Purpose of the study: The survival of a total hip arthroplasty (THA) depends mainly on the choice of the implant and the quality of the implantation. Mini-incisions have been criticised because of the increased risk of complications and the uncertainty concerning implant position. The main objective of this work was to assess this later feature.

Material and method: This was a prospective series of consecutive patients attending different centres from January 2008 to January 2009 comparing 100 THA implanted via the reduced Watson-Jones approach (2 centres) and 520 THA implanted in a third centre via the anterior hemimyotomy. Objective assessment (PMA, Harris) and early functional outcome (WOMAC, SF12), biological aggression (myoglobinaemia, CPK, blood loss), complications, and scanographic position of the implants were analysed.

Results: For the mini-Watson-Jones arthroplasties, there was a longer operative time (p< 0.0001), smaller scar, less consumption of analgesics the first postoperative day (p=0.003), and better objective and functional recovery at six weeks (PMA: p < 0.0001; Harris: p = 0.004; WOMAC: p < 0.0001; SF12: p = 0.007). Conversely, there was no significant difference for intraoperative or postoperative blood loss, intraoperative and early postoperative complications, elevation of serum muscle markers, or duration of hospital stay. Regarding implant position, significantly greater acetabular and cumulated anteversion was observed with the mini-incision (p=0.03 and p=0.002 respectively). Nevertheless, the proportion of well positioned implants (Lewinnek criteria) was not significantly different.

Discussion: This series confirms the contribution of the mini-incision to more rapid recovery. We did not find any difference in implant malposition related to approach. The first analyses did however show that the position of the implants is more reproducible with the conventional approach.

Purpose of the study: The purpose of this study was to assess traumatic damage to muscles using biological markers. Two approaches were evaluated: a modified Hardinge approach (anterior hemimyotomy) and a reduced anterolateral approach (Rottinger).

Material and method: This was a multicentric prospective study conducted in three centres in 2008. The first 50 patients in each centre were included. Total creatinine phosphokinase (CPK) and serum myoglobulin levels were used to evaluate muscle damage. Blood samples were taken ten hours after surgery for myoglobulaeia and at one and two postoperative days for CPK. Student’s t test was used for the statistical analysis.

Results: There was no statistically significant difference in serum myoglobulin levels 10 hours postoperatively (p=0.25) or for CPK level at day 1 (p=0.098) and day 2 (p=0.105). Objective clinical recovery (Postel-Merle-d’Aubigné, Harris) and function (WOMAC and SF-12) were better at six weeks with the reduced anterolateral approach.

Discussion: These findings show that muscle aggression after mini-incision is to the same order as with the standard approach. The damage is however different: section for the Hardinge type approaches, stretching and contusion for the mini-incisions.

Conclusion: Use of biological markers specific for muscle tissue appears to be a simple way of quantifying muscle damage. However, adjunction of an imaging technique (MRI) might provide a more precise assessment of muscle injury.

Purpose of the study: Radiographs of 24 patients who underwent surgery for total hip arthroplasty (THA) with a locked stem were reviewed at 38 months mean follow-up using a dedicated software. This software enables digital analysis of standard radiographs with semiquantitative evaluation of bone density.

Material and method: Good quality postoperative AP views of the femur and the same view at last follow-up were selected using the same criteria. These images were digitalised then analyses with the software. Bone density was established along a horizontal line 1 cm below the lesser trochanter perpendicular to the femur shaft. Computer analysis of bone density established three categories of patients as a function of cortical density: no cortical modification (n=5 hips), modification of only one cortical (n=11) and modification of both corticals (n=8).

Results: Bone density increased, suggesting improve cortical bone stock as has been reported by most authors using the transfemoral approach and a non-cemented locked stem.

Discussion: This result confirms the data in the literature; data which, unlike our series, were established on qualitative or subjective evaluations. The method presented here has the advantage of a semi-quantitative analysis, simple use, applicable to plain x-rays, and good reproducibility since all measures are made by the software. This study demonstrated the notion of cortical quality since it was not limited to a simple measurement of width, but also bone density, closer to real intraoperative observations.

Conclusion: Use of this method enables longitudinal study to establish the kinetics of bone remodelling, compare results between surgical methods, and search for factors explaining observed variations.

Purpose of the study: Prior assessment of haemorrhagic risk appears to be an essential element in orthopaedic surgery, particularly for lower limb procedures. This assessment is necessary for information delivery to the patient, for elaborating a transfusion strategy, and to choose between different therapeutic options. Despite this potential interest, data which could be used to validate this hypothesis and define and quantify what is called “haemorrhagic risk” are scarce in the literature. In order to furnish a preliminary element for reflection on this topic, a sample of 450 orthopaedic surgeons and 50 anaesthetists who perform routine arthropathy procedures for the lower limb were questioned.

Material and methods: This was an Internet questionnaire with 13 questions. Five hundred practitioners were surveyed in five western countries (France, Germany, United Kingdom, Spain, United States), 100 in each country.

Results: Globally, 90% of the practitioners considered it “important” or “very important” to evaluate the haemorrhagic risk. This percentage varied from 83% to 98% depending on the country. The main haemorrhagic complication was considered to be operative site bleeding, intra- or postoperatively, for 95% of the practitioners (89% to 98%) after hip or knee arthroplasty. The possible consequences of this haemorrhage were classified according to their gravity. Vital risk was classified N1, but not systematically or unanimously, since, for example, 75% of the French practitioners did not place vital risk in this category. Three other criteria of gravity of operative bleeding were reported, but with no clear hierarchy:

requirement for a revision of the operative site;

Discussion: This survey showed that evaluation of haemorrhagic risk is considered to be an important element in orthopaedic practice, particularly operative site bleeding. The main elements constituting signs of gravity were: vital risk, revision, a threshold of blood loss, and constitution of a haematoma.

The fractures of the hip are a main problem of health care. These fractures will be multiply by 2 in 2025 and 3 in 2050. In the population of old people, 1/3 of the women and 1/9 of the men will have a fracture of their hip. Some authors used the name of “EPIDEMIC”.

The aima of the INPECH project (Indicators of the Performance for the comparison between hospital) was to check if the comparison of performances of clinical teams, on the basis of indicators chosen by themselves, allowed to improve their performances. It was an experimentation of a volonteer processes of comparison of performance between 3 multidisciplinary teams.

The study followed some stages:

in every hospital, description of the process of care of the hip fractures with a choice of indicators of performance (difficulties of the care percepted by the professionals, possibilities of improvement, feasibility of the record of the indicators during the whole process)

The analysis of this second inclusion authorized a real change in our professional practices and showed the efficacy of the indicators which were improved.

This study had permitted to show qualitative differences of care of hip fractures between the hospitals. The confrontation between the teams had authorized a positive reflexion of some of our professional practices and the improvement was underlined by the second series of inclusion.

Purpose: Villonodular synovitis is a highly proteiform disease. The classical localisation is in the hand joints, but we focused on pseudomalignant forms which must be recognised to avoid unnecessarily aggressive treatment.

Material and methods: This series included ten files of patients seen for soft tissue tumour of the knee (n=6) or the hip (n=4). Time from first clinical sign to first consultation was two years on the average. The clinical presentation was dominated by major tumefaction of the soft tissues in all patients. There were no signs of joint disease in about half the patients. Radiological signs were noted in six patients. When obtained, MRI demonstrated, in all cases, a tumour formation with ferric deposits and thus contributed considerably to diagnosis.

Results: All patients underwent surgery. Five developed recurrence, as many as four times. One of these recurrent episodes was noted 17 years after the initial intervention that was considered satisfactory (wide monobloc resection). Joint involvement was minimal in these patients with a strong discordance between the minimally troublesome clinical presentation and the major anatomic modifications revealed radiographically.

Discussion: The risk of misdiagnosis is illustrated in our series which included two patients proposed for amputation with one which was actually performed due to a doubtful diagnosis of synovialosarcoma. This observation points out the review of the Swedish registry of synovialosarcomas: of the 81 files enrolled in the registry, 12 were found to be an aggressive form of villonodular synovitis.

Conclusion: The diagnosis of synovialosarcome, considered in patients who present with major tumefaction of soft tissues, signs of joint involvement, or ferric deposits identified on the MRI, should be evaluated with excessive care to rule out possible villonodular synovitis which responds to minimally aggressive treatment to be adapted to each individual case.

Purpose: The purpose of this study was to establish the map of the motor branches of the median and ulnar nerves of the forearm and to count the Martin-Gruber anastomoses. Knowledge of anatomic variability would be useful for hyponeurotisation surgery of the spastic hand. Variations in the antebrachial emergence of the six motor branches of the medial nerve and the three motor branches of the ulnar nerve were studied.

Material and methods: This study was conducted on twenty anatomic specimens obtained from five men and five women. We measured the length of the forearm and identified the origin of each motor branch of the medial and ulnar nerves using a horizontal line between the meidal and lateral epicondyles as the reference line.

Results: Mean length of the forearm was 26.93±2.6 cm. Unlike the origin of the superior and inferior pronator teres nerves, and the palmaris longus, flexor carpi radialis, and flexor digitorum superficialis nerves which were very variable (coefficient of variation 49%–113%), the origin of the anterior interosseous nerve of the forearm (CV=39%) and its branches, and the flexor pollicis longus nerve and the flexor digitorum profondus nerves (CV =23% and 29% respectively) were much more regular. The superior and inferior origins of the flexor carpi ulnaris nerve were variable (CV = 157 and 22%) while the origin of the nerves for the deep flexor of the IV and V fingers showed a better coefficient of variation (13%). We observed four Martin-Gruber anastomoses (20%).

Conclusion: This study demonstrated the wide anatomic variability of the medial and ulnar nerves both interin-dividually and intraindividually. Emergence of certain nerve branches appeared to be more regular, particularly the lower group of the median nerve and the anterior interosseous nerve of the forearm. It was however impossible to identify two groups exhibiting a statistically significantly greater frequency for the median nerve. The anatomic variations of the ulnar nerve were less pronounced. The inconsistency of the inferior flexor carpi ulnaris is noteworthy.

Purpose: During surgery for repair of rotator cuff tears, some authors always associate tenotomy-tenodesis of the long head of the brachial biceps. Others decide as a function of the gross aspect of the tendon and its position in relation to the bicipital groove. It is a classical notion the preservation of the long head of the brachial biceps is a cuase of persistent pain in operated shoulders. This study was conducted to search for a histological validation of the decision to perform tenotomy.

Material and methods: Fifty tendons of the long head of the brachial biceps presented a thick and inflammatory aspect with or without subluxation during 68 procedures to repair recent rotator cuff tears (23 men, 27 women, mean age 53.5 years). Tenodesis of the long head of the brachial biceps was associated with proximal tenotomy. The histological examination concerned the most proximal centimeter of the tendon. Four parameters were studied: two concerned the tendon (organisation of the collagen network and aspect of the interstitial connective tissue), two concerned the synovial border (sub-synoviocytic layer and synovial mesothelium). Sixteen tendons which appeared perfectly healthy were harvested from cadaver shoulders to determine the normal aspect of histological parameters (parallel and cohesive orientation of the collagen network, absence of hypertrophic interstitial connective tissue, thin subsynovio-cytic layer and pluristratified synovial mesothelium).

Results: The tendon. The collagen bundles were oriented in 32 cases but thick in 40 and dissociated in 47. Microscopic signs of fissuration or intratendinous tears were present in 17 cases. The tendinous connective tissue was oedematous in 49 cases, presenting fibroblastic hyper-cellularity in 37 and hypervascularity in 43. Scar-like fibrosis was observed in 28 cases. The synovial layer was regular in 11 tendons and clearly thickened in 26 with a mixed irregular aspect in the others. The subsynoviocytic layer was thick in 33 tendons with signs of hypervascularity or hypercellularity in 12. The synovial mesothelium was paucistratifed in 23 cases, thick in 12, and regular in 15. Lesions had an inflammatory aspect and were intense in 26 cases. Degenerative lesions were observed in 21 tendons. These four histological parameters demonstrated that the lesions were advanced and associated with degenerative sclerosis with reactional synovitis in 30 cases, moderate combined lesions in 13, tendon and synovial inflammation alone in four, and advanced degenerative lesions of the tendon and the synovial in six.

Discussion: Histological lesions of the long head of the brachial biceps tendon are generally degenerative and irreversible while most synovial lesions are reversible inflammatory reactions. The zones of intratendinous fibrosis, vascularity and weak or absent cellularity constitute the anatomic conditions before tendon tears in chronic tendinopathy. This histological study confirmed the validity of the intra-operative decision for tenodesistenotomy of the long head of the brachial biceps in 46 (92%) of the cases. The oedematous and fissu-rated aspect of the tendon appeared to be a reliable criteria while inflammatory synovitis, which surrounds the tendon, does not constitute in itself a formal argument in favour of tendon sacrifice.

Purpose of the study: The aim of this work was to assess results after treatment by nailing of nonunion of the humeral shaft. In particular, we focused on consolidation and factors predictive of failure.

Material and method: A prospective study was conducted in 13 consecutive patients presenting aseptic nonunion of the humeral diaphysis. There were five cases after orthopedic treatment and eight cases after internal fixation. Two patients had iterative nonunions. Locked nailing was performed with three successive types of nails: the Seidel nail in four cases, the Russel Taylor nail in seven, and the ACE nail in two. Anterograde nailing was used for the first three cases and retrograde nailing for the others. All patients were followed regularly in our department. Last follow-up was one to seven years after nailing.

Results: Five nonunions (38%) did not consolidate after locked nailing. Consolidation was achieved in the other patients after four to 18 months. The anatomic result was good in these patients. Between the success and failure groups, there was no significant difference in age, gender, type of fracture, first intention treatment, delay from fracture to nailing, type or diameter of the nail, surgical access or not to the fracture site during nailing, or duration of complementary fixation. Anterograde nail insertion, used in our first three patients in this series, appeared to affect shoulder function. The retrograde route was used in other patients and did not appear to have any impact on the elbow itself or the elbow region.

Discussion: This clinical study was unable to identify clinical factors explaining failures but did provide several arguments suggesting that defective primary stability of the initial fixation could be incriminated in the failures.

Conclusion: Centromedullary locked nailing is a simple technique with potential for resolving difficult problems of nonunion. Good functional outcome can be obtained when consolidation is achieved. Rather than abandoning this technique, it would be advisable to conduct further research to determine what factors are determinant in its failures.

Purpose of the study: A clinical trial on the treatment of humeral shaft nonunions with locked nailing evidenced 5 failures among 13 cases. The circumstances leading to the nonunion, the patient’s condition, and the nailing method were not found to have a predominant effect explaining this outcome. Inversely, clinical data suggested that abnormal mobility of the nonunion appeared to result from play in the assembly. To check this hypothesis, we measured primary stability in three nailing models using cadaver bones.

Materials and methods: Three nailing models, Seidel (S), Russel-Taylor (RT) and ACE were tested, each on 5 cadaver specimens. A 1 cm segmental resection was made in the mid third of the humerus to simulate an unstable nonunion. The nailing was performed in accordance with the instructions furnished by the manufacturers. The nailed specimens were placed in a testing device which alternatively applied a rotation force around the longitudinal axis (± 0.5 Nm), an axial compression-traction force (± 20 N) and a transverse shear force applied at the level of the osteotomy (± 20 N).

Results: This study demonstrated an instability of the three nails when submitted to a rotation force or a shear force: 14 to 28° and 1.6 to 3.4 mm respectively for the RT nail; 8 to 20° and 1 to 3 mm for the S nail; 5 to 15° and 1.7 to 3.2 mm for the ACE nail. The ACE nail appeared to be more stable when submitted to compression-traction force; the S nail accepted a 0.05 to 0.65 mm play which reached 9.7 mm for the RT nail. This instability appeared to result from play in the locking systems.

Discussion: These findings would demonstrate that these nailing systems cannot, in themselves, provide satisfactory primary stability. The experimentally evidenced instability would contribute, probably in association with locally unfavorable physiological or biological conditions, to the failure rate observed when nailing is used alone.

Conclusion: The locking system for tested nails would have to be modified to eliminate play in the assembly before continuing their use for the treatment nonunion of the humeral shaft.