Proximal row carpectomy generates better mid- to long-term outcomes than four-corner arthrodesis for post-traumatic wrist arthritis: A meta-analysis

INTRODUCTION

In posttraumatic wrist arthritis of intermediate severity, two main palliative procedures are used to preserve some mobility in the wrist: proximal row carpectomy (PRC) and scaphoid excision followed by four corner arthrodesis (4CA). Despite satisfactory overall results, the debate continues about which one provides the best results and long-term outcomes, particularly prevention of arthritis progression. Recent comparative studies now provide us with information about mid- and long-term results. The aim of this study was to compare the clinical results, complications, conversion rate to total wrist arthrodesis and progression to osteoarthritis of PRC versus 4CA in the medium and long term.

HYPOTHESIS

The null hypothesis was that there is no significant difference between PRC and 4CA in the clinical results, complications, conversion to total wrist arthrodesis and arthritis progression.

MATERIALS AND METHODS

A systematic literature review was carried out by following the PRISMA guidelines. Included were studies comparing 4CA and PRC for the treatment of post-traumatic wrist arthritis secondary to scapholunate dissociation (SLAC) and scaphoid nonunion (SNAC) with a mean follow-up of 5 years. A search was performed of the MEDLINE, EMBASE and Cochrane databases that identified 831 articles. After removing 230 duplicates and excluding 595 articles based on their title and/or abstract, and then adding 1 article manually, 7 articles were included in our analysis. Parameters analyzed were range of motion (ROM), pain, grip strength, functional scores, complications, conversion to total wrist arthrodesis, and arthritis progression.

RESULTS

In the 7 articles, 1059 wrists - 582 PRC and 477 4CA - were analyzed with follow-up ranging from 5.2 to 18 years. PRC produced significantly better ROM in flexion (weighted mean difference [WMD]=10.0°; p<0.01) and in ulnar deviation (WMD=8.7°; p<0.01) along with significantly lower complication rates (OR=0.3; p<0.01) and reoperation rates (OR=0.1; p<0.01). There was no significant difference in the conversion rate, grip strength, extension, radial deviation, pain, DASH and PRWE scores. The progression of osteoarthritis could not be analyzed due to lack of data.

DISCUSSION

This meta-analysis was the first to include recently published mid- and long-term studies comparing PRC and 4CA. The main finding is that PRC is superior overall with better ROM and a lower complication rate. Another important finding was the absence of differences in grip strength and the conversion rate to total wrist arthrodesis. Unfortunately, the lack of systematic studies on arthritis progression leaves this question unanswered. Our findings must be interpreted cautiously because it was impossible to stratify the cases by etiology and osteoarthritis stage.

LEVEL OF EVIDENCE

III; systematic review and meta-analysis.

Tarsal Tunnel Syndrome: Outcome According to Etiology

Surgical results in tarsal tunnel syndrome are variable, and etiology seems to be a factor. Three possible etiologies can be distinguished. The aim of the present study was to compare surgical results according to etiology. Three continuous retrospective series (45 patients overall) of tarsal tunnel syndrome were compared. Group 1 presented a permanent intra- or extra-tunnel space-occupying compressive structure. Group 2 presented intermittent intra-tunnel venous dilatations. Group 3 comprised idiopathic tarsal tunnel syndrome. The mean follow-up was 3.6 +/- 1.8 years. The main endpoint was subjective postoperative improvement on Likert scale. Group 1 reported greater improvement than groups 2 and 3. Preoperative neuropathy on ultrasound was associated with poorer improvement, which was not the case for neuropathy on electromyography. Surgical treatment of tarsal tunnel syndrome provides better results in etiologies involving structural compression.

Psychological risk factors for the occurrence of frozen shoulder after rotator cuff repair

INTRODUCTION

Frozen shoulder is a dreaded complication after rotator cuff repair.

HYPOTHESIS

There are psychological determinants for this complication.

MATERIALS AND METHODS

We prospectively included 77 consecutive patients who underwent arthroscopic rotator cuff repair between May 2018 and April 2019. Along with a functional evaluation, we determined the Constant score, anxiety and depression levels based on the HADS, and kinesiophobia based on the Tampa Scale preoperatively and 6months after the surgery.

RESULTS

At the 6-month follow-up, 8 patients had been diagnosed with frozen shoulder (group A), 65 patients had satisfactory joint range of motion (group B) and 4 were lost to follow-up. In the frozen shoulder group, the preoperative anxiety rate was significantly higher than in group B (50% versus 17%, p=0.04). Furthermore, there were significantly more women (p=0.028) and more patients with an occupational disease in group A (75% versus 18%, p=0.027). At 6months postoperative, the Constant score was 55 in the group with a frozen shoulder versus 72 in group B (p=0.004). Neither depression nor kinesiophobia were risk factors for the development of frozen shoulder after rotator cuff repair.

CONCLUSION

Preoperative anxiety, the female sex and occupational disease are all risk factors for the occurrence of frozen shoulder after rotator cuff repair. Knowing these predisposing factors will help us better manage at-risk patients.

LEVEL OF EVIDENCE

III, prospective study.

A higher reliability with a computed tomography scan-based three dimensional technique than with a two dimensional measurement for lower limb discrepancy in total hip arthroplasty planning

PURPOSE

The goal was to compare the reliability of a novel 3D method with the standard 2D technique for lower limb discrepancy (LLD) measurement during pre-operative THA planning.

METHODS

This prospective study included 100 consecutive patients who underwent THA using 3D planning based on a low-dose CT scan. The LLD was subdivided into three parameters: the intra-articular LLD (IA-LLD), the segmental extra-articular LLD (EA-LLD), and the total LLD (T-LLD). The LLD was assessed with a standard 2D technique on CT scanograms and also with a 3D method. A pelvic reference line (PBL) was determined as the 3D line joining the deepest part of the two great sciatic notches. The IA length was measured from the lesser trochanters (MLT) to the PBL. The EA length was measured from the MLT to the ankle center, and the total length was measured from the ankle center to the PBL. The intra- and inter-observer reliability of the measurements was assessed with the intra-class correlation coefficient (ICC).

RESULTS

The intra-observer ICC was higher with the 3D technique for IA-LLD (0.96-0.97 vs. 0.79-0.84), EA-LLD (0.96 vs. 0.78-0.92), and T-LLD (0.99 vs. 0.90-0.97). Inter-observer ICC was also higher with the 3D technique for IA-LLD (0.90-0.94 vs. 0.70-0.84) and EA-LLD (0.93-0.96 vs. 0.80-0.82), but not for T-LLD (0.91-0.94 vs. 0.91-0.94).

CONCLUSION

The presented 3D method has a higher reliability than 2D assessment of LLD during pre-operative THA planning. This article presents the first discussion of measuring LLD from 3D models. As 3D reconstruction becomes both more feasible and less-invasive, this study has interest to the orthopaedic surgeon.

Preoperative Osteopathic Manipulative Therapy Improves Postoperative Pain and Reduces Opioid Consumption After Total Knee Arthroplasty: A Prospective Comparative Study

Context

Pain is a therapeutic challenge after total knee arthroplasty (TKA), and it could lead to the overuse of opioids. Few methodologically robust clinical studies have been performed to assess the effectiveness of osteopathic manipulative therapy (OMTh; manipulative care performed by non-US-trained osteopaths) for postsurgical pain.

Objective

To evaluate the effectiveness of standardized preoperative OMTh on early postoperative pain and opioid consumption after TKA.

Methods

This comparative, nonrandomized study took place from 2013 to 2015 and included patients who had primary unilateral TKA for osteoarthritis in a knee that had not undergone any previous surgery. Patients were divided into 2 consecutive groups: 1 group received traditional preoperative management, and the other group received associated preoperative OMTh (general OMTh [rhythmic mobilization of all the body joints, from the ankles to the skull, using long-lever manipulation] and myofascial relaxation). The primary evaluation criterion was knee pain at rest 1 month after surgery: 0 (no pain) to 100 (the worst imaginable pain). The secondary evaluation criteria were: (1) knee pain while walking 1 month after surgery, (2) average weekly knee pain during the first month after surgery, (3) the presence of night pain and the consumption of sleeping pills and opioids or morphine at least once per week, (4) the International Knee Society scores and the Western Ontario and McMaster University Osteoarthritis index at postoperative 6 months and 1 year. The number of patients needed for a superiority trial was determined.

Results

No eligible patient refused OMTh when proposed. Seventy patients were evaluated (mean [SD] age, 75 [8] years; 47 women and 23 men). The 2 treatment groups contained 35 patients each. At postoperative month 1, the OMTh group had significantly less pain at rest (mean [SD], 6.8 [6] vs 20.9 [17.3]; P=.00001) and while walking (7.9 [9.4] vs 23.5 [20.6]; P=.0001) compared with the group that received traditional preoperative management. The consumption of opioids during the first postoperative week was significantly lower in the OMTh group (P=.0001). No statistically significant difference was found in the International Knee Society or Western Ontario and McMaster University Osteoarthritis scores between the 2 groups at 6 months and 1 year of follow-up.

Conclusion

Standardized preoperative OMTh was found to be effective in reducing pain in the first month after TKA for osteoarthritis and significantly reduced opioid consumption during the first postoperative week.

Can primary total hip arthroplasty be performed in an outpatient setting? Prospective feasibility and safety study in 321 patients in a day-surgery unit

INTRODUCTION

Total hip arthroplasty (THA) performed as day-surgery is an emerging and growing practice. The main aim of the present study was to assess the feasibility and safety of primary THA in an outpatient setting. The study hypothesis was that, within a specifically dedicated structure, such surgery is feasible and safe.

MATERIAL AND METHODS

A prospective observational study was performed in two centers, one private hospital and one university hospital, including all patients operated on by two senior surgeons between 2014 and 2017 for primary THA and eligible for day-surgery. The clinical pathway was governed by a pre-established protocol. Preoperatively, all patients took part in an information workshop, with their spouses and the surgeon. Postoperative phone interviews were held on D1 and D3, then out-patient consultations were conducted at 1 and 6 weeks. The main study endpoint was successful outpatient management, failure being defined as crossover or readmission within 1 week of discharge. Secondary endpoints comprised complications rate and satisfaction as assessed by patient and spouse at 6 weeks.

RESULTS

During the study period, 1,303 patients received primary THA. 338 (25.9%) were eligible for day-surgery, but 17 (5%) declined; the day-surgery series thus comprised 321 patients (24.6%): 166 men, 155 women; mean age, 61.2±9.7 years. Same-day discharge was not possible for 14 patients (4.5%): 9 due to persistent faintness, 2 to intraoperative femoral fracture, 1 to organizational issues, 1 to an uncomplicated fall, and 1 to hemoglobinemia<11g/100ml in a coronary patient. There were no readmissions during week 1. At 6 weeks' follow-up, there had been 3 adverse events: 2 dislocations, and 1 periprosthetic fracture. 312 patients (97.2%) were satisfied.

CONCLUSION

The present prospective study found no major adverse events in patients undergoing day-surgery for primary THA. However, patients should be selected, consenting, prepared and managed on a standardized clinical pathway.

LEVEL OF EVIDENCE

IV; non-comparative prospective study.

Risk factors for passive anterior tibial subluxation on MRI in complete ACL tear

INTRODUCTION

In anterior cruciate ligament (ACL) tear, passive spontaneous anterior tibial subluxation (ATS), with respect to the femur, is sometimes observed on MRI. In a case-control study, ATS>3.5mm showed 100% specificity (±3.6, 95% CI) for complete ACL tear. The aim of the present study was to assess the relation between ATS on MRI and associated lesions in complete ACL tear. The study hypothesis was that associated lesions are a risk factor for ATS.

MATERIAL AND METHODS

A retrospective study included patients operated on for complete ACL tear between 2010 and 2015. Exclusion criteria comprised associated posterior cruciate ligament tear, partial ACL tear, and history of knee surgery. Preoperative MRI was performed with the patient in supine position and the knee in 20° flexion in neutral rotation. ATS was measured by axial superimposition of the bicondylar slice on the slice through the tibial plateau. Associated lesions were assessed: medial and lateral menisci, collateral ligaments, posteromedial and posterolateral corners, tibiofemoral compartment cartilage and cancellous bone. Factors associated with ATS>3.5mm were analyzed. Ninety-one patients were included: mean age, 31.1±10.1 years; 34 female, 57 male. Mean time from injury to MRI was 7.8±11.7 months (range, 0.7-60 months).

RESULTS

Mean ATS was 4.7±2.3mm. Inter- and intra-observer reproducibility for ATS measurement were excellent. On preoperative MRI, 61.1% of patients showed bone edema, 48.4% medial meniscal tear, and 36.3% lateral meniscal tear. ATS was significantly greater in case of medial meniscal tear (5.4±2.3mm vs. 4±2.1mm; p=0.003). No significant differences were found according to other lesions. Fifty-four patients (59.3%) showed ATS>3.5mm; risk factors comprised medial meniscal tear (OR=2.6, 95%CI [1.1-6.2]; p=0.03) and injury-to-MRI time>9 months (OR=9.8, 95% CI [1.1-85.2]; p=0.04).

CONCLUSION

Spontaneous anterior tibial subluxation on MRI in complete ACL tear was significantly associated with medial meniscal tear and accident-to-MRI time.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Vancomycin-soaked autografts during ACL reconstruction reduce the risk of post-operative infection without affecting return to sport or knee function

PURPOSE

To compare return to sport and knee function 1 year after anterior cruciate ligament (ACL) reconstruction using autografts with and without vancomycin presoaking.

METHODS

A case-control study based on a retrospective analysis of prospective data included athletes over the age of 16 operated from 2012 to 2018 for ACL reconstruction. There were two groups of patients due to a change in treatment protocols: Group 1 « without vancomycin » before November 2016 and Group 2 « with vancomycin» after this date. In Group 2, the graft was soaked in a vancomycin solution for 10 min and then fixed into the bone tunnels. The primary evaluation criterion was the return to sport 1 year after surgery. The secondary criteria were various knee scores. The number of patients needed to perform a non-inferiority study was calculated.

RESULTS

1674 patients fulfilled the selection criteria, 1184 in Group 1 and 490 in Group 2. The series included 1112 men and 562 women, mean age 30 ± 9.7 years, 68 professional athletes, 674 competitive athletes and 932 recreational athletes. While seven patients presented with post-operative septic arthritis in Group 1, this complication was not found in Group 2. No significant difference was identified in the return to running between the two groups 1 year after surgery (75.9% vs. 76.1%, n.s.). Significantly more of the patients in Group 2 returned to their preinjury sport (p = 0.04). Knee function was comparable between the groups.

CONCLUSION

Vancomycin-soaked grafts during ACL reconstruction reduce the risk of post-operative infection of the knee without affecting the return to sport or knee function.

LEVEL OF EVIDENCE

III.

TRIAL REGISTRATION

https://clinicaltrials.gov/ , ClinicalTrials.gov Identifier: NCT02511158.

Correction to: Vancomycin-soaked autografts during ACL reconstruction reduce the risk of post-operative infection without affecting return to sport or knee function

The article Vancomycin‑soaked autografts during ACL reconstruction reduce the risk of post‑operative infection without affecting return to sport or knee function, written by Yoann Bohu.

Reliability of a new dynamic ultrasound test for quantifying first-ray mobility

BACKGROUND

First-ray hypermobility (FRHM) is a documented abnormality whose pathogenic role is controversial. FRHM has been suggested to participate in many common disorders such as paediatric hallux valgus and recurrence after hallux valgus surgery. The controversy is due to lack of functional data on the first tarso-metatarsal joint (TMT1) in real-life situations, to its major anatomical variability, and to the absence of simple investigation methods. The objective of this study was to assess the feasibility and the inter- and intra-observer reproducibility of a new dynamic ultrasound test that quantifies TMT1 mobility and is simple to use provided a good-quality ultrasound machine is available.

HYPOTHESIS

The new ultrasound TMT1 mobility test is reproducible.

MATERIAL AND METHODS

The 32 feet of 16 consecutive patients whose first ray was considered normal were included. Ultrasonography was performed at rest and during a stress test consisting in causing TMT1 gaping by applying a distal dorsal drawer movement to the first metatarsal. The two plantar bony prominences on either side of the TMT1 were identified, and the distance between them was measured at rest and during the stress test. The stress/rest ratio was computed. Each foot was tested twice by two different examiners, for a total of 128 tests.

RESULTS

Mean TMT1 gaping distance was 1.38mm (range, 1.01-2.02mm) at rest and 1.67mm (range, 1.12-2.95mm). The mean stress/rest ratio was 1.21 (range, 1.02-1.62). Both inter- and intra-observer reliability was strong for all measured parameters.

DISCUSSION

A simple and reproducible ultrasound test for measuring TMT1 mobility is described for the first time. The good reproducibility confirms the working hypothesis. This preliminary study was designed to validate the new test. The measured values need to be assessed in various disorders including FRHM, for which the test was designed. Should the results prove conclusive, the TMT1 gaping test may become a pivotal diagnostic tool.

LEVEL OF EVIDENCE

IV, diagnostic study.

Can the number of surgery delays and postponements due to unavailable instrumentation be reduced? Evaluating the benefits of enhanced collaboration between the sterilization and orthopedic surgery units

INTRODUCTION

The development of outpatient surgery, cost-reduction pressures and instrumentation storage limitations have led to their use "just-in-time". A recent study showed that stoppage of surgical procedures immediately before the incision (No-Go) was often due to the management of supplies and implantable medical devices. To our knowledge, since the development of outpatient surgery and the shortening of hospital stays, managing the flow of instrumentation has not been optimized. At our hospital, we used a two-prong approach consisting of a tool to manage instrumentation and working group from the sterilization and orthopedic surgery units. The aims of this study were to: 1) evaluate whether this approach led to better notification of the risk of supply shortage for instrumentation and 2) determine whether it could reduce by at least half operating room disruptions such as delays or cancellation of surgical procedures.

HYPOTHESIS

This approach results in better notification of the risk of supply shortage for instrumentation and reduces by at least half operating room disruptions such as delays or cancellation of surgical procedures.

MATERIAL AND METHODS

A tool was developed to manage instrumentation flow based on a retrospective analysis of data from 2015. This tool consisted of: (1) a list of instrumentation needed for each surgical procedure from an analysis of the surgical schedule and verification of traceability labels of the instrumentation actually used, (2) a list of reasons for supply shortage identified from an analysis of non-conformities occurring in the sterilization process of instrumentation kits. These analyses resulted in the development of checklists for instrument sets for each procedure, while identifying those with a high risk of shortage. In 2017, a working group focused on instrumentation was set up with personnel from the sterilization unit and the orthopedic surgery unit. Based on the check-lists and the schedule 24hours before the surgery, the sterilization unit alerted the surgery unit by email of the risk of material shortage; the surgery ward replied with potential changes to the material or the surgery planning. This approach (instrumentation management tool and working group) was named just-in-time (JIT). The main outcome was the number of notifications of potential supply shortage with and without JIT over a 10-week period. The secondary outcomes were the number of notifications resolved in time and the occurrence of operating room disruptions (delay>30min or postponement of surgery) related to unavailable instrumentation.

RESULTS

Nine reasons for potential supply shortage were identified such as instrumentation kits used for several types of procedures, those with fast rotation and low stock, or in double pathways (on loan and on deposit). The working group reported 163 potential shortages with JIT versus 41 without (p<10^-5), of which 150 (92.5%) were resolved. Thirteen operating room disruptions occurred; only one was not detected by the JIT approach.

CONCLUSION

Our JIT approach (instrumentation management tool and working group) is effective at preventing instrumentation supply shortages.

LEVEL OF EVIDENCE

III, prospective comparative study.

Autologous Conditioned Plasma for tendon healing following arthroscopic rotator cuff repair. Prospective comparative assessment with magnetic resonance arthrography at 6 months' follow-up

INTRODUCTION

Despite improvements in technique and materials for rotator cuff repair, mean re-tear rates remain close to 30%. The aim of the present study was to assess injection of Autologous Conditioned Plasma (ACP™, Arthrex) for tendon healing after arthroscopic repair. The study hypothesis was that ACP™ improves the tendon-healing rate.

MATERIAL AND METHOD

A non-randomized comparative prospective study included all patients aged over 18 years operated on in 2010 for arthroscopic repair of full-thickness rotator cuff tear with≤2 fatty degeneration on the Goutallier classification, whatever the severity of retraction, on virgin non-osteoarthritic shoulder without contraindications for magnetic resonance (MR) arthrography. The surgical protocol was standardized. The first half of the patient sample received end-of-procedure ACP™ injection to the repaired tendon, tuberosity freshening surface and subacromial space, and the second (control) half received no supplementary treatment. The main endpoint was tendon healing on MR arthrography at 6 months according to Sugaya. Secondary endpoints comprised shoulder pain at rest on a numerical scale (0=no pain to 10=worst imaginable pain) and Constant functional score.

RESULTS

Two of the 58 patients refused MR arthrography and 7 were lost to follow-up. Forty-nine patients (26 ACP™, 23 controls) were analyzed: 20 male, 29 female; mean age, 61±7.3 years. There were no significant intergroup differences in healing rate at 6 months (ACP™ 73.1% vs. 78.3% controls; p=0.75), shoulder pain (2±1.8 vs. 2.6±1.7, respectively; p=0.24), or Constant score (77±13.5/100 vs. 72.4±12.3, respectively; p=0.18).

CONCLUSION

Associating ACP™ did not improve healing after arthroscopic rotator cuff repair. Sample size, however, had been calculated for a large expected difference, leading to lack of power.

LEVEL OF EVIDENCE

III; case-control study.

A threshold value of 3.5 mm of passive anterior tibial subluxation on MRI is highly specific for complete ACL tears

PURPOSE

To identify and quantify passive anterior tibial subluxation on MRI using a standardized measurement protocol and determine the diagnostic threshold of subluxation for complete anterior cruciate ligament tears.

METHODS

A retrospective case-control study was performed. Patients who underwent surgery for a complete isolated ACL tear between 2009 and 2015 were matched for age and gender to controls with an intact ligament on knee MRI. All subjects underwent 1.5 T closed field MR imaging with the same protocol. Measurements were performed on axial sequences to evaluate translation of the medial and lateral condyles compared to the tibial plateau. Each compartment was measured between the vertical tangent to the posterior femoral condyles and the most posterior part of the tibial plateau. The main criterion was global passive subluxation measurements on MRI, corresponding to mean medial and lateral compartment subluxation. The reproducibility and diagnostic value of passive subluxation were calculated.

RESULTS

Sixty (30/30) subjects were included, mean age 27.1 ± 1.7 years, 20 women and 40 men. Patients had a significantly higher global passive subluxation than controls (3.3 ± 0.6 mm vs 0.6 ± 0.2 mm, respectively p < 0.00001). Reproducibility was excellent and the diagnostic value of passive subluxation for a complete ACL tear was fair. A passive subluxation threshold of 3.5 mm had a sensitivity of 55.2%, a specificity of 100% and 77.6% of well-classified subjects.

CONCLUSION

The calculated cutoff value for global passive subluxation to identify patients with a complete ACL tear was 3.5 mm, with excellent specificity and a high positive likelihood ratio. Suboptimal clinical results following ACL reconstruction could be partially due to failure to restore an anatomical femorotibial relationship.

LEVEL OF EVIDENCE

III.

Local infiltration analgesia versus interscalene nerve block for postoperative pain control after shoulder arthroplasty: a prospective, randomized, comparative noninferiority study involving 99 patients

BACKGROUND

The aim of this study was to compare the efficacy of local infiltration analgesia (LIA) and interscalene nerve block (ISB) for early postoperative pain control after total shoulder arthroplasty (TSA). The hypothesis was that LIA is not inferior to ISB.

METHODS

A prospective, randomized controlled study was performed in 2014-2016. All patients who underwent TSA for shoulder osteoarthritis were included. Patients in the ISB group received a continuous infusion of 0.2% ropivacaine by perineural catheter for 48 hours. The surgeon injected 110 mL of 0.2% ropivacaine, 30 mg of ketoprofen, and 0.5 mg of epinephrine before TSA in the LIA group and inserted a catheter into the glenohumeral joint. The next morning, 10 mL of 0.2% ropivacaine, 30 mg of ketoprofen, and epinephrine were injected through the catheter, which was then removed. The primary outcome was the mean shoulder pain score for the 48-hour postoperative period on a numerical scale (0-10). The secondary outcomes were postoperative opioid requirements, complications, and shoulder function at the 1-month follow-up visit. The sample size was calculated for a noninferiority study.

RESULTS

The study included 99 patients (50 LIA and 49 ISB patients) with a mean age of 72 ± 9.6 years. Although no significant difference in the mean pain score was found between the 2 groups for the 48-hour postoperative period (1.4 ± 0.9 for LIA vs 1.7 ± 1 for ISB, P = .19), the LIA group had significantly less severe pain (P = .003) and less opioid consumption (P = .01) in the recovery room. No complications occurred. A negative but nonsignificant correlation was found between postoperative pain and Constant score at the 1-month follow-up.

CONCLUSION

LIA is not less effective than ISB for early postoperative pain control after TSA.

Professional Athletes Are Not at a Higher Risk of Infections After Anterior Cruciate Ligament Reconstruction: Incidence of Septic Arthritis, Additional Costs, and Clinical Outcomes From the French Prospective Anterior Cruciate Ligament Study (FAST) Cohort

BACKGROUND

The rate of septic arthritis in the knee after anterior cruciate ligament (ACL) reconstruction varies in the literature but is generally less than 1%. It has been reported to be higher in professional athletes (5.7%).

PURPOSE

The primary goal was to evaluate the rate of septic arthritis after ACL reconstruction in professional athletes compared with other patients. The secondary goals were to analyze the risk factors; increased cost of infections; return to sport, satisfaction, and functional results at 1-year follow-up; and resolution rate of infections at final follow-up.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This retrospective analysis of prospective data included a continuous series of patients who underwent isolated ACL reconstruction between 2012 and 2016. The main outcome criterion was the development of intra-articular infections in the operated knee. An infection was suggested clinically (knee pain with fever and/or chills) and confirmed bacteriologically in deep tissue samples obtained during revision surgery. All infected patients underwent an emergency reoperation with lavage and debridement along with dual antibiotic therapy first by an intravenous route and then orally for 6 weeks.

RESULTS

A total of 1809 of 1859 patients included in the cohort during this period fulfilled inclusion criteria; there were 1632 (90.2%) who underwent primary reconstruction and 177 (9.8%) who underwent revision. The series included 1249 (69%) men and 560 (31%) women, with a mean age of 29.1 ± 9.8 years. Ninety-eight percent of the patients participated in a sport, including 90 (5.0%) at a professional level and 712 (39.4%) competitively. Septic arthritis of the knee developed after a mean 15.7 ± 5.5 days in 7 (0.38%) patients: 5 of 1632 (0.31%) who underwent primary reconstruction and 2 of 177 (1.13%) who underwent revision. Septic arthritis did not develop in any professional or competitive athletes; all affected patients were recreational athletes ( P = .02). The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery (odds ratio [OR], 15; P = .002) and hemarthrosis during the immediate postoperative period (OR, 127.2; P = .002). There were no recurrent infections after a mean follow-up of 2.8 ± 1.2 years.

CONCLUSION

None of the professional athletes in this cohort had septic arthritis after ACL reconstruction. There are no particular precautions to be taken in this population. The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery and hemarthrosis during the immediate postoperative period. Similar to all studies published on the subject, there were very few infected patients, which limits the identification of risk factors.

REGISTRATION

NCT02511158 (ClinicalTrials.gov identifier).

Bioabsorbable screws, whatever the composition, can result in symptomatic intra-osseous tibial tunnel cysts after ACL reconstruction

PURPOSE

To describe the clinical results of patients who underwent surgical treatment for a intra-osseous tibial tunnel cyst on a bioabsorbable interference screw following anterior cruciate ligament reconstruction (ACL).

METHODS

This retrospective study included all patients who underwent surgery between 2004 and 2016 for an intra-osseous tibial tunnel cyst on bioabsorbable interference screw following ACL reconstruction. The diagnosis was suggested clinically by pretibial pain at the incision site, sometimes associated with a palpable subcutaneous nodule and then confirmed on MRI. The first stage of surgery included exploratory arthroscopy followed by open excision/curettage of the cyst and then the tunnel was filled. The main criterion for outcome was a clinically normal knee (no pain, 0-120 range of motion, stable, with no effusion) at 6 months of follow-up.

RESULTS

This series included 53 patients, mean age 35.3 ± 9.9 years old w ith a mean 4.6 ± 3.1 years (between 3.1 months and 19 years) of follow-up after ligament reconstruction. The tibial screw was completely absorbed in 9/53 (17%) of patients, and fragmented in 22/53 (41.5%). At the 6-month follow-up, 42/53 (79.2%) patients had a normal knee, 11/53 (20.8%) persistent pain in the cyst area, 52/53 (98.1%) normal range of motion and 53 (100%) a stable knee. A recurrent cyst developed at 2 years of follow-up in one patient.

CONCLUSION

Complete absorption of a bioabsorbable interference screw is long, increasing the risk of developing intra-osseous tibial cysts during this period. The development of new materials with improved absorption properties is needed.

LEVEL OF EVIDENCE

IV-Retrospective study.

Are athletes able to resume sport at six-month mean follow-up after anterior cruciate ligament reconstruction? Prospective functional and psychological assessment from the French Anterior Cruciate Ligament Study (FAST) cohort

BACKGROUND

The decision to return to sport following anterior cruciate ligament (ACL) reconstruction should not only be based on time since surgery. This study aimed to assess, using isokinetic and neuromuscular (hops) testing in a large group, postoperative objective functional recovery of the knee. The secondary objective was to determine the relationship between psychological, functional scores, and these postoperative tests.

METHODS

This prospective study included athletes who underwent surgery between 2013 and 2016 for an isolated full-thickness ACL tear. They received a complete evaluation of functional performance of the knee by isokinetic tests performed on a dynamometer to measure quadriceps and hamstring strength, and neuromuscular assessment based on single-leg hop tests. The main judgment criterion was satisfactory functional recovery (yes/no) defined as a difference of ≤10% both in the quadriceps 60°/s and the single hop at a minimum of four months of follow-up.

RESULTS

A total of 234 athletes were analyzed. The mean age was 28.4 ± 8.6 years. At 6.5 ± 1.7 months mean follow-up, 44 (18.5%) patients had satisfactory functional recovery of the knee. The correlations between isokinetic/hop tests and the different scores were variable. During follow-up, two patients presented with a graft tear and two with a contralateral ACL tear, all in the group with unsatisfactory functional recovery.

CONCLUSION

At a mean of six months after ACL reconstruction, objective functional recovery of the knee was generally unsatisfactory and this seemed to be a risk factor for recurrent tears.

LEVEL OF EVIDENCE

IV; case series.

Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST)

Background:

Successful return to sport after anterior cruciate ligament (ACL) reconstruction requires optimal physical and psychological recovery. The main validated tool to quantify a patient’s psychological readiness to return to sport after this surgery is the Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale.

Purpose:

The primary aim was to analyze the progression of the ACL-RSI score from preoperatively to 2-year follow-up. A secondary goal was to identify the factors associated with returning to the same preinjury sport.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

This prospective study included athletes older than 16 years in all sports and levels of play who underwent primary and revision isolated ACL reconstruction from 2012 to 2015 and responded to all study questionnaires at 2-year follow-up. The primary outcome was the ACL-RSI score obtained preoperatively and at 4-month, 6-month, 1-year, and 2-year follow-up. The secondary outcomes were return to sport (running and the same preinjury sport) and various functional scores. The optimal threshold value of the ACL-RSI score for returning to the same preinjury sport was determined with the receiver operating characteristic curve. Multivariate analysis was performed to identify other factors associated with returning to the same sport at 2-year follow-up.

Results:

A total of 681 patients were analyzed (467 men, 214 women; mean age, 30.2 ± 9.5 years); 298 (43.8%) patients were professional or competitive athletes. The ACL-RSI score improved significantly over time: 41.3 ± 25.4 preoperatively, 55.1 ± 21.3 at 4 months, 58.3 ± 22.3 at 6 months, 64.7 ± 24.2 at 1 year, and 65.2 ± 25.3 at 2 years (P < .00001). At 2-year follow-up, 74.9% of patients had returned to running and 58.4% to their same preinjury sport. The ACL-RSI score was significantly higher in patients who had returned to sport and in those who returned to the same level of play or higher (P < .00001). The optimal ACL-RSI score threshold to return to the same sport at 2-year follow-up was ≥65. Multivariate analysis showed that the predictive factors of returning to the same preinjury sport at 2-year follow-up were primary reconstruction, professional or competitive level of play, an ACL-RSI score ≥60 at 6-month follow-up, and the absence of postoperative complications.

Conclusion:

The psychological ACL-RSI score improved regularly after ACL reconstruction and was strongly and significantly associated with return to sport.

Registration:

NCT02511158 (ClinicalTrials.gov identifier)

Treatment of infected non-unions of the femur and tibia in a French referral center for complex bone and joint infections: Outcomes of 55 patients after 2 to 11 years

INTRODUCTION

An infected non-union is a major complication following bone fracture. While bone union can be obtained in 70% to 100% of cases, treatment of osteomyelitis is less predictable, with reported healing rates ranging from 40% to 100%. The primary aim of this study was to assess the success rate of treating infected non-unions of the tibia and femur by a team specializing in complex bone and joint infections.

MATERIAL AND METHODS

This single-center retrospective study included all patients operated between 2002 and 2012 due to an infected non-union of the femur or tibia using standardized surgical methods. The procedure was typically done in two phases: excision of the infected site and stabilization, followed by bone reconstruction after a waiting period. Additional procedures (lavage and/or bone grafting) were performed in some cases. A minimum 6-week course of antibiotic therapy was given. The primary endpoint was successful medical and surgical treatment after a minimum 2 years' follow-up defined as healing of the infection (no local clinical signs of infection, ESR≤20mm and CRP≤10mg/L, no mortality attributed to the infection) and radiological and clinical bone union, with the lower limb spared.

RESULTS

Fifty-five patients (39 men, 16 women) were included with an average age of 37±11 years. There were 40 tibial fractures and 15 femur fractures. A polymicrobial infection was present in 47% of cases. Repeat surgery was required in 56.4% of patients. At an average of 4±2 years from the first surgical procedure, the treatment was successful in 49 patients (89%): 36 tibia (90%) and 13 femur (87%). The mean time to union was 9±4 months. There were six failures: 3 amputations at 5, 6 and 16 months; 1 mechanical and infection-related failure; 2 failed union.

CONCLUSION

This study found that 89% of patients with an infected tibial or femoral non-union treated by a team specialized in complex bone and joint infections using a standardized surgical protocol had bone union and healing of the infection in an average of 9 months.

LEVEL OF EVIDENCE

IV, retrospective study.

Acromial J-bone graft on the acromion for surgical treatment of glenohumeral instability: an anatomical study

BACKGROUND

Anterior glenohumeral instability is frequently associated with anteroinferior glenoid bone defects. One original technique has been described in the literature that incorporates a J-shaped graft from the iliac crest into the anterior glenoid rim. The main goal of the present study was to evaluate the feasibility of harvesting a J-shaped graft from the acromion that corresponds to previously described dimensions. The secondary goal was to determine the ideal harvesting site.

METHODS

Forty shoulders from 20 cadavers were included. Twenty grafts were harvested from the posterior acromion and 20 from the lateral acromion. The length, width and thickness of the grafts were measured. The incision was then enlarged to confirm the absence of an acromial fracture by fluoroscopic control.

RESULTS

Harvesting a graft whose size was similar to a J-graft was successfully performed in all cases (100%) with a mean (SD) incision of 4.2 (0.3) cm. Mean (SD) harvesting time was 4.5 (0.5) minutes. Two acromial fractures were identified during lateral harvesting (10%) and none during posterior harvesting (p = 0.49).

CONCLUSIONS

It is always possible to harvest a J-graft on the acromion. The posterior side of the acromion is the best site to harvest a graft that has the necessary size to treat glenoid bone defects.

Efficacy of vitamin C in preventing complex regional pain syndrome after wrist fracture: A systematic review and meta-analysis

BACKGROUND

Complex regional pain syndrome type I (CRPS-I), previously known as reflex sympathetic dystrophy, is common after conservatively or surgically treated wrist fractures. Several studies support the efficacy of vitamin C in preventing CRPS-I, although the data are somewhat conflicting. The primary objective of this systematic literature review and meta-analysis was to assess the efficacy of vitamin C therapy in preventing CRPS-I after a wrist fracture.

METHODS

Randomised, placebo-controlled trials of vitamin C to prevent CRPS-I after wrist fractures were sought in the three main databases: PubMed (1980 to December 2015), CENTRAL (Central 2015, number 12), and Embase (1980 to December 2015). Two authors worked independently to select articles. Data from selected articles were collected independently.

RESULTS

Three randomised placebo-controlled trials in a total of 875 patients were included. Treatment was non-operative in 758/890 (85.1%) fractures and operative in 132 (14.9%) fractures. Vitamin C supplementation was started on the day of the injury and continued for 50 days. In the group given 500mg of vitamin C daily, the risk ratio for CRPS-I was 0.54 (95%CI, 0.33-0.91; P=0.02). Thus, the risk of developing CRPS-I was significantly decreased by prophylactic treatment with 500mg of vitamin C per day. The heterogeneity rate was 65% (non-significant).

CONCLUSION

Daily supplementation with 500mg of vitamin C per day for 50 days decreases the 1-year risk of CRPS-I after wrist fracture.

LEVEL OF EVIDENCE

II, systematic review of level I and II studies.

Cortical onlay strut allograft with cerclage wiring of periprosthetic fractures of the humerus without stem loosening: technique and preliminary results

The goal of this study was to describe an internal fixation technique for periprosthetic humeral fractures using a cortical onlay strut allograft stabilized with cerclage wires and to evaluate the preliminary results of this approach. An anterolateral approach was used to direct access the fracture and to protect the radial nerve. The fracture was reduced with two forceps, under visual control. The fracture was surrounded by two hemicylinder tibial allografts, placed around the humerus with no prior reaming to create a "sarcophagus" system. The allograft was as long as possible for optimal mechanical stability, without creating impingement with the glenoid and the elbow. Final fixation of the allograft was obtained with two cerclage wires. The arm was immobilized in a simple sling. Passive then active rehabilitation was begun after 1 month. Six women, mean age 74.3 ± 10.9 years old, were included in the study between 2013 and 2015 with a mean follow-up of 10 ± 2 months. Bone union was obtained in all patients after 6 months of follow-up with no recurrent fractures.

Return to Sport After Primary and Revision Anterior Cruciate Ligament Reconstruction: A Prospective Comparative Study of 552 Patients From the FAST Cohort

BACKGROUND

Few studies have reported the return-to-sport rate at 1-year follow-up after primary and revision anterior cruciate ligament (ACL) reconstruction.

PURPOSE

To compare the return-to-sport rate 1 year after primary and revision ACL reconstruction in the same cohort according to 2 modalities: any kind of sport and the patient's usual sport at the same level as before the injury.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A single-center, prospective cohort study of patients undergoing ACL reconstruction (French prospective Acl STudy [FAST]) was begun in 2012. A comparative study was performed based on a retrospective analysis of data collected prospectively. Included were all athletes aged 18 to 50 years who underwent primary or revision isolated ACL reconstruction between 2012 and 2014. Two groups were formed: primary reconstruction and revision reconstruction. The main criterion was return to sport at 1-year follow-up (yes/no); secondary criteria were return to the usual sport at 1-year follow-up, knee function (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS] scores), and psychological readiness (ACL-Return to Sports after Injury [ACL-RSI] score) at 6 months and 1 year.

RESULTS

A total of 552 patients (primary reconstruction group: n = 497, revision reconstruction group: n = 55) were included in the study. There were 373 men and 179 women (mean [±SD] age, 30.2 ± 8.4 years). No significant difference in the return-to-sport rate was found between the 2 groups at 1-year follow-up (primary reconstruction group: 90.9%, revision reconstruction group: 87.3%; P = .38), but patients in the primary reconstruction group resumed their usual sport significantly more often (primary reconstruction group: 63.6%, revision reconstruction group: 49.1%; P = .04). Eight (1.4%) retears occurred during a new sport-related injury within a mean 8.9 ± 2.9 months: 7 (1.4%) in the primary reconstruction group and 1 (1.8%) in the revision reconstruction group ( P = .8). At 1-year follow-up, functional scores were significantly better in the primary reconstruction group for subjective IKDC (82.6 ± 13.3 vs 78.4 ± 16.6; P = .04); KOOS Symptoms/Stiffness (73.3 ± 15.2 vs 67.7 ± 19.6; P = .02), Activities of Daily Living (96.3 ± 6.4 vs 94.3 ± 9.1; P = .04), Sport (79.7 ± 19.1 vs 69.1 ± 24.8; P = .0004), and Quality of Life (69.6 ± 22.7 vs 54.7 ± 24.8; P < .00001) subscales; and ACL-RSI (65 ± 23 vs 49.5 ± 24.8; P < .00001). On multivariate analysis, patients who were more likely to resume their usual sport at 1 year were high-level players (odds ratio [OR], 2.2) who underwent primary reconstruction (OR, 2.0) and had better KOOS Quality of Life (OR, 1.7) and subjective IKDC (OR, 2.1) scores at 6-month follow-up without complications or retears during the first postoperative year (OR, 2.6).

CONCLUSION

At 1-year follow-up, there was no significant difference in the return-to-sport rate between primary and revision ACL reconstruction. Patients who underwent primary reconstruction returned to their usual sport significantly more often.

TRIAL REGISTRATION

NCT02511158 ( ClinicalTrials.gov identifier).

Peri-articular local infiltration analgesia versus femoral nerve block for postoperative pain control following anterior cruciate ligament reconstruction: Prospective, comparative, non-inferiority study

INTRODUCTION

Femoral nerve block (FNB) is considered as a major advance in anterior cruciate ligament (ACL) reconstruction as it reduces the need for parenteral opioids. However, the incidence of transient or even permanent neurological deficits due to the FNB is estimated at 1.94% after knee surgery. The primary objective of this study was to compare local infiltration analgesia (LIA) to FNB during ACL reconstruction procedures. The study hypothesis was that LIA was not less effective than FNB on early postoperative pain.

PATIENTS AND METHODS

A retrospective analysis of data collected prospectively in the FAST cohort included a series of continuous patients who underwent primary repair for isolated ACL with a hamstring graft in 2013-2014. Changes in our anesthesia practices over time allowed us to form three successive groups: Group 1 - FNB, Group 2 - FNB+LIA, Group 3 - LIA only. Ultrasound-guided FNB was done pre-operatively. The LIA was done at the end of the procedure by the surgeon with systematic infiltration of all skin incisions and the hamstring donor site; no intra-articular injections were performed. The primary endpoint was the average early postoperative pain (Days 0-3) described by the patient on a visual analogue scale (0-10). Sample size calculation pointed to 36 subjects being needed per group for a non-inferiority study.

RESULTS

The study involved 126 patients: G1=42, G2=38, G3=46. The patients were comparable at enrolment. The average early postoperative pain levels were 3.1±2.4, 2.8±2.0 and 2.5±2.2, respectively (P=0.66). A trend toward higher intake of tramadol was noted in the LIA group on D0 to D3, with a significant trend test on Day 1 (P=0.03) and Day 2 (P=0.02).

CONCLUSION

After reconstruction of isolated ACL tears with a hamstring graft, FNB is not more effective than LIA on patients' early postoperative pain. Patients who received a FNB consumed significantly less opioid-like analgesics.

LEVEL OF EVIDENCE

III - Prospective, comparative, non-randomized study.

Description and reproducibility assessment of a new computerised tomography scan index to measure the glenoid orientation in relation to the anterior glenoid surface

PURPOSE

To propose and to assess the reproducibility of a new method (GO [glenoid orientation] index) for the estimation of the glenoid orientation in relation to the anterior surface of the glenoid.

METHODS

This is a retrospective study on computed tomography (CT) scan. The GO index was defined as the angle formed by a line perpendicular to the tangent to the anterior surface of the scapula and the glenoid line (which is defined as the line connecting the anterior and the posterior rim of the glenoid). The measurements were performed at the level of the glenoid where its diameter is the greatest. Two independent observers performed each measurement twice. The intra- and inter-observer reproducibility was evaluated by the Pearson coefficient (r) and the intra-class correlation coefficient (ρ, ICC). The correlation between GO index and glenoid version as described by Friedman was also studied.

RESULTS

Seventy-eight CT scans were analysed, 38 shoulders with glenohumeral arthritis and 40 healthy shoulders, 32 females/46 males, mean age 53.9 ± 22.7 years. The measures were all highly correlated (r > 0.50, p = 0.00001). The intra- and inter-observer reproducibility was good to excellent (0.71 < ρ < 0.84, p = 0.00001). GO index was 26.9 ± 6.3°, 28.4 ± 6° in the group with glenohumeral osteoarthritis and 25.5 ± 6.4° in the healthy group, p = 0.04. The glenoid version was -0.8 ± 7.9° in the group with glenohumeral osteoarthritis and -3.9 ± 6° in the healthy group, p = 0.05. No agreement was found between the glenoid version and GO index.

CONCLUSIONS

GO index is simple and reproducible. It could be very useful for the pre-operative planning and intra-operative positioning of the implants in total shoulder arthroplasty.

Return to Sport After Rotator Cuff Tear Repair: A Systematic Review and Meta-analysis

BACKGROUND

One of the most frequent demands from athletes after rotator cuff tear repair is to return to sport, if possible at the same level of play.

PURPOSE

The main goal of this study was to determine the rate of return to sport after treatment of rotator cuff tears.

STUDY DESIGN

Meta-analysis and systematic review.

METHODS

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 for the presentation of results. A search of the literature was performed on 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) checklist. Inclusion criteria were studies in English evaluating return to sport after treatment of traumatic, degenerative, partial or full-thickness rotator cuff tears in patients practicing a sport regularly, whatever the level, all ages and sports included. The main judgment criterion was the number of patients who returned to a sports activity after treatment of a rotator cuff tear. The criterion was analyzed in 2 ways: return to sport (yes/no) and the level of play (identical or higher/lower level).

RESULTS

Twenty-five studies were reviewed, including 859 patients (683 athletes), all treated surgically after a mean follow-up of 3.4 years (range, 0.3-13.4 years). The level of sports was recorded in 23 studies or 635 (93%) athletes and included 286 competitive or professional athletes and 349 recreational athletes. The most commonly practiced sports were baseball (224 participants), tennis (104 participants), and golf (54 participants). The overall rate of return to sport was 84.7% (95% CI, 77.6%-89.8%), including 65.9% (95% CI, 54.9%-75.4%) at an equivalent level of play, after 4 to 17 months. Of the professional and competitive athletes, 49.9% (95% CI, 35.3-64.6%) returned to the same level of play.

CONCLUSION

Most recreational athletes return to sports at the same level of play as before their injury, but only half of professional and competitive athletes return to an equivalent level of play.

Arthroscopic Bankart shoulder stabilization in athletes: return to sports and functional outcomes

PURPOSE

The aim of this study was to evaluate return to sports after arthroscopic Bankart stabilization.

METHODS

This is a retrospective study including all athletes aged <50 years who underwent arthroscopic stabilization in 2010 and 2011 (m, 36; f, 10; mean age 28.9 ± 8.1 years; follow-up 24.4 ± 7.7 months). Sixteen patients were practicing competitive sports and 30 recreational sports. Level and delay of return to sports, sports classification according to Allain, Western Ontario Shoulder Instability Index (WOSI) score, patient satisfaction, apprehension level and avoidance behaviour were noted.

RESULTS

95.7 % returned to the same level after an average of 9.8 ± 5.4 months. Sports level was unchanged or better in 82.6 %, lower in 8.7, and 4.5 % changed sport because of their shoulder. Patients with more than 10 dislocations returned to sports and to their preoperative level later than patients with <10. Male athletes returned to preoperative sports levels faster than female athletes (p < 0.001). The WOSI score and also its item "sports" were worse in those who had not returned (p = 0.0002 and 0.006, respectively). Satisfaction correlated with the WOSI score (p = 0.0004) while 93.3 % were satisfied/very satisfied. The decrease in the apprehension level was significant (p < 0.00001). 36.9 % still experienced avoidance behaviour.

CONCLUSIONS

Most athletes resumed their main sport often at the same level, but the threshold of 10 dislocations should be considered a risk factor for longer return to sports at any level. The WOSI score is a valuable outcome score after Bankart stabilization. Postoperative avoidance should be distinguished from apprehension.

LEVEL OF EVIDENCE

IV.

Outpatient Latarjet surgery for gleno-humeral instability: Prospective comparative assessment of feasibility and safety

BACKGROUND

Some surgical procedures are rarely done on an outpatient basis. The primary objective of this study was to assess the safety of outpatient surgical shoulder stabilisation using the Latarjet procedure.

HYPOTHESIS

The Latarjet procedure is safe when performed on an outpatient basis provided the patients are managed according to a specifically designed programme starting at the decision to undergo surgery and ending at the end of the early postoperative period.

PATIENTS AND METHODS

Consecutive patients with unidirectional anterior shoulder instability managed in 2013-2014 by primary open, minimally invasive surgery involving coracoid process transfer as described by Latarjet was included prospectively. One of the surgeons routinely offered outpatient surgery to patients who met none of the usual exclusion criteria (age>60years, ASA 3-4, and long distance from home to hospital). Standardised protocols were applied for anaesthesia and analgesia. The primary evaluation criterion was failure of the admission modality, defined as inpatient admission of a patient after outpatient surgery either without prior discharge or within 1week after discharge. Secondary evaluation criteria were early postoperative symptoms and functional outcomes after at least 1year. All self-reported criteria were entered online by the patients.

RESULTS

Of 46 included patients, 17 had outpatient surgery and 29 inpatient surgery. There were 41 males and 5 females, with a mean age of 25.3±6.4years. No significant baseline differences were found between the two groups. None of the outpatients required inpatient admission or readmission. No postoperative complications were recorded. After a mean follow-up of 18.5±5.2months, the two groups showed no significant differences for return to sports, apprehension, avoidance behaviours, or functional outcomes. Most patients were satisfied with their management and outcomes.

CONCLUSION

No serious adverse events were recorded in this first French prospective evaluation of the safety of open, minimally invasive shoulder stabilisation by the Latarjet procedure performed on an outpatient basis. Thus, in selected patients, the risks of outpatient surgery are similar to those of inpatient surgery.

LEVEL OF EVIDENCE

III, prospective, comparative, non-randomised study.

Anterior shoulder stabilization by Bristow-Latarjet procedure in athletes: return-to-sport and functional outcomes at minimum 2-year follow-up

PURPOSE

The aim of this study was to assess return-to-sport outcomes following the Latarjet-Bristow procedure.

METHODS

This retrospective study included all athletes <50 years old, who underwent a Latarjet-Bristow procedure for anterior shoulder instability in 2009-2012. Main criteria assessments were the number of athletes returning to any sport and the number returning to the same sport at their preinjury level. The main follow-up was 46.8 ± 9.7 months.

RESULTS

Forty-seven patients were analyzed, 46 men/1 women, mean age 27.9 ± 7.9 years. Eighteen patients practiced competitive sports and 29 recreational sports. None of them were professional athletes. One hundred percent returned to sports after a mean 6.3 ± 4.3 months. Thirty/47 (63.8 %) patients returned to the same sport at the same level at least and 10/47 (21.3 %) patients changed sport because of their shoulder. Compared to patients who returned to the same sport at the same level, patients who changed sports or returned to a lower level had practiced overhead or forced overhead sports [OR = 4.7 (1.3-16.9), p = 0.02] before surgery, experienced avoidance behavior at the final follow-up (p = 0.002), apprehension (p = 0.00001) and had a worse Western Ontario Shoulder Instability Index score and sub-items (p = 0.003) except for daily activities (p = 0.21). At the final follow-up, 45/47 (95.7 %) patients were still practicing a sport.

CONCLUSION

All the patients returned to sports, most to their preinjury sport at the same level. Patients who practiced an overhead sport were more likely to play at a lower level or to change sport postoperatively.

LEVEL OF EVIDENCE

IV, retrospective study-Case series with no comparison group.

Coracoid graft positioning in the Latarjet procedure

PURPOSE

The success of shoulder stabilization with the Latarjet procedure depends on the correct positioning of the coracoid graft at the glenoid. The aim of this study was to assess intra-observer reproducibility and inter-observer reproducibility of a new standardized CT scan analysis for coracoid graft positioning in the axial plane after the Latarjet procedure and to assess the positioning in the study group.

METHODS

A consecutive series of 27 patients (22 men, 5 woman, 26.1 ± 6.4 years-13 right, 14 left shoulders) were followed up with CT scans between 2010 and 2012. The analysis of the CT scans (2.4 ± 0.7 months postoperatively) was performed with Osirix™ software. The assessment included two criteria in the axial plane: relation of the graft to the articular surface of the glenoid and impingement of the graft with the maximal humeral head circumference. Grafts were judged to be lateral, congruent, flush or medial. The strength of intra-observer agreement and inter-observer agreement was measured by the Kappa coefficient.

RESULTS

The Kappa coefficient for intra-observer agreement was "substantial" (K = 0.64 ± 0.14, z = 4.6) to "almost perfect" (K = 0.81 ± 0.14, z = 5.7). The Kappa coefficient for inter-observer variability was "substantial" (K = 0.59 ± 0.14, z = 4.3) to "almost perfect" (K = 0.89 ± 0.14, z = 6.0). In our study, in the axial plane, 3 (11 %) transplants were lateral; 6 (22 %) transplants were congruent; 16 (60 %) flush and 2 (7 %) medial.

CONCLUSION

This standardized CT scan analysis after Latarjet procedure has shown to accurately describe graft positioning in the axial plane with both good intra-observer reproducibility and inter-observer reproducibility.

LEVEL OF EVIDENCE

Case series, treatment study, Level IV.

Inefficacy of Kinesio-Taping(®) on early postoperative pain after ACL reconstruction: Prospective comparative study

INTRODUCTION

Kinesio-Taping(®) (K-Tape) is used in sports traumatology with the aim of reducing pain and improving blood and lymph circulation. The main objective of the present study was to assess the efficacy of K-Tape on early postoperative pain after anterior cruciate ligament (ACL) reconstruction. The study hypothesis was that K-Tape significantly decreases pain.

METHOD

A prospective non-randomized comparative study was conducted in 2013-2014 and included all patients who underwent primary ACL reconstruction by hamstring graft. Analgesia was standardized. Two groups, "K-Tape" and "controls", were formed according to the days on which the study physiotherapist was present. The K-Tape compression/decompression assembly was applied immediately postoperatively and maintained for 3days. Patients filled out online questionnaires. The main assessment criterion was mean postoperative pain (D0-D3) on a 0-to-10 scale. Secondary criteria were analgesia intake on the three WHO levels, awakening during the night of D0 due to pain, signs of postoperative discomfort, and patient satisfaction.

RESULTS

Sixty patients (30 per group) were included, 57 of whom could be assessed: 28 K-Tape, 29 controls; 44 male, 13 female; mean age, 30.9±8.9 years. At inclusion, the two groups were comparable. There was no significant difference in mean (D0-D3) knee pain intensity: 3.8±2.2 for K-Tape, and 3.9±2 for controls (P=0.93). Analysis of variance (ANOVA) found no significant intergroup difference in evolution of pain (P=0.34). There were no other significant differences on the other assessment criteria.

CONCLUSION

K-Tape showed no efficacy on early postoperative pain following ACL reconstruction.

LEVEL OF EVIDENCE

III; prospective non-randomized comparative study.

Direct anterior Hueter approach is a safe and effective approach to perform a bipolar hemiarthroplasty for femoral neck fracture: outcome in 82 patients

BACKGROUND AND PURPOSE

The direct anterior (DA) approach in total hip arthroplasty has recently been associated with faster functional recovery than the posterolateral (PL) approach. We hypothesized that the same should hold for the DA approach in bipolar hemiarthroplasty for femoral neck fractures.

PATIENTS AND METHODS

82 patients with a displaced femoral neck fracture and candidates for bipolar hemiarthroplasty were enrolled after IRB approval in this prospective non-randomized comparative study (DA: n = 38; PL: n = 44). The postoperative protocols were similar in both groups. Evaluation included surgical complications, component placement, and early functional outcomes, assessed 6 weeks postoperatively using a timed up-and-go (TUG) test. The incidence of dislocation was assessed by telephone interview at least 1 year after the surgery.

RESULTS

The DA-group patients had better results in the TUG test than the PL-group patients 6 weeks after surgery: half were under 19 seconds as opposed to only one third for PL (p = 0.06). We did not record any intraoperative femoral fracture or any lateral femoral cutaneous neuropraxia in the DA group. We observed a significant difference (p = 0.04) in lateral offset between the PL group (4.2 (SD 6.4) mm) and the DA group (-1.6 (SD 8.5) mm). Stem alignment was similar between groups. The dislocation rate for DA patients was lower than for PL patients (1 of 38 cases vs. 9 of 44 cases; p = 0.02).

INTERPRETATION

Our findings indicate that relative to the posterolateral approach, the direct anterior approach for bipolar hemiarthroplasty may improve gait in the early postoperative period and decrease the dislocation rate.

Survival and functional results after a mean follow-up of 9 years with the Ceragyr® highly congruent mobile-bearing TKA

INTRODUCTION

Fixed-bearing total knee arthroplasty (TKA) implants have excellent long-term survival. Mobile-bearing implants were developed to reduce bone-implant interface stresses and polyethylene insert wear. The primary objective of this study was to analyze the survival rate of a highly congruent mobile-bearing TKA implant (Ceragyr(®)) in patients having a minimum follow-up of 7 years. We hypothesized that the survival rate would be 95-100% at that time point.

PATIENTS AND METHODS

A single-center prospective study included all the patients operated for a primary TKA procedure with a Ceragyr(®) implant between 2000 and 2003. All the implants were cemented. Patellar resurfacing was not carried out systematically, but could be carried out secondarily in cases of persistent anterior knee pain. Clinical and radiological data were collected before the surgery, at 3 months postoperative, at 1 year and then at a minimum follow-up of 7 years. The primary endpoint was the overall revision-free survival rate. Secondary endpoints were the survival without mechanical failure, IKS scores, knee range of motion and implant positioning.

RESULTS

One hundred and thirty-four patients (143 Ceragyr(®) TKA cases) were included; 9 patients (10 TKA) were lost to follow-up (6.7%) and the remaining 125 patients (133 TKA) were contacted. At the final review, 7 of the 133 TKA cases (5.3%) had been revised (6 men, 1 women; P = 0.002), 2 (1.5%) because of mechanical failure and 5 (3.8%) because of an infection. The overall revision-free survival rate was 94.8% [95% CI: 89.3-97.5]; survival was 98.4% [95% CI: 93.8-99.6] with mechanical failure as an endpoint. An in-person assessment was conducted on 76 patients (80 TKA cases) (49 women; 27 men) who had an average age of 70.3 ± 8.4 years at the time of the arthroplasty procedure. The patella had been resurfaced during the initial procedure in 49 cases, and was either not resurfaced or secondarily resurfaced in 31 cases. The average follow-up was 8.7 ± 1.1 years. The IKS score had significantly improved relative to the preoperative values (P < 0.00001). Knee flexion and the IKS knee score remained stable over time (P > 0.05). Patients who underwent patella resurfacing during the initial TKA procedure had better clinical results (P = 0.03).

CONCLUSION

After a minimum follow-up of 7years, the overall revision-free survival rate for the Ceragyr(®) was 94.8%; the survival was 98.4% with mechanical failure as an endpoint. The results were stable over time.

How accurate are anatomic landmarks for femoral tunnel positioning in anterior cruciate ligament reconstruction? An in vivo imaging analysis comparing both anteromedial portal and outside-in techniques

PURPOSE

To assess the ability of 2 independent surgical techniques, an inside-out technique and an outside-in technique, using bony landmarks on the femoral wall, to place the anterior cruciate ligament graft anatomically.

METHODS

A retrospective single-center study was conducted in 2012 and included patients who underwent anterior cruciate ligament reconstruction. Two techniques were used: The lateral condylar wall was visualized from the anterolateral portal and tunnels were drilled "outside-in" in one group, whereas viewing was performed from the anteromedial portal and retrograde drilling ("inside-out") was performed in the other group. The primary outcome measure was the placement of the tunnel center point on postoperative computed tomography scans with 3-dimensional reconstruction, according to the radiographic quadrant method of Bernard and Hertel. The measurements were compared with optimal placements according to Bird et al. Their reliability was assessed with Spearman (rho) and intraclass correlation coefficients.

RESULTS

Forty patients were included, with 20 in each group; the mean age was 29.8 ± 9.6 years, and there were 33 men and 7 women. The interobserver reliability and intraobserver reliability of measurements were good, with a Spearman ρ between 0.46 (P = .002) and 0.93 (P < .001) and an intraclass correlation coefficient between 0.44 (P = .001) and 0.86 (P < .001). The femoral tunnel positions of both techniques were close to the previously published anatomic placements, but there was a significant difference between our results and the theoretical position in proximal-distal measurements (P = .01). There was no difference in the anteroposterior measurements. There was no statistical difference in the accuracy of placement of the femoral tunnel center point between these 2 independent techniques.

CONCLUSIONS

The direct arthroscopic visualization of bony landmarks seems sufficient for accurate positioning of the femoral tunnel whatever the drilling technique. This finding is clinically relevant because the routine use of direct measurement techniques or intraoperative radiographs may not be necessary to obtain anatomic tunnel placement.

LEVEL OF EVIDENCE

Level IV, case series.

Translation, cross-cultural adaptation and validation of the French version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale

PURPOSE

The aim of this study was to translate, adapt and validate in French the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), a 12-item English language scale assessing the psychological impact of returning to sports after ACL reconstruction.

METHODS

The ACL-RSI scale was forward and back translated, cross-culturally adapted and validated using international guidelines. The study population included all patients who were active in sports and underwent primary arthroscopic ACL reconstruction. The control group included subjects with no history of knee trauma. At the 6-month follow-up, the study population completed the ACL-RSI scale twice within 3-4 days, Knee injury and Osteoarthritis Outcome Score (KOOS) and subjective International Knee Documentation Committee (IKDC) scores. Statistical tests assessed the construct validity, discriminant validity, internal consistency, reliability and feasibility of the ACL-RSI scale.

RESULTS

Ninety-one patients with ACL tears and 98 control subjects were included: mean age 31.7 ± 8.1 and 21.8 ± 2, respectively. The ACL-RSI scores were correlated with all KOOS sub-categories (r = 0.22-0.64, p < 0.05) as well as the subjective IKDC score (r = 0.42, p < 0.00001). The mean scores of the study and control groups were significantly different (62.8 ± 19.4 vs. 89.6 ± 11.5, p < 0.00001), and scores were significantly better in patients who returned to the same sport (72.1 ± 21.4 vs. 60.3 ± 18.1, p = 0.008). Internal consistency was high (α = 0.96). Test-retest reproducibility was excellent: ρ = 0.90 (0.86-0.94), p < 0.00001. Administration time was 1.32 ± 0.7 mn, and all items were answered.

CONCLUSION

This study showed that the cross-cultural adaptation of the English version of the ACL-RSI was successful and validated in a French-speaking population. The discriminant capacity of the scale between patients who underwent reconstruction and healthy subjects was confirmed.

LEVEL OF EVIDENCE

II.

Postoperative discomfort after outpatient anterior cruciate ligament reconstruction: a prospective comparative study

INTRODUCTION

The principal objective of the present study was to compare rates of postoperative discomfort after anterior cruciate ligament (ACL) reconstruction between inpatient (In) and outpatient (Out) management.

PATIENTS AND METHOD

A single-surgeon non-randomized prospective comparative study included patients undergoing primary surgery for isolated ACL tear by short hamstring graft in 2012-13. The Out group comprised patients eligible for and consenting to outpatient surgery and the In group, those not eligible or not consenting. The principal assessment criterion was onset of at least 1 symptom of postoperative discomfort (SPD): anxiety, nausea and vomiting, malaise, vertigo or stomach pain, between postoperative days 0 and 3. Secondary assessment criteria were difficulty in getting to sleep, getting up during the night, regular walking or going out, number of episodes of knee pain and waking because of pain. All criteria were assessed on-line by the patient.

RESULTS

One hundred and thirty-three patients filled out the questionnaire, 70 in the Out group and 63 in the In group; 42 females, 91 males; mean age, 30±9 years. Between D0 and D3, the proportion of patients with ≥l SPD was comparable between groups (Out 37% vs In 41%, P=0.62). Out-group patients had significantly less difficulty sleeping the first postoperative night (P=0.01), got up significantly more often during the first night after surgery (P<0.0001), more often walked regularly on day 1 (P=0.03), and were significantly less often woken by pain during the first night (P=0.003). Risk factors for SPD were female gender (OR=4.8±1.9) and postoperative complications (OR=3.8±2.5).

CONCLUSION

Patients undergoing ACL reconstruction on an outpatient basis did not show more symptoms of postoperative discomfort than those managed as conventional inpatients.

LEVEL OF EVIDENCE

IV; prospective comparative study.

Reliability of a new radiological method for assessment of the postoperative immobilization of the first metatarsophalangeal joint

BACKGROUND

The success of the operative treatment of mild to moderate hallux valgus (HV) relies greatly on the osseous union of the osteotomies at the desired position. Full weight-bearing is often allowed immediately postoperatively with special forefoot off-loading shoes. No precise methodology exists for the estimation of foot immobilization inside those shoes. The aim of this study was to assess the reliability of a new radiological measurement method to assess the immobilization of the first metatarsophalangeal (M1P1) joint inside a postoperative forefoot off-loading rocker shoe.

METHODS

A prospective single-center study was conducted during 2012. Patients operated on for mild or moderate HV deformity with a percutaneous technique by the same surgeon were included. Twenty-four patients (33 feet) fulfilled the inclusion criteria, all women and mean age of 56.6 ± 12.7 years. Standard lateral foot X-rays were obtained 1 week postoperatively with the patient standing in 2 positions, wearing the same forefoot off-loading rocker shoe: the foot flat on the ground (imitating midstance) and on the toes (imitating propulsion). The main evaluation criterion was the immobilization of the M1P1 joint estimated through the difference between the values of the M1P1 angle in the sagittal plane in these positions. Validity and reliability of this new measurement were assessed with Pearson's correlation coefficients (r) and intraclass correlation (ICC, ρ) coefficients.

RESULTS

The inter- and intraobserver reliability of the measurement was excellent to good. The mean M1P1 angle was 17.5 ± 7 degrees in the position imitating the midstance and 20.7 ± 7.5 degrees in the position imitating propulsion (P < 10(-5)).

CONCLUSION

This new radiological measurement for assessing immobilization of the M1P1 joint was a valid and reliable method.

Arthroscopic meniscal allograft transplantation with two tibia tunnels without bone plugs: evaluation of healing on MR arthrography and functional outcomes

INTRODUCTION

Meniscal allograft transplantation seems to be a valid therapeutic option to restore the knee function and limit the development of osteoarthritis after menisectomy. No surgical technique has been shown to provide better results than others. The main objective of this study was to assess graft healing after arthroscopic meniscal allograft transplantation without bone plugs.

METHODS

This retrospective study included all patients who underwent arthroscopic meniscal allograft transplantation during 2005-2010. The meniscal horns were fixed through two tibia tunnels without bone plugs. The primary endpoint was graft healing according to Henning's criteria on MR arthrography (MRA) at 6-month follow-up. The secondary endpoints were the KOOS questionnaire, the IKDC score, measurement of the joint space and meniscal extrusion on both MRA at 6-month and MRI at last follow-up. The series included 22 patients, mean age 37 ± 7.5 years. The allograft was lateral in 20 cases and medial in 2 cases. The mean follow-up was 4.4 ± 1.6 years with one lost to follow-up.

RESULTS

MR arthrography was performed in 14/21 patients at 6-months of follow-up: 8/14 (57.1%) had total graft healing, 2/14 (14.3%) partial healing and 4/14 (28.6%) no healing. At final follow-up, all functional scores had significantly improved. The average pre- and post-operative joint space thickness was similar. MRI showed meniscal extrusion in 75% of patients.

CONCLUSION

The meniscal allograft transplantation without bone plugs effectively treats painful and functional sequellae of meniscectomies. The graft healed in most patients at 6-month follow-up. The long-term clinical relevance of meniscal extrusion has to be evaluated.

LEVEL OF EVIDENCE

Retrospective study, Level IV.

Metatarsalgia and Morton's Disease: Comparison of Outcomes Between Open Procedure and Neurectomy Versus Percutaneous Metatarsal Osteotomies and Ligament Release With a Minimum of 2 Years of Follow-Up

The present study compared the clinical results of open neurectomy versus a percutaneous procedure for Morton's disease. This was a retrospective study comparing the functional results after 2 surgical procedures: open neurectomy and a percutaneous procedure (with deep transverse metatarsal ligament release and distal metatarsal osteotomies). The present study included 52 patients (26 in each group), and the mean follow-up period was 4 (range 2 to 7) years. The patient evaluation criteria included the presence of painful symptoms of Morton's disease, American Orthopaedic Foot and Ankle Society (AOFAS) functional scale score, patient satisfaction, and delay for recovery. Percutaneous treatment of Morton's disease and open neurectomy produced complete relief of pain in 25 of 26 patients in each group. At the latest follow-up visit, the mean AOFAS score had significantly improved from 36 ± 11 preoperatively to a mean of 89 ± 18 (p < .001). After 2 years, the functional improvement obtained with the percutaneous procedure persisted, with a stable AOFAS score (96 ± 10). Persistent metatarsalgia was reported by patients who had undergone open neurectomy, with a significantly decreased AOFAS score (81 ± 21, p = .009). The percutaneous procedure for Morton's disease provided excellent functional outcomes (AOFAS score >90) significantly more often with a shorter delay than after open neurectomy (p = .03). At the latest follow-up visit, metatarsalgia due to plantar hyperpressure or bursitis and requiring plantar orthotics was present in 11 of 26 patients (44%) after open neurectomy and in 1 of 26 patients (4%) after the percutaneous procedure (p = .002). Percutaneous treatment of Morton's disease is a reliable procedure providing results as good as those after open neurectomy, with significantly better outcomes in the longer term and a lower rate of late metatarsalgia.

Return to rugby after brain concussion: a prospective study in 35 high level rugby players

Background:

Although guidelines based on expert opinions have been developed for the immediate management and return to play of athletes after a concussion, data are lacking on this issue.

Objectives:

Evaluate a standardized management of brain concussion among rugby players to prevent the recurrence.

Patients and Methods:

A prospective study was performed from September 2009 to June 2012. All rugby players who had a concussion when playing rugby were included. Patients were managed by a specialized hospital team with a specific protocol developed in collaboration with the medical staff of the rugby clubs included in the study. The series included 35 rugby players, with 23 professionals and 12 high-level players, 30 men and 5 women, mean age 23.1 ± 5.5 years old. The median number of previous concussions was 2 (0-30) episodes. According to the Cantu concussion severity classification, 3 athletes were grade 1, 12 were grade 2 and 20 were grade 3. None of the injured athletes was lost to follow-up. The primary endpoint was the occurrence of a new concussion within 3 months after the first in patients who returned to rugby.

Results:

Thirty-three patients returned to rugby after a mean 22.1 ± 10 days. The recurrence rate within 3 months was 2/33 (6.1%). The median delay before returning to rugby was 21 (7-45) days. Factors associated with a delayed return to play were young age, initial loss of consciousness, severity Cantu grade 3 and post-concussive syndrome of more than 5 days. Analysis of two failures showed that the initial injury was grade 3 and that both were professional athletes and had a history of concussion.

Conclusions:

This prospective study validated the study protocol for the management of concussion in rugby players.

Treatment of pigmented villonodular synovitis of the knee

PURPOSE

We aimed to determine the rate of local recurrence, the rate of postoperative complications, and the functional outcome at final follow-up of surgical and nonsurgical treatment approaches for pigmented villonodular synovitis (PVNS) of the knee.

METHODS

Medline, Embase, and the Cochrane Library were systematically searched for studies that reported the results of treatment for any type of PVNS between January 1, 1950, and August 1, 2013. Two authors extracted the data independently using predefined data fields including study quality indicators.

RESULTS

Sixty studies (1,019 patients) met the inclusion criteria. Thirty-five presented data on the treatment of localized pigmented villonodular synovitis (LPVNS), 40 on diffuse pigmented villonodular synovitis (DPVNS), 1 on extra-articular LPVNS, and 7 on DPVNS with extra-articular involvement. Many therapeutic options were reported. Depending on these options, DPVNS recurred in 8% to 70% of the series and LPVNS recurred in 0% to 8% of the series. For LPVNS, the 2 most-reported options were open localized synovectomy and arthroscopic local synovectomy. Between these 2 courses of treatment, no difference was found in terms of local recurrence (8.7% for open synovectomy and 6.9% for arthroscopic synovectomy) and postoperative complications (<1% for open synovectomy and 0% for arthroscopic synovectomy). For DPVNS, the 2 most-reported options were open total synovectomy and arthroscopic total synovectomy. Between these 2 courses of treatment, no difference was found in terms of local recurrence (22.6% for open synovectomy and 16.1% for arthroscopic synovectomy). However, we found a lower rate of reported complications between open synovectomy (19.3%) and arthroscopic synovectomy (0%). Internal irradiation or external beam radiation as an adjuvant treatment to surgical synovectomy seemed to decrease the rate of local recurrence in DPVNS cases with a high risk of recurrence. Finally, we found a great heterogeneity in the way the functional results were reported, and no valid conclusion could be made based on the data we extracted.

CONCLUSIONS

We found no difference in local recurrence rates after open or arthroscopic surgery for either LPVNS or DPVNS. However, a lower rate of postoperative complications was reported after arthroscopic surgery for DPVNS.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV therapeutic studies.