA-2. Death and early complications during the first 90 days postoperative, the early readmission rate and the blood-sparing strategy were analyzed using the clinical and paraclinical data collected during the hospital stay, during the convalescent care center stay, and during the follow-up visits at 6 weeks and 3 months postoperative. The analysis was completed using the intrahospital software Clinicom, which allowed us to trace all the events and episodes for each patient. RESULTS: The early mortality rate was 0%. There were five major complications (4.3%) and thirteen minor complications (11%). The early readmission rate was 5.2%. Homologous blood transfusion was performed in 36% of patients. Administration of tranexamic acid reduced this rate to 24.3% versus 44% in patients not taking it (p=0.06). CONCLUSION: The perioperative mortality in this selected population is zero and the early morbidity is acceptable. The early readmission rate is also low. Thus proposing single-stage bilateral TKR to patients meeting the criteria defined in this study is a valid strategy. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Health assessment of French university students and risk factors associated with mental health disorders.

OBJECTIVE: The first year of university is a particularly stressful period and can impact academic performance and students' health. The aim of this study was to evaluate the health and lifestyle of undergraduates and assess risk factors associated with psychiatric symptoms. MATERIALS AND METHODS: Between September 2012 and June 2013, we included all undergraduate students who underwent compulsory a medical visit at the university medical service in Nice (France) during which they were screened for potential diseases during a diagnostic interview. Data were collected prospectively in the CALCIUM database (Consultations Assistés par Logiciel pour les Centres Inter-Universitaire de Médecine) and included information about the students' lifestyle (living conditions, dietary behavior, physical activity, use of recreational drugs). The prevalence of psychiatric symptoms related to depression, anxiety and panic attacks was assessed and risk factors for these symptoms were analyzed using logistic regression. RESULTS: A total of 4,184 undergraduates were included. Prevalence for depression, anxiety and panic attacks were 12.6%, 7.6% and 1.0%, respectively. During the 30 days preceding the evaluation, 0.6% of the students regularly drank alcohol, 6.3% were frequent-to-heavy tobacco smokers, and 10.0% smoked marijuana. Dealing with financial difficulties and having learning disabilities were associated with psychiatric symptoms. Students who were dissatisfied with their living conditions and those with poor dietary behavior were at risk of depression. Being a woman and living alone were associated with anxiety. Students who screened positively for any psychiatric disorder assessed were at a higher risk of having another psychiatric disorder concomitantly. CONCLUSION: The prevalence of psychiatric disorders in undergraduate students is low but the rate of students at risk of developing chronic disease is far from being negligible. Understanding predictors for these symptoms may improve students' health by implementing targeted prevention campaigns. Further research in other French universities is necessary to confirm our results.