Intramedullary nailing of femoral shaft fractures: an analysis of rotational malunions using 3D EOS

PURPOSE

Rotational malalignment and leg length discrepancy after intramedullary nailing of femoral shaft are frequent. This study has three objectives: evaluate the rate of femoral rotational malalignment and leg length discrepancy using EOS imaging after antegrade intramedullary nailing of femoral shaft fracture, find a relevant clinical examination to detect malrotation and identified risk factors.

METHODS

We performed a retrospective single-centre study between January 2014 and January 2022. Fifty-eight patients were clinically and radiographically assessed at a minimum of three months.

RESULTS

The femoral rotation of the operated side was significantly greater by a mean of 15.4° in internal rotation compared to the healthy side. There was no statically significant difference for the femoral length (p = 0.08).

CONCLUSION

When using EOS stereography following antegrade intramedullary nailing of post-traumatic diaphyseal femur fractures, a statistically significant difference of more than 15.4° in internal rotation was found for femoral rotation on the operated side compared to the healthy side.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [B. Poirot] Last name [Seynaeve]. Also, kindly confirm the details in the metadata are correct.The last name of the first author was corrected : Given name = B. and last name = Poirot Seynaeve The details in matadata are correct LEVEL OF EVIDENCE: III.

Evaluation of a method to quantify posture and scapula position using biplanar radiography

BACKGROUND

Recent studies have stated the relevance of having new parameters to quantify the position and orientation of the scapula with patients standing upright. Although biplanar radiography can provide 3D reconstructions of the scapula and the spine, it is not yet possible to acquire these images with patients in the same position.

METHODS

Two pairs of images were acquired, one for the 3D reconstruction of the spine and ribcage and one for the 3D reconstruction of the scapula. Following 3D reconstructions, scapular alignment was performed in two stages, a coarse alignment based on manual annotations of landmarks on the clavicle and pelvis, and an adjusted alignment. Clinical parameters were computed: protraction, internal rotation, tilt and upward rotation. Reproducibility was assessed on an in vivo dataset of upright biplanar radiographs. Accuracy was assessed using supine cadaveric CT-scans and digitally reconstructed radiographs.

FINDINGS

The mean error was less than 2° for all clinical parameters, and the 95 % confidence interval for reproducibility ranged from 2.5° to 5.3°.

INTERPRETATION

The confidence intervals were lower than the variability measured between participants for the clinical parameters assessed, which indicates that this method has the potential to detect different patterns in pathological populations.

3D reconstruction of the scapula from biplanar X-rays for pose estimation and morphological analysis

BACKGROUND

Patient-specific scapular shape in functional posture can be highly relevant to clinical research. Biplanar radiography is a relevant modality for that purpose with already two existing assessment methods. However, they are either time-consuming or lack accuracy. The aim of this study was to propose a new, more user-friendly and accurate method to determine scapular shape.

METHODS

The proposed method relied on simplified manual inputs and an upgraded version of the first 3D estimate based on statistical inferences and Moving-Least Square (MLS) deformation of a template. Then, manual adjustments, with real-time MLS algorithm and contour matching adjustments with an adapted minimal path method, were added to improve the match between the projected 3D model and the radiographic contours. The accuracy and reproducibility of the method were assessed (with 6 and 12 subjects, respectively).

FINDINGS

The shape accuracy was in average under 2 mm (1.3 mm in the glenoid region). The reproducibility study on the clinical parameters found intra-observer 95% confidence intervals under 3 mm or 3° for all parameters, except for glenoid inclination and Critical Shoulder Angle, ranging between 3° and 6°.

INTERPRETATION

This method is a first step towards an accurate reconstruction of the scapula to assess clinical parameters in a functional posture. This can already be used in clinical research on non-pathologic bones to investigate the scapulothoracic joint in functional position.

Treatment of thoracolumbar fractures: comparison of the clinical and radiological outcomes of percutaneous versus open surgery

STUDY DESIGN

Retrospective study.

INTRODUCTION

Spinal fractures are common trauma that can be treated by a range of techniques, from functional to surgical. Spine surgery has been around for many years. The first procedures were done open but have been plagued by numerous complications-sometimes severe-and substantial intraoperative blood loss. Percutaneous surgery was developed to help reduce the complications while providing similar clinical and radiological outcomes to open surgery. We conducted a study to compare open and percutaneous surgery and to evaluate other complications as well as short- and medium-term clinical and radiological results.

MATERIAL AND METHODS

Retrospective, single-center study comparing two cohorts of patients suffering from an isolated vertebral fracture who were operated using either an open or percutaneous technique. Included were patients who had an isolated vertebral fracture between T10 and L3 and were operated between 01/01/2016 and 31/12/2018 at the Reims university hospital. These patients were reviewed in person after a minimum of 18 months postoperative for clinical and radiological assessments. The Mercuriali and Brecher formula was used to calculate intraoperative blood loss based on pre- and postoperative hematocrit; the total blood volume was determined with the Nadler formula.

RESULTS

The study cohort consisted of 79 patients operated by percutaneous surgery and 55 patients operated by open surgery. The blood loss in the percutaneous surgery group was 176 mL versus 220 mL in the open surgery group (p = 0.02). The length of hospital stay was shorter after percutaneous surgery (mean of 3.6 days) than after open surgery (mean of 5.5 days) (p < 0.001). Also, the pedicle screw placement was optimal in 88% of percutaneous procedures versus 67% of open procedures (p < 0.001).

CONCLUSION

Percutaneous surgery for thoracolumbar fractures causes less blood loss than conventional open surgery. The clinical and radiological results are on par with conventional open surgery. The mean length of hospital stay is shorter and the accuracy of pedicular screw placement is higher with percutaneous surgery. Thus, we can conclude that percutaneous surgery is the preferred treatment for thoracolumbar fractures when no neurological deficit is present.

LEVEL OF EVIDENCE

IV.

Bone marrow mesenchymal stem cells offer an immune-privileged niche to Cutibacterium acnes in case of implant-associated osteomyelitis

Considered as some of the most devastating complications, Cutibacterium acnes (C. acnes)-related osteomyelitis are among the hardest infections to diagnose and treat. Mesenchymal stem cells (MSCs) secrete number of immunomodulatory and antimicrobial soluble factors, making them an attractive treatment for bacterial infection. In this study, we examined MSCs/C. acnes interaction and analyzed the subsequent MSCs and bacteria's behaviors. Human bone marrow-derived MSCs were infected by C. acnes clinical strain harvested from non-infected bone site. Following 3 h of interaction, around 4% of bacteria were found in the intracellular compartment. Infected MSCs increased the secretion of prostaglandin E2 and indolamine 2,3 dioxygenase immunomodulatory mediators. Viable intracellular bacteria analyzed by infrared spectroscopy and atomic force microscopy revealed deep modifications in the wall features. In comparison with unchallenged bacteria, the viable intracellular bacteria showed (i) an increase in biofilm formation on orthopaedical-based materials, (ii) an increase in the invasiveness of osteoblasts and (iii) persistence in macrophage, suggesting the acquisition of virulence factors. Overall, these results showed a direct impact of C. acnes on bone marrow-derived MSCs, suggesting that blocking the C. acnes/MSCs interactions may represent an important new approach to manage chronic osteomyelitis infections. STATEMENT OF SIGNIFICANCE: The interaction of bone commensal C. acnes with bone marrow mesenchymal stem cells induces modifications in C. acnes wall characteristics. These bacteria increased (i) the biofilm formation on orthopaedical-based materials, (ii) the invasiveness of bone forming cells and (iii) the resistance to macrophage clearance through the modification of the wall nano-features and/or the increase in catalase production.

Short duration of post-amputation antibiotic therapy in diabetic foot patients with total resection of osteomyelitis

BACKGROUND

Short duration of post-amputation antibiotic therapy (2-5 days) is recommended in patients with diabetic foot osteomyelitis after total resection of infected bone tissue.

OBJECTIVE

To evaluate the long-term effectiveness of short-duration post-amputation antibiotic therapy in diabetic patients with total resection of osteomyelitis assessed by sterile bone bacteriological samples obtained from the resection margin.

METHODS

The endpoint was the absence of osteomyelitis relapse at 6 months, defined as recurrence of osteomyelitis with the need for surgical revision and/or new bone antibiotic therapy.

RESULTS

Among 15 patients included, 12 (80%) were cured without recurrence of osteomyelitis at 6 months, with a mean duration of antibiotic therapy of 8.3±5.9 days post surgery. This result is comparable to literature data, while all of them reported longer duration of antibiotic therapy and/or shorter follow-up.

CONCLUSION

Short duration of post-amputation antibiotic therapy in diabetic patients with sterile bacteriological samples obtained from resection margin seems effective.

Posterolateral fusion versus Dynesys dynamic stabilization: Retrospective study at a minimum 5.5years' follow-up

INTRODUCTION

Lumbar fusion is one of the most widespread techniques to treat degenerative lumbar pathology. To prevent complications such as non-union or adjacent segment degeneration, dynamic stabilization techniques were developed, but with controversial results. The aim of the present study was to compare long-term radiologic and clinical results between fusion and dynamic stabilization.

MATERIAL AND METHODS

A single-center retrospective study included patients with recurrent lumbar discal hernia or lumbar canal stenosis managed by posterolateral fusion or by dynamic stabilization associated to neurologic release. Patients were seen in follow-up for radiological and clinical assessment: visual analog pain scale (VAS), Oswestry Disability Index (ODI), Short Form-12 (SF-12), adjacent segment disease (ASD), and intervertebral range of motion (ROM).

RESULTS

Fifty-eight patients were included: 25 in the fusion group (FG), and 33 in the Dynesys^® group (DG). VAS scores were significantly lower in DG than FG. ODI was 14.6±2.8 in DG, versus 19.4±3.3 in FG (P=0.0001). SF-12 physical subscore was significantly higher in DG. ROM was 4.1±2° in DG, vs. 0.7±0.5° in FG (P=0.001). Radiologic ASD was significantly greater in FG than DG (36% vs. 12.1%; P=0.012), without difference in clinical expression (DG, 1 case; FG, 2 cases).

CONCLUSION

Dynamic stabilization provided clinical and radiological results comparable to those of posterolateral fusion in these indications (although level L5-S1 was not studied).

LEVEL OF EVIDENCE

IV.

Transcultural validation of the Oxford Shoulder Score for the French-speaking population

PURPOSE

Patient-reported outcome measures (PROMs) have been gaining in popularity over the last decade. The Oxford Shoulder Score (OSS) is a well-established self-administered questionnaire for shoulder evaluation adapted for the English-speaking population. The aim of the present study was to develop a translation and a transcultural adaptation of the OSS and to assess its validity in native French-speaker patients with shoulder pain.

METHODS

The translation process was carried out following a translation/back-translation methodology by two translators. All patients completed the French OSS, the Subjective Shoulder Value (SSV), and the Constant score. Internal consistency was tested using Cronbach's α coefficient. Validity was assessed by calculating the Pearson correlation coefficient between the OSS and the Constant score and the SSV.

RESULTS

One hundred forty-four patients suffering from degenerative or inflammatory diseases of the shoulder were included in this study. The average time required to complete the French OSS was 2min and 45s. Seventy patients were asked to complete the questionnaire twice (test/retest reliability). Internal consistency was high with Cronbach's α coefficient=0.93. The intraclass correlation coefficient was 0.91 (95% CI: 0.88-0.94) for test/retest reliability. The French OSS score was significantly correlated with the Constant-Murley score (r=0.73 and P<0.0001) and with the SSV (r=0.68 and P<0.0001).

CONCLUSIONS

The present study shows that the French version of the OSS is reliable, valid, and reproducible. The sensitivity to change now needs to be evaluated. This score was adapted to the French-speaking population for the self-assessment of patients with degenerative or inflammatory disorders of the shoulder.

LEVEL OF EVIDENCE

Level 1, Test of previously developed criteria, diagnostic test study.

Papillary endothelial hyperplasia (Masson's tumor) in children

The intravascular papillary endothelial hyperplasia (IPEH/Masson's tumor) is a rare benign tumor of the skin and subcutaneous vessels. We report, in four pediatric cases, clinical presentation, care (diagnostic and surgical) of Masson's tumor in children. Two boys (two years) and two girls (four and six years) showed a pain subcutaneous tumor (one to five centimeters). They were in the transverse abdominal muscle, between two metatarsals, at the front of thigh and in the axilla. Imaging performed (MRI, Doppler ultrasound) evoked either a hematoma, a lymphangioma or hemangioma. The indication for removal was selected from pain and/or parental concern. The diagnosis was histologically. A lesion persisted in residual form (incomplete initial resection), and is currently not scalable for eleven years.

DISCUSSION

This tumor is characterized by excessive proliferation and papillary endothelial cells in the vessels, following a thrombotic event. It is found mainly in adults (no specific age), and preferentially localizes in the face and limbs. The clinical differential diagnosis of this tumor is angiosarcoma. The imagery has not allowed in our series to diagnose but still essential to eliminate differential diagnoses. Only surgical excision with histological examination can differentiate. Our study emphasizes the possibility of pediatric cases with two cases of unusual locations (abdominal and axilla). Clinical presentations we met, now lead us to direct our histologist looking for a Masson tumor in any child with a subcutaneous tumor and/or intramuscular pain, sudden onset, and vascular appearance (after excluding an arteriovenous malformation).

Bone erosion and subacromial bursitis caused by diphtheria-tetanus-poliomyelitis vaccine

Revaxis(®) is a vaccine against diphtheria, tetanus and poliomyelitis (dT-IPV). This vaccine should not be administered by the intradermal or intravenous route. Poor injection techniques and related consequences are rare. We report a case of bursitis associated with reactive glenohumeral effusion complicated by bone erosion occurring after injection of the dT-IPV vaccine. A 26 year old patient was admitted for painful left shoulder causing functional impairment. Control magnetic resonance imaging showed bone oedema on the upper outer part of the humeral head, with a slight cortical irregularity, indicating that the vaccine was injected in contact with the bone at this location, causing erosion. Outcome was favourable after intra-articular corticosteroids. Reports of articular or periarticular injury after vaccination are extremely rare, in view of the substantial number of vaccines administered every year. The potential complications of vaccination are well known to general practitioners but under-reported in the literature.

Muscle recovery after ACL reconstruction with 4-strand semitendinosus graft harvested through either a posterior or anterior incision: a preliminary study

INTRODUCTION

Harvesting of a 4-strand semitendinosis (ST4) graft during anterior cruciate ligament (ACL) reconstruction can be performed through either a posterior or anterior approach. The objective of this study was to evaluate the recovery of the quadriceps and hamstring muscles as a function of the graft harvesting method. We hypothesized that posterior harvesting (PH) would lead to better recovery in hamstring strength than anterior harvesting (AH).

METHODS

In this prospective study, the semitendinosus was harvested through an anterior incision in the first group of patients and through a posterior one in the second group of patients. The patients were enrolled consecutively, without randomization. Isokinetic muscle testing was performed three and six months postoperative to determine the strength deficit in the quadriceps and hamstring muscles of the operated leg relative to the uninjured contralateral leg.

RESULTS

Thirty-nine patients were included: 20 in the AH group and 19 in the PH group. The mean quadriceps strength deficit after three and six months was 42% and 26% for AH and 29% and 19% for the PH, respectively (P=0.01 after three months and P=0.16 after six months). The mean hamstring strength deficit after three and six months was 31% and 17% for AH and 23% and 15% for the PH, respectively (P=0.09 after three months and P=0.45 after six months). After three months, the PH group had recovered 12% more quadriceps muscle strength than the AH group (P=0.03).

CONCLUSION

Our hypothesis was not confirmed. Harvesting of a ST4 graft for ACL reconstruction using a posterior approach led to better muscle strength recovery in the quadriceps only after three months.

CASE CONTROL STUDY

Level 3.

Primary shoulder reverse arthroplasty: surgical technique

Total reverse shoulder replacement is now a very common surgical procedure that has been shown to be effective in the treatment of rotator cuff tear arthropathies or massive rotator cuff tears with pseudo paralysis, even without arthritis. However, the survival curves of the oldest series decrease between 8 and 10 years after arthroplasty (events: implant survival, or worsening of clinical outcome) which explains why the indication for this type of arthroplasty is usually limited to patients over seventy. Moreover, details and technical modifications have been suggested to improve the surgical technique, the quality of fixation and the mechanical conditions of this non-anatomical prosthesis to improve clinical outcome and implant survival. Within the framework of primary surgery, excluding traumatic or revision surgery, the primary indications for this option are massive rotator cuff tears with (or without) osteoarthritis and primary osteoarthritis with rotator cuff tears and/or with severe glenoid wear and finally, rheumatoid arthritis. The purpose of this conference was to assess and describe the most important preoperative criteria and surgical conditions necessary for this procedure as well as specific technical details about the surgical procedure itself based on available options and options under evaluation such as the positioning of the glenoid component (lateralization, bone graft, orientation) and the association of muscle transfers.

Dorsally displaced distal radius fractures: comparative study of Py's and Kapandji's techniques

INTRODUCTION

Within the framework of a regional clinical study, the radiographic results of Py's and Kapandji's fixation techniques for dorsally displaced distal radius fractures were compared.

PATIENTS AND METHODS

A prospective randomised monocenter and multi-operator study (phase III clinical trial) comparing the Py's (isoelastic pinning) and Kapandji's (intrafocal pinning) techniques was conducted. Two comparable groups were established: the Py (P) and Kapandji (K) groups. The frontal radial tilt (FRT), sagittal radial tilt (SRT), radial length and ulnar variance were measured. Analysis of subjective and objective function was based on the range of motion according to six parameters, the DASH and Jakim scoring systems. The quality of anatomical restoration was assessed arthroscopically during pin removal at 6 postoperative weeks.

RESULTS

Ninety-seven patients were included in the study with a follow-up period of 1 year. The preoperative FRT was 15.17° and SRT was -19.2°. At one-year follow-up, the FRT was 25.5° in the PY group and 22.6° in the K group (p=0.009), the SRT was 10.5° in the PY group and 6.7° in the K group (p=0.04). For fractures with postero-medial fragment and Gerard Marchand's fractures, the DASH score at last follow-up was 22 in the Py group, 42 and 32 respectively in the K group. The Jakim score was 71 in the PY group and 58 in the K group (p=0.03) for fractures with postero-medial fragment. There was no report of tendon rupture in our study.

DISCUSSION

Besides the good results achieved with both pinning techniques in the treatment of distal radius fractures, this series also underlines the importance to adapt the type of fixation to the fracture pattern and patient.

CONCLUSION

Pinning for treating dorsally displaced distal radius fractures appears a suitable option provided that the indications and the surgical technique for each method are respected. However, pinning is not suitable for all types of fractures.

LEVEL OF EVIDENCE

Level II. Randomised prospective therapeutic study.

Low-intensity pulsed ultrasound for non-union treatment: a 14-case series evaluation

INTRODUCTION

Non-union is presently managed exclusively by surgery, but alternative treatments are under evaluation.

OBJECTIVE

To assess the benefit of external ultrasound stimulation in surgically treated lowerlimb long-bone non-union.

PATIENTS AND METHODS

A retrospective series of 14 patients were treated using the Exogen(®) ultrasound stimulator (Smith & Nephew Inc., Memphis, TN, USA) as part of management of surgically treated long-bone non-union. They received 20min stimulation daily over a period of 3 months. Regular clinical and radiological follow-up checked treatment efficacy.

RESULTS

The mean interval to initiation of Exogen(®) treatment after initial surgery was 361 days (range, 6, 38 months). Bone consolidation was obtained in 11 of the 14 cases (79%), and within 3 months of initiation of Exogen(®) treatment in 27% (3/11), within 6 months in 27% (3/11) and within 9 months in 46% (5/11). There were no treatment-linked complications. There was no significant correlation between interval to initiation of ultrasound treatment and bone consolidation. Associated sepsis or atrophy did not significantly impact treatment efficacy.

DISCUSSION

The reference treatment strategy in non-union is surgical revision, with consolidation rates ranging from 85 to 100% according to the series. This attitude entails risk of complications, notably infection and postoperative pain. The present results were comparable to those of the literature, with 79% bone consolidation and no complications. Ultrasound stimulation proved an effective and non-invasive treatment for non-union.

LEVEL OF EVIDENCE

Retrospective study, level IV.

Odontoid fractures anterior screw fixation: a continuous series of 36 cases

INTRODUCTION

Fracture of the odontoid process represents 5 to 15% of cervical spine fractures. Anterior screw fixation is the reference technique in unstable posterior oblique or horizontal odontoid fracture.

OBJECTIVE

We describe results with an original anterior screw fixation technique using a curved thoraco-lumbar pedicle awl to facilitate intra-operative reduction.

PATIENTS AND METHODS

This is a retrospective study of 36 consecutive patients who underwent anterior screw fixation for odontoid process fracture. Mean age was 70.3 years. Twenty six patients had type II and 10 type III fracture on the Anderson-D'Alonzo classification. On the Roy-Camille classification, there were 34 posterior oblique fractures and two horizontal fractures. There were no anterior oblique fractures. Bony union was assessed on CT-scan at 3 months. We describe the surgical technique, which used a 4.5mm cannulated cancellous lag screw in all cases.

RESULTS

Mean follow-up was 3 years (range, 4 months to 8 years). No intra-operative complications were observed. Union rate was 95% and the average time to union was 5 months (3 to 6 months).

DISCUSSION

Anterior screw fixation is a common surgical treatment for posterior oblique and horizontal odontoid process fractures. We detail a reliable and reproducible intra-operative reduction maneuver to obtain a good union rate without complications.

LEVEL OF EVIDENCE

Level IV. Retrospective therapeutic study.

Shoulder hemi arthroplasty radiological and clinical outcomes at more than two years follow-up

INTRODUCTION

Humeral head replacement is used for glenohumeral osteoarthritis in young or active patients, for conditions sparing glenoid cartilage or when glenoid implantation does not appear feasible. These surgical procedures usually give satisfactory results but there is a risk of glenoid erosion and a possible deterioration of long-term outcomes.

HYPOTHESIS

There is a risk of glenoid erosion after humeral head replacement which can be radiographically measured. The importance and progression of this erosion should be evaluated to determine its clinical relevance.

PATIENT AND METHODS

This is a retrospective study in 15 patients (19 shoulders) who underwent humeral head replacement between 1999 and 2006. There were 11 women and four men with an average age of 54.5 years. Etiologies were avascular necrosis (11 cases) and glenohumeral osteoarthritis (eight cases). All patients were reviewed in 2008 with more than two years follow-up. Clinical evaluation included measurements of range of motion and determination of the Constant and Murley score. In addition, the patients were asked to provide a subjective evaluation of their shoulder. Radiographic analysis included computer-assisted measurements.

RESULTS

The average follow-up was 45.8 months (26-108). At one year postoperative and at the final follow-up, clinical parameters such as the Constant and Murley score (37.4/100 preoperative to 64.4/100 at final follow-up) were significantly increased. During the first year, the rate of glenoid wear was 1.03 mm/year in case of avascular necrosis and 0.27 mm/year in case of osteoarthritis (p<0.001). Glenoid depth at the final follow-up was 6.97 mm for osteoarthritis compared to 4.59 mm for avascular necrosis (p<0.01). We did not find any correlation between glenoid erosion severity and clinical results.

DISCUSSION

Isolated humeral head replacement may result in glenoid erosion. The rate of progression of this erosion is clearly influenced by the etiology and therefore by the preexisting condition of the glenoid cartilage. At the average follow-up, the radiological glenoid deterioration is not correlated with pain or deterioration of clinical results.

LEVEL OF EVIDENCE

Level IV. Therapeutic study.