This was a retrospective analysis of the medium- to long-term results of 46 TC3 Sigma revision total knee replacements using long uncemented stems in press-fit mode.

Clinical and radiological analysis took place pre-operatively, at two years post-operatively, and at a mean follow-up of 8.5 years (4 to 12). The mean pre-operative International Knee Society (IKS) clinical score was 42 points (0 to 74), improving to 83.7 (52 to 100) by the final follow-up. The mean IKS score for function improved from 34.3 points (0 to 80) to 64.2 (15 to 100) at the final follow-up. At the final follow-up 30 knees (65.2%) had an excellent result, seven (15.2%) a good result, one (2.2%) a medium and eight (17.4%) a poor result. There were two failures, one with anteroposterior instability and one with aseptic loosening.

The TC3 revision knee system, when used with press-fit for long intramedullary stems and cemented femoral and tibial components, in both septic and aseptic revisions, results in a satisfactory clinical and radiological outcome, and has a good medium- to long-term survival rate.

Purpose of the study: Dementia in the elderly subject aged over 75 years is currently an important public health problem. An important part of the activity in orthopaedic surgery involves this age group. In 2007, 16,812 elderly persons aged over 75 years were hospitalised in our University Hospital (769 in orthopaedic surgery): 1380 patients were considered demented (40 in orthopaedic surgery). The purpose of this work was to evaluate the cognitive function of this population in a teaching hospital unit of orthopaedic and traumatology surgery where the prevalence of dementia appears to be underestimated.

Material and methods: Data were collected over a period of four years. This study concerned 113 patient, including 83 women, mean age 81.8 years (range 75–92). The reason for hospitalisation was predominantly fracture of the proximal femur (73%); thirty patients had hip, knee or shoulder arthroplasty and 24 other situations. The Mini Mental State Examination (MMSE) was performed.

Results: The MMSE could be interpreted for 100 patients: < 24 for 33, 24 to 26 for 29 and > 27 for 38. Among the 24 patients with no cognitive disorder known before hospitalization (nine patients known to be demented were removed from the analysis) and for whom the MMSE was completed entirely, the most frequent alterations were noted for attention, calculation, and recall-memory items.

Discussion: Finally, one-third of the subjects aged over 75 years and hospitalized in our unit presented signs of altered cognitive function according to the MMSE(< 24). This score is one of the criteria for frailness of the elderly subject. This population has an unstable precarious medicosocial status with defective adaptation to stress and change in environment. These persons are exposed to a high risk of morbidity, mortality, dependence, longer hospital stay and institutionalization. The purpose of this screening is to improve management for these patients by proposing more specifically adapted care.

Conclusion: It is thus indispensable to screen for cognitive disorders systematically in patients aged over 75 years hospitalized in a surgery unit. The MMSE score can be used for this purpose. This work is in favour of a physician or better a geriatrician within the unit who could be financed directly by his-her own sector of activity.

Purpose of the study: Restrained implants with intrinsic stability guaranteed by a large central stem have been developed for revision knee arthroplasty, irrespective of the underlying cause. Successful restraint implies excellent fixation of the prosthetic implants which can be obtained using press-fit centromedullary stems. The purpose of this work was to assess the long-term results of this mode of fixation in this indication and to search for clinical correlations with potential radiological images around the stems.

Material and methods: We report 46 cases of Sigma^®PFC TC3 revision total knee prostheses reviewed retrospectively at two years with a mean follow-up of eight years. Mean age at surgery was 68 years. Revision was indicated for aseptic loosening (n=24) and septic loosening (n=22). The knee society criteria were used for the clinical evaluation. Radiographic measurements were made semiautomatically with the Imagika^® software.

Results: The mean clinical score improved from 42 points preoperatively to 84.7 at two years and 83.7 at last follow-up. Outcome was excellent (n=30), good (n=7), fair (n=1) and poor (n=1). The mean function score improved from 34.3 preoperatively to 69.1 at two years and 64.2 at last follow-up. Radiographic alignment was correct in all cases. The press-fit effect was observed for 63% of the femoral implants and 76% for the tibial implants. Around the stems, 57% of the implants exhibited condensation lines and 23% lucent lines measuring less than 2 mm. There was no relation between radiological findings and the clinical or functional scores. There were two failures, one for frontal instability at six years and the other for aseptic loosening at eight years. Excepting these two cases, there was one case of femoral implant migration with no clinical expression. For all other patients, the radiographic image remained unchanged between the two year check-up and the final follow-up.

Discussion: Thee presence of lucent lines or condensation lines is well known for this type of implant with long centromedullary stems. Nevertheless, this is the first clinical series evaluating the clinical impact of these radiographic images. In our opinion, these images are related to the relative mobility of these implants which should be checked regularly, although no long-term clinical expression occurs. For us, this type of implant enables good function and long-term stability.

Purpose of the study: Theoretically, in first-intention total hip arthroplasty (THA), restoration of femoral offset (distance between the femoral axis and the joint centre) enables optimal function. The purpose of this study was to determine acceptable limits for variation in femoral offset without loss of function.

Material and method: We studied 122 hips (108 patients) who had THA with a straight cemented stem and a modular cone which could be adapted to enable three dimensional adjustment of the offset (more than 100 configurations). Mean patient age was 64 years. Most had primary or secondary degenerative disease (n=80) of the hip joint or osteonecrosis of the femoral head (n=21). The preoperative PMA score was 11.9 and the Harris score 49. Clinical and radiographic assessment was noted at mean 4.5 years follow-up. The radiographic femoral offset was measured semiautomatically in comparison with the healthy hip using the method described by Steinberg and Harris.

Results: At last follow-up, the mean PMA score was 16.4 and the mean Harris score 89. These clinically scores were statistically different depending on the degree of variation of the femoral offset. Outcome was better for offset increased 0 to 5 mm (PMA 17 and Harris 93). They were less satisfactory for decreased offset (PMA 15.9 and Harris 83) (p=0.01). They were also less satisfactory for an offset increased more than 8 mm, but non significantly.

Discussion: It has been established that increasing the femoral offset decreases the rate of dislocation, reduces the incidence of limping, the use of crutches, and increases the force of the gluteus medius, as well as range of motion and abduction. However, there is no known limit value.

Conclusion: It is advisable to increase the femoral offset during total hip arthroplasty; the increase should be to the order of 0 to 5 mm, and never be too great.

Purpose of the study: Use of the metal-on-metal bearing has been validated in total hip arthroplasty (THA) for conventional diameters and for resurfacing but not with large-diameter implants. The purpose of our study was to establish the short-term clinical validity of large diameter implants.

Material and methods: This was a retrospective study of a consecutive series of 106 press-fit cups (Durom^®) in 102 patients with minimum two years follow-up. Mean age at surgery was 66 years. Aetiologies were primary degenerative diseases (n=83), aseptic osteonecrosis (n=11), secondary degeneration (n=7), degeneration on acetabular dysplasia (n=2), rapid destructive osteoarthritis (n=1), fracture of the femoral neck (n=1) rheumatoid disease (n=1). Patients were reviewed with mean 30 months follow-up with the PMA and Harris scores. Radiographic measurements were made on semi-automatically (Imagicka^®) and included the ratio of prosthesis head to native head diameter, acetabular offset, and any implant migration, gap or lucency.

Results: There were two traumatic dislocations due to falls with regressive tendonitis of the gluteus medius with no later consequence. The mean Harris score was 91.6 and the mean PMA score 17. Outcome was excellent (n=70), good (n=31), fair (n=3) and poor (n=2). The ratio showed that head diameter had been restored for 65 hips (0.95 to 1.05). There were no cases of cup migration. Acetabular offset showed a mean lateralization of 1.1 mm. For 67 immediate posterior gaps, including ten measuring > 2mm, only two had not filled at review. None of the radiographic measurements had an effect on the clinical outcome.

Discussion: These results are comparable with those published for metal-on-metal bearings with 28mm heads and press fit cups. We did not find any mechanical or medical cause explaining the persistent pain observed in our patients with fair or poor outcome. The low level of dislocation (1.8%) confirms the improved prosthetic stability compared with 28 mm heads.

Conclusion: In our opinion, these early results demonstrate a clear improvement in stability, but at the cost of possible unexplained pain. Long term clinical and radiographic surveillance is needed to validate this option in terms of implant wear and survival.

Background: Femoro-patellar arthritis (FPA) is less frequent than femoro-tibial arthritis, but still a challenging problem for orthopaedic surgeons. Several treatment have been described from lateral retinaculum release to TKR, with special features to patellar prosthesis. The purpose of this study was to evaluate a large consecutive series of femoro-patellar prosthesis (FPP), to learn about the late outcome, complications and performance.

Material and Methods: Between 1992 and 2004, 60 prosthesis were performed by one of the authors in 55 patients with a mean age of 59 years; 44 were femal and 13 male, 5 had bilateral prosthesis. 62% had essential arthritis with trochlear dysplasia. 78% were graded Iwano III or IV.

Resurfacing cemented Themis^® prosthesis was used in all cases, with a lateral approach associated with a tibial tubercle osteotomy to achieve correct aligment of extensor mechanism. None patient was lost to follow-up.

Results: Mean follow-up was 10 years (46–218 months). During the study, 12 prosthesis were converted to TKR because of femoro-tibial arthritis; but the mean delay between FPP and TKR was 12 years. At revision, 48 FPP were evaluated by an independent examinator. IKS score raised from 106 to 157, knee score from 57 to 89 and function score from 49 to 78. Pain, ability to walk and to climb stairs were improved. Radiography did not demonstrate radio-lucent lines, wear or loosening. 95% had correct aligment of patellar button, without tilting. Survival rates of FPP were 89% at 10 years and 82% at 15 years.

Conclusion: Resurfacing FPP is a reliable procedure offering good clinical performance and outcomes. The authors recommend the use of FPP for isolated FPA, without knee diformity, in association with tibial tubercle osteotomy.

Treatment of recurrent total hip arthroplasty (THA) dislocation is always a surgical challenge. Numerous treatments have been developed, but until now there is no gold standard. The goal of our study was to evaluate the results of a non-constrained tripolar implant (Novae) in this indication.

Material and Methods: The study was retrospective. The inclusion criterion was a dislocated THA which underwent reoperation for changing acetabular stem for a Novae cup. 59 patients were included. Femoral stem was always cemented and was never changed. All patients were reviewed with clinical and radiological examinations. The mean follow up is 8 years (6–11 years). 9 patients died before clinical examination and there was no lost to follow up.

Radiological examination was performed numerically with the software Imagika^®

Results: Only one patient had an early dislocation, treated by external reduction. After reduction, no more dislocation occurred. One patient had a femoral fracture below the femoral stem treated by plate. Dislocation rate in our study was 1.7%. The mean Postel Merle d’Aubigné score was 16.5 (12–18) and the mean Harris score was 86.7 (49–99). Radiologically, there wasn’t aseptic loosening neither implant migration, but 19% of the radiographs showed a radiolucent line (less than 1 mm).

Discussion: We compared the results of our study with the results of the other treatments of dislocation. With a dislocation rate of 1.7%, the efficacy of the tripolar non-constrained implant is much better than that of several other treatments, such as external braces, allograft, re-orientation of acetabular shell, change of liner or acetabular augmentation. Constrained implants have also a low dislocation rate, but they have an increased risk of early aseptic loosening. The high rate of radiolucent lines at the last examination is possibly due to the absence of osteointegrating surface of the shell. New implants with osteointegrating surface have been developed.

Conclusion: The efficacy of the studied non-constrained implant is very good with a re-dislocation rate of 1.7%. At 8 years of follow-up, the clinical and radiological results are excellent. We continue to use this implant in the prevention and treatment of dislocation.

Introduction: Modular necks used during primary or revision total hip arthroplasties permit to restor the ideal femoral offset and arm of abductors muscles, to ajust leg length and to reduce impingment between the neck and the socket with good hip balancing.

Material and methods: Modular necks are titanium implants manufactured with a double Morse taper: one cylindrical for the junction with the head, and one flat for the junction with the stem. They are avalaible in 2 lengths (short and long) with 6 different geometries: straight (CCD:135°), antevreted of 8° or 15°, 8° and 15° of varus (CCD: 127° and 120°), and a combination of anteverted and varus neck.

362 revision and 920 primary THA were performed with a minimal of 5 years follow-up in the Orthopaedic Department of Amiens University Hospital with modular necks.

Results: 23 patients died and 11 were lost of follow-up. None rupture was deplored. Femoral offset was restored in 97% of these cases even in the revision surgery, end equalization of leg length was obtained in 98% of the patients. Residual Trendelemburg sign was noted in 37 patients, always after revision. The rate of dislocation was low with 2% because of the absence of impingment.

Discussion: Because proximal femoral geometry is different for each patient and femoral offset independent from the IM canal diameter, modular neck is one easy solution to restor independent parameters. In addition, the per-operative trials permit to choose the best implant to avoid any impingment, reducing the risk of dislocation and increasing the range of motion. It’s ideal now for the use of hard bearings. Laboratory analysis have demonstrated very good resistance in assembly-distraction, deep flexion and rupture tests. No corrosion was noted and retrieved weight loss was minimal.

Purpose of the study: Osteosynthesis procedures proposed for fractures of the proximal humerus have evolved greatly since the development of anterograde nailing systems with the objective of providing a conservative surgical solution for sometimes complex fractures. We analyzed retrospectively the results obtained in a consecutive series of 30 patients treated in our unit with a Telegraph® nail.

Material and methods: Between March 2001 and August 2003, 39 patients presenting fractures of the proximal humerus were treated with a Telegraph® nail. Accorrding to the Duparc classification, the fractures were: 17, 11 ST+T, 4 CT II, and 7 CT III. Five patients died before the review presented here. Four CT III fractures presented material disassembly early and required revision with a hemiarthroplasty. For the 30 patients reviewed here, we noted the Constant score and the results of the Matsen test as well as radiographic findings.

Results: Mean follow-up for the 30 patients was 16 months (range 6–33). Mean age at trauma was 58.7 years (range 19–91). The mean Constant score was 57.4 (range 16–84) with 72% after weighting. The Matsen test was positive for 59%. Subjectively, 69% of patients were satisfied or very satisfied. There were several complications: secondary intraoperative shaft fracture treated orthopedically, four nonunions of the surgical neck, four tuberosity migrations, three cases of head necrosis, two subacromial impingements (one with rotator cuff tear). Nonunion was generally observed with static locking and in one case with an oversized nail. We were unable to identify any factor predictive of head necrosis due to the small number of cephalotuberosity fractures. Disassembly was generally observed in patients with an initially displaced fracture with periosteal rupture, osteoporosis and old age.

Discussion and conclusion: Our results are less satisfactory than others published in the literature for series using this material and it is difficult to compare with results for series using other types of material because the study criteria were highly variable. Although all fractures in this series, including the most complex, appear to benefit from this nailing system, we did note that complications were not exceptional even though certain compliations observed were related to our learning curve. Surgeons should be aware that the planned option can be changed intraoperatively. Arthroplasty may be necessary in certain cases if the conditions are not adequate for stable osteosynthesis.

Purpose: We report a series of 78 total hip arthroplasty revisions using a locked femoral stem, Ultime.

Material and methods: These patients presented aseptic loosening (88%) and septic loosening (12%). Fracture was associated in 17%. The preoperative Postel Merle d’Aubligné (PMA) score was 10.2 points. Using the Vives-SOFCOT classification, 29% of the loosenings were stage I, 37% stage II, 24% stage III, and 10% stage IV. All fractures were associated with lossening. We used a femoral window in 57% and trochanterotomy in 14 cases. The first eight patients in this series had an allograft (impacted piecemeal). Most of the patients resumed weight bearing the first week. The PMA score was used to assess outcome. AP and lateral views were used to evaluate stem-bone contact and cortical thickness at three levels.

Results: Early complications were phlebitis (n=1) and superficial haematoma (n=5). Late complications were dislocation (n=6), stem fracture (n=2), deep infection (n=3). At last follow-up, 81% of the aseptic loosenings, 77% of the septic loosenings, and 70% of the fractures on stem had a good or excellent PMA score with a mean gain of 4, 5, and 1 points respectively. Bone reconstruction showed an increase in internal cortical (2 to 4.4 mm) and stem-bone contact increased in the lower two-thirds of the stem. Allografts did not improve results. Furthermore, 28% of the patients had hip pain which could not be related to clinical findings or implant characteristics. Half of the patients were reoperated.

Conclusion: In this series, functional improvement was similar to that in published series. The femoral window facilitated the procedure and decreased intraoperative complications. The Ultime prosthesis met the objectives set by the manufacturer, i.e. primary stability and bone reconstruction authorising subsequent revision.

Purpose: Deep infections of the operative bed are rare but serious complications of first-intention total hip arthroplasty. Data from French series are scarce. We present a study of incidence, characteristic features and potential risk factors using a consecutive series of 790 implants performed during first-intention procedures in the same university hospital.

Material and methods: All patients who underwent first-intention surgery from November 1995 to May 1999 were included. We collected demographic, clinical, and therapeutic data. Deep infection was defined as bacteriological demonstration of the infectious agent from at least two intra-operative specimens during the revision procedure. Patient follow-up ranged from one month to four years. Univariate analysis was used to search for potential risk factors. The chi-square and Fischer exact tests were applied.

Results: Overall incidence was 1.77 deep infections for 100 operations (95%IC 0.84–2.7). Mean time to development ranged from 14 days to 32 months. Eleven infections were recognised within the first year and three after one year. Two risk factors were identified: absence of systemic antibiotic prophylaxis (relative risk = 4.74, p=0.03), and drainage discharge after 48 hr (relative risk = 3.62, p=0.02). Other variables associated with infection with a relative risk greater than 2 were obesity, corticosteroid therapy, and haematoma or postoperative wound healing problem.

Conclusion: The incidence found in this series is slightly higher than generally described in other countries. This study has incited us to revisit our protocols for preoperative skin preparation and to establish a systemic antibiotic prophylaxis.

Purpose: We report a series of 50 pilon fractures treated by osteosynthesis and report outcome at minimum seven years.

Material and methods: The series included 28 men and 22 women, mean age 44 years. Thirty-one patients were fall victims. The AO classification was type B (n=24) and type C (n=26). According to the De Lestang classification there were 12 simple fractures and 38 complex fractures (including 26 complete fractures) Sixteen fractures were open and 39 were associated with a fracture of the lateral malleolus. Most of the fixations were achieved via an anterolateral approach (n=22) using a prebent plate, or via a medial approach using a clover-leaf plate. A cancellous graft was used in seven cases. The Kitaoka classification was established at last follow-up.

Results: The radiographic work up included a lateral view and an anteroposterior view with moderate medial rotation. Mean follow-up was fourteen years. There were ten secondary displacements. Late complications were: non-union (n=14, including 10 cases requiring revision for arthrodesis), reflex dystrophy (n=6), deformed callus formation requiring revision, and one case of amputation after infection. At last follow-up, 33 ankles were painful (including 13 permanently painful ankles). Twenty-four patients had a residual limp (13 permanent) limiting walking distance in half of them. The talocrural joint motion was normal in 20 patients and the subtalar joint was normal in 24. Twenty-three patients resumed their former activities. For patients with sports activities, 64% resumed activities at the same level. The Kitaoka score was 79 points at last follow-up with outcome scored good in 70%, fair in 16% and poor in 14%. Excepting the patients who had secondary arthrodesis, 24 patients developed secondary osteoarthritis (including ten stage 2 and 3).

Discussion: Good outcome depends on the intraoperative reduction, both at the epiphyseal level (for complete fractures) and the metaphyseal level. This reduction must be maintained over time with a good fixation rigid enough to avoid secondary displacement which is a cause of callus deformation. The severity and complexity of the initial fracture constitute the main factors affecting outcome. In our opinion, computed tomography provides the best means of establishing the therapeutic indications. Pilon fractures remain a difficult challenge in orthopaedic surgery. Perfect reduction is the best guarantee of good outcome.

Purpose: Total ankle arthroplasty remains a difficult procedure. Some patients require revision surgery for arthrodesis.

Material and methods: We report nine patients with total ankle arthroplasties mainly implanted for post-traumatic osteoarthritis whose results deteriorated, requiring arthrodesis. One of these patients had rheumatoid arthritis.

Revision surgery was performed six months to seven years after arthroplasty. Arthrodesis was required for pain related or not to implant loosening or talar necrosis. One patient developed a major deviation of the hind foot secondary to progressive loosening. One patient developed infection early. An iliac graft was used to fill the bone defect in eight patients. An anterior plate-screw fixation was used for six patients, crossed screws for one, a tibiotalar nail for one, and an external fixator for one (with infection).

Results: Eight patients achieved bone healing with good pain relief. The functional result depended on the type of arthrodesis: talocrural alone or extended to the torsion couple.

Discussion: The evolution of ankle prostheses toward better bone sparing has allowed, in our experience, for revision arthrodesis under relatively good conditions using an iliac graft. We have not preferred one standard type of fixation but the anterior plate fixation has provided excellent stability.

Purpose: We report a series of 32 cases of recurrent hallux valgus treated by metatarsophalangeal arthrodesis and followed for at least five years.

Material and methods: Mean follow-up after the initial surgery was 11 years. All patients complained for pain of the forefoot. The mean phalangeal valgus was 39° with metatarsalgia in 16 cases. According to the Regnauld classification, the metatarsophalangeal space of the great toe was grade 1 in two, grade 2a in eight, grade 2b in six, and grade 3 in sixteen. Arthrodesis was achieved with an axial screw and adductor hallux plasty. Results were assessed at least five years after surgery according to the Kitaoka criteria.

Results: At last follow-up 78% of the patients were pain free. The valgus deviation was corrected with a mean angle of 19°. The arthrodesis fused in 90.6% of the cases. Statistical analysis revealed the influence of pre- and postoperative great toe valgus on the final result. The final results were less satisfactory with older age. Outcome was very good in 84%, fair in 6%, and poor in 10%.

Discussion: These results demonstrate that arthrodesis of the great toe is not an invalidating solution. Interpha-langeal joint degeneration can develop after excessive solicitation of the articulation.

Purpose: We reviewed 30 cases of osteochondrial lesions of the astragalus dome treated surgically.

Material and methods: Among the 30 patients, 17 practised sports and 24 had a history of trauma. Delay to surgery was ten months. All patients were treated by curettage using perforations according to Pridie. There were 11 direct approaches, 13 malleolar osteotomies and six arthroscopies. Cancellous grafts completed the treatment in six cases.

Results: Mean follow-up was three years seven months (minimum two years). All the patients had an arthroscan at last follow-up. The postoperative results were assessed according to clinical and arthroscan criteria.

Discusion: We emphasise the importance of the Fracture Osteonecrosis Geode (FOG) classification system and the subsequent pathophyisiological and prognostic conclusions. The Berndt and Harty classifications should be abandoned. Only symptomatic lesions should be treated. Surgical treatment (arthroscopy or direct access with cancellous graft) is required for efficacy at this stage. Surgical treatments provides very good results in 75% of the cases with pain relief and improved walking distance. We advocate arthroscopic perforation curettage for localised necrosis. In case of major substance loss, cancellous grfat requires a direct access.

Purpose of the study: We reviewed a series of 52 cases of chronic Achilles tendinopathy treated surgically by release of the fascia cruris, resection of peritendon, longitudinal incision of the tendon and occasional excision of intratendinous lesions.

Materials and methods: The mean course prior to surgery was about 18 months. Twenty-six patients practiced sports. Complaints were bilateral in 12 cases. Pain was always present. Ultrasound exploration evidenced paratendinitis (n = 21), tendinosis (n = 22) and paratendinitis with tendinosis (n = 9) (Puddu classification). Patients were reviewed after a minimal 2-year follow-up. Results were assessed on the basis of clinical findings.

Results: Mean follow-up was 5 years 6 months. Twenty-nine patients were free of pain. The range of motion was normal in 48 cases and 29 patients resumed sports activities at the same level as prior to surgery. Outcome was very good in 29 patients, good in 14 average in 6 and poor in 3.

Discussion: Stiffness of the tibio-tarsal joint can be avoided by proper mobilization. Outcome appears to be better in middle-aged patients. Poor outcome is closely related to amyotrphy. The presence of a foot deformity does not appear to have an unfavorable influence on outcome. The Achilles tendon must not be infiltrated. Ultrasound is highly contributive, but MRI provides a more accurate analysis.

Conclusion: Surgical treatment of chronic Achilles tendinopathies can be proposed when conservative treatment has been unsuccessful. Outcome is better in young active patients and in cases where paratendinitis predominates.