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Since 2002, France has adopted the Patients' Rights Law, an alternative malpractice scheme creating a faster, less expensive out-of-court settlement ensuring compensation even in the absence of fault. We aimed to describe the implications of this system by analyzing 5 years of claims for infections related to spinal surgeries collected by the main insurer of French spine surgeons.We retrospectively analyzed 98 anonymized malpractice claims from 2015 to 2019 (20% of overall claims), including anonymized medical records of the patients, reports of the independent experts, final judgments, and entities supporting the compensation if any.Claims included 8 deaths and 17 newly acquired neurological sequelae. The conclusions identified 22 faulty cases. The most frequent fault was a delay in diagnosis (10 cases), followed by inadequate surgical management (6 cases), inadequate antibiotic therapy (5 cases), and inadequate follow-up (1 case). Among the 67 cases (68.4%) proved not to be at fault, 10 were covered by the national solidarity fund because of their severity, and the remaining 57 were covered by hospitals.Since the 2002 Patients' Rights Law, patients with postoperative infections have always received compensation. The out-of-court settlement offers the patients incurring morbidities the assurance of faster compensation. Although certainly subject to selection criteria, this procedure is free and does not necessitate the presence of a lawyer. The analysis of expert reports and the resulting court decisions imply prevention, anticipation, and collaboration of all health care providers and open an opportunity to improve their practices to limit these crucial followings.

Resume Introduction Le positionnement des implants d’une prothese totale de hanche (PTH) est essentiel pour limiter les complications et optimiser les resultats fonctionnels. Dans une etude recente sur plus de 100 PTH posees par voie anterieure sur table orthopedique, nous avions constate que l’anteversion moyenne de la cupule etait plus importante (30°) que celle recommandee (20°). Pour expliquer ce phenomene, nous avons evoque que le plan pelvien anterieur (PPA), defini par le plan passant par les epines iliaques anterosuperieures et la symphyse pubienne, qui sert de repere a la pose et au calcul de l’anteversion de la cupule n’etait pas horizontal une fois le patient allonge sur la table orthopedique. Cette notion n’a pas ete evaluee ; aussi, nous avons mene une etude prospective afin de : 1) mesurer la position du bassin sur table orthopedique ; 2) comparer a la position debout ; 3) evaluer son retentissement sur l’anteversion de la cupule. Hypothese La version du bassin debout etait identique a la version du bassin couche sur table orthopedique. Materiel et methodes Une etude monocentrique prospective sur 3 mois a ete menee. Tous les patients operes pour une PTH sur table orthopedique par voie anterieure directe ont ete inclus. La position du bassin a ete evaluee par la mesure de l’inclinaison du PPA sur des radiographies de bassin de profil installe sur table orthopedique et debout. Pour le retentissement de la position du bassin sur le positionnement de la cupule, la mesure de l’anteversion etait faite grâce au systeme d’imagerie EOS. L’anteversion anatomique de la cupule etait celle mesuree par rapport au PPA. Resultats Cinquante-huit patients ont ete inclus (32 femmes, 26 hommes) avec un âge moyen de 67 ans. L’inclinaison du PPA couche etait 6° ± 8,3 [extremes de −10,5 a 31,0] (indiquant un bassin retroverse sur la table orthopedique). La difference entre l’inclinaison du PPA debout et couche (a 90° pres) etait non significative (debout en moyenne 4,5° [extremes de −11,0 a 27,0] contre couche sur table en moyenne de 6° [extremes de −10,5 a 31,0] (p = 0,75). Une forte correlation entre inclinaison du PPA couche et anteversion anatomique de la cupule etait observee (p Conclusion Le bassin couche sur table orthopedique n’est pas systematiquement horizontal et sa position sur la table orthopedique est similaire a sa position debout, a 90 degres pres. L’analyse du positionnement du bassin preoperatoire nous semble indispensable en programmation d’une PTH. Niveau de preuve IV ; etude prospective de cohorte.

Resume Introduction La rehabilitation amelioree apres chirurgie (RAAC) est desormais bien decrite dans de nombreuses specialites chirurgicales dont l’orthopedie. Sa mise en place en chirurgie du rachis est en revanche plus recente et sans evaluation precise. Cette etude evalue la mise en place d’un programme de RAAC et son retentissement sur la duree de sejour et le taux de complications dans un service hospitalier de chirurgie rachidienne europeen. Materiels et methodes Il s’agit d’une etude observationnelle comparative comparant le devenir de patients avec et sans prise en charge de type« RAAC ». A partir de la date de lancement du programme de RAAC, l’ensemble des patients admissibles au protocole ont ete retenus pour cette etude pendant 6 mois. Le groupe controle a ete constitue, a posteriori, sur les memes 6 mois de l’annee precedente, en gardant les memes pathologies, les memes degres de comorbidite et les memes operateurs. Les criteres de jugement etaient la duree moyenne de sejour ainsi que la survenue de complications majeures (necessite d’une re-hospitalisation ou une re-intervention dans les 90 jours postoperatoires). Resultats Quatre-vingt-huit patients ont pu etre compares (44 dans chaque groupe). Les caracteristiques demographiques des deux groupes n’etaient pas significativement differentes. La duree moyenne de sejour toutes pathologies confondues etait de 3,3 jours dans le groupe RAAC versus 6 jours dans le groupe controle (p Discussion L’avenement de la RAAC, permet aux equipes de soignants refaire le point sur les bonnes pratiques et mettre en place de facon synchrone un ensemble de mesures generalement deja reconnues comme etant efficaces de facon isolee. Notre etude montre que la RAAC est tout a fait applicable dans une structure publique, avec une diminution de la duree de sejour sans augmentation des complications. Niveau de preuve IV ; CEBM.

Purpose In the general context of medical judicialization, spine surgeons are impacted by the part that medical responsibility and the risk of malpractice play in their actions and decisions. Our aim was to evaluate possible shifts in practices among private neurosurgeons who are highly exposed to this judicial risk and detect alterations in their pleasure in exercising their profession. We present the first national survey on French physicians’ perception of surgical judicialization and consequences on their practice. Methods An online survey was submitted to the 121 members of the French Society of Private Neurosurgery, who represent 29.1% of the total number of spine surgeons and perform 36.0% of the national total spine surgery activity. The French law (no-fault out-of-court scheme) significantly impacts these surgeons in the event of litigation. Results A total of 78 surveys were completed (64.5% response rate): 89.7% of respondents experienced alteration of doctor-patient relationship related to judicialization and 60.2% had already refused to perform risky surgeries. Fear of being sued added negative pressure during surgery for 55.1% of respondents and 37.2% of them had already considered stopping their practice because of this litigation context. Conclusion The increasing impact of medical liability is prompting practitioners to change their practice and perceptions. The doctor-patient relationship appears to be altered, negative pressure is placed on physicians and defensively, some neurosurgeons may refuse high-risk patients and procedures. This situation causes professional disenchantment and can ultimately prove disadvantageous for both doctors and patients.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience\ud and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.\ud PURPOSE: This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an\ud ERAS program.\ud STUDY DESIGN: This is a review article.\ud METHODS: Under the impetus of the ERAS� society, a multidisciplinary guideline development\ud group was constituted by bringing together international experts involved in the practice of ERAS\ud and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in\ud the English language was performed in MEDLINE, Embase, and Cochrane Central Register of\ud Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were\ud included, and the evidence was graded according to the Grading of Recommendations, Assessment,\ud Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the\ud group after a critical appraisal of the literature.\ud RESULTS: Two hundred fifty-six articles were included to develop the consensus statements for\ud 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to\ud very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS\ud items, 28 recommendations were included. All recommendations on ERAS protocol items are\ud based on the best available evidence. These included nine preoperative, eleven intraoperative, and\ud six postoperative recommendations. They span topics from preoperative patient education and\ud nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.\ud CONCLUSION: Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS� Society presents this comprehensive consensus\ud review for perioperative care in lumbar fusion.

Introduction Enhanced recovery after surgery (ERAS) has been well described in many surgical specialties, including orthopedics. Application in spine surgery, on the other hand, is more recent and not yet precisely assessed. The present study aimed to assess the implementation of an ERAS program in a European spine surgery department and its impact on length of hospital stay and complications rate. Materials and methods A comparative observational study was conducted on patient progression with and without ERAS. As of the launch date of the program, all eligible patients were included over a 6-month period. A retrospective control group comprised patients managed over the same 6-month period of the previous year, matched for pathology, comorbidity and individual surgeon. Endpoints comprised mean length of stay and major complications (i.e., requiring readmission or revision surgery within 90 days). Results Eighty-eight patients were included: 44 per group. Demographic characteristics did not significantly differ between groups. Mean length of stay, taking all pathologies together, was 3.3 days in ERAS versus 6 days in the control group (p Discussion The introduction of the ERAS program gave care teams the opportunity to think over good practices and set up a number of concomitant measures generally agreed to be effective in isolation. The present study showed ERAS to be perfectly feasible in a public-sector structure, reducing length of stay without increasing the rate of complications. Level of evidence IV CEBM.

Resume Introduction Dans la stenose canalaire lombaire degenerative, la relation entre la variabilite des symptomes et la severite de la compression est mal comprise. Ainsi, un autre facteur pouvant influencer le resultat clinique de ces patients a ete evoque : la presence de comorbidites. L’objectif de cette etude etait d’analyser le role des comorbidites sur les resultats cliniques et les scores fonctionnels de patients suivis pour stenose canalaire lombaire. Methodes Dans cette etude prospective, les patients traites pour stenose canalaire lombaire ont ete consecutivement inclus durant une annee. Le diagnostic de stenose lombaire etait realise apres un examen clinique et radiologique. Les donnees demographiques, cliniques et radiographiques etaient recueillies. Deux questionnaires ont ete utilisees pour evaluer la gene fonctionnelle : un score specifique aux stenoses lombaires (l’auto-questionnaire Beaujon) et un score non specifique (le Short Form 36, SF36). Quatre scores de comorbidite ont ete calcules : cumulative illness rating scale, Charlson index, functional comorbidity index et index of coexistent diseases. Les correlations entre les scores fonctionnels et de comorbidites ont ete effectuees. Resultats Au total, 250 patients ont ete inclus, d’âge moyen 65,6 ± 12 ans. Les quatre scores de comorbidites etaient significativement correles a l’auto-questionnaire Beaujon, ainsi qu’aux sous-dimensions « lombaire » et « ischemie radiculaire » de ce score. Les meilleures correlations etaient observees entre le cumulative illness rating scale et l’auto-questionnaire Beaujon ; deux facteurs influencaient significativement cette relation : l’existence d’une hernie discale et la composante « general health » du SF36. Discussion Cette etude met en evidence l’existence d’une influence des comorbidites sur les signes fonctionnels des patients atteints de stenose canalaire lombaire. De plus, des correlations existent entre les comorbidites et les symptomes liees a la lombalgie ou a la claudication, contrairement a la douleur radiculaire isolee. Par consequent, les comorbidites semblent avoir un role dans la variabilite de la presentation clinique de ces patients en preoperatoire et ceci pourrait etre inclus dans l’information des patients. L’influence des comorbidites sur les resultats postoperatoires necessite d’etre exploree.

Introduction In degenerative lumbar spinal stenosis (DLSS) variability of symptoms according to the severity of stenosis is not well understood. Therefore, another factor that impacts functional outcomes of DLSS patients has been evoked: patient's comorbidities. The aim of this study was to investigate influence of comorbidities on clinical symptoms and functional outcomes in DLSS patients. Methods In this prospective study, patients treated for DLSS were included during 12 consecutive months. Both clinical and radiographic exams were required to confirm DLSS diagnosis. Epidemiologic, clinical and radiographic data were collected. Two questionnaires were used to assess functional outcomes: a specific score dedicated to lumbar stenosis consequences assessment (self-administered Beaujon questionnaire, SABQ) and a non-specific score (Short Form 36, SF-36). Four comorbidity scores were calculated: Cumulative Illness Rating Scale, Charlson index, Functional Comorbidity Index and Index of Co-Existent Diseases Correlations between functional and comorbidity scores were calculated. Results 250 patients were included (65.6 ± 12 years). The four comorbidities scores were significantly correlated to total SABQ, as well as lumbar and radicular ischemia components. Best correlations were observed for cumulative illness rating scale and SABQ. Two factors were observed that significantly influenced the relationship between SABQ and cumulative illness rating scale: herniated disc and SF-36 general health perception. Discussion This study highlighted that preoperative function is influenced by comorbidities in DLSS patients. Relationships existed between comorbidities and symptoms related to low back pain and neurogenic claudication, contrary to radicular pain. Therefore, comorbidities might impact the variability of patients’ outcomes. This finding should be part of the patient's preoperative information. Moreover, role of comorbidities on postoperative outcomes need to be investigated.

The placement of prostheses for a total hip arthroplasty (THA) is essential to limit complications and optimize functional results. In a recent study of more than 100 THA placed through a direct anterior approach using a traction table, we found that the mean anteversion of the cup was greater (30°) than recommended (20°). To explain this phenomenon, we considered that the anterior pelvic plane (APP), defined by the plane passing through the anterior-superior iliac spines and the pubic symphysis, which serves as a landmark for the placement and calculation of the anteversion of the cup, was not horizontal when the patient was lying on the traction table. This concept has not been evaluated so we conducted a prospective study to: 1) measure the position of the pelvis on a traction table; 2) compare to the standing position, 3) assess its impact on the anteversion of the cup.The standing pelvic version is identical to the supine pelvic version on the traction table.A prospective 3-month monocentric study was conducted. All patients operated on for a THA by a direct anterior approach, on a traction table, were included. The position of the pelvis was assessed by measuring the tilt of the APP on lateral pelvic X-rays, while on the traction table and while standing. The impact of the position of the pelvis on the positioning of the cup, as well as the anteversion, were measured using the EOS imaging system. The anatomic anteversion of the cup was measured in relation to the APP.Fifty-eight patients were included (32 women, 26 men) with an average age of 67 years. The tilt of the supine APP was 6°±8.3 [range of -10.5 to 31.0] (indicating a retroverted pelvis on the traction table). The difference between the tilt of the standing and lying APP (within 90°) was not significant (standing was on average 4.5° [range of -11.0 to 27.0] versus lying on the table, was on average 6° [range of -10.5 to 31.0] (p=0.75). A strong correlation was observed between the tilt of the supine APP and the anatomic anteversion of the cup (p0.001). Thus, the more retroverted the pelvis was on the traction table, the lower the anatomic anteversion of the acetabular cup.The supine pelvis on the traction table is not always horizontal and its position on the traction table is similar to its standing position, within 90 degrees. The analysis of the positioning of the preoperative pelvis appears to be essential in the planning of a THA through direct anterior approach using a traction table.IV; Prospective Cohort Study.

Summary Objectives The aim of this study was to present a 15-year experience and provide a comprehensive analysis of a large cohort of patients with Pseudomonas aeruginosa osteomyelitis. Methods We reviewed the medical records of patients admitted to a large French university hospital for P. aeruginosa osteomyelitis over a 15-year period. Patient outcome was assessed at follow-up after at least six months. Results Sixty-seven patients were included, comprising 57% with chronic osteomyelitis. Polymicrobial infection was predominant (63%), and an infected device was involved in 39% patients. The overall treatment success rate was 79.1%. All but one patient were treated with a combination of surgery and antibiotic therapy. The antibiotic treatment had a mean duration of 45 days (range, 21–90 days). Single-antibiotic therapy was preferred in nearly all cases. Treatment failure was reported for 14 (21%) patients and was due to the persistence of P. aeruginosa in four cases. No significant risk factor for treatment failure was identified, especially when treatment strategies were compared. Conclusions We advocate optimal surgical debridement combined with initial parenteral antibiotics for a maximum of 15 days, followed by an oral fluoroquinolone. Total treatment duration should not exceed six weeks, and antibiotic treatment with two-drug combinations does not seem necessary.

To report the radiologic and functional results of a multicenter, prospective case series of patients with comminuted lumbar fractures treated with 2-stage circumferential arthrodesis.A multicenter prospective case series of 74 patients with comminuted lumbar fractures was analyzed. The strategy entailed initial posterior osteosynthesis, followed by physical replacement with an expandable titanium cage filled with autologous bone via retroperitoneal lumbotomy. The mechanism of lesion formation and epidemiologic characteristics were recorded. Clinical and quality-of-life analyses (visual analog scale [VAS], Oswesty Disability Index [ODI], Short Form 12 [SF-12]) were performed over a minimum observation period of 1 year. Radiologic parameters, including deformity measurements, were recorded at each evaluation. Fusion was analyzed by means of a 1-year monitoring scan.The mean patient age was 38.1 years, and median duration of follow-up was 2.1 years (interquartile range, 1.3-2.9). The distribution of fractures according to the Magerl classification scheme was as follows: A, 64.8%; B, 16.7%; C, 18.5%. At the last follow-up, fusion was considered certain in 57 cases (77%). The mean VAS score was 2.1 ± 1.3, mean ODI was 14.7 ± 8.0, mean SF-12 Physical Component Summary score was 43.2 ± 9.3, and mean SF-12 Mental Component Summary score was 50.8 ± 5.9. Correction of the regional sagittal deformity was significant during the postoperative period, with a mean increase in lordosis of 9.0° (P0.0001). The loss of mean correction at the last follow-up (-2.9°) was not significant.Circumferential arthrodesis, including posterior osteosynthesis and physical replacement with an expandable cage and autologous graft, is applicable to the treatment of comminuted lumbar fractures. A high rate of fusion was obtained with significant and long-lasting correction of the sagittal deformity. Functional scores measured at 1 year suggest mild disability. The ODI, SF-12, and VAS scores were positively correlated with fusion at the last follow-up.

Aims In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder. Patients and Methods All patients who underwent primary arthroplasty of the shoulder at our institution between 1970 and 2012 were included in the study. There were 4636 patients with 1167 cemented humeral components and 3469 cementless components. Patients with the two types of fixation were matched for nine different covariates using a propensity score analysis. A total of 551 well-balanced pairs of patients with cemented and cementless components were available after matching for comparison of the outcomes. The clinical outcomes which were analysed included loosening of the humeral component determined at revision surgery, periprosthetic fractures, post-operative infection and operating time. Results The overall five-, ten-, 15- and 20-year rates of survival were 98.9%, 97.2%, 95.5%, and 94.4%, respectively. Survival without loosening at 20 years was 98% for cemented components and 92.4% for cementless components. After propensity score matching including fixation as determined by the design of the component, humeral loosening was also found to be significantly higher in the cementless group. Survival without humeral loosening at 20 years was 98.7% for cemented components and 91.0% for cementless components. There was no significant difference in the risk of intra- or post-operative fracture. The rate of survival without deep infection and the mean operating time were significantly higher in the cemented group. Conclusion Both types of fixation give rates of long-term survival of > 90%. Cemented components have better rates of survival without loosening but this should be weighed against increased operating time and the risk of bony destruction of the proximal humerus at the time of revision of a cemented humeral component. Cite this article: Bone Joint J 2017;99-B:666–73.

Background On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. Methods This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. Results Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for >24 h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. Conclusion Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45 days after the initial event.

Resume Introduction L’attitude therapeutique dans la prise en charge des spondylolisthesis L5-S1 de haut grade reste controversee. La reduction du glissement, la correction de la cyphose lombosacree ainsi que la necessite d’un temps anterieur complementaire sont les points de debat actuels dans la litterature. L’objectif de cette etude est d’exposer les resultats cliniques et radiologiques a long terme d’une technique chirurgicale de reduction et d’arthrodese instrumentee par un temps posterieur unique. Materiel et methode Il s’agit d’une etude retrospective incluant tous les patients operes consecutivement par le meme operateur (D.C.) d’un spondylolisthesis L5-S1 a grand deplacement (grades 3, 4 et 5 de Meyerding). La technique chirurgicale consistait en une reduction de la cyphose lombosacree et une arthrodese posterolaterale par un temps posterieur unique, sans resection du dome sacre ni temps anterieur complementaire chez les adolescents et les adultes jeunes. Seuls les cas de ptose de l’adulte ont necessite une greffe intersomatique a l’aide d’un greffon tibial encastre. L’analyse des complications cliniques et des parametres radiologiques lombopelviens, ainsi que l’equilibre sagittal ont ete realises au plus long recul. Resultats Cinquante patients ont ete revus dans cette etude. L’âge moyen etait de 21 ans (DS : 11 ans) au moment de l’intervention. Le recul etait de 5,5 ans (±4,6). La reduction de l’angle lombosacre etait en moyenne de 25°, passant de 76° a 101° ( p p p p p = 0,1). Dans17 cas (34 %), un deficit neurologique radiculaire postoperatoire etait constate, sans sequelle au recul. Aucune lesion de la queue-de-cheval n’a ete observee. La fusion osseuse a ete obtenue chez 42 patients (84 %) en un temps chirurgical. Apres reprise par greffe intersomatique complementaire, aucune pseudarthrose n’a ete observee. Conclusion Un temps chirurgical posterieur unique est une solution therapeutique fiable dans le traitement des spondylolisthesis de haut grade de l’adolescent et de l’adulte jeune. Cependant, ce type de traitement n’est pas sans risque (deficit transitoire et pseudarthrose) et le patient doit en etre prevenu. Une greffe intersomatique complementaire peut etre reservee aux cas de ptoses avec reduction incomplete de la cyphose lombosacree chez l’adulte et aux cas de reprise pour pseudarthrose. Niveau de preuve Etude retrospective de niveau IV.

Aims The primary aim of this study was to analyse the position of the acetabular and femoral components in total hip arthroplasty undertaken using an anterior surgical approach. Patients and Methods In a prospective, single centre study, we used the EOS imaging system to analyse the position of components following THA performed via the anterior approach in 102 patients (103 hips) with a mean age of 64.7 years (sd 12.6). Images were taken with patients in the standing position, allowing measurement of both anatomical and functional anteversion of the acetabular component. Results The mean inclination of the acetabular component was 39° (standard deviation (sd) 6), the mean anatomical anteversion was 30° (sd 10), and the mean functional anteversion was 31° (sd 8) five days after surgery. The mean anteversion of the femoral component was 20° (sd 11). Anatomical and functional anteversion of the acetabular component differed by > 10° in 23 (22%) cases. Pelvic tilt was the only pre-operative predictive factor of this difference. Conclusion Our study showed that anteversion of the acetabular component following THA using the anterior approach was greater than the recommended target value, and that substantial differences were observed in some patients when measured using two different measurement planes. If these results are confirmed by further studies, and considering that the anterior approach is intended to limit the incidence of dislocation, a new correlation study for each reference plane (anatomical and functional) will be necessary to define a ‘safe zone’ for use with the anterior approach. Take home message: EOS imaging system is helpful in the pre-operative and post-operative radiological analysis of total hip arthroplasty. Cite this article: Bone Joint J 2016;98-B:326–333.

Purpose The purpose of this study was to conduct a systematic review to determine the effectiveness of virtual reality (VR) training in orthopaedic surgery. Methods A comprehensive systematic review was performed of articles of VR training in orthopaedic surgery published up to November 2014 from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases. Results We included 10 relevant trials of 91 identified articles, which all reported on training in arthroscopic surgery (shoulder, n = 5; knee, n = 4; undefined, n = 1). A total of 303 participants were involved. Assessment after training was made on a simulator in 9 of the 10 studies, and in one study it took place in the operating room (OR) on a real patient. A total of 32 different outcomes were extracted; 29 of them were about skills assessment. None involved a patient-related outcome. One study focused on anatomic learning, and the other evaluated technical task performance before and after training on a VR simulator. Five studies established construct validity. Three studies reported a statistically significant improvement in technical skills after training on a VR simulator. Conclusions VR training leads to an improvement of technical skills in orthopaedic surgery. Before its widespread use, additional trials are needed to clarify the transfer of VR training to the OR. Level of Evidence Systematic review of Level I through Level IV studies.

Enhanced recovery after surgery (ERAS), still emerging for the spine, proposes a multimodal approach of perioperative care involving the optimization of every procedural step, with the patient in a proactive position regarding his/her management. We aimed to demonstrate a reduction in the length of hospital stay for ACDF without increasing the risk for patients by comparing 2 groups before and after ERAS implementation using propensity score (PS)-matched analysis. We selected 2 periods of 1 year, before (n = 268 patients) and after ERAS implementation (n = 271 patients). Data were collected on patient demographics, operative and perioperative details, 90-day readmissions and morbidity. ERAS-trained nurses were involved to support patients at each pre/per/postoperative step with the help of a mobile app. A satisfaction survey was included. PS analyses were used for dealing with confounding bias in this retrospective observational study. After PS matching, the outcomes of 202 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was reduced from 2.96 ± 1.35 to 1.40 ± 0.6 days (Student, p

Resume Introduction Les versions cimentees des cupules a double mobilite (CDM), utiles en cas d’alteration du stock osseux, sont habituellement fixees dans une armature de soutien. Afin de simplifier l’intervention chez les sujets âges et/ou avec un capital osseux fragile, elles peuvent etre cimentees directement dans l’os, mais leur devenir dans cette indication est mal connu. Aussi, nous avons mene une etude retrospective dans cette population afin : 1) d’evaluer si la fixation cimentee isolee d’une CDM n’entraine pas un surcroit de descellement ; 2) de confirmer l’efficacite dans la prevention des luxations chez des sujets a haut risque d’instabilite ; 3) de mesurer les resultats fonctionnels. Hypothese La fixation cimentee isolee d’une CDM est fiable en cas d’alteration moderee du stock osseux. Materiel et methodes Soixante-quatre patients (66 hanches) operes d’une CDM cimentee (Saturne™) sans armature de soutien ont ete inclus dans cette etude retrospective monocentrique. L’âge moyen etait de 79,8 ans (40–95). Les indications etaient variables : coxarthrose (30,3 %), revision prothetique (44,0 %), traumatologie (25,8 %). Une evaluation radioclinique etait realisee au recul. Le critere de jugement principal etait le taux de revision pour descellement aseptique. Les luxations, le taux d’infection et le score Postel Merle d’Aubigne (PMA) etaient releves. Resultats Au recul moyen de 4,2 ans, 3 (4,6 %) patients ont ete perdus de vue et 22 (33,3 %) etaient decedes. Il y a eu 1 descellement aseptique (1,5 %). La survie de la cupule etait de 98 % a 5 ans (IC 95 % : [94–100]). Il n’est survenu aucun episode de luxation. Il y a eu 1 revision pour infection. Le score PMA moyen au recul etait de 15,5 (9–18). Discussion La frequence des descellements acetabulaires etait comparable a celle des series de CDM cimentees avec armature de soutien. L’emploi d’une CDM cimentee est possible sans armature de soutien et constitue une option simple et viable en cas d’alteration moderee du capital osseux. Niveau de preuve IV, etude de cohorte retrospective.

Resume Objectif La chirurgie rachidienne instrumentee a un taux eleve d’infection du site operatoire (ISO). Cependant, les resultats sont variables en fonction de la methodologie de la surveillance, du type de procedures, ou de la qualite du suivi. Notre objectif etait d’etudier l’incidence reelle des ISO dans la chirurgie rachidienne instrumentee grâce a une methodologie stricte de recueil de donnee et de surveillance, et de comparer les resultats avec ceux obtenus grâce au recueil automatise du systeme informatique hospitalier, afin de pouvoir valider cette derniere methode de surveillance. Methode Il s’agit d’une etude de cohorte monocentrique prospective incluant tous les patients operes consecutivement d’une chirurgie rachidienne instrumentee par voie posterieure, quelle que soit l’etiologie, sur une periode de six mois. Pour tous les patients, le service d’hygiene hospitaliere procedait a une surveillance active et poussee de la survenue d’ISO, durant une periode minimale de 12 mois apres la chirurgie. Les resultats etaient ensuite compares a ceux obtenus par une recherche automatique grâce au systeme informatique hospitalier. Resultats Au total, 154 patients ont ete inclus. Il n’y avait pas de difference significative entre la surveillance « haute qualite » et la surveillance automatisee grâce au systeme informatique hospitalier, meme si ce dernier a sous-estime le taux d’ISO : le taux d’infection du site operatoire etait de 2,60 %, quand le taux d’ISO obtenu grâce au systeme informatique hospitalier etait de 1,95 %. La consommation d’alcool et le tabagisme etaient retrouves comme facteurs de risque d’ISO. Conclusion Notre taux d’ISO reflete la reelle incidence des complications infectieuses dans la chirurgie instrumentee du rachis par voie posterieure de l’adulte au sein de notre centre et est en accord avec les taux les plus faibles publies. Nous n’avons pas trouve de difference significative entre les deux methodes de surveillance dans la detection des ISO. De nouvelles etudes aux effectifs plus importants sont necessaires pour conclure, mais une detection automatisee des ISO grâce au systeme informatique hospitalier pourrait etre une methode alternative fiable.

Background Meniscal substitutes have been suggested for the treatment of knee pain after partial meniscectomy. However, despite the partial nature of the initial meniscectomy, secondary extrusion of the substitute is common. The primary objective of this study was to evaluate morphological outcomes of meniscal substitute implantation and their potential associations with preoperative meniscal extrusion. Hypothesis Preoperative absolute meniscal extrusion in the coronal plane predicts poorer morphological and clinical outcomes. Material and methods Consecutive patients who received an Actifit ® meniscal substitute between 2008 and 2011 were included prospectively. After 1 year and 2 years, the IKDC score and KOOS were determined and magnetic resonance imaging performed. The morphological evaluation consisted in measuring meniscal extrusion and cartilage coverage by the substitute in the coronal and sagittal planes. Results Twenty patients were included. Among them, 3 required subsequent removal of the substitute. The mean subjective IKDC score increased from 48.1 preoperatively to 56.4 after 2 years. Over the same period, the function/sports/recreational activities component of the KOOS improved significantly (42.9 vs. 55.0, P = 0.04). Positive correlations between preoperative and 1-year values were demonstrated for both cartilage coverage in the coronal and the sagittal planes ( P = 0.03 and P = 0.04, respectively) and coronal absolute meniscal extrusion ( P = 0.05). No significant differences were found between preoperative and 2-year values of cartilage coverage in the coronal and sagittal planes ( P = 0.38). There was a negative correlation linking preoperative meniscal extrusion in the coronal plane to 1-year cartilage coverage in the coronal and sagittal planes ( P = 0.01 and P = 0.04, respectively). Preoperative absolute meniscal extrusion in the coronal plane correlated negatively with the subjective IKDC score after 1 year ( P = 0.02). Discussion Preoperative meniscal extrusion in the coronal plane strongly predicts clinical and morphological outcomes. Marked preoperative meniscal extrusion, even in a patient with symptoms after partial meniscectomy, should prompt an appraisal of whether allograft replacement may be more appropriate than a meniscal substitute. Level of evidence IV, prospective study.

Resume Les substituts meniscaux ont ete proposes dans les syndromes douloureux post-meniscectomie partielle. Malgre le caractere partiel de la meniscectomie initiale, l’extrusion secondaire du substitut est cependant frequente. L’objectif principal de cette etude etait d’evaluer les resultats morphologiques apres substitut meniscal et de les rapporter a une eventuelle extrusion preoperatoire. Hypothese L’extrusion meniscale absolue frontale preoperatoire est un facteur pronostique pejoratif sur les resultats morphologiques et cliniques. Materiel et methodes Cette etude prospective continue a inclus tous les patients ayant eu un substitut meniscal Actifit ® entre 2008 et 2011. Les scores IKDC et Koos, une IRM ont ete realises a 1 et 2 ans de recul. L’etude morphologique a consiste en l’evaluation de l’extrusion meniscale frontale, sagittale et la couverture cartilagineuse frontale et sagittale par le substitut. Resultats Vingt patients ont ete inclus. Trois patients ont subi une ablation secondaire du substitut. Le score IKDC subjectif moyen passait de 48,1 en preoperatoire a 56,4 a 2 ans de recul. Le score Koos sport etait significativement ameliore (42,9 vs 55, p = 0,04). Une correlation positive a ete retrouvee entre la couverture cartilagineuse frontale ( p = 0,03) et sagittale ( p = 0,04) preoperatoire et a 1 an et entre l’extrusion meniscale frontale absolue preoperatoire et a 1 an ( p = 0,05). Aucune difference significative n’a ete retrouvee entre la couverture cartilagineuse frontale et sagittale preoperatoire et a 2 ans ( p = 0,38). Une correlation negative a ete retrouvee entre l’extrusion frontale preoperatoire et la couverture cartilagineuse frontale ( p = 0,01) et sagittale ( p = 0,04) a 1 an et l’extrusion absolue frontale preoperatoire et le score IKDC subjectif a 1 an ( p = 0,02). Discussion L’extrusion meniscale frontale preoperatoire est un element majeur du pronostic clinique et morphologique. Une extrusion meniscale preoperatoire forte, meme en presence d’une sequelle de meniscectomie partielle, doit faire reconsiderer l’indication d’un substitut pour une allogreffe. Niveau de preuve IV, etude prospective.

Resume Introduction Peu de donnees recentes existent en France concernant l’epidemiologie de la traumatologie rachidienne. Les therapeutiques ont pourtant evolue par une meilleure connaissance de l’equilibre sagittal et grâce aux techniques mini-invasives. Objectif Decrire l’epidemiologie de la traumatologie rachidienne et sa prise en charge. Analyser l’evolution a 1 an et les facteurs de risque de mauvais resultats fonctionnels. Materiel et methode Etude de cohorte francaise, prospective, multicentrique conduite pendant 6 mois en 2011. Toutes les fractures rachidiennes operees etaient incluses. Les donnees etaient recueillies par un questionnaire informatique via internet. Les caracteristiques demographiques, le type de lesion et les modalites de l’intervention etaient renseignes. Une evaluation clinique, fonctionnelle et radiologique etaient realisees a 1 an. Resultats Cinq cent dix-huit patients d’âge moyen 47 ans ont ete inclus. Soixante-sept pour cent des fractures interessaient le segment thoracique ou lombaire. Trente pour cent des patients ont ete hospitalises dans le cadre d’un polytraumatisme et 28 % presentaient une atteinte neurologique. Une technique mini-invasive a ete realisee dans 20 % des cas et une liberation neurologique pour 25 % des patients. Quarante-deux breches durales (8 %) peroperatoires ont ete constatees. A 1 an, 70 % des patients ont ete revus. Sur le plan fonctionnel, une deterioration du score SF-36 etait observee pour toutes les dimensions, associee significativement a l’âge, au deficit neurologique persistant, aux lesions associees, et au desequilibre anterieur. Enfin, 38 % des patients actifs n’ont pas repris leur travail. Sur le plan radiologique 74 % presentaient un rachis equilibre et 70 % une consolidation osseuse certaine. Discussion Malgre l’evolution de la prise en charge, les traumatismes rachidiens restent en 2011 la source d’une morbidite importante. Une preservation de l’equilibre sagittal semble etre associee a une meilleure evolution fonctionnelle.

Resume Introduction La mise en commun des connaissances et des pratiques lors des Congres francais sur la chirurgie du rachis a mis en evidence une variabilite entre les differentes « ecoles » de chirurgie et entre les deux specialites (orthopedie et neurochirurgie). Cette variabilite semble maximale dans le cadre de la traumatologie rachidienne. Objectifs Objectiver cette difference de pratiques par la mise en place d’un questionnaire base sur un cas fictif de traumatologie du rachis. Evaluer l’etat de la litterature pour les pratiques les plus variables. L’hypothese etant que cette variabilite est due a une absence de recommandations forte dans le domaine de la chirurgie du rachis. Methodes Le cas presentait un homme de 31 ans qui avait une fracture de L1, avec comme seul symptome neurologique, des paresthesies dans les cuisses. Les chirurgiens recevaient le cas suivi de quatorze questions sur la prise en charge du malade de son entree a son suivi tardif. Pour chaque question, le chirurgien avait a choisir parmi 5 possibilites de reponses. L’index de variabilite qualitative (IQV) objectivait les differences (IQV = 0 : pas de variabilite, IQV = 1 : maximum de variabilite). Le chirurgien remplissait a la fin un petit questionnaire sur ses caracteristiques personnelles (sexe, âge, niveau, volume d’activite, type de centre). Resultats Sur 405 chirurgiens invites a participer, 200 chirurgiens ont participe. Les variabilites les plus importantes (IQV > 0,9) etaient retrouvees pour les questions : sur la necessite de faire un IRM en urgence (IQV = 0,93), sur le degre d’urgence a operer le patient (IQV = 0,93), sur la necessite de rechercher un fusion osseuse avec une greffe (IQV = 0,93), sur l’interet d’un corset en postoperatoire (IQV = 0,93) et sur l’interet d’enlever le materiel chez un patient asymptomatique (IQV = 0,93). Deux questions etaient, en revanche, peu debattues (IQV Conclusion La variabilite des pratiques entre les chirurgiens du rachis francais en traumatologie est importante. Peu de recommandations dans ce domaine peuvent expliquer ces variabilites.

Electronic survey.The aim of this study was to identify the international nuances in surgical treatment patterns for severals lumbar degenerative conditions, specifically, to identify differences in responses in each country groupand different treatment trends across countries.Significant variations in treatment of lumbar degenerative conditions exist among spine surgeons, related to the lack of established consensus in the literature.An online survey with preformulated answers was submitted to 52 orthopedic surgeons, 50 neurosurgeons from four different countries (United States, France, Spain, and Germany) regarding five vignette-cases. Cases included: multilevel stenosis, monolevel stenosis, lytic spondylolisthesis, isthmic lysis, and degenerative scoliosis. The variability for each country was calculated according to the Index of Qualitative Variation (IQV = 0: no variability and 1: maximal variability). We used Fleiss kappa (range: from -1, poor agreement, to 1, almost perfect agreement) for assessing the reliability of agreement between the participants concerning specialties, countries, and age groups.For the two stenosis cases, US surgeons were more likely to propose decompression (IQV multilevel = 0.47 and monolevel = 0.32) comparing with European countries more heterogeneous (all IQV0.70) and more frequently proposing fusion. As regards degenerative scoliosis, all attitudes were extremely heterogeneous with IQV0.8. Fusion for isthmic spondylolisthesis was more consensual (all IQV0.63), but attitudes were more heterogeneous for isthmic lysis (IQV ranged from 0.48 to 0.76) with anterior approach proposed in France (37%) and United States (19.2%).The overall interrater agreement was equally slight not only for neurosurgeons (Fleiss Kappa = 0.04) and orthopedic surgeons (Kappa = 0.13), but also for countries (Kappa0.13) and age groups (Kappa0.1).In this study, we found substantial agreement for some spinal conditions but a high variability in some others: intranational and international variations were observed, reflecting the lack of literature consensus.2.

Introduction Spinal neuroarthropathy (SNA), also called “Charcot spine”, is very uncommon disease of unknown etiology. Kronig first reported this pathology in 1884 on a patient with Tabes dorsalis (also known as syphilitic myelopathy). As syphilis tends to disappear in developed countries, spinal cord lesion is the most frequent etiology of SNA. Objectives To describe clinical and radiographic results in 12 patients suffering from spinal neuroarthropathy (SNA). Methods Twelve patients diagnosed with SNA were included in the study. All patients were wheelchair users. The average delay between the neurological disease and the diagnosis of SNA was 18 years. All patients were initially treated conservatively. Surgery was only indicated in persistent symptomatic or instable cases, and for infected SNA. Surgery was a circumferential arthrodesis. Results From 12 patients, with a median follow-up of 4 years, five patients were operated on and 7 patients were still conservatively treated. Two patients with back pain and evolutive destruction were declined for surgery. One suffered of bilateral hip ankylosis and extensive spinal surgery would have confined him to bed, and one due to an evolutive bedsore. One patient improved with a complete regression of back pain. Conclusion Nowadays, surgical treatment is recommended with an extensive and circumferential fusion, in order to prevent relapses. Good radiographic outcome is reported but functional results have not been studied. Natural evolution of SNA remains unknown but can be less disabling than surgery. This pathologic mobility can contribute to patient's autonomy and can therefore be considered as opportune. Conservative therapy can be considered for SNA. Level of evidence Level IV.

Purpose The morphological and biomechanical features of the thoracic spine, together with its close proximity to the spinal cord, set it apart from other spinal segments. Management of thoracic spine injuries consists of achieving a reduction and an immediate and long-lasting stabilization of the spine while constantly protecting the central and peripheral nervous system. The aim of this study was to determine the best treatment for surgical thoracic spine fractures. Materials and methods We studied the baseline characteristics of 68 patients admitted to our neurosurgical department for one or several thoracic spine fractures between 2008 and 2010. We analysed on this group of patient the surgical management, complications and functional outcomes. We detailed the 2-years radiological outcome on 50 patients (23 months mean follow-up). Results The majority of patients underwent an extensive posterior arthrodesis bridging, on average, 5.3 vertebrae. The median time between diagnosis and surgery was 2 days and the median length of stay in hospital was 13.5 days. About 94% of hooks and 80% of pedicle screws were considered stable. Mean values of reduction and correction loss were similar (about 4.5°). We concluded to the superiority of extensive procedures and of pedicle screws fixation for the reduction and the maintenance of the correction by the end of follow-up. Functional data indicated daily discomfort and moderate pain. Conclusion A prospective study comparing the different procedures and instrumentations is needed to better define guidelines for the management of thoracic spine injuries. Level of evidence Level IV.

Meniscus allograft transplantation (MAT) is used to treat patients with knee pain after total or subtotal meniscectomy. The graft can be inserted during open or arthroscopic surgery. The objectives are anatomic horn positioning and strong fixation to the bone and capsule of an appropriately sized graft. Hypothesis Arthroscopic MAT with trans-tibial bone fixation ensures better mid-term functional outcomes and limits allograft extrusion. Patients and methods We conducted a retrospective single-centre study of 23 consecutive patients who underwent MAT between 2001 and 2010. Among them, 11 had open surgery and anchoring of the horns without tunnels and 12 had arthroscopically-assisted surgery with bony fixation of the horns through trans-tibial tunnels. The two groups were comparable at baseline. Mean follow-up was 66.1 months. Post-operative outcomes were assessed using the IKDC score and KOOS, standard radiographs of both knees, and either magnetic resonance imaging or computed arthrotomography. We measured joint space narrowing, meniscal extrusion in the sagittal and coronal planes; and the degree of cartilage coverage by the graft using an index developed for this study. Results The overall failure rate was 17.4% (4/23, two cases each of complete and partial graft removal). Joint space narrowing increased by 28% versus the pre-operative value (P = 0.009). IKDC and KOOS values were not significantly different between the two groups. Absolute meniscus extrusion was greater in the arthroscopy group (4 mm vs. 3 mm, P = 0.03). Discussion Osteoarthritis of the transplanted compartment is unavoidable. Open surgery is associated with less meniscal extrusion. The clinical outcomes are independent from the technique used. Other factors require investigation, including graft rehabilitation, quality peripheral suturing, and intermeniscal ligament reconstruction. Level of evidence IV, retrospective study.

Resume L’allogreffe meniscale s’adresse aux sequelles douloureuses de meniscectomie totale ou subtotale. Elle est realisee par une technique a ciel ouvert ou par arthroscopie, l’objectif etant d’obtenir un positionnement anatomique des cornes et une fixation osseuse et capsulaire solide d’une greffe meniscale correctement calibree. L’hypothese de l’etude etait qu’une technique arthroscopique utilisant une fixation osseuse transtibiale des cornes permettait d’obtenir a moyen terme un resultat fonctionnel meilleur et de limiter l’extrusion de l’allogreffe meniscale. Materiel et methodes L’etude, retrospective monocentrique successive, bi-operateur entre 2001 et 2010 a porte sur 23 allogreffes laterales : 11 a ciel ouvert sans fixation transosseuse des cornes et 12 par arthroscopie (avec insertion transosseuse des cornes par des tunnels tibiaux). Les deux series etaient comparables. L’evaluation postoperatoire a porte sur les scores IKDC et Koos, la realisation d’un bilan radiographique standardise bilateral et d’une IRM ou arthroscanner. Ont ete mesures, le pincement de l’interligne, l’extrusion meniscale frontale et sagittale, l’index de couverture cartilagineuse de la greffe selon un protocole original. Resultats L’ensemble de la serie a montre au recul moyen de 66,1 mois un taux d’echec de 17 % (deux resections completes et deux partielles de la greffe). Le pincement s’aggravait de 28 % par rapport au preoperatoire ( p = 0,009). Aucune difference significative n’a pu etre mise en evidence entre les scores cliniques du groupe ciel ouvert et du groupe arthroscopie. Une extrusion meniscale absolue superieure a ete retrouvee dans la serie arthroscopique (4 mm vs 3 mm, p = 0,03). Discussion La degradation arthroscopique du compartiment greffe est ineluctable. La technique a ciel ouvert permet de limiter l’extrusion meniscale. L’evolution clinique est independante de la technique. D’autres facteurs necessitent d’etre approfondis : rehabitation de la greffe, qualite des sutures peripheriques, reconstitution du ligament intermeniscal. Niveau de preuve Niveau IV, etude retrospective.

STUDY DESIGN Outcome study to determine the internal consistency, reproducibility, and concurrent validity of the French-Canadian version of the Scoliosis Research Society 22 (SRS-22 fcv) patient questionnaire in France. OBJECTIVE To determine whether the SRS-22 fcv can be used in a population from France. SUMMARY OF BACKGROUND DATA The SRS-22 has been translated and validated in multiple countries, notably in the French-Canadian language in Quebec, Canada. Use of SRS-22 fcv seems appropriate for evaluating adolescent idiopathic scoliosis in France. However, French-Canadian French is noticeably different from the French spoken in France, and no study has investigated the use of a French-Canadian version of a health-quality questionnaire in another French population. METHODS The methods used for validating the SRS-22 fcv in Quebec were adopted for use with a group of 200 adolescents with idiopathic scoliosis and 60 healthy adolescents in France. Reliability and reproducibility were measured by the Cronbach α and intraclass correlation coefficient (ICC), construct validity by factorial analysis, concurrent validity by the Short-Form of the survey, and discriminant validity by analysis of variance and multivariate linear regression. RESULTS In France, the SRS-22 fcv showed good global internal consistency (Cronbach α = 0.87, intraclass correlation coefficient = 0.92), a coherent factorial structure, and high correlation coefficients between the SRS-22 fcv and Short-Form of the survey (P < 0.001). However, reliability and validity were slightly less than that for the instrument's original validation and the validation of the SRS-22 fcv in Quebec. These differences could be explained by language and cultural differences. CONCLUSION The SRS-22 fcv is relevant for use in France, but further development and validation of a specific French questionnaire remain necessary to improve the assessment of functional outcomes of adolescents with scoliosis in France. LEVEL OF EVIDENCE N/A.

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

Propensity score matching (PSM) is a popular method in clinical researches to create a balanced covariate distribution between treated and untreated groups. However, the balance diagnostics are often not appropriately conducted and reported in the literature and therefore the validity of the findings from the PSM analysis is not warranted. The special article aims to outline the methods used for assessing balance in covariates after PSM. Standardized mean difference (SMD) is the most commonly used statistic to examine the balance of covariate distribution between treatment groups. Because SMD is independent of the unit of measurement, it allows comparison between variables with different unit of measurement. SMD can be reported with plot. Variance is the second central moment and should also be compared in the matched sample. Finally, a correct specification of the propensity score model (e.g., linearity and additivity) should be re-assessed if there is evidence of imbalance between treated and untreated. R code for the implementation of balance diagnostics is provided and explained.

SummaryAs spinal surgery in elderly patients is becoming increasingly frequent, comorbidities likely to be decompensated after such procedures must be kept in mind. We report here the case of an 82-year-old woman who presented rapidly progressive spinal cord compression following lumbar surgery for radiculopathy. Investigations showed a thoracic intradural extramedullary compressive lesion, which after removal turned out to be a meningioma. We suggest that radiculopathy and non-specific degenerative modifications partially masked this lesion, and that lumbar surgery caused this acute neurological deterioration. Therefore, we advice caution in older patients among whom such ambiguous clinical presentation is frequent.

Resume La frequence des traumatismes du rachis cervical chez le sujet âge est en constante augmentation avec une predominance des lesions du rachis cervical superieur. Ces fractures exposent a des complications parfois mortelles mais peu d’etudes les analysent precisement. L’objectif de ce travail etait l’identification dans la litterature de l’incidence des complications (mortalite et morbidite) apres traumatisme du rachis cervical superieur du sujet âge. Methodes Une recherche systematique sur la base Medline sans restriction de langues ni de temps a ete realisee pour repertorier toutes les etudes rapportant le taux de complications apres traumatisme du rachis cervical superieur chez le sujet de plus de 60 ans. Resultats Vingt-quatre etudes observationnelles ont ete retenues dont seulement quatre etaient comparatives. L’ensemble de ces etudes representait 857 patients, avec un âge moyen de 76 ans. La quasi totalite des traumatismes etait des fractures de l’odontoide traitees majoritairement de facon chirurgicale (57 %). Le taux median de mortalite etait de 9,2 % (Q1–Q3 : 2,5–19,6) et le taux median de complications a court terme etait de 15,4 % (Q1–Q3 : 5,8–26,9). La principale complication tardive etait la pseudarthrose qui survenait en moyenne entre 10 et 12 % selon le traitement choisi. Conclusion Les complications des traumatismes du rachis cervical chez le sujet âge sont frequentes quel que soit le type de traitement. La connaissance du taux de survenue et des potentiels facteurs de risques est indispensable au clinicien pour mieux en informer son patient et prevenir les complications. Type d’etude Revue systematique de la litterature. Niveau de preuve Niveau IV.

To describe the evolution of the use and reporting of propensity score (PS) analysis in observational studies assessing a surgical procedure.Assessing surgery in randomized controlled trials raises several challenges. Observational studies with PS analysis are a robust alternative for comparative effectiveness research.In this methodological systematic review, we identified all PubMed reports of observational studies with PS analysis that evaluated a surgical procedure and described the evolution of their use over time. Then, we selected a sample of articles published from August 2013 to July 2014 and systematically appraised the quality of reporting and potential bias of the PS analysis used.We selected 652 reports of observational studies with PS analysis. The publications increased over time, from 1 report in 1987 to 198 in 2013. Among the 129 reports assessed, 20% (n = 24) did not detail the covariates included in the PS and 77% (n = 100) did not report a justification for including these covariates in the PS. The rate of missing data for potential covariates was reported in 9% of articles. When a crossover by conversion was possible, only 14% of reports (n = 12) mentioned this issue. For matched analysis, 10% of articles reported all 4 key elements that allow for reproducibility of a PS-matched analysis (matching ratio, method to choose the nearest neighbors, replacement and method for statistical analysis).Observational studies with PS analysis in surgery are increasing in frequency, but specific methodological issues and weaknesses in reporting exist.

Resume Introduction La chirurgie du rachis est connue pour son risque d’infection du site operatoire (ISO). Beaucoup d’auteurs se sont interesses aux facteurs de risque et a l’incidence des ISO en chirurgie programmee, mais seules deux etudes retrospectives sont consacrees aux ISO en chirurgie rachidienne traumatique. Patients et methodes Une etude de cohorte prospective, rassemblant tous les patients operes d’un traumatisme du rachis sur une periode de trois mois dans 13 centres francais a represente la base de ce travail. Le critere principal d’evaluation etait la survenue d’une ISO dans les trois mois. Les patients polytraumatises et les fractures ouvertes etaient exclus de l’etude. Resultats Sur les 169 patients revus a trois mois minimum, six ont presente une ISO aigue (3,55 %). Etaient significativement lies a l’ISO : l’âge, le score ASA, le diabete, la duree d’intervention, le delai entre accident et intervention, le nombre d’etages fusionnes, le saignement et la presence prolongee d’une sonde urinaire. Discussion Nos resultats sont coherents avec ceux de la litterature, en termes de taux d’infection allant de 2 a 10 %, et pour les facteurs de risque qui ont tous ete deja retrouves dans d’autres etudes pour la chirurgie rachidienne programmee. Niveau de preuve Type IV. Etude de cohorte prospective.

Resume Introduction L’infection du site operatoire (ISO) est une complication classique de la chirurgie rachidienne avec des risques fonctionnels et des enjeux neurologiques en cas de meconnaissance ou de mauvaise prise en charge. Le diagnostic et le traitement ont souvent ete analyses dans le domaine degeneratif mais tres peu en chirurgie rachidienne traumatique. Materiels et methodes Une etude retrospective multicentrique, rassemblant toutes les ISO apres intervention pour un traumatisme du rachis sur une periode de deux ans a represente la base de ce travail. Les donnees epidemiologiques, le mode d’expression de l’infection, la microbiologie, la strategie chirurgicale et antibiotique et enfin les resultats sur l’infection ont ete analyses. Resultats Sept cent quatre fractures du rachis ont ete operees dans cinq centres universitaires francais entre janvier 2004 et decembre 2006. Trente-quatre ISO ont ete repertoriees (4,8 %) touchant exclusivement les voies d’abord posterieures, cervicales ou thoraciques. Les germes les plus frequents etaient le staphylocoque methisensible et les bacilles Gram negatif. Le debridement chirurgical, le maintien des implants et une double antibiotherapie suppressive s’est averee efficace dans 91 % des cas. Discussion Nos resultats sont coherents avec ceux de la litterature, en termes de taux d’infection, de microbiologie avec predominance d’infection a staphylocoque, d’attitude therapeutique et de resultats. Niveau de preuve Etude retrospective, niveau de preuve : IV.

Summary Introduction Spine surgery is known to have a high risk of surgical site infection (SSI). Multiple studies have looked into the risk factors and incidence of SSI during elective surgery, but only two retrospective studies have specifically evaluated SSI during surgery following spine trauma. Materials and methods This work was based on a prospective cohort study that included all the patients operated on for spinal trauma at 13 French hospitals over a three-month period. The main endpoint was the occurrence of a SSI during the three-month period. Patients with multiple trauma or open fractures were excluded from the study. Results Of the 169 patients re-examined after a minimum of three months, six had had an acute SSI (3.55%). The following factors were significantly related to a SSI: age, ASA score, diabetes, procedure duration, delay elapsed between accident and procedure, number of levels fused, bleeding and prolonged presence of urinary catheter. Discussion Our results were consistent with the published infection rates of 2 to 10%. The risk factors identified have all been described in previous studies on elective spine surgery. Level of evidence Level IV, prospective cohort study.

Treatment strategies in high-grade L5-S1 spondylolisthesis are controversial. Reduction of slippage, correction of lumbosacral kyphosis and the necessity of a complementary anterior approach are debated in the literature. The present study reports clinical and radiological outcome for reduction and instrumented fusion on a single posterior approach.A retrospective study included all consecutive adolescent and young adult patients operated on by a single surgeon (D.C.) for high-grade (Meyerding 3-4-5) L5-S1 spondylolisthesis. The technique consisted in reduction of lumbosacral kyphosis and posterolateral fusion on a single posterior approach without resection of the sacral dome or complementary anterior approach. Only cases of adult ptosis required impacted tibial interbody graft. Clinical complications, radiologic lumbopelvic results and sagittal balance were analyzed at last follow-up.Fifty patients, with a mean age at surgery of 21±11 years, were followed up for a mean 5.5±4.6 years. Mean lumbosacral angle was reduced by 25° (from 76° to 101°; P0.05), and mean listhesis grade by50% (from 75% to 23%; P0.0001), without correction loss at last follow-up. C7 sagittal offset was corrected (from 8° to 4°; P0.05), with harmonization of lumbar (from 57° to 64°; P0.001) and thoracic curvature (from 37° to 44°; P=0.1). Seventeen patients (34%) showed postoperative radicular deficit, without sequelae at last follow-up. There were no cauda equina lesions. Bone fusion was achieved in 42 patients (84%), in the same surgical step. After revision by complementary interbody graft, there was no residual non-union.Surgery on a single posterior approach gave reliable results in high-grade spondylolisthesis in adolescents and young adults. The technique is not however, free of risk (transient neurologic deficit and non-union), and patients should be forewarned. Complementary interbody graft can be reserved to adult ptosis with incomplete reduction of lumbosacral kyphosis and to revision surgery for non-union.IV, retrospective study.

Introduction Cemented versions of dual-mobility cups (DMCs), helpful in cases of bone stock alteration, are usually used in association with a reinforcement device. To simplify the intervention in elderly subjects or those with a poor bone stock, the cups can be cemented directly into the bone, but the long-term result remains uncertain. We conducted a retrospective study in this population so as to: (1) assess whether cemented fixation of a DMC without a reinforcement device leads to a higher loosening rate, (2) confirm its efficacy in preventing dislocations in subjects at high risk of instability, and (3) measure the functional results. Hypothesis Cemented fixation of a DMC is reliable in cases of moderate alteration of bone stock. Material and methods Sixty-four patients (66 hips) undergoing implantation of a cemented DMC (Saturne™) without a reinforcement device were included in this single-center retrospective study. Their mean age was 79.8 years (range, 40–95 years). The indications varied: hip osteoarthritis (30.3%), prosthesis revision (44.0%), and trauma (25.8%). The patients were evaluated radiologically and clinically at follow-up. The main evaluation criterion was the revision rate for aseptic loosening. Dislocations, the infection rate, and the Postel Merle d’Aubigne (PMA) score were noted. Results At the mean follow-up of 4.2 years, three (4.6%) patients had been lost to follow-up and 22 (33.3%) had died. There was one case of aseptic loosening (1.5%). Cup survival was 98% at 5 years (95%CI [94–100]). There were no dislocations. There was one revision for infection. The mean PMA score was 15.5 (range, 9–18). Discussion The frequency of acetabular loosening was comparable to the frequency in cemented DMCs with a reinforcement device. A cemented DMC without a reinforcement device is possible and is a simple and viable option when there is moderate bone stock alteration. Level of evidence IV, retrospective cohort study.

International audience; PURPOSE:To investigate the incidence of surgical-site infection (SSI) and determinate the risk factors of SSI in the context of spinal injury.METHODS:From February 1, 2011 to July 31, 2011, for a multicentre cohort of patients with acute spinal injury, we prospectively censored those with SSI for at least 12 months. We recorded epidemiologic characteristics and details of surgical procedure and postoperative care for each patient. We calculated the incidence of SSI at 1, 3 and 12 months after surgery. Univariate and multivariate analysis were used to establish the association of risk factors and SSI. We studied clinical outcomes by a visual analog scale for pain and physical and mental component summaries (PCS and MCS) of the Medical Outcomes Survey 36-Item Short Form (SF-36).RESULTS:At 1 year, among 518 patients, we recorded 25 SSI events, with median occurrence at 16 days (25-75 % quartile: 13-44 days). Incidence of SSI was 3.2 % (95 % confidence interval [1.9-5.3 %]) at 1 month, 3.7 % (95 % [2.2-5.8 %]) at 3 months and 4.6 % (95 % CI [3-6.9 %]) at 12 months. On multivariate analysis, age, presence of diabetes and surgical duration were predictors of SSI (p = 0.009, p = 0.047, and p = 0.015 respectively). At 12 months, infected and non-infected patients did not differ in pain (p = 0.58) or SF-36 PCS (p = 0.8) or MCS (p = 0.68).CONCLUSIONS:In this large prospective multicentre study in the context of spinal injury, we obtained an equivalent incidence rate and risk factors of SSI as found in the literature for elective spinal surgery.

Introduction Rapporter les resultats radiologiques et fonctionnels des patients atteints de fractures lombaires comminutives traitees par arthrodese circonferentielle en deux temps. Materiel et methodes Cette serie prospective, multicentrique, regroupe 74 patients atteints de fractures lombaires comminutives. La prise en charge therapeutique comprenait d’une osteosynthese posterieure initiale puis d’une corporectomie avec pose d’une cage extensible en titane remplie d’os autologue posee par lombotomie retroperitoneale. Le mecanisme fracturaire et les caracteristiques epidemiologiques des patients ont ete releves. Les indications ont ete evaluees a partir de la classification de MacCormack. Les scores de qualite de vie (VAS, ODI, SF12) ont ete renseignes au decours d’une periode minimale d’observation d’un an. Les parametres radiologiques incluant la deformation regionale et les parametres de l’equilibre sagittal pelvi-rachidien ont ete evalues a chaque consultation de suivi. La fusion a ete analysee au moyen d’une tomodensitometrie realisee a 1 an postoperatoire. Resultats L’âge moyen des patients etait de 38,1 ans et la duree moyenne de suivi de 2,1 ans (1,3–2,9). La repartition des fractures selon la classification de Magerl etait la suivante : type A (64,8 %), type B (16,7 %) et type C (18,5 %). Toutes les fractures presentaient un score > 6 selon la classification de MacCormack. Au dernier suivi, la fusion a ete jugee certaine dans 57 cas (77 %). Le VAS moyen etait de 2,1 (± 1,3), ODI 14,7 (± 8,0), SF12 PCS 43,2 (± 9,3) et SF12 MCS 50,8 (± 5,9). La correction de la cyphose regionale a ete significative avec une augmentation moyenne de la lordose de 9,0° (p Conclusion Le traitement des fractures lombaires comminutives par arthrodese circonferentielle comprenant une osteosynthese posterieure et une corporectomie par une cage expansible et un greffon autologue ont donne des resultats cliniques et radiologiques satisfaisants. Un taux eleve de fusion a ete obtenu associe a une correction perenne de la cyphose regionale. Les scores fonctionnels (ODI, SF-12 et VAS) a un an sont satisfaisants et sont correles a la fusion evaluee au dernier suivi.

Object Spinal instrumentation has a high rate of surgical site infection (SSI), but results greatly vary depending on surveillance methodology, surgical procedures, or quality of follow-up. Our aim was to study true incidence of SSI in spinal surgery by significant data collection, and to compare it with the results obtained through the hospital information system. Methods This work is a single center prospective cohort study that included all patients consecutively operated on for spinal instrumentation by posterior approach over a six-month period regardless the etiology. For all patients, a “high definition” prospective method of surveillance was performed by the infection control (IC) department during at least 12 months after surgery. Results were then compared with findings from automatic surveillance though the hospital information system (HIS). Results One hundred and fifty-four patients were included. We found no hardly difference between “high definition” and automatic surveillance through the HIS, even if HIS tended to under-estimate the infection rate: rate of surgical site infection was 2.60% and gross SSI incidence rate via the hospital information system was 1.95%. Smoking and alcohol consumption were significantly related to a SSI. Conclusion Our SSI rates to reflect the true incidence of infectious complications in posterior instrumented adult spinal surgery in our hospital and these results were consistent with the lower levels of published infection rate. In-house surveillance by surgeons only is insufficiently sensitive. Further studies with more patients and a longer inclusion time are needed to conclude if SSI case detection through the HIS could be a relevant and effective alternative method.

Background In France, attempts to define common ground during spine surgery meetings have revealed significant variability in clinical practices across different schools of surgery and the two specialities involved in spine surgery, namely, neurosurgery and orthopaedic surgery. Objectives To objectively characterise this variability by performing a survey based on a fictitious spine trauma case. Our working hypothesis was that significant variability existed in trauma practices and that this variability was related to a lack of strong scientific evidence in spine trauma care. Methods We performed a cross-sectional survey based on a clinical vignette describing a 31-year-old male with an L1 burst fracture and neurologic symptoms (numbness). Surgeons received the vignette and a 14-item questionnaire on the management of this patient. For each question, surgeons had to choose among five possible answers. Differences in answers across surgeons were assessed using the Index of Qualitative Variability (IQV), in which 0 indicates no variability and 1 maximal variability. Surgeons also received a questionnaire about their demographics and surgical experience. Results Of 405 invited spine surgeons, 200 responded to the survey. Five questions had an IQV greater than 0.9, seven an IQV between 0.5 and 0.9, and two an IQV lower than 0.5. Variability was greatest about the need for MRI (IQV = 0.93), degree of urgency (IQV = 0.93), need for fusion (IQV = 0.92), need for post-operative bracing (IQV = 0.91), and routine removal of instrumentation (IQV = 0.94). Variability was lowest for questions about the need for surgery (IQV = 0.42) and use of the posterior approach (IQV = 0.36). Answers were influenced by surgeon specialty, age, experience level, and type of centre. Conclusion Clinical practice regarding spine trauma varies widely in France. Little published evidence is available on which to base recommendations that would diminish this variability.

Introduction Recent epidemiological data for spinal trauma in France are sparse. However, increased knowledge of sagittal balance and the development of minimally invasive techniques have greatly improved surgical management. Objectives To describe the epidemiology and management of traumatic vertebral fracture, and to analyze evolution and risk factors for poor functional outcome at 1 year's follow-up. Materials and methods A prospective multicenter French cohort study was performed over a 6-month period in 2011, including all cases of vertebral fracture surgery. Data were collected by online questionnaire over the Internet. Demographic characteristics, lesion type and surgical procedures were collected. Clinical, functional and radiological assessment was carried out at 1 year. Results Five hundred and eighteen patients, with a mean age of 47 years, were included. Sixty-seven percent of fractures involved the thoracic or lumbar segment. Thirty percent of patients had multiple fractures and 28% neurological impairment. A minimally invasive technique was performed in 20% of cases and neurological decompression in 25%. Dural tear was observed in 42 patients (8%). Seventy percent of patients were followed up at 1 year. Functionally, SF-36 scores decreased on all dimensions, significantly associated with age, persistent neurological deficit and previous spine imbalance. Thirty-eight percent of working patients had returned to work. Radiologically, sagittal balance was good in 74% of cases, with fracture consolidation in 70%. Discussion Despite progress in management, spinal trauma was still a source of significant morbidity in 2011, with pronounced decrease in quality of life. Conserved sagittal balance appeared to be associated with better functional outcome.

Introduction Dans le cadre d’une prothese totale de hanche (PTH), le positionnement des implants est un enjeu majeur pour le chirurgien. Une bonne position des implants permet d’optimiser le resultat fonctionnel pour le patient en limitant les complications. Une zone de securite a ainsi ete decrite. L’objectif de cette etude etait de faire une analyse radiologique descriptive en 3D, grâce au systeme EOS, du positionnement des implants d’une serie de PTH posees par voie anterieure (dite de Hueter). Patients et methode Une etude prospective, sur 6 mois, a ete realisee. Tous les patients de plus de 18 ans programmes pour une PTH de premiere intention ont ete inclus dans l’etude. Les patients realisaient une acquisition radiographique EOS (positon debout) en preoperatoire et en postoperatoire. Le positionnement des implants etait analyse grâce au logiciel SterEOS. Deux types de positionnement de la cupule ont pu etre calcules du a l’acquisition en position debout – un positionnement dit anatomique (plan pelvien anterieur) et un positionnement dit fonctionnel (plan patient). Resultats Cent deux patients pour 103 PTH ont ete inclus dans l’etude, 46 hommes et 56 femmes. L’âge moyen etait de 64,7 annees et l’IMC moyen de 26,3. L’etiologie de l’arthrose de hanche etait majoritairement essentielle (72 %). Dix-neuf patients avaient deja ete operes d’une PTH de l’autre cote. Le positionnement anatomique des implants poses par voie anterieure retrouvait une inclinaison moyenne de la cupule acetabulaire de 39° (± 6), une anteversion anatomique de la cupule acetabulaire de 30° (± 10) et une anteversion femorale de 20° (± 11). Le positionnement fonctionnel de la cupule acetabulaire etait similaire en moyenne au positionnement anatomique. Conclusion L’etude revele que le positionnement de la tige femorale et l’inclinaison de la cupule acetabulaire sont en moyenne conformes au standard recommande. En revanche, l’anteversion de la cupule acetabulaire posee dans le cadre d’une voie anterieure est plus importante que la cible recommandee. Cependant, la zone de securite n’a pas ete etablie dans le cadre de PTH posees par voie anterieure et cette hyper anteversion pourrait proteger de la luxation posterieure sans pour autant exposer a la luxation anterieure dans le cadre d’une voie dite anatomique O. Une etude de correlation entre positionnement et luxation est necessaire pour definir une zone de securite propre aux PTH posees par voie anterieure.