Femoral shaft fractures treated by antegrade locked intramedullary nailing: EOS stereoradiographic imaging evaluation of rotational malalignment having a functional impact.

INTRODUCTION: The standard treatment of femoral shaft fractures is intramedullary nailing. One of the most frequent complications is femoral malrotation. Our study sought to: 1) use EOS imaging to determine the amount of rotational malalignment after intramedullary nailing that has an impact on 6-month functional results; 2) determine the incidence of femoral malrotation based on EOS imaging; 3) determine the risk factors for postoperative femoral malrotation that impacts the 6-month functional results. The hypothesis was that EOS imaging can be used to determine the amount of femoral malrotation that has a functional impact in patients treated by percutaneous femoral intramedullary nailing. MATERIAL AND METHODS: We performed a prospective, single-center study between September 2017 and February 2020. Patients who had suffered a femoral shaft fracture treated with antegrade intramedullary nailing were included in this study. Femoral anteversion was measured at 6 months with an EOS stereoradiographic imaging system. Patients were assessed at 6 months with the WOMAC, Oxford, Harris and MDP functional scores. The SF-12 quality of life score was also determined. RESULTS: Thirty patients were evaluated at 6 months postoperatively, 15 women (50%) and 15 men (50%) who were 47 years old on average [16; 94]. The average anteversion was 19.9°C [-23°; 75°]. The functional scores (Oxford and Harris) were altered when there was 14° or more difference in femoral torsion between the operated side and the healthy side with a sensitivity of 0.88 and a specificity of 0.77. The risk factors for femoral malrotation were age under 35 years (p=0.01), urgent surgical management (p=0.008), location in middle third of femoral shaft (p=0.05), and short spiral fracture (p=0.02). CONCLUSION: The use of EOS imaging allowed us to demonstrate that functional hip outcomes are altered at 6 months postoperatively when greater than 14° femoral malrotation is present compared to the contralateral side after femoral intramedullary nailing. The risk factors that contributed to intraoperative rotational malalignment were age less than 35 years, urgent surgical management, mid-shaft femoral fracture and short spiroid fractures. LEVEL OF EVIDENCE: II.

Factors influencing the mid-term radiological and functional outcomes of 41 post-fracture bipolar radial head arthroplasty cases at a mean follow-up of 87 months.

INTRODUCTION: When treating comminuted radial head fractures that cannot be adequately fixed, the next option is arthroplasty (radial head replacement). We hypothesized that the radiological and functional outcomes of bipolar mobile cup radial head arthroplasty is not influenced by the length of follow-up but instead by the correct positioning of the implant intraoperatively and by the presence of associated bone or ligament injuries. PATIENTS AND METHODS: Between May 1998 and December 2016, 82 cases of radial head arthroplasty were performed at our hospital. The mean age of patients at the time of arthroplasty was 53 years (22-81). Ligament or bone injuries complicated the radial head fractures in 70% of patients. RESULTS: For the final assessment, 41 patients were reviewed and included in the statistical analysis with a mean of 82 months (12-228). The mean MEPS at the final assessment was 88.7 (61-100). There were 23 excellent, 9 good, 9 average and 0 poor results. The average DASH score was 18.7 (0-55). The average VAS for pain was 1.0 (0-5). Five patients (12%) required surgical revision, including one implant change. Our statistical analysis found no relationship between follow-up time and functional outcomes. The appearance of periprosthetic radiolucent lines was not affected by the length of follow-up. Associated bone or ligament injuries significantly increased the probability of periprosthetic radiolucent lines, humeroulnar joint degeneration and decentering of the implanted cup. Radiological evidence of a suspended implant was associated with significantly worse functional outcomes. CONCLUSION: This study confirms the long-term stability of the clinical outcomes of radial head arthroplasty. There was no relationship between worsening radiological appearance of the implant and the clinical outcomes. It is critical that this implant not be oversized or suspended, as this can trigger premature capitellar erosion and painful stiffness of the operated elbow. LEVEL OF EVIDENCE: IV; systematic retrospective analysis.

Treatment of cephalotuberosity fractures in elderly patients treated by reverse shoulder prosthesis: a study of functional results in relation to deltoid tension.

INTRODUCTION: The treatment of proximal humerus fractures is a therapeutic challenge in the elderly as the functional demands of these patients are high. We postulated that there may be a relationship between functional results and deltoid tension when these fractures are treated with a reverse prosthesis. This study was performed to determine the optimal tension of the deltoid. The primary outcome was the constant score in relation to humeral length at the final follow-up. MATERIALS AND METHODS: Our retrospective cohort consisted of 45 patients treated with a reverse fracture prosthesis during the period from January 2010 to July 2017. The fractures were all classified as Neer III or IV, 91% of our patients were women and the average age was 82 years. RESULTS: Constant score and antepulsion were improved with humeral elongation between 10 and 25 mm (p < 0.02 and p < 0.05, respectively). External rotation was improved with humeral elongation (p < 0.03). CONCLUSION: Tuberosity reinsertion improves mobility in patients treated surgically for a reverse fracture prosthesis. The recovery of anatomical retroversion seems of fundamental importance, and we confirmed that deltoid tension that must also be taken into account to improve functional results of reverse shoulder prosthesis on fracture. The ideal humeral elongation seems to be between 10 and 25 mm, in relation to the contralateral side, to obtain better functional results.

Are orthopedic surgeons exposed to excessive eye irradiation? A prospective study of lens irradiation in orthopedics and traumatology.

INTRODUCTION: Numerous studies in recent years highlighted an increased risk of pathologies related to ionizing radiation in caregivers. A new French decree was adopted on June 4, 2018, dividing by 7.5 the radiation dose authorized in the lens for exposed workers. HYPOTHESIS: The hypothesis of the present study was that ocular irradiation in orthopedic surgeons was below the new legal threshold. METHOD: The equivalent dose (mSv) received by the lens was prospectively assessed in 10 orthopedic surgeons (5 senior, 5 residents), using 3 passive dosimeters placed at the forehead and either temple. Each intervention of each operator was recorded, with dose per area in the operating room at each use of the fluoroscope. RESULTS: All equivalent doses to the lens at the end of the 4 month study period were well below threshold. Doses were not significantly different between forehead and either temple (p=0.7, p=0.6 for the 2 temples). There was no difference according to side of the head (p=0.3). The dose received in the lens correlated with the dose delivered in the room (p=0.004). There were no significant differences in irradiation according to the surgeon's experience (p=0.2) or trauma activity rate (p=0.4). DISCUSSION: No studies have reported equivalent doses to the lens exceeding the authorized limit. But none previously measured equivalent dose to the lens according to the axis of irradiation in the eyes. The present study showed that orthopedic surgeons received as much eye radiation laterally as frontally. Ocular radiation protection needs therefore to be as effective laterally as frontally. The surgeon's experience did not emerge as a protective factor against ocular irradiation.

Is non-operative treatment still relevant for Garden Type I fractures in elderly patients? The femoral neck impaction angle as a new CT parameter for determining the indications of non-operative treatment.

BACKGROUND: The indications of non-operative treatment of undisplaced femoral neck fractures are controversial. The objective of this study was to assess whether two computed tomography (CT) parameters, the femoral neck impaction angle (IA) and the femoral neck posterior tilt angle (PTA), were effective in predicting the risk of secondary displacement after non-operative treatment of Garden I femoral neck fractures in patients aged 65 years or over. HYPOTHESIS: The working hypotheses were that the IA in the coronal plane and PTA in the axial plane predicted secondary displacement after non-operative treatment of Garden I femoral neck fractures, could be reproducibly and reliably measured on CT scans, and could serve to identify Garden I fractures at risk for secondary displacement after non-operative treatment. METHODS: Forty-nine patients aged 65 years or over with Garden I fractures treated non-operatively were included in a prospective single-centre study. CT images were used to measure the IA as the position of the fracture line relative to the femoral head in the coronal plane and the PTA as the position of the femoral head centre relative to the femoral neck axis in the axial plane. RESULTS: After non-operative treatment, secondary displacement occurred in 22 (45%) patients. The PTA was not significantly different between the groups with vs. without secondary displacement (p=0.62). IA values≤135° were significantly associated with secondary displacement (odds ratio, 11.73; 95% confidence interval [95%CI], 3.04-45.28; p=0.004). An IA≤135° was 72.73% sensitive and 81.48% specific for predicting secondary displacement. IA measurement was reproducible, with intra-class and inter-class Cohen's kappa values of 0.94 (95%CI, 0.90-0.97) and 0.9011 (95%CI, 0.83-0.94), respectively. DISCUSSION: The IA measured on CT images may hold promise for identifying Garden I hip fractures at high risk for secondary displacement after non-operative treatment. IA measurement is reproducible and reliable and may help to determine the indications of non-operative treatment. LEVEL OF EVIDENCE: II, prospective cohort study.

Hemiarthroplasty for Complex Distal Radius Fractures in Elderly Patients.

Background In elderly patients, distal radius fractures frequently occur in osteoporotic bone and may be nonreconstructable. It is our hypothesis that a hemiarthroplasty replacment of the articular surface can provide satisfactory results in terms of range of motion, pain, and function for immediate salvage of a fracture that is not amenable to internal fixation. Methods Between July 2009 and January 2012, eight elderly patients were treated with insertion of a Sophia distal radius implant (Biotech, Paris, France). Inclusion criteria consisted of an isolated AO type C2 distal radius fracture in patients over 70 years old. All patients were reviewed by an independent surgeon. Results The mean follow-up was 25 months (range, 17-36 months). Mean wrist range of motion (ROM) was 45° (40-50°) of flexion, 44° (40-50°) of extension, and a mean pronation-supination arc of 160°. Mean grip force was 18 kgf. The mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) was 18.2/100 (6.82-29.55), and the mean visual analog scale (VAS) was 2.33 (0-4). X-ray images did not demonstrate implant loosening or ulnar translation of the carpus. Conclusions The Sophia hemiarthroplasty provided rapid recovery of independence in elderly patients with a nonreconstructable comminuted distal radius fracture.