Aim

Prosthetic joint infection (PJI) due to Candida spp. is a severe complication of arthroplasty but is little reported. This study describes Candida PJI epidemiology, management, and outcome.

Aims

To evaluate the place of the massive prostheses in the most complex periprosthetic infections cases (PJis).

Aim

The aim of our study was to identify pathogens involved in septic knee arthritis after ACLR and to describe clinical features, treatment and outcome of infected patients.

INTRODUCTION

The functional and anatomical results of TKA revisions are less good than a primary TKA. The TKA revision frequency increases and we must improve our surgeries and prepare the next standard of these surgeries. The aim of this study was to evaluate the CAOS / one stage strategie to treat the knee PJIs.

Aim

In private healthcare facilities, the access to a specialized infectious disease (ID) advice is difficult. More, the lack of traceability is problematic and harmful for treatment and follow-up. We have tested an information technology (IT) application to improve medical transmission and evaluate an interdisciplinary ID activity.

Aim

European population is ageing concurrently with an increase number of arthroplasties. Prosthetic joint infection (PJI) in the elderly is considered more severe. The aim of this study is to describe PJI's management of patients over 79 years of age.

Aim

Pre-operative distinction between prosthetic joint infections (PJI) and non-infectious causes of joint failure is particularly challenging, especially in chronic situations. Guidelines propose different algorithms using numerous preoperative tests. We evaluated place of serology.

Aim

Ceftobiprole, a broad-spectrum cephalosporin, could be used for post-operative treatment of bone implant-associated infections. The aim of the study is to evaluate the in vitro susceptibility of bacteria isolated from bone implant-associated infections to ceftobiprole.

Aim

Prosthetic joint infections (PJI) due to Enterobacter cloacae are rare and often severe. The aim of this study is to describe cases with E. cloacae PJI.

Aim

When a prosthetic joint infection (PJI) is suspected, guidelines recommend performing periprosthetic samples, at least one for histopathological examination and 3 to 6 for microbiological culture. The diagnosis of infection is based on the presence of neutrophil granulocytes whose number and morphology can be variable, resulting in definition of “acute” inflammation. The acute inflammation of periprosthetic tissue is supportive of infection. Since 2007, in our hospital, for all patients with suspected PJI who underwent surgery, from each sample taken by the surgeon, one part has been sent to the pathologist and the other one to the microbiologist. Our aim was to compare histopathological to microbiological results from samples taken intraoperatively at the same site.

Aim

To introduce and promote a new technic and a new component using the 3D technology in the extreme acetabular revisions.

Total knee arthroplasty (TKA) is a common procedure with good success rates. The literature shows resection accuracy plays a crucial role in device longevity¹. Computer guidance is used by some surgeons to enhance accuracy.

This study reports on a continuous series of Optetrak knee prostheses (Exactech Inc., FL, USA) implanted by three senior surgeons between October 2010 and December 2013.

324 TKA were implanted at the Joseph Ducuing Hospital, Toulouse, France (Site 1), the Cleveland Clinic, Cleveland, OH, USA (Site 2) and the Riverview Hospital, Noblesville, IN, USA (Site 3) using Exactech GPS (Blue-Ortho, Grenoble, FR), a new computer-assisted guidance system. Each centre in this study used different surgical profiles defined specifically for their surgeical preferences. Planned tibial and femoral cuts were compared to actual cuts digitised using GPS. Operating time was analyzed and post-operative leg alignment was compared to pre-operative.

The mean error between planned and digitised proximal tibial cuts was 0.06°±0.89 of valgus and 0.53°±0.90 of anterior slope for Site 1, 0.18°±0.85 of varus and 0.25°±1.18 of posterior slope for Site 2, and 0.02°±0.51 of valgus and 0.60°±1.15 of anterior slope for Site 3.

The mean error between planned and digitised femoral distal cuts was 0.14°±0.85 of valgus and 0.49°±0.93 of flexion for Site 1, 0.15°±0.96 of varus and 0.04°±1.54 of extension for Site 2, and 0.09°±0.54 of varus and 0.48°±1.21 of extension for Site 3. Average operating time was 29 minutes for Site 1, 39 minutes for Site 2, and 33 minutes for Site 3.

Post-operative Hip-Knee-Ankle angle (HKA) varied between 172° and 184° with an average of 179° for Site 1, 177° to 183° with an average of 179° for Site 2, and 177° to 185° with an average of 180° for Site 3. Pre-operative HKA ranged from 162 to 189°.

Site 1 was already reporting in the series presented at ISTA 2013². Sites 2 and 3 were added later and could therefore benefit from the early feedback the analysis of site 1 cases provided. The use of the computer guidance at the new sites was associated with promising results and it did not take long to the surgeons to reach a reproducibility equivalent to the one of site 1.

Average surgical time was similar in all three sites. GPS guidance added an average of 10 minutes to standard surgical times. All surgeons agreed the increased accuracy justified the additional time.

Average post-operative HKA was 179°. HKA scores were within 3° of perfect alignment in 96% of the cases of Site 1, 99% of Site 2 and 97% of Site 3. According to the literature¹, HKA between 177° and 183° is linked with high implant survival.

Participating surgeons still associated Exactech GPS with satisfactory immediate post-operative results.

To evaluate the value of the use of massive prostheses in periprosthetic infections both in one stage and two stages procedures

Between 2008 and 2014, 236 revisions for PJI had been performed in our hospital by the same surgeon. For the most complex cases, we decided to introduce megaprostheses in our practice in 2011.

We report a prospective series of 33 infected patients treated between 2011 and the end of 2014, 14 male and 19 female with on average 67.9 years old (38–85) Infection involved TKA in 22 cases (17 TKA revisions, 4 primary TKA), THA in 9 cases (6 revisions, 3 primary THA), a femoral pseudo-arthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used a total femoral component for two patients: the first one for a hip PJI with extended diaphyseal bone loss and multiples sinus tracks, and the second one for a massive infected knee prosthesis used in a knee reconstruction for liposarcoma.

We used one stage procedures in 20 cases (8 hips, 12 knees, 1 shoulder) and two stages in 13 cases (12 knees and 1 hip). Additional technics included 3 massive extensor system allografts, two local flaps. Perioperative hyperbaric treatment was used for 2 patients.

The average follow up is 19.8 months (6–48 months). The most frequent complications were wound swelling and delayed healing in 8 cases;). In 3 cases of one stage surgery a complementary debridement was necessary in the three weeks after the surgery with always a good local and infectious evolution. VAC therapy was used in four cases with good results. We report one early postoperative dead.

In summary, the use of massive prostheses in PJI is a good option for complex cases. It can be a good alternative to knee arthrodesis. These components must be used preferentially for older patients, in cases of extreme bone loss or extensive osteomyelitis to secure the bone debridement and the quality of the reconstruction.

In our series, the one stage procedure is a validated option even by using complementary technics as bone allografts, extensor system allografts or flaps. We believe the two stages surgery is a secondary option, particularly when soft tissues status is compromised before or after the debridement, and mostly for the knees. The longevity of the implantation must be evaluate by a long term follow up.

Tc 99m labelled leukocytes scintigraphy (LLS) could be useful for the diagnosis of bone and joint infections. The aim of our study was to evaluate its performances specifically in the diagnosis of prosthetic joint infection (PJI).

We conducted a multicenter -7 year- retrospective study including 164 patients with suspected PJI who underwent surgical treatment. In each case, 5 intraoperative samples were taken. Diagnosis of infection was confirmed if two or more samples yielded the same microbial agent. LLS was considered as « positive » if an accumulation of leukocytes was observed in early stage and increased in late stage (24 hours). Among these patients, 123 had also a bone scintigraphy.

A total of 168 PJ were analyzed: 150 by in vitro polymorphonuclear labelled leukocytes scintigraphy (PLLS) and 18 by anti-granulocytes antibodies labelled leukocytes scintigraphy (LeukoScan®). Location of PJ were: hip (n = 63), knee (n = 71), miscellaneous (n = 4). According to microbiological criteria 62 hip prosthesis and 48 knee prosthesis were considered as infected. Sensitivity (Se), Specificity (Sp), Positive Predictive Value (PPV) and Negative Predictive Value of PLLS were: 72%, 60%, 80% and 47%. Se of LLS was higher for knee PJI (87%) than for hip PJI (57%) [p = 0.002]. Although Sp was higher for hip PJI (75%) than for knee PJI (52%) [p = 0.002]. The lowest Se was found for coagulase negative staphylococci (70%) and the highest for streptococci (87.5%). However the difference of Se between bacteria was not significant. Regarding bone scintigraphy, Se, Sp, PPV and NPV were: 94%, 11%, 65% and 50%.

In our study, performances of LLS were rather low and varied according to the location of infection. Differences of LLS Se between bacteria was not significant. Bone scintigraphy has a high Se but lacks Sp.

To evaluate a innovate one stage procedure of the PJI knee treatment using computed assisted guidance. Our objectives; to increase the functional results by optimizing the anatomical joint reconstruction and to verifie if CAS help to simplifie and standardize these complex surgeries

It's a prospective, single surgeon study. Since septembre 2011, 41 patients treated for chronic knee PJI in a one stage revision (one of them had a ipsilateral chronic knee arthritis). For all of them, a computed assisted guidance, the ExactechGPS® system was used. This system offers the possibility to define specific profiles to performe primary TKA surgeries. A personnalized profile of revision was created.

All surgeries were performed with the same protocole; independently of the type of germ, with no use of tourniquet, no drainage by performing the same debridement procedure step by step and by using the same knee components

27 males, 14 female with 26 PJI of primary TKA, one infected unicompartimental prosthesis and 15 PJI of first revised TKA has been treated. The average age was 71 years old (55–87). The time of surgery was on average 135 mn (120 – 195 mn). The average time of hospitalization was 10 days (7–16). The average follow up was 20,9 months (6–47 months). The ROM were on average 114,7% (90°–130°), None post operative HKA outliers were reported.

3 patients presented a failure of the PJI treatment (one after a local open traumatism, one diabetic patient, one after a early revision for mechanical complication). None specific CAS complications and no failure of the CAS procedures are reported. As surgeon, CAS simplified the management of the bone loss after debridement and the control of the differents parameters (HKA, external femoral rotation, ligamentary balancing, lign joint…) by a real time feedback. we changed our practise by using more constraint condylar component instead hinge prostheses

With a rate of success of 92,7% at this follow up, the one stage option appears to be valided. Using CAS is a safe option with no specific complication. It increases the quality of the ROM, a earlier functional recovery and a better middle term clinical result. Both combined, It should be a optimal medicoeconomical solution.

compared revision using mechanical ancillary.

The objective was to compare susceptibility testing of all coagulase negative species (CNS) found in periprosthetic joint infections (PJI).

We conducted a multicentre retrospective study in a same area from 2011 to 2014, including 215 CNS strains.

Diagnosis of PJI was based on clinical, radiological and biological criteria. Microbiological criterion was at least 2 per-operative deep positive cultures with the same species of CNS. Identification and susceptibility testing were performed on automated Vitek2 (Biomérieux, France).

PJI localizations were 54% knees, 39% hips, 7% other sites.

CNS found in our study were by dicreasing order:

S. epidermidis (SE) 60%, S. capitis 11%, S. lugdunensis (SL) 10%, S. caprae 5%, S. warneri (SW) 4%, S. hominis (SHo) 3%, S. haemolyticus (SHa) 3%. Fifty two percent of CNS strains were meticillin (oxacillin) resistant and 31%, 33%, 41%, 20% were also resistant to clindamycin (CLI), trimethoprim-sulfamethoxazole (SXT), ofloxacin (OFX), rifampicin (RMP) respectively. Regarding CNS species, meticillin resistance was detected for 70% SE, 71% SHo and 71% SHa. SE was the most resistant species, with 34% of the strains resistant to CLI, SXT, OFX and RMP simultaneously. Half of SE and SHa were resistant to the reference treatment levofloxacin+rifampicin. Thirteen percent of CNS were resistant to teicoplanin and only 1% to vancomycin.

Susceptibility testing profiles are presented in table field.

In our study, S. epidermidis was the main species found in PJI. Emerging species like S. lugdunensis or S. caprae were found, with more susceptible antibiotic profiles. The most active antibiotics in vitro were daptomycin, linezolid, vancomycin and teicoplanin.

PJI du to Enterobacter cloacae are rare and often severe. The aim of our study is to define the history of patients with such infections and their outcome.

We conducted a retrospective monocentric study in an orthopedic unit where complex bone and joint infections are supported. From 2011 to 214 we selected patients with E. cloacae PJI based on data from the microbiology laboratory. In their files we collected information on their background, their medical and surgical history, antibiotics they received in the year before infection, the suspected portal of entry, the management and the outcome.

Twelve patients were included, 7 male and 5 female. PJI was located to the hip in 8 cases, the knee in 3 cases and the ankle in one case. The average time between the placing of the first prosthesis and infection was 3 years. Eleven patients had one or more surgery for previous PJI. The average time elapsed since the last surgery was 30 days. Eleven patients had been treated with antibiotic combinations for at least 6 weeks, in the year before E cloacae infection. A portal of entry was identified only two times: urinary tract infection in one patient and catheter-related infection in one patient. Antibiotics the more often prescribed were carbapenems (n = 5) and cefepime (n = 4), each combined with quinolones (n =4) or fosfomycin (n = 3). Two patients required an additional debridement within an average of 18 days. Infectious outcome was favorable in 8 cases (67%) with a median duration of follow-up of 26 months. Two patients had a recurrent infection, one due to Streptococcus oralis and one to Candida albicans. One patient had a relapse of E cloacae infection. One patient died from unknown cause.

PJI infections due to E.cloacae usually occur early after prosthetic surgery, typically in patients with complex surgical history. Despite a high rate of multi-resistance to antibiotics, outcome may be favorable in a large majority of patients.

Total knee arthroplasty (TKA) is a common procedure with good success rates. The literature shows resection accuracy plays a crucial role in device longevity¹. Computer guidance is used by some surgeons to enhance accuracy.

This study reports on a continuous series of Optetrak knee prostheses (Exactech Inc., FL, USA) implanted by three senior surgeons between July 2010 and April 2013.

259 TKA were implanted at the Haguenau Hospital, Haguenau, France (Site 1), Joseph Ducuing Hospital, Toulouse, France (Site 2) and Saint Michaels Medical Center, Newark, NJ, USA (Site 3) using Exactech GPS (Blue-Ortho, Grenoble, FR), a new computer-assisted guidance system. Surgeons can use the unique Exactech GPS profiler to define steps to be computer-assisted during surgery. Each centre in this study used different surgical profiles. Planned tibial and femoral cuts were compared to actual cuts digitised using GPS. Operating time and external femoral rotation were analyzed and post-operative leg alignment was compared to pre-operative.

The mean error between planned and digitised proximal tibial cuts was 0.26° ± 1.11 of valgus and 0.06° ± 0.99 of posterior slope for Site 1, 0.07° ± 0.89 of varus and 0.53° ± 0.90 of anterior slope for Site 2, and 0.19° ± 0.73 of varus and 0.10° ± 1.17 of posterior slope for Site 3 (see Fig. 1). The mean error between planned and digitised femoral distal cuts was 0.03° ± 0.99 of varus and 0.67° ± 1.36 of extension for Site 1, 0.14° ± 0.85 of varus and 0.49° ± 0.94 of extension for Site 2, and 0.26° ± 0.86 of varus and 0.09° ± 1.22 of flexion for Site 3. Average operating time was 38 minutes for Site 1, 29 minutes for Site 2, and 34 minutes for Site 3. External femoral component rotation ranged from 0° to 18° with an average of 3.7° degrees for Site 1 and from −3° to 8° with an average of 3.0° for Site 2. External rotation was fixed at 3° for Site 3. Post-operative Hip-Knee-Ankle angle (HKA) varied between 177° and 182° with an average of 179° for Site 1, 172° to 184° with an average of 179° for Site 2, and 178° to 185° with an average of 180° for Site 3. Pre-operative HKA ranged from 162 to 191°.

Despite different techniques and teams, all surgeons experienced similar results. Cuts were aligned in the frontal plane, while guidance was harder to follow in the sagittal plane, possibly due to saw blade bending during resection. Average surgical time was similar. GPS guidance added an average of 10 minutes to standard surgical times. All surgeons agreed the increased accuracy justified the additional time. Regardless the site, all average femoral rotations were close to the accepted 3° standard. Average post-operative HKA was 179°. HKA scores were within 3° of perfect alignment in all Site 1 cases and 96% of Site 2 and Site 3 cases. According to the literature¹, HKA between 177° and 183° is linked with high implant survival.

Participating surgeons associated Exactech GPS with satisfactory immediate post-operative results.

We have shown in a previous study that patients with combined lesions of the anterior cruciate (ACL) and medial collateral ligaments (MCL) had similar anteroposterior (AP) but greater valgus laxity at 30° after reconstruction of the ACL when compared with patients who had undergone reconstruction of an isolated ACL injury. The present study investigated the same cohort of patients after a minimum of three years to evaluate whether the residual valgus laxity led to a poorer clinical outcome.

Each patient had undergone an arthroscopic double-bundle ACL reconstruction using a semitendinosus-gracilis graft. In the combined ACL/MCL injury group, the grade II medial collateral ligament injury was not treated. At follow-up, AP laxity was measured using a KT-2000 arthrometer, while valgus laxity was evaluated with Telos valgus stress radiographs and compared with the uninjured knee. We evaluated clinical outcome scores, muscle girth and time to return to activities for the two groups.

Valgus stress radiographs showed statistically significant greater mean medial joint opening in the reconstructed compared with the uninjured knees (1.7 mm (sd 0.9) versus 0.9 mm (sd 0.7), respectively, p = 0.013), while no statistically significant difference was found between the AP laxity and the other clinical parameters. Our results show that the residual valgus laxity does not affect AP laxity significantly at a minimum follow up of three years, suggesting that no additional surgical procedure is needed for the medial collateral ligament in combined lesions.

Traumatic anterior shoulder dislocation and sub-luxation are common injuries. But few studies have compared arthroscopic and open stabilization of the shoulder at long-term follow up. The purpose of our study is to show whether an arthroscopic approach to repair Bankart lesion can obtain the same results at long follow up as an open procedure. We analyzed 110 non-randomized consecutive shoulders in 110 patients who underwent a surgical repair of recurrent anterior shoulder instability between 1990 and 1999. Eighty-two patients were available at long term follow up (74,5% retrieval rate). In particular, 49 patients (59.8%) (group A) were treated with arthroscopic transglenoid suture (modified Caspari) between 1990 and 1995 (mean 15,7 year FU), whereas, 33 patients (40.2%) (group B) were treated with open repair between 1995 and 1999 (mean 12,7 year FU). We evaluated the patients in terms of failure rates, Rowe and UCLA scores. The failure cases in the forty-nine patients treated with arthroscopic suture were 13, six dislocations and seven subluxations. The group A had also a Rowe score: function 24.2+8.2, stability 42.4+13.9, range of movement 18.6+3.8, total score 85.0+22.46. The UCLA score was: pain 8.8+1.7, function 8.6+2.1, muscle power 9.2+1.6, total score 26.4+4.8. Of the thirty-three patients treated with open repair, three had at least one post-op dislocations and four felt sometimes subluxations. The Rowe score in group B was: function 23.6+9.7, stability 41.2+14.9, range of movement 18.3+3.9, total score 83.2+24.4. Moreover the UCLA score was: pain 8.8+1.9, function 8.8+1.9, muscle power 9.2+1.2, total score 26.9+4.2. We showed that both techniques were fairly good in treatment of shoulder instability. In our series no significant difference was observed in redislocation rate and in Rowe and UCLA scores between the two groups. The recurrence rate (subluxations and dislocations) was high in both groups: the arthroscopic group had 26.5% and the open one had 21.2%. Our recurrence rate following open repair was higher than in many studies, while the rate after arthroscopic transglenoid procedure was almost equivalent. We hypothesize that one of the reasons for these higher recurrence rates may be the long term follow up. Another cause could be our decision to include subluxation as a failure value, even if there is no agreement about. In fact we believe it to be an important disability factor in sport as in life activities. After surgery, most of the patients returned to their preinjuried activities. But at long term follow up almost all patients have stopped high level sport activity. Moreover, at this long term follow up, some patients told us a feeling of muscle weakness in the last years. In conclusion patients had good impressions about their shoulders thanks to surgery, but also because of lower functional demand.

We performed a clinical, instrumental and radiographic study on a highly homogeneous series of 100 consecutive patients with unilateral ACL lesion at 7 years of minimum follow up, alternatively assigned to a single bundle reconstruction using patellar tendon (PT) or to a double bundle reconstruction using hamstrings (DB). Mean Tegner score was 4,8 for PT and 6,5 for DB (p=0,0005). Time for sport resumption was 6,6 months for PT and 3,8 months for DB (p=0,0052). There were no significative differences between the two groups regarding range of motion and functional subjective self-evaluation. Mean anterior displacement at instrumental evaluation performed with KT2000 showed no significative differences between the two groups. Objective clinical evaluation with IKDC was superior for DB group (A=86,5%; B=13,5%) respect to PT group (A=18,7%; B=75%; C=6,3%) (p< 0,0001). We found no differences regarding anterior knee pain between and Ahlback radiographic score the two groups and we have observed no recurrence of instability after surgical treatment. Double bundle ACL reconstruction with hamstrings has showed higher results respect to single bundle ACL reconstruction with patellar tendon in terms of Tegner score, IKDC, time for sport resumption.

Arthroscopic selective resurfacing of the knee may be considered a treatment option for selected patients with focal articular damage.

From more than 2 years in IX Division of Rizzoli Orthopaedics Institute(Bologna- Italy) we use, in selected cases with only one articular compartment damaged, an innovative resurfacing prosthesis.

We mad a new design of focal resurfacing (MAIOR) that is possible to implant with arthroscopic technique and that realize both mini-invasive and mini-traumatic surgery.

The fixation method of the MAIOR allows higher osteointegration by biomaterials and hydrossiapatite of new generation that permit a press-fit fixation of the implant.

The new philosophy of this implant consist of early focal treatment with low compromise of bone. Many surgeons, in case of focal articular damage, prefer to attend to made an unique definitive surgical operation when the degenerative changes are more severe.

This new implant permit to substitute, also in arthroscopic technique, only the articular damage and to avoid to attend a more important and diffuse articualr damage.

It is an uncemented, focal resurfacing prosthesis that requires minimal bone sacrifice and utilizes a minimal invasive surgical (MIS) approach with or without arthroscopic assistance.

In a prospective and consecutive study, 78 patients were followed up at least for 12 months. Subjective pain and joint function were assessed using Visual analogue scale (VAS) and Knee society scores respectively. The preliminary results are interesting and encouraging with subjective evaluation equal to 85% of normal knee.

Significant reduction of pain and improvement in joint function was observed. Although, long term study will determine the real performance of the prosthesis, trend seems to be positive.

Background: The Rangeuil orthopaedics surgical team has developed a special installation using a rigid corset for the combine Kocher Languenbeck and ilioinguinal surgical treatment of complex acetabular fractures. The purpose of this study was to retrospectively evaluate the results of 53 complex acetabular fractures treated by open reduction and internal fixation with a combined double approach facilitated by this particular operative installation.

Methods: A retrospective review of the cases was performed. The functional outcome, operative times, blood loss were recorded. Pre-operative, post-operative and last follow-up radiographs were assessed for fracture classification and adequacy of reduction. The development of heterotopic ossification, the presence of infection, avascular necrosis and post-traumatic osteoarthritis were also noted.

Results: The mean follow-up was 5.2 years. The clinical outcome at the time of final follow-up was graded as excellent in 16 patients, good in 22, fair in 7 and poor in 8 The reduction of the fracture, as determined with plain radiography, was graded as anatomic in 32 patients, unperfect in 15 and unsatisfactory in 6. Bony union was achieved in all cases. 6 patients had Brooker 3 or 4 heterotopic ossifications. 9 patients developed osteoarthritis. 4 patients developed avascular necrosis. An arthroplasty was necessary for 10 patients. 3 patients had a delayed wound infection.

Conclusions: The combined simultaneous approach remains a reliable surgical solution in selected complex acetabular fractures. The installation using the corset we developed considerably simplifies the operation and access to the operated site.

Purpose of the study: Percutaneous compressive plating (PCCP) enables minimally invasive surgery using closed focus technique. We report a prospective consecutive series of 67 fractures (December 2003 – February 2005) followed to bone healing.

Material and methods: Mean patient age was 83 years (range 37–95) with 83% females in a frail population (ASA 3, 4). Two-thirds of the patients had unstable fractures (AO classification) which were reduced on an orthopedic table under fluoroscope. Two minimal incisions were used to insert the material without opening the fracture and without postoperative drainage. Blood loss was noted. Verticalization and weight bearing were encouraged early depending on the patient’s status but were never limited for mechanical reasons. Patients were reviewed at 2, 4 and 6 months.

Results: Anatomic reduction was achieved in 84% of hips, with screw position considered excellent for 45, good for 14, and poor for 6. There were no intraoperative complications. The material was left in place. The hemoglobin level fell 2.2 g on average. Mean operative time was 35 minutes and the duration of radiation exposure 60 seconds. Mean hospital stay was 13 days. General complications were: urinary tract infections (n=10), phlebitis (n=2), talar sores (n=5). Gliding occurred in three cases (4%) with telescopic displacement measuring less than 10 mm in ten cases. There were two varus alignments with no functional impact. There were four deaths within the first three weeks. All fractures healed within three months.

Discussion and conclusion: PCCP has its drawbacks (mechanical, stabilization) as do all osteosynthesis methods used for trochanteric fractures. The technique is reliable and reproducible and is indicated for all trochanteric fractures excepting the subtrochanteric form. PCCP has the advantage of a closed procedure with a minimal incision and limited blood loss for a short operative time. An advantage for this population of elderly frail subjects (ASA 3, 4). PCCP enables immediate treatment with a low rate of material disassembly compared with other techniques.

Purpose: We evaluated male sexual function after utilisation of the orthopaedic table for centromedullary nailing in patients with femoral shaft fractures treated between 1995 and 2001. The objective was to determine the frequency of altered function and search for favouring factors.

Material and methods: Sexual function was assessed with a self-administered questionnaire using the International Index of Erectile Function (IIEF). We contacted by mail 109 patients aged 20 – 50 years treated in the orthopaedic traumatology unit between 1995 and 2001. The Mann-Whitney test was used to compare quantitative variables and Student’s t test for classed variables.

Results: Seven patients declined to respond and three died; 55 responded (81.8%). Patients were grouped by erectile function (EF) score (< 22 or 22) according to Cappelleri. Erectile dysfunction was identified in 19 patients. Altered sexual function did not appear to be related to age, weight or height. The duration of the operation was not different between the two groups.

Conclusion: This study demonstrates a increase in iatrogenic lesions having an impact on erectile function in patients treated on an orthopaedic table when curare is not used during the intervention. The frequency of these lesions decreases significantly if the surgery is performed by a senior surgeon.

Material and methods: Two series of 35 total hip arthroplasties (THA) implanted by the same surgeon using the posterior approach were compared. The first group underwent surgery in 1999 and the second in 2001. Ligation of the posterior medial circumflex artery was systematically performed in the second group. The same prosthesis was used in all cases: an omnicase stem and a Schuster (Centerpulse) or polyethylene cup. The series included cemented (n=37) and non-cemented (n=32) prostheses with one hybrid implant. We analysed retrospectively, intra- and postoperative bleeding, haematocrit before and just after surgery, and the number of packed red cell units transfused during and after surgery in order to determine the degree of intra- and postoperative bleeding. Statistical tests were applied.

Technique: Via the posterior approach, before sectioning the pelvitrochanteric muscles, the upper third of the fibres of the quadratus femoris muscle were dissociated. The artery runs upwardly and anterior toward the posterior border of the greater trochanter and is difficult to identify in the fatty tissue. Ligation is performed at this level with the satellite veins. Ligation decreases bleeding when the pelvitrochanteric muscles and the capsule are sectioned. Likewise, section of the femoral neck appears to be less haemorrhagic as is the preparation of the proximal greater trochanter.

Results: Intra- and postoperative bleed, expressed in ml, was significantly decreased by ligation of the posterior circumflex artery and its two satellite veins. Mean intraoperative bleeding was decreased by more than half. Six of the 35 patients who did not have ligation lost more than 600 cc blood during the operation. This degree of bleeding was not observed in the ligation group. The postoperative haematocrit was significantly higher in the ligation group and the difference in pre- and postoperative haematocrit was decreased 7-fold. Postoperative transfusion became exceptional. Finally, it is interesting to note that among the variables studied, mode of implant fixation did not affect blood loss.

Discussion: The conventional technique without ligation of the posterior circumflex artery does not always lead to significant bleeding. It is quite possible to perform such procedures with less than 200 cc blood loss. Use of posterior circumflex artery ligation leads to much more regular control of intraoperative bleeding, making autologous blood collection and postoperative transfusions unnecessary. The ligation is a simple procedure. Electric coagulation is generally insufficient for the calibre of these vessels and veins are not always accessible to effective coagulation. Intraoperative bleeding due to section of the circumflex artery is underevaluated due to the tension created by the forced internal rotation. Haemostasis after section is difficult due to retraction of the proximal segment under the muscles.

Purpose: Bone remodelling and osteolysis around total hip prostheses remains an ineluctable corollary of prosthetic loosening. Alendronate (biphosphonate) has proven its efficacy for the treatment of osteoporosis of the lumbar spine and the femoral neck. There has been some in vitro work pointing out its contribution to the inhibition of osteolysis induced by particles. One in vivo study has demonstrated its interest in prevention of osteolysis around non-cemented total hip arthroplasties. The purpose of our work was to study the efficacy of this drug in the prevention of periprosthetic osteolysis around cemented total hip arthroplasties using biphotonic absortiometry (DPX).

Material and methods: The series included 38 patients who underwent unilateral total hip arthroplasty for degenerative hip disease. After double blinded randomisation, 20 patients were given 10 mg Alendronate per day with 600 mg calcium and 18 patients were given a placebo with 600 mg calcium for two years. All patients were followed with standard x-rays and DPX of the operated hip. Examinations were performed on the fourth postoperative day and on the third, sixth, twelveth and twenty-fourth postoperative month. The analysis concerned the periprosthetic zones defined by Gruen.

Results: DPX demonstrated significant reduction in bone mineral density (BMD) in all patients included in the study. This reduction was the same for the two groups early in the study and reached a maximum at three months; a divergence was observed thereafter. For the placebo group, the loss reached a plateau up to the sixth month after which the BMD started to rise progressively remaining at 12.7% reduction at two years (p< 0.002). In the ALN group, there was no plateau, BMD increased directly to reach 6.9% bone loss at two years (p< 0.003).

Discussion:The use of Alendronate enabled a significant reduction of periprosthetic bone loss at two years post-op. Our results are the first to our knowledge demonstrating a beneficial effect in vivo of the use of Alen-dronate on bone behaviour around cemented total hip arthroplasties.

Conclusion: Taking into account the short follow-up in this series, and its small size, other studies are indispensable to confirm this beneficial effect in vivo. The action of Alendronate could facilitate revision surgery by preserving bone stock.

Purpose: The floating shoulder is a special entity in traumatology of the upper limb. Bioechanically, the floating shoulder corresponds, as defined by Goss, to a rupture of the suspensor complex. Management is not well defined but must target the proper balance between the need for anatomic restauration and quality functional results obtained in the majority of cases treated orthopaedically. This apparent paradoxical situation is probably related to the precision of indications.

Material and methods: Forty-five patients managed between 1980 and 2001 were reviewed retrospectively. Thirty-five presented a scapulo-cleido-thoracic syndrome, ten a scapulocleidal syndrome. Mean age at the time of trauma was 39 years and mean follow-up was 2.4 years (1–16). The patients, 36 men and nine women were mainly (76%) traffic accident victims (58% motorcycle, 33% automobile, 9% pedestrians) and 76.8% had multiple injuries. Cleidal lesions were 18 mid-third fractures, 12 acromiocleidal dislocations, three sternocleidal dislocations, seven bifocal fracrturs, three lateral third fractures and two medial third fracturs. The scapular lesion involved the body of the bone in 19 patients, the neck in 14, the glenoid cavity in two, the coracoid process in one, and multifocal fractures in nine.

Results: Thirty-two patients were treated orthopaedically and twelve patients surgically, four with cleidal osteosynthesis, eight with both. The postoperative x-rays were used to assess anatomic results and the Constant score to assess functional results. Complications included six deformed calluses, with four causing major functional impairment and one requiring revision. All resulted from orthopaedic treatments.

Discussion: While most patients have an indication for orthopaedic treatment, analysis of the displacemens can lead to a surgical indication. We retained the following criteria for surgical treatment: scapular neck fracture causing more than 40° angulation, glenoid medialisation-ventralisation greater than 2 cm, and displaced articular fracture. Osteosynthesis of the clavicle for floating shoulders with a major displacement appears to be the minimum prerequisite if the multiple injuries prevent optimal management.

Purpose: Insertion of the femoral stem during total hip arthroplasty provokes a bridge between the proximal femoral forces leading to well-documented bone resorption. A review of the literature concerning the behaviour of the contralateral femur and the spine reveals conflicting data. Some authors report variable bone mineral density of the lumbar spine while the contralateral neck, studied with non-cemented prostheseis in all cases, shows a significant fall in bone density. All patients in these studies needed an unloading period to achieve definitive fixation of the hip prosthesis. The purpose of this study was to assess bone behaviour in the contralateral femur and the lumbar spine after unilateral cemented total hip arthroplasty with immediate postoperative weight bearing.

Material and methods: The study series included 52 patients who underwent unilateral cemented total hip arthroplasty for degenerative hip disease. All were followed with standard x-rays and DPX of the contra-lateral hip and the lumbar spine. These examinations were performed one month before surgery then on D8, M3, M6, one year and two years. Bone mineral density (BMD) was measured in the femoral neck cortical and the L2–L4 trabecularlar bone. Patients were verticalised and encouraged to walk with full weight bearing on the average on day 3 to 4 after surgery.

Results: DPX did not demonstrate any significant decrease in BMD in any of the patients included in this study, neither in the lumbar spine nor in the contralat-eral femoral neck.

Discussion: Several studies in the literature point out the difficulty in recovering bone mass lost after a period of immobilisation or unloading. This bone loss could reach 10% of the bone mass even for short periods of unloading. Furthermore, minimal bone loss, to the order of 2.5% could accelerate the transformation of osteopenia into osteoporosis and increase the risk of fractures. The importance of minimising periods of unloading in older patients is thus evident.

Purpose: Van Den Bosch reported diminished quality of sexual intercourse in 40% of the patients victims of pelvic fractures. Using the Rosen self-administered questionnaire, five aspects of sexual activity were analysed: erectile function and orgasm, sexual desire, satisfaction with sexual intercourse and overall satisfaction. This retrospective series included patients with pelvic ring fractures in 1999.

Material and methods: The situation of 46 patients, aged 30 to 70 years was assessed with the International Index of Erectile Function self-administered questionnaire and a questionnaire concerning the patient’s status. The radiographic analysis included the Tyle classification. Associated injury to the membranous urethra were noted. Students t test was used to compare the IIEF scores in the study population and in a control population constituted for validation of the questionnaire.

Results: Forty-six patients responded (60.1%). None of the patients complained of disorders before the accident. Thirty-seven patients had sexual activities during the four weeks before responding including 11 (29.7%) with variable degrees of dyserection. Pubic dysfunction was the only factor associated with impaired sexual activity, leading to lower satisfaction and erectile function. There was no relationship between the five IIEF items and age, duration of follow-up, Tyle classification, branch fractures.

Discussion: This study is the first using the IIEF score to ascertain the degree of male sexual dysfunction after pelvic fractures. This self-administered questionnaire provides a tool adapted to the patient’s needs. Compared with the control group, we noted a prevalence of erectile dysfunction to the order of 30% with a significant diminution of overall satisfaction (p < 0.05). There was no significant correlation between male sexual sequelae, type of fracture and the notion of urethra injury. Pubic dysjunction is regularly correlated with decreased erectile function and overall satisfaction, probably in relation with injury to the cavernous bodies. Impaired sexual function, found long after the trauma (mean follow-up 26.8 years) suggests a permanent injury.

Conclusion: The IIEF self-administered questionnaire is interesting for young male patients victims of pelvic trauma, particularly in case of pubic dysjunction. Used during rehabilitation, it can identify patients with sexual sequelae (erectile function) in an overall medical and medicolegal management scheme.

We undertook a prospective controlled clinical trial of 109 patients to determine whether postoperative blood salvage in patients undergoing total hip or knee arthroplasty decreased the need for transfusion with banked blood. The average amount of blood collected in our series was 493 ml, most of which was collected in the first four postoperative hours. In patients undergoing bilateral total knee arthroplasty, there was a 54% reduction in banked blood utilisation. None of our patients developed adverse effects from the reinfused material. The cost of collecting and processing wound drainage using the Haemolite cell washer was $175 per patient, regardless of the volume processed, compared to $125 for a unit of banked blood. By reducing the requirement for homologous transfusion, blood salvage diminishes the risks of transmission of HIV and hepatitis viruses. In those cases where the equivalent of two units of blood are reinfused, blood salvage saves money. However, due to the small amounts of blood collected in unilateral hip or knee arthroplasty, we do not recommend its routine application in these cases.