Background: Early or later dislocation is a frequent complication associated with total hip arthroplasty. The Bousquet’s acetabular component, an original concept of dual mobility socket has been used, for increase stability and mobility. The first mobility is between the femoral head and the polyethylene insert, and the second mobility between the polyethylene and the metal cup socket. The cup, covered with alumina was impacted without cement. The purpose of this study was to evaluate the long-term results of a retrospective series of primary arthroplasty with this cup and a cemented Charnley type femoral component.

Materiel and methods: This study included 437 hip replacements performed between 1984 and 1990, in 389 patients with osteoarthritis (62.5%), dysplasia (11.4%), necrosis (8%), rheumatoid arthritis (5%), post-traumatic and others (13.1%). The average age of the patients at the time of the index procedure was 61 years. The patients were followed at routine intervals for clinical and radiographic review. The clinical results were appreciated with Postel–Merle d’Aubigne score (PMA). Osteolysis was noted according to Gruen zones.

Results: The outcome is known for 345 hips (79%): 164 alive without revision at a mean of 16,5 years follow-up, 137 died without revision, and 44 failures. 92 (21%) were lost at follow up. Revision, for aseptic loosening of femoral or acetabular component, was performed in 30 hips(6.8%). 5 dislocation occurred and were revised: 2 early regarding to technical errors and 3 after 10 years or more of follow up. 7 hips were revised for deep infection, and 2 for unaccountable pain.

At more than 15 years follow-up, the mean PMA hip functional score was 17.1. 66% of the hips was A, 4% were B and 30% were C according to the Charnley’s score. Of the 164 hips in the patients who had survived at least 15 years, 28 had femoral osteolysis in zone 7, and 31 had femoral osteolysis in one (or more) of the other 13 zones. 6 hips had an impingement sign on the neck of the femoral component, without aseptic loosening.

According to Kaplan-Meier analysis, the fifteen year survival rate, was 84.36% with revision for any reason (infection, dislocation, osteolysis…) for end point. The young age of the patients at the time of the index surgery is correlated with loosening.

Conclusion: The long term results of the press fit, double mobility socket with cemented Charnley type femoral stem are good. The prevalence of revision for dislocation is very low in our series. But this concept do not avoid wear, osteolysis and aseptic loosening, specially in young active patients. We can recommand this type of prosthesis for patients over 70 years, and/or with high risk of dislocation.

Purpose of the study: The objective of this retrospective analysis was to examine the functional and radiographic results of 33 resvisions for femoral implants using a long locked stem inserted without cement and coated with hydroxyapatite.

Material and methods: Mean follow-up was two years for 33 patient who underwent revison total hip arthroplasty (rTHA) with implantation of a press-fit long locked hydroxyapatite coated femoral stem (Aura or Linea) between 2000 and 2004. The explanted prosthesis was cemented in 23 cases. The reason for revision was femoral loosentng for 60%, femoral fracture for five pateints, and infection for two. According to the SOFCOT 1999 criteria, ten patients had bone defects score grade III or IV. Femorotomy was performed in 21 cases. Patients were reviewed clinically and radiologically. Function was assessed with the Postel-Merle-d’Aubligné (PMA) score and radiographic analysis determined the quality of osteointegration of the implants and the restitution of bone stock.

Results: There were six early complications (one death, one disloction with sciatic paralysis), and six late complications, mainly related to defective locking. The PMA score was less than 3 for only three patients. Twenty-six patients were satisfied or very satisfied and seven patients reported thigh pain which was generally moderate. The locking was released for five prostheses because of failure or pain (relief observed in three cases). Migration was noted in three cases, illustrating their non-integration. For 15 patients, corticalisation around the lower part of the prosthesis suggested implant mobility. This image was observed in all patients who complained of thigh pain (p=0.057). There was a significant increase in the cortical index, reflecting progression of the bone stock favoring the internal cortex.

Conclusion: This type of implant has provided a solution for the difficult problems of explantation and reimplantation of THA. These prostheses provide satisfactory short-term results and a significant improvement in bone stock. There remains the problem of osteointegration of certain implants. Technical factors can contribute to improved clinical results.

Purpose of the study: Free patellar tendon plasty is the most common technique for repairing anterior knee laxity. Functional outcome can be compromised by invalidating knee pain. The purpose of this prospective randomized study was to compare the outcome of plasty procedures using hamstring tendon versus patellar tendon autografts.

Material and methods: From May 1998 through May 2001, 100 patients presenting an isolated grade I anterior cruciate ligament (ACL) tear were included. Exclusion criteria were: history of fracture, advanced-stage laxity (grade II or greater), and contralateral ACL tear. Randomization was performed in the operative theater using the closed envelop method. Two groups of 50 patients were designated: group A: arthroscopic free bone-tendon-bone patellar autograft; group B: arthroscopic free four-strand hamstring autograft. Two metallic interference screws were used for fixation in both groups. The two groups were comparable for demographic features and clinical, radiological, and instrumental laxity variables recorded before surgery. The position of the tunnels was noted according to Aglietti and was the same in the two groups. The same rehabilitation protocol in a dedicated center was used for both groups. All patients (none lost to follow-up) were assess using the IKDC 1993 criteria with objective instrumental measurement of residual laxity. The level of significance was set at 5%.

Results: There was no significant difference between the groups regarding: resumption of sports activity (level and delay), joint motion, ligament examination, the overall IKDC score, and radiological findings ate mean 40±13 months (range 13–69 months) follow-up. Pain at the harvesting site was observed in 34.78% of patients in group A at six months and in 39.5% of those in group B. Conversely, anterior pain was found in 8.5% of patients in group B at six months and 6.6% at one year (p< 0.05). This statistically significant difference disappeared at two years. Instrumental differential laxity was 0.57±1.3 mm in group A and 1.22±1.9 mm in group B (p=0.56, but with power < 80%). There were two cases of repeated traumatic tears in each group. Repeated meniscectomy was performed in one patient in group A and in three in group B (p=0.3074).

Conclusion: The results at 40 months follow-up of this prospective randomized study with no patients lost to follow-up confirmed the minimal morbidity observed at the harvesting site for hamstring plasty. There was no significant difference between the transplants (patellar tendon, hamstring). Anterior pain with the patellar tendon plasty attenuated after two years. Residual laxity was greater when using the hamstring method.

Purpose of the study: The purpose of this retrospective study was to analyze outome at more than one year of 33 anterior cruciate ligament (ACL) ligmanetoplasties performed in subjects aged over 50 years.

Material and methods: Between 1997 and 2002, arthroscopic ACL ligmantoplasty with a free graft was performed for 33 patients aged 50–67 years (mean 55.2 years). All patients were reviewed clinically and radiologically at least one year after surgery (mean follow-up 31 months, range 12–60 months). IKDC criteria and manual KT-1000 measurements were recorded. All subjects were classified C or D before the operation (IKCD 93 criteria). Plain x-rays were considered normal for 21 patients (63.5%) and eight (24%) presented remodeling of the medial femorotibial compartment or the intercondylar eminences. Four knees (12.5%) presented an asymptomatic narrowing of the medial femorotibial space (< 50%). In all patients, the indication for surgery was instability for daily life and/or sports activities, even for patients presenting an asymptomatic narrowing. An inter-articular patellar tendon graft, using two independent tunnels was performed for 29 patients. A hamstring plasty was performed for the others. Mean time from injury to surgery was 18 months. There were 15 lesions of the medial meniscus (45.5%). Six lesions were not repaired because they were considered stable. The lateral meniscus was involved less often (n=11 lesions). The lateral meniscal stock was preserved in nine knees. The rehabilitation protocol was the same as used for ligamentoplasty in young sportive patients.

Results: There were no intraoperative complications. Supplementary fixation of the tibia was required for three knees. All patients resumed their sports activities at the same level. The overall IKDS score was A for eight patients, B for 19 and C for six. For the patients in class C, the poor IKDC score resulted from persistent pain, generally present before the operation. Joint motion was preserved in 30 patients. IKDC laxity was A or B in all patients. At last follow-up, there was no radiological worsening and no meniscal injury left unrepaired required secondary treatment.

Conclusion: The operative technique was joint instability for daily life activities. Stability was improved in all patients, but the surgery did not improve pain relief. Age greater than 50 years is not a contraindication for arthroscopic reconstruction of the central pivot for chronic anterior instability. Fixation of the implant must be precise. The indication for surgery depends on the severity of the instability for daily life activities in a motivated patient.

Purpose of the study: The issue of which graft to choose for anterior cruciate ligament (ACL) reconstruction is still a matter of debate. An analysis of the literature reveals the difficulty encountered when performing comparative trials. It is also difficult to demonstrate significant differences with results obtained with an insufficient number of patients. We propose here a meta-analysis in order to combine the results obtained with different comparative studies.

Material and methods: The literature search (Medline 1990–2005) was based on the following selection criteria: ACL reconstruction, patellar tendon (PT), gracilis and semitendinous (four-strand hamstring) reconstruction and comparative prospective study. Studies were retained with: > 30 patients per group, minimum follow-up 24 months, IKDC score. Evaluation criteria retained were: anterior pain, resumed activity, IKDC score, differential laxity. The relative risk (RR) statistical method with 95% confidence interval (CI) was applied. Means were calculated and the chi-square and z-tests were applied.

Results: Thirteen studies satisfied our inclusion criteria. These studies had included more than 1300 transplants. Mean rate of anterior pain was 23.2% with PR and 17.3% with hamstring reconstructions. The RR was 0.73 with a CI different from 1. The difference was significant. Resumption of sports activities at the same level, subjective assessment, number of failures, and overall IKDC score were not statistically different between the two types of transplants. The IKDC laxity score was not different but the residual maximal manual differential laxity was greater in the hamstring patients than in the patellar patients in 80% of the cases.

Conclusion: At the observed follow-up, free grafting with a four-strand hamstring tendon or a patellar tendon is an effective method for reconstruction of the ACL. Anterior pain is more frequent with the patellar tendon method and residual laxity is greater with the hamstring method. The long-term outcome will determine whether the residual laxity observed with the hamstring graft has a deleterious effect on the meniscocartilaginous structures. This criteria would minimize the advantage of this technique over the patellar tendon technique concerning the initial anterior pain.

Purpose: After implantation of a total knee arthroplasty (TKA) for osteoarthritis, early demineralisation of the superior tibial epiphysis occurs with modification of bone mineral density (BMD) in the two compartments. The long-term trend is not known to date. We report the results of 38 prostheses followed prospectively with densitometric measurements at minimum five years.

Material and methods: This prospective analysis included 38 TKA implanted for primary degenerative disease in patients with a mean age of 70±4 years at implantation, 60% women. Clinical assessment (IKS) and radiography (HKA) as well as osteodensitometry were recorded before surgery, at six months, one year, two years and five years. Bone mineral status was assessed using the densitometry of the femoral neck before surgery and at five years for all patients. The DEXA method was used for each knee on the anteroposterior film. Seven zones were defined around the tibial implant, in particular two under the medial and lateral plateaus, and under the stem. We studied changes in each zone over time. The alpha risk was set at 5%. Inter- and intraobserver reproducibility was 2.9% and 2.8% respectively.

Results: At five years follow-up, the mean IKS function score was 85±19 and the knee score was 918. The mean mechanical axis was 180±2° with symmetrical distribution. There were no progressive lucent lines. The BMD of the homolateral femoral neck did not change significantly (0.763 g/cm2 at inclusion and 0.750 g/cm2 at five years), unlike the natural evolution in a reference population (women -4.5%, men -2.4%). The mean BMD in the seven zones decreased significantly (11.6%, p< 0.0001. Mean BMD was 0.936 g/cm2 at inclusion and 0.863 g/cm2 at six months), 0.823 g/cm2 at five years. BMD decreased very strongly from 0 to 6 months (−6.51%, p< 0.0001) then more slowly to the end of the first year (−3%) and finally declining regularly, but non-significantly, at a slower rate from 1 to 5 years. Study of the seven zones showed a difference in changes in the BMD between the medial, lateral and stem zones. The two medial zones decreased significantly from 6.33% to 6.18% especially during the first year (−2.06% and −2.09%) and more moderately from 1 to 5 years (−1.6%, −2.65%). The lateral zones showed a greater average decline in BMD (−10.5%, −8.92%) between 0 and 5 years: −8.57% and −6.75% during the first year then at a slower rate. The greatest loss in BMD was found under the stem; −14.3% at five years. Here again, between 0 and 6 months the decline was rapid: −8.09%. It reached −12.74% at one year then varied little, −1% and −2% between 1 and 5 years.

Conclusion: 1) Bone remodelling under the tibial base plate occurs early after implantation of a TKA. It occurs during the first year (especially the first six months). 2) Remodelling is more pronounced laterally than medially (good realignment but persistent varus stress with greater stress on the medial than lateral side). 3) The greatest loss in BMD occurs under the stem. 4) BMD of the femoral neck remains stable, unlike the evolution observed in a reference population.

Purpose: Free patellar tendon plasty is classically used for the treatment of chronic anterior instability of the knee. Good functional results may however be compromised by invalidating anterior pain. The purpose of this randomised trial was to obtain a prospective comparison of outcome after hamstring plasty or patellar tendon plasty.

Material and methods: One hundred patients with an isolated tear of the anterior cruciate ligament were included in the study between May 1998 and 2001. Exclusion criteria were history of fracture, grade II laxity, and tear of the contralateral ACL. Patients were assigned to one of the treatment arms in random order in the operating room: Group A: arthroscopic free patellar tendon-bone graft; Group B: arthroscopic free four-strand hamstring graft. Two metal interference screws were used for fixation in all cases. The Aglietti method was used to calculate the position of the bore holes in all cases. The same rehabilitation protocol, in the same centre, was applied in all cases. The two groups were comparable for epidemiological, clinical, radiological, and instrumental laxity (KT1000®) data. IKDC criteria, activity level (sports), and instrumental measurement of laxity (KT1000® Medtronic) were used to assess outcome. Differences were considered significant for p < 0.05.

Results: At mean follow-up (24 months, range 6 – 38) groups A and B were not significantly different for delay to resumed sports activity at the initial level, motion, clinical examination of ligaments, IKDC global score, and radiological evolution. At six months, 30% of the patients in group A complained of anterior pain; 20% of the patients still complained of pain at one year. In group B, femoropatellar pain or pain at the harvesting site was reported by 8% of the patients at six months and 4% at one year (p = 0.0005). These differences were no longer present at two years. The instrumental differential laxity was 0.66±1.1 mm in group A and 1±1.5 mm in group B (p =0.20). Two repeated trauma-induced tears were observed in group B.

Conclusion: The preliminary results of this prospective randomised trial confirm the low morbidity of the harvesting site for hamstring grafts and the reliable stability of hamstring repair of isolated ACL laxity. A longer follow-up is however needed for long-term validation, particular concerning secondary distension of hamstring grafts as is frequently reported in the literature and which we have also observed in certain patients treated before this series.