Purpose of the study: For young active patients, implantation of metal backed socket with a metal-on-metal bearing is an attractive tribological alternative when a standard prosthesis cannot be implanted. Metal ion assays have not been reported in this type of population. The purpose of this work was to present the clinical, radiographic and metal ion results.

Material and methods: Between 1998 and 2003 23 total hip arthroplasties (THA) (six primary and 17 revision) were implanted with a cemented Metasul™ bearing in a Muller inlay. Mean follow-up was 6.1 years (5–10). None of the patients was lost to follow-up. The Harris and PMA scores were noted as were signs of implant loosening or migration. Metal ions were assayed in total blood (Cr and Co) by mass spectrometry and atomic emission spectrometry (Ti).

Results: At follow-up, the mean Harris and PMA scores were significantly increased, from 62.2 to 95.2 (p = 0.01) and from 12.9 to 17.4 (p = 0.02) respectively. No revisions were required for aseptic loosening or failure of fixation. The radiographs did not reveal any signs of osteolysis or lucency. The mean levels of Cr, Co and Ti were 1.85μg/l (0.8–3.2). 1.24μg/l (0.5–1.86) and 9.62μg/l (5–18) respectively. Ti > 10μg/l was noted in six patients; Ti > 10 μg/l and Cr > 2μg/l in five patients. There was no correlation of metal ion levels with size of the implants, activity level, gender, clinical scores or cup inclination.

Discussion: The mean Co and Cr levels observed in this series were similar to those reported in the literature for standard THA (cementless press fit cups). Ti levels have only been reported in rare studies so that comparison with other series is hazardous. The Ti level observed here appeared to depend on the femoral stem resurfacing (in our series, the porous surface of the stem was coated with a Ti-6Al-7nB alloy).

Conclusion: Cementing the metal-on-metal bearing in the supporting inlay appears to be a reliable and attractive technique for this young and active population. Levels of Cr and Co in blood were the same as reported for standard implants. These levels of metal ions should be followed to confirm the long-term results.

Purpose of the study: Locked implants have yielded favourable results for femoral bone reconstruction for revision total hip arthroplasty, but defective integration has also been reported due to insufficient bioactive coating. The purpose of this work was to evaluate a locked pivot with a two-third proximal hydroxyapatite coating.

Material and methods: From 1996 to 2007, 158 femoral implants (Linea™) were implanted for hip arthroplasty revision. The 143 cases with more than one year follow-up were reviewed (14 deaths, 1 lost to follow-up); 83 revisions for aseptic loosening, 41 periprosthetic fractures, 19 revisions in an infected context. Patients were reviewed retrospectively by a non-operator observer. These were older patients (mean age 68 years, range 31–93) and 36 patients had complex situations requiring at least two prior prostheses; 25% had severe grade 3 or 4 (SOFCOT) bone lesions and 59% diaphyseal damage.

Results: Clinical improvement was significant, the Postel Merle d’Aubigné score improved from 7.7 + 4.3 (0–17) to 15.6 + 2.2 (8–18) at mean 50 months (14–131) (p< 0.001). At last follow-up, 14 patients (10%) reported thigh pain and only seven pivots (5%) had not achieved Engh osteointegration (five with thigh pain two without). There were no fractures. There was on non-union of the femorotomy. According to the Hoffman index, femoral bone regeneration was significant at the metaphyseal and diaphyseal levels. Eighteen of the 19 infections cured, all periprosthetic fractures healed. The implant survival was 88.9% at 91 months (65–96.7%). There were five pivot replacements for non integration and/or thigh pain which resolved in all cases; there were no other pivot replacements. The quality of the metaphyseal and diaphyseal filling was predictive of the quality of the bone fixation of the pivot (p< 0.01).

Discussion: Compared with older models of locked pivots, this implant reduced the rate of thigh pain while allowing constantly satisfactory bone reconstruction. The metaphyseal and diaphyseal filling index is the main factor predictive of clinical and radiological success by favouring osteointegration. Maximal filling, obtained with a full range of implant diameters and lengths, contributes to this good result.

Purpose of the study: Drilling along yields disappointing results for osteonecrosis of the femoral head due to the high failure rate despite prolonged rest and also because of the risk of fracture. To prevent these problems, we have developed a new drilling technique which was evaluated prospectively.

Material and methods: The procedure performed percutaneously uses a lateral cortical orifice measuring 5mm, non-concentrated autologous bone marrow was injected after drilling. Osteoinductive protein (BMP7) was associated in random fashion (groups BMP+ and BMP−). Ficat stage 1 and 2 necrosis was included. Outcome was the rate or revision for prosthesis.

Results: Forty hips (36 patients) were included and assessed at mean four years (range 2–6). The necrosis was related to: alcoholism (n=5), cortisone (n=25), barotraumas (n=2), metabolic disease (n=4), idiopathic condition (n=4). Group BMP- (drilling+bone marrow) included 24 hips and group BMP+ (drilling+bone marrow+BMP7) 16 hips. The groups were comparable regarding necrosis stage (15% stage 3, 65% stage 2, 20% stage 1) and mean Koo index (27 BMP+ vs 34 BMP-; NS). There were no infections and no fractures despite immediate and complete weight-bearing. The revision rate for prosthesis was higher in the BMP- group (67%) than in the BMP+ group (43%) but the difference did not reach significance (p=0.10). The failure rate was not affected by the severity of the necrosis in the BMP+ group: all stage 3 hips were revised in the BMP- group versus none in the BMP+ group. The only variable predictive of revision for prosthesis was the Koo index (p=0.02).

Discussion: Adjunction of BMP did not improve significantly the success rate of drilling with bone marrow adjunction but adding BMP appeared to limit the unfavourable impact of server necrosis observed in the BMP- group. To reach a statistical power of 80%, 40 cases would be needed in each arm. This threshold has not yet been reached. It can be noted however that the proposed method does ensures early weight bearing without the risk of complications. Similarly, since it is a percutaneous procedure, later arthroplasty is not compromised. The principle confounding factor, the richness of the bone marrow, was not assessed, motivating a new randomized trial with measurement of CFU-F.

Introduction: Cementless revision hip arthroplasties require a stable initial fixation that does not compromise a subsequent bone reconstruction. In case of severe femoral bone loss, stems usually requires distal fixation that may induce stress shielding and finally reduce the spontaneous bone reconstruction. We introduced the use of distally locked revision stems in 1993 hoping strong fixation and bone reconstruction. The goal of the current study was to assess if these components fulfill these two objectives.

Materials and Methods: 101 cementless femoral revision stems with distal locking by screws (Ultime™ Wright-Cremascoli) were inserted from 1993 to 2001. These stems were smooth distally and porous coated with or without HA 1/3 proximally. The indication to use these components was severe bone loss (Paprosky grade IIC and III in 51%) when press fit distal fixation could not be obtained. The use of bone graft was limited to segmental defects or to treat trochanteric non-union. An extended trochanteric osteotomy was performed in 89%. The revision was performed because of aseptic loosening in 43,4%, periprosthetic fracture in 24,2% and infected loosening in 25,2%. The results were assessed after a mean follow-up of 6 years (5–12).

Results: 13 patients deceased and 2 were lost for follow-up. All the extended trochanteric osteotomies healed. Merle d’Aubigné hip score increased from 8.3 to 13.4, but thigh pain was observed in 44%. Bone reconstruction was significant according to Hoffman index at 3 levels of assessment. The 5-year survivorship was 87% considering aseptic revision for any reason. Seventeen repeated femoral procedures were performed: 9 related to thigh pain (because there was no proximal osteointegration) that were revised for short primary stems, 8 because of stem fractures (all occurred at the level of the proximal hole with the same stem size because there was no proximal fixation as long as the stems were smooth or without HA-coating.

Discussion: This serie has the longest follow-up using locked revision stems. Despite severe pre-operative bone loss, primary fixation and significant bone reconstruction were obtained for all the cases without extensive bone grafting. The major weakness, thigh pain and stem break, were related to unadequate femoral coating for these cementless stems that did not achieved osteointegration. Conversly, the reoperations were simple, allowing the use of short primary designs as bone reconstruction was achieved in all cases without extensive bone grafting. These locked stems allow a strong primary distal fixation that does not compromise bone regeneration. An improvement of femoral coating (extension to 2/3 and use of hydroxyapatite) may reduce the rate of thigh pain and reoperation.

Purpose of the study: Theoretically, long-term functional and radiographic degradation is predictable after ankle fusion, but sound evidence from consecutive analysis of the same cohort is lacking. The purpose of this study was to evaluate the same cohort of patients who underwent ankle fusion.

Material and Methods: The cohort included 52 ankle fusions which had been analyzed in 1984 at seven years (2–22 years) of follow-up then again in 2000 using the same evaluation criteria. Among the 52 patients, six were lost to follow-up, 20 had died and one had undergone leg amputation. The second analysis thus included 25 patients (18 men and 7 women), mean age 62±12.6 years (40–94) at the 2000 assessment performed 23±4.5 years (19–36 years) after the fusion. Functional outcome was assessed with the 100-point Duquennoy scale. Osteoarthritis of the subtalar and mediotarsal joints were assessed preoperatively and at follow-up using the same scale.

Results: The functional outcome did not deteriorate significantly between 1984 and 2000. The mean score was 65.8±22.6 (19–92) in 1984 and 64.7±18.3 (34–90) in 2000 (p=0.67). Fifteen patients (60%) had a good or very good outcome at seven years, and 14 (56%) at 23 years. Between 1984 and 2000, ten patients improved their score (on average 10.4 points, range 1–21 points), two had an unchanged score and thirteen a lower score (on average 10 points, range −1 to −24). Ten of these thirteen patients developed severe intercurrent conditions explaining the degradation. At last follow-up, sixteen ankles were pain free or nearly pain free. Twelve patients considered their ankle as a forgotten problem and had no regrets concerning the operation. The evolution of the subtalar joint in 16 cases (nine fusions including five at the same time as the ankle fusion and four performed within four years) showed that all developed early osteoarthrtic degradation with aggravation between 1984 and 2000, leading in the majority of cases to severe degenerative disease. This osteoarthritis was painful in less than one-third of the cases (including the four secondary subtalar fusions and the four sub-talar fusions which were painful at mobilization). The mediotarsal joints degradation was later and less severe than for the subtalar joint with a majority of moderate osteoarthritis. Ten ankles exhibited compensatory hypermobility of the forefoot measured at more than 15° without pain.

Discussion: This long-term follow-up with two successive assessments using the same evaluation criteria did not demonstrated late degradation of function expected after ankle fusion. It did show however the presence of radiographic degradation of the subtalar joint but with little clinical expression at a minimal follow-up of 19 years. There was no need for complementary fusion between 4 and 23 years follow-up.

Purpose of the study: In order to evaluate the influence of prosthesis design and resurfacing on the outcome of total hip arthroplasty (THA) implanted without cement, we reviewed the orthopedic literature from 1980 to 2004.

Material and methods: The PubMed database was screened from 1980 to 2004 for publications reporting cementless THA with a follow-up analysis. The same criteria were used to screen three registries. In all, the publications retained had studied 50,162 cementless THA (mean patient age 48.9 years, mean follow-up 6.5 years) where were studied according to rate of revision, presence of osteolysis, and presence of operative fractures. Eleven families of components grouped together the majority of prostheses: five acetabular families [screw fixation without resurfacing (n=2997), screw fixation with hydroxyapatite (HA) resurfacing (n=3618), screw fixation with corindon resurfacing (2360), press-fit mac-roporous (15691), press-fit HA (6094)]; and six families of femoral pivots [straight macroprous (n=7502), straight HA (n=3255), straight corindon (n=6136), anatomic HA (n=3468), anatomic macroporous (n=1215), anatomic corindon (n=1041)].

Results: The rates of revision and of osteolysis were higher for screw fixed cups without resurfacing. For screw fixed or press-fit cups, HA resurfacing did not reduce the rate of revision compared with corindon coated or macroporous implants. For anatomic pivots, adjunction of HA resurfacing reduced the rate of revision but at the shortest follow-up and without reducing the rate of osteolysis. Corindon-coated pivots gave comparable results for straight or anatomic implants. Conversely, HA-coated pivots gave better results with an anatomic design. The shape of the pivot had les effect than resurfacing on osteolysis and revision, but had a greater influence on operative fractures (2.9% for straight implants versus 4.6% for anatomic versions).

Conclusion: In all:

uncoated implants should be abandoned;

Purpose of the study: Because of its specific properties, linezolid (LZD) is an alternative to glycopeptides for the treatment of BJI causes by resistant Gram-positive cocci. The efficacy and tolerance of long-term (> 28d) administration remain to be determined with precision.

Material and methods: This was a retrospective analysis of the files of patients who received long-term LZD for BJI with a post-treatment follow-up of at least twelve months.

Results: Between January 2001 and December 2003, 68 patients (mean age 54.6 years) received LZD (600 mg/12h) intravenously then orally for a mean duration of 14.6 weeks on average (range 6–36 weeks). The orthopedic implants were infected in 31 patients (45.6%, 27 prostheses and 4 external fixators). A fistulization was diagnosed in 29 patients (42.6%). Medical and surgical treatment was undertaken in 51 patients (75%). Germs isolated from deep samples were staphylococci (n=57, 51 meti-R), and strepotococci (n=11). A polymicrobial infection was recorded in six patients (8.8%). Clinical success was achieved in 52 patients (76.5%) at the end of treatment, a result which was sustained for 48 of them to mean follow-up of 16.8 months (range 12–48). Sixty-three episodes of side effects were noted: anemia (n=29), peripheral neuropathy (n=9), nausea (n=14), headache (n=2), neutropenia (n=2), and thrombopenia (n=1), leading to discontinuation of LZD in 23 patients (33.8%) on average 11.9 weeks (range 6–36) after onset of treatment. Fifteen patients (22.1%) required transfusion.

Discussion: Among the patients in this series with BJI, most caused by a multiresistant germ, the rate of success was satisfactory (48/68, 70.6%) with LZD. Treatment was associated with a high frequency of serious adverse effects leading to discontinuation in one-third of patients.

Conclusion: Long-term treatment of BJI with LZD appears to be effective, including in patients with infected orthopedic material. Conversely, tolerance problems can limit is use to infections caused by mul-tiresistant Gram-positive cocci unresponsive to other compounds.