Purpose of the study: Prevention of operative site infections (OSI) in orthopaedic surgery requires strict observation of validated practices during hospitalisation and in the operative theatre, review of morbidity and mortality, and surveillance of OSI. Certain intrinsic patient-related risk factors of OSI cannot be controlled without direct implication of the patient and the referring physician. Search for Staphylococcus aureus (SA) colonisation and bacteriuria should be done in the ambulatory setting, before hospitalisation. The purpose of this work was to evaluate the feasibility of a search for SA in the nasal swabs and urine samples in patients scheduled for prosthesis surgery.

Material and methods: This was a prospective study on 335 patients who had a total hip arthroplasty (THA) or a total knee arthroplasty (TKA) from January 1, 2007 to December 31, 2008. Bacteriological tests were performed before hospitalisation. Before hospitalisation, the patient and the primary care physician were give information on the proper procedure for chemical decontamination. The results of these laboratory tests were analysed and OSI were followed.

Results: Three hundred thirty-five patients (195 THA and 143 TKA) were included; the sex-ratio was 0.95 M/F. Sixty-one patients (18%) exhibited SA colonization, including two meticillin resistant strains. Urine samples were positive in 30/323 patients (9.3%). Three patients presented an early OSI: two infections of a revision THA and one infection of a revision TKA. Two of these patients had an SA infection, including one who was colonized and had applied the chemical decontamination protocol before hospitalization.

Discussion: By treating bacteriuria before hospitalization, deferral of the scheduled operations could be avoided. Laboratories must run two sets of tests to search for both met-S and met-R SA, which in our experience was not always the case despite written prescriptions. Implementation of chemical decontamination of the nasal passages and skin before surgery requires a well-established cooperation between the primary care physician and the hospital. The three infections recorded in this series involved revision procedures, with a context of rheumatoid polyarthritis for two patients.

Conclusion: Systematic screening for SA colonization in orthopaedic surgery remains a subject of debate, particularly concerning the cost-efficacy balance, but can be quite useful in certain situations such as revision or prosthetic surgery in immunodepressed patients.

Purpose of the study: To compare the DHS plate fixation with the Targon PF nail for the treatment of intratro-chanteric fractures.

Material and methods: This was a prospective randomized study including 60 patients hospitalized in the emergency setting between December 2003 and June 2004for intratrochanteric fractures. The AO classification was used. We analyzed: patient status (ASA), operative time (type of implant, duration), the postoperative period (blood loss, radiologic findings, duration of hospital stay, early postoperative complications) and at last follow-up, Harris hip score, date of resumed walking, mortality. Patients were assessed at three months postop. This study included 60 patients, 34 with a Targon PF nail and 26 with a DHS. Mean patient age for nailing was 81 years (SD 12.8, range 23–86); for DHS it was 82 years (SD 9.8; range 47–97).

Results: Mean blood loss was 410 ml with the Targon PF nail and 325 ml with the DHS, a nearly significant difference (p=0.07). The other results did not demonstrate any significant difference. At three months five cases of screw cut out were noted. Bone healing was achieved in all cases. The Trargon PF nail and the DHS provide equivalent results, with less bleeding an lesser cost for the DHS.

Purpose: Classically reported, degenerative femorotibial remodelling after meniscectomy results from different biomechanical mechanisms depending on the compartment considered. Occurring in the medial compartment, the most frequent situation, the lesions result from punctual contact compression of the cartilage. In the lateral compartment the mechanism involves increased relative instability of the structures controlling mobility. Lateral meniscectomy disrupts femorotibial kinetics of the meniscotibial gliding articulation leading to horizontal instability and subsequent generation of osteoarthritic degeneration which explains the development of lateral decompensations without genu valgum. Based on work by Grammont and Rudy, we proposed a method to limit this horizontal instability and transfer part of the stress to the medial compartment by medial translocation of the tibial tubercle.

Material and methods: Eighteen patients, mean age 44 years, underwent treatment for disabling degeneration without major misalignment (mean HKA 181°) a mean ten years after lateral meniscetomy. Degenerative remodelling of the lateral compartment was observed on the AP views in 30% of the knees and on the tangent views in 57% Five patients had early-stage lesions of the medial compartment and femoropatellar degradation was observed in 53%. Involvement of the lateral compartment was confirmed by systematic articular exploration and patellofemoral chondropathy was observed in eight knees. Translocation of the anterior tibial tubercle was associated with section of the lateral patellar wing in all knees associated with tension plasty medially.

Results: In 88% of the knees, the postoperative period was uneventful. Weight-bearing supported with a Zimmer cast was maintained for 21 days. Functional outcome was assessed at mean 28 months. Eleven patients had a new clinical and radiographic work-up (mean 34 months). Pain was improved in 88% of the knees, allowing sustained resumption of occupational activities at three months (four knees completely forgotten). Radiographically, at mean 34 months, the lateral cartilage lesions had stabilised with no impact on the medial compartment.

Discussion: In light of these results, we have decided to continue this therapeutic approach, reserving the technique for cases of symptomatic lateral decompensation in young subjects without major valgus malalignment.

Purpose of the study: Cases of serious trauma to the cervical spine requiring surgical management in older subjects goes in hand with the general trend towards a more active elderly population. We analyzed retrospectively our experience with 28 patients cared for in our unit from 1990 to 1999.

Patients and methods: Mean age of these 11 women and 17 men was 73 years (range 65–93). High-energy trauma was the cause of the cervical injury in 12 patients (42%). The others were victims of falls in their homes. This later cause explains the long delay to care (21 days on the average with a range from zero days to six months). The six patients who had injuries to the upper cervical spine had fractures of the odontoid process secondary to a fall. The mobile segment of the spine was involved in most of the injuries involving the lower cervical spine (eleven severe sprains and six dislocations) resulting from high-energy trauma in half of the cases. These injuries occurred above an osteoarthritic block. Half of the patients had neurological complications: eleven immediate, three late. The Franckel classification was: A=2, C=4, D=7. The same repair technique was used for the upper an lower cervical spine. Five of the six fractures of the odontoid process were fixed with a Bölher screw, and one with posterior fusion. An anterior graft with plate fixation was used 18 times for the lower spine. Roy Camille posterior fixation was used four times because of the irreducible nature of the fracture or because of the need for posterior fusion.

Results: Morbidity was high. Seven patients (25%) had serious cardiorespiratory complications leading to death in five patients. All these patients had neurological sequelae (Franckel A and C). For the other patients, the postoperative period was uneventful and similar to that observed in younger patients (immobilization, neurological recovery, consolidation).

Discussion: The high frequency of upper cervical spine trauma observed in our series is also reported in the literature. It increases with age. The frequency of neurological involvement was identical to that observed by Roth and Spivak. Prognosis was poor in case of neurological involvement. The appropriateness of surgery in Franckel A patients may be questionable. Surgery cannot avoid the risk of mortality in these patients but it can enable mobilisation and nursing care, avoiding the need for a halo jacket.

Conclusion: Spinal trauma in the elderly can be managed similarly to that in young adults, at least in cases without major neurological involvement.

Purpose: For many years, single-compartment knee inserts have been one of our most frequent operative indications, but the uncertain nature of the results and early deterioration have led us to revisit the failure cases and modalities for total knee arthroplasty.

Material and methods: From 1994 to 2001, we reoperated 33 single-compartment knee inserts (28 medial and five lateral inserts). Mean delay from initial implantation was 4.3 years (range nine months to ten years). Clinical and radiological assessment was done with the IKS score. Peroperative exploration searched for the underlying cause.

Results: All single-compartment inserts were replaced with a total knee arthroplasty. The mean HSS improved from 42.8±15 to 83.6±18% good and very good results. The causes of failure were loosening in 22 cases including four cases of implant fracture or displacement. We had three stress fractures of the tibial plateau. The revision procedure required compensation blocks for the tibia in two cases, and a bone graft in four. Finally, a tibial stem extension was needed in nine cases. There were two mechanical complications after revision, one recurrent stiff knee and one recurrent dislocation of a posterior stabilised prosthesis.

Discussion: Ligament tension and balance both in extension and flexion remains an important problem in revision procedures on single-compartment inserts. The difficulty in setting the femoral rotation is well known due to the loss of posterior condyle tissue. Tibial stem extensions can be useful, particularly if a graft of the medial compartment is used. Use of adapted instrumentation facilitates revision of these single-compartment knee inserts and may provide further confidence in first intention total knee arthroplasty.

Purpose: The rate of failure knee arthrodesis can be high when performed after an infectious complication of a total knee arthroplasty. We evaluated, in 14 patients at a mean 19 months (3–44 months) follow-up, a technique for knee arthrodesis using a custom-made endomedullary implant.

Material and methods: Mean age of these eight women and six men was 68 years. There were 11 patients with an infected prosthesis, one with post-trauma arthritis, one with aseptic loosening of a hinge prosthesis, and one with pseudarthrodesis. For the 12 patients with ongoing infection, surgery was performed in two times with insertion of a spacer (with antibiotics) between the operations. Mean delay between the two operations was 18 weeks. The surgical procedure was associated with a two-drug antibiotic regimen given for a mean three months after arthrodesis. All arthrodeses were stabilised with a custom-made femora-tibial implant with reaming and fixation with two screws. A graft was always used, composed of the reaming products and powder bone substitute in seven cases, reaming products alone in three, and bone-bank heads in four.

Results: Morbitiy: There was one misalignment of the tibial insertion that was not revised. One skin cover problem was treated with a vastus medius flap. One nonunion evolved favourably after a new graft. There were two recurrent infections: chronic fistulae that were controlled by local care and adapted antibiotic therapy. Weight-bearing was started during the first postoperative week in 13 patients. Bone healing (assessed radiographically with resolution of pain) was achieved at a mean three months (2–6 months) in 13 cases. At last follow-up all patients had achieved a satisfactory level of independence.

Discussion: According to the literature, intramedullary devices are superior for consolidating knee arthrodeses, with a lower rate of complications. Use of custom-made endo-medullary implants facilitates the operation and assures better stabilisation of the arthrodesis, allowing rapid weight-bearing. The infection must be controlled before using these implants. The results in our patients are in agreement with the most recent series reported (Barry, Stephen, Kuoan).

Conclusion: In our hands, this type of implant provides an effective means of attaining bony fusion, including in patients who require arthrodesis for an infected prosthesis.

Purpose: We were confronted with four cases of major loosening with migration of the metal-backed implant and acetabular osteolysis at seven years follow-up. We thus conducted a retrospective clinical and radiological analysis of our 192 prosthesis of this type implanted in 1993.

Material and methods: The clinical results were analysed using the Postel Merle d’Aubigné score (PMA). Radiographic wear was measured on the AP views without loading according to the Charnley method. Osteolysis was determined on the AP view using the De Lee and Charnley criteria. Certain files also had a scintigraphy or a CT scan performed to search for bone lysis. Osteolysis and femoral loosening were studied on the AP and lateral views. In agreement with the literature, wear of 0.1 mm/year was considered normal for these cemented prostheses and 0.15 mm/year for metal-backed cups.

Results: For the femoral component, there were two cases of loosening with massive osteolysis with a sanded titanium inserted with cement. None of the patients, with a cemented or non-cemented prosthesis underwent revision for pain. At the acetabular level, there were no failures for primary instability. Wear was normal (mean 0.08) in 89 cases (46.5%) and excessive (mean 0.26) in 103 cases (53.5%). Significant factors for wear were: patient age, gender, and level of activity. Factors without a significant influence were: size of the acetabular cup, type of bead, patient overweight. Osteolysis was the consequence of abnormal wear since in 42% of the abnormal wear cases showed osteolysis compared with 20% when wear was less than 0.15. The same observations were made for the clinical impact as 15.5% of the worn cups were symptomatic (PMA < 4) and 18 of the 103 patients (17.5%) underwent or will undergo revision.

Conclusion: Metal-backed cups present excessive wear at mid term causing early failure by osteolysis and implant migration. There are two options: remove the polyethylene sing a new metal-on-metal combination or a ceramic-ceramic combination, or returning to the metal-polyethylene combination with a cemented cup.