Introduction

The action of the radial head in the stability of the elbow is currently admitted. Its conservation is not always possible in complex fractures. The association with a posterolateral dislocation of the elbow leads to a higher risk of instability of the elbow joint and also at a longer term to degenerative changes. Some authors recommend the use of metallic radial head implant, acting as a spacer. The results seems encouraging but should the resection arthroplasty associated with the repair of the medial collateral ligament be abandoned?

Purpose of the study: We have had a growing number of revision total hip arthroplasty (rTHA) which have required femorotomy, either planned preoperatively, or required because of difficult extraction of the cemented implant. Few results have been reported in the literature. The purpose of this work was to evaluate late healing of femoral bone and complications.

Material and methods: For this retrospective analysis, we included 43 patients, mean age 66 years. These patients had a femorotomy during rTHA performed from 1997 to 2008. There were 37 revisions in an aseptic context for isolated femoral loosening (n=26), bipolar loosening (n=4), acetabular loosening (n=4), recurrent dislocation, fracture of the femoral stem, and periprosthetic fracture (n=1 each); there were six revisions in septic conditions. Techniques were: femorotomy (n=22), wide trochanterotomy measuring proximally to distally 12 cm, four cortical cuts and one oblique osteotomy to correct valgus. The reconstruction used locked femoral stems (n=17), cemented stems (n=17) and non-cemented stems (n=10). The osteotomies were closed with cerclage or steel wires.

Results: Bone healing was assessed on the plain x-rays of the hip joint at three, six and twelve months. Among the 43 patients included in this analysis, complete data were available for 37. There were 36 cases of successful healing and one case of nonunion on a wide trochanterotomy. The function outcome was assessed a mean three years.

Discussion: Femorotomy remains a difficult technique, sometimes facilitating stem extraction, but with a high risk of morbidity. The morbidity is difficult to evaluate initially, linked more with time to weight-bearing at two months on average. In this small series we nevertheless found few problems with bone healing, even in septic conditions.

Conclusion: Femorotomy remains a valid option when required. It is a difficult technique but provides reliable results in terms of complete healing three months postoperatively.

Purpose of the study: Although the role of the radial head is clearly established regarding elbow stability, it cannot always be preserved after complex fractures. Association with a posteriolateral dislocation, besides the risk of short-term recurrent dislocation, raises the problem of long-term osteoarthritic degeneration. Certain authors advocate a metal prosthesis which works like a spacer in lieu of the head; their mid-term results have been encouraging, but should complete resection with suture of the medial ligament plane be ruled out definitively?

Material and methods: We reviewed 13 files of patients who had had an initial resection of the radial head after trauma. For seven of these patients, there was an associated dislocation; the medial ligament structures were sutured. All patients were reviewed with mean 13 years follow-up (5–15) and evaluated clinically with the American Shoulder and Elbow Surgeon (ASES) system to establish the Mayo Clinic Elbow Performance (MCEP) score. Osteoarthritis of the ulnar trochlea was analysed on the plain x-rays, completed by an axial view, using the Morrey radiographic classification of 4 stages.

Results: There were not cases of recurrent dislocation. According to the Broberg and Morrey index, 92% of patients had good outcome with total resumption of occupational activities; there was no difference between patients with and without dislocation. All patients developed grade 1 or 2 osteoarthritis, with very good clinical tolerance. All were satisfied with their operation despite efforts to spare joint movements.

Discussion: The studies evaluating the use of radial head prostheses have reported similar findings for functional outcome. Radiographic degeneration of the ulnar trochlea is also comparable. Immediate rehabilitation is necessary to prevent loss of range of motion and warrants surgery to stabilize the joint as wells as possible use of an adapted dynamic orthesis.

Conclusion: Resection of the radial head without prosthetic reconstruction remains a reasonable option when the head cannot be saved. Associated dislocation implies repair of the medical collateral ligament. At long-term, the functional impairment is minimal despite the moderate osteoarthritis; the problematic of implant survival is avoided.

Purpose of the study: The theoretical advantage of a disc prosthesis compared with fusion is to preserve spinal mobility. The purpose of our study was to determine the relationship, at nine years follow-up, between range of motion and clinical outcome after lumbar disc replacement.

Material and methods: This retrospective analysis concerned the clinical and radiographic outcome observed in 38 patients who had undergone one- or two-stage disc replacement surgery (51 implanted prostheses). Mean follow-up was 8.6 years (range 6.9–10.7). Clinical outcome was assessed with the Stauffer-Coventry modified score (SCM), the Oswestry score (ODQ) and a visual analog scale (VAS) for lumbar and radicular pain. Flexion-extension range of motion (ROM) was measured on the upright films (Cobb method) at last follow-up. Each clinical element was compared with the ROM (Spearman coefficient of correlation). Two groups of patients were distinguished: high (> 5°) and low ≤ 5°) ROM for comparison with the Mann-Whitney test.

Results: The Spearman coefficient of correlation disclosed a weak to moderate but statistically significant association between ROM, lumbar VAS (r=−0.35, p=0.034), ODQ (r=−0.33, p=0.046), SCM (r=0.42, p=0.0095); but no significant correlation between ROM and radicular VAS (r=−0.12,p=0.48). Patients with greater ROM had better clinical results and ODQ (mean difference 6.3 points, p=0.031) and SCM (mean difference 2.2 points, p=0.017); but no significant difference between the preoperative characteristics in each group (age, sex, weight, surgical history, lumbar and radicular pain, ODQ and SCM).

Discussion: There are no data in the literature comparing range of motion and clinical outcome after lumbar disc replacement. The present study demonstrated a weak to moderate but statistically significant relationship (r=0.35) between range of flexion-extension motion and clinical outcome at nine years. In addition, patients with lesser ROM (< 5°) have slightly less favorable results compared with those with greater ROM (> 5°). This study suggests the preservation of motion has a positive effect on mid-term clinical outcome.

Conclusion: These results need to be confirmed with long-term prospective data comparing discal prosthesis with fusion and non-surgical treatment in order to demonstrate the usefulness of preserving motion on the quality of the clinical outcome.

Purpose of the study: Discal arthroplasty is warranted as a part of the treatment of discopathy to guarantee mobility after disc removal. Depending on the type of discopathy, the diseased disc can be classified into different categories: absence of herniation (H0), disc herniation (H1), recurrent disc herniation (H2), post discectomy syndrome (H3), or stenosis of a single unit (including grade 1 degenerative spondylolisthesis) (St-SPd). The purpose of this study was to compare clinical outcome after discal arthroplasty for these different clinical situations.

Material and methods: This was a prospective study of 152 patients who underwent a single-stage operation for insertion of a lumbar disc prosthesis. Pain was assessed with a visual analog scale for the lumbar level (VAS-L), and for radicular pain (VAS-R) and the Oswestry index (ODI). Patients were classified as follows: 39 H0, 52 H1, 22 H2, 29 H3, 10 ST-SPd).

Results: Outcome in patients in groups H0, H1, and St-SPd, i.e. first-intention surgery patients, presented equivalent results for lumbar and radicular pain and for function: VAS-L and VAS-R declined concomitantly. Results at three months postop were equivalent to those observed at 24 months. Patients in groups H2 and H3 who had had prior operation(s) for posterior discectomy experienced rapid relief of lumbar pain but radicular pain persisted postoperatively (6 to 12 m).

Discussion: These data confirm the excellent results obtained with single-level disc replacement as assessed by VAS and ODI. The persistence of radiculalgia which then resolves several months later in patients with a history of discal surgery can be explained by the combination of chronic compression, postoperative adherences and restored disc height. In the present series, none of the patients required complementary surgery for posterior radicular release.

Conclusion: Discal arthroplasty provides satisfactory results for the different stages of discal disease. The procedure should however be undertaken with prudence for patients who have had prior surgery. A perfect analysis of other factors involved should be helpful in chosing the most appropriate technique and avoid the development of postoperative radiculalgia. The present results could be usefully confirmed with a long-term randomized prospective study comparing discal prosthesis with fusion for the treatment of discal disease.