BACKGROUND:Anterior cruciate ligament (ACL) injuries are common, yet little is known about the relationship between time from injury to reconstruction and biological characteristics at the femoral insertion site. This study evaluated whether longer time from ACL injury to reconstruction was associated with differences in vascularity and bone microarchitecture at the femoral ACL footprint. METHODS:In this observational cohort study with cross-sectional histological assessment, 60 adult patients (22-53 years) undergoing primary ACL reconstruction and 10 reference patients (55-65 years) undergoing total knee arthroplasty (TKA) were enrolled. A 4.5-mm femoral bone core was harvested from the ACL femoral footprint or an anatomically corresponding site in the TKA reference cohort. Specimens underwent histological analysis and CD34 immunohistochemistry. The primary outcome was microvessel density (MVD; vessels/mm²). Secondary outcomes included CD34-positive cell cluster density and osteocyte lacunar density, quantified separately in three predefined regions (articular, median, and cranial). Analyses included correlation analyses, mixed-model ANOVA, and exploratory subgroup analyses according to age and time from injury to surgery. RESULTS:Longer time from injury to surgery was associated with lower MVD and CD34-positive cluster density. Patients undergoing ACL reconstruction within 9 months of injury had higher mean articular-region MVD than those undergoing reconstruction after ≥9 months (2.96 ± 0.89 vs 0.40 ± 0.96 vessels/mm²; p = 0.014). Osteocyte lacunar density was also associated with time from injury to surgery. Exploratory age-stratified analyses suggested that the magnitude of some associations may vary according to age. Smoking was associated with lower vascular parameters, with smokers demonstrating lower mean vessel density than non-smokers (2.6 vs 3.4 vessels/mm²; p = 0.032). CONCLUSIONS:Longer time from ACL injury to reconstruction, particularly intervals exceeding 9 months, was associated with lower vascular and bone microstructural parameters at the femoral insertion site. Exploratory subgroup analyses suggested potential age-related differences, while smoking was also associated with lower vascular parameters. These findings indicate that prolonged time from injury to surgery may be accompanied by differences in the local biological environment; however, the cross-sectional design precludes causal inference, and the relationship between these histological findings and postoperative graft performance remains uncertain. LEVEL OF EVIDENCE:III; cohort study with histological evaluation.
INTRODUCTION:The management of chronic prosthetic hip joint infection is complex, typically requiring prolonged antibiotic therapy in combination with complete prosthesis exchange, performed either in a single stage or in two stages. However, the removal of a well-osseointegrated prosthetic component carries significant surgical risks that may adversely affect the outcome of the therapeutic strategy. The partial exchange strategy, understood as the removal of a single prosthetic component while retaining the well-integrated one, has emerged as an alternative approach for the management of selected chronic prosthetic hip joint infections. The primary objective of this study was to review the available evidence on partial prosthetic exchange for the management of chronic hip prosthetic joint infection (PJI). PATIENTS AND METHODS:Studies evaluating partial prosthetic exchange as a treatment for chronic hip prosthetic joint infection up to February 2025 were included. The search terms used were "management prosthetic infection", "partial joint arthroplasty", "retention of well-fixed stem" and "partial exchange". The search was conducted using databases such as PubMed and Ovid. Studies involving other joints, partial prostheses, or cases of acute or hematogenous infection were excluded. RESULTS:Twenty-one studies with chronic prosthetic hip infection treated with partial exchange were included (319), most published between 2009 and 2025 and all studies were retrospective. The mean age was 63.1 (SD7 years). A two-stage strategy predominated (250 PJIs, 78.4%) compared to one-stage procedures (69 PJIs, 21.6%). Among monomicrobial infections, Gram-positive bacteria were the predominant pathogens (202 cases, 74.7%), with coagulase-negative staphylococci and Staphylococcus aureus being the most frequently isolated microorganisms. The mean time between surgeries was 18.2 weeks (SD 11.9), with substantial heterogeneity in antibiotic regimens. The mean follow-up was 4.9 years (SD 2.0). The overall success rate was 89.3% in the intention-to-treat analysis (285 cases), similar to the per-protocol analysis (89.2%, 281 cases). Two-stage partial exchange showed a higher success rate (90.4%; 226 PJIs) than one-stage procedures (85.5%; 59 PJIs). A total of 34 failures were reported, frequently associated with Staphylococcus spp. (14 PJIs; 41.2% of the failures). Functional outcomes, when reported, showed improvement after the procedure, although this information was not systematically provided across all studies. DISCUSSION:Partial exchange may be a viable strategy for managing chronic prosthetic hip joint infection in a selected group of patients, specifically those with a well-fixed prosthetic component. Removing this component is associated with intraoperative and postoperative complications that may compromise joint stability and function. However, the heterogeneity of the studies limits the establishment of clear patient selection criteria. Further studies with higher-quality and larger populations are needed. LEVEL OF EVIDENCE:IV.
BACKGROUND:Native knee septic arthritis is commonly treated arthroscopically with the primary aim of infection eradication. However, the incidence of postoperative knee stiffness and the need for subsequent surgical procedures after successful treatment remain poorly defined. HYPOTHESIS:We hypothesized that, despite successful infection control, postoperative stiffness and the need for secondary surgical procedures represent frequent and clinically significant complications after arthroscopic treatment of native knee septic arthritis. METHODS:A retrospective single-centre cohort study was conducted including adult patients treated arthroscopically for culture-confirmed native knee septic arthritis between 2013 and 2022. Postoperative stiffness was defined as knee flexion ≤90 ° and/or extension deficit ≥10 ° at 1 year after infection eradication. Range of motion was assessed using standardized clinical goniometric measurements. Secondary outcomes included aseptic reoperations, arthrolysis, conversion to total knee arthroplasty, and Knee injury and Osteoarthritis Outcome Score (KOOS-12). Associations between patient-, infection-, and surgery-related variables and outcomes were analysed. RESULTS:Eighty-two patients met the inclusion criteria. Seventy-four had available 1-year follow-up data and were analysed for the primary outcome. Among these 74 patients, mean follow-up was 45.5 ± 28.4 months (range, 12-123). At 1 year, 45/74 patients (60.8%) met at least one stiffness criterion. Flexion ≤90 ° and extension deficit ≥10 ° occurred in 27/74 (36.5%) and 22/74 (29.7%), respectively. Mean flexion was 105.9 ° ± 16.8 (range, 60-130), and mean extension deficit was 4.9 ° ± 5.3 (range, 0-20). Aseptic reoperation was required in 28/74 patients (37.8%), including arthrolysis in 15/74 (20.3%) and total knee arthroplasty in 7/74 (9.5%). Kaplan-Meier aseptic-reoperation-free survival was 77.0% (95% CI, 65.7-85.0) at 12 months and 60.6% (95% CI, 48.1-70.9) at 45 months. Final KOOS-12 was significantly lower in patients with stiffness than in those without stiffness (65.3 ± 17.3 vs 80.0 ± 15.5; p < 0.001). CONCLUSION:Postoperative stiffness is a frequent and clinically relevant complication following successful arthroscopic treatment of native knee septic arthritis. Successful infection eradication was not systematically synonymous with complete functional recovery, and secondary surgery was frequently required during follow-up. LEVEL OF EVIDENCE:Level IV, retrospective cohort study.
INTRODUCTION:Distal femur fractures are common in the geriatric population with a concurrent high risk of mortality. When treating these injuries, surgeons consider interfragmentary strain at the fracture site an important variable due to its large influence on the potential for fracture healing. The lateral condylar plate is a common implant used to fix distal femur fractures. Modulating different properties of the lateral condylar plate has the potential to change the interfragmentary strain. Our primary research question was therefore whether fracture-site strain in osteoporotic distal femur fractures stabilized with lateral condylar plates was significantly different with solid versus cannulated distal block screws during axial loading. We hypothesized that cannulated screws or solid screws used in the distal fracture fragment may affect fracture site strain. METHODS:We performed finite element analysis of a femur model with concurrent synthetic femur validation of cannulated screws and solid screws in the distal fracture fragment (n = 5 trials each). The cortical bone and trabecular bone sections of the virtual femur were split into two different sections with unique material properties. Femur constructs were loaded vertically axially with body weight (80 kg patient with 784 N), both in the finite element analysis and synthetic femur trials. Differences between cannulated and solid screw groups were assessed. RESULTS:The finite element simulations were determined to be valid, with no significant difference between the finite element analysis and synthetic femur trials in the cannulated screw scenarios (p = 0.076) or the solid screw scenarios (p = 0.25). In both the synthetic femur trials and finite element analysis trials, we found no significant difference between the cannulated screw and solid screw scenarios (p = 0.96). CONCLUSION:No difference in distal femur fracture interfragmentary strain was found between lateral condylar plates with solid and cannulated screws in the distal block during axial loading. LEVEL OF EVIDENCE:N/A; Study type: Biomechanical.
PURPOSE:To determine whether postoperative coronal plane alignment of the knee (CPAK) phenotype influences mid-term clinical and sport-related outcomes after high tibial osteotomy (HTO) for medial compartment osteoarthritis and varus alignment. Secondary objectives were to analyse CPAK phenotype switching patterns and to evaluate joint line convergence angle (JLCA) behaviour following correction. METHODS:Patients undergoing high tibial osteotomy were retrospectively reviewed at a minimum follow-up of 2 years. Postoperative CPAK phenotype was defined based on mechanical axis alignment and joint-line orientation, and phenotype switching was assessed by comparing pre- and postoperative classifications. Clinical outcomes were evaluated using the WOMAC score, Tegner activity scale, and modified Weiss score. JLCA behaviour was analysed in relation to postoperative alignment, CPAK phenotype, and phenotype switching. RESULTS:At a mean follow-up of 7.5 years, no significant differences in WOMAC, Tegner, or modified Weiss scores were observed across the most frequent postoperative CPAK phenotypes or between knees achieving neutral versus valgus alignment. CPAK phenotype switching occurred in more than 90% of cases and was not associated with differences in clinical or sport-related outcomes. JLCA demonstrated heterogeneous postoperative behaviour; ΔJLCA showed a weak association with ΔMPTA (R2 = 0.052, p = 0.006) and no meaningful relationship with postoperative HKA, final MPTA, or postoperative CPAK phenotype. CONCLUSION:Postoperative CPAK phenotype and phenotype switching were not significantly associated with mid-term clinical or sport-related outcomes after high tibial osteotomy. Clinical improvement was primarily associated with correction out of pathological varus, whereas coronal phenotype configuration and JLCA behaviour showed limited association with patient-reported outcomes. LEVEL OF EVIDENCE:III.
BACKGROUND:Septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) is a rare but serious complication with significant clinical and economic consequences. Presoaking ACL grafts in vancomycin has shown to reduce postoperative SA, but its effectiveness, cost-efficiency, and adoption in clinical practice remain debated. The objectives of this study were (1) to report the incidence of SA after ACLR when using a vancomycin pre-soaked graft compared to a non-pre-soaked graft, and (2) to conduct a cost-effectiveness analysis of this procedure based on healthcare costs in France. HYPOTHESIS:Vancomycin graft presoaking would represent a cost-effective preventive strategy within the French healthcare system. PATIENTS AND METHODS:A retrospective multicenter study was conducted using the Francophone Society of Arthroscopy (SFA) registry, including primary and revision ACLR performed between November 2021 and April 2024. A total of 3,278 patients were included, of whom 2,993 (91.3%) received vancomycin-soaked grafts and 285 (8.7%) received non-soaked grafts. Postoperative complications at 6 months, including septic arthritis, were recorded. A cost-effectiveness analysis compared both strategies using the observed registry infection rate in the vancomycin group together with a literature-derived baseline infection rate and French healthcare cost estimates. RESULTS:Two cases of SA (0.07%) were identified in the vancomycin group. There was no difference between the two groups in term of SA rates (p = 1.00). Cost-effectiveness analysis demonstrated that vancomycin presoaking was a dominant strategy, with lower expected costs. Based on the assumptions of the economic model, the number needed to treat to prevent one septic arthritis was estimated at 556 patients. DISCUSSION:Vancomycin graft presoaking was associated with a very low rate of postoperative septic arthritis and appeared to be a cost-saving preventive strategy in the economic model. However, the study was not powered to demonstrate a difference in infection rates between groups. LEVEL OF EVIDENCE:III; retrospective comparative study.
BACKGROUND:Primary bone sarcomas - osteosarcoma, Ewing sarcoma, and chondrosarcoma - are rare malignant tumours with insufficient public awareness. Infodemiology through Google Trends (GT) enables analysis of population-level interest in these entities over time. No French analysis covering a long observation period has been published. This study addresses three specific questions: (1) Is celebrity-driven media exposure the primary driver of public online interest in bone sarcomas? (2) Do Sarcoma Awareness Month campaigns (July) generate a measurable increase in search volume? (3) Is there a quantifiable lexical gap between lay and expert terminology, and what are its implications? METHODS:Monthly GT data (June 2006 - June 2026, n = 241 months) were extracted using both "terms" and "topics" modes for five query groups: osteosarcoma, Ewing sarcoma, sarcoma (generic term), chondrosarcoma, and lay terminology ("bone cancer", "bone tumour"). Secular trends were analysed by linear regression, the July effect by Mann-Whitney test, and inter-entity correlations by Spearman coefficient, with multiplicity correction using the Benjamini-Hochberg false discovery rate (FDR) procedure. RESULTS:Lay terminology generated a median Search Volume Index (SVI) of 56 [51-60] versus 14 [11-18] for osteosarcoma, 8 [2-11] for Ewing sarcoma, and 4 [3-5] for chondrosarcoma (×13 gap vs chondrosarcoma). The osteosarcoma series showed a sustained high-volume period temporally associated with the media trajectory of Xana Martínez (peak ×7.1 above baseline, August 2019); as Google Trends measures online search behaviour rather than direct campaign or media exposure, these associations remain descriptive. Ewing sarcoma showed the strongest secular trend (R² = 0.253). No July effect was significant after FDR correction for any group (all q ≥ 0.373). All inter-entity sarcoma correlations were significant (q < 0.001). Two of four lay-sarcoma correlations were non-significant (ρ = -0.142 to -0.124, NS); Ewing sarcoma and generic sarcoma each showed a significant negative correlation with lay terminology (ρ = -0.265 and -0.153 respectively, both q < 0.05). DISCUSSION:Public interest in bone sarcomas over twenty years has been structured by celebrity events rather than institutional campaigns. The lexical gap (×13 vs chondrosarcoma, ×4.0 vs osteosarcoma) and the near-invisibility of chondrosarcoma have direct implications for NETSARC + communication strategy and diagnostic delay reduction. LEVEL OF EVIDENCE:IV; Retrospective observational study (analysis of publicly available data).
INTRODUCTION:While mechanical alignment (MA) has long been the gold standard in total knee arthroplasty (TKA), functional alignment (FA) has recently emerged as a promising alternative, particularly with the advent of robotic-assisted techniques. Despite its growing adoption in clinical practice, comparative evidence between functional and mechanical alignment remains limited, especially for postero-stabilized (PS) TKA. The present study means to compare mechanical and functional alignment in TKA in terms of patient-reported and functional outcomes at a minimum of one year follow-up. HYPOTHESIS:Functional alignment would result in superior functional outcomes compared to mechanical alignment in total knee arthroplasty, without compromising perioperative safety. METHODS:This single-center, retrospective cohort study included 172 patients undergoing primary TKA performed by the same surgeon between 2016 and 2024. Following a 1:1 propensity score matching, patients receiving MA-TKA with navigation (n = 86) were compared with those receiving FA-TKA with robotic assistance (n = 86). The primary outcome was the rate of persistent pain (VAS ≥ 4/10) at six months. Secondary outcomes included validated patient-reported outcomes (PROs), operative time, hospital stay, and complications. RESULTS:At six months, the prevalence of persistent pain was comparable between groups (MA: 15.1%, FA: 19.8%; p = 0.55). At one-year, PROs were similar across all metrics (p > 0.05), although the FA group consistently demonstrated numerically superior scores. Two isolated WOMAC items (pain and difficulty walking on a flat surface; both p = 0.02) favored the FA group. Operative time (101.7 ± 16.7 vs 119.6 ± 16.0 min; p < 0.01) and hospital stay (7.7 ± 2.0 vs 9.2 ± 3.8 days; p < 0.01) were significantly shorter in the FA group. Complication and revision rates were low and not significantly different between groups. As the two cohorts also differed in surgical technology and treatment era, these perioperative findings should be interpreted as exploratory and not necessarily attributable to alignment strategy alone. CONCLUSION:Functional alignment in robotic-assisted TKA resulted in pain and functional outcomes comparable to mechanical alignment with computer navigation, without demonstrating clinical superiority. Perioperative differences (operative time and hospital stay) were observed but may reflect differences in technology and treatment era rather than alignment strategy alone. These findings support the safety of functional alignment as an individualized alternative to mechanical alignment in contemporary TKA. LEVEL OF EVIDENCE:III; comparative retrospective investigation.
BACKGROUND:Many authors have highlighted the importance of assessing spinal alignment and mobility during total hip arthroplasty (THA), particularly regarding acetabular positioning. However, few studies have investigated the impact of spinal morphology on pelvic mobility from the standing to supine positions at the time of THA, performed via a direct anterior approach. The study aims to analyse this relationship in preoperative patients and its implications for planning acetabular anteversion. METHODS:This retrospective study included 93 patients who underwent THA between January 2021 and December 2022, using 3D CT-based planning and a preoperative EOS image in the standing position. The following parameters were measured: sacral slope (SS), pelvic incidence (PI), pelvic tilt (PT), and lumbar lordosis (LL). These measurements were taken from EOS (standing) and scout view (supine). Spinal morphology was classified according to the modified Roussouly classification. RESULTS:The mean SS was significantly higher in the supine position compared to the standing position (46° (SD 8°) vs. 41° (SD 8°); p < 0.001). The mean difference in sacral slope (SS) between these two positions was 4.2° (-12° to 17°, SD 6.1°). The SS increased significantly in 56% of patients, remained unchanged in 35%, and decreased in 9%. An anterior pelvic tilt when moving to the supine position was observed in patients with Roussouly type 1 and type 3 spinal morphologies (p < 0.01), whereas patients with Roussouly type 3A and type 4 morphologies showed no significant change in SS between the standing and supine positions. CONCLUSION:Contrarily to the other groups who experienced an anterior pelvis tilt when moving from standing to supine, in patients with Roussouly types 3A and 4, the pelvis orientation and consequently the acetabular anteversion remained unchanged. A paradoxical posterior pelvic tilt was observed in 9% of patients (mainly DDH), resulting in increased functional acetabular anteversion and a potentially higher risk of anterior dislocation. In these patients, a reduction in cup anteversion may be considered during THA. LEVEL OF EVIDENCE:IV; prospective cohort study.
Hip resurfacing (HR) is an alternative to total hip arthroplasty in young, active patients; however, improper femoral implant positioning may increase failure risk. This study evaluated the feasibility and accuracy of custom guides for femoral cup positioning during HR via the direct anterior approach (DAA). Although custom guides have been used with other surgical approaches, their use via DAA has not been reported. Six patients underwent HR using preoperative 3D planning to align the femoral cup with the native femoral neck axis and avoid notching. Custom tripod-type guides were designed for medial femoral neck positioning. Radiographs assessed coronal neck-shaft angle (F-NSA) and profile (P-NSA) neck-shaft angles. No adverse events occurred. Implant sizes matched planned components except in one case requiring a larger cup. Median differences from planned values were -2 ° (range, -3.7 ° to 0.5 °) for F-NSA and 0 ° (range, -3 ° to +3 °) for P-NSA. No femoral notching occurred. Custom guides for HR via DAA are feasible and provide accurate positioning. LEVEL OF EVIDENCE: IV; prospective cohort study.
BACKGROUND:Mastering pelvic radiographic views and percutaneous fixation techniques is a critical skill for young orthopedic surgeons, yet the learning curve remains steep due to the anatomical complexity of the pelvis and the limited exposure during training. Simulation-based training enhances technical proficiency within a safe and reproducible environment. By enabling risk-free practice, it accelerates the learning curve and optimizes surgical education. OBJECTIVE:To compare learning curves between junior and senior surgeons and to assess performance progression over training sessions. HYPOTHESIS:Simulator-based training improves accuracy, efficiency, and radiation exposure in percutaneous pelvic fixation, with a greater effect in junior trainees. MATERIAL AND METHODS:Eight participants, four junior residents and four senior trainees experienced in fluoroscopy-guided percutaneous techniques, were assessed over 6-8 simulation sessions between May 2024 and February 2025. Each session included: (1) S1 iliosacral screw fixation, (2) antegrade anterior column screw placement, and (3) supra-acetabular (LC2) screw fixation. Outcome measures included: screw progression in the bone corridor (%), cortical breach (yes/no), number of wire repositioning, operative time (sec), and radiation exposure (mGy). All participants completed the training protocol. RESULTS:Juniors showed a marked reduction in operative time and radiation dose for sacroiliac screw placement (522 ± 100 s to 205 ± 87 s; and 19.8 ± 5.9 mGy to 9.8 ± 2.4 mGy, respectively; p < 0.01), and similar improvements were observed for LC2 fixation. Accuracy increased across all procedures in the junior group, particularly for anterior column screw placement (38%-94%). Seniors exhibited limited improvement, with a modest decrease in radiation exposure for S1 screw fixation only. Learning curves for all participants demonstrated rapid improvement during the first four sessions, followed by a plateau phase. Mean radiation exposure progressively decreased in juniors, whereas it remained stable in seniors. No statistically significant differences were observed between groups for final performance metrics. DISCUSSION:Simulation-based training improved efficiency and accuracy across all screw placements. The progression was especially notable in less experienced participants, who achieved performance levels comparable to those of more experienced surgeons. CONCLUSION:Percutaneous pelvic fixation can be effectively taught through simulator-based training. Junior residents benefit the most, showing rapid improvement in technical accuracy and procedural efficiency. These findings support the integration of simulation into early surgical training programs for pelvic trauma. LEVEL OF EVIDENCE:III; Non-randomized prospective comparative study.
AIMS:Persistent pain after total knee arthroplasty (TKA) remains a major cause of patient dissatisfaction despite satisfactory surgical results. The primary objective was to identify psychological predictors of persistent pain. Several studies have investigated psychological predictors of postoperative pain, but few prospective studies have simultaneously evaluated psychological factors alongside clinical, radiological, and surgical parameters. Therefore we performed a prospective investigation aiming: (1) to identify psychological predictors of persistent pain, (2) to evaluate the relationship between psychological factors, postoperative pain, patient satisfaction, and functional outcomes at one year. HYPOTHESIS:We hypothesized that preoperative psychological factors would be independently associated with pain one year after primary TKA. METHODS:This prospective monocentric study included 111 consecutive patients undergoing primary TKA for knee osteoarthritis between February 2022 and May 2024. Preoperative evaluation included demographic and clinical data, psychological assessment using the Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), and Amsterdam Preoperative Anxiety and Information Scale (APAIS), as well as neuropathic pain screening. Radiological parameters and perioperative surgical variables were collected. Persistent pain was defined as a numeric rating scale (NRS) score ≥4 at one year, corresponding to at least moderate pain intensity. Functional outcomes and patient satisfaction were recorded at one year. Variables with p < 0.20 in univariate analysis were entered into multivariate logistic regression models. RESULTS:A total of 111 patients were analyzed, of whom 28 (25.2%) reported persistent pain at one year. In multivariate analysis, a higher number of medical comorbidities (OR 1.74, 95% CI: 1.10-2.77 (p = 0.019)) and preoperative pain catastrophizing (PCS > 30) (OR 4.94, 95% CI: 1.60-15.25 (p = 0.005)) were independently associated with persistent pain. Radiological alignment and surgical variables were not associated with residual pain. CONCLUSION:Preoperative psychological factors, particularly pain catastrophizing, are independently associated with persistent pain after TKA and with poorer clinical outcomes. Integrating psychological evaluation into preoperative assessment may improve patient selection and perioperative management. LEVEL OF EVIDENCE:III; prospective observational cohort study.
INTRODUCTION:Developmental dysplasia of the hip (DDH) often affects young, active patients and can lead to early osteoarthritis. Periacetabular osteotomy (PAO) is a joint-preserving surgery to reorient the acetabulum and delay arthritis. The impact of PAO on return to sports and the factors influencing return to sport or patient satisfaction remain insufficiently documented. Therefore we performed a retrospective investigation aiming to: 1) evaluate the rate of return to sport after PAO, 2) identify factors associated with return to sport, patient satisfaction, and the achievement of a patient-acceptable symptom state (PASS). HYPOTHESIS:PAO allows return to sport at a rate exceeding 80%. MATERIAL AND METHODS:We reviewed a consecutive series of 43 hips in 42 patients who underwent PAO between 2012 and 2020 at a single center. Data were collected prospectively and analyzed retrospectively. The mean age at surgery was 29.7 ± 9.7 years (range, 13-52), with 35 (83%) women. All patients met inclusion criteria of symptomatic hip dysplasia painful groin symptomatology with a LCEA < 25° and Tönnis grade ≤1 osteoarthritis. Clinical outcomes were assessed preoperatively and at last follow-up using patient-reported outcome measures (UCLA, mHHS, HOOS). Patients were surveyed about their return to sports (three‑level, referenced to the pre‑symptom level) and rated their satisfaction (5‑level Likert‑type item). Acceptable symptomatic status (PASS) was defined as reaching threshold scores. Complications were graded with a hip‑adapted Clavien-Dindo scheme. Radiological analysis included LCEA and Tönnis angles pre- and postoperatively, as well as the evolution of osteoarthritis according to the Tönnis classification. Native hip survivorship was estimated using the Kaplan-Meier method, with conversion to, or formal listing for, total hip arthroplasty (THA) defined as the endpoint. RESULTS:At last follow-up (mean follow-up 3.8 years, range 2-12), PROMs improved substantially. UCLA, mHHS and HOOS scores increased from 6.7 ± 1.1 to 8.5 ± 1.3, from 55.9 ± 18.4 to 80.9 ± 14.6 and 49.5 ± 18.5 to 80.9 ± 14.6 respectively (p < 0.001). In total 39/43 patients (91%) returned to sports (22/43 (52%) at a level higher than pre‑op but below pre‑symptom, 17/43 (40%) at the pre‑symptom level); 4/43 (9%) did not return. Return to sport was strongly associated with achieving acceptable symptom status (PASS), with 35/39 (89.7%) of patients returning to sports reaching the PASS threshold compared to 1/4 (25%) among those who did not (p = 0.01). Radiographic parameters did not emerge as significant independent predictors of clinical success in this cohort. No signal of accelerated radiographic deterioration was observed: preoperatively, 42 of 43 hips (98%) were Tönnis grade 0 or 1. Among the 24 hips with available radiographs at final follow-up, 20 out 24 (83%) maintained their preoperative Tönnis grade, with only 4 (17%) showing osteoarthritic progression. The Kaplan-Meier survival probability of the native hip at the mean follow-up of 3.8 years was 97.7% (95% CI: 93.2%-100%). DISCUSSION:PAO yielded a high short‑term return‑to‑sports rate with large, clinically meaningful PROM gains that align with satisfaction and PASS, with an overall return-to-sport rate above 90%. Limitations include retrospective design, non‑standardized records of sport discipline/exposure, use of non‑PAO‑validated PASS thresholds (used here as a comparability endpoint), and limited long‑term radiographic follow‑up. LEVEL OF EVIDENCE:IV; case series.
INTRODUCTION:Robot-assisted and computer-assisted hip arthroplasty rely on preoperative CT imaging and digital twins, but real-time intraoperative 3D imaging remains limited. Elliptical acquisition using a mobile cone-beam CT system could provide repeatable intraoperative 3D images with lower radiation exposure than conventional CT. HYPOTHESIS:Elliptical acquisition would provide accuracy and precision comparable to conventional CT for these measurements. MATERIALS AND METHODS:An isolated Sawbone pelvis with a previously implanted right total hip and a native left hip was imaged using a 2D/3D C-arm with elliptical acquisition and a conventional CT scanner. Four metallic markers were placed to define distances of interest. The primary endpoint was prosthetic femoral head diameter. Secondary endpoints were the sciatic spine-greater trochanter (SS-GT), pubic spine-greater trochanter (PS-GT), and anterior superior iliac spine-greater trochanter (ASIS-GT) distances. For each parameter, 10 repeated measurements were obtained on 5 acquisitions per modality and compared with 10 direct digital caliper measurements used as the reference standard. Accuracy was assessed as bias relative to the reference standard, and precision as the standard deviation of repeated measurements. Radiation dose was recorded as dose-area product (DAP). RESULTS:The reference prosthetic femoral head diameter was 28.08 mm (SD 0.06). Mean CT-based diameter was 28.18 mm (SD 0.29; bias +0.10), and mean elliptical diameter was 28.01 mm (SD 0.25; bias -0.07). For the SS-GT, PS-GT and ASIS-GT distances, mean biases of CT and elliptical measurements remained below 0.2 mm for all parameters. Elliptical measurements tended to show slightly lower bias and, for most distances, lower dispersion than CT. Mean DAP per acquisition was 7.62 × 10-5 Gy·m2 for CT and 5.48 × 10-5 Gy·m2 for elliptical acquisition. CONCLUSION:In this Sawbone model of hip surgery, intraoperative elliptical acquisition provided femoral head and marker distance measurements with accuracy and precision comparable to conventional CT, with slightly lower radiation exposure in this experimental setup. These preliminary findings support technical feasibility for intraoperative three-dimensional assessment, but clinical relevance remains to be established. LEVEL OF EVIDENCE:IV.
BACKGROUND:Transtibial pull-out repair is widely used for the treatment of medial meniscus posterior root tears (MMRTs). However, the optimal suture material remains unclear despite differences in biomechanical and biological properties between absorbable and non-absorbable sutures. This study aimed to evaluate whether suture material influences clinical and radiological outcomes after transtibial pull-out repair for MMRTs through a systematic review and meta-analysis. METHODS:This systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Eligible studies reporting clinical or radiological outcomes after transtibial pull-out repair for MMRTs were included. Extracted data included patient-reported outcomes, magnetic resonance imaging (MRI)-based meniscal healing, meniscal extrusion, Kellgren-Lawrence (KL) grade progression, and conversion to total knee arthroplasty (TKA). Random-effects meta-analyses and subgroup analyses were performed according to suture absorbability, and meta-regression was used to explore potential sources of heterogeneity. RESULTS:Sixteen studies encompassing 647 patients were included; these comprised one Level II study, seven Level III studies, and eight Level IV studies. No significant subgroup differences according to suture absorbability were identified for changes in International Knee Documentation Committee score (P = 0.07), Lysholm score (P = 0.43), meniscal extrusion (P = 0.19), MRI-based meniscal healing (P = 0.77), KL grade progression (P = 0.75), or conversion to TKA (P = 0.06). The pooled healing proportions were 0.60 (95% CI, 0.33-0.82) for non-absorbable sutures and 0.68 (95% CI, 0.00-1.00) for absorbable sutures. The corresponding pooled proportions of conversion to TKA were 0.05 (95% CI, 0.00-1.00) and 0.22 (95% CI, 0.10-0.38), respectively. CONCLUSION:The available evidence did not identify statistically significant differences in clinical or radiological outcomes between absorbable and non-absorbable sutures after transtibial pull-out repair for MMRTs. However, because these findings were derived primarily from indirect comparisons across heterogeneous studies, they should not be interpreted as evidence of equivalence, and the current evidence remains insufficient to determine whether suture absorbability independently influences postoperative outcomes. LEVEL OF EVIDENCE:IV; systematic review and meta-analysis of Level II-IV studies.
BACKGROUND:Terrible triad injury of the elbow (TTI) is usually managed surgically because of instability and the risk of poor outcomes. Recent reports suggest that a carefully selected subgroup with concentric reduction and satisfactory early stability may be managed nonoperatively. This study aimed to describe the long-term functional and radiographic outcomes of patients with TTI in whom nonoperative management was maintained and to identify the common characteristics of this selected subgroup. HYPOTHESIS:We hypothesized that, in carefully selected TTIs with stable concentric reduction and low-grade radial head and coronoid fractures, maintained nonoperative treatment may be associated with high long-term functional scores and limited radiographic degeneration. PATIENTS AND METHODS:This retrospective single-center case series included adult patients with TTI who were initially selected for nonoperative management between 2002 and 2022 and had at least 2 years of follow-up when available. Initial candidacy for nonoperative management required concentric reduction, no mechanical block, and fluoroscopic stability through a functional arc or to at least 30 degrees short of full extension. Among 17 patients initially selected for nonoperative treatment, 3 underwent acute-phase surgical conversion, 4 were lost to follow-up, and 2 declined participation, leaving 8 patients for final evaluation. Mayo Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), range of motion (ROM), and radiographic osteoarthritis graded with the Broberg-Morrey classification were assessed. RESULTS:Eight patients (7 men) with a mean age of 36.4 ± 7.7 years were evaluated at a mean 11.3 ± 7.4 years after injury. All had Mason type I-II radial head fractures and Morrey type I coronoid fractures. Among patients in whom nonoperative management was maintained, no delayed surgery was required. Mean MEPS was 96.3 ± 7.4, mean QuickDASH was 1.7 ± 2.3, and mean flexion was 128.8 ± 3.5 degrees. Radiographically, 7 patients had Broberg-Morrey stage 0 changes and 1 had stage I changes. DISCUSSION:In this highly selected subgroup, patients in whom nonoperative treatment was maintained had high functional scores, minimal pain, preserved motion, and limited radiographic degeneration at long-term follow-up. These data do not estimate the overall success rate of nonoperative treatment, because 3 of 17 initially selected patients underwent acute-phase surgical conversion. The findings should therefore be interpreted as descriptive and hypothesis-generating rather than as evidence of equivalence or superiority to surgery. LEVEL OF EVIDENCE:IV; retrospective case series.
French innovation has profoundly shaped the evolution of spinal surgery over the past fifty years. While many French contributions are now internationally recognized, few studies have explored their impact on the biomechanical understanding of the spine, the development of surgical techniques, or their broader implications. This review aims to trace France's contributions to advancing spinal physiology, deformity surgery, and spinal stabilization, while outlining future perspectives for the specialty. From a surgical standpoint, the work of Stagnara, Duval-Beaupère, Legaye, and Roussouly laid the foundation for modern concepts of sagittal balance and spinal alignment. Cotrel and Dubousset revolutionized scoliosis management by introducing the three-dimensional deformity model and segmental instrumentation. Meanwhile, Roy-Camille, Louis, Argenson, Onimus, and Marnay advanced spinal trauma surgery, surgical approaches, and instrumentation techniques. Technological innovations include EOS imaging, vertebroplasty, disc prostheses, PediGuard® pedicle guidance systems, preoperative planning tools, custom rods, and data analysis platforms. More recently, France has emerged as a key player in robotic surgery, artificial intelligence, personalized surgery, and surgical simulation. LEVEL OF EVIDENCE: V; Narrative review.
INTRODUCTION:Lateral extra-articular tenodesis (LET) has gained popularity as an adjunct to anterior cruciate ligament reconstruction (ACLR) in high-risk athletes, particularly when combined with hamstring tendon grafts. However, its added value compared with established graft options such as bone-patellar tendon-bone (BPTB) remains unclear. The purpose of this study was to compare the mid-term clinical, functional, and radiographic outcomes between isolated BPTB ACL reconstruction and hamstring tendon ACL reconstruction combined with LET in competitive soccer players. HYPOTHESIS:We hypothesized that the addition of LET within a surgical strategy combining hamstring tendon ACL reconstruction would not provide superior clinical outcomes nor reduce graft failure rates compared with isolated BPTB reconstruction. METHODS:This prospective cohort study included 140 competitive soccer players undergoing primary ACLR between 2018 and 2020: BPTB (n = 70) and hamstring tendon plus LET (n = 70), with a minimum follow-up of 5 years. Primary outcomes included International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner activity scale, graft failure, and reoperation rates. Secondary outcomes included objective knee stability, return to sport (RTS), and radiographic osteoarthritis. RESULTS:Both groups demonstrated significant improvements from baseline (p < 0.001 for all). At final follow-up, no significant between-group differences were observed in IKDC (87.1 vs 88.3; p = 0.48), Lysholm (91.5 vs 92.0; p = 0.62), or Tegner scores (7.8 vs 7.9; p = 0.71), with small and clinically non-meaningful differences (IKDC + 1.2 [95% CI, -2.1 to 4.5]). Graft failure occurred in 4/70 (5.7%) versus 6/70 (8.6%) (RR, 1.50; 95% CI, 0.45-5.01; p = 0.48), and reoperation rates were 8/70 (11%) versus 9/70 (13%) (RR, 1.13; 95% CI, 0.46-2.76; p = 0.34). Return-to-sport rates were comparable (60/70 [85.7%] vs 56/70 [80.0%]; p = 0.46). Side-to-side difference improved to 1.8 mm versus 1.7 mm (p = 0.92). Radiographic osteoarthritis (Kellgren-Lawrence grade 1-2) was observed in 12/70 (17.1%) versus 17/70 (24.3%) (p = 0.30). CONCLUSION:At mid-term follow-up, HT + LET did not demonstrate statistically significant superiority over isolated BPTB ACL reconstruction in clinical outcomes, knee stability, RTS, graft survival, reoperation, or radiographic osteoarthritis among competitive soccer players. As this was not an equivalence or non-inferiority study, smaller clinically relevant differences cannot be excluded. These findings should be interpreted as a comparison of two surgical strategies, rather than as evidence of the independent effect of LET. LEVEL OF EVIDENCE:III.
