Introduction: The anterior pelvic plane (APP), described by Lewinnek, is defined by the following points : anterior iliac spines, pubic symphysis. This plan is mostly considered as vertical in weight bearing and is currently used as the reference to guide cup insertion by means of imageless computer assistance (CAS). However, to our knowledge, there is no data that strongly confirm APP is vertical in weight bearing and how much his orientation is modified with regards operative position, or THA insertion. This study assessed these data by means of a radiological analysis.

Material and Methods: The orientation of the APP was measured with regards to the vertical plane on weight-bearing profile X-rays of the pelvis in 106 subjects including:

1) 82 patients with THA (40 who had at least one dislocation, and 42 matched patients without instability randomly selected, 19 of these 42 underwent a profile X-ray of the pelvis before and after THA insertion)

Results: Thirty-eight percent of the subjects in weight-bearing had an orientation of the APP different of more than ± 5° from vertical plane and 13% were out of the interval ±10°. The orientation of the APP was not significantly different between the groups (standard and THA) nor between the groups who had stable or unstable THA. The orientation of the APP was significantly modified between lying and weight-bearing posture, from a mean of 1,2° lying to −2,25° upright. Under these conditions, 12 subjects presented a variation of more than 7°. Insertion of a THA did not significantly modify the orientation of the APP in weight-bearing among the 19 subjects (variations were small (−1° ± 7° [from – 21° to 8°]), but were more than 5° for 7 of the 19 subjects).

Discussion and Conclusion: Most of the surgeons use the APP as a reference to guide navigation for cup insertion, considering it is vertical in weight-bearing. However, it is not true for 38% with a margin of 10°, which is equivalent to approximately half of the anatomical anteversion of the acetabulum. Standing up produced a significant variation of the orientation of the APP with regards to lying position. These errors that are not integrated by most of the CAS without preoperative CT scans, may produce cam effect or dislocation when the patient is moving to sited position. The variations of APP orientation with regards to vertical plane suggest it is not adequate to guide the CAS insertion of the cup. There is no reliable reference, easily identifiable during surgery that integrates the variations of position of the pelvis. This leads us to promote a new CAS for THA insertion free of reference plane, based on kinematics.

Purpose of the study: Most systems used for computer-assisted total hip arthroplasty require preparatory computed tomography acquisition or use of multiple bone markers fixed on the pelvis. In order to overcome these problems, we developed a novel system for CT-free computer assisted hip surgery based on a functional approach to the hip joint. The concept is to orient the cup within a cone describing hip motion. The purpose of the present study was to analyze preliminary results obtained with this new system.

Material and methods: This new system was used to implant 18 primary total hip arthroplasties in 16 women and 2 men (mean age 68±7.8 years, age range 54–83 years) with degenerative disease. Two optoelectronic captors were fixed percutaneously on the pelvis and the distal femur. The acetabulum was reamed, then the femur prepared with instruments of increasing caliber. The last reamer positioned in the shaft carried an upper head which matched the size of the prepared acetabulum. Hip joint motion was recorded to determine the cone of maximal hip mobility. The system then oriented the cup so that this cone was completely included the cone described by the prosthesis.

Results: There was one traumatic posterior dislocation (fall in stairs) at three weeks, without recurrence. The Postel Merle d’Aubigné score improved from 8±2.9 (3–12) preoperatively to 17±0.8 (16–18) at last follow-up. None of the patients complained about the sites where the percutaneous markers were inserted and ther were no cases of hematoma or fracture. Mean leg length discrepancy was 5.6±7.5 mm (range 0–25 mm) before surgery and 0.6±3 mm (range −5 to 10 mm) at last follow-up. Mean anteversion of the femoral implant was 22.3±6.7° (14–31). Anatomic anteversion of the cup (measured from a marker linked to the pelvis and thus independently of the position of the pelvis) was 25.9±10.4° (12–40). The sum of the femoral and acetabular anteversions was 48.2±14.6° (range 27–71°).

Conclusion: This method can be used in routine practice without lengthening operative time excessively. It provides a safe way to control the length of the limb and helps position the cup. This study demonstrated that there is no ideal position for the cup that can be applied for all patients. Because of the wide spread of the inclination and anteversion figures, half of the cases were outside the safety range recommended by Lewinnek.

Purpose of the study: Because of its specific properties, linezolid (LZD) is an alternative to glycopeptides for the treatment of BJI causes by resistant Gram-positive cocci. The efficacy and tolerance of long-term (> 28d) administration remain to be determined with precision.

Material and methods: This was a retrospective analysis of the files of patients who received long-term LZD for BJI with a post-treatment follow-up of at least twelve months.

Results: Between January 2001 and December 2003, 68 patients (mean age 54.6 years) received LZD (600 mg/12h) intravenously then orally for a mean duration of 14.6 weeks on average (range 6–36 weeks). The orthopedic implants were infected in 31 patients (45.6%, 27 prostheses and 4 external fixators). A fistulization was diagnosed in 29 patients (42.6%). Medical and surgical treatment was undertaken in 51 patients (75%). Germs isolated from deep samples were staphylococci (n=57, 51 meti-R), and strepotococci (n=11). A polymicrobial infection was recorded in six patients (8.8%). Clinical success was achieved in 52 patients (76.5%) at the end of treatment, a result which was sustained for 48 of them to mean follow-up of 16.8 months (range 12–48). Sixty-three episodes of side effects were noted: anemia (n=29), peripheral neuropathy (n=9), nausea (n=14), headache (n=2), neutropenia (n=2), and thrombopenia (n=1), leading to discontinuation of LZD in 23 patients (33.8%) on average 11.9 weeks (range 6–36) after onset of treatment. Fifteen patients (22.1%) required transfusion.

Discussion: Among the patients in this series with BJI, most caused by a multiresistant germ, the rate of success was satisfactory (48/68, 70.6%) with LZD. Treatment was associated with a high frequency of serious adverse effects leading to discontinuation in one-third of patients.

Conclusion: Long-term treatment of BJI with LZD appears to be effective, including in patients with infected orthopedic material. Conversely, tolerance problems can limit is use to infections caused by mul-tiresistant Gram-positive cocci unresponsive to other compounds.

Purpose of the study: In order to evaluate the influence of prosthesis design and resurfacing on the outcome of total hip arthroplasty (THA) implanted without cement, we reviewed the orthopedic literature from 1980 to 2004.

Material and methods: The PubMed database was screened from 1980 to 2004 for publications reporting cementless THA with a follow-up analysis. The same criteria were used to screen three registries. In all, the publications retained had studied 50,162 cementless THA (mean patient age 48.9 years, mean follow-up 6.5 years) where were studied according to rate of revision, presence of osteolysis, and presence of operative fractures. Eleven families of components grouped together the majority of prostheses: five acetabular families [screw fixation without resurfacing (n=2997), screw fixation with hydroxyapatite (HA) resurfacing (n=3618), screw fixation with corindon resurfacing (2360), press-fit mac-roporous (15691), press-fit HA (6094)]; and six families of femoral pivots [straight macroprous (n=7502), straight HA (n=3255), straight corindon (n=6136), anatomic HA (n=3468), anatomic macroporous (n=1215), anatomic corindon (n=1041)].

Results: The rates of revision and of osteolysis were higher for screw fixed cups without resurfacing. For screw fixed or press-fit cups, HA resurfacing did not reduce the rate of revision compared with corindon coated or macroporous implants. For anatomic pivots, adjunction of HA resurfacing reduced the rate of revision but at the shortest follow-up and without reducing the rate of osteolysis. Corindon-coated pivots gave comparable results for straight or anatomic implants. Conversely, HA-coated pivots gave better results with an anatomic design. The shape of the pivot had les effect than resurfacing on osteolysis and revision, but had a greater influence on operative fractures (2.9% for straight implants versus 4.6% for anatomic versions).

Conclusion: In all:

uncoated implants should be abandoned;

Delayed sciatic nerve palsy is uncommon after primary hip replacement. Two kinds of sciatic palsy have been reported with regard to the time of onset: early palsy related to wound haematoma or lumbosacral nerve elongation which occurs between surgery and 18 days, is more frequent than delayed palsy, occurring between 10 and 32 months, which is usually caused by cement extrusion or heat produced by cement polymerisation.

We present two cases of delayed, transient sciatic nerve palsy arising at three weeks and four months after primary cementless arthroplasty, respectively, without haematoma and with a normal lumbar spine. These palsies were possibly caused by excessive tension from minor limb lengthening of 2 cm to 4 cm required to achieve leg-length equality. As the initial symptoms were limited to calf pain and mild numbness in the foot, surgeons should be aware of this mode of onset, particularly when it is delayed after hip replacement. Both patients recovered fully by 12 months after surgery so we did not undertake surgical exploration of the nerve in either patient.

Thirty-nine cementless hip replacements using metal-on-metal articulation were consecutively implanted in thirty patients less than fifty years of age and compared with a matched control group of cementless replacements using ceramic-on-polyethylene articulation. The Harris hip score at follow-up (minimum five years) for the metal-on-metal was 94.9 (range, 74–100). After the same follow-up, the results of the ceramic-on-polyethylene were significantly worse: nine osteolyses and seven surgical revisions related to wear. Five-year survival rates were 97% +/− 2% for the ceramic-on-polyethylene and 100% for the metal-on-metal. The metal-on-metal may be recommended to prevent wear problems in younger and more active patients.

The aim of the current study was to assess the results of metal-on-metal articulating components inserted as a primary hip replacement in patients under the age of fifty, comparated with a matched control group using ceramic-on-polyethylene.

Patients and methods

The inclusion of patients was: under fifty years of age and a diagnosis of arthrosis or necrosis of the femoral head.

Femoral stem and cup migration was detected. A variation over five millimeters between the follow-up radiographs was considered as migration.

At the follow-up in 2003, the cobalt concentrations in the whole blood were assessed in the metal-on-metal cohort. The detection limit of cobalt in the whole blood was 0.06 μg/L.

None of the components had migration.

At a mean follow-up of sixty-nine months, the median concentration of cobalt in the whole blood was 0.62μg/L. Only eight patients had cobalt levels greater than 1 μg/L.

Considering a reoperation with the exchange of one of the components as end point, the five year survival rates were 100% for the metal-on-metal group and 97% + 2 for the ceramic-on-polyethylene group. Our study suggests that the metal-on-metal articulation gives a significant improvement in terms of resistance to wear when compared with these conventional bearing components. Our results suggest the metal-on-metal articulation with cementless components can be recommended in the young and active patient to prevent the occurrence of wear and osteolysis. A careful assessment of patients with high levels of whole-blood cobalt should be performed.

Funding: Aucun

Purpose: In young active subjects, total hip arthroplasty (THA) raises the risk of early polyethylene wear eventually warranting the use of alternative bearings. The purpose of this study was to analyze outcome in subjects aged less than 50 years implanted with a primary metal-on-metal prosthesis.

Material and methods: Between 1995 and 1998, thirty-nine THA with a metal-on-metal bearing were implanted without cement in 30 consecutive patients aged less than 50 years, mean age 23–50). There were nine bilateral implantations. The cementless implants had surface treatment without hydroxyapatite and 28 mm heads. The indication for THA was necrosis in twenty cases, osteoarthritis in nineteen, most in patients with hip dysplasia. The Devane classification placed 84% of the patients in levels 4 or 5, indicating heavy work and/or sports activities. Inclusion criteria were: 1) age less than 50 years, 2) significant activity (occupation and/or sports), 3) osteoarthritis or necrosis. Patients were included and followed prospectively. Serum cobalt level was measured at last follow-up. None of the patients were lost to follow-up.

Results: The Postel-Merle-d’Aubigné score (PMA) improved from 12.8±2.2 (7–15) before surgery to 17.2±1 (14–18) at 5.1 years (5–6.3). None of the patients complained of hip pain. Two patients has moderate inguinal pain related to a cupiliopsoas conflict. All patients achieved complete weight bearing on the fourth postoperative day excepting three who resumed weight bearing at six weeks due to an acetabular augmentation graft. There were no cases of implant migration and all implants exhibited signs of osteointegration on the radiograms. There were no postoperative dislocations and no cases of osteolysis could be identified, particularly in the eight patients who had increased serum cobalt (four bilateral implants) and who had no other statistically significant favouring factor.

Conclusion: The results at five years suggest that the second-generation metal-on-metal bearing is a reliable alternative when THA is proposed for young active subjects. Long-term follow-up of this cohort of subjects at high risk of wear is necessary to confirm these encouraging results.

Purpose: Femoral revision can be difficult when associated with important loss of bone stock and femoral deformation, particularly when the deformation prevents using a long prosthesis despite major loss where it would be useful. We describe a novel technique allowing a simultaneous solution to these two problems and report preliminary results in five patients.

Material and methods: The technique was applied in five patients. Briefly, one or several osteotomies at different levels were performed to correct the deformation in one or more planes, and fixed with a locked femoral implant. Femorotomy was associated in four patients to facilitate removal of prior implants and constituted one of the correction osteotomies. In one patient, non-union of the greater trochanter was treated with a plated autograft. The series included three men and one woman, mean age 72 years (65–83). According to the SOFCOT score, femoral bone loss was grade II in four patients and grade III in one. All femurs had varus deformation (mean 21°, range 16°–40°), and two femurs exhibited permanent flexion (40° and 45°). One shaft osteotomy was used in four patients and two osteotomies in one. The locked femoral implant measured 250 mm in three and 300 mm in two.

Results: Mean follow-up was 3.5 years (0.5–5). One patient committed suicide at six months. The mean Postel Merle d’Aubigné score improved from 9.4 (7–11) to 16.4 (15–18). The trochanter non-union and all osteotomies head at three to four months except one case of shaft non-union which was well tolerated (PMA=16, in a patient without femorotomy who did not require recalibration of the proximal femur). In these healed cases, remodelling and/or spontaneous reconstruction of the femur was observed without grafting for the shaft. There was no stress shielding aspect in the patients with the longest follow-up although they had non-cemented stems with distal locking and no surface treatment.

Conclusion: The technique proposed for this specific indication enables resolution of the double problem of fixation and correction of deformation while allowing spontaneous reconstruction around the non-cemented locked implant. Use of femorotomy is recommended to allow recalibration and stabilisation of the proximal femur around the stem. Longer follow-up is needed to ascertain longevity of the spontaneous reconstruction. Nevertheless, these non-reintegrated implants behave like locked centromedullary nailing.

Purpose: The purpose of this retrospective study was to detail factors influencing outcome of corticocancellous grafts for the treatment of scaphocarpal non-union and to determine ideal indications.

Material and methods: Between 1984 and 1999, this grafting technique was used for 103 patients; we retained for analysis 57 wrists (58 nonunions). Mean follow-up was 106 months. Mean age was 36 years. For 45 patients, non-union occurred because of misdiagnosis. According to the Schernberg classification, eleven nonunions were in zone II, 40 in zone III, and seven in zone IV. Time from fracture to treatment was 35 months on average. The Alno classification of non-union was: stage I=13, stage IIA=20, stage IIA=22, stage IIIA=2, stage IIIB=1. The graft was harvested from the pelvis in 50 cases. Osteosynthesis was associated with a graft in 33 of the 58 cases. Postoperative immobilisation was maintained for 2.7 months on average. Bone healing was achieved within thee months.

Results: Thirty-six patients were very satisfied. Twenty-seven had significant pain on the pelvic harvesting site (50 harvestings). Wrist motion was 56.2° flexion, 56° extension, 83° supination, 83° pronation, and 11° radial and 32.7° ulnar inclination. Thumb opposition was noted 9.4/10 and average contraopposition was 4. Mean index of carpal height was 0.547. The mean radiolunate angle was 4.8°. A DISI deformation was observed for 20 wrists. Thirty-six patients (62%) developed little or no osteoarthritis. The rate of bone healing was 81% but eleven nonunions did not heal, including seven cases of necrosis of the proximal pole. The absence of DISI deformation correction at the time of grafting favoured development of radiocarpal osteoarthritis. The presence of necrosis favoured persistent non-union. Concomitant osteosynthesis did not improve the healing rate.

Discussion: Treatment of scaphoid non-union with a corticocancellous graft remains the choice alternative, providing 81% healing. Grafts consolidation must occur at the radial epiphysis in order to limit painful sequelae. This procedure can be performed for patients with a DISI deformation, but vascularised grafts should be preferred in the event of necrosis of the proximal pole of the scaphoid.

Aims: Rosenow’s broth is an enriched liquid medium used at laboratory for culture of anaerobes. It has never been tested for transport and culture of bacteria, particularly those that are frequently involved in chronic prosthetic infections. This prospective study assessed these data. Methods: 154 intraoperative specimens and joint aspirations were harvested between 1998 and 2000 in 80 patients that had infected knee (24) or hip (56) prostheses. For each of the 154 specimens there was a standard and a Rosenow recipient. Culture obtained on agar medium was called “direct culture” (DC) and culture from any liquid medium was called after “enrichment” (AE). The similitude between bacteria isolated from different specimens was assessed. Results: A bacteria was isolated from DC in 59 specimens (38%) and after AE in 95 specimens (62%). Among the 59 positive DC there was agreement between standard and Rosenow in 87%, and no agreement in 13% [ Staphylococcus sp. (6), Pseudomonas sp.(1) Enterobacteriacae (1)]. Among the 95 cultures AE, Rosenow and standard cultures were in agreement in 41 (43,1%), only standard was positive in 13 (13,6%), but only Rosenow’s broth was positive in 41 (43,1%) with negative standard cultures [16 Staphylococcus sp(13 S. epidermidis), 5 Streptococcus sp., 2 Enterococcus sp., 1 Corynebacterium sp, 3 Enterobacteriacaeand 14 anaerobes]. Sensibility and predictive positive value of Rosenow were respectively 0.86 and 0.86. Conclusion: This study suggest the accuracy of the Rosenow’s broth for transport and culture as agreement was observed in 87% with the DC that is considered as the “gold standard”. When only cultures AE were positive, the Rosenow’s broth corrected the diagnosis in 43%, particularly for infections related to S. epidermidis-and anaerobes.

Aims: The goal was to determine if young patients respect the instructions for medical supervision control instructions after a total hip arthroplasty (THA). Methods:We performed 50 THA (Harris cups and ABG I stems) in 39 patients, mean age 38 years ± 11 (15–58). There were thirty-eight 28mm femoral heads (30 zirconia, 8 chromium-cobalt) and 12 chromium-cobalt heads in 22mm. Each patient was told how necessary a regular medical supervision was with the following schedule: controls at 2 months, 1 year then every two years. In 2000, all the patients were evaluated (no lost for follow-up). Wear was measured according to Livermore with a digitizer. Results: At 72 ± 14 months of follow-up (5–9 years), 51% of the patients (20/39) did not come back for the intermediate controls. No factor could be accounted for that, except being a male (p=0.04). Wear was rather severe (average 0.23 mm/year). 37% of the patients with a severe wear (> 0.2 mm/year) did not come back for intermediate controls and were all free of symptoms. There were 3 revisions because of wear (> 2 mm) and 3 others hips are awaiting revision because of wear. Three of these 6 patients did not come back for intermediate examination. The 28mm heads induced more wear than the 22mm heads (p=0.008). No other factor was related to how severe wear was (age, sex, activity or thickness of polyethylene inserts). Moreover the zirconia did not reduce wear. Conclusion: In spite of the recommendations, half of the patients did not respect the medical supervision schedule and that was unpredictable. We recommend a careful follow-up of young patients after a THA in order to detect wear (usually free of symptoms). Moreover our study underlined that the zirconia wasn’t so efficient to prevent wear phenomena.

Aims: Three methods of mobilization are currently performed: arthroscopic release (AR), manipulation under general anesthesia (MUGA), open surgical release (OSR). This study assessed the accurate indications of these 3 procedures to treat stiff knee arthroplasties. Methods: Sixty-two of these procedures were performed between 1989 and 2001 and followed at least 1 year: 34 MUGA, 18 AR and 10 OSR. The 3 groups were comparable excepted for the delay between the prosthetic insertion and the mobilization procedure: 17 weeks for MUGA, 46 weeks for AR, 97 weeks for OSR. All the patients had the same postoperative analgesia and rehabilitation program. Results: For the 62 procedures there was an improvement in range of ßexion from preop-erative (mean 58.4¡) to follow-up (mean 94.6¡) and a decrease in ßessum deformity from 7.6¡ to 2.5¡ (p= 0.001). From surgery to 1 year of follow-up, there was a decrease in ßexion (104.6¡ to 94.6¡) and an increase in ßessum deformity (1.3¡ to 2.5¡) (NS). The worst postoperative ranges of motion were observed at 6 weeks after the procedure, and then an improvement was observed up to 6 months but was non-signiþcant. Flexion did not improved beyond 6 months after the procedure. The results of the 3 techniques were not signiþcantly different. However, failures were more frequent when MUGA were performed beyond 8 weeks after prosthetic insertion, and when AR were performed beyond 6 months after prosthetic insertion (p< 0.01). Conclusions: We recommend to treat stiff total knee prostheses by MUGA until 8 weeks after insertion, by AR between 8 weeks and 6 months, and by OSR later on. This protocol addresses stiff prostheses without infection and without component malposition. The deþnitive ranges of motions were obtained at 6 months after mobilization.

Aims: This study compared in vivo kinematics of a posterior stabilized TKA inserted either with a fixed (FBC) or with a mobile bearing component (MBC). Methods: Ten patients with unilateral previously defined TKA were selected among 150 TKA performed in 2000 by a single surgeon according to the following criteria: primary TKA because of osteoarthritis, controlateral knee free of clinical symptoms, patient < 80, TKA flexion > 90°, knee IKS score > 80/100. Ten TKA (10 patients) were selected differing only by the adjunction of the mobile bearing (5 MBC and 5 FBC). The range of the 3 knee rotations (flexion, axial rotation, varus-valgus) were assessed by means of a 6-degree freedom electromagnetic goniometer during: level walking, rising from a chair, non weight-bearing flexion. Non-parametric tests compared motions between TKA and contro-lateral knee and between MBC and FBC. Results: FBC had a better mobility that MBC in valgus-varus, which was related to a larger frontal laxity. According to the increase in frontal laxity, FBC demonstrated better axial rotations that MBC in non-weight-bearing (NS). However, better ranges of axial rotation were recorded in MBC in weight-bearing (p< 0.05) (MBC axial rotation exceeded by 10° the motions of FBC). In patients with MBC, there was no difference in range of motion between the TKA and the controlateral healthy knee. In the FBC group the range of axial rotation was lower in the TKA by comparing with the controlateral knee (p< 0.05). Conclusion: With a unique prosthetic design our study suggests the role of MBC to reproduce a physiological range of axial rotation in weight-bearing. The MBC better reproduced knee kinematics Shoulder instability

Aims: Henri Dejour promoted a mechanism involving a third femoral condyle to achieve Posterior Stabilization (PS) in total knee arthroplasty (TKA) introducing the HLS II prosthesis. This retrospective study was conducted to assess the behavior of such PS mechanism. Methods: Between 1992 and 1993, 105 HLS II prostheses (94 patients) were consecutively inserted (78% arthrosis, 19% rheumatoid arthritis). No patient was lost for follow-up but 14 had died, 6 were unable to walk (severe neurological disorder), 4 were contacted by phone. Consequently, 70 patients (77 TKA) mean aged 66 years (22–79) were assessed after a mean follow-up of 7 years (6–8). All the components were fixed with cement and patellar resurfacing was always performed. Results: The knee IKS score increased from de 27 points [0–63] before surgery to 81 [21–100] at follow-up and functional IKS from 35 points [0–75] to 64 [0–100] (p< 0,0001). Similarly range of motion improved from 114° [60°–140°] to 116° [80°–135°] (NS). At follow-up, 86% of the patients were able to practice stairs (13% without support and 28% in alternative manner) against 52% before surgery (1% without support and 1% in alternative manner) (p=0,001). Tibial bone-cement radiolucencies were observed without loosening in 30% (all < 1 mm and non- progressive) mainly related to severe preoperative varus deformation (p = 0.01). One late infection required reoperation. Ninety months survival was 97% ± 1.3% with reoperation related to infection or mechanical disorder as end-point. Conclusion: The posterior stabilization, by means of a third condyle, allowed a satisfactory range of flexion and improved ability to practice stairs. Mid-term follow-up did not identified adverse effects of this PS mechanism on component fixation or knee stability.

Purpose: The distal tibiofibular joint is implicated in ankle movement but has been the topic of less work than the talotibial joint. Its mobility within the talo-crural complex has not been described in detail as precisely as its static role. The purpose of this work was to develop a simple noninvasive method for characterising in vivo the mobility of the fibula at the ankle level between is positions in dorsal and plantar flexion.

Material and methods: We used 32 computed tomo-graphic studies of the ankle in 16 healthy volunteers (men and women), one study in each position of ankle flexion. We identified one cross-sectional slice through the syndesmosis in each of the two positions. A medio-lateral reference line was drawn tangent to the posterior cortical of the tibial metaphysis. The displacement of the fibula in relation to the tibia when moving between the two positions of ankle flexion was calculated using a remarkable landmark on the tibia, the anterior rim of the posterior tibial incisure, and the polar co-ordinates of the ends of the anteroposterior axis of the fibula.The repeatability and reproducibility of this method were tested.

Results: Repeatability was satisfactory for translation movements. Reproducibility was fair except for the reference line where it was good. When the ankle moved from dorsal flexion to plantar flexion, the fibula moved medially 1.25 mm (0.03–2.58 mm) (p< 0.0001) without correlation with the amplitude of the ankle flexion. Mean anterioposterior displacement was 0.46 mm (NS) with a wide range from −1.58 to +7.2 mm. It was correlated with lesser amplitude of ankle flexion.

Discussion: This dynamic method confirms published data concerning active mediolateral tibiofibular approach during plantar flexion. The results point out the variability of the anteroposterior movement of the fibula, the influence of the amplitude and the flexion position of the ankle, and the possible antepulsion effect of fibular tendons. The three-dimensional movement of the ankle joint merits further study including its tibio-fibular and talofibular components in view of potential prosthetic repair of the ankle.

Conclusion: Distal tibiofibular mobility is undeniable. We call for more work to achieve a better understanding of the lateral component of the talocrural complex.

Purpose: The Rosenow enriched medium (RW) enables culture of anaerobic germs as well as slow-growing germs sometimes causing chronic infections on implanted material. The purpose of this work was to determine the usefulness of RW for the bacteriological diagnosis of infections on total hip arthroplasty (THA) and total knee arthroplasty (TKA°.

Material and methods: One hundred fifty-four pre- or intraoperative standard and RW samples were obtained in a prospective study of 80 consecutive patients (mean age 67.6 years) with an infected THA (n=56) or TKA (n=24) between January 1998 and June 2000. A bacteria was considered “infecting” if it grew on direct culture on at least two samples after enrichment. A single positive sample after enrichment was considered a contamination except for strict anaerobes for which direct culture could not be achieved. For these germs, growth after enrichment was thus considered significant.

Results: Among the 154 samples, 59 (38%) gave positive direct cultures and 95 (62%) positive enriched cultures. Among the 59 positive direct cultures, the RW culture was concordant in 87% of the cases. For the 13% of discordant cultures, the germs did not grow on standard medium: Staphylococcus (n=6), Pseudomonas (n=1), and enterobacteria (n=1). For the 95 positive enriched cultures, 41 (43.1%) of the RW cultures were condordant with the standard culture; the standard was positive in 13 (13.6%) and the RW negative (11 Staphylococcus including five aureus, one Pseudomonas, and one Corynebacterium), but in 41 cases, the RW was positive while the standard was negative (16 Staphylococcus, including 13 coagulase negative, five Streptococcus, two Entero-coccus, one Corynebacterium, three enterobacteria, and fourteen anaerobes). The infecting nature of the aerobic bacteria was retained because earlier or later samples were positive. The sensitivity and predictive value of a positive RW culture were 86% and 86% respectively.

Discussion: Using RW medium and standard samples is useful if germs grow after enrichment in order to confirm the infecting nature of the isolated germ (double culture). The reliability of RW medium was confirmed since it was concordant in 87% of the cases with a positive “gold standard” culture. For positive cultures after enrichment with a negative standard culture, RW allows correcting the diagnosis of infection in 43% of the cases. Its usefulness lies basically in the isolation of coagulase negative Staphylococcus and anaerobes (especially Propionibacterium spp. and Peptostreptococcus spp.).

Purpose: Use of a mobile tibial plateau for total knee arthroplasty (TKA) is designed to reduce wear and improve prosthetic kinetics. The purposes of this study were: 1) to compare the kinetics of a posterior stabilised TKA implanted with a fixed plateau (FP) or a mobile plateau (MP) and, 2) to determine whether the mobile plateau improves axial rotation.

Material and methods: Ten patients with a unilateral TKA (HLS) with a fixed or mobile plateau were selected for this study according to the following criteria: arthroplasty for degenerative knee disease, healthy contralateral knee, age < 80 years, pain-free prosthesis, IKS > 80/100, flexion > 90°, follow-up > 1 year. There were five patients with a fixed plateau and five patients with the same prosthesis except with a mobile plateau. Knee movement (flexion-extension, axial rotation, valgus-varus) were measured with an electromagnetic goniometer on the implanted and healthy sides. Four movements were recorded: walking, standing up sitting down, flexion-extension without loading. Amplitudes were compared with non-parameteric statistical tests between the healthy side and the implanted side and between the two types of implants

Results: The FP knees were more mobile in valgus-varus due to greater residual frontal laxity than the MP knees. This extra laxity generated excessive axial rotation on the FP during non-loaded movements. Conversely, when loaded, axial rotation of the MP knees was 10° greater (mean, p < 0.05) than for the FP knees, giving better stability in the frontal plane. This study did not demonstrate any difference in flexion between FP and MP. Patients with an MP prosthesis did not have significantly different amplitudes of the three movements for the healthy versus implanted knee. For the patients with a FP prosthesis, axial rotation and frontal plane movement was lower in the implanted knee than in the healthy knee (p< à.05).

Discussion: This study devoted to the design of a single prosthesis demonstrated the usefulness of the mobile plateau for axial rotation during loaded movement. The kinetics of MP prostheses is similar to that of the healthy knee. Better axial rotation with MP prostheses during loaded movements suggests the persistence of the plateau mobility which should be confirmed with a cinematographic study.

Purpose: Management of extensive tibial loss raises the question of indications for vascularised grafts. These techniques depend on the number of functional vascular trunks available. We developed a modified technique which allows using this type of graft without sacrificing the tibial pedicle, making it usable when only one trunk remains functional. We use the fibular arterial supply to bridge the remaining axis. The purpose of this work was to detail the modalities of this technique and provide early results.

Material and method: Since 2000, we have reserved this technique for infected nonunion with loss of tibial tissue extending over 5 cm in patients who decline amputation. Four patients (four men, mean age 30 years) underwent the procedure. The initial trauma resulted from a motorcycle (n=3) or firearm (n=1) accident. The patients were referred to our unit within three months on the average. Prior treatments (cancellous graft in an open or intrafocal procedure) had failed in all patients who presented persistent infection. Antibiotics were administered until bone healing in all patients. Mean length of the gap was 10 cm (7 – 15 cm). The composite graft (skin and fibula with a vascularised fibular bundle) was raised from the contralateral limb and cross-leg anastomosed proximally and distally on the receiver anterior tibial bundle (all four cases).

Results: All fractures consolidated between six and twelve months after initiating management of this technique. Bone and soft tissue losses healed without shortening. There were not repeated fractures after mean follow-up of twelve months (range eight months to two years). No complementary bone graft was necessary. Infection resolved in all patients.

Discussion and conclusion: As for classical vascularised fibula grafts, this technique enables controlling bone and soft tissue problems together (composite graft). The graft is vascularised favouring antibiotic diffusion. The mechanical quality is better than with a pure cancellous graft but longer follow-up would be required to determine the rate of repeated fractures. This technique broadens indications for vascularised fibula grafts which can be used in unfavourable vascular contexts where only one or two leg trunks persist.

Purpose: Posterior stabilisation with a third condyle was introduced by Henri Dejour with the HLSI prosthesis. While the posterior stabilisation process has been validated, this implant still raises some problems with the tibial fixation in patients with advanced joint degeneration, leading to the development of the HLSII model. The purpose of the present retrospective work was to evaluate functional outcome and persistance of the HLSII prosthesis fixation.

Material and methods: Between January 1992 and December 1993, 105 total knee arthroplasties (TKA) were performed in 94 consecutive patients using posterior stabilised HLSII prostheses. Indications were joint degeneration (40% stage 4) in 78% and polyarthritis in 19%. None of the patients were lost to follow-up but 14 patients died, six were bedridden (stroke sequela) and four were contacted by phone only. In all, 70 patients (77 TKA), mean age 66 years (22–79) were retained for clinical and radiological assessment at mean follow-up of seven years (range 6–8 years). All implants were cemented and the patella was resurfaced in all cases. Eight operators participated in this series. Junior surgeons (n=5) implanted one-third of the prostheses.

Results: The mean IKS knee score rose from 27±18 points (0–63) preoperatively to 81±18 (21–100) at last follow-up, function score from 35±20 (0–75) to 64±24 (0–100) (P< 0.0001). Motion changed from 114° (60–140°) to 116° (40–135°) (NS).Eighty-six percent of the patients used stairs (13% without handrail and 28% with alternate steps) versus 52% before the intervention (1% without handrail and 1% with alternate steps). (P=0.001). Knee alignment was normal ±5° in 87% of the cases versus 27% before surgery (P< 0.0001). Seventy-nine percent of the knees had a slope ±2° (desired slope 0°). The patellar retinaculum was sectioned in one quarter of the knees which led to four of the five postoperative haematomas (no revision). Five patellar fractures were noted, including two with patellar loosening (revised) and one clunk (cured after arthroscopic release). Lucent lines observed under the medial tibial plateau in 30% of the cases (all < 1 mm) were more frequent in patients with more severe joint degeneration and genu varus preoperatively (P =0.01). There was no case of aseptic femorotibial loosening. One case of late infection (30 months) was followed by replacement arthroplasty. Survival rate, taking mechanical and/or infectious failure as the endpoint, was 97± 1.3% at 90 months.

Discussion: Good axial control emphasises the reliability of the instrumentation since one-third of the prostheses were implanted by junior surgeons. Improvements in tibial fixation with the HLSII appear to be effective, particularly for stage 4 degeneration. Long-term surveillance is however necessary. The femoropatellar joint can give rise to non-infectious complications and should be improved. The concept of posterior stabilisation with a third condyle authorises good flexion amplitude and favours use of stairs.

Purpose: The few reports of long-term outcome of Kien-böck disease are helpful in establishing therapeutic indications.

Material and methods: Between 1970 and 1995, radius shortening procedures were performed in 44 patients. Among these 31 patients (eight women and 23 men), mean age 32 years (18–48) at surgery, with 33 operated wrists (18 right, 11 left, 2 bilateral, 19 dominant hands) were reviewed clinically (25 patients by an independent observer, three by their family physician) and radiologically (26 patients) or responded to a phone interview (five patients) at a mean 12 years follow-up (4–19 years). Four patients had died, nine were lost to follow-up. Before surgery the pain was intense (Michon scale): 32 grade I, one grade II. According to Lichtman, there were three grade I, seven grade II, eighteen grade IIIa and five grade IIIb. There was one case of haematoma and one reflex dystrophy, five late consolidations and five nonunions (three diaphyseal out of eight and two metaphyseal out of 25).

Results: The Michon pain score was variable, 11 grade IV, six grade III, nine grade II, but also seven grade I and four secondary arthrodeses. Postoperative amplitudes ere: flexion 50°, extension 53°, abduction 20°, adduction 29°, pronation 83°, supination 74°. Mean amplitudes increased for flexion (+12°), extension (+13°), abduction (+6°), and adduction (+11°), but decreased for pronation (−3°) and supination (−13°). The postoperative wrist fore (Jamar) was 32 kg (80° of other side). Eighteen patients were able to resume an occupational activity, requiring equivalent (14 patients, including 12 manual labourers) or greater (two patients) wrist force. At last follow-up the Lichtman classification was one grade I, four grade II, eight grade III1, three grade IIIb, and seven grade IV. The pre- to postoperative radiography comparison (26 wrists) showed two improvements, seven stabilisations, 14 aggravations, and three arthrodeses. There were also three cases of ulnocarpal impingement (one reoperated). Discussion: the factors predictive of good outcome were minimally advanced disease (Lichtman), little reduction in lunatum height (Stahl), absence of carpal collapse (McMurtry), absence of complication.

Conclusion: Shortening of the radius is an excellent procedure to Lichtman grade IIIa. Results are less satisfactory for grade IIIb but still acceptable compared with resections of the first row or intracarpal arthrodesis. To avoid the risk of ulnocarpal impingement, it would be preferable to reorient the glenoid or shorten the capitatum rather than shorten the radius in patients with a normal radioulnar index.