Aims

The primary aim of this study was to analyse the position of the acetabular and femoral components in total hip arthroplasty undertaken using an anterior surgical approach.

We present a series of 16 patients who have had a failed ankle arthroplasty converted to an ankle arthrodesis using a surgical technique of bone grafting with internal fixation. We describe our technique using tricortical autograft from the iliac crest to preserve length and an emphasis is placed on maintaining the malleoli and subtalar joint.

A successful fusion was achieved in all cases with few complications. Our post operative AOFAS improved to a mean of 70 with good patient satisfaction and compares well to other published series. From this series and an extensive review of the literature we have found fusion rates following failed arthroplasty in patients with degenerative arthritis to be very high. In this group of patients a high fusion rate and good clinical result can be achieved when the principles of this surgical technique are adhered to.

It would appear that a distinction should be made between treating patients with poor quality bone and more extensive bone loss, as is often the case with rheumatoid patients; and the patients with a non inflammatory arthropathy and better bone quality. The intramedullary nail would appear to be the preferred option in patients with inflammatory polyarthropathy where preservation of the subtalar joint is probably not of relevance as it is usually extensively involved in the disease process, and a higher rate of complications can be anticipated with internal fixation.

Aim

This controlled study uses gait analysis to evaluate patients' pre- and post-ankle arthroplasty, post-ankle arthrodesis and compares the results with a healthy control group to assess whether these theoretical benefits are borne out in clinical practice.

Purpose of the study: From November 2001 to January 2008, among 110 patients who underwent surgery for spastic hands due to a central neurological disorder, the management involved surgical treatment of long finger intrinsic and extrinsic deformities in 57 brain injury adults.

Material and methods: At least one procedure for the intrinsics and one for the extrinsics was performed during the same operative. Twelve patients had bilateral operations. The goal of the surgery and the treatment was established during multidisciplinary consultations with rehabilitation physicians, neurologists, surgeons and anaesthesists after a minute physical examination with selective neuromuscular blocks to differentiate muscle spasicity and tendon retraction from extrinsic and intrinsic disorders. The objective was established in the form of a contract with the patient and the family: hygiene and analgesia (47 patients), aesthetic aspect (15 patients, and/or function (21 patients.) For the spasticity and/or retraction of the exrinsics, we used 23 transfers of the FCP to the FCS, 6 Z lengthening of the FCP and the FCS, 14 intramuscular lengthening of the FCP and 11 of the FCS, 10 Page interventions, 10 selecive muscle disinsertions from the epitrochlears and one FCS tenotomy. Concerning the spasticity and/ol retraction of the intrinsic, we performed 4 neurotomies of the deep motor branch of the ulnar nerve, 48 interosseous tenotomise, 6 proximal disinsertions with mobilisation of the interosseous, 18 tenotomies of the 5th adductor, and 29 distal tenotomise of the extensor system.

Results: Outcome was good for 60 of the 69 operated hands (achievement of contract: function 18, aesthetic 14, hygiene 44). Seven hands required revision with a good final result for six of them. One patient developed reflex dystrophy.

Discussion: In adults, despite the modest functional results achieved in only one-third of the patients, corrective surgery for spastic mixed extrinsic and intrinsic deformities provides an important improvement for these patients.

Purpose of the study: The purpose of this prospective controlled trial was to evaluate the influence of the tibial stem design on the primary fixation of the tibial base of a total ankle arthroplasty (TAA) and on radiographic remodelling of adjacent bone.

Material and methods: Sixty Salto™ TAA with a short stem were studied with one to three years follow-up. This series was mated with a control series of 60 TAA using conventional ‘cannon’ implants. All patients were assessed clinically with the AOFAS score and radiographically on the loaded ankle.

Results: The two consecutive series were reviewed a mean 23 months. The mean AOFAS score at review was 83.6 points (mean gain 45 points). The functional analysis did not disclose any difference between the two series. There was no evidence of tibial piece migration. The incidence of lucent lines, all partial (32.5%) and bone remodelling was higher in the cannon TAA series than in our short-stem TAA series, but the difference did not reach statistical significance. Considering all prostheses together, the incidence of bone condensation was 39.3%; and bone defects 16%. Young age appeared to be the only factor correlated with the development of defects (p=0.01). One progressive defect was grafted. Two prostheses were removed (one talar necrosis and one malposition).

Discussion: Primary fixation of the tibial base of the Salto™ prosthesis is excellent, irrespective of the design of the anchor stem. Suppression of the cannon did not reduce statistically the phenomena of osteolysis. The mechanism of the periprosthetic osteolysis is probably plurifactorial, associating biochemical and mechanical factors.

Purpose of the study: The results of the first total ankle arthroplasties (TAA) using the Salto™ prosthesis were published in 2004 with mean 35 months follow-up. The purpose of this work was to update the results of the initial multicentric series.

Material and methods: From 1997 to 2000, 98 TAA were performed with a Salto™ prosthesis in three centres: 62 women, 36 men, mean age 56 years, age range 26–81 years, mean BMI 24.3 kg/m². The patients had osteoarthritis (n=65; posttraumatic 43, post-instability 8, primary 14), rheumatoid arthritis (n=29), and sequel of septic arthritis (n=4). At last follow-up, nine patients had died (none had had revision surgery of the ankle) and one patient had been amputated for an unrelated reason. The remaining patients (88 TAA) were reviewed in an outpatient clinic with a mean 102 months follow-up (range 65–134). None of the patients were lost to follow-up.

Results: Seven prostheses were replaced by an arthrodesis (six osteoarthritis and one rheumatoid arthritis): three for defects at 44, 72 and 101 months after implantation, two for unexplained pain after 32 and 57 months, one for tibial loosening after 62 months and one for infection after six months. One tibial piece was changed for loosening and fracture of the polyethylene insert after 100 months (revision with a longer anchor piece). Two 3 mm polyethylene inserts were changed alone for fracture after 72 and 122 months. Five TAA were reoperated for stiffness: removal of bone fragments±synovectomy. Four TAA were grafted for secondary defects (two tibia and two talus). One lateral maleolar piece was removed for loosening after 88 months. There were two infections treated by synovectomy, wash-out and antibiotic therapy. The survival rates were 92% for failure=removal of the prosthesis; 91% for removal or replacement of one component; 89% for removal or replacement of one piece, including the polyethylene insert. The survival rate (prosthesis removal) was better for rheumatoid disease (97%). The AOFAS score at last follow-up was 81.5±12 (80.5±10.3 for osteoarthritis and 76.4±14.8 for rheumatoid disease).

Conclusion: These results underscore: the importance of rigorous technique and careful patient selection (five revisions for defective technique); the higher risk of infection (three cases); the importance of the thickness of the poly-ethylene insert (three fractures on 3mm inserts). Seven patients underwent revision to graft defects, four successfully and three failures (secondary arthrodesis).

Introduction: The goal of this study is to relate our experience about a third generation model of a Total Ankle Arthroplasty (TAA) Salto^® (Tornier™) by evaluating a prospective, homogenous and continuous serie of 130 TAA.

Materials and Methods: From 1997 to 2002, 130 TAA had been implanted to 125 patients, mean age 57 year (19 to 84). This procedure was performed by two experimented surgeons. Indications for arthoplasty were post-traumatic osteoarthritis in 57%, osteoarthritis in chronic laxity in 15%, rheumatoïd arthritis in 12%, primitive osteoarthritis in 10%, and 6% other. Collection of preop, postop and follow up datas was prospective. Radiographs were numerised and treated by a specific software. We considered as a failure when the implant was removed.

Results: After a mean follow up period of 44 months [12 – 108], 10 patients were lost to follow up, without complication, 4 patients died, without relationship to the TAA, but they had sufficient follow up, 9 arthroplasties were converted to arthrodesis, leaving a 92,5% success rate. Postoperative main complications were cutaneous problems (18/130). In one case, a skin necrosis led to a secondary infection that requested implant removal.

Long folllow up showed that main complications were pain and bone cysts, which required arthrodesis in 8 cases. Survivorship analysis at 108 months were 83% [IC5%: 72–95]. At follow up, clinical AOFAS ankle score was significantly raised (31% preoperative to 84% at follow up). A SF36 quality of life score was available for 85 patients. Physical score was 60, mental score 66 and total score was 64.

Discussion: This study has the avantages of being prospective and continuous. Clinical results and failure rate were encouraging. Infection rate less than 1% may be in relation with the low rate of patient with rheumatoïd arthritis. No significant difference of the result could be find according to the initial indication.

Conclusion: These mid-term results are concordant with orther series of third generation TAA. We remain concerned because of bone trabeculation modification and pain without obvious anatomical abnormality: long term follow up is necessary. Mid term results confirm TAA as a therapeutic option for ankle pathology.

Objective: This study compares the results obtained from arthrolysis of the elbow performed arthroscopically with those done open.

Material and Methods: 139 patients from 3 hospitals, who had undergone an arthrolysis of their elbow, were studied retrospectively. 58 had an arthroscopic arthrolysis and 81 were open. The patients included were aged between 18 and 65, had a loss of passive range of motion, due to either osteoarthritis or post trauma. Patients with previous extra articular osteotomy, septic or inflammatory synovitis were excluded. The clinical evaluation comprised measuring their: range of motion, pain, level of activities, presence of effusion or locking. The images obtained were standard radiographs, CT scan and bone scans to allow us to accurately determine the presence of loose bodies, fibrous tissue in the fossae, the presence of osteophytes or arthritis. All data was recorded in preoperative, postoperative and final assessment.

This study also discusses various issues regarding operative techniques (surgical approaches, debridement of joint and capsular releases).

Results: The two groups were similar on all points with the exception of their aetiologies. There was no clinical difference preoperatively. The arthroscopy was performed through 4 portals in 94% of cases; in the open cases the most common approach was lateral (53%). Intra operatively the significant differences were the removal of posterior osteophytes and capsular releases (p< 0.001) were performed more frequently in the open procedure. At the end of the procedure, the flexion and the gain in flexion-extension range was greater in the arthrotomy group; however the arthroscopic group lost less motion from end of procedure to the final result (8 versus 17 degrees). At the last review, the gain in range of motion remained greater in the group with the open arthrotomy. The number of complications in the 2 groups was identical, though the location of any nerve injury was different. The method of rehabilitation was the same; however this was continued for longer in the arthroscopic group. Final radiographic assessment showed that a less extensive debridement of bone was achieved arthroscopically.

Conclusion: A more extensive release and an easier intra operative evaluation resulting in a better improvement in range of motion at the end of procedure are achieved with arthrotomy. The subsequent loss of motion is more significant in this group however the final outcome showed the gain in range of motion remained greater. It was noted however, that even with less improvement in mobility, with either technique, the patients were equally satisfied.

Purpose of the study: The aim of this study was to analyze the mechanical function of the ankle after implantation of a total ankle arthroplasty. Gait analysis included kinematic and dynamic parameters of the lower limbs before and after prosthesis implantation in comparison with ankle fusion.

Material and methods: This prospective non-randomized study included three cohorts of patients. The first cohort included 12 patients presenting osteoarthritic lesions of the ankle requiring total ankle arthroplasty; these 12 patients were reviewed six months postoperatively and for six of them twelve months postoperatively. The second cohort was composed of 12 patients reviewed twelve months after tibiotalar arthrodesis. The third cohort was composed of 12 healthy volunteers who participated in the same study protocol. The gait analysis was conducted with the Motion Analysis optoelectronic system. Parameters recorded were: self-selected speed, fastest speed, stride rate, step length, stride symmetry and length, symmetry of floor contact, and symmetry of toe lift-off. In addition, patients participated in specific tests to step over an obstacle and go up and down stairs.

Results: Gail was slower an asymmetrical in patients with ankle fusion. Fusion enabled good recovery of gait speed but at the cost of imbalanced weight-bearing times and asymmetrical toe lift-off. Total ankle arthrodesis provided little improvement in gait speed but enabled progressive and persistent recovery of symmetrical gait.

Discussion: It is well established that an ankle prosthesis improved joint force and motion in comparison with the osteoarthritic ankle. Fusion provides good clinical and kinetic results but at the const of compensation by the joints above and below the ankle. Few studies have examined gait symmetry which in our opinion would be a good criterion for evaluating the quality of gait.

Conclusion: The raw data obtained in this study demonstrate that patients with an osteoarthritic or fused ankle can recover gait speed but that they retain a limp. Total ankle arthroplasty enables a more balanced fluid and symmetrical gait which is much more comfortable for the patient.

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.

Spinal deformities are a common feature of Marfan’s syndrome and can be a significant cause of morbidity. The morphology of the scoliosis associated with this condition was previously described by Sponseller, but no correlation with the pelvic parameters has been seen. We performed a retrospective radiological study of 58 patients with scoliosis, secondary to Marfan’s syndrome and related the findings in the thoracolumbar spine to the pelvic parameters, including pelvic version (tilt), pelvic incidence and sacral slope. Our results showed marked abnormalities in the pelvic values compared with those found in the unaffected population, with increased retroversion of the pelvis in particular. In addition we found a close correlation between the different patterns of pelvic parameters and scoliosis morphology. We found that pelvic abnormalities may partially dictate the spinal disorders seen in Marfan’s syndrome. Our results supplement the well-established Sponseller classification, as well as stressing the importance of considering the orientation of the pelvis when planning surgery.

Purpose: Prosthetic replacement of the ankle joint is a controversial issue. Minimally invasive noncemented third-generation implants with a third component have enabled improved clinical results and prolonged mid-term implant survival. These results authorise prosthetic implantation as an alternative to arthrodesis in selected patients. New developments in prosthesis concepts and design, aimed at overcoming the insufficient results of earlier implants, require early validation with a prospective clinical and radiological follow-up. The objective of this work was to present the mid-term results with the SALTO prosthesis implanted in 42 patients.

Material and methods: Forty-two SALTO prostheses implanted between February 1997 and December 2000 were followed prospectively for two to six years. The implant design, which mimics the anatomic asymmetry of the talar dome, uses a mobile polyethylene insert and optional fibular resurfacing for optimal primary and long-term stabilisation. Data were collected prospectively using a computer database which provides the AOFAS score. Metrological analysis of the digitalized x-rays (AP, lateral and stress) were used to study the precision of the insertion, implant stability, and prosthesis kinematics. Posttraumatic osteoarthritis predominated (n=29) in this series. Mean age was 54 years (30–79).

Results: None of the patients were lost to follow-up. Three patients had a revision procedure for arthrodesis (persistent pain in two and sepsis in one). The clinical score was excellent or good in 88% of patients. The mean clinical score was 20.5 points preoperatively and 70 points at last follow-up. The radiological analysis demonstrated the precision of the insertion technique and did not disclose any evidence of significant implant mobilisation with time. There were no failures related to the lateral malleolar implant (n=12). Radiographically, mean ankle movement was 15.2–23°. Changes in the periprosthetic bone were noted.

Discussion: The quality of the results with the prosthesis under study and the short- and mid-term stability enable envisaging implantation when the local or regional anatomic conditions suggest arthrodesis would produce unsatisfactory results. The improvement in function (exceptionally total recovery) remains difficult to predict. Further follow-up of these patients is needed.

Purpose: Although hamstring retraction is a frequent complication of spastic hypertoniq, very few series have been reported in adults. The purpose of this study was to evaluate results of therapeutic modalities proposed: distal hamstring tenotomy and use of an external fixator in case of permanent knee flexion.

Material and methods: This retrospective series included 37 cerebral palsy patients, 59 with permanent knee flexion. Mean flexion was 69° (20–130°). Mean motion was 61° (10–100°). Deformation of the supra and infra joints was present in 82%. There were 22 patients with bilateral permanent knee flexion. Simple tenotomy of the sartorius, the semitendinous and the gracilis with lengthenings of the semimembranous and biceps. Disinsertion of the gastrocnemius and section of posterior aponeurosis were associated as needed. Postoperative immobilization was achieved with a Zimmer cast in case of moderate flexion and with an external femorotibial fixator in case of major deformation. Postoperative rehabilitation exercises performed several times daily were initiated in all patients.

Results: At mean follow-up of 641 days, residual flexion was 6° (0–40°) and mean joint motion was 111°. All knees were stable. Three dehiscent wounds required surgical repair. The function objective, established pre-operatively, was achieved or exceeded.

Discussion: When postoperative immobilization is necessary, external fixation limits cutaneous risks and facilitates rehabilitation. It appears to be better than successive cases. Unlike other authors, we did not find section of the posterior cruciate ligament to be necessary.

Conclusion: Distal hamstring tenotomy associated with postoperative immobilization with an external fixator is a reliable and effective technique for the treatment of permanent knee flexion in cerebral palsy adults.

Purpose: The purpose of this work was to evaluate the mid-term clinical and radiological outcome of a homogeneous and continuous series of third-generation total ankle prostheses (resurfacing, cylindric, noncemented, triple-compartment).

Material and methods: From March 1990 to June 1996, 26 patients aged 57 years (32–73) were treated with a New Jersey LCS (n=5) or Buechel-Pappas (n=21) prosthesis. Most of the patients (n=21) had a posttraumatic ankle. Preoperatively, mean ankle motion was 17°. The AOFAS score was used for the clinical assessment. The position of the prosthesis and its stability over time were assessed on the x-rays together with the insert, the bone-prosthesis interface, the bone structure and periprosthetic ossifications.

Results: Intra and postoperative complications were malleolar fracture (n=5), haematoma (n=1), late wound healing (n=1), insert instability (n=2), and medial malleolar conflict (n=1) requiring reoperation with preservation of the implant. At mean follow-up of seven years, two patients had died and one was lost to follow-up. Three had an arthrodesis: failed fixation at two years, secondary talar mobilisation at seven years, and secondary infection at eight years. For the other twenty patients: the AOFAS score was poor for two patients (including one with patent wear), fair in two, and good in 16. Mean joint motion at last follow-up was 24°. Radiographically, there were no significant changes in the position of the tibial and talar elements. Anchorage of the tibial element was fibrous in half of the patients and ossesous in the other half. A macro defect aspect was observed below the talar element in four patients. There were active periprosthetic ossifications in the majority of the patients.

Discussion: The insufficient ancillary for this prosthesis and its old concept explain the frequency of malleolar fractures and the level of the functional outcomes. Improved prostheses should be used. The stability of the results observed in this series of patients followed up to 12 years is an argument favouring indicating prosthesis insertion as an alternative to arthrodesis, particularly since revision of an arthrodesis is not particularly difficult, even with an iliac graft. The radiographic evidence of periprosthetic ossifications or bone resorption, particularly under the implant, emphasises the need for prolonged surveillance.

Purpose: We analysed prospectively our experience with the zincrone-polyethylene bearing for total hip arthroplasty for implantations performed between 1987 and 1997. This bearing is designed to reduce in vivo wear due to the excellent biological qualities of this ceramic.

Material and methods: Total hip arthroplasty was performed on 867 hips over the ten year period (1987–1997) in patients followed for mean seven years. All had titanium or stainless steel stems with a cemented or press fit cup (inner diameter 26-mm or 28-mm). We used Y-TZP zircone, a polycrystalline tetragonal-phase zircone stabilised by adjunction of ytterium (Prozyr). Mean patient age was 58 years (17–87). Mean body weight was 70 kg (40–125) and mean height was 167 cm (140–196). The sex-ratio was 1.3.

Results: Overall survival determined with the Kaplan-Meier method was 60% at 13 years (95%CI=55–65%). Revisions (all causes including infection) were performed on 118 hips. To our knowledge, for the entire cohort, one patient presented a zircone head fracture. Radiographic analysis showed a particular type of fracture related to isolated acetabular loosening. Comparative analysis of this type of loosening for 785 heads (26-mm) and 92 heads (28-mm) was not significant (log rank test). Taking surgical revision as the endpoint for isolated acetabular failure, implant survival at 13.5 years was 74% (95%CI=68–80), confirming the particular mode of failure with this bearing.

Discussion: This prospective analysis showed the absence of superiority of the zircone head in vivo for reduction of wear in comparison with metal heads in young subjects. The purely epidemiological data reveal formal evidence of the deleterious nature of zircone in contradiction with the expected beneficial tribiological effect. We have no physicochemical explanation for these failures. The pathology findings were non-specific, but the failure was real.

Conclusion: Considering these findings, we have abandoned use of this ceramic since 1997.

Neurogenic myositis ossificans is a disabling condition affecting the large joints of patients with severe post-traumatic impairment of the central nervous system. It can result in ankylosis of the joint and vascular or neural compression. Surgery may be hazardous with potential haemorrhage, neurovascular injury, iatrogenic fracture and osteochondral injury. We undertook pre-operative volumetric CT assessment of 45 ankylosed hips with neurogenic myositis ossificans which required surgery. Helical CT with intravenous contrast, combined with two- and three-dimensional surface reconstructions, was the only pre-operative imaging procedure. This gave good differentiation of the heterotopic bone from the adjacent vessels. We established that early surgery, within 24 months of injury, was neither complicated by peri-operative fracture nor by the early recurrence of neurogenic myositis ossificans. Surgical delay was associated with a loss of joint space and a greater degree of bone demineralisation. Enhanced volumetric CT is an excellent method for the pre-operative assessment of neurogenic myositis ossificans and correlates well with the operative findings.

We report the results of a prospective study of 140 consecutive cases of acetabular revision using large frozen femoral head allografts and cemented all polyethylene acetabular components. The mean follow-up time was 10 years (5 Ð 16).

Thirty patients died, seven were lost to follow-up and 26 had failed and undergone further surgery. Nineteen failures were due to aseptic failure and collapse of the graft. Kaplan-Meier survival analysis calculated a mean survival at 10 years of 88.5% for revision for any reason.

We compare all reported techniques of acetabular reconstruction for similar defects and recommend a surgical strategy based on the available evidence, but weighted towards a preference to reconstitute bone stock rather than removing further bone in the revision situation.

Purpose: Fractures of the anterior acetabular wall with preservation of the pelvic inlet are rare. These lesions were not noted or classiþed by Judet and Letournel in their classiþcation system Ð Ç In fractures of the anterior wall, the anterior part of the articular horseshoe breaks off with a major portion of the middle segment of the anterior column È. The ilio-inguinal approach was recommended for the surgical treatment of these fractures. Method : We have encountered two cases involving purely the anterior wall with preservation of the pelvic inlet, rather than the anterior wall fracture described by Judet and Letournel. We have identiþed only two other cases in the international literature. The recognition that these fractures were not as that described by Judet and Letournel was essential, as an alternative surgical approach was necessary for reconstruction. The ilioinguinal approach of Judet and Letournel is the technique of choice in anterior fractures, but provides only very limited potential for intra-articular manipulation through the line of fracture. The Smith-Petersen approach was practically the only feasible choice as intra-articular exposure is difþcult or impossible to obtain with the classical approaches used for anterior acetabular fractures. Results: Both of our cases were reconstructed via the Smith-Petersen approach. Postoperative review at 18 months demonstrated painless, fully mobile hips with evidence of radiological union of the fractures. Conclusion: We propose designating as ñfracture of the anterior columnñ all the anterior fractures described by Judet and Letournel (column and wall) that justify the ilioinguinal approach. We would reserve the term ñanterior wallñ for large anterior acetabular rim fractures, with the extension exclusively lateral to and below the pelvic brim. We recommend the use of a Smith-Petersen approach for reconstruction once this fracture pattern is identiþed.

Purpose: Talipes equinus is a frequent deformity observed in patients with central nervous disease. The surgical strategy is based on an assessment of the spasticity and retraction elements in the deformity and the presence or not of antagonistic muscles. We propose a codified treatment strategy and present results obtained over the last two years.

Material and methods: All patients who underwent surgical treatment for central neurological talipes equinus between 1998 and 1999 were included in this study. All patients were seen by the orthopaedic surgeon and the physical education and rehabilitation physician at the preoperative consultation. Selective neuromotor nerve blocks completed the physical exam in order to assess spasticity and retractions (soleus, gastocnemius, flexor digitalis). Functional antagonistic or transferable muscles were identified. A function contract was established with the patient. All patients were operated on by the same surgeon and were reviewed late after surgery by an independent clinician. Gain in joint movement and function were recorded as well as any complications.

Results: Thirty-five patients underwent surgery (42 feet). The analytic results were good: mean gain in joint movement = 37.5°.

The functional objectives (walking for 31 patients, verticalisation for ten, comfort for one) were achieved in all patients except five. There was one taluseversus, one anterior subluxation of the talus, one persistent stepping. For two patients underlying neurological disorders did not allow fulfilment of the contract. There were also three cases of claw toes with moderate functional impact.

Discussion: Preponderant retraction makes it difficult to assess antagonistic and intrinsic muscles, leading to the complications observed. A dynamic EMG recording might provide a solution. Functional outcome depends on correct assessment of the underlying neurological status.

Conclusion: The good results achieved in this series of patients validates the proposed decisional algorithm. The surgical strategy must be inscribed within a functional contract established with each individual patient.

Purpose: We have used monoblock cryopreserved femoral heads for acetabular reconstruction without supporting material since 1985 for cemented total hip arthroplasty in patients with major acetabular defects. From 1985 to 1995, 140 reconstructions were performed. We present a prospective analysis of the clinical and radiological outcome at 10 years follow-up.

Material and methods: Mean age of the population was 61 years. Most of the patients had had two prior interventions. According to the SOFCOT classification, the 140 defects were: grade II 50%, grade III 35% and grade IV 15%.

The cryopreserved graft (femoral head bone bank) was used to reconstruct the acetabular defect. The graft was adapted to the size of the defect to fashion a congruent construct aimed at achieving primary stability. We did not use any supporting material in addition the primary osteosynthesis with one or two screws. A poly-ethylene cup was cemented in the graft. Most of the cement was applied onto the graft which was reamed to the size of the acetabulum. We retained a theoretical 6-year follow-up for review. All patients were seen for follow-up assessment using the Postel-Merle-d’Aubigné (PMA) clinical score and standard x-rays analysed according to the Oakeshott method. Kaplan-Meier survival curves were plotted taking change in status, revision for clinical failure as the endpoint.

Results: Mean overall follow-up was 8.5 years; it was 10 years for patients with an implant still in situ. Eight patients (5.7%) lost to follow-up were included in the series retained for analysis at mean 5-year follow-up. Thirty-five patients died during the follow-up period (25%). These patients had been followed for a mean four years before their death. Radiologically, cup tilt was not significantly altered over time. Conversely, the centre of the cup, measured from the U line, was not modified in the patients who died or in the group of living patients without revision at last follow-up. It was modified in the group of failure group: mean 28 mm postoperatively in the failure group reaching 39 mm at time of failure (ANOVA < 10-3). We had 26 failures (18%) which occurred at six years (mean); there was a peak at two years and another at nine years. Mean Kaplan-Meier survival was 13.5 years (95CI 12.5–14). The PMA clinical score improved from 3/5/3 (11) pre-operatively to 5.3/5.6/4.3 (15.2) at last follow-up.

Discussion: The overall results at 10 years in this series were globally satisfactory with a success rate above 70%. Failures were related to radiologically demonstrated graft compression with ascension of the centre of the cup measured from the U line. Comparing these results with data in the literature shows an improvement over the Harris series (7-year follow-up in a small group of 48 patients).

Conclusion: This method of acetabular reconstruction reserved for major bony defects has provided a 73% rate of success at ten years.

Purpose: Multiple deformations of the lower limbs are common orthopaedic complications of central nervous system disease. Assessment is difficult. Intrathecal Liorésal® was proposed for the patients to establish the relative effects of spasticity and musculotendinos retraction and define a medico-surgical therapeutic strategy.

Material and methods: Between January 1999 and December 2000, 31 patients consulted for persistent knee flexion. Baclofen tests (75 – 100 μg Baclofen intrathecal) were performed in ten patients because the relative contribution of spasticity and retraction was difficult to assess. The anti-spasticity effect was observed within the first hour, with a maximal effect between the second and fourth hour. Motor function, joint motion, and function were tested during this time interval. The test was repeated approximately three days later, sometimes with higher doses depending on the level of the anti-spastic effect. Residual orthopaedic limitations were explained by musculotendinous retractions.

Results: For the ten evaluated patients, three presented musculotendinous retractions amendable by surgical treatment (tendon lengthening, proximal disinsertion), sometimes in combination with arthrolysis. For the seven patients who had hypertonic spastic contractions, medical treatment was given with, for three patients, continuous intrathecal Lioresal via pump delivery. There was a correlation between the deformation assessed after the test and the test conducted under general anaesthesia during the procedure in all patients.

Discussion: Other methods for evaluating orthopaedic deformities of the lower limbs can be used. Selective motor blocks using local anasethetics are generally reserved for patients with localised stiffness or when it may be difficult to achieve in certain patients (hip flexion). Mobilisation under general anaesthesia is another solution, but does not allow an assessment of functional gain, particularly if the goal is walking. The intrathecal Baclofen test not only allows an accurate assessment of orthopaedic retraction, but also an assessment of the functional impact of the spasticity, sometimes useful for verticalisation or walking.

Conclusion: The Baclofen intrathecal test is a simple test with a particular place in the preoperative and functional assessment of neuro-orthpaedic stiffness of the lower limbs.

Purpose: Few studies have been devoted to neurogenic paraosteoarthorpathy (PAOn). We characterised the expression of genes specific for osteoblastic and chon-drocytic phenotypes using the osteomy wedge and non-mineralised tissue near the osteotome.

Material and methods: Osteotomy fragments and non-mineralised tissue near the osteotomy were obtained during surgery performed in 25 patients. The explants were cultured for 56 days. We searched for the messenger RNA of the principal markers of osteoblastic, chon-drocytic, and adipocytic phenotypes, as well as certain specific proteins. Serial cryotome sections were stained for histology and immunolabelling tests.

Results: Cells issuing from the osteotomy fragment and neighbouring tissues formed structures that miner-alised in culture. The following osteoblast markers were observed: alkaline phosphatase (bone isoform), osteo-calcin, Cbfa1, type 1 collagen; for chondrocytes: type II collagen, aggrecane; type X collagen as well as VEGT demonstrating the presence of hypertrophic chondrocytes.The adipocyte-specific transcription factor PPAR 2 was also found in the two cultures. The proportions and chronological expression of these markers were slightly different for the two tissues. Ex vivo study demonstrated the typical sequence of enchondral type bony formation from non-osseous cell populations.

Discussion: This work provided the first characterisation of non-mineralised tissue near osteotomy. It also provided clear indications concerning the history of ectopic bone formation. The osteochondrogenic potential of connective tissue lying close to an osteotomy has not been reported previously. The persistence of this potential could explain recurrence after resection. The observation that this potential is suppressed in vivo but expressed in vitro opens a new avenue of research concerning the mechanisms controlling bone formation.

Conclusion: The culture model developed in this study provides a means of studying factors determining the outcome of cell populations implicated in the formation of neurogenic paraosteoarthropathies.

We evaluated the use of a hemipelvic acetabular transplant in twenty revision hip arthroplasties with massive acetabular bone defects (Paprosky IIIB) at a mean follow-up of 5-years (4–10 years). These defects were initially trimmed to as geometric a shape as possible by the surgeon. The hemipelvic allografts were then cut to a geometric shape to match the acetabular defects and to allow tight stable positioning of the graft between the host ilium ischium and pubis. The graft was further stabilised with screw fixation. A cemented cup (without a reinforcement ring) was entirely supported by the allograft in all procedures.

We report 65% good intermediate-term results.

There were seven failures (five aseptic loosening and two deep infections). Radiographic bone bridging between the graft and host was evident in only one of these cases. Aseptic graft osteolysis began radiographically at a mean of 14 months and revision occurred at a mean of 2 years in the 5 aseptic failure cases. All 5 cases could be reconstructed again due to the restoration of bone stock provided by the hemipelvic graft. One infected case was able to be reconstructed using impaction allografting and the other was converted to a Girdlestone hip.

Thirteen of twenty acetabular reconstructions did not require revision. Radiographic bone bridging between the graft and host was evident in 12 cases. In 2 cases, ace-tabular migration began early (at 5 and 27 months) but stopped (at 35 and 55 months). These 2 cases have been followed for 6 and 9 years respectively, with no further migration. Two dislocations occurred but did not require acetabular revision.

The function of these hips is good with a mean Postel Merle D’Aubigne score of 16.5.

We feel that these are satisfactory intermediate term results for massive acetabular defects too large for reconstruction with other standard techniques.

Purpose: We report our experience with acetabular reconstruction using cyropreserved bone bank hemipevli without a scaffold and total hip arthroplasty for major acetabular defects. Between 1985 and 1999, among 262 acetabular reconstructions requiring massive allografts using cryopre-served bone, 20 cases were performed with hemipelvi.

Material and methods: Mean age of the population was 56 years. The acetabulum had been operated on a mean three times. The 20 defects corresponded to Paprosky grade IIIB or SOFCOT grade IV bone loss. Clinical and radiological review of the 20 hips was made at a mean five years after treatment. None of the patients was lost to follow-up. The overall Postel Merle d’Aubigné (PMA) score at last follow-up was 17 for preoperatively scores at D2, M4 and S3 respectively. The acetabular defects were major and poorly described by the conventional systems. For example, the mean height of the bony defects was about 10 cm measured from the base of the radiographic U and the superolateral rim of the remaining roof.

Results: Globally, 13 patients had not required a reoperation at last follow-up. We had one postoperative death and two early displacements as well as two infections including one haematogenous infection. The Oakeschott criteria were used to analyse the review radiographs. Aseptic lysis of the graft was observed in five cases (generally around the 13th postoperative month) that required revision; a bone graft and a supporting ring were used in all cases because more bone stock was available than for the first revision. Among the 13 cases that did not require a new procedure, there were two with an ascended graft displacing the centre of rotation about 10 mm, followed by radiographic stability. The overall functional score for these 13 hemipelvi at last follow-up was 17 demonstrating the superior functional result compared with arthroplastic resection, the only alternative for such important loss of bone stock. It is not possible to implant a large non-cemented socket in these cases. Radiographic fusion was achieved, documented in 13 cases by the development of bony bridges or disappearance of the interface with oriented lines of force. Early graft resorption does not appear to occur when a metallic scaffold is associated (Garbuz).

Discussion: In all, 19 hips still had their total arthroplasty at last follow-up (one patient with failure preferred trocahntero-iliac coaptation.

Conclusion: Due to the inefficacy of alternative methods, this mode of restoration for major bone loss of the acetabular region (which facilitates secondary revision) appears to provide satisfactory results since the probability of preserving the prosthesis at a mean five years was slightly greater than 3/5. A stronger metallic scaffold may be the solution for the future.

We report our experience over seven years with a floating radial-head prosthesis for acute fractures of the radial head and the complications which may result from such injury. The prosthesis has an integrated articulation which allows change of position during movement of the elbow.

We present the results in 12 patients with a minimum follow-up of two years. Five prostheses had been implanted shortly after injury with an average follow-up of 49 months and seven for the treatment of sequelae with an average follow-up of 43 months.

All prostheses have performed well with an improved functional score (modified from Broberg and Morrey 1986). We have not experienced any of the complications previously reported with silicone radial-head replacement. Our initial results suggest that the prosthesis may be suitable for the early or delayed treatment of Mason type-III fractures and more complex injuries involving the radial head.