Purpose of the study: Dementia in the elderly subject aged over 75 years is currently an important public health problem. An important part of the activity in orthopaedic surgery involves this age group. In 2007, 16,812 elderly persons aged over 75 years were hospitalised in our University Hospital (769 in orthopaedic surgery): 1380 patients were considered demented (40 in orthopaedic surgery). The purpose of this work was to evaluate the cognitive function of this population in a teaching hospital unit of orthopaedic and traumatology surgery where the prevalence of dementia appears to be underestimated.

Material and methods: Data were collected over a period of four years. This study concerned 113 patient, including 83 women, mean age 81.8 years (range 75–92). The reason for hospitalisation was predominantly fracture of the proximal femur (73%); thirty patients had hip, knee or shoulder arthroplasty and 24 other situations. The Mini Mental State Examination (MMSE) was performed.

Results: The MMSE could be interpreted for 100 patients: < 24 for 33, 24 to 26 for 29 and > 27 for 38. Among the 24 patients with no cognitive disorder known before hospitalization (nine patients known to be demented were removed from the analysis) and for whom the MMSE was completed entirely, the most frequent alterations were noted for attention, calculation, and recall-memory items.

Discussion: Finally, one-third of the subjects aged over 75 years and hospitalized in our unit presented signs of altered cognitive function according to the MMSE(< 24). This score is one of the criteria for frailness of the elderly subject. This population has an unstable precarious medicosocial status with defective adaptation to stress and change in environment. These persons are exposed to a high risk of morbidity, mortality, dependence, longer hospital stay and institutionalization. The purpose of this screening is to improve management for these patients by proposing more specifically adapted care.

Conclusion: It is thus indispensable to screen for cognitive disorders systematically in patients aged over 75 years hospitalized in a surgery unit. The MMSE score can be used for this purpose. This work is in favour of a physician or better a geriatrician within the unit who could be financed directly by his-her own sector of activity.

Background: Femoro-patellar arthritis (FPA) is less frequent than femoro-tibial arthritis, but still a challenging problem for orthopaedic surgeons. Several treatment have been described from lateral retinaculum release to TKR, with special features to patellar prosthesis. The purpose of this study was to evaluate a large consecutive series of femoro-patellar prosthesis (FPP), to learn about the late outcome, complications and performance.

Material and Methods: Between 1992 and 2004, 60 prosthesis were performed by one of the authors in 55 patients with a mean age of 59 years; 44 were femal and 13 male, 5 had bilateral prosthesis. 62% had essential arthritis with trochlear dysplasia. 78% were graded Iwano III or IV.

Resurfacing cemented Themis^® prosthesis was used in all cases, with a lateral approach associated with a tibial tubercle osteotomy to achieve correct aligment of extensor mechanism. None patient was lost to follow-up.

Results: Mean follow-up was 10 years (46–218 months). During the study, 12 prosthesis were converted to TKR because of femoro-tibial arthritis; but the mean delay between FPP and TKR was 12 years. At revision, 48 FPP were evaluated by an independent examinator. IKS score raised from 106 to 157, knee score from 57 to 89 and function score from 49 to 78. Pain, ability to walk and to climb stairs were improved. Radiography did not demonstrate radio-lucent lines, wear or loosening. 95% had correct aligment of patellar button, without tilting. Survival rates of FPP were 89% at 10 years and 82% at 15 years.

Conclusion: Resurfacing FPP is a reliable procedure offering good clinical performance and outcomes. The authors recommend the use of FPP for isolated FPA, without knee diformity, in association with tibial tubercle osteotomy.

Treatment of recurrent total hip arthroplasty (THA) dislocation is always a surgical challenge. Numerous treatments have been developed, but until now there is no gold standard. The goal of our study was to evaluate the results of a non-constrained tripolar implant (Novae) in this indication.

Material and Methods: The study was retrospective. The inclusion criterion was a dislocated THA which underwent reoperation for changing acetabular stem for a Novae cup. 59 patients were included. Femoral stem was always cemented and was never changed. All patients were reviewed with clinical and radiological examinations. The mean follow up is 8 years (6–11 years). 9 patients died before clinical examination and there was no lost to follow up.

Radiological examination was performed numerically with the software Imagika^®

Results: Only one patient had an early dislocation, treated by external reduction. After reduction, no more dislocation occurred. One patient had a femoral fracture below the femoral stem treated by plate. Dislocation rate in our study was 1.7%. The mean Postel Merle d’Aubigné score was 16.5 (12–18) and the mean Harris score was 86.7 (49–99). Radiologically, there wasn’t aseptic loosening neither implant migration, but 19% of the radiographs showed a radiolucent line (less than 1 mm).

Discussion: We compared the results of our study with the results of the other treatments of dislocation. With a dislocation rate of 1.7%, the efficacy of the tripolar non-constrained implant is much better than that of several other treatments, such as external braces, allograft, re-orientation of acetabular shell, change of liner or acetabular augmentation. Constrained implants have also a low dislocation rate, but they have an increased risk of early aseptic loosening. The high rate of radiolucent lines at the last examination is possibly due to the absence of osteointegrating surface of the shell. New implants with osteointegrating surface have been developed.

Conclusion: The efficacy of the studied non-constrained implant is very good with a re-dislocation rate of 1.7%. At 8 years of follow-up, the clinical and radiological results are excellent. We continue to use this implant in the prevention and treatment of dislocation.

Introduction: Modular necks used during primary or revision total hip arthroplasties permit to restor the ideal femoral offset and arm of abductors muscles, to ajust leg length and to reduce impingment between the neck and the socket with good hip balancing.

Material and methods: Modular necks are titanium implants manufactured with a double Morse taper: one cylindrical for the junction with the head, and one flat for the junction with the stem. They are avalaible in 2 lengths (short and long) with 6 different geometries: straight (CCD:135°), antevreted of 8° or 15°, 8° and 15° of varus (CCD: 127° and 120°), and a combination of anteverted and varus neck.

362 revision and 920 primary THA were performed with a minimal of 5 years follow-up in the Orthopaedic Department of Amiens University Hospital with modular necks.

Results: 23 patients died and 11 were lost of follow-up. None rupture was deplored. Femoral offset was restored in 97% of these cases even in the revision surgery, end equalization of leg length was obtained in 98% of the patients. Residual Trendelemburg sign was noted in 37 patients, always after revision. The rate of dislocation was low with 2% because of the absence of impingment.

Discussion: Because proximal femoral geometry is different for each patient and femoral offset independent from the IM canal diameter, modular neck is one easy solution to restor independent parameters. In addition, the per-operative trials permit to choose the best implant to avoid any impingment, reducing the risk of dislocation and increasing the range of motion. It’s ideal now for the use of hard bearings. Laboratory analysis have demonstrated very good resistance in assembly-distraction, deep flexion and rupture tests. No corrosion was noted and retrieved weight loss was minimal.

Purpose of the study: Osteosynthesis procedures proposed for fractures of the proximal humerus have evolved greatly since the development of anterograde nailing systems with the objective of providing a conservative surgical solution for sometimes complex fractures. We analyzed retrospectively the results obtained in a consecutive series of 30 patients treated in our unit with a Telegraph® nail.

Material and methods: Between March 2001 and August 2003, 39 patients presenting fractures of the proximal humerus were treated with a Telegraph® nail. Accorrding to the Duparc classification, the fractures were: 17, 11 ST+T, 4 CT II, and 7 CT III. Five patients died before the review presented here. Four CT III fractures presented material disassembly early and required revision with a hemiarthroplasty. For the 30 patients reviewed here, we noted the Constant score and the results of the Matsen test as well as radiographic findings.

Results: Mean follow-up for the 30 patients was 16 months (range 6–33). Mean age at trauma was 58.7 years (range 19–91). The mean Constant score was 57.4 (range 16–84) with 72% after weighting. The Matsen test was positive for 59%. Subjectively, 69% of patients were satisfied or very satisfied. There were several complications: secondary intraoperative shaft fracture treated orthopedically, four nonunions of the surgical neck, four tuberosity migrations, three cases of head necrosis, two subacromial impingements (one with rotator cuff tear). Nonunion was generally observed with static locking and in one case with an oversized nail. We were unable to identify any factor predictive of head necrosis due to the small number of cephalotuberosity fractures. Disassembly was generally observed in patients with an initially displaced fracture with periosteal rupture, osteoporosis and old age.

Discussion and conclusion: Our results are less satisfactory than others published in the literature for series using this material and it is difficult to compare with results for series using other types of material because the study criteria were highly variable. Although all fractures in this series, including the most complex, appear to benefit from this nailing system, we did note that complications were not exceptional even though certain compliations observed were related to our learning curve. Surgeons should be aware that the planned option can be changed intraoperatively. Arthroplasty may be necessary in certain cases if the conditions are not adequate for stable osteosynthesis.

Purpose of the study: The aim of this work was to compare the long-term clinical, ultrasonographic and iso-kinetic results obtained with two approaches to repair of the torn Achilles tendon.

Material and methods: The patients were reviewed at mean six years follow-up (range 2–12 years) and served as their own control. The series was composed of two groups of ten patients. The first group underwent open suture (OS) (mean age 48 years, age range 38–64 years) and the second was treated percutaneously with Tenolig® (PCS) (mean age 43 years, age range 25–68 years). The Mann, McComis and Kitaoka scores were noted as was the distance from the heal to the ground in one leg stance (comparison with opposite side). Cybex® was used to measure the isokinetic force and an ultrasound control was performed (tendon structure, dimensions).

Results: The calf of the operated side displayed amyot-rophy compared with the healthy side in all cases of PCS (mean 2 cm, range 0.5–6 cm). The heal-ground distance was often smaller compared with the healthy side in PCS. The Mann scores were equivalent for OS and PCS. The Kitaoka and McComis scores were, on average 86 (80–100) and 94 (60–95) respectively for OS versus 82 (85–100) and 91 (60–95) for PCS. Mean caliber of the operated Achilles tendon increased compared with the healthy side for both suture techniques. Isokinetic force was 3–6% greater with OS for peak force, average force, and total work.

Discussion and conclusion: Both techniques have specific complications: recurrent tears and sural nerve injury for PCS, risk for the skin and adherences for OS. The long-term outcome after PCS of the Achilles tendon is comparable with that of OS in terms of healing quality. Recorded values are however slightly higher with OS. Our results are in line with data in the literature. OS can be reserved for particularly active patients who wish to recover maximum function.

Purpose: We report a series of 78 total hip arthroplasty revisions using a locked femoral stem, Ultime.

Material and methods: These patients presented aseptic loosening (88%) and septic loosening (12%). Fracture was associated in 17%. The preoperative Postel Merle d’Aubligné (PMA) score was 10.2 points. Using the Vives-SOFCOT classification, 29% of the loosenings were stage I, 37% stage II, 24% stage III, and 10% stage IV. All fractures were associated with lossening. We used a femoral window in 57% and trochanterotomy in 14 cases. The first eight patients in this series had an allograft (impacted piecemeal). Most of the patients resumed weight bearing the first week. The PMA score was used to assess outcome. AP and lateral views were used to evaluate stem-bone contact and cortical thickness at three levels.

Results: Early complications were phlebitis (n=1) and superficial haematoma (n=5). Late complications were dislocation (n=6), stem fracture (n=2), deep infection (n=3). At last follow-up, 81% of the aseptic loosenings, 77% of the septic loosenings, and 70% of the fractures on stem had a good or excellent PMA score with a mean gain of 4, 5, and 1 points respectively. Bone reconstruction showed an increase in internal cortical (2 to 4.4 mm) and stem-bone contact increased in the lower two-thirds of the stem. Allografts did not improve results. Furthermore, 28% of the patients had hip pain which could not be related to clinical findings or implant characteristics. Half of the patients were reoperated.

Conclusion: In this series, functional improvement was similar to that in published series. The femoral window facilitated the procedure and decreased intraoperative complications. The Ultime prosthesis met the objectives set by the manufacturer, i.e. primary stability and bone reconstruction authorising subsequent revision.

Purpose: Deep infections of the operative bed are rare but serious complications of first-intention total hip arthroplasty. Data from French series are scarce. We present a study of incidence, characteristic features and potential risk factors using a consecutive series of 790 implants performed during first-intention procedures in the same university hospital.

Material and methods: All patients who underwent first-intention surgery from November 1995 to May 1999 were included. We collected demographic, clinical, and therapeutic data. Deep infection was defined as bacteriological demonstration of the infectious agent from at least two intra-operative specimens during the revision procedure. Patient follow-up ranged from one month to four years. Univariate analysis was used to search for potential risk factors. The chi-square and Fischer exact tests were applied.

Results: Overall incidence was 1.77 deep infections for 100 operations (95%IC 0.84–2.7). Mean time to development ranged from 14 days to 32 months. Eleven infections were recognised within the first year and three after one year. Two risk factors were identified: absence of systemic antibiotic prophylaxis (relative risk = 4.74, p=0.03), and drainage discharge after 48 hr (relative risk = 3.62, p=0.02). Other variables associated with infection with a relative risk greater than 2 were obesity, corticosteroid therapy, and haematoma or postoperative wound healing problem.

Conclusion: The incidence found in this series is slightly higher than generally described in other countries. This study has incited us to revisit our protocols for preoperative skin preparation and to establish a systemic antibiotic prophylaxis.

Purpose: We report a series of 50 pilon fractures treated by osteosynthesis and report outcome at minimum seven years.

Material and methods: The series included 28 men and 22 women, mean age 44 years. Thirty-one patients were fall victims. The AO classification was type B (n=24) and type C (n=26). According to the De Lestang classification there were 12 simple fractures and 38 complex fractures (including 26 complete fractures) Sixteen fractures were open and 39 were associated with a fracture of the lateral malleolus. Most of the fixations were achieved via an anterolateral approach (n=22) using a prebent plate, or via a medial approach using a clover-leaf plate. A cancellous graft was used in seven cases. The Kitaoka classification was established at last follow-up.

Results: The radiographic work up included a lateral view and an anteroposterior view with moderate medial rotation. Mean follow-up was fourteen years. There were ten secondary displacements. Late complications were: non-union (n=14, including 10 cases requiring revision for arthrodesis), reflex dystrophy (n=6), deformed callus formation requiring revision, and one case of amputation after infection. At last follow-up, 33 ankles were painful (including 13 permanently painful ankles). Twenty-four patients had a residual limp (13 permanent) limiting walking distance in half of them. The talocrural joint motion was normal in 20 patients and the subtalar joint was normal in 24. Twenty-three patients resumed their former activities. For patients with sports activities, 64% resumed activities at the same level. The Kitaoka score was 79 points at last follow-up with outcome scored good in 70%, fair in 16% and poor in 14%. Excepting the patients who had secondary arthrodesis, 24 patients developed secondary osteoarthritis (including ten stage 2 and 3).

Discussion: Good outcome depends on the intraoperative reduction, both at the epiphyseal level (for complete fractures) and the metaphyseal level. This reduction must be maintained over time with a good fixation rigid enough to avoid secondary displacement which is a cause of callus deformation. The severity and complexity of the initial fracture constitute the main factors affecting outcome. In our opinion, computed tomography provides the best means of establishing the therapeutic indications. Pilon fractures remain a difficult challenge in orthopaedic surgery. Perfect reduction is the best guarantee of good outcome.

Purpose: Total ankle arthroplasty remains a difficult procedure. Some patients require revision surgery for arthrodesis.

Material and methods: We report nine patients with total ankle arthroplasties mainly implanted for post-traumatic osteoarthritis whose results deteriorated, requiring arthrodesis. One of these patients had rheumatoid arthritis.

Revision surgery was performed six months to seven years after arthroplasty. Arthrodesis was required for pain related or not to implant loosening or talar necrosis. One patient developed a major deviation of the hind foot secondary to progressive loosening. One patient developed infection early. An iliac graft was used to fill the bone defect in eight patients. An anterior plate-screw fixation was used for six patients, crossed screws for one, a tibiotalar nail for one, and an external fixator for one (with infection).

Results: Eight patients achieved bone healing with good pain relief. The functional result depended on the type of arthrodesis: talocrural alone or extended to the torsion couple.

Discussion: The evolution of ankle prostheses toward better bone sparing has allowed, in our experience, for revision arthrodesis under relatively good conditions using an iliac graft. We have not preferred one standard type of fixation but the anterior plate fixation has provided excellent stability.

Purpose: We report a series of 52 chronic Achilles tendinopathies. Surgical treatments included peritendon dissection, release of the fasia cruris, limited blunt combing of the tendon, and resection of nodules, calcifications and cysts as needed.

Material and methods: Mean duration of disease before treatment was 18 months. Twenty-six patients had sports activities. There were 12 bilateral cases. Pain was present in all cases. Ultrasonography was used to establish the PUDDU classification: paratendinitis 21, tendinitis 22, paratendinitis with tendinitis 9. All patients were reviewed at two years. Clinical criteria were used to assess outcome.

Results: Mean follow-up was five years six months. Complete pain relief was achieved in 29 cases. Motion was normal in 48 with recovery of former sports level in 29. Overall outcome was very good in 29, good in 14, fair in six and poor in three.

Discussion: The mean age of patients with poor outcome was relatively high. All the poor results were correlated with amyotrophy. The presence of a foot deformity did not appear to have an unfavourable effect on outcome. Infitration of the Achilles tendon should be avoided. Avoiding immobilisation appears to prevent tibiotalar stiffness. Ultrasonography can distinguish paratendinitis, tendinitis and paratendinitis with tendinitis but MRI offers very precise images of the lesions.

Conclusion: Surgical treatment of chronic Achiles tendinopathy can be proposed after failure of medical treatment. Outcome is better in younger subjects who participate in sports activities and who have paratendinitis.