Rémy Nizard

Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis

Abstract Objectives To compare bone-patellar tendon-bone autografts with hamstring autografts for reconstruction of the anterior cruciate ligament. Data sources Medline, WebSPIRS, Science Citation Index, Current Contents databases, and Cochrane Central Register of Controlled Trials. Review methods All randomised controlled trials reporting one or more outcome related to stability (instrumented measurement of knee laxity, Lachman test, or pivot shift test) and morbidity (anterior knee pain, kneeling test, loss of extension, or graft failure). Study quality was assessed by using a 5 point scale. Random effect models were used to pool the data. Heterogeneity in the effect of treatment was tested on the basis of study quality, randomisation status, and number of tendon strands used. Results 24 trials of 18 cohorts (1512 patients) met the inclusion criteria. Study quality was poor for nine studies and fair for nine studies. The weighted mean difference of the instrumented measurement of knee laxity was 0.36 (95% confidence interval 0.01 to 0.71; P = 0.04). Relative risk of a positive Lachman test was 1.22 (1.01 to 1.47; P = 0.04), of anterior knee pain 0.57 (0.44 to 0.74; P < 0.0001), of a positive kneeling test 0.26 (0.14 to 0.48; P < 0.0001), and of loss of extension 0.52 (0.34 to 0.80; P = 0.003). Other results were not significant. Conclusion Morbidity was lower for hamstring autografts than for patellar tendon autografts. Evidence that patellar tendon autografts offer better stability was weak. The poor quality of the studies calls into question the robustness of the analyses.

ACL reconstruction: a meta-analysis of functional scores.

From individual randomized studies, it is unclear whether patellar tendon grafts or hamstring tendon grafts yield the best functional results after ACL reconstruction. Therefore, we performed a meta-analysis to provide quantitative data to compare patellar with hamstring grafts after ACL reconstruction with regard to knee function. We searched computerized databases for randomized controlled trials reporting one of the following outcomes related to function: final overall International Knee Documentation Committee score and return to preinjury level of activity. Studies were abstracted independently by two reviewers. Random effect models were used to pool the data. Fourteen trials (1263 patients) met the inclusion criteria. We found no difference in final overall International Knee Documentation Committee score or in the number of patients returning to full activity after patellar and hamstring graft reconstruction. Relative risk was 0.90 for final overall International Knee Documentation Committee Class A and 0.94 for return to preinjury level of activity in favor of patellar grafts. Quantitative interaction tests on the effect of treatment based on study quality, randomization status, number of strands used, and length of followup were non significant. At last followup, only 41% and 33% of patients, respectively, had patellar and hamstring grafts reconstructed reported as normal based on the final overall International Knee Documentation Committee score.Level of Evidence: Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ten-year survivorship of cemented ceramic-ceramic total hip prosthesis.

In the first 187 consecutive alumina-alumina combination hip arthroplasties performed from 1977 to 1979, both components were cemented with conventional techniques. At ten-year follow-up evaluation, 87 patients were reviewed or interviewed by telephone, 37 were dead, 39 were lost to follow-up evaluation, and 24 failures were reoperated on before the end of ten years. The major cause of failure was aseptic loosening of the acetabular component (15 failures). Fracture of the socket and of the femoral head occurred in five patients in this series. However, these complications were not seen with components manufactured after 1979. At the end of ten years, survivorship analysis depicted a 82.59% survival rate when reoperation was considered as failure and a 88.57% rate when reoperation for aseptic loosening was considered as failure. The femoral component had a 99.16% survival rate and the acetabular component had an 88.57% survival rate when reoperation for aseptic loosening was considered as failure. Age, appearance of a two- or three-zone demarcation at the intermediate follow-up evaluation, and outer diameter of the acetabular component were the major parameters influencing the results. Better results observed in the population younger than 50 years of age may be related to the small amount of wear debris produced by the alumina-alumina combination. This combination in hip prosthesis is secure, but should be implanted in young and active patients; the outer diameter of the acetabular component must be at least 50 mm. The major problem that remains is the sockets fixation. It could be improved by a design modification, by choosing another mode of fixation, or both.

Complete Traumatic Brachial Plexus Palsy. Treatment and Outcome After Repair

Seventy-eight patients who had a complete brachial plexus palsy caused by a stretching injury were operated on by the same surgeon between January 1980 and December 1991. The aim of the operative intervention was to obtain the best functional result, including at the level of the hand, that was possible in view of the initial lesions and the intraoperative findings. Therefore, the treatment strategy included not only nerve repair with grafting (124 grafts) or nerve transfer (twenty-seven transfers) but also palliative procedures, the latter of which sometimes were performed several years later. Sixty-three patients were evaluated by an independent observer at least three years postoperatively. The results associated with each type of lesion and each type of nerve repair were assessed according to the function of the muscles that were innervated by the recipient nerve. Six patients had a neurolysis only. The remaining fifty-seven patients had grafts or nerve transfers to repair the biceps. Thirty-six of the fifty-seven received a rating of 3+ or more (meaning that the patient was able to flex the elbow repeatedly); the remaining twenty-one received a rating of 3 or less (meaning that the patient was able to flex the elbow only once or not at all), which we considered unsatisfactory. The function of the triceps recovered after eleven of thirty-one procedures that were performed to restore that nerve; that of the extensor carpi radialis, after five of thirty-one procedures; that of the flexor carpi radialis, after six of thirty-one procedures; and that of the flexor digitorum, after four of thirty-one procedures. A statistical analysis revealed that an operative delay of less than six months was a significant factor with respect to recovery of the function of the biceps (p = 0.003). The thirty-nine grafts that were sutured onto the lateral or posterior cord produced better results than did the thirty-six that were sutured onto the distal branches (the musculocutaneous and radial nerves); however, with the numbers available, this difference was not found to be significant (p = 0.08). Eleven patients had a successful result (a rating of 3+ or more) and eight, a fair or poor result, with respect to recovery of biceps function after transfer of the spinal accessory nerve to the musculocutaneous nerve. Overall, twenty-nine patients had relief of pain postoperatively. Sixteen patients had grade-3 pain preoperatively compared with only three after the operation. According to a self-rating scale, twenty-five patients were satisfied with the overall result, sixteen were fairly satisfied, and twenty-two were dissatisfied.

Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the Anterior Cruciate Ligament A Meta-Analysis Based on Individual Patient Data

Background The best means of ensuring knee stability after anterior cruciate ligament (ACL) reconstruction remains a core debate in sports medicine. Hypothesis There is no difference between ACL reconstruction with patellar tendon or hamstring tendon autografts with regard to postoperative knee laxity and instability. Study Design Meta-analysis of individual patient data. Methods Pooled analysis of individual patient data from 6 published randomized clinical trials included 423 patients with symptomatic unilateral anterior cruciate ligament injury randomly assigned to reconstruction with patellar tendon or hamstring tendon autograft. Knee instability, defined as a positive pivot-shift test result, was the primary outcome, and knee laxity, defined as a positive Lachman test result, was the secondary outcome. Odds ratios were computed before and after adjustment for potential confounders and trial effect. Regression analyses were performed to look for effects of covariates on outcomes, and mixed-effects models were used to account for a trial effect. Sensitivity analyses were conducted to explore the effects of missing data and excluding each trial. Results Anterior cruciate ligament reconstruction with patellar tendon autograft was significantly associated with a decreased risk of a positive pivot-shift test result (adjusted odds ratio, 0.46; 95% confidence interval, 0.24–0.86; P = .016). The risk of having a positive Lachman test result was not significantly different between the 2 groups. The estimated treatment effect was not substantially changed by differences in handling missing data or exclusion of any of the trials. A positive pivot-shift test result was more common in female (P = .003) and younger patients (P = .017). Conclusion Postoperative knee instability was less common after ACL reconstruction with patellar tendon autograft than with hamstring tendon autograft.

A meta-analysis of patellar replacement in total knee arthroplasty

From individual randomized studies it is unclear whether the patella should be replaced during total knee replacement. We did a meta-analysis to provide quantitative data to compare patellar resurfacing with nonresurfacing during total knee arthroplasty. Only randomized, controlled trials reported between January 1966 and August 2003 comparing patellar replacement with patella retention were included for a total of 12 studies. Two reviewers assessed trial quality and extracted data from papers. The outcomes identified were reoperations for patellar problems, anterior knee pain, knee scores, stair climbing, and patient satisfaction. The resurfaced patella performed better, and we found an increased relative risk (defined by the ratio of the risk of the event in the resurfaced group on the risk of the event in the nonresurfaced group) for reoperation, for significant anterior knee pain, and for significant pain during stair climbing when the patella was left unresurfaced. No differences were observed between the two groups for International Knee Society function score, Hospital for Special Surgery score, and for patient satisfaction. Despite these general findings, forming a definitive conclusion is difficult because many confounding factors, such as component design, surgeon experience, and technical aspects of the surgery, might influence the result in a patient. Level of Evidence: Therapeutic study, Level II-3 (systematic review. b. Nonhomogeneous Level I studies)

Hybrid alumina total hip arthroplasty using a press-fit metal-backed socket in patients younger than 55 years A SIX- TO 11-YEAR EVALUATION

Between 1990 and 1992, we implanted 71 hybrid alumina-on-alumina hip arthroplasties in 62 consecutive patients under the age of 55 years, with a mean age of 46 years at surgery. There were 56 primary and 15 secondary procedures. The prostheses involved a cemented titanium alloy stem, a 32 mm alumina head, and a press-fit metal-backed socket with an alumina insert. Three patients (four hips) died from unrelated causes. Four hips had revision surgery for either deep infection, unexplained persistent pain, fracture of the alumina head, or aseptic loosening of the socket. The nine-year survival rate was 93.7% with revision for any cause as the end-point and 98.4% with revision for aseptic loosening as the end-point. The outcome in the surviving patients (50 patients, 57 hips) with a minimum five-year follow-up (mean eight years) was excellent in 47 hips (82.5%), very good in eight (14%), good in one and fair in one. A thin, partial, lucent line, mainly in zone III was present in 38% of the sockets and one socket had a complete lucency less than 1 mm thick. One stem had isolated femoral osteolysis. There was no detectable component migration nor acetabular osteolysis. This hybrid arthroplasty gave satisfactory medium-term results in active patients. The press-fit metal-backed socket appeared to have reliable fixation in alumina-on-alumina hip arthroplasty. The excellent results using cemented fixation of the stem may be related to the low production of wear debris.

Alumina-alumina hip replacement in patients younger than 50 years old

From April 1977 to December 1990, 131 total hip arthroplasties were performed on 113 patients younger than 50 years of age (median, 41 years); 64 were men and 49 women. The majority were active people. Sixty-six hips had no previous operations, and 33 had at least one previous arthroplasty. The femoral component was a cemented collared titanium alloy stem, and alumina socket was cemented for 99 hips and press-fit for 32. The mean follow-up period was five years, with 32 hips followed for more than ten years. Revision arthroplasty was considered as a failure. Survivorship analysis depicted a 97.5% rate of survival at five years, an 89.4% rate at ten years, and an 86.2% at 11 years. Nine revisions were performed: one experienced a femoral head rupture after three years, one had bipolar loosening, one experienced femoral cystic formation, and six were revised for acetabular cup loosening, all from the cemented group. Two revisions occurred on the same patient. No stem revision was necessary before ten years. Only one of these revisions was required in patients aged 40 or younger (64 patients). Alumina-alumina friction is an extremely interesting phenomenon in young patients, and could be related to the low wear debris production.

Comparison of treatment effect estimates from prospective nonrandomized studies with propensity score analysis and randomized controlled trials of surgical procedures.

Objective:We aimed to compare treatment effect estimates from NRSs with PS analysis and RCTs of surgery. Background:Evaluating a surgical procedure in randomized controlled trials (RCTs) is challenging. Nonrandomized studies (NRSs) involving use of propensity score (PS) analysis to limit bias are of increasing interest. Design:Meta-epidemiological study. Methods:We systematically searched MEDLINE via PubMed for all prospective NRSs with PS analysis evaluating a surgical procedure. Related RCTs, addressing the same clinical questions, were systematically retrieved. Our primary outcome of interest was all-cause mortality. We also selected 1 subjective outcome. We calculated the summary odds ratios (OR) for each study design, the ratio of OR (ROR) between the designs and the summary ROR across clinical questions. An ROR < 1 indicated that the experimental intervention is more favorable in NRSs with PS analysis than RCTs. Results:We retrieved 70 reports of NRSs with PS analysis and 94 related RCTs evaluating 31 clinical questions, of which 22 assessed all-cause mortality and 26 a subjective outcome. The combined ROR for all-cause mortality was 0.83 (95% confidence interval: 0.65–1.04). For subjective outcomes, the combined ROR was 1.07 (0.87–1.33). Conclusions:There was no statistically significant difference in treatment effect between NRSs with PS analysis and RCTs. Prospective NRSs with suitable and careful PS analysis can be relied upon as evidence when RCTs are not possible.

Quantitative and individualized assessment of the learning curve using LC-CUSUM.

Current methods available for assessing the learning curve, such as a predefined number of procedures or direct observation by a tutor, are unsatisfactory. A new tool, the cumulative summation test for learning curve (LC‐CUSUM), has been developed that allows quantitative and individual assessment of the learning curve.