Medial patellofemoral ligament reconstruction for recurrent patellar dislocation allows a good rate to return to sport

PURPOSE

Recurrent patellar dislocation is a frequent knee disorders in young, active patients. Medial patellofemoral ligament reconstruction (MPFLR) can restore knee stability and function, but the rate of return to sports is less clear. The aim of this study was to evaluate rate of return to sport following treatment of recurrent patellar dislocation with isolated MPFLR.

METHODS

Between 2011 and 2018, 113 patients with recurrent patellar dislocation were treated with isolated MPFLR at an academic center. Pre-injury sports participation and Tegner score, pre-operative subjective IKDC score, time to return to sports, and post-operative Tegner and subjective IKDC scores were collected, with a minimum of follow-up of 2 years.

RESULTS

One hundred and three patients (91%) were evaluated at a mean of 4.5 ± 2.5-year post-operative. 92 patients (89%) participated in sports prior to onset of patellar instability. At final follow-up, 84 of these 92 patients (91%) were able to return to sports. The mean time from surgery to return to sports was 10.4 ± 8.6 months (range: 2-48 months). 62 patients (67%) returned to the same (50 patients) or higher (12 patients) level. 22 patients (26%) returned at a lower level. 19 of these patients attributed this decreased participation to ongoing knee problems. The median Tegner score was noted to decrease from 5 pre-injury to 4 post-operatively (p = 0.02).

CONCLUSION

Isolated MPFL reconstruction allowed return to pre-injury sports in 91% of patients, with 67% of patients returning to the same or higher level than pre-injury. Mean time to return to sports was 10 months and post-operative Tegner score was noted to be modestly decreased from pre-injury level.

LEVEL OF EVIDENCE

IV.

Dual mobility cups associated with proximal femoral replacement in nontumoral indications: Results and complications

INTRODUCTION

Reconstruction of extensive proximal femoral bone loss is a major challenge during total hip arthroplasty (THA). Proximal femoral replacement (PFR), initially used for bone tumors, is an alternative to allograft-prosthetic composite reconstruction. However, PFRs present a high complication rate, particularly related to dislocation. Moreover, dual mobility cups (DMCs) are effective in preventing dislocation, and no study has yet assessed their association with PFRs. Therefore, the aim of this study was to assess the dislocation and complication rates in THA using PFRs with DMCs.

HYPOTHESIS

The use of a DMC decreases the dislocation rate associated with PFRs in nontumoral indications.

METHODS

From 2008 to 2017, 66 PFRs associated with a DMC (40 women, mean age=71 years [26-94]) were included in our total joint registry and retrospectively reviewed. The main indications were complex periprosthetic and pertrochanteric fractures (26 THAs, 40%), aseptic loosening (22 THAs, 33%) and periprosthetic joint infections (18 THAs, 27%). A single design of PFR implant was used (Global Modular Replacement System (GMRS), Stryker, Mahwah, NJ, USA) with an uncemented stem in 54 THAs (82%).

RESULTS

Eighteen complications (27%) were reported at a mean follow-up of 4.6 years [2-10]: 5 dislocations (7.5%), 9 periprosthetic joint infections (13.6%), 2 aseptic loosening (3%) and 2 femur fractures (3%). Overall survivorship at 5 years was 72% (95% CI: 58-82). Survivorship free from dislocation was 94% (95% CI: 85-98) at 1 year. The mean Harris Hip Score was 70±16.4 [26-100] at latest follow-up.

CONCLUSION

The use of DMCs limits the risk of PFR dislocation, in comparison to other series in the literature that used large femoral heads, without compromising implant survivorship. In addition, DMCs make it possible to overcome the potential risks of mechanical failure associated with constrained acetabular components.

LEVEL OF EVIDENCE

IV; retrospective cohort.

Primary osteoarthritic knees have more varus coronal alignment of the femur compared to young non-arthritic knees in a large cohort study

PURPOSE

Many surgeons are performing total knee arthroplasty (TKA) with an aim to reproducing native anatomical coronal alignment. Yet, it remains unclear if primary osteoarthritic and non-osteoarthritic populations have similar knee coronal alignment. This study aims to describe and compare the distribution of femoral and tibial coronal alignment in a large primary osteoarthritic cohort and a young non-osteoarthritic cohort.

METHODS

This is a retrospective analysis of a monocentric prospectively gathered data, from 1990 to 2019, of 2859 consecutive primary osteoarthritic knees in 2279 patients. Patients underwent standardized long-leg radiographs. Femoral mechanical angle (FMA) and tibial mechanical angle (TMA) were digitally measured using software. Femoral, tibial and knee phenotypes were analyzed, and descriptive data were reported. Data were compared to a young non-osteoarthritic population previously described.

RESULTS

In osteoarthritic knees, the mean FMA was 91° ± 2.9° (range 86°-100°) and the mean TMA was 87° ± 3.1° (range 80°-94°). No significant difference was observed for FMA and TMA between genders. The most common femoral and tibial phenotypes were varus (38.7%) and neutral (37.1%). The most frequent knee phenotype was a varus femoral phenotype with a neutral tibial phenotype (15.5%), which is different to the non-osteoarthritic population.

CONCLUSION

This study showed the wide distribution of knee phenotypes in a large osteoarthritic cohort. There was more varus distribution of the femoral coronal alignment compared to a non-osteoarthritic population, suggesting consideration and potential adaptation of the realignment strategy of the femoral component during TKA.

LEVEL OF EVIDENCE

III.

No significant clinical and radiological differences between fixed versus mobile bearing total knee replacement using the same semi-constrained implant type: a randomized controlled trial with mean 10 years follow-up

PURPOSE

The aim of this study was to compare the long-term clinical and radiological results between fixed (FB) and mobile bearing (MB) implants with identical design from the same manufacturer.

METHODS

From March 2007 to May 2009, we recruited 160 patients in a prospective, single centered, randomized controlled trial. The authors compared 81 FB total knee arthroplasty (TKA) versus 79 MB with medial compartment osteoarthritis. The same posterior stabilized HLS Noetos knee prosthesis (CORIN) was used in all patients. The two groups only differed by the tibial insert (fixed or mobile). The authors compared the postoperative Knee Society Score (KSS), the passive clinical and active radiological knee flexion, the implant survivorship, the complications, and the presence of radiolucent lines.

RESULTS

At mean 10.5 years' follow-up (range 8-12.1 years) no significant differences were found in clinical scores (KSS (p = 0.54), pain score (p = 0.77), stair climbing (p = 0.44), passive maximum flexion (p = 0.5)) or for radiological analyses (maximum active radiological flexion (p = 0.06), presence of progressive radiolucent lines (5 (MB group) versus 6 (FB group); p = 0.75)) between groups. No significant difference was found in overall implant survivorship (82% (MB group) versus 78% (FB group) p = 0.58) or complication rate (p = 0.32) at the last follow-up.

CONCLUSION

No significant clinical and radiological differences were found between fixed and mobile bearing TKA using the same semi-constrained implant type with comparable overall survivorship. The choice between a fixed or mobile bearing implant should be based on surgeon preference and experience with the selected implant.

LEVEL OF EVIDENCE

Prospective randomized controlled trial, Level II.

How a Patient Personalised Clinical Pharmacy Programme Can Secure Therapeutic Care in an Orthogeriatric Care Pathway (5P Project)?

Background

A new model was developed for integrating a personalised clinical pharmacy programme (5P project) into the orthogeriatric care pathway.

Objective

To secure the therapeutic care of orthogeriatric patients.

Design and Setting

Prospective descriptive study in a multisite teaching hospital from June 2019 to January 2020.

Subjects

Patients aged ≥75 years admitted for hip fracture.

Methods

A prescription review was performed for all patients at inclusion. Other clinical pharmacy activities (additional prescription review, pharmaceutical interviews, medication reconciliation) were dedicated to “high-risk” patients. Potential medication errors (ME), either pharmaceutical interventions (PI) or unintentional discrepancies (UID), were recorded. The potential clinical impact of PI was evaluated by a pluriprofessional expert panel using a validated tool.

Results

In the 455 patients included, 955 potential ME were detected, that is ≥1 potential ME for 324/455 (71%) patients. In acute care, 561 PI were formulated during prescription review for 440/455 (97%) patients and 348/561 (62%) were accepted by physicians. Medication reconciliation was performed for 213 patients, 316 UID were identified. In rehabilitation units, a second prescription review was performed for 112/122 (92%) “high-risk” patients, leading to 61 PI. The clinical impact was evaluated for 519/622 (83%) PI. A consensus was obtained for 310/519 (60%) PI: 147/310 (47%) were rated as having minor clinical impact, 138/310 (45%) moderate, 22/310 (7%) major, 2/310 (0.6%) vital, and 1/310 (0.3%) null.

Conclusion

The 5P project secured the orthogeriatric care pathway by detecting a great number of potential ME, including PI mostly considered as having a significant clinical impact.

Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: A cohort study of 184 consecutive patients

BACKGROUND

Intramedullary nailing is the standard of care for tibial shaft fractures. The risk factors for infectious and/or mechanical complications, notably non-union, remain incompletely understood. The objective of this study was to evaluate risk factors for complications, notably non-union.

HYPOTHESIS

Active smoking and an initial open wound are independent risk factors for complications.

MATERIALS AND METHODS

We retrospectively included consecutive patients managed for open or closed tibial shaft fractures by primary intramedullary nailing between 2013 and 2018. We collected data on preoperative factors related to the patient and to the mechanism of injury (age, sex, smoking history, energy of the trauma, open wound), on intraoperative factors (residual interfragmentary gap), and on postoperative factors (early or delayed weight-bearing). We evaluated the associations between these factors and the occurrence of complications, notably non-union, by performing a univariate analysis followed by a multivariate analysis.

RESULTS

We included 184 patients [mean age, 38.5±17.6 (range, 15-91), 72.2% of males]. One or more complications developed in 28 (15.2%) patients and non-union occurred in 15 (8.1%) patients. There were three significant risk factors for complications: active smoking (OR, 7.93; 95%CI, 2.76-22.7), a residual interfragmentary gap >5mm (OR, 4.92; 95%CI, 1.72-14.02), and an initial open wound (OR,5.16; 95%CI, 1.62-16.43) (p<0.05). The same three factors were significant risk factors for non-union. Energy of the trauma, age, sex, and early or delayed weight bearing were not significantly associated with an excess risk of complications.

DISCUSSION

Active smoking, a residual interfragmentary gap >5mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing to treat a tibial shaft fracture. Preventive strategies and specific information could be implemented for these patients.

LEVEL OF EVIDENCE

IV; single-centre retrospective cohort study.

Phage Therapy as Adjuvant to Conservative Surgery and Antibiotics to Salvage Patients With Relapsing S. aureus Prosthetic Knee Infection

Objectives: To report the management of three consecutive patients with relapsing Staphylococcus aureus prosthetic knee infection (PKI) for whom explantation was not feasible who received a phage therapy during a “Debridement Antibiotics and Implant Retention” (DAIR) procedure followed by suppressive antimicrobial therapy.

Methods: Each case was discussed individually in our reference center and with the French National Agency (ANSM). The lytic activity of three phages targeting S. aureus, which was produced with a controlled and reproducible process, was assessed before surgery (phagogram). A hospital pharmacist extemporaneously assembled the phage cocktail (1 ml of 1 × 10¹⁰ PFU/ml for each phage) as “magistral” preparation (final dilution 1 × 10⁹ PFU/ml), which was administered by the surgeon directly into the joint, after the DAIR procedure and joint closure (PhagoDAIR procedure).

Results: Three elderly patients were treated with the PhagoDAIR procedure. Phagograms revealed a high susceptibility to at least two of the three phages. During surgery, all patients had poor local conditions including pus in contact to the implant. After a prolonged follow-up, mild discharge of synovial fluid persisted in two patients, for whom a subsequent DAIR was performed showing only mild synovial inflammation without bacterial persistence or super-infection. The outcome was finally favorable with a significant and impressive clinical improvement of the function.

Conclusions: The PhagoDAIR procedure has the potential to be used as salvage for patients with relapsing S. aureus PKI, in combination with suppressive antibiotics to avoid considerable loss of function. This report provides preliminary data supporting the setup of a prospective multicentric clinical trial.

Factors lead to return to sports and recreational activity after total knee replacement - A retrospective study

Introduction: The number of total knee replacements performed (TKR) is increasing and so are patient expectations and functional demands. The mean age at which orthopedic surgeons may indicate TKR is decreasing, and therefore return to sport (RTS) after TKR is often an important expectation for patients. The aim of this study was to analyze the mid-term RTS, recreational activities, satisfaction level, and forgotten joint level after TKR. Methods: Between January 2015 and December 2016, 536 TKR (same implant design, same technique) were performed in our center. The mean age at survey was 69 years with a mean follow-up of 43 months. All patients who did not have a follow-up in the last 6 months were called. Finally, 443 TKR were analyzed. RTS was assessed using the University of California Los Angeles Scale (UCLA), forgotten joint score (FJS), and Satisfaction Score. Results: In this study, 85% of patients had RTS after TKR with a mean UCLA score increasing from 4.48 to 5.92 and a high satisfaction rate. Satisfaction with activity level was 93% (satisfied and very satisfied patients). The RTS is more important for people with a higher preoperative UCLA score and a lower American Society of Anesthesiologist score (ASA). Each point increase in ASA score is associated with reduced probability to RTS by 52%. Discussion: RTS and recreational activity were likely after TKR with a high satisfaction score. Preoperative condition and activity are the two most significant predictive factors for RTS. Level of evidence: Retrospective case series, level IV.

Lateral retinacular release is not recommended in association to MPFL reconstruction in recurrent patellar dislocation

PURPOSE

Reconstruction of the medial patellofemoral ligament (MPFL) has become the gold standard for the treatment of the recurrent patellar dislocation (RPD). Lateral retinacular release can be performed in association with MPFL reconstruction, but the effect on outcomes is not clear. To evaluate the effect of lateral release on outcomes following MPFL reconstruction is the aim of this study. It is hypothesized that isolated MPFL reconstruction was not inferior to MPFL reconstruction and lateral retinacular release in terms of IKDC subjective score and patellar tilt (PT).

METHODS

Patients between ages 18 and 45 scheduled to undergo MPFL reconstruction without an associated bony procedure (tibial tubercle osteotomy or trochleoplasty) were randomized to isolated MPFL reconstruction or MPFL reconstruction (no LRR group) and arthroscopic LRR (LRR group). Evaluation criteria were subjective IKDC score as the primary outcome and PT evaluated with a CT-scan. PT was evaluated with the quadriceps relaxed (PTQR) and contracted (PTQC).

RESULTS

Of 43 patients included in the trial, 7 were lost of follow-up, 3 were not able to complete evaluation because of medical reasons, and 33 patients were evaluated with a minimum of 12 months and a median follow-up of 24 (12-60) months. The average subjective IKDC score was at 86 ± 20 (29-94) in the LRR group and 82 ± 15 (39-95) in the no LRR group (p = 0.45). The PTQR was at 22° ± 7° (13-37) in the LRR group and 21 ± 10 (4-37) in the no LRR group (n.s.). The PTQC was at 27° ± 9° (12-40) in the LRR group and 25 ± 12 (5-45) in the no LRR group (n.s.). No complications were noted in either group.

CONCLUSIONS

No significant differences were found in subjective IKDC score or patellar tilt based on the addition of an arthroscopic LRR to an MPFL reconstruction in patients with RPD not undergoing associated bony procedures. There is no indication to a systematic lateral retinacular release in association with MPFL reconstruction in the treatment of RPD.

LEVEL OF EVIDENCE

II.

Bone and parietal anterior iliac crest reconstruction for trans-iliac hernia after tricortical graft harvesting: An original technique

Tricortical cortico-cancellous bone allografts from the anterior iliac crest are routinely used in revision arthroplasty and to treat non-union. Trans-iliac herniation (TIH) has been reported as an exceptional complication after extensive graft harvesting. The various reconstruction techniques include isolated parietal reconstruction and combined parietal and bone reconstruction using allografts or a spacer to reconstruct the bone defect. No previous study has evaluated a combined reconstruction technique involving both bone reconstruction with a titanium plate and abdominal wall reconstruction with a parietal reinforcement prosthesis. This technical note describes the evaluation of an original combined reconstruction technique used after failure of isolated parietal reconstruction to treat TIH. Through a direct approach to the anterior iliac crest, the bone defect was repaired using a flexible titanium cranio-facial reconstruction plate and the abdominal wall defect using a polypropylene/poliglecaprone parietal reinforcement prosthesis. This original technique was demonstrated to be effective for treating TIH, with no recurrence after 2.5 years of follow-up. In addition, this technique involves no added morbidity related, for instance, to allograft using or spacer migration.

Comparison of screw versus locked plate fixation for Scarf osteotomy treatment of hallux valgus

INTRODUCTION

The Scarf osteotomy is a commonly used surgical procedure for treating hallux valgus in Europe. Screw fixation is standard practice, although some surgeons now go without internal fixation. Plate fixation is still being studied. The aim of this study was to compare the radiological outcomes of these fixation methods, which has not been performed up to now.

HYPOTHESIS

Relative to screw fixation, plate fixation of a Scarf osteotomy of the first metatarsal (M1) prevents secondary impaction, without increasing the complication rate or recurrence rate.

MATERIALS AND METHODS

A retrospective study was performed of two internal fixation methods for Scarf osteotomy (screw vs. plate), by analyzing the secondary impaction of the first metatarsal, recurrence of the hallux valgus (angle M1P1>20) on X-rays, incidence of complications and potential discomfort related to the hardware. The osteotomy procedure was the same in both groups: 50patients were included consecutively in each fixation group between February 2014 and November 2015.

RESULTS

The mean follow-up was 13.0±2.7months in the screw group and 12.3±1.1 months in the plate group. There were no severe complications, although four cases of delayed wound healing occurred (3in plate group, 1in screw group). In the screw group, there was one case of secondary impaction, two cases of recurrence (4%) and one case of discomfort. In the plate group, there were no cases of impaction, three recurrences (6%) and five cases of discomfort, leading to plate removal in three of these cases.

DISCUSSION

There was no significant difference between groups in the M1 secondary impaction rate or recurrence rate: screw fixation did not lead to a higher recurrence rate. Systematic fixation with a locked plate for Scarf osteotomy had no advantages over screw fixation in our study.

LEVEL OF EVIDENCE

II, Comparative study with continuous cohorts.

Total Hip Arthroplasty for Periacetabular Metastatic Disease. An Original Technique of Reconstruction According to the Harrington Classification

BACKGROUND

Periacetabular metastatic disease requires complex acetabular reconstruction. The complication rate for these frail patients is high. Various cement-rebar reinforced techniques allowing cemented total hip arthroplasty (THA) have been described. The optimal procedure has not yet been identified.

METHODS

A continuous series of 131 THAs performed in 126 patients with periacetabular metastatic disease was prospectively included in this study. After bone metastasis curettage and cementation, an original technique of acetabular reconstruction was performed using a dual mobility cup cemented into an acetabular reinforcement device (ie, Kerboull cross-plate or Burch-Schneider antiprotrusio cage) according to the Harrington classification. Functional outcome for independent ambulation in the community, pain relief, and occurrence of dislocation or mechanical failure of the acetabular reconstruction were assessed.

RESULTS

At a mean follow-up of 33 ± 17 months, the improvement in the preoperative to postoperative functional outcome and pain relief was significant (P < .001). The dislocation rate was 2%. Two of the 3 cases of dislocation occurred in acetabular reconstructions associated with a proximal femoral arthroplasty. No mechanical failure or aseptic loosening of the acetabular reconstruction was observed.

CONCLUSION

This study emphasized that our original technique combining bone metastasis curettage and cementation, acetabular reinforcement device and cemented dual mobility cup was effective to restore a painless functional independence and ensure a durable acetabular reconstruction able to face to adjuvant radiation therapy and mechanical solicitations for long survivors. In addition, dual mobility cup limited the risk of dislocation in patients undergoing THA for periacetabular metastatic disease.

Ramp lesions in ACL deficient knees in children and adolescent population: a high prevalence confirmed in intercondylar and posteromedial exploration

PURPOSE

Ramp lesions are common in ACL deficient knees. Their diagnosis is difficult and, therefore, they may be underestimated. So far, no study analyzed their prevalence in a pediatric population. The diagnosis of these Ramp lesions is of major clinical relevance because of a frequent misestimating and technic difficulties. Ramp lesions might be associated with residual knee pain and instability after ACL reconstruction. The aim of this study was to evaluate the prevalence of ramp lesions explored through a systematic intercondylar and posteromedial arthroscopic approach during an ACL reconstruction in a pediatric and adolescent population.

METHODS

Children and adolescents who underwent an ACL reconstruction were screened prospectively between October 2014 and 2016. The presence or absence of a ramp lesion was evaluated after each of three arthroscopic steps: (1) an anterior approach, (2) an intercondylar inspection, and (3) a posteromedial approach. Ramp lesions were screened at each step and their prevalence was evaluated. Furthermore, their presence was correlated to age, weight, size, sex, and state of the physis (open or closed). Finally, the meniscal status on MRI and arthroscopic findings were compared.

RESULTS

Fifty-six patients were analyzed. The median age was 14.0 ± 1.3 years (12-17). The median interval between injury and surgery was 11.5 months (1-108). During step 1 (anterior approach), only 1 ramp lesion (2%) was diagnosed. 13 (23%) ramp lesions were found after inspection through the intercondylar notch. No additional lesions were found with a direct view through the posteromedial approach. No correlation between ramp lesions and side, sex, weight, size, or state of physis was found. 10 ramp lesions out of 13 could not be diagnosed on MRI.

CONCLUSIONS

The prevalence of ACL-associated ramp lesions in children and adolescents is similar to adult populations. A systematic inspection through the intercondylar notch is recommended during ACL reconstruction to make a precise diagnosis. The posteromedial approach is essentially useful for meniscal repair LEVEL OF EVIDENCE: Testing, previously developed diagnostic criteria in a consecutive series of patients and a universally applied "gold" standard, Level I.

Highly crosslinked polyethylene: a safe alternative to conventional polyethylene for dual mobility cup mobile component. A biomechanical validation

PURPOSE

Dual mobility cup (DMC) consists of a cobalt-chromium (CoCr) alloy cup articulated with a polyethylene (PE) mobile component capturing the femoral head in force using a snap-fit technique. This biomechanical study was the first to evaluate and compare the generation of cracks in the retentive area of DMC mobile components made of highly crosslinked PE (XLPE) or conventional ultra-high molecular weight PE (UHMWPE).

METHODS

Eighty mobile components designed for a 52-mm diameter Symbol® DMC (Dedienne Santé, Mauguio, France) and a 28-mm diameter femoral head were analyzed. Four groups of 20 mobile components were constituted according to the PE material: raw UHMWPE, sterilized UHMWPE, annealed XLPE and remelted XLPE. Ten mobile components in each group were impacted with a 28-mm diameter CoCr femoral head using a snap-fit technique. The occurrence, location and area of the cracks in the retentive area were investigated using micro-CT (Skyscan 1176®, Bruker, Aarsellar, Belgium) with a 35 μm nominal isotropic voxel size by two observers blinded to the PE material and impaction or not of the mobile components.

RESULTS

Compared to conventional UHMWPE, the femoral head snap-fit did not generate more or wider cracks in the retentive area of annealed or remelted XLPE mobile components.

CONCLUSION

This biomechanical study suggests that XLPE in DMC could be a safe alternative to conventional UHMWPE regarding the generation of cracks in the retentive area related to the femoral head snap-fit.