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Background: Knee periprosthetic femoral fractures (KPPFF) are becoming more frequent due to the increasing number of arthroplasties and the aging population, for whom maintaining autonomy and function remains a challenge. The use of locking plates has improved functional results and promoted the development of "minimally invasive" surgical (MIS) approaches. Despite the availability of literature comparing between different types of osteosynthesis for KPPFF, there is a paucity of information available on the complications of osteosynthesis using locking plates, depending on the approach. We therefore carried out a retrospective multicenter study (nine centers: Dijon, Grenoble, Lille, Marseille, Nice, Paris, Saint-Étienne, Strasbourg, Colmar) as part of a Symposium of the French Society of Orthopedic Surgery and Traumatology (SOFCOT). Following osteosynthesis of KPPFF by locking plates carried out by a standard approach or by a minimally invasive approach (MIS), the objectives were: (1) to compare the complications, (2) to evaluate whether the radiological and clinical results (rate and time of consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy) were comparable in the two groups., Hypothesis: The hypothesis was that performing an MIS approach in these indications does not confer more complications than a standard approach, and rather, the MIS approach offers better functional and radiological results., Material and Method: Five hundred and seventy-three patients presented with KPPFF over the periods studied (retrospective series from January 2012 to December 2016, then prospective series from January to December 2019). After applying the inclusion criteria (KPPFF by locking plate) and exclusion criteria (tumor context, infectious, intraoperative fractures, fractures on loose prostheses, other osteosynthesis methods, treatment by prosthetic revision, patients under the age of 18, follow-up less than 1-year, incomplete files), a global series of 306 patients was retained. Two groups were created according to the approach performed: a standard approach group (S, n=228) and a minimally invasive approach group (MIS, n=78). The demographic data of the population were recorded, as was the criteria for autonomy (Parker score, place of living). Postoperative complications were sought (infection, mechanical complication, surgical revision). Finally, the radiological and clinical results were evaluated (rate of, and time to consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy)., Results: The comparison of the two subgroups, S and MIS, found complication rates are comparable in the two groups in terms of infections [S group: n=18 (7.9%), MIS group: n=2 (2.6%)], mechanical complications [S: n=23 (10.1%), MIS: n=2 (2.6%)], and surgical revision [S: n=33 (14.5%), MIS: n=7 (8.9%)], and a lack of difference in postoperative autonomy [Parker; S group: 4.7±2.4 (0-9) vs. MIS group: 5±2, 7 (0-9)]. On the other hand, the time to return to weight bearing was shorter in the MIS group [4.3±3.5weeks (0-12) versus 10.1±10.1weeks (0-110), p<0.001]. The rate of nonunion was lower in the MIS group [n=1 vs. n=20, i.e. 1.7% vs. 11.1% (p=0.031)] and the time to consolidation was shorter [7.5±4.3weeks (6-30) versus 15.2±9.4weeks (5-78) (p<0.001)]., Conclusion: Performing an MIS approach in the management of KPPFF by locking plate osteosynthesis does not cause any more complications than a standard approach. In addition, higher consolidation rates can be obtained in shorter periods of time. This study suggests that it proposing osteosynthesis using the MIS approach as a primary surgery is a reasonable choice when treatment using locking plates is chosen for a KPPFF, subject to technical expertise., Level of Evidence: III; observational study., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Objectives: Periprosthetic femur fractures after total knee arthroplasty in older adults are mostly treated by internal fixation. Members of the GETRAUM (French Orthopedic Trauma Society) sought to compare two surgical techniques - conventional open surgery and minimally invasive surgery - with the aim of analyzing the patients' functional recovery. We hypothesized that a minimally invasive technique would produce better early functional outcomes with recovery of independence., Materials and Methods: This retrospective multicenter study of patients treated between 2009 and 2015 consisted of 90 fractures with a follow-up of 1 year. Demographic, preoperative data and the characteristics of fractures, type of fixation and the surgeon's experience level were collected. The endpoints were the Parker Mobility score, Katz ADL, place of residence at the time of fracture and at 6 months and one-year follow-up. All complications and one-year mortality during the follow up were searched., Results: At 6 months follow-up, the minimally invasive technique contributed to significantly better functional recovery as measured by the Parker (p < 0.05) and Katz scores (p < 0.05). However, there were no differences in these scores at one-year follow-up. The complication rate was 31% at one year follow-up. Mortality rate was 12 % (11 patients)., Conclusion: Our hypothesis was confirmed, as there was a difference between techniques that impacted functional recovery and independence, but only in the early postoperative phase. A minimally invasive technique appears to be beneficial in the short term for distal femur fractures after total knee arthroplasty but must be evaluated in a comparative and prospective study to fully confirm its reliability., Competing Interests: Declaration of competing interest Christophe Chantelot, Marc Saab, Arnaud Kaba, Thierry Bégué, Henri Favreau: none Matthieu Ehlinger: educational consultant for DePuy Synthes, Newclip Technics and Lépine, (Copyright © 2024. Published by Elsevier Ltd.)

Objective: Extra-articular open fractures of the leg often result from high energy trauma. After healing, a painful ankle impingement may occur. In the event of anterior and posterior impingements, arthroscopic treatment may require two surgical positions. We propose an operative strategy to treat anterior and posterior ankle impingement after extra-articular open fracture of the leg. Our hypothesis is that this strategy is simple, effective and with a low risk of complication., Material and Method: Anterior ankle impingements were treated by anterior arthroscopy in supine position; anterior and posterior impingements were treated by anterior and posterior arthroscopy in supine position; anterior and posterior impingements associated with retraction of gastrocnemius muscles were treated with anterior arthroscopy in supine position followed by posterior arthroscopy in prone position, and an open tendon lengthening of the calcaneal tendon in the same position. The anterior and posterior arthroscopic release was tested in the cadaver laboratory. Then, the surgical strategy was applied to our patients in our clinical practice. After, we analysed retrospectively the results of the strategy in the first patients treated for a painful ankle impingement after extra-articular open fracture of the leg. The data retrieved were the importance of pain (VAS), the presence of clinical instability, ankle mobility, gastrocnemius retraction and the AOFAS functional score and the post-operative complications. Then, these data were compared before the surgery and at last follow-up., Results: From the cadaver laboratory, anterior and posterior arthroscopic release was possible in all cases without changing position. From our clinical practice, we included 5 patients (3 women and 2 men, mean age 43 years) suffering from an ankle impingement after extra-articular open fracture of the leg (2 patients with isolated anterior impingement, 1 patient with anterior and posterior impingement, and 2 patients with anterior and posterior impingement plus a gastrocnemius retraction). All post-operative parameters (pain, range of motion and AOFAS score) at mean follow-up of 53 months were improved. No post-operative complication was reported., Conclusion: We propose a surgical strategy adapted to the different clinical presentations of ankle impingement after extra-articular open fracture of the leg., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Thierry Bégué (TB): editorial board associate editor for JBJS, OTSR Patricia Thoreux (PT): Board member of SOFCOT Other authors: they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Introduction: Proximal femur fractures in elderly patients pose a common problem that requires surgical management. The main objective of this study was to compare the results of treatment by locked plate (LP) and by anterograde (AIN) or retrograde (RIN) intramedullary nailing. The secondary objective was to analyze the complications related to each group. The hypothesis of this study was that the radiological and clinical results of each group were comparable., Materials and Methods: The data of 438 patients from 8 centers were studied retrospectively with 365 LP and 69 cases of intramedullary nailing (49 AIN and 20 RIN). The groups were comparable in terms of mean age (75±2years), mean preoperative Parker score (5.3±0.5) and mean KOOS score (74±2). Most patients lived at home before their fracture [n=375 (86%)]. At follow-up, the joint range of motion, the KOOS and Parker scores, living premises, the time required to regain full weight-bearing, the time required for consolidation as well as the reduction alignment: frontal, sagittal, horizontal., Results: The average follow-up was: 79±2weeks (65 to 82). The functional and radiological results were comparable, although nailing allowed a faster return to weight-bearing (1±2weeks for nailing versus 7±2weeks for LP, p=0.048) and a better postoperative Parker score (5.5±0.5 for nailing versus 4.7±0.2 for LP, p=0.045). Rotational malalignment in femoral nailing was often in the direction of internal rotation, compared to the LP (p=0.045). Complications were comparable with the exception of mortality, which was more frequent for LP [22.5% in the LP group versus 13% in the nailing group (p=0.045)]. Complications were categorized as: mechanical complications 6.8% of LP, 5.7% of nailing (p>0.05), infections [11% of LP, 5.8% of nailing (p>0.05)], surgical revisions [2% of LP, 10% of nailing (p>0.05)]., Discussion and Conclusion: The hypothesis was refuted. These results show that nailing conferred a faster recovery of weight-bearing, a better Parker score, and is associated with a lower mortality rate. The morbidity rate is comparable between the two techniques. Indeed, when the indication for osteosynthesis by LP or by nailing is made, and both choices are technically justifiable, it would be prudent to favor the technique, which carries the least risk, which in this case is nailing. This conclusion must, however, be taken in to consideration with regard to the reduced number of nailing. A larger series of nailing, particularly retrograde, would be necessary to be able to confirm this last difference between the 2 groups., Level of Evidence: IV; comparative retrospective study., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: The definition of a great surgeon is usually reported by surgeons themselves. The objective of the study was to define a multifaceted definition of a great surgeon , by confronting patients', healthcare workers', and surgeons' perspectives., Study Design: An online open-ended questionnaire was created to identify three qualities and three shortcomings defining a great surgeon . Age, gender, and profession of respondents were collected. Responses with a similar meaning were combined into word groups and labeled within four themes: human qualities, technical surgical skills (TSS), non-technical skills (NTS), and knowledge. Multivariate analyses were conducted between themes and respondent characteristics., Results: Four thousand seven hundred and sixty qualities and 4,374 shortcomings were obtained from 1,620 respondents including 385 surgeons, 291 patients, 565 operating theater (OT) health professionals, and 379 non-OT health professionals. The main three qualities were dexterity (54% of respondents), meticulousness (18%), and empathy (18%). There was no significant difference between professional categories for TSS. Compared with surgeons, non-OT health professionals and patients put more emphasis on human qualities (29 vs. 39% and 42%, respectively, p < .001). OT health professionals referred more to NTS than surgeons (35 vs. 22%, p < 0.001). Knowledge was more important for surgeons (19%) than for all other professional categories ( p < 0.001)., Conclusions: This survey illustrates the multifaceted definition of a great surgeon . Even if dexterity is a major quality, human qualities are of paramount importance. Knowledge seems to be underestimated by non-surgeons, although it essential to understand the disease and preparing the patient and OT team for the procedure., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Luscan, Malheiro, Sisso, Wartelle, Parc, Fauroux, Bégué, Johanet, Denoyelle, Garabédian and Simon.)

Aseptic humeral shaft nonunions are rare lesions, with less than 700 cases per year in France. This low frequency explains why they are difficult to manage. They can be hypertrophic or atrophic, with or without a defect. The diagnosis is made based on radiographs and/or CT scan images. Nonunion is suspected early on when a patient presents with abnormal motion at the fracture site 6 weeks after the initial injury event in the context of conservative treatment or has large residual displacement after initial treatment or an open fracture. The treatment for hypertrophic nonunion consists in applying stable, rigid fixation, most often using a large-fragment plate with 4.5 mm screws, combined with cancellous autograft. When combined with the osteoperiosteal decortication first described by Judet, it produces union in 98% of cases. Intramedullary (IM) nail fixation with an autograft is another possibility. In atrophic nonunions, resecting the ends and ensuring the soft tissues have good vitality will generally lead to fracture union. Nonunions with critical size defects (larger than 5 cm), which have a high risk of infection, are a treatment challenge that requires stable fixation and recourse to more complex treatments like the two-step induced membrane technique or vascularized fibular graft. In all cases, to avoid complex repeat revision, internal fixation with plate or IM nail must be combined with a bone graft in situ to maximize the chances of union., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

In orthopedic surgery, the well-known iatrogenic risk of oral anticoagulants is particularly increased due to surgical management (suspension and resumption of treatment). In order to prevent avoidable iatrogenic events linked to incomplete discharge documents, targeted medical reconciliation (MR) has been deployed. This is a single-center prospective study conducted in orthopaedic surgery for six months including any patient treated upon admission with an oral anticoagulant. The analysis of the compliance of discharge documents (hospitalization report and prescriptions) was carried out before and after pharmaceutical interventions. The criteria analysed included the mention of the oral treatment, its dosage as well as the supervision of the switch from heparin therapy to the usual oral treatment. The documents were compliant if the mention of oral anticoagulant treatment and the date of the shift were correctly documented. Thirty-seven patients were included. The compliance rate of discharge documents was significantly improved by MR, going from 13.5 % to 78.4 % (P <0.05). The non-compliances before the intervention concerned the absence of mention of: the usual treatment (64.9 %), its dosage (81.1 %) or the switch's securing (75.7 %). Discharge from surgery of the patient on anticoagulants is a stage presenting a real risk which can be managed by the intervention of pharmacists. Improving the compliance of discharge documents is a first step towards better securing drug management., (Copyright © 2022 Académie Nationale de Pharmacie. Published by Elsevier Masson SAS. All rights reserved.)

Background: The induced membrane technique has been developed to address bone defect of critical size from various origins. Despite its exceptional efficacy, several cases underwent a failure, which is regularly associated with a septic problem. The best way to conduct in this situation remains debated., Purpose: To estimate use of bioactive glass S53P4 (BAG-53P4) in induced membrane technique failures or with an anticipated high risk of failure., Material and Method: We conducted a retrospective analysis of patients from several medical centers in Europe where BAG-S53P4 has been used inside an induced membrane. The etiology of the defect, the bone fixation used, the delay the bioactive glass was placed, the reason why the bioactive glass was used and the results were reported., Results: Eight cases were included (3 women and 5 men). Mean age was 43 years (16-82; Standard deviation 23). Mean height was 171 cm (162-184; SD 7), mean weight was 69 kg (60-85; SD 8) and Body Mass Index was 23,39 M/Kg2 (21,9-25,1; SD 1,22). Mean length of defect was 68 mm (40-100mm, SD 23). All patients received BAG-S53P4 granules (BonAlive Biomaterials Ltd, Turku, Finland) to fill the resultant cavity (3 as a stand-alone in the induced membrane and 5 mixed with autograft). Three patients were implanted with BAG-S53P4 during the second stage of a first induced membrane technique because of a high risk of infection (three open fractures); two patients were implanted with BAG-S53P4 during the second stage of a first induced membrane technique because of the great size of the defect (two infectious non-union); two patients were implanted with BAG-S53P4 as a third stage of induced membrane technique, i.e. inside a previously grafted membrane, because of a recurrence of the infection; and one patient was implanted with BAG-S53P4 during the second stage of a second induced membrane technique to avoid a new failure. At a follow-up of 16 months, all healed without any recurrence of the infection., Discussion: Critical size bone defects caused by an open fracture or an active infection can usually be addressed by the induced membrane technique. However, some cases are at high risk of failure because of the occurrence or recurrence of an infection. In these cases, bioactive glass may help the surgeon to improve the rate of bone union., Conclusion: BAG-S53P4 may be considered as bone graft in an induced membrane technique, especially when there is a high probability of occurrence or recurrence of a bone infection., (Copyright © 2022. Published by Elsevier Ltd.)

Purposes: Management of distal tibia fractures in the elderly is complex. The results of conservative treatments may be disappointing and primary ankle arthrodesis is now regularly offered as an alternative. In this study, we aimed to review the outcomes of primary ankle arthrodesis for distal tibia fracture in the elderly., Methods: We conducted a systematic review of the literature, from the Cochrane, MEDLINE, and Embase databases, on studies published in English and in French between 1950 and 2020. Only studies reporting the clinical results, the function, or the complications of primary ankle arthrodesis after ankle fracture in the elderly were included., Results: We included nine studies. The total number of patients was 229: 21% of them (50/229) sustained open fractures and 41% (95/229) had three or more comorbidities. All the patients underwent a tibio-talo-calcaneal arthrodesis with a retrograde transplantar intramedullary nailing (TIMN): short nail in 52% (151/229) and long nail in 48% (78/229) of the cases. At a mean follow-up comprised between six and 21 months, 94.5% of patients (190/201) achieved bone union, 87% (123/140) recovered an ankle range of motion close to their pre-operative status, 19% (40/211) had a complication, and 11.3% (24/211) required a revision. The use of a short nail resulted in a higher rate of peri-implant complication (2%) as well as a higher rate of revision (12.4%)., Conclusion: Primary ankle arthrodesis in recent fractures of the distal end of the tibia in the elderly frequently results in satisfactory results. The use of a long nail may be associated with a lower rate of implant specific complications., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Background: In more than 50% of cases, anterior cruciate ligament (ACL) lesions lead to post-traumatic osteoarthritis. Ligament reconstruction stabilizes the joint, but the tear seems to impair the poroelasticity of the cartilage: synovial membrane fluid inflammation is observed 3 weeks after tearing. There have been some descriptions of visible cartilage changes, but poroelasticity has never been analyzed at this early stage. The present animal study aimed to determine (1) whether cartilage showed early poroelastic deterioration after ACL tear; (2) whether an impairment correlated with macroscopic changes; and (3) whether cartilage poroelasticity deteriorated over time., Hypothesis: In the days following trauma, cartilage poroelasticity is greatly impaired, without macroscopically visible change., Material and Methods: ACL tear was surgically induced in 18 New-Zealand rabbits. Cartilage poroelasticity was assessed on indentation-relaxation test in 3 groups: "early", at 2 weeks postoperatively (n=6), "mid-early" at 6 weeks (n=6) and in a non-operated control group ("non-op"). Macroscopic changes were scored in the same groups., Results: Poroelastic impairment was greatest at the early time-point (2 weeks). Permeability ranged from a mean 0.08±0.05×10 -15 m 4 /Ns (range, 0.028-0.17) in the "non-op" group to 1.03±0.60×10 -15  m 4 /Ns (range, 0.24-2.15) in the "early" group (p=0.007). Shear modulus ranged from 0.53±0.11MPa (range, 0.36-0.66) to 0.23±0.10MPa (range, 0.12-0.43), respectively (p=0.013). Macroscopic deterioration, on the other hand, differed significantly only between the "mid-early" and the "non-op" groups: p=0.011 for cartilage deterioration and p=0.008 for osteophyte formation. At the "mid-early" time point, poroelastic deterioration was less marked, with 0.33±0.33×10 -15  m 4 /Ns permeability (range, 0.06-1.06) and shear modulus 0.30±0.10MPa (range, 0.13-0.41: respectively p=0.039 and p=0.023 compared to the "non-op" group., Discussion: The severe rapid deterioration in poroelasticity following ACL tear in an animal model, as notably seen in increased permeability, corresponds to changes in cartilage microstructure, with easier outflows of interstitial fluid. This mechanical degradation may underlie onset of microcracks within the cartilage, leading to physiological loading that the cartilage by its nature is unable to repair. Further investigations are needed to correlate these experimental data with clinical findings., Level of Evidence: III; comparative study with control group., (Copyright © 2021. Published by Elsevier Masson SAS.)

Introduction: This work relates the experience of three French surgical missions in the care of the war wounded during the armed conflict in Nagorno Karabakh which took place from September 27 to November 10, 2020., Materials and Methods: Three surgical missions were carried out in Armenia between October 2020 and January 2021. Surgeons intervened in different hospitals, at different times of the conflict and on various war wounds., Results: The presence of a plastic surgeon proved to be essential in the care of war wounded, especially in delayed emergency and secondary care. The ortho-plastic treatment offered during these missions has proven to be effective in the reconstruction of limbs. These missions made it possible to introduce the induced membrane technique of Masquelet AC in Armenia. During our visit to the Yerevan burn center, we mentioned the very probable use of white phosphorus as an etiology in several of the cases analyzed., Conclusion: We relate the particular experience of civilian surgeons in the context of a modern armed conflict. The presence of a plastic surgeon proved to be indispensable in the care of war wounded and especially in their secondary reconstructions., (Copyright © 2021. Published by Elsevier Masson SAS.)

Objective: The main objective of this study was to evaluate the influence of L4-5 total disc replacement (TDR) positioning on functional outcome at the 2-year follow-up. The secondary objective was to assess its influence on sagittal balance., Methods: Prospective data were compiled for 38 single-level L4-5 ProDisc-O TDRs. Anteroposterior placement (APP) was the distance between the center of the implant and the center of the L5 endplate divided by the total length of the L5 endplate. This ratio was expressed as a percentage (APP 0%-49%, anterior off-centering; 50%, perfect centering; and 51%-100%, posterior off-centering). The patients were divided into 3 groups depending on the APP and using quartile values: group 1, anterior placement (APP 0%-46%); group 2, central placement (APP 46.1%-52%, the 2 central quartiles); and group 3, posterior placement (APP 52.1%-100%). The sagittal balance parameters assessed were overall lordosis, segmental lordosis, and pelvic incidence. Adequate lordosis was defined for each patient according to their pelvic incidence. The Oswestry Disability Index and visual analog scale (VAS) scores for back and leg pain were assessed., Results: The average APP was 48% (range 40%-64%). There were 10 patients in group 1, 18 in group 2, and 10 in group 3. There was a significant difference in functional outcomes among the 3 groups. APP influenced the VAS back (p = 0.04) and VAS leg (p = 0.05) scores. Group 1 consistently showed the highest performance scores. No significant association between APP and the sagittal balance parameters was found. Patients who had preoperative sagittal imbalance or those who significantly modified their balance after the surgery had the poorest outcomes., Conclusions: Disc prostheses at L4-5 seem to provide better functional outcome when they are positioned anteriorly to the center of the vertebral body.

Purpose: The aim of this study was to report on mid- to long-term results following large humeral tumoral resection and reconstruction with the induced-membrane technique in skeletally immature patients suffering from primary malignant bone tumours., Methods: A retrospective analysis identified all children who underwent the two stages of a humeral reconstruction using the induced-membrane technique for primary malignant humerus tumours between 2002 and 2020. Functional assessment was conducted by an independent observer using the Musculoskeletal Tumor Society (MSTS) scoring system for the upper limb. Radiological assessment was performed by two independent observers and the healing index was calculated (i.e., months/cm)., Results: Eight adolescents (5 osteosarcomas and 3 Ewing sarcoma), with a mean age of 14.2 years (SD = 2.7), were included. The mean length of the bone resection was 17.4 cm (SD = 3.8), and the mean delay of the resection and reconstruction stages was 9.4 months (SD = 4). The mean follow-up was 6.6 years (SD = 4.3). The mean MSTS score was 77.4% and the global average healing index was 1.04 months/cm (SD = 2.2). Four complications (i.e., prominence device, fracture, aseptic pseudarthrosis, radial palsy) and one local recurrence were observed in four patients, requiring four unplanned surgical procedures in three patients. One patient died fourteen years after the initial treatment due to a lung recurrence., Conclusion: The induced-membrane technique is an effective and safe alternative for reconstructing large humeral bone defects after tumour resection in adolescents. Although this is a two-stage technique, it gives good functional results comparable to other strategies found in the literature., Level of Evidence: IV., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)