This paper offers a summary of the ethical guide for the European orthopaedic community; the full report will be published in the EFORT Journal.

Cite this article: Bone Joint J 2014;96-B:1130–2.

Background

Floating shoulder (FS) is, according to Goss et al, a double disruption of the superior shoulder suspensory complex which usually results from a glenoid neck fracture and a ipsilateral midclavicular fracture. However, the interruption can interest the whole scapular belt from acromion to sterno-clavicular joint. It occurs mostly after a violent traumatism with direct lateral impact on the shoulder. That leads to complex therapeutic issues with sometimes uncertain results.

Introduction

The same cup orientation is classically applied to all cases of hip replacement (45° abduction, 20° anteversion). We hypothesize that this orientation must be adapted to the patient's hip range of motion. We tested this hypothesis by means of an experimental study with respect to hip range of motion, comparing the classical orientation (45° and 20°), and the orientation obtained with computer-assisted navigation.

Purpose of the study: We report the clinical and radiographic results of a series of revision total hip arthroplasties performed for aseptic loosening using a non-demented modular femoral implant (PP).

Material and methods: From 1991 to 2003, 146 revisions of total hip arthroplasty were performed using the same non-cemented modular femoral implant (PP). At mean nine years follow-up (3.5–17 years), 24 patients had died, 26 had insufficient data for review and 39 were lost to follow-up. The analysis thus included 54 cases. All revisions were performed for aseptic loosening. Mean age at surgery was 60 years. Preoperative bone damage, according to the Sofcot classification, was grade I and II (69%), grade III (26%), grade IV (5.5%). Clinical outcome was assessed with the Harris and Postel-Merle-d’Aubigné scores. The radiological review analysed stem anchoring, lucency and periprosthetic reconstruction.

Results: At mean nine years follow-up, the mean Harris score was 71 points, the mean PMA score 12.8 points. Patient satisfaction was 70%. There were five cases with deep infection (9%), five with dislocation and six intra-operative periprosthetic fractures. Trochanterotomy non-union was noted in 26% of patients. Mean impaction of the femoral stem was 5 mm (range 0–16 mm). There was a statistically significant association between the degree of bone damage and the quality of the bone reconstruction (p=0.012). Mean increase in cortical thickness in zones 1 and 2 (Gruen) was 1.1 mm and 1.6 mm respectively. In Gruen zones 2 and 6, the gain was 6 and 10 mm respectively. There were nine surgical revisions (17%) for deep infection (n=4), recurrent aseptic loosening and fracture of the femoral implant (n=1). The ten-year survival taking aseptic loosening as the endpoint was 90%.0

Discussion and Conclusion: Our work showed the good long-term results obtained with this implant for revision total hip arthroplasty. It allows clinical improvement, periprosthetic bone reconstruction and a low rate of surgical revision.

Purpose of the study: Correct implant position is one of the factors of long-term success of total hip arthroplasty (THA). Acetabular architectural defects caused by trauma can create difficult situations leading to potential complications and poor outcome. The purpose of this study was to examine retrospectively the results of THA implanted after fracture of the acetabulum treated surgically. The objective was to analyse the specific features and search for factors favouring poor outcome.

Material and method: The series included 43 patients who had a THA implanted after treatment of an acetabular fracture. Mean age at trauma was 44.5 years (range 16–87). Five patients had a THA immediately, mean age 75 years (63–87). Thirty eight patients had osteosynthesis. According to the Letournel classification, the fracture was elementary in 12 cases and complex in 26. In ten patients, there was residual joint incongruence measuring more than 2 mm after osteosynthesis. The hips evolved to degenerated joint (n=34) and or necrosis (n=10).

Results: Mean time from acetabular osteosynthesis to THA was 94.6 months (range 3–444), excluding those patients whose THA was implanted at the time of the osteosynthesis. Arthroplasty required removal of the osteosynthesis material (n=11), insertion of a supportive ring (n=14) associated with a bone graft (n=13). The acetabular implant was considered to be well positioned according to the Pierchon criteria in 16 hips and was lateralised (n=21) and/or ascended (n=17) in the other hips. Inclination was 42.8 on average, range 10–18. The five-year survival was 80%.

Discussion: Arthroplasty after surgical treatment of an acetabular fracture is a difficult procedure. Complementary procedures are often necessary complicating the surgery and increasing the risk of perioperative complications, particularly infection. It is difficult to position the acetabular implant, increasing the risk of postoperative instability and early loosening. This study demonstrated the difficulties of implanting a THA in this context where the revision rate is significantly higher than in first-intention THA.

Introduction: Double mobility acetabular implant has a semicircular shape, it is covered with hydroxyapatite, the entire surface has a thickness of 3 mm and its centers of rotation are shifted.

The polyethylene employed is a high density one and it has some chanfers to avoid the cam effect.

Methods and materials: We present the results o an homogeneous series of 200 patients, operated between 2003 and 2007. Clinical and radiographic parameters were analyzed prospectively. The mean follow-up was done during 15 months. Clinical results were evaluated by the HHS at the out patients clinics: previous and post surgery.

Results: From the 200 patients operated (130 women-70 men / Mean age: 81 years old): 57,63% had a primary hip osteoarthritis; 5,77 % femoral necrosis ; 1,13 % rheumatoid arthritis; 16,95 % revision surgeries; 13,45% femoral neck fractures; 3,2% acetabular fractures y 1,5 % hip tumours.

HHS before surgery was 45, 83 points on average (from 12 to 79) y post surgery HHS was 80, 03 points (from 37 to 100), increasing the total score after the arthroplasty in a mean of 34, 17 points

Post surgery complications were as follow: 3 dislocations (1 after an enormous fall and 2 in patients with Alzheimer. In our series there are 50 patients diagnosed of dementia-Alzheimer); 1 per prosthetic fracture (revision surgery); 4 deep infections (2 acute: lavage+ antibiotherapy; 2 late ones: spacer + antibiotherapy +second time surgery); 2 Deep vein thromboses (Eco Doppler +) ; 10 urinary infections; 2 urinary retentions and 17 deaths.

Discussion: Double Mobility acetabular implant has shown good results in all the following indications: Revision surgery, hip osteoarthritis, femoral necrosis, Rheumatoid arthritis, femoral neck and acetabular fractures, hip tumours and as an implant for Computer Assisted Hip Surgery.

Conclusions: The complications founded while this acetabular implant is used appeared with the same percentage than others. The dislocation rate is lower than standard acetabular implants, especially in patients with neuromuscular or cognitive illnesses.

Those clinical results are hopeful and they could increase the number of actual indications (hip osteoarthritis in people over 70 years old, multiple illnesses associated, iterative dislocations…) for the double mobility implant on the future.

Background: The Rangeuil orthopaedics surgical team has developed a special installation using a rigid corset for the combine Kocher Languenbeck and ilioinguinal surgical treatment of complex acetabular fractures. The purpose of this study was to retrospectively evaluate the results of 53 complex acetabular fractures treated by open reduction and internal fixation with a combined double approach facilitated by this particular operative installation.

Methods: A retrospective review of the cases was performed. The functional outcome, operative times, blood loss were recorded. Pre-operative, post-operative and last follow-up radiographs were assessed for fracture classification and adequacy of reduction. The development of heterotopic ossification, the presence of infection, avascular necrosis and post-traumatic osteoarthritis were also noted.

Results: The mean follow-up was 5.2 years. The clinical outcome at the time of final follow-up was graded as excellent in 16 patients, good in 22, fair in 7 and poor in 8 The reduction of the fracture, as determined with plain radiography, was graded as anatomic in 32 patients, unperfect in 15 and unsatisfactory in 6. Bony union was achieved in all cases. 6 patients had Brooker 3 or 4 heterotopic ossifications. 9 patients developed osteoarthritis. 4 patients developed avascular necrosis. An arthroplasty was necessary for 10 patients. 3 patients had a delayed wound infection.

Conclusions: The combined simultaneous approach remains a reliable surgical solution in selected complex acetabular fractures. The installation using the corset we developed considerably simplifies the operation and access to the operated site.

Purpose of the study: We conducted a retrospective study of 66 cases of non-traumatic osteonecrosis of the femoral head by percutaneous drilling and autograft. This technique associated drilling with graft conductor effects and bone marrow inducers.

Material and Methods: Forty-six patients (41 male, 5 female) with non-traumatic osteonecrosis were included in this study. Mean age at surgery was 46 years (22–68). The 66 cases involved 32 right hips and 34 left hips (21 bilateral cases), six asymptomatic. Osteonecrosis was related to corticosteroid therapy (n=17), chronic ethylism (n=14), dyslipidaemia (n=7), barotraumatism (n=3), and renal transplantation (n=1). Four were found idiopathic. The preoperative ARCO classification was: 8 stage IIA, 21 stage IIB, 15 stage IIC, 7 stage IIIB, 13 stage IIIC and 2 stage IV. A minimally invasive surgical technique combined simple percutaneous drilling with a cancellous iliac bone graft harvested percutaneously homolaterally. Metaphyseal grafts were excluded from this analysis. Minimum postoperative follow-up was two years. The main outcome was rate of prosthesis conversion at two years.

Results: Considering all stages, 38 hips did not have a total prosthesis at two years (58% success) with a mean follow-up of 40 months (25–65). Twenty-eight hips had total prosthesis at two years (42% failure) with mean follow-up of 11 months (3–23). Mean survival was 29 months (3–65) with stabilisation of the initial lesions in 50% of hips. For the 44 stage II hips, success was achieved in 28 (64%). The success rate for stages IIA and IIB was 70% with mean follow-up of 29 months (19–65). For the 20 stage III hips success was achieved in nine (45%), with 30% for stage IIIB and 54% for stage IIIB and mean follow-up of 21 months (12–45). There were no cases of mechanical complications. One superficial skin infection cured favourably.

Discusssion and conclusion: Subchondral fracture (stage III) and necrosis volume > 30% appear to be unfavourable factors for outcome with this technique. There are other conservative treatments but all with technical difficulties or cost considerations despite sometimes questionable results. This technique is simple and very attractive. In one hand, it combines the advantages of the decompression-effect for the local vascularization with the bone inducer effect of the marrow auto-graft. And in the other, it is a non-invasive and conservative procedure which does not modify the morphology of the upper extremity of the femur and does not jeopardize a future total hip replacement. This is a reliable technique which merits confirmation with a larger series. The best indication remains stage IIA and IIB.

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure.

At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively).

We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided.

Introduction: The minimally invasive posterior approach has become a standard for total hip replacement (THR) but the interest for the other minimally invasive approaches has not waned in any way. We carried out a prospective and comparative study in order to analyse the interest of the anterolateral minimal invasive (ALMI) approach in comparaison to a minimally invasive posterior (MIP) approach for THR.

Material and method: We carried out a prospective and comparative study. A group of 35 primaries THR with large head using the ALMI approach, as described by Bertin and Röttinger, was compared to a group of 43 primaries THR performed through the MIP approach. The groups were not significantly different with respect to age, sex, bony mass index, ASA score, Charnley class, diagnoses and preoperative Womac index and PMA score. The preoperative Harris hip score was significantly lower in ALMI group. Early functional results have been evaluated thanks to Womac index and modified Harris hip score at 6 weeks, 3 and 6 months. A p value < 0.05 has been considered as significant.

Results: The duration of surgical procedure was longer and the calculated blood loss more important in ALMI group (respectively p=0.045 and p=0.07). The preoperative complications were significantly more frequent in this group with 4 greater trochanter fractures, 3 false routes, 1 calcar fracture, and 2 metal back bascules versus one femoral fracture in MIP group. Other postoperative data (implant positioning, morphine consumption, length of hospital stay, type of discharge) were comparable. The early functional results at 6 weeks, 3 and 6 months were also comparable. No other complication has been noted during the first 6 months in the two groups.

Discussion and Conclusion: The ALMI approach uses the intermuscular interval between the tensor fascia lata and the gluteus medius. It leaves intact the abductors muscles and the posterior capsule and short external rotators. The early clinical results are excellent despite of the initial complications related to the initial learning curve for this approach and the use of the large head with metal-on-metal bearing. The stability of the arthroplasty and the absence of muscular damage should permit to accelerate the postoperative rehabilitation in parallel with less preoperative complications after the initial learning curve.

Purpose of the study: Acetabular version is a most important parameter for repositioning the acetabular fragment during periacetabular osteotomy. Recently, a few studies have presented a significant number of dysplastic hips with acetabular retroversion. There have not however been any studies devoted specifically to the severity of bilateral acetabular retroversion. The purpose of this work was to determine the incidence of bilateral retroversion in patients undergoing periacetabular osteotomy for dysplasia in order to identify and validate a retroversion index which would be predictive of the degree of retroversion. This index could be added to congenital hip dysplasia classifications to include acetabular version.

Material and methods: The Lequesne lateral view of the hip was obtained in 174 patients (348 hips, 137 women and 37 men, mean age 30 years) undergoing periacetabular osteotomy for symptomatic dysplasia. One hundred ninety-five hips (56%) were operated on and 153 (44%) were considered normal or non-symptomatic and were not operated. The following parameters were noted for each hip: VCE, VCA, HTE, femoral head extrusion, index of acetabular depth, crossing-over, retroversion index. The retroversion index was checked on a bone model of the pelvis which was x-rayed in the neutral position then turned progressively. Statistical data were analyzed with SAS.

Results: Five percent of the operated hips presented neutral version, 53% anteversion and 42% retroversion. Twenty-four percent of the non-operated hips were normal, 22% presented pure retroversion and 54% were dysplastic. All of the measurements were significantly deviated towards dysplasia for operated hips, with the exception of the retroversion index and the VCA.

Discussion: These data validated the retroversion index and confirmed that one out of three dysplastic hips displays retroversion. In addition, it would appear that for dysplastic hips with retroversion, the degree of lateral coverage or the HTE angle determines whether surgery is needed or not and not the degree of retroversion. But as pure retroversion can be symptomatic in itself, and since the majority of these version or cover anomalies can be treated by periacetabular osteotomy, we propose a classification of hip dysplasia included acetabular version.

Conclusion: This classification is designed as an aid for the orthopedic surgeon for reorienting the acetabular fragment to obtain the optimal position.

Purpose of the study: Most systems used for computer-assisted total hip arthroplasty require preparatory computed tomography acquisition or use of multiple bone markers fixed on the pelvis. In order to overcome these problems, we developed a novel system for CT-free computer assisted hip surgery based on a functional approach to the hip joint. The concept is to orient the cup within a cone describing hip motion. The purpose of the present study was to analyze preliminary results obtained with this new system.

Material and methods: This new system was used to implant 18 primary total hip arthroplasties in 16 women and 2 men (mean age 68±7.8 years, age range 54–83 years) with degenerative disease. Two optoelectronic captors were fixed percutaneously on the pelvis and the distal femur. The acetabulum was reamed, then the femur prepared with instruments of increasing caliber. The last reamer positioned in the shaft carried an upper head which matched the size of the prepared acetabulum. Hip joint motion was recorded to determine the cone of maximal hip mobility. The system then oriented the cup so that this cone was completely included the cone described by the prosthesis.

Results: There was one traumatic posterior dislocation (fall in stairs) at three weeks, without recurrence. The Postel Merle d’Aubigné score improved from 8±2.9 (3–12) preoperatively to 17±0.8 (16–18) at last follow-up. None of the patients complained about the sites where the percutaneous markers were inserted and ther were no cases of hematoma or fracture. Mean leg length discrepancy was 5.6±7.5 mm (range 0–25 mm) before surgery and 0.6±3 mm (range −5 to 10 mm) at last follow-up. Mean anteversion of the femoral implant was 22.3±6.7° (14–31). Anatomic anteversion of the cup (measured from a marker linked to the pelvis and thus independently of the position of the pelvis) was 25.9±10.4° (12–40). The sum of the femoral and acetabular anteversions was 48.2±14.6° (range 27–71°).

Conclusion: This method can be used in routine practice without lengthening operative time excessively. It provides a safe way to control the length of the limb and helps position the cup. This study demonstrated that there is no ideal position for the cup that can be applied for all patients. Because of the wide spread of the inclination and anteversion figures, half of the cases were outside the safety range recommended by Lewinnek.

Purpose of the study: The majority of acetabular bone defects observed during revision hip surgery can be treated with a hemispheric implant, associated or not with a bone graft. In many patients however, loss of bone stock is so great that a more complex system must be used with a sustaining ring, multilobulated implants, or massive allografts. All have their technical difficulties or problems with fixation. The purpose of this work was to evaluate a new technique for acetabular reconstruction using modular implants fashioned with a new biomaterial, porous tantalum, which had specific properties favoring osteointegration.

Material and methods: These modular implants were fashioned so as to enable reconstruction of the acetabular cavity in cases with complex loss of bone stock. The design allows simultaneous biological incorporation and mechanical support with a press-fit hemispheric cup. These implants were used for 16 hips (16 patients, 12 women and 4 men, mean age 63.6 years, age range 34–86 years). These patients were followed for 31.9 months on average (range 24–39 months). The acetabular defects were Paprosky 2A (n=1), 2B ‘n=3), 2C (n=1), 3A (n=5), 3B (n=6). On average, these patients had undergone 2.8 cup replacements (1–9) on the same hip.

Results: The mean Harris hip score improved from 39.31 (range 33–52) preoperatively to 75.18 (range 52–92) at last follow-up. Preoperatively, the center of rotation of the prosthetic hip was situated a a mean horizontal distance of 18.6 mm (range −3 to 46 mm) and a mean vertical distance of 27.6 mm (range −16 to 52 mm) from the ideal center of rotation according to Ranawat. Postoperatively, the prosthetic center of rotation was situated at a mean horizontal distance of 10.5 mm (range 1–25 mm) and a mean vertical distance of 7.4 mm (range −15 to 25 mm) front the ideal center of rotation. None of the implants presented loosening or migration at last follow-up.

Discussion: At short-term follow-up, this modular system for acetabular reconstruction has provided good results for acetabular reconstruction which can accept a hemispheric cup alone and which would have required use of other reconstruction methods such as structural allografts, sustaining rings or other.

Conclusion: A longer follow-up will be needed to determine whether these good clinical and radiological results persist with time.

Purpose of the study: Percutaneous compressive plating (PCCP) enables minimally invasive surgery using closed focus technique. We report a prospective consecutive series of 67 fractures (December 2003 – February 2005) followed to bone healing.

Material and methods: Mean patient age was 83 years (range 37–95) with 83% females in a frail population (ASA 3, 4). Two-thirds of the patients had unstable fractures (AO classification) which were reduced on an orthopedic table under fluoroscope. Two minimal incisions were used to insert the material without opening the fracture and without postoperative drainage. Blood loss was noted. Verticalization and weight bearing were encouraged early depending on the patient’s status but were never limited for mechanical reasons. Patients were reviewed at 2, 4 and 6 months.

Results: Anatomic reduction was achieved in 84% of hips, with screw position considered excellent for 45, good for 14, and poor for 6. There were no intraoperative complications. The material was left in place. The hemoglobin level fell 2.2 g on average. Mean operative time was 35 minutes and the duration of radiation exposure 60 seconds. Mean hospital stay was 13 days. General complications were: urinary tract infections (n=10), phlebitis (n=2), talar sores (n=5). Gliding occurred in three cases (4%) with telescopic displacement measuring less than 10 mm in ten cases. There were two varus alignments with no functional impact. There were four deaths within the first three weeks. All fractures healed within three months.

Discussion and conclusion: PCCP has its drawbacks (mechanical, stabilization) as do all osteosynthesis methods used for trochanteric fractures. The technique is reliable and reproducible and is indicated for all trochanteric fractures excepting the subtrochanteric form. PCCP has the advantage of a closed procedure with a minimal incision and limited blood loss for a short operative time. An advantage for this population of elderly frail subjects (ASA 3, 4). PCCP enables immediate treatment with a low rate of material disassembly compared with other techniques.

Purpose: We evaluated male sexual function after utilisation of the orthopaedic table for centromedullary nailing in patients with femoral shaft fractures treated between 1995 and 2001. The objective was to determine the frequency of altered function and search for favouring factors.

Material and methods: Sexual function was assessed with a self-administered questionnaire using the International Index of Erectile Function (IIEF). We contacted by mail 109 patients aged 20 – 50 years treated in the orthopaedic traumatology unit between 1995 and 2001. The Mann-Whitney test was used to compare quantitative variables and Student’s t test for classed variables.

Results: Seven patients declined to respond and three died; 55 responded (81.8%). Patients were grouped by erectile function (EF) score (< 22 or 22) according to Cappelleri. Erectile dysfunction was identified in 19 patients. Altered sexual function did not appear to be related to age, weight or height. The duration of the operation was not different between the two groups.

Conclusion: This study demonstrates a increase in iatrogenic lesions having an impact on erectile function in patients treated on an orthopaedic table when curare is not used during the intervention. The frequency of these lesions decreases significantly if the surgery is performed by a senior surgeon.

Material and methods: Two series of 35 total hip arthroplasties (THA) implanted by the same surgeon using the posterior approach were compared. The first group underwent surgery in 1999 and the second in 2001. Ligation of the posterior medial circumflex artery was systematically performed in the second group. The same prosthesis was used in all cases: an omnicase stem and a Schuster (Centerpulse) or polyethylene cup. The series included cemented (n=37) and non-cemented (n=32) prostheses with one hybrid implant. We analysed retrospectively, intra- and postoperative bleeding, haematocrit before and just after surgery, and the number of packed red cell units transfused during and after surgery in order to determine the degree of intra- and postoperative bleeding. Statistical tests were applied.

Technique: Via the posterior approach, before sectioning the pelvitrochanteric muscles, the upper third of the fibres of the quadratus femoris muscle were dissociated. The artery runs upwardly and anterior toward the posterior border of the greater trochanter and is difficult to identify in the fatty tissue. Ligation is performed at this level with the satellite veins. Ligation decreases bleeding when the pelvitrochanteric muscles and the capsule are sectioned. Likewise, section of the femoral neck appears to be less haemorrhagic as is the preparation of the proximal greater trochanter.

Results: Intra- and postoperative bleed, expressed in ml, was significantly decreased by ligation of the posterior circumflex artery and its two satellite veins. Mean intraoperative bleeding was decreased by more than half. Six of the 35 patients who did not have ligation lost more than 600 cc blood during the operation. This degree of bleeding was not observed in the ligation group. The postoperative haematocrit was significantly higher in the ligation group and the difference in pre- and postoperative haematocrit was decreased 7-fold. Postoperative transfusion became exceptional. Finally, it is interesting to note that among the variables studied, mode of implant fixation did not affect blood loss.

Discussion: The conventional technique without ligation of the posterior circumflex artery does not always lead to significant bleeding. It is quite possible to perform such procedures with less than 200 cc blood loss. Use of posterior circumflex artery ligation leads to much more regular control of intraoperative bleeding, making autologous blood collection and postoperative transfusions unnecessary. The ligation is a simple procedure. Electric coagulation is generally insufficient for the calibre of these vessels and veins are not always accessible to effective coagulation. Intraoperative bleeding due to section of the circumflex artery is underevaluated due to the tension created by the forced internal rotation. Haemostasis after section is difficult due to retraction of the proximal segment under the muscles.

Purpose: Improved surgical technique and facilities enable emergency salvage of very damaged limbs. Functional outcome after this type of conservative treatment is generally satisfactory but at the risk of more or less quiescent osteitis. In the event of chronic osteitis, the neighbouring skin can undergo malignant degeneration (squamous-cell carcinoma). The purpose of our work was to report three such transformations and discuss therapeutic indications.

Material and methods: The study series included three patients with chronic osteitis of the tibia after trauma. During surveillance, several years later we observed changes in local signs: increasing pain, purulent discharge and bleeding (Rowlands triad). In each patient, biopsy led to the diagnosis of transformation to squamous-cell carcinoma. All patients were treated by above knee amputation.

Results: Outcome was satisfactory with an excellent quality scar formation. The search for extension was still negative a three years follow-up.

Discussion: The frequency of carcinomatous degeneration near zones of chronic osteitis varies depending on the series to 0.2% to 1.7%. This is in sort the cost of conservative treatment. Changes in the clinical presentation, Rowland’s triad, associated with modification of the bacterial flora and development of a nauseous odour are important signs which should be followed by a biopsy. The treatment of choice for most authors is amputation in order to increase patient survival.

Conclusion: The desire to pursue conservative reconstruction surgery even in the most difficult cases should not mask the risk of potential malignant transformation. Secondary amputation should not be considered as a failure in these extreme clinical situations.

Purpose: Bone remodelling and osteolysis around total hip prostheses remains an ineluctable corollary of prosthetic loosening. Alendronate (biphosphonate) has proven its efficacy for the treatment of osteoporosis of the lumbar spine and the femoral neck. There has been some in vitro work pointing out its contribution to the inhibition of osteolysis induced by particles. One in vivo study has demonstrated its interest in prevention of osteolysis around non-cemented total hip arthroplasties. The purpose of our work was to study the efficacy of this drug in the prevention of periprosthetic osteolysis around cemented total hip arthroplasties using biphotonic absortiometry (DPX).

Material and methods: The series included 38 patients who underwent unilateral total hip arthroplasty for degenerative hip disease. After double blinded randomisation, 20 patients were given 10 mg Alendronate per day with 600 mg calcium and 18 patients were given a placebo with 600 mg calcium for two years. All patients were followed with standard x-rays and DPX of the operated hip. Examinations were performed on the fourth postoperative day and on the third, sixth, twelveth and twenty-fourth postoperative month. The analysis concerned the periprosthetic zones defined by Gruen.

Results: DPX demonstrated significant reduction in bone mineral density (BMD) in all patients included in the study. This reduction was the same for the two groups early in the study and reached a maximum at three months; a divergence was observed thereafter. For the placebo group, the loss reached a plateau up to the sixth month after which the BMD started to rise progressively remaining at 12.7% reduction at two years (p< 0.002). In the ALN group, there was no plateau, BMD increased directly to reach 6.9% bone loss at two years (p< 0.003).

Discussion:The use of Alendronate enabled a significant reduction of periprosthetic bone loss at two years post-op. Our results are the first to our knowledge demonstrating a beneficial effect in vivo of the use of Alen-dronate on bone behaviour around cemented total hip arthroplasties.

Conclusion: Taking into account the short follow-up in this series, and its small size, other studies are indispensable to confirm this beneficial effect in vivo. The action of Alendronate could facilitate revision surgery by preserving bone stock.

Purpose: Insertion of the femoral stem during total hip arthroplasty provokes a bridge between the proximal femoral forces leading to well-documented bone resorption. A review of the literature concerning the behaviour of the contralateral femur and the spine reveals conflicting data. Some authors report variable bone mineral density of the lumbar spine while the contralateral neck, studied with non-cemented prostheseis in all cases, shows a significant fall in bone density. All patients in these studies needed an unloading period to achieve definitive fixation of the hip prosthesis. The purpose of this study was to assess bone behaviour in the contralateral femur and the lumbar spine after unilateral cemented total hip arthroplasty with immediate postoperative weight bearing.

Material and methods: The study series included 52 patients who underwent unilateral cemented total hip arthroplasty for degenerative hip disease. All were followed with standard x-rays and DPX of the contra-lateral hip and the lumbar spine. These examinations were performed one month before surgery then on D8, M3, M6, one year and two years. Bone mineral density (BMD) was measured in the femoral neck cortical and the L2–L4 trabecularlar bone. Patients were verticalised and encouraged to walk with full weight bearing on the average on day 3 to 4 after surgery.

Results: DPX did not demonstrate any significant decrease in BMD in any of the patients included in this study, neither in the lumbar spine nor in the contralat-eral femoral neck.

Discussion: Several studies in the literature point out the difficulty in recovering bone mass lost after a period of immobilisation or unloading. This bone loss could reach 10% of the bone mass even for short periods of unloading. Furthermore, minimal bone loss, to the order of 2.5% could accelerate the transformation of osteopenia into osteoporosis and increase the risk of fractures. The importance of minimising periods of unloading in older patients is thus evident.

We describe a 46-year-old woman who presented at intervals of seven years with osteonecrosis of the outer end of both clavicles. The clinical, radiological features and the appearances of the bone scans are described. Although the condition may be confused with osteolysis there is a clear histological distinction between the two conditions. If the symptoms fail to respond to conservative treatment, excision of the outer end of the clavicle is recommended.