The fractures of the hip are a main problem of health care. These fractures will be multiply by 2 in 2025 and 3 in 2050. In the population of old people, 1/3 of the women and 1/9 of the men will have a fracture of their hip. Some authors used the name of “EPIDEMIC”.

The aima of the INPECH project (Indicators of the Performance for the comparison between hospital) was to check if the comparison of performances of clinical teams, on the basis of indicators chosen by themselves, allowed to improve their performances. It was an experimentation of a volonteer processes of comparison of performance between 3 multidisciplinary teams.

The study followed some stages:

in every hospital, description of the process of care of the hip fractures with a choice of indicators of performance (difficulties of the care percepted by the professionals, possibilities of improvement, feasibility of the record of the indicators during the whole process)

The analysis of this second inclusion authorized a real change in our professional practices and showed the efficacy of the indicators which were improved.

This study had permitted to show qualitative differences of care of hip fractures between the hospitals. The confrontation between the teams had authorized a positive reflexion of some of our professional practices and the improvement was underlined by the second series of inclusion.

PURPOSE: Oldest elderly trochanteric fractures treatments are common but long term follow up studies are indistinct. Previous data about all outcomes are not reported for oldest one. The purpose was to update all the results for these oldest old patients.

METHODS: A prospective, longitudinal study was undertaken of 455 “31 A1, A2, A3” (OTA) peritrochanteric femur fractures through 2002. There were 84% female patients. The age was 88 (80–105) ±5 years. Associated hip arthritis rate was 10%. 31 A1 and 31 A2 really trochanteric fractures were 90% (31 A1: 52% and 31 A2: 38%), 31 A3 subtrochanteric were 10%. Surgical treatment was achieved for 97%: [extramedullary internal fixation (dynamic hip screw): 36%, intramedullary (trochanteric nail): 56%, hip arthroplasty: 5%]. Functional treatment (not displaced or contra-indicated) was achieved for 3%. Katz, mental, Parker, walking scores, live place before and at long term after fracture, radiological healing and complications were registered.

RESULTS: The radiological healing rate after 3 months was 85% and after 6 was 97%. Complications rate: the general complications rate during 1st month was 12% and between 1st and 3rd month was 8%. The local complications rate during the 1st month was 4% (local infection: 1%) and between 1st and 3rd month was < 1%. The new surgical procedures rate during the 1st month was < 0.5%, between 1st and 3rd month was 3%, between 3rd and 6th month was 3%. Clinical results: Post-operative weight bearing was uncertain. 6th month after fracture 72% of the patients were alive (dead: 28% and non-surgically treated: twice more). All scores and live place demonstrated dependence increase. > 6th month after fracture mortality was common.

CONCLUSION AND SIGNIFICANCE: Intra/extra capsular hip fractures ratio increases after 80. These are older, more dependant and help demanding. Hip arthritis inflates hip fracture risk. Success points technical procedures had been demonstrated by randomised studies: dynamic hip screws for stable fractures and trochanteric nails for unstable; hip prosthesis for arthritis or poor bone. Practice surgery for all trochanteric fractures. Don’t separate trochanteric/subtrochanteric. The prognostic is rather poor (mortality rate, functional outcomes), depending on initial functional score and dependence. Modern internal fixation is reliable. Arthroplasty should be considered.

Purpose: Publications reporting compression flexion fractures are rather old and rarely individualise this type of fracture. There is a consensus on anterior plate fixation which generally provides good outcome. We propose a retrospective analysis of our series to revisit the classification system and analyse outcome after surgical treatment.

Material and methods: From January 1983 to November 2001, 96 fractures of the lower extremity of the radius with anterior displacement were treated in our unit. There were 95 patients (50 men and 45 women), mean age 42.7 years (15–88). The fracture resulted from a traffic accident in 52 patients. Twenty-seven patients had associated injuries. For lateral simple or complex anterior marginal fractures, the Castaing and Cauchoix classification was modified to take into account the importance of the fragment, relative to the middle of the radial glenoid, with or without associated lesion of the radial borders on the lateral and AP views (types I and II fractures). Type III factures were Goyrand fractures and type IV associated Goyrand fractures with one or more joint fracture lines. Our series thus included 43 anterior marginal fractures including 27 type II fractures where more than 50% of the joint surface was displaced, 53 Goyrand fractures (25 type III and 28 type IV). Plate fixation was used for 90 wrists, associated with complementary fixation in 17. Outcome was assessed with Laulan clinical criteria and Mouilleron radiological criteria.

Results: Bone healing was achieved in all cases, without changing the initial fixation in 85 wrists. There were 49 men and 35 women, mean age 40.7 years (20–87). Type I/II fractures were found in 40 wrists, simple Goyrand fracture (type III) in 23 and comminuted Goyard fracture (type IV) in 22. At three months, reduction was good in 57 cases (67%), fair in 23 and poor in five.There were eleven secondary displacements in eight women and three men, mean age 57.7 years. They had four type I/II fractures and seven Goyrand fractures (1 type III, and 6 type IV). Plate fixation used for eight wrists had to be completed with pinning or a fixator. Radiological reduction was good in two cases (18%), fair in three and poor in six (55%). Twenty-five patients (30%) presented residual pain (10 patients), carpal tunnel syndrome (7 patients), wrist or finger stiffness (4 patients), radiocarpal osteoarthritis (3 patients), and cutaneous palmar neuroma (1 patient). At mean 61 follow-up (12–204), clinical outcome was good for 70 wrists; 78 wrists were pain free. The radiological outcome was good in 64 wrists, fair in 18 and poor in five.

Discussion: Better radiographic analysis distinguishing type II and IV fractures, which were the cause of three-quarters of the displacements, improves identification of wrists which must have complementary fixation with pins or fixator in addition to the anterior plate which in these cases should be prebent. For the other wrists, initial reduction was satisfactory in 67%, explaining the good functional tolerance demonstrated subjectively (89%) and objectively (80%). There were only rare sequelae in this series and complications were limited: painful wrist in 10%, secondary to reflex dystrophy in two.

Conclusion: Good interpretation of the radiographs enables prediction of difficult reduction where complementary fixation in addition to the anterior plate can be useful for type II and IV fractures.

Purpose: According to the Finnish registry, the ABG1 stem has a 94% survival (90–98) at seven years. A multi-centric study in Torino found 99% survival at five years. These studies have however reported worrisome radiographic images showing absorption of the calcar in 27% of the cases. We studied the clinical and radiological outcome of 102 ABG1 stems inserted between September 1990 and December 1996.

Material: This prospective study included 91 consecutive patients (102 hips): 75 men and 27 women, mean age at surgery 63.1 years (range 34–81). The posterior approach was used for treatment of degenerative joint disease (82%) or osteonecrosis (11%). A size 5 or 6 stem was inserted in 60% of the cases. A metal-backed cup with a polyethylene insert was used in 45%, a zircona cup in 55%. The head diameter was 28 mm in 91% of the cases. At review, five patients had died, ten were lost to follow-up, eight responded to a phone interview, and x-rays were obtained for 79. Mean follow-up was 90.6 months (median 86.4 months).

Methods: The Postel Merle d’Aubigné (PMA) and Harris (HHS) scores were recorded for all patients. Position and quality of bone fixation were analysed. Stem migration was calculated on the different x-rays by calculating the distance between the centre of the head and the summit of the greater trochanter. Lucent lines (Gruen), osteolysis and the ARA score were noted. The SOFCOT 1997 radio-clinical classification was used. Actuarial survival curves were plotted taking stem revision as the endpoint. Quantitative data were compared with the chi-square test.

Results: The PMA pain score improved from 2.9 to 5.7 and the overall PMA score from 11.2 to 15.7. The HHS at last follow-up was 83.6 points. The stem was perfectly aligned in 81 cases, showed varus deviation in 26 and valgus deviation in four. A change from the initial alignment was noted in three cases and stem impaction in two. Six stem revisions were required for malposition (n=1), fracture during operation (n=3), or pain (n=2). Finally, there were no radiographic anomalies for 53 hips (class A), radiographic anomalies without clinical expression for 17 (class B), pain without detectable radiographic anomaly for six (class C), and poor clinical results with radiographic anomalies for four (class D). The ARA score was 5 or 6 in 51 cases. The 15-year actuarial survival rate was 88.9±4%.

Discussion: The form of the ABG1 implant allows an excellent alignment in only 80% of the cases. The metaphyseal anchor is achieved by bone remodelling of the calcar (23 atrophies including 10 severe cases)—to be differentiated from osteolysis (8 cases)—and an excessively transparent femur in the proximal 1A, B and 7 (12 cases). Transmission of force to the diaphyseal zone remains abnormal (30 thickenings with four overall thickenings) and two severe cases of diaphyseal necrosis.

Conclusion: The changes in the design of the ABG2 which has an under-dimensioned stem should improve shaft remodelling. The form of the implant and the favourable effect of hydroxyapatite coating responsible for bone remodelling in zone 1 and 7 (Gruen) should be given particular attention in the upcoming years.

Purpose: The long-term outcome of the Harris-Galante 1 (HGP1) stem is a controversial issue. A randomised study reported by Thanner (AOS 1999) mentioned a 72% survival at ten years, basically related to femoral osteolysis observed in 18% of the cases with mechanical failure requiring revision in 20%. We studied the clinical and radiological outcome of 191 HGP1 stems reviewed at a mean 12.5 years.

Material: This prospective study included a consecutive series of 181 patients (191 hips) 101 men and 80 women, mean age 62.1 years (range 19–83). Indication for arthroplasty was primary hip degeneration (80%), or osteonecrosis (14.6%). A metal-backed polyethylene cup and a 28 mm head were inserted in 86% of the cases. At review, 41 patients had died (43 hips), two were lost to follow-up, and x-rays were available for 109. Mean follow-up was 150.2±15.3 months.

Methods: The Postel Merle d’Aubigné (PMA) and Harris (HHS) scores were recorded for all patients. Position and quality of bone fixation were analysed. Stem migration was calculated on the different x-rays by calculating the distance between the centre of the head and the summit of the greater trochanter. Lucent lines (Gruen), osteolysis and the ARA score were noted. The SOFCOT 1997 radioclinical classification was used. Actuarial survival curves were plotted taking stem revision as the endpoint. Quantitative data were compared with the chi-square test.

Results: One patient died on day three. There were three displacements. The PMA pain score improved from 2.5 to 5.6 and the HHS improved from 52.5 to 85.6 points. The stem was perfectly aligned in 80 cases, and presented a varus deviation ≤ 3° in 26 cases. A change in the initial alignment was noted in three cases and stem impaction in 14. Eleven revisions were necessary for fibrous fixation (n=5), pain (n=2), femoral malposition, (n=1), fracture of the femur during the operation (n=1, and diaphyseal osteolysis (n=1). Finally, there were no radiographic anomalies for 69 hips (class A), radiographic anomalies without clinical expression for 34 (class B), basically because of severe osteolysis of the calcar (n=6), and stress shielding in zone 1A-B. Three hips caused pain without a detectable radiographic anomaly (class C), only one hip was in class D because of the poor clinical and radiological result. The 15-year actuarial survival taking stem revision as the endpoint was 89.5±3.7%.

Discussion: The 5% rate of unstable fibrous fixation observed in this series is very different from the 16% reported by Garcia Cimbrelo (2001). There was only one case of femoral shaft osteolysis limited to zone 3 which required revision, contrasting with the 16% (Thanner) and 24% (Garcia Cimbrelo) reported for shorter follow-ups.

Conclusion: With an 89.5% mid-term survival, the Harris Gallante 1 femoral stem has provided good clinical results and a solid fixation due to the proximal porous coating on the titanium. Although rare, stem failure was observed during the first six years of implantation.

Introduction: Dislocation after primary total knee arthroplasty is a very uncommon complication. Some case reports referred to Total Condylar, Insall Burstein or more recently Mobile bearing prostheses.

Frequency is probably under evaluated and their treatment and consequences subject to discussion.

Dislocation has to be differentiated from knee instability, subluxation and expulsion of the PE tibial insert.

The purpose of this review was to study their mechanism, treatment and consequences.

A modification of the surgical technique and the insert design was deduced.

Materials and methods: From 9/1994 to 9/1998, 229 primary Wallaby 2 with an original modular PE tibial insert were performed by the Guepar in 11 centers. Eleven posterior dislocations occurred less than 2 years postoperatively.

A prospective analysis was performed to compare the following variables of these patients (study group) to 56 cases who did not experience that complication (control group): age, sex, weight, component size, surgical approach, importance of release, pre and post surgical scores, alignment, stability, patella and component thickness. Statistical analysis of these parameters was performed.

Results: There were no statistical differences between the two groups for any variable assessed except importance of the valgus knee deformity (11° vs 6°), Keblish approach, lateral release and postoperative flexion (119° vs 106°) p< 0.01.

Conservative treatment was successful in 10 cases, but 3 recurrent dislocations and a neglected dislocation were treated surgically after modification of the tibial insert.

Discussion: Possible factors contributing to these dislocations are discussed as surgical procedure, quality of knee stability, characteristics of the tibial post compared to other implant (placement, dislocation safety factor).

After modifications of the stabilizer concerning height and slight posterior displacement, in a personal series of 129 TKA, dislocations disappeared.

Introduction: The purpose of this retrospective study was to evaluate the results of retrograde pinning, according to Hacketal procedure, for unstable fractures of the humeral neck with particular attention to three and four part fractures.

Materials and Methods: Between 7/1990 and 4/2001, we treated 44 patients (26 females and 18 males) ranging in age from 16 to 92 years (mean: 59/5 years). 75% of the cases followed a domestic trauma. Using Neer classification there were 30 two part fractures, 12 three part and 2 four part fractures. After closed reduction was performed under biplane image intensification, a small incision was made to expose the distal humerus by blount dissection. A 5 mm hole was drilled. Three to five prebend Kirschner (25 cases) or Metaizeau pins (19 cases) were introduced retrograde achieving a ‘bouquet’-type fixation within the humeral head. Post operatively, the arm was immobilized in a Mayo-type sling for 2–3 weeks. Then mobilization was started in all directions except rotation, who was cautiously done later. The results were evaluated according to consolidation, pain and range of motion. Complications associated with the treatment were recorded. We considered as excellent results, asymptomatic shoulder with full motion, good results patients with slight pain or reduction of motion and bad results, those with any pain, valuable restriction of motion and functional handicap.

Results: The mean follow up was 21/7 months. Two patients died before callus formation. All patients were re-examined or contacted by phone. No patient was lost to follow-up. The mean hospitalization range was 6.4 days. Two patients had loss of fixation. Fractures united with callus formation in 4 to 8 week. Patients regained a full range of motion in 64% of the cases, 88% were free of pain. No avascular necrosis was noted in that series.

The functional outcome was excellent in 64% of the cases, good in 21.5% of the cases. Pins removal was almost necessary for proximal pins migration in 45% of the cases and distal migration in 7.5% of the cases.

Discussion: The overall finding of good results in this series compares favorably with results of other operative treatment. We believe that our technique offers distinct advantages: few displacement, no osteonecrosis but our follow-up can be considered as insufficient. Migrations of the pins remain a matter of concern.

Conclusion: Retrograde pinning by the olcranon fossea is a demanding technique which makes sense biologically from the stand point of respect of vascularity. It is a useful alternative to open reduction and internal fixation. In three or four part fractures, it has to be tested before primary hemiarthroplasty.

Purpose: Removing cement for revision total hip arthroplasty is always a challenge. The OSCAR device (Orthosonics Ltd UK) provides an elegant solution. We conducted a prospective study of ultrasound ablation using this device in 19 patients undergoing revision total hip arthroplasty to assess feasibility.

Material and methods: Between March 1999 and January 2001, 17 patients, ten women and seven men underwent revision of their femoral component for aseptic loosening (14 cases) or infection (five cases). The Vives criteria as modified by SOFCOT were six grade 1, six grade 2, five grade 3 and two grade 4. The femoral stem removed had a standard length in 17 cases and measured 250 mm in one. The cement obturated the femur in one case with a proximal misinsertion. On the average, the terminal plug went 40 mm beyond the tip of the stem. Trochanterotomy was used ten times and anterior approach in nine. Two ultrasound probes were used: scraper probes that removed cement from the walls and a perforating probe when needed to remove the terminal plug. We recorded the time needed to remove all the cement, the ease or difficulty of the process, the presence of misinserted cement, need for other methods (new window, femorotomy), duration of the hospital stay, and delay to weight-bearing with crutches. The quality of the cementing and presence of cement overflow were determined on plain radiographs. All patients were reviewed for this work.

Results: It took less than 60 min to remove the cement in 14 cases and from 60 to 90 min for four cases; the cement could not be totally removed in one case. There was one fracture (grade 4 during a third revision operation). The end plug was removed under good conditions in 14 cases. The femoral stem could be recemented in nine cases using a longer stem in five. Cementing was satisfactory in 12 cases. Deferred surgery was required for the five cases with infection; in two cases the cement persisted at the second operation requiring a new ablation process. There were no cases of misinsertion. Mean hospital stay was 10.1 days and weight-bearing was authorised on the third day for patients without infection. At a mean follow-up of 8.5 months, there have been no cases of revision, fracture or stem migration.

Discussion: The rate of total hip arthroplasty revision is an estimated 10%. The risk of an incident during cement ablation is an estimated 18% to 28%. Advantages of the ultrasound technique include: shorter operative time, simple material, less danger for weak bone as noted in our patients, absence of the need for complementary fixation, shorter hospital stay, and lower cost. Histology studies have demonstrated the absence of deleterious effects of ultrasound ablation explaining the good quality of recementing (12 cases).

Conclusion: Ultrasound ablation of femoral cement is effective for aseptic revision. In case of infection, the presence of persistent cement might be related to recurrent infection.

Purpose: Bilateral hip disease is a common finding. For patients in good general health the question is whether total hip arthroplasty should be performed on both sides during the same operation or whether a deferred strategy would be better. We compared 24 patients (48 hips) to determine the relative advantages of these two treatment strategies.

Material and methods: Two treatment groups were formed: the first group (group A) was a prospective series of 12 patients who underwent total hip arthroplasty for both hips during the same operation between January 1992 and September 1999; the second group (group B) was composed of 12 patients who had total hip arthroplasty for both hips implanted during two different operations separated by at least one year and chosen by random selection among patients operated during the same period as group A patients. Group A was composed of five women and seven men, mean age 48.4 years (23–67). Group B was composed of five women and seven men, mean age 60 years (50–75). Pressfit cups were used in both groups (except one in group A). The femoral stem was cemented in seven patients in group A and in five in group B. Peroperative data (transfusion, complications, anaesthesia agents, duration of anaesthesia and operation) and post-operative data (transfusions, blood loss, haemoglobin, temperature curve, hospital stay, drugs, early and late complications, radiologic findings) were studied. LWMH was given prophylactically and all patients had a duplex Doppler exploration before discharge. All patients were reviewed regularly: mean follow-up was 5.75 years (2–9) in group A and 6.42 years (2.33–8.5) in group B.

Results: We added the two hospitalisations for group B patients. Mean duration of the operation was 6h in group A and 4h22m in group B. Anaestheia lasted 7h in group A and 6h16min in group B. Blood transfusions amounted to 5.27 packed cell units and 3.09 fresh frozen plasma units in group A, 4.75 and 2.83 respectively in group B. Blood loss was 1439 cc in group A and 1642 cc in group B. Haemoglobin and temperature curves were similar between the two groups. There were two cases of postoperative phlebitis in group A and one revision procedure on day 9 for haematoma in group B. There were no cases of infection. Mean hospital stay was 14.66 days in group A and 22.5 days in group B. Radiographs did not show evidence of loosening.

Discussion: The results obtained in our two series are similar to other reports in the literature (Eggle 1996, Shih 1985). Per- and postoperative complications were not more frequent for one or two procedures. Hospitalisation stays were much shorter in group A patients, providing an important cost savings (34.8% for simultaneous implantations).

Conclusion: Bilateral total hip arthroplasty during a single operation offers an advantage in terms of hospital stay and overall cost. Comparison with two different operations shows that complications are not more frequent. Inversely, work stoppage is shorter, making this strategy particularly interesting for younger patients.

Purpose: Loosening and wear of the polyethylene insert remains an important problem after ten years. The Harris-Galante 1 (HGP1) press fit titanium backed cup appears to provide an interesting alternative. We studied the clinical and radiological outcome of 191 total hip arthroplasties performed between June 1985 and June 1990.

Material and methods: This prospective continuous series included 174 patients (191 hips), 76 women and 98 men, mean age 62.1 years (19–83). The posterior approach was used in all cases for treatment of degenerative hip disease (80%) or osteonecrosis (14.6%). The polyethylene-metal cup was used with a 28mm head in 90.7% of the cases. The press-fit cup was fixed with three screws. At review, 39 patients had died (45 hips), 25 were contacted for a phone interview, and two were lost to follow-up; 119 patients were re-examined and had a standard radiography series at last follow-up. Mean follow-up was 11.9 years (10–15). The Postel Merle d’Aubigné (PMA) score and the Harris hip score (HHS) were used to assess outcome. Quality of bone fixation and cup migration were studied as were lucent lines classed according to De Lee. Wear was calculated using the Livermore method and osteolysis using the Mulroy method. Actuarial survival curves were plotted using reoperation as the end-point if the polyethylene insert was changed or revision if the cup was changed for any reason. Qualitative data were compared using chi square test.

Results: There was one death on day three and three dislocations including two requiring reoperation for an insert overhang. The PMA pain score improved from 2.58 to 5.5 and the overall PMA score from 10.5 to 16.2. the HHS improved from 53.5 to 87.2 points. A lucent line measuring < 1 mm was found in 12 cases; one was complete, nine were in a single zone. Osteolysis was found in 28 cases and was qualified as severe in four. Mean polyethylene wear was 0.1 mm (volume 65.5 mm³). There was no case with cup migration or cup tilt and none of the cups had to be changed. Five polyethylene inserts were changed due to wear at a mean 145 months. The actuarial survival curve taking into account the seven insert changes showed a mean 15-year survival of 96.7±3%.

Discussion: The Harris-Galante press-fit cup has exhibited good behaviour at a mean 11.9 years follow-up. Mean annual wear was = 0.1 mm in 42 patients; it was > 0.2 mm in 18 patients including five who required reoperation to change the insert at 145 months. Osteolysis was noted in 28 cases, an important problem.

Conclusion: With only two patients lost to follow-up at ten years, this prospective review demonstrates well that the press-fit cup is well tolerated which has suffered from comparison with cemented cups. Five worn inserts had to be changed, requiring a simple operation. There were four cases of severe osteolysis.

We studied the time course of micro-embolism by recording high intensity transient signals (HITS) on Doppler venous blood flow studies during a 7-day period in 57 of 63 consecutive patients after hip or knee replacement.

No HITS were found before surgery, or in the non-operated leg after surgery. In the operated leg, the median number of HITS per minute showed an exponential decrease with time; a 50% reduction in the number of HITS took 72 minutes. Regardless of the duration and severity of HITS, we found no clinically apparent embolic event. Colour Doppler imaging at days 8 to 10 after operation showed a deep venous thrombosis in 17% of our patients with one thrombosis of the long saphenous vein. The presence or severity of HITS did not predict the venous thrombi. Although we found no pulmonary complications, we detected micro-emboli over a longer period after surgery than is usually reported. Spectral analysis of the Doppler venous signal is a repeatable and non-invasive monitoring technique in the post-surgical period. We failed to prove a correlation between deep venous thrombi and micro-emboli detected by this method.