Purpose of the study: We report the clinical and radiographic results of a series of revision total hip arthroplasties performed for aseptic loosening using a non-demented modular femoral implant (PP).

Material and methods: From 1991 to 2003, 146 revisions of total hip arthroplasty were performed using the same non-cemented modular femoral implant (PP). At mean nine years follow-up (3.5–17 years), 24 patients had died, 26 had insufficient data for review and 39 were lost to follow-up. The analysis thus included 54 cases. All revisions were performed for aseptic loosening. Mean age at surgery was 60 years. Preoperative bone damage, according to the Sofcot classification, was grade I and II (69%), grade III (26%), grade IV (5.5%). Clinical outcome was assessed with the Harris and Postel-Merle-d’Aubigné scores. The radiological review analysed stem anchoring, lucency and periprosthetic reconstruction.

Results: At mean nine years follow-up, the mean Harris score was 71 points, the mean PMA score 12.8 points. Patient satisfaction was 70%. There were five cases with deep infection (9%), five with dislocation and six intra-operative periprosthetic fractures. Trochanterotomy non-union was noted in 26% of patients. Mean impaction of the femoral stem was 5 mm (range 0–16 mm). There was a statistically significant association between the degree of bone damage and the quality of the bone reconstruction (p=0.012). Mean increase in cortical thickness in zones 1 and 2 (Gruen) was 1.1 mm and 1.6 mm respectively. In Gruen zones 2 and 6, the gain was 6 and 10 mm respectively. There were nine surgical revisions (17%) for deep infection (n=4), recurrent aseptic loosening and fracture of the femoral implant (n=1). The ten-year survival taking aseptic loosening as the endpoint was 90%.0

Discussion and Conclusion: Our work showed the good long-term results obtained with this implant for revision total hip arthroplasty. It allows clinical improvement, periprosthetic bone reconstruction and a low rate of surgical revision.

Purpose of the study: Correct implant position is one of the factors of long-term success of total hip arthroplasty (THA). Acetabular architectural defects caused by trauma can create difficult situations leading to potential complications and poor outcome. The purpose of this study was to examine retrospectively the results of THA implanted after fracture of the acetabulum treated surgically. The objective was to analyse the specific features and search for factors favouring poor outcome.

Material and method: The series included 43 patients who had a THA implanted after treatment of an acetabular fracture. Mean age at trauma was 44.5 years (range 16–87). Five patients had a THA immediately, mean age 75 years (63–87). Thirty eight patients had osteosynthesis. According to the Letournel classification, the fracture was elementary in 12 cases and complex in 26. In ten patients, there was residual joint incongruence measuring more than 2 mm after osteosynthesis. The hips evolved to degenerated joint (n=34) and or necrosis (n=10).

Results: Mean time from acetabular osteosynthesis to THA was 94.6 months (range 3–444), excluding those patients whose THA was implanted at the time of the osteosynthesis. Arthroplasty required removal of the osteosynthesis material (n=11), insertion of a supportive ring (n=14) associated with a bone graft (n=13). The acetabular implant was considered to be well positioned according to the Pierchon criteria in 16 hips and was lateralised (n=21) and/or ascended (n=17) in the other hips. Inclination was 42.8 on average, range 10–18. The five-year survival was 80%.

Discussion: Arthroplasty after surgical treatment of an acetabular fracture is a difficult procedure. Complementary procedures are often necessary complicating the surgery and increasing the risk of perioperative complications, particularly infection. It is difficult to position the acetabular implant, increasing the risk of postoperative instability and early loosening. This study demonstrated the difficulties of implanting a THA in this context where the revision rate is significantly higher than in first-intention THA.

Purpose of the study: We conducted a retrospective study of 66 cases of non-traumatic osteonecrosis of the femoral head by percutaneous drilling and autograft. This technique associated drilling with graft conductor effects and bone marrow inducers.

Material and Methods: Forty-six patients (41 male, 5 female) with non-traumatic osteonecrosis were included in this study. Mean age at surgery was 46 years (22–68). The 66 cases involved 32 right hips and 34 left hips (21 bilateral cases), six asymptomatic. Osteonecrosis was related to corticosteroid therapy (n=17), chronic ethylism (n=14), dyslipidaemia (n=7), barotraumatism (n=3), and renal transplantation (n=1). Four were found idiopathic. The preoperative ARCO classification was: 8 stage IIA, 21 stage IIB, 15 stage IIC, 7 stage IIIB, 13 stage IIIC and 2 stage IV. A minimally invasive surgical technique combined simple percutaneous drilling with a cancellous iliac bone graft harvested percutaneously homolaterally. Metaphyseal grafts were excluded from this analysis. Minimum postoperative follow-up was two years. The main outcome was rate of prosthesis conversion at two years.

Results: Considering all stages, 38 hips did not have a total prosthesis at two years (58% success) with a mean follow-up of 40 months (25–65). Twenty-eight hips had total prosthesis at two years (42% failure) with mean follow-up of 11 months (3–23). Mean survival was 29 months (3–65) with stabilisation of the initial lesions in 50% of hips. For the 44 stage II hips, success was achieved in 28 (64%). The success rate for stages IIA and IIB was 70% with mean follow-up of 29 months (19–65). For the 20 stage III hips success was achieved in nine (45%), with 30% for stage IIIB and 54% for stage IIIB and mean follow-up of 21 months (12–45). There were no cases of mechanical complications. One superficial skin infection cured favourably.

Discusssion and conclusion: Subchondral fracture (stage III) and necrosis volume > 30% appear to be unfavourable factors for outcome with this technique. There are other conservative treatments but all with technical difficulties or cost considerations despite sometimes questionable results. This technique is simple and very attractive. In one hand, it combines the advantages of the decompression-effect for the local vascularization with the bone inducer effect of the marrow auto-graft. And in the other, it is a non-invasive and conservative procedure which does not modify the morphology of the upper extremity of the femur and does not jeopardize a future total hip replacement. This is a reliable technique which merits confirmation with a larger series. The best indication remains stage IIA and IIB.

Introduction: The minimally invasive posterior approach has become a standard for total hip replacement (THR) but the interest for the other minimally invasive approaches has not waned in any way. We carried out a prospective and comparative study in order to analyse the interest of the anterolateral minimal invasive (ALMI) approach in comparaison to a minimally invasive posterior (MIP) approach for THR.

Material and method: We carried out a prospective and comparative study. A group of 35 primaries THR with large head using the ALMI approach, as described by Bertin and Röttinger, was compared to a group of 43 primaries THR performed through the MIP approach. The groups were not significantly different with respect to age, sex, bony mass index, ASA score, Charnley class, diagnoses and preoperative Womac index and PMA score. The preoperative Harris hip score was significantly lower in ALMI group. Early functional results have been evaluated thanks to Womac index and modified Harris hip score at 6 weeks, 3 and 6 months. A p value < 0.05 has been considered as significant.

Results: The duration of surgical procedure was longer and the calculated blood loss more important in ALMI group (respectively p=0.045 and p=0.07). The preoperative complications were significantly more frequent in this group with 4 greater trochanter fractures, 3 false routes, 1 calcar fracture, and 2 metal back bascules versus one femoral fracture in MIP group. Other postoperative data (implant positioning, morphine consumption, length of hospital stay, type of discharge) were comparable. The early functional results at 6 weeks, 3 and 6 months were also comparable. No other complication has been noted during the first 6 months in the two groups.

Discussion and Conclusion: The ALMI approach uses the intermuscular interval between the tensor fascia lata and the gluteus medius. It leaves intact the abductors muscles and the posterior capsule and short external rotators. The early clinical results are excellent despite of the initial complications related to the initial learning curve for this approach and the use of the large head with metal-on-metal bearing. The stability of the arthroplasty and the absence of muscular damage should permit to accelerate the postoperative rehabilitation in parallel with less preoperative complications after the initial learning curve.

Purpose of the study: Percutaneous compressive plating (PCCP) enables minimally invasive surgery using closed focus technique. We report a prospective consecutive series of 67 fractures (December 2003 – February 2005) followed to bone healing.

Material and methods: Mean patient age was 83 years (range 37–95) with 83% females in a frail population (ASA 3, 4). Two-thirds of the patients had unstable fractures (AO classification) which were reduced on an orthopedic table under fluoroscope. Two minimal incisions were used to insert the material without opening the fracture and without postoperative drainage. Blood loss was noted. Verticalization and weight bearing were encouraged early depending on the patient’s status but were never limited for mechanical reasons. Patients were reviewed at 2, 4 and 6 months.

Results: Anatomic reduction was achieved in 84% of hips, with screw position considered excellent for 45, good for 14, and poor for 6. There were no intraoperative complications. The material was left in place. The hemoglobin level fell 2.2 g on average. Mean operative time was 35 minutes and the duration of radiation exposure 60 seconds. Mean hospital stay was 13 days. General complications were: urinary tract infections (n=10), phlebitis (n=2), talar sores (n=5). Gliding occurred in three cases (4%) with telescopic displacement measuring less than 10 mm in ten cases. There were two varus alignments with no functional impact. There were four deaths within the first three weeks. All fractures healed within three months.

Discussion and conclusion: PCCP has its drawbacks (mechanical, stabilization) as do all osteosynthesis methods used for trochanteric fractures. The technique is reliable and reproducible and is indicated for all trochanteric fractures excepting the subtrochanteric form. PCCP has the advantage of a closed procedure with a minimal incision and limited blood loss for a short operative time. An advantage for this population of elderly frail subjects (ASA 3, 4). PCCP enables immediate treatment with a low rate of material disassembly compared with other techniques.

Purpose: Improved surgical technique and facilities enable emergency salvage of very damaged limbs. Functional outcome after this type of conservative treatment is generally satisfactory but at the risk of more or less quiescent osteitis. In the event of chronic osteitis, the neighbouring skin can undergo malignant degeneration (squamous-cell carcinoma). The purpose of our work was to report three such transformations and discuss therapeutic indications.

Material and methods: The study series included three patients with chronic osteitis of the tibia after trauma. During surveillance, several years later we observed changes in local signs: increasing pain, purulent discharge and bleeding (Rowlands triad). In each patient, biopsy led to the diagnosis of transformation to squamous-cell carcinoma. All patients were treated by above knee amputation.

Results: Outcome was satisfactory with an excellent quality scar formation. The search for extension was still negative a three years follow-up.

Discussion: The frequency of carcinomatous degeneration near zones of chronic osteitis varies depending on the series to 0.2% to 1.7%. This is in sort the cost of conservative treatment. Changes in the clinical presentation, Rowland’s triad, associated with modification of the bacterial flora and development of a nauseous odour are important signs which should be followed by a biopsy. The treatment of choice for most authors is amputation in order to increase patient survival.

Conclusion: The desire to pursue conservative reconstruction surgery even in the most difficult cases should not mask the risk of potential malignant transformation. Secondary amputation should not be considered as a failure in these extreme clinical situations.

Purpose: Prevention of post-trauma infections is basically aimed at streptococcal, staphylococcal and anaerobic germs. An increasing number of open fractures are however contaminated with Bacillus cereus leading to a multidisciplinary discussion involving infectious disease specialists, orthopaedic surgeons, and bacteriologists concerning the appropriate management. Bacillus is an ubiquitous genus of sporulated telluric Gram positive germs found in soil and plants. B. cereus can lead to local wound infection. This environmental (including hospital) bacterium is often a temporary host of the skin flora and its isolation can be taken as a simple contamination with no therapeutic consequence. B. cereus is sensitive to fluoroquinolones.

Material and methods: Between August 1995 and December 2000, B. cereus was isolated in 41 patients from surgical specimens taken from deep muscle and bone tissues. Ordinary medium was used for culture. Genomic analysis was used to type the Bacillus. Statistical analysis was conducted in cooperation with the epidemiology unit.

Results: In our unit, isolation of B. cereus was significantly associated with severe open leg fractures (Gustilo grades IIA and IIIB) with soil contamination. Samples were taken due to fever, wound discharge, elevation of C reactive protein despite antibiotic prophylaxis beyond 48 hours using the standard protocol of aminopenicillin + betalactamase inhibitor, constantly inactive against B. cereus. The strains identified presented different genomic types ruling out nosocomial contramination. One amputation, one chronic osteitis and one anteriolateral leg compartment necrosis resulted from B. cereus infection in this series.

Conclusion: Arguments developed here allow us to recall the importance of careful surgical debridement of open fractures and to emphasise the requirement for bacteriological samples and appropriate antibiotic therapy for 48 hours, combining, in agreement with the 1998 Consensus Conference, aminopenicillin + betalactamase inhibitor and gentamycin which is active against B. cereus. Severe open leg fractures which follow an unfavourable course should suggest possible B. cereus infection requiring early antibiotic therapy using a regimen with good bone diffusion including a fluoroquinolone which is always active against B. cereus.