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.

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings.

In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications.

The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO.

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.

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.

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: The Exeter technique opens new perspectives for the treatment of femoral bone loss observed at revision hip arthroplasty. Early migration of the implant, considered by the advocates of the technique to be beneficial when limited, can, in the absence of secondary instability, weaken the cement shield leading to early revision. Several publications on this topic have examined the improvement in primary stability achieved by modifying the impaction technique or by searching for the ideal size of the grafts. The purpose of the present study was to examine the reproducibility of this method and its effect on transformation of the allograft.

Material and methods: We performed a prospective analysis of outcome in 46 patients operated on since 1996. The Poste-Merle-d’Aubigné (PMA) clinical score and the Ling and Gie radiographic score as well as the SOFCOT score for substance loss were determined. We used frozen fragmented allografts without consideration of graft size. A standard sized femoral implant was used in all cases.

Results: Mean follow-up was 3 years (range 12 – 66 months). Four patients were not followed beyond 9 months because of major complications requiring revision surgery (infection, fracture of the femur, malposition) or patient death (stroke). For the remaining 42 patients, loss of femoral stock was scored I in 6, II in 23, III in 13. The functional score improved from 9.13±3.9 preoperatively to 16.07±2.5 postoperatively. Radiographically, bone lines were observed in the graft in 36 patients, associated with bone remodelling in ten. In six patients, the allograft exhibited a heterogeneous aspect. Three implants migrated 4 mm. Defective distal sealing was noted in all three. One prosthesis implanted in a varus position worsened before stabilising.

Discussion: This technique is a reliable method since primary stability of the implant was obtained in 90% of the cases and was maintained during long follow-up. This did not prevent graft remodelling.

Purpose: Several techniques have been proposed for C1-C2 fusion. The anterior transoral technique is the most direct approach but at the cost of major risk of infection. The posterior approach allows wiring (Gallie technique) or direct atloidoaxoid screw fixation (Magerl technique). The retrosternomastoid bilateral approach (Du Toit technique) allows direct screwing in the lateral masses. The rate of nonunion reported in the literature is high for wiring techniques. Biomechanical studies have demonstrated the mechanical superiority of trans-articular screwing which has been confirmed in clinical series. The purpose of the present study was to describe a modification of the Du Toit technique and describe results in a short series.

Material and methods: This modification of the Du Toit technique consists in an abrasion of the C1 lateral mass at its origin enabling the penetration of a Cloward curette to create a stable introduction point for the drill bit and thus avoid slippage forward as can occur with the conventional technique. The screw is directed towards C2, in a strict frontal plane. The obliquity depends on the room allowed by the mastoid. The drill bit should cross both corticals of the inferior facet of C1 and the superior facet of C2. The screws must cross in a coronal plane just under the odontoid. Fusion of the C1-C2 lateral masses is achieved by abrasion and grafting.

We have used the modified Du Toit technique for C1-C2 arthodesis in four patients with rheumatoid arthritis, fracture of the odontoid, an odontoid bone, and isolated degeneration. The procedure was a first intention treatment for the patient with primary degeneration, and a second intention procedure for the others who had developed nonunion after wiring.

Results: Mean hospitalisation was six day. Operative time was 2 h 10 min. Mean blood loss was 200 ml peroperatively and 120 ml postoperatively. None of the patients had developed nonunion or mechanical failure at a mean follow-up of 2.7 years (range 1 – 5 years). Operative complications included one case of venous bleeding which was treated with vascular clips and two cases were the lateral mass of C1 was weakened requiring cementing. There was one early postoperative neurological complication with hypoaesthesia of the hemitongue that regressed spontaneously. None of these complications produced sequelae.

Conclusion: The advantages of the modified technique for lateral screw fixation of C1-C2 is the improvement in the entry point for the drill bit allowing an optimal screw position and a stable drilling to achieve good mechanical fixation and certain union.

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: We analysed retrospectively 32 cases of posterior cervicothoracic fixation for spinal tumours. We evaluated spinal stability, spinal alignment, and associated complications.

Material and methods: Thirty-two patients underwent surgery: 27 men and five women, mean age 52 years, age range 17–72 years. We implanted 96 articular screws in C4 to C6, 54 screws in C7 and 180 pedicular screws in T1 to T8. Nineteen patients had primary lung cancer with spinal invasion, eleven had spinal metastases, one had a chondrosarcoma and one had a myeloma. For the first group of 19 patients, en bloc resection of the tumour with the vertebra was performed: four total vertebrectomies, 15 partial vertebrectomies. In a second group of 15 patients, palliative posterior fixation was performed with laminectomy decompression.

Results: Follow-up ranged from three to 54 months with a mean of 15 months. Mean survival after total or partial vertebrectomy was 16 months (range 3 – 54 months). Survival after palliative decompression was eleven months with a range from five to 19 months. There were no changes in the sagittal alignment in 30 patients: two patients developed mechanical complications late after surgery requiring revision. We did not have any case of screw, plate or rod fracture. There were no neurological complications related to screw insertion either at the thoracic level (180 screws) or the cervical level (96 screws in C4C5C6 and 54 screws in C7). A control scan was available for 21 patients and revealed a malposition of the implanted screws for 2.5% of the screws with no clinical impact.

Discussion: Posterior screw fixation is a good method to stabilise the cervicothoracic spine during tumour surgery. Articular cervical screws and transpedicular thoracic screws provide effective stability postoperatively. In addition, this type of instrumentation does not interfere should subsequent laminectomy or wider resection be necessary.