Purpose of the study: The difficulty of achieving successful reconstruction after tissue loss involving the lower third of the leg, particularly the malleolar region in septic cases, is well known. We report our experience with sequential surgery to treat open fractures of the lower leg and examine the contribution of the distally-based neurocutaneous sural flap.

Material and methods: The following protocol was used for the treatment of tissue defects involving the lower third of the leg and the ankle in 16 patients: repeated wound debridement, change in fixation system for 13 cases, rapid cover of the posterior segment of the leg with an island-dissected distally based neurocutaneous sural flap. Ten nonunions were treated later with a bone graft. Mean age in this series of 14 men and 2 women was 34 years (range 21–70 years). Thirteen patients were secondary hospitalization patients. The Gustilo classification after debridement was class IIIb. Time to cover ranged from one to eight months.

Results: Healing was achieved in three weeks. For three cases, revision was necessary due to re-activation of an infectious focus. All fractures healed (with tibiotalar fusion in two cases).

Discussion: The distally-based pediculated neurocutaneous sural flap is an interesting alternative to microanastomosis flaps for reconstruction of tissue defects of the lower third of the leg. Harvested from the posterior aspect of the calf which is generally spared, this flap must be carefully planned since there is no potential for augmenting the covering capacity. Great care must be taken to protect the pedicle; in our experience tunnelisation must be avoided. This flap also allows cover of a sterile osteosynthesis plate and resists local infection well. It can be raised easily if a bone graft is later necessary. In trauma victims, the esthetic and sensorial prejudice can be considered minor.

Conclusion: The distally-based neurocutaneous sural flap greatly contributes to our strategy for the management of tissue defects involving the lower third of the leg. Its main limitation is its size which can rarely exceed 80 cm2 in our experience.

Purpose: Total hip arthroplasty after failure of femoral osteotomy raises high risk of complications. Outcome has been controversial. The purpose of this retrospective analysis was to evaluate the difficulties and results.

Material and methods: Between March 1974 and January 1995, 68 patients (82 hips), 51 women and 17 men, mean age 59±11.5 years (32–84) underwent surgery. Initial indications were mainly acetabular and/or femoral dysplasia (n=47 hips) or congenital dislocation (n=21 hips). Mean time between osteotomy and arthroplasty was 13.8±8.4 years (10 months-45 years). We used cemented titanium femoral stems (Ceraver Ostal) with an alumina (n=66) or polyethylene (n=16) cup. An alumina-alumina bearing was used in 67 hips (81%). Functional outcome was assessed with the Postel-Merle-d’Aubligné score. Radiological analysis searched for lucent lines and signs of wear. The actuarial survival was determined.

Results: One patient (1 hip) was lost to follow-up. Thirteen patients (14 hips) died of intercurrent causes. Six hips required revision for aseptic loosening (isolated cup loosening in five and bipolar loosening in one) at 8.5 years on average (4.5–12). There were 22 intraoperative complications (27%) including 18 fractures or femoral stem misalignments and four cases of damage to the acetabular fundus. Other complications included one postoperative dislocation, two sciatic nerve palsies with partial recovery, and one non-union of the greater trochanter. There were no infections. At maximum follow-up (11.8±4.7 years, ragne 5.4–20), the mean functional score was 16.5 (15–18) versus 9.9 (6–14) preoperatively (p< 0.05). There were no femoral lucent lines. A complete lucent line around the cup was observed in eleven hips including six with a massive cemented alumina cup. Considering revision for aseptic loosening as failure, cumulative survival at 12 years was 82% (95%IC 67–96%) for the cup and 98% (92–99.7%) for the femoral stem.

Discussion: These results confirm the high risk of intraoperative complications of total hip arthroplasty performed for failure of femoral osteotomy. Architectural changes expose these patients to technical problems. The survival of the implants appears to be relatively unaffected by the prior procedure but the functional results are slightly less satisfactory then for primary arthroplasties.

Purpose: The aim of this study was to evaluate quality-of-life (QoL) in patients undergoing bilateral hip arthroplasty implanted during the same operation.

Material and methods: Sixty-one patients (28 women and 33 men) underwent surgery between November 1989 and February 2002. Average age was 42±14 years (13–76). Indications were primary osteoarthritis (n=24), secondary osteoarthritis (n=31), aseptic osteonecrosis (n=25) and rheumatoid disease (n=6). The implants (Ceraver Osteal) were cemented (50 stems, 11 cups) or coated with hydroxyapatite (72 stems, 11 cups). An alumina-alumina bearing was used in all cases. The Postel-Merle-d’Aubigné score was noted to assess function. QoL was measured prospectively in 27 patients using the SF-36 and the WOMAC, preoperatively and every three months.

Results: None of the patients were lost to follow-up. Complications included two intraoperative femoral fractures treated by cerclage, one early dislocation, three thromboemoblic events (including one case of pulmonary embolism). Unipolar revision was required for one hip due to aseptic acetabular loosening at 6.5 years. Surgical cleansing was performed in one other hip for infection. Intraoperative blood loss was 1529±451 ml (540–2550). Mean hospital stay was 13±2.5 days (8–22). At mean follow-up of 49±33 months (12–162), the mean function score was 17.8±0.5 (16–18) versus 10±2.7 (3–14) preoperatively (p< 0.05). Clinical outcome was good or excellent in 98% of the hips. There were no radiological signs of wear. A complete lucent line developed around one cup. The quality of life scores improved significantly (p< 0.01) as soon as three months postoperatively for the items ‘social activity’, ‘physical activity’ and ‘pain’, particularly in men p< 0.05).

Discussion: Bilateral hip arthroplasty during the same operative time is not advocated by all authors. It is a difficult surgical situation requiring rigor and skill. The drawbacks include longer operative time, greater blood loss, and in some patients, higher morbidity. This approach however enables treating bilateral disease in one operation, particularly in younger subjects. Use of an alumina-alumina bearing and non-cemented implants is particularly indicated. The results of this series validate the efficacy of this technique which allows rapid improvement in the patients’ quality-of-life.

Purpose: Classical instrument sets for implantation of total knee arthroplasty (TKA) can be perfected. Computer-assisted implantation appears to offer improved technical quality. The purpose of this study was to compare a matched series of TKA implanted with the conventional method and with a computer-assisted navigation system.

Material and methods: Seventy-eight prostheses implanted with a computer-assisted system based on 3D CT-scan reconstruction of the lower limb were matched with 78 prostheses implanted by a highly-trained operator. The knees were matched for gender, aetiology, surgical approach, and axial deviation. There were no significant differences between the groups for these variables. An intramedullary aiming device was used for knees undergoing the conventional procedure. Navitrack(r) was used for the computer-assisted implantations. The same prosthetic system (Wallaby) was used for both series. An independent operator assessed the double-foot stance gonometries. The femorotibial axis was measured as was the individual position of the tibial and femoral pieces.

Results: Axis was within 3° varus and 3° valgus for 92% of the knees operated on with the navigation system. This same range was found for 59% of the conventional procedures. The difference was significant (p< 0.0001). Analysis of the individual femoral and tibial components did not demonstrate any significant difference.

Discussion: Results of TKA are dependent in part on operative technique. The objective is generally achieved with the computer-assisted technique but is not with the conventional technique. Navigation could be useful to achieve successfully short-term objectives. Its contribution to mid-term outcome remains to be demonstrated.