Shahnaz Klouche

Infected total hip arthroplasty revision: one- or two-stage procedure?

INTRODUCTION Better outcomes have been reported for two-stage total hip arthroplasty (THA) revision for infection. However, one-stage revision arthroplasty remains an attractive alternative option since it requires only one operation. A decision tree has been developed by the authors in order to determine which type of surgical procedure can be performed safely. The goal of this study was to assess this decision tree for THA replacement in the case of a peri-prosthetic infection. HYPOTHESIS A one-stage procedure may be as successful as a two-stage procedure provided some criteria are fulfilled. METHODS A prospective study included 84 patients, all diagnosed with infected THA who had prosthesis replacement. A one-stage exchange was performed in 38 cases and a two-stage procedure in 46 cases. A two-stage procedure was decided in the case of important bone loss or unidentified germ. Postoperatively, patients received intravenous antibiotics (six weeks), then oral antibiotics (six weeks). The main evaluation criterion was the rate of infection eradication at 2 years minimal follow-up since surgery. If new infection was suspected, a hip aspiration was performed to determine whether it was non-eradication (same germ) or a new re-infection (other germ), which was not considered as a failure. RESULTS The initial infection was cured in 83 out of 84 patients (98.8%), 38 (100%) for the one-stage group and 45 (97.8%) for the two-stage group. Three patients were re-infected with different germs in the two-stage group. Eighty out of 84 (95.2%) patients were infection free, all patients (100%) of the one-stage group and 42 patients (91.3%) of two-stage group. DISCUSSION If some selection criteria were respected, a high success rate in THA replacement for infection may be achieved with a one-stage procedure. It permits to reduce the costs with no loss of chance for the patients. The decision tree was validated. LEVEL OF EVIDENCE Level III; prospective case control study.

Does arthroscopic rotator cuff repair actually heal? Anatomic evaluation with magnetic resonance arthrography at minimum 2 years follow-up

PURPOSE The goal of this series was to evaluate the clinical and anatomical outcomes of all-arthroscopic rotator cuff tears repair at a mid-term follow-up, using MR arthrography in order to assess tendon-to-bone healing. MATERIALS AND METHODS This retrospective study included 29 patients (31 shoulders) presenting, according to Cofield classification, a small or moderate-sized supraspinatus full thickness tear with (7/31) or without (24/31) infraspinatus extension. The mean size of the tear was 2.64 ± 1.61 cm. The Constant score was used for pre- and postoperative clinical evaluation. All tendons were repaired under arthroscopic control. A single row technique was used. Biceps tenotomy and subacromial decompression were systematically performed. All patients operated arm were immobilized in a sling for 4 weeks and full activity was allowed at 6 months. At last follow-up, a rotator cuff MR arthrography was performed by an independent radiologist to evaluate the anatomical status of repair. RESULTS The mean follow-up was 49.4 ± 17.3 months. Sixteen patients (17 shoulders) had a rotator cuff MR arthrography. Mean Constant score at last follow-up was 82.3 ± 12.4, with a mean improvement of 24%. Eighty-eight percent of repairs (15/17) showed a small or a large leakage at the MR arthrography. There was no significant correlation between the clinical and anatomical outcomes. CONCLUSION The interest of this series is to show, at a mid-term follow-up and using an invasive imaging technique, the low rate of tendon-to-bone healing in arthroscopic rotator cuff repair but with a minimal influence on clinical outcome.

The effect of femoral offset modification on gait after total hip arthroplasty

Background and purpose — A decrease of 15% in femoral offset (FO) has been reported to generate a weakness of the abductor muscle, but this has not been directly linked to an alteration of gait. Our hypothesis was that this 15% decrease in FO may also generate a clinically detectable alteration in the gait. Patients and methods — We performed a prospective comparative study on 28 patients who underwent total hip arthroplasty (THA) for unilateral primary osteoarthritis. The 3D hip anatomy was analyzed preoperatively and postoperatively. 3 groups were defined according to the alteration in FO following surgery: a minimum decrease of 15% (9 patients), restored (14), and a minimum increase of 15% (5). A gait analysis was performed at 1-year follow-up using an ambulatory device. Each limb was compared to the contralateral healthy limb. Results — In contrast to the “restored” group and the “increased” group, in the “decreased” group there was a statistically significant asymmetry between sides, with reduced range of motion and a lower maximal swing speed on the operated side. Interpretation — A decrease in FO of 15% or more after THA leads to an alteration in the gait. We recommend 3-D preoperative planning because the FO may be underestimated by up to 20% on radiographs and it may therefore not be restored, with clinical consequences.

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.

Recurrence after arthroscopic Bankart repair: Is quantitative radiological analysis of bone loss of any predictive value?

INTRODUCTION Bone defects in the humeral head or antero-inferior edge of the glenoid cavity increase recurrence risk following arthroscopic Bankart repair. The present study sought to quantify such preoperative defects using a simple radiological technique and to determine a threshold for elevated risk of recurrence. MATERIALS AND METHODS A retrospective study conducted in two centers enrolled patients undergoing primary arthroscopic Bankart repair for isolated anterior shoulder instability in 2005. The principle assessment criterion was revision for recurrent instability. Quantitative radiology comprised: the ratio of notch depth to humeral head radius (D/R) on AP view in internal rotation; Gerbers X ratio between antero-inferior glenoid cavity edge defect length and maximum anteroposterior glenoid cavity diameter on arthro-CT scan; and the D1/D2 ratio between the glenoid joint surface diameters of the pathologic (D1) and healthy (D2) shoulders on Bernageau glenoid profile views. Seventy-seven patients were included, with a mean follow-up of 44 months (range, 36-54). RESULTS Overall recurrence rate was 15.6%. Recurrence risk was significantly greater when the humeral notch length was more or equal to 20% of the humeral head diameter and the Gerber ratio more or equal to 40%. On Bernageau views, mean D1/D2 ratio was 4.2% (range, 0-23%) in patients without recurrence, versus 5.1% (range, 0-19) in those with recurrence (P=0.003). DISCUSSION Beyond the above thresholds, bone defect as such contraindicates isolated arthroscopic stabilization. The D/R and Gerber ratios are simple and reproducible quantitative measurements can be taken in routine practice, enabling preoperative planning of complementary bone surgery as needed. LEVEL OF EVIDENCE Level IV; retrospective cohort study.

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).

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.

Pain evaluation after all-inside anterior cruciate ligament reconstruction and short term functional results of a prospective randomized study☆ , ☆☆

PURPOSE To assess post-operative pain in patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction by the all-inside technique. METHODS A prospective randomized comparative parallel trial was performed in 2010-2011 including all patients who underwent an ACL reconstruction in an orthopaedic department in accordance with the CONSORT statement 2010. Patients were randomized to the surgical procedure, all-inside or classical, and were blinded to the surgical technique. Primary evaluation criterion was pain assessed on the Visual Analogical Scale 1 month after surgery. Secondary parameters were analgesic consumption, tunnel positioning on X-ray according to Agliettis criteria and functional evaluation at six months with IKDC score. None of the patients was lost to follow-up. RESULTS 46 consecutive patients were included, 23 in each group, mean age 29.3±9 years. Two patients were excluded due to postoperative complications that required early revision surgery. Forty-four patients were analyzed, 22 in each group. At one month, the pain level was 3.2±5.5 for the all-inside group and 8.6±10 for the classical group, p=0.057 (95%CI 0.5-10.4). Postoperative analgesic consumption was similar. The position of the tibial tunnels was better with the all-inside method, p=0.002 (95%CI 1.9-6.6%). There was no significant difference in the mean IKDC subjective score at six months, p=0.92 (95%CI-9.7 to 9.2). CONCLUSION At one month, the pain level seemed lower in the all-inside group than in the classical group, at the limit of statistical significance because the study was underpowered. The all-inside technique is a reliable procedure with very good results for pain, stability and knee function. LEVEL OF EVIDENCE I; Therapeutic study.

Outpatient surgery feasibility in anterior cruciate ligament reconstruction: a prospective comparative assessment.

INTRODUCTION The main objective of this study was to assess the feasibility of outpatient surgery in anterior cruciate ligament (ACL) reconstruction. We hypothesized that if the patient underwent the procedure within a dedicated organization, safety would be ensured. PATIENTS AND METHODS A non-randomized, prospective, comparative, single-operator study conducted in 2012-2013 included all patients undergoing first-line surgery for ACL arthroscopic reconstruction using a short hamstring graft. The outpatient group (OP) included patients who were eligible for outpatient surgery and provided consent; the conventional hospitalization group (CH) comprised those patients not suitable for outpatient surgery and those who refused it. The main evaluation criterion was failure of the admission modality defined as hospitalization of a patient who had undergone outpatient surgery or rehospitalization in the first week after discharge. The secondary evaluation criteria were the rate of postoperative complications, postoperative pain, use of analgesics, and patient satisfaction. A total of 138 patients were included: 71 in the OP group and 67 in the CH group, with a mean age of 29.6±9 years. Twenty-nine percent of the patients refused outpatient surgery. In the CH group, the mean hospital stay lasted 2.7±0.8 days. RESULTS One patient in the OP group was hospitalized with localized bleeding and there were no rehospitalizations. Six early postoperative complications were noted in each group. The mean postoperative pain on D0-D4 and patient satisfaction were similar in the two groups. CONCLUSION This prospective study encountered no serious events after outpatient ACL reconstruction surgery. In a selected population, the risks are comparable to those in conventional hospitalization. LEVEL OF EVIDENCE Level III, comparative study.

Total hip arthroplasty dislocation rate following isolated cup revision using Hueter's direct anterior approach on a fracture table.

INTRODUCTION Instability is a major complication after revision total hip arthroplasty. Studies in the literature have shown that the dislocation rate after primary arthroplasties by anterior approach on a fracture table is satisfactory, but the rate of instability following revision surgery is not known. HYPOTHESIS AND AIMS We hypothesized that the Hueter direct anterior approach would result in a lower rate of postoperative dislocation following revision surgery. This hypothesis was tested in a series of isolated acetabular component replacements. PATIENTS AND METHODS Seventy-three consecutive isolated acetabular component replacements were performed between January 2000 and December 2007. Twelve revisions using constrained liners or dual mobility cups were excluded, thus 61 revisions in 59 patients, mean age 65.8-year-old (range 27-86) were included. The indications for revision arthroplasty were: 51 (83.6%) cases of aseptic loosening, five (8.2%) non-integration of cementless cups, three (4.9%) cases of instability, one (1.6%) case of impingement with the psoas and one (1.6%) case of excessive (3cm) lengthening. Acetabular bone defects were moderate, with 12 stage I, 26 stage II, 19 stage III, and only four stage IV defects on the SOFCOT bone stock deficiency score. There was no acetabular reconstruction in 18 cases, while there were four isolated reconstruction cages and 39 cages with a graft. The replacement cup was cemented in 52 cases and cementless in nine. Inclination and anteversion were measured by the Pradhan method on standard X-rays. RESULTS Results were evaluated after a mean follow-up of 2.4 years±1.7 years (1-7 years). Four dislocations were observed (6.6%) all anterior and early in the postoperative period (less than 2 months): three patients had a single episode of dislocation and one patient again underwent revision cup replacement by Hueter anterior approach for recurrent anterior dislocation. The only factor associated with a risk of dislocation was a high body mass index: 29.7±0.8 in the group with dislocation compared to 25.6±3.2 in the group without (P=0.008). A high number of prior interventions was also a significant risk factor (P=0.045). On the other hand, there was no difference in cup inclination or femoral offset between the group with dislocation and that without. DISCUSSION Although the rate of dislocation is higher than after primary THA by anterior approach, it remains acceptable for revision THA and is similar to rates observed with other approaches. The literature does not clearly establish that one surgical approach is better than another in terms of instability. This study was limited by the absence of CT-scan measurements of component orientation both preoperatively to evaluate the femoral component which is preserved, as well as during follow-up to evaluate cup angle and compare the groups with and without dislocation. CONCLUSION The Hueter direct anterior approach is a viable option for isolated cup revision, as long as femoral loosening has been excluded, and the orientation of the preserved femoral component is known. LEVEL OF EVIDENCE Level IV; retrospective study.