Orthopaedics & Traumatology-Surgery & Research最新文献

While the first conflicts of the 21st century involved asymmetric warfare in the fight against terrorism, recent geopolitical events require us to prepare for the possibility of high-intensity conflicts. Modern wounding agents mainly consist of explosive devices and high-velocity bullets. Every trauma surgeon must be familiar with the mechanisms of injury specific to armed conflicts. The initial care of these injuries is based on applying damage control surgery to save the patient's life, save their limb if possible and preserve their function. Blast injuries are the most common in modern armed conflicts; the resulting combination of severe injuries can be challenging to treat. Limb reconstruction involves a sequential strategy based on simple, reliable and reproducible techniques which can be used by non-specialized surgeons working in sometimes austere situations. LEVEL OF EVIDENCE: Expert opinion.

Normal lower limb alignment is with the tibia in varus and the femur in valgus, forming an oblique joint line in bipedal stance and a horizontal line in unipedal stance. Alignment may be valgus or varus in case of femoral metaphyseal or tibial-femoral deformity, respectively. Bone correction must be performed at the site of the deformity. If a femoral deformity is corrected at the tibia, this results in an oblique joint line and malunion, with poor functional outcome. In genu valgum, distal femoral osteotomy (either medial closing or lateral opening wedge) may be indicated in case of lateral femorotibial osteoarthritis secondary to extra-articular femoral deformity. Likewise, in genu varum of femoral origin, lateral closing or medial opening wedge osteotomy is indicated. Preoperative planning is essential to achieve the ideal correction target, which is a key to success. Surgery should adhere strictly to the plan, with ideally biplanar oblique osteotomy, precise correction and stable fixation by locking plate. Complications are due to technical errors. The most frequent error is in correction, with malunion. Hinge fracture is also common, aggravating correction error. Patient-specific cutting guides are the state-of-the-art means of improving preoperative planning, surgical precision and hinge protection. LEVEL OF EVIDENCE: expert opinion.

Septic arthritis of the hip (SAH) in children is a common pediatric ailment that must be diagnosed immediately as proper treatment is needed to ensure good outcomes. It mostly affects children less than 2 years of age. The causative bacteria depend on age. The most widespread pathogen found at all ages is Staphylococcus aureus (S. aureus), while Kingella kingae (Kk) is most common in children 6 months to 4 years of age. SAH is suspected based on a wide set of clinical, laboratory and radiological (sonography) criteria. MRI is especially useful for diagnosing complications when the child's condition worsens. The diagnosis is only confirmed when joint aspiration finds evidence of bacteria being present. Targeted PCR techniques have largely improved the microbiological diagnosis of Kk. The clinical presentation varies greatly from a limp to prevent weightbearing on the affected leg in a small child with or without fever and very mild to non-existent systemic inflammation, suggestive of SAH due to Kk, to septic shock with quasi-paralysis of the lower limb. Treatment mainly consists of joint drainage and surgical lavage, open or arthroscopic, combined with empirical antibiotic therapy against the likely cause of the infection. A short course of antibiotics is widely used in uncomplicated cases of SAH. The functional prognosis depends highly on the time elapsed before the diagnosis and the start of treatment. Functional sequelae can be severe (growth disturbances, long-term joint damage). LEVEL OF EVIDENCE: Expert opinion.

Metatarsal fractures are frequent, at one-third of all fractures in the foot. The present study reviews the field, addressing 4 questions. Isolated or associated, benign but, in case of crush injury, sometimes severe, prognosis varies and sequelae can be serious. Fatigue fracture is common, often implicating sports activity. It is important to group metatarsal fractures according to the metatarsal or metatarsals involved: first (M1), central (CM) or fifth (M5). Lesion mechanism is a determining factor in management, especially for M5 fatigue fractures. Severity is a matter of associated lesions, particularly in the tarsometatarsal joint and adjacent soft tissue, directly related to trauma kinetics and mechanism. Treatment depends on the site of the fracture, whether it is recent or old, and the severity of the causal trauma. M1 fractures can be managed non-operatively if not displaced; otherwise, internal fixation is recommended. In the CMs and distal M5, non-operative treatment gives excellent results in fractures with little or no displacement, but reduction and internal fixation should be considered for displacement exceeding 3-4 mm or angulation exceeding 10° in whatever plane. In M5, non-operative treatment is indicated for fractures in Lawrence-Botte zones 1 or 2, but particular care is needed for high-level sports players; zone 3 fractures are fatigue fractures, requiring internal fixation. High-energy trauma is associated with skin complications and infection. Surgery is also a risk factor, notably for neurologic complications. Non-union, delayed healing and iterative fracture mainly affect the base of M5, particularly in zone 3. Malunion is associated with poor prognosis due to severe functional disorder in the foot or limb. Post-traumatic osteoarthritis generally follows joint injury at M1 or a CM, or sometimes associated tarsometatarsal joint involvement. LEVEL OF EVIDENCE: V; expert opinion.

Introduction: Osteogenesis imperfecta (OI) is a rare genetic bone disorder, mainly caused by autosomal dominant mutations of the COL1A1 or COL1A2 genes that encode the alpha chains of type 1 collagen. In severe forms and in nonambulatory patients, for whom physical exercise is difficult, exposing the bone to mechanical stimuli by promoting movement, especially with physiotherapy and mobility aids, is an essential part of clinical practice. However, the effects of mechanical stimulation at the cellular level remain unknown for this disease.

Hypothesis: The study hypothesis was that human mesenchymal stem cells (hMSCs) from patients with OI were as sensitive to mechanical stimulation as those from healthy patients, validating the current clinical practice.

Materials and methods: hMSCs were harvested from 3 healthy control subjects and 3 patients with OI during an elective osteotomy of a long bone of the lower limb. The healthy and OI hMSCs were then exposed to mechanical stimuli, such as intermittent shear stress of 0, 0.7, 1.5, and 3 Pascal (Pa) at a frequency of 2.8 Hertz (Hz) for 30 minutes using a commercial ibidi system. The immediate early gene expression of themechanosensitive prostaglandin-endoperoxide synthase 2 (PTGS2) was examined 1 hour after stimulation to determine the best level of mechanical stimulation. The expression of 7 other mechanosensitive genes was also examined for this level of mechanical stimulation after applying intermittent shear stress at 1.5 Pa.

Results: In all hMSCs, mechanical stimulation induced PTGS2 gene overexpression with a maximum after exposure to intermittent shear stress of 1.5 Pa and without significant differences between OI and healthy donors. Except for fibroblast growth factor 2, gene expression in OI donors was found to be significantly different from that in hMSCs not exposed to shear stress. Moreover, the relative expression associated with mechanical stimulation was not significantly different between healthy and OI donors for most other genes.

Discussion: This is the first study to demonstrate that hMSCs from patients with OI are as sensitive to mechanical shear stress as those from healthy donors. The mechanical stress that resulted in the greatest change in the expression of PTGS2 in patients with OI was similar to that previously reported in the literature for healthy subjects. These findings are an important step toward further fundamental research aimed at confirming the effects of mechanical stress at the cellular level over the long term and, more importantly, toward developing clinical protocols for delivering mechanical stimuli to these patients.

Level of evidence: III; comparative case-control study.

Our understanding of the pathophysiology of anterior ankle impingement has steadily progressed since the princeps description almost 70 years ago. The same is true of diagnosis and treatment, which have greatly changed over time. The present study provides an update on this pathology, addressing the following questions: Anterior ankle impingement is suspected in case of anterior ankle pain reproducible by palpation and exacerbated by dorsiflexion imposed by the examiner or squatting, and Molloy's sign. Etiologies are varied: tumoral, post-traumatic, lateral ankle instability, osteoarthritis and microtrauma. Complementary cross-sectional imaging, and especially MRI, is indispensable for identifying the cause. A dichotic classification in terms of anterolateral impingement of tissular origin and anteromedial impingement of osteophytic origin is incompatible with current pathophysiological concepts. An etiological classification, completed by a topographic classification in 3 zones, provides a better guide for treatment strategy. Tumoral or post-traumatic impingement requires a specialized team. Impingement by microtrauma associated with instability or osteoarthritis is best treated arthroscopically, for exhaustive exploration of intra-articular elements that may be implicated. Treatment consists in removing osteophytes and any pathological synovial or ligamentous soft tissue. Anterior talofibular ligament or medial collateral ligament repair may be associated. Results can be expected to be good, with clear improvement in pain and function and excellent patient satisfaction. LEVEL OF EVIDENCE: V, expert opinion.

Introduction: Spinal deformity in adults is a major public health problem. After failure of conservative treatment, correction and fusion surgery leads to clinical and radiological improvement. However, mechanical complications and more particularly - proximal junctional kyphosis (PJK) - are common with an incidence of 10%-40% depending on the studies.

Analysis: Several risk factors have been identified and can be grouped into three categories. Among the patient-related factors, advanced age, comorbidities, osteoporosis and sarcopenia play a determining role. Among the radiological factors, changes in sagittal alignment (cranial migration of thoracolumbar inflection point, over-correction of lumbar hyperlordosis, preoperative thoracolumbar kyphosis) play a key role. Finally, the fusion technique itself may increase the risk of PJK (use of screws instead of hooks) as a surgical factor.

Prevention: Prevention happens at each phase of treatment. A patient assessment is done preoperatively to identify those at risk of PJK. Treating osteoporosis is beneficial. The surgical strategy must also be adapted: the choice of transitional implants such as sublaminar links or hooks and the use of ligament reinforcement techniques can help minimize the risk of PJK. Finally, methodical clinical and radiological follow-up will help to detect early signs of PJK and allow a surgeon to reoperate right away.

Treatment: Not all PJK requires surgical revision. Radiological monitoring and functional treatment is sometimes sufficient. However, if the patient develops pain, neurological complications or instability detected by imaging (unstable fracture, spondylolisthesis, spinal cord compression), revision surgery is necessary. It may consist of proximal extension of the fusion combined with decompression of the stenosis levels at a minimum.

Conclusion: PJK is a major challenge for surgeons. The best treatment is prevention, with a thorough analysis of risk factors leading to a well-planned and personalized surgery. Regular postoperative follow-up is essential.

Level of evidence: Expert opinion.

The initial approach to soft tissue tumors in children and teenagers is everyone's responsibility. While the vast majority is benign, all practitioners dread missing a malignant lesion. The first step involves taking the patient's history and performing a clinical examination. Useful information can be gained from radiographs, ultrasound imaging and MRI. If there is no diagnosis at this stage, a biopsy (preferably percutaneous) is essential because unplanned excision can have serious consequences in terms of morbidity and even mortality. This should only be undertaken at a specialized facility after careful planning by the surgeon and interventional radiologist. Once the diagnosis has been made, the case should be discussed at a tumor board meeting to benefit from multidisciplinary expertise and input. Surgery is an essential component of the treatment and must be done at the appropriate time, after potential systemic (chemotherapy, targeted therapy) or local treatment (radiation therapy). LEVEL OF EVIDENCE: Expert opinion.

Bacteriological sampling in orthopedic revision surgery for arthroplasty or internal fixation raises several questions. 1) When? And should sampling be systematic? Sampling should not be systematic in revision surgery, but only in case of suspected infection, in which case empirical antibiotic regimen should be systematically implemented. 2) How? Which tissues, how many and what transport? Only deep samples, preferably taken without ongoing antibiotic therapy, allow reliable interpretation of results. The optimal number of intra-operative samples is 5, or 3 if the laboratory uses seeding in aerobic and anaerobic vials. Samples should be transported to the laboratory within 2 h, at room temperature. 3) What conclusions can be drawn, using what references? There are several classifications, leading to divergent interpretation. The EBJIS (European Bone and Joint Infection Society) classification showed the best sensitivity in a multicenter study. 4) What duration of antibiotic washout before revision, and how to proceed if it cannot be achieved? The antibiotic-free period before sampling should be 14 days, or 21 days in case of prior treatment by cyclins, clindamycin, rifampicin or drugs with a very long half-life such as lipoglycopeptides, except when surgical intervention is required urgently. 5) How to deal with microbiological sampling and antibiotic prophylaxis at the time of revision surgery? Pursuing prophylactic antibiotic therapy during bone and joint implant revision does not greatly impair the value of intra-operative sampling. However, evidence of benefit of continuing antibiotic prophylaxis during revision arthroplasty is lacking. 6) What samples for atypic infection? Atypic micro-organisms (mycobacteria, fungi, etc.) require specific screening, guided by the clinical context and discussed before sampling is carried out. LEVEL OF EVIDENCE: V; expert opinion.

Stiffness following total knee replacement is defined as >15° flexion contracture and/or flexion <75° or, for other authors, arc of motion <70° or 45° or 50°. Alternatively, it could be defined as a range of motion less than the patient needs in order to be able to do what they wish. The first step in management is to determine the causes: preoperative (history of stiffness, patient-related risk factors, etc.), intraoperative (technical error: malpositioning, oversizing, overhanging, etc.), and postoperative (defective pain management and/or rehabilitation, etc.). Treatment depends on the interval since replacement and on the type of stiffness (flexion or extension), and should be multidisciplinary (surgery, rehabilitation, pain management). For intervals less than 3 months, manipulation under anesthesia gives good results for flexion. If this fails, surgery should be considered. If there was no significant technical error, arthrolysis may be indicated, and is usually arthroscopic. It is technically difficult, but has a low rate of complications. Open arthrolysis allows greater posterior release and replacement of the insert by a thinner model. In case of malpositioning or oversizing or of failure of other procedures, implant revision is the only option, although the risk of complications is high. After exposure, which is often difficult, the aim is to correct the technical errors and to restore joint-line height and two symmetrical, well-balanced spaces in extension and flexion. A semi-constrained or even hinged implant may be needed, although with uncertain lifetime for young patients in the latter case. In all cases, the patient needs to accept that treatment is going to be long, with more than the intervention itself (i.e., specific pain management and rehabilitation), and that expectations have to be reasonable as results are often imperfect. LEVEL OF EVIDENCE: expert opinion.