Epidemiology of limb trauma interventions in France: Current state and future projections

CONTEXT

The distributions and projections of trauma, treated according to the anatomical region, have not been studied in France. The objectives of this study were to obtain French epidemiological data specific to trauma procedures in orthopedic surgery, as well as to establish a statistical trend on the evolution of medical and surgical procedures resulting from this, since 2013 and over the years to come. Our hypothesis was that an increasing trend in trauma procedures since 2013 exists, with an epidemiological forecast of a continuing increase over 50 years, mainly in the context of the management of osteoporotic fractures related to the ageing French population.

MATERIAL AND METHODS

We conducted a retrospective study using national data to obtain completion of procedures between the start of 2013 and the end of 2021.

RESULTS

From 2013 to 2021, we noted a total of 5,216,567 procedures related to orthopedic traumatology for an average of 579,618 procedures per year. We noted an overall increase in all procedures, continuing from 2013 to 2019, with an average annual increase of 1.125%. The most commonly performed procedure was osteosynthesis, with an average of 276,989 procedures per year. This was followed by wound sutures with an average of 185,023 procedures, orthopedic reductions of fractures and/or dislocations at an average of 62,960, then arthroplasties with 25,425 procedures per year, musculotendinous ruptures were 19,755 procedures per year, surgical reductions of fractures and/or dislocations represented 6920 procedures per year, and fasciotomies with 2848 procedures. From 2013 to 2021, there was an annual average of 276,989 osteosynthesis procedures. Open osteosynthesis, with an average of 146,547 procedures per year, represented 55% of osteosynthesis procedures. Fractures of the proximal end of the femur represented 79,549 procedures on average per year, including 46,621 (58%) involving the trochanter, while 32,852 (41%) were of the femoral neck. Wrist fractures accounted for an annual average of 55,300. Hand fractures represented an annual average of 38,444, of which 52.2% were closed (17,778). On average, 1000 fractures per year involved the carpus without scaphoid involvement, and 2177 scaphoid fractures. Ankle fractures represented 37,951 procedures on average per year, including 74% of the malleolar complex (28,199). Leg fractures represented 17,613 procedures per year, 58% tibial diaphysis (10,091), 41% tibial plateau (6,857). The strengths of this study are the exhaustiveness of the data, presenting all the Common Classification of Medical Procedures (CCAM) chosen during the defined period.

CONCLUSION

This study allowed us to establish, to our knowledge, the first epidemiological database of French orthopedic traumatology.

LEVEL OF EVIDENCE

IV; epidemiological descriptive study.

Does a sign restricting operating room access reduce staff traffic in the surgical department?

INTRODUCTION

Infections following orthopedic surgery are rare but difficult to treat. Among the prevention measures reviewed during the Musculoskeletal Infection Society's (MSIS) 2023 international consensus meeting, the only strategy to obtain 100% agreement was the control of traffic in and out of the operating room (OR). Although this recommendation makes good sense, to our knowledge, it has not been previously investigated in a comparative study. We, therefore, conducted a prospective, observational, before-and-after study of the implementation of an informational sign designed to limit traffic in and out of the OR to (1) determine its impact on door openings and the number of people present during orthopedic surgery and (2) assess the risk of surgical site infection after the institution of this sign.

HYPOTHESIS

This type of sign reduces the number of door openings.

MATERIALS AND METHODS

This prospective, observational study included all patients operated on in one of our ORs over a 6-week period. The number of entrances and exits from the OR and how long the doors were kept open were recorded during the entire study period. After 3 weeks, an informational sign was posted on the OR doors warning people that unnecessary traffic in and out of the OR increases the risk of infection. During this period, we also recorded the type of procedure, operative time, the number of people in the OR at the time of the incision, and the number of entrances and exits. Patients underwent a follow-up at 2 years to check for postoperative infection. The primary endpoint was the number of OR door openings, and the secondary endpoint was the number of infections at 2 years postoperatively.

RESULTS

The 2 groups (before and after the implementation of the sign) were homogeneous. The average total number of door openings for all ORs was 28.9±19.6 [2-90]. In the no sign group, it was 33.3±20.9 [3-90], and in the sign group, it was 21.0±14.7 [2-50] (p=0.011). The maximum number of people in the OR at one time was 8.32±1.84 [4-12] in the no sign group and 8.44±1.98 [5-12] in the sign group (p=0.8). There were 3 postoperative infections at the 2-year follow-up, all occurring in the no sign group. The infection rate was 6.4% (3/47) in the no sign group versus 0% (0/25) in the sign group (p=0.197).

DISCUSSION

Our prospective study demonstrated a simple strategy to reduce the number of entrances and exits, the number of people in the OR, and potentially the risk of surgery-related infection. Another larger-scale study is needed to assess the exact impact of this type of sign, particularly on the risk of infection.

LEVEL OF EVIDENCE

III; prospective non-randomized comparative study.

Unipolar Hip Hemiarthroplasty in Geriatric Patients: A Prospective Study and Analysis of Clinical and Radiological Outcomes

Introduction

Femoral neck fractures (FNF) in the geriatric population are commonly treated with hip replacement procedures, such as total hip arthroplasty, unipolar hip hemiarthroplasty (UHA), and bipolar hip hemiarthroplasty (BHA). The optimal treatment remains controversial, considering outcomes and cost-effectiveness, with UHA often being cheaper. This prospective observational study aims to evaluate UHA's clinical and radiological outcomes, safety, and survivorship compared to existing literature.

Methods

We followed 90 elderly patients who underwent UHA following FNF. We assessed patients using the Parker score before and after surgery, as well as Harris Hip Score (HHS), and Postel-Merle d'Aubigné (PMA) scores postoperatively. All complications, acetabular erosions and heterotopic ossifications (HO), were documented.

Results

One year post-surgery, 26.7% of patients had passed away, mostly due to declining general health status. Systemic complications occurred in 14.4% of cases, with a 1.1% rate of deep surgical site infections. A single dislocation resulted from excessive stem anteversion. UHA implant survival rate was 97.8% after 4 years. The Parker score remained stable, and HHS at 6 and 12 months was 71.5 ± 12.9 and 70.9 ± 11.8, respectively, while PMA score was 14.3 ± 2.4 and 14.5 ± 2.1, respectively. Five hips showed Baker I acetabular wear. HO were noted as Brooker I in 12 patients, II in 4 patients, and IV in 1 patient.

Discussion

UHA exhibited comparable systemic complication rates, implant survivorship, and dislocation rates to those in the literature for both UHA and BHA. The deep surgical site infection rate was lower than reported for BHA. Patients' functional and mental abilities did not decline based on clinical scores. Acetabular wear in UHA was similar to its bipolar counterpart, while HO were only minor findings with no clinical implications.

Conclusion

In elderly patients, UHA demonstrated clinical and radiological outcomes similar to BHA in existing literature. UHA may represent a cost-effective alternative for patients with limited life expectancy.

Assessment and trends in the methodological quality of the top 50 most cited articles in shoulder arthroplasty

INTRODUCTION

Shoulder arthroplasty is increasingly frequent, and the associated literature is abundant. Citation rate is often considered a good means of assessing impact and scientific value. However, analysis of methodological quality is also essential in evidence-based medicine.

OBJECTIVES

(1) To identify the 50 most cited articles on shoulder arthroplasty, and (2) to assess the correlation between citation rate and methodological quality. The study hypothesis was that there is no correlation between citation rate and methodological quality.

METHOD

Articles were retrieved from PubMed and Google Scholar, identifying the 50 most cited articles on shoulder arthroplasty via the keywords "shoulder joint replacement", "shoulder arthroplasty", "anatomic shoulder prothesis", "reverse shoulder prothesis", and "glenohumeral arthritis". Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS) were calculated.

RESULTS

Mean citation rate for the 50 articles was 312.4±169.5 (range, 151-841.5), with a mean citation density of 18.8±10.6 (range, 4.7-46.7). 56% of the studies (28/50) were retrospective case series with level of evidence IV. There was no correlation between citation rate and methodological quality.

DISCUSSION

The 50 most cited articles on shoulder arthroplasty mostly showed low levels of methodological quality. There was no correlation between citation rate and methodological quality: the literature needs to be read with a critical eye.

LEVEL OF EVIDENCE

IV.

The acute inflammatory response to copper(II)-doped biphasic calcium phosphates

Infection and inflammation are two key features to consider to avoid septic or aseptic loosening of bone-implanted biomaterials. In this context, various approaches to fine-tune the biomaterial's properties have been studied in order to modulate the crosstalk between immune and skeletal cells. Cation-doping strategies for tuning of calcium phosphates properties has been evidenced as a promising way to control the biomaterial-induced inflammatory process, and thus improving their osteoimmunomodulatory properties. Copper(II) ions are recognized for their antibacterial potential, but the literature on their impact on particulate material-induced acute inflammation is scarce. We synthesized copper(II) ions-doped biphasic calcium phosphate (BCP), intended to exhibit osteoimmunomodulatory properties. We addressed in vitro, for the first time, the inflammatory response of human primary polymorphonuclear neutrophils (PMNs) to copper(II) ions-doped or undoped (BCP) powders, synthesized by an original and robust wet method, in the presence or absence of LPS as a costimulant to mimic an infectious environment. ELISA and zymography allowed us to evidence, in vitro, a specific increase in IL-8 and GRO-α secretion but not MIP-1β, TNF-α, or MMP-9, by PMNs. To assess in vivo relevance of these findings, we used a mouse air pouch model. Thanks to flow cytometry analysis, we highlighted an increased PMN recruitment with the copper(II) ions-doped samples compared to undoped samples. The immunomodulatory effect of copper(II) ions-doped BCP powders and the consequent induced moderate level of inflammation may promote bacterial clearance by PMNs in addition to the antimicrobial potential of the material. Copper(II) doping provides new insights into calcium phosphate (CaP)-based biomaterials for prosthesis coating or bone reconstruction by effectively modulating the inflammatory environment.

Single-use versus reusable ancillaries for dual mobility cup in total hip replacement. A prospective randomized short-term safety and feasibility comparison

BACKGROUND

Single-use (SU) ancillaries for cup preparation in total hip arthroplasty (THR) aim to reduce the costs of hip replacement surgery. These devices have been recently introduced, but their safety and feasibility have not been studied. Therefore, we performed a prospective randomized study aiming to assess the impact in our department of using these SU ancillaries versus standard reusable ancillaries for dual mobility THR regarding 1) the cost, 2) operative time, 3) quality of primary fixation.

HYPOTHESIS

We hypothesized that the use of SU ancillaries for acetabular preparation would reduce maintenance costs, and so optimise the operating procedure, reduce the overall cost of surgery, save time, while maintaining the same quality of prosthesis fitting.

METHOD

We conducted a randomised, controlled, open-label, two-arm, single-centre, prospective therapeutic trial with a medico-economic objective. Inclusions were made prospectively from patients hospitalised and surgically managed in our department for arthrosis over 18 years old treated with dual mobility THR.

RESULTS

In the current study, 18/20 (90%) of the cases required the use of one SU reamer when using SU ancillaries. Only two cases (10%) required a second SU reamer (without SU failure regarding the acetabular implant) because there was too much subchondral bone left and not enough cancellous bone allowing correct cup fitting. We also found that the test implant supplied in the SU kit had a less secure press-fit than the reusable metal test implants. There was one of primary press-fit failure in the SU group requiring a different cup with additional screws. The estimated cost to the supplier per procedure was 20,105 euros using single-use reamers versus 26,666 euros using conventional ancillary kits, a saving of 6561 euros (p<0.001). For the healthcare institution, the median price per intervention on the differentiating points was 2648 euros versus 2580 euros, with no significant difference (p=0.297). The results show an average societal cost of 52,199 euros using single-use and 53,572 euros using reusable ancillary equipment, with a significant difference between the two groups (p<0.003). The average cost of Healthcare Risk Waste (HCRW) disposal in the SU group was 5.2 euros per intervention against 5.1 euros in the RU group, without significant difference (p=0.910). We found a similar result for the cost of disposal of non-HCRW waste per procedure: 0.37 euros in the SU group versus 0.34 in the RU group, without significant difference (p=0.345).

CONCLUSION

SU ancillaries significantly reduce the table set up time and have the potential to facilitate time and cost savings but further research is needed in this direction. Our study shows that the daily workload, operating times, and the number of boxes of instruments to be sterilised are decreased. The associated environmental gain is significant. Nevertheless, the economic promise of these SU ancillaries is only partially supported in this trial owing to the small number of patients. Further work will be needed to obtain a more powerful medico-economic assessment of this promising ancillary product.

LEVEL OF EVIDENCE

II; prospective randomized study.

Growth progression of anterior cruciate ligament bone grafts in a pediatric population: magnetic resonance imaging analysis

BACKGROUND

In children, the incidence of anterior cruciate ligament (ACL) ruptures and reconstructions has significantly risen. Unfortunately, re-rupture rates following surgery are substantially higher in children than adults. Previous research suggests that smaller graft diameters are predictive of re-rupture.

OBJECTIVE

This study aimed to investigate the growth progression of the ACL bone graft, specifically in terms of width and length, within the intra-articular portion and tunnels, using successive magnetic resonance imaging (MRI) scans. The hypothesis was that the ACL grafts would undergo thinning during growth.

MATERIALS AND METHODS

The cohort comprised 100 patients who underwent ACL reconstruction. Among them, 37 patients with significant residual growth were selected for analysis. Of these, 4 patients experienced graft rupture, 5 had "over-the-top" techniques, 12 had missing MRI scans and 5 were lost to follow-up. Each included patient underwent two MRI scans; the analyses of which were conducted in a double-masked manner.

RESULTS

A total of 13 knees (and patients) were analyzed, with a mean ± SD (range) delay of residual growth between the two MRI scans of 3.3 + / - 1.4 (1.2-5.2) years. The graft exhibited elongation, thinning and eventual integration with the surrounding bone in the tunnels. Within the intra-articular portion, the mean [95% CI] increase in graft size between the two MRI scans was 30.8% in length and 14.8% in width. The width/length ratio in the intra-articular part was 20.4% on the first MRI and 20.8% on the second MRI. Since this difference in the ratio (+ 0.4%) was not statistically significant (P=0.425), our results indicate that the grafts remained stable in terms of proportions without thinning or thickening. Therefore, the initial hypothesis was validated for the tunnel portion but not the intra-articular portion of the grafts.

CONCLUSION

In children with open physes, ACL grafts demonstrate smooth growth progression in all dimensions. However, this finding does not fully explain the high rate of re-rupture observed in children. Further research is needed to elucidate the underlying factors contributing to re-rupture in this population.

In vitro osteoblast activity is decreased by residues of chemicals used in the cleaning and viral inactivation process of bone allografts

Allograft bone tissue has a long history of use. There are two main ways of preserving allografts: by cold (freezing), or at room temperature after an additional cleaning treatment using chemicals. These chemicals are considered potentially harmful to humans. The aim of the study was (i) to assess the presence of chemical residues on processed bone allografts and (ii) to compare the in vitro biocompatibility of such allografts with that of frozen allografts. The presence of chemical residues on industrially chemically treated bone was assessed by high performance liquid chromatography (HPLC) after extraction. Biocompatibility analysis was performed on primary osteoblast cultures from Wistar rats grown on bone disks, either frozen (F-bone group) or treated with supercritical carbon dioxide with no added chemical (scCO2-bone group) or industrially treated with chemicals (CT-bone group). Cell viability (XTT) was measured after one week of culture. Osteoblastic differentiation was assessed after 1, 7 and 14 days of culture by measuring alkaline phosphatase (ALP) activity directly on the bone discs and indirectly on the cell mat in the vicinity of the bone discs. Residues of all the chemicals used were found in the CT-bone group. There was no significant difference in cell viability between the three bone groups. Direct and indirect ALP activities were significantly lower (-40% to -80%) in the CT-bone group after 7 and 14 days of culture (p < 0.05). Residues of chemical substances used in the cleaning of bone allografts cause an in vitro decrease in their biocompatibility. Tissue cleaning processes must be developed that limit or replace these chemicals to favor biocompatibility.

Does metaphyseal modularity in femoral revision stems have a role in treating bone defects less severe than IIIB? Clinical and radiological results of a series of 163 modular femoral stems

INTRODUCTION

Revision for loosening of femoral stems requires an extensive analysis of bone defects to determine the most appropriate course of action. The drawbacks of using modular stems are that they can break or corrode at their junction. They have rarely been evaluated based on the extent of bone loss and particularly in patients with less severe bone loss. This led us to carry out a retrospective study to analyze modular femoral stems as a function of the initial bone defect (stage IIIB versus less severe in the Paprosky classification): 1) implant survivorship, 2) osteointegration and subsidence of the stem, and 3) breakage of implant.

HYPOTHESIS

Modular femoral stems can be used for all types of bone defects (not only IIIB) as the complication rate is identical.

PATIENTS AND METHODS

Between January 1, 1996, and December 31, 2016, 163 patients were included who had received a modular femoral revision stem. The minimum follow-up was 4 years; the mean was 6.7 years±3.3 [4-21]. One patient was lost to follow-up, 88 had died before the analysis date and 74 were still alive; however, 10 of them had the stem removed less than 4 years after implantation. Thus 64 patients were available for the clinical evaluation. There were 44% (72 patients) with Paprosky stage IIIB femoral bone loss and 56% (91 patients) with stage I, II or IIIA bone loss. The stem's bone integration was evaluated using the Engh and Massin score. All complications were documented.

RESULTS

The survivorship of the femoral stem was 93.75% (95% CI: 83.33-96.70) at 5 years with removal for any reason as the end point. There was no significant difference (p=0.0877) in survivorship relative to the severity of the initial bone loss: 89.84% (95% CI: 78.73-95.31) for stage IIIB; 95.23% (95% CI: 82.24-98.79) for stage IIIA; 97.06% (95% CI: 80.90-99.58) for stage II. Bone integration was considered as being achieved in 76% of stems based on available radiographs (119 of 156 patients) with the severity of bone loss having no effect. We found 18 instances of stem subsidence out of 156 stems with available data (11.5%). The mean subsidence was 14.7 mm ± 12.3 [5-40]. Among the 18 stems with postoperative subsidence, 13 had been implanted for stage IIIB defects, while 5 were for less severe defects (p=0.751). Two stem fractures occurred in patients with stage IIIB bone loss, thus 2/66 for stage IIIB and 0/86 in the less severe bone loss cases (p=0.188).

CONCLUSION

Modularity provides similar results no matter the severity of initial bone loss, without the risk of additional complications.

LEVEL OF EVIDENCE

IV, Retrospective study.

Magnetic bioactive glass nano-heterostructures: a deeper insight into magnetic hyperthermia properties in the scope of bone cancer treatment

Primary bone cancers commonly involve surgery to remove the malignant tumor, complemented with a postoperative treatment to prevent cancer resurgence. Studies on magnetic hyperthermia, used as a single treatment or in synergy with chemo- or radiotherapy, have shown remarkable success in the past few decades. Multifunctional biomaterials with bone healing ability coupled with hyperthermia property could thus be of great interest to repair critical bone defects resulting from tumor resection. For this purpose, we designed superparamagnetic and bioactive nanoparticles (NPs) based on iron oxide cores (γ-Fe₂O₃) encapsulated in a bioactive glass (SiO₂-CaO) shell. Nanometric heterostructures (122 ± 12 nm) were obtained through a two-step process: co-precipitation of 16 nm sized iron oxide NPs, followed by the growth of a bioactive glass shell via a modified Stöber method. Their bioactivity was confirmed by hydroxyapatite growth in simulated body fluid, and cytotoxicity assays showed they induced no significant death of human mesenchymal stem cells after 7 days. Calorimetric measurements were carried out under a wide range of alternating magnetic field amplitudes and frequencies, considering clinically relevant parameters, and some were made in viscous medium (agar) to mimic the implantation conditions. The experimental specific loss power was predictable with respect to the Linear Response Theory, and showed a maximal value of 767 ± 77 W g_Fe^-1 (769 kHz, 23.9 kA m^-1 in water). An interesting value of 166 ± 24 W g_Fe^-1 was obtained under clinically relevant conditions (157 kHz, 23.9 kA m^-1) for the heterostructures immobilized in agar. The good biocompatibility, bioactivity and heating ability suggest that these γ-Fe₂O₃@SiO₂-CaO NPs are a promising biomaterial to be used as it is or included in a scaffold to heal bone defects resulting from bone tumor resection.

Allograft and autograft provide similar retear rates for the management of large and massive rotator cuff tears: a review and meta-analysis

PURPOSE

Currently, autografts and allografts are largely used to treat large or massive rotator cuff tear (RCT), without any evidence in favour of one graft or the other. The purpose of this study was to determine the rate of retear of autograft and allograft in the treatment of large or massive posterosuperior RCT.

METHOD

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis of the results in the literature as well as the presentation of results. A search of the literature was performed in the electronic databases MEDLINE, Scopus, Embase, and the Cochrane Library. The quality of the included studies was evaluated according to the MINORS (Methodological Index for Nonrandomized Studies) score. Inclusion criteria were studies in English evaluating clinical and radiological results of surgical treatment with autograft or allograft for large or massive RCT since 2008. The main criterion was the retear rate of the graft assessed on MRI or US scan at 1-year minimum follow-up. Partial tear were classified as "tear".

RESULTS

The overall retear rate was 23.6% (15.5-32.7) at a mean follow-up of 18.4 ± 7.8 (12-36) months. There was no significant difference between the two kinds of graft, with a retear rate of 27.0% (15.4-40.2) and 20.9% (9.9-34.2) with autograft and allograft respectively (n.s.). Similar improvements of functional scores (+ 28.8 to 38.4 points for the Constant score, + 33.6 to 38.4 points for the ASES, and - 4.0 to - 4.1 points for pain-VAS) were reported in the two groups after at 27.2 ± 11.1 (12-48) months. The rate of complications except retear was 1.8% (0.2, 3.7) with autograft and 0.5% (0.8, 1.8) with allograft (n.s.).

CONCLUSION

The use of autograft and allograft for the treatment of large or massive RCT leads to similar retear rate and clinical outcomes at short to medium terms.

LEVEL OF EVIDENCE

Level IV.

French Hip & Knee Society classification of short-stem hip prostheses: Inter- and intra-observer reproducibility

INTRODUCTION

In total hip replacement (THR), a short stem theoretically provides more physiological force transfer to the proximal femur, conserves bone stock and facilitates minimally invasive surgery. On the other hand, such implants involve a learning curve and incur risk of malpositioning or fracture and of secondary mobilization. There are several types of short stem, and classification is needed. Classifications exist, but are based more on implant length than on anchorage zone, and most have not been tested for reproducibility. The French Hip & Knee Society (SFHG) developed a short-stem classification based on anchorage zone inside the femur. The objectives of the present study were: (1) to present the classification, (2) to apply it to the short-stem models available in France and those widely used worldwide, and (3) to assess reproducibility.

HYPOTHESIS

The SFHG short-stem classification enables reproducible comparison.

MATERIAL AND METHOD

A short-stem classification according to anchorage zone was drawn up by an expert group. The stems and the classification were presented to 12 surgeons performing THR, who classified the stems according to the classification; a retest was performed 2 months later.

RESULTS

The classification is based on femoral stem anchorage site, in 5 types: type 1, cephalic; type 2, isolated cervical; type 3, Calcar femorale; type 4, metaphyseal; and type 5, conventional metaphyseal-diaphyseal, with shortened stems. Inter-observer reproducibility was 92.7% [95%CI: 91.7%-93.6%], with kappa 0.785 [95%CI: 0.755-0.814], and Lin test-rest concordance correlation coefficient 0.852 [95%CI: 0.836-0.869]. Intra-observer reproducibility was 94.0% [95%CI: 91.9%-96.1%], with kappa 0.820 [95%CI: 0.759-0.882], and Lin test-retest concordance correlation coefficient 0.820 [95%CI: 0.792-0.849].

DISCUSSION

This new classification enables femoral implants to be reproducibly compared according to anchorage zone.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

What are the rates and validity of French authors' conflicts of interest disclosures in Orthopaedics & Traumatology: Surgery & Research? Analysis of the year 2017 with comparison versus the Transparence.sante.gouv.fr database

INTRODUCTION

Authors are responsible for their own Disclosure of Interests in submitting to Orthopaedics & Traumatology: Surgery & Research (OTSR). Disclosure may be incomplete or false, by deliberate or unintended omission. Omission may impact the analysis of results or at least the reader's perception of it. The rate of validity of disclosure in OTSR is not known, and we therefore conducted a bibliometric study on articles published in 2017, in order to: 1) determine the proportion of articles in which authors disclose interests; and 2), when interests are disclosed, to assess their validity by comparison against the Transparence.gov.fr database.

HYPOTHESIS

Disclosure rates exceed 75%.

MATERIAL AND METHOD

We analyzed all articles published in OTSR in 2017, and extracted those with at least one French author. We also analyzed data from the Transparence.gouv.fr corporate declaration database, for comparison with the authors' own disclosures in each article. Significant interest was defined by a €1000 threshold, although higher thresholds (>€5000, >€10,000 and >€100,000) were also investigated.

RESULTS

In 2017, 337 articles were published in OTSR, 210 of which had at least 1 French author. Of these, 201 (95.7%) had at least 1 author with significant interest (>€1000) according to the Transparence data. In 189 of these 201 articles (94%), authors had failed to disclose at least 1 direct or indirect conflict of interest. This omission rate fell to 22/45 (48.9%) for more substantial interests, which were more faithfully disclosed. At the €1000 threshold, in only 8/201 articles (4%) did authors disclose all their interests with perfect validity, but this rate increased up to 25/45 (55.5%) at higher thresholds. At the €1000 threshold, 66 of the 201 articles cited the trade-name of interest, resulting in 54/66 (82%) correct disclosure of direct interest; this rate increased up to 25/26 (96%) at higher thresholds.

DISCUSSION

At a threshold of €1000, the rate of complete and valid disclosure was 4% and the rate of omission 94%. At higher thresholds, rates were better, with just 48.9% omission and, above all, 55.5% validity, even if these rates were lower than hypothesized (75%). Authors and editors need to take greater care. Disclosures were often made, but incompletely, and authors need reminding that they must disclose not only interests related to the article in question but also all interests that might directly or indirectly influence their interpretation of the results reported, allowing readers to make up their own minds.

LEVEL OF EVIDENCE

IV; systematic retrospective study.

Results of slotted acetabular augmentation in adults with Crowe stage 1 and 2 hip dysplasia

To determine the survival of slotted acetabular augmentation in adult dysplasia, we reviewed all cases operated on between 2002 and 2020 with clinical and radiological assessment and a 2.63 year minimum of follow-up. Twenty-three patients were included, with 91% of Crowe 1 hip dysplasia. Seven patients underwent THA at a mean 6.0 ± 3.5 years; 15 retained SAA without THA at a mean 9.5 years' follow-up; 1 was lost to follow-up. There was a significant improvement in PMA and HHS scores, with decreased pain. WOMAC and SF12 quality-of-life scores were moderate due to frequent pain. The patients with preoperative osteoarthritis showed little progression at seven years 'follow-up. We concluded SAA is a corrective treatment for residual hip dysplasia. Its goal is to normalize joint loading by increasing the contact area and improving the lever arm of the hip. Its postponed onset of osteoarthritis and reduced pain, thereby allowing to postpone THA.

No Detectable Alteration of Inorganic Allogeneic Bone Matrix Colonizing Mesenchymal Cells: A Step Towards Personalized Bone Grafts

Background

During major bone substance loss, secured allogeneic bone matrix (ABM) is normally utilized for bone repair. Here, we propose a method to colonize ABM using autologous mesenchymal cells (MCs) to improve their integration. Moreover, in this study, the consequences of in vitro colonization on MCs have been evaluated.

Methods

After in vitro propagation of MCs, their proliferation kinetics on ABM pre-coated with gelatin, fibronectin, collagen IV and human serum (HS) was monitored, and they were compared with cells cultured without ABM for 8 weeks. The effect of ABM on cell phenotype was also assessed. Lastly, the ability of ABM-colonizing MCs to perform hematopoiesis, a function normally preserved in selected culture conditions, and their differentiation towards osteoblastic lineage were evaluated.

Results

MC and colony-forming unit-fibroblast proliferated 930- and 590-fold, respectively. The proliferation rate of the expanded MCs was higher, forming a 3-dimensional structure in all ABMs. Pre-coating with HS was the most efficient treatment of ABMs to increase the initial adherence of MCs, and it partly explains the reason for the higher propagation of MCs. Flow cytometry analyses revealed subtle alterations in ABM-colonizing cells; however, the ability of MCs to maintain long-term culture initiating cells proliferation and differentiate into osteoblastic lineage was preserved.

Conclusions

In this study, the in vitro biocompatibility of bone marrow (BM) MCs with ABMs, the role of HS in scaffold coating, and the possibility of initially using a small BM sample for this approach were demonstrated.

Copper-Doped Biphasic Calcium Phosphate Powders: Dopant Release, Cytotoxicity and Antibacterial Properties

Cytotoxicity and antibacterial properties associated with the dopant release of Cu-doped Biphasic Calcium Phosphate (BCP) powders, mainly composed of hydroxyapatite mixed with β-tricalcium phosphate powders, were investigated. Twelve BCP ceramics were synthesized at three different sintering temperatures (600 °C, 900 °C and 1200 °C) and four copper doping rates (x = 0.0, 0.05, 0.10 and 0.20, corresponding to the stoichiometric amount of copper in Ca₁₀Cu_x(PO₄)₆(OH)_2-2xO_2x). Cytotoxicity assessments of Cu-doped BCP powders, using MTT assay with human-Mesenchymal Stem Cells (h-MSCs), indicated no cytotoxicity and the release of less than 12 ppm of copper into the biological medium. The antibacterial activity of the powders was determined against both Gram-positive (methicillin-sensitive (MS) and methicillin resistant (MR) Staphylococcus aureus) and Gram-negative (Escherichia coli and Pseudomonas aeruginosa) bacteria. The Cu-doped biomaterials exhibited a strong antibacterial activity against MSSA, MRSA and E. coli, releasing approximatively 2.5 ppm after 24 h, whereas 10 ppm were required to induce an antibacterial effect against P. aeruginosa. This study also demonstrated that the culture medium used during experiments can directly impact the antibacterial effect observed; only 4 ppm of Cu²⁺ were effective for killing all the bacteria in a 1:500 diluted TS medium, whereas 20 ppm were necessary to achieve the same result in a rich, non-diluted standard marrow cell culture medium.

Place of residence before and place of discharge after femoral neck fracture surgery are associated with mortality: A study of 1238 patients with at least three years' follow-up

BACKGROUND

Femoral neck fractures constitute a major public health challenge. The risk of death after surgery depends chiefly on the patient's general health and comorbidities. No studies assessing place of residence are available. The objectives of this study were to determine whether mortality differed according to the patient's previous place of residence and to the place of discharge, and to describe the complications occurring after femoral neck fracture surgery.

HYPOTHESIS

After femoral neck fracture surgery, the place of discharge is associated with the risk of death, and the complication rate is high.

METHODS

This single-centre retrospective study included 1241 adults who sustained a true femoral neck fracture between 2006 and 2016 and were followed up for at least 3 years. The following data were collected: age at the time of the fracture, sex, hospital stay length, place of residence before and after the fracture, characteristics of the fracture, type of treatment, time from the fracture to surgery, and whether anticoagulant therapy was given. We then recorded data on mortality and complications.

RESULTS

The 3-year mortality rate was 36.0±1.4% (95%CI, 33.3-38.7). Place of residence before the fracture was strongly associated with mortality: the risk of death was higher in patients who lived in care homes (hazard ratio [HR], 2.18) or were hospitalised (HR, 1.78) and lower in patients who lived at home (HR, 0.46). The risk of death was also higher in patients discharged to care homes (HR, 1.82) or to hospitals (HR, 1.90) and lower in patients discharged home (HR, 0.30). All these differences were statistically significant (p<0.0001).

CONCLUSION

Place of residence and likely place of discharge should be evaluated as soon as the patient is admitted to the emergency department, in order to provide the best information possible to the patient and family and to establish the most appropriate treatment strategy. Patient self-sufficiency is a major parameter that should be preserved to the extent possible.

LEVEL OF EVIDENCE

IV.

Survival at 11 to 21 years for 779 Metasul® metal-on-metal total hip arthroplasties

BACKGROUND

Total hip arthroplasties (THAs) bearing is one of the most important factors for hip replacement because THA survival depends on it. Metal-on-metal (MoM) bearing has lower wear than metal-on-polyethylene but lot of aseptic loosening decrease utilization. We analyze the survival rate of 28 mm Metasul® bearings after a mean follow-up of 12.9 years.

METHODS

The main objective of this study was to evaluate the survival of the MoM. We evaluate 779 consecutive THAs performed between January 1995 and December 2005 for primary osteoarthritis, congenital dysplasia classified Crowe I, or rheumatoid arthritis. Survival rate was calculated by the Kaplan-Meir method. The association between survival and age, gender, body mass index (BMI), and surface coating was investigated with a proportional odds model. The clinical assessment included Oxford score.

RESULTS

Six hundred fifty-two THAs were reviewed. Sixty-two revisions (9.5%) were performed including 34 aseptic loosening and 11 deep infections. The survival for prosthesis with any reason at 20 years was 87% (confidence interval (CI) 83-90.2) for aseptic loosening at 20 years was 90.1% (CI 87-93.8). There was no association with age, BMI, and surface coating. Gender was significant with lower aseptic loosening for men, hazard ratio = 0.45, p value = 0.035. Oxford score was 57 ± 6.7 (19-60).

CONCLUSION

The survival rate of Metasul was well and seems to be like our clinical finding. However, radiographic aseptic loosening without surgery is not included in the survival rate. The Oxford score was very good with a lot of patients with asymptomatic hip.

LEVEL OF EVIDENCE

Level IV/Retrospective study.

Population status and trend of the threatened ivory gull Pagophila eburnea in Svalbard

The ivory gull Pagophila eburnea is a high-Arctic seabird associated with sea ice throughout the year. It breeds at high latitudes, mostly in the Atlantic sector of the Arctic. It is rare (<11500 breeding pairs globally) and remains one of the most poorly known seabirds in the world. Although Svalbard (Norway) supports breeding populations of international significance, the population trend in the region was unknown prior to this study. We conducted annual surveys of known breeding sites from 2006 to 2019 to estimate the size of the ivory gull population in Svalbard and to assess the population trend. We visited 117 colonies, 60 of which were new discoveries during this study. All breeding sites were situated in cliffs, and no ground-breeding ivory gulls were found. Based on the most complete survey in 2019, we estimated the Svalbard breeding population to be between 1500 and 2000 breeding pairs. We recorded an overall 40% decline in the number of breeding ivory gulls, but the trends varied significantly among colonies. The inter-annual fluctuations in the number of breeding pairs were not synchronous among colonies, which can be explained by the movements of adult breeding birds between colonies. The current decline in the Svalbard ivory gull population could be related to the ongoing decline in sea ice extent and quality in the Barents Sea. It may also be driven by ecological changes along the migration routes or at the wintering grounds, as hypothesized for the Canadian breeding population.

Do bibliometric findings differ between Medline, Google Scholar and Web of Science? Bibliometry of publications after oral presentation to the 2013 and 2014 French Society of Arthroscopy (SFA) Congresses

INTRODUCTION

Bibliometrics consists in quantitative and qualitative analysis of an individual's or group's communication (volume, visibility), and impacts research funding. There are a number of bibliometric data sources, functioning in different ways and liable to give rise to differing statistics. This point has not been investigated in relation to publication following presentation to a French congress. We therefore conducted a study comparing the main bibliometric instruments, aiming to assess: (1) publication rates following oral presentation to the 2013 and 2014 French Society of Arthroscopy (SFA) Congresses according to the database used, and (2) citation rates for these publications according to database.

HYPOTHESIS

Publication and citation rates differ according to database. Material and method All 199 Abstracts of oral presentations to the 2013 and 2014 SFA Congresses were included. Based on author names and key-words, manual search was conducted in the Medline, Web of Science and Google Scholar databases. Publication characteristics (citation rate) were studied using the 3 databases and the French SIGAPS (Système d'Interrogation, de Gestion et d'Analyse des Publications Scientifiques: Scientific Publication Search, Management and Analysis System) website.

RESULTS

Publication rates according to Medline and Google Scholar were the same (48.2%: 96 articles for 199 presentations), but significantly lower on Web of Science (44.7%: 89/199; p=0.002). Citation rates differed significantly (p<0.001) between sources, with Google Scholar listing a mean 1.5-3.4-fold more citations per article than the other 2 databases. Citation rates between the 3 databases correlated strongly (r=0.93).

DISCUSSION

The example presented in this study illustrates the differences in bibliometrics found between different databases. There was a 4% difference (7/199 articles) in publication rates following oral presentation to an SFA Congress, and even greater differences in citation rates per article, with 1.5-3.4-fold more citations according to Google Scholar. Bibliometric studies need to acknowledge the database(s) being used, which should be as many as possible to enhance exhaustiveness.

LEVEL OF EVIDENCE

IV; descriptive epidemiologic study.

Bibliometric analysis of case report citations and their effect on the impact factor: How does publishing case reports impact journals?

INTRODUCTION

Given their low citation rate, case reports may reduce a journal's impact factor (IF), making a journal less likely to accept them for publication. However, this concept has never been proven in a bibliometric study. This led us to carry out a bibliometric analysis to evaluate (1) the exact number of case reports published in orthopedics over a 2-year period, (2) their citation rate, (3) what the journals' IF would be if they had not published these case reports.

HYPOTHESIS

Publishing case reports reduces a journal's IF, bringing into question whether they should be published.

MATERIALS AND METHODS

This was a retrospective bibliometric study. We focused on all the articles influencing the year 2017. We looked at all the journals in the "Orthopedics" discipline that had published at least one article in the years n-2 (=2015) or n-1 (=2016).

RESULTS

There were 1925 case reports among the 28,903 articles published in all orthopedics journals in 2015-2016, a 6.7% share of publications. Individually, each case report in 2015-2016 was cited an average of 0.86 times±1.4 [0-13] in 2017. Of all the case reports published in 2015-2016, 571 (30%) had not been cited in 2017. When comparing the individual number of each case report citation to the journal's IF, we found 413 instances (21.5%) where the case report was cited more than expected and 1512 (78.5%) where it was cited less than expected based on the journal's IF. The mean IF was 2.013. If the journals had not published any case reports, the mean IF would have been 2.072 (p<0.0001). For all the SIGAPS categories, the mean IF would have been higher if no case reports had been published. On average, the IF was lower by 0.059 points±0.121 [-0.165-0.537], with the difference being statistically significantly only for SIGAPS C and D journals. In 69 instances, the IF would be higher if the journal had not published any case reports. Conversely, the IF improved in 8 instances by publishing case reports: 3 were tier D journals and 5 were tier E journals.

DISCUSSION

Our study brings into question whether case reports should be published. Indeed, the publication of case reports lowers the IF of scientific journals. However, we should not completely stop publishing case reports since they can be useful to clinicians caring for patients with rare diseases or medical conditions.

LEVEL OF EVIDENCE

IV, systematic retrospective study.

Biological properties of copper-doped biomaterials for orthopedic applications: A review of antibacterial, angiogenic and osteogenic aspects

Copper is an essential trace element required for human life, and is involved in several physiological mechanisms. Today researchers have found and confirmed that Cu has biological properties which are particularly useful for orthopedic biomaterials applications such as implant coatings or biodegradable filler bone substitutes. Indeed, Cu exhibits antibacterial functions, provides angiogenic ability and favors osteogenesis; these represent major key points for ideal biomaterial integration and the healing process that follows. The antibacterial performances of copper-doped biomaterials present an interesting alternative to the massive use of prophylactic antibiotics and help to limit the development of antibiotic resistance. By stimulating blood vessel growth and new bone formation, copper contributes to the improved bio-integration of biomaterials. This review describes the bio-functional advantages offered by Cu and focuses on the antibacterial, angiogenic and osteogenic properties of Cu-doped biomaterials with potential for orthopedic applications.

Progression and projection for shoulder surgery in France, 2012-2070: Epidemiologic study with trend and projection analysis

INTRODUCTION

Shoulder surgery has been rapidly expanding over the past 20 years and now makes up a large share of orthopedic surgery practice. Data on how this activity has changed is not available in France due to a lack of registries. The study objectives were to: (1) quantify the number of shoulder surgeries in France, (2) predict how this activity will change over the next 50 years based on extreme scenarios.

METHODS

This study involved an analysis of shoulder surgery data taken from the French hospital discharge database (PMSI). Two mathematical scenarios were applied to define the change over time: the first only considered the evolution in the population and changes in the age brackets over time; the second extrapolated the trends observed over the past few years (2012 to 2018).

RESULTS

In 2018, there were 234,612 procedures coded as primary shoulder surgery procedures in France. This activity increased 24.5% between 2012 and 2018 and is projected to increase 18% to 161% from now to 2050, depending on the scenario (p<0.0001). Rotator cuff surgery procedures were done 173,799 times - of which 61,055 were tendon repair - representing 74% of all shoulder procedures. The scenarios point to an increase of 13.6% to more than 300% (p<0.0001). Primary shoulder arthroplasty corresponded to 17,043 procedures in 2018 (7.3% of all procedures), with a 47% increase between 2012 and 2018. Between 2018 and 2050, the number of total shoulder arthroplasty procedures is expected to increase 31% to 322% (p<0.0001). The total number of revision arthroplasty procedures was 1508, increasing by 39% from 2012 to 2018. There were 14,229 procedures done for anterior or posterior instability in 2018 (6% of total). Bone block procedures made up 53% of these cases. This increased 17% between 2012 and 2018, with a projected increase of 5% to 82% up to 2050 (p<0.01).

DISCUSSION

Shoulder surgery is the third largest activity in the orthopedic realm after hip and knee surgery, although it has seen the largest increases in recent years. This growth in shoulder procedures should continue over the next decades.

LEVEL OF EVIDENCE

IV, descriptive epidemiology study.

Hip preserving surgery for avascular hip necrosis: does terminating exposure to known risk factors improve survival?

Introduction: Avascular necrosis of the hip is rarely detected in early pre-radiographic stages (Arlet-Ficat stages I and II) where conservative treatment would still be possible. Studies of risk factors were often merely descriptive. The aim of the present study was to make a retrospective assessment of treatment survival rate for conservative management of avascular hip necrosis according to whether exposure to avoidable risk factors is eliminated or not. The study hypothesis was that eliminating avoidable risk factors is effective and reduces the risk of failure, and hence of hip replacement. Material and method: A single-center retrospective study was performed for conservatively managed avascular hip necrosis. Thirty-seven consecutive hips in 34 patients underwent decompression drilling, with a minimum 3-year follow-up. Known risk factors for osteonecrosis were classified as avoidable or non-avoidable. Results were analyzed according to the elimination of avoidable risk factors. The main endpoint was survival, with failure defined as femoral head collapse and/or recourse to total hip replacement. Avoidable risk factors (corticosteroids, smoking, alcohol consumption, blood pressure elevation, hypercholesterolemia) persisted for 17 hips (45.9%) and were prevented for 15 (40.5%). Five patients (5 hips: 13.5%) did not show preoperatively identified risk factors. Groups were demographically comparable. Results: Mean follow-up was 7.5 ± 3.7 years (range, 3.1-16.0 years). At last follow-up, there was a significant difference in survival at cumulative 9-year follow-up between patients with no risk factors (100%), with risk factors eliminated (59.3%; 95% CI, 0.273-0.012), and with persisting risk factors (23.5%; 95% CI, 0.013-0.458) (p = 0.001). Discussion: No studies were found in the literature assessing the survival of hip preserving surgery according to persistence or elimination of known risk factors for osteonecrosis. Eliminating risk factors significantly improved the survival rate for conservative treatment of femoral head necrosis.

Knee surgery trends and projections in France from 2008 to 2070

INTRODUCTION

Knee surgery makes up a large share of the orthopedic surgery practice. Data on how this activity has changed over time is not available in France, thus we wanted to do a study to determine 1) how many knee surgeries were performed in France in 2018, 2) how this changed between 2012 and 2018, and 3) how it is projected to change by 2070. The hypothesis is that the number of knee surgeries will increase over the next 50 years.

METHODS

This was an epidemiology study analysing coding data for surgical procedures in France between 2012 and 2018. Two scenarios were defined to assess the change over time: the first only considered population growth and how the age distribution changes over time, and the second extrapolated the trends observed over the past few years.

RESULTS

In 2018, 321,179 procedures were coded as a main knee surgery procedure. The three most frequent were primary knee arthroplasty with 113,600 procedures (31.2% of procedures) then meniscus surgery (110,510 procedures or 30.3%) and then ligament surgery (57,053 procedures or 15.7%). The number of primary knee arthroplasty procedures increased by 32.2% between 2012 and 2018. Between 2018 and 2050, the different scenarios suggested an increase of 30.8% to 152.8%. The number of ligament surgery procedures increased by 17.3% between 2012 and 2018. Between 2018 and 2050, an increase of 1.2% to 49.2% is expected. The number of meniscus procedures decreased by 14.2% between 2012 and 2018. Between 2018 and 2050, scenario 1 projects a 5.6% increase and scenario 2 a 73.6% reduction.

DISCUSSION

The number of knee surgery procedures per year has increased over the past few years in France and should continue to increase.

LEVEL OF EVIDENCE

IV, descriptive epidemiology study.

Bacterial skin recolonization in the operating room: comparison between various antisepsis protocols

BACKGROUND

Surgical site infection (SSI) largely implicates the patient's endogenous skin microbiota. Perioperative disinfection protocols do not follow a general agreement.

AIM

To compare antisepsis and skin protection protocols on quantitative analysis of recolonization in the operating room at regular time-steps. The study hypothesis was that one protocol would be more effective than others.

METHODS

A single-centre prospective interventional study was conducted between January and June 2019. Healthy volunteers were randomized between protocols and served as their own controls. The protocols began ahead of scheduled orthopaedic surgery with a preoperative shower, mechanical cleansing, application of major antiseptics (alcoholic Bétadine™ 5% or alcoholic chlorhexidine 0.5%), sterile draping, then adhesive draping (3M™ Steri-Drape™ or iodine-impregnated 3M™ Ioban2™). Sampling was by swabbing in the operating room at 30 min intervals up to 90 min after draping. Cultures were performed under aerobic and anaerobic conditions. Qualitative and quantitative (cfu/mL) bacteriology was performed in the laboratory by direct reading on the blood agar plates.

FINDINGS

Thirty subjects were included; none was lost to follow-up or excluded from analysis. Bacterial load before manipulation (T0) was significantly higher in males (P < 0.0001) despite a significantly shorter shower-to-sampling interval (P = 0.03). Smoking (P = 0.85), body mass index (P = 0.38), and depilation (P = 0.50) did not significantly affect preoperative load. Mean load increased significantly under all protocols up to T90 min, without significant superiority for any one protocol. Associated Bétadine™/Ioban™ showed the lowest T90 load, and chlorhexidine alone the highest, but without significant difference. Isolates at T0 were predominantly healthy skin commensals: coagulase-negative staphylococci, micrococci, and coryneforms.

CONCLUSION

No one protocol demonstrated superiority, whether in immediate bactericidal action or in preventing skin recolonization in the operating room. Further studies are needed to define generally agreed protocols for SSI risk management.

Poor results of functional treatment of Garden-1 femoral neck fracture in dependent patients

INTRODUCTION

Variable results are reported after functional treatment for Garden-1 femoral neck fracture, with no definite factors for failure, particularly in the absence of selection for risk. It seems well indicated in frail and/or dependent patients with comorbidities, but this has not been specifically assessed, and failure is frequent in this target population. We therefore performed a retrospective study to: (1) assess results of functional treatment for Garden-1 impacted femoral neck fracture in dependent patients, and (2) analyze survival in terms of complications and death, and related factors.

HYPOTHESIS

Functional treatment for Garden-1 fracture in dependent patients gives poor results, with a high rate of surgical revision.

MATERIAL AND METHODS

A retrospective analysis was made of Garden-1 femoral neck fracture in dependent patients (Parker score≤5), with a minimum 2 years' follow-up. One hundred and forty-six patients were included: mean age, 81.3±8.7 years (range, 55.7-99.6 years). The endpoint was survival in terms of complications requiring surgery, secondary displacement requiring surgery, excessive pain requiring surgery, non-union or femoral head osteonecrosis. Secondary endpoints were overall mortality and mortality related to complications.

RESULTS

Mean follow-up was 4.2±2.6 years (range, 2.0-10.3 years). Ninety-one of the 146 patients (62.3%) required secondary surgery: 79 (54.1%) early (<3 months post-fracture), with 77 (52.7%) secondary displacements and 2 cases (1.4%) of excessive pain; and 12 (8.2%) late (162.2±132.3 days; range, 90-454 days), with 8 (5.4%) non-unions and 4 (2.7%) osteonecroses. Mean time to onset of secondary displacement was 13.6±11.8 days (range, 0-67.0 days). Two-year survival in terms of revision surgery was 34.1% [95% CI: 26.0-42.4]. At last follow-up, 91 patients (62.3%) had died; 2-year survival in terms of death was 69.9% [95% CI: 62.4-77.3]. Survival analysis in terms of complications revealed greater mortality in absence of complications: 42 of the 55 patients (76.3%) without complications requiring surgery died, versus 49 of the 91 (53.8%) with complications requiring surgery (p=0.012); relative risk of death in absence of complications requiring surgery was 1.42 [95% CI: 1.33-5.77].

DISCUSSION

Functional treatment for Garden-1 fracture in dependent patients gave poor short- and medium-term results. Surgery is therefore recommended in this specific population; the present findings should improve survival.

LEVEL OF EVIDENCE

IV, retrospective study.

Antarctic petrels 'on the ice rocks': wintering strategy of an Antarctic seabird

There is a paucity of information on the foraging ecology, especially individual use of sea-ice features and icebergs, over the non-breeding season in many seabird species. Using geolocators and stable isotopes, we defined the movements, distribution and diet of adult Antarctic petrels Thalassoica antarctica from the largest known breeding colony, the inland Svarthamaren, Antarctica. More specifically, we examined how sea-ice concentration and free-drifting icebergs affect the distribution of Antarctic petrels. After breeding, birds moved north to the marginal ice zone (MIZ) in the Weddell sector of the Southern Ocean, following its northward extension during freeze-up in April, and they wintered there in April-August. There, the birds stayed predominantly out of the water (60-80% of the time) suggesting they use icebergs as platforms to stand on and/or to rest. Feather δ15N values encompassed one full trophic level, indicating that birds fed on various proportions of crustaceans and fish/squid, most likely Antarctic krill Euphausia superba and the myctophid fish Electrona antarctica and/or the squid Psychroteuthis glacialis. Birds showed strong affinity for the open waters of the northern boundary of the MIZ, an important iceberg transit area, which offers roosting opportunities and rich prey fields. The strong association of Antarctic petrels with sea-ice cycle and icebergs suggests the species can serve, year-round, as a sentinel of environmental changes for this remote region.

Bilateral simultaneous chronic exertional compartment syndrome of the lateral forefoot: A case report (compartment syndrome of the forefoot)

A 20-year-old patient came to the sport medicine clinic for bilateral forefoot pain during sport activities (running) progressing for the last 3 months. Thanks to a positive measurement of the compartment pressure during a running test reproducing the symptomatology and exclusion of classical differential diagnosis, a bilateral chronic compartment syndrome of the lateral forefoot was confirmed. Three months after a surgical fasciotomy, the patient fully recovered. No previous study described this specific compartment of the forefoot. Level of evidence: IV.

Duration of rifampin therapy is a key determinant of improved outcomes in early-onset acute prosthetic joint infection due to Staphylococcus treated with a debridement, antibiotics and implant retention (DAIR): a retrospective multicenter study in France

Introduction: In patients undergoing a « debridement, antibiotics, and implant retention » (DAIR) procedure for acute staphylococcal prosthetic joint infection (PJI), post-operative treatment with rifampin has been associated with a higher probability of success.(1,2) However, it is not known whether it is the total dose, delay of introduction or length of therapy with rifampin that is most strongly associated with the observed improved outcomes.

Methods: A multicentric, retrospective cohort study of patients with acute staphylococcal hip and knee PJI treated with DAIR between January 2011 and December 2016. Failure of the DAIR procedure was defined as persistent infection, need for another surgery or death. We fitted logistic and Cox regression multivariate models to identify predictors of DAIR failure. We compared Kaplan-Meier estimates of failure probability in different levels of the 3 variables of interest - total dose, delay of introduction or length of therapy with rifampin - with the log-rank test.

Results: 79 patients included (median age 71 years [63.5-81]; 55 men [70%]), including 54 (68%) DAIR successes and 25 (32%) DAIR failures. Patients observed for a median of 435 days [IQR 107.5-834]. Median ASA score significantly lower in DAIR successes than in DAIR failures (2 vs. 3, respectively p = 0.011). Bacterial cultures revealed 65 (82.3%) S. aureus and 16 (20.3%) coagulase negative staphylococci, with 2 patients being infected simultaneously with S. aureus and CNS. Among S. aureus isolates, 7 (10.8%) resistant to methicillin; 2 (3.1 %) resistant to rifampin. Median duration of antimicrobial therapy was 85 days [IQR 28.5-97.8]. Fifty-eight patients (73.4%) received rifampin at a median dose of 14.6 mg/kg/day |IQR 13-16.7], started at a median delay of 8.5 days [IQR, 4-7.5] after debridement surgery. Twenty-one patients (26.6%) developed a drug-related adverse event, leading to rifampin interruption in 6 of them (7.6% of total cohort). Determinants of DAIR failure were rifampin use (HR 0.17, IC [0.06, 0.45], p-value <0.001), association of rifampin with a fluoroquinolone (HR 0.19, IC [0.07, 0.53], p-value = 0.002) and duration of rifampin therapy (HR 0.97, IC [0.95, 1], p-value = 0.022). We did not observe a significant difference between DAIR successes and failures in rifampin use, dose and delay of introduction. In a multivariate Cox model, only duration of rifampin therapy was significantly associated with DAIR failure. Kaplan Meier estimate of DAIR failure probability was significantly higher in patients receiving less than 14 days of rifampin in comparison with those receiving more than 14 days of rifampin (p = 0.0017).

Conclusion: Duration of rifampin therapy is a key determinant of improved outcomes in early-onset acute prosthetic joint infection due to Staphylococcus treated with DAIR.

Chondroprotective Properties of Human-Enriched Serum Following Polyphenol Extract Absorption: Results from an Exploratory Clinical Trial

Polyphenols are widely acknowledged for their health benefits, especially for the prevention of inflammatory and age-related diseases. We previously demonstrated that hydroxytyrosol (HT) and procyanidins (PCy), alone or in combination, drive preventive anti-osteoathritic effects in vivo. However, the lack of sufficient clinical evidences on the relationship between dietary phytochemicals and osteoarthritis remains. In this light, we investigated in humans the potential osteoarticular benefit of a grapeseed and olive extract (OPCO) characterized for its hydroxytyrosol (HT) and procyanidins (PCy) content. We first validated, in vitro, the anti-inflammatory and chondroprotective properties of the extract on primary cultured human articular chondrocytes stimulated by interleukin-1 beta (IL-1 β). The sparing effect involved a molecular mechanism dependent on the nuclear transcription factor-kappa B (NF-κB) pathway. To confirm the clinical relevance of such a nutritional strategy, we designed an innovative clinical approach taking into account the metabolites that are formed during the digestion process and that appear in circulation after the ingestion of the OPCO extract. Blood samples from volunteers were collected following ingestion, absorption, and metabolization of the extract and then were processed and applied on human primary chondrocyte cultures. This original ex vivo methodology confirmed at a clinical level the chondroprotective properties previously observed in vitro and in vivo.

The top 100 most-cited Orthopaedics & Traumatology: Surgery & Research articles

BACKGROUND

The French peer-reviewed journal Revue d'Orthopédie founded on 1st January 1890 extended its scope in 2009 by creating the English-language, online-only, indexed journal Orthopaedics & Traumatology: Surgery & Research (OTSR). Bibliometric data help authors and readers assess the citation potential of articles published in a given journal. We found no bibliometrics for the first 10years of OTSR. The objectives of this bibliometric study were to identify (i) the 100 most-cited OTSR articles and (ii) the specialties or article types most often involved in citations.

METHODS

The Scopus database was used to determine the citation rates of the 2158 articles published in OTSR during the journal's first 10years. A bibliometric analysis was performed on the 100 most-cited articles.

RESULTS

Mean time since publication of the 100 most-cited articles was 6.60±1.66years (range: 2-10years) and mean number of citations per article was 49.59±24.16 (range: 30-169). Mean number of citations per year was 7.75±3.26 (range: 4-18.78) and mean number per author was 5.52±3.14 (range: 1-21). The first author was French in 89/100 cases. Of the 100 articles, 56 were based on a multi-centre study and 21 on an international study. Finally, 22/100 articles reported studies sponsored by a scientific society.

DISCUSSION

The 100 articles identified in this study deserve to be viewed as influential. The number of citations will continue to rise, thereby amplifying the impact of OTSR on worldwide research in orthopaedic surgery.

LEVEL OF EVIDENCE

IV, systematic retrospective analysis.

Long-term survival of hybrid total hip arthroplasty with the uncemented CLS cup, cemented Müller cobalt-chromium stem, and 28-mm Metasul™ bearings: Retrospective review of 115 hips after a minimum of 17.8 years

BACKGROUND

Hard-on-hard bearings require a meticulous implantation technique but may be associated with lower wear rates in young active patients. Among them, metal-on-metal (MoM) bearings have been blamed for specific complications including adverse reactions to metal debris and metal hypersensitivity. These complications have been chiefly reported with large-head MoM implants (except when used for hip resurfacing). Most of the published data on small-head MoM implants were obtained using uncemented stems. To our knowledge, no information on outcomes beyond 15 years is available for small-head MoM implants with cemented cobalt-nickel-chromium (Co-Ni-Cr) stems, which might increase the risk of complications. The objective of this study was to collect long-term follow-up data on patients who underwent hybrid total hip arthroplasty (THA) with 28-mm MoM Metasul™ bearings in order to assess: (1) long-term survival (based on the revision rate), (2) and the occurrence of adverse reactions to metal debris documented during revision.

HYPOTHESIS

Survival of 28-mm Metasul™ bearings used with hybrid THA is acceptable.

PATIENTS AND METHODS

A single-centre retrospective study was conducted in consecutive patients managed using 28-mm Metasul™ bearings in a press-fit cup, with a cemented Co-Ni-Cr stem. Follow-up was at least 17 years. The clinical and radiographic data were analysed. Mean age at surgery was 57.3±7.9 years (range, 29.6-75.3 years).

RESULTS

The study included 115 hips with a mean follow-up of 20.3±0.8 years (range, 17.8-21.6 years). Survival to revision for any reason was 86.10% (95% CI, 79.8-92.4%) and survival to revision for aseptic loosening was 92.6% (95% CI, 87.7-97.6). Half the specimens obtained during revision showed a macrophage reaction and a non-specific inflammatory infiltrate. No patient experienced complications specifically related to the use of Metasul™ bearings with a cemented Co-Ni-Cr stem.

DISCUSSION

Long-term survival of 28-mm MoM Metasu™ bearings was close to that of metal-on-polyethylene bearings and lower than that of ceramic-on-ceramic or small-head MoM bearings in other studies. No complications specifically related to the use of small-head MoM bearings with a cemented Co-Ni-Cr stem were recorded.

LEVEL OF EVIDENCE

IV, retrospective study.

Progression and projection for hip surgery in France, 2008-2070: Epidemiologic study with trend and projection analysis

INTRODUCTION

Hip replacement was declared "operation of the century" in tribute to the functional improvement it provides. Frequency is increasing, but it is difficult to estimate the actual number of procedures performed and the expected progression, because of changes in indications and lengthening life-expectancy, and also, in France, because there is no registry. As data are lacking in France, we conducted an investigation 1) to update the number of hip surgeries in France, and 2) to forecast progression over the coming decades, considering extreme scenarios.

HYPOTHESIS

The number of hip procedures can be expected to increase considerably over the coming 50 years.

MATERIAL AND METHOD

A study was conducted to analyze national coding data for the number of hip surgeries performed in France. Two scenarios were defined: one taking account of population progression and age structure, the other also extrapolating trends observed over recent years. Current hip surgery activity in France was measured, and progression estimated according to population changes.

RESULTS

In 2018 in France, 183,139 procedures were coded as principally concerning the hip. There was a clear predominance of reconstruction procedures, with 148,965 primary hip replacements, 124,251 of which were total. There were 19,304 hip replacement revision procedures. There were strong regional differences in revision according to the type of center performing surgery (p<0.0001). Between 2018 and 2050, primary hip replacement could be expected to increase by 41.9% or 114.3% and hip surgery overall by 42.0% or 98.3%, depending on the scenario.

DISCUSSION

The present results are subject to future technological breakthroughs and medical discoveries, but forecast a major increase in hip surgery requirements. These results extend the present state of medical knowledge.

LEVEL OF EVIDENCE

IV, descriptive epidemiological study.

Use of morselized allografts for acetabular reconstruction during THA revision: French multicenter study of 508 cases with 8 years' average follow-up

BACKGROUND

In the context of acetabular reconstruction, bone defects can be filled with processed or unprocessed bone allografts. Published data are often contradictory on this topic and few studies have been done comparing processed allografts to fresh-frozen ones. This led us to conduct a large study to measure the factors impacting the survival of THA revision: (1) type of allograft and cup, (2) technical factors or patient-related factors.

HYPOTHESIS

Acetabular reconstruction can be performed equally well with frozen or processed morselized allografts.

MATERIALS AND METHODS

This retrospective, multicenter study of acetabular reconstruction included 508 cases with a minimum follow-up of 5 years. The follow-up for the frozen grafts was shorter (7.86 years±1.89 [5-12.32]) than that of the processed grafts (8.22 years±1.77 [5.05-15.48]) (p=0.029). However, the patients were younger at the time of the primary THA procedure in the frozen allograft group (51.5 years±14.2 [17-80]) than in the processed group (57.5 years±13.0 [12-94]) (p<0.001) and were also younger at the time of THA revision (67.8 years±12.2 [36.9-89.3] versus 70 years±11.7 [25-94.5]) (p=0.041).

RESULTS

There were more complications overall in the frozen allograft group (46/242=19.0%) than the processed allograft group (35/256=13.2%) (p=0.044) with more instances of loosening in the frozen group (20/242 [8.2%]) than in the processed group (6/266 [3.3%])(p=0.001). Conversely, the dislocation rate (16/242=6.6% vs. 17/266=6.4%) (p=0.844) and infection rate (18/242=7.4% vs. 15/266=5.7%) (p=0.264) did not differ between groups. The subgroup analysis reveal a correlation between the occurrence of a complication and higher body mass index (BMI) (p=0.037) with a higher overall risk of complications in patients with a BMI above 30 or under 20 (p=0.006) and a relative risk of 1.95 (95% CI: 1.26-2.93). Being overweight was associated with a higher risk of dislocation (relative risk of 2.46; 95% CI: 1.23-4.70) (p=0.007). Loosening was more likely to occur in younger patients at the time of the procedure (relative risk of 2.77; 95% CI: 1.52-6.51) (p=0.040) before 60 years during the revision. Lastly, patients who were less active preoperatively based on the Devane scale had an increased risk of dislocation (relative risk of 2.51; 95% CI: 1.26-8.26) (p=0.022).

DISCUSSION

Our hypothesis was not confirmed. The groups were not comparable initially, which may explain the differences found since the larger number of loosening cases in the frozen allograft group can be attributed to group heterogeneity. Nevertheless, morselized allografts appear to be suitable for acetabular bone defect reconstruction. A randomized study would be needed to determine whether frozen or processed allografts are superior.

LEVEL OF EVIDENCE

III, comparative retrospective study.

Fifteen-year survival of the Cedior™ total knee prosthesis

Total knee arthroplasty (TKA) is an effective treatment for advanced osteoarthritis of the knee. No large and long-term follow-up study has been done about Cedior^® prosthesis. The study hypothesis was that 15-year survival for the Cedior™ prosthesis is at least as good as rates reported for other models. A continuous retrospective single-center study included patients managed by Cedior™ TKA with at least 15-year follow-up. The main endpoint was prosthesis survival; secondary objectives were to identify factors for implant revision and to assess functional scores at 15 years. In the present series, 15-year all-cause survival for the Cedior^® knee prosthesis was 93.03%; comparable to rates in the literature, posterior-stabilized implants showed higher revision rates. No other factors for revision emerged. These findings are comparable with those of the literature.

7-year results of primary total hip arthroplasty with the uncemented Avenir stem

AIMS

The aim of the present study was to evaluate the 7-year functional outcome and radiographic results of primary total hip arthroplasties (THAs) performed with the uncemented Avenir stem.

PATIENTS AND METHODS

Between January 2006 and October 2008, 100 consecutive primary hips in 92 patients were enrolled at 2 centres. The mean age at operation was 58.5 years (27-87 years). Mini-incision (50%) and standard approaches (50%) were used to implant 22 standard and 78 lateralised stems.

RESULTS

The 7-year Kaplan-Meier survival rate was 98.9% (95% CI, 92.9-99.8) with stem revision for any reason as endpoint. No stem related complications occurred. 1 stem revision was due to deep infection at 51 months post-op. We had 4 acetabular revisions. The mean Harris Hip Score (HHS) at 7 years follow-up was 93.1 points (60-100). Radiographic analysis showed 2 patients had non-progressive radiolucent lines and no patient had any signs of stem subsidence or loosening.

CONCLUSION

The 7-year implant survival and the functional outcomes for THA performed with the study device are excellent and were in line with those documented for comparable contemporary uncemented fully HA-coated stems. Longer term follow-up of this consecutive series needs to be performed.

French translation and cultural adaptation of a questionnaire for patients with hip or knee prosthesis

INTRODUCTION

The Kingsbury questionnaire offers the possibility of follow-up by means of an X-ray and a simple questionnaire sent to the home address of the patient, who will not need to come in consultation if there are no problems. The questionnaire detects any anomaly in follow-up. In case of anomaly in the questionnaire or radiograph, the patient is contacted and/or seen again, as appropriate. The Kingsbury questionnaire has had no transcultural validation, and we therefore conducted a prospective study in order to 1) translate into French the questionnaire, previously validated in English; 2) adapt it for good understanding according to cultural habits; and 3) assess the translated version on a test-retest procedure.

HYPOTHESIS

The study hypothesis was that the translated questionnaire would show good test-retest reproducibility.

MATERIAL AND METHODS

The exact English version of the questionnaire was obtained directly from the authors of the index publication. A methodology of translation, back-translation and test-retest enabled assessment of the translation and of the reproducibility of the French version. The reference method of cultural adaptation of self-administered questionnaires and patient information documents was used. The questionnaire was tested prospectively.

RESULTS

One hundred patients were contacted, providing 73 clinical tests with radiographic validation and 48 complete test-retests in a representative population of total hip and total knee arthroplasty (THA, TKA). Internal coherence showed a KR-20 coefficient of 0.71 and Cronbach alpha of 0.76: e.g., good internal coherence. Item difficulty, requiring renewed contact, was low for all questions. Mean variance was low on the first 7 questions: 0.08 (range, 0.02-0.16). Correlation was close to 0.5 for each question. Analysis of reproducibility found excellent agreement (>90%) for the first 7 questions, which were binary; for question 8, agreement was good (83.3%) considering that there were 5 possible responses. For 19 of the 73 respondents, the questionnaire results indicated a need for further contact. After analysis of their radiographs, 4 needed to be seen in consultation again. The other 15 had unfavorable responses but without deterioration since the last classical consultation or any radiologic abnormality consultation, and were not called back for consultation.

CONCLUSION

The French version of the Kingsbury questionnaire provided reproducible assessment, avoiding the need to call the patient back for consultation unnecessarily. The questionnaire needs validating in a larger sample before being widely used: the present study was just a first step.

LEVEL OF EVIDENCE

IV, Prospective without control group.

Comparison of microbiological results obtained from per-wound bone biopsies versus transcutaneous bone biopsies in diabetic foot osteomyelitis: a prospective cohort study

Transcutaneous bone biopsy (TCB) is the gold standard for taking microbiological specimens in diabetic foot osteomyelitis (DFO), but this technique is not widely used in diabetic foot care centers. We aimed to evaluate the reliability of per-wound bone biopsy (PWB) cultures by comparing them with concomitant TCB cultures obtained through healthy skin. This is a prospective monocentric study including patients seen in consultation for clinical and radiological diabetic foot osteomyelitis with positive probe-bone tests between April 2015 and May 2018. Two bone biopsies were performed on each consenting patient: TCB through a cutaneous incision in healthy skin, and PWB, after careful debridement of the wound. A total of 46 paired cultures were available from 43 eligible patients. Overall, 16 (42%) of the PWB and TCB pairs had identical culture results, but the TCB cultures were sterile in 8 (17%) cases. For 38 paired cultures with positive TCB, the correlation between PWB results and TCB results was 58.4%. PWB revealed all microorganisms found in the transcutaneous specimen in 26/38 samples (68.5%). In patients with DFO, the culture results of specimens taken by per-wound biopsies did not correlate well with those obtained by TCB. PWB should be reserved for cases where the transcutaneous biopsy is sterile or not feasible.

Irradiation at 11 kGy conserves the biomechanical properties of fascia lata better than irradiation at 25 kGy

The objective of this study was to determine the biomechanical properties of the fascia lata and the effects of three preservation methods: freezing, cryopreservation with dimethylsulfoxide solution and lyophilization; and to compare the effects of low-dose (11 kGy) and normal-dose (25 kGy) gamma-ray sterilization versus no irradiation. 248 samples from 14 fasciae latae were collected. Freezing samples were frozen at -80 °C. Cryopreservation with dimethylsulfoxide solution samples were frozen with 10 cl dimethylsulfoxide solution at -80 °C. Lyophilization samples were frozen at -22 °C and lyophilized. Each preservation group were then randomly divided into 3 irradiation groups. The cryopreservation with dimethylsulfoxide solution samples had significantly worse results in all 3 irradiation conditions. Young's modulus was lower for the freezing samples (p < 0.001) and lyophilization samples groups (p < 0.001). Tear deformation was lower for the freezing samples (p = 0.001) and lyophilization samples groups (p = 0.003), as was stress at break (p < 0.001 and p < 0.001). Taking all preservation methods together, samples irradiated at 25 kGy had worse results than the 0 kGy and 11 kGy groups in terms of Young's modulus (p = 0.007 and p = 0.13) and of stress at break (p = 0.006 and p = 0.06). The biomechanical properties of fascia lata allografts were significantly worse under dimethylsulfoxide cryopreservation. The deleterious effects of irradiation were dose-dependent.

1210. Staphylococcal Acute Post-Operative Prosthetic Joint Infection (PJI) Treated With “DAIR” (Debridement and Implant Retention) and Impact of Rifampin: A Retrospective Cohort Study in France

Background

Staphylococci are the most frequent bacteria in PJI. In patients with acute PJI (i.e., <1 month following the implantation), DAIR with exchange of removal components followed by a combination of antibiotics including rifampin (RMP) (particularly RMP + fluoroquinolone) are recommended. Unfortunately, some patients could not receive RMP due to drug–drug interaction or stopped it due to an adverse event. Finally, it is unclear whether the dose and the duration of RMP influenced the prognosis.

Methods

Retrospective cohort study in four hospitals including patients with staphylococcal acute post-operative PJI treated with DAIR in 2011–2016. Univariate and multivariate Cox analysis and Kaplan–Meier curves were used to determine the risk factors for treatment failure.

Results

Seventy-nine patients were included (median age: 71 years [IQR 53–89]; 55 men [69.6%]; median ASA score: 2 [IQR 2–3]). Cultures revealed 65 (82%) S. aureus and 15 (19%) coagulase negative staphylococci infections, including 14 methicillin-resistant strains (18%). Among all isolates, only two (3%) were resistant to RMP and 16 (20%) were resistant to fluoroquinolone. The median duration of antimicrobial therapy was 92 days (IQR 31–152). Only 59 patients received RMP (75%), and 35 (44%) the combination RMP + fluoroquinolone. Median duration of RMP was 57 days (IQR 16–86) and median dose 14.6 mg/kg/d (IQR 13–17). Forty patients (51%) received RMP in the first 2 weeks and 43 patients (54%) received at least 2 weeks of RMP. Six patients (8%) developed an adverse event leading to RMP interruption. During a median follow-up of 443 days (IQR 220–791), 21 patients (27%) experienced a treatment failure including 12 persistence of the initial pathogen (57%) and nine superinfections (43%). An ASA score >2 (OR 2.8; 95% CI 1.26–6.15), the use of RMP (OR 0.4; 95% CI 0.71–0.95) and the duration of RMP treatment (OR 0.83; 95% CI 0.75–0.92 per week of treatment) were significant determinants of the outcome (but not methicillin-resistance). Receiving >2 weeks of RMP prevented the failure, but an introduction during the first 2 weeks did not influence the outcome.

Conclusion

In patients with staphylococcal acute PJI, the use of RMP and its duration strongly influenced the prognosis. As 25% of patients could not receive RMP, new drugs with anti-biofilm activity are required.

Disclosures

All authors: No reported disclosures.

Update on the supply and use of allografts in locomotor system pathologies in France

Allografts are increasingly used in orthopedics. The main aim of the present study was to map the use of locomotor system allografts in France between 2012 and 2016. The study hypothesis was that there are great differences in the distribution and activity of tissue banks and graft preservation procedure quality, failing to meet national requirements.

MATERIAL AND METHODS

Data from activity reports of the French Biomedicine Agency (ABM) were collected for the period 2012-2016. Existing viral inactivation procedures were described. Preliminary results from a study of allograft requirements by the French Society of Arthroscopy (SFA) were reported.

RESULTS

Nineteen tissue banks were located. Four dealt exclusively with cryopreserved tissue, 3 exclusively with virus-inactivated bone, and 12 with both. Distribution analysis found wide disparities in geographic location and in type of activity. Viral inactivation is presently implemented only for femoral heads derived from hip replacement. Stocks of long bones, femoral heads and ligaments/tendons increased constantly over the study period, by 8.3%, 50.8% and 316.2% respectively. The SFA questionnaire confirmed a serious shortage of tissues, necessitating importation of allografts.

DISCUSSION

Each tissue bank had its own specificities and specialization. They should probably be coalesced, so as to centralize both supply and demand and improve nationwide response to requirements. Locomotor system tissue harvesting also needs to be expanded to meet increasing demand.

Should we expand the indications for the DAIR (debridement, antibiotic therapy, and implant retention) procedure for Staphylococcus aureus prosthetic joint infections? A multicenter retrospective study

To evaluate factors associated with failure in patients treated with DAIR (debridement, antibiotic therapy, and implant retention) for Staphylococcus aureus prosthetic joint infections (PJIs). We retrospectively analyzed consecutive patients with stable PJI due to S. aureus treated with DAIR at six hospitals between 2010 and 2014. Cox proportional hazards regression was used to study factors associated with treatment failure at 2 years. Of 154 eligible patients, 137 were included (mean age 73 ± 13 years; male 56%). The estimated success rate according to the Kaplan-Meier method was 76.2 [95% CI 68-83] at 2 years of follow-up. In multivariate analysis, longer duration of treatment (hazard ratio (HR) 0.78 [0.69-0.88]; p < 0.001) and combination therapy including rifampin (HR 0.08 [0.018-0.36]; p = 0.001) were independently associated with success, whereas active smoking was independently associated with failure (HR 3.6 [1.09-11.84]; p = 0.036). When the analysis was restricted to patients with early infection onset (< 3 months), early acute infection was also predictive of a better prognosis (HR 0.25 [0.09-0.7]; p = 0.009). Failure was not associated with time from prosthesis insertion to debridement, nor with duration of symptoms > 3 weeks and type of prosthesis (hip or knee). These results remained unchanged when the 14 patients under immunosuppressive therapy were removed from analysis. These data suggest that DAIR can be performed even if infection and symptoms are delayed but reserved to patients who are able to follow rifampin-based combination therapy for a prolonged duration that should not be different for hip and knee PJI.

Usefulness of sonication for diagnosing infection in explanted orthopaedic implants

BACKGROUND

Orthopaedic implant infection is a rare but serious complication whose optimal treatment requires an accurate microbiological diagnosis. The objective of this study was to determine whether culturing sonicated explants improved sensitivity compared to culturing standard sonicated soft-tissue samples.

HYPOTHESIS

Cultures of explant sonication fluid are more sensitive than cultures of soft-tissue sonication fluid in patients with implant infection.

METHODS

This single-centre retrospective study included all sonication fluid samples from implants explanted in orthopaedic surgery theatres for any reason. The microbiological results of the implant sonication fluid cultures were compared to those of cultures of sonicated soft-tissue and bone samples taken during the same procedure. The primary evaluation criterion was the difference in microorganisms recovered from explant sonication fluids versus fluid/tissue cultures.

RESULTS

The study included 187 explants removed between September 2009 and June 2015. Of the definite infections, 83% were identified by explant sonication, 86% by fluid/tissue cultures, and 91% by both techniques combined. Explant sonication recovered causative organisms in 10 patients with definite infection but negative fluid/soft tissue cultures. Antibiotic therapy prior to explantation was associated with lower sensitivity of explant sonication (57% vs. 67% for fluid/soft tissue cultures).

CONCLUSION

Explant sonication improved the diagnosis of infection when combined with fluid/soft tissue cultures.

LEVEL OF EVIDENCE

IV, retrospective single-centre study.

Collection and reconstruction after harvesting donor tissues from the musculoskeletal system: Technique specific to the lower limbs

The lack of available musculoskeletal grafts in France forces us to import a very large quantity of these tissues to use in complex reconstruction procedures. The goal of this article is to describe methods for collecting donor tissues from the musculoskeletal system and for reconstructing the harvested areas. We also provide a summary of the collection procedures performed, harvested grafts and available tissues. While tissue collection requires a significant time investment, the emergence of dedicated teams may be a solution for increasing the number and quality of human musculoskeletal allograft tissues.

Mixed qualitative and quantitative approach for validating an information booklet before total hip arthroplasty

OBJECTIVE

Providing patients with validated information before total hip arthroplasty may help lessen discrepancies between patients' expectations and the surgical result. This study sought to validate an information booklet for candidates for hip arthroplasty by using a mixed qualitative and quantitative approach based on a panel of patients and a sample of healthcare professionals.

METHODS

We developed a booklet in accordance with the standard methods and then conducted focus groups to collect the opinions of a sample of multidisciplinary experts involved in the care of patients with hip osteoarthritis. The number of focus groups and experts was determined according to the data saturation principle. A panel of patients awaiting hip arthroplasty or those in the immediate post-operative period assessed the booklet with self-reporting questionnaires (knowledge, beliefs, and expectations) and semi-structured interviews.

RESULTS

All experts and both patient groups validated the booklet in terms of content and presentation. Semi-structured interviews were uninformative, especially for post-operative patients. Reading the booklet significantly (P<0.001) improved the knowledge scores in both groups, with no intergroup differences, but did not affect beliefs in either patient group. Only pre-operative patients significantly changed their expectations.

CONCLUSION

Our mixed qualitative and quantitative approach allowed us to validate a booklet for patients awaiting hip arthroplasty, taking into account the opinions of both patients and healthcare professionals.

Cu-doping of calcium phosphate bioceramics: From mechanism to the control of cytotoxicity

In this study, the Cu-doping mechanism of Biphasic Calcium Phosphate (BCP) was thoroughly investigated, as was its ionic release behavior, in order to elucidate cytotoxicity features of these bioceramics. BCP are composed of hydroxyapatite (Ca₁₀(PO₄)₆(OH)₂) and β-TCP (Ca₃(PO₄)₂). The two phases present two different doping mechanisms. Incorporation into the β-TCP structure is achieved at around 700 °C thanks to a substitution mechanism leading to the Cu-doped Ca_3-xCu_x(PO₄)₂ compound. Incorporation into the HAp structure is achieved thanks to an interstitial mechanism that is limited to a Cu-poor HAp phase for temperatures below 1100 °C (Ca₁₀Cu_x(PO₄)₆(OH)_2-2xO_2x with x < 0.1). Above 1100 °C, the same interstitial mechanism leads to the formation of a Cu-rich HAp mixed-valence phase (Ca₁₀Cu²⁺_xCu⁺_y(PO₄)₆(OH)_2-2x-yO_2x+y with x + y ∼ 0.5). The formation of both high-temperature Cu-doped α-TCP and Cu₃(PO₄)₂ phases above 1100 °C induces a transformation into the Cu-rich HAp phase on cooling. The linear OCuO oxocuprate entity was confirmed by EXAFS spectroscopy, and the mixed Cu⁺/Cu²⁺ valence was evidenced by XPS analyses. Ionic releases (Cu⁺/Cu²⁺, Ca²⁺, PO₄^2- and OH^-) in water and in simulated body media were investigated on as-synthesized ceramics to establish a pretreatment before biological applications. Finally the cytotoxicity of pretreated disks was evaluated, and results confirm that Cu-doped BCP samples are promising bioceramics for bone substitutes and/or prosthesis coatings.

STATEMENT OF SIGNIFICANCE

Biphasic Calcium Phosphates (BCP) are bioceramics composed of hydroxyapatite (HAp, Ca₁₀(PO₄)₆(OH)₂) and beta-Tricalium Phosphate (β-TCP, Ca₃(PO₄)₂). Because their chemical and mineral composition closely resembles that of the mineral component of bone, they are potentially interesting candidates for bone repair surgery. Doping can advantageously be used to improve their biological behaviors; however, it is important to describe the doping mechanism of BCP thoroughly in order to fully appraise the benefit of the doping process. The present paper scrutinizes in detail the incorporation of copper cation in order to correctly interpret the behavior of the Cu-doped bioceramic in biological fluid. The understanding of the copper doping mechanism, related to doping mechanism of others 3d-metal cations, makes it possible to explain the rates and kinetic of release of the dopant in biological medium. Finally, the knowledge of the behavior of the copper doped ceramic in biological environment allowed the tuning of its cytotoxicity properties. The present study resulted on pre-treated ceramic disks which have been evaluated as promising biocompatible ceramic for bone substitute and/or prosthesis coating: good adherence of bone marrow cells with good cell viability.