Mechanical failure in total hip arthroplasty is usually due to aseptic loosening related to wear particles as seen with polyethylene bearing. Alumina has been proposed for avoiding wear problems. In vitro and mid-term clinical studies showed tribological advantages but early acetabular fixation issues. Since alumina on alumina bearing is currently used with new fixation techniques, updated evaluations of the ancient series are informative regarding the long-term tolerance of alumina in vivo. In this paper, we investigated 104 consecutive lumina on alumina cemented total hip arthroplasties (CER-VAER-OSTEAL, Roissy, France) implanted 20 years ago in 81 patients (from 1979 to 1983). Alumina femoral head was 32 mm in diameter. Alumina acetabular socket and titanium femoral stem were cemented. The clinical evaluation used Postel Merle d’Aubigné score. Radiological wear and appearance of osteolysis or loosening were noted for establishing actuarial curves. When accessible, histological samples from revision procedures were analyzed. Six infected cases were not taken into account later. The average follow-up was 11 years, reaching 18 years in 38 cases. Twenty-three hip were revised for changing 23 acetabular sockets, 12 femoral heads, and 1 femoral stem. We noted 1 femoral head fracture, 24 definite ace-tabular loosenings, 12 probable acetabular loosenings, and 3 definite femoral loosenings. Radiological acetabular osteolysis was present in 4 cases, always limited to De Lee zone 1, and associated with loosening. Radiological wear was below eye detection. Peri-prosthetic tissue showed non-specific histological reaction to cement particles. Survival rate at 20 years was 61.4% in term of revision (57.1% and 95.2% concerning acetabular and femoral defininte loosening). Beside the high rate of cemented fixation failure of the socket, loosened and non loosend cases showed an excellent tolerance of alumina on alumina bearing in the long-term, with minimal wear and osteolysis. This may also have protected the femoral component from complications.
The variation between the postoperative and last follow-up goniometry data exhibited a statistical correlation with the tibiofemoral index (p = 0.0005). If the index was less than 13°, most of the knees showed an increase in valgus (13 out of 19 knees); if valgus was greater than or equal to 13°, valgus was lost (for 12 of 19 knees).
Leakage after simple suture repair of rotator cuff tears depends on the overall preoperative fatty degeneration index (FDI) of the muscles and preoperative fatty degeneration (FD) of the infraspinatus. When the FDI is = 2, cuff leakage is always observed after repair. The risk of recurrent tears of the supraspinus is high if the FD of the infraspinatus is >
1. However if the FDI is very low or nil, the rate of recurrent tears is 15%. These tears can be explained by tension on sutures in macroscopically and histologically abnormal tendons.
Conclusion: Despite the almost constant need for plasty, rotator cuff repair using sutures without tension after resection of macroscopically abnormal tendon stumps gives, for an equivalent preoperative degree of fatty degeneration and an equivalent number of tendon repairs, better anatomic results than simple suture.
Between January 1988 and January 1991 we performed 100 consecutive cemented total hip replacements using a zirconia head, a titanium alloy stem and a polyethylene cup. We reviewed 78 of these hips in 61 patients in detail at a mean of 5.8 years (1 to 9). Aseptic loosening was seen in 11 hips (14%). Eight needed revision. In total, 37 cups (47.5%) showed radiolucent lines, all at the cement-bone interface, with 18 (23%) involving all the interface. Of the 78 femoral implants, 17 (21.7%) showed radiolucent lines, and two, which had a complete line of more than 1 mm thick, definite endocortical osteolyses. There was also an abnormally high incidence of osteolysis of more than 2 mm at the calcar. Survivorship analysis showed that only 63% were in situ at eight years. These worrying results led us to abandon the use of zirconia heads, since at the same hospital, using the same femoral stem, cement and polyethylene cup, but with alumina femoral heads, the survival rate was 93% at nine years. We discuss the possible reasons for the poor performance of zirconia ceramic.
A 65-year-old man presented with a painful hip five years after a cemented replacement. Histological examination of a biopsy taken from tissue surrounding the femoral implant showed infiltration of a squamous-cell carcinoma. Further investigation revealed a primary growth in the left lung. This rare example of a metastasis in relation to a joint replacement illustrates the necessity for histological examination of the tissue adjacent to a loose prosthesis.
We performed a prospective study on 96 patients with extra-articular or intra-articular fractures of the distal radius with a dorsally displaced posteromedial fragment. After closed reduction, we compared trans-styloid fixation and immobilisation with Kapandji fixation and early mobilisation. Forty-two patients of mean age 57.1 years +/- 18.1 (SD) were treated by trans-styloid K-wire fixation and 45 days of short-arm cast immobilisation. Fifty-four patients of mean age 57.7 years +/- 18.7 (SD) had Kapandji fixation and immediate mobilisation according to the originator. All the patients had clinical and radiological review at about six weeks and at 3, 6, 12 and 24 months after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, radial tilt, ulnar variance, and radial shortening were assessed radiologically. Statistical analysis was applied to comparisons with the normal opposite wrist. Pain and reflex sympathetic dystrophy were more frequent after Kapandji fixation and early mobilisation, but the range of motion was better although this became statistically insignificant after six weeks. The radiological reduction was better soon after Kapandji fixation, but there was some loss of reduction and increased radial shortening during the first three postoperative months. The clinical result at two years was similar in both groups.
From 1984 to 1988 we implanted 127 massive allografts irradiated with a dose of 25,000 grays. These were reviewed at a minimum follow-up of three years to determine the effect of irradiation on infection, the complications and the functional result. No bacteriological infection was seen in the 44 patients who had allografts for revision of joint arthroplasty or for a tumour with no adjuvant therapy. For the 83 patients who also had chemotherapy or radiotherapy or both for a bone tumour, the rate of infection was 13%. The major mechanical complications were nonunion in seven grafts (5.5%) and fracture in eight (6%). These rates do not differ greatly from those reported for non-irradiated grafts. Our results suggest that irradiation, which remains the most convenient and acceptable method of sterilisation, does not jeopardize the clinical results.
We investigated the possible use of acrylic cement containing chemotherapeutic drugs in the treatment of malignant lesions in bone. The diffusion of methotrexate (MTX) from methylpolymethacrylate implants was studied in vitro: polymerisation of the cement did not destroy the drug; liberation began immediately and about 10% was released by 18 hours. Some release continued for as long as six months. In vivo experiments on rats with induced osteosarcoma showed that MTX in cement had both local and general effects which were dependent on the dosage. A series of 17 large dogs with spontaneous osteosarcoma were then treated by local resection and cement containing MTX. General chemotherapeutic effects were detectable from 2 hours to 5 days, survival was increased and local recurrence was reduced, but there were four cases of delayed wound healing. Preliminary studies in human patients confirm the possibility that this method of local chemotherapy could be a useful addition to the treatment of malignant tumours of bone.