AB0862 CONSENSUS STATEMENT ON INTRA-ARTICULAR INJECTIONS OF PLATELET-RICH PLASMA FOR THE MANAGEMENT OF KNEE OSTEOARTHRITIS

Background:

There has been much debate regarding the use of intra-articular injections of platelet-rich plasma (PRP) as symptomatic treatment for knee osteoarthritis. The heterogeneity of the preparation and injection protocols limits the extrapolation of data from randomized controlled trials and meta-analyses.

Objectives:

The objective of this expert consensus was to develop the first clinical practice recommendations for PRP injections in knee osteoarthritis.

Methods:

Fifteen physicians (10 rheumatologists, 4 specialists in rehabilitation and sport medicine and 1 interventional radiologist) from different countries were selected given to their expertise in the fields of PRP and osteoarthritis. Twenty-five recommendations were finally retained after several meetings using the modified Delphi method to establish clinical consensus. All experts voted their agreement or not for each recommendation using a score between 1 (totally inappropriate) and 9 (totally appropriate). Depending on the median value and extreme scores, recommendations were judged as appropriated or unappropriated with a strong or relative agreement but could also be judged as uncertain due to indecision or absence of consensus.

Results:

The main recommendations are listed below:

Conclusion:

Twenty-five recommendations were discussed by an international multidisciplinary task force group in order to provide a basis for standardization of clinical practices and future research protocols.

Disclosure of Interests:

Florent Eymard Consultant of: Regenlab, Paul Ornetti: None declared, Jérémy Maillet Consultant of: Regenlab, Eric Noel Consultant of: Regenlab, Philippe Adam Consultant of: Regenlab, Virginie Legré Boyer Consultant of: Regenlab, Thierry Boyer Consultant of: Regenlab, Fadoua Allali: None declared, Vincent Grémeaux Bader: None declared, Jean-François Kaux: None declared, Karine Louati: None declared, Martin Lamontagne Consultant of: Pendopharm, Fabrice Michel: None declared, Pascal Richette: None declared, Hervé Bard Consultant of: Regenlab

Development and validation of a questionnaire to measure research impact

Although questionnaires are widely used in research impact assessment, their metric properties are not well known. Our aim is to test the internal consistency and content validity of an instrument designed to measure the perceived impacts of a wide range of research projects. To do so, we designed a questionnaire to be completed by principal investigators in a variety of disciplines (arts and humanities, social sciences, health sciences, and information and communication technologies). The impacts perceived and their associated characteristics were also assessed. This easy-to-use questionnaire demonstrated good internal consistency and acceptable content validity. However, its metric properties were more powerful in areas such as knowledge production, capacity building and informing policy and practice, in which the researchers had a degree of control and influence. In general, the research projects represented an stimulus for the production of knowledge and the development of research skills. Behavioural aspects such as engagement with potential users or mission-oriented projects (targeted to practical applications) were associated with higher social benefits. Considering the difficulties in assessing a wide array of research topics, and potential differences in the understanding of the concept of ‘research impact’, an analysis of the context can help to focus on research needs. Analyzing the metric properties of questionnaires can open up new possibilities for validating instruments used to measure research impact. Further to the methodological utility of the current exercise, we see a practical applicability to specific contexts where multiple discipline research impact is requires.

Vascular complication after percutaneous femoral cerclage wire

Cerclage wire is an effective fracture fixation method. However, its mechanical benefits are countered by local ischemia. Its efficacy for treating femoral periprosthetic fractures has been demonstrated since femoral fixation is possible even there is a stem in the diaphysis. It securely holds the proximal femur typically with an additional plate. The development of minimally-invasive surgery with plate fixation has led to the cerclage wire being inserted percutaneously. Here, we report on a case of secondary femoral ischemia following percutaneous cerclage wire of a periprosthetic femoral fracture. This was a Vancouver type B1 fracture. On the 3rd day after admission, minimally-invasive fixation with a femoral locking plate was performed with five cerclage wires added percutaneously. During the immediate postoperative course, the patient developed ischemia of the operated leg that required vascular surgery after confirmation by CT angiography. An arterial stop was visible with deviation of the superior femoral artery, which was not properly surrounded by the cerclage wire. The latter pulled perivascular tissues towards the femur. When combined with reduced arterial elasticity due to severe atherosclerosis, it resulted in arterial plication. The postoperative course was marked by multiple organ failure and death of the patient. Percutaneous surgery is an attractive option but has risks. The presence of severe atherosclerosis is a warning sign for loss of tissue elasticity. This complication can be prevented by preparing the bone surfaces and carefully positioning the patient on the traction table to avoid forced adduction. The surgeon must also be familiar with alternative techniques to cerclage wire such as polyaxial screws and additional plates.

Luxations aiguës d'épaule : évaluation rétrospective aux urgences et proposition d'un protocole de sédation procédurale

Introduction : Les luxations d'épaule sont des pathologies fréquentes aux urgences, parmi les plus douloureuses et pour lesquelles il n'existe pas de recommandations spécifiques. Elles représentent 45 % de l'ensemble des luxations. L'objectif principal de cette étude était d'analyser la gestion de la douleur dans cette pathologie.

Matériel et méthodes : Nous avons conduit une étude observationnelle, monocentrique et rétrospective colligeant 238 patients ayant consulté aux urgences pour une luxation aiguë d'épaule (01/01/2012-30/04/2015). Les luxations réduites spontanément, les luxations sur prothèse et les luxations chroniques étaient exclues de l'étude.

Résultats : Les luxations aiguës d'épaule étaient majoritairement réduites aux urgences (90 %, IC95 % : [86-94]). Il s'agissait d'une pathologie hyperalgique (Echelle numérique médiane : 8/10, [EIC : 6-9]) touchant plutôt les sujets jeunes (âge médian : 48 ans, EIC : 28-73). Il existait une grande hétérogénéité dans la répartition des antalgiques utilisés, le mélange équimolaire d'oxygène et de protoxyde d'azote (MEOPA) était l'antalgique le plus prescrit (50 % (IC95 % : [42-55])), suivi par le paracétamol (25 %) et le néfopam (15 %). Dans le sous-groupe des luxations compliquées d'une fracture, le MEOPA était également le plus prescrit. La répartition des autres antalgiques était par ailleurs similaire. Enfin, la comparaison entre les deux équipes médicales (urgentiste vs orthopédiste) ne retrouvait aucune différence de prescription en dehors du midazolam davantage utilisé par les urgentistes (16 % vs 4 %, p=0,001).

Conclusion : Il existait une grande hétérogénéité des pratiques et une sous-utilisation d'antalgiques et d'hypnotiques malgré des douleurs importantes dès l'admission. Un chemin clinique visant à améliorer cette prise en charge est proposé afin d'homogénéiser les pratiques.

ISRIA statement: ten-point guidelines for an effective process of research impact assessment

As governments, funding agencies and research organisations worldwide seek to maximise both the financial and non-financial returns on investment in research, the way the research process is organised and funded is becoming increasingly under scrutiny. There are growing demands and aspirations to measure research impact (beyond academic publications), to understand how science works, and to optimise its societal and economic impact. In response, a multidisciplinary practice called research impact assessment is rapidly developing. Given that the practice is still in its formative stage, systematised recommendations or accepted standards for practitioners (such as funders and those responsible for managing research projects) across countries or disciplines to guide research impact assessment are not yet available.In this statement, we propose initial guidelines for a rigorous and effective process of research impact assessment applicable to all research disciplines and oriented towards practice. This statement systematises expert knowledge and practitioner experience from designing and delivering the International School on Research Impact Assessment (ISRIA). It brings together insights from over 450 experts and practitioners from 34 countries, who participated in the school during its 5-year run (from 2013 to 2017) and shares a set of core values from the school's learning programme. These insights are distilled into ten-point guidelines, which relate to (1) context, (2) purpose, (3) stakeholders' needs, (4) stakeholder engagement, (5) conceptual frameworks, (6) methods and data sources, (7) indicators and metrics, (8) ethics and conflicts of interest, (9) communication, and (10) community of practice.The guidelines can help practitioners improve and standardise the process of research impact assessment, but they are by no means exhaustive and require evaluation and continuous improvement. The prima facie effectiveness of the guidelines is based on the systematised expert and practitioner knowledge of the school's faculty and participants derived from their practical experience and research evidence. The current knowledge base has gaps in terms of the geographical and scientific discipline as well as stakeholder coverage and representation. The guidelines can be further strengthened through evaluation and continuous improvement by the global research impact assessment community.

Ankle fusion in hemophilic patients

INTRODUCTION

Hemophilic arthropathy is painful and disabling. We report a retrospective study of ankle fusion with intra- and peri-operative clotting factor perfusion. The objective was to assess the efficacy of maintaining perioperative clotting factor rates close to 100%, and report long-term results. The study hypothesis was that results would be good, without early hemorrhagic complications.

MATERIAL AND METHOD

Between 2000 and 2013, 12 ankle fusions were performed in 9 patients, with a mean age of 39years (range, 19-58years). Anti-hemophilic factor perfusion was controlled by the reference physician of the Regional Hemophilia Treatment Center. Clinical AOFAS and Olerud scores and the Pettersson radiologic score were used for assessment. Mean preoperative AOFAS score was 22 (range, 2-55) and mean Olerud score 7 (range, 5-12). Mean preoperative factor VIII concentration was <1% (range, <1-3%).

RESULTS

Mean follow-up was 8years (range, 2-16years). Mean AOFAS score at follow-up was 69 (range, 35-92) and mean Olerud score 70 (range, 30-100). Improvement mainly concerned the Pain dimension. Statistical analysis found a significant difference between pre- and post-operative clinical scores (AOFAS, P=0.004; Olerud, P=0.004). Mean factor VIII concentration at surgery was 90% (range, 24-117%), and 109% (range, 75-152%) the day following surgery. There were no cases of hematoma or surgical site infection. Radiologic fusion was systematic at a mean 3.5 months (range, 3-4months).

CONCLUSION

The study hypothesis was confirmed. Ankle fusion in advanced hemophilic arthropathy improved function and quality of life. Perioperative clotting factor perfusion contributed to these good results, providing supplementary prevention of hemorrhagic risk.

LEVEL OF EVIDENCE

IV, retrospective study.

Internal fixation of intra-capsular proximal femoral fractures in patients older than 80 years: Still relevant? Multivariate analysis of a prospective multicentre cohort

BACKGROUND

Arthroplasty is now widely used to treat intra-capsular proximal femoral fractures (PFFs) in older patients, even when there is little or no displacement. However, whether arthroplasty is associated with lower mortality and complication rates in non-displaced or mildly displaced PFFs is unknown. The objectives of this prospective study were: (1) to evaluate early mortality rates with the two treatment methods, (2) to identify risk factors for complications, (3) and to identify predictors of functional decline.

HYPOTHESIS

Arthroplasty and internal fixation produce similar outcomes in non-displaced fractures of patients older than 80 years with PFFs.

MATERIAL AND METHODS

This multicentre prospective study included consecutive patients older than 80 years who were managed for intra-capsular PFFs at eight centres in 2014. Biometric data and geriatric assessment scores (Parker Mobility Score, Katz Index of Independence, and Mini-Nutritional Assessment [MNA] score) were collected before and 6 months after surgery. Independent risk factors were sought by multivariate analysis. We included 418 females and 124 males with a mean age of 87±4years. The distribution of Garden stages was stage I, n=56; stage II, n=33; stage III, n=130; and stage IV, n=323. Arthroplasty was performed in 494 patients and internal fixation in 48 patients with non-displaced intra-capsular PFFs.

RESULTS

Mortality after 6 months was 16.4% overall, with no significant difference between the two groups. By multivariate analysis, two factors were significantly associated with higher mortality, namely, male gender (odds ratio [OR], 3.24; 95% confidence interval [95% CI], 2.0-5.84; P<0.0001) and high ASA score (OR, 1.56; 95% CI, 1.07-2.26; P=0.019). Two factors were independently associated with lower mortality, with 75% predictive value, namely, high haematocrit (OR, 0.8; 95% CI, 0.7-0.9; P=0.001) and better Parker score (OR, 0.5; 95% CI, 0.3-0.8; P=0.01). The cut-off values associated with a significant risk increase were 2 for the Parker score (OR, 1.8; 95% CI, 1.1-2.3; P=0.001) and 37% for the haematocrit (OR, 3.3; 95% CI, 1.9-5.5; P=0.02). Complications occurred in 5.5% of patients. Surgical site infections were seen in 1.4% of patients, all of whom had had arthroplasty. Blood loss was significantly greater with arthroplasty (311±197mL versus 201±165mL, P<0.0002). Dependency worsened in 39% of patients, and 31% of patients lost self-sufficiency. A higher preoperative Parker score was associated with a lower risk of high postoperative dependency (OR, 0.86; 95% CI, 0.76-0.97; P=0.014).

DISCUSSION

Neither treatment method was associated with decreased mortality or better function after intra-capsular PFFs in patients older than 80 years. Early mortality rates were consistent with previous reports. Among the risk factors identified in this study, age, preoperative self-sufficiency, and gender are not amenable to modification, in contrast to haematocrit and blood loss.

CONCLUSION

Internal fixation remains warranted in patients older than 80 years with non-displaced intra-capsular PFFs.

LEVEL OF EVIDENCE

III, prospective case-control study.

Tibiofemoral syndesmosis injury treated by temporary screw fixation and ligament repair

INTRODUCTION

Tibiofemoral syndesmosis injuries are common but have not been extensively researched. The primary objective of this study was to evaluate the outcomes after temporary screw fixation with ligament repair of these injuries. The secondary objective was to look for factors that could impact these outcomes. We hypothesised that this double fixation (screw+suture) would lead to good outcomes with minimal secondary opening of the syndesmosis upon screw removal.

MATERIAL AND METHODS

This was a retrospective study of 285 patients with a tibiofemoral syndesmosis injury (01/2004-12/2011) who were treated by temporary tricortical or quadricortical screw fixation and ligament repair. The operated leg was unloaded for 6-8 weeks postoperative with the patient wearing a walking cast. The screw was removed in all patients before weight bearing was allowed. At follow-up, the range of motion, return to sports, pain, and functional scores (AOFAS and OMAS) were determined, and a radiological assessment was performed.

RESULTS

One hundred twenty-six patients were reviewed after a mean follow-up of 5.9±5.7years (2.9-10.5). Mean plantarflexion was 95% of the contralateral side and mean dorsiflexion was 93%. Return to sports occurred after a mean of 10weeks; 83% of patients returned to their pre-injury level of participation. Pain on VAS was 0.8/10 on average. The mean AOFAS and OMAS scores were both above 90 points. At the review, 4% of screws had broken. Diastasis was found in 5.6% of cases, osteoarthritis in 6.3% and an osteophyte in 11.1% of cases, but with no clinical repercussions. No risk factors were identified.

DISCUSSION AND CONCLUSION

Treatment by temporary screw fixation and ligament repair leads to good objective results, confirming our hypothesis. However, there is little published data and no consensus on the fixation method or the need to remove the screw.

LEVEL OF EVIDENCE

IV, retrospective, non-comparative.

Villonodular synovitis of the ankle. Analysis of the risk of recurrence

INTRODUCTION

Villonodular synovitis (VNS) is a rare disease with an incidence of 1.8 per 1,000,000 inhabitants. VNS of the ankle has seldom been described and evaluated given its extreme rarity (2.5% of VNS cases). It presents an 11% recurrence rate. We report a continuous retrospective series with the main objective of clinically and radiologically evaluating these ankles searching for any risk factors of recurrence. At revision the study's main endpoint was the existence of local recurrence (radiological and clinical) and the secondary endpoint was the existence of tibiotalar osteoarthritis. The working hypothesis was that recurrence could be subclinical, warranting systematic imaging studies during follow-up.

MATERIAL AND METHODS

The study was retrospective, conducted on seven patients (six males) whose mean age was 42 years treated over a period of 9 years (two diffuse forms and five localized forms). The initial treatment consisted in synovectomy via the conventional approach. Four patients also received adjuvant isotopic synoviorthesis treatment. The revision was clinical (MMTS, AOFAS, and OMAS scores) and radiological (standard and MRI) to evaluate the joint after-effects and search for recurrence.

RESULTS

Six patients were seen at a mean 6.5 years of follow-up. One case of early recurrence (4 years) was noted, with a major clinical manifestation because it was associated with joint destruction requiring arthrodesis, and one case of late asymptomatic recurrence (9 years), diagnosed radiologically on the follow-up MRI. The functional results remained good at follow-up (MMTS 77%, AOFAS 71, OMAS 71). Five of the six patients returned to their daily activities. At revision, no sign of osteoarthritis was observed. No risk factor for recurrence was demonstrated.

DISCUSSION/CONCLUSION

The hypothesis was confirmed with the existence of asymptomatic recurrence at revision, underscoring the value of systematic MRI at follow-up. Other than major joint destruction, the prognosis remains good even in case of recurrence. The literature emphasizes the existence of an initial diffuse form and partial surgical resection as risk factors of recurrence. None of the reports in the literature has proven that adjuvant treatment, whose modalities do not meet with consensus, reduces this risk.

LEVEL OF EVIDENCE

Retrospective series, level IV.

A global call for action to include gender in research impact assessment

Global investment in biomedical research has grown significantly over the last decades, reaching approximately a quarter of a trillion US dollars in 2010. However, not all of this investment is distributed evenly by gender. It follows, arguably, that scarce research resources may not be optimally invested (by either not supporting the best science or by failing to investigate topics that benefit women and men equitably). Women across the world tend to be significantly underrepresented in research both as researchers and research participants, receive less research funding, and appear less frequently than men as authors on research publications. There is also some evidence that women are relatively disadvantaged as the beneficiaries of research, in terms of its health, societal and economic impacts. Historical gender biases may have created a path dependency that means that the research system and the impacts of research are biased towards male researchers and male beneficiaries, making it inherently difficult (though not impossible) to eliminate gender bias. In this commentary, we – a group of scholars and practitioners from Africa, America, Asia and Europe – argue that gender-sensitive research impact assessment could become a force for good in moving science policy and practice towards gender equity. Research impact assessment is the multidisciplinary field of scientific inquiry that examines the research process to maximise scientific, societal and economic returns on investment in research. It encompasses many theoretical and methodological approaches that can be used to investigate gender bias and recommend actions for change to maximise research impact. We offer a set of recommendations to research funders, research institutions and research evaluators who conduct impact assessment on how to include and strengthen analysis of gender equity in research impact assessment and issue a global call for action.

Critical analysis of olecranon fracture management by pre-contoured locking plates

BACKGROUND

Fractures of the proximal ulna are rare and usually managed surgically. Strong fixation of the harware is essential to obtain good outcomes. We report our experience with pre-contoured locking plate fixation of complex olecranon fractures and present a critical appraisal of the outcomes.

HYPOTHESIS

Pre-contoured locking plates provide good outcomes, but their clinical tolerance may be limited in some instances.

MATERIALS AND METHODS

From September 2009 to December 2011, 28 patients were managed using a pre-contoured locking compression plate (LCP(®)). Among them, 6 were excluded because of missing data, which left 22 patients (11 males and 11 females) with a mean age of 55.7 years, including 12 who were employed. The fracture was on the dominant side in 11 patients. According to the Mayo Clinic classification, 15 fractures were type II and 7 type III. In addition to the ulnar fracture, a radial head fracture was present in 9 patients and a coronoid process fracture in 5 patients. Functional recovery was assessed using the Broberg-Morrey score and Mayo Elbow Performance Score (MEPS). Radiographs were obtained to evaluate the quality of fracture reduction and fracture healing, as well as to look for ossifications and osteoarthritis.

RESULTS

Mean follow-up was 20 months. Flexion was 131°, extension loss was 9.5°, pronation was 79°, and supination was 80.5°. The mean Broberg-Morrey score was 96.7 and the mean MEPS score 96.6. Fracture healing occurred in all patients, within a mean of 10.6 weeks. Evidence of early osteoarthritis was found in 6 patients, ossifications in 3 patients, and synostosis in 1 patient. An infection was successfully treated with lavage and antibiotic therapy in 1 patient. The fixation hardware was removed in 6 patients. No prognostic factors were identified.

DISCUSSION-CONCLUSION

Our hypothesis was confirmed. The outcomes are encouraging and comparable to those reported in the literature. The critical issue is the limited clinical tolerance of the plate with a high rate of posterior impingement requiring plate removal (27%). Rigorous technique is essential during plate implantation.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Impact of a priority system on patients in waiting lists for knee arthroplasty

RATIONALE, AIMS AND OBJECTIVES

The Agency for Health Quality and Assessment of Catalonia (AQuAS) developed a system for the prioritization of patients on non-urgent waiting lists for cataract as well as knee and hip arthroplasty. The aim was to evaluate the impact of the priority system's application for primary knee arthroplasty (PKA).

METHODS

A retrospective evaluative study with data from the Data Tracking and Management Registry of the CatSalut Waiting Lists for PKA of hospitals in the public hospital network in the period 2003-2009. A description of the characteristics of patients on waiting lists was made and the association between priority scoring and waiting time and the order of operation analysed. Finally, waiting times were simulated that patients would have experienced if being operated on strictly according to a first in first out system or one of priority scoring, to compare them with real waiting times.

RESULTS

The number of people included on waiting lists for PKA was 67403. 67% had a priority score. The distribution of the priority score was negatively skewed with an average score of 70 points. The association with the priority score for the waiting time as well as the order of the operations performed was practically null.

CONCLUSIONS

The study concludes that, globally, the prioritization system for PKA has been implemented but had no effect on the prioritization of patients based on their severity. Nevertheless, in some centres, a moderate correlation between the order of operations performed and the priority score was identified.

[Mesothelial proliferation in rectal cancer]

In an epiphrenic lymph node of a 55 years old female patient who underwent surgical resection of a rectal adenocarcinoma epitheloid proliferations with papillary and solid growth pattern were seen additional to a metastasis of the carcinoma. Adjacent vessels contained similar infiltrates. Immunohistochemically a co-expression of pan-keratin, calretinin and WT1 was seen, suggestive for a diagnosis of a metastasis of a malignant mesothelioma. However, radiologic examination yielded no morphologic correlate to this suspicion. Further immunohistochemical work-up showed positivity for desmin, negativity for EMA, GLUT1, p53 and a low ki67-fraction of 2-3 %. Therefore, a final diagnosis of benign mesothelial proliferations disseminated into the lymph node and the adjacent vessels was made.

Treatment of recent trochanteric fracture in adults

Recent trochanteric fracture is frequent in adults, and mainly affects elderly patients who risk loss of independence. Treatment is surgical, of various sorts. Open reduction internal fixation (ORIF) with intra- or extra-medullary implants is the most frequent attitude in these fractures, which usually heal easily. In elderly patients, arthroplasty is an alternative of choice for some authors. These different treatment modalities are presented, focusing on technical details. Possible technical difficulties and the means of dealing with them are considered. Published results help in choosing the treatment most suitable for a particular type of fracture in a particular patient.

Dual mobility retentive acetabular liners and wear: surface analysis of 40 retrieved polyethylene implants

PURPOSE OF THE STUDY

Dual mobility systems with retentive acetabular liners have been used in clinical practice for total hip arthroplasty since 1976. The dual mobility system preserves a wide range of motion while providing greater stability. This study measured wear on the concave and convex surfaces of 40 retrieved polyethylene liners, to evaluate the advantages of this system in relation to wear.

MATERIAL AND METHODS

Forty polyethylene inserts that had been removed due to infection or mechanical failure after a mean 8 years were analyzed. The mean age of patients at arthroplasty was 46 years old. Macroscopic analysis was followed by surface analysis with direct measurement of changes in the curvature radii. The internal concave surface was measured in three dimensions using a 4-mm stylus (BNH 706). External convexity was measured by lateral projection. The estimated error was ± 5 μm for both measurement methods. Manufacturers' tolerance for these implants was approximately 50 μm. Linear wear and wear volume was determined by comparing the measured dimensions with the theoretical dimensions of new liners.

RESULTS

Macroscopically, all of the pieces studied had lost the initial machined grooves on the convex surface; 40% of the pieces showed visible wear of the retentive collar. Mean annual convex surface wear was 9 μm (SD 9μm) and 73 μm (SD 69 μm) for the concave surface. Mean total wear, which was the sum of the wear on the convex and concave surfaces was 82 μm (SD 72 μm). Wear volume was 28.9 mm(3)/yr for the convex surface (SD 27.6) and 25.5 for the concave surface (SD 23.2) with a mean annual total wear volume of 54.3 mm(3)/yr (SD 39.6).

DISCUSSION

Total wear in the 40 dual mobility liners that had functioned in vivo was similar to that reported in metal-polyethylene bearings with 22.2mm femoral heads. The results of wear in both the convex and concave surfaces show that wear with the dual mobility system was not increased compared to conventional metal-polyethylene bearings, while providing better retention and greater stability.

CONCLUSION

The use of dual mobility acetabular liners is an attractive solution when a metal-polyethylene bearing is needed. The increased joint stability is not associated with increased wear.

Distal targeting device for long Gamma nail(®). Monocentric observational study

INTRODUCTION

Intramedullary nail distal locking screws make it possible to control length and rotation but include an increased risk of radiation exposure. A distal targeting device was recently developed for long Gamma(®) nails (Stryker(®)). The aim of this practical observational study was to evaluate the reliability of this system. Our hypothesis was that the targeting device would be systematically used without conversion or complications.

MATERIALS AND METHODS

All of the long Gamma(®) nails implanted between November 2011 and October 2012 were recorded: 91 nails (59W/32M, mean age 73.5years old) for 68 traumatic fractures, 14 preventive nailings and nine pathological fractures. A junior surgeon performed the procedure in 45 cases and a senior in 46 cases. The number of times the device was used, the difficulties and complications encountered, the duration of fluoroscopy and the dose of radiation were noted. Risk factors were looked for.

RESULTS

The targeting device was used 79 times (the surgeon chose not to use it 11 times, and it was not available in one case). There was a measurement error in one case, therefore 78 nails could be evaluated. Three wrong positions of the distal locking screw occurred. No statistically significant risk factors were identified. Distal locking screw corresponded to 18% of the entire procedure at a radiation dose of 7.44% (this was higher with titanium nails and pathological fractures). Total fluoroscopy time was longer with junior than with senior surgeons but the dose and duration for distal locking were not different.

DISCUSSION

The hypothesis was not confirmed. The device was not systematically used and the risk of complications was not null. No risk factors were identified. The distal locking screw is a difficult step but the use of the targeting device can limit the dose of radiation. This device is effective and allows young surgeons to perform distal locking without increasing the dose of radiation compared to senior surgeons.

LEVEL OF EVIDENCE

Level IV, cohort study, observational prospective follow-up.

Record of archaeal activity at the serpentinite-hosted Lost City Hydrothermal Field

Samples of young, outer surfaces of brucite-carbonate deposits from the ultramafic-hosted Lost City hydrothermal field were analyzed for DNA and lipid biomarker distributions and for carbon and hydrogen stable isotope compositions of the lipids. Methane-cycling archaeal communities, notably the Lost City Methanosarcinales (LCMS) phylotype, are specifically addressed. Lost City is unlike all other hydrothermal systems known to date and is characterized by metal- and CO2 -poor, high pH fluids with high H2 and CH4 contents resulting from serpentinization processes at depth. The archaeal fraction of the microbial community varies widely within the Lost City chimneys, from 1-81% and covaries with concentrations of hydrogen within the fluids. Archaeal lipids include isoprenoid glycerol di- and tetraethers and C25 and C30 isoprenoid hydrocarbons (pentamethylicosane derivatives - PMIs - and squalenoids). In particular, unsaturated PMIs and squalenoids, attributed to the LCMS archaea, were identified for the first time in the carbonate deposits at Lost City and probably record processes exclusively occurring at the surface of the chimneys. The carbon isotope compositions of PMIs and squalenoids are remarkably heterogeneous across samples and show highly (13) C-enriched signatures reaching δ(13) C values of up to +24.6‰. Unlike other environments in which similar structural and isotopic lipid heterogeneity has been observed and attributed to diversity in the archaeal assemblage, the lipids here appear to be synthesized solely by the LCMS. Some of the variations in lipid isotope signatures may, in part, be due to unusual isotopic fractionation during biosynthesis under extreme conditions. However, we argue that the diversity in archaeal abundances, lipid structure and carbon isotope composition rather reflects the ability of the LCMS archaeal biofilms to adapt to chemical gradients in the hydrothermal chimneys and possibly to perform either methanotrophy or methanogenesis using dissolved inorganic carbon, methane or formate as a function of the prevailing environmental conditions.

Minimally invasive fixation of type B and C interprosthetic femoral fractures

INTRODUCTION

Interprosthetic femoral fractures are rare and raise unresolved treatment issues such as the length of the fixation material that best prevents secondary fractures. Awareness of the advantages of locked-plate fixation via a minimally invasive approach remains limited, despite the potential of this method for improving success rates.

HYPOTHESIS

Femur-spanning (from the trochanters to the condyles) locked-plate fixation via a minimally invasive approach provides high healing rates with no secondary fractures.

MATERIALS AND METHODS

From January 2004 to May 2011, all eight patients seen for interprosthetic fractures were treated with minimally invasive locked-plate fixation. Mean time since hip arthroplasty was 47.5 months and mean time since knee arthroplasty was 72.6 months. There were 12 standard primary prostheses and four revision prostheses; 11 prostheses were cemented and a single prosthesis showed femoral loosening. Classification about the hip prostheses was Vancouver B in one patient and Vancouver C in seven patients; about the knee prosthesis, the fracture was SoFCOT B in three patients and SOFCOT C in five patients, and a single fracture was SoFCOT D. Minimally invasive locking-plate fixation was performed in all eight patients, with installation on a traction table in seven patients.

RESULTS

Healing was obtained in all eight patients, after a mean of 14 weeks (range, 12-16 weeks). One patient had malalignment with more than 5° of varus. There were no general or infectious complications. One patient died, 32 months after surgery. The mean Parker-Palmer mobility score decreased from 6.2 pre-operatively to 2.5 at last follow-up. Early construct failure after 3 weeks in one patient required surgical revision. There was no change in implant fixation at last follow-up. No secondary fractures were recorded.

DISCUSSION

In patients with type B or C interprosthetic fractures, femur-spanning fixation not only avoids complications related to altered bone stock and presence of prosthetic material, but also decreases the risk of secondary fractures by eliminating stress riser zones. The minimally invasive option enhances healing by preserving the fracture haematoma. Thus, healing was obtained consistently in our patients, with no secondary fractures, although the construct failed in one patient.

LEVEL OF EVIDENCE

Level IV.

Surface plasmon resonance optical cavity enhanced refractive index sensing

We report on a method for surface plasmon resonance (SPR) refractive index sensing based on direct time-domain measurements. An optical resonator is built around an SPR sensor, and its photon lifetime is measured as a function of loss induced by refractive index variations. The method does not rely on any spectroscopic analysis or direct intensity measurement. Time-domain measurements are practically immune to light intensity fluctuations and thus lead to high resolution. A proof of concept experiment is carried out in which a sensor response to liquid samples of different refractive indices is measured. A refractive index resolution of the current system, extrapolated from the reproducibility of cavity-decay time determinations over 133 s, is found to be about 10(-5) RIU. The possibility of long-term averaging suggests that measurements with a resolution better than 10(-7) RIU/√Hz are within reach.

Impact of clinical and health services research projects on decision-making: a qualitative study

Background

This article reports on the impact assessment experience of a funding program of non-commercial clinical and health services research. The aim was to assess the level of implementation of results from a subgroup of research projects (on respiratory diseases), and to detect barriers (or facilitators) in the translation of new knowledge to informed decision-making.

Methods

A qualitative study was performed. The sample consisted of six projects on respiratory diseases funded by the Agency for Health Quality and Assessment of Catalonia between 1996 and 2004. Semi-structured interviews to key informants including researchers and healthcare decision-makers were carried out. Interviews were recorded, transcribed verbatim and analysed on an individual (key informant) and group (project) basis. In addition, the differences between achieved and expected impacts were described.

Results

Twenty-three semi-structured interviews were conducted. Most participants indicated changes in health services or clinical practice had resulted from research. The channels used to transfer new knowledge were mainly conventional ones, but also in less explicit ways, such as with the involvement of local scientific societies, or via debates and discussions with colleagues and local leaders. The barriers and facilitators identified were mostly organizational (in research management, and clinical and healthcare practice), although there were also some related to the nature of the research as well as personal factors. Both the expected and achieved impacts enabled the identification of the gaps between what is expected and what is truly achieved.

Conclusions

In this study and according to key informants, the impact of these research projects on decision-making can be direct (the application of a finding or innovation) or indirect, contributing to a more complex change in clinical practice and healthcare organization, both having other contextual factors. The channels used to transfer this new knowledge to clinical practice are complex. Local scientific societies and the relationships between researchers and decision-makers can play a very important role. Specifically, the relationships between managers and research teams and the mutual knowledge of their activity have shown to be effective in applying research funding to practice and decision-making. Finally the facilitating factors and barriers identified by the respondents are closely related to the idiosyncrasy of the human relations between the different stakeholders involved.

Distal femur fractures. Surgical techniques and a review of the literature

Fractures of the distal femur are rare and severe. The estimated frequency is 0.4% with an epidemiology that varies: there is a classic bimodal distribution, with a frequency peak for men in their 30s and a peak for elderly women; however, at present it is found predominantly in women and in the elderly with more than 50% of patients who are over 65. The most common mechanism is an indirect trauma on a bent knee, and more rarely direct trauma by crushing. The anatomy of the distal femur explains the three major types of fracture. Because of the anatomy of the distal femur, only surgical treatment is indicated to stabilize the fracture. A non-surgical treatment is a rare option. The aim of this report was to provide an update on the existing surgical solutions for the management of these fractures and describe details of the surgical technique applicable to these injuries. Recent radiological, clinical and biomechanical data published in the literature are reported to compare different surgical options.

Treatment of distal humerus fractures with LCP DHP™ locking plates in patients older than 65 years

INTRODUCTION

Fractures of the distal humerus are often complex and therefore challenging to treat. In elderly patients with decreased bone strength due to osteoporosis, strong fixation is crucial to allow resuming early motion that guarantees a good functional outcome as well as minimising mechanical complications. Locked implants meet these requirements. Here, we report outcomes in a uniform series of patients older than 65 years with distal humerus fractures managed with LCP DHP(®) (Synthès) fixation. Our objective was to evaluate the efficacy and limitations of this technique.

HYPOTHESIS

LCP DHP provides strong fixation of osteoporotic bone and leads to good clinical and radiological outcomes.

MATERIALS AND METHODS

We retrospectively studied 46 consecutive patients (2004-2010) with a mean age of 80 years including 15 with extra-articular and 31 with articular distal humerus fractures. At presentation, 11 complications were noted in nine patients (compound fractures and trauma-related nerve injuries). The transolecranon approach was used in 31 patients. Mean duration of immobilisation was 2.7 weeks in 33 patients.

RESULTS

Forty-three patients were re-evaluated after a mean follow-up of 25 months (range, 10-64 months); two patients died and one was lost to follow-up. Flexion was 127° and loss of extension was 23°, producing an average range of motion of 104°. Functional recovery was highly satisfactory with a Mayo Clinic Performance Score of 87 (70-100) and 95% of good and very good results. Postoperative complications consisted of infection (n=3), metaphyseal non-union (n=2), ulnar nerve injury (n=6), transient radial nerve palsy (n=1), and peri-articular ossification (n=4). Compound fracture and worse AO fracture type were associated with worse functional outcomes.

DISCUSSION

Despite the high complication rate, functional recovery was similar to that reported in previous case series, including after arthroplasty. Furthermore, the rate of mechanical complications was lower. Thus, our working hypothesis was confirmed.

LEVEL OF EVIDENCE

Level IV retrospective non-comparative study.

Characteristics of Spanish articles of "scientific quality" cited in clinical practice guidelines on mental health

INTRODUCTION

The study aims to illustrate the impact of Spanish research in clinical decision making. To this end, we analysed the characteristics of the most significant Spanish publications cited in clinical practice guidelines (CPG) on mental health.

MATERIAL AND METHODS

We conducted a descriptive qualitative study on the characteristics of ten articles cited in Spanish CPG on mental health, and selected for their "scientific quality". We analysed the content of the articles on the basis of the following characteristics: topics, study design, research centres, scientific and practical relevance, type of funding, and area or influence of the reference to the content of the guidelines.

RESULTS

Among the noteworthy studies, some basic science studies, which have examined the establishment of genetic associations in the pathogenesis of mental illness are included, and others on the effectiveness of educational interventions. The content of those latter had more influence on the GPC, because they were cited in the summary of the scientific evidence or in the recommendations. Some of the outstanding features in the selected articles are the sophisticated designs (experimental or analytical), and the number of study centres, especially in international collaborations. Debate or refutation of previous findings on controversial issues may have also contributed to the extensive citation of work.

CONCLUSIONS

The inclusion of studies in the CPG is not a sufficient condition of "quality", but their description can be instructive for the design of future research or publications.

Survivin in adrenocortical tumors - pathophysiological implications and therapeutic potential

Treatment options for adrenocortical carcinoma (ACC) are very limited. In other solid tumors, small vaccination trials targeting the anti-apoptotic molecule survivin suggested immunological and clinical benefit in selected patients. Therefore, we investigated whether survivin might be a suitable target for immunotherapy in ACC. Survivin mRNA and protein expression was assessed in adrenal tissue specimens [by real-time-PCR in 29 ACC, 24 adrenocortical adenomas (ACA) and 12 normal adrenal glands; by immunohistochemistry in 167 ACCs, 15 ACA, and 5 normal adrenal glands]. Expression was correlated with clinical outcome using Kaplan-Meier and Cox regression analyses. The anti-apoptotic role of survivin was investigated in the SW13 ACC cell line using survivin siRNA. The presence of spontaneous survivin specific T-cells in peripheral blood was assessed by FACS dextramere staining in 29 ACC patients in comparison to healthy controls. Survivin mRNA in ACC was significantly overexpressed when compared with ACA or normal adrenal glands. Immunohistochemistry confirmed survivin protein expression in 97% of the ACCs. In 83% of samples, staining was moderate or high and clinical outcome in this subgroup showed a trend towards poorer prognosis [hazard ratio for death 2.28 (95% CI 0.99-5.28); p=0.053]. Survivin knockdown in SW-13 cell significantly increased the rate of apoptosis. Finally, spontaneous survivin-reactive T cells were detectable in 3 of 29 ACC patients. In conclusion, our data suggest that survivin could play an important role in the anti-apoptotic mechanisms in ACC and provide first hints that targeting survivin might be an interesting new therapeutic approach in this rare disease.

Complex fractures of the distal humerus in the elderly: is primary total elbow arthroplasty a valid treatment alternative? A series of 20 cases

INTRODUCTION

Distal humerus fractures are fairly rare. But as our population ages, these fractures become more complex and the choice of treatment more delicate. Poor bone quality results in many technical problems and the fixation hardware stability remains at risk. The goal of this study was to evaluate the functional recovery and morbidity of complex distal humerus fractures in elderly patients when treated with elbow prosthesis.

HYPOTHESIS

Good functional recovery can be achieved with a total joint replacement.

PATIENTS AND METHODS

This series consisted of 20 patients (18 women and two men) having an average age of 80years (range 65-93, median 80). Based on the AO classification, there were two Type A2 fractures, two Type B fractures, 15 Type C fractures and one fracture that could not be classified because of previous rheumatoid disease history at this elbow. Two fractures were open. In two cases, the olecranon was also fractured. Treatment consisted of the implantation of a Coonrad-Morrey, hinge-type total elbow prosthesis (Zimmer(®), Warsaw, IN, USA). The Mayo Clinic surgical approach was used 17 times and the transolecranon approach was used three times. Primary arthroplasty was performed in 19 cases and the surgery was performed after six weeks of conservative treatment (diagnostic delay) in one case. Unrestricted motion was allowed after surgery, but a maximum of 0.5kg could be carried during the first 3months; this was subsequently increased to 2.5kg.

RESULTS

Fifteen of the 20 patients were available for reevaluation with an average follow-up of 3.6years (range 1.7-5.5, median 3.4). Four patients had died and one was lost to follow-up. The average range of motion was 97° (range 60-130°), comprising an average flexion of 130° (range 110-140°) and average loss of extension of 33° (range 0-80°). Pronation and supination were normal. The average Mayo Elbow Performance Score (MEPS) was 83 (range 60-100, median 80). X-rays revealed seven cases of radiolucent lines, with two being progressive. There was no visible wear of the polyethylene bushings at the hinge. Six patients had moderate periarticular heterotopic ossification. The two cases of olecranon osteotomy and one case of olecranon fracture had healed. There were no surgical site infections but two cases of ulnar compression, one of which required neurolysis. There was one case of humeral component loosening after 6years, but the implant was not changed.

DISCUSSION

The clinical range of motion results were comparable to published data. The functional scores were slightly lower, mainly because of the pain factor. The initial results were encouraging and consistent with published data as long as the indications were well-chosen. Based on this retrospective study, total elbow arthroplasty can be a valid alternative in the surgeon's treatment armamentarium for complex distal humerus fractures in elderly patients who have moderate functional demands. Our results support our hypothesis, since we found good functional recovery without associated morbidity.

LEVEL OF EVIDENCE

Level IV retrospective study without comparator.

Early surgical site infection in adult appendicular skeleton trauma surgery: a multicenter prospective series

INTRODUCTION

Surgical site infections (SSI) studies rely on an imprecise and debatable definition. The term "wound healing problems" (WHP), not necessarily septic, is also frequently cited. This study had the objectives of determining the frequency of early SSIs in traumatology, these terms eventual correlation, and the factors influencing onset.

PATIENTS AND METHODS

A multicenter prospective observational study was conducted in 12 centers. The exclusion criteria were open lesions as well as multiple injuries and multiple fractures (more than two fractures treated surgically). All patients were followed for the first three postoperative months until there was clinical certainty of healing and absence of infection. The presence of any WHP or SSI required a minimum follow-up of 1 year. WHP and SSI risk factors were determined using logistical regression adjusted on the centers.

RESULTS

Out of 1617 cases, 103 were complicated by a WHP and 22 by a SSI. The SSIs were mainly secondary to Staphylococcus infections. The factors predisposing the patients to WHP and SSI (p≤0.05) were age; the NNIS, ASA, and Parker scores; alcoholism; antiaggregant use; and the locoregional aspect at the time of injury. The 522 subcutaneous osteosyntheses "near the skin" resulted in 58 WHPs (11%) and 14 SSIs (2.7%); 13 of the 58 WHPs (22%) resulted in one SSI. Out of 707 deep osteosyntheses, 24 (3.4%) presented a WHP and seven (1%) a SSI; Four SSIs originated from a WHP. The 352 fractures of the trochanter were complicated by a WHP in 15 cases (5.5%) and a SSI in one case (0.4%) after interlocked nailing and two WHPs and two SSIs (2.5%) after screw and plate fixation. Of the 388 first-line arthroplasties, only the prostheses implanted for a proximal femur fracture presented complications: 21 WHPs (6%) and one SSI (0.02%). Of the 103 WHPs of the entire series, 18 became SSIs. In absence of WHP, the SSI rate was 0.2%, whereas the probability of a WHP evolving toward a SSI was 100 times higher. The only factor significantly associated with a WHP becoming a SSI was osteosynthesis material exposure.

DISCUSSION

This prospective study can be criticized on several points: the deliberately limited inclusion criteria, the short follow-up, and the possible subjectivity of the data collection. The SSI rates reported are for the most part in agreement with the literature. This study is innovative in traumatology given the large number of patients and the notion of WHP that was preferred over superficial infection. It demonstrates the relations between WHP and SSI, in particular for osteosyntheses near the skin.

LEVEL OF EVIDENCE

Level III.

Advantage and limitations of a minimally-invasive approach and early weight bearing in the treatment of tibial shaft fractures with locking plates

OBJECTIVES

Intramedullary nailing is a common method of treating tibial shaft fractures. However, precise control of reduction at the proximal and distal quarters is difficult to achieve. The purpose of this study was to assess the results of plating using locking screws and the feasibility of a minimally-invasive approach.

PATIENTS/PARTICIPANTS

All patients with tibial shaft fracture treated by means of locking plates from January 2004 to October 2006. Thirty-two fractures were treated in 32 patients with a mean age of 43.8 years.

INTERVENTION

Internal fixation with a locking plate and screw construct, using a minimally-invasive or standard approach.

MAIN OUTCOME MEASUREMENTS

Surgical approach, time to weight bearing, complications and their type, time to bone union, alignment in the frontal and sagittal planes on anteroposterior and lateral radiographs.

RESULTS

The minimally-invasive approach was performed in 28 cases and immediate full weight bearing allowed in 25 cases. At a mean follow-up of 27 months, two patients had died and two patients were lost to follow-up. The mean time to bone union was 9.1 weeks. Four cases had a complicated course: one infection, one compartment syndrome, one hardware breakage and one pseudarthrosis. Six cases ended up with valgus malunion exceeding 5° in the frontal plane, already present at the time of surgery.

CONCLUSION

Where a minimally-invasive approach can be performed, immediate pain-free weight bearing can be allowed without further displacement at follow-up. The observed rate of malunion underlines the need for adequate reduction and shows that the rationale for success does not solely depend on the plate anatomic design but also on the skills of the operating surgeon.

SETTING

Level I university regional hospital Cohort study.

Dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. A prospective, systematic, multicenter study with specific focus on postoperative dislocation

INTRODUCTION

Displaced fractures of the femoral neck in the elderly are best treated with arthroplasty. The type of arthroplasty to be used, either hemi- or total hip arthroplasty, remains controversial as total hip replacements potentially have a higher rate of dislocation.

HYPOTHESIS

Dual mobility cups have a low dislocation rate when used to manage acute fractures of the femoral neck.

PATIENTS AND METHODS

In a multicenter prospective study conducted in France over an inclusion time of 3 months, all displaced fractures of the femoral neck treated with arthroplasty were operated on with insertion of a dual mobility cup. Patients had clinical and radiological assessment at 3, 6, and 9 months postoperative.

RESULTS

Two hundred and fourteen hips in 214 patients with a mean age of 83 years (range, 70-103 years) were included. None of the patients was lost to follow-up. The mortality rate after 9 months was 19%. Two patients (1%) had early postoperative infection successfully treated with lavage and antibiotics. Three patients (1.4%), operated through a posterior approach, presented one postoperative dislocation, all of which were posterior. Reduction was performed through closed external manipulation under general anesthesia. There was no recurrence of dislocation.

DISCUSSION

This low rate of dislocation after acute total hip replacement using dual mobility design cups favorably compares with hemiarthroplasties. Dual mobility cups might therefore be considered a valuable option to prevent postoperative dislocation when treating displaced intracapsular fractures of the proximal femur in elderly patients if a total hip replacement is recommended. Further study is needed before extending the indications for total hip arthroplasty following a fracture of the femoral neck, to assess the potential cost and complications of a longer procedure with its potential acetabular complication, and weigh them against the potential benefits.

Reliability of locked plating in tibial plateau fractures with a medial component

BACKGROUND

Tibial plateau fractures are notoriously difficult to manage, particularly when there is a medial or posteromedial component. We report a retrospective analysis of our experience with consecutive tibial plateau fractures including a medial component that were managed using a single lateral locking plate.

HYPOTHESIS

Tibial plateau fractures with a medial component can be effectively managed using a single lateral locking plate.

MATERIALS AND METHODS

From January 2005 to December 2008, 20 patients (ten women and ten men, mean age 47 years) were managed for tibial plateau fractures having a medial component, including five Schatzker IV, five Schatzker V, and ten Schatzker VI. One patient had an open fracture. A single lateral anatomically contoured locking compression plate (LCP™) was used with or without additional isolated screws. Mobilization was started immediately after the procedure, and non-weight-bearing was maintained for at least 6 weeks.

RESULTS

All patients were followed until healing. A final evaluation was available for 13 patients after a mean of 39.1 months (12-72); five patients were lost to follow-up and two died. Early revision was needed in one patient for 20° malreduction within the fracture site. We recorded one case each of deep vein thrombosis, superficial infection, knee stiffness, and spontaneously regressive common fibular nerve dysfunction. At final evaluation (n=13), mean range of motion was 0°/2°/130° with a mean Lysholm score of 94.1 (73-100) and a mean HSS score of 93.6 (74-99). All previously employed patients returned to work at the same level after a mean of 4.5 months. Mean healing time (n=20) was 10 weeks (6-12). Initially, articular step-offs greater than 2mm were noted in five patients. At healing, no further displacements or aggravation of articular step-offs were recorded. The reductions remained stable over time. At final evaluation (n=13), mean tibiofemoral mechanical angle was 179.7° (176-184) and no patients had evidence of osteoarthritis.

DISCUSSION

The radiological and clinical outcomes in our patients were satisfactory. A single lateral locked plate ensured stable reduction of tibial plateau fractures with a medial component. Biomechanical studies of these fractures have provided conflicting data on the stability of reduction using single plate systems. However, previously reported clinical outcomes are similar to those found in our study and support the effectiveness of favouring the use of single locking plate fixation.

LEVEL OF EVIDENCE

Level IV, noncomparative retrospective study.

Periprosthetic femoral fractures treated by locked plating: feasibility assessment of the mini-invasive surgical option. A prospective series of 36 fractures

INTRODUCTION

The treatment of periprosthetic femoral fractures by conventional plating is associated with problems related to fracture union and eventual refracture. Additionally, locking nailing cannot be used in all cases because of the risk of malunion. To resolve these issues, locking plates have been proposed to combine the advantages of closed reduction and internal fixation while achieving a higher quality reduction with plate fixation.

HYPOTHESIS

Locking plates put into place by a mini-invasive surgical approach result in fixation without substantial misalignment or non-union.

PATIENTS AND METHODS

From June 2002 to December 2007 we prospectively treated 35 patients (one bilateral), 28 women and seven men with a fracture around the hip implant (21), around the knee (8), between the hip implant and the knee (2), between a trochanteric internal fixation device and the knee implant (5). The mean age was 76, (39-93). Internal fixation was always attempted by mini-invasive surgery using locking plate system with locking screws (Synthès™). Rehabilitation included immediate weight bearing with as much weight as the patient would tolerate. The preoperative Parker score was 5.25 (0-9).

RESULTS

There was one patient lost to follow-up, one early failure, and seven deaths (four of whom were included in the study group since their follow-up was at least 24 months) for a total of 31 fractures (30 patients), the mean follow-up for the series was 26 months (6-67). Twenty-six fixations were performed by mini-invasive approach and 10 through a conventional open surgery. Patients applied full weight (n=20), partial weight (n=3) or no weight for 6 weeks (n=13). Infections developed in two patients and there were three cases of mechanical failure. Fracture union was achieved in 35 out of 36 cases. More than 5° of misalignment was observed in five patients. Loosening of the implant did not occur in any patients during follow-up. The Parker score in patients seen at follow up was 4.3 (0-9).

DISCUSSION-CONCLUSION

Locking compression plates associated with a mini-invasive surgical approach result in a high rate of union (35/36) with no significant misalignment (only 5/36 cases of misalignment of more than 5°), no refractures (n=0) and a low rate of mechanical failure (3/36) while allowing full weight bearing in most cases (20/36). Locking plates for periprosthetic femoral fractures allow patients to begin walking again, with stable intermediate term results.

Minimally-invasive fixation of distal extra-articular femur fractures with locking plates: limitations and failures

Minimally-invasive fixation using a locking plate and early motion is normal practice. However, technical errors and pitfalls are common. This surgery has a set of rules that encompass both the mechanics of the internal fixation system and the implantation itself. If these rules are not strictly followed, alignment defects and/or early failure of the fixation can occur. We analysed four cases of clinical failure that were encountered after minimally-invasive distal femoral extra-articular fixation with locking plates. The following rules must be followed with this technique: extra-articular fracture, minimally-invasive approach, long plate alternating between locking screw and empty hole (five holes on either side of fracture), bi-cortical screws, placement of locking screws near a complex fracture but away from a simple fracture. Osteoporotic bone, obesity that interferes with the instrumentation, articular fracture, horizontal fracture line and surgeon experience are all limitations of this minimally-invasive technique.

[Recurrent pericardial effusion as first manifestation of Erdheim-Chester disease]

HISTORY AND ADMISSION FINDINGS

A 65-year-old woman presented with reduced general condition and dyspnoea that was progressive over the last months. Clinical findings revealed an exophthalmus on the right, xanthelasm and mild peripheral oedema. Previously, a pericardiocentesis had been performed due to a large pericardial effusion. A previous CT scan showed a mass attached to the pericardium extending through the atrio-ventricular groove and a thickened aorta. In addition, a retroperitoneal fibrosis and an occlusion of both Aa. iliacae internae were found.

INVESTIGATIONS

The ECG showed sinus rhythm. Laboratory findings demonstrated a microcytic anemia and a renal failure. Chest radiography showed a large cardiac silhouette, while the transthoracic echocardiography revealed a recurrent large pericardial effusion. A PET/CT scan of the chest and abdomen showed a tissue infiltration of the retroperitoneal structures, a mass surrounding the right coronary artery and the right orbita. Finally, a femur biopsy confirmed the diagnosis of Erdheim-Chester disease.

DIAGNOSIS, TREATMENT AND COURSE

With the diagnosis Erdheim-Chester disease we started a high dose immunsuppressive therapy using glucocorticoids and interferon-a. Tumour size slightly decreased during the following 2 months, however the patient developed a severe urosepsis and died from multiorgan failure.

CONCLUSIONS

We report a case of an Erdheim-Chester disease with cardiovascular involvement primarily diagnosed due to a recurrent large pericardial effusion. In case of cardial tumors with interatrial septum or coronary artery involvement together with cerebral manifestations, an Erdheim-Chester disease should be taken into account.

Reversed anatomic distal femur locking plate for periprosthetic hip fracture fixation

The incidence of femoral fracture on hip prosthesis is increasing. Plate fixation is the method of choice when the prosthesis is stable. In fracture with proximal extension, the quality of the bone fixation is critical and, despite the development of anatomic plates, may be endangered when there are too few proximal screws. To resolve this issue, we recommend using a reversed LCP™ anatomic distal femoral Less Invasive Stabilization System (LISS™) locking plate: e.g., a left distal femoral plate for femoral fracture on right-hip implant. This presents several advantages: minimally invasive surgery, the introduction of the plate being facilitated by the LISS™ ancillary; ease of locking, also thanks to the ancillary; and, above all, multiple proximal trochanteric fixation thanks to the form of this anatomic distal LISS™ plate, improving proximal bone fixation. The present technical note seeks to illustrate the interest of using a "reversed" plate, in terms of simplicity of fitting and quality of reduction and consolidation, while also specifying the associated limitations and tolerance.

Survivor of a traumatic atlanto-occipital dislocation

Atlanto-occipital dislocation is a devastating ligamentous injury that most often turns fatal. However, because of on-site resuscitation improvements, the emergency teams are increasingly dealing with this condition. We report a rare case of atlanto-occipital dislocation (AOD) in a surviving patient with more than one-year follow-up. The mechanism of injury appears to be an extreme hyperextension applied to the head. This injury occurs more frequently in children since they are anatomically predisposed (flat articulation between the occiput and the atlas, increased ligamentous laxity). The diagnosis should be suggested by severe neurological injury after high trauma but also post-traumatic cardiorespiratory deficit. There have been reports of atlanto-occipital dilocations without neurologic impairment. A radiographic examination must be performed and lateral cervical radiographs should be acquired. However, additional imaging with CT or MRI may be required to aid diagnosis of AOD in cases in which radiographic findings are equivocal. Once the diagnosis of AOD has been confirmed, an anatomical classification should be made according to the magnitude of displacement. Fatal lesions are of neurological and vascular origin and some authors advocate the systematic use of angiography. Consensus regarding the management of AOD in adults has been achieved. Occipito-cervical arthrodesis is the recommended treatment option. We advocate a two-stage surgery: the patient is initially fitted with a halo vest then occipitocervical fusion is performed. Surgical treatment should be combined with cardiorespiratory management. The emergency teams should get familiar with this injury since they will be increasingly confronted to it. Early recognition and standard appropriate management is essential to avoid delayed treatment and complications.

Minimally-invasive internal fixation of extra-articular distal femur fractures using a locking plate: tricks of the trade

Fractures of the distal femur are rare and occur in two distinct population categories: young patients after high energy traumas and elderly patients who fall from their full height, and often carry severe co-morbidities making especially difficult to manage theses complex injuries. In elderly patients the potential complications are numerous including infection, non-union and frequent function deterioration. We present a technique of minimally invasive internal fixation of the distal extra-articular femur using a locking plate and present the tricks of the trade to obtain successful reduction and achieve union. The hardware used includes plate fixation with a large fragment locking screw. This minimally invasive surgery combines stability of the internal fixation device with the principles of closed surgery, allowing early mobilization and immediate weight bearing to warrant good functional recovery.

[Autoimmune hepatitis: two case reports with different clinical courses - case 3/2011]

HISTORY AND CLINICAL FINDINGS

Case 1: A 46-year old female patient presented with a recently occurred icterus of unknown origin as well as dark urine and decolored stool. No diseases were found in the patient's medical history. Clinical examination showed no other findings exept from the icterus. Case 2: A 48-year old female patient was admitted to hospital with epigastric pain and icterus. Similar symptoms reoccurred regularly since several years. The patient already underwent cholecystectomy and an ERCP (endoscopic retrograde cholangiopancreaticography) that showed no pathological findings. She reported chronic pain in her finger joints and appearance of haematomas without adequate trauma.

CLINICAL INVESTIGATIONS

Case 1: We found highly elevated liver enzymes and bilirubin. Ultrasound examination was unremarkable.The laboratory examination showed a negative serology for hepatitis A, B and C, marked immunoglobulin G (IgG) elevation and hypergammaglobulinaemia. Liver biopsy and analysis of autoimmune antibodies were performed showing high titers of antinuclear antibodies (ANA) and smooth muscle antibodies (SMA). Case 2: We found a considerably reduced liver function with low albumin and prothrombin time, as well as a moderate elevation of liver enzymes and a high bilirubin. Ultrasound examination revealed hepatic parenchymal changes, splenomegaly, and ascites. Oesophagogastroduodenoscopy showed oesophageal varices I°. Serology for hepatitis A, B, and C was negative. Also in this case, a marked IgG elevation and hypergammaglobulinaemia were found. Liver biopsy was performed. Autoimmune antibodies (ANA and SMA) were detectable with high titers.

DIAGNOSIS, TREATMENT AND COURSE

In both cases, we diagnosed an autoimmune hepatitis by means of laboratory values, histological findings and detection of typical autoantibodies. Immediate therapy with high-dose prednisolone therapy was initiated (case 1: 60 mg/day; case 2: 100 mg/day), resulting in improvement of patients' condition, clinical findings and laboratory values in both cases. Case 1: The patient showed fast recovery under prednisolone and the further course was without any complications. Continuous therapy with 15 mg /day and clinical monitoring through day hospital was recommended. Case 2: We saw a slower recovery and prolonged reduced liver function with the necessity to substitute coagulation factors. Furthermore, the therapy of subsequent complications, such as surgical drainage of a haematoma, oedema, wound healing disorder and infections under prednisolone was necessary. Liver transplantation is planned if the disease progresses further.

CONCLUSION

Elevated liver enzymes should always be further investigated. Autoimmune hepatitis is a rare disease. Rapid response to immunosuppressive therapy, such as prednisolone, is characteristic. Early diagnosis and therapy are essential for the patients prognosis. Liver transplantation is indicated in advanced disease.