Orthopaedics & Traumatology-Surgery & Research最新文献

Background: We rely on sound clinical research to ensure the safety and effectiveness of medical interventions. We are nowadays experiencing an increased utilization of Patient Reported Outcome Measures (PROMs) in research, for which there is good evidence on validity and reliability. However, these measures are often validated in isolation and not in a real-life setting where they are used in conjunction with other questionnaires and measures. Our study objective was to determine if the number of PROMs questionnaires completed by fracture patients affected their reliability; more specifically, the internal consistency of the EuroQuol Five Dimension-Five Level (EQ-5D-5L) questionnaire.

Hypothesis: Our hypothesis was that there is a progressive decline in reliability as we increase the number of questionnaires given to participants.

Patients and method: This is a randomized study carried out in a single Level I academic trauma center. Patients presenting to the fracture clinic for follow-up were screened. Participants were randomly assigned to 4 groups: group 1 only answered the EuroQol Five Dimension-Five Level (EQ-5D-5L) questionnaire, group 2 answered one additional questionnaire before the EQ-5D-5L, group 3 answered two and group 4 answered three additional questionnaires before the EQ-5D-5L. The primary outcome measured was the internal consistency of the EQ-5D-5L as a measure of reliability.

Results: Enrolment was 115 participants. Twenty-eight participants were randomized to Group 1, 29 to Group 2, 29 to Group 3, and 29 to Group 4. There was a progressive decline of reliability as number of questionnaires increased except for a sudden rise in group 4. (Group 1: 0.83, 95% Confidence Interval (CI) 0.70 to 0.91; Group 2: 0.74, 95% CI 0.56 to 0.87; Group 3: 0.68, 95% CI 0.44 to 0.83; Group 4: 0.81, 95% CI 0.68 to 0.90). Completeness was 100% for Group 1, 98.5% for Group 2, 100% for Group 3, and 92% for Group 4.

Discussion: These results cannot strongly support our initial hypothesis. Although there is an initial decrease in Cochran's alpha for Groups 2 and 3 consecutively, the sudden rise in group 4 limits the validity our results. Notwithstanding, researchers should consider these findings when designing their research trials to avoid potential misleading results. Hence, the number of given questionnaires in research should be limited in order for these to maintain their reliability.

Level of evidence: II.

Background: While performing a hip joint aspiration for culture, a lidocaine diagnostic injection called block test can be performed during the investigation of painful total hip arthroplasties (THA). This test was formerly applied to limited series in pre-operative and without assessing the predictive value on the results of THA revision. Therefore we investigated a consecutive series of THA revisions who underwent pre-operative aspiration-block test to determine if patients with pre-operative positive block test (disappearance of symptoms) have a better clinical improvement after revision.

Hypothesis: The positive pre-operative block test has a positive predictive value greater than 80% in predicting the favourable result of THA revisions.

Materials and methods: We reviewed 152 patients who had a hip aspiration associated with a block test before their THA revision. The patients were evaluated according to the Oxford hip score (OHS). The primary outcome was considered positive if the patient presented an improvement in the OHS greater than the Minimal Clinically Important Difference (MCID; 9 points) and/or if the postoperative OHS was higher than the Patient Acceptable Symptom State (PASS, defined as 39/48).

Results: Block tests were positive for 61.2% (93/152) of patients. The median improvement in the OHS was 23.0 [IQR 16.0; 30.0] if the block test was positive versus 16.0 [IQR 4.0; 17.0] if negative (p = 0.002). The primary outcome after revision was strongly associated with block test positivity (p < 0.0001). The positive block test had a 67.7% sensitivity, 73.3% specificity, 91.4% Positive Predictive Value and 37.3% Negative Predictive Value for significant improvement after revision surgery.

Conclusion: Hip joint aspiration for culture with concomitant block test seems to be an interesting tool in predicting outcomes of revision surgery for painful THA.

Level of evidence: IV; retrospective study.

Background: Anterior cruciate ligament (ACL) rupture is a common lesion among young sports players, for whom isolated surgical repair remains the gold standard. However, there is a high risk of re-rupture after ACL reconstruction. Recent results of ACL reconstruction combined with reconstruction of the anterolateral ligament (ALL) have shown a significant decrease in this risk. However, as with all new techniques, this requires a learning curve.

Hypothesis: Combined reconstruction of the ACL and ALL would have a short learning curve, be reproducible and have no specific complications.

Patients and methods: This retrospective study included the first 108 patients who underwent combined ACL and ALL reconstruction by a single surgeon. The patients were divided into four similar sized chronological groups (groups 1-4). Tourniquet time and associated procedures were analysed. The results of the IKDC subjective knee evaluation, Lysholm, KOOS and SANE functional scores were collected postoperatively at 1-year through an online database. The position of the femoral tunnel was evaluated using the quadrant method of Bernard and Hertel.

Results: A significant improvement in the position of the femoral tunnel in the proximo-distal axis was observed between groups 1 and 4 (p < 0.01), as well as between groups 3 and 4 (p < 0.001). The Lysholm functional score was significantly higher in group 4 at 1-year (difference between groups 1 and 4 (+ 3.2 (1.4-5.1), p = 0.017)). The tourniquet time decreased significantly between the first group and groups 2, 3 and 4 (p < 0.002).

Discussion: Precise positioning of the femoral tunnel in the proximo-distal axis is important during combined reconstruction of the ACL and ALL. The combined technique had a rapid learning curve, was reproducible, and resulted in a rapid decrease in the tourniquet time.

Level of evidence: III; observational study.

Knee ligament and meniscus injuries in children and teenagers are becoming more numerous because of increased sports participation but also better diagnosis. Meniscus injuries occur either in a normal meniscus or due to a congenital anomaly. The diagnosis is made clinically and confirmed by MRI. Treatment depends on the findings: meniscoplasty for discoid meniscus and primary repair of meniscus tears. Meniscus preservation is the rule. Injuries to the central pivot of the knee typically involve either the anterior cruciate ligament (ACL) or the tibial spine. Age, anatomy and the mechanism of injury determine the specific nature of the injury. The treatment of tibial spine fractures is highly standardized and typically surgical, with the aim of limiting residual laxity. ACL tears can be treated either by primary repair or non-surgically with guided rehabilitation. ACL reconstruction in skeletally immature patients is feasible as long as the growth plates are protected. The rate of residual laxity or retear is lower when anterolateral reconstruction is performed simultaneously. LEVEL OF EVIDENCE: Expert opinion.

In two-stage revision of infected implants, the first stage involves removing the implant and implanting a joint spacer, and the second stage involves implanting a new prosthesis at least 6 weeks later. Spacers have two main functions: local administration of high-dose antibiotics, and preservation of the joint space by reducing soft tissue retraction and improving patient comfort until reimplantation. The present review aims to detail the necessary characteristics of antibiotics added to cement to achieve good joint diffusion, to describe the steps of two-stage revision, and to present the types of spacer available according to the joint and complications. The antibiotic used in the spacer must be heat-resistant, water-soluble and chemically stable in the cement. Gentamicin and vancomycin are generally preferred. We recommend at least 3 months' systematic antibiotic therapy for periprosthetic joint infection. Reimplantation is performed either at 6 weeks without antibiotic washout or 3 months after 2 weeks' washout Spacers may be static (non-articulating) or dynamic (articulating). Static spacers are mainly used in the knee or hip in cases of severe bone defect or risk of soft-tissue lesions. An articulating spacer enables some joint functions to be preserved in the knee, hip or shoulder. The most frequent complications are the dislocation of dynamic spacers and the breakage of static or dynamic spacers. To optimize efficacy and minimize complications, the biomechanical and bacteriological characteristics of spacers must be considered. LEVEL OF EVIDENCE: Expert opinion.

Supramalleolar osteotomy (SMO) aims to correct extra-articular deformities of the distal lower leg. There are several indications, the most common being varus osteoarthritis of the ankle. The rationale in this indication is to modify talocrural stress and pressure distribution by reorienting the limb axis. Preoperative planning is essential to optimize functional outcome, limiting the risk of under- or over-correction. Several SMO procedures have been described, and are preferably performed at the deformity site or center of rotation and angulation (CORA). They aim to restore talocrural joint-line anatomy and correct talar tilt while conserving physiological hindfoot valgus. Techniques use K-wires as cut guides. 3D imaging and patient-specific instrumentation now play key roles in this surgery, which is difficult both to plan and to execute. The present study addresses the following questions: What are the indications and contraindications? What are the technical principles? What preoperative work-up is required for planning and execution? What are the technical particularities? And what contribution can new technologies make? LEVEL OF EVIDENCE: V.

High-energy tibial plateau fracture is complex and hard to treat, with functional sequelae and frequent soft-tissue lesions. Several classifications, strategies, approaches and fixation techniques have been reported. High-energy trauma is defined by high-velocity impact: fall from height, high-speed road or sport accident, firearm injury, etc. Description should include all components, and notably posterior components (on the "3 column" theory), for integral management. A sequential strategy, with temporary fixation, imaging assessment and then definitive fixation, seems mandatory, controlling cutaneous and infectious risks. Long-term results suffer from serious functional sequelae and progression toward osteoarthritis, with a rate of at least 5% secondary knee arthroplasty. The present review addresses 6 questions: These fractures should ideally be described according to mechanism and to the involvement of the various columns or quadrants (medial/lateral, anterior/posterior) on the modified Schatzker classification. Immediate management comprises systematic neurovascular and soft-tissue assessment. For such high-energy fractures, a sequential "scan-span-plan" strategy with temporary external fixation is indicated. Definitive treatment consists in internal fixation by plate, with reduction and fixation of the various bone lesions, and especially fixation of posterior lesions. The surgical approach should be adapted to the fracture. Arthroscopy can be useful for controlling reduction and treating any meniscal and/or ligament lesions and fractures showing little or no displacement. A strategy that avoids acute complications provides satisfactory medium-to-long-term results if definitive treatment objectives are achieved. Despite a fairly low rate of 5% conversion to total knee replacement, progression often shows impaired quality of life and of activities. LEVEL OF EVIDENCE: V; expert opinion.

Periprosthetic acetabular fractures are a major challenge in orthopedics. Proper recognition of these complex cases helps to identify and treat patients with different presentations. These fractures can occur intraoperatively and be treated immediately, or they can occur postoperatively, following trauma or in the context of chronic low bone quality or associated implant loosening. The existing classification systems categorize these fractures as a function of the acetabular cup's stability and the context surrounding the fracture. When a fracture is detected intraoperatively, immediately analyzing its stability is crucial for choosing between a conservative strategy, the need for additional fixation, or the need to change the cup or use of an acetabular reinforcement ring. When the patient has symptoms such as persistent pain or instability, secondary diagnosis of a fracture requires diagnostic imaging. Its treatment depends on the cup's stability, with options ranging from conservative treatment with functional limitations, cup revision potentially combined with stabilization of the fracture site, and also management of potential periprosthetic bone defects. Traumatic fractures require a comprehensive assessment to determine whether the acetabular cup is still stable. The treatment may be conservative or surgical (internal fixation or cup revision). Chronic pelvic discontinuity is associated with bone loss and implant loosening. Acute pelvic discontinuity requires treatment tailored to each patient, often with acetabular rings or custom triflange cups to restore function. This article aims to provide an in-depth review of periprosthetic acetabular fractures, touching on their causes, classification, assessment and treatment, along with specific considerations for fractures diagnosed postoperatively and following acute trauma. LEVEL OF EVIDENCE: IV; systematic review of level II-IV studies.

Patellar instability can be defined as dislocation or subluxation of the patella relative to the femoral trochlea. It is a common reason for consulting a pediatric orthopedic surgeon. Its etiology is multifactorial. Because of the work of Hughston, Merchant, Ficat, Insall and Dejour, the overall care of this pathology has changed greatly. Surgical stabilization of the patella in children is being performed more often due to better understanding of the pathology and widespread adoption of reconstruction techniques for the medial patellofemoral ligament. However, some surgical techniques should not be used in children. Determining the type of instability is the first step to selecting the appropriate technique and to avoiding the biggest pitfall - recurrence. LEVEL OF EVIDENCE: Expert opinion.