Introduction

The action of the radial head in the stability of the elbow is currently admitted. Its conservation is not always possible in complex fractures. The association with a posterolateral dislocation of the elbow leads to a higher risk of instability of the elbow joint and also at a longer term to degenerative changes. Some authors recommend the use of metallic radial head implant, acting as a spacer. The results seems encouraging but should the resection arthroplasty associated with the repair of the medial collateral ligament be abandoned?

Purpose of the study: We have had a growing number of revision total hip arthroplasty (rTHA) which have required femorotomy, either planned preoperatively, or required because of difficult extraction of the cemented implant. Few results have been reported in the literature. The purpose of this work was to evaluate late healing of femoral bone and complications.

Material and methods: For this retrospective analysis, we included 43 patients, mean age 66 years. These patients had a femorotomy during rTHA performed from 1997 to 2008. There were 37 revisions in an aseptic context for isolated femoral loosening (n=26), bipolar loosening (n=4), acetabular loosening (n=4), recurrent dislocation, fracture of the femoral stem, and periprosthetic fracture (n=1 each); there were six revisions in septic conditions. Techniques were: femorotomy (n=22), wide trochanterotomy measuring proximally to distally 12 cm, four cortical cuts and one oblique osteotomy to correct valgus. The reconstruction used locked femoral stems (n=17), cemented stems (n=17) and non-cemented stems (n=10). The osteotomies were closed with cerclage or steel wires.

Results: Bone healing was assessed on the plain x-rays of the hip joint at three, six and twelve months. Among the 43 patients included in this analysis, complete data were available for 37. There were 36 cases of successful healing and one case of nonunion on a wide trochanterotomy. The function outcome was assessed a mean three years.

Discussion: Femorotomy remains a difficult technique, sometimes facilitating stem extraction, but with a high risk of morbidity. The morbidity is difficult to evaluate initially, linked more with time to weight-bearing at two months on average. In this small series we nevertheless found few problems with bone healing, even in septic conditions.

Conclusion: Femorotomy remains a valid option when required. It is a difficult technique but provides reliable results in terms of complete healing three months postoperatively.

Purpose of the study: Although the role of the radial head is clearly established regarding elbow stability, it cannot always be preserved after complex fractures. Association with a posteriolateral dislocation, besides the risk of short-term recurrent dislocation, raises the problem of long-term osteoarthritic degeneration. Certain authors advocate a metal prosthesis which works like a spacer in lieu of the head; their mid-term results have been encouraging, but should complete resection with suture of the medial ligament plane be ruled out definitively?

Material and methods: We reviewed 13 files of patients who had had an initial resection of the radial head after trauma. For seven of these patients, there was an associated dislocation; the medial ligament structures were sutured. All patients were reviewed with mean 13 years follow-up (5–15) and evaluated clinically with the American Shoulder and Elbow Surgeon (ASES) system to establish the Mayo Clinic Elbow Performance (MCEP) score. Osteoarthritis of the ulnar trochlea was analysed on the plain x-rays, completed by an axial view, using the Morrey radiographic classification of 4 stages.

Results: There were not cases of recurrent dislocation. According to the Broberg and Morrey index, 92% of patients had good outcome with total resumption of occupational activities; there was no difference between patients with and without dislocation. All patients developed grade 1 or 2 osteoarthritis, with very good clinical tolerance. All were satisfied with their operation despite efforts to spare joint movements.

Discussion: The studies evaluating the use of radial head prostheses have reported similar findings for functional outcome. Radiographic degeneration of the ulnar trochlea is also comparable. Immediate rehabilitation is necessary to prevent loss of range of motion and warrants surgery to stabilize the joint as wells as possible use of an adapted dynamic orthesis.

Conclusion: Resection of the radial head without prosthetic reconstruction remains a reasonable option when the head cannot be saved. Associated dislocation implies repair of the medical collateral ligament. At long-term, the functional impairment is minimal despite the moderate osteoarthritis; the problematic of implant survival is avoided.

Introduction and Method: For 16 years, now, we have been using custom made femoral stems (titanium stem, HA coated) based on preoperative patient CT scans in young patients presenting with symptomatic osteoarthritis of the hip. The aim was to provide optimum initial fit-and-fill of the stem in the femoral medullary canal, conferring the best chance of secondary osteoin-tegration. This, with a goal of long term survivorship. The custom stem also enables dialling-in correction of the (often abnormal) femoral neck version (in young patients presenting with arthritis) to a more normalised 15 degrees of anteversion.

Results: We present the long term results (5–16 year, mean of 10 years), clinical, survivorship and radiological, of 312 primary total hip arthroplasties in 280 patients, all of whom were under the age of 50 years of age (mean age 40).

At 10 years we have a survivorship, if femoral aseptic loosening is used as an end point, of 97.6%. There was a deep infection rate of 1.2%, and a dislocation rate of 1.9%. There were no cases of thigh pain, and no intra-operative femoral neck/shaft fractures.

Discussion: The under 50’s with hip arthritis requiring total hip arthroplasty are a highly challenging group, they are young, active and tend to have distorted anatomy. Our results are superior to those previously published using either cemented or standard uncemented stems. Thus, justifying the increased initial financial outlay on the custom-made stem.