Introduction

Malpositioning of the acetabular cup during total hip arthroplasty increases the risk of dislocation, edge loading, squeaking and can be responsible for early wear and loosening. We hypothesized that the use of three-dimensional visualization tools showing during surgery the planned cup position relatively to the acetabular edge would increase the accuracy of cup orientation. The purpose of this study was to compare 3D planning-assisted with freehand insertion of the acetabular cup.

Because of post traumatic mal union or constitutionnal intraosseous femoral or tibial deviation, an extra articular deformity may be present in patients requiring TKR. In those cases, recreation of the mechanical axis will affect the orientation of femoral or tibial bone cuts and soft tissue balance. In those important deformities, an extra articular correction may be necessary. Between 1998 and 2013 we performed 31 TKR associated with femoral (6 cases) or tibial (25 cases) osteotomy in one time surgery. This study was prospective and the patients were examinated at 1, 2, 5, 10 and 15 years for the first patients. There were 17 males (one bilateral case) and 13 females with a 63 years average age (from 29 to 79). The deformity was constitutionnal in 14 cases, post trauma in 9 cases, post osteotomy in 8 cases. The extra articular deformity was between 10° and 35°: 15 in varus, 11 in valgus, 2 multidirectionnal, 1 intraosseous flessum, 1 important translation and 1 rotational deformity. In all the cases we used a long stem implant in the osteotomized bone: an osteosynthesis was performed in 26 cases (7 plates, 19 stapples). A posterostabilised prosthesis was used in 28 patients, a CCK implant in 3. We studied pre and post operatively with a 3 to 17 years follow up, IKS scoring, knee motion, knee stability and radiologicaly, HKA, tibial and femoral mechanical angle. In the knees with a varus deformity the average HKA was 158° before surgery and 181 after osteotomy combinated with TKR. In the valgus cases, the average HKA was 198° pre and 179° post operatively. Complications consisted in 1 peroperative fracture, 1 extension lag of 15° and 1 hematoma.

TKR associated with osteotomy seems to be a possible alternative in patients with severe constitutional or post traumatic extra articular deformities after discussion of the other solutions: osteotomy and TKR in two times surgery (particulaly in young patients) or constraint TKR (rotating hinged implants) in patients over 80 years of age.

Background

Recent literature points out the potential interest of standing and sitting X-rays for the evaluation of THA patients. The accuracy of the anterior pelvic plane measures is questionable due to the variations in the quality of lateral standing and sitting X-rays. The EOS® (EOS imaging, Paris, France) is an innovative slot-scanning radiograph system allowing the acquisition of radiograph images while the patient is in weightbearing position with less irradiation than standard imagers. This study reports the “functionnal” positions of a 150 THA cohort, including the lateral orientation of the cups.

Introduction

A decrease of 15% in femoral off-set (FO) was reported to generate a weakness of the abductor muscle after THA, which may increase the risk of limping and dislocation. However, this value was defined under experimental conditions using a CYBEX machine, which does not correspond to daily life activities. To our best knowledge, there is no reported study about the effect of the FO alteration on the gait, following THA.

Introduction

The ceramic-on-ceramic strategy in acetabular revision faces potential limitations due to the femoral stem, as the implantation of ceramic ball head on a previously used taper is not recommended. Delta (r) ball heads with titanium sleeves have been proposed to avoid femoral revision. The study reports a minimum 3 years follow-up experience using this strategy.

Introduction

Wear performances and fracture toughness of the alumina-matrix composite (AMC) Biolox-delta(r) are pointed out in the literature. This study is a prospective monocentric evaluation of 32 and 36 mm AMC/AMC bearing surfaces.

Background

A high precision of three-dimensional (3D) computerised planning of THA was recently reported. However, there is no comparative study analysing the value of 3D planning comparatively to the planning made on X-rays using 2D templates

Introduction: Computer assisted total hip replacement (THA) usually uses the anterior pelvic plane (plane of Lewinneck, APP) for reference because the anatomical landmarks are easy to access during the surgical procedure. However, a recent study shows the lack of correlation in between the Lewinnek angle in standing position (L) and the spinal radiological parameters for sagittal balance, specifically the incidence angle and the sacral slope. The anatomical variations of the anterior superior iliac spines account for the discrepancy. The authors propose here the assessment of the Lewin-nek – sacrum angle (LS) (anterior pelvic plane to the sacral endplate) Methods: 120 asymptomatic patients with THA had low dose lateral X-rays of the lumbo-pelvic area (Definium 8000, GE Healthcare ;dose 0,6 mSivert). The measurements of the sacral slope, incidence angle, and APP were done by two independent observers.

Results: The sacral slope and incidence angles were similar to other series. The APP was no clearly identified in 78 cases. The average L angle was −3° (SD 8°) in standing position, −23° (SD 11°) in sitting postion, and −2° (SD 8°) in lying position. The average LS angle was 47° (SD 13°). The geometrical relationship between the LS a ngle, the L angle and the sacral slope is reported.

Conclusion: THA stability supposes that the orientation of the acetabular component shall remain within extreme values in standing, sitting, and lying postures. The adjustment of the acetabulum takes into account the functionnal anatomy of the lumbopelvic area. The sacral slope is a reliable radiological reference and is related to the sagittal balance of the spine. The APP presents some interindividual variability and is poorly visible on the radiographs, but it is easily accessible during surgery. The author suggest using the Lewinnek sacrum (LS) angle for radiological planification and for surgical navigation procedures.

Introduction: Wear performances and fracture toughness of the alumina-matrix composite (AMC) Biolox-delta^® are pointed out in the literature. Clinical and radiological studies are needed to assess the potential benefits of AMC/AMC bearing surfaces. The aim of this study is the prospective evaluation of complications and risk factors in patients implanted with AMC liners and 32–36 mm AMC femoral heads.

Methods: 323 consecutive patients were included prospectively since 2006.

243 were implanted for primary surgery with 32 or 36 mm ball heads for a 10–12, 6° tapers.

In 80 cases, we used 32 and 36 mm Delta^® sleeved heads (M,L,XL) for the adaptation on 12–14,5°43 tapers or 10–12, 6° tapers (acetabular revisions in absence of stem exchange, or to increase the lenght of the femoral neck and the offset) All the clinical and radiological files were evaluated at a minimum 2 years follow-up with a special attention for the fracture risk and squeaking. Radiological data were analysed using Dicomesure^® software.

Results: We did not face any significant problem in this series. No fracture occurred. No abnormal wear or implants migration could be detected. We did not observe squeaking phenomenons. 2 THP were revised for septic complications ; the retrivials were analysed for transformation studies(Xray diffraction method XRD). The phase transformation tetragonal to monoclinic was mild, in accordance with previous experimental data.

Conclusion: The limitation of this study is its short follow-up; nevertheless the clinical results are in accordance with the previously published experimental data.

While there are many variation laboratory and clinical studies using metal-on-metal (MOM) bearings after introduction of the 28mm MOM THR in 1988, the mapping of wear phenomena in such retrieval cases has been mimimal. In laboratory study, 28mm MOM bearing’s wear-rate was low with “run-in” and “steady-state” than large diameter MOM without theory of fluid-filum lubrication. In clinical results were not superior to the same way of laboratory study. We present a detailed analysis of 33 retrieved MOM hip bearings with 1–11 years follow-up,

We compiled 33 retrieval cases (MetasulTM: Zimmer/CenterPulse Inc., Austin, TX) including clinical information, ion concentrations from ball diameters, cup designs and stripe wear damage. The bearing surfaces were mapped using reflected light microscope (RLM), white light interferometer (Zygo Newview 600, Zygo.) and SEM(XL-30 FEG). Wear maps were constructed according to types of surface wear identified.

Patients ranged from 36 to 76 years of age (Means: 56.9 years); 54% were males. Main causes for revision were progressive radiographic lines around the cups, osteolysis and pain. The 28mm ball diameter was used in 86% of cases (largest = 52mm ball). The CoCr liner incorporated a polyethylene adaptor in 75% of cases. Cup diameter > 50mm was present in 75% of cases. Eight femoral stems were recovered and all showed major impingement marks around the neck and five also had a metallosis (Mode-4A). Stripe wear was evident on 71% of CoCr balls with medial stripes twice as common as lateral. Stripe wear was identified in 25% of CoCr liners and extended 25–160° circumference around the liners. Clear liner rim damage was present in 10 (30%) and 3 demostrated severe damage of polyethelene adaptors.

There are many limitations to such retrieval studies. These data are biased to cases that failed due to hip pain, radiographic signs of progressive osteolysis and some with high levels of metal ions. There was also the bias of having predominantly a CoCr sandwich design (polyethylene adaptor in 75% of cases). In early 1980s, the thin walled UHMWPE cup was introduced and used larger diameter balls for decreased risk of dislocation. However, unfortunally these big-ball cups produced significant PE wear debris, and diameter trends were returned to the Chanley’s small-ball paradigm again. In the same time (late of 1980’s), these second-generation MOM (28,32mm) was introduced for low wear characteristics alternate THR bearings, with sacrificing of joint stability and motion range. However, use of the small ball added well-known risks of impingement, subluxation and dislocation with rigid cups. In this study, using the ‘damage modes’ from McKellop, normal mode-1 wear occurred in only 14% of cases whereas modes 2–4 had an incidence approaching 30% each and signs of cup impingement were evident in 64% of cases. Thus summarizing MOM wear phenomena in “small” 28mm sandwich cup designs, there was retrieval evidence showing that damage modes 2–4 likely placed these patients at risk for adverse wear effects.

Purpose: Patients with advanced Blount disease present severe metaphyseal varus associated with an oblique medial tibial plateau. Prior to 1987, we used tibial wedge osteotomy to correct the varus deformation and in certain situations also raised the medial plateau with the wedge. From 1987, we performed both procedures during the same operation. The purpose of this work was to describe our technique and evaluate the results of the dual technique.

Material and methods: Between 1987 and 2000, we performed 31 dual procedures. Fifteen patients who had advanced-stage Blount disease were seen late (eight before complete fusion of the growth cartilage and seven as adults). Thirteen children presented recurrent varus deformation after osteotomy during childhood. One patient presented tibia vara during adolescence and three others had poly-epiphyseal dysplasia. Mean age at osteotomy was 17 years (range 10–40). For all patients, the operative technique consisted in lateral closed wedge osteotomy associated with a second access for an oblique osteotomy directed towards the tibial spikes to insert the lateral wedge medially and raise the medial plateau. A mid-third fibular osteotomy was also performed together with stapling for tibial epiphysiodesis superior and lateral when the growth cartilage was still active. We recorded pre- and postoperatively: mechanical femoro-tibial angle, the tibial and femoral mechanical angles to determine intra-osseous deformation, the slope of the medial plateau, and the length of the lower limbs at the end of growth.

Results: Mean follow-up was eight years. Fusion was achieved in all patients. The mechanical femoro-tibial angle was 148.5 (mean) preoperatively giving 31.5° (20–42) varus and 178° postoperatively. The mean femoral mechanical angle was 94°, giving 4° valgus (range 88–102°) preoperatively, with no change postoperatively. The mean mechanical tibial angle was 71° preoperatively (intra-osseous varus of 19°) and 89° postoperatively. The medial tibial plateau slope was 45° preoperatively and 22° postoperatively. Leg length discrepancy was 2.2 cm at last follow-up (range 0.5–5 cm).

Discussion: Different techniques have been described for correcting two deformation components during the same operation. Here, we used the metaphyso-epiphyseal oblique osteotomy technique. This technique assumes that the medial part of the cartilage has already fused and requires fusion of the lateral part when it is active. Currently, we use chondrodiastasis with a special external fixator when the cartilage is still active. This corrects the alignment and raises the plateau, treating the length discrepancy by lengthening. The dual osteotomy technique is reserved for patients with total physis fusion. A long-term analysis after dual osteotomy in comparison with chondrodiastasis will be needed to determine the relative merits of the two techniques and the frequency of secondary osteoarthritis. This work is being conducted at the orthopaedic surgery department of the Fort-de-France University Hospital in Martinique.

Purpose: Loosening remains a problem with semi-constrained total elbow prostheses. The trend in recent years has been to improve prosthesis design to achieve stability of the humeral implant. We report a small series of nine Coonrad-Morrey total elbow prostheses where three early loosenings were observed in the ulnar implant. We attempt to analyse the causes and present a review of the recent literature.

Material and methods: Nine patients, mean age 60 years, age range 57–63 years, underwent total elbow arthroplasty with a Coonrad-Morrey prosthesis for rheumatoid disease (n=5), stiff degenerative joints after trauma (n=3, flexion-extension 20°), floating joint after trauma (n=1). The posterolateral approach described by Bryan and Morrey was used for eight elbows and the posterior approach for one. Clinical and radiological results were assessed with the performance index and the Mayo clinic score respectively.

Results: Mean follow-up was 3.6 years (1.5–4.7). Outcome was very good or good for seven elbows (score > 75 and > 50), fair for one (< 50) and poor for one (< 25). Three elbows were pain free, two presented pain during movement against force. Flexion was greater than 120° in four elbows (all four rheumatoid polyarthritis). Radiologically, we observed three cases of ulnar implant loosening with two type IV lucent lines, and one type III line. There was one humeral implant with a lucent line which did not change over time (type I). The two cases of type IV lines were associated with radial and anterior translation migration of the prosthetic stem with effraction or lysis of the ulnar cortical. The three ulnar loosenings appeared between the second and third postoperative year on two post-trauma stiff degenerative elbows (flexion-extension < 20°) and one rheumatoid elbow. At last follow-up, there was one poor result requiring revision surgery, one fair result, and one very good result (totally asymptomatic type 4 lucent line).

Discussion: The causes of these loosenings were studied: difficult cementing technique in a tight canal, mediocre primary stability of the ulnar implant opposing the excellent fit of the humeral implant with an encased graft under the anterior wing, excessive constraint. Our results are similar to those reported by Hilebrand who had 30% evolving ulnar lucent lines and suggest that we should reserve this prosthesis for unstable elbows.

Purpose: Necrosis of the navicular bone, described by Müller then Weiss in 1927, is an uncommon finding, unlike talonavicular degeneration which is a rather frequent complication of talipes planovalgus. Between 1985 and 2000, we cared for 25 patients with this condition. The purpose of this retrospective analysis was to describe the clinical and radiological presentation and attempt to reconstruct its natural history with the aim of determining therapeutic indications.

Material and methods: We analysed 25 cases of navicular bone necrosis observed in 14 women and 3 men (eight bilateral cases). Mean age of the patients was 39 years (range 16–59). The diagnosis of necrosis was established on the basis of structural alterations (densification, bone defects) and in the more advanced cases, flattening and “expulsion” of the navicular bone. We looked for clinical signs and described the radiological aspect of the necrotic zone. A computed tomography was available in 14 cases and magnetic resonance imaging in the five most recent cases.

Results: Pain was the major sign in all cases. One-third of the cases occurred in a foot with prior planovalgus. History taking revealed elements suggestive of an aetiology in three cases: probable Köhler-Mouchet disease in a 16-year-old boy, sickle cell disease in a 35-year-old man, and prolonged walking with signs suggesting stress fracture in a 40-year-old woman. In the other 19 cases (11 women and 1 man, 7 bilateral cases), necrosis was considered idiopathic. Radiologically, we used the Ficat classification (described for hips): stage 0 with normal x-ray and strong uptake on scintigram (n=1), stage 1 with a normally shaped navicular bone but condensation or bone defect, stage 2 with modification of the shape of the bone without signs of degeneration, stage 3 where changes in the shape of the bone are associated with narrowing of the talonavicular then cuneonavicular space. Computed tomography included frontal and horizontal slices as well as lateral reconstructions indispensable to assess the posterior part of the interarticular spaces. Treatment was surgical in 12 cases and medical in 13. Well tolerated forms were treated with plantar ortheses with regular surveillance. Surgical procedures included triple arthrodesis (early in our experience), mediotarsal arthrodesis (n=2), talonavicular arthrodesis (n=7) and talocuneate arthrodesis with replacement of the scaphoid by an iliac graft (n=2). The natural course of necrosis was studied in the cases without surgery. The first sign was medial mediotarsal pain. At this stage scin-tigraphy or MRI was required for positive diagnosis. At stage 0 condensation of the navicular bone, confirmed by computed tomography, preceded bone flattening then expulsion upwardly and medially, sometimes with fragmentation and onset of talonavicular degeneration. Cuneonavicular degeneration appeared to occur later (except in one case). Long-term results of surgery were good with pain relief and renewed activity.

Discussion: The clinical presentation initially described as Müller-Weiss disease or scaphoiditis, which concerns a bilateral condition generally occurring after trauma and sometimes with a favouring factor (alcoholism, osteoporosis), appears somewhat different from our description. Mechanical factors predominated in our patients and the aetiologies were quite similar to those observed in Kienböck syndrome. Excessive pressure on the navicular bone, which leads to avascular necrosis, flattening, and expulsion, is undoubtedly the essential cause of this condition. It is well tolerated in some individuals and can lead to spontaneous fusion. In this situation, treatment can be limited to surveillance or orthopaedic care. If the functional impact is important, surgical treatment can be proposed, generally limited to talonavicular arthrodesis. If the navicular bone is sclerosed and flat, the remaining fragment can be replaced by an iliac graft to achieve talocuneate fusion.

Conclusion: Necrosis of the navicular bone appears to be less uncommon than in the classical description, particularly in black women aged 25–50 years. A more precise study of favouring anatomic factors (length of the medial ray, size of the talar neck, depression of the medial arch) could provide further information concerning the aetiology which appears to be similar to that of Kienböck disease.