Orthopaedics & Traumatology-Surgery & Research最新文献

Background: Intramedullary nailing (IMN) for proximal humerus fractures is commonly performed through an anterolateral approach. A percutaneous approach through the Neviaser portal has been shown to be an alternative to avoid cuff tendon insertion violation and be used for a third-generation IMN. The aim of the present cadaver study was to confirm whether the Neviaser approach was reproducible to reach the optimal nail entry point, at the top of the humeral head, passing through the muscular portion of the supraspinatus and to evaluate the risk of biceps and neurovascular bundle damage.

Methods: This was a basic science surgical technique study with sixteen preserved frozen shoulders from 11 donors (8 females, 3 males) used. All surgical procedures were performed using the third-generation AEQUALIS™ IM Nail. Dissection of each specimen was then performed. The nail entry point through the soft-tissue layer was assessed, determining whether the device was inserted through the supraspinatus muscular or tendinous part. A manual caliper with a precision of 0.1 mm was then used to measure the distances of the device to different anatomic structures.

Results: The nails were inserted through the muscular part in all specimens still having a rotator cuff (RC). The mean distances from the nail entry point to the myotendinous junction and RC footprint were 4 mm (range, 2-6 mm) and 39 mm (range, 36-42 mm), respectively. The distances from the lower tuberosity (LT) head screw and most lateral greater tuberosity (GT) head screw to the long head of the biceps (LHB) groove were 9 mm (range, 8-11 mm) and 15 mm (range, 14-17 mm), respectively. The distance of LT head screw to the anterior circumflex pedicle and the lateral cord of the brachial plexus was 15 mm (range 14-17 mm) and 41 mm (range 32-45 mm), respectively. The distance of the highest distal screw and the lowest proximal screw to the axillary nerve was respectively 32 mm (range, 28-40 mm) and 23 mm (range, 21-25 mm). The nail entry point was entirely within the humeral articular surface and at the bone-cartilage junction in 14 and 2 specimens respectively.

Conclusion: This study demonstrated that a third-generation IMN might be inserted via the Neviaser portal. This approach is safe and allows the insertion of the device through the RC muscular part with a reproducible access to the hinge point and with no risk of neurovascular injury.

Level of evidence: IV; Anatomy study; Cadaver Dissection.

Background: Reconstruction of segmental bone loss of the limbs is a surgical challenge, particularly regarding the reconstruction strategy and choice of bone graft. Several bone reconstruction techniques have been validated, but the gold standard remains bone autograft. However, in certain situations, the availability or volume of bone autograft may be insufficient. The use of bone substitutes as a replacement is debated in the treatment of segmental non-union of the tibia, and little is known about bone substitute in such circumstances. Therefore we performed a retrospective study aiming: 1) to determine whether the use of bone substitutes achieves the same rate of consolidation as the use of autografts in surgical treatment of segmental non-union of the tibia, 2) to determine differences in time to consolidation and in the occurrence of complications.

Hypothesis: The consolidation rate of bone substitute reconstruction is equivalent to that of autograft reconstruction.

Material and methods: Sixty patients operated for aseptic non-union of the tibia with segmental bone loss were analyzed. Forty-three were reconstructed with bone autograft (group A) and 17 with calcium triphosphate hydroxyapatite biphasic ceramic substitute (SCBHTC) (group S). Consolidation was assessed clinically and radiologically, with a minimum follow-up of 2 years. Segmental bone loss averaged 3.36 ± 1.3 cm in group A, and 3.64 ± 1.7 cm in group S (NS).

Results: After an average follow-up of 27 months, consolidation was achieved in 91% (n = 39/43) in group (91%) and 88% in group S (n = 15/17) (p = 0.08), with an average delay of 142 ± 64 days in group A and 189 ± 114 days in group S (p < 0.01). There were 5/43 (11.6%) iterative surgeries in group A versus 4/17 (23.5%) in group S (p < 0.05).

Discussion: SCBHTC reconstructions of tibia bone loss appear to achieve the same bone consolidation rates as autograft techniques in segmental non-union tibia, with no risk of complication. However, autograft reconstructions achieved significantly faster consolidation than those using substitutes. The use of SCBHTC could be considered in reconstructions of segmental non-union tibia, as a second-line treatment in cases when bone autograft use is not possible.

Level of evidence: III; retrospective case control.

Introduction: The outpatient prescription of morphine is not without risk and its use following arthroscopic ankle surgery is increasingly frequent. The goal of this study was to evaluate the impact of morphine on postoperative pain following arthroscopic lateral ankle ligament repair. The secondary goal was to identify the adverse effects of morphine.

Materials and methods: This is a retrospective case-control study of prospective data from 62 patients who underwent primary reconstruction of the lateral ankle ligaments between January 2022 and May 2024. The patients were divided into two groups: those with «no morphine» (31 patients who underwent surgery before April 1 2023) and those «with morphine» (31 patients who underwent surgery after April 1, 2023), paired for age, sex, preoperative Foot and Ankle Outcome Score (FAOS), preoperative Cumberland Ankle Instability Tool (CAIT) score and the grade of the anterior talofibular ligament (ATFL) tear. The main evaluation criterion was pain measured by the visual analog scale (VAS) on D+0 evening, D+0night, D+1, D+2 and D+3, and analyzed in relation to the threshold of Pain Acceptable Symptom state (PASS). The adverse effects of morphine were secondary criteria.

Results: The mean age of the patients was 34.8 years old (±10,4). The postoperative VAS values (D+0 evening and night, D+1, D+2, D+3) were not significantly different between the groups (p > 0.05). On univariate analysis male gender was associated with a significant decrease in pain on D+3 (β = -1.3; IC95% [-2,4; -0.07], p = 0.043). The threshold of the PASS for the VAS was similar in both groups, with no significant difference (p > 0.05). Adverse effects such as nausea and dizziness were comparable between the groups (p > 0.05).

Conclusion: The prescription of morphine following arthroscopic lateral ankle ligament reconstruction does not significantly decrease early postoperative pain. The incidence of adverse effects does not increase with the prescription of morphine.

Level of evidence: III; case control studies.

Introduction: Achieving planned alignment is one of the keys to implant survival and patient satisfaction in total knee arthroplasty (TKA). New technologies have been developed, such as robotics, patient-specific instruments (PSI), and augmented reality (AR). This study evaluated the contribution of AR through the Knee+™ device (PIXEE Medical Company, Besançon, France). This TKA navigation device uses AR to orient the distal femoral and proximal tibial cutting guides in the frontal and sagittal planes. Measurements are independent for the tibia and femur. The device requires no robot, no engineer, and no additional preoperative three-dimensional imaging. There are several papers dedicated to the Knee+™ device; this study is the largest prospective study to date and is independent of the device's promoter, to determine: (1) the accuracy of the Knee+™ device, (2) the existence of a learning effect on operative time and on accuracy, (3) the risk of using the device by reporting the intra-operative events and adverse events occurring within 3 months postoperatively.

Hypothesis: Knee+™ admits an error of less than 1.5 ° between the value announced by the device and post-operative radiographic measurements.

Material and methods: This was a prospective, monocentric study involving 60 patients undergoing TKA with the device under study; mechanical alignment was planned. The accuracy of the procedure was analyzed during the intraoperative cutting inspection stage and then by measuring the Lateral Distal Femoral Angle (LDFA), Medial Proximal Tibial Angle (MPTA), and tibial slope on postoperative radiographs.

Results: There were no intraoperative adverse events and no revision surgery during the 3-month follow-up period. The mean error of the device was 1.23 ° ± 0.94 ° for the LDFA, 1.22 ° ± 1.05 ° for MPTA, and 2.15 ° ± 1.43 ° for the tibial slope. For the femur, no patient had an angle value with an error >3°; for the tibia, one patient (1.7%) had an angle value with an error >3° in the frontal plane, and twelve patients (21%) had an angle value with an error >3° in the sagittal plane. The learning curve showed no effect on accuracy, but operating time was reduced by 20 min after the tenth prosthesis was fitted with the device.

Conclusion: This study showed that the Knee+™ device is a safe, reliable, and reproducible AR tool. It has a rapid learning curve for TKA placement. It can be considered as an alternative or an aid to conventional instrumentation in TKA.

Level of evidence: IV; prospective non-comparative study.

Introduction: To date, no national registry has provided a dedicated report on short femoral stems (SFS) in primary Total Hip Arthroplasty (pTHA). In the historical SOFCOT hip arthroplasty multicentre registry (HAMR, now RENACOT), the first SFS used in pTHA was registered in 2011. Aims of this specific report are: 1) to evaluate the outcome of SFS-pTHAs after 13 years (2011-2023) of monitoring and, 2) to evaluate concerns regarding the increasing use of these femoral implants in older patients.

Hypothesis: This multicentre study indicates that use of SFS in pTHA is safe at mid-term in a French orthopaedic community.

Material & methods: As of December 31, 2023, a total of 5,876 SFS-pTHAs were registered, mostly for primary osteoarthritis (4,866, 82.8%). The mean patient age was 68.7 years (SD, 11.4) with a slight female majority (3,046, 52%). Of the 14 registered SFS brands, only one (489 AMIStem C™/5,876 hips, 8.3%) was cemented. Among 733 revisions linked to a previously registered pTHAs after an average follow-up (FU) of 4.7 years, 64 (8.7%) were SFS-THAs, including 59 cementless and 5 hybrids (stem cemented) constructions. SFS performance was assessed by calculating the revision percent observed component year (Rp100ocy, with an alert threshold if >1.3) and by comparing SFS and conventional femoral stems (CFS) using Kaplan-Meier (KM) cumulative revision risk estimates.

Results: The leading causes of early revision among the 64 SFS-rTHAs were hip dislocation (17/64, 26.6%), periprosthetic fractures (11/64, 17.2%), aseptic loosening (10/64, 15.6%), and acute deep infection (7/64, 10.9%). The Rp100ocy for cementless and cemented SFS-pTHAs was 0.25 (95%CI: 0.19-0.31) at 4.4 years, and 0.24 (95%CI: 0.10-0.57) at 4.2 years, respectively. At 10 years, cumulative revision rates by KM were: 1 (95% CI: 0.4-2.5) for cemented SFS-THA, 1.3 (95% CI: 1.1-1.5) for cemented CFS, 1.4 (95% CI: 1.1-1.9) for cementless SFS, and 1.9 (95% CI: 1.7-2.1) for cementless CFS. The overall Rp100ocy for SFS-pTHAs was 0.246 (CI: 0.193-0.315) at 4.4 years, and 0,245 for CFS-pTHAs (CI: 0.227-0.264) at a 1-year longer follow-up (5.5 years). The revision risk for periprosthetic fracture was 17.2% (11/64) for SFS and 24.5% (164/669) for CFS-pTHAs, that is not significant (p = 0.2).

Discussion: Dislocation was the primary reason for revision in this SFS-pTHA series, despite the use of dual mobility cups (DMC) in 36.7% of primary cases, followed by periprosthetic fracture. Ten-year survival of SFS-pTHAs is comparable to that of CFS-pTHAs. This 13-year multicenter monitoring raises no significant concerns regarding SFS use in pTHA, even with increasing use in older patients.

Level of evidence: III; prospective comparative study.

Background: Hip osteoarthritis in young patients, particularly when related to developmental dysplasia of the hip or cam-type femoroacetabular impingement, poses complex therapeutic challenges, and while isolated arthroscopic treatments show promising outcomes in borderline cases, the effectiveness of combining arthroscopic shelf acetabuloplasty with femoroplasty and labral repair remains insufficiently documented. Therefore we performed a retrospective investigation aiming to evaluate the functional outcomes of combined treatment using arthroscopic shelf acetabuloplasty based on the Chiron et al. technique and cam-type femoroacetabular impingement correction for patients with mild and borderline hip dysplasia.

Hypothesis: After a mid term follow up combined surgery led to a satisfactory improvement in clinical and radiological parameters.

Patients and methods: This retrospective study involved a continuous cohort of 13 patients undergoing combined surgery for arthroscopic shelf acetabuloplasty and cam-type femoracetabular impingement correction at a minimum of twenty-two months follow up. Clinical and radiographic assessments were made pre- and post-operatively, including validated tools such as the femoral epiphyseal acetabular roof index, Tönnis grading, Cliff sign and iHot-12 scores for functional outcomes. The intraoperative findings were also reported, as well as complications and reoperation.

Results: At a mean follow-up of 27.2 ± 3.7 months (range, 22-34 months), there was a trend toward improvement in iHOT-12 scores, which did not reach statistical significance (mean Δ +27.2/100 (p = 0.084)), and overall patient satisfaction was favorable (6.9 ± 2.9 out of 10). The lateral center-edge angle increased significantly from 17.4 ± 3.4 ° (range, 14-25) to 39.9 ± 3.8 ° (range, 32-45), while the alpha angle decreased significantly from 61.4 ± 10.0 ° (range, 44-78) to 43.0 ± 6.5 ° (range, 34-54). Postoperative complications included one nonunion (7.7%), partial shelf lysis / remodeling in 6 of the 13 patients (46.2%) of patients and hardware discomfort necessitating removal in 12 of the 13 patients (92.3 %).

Discussion: The preliminary findings of this study indicate that the combined approach of arthroscopic shelf acetabuloplasty with cam-type femoroacetabular impingement correction is a promising treatment option for patients with mild and borderline hip dysplasia with concomitant cam-type femoroacetabular impingement. This approach can lead to improvements in functional scores, normalised radiographic parameters, and acceptable patient satisfaction. Nonetheless, there was a high rate of complications and reoperations, mostly due to hardware-related discomfort.

Level of evidence: IV; Retrospective cohort study.

Introduction: Injuries to the posteromedial corner of the knee are common and often require surgical reconstruction. This cadaveric study aimed to compare three reconstruction techniques-Lind, LaPrade, and Versailles-in terms of valgus laxity control, as well as internal and external rotational stability.

Hypothesis: Authors hypothesized that the three posteromedial reconstruction techniques-Versailles, Lind, and LaPrade-would provide comparable restoration of valgus and rotational stability when performed anatomically.

Materials and methods: Fifteen cadaveric knees were tested to compare the three surgical techniques. Valgus laxity in full extension, external rotation at 30 ° (dial test), and internal rotation in extension were measured in three conditions: intact knee, after sectioning of the posteromedial corner and the medial collateral ligament (superficial and deep layers), and after anatomical posteromedial reconstruction using one of each technique.

Results: No significant differences in valgus laxity in full extension were found among the three techniques in the intact, sectioned knees, meaning that the specimens were comparable. After sectioning, valgus laxity increased significantly in all specimens from 6.92 mm to 12.98 mm for Lind, 6.52 mm-12.58 mm for Versailles, and 6.53 mm-12.3 mm for LaPrade. After reconstruction, valgus laxity was restored in all three groups without significant differences compared to the intact knee (p = 0.25), with values of -1.76 mm, -1.35 mm, and -1.16 mm for Lind, LaPrade, and Versailles techniques, respectively. Similarly, no significant differences were observed in external rotation at 30 ° or internal rotation in extension among the three groups: intact knee (p = 0.14, p = 0.47), sectioned state (p = 0.83, p = 0.36), and after reconstruction (p = 0.071, p = 0.17). External and internal rotational stability were restored without significant differences compared to the intact state (p = 0.11, p = 0.15).

Conclusion: Two anatomic reconstructions (Versailles, LaPrade) and one anatomy-aligned technique (Lind) achieved comparable restoration of valgus stability in extension and rotational control.

Level of evidence: IV; cadaver study.

Background: Although surgical correction of hallux valgus (HV) is the most common procedure in foot surgery, nearly one-third of patients express dissatisfaction, primarily due to lack of correction or recurrence. Reported recurrence rates in the literature vary widely, ranging from 2% to 72%. Accurately estimating the prevalence of recurrence is challenging due to the lack of a consensus on its definition and the heterogeneity of the surgical techniques studied. While recurrence can be a slowly progressive phenomenon, most published cohorts have a postoperative follow-up limited to only one or two years. The aims of this study were 1) to assess the radiologic recurrence rate of HV following Scarf osteotomy, with a minimum follow-up of 8 years. 2) to identify factors associated with recurrence.

Hypothesis: At long-term follow up, hallux valgus recurrence is common.

Materials and methods: A retrospective observational study was conducted, including patients who underwent Scarf osteotomy for hallux valgus correction between January 2001 and January 2014. During this period, 3450 patients underwent Scarf osteotomy for HV correction. Among them, 237/3450 (6.9%) had complete medical records and were included in the analysis. The primary outcome was radiologic recurrence, defined as a hallux valgus angle (HVA) exceeding 20 degrees.

Results: At a mean follow-up of 12.2 ± 2.77 years, the recurrence rate was 15.2% (36/237). Mean HVA was 10.53 ± 8 degrees. The identified factors associated with recurrence included the severity of the preoperative deformity (HVA, p < 0.001; sesamoid position, p < 0.001; Intermetatarsal angle, p = 0.018) and the quality of postoperative correction (HVA, p<0.001; sesamoid position, p = 0.0031 and MTP1 joint congruency, p = 0.0037).

Discussion: Over the long term, recurrence of hallux valgus following Scarf osteotomy is a frequent phenomenon, particularly in patients presenting with more severe preoperative deformities. These results may allow for appropriate patient information about long-term recurrence before surgery, even though the recurrence rate is likely underestimated, since only 6.9% of patients benefited from long-term follow-up in this retrospective study.

Level of evidence: III; Retrospective cohort study.

Background: Endoscopic flexor hallucis longus (FHL) tendon transfer is now a common technique for the treatment of chronic Achilles tendon ruptures. In most cases, the FHL is harvested in zones 1-2 and fixed using an interference screw within a vertical calcaneal tunnel. To enhance fixation we developed an original technique involving fixation of the FHL by tenodesis in a horizontal calcaneal tunnel combined with tendon-to-tendon suturing. The aim of this study was to evaluate the outcomes of endoscopic FHL transfer with fixation using a tenodesis screw in a horizontal calcaneal tunnel combined with tendon-to-tendon suturing regarding: (1) iterative rupture and complications, (2) Pain and function according to European Foot and Ankle Society (EFAS) score, (3) return to work and participation is sports.

Hypothesis: This method of FHL transfer would provide satisfactory functional results and enable early return to activities.

Material and methods: Thirty-six patients operated between January 2019 and June 2023 were assessed retrospectively after a mean follow-up of 38 months (range, 12-58 months). The cohort consisted of 30 men and 6 women, with a mean age of 53.6 years (range, 16-76 years) at the time of surgery. Seven cases (19.4%) involved iterative ruptures, and 29 cases (80.6%) involved chronic ruptures. All procedures were performed by the same surgeon using the same FHL transfer technique. The Visual Analog Scale (VAS) for pain and the European Foot and Ankle Society (EFAS) score were used as primary outcome measures.

Results: At the final follow-up, the median VAS decreased from 7 (Inter Quartile Range (IQR), 6-8) preoperatively to 0 (IQR, 0-1.3) (p < 0.001), and the EFAS score improved from 8 (IQR, 4.8-10) to 32 (IQR, 29.5-35,3) (p < 0.001). Three surgical revisions were required for infection (8.3%). Two patients (5.6%) developed complex regional pain syndrome type 1, and three patients (8.3%) reported disabling plantar dysesthesias. No secondary graft rupture was observed. The return-to-work rate among active patients was 100%, with a median time of 3 months. Among athletes, 75.9% (22/29) resumed sports activity, with a mean postoperative Victorian Institute of Sport Assessment - Achilles (VISA-A) score of 69.2/100 (range, 44-100). Only one patient reported dissatisfaction with the surgical outcome.

Discussion: Endoscopic FHL transfer with double fixation appears to be a safe and reliable technique, allowing rapid return to work and sports activities.

Level of evidence: IV; retrospective cohort study.