Purpose of the study: Several series have been reported on arthroscopic treatment of anterior instability. Few authors have focused on patient outcome after recurrent instability following arthroscopic stabilisation. Did these patients undergo revision surgery? What proportion? What were the results of secondary surgical coracoids block?

Material and methods: This was a retrospective analysis of 53 failures after arthroscopic stabilisation collected among a cohort of 182 patients who underwent surgery in our institution between 1988 and 2006. At last follow-up, shoulder function was noted using the Walch-Duplay score. The degree of joint degenerative disease was noted on the radiographs using the Samilson classification.

Results: Mean time to recurrence after arthroscopic stabilisation was 21 months (range 3–114). Patients were reviewed at mean 68 months. Twenty-four patients (45%° had not had revision surgery: 17 (32%) had declined a new operation and 7 (13%) had a unique episode of instability. Twenty-nine patients (55%) had revision surgery: 27 underwent an open procedure in our institution for a coracoids block. The revision was performed in another institution for two patients who were excluded from the analysis. Mean time between the two operations was 29 months. At last follow-up, 89% of the reoperated patients were satisfied. The mean Walch-Duplay score was 83.6/100 (activity=18.5; stability=15.9; pain=23.9; mobility=24.2). The Duplay score was 100 for 48% of the reoperated patients; 41% had persistent apprehension. Three patients (11%) developed recurrent dislocation at a mean 23 months (19–29). Among the 53 patients included in the study, 26% had moderate osteoarthritic lesions (Samilson 1 or 2). The reoperated patients were free of such lesions. Hyperlaxity, age, and sport practiced did not have any impact on surgical revision.

Discussion: In this overall series of 53 patients, 20 (37%) retained an unstable shoulder. Among them, 17 had declined new surgery. Eleven percent of the reoperated patients developed subsequent recurrence. This rate is higher than after first-intention blocks. Published series of arthroscopic revisions reported a higher recurrence rate (Kim, Arthroscopy 2002: 21 % recurrence; Neri, JSES 2007: 27 % recurrence).

Conclusion: The Latarjet block is the treatment of choice after failure of arthroscopic stabilisation, despite a high recurrence rate.

Purpose of the study: There are several goals for the treatment of septic nonunion of the leg: control the infection, achieve healing, preserve function. The purpose of this work was to report the results obtained with a two-phase technique using a cement spacer.

Material and method: From 1994 to 2007, 27 patients were treated for a septic nonunion of the tibia (19 proven, 8 suspected). There were 22 women and 5 men, mean age 39 years (range 16–66). The first phase of the surgical technique involved “cancerological” cleaning and insertion of an antibiotic cement spacer. Osteosynthesis was performed if necessary. Antibiotics were adapted to sample results. The second phase involved an autologous bone graft with osteosynthesis after biological markers had returned to normal and an antibiotic window. Antibiotics were then discontinued if samples were negative. Patients were reviewed with physical examination, radiology, and laboratory tests at one year.

Results: Mean follow-up was 4 years (range 1–11). At the first phase, mean bone defect after cleaning was 5 cm (range 3–8); osteosynthesis procedures were required for 22 patients (81.5%), mainly with plate fixation. Mean time to the second phase was 4 months (range 1.5–22). At the second phase, bone loss was filled with isolated bone fragments (44%) or associated with a tricortical graft (52%) or a plate nail combination (37%). Bacteriological samples were negative for 25 patients after the second phase. Six patients required surgical revision for recurrent aseptic non-union (22%).

Discussion: All patients healed at mean one year with a tolerable misalignment in 37%. At last follow-up there were no cases of infection. Nineteen patients had residual stiffness of the ankle or knee but 80% had resumed their sports activities and 85% their occupational activities.

Conclusion: A two-phase surgical treatment of septic non-union of the leg is effective. We were able o achieve cure of the infection in all patients with per primam healing in 78% in addition to an acceptable functional outcome. The spacer offers the advantage of preparing a bed for the graft and preserving autonomy between the two phases.

Purpose of the study: The PFM-R (Zimmer) prosthesis is a straight modular stem made of sanded titanium designed to favour spontaneous bone reconstruction. The purpose of this work was to analyse the clinical and radiographic results of this implant.

Material and methods: This was a consecutive prospective series of 154 patients who underwent surgery from 1998 to 2007 (15 first-intention prostheses and 139 revisions for severe loosening [Paprosky stages 3 and 4]). Revision included a clinical evaluation (PMA score) and radiographic assessment (migration, bone regeneration, stress shielding, osteointegration, Le Béguec score) as well as a survival analysis.

Results: At mean 4.6 years follow-up (1–10 years), three patients had died, two were lost to follow-up and 18 implants were removed, 11 for infection, six for migration and one for defective technique. The PMA score improved from 8 (0–16) to 15.8 (5–18). Mean pivot impaction was 4 mm (0–50), statistically dependent on initial bone stock, form of the isthma, the corticomedullary index in the implantation zone, length of anchor, and time to weight bearing, but not femorotomy nor zone of primary stability. Bone stock was good in 73% at poor in 27% (15 stress shielding, nine infectious osteolysis, 16 absence of bone regeneration). Stress shielding was related to length and diameter of the implanted pivot (p< 0.05). Bone regrowth was statistically dependent on the number of prior operations, type of stem explanted (cemented), initial bone stock, form of the isthma and quality of the surgical reconstruction. The implant was osteointegrated in 128 cases (86%). The analysis of the prosthetic anchoring showed that primary stability was mainly diaphyseal (90%) then secondarily global (83%). Osteointegration depended statistically on the number of prior operations, initial bone stock, form of the isthma and bone regrowth, but not femorotomy. The overall Le Béquec score reached 14.7 (2–20) at last follow-up.

Discussion: The PFM-R enabled bone regeneration and osteointegration in the majority of patients. The quality of the femoral reconstruction around the implant appears to be fundamental. Massive stems should be avoided as they lead to stress shielding. The limits for use of this implant are osteopenia and absence of an isthma.

Introduction: Treatment of acetabular defects can be difficult, especially in case of roof destruction. Since 9 years, we use a variant of Paprosky’s technique which consists in rebuilding the roof by structural allograft and acetabular reinforcement ring. The purpose of this study is to present this technique and the follow up results.

Patients: This retrospective study concerns 21 patients (23 hips) with severe acetabular bone loss (8 cases of stage 2 and 15 cases of stage 3 of Paprosky): 4 septical and 19 aseptical loosening. Between 1998 and 2005, all patients were operated with the same surgical technique using an allogeneic structural allograft (femoral head or distal femur) and an acetabular reinforcement ring (20 of KERBOULL, 3 of GANZ) associated with a cemented PE cup.

Method: Review included a clinical and X-ray evaluation (analysis of the refocusing of the hip, the positioning and the stability of implants and the graft incorporation).

Results: Mean duration of follow-up is 3,5 years [1–8,3]. Preoperative PMA score rised from 6,6 [0–12] to 15,8 [12–18] in postoperative. There was no peroperative complication. After surgery, 2 cases of early hip dislocation required PE block; 2 cases of sepsis were treated, one by washing and one by a surgical revision. In 60% of cases, immediate total weight bearing was allowed.

The immediate postoperative X-rays showed that the rotation center of the hip was 5,2 mm [0–10] far from the ideal rotation center (26% of cases: 0 mm) and the PE cup was implanted with a lateral inclination of 42,5° [30–55]. In postoperative X-ray follow up, one case of acetabular aseptic loosening was found which didn’t need hip revision. In all other cases no modification of implants position neither of hip rotation center was noted. In 79% of cases, we had total graft incorporation; in 17% of cases, an non evolutive radiolucent area between graft and bone and in 4% of cases (loosening) a graft migration.

Conclusion: The use of a structural allograft combined with acetabular reinforcement ring allows hip reconstruction in severe acetabular bone loss with good medium term results.

Purpose of the study: Static metatarsalgia is a common complaint in podology surgery. Most cases are related to the great toe, but in certain cases, isolated metatarsal disharmony, without hallux vlgus, can be observed. We report 45 such cases.

Material and methods: This was a retrospective analysis of isolated metatarsal disharmony observed in patients who underwent metatarsal surgery between 1986 and 2003. There were 36 women and 9 men, mean age 49 years. Three subgroups were distinguished: posttraumatic disharmony, isolated disharmony of the second ray, iatrogenic disharmony. Conditions related to rheumatoid disease, aseptic osteonecrosis of the metatarsal heads, and rear foot disorders were excluded. Surgical treatment was osteotomy of the base of the metatarsal for 24 patients, and Weil’s osteotomy for 21. Clinical and radiological assessment used the Kitaoko and Maestro criteria.

Results: Mean preoperative score was 38 (range 21–58). Mean gain one year after osteotomy was 35 points. The score was 76 after osteotomy of the metatarsal base and 79 after Weil osteotomy. The less favorable results were observed in the group of posttraumatic metatarsalgias. Outcom was less satisfactory in the male population where residual metatarsalgia was noted in 75%. Reflex dystrophy occurred in 15% of the patients who had multiple osteotomies. Radiographically, The SM4 line was centered with progressive geometry in 50%.

Discussion: While the short-term results obtained with these two surgical methods were similar, osteotomy of the metatarsal base offers better long-term outcome. The osteotomy improved the functional score, even without improvement of radiological criteria. Initial treatment of metatarsal fractures should attempt to restore correct alignment of the metatarsals because of the poor results obtained with corrective osteotomy for posttraumatic misalignment.

Conclusion: When metatarsal disharmony is symptomatic, we propose osteotomy of the base of the metatarsals for the median rays in order to avoid transfer metatarsalgia. Complementary osteotomy of the fifth metatarsal is not always necessary.