Mechanical failure in total hip arthroplasty is usually due to aseptic loosening related to wear particles as seen with polyethylene bearing. Alumina has been proposed for avoiding wear problems. In vitro and mid-term clinical studies showed tribological advantages but early acetabular fixation issues. Since alumina on alumina bearing is currently used with new fixation techniques, updated evaluations of the ancient series are informative regarding the long-term tolerance of alumina in vivo.

In this paper, we investigated 104 consecutive lumina on alumina cemented total hip arthroplasties (CER-VAER-OSTEAL, Roissy, France) implanted 20 years ago in 81 patients (from 1979 to 1983). Alumina femoral head was 32 mm in diameter. Alumina acetabular socket and titanium femoral stem were cemented. The clinical evaluation used Postel Merle d’Aubigné score. Radiological wear and appearance of osteolysis or loosening were noted for establishing actuarial curves. When accessible, histological samples from revision procedures were analyzed.

Six infected cases were not taken into account later. The average follow-up was 11 years, reaching 18 years in 38 cases. Twenty-three hip were revised for changing 23 acetabular sockets, 12 femoral heads, and 1 femoral stem. We noted 1 femoral head fracture, 24 definite ace-tabular loosenings, 12 probable acetabular loosenings, and 3 definite femoral loosenings. Radiological acetabular osteolysis was present in 4 cases, always limited to De Lee zone 1, and associated with loosening. Radiological wear was below eye detection. Peri-prosthetic tissue showed non-specific histological reaction to cement particles. Survival rate at 20 years was 61.4% in term of revision (57.1% and 95.2% concerning acetabular and femoral defininte loosening).

Beside the high rate of cemented fixation failure of the socket, loosened and non loosend cases showed an excellent tolerance of alumina on alumina bearing in the long-term, with minimal wear and osteolysis. This may also have protected the femoral component from complications.

Purpose: In our records on bone tumours, secondary chondrosarcomas account for slightly less than 15% of all chondrosarcomas (20/150). The presentation is quite variable making diagnosis relatively difficult. We reviewed our experience to evaluate diagnosis, frequency, and prognosis.

Material and methods: From 1981 to January 2002, we had 20 chondrosarcomas which developed on pre-existing lesions: solitary exostoses (n=11), solitary chondroma (n=1), multiple exostosis (n=6), multiple enchondromatosis (n=2). Localisations were: pelvis (n=9), femur (n=3), humerus (n=2), tibia (n=3), spine (n=2), scapula (n=1). Histological classification was: grade I (n=7), grade II (n=9), grade III (n=1), and dedifferentiated sarcoma (n=3). Surgery was performed in all patients, alone for grade I and II chondrosarcoma, in association with chemotherapy (n=3) and radiotherapy (n=1) in three patients with dedifferentiated sarcoma.

Results and prognostic factors: At last follow-up (mean 9 years 10 months), five patients had died after local recurrence (n=3) or metastatic dissemination (n=2). The other fifteen patients were living (mean follow-up 155 months). The main prognostic factor was histological grade of chondrosarcoma. All patients with grade I chondrosarcoma (n=7) survived versus only two-thirds of those with grade II chondrosarcoma and half (2/4) of those with grade III or dedifferentiated chondrosarcoma. The second prognostic factor was initial management. Inadequate care initially led to misdiagnosis or delayed diagnosis (n=4), local recurrence (n=3) and loss of chance of survival (n=3). Grade I chondrosarcoma was occasionally taken for benign exostosis despite a cartilage cuff measuring more than 1 cm, normally a sign of chondrosarcoma.

Conclusion: 1. Because of the severity of secondary dedifferentiated chondrosarcoma, resection should be performed in adults presenting exostosis with a large residual cartilage cuff, particularly in high-risk locations (pelvis). 2. Because of the difficulty in recognising the histological features of grade I chondrosarcoma, the diagnosis of degeneration should be retained in adults if the cartilage cuff exceeds 1 cm. Lesions are suspicious if the cartilage cuff exceeds 5 mm.

Purpose: Alumina is a bioinert ceramic used for total hip arthroplasty as an alternative to metal-on-polyethylene bearings which can wear producing massive osteolysis and loosening. The purpose of this retrospective analysis was to examine the Ceraver combination implant which uses a cemented smooth titanium femoral stem, a 32 mm alumina head, and a cemented alumina cup.

Material and methods: Between December 1979 and February 1983. 104 total hip arthroplasties were performed in 81 patients, mean age 57.8 years (2.1–70.9). The main indication was primary degenerative disease (71 hips). The Postel Merle d’Aubigné score was used for clinical assessment. Plain x-rays were used to establish the actuarial survival curves using the Harris criteria for radiological loosening for the cup and the Massin criteria for the femoral piece. Periprosthetic femoral and acetabular osteolysis were noted. Histological samples taken during revision procedures were analysed.

Results: Six hips with suppuration were not retained for analysis. The clinical scores for the other 98 hips were, at last follow-up: excellent in 34, very good in 21, good in 16, fair in 21, and poor in 6. Mean follow-up was eleven years and reached 18 years for 38 hips. Fracture of the alumina head (n=1), aseptic certain radiographic loosening of the cup (n=24), probable radiolographic loosening of the cup (n=12), and certain radiographic loosening of the femoral piece (n=3) were noted. Revision was required for 23 hips for replacement of the cup (n=23), the head (n=12), or the femoral stem (n=1). There were no cases of massive radiographic osteolysis. The histological examination of surgical specimens obtained at revision were normal in all cases (very moderate aseptic foreign body reaction). Excepting the cases of suppuration, the estimated actuarial survival without revision at 20 years was 61.4% (57.1% for he radiographic cup loosening criteria and 95.2% for the radiographic femoral implant criteria).

Discussion: This analysis confirms the long-term biotolerance of the alumina-alumina bearing despite the poor maintenance of the cemented alumina cup. It also confirms the good maintenance of the cemented smooth titanium femoral stem.

Conclusion: Cup anchorage must be improved to use the alumina-alumina bearing which does not cause osteolysis nor histological reactions.

Purpose: It was demonstrated in 1986 that to obtain a good radioclinical result at 10–13 years after valgus tibial osteotomy for the treatment of medial femorotibial osteoarthritis that the frontal valgus at this follow-up had to be 3–6°. In 1995, it was demonstrated that the side of deterioration in knees initially aligned between 2° varus and 2° valgus or with genu valgum (≥ 3° valgus) depended on the tibiofemoral axis: a positive index (tibial torsion greater than femoral torsion) favouring medial femorotibial deterioration and progressive varisation, and a negative index favouring lateral femorotibial deterioration and progressive valgisation. Can the post-osteotomy valgus be modified by the tibiofemoral index and prevent obtaining ideal correction at 10–13 years?

Material and methods: Forty-five knees with femortibial deterioration of the medial compartment were treated between 1987 and 1990 by tibial medial opening osteotomy for valgisation. Functional outcome in the 45 knees was assessed at a mean follow-up of 11 years (range 10–13 years). Postoperative frontal axis after healing and frontal axis at last follow-up was measured by goniometry in the standing position for all knees. A scan in the torsion position was obtained for 36 knees to measure the tibiofemoral index.

Results: At maximum follow-up, outcome was good in 58% of the knees, fair in 24%, and poor in 18%, differences which were not statistically different. Frontal axis changed with time. Among the 36 knees which had been realigned correctly (3–6° valgus) after healing, four exhibited an increase in valgus beyond 6° and five lost valgus passing below 3°. But ideal valgus was achieved at last follow-up for three of five knees which had been undercorrected, Among the 38 knees for which a torsion scan was available, 33 were correctly realigned postoperatively and 22 were well aligned at last follow-up. There was no statistical difference between knees with good, fair, or poor outcome among the 33 knees well corrected postoperatively (3–6° valgus). There was however a statistical difference between the good (64%), fair (27%), and poor (9%) functional results among knees with ideal valgus at last follow-up (p = 0.03).

The variation between the postoperative and last follow-up goniometry data exhibited a statistical correlation with the tibiofemoral index (p = 0.0005). If the index was less than 13°, most of the knees showed an increase in valgus (13 out of 19 knees); if valgus was greater than or equal to 13°, valgus was lost (for 12 of 19 knees).

Conclusion: To have the best chance of obtaining a good functional result 10 to 13 years after tibial osteotomy for valgisation, the valgus at this follow-up must be between 3° and 6°. But to achieve this valgus, the postoperative valgus must be modulated in relation to the tibiofemoral index. For an index ≥ 13°, the postoperative valgus should be pushed towards 6°; for an index < 13°, valgisation should aim at achieving a 3° postoperative valgus or less.

Leakage after simple suture repair of rotator cuff tears depends on the overall preoperative fatty degeneration index (FDI) of the muscles and preoperative fatty degeneration (FD) of the infraspinatus. When the FDI is = 2, cuff leakage is always observed after repair. The risk of recurrent tears of the supraspinus is high if the FD of the infraspinatus is > 1. However if the FDI is very low or nil, the rate of recurrent tears is 15%. These tears can be explained by tension on sutures in macroscopically and histologically abnormal tendons.

Purpose: The purpose of this study was to determine whether repair of rotator cuff tears using sutures without tension after removal of abnormal tendon stumps, a technique requiring tendon plasty, can improve the leakage rate.

Material and methods: Total repair of 24 rotator cuff tears was performed without tension on the sutures after resection of at least one centimetre of the supraspinatus tendon stump. This consecutive series was studied prospectively. The tears involved the supraspinatus and the infraspinatus in ten cases, all three tendons in 13 cases and only the supraspinatus in one case. Mean preoperative FDI was 1.18 (0.5–2.16); pre-operative FD of the infraspinatus was a mean 1.19 (0–2). The supraspinatus stump was resected from the trochiter in 14 cases, on the apex of the head of the humerus in seven and facing the glenoid cavity in three. Repair required translation advancement of the supraspinatus in 24 cases, translation advancement of the infraspinatus in six (associated with a rhomboid flap) and a trapezeal flap in three cases. Postoperative leakage was assessed with arthroscan (n=23) and ultrasonography (n=1) at one year.

Results: No leakage was observed in 20 of the 24 cuffs (83%). Recurrent tear of the supraspinatus was observed in three cases and in the supraspinatus and infraspinatus in one case each. The FDI of cuffs with recurrent tears (1.31) was not significantly greater than the FDI of cuffs without leakage (1.15) (p = 0.085). Preoperative FD of the infraspinatus of cuffs with recurrent tears (1.5) was significantly higher than that for cuffs without leakage (1.12) (p = 0.16). For the supraspinatus and the subscapularis, there was no significant difference between preoperative fatty degeneration of cuffs with recurrent tears and cuffs without leakage. The number of repaired tendons had a statistically significant effect (p = 0.012) on postoperative leakage: 23% of the recurrent tears after repair of three tendons showed no leakage compared with 9% after repair of one or two tendons (there was no significant difference for preoperative FDI, p = 0.33).

Discussion: Resection of macroscopically abnormal tendon stumps which requires tendinomuscular plasty, gives better anatomic results than simple suture. For an equivalent FDI, this allows fewer cases of leakage (83% without leakage compared with 50% after simple suture). Results were also better for an equivalent number of tendons repaired: 77% and 50% for three tendons and 91% and 55% for two tendons respectively).

Conclusion: Despite the almost constant need for plasty, rotator cuff repair using sutures without tension after resection of macroscopically abnormal tendon stumps gives, for an equivalent preoperative degree of fatty degeneration and an equivalent number of tendon repairs, better anatomic results than simple suture.

Purpose of the study: Surgical treatment of degenerative spondylolisthesis generally requires spinal fusion. Arthrodesis can be achieved via an anterior or posterior approach. Over the last ten years, minimally invasive methods have been developed to limit operative trauma secondary to the anterior approach. There have however been few studies comparing outcome after this new technique with classical open surgery. The aim of this work was to compare spinal fusion achieved with a cage implanted retroperitoneoscopically with conventional screw-plate fixation using open lombotomy.

Material and methods: Sixty two patients with degenerative spondylolisthesis (L3-L4, L4-L5, L5-S1) were reviewed: 39 had had conventional spinal fusion (group 1) and 23 had undergone a minimally invasive procedure (group 2). Clinical (Beaujon score) and radiographic assessment was recorded at last follow-up. All patients in group 1 were operated on by the same surgeon via lombotomy (L3-L4 or L4-L5 fusion) or subumbilical laparotomy (L5-S1 fusion). An intersomatic graft was combined with screw-plate fixation in all cases. Patients in group 2 were also operated on by the same surgeon (different from group 1) who used a retroperitoneoscopic approach (L3-L4 or L4-L5 fusion). An intersomatic cage was filled with cancelous bone and screwed into the intersomatic space.

Results: Mean follow-up was four years in group 1 and two years in group 2. Mean Beaujon score improved from 8 to 17 in group 1 and from 9 to 16.5 in group 2. All patients achieved bone healing at last follow-up without secondary displacement or disassembly of the osteosynthesis. There were no neurological complications and no infections of the operative site. One patient in group 2 developed a vascular complication requiring conversion to classical lombotomy. Blood loss was 1100 ml in group 1 and 200 ml in group 2.

Conclusion: Anterior fusion with implantation of an intersomatic cage via retroperitoneoscopic access is a reliable and effective method for the treatment of degenerative spondylolisthesis. It reduced postoperative morbidity but must obviously comply with classical indications for lumbar fusion.

Between January 1988 and January 1991 we performed 100 consecutive cemented total hip replacements using a zirconia head, a titanium alloy stem and a polyethylene cup. We reviewed 78 of these hips in 61 patients in detail at a mean of 5.8 years (1 to 9).

Aseptic loosening was seen in 11 hips (14%). Eight needed revision. In total, 37 cups (47.5%) showed radiolucent lines, all at the cement-bone interface, with 18 (23%) involving all the interface. Of the 78 femoral implants, 17 (21.7%) showed radiolucent lines, and two, which had a complete line of more than 1 mm thick, definite endocortical osteolyses. There was also an abnormally high incidence of osteolysis of more than 2 mm at the calcar.

Survivorship analysis showed that only 63% were in situ at eight years. These worrying results led us to abandon the use of zirconia heads, since at the same hospital, using the same femoral stem, cement and polyethylene cup, but with alumina femoral heads, the survival rate was 93% at nine years. We discuss the possible reasons for the poor performance of zirconia ceramic.

A 65-year-old man presented with a painful hip five years after a cemented replacement. Histological examination of a biopsy taken from tissue surrounding the femoral implant showed infiltration of a squamous-cell carcinoma. Further investigation revealed a primary growth in the left lung. This rare example of a metastasis in relation to a joint replacement illustrates the necessity for histological examination of the tissue adjacent to a loose prosthesis.

We performed a prospective study on 96 patients with extra-articular or intra-articular fractures of the distal radius with a dorsally displaced posteromedial fragment. After closed reduction, we compared trans-styloid fixation and immobilisation with Kapandji fixation and early mobilisation. Forty-two patients of mean age 57.1 years +/- 18.1 (SD) were treated by trans-styloid K-wire fixation and 45 days of short-arm cast immobilisation. Fifty-four patients of mean age 57.7 years +/- 18.7 (SD) had Kapandji fixation and immediate mobilisation according to the originator. All the patients had clinical and radiological review at about six weeks and at 3, 6, 12 and 24 months after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, radial tilt, ulnar variance, and radial shortening were assessed radiologically. Statistical analysis was applied to comparisons with the normal opposite wrist. Pain and reflex sympathetic dystrophy were more frequent after Kapandji fixation and early mobilisation, but the range of motion was better although this became statistically insignificant after six weeks. The radiological reduction was better soon after Kapandji fixation, but there was some loss of reduction and increased radial shortening during the first three postoperative months. The clinical result at two years was similar in both groups.

From 1984 to 1988 we implanted 127 massive allografts irradiated with a dose of 25,000 grays. These were reviewed at a minimum follow-up of three years to determine the effect of irradiation on infection, the complications and the functional result. No bacteriological infection was seen in the 44 patients who had allografts for revision of joint arthroplasty or for a tumour with no adjuvant therapy. For the 83 patients who also had chemotherapy or radiotherapy or both for a bone tumour, the rate of infection was 13%. The major mechanical complications were nonunion in seven grafts (5.5%) and fracture in eight (6%). These rates do not differ greatly from those reported for non-irradiated grafts. Our results suggest that irradiation, which remains the most convenient and acceptable method of sterilisation, does not jeopardize the clinical results.

We investigated the possible use of acrylic cement containing chemotherapeutic drugs in the treatment of malignant lesions in bone. The diffusion of methotrexate (MTX) from methylpolymethacrylate implants was studied in vitro: polymerisation of the cement did not destroy the drug; liberation began immediately and about 10% was released by 18 hours. Some release continued for as long as six months. In vivo experiments on rats with induced osteosarcoma showed that MTX in cement had both local and general effects which were dependent on the dosage. A series of 17 large dogs with spontaneous osteosarcoma were then treated by local resection and cement containing MTX. General chemotherapeutic effects were detectable from 2 hours to 5 days, survival was increased and local recurrence was reduced, but there were four cases of delayed wound healing. Preliminary studies in human patients confirm the possibility that this method of local chemotherapy could be a useful addition to the treatment of malignant tumours of bone.