Purpose: Instability is a major cause of revision total hip arthroplasty (rTHA). It was the third leading cause (5%) after aseptic loosening (75.7%), and infection (7.2%) in the Swedish registry for 2000. The rate of dislocation is however variable depending on the reported series. We conducted a statistical analysis of nearly 3000 files of rTHA to study factors favouring failure.

Material and methods: AVIO, a watch association for orthopaedic implants, was created in 1994 to evaluate factors favouring failure of THA in France, and to furnish statistical data on prosthesis revision. About one hundred orthopaedic surgeons throughout France completed an information card for each revision for a five year period (September 1994 to September 1999). A total of 2926 card were analysed. Patient data (gender, side, number of revisions, age at implantation, age at removal, reason for THA, reason for revision, duration of THA) were cross analysed. The statistical analysis was conducted with chi-square tests and non-parametric tests. Significant results were compared with data in the literature. We present here the results concerning dislocation as the reason for revision.

Results: The rTHA for dislocation accounted for 9.2% of the revisions. Dislocation was the primary reason for revision in patients with repeated revisions and was also the main reason for revision in patients aged over 70 years (20.6%). In this group of older patients, 72.8% of the prostheses were implanted for degenerative disease.

Discussion: The original finding in this study, not clearly reported in the literature, is that dislocation is the primary cause of revision after 70 years, coming before aseptic acetabular loosening. Although mentioned by Charnley in 1979, very few studies (Newington in 1990, Edelund in 1992) have studied the relationship between dislocation and age.

Conclusion: Patient-related factors play an important role in the stability of THA. After 70 years, dislocation becomes the primary reason for revision and should be taken into consideration in our ageing population. This study has led us to modify our therapeutic strategy in patients aged over 70 years.

Purpose: Wound dressing is the last phase of any surgical intervention. The purpose is to isolate the surgical wound to reduce the risk of airborne contamination. In certain situations such as skin trauma, burns, acute or chronic loss of skin cover, or open fractures, wound dressings can however have a deleterious effect (maceration, adherence). Prevention of secondary infection of surgical wounds and spread of infection from septic patients is an integral part of our routine practice. We have developed a specific system useful in certain situations to isolate a septic or “at-risk” limb.

Material and methods: Our system is composed of a closed 100-cm polyvinyl chloride isolator measuring 40 cm in diameter. Two “absolute” filters allow internal ventilation with a variable flow filtered-air generator. Sterile products are introduced into the isolator via a shuttle chamber. With this system, the wound can be isolated without isolating the patient. We have used this system for more than 250 patients since 1986. A dedicated chart has been used to monitor results obtained with the system since 1993.

Results: The isolator was used for 258 patients, 185 men (71%), with 271 limb wounds on 227 lower limbs (83%) (63% legs and ankles). Half of the patients had open fractures associated with loss of skin cover. The clinical course was satisfactory in 75% of the patients (complete healing or complementary skin graft). The system was psychologically unacceptable for seven patients. There was only one case of a new germ isolated from a wound.

Conclusion: This dressing isolator requires a significant “logistic” investment but provides considerable bacteriological safety for difficult cases.

Purpose: Following up patients who have undergone total hip arthroplasty (THA) is useful but raises many technical and logistic problems. A systematic analysis of data collection for THA patients allows an evaluation of the value and the limitations of the method.

Material and methods: During a five-year period, French, Belgium, and Spanish surgeons volunteered to participate in the AVIO program. For all revision THA, they completed a brief information card recording data on the patient, the reason for the revision, the type of prosthesis replaced, its current status and the status of the bone. Data were centralised for statistical analysis. More than 3000 information cards were collected. Analysis provided information on the patients (age, gender, side, etc.) but also on survival of the revised prostheses, the principal reasons for revision, and the anomalies observed on the implants and bones and the relationships between these points.

Results: The reasons for revision could be divided into two categories: early problems (dislocation, infection, pain) and late problems (loosening, bone lysis, dislocation). Revisions directly related with defective material accounted for only 5% of the cases but a default was present in 75% of the cases at revision.

Discussion: This work provides interesting insight into revision THA and the patients concerned as well as the limiting technical problems. Conversely, it did not reveal any significant indication concerning the outcome of the prostheses themselves due to lack of information on first-intention implantation. Systematic data collection was also hindered by several factors: irregular mailings, imprecise information, difficulty in determining which implant was removed.

Conclusion: Systematic collection of data on technical failures can provide useful information on the technique, but cannot allow in itself a valid evaluation.

Purpose: Classification of the lower extremity of the radius does not have prognostic value. We propose a severity score based on the initial radiographic presentation. We tested five radiographic criteria to determine their correlation with the final outcome (function, radiographic aspect, subjective assessment).

Material and methods: The study series included 86 patients (91 wrist fractures) hospitalised between January 1998 and March 2000. The initial radiological severity score (IRSS) was noted on a scale of 20 points (five items): comminution (extent, aspect, localisation), cancellous impaction (metaphyseal, epiphyseal, both), ulnar fractures (localisation), severe fracture deviation, carpal and ligamentary injury. Each item was scored 0 to 4. Higher IRSS indicated a more severe fracture. Initial radiograms with or without traction were analysed carefully. Intra- and inter-observer reliability was proven. To evaluate the prognostic significance of the IRSS, the final outcome was scored using four items: motion (palmar and dorsal flexion, radial and ulnar inclination, pronosupination), final radiogram (frontal and sagittal tilt, index of deviation), subjective outcome (very good, good, fair, poor), osteoarthritis (one or two facets involved). The outcome score was noted on a 20 point scale (higher score indicating poorer outcome).

Results: We found a statistically significant relationship between the IRSS and the final outcome score.

Discussion: Precise analysis demonstrated other significant correlations with the IRSS: skin opening and occupational accident were generally related with poor initial scores. There was no statistically significant relationship with age, gender, high or low-energy trauma, associated upper limb damage, multiple injury, osteoporosis or reflex dystrophy. The final outcome was statistically and logically related with age, osteoporosis, open fractures, but also with reflex dystrophy and degree of secondary displacement.

Conclusion: This study validated the prognostic severity score of fractures of the lower extremity of the radius. The IRSS can be determined solely from the initial radiograms with or without traction. This score should be useful to modulate aggressive treatment as a function of the patient’s age and functional demands.