Total Knee Arthroplasty (TKA) patients may present with effusion, pain, stiffness and functional impairment. A positive metal hypersensitivity (positive LTT) may be an indication for a revision surgery with a custom-made implant devoid of any hypersensitivity-related metal or an implant with the least possible ion content of the metal hypersensitivity, if no custom-made is available. The purpose of the current study is to assess the prevalence of metal hypersensitivity in subjects requiring a primary TKA and assess their early functional outcomes.

We are recruiting 660 subjects admitted for TKA. Subjects are randomly assigned to 2 groups: oxidized zirconium implant group or cobalt-chrome implant group. Functional outcomes and quality of life (QoL) are measured pre operatively, 3, 6 and 12 months post operatively with WHOQOL-BREF (domain1-Physical Health, domain 2- Psychological, domain 3- Social relationships, domain 4-Environment), KSS, KOOS and pain Visual Analog Scale (VAS). LTT and metal ions are evaluated pre operatively and 12 months post-surgery.

One hundred-sixty patients, 98 women, were enrolled in the study. Mean age was 65.6±8.9. Mean follow up (FU) was 7.1±3.8 months. Eighty-one (50.6%) were randomised in the cobalt-chrome group. Infection rate was 1.9%, one patient required debridement. Three patients (1.9%) presented with contracture at three months FU. At 12 months, WHOQOL-BREF domain 1, 2 and 4 improved significantly (p0,05).

Overall, all 160 patients improved their functional outcomes and QoL. At 12 months, VAS scores decreased from 7±2.06 at baseline to 1.95±2.79. Furthermore, the high prevalence of positive LTT (27/65) do not seem to affect early functional outcomes and QoL on patients that may have received a potential implant with hypersensitivity (18/27).

Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study.

From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH.

A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012).

The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation.

Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. We sought to explore this association.

We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 year.

Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high SPOC scores [odds ratio: 5.63, 99% confidence interval (CI): 3.59–8.84, absolute risk increase 40.6%, 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06, 99% CI: 3.97–9.25, absolute risk increase: 18.3%, 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr.

Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr.

In this study, we describe a morphological classification for greater tuberosity fractures of the proximal humerus. We divided these fractures into three types: avulsion, split and depression. We retrospectively reviewed all shoulder radiographs showing isolated greater tuberosity fractures in a Level I trauma centre between July 2007 and July 2012. We identified 199 cases where records and radiographs were reviewed and included 79 men and 120 women with a mean age of 58 years (23 to 96). The morphological classification was applied to the first 139 cases by three reviewers on two occasions using the Kappa statistic and compared with the AO and Neer classifications. The inter- and intra-observer reliability of the morphological classification was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59 to 0.65) classifications. The distribution of avulsion, split and depression type fractures was 39%, 41%, and 20%, respectively. This classification of greater tuberosity fractures is more reliable than the Neer or AO classifications. These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique.

Cite this article: Bone Joint J 2014;96-B:646–51.

Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO.

The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome.

Cite this article: Bone Joint J 2013;95-B:95–100.

Purpose: The literature contains little information on an objective method of measuring radiocapitellar joint translations, as would be seen with joint instability. The purpose of this study was to develop and validate a measurement method that was simple and that could be easily reproducible in a clinical setting or intra-operatively to assess radiocapitellar joint translations.

Method: We performed a radiological study on a synthetic elbow specimen in order to quantify radial head translations as related to the capitellum: the Radio-capitellum ratio (RCR). Thirty (30) lateral elbow x-rays were taken in different magnitude of subluxation of the radial head. The subluxation was created randomly by manipulation. X-rays where taken by fluoroscopy to obtain a perfect lateral view of the distal humerus. First, the evaluators determined the long axis of the radius and the center of the capitellum. The displacement of the radial head (in mm) was obtained by measuring the distance of the line perpendicular to the long axis of the radius passing through the center of the capitellum. Then, in order to adjust for variation of magnification, a ratio of the displacement of the radial head about the diameter of the capitellum was done. The RC ratio would be of zero because the long axis of the radius always crosses the center of the capitellum in a perfectly aligned joint. A five mm translation of the radial head and a capitellum diameter of twenty (20) mm would give a RCR of 25% and would be positive if anterior and negative if posterior. The measurements were done two times at one week intervals by three independent evaluators to test inter-observer agreement and intra-observer consistency. The radiological incidences were randomly ordered to minimize observer recall bias. Intra/inter-observer reliability was calculated using Intra-Class Correlation (ICC) and paired T-tests.

Results: The mean translation in the trial group was of 6,06% (SD 70.7%) from – 167% to 125%. A result over 100% means that it is a complete dislocation ie – the axis of the radius is outside of the capitellum. Negative values signify posterior translation and positive values an anterior translation. Intra-observer reliability was excellent for the Radio-capitellum ratio (ICC 0.988 and 0.995) and inter-observer reliability was excellent (ICC 0.984 in average). Paired T-test results confirm a high intra-observer repeatability (p=0.97 and p=0.99) as well as a large inter-observer reproducibility (p=0.98 in average).

Conclusion: The proposed measurement of radial head translation about the capitellum (in percent): radio-capitellum ratio (RCR) has excellent inter – and intra-observer reliability when using our measurement method.

Purpose: To determine if early functional assessment correlates and/or predicts long term function after hemi-arthroplasty for displaced femoral neck fractures.

Method: We evaluated prospectively fifty six (56) patients with Garden-type III and IV femoral neck fractures in a Level 1 trauma center with a minimum of two years follow-up. Validated functional measures including Lower Extremity Measure (LEM) and Timed Up and Go (TUG) were used. Score progression was recorded and analyzed in relation to patient baseline data.

Results: The regression analysis between TUG times at three months and the mean LEM scores at two years follow-up showed a good correlation (R2=0.659). Further analysis determined that patients with TUG times of less than twenty (20) seconds at six weeks of follow-up had a mean LEM score significantly higher at both one year (81.5 vs 56.2; p< 0.001) and two years follow-up (77.1 vs 41.8; p< 0.001). This difference between mean LEM scores was also noted for the TUG values at three months.

Conclusion: The TUG test is an early clinical indicator of future function. Innovative clinical approaches such as the one demonstrated in this study to anticipate future function will contribute to increasing efficiency in the overall management of this growing patient population.

Purpose: Anatomic repair of an acute distal biceps tear has been demonstrated to improve flexion and supination strength compared with conservative treatment. The most commonly used fixation methods for a distal biceps tendon repair include suture anchors, bioabsorbable screws, and endobutton. The goal of this study was to

perform a radiologic evaluation of bioabsorbable screw tunnel osteolysis and

Method: We included twenty (20) consecutive patients who underwent primary anatomic repair of the distal biceps tendon since 2005. We used a 7x23mm biote-nodesis^® screw (Arthrex) in 18 cases, and 8x23mm and 8x12mm screws in the other two cases. First, from the x-ray view done in the immediate postoperative period showing the complete screw tunnel, we measured the ratio of the volume of the bone tunnel to the volume of the radius bone section. A mathematical formula for cylindrical volume was used (¶ x r2 x h). We used a relation between two volumes rather than the tunnel volume itself for scaling purposes. Secondly, we calculated the same relation on the x-ray from the last follow-up. We then obtained the percentage of tunnel enlargement by relating the volumetric ratio from the first x-ray to the ratio from the last x-ray. Afterwards, we performed a retrospective chart review noting any bioabsorbable screw-related and postoperative complications.

Results: In the group, the average age was forty-six (46) years. All subjects were male. Eighteen (18) cases were acute complete ruptures operated in the first three weeks, one case was a partial rupture and one case was chronic (one year). The average follow up was eighteen (18) months. We found that the average initial relative volume occupied by the screw tunnel was 47 % of the bone section. At the last follow-up, this volume increased to 68%. After our chart review, we found that one patient presented with a broken screw and increased pain and that another patient developed a severe foreign-body reaction with re-rupture of the tendon requiring three reoperations.

Conclusion: The use of a bioabsorbable screw for distal biceps tendon fixation results in significant osteolysis of the radial bone at short term follow-up. Consequences of osteolysis in the radius are worrisome since iatro-genic fractures are more likely to occur. Osteolysis can be secondary to an inflammatory reaction to the screw material, bone necrosis secondary to pressure or initial thermal necrosis. We also noted two cases of severe bio-tenodesis screw-related complications among our series of twenty (20) patients. These results call into question the use of the bioabsorbable screw in distal biceps tendon repair and are important to present. Exact volume of bone loss using 3D computed tomography scan analysis as well as quality of life questionnaires and strength testing will be available for presentation.

Purpose: The age of patients presenting with acetabular fracture has increased over the last ten years. Older patients tend to have patterns involving the anterior column with comminution of the quadrilateral plate. Our goal was to investigate the appropriateness of open reduction and internal fixation using the modified Stoppa approach for geriatric acetabular fractures.

Method: A retrospective review of patients over the age of 60 having presented to an academic level I trauma center over the course of four years. Twenty patients were identified and treated using the modified Stoppa approach with plating of the quadrilateral surface. Patients were evaluated clinically using both SF-36 and Harris Hip Score. Records and radiographs (using criteria described by Matta) were reviewed retrospectively.

Results: All patients were followed for a minimum of two years with no lost at follow-up. Mean age for patients at time of intervention was 68 years. Average blood lost was 800cc and surgical time was 130 minutes (range, 55–210). There was one traumatic injury to the obturator nerve and two patients were noted to have temporary weakness of the hip adductors postoperatively. Average Harris Hip Score and the SF-36 were improved significantly (p< 0.05). Significant lost of reduction was seen in two patients and was correlated to superior dome impaction (p < 0.0001). Three patients required re-intervention with a Total Hip Arthroplasty.

Conclusion: Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures of the anterior column in the elderly.

Purpose: Lors de la réduction chirurgicale des fractures de la cheville avec instabilité syndesmotique, le chirurgien se fie généralement sur les vues de mortaise et antéro-postérieure. Toutefois, une subluxation ou luxation antérieure du péroné par rapport au tibia distal peu survenir et passer inaperçu (trois exemples cliniques prouvés par CT Scan post-opératoire), spécialement lors de la pose de vis syndesmotique(s). La présente étude a pour but d’établir la relation radiologique précise sur une vue latérale fluoroscopique entre les tibia et péroné distaux qui permettra au chirurgien de confirmer en peropératoire que l’articulation tibio-péronière distale est bel et bien réduite.

Method: Les chevilles normales de trente volontaires sans antécédent de traumatisme ou de maladie de la cheville ont été imagées sous une vue latérale fluoroscopique parfaite, avec un Mini C-Arm. Les images ont été analysées et comparées entre elle afin d’établir une relation radiologique fiable et reproductible entre le tibia et le péroné distaux.

Results: Dans les trente cas, il y avait intersection du milieu de la cicatrice physaire et du cortex antérieur du péroné. Cette relation a été trouvée statistiquement significative.

Conclusion: La réduction chirurgicale parfaite de l’articulation tibio-péronière distale peut être confirmée avec une vue latérale fluoroscopique de la cheville. Le cortex antérieur du péroné doit toucher le milieu de la cicatrice physaire.

Purpose: Greater trochanter reattachment is frequently accomplished using cable grip type systems. There is a relatively high failure rate for these systems, the mechanisms of which are unclear. One possible source of instability could be femoral neck cut location. Another concern is the effect of variability in cable tension. The objective is to create a femur implant model which allows for variation in cable tension, common muscle forces and the placement of the femoral neck cut in order to analyse trochanter fragment fixation.

Method: A finite element model (FEM) of a femur with simulated greater trochanter osteotomy (30°) was combined with the femoral component of a hip prosthesis and a greater trochanter reattachment system with 4 cables (Cable-Ready®, Zimmer). A total of 18 simulations were modeled in a full factorial design using three independent variables; cable tightening (178N, 356 N and 534 N), muscle forces (rest, walking and stair climbing) and femoral neck cut (10 mm and 15 mm above the lesser trochanter). Displacement of the fragment, in terms of both gap and shear components, as well, stress in the bone were investigated.

Results: The location of the femoral neck cut reduced contact surface area by 20% and had the largest influence on displacement (0.24 mm). Pivoting of the fragment was observed with a maximum gap (0.38 mm) and maximum total displacement (0.41 mm) at the bottom of the fragment. This was observed during stair climbing, while the cables were tightened to 177.9 N and with the femoral neck cut at 10 mm. Increased tightening of the cables provided no significant reduction in fragment displacement. However, higher cable tension significantly increased the stress in the bone (8 MPa and 26 MPa for cable tension of 178 N and 534 N respectively).

Conclusion: Placement of the femoral neck cut closer to the lesser trochanter significantly increased fragment displacement. Preservation of the contact surface area is recommended. Excessive cable tightening did not reduce fragment movement and only exacerbated bone stress. Caution must be used to not over tighten the cables. This model can be used to test and compare the performance of new implant designs.

A total of 30 patients with lateral compression fractures of the pelvis with intra-articular extension into the anterior column were followed for a mean of 4.2 years (2 to 6), using the validated functional outcome tools of the musculoskeletal function assessment and the short-form health survey (SF-36). The functional outcome was compared with that of a series of patients who had sustained type-B1 and type-C pelvic fractures. The lateral-compression group included 20 men and ten women with a mean age of 42.7 years (13 to 84) at the time of injury.

Functional deficits were noted for the mental component summary score (p = 0.008) and in the social function domain (p < 0.05) of the SF-36. There was no evidence of degenerative arthritis in the lateral-compression group. However, they had high functional morbidity including greater emotional and psychological distress.

Plate fixation of the proximal humerus fractures may now be more desirable with the use of a biological approach by limiting surgical insult and allowing accelerated rehabilitation by a solid fixation. To evaluate the safety and efficacy of minimally invasive plating of the proximal humerus using validated disease-specific measures.

During a period of one year, thirty patients were operated with use of the LCP proximal humerus plate (Synthes) through a 3cm lateral deltoid splitting approach and a second 2 cm incision at the deltoid insertion. The axillary nerve was palped and easily protected during insertion. Only two-part (N=22) and three-part impacted valgus type (N=8) were included in this study since they can be reduced indirectly thru this percutaneous technique. The average follow-up was thirteen months (eight to twenty months). All patients had the Constant and DASH evaluations.

All fractures healed within the first six months with no loss of correction. The surgical technique was found easy by all surgeons, the axillary nerve was palpated and protect with this new technique. No infection or avascular necrosis were seen. No axillary nerve deficit was identified. At the last follow-up (average nineteen months, twelve months minimum), the median Constant score was sixty-eight points, with an age ajusted score of seventy-six. The mean DASH score was twenty-seven points. Only age was independently predictive of both the Constant and DASH functional scores. Patients improved until one year of follow up.

Percutaneous insertion of a locking proximal humerus plate is safe and produces gives good early functional and radiologic outcomes. Recuperation from a proximal humerus fracture can be seen until one year.

We retrospectively reviewed the operative treatment carried out between 1988 and 1994 of eight patients with habitual patellar dislocation. In four the condition was bilateral. All patients had recurrent dislocation with severe functional disability. The surgical technique involved distal advancement of the patella by complete mobilisation of the patellar tendon, lateral release and advancement of vastus medialis obliquus. The long-term results were assessed radiologically, clinically and functionally using the Lysholm knee score, by an independent observer.

The mean age at operation was 10.3 years (7 to 14) with a mean follow-up of 13.5 years (11 to 16). One patient required revision. At the latest follow-up, all patellae were stable and knees functional with a mean Lysholm knee score of 98 points (95 to 100). In those aged younger than ten years at operation there was a statistically significant improvement in the sulcus angle at the latest follow-up (Student’s t-test, p = 0.001). Two patients developed asymptomatic patella infera as a late complication.

This technique offers a satisfactory treatment for the immature patient presenting with habitual patellar dislocation associated with patella alta. If performed early, we believe that remodelling of the shallow trochlea may occur, adding intrinsic patellofemoral stability.