Advertisement for orthosearch.org.uk
Orthopaedic Proceedings Logo

Receive monthly Table of Contents alerts from Orthopaedic Proceedings

Comprehensive article alerts can be set up and managed through your account settings

View my account settings

Visit Orthopaedic Proceedings at:

Loading...

Loading...

Volume 86-B, Issue SUPP_I January 2004

D.D. D’Lima

Osseointegration has been shown to be directly affected by surface roughness and bioactive coatings. This report compares bone response to hydroxyapatite coatings on differing substrate treatments.

Titanium cylinders was implanted bilaterally in the distal femora of 30 rabbits. One of three surface treatments was applied to each implant: plasma sprayed titanium surface without hydroxyapatite coating (P), plasma sprayed titanium surface with hydroxyapatite coating (PHA), and acid-etched surface with hydroxyapatite coating (CHA). Osseointegration was measured at 6 and 12 weeks, by histomorphometry of scanning electron microscopy images of histologic sections taken through the implant at three levels: diaphysis, metaphysis, and intermediate. Bone growth was measured up to 3 mm from the edge of the implant to determine changes in patterns of bone growth.

Overall, bone response was greatest in the diaphyseal sections. Mean osseointegration was significantly different between hydroxyapatite coated and non-hydroxyapatite coated implants (CHA: 74+10%, PHA: 65+12%, and P: 39+10%, p< 0.01). Both hydroxyapatite coated implants demonstrated increased bone growth closer to the implant which dropped off with increasing distance from the implant. Lower and relatively unchanging levels of bone growth were seen in non-hydroxyapatite coated implants.

Osseointegration and bone growth was higher in both hydroxyapatite coated surfaces confirming previous reports. The differences in substrates (acid etched vs. plasma sprayed titanium) did not yield a significant difference in bone growth, suggesting that the hydroxyapatite coating provided a much larger benefit. This study supports the hypothesis that enhanced osseointegration is primarily due to the bioactive coating.


W.L. Bargar T.J. Blumenfeld J.K. Taylor

A common finding in acetabular revisions is loss of medial bone stock. Using a standard cementless hemispherical component, alternatives for reconstruction include medialisation of the cup, medial particulate allograft with rim fixation on host bone, or use of a “mega-cup”. A cementless shell that has 6 mm of lateral augmentation is useful in restoring the joint centre while at the same time achieving implant stability and increasing host bone contact without loss of additional bone.

From 1991 to 2000, a total of 142 acetabular revisions were performed with the Arthropor TM DP+6 implant (Joint Medical Products/J& J/DePuy). These patients have been prospectively followed bi-annually with Harris Hip Scores and monitoring of complications and radiographic findings. Average follow-up is 5 years (range 2 to 11 years).

Implant survivorship is 100%. There have been seven re-operations: one for infection (debrided), two for femoral revision and four head/liner changes for recurrent dislocations. Dislocation incidence is 7.8%. The average Total Harris Score at 5 years is 74.3, with an average Harris Pain Score of 34.9 (out of a maximum of 44). Radiographic analysis showed frequent zone 3 radiolucent zones. Initial migration of > 2 mm with subsequent stabilisation occurred in 18%. The joint centre was restored to within 5 mm of the contralateral hip in 85% of cases.

We have found this type of implant to be efficacious in the more common acetabular revisions where the loss of bone stock is mainly medial/cavitary, with an intact posterior column and small medial segmental defects.


C.J. Wilson G. Tait

In this study we intend to evaluate the outcomes for patients with the Rotaglide mobile meniscal knee prosthesis implanted for osteoarthritis. All patients reviewed had this prosthesis implanted as a primary total knee arthroplasty in Crosshouse hospital.

The minimum follow up period was 5 years (range 5 to 8.2). Patients were assessed clinically by the junior author (CW) and the results were standardised using the Hospital for Specialist Surgery (HSS) knee score. Standard radiographs were taken in AP and lateral planes to assess for loosening using the Knee Society roentgenographic system. Case notes were then examined for evidence of complications in the peri and postoperative complications.

Sixty-five patients (71 knees) were reviewed. There was an excellent clinical outcome with HSS scores of 85 in 97.1% of patients. Two knees (2.9%) were revised, one for meniscal fracture and one for meniscal dislocation. Both these patients also attended for review and were making good progress. Both of these failures occurred early in our series and in a total of 312 knees to date there have been no other meniscal failures. No knees were revised for aseptic loosening and there have been no deep infections.

We feel this prosthesis offers a safe and effective treatment for osteoarthritis with a good clinical outcome at 5 years with a low level of complications.


W.L. Bargar

Genetic defects causing dwarfism occur in approximately 1 in 10 000 live births. There are over 200 types. Another frequent cause of short stature is juvenile rheumatoid arthritis. Most types of dwarfism result in arthrosis of major joints resulting in significant disability. Hip replacement can offer significant improvement in quality of life, but there are inherent difficulties due to size and anatomic variations.

Short stature of less than 4 feet 10 inches was defined as dwarfism. Eight patients meeting this criterion underwent either primary or revision total hip replacement, with six being bilateral, resulting in a total of 14 hips for study (six primaries and eight revisions). The diagnoses were: two JRA, two Mucolipdosis III, one Dyastrophic Dwarfism, one Spondyloepiphyseal Dysplasia, one Thalasemia, and one Congenital Rickets. In eight hips a CT-based custom cementless femoral component was used. Average follow-up was nine years (2 – 14).

The average Total Harris Hip Score improved from 35 pre-operatively to 66 at last follow-up, with the average Harris Pain Score increasing from 10 to 31 (out of a maximum of 44). Of the six primary hips, two hips in the same patient have been revised for combined acetabular and femoral loosening. Of the eight revision hips, there have been three re-operations: one re-revised for acetabular loosening, one re-revised for late hematogenous infection and one head/liner change for recurrent dislocations.

Hip replacement in dwarfs presents a complex technical challenge, but can result in significant improvement in pain, function and quality of life. CT-base custom femoral components are recommended.


S. Tarabichi

Patients with advanced osteoarthritis tend to have limited range of motion; the purpose of this in vivo anatomical study is to identify the anatomical structures responsible for limited knee movement in patients with osteoarthritis.

Forty-two quadriceps releases were performed in patients who had TKA. The releases were carried out utilising subvastus approach and just before proceeding with the knee replacement surgery. The ranges of motion were documented before and after the release using digital photography and lateral portable X-ray. No bony resection was done, and no ligament release was performed. Quadriceps excursion was also studied under fluoroscopy in six volunteers throughout the range of movement.

The quadriceps release improved the range of motion in all patients; at least 135 degrees of flexion were obtained. The improvements were more dramatic in patients who had previous surgeries. The average of improvement in knee flexion after the release was 36 degrees. The presence of osteophytes or gross deformity did not influence the degree of improvement. The fluoroscopy study has shown that the average excursion of quadriceps muscle from 0 to 145 degrees is 7 cm. The excursion per degree varies throughout the range of motion; it is more per degree near full flexion and extension than around 90 degrees of flexion.

The limited excursion of the quadriceps muscle is the main limiting factor to full knee flexion. Other pathological changes such as osteophytes, surface pathology, posterior capsule and the cruciate ligaments play very limited roles.


B.M. Jolles P. Genoud P. Hoffmeyer

The aim of the study was to determine the precision of conventional versus computer-assisted techniques for positioning the acetabular component in total hip arthroplasty (THA).

Malposition of the acetabular component during THA increases the occurrence of impingement, reduces range of motion, and increases the risk of dislocation and long-term wear. To prevent malpositioned hip implants, an increasing number of computer assisted surgery systems have been described, but their accuracy is not well established.

Using a lateral approach, 150 cups were placed by 10 different surgeons in 10 identical plastic pelvis models. Only the immediate operating field was visible. Pre-operative planning was performed with a computerised tomography scan. Fifty cups were placed free hand, 50 others with the standard cup positioner, and the remaining 50 cups using computer-assisted orthopaedic surgery (Medivision). The accuracy of cup abduction and anteversion was assessed with an electromagnetic system (Fastrak™).

Using conventional techniques, free hand placement revealed a mean precision of cup anteversion and abduction of 10° [range 5.5 to 14] and 3.5° [2.5 to 5] respectively. With the cup positioner, these angles measured 8° [5 to 10.5] and 4° [3 to 5.5] respectively, and using the computer assisted method, the mean cup anteversion precision was 1.5° [1 to 2] and mean cup abduction measured 2.5° [2 to 3.5].

Computer assisted cup placement is a very accurate and reproducible technique during THA. It is clearly more precise than either of the two traditional methods of cup positioning, even for well-trained surgeons.


A. Mofidi

Absorbable cement restrictors have been in use over the last few years. They have been shown to be as effective as the standard non-absorbable cement restrictors in achieving cement pressurisation and stopping distal cement migration in in vitro studies. The aim of this study is to compare in vivo, the effectiveness of absorbable with non-absorbable cement restrictors.

One hundred and thirty-six consecutive patients who had total hip replacement performed using charnley cemented femoral prosthesis were selected and randomly divided in to two groups pre operatively. One group received Hardinge TM non-absorbable cement restrictor and the second group received Biostop TM absorbable cement restrictor. Type of the prosthesis, the surgical approach, the time from start of mixing of the cement to insertion of the cement (measure of viscosity of the cement), the cementing technique and the distance at which the cement restrictor was inserted were noted intraoperatively, the canal diameter was measured from the preoperative AP radiograph of the hip. The distance at which the cement restrictor was inserted was measured on the AP radiograph of the hip taken twenty-four hours postoperatively. All the above factors were statistically assessed as to their effect in the distal migration on cement restrictor using multiple regression analysis.

There was no statistical difference between the two types of cement restrictors (P= 0.44). Surgeon, Surgical approach, femoral canal diameter P> 0.2 cementing technique P> 0.1 and Cement viscosity P= 0.082 had no effect on the degree of distal migration of the cement.

In conclusion Biostop TM absorbable cement restrictor is as effective as Hardinge TM non-absorbable cement restrictor. We could not show any relationship between femoral canal diameter cementing technique and cement viscosity and distal cement migration which leads us to conclude that in the presence of adequate cement restriction these factors have little effect in distal migration of cement mantle.


T.J. Blumenfeld W.L. Bargar

Revision total hip arthroplasty, with retention of well fixed femoral and acetabular components and exchange of modular femoral heads and acetabular liners, is seeing increasing usage, primarily for the treatment of osteolysis or recurrent dislocations. The purpose of this study was to determine the dislocation rate after this procedure.

From January 1993 to December 2000, 54 patients underwent isolated head and liner exchange performed by two surgeons. These patients have been followed bi-annually with clinical and radiographic evaulation. There were 36 males and 18 females. Diagnoses at the time of revision surgery were recurrent dislocations in 27 and osteolysis in 27.

The overall dislocation rate was 11% (6/54). In the 49 non-constrained revisions, a 28 mm diameter femoral head was used in 27 and a 32 mm head in 22. At the time of revision, 60% of the femoral heads were lengthened, 40% were increased in diameter, and 25% were increased in both dimensions. Hooded or later-alised liners were used in 55% of the revisions. Operative stability was documented in all operative notes, and in 85% Ranawat’s sign was used to determine liner placement based on relative component version. The dislocation rate in the non-constrained revisions was 8% (4/49). Two out of five constrained revisions, performed for recurrent dislocations, subsequently dislocated. In this study isolated head and liner revision had a comparable dislocation rate to full revision total hip arthroplasty.


M.T. Manley R.M. Streicher

Fluid pressure generated in the hip during activity has been implicated in component loosening. Animal studies show both the adverse effect of direct pressure on osteocytes and the resorption of bone subjected to cyclic loads. Pressure fluctuation measured in contained pelvic osteolytic lesions during manipulation of the hip at revision surgery suggests cyclic pressure may have a direct effect on bone resorption leading to pelvic osteolysis.

To determine the cause of pressure fluctuation in pelvic structures supporting a hip implant, we conducted an experimental and numerical analysis of relative motion at modular interfaces of acetabular cups as load was applied and removed.

We showed that for polyethylene bearing inserts supported primarily at the rim, the application of cyclic load caused cyclic motion between the insert and the inside surface of the acetabular shell. In a fluid environment, this motion can generate cyclic pressure pulses that may be applied to bone directly through the holes in the shell provided for screw fixation.

We conclude that motion at modular interfaces of acetabular components may contribute to pelvic osteolysis. Our hypothesis is that the motion of a bearing liner under cyclic load can produce fluctuating pressure pulses that are applied to bone directly through screw holes. In addition, the pulses may aid the transport of polyethylene wear debris particles into fixation interfaces. It is possible that lytic lesions previously associated with backside wear of the liner may be related to pumping of joint fluid by the liner.


P.J. Singh R.E. Field

We report a three year Medical Devices Agency and Local Ethical Committee approved prospective study for a new tri-tapered polished cannulated cemented femoral component. Our stem was implanted in 53 primary total hip replacements. Eleven male patients (11 hips) and 39 female patients (39 hips). The mean age at surgery was 73 (range 65 to 84). The mean weight was 71.76 kg (range 49.3 kg to 94.6 kg) with a mean BMI of 28 (range 20.20 to 40.26). All patients had a pre operative diagnosis of osteoarthritis. All the hips were implanted via the anterolateral approach. Twenty-six (51%) hips were implanted by a single consultant and 24 (49%) were implanted by six different registrars. Pre-operative and sequential post-operative clinical and radiological evaluations were undertaken.

The mean pre-operative Oxford hip score was 47 points.which declined 19 points at three years. Radiological analysis, using the Johnston criteria, did not reveal any untoward features. Prosthetic stem migration was measured using a technique developed in our unit and validated as accurate to 0.61 mm; as previously reported. Stem migration measured averaged 1.38 mm (n=52; sd ±1.38) 6 months post implantation. This progressed to 1.71 mm (n=50; SD=1.18) at one year; 1.61mm (n=48; sd ±1.17) at 2 years. and 1.55 mm (n=28; SD 1.13). At 3 years average stem migration for hips implanted by the registrar group and the consultant group was not sig-nificantly different (p=0.2048) and the migration curve, against time was similar for both groups.

Our study has demonstrated initial component migration, comparable to that of other polished tapered cemented stem designs. The improvement in Oxford hip score parallels other reported series and no adverse radiological signs have been observed. Long-term surveillance of our cohort will provide further data to compare the new design with substantial equivalents. More sophisticated studies, such as RSA analysis would provide further data on early femoral component migration.


T. Sato H. Umeda H. Terashima N. Ono

Prevention of joint dislocation after total hip arthroplasty (THA) is important to keep suitable relationships between surgeons and patients. Capsule has an essential role for stability of joint, especially in hip. Reserving a part of capsule in THA can increase stability. We examined the effect of partial capsulotomy in hip joint for prevention of dislocations after THA.

In 178 primary THA for osteoarthritis, partial capsulotomy were performed in 92 cases and generous capsulectomy in 86 cases from 1993 to 2001. Age, gender, pre-operative complications of both groups were matched. All THA were performed from a posterior approach, and in case of partial capsulotomy, anterior one third of hip joint capsule was reserved before placing acetabular component. Posterior capsulorrhaphy was not performed.

No hip dislocations have been seen in partial capsulotomy cases, and four posterior dislocations following THA were observed in general capsulectomy cases during one to nine year follow up.

Soft tissue imbalance of THA is most at risk for dislocation. The present study showed a satisfying result of partial capsulotomy for prevention of THA dislocation. Residual hip joint capsule can increase joint stability and can resist to dislocation after THA in osteoarthritis.


N. Takahira K. Uchiyama H. Minehara J. Aikawa H. Ohtsuka S. Takasaki T. Ohkawa M. Itoman

The aim of this study is to compare the clinical results of the Pin-Sleeve System (AI Wiring System; AIWS) with the Dall-Miles Cable Grip System (DMCGS) for reattachment after dissection of the greater trochanter in hip arthroplasty.

The DMCGS was used in 33 cases 35 hips from 1994 to 1998 and AIWS in 40 cases 42 hips from 1998 to 2001. The age at operation was 61.3 years (24 to 85 years) in the DMCGS group and 67 years (24 to 86 years) in the AIWS group. The postoperative follow-up period was 24 months (4 months to 54 months) in the DMCGS group and 30 months (11 months to 42 months) in the AIWS group.

Bone union failure of the great trochanter occurred in the DMCGS group eight hips (22.9%) and AIWS group five hips (11.9%). The DMCGS group four hips (11.4%) had broken cables, while not even one case of the AIWS group had them (p< 0.05). Fragments from the cable were found in the DMCGS group seven hips (20%) and AIWS group two hips (4.8%). Bone resorption around the cable, grip or sleeve occurred in the DMCGS group 19 hips (54.3%) and AIWS group five hips (11.9%) (p< 0.05). Clinically, the DMCGS group 13 hips (37.1%) and AIWS group seven hips (16.7%) had dysphoria at the greater trochanter; the DMCGS group 17 hips (48.6%) and AIWS group eight hips (19%) had pain at the greater trochanter in the recumbent position with the affected side down (p< 0.05); the DMCGS group 13 hips (37.1%) and AIWS group six hips (14.3%) had pain on exertion.

The AIWS is considered to be a useful implant for reattachment of the greater trochanter compared with the DMCGS.


M. Kubiak-Langer F. Langlotz R. Bächler J. Richolt L.-P. Nolte F. Kerschbaumer M. E. Müller

The most common reason for possible complications after total hip replacement (THR) surgery is improper positioning of the implant components within the hip joint. Systems for computer assisted planning and navigation during THR have been developed. However, these established modules focus on the acetabular implant component only; disrespecting the fact that proper implant functioning relies upon correct placement of both components relative to each other. Therefore, we developed an extension to the existing CT-based SurgiGATE-Prosthetics system (Medivision, Oberdorf, Switzerland) for planning and placing of the acetabular component to give the surgeon a tool, which can help him/her to also plan and insert the femoral implant.

Preoperatively, the appropriate size and position as well as the orientation of both implants components were planned. Following navigated cup placement a dynamic reference base (DRB) was fixed to the thighbone and the registration procedure was executed. For the preparation of the femoral cavity a modular PPF rasp system (Biomet-Merck, Darmstadt, Germany) was developed. All surgical action was visualised graphically within the patient’s image data. In addition, the surgeon was provided with real-time information about the depth of tool insertion, antetorsion angle, varus/valgus deviation, and the postoperative change in leg length and lateralisation of the hip joint.

After extensive validation and accuracy analyses performed on plastic models the presented system was used during one operation. An extended clinical study is currently being started.

We expect that the developed application will help the surgeon to better plan the appropriate size and position of the both parts of a hip endoprosthesis and will supply intraoperative feedback of the position of the surgical instruments relative to the patients’ anatomy and to the preoperative plan. Safer and more accurate placement of the implants components during free-hand THR surgery may be expected from this technology.


A. Croce D. Brioschi S. Nella E. Borgo

The actual data about prevalence of knee osteoarthritis, the concurrent increasing of mean age and therefore the high social costs for the care of this pathology, make particularly important to do the correct choice in knee artroprosthesis. In this work we mean compare three different type of knee prostheses implanted in our institute. We have evaluated 120 patients (98 females, 22 males) treated with TKR in I° Orthopaedic Division of Istituto Ortopedico “Gaetano Pini” – Milano. All patients were affected by primary knee osteoarthritis of high degree and 3 groups were made due to the type of prosthesis implanted.

Our evaluation protocol includes: 1. Local objective examination and evaluation of Range of Motion (R.O.M.); 2. Subjective functional questionnaire (Lequesne Index modified for knee osteoarthritis); 3. Stabilometric evaluation for Proprioceptive knee structures (KAT-2000 Breg Inc. USA); 4. Standard X-Ray, both in AP and lateral planes, with patient in standing position.

The X-Ray controls showed no early mobilisations or malfitting of all implants. In consideration of the short follow-up period we have to do a continuous monitoring for at least 5 years to express a definitive evaluation of implant stability; significatively better results regarding the post-op R.O.M. and subjective results with Lequesne Index have been obtained with the use of mobile plate prosthesis.

The first results have pointed out better results in the use of a fully mobile plate prosthesis, compared with the other results using rotating and fixed plate prostheses.

In our opinion this is obtained through the research of a better reproduction of human anatomy and trying to respect the common kinematics of knee, which has to be the future objective in design and technical development of knee arthroplasty.


D.C Markel R. Klein M. Bushelow M. Kester

Rotational mal-alignment of the patella-femoral interface will result in increased wear. Highly cross-linked polyethylene will decrease wear even if mal-aligned.

A biomechanical model based on high load and flexion was used to measure wear of rotationally aligned and mal-aligned all-polyethylene patellae. The components were articulated against “aligned” and “mal-aligned” (60 internally rotated) femoral components. The patella were subjected to a constant 2224 N force and the femoral components rotated from 600 to 1200 at 1.33 Hz. Patellae of identical geometry made of conventional UHMWPE and highly crosslinked UHMWPE were tested to 1 000 000 cycles. Wear was determined by gravimetric measurement relative to cemented soak controls.

Conventional UHMWPE: All samples demonstrated damage (burnishing and scratching) of the articulating surfaces. There was a significant increase in wear (p< .05) in the mal-aligned patella.

Highly cross-linked patellae: All components fractured in the mal-aligned construct (gamma irradiated remelted n=6, gamma irradiated and annealed n=2). Failure first occurred at the cement interface then at the posts.

Correct femoral rotation is important during TKA. The intertrochlear line, tibial cut, epicondylar axis and posterior condyles are helpful landmarks, but there is still eyeball control of rotation. It is clear from this study that rotational mal-alignment will result in increased polyethylene wear.

Highly cross-linked polyethylene has decreased wear in THA. Unfortunately, the decrease in ductility and toughness may make the use of these materials unsuitable for TKA. Based on this study model, patellar components would need to be redesigned if highly cross-linked polyethylene were to be applied.

The wear rate of conventional UHMWPE patellae is increased by rotational mal-alignment. Highly cross-linked components were a poor solution to problem. Use of highly cross-linked polyethylene resulted in component fracture.


H. Iwaki

Recently, highly cross-linked polyethylene has been highlighted in THAs which is thought to reduce wear. However, little is known about an accurate nature of cross-linked polyethylene particles and long term wear in vivo. One of the authors implanted all polyethylene cups irradiated by 100 Mrad in 1970s. Recently, we performed two revisions with this cup. In the present study, we extracted polyethylene particles and made direct wear measurements on retrieved cups.

Case one was revised for a stem fracture and acetabular loosening at 25 years postoperatively and case two for acetabular loosening at 27 years postoperatively. There was no osteolysis on X rays. We extracted polyethylene particles using a tiussue digestion and image analysis developed by Cambell and measured wear of retrieved cups using casting and 3D scanner developed by us.

Equivalent circle diameter (ECD) was 0.73 um, roundness was 0.69, aspect ratio (AR) was 1.4 and number of particles was 6.0 hundreds million/g wet tissue in case one. ECD was 0.57 um, roundness was 0.62, AR was 1.54 and number of particles was 5.8 hundreds million/g in case two. SEM showed that granule or globular shapes were abundant and fibril shapes were rare. Direct wear measurement showed concentric wear patterns were observed with very low linear wear (less than 0.03 mm).

Cross-linked polyethylene particles were less, a little smaller and much rounder in compared with our previous result of conventional polyethylene in peri-implant tissue. No unidirectional and significant amount of wear was observed in retrieved cups even after over 25 years.


J. DeOrio

Orthopedic surgeons are taught to remove the under surface of the patella in accordance with the thickness of polyethylene used to replace an equivalent amount of bone. Inability, however, to obtain a symmetrical removal of bone can lead to subluxation, increased tension producing pain, and affect range of motion. A convenient and fast way to recognise this asymmetry and remove an additional sliver of bone from the patella would be an advantage in creating a patella of even thickness.

Eight orthopedic surgeons were asked to evaluate 24 pre-cut patellar specimens with varying asymmetric thicknesses in a bag without visualisation. By feeling the patella between the thumb and forefinger, they were instructed to identify the thickest portion of the patella as well as to determine the difference in thickness between the thinnest and thickest sides. Two trials were conducted with each orthopedic surgeon consecutively.

Orthopedic surgeons were able to determine through proprioception the thickest one-half of the patella 91% of the time. This did correlate with experience in total knee arthroplasty. They were able to differentiate a 1 mm difference in patellar asymmetry 36% of the time, a 2 mm difference 61% of the time, and a 3 mm difference 81% of the time.

Orthopedic surgeons can identify an asymmetrically cut patella by assessing thickness of the patella between their thumb and forefinger the majority of the time. By doing this technique, inadvertent asymmetrically thick patellas at the time of total joint arthroplasty can be min-imised. This technique should be incorporated into the standard regimen of performing total knee arthroplasties.


S. Murphy R. Gobezie C. Lyons C. Harber G. Goodchild

Common problems following total knee arthroplasty include tibial component malpositioning, ligament imbalance, and clinical and subclinical fat embolism associated with intramedullary alignment guides. Tibial component malaligment can lead to component loosening. Ligament imbalance can lead to dysfunction and the need for revision. Fat embolism had been shown to occur in 46% of unilateral and 65% of bilateral total knee arthroplasty patients with neurological sequelae in 2 and 4% of patients respectively (Kim YH, J. Arth. 1999). All three of these common problems can be addressed with the use of surgical navigation.

Instruments designed for the Genesis II total knee arthroplasty (Smith-Nephew, Memphis, TN) are tracked optically using the ION virtual fluoroscopy surgical navigation system (Medtronics SNT, Louisville, CO). A software system specifically designed for TKR navigation is employed. Following exposure, reference frames are attached to the femur and tibia and fluoroscopic images of the knee are obtained. Hip and Ankle centres can be determined either kinematically or with images. Proper alignment and component rotation is determined using navigation without intramedullary alignment guides. Proper implant sizing is determined before the cuts are made by superimposing images of the proposed implants into the fluoroscopic images of the knee. Motion and ligament integrity can be quantified kinematically. The system was used to perform total knee arthroplasty on 14 cadavers. Post-operative alignment was measured radiographically.

As compared to the mechanical axis measured radiographically, the coronal femoral alignment measured 0.03 degrees of valgus (95% confidence:−1.81 to 1.88 degrees). Coronal tibial aligment measured 0.88 degrees of valgus (95% confidence: −2.17 to 0.41 degrees). Sagittal tibial aligment measured 1.81 degrees of posterior slope (95% confidence: −0.14 to 3.76 degrees)

The use of surgical navigation for TKA results in appropriately aligned implants. Surgical navigation has the potential to improve many of the most common problems encountered during and following total knee arthroplasty including component malaligment and malsizing, malrotation, ligament imbalance, and fat embolism.


F. Langlotz D. Herren B. Simmen W. Baumgartner

Correct placement of the total elbow endoprosthesis is a critical factor for the long-term success of an artificial joint. Correct restoration of the centre of rotation is essential for optimal outcome. To evaluate whether surgical navigation has the potential to improve accuracy during Total Elbow Arthroplasty (TEA), an existing CAS system was applied on one plastic model and three patients.

The spine module of the SurgiGATE™ navigation system (Medivision, Oberdorf, Switzerland) was used. To apply it during TEA, a standard 3.5-mm drill guide was instrumented with infrared LEDs and calibrated. A dynamic reference base (DRB) was developed. Its base consisted of an X-shaped, scissors-like construct that could be clamped rigidly onto the distal humerus after exposure. On a plastic model, the DRB design was evaluated, and three landmarks suitable for intraoperative matching were identified. Subsequently, the Spine system was applied during three TEA surgeries. For the first surgery no pre-operative CT scan was acquired, but the design of the DRB, its camera visibility, and the accessibility of the landmarks were verified. For the other cases, the elbows were CT-scanned preoperatively. Planning consisted of 3-D segmentation as well as the definition of matching landmarks and a trajectory representing the position of a Steinmann pin, with which the humeral implant position is defined. Intraoperatively, the DRB was fixated, and matching was performed. Using the navigation system, the drill guide could then be aligned with the planned trajectory.

For the second patient, no accurate matching was achieved, hence surgery was completed conventionally. The last patient could be registered precisely, and the Steinmann pin was placed as planned.

Preliminary results show that CT-based navigation can be applied during TEA. Given a positive output of an ongoing clinical study, the development of a special TEA navigation system is planned.


S. Murphy

Acetabular component malposition is the cause of half of all cases of recurrent hip dislocation. Intraoperative xrays after component insertion are helpful, yet it is certainly more useful to know the exact component position before final component insertion. The current study reviews results of acetabular component positioning using surgical navigation.

A prospective study of acetabular component positioning using surgical navigation was conducted in 22 hips of 21 patients. The technique involves insertion of a dynamic reference frame onto the pelvis during the surgical exposure and the acquisition of AP fluoroscopic views of each hip. Using the Fluoronav software and the ION surgical navigation system (Medtronics, Louisville, Colorado) a virtual horizontal line was then drawn between the teardrops. Acetabular component abduction was then aimed for 41 degrees. Component abduction was measured intra-operatively during component insertion by measuring the angle between the acetabular insertion handle and the virtual horizontal line between the teardrops. Post-operative xrays were analyzed for acetabular component abduction angle.

Using surgical navigation and aiming for 41 degrees of abduction resulted in post-operative cup positions averaging 40.8 degrees (range 37 to 44 degrees). These results show dramatically improved accuracy as compared to 85 acetabular component inserted without navigation showing a mean abduction of 42.8 degrees but with a range of 25 to 59 degrees. Frame placement and image acquisition required about 10 minutes. All intra-operative imaging after component insertion in complex cases was unnecessary. Having the dynamic reference frame in place also allowed assessment of pelvic position during surgery. Pelvic orientation varied greatly between patients on the operating table from about 12 degrees abducted to 12 degrees adducted. Further, pelvic orientation varied during surgery.

Surgical navigation allows extremely accurate positioning of the acetabular component at the time of total hip replacement surgery with an accuracy far greater than any study of acetabular component positioning reported in the literature. The pelvis is typically not orthogonal to the operating table during total hip arthroplasty and its position varies widely between patients and in the same patient during the procedure. Since acetabular component malposition represents the cause of half of all cases of recurrent dislocation, surgical navigation has been shown to directly address and potentially eliminate the problem of acetabular component malposition.


G.J. Roger D.P. Brazil

It is well established in the literature that the tribological properties of sliding metallic and ultra-high molecular weight polyethylene (UHMWPE) counterfaces are a major contributor to accelerate wear rates that contribute to osteolysis. The majority of the research over the years has been on improving the UHMWPE properties through manufacture and secondary processing of the polymer. Little attention has been directed towards the optimisation of the Chromium Cobalt Molybdenum (CrCoMo) surface finish.

The focus of this research has been on the highly polished CrCoMo metallic surface. A new surface finishing technique was applied to CrCoMo femoral knee prosthetic implants. The surface finish of our finished implants was compared to that finished by traditional mechanical polishing techniques. A representative number of polished CrCoMo knee femoral components were compared under the following topics; tribological, topographical and the extent of processing containments present.

It was found that traditional mechanically polished parts contained a significant amount of embedded polishing compounds (Al2O3), coarse interdendritic (M7C3) and fine (M23C6) carbide elements. Both the polishing containments and carbide elements stand proud of the articulating surface and thus act as micro cutting tools to accelerate UHMWPE wear. The new polishing technique completely eliminated hard carbide particles and embedded polishing compound media. Consequently, the samples prepared using the new polishing technique produced lower UHMWPE wear debris and improved wear patterns to that of the traditionally polished samples. Additionally, all sub-micron scratching was removed from the surface of the samples.

This polishing technique for CrCoMo prosthesis represents a milestone in CrCoMo surface finishing and will significantly reduce the UHMWPE wear debris generated and consequently increasing prosthesis longetivity.


J.A. D’Antonio W.N. Capello M.T. Manley B. Bierbaum

Today’s major challenge for total hip arthroplasty is to minimise wear and osteolysis in our younger and more active patients. Alumina ceramic bearings have known superior wear resistance and lubrication and do not carry a risk of ion release. Utilising new improved alumina ceramic materials and implant design 514 hips were implanted in a multicentre US IDE prospective and randomised study. The study compared alumina-on-alumina ceramic bearings to a cobalt chrome-on-polyethylene bearing.

All patients received the same press-fit hydroxylapatite coated femoral stem while two-thirds (349 hips) received alumina ceramic bearings and one-third (165 hips) received the cobalt chrome on polyethylene bearing. All patients suffered from non-inflammatory arthritis and were young and active with an average age of 53 years.

At a follow-up of 24–60 months (mean 39.8 months) there was no significant difference in clinical performance between the patient cohorts.


W.N. Capello J.A. D’Antonio P. Bonutti M.T. Manley

Utilising a new implant design and improved alumina ceramic materials, 514 hips were implanted in a US IDE prospective, randomised study. All patients received the same press-fit hydroxylapatite (HA) coated femoral stem. Two-thirds (349 hips) received alumina ceramic bearings, and one-third (165 hips) received CoCr heads on polyethylene liners. The alumina group was further divided. Approximately one-half (172 hips – System I) received a porous-coated titanium shell and an alumina insert, and one-half (177 hips – System II ) received a HA-coated, arc-deposited titanium shell and an alumina insert. System III (the control) consisted of a porous-coated titanium shell and a polyethylene insert. External geometry of all shells was identical.

An independent orthopaedic surgeon who did not participate in the study reviewed all radiographs. At latest follow-up, (minimum 2 years; range 2-4 years), differences were noted in the developmental pattern of the radiolucent line around the acetabular component. Radiolucent lines were most often noted with System I and System III (porous acetabular shells) in De Lee and Charnley Zone 3 and were absent in System II (arc-deposited titanium with HA) (p=0.001). Other standard radiographic parameters evaluated were found to be comparable, with one exception: In 10 cases in the control group, the development of a small erosive lesion (scalloping) in femoral Gruen Zone 8 was observed on the lateral film. This compares to two cases in System I, and no cases in System II (p=0.001).

Dislocation rates were comparable for all three Systems. Seven acetabular components were revised: one in System I, three in System II and System III. The two revisions for aseptic loosening were both in the control group.


J.C. Hermida S. Patil P.C. Chen C.W. Colwell D.D. D’Lima

This study measured polyethylene wear and correlated it with design features such as tibiofemoral conformity and contact areas.

Two femoral component designs were tested in a knee wear simulator. The femoral condyles of design A were flat-on-flat in the coronal plane, while those of design B were curved-on-curved. These femoral components were tested with two inserts. Insert PLI had a posterior lip, while insert C had a more curved sagital geometry, to improve stability in the anteroposterior direction. All components were tested for up to five million cycles in bovine serum lubricant. Triaxial forces were monitored to ensure that loading conditions were similar in all combinations tested. Gravimetric wear measurements were made at 500 000 cycle intervals. Contact stresses were measured using pressure sensitive film and dynamic finite element analysis.

Contact stresses were 22% higher for inserts tested with design A compared to design B. Sliding distance, sliding velocity, and patterns of crossing motion were found to be comparable between the two femoral designs. Inserts tested with design A wore significantly more (mean 10.9 mg/million cycles) than design B (mean 5.71 mg/million cycles, p < 0.001). No appreciable differences were found between wear rates of insert PLI and insert C.

Component design can have a significant impact on polyethylene wear rate. Careful control of kinematic and loading conditions allowed for comparison between specific design features. Increase in tibio-femoral contact area led to reduction of contact stresses, which was reflected in the reduced wear rate.


R.E. Field N. Rushton P.J. Singh J. Krysa

The novel horseshoe shaped cup was designed by the senior authors to minimise the resection of healthy bone in total hip arthroplasty. It replaces the cartilage and underlying sub-chondral bone of the acetabulum socket with a cup that is designed to flex in harmony with the surrounding bony structure.

Fifty female patients with a displaced, subcapital, femoral neck fractures were chosen for the study. In half of the group of patients, the composite support shell was coated with HA, with the other half remaining uncoated. Clinical and radiological assessments were undertaken regularly for five years.

To date 20 patients have died and 13 have withdrawn from the study due to poor medical health unrelated to the study. Charnley modified Merle d’Aubigne score at five years was as good as the preoperative score with 80% of patients having full range of movement, no pain and walking unaided.

Radiographic results showed no evidence of loosening of HA coated cups, in contrast to non HA coated cups which migrated significantly in 80% of cases. Four patients with loose non HA coated cups underwent revision surgery.

This trial has demonstrated success at 5 years with the HA coated Cambridge Acetabular Cup. Cups from which HA coating has been removed have migrated significantly in 80% of cases. There is an advantage of the HA fixation which will be taken into account before wider clinical usage is advocated.


W.L. Jaffe K. Iesaka F.J. Kummer

The site of initiation of failure of a cemented femoral component is usually the prosthesis-cement interface. Strengthening this interface with porosity reduction may improve survivorship. Cement pores which propagate crack formation can be reduced by vacuum mixing or centrifugation, but this does not effect interface porosity.

Utilising simulated stems cemented into a “Sawbones” femur in a manner replicating surgery, we determined the effect of stem warming on various parameters. Maximum temperature and time of polymerisation, mechanical strength, porosity reduction and pore distribution in the cement mantle were measured with stems at room temperature (RT), 37, 44, and 50 degrees Celcius. Mechanical testing included initial “push-out” tests, tests after agiing in 37 degrees Celcius saline for two weeks,and fatigue testing (3 HZ at 90% initial failure load). Porosity distribution was measured by the percentage area of pores on the interface surfaces and the transverse plane.

Polymerisation time decreased as the stems were heated. The time decreased from 8.1 minutes at RT to 5.9 minutes at 50 degrees Celcius. The maximum temperature in the cement mantle rose from 50.2 to 56.4 degrees Celcius comparing stems at RT to those at 37 degrees Celcius, and did not elevate further as stems were preheated to 44 and 50 degrees Celcius. Similarly, static and fatigue interface strength improved by preheating stems, but no significant gain compared to RT stems was realised by heating above 37 degrees Celcius.

A dramatic reduction in porosity at the prosthesis-cement region was found with the heated stems, with no additional benefit to heating beyond 37 degrees Celcius. An increase in porosity at the cement-bone interface was noted as stems were heated. This may be due to the direction of polymerisation shrinkage in the cement mantle as influenced by stem temperature.


J. Chitnavis P. Dixon E.N. Parish M.J. Cross

Although hydroxyapatite (HA) coating is known to enhance fixation in THR, its role in the fixation of Total Knee Replacements is less well appreciated. This study was performed to assess the medium-term results of an HA-coated TKR.

Between August 1992 and 1998 all patients requiring a primary TKR were treated with a hydroxyapatite-coated, PCL-retaining prosthesis implanted by the senior author. The HA coating used was 70 microns thick with 75% crystallinity and 20% porosity. It is deposited on a beaded heat-sintered surface. A combined Hospital for Special Surgery and Knee Society Score was recorded pre-operatively and at three, six, 12, 24 and 60 months post-operatively. Fluoroscopically-controlled interface views were performed on the first 161 knees immediately post-operatively and repeated 24 months postoperatively.

Six hundred and ninety two patients (Male:Female 335:357) with a mean age of 68 years (31–88 years) underwent 1 000 TKR mainly for OA (93%) and inflammatory arthropathies (RA 3%, psoriasis 1%). The mean follow up was 75 months (40–115). There were 461 unilateral (R:L 256:205) and 539 bilateral replacements (462 simultaneous and 77 staged).

The pre-operative knee score was 95/200, ROM 6–115 degrees and at latest review was 182/200, ROM 1–113 degrees.

Forty four patients have died (mean age 73 years, range 54 to 88). There have been 14 deep infections (1.4%), 22 proven pulmonary emboli (2.2%) and five periprosthetic fractures (0.5%). Six revisions have been performed. Visible gaps between bone and implant were present in 91% of femora and 58% of tibiae initially and in 6% of femora and 8% of tibiae at two years on interface views. There have been no cases of clinical loosening.

Currently, this study comprises the largest known series of HA-coated total knee replacements. These results demonstrate that HA appears to enhance fixation of uncemented knee prostheses which maintain good clinical outcomes.


D.D. D’Lima P.C. Chen C.W. Colwell

Polyethylene contact stresses have been shown to correlate with wear in total hip arthroplasty (THA). Several liner designs have been introduced in an attempt to increase stability or reduce impingement and increase range of motion. This study analyzed the effect of liner design on range of motion (ROM) and PE contact stresses in a finite element model (FEM).

FEMs of four liner designs were generated: Generic was modelled as a simple hemisphere, Chamfer had a wide chamfer on the inner edge of the liner to increase ROM, Highwall had an extended lip to increase stability, and Anteverted created a 20° anteversion with lat-eralisation of the centre of rotation. With the liners in varying positions of abduction and anteversion, physiologic loads were applied through the femoral head. Hip ROM was measured by rotating the head and neck in different directions until prosthetic impingement.

Significant differences in ROM were seen relative to the Generic liner. Chamfer increased ROM by mean 16%. Highwall reduced ROM by mean 12%. Anteverted increased flexion by 17% but decreased extension, abduction, and external rotation. Contact stresses were also significantly affected by liner design and acetabular orientation. Overall for the same acetabular position, contact stresses were higher for Chamfer and lower for Highwall and Anteverted.

These results underline the complex interaction between cup design, hip stability, range of motion and contact stresses. Design features that increase stability tend to reduce contact stresses and ROM, while those features that increase ROM, tend to increase contact stresses. This data can help the surgeon match liner design to specific patient requirements.


J.N. Argenson D.A. Dennis R.D. Komistek D.T. Anderson M. Anderele

The objective of this present study was to determine the in vivo kinematic patterns for subjects implanted with a patellofemoral arthroplasty (PFA).

Twenty subjects, all having a PFA, were studied (< 2 years post-op) under fluoroscopic surveillance to determine patellofemoral contact positions, sagittal plane, and medial/lateral translation using a skyline view.

The patellofemoral contact patterns for each subject having a PFA was highly variable, 11.9 mm of translation. The average amount of patella rotation during the full flexion cycle was 26.3 degrees, while one subject experienced 48.6 degrees. The average amount of medial/lateral translation was 3.8 mm (5 > 5 mm). Five subjects experienced grater than 5 mm of motion.

This was the first study to ever determine the in vivo kinematics for subjects having a PFA and the in vivo medial/lateral translation patterns of the patellofemoral joint. Subjects in this study experienced high variability and some abnormal rotational patterns. Most of the subjects who underwent PFA in this study had a previous history of subluxed or dislocated patella which affects the normal patella tracking, especially regarding tilting and translation. This tracking may also be directly affected by patellofemoral conformity, a consequence of femoral implant design. Finally, after PFA the patello-tibial tilt angle is influenced by the anteroposterior positioning of the femoral component.

The results of this very first in vivo kinematic study may play an important role, not only for design consideration of patellofemoral replacement but also for surgical technique in order to obtain optimal implant positioning.


J.N. Argenson R.D. Komistek D.A. Dennis D.T. Anderson T. Langer

The objective of the present study was to analyse kinematics of subjects having a UKA during stance phase of gait, where the ACL was intact at the time of the operative procedure.

Femorotibial contact positions for nineteen subjects (15 medial UKA (MUA); 14 lateral UKA (LUA); HSS > 90, post-op > 3 yrs) were analysed using video fluoroscopy.

During stance-phase of gait, on average, subjects having a medial UKA experienced 0.8 mm of anterior motion (7.7 to – 2.3 mm), while subjects having a lateral UKA experienced −0.4 mm (0.9 to – 2.1 mm) of posterior femoral rollback (PFR). Eight of 15 subjects having a medial UKA and two out of four lateral UKA experienced PFR. Eight of 15 subjects having a medial UKA experienced normal axial rotation (average = 0.9 degrees) and one out of four subjects having a lateral UKA experienced normal axial rotation (average = −6.0 degrees).

High variability in the kinematic data for subjects experiencing an anterior slide and opposite axial rotation suggests that these subjects had an ACL that was not functioning properly and was unable to provide an anterior constraint force with the necessary magnitude to thrust the femur in the anterior direction at full extension. Progressive laxity of the ACL may occur over time, and at least in part, lead to premature polyethylene wear occasionally seen in UKA. Our results support the findings of other studies that the ACL plays a significant role in maintaining satisfactory knee kinematics, which may also, in part, contribute to UKA longevity.


S. Kim H. Oonishi H. Fujita S. Ito

Improved cement technique by interposing less than two layers of hydroxyapatite (HA) granules between bone and bone cement at the cementing (Interface Bio-active Bone Cement : IBBC) have been performed in total knee arthroplasty (TKA) since 1987.

We performed IBBC technique in 153 knees (130 patients) in TKA from 1987 to 1993. One hundred and forty knees (120 patients) could be followed up clinically and radiologically. Follow up rate was 91.5%. A mean follow-up period was 9.5 years (6 to 13 years) after surgery. As a control, clinical results of TKA with conventional cementing (Non-IBBC) which were operated in 44 knees (44 patients) in 1986 were used.

In IBBC cases, radiolucent lines on the tibial components were seen 7.1%, 2.9%, 1.4%, 3.6%, 0%, 0% and 0% at Zone ‡T to ‡Z of the anteroposterior view, while in Non-IBBC cases, 40.9%, 13.6%, 9.1%, 27.3%, 11.4%, 4.5% and 13.6% at Zone ‡T to ‡Z, respectively. In IBBC cases peri-prosthetic osteolysis of the tibial components were seen in three knees (2.1%), while 29.5% in Non-IBBC cases. Aseptic loosening of the tibial component was only one case (0.7%) in IBBC cases, while 9.1% in Non-IBBC cases.

In IBBC, bone cement bound to HA mechanically immediately after surgery and HA granules bound to the bone physicochemically after bone ingrowth into the spaces around the HA granules. In Non-IBBC, spaces will appear between bone and bone cement due to osteoporosis and/or atrophy after long years. However, in IBBC, bone and bone cement will contact by interposing HA forever due to osteoconductive effect of HA.

In conclusion, the IBBC has significantly reduced the incidence of radiolucent lines and periprosthetic osteolysis in TKAs. IBBC is a method combining the advantage of cementless HA coating and bone cement.


S. Kim H. Oonishi H. Fujita S. Ito

We have used Interface Bioactive Bone Cement (IBBC) in all cases of total joint arthroplasties since 1987. The method is improved cement technique by interposing less than two layers of hydroxyapatite (HA) granules between bone and the polymethylmethacrylate (PMMA) bone cement. We report one patient who underwent revision surgery after total knee arthroplasty (TKA) using IBBC.

The patient is a woman aged 70 years at the time of revision surgery. Right TKA was performed with the diagnosis of rheumatoid arthritis. An alumina ceramic total knee prosthesis was inserted using IBBC. Pain and walking ability were once improved after the primary TKA. However, the gait disturbance recurred after the patient fell on the ground. Radiographic findings showed severe genu varum, but neither radiolucent lines around the components nor migration of the components were seen. This was revised with semiconstrained prosthesis for the purpose of improving lateral instability at 31 months after the primary TKA.

Avulsion of fibular attachment of collateral ligament was seen at the time of the revision surgery. As PMMA cement was strongly adhered to the bone, it was removed together with cancellous bone. Histologically, HA granules bound to the bone directly after bone ingrowth into the spaces around the HA granules. This is the reason we have described IBBC as a method having the both advantages of cementless HA coating and PMMA bone cement.

After the revision surgery, the walking ability was improved.

In conclusion, this case showed excellent characteristics of IBBC.


R.D. Komistek D.A. Dennis D.T. Anderson B.D. Haas

The objective of this present study is to conduct a comparative analysis of the kinematic data derived for all subjects having a TKA who were analysed over the past eight years at our laboratory.

Femorotibial contact positions for 705 subjects having either a fixed bearing PCR or PS TKA or mobile bearing TKA were analysed in three-dimensions using video fluoroscopy.

During a deep knee bend, all PS TKA types subjects experienced a medial pivot motion, averaging −3.8 of lateral condyle posterior femoral rollback (PFR), respectively. Subjects having a fixed bearing PCR TKA experienced only −0.7 mm of lateral condyle PFR and an anterior slide of 1.6 mm for the medial condyle. Twenty-nine percent of the PCR TKA analysed had a lateral pivot and 71% experienced a medial pivot. Subjects having a mobile bearing TKA experienced −2.8 mm of lateral condyle PFR and 0.4 mm of medial condyle anterior slide. Fifty-one percent of the moble bearing implants experienced a medial pivot and 43% experienced a lateral pivot. During gait, PS and PCR fixed bearing TKA types experienced similar kinematic patterns. Subjects having a mobile bearing TKA experienced minimal motion, probably due to the mobile bearing TKA having greater sagittal conformity and had the lowest standard deviation.

There was great variability in the data comparing various TKA designs. Subjects in this multicentre analysis predominantly experienced a medial pivot motion, although certain TKA designs did demonstrate a lateral pivot motion.


S.A. Jones M. Ganapathi P. Roberts

The use of exhaust suit systems is commonplace in arthroplasty surgery where isolation of the surgical team is desirable in an attempt to reduce the risk of infection transmission. Elevated carbon dioxide levels have been reported in the non-clinical setting with such systems the consequences of which can include fatigue, diapho-resis, nausea, headache and irritability.

The aim of our study was to determine the levels of carbon dioxide present within an exhaust suit system during hip arthroplasty and to compare these with the recommended occupational exposure limit levels published by the Health and Safety Executive (HSE).

Data was collected during ten primary hip replacements performed by the same surgeon whilst wearing the Stryker Steri-Shield Helmet Exhaust System. This is a self-contained unit with an integrated blower used in conjunction with a full-length gown. In addition the helmet was fitted with an air-sampling probe connected to a portable infrared CO2 monitor and also a temperature probe. Thus continuous monitoring of both CO2 and temperature level during surgery was possible.

The mean initial CO2 concentration in the helmet at the beginning of surgery was 3 000 parts per million (ppm) and the mean maximum CO2 level recorded was 13 000 ppm. The mean time the surgeon was within an exhaust suit to perform a primary hip replacement was 1 hr 54 mins and for 86% of this time period the CO2 level within the helmet exceeded the recommended level of 5 000 ppm as stipulated by the HSE.

In conclusion we have demonstrated significantly elevated CO2 levels within the Stryker Steri-shield Exhaust Suit System during hip surgery. Surgeons who use this system should be aware of this together with the physical symptoms that may result.


R.D. Wills M. Grimm D.C. Markel

Initial fixation affects ingrowth of uncemented tibial components. Previous studies assessed initial fixation, however most used limited one-dimensional motion measurements. Therefore, a three-dimensional micro-motion and migration analysis was performed to compare initial fixation of four different tibial tray configurations: 1) Keeled component 2) Non-keeled component (post but no keel) 3) Keeled component with screws 4) Non-keeled component with screws.

Osteonics series 7 000 tibial trays (identical to Scorpio design) with and without standard keels were obtained. The 30 mm posts were left intact. The components were implanted without cement into twenty-four fresh-frozen cadaveric tibiae. Specimens were loaded through matched femoral components via two separate loading conditions: 1) sinusoidal medial load from 200 to 2 200 N at 0.5 Hz and 2) sinusoidal torsion load from −5 Nm to +5 Nm at 0.5 Hz with constant 1 200 N axial load. Motion data were collected from reference cubes and transducers rigidly attached to the trays, during 3 000 cycles of loading. Rigid-body mechanics were used to calculate the motion of a wire-frame computer model. Comparisons were made of micro-motion and migration magnitudes.

A keel did not significantly decrease micromotion or migration under medial or torsion loading compared to a post alone (p=1.04). The addition of four cancellous screws decreased motion (p< .05) regardless of the presence of a keel under medial loading. No significant differences were noted under torsional load for any tray configuration.

A keel did not enhance initial fixation compared to screws or a post alone. Screws enhanced fixation under axial offset loading in all constructs. Screw fixation did not affect motion under torsion loads perhaps due to the limited magnitude of torque transmitted across the unconstrained femoral-tibial articulation. Based on these data, initial fixation of uncemented tibial implants should include screw fixation to counter the effects of offset axial loads.


J.G. Bowsher J.C. Shelton

Large diameter metal on metal hip bearings have been shown to display exceptionally low wear in vivo. However, as these components are often cast, they may be heat treated to improve homogeneity, although it has been suggested that this may adversely affect wear. Therefore a hip simulator study was commissioned to investigate this further.

Multi-station hip simulator testing was carried out on 40 mm diameter high carbon cast cobalt chrome alloy components, all having similar radial clearances (~100mm), surface finishes (0.01mm Ra) and sphericity deviations (< 10mm). Three bearing couples were hot isostatic pressed (HIPed) and solution heat treated, generating a fine carbide structure, and three bearing couples were left as cast, creating a coarse carbide structure. All sockets were mounted in an MTS hip simulator, inclined at 35° to the horizontal, and subjected to standard walking conditions (2450 N max) using 25% bovine serum as a test lubricant. Wear was calculated gravimetrically using temperature controls.

Running-in wear was observed for both groups generating a similar combined head and cup mean wear rate of 2.3 mm3/106 cycles. The mean steady-state wear rate (SE) for the as cast and HIPed components was 0.38 (0.13) and 0.57 (0.11) mm3/106 cycles respectively showing no statistical difference (p > 0.2). Wear was generally higher for the cups than the heads.

These wear rates are two orders of magnitude lower than published wear rates of metal-UHMWP E under similar conditions and one order of magnitude lower than lightly crosslinked UHMWPE articulating against CoCrMo under the same conditions.

In this test, the effect of HIPing and solution heat treatment on metal-metal wear would therefore appear to be insignificant. This is in contrast to the published influences of both bearing diameter and bearing tolerances, i.e. sphericity and radial clearance on the wear of metal-metal hip joints.


R. Wixson

Since acetabular osteolytic lesions following total hip arthroplasty (THA) may be asymptomatic until extensive bone loss occurs, early detection and monitoring the progression of these lesions is important. The purpose of this study was to use high resolution helical CT to determine the progression of the osteolytic lesions over time by comparing serial studies.

Fifty patients (Fifty-eight hips) with primary, cementless THA done between 1984–1996 were evaluated as part of an ongoing prospective study. These patients had a history of a high level of activity that was believed to place them at increased risk for accelerated polyethylene wear. The mean age was 51 yrs, 55% male:45% female. The average time from date of surgery to initial scan was 8.0 years (4.7–16.6). If an acetabular lytic lesion was identified, the patients were offered Alendronate for potential suppression of bone resorption with a repeat CT scan for follow-up. The area of the maximum size osteolytic lesions on axial images were measured on the initial scan and compared at the same level on the subsequent study.

The interval between scans averaged 15 months (10 – 27). Progression was noted on 87% hips. The mean initial area was 328 mm2 (40–1084) with the follow-up area of 386 mm2 (46–1344) with a mean of progression of 15.7%.

Once established, peri-acetabular lysis appears to be a slowly progressive, relentless process. Analysis of changes on serial CT, along with an assessment of the degree and location of lysis, provides an additional tool to evaluate the need for surgical intervention.


Y. Kadoya T. Masada A. Kobayashi K Takaoka

The benefit of mobile-bearing mechanism in total knee arthroplasty (TKA) has been controversial. The aim of this paper is to analyse the rotation of polyethylene (PE) and its effect on the range of motion (ROM) in mobile-bearing, posterior stabilised TKA (LPS-Flex™, Zimmer Co. Ltd.).

Thirty-four consecutive PS-Flex™ TKAs (28 patients) were analysed. Three tantalum markers were inserted in the PE and the tibia (one for medial side and two for lateral side; total six markers). The rotation of the PE and the tibia was analysed in fluoroscopically-controlled radiograph taken at one years in full extension, 90 degrees flexion and passive maximum flexion. The markers in the tibia were identifiable in 19 knees and the analysis was based on these knees.

The tibia rotated internally relative to the femur by 7.1± 5.2 degrees (mean ± SD, range −1 to 20 degrees). The amount of tibial rotation has no correlation to ROM. The rotation of the PE relative to the femur was unpredictable showing three knees with external rotation and four knees without rotation (Average; 4.0 ± 4.5 degrees internal rotation). The rotation of the PE on the tibia was 4.2± 5.2 degrees and seven knees (37 %) showed no rotation and 12 knees (63 %) showed less than 5 degrees rotation. There was a positive correlation between the amount of PE rotation on the tibia and ROM, which approached to statistical significance (p = 0.0684).

This study has demonstrated that the rotation of the PE on the tibial tray is generally small (< 5 degrees). Because not tibial internal rotation but PE movement on the tibia correlated to ROM, the essential benefit of the mobile-bearing mechanism could be to compensate the rotational mismatch between the components rather than to reproduce normal knee kinematics.


M.A. Frankle M.A. Mighell A. Kumar

Outcomes for a RSP to treat either a previous operated shoulder (revision procedure) was compared to a primary RSP.

Twenty primary RSP (6M, 14F) for an irreparable rotator cuff tear (IRCT) with glenohumeral arthritis /anterior superior arch deficiency and 31 revision RSP (10M, 21F) (previous rotator or cuff surgery, hemi or total shoulder arthroplasty) were evaluated at an average of 24 months postoperatively. Mean age at the time of RSP was 72.3 for primaries 67.2 for revisions. Assessment with pre- and postoperatively SF-36, SST, ASES scores, physical exam, satisfaction surveys, and radiographs was performed.

Primary RSP improvements /Revision RSP improvements were: 9.4 sf-36 PCS/ 6.3 sf-36 PCS, 1.8 SST/ 1.6 SST,31.8ASES / 17.5ASES (p< 0.05),49.2 elevation/ 14.2 elevation (p< 0.05) and 57.8 external rotation/ 30 external rotation. 71.3% Excellent/good/. 56% Excellent/ good (p< 0.05), 21.4% satisfactory/ 33.3% satisfactory, 7.1% unsatisfactory outcome/ 9.5% unsatisfactory outcome. Complications only occurred in the revisions including component disassociation, glenoid loosening, recurrent instability, and infection

Primary RSP provides predictable improvements in pain and function with minimal complications. Revision RSP has a higher complication rate and improvements in pain and function are less reliable. Conventional shoulder arthroplasty for patients with IRCT with gle-nohumeral arthritis/anterior superior arch deficiency has resulted in adequate pain relief but functional improvement has not been predictable. Thus, the initial operative selection for these patients must consider the effect of a failed reconstructive attempt on patient outcomes.


G. Maale

The determination of the cause of prosthetic failures in total hip arthroplasties can be difficult. Pre-operative imaging, including plain x-rays, tri-phse bone scan and MRI imaging have not been able to discern septic from aspectic causation. White blood cell scans, once thought specific for infection when positive, has demonstrated positivity in”wear and debris” reactions. Labs including WBC, Sed Rate, CRP can be elevated in septic, as well as, aseptic failures. Although frozen section is reliable showing acute inflammation for infection, chronic active inflammation which often is seen with chronic infections, can also be seen in aspectic failures. Cultures are often falsely positive, but in chronic infection it may be associated with less than 80% retrieval.

Five cases of acetabular loosening associated with radiolucencies around a prosthesis were studied. These cases had rapid failures and were thought to be secondary to an oil residual left after processing of an in growth prosthesis. All patients had a radiolucent zone around the bone prosthetic intersurface. The patients had increasing pain on weight bearing and a positive bone scan. Frozen section at the time of surgery demonstrated chronic inflammation and was culture negative. The acetabular prosthesis and associated parts were placed immediately in 80% Etoh and Tris buffer. Combinations of confocal laser microscopy with live-dead stains, FISH Probes for Staph., or scanning electron microscopy was performed looking for biofilm.

All five of the prosthesis or related parts showed the presence of bacterial biofilm. One of these had cement covering the porous portion.

These results demonstrate our inability to discern aseptic from septic loosening in total hip arthroplasty by the current clinical means.


J.P. Waddell J. Lever E.H. Schemitsch M. Nousiainen S.A. Aksenov

Twelve pairs of fresh-frozen, cadaveric femora were harvested. Each right femur was prepared for the cemented insertion of the femoral component of a total hip implant. Left femora served as matched intact controls. Following insertion of the implants, the distal tip of the stem was identified and an oblique osteotomy was made to represent a periprosthetic fracture. Proximally, plates were secured with cables and distally by bicortical screw fixation (c+s). The twelve pairs of femora were randomly divided into three groups: 1. Zimmer Cable-Ready System, 2. AO 4.5 mm broad, LC-DCP, with Wire Mounts and Double Luque Wires, 3. Dall-Miles Cable Grip System. Specimens were mounted and deforming forces were applied to test the biomechanical stiffness of the constructs. Following testing the plate-cable combinations, the proximal cables were removed and replaced with unicortical screws (s+s). Repeat testing was then performed as per the above protocol.

The stiffness of the constructs relative to intact bone decreased (p< 0.05) with fixation utilising cables plus screws (c+s) during four-point bending (69–77%) and offset rotational loading (61–64%). When testing unicor-tical plus bicortical screw fixation (s+s) in these modes, a similar effect was seen. There was no difference between plate systems (ANOVA, p> 0.05). Comparisons of stiffness between cable plus screw combination versus unicor-tical plus bicortical screw combination revealed that the latter method of fixation (s+s) was more rigid (p< 0.05).

Our study showed that the three plate-cable systems displayed similar biomechanical stiffness. In addition, when the cables were replaced proximally with unicortical screws, more rigid fixation was obtained in all but one plane of testing.

We conclude that the method of plate stabilisation by screws or cables is more significant than the type of plate used for periprosthetic fracture stabilisation.


I.C. Heyligers J. Klein-Nulend

Impacted morsellised donor bone is succesfully used to treat bone loss in revision total hip arthroplasties. After implantation new bone is formed in the donor bone. It is generally thought, but not proven, that the processing and storage at −80°C of the donor bone kills all cells. There is however general concern about viral, bacterial, and/or oncogenetic contamination with donor bone. Based on these considerations it is essential to know whether the donor bone does contain viable bone cells.

Fragmented biopsies from eleven femoral heads from our bone bank, which is processed according to the Musculo-skeletal Council of the American Associations of Tissue Banks (AATB) and the European Association of Musculo Skeletal Transaplantation (EAMST), were tested for their capacity to give rise to proliferating cells in vitro. This was repeated with five other femoral heads from the same bone bank after irradiation. Microscopic analysis of cell growth, aspect, and number was performed on the established cell cultures. DNA marker analysis of the cultured cells and freshly obtained buccal cells from the donor was done in order to verify the origin of the cultured cells.

All fragmented biopsies showed cell growth. Cell outgrowth time as well as cell number varied between donors, and was independent of the length of storage time at −80°C. No cell outgrowth was observed from irradiated bone. DNA marker analysis showed identical alleles for cultured cells from frozen bone and DNA from freshly obtained unfrozen buccal cells from the donor.

Biopsies from femoral heads from a bone bank according to the AATB and the EAMST contain living bone cells with growth capacity. It is unclear which role these vital cells play in the process of new bone formation in the donor bed, or in the risk of contamination.


J.P. Waddell E.H. Schemitsch F. Hoe J. Morton

Two hundred and seventeen consecutive patients (238 hips) underwent total hip arthroplasty using the St Michael’s stem and a non-porous screw ring cup. Patients were followed prospectively clinically using the St Michael’s hip score and radiographically. At an average of 11.9 years (10-13.5 years), 55 patients (59 hips) had died, 23 patients (23 hips) were lost to follow-up. The St Michael’s hip score improved from 13.4 pre-operatively to 21.7 (out of a possible 25) at the latest follow-up. Thirty-seven (24%) of the acetabular components have been revised for aseptic loosening and an additional seven components are radiographically loose. No femoral components have been revised. Using Engh’s criteria one femoral component is definitely loose and two femoral components have stable fibrous ingrowth. Significant stress shielding was noticed in 23 hips (17%) without clinical consequences. Minor osteolysis was seen in 13 hips most commonly around the proximal femur and has not caused symptoms. The St Michael’s stem with its large pore size madreporic surface has comparable results to other porous coated stems with smaller pore size.

The St Michael’s stem provided reliable ingrowth and fixation with an acceptable degree of stress shielding. The non-porous screw ring cup had a high failure rate.


H.M.J. McEwen P.I. Barnett D.D. Auger R. Farrar M.H. Stone J. Fisher

Reduction of ultra high molecular weight polyethylene (UHMWPE) surface wear in total knee replacements (TKR) may delay the onset of osteolysis and loosening of components. This study examined the wear of fixed bearing and rotating platform (RP) mobile bearing TKR with two different bearing materials.

Testing was completed on a Leeds ProSim six-station knee simulator under ‘high’ kinematics [1]. PFC Sigma fixed bearing and LCS RP mobile bearing knee designs were tested (DePuy). Non-crosslinked (non-irradiated (NI) or gas plasma (GP) sterilised) and moderately cross-linked (4.0 MRad gamma irradiation sterilisation under vacuum (GVF)) GUR1020 UHMWPE bearings were investigated for each TKR design. Components were tested in 25 % bovine serum solution for up to five million cycles (frequency = 1 Hz). Volumetric wear was determined from gravimetric measurements of the inserts.

The 1020 GVF fixed bearings exhibited a wear rate of 16.4 ± 4 mm3 per million cycles (MC). This was significantly greater (p < 0.05) than wear of the same bearing material in the rotating platform mobile bearing TKR (10.85 ± 2.39 mm3/MC). Similarly, when uncross-linked 1020 UHMWPE was introduced as the bearing material, a significant (p < 0.05) reduction in wear was observed between the fixed bearing (16 ± 7 mm3/MC) and the RP knee designs (5.85 ± 2.05 mm3/MC).

The RP design decouples the motions between the femoral-insert and tray-insert articulating surfaces. This translates complex knee motions into more unidirectional motions at two interfaces, thus reducing wear under high kinematics compared with fixed bearing TKR. This significant reduction in wear was observed with uncross-linked and moderately cross-linked bearing materials. Design of TKR is an important factor that influences UHMWPE surface wear and may affect long-term success of knee replacements in highly active patients.


S. Williams T.D. Stewart E. Ingham M.H. Stone J. Fisher

Following total hip replacement surgery, fluroscopy studies have shown that a mean separation of 2 mm can occur between CoCr femoral heads and UHMWPE acetabular cups during the swing phase of gait [1]. In vivo and in vitro studies [2, 3] of alumina ceramic on ceramic hip replacements have demonstrated that swing phase microseparation followed by the impact of the femoral head on the acetabular insert rim can lead to accelerated wear. However, wear remains low. A similar trend was observed when metal on metal hip replacements were tested under microseparation conditions [4]. The purpose of the current study was to examine the wear of ceramic on polyethylene bearings under standard and microseparation conditions.

A physiological hip simulator was used, loads and motions were applied to approximate in vivo conditions. The alumina ceramic heads and polyethylene cups were 28 mm in diameter and were tested for 5 million cycles in 25% new born calf serum at 1 Hertz. Microseparation was achieved by displacing the femoral head inferiorly during swing phase, where the head contacted the inferior cup rim and was laterally displaced. On heel strike the head contacted the superior cup rim prior to relocation.

The volumetric wear of the polyethylene inserts was approximately four times less under microseparation conditions (5.6 ± 5.3 mm3 per million cycles), in comparison to standard conditions (25.6 ± 5.3 mm3 per million cycles). Deformation of the cup rim was observed, but some of this was attributed to creep. It is postulated that this reduction in wear was due to the separation of the components in swing phase improving the entrapment of lubricant, hence reducing wear via a squeeze film lubrication mechanism. In conclusion, surgical procedures that produce a small and controlled amount of joint laxity and microseparation may lead to a reduction in wear of the polyethylene acetabular cups.


Full Access
A. Leardini J.J. O’Connor F. Catani S. Giannini

Only recently has the mobility of the ankle joint been elucidated. Sliding/rolling of the articular surfaces and slackening/tightening of the ligaments have been explained in terms of a mechanism guided by the isometric rotation of fibres within the calcaneofibular and tibiocalcaneal ligaments. The purpose of this investigation was to design a novel ankle prosthesis able to reproduce this physiological mobility.

A four-bar linkage computer-based model was used to calculate the shapes of talar components compatible with concave, flat and convex tibial components and appropriate fully congruous meniscal bearings. Three-component designs were analysed, and full congruence of the articular surfaces, appropriate entrapment of the meniscal bearing and isometry of the two ligaments were required.

A convex tibial component with 5 cm arc radius gave a 2 mm entrapment together with a 9.8 mm amount of tibial bone cut, while maintaining ligament elongation within 0.03 % of the original length. The physiological patterns of joint motion and ligament tensioning were replicated. The talar component slid backwards while rolling forwards during dorsiflexion. These movements were accommodated by the forward displacement of the meniscal bearing on the tibial surface under the control of the ligaments. The complementary surfaces provide complete congruence over the entire range of flexion, such that a large contact area is achieved in all positions.

To restore the physiological mobility at the ankle joint, not only should the components be designed to be compatible with original ligament pattern of tensioning, but also these should be mounted in the appropriate position. A suitable surgical technique was devised and relevant instrumentation was manufactured. Five below-knee amputated specimens replaced with corresponding prototype components showed good agreement with the model predictions.

Current three-component designs using a flat tibial component and physiological talar shapes cannot be compatible with physiological ligament function.


A. Race M.A. Miller D.C. Ayers K. A. Mann

Bone-cement shrinkage has never been quantified in a stem/cement/femur construct. We observed gaps around femoral stems in transverse sections of stem/cement/femur constructs; a greater proportion of stem/cement (s/c) interface gaps were found around grit blasted sections of stems than satin finished sections. If s/c gap formation were a shrinkage artifact then mantles with few s/c interface gaps must manifest shrinkage elsewhere, at the c/b interface or voids. ‘Mould-gaps’ at a c/b interface have been described previously but not quantified. We analysed the area of gaps at both interfaces. We hypothesised 1) Total gap area was the same for all transverse sections. 2) Satin sections had greater c/b gap areas than grit sections.

Transverse sections of stem/cement/femur constructs were processed to highlight gap areas. Five stems had a satin finish (Ra 0.75 um) and five were proximally grit-blasted (Ra 5.3 um). Sections were coated with matt black spray paint and then polished with emery paper. This process left all interface gaps and voids filled with black paint, which facilitated digital imaging. Gaps were visually identified and measured using Image-Pro. Gap areas for each transverse section were normalised by the area of cement in that section.

Gaps were not evenly distributed; there was obvious localisation at both interfaces. No significant difference found between surface finishes in total gap area ((satin 3.1% ± 1.4):(grit 3.4% ± 1.5)), supporting our first hypothesis. S/c gap areas were significantly greater around grit blasted sections ((satin 0.1% ± 0.4):(grit 1.9% ± 1.7) p< 0.0001). C/b gap areas were significantly greater around satin finished sections ((satin 2.3% ± 1.3):(grit 1.0% ± 0.9) p< 0.0001), supporting our second hypothesis.

Shrinkage can localise into large interface gaps; which must lead to stress concentrations. C/b gaps are potentially benign as they can fill with bone. Cement failure at points of s/c contact would generate debris hindering bone formation.


M.A. Frankle L.E. Ondrovic A. Kumar L. Harris W.E. Lee S. Gutierrez

There are multiple proximal prosthetic geometries available for a surgeon to select when humeral head replacement is indicated for four-part proximal humerus fractures. We compared different proximal prosthetic geometries in stable and unstable fracture patterns, with a standard tuberosity fixation method.

Simulated four-part fractures were created with an oscillating saw in six synthetic shoulder models. Three different proximal prosthetic geometries used polymetylmethacrelate (PMMA) – a smooth circular shape (SCS), a diamond shape (DS) and an irregular multiple fin shape (IMFS) prostheses. A standardised fixation method using vertical, and horizontal straps along with a medial based cerclage strap was performed. Passive motion was then carried out using a robotic articulator. Interfragmentary displacement was measured from tuberosity to tuberosity as well as tuberosity to shaft using mercury strain gauges.

The least amount of interfragmentary motion occurred when an IMFS was used in a stable fracture pattern. This geometry provided more interfragmentary stability even with the unstable fracture pattern than the DS or SCS. The least stable construct was the SCS prosthesis with an unstable fracture pattern.

Prosthetic geometry does affect stability of tuberosity reconstruction in proximal humerus fractures. An irregular shaped prosthesis augments the fixation construct. When using a smooth prosthetic design a stable fracture pattern must be achieved to prevent excessive interfragmentary motion. A smooth prosthetic design for tuberosity reconstruction is not recommended.


A. Race M.A. Miller D.C. Ayers K.A. Mann

There is little information available regarding mechanical aspects of cemented implant loosening and the initiation and development of cement damage. Previous studies have come to a variety of conclusions about the development of cement damage and the relative importance of voids, the stem/cement interface and the cement/bone interface.

Cement micro-cracks and stem/bone micro-motions were quantified for Charnley Cobra stems under “stair-climbing” loads. Six stem/cement/femur constructs were subjected to loads based on estimated body weight for 300 kcycles at 2 Hz; two additional constructs were not loaded. Transverse sections were cut at 10 mm intervals, stained with a fluorescent dye penetrant and examined using epifluorescence stereo-microscopy.

Despite the aggressive loading, all stem/bone micro-motions were small and all stems were “well fixed” at the end of the loading. The only consistent micro-motion was internal rotation but this did not significantly correlate with cement damage (p=0.9). For cyclically loaded constructs mean crack length was 0.49 mm (SD 0.37, range 0.07 to 4.42) and for non-loaded controls mean crack length was 0.25 mm (SD 0.18, range 0.03 to 1.16). Total crack length (46–281 mm) was significantly correlated (R2=0.819, p=0.002) with femoral head load (0 & 1.0–1.8 kN). There was a significantly (p< 0.05) greater proportion of damage at the cement/bone interface (66% ± 9) than at the stem/cement interface (28% ± 8). A small fraction of micro-cracks involved voids (5% ± 5), but these were significantly (p< 0.001) less than the cement/ bone fraction. Micro-cracks in unloaded specimens were evenly distributed axially (R2=0.0002, p=0.95) consistent with the theory that they were induced by cement shrinkage. ANCOVA for total crack density using head load and axial position as covariates showed a significant positive effect for head load (p< 0.0001) and a significant interaction between head load and axial position (p=0.001); under load, micro-crack density increased proximally, and this effect was stronger with increasing head load.


B.R. Burroughs D. O’Connor M. Sargent O. Muratoglu H. Rubash A. Freiberg D. Estok M. Jasty W.H. Harris K. Deluzio J. Krevolin U. Wyss M. Shen

A high proportion of complications following TKR occur at the patellofemoral articulation secondary to delami-nation and adhesive/abrasive wear. Electron beam cross-linking and melting has been shown to substantially reduce delamination and adhesive/abrasive wear in polyethylene tibial inserts. A series of in-vitro patella wear and fatigue tests were developed to explore the benefits of this material at the patellofemoral articulation.

Patellae (NKII, Sulzer Orthopedics, Inc., Austin, TX) were tested on an AMTI (Watertown, MA) knee simulator articulating against the trochlear grove of the femoral component. The simulator controlled flexion/ extension and patellofemoral contact force. Each test included patellae manufactured from conventional and electron beam crosslinked and melted polyethylene. Three different simulations were created: i) normal gait (5 million cycles) with optimal component alignment, ii) stair climbing (2 million cycles) with optimal component alignment, iii) stair climbing (2 million cycles) with 4° of femoral component internal rotation to simulate a component malalignment condition. In the last two simulations all patellae were artificially aged for 35 days in 80°C air to simulate one aspect of the long term oxidative state of each material.

In normal gait, the unaged conventional and highly cross-linked materials demonstrated similar behaviour. In stair climbing with optimal component alignment, the aged conventional patellae developed cracks by 2 million cycles. In stair climbing with component malalign-ment the aged conventional patellae developed cracks and delamination by 1 million cycles. None of the highly cross-linked components showed cracks or delamination. These results demonstrate the potential advantage of highly cross-linked polyethylene for the patella.


O.P.P. Temmerman I.C. Heyligers L. Hooft G.J.J. Teule O.S. Hoekstra1 P.G.H.M. Raymakers

With the growing number of patients that are being treated with hip arthroplasty, the number of patients that require revision surgery is increasing as well. In clinical practice, the diagnosis of a loose hip prosthesis is, in addition of clinical evaluation and radiographic techniques, often made using scintigraphic techniques. However, with regard to the performance of these techniques, reported results have shown to be inconsistent or sometimes even contradict when assessing the acetabular component. Therefore, in order to evaluate the test performance and efficacy of radiographic and scintigraphic techniques in the evaluation of patients suspected of aseptic loosening of acetabular components, we conducted a systematic review and meta-analysis of clinical studies.

In order to identify all studies that examined the use of radiographic or scintigraphic techniques in the evaluation of aseptic loosening of the acetabular component, we used systematic methods to identify English-language published papers and human-adult studies published between January 1975 and December 2001. Using a modified checklist, designed by the Cochrane Methods Group on Systematic Review of Screening and Diagnostic Tests, a quality analysis was performed by two independent reviewers.

There were 18 studies (n=1026) analysing the performance of plain radiography, 24 studies (n=825) regarding contrast arthrography, five studies (n=203) describing the performance of nuclear arthrography and 15 studies (n=549) regarding bone scintigraphy. Pooled sensitivity for plain radiography was 77% (spec. 82%), contrast arthrography revealed a sensitivity of 82% ( spec. 73%), nuclear arthrography 82% (spec.58%) and bone scintig-raphy 70% (spec.73%).

Pooled sensitivity and specificity showed that plain radiography, due to the high specificity, appears to be the technique of first choice in the assessment of patients suspected of aseptic loosening of a acetabular component, followed by contrast arthrography, due its higher specificity compared with nuclear arthrography. However, the methodological quality of the majority available studies was limited.


R. de Steiger B. Swoboda C. Westphal K. Schmidt M. Wiese M. Slomczykowski

Correct alignment is important for success in total knee replacement. Currently this is achieved by a combination of intramedullary and extramedullary alignment using jigs and cutting blocks. This multicentre study evaluates the use of computer assisted planning and the interactive guidance of instruments for total knee replacement.

Prior to surgery computer scans of the hip, knee and ankle were performed of patients enrolled in the study. Pre operative planning of the position and size of the knee components was performed by the surgeon using a CT based Vector Vision Navigation System (Brain LAB AG, Heimstetten, Germany). P.F.C.x (De Puy Leeds UK) knee replacements were then implanted in 38 patients. Surgery was carried out according to the standard surgical technique using traditional instruments. Information of the planned and intraoperatively recorded position of the cutting blocks were analysed to check varus/valgus alignment, flexion/extension alignment, the amount of planned resection from both the femoral and tibial bones and the size of the components. Information from all the separate centres was sent to a central data processing base for analysis.

Results were calculated comparing the differences between the planned and performed cuts for each of the different variables studied. Graphs demonstrate the differences in the alignment between that planned by the surgical navigation system and what was actually carried out by the instrumented cuts.

Based on the data obtained from the multicentre study we have concluded that the planned position of the implants using the standard instruments was similar to that using the Vector Vision Navigation System. We believe that it is safe to proceed with surgical navigation total knee arthroplasty using the P.F.C.x total knee prosthesis with Image Guided Surgery and a further multicentre study is currently underway evaluating this.


T. Yamaguchi M. Naito I. Asayama T. Ishiko T. Kambe M. Fujisawa

There are many previous reports dealing with the relationship between the abductor moment arm or femoral offset (FO), and other factors such as the abductor muscle strength after total hip arthroplasty (THA). Moreover, there have been no studies involving quantitative examination of the influence of posterolateral reconstruction on abductor muscle strength and FO. This study was to evaluate posterolateral reconstruction including posterior capsule, piriformis tendon and external rotators in THA and the relationship among the posterolateral reconstruction, abductor muscle strength, and FO.

We arbitrarily selected 48 limbs of 24 patients who underwent unilateral THA using a posterolateral approach. In 16 patients (12 women and 4 men; mean age, 66.8 years; range 50 to 82 years), posterolateral reconstruction was not performed (non- reconstruction group). In eight patients (6 women and 2 men; mean age, 61.6 years; range 52 to 72 years), posterolateral reconstruction was performed (reconstruction group). None of the selected cases were revision cases, cases in which the patient showed marked acetabular dysplasia, or cases involving the osteotomy of the greater trochanter. We compared these two groups. FO was measured on standard antero-posterior hip radiographs. Isometric abductor muscle (N) was measured with hand-held dynamometer. Each muscle strength was converted into a ratio of force to body weight (N/kg), and this ratio was used for comparison.

The reconstruction group showed higher value than the non-reconstruction group on the abductor muscle strength (p< 0.05). The correlation was recognised in the reconstruction group between abductor muscle strength and FO (p< 0.01 r=0.68).

There have been no studies involving quantitative examination of the influence of posterolateral reconstruction on abductor muscle strength and FO. Our results suggested that posterolateral reconstruction and appropriate reconstruction of FO were important in order to obtain the improvement on the abductor muscle strength after THA.


H. Oonishi S.C. Kim I.C. Clarke T. Asano B.S. Bal M. Kyomoto S. Masuda

According to the knee simulator test results in 1970s, the total decrease in thickness of UHMWPE tibial tray in combination with ceramic femoral component [F-Comp] was less than one tenth as that of the combination with metal [1]. These advantages led to development of total knee prosthesis [TKP] with alumina ceramics. In this study, we report the wear surface observation, the clinical wear and the oxidation of the retrieved TKP used clinically for 23 years, comparing with a metal TKP.

The retrieved TKP was implanted in 1979, and retrieved on January 9th in 2002. This TKP consisted of an alumina ceramic F-Comp and a UHMWPE tray combined with a alumina ceramic tibial component. Observations of the surface of alumina F-Comp and UHMWPE tray were carried out using SEM. Shape of UHMWPE tray was determined three-dimensionally. Comparing the result with original shape based on the product’s plan, liner wear and volumetric wear were calculated. Oxidation index was determined by Fourier transform infrared spectrophotometry.

Alumina F-Comp did not have any scratch on the surface by seeing with naked eye. UHMWPE tray had deformation and scratches obviously. The liner wear rate was 37 micrometer/year and volumetric wear rate was 18.8 mm3/year. The oxidation indexes were 0.6 in the unworn area, 1.2 in the worn area and 0.2 in the inner area.

SEM observations of the F-Comp demonstrated no scratch or pit. In contrast, many scratches were clearly observed on the UHMWPE tray. However, higher magnification observations did not demonstrate severe wear, which was shown on the wear analysis of a metallic F-Comp. Oxidation degradation is a problem to solve. However, the low wear rate and mild wear pattern demonstrate that ceramic F-Comp reduced UHMWPE wear.


Y.S. Yoon T.R. Oxland A.J. Hodgson C.P. Duncan B.A. Masri J.J. Lee

In clinical studies of cemented total hip arthroplasty (THA), polished stems produce less slippage at the bone-cement interface than roughened stems. Our objective is to assess the effect of stem-cement debonding on the bone-cement interface shear behaviour of hip implants using simplified axisymmetric stem-cement-aluminum models.

We emulated the femoral stems using stainless steel tapered plugs with either a rough (i.e. bonded) or smooth (i.e. unbonded) surface finish. Three different taper angles (5°, 7.5°, 10°) were used for the unbonded constructs. Non-tapered and tapered (7.5°) aluminum shells were used to emulate the diaphyseal and metaphyseal segments of the femur. In all cases, the cement-aluminum interface was designed to have the same shear strength as has been reported for bone-cement interfaces (~8 MPa). The test involved applying axial compressive loading at a rate of 0.02 mm/s until failure. Six specimens were tested for each combination of the parameters.

The unbonded stems sustained about twice as much load as the bonded stem, regardless of taper angle, and the metaphyseal model carried 35-50% greater loads than the diaphyseal models before shear failure or slippage. The unbonded constructs reached peak load with excessive displacement due to creep of the cement mantle while the bonded constructs failed in shear at the cement-aluminum interface. This result supports the hypothesis that the wedging forces created in the unbonded construct increase the compression forces across the aluminum-cement interface, thereby increasing its shear resistance. A finite element analysis predicted that the cement could withstand the hoop stress under these loading circumstances and this prediction was confirmed by visual inspection of the cement after each test.

Our results suggest that smooth or unbonded stems should sustain less slippage and shear damage at the bone-cement interface than roughened or bonded stems due to the wedge-induced compressive stress; this increased load capacity will be particularly valuable when the condition of the bone-cement interface is suboptimal.


J.N. Argenson S. Airaudi J.M. Aubaniac

This comparative clinical and radiographic study evaluates the role of implant design and positioning on maximum postoperative flexion after TKR.

Two groups of cemented posterostabilised mobile prosthesis were studied. In group A (23 cases) bearing mobility was possible in rotation and translation. In group B (36 cases) solely rotation was possible and the radius of the posterior femoral condyle was larger. In both groups the same medial transquadricipital approach was used and the postoperative rehabilitation was identical.

There were no significant difference between the two groups for patient age, sex, weight and etiology. The average preoperative flexion was 120.8° in group A and 120.7° in group B. The average postoperative flexion at one year was 114.8° in group A and 130.4° in group B. Instability was noted twice in group A and none in group B. Radiographically there was no difference in mechanical axis or patellar height. There was a difference in joint line elevation and anteroposterior joint size.

Higher flexion angle may be related to smaller antero-posterior joint size, better posterior osteophytes removal and larger posterior femoral condyle radius. Greater stability correlates with greater jumping distance over the tibial post. This study showed that deep flexion can be achieved in some patients after TKR, with implications on surgical technique and implant design.


P.A. Grützner B. Vock U. Langlotz J. Korber L-P. Nolte A. Wentzensen

After experimental and preclinical evaluation (HAP Paul Award 2001) of a CT-free image guided surgical navigation system for acetabular cup placement, the system was introduced into clinical routine. The computation of the angular orientation of the cup is based on reference coordinates from the anterior pelvic plane concept. A hybrid strategy for pelvic landmark acquisition has been introduced involving percutaneous pointer-based digitisation with the non-invasive bi-planar landmark reconstruction using multiple registered fluoroscopy images.

From January 2001 to May 2002 a total of 118 consecutive patients (mean age 68 years, 82 male, 36 female, 62 left and 56 right hip joints) were operated on with the hybrid CT-free navigation system. During each operation the angular orientation of the inserted implant was recorded.

To determine the placement accuracy of the acetabular components the first 50 consecutive patients underwent a CT scan seven to ten days postoperatively to analyse the cup position related to the anterior pelvic plane. This was done blinded with commercial planning software. There was no significant learning curve observed for the use of the system.

Mean values for postoperative inclination read 43° (SD 3.0, range 37 to 49) and anteversion 19° (SD 3.9, range 10 to 28). The resulting system accuracy, i.e., the difference between intraoperatively calculated cup orientation and postoperatively measured implant position shows a maximum error of 5° for the inclination (mean 1.5°, SD 1.1) and 6° for the anteversion (mean 2.4°, SD 1.3).

An accuracy of better than 5° inclination and 6° ante-version was achieved under clinical conditions, which implies that there is no significant difference in performance from the established CT-based navigation methods. Image guided CT-free cup navigation provides a reliable solution for future THA.


R.E. Field T.G. Kavanagh. P.J. Singh

Hip resurfacing is widely recognised as a bone conserving procedure with respect to proximal femoral resection. However, it has been argued that this is not the case for the acetabulum due to the thickness of the acetabular component and the large diameter bearing surfaces. We have investigated whether the Birmingham Hip is a bone conserving procedure with respect to the acetabular bone stock.

Data was obtained from 257 consecutive Midland Medical Technology (MMT) surface replacements and 458 primary hybrid total hip replacements implanted under our care. The surface replacement group comprised 185 males (185 hips) and 72 females (72 hips) with a mean age at surgery of 55 years. The hybrid primary total hip replacement group comprised 207 males (207) and 251 females (251 hips). The mean age at surgery was 65 years old. In the surface replacement group the mean uncemented acetabular size implanted was 54.88 mm (females = 51.9 mm; males = 57.8 mm). In the hybrid primary total hip replacement group the mean uncemented acetabular size of 55.04 mm (females =52.9 mm; males = 57.2 mm).

Statistical analysis was undertaken to compare the uncemented acetabular sizes in the surface replacement group with the uncemented acetabular sizes implanted in the primary hybrid total hip replacement group. We report no significant difference in the size of acetabular component used for the two groups (p = 0.4629; 95% C.I. −0.28 to 0.61). The effect of gender was analysed and the mean size of uncemented acetabular component implanted in males for the surface replacement group was not significantly different (p = 0.06) to the hybrid primary total hip replacement group. However the mean size of uncemented acetabular component in females for the surface replacement group was significantly smaller (p = 0.016) compared to the primary total hip replacement group.

We conclude hip resurfacing is not bone sacrificing on the acetabular bone stock and can be bone conserving for females.


K.A. Hing E. Damien T. McInness P.A. Revell

The use of porous ceramics as bone graft substitutes (BGS) has been under consideration for over 30 years [1]. In particular calcium phosphates such as hydroxyapatite (HA) have been promoted as a result of their osteoconductive properties, i.e. that they stimulate bone apposition within their macroporous structures.

It is well established that both pore size [1] and pore connectivity [2] are critical morphological elements for a successful BGS. Thus biologically ‘optimal’ structures, with relatively large levels of porosity (> 70%) are consequently low in mechanical strength, with typical UCS values of between 1–8 MPa depending on the precise level of porosity and the pore size distribution. The aim of this investigation was to study the biological response to a porous HA with a relatively low level of macro-porosity (64%), but which possessed a highly interconnected micro-pore structure within the HA struts.

Phase pure porous HA implants were manufactured using a novel technique [3] with a mean macro-pore size of 230 ìm and a mean pore interconnection size of 110 μm. Cylindrical specimens 4.5 mm in diameter were implanted in the distal femur of 6 month New Zealand White rabbits and retrieved for histological and histomorphometric analysis at 4 weeks. The mineral apposition rate (MAR) was determined through the administration of fluorochrome labels at 1, 2 and 3 weeks.

After 4 weeks new bone had penetrated deep within the macro-pore structure and at high magnification osteocyte-like cells were observed occupying micro-pores within the ceramic struts. Furthermore, there was a significant increase in the MAR of bone formed within and surrounding the PHA (5.21 ìm.day-1, 4.42 ìm.day-1) as compared to the normal turnover rate of control bone (2.07 ìm.day-1, 2.09 ìm.day-1) during weeks 1-2 and 2–3, respectively.

The micro-porous network within the scaffold struts clearly influenced the host response. This could be linked to an associated increase in roughness or surface area, or it may reflect the greater level of strut permeability underlining the importance of nutrient transfer and the promotion of angiogenesis in scaffolds for bone repair.


P. Thümler M. Starker A. Weipert S. Hannusek

With 3D CT data of proximal femora it is possible to develop a computer programme for optimising femoral component fit and simulation of implantation. The implantation of the femoral stem can be simulated with any femoral component that has cortical press fit.

Five different currently used femoral components were virtually “implanted” in over 200 different femoral bone data. Optimal femoral fit was defined, when the component showed best diaphyseal and metaphyseal congruent contact with all CT data available. Position of neck and head were secondary, since an optimal press fit situation had priority in our set-up. Best fit was considered taken cortical contact and reconstruction of joint geometry into account.

There were numerous failures in all tested standard components, when correct angle of antetorsion, off-set, and leg length were expected. There were considerably better results with the use of CTX standard prosthesis (CTX-S).

The data of this study indicate a high proportion of less optimal fit with femoral standard components tested in this series. Indication for choosing CTX-S femoral components is dependent upon the individual geometry of dysplastic hip joint and the simulation results of standard components using the VIP method.


K.A. Mann A. Race M.A. Miller D.C. Ayers

Highly polished femoral stems with a double taper have had outstanding long-term clinical results. Recently a stem with a third, cross-sectional taper was introduced with the goal of providing additional stability while still utilising the polished taper concept.

The goal of the present study was to determine if there were differences in the mechanical stability and cement damage due to cyclic loading of a triple-tapered (C-stem, J& J-DePuy) and a double-tapered design (TPS, J& J-DePuy). Six pairs of cadaveric femurs were cemented with either C-stem or TPS stems using contemporary techniques. Specimens were cyclically loaded using a stair-climbing apparatus with femoral head and abductor loads for 1 000 to 266 000 loading cycles. Motion between the stem and bone was measured using a 6 dof measurement system. Following testing, specimens were sectioned at four transverse levels and the number and length of cracks in the cement were measured.

All stems were extremely well fixed after loading. The C-stem did not subside during loading except for one outlier that was cemented ‘high’. The TPS stem had a pattern of rapid subsidence over the first 100 cycles (mean 0.032 mm) followed by a more gradual subsidence (0.05 mm at 266 k cycles). ANCOVA showed that the TPS-stems rotated significantly more than the C-stems (p< 0.0001), that the rotation of both stems increased with number of loading cycles (p=0.022) and that the effect of number of loading cycles was greater for the TPS stems (p=0.047). Total crack length was not a function of number of loading cycles, nor was it different for the two stem designs (p=0.33).

The outlier C-stem had micromotion behavior similar to the TPS stem. The reason for this is unclear, but could be due to reduced lateral-proximal cement. Thus it is possible that both the stem cross-sectional and in-plane shape contribute to the stability of the C-stem design.


J. Stolk N. Verdonschot R. Huiskes

Proper pre-clinical testing of cemented THA implants may help to prevent bad implants from entering the market. Within the frame of a multinational EU-program, a finite element (FE) simulation was developed, for FE-based pre-clinical testing of cemented THA stems against the damage accumulation failure scenario. The simulation allows monitoring of cement crack formation and implant migration in cemented THA reconstructions. The current study is concerned with the clinical validation of the test. The damage accumulation failure scenario was simulated for four cemented hip stems, with well-known survival rates. The question was: Can the FE simulation rank the stems according to their clinical survival rates?

Four stems were analysed: the Lubinus SPII, the Exeter, the Charnley and the Mueller Curved. The Swedish hip register [1] reports survival rates of 4, 5, 8 and 13%, respectively, at 10 years after surgery. Four FE models were created, representing cemented THA reconstructions with the four stems in composite femurs. The stem-cement interfaces were unbonded (m = 0.25). A loading history was applied to the models, representing 20 million cycles of alternating walking and stair climbing. Using a 3D continuum damage mechanics approach, the damage accumulation and creep processes in the cement, and subsequent prosthetic migration were monitored.

The Mueller C. produced a considerably higher number of cement cracks than the other three stems. Cracks were formed around the entire stem. The cracked zones often extended over the thickness of the mantle. The Charnley performed better, with a lower number of cracks. Proximo-distal damage pathways were formed, although at a much lower rate than around the Mueller C. The Exeter performed better. Full thickness crack zones were produced only in the proximo-medial region. The Lubinus performed best, with the lowest number of cement cracks. No full thickness cracks were formed. Concerning migration, the Exeter migrated more than the other stems. From the collared implants, the Lubinus SPII showed the lowest migration values.

When considering the number of cement cracks produced in the simulation, the ranking of the stems would be, from superior to inferior: Lubinus SPII, Exeter, Charnley, Mueller Curved. This ranking corresponds to a ranking based on clinical survival rates. The stems behaved according to their design concepts, with the highest migration values for the Exeter stem. In conclusion, the FE simulations produced a clinically valid ranking of four cemented THA implants. This corroborates the use of the FE simulation for pre-clinical testing purposes.


I. Tatsumi S. Makajima Y. Kadoya K. Takaoka

The new 3-Dimensional (3D) polyethylene wear measurement software GAWDI (Genetic Algorithm for Wear Detect Instrument) was developed to evaluate in vivo movement of the femoral head into the polyethylene liner. It enabled to detect 3D position of femoral head against polyethylene socket from two radiographs. Inter observer error of this system was 0.09 mm, intra observer error was 0.08 mm. Fifteen patients after THA was taken anterior-posterior (AP) and semi-lateral radiographs in both standing and supine position one year post operation. The difference of the 3D position of the femoral head was not observed between standing and supine position. However 8.1 degrees (mean) and 0.2 to 16.5 degrees (range) pelvic tilt was observed between these positions. 0.8 mm (mean) difference was observed by 2-Dimensional measurement system although no difference was observed by 3D system. Small separation between head and socket was observed in a few patients. However the influence of pelvic tilt was main origin of the difference between 2D and 3D measurement methods.


H.G. Pandit A.J. Price J.L. Rees D.J. Beard H.S. Gill C.A.F. Dodd D.W. Murray

The indications for unicompartmental knee arthroplasty (UKA) can be contentious. Concerns exist about implanting a UKA in younger individuals. It has been reported that it is contra-indicated in patients under the age of 60. The suggestion is that younger patients may compromise their outcome after surgery by their increased activity levels. However, the number of publications with data on UKA in young patients is minimal and the age/activity related criteria for UKA remains unknown.

The aim of the study was 1) to confirm that younger UKA patients have higher activity levels than older patients, and 2) to test the hypothesis that younger, more active patients have inferior outcome when compared to older less active patients.

Fifty consecutive patients undergoing UKA who were under 60 years (Group Y) and 50 patients over 60 years (Group O) were recruited. Indications were anteromedial arthritis with full thickness lateral compartment cartilage, a functioning ACL and a correctible varus. All patients underwent Oxford UKA using the minimally invasive technique. This device employs an unconstrained fully congruous meniscal bearing. Outcome was evaluated using Knee Society Scores. Activity level was documented using Tegner Activity Score.

Average age of patients for group Y and O was 55 and 68 years respectively. Minimum follw-up was 2 years. pre-op. knee scores were comparable for each group. (y: 38.8, O: 35.8) and patients in both groups siginificantly improved after surgery. A significant difference in Tegner score was found between the two groups after surgery (y:4.1, O:2.6). More than 50% of younger patients regularly participated in high demand activities like skiing, tennis and manual labour. No statistically significant differences in any other post op. knee scores or complication rate were found despite adequate study power.

Younger patients have increased activity levels after UKA when compared to an older age group. There is no evidence that the outcome of UKA in younger more active patients will be inferior to those who are older and more sedentary.


B. Kleffner P. Thümler P. Brehm P. Müller

The disadvantages of sawing for precise bone cuts are well known: untrue cuts, heat and metal wear. The main limiting factors of available milling devices are the difficult handling and high costs, especially if the devices are based on a robot. Supported by clinical users and mechanical engineers a milling concept adopted from industrial machining has been realised in order to overcome this limitations. The “All-in-One Milling-Tool” achieves the same precision of a robot by a mechanically guided milling resection far below the necessary investment for a robot. Once fixed at the femur, the device allows all femural and tibial resections. Three methods are provided for the alignment of the resection planes and will be discussed: intramedullary adjustment, 3D CT-based planning and intramedullar performance as well as the performance under navigation control. All versions are based on a handheld resection and guarantee a visual and haptical feedback for the surgeon. The use of navigation has the advantage of the accurate transfer of the 3D plan into the OR, the interactive guided and facilitated alignment und resection steps and the documentation of planned and actual implant position.


P.R. Aldinger D. Sabo S.J. Breusch

We analysed periprosthetic bone mineral density (BMD) by dual-energy X-ray absorptiometry (DEXA) in patients after uncemented total hip arthroplasty (THA) (press-fit CLS Spotorno stem). Only patients with good clinical outcome (Merle d‘ Aubigne score > 12) were included to obtain normative data for regular bone response.

Two separate studies were performed: A prospective longitudinal study over a time period of 7 years (group A) (n = 26 patients: 12 women, 14 men) and an additional cross-sectional study, mean follow-up13 years (10 to 15 years) (group B) (n = 35 patients: 18 women, 17 men). Regions of interest were defined according to Gruen (ROI 1–7) and as netto average ROI (NETAVG) for the periprosthetic femoral bone. After the initial remodelling process, BMD at 1 year was compared to the 7-year (longitidinal) and to the 13-year (cross-sectional) follow-up values of the affected limb to determine long term periprosthetic changes of bone mineral density.

The longitudinal study (group A) showed BMD values of 91.1% and 92.8% after 1 year, 91.2% and 90.2% after 7 years compared to the initial post-operative values for women and men, respectively. ROIs around the proximal stem (ROI 1 and 7) showed the lowest absolute values and decreased most during follow-up (ROI 1: 80.7% and 84.5%, ROI 7: 71.1% and 75.5% after 7 years, for women and men respectively). In the cross-sectional study (group B) BMD was determined 89.1% and 87.8% after 13 years compared to the initial values of group A for women and men. Distribution of BMD in ROIs 1-7 (group B) showed no significant changes compared to the 1 year and 7 year results of group A. The results reflect normative long term changes in the periprosthetic bone after implantation of THA in defined ROIs of a well functioning tapered corundum-blasted titanium stem.


A. Aamodt K. Haugan P. Benum

CT-based, customised femoral stem enables optimal reconstruction of hip mechanics and leg length. However, traditional planning and execution of cup insertion may jeopardise these biomechanical parameters. The aim of this study was to examine the agreement of the preoperative planning of cup position and the final position of the cup.

Thirty total hip replacements with an uncemented acetabular cup (Duraloc, DePuy) or a cemented cup (Elite-Plus, DePuy) were included. A customised femoral stem was used in all hips. On the preoperative X-rays the planned position and orientation of the cup had been marked prior to the surgery. The pre- and postoperative X-ray images were then digitised and scaled. The planned and final positions of the cup centre in the frontal plane was then measured relative to a horizontal line defined by the tear-drops and to a vertical line through the centre of the tear-drop on the operated side. In addition the concurrence between the planned and final cup size was examined.

In the horizontal direction the cups were positioned 1.4 (7.6) mm (median, ±2SD) more medial than planned on the preoperative X-rays. In the vertical direction the corresponding figures were 1.2 (6.6) mm (median, ±2SD) and the cups were usually placed more cranially than was planned. The maximum discrepancy between the planned and final position was 10,6 mm in the horizontal direction (medial) and 7.1 mm in the vertical direction (cranial). In 63% of the hips there was agreement between the size of the cup planned preoperatively and the cup that was finally inserted. In 25% of the hips the final cup was larger and in 12% the final cup was smaller.

In most cases the acetabular cups were inserted within a few millimetres of the planned position. The combination of a standard uncemented or cemented cup with a custom femoral stem enables the surgeon to restore hip mechanics and leg length.


D.M. Sirkett G. Mullineux L. Leonard G.E.B. Giddins A.W. Miles

The wrist is arguably the most complex joint in the body and is essential for optimal hand function. The joint may be represented as two roughly orthogonal hinge axes, providing flexion-extension and radial-ulnar deviation. The location and orientation of these axes with respect to the underlying anatomy is essential for the design of successful joint prostheses. A population study was performed in order to obtain the parameters of this two-hinge joint.

Data for 108 normal right wrists was gathered using a Fastrak electrogoniometer with sensors fixed to the distal medial radial styloid and the distal third metacarpal head. Data was recorded as a series of three-dimensional coordinates covering the entire locus of movement.

The two-hinge geometry of the joint was represented mathematically with nine parameters describing the configuration of the axes and two angles controlling rotation about these axes. The configuration giving the closest kinematic match to the experimental data was determined using two nested optimisation processes. During the inner optimisation process, the third metacarpal head was brought as close as possible to each of the experimental points in turn by adjusting the two positioning angles. The sum of distances from each experimental point to the point of closest approach gave the “cost” of the current configuration. The outer optimisation process repeated the inner process iteratively, minimising the cost by adjusting the nine configuration parameters.

The double optimisation method was found to offer an innovative solution to the problem of analysing kinematic data from a population study. The mean joint configuration showed the axis of radial-ulnar deviation to be 1.9 mm (sd = 12.5 mm), distal to the flexion-extension axis, with axes almost orthogonal to one another. This data together with the radii of the rotations is invaluable in determining the optimal articulation geometries for wrist joint replacement prostheses.


B.M. Jolles P. Genoud P. Hoffmeyer

To determine the precision of conventional versus computer assisted techniques for positioning the acetabular component in total hip arthroplasty (THA).

Malposition of the acetabular component during THA increases the occurrence of impingement, reduces range of motion, and increases the risk of dislocation and long-term wear. To prevent malpositioned hip implants, an increasing number of computer assisted surgery systems have been described, but their accuracy is not well established.

Using a lateral approach, 150 cups were placed by 10 different surgeons in 10 identical plastic pelvis models. Only the immediate operating field was visible. Pre-operative planning was performed with a computerised tomography scan. Fifty cups were placed free hand, 50 others with the standard cup positioner, and the remaining 50 cups using computer-assisted orthopaedic surgery (Medivision). The accuracy of cup abduction and anteversion was assessed with an electromagnetic system (Fastrak™).

Using conventional techniques, free hand placement revealed a mean precision of cup anteversion and abduction of 10° (range 5.5 to 14) and 3.5° (2.5 to 5) respectively. With the cup positioner, these angles measured 8° (5 to 10.5) and 4° (3 to 5.5) respectively, and using the computer assisted method, the mean cup anteversion precision was 1.5° (1 to 2) and mean cup abduction measured 2.5° (2 to 3.5).

Computer assisted cup placement is a very accurate and reproducible technique during THA. It is clearly more precise than either of the two traditional methods of cup positioning, even for well-trained surgeons.


H.E. Ash S.C. Scholes R. Parkin A. Unsworth

Modular knee bearings typically consist of a femoral component, a tibial base-plate and a polyethylene insert, which is located in the tibial base-plate using some sort of locking mechanism. Although modular knee bearings offer many advantages there is the potential for micro-motion between the tibial insert and the base-plate.

Tests were performed on six large Kinemax Plus knee bearings (snap-fit design) to evaluate the amount of movement between the tibial inserts and the tibial base-plates. The knee bearings were tested up to one million cycles on the Durham Six-Station Knee Wear Simulator which subjected the bearings to similar motion and loading profiles that would be experienced by the natural knee during walking. The movement of the tibial inserts was measured with dial gauges (accuracy of ±0.01 mm) before and after the bearings were tested on the simulator, when unloaded, and throughout the tests whilst the bearings were being dynamically loaded in the simulator. Movement occurred between the tibial insert and the tibial base-plate after initial assembly due to the snap-fit mechanism used to locate the tibial insert within the tibial base-plate. However, this decreased appreciably when the bearings were loaded in the simulator. The amount of movement did not change with time when the bearings were continuously loaded in the simulator. However, after each test the amount of movement of the tibial inserts, when unloaded, was less than before the test. This was thought to be due to creep of the UHMWPE inserts. The movement between the tibial insert and tibial base-plate in-situ is likely to be much less than that observed by a surgeon at the time of assembly due to loading of the knee bearing in the body. However, the amount of movement when the tibial inserts are loaded may still be great enough to produce a second interface where wear of the tibial insert may take place.


B.L. Kaptein E.R. Valstar B.C. Stoel P.M. Rozing J.H.C. Reiber

To measure micromotion of an orthopaedic implant with respect to its surrounding bone, Roentgen Stereo-photogrammetric Analysis (RSA) was developed. A disadvantage of conventional RSA is that it requires the implant to be marked with tantalum beads. This disadvantage can potentially be resolved with model-based RSA, whereby a 3D model of the implant is used for matching with the actual images and the assessment of position and rotation of the implant. In this study, an improved model-based RSA algorithm is presented and validated in phantom experiments. This algorithm is capable to process projection contours that contain drop-outs. To investigate the influence of the accuracy of the implant models that were used for model-based RSA, we studied both Computer Aided Design (CAD) models as well as models obtained by means of Reversed Engineering (RE) of the actual implant.

The results demonstrate that the RE-models provide more accurate results than the CAD models. If these RE models are derived from the very same implant, it is possible to achieve a maximum standard deviation of the error in the migration calculation of 0.06 mm for translations in x- and y-direction and 0.14 mm for the out of plane z-direction, respectively. For rotations about the y-axis, the standard deviation was about 0.1 degree and for rotations about the x- and z-axis 0.05 degree. For the femur component, it was also possible to reach these accurate results for non-scanned components. The results show that the new algorithm is an improvement with respect to a study we presented earlier [1].

Studies with clinical RSA-radiographs must prove that these results can also be reached in a clinical setting, making model-based RSA a possible alternative for marker-based RSA.


H. Iwata K. Hirose H. Takagi K. Hosono M. Yanase

The aim of the study was to evaluate THA using Robodoc system for osteoarthritis of the hip joint.

The Robodoc system consists of: 1. the Orthodoc computer workstation that simultaneously displays computerised tomography images of patient’s femur and a selected prosthesis, 2.a five-axis robot, 3.the operating room display, 4. the control cabinet.

Follow up were 3months and 1 year on 27cases (Male 5, Female 22). Selected stems: Zimmer anatomic, 13, Versis 14(VSS,7, VSL,7). Mean age 57.9. Among 27 cases of osteoarthritis, one is after osteotomy and two are after osteonecrosis. Pain, ROM, Radiographs and ADL were evaluated using JOA hip score system. Sockets were fixed with cementless conventional technique.

Mean operating time, 2 hours and 40min.; Mean bleeding, 455 ml; Mean Ant. Version, 29.26 degree (22.0–39.7); Level of osteotomy of the femur neck, Mean, 9.19 mm from the trochanter minor. JOA hip score after THA, 82.20. In one case, 5 mm sinking occurred 5 days after the operation. No intraoperative femoral fractures and varus or valgus insertion of stems occurred in 27cases. The thigh pains were nothing. The patients were discharged at 4weeks after the operation with one crutch. The results showed statistically better fit and fill of the femoral component in the Robodoc system.

The Robodoc system is thought to be safe and effective in producing radiographically superior implant fit and positioning without fractures and other complication. Precise fit of the implant may be increase bone-to-implant contact, providing stress transfer from prosthesis to bone and more bone growth into prosthesis.


C. L. Barnes S. J. Incavo E. Mullins K. Coughlin S. Banks A. Banks J. DeBeers B. Beynnon

Kneeling is an important aspect of daily living. Our goal was to describe the in vivo tibiofemoral kinematics during standing and kneeling after total knee arthroplasty (TKA).

Ten posterior substituting (PS) and 10 cruciate retaining (CR) TKA designs were studied in 18 patients. Radiographs were taken when standing, kneeling at 90°, and kneeling at maximal flexion. An image matching technique provided three-dimensional measurements of the femoral component position relative to the AP midpoint of the tibial baseplate.

When standing, the CR tibiofemoral contact position (medial: 7 mm ± 3; lateral: 6 mm ± 3) was more posterior than the PS design (medial: 5 mm ± 2; lateral: 5 mm ± 2). Movement from standing to kneeling at 90° produced different responses. CR knees translated anteriorly (medial: 4 mm ± 4; lateral: 2 mm ± 6), while PS knees translated posteriorly (medial: 0.2 mm ± 3; lateral: 1 mm ± 4). During kneeling, movement from 90° to maximum flexion produced posterior translation of the femur (CR medial: 5 mm ± 4: CR lateral: 5 mm ± 4; PS medial: 6 mm ± 4; PS lateral: 6 mm ± 3). The relationship between the tibiofemoral contact position and flexion angle during kneeling was more variable for CR knees (r2=0.38) than PS knees (r2=0.64), indicating that PS knees provide a more reliable AP position than CR knees.

PS knees dislocate when the arch of the femoral cam slides over the tibial post; CR knees sublux when the femoral contact position translates beyond the edge of the tibial baseplate. The distance to dislocation averaged 13 mm ± 2 for PS knees, and 20 mm±4 for CR knees.

Many patients wish to resume normal activities, including kneeling after TKA. This study provides information for surgeons and patients considering kneeling after TKA.


D.C. Ayers R.K. Jain M. Rogers P.D. Franklin M. VanGlynn G. Bertolo

The effect of pre-operative pain, physical function, mental function and multiple patient factors on patient outcome following TKR was examined.

After informed consent, 105 patients undergoing primary TKR completed preoperative SF-36 and WOMAC questionnaires and a Knee Society Score (KSS) was determined. These scores were repeated at 12 months. Patient data studied included age, gender, BMI and significant comorbid conditions such as diabetes, cardiac disease, and COPD. Statistical analysis included a univariate analysis, followed by a bivariate analysis and multiple regression analysis.

All physical dimensions of the SF-36, WOMAC and KSS showed highly significant improvements after one year. The KSS improved to a mean of 94.8 (p< 0.000001). For patients greater than 65 years of age, postoperative physical function was returned to normative scores for age matched controls. For patients less than 65, physical function did not reach age matched controls even though similar improvements in physical function were seen. Patients with lower physical function scores (PCS) pre-operatively showed greater improvement postoperatively yet did not reach the same absolute level of function as patients who had higher preoperative physical function. The mean PCS for men increased from 35 to 42, while for women it increased from 29 to 42 (p=0.042). Preoperative mental function (MCS) was a strong predictor of postoperative physical function. Patients with low preoperative MCS and one or more comorbid conditions were 10.1 times more likely to have a poor outcome following TKR.

Knowledge of preoperative physical function, mental function, gender, age and comorbid conditions improves prediction of post-operative physical function after TKR. Patients at high risk for little improvement following TKR are those with low preoperative mental function (MCS< 50) in addition to one or more comorbid conditions. These patients can be identified during the pre-operative period.


G. Gasparini L. Tafuro S. Cerciello E. Pola E. De Santis

Aseptic loosening is one of the most frequent cause of total knee arthroplasty (TKA) failure; it is related to a fatigue-type wear which can rapidly break up a tibial polyethylene (PE) inlay. PE debris production is the result of this wear and depend on contact stress between the components. This crucial parameter is more related to conformity than to load tranfer. That is why mobile bearing TKA seems to represent a valid solution to the PE debris production. In fact this implant offers great tibio-femoral conformity without an increased risk of loosening due to increased axial torque. Mobile bearing TKA also eneables the surgeon to self correct tibial component malrotation. On the other hand this implant could lead to new problems such as bearing dislocation or breakage and a possible new wear pattern at the PE-tibial metal tray interface.

We performed 100 consecutive cemented posterior stabilised TKA using randomly in 50 cases a mobile bearing and in 50 cases the same implant with a fixed bearing. The mean follow up was 15 months. The results in mobile bearing group are the following. Hospital for Special Surgery (HSS) score improved from 38 to 91 after the surgery. Preoperative Range of Movement (ROM) was 71 while the post op value was 107. No lucencies > 1 mm were observed. There were no statistically significant differences among the mobile bearing group and the fixed bearing one. Despite our short follow up, this implant offers the same good clinical results if compared to other devices, and allows the surgeons to correct errors in positioning the implant.

In future we have to consider that this possibility will lead to an abnormal load stresses distribution and to a higher risk of late loosening.


W. Ward

Massive bone replacing endoprostheses have become a well-recognised option in reconstruction of massive bone defects following tumor resections of the humerus, femur and proximal tibia. While the design of such bone replacements is somewhat standardised, massive endo-prosthetic replacements of the proximal radius have not been described. Previous work with radial head replacements for arthritis and fracture indications has been performed, but a massive replacement of the proximal radius has not been reported. The design for such a prosthesis has not been described. Herein, we present our initial case with a massive custom proximal radius replacement, and the incorporated design features.

A 43 year old gentleman presented with progressive destruction of the proximal right radius from meta-static renal cell carcinoma despite radiation treatment. His systemic disease was under satisfactory control. He had undergone a nephrectomy (37 months previously), hip replacement for metastatic disease (28 months previously) and internal fixation of a humerus fracture (10 months previously). Prior treatment of his radius included cast immobilisation and radiation treatment of a pathologic fracture 13 months preoperatively. He refractured his partially healed pathologic fracture two weeks prior to presentation. Following staging with CT and MRI scan, a custom proximal radius endoprosthe-sis was designed that replaced 13 cm of the proximal radius. It was designed with 6 degrees of radial bow. The design specifics will be presented during the presentation. Surgical technique will be demonstrated. By one month postoperatively, his elbow range of motion was from 10 degrees to 140 degrees of flexion, with 90 degrees each of supination and pronation. He continued to have excellent use of his arm until he developed brain metastasis 10 months postoperatively.

Massive custom proximal radius endoprostheses of this design may be useful in the reconstruction of meta-static and primary tumors of the forearm. They are compatible with preservation of motion, and may provide additional stability to the elbow in patients whom soft tissue may be compromised due to tissue destruction or tissue loss secondary to neoplasia.


O.G. Meijer N. van den Dikkenberg R.M.A. van der Slikke R.C. van Lummel J.H. van Dieën B. Pijls R.J. Benink P.I.J.M. Wuisman

We present the rationale and design of the DynaPort KneeTest. The test aims at measuring knee patients’ functional abilities in an unobtrusive, user-friendly way. Test persons wear several belts around their trunk and legs. The belts contain accelerometers, the signals of which are stored in a recorder, embedded in one of the belts. The knee test consists of a set of 29 tasks related to activities of daily life (“test items”). Accelerometer signals are analysed in terms of 30 “movement features” (accelerations, angles, durations, frequencies, and some dimensionless numbers). In data analysis, the beginning and end of each test item is marked by hand; otherwise, analysis is automatic.

We compared 140 knee patients with 32 healthy controls and found 541 of the 29 x 30 =870 test item movement feature combinations differed significantly between the two groups. From these 541 combinations the DynaPort knee score is calculated by the weighted averages of movement features per item, then weighted averages of items per cluster (locomotion, rising and descending, transfers, lifting and moving objects), and finally the average of the clusters. In an initial study the test-retest reliability of the knee test proved high, and the test turned out to be sufficiently responsive (0.7 patients’ standard deviations improvement after 24 months). However, it remains difficult to interpret the scores in more meaningful terms than merely “better” or “worse”. Extensive reliability studies in the future will further assess the validity of the test and provide more insight into the meaning of the scores.

The DynaPort knee test may thus become an important instrument for evaluating patients’ functional abilities in knee-related clinical practice and research.


E. De Santis S. Cerciello L. Tafuro M. Marinangeli G. Gasparini

The problem of early mechanical stability and late biological osseointegration of the tibial component is still a debated issue in total knee arthroplasty. We are among those authors that stress the necessity of cementing the tibial component to avoid the risk of failure due to the high torque stresses at this interface. In fact while on the femoral edge a good stability can be achieved even in uncemented implants, the stability of traditional tibial components is harder to obtain even in cemented implants.

To solve this problem it has been proposed to use additional devices such as screws, pegs or keels to better fix the tibial plateau. Tantalum monobloc tibial tray is a new answer to this problem. It consists in a cement-less tibial tray made of porous tantalum with monobloc polyethylene. Chemical, physical and biological properties of the raw tantalum are very similar to those of titanium. Porosity of the processed material is 80% (2–3 times compared to plasma spray, beads and fiber mesh coatings) and pores, which diameter is 650 mm, are fully interconnected in the whole bulk of the implant. This trabecular spongy structure, that is not a coating, allows the bone at the interface to deeply grow into the pores, and to achieve optimal stability. In addiction, the fusion of polyethylene into the tantalum mesh completely abolish the back side wear problem. With this technology is yet in use an acetabular component, with which we have a 5 years experience in 150 implants, and now is available a new tibial plateau; the first implant in Europe was performed in our department.

Despite our short series and follow up (6 implants in 2 months) the properties of porous tantalum, already tested in acetabular implants, represent an alternative to the traditional ways of tibial tray fixation.


S.A. Banks W.A. Hodge

Tibiofemoral motions are fundamental to the function (strength, stability, ROM) and longevity of total knee replacements (TKR). Although a wide range of TKR kinematics have been reported, few studies have reported kinematics of a single TKR design utilising a variety of tibial articular surfaces. We hypothesised that increased articular constraint, from four different tibial inserts, would result in reduced tibio-femoral translations during dynamic activities.

We tested 22 knees with excellent early clinical outcomes after primary TKR. All knees received the same PCL retaining arthroplasty; with six curved tibial inserts, six flat inserts, six laterally pivoting inserts and four translating/rotating mobile bearing inserts. Fluoroscopic images of knees were acquired during gait, stair, and deep flexion activities. CAD model based shape matching was performed to determine 3D knee kinematics.

There were significant differences in medial condy-lar translations for all activities, none for the lateral condyle. The medial condyle in knees with flat and mobile bearing inserts translated more anterior with flexion than knees with curved or pivoting inserts. Medial condyle translations were greater in mobile bearing knees than knees with flat inserts.

Our results indicate that condylar motions in TKR’s during dynamic activities can be modulated in a reasonably predictable manner by varying the degree of tibio-femoral constraint. Furthermore, the results show that significant control of translation can be achieved through asymmetric tibial insert conformity. These findings suggest it is possible to achieve a particular pattern of tibio-femoral translations and rotations in vivo through careful selection or design of the articular geometry.


T.M. Wright S.A. Maher B.D. Furman

Improving the wear resistance of polyethylene is considered paramount to improving knee implant longevity. Consequently, a range of polymer fabrication techniques have evolved in the quest for a highly wear resistant material. The objective of this study was to explore the wear performance of polyethylene as fabricated in a variety of ways.

The following materials were prepared, sterilised, artificially aged, and machined into wear specimens (n = 4 for each material): Compression molded GUR1050 with three levels of cross-linking (120 kGy, 65 kGy, and 0 kGy irradiation – control); ram extruded GUR4150 high modulus material; compression molded GUR4150 low modulus material; and HSS/PolySolidur/Hoechst reference polyethylene. Using a custom designed joint articular wear simulator, samples were loaded for 2 million cycles at a frequency of 0.5 Hz under loads of 2.1 kN. Tests were stopped every 250 000 cycles; and wear surfaces were examined microscopically for surface damage (pitting, cracking, delamination).

After 2 million loading cycles the following specimens were pitted and delaminated: 2 GUR1050 control samples, 3 GUR4150 high modulus specimens, and all 4 reference polyethylene specimens. Burnishing, but no pitting, was seen in all GUR1050 elevated cross-linked polyethylene specimens, and in all GUR4150 low modulus specimens.

The materials tested in this study represent a broad range of fabrication techniques. Differences in starting resin cannot fully account for the differences in wear behaviour seen between the groups; as damage was not limited to one resin group. The cross-linked specimens were melt-annealed, prior to cross-linking. It is possible that this processing step, and not the actual cross-linking, contributed to the improved wear performance of this group. However, of most interest is the comparable wear performance of GUR1050 cross-linked polyethylene and GUR4150 low modulus polyethylene suggesting that cross-linking polyethylene is not the only route towards obtaining a polyethylene with superior wear characteristics.


S. Banks L. Breslauer G. Davidson P. Merritt A. Hedley

Range of motion after total knee arthroplasty (TKA) is increasingly an issue of critical concern in the performance of knee replacements and their ability to meet the functional demands of diverse patient populations. The goal of this study was to measure maximum weight bearing flexion in patients with one knee replaced using a posterior cruciate retaining (CR) device and the other a cruciate substituting (PS) device on a prospective basis.

Sixteen patients (32 knees) with bilateral TKA and excellent clinical/functional outcomes at least one year after surgery participated in this study. Eight patients received knee replacements from one surgeon, and eight patients received knee replacements of another design from a second surgeon. Their knees were imaged using fluoroscopy as the patients were asked to bend to maximum flexion with their foot on a 25 cm step. CAD model based shape matching techniques were used to measure knee flexion, axial rotation, and the anterior/ posterior (AP) location of tibio-femoral contact relative to the AP centre of the tibial insert. Paired t-tests were used to evaluate differences in means (p = 0.05).

PS knees had larger average flexion angles (121±8 deg vs. 114±5 deg, p=0.01) and greater femoral rollback (14±3 mm vs. 12±3 mm, p=0.02) than the CR knees. There was no difference in axial rotation (6±4 deg vs. 5±6 deg). The same trends were observed within the single design subgroups.

In patients with heterogeneous bilateral TKA, greater femoral rollback and weight-bearing flexion is exhibited by the knee with a posterior stabilised TKA.


J. Essig C. Picault C. Nourissat N. Deloge

Hip revision failures are partly due to the poor quality of femoral bone stock. Several work showed that bone reconstruction without grafts is possible around a non cemented, stable stem. It is enhanced by a transfemoral approach.

We designed the Restoration TM DLS stem (anatomical, S curved, HA coating and distal locking to ensure a primary stability).

Preoperative planning is necessary. The operative technique is based on a double postero-lateral femoral flaps approach. An innovating and modular instrumentation was developed. It rests on a femoral clamp that solidarises the femur and the trial stem, and allows a precise adjustment of the length and the stem anteversion. A targeting device allows a precise distal locking of the final implant. Osteosynthesis of the flaps is carried out by cerclages in order to bring the bone around the prosthesis.

Forty-seven revisions cases were followed up. No major peroperative incident has occurred. We report one case of locking error. Compared to the planning, the instrumentation was considered to be precise in 94% for the adjustment of the leg length and of the ante-version. The bone adaptation around the implant was generally correct. In 21 cases, it was necessary to carry out metaphysal re-calibration or osteotomies for correction of a femoral deviation. The synthesis of the flaps is stable in 92%. For follow up greater than 3 months, the consolidation of the osteotomies is effective in 90%.

This study made it possible to validate a surgical procedure by transfemoral approach that makes safe implant and cement removal. It also allowed us to validate an innovating, precise yet flexible instrumentation that allows, after preoperative planning, the anatomical reconstruction of the femur around the stem. A perfect proximal adaptation of the femur to the implant is necessary to the good tolerance of the distal locking.


S.A. Banks W.A. Hodge

Observations of knee arthroplasty kinematics generally show differences in anteroposterior translation when comparing posterior cruciate retaining (CR) and posterior stabilised (PS) designs. However, the PS cam/post mechanism is not engaged in extension. We hypothe-sised that there would be little difference between CR and PS knee kinematics during stance in gait.

Videofluoroscopy and shape matching techniques were used to quantify motions of 47 fixed-bearing knee arthroplasties (24 CR, 23 PS) during gait and stair-climbing in consenting patients with excellent clinical/ functional performance at least one year post-surgery. The average centre of rotation (COR) was computed for each knee during the two activities; a lateral COR (−50% to 0%) indicates anterior femoral translation with flexion, a medial COR (0% to +50%) indicates posterior femoral translation with flexion.

There was a significant difference between the average COR in the PS (+9%) and CR (−15%) knees for the stair climbing activity (p< 0.001), but not the stance phase of gait (−5% vs. −14%, respectively, p=0.664). The COR was more lateral for the stance phase of gait than for stair climbing in the PS knees (p=0.008), but not the CR knees (p=0.948). All knees showed more axial rotation during the stair activity (8°) than the stance phase of gait (5°, p< 0.001).

During stance in gait, there were small but not significant differences in the centre of rotation between the CR and PS knees. For stair climbing, there were significant differences between CR and PS knee kinematics. These observations are consistent with the hypothesis that CR and PS kinematics ought to be similar near extension, where the articular constraints are similar, but might differ in deeper flexion activities where the intrinsic constraints of the arthroplasty are different. An improved understanding of arthroplasty function should facilitate further evolution of design, surgical techniques, and numerical analyses to optimise patient performance.


S.D. Stulberg

Many recent studies emphasise the importance of surgical technique for achieving long-lasting, pain-free, optimally functioning TKR. However, little information exists in the accuracy with which each step of the TKR procedure is performed using current instrumentation. This study examines the accuracy with which each step of the TKR procedure using current, intramedullary instrumentation.

Twenty primary TKR were performed using a current, intramedullary instrumentation system. The accuracy of each femoral and tibial cut and the accuracy of the final frontal and sagittal limb alignment were measured using an image-free computer assisted navigation system. The system made it possible to measure: 1) frontal femoral implant alignment; 2) sagittal femoral implant alignment; 3) femoral implant rotational alignment; 4) frontal tibial implant alignment; 5) sagittal tibial implant alignment; 6) frontal limb alignment; 7) sagittal limb alignment. Alignment results are expressed in terms of the mechanical axis. Optional results are a frontal and sagittal axis of 90° relative to the mechanical axis. The optimal femoral rotational alignment is 3 degrees externally rotated from the posterior femoral condyles or zero degrees externally rotated from Whitesides line.

The alignment results were: 1) frontal femoral alignment: 89° (range 87 to 92°); 2) sagittal femoral alignment: 89 (range 88 to 193°); 3) femoral rotational alignment: 1° external rotation vs. femoral condyle; 2 degrees internally rotated vs. Whitesides line (range 0.5° to 3.5°); 4) frontal tibial alignment: 88° (87° to 93°); 5) sagittal tibial axis: 87° (range 86° to 91°); 6) frontal limb alignment: 179° (range 177 to 181°); 7) sagittal limb alignment 179° (range 174 to 180°).

Intramedullary instrumentation allows reasonably accurate and reproducible frontal limb alignment. There is a tendency to leave the limb in slight flexion when using intramedullary instruments. There is also a consistent tendency to internally rotate the femur with current anterior –posterior alignment guides and to excessively posteriorly flex the tibial component, although almost all of the 20 TKR’s resulted in final limb alignment within 3 degrees of frontal and sagittal axes. Very few (4) TKR’s were performed in which all of the measured steps were within 3 degrees of the optimal position.

The study emphasises that current intramedullary instrumentation does not result in a high incidence of accuracy when each step of the procedure is measured. Computer assisted techniques permit measurement of the steps of the TKR procedure with a high degree (error < 1°) of accuracy. Longevity, pain-relief and funtion should be related to the total accuracy with which TKR are performed.


A. Price A. Short C. Kellett J. Rees H. Pandit C. Dodd P. McLardy-Smith R. Gundle D. Murray

The aim of the study was to measure in-vivo the 10-year linear and volumetric polyethylene wear of a fully congruent mobile bearing unicompartmental knee arthroplasty (OUKA).

We studied six OUKA’s that had all been implanted 10 years previously. Each patient was examined in even double leg stance at a range of knee flexion angles, in a calibration cage. A stereo pair of X-ray films was acquired for each patient at 0°, 15° and 30° of flexion. The films were analysed using an RSA style calibration and a CAD model silhouette-fitting technique. The position and orientation of each femoral and tibial component was found relative to each other and the bearing position inferred. Penetration of the femoral component into the original volume of the bearing was our estimate of linear wear. The volumetric wear is calculated from the measured linear wear and the known surface area of the bearing. In addition eight control patients were examined less than 3 weeks post-operation where no wear would be expected.and 30We studied seven OUKA’s that had all been implanted at least 10 years previously. A stereo pair of X-ray films was acquired for each patient at 0 Results: The control group showed no measured wear. The seven OUKA’s had an average maximum depth of linear penetration of 0.40 mm at a mean follow-up of 10.9 years. The linear wear rate was 0.033 mm/year. The volumetric material loss was 79.8 mm3. If a steady gradual material loss is assumed, 8 mm3 of UHMWPE was lost per year.

Polyethylene particulate wear debris continues to be implicated in the aetiology of component loosening and implant failure knee following arthroplasty. The OUKA employs a spherical femoral component and a fully congruous meniscal bearing to increase contact area and theoretically reduce the potential for polyethylene wear. The results from this in-vivo study confirm that the device has low 10-year linear and volumetric wear in clinical practice. This may protect the device from component loosening in the long term.


E.R. Valstar C.P. Botha P.M. Rozing F.H. Post F.C.T. van der Helm A.M. Vossepoel

We would like to present an overview of a research programme that aims to improve drastically the state-of-the-art in shoulder joint replacement surgery. Development of Improved endoProstheses for the upper EXtremities (DIPEX), as this effort is called, is a clinically driven multi-disciplinary programme consisting of many contributory projects. Within the project two main directions of research can be distinguished: the development of an improved shoulder prosthesis and the improvement of the surgical process. For this audience, we would like to present our approach to the improvement of the surgical process.

A newly designed visualisation platform called DSCAS (Delft Shoulder Computer Assisted Surgery) will play a central role within the DIPEX project. This platform is not only able to visualise CT and MRI datasets with a range of different algorithms, but is also able to calculate parameters that are essential for surgery and extract information from these datasets. The extracted information serves as input for the Delft Shoulder Model, an inverse dynamic musculo-skeletal finite element model, with which the effect of surgical decisions on the functional outcome, i.e. range of motion, stability of the joint etc. can be predicted and visualised.

Concerning per-operative guidance two approaches are currently studied – a camera-based approach and mechanical approach – that have both their advantages and disadvantages. Comparison of the two approaches in an experimental setting as well as in a clinical setting is part of the DIPEX project.

The ultimate goal of this part of the DIPEX project is to create a surgical support infrastructure that can be used to predict the optimal surgical protocol and can assist with the selection of the most suitable endoprosthesis for a particular patient. Subsequently, this support infrastructure must assist the surgeon during the operation in executing his surgical plan.


P.T.H. Lee M.T. Clarke R.N. Villar

Lubricated metal-on-metal (MOM) bearing surfaces are not easily separated, unlike ceramic- or metal-on-UHMWPE (COP, MOP), due to interfacial forces and low diametric clearance that provides a ‘suction-fit’. In vivo videofluoroscopic studies have shown that patients with MOP/COP THRs exhibit separation of bearing surfaces by up to 3.1 mm during normal gait and 5.4 mm during active abduction while patients with MOM bearings do not. In this regard, MOM bearings may have similarities to constrained bearings with the potential to lower dislocation rates.

All patients under 70 years old undergoing primary THRs for primary osteoarthritis were prospectively registered on a computer database. From 1993–8, patients were offered a 28 mm COP bearing. After 1998, as part of a clinical trial, a 28 mm MOM bearing was inserted instead. For all cases, we used a metal-backed, uncemented acetabulum allowing a modular 10-degrees posteriorly augmented insert (Duraloc/PFC/Ultima, J& J) and the same cemented femoral stem (Ultima, J& J). The same experienced surgeon performed all operations using the posterior approach. Interfacial forces between bearing surfaces were assessed in vitro with a variable-speed-motor winch (APT) and a load-cell (E375/RDP) by recording peak-retaining-forces of bearing couples during separation with variable impact-distraction velocities. Statistical analysis used the Chi-square and student’s t-test.

We identified 140 COP THRs in 129 patients and 109 MOM THRs in 100 patients. Nine of 140 (6.4%) COP bearings dislocated within 3 months of surgery compared to 1 of 109 (0.9%) in the MOM group (p=0.024). No significant differences were identified between groups when comparing patient and prosthesis factors. In vitro assessment demonstrated that MOM bearing possessed interfacial retaining forces up to 30N more than COP bearing (p< 0.001).

This study demonstrates a significantly lower dislocation rate in THR with MOM bearing compared with COP. A potential explanation is the differential ease of separation that the two lubricated bearing couples possess due to interfacial retaining forces (viscous tension and ionic adhesive forces) exerted by the lubricating fluid.


M.K. Harman S.A. Banks W.A. Hodge

Many total knee replacements (TKR) are designed with more conforming articular geometry to increase the femoral contact area and decrease surface stresses. These designs are supported by studies suggesting that implants with coronally flat articular surfaces are vulnerable to medial-lateral lift-off and edge-loading on the polyethylene insert. However, few retrieved inserts from contemporary TKR’s have shown wear consistent with this loading mechanism. This study presents wear measurements from 37 consecutively retrieved polyethylene inserts of the same PCL-retaining design with coronally flat-on-flat articulations. If substantial edge-loading occurred in-vivo, it was hypothesise that wear would be located closer to the medial or lateral edge of the articular surface with a high incidence of delamination.

Inserts were retrieved at autopsy (n=12) after 41 (15–74) months in-situ and at revision TKR (n=25) after 26 (1–71) months in-situ. Reason for revision was infection (28%), patellar component complications (24%), loosening (24%), patellar resurfacing (20%), and supra-condylar fracture (4%). Articular damage was measured using light microscopy and digitising the circumference of each damage region on calibrated images. Surface deformation was measured relative to unused control inserts using a hand-held digitising stylus.

Wear patterns were not significantly different between autopsy or revision retrievals (ANOVA, p> 0.05). Articular wear covered 48%+16% and 47%+14% of the medial and lateral surfaces, respectively. The most frequent wear modes were burnishing and scratching. Delamination occurred on 4(11%) inserts, but involved < 2% of the articular surface. Wear patterns were internally rotated and centrally located. Not one insert had a wear area centroid located in the medial or lateral third of the articular surface. Surface deformations were greatest in the inserts’ central region and the linear deformation rate decreased with time.

Concerns of high contact stresses associated with edge-loading were unsupported by these retrievals. Condylar lift-off, if it occurs, does not appear to substantially impact polyethylene damage in coronally flat-on-flat articulations.


J.B. Grimes H. Boozari

In vitro loading of the proximal femur has improved our understanding of stress shielding after total hip arthroplasty. However, previous load simulators often use simplified loading regimens that may not produce physiologic baseline strains. The purpose of this study was to compare the femoral strain levels produced when using simplified and more complex loading.

A mechanical load simulator was developed which could simultaneously apply a spinal load and nine of eleven available muscle loads to the proximal femur in heelstrike and stair climbing modes. Computer controlled electromechanical actuators were attached to a strain gauged fresh cadaver femur (donor body weight 39 6kg) with metal cables. A spinal load of 668 N (SPL) was applied alone and in combination with individual muscle loads of 267 N to determine the effect of each muscle on femoral strain. The magnitude and direction of the joint reaction force (JRF) was monitored in real time by a three-dimensional force transducer proximal to a metal acetabulum. Anterior, middle and posterior portions of the gluteus medius (ABD), iliotibial band (ITB), short external rotators (SER), vastus lateralis, adductors, rectus femoris, hamstrings, iliopsoas, and gluteus maximus were simulated.

SPL was applied and ABD and ITB were adjusted to produce a JRF magnitude of 2.0 BW. SPL was applied with two combinations of nine muscle loads adjusted in heelstrike mode to produce a JRF magnitude of 2.0 and 2.5 BW and JRF trajectory aligned within one degree of the radiographically determined compression trabecular stream axis.

Both nine-muscle combinations produced lower medial compression strains and substantially lower lateral tension strains than SPL+ABD+ITB in heelstrike and stair climbing. Simplified loading caused a bending moment in the proximal femur resulting in higher strains. Combined loading at 2.5 BW produced compression at 10 of 12 gauges in heelstrike mode and 9 of 12 gauges in stairclimbing.


M.A. Hafez A.J. Edge R.W. Morris

Total knee replacement (TKR) is intended to satisfy patients rather than surgeons. The latter could be more optimistic when they assess the outcome of their own operations. We envisage that there is a variation between patients’ own assessment and those of surgeons. This study reviewed long-term results of TKR and compared between patients’ assessment and surgeon’s assessment.

Four hundred and six TKR were performed between 1980 and 1994 in a DGH by one surgeon using single knee prosthesis. The follow up was up to 14 years (mean 7.2). Clinical assessment was done by the surgeon in out patient clinic and was compared to the patients’ assessment, which was done through a confidential postal questionnaire (PQ).

Response rate to PQ was 84 %. There was an obvious discrepancy in reporting pain and patients’ satisfaction between the two methods of assessment however there was similarity in other parameters. Surgeon rated satisfaction more highly and patients reported more pain in PQ. In this study revision rate was 4 %, infection 1.7 %, instability 1.4 % and patellar pain 20 %.

There is a variation between patients’ own assessment and those of surgeons. For accurate assessment of the outcome of TKR we recommend the use of postal questionnaire alongside clinical assessment.


A.B. Mor J.E. Moody R.S. LaBarca D.M. Sell C. Nikou A.Z. Omer B. Jaramaz A.M. DiGioia

Surgical navigation, coupled with preoperative plans, allows surgeons to plan and execute procedures to improve the likelihood of positive outcomes. In real life these navigation systems, which track both the patient and the surgical tools, are not absolutely accurate. Therefore, there is a need to know how much error there may be in the navigation system, so that the surgeon can assess the effects of possible errors in positioning.

The methodology for assessing the accuracy of a surgical navigation system is similar across surgical specialties. We developed a framework for assessing the accuracy of the HipNav system, a computer assisted surgical system used for planning and intra-operative surgical navigation for total hip arthroplasty. This framework can be adapted to other systems and surgical procedures. To assess navigational accuracy, we compared acquired values to a ground-truth model: rigid plastic Sawbones pelvii with mounted fiducials and acetabular implants, whose positions were measured with a coordinate measuring machine. We then identified the individual components of the system that can contribute to overall accuracy, and characterised their contributions to the accuracy of the system. We also measured the end-to-end accuracy of the HipNav system, from initial CT scan through to acetabular cup orientation. This value is of direct importance to the practicing surgeon, and indicates how far off the final measured orientation of the cup may be from its actual location. For the HipNav system, we found that the end-to-end square root of the mean square error was 0.82° in abduction and 0.76° in version.

The accuracy of a surgical navigation system is of vital importance to insure that a preoperative plan is executed properly. To measure the accuracy of a navigation system, accurate models that reflect the relevant anatomy are necessary, and allow true measurement of end-to-end and component accuracy. This example shows how the accuracy of HipNav was assessed, and that the final orientation of the acetabular implant was accurately guided.


S.D. Stulberg V.A. Brander A. Adams

Osteolysis secondary to polyethylene wear is the most serious aseptic long-term complication following THR. Studies have shown that fixation with screws, modularity and lack of extensive bone ingrowth are associated with increased osteolysis. This study examines the initial experience with a cup designed to address these issues.

One hundred and twenty-seven consecutive primary THR were performed between 1997–1999 using unce-mented monoblock, elliptical, tantalum cup without screw holes. Average follow-up 40 months (range 24 to 61). 79 THR in females, 48 in males. 48% THR hybrid fixed, 52% uncemented. Average age 61.6 years (range 19 to 88). Pre and post-operative clinical assessment with Harris hip score (hhs), WOMAC, SF-36. One independent, blinded observer performed zonal radiographic analysis with modified DeLee and Charnley method.

Average hhs at recent follow-up 93 (range 85 to 100). All shells appear fixed with bone ingrowth. Dome-gaps present in 6 cups post-op; all have filled in. Radiolucencies at follow-up: 4% zone 1, 8% zone 2; none greater than 1 mm. No cup migration. 8 cup related complications: 5 dislocations (4%) 1 subluxation, 2 undisplaced rim fractures (1.7% – no treatment). 3 dislocations, 1 subluxation occurred more than three months post-op. 3 revisions: 1 deep wound infection, 1 liner exchange (using reaming technique), 1 femoral head exchange.

Uncemented monoblock, elliptical tantalum cup without holes provides secure, symptom-free fixation at 4 years. No complications associated with use of tantalum. Elliptical shape associated with dome gaps, all of which appeared to fill by 3 months. Monoblock design results in increased polyethylene lip prominence associated with 6 cases of instability. Effect of prominent rim on impingement and long-term wear requires careful follow-up.


S.D. Stulberg D. Anderson A. Adams V. Brander G. Myo J. Bernfield R. Wixson

Pelvic osteolysis secondary to polyethylene wear is a major complication following THR. Identification of implant specific characteristics associated with osteolysis is essential. The purpose of this study is to compare incidence of CT scan identifiable osteolysis in 2 groups of young, active patients following THR; one with multi-holed acetabular shells with screws, one with cups without screw holes.

Between 1990–1993, 77 patients (85 hips) underwent THR with a cementless titanium, multi-holed shell with screws, modular, compression molded polyethylene and an uncemented titanium femoral stem. Average follow-up: 9 years, average age at surgery: 51 years. Between 1984–1987, 163 patients (183 hips) underwent THR with a cementless cobalt-chrome, solid shell, modular, heat-pressed polyeth-ylene liner and uncemented cobalt-chrome femoral stem. Average follow-up: 16 years, average age at operation: 52 years. All polyethylene was irradiated in air. At most recent follow-up, CT scans with metal suppression software was obtained to evaluate incidence of pelvic osteolysis. Patients classified: Group 1-no osteolysis, Group 2-cavitary osteolysis, Group 3-segmental osteolysis.

Patients with titanium, multi-holed shells had: Group 1-50.0%, Group 2-38.7%, and Group 3-11.3%. Patients with cobalt-chrome, solid shells had: Group 1-59.3%, Group 2-33.3% and Group 3-7.4%.

Although the patients with solid cups had much longer follow-up, less secure capture mechanism, less congruency between polyethylene and shell, and heat-pressed polyethylene, the incidence and extent of pelvic osteolysis was less than in the patients with multi-holed shell with screws. The presence of 6.5 mm cancellous screws is a serious independent risk factor for pelvic osteolysis following THR.


M. Conditt

In PCL-retaining TKA, tension in the PCL is sensitive to changes in the posterior slope of the tibia component. However, it is not understood how PCL tension, in combination with the absence of the ACL, affects knee kinematics. This study demonstrates the effects of varying posterior tibial slope on the tibiofemoral and patello-femoral kinematics after PCL-retaining TKA.

Eight fresh-frozen lower limb specimens were mounted in a kinematic knee simulator. External forces were applied to create a deep knee bend from 0–110 degrees of flexion, while the three-dimensional motions of the femur, patella and tibia were tracked in real time using a motion analysis system. A PCL-retaining TKA was implanted into each cadaver with the tibial component matching the natural posterior slope of the tibia. After testing, the tibial slope was reduced by four degrees compared to the natural slope, then increased by four degrees compared to the natural slope. With each change in slope, the kinematics of the knee were recorded.

A dramatic change in femoral rollback was observed with increasing slope of the tibial component. In full extension, matching the natural tibial slope displaced the femur 5.7 ± 1.5 mm posteriorly, while more anterior slope and more posterior slope displaced the femur 5.1 ± 2.6 mm and 8.7 ± 2.0 mm posteriorly, respectively. Paradoxically, increased posterior slope resulted in less rollback of the femur during flexion. At 100° a of flexion, total rollback was 11.8 ± 2.6 mm in the intact knee, 6.9 ± 2.4 mm with the natural slope, 9.0 ± 2.8 mm with the anterior slope, and 5.7 ± 2.3 mm with the posterior slope.

Preserving the PCL allows the femur to rollback on the tibial plateau with knee flexion. However, increasing the natural slope of the tibia causes a significant posterior shift of the femur in extension thus reducing rollback in flexion.


J.B. Grimes

Proximal femoral bone loss is often observed after total hip arthroplasty (THA) and continues to complicate revisions. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients with the unusual finding of proximal femoral cortical hypertrophy after THA or endoprosthesis.

Three patients were identified with femoral stem tip perforation through the posterolateral femoral shaft cortex. Known risk factors for perforation were osteoporosis, distal osteolysis causing late stem migration, and endoprosthesis after previous fracture/internal fixation. Two patients had dual energy x-ray absorptiometry (DXA) of both hips. Follow-up was 16, 17 and 28 years.

All three patients had clinically stable femoral components and none had thigh loading pain. All three patients had dense cortical bone buttressing the undersuface of the implant collar and a dense medial femoral cortex. Proximal femoral DXA regions of interest were 120 and 145% of the contralateral femur in the migration and post-fracture endoprosthesis patients, respectively.

The endoprosthesis patient was revised to a THA 28 years post-operatively due to acetabular erosion. Excess dense cortical bone in the proximal femur was removed with a high speed bur and enabled revision with a primary non-cemented femoral component.

Common factors which appeared to be necessary for a stable implant with proximal femoral densification included collared femoral components, stem alignment more vertical than the femoral neck axis, stem perforating the posterolateral femoral cortex, no inhibition of translation along the stem axis by cement or biological ingrowth, and not having the implant revised despite its unorthodox appearance.

Long-term maintenance of the proximal femoral cortex after THA or endoprosthesis is possible. Paradoxically, a rare subset of the complication of femoral shaft perforation demonstrated by these anomalous cases suggested an alternative approach to the prevention of stress shielding bone loss after THA.


P. Rea A. Short P. Kyberd H. Pandit A. Price D.W. Murray J.J. O Connor

Radiolucencies are generally thought to be a manifestation of loosening. They are commonly seen under the tibial component of the Oxford Unicompartmental knee replacement. However, they are not associated with long term failure [1]. The aim of this study was to investigate any relationship between radiolucencies and component migration.

Eight medial Oxford Unicompartmental knee prostheses were examined post-operatively, at 12 months and at 24 months using Roentgen Stereophotogrammetric Analysis (RSA). The serial radiographs were calibrated and three dimensional CAD models were matched to the extracted component shapes. Implanted bone marker balls were then selected on all radiographs. The components were superimposed. Migration calculation was achieved by comparing relative positions of components to bone marker balls in the serial radiographs. Fluoroscopically screened X-rays were taken to determine whether there were any radiolu-cencies under the tibial component.

By 12 months, the femoral component had migrated significantly anteriorly (0.35 mm) and proximally (0.61 mm). The tibial component had migrated significantly distally (0.42 mm) and anteriorly (0.47 mm). Although on average there appeared to be a small further migration between 12 and 24 months, this was not statistically significant in any direction.

Six of the eight patients had radiolucencies at 24 months. None of the radiolucencies were was complete. The maximum radiolucency was 1 mm thick and the average was 0.57 mm. There was no correlation between radiolucency and migration.

The proximal femoral migration and distal tibial migration can be explained by the load across the knee. We cannot yet explain the anterior tibial migration. Radiolucencies almost always occur and are not related to migration.This confirms they are not associated with loosening.


B. Kleffner P. Thümler P. Brehm P. Müller

The disadvantages of sawing for precise bone cuts are well known: untrue cuts, heat and metal wear. The main limiting factors of available milling devices are the difficult handling and high costs, especially if the devices are based on a robot. Supported by clinical users and mechanical engineers a milling concept adopted from machining has been realised in order to overcome this limitations. The „All-in-One Milling-Tool“ achieves the same precision of a robot by a mechanically guided milling resection far below the necessary investment for a robot. Three methods are provided for the alignment of the resection planes and will be discussed: intramedullary adjustment, 3D CT-based planning and intramedullar performance as well as the performance under control by navigation. All versions are based on a handheld resection and guarantee a visual and haptical feedback for the surgeon. The use of navigation has the advantage of the accurate transfer of the 3D plan into the OR, the interactive facilitated alignment und resection steps and the documentation of planned and actual implant position.


B.J. Robinson S. Halliday A.J. Price D.J. Beard J.L. Rees C.A.F. Dodd D. Murray J.W. Goodfellow J.J. O’Connor

When the Oxford unicompartmental meniscal bearing arthroplasty (UCA) is used in the lateral compartment of the knee 10% of the bearings dislocate. An in-vitro cadaveric study was performed to investigate if the anatomy and joint geometry of the lateral compartment was a contributory factor in bearing dislocation. More specifically, the study investigated if the soft tissue tension of the lateral compartment, as determined by the length of the lateral collateral ligament (LCL), was related to bearing dislocation. A change in length of greater than 2 mm is sufficient to allow the bearing to dislocate.

The Vicon Motion Analysis System (Oxford Metrics, Oxford, UK) was used to assess length changes in the LCL of seven cadaveric knees. Measurements were made of the LCL length through knee flexion and of the change in LCL length when a varus force was applied at a fixed flexion angle. Measurements were made in the normal knee and with the knee implanted with the Oxford prosthesis.

In the intact knee the mean LCL change was 5.5mm (8%) over the flexion range. After implantation with the Oxford UCA the mean change in length was only 1 mm (1%). There was a significant difference in the LCL length at 90° (p=0.03) and 135° (p=0.01) of knee flexion compared to the intact knee. When a varus force was applied the LCL length change of the intact knee (5.4 mm) was significantly different (p=0.02) to that of the knee with the prosthesis implanted (2.7 mm)

This study used a new method to dynamically measure LCL length. It found that after implantation of the Oxford lateral UCA the LCL remains isometric over the flexion range and does not slacken in flexion as it in the normal knee. This would suggest that the soft tissue tension was adequate to contain the bearing within the joint.

However, when a varus force was applied the LCL did not sufficiently resist a displacing force producing an LCL length change greater than 2 mm.

The evidence provided by this study is contradictory. The “lack of change in LCL length through flexion” suggests that the ligament remains tight through range and is unlikely to allow dislocation. However, the amount of distraction possible when an adducting moment is applied is sufficient to allow bearing dislocation. The length tension properties of the lateral structures are therefore implicated in the mechanism of dislocation.


O.M. Mahoney M.S. Ferrara T.L. Kinsey A.M. Vural

To determine the effect of altering tibial slope on the two-year range of motion (ROM) of patients undergoing condylar total knee replacements (TKR).

A single surgeon performed 74 primary cemented posterior stabilised tri-compartmental TKR’s on 56 patients (19 male, 37 female) with mean age of 67.1 years, height 66.7in., weight 187.4 lb, and BMI 29.58 kg/m2. 51 had osteoarthritis, and five had rheumatoid arthritis. A standard surgical technique was employed utilising flexion axis localisation to position the femoral components. Patients were followed for two years minimum using outcome measures and x-rays. Knees where tibial slope was restored to a degree angle equal to, or slightly greater than, their pre-op slope (group 1) were compared to knees where tibial slope was decreased (group 2).

The average 2 year post-op ROM in Group 1 was significantly greater than that of Group 2 (129.3 degrees vs. 120.5 degrees, p=.001). The average pre-op to post-op increase in ROM in Group 1 was significantly greater than Group 2 (38.1 degrees vs.27.7 degrees, p=.003). Correlational analysis revealed that restoration of pre-op tibial slope was the primary determinant of post-op ROM, followed by pre-op ROM, then weight and BMI (each to significance of p< 0.05).

Restoration of tibial slope clearly produced increased ROM in this study. Using one standard slope cut for every tibia may prevent many patients from achieving their maximum potential ROM.


K. Yasuda T. Majima Y. Aoki A. Minami H. Tohyama

The aim of the study was to compare clinical results after cruciate-retaining total knee arthroplasty (TKA) between the ceramic and the Co-Cr alloy condylar prostheses.

In a prospective semi-randomised study, 218 patients underwent cruciate-retaining TKA with the Co-Cr alloy prosthesis (Kinemax®, Howmedica) or the LFA-I® prosthesis (Kyocera) composed of an alumina ceramic femoral component and a titaniumalloy tibial component with a UHMWPE insert. In each surgery, both components were fixed with PMMA cement. All the patients underwent the same postoperative management. Finally, 110 knees with the ceramic prosthesis and 84 knees with the Co-Cr prosthesis were followed up for 24 to 124 months (the average of 56 months).

Two revisions were performed in each group (tibial tray breakage and infection in the ceramic group, and loosening and infection in the Co-Cr group). In the remaining patients, there were no significant differences in the HSS knee score (85 and 86 points, respectively) and the ROM (112 and 113 degrees) between the two groups. In radiological evaluation, a radiolucent line was more frequently observed with the significance (p< 0.05) in the Co-Cr alloy group (9.5 %) than in the ceramic group (2.7 %).

In the mid-term follow-up evaluations, the clinical results of the ceramic TKA are equivalent to those of the Co-Cr alloy TKA. In addition, the ceramic prosthesis showed some statistical tendency of superiority to the Co-Cr prosthesis concerning the radiolucent line. These results encouraged us to conduct a long-term follow-up study on the ceramic total knee prosthesis.


J. Cobb J. Henckel S.J. Harris M. Jakopec F.M. Rodriguez y Baena M.P.S.F. Gomes B.L. Davies

The Acrobot®, an active constraint “hands-on” robotic system, gives navigation cues to the surgeon, and also assists him in the surgery, using active software constraints if he tries to depart from the preoperative plan. It has just entered clinical trials. We report the first 5 cases.

The Acrobot® system for precision total knee arthroplasty comprises the following components:

1. A CT-based planning system

2. The limb positioning system

3. The Acrobot’s hardware components:

a gross positioning device with separate brakes and encoders, locked off for safety during the procedure,

a fully back-driveable low force robot, and

a force control handle on the robot close to the high-speed milling tool.

4. The Acrobot’s software which:

imports the preoperative plan,

allows anatomic registration

provides navigation,

physically assists the surgeon perform his plan

Each patient’s knee scores were monitored and postoperative CT scan was compared with the preoperative plan.

Seven robot assisted arthroplasties have been performed. No significant complications have been encountered. The Knee and Womac Scores show that the procedure is safe and comparable to conventional surgery in the early postoperative period. The envelope of error on postoperative CT scans has been within the accuracy of the method of measurement, at < 1 mm and < 10 without the outliers which haunt every clinical series.

The Acrobot® system for total knee arthroplasty has completed its preliminary trial satisfactorily. It provides a handson operation but with robotic levels of accuracy. It is suitable for conventional open surgery, but its real place will be in the arena of minimally invasive unicondylar knee arthroplasty, hip arthroplasty and resurfacing, and in the spine, where active constraint will prevent potentially dangerous surgical errors.


M. Viceconti

Most of the approaches to computer aided surgery currently in use share the need for an accurate pre-operative surgical planning to establish the optimal conditions that the surgeon should achieve using such specialised instrumentation.

The penetration of these computer-aided planning tools in the clinical practice is still limited. The systems that replicate such 2D planning are user-friendly, but lack the full three-dimensional definition of the implant position. On the contrary, systems based on CT data, which allow a fully 3D planning, usually have cumbersome interfaces. Last but not least all programs currently available are only aimed to visualise the position and orientation of the prosthetic components, presuming that the anatomical referencing is sufficient for the surgeon to decide the correctness of the planning.

The Hip-Op research project was aimed to the development of a complete surgical simulation software environment for the pre-operative planning of total hip replacement surgery. The software had to fulfil the following basic requirements: a CT-based three-dimensional planning environment; a user-friendly graphic user interface based on the Multimodal Display approach; the possibility to integrate analysis modules aimed to provide the surgeon with additional functional data; complete independence from the type of hip prosthesis or from the intra-operative instrumentation.

The graphical interface of Hip-Op is based on an innovative visualisation paradigm, which is called Multimodal display. Hip-Op represents the anatomical objects by means of multiple views, each of which simulates a different medical imaging modality familiar to the medical professional. Two analysis modules are currently integrated in Hip-Op to provide clinically relevant 3D indicators of the implant fit and fill in the host femur.


S. Glyn-Jones H.S. Gill P. McLardy-Smith D.W. Murray

The relative motion between a prosthesis, the cement mantle and its’ host bone during weight bearing is not well understood. Using Radiostereophotogrammetric Analysis (RSA), we examined the dynamically inducible micromotion that exists at these interfaces when an increased load is placed through the prosthesis.

Dynamically inducible micromotion was measured in the femoral components of 21 subjects undergoing total hip replacement with polished Exeter stems. Two standing RSA studies were performed, at 3 and 12 months postoperatively. Firstly in double-leg stance, and secondly fully weight bearing through the operated hip.

Subjects had no signs of clinical or radiological signs of loosening at 1 year. Significant micromotion was detected at the prosthesis-cement interface at 3 months.

Similar patterns of micromotion were observed at 12 months. The prosthesis appeared to bend during single-leg stance weight bearing, however this accounted for less than half of the total observed movement.

Conventional RSA studies were conducted at 3 months, 6 months and 1 year to confirm that the implants showed normal migration patterns.

This study demonstrates that movement exists between the prosthesis and bone during cyclical weight bearing. This dynamically inducible micromotion probably occurs at the prosthesis-cement interface. It could account for the wear that is observed on the surface of retrieved secure prostheses. This may be a mechanism by which failure eventually occurs.


S. Glyn-Jones H.S. Gill P. McLardy-Smith D.W. Murray

The Birmingham reSurfacing Arthroplasty (BSA) is a metal on metal prosthesis with no published independent clinical studies. Despite this, it is increasing in popularity, especially as an alternative to stemmed prostheses in younger patients. This study presents the 1year migration results of the BSA femoral component using Roentgen Stereophotogrammteric Analysis (RSA).

Twenty six subjects underwent a BSA, through the postero-lateral approach using CMW3G cement, with RSA marker balls placed intra-operatively. The femoral component migration was measured at intervals of 3, 6 and 12 months using the Oxford RSA system. Geometric algorhythms were used to identify the femoral component. The data was examined for distribution prior to analysis. All statistical analysis was performed using the t-test.

The data was normally distributed. The 1 year migration results of the BSA femoral component are displayed below.

All cemented implants migrate in vivo. The majority of cemented stemmed implant migration occurs within the first post-operative year. High rates of migration within the first post-operative year correlate with premature component failure in some instances. The BSA is a fundamentally different design to most cemented prostheses, despite this we know that very large migrations, those in excess of 2mm/year in any direction are generally regarded as poor indicators of long term outcome. These results suggest that the BSA femoral component is an inherently stable device as it does not migrate significantly within the first post-operative year. Only long-term independent clinical studies and continued RSA follow-up will enable a comprehensive evaluation of the device.


J.K. Taylor

Limitations in the material properties of arthroplasty bearings have been a major impediment to increasing the longevity and durability of total joint replacement. These limitations most often manifest as wear debris related osteolysis and bearing failure. While these problems cause serious complications in THR and TKR, as arthroplasty is applied to the spine, such problems could become catastrophic. An ideal bearing material and design would be biocompatible, provide for restoration of normal range of motion, and be durable enough to sustain long term unrestricted high demand activities without mechanical failure, significant wear, or contribution to particulate related osteolysis. A new material, Polycrystalline Diamond Compact (PDC), appears to closely approximate the ideal bearing material for applications from large joints to intervertebral discs.

PDC is a diamond structure formed at ultra high pressure and temperature and bonded to a metal substrate. Bond strength to substrate approximates substrate tensile strength. PDC has unprecedented impact toughness and hardness, and has the lowest unlubricated coefficient of friction of any manmade contact bearing. A screening study was used to evaluate wear properties with ceramic and CoCr controls. Full prototypes were tested in a PMED hip simulator for 10 million cycles and on a spinal disc simulator for 30 million cycles.

In the screening study, PDC specimens demonstrated a significant advantage in wear over controls, whose wear rates were consistent with earlier studies. In simulator studies, the PDC specimens experienced extremely low wear at 10 million cycles (~1.0 mg per bearing surface) under austere conditions of no lubrication. In the spinal disc simulator, wear was approximately 0.3 mg at 20 million cycles under similar austere condition.

PDC’s unique material properties lend themselves to designs with thin (5 mm) acetabular bearings that provide for improved ROM and decreased dislocation risk, as well as to spinal applications where space is at a premium. Its properties of extraordinary impact toughness and high wear resistance lend themselves to arthroplasty applications which may require no undue activity restrictions, and may make prostheses available in which bearing wear and mechanical failure are no longer a factor affecting longevity.


C. Charpenay F. Chotel E. Garnier T. de Polignac J. Bérard

Purpose: Management of supracondylar fractures of the humerus becomes a controversial issue when there is major displacement. The risk of vessel and nerve injury is very high, making reduction and fixation particularly difficult.

Material and methods: We conducted a retrospective analysis of 100 supracondylar fractures managed over a ten year period. All of these fractures were in extension and exhibited a bone gap. We analysed early and late complications.

Results and discussion: Mean age at trauma was 6.5 years, with six boys for four girls. The left side was involved in 69% of the cases. Falls were the predominant cause (48%).

Thirty-two percent of fractures were complicated initially: nerve injury (n=17), vascular injury (n=12) (including three cases with nerve and vascular injury), open fractures (n=7). The medial nerve was injured in most cases (n=12). Ulnar palsy was noted in four patients and radial palsy in one. Vessel injury led to abolition of the radial pulse in eight patients and the ulnar pulse in one; all resolved after reduction. Ischaemia of the hand was noted in two cases before reduction of the fracture but vascular surgery was not required.

Most of the fixations were achieved with cross pinning (percutaneous insertion in 47 patients and open surgery in 13). Despite minimal medial skin incision, ulnar nerve deficiency was observed after surgery in seven cases; four were rapidly regressive and three required surgical exploration with neurolysis. Six revision procedures were required for secondary displacement (10%).

The 26 Judet fixations led to ten secondary displacements requiring surgical revision for cross pinning. Four cases of postoperative ulnar nerve deficiency were noted: reoperation to release the nerve pinched in the fracture was required for only one patient.

The Blount technique was used in nine cases with four secondary displacements, including one related to two sites of nerve impingement.

Five cases of superficial pin tract infection which resolved rapidly and two cases of deep infection were noted in the early postoperative period.

Formation of a varus ulnar callus was noted in five cases: two required secondary surgery for correction.

Conclusion: Our results point out the high rate of vessel and nerve complications related to these supracondylar fractures of the humerus with displacement. We recommend cross pinning which is mechanically superior and which does not compromise the neurological result if a minimal medial incision is used.


B. Dohin D. Lubanziado

Purpose: A prospective study was conducted in 160 children presenting varus trauma of the ankle. The purpose of the study was to validate the Ottawa ankle rules in children. Application of the Ottawa rules can reduce the number of x-rays by 25% but little work has been reported concerning their validation (Chande 1995).

Material and methods: One hundred sixty children, 71 boys and 89 girls, mean age eleven years three months (range 3 – 15 years) were included in this study conducted between February 2001 and December 2001. Clinical presentations with an obvious diagnosis of ankle fracture were excluded (six patients). Epidemiological and clinical data and the initial Ottawa criteria were recorded on a data sheet with a specific number of assigned items. A standard radiographic work-up with an anteroposterior, lateral and oblique view of the ankle was obtained in all cases. All patients were seen at a second consultation on day 8 by another physician to confirm diagnosis. The x-rays were read three times: by the emergency care physician, and by a second physician and a paediatric orthopaedic surgeon at the 8-day consultation.

Results: Diagnosis which were confirmed were: benign sprains (BS) (n=71), moderately severe sprains (MS) (n=47), severe sprains (SS) (n=2), type I epiphyseal detachment (ED) (n=21), fractures (n=13) (8 fifth metatarsal, 1 triple fracture line, 1 medial malleolus, 2 lateral malleolus, 1 tarsal scaphoid).

For the Ottawa criteria, ankles positive for pain and at least one other criterion were: 64/77 BS, 43/47 MS, 2/2 SS, 21/21 DE and 13/13 fractures. All fractures were diagnosed at the first exam or at the 8-day exam.

Discussion: Based on our findings, the clinical Ottawa rules cannot be considered to be validated for children. Using these rules, x-rays would have been performed in 143 patients to identify 13 fractures that were not clinically obvious. Because the Ottawa rules are insufficiently specific for children, we recommend, like Brooks (1981) to use more rigorous clinical criteria for the diagnosis of ankle trauma in children.

The diagnostic criteria used in this study enabled correct first intention diagnosis in 129 patients with trauma. We propose ordering x-rays only for children with signs of moderate or severe sprain or pain in zone C (base of the fifth metatarsal: 8/8) or E (medial border of the foot: tarsal scaphoid fracture). For other cases (98/160) physical examination is sufficient.

Conclusion: We do not consider the Ottawa clinical rules to be valid for varus ankle trauma in children. We propose clinical criteria which can limit the number of x-ray work-ups by 60% in children with this type of trauma.


G. Bollini S. Minaud F. Launay E. Viehweger A. Marty J.-L. Jouve

Purpose: The purpose of this work was to present the long-term outcome after resection of thoraco-lumbar, lumbar, or lumbosacral hemivertebrae in 69 children.

Material and methods: Sixty-nine children (35 girls and 34 boys) underwent surgery at a mean age of 3 years (range 1 year – 10 years 6 months). Mean follow-up was 6 years (range 6 months – 18 years). Resections involved thoracolumbar (n=20), lumbar (n=34), and lumbosacral (n=15) hemivertebrae. Congenital vertebral and visceral malformations were present in 32% and 41% of the children respectively. Ten patients had an underlying neurological malformation.

A single operation was performed in 60 patients using a combined anterior and posterior approach and convex posterior CD baby instrumentation. Nine patients underwent two operations one week apart. All patients wore a corset brace for six months.

Results: Structure curvature: the mean Cobb angle was 35° preoperatively, 16° postoperatively, and 15° at last follow-up.

Compensating curvature: the mean Cobbe angle was 21° preoperatively and 12° at last follow-up. Complications: partial deficit of the anterior tibialis (n=1), nonunion (n=3), infection (n=1), disassembly (n=3), valgum tibia at the site of the fibular graft harvesting (n=1).

Discussion: At these spinal levels, hemivertebral resection appears to be the most appropriate technique for children aged less than three years as long as there are no clear signs of progressive curvature.


A. Milet C. Glorion C. Cadilhac J. Langlais T. Odent J.-C. Pouliquen

Purpose: Tillaux fractures correspond to type III joint fractures involving the anterolateral tubercle of the inferior tibia in the Salter and Harris classification. These fractures generally occur by external rotation in children about 13 years old at the time the medial part of inferior growth cartilage of the tibial epiphysis has fused. The purpose of the present study was to analyse long-term outcome in a retrospective series of twenty children.

Material and methods: All twenty patients underwent physical examination and a standard radiographic work-up at last follow-up. Results were classed into three categories: good (free of pain, stiffness, gait impairment, joint degeneration), faire (moderate pain and/or stiffness and/or gait impairment without joint degeneration), poor (severe pain and/or severe stiffness and/or limping and/or joint degeneration).

Results: This series included eight boys and twelve girls, mean age 12.8 years (range 3.4 – 14.9). Mean follow-up was three years eleven months (range 12 months – 8 years 9 months). Eleven patients underwent surgical treatment and nine orthopaedic treatment. The lateral segment of the growth cartilage was open in all cases but the medial segment was open in two and completely closed in six. A computed tomography scan was required in one patient to assess displacement. Outcome was considered good in eighteen patients and fair in two. These two patients had persistent pain without functional impairment at about one year follow-up.

Discussion: Overall, the long-term outcome is good for Tillaux fractures if they are correctly identified and evaluated, with computed tomography if necessary, to enable appropriate surgical or orthopaedic treatment. Inappropriate management of this joint fracture can lead to joint incongruency and secondary degeneration. Most of these fractures occur in adolescents and secondary growth impairment is negligible. This type of fracture may also occur in adults. Prognosis is excellent with adapted treatment.


J.-L. Jouve R. Legré S. Malikov F. Launay S. Mineaud G. Bollini

Purpose: Reconstruction after resection of malignant bone tumours remains a major challenge. Free vascularised fibular grafts may be a useful alternative in this indication.

Material: Thirty children (nine girls, twenty-one boys) were treated between 1993 and 2000. Mean age was eleven years. Tumour histology was: osteogenic osteo-sarcoma (n=20), Ewing tumour (n=5), justacortical osteosarcoma (n=3), synovialosarcoma (n=1), and chondrosarcoma (n=1). Tumours were located in the femur (n=17), the tibia (n=6), the humerus (n=5), the radius (n=1), and the distal fibular (n=1). The length of resection varied from 100 mm to 260 mm (mean 160 mm). Internal fixation was used in 27 cases and external fixation in three. The adjacent epiphysis was preserved in 22 cases and initial arthrodesis was performed in eight.

Method: Patients were followed clinically and radiographically. A bone scintigram was obtained in all patients at least once during the postoperative period. Radiological assessment was based on the hypertrophy index of the graft using the method described by DeBoer and Wood. Functional outcome was assessed using the Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was required in two patients due to local ocological complications. One patient died at eight months follow-up due to lung metastasis. Among the remaining 27 patients, primary bone healing was achieved in 22. The five other patients exhibited clear signs of non-vascularisation. Successful healing was achieved in four of these patients after a complementary autologous graft. All cases of stress fracture healed after simple immobilisation.

The twenty-two patients who achieved primary bone healing developed a hypertrophic graft (mean 61%, range 22 – 190%). Graft hypertrophy was not observed in the five cases requiring a secondary graft after the scintigram demonstrated lack of vascularisation. Hypertrophy of the vascularised fibular graft was more marked for lower limb reconstructions than for upper limb reconstructions..

Functional outcome was satisfactory in all cases. On the 30-point Enneking scale as modified, our patients achieved a mean 26 points (range 19 – 30).

Discussion: Outcome was directly related to patency of the vascular anastomoses. Bone scintigraphy, performed one month after reconstruction surgery, was an important element for assessing prognosis. In case of unsuccessful vascularisation, a complementary cortico-cancellous graft should be used. Early weight-bearing is advisable using adequate protective devices. Dynamic osteosynthesis systems should be helpful in improving graft hypertrophy.


E. Mascard G. Missenard P. Wicart C. Kalifa J. Dubousset

Purpose: Amputation is often proposed for malignant tumours of the distal tibia. The purpose of our study was to report outcome and complications after conservative treatment of osteosarcoma of the distal tibia.

Material and methods: Eight patients, four boys and four girls aged 8 – 16 years (mean 12 years) were managed conservatively with high-dose methotrexate chemotherapy for osteosarcoma of the distal tibia between 1983 and 1998. Wide resection was performed in all cases and one patient had a lung metastasis. Mean length of resection was 13 cm (9–19). Tibiotalar reconstruction arthrodesis was performed in seven patients. Tibial grafts and a centromedullar nail associated with fibulotalar arthrodesis with screw fixation were used in four patients. Plate fixation was used in two, and one patient had a cement spacer while waiting for biological reconstruction. After surgery, the patients were immobilised in a plaster cast for three to six months. Weight bearing began two to four months after surgery.

Results: Resection was wide in four cases, marginal in three , and contaminated in one. Four patients responded well to chemotherapy and four responded poorly. Outcome was assessed at a mean follow-up of 5.5 years (2–17 years). At last follow-up, six patients were in remission, and two had died, including one after local recurrence despite amputation. Three patients had a deep infection which cured in all three without surgery. Two revisions were required in one patient with nonunion before achieving a solid union. All the patients who had a tibiotalar arthrodesis progressively developed nearly normal “ankle” function subsequent to progressive sub-talar hypermobility. The mean MSTS score was 27.7/30 (range 22 – 30).

Discussion: Conservative management of osteosarcoma of the distal tibia appears to be feasible and provides excellent functional results despite an important risk of infection. Wide surgical margins requires a good response to chemotherapy. In case of doubt, reconstruction must avoid contaminating the rest of the tibia in order to allow secondary amputation if needed.


P. Laudrin P. Wicart E. Mascard J. Dubousset

Purpose: Infection after resection and total knee arthoplasty for malignant bone tumours in children is a serious complication which may compromise limb salvage. The purpose of this work was to study the aetiology, treatment and prognosis of this event.

Material and methods: Among the 169 total knee arthroplasties performed for malignant bone tumours between 1981 and 1999, we selected 17 patients meeting the following criteria: proven infection with identified germ on deep samples or presence of a fistula more than two years after surgery. All of the patients had osteogenic sarcomas (excluding Ewing sarcomas which account for 30% of the tumours in this localisation). The bone tumour involved the femur (n=11) or the tibia (n=6) and required extraarticular (n=14) or transarticular (n=2) resection. Infections were primary (n=9) developing after the first operation, or secondary (n=8) to surgical revision in six, joint wound in one, or haematogeneous dissemination in one patient. The causal germ was identified in thirteen patients (76%) and was a staphylococcus in all cases. Treatment included systemic antibiotics and lavage (n=10), one-procedure change in prosthesis (n=3), removal of the implant with replacement by a spacer (n=2), surgical abstention (n=2), or amputation (n=1).

Results: Mean follow-up was eight years (2 – 16 years). On the average, treatment of infection lasted 51 months and required a 3.9 surgical interventions. At last follow-up, infection was considered cured in 70% of the patients who were free of clinical or laboratory signs of infection without antibiotics for at least one year. The arthroplasty could be preserved in one-third of the cases (22% of the primary infections and 50% of the secondary infections). Another treatment, arthrodesis (n=6), Borggreve procedure (n=1), or amputation (n=4), was given in the other two-thirds.

Discussion: The 10% complication rate observed here is in agreement with data in the literature. Development of primary infection is influenced more by the histology of the tumour and the presence of skin wounds (methotrexate) than by tumour site or type of resection. The diagnosis of primary infection is made late, often at the end of the postoperative chemotherapy protocol. Changing the implant is the ideal treatment. Secondary infection is characteristically less difficult to diagnose; infection is recognised earlier and the chances of preserving the implant are better.


L. Wattincourt E. Mascard M. Germain P. Wicart J. Dubousset

Purpose: Therapeutic options for shaft reconstruction are allografts, shaft prosthesis, and autografts, which may be vascularised or not. The purpose of this work was to assess mid-term results and complications after upper limb reconstructions using a vascularised fibula in children and adolescents undergoing surgery for tumour resection.

Material and methods: A vascularised fibular graft was used for reconstruction in ten patients who underwent surgery for resection of upper limb tumours between 1994 and 2000. The patients were seven boys and three girls, aged seven to seventeen years. the vascularised fibula was used for reconstruction after tumour resection in the same operation for eight patients and to salvage a proximal humeral prosthesis in two patients. The eight single-procedure reconstructions concerned four resections of the humeral shaft and four resections of the radius. Tumour histology was: classical osteosarcoma (n=7), low-grade osteosarcoma (n=1), Ewing tumour (n= 1) and aggressive enchondroma (n=1). Six patients were on chemotherapy at the time of the fibular transfer.

Graft lengths varied from nine to 21 cm (mean 14 cm). Plate fixation was used in most cases. All patients wore a cast for six to twelve weeks after surgery.

Results: Results were analysed retrospectively after 3.9 years follow-up (range 1 – 7 years). Mean time to bone healing was three months (range 1.5 – 5 months). Five of the six humeral shaft reconstructions fractured due to trauma, requiring revision surgery in four cases. All patients who were reoperated achieved bone healing rapidly. One radius had to be revised to add supplementary bone. The mean functional score (MSTS) was 25.5/30 (range 21 – 30). One patient died from lung metastasis and the others exhibited complete tumour remission.

Discussion: Vascularised fibula reconstruction of the upper limb provides good radiological results, particularly for the radius. For the humerus, the results are better for younger children because the bone can grow in thickness. Certain mechanical complications may occur if normal sports activities are resumed too early. Functional outcome after these shaft reconstructions is nearly normal.


E. Garron J.-L. Jouve C. Tardieu M. Panuel S. Airaudi G. Lollini

Purpose: We performed a biometric evaluation of the femoral trochlea in the human foetus and compared measurements with those observed in the adult in order to search for correlations with other biometric parameters of the human femur.

Material: Twenty-two foetuses with no orthopaedic anomalies were preserved in formol. The 44 knees were studied. Fœtal age varied from 26 to 40 weeks.

Method: After anatomic dissection, digital photographic documents were analysed using angular measurement software. The following dimensions were measured on the distal epiphysis: anteroposterior thickness of the condyles, protrusions of the lateral and medial trochleal edges, the difference in condyle height, the trochlear opening angle alpha, trochlear slope. Femoral anteversion, length of the femoral neck, and the neck-shaft angle were measured on the AP view of the femur.

Spearman’s test was used to search for correlations. Results were compared with those measured under the same conditions in a series of 32 adult knees published by Wanner.

Results: The alpha angle of trochlear opening was 148° with a coefficient of variability of 4%. The alpha angle was greater than 150° in 18 trochleae. The lateral edge of the trochlea was higher than the medial edge in 37/44 trochleae. There was no correlation by age and sex.

The femoral measurements showed 27.01° anteversion with very wide variability (coefficient 46%) and no correlation with trochlear opening.

No significant differences were observed between the fœtal and adult measurements.

Discussion: Our data are the first reporting anatomic measurements of the fœtal trochlea. The morphology of the lower extremity of the femur during the third trimester of pregnancy is globally the same as in adult femurs. Morphological changes of the proximal femur occurring during growth do not appear to modify the morphology of the distal femur. The deep and asymmetrical engagement of the patella onto the trochlea is a characteristic of modern man and is considered to be a consequence of bipedal stance. Our study would appear to confirm that the anatomic characteristics of the human trochlea have been integrated into the genome in the course of evolution. This suggests that a genetic origin of trochlea dysplasia, as suggested by Dejour, is a reasonable hypothesis.


P. Journeau C. Couturier A. Salon S. Guero

Purpose: We reviewed a series of pollicizations in children with congenital thumb malformations. The purpose of this study was to assess the influence of anatomic or technical factors on functional and cosmetic outcome.

Material: The series included 33 operations in 26 children. The Blauth classification was: grade IIIA (n=1), grade IIIB (n=8), grade IV (n=8), grade V (n=13), mirror hand (n=8). We noted the type of skin incision, technique used to fix the metacarpal head on the carpus, and tendon shortenings. Results were assessed at mean 4 years follow-up on the basis of the cosmetic aspect (parent satisfaction) and functional outcome measured with the Kapandji index and flexion-extension of inter-phalangeal joint, thumb finger opposition, and sensitivity.

Results: Mean age at surgery was 32 months. Fixation was achieved with sutures in 24 cases and pinning in nine. Tendon shortening was performed in 16 cases on the extensor system and in one case on the deep flexor system. Mean follow-up was four years. There was no significant difference between groups A and B for cosmetic outcome. The main factor influencing objective functional outcome was the association of a grade III or IV radial club hand. In these patients, the final outcome was compromised by the stiffness or deformation of the radiocarpal joint and the stiffness of the preoperative Kapandji index which was 7 (mean) in group A and 4.75 in group B.

Discussion and conclusion: The following technical aspects did not have a significant effect on the final functional result in our series: type of skin incision, type of carpal fixation, shortening the extensor or flexor system. Technical aspects which must be performed with particular care include reconstruction of the thenar muscles using interosseous muscles, curettage of the growth cartilage of the head of the second metacarpus, and hyper-extension of the head of the second metacarpus during fixation onto the carpus. Careful technique avoids future complications such as excessive growth of the neometa-carpus or Z-thumb.


G. Mary M. Larrouy D. Hannouche G. Filipe

Purpose: We searched to define a fracture index useful for predicting the risk of bone fracture in children with essential bone cysts.

Material and method: We reviewed 96 children with an essential bone cyst. The following clinical data were recorded: age, cyst localisation, circumstances of diagnosis.

The radiological analysis was based on 193 AP and lateral x-rays. We measured: 1) the distance separating the superior pole of the cyst from the suprajacent growth cartilage, 2) the largest cyst diameter, 3) the greatest cyst height, 4) the thinnest cortical width facing the cyst, 5) the cyst surface area calculated exactly using surface area software and expressed as a a ratio of shaft diameter (S/d2, Kaelin index). These different parameters were compared for cysts associated with fracture or not.

Results: Mean age at diagnosis was 10.4 years (range 2 – 12.8 years). Most of the cysts were located in the upper portion of the humerus (72%). Fracture was the inaugural sign in 68% of the cases.

Comparing the two cohorts of patients demonstrated that the following differences were significant (Student’s t test): 1) cyst width (p=0.0038): below 16 mm none of the cysts fractured. For wider cysts, there was no difference between the fracture and non-fracture cysts. 2) cortical thickness (p=0.0002); cortical thickness greater than 5 mm protected against fracture. If the cortical measured less than 3 mm, the risk of fracture was greater than 50%. 3) Kaelin index: (p< 0.0001) was directly correlated with fracture risk but no cutoff could be identified.

For an 80 – 100% risk of fracture, the cyst must have the following characteristics: width > 30 mm, height > 75 mm, cortical thickness < 2.4 mm, Kaelin index > 5.

For a 50% risk of fracture, the cyst must have the following characteristics: width > 24 mm, height > 55 mm, cortical thickness < 3 mm, Kaelin index > 3.

Conclusion: The Kaelin index is reliable but difficult to calculate in the consultation setting. Cortical thickness is a good indicator. Its predictive value can be improved by correlating the height of the cyst with its width. These measure can be obtained easily during consultation.


C. Hazuke A. Kaelin

Purpose: The immature skeleton demonstrates a remarkable capacity for correcting residual deformations after fracture. Classically, a residual angle of less than 25° can be tolerated for distal fractures of the forearm in children. The degree of remodelling depends on the distance between the fracture line and the epiphyseal line, the time remaining before closure of the growth cartilage, the residual angle after reduction, and is orientation in relation to the motion of the adjacent joint. The purpose of the present study was to better define the upper limit for acceptable deformation by age in order to determine when surgical correction is indicated.

Material and methods: We reviewed the radiography files of 106 children with one or two fractures of the distal third of the forearm who had required closed reduction and brachio-antebrachial cast immobilisation. We measured the angle of deformity on the AP and lateral views after reduction, at six weeks and at three, six, and twelve months after trauma. The series included 79 boys and 27 girls, mean age 8.5 years (range 2.5 – 15). Twenty-five fractures were epiphyseal fractures and 81 were metaphyseal fractures.

Results: Remodelling was nearly complete one year after fracture in most cases, especially in younger children and more distal fractures. Salter I or II fractures remodelled very rapidly, within four to five months of trauma. This remodelling was mainly achieved by apposition-resorption in the metaphyseal area by reorientation of the epiphyseal line. For the metaphyseal fractures, rate of remodelling was inversely proportional to the distance between the fracture line and the growth cartilage. Remodelling was greatly perturbed in case of open fracture requiring surgical reduction and in case of secondary infection.

Discussion and conclusion: These data show that posterior inclination can be tolerated up to 30° for children under eight years of age and up to 25° between eight and ten years and up to 20° at prepuberty. Knowledge of these limits for distal fractures of the forearm is important for proper management and can be helpful in reducing the number of primary or secondary reductions under general or locoregional anaesthesia.


M.-C. Giacomelli P. Gicquel P. Clavert C. Karger J.-M. Clavert

Purpose: Continuous monitoring of the interstitial pressure of muscle compartments is a useful method for preventing compartment syndrome. The perfusion pressure is the key measurement (difference between the arterial diastolic pressure and the interstitial pressure). It should always remain above 30 mm Hg. Our postoperative monitoring data provided new insight into circumstances where there is a higher risk of compartment syndrome due to a fall in arterial diastolic pressure.

Material and methods: Twenty patients (13 boys and 7 girls) underwent continuous monitoring of the interstitial pressure of the anterolateral compartment of the lower limb. These children had undergone lengthening-realignment procedures, realignment procedures, or treatment of fracture. Mean age was 11.5 years. Preventive subcutaneous aponeurotomy was performed in 15 patients. The patients were monitored for a mean 55 hours. The interstitial pressure was noted every hour, in addition to pain on a visual scale, and the type and administration route of antalgesics. A risk condition was defined as perfusion pressure (diastolic arterial pressure – interstitial pressure) less than 30 mmHg.

Results: One or more episodes of low perfusion pressure (< 30 mmHg) were observed in eleven of the twenty patients, during the first five postoperative hours in five and during sleep and awakening phases in eight. Pain was not increased during these periods during which antalgesics were administered. The common denominator for these risk conditions was high pressure in the muscle compartment but low diastolic pressure. None of the children developed a compartment syndrome with sequela. Preventive aponeurotomy did not protect against the development of these risk conditions.

Discussion: These results provide new insight into the haemodynamic conditions occurring during the recovery period and point out the need for rapid recovery of an elevated diastolic arterial pressure. This would decrease the risk of compartment syndrome and also limit postoperative oedema.

Conclusion: Immediate postoperative monitoring of the interstitial pressure demonstrated that the risk of compartment syndrome occurs when the diastolic pressure is low, that is during postoperative awakening and periods of sleep in children given antalgesics.


R. Sarrail F. Launay M.C. Marez B. Puech P. Chrestian

Purpose: Reflex dystrophy is a poorly understood condition which must not go unrecognized due to the invalidating consequences.

Material: Twenty-four children aged seven to fifteen years were treated for reflex dystrophy since 1998. The foot or ankle was involved in 73% of the cases, generally secondary to ankle sprain. The diagnosis was established on the basis of the clinical presentation and on bone scintigram data obtained in all cases. Mean delay to diagnosis was 17.9 weeks, one case being diagnosed at 2.5 years.

Methods: An intravenous block (xylocaine and buflomedil) using a low-pressure tourniquet and without anaesthesia was performed in 23 patients. The local anaesthesia allowed gentle manipulation of the stiff joint so the child could visualise renewed mobility. The block was associated with gentle physical therapy, balneotherapy, and psychological support.

Results: The intravenous block was immediately and totally effective in 78% of the cases, the child being able to walk with full weight bearing without pain. Recurrence rate was 17%, occurring within the first month after the block in 80% of the cases.

Discussion: Diagnosis of reflex dystrophy is basically clinical, but the scintigram supported the diagnosis and enabled better localisation of the anatomic region involved. We have abandoned first line calcitonin which has demonstrated less satisfactory results than intravenous blocks. Combining a local anaesthetic with a low-pressure tourniquet improves patient comfort without the inconvenience of general anaesthesia.

Conclusion: Care must be taken to no overlook reflex dystrophy in children and adolescents. First intention use of an intravenous block significantly shortens the clinical course allowing the child to resume physical activities.


S. Bourelle J. Cottalorda L. Vessenay V. Gautheron

Purpose: Assessment of orthopaedic or surgical treatment in children with cerebral palsy is essential. For the lower limb, the main objective is to improve walking. Gait and control of static and dynamic posture are closely related. In this preliminary study, we attempted to determine whether treatment of pes equin which perturbs gait and equilibrium improves control of static and dynamic posture.

Material: Four children with spastic diplegia, one boy and three girls, aged five to fourteen years participated in this preliminary study. These children had unilateral or bilateral fixed or dynamic pes equin requiring medical (injection of botulinic toxin and/or lengthening casts) or surgical (aponeurotomy of the gastrocnemius) management.

Methods: Balance Master® was used for the posturographic evaluation. This system uses a force platform for calculating the vertical component at the centre of downward force on the feet. Five tests were used: distribution of body weight, stability in different sensorial conditions, single stance stability, limits of stability, rhythmic balancing movements. These tests were performed during the month preceding treatment and two and four months after treatment.

Results: For distribution of body weight, two children clearly improved after treatment. For the stability test in different sensorial conditions, all children showed improvement. There was no real improvement in the single stance test but two children who had had a unilateral treatment exhibited degradation on the untreated side. The rhythmic balancing movements test revealed an improvement in directional control in three of the four children.

Discussion and conclusion: This preliminary study demonstrated the feasibility of obtaining an easily implemented patient-friendly assessment of static and dynamic posture control in very young children with cerebral palsy. The Balance Master® system appears to be an interesting research tool for assessing posture control before and after treatment and might also be a useful rehabilitation tool.


J.L. Dore

Purpose: Unless exposed to stress, bone undergoes lysis. Osteoconduction is not observed in hydroxyapatite in contact with dead bone. We wanted to know whether bone blocks positioned on metal back cups in patients with total hip arthroplasty for acetabular dysplasia are destroyed lysis or “adhere” to the hydroxyapatite.

Material and methods: The series included 22 bone blocks in 21 patients with low weight-bearing displacement (n=10), high weight-bearing displacement (n=6), high non-weight-bearing displacement (n=6). Mean follow-up was six years (17 patients > 5 years).

Technique: all blocks were fashioned with autologous bone. The size of the cup, and thus the volume of the bone block, was determined by the largest anteroposterior diameter compatible with the desired position. The block was fashioned with a trial cup in place. The definitive cup was inserted separately then lag screwed to the bone block.

Implants: twenty-two titanium cups (3 mm) with hydroxyapatite surfacing, bone block width: approximately 28° from the centre of the prosthetic head.

Cup position: native acetabulum (n=11), neoacetabulum (n=11).

Results: Complications were : sciatic paresia (n=0), displacement (n=0), shift in cup position (n=1 at day 21). Partial lysis of the bone block was observed but there was no case of total lysis.

Titanium-hydroxyapatite-block adhesion: no lucent line was visible in 17 cases at more than five years. There were no cases of bony nonunion.

Discussion: Are grafts necessary with a metal back cup? The cup is slightly exposed in some primary degenerative hips but all goes well for ten years without a bone block. At what point would cup “exposure” require a bony support? As autograft material is available, it would appear inappropriate to not use it, especially since the lack of lysis suggests grafts are useful. All bony structures behave in an intelligent manner: an oversized bone block undergoes lysis but the part under stress above the cup becomes more dense.

Conclusion: Autologous bone blocks placed on metal back cups are not destroyed by lysis. The bone-hydroxyapatite couple adheres normally. Autologous bone blocks above metal back cups behave intelligently, like blocks inserted above cemented polyethylene cups.


F. Lecuire P. Benareau J. Rubini M. Basso

Purpose: The double mobility of the G. Bousquet cup—head-polyethylene,polyethylene metal cup—considerably reduces the risk of total hip arthroplasty displacement.

Material and methods: We observed seven cases of “intra-prosthetic” displacement in patients with this type of cup. Progressive wear of the polyethylene retention ring allowed displacement of the femoral head. These displacements occurred in six patients (one bilateral case) aged 43–58 years, on the average ten years after the implantation (range 3.5 – 15 years).

All patients underwent revision.

Results: The polyethylene retention ring was worn in all cases allowing the femoral head to escape. Revision surgery was performed very early in six hips to change the modular base and the polyethylene ring and re-establish retaining capacity. A satisfactory result was achieved in all cases. One patient required revision five years later to change the prosthesis subsequent to haematogenous infection. Another patient underwent a late revision to change the modular base and the entire cup of a press fit implant. This hip was in excellent condition but revision was decided on because of four dislocations.

Discussion: Intra-prosthetic displacement of the polyethylene head of a double-mobility cup is exceptional in our experience. Wear of the retention ring is favoured by different elements: 1) direct phenomena: neck and head diameter causing early contact between the neck and the cup; 2) indirect phenomena: factors limiting the mobility of the polyethylene metal cup couple (fibrosis, repeated interventions, ossification).

In our experience, intra-prosthetic displacement occurs more readily in patients with favouring conditions (alcoholism, muscle deficiency, psychiatric disorder, obesity) observed in six of our seven cases.

Conclusion: Intra-prosthetic displacement of a double-mobility cup is a possible but exceptional complication requiring a technically simple revision. Some teams use this type of cup systematically and for us is an essential element for preventive treatment in high-risk patients and for curative revision of recurrent dislocation.


L. Béguin R. Limozin A. Demangel P. Adam M.H. Fessy

Purpose: Amstuz introduced the notion of a lever arm ratio to describe the relationship between the abductors and weight in arthroplasty. He demonstrated that patients may limp if defective lateralisation produces a low lever arm ratio. We analysed a continuous series of arthroplasty patients with excellent outcome at one year to compare restoration of lateralisation with the preoperative status. We also performed the same analysis in a series of patients who limped after arthroplasty, excluding cases with classical causes of failure. We then compared these two series.

Material and methods: We had a series of 100 arthroplasties with excellent results at one year. These patients had undergone unilateral arthroplasty and had a healthy contralateral hip. The centre of the arthroplasty head was identified on preoperative and one-year AP x-rays of the pelvis (same magnification). We measured the lateralisation in relation to the femoral axis. The position of the cup was measured with a U ratio. Results were expressed in percent restitution of the preoperative status. Amstutz’s lever arm ratio was also measured. Finally, we measured the distance between the pubic symphysis and the outermost point of the femur on the prosthetic and healthy side.

We also had a second population of twelve patients presenting persistent limping at one year with no objective cause. The same parameters were measured for this population.

Results: We found that we had achieved only partial restitution of the initial lateralisation and had a tendency to medialise the acetabulum. The restitution of lateralisation was significantly different between the series with excellent outcome and the series with limping.

Discussion: Deficient lateralisation appears to be a factor involved in persistent limping. There is a threshold for restitution of lateralisation; limping is always observed under this threshold. Data in the literature reveal a very wide variability in lateralisation. It would thus appear important to restore the initial lateralisation to avoid limping; this has led us, like others, to use lateralised implants for certain patients.


M. Hamadouche B. Zniber M. Kerboul L. Kerboul J.P. Courpied

Purpose: Nonunion of the trochanter after total hip arthroplasty using the transtrochanteric approach is a serious complication. Incidence is estimated at 3%. Failure after simple cerclage reaches 40%. A plate was therefore designed specifically for fixation of trochanteric fractures. The purpose of this retrospective analysis was to assess outcome in a continuous series of trochanteric fractures treated with this plate.

Material and methods: The series included 72 nonunions in 71 patients treated between 1986 and 1999. Mean age was 66 years. Most of the arthroplasties had been performed for primary degenerative joint disease or for hip dysplasia. The time interval between artrhoplasty and treatment of the nonunion was eight months on the average. The trochanter was fixed with a plate alone in 47 hips and in combination with a frontal wire in 25. The primary outcome criterion was trochanter healing scored as: union (pain free hip, radiological fusion and stability), nonunion (lack of radiological fusion and/or presence of an instability), and doubtful union (moderate pain, no instability, radiological fusion difficult to affirm).

Results: Mean follow-up was 47 months (range 12 – 14). Mean functional score at last follow-up was 15/9 compared with 13.5 preoperatively (paired test, p < 10–4) with 51 unions, 12 nonunions and 9 doubtful unions. Among the factors studied, trochanter fixation technique was the only factor predictive of outcome. Results were as follows for plate fixation alone: union 62%, doubtful union 13% and failure 25%. For hips with wire and plate fixation, the results were union 87.5%, doubtful union 12/5%, failure 0%. The difference was highly significant (chi-square, p = 0.006) in favour of wire-plate fixation of trochanteric fractures.

Discussion and conclusion: This study leads to the conclusion that the treatment of choice for trochanteric nonunion is wire-plate fixation which provides more than 90% good and very good results.


P. Hernigou T. Bahrami

Purpose: We compared two series of total hip arthroplasties (THA) at more than 12 years. The only difference between the two series was the nature of the femoral head: 28-mm zincronia head versus 32-mm alumina head.

Material and method: All THAs were performed during the same period (1988–1990) and the polyethylene inserts, the femoral components, the surgical cement and the operator were the same for both series. Patient age and mean weight were the same for the two series of 40 Zir/PE and 62 AL/PE implants: 98 and 63 years and 72 and 73 kg respectively. Implant survival, polyethylene wear on AP and lateral x-rays, and Merckel osteolysis were studied.

Results: Three revisions were required at eight, ten and eleven years in the Zir/PE group. No revisions were required in the Al/PE group where there were no signs of loosening on the radiograms.

During the first four years, polyethylene wear appeared to be the same in the two series. Beyond the fifth year, penetration of the alumina heads exhibited a regular mean 0.07 mm progression per year. Beyond the fifth year, penetration of the zircona heads accelerated reaching a mean 0.4 mm per year at twelve years. Mean volumetric wear of the polyethylene cups was 1360 mm3 for the zircona heads and 755 mm3 for the alumina heads. Osteolysis was seen as a defected facing the merckel and measured 2.5 cm2 for the Zir/PE couple and 0.35 cm2 for the Al/PE couple. The differences between the two series in linear penetration, volumetric wear, and osteolysis were significant (p < 0.05). The three zircona heads that were removed showed partial transformation from the tetragonal phase to the monoclinical phase (19%, 25% and 30%) and a roughened surface which was not sufficient to explain the polyethylene wear. Abnormal wear was explained more by loss of spherical shape and the greater volume of the zircona heads, probably related to a modification of the crystalline phase (change from the tetragonal to the monoclinical phase usually is associated with a 3% increase in volume). Analysis of the fingerprints left on the morse code of the zircona heads suggest the change in volume of the zircona heads was associated with a change in the contact between the morse cone and the zircona head over time. Analysis of the explanted cups showed wear with delamination in two cases. For one of the implants, the polyethylene insert was deformed exhibiting a fusion aspect corresponding to abnormal increase in temperature.

Discussion and conclusion: The zircona implants manufactured more than twelve years ago probably do not meet current manufacturing standards. Nevertheless, the changes observed in the explanted pieces would suggest they are related not only to the manufacturing process but also to the material itself.


J.M. Durand J. Henner G. Vaz J. Béjui-Hughes

Purpose: There has only been one reported series of 30 cases of greater trochanter fracture during total hip arthroplasty and 26 of these were postoperative discoveries. We evaluated the frequency of this event and its postoperative consequences.

Material and methods: Among our series of 1171 total hip arthroplasties performed between 1985 and 2000, 38 patients (3.2%) with greater trochanter fracture were identified (mean age 63 years). Osteosynthesis was performed in all cases. Thirty-one fractures were observed during primary arthroplasty and seven during revision procedures.

Results: Eighteen patients had a favouring condition: corti-costeroid therapy,alcoholism,osteoporosis,diabetes,Paget, ablation of trochanteric material, periprosthetic osteolysis. The anterolateral approach was used in 22 and the posterolateral approach in 16. The fracture occurred along the access route in four (material removal or prefracture situtation), at removal of a previously implanted stem in two, and during implantation in 32. Twelve different stems were involved but a screwed stem was involved in 18 cases, i.e. 10% of all implanted screwed stems, while this complication only occurred in 1.2% of other implanted stems. Immediate weight bearing was authorised in 27 patients and deferred three weeks to three months in eleven. There were two deaths, so follow-up data was available for 36 hips: we observed anatomic bone healing in 22, deformed calluses in five and nonunion in nine, including two cases with infection (three revision procedures were required). Pain persisted at two months for eleven hips and limping persisted for ten (eight nonunions).

Discussion: Prostheses with a large metaphyseal component were involved in the majority of the fractures. The surgical approach was not incriminated. When well stabilised, trochanter fractures healed well. Nonunion, often announced by persistent pain, is an important risk in patients with osteoporosis and a poorly stabilised fracture. Although all cases of nonunion were observed in patients with deferred weight bearing, this criterion is simply the expression of the surgeon’s apprehension in case of less than satisfactory fixation.

Conclusion: Because of the deficient bone stock, which explains the higher rate of nonunion, fracture of the greater trochanter cannot be considered in the same light as a planned osteotomy. Prevention requires choosing a less cumbersome metaphyseal component in patients with favouring conditions. Osteosynthesis must be performed with particular care in order to obtain rapid healing and good functional outcome.


C. Nich M. Hamadouche M. Keroboull M. Postel J.P. Courpied

Purpose: The purpose of this retrospective study was to assess clinical and radiological outcome at ten years follow-up at least in a continuous series of total hip arthroplasties performed in patients with aseptic necrosis of the femoral head.

Material and methods: The series included 122 arthroplasties performed between January 1980 and December 1996 in 96 patients (26 women and 70 men), aged 50.8±13.3 years (range 21–85 years). The underlying cause was essential necrosis in 40.6%, cortocosteroid threapy in 19.8%, chronic alcoholism for 17%, trauma for 12%, and another medical cause for 10%. The Ficat and Arlet classification was grade IV 80 hips, grade III 42 hips. All arthroplasties were performed via the transtrochanteric approach. Cemented Charnley-Kerboull implants were used with a metal-polyethylene couple in all cases. The Merle d’Aubigné score was used to assess functional outcome. Cup wear was measured according to Livermore. Actuarial survival curves were calculated.

Results: Follow-up was greater than ten years for all patients (mean 13±2.6 years, range 10–21 years). At last follow-up 59 patients (75 hips) were living and had not undergone revision and seven patients (seven hips) had undergone revision of the acetabular and/or femoral component. Twenty patients (24 hips) had died and ten patients (16 hips) were lost to follow-up. Revision procedures were performed for periacetabular osteolysis in one hip, infection in one hip, and acetabular loosening in five hips. Three patients experienced luxation or subluxation. The mean preoperative function score was 11 (range 5 – 16) compared with 17 (14–18) at last follow-up (p < 0.05). Clinical outcome was good or excellent in 95% of the patients and fair or poor in 5%. Mean overall cup wear was 0.965 mm (0–5) for non revised hips. Lucent lines were found around eleven acetabular implants and six femoral implants. Cumulative survival, considering revision as failure, was 88.5% at 15 years (95% confidence interval 80.2 – 96.9%).

Discussion and conclusion: The results of this series lead to the conclusion that low-friction total hip arthroplasty is the treatment of choice for advanced stage femoral head necrosis.


P. Beaule T. Schmalzried F. Dorey H. Amstutz

Purpose: Treatment of Ficat III and IV femoral head necrosis is a serious challenge and a controversial issue due to the young age of the patients and disappointing results obtained with total hip arthroplasty (THA). We reviewed our experience with the cemented adjusted cup to identify factors leading to surgical revision and assess long-term clinical outcome.

Material and methods: Sixty hips presenting necrotic heads were treated by cemented adjusted cups. Mean age of the patients was 33.6 years (range 18–51); 23% women and 77% men. The Ficat classification was: grade II 6%, grade III 85%, grade IV 9%. Mean necrotic Kerboull angle was 192°. In addition, the status of the acetabular cartilage was recorded at surgery: grade I normal 17%, grade II fissuration 30%, grade IIIA fibrillation without osteophytes 28%, grade IIIB fibrillation with osteophytes 10%, grade IV partial erosion reaching subchondral bone 10%.

Results: At mean follow-up of 7.8 years (range 1 – 21 years), there were no cases of dislocation, femur neck fracture, or osteolysis. Mean UCLA score showed significant improvement in pain (from 4.5 to 8.1), walking (6.1 to 8.8), function (5.3 to 7.6), and activity (4.2 to 5.8). Five-, ten-, and fifteen-year survival rates were 81, 57, and 40% respectively. Fifteen hips required THA, twelve for acetabular cartilage wear, one for femoral loosening, and one for infection. A positive correlation (p = 0.005) was observed between the duration of signs preoperatively and degradation of the acetabular cartilage, suggesting a relationship also with shorter prosthesis survival. The Kerboull necrosis angle and Ficat grade were not correlated with prosthesis survival.

Discussion: Survival of the adjusted cup is better when symptoms have been perceptible for less than one year, probably because the acetabular cartilage is less damaged. These results are better than those with other conservative solutions such as osteotomy or vascularised graft which do not reach 80% survival at five years and which provide less effective pain relief. If necessary, conversion to a THA can be performed without compromising clinical outcome.


C. Nich D. Hannouche R. Nizard P. Bizot L. Dedel

Purpose: Fracture of alumina implants is a rare cause of total hip arthroplasty (THA) failure. Over the last twenty years, improvement in the design of ceramic implants has helped reduce this risk. We observed five cases of alumina implant fracture over the last year. The purpose of this work was to analyse these recent events and to examine our experience to search for an explanation.

Material and methods: Between 1976 and 2002, eleven patients, five women and six men, mean age 57 years (range 32–87 years) required revision surgery for fracture of an alumina component. The time interval from primary surgery to revision was 36.5 months (range 7 – 106 months). An alumina-alumina couple was involved in nine cases and an alumina-PE couple in two. The primary THA used a press-fit metal backed alumina cup for five hips, a cemented alumina cup for three hips and a massive press-fit alumina cup for one. The alumina head measured 32 mm for ten hips, 22.2 mm for one. The femoral stems were cemented in seven cases, and hydroxyapatite surfaced in four. The acetabular component was involved in four cases and the femoral head in seven.

Results: Identified causes of ceramic implant fracture were: high-power trauma (insert) (n=1), insufficient head diameter (n=1), and defective head match (n=1). For the eight other fractures, involving three insets and five heads, no triggering factor could be identified. The three insert fractures involved two 50-mm cups and one 52-mm cup. Insert design had been changed before these fractures. Mean time from insertion to fracture was 12 months (range 8.5–15 months) in these cases.

Discussion: To our knowledge, all reported cases of ceramic implant fracture have concerned the prosthetic head. The present series demonstrates a recent development, fracture of acetabular implants. It is hypothesised that these fractures could be explained by an insufficient cup diameter associated with a recent change in the design of the metal-backed flush ceramic insert. These inserts have been modified and now have an “overhang” design associated with a thicker layer of ceramic for the smaller cup diameters. These accidents remain rare but justify careful surveillance, particularly during the first postoperative year.


J.P. Clarac H. Hamcha J. Soyer P. Priès M. Freslon G. Thierry

Purpose: We report the clinical and radiological outcome observed with Charnley total hip arthroplasties in a series of patients aged less than 60 years followed for at least 25 years.

Material and methods: This retrospective analysis included 141 consecutive total hip arthroplasties performed between 1972 and 1975 with a Charnley implant. The same surgeon used the same technique for all implants. All of these patients had been followed regularly for at least 25 years. We recorded radiographic measures of polyethylene cup wear and its impact on prosthesis life. We tested the influence of different factors on the development of femoral or acetabular loosening. Survival curves were calculated for acetabular and femoral components.

Results: At last follow-up 28 prostheses were still in place, 44 had undergone revision, 42 were lost to follow-up and 27 patients had died. At last follow-up, including the revised hips, joint function was considered, good, very good or excellent in 86% of the cases (merle d’Aubigné score 15 – 18 points). Polyethylene wear was 0.12 mm/year. Merkel osteolysis was observed in 50% of the cases.

Discussion and conclusion: This work demonstrates the good functional outcome provided by Charnley total hip arthroplasty. The wear and loosening rates were higher than observed in older patients. Prognosis depends on polyethylene wear and its biological consequences.


J.P. Steib R. Dumas D. Mitton F. Laviste W. Skalli

Purpose: Scoliosis is a three-dimensional deformation of the spinal column. Modern surgical techniques have attempted to address this 3D component of the problem but pre- and postoperative measurements lack precision. A solution is stereoradiographic 3D reconstruction providing 1.1 mm precision for vertebral shape and 1.4° precision for axial rotation.

Material and methods: Ten patients (seven adolescents and three adults) with idiopathic scoliosis (mean 56°, range 36°–78°) were treated with an in situ arching method. A calibrated teleradiogram (AP and lateral view) was obtained before and after surgery. The spinal columns were reconstructed by stereoradiography. Six rotation angles were measured in the three planes for each vertebra and each intervertebral space, taking into account the curvatures and their apical and junctional zones.

Results: Preoperatively, for thoracic scoliosis, measurements were: mean vertebral axial rotation (VAR) measured at the apex = 20°; mean lateral axial rotation (LAR) of the junctional zones = 30°; mean intervertebral rotation (IVR) = 10°. Depending on the curvatures, in situ arching yielded a 52–60% correction of the VAR at the apex, and 78–79% correction of the junctional zones. VLR of the junctional zoenes was improved 58–74%. Intervertebral sagittal rotation (ISR) at the summit (kyphosis) was improved 5.5° on the average.

Discussion: Unlike computed tomoraphy where scans are obtained in the supine position, three-dimensional reconstruction of the spinal column enables a precise analysis of the loaded spine. Improvement was significant in the frontal plane with 18.3° and 21.4° improvement of the VLR for the thoracic and thoracolumbar junctional zones respectively, compared with the rod rotation where the peroperative stereophotogram showed a 9.6° and 8.6° gain respectively. There was a real improvement in VAR, differing from the literature where the rotation of the rod appears to be less pronounced.

Conclusion: Three-dimensional reconstruction of the spinal column enables a segmentary analysis of scoliosis deformations. In addition, by enabling a view of the spinal column in all directions, angle measurements can be made with precision allowing repeated measurements and comparisons. This technique demonstrated the efficacy of in situ arching in improving vertebral rotation.


P. Bizot R. Nizar J. Witvoet L. Sidel

Purpose: Alumina resistance to wear is now well established. In the eighties, improvement in manufacturing processes and implant design led to a significant reduction in the risk of fracture but failure of acetabular fixation remained a cause leading to revision. The purpose of this work was to present our results with a consecutive series of press-fit cementless metal backed alumina-alumina THA implanted between 1990 and 1992 in patients aged less than 55 years.

Material and methods: The series included 62 patients and 71 hips. Mean age at surgery was 46 years (range 21 – 54). A cemented titanium femoral stem with a 32-mm alumina head was implanted with a press-fit metal-backed cup with an alumina insert. Three patients (4 hips) died. Four hips required revision for infection (n=1), unexplained pain (n=1), fracture of the alumina head (n=1), and aseptic cup loosening (n=1). At nine years the survival rate was 93.7% taking revision for all cause as the end point and 98.4% taking revision for aseptic loosening as the end point.

Results: Fifty patients (57 hips) were reviewed with at least five years follow-up (mean 8 years, range 6–11 years). According to the Postel-Merle d’Aubigné score, functional outcome was excellent or very good in 96% of the patients. A minimal partial lucent line was observed around 38% of the cups, mainly in zone III and one cup exhibited a complete line measuring < 1 mm. Isolated osteolysis of the femur was observed in one hip. There was no case with acetabular osteolysis or implant migration.

Discussion: Combining a cemented stem with a pressfit metal backed cup has provided very satisfactory mid-term results in these active patients. Use of a press-fit hemispheric cup has been found to be a reliable fixation method for alumina cups and improves results of Al-AL THA significantly. In light of the excellent resistance of the alumina cups against wear, these results can be expected to continue for a long period.


F. Chalencon J.P. Fayard R. Limozin

Purpose: We report a retrospective continuous series of 107 total hip arthroplasties using a hydroxyapatite-coaated cup followed for a mean 9.67 years. We studied implant stability and component wear.

Material and methods: One hundred total hip arthroplasties were performed between January 1991 and January 1992. The series included 67 women and 40 men operated by the same surgeon who used the same Alizé cup and Aura cementless stem. Mean age at surgery was 66.5 years (range 30–85). Mean follow-up at review was 9.6 years. We retained 63 hips for analysis excluding 17 deaths, 16 patients lost to follow-up, 10 patients who could not be followed correctly, and only one implant ablation (0.9%). The implant was a first intention prosthesis in 90.7% of the cases and a second operation to replace a loosened primary prosthesis.

The Postel Merle d’Aubigné score was used to assess clinical outcome and all patients responded to a self administered questionnaire. Radiographically, we searched for signs of instability (tilt, displacement) and implant wear using precise digitalized measurements on successive digitalized x-rays with MetrOs software. We searched for qualitative radiological signs of bone reaction in contact with the implant.

Results: The overall PMA score improved from 10.63 preoperatively to 16.98 at the intermediary 5-year follow-up and was 15.77 at the 10-year follow-up. Satisfactory results were obtained in 93.9% of the patients at five years and 98.5% of the patients (64 hips) at 10 years. There were two fractures of the ceramic head after direct fall on the greater trochanter (requiring changing the femoral implant, the head and the polyethylene insert). There was one cup loosening at 9.5 years with verticalisation of the implant in an active athlete. Analysis of the x-rays did not demonstrate any abnormal condensation or lucent lines. Bony defects were observed in one case. The MetrOs radiographic data were available for 55 hips. At five years, mean wear was 0.53 mm, which increased to 0.76 mm at ten years (range 0.16 – 2.24 mm). Cup ascension was 0.15 mm at five years and 0.76 mm at 10 years. Mean cup tilt was 46.2° immediately after implantation and varied a mean 0.7° at five years and 1° at ten years.

Discussion and conclusion: This radioclinical study at ten years follow-up demonstrates that the hydroxyapa-tite surfaced Alizé implant is stable over time. The clinical results in this study were satisfactory with minimal regression of the PMA score related to patient ageing. The x-rays analysed with a rigorous and precise measurement instrument provided reassuring results. We discussed the one cup loosening and the clinical course of the two patients who underwent revision procedures after trauma-induced fracture of the ceramic head.


I . Yugue K. Shiba N. Uezaki

Purpose: Cervical laminoplasty has been used for the treatment of cervical arthrosic myelopathy in Japan. The purpose of this work was to assess clinical and radiological outcome at more than two years follow-up.

Material: Thirty-one patients underwent laminoplasty of three levels or more for cervical arthrosic myelopathy and were reviewed more than two years after surgery.

Methods: The Japanese Orthopaedic Association score was used to assess function preoperatively and at last follow-up. Preoperative and last follow-up standard strict lateral and flexion and extension x-rays of the cervical spine were available for all patients. The curvature was assessed on the lateral view in the neutral position (C2–C7 Cobb angle). Overall mobility was assessed on the dynamic views.

Results: The mean preoperative score was 9.7, improving to 138 at last follow-up (p < 0.0001, paired t test). Mean relative gain was 52.9%. The mean Cobb angle was 17° preoperatively and 8.9° at last follow-up. Cervical spine curvature and overall mobility had no influence on the score at last follow-up. The postoperative Cobb score was only influenced by the preoperative angle (p < 0.0001). There were no reoperations for instability.

Discussion: Guigui has demonstrated that mean loss of cervical lordosis in a series of extended laminectomies was 14°. In our series, mean loss of cervical lordosis was 8.1°. Laminoplasty enables a better preservation of cervical lordosis than laminectomy. Guigui also reported three patients requiring reoperation because of an unstable spine after laminectomy. Inversely, we did not have any cases requiring reoperation. During laminoplasty, a gutter is fashioned in a medial quarter of the articular masses to open the lamina, producing their fusion. This unexpected fusion diminishes overall mobility but also has a less destabilising effect on the spine than laminectomy.


O. Gille C. Schaeldele V. Pointillart J.M. Vital

Purpose: A retrospective study of 17 fractures of the cervical spine in patients with ankylosing spondylitis is reported. The purpose of this study was to search for risk factors of fracture in ankylosing spondylitis an to assess treatment outcome.

Material and methods: Seventeen patients treated between 1982 and 2201 were reviewed with a mean follow-up of five years. There were three women and fourteen men, mean age 60 years at trauma. Fifteen patients underwent surgery and two were treated orthopaedically.

Results: This group of patients with ankylosing spondylitis with fracture of the cervical spine was homogeneous: age 60 years, disease duration 30 years, fracture due to fall. The fracture was at the C6/C7 level in 47% of the patients where the lever arm is the greatest and also a level that is difficult to explore, explaining the late diagnosis in 35% of the patients. Sixty percent of the patients were in Frankel classes D or E and 23% in classes A or B. Anterior fixation was used for 14 patients, posterior fixation in one. A long osteosynthesis involving several levels was used in all cases. Major kyphosis had developed in three patients after fracture which was not recognised initially; at fixation, an anterior wedge graft was inserted in the fracture line for correction. Mean correction was 20° with good restoration of the lordosis and rehorizontalization. Bone healing was achieved in all operated patients without loss of the reduction of the kyphosis at last follow-up. The neurological status did not worsen in any patient. Anterior fixation was insufficient to reduced an old fracture-dislocation in one patient who required posterior decompensation. Orthopaedic treatment was used in two patients: the first (Frankel A) died at two months and the second healed with a 10° aggravation of the cervical kyphosis. All the Frankel A and B patients in this series died.

Conclusion: All patients with severe neurological involvement died. The anterior approach, used alone, provided good stabilisation of the cervical spine. For the patients without neurological involvement, reduction of the cervical kyphosis should be associated with a stabilisation procedure in case of fracture with kyphosis.


J.L. Marmorat C. Mazel P. Antonietti O. Guinand E. de Thmasson R. Terracher

Purpose: Several techniques have been proposed for C1-C2 fusion. The anterior transoral technique is the most direct approach but at the cost of major risk of infection. The posterior approach allows wiring (Gallie technique) or direct atloidoaxoid screw fixation (Magerl technique). The retrosternomastoid bilateral approach (Du Toit technique) allows direct screwing in the lateral masses. The rate of nonunion reported in the literature is high for wiring techniques. Biomechanical studies have demonstrated the mechanical superiority of trans-articular screwing which has been confirmed in clinical series. The purpose of the present study was to describe a modification of the Du Toit technique and describe results in a short series.

Material and methods: This modification of the Du Toit technique consists in an abrasion of the C1 lateral mass at its origin enabling the penetration of a Cloward curette to create a stable introduction point for the drill bit and thus avoid slippage forward as can occur with the conventional technique. The screw is directed towards C2, in a strict frontal plane. The obliquity depends on the room allowed by the mastoid. The drill bit should cross both corticals of the inferior facet of C1 and the superior facet of C2. The screws must cross in a coronal plane just under the odontoid. Fusion of the C1-C2 lateral masses is achieved by abrasion and grafting.

We have used the modified Du Toit technique for C1-C2 arthodesis in four patients with rheumatoid arthritis, fracture of the odontoid, an odontoid bone, and isolated degeneration. The procedure was a first intention treatment for the patient with primary degeneration, and a second intention procedure for the others who had developed nonunion after wiring.

Results: Mean hospitalisation was six day. Operative time was 2 h 10 min. Mean blood loss was 200 ml peroperatively and 120 ml postoperatively. None of the patients had developed nonunion or mechanical failure at a mean follow-up of 2.7 years (range 1 – 5 years). Operative complications included one case of venous bleeding which was treated with vascular clips and two cases were the lateral mass of C1 was weakened requiring cementing. There was one early postoperative neurological complication with hypoaesthesia of the hemitongue that regressed spontaneously. None of these complications produced sequelae.

Conclusion: The advantages of the modified technique for lateral screw fixation of C1-C2 is the improvement in the entry point for the drill bit allowing an optimal screw position and a stable drilling to achieve good mechanical fixation and certain union.


P. Bacon B. Watier F. Lavaste J.M. Vital

Purpose: The biomechanical behaviour of the cervical spine was studied in vitro with an optoelectronic system in order to better understand its physiology.

Material: Twenty fresh cervical spines (occiput-D1) from fourteen men and six women, mean age 66.5 years, were sterilised with ß radiation (2.5 Mrad) and stored at −24°C then studied after slow thawing and excision of the paraspinal muscles.

Methods: Three-point reflecting markers were rapidly attached to each vertebral segment (4 or 5 vertebrae). The inferior vertebra was blocked. Six pure moment couples (2 N.m maximum, 10 increments) were applied in the three anatomic planes using a loading device lodged on the superior vertebra. Displacements were measured with the VICON 140 using a kinematic software.

Results: The three-dimensional behaviour curves of each functional unit (FU) were recorded for each solicitation to analyse the principal movement and coupled movements (maximum mobility, neutral zones, rigid zones, rigidity). Mean maximal flexion-extension movements were C0/C1= 28.7°; C1/C2 = 22.3°; C2/C3 = 7.3°; C3/C4 = 10.6°; C4/C5 = 13.8°; C5/C6 = 13.4°; C6/C7 = 10.8°; C7/T1 = 6.4°. Maximum overall lateral inclinations were: C0/C1= 8.7°; C1/C2 = 9.3°; C2/C3 = 8.7°; C3/C4 = 6.7°; C4/C5 = 10.5°; C5/C6 = 12.2°; C6/C7 = 8.6°; C7/T1 = 5.7°. Maximal overall axial rotations were: C0/C1= 11°; C1/C2 = 71°; C2/C3 = 9.5°; C3/C4 = 10.8°; C4/C5 = 12.3°; C5/C6 = 9°; C6/C7 = 5.6°; C7/T1 = 5.7°. All the FU exhibited flexion-extension movement. Lateral inclination coupled important controlateral rotation for C1/C2 and minimal ipsilateral rotation (< 10°) in the lower FU of the cervical spine. Axial rotation of the C1/T1 functional unit was coupled with homolateral rotation (< 10°).

Discussion: Our experimental protocol provided precision of < 1° and good reproducibility allowing simultaneous three-dimensional analysis of the spinal functional units. Making measurements without direct contact is particularly useful for the cervical spine. Our results are within the experimental corridor defined by Goel, Panjabi and Wen.

Conclusion: This work on a large number of functional units adds further support to data in the literature concerning the biomechanical behaviour of the cervical spine. Our protocol could be applied to analyse the impact of surgical procedures used for the cervical spine, particularly for the evaluation of new fixation systems or prostheses.


S. Takahashi H. Kitagawa T. Ishii M. Fujiwara J. Delecrin

Purpose: Fat or marrow embolism during or after bone and joint surgery is a serious complication. We wanted to determine the incidence and circumstances of peroperative embolism in patients undergoing lumbar spine surgery with and without instrumentation.

Material and methods: Sixty adult patients with degenerative lumbar spines underwent peroperative and early postoperative transoesophageal ultrasonography. The lumbar procedure involved instrumentation with insertion of pedicular screws in 40 patients.

Results: Moderate to severe signs of embolism (Pitto classification grade 2 or 3) were observed in 80% of the patients who underwent instrumentation procedures but in none of those who had not been instrumented (p < 0.001).

Discussion: Among the different procedures performed on the posterior lumbar spine, insertion of pedicular screws appears to be the leading cause of pulmonary embolism. The approach, laminectomy, discectomy, and bone abrasion do not appear to produce detectable embolism.

Conclusion: We consider that the observed embolic manifestations, also observed in intramedullar procedures, are potentially fatal after spinal surgery.


F. de Peretti J.C. Sane G. Dran C. Razafindratsiva

Purpose: Ankylosing spondylitis and Forestier hyperosteosis produces a fused vertebral column. The fused vertebrae can be considered like a “spine-bone” which has particular features different from those of the mobile spine. The purpose of this retrospective analysis was to investigate the clinical and radiological particularities of the spine-bone in order to reduce the delay to diagnosis.

Material and results: Forty-eight spinebone fractures were observed over a 17-year period by one practitioner. Twenty of the patients (mean age 62 years) had ankylosing spondylitis and 28 (mean age 81 years) had hyperosteosis. All of the patients were men. Twenty-five were victims of falls, eleven victims of traffic accidents, and six victims of sports accidents (all with ankylosing spondylitis). No notion of trauma could be identified for six patients. Sixteen fractures were diagnosed within 1 to 28 days. Forty-four patients had cord injury including 16 cases which developed secondarily. Four types of fracture were identified:

- type I = anterior opening fracture: 30 patients,

- type II = “sawbone” fracture: 4 patients,

- type III = “rasp line” fracture: 8 patients,

- type IV = fractures comparable to other fractures of the vertebral column: 6 patients.

Fractures diagnosed late were four anterior opening fractures, eight “rasp line” fractures, and four “sawbone” fractures. A CT scan was obtained in all cases and an MRI in 30. Three compressive spinal extradural haematomas were diagnosed. Thirty-two patients died, 31 patients with spinal injuries due to decubitus-related complications and one by rupture of an aneurysm of the aorta.

Discussion: This series illustrates several points. Fracture without trauma is frequent. Diagnosis is made late. Fractures gone undiagnosed lead to neurological complications or nonunion. Diagnosis of “rasp line” fractures cannot be made on standard x-rays, leading us to order a scanner and/or an MRI in all patients with a painful ankylosed spine even if the standard x-ray does not show any fracture. Neurological and extradural haematoma are serious complications. Mortality is high in these debilitated patients. Knowledge of these exceptional fractures of the vertebral column is necessary to improve diagnosis and prognosis.


V. Pointillart Y. Carlier M. Pedram P. Bacon O. Gille J.M. Vital

Purpose: There is growing concern about the effect of anterior fusion of the cervical spine on the adjacent levels. Long-term assessment is indispensable to understand the mechanisms involved in the degradation observed and to support the development of materials preserving discal mobility.

Material: Three hundred patients who underwent cervical arthrodesis were reviewed in 1996 forty months after the procedure for physical examination and an x-ray work-up including stress views. Cervical spine and radicular pain were assessed on a visual analogue scale.

Methods: A complete data set was available for 136 patients and a partial set for 34. Twenty-two patients only accepted a phone interview. The clinical outcomes in these three groups were not significantly different and the mean scores for these three groups were in the general average in 1996. Eight patients had died.

Results: Patients were divided into three groups by type of disease diagnosed preoperatively (trauma, degenerative spine, myelopathy). Mean follow-up was 102.5 months (range 84 – 180 months).

Trauma: Among the 42 patient reviewed again in 2001, mean deterioration in the subjacent segment increased from 21% in 1996 to 69% in 2001. Deterioration of the supraja-cent segment increased from 26% to 47.6%. Cervical pain remained moderate (20/100 in 1996 and 27/100 in 2001). Degenerative spine (root compression requiring simple discectomy or with arthrodesis or single-level corporectomy): Among the 42 patients reviewed again in 2001, deterioration of the subjacent segment increased from 57% in 1996 to 89% in 2001. Deterioration of the suprajacent segment increased from 22% to 41%. Cervical pain increased from 14/100 in 1996 to 41/100 in 2001.

Myelopathy: Among the 52 patients reviewed again in 2001, deterioration of the subjacent segment increased from 54% in 1996 to 81% in 2001 when there had been one or two corporectomies and from 40% to 70% beyond two. Deterioration of the suprajacent segment increased from 26% to 50%. Cervical pain remained moderate (18/100 in 1996 and 23/100 in 2001).

Conclusion: Although a statistical analysis was not possible because of the small number of patients and the large percentage lost to follow-up, these results confirm that fusion of the cervical spine accelerates the degradation of adjacent levels. Longer follow-up demonstrates that the trauma group “catches up” with the degenerative group.

Use of mobile materials should enable differentiating between effects related to the degenerative process and those induced by the arthrodesis.


J.Y. Lazennec N. Arafati N. Charlot G. Aillant

Purpose: Single-segment wedge osteotomy is classically proposed to correct for kyphosis subsequent to ankylosing spondylitits. We analysed the usefulness of this technique for other indications (revision procedures for flat back and deformed calluses of the lumbar spine) by studying the overall sagittal balance of the spine and tilt of the sacrum.

Material and methods: Between 1980 and 1999, we retained 68 patients with complet clinical and radiological data (37 patients with ankylosing spondylitis and 31 patients with “post-operative” flat back, including nine trauma cases and 22 degenerative spines). Opening osteotomy was performed in the first 19 patients and closure osteotomy in the next 49. The correction level was L2L3 in 26 patients and lower in 42. Digitalised lateral views of the entire spine were obtained at minimum follow-up of three years to measure:

- posterior displacement of T9 (between the vertical line and a line joining the geometric centre of T9 and the femoral heads (normal 11±5°),

- tilt of the sacrum (angle between the horizontal line and a line tangent to the superior surface of the sacrum (normal 41±5°).

Results and discussion: The overall angle of local correction was 44° and the correction of T9 displacement was 30.6°. For the low osteotomies, the local correction was 49° and the T9 displacement was +28° (−2° to +26°). Tilt of the sacrum varied from 4° to 7°. Tilt of the sacrum was influenced more and more for lower and lower osteotomies. T9 displacement stabilised between 12° and 26° (mean 19°) irrespective of the osteotomy level, although the angle of local correction was greater (up to 60°). This discordance was explained by adaptation of the pelvis. Seven patients developed secondary functional kyphosis (limited hip movement preventing the necessary adaptation to the overall correction of the sagittal balance).

Conclusion: Single-segment spinal osteotomy remains difficult but offers very important correction possibilities affecting the position of the trunk and adaptation of the pelvis. The level for the correction must be chosen with care because it conditions final adjustment and function consequences affecting the pelvis.


J.L. Polard W. Daoud J.M. Hamon L. Montron G. Kerhousse J.L. Husson

Purpose: We report the clinical and radiological course in a continuous series of 194 patients treated by the same team between 1996 and 2001 for thoracolumbar fracture. Cotrel frame instrumentation and Boëhler corset immobilisation were used.

Material and methods: In this series of 65 women and 129 men, age range 16 – 77 years, we retained one year follow-up at least for inclusion in the study. More than 85% of the patients were retained for study and the final analysis concerned 150 patients who were contacted.

All patients were in Frankel class E. In compliance with the SOFCOT 1995 Symposium, the method described by Rosset and Laulin and the international classification described by Magerl were applied to pre-operative x-rays to search for the pathogenic mechanism involved. The radiological analysis was conducted on preoperative, immediate post-operative, 1-month, 3-month, and last follow-up x-rays. The course of spinal kyphosis and angular deformation of the trauma zone and the subjacent disc were analysed. In addition to the overall series, patients with limit therapeutic indications, according to the local kyphosis and trauma-induced regional angular deformation, were also studied.

Results: For the initial indication of choice, type A1 fracture, gain in reduction was minimal for the constraining treatment. For type A3 fractures, posterior displacement of the posterior wall was not a contraindication because the posterosuperior reduction could be achieved by ligamentotoxis in the majority of the cases The gain in correction of spinal kyphosis was greater in these patients. Nevertheless, for this type of fracture, spinal kyphosis greater than 15° was an implicit sign of a potential posterior distraction lesion where osteosynthesis might be indicated, especially since the USS fixator uses a parallel assembly and authorises short instrumentations.

Conclusion: The Boëhler technique is a safe, minimally invasive and low-cost method for the treatment of thoracolumbar spine fractures, which enabled 30% correction of the spinal kyphosis. This method retains its indications for type A fractures.


J.C. Le Huec C. Dickman M. Liu J. Magendie

Purpose: Cage fusion of the L5–S1 segment is a controversial issue due to the weak stabilisation of the spine during extension and axial rotation. Complementary fixation appears to be needed to improve stability, but the presence of the bifurcation of the great vessels is an anatomic limitation. We studied the anatomy of this area to examine the feasibility of anterior plate fixation.

Material and methods: According to the recognised anatomic references (Rouvière, Bouchet and Cuilleret, Louis), a 33-mm safety zone was described at the aortoiliac and iliocaval bifurcation. This space free from contact with the greater vessels lies in front of the L5–S1 disc. Pre-operative angio-MRI was used to assess the size of this safety zone. A triangular anterior plate was designed for arthrodesis (Pyramid Sofamor Danek, USA). An L5–S1 arthrodesis was performed in 15 consecutive patients using this plate. Follow-up was one year. A video-assisted anterior retroperitoneal approach was used in all cases. The Prolo and Oswestry scores were used for the preoperative and last follow-up evaluations.

Results: According to the anatomic study and the MRI views, 89% of the patients had a sufficient safety zone for plate fixation. The method was contraindicated in two patients who had a low bifurcation. Angio-MRI was found to be simple and reproducible. The MRI analysis was confirmed at surgery (no false negatives). The plate was successfully implanted in 15 patients with no contact with the great vessels. There were no serious complications (vascular, neurological, urological, digestive). The economic Prolo score was improved from 2.7 to 4.2 and the functional score from 2.6 to 4.3. The Oswestry score improved 33%. The rate of clinical success was 93% (14/15 patients).

Discussion and conclusion: Implantation of an anterior plate for L5-S1 fusion is feasible. The key points are: 1) rigorous preoperative evaluation of the greater vessel bifurcation; 2) anatomic plate design; 3) appropriate surgical technique. The risk of retrograde ejaculation is related to retraction of the hypogastric plexus and should be investigated with a prospective study. This osteosynthesis technique can avoid secondary operations for fixation with pedicular or transarticular screwing.


R. Sasso J.C. Le Huec C. Shaffrey F. Pain

Purpose: Retrograde ejaculation after anterior approach for intersomatic L5-S1 arthrodesis is one of the most serious complications for young patients. The risk is related to the destruction of the hypogastric plexus during exposure of the lumbosacral segment. The rates reported in the literature vary from 0.42 to 5.9%. The purpose of this study was to compare the incidence of retrograde ejaculation in a prospective study of two groups of patients undergoing L5-S1 fusion via a trans-peritonial or retroperitoneal approach.

Material and methods: One hundred forty-six male patients underwent L5-S1 arthrodesis. Group A included 116 patients for whom a video-assisted retroperitoneal approach was used. Group B included 30 patients for whom a video-assisted transperitoneal approach was used. Patients were questioned concerning the presence or not of retrograde ejaculation at the preoperative examination then at 3, 6, and 24 months.

Results: Among the 146 patients, six exhibited retrograde ejaculation at three months. Two (1.72%) were in the retroperitoneal group (group A) and four (13.35) were in the transperitoneal group (group B). This difference was significant (Fisher test, p = 0.0015). Retrograde ejaculation regressed in two of these six patients at one year, one in group A and one in group B. At the end of the study with two years postoperative follow-up, four patients exhibited persistent retrograde ejaculation, one in group A (0.86%) and three in group B (10%). The difference was statistically significant (Fisher test, p = 0.025).

Discussion: This study provides to our knowledge the only prospective data available concerning the risk of retrograde ejaculation in patients undergoing anterior L5-S1 arthrodesis. The risk was significantly higher with the transperitoneal approach than the retroperitoneal approach (10% versus 0.86%).


D. Oucet L. Favard S. Lautmann F. Siveaux J.C. Schaeffe D. Huguet G. Walch

Purpose: The purpose of this multicentric study was to report results obtained with the Aequalis system using the simple humeral or total prosthesis, at at least two years follow-up in patients with shoulder joint degeneration and non-repairable rotator cuff tears.

Material and methods: Sixty-eight Aequalis arthroplasties were performed between 1992 and 1998. Outcome was assessed on the basis of the Constant score and radiological findings. Female gender predominated (78%) in this series with a mean age of 72 years. There were 62 simple humeral implantations and six total shoulder arthroplasties. The deltopectoral approach was used in 63 cases and the superior approach in five. All stems and sockets were cemented. There were no neurological or infectious complications.

Results: Two humeral stem implants were failures and required revision with a Grammont prosthesis. There was also one reoperation for arthrolysis with preservation of the implant; the outcome was fair.

Functional outcome: Sixty-six patients were reviewed with a mean follow-up of 45 months. All implantations except one were performed to achieve pain relief. The absolute Constant score improved by 20 points (from 25 to 46) with a 7-point gain for pain (3 to 10), a 20° gain for active elevation, an 18° gain for external rotation, and a 0.4 point gain for force. Pain relief was greater with total prostheses. Only five patients stated they were dissatis-fied with the outcome despite the fact that 18 reported significant persistent pain. The Constant score was analysed as a function of follow-up, size of the humeral head, and preoperative morphology of the glenoid surface. Radiological outcome: Certain loosening was recognised for one glenoid and one humeral stem. Among 52 shoulders with strictly identical radiological results, 33 exhibited deterioration either for the vault or the glenoid or both, with no effect on the Constant score.

Discussion: In this indication the Adqualis prosthesis is implanted to achieve a “limited” objective: pain relief. The deltopectoral approach is preferable in order to preserve elements inhibiting superior migration of the humerus (in a parallel study, the absence of these elements explains the poor outcome observed in 3 out of 9 patients). Unlike other series, the present series exhibited a significant effect of a type E2 biconcave glenoid surface. The pain score was better with total shoulder prostheses than with humeral stems alone and four of the six glenoid sockets remained perfectly fixed. The long-term outcome of these glenoid surfaces remains unknown so it would be inappropriate to advise systematic use. Clinical outcome did not show any deterioration over time despite deterioration of the vault, the glenoid, or both. Indications for non-constrained pros-theses should however be retained with caution due to open questions concerning long-term outcome, particularly for shoulders which have already been operated on or with type E2 glenoids. Considering these reservations, the Aequalis prosthesis has reached, at nearly five years follow-up, the assigned objectives: significant pain relief, satisfactory overall shoulder function.


S. Audebert C. Maynou E. Petroff H. Mestdagh

Purpose: We assessed mid-term outcome of mobile cup shoulder prostheses for the treatment of degenerative shoulders with a destroyed cuff.

Material and methods: Forty-four biopolar prostheses were assessed with a mean follow-up of 32 months (range 13 – 50 months). The SOFCOT scoring chart was used. The morphological features of the different forms of shoulder degeneration with cuff destruction were analysed on standard x-rays to define anatomic conditions favourable for his type of implant.

Results: At last follow-up 86% of the shoulders exhibited little or no pain. Mean active anterior elevation was 59.6° – 82.84°, external rotation in position 1 was 8.86° to 301.68°, and internal rotation was 3.13 points to 5.68 points. The mean Constant score was 48.86 points (weighed score 69.13%). Seventy-seven percent of the patients were satisfied and had resumed their former activities. We had one anterior displacement of a shoulder with deltoid palsy and three complications requiring revision: one polyethylene insert which slipped out of the mobile cup, one conflict between the tendon of the long head of the biceps and the cup, and one anterioposterior conflict because of an oversized cup. One non-cemented prosthesis exhibited mobility at 33 months follow-up. One case of excessive lateralisation of the humerus, one mediocre joint congruency, and atrophy of the deltoid were also recorded.

The best outcomes were observed in joints with “centred” degeneration and cuff destruction. Preservation of a satisfactory centring of the cup avoided pain and enabled a mean anterior elevation of 1112.3° with a weighted Constant score of 90.5%.

For early excentred degeneration, preservation of the glenoid bone stock prevented perfect joint congruency leading to excessive lateralisation of the humerus: 20% of the shoulders remained painful and anterior elevation reached 68° with a weighted Constant score of 56%. Paradoxically, results were better in patients with severely excentered degeneration. “Acetabulation” of the shoulder preserved joint congruency and lengthened the lever arm of the deltoid by medialisation and lowering of the centre of rotation. Full pain relief was achieved in all such cases, with anterior elevation at 86° and a weighted Constant score at 78%.

Discussion: Biopolar arthroplasty is effective in shoulders with centred degeneration and cuff destruction. It is an interesting salvage solution for advanced-stage excentric degenerated shoulders beyond the limits of other implants. We propose a decisional tree based on an anatomic classification of the shoulder degeneration with cuff destruction.


A. Godenèche L. Nové-Josserand L. Favard D. Molé P. Boileau C. Levigne J. de Beer J.M. Postel G. Walch

Purpose: The purpose of this study was to analyse outcome of shoulder prostheses after radiotherapy, to define a specific clinicoradiological entity, and evaluate incidence of complications.

Material and methods: Fourteen shoulder prostheses were implanted in 13 women who had been treated for breast cancer with complementary radiotherapy and one man treated for Hodgkin’s lymphoma. The time from radiothearpy to implantation was 16 years, seven months. Two forms were identified on the preoperative x-rays: seven cases with typical avascular osteonecrosis according to the Arlet and Ficat classification, and seven cases with a radiographic presentation of arthritis or degenerative disease. Humeral prostheses were used in five cases and a total shoulder arthroplasty in nine.

Results: Four implants had to be removed, three for sepsis, and five patients required revision surgery. The mean postoperative Constant score for the ten prostheses still in place was 53.1 points with a mean elevation of 111° at three years seven months follow-up. The gain in pain score was 8.5 points with a mean result of 10.9 points. The results were different depending on the initial radiological form, with less favourable outcome observed in typical osteonecrosis.

Discussion: This study demonstrated a particular radio-clinical entity independent of classical osteonecrosis of the humeral head. The surgical procedure was more difficult and the outcome was less satisfactory than in the classical forms with a high rate of complications.


O. Léger C. Trojani J.S. Coste P. Boileau J.C. Le Huec G. Walch

Purpose: Nonunion of the surgical neck of the humerus can occur after orthopaedic or poorly-adapted surgery after displaced subtuberosity or cephalotuberosity fracture. The purpose of this study was to report functional and radiographic outcome after treatment with shoulder prosthesis.

Material and methods: Twenty-two patients who had a non-constrained shoulder prosthesis were included in this retrospective multicentric study. Mean age was 70 years and mean follow-up was 45 months (range 2 – 9 years). The initial fracture had two fragments in six patients and was a three-fragment fracture involving the head and the tubercle in thirteen and a four-fragment fracture in three. Orthopaedic treatment was given in ten cases and surgical osteosynthesis was used in twelve. Time from fracture to implant insertion was 20 months. The deltopectoral approach was used for 21 humeral implants and one total shoulder arthroplasty (glenohumeral degeneration). The tuberosities were fixed to the cemented humeral stem and a crown of bone grafts were placed around the nonunion of the surgical neck. All patients were reviewed after a minimum of two years and assessed with the Constant score and x-rays.

Results: The absolute Constant score improved from 23 reoperatively to 39 postoperatively with an anterior elevation of 53° to 63°. Pain score (from 3 to 9, p = 0.001) and external rotation (from 13° to 28°, p = 0.01) were significantly improved. Forty-five percent of the patients were satisfied and 55% were dissatisfied. The type of initial treatment, type of initial fracture, and time before implantation of the prosthesis did no affect final outcome. The complication rate was 36% (eight patients), and led to five revision procedures. The radiographic work-up disclosed six cases of persistent nonunion of the greater tuberosity, two proximal migrations of the prosthesis, and one humeral loosening.

Conclusion: Outcome of shoulder prosthesis for sequela after fracture of the proximal humerus with nonunion of the surgical neck is poor. No improvement in anterior elevation, force, or motion was achieved. Shoulder prosthesis for sequelae of fracture of the proximal humerus with nonunion of the surgical neck should be considered as a “limited-objective” indication only providing beneficial pain relief.


L. Favard F. Sirveaux D. Oudet D. Huguet D. Molé

Purpose: The purpose of this work was to compare outcome after hemiarthroplasty and after inverted arthroplasty for the treatment of excentred degeneration of the shoulder joint.

Material and methods: This multicentric study inclued 136 patients, 110 women and 26 men, mean age 72.4 years (range 55 – 86 years) with 142 shoulder prostheses. Among the 142 shoulders operated on, 62 underwent Aequalis hemiarthroplasty and 80 inverted arthroplasty. The preoperative handicap was more severe in the hemiarthroplasty group (Constant score 26) than in the inverted arthroplasty group (Constant score 23).

Results: Clinical and radiological follow-up data were collected at a mean follow-up of 44 months for the Aequalis prostheses and at 45 months for the inverted prostheses. There were seven failures requiring five revision procedures: three in the hemiarthroplasty group and four in the inverted arthroplasty group.

The differences between the hemi- and inverted arthroplasty groups concerned the Constant score, which was significantly better in the inverted prostheses (65.5) than in the hemiarthroplasties (46.1), for all subscores. Active elevation was 138° for the inverted prostheses and 97° for the Aequalis prostheses (p < 0.01). Mean external rotation in position 1 was 22° for the Aequalis prostheses and 11° for the inverted prostheses (p < 0.01) with no difference in elevation rotation. These results remained equivalent and significant over time, even beyond five years.

Radiographically, there was one case with an anomalous humeral component (impaction) in the inverted group. For the inverted prostheses, there were three migrations that have not been revised to date and three partial screw loosenings. The main problem was the development of notches in the scapular column observed in 50% of the cases including 20% which reached the lower screw. For the Aequalis prostheses, the main problem was deterioration of the acromial vault observed in 50% of the cases leading to altered function.

Discussion: Inverted prostheses provide clearly better mid-term results, even after five years. With hemiarthroplasty there is a long-term risk of vault wear. The long-term course of the inverted prostheses is worrisome due to the notches in the scapular column and the stress on the fixation. These prostheses should be used preferably for old persons with a deteriorated vault.


J.S. Coste C. Trojani P.M. Ahrens P. Boileau

Purpose: Consolidation of the tuberosity is the key to success of shoulder arthroplasty for fracture. The purpose of this study was to assess the number and causes of tuberosity complications in order to find solutions for this problem.

Material and methods: This retrospective multicentric study included 334 shoulder prostheses implanted for fracture between 1991 and 2000. Two different prostheses were used: 300 standard Aequalis prostheses implanted between 1991 and 1997 (mean follow-up four years) and 31 Aequalis Fracture prosthesis between 1999 and 2000 (mean follow-up nine months). Radiological results were assessed on the postoperative and last follow-up x-rays. The Constant score was used for clinical assessment.

Results: For the 300 standard prostheses, the Constant score was 54 points with active anterior elevation = 104°. For the 31 fracture prostheses, the Constant score was 58 points with active anterior elevation = 114°. According to the operator’s assessment, 49% of the postoperative radiological results were fair or poor and objectively 35% of the tuberosities were poorly positioned with the standard prosthesis and 22% with the fracture prosthesis. Twenty-six percent of the good or poorly positioned tuberosities migrated secondarily with the standard prosthesis and 10% with the fracture prosthesis. Statistically significant prognostic factors limiting tuberosity complications were: satisfactory initial osteosynthesis with correct prosthesis height and retroversion facilitated by use of the fracture system, rehabilitation in a specialised centre, relative immobilisation during the first postoperative month limiting exercises to balancing movements which divided the number of secondary migrations by two compared with immediate moblisation (14% versus 27%).

Discussion: A precise analysis of the radiograms revealed a very high rate of tuberosity complications (50%). There has been little study of these complications which are underestimated in the literature. The Aequalis fracture prosthesis can reduce these tuberosity complications two-fold. Postoperative immobilisation also reduces two-fold tuberosity migrations. These observations are against the early passive motion advocated by Neer. Finally, the quality of tuberosity fixation is crucial for success. The surgeon must concentrate on this element, searching to achieve a perfectly positioned prosthesis on the peroperative x-ray.


P. Sauzières P. Valenti R. Costa N. Lefevre

Purpose: Surgical prosthetic treatment of excentred degeneration of the shoulder joint has long been limited to simple humeral prostheses. Inverted total shoulder arthroplasty (ITSA) using the Grammont system appears to provide real improvement. What is the comparative outcome? Does the Grammont prosthesis give constant results? Is the simple humeral prosthesis still indicated for selected cases? In order to respond to these questions, we reviewed 84 patients who had undergone surgery between 1986 and 2000 for implantation of 52 simple humeral prostheses (mean follow-up 7.1 years) and 32 ITSA (mean follow-up 4.3 years).

Material and methods: Between 1986 and 1995, all patients with excentred degeneration of the shoulder joint were treated with a simple humeral prosthesis (36 cases). Between 1995 and 2000, either ITSA or simple humeral prosthesis (16 cases) was used. For the ITSA, indications were limited to excentred degeneration in patients aged over 70 years with a painful pseudoparalytic shoulder or contraindication for a simple prosthesis (alteration of the acromiocorocoid vault or the subscapular area). Simple prostheses were used either when an ITSA could not be implanted (patient too young, overly deteriorated glenoid, deltoid insufficiency) or when there was a preferential indication (excentred degeneration in young patients < 65 years, preservation of active motion, Favard type 1 or 2 glenoid…).

Results: For the simple humeral prosthesis series (1986–1995): the Constant score improved from 16.4 preoperatively to 489.6 postoperatively; radiographically there were one humeral loosening, three superior migrations, and three glenoid degenerations; three revision procedures were required. For the ITSA: the Constant score improved from 14.2 preoperatively to 61.6 postoperatively; radiographically there was one humeral loosening; 32% glenoid alterations in Nérot grades 3 and 4; one revision procedure was required. For the later simple humeral protheses (1995–2000): the Constant score improved from 18.2 preoperatively to 56.4 postoperatively (60.2 excluding cases with a simple prosthesis due to contraindication of an ITSA); radiologically there were one superior migration and two glenoid deteriorations.

Discussion: For a given indication, the results with the ITSA were better than with the simple prosthesis (p < 0.001). However, excluding salvage procedures where the ITSA could not be used, simple prostheses inserted for precise indications provided results nearly equivalent to the ITSA (p < 0.05) with less uncertainty concerning the future. For us, the inverted total shoulder prosthesis and the simple humeral prosthesis share indications for surgical repair of excentred degeneration of the shoulder joint.


J.P. Marchaland G. Versier

Purpose: We report the satisfactory results obtained in a retrospecive multicentric series of 80 shoulder prostheses implanted for aseptic osetonecrosis of the head of the humerus.

Material and methods: Seventy-four patients (43 men, 31 women, men age 59 years) with aseptic osteonecrosis of the head of the humerus treated with a shoulder prosthesis were reviewed at least two years after surgery. The mean weighted score before surgery was 37%. Twenty-six total prostheses and 54 humeral prostheses were implanted via the deltopectoral approach. There had been few complications at review: seven stiff shoulders, one torn suture of the subscapularis with instability, two inflammatory glenoids, one migration. Physical exam and x-ray (ossifications, lucent lines) findings were recorded.

Results: Mean follow-up was 47 months (24–104 months). The Constant score was improved significantly (p < 0.05). The total weighed score was 88% on the average and was not affected by gender, side, or dominant side. Ninety percent of the patients were satisfied or very satisfied. Gain in motion was significant in all movements with a mean 53° for active anterior elevation. For grade V shoulders, the improvement was significantly better with total shoulder arthroplasty while for grade II and III shoulders a humeral prosthesis was preferable. Full thickness tears of the rotator tendons did not influence overall outcome despite less recovery of motion (p < 0.05) and force (p = 0.09). Complications did not alter results.

Discussion: A humeral prosthesis should be preferred for grade II–III shoulders and a total shoulder arthroplasty for major degeneration of the glenoid (grade V). For grade IV, either prosthesis may be used depending on the patient’s age, activity level, and status of the rotator cuff. For very young or very old patients, high levels of physical activity may argue against prosthesis implantation due to the risk of loosening or rotator cuff tears which are unfavourable factors.

Conclusion: The results of this multicentric series corroborate data in the literature that shoulder arthroplasty provides good results for the treatment of aseptic necrosis of the head of the humerus. In generally, arthroplasty allows pain relief, good motion, particularly for external rotation, and good force recovery, explaining the better results obtained in active younger subjects.


F. Duparc C. Trojani P. Boileau J.C. Le Huec G. Walch

Purpose: Collapse or necrosis of the head of the humerus after fracture of the proximal humerus can be an indication for shoulder arthroplasty. The poor results classically reported have led to a search for factors predictive of the anatomic and functional outcome after arthroplasty for fracture sequelae.

Material and methods: Among the 221 Aequalis prostheses implanted for the treatment of sequelae after fracture of the proximal humerus, 137 (62%) developed post-traumatic avascular osteonecrosis of the humeral head with a deformed callus of the tuberosity. Head tilt was in a valgus position in 83 shoulders and in a varus position in 54. Mean age was 61.49 years. The initial fractures were subtuberosity fractures in 20% of the cases, three-fragment fractures in 32%, and cephalobituberosity fractures with four fragments in 48% of the cases.Twenty-five percent of the patients had undergone initial osteosynthesis. The rotator cuff was repaired in 4.5%, and two osteotomies of the less tuberosity and four osteotomies of the greater tuberosity were performed at implantation. Pre- and postoperative clinical and functional outcomes were assessed with the Constant score and a function index composed of eleven usual movements.

Results: Mean follow-up was 44 months (24–104), with a mean 42° gain in anterior elevation and a 29° gain in external rotation. The gain in the Constant score was +32 points (mean score 61), and +43% with the weighted score. The four subscores (pain, motion, activity, force) improved two-fold. Analysis of the eleven usual movements demonstrated recovery in 88% of the patients. The subjective satisfaction index was 86%. The mean Constant score improved significantly more after total arthroplasty (67 points) than after humerus prosthesis (55 points). Complications (per- or postoperative mechanical problem, infection, neurological disorder) or the need for revision were unfavourable elements.

Discussion: Deformation and deviation of the tuberosities, especially the greater tuberosity, often leads to osteotomy during the implantation procedure. In this series, osteotomies were exceptional and functional outcomes showed that deviated tuberosities could be preserved without having an unfavourable effect on functional prognosis. Much on the contrary, the absence of a tuberosity osteotomy simplified the operative procedure and produced much better functional outcome than observed in earlier studies. The rate of complication for secondary prosthetic implantation is not negligible (15%) and a simplified procedure without osteotomy is a useful criterion. Furthermore, rehabilitation may be started earlier after implantation when it is not retarded by osteotomy bone healing, found to be an unfavourable factor.

Conclusion: Implantation of a shoulder prosthesis after collapse or necrosis of the head of the humerus after proximal fracture with varus or valgus impaction has provided good functional outcome without tuberosity osteotomy since the deformation of the tuberosity is generally well tolerated.


J.F. Kempf G. Walch B. Edwards L. Lafosse A. Boulaya

Purpose: Centred degeneration of the shoulder joint is defined as a degeneration of the glenohumeral surfaces without ascension of the humeral head. We investigated the influence of partial or full thickness rotator cuff tears and/or fatty degeneration of the supraspinatus on the results of total shoulder arthroplasty.

Material and methods: During a multicentric review of 766 cases of centred degeneration of the shoulder joint treated with the Aequalis prosthesis, we identified 555 shoulders in 478 patients with an interpretable preoperative arthroscan. All patients were reviewed with a minimum follow-up of two years (mean 3.6 years). Constant score and radiological findings were recorded. We identified 41 shoulders with partial tears of the supraspinatus and 42 shoulders with full-thickness tears of the supraspinatus alone. Moderate fatty degeneration was observed in 90 shoulders (≤ 2) and severe fatty degeneration of the infraspinatus or the subscapularis (> 2) in 15. We analysed the Constant scores, subjective results, radiological results, and rate of complications in each of these populations.

Results: Rotator cuff tears involving the supraspinatus alone did not have a destabilising effect, the head of the humerus did not influence the postoperative result assessed by the overall Constant score, motion in all planes, subjective result, radiological result, or rate of complications. There was no significant difference in complication rate. Presence or not of cuff repair did not influence these results. Inversely, fatty degeneration ≥ 2 involving the infrastpinatus or the subscapularis had a significant effect, decreasing the Constant score, active external rotation, active anterior elevation, and subjective result. On the contrary, it did not influence the radiological results or the rate of complications.

Discusssion: This multicentric study confirms that the degenerated shoulder joint can remain centred with a solitary tear of the supraspinatus. This has no effect on the clinical result and does not require repair. Inversely, fatty degeneration is highly predictive of the quality of the final result.


J.F. Kempf G. Walch G. Fama L. Lafosse B. Edwards A. Boulaya

Purpose: The best strategy to adopt for the long head of the biceps during total shoulder arthroplasty for centred primary joint degeneration remains a controversial issue. We analysed the influence of long head of the biceps (LHB) tenodesis on outcome.

Material and methods: From retrospective multicentric series of 766 shoulder prostheses implanted for centred primary degeneration of the shoulder joint, we selected 625 shoulders with sufficient data concerning the LHB. We defined two groups: 131 shoulders with LHB tenodesis and 494 shoulders with a preserved LHB. We analysed clinical outcome with the Constant score and subjective outcome at two years. We identified four groups: 70 humeral prostheses without tenodesis, 10 humeral prostheses with tenodesis, 424 total shoulder arthroplastues without tenodesis, and 121 total shoulder arthroplasties with tenodesis.

Results: The Constant score was significantly better in the tenodesis group (74.7) than in the group without tenodesis (70.8). This significant difference was also found for the weighted score and likewise for active anterior elevation and active external rotation in position 1. There was no difference concerning postoperative fatty degeneration. By subgroups, the analysis showed significant improvement in the Constant score for humeral prostheses with tenodesis and total shoulder arthroplasty with tenodesis over the same implants without tenodesis. This same significant difference was observed for the 364 patients who had a minimum follow-up of 36 months: tenodesis improved the Constant score, the weighted Constant score, active anterior elevation, and active external rotation.

Discussion: The causal role of the LHB in shoulder pain is now well documented in the literature. Several authors have advocated tenotomy or tenodesis of the LHB during surgical treatment of rotator cuff tears. The same is not true for shoulder arthroplasty for the treatment of primary degeneration. Dines and Hersch reported their experience with ten patients with a painful total shoulder arthroplasty who were improved with arthroscopic tenotomy or tenodesis.

Conclusion: Our large series confirms that tenodesis of the LHB is preferable during implantation of a humeral prosthesis or a total shoulder prosthesis for the treatment of centred primary joint degeneration with good results that persist over time.


M. Basso L. Nové-Josserand G. Versier W.J. Willems A. Godenèche

Purpose: The purpose of this study was to analyse the factors affecting outcome after prosthesis implantation for osteonecrosis of the humerus in order to ascertain details concerning the indications for humerus or total prostheses in this condition.

Material and methods: Forty-seven women and 27 men, mean age 57 years with osteonecrosis of the humerus underwent surgery for implantation of 80 shoulder prostheses. According to the Arlet and Ficat classification as modified by Cruess there were five grade II, fifteen grade III, 41 grade IV and fourteen grade V shoulders, with five unclassifiable shoulders. there were 14 supraspinatus tears and five infraspinatus tears. The 26 total shoulder prostheses and 54 humeral prostheses were reviewed at a mean 47 months follow-up. Pre-operative x-rays were available for 65 shoulders and postoperative x-rays for 58.

Results: The subjective outcome was considered good irrespective of the grade (very satisfied 60%, satisfied 30%, dissatisfied 4%). The mean postoperative Constant score was 70 ± 15. The preoperative score was lower for more advanced disease but the difference was not significant at postoperative assessment. The total prosthesis provided better results in grade V shoulders and the hemiprosthesis in grade II and III shoulders.

The result of the humeral prostheses depended on the grade of necrosis. The postoperative Constant score was lower for advanced necrosis with lower scores for motion, force and pain (which was not influenced by age). At last follow-up, 31% of the x-rays revealed a significant narrowing of the glenoid-head space. The clinical outcome was significantly less satisfactory for all Constant scores. Rotator cuff tears, preoperative stiffness favoured glenoid wear. Tears of both cuff tendons led to poor outcome. Bone collapse with impaction of the head into the glenoid and medialisation of the humerus was a significant factor predictive of less satisfactory outcome.

Discussion: The grade of necrosis is a determining factor for indications for humerus or total shoulder arthroplasty for the treatment of osteonecrosis. Our objective results lead us to recommend a humeral prosthesis for grade II and III patients and a total shoulder arthroplasty for grade V patients. For grade IV patients, the choice depends on patient age, shoulder stiffness, the status of the cuff, and most importantly, collapsus of the head of the humerus with impaction-medialisation of the humerus.


T. Aït Si Selmi C. Bussière P. Neyret

Purpose: We report the results of a prospective consecutive series of 25 patient with non-degenerative chondral lesions treated by mosaicplasty osteochondral grafts.

Material and method: The main group was composed of 22 knees, including 16 with osteochonritis dissecans, five with cartilage damage concomitant with chronic anterior laxity, and one with necrosis of the medial condyle. The other lesions involved the talus. Mean patient age was 28 years. Mean follow-up was 13 months (range 1 – 39 months). Among the knee group, 15 patients underwent standard mosaicplasty. The lesion measured 1.96 cm2 on the average. For the other cases, associated procedures included: valgus tibial osteotomy (n=4), anterior ligamentoplasty (n=3). There were few complications except one case of infection. Clinical assessment was based on the new ICRS chart (with an updated IKDC subjective score sheet). The subjective IKDC score was 48.7% preoperatively.

Results: Mean coverage of the lesion was 68.5%. Solitary mosaicplasty provided good results. The subjective IKDC score was 67.5% and 77% of the patients experienced little or no pain in their knee. Two-thirds of the patients scored their performance at 8 or more on the 10 point scale. The objective IKDC score gave 11/15 A and 4/15 B. There was one complication related to the donor site causing femoropatellar impingement after harvesting substantial graft material. Recovery was more difficult for patients with associated procedures and results were less satisfactory. All patients underwent an MRI at six months that showed in general a good morphological aspect.

Discussion: The technique used is particularly important due to a number of pitfalls and difficulties requiring much surgical skill. While we have found that most associated procedures such as grafting the anterior cruciate ligament are warranted, the appropriateness of an associated osteotomy would be highly debatable. Lesions measuring more than 3 cm2 correspond to the limit of this technique.

Conclusion: Mosaicplasty is a reliable method for cartilage repair. Long-term assessment will allow better indications and identification of any iatrogenic factors in order to determine the appropriate place for this technique among the other methods used for cartilage repair.


E. Servien T. Aït Si Selmi P. Neyret

Purpose: The purpose of this work was to analyse functional results in patients with objective patellar instability who underwent surgery between 1988 and 1999.

Material and methods: One hundred eighty knees, 140 patients, were included in this series. Minimum follow-up was two years, and the mean follow-up was five years (range 24 – 152 months). The IKDC 99 subjective knee chart was used for postoperative assessment. This chart has ten items for sports activities and functional status of the knee for everyday activities. Eighty-three percent of the patients (118 patients) responded to the questionnaire.

Results: Clinical assessment was available for 98 patients (63%) and phone interview data for 29 (20%). Subjectively, 111 (94.87%) patients were very satisfied, five (4.27%) were satisfied, and one was dissatisfied. We assessed results by pain level (37.6% mild or weather-related pain), residual oedema, sensation of blockage (15.8%), instability, daily activities (68% with difficulty in the kneeling position), sports activity and level.

Discussion: Certain authors (Insall) question the pertinence of operating objective patellar instability because of the risk of secondary femoropatellar degeneration. For us, surgical treatment is indicated when there has been at least one dislocation associated with morphological anomalies. We have not observed any cases of femoroatellar degeneration among our patients who were operated on more than ten years ago. The patients’ own subjective assessment shows that surgical treatment with medialisation and/or lowering of the tibial tuberosity has been effective with a very excellent rate of satisfaction. The quality of the results is directly related to correct treatment of the lesions (for patients without recurrent dislocation) and systematic analysis of the different factors contributing to patellar instability (trochlear dyplasia, patellar height, quadriceps dyplasia, length of the patellar tendon). Our rate of revision appears to be low but was directly related to the young age of this population and is close to or above the revision rates observed in series with follow-ups greater than two years.

Conclusion: Surgery for objective patellar instability gives good mid- and long-term results. The subjective IKDC score allows precise self-evaluation. We have not been able to find any correlation between subjective results and objective results.


C. Boeri L. Ballonzoli J.Y. Jenny

Purpose: Knowledge of the radiological axes in the normal lower limb is important for correction and reconstruction surgery. Classically, the femorotibial mechanical axis presents a zero angle on the anteroposterior view, with 3° femoral valgus being compensated by an equivalent tibial varus. Reference data have however been established with questionable methodology because they have been obtained with small selected samples.

Material and methods: We obtained teleradiograms of the lower limbs in 100 healthy volunteers free of any disease of the lower limbs and selected randomly among patients undergoing surgery for trauma or degenerative lesions of the upper limb. The following angles were measured by the same senior surgeon: mechanical femorotibial angle, orientation of the femoral condylar complex in relation to the mechanical axis of the femur, angle between the mechanial axis and the anatomic axis of the femur, orientation of the tibial plateaux in relation to the mechanical axis of the tibia.

Results: Sixty-nine men and 31 woman, mean age 39 years (range 17 – 62 years) participated in this study. The mean mechanical femorotibial angle was 179° (SD 3°, median 179°, range 168°–185°). The mean orientation of the femoral condylar complex in relation to the femoral mechanical axis was 91° (SD 2°, median 91°, range 86°–98°); 17 subjects had the classical value of 93°. The mean angle between the mechanical and anatomic axis of the femur was 6° (SD 1°, median 6°, range 3°–9°); 29 subjects had the classical value of 7°. The mean orientation of the tibial plateaux in relation to the mechanical axis of the tibia was 88° (SD 2°, median 88°, range 82°–84°); 14 subjects had the classical value of 87°.

Discussion and conclusion: The values considered to be normal in the literature only included 15–20% of the subjects in this study. Although there could be a theoretical selection bias in this series, it can be assumed that there is a wide dispersion of “normal” values around the means. The pertinence of this dispersion in clinical practice remains to be established. The question of individualising reconstruction or prosthetic procedures is raised.


P. Beaufils B. Moyen O. Charrois

Purpose: The collagen meniscus implant (CMI, Sulzer) is a meniscal substitute with a collagen matrix serving as a tutor for autologous regeneration of meniscal tissue. The goal is to prevent mid-term degradation after meniscectomy. The CMI is inserted arthroscopically. The purpose of this multicentric European study was to verify the safety, technical feasibility, and short-term clinical efficacy of the CMI in a population of patients undergoing medial meniscectomy. The long-term results should be obtained within a delay of five years at least.

Material and results: The series included patients with medial meniscus lesions alone, with or without lesions of the anterior cruciate ligament (present in 44% of the patients and repaired at the same time). Patient consent was obtained in all cases (in France in accordance with the Huriet law). Patients with lesions of the lateral ligament, associated trade IV cartilage lesions, or lesions of the posterior cruciate ligament were excluded. The study included 98 patients, mean age 33 years. Four patients were excluded from the analysis due to complications. Currently, 66 patients are available for evaluation one year after insertion of the CMI. Subjective outcome, the Lysholm score, and x-ray and MRI findings were recorded. Evaluation up to five years follow-up is scheduled.

Results: Complications: There were four early complications: infectious arthritis (n=1), puriform arthritis without germ (n=2), implant rupture (n=1). There were no implant-related postop complications.

Clinical results: At one year follow-up, the Lysholm score was 97. Pain was mild (1 on the visual analogue scale) and was only observed in one out of six patients: 87% of the patients had a normal or nearly normal knee.

Radiological results: There were no radiological signs of early degeneration. It was difficult to interpret the MRI results which visualised a structure with an intermediary signal in the form of a meniscal triangle. MRI did on show any sign of deleterious effect on the neighbouring cartilage.

Discussion: This technique for replacing the meniscus is an alternative to allogenic grafting. These preliminary results must of course be interpreted with caution. They show that arthroscoic implantation of the CMI is feasible but difficult. There was no evidence of an immunological reaction. Complications were related to the operative difficulty. Clinical results were satisfactory at one year, particularly in terms of pain. On the other hand, the biomechanical value of the implant cannot be assessed until longer follow-up data becomes available.

Conclusion: In light of the operative difficulty, the long postoperative recovery due to the rehabilitation protocol, the CMI should be used for symptomatic knees after meniscectomy, particularly in case of anterior laxity.


R. Frikha J. Dahmene K. Bouattour R. Ben Hamida M.L. Ben Ayeche

Purpose: Congenital absence of the anterior cruciate ligament (ACL) is an uncommon finding. Cases reported in the literature have been sporadic. The aetiology remains obscure. The purpose of this study was to describe results obtained in five patients (eight knees) with agenesia of the ACL to determine the characteristic features and search for elements differentiating the natural course of agenesia and post-traumatic ACL rupture.

Material and methods: The patients were four men and one woman, mean age 46 years. All five patients had a common ancestor, raising the question of the hereditary nature of the condition.

Results: The cardinal sign was medial femorotibial and femoropatellar pain, found in all patients. Physical exam revealed major anterior laxity (pivot shift +, Trillat Lachman +) and an abnormal protrusion of the anterior tuberosity of the tibia. The standard x-rays revealed elements suggestive of ACL agenesia and the MRI confirmed the diagnosis in all cases.

Discussion: In comparison with reports in the literature, our patients illustrated a few specific points:

- the familial nature of the condition in our patients suggestive autosomal dominant inheritance with variable penetration;

- the rare occurrence of instability, probably due to adaptation since childhood;

- hypoplasia of the tibial spines and the lateral condyle, consequence of ACL agenesia.

Comparing the natural history of ACL agenesia with that of post-trauma rupture led to certain observations:

- clinical and radiological congenital laxity is well tolerated;

- degeneration appears inevitable in case of congenital anterior laxity. It occurs late, progresses slowly, slower than after traumatic rupture of the ACL;

- unlike trauma-induced rupture, the lateral femototibial and femoro-patellar compartments are preserved for a very long period.

The lack of genetic studies and the familial nature of the cases reported here suggest that genetic surveys would be useful to elucidate this condition.


R. Cloutier J. Lamontagne F. Goulet

Purpose: The purpose of our tissue engineering work was to produce a substitute for the anterior cruciate ligament (ACL) in laboratory cultures for human implantation and to conduct fundamental studies on healing mechanisms.

Material: We used cells isolated from ACL biopsies obtained from the host, type I bovine collagen, and two bone blocks to produce ACL in culture.

Methods: Several layers of collagen containing host autologous ACL cells were superposed and linked to two bones that were placed on either side, according to a process currently being patented. The cells, or fibroblasts, enter into contact with the collagen matrix and start remodelling it, in the laboratory, before implantation. This ACL produced by tissue engineering can be ready for implantation 10–12 days after isolating the autologous cells from a ruptured ACL.

Results: Implantation of autologous ACL reconstructs was successful in eight goats. Histological analysis of the implanted grafts showed permanent integration into the tissues after 1–13 months. Th synovial membrane was reformed and rapidly vascularised, about one month after the graft. Thereafter, remodelling of the collagen matrix led to the formation of a very dense network of fibres, organised in bundles, very comparable to the normal histological aspect of the ACL. The bone blocks were also integrated by incorporation into the femur and tibia of the host. Sharpey fibres were present at the bone-ligament surface and a well structured fibro-cartilage was observed. In addition, the synovial membrane around the graft was innervated five months after implantation, suggesting that propioception could be recovered over time. Finally, progressive gain in force reached 20 – 36% of the normal ACL, 9 to 13 months after implantation;

Discussion: These promising data demonstrate that an autologous ACL with an interesting potential for regeneration can be produced in the laboratory, avoiding the risk of rejection and sparing healthy knee structures, thus favouring more rapid functional rehabilitation.

Conclusion: Tissue engineering is a new avenue of research with potential applications in orthopaedic surgery, particularly for reconstruction of the ACL.


L. Galois S. Etienne L Grossin C. Cournil P. Netter D. Minard P. Gillet

Purpose: Section of the anterior cruciate ligament (ACL) is classically used to induce experimental joint degeneration in animal models (dog, rabbit, rat…), but the contribution of physical activity to the course of the cartilage damage observed in this model remains unknown. We studied the influence of moderate physical activity on the course of experimental knee joint degeneration induced by section of the ACL in the rat.

Material and methods: The right knee ACL was sectioned with and arthrotome in 60 male Wistar rats (180 g) under general anaesthesia. Full section of the ACL, performed with a fine lancet, was verified clinically by demonstrating anterior drawer. The non-operated knee served as a control. The rats were separated at random into two groups, with or without exercise. Exercise was calibrated on a treadmill running at constant speed (30 cm/s for 30 min, i.e. 15 km for 28 days). Rats were sacrificed on days 7, 14 and 28. Macroscopic inspection, histological analysis and immunohistochemistry tests (Caspase 3) were performed on each knee segment. NO was also assayed in the synovial fluid.

Results: No cartilage damage was observed in the non-operated knees after running 15 km. Marked synovitis was observed in the knees with a sectioned ACL starting on day 7, associated with fibrillary surface formations. The severity of the cartilage damage increased from day 14 to day 28, predominantly on the medial tibial plateau and to a lesser extent on the adjacent femoral condyle, in the weight-bearing zone. Damage was minimal on the patella. Chondrocyte apoptotic phenomena were also observed, reaching maximum on day 7 and sustained thereafter. Physical activity had a significant effect on these parameters showing an improvement in the macroscopic and histological lesions from day 14 to day 28, and improvement in chondrocyte apoptosis from day 7 to day 14 and to day 28.

Discussion: This novel work confirms the beneficial effect of moderate physical activity in an experimental joint degeneration rat model. Elsewhere, it has been well established experimentally that intense joint activity has a deleterious effect on chondral lesions after meniscectomy and/or section of the ACL. This unfavourable effect of intense physical activity has also been observed clinically in high-level athletes. Our experimental data suggest that moderate physical activity does not increase the risk of joint degeneration and could, under certain conditions, have a beneficial effect, as has been suggested by certain recent clinical data.


M. Bonnin Y. Carillon

Purpose: The transepicondylar axis (TECA) is an important landmark for positioning the femoral component in correct the rotation during total knee arthroplasty. In vivo studies have shown that the TECA corresponds to the flexion-extension axis of the knee joint. Two TECA have been defined in the literature depending on the landmark used for the medial epicondyle: the eminence for the “clinical” TECA and the depression for the “surgical” TECA. The purpose of the present study was to investigate in vivo the relations between the TECA and the mechanical axis of the femur (FA) and the tibia (TA) measured on computed tomography (CT) scans of the flexed knee, analysing separately the two TECAs.

Material and methods: CT scans of the right knees of ten volunteers were studied. Goniometric data was acquired on the scans. Five controls with genu varum and five with genu valgum were also studied. Images were acquired at 0°, 45° and 90° flexion. The epicondyles were identified on the horizontal sections and three frontal sections parallel to the posterior cortical of the tibia were reconstructed. Superoposition of these three sections, for each flexion angle, gave a frontal section with TECA-clin, TECAsurg, TA, and the posterior bicondylar line (PBL). The angles between TECA and TA, FA and PBL were analysed during flexion. Angles were measured by the medial side.

Results: TECAsurg remained perpendicular to the TA throughout flexion but with considerable interindividual variability. The mean variation during flexion was 3.4±1.5°. The FA-TECA angle was 88.5±0/8° and did not vary with morphotype. The TECA/PBL and TECA/TA angles varied with morphotype but less with flexion.

Conclusion: The surgical TECA maintains constant relations with the tibial axis during knee flexion. It can thus be used as a landmark for positioning the femoral component for total knee arthroplasty in order to optimise femorotibial kinematics. The relations between the clinical TECA and the TA are variable and preoperative identification on the main medial epicondylar eminence may give variable results.


G. Boeri J.Y. Jenny J.C. Dosch M. Dupuis A. Moussaoui F. Mairot

Purpose: According to the Ottawa rules, x-rays are not needed after knee trauma unless one or more of the following clinical criteria are present: age over 55 years, pain at palpation of the head of the fibula, pain at palpation of the anterior aspect of the patella, impossible knee flexion beyond 90°, inability to walk four steps immediately after trauma and at the emergency consultation. We conducted a prospective study in a consecutive series of patients to check the validity of this rule in daily practice.

Materials and methods: From December 2001 to January 2002, we included all patients consulting in an emergency situation for recent trauma involving only the knee joint. We excluded patients aged less than ten years, wounds without trauma, trauma more than two days before consultation, and patients with a history of trauma involving the same knee. An emergency physical exam was performed in all cases with identification of the study criteria. Standard x-rays (AP and lateral view in the supine position) were obtained for all patients. The patients and the x-rays were seen later by a senior orthopaedic surgeon and a senior radiologist who noted the presence of fracture requiring specific therapeutic management. The sensitivity, specificity and positive and negative predictive values of the Ottawa rule were determined for search for fracture.

Results: One hundred thirty-eight patients met the inclusion criteria during the study period. The sensitivity and negative predictive value of the Ottawa rule were 100%; the specificity was 36%, and the positive predictive value was 25%. Nineteen fractures (14%) requiring specific therapeutic management were identified: all patients had at least one positive sign. Seventy-six patients (55%) without fracture had at least one positive sign. Forty-three patients (31%) without fracture did not have any positive sign. The x-rays were not contributive for these patients.

Discussion and conclusion: This study demonstrated the validity of the Ottawa rule in the clinical setting of our practice. With widespread use of this rule, approximately one-third of the x-rays performed for recent trauma involving the knee alone could be avoided.


M. Bercovy A. Duron H. Siney E. Weber M. Zimmerman

Purpose: This comparative study of femoropatellar function in four types of total knee arthroplasty (TKA) was conducted to demonstrate the relation between the form of the femoropatellar articulation and the function outcome achieved with these prostheses.

Material and methods: Forty patients who had undergone first-intention TKA for primary degenerative joint disease were selected at random. Minimum follow-up was one year. The functional IKDC score was greater than 85/100. All TKA had been inserted without preservation of the posterior cruciate ligament. Four types of prostheses were used:

- posterior stabilised prosthesis with a fixed plateau, toric trochlea, cemented dome patella (n=10);

- TKA with a rotating platform, 2-facet trochlae, rotatory congruent patella (n=10);

- TKA with a rotating platform, 2-facet trochale, without resurfacing (n=10);

- TKA with a rotating platform, hollow anatomic trochlae (n=10).

The following parameters were studied prospectively:

- pain assessed on a visual analogue scale;

- clinical assessment of going up and down stairs (normal, step-by-step, with handrail);

- kinematic assessment of active flexion extension (0°–120°) during which the position of the patella was measured in the three planes and the trajectory of the patella was noted in comparison with the healthy side and with the moment of the quadriceps;

- efficacy of the quadriceps (Cibex).

Results: The kinematic data demonstrated a significant difference between:

- TKAs with a dome patella and those with an anatomic patella;

- TKAs with an anatomic trochlae and those with a hollow trochlae;

This difference basically involved the patellar tilt, lateral subluxation of the patella, and especially, the patellar trajectory between 20° and 90°, the toric trochlae with a dome patella having a more anterior trajectory than the normal knee.

The clinical and functional study showed that:

- the percentage of totally pain-free femoropatellar articulations was higher for the hollow anatomic trochlae (96%) than for the three other types (75%) (p = 0.04);

- the stairs function was better for all the anatomic trochlae compared with the dome trochlae (p = 0.05);

- the efficacy of the quadriceps was the same for the four types of TKA.

Discussion and conclusion: This study confirms the theoretic work reported by Walker and the clinical work reported by Andriacchi on the anterior curvature of the trochlae and the kinematic work reported by Stichl on the advantage of anatomic trochlae. These findings point out the advantage of the hollow anatomic trochlae where the patella is applied on the trochlear groove situated at the same depth as the normal trochlae, which is not the case with most TKAs. This advantage is seen by the absence of pain and by the propulsion when climbing stairs.


F. Buscayret C. Buscayret P. Maury

Purpose: We studied early recovery of knee muscles after harvesting the hamstrings for arthroscopic reconstruction of the anterior cruciate ligament (ACL) using an isokinetic testing device (Biodex®).

Material: This prospective consecutive series included 22 athletes (twelve amateur athletes and ten competition level athletes) who presented a full thickness tear of the ACL without associated lesions. Intra-articular and extra-articular ligamentoplasty using the gracilis and semi-tendinous was performed arthroscopically by the same surgeon. The same rehabilitation program was prescribed for all patients.

Method: The flexor and extensor system of both knees was assessed for each patient using the Biodex® device operating in concentric isokinetic mode. Tests were performed at two speeds 90 and 180°/s and at three times: preoperatively, and four and seven months postoperatively. The peak couple and mean power during a series of six flexion-extension movements were retained for this analysis.

Mean values remained unchanged for the three test times for the healthy knees. We therefore chose the preoperative values obtained for the healthy knee as the paired reference value for each patient. The values obtained for the operated knees were compared with these control values using two-way analysis of variance for paired variables.

Results: At four months postop, flexor and extensor muscles exhibited significant (p < 0.05) and equivalent diminution. However, 25% of the patients had already achieved 80% recovery, sufficient for renewed sports activities. At seven months postop, the extensors had totally recovered and the flexors remained significantly diminished (related to hamstring harvesting); 65% of the patients had reached 80% recovery, but 90% of the competition level athletes had recovered more than 80%. The statistical analysis demonstrated a positive correlation between muscle recovery at seven months and preoperative muscle level: the patients with higher preop levels having the higher postop levels.

Discussion: These results suggest the following: preoperative rehabilitation exercises (to start with a higher preop level), more work on the flexors (limiting factor), new recovery objectives (80% at four months, 100% at seven months). Currently, we authorise renewed sports activities on the basis of muscle recovery as assessed by isokinetic tests which are performed at four months for competition level athletes and seven months for amateur athletes.


P. Paillard D. Goutallier C. Radier S. Van Driessche

Purpose: It was demonstrated in 1986 that to obtain a good radioclinical result at 10–13 years after valgus tibial osteotomy for the treatment of medial femorotibial osteoarthritis that the frontal valgus at this follow-up had to be 3–6°. In 1995, it was demonstrated that the side of deterioration in knees initially aligned between 2° varus and 2° valgus or with genu valgum (≥ 3° valgus) depended on the tibiofemoral axis: a positive index (tibial torsion greater than femoral torsion) favouring medial femorotibial deterioration and progressive varisation, and a negative index favouring lateral femorotibial deterioration and progressive valgisation. Can the post-osteotomy valgus be modified by the tibiofemoral index and prevent obtaining ideal correction at 10–13 years?

Material and methods: Forty-five knees with femortibial deterioration of the medial compartment were treated between 1987 and 1990 by tibial medial opening osteotomy for valgisation. Functional outcome in the 45 knees was assessed at a mean follow-up of 11 years (range 10–13 years). Postoperative frontal axis after healing and frontal axis at last follow-up was measured by goniometry in the standing position for all knees. A scan in the torsion position was obtained for 36 knees to measure the tibiofemoral index.

Results: At maximum follow-up, outcome was good in 58% of the knees, fair in 24%, and poor in 18%, differences which were not statistically different. Frontal axis changed with time. Among the 36 knees which had been realigned correctly (3–6° valgus) after healing, four exhibited an increase in valgus beyond 6° and five lost valgus passing below 3°. But ideal valgus was achieved at last follow-up for three of five knees which had been undercorrected, Among the 38 knees for which a torsion scan was available, 33 were correctly realigned postoperatively and 22 were well aligned at last follow-up. There was no statistical difference between knees with good, fair, or poor outcome among the 33 knees well corrected postoperatively (3–6° valgus). There was however a statistical difference between the good (64%), fair (27%), and poor (9%) functional results among knees with ideal valgus at last follow-up (p = 0.03).

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).

Conclusion: To have the best chance of obtaining a good functional result 10 to 13 years after tibial osteotomy for valgisation, the valgus at this follow-up must be between 3° and 6°. But to achieve this valgus, the postoperative valgus must be modulated in relation to the tibiofemoral index. For an index ≥ 13°, the postoperative valgus should be pushed towards 6°; for an index < 13°, valgisation should aim at achieving a 3° postoperative valgus or less.


M. Bonnin M. Bouysset J. Tebib E. Noël F. Buscayret

Purpose: The purpose of this work was to assess results of total ankle arthroplasty (TAA) for rheumatoid arthritis and determine the technical difficulties.

Material and methods: Between 1993 and 1999, 32 TAA were performed for rheumatoid arthritis: 26 women and 16 men, mean age at implantation 55 years, age range 32 – 81 years, disease duration 17 years (range 2 – 35 years), long-term corticosteroid treatment 18, metotrex-ate 17. Non-cemented prostheses with a mobile insert were implanted: Buechel-Pappas (n=7), STAR (n=5), Salto (n=20). For 21 patients, subtalar and mediotarsal arthrodesis was associated with the TAA because of associated subtalar deterioration or valgus tilt due to tendiopathy of the posterior tibial tendon. All patients were seen at three, six and twelve months then every year for physical examination and x-rays. None of the patients were lost to follow-up. Mean follow-up was 57 months (range 26 – 90 months). Clinical outcome was assessed with the AOFAS.

Results: There were two failures requiring revision: one loose talar piece migrated four years after implantation requiring arthrodesis; one over-sized talar piece leading to pain had to be changed after one year with good results (AOFAS = 92). Among the other 30 patients, the mean overall score and the pain score were 82/100 (73–92) and 35/40 (20–40) respectively. Several complications were observed: wound necrosis (n=2), impaction of the talar piece (n=1), and impaction of the tibial piece (n=2) which developed at weight bearing then remained unchanged. One anterior translation of the tibial piece was asymptomatic at two years, fractures of the medial malleolus healed without difficulty.

Discussion: TAA is the treatment of choice for rheumatoid tibiotarsal degeneration. Associated lesions of the hind foot influence prognosis and results. Preoperative analysis of the deformation and loss of bone stock must be achieved with careful physical examination and appropriate x-ray or computed tomography imaging. Subtalar valgus deformation or tendinopathy of the posterior tibial tendon require an associated subtalar and mediotarsal arthrodesis.


J.L. Besse P. Michon M. Kawchagie X. Ducottet B. Moyen J. Orgiazzi

Purpose: Since 1996, our multidisciplinary medicosurgical team has decided to propose orthopaedic treatment for diabetic perforating ulcers with osteitis, cellulitis, or necrosis (“cooling down” the acute infected ulcers before programmed surgery) rather than conservative treatment with prolonged antibiotic therapy. We present here a prospective study of 44 cases of diabetic perforating ulcers.

Material and methods: Thirty-two diabetic patients underwent surgery: 77% males, mean age 65.2±8.6 year (range 43–86 years), 87% type 2 diabetes, 52% with a history of perforating ulcers, 45% with minor amputations, and 14% with history of vascular surgery. The lesions—perforating ulcer with osteitis (n=34), vascular necrosis of the toes (n=2), “acute feet” with cellulitis (n=8)—had progressed over 13.2±15.1 weeks. The preoperative work-up included: bacteriology samples 89%; standard x-rays of the foot 100% (osteitis 84%); duplex Doppler of the lower limb arteries 77% (tibial arteriopathy 87%); double bone scintigraphy 34% (osteitis 93%); TcPO2 (40±14mmHg); arteriography 27%; vascular surgery consultation 18%. Before surgery, 77% of the patients were hospitalised in an endocrinology unit (13±3 days) and 88% were on an antibiotic regimen for 26±18 days (50% i.v.).

Orthopaedic surgery (without tourniquet, anaesthesia block, mean duration 53±24 min) involved: partial resection of a toe 23%; amputation of a ray 36% (first ray one, second ray five, third ray one, fourth ray two, fifth ray six); transmetatarsal amputation 32%; resection of the metatarsal heads 4%; calcanectomy (n=1); below knee amputation (n=1); and systematic and multiple samples for bacteriology (deep soft tissue and bone tissue) and for pathology.

Results: Mean hospital stay in the surgery unit was 4±1 days, followed by 18±10 days in the endocrinology unit with antibiotics (oral for 88%) for 34±22 days, 91% of the lesions healed within 33±18 days; four required repeated procedures (two transmetatarsal amputations, one amputation of the first ray, one lower limb amputation); three lesions relapsed.

The peroperative bacteriology samples of the deep soft tissue and bone tissue demonstrated, in comparison with the preoperative samples, that antibiotics had sterilised only 14% of the lesions; with discordant comparison in 40%, partial concordance in 24%, and total concordance in 24%. For the diagnosis of osteitis (confirmed by histology of peroperative bone samples), the x-ray interpretations were largely confirmed (79% exact diagnosis, 87% sensitivity, false positives 12%), as were the bone scintigrams with labelled polymorphonuclears (exact diagnosis 93%, sensitivity 93%, false positives 7%).

Conclusion: This prospective study demonstrated the advantages of programmed surgery over emergency surgery, including for “acute feet”: limited resection, primary suture, rapid wound healing, short antibiotic treatment. It raises some questions concerning the validity of non-surgical bacteriological samples for perforating ulcers, even when performed under rigorous conditions (unique strain isolated from 76% of the samples) and on the possibility of antibiotic pressure on bacterial selection.


A. Gabrion O. Jarde E. Hvet P. Mertl M. de Lestang

Purpose: Total ankle arthroplasty remains a difficult procedure. Some patients require revision surgery for arthrodesis.

Material and methods: We report nine patients with total ankle arthroplasties mainly implanted for post-traumatic osteoarthritis whose results deteriorated, requiring arthrodesis. One of these patients had rheumatoid arthritis.

Revision surgery was performed six months to seven years after arthroplasty. Arthrodesis was required for pain related or not to implant loosening or talar necrosis. One patient developed a major deviation of the hind foot secondary to progressive loosening. One patient developed infection early. An iliac graft was used to fill the bone defect in eight patients. An anterior plate-screw fixation was used for six patients, crossed screws for one, a tibiotalar nail for one, and an external fixator for one (with infection).

Results: Eight patients achieved bone healing with good pain relief. The functional result depended on the type of arthrodesis: talocrural alone or extended to the torsion couple.

Discussion: The evolution of ankle prostheses toward better bone sparing has allowed, in our experience, for revision arthrodesis under relatively good conditions using an iliac graft. We have not preferred one standard type of fixation but the anterior plate fixation has provided excellent stability.


J.L. Besse M. Maestro E. Berthonnaud F. Langlois A. Meloni M. Bouharoua J. Dimnet J.L. Lerat B. Moyen

Purpose: Constitutional factors responsible for hallux falgus and hallux rigidus remain unclear. The purpose of this work was to compare the radiological feature of the forefoot in three populations with “normal” feet, hallux rigidis, and hallux valgus.

Material and methods: One standard protocol was used within the same unit to obtain dorsoplantar AP views of the foot in the standing position in all subjects. Fifty “normal” feet, with no apparent deformation, callosity, or pain, were selected among the orthopaedic unit personnel; mean age of the 25 subjects was 30.3±9.6 years, and 44% were women. The 30 patients with hallux rigidus were operated on at a mean age of 57.4±10.7 years, and 48.4% were women. The 50 patients with hallux valgus were operated on at a mean age of 50.8±12.8 year and 92% were women.

All radiograms were digitalised (Vidar VXR-12 plus) and analysed by four observers using the FootLog software which provides semiautomatic measurements. The following parameters were recorded: distance between the lateral sesamoid and the second metatarsal (LS-M2), the M1P1 angle (for the diaphyseal and mechanical axes of M1), the diaphyseal and mechanical distal metatarsal articular angle (DMAA) of M1, Meschan’s angle (M1–M2–M5), the distance between a line perpendicular to the axis of the foot drawn through the centre of the lateral sesamoid and the centre of the head of M4 (MS4–M4) (a corrective factor was introduced for the MS4–M4 distance to account for the displacement of the lateral sesamoid in hallux valgus), the M1 index = d1-D2 (length of the head of M1/MS4 – length of the head of M2/MS4), maestro 1 = d2–d3, maestro 2 = d3–d4, maestro 3 = d4–d5. The measured parameters were recorded automatically on an Excel data sheet and statistical analysis was performed with SPSS 9.0.

Results and discussion: Intra- and inter-observer reproducibility of measurements and morphological classifications were excellent. The LS/M2 distance was comparable in the three populations, proving that the lateral sesamoid is relatively fixed compared with the M2 and enabling its use as reference for the MS4 line. The Meschan angle did not discriminate between the three populations, likewise for the mean M1/M2 index, the M1P1, M1M2, and DMAA angles which were different in the three populations; there were 2° to 3° variations for the mechanical or shaft axis. The morphotype analysis demonstrated objective evidence of morphological differences of the forefoot in the three populations. The hallux rigidus group showed a predominance of the index plus and plus-minus with long M23 lateral patterns, while the hallux valgus group exhibited a predominance of M4M5 hypoplasia.

Discussion: Morphotypic definition of the metatarsals is an interesting approach providing a measurable way of interpreting forefoot disorders and guide surgical correction. These results should be confirmed with measures in larger series, which can be accomplished with FootLog software. It would also be useful to combine radiological studies with baropodometric studies.


Full Access
J.P. Delagoutte D. Mainard L. Galois F. Pfeffer R. Traversari

Purpose: Global metatarsus varus is a deformity of the forefoot characterised by medial deviation of all the metatarsals. The condition is often associated with hallux valgus and pes cavus (metatarsus varus sometimes being considered a clinical form of cavus), as well as metatarsal verticalisation predominating on the first ray.

Material and methods: Among twenty patients with metatasus varus in this study fifteen had undergone surgical correction. There were seven men and eight women, mean age 43 years. The deformity was bilateral in most patients (n=10, operated =9) but predominantly on one side in five of them. Metatarsalgia was the common complaint, considered to be global involving the middle rays (n=12 patients), or localised under the head of the first metatarsal (n=3). The calcanean tendon was short in all cases, aggravating subcapital anterior loading. Likewise, 12 of the 15 patients had hallux valgus; mean 45°. For one patient calcaneal osteotomy for valgisation was also performed.

Hallus valgus was corrected whenever present: in three cases an osteotomy was performed alone to raise the first metatarsal followed by a plantar prosthesis. A basal osteotomy of the three middle metatarsals was performed to achieve elevation, valgisation, and shortening: for three cases a Weil osteotomy was performed.

Results: Hallus valgus recurred in all patients who had had correction surgery, with recurrence of metatarsus varus. Basal metatarsal osteotomies healed but after a long period (about six months. Metatarsalgia was unchanged and was situated under the heads that were not perfectly aligned. The Weil osteotomies did not improve the evolution because, like basal osteotomies, they did not prevent recurrence of global metatarsus varus.

Discussion and conclusion: Metatarsus varus is a challenging deformity which responds very poorly to classical treatments of the forefoot. Osteotomy, irrespective of the type, does not prevent recurrence, both for the lateral rays but also for the hallux. Certain authors suggest that metatarsophalangeal arthrodesis could be useful to stabilise the hallux in the corrected position. We have no experience with this method but in light of our results after conservative treatment for joint motion, this would appear to be an interesting option. We have modified our indications in this direction, using a basi-metatarsal osteotomy instead of a Weil osteotomy for the small toes. Lengthening the extensor tendons may be needed.


P. Denormandie E. Lô C. Kieffer D. Ben Smail B. Bussel J.B. Elis T. Judet

Purpose: Multiple deformations of the lower limbs are common orthopaedic complications of central nervous system disease. Assessment is difficult. Intrathecal Liorésal® was proposed for the patients to establish the relative effects of spasticity and musculotendinos retraction and define a medico-surgical therapeutic strategy.

Material and methods: Between January 1999 and December 2000, 31 patients consulted for persistent knee flexion. Baclofen tests (75 – 100 μg Baclofen intrathecal) were performed in ten patients because the relative contribution of spasticity and retraction was difficult to assess. The anti-spasticity effect was observed within the first hour, with a maximal effect between the second and fourth hour. Motor function, joint motion, and function were tested during this time interval. The test was repeated approximately three days later, sometimes with higher doses depending on the level of the anti-spastic effect. Residual orthopaedic limitations were explained by musculotendinous retractions.

Results: For the ten evaluated patients, three presented musculotendinous retractions amendable by surgical treatment (tendon lengthening, proximal disinsertion), sometimes in combination with arthrolysis. For the seven patients who had hypertonic spastic contractions, medical treatment was given with, for three patients, continuous intrathecal Lioresal via pump delivery. There was a correlation between the deformation assessed after the test and the test conducted under general anaesthesia during the procedure in all patients.

Discussion: Other methods for evaluating orthopaedic deformities of the lower limbs can be used. Selective motor blocks using local anasethetics are generally reserved for patients with localised stiffness or when it may be difficult to achieve in certain patients (hip flexion). Mobilisation under general anaesthesia is another solution, but does not allow an assessment of functional gain, particularly if the goal is walking. The intrathecal Baclofen test not only allows an accurate assessment of orthopaedic retraction, but also an assessment of the functional impact of the spasticity, sometimes useful for verticalisation or walking.

Conclusion: The Baclofen intrathecal test is a simple test with a particular place in the preoperative and functional assessment of neuro-orthpaedic stiffness of the lower limbs.


R. Maes Y. Andrianne B. Burny

Purpose: In 1928, Schwartz defined for the first time a quantitative measure of the plantar vault acquired from the footprint. Since that time, a whole series of parameters have been described in the literature. The purpose of the present work was to study the correlations between different footprint parameters and radiographic data obtained in the weight-bearing position.

Material and methods: This retrospective series included a sample of 158 patients (35 men, 123 women) who attended a specialised adult podology clinic. Mean age was 46 years, range 14 – 86 years. Footprints were obtained in two-leg stance on two sheets of standard paper after spreading an iodine (or eosin in case of allergy) alcohol solution on the plant of the foot. Five graphic indexes were retained for analysis. The angle of the arch, the Chippaux-Smirak index, and the contact angles II, II, IV described by Qamra. Indexes described in the literature which require sophisticated equipment (computer, planimeter, pressure captors…) were intentionally not included in the analysis. The Djian-Annonier angle was measured on the radiograms. These measures were chosen because they are used in daily practice in our unit.

Results: The results were evaluated for all 316 feet taken as one population and for the 158 left and 158 right feet as two subpopulations. The coefficient of correlation between the Djian-Annonier angle and the five selected footprint parameters were greater than 0.5 (excepting the arch angle, where −0.24 < r < −0.31). The best correlation was found between the Djian-Annonier angle and the Chippaux index (about 0.60). Intercorrelation between the five footprint parameters showed a coefficient of correlation greater than 0.79, except for the arch angle where r was negative.

Discussion: The Chippaux-Smirak index is a simple way to obtain objective measurement which is statistically related with the Djian-Annonier angle, exhibiting better correlation than more sophisticated indexes such as those described by Qamra in a symptomatic population. But these conclusions are applicable for a population of feet exhibiting normal distribution. The podometric parameters cannot be measured for feet at the extremes of the distribution because the plantar vault is measured in the middle part of the footprint. In case of severe pes cavus there would be no footprint at this area and for a very flat foot the printed/nonprinted ratio would be one.


V. Shevtsov G.R. Imailov

Material: This work presents the treatment of 114 patients (125 feet), aged 9 – 53 years for:

- 82 short feet due to congenital metatarsal hypoplasia,

- 3 first toe stumps (P1),

- 32 post-trauma and post-surgery cases including two after resection of the metatarsal heads.

The cosmetic defect was the principal complaint in most patients (95 women), as well as complications related to wearing shoes. Pain in the forefoot resulted from biomechanical conflicts between the toes and the metatarals.

Methods: An oblique or transverse osteotomy for lengthening was performed on the base of the metatarsals and the phalanges. An external fixator, with modifications, was used. Pins were driven through the joints during the osteosynthesis to prevent dislocations. Traction was started three to five days after surgery at the rate of 0.5–1 mm/24 hr. Partial weight bearing on the operated limb was recommended. The external fixator was dismounted progressively with ablation of the pins allowing complete rehabilitation of the toes and walking exercises. These measured favour formation of regenerated bone and remodelling into hard bone, shortening treatment which was 45 ± 6 days in the study group.

Results: Outcome was followed for 1 – 3.5 years. The desired lengthening of the forefoot (1.5 – 5 cm was achieved in all feet. All feet were pain free and the cosmetic result and foot bearing on the floor was improved. The patients were satisfied, with no complaints, and walked with full weight bearing without complementary prostheses and wearing ordinary shoes.

Discussion: This experience in lengthening short tubular bones of the feet confirms the efficacy of the techniques used which provided good cosmetic and anatomo-functional results with one treatment.


S. Poulain P. Hardy

Purpose: A prospective multicentric study was conducted in a concentric and consecutive series of 204 patients operated on between Mai 1999 and August 2001 for fracture of the proximal femur. The purpose of this study was to assess quality of life after surgery in patients undergoing implantation of the Intermedia® prosthesis.

Material and methods: Mean patient age was 79.6± 8.6 years), 18.8% men. Most of the fractures were Garden III and IV fractures (87.4%) and 90.9% were recent (< 21 d). The intermediary Intermedia® prosthesis was implanted via the posterolateral approach in 73.9% of the patients with acetabular preparation in 13.7%; a head with a restraining skirt was used in 20.8%. The Robinson score for motion, lifestyle, degree of osteoporosis (Singh score), history (ASA), psychomotor index (Hodkinson score) were determined preoperatively (19/26 (±6.89). The Merle d’Aubigné score was calculated at one year. Adaptation of the femoal stem (3 sizes) to the shaft was assessed on standard x-rays. The Kobayashi method was used to study stem to shaft fit; this score gives a rate of shaft filling used to determine whether the self-blocking contact was well achieved with the three stem sizes available.

Results: There were eleven (5.4%) posterior dislocations including four which were reduced orthopaedically. Among the 203 patients, 40 (19.7%) were lost to follow-up and 34 died. The Merle d’Aubigné score at one year showed 84.7% satisfactory results (excellent, very good, good). Preoperatively 59% of the patients were independent and 7% resided in nursing homes, these figures at one year were 55.5% and 5% respectively. Radiologically, the rate of migration (impaction) was 3.9% at one year. Stem-to-shaft fit was, according to Kobayashi for the proximal, middle, and distal portions 73%, 75% and 75% respectively.

Discussion: Mortality due to fracture of the proximal femur is high (16.7% at one year). Morbidity was due to infection (1%) and eleven displacements (5.4%). The difference in motion and lifestyle between the pre- and postoperative period was not significant. Simplification of the implantation procedure by using three stem sizes did not produce any radiological differences at one year.


P. Denormandie L. Hailhan C. Kiefer I. Laffont T. Judet

Purpose: Talipes equinus is a frequent deformity observed in patients with central nervous disease. The surgical strategy is based on an assessment of the spasticity and retraction elements in the deformity and the presence or not of antagonistic muscles. We propose a codified treatment strategy and present results obtained over the last two years.

Material and methods: All patients who underwent surgical treatment for central neurological talipes equinus between 1998 and 1999 were included in this study. All patients were seen by the orthopaedic surgeon and the physical education and rehabilitation physician at the preoperative consultation. Selective neuromotor nerve blocks completed the physical exam in order to assess spasticity and retractions (soleus, gastocnemius, flexor digitalis). Functional antagonistic or transferable muscles were identified. A function contract was established with the patient. All patients were operated on by the same surgeon and were reviewed late after surgery by an independent clinician. Gain in joint movement and function were recorded as well as any complications.

Results: Thirty-five patients underwent surgery (42 feet). The analytic results were good: mean gain in joint movement = 37.5°.

The functional objectives (walking for 31 patients, verticalisation for ten, comfort for one) were achieved in all patients except five. There was one taluseversus, one anterior subluxation of the talus, one persistent stepping. For two patients underlying neurological disorders did not allow fulfilment of the contract. There were also three cases of claw toes with moderate functional impact.

Discussion: Preponderant retraction makes it difficult to assess antagonistic and intrinsic muscles, leading to the complications observed. A dynamic EMG recording might provide a solution. Functional outcome depends on correct assessment of the underlying neurological status.

Conclusion: The good results achieved in this series of patients validates the proposed decisional algorithm. The surgical strategy must be inscribed within a functional contract established with each individual patient.


O. Taçkin T. Bégué A.C. Masquelet

Purpose: Bone quality in elderly patients always subject to osteoporosis can compromise the stability of osteosynthesis materials. The fixation can be reinforced by using acrylic cement, allowing early rehabilitation. The purpose of the present work was to investigate the quality of acrylic cement-reinforced osteosyntheses and to study the functional consequences of this method. We also analysed early or secondary complications and determined the mid- and long-term advantages and disadvantages for the patient’s quality of life and also for later interventions on the fracture site.

Material and methods: Forty female patients treated between 1990 and 2000 were studied retrospectively. These elderly women (mean age 86.2 years at fracture), had 44 fractures (38 femurs including two with double fractures; four humeri) which had been treated by acrylic cement reinforced ostheosynthesis. The physiological status of the patients before trauma was assessed with the Robinson score and the degree of osteoporosis with the Sinon index. The quality of the cementing was assessed using the Cameron technique. Minimum follow-up was six months, necessary for inclusion.

Results: The preoperative Robinson score was 18.8. The mean Singh index was four. Cementing was satisfactory for 29 fractures. Immediate weight bearing or complete use of the limb was possible early for 42 of the 44 fractures. Bone healing was achieved at a mean 2.8 months for 43 fractures. Mean follow-up was 9.8 months. Twelve patients died before the end of the first postoperative year. At last follow-up, there was one nonunion and five infections, including three bone infections. The Robinson score at last follow-up was 16 on the average. Subsequent interventions did not have to be modified or abandoned because of the acrylic cement reinforcement of the osteosynthesis.

Discussion: The results of this retrospective series are comparable with those obtained with other centromedullary nailing or primary or secondary bone grafting techniques used for the treatment of patients with severe osteoporosis.


O. Vanel L. Béguin F. Farizon M.H. Fessy

Purpose: Fracture of the neck of the femur in elderly subjects is generally treated by arthroplasty, either using a total or intermediary hip prosthesis, but with a high risk of dislocation, estimated at about 10% in the literature. We investigated the contribution of a double mobile cup to lower this risk.

Material and methods: This prospective study was conducted by several operators in the same university unit between 1998 and 2001. A total of 177 mobile prostheses were implanted in patients with fracture of the anatomic neck of the femur (n=145), the neck and trochanter (n=22), or pathologic fracture (n=4). For six patients, the prosthesis was implanted after failed osteosynthesis of a trochanteric fracture. The postero-lateral approach was used for 136 women and 41 men (age range 61 – 92 years) living at home (n=124), or in an institution with a high degree of independence (n=53). The femoral stem was cemented (n=115) or impacted (n=62). A double mobile cup was used in all cases. A chromium-cobalt/ polyethylene couple was used and head diameters were 28 mm (n=150) or 22.2 mm (n=27). We studied outcome and risk of dislocation one year after implantation.

Results: There were six deaths during the postoperative period. Among the 171 patients, 134 were seen at two months, 108 at six months and 89 at one year: 39 were questioned to ascertain outcome. During the first postoperative year, there were 37 deaths; these patients were followed. Six patients were lost to follow-up. We had two cases of intraprosthetic dislocation related to a defect in the chromium-cobalt head retention of the polyethylene insert. These two cases required revision and were reported to material surveillance with corrective measures for the manufacturer.

There were three true dislocations (2%): 1) a posterior dislocation on day 24 in a female patient presenting a fracture with impaction of the femoral stem; 2) a posterior dislocation on day 22 in a female patient in very poor general condition (severe cardiorespiratory failure, death at 48 hr); 3) one recurrent posterior dislocation related to major acetabular retroversion, revised at four months.

Discussion and conclusion: The double-mobile cup appears to be a simple reproducible method for preventing dislocation of prostheses implanted for fracture of the neck of the femur.


R. Traversari F. Pfeffer L. Galois D. Mainard J.P. Delagoutte

Purpose: The purpose of this study was to analyse mechanical failures involving dismonted osteosynthesis materials implanted to fix pertrochanteric or subtrochanteric fractures with a dynamic hip screw (DHS), a Gamma nail, or a plate nail system (STACA).

Material and methods: Our cohort included 16 patients among a series of 350 patients who had been treated with 240 DHS, 80 Staca nailplates, and 30 Gamma nails between 1996 and 1999. We used the Ender classification for the x-ray analysis and the Cuny criteria which describe the most common causes of dismounted material.

Results: According to the defined criteria, 70/350 osteosynthesis assemblies (20%) were considered insufficient on the immediate postoperative x-rays and eventually dismounted in 16 patients. Two of these patients had major osteopaenia according to the Singh criteria and ten underwent revision because of poor clinical tolerance. These patients had six DHS (3 “swinging” cervical nails, two dismounted plates, and one screw protruding into the joint space). A protruding screw was the problem for the eight Staca nail-plates. Two Gamma nails had a “swinging” screw. These cases of dismounted material were predominantly observed in patients with Ender grade 5, 7 and 8 pertrochanteric fractures.

Discussion: Our analysis of these cases revealed several important factors: 1) the quality of the fracture reduction with restitution of the medial pillar of the per-trochanteric mass; 2) central anchoring in the femoral head essential for stable fixation; 3) superior stability of the DHS in grade 1 and 6 fractures due to the greater projected surface improving hold in cancellous bone. Inversely, for subtrochanteric fractures (grade 7 and 8), centromedulary shaft anchoring with a Gamma nail reduces mechanical stress in varus and thus the risk of “swinging” screws. Finally, the monoblock construct of the Staca nail-plate, which does not have the dynamic potential of the DHS and the Gamma nail, raises a risk of protrusion, particularly in case of “internal rotation” fractures with major metaphyseal comminution (grades 4 and 5). This latter type of fixation is however very effective for simple pertrochanteric fractures with minimal comminution (grades 1 to 3).

Conclusion: Material dismounting results from a series of factors related both to the material used and to the operative technique. We thus reserve the Staca nail-plate for grade 1 to 3 fractures in the Ender classification, the DHS for grades 1 to 6 and the nail-screw fixation for subtrochanteric (grade 7 and 8) fractures.


G. Asencio R. Bertin P. Kouyoumdjian B. Megy P.P. Mill A. Ben Lassoued Y. Roussanne

Purpose: Fractures involving both the shaft of the femur and the proximal portion of the femur are uncommon. In a meta-analysis of cases reported between 1951 and 1985, Alho recorded 659 cases where a wide range of management strategies were used. We report here a homogeneous series of 17 patients treated with ascending locked anterograde nailing.

Material: This series of 17 patients were young (mean age 36 years). These eleven men and six women were all victims of high-energy trauma; 12 had multiple fractures. The shaft fracture involved the middle third in 15 patients, the lower third in two; the shaft fracture was open in six cases. The proximal fracture was transcervical in nine patients (7 B21, 1 B22, 1 B23) and trochanteric in six (A A32, 1 A31, 2 A12, 2 A33).

Methods: The fracture was reduced under fluorescent guidance on the orthopaedic table in the supine position followed by anterograde nailing with ascending proximal locking in the axis of the neck using a Russel and Taylor reconstruction nail. The osteosynthesis was performed on day 0 in eleven patients, during the first week in three and later in three.

Results: Results are reported for 17 patients. There was one early superficial suppuration which healed favourable after local care. Two shaft fractures exhibited nonunion and were revised to decorticalise the graft. The cervical fracture exhibited early displacement in one patient who underwent revision on day 15; bone healing did not ensue and a total hip arthroplasty was implanted at ten months. All the other fractures healed within three to five months after the first-intention treatment. The long-term follow-up has revealed one case of cephalic necrosis at five years which has required a total hip arthroplasty.

Discussion: These double fractures involving the proximal femur and the shaft of the femur account for 1 to 5% of the femur fractures reported in the literature. They are observed in young victims of high-energy trauma, often associated with other multiple injuries. Diagnosis is not always easy to establish since there may be little or no displacement of the proximal fracture, which may be recognised secondarily after standard nailing (2 out of 17 cases).

The trochanteric fractures are generally easier to diagnose and reduce, and usually heal well. The shaft fractures are more often displaced and readily comminutive, sometimes open, having absorbed the greater part of the trauma energy. These fractures heal like ordinary shaft fractures. Neck fractures are often seen in the lower portion with a vertical fracture line, with or without displacement.

Using a single centromedullary nail for the osteosynthesis of both fractures is an attractive solution. The proximal fracture must however be carefully reduced with percutaneous pins before attempting nail insertion. The postoperative period is generally uneventful. Problems may be encountered if the cervical fracture cannot be perfectly reduced, in which case two separate fixations would be preferable.


G. Cochu C. Baertich F. Fiorenza J.L. Charissoux J.P. Arnaud C. Mabit

Purpose: The purpose of this study was to assess outcome after first-intention total hip arthroplasty for fresh fractures of the acetabulum in elderly patients.

Material and methods: We present a retrospective analysis of 18 recent fractures of the acetabulum observed in nine men and nine women, mean age 74.8 years which were treated by first-intention total hip arthroplasty. The fractures were considered equivalent to acetabular bone deficits observed at revision of total arthroplasty (five grade III, 13 grade IV in the SOFCT 1988 classification).

The prosthesis was implanted 15.6 days (mean) after initial trauma and included a metal-backed acetabular implant (except one case) and a bone autograft (except three cases). Complete weight bearing was authorised on day 3 postop for five patients, and at six weeks for ten; at three months for the other three.

Mean follow-up was 2.5 years. Thirteen surviving patients were reviewed clinically and radiographically. Five patients who had died were also included in the analysis using data reported by family before death.

The Postel-Merle d’Aubigné (PMA) and Harris scores were recorded. Survival curves were plotted. Radiological assessment included bone healing, status of the prosthetic assembly, presence of a lucent line or signs of loosening in the three acetabular zones described by De Lee and Charnley.

Results: The mean functional scores were 13.6/18 (PMA) and 71.8/100 (Harris). There were no cases of infection or dislocation. Median Kaplan-Meier survival was six years. The one-year survival rate was 94.4%. Five deaths were recorded, all due to causes independent of the surgical intervention.

Radiologically, all fractures had healed. There were no mechanical complications and no signs of acetabular loosening.

Discussion: Several authors have demonstrated that prognosis is poor in elderly subjects undergoing surgical osteosynthesis or functional treatment due to the presence of risk factors (osteoporosis, comminution, deferred surgery due to poor general status). Prolonged bed rest may also have life-threatening consequences. Other work has emphasised the very high rate of complications after revision surgery for dismounted material, post-traumatic deterioration, or osteonecrosis.

The absence of early deaths and the low rate of intervention-related morbidity in this series of elderly patients is in agreement with a very small number of publications devoted to this topic.

Conclusion: This therapeutic attitude enables early verticalisation avoiding the complications related to the bedridden state in the elderly. In addition, subsequent revision for osteonecrosis of the femoral head or post-traumatic deterioration can be avoided. These results have incited us to pursue this therapeutic option.


A. Veil-Picard L. Sedel P. Bizot

Purpose: The purpose of this work was to analyse different techniques and outcome of total hip arthroplasty for acetabular degeneration after orthopaedically or surgically treated fracture of the acetabulum.

Material and methods: This retrospective analysis of a consecutive series was conducted by an independent observer. Sixty-four arthroplasties in 63 patients performed between 1979 and 2000 were included. Twenty-eight acetabular fractures had been treated surgically and 36 orthopaedically. Five types of cups were implanted (25 cerafit, 3 cerapress, 17 cemented alumina, 11 screwed, 7 polyethylene). All patients were assessed preoperatively and at last follow-up with the Merle d’Aubigné clinical scale. The postoperative and last follow-up radiograms were assessed according to Charnley and De Lee. Operative difficulties were assessed in terms of operative time, blood loss, and analysis of the operation reports. Actuarial survival was calculated.

Results: Mean follow-up was five years two months. Six patients were lost to follow-up early. Clinical outcome was satisfactory with significant improvement in the Merle d’Aubigné score. The 10-year survival rate was 81% taking aseptic loosening as the endpoint and 74% taking surgical revision as the endpoint. Operative time and blood loss were significantly related to loss of ace-tabular bone stock and to operator experience (p < 0.05). Survival was significantly related to acetabular bone defect (p < 0.05). There was no difference between the treatment modes used for the initial acetabular fracture for peroperative difficulty or survival.

Discussion: Total hip arthroplasty for acetabular degeneration secondary to acetabular fracture has given good functional results. Long-term survival is below that for primary arthroplasty, the only unfavourable factor identified being loss of acetabular bone stock. The surgical procedure is more difficult and requires a certain experience. We did not find any difference related to the type of treatment (orthopaedic or surgical) used for the initial acetabular fracture. It was difficult to interpret the influence of cup type due to the wide range of cups used in this series.


P.Y. Glas Y. Vallese J.P. Carret J. Bejui-Hugues

Purpose: Twenty-one total hip arthroplasties after ace-tabular fracture were reviewed at a minimum two-year follow-up. The purpose of this analysis was to study operative difficulties and complications in implanting a total hip arthroplasty on a sequelar acetabulum.

Material and methods: Ten acetabula had been treated surgically and eleven orthopaedically. Mean time interval between the initial trauma and the arthroplasty was 14 years (range 2 – 36). The posteriolateral approach was used in thirteen cases and the anterolateral approach in eight. Osteosynthesis material was totally removed in two patients and partially in three. Arthrolysis was performed in one patient who had grade IV heterotopic ossifications. Most of the cups were hydroxyapatite coated uncemented cups; two cups were cemented in a Postel Kerboul ring.

Results: An autologous graft was required for nine of the eleven orthopaedically treated fractures versus two of the ten surgically treated fractures (p < 0 .05). Mean operative time was 136 minutes and mean blood loss was 1200cc. Postoperative complications included one superficial phlebitis, one infraperitoneal bladder wound, one superficial haematoma, one incomplete popliteal palsy, one dislocation and two heterotopic ossiications (1 Brooker I and 1 Brooker IV). At review, the mean Postel Merle d’Aubigné score was 16.5. Radiologically there was no evidence of loosening or defective fixation.

Discussion: The operative difficulty was basically encountered in the group of orthopaedically treated acetabular fractures due to the callus (protrusion of the femroal head into the ovalised acetabulum. For these cases, an autologous graft was indispensable for reconstruction or defect filling (82% of the cases) to avoid excessive medialisation of the cup. For the fractures treated surgically, the osteo-synthesis material was only removed when it prevented proper cup position. An autologous graft was used to fill defects (18%) (wall or roof necrosis). Cup insertion without cement is the rule for first-intention treatment in these young patients, the supporting ring being used when required for second-intention treatment.


J. Tonetti J. Cazal A. Eid T. Martinez S. Plaweski P. Merloz

Purpose: This study analysed nerve trunk injury associated with posterior fractures of the pelvic girdle, distinguishing initial post-trauma damage from morbidity correlated to treatment by reduction and iliosacral screw fixation.

Material: Fifty bone or ligament injuries to the posterior pelvic girdle were identified in 44 patients. Management included initial external reduction and differed fixation using iliosacral screws inserted under fluorescence guidance.

Methods: The metameric examination of the lumbar and sacral trunks (L2, L3, L4, L5, S1, S2, S3) was performed at admission when the patient was conscious. The postoperative work-up included a complete neurological exam and computed tomography assessment of the screw trajectory. The quality of the reduction was quantified on the anterioposterior view of the pelvis. At last follow-up, evolution of symptoms ± EMG, Trendenburg gait, Mageed score, QMS score and pain (assessed on a visual analogue scale) were recorded.

Results: Preoperatively, 14 deficits of the nerve trunks were identified. The neurological status was unknown for eleven bone and ligament injuries because the patients were sedated at admission. Postoperatively, 28 deficits were identified. Fourteen (50%) involved the lumbosacral trunks L4 and L5, five the S1 root, six L4, L5, S1 territories, and three L5 to S4.

Computed tomography demonstrated 15 extraosseous screws lying anteriorly to the sacral ala or in the sacral canal. These extraosseous screws were associated with neurological deficits in nine cases without a preoperative diagnosis. In six cases, the extra-ossesous screw was not associated with any postoperative deficit. In five cases, neurological lesions diagnosed after the operation were not associated with an extra-osseous screw. Twenty-six neurological lesions were reviewed at a mean follow-up of 25 months: improvement was observed in 19, no change in five and aggravation in two.

Conclusion: Initial diagnosis of neurological injury with precision of the localisation can be established for only half of pelvic girdle fractures. The main mechanism involves stretching of the lumbosacral trunk by displacement of the sacral ala. Injury to the superior gluteal nerve is often associated. Closed reduction or compression of a nerve trapped in the fracture gap during screw fixation could be a second mechanism. Finally, rigorous screw insertion is necessary to avoid extra-osseous trajectories lying anteriorly to the sacral ala.


P. Beaule J. Matta

Purpose: The surgical approach is an essential element for precise reduction and rigid fixation of fractures of the acetabulum. In cases where the anterior column is mainly involved and total hip arthroplasty (THA) is indicated, classical approaches do not allow double assess to the anterior column necessary for reduction and fixation and to the femoral canal for insertion of the prosthesis. Combining Heuter’s anterior approach and Letournel’s ilio-femoral approach provides access to the anterior column and to the often associated posterior hemi-transverse fracture, while allowing insertion of the total hip prosthesis.

Material and method: This combined approach was used for ten among 60 THA performed for fracture of the acetabulum. Seven were primary procedures and three were differed reconstruction procedures. Mean patient age was 60.6 years (range 50 – 85 years). Fracture types were: acetabular wall and anterior column (n=8), anterior column and posterior hemi-transverse (n=2). All fresh fractures exhibited major acetabular damage associated with fracture of the femoral neck. A hybrid THA was used for all cases after fixation of the fracture. The femoral heads were used as graft material for deficient anterior columns in two patients and as “piecemeal” grafts for the others.

Results: Mean follow-up was 36 months (range 24–35 months). At last follow-up all fractures had healed and all acetabular components exhibited solid fixation with no sign of migration. The mean outer diameter of the ace-tabular components inserted was 56 mm (52–64) using a 2 mm press-fit and one screw. The only complication was one postoperative anterior dislocation. Pain relief and function were satisfactory in all patients at last follow-up with a Postel Merle d’Aubigné score of 16 (13–18).

Discussion: This anterior surgical approach enables good access to the acetabular walls and anterior columns, allowing solid fixation and relatively easy THA. The Kocher-Langenbech approach is still better in case of posterior deficiency or when posterior fixation requires space for inserting an acetabular component. We reserve it for THA used to treat fresh fractures of the acetabulum with major damage to the acetabulum and/or the femoral head, with or without neck fracture in patients aged 55 years or more. For differed reconstruction, we also use this approach if the acetabular damage involves the anterior column.


M. Szpalski R. Gunzburg J.P. Hayez N. Passuti

Purpose: Healing may be problematic after lag screw osteosynthesis of pertrochanteric fractures in osteoporotic bone due to the greater risk of defective fixation. Acrylic cement has been proposed to reinforce the fixation of the lag screw in these patients, principally to avoid the risk of cutout, but the acrylic cement’s thermal toxicity, its poor biocompatibility, and the difficult manipulation are important drawbacks. Cortoss® is a new composite biomaterial composed of bisphenol-aglycidly (bis-GMA) which could be an attractive alternative to classical cements. Cortoss is an injectable material with mechanical properties similar to human cortical bone. The purpose of this clinical study was to describe the new method for injection the material and to assess the anchoring force and safety of Cortoss in osteoporotic patients undergoing surgical fixation of pertrochanteric fractures.

Material and methods: This prospective study was approved by the local ethics committee. Twenty consecutive patients aged 70 years or more with pertro-chanteric fracture were included. The lag screw was inserted under fluoroscopic guidance, and the maximum insertion torque was measured. The screw was then unscrewed seven turns (length of the threaded head), and 2.5 cm Cortoss was injected via a polyimide catheter measuring 2.5 mm in diameter. The screw was then rescrewed in place to a troque 30% above that measured without Cortoss

Results: Eighteen women and two men, age 70 – 96 years, gave their informed consent to participate in the study. Mean maximal insertion torque without Cortoss was 1.23 Nm (min 0, max 4.8 Nm), which was increased 30% with Cortoss. Posto-operative x-rays showed that the screw head was embedded in an envelope of Cortoss and that the Cortoss had diffused into the adjacent bone. There were no adverse effects.

Discussion and conclusion: Cortoss provided effective reinforcement of the fixation as demonstrated by the higher insertion torque. Cortoss can also increase the mechanical resistance of the screw-cancellous bone interface, limit fixation default, and reduce secondary displacement of the lag screw in patients with osteoporotic bone. Improved stability can also reduce immobilisation time and facilitate bone healing without increasing the risk of secondary displacement and subsequent morbidity. Due to its safety, easy use, and efficacy, Cortoss provides a better alternative than acrylic cement for reinforcement of lag screw fixation of porotic bone.


P. Collin P. Brasseur J.C. Lambotte H. Thomazeau Q. Nguyen F. Langlais

Purpose: A spacer can be used for two-phase replacement of an infected total hip prosthesis. The goal is to facilitate reimplantation by avoiding soft tissue retraction. Several types of spacers can be used. We searched for a spacer which avoids wear debris due to methacrylate friction against bone, delivers a local antibiotic, is easily removed, and does not worsen bone damage. Since 1995, we have used a Charnley Kerboull type prosthesis as a spacer. The purpose of the present study was to 1) verify the absence of spacer-related complications, 2) assess outcome in terms of cure of infection and improved function.

Material and methods: We used 14 articulated spacers for two-phasee prosthesis replacement in nine men and five women, mean age 64 years. Erythrocyte sedimentation rate was 32 and C-reactive protein was 17. The mean Postel-Merle d’Aubigné (PMA) score was 3+5+2. All patients were reviewed at a minimum 37 months follow-up. Technique: The approach was generally a digastric trochanterotomy, associated with a more or less extensive femoral procedure (depending on the length of the plug to remove) to achieve removal of all implants and cement. A small-size polyethylene cup was inserted with cement delivering at least one antibiotic on a Surgicel bed to facilitate later extraction. A long small-diameter femoral stem was then inserted (bridging the femoral window) and blocked with cement, also on a Surgicel bed. Partial then total weight bearing was authorised between the phases.

Results: There were no dislocations. All patients achieved total weight bearing between the two phases. The same germ identified at the first operation was also identified at the second in two patients, requiring prolonged antibiotic therapy. There was one septic failure, in a different patient. The mean PMA score was 5.7+5.8+5.2.

Conclusion: This technique avoids methacrylate wear induced by classical spacers and does not modify polymorphonuclear chemotactism, facilitating the efficacy of medical treatment. Patient comfort is also improved between the two phases and muscle atrophy, which could compromise long-term function, is avoided.


D. Waast V. Goudiot E. Caremier S. Touchais N. Passuti F. Gouin

Purpose: We report a retrospective monocentric evaluation of surgical lavage for early infection(≤ 30 days) after total hip arthroplasty.

Material and methods: Thirty-four patients, mean age 67.8± 12.1 years) who developed grade II infection in the Gustillo and Tsukayama classification were treated between 1992 and 1995 by surgical debridement and adapted antibiotherapy for a limited duration. Arthroplasty was indicated for primary hip degeneration (n=17), secondary hip degeneration (n=11), or neck fracture (n=6). There were 25 first-intention arthroplasties and nine revision arthroplasties. Seventeen patients had risk factors for infection.

All patient were followed for at least four years. Therapeutic efficacy was assessed on the basis of clinical and laboratory findings and radiographic results. We searched for biological or bacteriological factors predictive of good outcome. The chi-square test and Fisher exact tet were used to compare population distributions and Student’s t test and Mann Whitney test to compare means.

Results: Mean follow-up was five year, 74% of the patients developed recurrent infection. A second treatment protocol was implemented for only 56% of these patients and was effective against the infection and satisfactory for functional outcome (28% of the patients underwent revision for extraction of the prosthesis and 16% were given continuous antibiotics). There was a significant difference in the efficacy of the surgical lavage for delay ≤ 21 days (p = 0.02). Statistical analysis suggested the type of germ (p = 0.006), and presence of risk factors (p= 0.0052) had a significant influence.

Discussion: Attractive because minimally invasive, surgical lavage appears to limit acute symptoms without eradicating infection. Furthermore, if the failure is recognised late after infection has become chronic, the efficacy of revision is compromised and may lead to poor mid-term function. Like other authors, we identified delay to treatment as the one significant factor. These poor results have incited us to limit indications for surgical lavage to cases of infection diagnosed very early, programming secondary revision for very debilitated patients. Close and prolonged follow-up is indispensable.


G. Pietu D. Waast M. Barrera L. Bigotte F. Gouin J. Letenneur

Purpose: Shaft fractures are not uncommon in elderly subjects who have proximal osteosynthesis material. There are several options for the surgical technique and the fixation method, the choice depending on their aggressiveness.

Material and methods: Between January 1998 and January 2002, retrograde nailing with proximal locking using the fixation screws already in the femur was used for eight women aged 79–99 years (mean 92). The classical ascending nailing procedure was used to insert a Russell-Taylor nail in six patients and a supracondylar Stryker nail in two. The proximal locking was used by apposing the fixation screw, which implied coinciding the locking holes in the nail with the plate screws. This required using only one screw for locking in some cases because of the distances between the holes.

Results: There were no infectious complications. Fracture alignment was correct in all cases. Subjectively, total recovery of motion and independence was achieved. Likewise for pain relief although assessment was difficult. Bone healing was achieved in four months. Secondary varus displacement occurred due to insufficient hold of the proximal locking screw in the medial cortical.

Conclusion: Although not perfect, the retrograde nail locked in the proximal implant provides a satisfactory solution for these often debilitated elderly patients. This option enables a minimally aggressive operation allowing a composite osteosynthesis protecting the entire femur without imposing points of peak stress.


V. Gaudio D. Waast S. Touchais F. Gouin N. Passuti

Purpose: We studied a consecutive multicentric series retrospectively to assess outcome after one-stage revision total hip arthroplasty without cement for infection-related failed total hip arthroplasty in patients with chronic infection (> 30 days).

Material and method: Thirty-four patients (12 women and 22 men) underwent primary arthroplasty between 1992 and 1998. Mean age was 67.8 years (range 45 – 89). Indications were primary hip degeneration (n=17), neck fracture (n=5), secondary hip degeneration (n=12). Twenty-two patients had risk factors for infection. The same treatment protocol was used for all patients: single-phase replacement of the infected implant with insertion of a hydroxyapatite coated implant without cement and a three-month antibiotic regimen adapted to intraoperative samples. Seven femorotomies were performed. Clinical, laboratory and radiological findings were used to assess outcome. Patients were considered to be cured when laboratory tests were normal and x-rays showed no signs of suspected complications.

Results: There were three failures and 31 successful revisions. Intraoperative fracture of the femur required osteosynthesis in six patients. five patients developed a drug-related complication. Isolated germs were: meticillin-sensitive staphylococcus (n=18), meticillin-resistant staphylococcus (n=6), multiple germs (n=2), other germs (n=6), undetermined (n=2). The three failures occurred in patients with meticillin-resistant staphylococcal infections.

Discussion and conclusion: Our 88% success rate is in line with data in the literature. For us, one-phase revision is the best first intention option: other techniques may be required for patients with severe infections, after failure of one-stage revision, or massive loss of bone stock. Based on the present results, we have continued to prefer this therapeutic option but long-term follow-up is needed to further support these early findings.


J.C. Chatelet L. Setiey

Purpose: Exposure to polyethylene debris and bearing wear is a common feature of total hip prosthesis inserted with or without cement. Osteolysis depends on the number of particles involved and their size. This continuous series of total hip arthroplasties using a Corail prosthesis with 12 years follow-up was studied to assess the course of osteolysis around the prosthesis and the resistance of hydroxyapatite coated implants to the aggression of wear debris.

Material and methods: One hundred fifteen patients underwent total hip arthroplasty in 1989 with a Corail prosthesis implanted by the same operator with a metal backed cup and a polyethylene insert. Mean age at implantation was 65 years. Review radiograms were available for 80 patients (38 women and 42 men). Twenty-seven patients had died, five answered a phone interview and three were lost to follow-up. The follow-up was 12 years and analysis was performed on the population with review data and x-rays.

Results: There was no case with a loosened stem and none of the patients underwent revision. Twelve cups were however revised for loosening with granuloma. Polyethylene insert wear was seen in 62% of the cases. There was a relationship between the amount of wear debris and the extent of the gramulomas on the femur. These granulomas were basically observed in zones I and VII. Bone defects were curetted and filled with grafts for the 12 cup revisions. The cup bearing was changed in young patients. Good bone healing was a constant finding on follow-up x-rays.

Discussion: Hydroxyapatite coated prostheses exhibit good long-term resistance to wear debris which causes osteolysis since none of the Corail femoral stems were destabilised. The granulomas remain localised in the proximal zone and do not descend along the stem or the cement as seen in cemented prostheses. The intimate contact between the recipient bone and the implant appears to form a barrier against migration of wear debris. It thus appears important to achieve good contact all along the stem and to use a totally hydroxyapatite coated implant.

Conclusion: Total hip arthroplasty without cement is spared the problem of polyethylene wear debris, but debris must be limited to prevent osteolysis. This observation questions the long-term appropriateness of metal-backed cups with polyethylene inserts and suggests that low friction arthroplasty or use of a hard bearing couple (Cr-Co-Cr-Co or alumina-alumina) should be preferred.


L. Pidhorz P. Ridreau C. Cadu

Purpose: The long-term outcome of the Harris-Galante 1 (HGP1) stem is a controversial issue. A randomised study reported by Thanner (AOS 1999) mentioned a 72% survival at ten years, basically related to femoral osteolysis observed in 18% of the cases with mechanical failure requiring revision in 20%. We studied the clinical and radiological outcome of 191 HGP1 stems reviewed at a mean 12.5 years.

Material: This prospective study included a consecutive series of 181 patients (191 hips) 101 men and 80 women, mean age 62.1 years (range 19–83). Indication for arthroplasty was primary hip degeneration (80%), or osteonecrosis (14.6%). A metal-backed polyethylene cup and a 28 mm head were inserted in 86% of the cases. At review, 41 patients had died (43 hips), two were lost to follow-up, and x-rays were available for 109. Mean follow-up was 150.2±15.3 months.

Methods: The Postel Merle d’Aubigné (PMA) and Harris (HHS) scores were recorded for all patients. Position and quality of bone fixation were analysed. Stem migration was calculated on the different x-rays by calculating the distance between the centre of the head and the summit of the greater trochanter. Lucent lines (Gruen), osteolysis and the ARA score were noted. The SOFCOT 1997 radioclinical classification was used. Actuarial survival curves were plotted taking stem revision as the endpoint. Quantitative data were compared with the chi-square test.

Results: One patient died on day three. There were three displacements. The PMA pain score improved from 2.5 to 5.6 and the HHS improved from 52.5 to 85.6 points. The stem was perfectly aligned in 80 cases, and presented a varus deviation ≤ 3° in 26 cases. A change in the initial alignment was noted in three cases and stem impaction in 14. Eleven revisions were necessary for fibrous fixation (n=5), pain (n=2), femoral malposition, (n=1), fracture of the femur during the operation (n=1, and diaphyseal osteolysis (n=1). Finally, there were no radiographic anomalies for 69 hips (class A), radiographic anomalies without clinical expression for 34 (class B), basically because of severe osteolysis of the calcar (n=6), and stress shielding in zone 1A-B. Three hips caused pain without a detectable radiographic anomaly (class C), only one hip was in class D because of the poor clinical and radiological result. The 15-year actuarial survival taking stem revision as the endpoint was 89.5±3.7%.

Discussion: The 5% rate of unstable fibrous fixation observed in this series is very different from the 16% reported by Garcia Cimbrelo (2001). There was only one case of femoral shaft osteolysis limited to zone 3 which required revision, contrasting with the 16% (Thanner) and 24% (Garcia Cimbrelo) reported for shorter follow-ups.

Conclusion: With an 89.5% mid-term survival, the Harris Gallante 1 femoral stem has provided good clinical results and a solid fixation due to the proximal porous coating on the titanium. Although rare, stem failure was observed during the first six years of implantation.


L. Pidhorz C. Dau P. Ridereau

Purpose: According to the Finnish registry, the ABG1 stem has a 94% survival (90–98) at seven years. A multi-centric study in Torino found 99% survival at five years. These studies have however reported worrisome radiographic images showing absorption of the calcar in 27% of the cases. We studied the clinical and radiological outcome of 102 ABG1 stems inserted between September 1990 and December 1996.

Material: This prospective study included 91 consecutive patients (102 hips): 75 men and 27 women, mean age at surgery 63.1 years (range 34–81). The posterior approach was used for treatment of degenerative joint disease (82%) or osteonecrosis (11%). A size 5 or 6 stem was inserted in 60% of the cases. A metal-backed cup with a polyethylene insert was used in 45%, a zircona cup in 55%. The head diameter was 28 mm in 91% of the cases. At review, five patients had died, ten were lost to follow-up, eight responded to a phone interview, and x-rays were obtained for 79. Mean follow-up was 90.6 months (median 86.4 months).

Methods: The Postel Merle d’Aubigné (PMA) and Harris (HHS) scores were recorded for all patients. Position and quality of bone fixation were analysed. Stem migration was calculated on the different x-rays by calculating the distance between the centre of the head and the summit of the greater trochanter. Lucent lines (Gruen), osteolysis and the ARA score were noted. The SOFCOT 1997 radio-clinical classification was used. Actuarial survival curves were plotted taking stem revision as the endpoint. Quantitative data were compared with the chi-square test.

Results: The PMA pain score improved from 2.9 to 5.7 and the overall PMA score from 11.2 to 15.7. The HHS at last follow-up was 83.6 points. The stem was perfectly aligned in 81 cases, showed varus deviation in 26 and valgus deviation in four. A change from the initial alignment was noted in three cases and stem impaction in two. Six stem revisions were required for malposition (n=1), fracture during operation (n=3), or pain (n=2). Finally, there were no radiographic anomalies for 53 hips (class A), radiographic anomalies without clinical expression for 17 (class B), pain without detectable radiographic anomaly for six (class C), and poor clinical results with radiographic anomalies for four (class D). The ARA score was 5 or 6 in 51 cases. The 15-year actuarial survival rate was 88.9±4%.

Discussion: The form of the ABG1 implant allows an excellent alignment in only 80% of the cases. The metaphyseal anchor is achieved by bone remodelling of the calcar (23 atrophies including 10 severe cases)—to be differentiated from osteolysis (8 cases)—and an excessively transparent femur in the proximal 1A, B and 7 (12 cases). Transmission of force to the diaphyseal zone remains abnormal (30 thickenings with four overall thickenings) and two severe cases of diaphyseal necrosis.

Conclusion: The changes in the design of the ABG2 which has an under-dimensioned stem should improve shaft remodelling. The form of the implant and the favourable effect of hydroxyapatite coating responsible for bone remodelling in zone 1 and 7 (Gruen) should be given particular attention in the upcoming years.


G. Gacon M. Philippe A. Ray.

Purpose: The purpose of this work was to study the radiological outcome more than seven years after implantation of 89 anatomic non-cemented femoral stems with hydroxyapatite coating around the metaphyseal circumference.

Material: These 81 patients underwent primary arthroplasty (89 hips) between 1991 and 1994 for joint degeneration or necrosis: 48 men and 33 women, mean age 59 years (range 41–78). The inclusion criteria for this study were physical examination and complete radiographic work-up in the second half of 2001. Mean follow-up was nine years (range 7–10).

Methods: All x-rays were analysed by four independent surgeons who used the Engh and Massin criteria. The evaluators, who had not participated in patient care, made their assessment on the basis of the last follow-up clinical report and x-rays. They search for radiographic evidence of stem stability and bony integration as well as signs of osteolysis using the Gruen criteria.

Results: At last follow-up only one femoral stem was painful, but stable. This stem was revised at seven years. Six cups had been changed due to polyethylene wear with iliac osteolysis but without femoral participation. There were no other reoperations. Polyethylene wear was observed in about one-half the hips (44 hips) and was considered severe (1–2 mm) in nine cases. There were no lucent lines nor reactive lines in the metaphyseal area (zones 1 and 7) but 16% of the hips presented reactive lines along the lower, smooth, part of the stem. Endosteal ossification was observed in zones 2 and 6 in 72% of the hips, and less often (13%) in zones 9 and 13. Five hips (5.6%) exhibited bony growth at the tip of the stem producing a thickening in zone 5; these were the only cases with cortical thickening excepting the revised stem (thickening in zones 2 and 6). There was no case of cortical narrowing. Calcar atrophy was observed in 42 hips (47%) with five showing a “drop” aspect. Four hips exhibited osteolysis of the proximal femur in zone 1A, but there were no images of distal osteolysis of the femur.

Discussion: This independent analysis of 89 x-ray files demonstrated that endosteal growth is frequent in the isthmic region. The radiological tolerance was good for this stem (no cortical changes) but there were modifications of the calcar which were difficult; it could be speculated that certain of these modifications might correspond to localised osteolysis at the lowest part of the joint, migration point of polyethyene debris. The role of hydroxyapatite in the observed absence of distal osteolysis is noteworthy.

Conclusion: At nine years follow-up, the absence of osteolysis of the distal femur despite usual polyethylene wear allows the conclusion that hydoxyapatite coating of the metaphyseal circumference creates an effective barrier against wear debris.


T. Fabre I. Bébézis J. Bouchain F. Farlin J. Rezzouk A. Durandeau

Purpose: Meralgia paraesthetica is usually caused by entrapment of the lateral femoral cutaneous nerve (LFCN) at the inguinal ligament. We present our experience with 114 patients who underwent surgical management for meralgia paraesthetica.

Material: We reviewed 114 patients (48 men, 66 women, five bilateral cases) who underwent surgery for meralgia paraesthetica between 1987 and 1999; local anaesthesia was used for neurolysis in most cases. We identified five aetiologies: idiopathic (n=69, three bilateral), abdominal surgery (n=19), iliac graft harvesting (n=12, one bilateral), hip surgery (n=7), trauma (n=7, one bilateral).

Methods: We analysed outcome at more than two years follow-up for the entire series and by aetiology using a standard 12-point evaluation scale accounting for residual pain, sensorial disorders, and patient satisfaction.

Results: The overall results were good, mean score 9/12 (range 1–12). Ninety-two patients were very satisfied or satisfied. Among the 27 patients who were not satisfied, five developed recurrence. Mean time to full pain relief was 70 days (range 1 – 364 days). Recovery of thigh sensitivity was noted at 128 days (range 1 – 364).

Discussion: The essential criteria of poor prognosis were duration of the meralgia before surgery and its aetiology. Neurolysis of an LFCN injured by trauma or iliac graft harvesting provided less satisfactory results (scores 7 and 6 respectively) than for idopathic meralgia paraesthetica or abdominal-surgery injury (scores 9 and 10 respectively). Eight of the neurolysis procedures in this series did not provide satisfactory results (score 5).

Conclusion: Neurolysis appears to be the surgical treatment of choice for mearlgia paraesthetica. In skilled hands, neurolysis can be performed under local anaesthesia, although certain difficulties can be encountered: obesity, modified anatomy due to prior operations, nerve variability (frequent). Knowledge of these different elements is essential not only to achieve neurolysis but also prevent iatrogenic injury.


J. Caton P. Reynaud Z. Merabet

Purpose: Between 1979 and 2000, we performed 115 total hip arthroplasties with a bone block, mainly for degenerative hips secondary to congenital dislocation. Up to 1992, we used the classical bone block fixed with a screw and a cemented all-polyethylene Charnley cup inserted in the paleoacetabulum. The drawback of this technique was the two-month delay required for bone healing before weight bearing could be attempted. Since 1992, we have modified this technique, using an embedded bone block impacted into the dihedral angle between the capsule – neoacetabulum and the non-cemented press-fit cup with a screw in the paleoacetabulum. This method allowed immediate postoperative weight bearing, just like after first-intention total hip arthroplasty.

Material: Between 1992 and 2002, we operated 56 patients (63 hips) using this technique, 50 (56 hips) were reviewed at a mean five years (range 1 – 9.5). Three patients had died (three hips) and three (four hips) were lost to follow-up. The purpose of this work was to check integration of the bone block and absence of acetabular complications related to early weight bearing. Mean age at surgery was 58.5 years (range 17 – 88). There had been one earlier intervention for 17 hips, two for 13 and three for four.

Methods: Physical examination and standard x-rays (AP, lateral, Lequesne oblique views) were available at last follow-up. In addition to the radiographic assessment of the bone block, the Postel Merle d’Aubigné (PMA) objective clinical score and subjective patient satisfaction were recorded.

Results: The mean PMA score was 11.7 preoperatively and 17.6 at last follow-up. Ninety-four percent of the patients were very satisfied or satisfied, 6% were dis-satisfied (three postoperative dislocations). Radiographically, we noted block lysis (n=1), non-integrated block (n=8), perfect osteointegration (n=47). The cup showed no radiographic sign of ascension. There were two lucent lines in zone 1 (14.8%) and three in zone 3 (16.8%). There was no relation between bone block integration and presence of acetabular lucent lines. Four complications were recorded: one loosening at eight months, one sudden loosening treated by changing the cup, and three dislocations including one treated four years after implantation by anti-dislocation crescent. There was no relationship between complications and block behaviour.

Discussion: The advantage of the embedded block technique with a hybrid prosthesis using a metal-backed polyethylene cup (22.225) is that the postoperative rehabilitation is the same as after a standard prosthesis in good position. Immediate weight bearing on the press-fit cup without cement did not lead to deleterious complications whether clinically or for bone block behaviour.

Conclusion: This technique is a reliable method allowing early weight bearing and a shorter recovery time with satisfactory cup stability.


M. Hamadouche M. Mathieu G. de Pineux V. Topouchian J.P. Courpied

Purpose: The cause of Paget’s disease, osteitis deformans, defined by increased bone resorption followed by excessive attempts at repair, remains unclear. The current hypothesis is that bone is slowly infected by paramyxovirus in genetically predisposed patients. We report the case of a patient with monostotic Paget’s disease of the pelvis which was transferred to the homolateral distal femur after total hip arthroplasty.

Case report: A 66-year-old man with Paget’s disease of the hemi-pelvis developed pagetic hip deformation requiring a total hip arthroplasty performed in 1993. A Charnley-Kerboull cemented prosthesis was implanted. The medullary canal was plugged with fragments of cancellous bone harvested from the acetabulum (drill holes required to achieve rotatory stability of the acetabulum). One year later, an asymptomatic osteolytic lesion of the distal femur was identified at the level of the medullary plug. Hip function remained excellent despite extension to the distal and proximal femur. All inflammatory parameters were normal and the femoral component was not loosened. 99m-technetium scintigraphy revealed strong uptake in the pelvis but also in the distal femur under the femoral stem. Isolated femoral stem revision was performed in 1996 as a preventive measure against stress fracture. Pathology analysis of surgical specimens identified Paget’s disease (osteoclast hyperactivity, mosaic aspect of the osteoblasts. After femoral revision with a long stem and medical treatment with biphosphonates, the osteolytic lesion disappeared progressively, taking on the classical sclerous sequelar aspect of osteitis deformans. The disease remained quiescent six years after revision. Hip function remained excellent at last follow-up.

Discussion and conclusion: This is the first report of this type of complication after total hip arthroplasty. This observation that Paget’s disease can be transferred via a autologous cancellous bone graft is in favour of the viral hypothesis, suggesting osteoclastic infection by contiguity. This complication has never been observed with frozen or radiated allograft material although such material may have been harvested from pathological bone, notably with Paget’s disease


X. Flecher E. Ryembault J.M. Aubaniac

Purpose: Hip prosthesis for sequelar developmental dysplasia of the hip is a therapeutic challenge because of the anatomic deformity and the young age of the patients. The purpose of this work was to report results obtained using a non-cemented femoral stem with an intramedullar design and a prosthetic neck custom-made to match individual anatomy observed on preoperative computerised tomographic.

Material and methods: This study included 257 hips with a mean follow-up of 5.6 years. Mean age at implantation was 55 years (range 17–78). The computed tomography study assessed: dislocation according to Crowe, leg length discrepancy, and acetabular anteversion and diameter. The cup was not cemented and was inserted with an anchor hook in the obturator foramen for implantation in the paleoacetabulum. The medullary canal was prepared using a blunt reamer shaped like the definitive prosthesis. The prosthetic neck was designed individually to match the lever arm and anteverion.

Results: There were 174 cases of dysplasia and 83 dislocations (39% grade 1, 30% grade 2, 14% grade 3 and 17% grade 4). Mean lengthening was 39 mm. The mean ante-verion was 28±16° and the mean anteroposterior diameter of the acetabulum was 51 mm. The Harris clinical score improved from 58 points preoperatively to 93 points at last follow-up. The follow-up x-rays showed osteointegration in 88% of the cases with osteolysis in 5% and one stem impaction. The prosthesis had to be changed for six hips: two for infection, one for dislocation and two for nonfixation. The 11-year survival rate was 97%.

Discussion and conclusion: This study illustrates the anatomic sequelae observed in patients with developmental dysplasia of the hip and demonstrates a surgical solution for these problems. There is no correlation between dislocation and the degree of anteversion so it is difficult to assess the difficulty of inserting a non-cemented stem without preoperative computed tomography. The good 11-year survival is encouraging for this young and active population.


P. Beaule M. Leduff F. Dorey H. Amstutz

Purpose: Removing a non-cemented cup can increase operative morbidity destroying bone stock. Data are thus needed concerning the long-term behaviour of non-cemented acetabular implants left in place after revision of the femoral component of a total hip arthroplasty.

Methods: We studied clinical and radiological outcome at five and fifteen years in a consecutive series of 83 patients (88 hips) with a non-cemented acetabular implant that was left in place after revision of the femoral component of a total hip arthroplasty. Mean age of the patients at revision surgery was 54 years. Two types of acetabular implants had been used: 69 titanium screen and 19 with a porocoat surface. All revisions were performed for isolated loosening of the femoral component. At revision, 33% of the patients had an osteolytic acetabulum and 52% had a bone graft.

Results: At mean follow-up of 7.5 years after revision (acetabular implants in situ for 11.6 years on the average), the mean UCLA function scores, preoperatively and at last follow-up were, respectively, pain 3.8 versus 8.9, gait 6.3 versus 8.4; function 5.8 versus 7.9; activity 4.8 versus 6.1. Six acetabular implants required a revision procedure at 7.5 years (mean, range 2 – 14 years) after the femoral revision (acetabular implants in situ for 13.3 years on the average) or acetabular loosening (n=1), conversion to a metal-on-metal bearing (n=1), and for repeated dislocation and infection (n=1). There were no hips with recurrent or worsening osteolysis.

Discussion: The duration of implantation or prior revision would not appear to be sufficient to justify removing a non-cemented acetabular implant. Presence of osteolysis does not appear to affect long-term fixation of the non-cemented acetabular implant after femoral revision. We recommend removing the acetabular screw at revision in order to correctly assess the component’s fixation.


G. Brunelli

Purpose: Carpal instability with scapho-lunate dissociation is still considered to result from the rupture of the so-called scapho-lunate (SL) ligament. Actually, this is not a ligament but a loose capsule allowing flexion of the scaphoid and lunate of very different magnitudes (92° versus 20°. Reconstruction of the SL “ligament” have often provided very disappointing results.

Material: Sections of the SL “ligament” on cadaveric specimens never produce SL dissociation. This dissociation can only occur if the scaphoid remains well-positioned in the articular facette of the radius. Rotory subluxation is possible only if the scapho-trapezotrapezoidal is cut, which allows posterior displacement of the scaphoid. This ligament is not described in anatomy textbooks because it is hidden by the sheath of the palmaris longus. Posterior luxation of the proximal pole of the scaphoid is required for dissociation from the semi-lunate.

Operative method: A reconstruction method for the volar scaphotrapezoid ligament using a band of the flexor carpi radialis tendon was developed on cadaveric specimens before application in 38 patients. The 7-cm band of the palmaris longus tendon, with an intact metatarsal attachment was passed through a tunnel drilled in the distal pole of the scaphoid. The band was then pulled dorsally (correctly positioning the scaphoid) and sutured to the dorsoulnar border of the radius.

Results: Carpal height was restored as was scaphoid-lunate mobility (flexion in radial deviation, extension in cubital deviation). The reduction was maintained at mid- and long-term with prevention of carpal collapse and arthritis. Among the 38 operated patients, 35 achieved full pain relief, three complained of moderate pain under stress. All patients were satisfied.

Discussion: Anatomic research and clinical results confirmed that the scaphotrapezoidal ligmament is the key element for dissociation and its repair.

Conclusion: This operation is currently the only procedure capable of providing easy and definitive repair of carpal instability with scapho-lunate dissociation.


J.N. Goubier B. Bauer J.Y. Alnot

Purpose: Scaphotrapezotrapezoidal (STT) pain is common but often asymptomatic. Medical treatment may be proposed if symptoms become bothersome. In case of failure, several surgical solutions may be proposed. The purpose of this work was to assess outcome in a series of eleven STT arthrodeses performed for isolated STT osteoarthritis.

Material and methods: Ten patients, three men and seven women (11 hands), mean age 63 years, developed STT osteoarthritis which was treated by arthrodesis. All patients experienced pain for daily life activities and had diminished wrist movement. According to the Crosby radiographic classification, three were one grade I, four grade II, and five grade II with carpal misalignmen t. One patient had chondrocalcinosis and six had tendinitis of the flexor carpi radialis. The anterior approach was used for three patients and the lateral approach for seven. Nine patients had an iliac graft to fill bony defects resulting from anterior wear. Pin fixation was used in six cases and staple fixation in five. An antebrachiopalmar cast was maintained for at least six weeks after surgery.

Results: At mean follow-up of 62 months, the pain score improved in all patients (p=0.05). There was no significant difference in motion, excepting decreased wrist extension (12°, p=0.03). Grasp and pinch force were not modified by STT arthrodesis. All patients were able to resume their former recreational and occupational activities. There was no worsening of the five cases with intracarpial deaxation. Four patients developed non-union (three pin fixations, one staple fixation), which was symptomatic in only two. These patients underwent successful revision using the same fixation technique. There were no complications.

Discussion: Like other series reported in the literature, our series of STT arthrodeses demonstrated effective pain relief. However, unlike former work, we were unable to obtain a significant reduction in the radial inclination force, or radio-carpal conflict. The other therapeutic option is resection of the distal pole of the scaphoid which provides more rapid clinical results but which leads to inevitable misalignment of the carpus.

Conclusion: We have decided to retain STT arthrodesis with iliac graft for patients with STT osteoarthritis, especially for young patients.


A. Pierre D. Le Nen A. Saraux F. Chaise

Purpose: The pisitriquetral articulation can be a source of pain, particularly after trauma. If conservative treatment fails, pisiformectomy appears to be the best alternative. The purpose of this work was to assess clinical and functional outcome after pisiformectomy.

Material and method: Thirteen patients were reviewed 31.5 months (mean) after pisiformectomy. Two patients had a bilateral procedure giving 15 pisiformectomies. Occupation-related trauma was the principal cause. Four patients also had ulnar neuropathy. The same operative technique was used for all patients and a visual analogue scale was used to assess pain.

Results: There were no postoperative complications. At last follow-up, outcome was excellent in twelve cases, good in two and fair in one (n=15). Residual pain was scored a mean 0.8 points versus 6.4 points preoperatively (p< 0.001). Wrist motion was improved after surgery.

Conclusion: There are many causes of pisotriquetral disease, but trauma, or microtraum, predominates. Pisiformectomy is the best treatment after failure or deterioration of results of conservative treatment. It must be remembered however that pisotriquetral disease may be a revealing sign of a regional disorder that must be identified.


G. Polle P.Y. Milliez F. Duparc I. Auquit-Auckbur F. Dujardin

Purpose: The purpose of this study was to establish the map of the motor branches of the median and ulnar nerves of the forearm and to count the Martin-Gruber anastomoses. Knowledge of anatomic variability would be useful for hyponeurotisation surgery of the spastic hand. Variations in the antebrachial emergence of the six motor branches of the medial nerve and the three motor branches of the ulnar nerve were studied.

Material and methods: This study was conducted on twenty anatomic specimens obtained from five men and five women. We measured the length of the forearm and identified the origin of each motor branch of the medial and ulnar nerves using a horizontal line between the meidal and lateral epicondyles as the reference line.

Results: Mean length of the forearm was 26.93±2.6 cm. Unlike the origin of the superior and inferior pronator teres nerves, and the palmaris longus, flexor carpi radialis, and flexor digitorum superficialis nerves which were very variable (coefficient of variation 49%–113%), the origin of the anterior interosseous nerve of the forearm (CV=39%) and its branches, and the flexor pollicis longus nerve and the flexor digitorum profondus nerves (CV =23% and 29% respectively) were much more regular. The superior and inferior origins of the flexor carpi ulnaris nerve were variable (CV = 157 and 22%) while the origin of the nerves for the deep flexor of the IV and V fingers showed a better coefficient of variation (13%). We observed four Martin-Gruber anastomoses (20%).

Conclusion: This study demonstrated the wide anatomic variability of the medial and ulnar nerves both interin-dividually and intraindividually. Emergence of certain nerve branches appeared to be more regular, particularly the lower group of the median nerve and the anterior interosseous nerve of the forearm. It was however impossible to identify two groups exhibiting a statistically significantly greater frequency for the median nerve. The anatomic variations of the ulnar nerve were less pronounced. The inconsistency of the inferior flexor carpi ulnaris is noteworthy.


C. Baudon M. Chammas B. Coulet Y. Allieu

Purpose: We analysed outcome in a retrospective consecutive series of 30 Kapandju-Sauvé procedures performed between January 1993 and September 2000 for correction of antebrachial injuries (five patients) and distal radioulnar injuries (25 patients).

Material and methods: All patients (mean age 42 years) were reviewed by the same observer at a mean follow-up of 44 months. Mean time from initial trauma to surgery was 26 months.

Results: For the distal radio-ulnar injuries, the objectives were achieved (158° pronation-supination) with preservation of force (73% of healthy side). The Mayo Clinic functional score, as modified, was 72/100 at last follow-up and 24/25 patients were satisfied. For the ante-brachial injuries, outcome was slightly inferior: 110° pro-nation-supination, force 48% of healthy side, functional score 56/100, three out of five patients very satisfied or satisfied, resumed occupational activity in four out of five patients. There were however no cases with an unstable ulnar stump in this group.

Conclusion: This study confirmed the efficacy of the Kapandji-Sauvé procedure for the treatment of sequelae of distal radio-ulnar injuries, particularly in young patients. The novel indication for antebrachial injuries also provided satisfactory results after a simple procedure compared with shaft osteotomy of the two ante-brachial bones.


D. Hannouche T. Bégué D. Ring A.C. Masquelet J.C. Jupiter

Purpose: Post-traumatic instability of the elbow is defined as a subluxation of the humeroulnar joint at least three weeks after trauma. Treatment is based on restitution of the three elements essential for stability: the coronoid process, the height of the head of the radius, repair of the lateral ligaments. The purpose of this study was to analyse treatment modalities for these unstable elbows and assess mid-term results.

Material and methods: This consecutive series included all patients who underwent surgery between 1992 and 2000. There were 22 patients (twelve men and ten women, mean age, 46 years, age range 26–74 years). The left elbow was involved in 16 cases (two dominant) and the right elbow in six cases (six dominant). The initial trauma was isolated dislocation in six patients, dislocation with fracture of the coronoid process and the head of the radius in nine, trans-olecranon fracture-dislocation in seven. Mean time from trauma to revision for instability was four months. A dynamic external fixator was used for stabilisation in all cases, with or without restoration of the height of the radius with a radial head prosthesis (n=12), and reconstruction of the coronoid process (n=7). Reinsertion of the lateral ligaments was necessary in 17 patients.

Results: Mean follow-up was 33 months. Six patients required a second procedure for transposition of the ulnar nerve in three and arthrolysis of the elbow joint in three. There was one failure requiring total elbow arthroplasty less than one year after revision. At last follow-up, outcome according to the Mayo Clinic classification was excellent in ten patients, good in five, fair in one, and poor in five (four trans-olecranon fracture-dislocations). Twenty patients had a stable elbow. Mean flexion-extension was 113° with a 19° mean extension deficit. At last follow-up, six patients had radiographic signs of osteoarthritis.

Discussion and conclusion: The results were directly correlated with the nature of the initial trauma and the quality of the restoration of he stabilising elements. The poorest results were observed after trans-olecranon fracture-dislocation, which led to osteoarthritic degradation in three out of four cases. In our experience, treatment of sequelae of elbow dislocation, or the terrible triade, can give satisfactory results with an appropriate treatment strategy.


C. Chantelot C. Feugas M. Schoofs P. Leps C. Fontaine

Purpose: Reconstruction of long bones with significant loss of bone stock is a major challenge particularly if the gap is greater than 5 cm. Complementary bone resection is often necessary. A conventional cancellous graft may be used when loss of bone substance is not too extensive, but when the defect extends over several centimeters a vascularised bone graft with a microanastomsed fibular graft may be indicated. This technique is widely used for the lower limb but rarely applied for the forearm. The purpose of this work was to examine the modalities and report our experience.

Material and methods: This retrospective study included six microvascularised free fibular grafts performed to reconstruct the forearm bones after massive loss of bone stock. The mean age of the five men and one woman was 34 years. Bone loss (mean 10 cm, range 6 – 18 cm) involved the radius in five cases and the ulna in one. All six patients were victims of crush injuries with open fractures and expulsion of part of the forearm skeleton. Initial treatment included debridement, wound closure, and temporary external fixation. The fibular graft was performed eight weeks (mean) after trauma in five patients and six months after trauma in the sixth patient who also had multiple autologous cancellous grafts which left a nonunion of the ulna and an 18 cm defect. The Meyer method using a saphenous loop was used for vessel anastomosis in five cases. A vascularised fibular bypass was used in one. Osteosynthesis was achieved with screw or plate fixation.

Results: Bone healing was achieved in all patients four to six months after grafting. Mean follow-up was three years (range 1–5). There were no secondary fractures. Mean flexion-extension of the elbow was 100° at last follow-up. Mean pronation-supination was 100°.

Discussion and conclusion: Free fibular transfer enabled reconstruction of the forearm skeleton after massive bone loss. The vascularised graft shortened time to bone healing for these extensive defects with a mechanical quality superior to that obtained with conventional non-vascularised grafts. These vascularised grafts can be indicated for infected nonunion because the vascularised graft favours antibiotic diffusion.


C. Mathoulin

Purpose: Arthroscopy of the wrist can be an alternative to open surgery for joint fractures of the radius by checking reduction of often impacted fragments and analysing associated injuries.

Material: Twenty-eight patients (15 men and 13 women) were treated arthroscopically. Mean age was 51 years (range 19–82). There were four fractures of the styloid process of the radius, six posteromedial fractures, eleven 3-fragment T fractures and seven fractures with four or more fragments. There were 19 associated injuries (six lesions of the triangular ligament, four lesions of the luno-triquetral ligament, and nine lesions of the scapho-lunate ligament including four requiring pinning.

Methods: Loco-regional anaesthesia was used for all patients. The elbow was flexed at 90° and the wrist placed under axial traction using a “Japanese” device. After careful cleaning of the joint, reduction was achieved by pinning under arthroscopic and fluoro-scopic guidance. In certain very unstable cases (i.e. the fractures with four or more fragments), additional plate fixation was required. An external prosthesis was worn for 45 days.

Results: Mean follow-up was 21 months (6–36 months). Wrist movement was normal in 24 patients and pain had totally resolved for 27. There were no secondary displacements requiring surgical revision. Horizontalisation of the radius was observed in two cases and inversion of the lower radio-ulnar index (about 0.5 cm) in four. The functional outcome was excellent or good in 22 patients, fair in five, and poor in one due to reflex dystrophy.

Discussion: The indication for surgical treatment of joint fractures is now well recognised. Our results are comparable to those in other series where arthroscopic management has been used for this type of fracture. The quality of the functional results appears to be directly related to the quality of the reduction and fixation achieved under traction.

Conclusion: Arthroscopic management of joint fractures of the lower quarter of the radius enables anatomic reduction necessary for good functional outcome.


S. Levante L. Merland T. Bégué A.C. Masquelet J.Y. Nordin

Purpose: Instability of the injured elbow early after repair can lead to recurrent dislocation or failed fixation. Complementary immobilisation increases the risk of stiffness. The purpose of this study was to assess the contribution of dynamic external fixation which allows protected mobilisation and controlled distraction. We wanted to determine feasibility and appropriate indications.

Material and methods: We used the Pennig articulated elbow fixator in twelve trauma victims. Most had complex injuries: five dislocations with lesions of the medial ligaments and fractures of the radial head, including two with early recurrent dislocation; five joint fractures (involving to various degrees the lateral condyle, the head of the radius, the olecranon, and the humeral surface). This fixation method was also used for old or sequelar lesions to achieve reconstruction of the humeral surface (n=3) or after extensive arthrolysis (n=2). Mobilisation was started on day five postop.

Results: For the fresh injuries, the humero-ulnar articulation was centred in all cases. In these patients, mean final flexion was 0.35.130° and pronation-supination was 0.10.155°. One purely lateral dislocation was observed. Radio-ulnar synostosis after fracture of the ulna (n=1) and osteoma (n=1) were also observed.

Discussion: This dynamic external fixation system is a simple and safe procedure if a rigorous technique is applied. This method enabled early rehabilitation without secondary displacement and also enabled reliable contention particularly important in these multiple injury patients. The patients experienced very little pain during rehabilitation exercises, probably due to the distraction which did not appear to provoke reflex dystrophy. For complex instability of the elbow, the reduction of stress forces during mobilisation movements enables an extension of the indications for preservation of the joint fragments. Less reliable results are obtained for stiff elbows with old lesions.


C. Chantelot c. Feugas M. Schoofs F. Giraud C. Fontaine

Purpose: Crush injury of the upper limb often causes bone and soft tissue damage leading to a paralytic hand. We report our experience with reactivating wrist and finger flexion using a neurotised latissimus dorsi transfer in patients with volkmann syndromes of the forearm.

Material and methods: Mean patient age was 25 years and mean follow-up was three years. The surgical procedure consisted in a free latissimus dorsi flap with arterial suture onto the ulnar artery and neurotisation using the largest median nerve branch innervating the finger flexors. The muscle was fixed proximally on the medial epicondyle; the distal fibrous lamina was divided for suture to the deep flexor tendons. Mobilisation started 21 days after surgery.

Results: The four-month electromyogram demonstrated reinnervation of the latissimus dorsi. The patient recovered thumb-index opposition with flexion of the long fingers enabling daily life activities. All patients required occupational reclassification but stated they were satisfied with the operation. Flexion of the fingers and wrist was active and was not obtained by tenodesis.

Discussion and conclusion: Volkmann syndrome leaves serious sequelae after crush injury to the forearm. The usual surgical techniques enable reduction of claw fingers by distention but do not, due to muscle necrosis, enable proper function. The free latissimus dorsi transfer method improves trophicity of the forearm and, by neurotisation, enables active hand flexion. Because the nervous pedicle of the flap is short, recovery is rapid, avoiding degeneration of the transferred muscle.


M. Valverde N. Deblock M. Chammas B. Coulet Y. Allieu

Purpose: Operative wounds are commonly washed with a more or less diluted antiseptic solution to prevent infection or to treated overt infection. Chlorhexidine is widely used. We report the cases of nine patients who developed joint destruction attributed to peroperative irrigation with a chlorhexidine solution.

Material and methods: Nine patients (three men and six women) who had undergone surgery in another facility were referred to our unit for unexplained postoperative chondrolysis. The joint localisations were: wrists (n=7) after surgery for a dorsal arthrosynovial cyst (mean age 37 years); elbow (n=1) after surgery for epicondylalgia (age 49 years); shoulder (n=1) after arthroscopy for sub-acromial impingement (age 51 years).

The time between surgery and the first consultation in our unit varied from three to nine years (mean five years four months). Persistent stiffness had been noted in the postoperative period with pain at joint mobilisation which worsened progressively. For the patients with chondrolysis of the wrist: the x-rays demonstrated destruction of the radius-first ray joint in one, the medio-carpal joint in four and overall destruction in two. Overall joint destruction was also observed in the elbow and shoulder patients. Search for other causes of joint destruction was negative; infection and inflammatory rheumatoid disease were ruled out. The common feature identified in all patients was joint irrigation with a chlorhexidine solution (Biseptine®).

Results: Four of the nine patients underwent surgical treatment: a four-bone arthrodesis with scaphoidectomy was used for the three patients with mediocarpal involvement and a shoulder arthrodesis was performed in one patient. The pathology study demonstrated cartilage defects filled with dense strongly hyalinised acellular tissue. Bacteriological specimens were all negative.

Discussion: The chondrolytic effect of chlorhexidine, a member of the biguanide family, was first reported in 1986 with a few cases described with knee involvement. Experimentally, there would be a dose-dependent effect. The mechanism involves a disorganisation of the cell membrane with cartilaginous necrosis and ostocartilaginous resorption. Individual predisposition cannot be ruled out.

Conclusion: In light of these observations, it would be advisable to avoid peroperative joint irrigation with chlorhexidine solution.


L. Béguin P. Adam O. Vanel M.H. Fessy

Purpose: A new locked nail is proposed for the treatment of proximal fractures of the humerus. This simple system with self-locking screws was designed for all types of proximal fractures. The purpose of this prospective study was to determine indications and identify limitations.

Material and methods: We used the proposed fixation method sparing the cuff muscles and using a cup-and-ball technique for complex three or four-fragment fractures with major displacement. All nails were locked proximally, with at least two screws, and distally. Early joint mobilisation recommended for this type of osteo-synthesis was applied diversely. This series included 50 fractures of the upper humerus which were all treated with a Telegraph nail between January 2000 and January 2002. We identified 18 fractures of the surgical neck and 32 cephalotuberosity fractures. Mean age was 67 years, range 23–94 years.

Results: The Constant score at maximum follow-up of 24 months was used to assess clinical outcome. Bone healing was effective in all cases but there were several complications: secondary displacement (n=3), fracture of proximal screws (n=5), nail ascension (n=3), rupture of the long head of the biceps (n=1), and stiffness at flexion (n=12), which required removal of the implant in five patients and prosthetic replacement in one.

Discussion: The self-locking screws used with this nail provide excellent stability. Despite the rigid assembly, we observed displacements which led to screw failure and tilting heads. The distal locking screw appears to play a deleterious role in impaction of the fracture. The high rate of complications, 26% in this series, has led to reconsider using plate fixation for complex fractures in young patients and ascending pinning with the Apprill or Hackethal method to avoid aggression on the rotator cuff for fractures of the surgical neck. The Telegraph nail thus does not appear to be indicated only for complex fractures of osteoporotic bone; arthroplasty should be retained for this indication.


J.F. Lahogue L. Hubert A. Talha P. Cronier J.L. Toulemonde P. Massin

Purpose: We report our first cases of retrograde nailing using the universal humerus nail (UHN).

Material and methods: Fifty patients (26 men and 24 women), mean age 60.2 years, with fracture of the humerus were treated with the UHN; most had shaft fractures, 40 were trauma victims, and ten had metastases.

Retrograde nailing was achieved by trepanation of the apex of the olecranon fossa. Proximal or distal locking was applied in all cases using one or more screws. Outcome was assessed with the S.O.O. criteria (1996).

Results: Two patients were lost to follow-up and two patients died early. Forty-six patients were reviewed with a mean follow-up of six months (range 3–18). Outcome was very good or good in 43 patients (bone healing at three months), fair in one, poor in two (two constructs dismounted at day 15); three asymptomatic fractures did not heal at one year (all healed two months after compression). Peroperative complications included: four fissures of the posterior cortical at the entry window and two supracondylar fractures. One patient developed radial palsy in the immediate postoperative period that resolved spontaneously. One of the proximal locking screws loosened early in four patients. Finally, one patient developed a supracondylar fracture at the point of entry following a fall four months after the nailed fracture had healed.

Discussion: The two cases of dismounting were subtuberosity fractures in elderly patients; likewise the one fair outcome was a minimal secondary displacement that had not healed at five months. The proximal locking screws did not hold well in osteoporotic heads explaining the three cases of early screw loosening. Impacting the curved nail into the last centimeters is a delicate operation and we had two fissures of the posterior cortical and peroperative supracondylar fractures early in our experience. Finally, the absence of an aiming device for the proximal locking screw complicates this procedure. The possibility for orthogonal proximal locking is however an advantage for rotatory stability. This nail allows early rehabilitation without mobilisation.

Conclusion: Retrograde locked nailing provides good results at three months for humeral shaft fractures. Subtuberosity fractures in elderly patients are not good indications. A straight nail would however be preferable and an aiming device for the proximal locking would be useful.


M. Gottin M. Labrada-Blanco H. Dintimille

Purpose : Compartment syndrome is a serious complication common to all trauma victims and may be life-threatening after fracture of the femur or require amputation after fracture of the lower leg. We report our experience with six cases and attempt to identify clinical signs suggestive of this severe complication.

Material and methods: This series included four fractures of the leg and two fractures of the femur. The leg fracture victims constituted a heterogeneous group. Their mean age was 39.5 years, range 24 – 54 years. These four women had one transverse fracture, one short oblique fracture, one isolated fracture of the tibia, and one comminutive fracture. Two of the fractures were open (grade 1 and 2). There were three low-energy fractures and one high-energy fracture. The femur fracture victims exhibited more similarity. These two young patients (18 and 20 years) both had a closed, high-energy, comminutive fracture.

Results: For the leg fractures, the diagnosis of compartment syndrome was suggested in three patients by postoperative pain refractory to medical treatment. Tension in the compartment was the inaugural sign in the other patient. Diagnosis was confirmed by pressure measurements which exceeded 45 mmHg in all cases and reached 60 mmHg in one. The anterior compartment was involved alone in three patients and all three compartments in one. Time to diagnosis ranged from 1 to 12 hr. Two patients underwent surgery within six hours and cured without sequelae. Anterior tibia palsy developed despite aponeurotomy before six hours in the patient with a peak pressure of 60 mmHg. The fourth patient developed severe sequelae with anaesthesia of the foot, anterior and posterior tibial palsy, and infected non-union of the leg bones.

For the femur fractures, diagnosis was suggested by high tension in the anterior compartment confirmed at pressure measurement: 60 and 70 mmHg. Rapid reduction in pressure was followed by signs of muscle necrosis in one patient. Aponeurotomy performed rapidly in the other patient did not prevent motor deficit involving the popliteal branches.

Discussion: Pressure monitoring should be performed systematically in patients with leg fractures, irrespective of the type of fracture or the causal mechanism. Pressure monitoring should also be a routine practice in patients with high-energy fracture of the femur. Outcome depends on two important factors: the level of the pressure peak and the duration of high pressure.


G. Biette C. Laporte F. Jouve

Purpose: We report our expeience with the medial and posteromedial approach to the humerus for plate fixation of fractures of the distal two-thirds of the humerus.

Material: Fifteen patients (eleven men and four women) were treated for fractures (n=13) or nonunion (n=2) situated below the proximal third of the humerus without radial nerve involvement.

Methods: Eight patients were installed in the supine position for median approach between the humerus bundle and the median nerve anteriorly and the ulnar nerve posteriorly. The posteriomedian approach, with the ulnar nerve posteriorly and the brachial triceps anteriorly, was used for seven other patients installed in the prone position. The fixation plate applied to the medial aspect allowed at least six corticals on either side of the fracture line. The patients were immobilised for 45 days. Passive rehabilitation exercises involved the elbow and the shoulder without external rotation. Clinical and x-ray follow-up data were available for all patients.

Results: One patient was lost to follow-up two months after surgery: at this time the x-ray had demonstrated bone healing. Function could not be assessed as the fracture had occurred on the same side as the hemiplegia also caused by the initial trauma. For the fourteen other patients, mean follow-up was 12 months (range 6 – 36). Three patients operated via the median approach presented paraesthesia in the median nerve territory which was regressive in two. There were no neurological complications in the posteromedian approach group. Function was good for elbow and shoulder except for two patients. Bone healing was achieved in all cases.

Discussion: These approaches allowed avoiding dissection of the radial nerve and provided a more aesthetic scar. Several difficulties were encountered with the median approach and reduction was difficult to control. In such cases it is advisable to widen the exposure to avoid stretching the median nerve. These approaches are contraindicated if radial nerve injury is identified preoperatively.

Conclusion: Osteosynthesis of the humerus via a median approach avoids the need for radial nerve dissection. Reduction appears to be easier via the posteromedian approach with less risk than with the median approach.


F. Welby C. Nourissat B. Bajer T. Bégué A.-C. Masquelet

Purpose: Reconstruction of massive bone loss with cancellous bone deposited in a pseudomembrane induced by a cemented strut was performed in 40 procedures. We evaluated the 5-year results of this technique for the treatment of gaps measuring more than 5 cm.

Material and methods: We reviewed 12 patients; all had suffered major loss of tibial bone. The operations consisted in resection, insertion of a cement strut, and closure with a local are free flap over he disinfected soft tissues. The second operation at least two years later used a fragmented autologous cancellous graft leaving the membrane intact. The fibula was used as a tutor whenever possible. Bone losses measured 5 to 25 cm in young men who had infection after trauma or, in one patient, tumour resection. We analysed clinical and radiological outcome.

Results: All patients were seen five to ten years after initial management. At last follow-up, all wounds had dried and bone healing was solid. All had required secondary repeated grafts, realignment surgery (for valgus and varus) or operations related to the initial injury (arthrodesis, claw toe). Generally, the patients had resumed their occupational and recreational activities. The walking distance was not limited and single leg stance was painless. The radiological analysis demonstrated a trend towards graft tubulisation.

Discussion: The stut technique using cement induces the formation of a pseudo-synovial membrane. This technique has been used for more than ten years in our unit to treat circumferential defects. Bone healing was achieved in all patients. The main complication was valgus malalignment which almost always requires surgical correction. Rapid healing is not a function of the extent of the gap but rather the radical nature of the resection and the quality of the cover. This technique should be compared with other alternatives used to fill major bone gaps (Illizarov, vascularised bone transfer).


C. Chantelot T. Aihonnou G. Gueguen H. Migaud C. Fontaine

Purpose: Management of extensive tibial loss raises the question of indications for vascularised grafts. These techniques depend on the number of functional vascular trunks available. We developed a modified technique which allows using this type of graft without sacrificing the tibial pedicle, making it usable when only one trunk remains functional. We use the fibular arterial supply to bridge the remaining axis. The purpose of this work was to detail the modalities of this technique and provide early results.

Material and method: Since 2000, we have reserved this technique for infected nonunion with loss of tibial tissue extending over 5 cm in patients who decline amputation. Four patients (four men, mean age 30 years) underwent the procedure. The initial trauma resulted from a motorcycle (n=3) or firearm (n=1) accident. The patients were referred to our unit within three months on the average. Prior treatments (cancellous graft in an open or intrafocal procedure) had failed in all patients who presented persistent infection. Antibiotics were administered until bone healing in all patients. Mean length of the gap was 10 cm (7 – 15 cm). The composite graft (skin and fibula with a vascularised fibular bundle) was raised from the contralateral limb and cross-leg anastomosed proximally and distally on the receiver anterior tibial bundle (all four cases).

Results: All fractures consolidated between six and twelve months after initiating management of this technique. Bone and soft tissue losses healed without shortening. There were not repeated fractures after mean follow-up of twelve months (range eight months to two years). No complementary bone graft was necessary. Infection resolved in all patients.

Discussion and conclusion: As for classical vascularised fibula grafts, this technique enables controlling bone and soft tissue problems together (composite graft). The graft is vascularised favouring antibiotic diffusion. The mechanical quality is better than with a pure cancellous graft but longer follow-up would be required to determine the rate of repeated fractures. This technique broadens indications for vascularised fibula grafts which can be used in unfavourable vascular contexts where only one or two leg trunks persist.


A.M. Abou Chaaya M. Moukhalalati A. Bazeli A. Vinassé P. Cottias

Purpose: Compartment syndrome of the leg is an exceptional (0.8% of leg fractures) but serious complication with a risk of muscle necrosis. The purpose of this work was to propose an original therapeutic approach to compartment syndromes that have progressed to the stage of muscle necrosis.

Material and method: Between November 1999 and January 2001, we treated eleven patients with acute compartment syndrome of the leg. There were ten men and one women, mean age 38 year (range 19–70). The causal mechanism was fracture of the two leg bones in nine patients (during the study period, 129 leg fractures were managed in the unit). For two patients the causal mechanism was prolonged compression. The compartment syndrome was present at admission in seven patients and developed after nailing in two. Emergency aponeurotomy was performed in all cases.

Results: Mean follow-up was six months, range 3 – 26 months. Outcome was favourable in six patients and the aponeurotomy was closed between day 5 and 10 (mean day 7), associated with a skin graft in some patients. Muscle necrosis developed in four patients. These patients were treated by wide muscle excision and immediate wound closure with aspiration drainage, followed by a prolonged adapted antibiotic regimen. Complete healing with total regression of the infectious syndrome was achieved. Partial recovery of sensory and motor function was obtained in all cases. One patient required a cross-leg flap for cover after infectious necrosis. One other patient aged 57 years died a few hours after aponeurotomy due to cardiac failure of undetermined origin.

Discussion: Compartment syndrome is a recognised surgical emergency. All authors recommend emergency aponeurotomy. There is no standard treatment after progression to muscle necrosis.

Conclusion: Muscle necrosis is not uncommon despite aponeurotomy (4 out of 11 patients in our series). In case of muscle necrosis, we propose wide excision and immediate wound closure associated with adapted antibiotics. Despite the muscle excision, partial recovery of sensorial and motor function of the foot was achieved several months after the initial treatment.


A. Fabre B. Bauer F. Lamber S. Rigal

Purpose: Inverted pediculated fasciocutaneous flap is an alternative to microanastomosed free flap for cover of tissue loss of the lower third of the leg in trauma victims. We report our experience in fourteen patients.

Material and methods: Fifteen fasciocutaneous inverted pediculated island flaps were performed in fourteen trauma victims with major tissue loss of the lower limbs. Mean age was 42 year (range 24 – 70). There were thirteen men and one woman. The fracture was located on the lower third of the leg and involved the diaphysome-taphyseal junction in thirteen patients (associated with loss of heal tissue on one), the fibular malleolus in one and the tibial column in one. The Gustilo classification was two grade 0, three grade I, eight grade IIIB, and one grade IIIC. Four patients were given first-intention treatment. For the referral patients treated secondarily, three had a dehiscent wound with an exposed fixation plate.

A supramalleolar lateral flap was used in six patients (40%), a sural neurocutaneous flap with a distal pedicle in seven (47%), and a sural neurocutaneous flap with a distal pedicle in two (13%). Seven patients (50%) had a bone graft.

Results: Wound healing was achieved in thirteen patients, with three infectious complications. The one failure involved a sural neurocutaneous flap (grade IIIC fracture). The fixation plate was preserved under the flap in one patient who developed secondary nonunion. Fracture healing was achieved in all cases.

Discussion: Use of island fasciocutaneous flaps with a distal pedicle for the treatment of tissue loss of the lower third of the leg has grown steadily since the introduction of the concept. The principal advantage, beyond the simplicity of the flap procedure, is to spare locoregional vessel and muscle stock. Our series confirmed that this method can give good results if the flaps are carefully planned. This method should not be recommended as an emergency procedure. Combining two fasciocutaneous flaps could be a salvage solution in certain cases where the trauma context implies less concentration in the aesthetic and sensorial result.

Conclusion: Use of fasciocutaneous flaps with a distal pedicle is a first choice solution for covering tissue loss of the lower third of the leg and foot. This method should not be proposed as an emergency procedure.


H. Ben Amor H. Mnif T. Aissaoui K. Zehi M. Zouari S. Karray T. Litaiem M. Douik

Purpose: Leg fractures are a daily problem in orthopaedic surgery. The frequency has increased due to the growing number of traffic accidents. Social impact is important because the injured population is young and active. The purpose of this work was to analyse anatomic and functional results obtained in a series of patients and to identify indications and limitations of centro-medullary alignment nailing for the treatment of leg fractures.

Material and methods: This series included 207 leg fractures treated with this method at the Kassab Orthopaedic Institute. There were 174 men and 33 women, mean age 35 years (15–75). Male predominance was considerable (84%). Centromedullary nailing was completed with a plaster cast and weight bearing after a mean four to five weeks with a Sarmiento walking case until bone healing.

Results: Results were analysed at mean 12 months follow-up (4 months–18 years). Bone healing was achieved in 99% of the cases within a mean time of 15.3 weeks (6–66 weeks). There were 16 cases with a deformed callus (7.8%) predominantly in varus (n=10) and thirteen secondary dislocations (6.3%). This was significantly more frequent for fractures of the proximal third in comparison with the mid third, or comminutive bifocal fractures, and when weight bearing occurred before the fourth week.

Discussion: The functional outcome showed pain at walking in 15% of the patients. Walking distance was unlimited in three-quarters of the patients and joint motion was good. Alignment nailing is a reliable easy to use technique providing satisfactory results for the treatment of simple fractures of the mid third of the leg. Fractures of the upper and lower third, as well as bifocal and comminutive fractures require a locked nail to neutralise the risk of secondary displacement and misalignment callus.


Y. Acquitter B. Galaud C. Hulet G. Burdin B. Locker C. Vielpeau

Purpose: Free patellar tendon plasty is classically used for the treatment of chronic anterior instability of the knee. Good functional results may however be compromised by invalidating anterior pain. The purpose of this randomised trial was to obtain a prospective comparison of outcome after hamstring plasty or patellar tendon plasty.

Material and methods: One hundred patients with an isolated tear of the anterior cruciate ligament were included in the study between May 1998 and 2001. Exclusion criteria were history of fracture, grade II laxity, and tear of the contralateral ACL. Patients were assigned to one of the treatment arms in random order in the operating room: Group A: arthroscopic free patellar tendon-bone graft; Group B: arthroscopic free four-strand hamstring graft. Two metal interference screws were used for fixation in all cases. The Aglietti method was used to calculate the position of the bore holes in all cases. The same rehabilitation protocol, in the same centre, was applied in all cases. The two groups were comparable for epidemiological, clinical, radiological, and instrumental laxity (KT1000®) data. IKDC criteria, activity level (sports), and instrumental measurement of laxity (KT1000® Medtronic) were used to assess outcome. Differences were considered significant for p < 0.05.

Results: At mean follow-up (24 months, range 6 – 38) groups A and B were not significantly different for delay to resumed sports activity at the initial level, motion, clinical examination of ligaments, IKDC global score, and radiological evolution. At six months, 30% of the patients in group A complained of anterior pain; 20% of the patients still complained of pain at one year. In group B, femoropatellar pain or pain at the harvesting site was reported by 8% of the patients at six months and 4% at one year (p = 0.0005). These differences were no longer present at two years. The instrumental differential laxity was 0.66±1.1 mm in group A and 1±1.5 mm in group B (p =0.20). Two repeated trauma-induced tears were observed in group B.

Conclusion: The preliminary results of this prospective randomised trial confirm the low morbidity of the harvesting site for hamstring grafts and the reliable stability of hamstring repair of isolated ACL laxity. A longer follow-up is however needed for long-term validation, particular concerning secondary distension of hamstring grafts as is frequently reported in the literature and which we have also observed in certain patients treated before this series.


C. Lazerges P.-A. Daussin F. Bacou M. Chammas

Purpose: Prolonged denervation resulting from deferred nerve repair or long distance between the muscle and the repaired nerve, leads to major alterations concerning muscle fibre degeneration and their replacement by fibrous or fatty tissue. These structural modifications of the muscle are unfavourable for reinnervation and consequently affect the final functional outcome after peripheral nerve repair with its corollary of reduced muscle force. The purpose of this work was to assess the potential for regeneration of denervated-reinnervated muscles and their improvement with adjuvant cell therapy using in situ transfer of cultured autologus satellite cells.

Material and methods: This work was conducted with the tibialis anterior muscle in different groups of New Zealand rabbits. The experimental model was a sectioned common fibular nerve and immediate or deferred (two months) microsurgical nerve suture. In vivo functional measurements and histomorphological analyses were performed four months after nerve repair.

Results: Reinervation led to loss of mucle weight and maximal force (Fmax) which were greater with longer deferral of repair. Transfer of satellite cells performed immediately after reinervation did not improve muscle properties. Conversely, transfer of satellite cells two months after nerve suture increased Fmax 25% (p < 0.01) and muscle weight 28% (p = 0.005) in comparison with control muscles undergoing reinervation without cell transfer. Furthermore, the morphology of the muscle was improved as demonstrated by anti-myosine labelling studies.

Discussion: Adjuvant cell therapy allows, in certain conditions, an improvement in functional recovery after peripheral nerve injury. Its clinical application still raises a certain number of ethical issues but taking into consideration data currently available, it would be reasonable to propose this therapeutic approach in humans to reduce involution of the denervated muscle and improve its receptivity for regenerating axons after peripheral nerve repair. Better post-operative results could be expected


C. Lazerges M.-N. Thaury R. Verdier M. Chammas

Purpose: Until recently, evaluation of surgical treatment for brachial plexus palsy has been purely analytic, not taking into account the patient’s overall functional capacity nor his/her quality of life. The unilateral nature of these palsies and the fact that the limb remains healthy requires a global assessment of outcome. We propose here to associate the classical analytical evaluation with a global quality of life evaluation to determine the beneficial effect of surgical treatment for partial or total brachial plexus palsy.

Material and methods: Forty-four patients, mean age 30 years (17–60) were reviewed with a mean follow-up of 34 months. These patients were divided into two groups: C5–C6 ± C7 palsy (n=18), C5-T1 palsy (n=26). In each group, we recorded a complete muscle analysis, a visual analogue scale test of pain, and results of three quality of life questionnaires (DASH, Abilhand, MOS SF-36). We studied for each group the influence of recovered elbow flexion (biceps ≥ M3+), recovered shoulder function (abduction ≥ M3+), and residual pain on quality of life.

Results: The overall analysis did not demonstrate any difference in quality of life between partial and complete palsy. The three questionnaires were correlated with each other (p< 0.03). Residual pain (visual analogue scale ≥ 4 in 59% of the patients) was correlated with quality of life (p< 0.05) while involvement of the dominant side did not have any influence. In the partial palsy group, recovery of shoulder function (61%, n=11) improved significantly all the quality of life scores (p< 0.01). Conversely, recovery of elbow flexion (72%, n=13) did not improve quality of life in patients with a functional shoulder (p< 0.02). In the group with total palsy, recovery of shoulder function (77%, n=20) appeared to be as least as important as elbow flexion on quality of life (p ≤ 0.05).

Discussion: Unlike generally accepted notions, postoperative assessment of quality of life in these brachial plexus palsy patients demonstrates the importance of shoulder function which appears to be as least as important as recovery of elbow flexion. Furthermore, persistent pain appeared as one of the main negative factors affecting quality of life. Appropriate management is necessary.


P. Boisrenoult S. Guillo A. Veil-Picard A. Lortat-Jacob

Purpose: Treatment of non-infected nonunion of the leg is a difficult challenge. Several technical solutions have been proposed. The purpose of this work was to assess the results achieved in patients treated with the Kuntscher technique and to detail indications.

Material and methods: Twenty-two patients who underwent surgery between 1987 and 1997 using the Kuntscher technique (reaming, renailing) for tibial nonunion were reviewed. There were 19 men and three women, mean age 36 years (range 16–58). Minimal follow-up was two years. The initial treatment consisted in non-locked cen-tromedular nailing the cruropedious (n=21) and screw-plate fixation (n=1). There were ten open fractures: Gustilo I (n=3), II (n=7). We noted: time to revision, time to healing, preoperative and last follow-up alignment, size and type of bone loss (fragment or segment), complementary procedures, complications.

Results: We had one infectious failure (Kuntschner nine months after screw-plate fixation, infection diagnosed at two months, bone healing after removal of the nail, reaming, external fixation and fibular strut with cancellous graft). There were no other complications. One patient was lost to follow-up at three months; this patient had a medial fragmental gap measuring 1 cm with a radiologically solid fracture at last follow-up. All other patients healed within a mean 3.44 months (2.5–10). Mean time before revision was six months (2.5–12). Segmental loss was 3–8 cm in six patients. There was not defective alignment at healing. A fibular osteotomy was performed in five cases. Complete weight bearing was initiated early in 15 patients (with crutches in seven).

Discussion: In our experience, the Kuntscher technique is a simple and effective method for the treatment of non-infected tibial nonunions. It is indicated for small gaps or small-sized segmental losses. The rapidity of the healing and the generally uneventful healing period suggest this method should be proposed early after diagnosis of nonunion.


M. Mseddi A. Siala M. Mtaoumi K. Bouattour R. Ben Hamida J. Dahmene M.-L. Ben Ayeche

Purpose: The purpose of this work was to emphasise the contribution of the Illizarov technique for the treatment of leg nonunions.

Material and methods: Our series included 30 cases of post-traumatic nonunion of the leg treated by the Illizarov method between January 1990 and December 1998. The injury involved mainly active male subjects. Traffic accidents predominated. The nonunion was infected in 27% of the cases, misaligned in 70% and associated with a bone gap in 17%. The technique adopted in this series was pure compression in 24 patients, compression-distraction in two and compression-bifocal distraction in four.

Results: Bone healing was achieved in 93% of the patients with a mean time of 6.5 months. There were two failures due to technical flaws. The infection resolved and the bony gap closed in all patients. The overall outcome was satisfactory both anatomically and functionally in 87% of the cases.

Discussion: The Illizarov method constitutes a precious tool for the treatment of this complex and variable surgical situation. It allows bone healing, resolution of the infection, and correction of misalignment as well a closure of bone gaps and preservation of functional independence.


C. Trojani N. Jacquot S.S. Coste P. Boileau

Purpose: Evaluate outcome after isolated intra-articular ACL graft in patients aged 40 to 60 years using patellar bone-tendon and gracilis grafts.

Material and methods: This retrospective comparative study included 30 consecutive patients who underwent arthroscopic surgery between September 1996 and September 1999 performed by the same operator: 14 patellar bone-tendon grafts and 16 gracilis grafts. The indication for surgery was knee instability in everyday or sports activities. Exclusion criteria were associated peripheral ligament plasty or bone procedures. The two populations were strictly identical except for gender and follow-up: patellar bone-tendon group: mean age 49 years, 12 men, follow-up 46 months, 6 associated menisectomies; gracilis series: mean age 48 years, 13 women, mean follow-up 30 months, 6 associated menisectomies. The IKDC score, laximetry (KT 2000), x-rays (AP, single stance lateral, 30° flexion) were used by two operators different from the operating surgeon to assess outcome.

Results: At last follow-up, there was a significant difference between functional and anatomic outcome in the two groups. 83% of the patients were classed IKDC A or B. Subjectively, 90% of the patients were satisfied or very satisfied. The pivot test was negative in 24 (80%), doubtful in 5 and positive in 1. 86% of the patients had a differential laxity less than 3 mm. In the gracilis group, two patients developed chronic hamstring pain. In the patellar bone-tendon group, two patients developed persistent patellar pain. Two patients underwent a second procedure for meniscectomy. At last follow-up the x-rays demonstrated early signs of degeneration in 20% of the patients and signs of medial femorotibial degeneration in 10%.

Discussion: Gracilis and patellar bone-tendon grafts provide strictly identical results; residual pain is not more prevalent after patellar graft; control of laxity is not less satisfactory after hamstring graft. In our series, ACL graft in patients over 40 years of age provided functional, laximet-ric, and radiographic results comparable to those in patients undergoing ACL grafts before the age of 40 years.

Conclusion: 1) ACL graft can be indicated after the age of 40 years for patients with knee instability bothersome for everyday or sports activities. 2) Functional and anatomic results are identical with those obtained in younger subjects. 3) Irrespective of the graft used, patellar or hamstring, outcome is satisfactory and morbidity is not different.


P. Christel P. Djian M. Branfaux

Purpose: We present the results obtained in a consecutive series of 48 patients who underwent surgical repair for chronic posterior knee laxity between 1995 and 2000.

Material and methods: The series included 33 men and 15 women, men age 29 years at the time of trauma. Mean duration of knee laxity before surgery was 32 months: 26 patients had undergone different procedures but without reconstruction of the posterior cruciate ligament (PCL). Preoperative physical examination revealed direct posterior laxity (DPL in 17 knees, posteroposterolateral laxity (PPLL) in 17, posteroposteromedial laxity (PPML) in 6, global posterior laxity (GPL) in one, and complex anteroposterier laxity (APL) in 7. The PCL was reconstructed arthroscopically using a two-strand graft using either the patellar tendon for the oldest cases (n=22) or the quadriceps tendon (n=26). Peripheral involvement was repaired by tension, reinforcement, or reconstruction with an autologous tendon graft. In the event of associated genu varum, a tibial osteotomy for normo-correction was also performed prior to the ligamentoplasty. Outcome was assessed with the IKDC 93 criteria and posterior laxity was measured on the stress x-rays.

Results: All patients were followed at least one year. Mean follow-up was 24 months. There were no postoperative complications. The principal results for the first three types of laxity, DPL, PPLL, and PPML, were as follows. Preoperative subjective evaluation for the entire series: 12C, 36D; symptoms: 6B, 10C, 32D; global score: 9C, 39D; laxity: 11.4±4.3 mm. DPL: subjective evaluation: 4C, 13D; symptoms: 2B, 2C, 12D; global score: 4C, 14D; laxity 9.9±3.3 mm. PPLL subjective evaluation: 7C, 10D; symptoms: 2B, 6C, 9D; global score: 3C, 14D; laxity 11.7±4.6 mm. PPML subjective evaluation: 6D; symptoms: 1B, 5D; global score: 6D; laxity 13.0±3.7 mm. At last follow-up for the entire series, subjective evaluation: 9A, 27B, 12C; symptoms: 6A, 26B, 14C; global score: 1A, 25B, 21C, 1D; laxity: 5.0±3.0 mm, giving a 62% gain. DPL subjective evaluation: 6A, 8B, 3C; symptoms: 5A, 10B, 2C; global score: 1A, 10B, 6C; laxity: 4.0±2.0 mm, giving a 62% gain. PPLL subjective evaluation: 2A, 11B, 14C; symptoms: 3A, 10B, 4C; global score: 4B, 12C, 1D: laxity: 5.7±3.5 mm, giving a 54% gain. PPML subjective evaluation: 6B; symptoms: 6B; global score: 5B, 1C; laxity: 5.9±3.0 mm, giving a 61% gain. For all parameters considered, category D disappeared at last follow-up in almost all knees. This improvement over the preoperative status was statistically significant (p=0.001).

Discussion: Reconstruction of the PCL with a two-strand graft combined with compensation of peripheral laxity and axial deviations provides significant correction in laxity similar to that obtained for the anterior cruciate ligament. Despite these satisfactory results, posteroposterolateral laxity has a less favourable prognosis than the other types of laxity.


F. Buscayret C. Buscayret P. Maury

Purpose: The purpose of this study was to: 1) assess outcome of ACL reconstruction with intra- and extra-articular hamstring plasty; 2) analyse the contribution of a synthetic lateral reinforcement by comparing two series.

Material and methods: This population of 100 patients was divided into two groups: group 1 with a synthetic lateral reinforcement (70 patients) and group 2 without lateral reinforcement (30 patients). Eighty-nine percent of the patients were reviewed. Mean age at operation was 28 years. Fifty-six percent of the patients were competition-level athletes (pivot sports) and lesions of the medial meniscus was observed peroperatively in 74% of the patients. Mean follow-up was 40 months. The two groups were comparable for all parameters studied except follow-up and age which were slightly lower in group 2 without reinforcement. ARPEGE and IKDC scores (with KT1000 at 89N) were established. We performed a precise analysis of residual laxity (TELOS at 15 kg). The position and the width of the bore holes were also analysed.

Results: According to the ARPEGE scores, outcome was excellent or very good in 71% of the patients and 87% were in IKDC classes A and B. Seventy percent of the patients who were competition-level athletes (pivot sports) resumed their activities at the same level. Residual differential laxity (TELOS) was 5.7 mm (mean). Tunnel width was 3.5 mm (mean). This work demonstrated the safety of hamstring harvesting.

Discussion Residual laxity was strongly correlated with clinical outcome: residual differential laxity less than 6 mm (threshold value) ensured a negative pivot test and 94% good results. We did not find any correlation between tunnel width and residual laxity. An overly anterior femoral position and medial meniscectomy significantly increased residual laxity. The femoral bore hole should be sufficiently posterior, 60 to 70% of the anteroposterior condylar width. Use of a synthetic reinforcement did not improve clinical or laximetric outcome in the reinforcement group; a natural plasty without synthetic reinforcement would be preferable.


J.C. Panisset

Purpose: Anterior cruciate ligament (ACL) repair is increasingly performed to allow athletes reach their earlier sports performance or higher, leading to the risk of repeated tears. Several grafts can be proposed: the contralateral patellar ligament, hamstring tendons and the rectus femoris tendon. The purpose of this study was to analyse results in a continuous series of repeated tears of the ACL repaired with the rectus femoris tendon.

Material and methods: Forty patients underwent surgical repair of the ACL after iterative tears between January 1998 and June 2000. All had had a patellar tendon graft. All were active athletes, 70% at a competition level. The second tear had occurred a mean two years after the first repair. A second graft was indicated because of persistent knee instability. Preoperative laxity was demonstrated with telos at 20 kg showing a mean differential of 12.2 mm with the healthy knee (range 5–25). The arthroscopic technique described by P. Chambat was used. A strand of the rectus femoris tendon was harvested with its bony patellar attachment. The graft was introduced laterally to medially with fixation in the tibial bore hole with a resorbable interference screw. The patellar bone was press fit into the femoral hole.

Results: Outcome was assessed in all patients at mean two years (range 1–3) using telos at 20 kg. Two vertical fractures of the patella occurred three months after the ACL repair subsequent to minimal trauma. Only 50% of the patients resumed competition level sports. Two patients out of 40 had a sensation of unstable knee. Mean residual differential laxity was 2.6 mm (range 0–9).

Discussion: Repair of the ACL with the rectus femoris tendon appears to provide satisfactory results after repeated tears. The thickness, width and stiffness of the tendon allow satisfactory repair even in case of severe laxity. The surgical technique is not particularly difficult if the prior surgery did not produce bony damage and if the bore holes are positioned correctly. The postoperative period is not different than after first intention ligamento-plasty. Complications are minimal. This type of graft can be used for ligamentoplasty of the central pivot. The major complication is the risk of patellar fracture which can be avoided by careful graft harvesting during the first intention procedure. Control of knee laxity can be improved by inverting the graft and fixing the patellar fragment in the tibia and the proximal tendon in the femur.


T. Bauer S. Tempesta

Purpose: The purpose of this work was to define clinical and microbiological criteria allowing the distinction of postoperative infections of joint implants from secondary infections and to propose a probability score.

Material and methods: This retrospective multicentric study was conducted on 134 cases of infections of hip and knee prostheses. The first step was to distinguish three populations of infections (postoperative, secondary, unknown) based on the germ isolated at diagnosis of prosthesis infection (coagulase-negative Staphylococus, other germs, and Staphylococcus aureus respectively). The second step was to analyse clinical features in the group of postoperative infections and in the group of secondary infections in order to evaluate the predictive value of each of the following parameters: infection-free period, time to infection, distant focus.

Results: Fifty-seven cases of secondary infections were identified. There were 34 cases of postoperative infection and 43 cases of infection of unknown category (Staphylococcus aureus infections). The diagnosis of prosthesis infection was retained on the basis of intraoperative samples in 81% of the cases. The infection-free period was less than 1 year (time between implantation and first joint signs) in 69% of the cases of postoperative infection and in 36% of the cases of secondary infection. The difference was significant (p=0.003). A distant focus of infection was found in 44% of the cases (and documented by a bacteriological sample in 13%, 18/134). An invasive therapeutic procedure was identified in 12% (4/34) of the postoperative infections and in 56% (32/57) of the secondary infections. The difference was significant.

Discussion: The duration of the infection-free period and the notion of a distant focus of infection (documented or not) are significant criteria enabling a distinction between postoperative and secondary infections after prosthesis implantation. The notion of time to infection (time between the infectious episode and diagnosis of infected prosthesis) is not a significant criteria for identifying secondary infection (p > 0.005). Staphylococcus aureus infection remains difficult to classify.

Conclusion: Analysis of clinical features as a function of the microbiological findings enabled identification of significant criteria of secondary infection of joint prostheses. This enables proposing a probability score to be evaluated on a larger scale.


P. Vichard D. Talon L. Jedunet

Purpose: With the growing risk of nosocomial infections, one might expect to see a reinforcement of septic isolation wards in orthopaedics and traumatology units. The question is however being revisited because of several factors. 1st: General Orthopaedics Units are practically the only hospital units caring for a minority of septic patients with often resistant germs and a majority of non-septic patients in the same setting. 2nd: The growing number of single-patient rooms procures confidence (whether justified or not). 3rd: Hygiene specialists are particularly wary of occult carriers of resistant bacteria and apply a single set of protective measures for all patients. 4th: Economic performance is given priority.

Material and methods: We studied 1) the current situation in Orthopaedic units in University Hospitals in France and 2) the statistics from the Besançon University Hospital Hygiene Unit and from data in the literature.

Results: 1) Interrogation of the 71 University Orthopaedics Units in France revealed that: 11 units have strict isolation wards; 40 have incomplete isolation wards; 20 make no distinction between septic and non-septic patients. 2) According to the Hygiene Unit statistics, the epidemiological load of S. aureus meti-R (SAMR), strains often implicated in orthopaedic infection, is much higher in the University Hospital polyvalent wards than in the Orthopaedic septic ward. Contamination between septic patients is low. Furthermore, hand-borne and airborne contamination are not controlled in wards other than septic wards. Data in the literature are not in agreement concerning this new trend in prevention by isolation.

Discussion: a) One argument retained by all is that septic wards have an advantage in terms of efficacy and concentration of preventive measures. b) The growing workload in mixed units hinders strict application of preventive measures. c) A large number of temporary personnel (trainees, temporary employees, personnel untrained in sepsis prevention) are present in polyvalent units. d) Standardisation of preventive measures leads to an average level of prevention which lengthens the duration of care for non-septic patients and simplifies care for septic patients. e) The financial argument is impertinent compared with the consequences of contamination. Furthermore, a departmental structure would allow common use of the septic ward.

Conclusion : Septic isolation wards (or a septic department) should be preserved. The orthopaedic surgeon, as a responsible actor in the fight against nosocomial infections, should in concert with the consulting hygienist, oppose purely administrative decisions.


G. Gagey V. Molina S. Raspaud S. Soreda

Purpose: Disposable medical devices have several advantages and are widely used. But since the financial burden of disposable devices is however significant for the hospital budget, it would be interesting to reassess multiple use devices in terms of efficacy and safety. The purpose of this study was to determine the safety aspects involved and to assess wear observed in new versions of autoclavable shavers and drill bits used in arthroscopic surgery.

Material and methods: After standard preparation and ten sterilisation cycles, fifteen instruments (shavers and drill bits) were used 10 times each during arthroscopic procedures performed on non-embalmed cadavers. The instruments were used on tissues, cartilage or tendons (shavers) or cancellous bone (drill bits). Duration of use was at least 10 min for each instrument. The instruments underwent standard preparation (decontamination-cleaning-immersion in 1N caustic solution) followed by sterilisation at 134°C for 20 minutes as defined by the regulatory decree (n° 138, 14 March 2001). A tracability sheet was completed at each order for sterilisation. The first phase consisted in an evaluation of the instrument’s resistance to sterilisation treatments, in particular the non-alteration of the cutting surface examined under optical magnification. The second phase was to determine the feasibility and performance level of the cleaning step based on assay of protein residue with UV spectrophotometry as described by Bradford.

Results: One hundred fifty complete cycles were performed. The results of the first phase demonstrated satisfactory instrument resistance to 10 uses with traces of erosion visible on 20% of the instruments after the 5th use. Two instruments were replaced during the study due to mechanical wear. The second phase revealed positive results in 2% of the cases (residual proteins > 8 μg/ml), the positivity threshold defined by the Pr EN ISO 15883-1 normalisation project concerning general requirements for desinfecting cleaners. Analysis of these results demonstrated that 12% of the instruments cleaned with ultrasounds carried traces of protein residues. There was no trace of proteins on instruments cleaned with a washing machine operating on the “endoscope” cycle, i.e. 143 successive cycles.

Discussion: Despite the difficulty in cleaning (double sheath), shavers and drill bits used in arthroscopic surgery can be reused without risk since the traces of residual protein are negligible when the instruments are cleaned with a endoscope-quality desinfecting washing machine. In addition, despite intensive use, wear is acceptable for ten cycles. Extensive use of disposable instruments should be carefully debated due to the financial consequences.


M. Romin J. Delecrin D. Heymanin C. Deschamps N. Passuti

Purpose: Adding bone marrow cells to ceramic materials provides an osteoprogenic capacity favouring bony regrowth. Likewise, addition of platelets, which contain growth factors, might increase the rate of bone formation. The purpose of this work was to quantify in vitro the osteogenic potential obtained by adding platelet-rich plasma (PRP) to the bone marrow culture on ceramic materials.

Material and methods: PRP was obtained by centrifugation of blood and added to bone marrow cells harvested from the iliac crest and cultured on biphasic macroporous ceramic materials. Addition of PRP was repeated with platelet counts every two days. Differentiation of bone marrow cell into cells with osteogenic potential was evaluated by quantifying alkaline phosphatase activity after 15 days culture.

Results: Proliferation of mesenchymatous cells was clearly enhanced in cultures with PRP (+31%). Mean prevalence of phasphatase-alkaline-positive colonies was also improved after addition of PRP (+38%). Similarly, alkaline phosphatase activity was higher after addition of PRP (+31%).

Discussion: Adjunction of PRP to bone marrow cells cultured on ceramic materials stimulates proliferation of osteoblast-like cells. Increased cell proliferation and differentiation observed in vitro provides quantitative elements favouring the combination of platelets with bone grafts using bone substitutes.


D. Hannouche H. Petite A. Meunier L. Sedel J.P. Vacanti

Purpose: Tissue engineering offers new therapeutic perspectives with the possibility of producing cartilage tissue for a large number of patients. These structures are composed of an absorbable synthetic support and competent cells. Two types of cells can be proposed: articular chondrocytes harvested from the peripheral part of the joint, or mesenchymatous stem cells (MSC) present in the bone marrow and possessing chondrogenic potential. The purpose of this study was to determine the optimal cell source and the best supporting material for in vitro production of cartilage.

Material and methods: Isolated rabbit MSC were harvested and amplified with cell culture for 21 days. After this period, 20–40 million cells/ml were combined with polyglycolic acid sponges (3 types of sponges 1x1x0.2 cm2) and cultured in TGFß-enriched medium under specific dynamic conditions allowing gas exchange. The tissue obtained was compared with structures of identical size obtained with differentiated chondrocytes harvested from the same animals. The study included a histological analysis and immunohistochemistry for type I, II, and X collagen and biochemistry for DNA content, glycosaminoglycanes (GAG) and type II collagen.

Results: After 3 weeks in culture, the composites obtained with MSC preserved their size and had the white pearly aspect of hyalin cartilage. The histological analysis and immunohistochemistry tests for type II collagen confirmed the presence of a cartilaginous matrix throughout the thickness of the fragments. The GAG and type II collagen contents were significantly higher with MSC compared with chondrocytes, irrespective of the supporting material.

Discussion: This study demonstrated that cartilaginous tissue fragments can be obtained with MSC cultured on PGA supporting material under very specific conditions. Use of these cells offers the advantage of easy harvesting followed by in vitro amplification, and thus less harvesting morbidity. Complementary studies are needed to evaluate the behaviour of these living materials after implantation in the articulation.


P. Piriou J.L. Marmorat C. Garreau de Loubresse T. Judet

Purpose: We have used monoblock cryopreserved femoral heads for acetabular reconstruction without supporting material since 1985 for cemented total hip arthroplasty in patients with major acetabular defects. From 1985 to 1995, 140 reconstructions were performed. We present a prospective analysis of the clinical and radiological outcome at 10 years follow-up.

Material and methods: Mean age of the population was 61 years. Most of the patients had had two prior interventions. According to the SOFCOT classification, the 140 defects were: grade II 50%, grade III 35% and grade IV 15%.

The cryopreserved graft (femoral head bone bank) was used to reconstruct the acetabular defect. The graft was adapted to the size of the defect to fashion a congruent construct aimed at achieving primary stability. We did not use any supporting material in addition the primary osteosynthesis with one or two screws. A poly-ethylene cup was cemented in the graft. Most of the cement was applied onto the graft which was reamed to the size of the acetabulum. We retained a theoretical 6-year follow-up for review. All patients were seen for follow-up assessment using the Postel-Merle-d’Aubigné (PMA) clinical score and standard x-rays analysed according to the Oakeshott method. Kaplan-Meier survival curves were plotted taking change in status, revision for clinical failure as the endpoint.

Results: Mean overall follow-up was 8.5 years; it was 10 years for patients with an implant still in situ. Eight patients (5.7%) lost to follow-up were included in the series retained for analysis at mean 5-year follow-up. Thirty-five patients died during the follow-up period (25%). These patients had been followed for a mean four years before their death. Radiologically, cup tilt was not significantly altered over time. Conversely, the centre of the cup, measured from the U line, was not modified in the patients who died or in the group of living patients without revision at last follow-up. It was modified in the group of failure group: mean 28 mm postoperatively in the failure group reaching 39 mm at time of failure (ANOVA < 10-3). We had 26 failures (18%) which occurred at six years (mean); there was a peak at two years and another at nine years. Mean Kaplan-Meier survival was 13.5 years (95CI 12.5–14). The PMA clinical score improved from 3/5/3 (11) pre-operatively to 5.3/5.6/4.3 (15.2) at last follow-up.

Discussion: The overall results at 10 years in this series were globally satisfactory with a success rate above 70%. Failures were related to radiologically demonstrated graft compression with ascension of the centre of the cup measured from the U line. Comparing these results with data in the literature shows an improvement over the Harris series (7-year follow-up in a small group of 48 patients).

Conclusion: This method of acetabular reconstruction reserved for major bony defects has provided a 73% rate of success at ten years.


M. Bandelier P. Denormandeie P Denys R. Sapena D. Enouf T. Youssefian Y. Blondeau M. Bonnet D. Ben Smail L. Mailhan T. Judet

Purpose: Few studies have been devoted to neurogenic paraosteoarthorpathy (PAOn). We characterised the expression of genes specific for osteoblastic and chon-drocytic phenotypes using the osteomy wedge and non-mineralised tissue near the osteotome.

Material and methods: Osteotomy fragments and non-mineralised tissue near the osteotomy were obtained during surgery performed in 25 patients. The explants were cultured for 56 days. We searched for the messenger RNA of the principal markers of osteoblastic, chon-drocytic, and adipocytic phenotypes, as well as certain specific proteins. Serial cryotome sections were stained for histology and immunolabelling tests.

Results: Cells issuing from the osteotomy fragment and neighbouring tissues formed structures that miner-alised in culture. The following osteoblast markers were observed: alkaline phosphatase (bone isoform), osteo-calcin, Cbfa1, type 1 collagen; for chondrocytes: type II collagen, aggrecane; type X collagen as well as VEGT demonstrating the presence of hypertrophic chondrocytes.The adipocyte-specific transcription factor PPAR 2 was also found in the two cultures. The proportions and chronological expression of these markers were slightly different for the two tissues. Ex vivo study demonstrated the typical sequence of enchondral type bony formation from non-osseous cell populations.

Discussion: This work provided the first characterisation of non-mineralised tissue near osteotomy. It also provided clear indications concerning the history of ectopic bone formation. The osteochondrogenic potential of connective tissue lying close to an osteotomy has not been reported previously. The persistence of this potential could explain recurrence after resection. The observation that this potential is suppressed in vivo but expressed in vitro opens a new avenue of research concerning the mechanisms controlling bone formation.

Conclusion: The culture model developed in this study provides a means of studying factors determining the outcome of cell populations implicated in the formation of neurogenic paraosteoarthropathies.


P. Hernigou G. Delepine

Purpose: Massive allografts have been used in orthopaedic surgery for many years. Early results have generally been encouraging, but the risk of long-term resorption remains to be evaluated. We analysed resorption of 39 allografts implanted more than 10 years earlier.

Material and methods: Thirty-nine massive allografts implanted to sheath hip, knee or shoulder prostheses were studied a mean 13 years (range 10 – 17) after implantation. These allografts had been prepared in the same manner: preservaton at −30°C, sterilisation by 25000 Gy before implantation. A radiological scale was used to class graft resorption as minor (less than 5 mm in depth and less than 1 cm in length), moderate, or major (concerning the entire thickness of the allograft over three quarters of the circumference, irrespective of the length involved. These allografts measured more than 15 cm and were used for revision of loosened total hip arthroplasties, or reconstruction after tumour resection (tibia, femur, humerus). Among the 39 patients, 21 had received postoperative chemotherapy alone or in combination with radiotherapy.

Results: The allograft healed within the first or second postoperative year. Peripheral resorption was only observed at last follow-up. Among the 39 massive allografts assessed more than 10 years after implantation, 28 exhibited radiologically visible resorption. Among these 28, resorption was minimal for 15, moderate for nine and major for four. The first factor favouring resorption was complementary treatment, particularly local radiotherapy after carcinological resection. To a lesser degree, chemotherapy, given alone, also favoured resorption. None of the allografts implanted during a revision procedure for loosened total hip arthroplasty exhibited signs of absorption 10 years later. Two patients who had undergone resection of a chondrosarcoma with no complementary treatment exhibited only minor allograft resorption. Minor and moderate resorption was observed preferentially in the upper portions of the tibia and humerus, compromising the implant (three loosenings at more than 10 years. Peripheral resorption of the allograft appeared generally between the third and seventh postoperative year. Beyond that time, resorption did not appear to occur or increase. Evident polyethyl-ene wear observed in several patients operated on more than 10 years earlier was not associated with endosteal osteolysis of the subjacent allograft.

Discussion: Resorption of massive allografts is preferentially observed in the upper portions of the humerus and tibia, and generally occurs in patients who have undergone carcinological resection of a tumour followed by complementary treatment. Resorption is exceptional for allografts inserted during total prosthesis revision.


C. Puig Abbs P. Semminario D. Valverde J. Fenollosa

Purpose: The purpose of revision surgery for a hip arthroplasty is to re-establish a stable assembly, recover bone stock, and re-establish the mechanical centre of the joint. The purpose of our work was to evaluate clinical and radiographic mid-term outcome of a press-fit cup on bone grafts for cup revision of total hip arthroplasty (THA).

Material and methods: We revised 55 hip arthroplasties in 1995 and 1996, for revision of the cup with reconstruction in 42 cases. For 16 patients (ten women and five men), we used the press-fix technique on bone grafts. Mean patient age was six years (range 34–82) and mean follow-up was 70 months (range 62–86). Besides four partial arthroplasties, the revised components were six screwed cups, five cemented cups and one press-fit cup. The reason for the first intervention was hip degeneration in most of the patients. We used the posterior approach in all patients. Bone bank stock was used, ground in fifteen cases and structured in two. Thirteen cups were coated with hydroxyapatite, three with a porous coating. Four components were reinforced with screws. We evaluated bony defects with the Paproski classification. The clinical aspect was assessed with the

Postel-Merle-d’Aubigné scale. For the radiographic analysis, we considered the situation of the implant after revision and possible later displacement. For the graft tissue, we studied integration in the De Lee-Charnley zones.

Results: None of the cups required revision. The component was well integrated in 62.5% of the patients. Function score improved from 11.5/18 preoperatively to 15/18 postoperatively then 15.9/18 at last follow-up. Subjectively patient satisfaction was good or excellent in 81% of the cases.

Discussion: This technique reinforces the bone stock since it preserves the bone present and adds new bone, facilitating integration. Likewise, it does not require changing the functional centre of the hip, good integration of the implant favours good assembly. Functional and subjective outcomes are good.

Conclusion: After at least six years follow-up, press-fit bone grafting for revision procedures is a promising technique.


C. Perrier V. Gaudiot D. Waast N. Passuti J. Delecrin G. Gouin

Purpose: Combining biomaterials with non-cemented cups is a new approach to acetabular construction in patients with bone stock loss after failure of conventional techniques. We evaluated our early results and attempted to ascertain limitations.

Material and methods: Between January 1, 1996 and December 31, 2000, we changed 229 cups. The reconstruction combined biomaterials with a non-cemented cup for 48 patients (mean age 57 years, age range 29–84). Mean retrospective follow-up was 37 months (7–67) with two patients lost to follow-up early.

Two types of cups coated with hydroxyapatite were used depending on the acetabular potential for retaining the implant: 26 ATLAS press-fit cups (four screwed) and 22 Cerafit cups with Surfix anchor screws. Bony defects were filled with grains of macroporous calcium phosphate ceramic, alone or in combination with an autol-ogous bone graft (five patients) and/or an iliac bone marrow graft (24 patients). The Harris and modified PMA clinical scores were used for assessment. According to the Antonio classification, preoperative bone loss was grade II in 18, grade III in 27, grade IV in 3. We attempted to determine the percent of bone support under the cup before reconstruction. The centre of the prosthesis rotation and the interfaces with the biomate-rials were checked regularly.

Results: At short-term, this technique provided a clear functional improvement (Harris improved from 53.7 to 81.3 points). The bone-biomaterial interface did not show any lucent lines and tended to become homogeneous (31 cases). Seven patients (15.2%) developed millimetric lucent lines around stable implants. We had nine failures (19.6%) and performed four surgical revisions (8.7%) for major inclination of the cup in three and recurrent dislocation in one. There were also five patients with an asymptomatic implant migration. Excepting one case, the cup inclinations occurred when the bony support was less than 50% of the acetabulum while only one migration was noted with less than 50% bony support (p=0.02).

Discussion: At short-term this technique, which is easy to perform and less costly and safer than allografting, provides similar results. We observed a continuous construct between the receiver bone and the macroporous biomaterial in all cases. Mechanically, the cup was stable when the bony support was healthy and involved more than 50% of the acetabulum. Other reconstruction strategies should be considered in other cases.


O. Gosselin O. Roche F. Sirveaux J.L. Aubrion M. de Gasperi D. Mole

Purpose: Acetabular reconstruction is particularly challenging in case of acetabular loosening with important loss of bone stock. The purpose of this retrospective study was to estimate long-term results after revision procedures using a fragmented allograft and a supporting ring.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent this procedure. Ninety-five files were reviewed (15 patients were lost to follow-up and 25 died). The 95 patients retained for analysis were 66 women and 29 men, mean age at surgery 70 years (range 42–86). The preoperative functional score (PMA) was 8/18. The acetabular implants in situ had been cemented in 62% of the cases and non-cemented in 38%. According to the SOFCOT criteria, 79% of the loosenings were associated with grade 3 bony lesions, 15.8% with grade 4 lesions and 5.2% with grade 2 lesions. In all cases, the acetabulum was reconstructed with fragments of allografts. An Eichler ring was used in 56% of the cases, a Ganz ring in 25%, and a Muller ring in 19%.

Results: Mean follow-up was eight years (60–157 months); 39% of the patients developed early postoperative complications including one dislocation and two haematomas. Mean functional score at last follow-up was 14.8/18 with 64% good or excellent results. Reconstruction of the centre of rotation was the only factor significantly affecting results. Radiographically, 85% of the cups presented no sign of loosening at last follow-up. The grafts were considered to be assimilated or unchanged in 81% of the cases, with partial or total lysis in 19%. Actuarial analysis of cumulative survival, considering surgical revision or clinical and radiographic loosening as the endpoint was 87% at 14 years.

Discussion: Fragmented allografts can be perfectly stabilised with a supporting ring to reconstitute bony stock of the acetabulum. Long-term clinical and radiographic results are encouraging.


D. Huten C. Jeanrot

Purpose: We report our results of revision procedures for severe acetabular loosening with saddle prostheses. The series concerned six patients, mean age 67 years age range 58–82 years, who initially presented rheumatoid disease (n=3), degenerative hip disease (n=3, one secondary to trauma), and radiation-induced hip disease (n=1). These patients had undergone one to three procedures for reconstruction with a bone graft and metal implants.

Material and methods: Failure was the indication for salvage with a saddle prosthesis due to massive loss of acetabular bone stock, complicated in five cases by an unstable hemipelvis due to transverse nonunion. An allograft was screw fixed in the iliac wing in two cases to stabilise the saddle prosthesis. Weight bearing was allowed early after surgery in all cases except two. The hip was immobilised in four cases for three to six weeks in a bermuda cast or with traction (n=4). Follow-up was 2 to 5 years.

Results: There was only one complication: stress fracture of the iliac bone at two years which did not heal. Bone graft with ostheosynthesis was proposed. Pain relief was nearly total in all cases. Four patients could walk without crutches and two walked with two crutches or an ambulator due to associated disease or alar fracture. The fixation was at 60 – 95° with abduction at 10–30°. All patients were satisfied and two felt the result was very superior to simple ablation of the prosthesis which they had experienced. Radiograpically, there was no evidence of ascension of the saddle but the risk remains at this short follow-up due to the rates described in the literature. One major migration was observed as was one stress fracture of a weak iliac bone which required removal of the implant.

Discussion: This difficult technique provides a better result and thus would be indicated for young patients able to sustain the intervention. It would be logical to associate a supporting bone graft on the iliac bone to prevent stress fracture and migration of the saddle. The saddle prosthesis appears to be the last resort after failure or insufficient results after prior reconstruction. The leading cause of failure is nonunion with hemipelvis mobility. This suggests the intervention should be considered before reaching this stage of well tolerated ace-tabular loosening.


E. de Thomasson O. Guuingand D. Mazel

Purpose: The rate of dislocation after revision total hip arthroplasty (RTHA) has varied from 8 to 28% in published series. Many causes are involved, but little work has been focused on the incidence of spinal disease in patients with postoperative dislocation.

Material and methods: We performed a prospective analysis of 267 patients who had undergone RTHA in search of risk factors of postoperative dislocation. Chi-square test or Student’s t test were used for the statistical analysis as appropriate. P < 0.05 was considered significant.

Results: We excluded 37 patients who had undergone first line THA with a restrained cup and who had not experienced dislocation. The 230 patients retained for analysis had undergone primary surgery with no intra or postoperative anti-dislocation measure. Among these, 31 (13.4% experienced dislocation). The cause was evident in ten cases (malposition, fracture of the greater trochanter, sciatic paralysis). For the other 21 patients, age, gender, types of surgery (uni or bipolary), surgical approach, size of the implant, and size of the femoral or acetabular defects were not found to influence the rate of postoperative dislocation. Conversely, a significant relationship was found between increased rate of dislocation and history of repeated dislocations (p < 0.001), prior surgery (p< 0.05), and association with spinal disease (p< 0.02). Characteristically, there was either radicular, or spinal disease, or both. Retrospective analysis of the radiograms showed that the measures of sacral incidence and inclination of lumbar lordosis were not predictive of dislocation. Inversely, the projection of a vertical line passing through the centre of rotation of the hips on L3 was different in patients who had experienced dislocation and those who had not (p< 0.02).

Discussion: This study confirms the role of a history of dislocation and prior surgery in the risk of postoperative dislocation. It also shows that associated spinal disease, which may results from radicular disease, as well as altered spinal static can have an influence. A prospective study is currently under way to distinguish these features.


E. de Thomasson O. Guingand J.L. Marmorat C. Mazel

Purpose: The Exeter technique opens new perspectives for the treatment of femoral bone loss observed at revision hip arthroplasty. Early migration of the implant, considered by the advocates of the technique to be beneficial when limited, can, in the absence of secondary instability, weaken the cement shield leading to early revision. Several publications on this topic have examined the improvement in primary stability achieved by modifying the impaction technique or by searching for the ideal size of the grafts. The purpose of the present study was to examine the reproducibility of this method and its effect on transformation of the allograft.

Material and methods: We performed a prospective analysis of outcome in 46 patients operated on since 1996. The Poste-Merle-d’Aubigné (PMA) clinical score and the Ling and Gie radiographic score as well as the SOFCOT score for substance loss were determined. We used frozen fragmented allografts without consideration of graft size. A standard sized femoral implant was used in all cases.

Results: Mean follow-up was 3 years (range 12 – 66 months). Four patients were not followed beyond 9 months because of major complications requiring revision surgery (infection, fracture of the femur, malposition) or patient death (stroke). For the remaining 42 patients, loss of femoral stock was scored I in 6, II in 23, III in 13. The functional score improved from 9.13±3.9 preoperatively to 16.07±2.5 postoperatively. Radiographically, bone lines were observed in the graft in 36 patients, associated with bone remodelling in ten. In six patients, the allograft exhibited a heterogeneous aspect. Three implants migrated 4 mm. Defective distal sealing was noted in all three. One prosthesis implanted in a varus position worsened before stabilising.

Discussion: This technique is a reliable method since primary stability of the implant was obtained in 90% of the cases and was maintained during long follow-up. This did not prevent graft remodelling.


D. Hannouche R. Nizard A. Meunier P. Bizot L. Sedel

Purpose: During revision of alumina-on-alumina prostheses, reimplantation of a ceramic head on the former stem raises the risk of head fracture. Furthermore, serious deformation of the metal head has been reported after failure of ceramic-on-ceramic prostheses. The purpose of this retrospective study was to evaluate the incidence of these complications and analyse clinical and radiological results of revision for alumina-on-alumina total hip arthroplasties.

Material and methods: This consectutive series included 107 patients (74 women and 33 men, mean age 65 years, age range 32–91 years) who underwent 118 revision arthroplasties from 1976 to 1997. The cause in the majority of the cases was isolated non-infected cup loosening (80%) or ceramic implant fracture (4%). There were 72 cemented alumina cups, 38 screwed cups, six press-fit metal-backed cups, and two massive alumina impacted cups. Cavitary acetabular osteolysis was present in 67% of the cases. The cup was replaced alone in 94 cases (80%). The implanted cup was a polyethylene cup in 93 cases and an alumina cup in 25. When the femoral stem was left in place, a new ceramic head was implanted in 49 cases (39 alumina, 10 zircone). The alumina head was replaced by a metal head in 18 cases.

Results: Four early dislocations and two infections were noted. Mean follow-up after revision surgery was 67 months. Fourteen patients were lost to follow-up. Sixteen patients required revision surgery, ten of them for repeated cup loosening. At last follow-up (mean 61 months), there were no failures among the 49 ceramic heads implanted on a stem left in place. No revisions were required for polyethylene cup wear or metal head wear. In all, 72 hips were evaluated at a minimum two years follow-up. The functional score at last follow-up was 15.2±3.5. Seven-year actuarial survival was 95.5% taking revision of non-infected revision as the endpoint.

Discussion and conclusion: Analysis of the results shows that acetabular loosening is the main cause of revision of alumina-on-alumina total hip arthroplasties. The femoral stem was loosened in only nine cases and could be preserved in 80% of the cases. Replacement of an alumina-on-alumina couple with a metal-on-polyethylene couple does not appear to be a contraindication in this series.


F. Delangle F.X. Veroot E. Chalenoon L. Béguin M.H. Fessy

Purpose: We report a prospective series of 70 explantations of the femoral pivot via a transfemoral approach required due to septic and aseptic loosening.

Material and methods: Aseptic loosening was observed in 61 cases, septic loosening in 9. The extended posterolateral approach was used to remove the implant in all cases and a femoral segment (Wagner method). Reconstruction of the femur was achieved with locked stems without cement (65 patients) or a long stem without cement (1 patient). Reimplantation was not attempted in four patients. Bone grafts were not used. Mean follow-up in this series was 3.5 years. The PMA score was used for clinical assessment. Radiographic assessment of segment healing and bone regrowth around the implant was done by measuring the cortical index.

Results: We observed a significant gain in the PMA score of more than 9 points. We had one intraoperative fracture of the femoral segment and two episodes of early dislocation. All femoral segments healed. Osteogenesis failed in three cases with fracture of the locking screw. There were also two cases of late fracture of the trochanter. At one year, bone regrowth measured from the cortical index was greater than 10% on the average.

Discussion: We discuss the characteristic features of this type of surgery in comparison with other solutions for femoral revision: operative time, blood loss, choice of implants, later weight bearing. We also found that this technique allows easier implant removal and more effective cleaning of the femoral shaft in the event of septic surgery with fewer cases of intraoperative accidents (malposition, femoral fractures). We were able to demonstrate that this method of femur reconstruction without bone graft provides a stimulation of osteogenesis in the floating segment. Stem locking provides primary stability in 100% of the cases. Secondary stability was achieved in 90% due to the quality of the newly formed bone.


A. Ben Lassoued G. Asencio R. Bertin B. Megy P. Kouyoumdjian S. Hacini

Purpose: The purpose of this work was to assess the quality of the bone reconstruction in contact with the long hydroxyapatite-coated locked femoral stem used in a consecutive series of patients undergoing revision total hip arthroplasty (RTHA).

Material and methods: This series of 20 patients underwent RTHA for aseptic loosening (n=15) or septic loosening (n=5) of an AURA prosthesis. Mean age was 70.5 years. Mean time between insertion of the first stem and revision was 11 years for the aseptic patients and 2.6 years for the septic patients. Bony lesions of the femur were assessed with the SOFCOT classification: grade I=5, grade II=4, grade III=4, and grade IV=1. A transfemoral approach with a floating femoral segment was used in 14 patients and an endofemoral approach in six. The septic loosenings were reconstructed in two operative times in four patients and in one operation in one patient. An AURA reconstruction stem was used in 15 cases and a revision stem in five. A complementary cancellous bone graft with the endofemoral approach was used in six patients.

Results: Two patients died. All others were reviewed at a mean follow-up of 26 months (range 12–46 months) for clinical and radiographic assessment (five patients also had a supplementary scan at more than three years follow-up). We had three dislocations at 15 days with no recurrence and one case of sepsis at three months which cured after wash out and adapted antibiotics. All the femoral segments healed starting on the tenth week. The PMA score improved from 9.1 to 15.66 and the Harris score from 43.5 to 85.5. At last follow-up, all femoral lesions had moved to a lower SOFCOT score. There was a tight contact between the AURA stem and the femur on the last follow-up scan which showed an increase in the cortical index from 1 to 8 cm from the metaphyseal spine of the stem. None of the patients experienced secondary unlocking or required revision for a shorter stem.

Discussion: Revision after femoral failure with bone destruction using a non-cemented hydroxyapatite-coated stem allows immediate prosthetic mechanical stability and intimate bone reconstruction in the metaphyseal diaphyseal region. This reconstruction is real even if a graft is not used and appears to be favoured by the femorotomy. Implantation of the long stem is not particularly difficult and can even make the operation easier. Femorotomy has a real advantage, particularly for the revision of septic stems or in the event of difficult explantation.


C. Nich P. Bizot P. Dekeuwer L. Sedel

Purpose: Filling bone loss during revision total hip arthroplasty raises many problems related both to the surgical technique and to the type of bone substitute used. The purpose of this study was to report the clinical and radiographic results obtained in a series of femur reconstructions using impacted calcium phosphate ceramics.

Material and methods: The technique used here was derived from the method developed for impacted fragmentary grafts by Ling and Gie. Grains of macroporous biphasic calcium phosphate ceramic (MBCP) were impacted into the femoral shaft to obtain a stable sheath into which the stem could be cemented (Ceraver Osteal). This technique was used from March 1996 to october 2000 in 18 patients (20 hips) undergoing revision for femoral loosening in 11 (including septic loosening in eight), femoral osteolysis (one hip), pain (one hip), and instability (one hip). Mean age ate revision was 66 years (range 30–79). Most of the femoral bone defects were classed grade IV. The grains of MBCP were used alone in 13 cases, in a mixture with allografts in five cases, and in a mixture with autologous bone in two cases.

Results: Mean follow-up was 31 months (range 8–70). None of the patients were lost to follow-up. There were two intraoperative femur shaft fractures which healed without sequela. Two patients required a second revision for loosening (including one septic) 20 and 16 months after the first revision. At last follow-up, the mean PMA score had improved to 16 (12–18) (p< 0.05) and 67% of the patients achieved a good or excellent clinical result. Radiologically, there were 14 cases of good osteointegration of the MBCP grains without implant migration. Mean shortening was 3 mm (3–5) was observed in three cases and a stable incomplete lucent line was observed in one patient with no clinical impact.

Discussion: Calcium phosphate ceramic material can be useful to overcome the problem of major bone loss in RTHA. It provides an attractive alternative to the disadvantages of bone grafting and helps, in theory, improve primary implant stability. The original technique presented here has allowed us to achieve promising short-term results in young patients with an adequate femur.


F. Damie L. Favard

Purpose: Wear of prosthetic implants, especially the metal-polyethylene head-cup couple, and dissemination of wear particles throughout the organisms the dominant long-term complication of total hip arthroplasty. We determined serum concentrations of chromium, cobalt, nickel, and molybdenum in patients bearing a total hip prosthesis with a chromium-cobalt metal-poly-ethylene head-cup couple. The purpose of our work was first to compare the levels observed with those found in a control population and then to study variations in these levels as a function of clinical and radiological signs commonly searched for during the follow-up of patients with a total hip arthroplasty.

Material and methods: During a period of 30 months, a total hip arthroplasty (PVL®) was implanted in 53 patients suffering from degenerative hip disease. Forty-eight patients were assessed at a minimum follow-up of 32 months with physical examination and standard x-rays as well as serum assay of the specified metals using mass spectrometry on whole blood samples. The control group was composed of 56 patients scheduled for total hip arthroplasty.

Results: At a mean follow-up of 44 months, 17% of the patients had a fair or poor functional score and 37% had radiological signs suggestive of femoral stem loosening. There was a significant increase in the serum level of cobalt compared with the control group. This increase was greater in patients with radiological signs of loosening.

Discussion: The metal-on-metal couple does not appear to be the only couple which increases serum metal levels. Serum metal assay could be a diagnostic tool useful for following patients with total hip prostheses.


J.Y. Lazennec E. Fourniols G. Saillant

Purpose: Infection of a posterior fixation can lead to a therapeutic dilemma, particularly if the extensive fixation involves a demineralised spine.

Material and methods: From 1998 to 2001, seven patients aged 19 to 76 years (mean 58) were treated with an interbody cage and an autologous graft. Four patients with scoliosis had had prior posterior surgery (mean five operations, range 3 – 9 operations). All had exhibited non-union with repeated fistulisation at each prior anterior approach, in four cases with meti-R Staphylococcus associated once with a Streptococcus and twice with an Enterococcus. Three patients suffered severe radicular pain. Three of the post-trauma patients had undergone revision procedures to remove the posterior implants. All had developed nonunion with total loss of the initial correction in two cases, one with septic instability concerning the level above the fixation. Both infections were caused by meti-R Staphylococcus, associated with an Enterococcus in one case. Two persistent posterior fistulae had been reoperated earlier. The grafts involved one to four levels with no new posterior fixation except for one patient (two accesses to the thoracolumbar junction, five lumbosacral fusions, immobilisation for four to six months with a corset). Mean duration of postoperative antibiotics was four months (3–12 months). Fusion was confirmed by the radiological aspect of the grafts on the scan obtained at a mean 22 months follow-up (minimum follow-up 12 months).

Results: There were no cases of anterior infection except for one post-trauma patient where a posterior screw touched the disc (reactivation of infection without anterior abscess, posterior approach for revision and final fusion in kyphosis). There was no appreciable improvement in correction, but the six other patients fused with a clear clinical improvement (removal of rigid corset, reduction of antalgesics, mean time 6 months). Improvement was observed in the three patients with radicular pain. One patient who had undergone three prior anterior operations underwent the minimally invasive posterior revision with no particular intraoperative problem but later presented ureteral necrosis (secondary nephrectomy).

Discussion: This interbody grafting strategy is a possible solution to salvage mechanical failures subsequent to recurrent severe infection often due to multiple germs. The technique is more difficult in older patients with complex malformations. A positive disc sample is a factor of less satisfactory outcome. In the event of prior anterior revision, an ureteral catheter is advisable to limit the risk of necrosis. Use of intersomatic cages is not a problem and has allowed us to achieve primary and secondary stability in these patients with poor bone stock and this without supplementary infection problems.


C. Mazel D. Grunenwald

Purpose: Tumours arising from the pulmonary apex or the posterior mediastinum may be removed en bloc in combination with total or partial vertebrectomy in the event of spinal invasion. Extra-tumour resection is a perfectly described surgical procedure recognised for its carcinological effectiveness. Raymond Roy-Camille and Bertill Steiner described en bloc spinal resection of a thoracic vertebra via a simple posterior approach. Paulson, described resection of tumours of the pulmonary apex (Pancoast Tobias) via a cervicothoracic approach. We associated these two techniques to allow en bloc resection of posterior mediastinal tumors or pulmonary apex tumours associated with spinal invasion.

Material and methods: We recommend different surgical approaches to the cervicothoracic and mid thoracic spine. For the cervicothoracic spine, an anterior approach is used with simple dislocation of the sterno-clavian joint without resection of the clavicle. The subclavian vessels and the brachial plexus are dissected and exposed. The tumour is then dissected followed by the peripheral, particularly œsophageal, attachments. The tumour is not detached from the spine to which it adheres tightly. Conventional thoracotomy is used for the thoracic level with dissection of the tumour from the adjacent soft tissue. In the event of a tumour in the posterior mediastinum, the anterior time is followed by a posterior approach. For primary pulmonary tumours, lobectomy or segmentectomy, or even pneumonectomy, is performed during the anterior time. Total or partial vertebrectomy, depending on the level of spinal involvement, is performed during the posterior approach.

Results: Thirty-six patients underwent this type of procedure. Total vertebrectomy was necessary in seven patients, partial vertebrectomy in 29. Mean follow-up has been six days to 7.2 years (mean 23.3). One patient died during the postoperative period due to a cause unrelated to the tumour. Only 35 patients were retained for analysis. Twenty-one patients (60%) died after a mean survival of 16.7 months (8–44 months). The 14 others (40%) are living at a mean 38.2 months survival (8–87 months).

Discussion: This technique requires a long learning curve and an extremely careful evaluation of tumour extension. Results obtained to date confirm the feasibility of the technique and point out its contribution in case of wide resection. Certain patients have lived more than five years after resection.


A. Crawford

Purpose: The purpose of this study was to analyse the learning curve of video-assisted thoracoscopic surgery in a consecutive series of 70 interventions for decompression and intervertebral fusion with rib bone grafts.

Material and methods: This series was composed of 70 patients followed for at least two years. The indication of video-assisted thoracoscopic surgery was idiopathic scoliosis (n=32), neuromuscular spinal malformation (n=13), neurofibromatosis (n=1), scoliosis secondary to Marfan disease (n=1), radiation-induced scoliosis (n=1), and nonunion (n=1). The first rib was resected in three patients due to compression. Resection of an intrath-roacic neurofibroma and a benign rib tumour was performed in two patients. Anterior fusion was necessary in one patient due to fracture-displacement of the thoracic spine.

Results: Mean operative time for thoracoscopic anterior decompression with discectomy and fusion was 256 minutes (range 150–405). On the average, eight discs were removed (range 4–11). Comparison of mean operative time per disc between the first interventions (n=31) and the later interventions (n=32) did not demonstrate any significant difference. Mean blood loss during thora-coscopic anterior decompression with discectomy and fusion was 285 ml (range 50–1300).

Discussion: Definitive postoperative correction was achieved in 68% and 90% of the patients with scoliosis and kyphosis respectively. A thoracoscopy-related complication was observed in three patients. Video-assisted thoracoscopic surgery is an interesting alternative to conventional thoracotomy allowing effective safe treatment of infantile spinal malformations despite a long learning curve.


J.Y. Lazennec R. Del Vecchio M. Amel Techentko N. Rafati G. Saillant

Purpose: We analysed the radiographic course of anterior lumbar interbody fusion achieved via a minimal anterior extraperitoneal approach.

Material and methods: From January 1996 to December 2001, we operated 198 patients with this technique. Twenty-one patients were excluded from the analysis (two deaths, three tumours, 16 follow-ups less than 12 months). Mean age of the 177 patients retained for study was 53 years (range 22–78). Mean follow-up was 2.7 years. The 55 post-trauma cases involved essentially thoracolumbar junction. The 122 cases of degenerative lumbar spine included 14 cases of scoliosis, 26 cases of spondylolisthesis, 72 cases of unstable spines after primary posterior surgery, and 10 isolated degenerative discs. Only eight patients did not have posterior fixation. Fusion (globally 360 levels) concerned one disc in 89 patients, two discs in 71, three discs in 17. Cancellous autologous grafts were used with cages. Tricortical grafts were implanted after corporectomy (n=23). Radiological fusion was confirmed by the absence of a mobility chamber around the pedicular screws, the cages or the tricortical grafts, and by searching for loss of sagittal angles (digitalized scans and x-ray, Auto Cad L.T.2000).

Results: 1) Early postoperative status. For the post-trauma cases (65 fused levels, 55 patients), a simple callus was observed in 28. For the others, mean correction was 4° per level. 2) Angle loss. For the trauma cases, mean angle loss was 3.9° in 36 cases (29 grafts on a single level). There were two partial expulsions of the tricortical grafts implanted in osteoporotic patients; revision was not attempted. Mean angle loss for the 65 grafted levels was 2°. For the degenerative cases, mean angle loss was 3.7° for 172 fused levels (112 patients). Cage expulsion on a grade 3 spondylolisthesis did not warrant revision. Two cage impactions did not cause significant loss of angle. 3) Anatomic status of the grafts. Fusion was achieved at all levels without cage or tri-cortical graft rupture. We observed a partial but stable lucent line around the case in five cases.

Discussion: The rate of fusion reported after anterior lumbar interbody fusion has varied from 55 to 100% in the literature. This technique is an original approach for trauma victims avoiding the need for extensive posterior assemblies and/or the damage caused by a wide anterior approach. For the degenerative spine, the mediocre quality of the bone and the frequency of several level fusions is not a particular problem.

Conclusion: Anterior lumbar interbody fusion is an interesting method for reinforcing posterior fixation with a real efficacy in terms of effective fusion.


P. Garçon

Purpose: The purpose of this study was to assess the efficacy and safety of treating extra-foramen discal herniation via a microsurgical extra-foramen approach.

Material and methods: Fourteen patients underwent this surgical procedure which enables release of the roots outside the foramen while preserving the vertebral isthma. The technique is described in detail together with the postoperative period. All patients were reviewed clinically and radiologically at at least one year. The PROLO score was used to assess results.

Results: Among the 14 operated patients, good or excellent results were obtained in 13, fair results in one. There was no postoperative neurological deficit. The small number of cases in this series did not allow a statistical analysis of this uncommon clinical presentation.

Discussion: The extra-formamen approach is an interesting alternative to isthmic resection requiring fixation for the treatment of disc-root conflicts in the extra-foramen position. With appropriate surgical skill, the technique is safe.


D. Andretta V. Pibarot J. Béjui-Hugues J.P. Carret

Purpose: Surgery is the mainstay treatment for chondro-sarcoma. About 35–40% of these tumours are located in the pelvis. Treatment requires significant sacrifices to ensure acceptable survival.

Material and methods: This retrospective analysis of ten patients treated between 1993 and 2001 for pelvic chon-drosaromas was undertaken to examine survival and functional sequelae as a function of treatment and tumour grade. All patients had primary chondrosarcoma. The population included seven men and three women, mean age 50.9 years (range 28–77). Mean survival was 39.7 months.

A biopsy was obtained in all cases (seven under scan guidance). Six patients required complementary surgical biopsy. According to the O’Neel and Ackermann classification, the tumours were grade I in five patients, grade II in two, grade III in three. Tumour classification according to the Enneking topography was: zone I one patient, zone I and II one patient, zone I+II+III one patient, zone II three patients, zone II+III three patients, and zone III one patient. Careful search for extension failed to identify metastasis preoperatively in any patient. For six patients, tumour resection was performed without reconstruction. Resection was associated with a Pugent reconstruction in three patients. All patients were reviewed with an AP view of the pelvis and a chest x-ray.

Results: In sano resection was achieved in eight out of nine patients. For the ninth patient, resection was marginal according to the pathology report. Postoperative survival revealed the presence of metastasis in three patients. One patient developed recurrent tumour. At last follow-up, two patients had died and one had multiple metastases. Seven are currently disease free. Early postoperative complications occurred in 80% of the patients.

Discussion: Currently, surgery remains the treatment of choice for pelvic chondrosarcoma, despite the major perioperative morbidity. Reconstruction, if attempted must always respect the rules of carcinological resection. Reconstruction does not appear to be mandatory since the rate of secondary and late complications remains particularly high in the case of extensive reconstruction. Histological grade, tumour size and quality of surgical resection are the predominant prognostic factors.


F. Fiorenza R. G. Grimer A. Abudu K. Ayoub R.M. Tillman J.L. Charissoux S.R. Carter

Purpose: The purpose of this work was to analyse survival and prognostic factors in a series of patients treated for pelvic chondrosarcoma.

Material and methods: This series included 67 patients (27 women and 40 men) treated between 1971 and 1996 for pelvic chondrosarcoma. Mean age at diagnosis was 45 years (range 18–78). Forty percent of the tumours were grade I. The most frequent localisation was the iliac bone. Conservative surgery was performed in 45 patients. The only surgical treatment possible in 22 patients was an inter-ilioabdominal disarticulation. Resection margins were adequate for only 19 patients (wide resection). Marginal resection was noted in 14 patients with intra-tumour resection in 17.

Results: Overall 5- and 8-year survival was 65% and 58% respectively. Local recurrence rate was 40%, occurring a mean 27 months after initial surgery. Statistical analysis did not reveal any correlation between tumour size, tumour grade, type of surgery, resection margin, and local recurrence. Results were nevertheless less favourable in case of inadequate surgical margins. Tumour grade, tumour size, patient age, gender, and quality of resection did not have a significant effect on overall survival. Local recurrence was the only negative factor predictive of survival (p< 0.05).

Discussion: Development of local recurrence appears to be the most important negative predictive factor in patients with pelvic chondrosarcoma. In this localisation, satisfactory resection margins are often difficult to achieve. Most authors propose inter-ilioabdominal disarticulation as a last resort procedure. The question of the indication for more aggressive initial surgery to obtain more radical resection margins remains open.


C. Mazel J.L. Marmorat J. William P. Antonetti R. Terracher O. Guingand E. de Thomasson

Purpose: We analysed retrospectively 32 cases of posterior cervicothoracic fixation for spinal tumours. We evaluated spinal stability, spinal alignment, and associated complications.

Material and methods: Thirty-two patients underwent surgery: 27 men and five women, mean age 52 years, age range 17–72 years. We implanted 96 articular screws in C4 to C6, 54 screws in C7 and 180 pedicular screws in T1 to T8. Nineteen patients had primary lung cancer with spinal invasion, eleven had spinal metastases, one had a chondrosarcoma and one had a myeloma. For the first group of 19 patients, en bloc resection of the tumour with the vertebra was performed: four total vertebrectomies, 15 partial vertebrectomies. In a second group of 15 patients, palliative posterior fixation was performed with laminectomy decompression.

Results: Follow-up ranged from three to 54 months with a mean of 15 months. Mean survival after total or partial vertebrectomy was 16 months (range 3 – 54 months). Survival after palliative decompression was eleven months with a range from five to 19 months. There were no changes in the sagittal alignment in 30 patients: two patients developed mechanical complications late after surgery requiring revision. We did not have any case of screw, plate or rod fracture. There were no neurological complications related to screw insertion either at the thoracic level (180 screws) or the cervical level (96 screws in C4C5C6 and 54 screws in C7). A control scan was available for 21 patients and revealed a malposition of the implanted screws for 2.5% of the screws with no clinical impact.

Discussion: Posterior screw fixation is a good method to stabilise the cervicothoracic spine during tumour surgery. Articular cervical screws and transpedicular thoracic screws provide effective stability postoperatively. In addition, this type of instrumentation does not interfere should subsequent laminectomy or wider resection be necessary.


C. Court L. Bosca V. Molina G. Missenard J.Y. Nordin

Purpose: Surgery is required for primary tumours invading the sacroiliac joint. The purpose of the present work was to analyse results obtained with surgical treatment in order to better ascertain indications.

Material and methods: Forty patients (24 men and 16 women), mean age 24 years (range 12–56) underwent surgery for high-grade sarcoma (n=30, osteosarcoma 12, Ewing 13, chondrosarcoma five) or more differentiated tumours (n=10, low-grade S chondrosarcoma five, fibro-sarcoma two, others three). Resection was achieved in 37 cases via two approaches and via a lateral approach in three. Resection involved vertical sacrectomy either via the homolateral foramen (n=27) or via the midline (n=10). Reconstruction consisted in stabilising the iliosa-cral assembly generally associated with vertebral osteo-synthesis, an autologous graft in 36 cases, cement in one, and an allograft in three. Functional outcome was assessed with the MSTS (Enneking).

Results: There were three infections (all three with extensive lateral approach) and five cases of postoperative lumbosacral trunk palsy. Late complications were three cases of spondylolisthesis and eight nonunions. Twenty patients died (eight local recurrences, ten metastases, one chemotherapy toxicity, one undetermined cause). Sixteen patients achieved complete remission at six years (follow-up 2–16 years) and four patients were lost to follow-up. Functional outcome was very good in eight, good in ten, fair in twelve, and poor in ten. Survival was 40% among patients with malignant tumours (38 patients) but only 20% for those with osteosarcomas.

Discussion: Technical improvements (combined approach rather than wide lateral approach and omentum flap) have allowed a reduction of cutaneous and infectious complications. Mechanical complications can be prevented by systematic lumbosacral fusion on the side opposite the resection reconstruction. This provides good functional results despite sacrificing a hemi-sacral plexus if the lumbo-sacral trunk is preserved. Reconstruction after extension of the resection to the acetabulum raises an unresolved problem and yields mediocre results. The quality of the surgical resection is determinant since risk of local recurrence is 8/100 after a contaminated resection edge.

Conclusion: Surgical resection of sacroiliac tumours is a source of numerous complications despite real technical improvements. This approach can be proposed if carcinological resection can be reasonably achieved. Local control is very poor in case of large osteo-osteogenic sarcomas.


Full Access
N. Karray A. Babinet B. Tomeno P. Anract

Purpose: Fibrous dysplasia is a rare condition accounting for about 1% of benign bone tumours. Both mono- and polyostotic dysplasia is described. Treatment of small tumours is not particularly difficult, but extensive or complicated tumours are another problem. The purpose of this work was to present the results of surgical treatment of a consecutive series of 64 patients. Particular focus was placed on complications.

Material and methods: This retrospective series included 64 patients with fibrous dysplasia. Mean age was 32 years. There were 37 women and 27 men. Monostotic dysplasia was noted in 58 cases. The femur was the most frequent localisation (n=19). Seven patients had a fracture. Histological proof was obtained in 61 patients. In three patients, fibrous dysplasia was associated with another tumour (aneurysmal cyst or adamantinoma). Several therapeutic strategies were proposed: abstention for three patients, biopsy alone for 13, resection for six, curettage for 34. The curettage was filled in 23 cases with osteosynthesis in 11. Eight patients were given other surgical treatments (prosthesis, osteosynthesis, amputation).

Results: We had five postoperative complications. At mean follow-up of 45 months, 14% of the patients still suffered from generally mild to moderate pain. Radiologically, there were four recurrences, 12 unchanged, 18 regressions, and 19 remissions (generally after resection or curettage with filling). Long-term follow-up revealed malignant transformation in two patients.

Discussion: Lesions treated by biopsy alone cured or regressed in 30% of the cases while curettage with filling led to cure or regression in 70% of the cases. We did not include patients treated by bisphosphonates in this series because of insufficient follow-up. Nevertheless, this treatment appears to have a promising effect on pain.

Conclusion: Results of treatment for fibrous dysplasia are not as good as might be suspected for this benign disease. The role of surgery appears to be on the decline, to be replaced by bisphosphonates whose long-term efficacy must be evaluated.


F. Delepine G. Delepine F.H. Dujardin

Purpose: Villonodular synovitis is a highly proteiform disease. The classical localisation is in the hand joints, but we focused on pseudomalignant forms which must be recognised to avoid unnecessarily aggressive treatment.

Material and methods: This series included ten files of patients seen for soft tissue tumour of the knee (n=6) or the hip (n=4). Time from first clinical sign to first consultation was two years on the average. The clinical presentation was dominated by major tumefaction of the soft tissues in all patients. There were no signs of joint disease in about half the patients. Radiological signs were noted in six patients. When obtained, MRI demonstrated, in all cases, a tumour formation with ferric deposits and thus contributed considerably to diagnosis.

Results: All patients underwent surgery. Five developed recurrence, as many as four times. One of these recurrent episodes was noted 17 years after the initial intervention that was considered satisfactory (wide monobloc resection). Joint involvement was minimal in these patients with a strong discordance between the minimally troublesome clinical presentation and the major anatomic modifications revealed radiographically.

Discussion: The risk of misdiagnosis is illustrated in our series which included two patients proposed for amputation with one which was actually performed due to a doubtful diagnosis of synovialosarcoma. This observation points out the review of the Swedish registry of synovialosarcomas: of the 81 files enrolled in the registry, 12 were found to be an aggressive form of villonodular synovitis.

Conclusion: The diagnosis of synovialosarcome, considered in patients who present with major tumefaction of soft tissues, signs of joint involvement, or ferric deposits identified on the MRI, should be evaluated with excessive care to rule out possible villonodular synovitis which responds to minimally aggressive treatment to be adapted to each individual case.


P. Massin B. Faguet B. Lebec

Purpose: Dynamic MRI studies have confirmed the posterior displacement of the lateral condyle during flexion of the knee.

Material and methods: We used bone morphing navigation equipment to study knee kinetics in cadaver specimens and determine the effect of ligament injury. Patellar movement was controlled with pins. Femur movement over the tibia was measured by the navigation system during knee flexion.

Results: We noted external rotation of the femur during knee flexion when the tibia was maintained with the foot in the walking angle (15° with the flexion/extension plane), the femur being free to rotate. This rotation was nevertheless suppressed by constraining external rotation of the tibia. Unlocking rotation between −5° and +5° was measured between 8 and 10°. It was prolonged by greater rotation, increasing regularly with flexion to reach about 30° at 130° flexion. The computer display of the kinetics of the bony components demonstrated the posterior displacement of the lateral condyle. From 130° flexion, there was an elevation of the medial condyle which lost contact with the medial tibial plateau.

Posterior displacement of the lateral condyle was confirmed by rotation of the patella in its longitudinal axis. The patella appeared to make a lateral translation movement to come in front of the lateral condyle at near complete flexion. It pulled the vastus medialis as is suggested by its movement around the anteroposterior axis.

Section of the anterior cruciate ligament had little effect on the observed kinetics. It limited the unlocking rotation which did not exceed 3°. At about 110° the femoral rotation reached a plateau for about twenty degrees. The computer display illustrated the movement of the condyles showing that the movement of both was influenced by the posterior thigh soft tissue. Section of the popliteal muscle clearly lessened external rotation of the cadaveric knee.

Discussion: Two types of movement can be described: – external rotation of the tibia at the end of extension due to the influence of the anterior cruciate ligament; – facultative external rotation of the femur during flexion under the control of the popliteal muscle. This is expressed during single leg stooping and could protect the patella from excessive pressure by progressively displacing the lateral condyle.


S. Plaweski R. Julliard G. Champeloux S. Ionescu C. Schuster P. Merloz

Purpose: No conventional surgical technique for ligament reconstruction can be used in all cases to achieve ideal position of the transplant. Navigation systems without visualisation of the anterior cruciate ligament should meet the requirements. This is an operative strategy based on one or more computer assisted procedures enabling ligament reconstruction without the need for conventional pre- per, or postoperative imaging. The principle is based at the present time on the use of a station (computer, localisers, display screen, command pedal) used for processing data (spatial measurements and positioning) delivered by markers fixed on rigid bodies and tools (palpation, aiming tools).

Material and methods: This study was conducted on ten cadaver knees. Each knee was instrumented with the station. Joint kinetics were recorded with and without the ACL and after harvesting the transplant: patellar ligament and hamstring ligaments. Bone morphing was used to draw the tibial and femoral surfaces. Two types of aiming tools were tested by recording the data points issuing from the tibial output and the femoral input. The position of the femoral and tibial holes was determined to achieve the smallest anisometry and absence of notch conflict. Isometric zones were compared with the anatomic zones of the ACL. We also compared the position of the transplant determined by the computer and that determined according to the methods of conventional arthroscopy. An x-ray of each knee was obtained to compare with data in the literature concerning the advised position of the femoral and tibial holes with that established by the computer navigation system. Each knee was tested with KT1000 before and after surgery.

Results: The precision of bone morphing was 0.1 mm. Anisometric curves were compatible with drilling holes calibrated to the size of the implant in four knees. The operator used the navigation system to determine the point of the femoral hole in six knees. The system then calculated the point of the tibial hole automatically eliminating the risk of notch conflict. The anisometric values were less than 2 mm; the distance roof of the notch/anterior border of the transplant was calculated as a function of the radius of the transplant (3.5–5 mm). The position of the tibial hole given by the computer system was always more medial than that given by the tibial aiming tools. The position of the femoral tunnel was always more anterior than that given by the femoral aiming tools. The postoperative KT1000 values were identical to the preoperative values.

Discussion: Navigation without visualisation of the ACL is able to position the ACL in an isometric plane or better in an “anatomometric” plane, to inscribe the joint orifice of the tibial hole on the projection of the anterior arch of the notch on the tibial surface, to draw in real time the isometric femoral map on the notch in order to centre the joint orifice of the tibial hole as well as the corresponding laxity map, to indicate on the femoral notch the point which will be the centre of the joint orifice of the femoral hole, to draw the isometric curve of a given fibre and its corresponding laxity map, and to detect and allow the treatment of any transplant-notch conflict.


D. Saragaglia C. Chaussard H. Pichon D. Berne M. Chaker

Purpose: Over recent years, several authors have estimated that the distal femur presents an epiphyseal torsion which can be measured intraoperatively or on the preoperative scan. This measurement does not however take into account the dynamic mechanical axis, particularly the mechanical axis at 90° flexion when walking. We used a computer-assisted navigation system (Ortho-pilot®) to attempt to measure femoral rotation by dynamic gonometry in extension and 90° flexion before and after implantation of a total knee arthroplasty.

Material and methods: We recorded the preoperative (Rx) and intraoperative (Orthopilot) HKA in extension and in 90° flexion before and after implantation of 50 total knee prostheses (Search®, Aesculup, AG, Tuttlingen) and again postoperatively (Rx). The series included 19 knees with genu valgum (mean HKA 187.36±5.4°, range 181°–203°), 30 knees with genu varum (HKA 169.2±4.11, range 160°–176°), and one normal axis knee.

Results: The radiographic values obtained preoperatively were confirmed by Orthopilot, respectively 186.68±5.25° and 169.76±3.84° in extension. At 90° flexion, HKA was 178.63±5.7° before implantation for genu valgum giving a significant varus due to lateral opening during flexion,and 171.6±4.15° for genu varum, showing persistence of varus. After implantation of the total knee prosthesis, the values were as follows. For the genu varum: HKA in extension 180.57±0.82° and HKA in 90° flexion 176.86±2.55° giving a mean residual varus of 3.16±2.86° (from 4–8° varus) without external rotation of the femoral implant. For genu valgum, HKA in extension was 179.60±0.92° and HKA in 90° flexion was 176.1±3.23°, giving a mean residual varus of 3.26±2.86° (0–10° varus), recalling that in the event of genu valgum we impose external rotation due to the frequent hypoplasia of the lateral condyle.

Discussion: Orthopilot-assisted implantation of total knee prostheses provides new information concerning dynamic gonometry, particularly the varus or valgus in flexion, which corresponds to measuring natural external or internal rotation. Measuring epiphyseal torsion of the distal femur with classical methods does not take into account the global rotation of the femur which is often an external rotation (up to 8° for genu varum). Systematic implantation of the femoral component in external rotation raises the risk of increasing considerably the varus forced to the implant during flexion.


H. Pichon D. Saragaglia C. Chaussard D. Berne

Purpose: Tibial osteotomy for valgisation is a difficult procedure with a risk of over-correction or under-correction which can have significant aesthetic, functional and medicolegal consequences. In order to improve the precision, we adapted a navigation system to tibial osteotomy for valgisation. The purpose of the present work was to evaluate the feasibility and results of this technique.

Material and methods: From March to November 2001, we used the Orthopilot system for 19 patients with genu varum. Mean patient age was 50.8±11.7 years (range 18–71). The indication for valgisation was genu varum, associated with joint degeneration (grade 1, 2, or 3 in the modified Ahlback classification) in 18. The aesthetic effect of genu varum was the only indication in one patient. Preoperatively, the mean HKA was 173.73±3.24° (range 169–178). The mechanical axis was determined with Orthopilot before performing an open medial osteotomy for valgisation which was fixed temporarily with a metal wedge to control as needed lower limb alignment. Orthopilot enabled verification of the desired axis. When obtained, the metal wedge was removed and replaced by a wedge of tricalcium phosphate (Biosorb®, B-Pharm) of the same size. The osteotomy was stabilised with a screw plate. The objective was to obtain a femorotibial axis between 182° and 186°, i.e. 2° to 6° valgus.

Results: HKA measured peroperatively with Orthopilot was 174.05±3.06°, exactly the same as on the preoperative x-rays. After oseotomy, HKA was 183.47±1.07° (180°–184°) with Orthopilot, and 183.47±1.44° (179°–186°) on the x-rays. Eighteen knees were within the objective of 182°–186° giving a success rate of 94.7%.

Discussion: Computer-assisted tibial osteotomy for val-gisation using Orthopilot is quite feasible. To have a valid assessment of this new method, results would have to be compared with a series performed without computer assistance.


J.N Argenson S. Airaudi J.M. Aubaniac

Purpose: The current concern to achieve 120° postoperative flexion in certain patients raises the problems of polyethylene wear, prosthesis stability, and surgical technique. The purpose of this clinical and radiographic comparative study was to analyse pertinent factors

Material and methods: We studied two groups of posterior stabilised total knee prostheses with mobile plateaux. In group A (23 knees), the plateau had rotatory and translation mobility. In group B (36 knees) the plateaux only had rotatory mobility and the posterior condyle was long. We studied clinical flexion before surgery and postoperatively at one year. The radiographic analysis included: mechanical axis, height of the articular space, patellar height, anteroposterior prosthetic surface. In both groups the patients had undergone medial parapatellar arthrotomy and had participated in the same rehabilitation programme.

Results: There was no statistically significant difference between the two groups for age, gender, weight, height, pre-operative diagnosis, or preoperative flexion (mean 120.8°, range 90–130° in group A and mean 120.7°, range 90–140° in group B). Mean postoperative flexion was 114.8° (50–140°) in group A and 130.4° (90–150°) in group B. The difference was statistically significant. There were two episodes of instability in group A and none in group B. There was no difference concerning the pre- or postoperative axis or patellar height. There was a difference in articular space height and anteroposterior prosthetic surface.

Discussion: The gain in flexion achieved in group B is related to the smaller anteroposterior prosthetic surface and the more systematic use of distractors to clear the posterior part of the knee. The design of the posterior condyle could also be involved, allowing better congruence beyond 120°. The difference in stability between the two groups could be related to a difference in the distance between the apex of the tibial attachment and the posterior stabilisation cam. This study demonstrated that increased flexion is possible after total knee arthroplasty in certain patients. It is related to surgical technique but also has direct implications for prosthesis design.


T. Trichard H. Migaud A. Diop W. Skall F. Lavaste F. Gougeon

Purpose: Use of a mobile tibial plateau for total knee arthroplasty (TKA) is designed to reduce wear and improve prosthetic kinetics. The purposes of this study were: 1) to compare the kinetics of a posterior stabilised TKA implanted with a fixed plateau (FP) or a mobile plateau (MP) and, 2) to determine whether the mobile plateau improves axial rotation.

Material and methods: Ten patients with a unilateral TKA (HLS) with a fixed or mobile plateau were selected for this study according to the following criteria: arthroplasty for degenerative knee disease, healthy contralateral knee, age < 80 years, pain-free prosthesis, IKS > 80/100, flexion > 90°, follow-up > 1 year. There were five patients with a fixed plateau and five patients with the same prosthesis except with a mobile plateau. Knee movement (flexion-extension, axial rotation, valgus-varus) were measured with an electromagnetic goniometer on the implanted and healthy sides. Four movements were recorded: walking, standing up sitting down, flexion-extension without loading. Amplitudes were compared with non-parameteric statistical tests between the healthy side and the implanted side and between the two types of implants

Results: The FP knees were more mobile in valgus-varus due to greater residual frontal laxity than the MP knees. This extra laxity generated excessive axial rotation on the FP during non-loaded movements. Conversely, when loaded, axial rotation of the MP knees was 10° greater (mean, p < 0.05) than for the FP knees, giving better stability in the frontal plane. This study did not demonstrate any difference in flexion between FP and MP. Patients with an MP prosthesis did not have significantly different amplitudes of the three movements for the healthy versus implanted knee. For the patients with a FP prosthesis, axial rotation and frontal plane movement was lower in the implanted knee than in the healthy knee (p< à.05).

Discussion: This study devoted to the design of a single prosthesis demonstrated the usefulness of the mobile plateau for axial rotation during loaded movement. The kinetics of MP prostheses is similar to that of the healthy knee. Better axial rotation with MP prostheses during loaded movements suggests the persistence of the plateau mobility which should be confirmed with a cinematographic study.


R. Miehlke J.Y. Jenny

Purpose: The purpose of this study was to conduct a multicentric comparison of total knee arthroplasty using the conventional technique versus digitalized navigation.

Material and methods: A prospective comparative study was conducted in five centres in 821 patients using the same implant (Search®, Aesculap, Chaumont): 555 procedures with the Orthopilot® navigation system (Aesculap, tutligen, group 1) and 266 conventional procedures, group 2). Radiographic results were analysed by an independent investigator who examined telemetric images obtained three months after surgery.

Results: The mechanical femorotibial axis was within desired limits (3° frontal deformation) in 88.6% of the knees in group 1 and in 72.2% of the knees in group 2 (p< 0.001). The rate of unacceptable implantations (> 5° deviation) was 2.5% in group 1 and 9.8% in group 2).

Frontal orientation of the femoral component was satisfactory in 89.4% of the knees in group 1 and in 77.1% in group 2. Sagittal orientation of the femoral component was satisfactory in 75.5% of the knees in group 1 and in 70.7% of the knees in group 2. Frontal orientation of the tibial component was satisfactory in 91.9% of the knees in group 1 and in 83.5% of the knees in group 2. The sagittal orientation of the tibial piece was satisfactory in 81.3% of the knees in group 1 and in 69.9% of the knees in group 2. Optimal implantation, considering all criteria studied, was achieved in 275 patients (49.5%) in group 1 and in 82 patients (30.8%) in group 2 (p< à.001). Ther was no difference in results between centres.

Discussion: Computer-assisted navigation facilitated prosthesis implantation with the desired orientation in comparison with manual instrumentation. The number of unacceptable implantations was significantly lower. After a short learning curve, the reliability of this system has proven very satisfactory, facilitating its use since this study.


S. Bolzer F. Gougeon

Purpose: Independent cuts are generally used for tri-compartment knee prostheses but interdependent cuts may be needed. This can modify the height of the articular space or induce alignment errors. The purpose of this study was to examine the position of the implants, and the effects on laxity and lower limb alignment after implantation of a tricompartment knee prosthesis with a ligament tensor.

Material and methods: Between January 1998 and October 2000, 109 total knee prostheses (posterior stabilised Legacy®) were implanted in 94 patients. Three patients died, 3 who lived far from the centre were questioned by phone, 88 patients (103 prostheses) were retained for analysis at mean follow-up of 22.5 months. None of the patients were lost to follow-up. All of the prostheses in this series were implanted with a V-STAT® ligament tensor used to guide medial and lateral capsuloligamentary balance in flexion and extension under constant tension.

Results: At review, the IKS radiological scores were mean alpha 95.9° (90–108°) with 76.7% of the implants between 93° and 99°. The mean gamma angle was 1° (−8° to +8°) with 73.8% of the implants between −3° and +3°. The mean beta angle was 89.8° (86–98°) with 81.5% of the implants between 87° and 93°. Mean tibial slope measured from the mechanical tibial axis was 8.4° (2–15.5°) with 67% of the implants between 4° and 10° (desired slope 7°). The mean HKA at last follow-up was 178.8° (172.5–191°) with 75.7% of the knees between 175° and 185°. Correction was more significant for more pronounced preoperative deviation. The height of the articular space was significantly increased compared with the preoperative value. Mean radiological laxity in varus at last follow-up was 3.1° for a preoperative value of 2.8°. Mean radiological laxity in valgus at last follow-up was 3.2° for a preoperative value of 4°, a significant decrease. Mean sum of the radiological frontal laxities at last follow-up was 6.4° for a preoperative value of 6.8°, a non-significant decrease. Mean radiological sagittal laxity at last follow-up was 4.2 mm. There was no significant difference between preoperative and last follow-up sagittal laxity.

Discussion: The mean values obtained in this series are in agreement with data reported in the literature. While the height of the articular space was significantly greater at last follow-up, it was not correlated with a decrease in the height of the patella at last follow-up. Decreased patellar height at last follow-up was correlated with increased patellar joint surface (AP distance of the Blackburne and Peel index) and with shortened patellar tendons. Use of the V-STAT® ligament tensor allowed homogeneous mediolateral distribution of the frontal laxity while controlling sagittal laxity and preserving a normal axis of the lower limb.


J.-Y Jenny C. Boéri

Purpose: The design of the contact surfaces of total knee prostheses is a recognised factor affecting polyethylene wear and thus prosthesis survival. Flat-on-flat prostheses have a limited surface area of contact and are thought to favour polyethylene wear. They are not currently recommended for implantation. Nevertheless, several series have reported similar survival with other more congruent prostheses. We studied a series followed for eight years.

Material and methods: We implanted 223 flat-on-flat design total knee prostheses between 1992 and 1996 (Search®, Aesculap, Chaumont). All patients were followed prospectively and seen at regular intervals for physical examination and x-rays. We noted any intervention for implant revision and recorded time to any such procedures as well as the underlying cause. Kaplan-Meier survival curves were plotted taking revision for any cause other than infection as the endpoint.

Results: Ninety-four percent of the patients were reexamined or questioned by phone for this study conducted during 2001. Six percent of the patients were lost to follow-up after a mean 24 months. Seventy-four percent of the prostheses were still in situ at the time of this study at a mean 78 months follow-up. Ten percent of the patients died with their initial implant in place at a mean 50 months. Ten percent of the patients underwent revision surgery at a mean 37 months, half of them for infection and one quarter for a mechanical cause. The overall rate of revision at eight years was 11%; The rate of revision, infection excluded, at eight years was 6%.

Discussion: Survival of this prosthesis in non-infected patients is similar to that of other more congruent implants. This study confirms earlier clinical findings.The undesirable effect of the linear contact surfaces is proven in the laboratory but must not be considered to be automatically transferable to the clinical level. Polyethylene wear is a multifactorial phenomenon which cannot be reduced to a simple question of prosthesis design.


F. Menguy C. Hulet Y. Acquitter D. Souquet B. Locker C. Vielpeau

Purpose: The position of the femoral implant in external rotation remains a controversial issue. It can be determined using bone landmarks (Whiteside line, parallel to the biepicondylar axis, 3° external rotation from the posterior condylar plane). For the last seven years, we have related femoral rotation to the orientation of the tibial cut in order to ensure good femorotibial stability in flexion using specific instruments (Cores®). This prospective study was conducted to examine the position of the femoral implant determined with this method and to measure the position from bone landmarks.

Material and methods: Twenty consecutive patients were included in this study. Bilateral computed tomographic measurements were made before and after surgery. Joining 8mm/8 slices were obtained for the femoral necks and 5mm/3 slices for the knees. The angle of femoral torsion was defined in two ways: the first by the angle formed between the axis of the femoral neck (on two superimposed slices) and the tangent to the most posterior part of the femoral condyles; the second by the angle formed between the epidondylar line and the posterior condylar line.

Results: The preoperative scans demonstrated that the angle between the biepicondylar line and the posterior condylar line was 5.8±1.5°. Using Cores®, led to an external rotation of the femoral implant to 2.7±0.6°. The postoperative scans demonstrated that the angle between the biepicondylar line and the posterior condylar prosthetic play was a mean 3.3°. The measurements using the femoral neck were less precise, with, in one case, an external rotation of 5°. The patella was well balanced postoperatively (irrespective of the external rotation position of the femoral implant).

Discussion: The angle of about 6° between the biepicondylar line and the posterior plane of the condyles has also been reported by others (Beaufils, Matsuda). To obtain a rectangular space in flexion, the posterior condyle cuts are more important medially than laterally. We found a correlation between the correction provided by the specific instrument set and the difference in the posterior condyle cuts, demonstrating the intraoperative precision of Cores®. It is difficult to orient the femoral piece parallel to the biepicondylar axis. This study demonstrates that there always remains 2 to 3° of inclination of the biepi-condylar axis from the posterior condylar plane.

Conclusion: The positioning the femoral implant parallel to the biepicondylar line leads to inducing an important external rotation. While using 3° rotation systematically would reduce the risk of internal malrotation, we feel it better to adapt the rotation to each individual knee depending on the anatomic presentation. Cores® enables positioning the femoral implant in external rotation as a function of the ligament balance obtained in flexion after peripheral tension is applied. This enables avoiding medial femorotibial laxity in flexion.


D. Huten P. Boyer M. Bassaine

Purpose: Patellar complications are among the most frequent after total knee arthroplasty. Encasing the patellar piece is one way of resisting the shear forces leading to loosening.

Material and methods: We studied at more than five years the results obtained with a total knee prosthesis implanted with preservation of the posterior cruciate ligament (PCL). This prosthesis has an asymmetric encased patellar insert with a cemented central pivot. The instrumentation ensures patellar thickness. We reviewed 104 implants at more than five years. Six had been lost to follow-up. Ninety-eight implants were still in place.

Results: The following complications were observed: four fractures of the upper rim with little displacement (these fractures healed and pain regressed but the insert had moved); three vertical patellar fractures with little displacement (these fractures healed; two were symptomatic temporarily); one transverse fracture of the upper pole with displacement causing a defect in active extension; eight moderate asymptomatic impactions which were visible on the lateral x-ray (modified orientation of the insert with cement fracture). There was no significant difference for functional results (pain 40.9; movement 21.9; knee score 84.3) between patients with or without a patellar complication.

Discussion: Insertion of an asymmetric prosthesis increased the risk of an orientation error (two cases early in our experience). Encasing the patellar insert limits medialisation yet the centering was satisfactory (centred patella 95.2%, shift 3.6%, subluxation 1.2%). Encasing provides a peripheral wall protecting against transverse sheer forces. The lateral wall did not fracture, demonstrating its efficacy. The upper wall can fracture under the force of flexion without functional consequences. The other fractures, favoured by section of the lateral patellar wing (p< 0.05), were not treated. Moderate but certain impaction was noted in eight cases at a mean 3.5 years (1–6 years). It was due to failure of bony support under the effect of the compression forces applied on a small surface. The diameter of the encased patellar inserts was rarely more than 25 mm. Once the prosthesis is in place, the periphery of the patella is the only component articulating with the trochlea and its impaction does not cause further aggravation. This contact did not lead to pain in any patients.

Conclusions: Complications observed with encased patellar components differ from the better known apposed prostheses.


G. Dauplat O. Le Rue C. Maynou H. Mestdagh

Purpose: Anterior tarsectomy (Méary procedure) has proven its efficacy for surgery of talipes cavus in adults. There has not however been any publication on long-term outcome. We reviewed 39 cases of pes cavus treated by tarsectomy and followed for a mean ten years. Our objective was to confirm long-term results and assess consequences on adjacent joints.

Material and methods: Mean age of the patients was 30 years. Neurological causes predominated (57.6%). Most of the deformations were complex, involving equin and varus deformation of the hindfoot, and pronation and adduction of the forefoot. The deformations were painful in 85% of the patients We used the AOFAS functional score to assess outcome. The preoperative x-rays demonstrated a Djian angle at 100° and a Tomeno angle at 23°.

Results: Mean final score was 69.2/100. The final result was considered excellent or good in 66% of the patients. Pain regressed considerably in 75% of the patients even though only 28% of the patients were totally symptom free. There was a spontaneous 6° reduction in the calcaneus inclination. Defective correction persisted in 80% of the patients but the Tomeno angle remained below 10° in 70%. Seventy-four percent of the feet had radiographic signs of degenerative joints, particularly the sub-talar and mediotarsal joints.

Discussion: There were only two preoperative criteria with prognostic value, aetiology which influenced the functional result and freedom of the hindfoot articulation which determined capacity for correction. Alignment, particularly hindfoot alignment, and degenerative joint disease influenced the functional outcome.

There was a correlation between the anatomic presentation and function, especially evident for the Méary-Tomeno line which must be re-established. While we obtained spontaneous correction of the compensating frontal and sagittal deformations of the hindfoot, specific procedures were required to alleviate claw toes and equinism. It is also important to preserve the Lisfranc space and the Chopart space. The corrective capacity of tarsectomy is limited. To achieve satisfactory anatomic and functional results, tarsectomy must be reserved for moderate pes cavus involving a sufficiently mobile forefoot with moderate and reducible calcaneal varus where the primordial joints can be saved.


P.P. Mill G. Asencio R. Bertin P. Kouyoumdjian S. Hacini B. Megy

Purpose: We report the results at more than five years of a consecutive series of total knee arthroplasties (TKAs) implanted without cement and with preservation of the posterior cruciate ligament (PCL).

Material and methods: This series included 98 patients who underwent 109 primary TKAs between 1994 and 1998. Mean patient age was 67.7 years. The press-fit Interax prosthesis has a macroporous hydroxyapatite coating since 1996. The patella was resurfaced in 92% of the cases with a cemented polyethylene button. Ligament balance and joint space were controlled by progressive release of the ligaments with a tensor derby. Clinical assessment was based on the KSS. Radiological assessment included the femorotibial axis, the position of the implants, and the bone-implant interfaces.

Results: Seven (6.4%) of the patients were lost to follow-up. Fifteen (13.4%) died or were demented and two (1.8%) developed late infection and were not included in the primary analysis. Thus, 85 patients (77.9%) were retained for analysis at a mean 5.2 years follow-up. The KSS improved from 33.4 preoperatively to 79.4 at last follow-up. The KSS function score improved from 55.1 to 82.4. Knee flexion was 124.5° preoperatively and 113.1° at last follow-up. Anteroposterior laxity greater than 5 mm was observed in 4.8% at last follow-up. Radiologically, the mechanical femorotibial axis changed from 184.4° to 180.6°. Alpha 95.6°, geta 89.1°, omega 4.77°, gamma 3.8°, sigma 89.4°. Patellar height was 0.84 preoperatively and 0.65 at last follow-up. Lucent lines were observed 3.5 times less frequently with hydroxyapatite coated implants. Patellar loosening and femorotibial loosening were observed in one patient each. Revision procedures were necessary for three prostheses for bipolar loosening, painful stiff knee, and anteroposterior instability. Non-infectious survival rate was 94.1% at 5.2 years.

Discussion: These mid-term clinical results are comparable with those reported in the literature for cemented or non-cemented implants with or without preservation of the posterior cruciate ligament. Longer follow-up is however necessary to assess the anteroposterior stability. The radiographic measurements provide a good demonstration of the operative precision and proper ligament balance. Hydroxyapatite coating improves bony fixation of the implants and provides a fixation comparable with cemented implants.

Conclusion: This series confirms the mid-term reliability of the non-cemented Interax THA with preservation of the posterior cruciate ligament.


O. Jarde J. Vernois S. Massy A. Damotte P. Mertl

Purpose: We report a series of 32 cases of recurrent hallux valgus treated by metatarsophalangeal arthrodesis and followed for at least five years.

Material and methods: Mean follow-up after the initial surgery was 11 years. All patients complained for pain of the forefoot. The mean phalangeal valgus was 39° with metatarsalgia in 16 cases. According to the Regnauld classification, the metatarsophalangeal space of the great toe was grade 1 in two, grade 2a in eight, grade 2b in six, and grade 3 in sixteen. Arthrodesis was achieved with an axial screw and adductor hallux plasty. Results were assessed at least five years after surgery according to the Kitaoka criteria.

Results: At last follow-up 78% of the patients were pain free. The valgus deviation was corrected with a mean angle of 19°. The arthrodesis fused in 90.6% of the cases. Statistical analysis revealed the influence of pre- and postoperative great toe valgus on the final result. The final results were less satisfactory with older age. Outcome was very good in 84%, fair in 6%, and poor in 10%.

Discussion: These results demonstrate that arthrodesis of the great toe is not an invalidating solution. Interpha-langeal joint degeneration can develop after excessive solicitation of the articulation.


Y. Catonne D. Ribeyre H. Pascal-Mousselard J.M. Cognet O. Delattre C. Poey J.L. Rouvillain

Purpose: Necrosis of the navicular bone, described by Müller then Weiss in 1927, is an uncommon finding, unlike talonavicular degeneration which is a rather frequent complication of talipes planovalgus. Between 1985 and 2000, we cared for 25 patients with this condition. The purpose of this retrospective analysis was to describe the clinical and radiological presentation and attempt to reconstruct its natural history with the aim of determining therapeutic indications.

Material and methods: We analysed 25 cases of navicular bone necrosis observed in 14 women and 3 men (eight bilateral cases). Mean age of the patients was 39 years (range 16–59). The diagnosis of necrosis was established on the basis of structural alterations (densification, bone defects) and in the more advanced cases, flattening and “expulsion” of the navicular bone. We looked for clinical signs and described the radiological aspect of the necrotic zone. A computed tomography was available in 14 cases and magnetic resonance imaging in the five most recent cases.

Results: Pain was the major sign in all cases. One-third of the cases occurred in a foot with prior planovalgus. History taking revealed elements suggestive of an aetiology in three cases: probable Köhler-Mouchet disease in a 16-year-old boy, sickle cell disease in a 35-year-old man, and prolonged walking with signs suggesting stress fracture in a 40-year-old woman. In the other 19 cases (11 women and 1 man, 7 bilateral cases), necrosis was considered idiopathic. Radiologically, we used the Ficat classification (described for hips): stage 0 with normal x-ray and strong uptake on scintigram (n=1), stage 1 with a normally shaped navicular bone but condensation or bone defect, stage 2 with modification of the shape of the bone without signs of degeneration, stage 3 where changes in the shape of the bone are associated with narrowing of the talonavicular then cuneonavicular space. Computed tomography included frontal and horizontal slices as well as lateral reconstructions indispensable to assess the posterior part of the interarticular spaces. Treatment was surgical in 12 cases and medical in 13. Well tolerated forms were treated with plantar ortheses with regular surveillance. Surgical procedures included triple arthrodesis (early in our experience), mediotarsal arthrodesis (n=2), talonavicular arthrodesis (n=7) and talocuneate arthrodesis with replacement of the scaphoid by an iliac graft (n=2). The natural course of necrosis was studied in the cases without surgery. The first sign was medial mediotarsal pain. At this stage scin-tigraphy or MRI was required for positive diagnosis. At stage 0 condensation of the navicular bone, confirmed by computed tomography, preceded bone flattening then expulsion upwardly and medially, sometimes with fragmentation and onset of talonavicular degeneration. Cuneonavicular degeneration appeared to occur later (except in one case). Long-term results of surgery were good with pain relief and renewed activity.

Discussion: The clinical presentation initially described as Müller-Weiss disease or scaphoiditis, which concerns a bilateral condition generally occurring after trauma and sometimes with a favouring factor (alcoholism, osteoporosis), appears somewhat different from our description. Mechanical factors predominated in our patients and the aetiologies were quite similar to those observed in Kienböck syndrome. Excessive pressure on the navicular bone, which leads to avascular necrosis, flattening, and expulsion, is undoubtedly the essential cause of this condition. It is well tolerated in some individuals and can lead to spontaneous fusion. In this situation, treatment can be limited to surveillance or orthopaedic care. If the functional impact is important, surgical treatment can be proposed, generally limited to talonavicular arthrodesis. If the navicular bone is sclerosed and flat, the remaining fragment can be replaced by an iliac graft to achieve talocuneate fusion.

Conclusion: Necrosis of the navicular bone appears to be less uncommon than in the classical description, particularly in black women aged 25–50 years. A more precise study of favouring anatomic factors (length of the medial ray, size of the talar neck, depression of the medial arch) could provide further information concerning the aetiology which appears to be similar to that of Kienböck disease.


C. Dujardin X. Cassagnaud H. Migaud A. Cotten C. Fontaine

Purpose: The distal tibiofibular joint is implicated in ankle movement but has been the topic of less work than the talotibial joint. Its mobility within the talo-crural complex has not been described in detail as precisely as its static role. The purpose of this work was to develop a simple noninvasive method for characterising in vivo the mobility of the fibula at the ankle level between is positions in dorsal and plantar flexion.

Material and methods: We used 32 computed tomo-graphic studies of the ankle in 16 healthy volunteers (men and women), one study in each position of ankle flexion. We identified one cross-sectional slice through the syndesmosis in each of the two positions. A medio-lateral reference line was drawn tangent to the posterior cortical of the tibial metaphysis. The displacement of the fibula in relation to the tibia when moving between the two positions of ankle flexion was calculated using a remarkable landmark on the tibia, the anterior rim of the posterior tibial incisure, and the polar co-ordinates of the ends of the anteroposterior axis of the fibula.The repeatability and reproducibility of this method were tested.

Results: Repeatability was satisfactory for translation movements. Reproducibility was fair except for the reference line where it was good. When the ankle moved from dorsal flexion to plantar flexion, the fibula moved medially 1.25 mm (0.03–2.58 mm) (p< 0.0001) without correlation with the amplitude of the ankle flexion. Mean anterioposterior displacement was 0.46 mm (NS) with a wide range from −1.58 to +7.2 mm. It was correlated with lesser amplitude of ankle flexion.

Discussion: This dynamic method confirms published data concerning active mediolateral tibiofibular approach during plantar flexion. The results point out the variability of the anteroposterior movement of the fibula, the influence of the amplitude and the flexion position of the ankle, and the possible antepulsion effect of fibular tendons. The three-dimensional movement of the ankle joint merits further study including its tibio-fibular and talofibular components in view of potential prosthetic repair of the ankle.

Conclusion: Distal tibiofibular mobility is undeniable. We call for more work to achieve a better understanding of the lateral component of the talocrural complex.


P. Turell O. Roche F. Sirveaux C. Marchal A. Blum D. Mole

Purpose: Maisonneuve fracture is a rare variant of malleolar fractures. Standard surgical care is not well defined. We performed a retrospective analysis of operated patients to propose a system to determine adequate care as a function of the type of lesions observed.

Material and methods: This retrospective analysis involved 20 patients who underwent surgery for Mai-sonneuve fracture between 1989 and 2000. Mean age was 42 years at surgery. Male gender predominated (16 patients). Seven patients (group 1) were treated without a syndesmodesis screw (osteosynthesis of the medial malleolus in six cases and suture of the medial collateral ligament in one). Thirteen patients (group 2) were treated via a first lateral approach and a syndesmodesis screw followed by a complementary medial approach in seven cases (two cases of medial malleolus osteocynthesis and five cases of medial collateral ligament suture). The Duquennoy functional score was determined at last follow-up. Quality of the reduction and presence of degenerative disease were determined on standard x-rays and computed tomographies.

Results: Mean follow-up was four years nine months (range 1–10 years). No case of tibiotalar diastasis was observed at at least one year. Among the five patients reviewed clinically, outcome was excellent in four and fair in one. In group 2 (syndesmodesis), we found two cases of residual diastasis and two cases of tight syndesmosis at at least one year. Among the nine patients reviewed clinically, outcome was excellent in three and fair or poor in six.

Discussion: This retrospective analysis collaborates the few data in the literature on Maisonneuve fractures. Ligament injury has varied greatly (with or without tear of the medial lateral ligament, more or less full thickness rupture of the interosseous membrane). In our experience, it is always difficult to reduce the diastasis via the primary lateral approach. Conversely, the primary medial approach has, after testing, enabled eliminating the syndesmodesis screw, with its recognised deleterious effects, in seven cases.

Conclusion: Due to the diversity of the ligament injuries encountered in patients with Maisonneuve fractures, we have adopted the following surgical strategy. If there is diastasis, after confirmation of any injury to the medical compartment, medial approach to suture the medial collateral ligament or osteosynthesis of the medial malleolus: in the case of diastasis reduction, we advocate a syndesmodesis screw; if diastasis persists, a secondary lateral approach is useful to reduce the medial malleolar rotation and insert a syndesmodesis screw.


G. Walch P. Adeleine B. Edwards P. Boileau D. Mole

Purpose: The glenoid and humeral head curvature radii are mismatched in non-constrained total shoulder prostheses. The purpose of this study was to evaluate the effect of this mismatch on radiographic lucent lines and clinical outcome.

Material and methods: The study population included 319 total shoulder prostheses issuing from a multicentric European cohort. The patients underwent surgery for primary shoulder degeneration. Mean age at surgery was 67 years. Female sex predominated (75%). Partial supraspinatous tears were present in 7% of the shoulders with full-thickness tears also in 7%. A single type of prosthesis was used composed of a humeral pivot with a modular head (seven head sizes) and a cemented polyethylene flat-surface spiked glenoid (three sizes). Variable association of humeral heads and prosthetic glenoids defined the mismatch which varied from 0 to 10 mm (difference in the curvature radii between the head and glenoid). The patients were reviewed clinically and radiologically at a mean follow-up of 53.5 months (24–110 months). Clinical outcome was assessed with the Constant score for pain (15 points), daily activity (20 points), motion (40 points), and force (25 points). The glenoid lucent line was evaluated on the AP view using a 0 to 18 point scale (0=absence, 18=lucent line in 6 zones). Analysis of variance and linear regression were used to assess the effect of mismatch on the glenoid lucent line and clinical outcome.

Results: There was a statistically significant linear relationship between mismatch and glenoid lucent lines. The lucent line score was significantly lower when the mismatch was between 6 and 10mm. Mismatch had no influence on the overall Constant score or the individual scores (pain, motion, force, daily activities) nor on early or late postoperative complications.

Discussion: Based on the results of this study, the first in vivo assessment, the “ideal” gleno-humeral mismatch for total shoulder prostheses would be between 6 and 10 mm, i.e. much greater than is classically recommended (0–5 mm).


F. Pfeffer R. Traversari L. Garlos J.P. Delagoutte

Purpose: Several techniques have been described for tenotomy of the Achilles tendon. The first method uses an open approach and consisted in classication stairstep tenotomy followed by suture. The second is a percutaneous method using two opposite transverse incisions along the width of the tendon followed by tension to glide the tendon fibres over each other. The biomechanical and histological properties of operated tendons was analysed in an experimental study in the rabbit.

Material and methods: Eighteen New Zealand rabbits were operated on. The operated and control tendons were harvested at the fifteenth and thirtieth day. Their biomechanical properties (resistance, elasticity, deformation) were measured with an Instrom device. Histological examination focused on the tendon junction using standard staining techniques.

Results: The two methods provide excellent technical reproducibility. We did not have any cases with skin problems or infection. Twelve tendons harvested at different times were tested in correct histological and technical conditions. The Instrom fixation system was the only factor limiting this method. Results for the first tendons tested did not demonstrate any difference for maximal force (TC15=118N, TP15=127 N) or for force at rupture (TC15=104N, TC15=114N). Conversely maximal lengthening before rupture (TC15=27mm, TP15=43mm), tendon section (TC15= 35mm2, TP15=27mm2), maximal strength (TC15=3.5mPa, TP15=4.6mPa), percentage of deformation at maximal force (TC15=39%, TP15=28%), fibre strength (TC15=6041 Cm/Denier, TP15=6451 Gm/Denier) and elasticity (TC15=27.7 mPa, TP15=43.7 mPa) were different.

Discussion: Section of the tendons is different with the two techniques. Macroscopically, TP tendons have a regular fusiform aspect which is not found for TC tendons. Maximal resistance and maximal force before rupture were identical for the two cohorts. We consider that if the two tendons have identical cross section, TP tendons would be significantly more resistant. Gliding the tendon fibres over each other is the explanation. Furthermore, gliding is achieved by applying force on the fibres, lengthening occurring at the cost of tearing the least resistant and least elastic fibres. Histologically, the healing process is also different between the two techniques, which has an effect on the final outcome.

Conclusion: The resistant and elastic properties are different between the two techniques of tenotomy. The biomechanical properties are excellent, tendon fibre healing and recruitment being adapted to physiological solicitations. Under these conditions, percutaneous lengthening is an excellent technique due to its reliability, easy execution, and the quality of the fibre healing.


P. Brunet F. Dubrana A. Burgaud De Le Nen C. Lefèbre

Purpose: Subtalar dislocation is an exceptional finding. En bloc dislocation under the talus leads to talocalcaneal talonavicular luxation, generally observed in young active adults. Prognsosis is related to the risk of infection and talar necrosis. We report a retrospective series searching for featues influencing long-term clinical outcome.

Material and methods: Between 1984 and 1990, twelve cases of subtalar dislocation were treated in our unit. There were nine lateral and three medial cases. Six lateral dislocations were open injuries, the head of the talus exposed medially. Treatment consisted in emergency orthopaedic reduction associated with debride-ment and closure in case of open injury. Temporary pinning (45 days) between the talus and the calcaneus was used in six cases. There were two lesions of the posterior tibial bundle which were repaired in the emergency setting. A supramalleolar lateral flap (Masquelet) was needed in one patient who developed cutaneous necrosis exposing the anterior tibial. Postoperative immobilisation consisted in a plaster boot for 45 days in all cases.

Results: Mean follow-up was ten years. Clinical outcome was good in eleven patients (slightly limited dorsal flexion, 10°) and fair to poor in one. We did not have any case of talar necrosis or subtalar degeneration.

Discussion: This series confirms data in the literature. Pure dislocation has as a rule a good prognosis although there is some discrepancy in the literature. In our series, lateral dislocation was more frequent than medial dislocation. Skin opening is frequent and is not a factor of poor prognosis. The absence of talar necrosis is related to preservation of the deltoid branch of the posterior tibial artery and respect of the fibular artery collaterals which supply the posteriolateral tubercle and the tarsal sinus. Emergency reduction of peritalar dislocations eliminates vascular suffering and limits the risk of infection. A temporary talocalcaneal pin is indispensable if the joint is unstable after reduction.


C. Boggione P. Thoreaux G. Saillant

Purpose: Choronic tendinopathy of the Achilles tendon is frequent. Conservative treatment is long and difficult. Surgical treatment is indicated when response to medical treatment is unsatisfactory. The purpose of this study was to assess at different times and according to the type of tendinopathy treated, the results of our open surgical technique.

Material and methods: We performed a retrospective analysis of 154 cases of Achilles tendonopathiy in 136 patients (104 men and 32 women) operated between March 1985 and October 1997. Mean age was 35.5 years (range 16–70). The majority of the patients (n=146) practised sports regularly (120 at a competition level). These patients had not responded to prolonged medical treatment (mean duration of prior treatment 33.4 months, range 3 months – 15 years) and had invalidating conditions according to the Blazina scale (72 grade III-A and 82 grade III-B). We had 78 cases of insertion tendionpathy (59 without desinsertion, 19 with partial des-insertion), 49 cases of body tendinopathy (32 nodular, 17 non-nodular), 16 partial tears, and 11 cases of isolated peritendinitis. The standard surgical technique consisted in resection of the peritendinous sheath and tendon combing. Depending on the injuries observed, we associated resection of nodules, tendon reinforcement, resection of the calcaneum, or bursectomy.

Results: The overall results were classed excellent (renewed sports activity at former level without pain), good (renewed sports activity at a slightly lower level), or poor (no improvement). Results of 110 cases with more than 43 months follow-up were evaluated at one year, three years, and last follow-up (7.1 years, range 43 months–147 months). Overall results were unchanged for the different assessment times and were, at last follow-up: excellent 70%, good 18.2%, poor 11.8%. Early local complications were observed in 40/154 cases (late healing in 18, haematomas in 12, skin necrosis in 6, and infection in four).

Discussion: The overall results were satisfactory and persisted over time. The final prognosis depends basically on the type of tendinopathy with better results being obtained for isolated peritendinitis and body tendinopathy.


S. Jambou C. Hulet O. Courage G. Pierrard B. Locker C. Vieolpeau

Purpose: The purpose of our retrospective analysis was to describe results of arthroscopic treatment of painful ankle instability without clinical or radiological laxity.

Material and methods: Eighteen patients, mean age 27 years (seven men and nine women) were operated on by the same surgeon between 1999 and 2000. Sixteen patients (90%) were reviewed by an independent investigator at 20±4 months. Fifteen patients were athletes, ten at the competition level, and five had amateur sports activities. The accident caused forced inversion in 15/16 cases, during sports activities in 85.5% of the cases. Mean age at injury was 17±6 years. Mean time between the accident and arthroscopy was eight years. All patients had pain in the anterolateral region associated with effusion in 50% and apprehension or instability for daily life activities. Standard x-rays were normal in fourteen patients (87.5%). Comparative stress images did not demonstrate pathological laxity. Complementary imaging (MRI, CT scan, arthroscan, ultrasonography) was obtained in six patients with 50% negative results. Arthroscopy revealed anterior tissue interposition (antero lateral in thirteen patients (81%) and anteromedial and anterolateral in three) which was removed with the shaver. Joint cartilage was intact in fifteen patients (81.25%).

Results: At last follow-up, functional outcome was good in all patients who had all resumed their sports activities. Subjectively, six patients felt they had normal function, seven nearly normal function and three abnormal function (81% satisfied or very satisfied). Six patients were symptom free even during intense physical activity. Eight patients reported some difficulties for strenuous exercise and two for moderate exercise. Joint motion was normal in ten patients and 5° dorsal flexion deficit was observed in six. There were no recurrent sprains. The x-ray was normal and identical to the initial image in 87.5% of the patients. Globally, 87.5% of the patients had good or excellent outcome. Two patients had fair or poor outcome.

Discussion: Diagnosis of anterolateral ankle conflict can be established in patients with a compatible history and a typical clinical presentation with normal x-rays. Arthroscopic treatment can remove tissue interposition allowing good functional results and total recovery of sports activities. Complementary MRI or arthroscan have little specificity and poor sensitivity.


Y. Kerjean J. Laulan Y. Saint-Cast G. Raimbeau

Purpose: In the hands of the conceptors, total elbow prostheses (TEP) have provided favourable results. The purpose of this work was to evaluate our own results in a consecutive series of GSBIII TEP in order to confirm or infirm the mid-term reliability of these prostheses

Material and methods: Over a ten year period, 20 GSBIII TEP were implanted by two operators in 17 patients. The same technique and approach were used in all cases. The patients were reviewed by an independent investigator 12 to 128 months after surgery (mean follow-up 4.3 years). We noted pre- and postoperative pain and motion and recorded the Morrey function score. Patient satisfaction was noted at last follow-up. The Morrey radiological classification (4 stages) was used. The position of the TEP, its stability and its evolution were studied.

Results: Mean age was 51 years (range 19–66) and the underlying rheumatoid polyarthritis had progressed for a mean 14 years. The main indication was pain (mean preoperative visual analogue evaluation = 7/10) All elbows were in stage 3 or more radiographically. At last follow-up, mean pain was 0.3/10 and the function score had improved from 11/25 to 24/25. Gain in motion was 49° in flexion-extension and 42° in pronosupination. Mean satsifaction was scored 8.85/10 and was related to joint motion. At the last follow-up radiological assessment, we found localized metaphyseal bone resorption in three elbows, humeral lucent lines in five, ulnar lucent lines in two (all measuring less than 1 mm, partial and unchanged). There were no neurological, cutaneous or infectious complications. Rate of survival was 100%.

Discussion:At mid-term, we had very favourable results for pain relief and function as well as patient satisfaction. The gain in joint motion was less with a mean extension defect of 20° and was closely related to patient satisfaction.

Conclusion: Our study confirms that this TEP model provides reliable and stable results: no clinical complications were observed during the follow-up nor any loosening. Patient satisfaction was less if the elbow was stiff but with little pain.


L. Noe-Joserand M. Basso G. Versier G. Walch

Purpose: The indication for humeral or total shoulder prosthesis in patients with avascular osteonecrosis of the shoulder depends on the radiographic stage of the necrosis. The purpose of this study was to analyse the prognostic radiographic features enabling proper identification of the indications for humeral or total prostheses.

Material and methods: This retrospective multicentric study included 53 shoulders operated on for prosthetic repair of avascular osteonecrosis. There were 20 men and 29 women, mean age 57 years. A humeral prosthesis was used in 34 cases and a total prosthesis in 19. Clinical assessment was based on the Constant score and the radiographic analysis used the Arlet and Ficat classification. Staging was II (n=4), III (n=16), IV (n=21) and V (n=12). Independently of the radiographic stage of necrosis, three characteristic groups were defined. Group 1 (19 shoulders) included necrosis without bony collapse of the humeral head. Group 2 (20 shoulders) included necrosis with bony collapse of the humeral head with preservation of the anatomic relations with the glenoid cavity. Group 3 (14 shoulders) included necrosis with bony collapse and impaction of the humeral head in the glenoid with medialisation of the humerus.

Results: Preoperatively, presence of bony collapse was associated with decreased pain and motion score. Major joint stiffness was noted in group 3 (8). The humeral prosthesis gave similar results for groups 1 and 2 (Constant score 73 and 75.3). Less satisfactory results was the rule in group 3 (Constant score 51.6). There was a postoperative erosion of the glenoid cavity in 83% of the shoulders in group 3 versus 12.5% in group 1 and 17% in group 2. The total prosthesis optimised results despite persistence of a difference between groups 2 and 3 (Constant score 83 and 64 respectively).

Discussion: Destabilisation of the glenohumeral joint by impaction of the humeral head against the glenoid cavity has an effect on the clinical result of the prosthetic surgery. Preservation of the anatomic relations of the articulation (groups 1 and 2) appears to be necessary for good results. Impaction medialisation of the humerus has a negative effect on the clinical result of humeral prostheses with a risk of glenoid erosion.

Conclusion: Independently of radiographic stage of necrosis, the presence of humeral impaction with medi-alisation should be considered individually as it has a negative effect on the clinical outcome of these prostheses, particularly humeral prostheses.


L. Neyton F. Sirveaux O. Roche P. Boileau G. Walch D. Mole

Purpose: Failure of the glenoid component is the main complication of total shoulder prostheses. When surgical revision is necessary, the surgeon has the option of a new implantation or non-prosthetic plasty (glenoido-plasty). The purpose of the present work was to analyse results obtained with these two techniques in order to propose proper indications.

Material and methods: This retrospective study included 16 patients, mean age 62 years at revision surgery. Fialures included loosening of a cemented glenoid implant (n=9) and failure of non-cemented implants (3 defective anchors, 4 unclipped polyethylene inserts). Mean time to revision was 39 months (2–178) after primary implantation. A new glenoid implant was cemented in nine patients (group A). Seven patients (group 2) had glenoidoplasty with an iliac graft in four.

Results: A mean follow-up of 37 months (19–73), the Constant score had improved from 18 points before revision to 52 points (+34). Two patients experienced a complication requiring a second revision (infection, instability) and one patient underwent subsequent surgery for biceps tenodesis. For the group with glenoidoplasty with iliac graft, insertion of an inverted prosthesis was achieved during a second operative time. In group 1, the mean Constant score at last-follow-up was 63 points (+45) with the pain score of 11, movement score of 29. In group 2, the mean Constant score was 37 (+19) with pain at 6 and motion at 16. In this group, the mean score was 48 points with a glenoid graft and 21 points with simple implant replacement.

Discussion: Revision surgery for a failed glenoid implant remains a difficult procedure but can be effective for pain relief and improved motion score. The small number of patients in this series makes it difficult to perform statistical analysis but the results do point in favour of prosthetic reimplantation when the bone stock is sufficient. For other patients, a graft would be preferable to simple implant removal. This would allow secondary revision if possible.


P. Boileau P. Ahrens G. Walch C. Trojani E. Hovorika J.S. Coste

Purpose: The purpose of our work was to report causes and results of treatment of anterior shoulder instability after implantation of a shoulder prosthesis.

Material and methods: This retrospective multicentric study included 51 patients with prosthetic anterior instability: 42 patients after first-intention shoulder prosthesis and nine after prosthesis revision. There were 39 women (79%) and 12 men, mean age 67 years, who underwent total shoulder arthroplasty (n=29, 57%) or hemiarthro-plasty (n=22, 43%). Thirty-eight patients (75%) had prosthetic dislocation and 13 (25%) subluxation associated with pain an loss of anterior elevation. The initial prosthesis was implanted for degenerative disease (n=29), rheumatoid arthritis (n=7), or fracture (n=15). Anterior prosthetic instability occurred early in 23 shoulders (first six weeks) and lat in 28 shoulders (7 after trauma, 21 without trauma). Conservative treatment by reduction-immobilisation was performed in 16 cases and prosthetic revision in 35. The patients were reviewed radiographically at mean 41 months follow-up (range 24–62).

Results: Subscapular tear or incompetence was the main cause of prosthetic anterior instability, observed in 87% of the cases. Technical errors concerning the prosthesis were also observed: oversized head, malrotation of the prosthesis. Associated complications were frequent: glenoid loosening (24%), polyethylene dissociation from the metal glenoid implant (10%), infection (10%), humeral fracture (4%). The final Constant score was 54 points and 55% of the patients were disappointed or dissatisfied. None of the shoulders were stable after consevative treatment. The prosthetic revision provided disappointing results with 51% recurrent anterior instability.

Discussion: Anterior instability of shoulder prostheses is a serious complication which responds poorly to treatment. Loosening of the subscapular suture is the main cause.


Full Access
J.S. Coste S. Reig C. Thjoàmas P. Boileau

Purpose: The purpose of this study was to analyse the epidemiology, management, and cure rate in 49 infected shoulder prostheses.

Material and methods: This retrospective multicentric study included 2396 shoulder prostheses with at least two years follow-up (mean 34 months): 2146 first intention prostheses and 250 revision prostheses. Results were analysed as a function of: — time to development of infection: 12 acute (less than 2 months after surgery), 6 subacute (2 to 12 months after surgery), and 29 chronic (more than one year after surgery); — cause leading to the first intention implantation; — therapeutic management of the infection.

Results: Two patients died and five were lost to follow-up. The results were thus evaluated in 42 patients. The rate of infection in this series was 1.8% for first intention prostheses and 4% for revision prostheses. Fracture, joint degeneration with massive rotator cuff tears and radiation-related necrosis were factors of high risk of infection (25% for radiation-related necrosis). Thirty patients achieved cure (71%). Three patients had a doubtful cure and nine patients remained infected (29%). The Constant score moved from 20 points before revision to 38 points. Active elevation was below the horizontal (74°). Eighty percent of the acute infections were cured but one-third of the cases required a new revision. Single-procedure replacements provided better functional results and better cure rates. There was a strong correlation between early surgical intervention, adapted antibiotic treatment, and rate of cure.

Discussion: The overall rate of infection in this series is comparable with data in the literature. The rate of certain cure of infection was disappointing (71%). For acute infections, the patients underwent surgery too late and treatment was too aggressive. If there is a doubt about possible infection, revision should be performed as early as possible to allow cure and preserved function. For chronic infections, time to diagnosis and management was too long. This led to anthroplastic resection in one-third of the patients. The choice of the antibiotics and duration of treatment, associated with rigorous surgical technique, should allow switching from arthroplastic to resection prosthetic replacement using one or two surgical times which, for these infected shoulder prostheses, appears to offer the best compromise between cure and function.


E. Becquet H. Migaud F. Giraud T. Ala Eddine F. Gougeon A. Dequennoy

Purpose: Posterior stabilisation with a third condyle was introduced by Henri Dejour with the HLSI prosthesis. While the posterior stabilisation process has been validated, this implant still raises some problems with the tibial fixation in patients with advanced joint degeneration, leading to the development of the HLSII model. The purpose of the present retrospective work was to evaluate functional outcome and persistance of the HLSII prosthesis fixation.

Material and methods: Between January 1992 and December 1993, 105 total knee arthroplasties (TKA) were performed in 94 consecutive patients using posterior stabilised HLSII prostheses. Indications were joint degeneration (40% stage 4) in 78% and polyarthritis in 19%. None of the patients were lost to follow-up but 14 patients died, six were bedridden (stroke sequela) and four were contacted by phone only. In all, 70 patients (77 TKA), mean age 66 years (22–79) were retained for clinical and radiological assessment at mean follow-up of seven years (range 6–8 years). All implants were cemented and the patella was resurfaced in all cases. Eight operators participated in this series. Junior surgeons (n=5) implanted one-third of the prostheses.

Results: The mean IKS knee score rose from 27±18 points (0–63) preoperatively to 81±18 (21–100) at last follow-up, function score from 35±20 (0–75) to 64±24 (0–100) (P< 0.0001). Motion changed from 114° (60–140°) to 116° (40–135°) (NS).Eighty-six percent of the patients used stairs (13% without handrail and 28% with alternate steps) versus 52% before the intervention (1% without handrail and 1% with alternate steps). (P=0.001). Knee alignment was normal ±5° in 87% of the cases versus 27% before surgery (P< 0.0001). Seventy-nine percent of the knees had a slope ±2° (desired slope 0°). The patellar retinaculum was sectioned in one quarter of the knees which led to four of the five postoperative haematomas (no revision). Five patellar fractures were noted, including two with patellar loosening (revised) and one clunk (cured after arthroscopic release). Lucent lines observed under the medial tibial plateau in 30% of the cases (all < 1 mm) were more frequent in patients with more severe joint degeneration and genu varus preoperatively (P =0.01). There was no case of aseptic femorotibial loosening. One case of late infection (30 months) was followed by replacement arthroplasty. Survival rate, taking mechanical and/or infectious failure as the endpoint, was 97± 1.3% at 90 months.

Discussion: Good axial control emphasises the reliability of the instrumentation since one-third of the prostheses were implanted by junior surgeons. Improvements in tibial fixation with the HLSII appear to be effective, particularly for stage 4 degeneration. Long-term surveillance is however necessary. The femoropatellar joint can give rise to non-infectious complications and should be improved. The concept of posterior stabilisation with a third condyle authorises good flexion amplitude and favours use of stairs.


L. Jacquot T. Aït Si Selmi E. servien P. Neyret

Purpose: The purpose of this work was to report mid-term results of a series of 162 total knee prostheses with an all-polyethylene plateau.

Material and methods: Between 1989 and 1995, 162 posterior stabilised cemented HLS2 total knee prostheses with an all-polyethylene plateau were implanted during first intention arthroplasties performed by the same surgeon. 142 prostheses were reviewed at more than one year, three patients died, and 17 were lost to follow-up (10%). Clinical results were assessed with the IKS criteria. Complete x-ray data included pangonograms. Mean follow-up was 4.5 years.

Results: Ninety-six percent of the patients were satisfied or very satisfied and 95% had no pain or mild pain. Mean flexion was 114°. The mean postoperative knee score was 81/100 and mean function score was 64/100. Radiographic findings showed the good position of the implants with mean AFT at 178.6°, mean AFm at 89.1° and mean ATm at 89°. There were eight failures (4.9%) requiring replacement of a component, two for frontal laxity, three for patellar fracture, one for infection, one for aseptic loosening, and one for an oversized tibial plateau. Two revision procedures were performed without implant replacement, one for pain (biopsy) and one for arthrolysis.

Discussion: These 162 prostheses with an all-polyethyl-ene plateau were retained among a consecutive series of 893 HLS prostheses. We compared the present results with those of the metal-backed prostheses implanted in this series and with data in the literature. We found a significant correlation between the presence of tibial lucent lines and postoperative alignment defects, explained by the type of tibial component, in these 162 all-polyethyl-ene plateau prostheses. These lucent lines did not progress with time and had no clinical consequence.

Conclusion: Clinial and radiological results with total knee prostheses with an all-polyethylene plateau, i.e. without metal backing, were very good in this series. We analysed our experience in comparison with the literature, focusing on the advantages and disadvantages of these two types of components.


O. Delattre H. Dintimille M. Gottin J.L. Rouvillain Y. Catonne

Purpose: Loosening remains a problem with semi-constrained total elbow prostheses. The trend in recent years has been to improve prosthesis design to achieve stability of the humeral implant. We report a small series of nine Coonrad-Morrey total elbow prostheses where three early loosenings were observed in the ulnar implant. We attempt to analyse the causes and present a review of the recent literature.

Material and methods: Nine patients, mean age 60 years, age range 57–63 years, underwent total elbow arthroplasty with a Coonrad-Morrey prosthesis for rheumatoid disease (n=5), stiff degenerative joints after trauma (n=3, flexion-extension 20°), floating joint after trauma (n=1). The posterolateral approach described by Bryan and Morrey was used for eight elbows and the posterior approach for one. Clinical and radiological results were assessed with the performance index and the Mayo clinic score respectively.

Results: Mean follow-up was 3.6 years (1.5–4.7). Outcome was very good or good for seven elbows (score > 75 and > 50), fair for one (< 50) and poor for one (< 25). Three elbows were pain free, two presented pain during movement against force. Flexion was greater than 120° in four elbows (all four rheumatoid polyarthritis). Radiologically, we observed three cases of ulnar implant loosening with two type IV lucent lines, and one type III line. There was one humeral implant with a lucent line which did not change over time (type I). The two cases of type IV lines were associated with radial and anterior translation migration of the prosthetic stem with effraction or lysis of the ulnar cortical. The three ulnar loosenings appeared between the second and third postoperative year on two post-trauma stiff degenerative elbows (flexion-extension < 20°) and one rheumatoid elbow. At last follow-up, there was one poor result requiring revision surgery, one fair result, and one very good result (totally asymptomatic type 4 lucent line).

Discussion: The causes of these loosenings were studied: difficult cementing technique in a tight canal, mediocre primary stability of the ulnar implant opposing the excellent fit of the humeral implant with an encased graft under the anterior wing, excessive constraint. Our results are similar to those reported by Hilebrand who had 30% evolving ulnar lucent lines and suggest that we should reserve this prosthesis for unstable elbows.


C. Conso R. Bleton

Purpose: This retrospective analysis was designed to determine the contribution of arthroscopy in the management of moderately stiff elbows arising from degenerative disease or trauma.

Material and methods: Between 1992 and 2001, we performed 31 arthroscopic examinations of the elbow in patients with moderately stiff elbows. Mean preoperative motion was 94.8°. Men age at surgery was 41.6 years; there were nine women and 22 men. The dominant side was involved in 70% of the cases. Twentyfive patients were available for clinical review at a mean 32 months follow-up (range 5 months to 9 years). The causal event was trauma in 13 cases. The stiff elbow was a consequence of degenerative disease in 13 cases with no notion of trauma. Three elbows had been exposed to repeated microtrauma. For the majority of the cases, the intervention consisted in an anterior time via two portals then a posterior time. In five cases, anterior capsulotomy was performed. The other interventions were limited to joint cleaning. For two elbows, we used the Kashiwagi Outerbridge technique. Neurolysis of the ulnar nerve was performed at the elbow level during the same operative time.

Results: Elbow motion in flexion was significantly improved after arthroscopy (P=0.01) and the flexion of the stiff elbow was reduced significantly (P=0.0001). At last follow-up none of the patients felt arthroscopy had worsened the elbow condition. The gain in joint motion was 25°. This gain was significantly greater when we performed anterior capsulotomy at the end of the procedure (P< 0.001). In three cases, there was a postoperative loss of motion. We did not have any intra or postoperative complications. Eighty percent of the patients felt arthroscopy had improved their elbow.

Discussion: Arthroscopy of the stiff elbow arising from variable causes remains a difficult intervention which in our series provided gain in motion comparable to that reported in other series in the literature. This could be an interesting less invasive alternative to open surgery in the case of moderately stiff elbow.


E. Dagher F. Bonnomet X. Chiffolot Y. Lefèbre P. Clavert J. Lano J.F. Kempf

Purpose: Removal of intra-articular foreign bodies (FB) constitues a major indication for elbow arthroscopy. The purpose of our study was to evalute our experience with arthroscopic treatment of elbow osteochondromatosis.

Material and methods: Between September 1988 and June 2001 we performed elbow arthroscopy in 25 active patients (15 manual workers, 8 athletes including 2 high-level) who presented intra-articular FB osteochon-dromatosis of the elbow. Male gender predominated (n=22). Mean age at intervention was 42 years (17–68). The right (n=21) and dominant (n=24) side predominated. The mean clinical course before arthroscopy was two years. Seven patients had had upper limb trauma (five with elbow injury) a mean 60 months (6–144) before arthroscopy. Clinical assessment before arthroscopy and at last follow-up (mean follow-up 60 months, 8–138) included pain score (visual analogue scale), the notion of blocking and joint effusion and joint motion, as well as index of functional impairment during occupational and recreational activities and a subjective satisfaction index. Standard x-rays and arthroscan were obtained before arthroscopy to identify and evaluate intra-articular foreign bodies. Cartilage damage and presence of synovial anomalies were evaluated on the preoperative scan and during the intervention. Arthros-copy was performed according to the same procedure in all cases: lateral decubitus, arm cuff, anterior expoloration (anteromedial and anterolateral access). Standard x-rays were also obtained after arthroscopy and at last follow-up.

Results: FB were found and extracted in all cases. Cartilage injury was associated in 14 cases. Synovectomy was performed systematically in case of synovitis, a macroscopic synovial anomaly, or to extract a FB trapped in the synovial (n=18). Osteophytes were shaved in 12 cases. The post-arthroscopic period was uneventful with no complications (vascular, nervous, infectious). Clinical improvement was significant and sustained and the occupational and recreational function indexes improved. The subjective satisfaction index remained high five years after arthroscopy. We did not have any clinical recurence (blockage) or radiographically detectable anomaly at last follow-up. Less favourable results (persistent pain) were obtained in patients who had cartilage injury.

Discussion: Arthroscopy appears to be a safe treatment with long-term efficacy for osteochondromatosis of the elbow. Long-term prognosis is influenced most by presence of cartilage injury.


L. Lino J.N. Argenson J.M. Aubaniac

Purpose: The Oxford unicompartmental prosthesis has congruent joint surfaces due to use of a mobile meniscus whose upper part matches the sphere constituted by the femoral component. The purpose of this work was to report results in a series of 75 prostheses studied with mean follow-up of 12.4 years (range 10–14 years).

Material and methods: Mean age of patients was 65 years (38–84), with 67% women and mean body mass index of 28.7 (21.2–40.6). Patients gave their subjective assessment of the arthroplasty and the IKS scores were determined. Radiographically, the mechanical alignment of the lower limb was evaluated pre- and postoperatively on the full stance images. The Kennedy classification (4 grades) was used to assess passage of the mechanical axis through the knee.

Results: At last follow-up, three patients were lost and eight had died. According to their subjective assessment, 84% of the patients were enthusiastic or satisfied. The overall IKS score showed that 52% of the patients were above 180 points, 25% above 150 points. Mean varus was 11° (2–24°) preoperatively and 5.7° (5° valgus to 14° varus) at last follow-up. The mechanical axis passed in the sufficient correction zone (c or 2) in 77% of the knees, undercorrection zone in 17% and in the overcorrection zone in 6%.Seven prostheses were revised for mechanical failure: four for loosening, two for extensive degeneration, and one for pain giving a survival curve of 90% at 12 years. It must be added that two meniscal dislocations occurred, one early due to wound dehiscence and infection and one late, both after a fall.

Discussion: Most loosenings occurred early and at the tibial level. Defective alignment could be incriminated in one case. The other knees exhibited a reactive line under the tibial plateau. The rate of dislocation should probably decline with the use of progressive reamers, not available at the time of this series. Finally none of the prostheses were revised for wear, confirming the proper prosthesis design.


Y. Cayonne D. Ribeyre C. Calvet C. Vaudois O. Delattre H. Pascal-Mousselard J.L. Roovillain

Purpose: Most series on revision total knee arthroplasty (TKA) have cited femorotibial instability as a frequent cause of failure, after loosening and patellar complications. The purpose of this study was to analyse TKA failure due to femorotibial instability and to search whether an initial defect in technique or indication was the cause of stability and thus to draw therapeutic conclusions for revision surgery.

Material and methods: Between 1989 and 2000, 43 aseptic TKA required revision with implant replacement (tibial, femoral or both). During the same period 1013 first-intention TKA were implanted. Among the failures, implant loosening (femoral, tibial or both) was noted as the cause in 22 cases, isolated femorotibial instability in 15. Among the 22 loosenings, there were seven cases of femorotibial instability not related to implant migration or wear. We retained the 22 cases of femorol instability related to ligaments (15 cases of isolated instability and 7 cases associated with loosening) for study. Clinical data recorded were: initial diagnosis, patient age and sex, manifestations of instability, time to revision after first intervention. Radiological data recorded were: type of prosthesis implanted, implant position (alpha and beta angles), pre- and postoperative mechanical femorotibial alignment, tibial slope, tibial and femoral mechanical angles (searching for extra-articular deformation).

Results: The 22 revisions conserned 17 women and five men. Signs were pain and sensation of instability. Mean time to revision was two years eight months for isolated instability and six and one half years for instability associated with loosening. Prostheses were implanted in different units and thus varied: all were semi-constrained implants. Among the 22 instabilities leading to revision, we found 13 frontal instabilities, three sagittal instabilities, and six global instabilities. Analysis of the patient files demonstrated that failure could be explained in 19 cases by several defects, sometimes associated: insufficient release during initial intervention (medial or lateral release), excessive release (n=1), varus or valgus frontal or tibial cut, excessive tibial slope, internal rotation of the femoral or tibial implant, extra-articular deformation corrected intra-articularly (n=4), insufficient medial collateral ligament with major genu valgum (n=3). Certain failures were particular for certain implants, posterior laxity after implant with preservation and insufficiency of the posterior cruciate ligament, dislocaton of a posterior stabilised implant (n=1).

Discussion: This analysis of factors contributing to failure by femorotibial instability demonstrated that the majority of the cases have a technical explanation: 1) defective cuts and ligament imbalance are frequent; the cut or ligament release should be revised when changing the prosthesis. 2) Ligament insufficiency generally involving the medial collateral ligament in knees with major genu valgum; a more constrained prosthesis should be used or, as advocated by some, ligamentoplasty. 3) Extra-articular deformations are generally observed in knees with major genu varum; osteotomy may be needed if the extra-articular deformation exceeds 10°.

Conclusion: Femorotibial instability is a frequent cause of early failure of TKA. Greater precision in prosthesis implantation and correct ligament balance as well as proper choice of the degree of constraint should allow reduction of this frequency.


T. de Polignac J.L. Lerat A. Godenèche K. Maatougui J.L. Besse B. Moyen

Purpose: We analysed knee prostheses preserving the posterior cruciate ligament (or both cruciates) performed after tibial osteotomy. We determined outcome as a function of any tibial callus deformation created by the tibial osteotomy.

Material and methods: This retrospective study included a consecutive series of 56 knee prostheses with preservation of the posterior cruciate ligament (n=43) or both cruciate ligaments (n=13). The patients had undergone prior tibial osteotomy for valgisation (n=47) or varisation (n=9). Seven groups were defined as a function of the preoperative tibial angle prior to TKA. The angle were measured with telegonometry. Minimum follow-up was one year, mean follow-up 4.1±2.8 years.

Results: The tibial tuberosity was raised in 15 cases. If there was major valgus or rotation deformation, tibial osteotomy was associated with the prothesis (n=9). At last follow-up, the mean IKSg, IKSf and HSS scores were 81.5, 77.6, and 82.3 respectively. The mean femorotibial angle was 177.4±4.2°. The mean tibial angle was 87.8±3° and the mean femoral angle was 89.8±2°. Preoperative tibial deformation was not influenced by clinical results. In case of preoperative tibial deformation situated between 5° valgus and 5° varus, operation time, blood loss, and femoraotibial axis at last follow-up were not significantly different. To correct for tibial valgus greater than 7°, tibial osteotomy was associated with prosthesis implantation during the same operative time in six out of thirteen cases. For preoperative tibial varus greater than 5°, the femorotibial axis was less well corrected.

Discussion: These clinical results were comparable to those reported in other series with preservation or not of the posterior cruciate ligament. Correction of the femorotibial angle was less satisfactory than in certain series, but the deformation and the surgical history were among the most marked in the literature. Preservation of the posterior cruciate ligament (or both cruciates) appears to have increased the technical difficulties for upper tibia exposure and position of the tibia implant. For tibial callus with valgus greater than 7°, the prostheses cannot be expected to provide a solution alone and osteotomy should be associated. For tibial callus with 5° or more varus, the indication for associated tibial osteotomy merits discussion.


P. Hernigou G. Dechamps

Purpose: This study was conducted on explanted uni-compartmental prostheses with a flat polyethylene plateau without metal backing. We search for clinical factors influencing polyethylene wear.

Material and methods: This series included 30 polyethylene inserts divided into two groups. Group A included revision procedures performed for a reason other than implant loosening (wear of the other compartment, femoropatellar problems). Group B implants were explanted after loosening. The duration of implantation of the 13 implants in group A was 126 months (mean, range 11–218 months); it was 167 months (range 137–224) in group B. Remaining insert thickness was measured with a micormetric device, mitutoyo, allowing palpation of the worn surface with a precision of 3 microns. The volume of the femoral penetration into the polyethylene was calculed in two ways to separate penetration related to polyethylene deformation from penetration related to polyethylene wear. The micrometric device palpated the surface of the polyethylene enabling calculation of the sum of the volumes corresponding to wear and deformation. To measure the volume corresponding to wear, the explanted pieces were weighed and the result was compared with implants of the same size which had never been implanted. Polyethylene wear was calculated from the weight loss and and polyethylene density. The difference between the two calculation methods was attributed to polyethylene deformation.

Results: Mean residual thickness of the polyethylene in group A without loosening was 7.16 mm, compared with 4.5 mm in group B. The volumetric femoral penetration into the polyethylene was a mean 19 mm3 per year in group A and 65 mm3 per year in group B. This imprint obtained with the micormetric measuring device was greater than the wear determined by weighing. This difference was about 25%. The decreased thickness of the implant was thus undoubtedly due, for three quarters, to wear alone. One quarter being attributed to polyethylene deformation. In group A (without loosening), each supplementary year of implantation corresponded to a decrease in the rate of wear of about 12% per yar, which would suggest that the wear mechanism is an abrasion and that with time the femoral and tibial implants become more congruent decreasing the rate of wear. Inversely in group B, each supplementary year of implantation after onset of loosening was associated with a 9% increase in the annual rate of wear. Microscopic examination of the group A implants demonstrate that abraison was the main mechanism of wear. In group B, delamination was observed, particularly when the loosening was associated with anterior cruciate ligament tear or major persistent deformation.

Discussion: The rates and mechanisms of polyethylene wear in unicompartmental prostheses are different for non-loosened implants and for loosened implants. Taking into account the fact that polyethylene deformation participates for about one quarter of the decreased thickness over time, adjunction of a metal back would appear indispensable for thin inserts.


F. Chatain A. Richard G. Deschamps P. Nevret

Purpose: The purpose of this work was to analyse results of revision procedures for unicompartmental prostheses (UNI) replaced by total knee arthroplasty (TKA) and to detail technical difficulties.

Material and methods: This series included 54 UNI revised with TKA. There were 45 medial and nine lateral UNI. The cause of failure was determined from the clinical history, the postoperative x-rays following UNI implantation and the preoperative x-rays before TKA as well as the operation report. Mean time from failure of UNI to TKA was four years. Clinical results were assessed with IKS criteria. The radiological work-up included an AP and lateral view in single leg stance and goniometry in 44.5% of the cases. Twenty-seven patients were reviewed with standard x-rays, eight patients were lost to follow-up, and 19 were studied from the medical files. One patient died.

Results: Mean follow-up was four years (range 2–12 years). There were seven failures (13%). We noted six cases of phlebitis, two plumonary emoblisms, one secondary infection, and three mobilisations under general anaesthesia. 55.5% of the patients were very satisfied, 36% were satisfied and 8.5% were disappointed. Revision was considered easy or moderately difficult in 82% of the cases. A standard gliding TKA was implanted in 39 cases (72%). Mean knee score was 85 points. Mean flexion was 113°. The mean function score was 62 points. For 91% of the cases, there was no laxity. The femorotibial angle was 90° in 54% of the cases and the mechanical tibial angle was 90° in 46%.

Discussion: Our results are similar to those reported in the literature. They were better than reports of TKA revision TKA. Results of TKA revision of UNI have been good. There is no technical problem related to bone loss, generally at the tibial level (45%). Preoperative planning allows defining the revision modalities (long pivot, metal backing, revision prosthesis). We recommend a long tibial pivot in the event of important tibial bone loss.


P.O. Pinelli A. Sbihi A. rochwerger J.P. Franceschi G. Curvale

Purpose: Lateral hypoaesthesia of the knee following peroperative section of an infrapatellar sensorial branch during anteromedial access for knee surgery is a well-known phenomenon. Development of a painful neurinoma at this level is much more exceptional but can be the cause of persistent pain, often becoming violent in the anteromedial region of the proximal tibia which may often evoke the diagnosis of mechanical failure of the prosthesis due to superficial conflict or loosening. There is relatively little in the French orthopaedic literature on this topic. We wanted to draw attention to this often missed diagnosis.

Material and methods: We report the cases of three patients with degenerative knee disease who underwent total knee arthroplasty using a posterior stablised prosthesis implanted via an anteromedial approach. Persistent pain which developed over more than six months led these patients to consult. Several surgeons evoked a “classical” cause of postoperative pain resulting from postoperative loosening but the x-ray and scintigraphy findings were inconclusive. Physical examination demonstrated dysaesthesia in the lateral infra-pateller region with a positive Tinel sign on the anteromedial aspect of the knee immediately below the tibial implant suggestive of a neurinoma of the infrapatellar branch of the saphenous nerve. An anatomic study conducted on ten knees enabled us to identify the anatomic bases necessary to achieve local anaesthesic blocks providing the pretherapeutic diagnosis. The diagnostic tests were performed with injection of 5 ml xylocaine in the subcutaneous tissue over the medial aspect of the knee upstream from the suspected neurinoma. Complete resolution of pain evaluated 10 minutes after injection led to proposing neurotomy of the infra-patellar nerve via a separate medial incision.

Results: Denervation provided immediate relief in three patients. For two, the pain and dysaesthesia regressed completely. Substantial improvement in hyperaesthesia was noted in one patient.

Discussion: The anatomic studies demonstrated that one or more branches of the infra-patellar nerve cross the mid line from the apex of the patella to the anterior tibial tuberosity in 98% of the cases. In ongoing work during revision procedures for total knee arthroplasty, we have noted hypoaesthesia or anaesthesia in the infra-patellar nerve territory in 15% of the patients. Dell reported a series of 70 patients with postoperative neurinomas of the knee and obtained 86% good results after denervation.

Conclusion: Hyperalgic iatrogenic neurinoma of an infra-patellar branch of the saphenous nerve is a certain but rare cause of pain after knee surgery, generally for prosthesis. Misdiagnosis of a mechanical complication is not uncommon. The clinically suggested diagnosis is easy to confirm by a subcutaneous local anaesthesia test. Neurotomy of the infra-patellar nerve can be proposed after failure of drug and physical treatments.


T. Bégué A.C. Masquelet

Purpose: Loss of cutaneous tissue during knee prosthesis procedures raises the risk of implant exposure and infection with subsequent removal and poor functional outcome. The clinical course of the tissue loss is unpredictable leading to retarded curative treatment.

Material and methods: We report a consecutive retrospective series of 39 knee prostheses implanted from 1990 to 2000 where cutaneous tissue loss was covered with a flap. We studied time to onset of tissue loss, wound border vitality, presence or absence of implant exposure, type of cover flap distinguishing faciocutaneous and muscle flaps, retention or not of the implant, and time of secondary reconstruction.

Results: In 38 of the 39 prostheses, the implant use of the cover flap enabled saving the implant and proper wound healing. The joint remained functional but only 18 knees recovered flexion greater than 90°. In one case, the implant had to be removed due to infection with resistant Serratia. Prognositic factors identified included: time from tissue loss to its treatment, usefulness of a cover flap to save the implant, or usefulness of two-procedure reconstruction in case of implant infection.

Discussion: We compared our therapeutic methods with the propositions in the Laing classification and preferred to distinguish a simplified three-step tactic based on time of exposure for determining the theraputic strategy for cutaneous tissue loss in knee prosthesis patients.


E. Senneville I. Nallet C. Savage L. Dubreil Y. Pinoit H. Migaud

Purpose: The Rosenow enriched medium (RW) enables culture of anaerobic germs as well as slow-growing germs sometimes causing chronic infections on implanted material. The purpose of this work was to determine the usefulness of RW for the bacteriological diagnosis of infections on total hip arthroplasty (THA) and total knee arthroplasty (TKA°.

Material and methods: One hundred fifty-four pre- or intraoperative standard and RW samples were obtained in a prospective study of 80 consecutive patients (mean age 67.6 years) with an infected THA (n=56) or TKA (n=24) between January 1998 and June 2000. A bacteria was considered “infecting” if it grew on direct culture on at least two samples after enrichment. A single positive sample after enrichment was considered a contamination except for strict anaerobes for which direct culture could not be achieved. For these germs, growth after enrichment was thus considered significant.

Results: Among the 154 samples, 59 (38%) gave positive direct cultures and 95 (62%) positive enriched cultures. Among the 59 positive direct cultures, the RW culture was concordant in 87% of the cases. For the 13% of discordant cultures, the germs did not grow on standard medium: Staphylococcus (n=6), Pseudomonas (n=1), and enterobacteria (n=1). For the 95 positive enriched cultures, 41 (43.1%) of the RW cultures were condordant with the standard culture; the standard was positive in 13 (13.6%) and the RW negative (11 Staphylococcus including five aureus, one Pseudomonas, and one Corynebacterium), but in 41 cases, the RW was positive while the standard was negative (16 Staphylococcus, including 13 coagulase negative, five Streptococcus, two Entero-coccus, one Corynebacterium, three enterobacteria, and fourteen anaerobes). The infecting nature of the aerobic bacteria was retained because earlier or later samples were positive. The sensitivity and predictive value of a positive RW culture were 86% and 86% respectively.

Discussion: Using RW medium and standard samples is useful if germs grow after enrichment in order to confirm the infecting nature of the isolated germ (double culture). The reliability of RW medium was confirmed since it was concordant in 87% of the cases with a positive “gold standard” culture. For positive cultures after enrichment with a negative standard culture, RW allows correcting the diagnosis of infection in 43% of the cases. Its usefulness lies basically in the isolation of coagulase negative Staphylococcus and anaerobes (especially Propionibacterium spp. and Peptostreptococcus spp.).


P. Cariven P. Bonnevialle P. Mansat L. Verhaeghe M. Mansat

Purpose: External fixation has restricted indications in fractures of the femur, particularly in the distal portion. Between 1986 to December 2001 we used external fixation for 21 first-intention treatments of metaphyseal epiphyseal distal femur fractures. This retrospective study was designed to detail the contribution of this type of fixation.

Material and methods: The series included 14 men and six women (one bilateral case), mean age 33 years (range 17–83). All patients were victims of high-energy trauma. Twelve had multiple injuries (mean ISS 20) and 16 had multiple fractures including ten floating knees. According to the Gustilo classification, the 20 open injuries were one type 1, five type II, fourteen type III including two IIIC with rupture of the femoral artery. Three patients had burns or degloving injury of the thigh. An exclusive femoro-femur fixation was used with a dynamic axial fixator associated with complementary epiphyseal screws in eight cases. The AO classification ws six metaphyseal injuries (4 C2, 7C22 and 3 C23). Associated procedures included two vessel repairs, two rectus dorsi flaps, and four modifications of the fixator or new reduction.

Results: One patient died from mulitple injuries. Two required amputation for failed vascular repair and free flap. Eight patients achieved bone healing with the fixator alone including two who had an autologous graft. Mean time to healing was 10 months (5–14). One patient developed secondary fracture at eight months treated successfully with retrograde nailing. The knee had to be mobilised in four cases and arthrolysis was necessary in three. For ten cases, the external fixator was replaced voluntarily with centromedularly nailing (n=2, one supracondylar and one Grosse Kempf), or plate fixation (n=8) associated with autologous graft in four (three fibular transfers and one iliac graft). These two operative times were consecutive in seven cases and separated by a period of traction in three. The two nailings and the five plate fixations healed in a mean eight months (5–10). Three plate fixations failed: two aseptic nonunions (prosthesis revision and arthrodesis) and one suppuration currently under treatment. At minimum follow-up of 18 months, 15 patients had a known clinical result with bone healing achieved: mean active flexion was 81° (50–120°). Only one patient had deficient extension (10°). Nine patients had achieved anatomic alignment in both the frontal and sagittal planes; three presented recurvatum of 5–10° and three had a frontal deviation less than 10°.

Discussion: This experience illustrates the difficulty in correctly reducing femoral alignment while maintaining active knee mobility. This series points out the risk of infection in case of secondary osteosynthesis. External fixation should be reserved for exceptional indications: rupture of the vascular trunk, major cutaneous injury, or a temporary solution in the case of multiple injuries before rapid osteosynthesis to achieve a stable fixation.


P. Boisrenoult P. Gaudin F. Duparc P. Beaufils

Purpose: The purpose of our work was to study the effects of sequential arthroscopic section of the anterior capsule of the shoulder joint using an experimental model of retractile capsulitis induced by heat treatment.

Material and methods: Twelve cadaver shoulders were studied. Passive mobility was initially normal. Anterior capsule retraction was first created under arthroscopic control (Arthrocare® generator, power 2). Twelve programmed sequential sections were then performed successively using the thermal probe (Arthrocare®, power 9) on: the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL), the middle gleno-humeral ligament (MGHL), the inferior glenohumeral ligament (IGHL), and the intra-articular portion of the subscapular muscle tendon (SST). The posterior capsule was not studied. At each step, motion was measured independently by two operators. At the end of the sequence, the articulation was opened to verify the sections as was the absence of any injury to noble structures.

Results: Measures were reproducible (mean difference 5° between two series). The sections were correctly achieved. Macroscopically, there were no injuries to noble structures. The role of the different elements studied were as follows: — rotator interval (CHL, SGHL): gain in RE1 (mean 40°) and RE2 (mean 35°) (greater than loss during retraaction; — IGHL: gain in elevation (mean 33°); — IGHL and rotator interval: potentialisation of gain in FE2 (mean 41°) and elevation (mean 50°); — MGHL: moderate increase in external rotation at 45° antepulsion and elevation (mean 20°); —SST: discrete gain in RE1 (10°) but risk of dislocation (n=1).

Discussion: Our model was reproducible. Section of the anterior capsule by a thermal method did not produce macroscopic injury to neighboring tissues. Our study pointed out the preeminent importance of sectioning the rotator interval for recovering external rotation. This section, combined with section of the IGHL has a potentialsing effect. The limitation of our study is the absence of examination of the posterior capsule.


S. Plaweski J. Cazal T. Martinez A. Eid P. Merloz

Purpose: Injury of both cruciate ligaments raises difficult therapeutic problems in trauma victims. The severity of such lesions is related to the context of multiple trauma and to the general regional context associating vascular and neurological injury. Therapeutic management should be multidisciplinary to determine the appropriate strategy. Orthopaedic treatment should take into account the different diagnostic and therapeutic aspects. The purpose of this work was to detail ligament injuries observed and to assess results of treatments proposed.

Material and methods: This retrospective series included 20 patients (14 men and 6 women), mean age 33 years (18–54). Five had multiple trauma with head injuries and multiple fractures. The initial diagnosis was traumatic knee dislocation in 14 patients. Seven patients underwent emergency vascular explorations with subsequent femoropopliteal bypass (n=3). Neurological lesions included three cases of complete section of the lateral popliteal sciatic. Orthopaedic treatment was used in three cases. We used external fixation for two months on the average in three patients. Six others underwent surgery (less than eight days after injury) after obtaining an MRI. The surgical strategy was based on several arguments: age, general status, level of the ligament injury. Three patients underwent secondary surgery on the anterior cruciate ligament. Outcome was assessed at a mean follow-up of 36 months (20–60). The clinical assessment of the objective result was based on frontal and sagittal laxity. The subjective result and the level of sports activities were also recorded. Radiographically, we studied the standard x-rays in single leg stance and also the stress images using telos with anterior then posterior drawer.

Results: Excepting one case of amputation necessary due to the vascular and nervous injuries, orthopaedic treatment allowed an acceptable functional result in sedentary patients: good frontal stability and minimal anteroposterior residual laxity. Fourteen athletes underwent emergency surgery to repair the posterior cruciate ligament: posterior approaches in eight knees with injury of the floor with no posterior drawer at last follow-up; anterior approaches in six knees for suture of the posterior cruciate ligament and insertion of a synthetic ligament tutor with anterior cruciate ligament repair during the same operative time (two floor reinsertions, one patellar tendon plasty, and three Cho plasties). The stability of the posterior pivot was excellent but the tibial reinsertions of the anterior cruciate ligament failed. Seven knees required mobilisation under general anaesthesia 2.5 months later. Three knees underwent secondary anterior cruciate repair using the Kenneth Jones technique with negative Lachmann at last follow-up.

Discussion: Excepting vascular and neurological emergencies dictating the initial therapeutic attitude, our orthopaedic management was based on a detailed identification of the lesion using emergency MRI: anterior or posterior approach, anterior cruciate repair technique dependng on association with peripheral ligament injury. Good results in terms of posterior laxity were achieved in this series, confirming the importance of emergency repair of the posterior cruciate. If the medial ligaments are intact, the anterior cruciate can be repaired in the emergency setting with a Cho plasy. In other situations, we prefer waiting before surgical repair of the anterior pivot.


F. Bonnomet P. Clavert E. Dagher P. Boutemy Y. Lefèbvre J. Lang J.F. Kempf

Purpose: Suture anchors used for reinserting soft tissue on bony structures have been studied with the purpose of evaluating hold in bone. There has not however been any work on the influence of the eye design on suture resistance. The purpose of this work was to examine this aspect of the question.

Material and methods: The following anchors were tested: Statak 4 (Zimmer, Warsaw, IN, USA), Corkscrew 3.5, Fastak 2.4 (Arthrex, Naples, FL, USA), PeBA C 6.5 (OBL, Scottsdale, AZ, USA), Mitek GII 5Mitek, Norwood, MA, USA), Harpoon 2 (Arthrotek, Warsaw, IN? USA), Ultrafix (Linvatec, Largo, FL, USA), Vitis 3.5 AND 5 (Tornier, St Isnier, France). The following suture threads were used: Vicryl dec 5, Flexidene dec 5, PDS dec 4. Three types of tests were performed on an Instron 8500+. To study loading at thread rupture, a loop with a constant length was placed under traction in the axis of the anchor until thread rupture. Two measurement modalities were used. For the first, static tension was applied to increase the linear load at the rate of 1.25 mm/s. In the second, cyclic traction applied tension five times at a frequency of 1 Hz with 10N loading increments. To study thread weakening in relation to each anchor, we imposed a back and forth movement on the strand running through the eye using a sinusoidal 10 mm movement at a frequency of 0.03 Hz, one end of the thread being fixed and the other supporting a constant 20 N load. Each thread was tested in each anchor and each type of test was run three times.

Results: Load at rupture of each thread was not affected significantly by the design of the anchor eyes. Rupture generally occurred at the knot level, sometimes at the eye (Harpoon, Fastak, Vitis) for the Flexidene dec 5 thread. Conversely, there were important differences in the thread weakness tests: a knitted thread such as Vicryl was much stronger than the two other threads tested, irrespective of the anchor. Furthermore, resistance for the dynamic test was very variable for the different anchors: 100±20 cycles for corkscrew 3.5 and 3±1 cycles for Vitis 3.5 with Vicryl or 6+/1 cycles for Harpoon 2 with Flexidene.

Conclusion: The design and finishing of each eye had an effect on the resistance of thread moving through the eye. For anchors which weakened thread after a few back and forth movements, it can be assumed that simple knotting damages the thread to a point where early failure occurs at reinsertion. The best results were obtained when the anchor eye had a bevelled groove.


P. Collin M. Ropars T. Dréano J.C. Lambotte H. Thomazzeau F. Langlais

Purpose: In 1996, we reported the results of 65 coracoid blocks for chronic anterior instability. We found 6% true recurrence and 34% persistent apprhension. In order to improve these results, we modified our operative technique, associating capsuloplasty in the event of hyperlaxity. The purpose of the present work was to assess mid-term results.

Material and methods: Eighty-eight coracoid blocks were performed between 1995 and 2000 by the same operator. In 41 cases, the classical technique was used. In 47 cases we associated capsuloplasty. The indication for surgery was documented recurrent instability in all cases, with radiographic, MRI or endoscopic confirmation of an anteroinferior capusloligament lesion. Capsuloplasty was associated if signs suggested hyperlaxity: self-reducing dislocation, absence of notch, external rotation arm to body (RE1) greater than 80°, presence of a significant groove, laxity of the inferior flap of a T capsulotomy. Mean patient age was 24 years (14–42) and mean follow-up was 40 months (24–60). Clinical results were assessed with the Duplay criteria and three x-rays were obtained (standard AP, Lamy lateral view and glenoid lateral view).

Results: Eighty-five percent of the patients achieved a good or very good result according to the Duplay criteria. Eighty-eight percent of the blocks held without modification and 12% developed osteolysis. There were no cases of degeneration. One patient experienced recurrent dislocaion. The rate of persistent apprehension declined (12%) compared with our earlier experience. This improvement was achieved at the cost of greater loss of RE1 in the group with capsuloplasty (−20° versus −8°), but without impact on sports activity (82£% returned to their sports activities including 72% at the same level without significant difference between the groups with and without capsulotomy).

Discussion: These results demonstrate that capsuloplasty is warranted if there are signs of hyperlaxity. This technique allowed us to improve results concerning recurrence and persistent apprehension at the cost of less mobility but without effect on sports activities. We detail the objective criteria used to define hyperlaxity and describe the usual clinical expression of radiographic, arthroscopic, and arthroscopic findings.


F. Jouve P. Hardy B. Rousselin A. Lortat-Jacob

Purpose: It is known that severe distention of the inferior glenohumeral ligament (IGHL) during anteror-inferior shoulder instability is an important factor of poor functional prognosis after arthroscopic stabilisation. O. Gagey proposed a clinical test to assess laxity of the IGHL. The purpose of this study was to assess the laxity of the IGHL using a dynamic radiological test (AP view in passive abduction of the glenohu-meral joint) and to correlate findings with arthroscopic observations..

Material and methods: We performed a prospective study in 21 patients scheduled for arthroscopic stabilisation for anteroinferior shoulder instability. Mean age was 24.6 years, 17 men and 4 women. The test was performed in the supine position with a strictly AP view of the shoulder. Bilateral comparative images were obtained. The shoulder was brought to forced passive abduction in neutral rotation without general anaesthesia or locoregional anaesthesia. The angle between the axis of the humeral diaphysis and the line passing through the inferior border of the glenoid cavity and the lateral border of the scapular tubercle was measured. Vuillemin has demonstrated that this test is reliable and reproducible. During arthroscopy performed for diagnostic and therapeutic purposes, the degree of distension was quantified using the Detrisac classification of four stages. We considered that stages 3 and 4 were frank pathological distension. We used the threshold of 15° for the difference between the healthy and pathological side for the radiological test. We assessed the ability to demonstrate severe laxity of the IGHL.

Results: For differences in abduction less than 15°, the test sensitivity was 77%, specificity 91%, positive predictive value 87% and negative predictive value 84%.

Discussion: A careful physical examination and appropriate complementary tests are essential for the evaluation of anteroinferior instability of the shoulder joint in order to obtain a precise diagnosis and search for contraindications for arthroscopic cure. The rate of recurrence after arthroscopic stabilisation remains above that obtained with open techniques. It has been demonstrated that major laxity of the IGHL constitutes a relative contraindication for arthroscopic stabilisation. Radiographic measurements provide precise information for evaluating the laxity of the IGHL. Taking a positive threshold of 15° difference identifies 87% of the cases of Detrisac stage 3 or 4 ligament distension.

Conclusion: We propose a preoperative complementary test using standard x-rays together with our dynamic radiological test of passive shoulder abduction. If the difference between the healthy and pathological side is greater or equal to 15°, the therapeutic strategy should include not only reinsertion of the rim but also retight-ening the ligament complex, or open stabilisation.


O. Gagey V. Molina S./ Paci S. Raspaud S. Soreda

Purpose: Study experimental instability by ligament section leaving intact all the periarticular elements.

Material and methods: Sixteen fresh cadaver shoulders were studied. Dissection was achieved via an axillary approach isolating the ligaments without muscle section. Instability was classified in five stages: 0) stable, 1) drawer and sulcus, 2) subluxation: the head crossed the glenoid border but remained in the plane of the glenoid, 3) reversible dislocation: the head was dislocated by returned spontaneously into place when the arm was left to hang along the body, 4) permanent dislocation. The ligaments were sectioned in the following order: 1) betrween 7h and 5h, 2) between 5h and 2h, 3) between 1h and 11h. Instability was tested with usual manœuvres: drawer, sulcus, hyperabduction test, provoked dislocation in elevation and maximal external rotation, downward pressure in the axis of the humerus.

Results: Dissection of the ligaments produced class 1 instability in 0% of the shoulders, Section between 7h and 5h (anterior part of the inferior glenohumeral ligament) yielded class 2 instability in 12 cases, and class 3 instability in six. The hyperabduction test was positive in all shoulders. Section between 5h and 3h (middle glenohumeral ligament) produced class 3 instability in all the shoulders but never permanent dislocation. To obtain class 4 instabilty, section between 1h and 11h (superior glenohumeral ligament) was required. Section of the cuff was not necessary to obtain permanent dislocation.

Discussion: The role of the superior glenohumeral ligament in the production of shoulder instability has not been detailed to date. Closure of the rotator interval, proposed by Nobuhar and by Field, corresponds to retightening this ligament. The function of the superior glenohumeral ligament should be taken into account during the treatment of shoulder instability.


C. Conso P. Hardy

Purpose: This study was conducted to analyse the importance of the Malgaigne notch and its position on standard x-rays taken in internal rotation or on arthroscan in patients treated for anterior instability of the shoulder. Our purpose was to search for criteria perdictive of outcome of arthroscopic stabilisation of the shoulder joint using the Bankart method.

Material and methods: Fifty-four patients were reviewed to determine the postoperative Duplay score. Mean follow-up was 68 months (32–100). Mean age at surgery was 29 years. We divided the patients into three populations as a function of preoperative symptoms: population A two dislocations or more, population B one dislocation then episodes of subluxation, population C no dislocation but pain. We divided this population according to the Duplay score. Group 1 patients had a fair or poor outcome, Group 2 patients had a good or excellent outcome. We reviewed 54 radiograms using patterns of increasing size (mm by mm) to assess the radius of the humeral head and the depth of the notch. We evaluate the reproducibility of this method by comparing the readings of ten senior orthopaedic surgeons. There were no false positives or false negatives. Variance of the measures taken by the ten surgeons was 0.67 at 1.31 mm, a small variance. We compared the ratio between the radius of the humeral head and the depth of the notch in the different groups.

Results: The Malgaigne notch was significantly deeper in population A (19%) than in population B (14%) or population C (14.3%). This suggests that the size of the notch has an effect on symptomatology of shoulder instability. The notch was also significantly deeper in group 1 patients (fair or poor outcome) (21%) than in group 2 (good or excellent outcome) (16%) (p=0.05).

Discussion: Beyond a threshold set at 15%, there were 54% fair or poor results. The position of the notch in height was significantly different in population A compared with populations B and C (p=0.01). It appears to be higher in case of true recurrent dislocation. We did not demonstrate any statistical link between the position of the notch on the CT scan and surgical outcome. This study demonstrates the importance of information on the internal rotation images in choosing the proper type of surgery for shoulder instability.


P. Mansat M. Guity B. Roques Y. Bellumore M. Rongières P. Bonnevialle M. Mansat

Purpose: The results of coracoid blocks for the treatment of anterior shoulder instability are satisfactory (SOFCOT 1991 and 1999). Little work has been devoted to complications of this operation. We report our results after surgical revision in a consecutive series of seventeen patients.

Material and methods: Fourteen men and three women, mean age 34 years, required a second interention after anterior coracoid block: for recurent instability in ten cases and for painful stiff shoulder in seven. Radiographic assessment demonstrated a conflict between the block and/or the screw with the humeral head in 13 cases and signs of joint degeneration in three. The block was malpositioned in eight shoulders. The stabilisation procedure (Bankart ± capsuloplasty) was performed for these unstable shoulders with debridement and removal of the screw and or the block for painful stiff shoulders. The subscapular tendon was normal preoperatively in two shoulders, fibrous or thin in eleven and torn in one. The time from the first operation to revision was eleven years on the average.

Results: At mean follow-up of 21 months, the patients were assessed with the Duplay score. Results were good or excellent for eleven patients (70% for stabilised unstable shoulders and 57% for debrided painful stiff shoulders), fair for four and poor for two. Clinical assessment of the subscapular demonstrated a deficiency in ten shoulders. The force of internal rotation of the operated shoulder was 3.3 kg less than for the controlateral shoulder. Computed tomography demonstrated significant fatty degeneration of the subscapular in four patients. Glenohumeral joint degeneration was observed in nine shoulders. The most significant prognostic factor for final outcome was the number of prior interventions (p< 0.01).

Discussion: The result of revision surgery after coarcoid block depends on the clinical presentation. While the results for painful stiff shoulders remained very limited due to frequent intra-articular lesions, adjunction of a capsuloplasty with or without reinsertion of the glenoid rim yielded satsifactory results in more than two-thrids of the unstable shoulders. Involvement of the subscapular muscle appears to be related to multiple interventions in these shoulders, as well as to the deleterious effect of the block (Picard 1998, Glasson 1999) and continues to be the crucial prognostic factor for final outcome.


G. Giordano F. Accabled C. Besombes J.L. Tricoire P. Chiron

Purpose: The floating shoulder is a special entity in traumatology of the upper limb. Bioechanically, the floating shoulder corresponds, as defined by Goss, to a rupture of the suspensor complex. Management is not well defined but must target the proper balance between the need for anatomic restauration and quality functional results obtained in the majority of cases treated orthopaedically. This apparent paradoxical situation is probably related to the precision of indications.

Material and methods: Forty-five patients managed between 1980 and 2001 were reviewed retrospectively. Thirty-five presented a scapulo-cleido-thoracic syndrome, ten a scapulocleidal syndrome. Mean age at the time of trauma was 39 years and mean follow-up was 2.4 years (1–16). The patients, 36 men and nine women were mainly (76%) traffic accident victims (58% motorcycle, 33% automobile, 9% pedestrians) and 76.8% had multiple injuries. Cleidal lesions were 18 mid-third fractures, 12 acromiocleidal dislocations, three sternocleidal dislocations, seven bifocal fracrturs, three lateral third fractures and two medial third fracturs. The scapular lesion involved the body of the bone in 19 patients, the neck in 14, the glenoid cavity in two, the coracoid process in one, and multifocal fractures in nine.

Results: Thirty-two patients were treated orthopaedically and twelve patients surgically, four with cleidal osteosynthesis, eight with both. The postoperative x-rays were used to assess anatomic results and the Constant score to assess functional results. Complications included six deformed calluses, with four causing major functional impairment and one requiring revision. All resulted from orthopaedic treatments.

Discussion: While most patients have an indication for orthopaedic treatment, analysis of the displacemens can lead to a surgical indication. We retained the following criteria for surgical treatment: scapular neck fracture causing more than 40° angulation, glenoid medialisation-ventralisation greater than 2 cm, and displaced articular fracture. Osteosynthesis of the clavicle for floating shoulders with a major displacement appears to be the minimum prerequisite if the multiple injuries prevent optimal management.


N. Mehdi C. Maynou P. Lesage X. Cassagnaud H. Mestdagh

Purpose: Arthroscopic tenotomy of the long head of the biceps brachial is indicated for pain relief in the treatment of unrepairable tears of the rotator cuff. The purpose of our study was to evaluate clinical and radiological outcome.

Material and methods: This retrospective study included 38 patients (21 women and 17 men) mean age 65 years (44–78) who presented rotator cuff tears that could not be repaired by suture. These patients underwent arthroscopic tenotomy associated with acromioplasty in eight cases. Preoperative imaging included arthroscan and standard radiograms to assess retraction of the supraspinatus stump and fatty degeneration. The clinical outcome was assessed with the Constant score and search for loss of biceps force (estimated in comparision of an age- and gender-matched cohort). Modifications of the subarcomial height and the stage of joint degeneration were assessed on AP radiograms (standing and reclining position).

Results: Mean follow-up was 31 months. There were no complications related to the operation. The overall constant score improved 19 points from 39 to 58 (pain +7 and motion +6.1 increased most). The activity score improved 6 points. Active joint motion in antepulsion, abduction, and lateral rotation (elbow to body) increased 36.5°, 13.1° and 20.8° respectively. The sub acromial height decreased very little (from 7.4 mm preoperatively to 7.4 mm postoperatively). We observed a 37% decrease in arm force in flexion/supination on the operated side (6.05 kg vs 9.65 kg). Subjectively, 85% of the patients were very satisfied or satisfied, 10% were disappointed and 2.5% were discontent. For 88% of the patients the decision for surgical intervention was wise.

Discussion: Tenotomy of the long head of the brachial biceps is effective for pain relief and consequently joint motion. It is a technically simple procedure which does not accelerate degeneration of the excentered joint, at the follow-up considered. It does however reduce flexion force of the arm.


F. Sirveaux J. Leroux O. Roche M. de Gasperi C. Marchal D. Mole

Purpose: Posterior instability of the shoulder requires surgical treatment in involuntary forms and after failure of functional treatment. As for anterior instability, a bone block can be fashioned from an iliac graft or a pediculated graft harvested from the acromion. This retrospective analysis concerned the results obtained in eighteen consecutive cases.

Material and methods: This series included ten men and eight women, mean age 26 years (15–42) at time of surgery. Fourteen (77%) practised sports activities including four at competition level. Symptoms had persisted for four years on the average. For three patients (16%) posterior instability was expressed by recurrent luxation subluxation. For nine patients (50%) posterior subluxation was a common involuntary event. Six patients suffered from painful shoulders due to an unrecognised posterior instability accident. Diagnosis of posterior instability was establised by arthroscopy in seven patients (39%). For nine shoulders the intervention consisted in a screwed posterior iliac block associated with a tension procedure on the capsule (group 1). For the other nine shoulders the block was harvested from the acromion and pediculated on the deltoid (group 2).

Results: Mean follow-up for all patients was eight years. The Duplay score was 75 points at last follow-up. Twelve patients (85% of the athletes) were able to resume their sports activities, half at the same level. Nine patients were pain free. Six patients (33%) had persistent apprehension but did not present true recurrence at physical examination. The Duplay score was 69.4 points in group 1 (follow-up 12 years) and 82.2 points in group 2 (follow-up three years). Thirteen patients (77%) did not have any sign of joint degeneration at last follow-up. One patient had advanced stage IV degeneration related to an intra-articular screw. All patients felt their shoulder had been improved by surgery and one third were disappointed with the results.

Discussion: Use of a posterior block is an effective treatent for posterior instability giving results comparable with those obtained with anterior blocks in terms of shoulder stability, pain, recovery of motion, and subjective outcome. This procedure favours joint degeneration less than anterior stabilisation. Results obtained with pediculated acromial blocks are encouraging.


P. Valenti S. Naser Chourif A. Gilbert

Purpose: Injury to the clavicle is a rare cause of outlet syndrome. We report eight cases to determine the diagnostic and therapeutic features and report outcomes.

Material and methods: This series of eight patients (five women and three men), mean age 48 years (11)70) sufferred from pain irradiating to the upper limb with paraesthesia in the ulnar teritorry of the hand together with diminished muscle force. The diagnosis was established 23.1 months (mean, range 1–10 years) after the initial comminutive mid-third fracture. The displaced bone which was treated orthopaedically. Standard x-rays revealed: four deformed calluses, two atrophic nonunions, one fracture with a vertical fragment (rapid osteosynthesis performed to avoid acute plexus compression) and finally one resection of the mid third (secondary to osteitis). The electromyogram confirmed the diagnosis, generally with compression of a secondary anteromedial trunk. 3D reconstruction scans (measurement of the costo-cleidal space) were obtained.

Results: Pain disappeared the day after surgery as did the paraesthesia in seven out of eight patients. The clavicle healed in 13 to 18 months.

Discussion: Different mechanisms can cause compression of the brachial plexus after displaced comminutive fracture of the clavicle. Different therapeutic modalities have been proposed. The outlet syndrome should be considered following displaced fractures of the mid third of the clavicle in patients presenting pain irradiating to the upper limb. The diagnosis is confirmed by electromyography. Proper analysis of the clavicle is obtained with 3D CT scan allowing adapted surgical treatment.


A. Kawadjii A. Babinet B. Tomeno P. Anract

Purpose: The purpose of this retrospective study was to assess the carcinological and functional results of resection-arthrodesis procedures for giant-cell tumours of the lower extreminty of the radius.

Material and methods: This series included 16 patients, nine men and seven women, mean ate 39 years (19–63). The initial symptom was pain in all patients. Nine of the 16 patients were referred for recurrence after primary curettage-filling: the seven others presented voluminous tumours encompasing nearly all of the epiphyseome-taphyseal region rendering curettage-filling impossible. En bloc resection of the tumour with reconstruction using two tibial splints applied proximally on the radius and distally on the first ray (eight cases) or the second ray (eight cases) of the carpus was performed in all cases. A plaster cast or external fixation protected the construct. All tumours were benign. Nine patients were reviewed for function (pain, motion, force) and radiographic assessment (lateral view of wrist in maximal flexion and extension). We collected data recorded at the last visit for the other patients.

Results: Mean follow-up was 70 months (12–205). The functional outcome was good with 15 patients totally pain free. For the eight patients whose mediocarpus could be preserved, dorsal flexion was 30° and palmar flexion was 15°. Pronosupination varied from 10° to 170°. Bone fusion was obtained in 15 patients. One developed nonunion which was revised with a bone graft and plate fixation and finally healed. Two graft fractures secondary to trauma consolidated normally after plate-screw fixation associated with a new graft. Three of the patients developed local recurrence in the form of subcutaneous nodules which were resected. One of these three patients had a bony recurrence at the graft-radius junction which was treated by a new bone resection and achieved cure.

Discussion: Resection-arthrodeis is indicated for recurrence after curettage-filling and for voluminous giant-cell tumours with extraosseous extension and failure of curetae-filling. Curettage is rarely possible in this location due to invasion of soft tissues and destruction of the joint surface which occurs early. It appears preferable to perform an arthrodesis between the radius and the first ray of the carpal bones to preserve partial motion of the wrist and good function.


F. Duparc J.L. Gahdoun C. Michot X. Roussignol F. dujardin N. Biga

Purpose: During surgery for repair of rotator cuff tears, some authors always associate tenotomy-tenodesis of the long head of the brachial biceps. Others decide as a function of the gross aspect of the tendon and its position in relation to the bicipital groove. It is a classical notion the preservation of the long head of the brachial biceps is a cuase of persistent pain in operated shoulders. This study was conducted to search for a histological validation of the decision to perform tenotomy.

Material and methods: Fifty tendons of the long head of the brachial biceps presented a thick and inflammatory aspect with or without subluxation during 68 procedures to repair recent rotator cuff tears (23 men, 27 women, mean age 53.5 years). Tenodesis of the long head of the brachial biceps was associated with proximal tenotomy. The histological examination concerned the most proximal centimeter of the tendon. Four parameters were studied: two concerned the tendon (organisation of the collagen network and aspect of the interstitial connective tissue), two concerned the synovial border (sub-synoviocytic layer and synovial mesothelium). Sixteen tendons which appeared perfectly healthy were harvested from cadaver shoulders to determine the normal aspect of histological parameters (parallel and cohesive orientation of the collagen network, absence of hypertrophic interstitial connective tissue, thin subsynovio-cytic layer and pluristratified synovial mesothelium).

Results: The tendon. The collagen bundles were oriented in 32 cases but thick in 40 and dissociated in 47. Microscopic signs of fissuration or intratendinous tears were present in 17 cases. The tendinous connective tissue was oedematous in 49 cases, presenting fibroblastic hyper-cellularity in 37 and hypervascularity in 43. Scar-like fibrosis was observed in 28 cases. The synovial layer was regular in 11 tendons and clearly thickened in 26 with a mixed irregular aspect in the others. The subsynoviocytic layer was thick in 33 tendons with signs of hypervascularity or hypercellularity in 12. The synovial mesothelium was paucistratifed in 23 cases, thick in 12, and regular in 15. Lesions had an inflammatory aspect and were intense in 26 cases. Degenerative lesions were observed in 21 tendons. These four histological parameters demonstrated that the lesions were advanced and associated with degenerative sclerosis with reactional synovitis in 30 cases, moderate combined lesions in 13, tendon and synovial inflammation alone in four, and advanced degenerative lesions of the tendon and the synovial in six.

Discussion: Histological lesions of the long head of the brachial biceps tendon are generally degenerative and irreversible while most synovial lesions are reversible inflammatory reactions. The zones of intratendinous fibrosis, vascularity and weak or absent cellularity constitute the anatomic conditions before tendon tears in chronic tendinopathy. This histological study confirmed the validity of the intra-operative decision for tenodesistenotomy of the long head of the brachial biceps in 46 (92%) of the cases. The oedematous and fissu-rated aspect of the tendon appeared to be a reliable criteria while inflammatory synovitis, which surrounds the tendon, does not constitute in itself a formal argument in favour of tendon sacrifice.


J. Rzzouk A. durandeau F. Farlin J. Bouchain T. Fabre

Purpose: Mucoid pseudocysts are infrequent benign tumours affecting all peripheral nerves near joints. Reported for the first time in 1891, these cysts raise an unresolved question as to their nature. Identifying the origin of these cysts could have an impact on management and the risk of recurrence.

Material and methods: Twenty-three patients (21 men two women), mean age 38 years, were followed for a mean six years. The mucoid cyst was located at the level of the common fibular at the neck of the fibula in 16 cases, the tibial nerve at the knee in one, the medial nerve in one, the ulnar nerve in three and the supra-scapular nerve in two. Pain was local in 18 patients, irradiated to the concerned territory in 20. In 17 patients, the nerve lesion was discovered due to development of motor deficit. An EMG was performed in all cases, an ultrasound exploration in 15, a CT scan in seven and an MRI in ten. All patients underwent surgery with neurolysis under microscopy for intraneural cysts. A pedicle communicating with the joint was search for during each intervention.

Results: An articular communication was found in 17 cases. Mean delay to recovery of motor force was five months with recovery of normal sensitivity in 16 cases at seven months. Total lack of recovery was noted in one patient. There was one recurrence requiring tibiofibular arthrodesis.

Discussion: Three theories have been put forward. Besides the cystic degeneration of certain schwannomas, degeneration of the nerve sheath connective tissue, the joint theory appears to be the most probable. The presence of a pedicle linking the cyst to the joint in more than 60% of the cases, the periarticular situation of the nerves involved and sometimes the migration along an articular nerve as well as the mucoid content of the cysts is in favour of an articular origin. The notion of recurrrence after complete minute resection is also in favour of a joint disease.

Conclusion: A mucoid cyst is a likely diagnosis for neruological lesions lying near a joint. Search for an articular communication both before and during the surgical procedure is important to limit the risk of recurrence.


F. Fiorenza A. Kulkarni R.G. Grimer S.R. Carter R.M. Tillman J.L. Charissoux P.B. Pynsent

Purpose: Primary bone tumours situated at the distal end of the humerus are exceptional and observed in only 1% of the cases. Reconstruction at this level is often difficult due to the wide bone resection. Choosing a massive prosthesis is an interesting method allowing correct carcinological and functional results. We report a series of ten patients who underwent reconstruction of the lower end of the humerus between 1970 and 2001 with a massive prosthesis after tumour resection.

Material and methods: This series included four men and six women, mean age 51 years (15–76). Eight patients had primary bone tumours and two had secondary bone lesions. Mean follow-up was 79 months (9–372). The custom-made constrained hinge prosthesis composed of chromium-cobalt and titanium was cemented. Regular clinical and radiological follow-up data were recorded. The Henneking score and the Toronto Extremity Survival Score (TESS) were used to assess functional outcome.

Results: Three patients underwent revision for aseptic loosening of the humeral component at 48, 56 and 366 months with problem of polyethylene insert wear for two of them. There were no infctions or local recurrences and no secondary amputations. The posterior or anterolateral approach was used for humeral resection (mean 153 mm, 63–160 mm). Postoperatively, three patients developed transient palsy (one radial and two ulnar) which regressed. Four patients died from metastasis and had a satsifactory prosthesis result at time of death. The mean TESS was 73% (29–93%) at last follow-up

Discussion: Although this is a small series, the long-term results appear to indicate that reconstruction of the lower extremity of the humerus with a massive prosthesis is a satisfactory option for this rare tumour localisation.


F. Gouin M. Touré F. Roland A. Moreau A. Bertrand-Vasseur

Purpose: Osteosarcoma is a rare disease after the age of 40 years. Most malignant bone tumours at this age are secondary lesions and the primary tumours observed are generally chondrosarcomas. We report a small retrospective series to study the characteristic features and point out diagnostic difficultis as well as the prognosis in this age group.

Material and methods: We included in this series histologically proven osteosarcomas observed in patients over the age of 40 years who had been treated between 1990 and September 2002, excluding tumours occurring in patients with predisposing conditions (radiation, paget). The series included six women and nine men, mean age 54 years (41–79). Only three patients were over 60.

Results: During this same period, 59 osteosarcomas were treated. Diagnosis before 40 years corresponded to 25% of the cases reported at our interdisciplinary reunion. Three patients were referred after inadequate treatment, i.e. curettage-filling without diagnosis. Two others had undergone surgery for symptoms related to the osteosarcoma. Finally three patients had an erroneous or doubtful pathological diagnosis. There was no histological specificity or tumour localisation. The lower femur predominated. Ten patients had undergone neo-adjuvant chemotherapy with only two responders. Marginal surgery was achieved in three cases, intralesional surgery with immediate revision in one and large resection in ten. Six patients died from their disease (within two years of diagnosis) and one developed postoperative pulmonary embolism (46%). Two patients were living with active disease. Only six patients were living disease-free (40%). These included one patient with resected pulmonary metastasis and one patient who had experienced two episodes of locoregional recurrence which were operated (follow-up 12 and 8 months from last event). Four patients (26%) were in complete remission without any event since treatment (including two low-grade tumours).

Conclusion: Osteosarcoma after 40 years is, in our experience, more frequent than reported in the literature. In at least six of our patients (40%) this tumour was mis-diagnosed leading to non-optimal treatment. The prognosis is very poor with only 26% of the patients in complete remission without an event since treatment.


M. Perrin J. Fraisse J. Cuisenier

Purpose: Replacing the entire femur for primary bone tumour is exceptional. Prostheses used in this series were custom-made by Link using the Endo Klinik (Hambourg) model. These prostheses have adjustable ante-version and a hinge type knee with rotation.

Patients and Results: Case n° 1. A 15-year-old boy, grade 2A osteosarcoma in the diaphyseal zone of the lower femur. Rosen chemotherapy. En bloc resection. Total femur prosthesis sleeved onto the trochanteric mass left in place. Excellent response:100%. Excellent functional result: mountain climbing! Current status: recurrence-free, metastasis-free at 16 years follow-up. Case n° 2. Adult osteosarcoma. 68-year-old woman with pulmonary metastasis at diagnosis. Indication due to fracture to mid third of femur. Excellent immediate result. Nine-month survival in very satisfactory condition. Case n° 3. 72-year-old woman treated one year earlier for T1N0M0 breast cancer. Metastatic image in the trochanter. Treatment by curettage and THA. Histology reported chondrosarcoma. Scintigraphy showed uptake in gluteus medius and the lower part of the femur. En bloc resection of entire femur and gluteus medius. Total femur replacement with prosthesis sleeved onto an allograft. Complete resection. Current status: recurrence-free, metastasis-free at five years. No limitation on walking distance. Walks with cane due to moderate limp. Case n° 4. Adult osteosarcoma (32 years). Low-grade tumour (1B) occupying the entire femur. Rizzoli Institute chemotherapy protocol. Resection and total femur replacement with prosthesis sleeved onto an allograf. Complete resection. Poor response. Excellent functional result, persistence of minimal limp. Active tumour with pulmonary metastasis at one year and death at 1.5 yers. Case n° 5. Grade 2B osseous leiomyosarcoma in the diaphyseal zone of the lower femur in a 37-year-old woman. Neoadjuvant chemotherapy followed by total femur resection. Excellent responder:100%. Excellent functional outcome at short follow-up (1 year).

Discussion: Total femur replacement with a prostheses sleeved on an allograft allows reinsertion of the gluteus medius and the psoas. This method is reliable and avoids major instability. Complications in this small number of patients were rare and were not serious. The functional results have been excellent and appear to depend primarily on the importance of muscle resection required to achieve tumour resection.


E. Mascard G. Lissenard P. Wicart J. Dubousset

Purpose: Use of massive knee prostheses in the treatment of malignant tumours allows excellent short-term oncological and functional results. The purpose of our work was to demonstrate that these good early results later require several revisions.

Material and methods: From 1981 to 1986, 48 patients, mean age 13.8 years (9–19) were treated for osteosar-coma of the knee by chemotherapy and resection. Six patients had metastases at the time of diagnosis. Resection involved the distal femur in 34 cases, the proximal tibia in 13 and both extremities in one case. Mean resection was 20 cm (12–29). Reconstruction was achieved with a cemented GUEPAR. Twenty of the initially implanted prostheses had a rotatory mechanism. Reconstruction of the diaphyseal segment was generally achieved with massive metal or polyethylene prostheses and in three cases with a prostheses sleeved on an allograft. After resection of the proximal tibia, reconstruction of the extensor system was achieved with the vastus medialus.

Results: Results were assessed retrospectively at a mean follow-up of eleven years (4 months – 20 years). Seven patients were lost to follow-up. At last follow-up of available patients, 34 were in remission, 14 had died, giving an actuarial survival rate at 15 years of 72%. For the 48 prostheses initially implanted, seven were revised for loosening, four became infected (two secondarily), four femoral stems fractured and two rotatory mechanisms fractured. All the prostheses followed more than three years required at least one surgical revision. Only eight of the initially implanted prostheses are still in situ after 15 years, giving an actuarial survival probability of 39±17%. Certain prostheses were changed four times. If all revisions are included, the 32 surviving patients have had 84 prostheses. Most of the recent revisions were indicated for hinge wear and to avoid changing the inserts within too short an interval. At last follow-up, one patient has undergone amputation, one has a rota-tionplasty, and one has an arthrodesis, all for infection. The functional results at last follow-up are good or excellent in 19 cases, fair in five, poor in three and could not be evaluated in 21 (14 deaths and seven lost to follow-up).

Discussion: Reconstructions using massive prostheses are associated with a high rate of mechanical complications making surgical revision inevitable. These complications are mainly due to wear of the hinge itself. The use of better designed prostheses in terms of mechanical properties should reduce the rate of mechanical complications. When the tumour extension spares the epiphysis, use of biological, non-prosthetic reconstruction methods should be preferred.


F. Langlais T. Dréano F.X. Sevestre H. Thomazeau P. Collin S. Aillet

Purpose: Reconstruction using a revascularised fibula has advantages in terms of remodelling the transplant to the stress forces and of better resistance against infections. Osteosynthesis offers mechanical advantages (stabilisaton facilitating primary and stress fracture healing) but with the risk of preventing hypertrophy of the fibula which is not exposed to the stress forces.

Material and methods: Our series of 25 vascularised fibular transfers (maximum follow-up 15 years) concerned post-trauma tissue loss (11 cases) and tumour resections (14 cases). For this study of remodelling, we retained only oncological reconstructions because in the event of trauma sequelae, many factors can interfer (infection, preservation of the homolateral fibula with tibial tissue loss). None of the patients were lost to follow-up and remodelling was assessed at two years or more.

Results: There was one failure requiring leg amputation (infected nonunion of the distal tibia on a radiated osteo-sarcoma). All the other fibulae healed. Three metaphyseal resections of the distal femur were assembled with a lateral plate using the fibula as a medial strut under compression. This type of assembly favours remodelling and excellent results were obtained in three cases. Five arthrodeses of the knee were performed using a fibula with a femorotibial nail. Healing was slow and the fibula thickened little, particularly when it was simply apposed on the tutor (three cases) rather than encased under compression (two cases). For five proximal humeri, use of a thin plate in three cases (forearm plate) was sufficient to allow healing without inhibiting remodelling.

Discussion: For the lower limb, good remodelling is obtained with an assembly allowing compression of the fibula placed medially to the shaft alignment. For metaphyseal loss, we advise a lateral plate with a fibular strut medially. For arthrodesis, a nail is probably more prudent. The position of the lateral tutor decreases the stress on the fibula and is recommended less than the medial strut position. For the humerus, synthesis is required but may be minimal to allow optimal remodelling.

Conclusion: Vascularised fibula transfer is a reliable technique which can be recommended for major resections (mean 160 mm) in active subjects. Axial compression forces applied to the graft and use of light osteosynthesis appear to favour healing and remodelling.


F. De Peretti A. Yiming P. Baque

Purpose: The purpose of this work was to study arterial blood supply to the coxal bone in order to minimise the risk of postsurgical necrosis during acetabular osteosynthesis. Necrosis of the coxal bone is a rare but well-known complication of acetabular fracture surgery.

Material and methods: Ten fresh cadavers were dissected after intra-arterial injection of coloured resin. All collaterals feeding the bone were described and counted. An arterial map was drawn.

Results: The acetabulum is supplied by four main arterial sources: 1) the ischion artery, a collateral of the pudendal artery, which supplies the posterior and lateral part of the acetabulum; 2) the artery of the roof of the acetabulum, a collateral of the superior gluteal artery, supplies the upper and lateral part of the acetabulum: 3) branches of the anterior and posterior division of the obturator artery which supply the upper part and the rim of the obturated foramen and the anteroinferior and posteroinferior parts of the acetabulum; 4) branches issuing from the obturator artery supply the quadrilateral surface.

Discussion: The Kocher approach can easily injure the ischion artery. The wide lateral approach described by Letournel and the triradiate approach described by Mears can injure the ischion artery and the artery of the roof of the acetabulum. Theoretically, the risk of bony necrosis would be greater if an endopelvic approach is associated due to the risk of injury to the endopelvic arteries issuing from the obturator artery. The anterior approach to the acetabulum appears to carry the less risk of ischemia, theoretically, than the other approaches to the acetabulum.


A. Nehme G. Maalouf J.L. Thicoire P. Chiron G. Giordano J. Puget

Purpose: Bone remodelling and osteolysis around total hip prostheses remains an ineluctable corollary of prosthetic loosening. Alendronate (biphosphonate) has proven its efficacy for the treatment of osteoporosis of the lumbar spine and the femoral neck. There has been some in vitro work pointing out its contribution to the inhibition of osteolysis induced by particles. One in vivo study has demonstrated its interest in prevention of osteolysis around non-cemented total hip arthroplasties. The purpose of our work was to study the efficacy of this drug in the prevention of periprosthetic osteolysis around cemented total hip arthroplasties using biphotonic absortiometry (DPX).

Material and methods: The series included 38 patients who underwent unilateral total hip arthroplasty for degenerative hip disease. After double blinded randomisation, 20 patients were given 10 mg Alendronate per day with 600 mg calcium and 18 patients were given a placebo with 600 mg calcium for two years. All patients were followed with standard x-rays and DPX of the operated hip. Examinations were performed on the fourth postoperative day and on the third, sixth, twelveth and twenty-fourth postoperative month. The analysis concerned the periprosthetic zones defined by Gruen.

Results: DPX demonstrated significant reduction in bone mineral density (BMD) in all patients included in the study. This reduction was the same for the two groups early in the study and reached a maximum at three months; a divergence was observed thereafter. For the placebo group, the loss reached a plateau up to the sixth month after which the BMD started to rise progressively remaining at 12.7% reduction at two years (p< 0.002). In the ALN group, there was no plateau, BMD increased directly to reach 6.9% bone loss at two years (p< 0.003).

Discussion:The use of Alendronate enabled a significant reduction of periprosthetic bone loss at two years post-op. Our results are the first to our knowledge demonstrating a beneficial effect in vivo of the use of Alen-dronate on bone behaviour around cemented total hip arthroplasties.

Conclusion: Taking into account the short follow-up in this series, and its small size, other studies are indispensable to confirm this beneficial effect in vivo. The action of Alendronate could facilitate revision surgery by preserving bone stock.


A. Hehme J.L. Tricoire P. Chiron G. Giordano G. Maaolouf J. Puget

Purpose: Insertion of the femoral stem during total hip arthroplasty provokes a bridge between the proximal femoral forces leading to well-documented bone resorption. A review of the literature concerning the behaviour of the contralateral femur and the spine reveals conflicting data. Some authors report variable bone mineral density of the lumbar spine while the contralateral neck, studied with non-cemented prostheseis in all cases, shows a significant fall in bone density. All patients in these studies needed an unloading period to achieve definitive fixation of the hip prosthesis. The purpose of this study was to assess bone behaviour in the contralateral femur and the lumbar spine after unilateral cemented total hip arthroplasty with immediate postoperative weight bearing.

Material and methods: The study series included 52 patients who underwent unilateral cemented total hip arthroplasty for degenerative hip disease. All were followed with standard x-rays and DPX of the contra-lateral hip and the lumbar spine. These examinations were performed one month before surgery then on D8, M3, M6, one year and two years. Bone mineral density (BMD) was measured in the femoral neck cortical and the L2–L4 trabecularlar bone. Patients were verticalised and encouraged to walk with full weight bearing on the average on day 3 to 4 after surgery.

Results: DPX did not demonstrate any significant decrease in BMD in any of the patients included in this study, neither in the lumbar spine nor in the contralat-eral femoral neck.

Discussion: Several studies in the literature point out the difficulty in recovering bone mass lost after a period of immobilisation or unloading. This bone loss could reach 10% of the bone mass even for short periods of unloading. Furthermore, minimal bone loss, to the order of 2.5% could accelerate the transformation of osteopenia into osteoporosis and increase the risk of fractures. The importance of minimising periods of unloading in older patients is thus evident.


M. Saudan N. Riand P. Saudan A. Keller P. Hoffmeyer

Purpose: Heterotopic ossification is a recognised complication after total hip arthroplasty. Prevalence can reach 53%, particularly if prophylaxis is not given, leading to postoperative pain and limiting the functional prognosis. Non-steroidal antiinflammatory drugs have proven efficacy but also present the risk of gastroduodenal toxicity making postoperative administration hasardous. Recently, selective COX-2 inhibitors have been shown to have a similar antiinflammatory activity with a clear reduction in gastrointestinal disorders. We hypothesised that selective COX-2 inhibitors could be as effective as classical NSAID for the prevention of heterotopic ossifications.

Material and methods: This clinical trial was conducted according to a prospective randomised protocol comparing a group of patients given prophylaxis with Celecoxib (Celebrex®) and another group of patients given ibuprofen (Brufen®). All patients scheduled for total elective prostheses were radomised in a prospective manner to one of the two groups, either Celecoxib 200mg b.i.d. or ibuprofen 400mg t.i.d. for ten immediate postoperative days. Radiological assessment was performed by two independent investigators blinded to the study (an orthopaedic surgeon and a radiologist) who scored calcifications according to the Brooker classification (type I to IV) at three months after surgery. Reproducibility of radiogram reading was tested and analysed with a kappa test K=0.74).

Results: Two hundred ten patients were randomised and 73 have had their three-month radiograms. The Cele-coxib group included 37 patients: 24 with Brooker stage 0, eleven with stage 1, two with stage 2. The ibuprofren group included 42 patients, 15 with Brooker 0, 16 with Brooker 1; nine with Brooker 2 and two with Brooker 3. The statistical analysis will be performed at the end of this study (June 2002).

Discussion: The preliminary results show that Celecoxib appears to have the same efficacy as ipubrofen for the prevention of heterotopic ossification after total hip arthroplasty. There was a clear trend in favour of Celecoxib.


C. Schuster A. Giebl R. Wuttge S. Plaweski L. Pettet X. Combaz J. Tonetti L Schuster

Purpose: A new software based on computed tomography data has been developed for individual unicompartmental reconstruction. The puropse is to achieve custom-made anatomic reconstruction of the medial compartment of the knee and to restore the physiological kinetics of each specific knee. This system can also be used to provide individualised tools for implantation

Material and methods: Custom-made unicompartmental prostheses and their corresponding implantation patterns were designed by this software. The data were fed to a rapid prototyping machine to produce a two-piece (cobalt-chromium and polyethylene) unicompartmental prosthesis and the guides for anatomic cuts specific for each knee. This method was tested on ten cadaver specimens in order to verify the precision of the reconstruction and alignment. A specially designed software was used to establish 3D reconstructions of the knee specimen taking precisely into account the cartilage surfaces. Virtual bone cuts were established to obtain the future seat for the implant. The data of the virtual bone cut were recovered to obtain a brute form of the future implant. The joint surfaces which still presented the degenerative lesions were repaired and finalised by interpolation and by use of the mirror data obtained from the contralateral knee. An individual support system was then installed to perform the bone cuts established virtually. The final data were then fed to a rapid prototyping machine and the aleasing machine to produce a two-piece unicompartment prosthesis and the guides for the anatomic cuts specific for each knee. The operation was then performed via a medial parapatellar 8cm incision. The implants were inserted without other fixation onto the knees and tested immediately to determine function. Anatomic reconstruction of the knee was checked with standard x-rays and CT images compared with the initial data.

Results: The implants could be inserted rapidly and easily. The impact of exhibited an excellent press fit and reproduced the initial morphology of the healthy articulation.

Discussion: Movement of the knee prosthesis reproduced all the characteristic physiological movements. Furthermore, the knee prosthesis obtained with this method allowed individualised and minimalised bone cuts, optimising congurency and contact zones between the bone and the implant and thus reducing the difficulties of surgical alignment. This system appears to offer high-performance restoration of individual physiological joint kinetics.


L A James T Ibrahim C N Esler

Background: Femoral heads donated at primary arthroplasty are screened microbiologically. Contaminated femoral heads are either discarded or irradiated in an effort to protect recipients from the risk of transmitted infection.

Aims:

Determine the contamination rate of donated femoral heads at primary arthroplasty within the Trent Region between July 1992 and July 2001.

Does femoral head contamination result in an increased rate of early infection in the allograft donor?

Method: We reviewed the culture results of all femoral heads donated to the Leicester Bone Bank. All patients with a contaminated femoral head that were operated upon in the Leicestershire region were then compared to a control group of patients with no contamination of their femoral heads. The two groups of patients were then cross-referenced against the data in the Trent Arthroplasty Audit Group database. Hospital records of all patients who had a complication or re-operation were also reviewed to determine their outcome

Results: A contamination rate of 9% was present with 365 of 4043 femoral heads culturing positive at the time of retrieval. Coagulase negative Staphylococcus was isolated in 75% of the cases. At a minimum of one year follow up, there was no statistically significant difference in the complication or revision rate of age matched patients whose femoral heads cultured positive compared to those whose heads were sterile.

Conclusion: The allograft contamination rate is similar to other published series with coagulase negative staphylococcus being the most prevalent contaminant. The available evidence confirms what has been anecdotal in the past. Femoral head culture results play no role in determining future joint failure in the donor


O R Wall D Duffy D A Macdonald

Abstract We have prospectively analysed a single-surgeon series of 35 consecutive revision THRs with AAOS bone loss grade II–III, requiring morcelised allograft (ethylene oxide sterilised) for acetabular defects. Patients have been followed up for a minimum of 5 years. Although the results are encouraging, we are observing migration patterns in some cases.

Method Twenty-one patients were eligible for final analysis (follow-up for at least 5 years, range 5 to 10 years). Follow-up has consisted of clinical assessment (Charnley activity, pain, function, satisfaction) and a radiographic assessment (AP X-ray) of the replacement hip. Our study end-points are 1) prosthesis revision and, 2) acetabular cup migration at last follow-up.

Results There were 6 deaths with less than 5 years follow-up (unrelated causes) and 2 cases have been lost to subsequent follow-up. Two cases had deep infection (revised to a girdlestones procedure at 9 months and 2 years respectively) and there were no early dislocations. One case underwent further revision at 4 years follow-up due to symptomatic (superior) cup migration and three cases are awaiting imminent out-patient assessment. Twenty-one cases have had a mean follow-up of 5.83 years. Eight cases (23%) have shown no cup migration. Five have shown only late stage migration, 4 cases have shown both initial and then late migration whilst 3 cases have shown only intermediate migration followed by stability. One case has shown progressive migration throughout follow-up. All 13 cases (37%) exhibiting migration are still asymptomatic.

Conclusion Our results show that use of morcelised acetabular allograft for revision hip surgery with deficient medial and superior acetabular wall is a useful surgical procedure. Our results over a minimum of 5 years follow-up are comparable to others in this field. However, the relatively high number of revision cases from our data which have shown, as yet, asymptomatic cup migration causes concern for future management of these patients. It is imperative that all such cases have regular (annual) indefinite follow-up. We are concerned that further cases may present with acetabular cup migration in view of our results.


P Bobak B M Wroblewski P Siney P Fleming

We report the result of 49 revisions for aseptic cup loosening using freeze-dried allografts.

We assessed the results according to the primary pathology, severity of bone loss, direction of socket migration before revision, method of bone grafting, socket position, graft incorporation and socket loosening.

Patient’s mean age at revision was 56 years 8 months. At a mean follow up of 7 years and 5 months four cups have been revised for aseptic loosening. Five sockets have migrated but remained stable while six showed full demarcation but have not migrated.

The other 34 remained stable and show radiographic evidence of graft incorporation.


S Buckley A Hamer R Kerry I Stockley

One of the major surgical challenges at revision arthroplasty is the management of bone stock loss in the acetabulum.

There are several options available for reconstruction; cemented sockets within thick cement mantles, custom sockets jumbo uncemented sockets, support rings and bone grafting. Slooff and others have shown good results with impaction grafting.(JBJS 80B 1998)

If one is to use bone graft, does the preparation of the graft have any effect on the graft itself? There are a number of ways bone can be presented, freeze dried, fresh frozen or frozen irradiated. Concerns have been raised that irradiated bone has an altered and weakened structure. There is a paucity of clinical results on this subject. In this study we present a series of patients using gamma irradiated bone for reconstruction.23% of the cases reconstructions secondary to failure due to sepsis.

Between 1987 and 2000 192 revision arthroplasties in 165 patients were performed with irradiated morcellised bone allograft for acetabular reconstruction. Only those patients with a minimum follow up of 24 months were reviewed. Clinical and radiological follow up was achieved in 130 hips in 115 patients. 9 patients had died at a range of 1 to 66 months after surgery. There were 23 (17%) re-revisions of the acetabular component. Of these 13 were for deep sepsis, 5 for persistent early dislocation and 4 for aseptic loosening. Of those hips revised for infection there was a 13% re-revision rate for reinfection. There was only one catastrophic failure of the graft and only three re-revisions for aseptic loosening to date.

We feel that impaction grafting of the acetabulum is a useful technique for reconstruction even when the index arthroplasty failed for sepsis. We have found no evidence to show that gamma irradiated bone performs any worse than other types of allograft bone.


B Kapoor C Wynn-Jones

Introduction: Peri-acetabular rotational osteotomy is recognized as the non-arthroplastic treatment for Developmental Dysplasia of the Hip (DDH). This procedure has increased in popularity during the last decade. It aims to restore the acetabular cover over the femoral head and thus delay secondary osteoarthritic changes in the hip.

Materials and methods: We reviewed 16 patients who underwent peri-acetabular rotational surgery at our hospital. The indication for surgery was DDH in all cases. Reinert’s approach was used for surgical exposure. Two patients underwent a valgus femoral osteotomy at the same time. Mean age was 40 years (range 15–49). The mean follow-up was 46.5 months (range 4–108). The results of the surgery were assessed with radiological indices and a patient satisfaction survey. The radiological indices recorded were Wiberg’s angle, acetabular inclination angle, femoral head extrusion index and Tonnis osteoarthritis grading.

Results: The intervention failed to benefit two patients who subsequently required a total hip arthroplasty. Both patients had Tonnis grade 3 osteoarthritis. One patient developed a necrotic skin flap requiring skin grafting. The mean pre-operative Wiberg’s angle was 11 degrees (range −7 to 25) which was corrected to 35 degrees (range 17 to 58). Mean pre-operative acetabular index was 25 degrees (range 14 to 40) which was corrected to 11 degrees (range of 2 to 21). Mean pre-operative femoral head extrusion index was 37 degrees (range 18–50) which was reduced to 14 degrees (range 0–32). In all but the two patients in whom the surgery had failed, patients reported reduction in hip pain.

Conclusions: Peri-acetabular rotational osteotomy is a challenging but worthwhile procedure for young patients with DDH. The early results from the procedure are encouraging providing patient selection is appropriate. We would like to initiate a debate to identify the ideal patient for this procedure.


P Li R Ganz J Forder

It is generally agreed that in acetabular dysplasia the acetabulum lies excessively anteverted. Although this is true for the majority of hips, we have found that in some patients with dysplastic hips, the acetabulum lies unexpectedly in retroversion.

Aim: To investigate the proportion of dysplastic hips which are retroverted.

Method: We studied the radiographs of over seven hundred patients with dysplastic hips and who had had a periacetabular osteotomy in the period 1984–1998. We excluded patients with neuromuscular dysplasia, Perthes disease of the hip, post-traumatic dysplasia and proximal focal femoral deficiency. We selected 232 radiographs of patients with congenital acetabular dysplasia. A number of parameters were measured including, lateral centre edge angle, anterior centre-edge angle, acetabular index of weight bearing surface, femoral head extrusion index and acetabular index of depth to width. Also recorded was acetabular version and congruency between femoral head and acetabulum.

Results: The lateral centre-edge angle of Wiberg had a mean value of 6.4° (SD 8.9°), the mean anterior centre-edge angle was 1.3° (SD 13.5°) and the acetabular index of weight bearing surface of the acetabulum had a mean value of 24.5° (SD 9.7°). The majority (192, 82.8%) of acetabula were anteverted as might be expected. However, a significant minority (40,17.2%) were retroverted. The mean anterior centre-edge angle in retroverted hips was 6.7° (SD 9.4°) compared with 0.4° (SD 13.3°) in anteverted hips.

Conclusion: The authors have shown that in a typical group of patients with congenital acetabular dysplasia, significant enough to warrant periacetabular osteotomy, the majority of hips as expected have anteverted acetabula. However, a significant minority are retroverted. This finding has an important bearing in the performance of the osteotomy.


F Ali R M Kerry R Cooper J M Wilkinson P A Norman I Stockley

Purpose: The role of hip aspiration as a preoperative investigation for the painful hip remains controversial. Since 1999, we have performed hip aspiration under local anaesthetics in the X-ray department. This paper reviews our experience with this technique.

Results: Hip aspirations were carried out subsequently on 182 patients from November 1999 to November 2002. Out of 68 patients that underwent revision hip surgery, 63 were included in the study. Three of the five patients excluded had received antibiotics at induction prior to obtaining the operative samples and two did not have any operative samples taken at the time of surgery. Fifteen (23.8%) of the 63 hips were found to be infected based on operative tissue cultures. The sensitivity and specificity of the test were 80% and 87.5%, respectively. Positive and negative predictive values were 66.6% and 93.3% respectively and the accuracy was 85.7%.

Conclusion: Hip aspiration in the Radiology department is a simple, cost effective and reliable preoperative test when used selectively. When used in combination with other laboratory and radiological investigation it can act as an important preoperative investigation in the diagnosis of sepsis. There is an added advantage of identifying the microorganism along with its antibiotic sensitivities. This can guide clinicians in choosing the correct antibiotic for the cement and also for the postoperative antibiotic therapy.


M H A Malik F Alvi A D Clayson

We present the early results of the Bernese osteotomy via an ilioinguinal approach performed at an U.K. district general hospital with no links to the Bernese group.

Between 1997 and 2002, 19 such osteotomies have been performed at our institution. Average follow-up is 3.2 years (range: 1–5.5 years). The male: female ratio was 1: 8.5. Average age at time of operation was 32.3 years (range 18 – 48). 14 were classified as having Severin grade 2 dysplasia and 5 as having Severin grade 3 dysplasia. The average preoperative Merle d’Aubigne and Postel score was 12.7 points (range 6 – 15). 21.1% of patients were rated as good, as 57.8% fair and 21.1% poor.

At most recent follow-up of preserved hip joints total mean score had increased to 16.3 (range 13 – 18). 26.3% of hips were graded as excellent, 58.9% as good and 14.8% as fair. The average postoperative values for the lateral centre-edge angle and acetabular index were 42.3° and 10.0° respectively which represents an average of 31.4° and 24.7° of improved lateral and loading zone coverage after osteotomy. The preoperative severity of osteoarthritis according to the criteria of Tonnis was grade 1 in 15.8% and grade 2 in 26.3%. Only one joint deteriorated sufficiently for it to be converted to a total hip arthroplasty. There was an overall complication rate of 59.9% comprised of 47.4% trivial, 10.4% moderate and 0.05% major complications. Our early results demonstrate the steep learning curve of this technically demanding operation and are encouraging.


A Adair A Cosgrove

Aim: To determine the clinical, functional and radiological results of triple pelvic osteotomy for DDH.

Method: An independent, retrospective review of 35 osteotomies, in 32 patients, with an average follow up of 48 months (4–48 months).

Results: 75% achieved excellent to good results in The Harris Hip Score. The centre edge angle improved significantly from 10° to 35°. 3 hips have required further surgery in the form of total hip arthroplasty. We had 3 cases of incomplete sciatic nerve palsy (8%).

Conclusion: On the basis of our results the Triple Pelvic osteotomy can be recommended for the treatment of acetabular dysplasia in adolescents and young adults.


M H A Malik F Jury F Salway H Platt E Zeggini W E R Ollier P R Kay

Tumour necrosis factor-alpha is a proinflammatory cytokine that has been implicated in the propagation of inflammatory responses to bacterial infection and wear debris particles around loosened total hip replacements (THR). Individual TNF responses to such stimuli may be dictated by genetic variation. Single nucleotide polymorphisms (SNPs) at several loci within the TNF gene are associated with disease severity and susceptibility in a number of inflammatory conditions, but only a few SNPs have been screened in any one study.

14 SNPs have been identified within the TNF gene. Our unit has previously demonstrated that 5 SNPs are monomorphic in a sample group of UK Caucasians. We performed a case control study of the remaining 9 polymorphic positions (−1031, −863, −857, −376, −308, −238, +489, +851 and +1304) for possible association with deep sepsis or aseptic loosening.

All patients included in the study were Caucasian and had had a cemented Charnley THR and polyethylene cup. Cases consisted of 44 patients with early aseptic loosening (defined as that occurring within 6 years of implantation and findings at revision surgery or by the criteria of Hodgkinson et al for the acetabulum and Harris for the femoral stem) and 30 patients with microbiological evidence at surgery of deep infection. Controls consisted of 85 THRs that had remained clinically asymptomatic for over 10 years and demonstrated no radiographic features of aseptic loosening or ‘at risk’ signs as described by Wroblewski et al. DNA was extracted from venous blood and genotyped by Snapshot assay.

Genotype and allele frequencies for all SNPs were in Hardy-Weinberg equilibrium between THR controls and a random sample of UK Caucasians. The most significant associations were between the −238A (p< 0.05) and −863T (p< 0.05) alleles and aseptic loosening. A trend towards association was found between the −863A SNP and deep infection (p=0.80). The −238 A/G and −863 G/T genotypes were associated with deep infection (p< 0.05). No other significant associations were found.

Genetic polymorphism of TNF appears to play a significant role in THR aseptic loosening and possibly in deep infection. SNP markers may serve as predictors of implant survival and response to therapy such as anti-TNF treatment.


N de Roeck A Hashemi-Nejad

Acetabular dysplasia may present as previously undiagnosed or as a sequel to treated DDH in a young adult, with a natural history of subsequent development of early osteoarthritis.

Patients with acetabular dysplasia and a normal neck shaft angle, no significant leg length inequality and who demonstrate congruency at arthrogram are considered suitable for realignment pelvic osteotomy.

We report the results of 15 young adults who underwent a modified Tonnis triple osteotomy with a mean 21-month follow up. The modification was the ischial osteotomy being performed through a groin incision.

The only common complication was the requirement of catheterisation post-operatively (60%). There were no infections. There was 1 delayed union but no non-unions. One patient developed a deep vein thrombosis. All patients reported an improvement in their symptoms and level of activity, with a mean post-operative Harris hip score of 92. All showed an improved centre-edge angle of 28° (mean increase of 18°) and acetabular angle 37° (mean decrease of 13°).

The early results of this procedure show this to be a safe and useful option to delay the natural history of early osteoarthritis in the young adult.


V Prasad E Mughal T Worthington D J Dunlop R B C Treacy P A Lambert T S J Elliott

Introduction: We have investigated the accuracy of a serological marker to distinguish between septic and aseptic loosening of Total Hip Replacements (THR). We present the preliminary results of our on-going prospective study.

Methods: After obtaining Ethical Committee approval, 46 patients were collected in 3 groups; “control” primary THR, revision THR for aseptic loosening, and revision THR for infection. Serum IgG responses to an exocellular bacterial antigen (Lipid S) were determined by enzyme-linked immunosorbent assay (ELISA).

Results: Our results show that the test can accurately differentiate between the patients with infected joint replacements and the control group. The test, to date, has a specificity of 93% and a sensitivity of 100%.

Clinical Relevance: This simple and cheap test can reliably assist in the accurate evaluation of a painful hip arthroplasty, and planning for revision surgery. It will also be useful in the management of patients in whom the microbiology results are either negative or based on a single isolate of an organism, which may be either a contaminant or a possible pathogen. This, inturn, would have implications on financial costs and the optimum use of available resources.


S M Davey D B Bennett J R Nixon J F Orr F J Buchanan G Bailie

Work carried out by Bennett [1], identified a link between patient gait pattern and total hip prothesis wear rate. This study found that the shape of the patient gait pattern (as quantified by aspect ratio) and sliding distance of the movement loci were found to have an improved positive correlation with wear rate compared to the factors of activity and patient weight. The distribution of theoretical shear stresses at selected points on the acetabular cup suggests that orientation of the polymer chains may occur. Wang et al, 1997 [2] has shown that failure of the UHMWPE wear surfaces occurs in the form of transverse rupture between oriented molecules.

This work investigates the hypothesis that the gait pattern of pre-revision THR patients has an effect on the wear, surface characteristics and material properties of the artificial hip joint, in particular the degradation of chemical and mechanical properties of the UHMWPE acetabular socket. Gait analysis is performed on patients prior to revision of a primary THR, with the retrieved socket used for subsequent analysis.

Chemical and mechanical analysis of a large number of retrieved UHMWPE acetabular sockets has shown clear structural changes, which are dependent on the length on time in-vivo. Increasing the length of time in-vivo between 2 and 20 years results in an increase in the percentage crystallinity of the UHMWPE of 12.7 %. A positive linear correlation (R2 = 0.765) between percentage crystallinity and number of years in-vivo is shown. This suggests recrystallisation of the polymer at a constant rate over time. This partial recrystallisation of the amorphous region correlates with degradation in the mechanical properties of the material. This pilot study aims to assess the effect of patient gait pattern on the chemical and mechanical degradation of UHMWPE, which will ultimately affect the clinical performance of the prothesis.


D Bennett D Beverland B Mockford S O’Brien J Orr

Introduction: Wear, and the resultant loosening and revision, of Total Hip Replacements (THRs) remains the limiting factor in the long term success of the prosthesis. Over 1 million Total Hip Replacements (THRs) are implanted each year, of which about 15% are revisions, most of which are a consequence of loosening of either femoral or acetabular components. This is frequently caused by either the mechanical (Wroblewski, 1986) or biological (Besong et al, 1997) response to the wear of ultra-high molecular weight polyethylene (UHMWPE) acetabular component.

In a previous study Bennett (2002, 2000) has demonstrated that the walking patterns of THR patients 5 years post operation directly correlated with the wear of the acetabular component, as measured radiographically. The present study considers THR patients 10 years post-operatively, ensuring more accurate wear measurements and more meaningful outcome measures.

Materials and Methods: Gait Analysis was performed on a number of THR patients following routine review using a Vicon 370 data capture system and a lower body marker set. This data was processed using Polygon software and joint angles were derived for the hip in the sagittal, coronal and transverse planes. A computer simulation was used to determine the path which each of 20 points on the prosthetic femoral head traces on the acetabulum during walking.

Results: It was found that patients exhibited different patterns of movement ranging from liner to multi-directional. Normal subjects have previously been found to exhibit multi-directional movement. Patients with mult-directional movement showed evidence of greater wear (Bennett et al., 2000).

Discussion and conclusion: Linear movement causes orientation hardening and wear resistance while multi-directional movement cause increased shear and greater wear rates. These differences in movement loci have a significant influence on UHMWPE wear rate and the long term survival of the implant.


A Gordon A G Wilson I Stockley A J Hamer D A Macdonald R Eastell J M Wilkinson

Aseptic loosening due to periprosthetic bone loss is a major cause of implant failure after total hip arthroplasty (THA). Interleukin 1-B (IL-1B) is thought to play a role in aseptic loosening by stimulating the activity of osteoclasts, the main bone resorbing cell type. A restriction fragment length polymorphism due to a C/T single base variation at +3954 in exon 5 of the IL-1B gene has been associated with differences in susceptibility to chronic periodontitis, a condition associated with bone loss. In this study we tested whether carriage of the C and T alleles at this site resulted in differential risk of aseptic loosening in 481 Caucasians (214 failed versus 267 radiologically intact implants) at 11.7± 4.1 years following primary cemented THA for osteoarthritis. Genomic DNA extracted from peripheral blood was genotyped using the Taqman 5′ nuclease method. Carriage rates were calculated and analysed using the 2 test.

In the intact implant group the frequency of the T allele was 0.253. The distribution of the C and T alleles was 147:105:15 (CC:CT:TT, respectively). In the failed implant group the frequency of the T allele was 0.241). The distribution of the C and T alleles was 124:77:13. The carriage rate of the T alleles in each group was 44.9% and 42.1%, respectively (odds-ratio P> 0.05). The genotype frequencies were in Hardy-Weinberg equilibrium for both intact and loose implant populations (Chi-squared P> 0.05).

Using the multivariate Cox proportional hazards model significant risk factors for loosening of both implant components included gender and age at THA (P< 0.05). However, carriage of the +3954 allele was not a significant independent risk factor for aseptic loosening (P> 0.05). Our data suggests that the IL-1B gene restriction fragment length polymorphism at +3954 does not influence the risk of aseptic loosening after THA.


B M Wroblewski P D Siney P A Fleming

Since wear and loosening of the ultra high molecular weight polyethylene is the one factor limiting the life of the arthroplasty we set out to identify factors associated with either low wear 0.02 mm/year or less, or high wear 0.2 mm/year or more.

In a group of 1092 patients, 1434 Charnley low-friction arthroplasties 190 (13.2%) showed low wear while 149 (10.4%) showed high wear. We used Chi square test to assess the significance.

The characteristics of the low wear group were: female gender (p=0.042) Rheumatoid arthritis (p= 0.014), Charnley category “C” patients (p=0.03) and varus position of the stem (p=0.003) The use of acetabular cement pressurization (p=0.07) and medialization of the cup (p=0.07) approached significance.

In the high wear group there was a predominance of males (p=0.042) with primary arthritis (p=0.006) as the underlying hip pathology, and the stem in valgus position (p=0.023). Rim position of the cup was approaching significance (p=0.07). There was no statistical significance between the two groups for revision for aseptic stem loosening or stem fracture (p= 0.49). There was a highly significant difference (p< 0.0001) between the two groups for revision for wear and aseptic cup loosening: 5.3% against 40%.

Changes in the cup geometry are sufficient to explain the increasing incidence with depth of cup penetration. There is much to be gained from the use of low wearing ceramic – ultra high molecular weight combination. Tissue reaction to the plastic particles cannot be the cause of stem loosening.


E Sherry M Egan A Henderson P Warnke

Aims: Minimal invasive surgery is now possible for hip replacement. We present our system (called the SE Hip SystemTM). It is a universal system and is here used with the LINKTM C.F.P stem and T.O.P cup.

Methods: We have used this system on forty patients. It involves five steps. One (incision) – a single 5cm. postero-lateral incision; two (neck cut) – application of a cutting block to the femoral neck and removal of the head; three (broaching the femur) – preparation of the femur; four (reaming the acetabulum) – ream using the modified reamers and precisely place the cup with the lollipop device; five- place the stem and soft tissue balance with the spacers. The hip is then reduced and the wound closed.

Results: The average pre-operative Harris hip score was 28.64; the average post-operative score was 82.65. Complications included one transient sciatic nerve palsy. Average blood loss was 250 mls, the average time in hospital was 3 days and the average number of physiotherapy sessions required was 4.

Conclusions: Minimal invasive hip surgery is now possible. There is a markedly reduced cone of dissection. Navigation systems and intra-operative imaging are not required. This technique should minimize maltracking (and wear) and shorten the recovery period allowing the possibility of day or outpatient hip surgery.


A Gordon E Kiss-Toth A G Wilson I Stockley A J Hamer R Eastell J M Wilkinson

Polyethylene wear particle-induced osteolysis is a major cause of implant failure after total hip arthroplasty (THA). Tumour necrosis factor (TNF) is a pro-inflammatory cytokine that is thought to play a pivotal role in this process. We have recently shown that carriage of the −238 ‘A’ allele in the TNF gene promoter is associated with a higher rate of osteolysis after THA versus carriage of the [more common] ‘G’ allele. The aim of this study was to determine the effect of this polymorphism on TNF gene transcriptional activation in response to polyethylene particle stimulation using a luciferase reporter gene assay.

A 691 bp fragment (−585 to +106) of the TNF gene was amplified by polymerase chain reaction and directionally cloned into the PGL3.basic vector (Promega, Madison, WI). Insert sequences were checked using an ABI 377 DNA sequencer (PE Applied Biosystems, Foster City, CA). RAW264.7 murine macrophage-like cells in rapid growth phase were transfected with plasmids containing either the TNF-238G allele or the TNF-238A allele. pTK-RL (Promega), that expresses the Renilla luciferase gene under the control of Herpes simplex virus minimal promoter, was used as a transfection control. The cells were then either left unstimulated or were induced using polyethylene particles generated from a hip simulator. Lipopolysaccharide (LPS) and LTA (Lipoteichoic acid) were used as positive controls. Luciferase reporter activity was measured after 4 hours (Dual luciferase assay, Promega Corp., Southampton, U.K.) and the relative firefly luciferase activity was calculated. Results were analysed using repeated measures ANOVA.

Polyethylene particle stimulation at concentrations of 0, 1, 15, and 30mg/mL resulted in relative luciferase activities (mean (SD)) of 21.4 (2.9), 36.2 (8.2), 45.9 (11.1), and 40.7 (5.1) for the −238A allele; and 19.7 (5.0), 26.4 (8.0), 35.9 (2.3), and 32.4 (2.4) for the −238G allele (ANOVA P=0.01). LPS and LTA stimulation also resulted in increased reporter activity for −238A versus −238G (ANOVA P=0.02 and P=0.04, respectively).

The promoter allele TNF-238A results in higher levels of transcriptional activation versus the TNF-238G allele in response to a clinically relevant stimulus, and provides functional evidence for the significance of this polymorphism in the development of osteolysis after THA.


G Bailie E Doran J Nixon

Introduction: The Spotorno cementless femoral stem relies on proximal press-fit at time of surgery and subsequent osseointegration for long-term fixation. The aim of the study is to assess the long-term survivorship and clinical outcome of the Spotorno stem used in primary hip replacement surgery in younger patients.

Materials and Methods: 74 patients were identified who had undergone 90 THRs using the Spotorno CLS stem between January 1987 and May 1992. There was variation in the acetabular components used. 5 patients (6 hips) were lost to follow-up, leaving a study group of 84 hips. The patients were assessed using the Harris Hip Score and the Oxford Hip Score.

Results: Mean age at operation was 40.1years (range 23–65years). Commonest diagnoses were primary osteoarthritis, developmental dysplasia of the hip and rheumatoid arthritis. Mean duration of follow-up was 12.25 years (range 8½ – 15yrs 3months). At most recent follow-up, the mean Oxford Hip Score was 23.8 and mean Harris Hip Score was 81. Taking revision for any cause as an end point, 19 hips from the initial group of 84 had undergone some form of revision surgery at most recent review. 15 of the 19 hips that failed had aseptic loosening of the acetabular component, which was the Mecring component, and underwent revision of acetabulum only. Four stems were revised, 2 for loosening and 2 for infection. 80 out of 84 of stems originally implanted remained intact at most recent review, which represents a stem survivorship of 95.2% at mean 12.25yrs follow-up when used in young patients.

Conclusion: Our findings indicate excellent long-term survival of this titanium alloy stem when used in patients under 65years. We attribute this to stem design and the principle of proximal press-fit fixation. Careful consideration must be given to acetabular component selection in cementless total hip arthroplasty.


M R Downing P Ashcroft D Lawrie J Hutchison D Knight W Ledingham P Gibson

Aims: To study prospectively the characteristic migration of four different cemented femoral stems using Radiostereometry.

Methods: 96 patients undergoing cemented femoral hip replacement for osteoarthritis were randomised to receive an Exeter (Howmedica Stryker), Ultima Tapered Polished Stem [TPS], Ultima straight stem [USS] (Johnson and Johnson) or Charnley Elite (Depuy/Johnson and Johnson) stem. RSA migration measurements were performed at postoperatively and at 6,12,18 and 24 months post surgery using the UMRSA system enhanced with locally developed software.

Results: Two significantly distinct patterns of distal migration in the y direction (subsidence) were seen compatible with previous studies. Tapered stems subsided rapidly by six months Exeter 0.85mm (+/−0.15) UTPS 0.85mm (+/−0.15) stabilising by 2 years Exeter 1.3mm(+/−0.35), UTPS 1.2mm(+/−0.25). The USS and Elite designs showed lower migrations of 0.1mm (+/−0.1) and 0.15 (+/−0.15) mm at six and 0.25mm(+/−0.15) and 0.35mm (+/−0.15) 24 months. For migrations and rotations in other directions differences were seen between prostheses with the same design concept. Whilst both the UTPS and Exeter exhibited posterior migration of the head, by 24 months this was expressed as a rotation about the transverse axis for the TPS and the axial axis for the Exeter. The Elite and USS differed in rates of posterior migration and varus tilt.

Conclusions: Patterns of migration for stems with the same design concept may vary due to subtle differences in prosthesis shape. These variations produce a distinct migration “signature” for each stem.


A P Molloy H Hennessey C Hopkins D J Pegg

Aims: To determine whether lumbar spinal injection in conjunction with general anaesthesia decreases peri-operative blood loss and thereby transfusion rates as compared to general anaesthesia alone in patients undergoing primary hip arthroplasty.

Methods: This is an observational study of 47 consecutive patients who underwent unilateral primary total hip arthroplasty. These were all performed by the same surgeon using the same approach, prosthesis and postoperative care. Group I consisted of 28 patients who had combined lumbar spinal and general anaesthesia performed by the same anaesthetist. Group II consisted of 19 patients who had general anaesthesia alone. Analysis was made of intra-operative blood pressure, post-operative haemoglobin levels using Mann-Whitney test and of transfusion rates using Fischer’s exact test.

Results: Group I had a mean intra-operative mean arterial pressure of 53 (range 38–72.5) compared to 65 (range 45–94) in group II. This was a statistically significant difference (p = 0.0006). There was a mean drop in haemoglobin of 29 (range 9–53) in group I and of 40 (range 22–56) in group II. This was a statistically significant difference (p = 0.0006). 2 patients ( 7.1%) in group I required blood transfusion as compared to 8 (42.1%) in group II. Again this result was significantly different (p = 0.0086).

Conclusion: Some previous studies have shown transfusion rates as high as 75 %. We recommend the use of combined lumbar spinal and general anaesthesia in primary total hip arthroplasty as it significantly reduces peri-operative blood loss and transfusion rates, in our study to only 4.1%. This may reduce the risk of infection and improve the bone cement interface in a cemented hip arthroplasty.


A Wrate J. Haines PR Kay

It has been proposed that scoring systems could be nationally used, initially on a secondary care level as a method of prioritising patients on waiting lists for hip and knee arthroplasty. If this were to be successful, scoring systems could be used as a way of tackling the ever increasing waiting list times for surgery which currently stand at around 15 months on the NHS.

I studied and compared the New Zealand and Oxford Hip and Knee Scores, collecting data from 79 patients over a period of seven weeks.

I found that generally, patients who scored highly were recommended for surgery; however I also found that in the group of patients recommended for surgery there was a wide range of scores obtained. There was also a great deal of overlap between the scores obtained by those who were recommended for surgery and those who were not. This means that it would be very difficult to predict a decision for an individual patient based purely on their scores. In addition, many confounding variables can affect the wide range of scores obtained.

I concluded that there was too much variation between the scores obtained by patients undergoing surgery to be able to consistently and fairly prioritise them. In order to implement the use of scoring systems in this country, nationally approved criteria and priority banding categories need to be established. Scoring systems need to be modified to be clearer and to cover more variables. Larger studies need to be conducted with more patients and over a longer period of time; and further work could be done into the proposal that GP’s could use these systems as a tool for referral to consultant out-patient clinics.


G M Mundy C N A Esler W M Harper

Introduction: With an ever-increasing elderly population the rise in primary total hip replacement is inevitable. This translates into a comparative rise in revision hip surgery. We performed an observational study to determine current revision hip surgical practices in one UK region.

Methods: We utilized a regional hip register (Trent Arthroplasty Audit Group (TAAG)) to review current revision hip surgical practice in our region. 136 surgeons in 21 different hospitals, covering a population of 6.2 million, contribute to the register. We analysed completed data forms to produce the following results.

Results: 875 revision THRs performed between 2000 and 2002 were identified. 54% were female, with a mean age of 70 (range 26–97). 45 different femoral stems requiring revision were identified. Reasons for revision were aseptic loosening of both components (23%), cup alone (24%), stem alone (17%), infection (14%), recurrent dislocation (10%), periprosthetic fracture (5%) and acetabular erosion (3%). Over 25 different femoral stems and over 30 different acetabular components were utilised by surgeons. In 70% of cases the femoral and acetabular components were made by different manufacturers. Bone graft was used in approximately 50% of cases. 90% of centres contributing to TAAG perform revision hip surgery. 24% of all revision THRs were performed by surgeons performing 5 or less per year. Only 40% of revision THRs were performed by ‘revision surgeons’ performing > 20 per year.

Conclusions: It is evident the majority of centres, both teaching and DGH, in our region regularly perform revision hip surgery, with up to a quarter performed by non-revision specialists. With increasing numbers of prostheses available, high numbers of component mismatch use, and the inevitable increase in future need for revision hip surgery, is the occasional revision surgeon compromising patient care? Will this have future medico-legal consequences?


S.J. Griffin N.A. Steele

Successful treatment of the infected arthroplasty remains a major concern to the revision surgeon. We aim to present our audit of the use of the Biomet Femoral Spacer in staged revision of the infected total hip arthroplasty.

Following removal and thorough debridement of the infected joint the spacer is created using the Biomet mould and the surgeon’s choice of cement with additional antibiotics.

Custom moulding allows for the incorporation of intramedullary devices to stabilize periprosthetic fractures.

The patient is then able to mobilize non weight bearing on the spacer until infectious parameters return to normal, before the second stage is attempted.

In our series fifty cases have been identified. Two dislocations, two prosthesis fractures and three repeat second stages are noted. Examples will be presented.

We believe the Biomet Femoral Spacer has a definite role in the management of this difficult problem.


N J Dunne J F Orr D E Beverland

Recent studies, including the Swedish Hip Register, have confirmed that modern cementing techniques are important to achieve long-term implant survival. Their ultimate goal is to obtain an increased strength of cement and its interfaces with bone, thereby maintaining secure fixation and effective load transmission.

The objective of this study was to measure the medullary pressures generated during bone cement injection, pressurisation and femoral prosthesis insertion for total hip arthroplasty. The measurements were recorded throughout the length of an in vitro femoral model while implanting a series of prosthetic hip stems using different pressurisation techniques. The prostheses used were the Charnley 40 flanged stem, an Exeter No. 3 stem, and a custom primary femoral component used in Belfast (Johnson & Johnson, DePuy International Ltd.). The following parameters were derived from the pressure data recorded; peak pressure, decay pressure and duration above 76 kPa, the pressure regarded as the threshold to obtain adequate bone penetration.

The range of peak distal stem pressures expected for all stems was 200–500kPa. The custom and Exeter stems generated proximal cement pressures in the range 100–300kPa. These pressures were attained through cement containment by stem design or auxiliary pressurising devices, respectively. It was observed that the Charnley femoral component did not perform as well with regard to proximal pressurisation, irrespective of which pressurisation technique was implemented. The durations of pressure maintenance above 76kPa are also important, 5 seconds being accepted as a minimum for an effective interface. These results reflect the pressure measurements, with adequate durations being maintained by those stems and pressurisers that were characterised by higher peak pressures.

It is concluded that stem design and the complementary cement management techniques are essential to realise the pressure/time characteristics that are regarded as necessary to form an optimum bone/cement interface.


C R Evans N A Steele L Jeys R Spencer Jones

The use of distal femoral centralising devices has been advocated in order to achieve an even cement mantle. This has been shown to improve femoral component survival but it is recognised that the presence of voids in the mantle has a deleterious effect on the mechanical strength of cement at laboratory testing and in terms of implant survival. The effect of centralising devices on the mantle in relation to the timing of stem insertion has not previously been investigated.

The purpose of this study is to assess the quality of the cement mantle in artificial bone using a polished taper stem with centralisation inserted at different stages of cement cure time and using different cements.

Three cement types were studied, 45‘saw bone’ models were used. The cementation was carried out in an operating theatre at constant temperature of 23.2Ê°C. The cement was mixed according to the manufacturers instructions and pressurised. Early, intermediate and late stem insertion times were determined for each cement type. The late group included stems with and without centralisers. Video recordings of the stem cement interface were made with a 4 mm endoscope after stem removal. Large cement mantle defects were noted in the ‘with centraliser’ group in 7 out of 15 late insertion times and all had small defects in the mantle. None of the ‘without centraliser’ group had cement mantle defects.

Based on our results we advise surgeons to be very aware of the timing of stem insertion when using centralisers.


G R Aspinall A Nicholls R M Kerry A J Hamer I Stockley

The Huckstep ( Bbraun Medical) interlocking hip prosthesis has been used in the Sheffield Lower Limb Arthroplasty Unit in cases of complex primary and revision hip arthroplasty since 1996. We reviewed the outcomes in cases performed prior to October 2001.

Eighty cases were identified. Of these, eight died within one year of surgery, four of which were in the peri operative period. A further thirteen were lost to follow up in the first year due to medical deterioration, move from area or refusal to attend. The remaining 57 patients had a mean time to follow up of 34 months (12–81m).

As a primary prosthesis the Huckstep was used to allow corrective osteotomy. In revision cases it was employed to bypass periprosthetic fractures and fragile proximal femoral bone, in cases requiring extended trochanteric osteotomy to facilitate cement removal, and to enable use of bulk proximal femoral allograft. The use of the Huckstep was planned pre operatively in 67 cases and as a salvage option in 13.The design of the implant allowed a stable construct without the need for bone cement which could interpose and prevent bone healing or graft incorporation. It avoids problems incurred in pressurising cement or impaction grafting against fragile bone.

Complications included infection requiring further surgery (5), dislocation (5), periprosthetic fracture (2), screw breakage (4), and mechanical failure (2). Eleven patients required further revision surgery. The apparently high complication rate reflects the complex nature of the surgery and the high degree of co morbidity in the elderly patient group.

In conclusion, we have found the Huckstep hip prosthesis to be a useful option in cases of complex hip surgery. Whilst the long term outcome is as yet unknown, our short term results show it to have allowed healing of fractures, osteotomy sites and cortical defects, allograft incorporation and replenishing of bone stock, hence facilitating further arthroplasty surgery.


M D A Fletcher R F Spencer V G Langkamer A M Lovering

Joint fluids obtained for diagnostic purposes from 25 patients were assayed for the presence of gentamicin. All of the patients had presented with failing or painful joints at periods up to 10 years following primary hip or knee arthroplasty using gentamicin-impregnated cement. Gentamicin was detected in the joint fluids from 9 of 15 patients with knee prostheses and 4 of 10 with hip prostheses. Gentamicin concentrations ranged from 0.06mg/L to 0.85 mg/L with no significant differences in concentration between patients with hip or knee prostheses, or type of prosthesis, and no identifiable relationship was found gentamicin concentration and the time after primary arthroplasty. Although the majority of the gentamicin concentrations were found to be below the levels required to inhibit susceptible pathogens, we conclude that gentamicin release around failing implants may lead to false negative cultures in some patients and provide selective pressure for the emergence of resistance where infection is present in others.


Mr William J Hart Mr R. Rees Mr IP. Wright Mr Richard Spencer-Jones

Aim: To determine the incidence of non-union of the trochanter and the rate of wire breakage encountered using a trochanteric osteotomy as an approach for primary total hip arthroplasty.

Method: 169 complete records were identified for patients who had undergone hip replacement surgery between 1999 and 2001. The age and sex of the patients, prosthesis used and seniority of the surgeon were recorded. The final position of the trochanter and the state of the wires were determined from the x-rays. An assessment was made of the relationship of the tip of the trochanter to the centre of rotation of the hip both pre and post-operatively.

Results: 169 patients. 98 female and 71 male. 118 cases were performed by consultants and 51 cases by registrars. 76% of cases used an Exeter stem, 16% a charnley elite and 8% a C Stem. The most significant determinant of union was the overall shift of the trochanter. In the healed group the average shift was 5.25mm and in the lifted this was 10.42mm(p=< 0.0001).

The average age of the of the patients that healed was 65.4yrs and 70.06 in those that lifted. Again this was significant (p=0.0078).

There was no correlation between sex of the patient, seniority of the surgeon or the prosthesis type with trochanteric union.

Conclusion: The age of the patient and positioning of the implant have a greater effect on the rate of union than the seniority of the surgeon and the patients sex.

We recommend careful planning pre-operatively to limit the change in position of the trochanter.


I J Brenkel R Cook

Venous Thromboembolism is a common complication following a hip replacement. Recently the pulmonary embolism prevention study was published. It reported that aspirin decreased the fatal pulmonary embolism rate in patients admitted with a fracture neck of femur. In addition new products (synthetic factor X inhibitor -Fondaparinux, and a direct thrombin inhibiter-Desirudin) have been reported to be more effective than low molecular weight heparin in preventing asymptomatic deep vein thrombosis. We felt it was important to repeat a survey, done in 1997, on the use thromboembolism prophylaxis among British Orthopaedic Surgeons.

A single page questionnaire was sent out to all 1308 consultants Orthopaedic surgeons who were members of the British Orthopaedic Association. Those who did not respond were sent a reminder letter.

We achieved a 72% response rate. All surgeons use some form of prophylaxis. Eighty five percent of surgeons use pharmacological prophylaxis. Low molecular weight heparin is used by 55% of surgeons. Twenty percent of surgeons use aspirin as their only form of pharmacological prophylaxis. Less than 1% (5 consultants) use early mobilisation alone and nearly 2% (13 consultants) use graded stockings and early mobilisation as their only form of prophylaxis. Seventy four percent of surgeons have a unit policy. Thirty percent have changed their regime in the last 3 years.

The majority of British Orthopaedic surgeons still use pharmacological thromboprophylaxis. There has been a significant increase in the use of Aspirin from 5% to 30%. Aspirin is often combined with a mechanical prophylaxis. This has led to an increase in the use of intermittent calf compression (3% to 22%), and foot pumps (12% to 19%). Low molecular weight heparin use has fallen by 10%.

The majority of British Orthopaedic surgeons still use pharmacological thromboprophylaxis. There has been a significant increase in the use of Aspirin from 5% to 30%. Aspirin is often combined with a mechanical prophylaxis. This has led to an increase in the use of intermittent calf compression (3% to 22%), and foot pumps (12% to 19%). Low molecular weight heparin use has fallen by 10%.


M H A Malik A K Gambhir N Pradhan L Bale M L Porter

In 1999 a statement of best practice in primary total hip replacement was approved by the Council of the British Orthopaedic Association and by the British Hip Society to provide a basis for regional and national auditable standards. We have compared practice in the North West of England to this document to ascertain adherence to this guide to best practice.

86 surgeons from 26 hospitals were included in the study. A mean of 93.3% of operations were performed in the surgeon’s usual theatre. All of these theatres had vertical laminar air flow systems. 42.2% of respondents routinely used exhaust suits. 68.1% of respondents routinely used impermeable disposable gowns, 26.1% used impermeable reusable gowns. The Charnley femoral and acetabular prostheses were the most commonly used prostheses.

All surgeons use some form of anti-thromboembolic prophylaxis. 66.2% use a combination of both mechanical and chemical means. All surgeons used antibiotic prophylaxis. The most popular choice of antibiotic was a cephalosporin. 70.7% used a three-dose regime over 24 hours. 2.6% of surgeons continued antibiotic prophylaxis for 48 hours after surgery. 93.7% of surgeons routinely use antibiotic-loaded cement.All surgeons routinely cleaned, irrigated and dried the acetabulum and femur before cement insertion. Only one surgeon did not use any form of femoral canal occlusion. 69.4% used an intramedullary bone block. Retrograde filling of the femoral shaft by means of a cement gun was practised by 65.1%.

This study has demonstrated considerable variation of practice in THA across the North West region and significant divergence from the statement of best practice approved by the BOA and BHS. The introduction of a properly funded national hip register will surely help to clarify the effect of such diverse practice on patient outcome. We would recommend that all trusts locally audit their practices and correlate them to these nationally agreed guidelines.


H Nagai B M Wroblewski P Kay P Siney P Fleming

Purpose: The purpose of this study was to assess preoperative bone stock and immediate postoperative cement-bone interface as factors affecting infection control and mechanical outcome after one stage revision total hip replacement (THR) for deep infection.

Material and methods: This study included 115 cases which satisfied following conditions; a) One stage revision THRs for deep infection were carried out by a single surgeon (BMW). b) Follow-up of more than five years was possible. c) Complete series of radiographs were available including preoperative, immediate postoperative and the latest follow-up ones. Preoperative bone stock was classified into four grades (Grade 0: No bone loss, Grade 1: Demarcation, Grade 2: Localized cavitation, Grade 3: Significant bone loss). Immediate postoperative cement-bone interface was also graded into four categories (Grade A: White-out, obscure interface, Grade B: Clear line, no measurable gap, Grade C: Gap> 1mm, Grade D< 1mm). These two factors were analysed in view of infection control and mechanical survival of implants after surgery.

Results: Preoperative bone stock did not show significant influence on infection control while it affected mechanical outcome. Immediate postoperative cement-bone interface was an affecting factor for not only mechanical survival of implants but cure of infection.

Conclusion: Preoperative bone stock and immediate postoperative cement-bone interface were assessed as influential factors in one stage revision THR for deep infection. There was a good chance of cure of infection even in cases with significant bone loss. Good cement fixation appeared to be important in view of infection control as well as mechanical survival of implants.


D J Duffy O Wall D A Macdonald

Objective: To compare the results of MRI Gadolinium Arthrograms and hip arthroscopy in patients with hip pain.

Design: Retrospective analysis

Setting: St. James University Hospital, Leeds

Participants: 15 patients (10 females and 5males) underwent hip arthroscopy between 1999 and 2002.The procedure was performed by a single surgeon. The mean age of the patients was 39 (Range 24–74).

Outcome Measures: A review of the findings of both the MRI and arthroscopy were undertaken. Attention was paid to the both the specificity and sensitivity of the MRI diagnosis when compared to the findings at arthroscopy.

Results: All 15 patients underwent MRI Arthrograms with intra-articular gadolinium prior to arthroscopy. The time that elapsed between radiological evaluation and surgery was a mean of 10 months (Range 7–15).During this time there had been no significant change in any of the patients’ clinical symptoms.

Of the 15 scans performed only 10 were found to provide an accurate diagnosis confirmed at the time of surgery, The presence of osteochondral defects, loose bodies, synovitis and AVN were all correctly identified.

Of the remaining five cases, two labral injuries were identified radiologically, but arthroscopy proved to be normal. MRI was also found to be particularly inaccurate when assessing for articular cartilage defects, failing to demonstrate moderate to advanced changes in three cases, later confirmed at surgery.

Discussion: MRI is the non-invasive investigation of choice for the assessment of both intra and extra articular hip pathology. However our results show that limitations do exist with the sensitivity and specificity of this investigation. Previous studies (Edwards et al, Villar et al) have demonstrated similar findings .The interpretation of MRI Arthrograms should therefore be carefully considered when establishing a diagnosis for hip pain.


K Ho A D Clayson J B Day D H Sochart J P Hodgkinson

Aims: As part of the guidelines recommended by NICE (National Institute of Clinical Excellent), we are presenting the early results of this new hip replacement component.

Methods: We reviewed 65 consecutive primary total hip replacements in 59 patients in which the Opera Flanged cemented acetabular component (smith & nephew) had been used. The mean follow-up was 47 months (36 to 63). In all cases a Charnley femoral prosthesis had been used. There were 39 women and 26 men with a mean age at operation of 67.4 years (33 to 90). Survival analysis of the acetabular components was performed.

Results: Two components were revised due to deep infection, and one of these cups was discovered to be well fixed at operation. None of the acetabular components required revision for aseptic loosening. After 5 years survival was 97% using the worst-case scenario. Radiological analysis of all acetabular components at 12 months post-operation and at yearly intervals revealed no cases of aseptic loosening. Radiolucencies around the cemented socket were noted in five patients, but were not progressive on sequential radiographs.

Conclusions: The early results are encouraging and the follow-up will be continued to assess the 10 years results.


V T Veysi J A Roberts

Aim: To evaluate the medium term results of revision hip replacements using the ‘Furlong’(© JRI, London) HAC covered total hip replacement system.

Methods: The first one hundred revision hip replacements were identified from the arthroplasty register of the senior author. The notes and x-rays at presentation were retrospectively analysed to ascertain the clinical and radiological state pre-operatively. The surgical findings were also noted. The final clinical and radiological states were obtained from the latest outpatient appointment. Modified Harris Hip Score was used to discern the clinical state. SPSS © vol 11.0 was used for statistical analysis.

Results: There were one hundred revision hip replacements performed in 97 patients between 1991 and 2000 by the senior author. There were 72 cemented and 18 uncemented prosthesis revised. 9 of the revisions were for infection. 79 were revised for aseptic loosening of one or both of the components. There were 4 recurrent dislocators and one revision was carried out for a peri-prosthetic fracture.

The median to follow up was 3 years (mean 3.8, range 1–8).The changes in the clinical state of the patient at the last follow up are shown in the table: At the time of the latest follow-up 74 of the cups and 69 of the stems showed definite radiological signs of osseointegration.

Discussion: Our results show that clinical results of revision surgery using this system give good results in the short to medium term. Radiological results are less easy to interpret as osseointegration can take a long time to become visible on x-rays. The need for longer term follow-up is highlighted by the results.


J K Barbosa J G Andrew

Resurfacing total hip replacement using metal on metal bearings is increasing in popularity, but the outcomes are currently unclear. We report a series of 23 hips in 20 patients who underwent resurfacing total hip replacement over a period of 4 years. The mean age at surgery was 47 years (21–61). There were 8 females and 12 male patients. The mean follow up was 27 months (range 6 to 50 months). Before performing this study, our impression was that most outcomes were good but that there appeared to be more variability in pain relief than anticipated after conventional total hip replacement. Most were performed for primary osteoarthritis; other diagnoses included AVN, DDH and multiple epiphyseal dysplasia. Outcomes were measured examining x rays, survival of the implant and the Oxford hip questionnaire.

There were no early revisions, but we are aware of one loose acetabular cup (in a patient with DDH) which is asymptomatic but which will probably require revision. There were no femoral neck fractures. The median score using the Oxford hip questionnaire was 15 (mean 23.5; range 12 to 41). These outcomes compare favourably with those reported at 6 months follow up after conventional total hip replacement by the Oxford group (OHQ median score 22; mean 24.3 (12 to 51)).

We conclude that resurfacing metal on metal hip replacement gives comparable results to total hip replacement at early follow up. The age of the Oxford groups patients was considerably older than ours (75 years), and a comparative trial of resurfacing versus conventional hip replacements will be required to determine which gives better short and long term results in young patients. There may be more variability in pain relief after resurfacing THR than after conventional THR, but this will require a larger study to determine with confidence.


WJ Hart R J Rees J Metcalfe R Spencer-Jones

Introduction: There are approximately 50000 hip and knee arthroplasties performed in the UK every year. With this increasing number the prevalence of periprosthetic fractures is also rising. These are often challenging problems with increased morbidity and mortality. The use of cortical strut allografts in periprosthetic fractures was first reported in the early 90’s with favourable results.The aim of this study was to assess the radiological outcome of cortical strut allografts used as the treatment for periprosthetic fractures of the femur in patients presenting to our institution.

Patients & Methods: 17 patients with who had received strut allografts as part of their treatment for a periprosthetic fracture of the femur were identified. 13 fractures were around a total hip replacement and 4 around other femoral implants (2 long stemmed TKR’s and 2 fracture fixation devices).

We undertook a radiological evaluation of this technique. We assessed fracture union and strut allograft incorporation using the radiological criteria of Emerson et al. The procedure was deemed a success if the fracture had united, with evidence of graft incorporation with a stable implant. We also undertook a notes review identifying any risk factors and any previous surgery.

Results: Two patients died in the early post-operative period. 15 patients were available for analysis. The average length of radiographic review was 16 months. 11/15 procedures (73%) were deemed a success. All these showed evidence of graft incorporation which was time dependent. There were four failures. In one patient the struts fractured at two months. There were three cases of deep sepsis, this required amputation in one and excision arthroplasty in two.

Conclusion: Cortical strut allografts are a good technique for the management of periprosthetic fractures of the femur. As well as providing initial support they also become incorporated which improves the host bone stock.


N J Donnachie R Finley N Bergman

Introduction & Aims: Revision hip arthroplasty surgery is technically demanding and good exposure is a pre-requisite to successful re-implantation. The traditional pertro-chanteric approach gives circumferential exposure of the acetabulum and excellent exposure of the proximal femur. The Trochanteric Slide approach theoretically reduces the incidence of trochanteric pull off and non-union. The aim of this study was to establish the efficacy of the Trochanteric Slide approach to revision hip arthroplasty.

Materials & Methods: Fifty revision hip replacements were performed using the Trochanteric Slide surgical approach. Fixation of the osteotomy was performed with the Dall Miles cable grip system. All patients were prospectively followed for a minimum of 18 months (Mean 3.4 years). 36 of the revisions were for aseptic loosening, 6 for septic loosening, 3 for peri-prosthetic fracture and 5 for recurrent dislocation. In 19 cases, previous revision surgery had been performed.

Results: 8 of the 50 trochanteric re-attachments showed suggestion of movement from the immediate postoperative x-ray. 8 showed less than 5mm migration, 3 showed 5–10mm migration, 1 showed 10–15mm migration and 1 showed 15–20mm migration. Radiological union was definite in 38 cases. Probable union was observed in 5 cases and non-union in 7 cases. 36 hips had a positive Trendelenberg test prior to surgery compared to 11 cases at 12-month review. Trochanteric bursitis was present in 15 cases. Cable end fraying occurred in 8 cases. There were 2 instances of cable breakage and one instance of cable migration onto the prosthesis.

Conclusion: The authors feel that the trochanteric slide approach gives excellent exposure whilst retaining the distal tether of vastus lateralis. This distal tether when combined with cable grip fixation appears to give a good outcome with regards trochanteric migration but is prone to causing trochanteric bursitis.


C A White A J M Miller C Mclean

The Collum Femoris Preserving (CFP) total hip system is an anatomically designed, Hydroxyapatite coated, Uncemented, end bearing prosthesis, requiring minimal bone resection of the femoral neck, with an anatomical,uncemented acetabular cup. We have performed 55 Total Hip arthroplasties using the CFP Total Hip system to date. The average age of our patients is 51.5 years (13 to 65). Original pathology was Osteoarthritis in 38 hips, avascular necrosis in 9 hips and rheumatoid arthritis in 8 hips. They have all been performed by the same surgeon via a posterior approach. The Average inpatient stay has been 6.5 days.We have had one lateral femoral wall burst (requiring no intervention), one calcar fracture, and three legs lengthened, but no other complications. Pain relief is equal to conventional hip replacement. The clinical scores have been excellent Harris hip scores average 93.8% at one year. 100% have been very satisfied on post operative ratings questioning.

This prosthesis is suitable for young patients in which maximal bone conservation is required with excellent short term follow up.


K R Wembridge A J Hamer

Aims: Cementing techniques in arthroplasty affect the outcome of the procedure. Pressurisation is used to improve the cement/bone interface, relying on ante-grade pressure against a resisting force. It is known that ultra high molecular weight polyethylene (UHMWPE) leaves particulate debris, which may lead to aseptic loosening, suggesting a biodegradable cement restrictor may be better. We compared cement restrictor migration at insertion between two types of restrictors, to find if they behaved in a similar fashion.

Methods: A prospective, randomised study with 16 patients per group was compared. Each group was allocated either a UHMWPE or a biodegradable restrictor, inserted according to the manufacturer’s instructions. All procedures used the same approach by one of two surgeons using a cemented polished, tapered stem prosthesis. At insertion the restrictor depth was measured from a fixed reference point, prior to cement introduction, which allowed comparison with post-operative standardised EBRA radiographs. By measuring stem lengths we were able to calculate the individual magnification and hence increase the accuracy of restrictor migration measurement.

Results: In each group 15 patients completed the study. The results showed a marked significance, with mean migrations of 3.0cm vs. 0.5cm (biodegradable vs. UHMWPE). Mann-Whitney U test gives a value for p< 0.002. The medians (2.9vs.0.4), standard deviations (1.8 vs.0.4) and ranges (0.6–6.4 vs.0–1.2) were also significant.

Conclusions: In this study, the biodegradable restrictor used was found to allow significantly more migration than the UHMWPE one used. Although there are positive advantages in avoiding the use of UHMWPE restrictors, further advances need to be made before abandoning it completely.


Full Access
R Elson

In the anatomical position the tendon of this powerful muscle curls round the inferior aspect of the neck of the femur to its insertion into the greater trochanter. A component of its action is therefore one of external rotation. However in flexion the tendon eventually comes to lie parallel with the neck of the femur; it is then purely an external rotator.

During an action as when rising from a sitting posture, it is commonly thought that the head of the femur is stressed backwards so as to produce an internal rotation strain at the shaft neck junction and thereby, in a prosthetic replacement, a potentially prejudicial torque is created around the shaft of the femoral component. It is suggested that the action of the obturator externus, in particular, prevents this by converting the torque into compression along the neck of the natural femur or of a prosthesis; this is a condition which is suited to the material properties of bone in the natural state.

This paper contrives to demonstrate the evidence for the mechanism described.

Obturator externus is less frequently violated than other muscles around the hip; however, it is suggested that all of these should be carefully preserved or repaired effectively because they all contribute to a similar conversion of otherwise bending forces around the neck, to compression. In our quest to identify minutiae that contribute to long term survival of hip replacements, this may be another factor for consideration.


A Gray P Walmsley M Moran I Brenkel

Background: Previous studies have reported mixed findings with regards to post operative complication rates and overall outcome in elderly patients undergoing total hip arthroplasty. The aim of this study was a prospective comparison of physical and functional outcome measurements following primary hip arthroplasty in patients aged 80–90 years to those aged 70–79.

Methods: Data was prospectively recorded from 1998–2002. 144 patients aged 80–90 years underwent primary hip arthroplasty compared to 441 aged 70–79. A pre-operative Harris Hip Score was obtained on all patients and a standardized follow up regimen was used for assessment at 6, 18 and 36 months post surgery. Data collection included: intraoperative blood loss; post operative transfusion rate; incidence of wound infection, DVT and pulmonary embolus; dislocation and mortality rates. Statistical analysis involved two-sample t-test and chi-squared with Yates correction.

Results: Pre-operative Harris Hip Scores were 41.6 (SD 11.2) in the younger cohort and 39.3 (SD 12.4) in the octogenarian (P = 0.04). This score had improved by 39.3 and 38.1 points respectively (P = 0.5) at 6 months; 42.3 and 37.7 at 18 months (P = 0.02); 43.4 and 39.8 at 36 months (P = 0.24).

The mortality rate at 3 months following surgery was 4% in our octogenarian group compared to 1% (P=0.02). Mean length of hospital stay was significantly (P< 0.001) longer at 12.9 (SD 7.0) days compared to 10.1 (SD 4.7). The transfusion rate in our octogenarian group was 40% compared to 28% (P = 0.009). The incidence of deep infection was 1.4% in the older group compared to 0.5% (NS). Each group had a dislocation rate of 1%. and an incidence of DVT and pulmonary embolus that was comparable.

Discussion: Total hip arthroplasty can be performed safely in octogenarians with excellent relief of pain and improved function.


Full Access
G Kumar M Ramakrishnan N J Donnachie

Hips and knees are commonly replaced joints for which several types of prostheses are available. As newer versions of the prostheses are brought in, older versions are phased out. When revision is for an isolated component failure as in, wear of acetabular cup, isolated revision of the acetabular cup is an accepted procedure. If the plan is to revise just the isolated component then that particular model of prosthesis should still be available.

In an attempt to check the availability of revision components for joint replacements we wrote to ten prostheses manufacturers enquiring the availability of prosthetic components. To have a comparison, we also wrote to eighteen leading car manufacturers enquiring about the duration and any guarantees on the availability of car spare parts.

From our survey we found that the availability of the revision implants was satisfactory in that all the prostheses manufacturers were eager to provide as much assistance as possible. The draw back is that there are no regulations to ensure the availability of these prosthetic components for any length of time after discontinuation of a particular model.

The car manufacturers are not under any obligation to provide spare parts for discontinued models. The argument put forward by some manufacturers for providing spare parts up to ten years from discontinuing the model was that “it would not reflect well on the company” if it were for any lesser length of time.

Conclusion: At present though there are no regulations on the time period of availability of total joint prosthetic components. The manufacturers have taken it upon themselves to provide the prosthetic components whenever a specific request is made. If the manufacturers say they can not provide the implants there is nothing in the governmental regulations that provide for recourse.


B J A Lankester J Stoney S Gheduzzi A W Miles G C Bannister

Introduction: Aseptic loosening is the main cause of revision in hip replacement surgery. Improved cementation techniques have reduced the rate of loosening of the femoral component, leaving the cemented acetabular cup as the major problem, with reported loosening rates as high as 25% at 12 – 15 years. The ideal method of acetabular cementation has not been fully evaluated.

Aim: To determine the ideal thickness of cement mantle to resist torsional forces.

Method: Mahogany blocks with a 54mm hemispherical hole were used to simulate an acetabular socket. Machined aluminium cups were created in 5 sizes (52mm to 44mm) to give a cement mantle that varied in size from 1mm to 5mm. Three 10mm keyholes were drilled in the blocks and appropriate-sized spacers were inserted to ensure the mantle was accurate and even. Silicone grease was used to prevent any micro-interlock between cement and wood. The cups were then cemented into the wooden blocks using vacuum-mixed Palacos R cement and left to cure in air for 7 days at 37 °C. The constructs were tested to failure using a servo-hydraulic testing machine. Each experiment was repeated six times.

Results: The stiffness of the cement mantle varied according to thickness as follows:

Thickness (mm) Stiffness (Nm / Degree)
1 58 +/− 4
2 37 +/− 1
3 39 +/− 1
4 25 +/− 0.3
5 24 +/− 0.3

Discussion: A stiffer cement mantle will transfer more torque to the bone-cement interface, possibly leading to earlier loosening of the prosthesis. This biomechanical analysis suggests that surgeons should aim to achieve a mantle at least 2mm thick. There appears to be little further mechanical advantage gained if the mantle is increased in thickness beyond 4mm.


N J Hancock E J Smith I D Learmonth D Coates

In the future, registration with a surgical speciality may require no more than the demonstration of core knowledge in the generality of that speciality and in the diagnosis and management of the related acute conditions. Sub-speciality training will be recognised separately. Rationalisation of referral patterns would then require that primary care practitioners are aware of these special abilities.

A questionnaire was sent to 1207 General Practitioners in the Avon, Leicestershire and Central London regions. The response rate was 86.2% (n = 1040). Views were sought on the management and referral of patients experiencing problems with existing hip replacements. These included the use of pre referral radiographs, whether practitioners would preferentially refer to a specialist hip surgeon and whether they believed that referral to a generalist could compromise patient care.

The majority GP’s arranged pre referral radiographs (84.2%). A third (34.2%) indicated that they would refer to any orthopaedic surgeon. 50.0% felt that outcome could be compromised if the patient was seen by an orthopaedic surgeon without a special interest in hip surgery.

There appears to be a need for more scientific information for GP’s and an agreed referral protocol. It is expected that rationalisation the referral system would lead to closer matching of patients needs with specialists’ abilities.


J Saksena S K Muirhead-Allwood

Introduction: The conversion of the fused hip to a total hip replacement poses a challenging reconstructive problem. The technical pitfalls depend on the aetiology of the arthrodesis, the surgical technique used and the available bone stock. Indications include painful pseudo arthrosis, disabling back or ipsilateral knee pain and malposition of the arthrodesed hip. There are often difficulties restoring appropriate biomechanics and providing a functionally useful outcome. We present a short series where a custom CAD/CAM femoral prosthesis was used to accommodate the anatomical problems caused by previous spontaneous and operative arthrodesis.

Patients and Method: 5 patients (4 female, 1 male) with primary diagnoses of septic arthritis, TB, trauma and DDH were reviewed. The average age at the time of conversion was 43.6 years (Range 20–62 years). The patients were reviewed with a mean follow up of 82 months (Range 24–110 months). All the patients were evaluated by an independent observer radiologically and clinically using Harris, WOMAC and Oxford hip scores.

Results: The patients improved from preoperative HHS 55 (Range 39–73), Oxford 40 (Range 37–46) and WOMAC 80 (Range 65–92) to postoperative HHS 73 (Range 44–94), Oxford 26 (Range 17–42) and WOMAC 45 (Range 24–79). These results compare poorly to a large series of age and sex matched cases undergoing primary and revision hip arthroplasty. Nevertheless, 4 patients were extremely satisfied with the results of their operation. 1 patient showed no improvement in his scores although he reports that his spinal symptoms are better. His operation was complicated by non-union of the greater trochanter.

Conclusion: Most series report poor results after the conversion of arthrodeses to total hip replacements. The commonest problems include instability, sepsis, fractures, limited mobility of the hip replacement and poor function. Careful planning is required to accommodate the atypical anatomy. The use of CAD/CAM femoral stems in the conversion of the arthrodesed hip has allowed preservation of valuable bone stock in anatomically abnormal femora whilst optimising biomechanics and improving function.


P T H Lee M T Clarke A Arora R N Villar

Aims: Cobalt (Co) and chromium (Cr) ion associated carcinogenesis and chromosomal damage in animals have raised concerns that metal-on-metal (MOM) total hip replacement (THR) in humans may produce the same effects over time. Considering that the risks may be related to the level of these ions in the body, this study compared the serum Co and Cr levels in patients with unilateral versus bilateral 28 mm diameter MOM THR.

Methods: All patients having THR at our institution were prospectively registered on a computerised database. From our database, 108 Ultima MOM THR with 28 mm CoCrMo bearing were identified. After patient review in clinic and before blood results were known, patient matching was performed by date after surgery, activity level and weight. Using these stringent criteria, 11 unilateral THR could be adequately matched with 11 bilateral THR. Blood serum was taken with full anti-contamination protocols and serum analysed via inductively coupled plasma mass spectrometry (ICP-MS) Statistical analysis used the Mann-Whitney U test.

Results: The median serum Co level after unilateral MOM THR was 22 nmol (range 15 to 37 nmol) compared to 42 nmol (range 19 to 221 nmol) for bilateral MOM THR (p=0.001). The median serum Cr level after unilateral MOM THR was 19 nmol (range 2 to 35 nmol) compared to 52 nmol (range 19 to 287 nmol) for bilateral MOM THR (p=0.04).

Conclusions: This study has shown that the serum Co and Cr levels in patients with bilateral MOM THR are significantly higher than those with unilateral MOM THR. With levels of up to 50 times the upper of limit of normal, this finding may be of relevance for the development of potential long-term side effects.


R.E. Field N. Rushton P.J. Singh J. Krysa

Aim: Evaluate a novel horseshoe shaped cup designed by the senior authors to minimise the resection of healthy bone in total hip arthroplasty.

Method: Fifty female patients with a displaced, subcapital, femoral neck fractures were chosen for the study. In half of the group of patients, the composite support shell was coated with HA, with the other half remaining uncoated. Clinical and radiological assessments were undertaken regularly for 5 years.

Results: To date 20 patients have died and 13 have withdrawn from the study due to poor medical health unrelated to the study. Charnley modified Merle d’Aubigne score at 5 years was as good as the preoperative score with 80% of patients having full range of movement, no pain and walking unaided.

Radiographic results showed no evidence of loosening of HA coated cups, in contrast to non HA coated cups which migrated significantly in 80% of cases. Four patients with loose non HA coated cups underwent revision surgery.

Conclusion: It replaces the cartilage and underlying sub-chondral bone of the acetabulum socket with a cup that is designed to flex in harmony with the surrounding bony structure. This trial has demonstrated success at 5 years with the HA coated Cambridge Acetabular Cup. Cups from which HA coating has been removed have migrated significantly in 80% of cases. There is an advantage of the HA fixation which will be taken into account before wider clinical usage is advocated.


P J Singh A J Marsh S M Kerry R E Field

Aim: To develop an accurate and reproducible validated digital technique for the two-dimensional measurement of longitudinal femoral stem migration on AP radiographs.

Method: Eight patients who underwent total hip replacement, under the care of the senior author, were randomly selected. In each case, three radio-opaque marker beads had been implanted into the greater trochanteric region at surgery. Using a standardised x-ray protocol, three consecutive AP standing hip x-rays were taken of each patient on the same day. The plain radiographs were digitised, and the vertical bead to stem tip distance measured by two orthopaedic trainees using Scion Image ‘freeware’ software package and standard computer equipment. Every patient had three different measurements on each of their three consecutive x-rays. The vertical bead to stem tip distance was averaged over the three beads.

Results: Statistical analysis was performed and the repeatability coefficient between x-rays was 0.61 (confidence interval 0.46 to 0.78). The limits of agreement for inter observer error for average bead to stem distance were −0.15 to 0.39.

Conclusion: Our results demonstrate the efficacy of our system for analysis of femoral stem migration in everyday clinical practice. This technique does require implantation of marker beads and a standardised protocol for patient positioning for radiographs.


R E Field T G Kavanagh P J Singh

Aim: Hip resurfacing is a bone conserving procedure with respect to proximal femoral resection. For previous generations of conservative hip replacement, preservation of the natural femoral head diameter necessitated additional sacrifice of acetabular bone in order to accommodate a sufficiently thick polyethylene acetabular component. We have investigated whether the BHR offers a bone conserving procedure with respect to the acetabular bone stock.

Method: We reviewed 284 Birmingham resurfacing hip replacements (BHR), and 479, primary hip replacements, in which an uncemented acetabular component (THUA) was used. The BHR and THUA group had mean age at surgery of 55 and 65 years respectively. In 32 BHR’s and 21 THUA, pre-operative templating measurements were available for subsequent comparison with size of component implanted.

Results: Comparison of component sizes, for both implant types, confirmed bi-modal distribution according to patient gender. BHR cups, implanted by the first author, in females, were significantly smaller than those implanted, by the same author, in THUA,(p< 0.0001). Pre-operative templating overestimated component size for all groups but the difference was only significant in male BHR cases;(p=0.03). BHR cups implanted by the first author were significantly smaller than the second author, for both male (p= 0.0001) and female patients;(p< 0.001).

Conclusion: In females, BHR is bone a conserving procedure for femoral and acetabular components. In males, the procedure is not bone sacrificing when compared to THUA. Pre-operative templating can overestimate size of acetabular component that will be used for men. A significant difference was found between size of acetabular components used by two surgeons for BHR.


P J Singh R E Field C Burtenshaw O Jaffer

Introduction: The acetabular cup comprises a 3mm thick bearing surface of UHMPE, a 1.5mm backing of 30% carbon fibre reinforced polybutyleneterephthalate (CFRPBT). Young’s modulus, of CFRPBT layer is similar to natural subchondral bony plate. The cup deforms, when loaded, with the surrounding acetabular bone so that micro-motion at the bone-prosthesis interface is reduced. We measured BMD in the periacetabulum

Method: BMD was analysed for 2 years (n=11 females) with Mean Barthel Index at 2 years 19. Regions of interest were defined according to De-Lee and Charnley (ROI I-III) for the acetabulum. BMD during follow-up was compared with immediate post-operative values. Mean precision error (CV%) was 1.8±0.87%.

Results: By 2 years the mean BMD in HA cup was 0.73gms/cm2 representing a decrease of 7% and 0.78gms/cm2, which representing a 4% decrease with the non-HA cup. With the HA cup at 2 years we measured an increase in ROI I of 3% and a reduction in ROI II and III of 3% and 20% respectively. With the non-HA cup at 2 years we measured an increase in ROI II of 7% and a reduction in ROI I and III of 3% and 16%. There was a significant difference (p< 0.05) in the BMD changes measured in non-weight bearing zone III and one of the weight bearing zones (zone II).

Conclusion: Changes in BMD measured reflect a pattern of maximally reduced stress in zone III followed by zone II and least in the load bearing axis of the acetabulum zone I.


B J A Lankester R F Spencer I D Learmonth

Introduction: The CPS-Plus cemented, collarless, polished stem, is a double-taper design with rectangular cross section. An additional proximal stem centraliser ensures optimal alignment of the stem and an even cement mantle and has been shown to increase cement pressurisation during insertion.

Guidelines from the National Institute of Clinical Excellence (NICE) recommend comparative clinical evaluation for prostheses without long-term follow-up data and set an initial ‘benchmark’ for performance at 3 years.

Data collection for the CPS-Plus stem is on-going as part of a multi-centre prospective clinical trial. 227 patients have been recruited to the trial and 70 of these have reached 3 years follow-up.

Method: Patients were recruited to the study by surgeons working at three centres in the UK and two in Norway. Patients were fully evaluated pre-operatively. Operative details, post-operative course and follow-up visits at 3, 6, 12, 24, and 36 months were recorded. Postoperative clinical progress was monitored using recognised scoring systems and radiographic assessment.

Results: The mean Harris hip score (0 – 100) improved from 42.7 pre-op to 91.6 at 6 months and 95.8 at 3 years. The mean Merle d’Aubigne and Postel score (0 – 18) improved from 8.55 pre-op to 16.09 at 6 months and 17.08 at 3 years. The mean Oxford hip score (60 – 12) improved from 41.6 pre-op to 14.1 at 3 years. Radiological subsidence at 3 years is less that 1.5mm in 97% of patients and less than 3mm in the remainder. From all 227 implants, there has been one revision for deep infection. There have been no cases of aseptic loosening. Other significant complications include one peri-prosthetic fracture and 4 dislocations, but these were not thought to be related to the design of the implant.

Discussion: The early results of the CPS-Plus femoral stem are encouraging and the prosthesis achieves the 3-year benchmark set out in the NICE guidelines, with a zero revision rate in the first 70 patients recruited to the trial. The prosthesis shares many design features with other well-established collarless, polished, tapered stems. The ease of accurate insertion and improved cement pressurisation resulting from its unique design features should ensure excellent medium to long-term outcome. The multi-centre clinical trial will continue to monitor progress.


SJ Mellor A Khaleel A Edwards P Gibb DS Elliott RD Pool

We have reviewed the intermediate term results of 56 out of 61 consecutive Wagner revision stems implanted without bone graft. After a mean of 5 years (range 4 to 7 years) 49 out of 56 hips were graded as excellent or good based on the Harris Hip Score. The clinical result was not related to the degree of femoral bone defect prior to revision.

49 Out of 56 hips were seen to subside, but this did not affect the hip score at final review. The mean subsidence was 4.8mm (range 0 – 19mm).Only one stem showed continued subsidence after 12 months post-operatively, and this stem achieved a stable position by 24 months. All osteotomies of the femur united with reconstitution of the femoral bone stock. There was a low incidence of complications; one stem showed catastrophic subsidence within 48 hours of surgery, requiring re-revision to a larger Wagner stem. There was one sciatic nerve palsy. 3 hips dislocated on one occasion in the early post-operative period, but were stable at latest follow-up.

In conclusion, the Wagner stem can bypass major proximal femoral bony defects and achieve initial axial and rotational stability in intact diaphyseal bone. Subsequent stem subsidence does not affect clinical outcome, and proximal femoral bony reconstitution is achieved without the need for bone grafting.


N Savva J C Campion W H Goode A C Ross

Aims: To assess the failure rate at 5 years of the Elite Plus (DePuy) femoral stem and identify reasons for early failure. Particular attention was paid to the quality of the cement mantle.

Methods: A cohort of the first 241 primary THR performed in 234 patients were identified. Each patient completed the Oxford Hip Score (OHS), and had AP and lateral radiographs. The cement mantle was graded by Mulroy’s modification of Barrack’s system using all AP and lateral radiographs.

Results: At follow up 39 patients (42 hips) had died, 14 were lost to follow up and 35 (36 hips) too unwell/ unwilling to take part leaving149 hips in 146 patients available for independent assessment. The mean follow up was 60.2 months (range 48.3–75.8 months). Five hips (3.4%), have been revised, 1 after traumatic dislocation, 1 for deep infection and 3 for aseptic loosening. In a further 11 (7.4%) patients there was radiological evidence of progressive femoral loosening, although only 2 of the 7 available for review were symptomatic. The median OHS was 20 (range 12–51). All those revised or radiologically loose had defective cement mantles (C2). A cement mantle less than 1 mm thick was associated with early failure (p< 0.03).

Conclusions: The revision rate at 5 years is 3.4%. Loosening is related to suboptimal cement mantles in particular mantle thickness of less than 1 mm. We have documented the invisible cohort of those who have loosened radiologically but are asymptomatic. Regular surveillance of this cohort is mandatory to allow comparison with longer-term results of other prostheses.


P J Singh R E Field

Aim: A prospective study was undertaken to define the pattern of bone remodelling using DXA following implantation of our polished, tri-tapered, collarless, cannulated cemented femoral component.

Method: Our stem was implanted in 20 primary THRs. Our subjects comprised 7 male and 13 female patients. At the time of surgery the mean age was 73 (range 65 to 131). The mean weight at surgery was 75.4kg (range 47kg to 131.8kg) with a mean BMI of 28(range 22 to 40). All patients had a pre operative diagnosis of osteoarthritis. All the hips were implanted via the anterolateral approach. Pre-operative and sequential post-operative DXA evaluations were undertaken at 3 weeks, 6 and 12 months.

Results: The mean precision error was 0.78%(range 0.8–3.4% depending on region of interest). Statistical analysis revealed a significant increase in BMD measured in zones 1,2,4,5,6 (p< 0.05). In zones 3 and 7, the increase in BMD was not significant (p> 0.05). The real percentage increase in BMD at 12 months was 43% in zone 1, 20% in zone 2, 8% in zone 3, 31% in zone 4, 12% in zone 5, 24% in zone 6 and 7% in zone 7.

Conclusion: Peri-prosthetic bone remodelling has been observed within one year following total hip replacement (THR), which has been demonstrated by an increase in BMD in all zones. The implantation of our tri-tapered cannulated cemented femoral component, thus provides favourable proximal femoral loading at 12 months. Additional studies will determine whether stabilization of this bone turnover continues in the long term.


R E Field P J Singh

Aim: Analyse the outcome of primary and revision total hip replacement using the Oxford hip score. To determine any variation in outcome when analysing for age of patient. In addition, to compare the outcome in the National Health Service compared to the Private hospital.

Method: We have used the Oxford Hip score to monitor the progress of 1441 primary and 173 revision hip replacements (THR) undertaken since the start of 1995 whose hips have been replaced, at St Helier Hospital, Carshalton and St Anthony’s Hospital, Cheam, over the last seven years. Our review programme was started in early 1999 and has generated 2286 Oxford assessments. ). A subgroup of 634 National Health Service (NHS) and 322 private patients (PP), treated by the senior author, has provided 1277 Oxford assessments.

Results: Mean pre-operative scores were 39.06 and 39.48 for primary and revision THR respectively. The mean annual scores, for primary THR, from 12 to 84 months declined to 21 points at 1 year, 21 at 2 years, 21 at 3 years, 20 at 4 years, 22 at 6 years and 21 at 7 years.

Conclusion: All postoperative reviews show a significant improvement (p≤0.0001). The 50–60 year old group scored significantly better than the over 80 year patients up to 48 months, (p< 0.01) The mean pre-operative score for the NHS patients was significantly higher than the PPs (p< 0.001). The PPs scored significantly better than the NHS group up to 36 months (p< 0.01).


B J Bolland I P Holloway D Remedios L S Freedman

Aim: To assess the mid term clinical and radiographic results of the ABG II uncemented hip arthroplasty.

Methods: All patients treated consecutively with the ABG hip (n=42) as a primary total arthroplasty were identified and contacted. The response rate was 89% (n=38). Responders were assessed by means of the Merle D’Aubigne1 (MDA) scoring system and radiographs taken. Radiographic assessment was carried out by two independent assessors who were blinded to the clinical outcomes. An overall assessment of loosening was made based on seven radiographic signs.

Results: The mean age of patients was 61 years (range: 44–73). Average MDA score at present day follow up was 17.6 (maximum 18) and did not decline with time post surgery. There was no evidence of radiographic loosening in any hips. There was one revision for a peri-prosthetic fracture sustained 10 days post op. Survivor-ship (all cases) was 100% for cup and 97.37% for stem at 7 years. There was no evidence of early cup loosening.

Discussion A recent study has shown unacceptably high rates of cup failure secondary to premature wear and osteolysis2 but this has not been evident in this series. Although this study did show cup eccentricity in 4 patients (representative of liner wear) there was no clinical nor radiographic evidence of cup loosening, osteolysis or failure.

Conclusion In the medium term we have shown excellent clinical outcomes with no evidence of early loosening of the ABG II hip prosthesis


C R McLean C White H Wynn-Jones A J Miller

In 1997 the “step-less” SL Plus (Endoprothetik, Rotkreuz, Switzerland) cementless total hip arthroplasty was introduced to our unit. During the passed 12 months, a retrospective study has been performed in order to evaluate the clinical and radiographic results of this arthroplasty. The preliminary results of the first 50 patients to have completed the clinical and radiographic follow-up have been evaluated. Of the 50 patients, 56 primary total hip arthroplasties were performed, in all cases the SL Plus stem was used. In 52 cases the cementless Doetz acetabular cup, made by the same manufacturer, was used. The other 4 acetabular components were: 2 long stemmed cementless components for developmental dysplasia, 1 standard cementless cup and 1 cemented cup, made by other manufacturers. All patients were reviewed clinically and radiographically. The mean follow-up time was 3 years, range 2 – 5 years. The mean Harris Hip Score was 90 (37 – 100). Patient satisfaction was: 98% satisfied, 2% dissatisfied (p < 0.001). Radiographic assessment demonstrated that all 52 (100%) Doetz acetabular cups osseointegrated, with 53 (95%) acetabular cups osseointegrating in total (p < 0.002). Of the SL Plus stems, 44 (79%) osseointegrated (p < 0.002). The following post-operative complications were observed: 2 dislocations, 2 superficial wound infections, 1 myocardial infarction, 1 sciatic nerve palsy and 1 deep vein thrombosis. The overall complication rate is high at 13%, but with no implant related failures. Nevertheless, the preliminary clinical and radiographic results of the SL Plus stem and Doetz acetabu-lar cup total hip arthroplasty are encouraging.


M R Acharya W M Harper G Eastwood A Bing

Background: Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of post-operative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery.

Method: 28 patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MES’s) were recorded during the operative procedure.

Results: Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. 12 out of 16 patients who had MES’s had undergone a cemented hemiarthroplasty the remainder had a sliding hip screw for an extracapsular hip fracture. 75% (9/12) of patients that had a cemented hemiarthroplasty, had the majority of MES’s after reaming and cementing. MES’s in the patients that had a sliding hip screw occurred throughout the operative procedure.

Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients.


C J Wolsley J M Murray R C McGivern D Beverland

Venous stasis is identified in Virchow’s triad as one of the risk factors leading to deep venous thrombosis (DVT). Preventing or reducing stasis during the peri- and post-operative states should minimise the risk of DVT. We have investigated the efficacy of a new device (Waveform, Amtec Medical Ltd), employing electrical calf stimulation to promote venous return in patients (n=18, mean age 67.2±7.9yrs) presenting for total hip replacement arthroplasty. The device placed over the soleus muscle, offers various levels of stimulation (70–90V) at six second intervals. Duplex ultrasound imaging was used to locate and measure venous flow in the popliteal vein. Velocity measurements were recorded at three time intervals: before (baseline) and after induction of spinal anaesthesia, and finally in response to electrical stimulation. Results showed that immediately following spinal anaesthesia there was an increase in venous flow velocity from the baseline by a factor of 2 (from 9.2cm/s to 17.2cm/s). Furthermore, each activation of the electrical stimulus caused an increase in flow velocity by on average a factor of 4.4 over pre-stimulus flow (8.6cm/s to 39.8cm/s). These data compare favourably with previous observations using the Belfast calf stimulator and demonstrate the effectiveness of electrical calf stimulation as a method of preventing venous stasis in the lower limbs during surgery.


R V Patel J Stygall J Harrington M G Harrison S Newman F S Haddad

Aims: To quantify the intraoperative cerebral microemboli load during primary total hip arthroplasty (THA) using transcranial Doppler ultrasound and to investigate whether a patent foramen ovale influences cerebral embolic load in general. The timing of the microemboli will be related to certain surgical activities to determine if a specific relationship exists.

Methods: Patients undergoing primary THA, with no history of stroke, TIA, ongoing CNS disease or alcoholism were included. All operations were carried out under a standardised general anaesthetic and performed by two consultant orthopaedic surgeons. Microemboli load was recorded, using transcranial Doppler ultrasound (TCD), onto VHS tape for subsequent playback and analysis. Patent foramen ovale detection was performed using bolus intravenous injection of agitated saline followed by valsalva manoeuvre technique and TCD. Timing of specific surgical steps was recorded for each operation and emboli load calculated for that period.

Results: 25 THA patients were studied (18 females, 7 males) 16 right and 9 left THA’s were performed. Cerebral microembolisation occurred in 10 patients (40%). Mean microembolic load was 5.52 per patient (range = 0–83). PFO was detected in 8 patients (32%). 37.5% of PFO positive patients displayed cerebral microemboli. However, 41.1% of PFO negative patients also displayed microemboli intraoperatively.

Insertion of the femoral component was associated with generating a larger microembolic load than the other phases of the operation.

Conclusion: Intraoperative cerebral microembolisation occurs in a significant proportion of patients during total hip arthroplasty. The presence of a patent foramen ovale does not appear to influence the incidence microemboli intraoperatively. Specific surgical activities are associated with generating greater embolic loads. These questions will be comprehensively assessed in the larger study currently underway..


K Ho K Giannakas D H Sochart J G Andrews A M Khan

Bladder catheterisation following joint arthroplasty is not uncommon but delaying catheterisation in the postoperative period until the patient is symptomatic can produce an atonic bladder due to the distension. This can prolong catheterisation and increase the risk of urinary tract infection. We prospectively determined if we could identify patients needing pre-operative catheterisation.

Method: 150 consecutive patients undergoing knee and hip arthroplasty were recruited. Pre-operative symptoms of frequency, nocturia, retention, incontinence and previous bladder or prostate surgery along with prior history of catheterisation were recorded. The type of anaesthesia and post-operative analgesia was noted. Details of catheterisation included duration, antibiotic administration, and reason for catheterisation and incidence of urinary tract infection.

Results: Patients mean age was 67.7 years. 47 patients required catheterisation of which 56.6% were female. The mean age of patients catheterised was 70.6 years in comparison to 66.3 years (Mann-Whitney P< 0.01). The frequency of catheterisation was unrelated to the surgical procedure.

Nocturia was significantly more common in-patients requiring catheterisation (Kruskal Wallis P=0.04) and its combination with pre-operative symptoms of frequency, retention or incontinence increased the significance further to P=0.001.

Patient age of greater then 66 years had a 76.6% predictive value for the subsequent need of catheterisation. This further increased to 91.5% when combined with a previous history of either catheterisation or nocturia. The type of anaesthesia or the post-operative analgesia did not significantly influence catheterisation frequency.

Conclusion: Patients aged greater then 66 years undergoing joint arthroplasty with previous history of catheterisation or nocturia may benefit from pre-operative bladder catheterisation. Peri-operative catheterisation of high-risk patients in theatre reduces patient discomfort caused by the observation period and avoids bladder atonia consequent of the distention, which may subsequently prolong catheterisation.


M R Acharya S C Williams J N Davison W M Harper

Background: Many patients with hip fractures have multiple medical problems that require attention. Pre-operative specialist interventions can often cause unnecessary delay. The aims of this study were to quantify the proportion of hip fracture patients that have an echocardiogram, to find out who and why the investigation was requested and to quantify the delay and its consequences.

Methods: Retrospective review of all patients over a 9 month period that were admitted to hospital with a diagnosed hip fracture and had an echocardiogram as part of their pre-operative assessment.

Results: 31 patients fulfilled the inclusion criteria. 23 sets of notes were reviewed. The majority of echocardiograms 17/23 were requested by orthopaedic SHOs without anaesthetic request. The reason for requesting the echocardiogram was the finding of a murmur on clinical examination.

The average delay from admission to having an operation for patients who had an echocardiogram was 6.7 days (mode 5days). Mean delay to patients having the echocardiogram was 3.2 days (mode 2 days) and the delay to theatre after the echocardiogram was 3.5 days (mode 1 day). 15/23 patients had adverse effects. All but one patient had a routine uncomplicated anaesthetic. Conclusion: 6–7% of hip fractures have an echocardiogram. Junior members of the orthopaedic team request the majority of echocardiograms without anaesthetic input. Requesting an echocardiogram causes a delay from admission to theatre of approximately 1 week. Delay is associated with adverse effects, which may have fatal consequences for the patient.


M R Acharya G Eastwood A Bing W M Harper

Background: The majority of extracapsular proximal femoral fractures are treated with a sliding hip screw. The barrel of the plate can slide over the shaft of the screw in two modes; keyed (locked) or unkeyed (unlocked). The purpose of the study was to determine whether there is a difference in outcome following fixation using a sliding hip screw in the locked and unlocked modes.

Methods: A prospective randomised controlled trial of patients requiring a sliding hip screw for a proximal femoral fracture. Patients were randomised to receive a sliding hip screw either in the locked or unlocked mode. 20 patients were randomised to each group. Patients were assessed clinically and radiologically post-operatively and at three months following discharge from hospital. Screw slide and fixation failure were used as primary outcomes. A Visual analogue scoring system (VAS) was used to assess pain.

Results: A total of 40 patients were recruited in this study. The mean age of patients in the locked group was 74.05 years (range 55–90) and 78.0 years (range 65–97) in the unlocked group. There was one case of fixation failure in the locked group compared to two in the unlocked group. The mean screw slide was 10.98mm (range 1.04–37.62) in the locked group and 12.94mm (range 1.91–20.82) in the unlocked group. The pain score according to the VAS improved over the three months. There was no significant difference in pain score between the two groups.

Conclusion: When comparing screw slide, fixation failure and pain, the results show there is no significant difference between using the sliding hip screw in the locked and unlocked mode.


A M Khan I Hutchinson P R Kay

The metabolic response of trauma may mimic infection and the reliability of serological parameters for diagnosing infection may be questionable. We prospectively assessed the changes in the acute inflammatory markers, febrile response and the immune profiles cytokine activation and collagen markers of 101 patients following primary hip arthroplasty and their association with infection.

Method: The clinical outcome of 101 patients was monitored. Serological analysis was performed pre-operatively and on the second and 8th post-operative day as well as in an out patient clinic 6 weeks following surgery. The serological markers included total white blood cell count along with T and B lymphocyte function. Levels of CD4, CD8 and CD56 were analysed for T helper, T Cytotoxic cell and Natural Killer cell activity. Inflammatory makers included plasma viscosity and CRP. Cytokine assays included IL-1, IL-6, IL-10 and TNF. Collagen markers included P1CP and P1NP as markers of Type I and Type III collagen synthesis. Serological titers of Staph. Aureus and Staph. Epidermis were performed pre-operatively and on day 8 and week 6 following surgery.

Results: Post-operative complications included 19 UTI, 11 chest infections and three URTI and six a confirmed deep vein thrombosis. Wound complications included 10 patients with wound erythema and 4 patients had pus discharge. 20 patients had elevated ASO titers and 19 patients had raised Staph. Epidermis titers.

Statistical comparison of WBC, Plasma viscosity, temperature profiles and T helper,

T cytotoxic cell and NK cell assays is not different between patients with and without systemic infection or raised titres of Staph. Aureus or Staph. Epidermis. Collagen markers were significantly higher in wound complications.

Conclusion: The acute phase responses following surgery and metabolic response to trauma obscures the changes seen in infective complications up to six weeks post-operatively. The use of serological parameters that are components of the acute phase response of surgery does not allow differentiation of infection from normal physiological changes.


D Michael P Mohandas S K Muirhead – Allwood

An observation was made in our unit that sciatic nerve injury following total hip arthroplasty seemed to be more common in women. This observation has been mentioned in the literature, but no anatomical explanation has been postulated. We aimed to confirm this and suggest an anatomical explanation.

Members of the British Hip Society were approached by means of a postal questionnaire regarding the sex incidence of sciatic nerve injury following both primary and revision hip surgery in their practice. In this cohort of surgeons, of 179 reported sciatic nerve injuries, 77% were in women (80% in primary hip replacement and 69% in revision surgery), which is statistically significant.

We suggest that the wider outlet of the female pelvis causes the path of the sciatic nerve to pass more closely to the posterior wall of the acetabulum so making it more vulnerable to surgical injury. This hypothesis has been explored by measurements taken from CT scans of the pelvis and hips. Results do confirm the closer proximity of the nerve to the hip joint in women. We therefore advise increased care when performing hip replacement in women and suggest that this be mentioned as a gender linked risk when consenting patients prior to surgery.


M T Clarke P T H Lee A Rayment R N Villar N Rushton

Aims: After Total Hip Replacement (THR), bearing surface pistoning during the gait cycle can affect wear rates. This ‘micro-separation’ has been shown clinically by video-fluoroscopy to be greater with a Metal-on-Polyethylene (MOP) bearing than a Metal-on-Metal (MOM) one. In this study, we quantified the suction forces that these bearings generate during the swing phase of the gait cycle as a result of interfacial tension from the thin fluid film present at the bearing surface. Methods: We used a servo-hydraulic universal testing machine with 250N load cell and programmed a sinusoidal waveform that could vary the loads and frequencies applied to MOP or MOM bearings submerged in 25% serum. We measured the bearing separation (±1μm) at tensile loads of 10N to 100N lasting 0.1s to 0.5s per 1Hz cycle.

Results: MOM bearings resisted tensile loads of up to 35N when applied for 0.1s to 0.5s of the simulated gait cycle. Bearing separation was measured at a maximum of 198 microns. Above 50N, the MOM bearing was unable to prevent separation occurring even when applied for only 0.1s of the simulated gait cycle (p< 0.001). The MOP bearing could not resist separation at any of the applied tensile loads (p< 0.0001).

Conclusions: The suction-fit of the MOM bearing used in this study is insufficient to prevent bearing separation due to gravity (110N). However, it may reduce the total bearing separation distance by delaying the time point at which separation occurs during the finite period of the swing phase (< 0.5s) during the gait cycle. This effect is crucially dependent upon the bearing clearance, bearing diameter, weight of the leg, speed of walking and soft tissue tension around the hip. This ultimately relies upon prosthetic design, patient selection and surgical technique.


P T H Lee M T Clarke A Arora R N Villar

Aims: Metal-on-Metal (MOM) bearings for Total Hip Arthroplasty (THA) are known to elevate the serum concentrations of metal ions, raising concern about possible long-term side-effects. One potential modifier of ion release is the bearing diameter used. Resurfacing MOM bearings have a large surface area available for corrosion, but may benefit from improved lubrication and reduced production of corrodible wear debris. The net effect of these two variables on metal ion release is unknown.

Methods: In this study, we measured the serum cobalt and chromium levels from 22 large diameter MOM resurfacing arthroplasties (Cormet2000 & Birmingham Hip Resurfacing) and compared them to 22 THA (Ultima) with a bearing diameter of 28 mm. Patients were prospectively matched for activity level, weight and date after surgery. All were at least 6 months after surgery.

Results: At a median of 16 months (range 7 to 56) after resurfacing arthroplasty, we found the median serum cobalt and chromium levels to be 38 nmol/l (14 to 44) and 53 nmol/l (23 to 165) respectively. Both these figures were significantly greater than the levels after 28 mm MOM THA, which were 22 nmol/l (15 to 87, p=0.021) and 19 nmol/l (2 to 58, p< 0.001) for cobalt and chromium respectively.

Conclusions: As the upper limit of normal in patients without implants is typically 5 nmol/l, both groups had significantly raised metal ion levels, albeit at a relatively short median follow-up period. Large diameter MOM bearings resulted in a greater systemic release of cobalt and chromium ions than did small diameter bearings. This may be of relevance for potential long-term side-effects. It is not known to what extent this difference is due to corrosion of the component surfaces or of the wear particles produced.


B Mohan E J Verzin D Beverland J R Nixon

Dislocation is a recognised complication following the posterior approach in total hip arthroplasty. The senior surgeons involved in this study had routinely repaired the short external rotators and capsule by directly suturing ‘tendon to tendon’ and ‘capsule to capsule’ using No 1 Vicryl®. Over a two-year period this had no impact on the incidence of dislocation as compared to “no soft tissue repair” that had been done historically. In order to assess the effectiveness of ‘soft tissue to soft tissue’ repair fifteen patients were assessed using radiographic markers inserted during surgery. In 14 of the 15 patients the repair was found to have failed by the time of the post-operative x-ray which was taken on day 3 to 5. Since then we have changed the repair so that the capsule and rotators are reattached to bone with No 5 Ethibond® using drill holes in the trochanteric region. This modification was evaluated using the same method. Of 15 patients in the second type of repair only 2 showed a failure of repair on the post operative X-ray. This appears to be a more secure form of repair. The impact of this on the incidence of dislocation is being evaluated.


J Millington J Ayers S Muirhead-Allwood

Intra-operative infiltration of local anaesthetic into peri-operative tissue has become part of the protocol of many units worldwide. It is claimed that this reduces post operative pain and improves the speed of mobilisation thereby improving the comfort of the patient and decreasing the hospital stay.

In order to test the validity of this concept we conducted a prospective randomised controlled clinical trial of 100 patients undergoing primary total hip arthroplasty or hip resurfacing. All procedures were performed by one surgeon (Miss Muirhead-Allwood) using a posterior-lateral approach. Patients were randomised to receive 30ml of 0.5% Marcaine injected under direct vision at the time of closure or no injection (placebo).

Post-operatively patients in both groups received a standardised regime of intravenous infusion of diclofenac for 48 hours and ‘rescue’ intramuscular injections of morphine on demand.

Patients’ pain levels post-operatively were independently recorded using both a verbal rating score (VRS) and a visual analogue scale (VAS) at regular intervals for the first five post-operative days. Periodicity of requests for opiate analgesia was documented. Time taken to reach mobility ‘goals’ were also documented as was time taken to discharge and patient satisfaction with the whole process.

Our results show no significant difference in the two groups previously defined and we suggest that routine use of intracapsular local anaesthetic is not indicated in primary hip replacements and surface replacements provided an adequate post-operative pain regime is already in use.


K J Daly M E Lovell S Hutchinson J Hardicre C N McCollum

Background: Cerebral emboli may be detected by transcranial Doppler (TCD) in patients undergoing hip arthroplasty. Venous – arterial circulation shunts (v-aCS), cerebral embolism and postoperative organ dysfunction were investigated in elective hip arthroplasty.

Methods: TCD was used to identify v-aCS in (i) elective hip arthroplasty (n=45), (ii) abdominal aortic aneurysm surgery (AAA) (n=20) and (iii) transurethral resection of prostate (TURP) (n=10). A v-aCS was diagnosed when 1 or more microbubbles were detected in the middle cerebral artery by TCD following intravenous injection of a microbubble emulsion. TCD was also used to monitor for intraoperative cerebral emboli (ICE). Cognitive function was measured by a battery of computerised tests before and 5 days after surgery. Troponin T, AST, ALP, Bilirubin, Creatinine, Urea and Creatinine clearance were measured pre-operatively and 24 and 48 hours post-operatively.

Results: Cerebral embolism occurred in 26 of 45 patients during hip arthroplasty (median 4, range 1 – 368) but not during AAA or TURP surgery. Cerebral embolism only occurred in patients with a v-aCS (p< 0.001) and was strongly associated with the size of the v-aCS (rs=0.8, p< 0.001). The number of ICE had no influence on Troponin T, renal function, liver function or cognitive function.

Conclusion: Cerebral embolism is common in patients with a v-aCS during hip arthroplasty. There was no evidence of cerebral or multi-organ damage due to paradoxical embolism.


V R M Reddy A Dorairajan S J Krikler

Aims: To study clinical and radiological outcome of acetabular revision in THR with porous, hydroxyapatite-coated cups.

Methods: 50 acetabular revisions (48 patients) operated by single surgeon were reviewed. Uncemented, hydroxyapatite coated cup (Mallory/Head, Biomet) was used. Preoperative acetabular bone loss graded by Paprosky’s classification (grade 1: 12, grade 2a: 26, grade 2b: 8, 2c: 2, grade 3a: 2). Acetabulum alone was revised in 22 hips. Duration of follow up: 35 months (24–52). Clinical outcome assessment was done using Merle d’Aubigne and Postel score & QALY index questionnaire. Radiological assessment by standard X-rays taken at the latest review date. No case was lost to follow up.

Results: Merle d’Aubigne & Postel scores improved from 2.1, 2.7 and 2.4 (pre-operative) to 5.0, 4.3 and 4.5 (post-operative) respectively with significant improvement in QALYs scores. Radiological assessment showed no mechanical failures. Good trabecular formation between HA-coating and the bone seen in the majority. Non-progressive radiolucency < 1mm in 6 cases, superior migration > 2 mm in 3 cups where bone graft was used, and < 2mm migration in 9 cups was noted. 2 cases had rerevision for recurrent dislocation.

Conclusions: Hydroxyapatite coating on the implant may enhance bony ongrowth at bone-implant interface giving additional stability. Good midterm results obtained in our study using hydroxyapatite-coated components favour the use of this type of cup in acetabular revisions for moderate bone loss, but a long-term follow up is essential.


S Cutts A Datta K Ayoub H Rhaman T Lawrence

In recent years there has been a resurgence of interest in the concept of hip resurfacing. Since 1996, we have treated 60 patients (65 hips) with the Corin Hip Resurfacing.

Of the 65 primary procedures, 13 have now required revision. 1 case was complicated by early deep infection and 12 (17%) for mechanical failure. 5 of these patients were male and 8 female. Mean time to failure was 11 months (range 48 hours to 53 months). 8 out of the 12 mechanical failures required revision within 6 months of the primary procedure. Mean age of the revision patients was 57 years (range 22 – 71 years).

The most common failure modality (6 cases) was fractured neck of femur. 4 out of 6 of these cases occurred in women over 60 years of age. All of these fractures occurred without a specific history of trauma. Since only 12 patients were women over 60, 1 in 3 women over 60 years of age in our series were complicated by fractured neck of femur.

In 4 cases, the indication for revision was acetabular loosening. One patient had ongoing pain of unknown aetiology and one developed progressive avascular necorsis of the femoral head with subsequent collapse.

Of the 12 cases requiring revision for mechanical failure, two cases required revision of the femoral component only and this was performed using the stemmed modular CTI prosthesis produced by Corin for this purpose. Three cases required revision of the socket only and the others were revised to total joint replacement. The one case of early deep infection was treated by two stage revision. There were no dislocations in our series and there was no evidence of metallosis.

Not for the first time in the history of orthopaedics, a DGH has been unable to repeat the excellent results reported by a specialist centre with a new technique. However, analysis of the above data has led us to believe that our results may be much improved by careful patient selection. It is also apparent that formal revision strategies need to be developed for hips resurfacing.


A P Molloy R Banerjee R S Scott C E Bruce

Low energy hip dislocation in children is an uncommon injury (0.335% of injuries ) which represents a true orthopaedic emergency.

Case 1 ; A 6 year old girl attended hospital non-weightbearing with right thigh pain after slipping whilst attempting to kick a football. The leg was shortened and internally rotated with no neurovascular deficit. Radiographs revealed a posterior dislocation of the right hip. A closed reduction was undertaken in theatre within four hours. She was immobilised in a hip spica for 6 weeks. At six month review she was pain free and back to full activities. Radiographs showed no abnormality.

Case 2 ; A 5 year old boy attended A+E non-weight-bearing with right lower leg and knee pain having done the splits playing football. Examination of knee and lower leg showed pain but nil else. Radiographs of the knee were normal. He was discharged with a diagnosis of possible ACL rupture. He re-attended 2 days later with immobility and increasing pain. Examination showed a 2cm leg length discrepancy. Radiographs revealed a posterior hip dislocation. He underwent a closed reduction in theatre. He progressed well under regular review until 5 months post-injury. He had increasing pain and decreasing range of movement. Radiographs showed trans-epiphyseal avascular necrosis. He therefore underwent a varus de-rotation osteotomy. One year on he has returned to full activities. He has a mild decreased range of movement. Radiographs show a flattened epiphysis and a united osteotomy.

Hip dislocation requires less trauma in children due to ligamentous laxity and a soft pliable acetabulum. Overall 64% are low energy and 80% are posterior dislocations. Complications include AVN, arthritis, nerve palsy and recurrent dislocation. AVN is 20 times more common if reduction is after 6 hours.

This report highlights the importance of thorough examination, accurate diagnosis and early treatment of paediatric hip dislocation.


K J Daly S McInnes S Hutchinson M E Lovell C N McCollum

Background: Confusion occurs in up to 60% of patients following neck of femur fracture, delaying hospital discharge. We investigated venous – arterial circulation shunts (v-aCS) and the influence of cerebral embolism before and during surgery on subsequent cognitive function.

Methods: Cerebral emboli were counted in 16 patients with an inter-trochanteric or Garden III/IV fracture by transcranial Doppler (TCD) monitoring over 1 hour pre-operatively and intra-operatively. A v-aCS was diagnosed when 1 or more microbubbles were detected in the middle cerebral artery by TCD following intravenous injection of a microbubble emulsion. Cognitive function was investigated by a battery of computerised tests preoperatively and at 5 days postoperatively.

Results: Cerebral emboli were detected in 9 of 16 patients preoperatively (median 2, range 1–23) and in 10 patients during surgery (median 10, range 4 – 617). A v-aCS was associated with preoperative emboli in 9 patients (p=0.036, Fisher’s Exact) and intraoperative emboli in 10 patients (p=0.011, Fisher’s Exact). Cognitive function deteriorated following surgery only in patients with emboli, with the median (range) overall reaction times increasing from 3220ms (1926–5868) to 7493ms (4690–15992) [p=0.008]. The overall accuracy deteriorated from 2.57 to 2.37 (NS).

Conclusion: Cerebral embolism is common following femoral neck fracture in patients with a v-aCS and was associated with a deterioration in cognitive function.


A C Maury W S Roy J Lewis C Carpenter R Brown J Davies

Introduction: Hip fractures are usually evident on plain radiographs. Some are not obvious and require further investigation. A review of the pertinent literature reveals different treatment algorithms for such patients but MRI is recommended as the investigation of choice. Little is stated about the clinical findings in patients with an occult fracture of the hip.

Aims: To investigate any correlation between clinical findings and the presence of fracture on MRI in occult fracture of the hip and use this as a means of speeding the diagnosis of such patients.

Methods: We report a prospective, multi-centre trial. 22 patients admitted with a suspected occult fracture of the hip were assessed clinically for evidence of resting deformity, ecchymosis, point tenderness, hip pain on heel percussion or pistoning and ability to straight leg raise (SLR). The same features were assessed in the contralateral limb. All patients were alert and orientated as to comply with examination. Plain radiograph and MRI findings of both hips were recorded in each case.

Results: Of 22 patients, 17 were unable to perform SLR on the affected side, 5 were able to do so. Of the 18 patients, all had a fracture of either the acetabulum or proximal femur on MRI. Of the group of 5, 2 had normal MRI scans, 1 had a pubic ramus fracture, 1 had bone marrow oedema secondary to osteoarthritis and 1 patient had a six week old valgus impaction fracture. All patients could SLR and had normal MRI of the contralateral hip.

Conclusions: Under the conditions of this study straight leg raise test is 95% sensitive and 95% specific for predicting the presence of fracture in either the acetabulum or proximal femur. We recommend that this simple test can be used to help speed up the diagnosis of and further management of occult fractures of the hip


S Cutts A Datta K Ayoub H Rhaman T Lawrence

One of the most commonly cited advantages of hip resurfacing is the technical ease of revision surgery on the femoral side of the joint. It is therefore reasonable to suggest that such surgery ought to be associated with reduced operative times, reduced blood loss and more rapid mobilisation than conventional hip revision. However, there is little objective evidence in the literature to support this view.

In our own unit, 6 consultants have now revised 15 hip resurfacings (13 Corins and 2 MMT Birmingham Hip Resurfacings). A retrospective study of the hospital records was performed to compare three well recorded parameters 1) On table operative times 2) Post Operative blood transfusion requirement 3) In patient length of stay.

Average on table time was 195 minutes for conventional THR revision and 120 minutes for revision of resurfacing i.e. a 1 third reduction in theatre time for resurfacing with attendant advantages in costs and risks. However, post operative length of stay was little different between the two groups.

Average blood transfusion requirement was 4.6 units for conventional THR revision (n=190) and 0.9 units for revision of resurfacing. However, these crude figures do not take into account the difference in physiological state between the two groups of patients. A more complex comparison of age matched revision THR patients shows and average transfusion requirement of 1.8 to 2.2 units for revision of THR versus 0.9 units for revision resurfacing.

In conclusion, there is now objective evidence of the advantages of resurfacing in the revision situation but that these advantages are more modest than those anticipated.


F Adeyemo M Lovell

We report on two patient groups questioned about travelling for surgery outside of their base hospital to cut waiting times.

Firstly 30 patients travelled approximately 50–60 miles to have hip replacements. After surgery we asked them their thoughts regarding an unknown surgeon, self and relatives expenses and any inconvenience. Five (17%) were anxious about taking part and 3 (10%) incurred extra expense (transport was provided). Eight (27%) stated that relatives incurred extra expense and 5 (17%) stated relatives had difficulty visiting. All were not concerned about having their operation carried outside of the local area by a new surgeon. Asking the question as: how keen were you on having the surgical team you first met at your local hospital to do your joint replacement? responses were: 1 not keen (4%), 25 not bothered (83%) and 4 very keen (13%). Three (10%) stated that relatives had to take time off work to visit them. All patients thought that the idea of reducing waiting lists by doing the operation in a private hospital was good. We felt their response was perhaps too positive and decided to look at a local preoperative group.

Our preoperative group involved thirty patients. Four (13%) were anxious about taking part in a waiting list initiative and 10 (33%) were worried about extra expense. Seven (23%) were worried about their relatives extra expense and 6 (20%) would be discouraged if their relatives had difficulty visiting. Fourteen (47%) raised concern about having their operation carried outside of the local area by a new surgeon. Fourteen were keen to have treatment from their original surgeon. None felt that relatives having to take time off work to visit them was a problem. All patients thought that reducing waiting lists by doing the operation early in another hospital was a good idea.

We conclude that patients are accepting of waiting list initiatives if their preoperative wait can be decreased.


M Moran Y L Soon P Walmsley I J Brenkel

Introduction: There is little published on the outcome of orthopaedic surgery performed by surgeons in training. The individual results of orthopaedic units and consultants are coming under increasing scrutiny. There may be concerns that trainee performed THR will negatively impact on these figures. This study compares the outcome of THR’s performed by consultants and supervised trainees.

Methods: Data was prospectively collected on 139 THR’s carried out by supervised specialist registrars (years 1 to 4) and 397 THR’s carried out by consultants. The Harris Hip Score (HHS) was used as the primary outcome measure and scores were taken at 7days pre-operatively, 6 and 18 months post-operatively. In addition data on co-morbidity, blood loss, transfusion requirements, re-operation, dislocation and death were recorded. Radiographs of 110 trainee and 110 consultant performed THR’s were compared at 6 months. Acetabular anteversion and abduction and femoral orientation were assessed on lateral and AP films. Cementation was judged using methods described by Hodgkinson and Barrack.

Results: Blood loss, transfusion requirement, dislocation, revision, deep infection and the HHS at 6 and 18 months showed no statistically significant difference between trainee and consultant (all p< 0.05). Component orientation and cementation quality again showed no significant difference (p< 0.05).

Discussion: This paper reveals no difference in the short term results of THR performed by consultants and supervised trainees. Our results show that quality can be maintained whilst training juniors to operate.


A R Norrish J Rao R N Villar

Resurfacing arthroplasty of the hip is currently enjoying a resurgence in popularity. There are many reasons why resurfacing may be indicated, but one is that the absence of proximal femoral reaming at surgery may reduce the occurrence of heterotopic ossification (HO) after surgery. The objective of this study was to compare the prevalence of postoperative HO for patients undergoing two different types of hip surgery, resurfacing arthroplasty or total hip replacement. Data were gathered from 43 consecutive patients undergoing metal on metal hip resurfacing (MoM-R) and 37 consecutive patients undergoing metal on metal total hip replacement (MoM-THR) with a minimum of six months’ follow up. The Brooker classification was used to grade HO from postoperative radiographs1. We found that, when undergoing MoM-R, women had a lower chance of developing HO than men (p=0.04). In addition, women who received a MoM-R had a reduced incidence of developing HO than women who received a MoM-THR (p=0.04). There were no differences in the incidence of postoperative HO between men undergoing either MoM-R or MoM-THR. It can be concluded from this study that resurfacing does reduce the incidence of HO in women and that care must be taken when selecting women to undergo total hip replacement in preference to hip resurfacing. This study has highlighted the need to inform patients of HO as a common complication when consenting for hip arthroplasty, and has established an 18% rate of postoperative HO for hip resurfacing arthroplasty.


M Moran P Walmsley I J Brenkel

Introduction: There is little evidence describing the influence of Body Mass Index (BMI) on the outcome of Total Hip Replacement (THR). There are concerns that an increasing BMI may increase complication rates such as superficial and deep infection, blood loss, operation time and aseptic loosening. There is evidence that obese patients receive good symptomatic relief from THR and so it is important that the advisability of surgery is made on good evidence.

Methods: 800 patients undergoing primary Charnley total hip replacement were followed prospectively for a minimum of 18 months. The Harris Hip Score (HHS) and SF-36 were recorded pre-operatively and at 6 and 18 months post-operatively. Other significant events were noted, namely death, dislocation, re-operation, superficial and deep infection and blood loss. Stepwise multiple regression analysis was performed to identify whether BMI was an independently significant predictor of the outcome of THR.

Results: The mean age of patients was 68 years, with 61% females. At 18 months 31 patients (39 hips) had died. There were 15 re-operations, 13 dislocations and 7 deep infections.

No relationship was seen between the BMI of an individual and the development of post-operative complications. The HHS was seen to increase dramatically postoperatively in all patients (mean 43 points at 18 months). BMI did predict for a lower HHS at 6 and 18 months and a lower physical functioning score on the SF-36.

Discussion: THR produces a significant improvement in symptoms in patients, irrespective of BMI. An increasing BMI does not result in an increase in the early complication rate following THR. There is a reduction in the HHS and physical function component of SF-36 with increasing BMI, although this effect is small. On the basis of this study we do not think that THR should be withheld solely on the grounds of BMI.


A K Gambhir N Pradham E Broxholme M L Porter

The use of rim mesh to augment acetabular defects at the time of revision hip surgery is a valuable technique. Where acetabular containment is compromised by segmental rim defects, it can be achieved by using a flexible wire mesh fixed to the wall of the ilium by multiple screws. Morsilised bone graft is then impacted onto the acetabular bed and wire mesh thus creating a new hemi-spherical acetabular bed for cementation of a new socket.

Standard AP and lateral radiographs are acceptable methods for assessing conventional socket revisions. However if a rim mesh has been used the mesh itself will obscure the socket and both columns of the acetabulum making interpretation difficult. We have modified the Judet views classically used in acetabular fracture surgery to allow better imaging of the socket. The views taken are dependant upon rim mesh position at surgery. Technique: Positioning for posterior acetabular rim mesh

From the supine position the patient is rotated 45° so that the side under examination is raised. Radiolucent pads are used to support the pelvis and leg. The hips and knees should not be flexed.

Positioning for anterior acetabular rim mesh

From the supine position the patient is rotated 45° so the non affected side is raised. Using radiolucent pads the pelvis is supported. The femur should not be flexed and externally rotated as they would be for an oblique hip

The film is centred approximately 2cm below the ASIS of the hip being examined.

These views of the hip allow complete imaging of the socket and the reconstructive construct. Radiographic evaluation of the bone graft and bone cement-graft interface can be reliably made.

We would recommend these views for the radiographic follow up of socket revisions involving the rim mesh technique.


N H Shah A M M A Mohsen K P Sherman R Phillips W J Viant

Hull Medical Engineering (HULMEC) group was established in 1992 as a collaboration of orthopaedic surgeons and various research groups from the University of Hull to promote multidisciplinary research especially the application of computers to aid in surgery. With the joint effort of researchers and surgeons CAOSS was developed.

The key aim of the CAOSS has been to use intra-operative surgical planning using fluoroscopic based images, hence this system aids in performing those procedure which requires fluoroscopy namely dynamic hip screw guide wire insertion, distal locking of the screw and placement of cannulated hip screw. The major steps of CAOSS are the precision calibration of the fluoroscopic images, use of these images for accurate intra operative surgical planning, innovative planning algorithms, and a safe, rapid and accurate approach to trajectory execution. CAOSS has been used on the plastic bones in the laboratory setting and was found to be accurate. Presently CAOSS has been used in an ethically approved clinical trial for guide wire insertion for the DHS placement.

Perceived Advantages of CAOSS

Safe

Passive system

Non-invasive

Surgeon maintains decision making

Decreasing radiation exposure

Reducing complexity of the procedure

Reducing technical failures

Reducing operating time

Improving accuracy of implant placement

Reducing bone damage (by reducing repeated guide wire insertion)

Improving Patient outcome

Cost Effective

Easy to use


N Pradhan A K Gambhir D Leonard M L Porter

A secure bone/cement interface at the bone cement junction is an important requirement for the long-term success in the cemented hip arthroplasty. Cementing techniques have evolved and now involve pressurisation of the acetabulum and femur. It can be difficult to get a complete rim seal and hence adequate pressurisation due to the unique anatomy of the acetabulum and the contyloid notch.

Several acetabular pressurisers are commercially available.

We have developed an instrument for controlled and reproducible cement pressurisation in the acetabulum before socket insertion. It is a T-bar incorporating a central plunger, which protrudes from an outer sleeve when force is applied. The protrusion of the central plunger and hence the amount of force applied can be limited by a stop-sleeve.

A laboratory saw bone model was designed to assess this system and compare it with two existing pressurisers. A polypropylene model of the acetabulum was used. Included in the model were two 1.3mm diameter capillary outlets, one at its pole and one at a point close to its rim opposite the cotyloid notch. Water was free to flow through the capillaries at a pressure of 13.5” WG to represent blood flow. 5 test per pressuriser were performed.

CMW 1 Gentamicin bone cement was mixed as per manufacturers instruction in a Vacuum Mix system. The cement was then pressurised using one of three systems; the Depuy T handle pressuriser, the Exeter pressuriser and our new instrument.

The cement mantle produced with the Depuy T-handle and the Exeter pressuriser was thicker at the pole than the rim and the cement intrusion was not consistent nor reproducible. The new pressurizer produced a cement mantle equal at the pole and the rim to within 1mm. A reproducible cement mantle compatible to the shape of the socket and with cement intrusion of 5mm (+/− 1mm) could be achieved. We recommend the use of this pressuriser.


NH Shah Mohsen AMMA KP Sherman R Phillips WJ Viant

Aims: Dynamic hip screw (DHS) is a common implant used for extracapsular fracture neck of femur. Accurate placement of the guide wires for the DHS insertion is the most important surgical step. In order to improve precision and accuracy of the guide wire placement, Computer Assisted Orthopaedic Surgery System (CAOSS) was used , which was developed at the University of Hull.

Methods: CAOSS helps in surgical planning and aid surgeons for accurate guide wire placement into femoral neck. After fracture reduction, intra-operative computer based surgical planning was performed using one fluoroscopic image in two planes each. A trajectory obtained thus helped surgeon to place a guide wire along with the required course under the computer guidance.

Results: CAOSS system was used on 11 patients for guide wire placement. Intra-operative fluoroscopic images of all the patients showed accurate position of the guide wire both in AP and lateral planes. In theory only 4 fluoroscopic images are required during this surgical procedure in total. But in practice, more than 4 were required depending upon the experience of the radiographer. None of the patient had any intra-operative complication. Conclusions: The computer aided surgery was found to be safe, accurate and reliable for guide wire placement for dynamic hip screw insertion.


H Nagesh A Bhargava C Brooks

Aims: Operative treatment of trochanteric fractures in patients with below knee amputation on the same limb is a rare and challenging problem. This is difficult not only because of the absence of foot but also due to coexisting medical problems. The aim of this study was to analyse the problems involved in the treatment of this rare problem.

Methods: We reviewed 13 such patients being treated at East kent Hospital Trust over 7 years between Nov 1994 and Dec 2001 constituting less than .026% of total fracture neck of femur patients. All patients were treated by DHS fixation. Six of these had Reverse boot traction applied during surgery and seven of these had upper tibial pin traction.

Results: We observed that boot traction is easy and quick method with less complications. Also these patients rehabilitated better than pin traction group. They started using their prosthesis in 3 days as compared to 7 days in pin traction group. Patients in whom Reverse boot technique was used were discharged home earlier (in 14 days as compared to 21 days) than patients who had pin traction applied during surgery.

Results: Although this study included a very small number of patients but it is a largest of its type. Based on our results we recommend that reverse boot traction should be used in all such patients.


A Ebied V Raut P Siney B M Wroblewski

Hip prostheses that do not reproduce the patients’ preoperative femoral offset have been correlated with increased wear rate, instability, abductor weakness and reduced range of motion. We have reviewed the results of 54 primary low friction arthroplasties with low offset stem commonly called “¾ neck Charnley” in 49 patients (47 females and 2 males). There has been no publication in literature on the results of this stem. Mean age was 68 years (range 30 to 83). The operations were performed by one of us, (VR) as an orthopaedic trainee, with a mean follow up of 8.7 ± 2 years. The preoperative diagnosis was 40 OA, 8 protrusio, 2 DDH, 2 post-traumatic, 1 SUFE and 1 RA. The preoperative offset was 41.9 ± 7.1 mm (mean ± STD), weight 65 ± 8.4 kg, height 156.4 ± 8 cm.

At their latest review 3 cases had been revised for infection or recurrent instability with a survivorship of 93.5% using Kaplan Meyer’s analysis. None of the femoral or acetabular components were loose or at risk of loosening. 16 cups showed demarcation in 1 zone of ≤ 1mm, and 2 cups had a 2 mm demarcation in 2 zones that was not progressive. 7 stems had ≤ 1mm demarcation in 1 zone, and 5 stems at 2 zones. Condensation at the tip of the stem was noted in 2 hips. The linear wear rate was 0.2 ± 0.08mm/year. Using Pearson’s correlation coefficient with P< 0.05, no statistically significant correlation was found between the preoperative offset and the linear wear rate.

We believe that the surgeon should try to reproduce the patient’s femoral offset aiming for the best intra-operative soft tissue balance. The linear wear rate in this series is higher than previously reported in cases that survived for over 20 years from this unit. However, at this stage of analysis low offset Charnley stems produce good medium term results.


Full Access
A C Maury R Rhys J Martin J Murray

Transient osteoporosis of the hip is a rare condition of unknown aetiology affecting middle aged men with no risk factors and women in their third trimester of pregnancy. The condition invariably resolves spontaneously, however, due to its rarity and initially normal plain radiographs, the syndrome is often not appreciated early in its development, and particularly represents a diagnostic problem of differentiation from osteonecrosis.

We present a case of unilateral transient osteoporosis of the hip in a 52 year old male and a case of bilateral hip involvement in a 32 year old female in her 35th week of pregnancy. Both cases include the initial and follow-up plain radiographs, MRI and DEXA scan findings, through to symptomatic resolution.

We present a literature review of the disease and analyse the current evidence on aetiology, the problems in diagnosis and the current treatment modalities.


N Pradhan J Hodgkinson P Wood R Vadhra P Wykes

Patients undergoing total hip replacement (THR) often require further orthopaedic surgery including other primary lower limb joint replacements and revision surgery in their lifetime. We analysed the 10-year data of 552 patients who underwent primary total hip replacement between April 1991 and March 1992 at our institute. Data was available for all patients before the index operation. 77% of patients attended their 5-year review and 67% attended their 10-year review. 233 (42%) had had or subsequently had the opposite hip replaced. 30 patients (5%) had a knee replaced and 19 (3%) had both knees replaced. 4.4% underwent revision surgery.

Concluding, nearly half the total number of these patients will in due course require the opposite hip replaced. 13% will need another major joint surgery (ie revision or TKR). At £6138 for a primary THR and £8500 for revision THR, and the cost of radiographs (£60) and follow-up appointment (£60), the approximate cost implications on a conservative estimate are 13 million pounds. For a single surgeon undertaking 40 THRs in a single year the cost would be approximately £900,000. In addition, the surgeon in 10 years practice would create enough work to last him the rest of his working lifetime. These factors including cost implications and human resource requirements will have significant influence on future planning of health care trusts.


J Miles S Muirhead-Allwood

We report a surgical technique for arthroplasty of the deformed hip after poliomyelitis.

A fifty three year old man presented to our unit with a long-standing history of hip problems since contracting poliomyelitis at the age of two. Unusually, both of his hips were affected. He had been operated on twice for his right hip. This had left him with a deformed upper femur with significant shortening. The right hip was sub-luxed on presentation; this was due to a markedly dysplastic acetabulum.

The polio and subluxation meant his muscles were weak and stretched. Like other authors, we were keen to achieve a stable hip. The senior author felt that a fully constrained socket would carry the following disadvantages:

Reduced range of movement.

It would be difficult to fit a constrained socket into the small amount of pelvic bone available.

Constrained sockets are more likely to loosen.

An alternative approach, using a large diameter unconstrained metal on metal articulation, was employed; stability was achieved with the large head and the relatively small socket still preserved bone stock. The components chosen were a 52mm MMT, Birmingham acetabular resurfacing prosthetic, articulating with a 46mm chromium cobalt head. A fluted stem CAD CAM (computer aided design, computer aided manufacture) femoral prosthesis was used, as he needed to fully weight-bear from the outset, because of the weakness in his left leg.

He has a good, pain-free range of movement. This represents a novel solution for arthroplasty in hips surrounded by weakened musculature. It avoids dramatic limitation of movement whilst minimising the bone stock loss and risk of dislocation. The patient is delighted with the medium term results.


H Mehta I G Mackie

Thigh pain and periprosthetic osteolysis associated with the femoral stem, is a common complication of cementless total hip arthroplasty. Treatment of this disabling complication is difficult but usually requires revision of the femoral stem, which is a procedure not without further morbidity. We describe a solution which does not require revision and which brought about resolution of the thigh pain.

The patient was a 79 year old male who had a primary Total hip replacement (year 1998),This was revised (early 2001) to an uncemented cup (ABG type) and uncemented femoral component (Link MP stem) . He continued to experience disabling thigh pain which limited walking to only a few yards.The pain was thought to be related to concomitant paget’s disease in the Right hemipelvis and proximal femur. Rheumatology assessment and treatment with IV Pamidronate (three courses of treatment) did not produce any relief of pain and indicated a mechanical prosthesis related cause of pain. Radiology assessment was also indicating the same with osteolysis at the tip of the prosthesis.

The patient did not want a further revision procedure, but wanted relief of pain.Therfore sufgicsl intervention to treat the osteolysis with allograft ground bone introdued retrogradely via an anterior knee approach with an intercondylar pilot hole and initial supracondylar reaming. Allograft was introduced using a 5 ml syringe and impacted with a 1 cm diameter metal rod. 50 ml of ground bone was introduced and impacted forcibly with rod and hammer impaction.

The knee wound was closed in layers over 2 drains and post-op management was same as for total knee replacement, CPM and active NWB mobilization for six weeks followed by PWB, progressing to full weight bearing mobilization. Walking was free of thigh pain and walking distance was improved.


J Miles S Muirhead-Allwood

We present a case report of postoperative pain following THR, which was initially diagnosed as infection. The salutary message is that the correct diagnosis was a secondary tumour.

A fifty three year old man had a primary right total hip replacement for osteoarthritis, using an uncemented CAD CAM (computer aided design, computer aided manufacture) prosthesis with a Trilogy cup. Postoperatively he recovered uneventfully, with a normal range of movement and good function; there were no radiographic abnormalities noted at the time. Two years after operation, he developed pain in the right thigh. His doctor referred him for investigation of his back, which was normal. He was then seen by an orthopaedic surgeon who diagnosed infection, based on an X-ray that revealed a destructive lesion of the upper femur. He was referred back to the senior author, who felt that the X-ray was more suggestive of tumour than infection; further investigation, with MRI and ultrasound confirmed the presence of a tumour; isotope bone scanning revealed it to be solitary. A needle biopsy showed follicular thyroid tumour to be present; this was confirmed by immunohistochemistry. His past medical history included a history of hemithyroidectomy eight years prior to the hip replacement – this was for what was believed to be a benign thyroid nodule. CT of his chest revealed multiple lung metastases.

Review of the X-ray taken six months post-operatively suggests, in retrospect, that the destructive process had already begun. He has been treated with a total thyroidectomy and radiotherapy to the right hip with encouraging early results. He is also having chemotherapy for the pulmonary metastases. Thyroid tumours metastasise by blood and commonly occur in bone; the proximal femur is a frequent site for metastasis. It is likely that the occurrence is coincidental.


E J Verzin B Mohan N W Thompson A Ruiz M Tohill J Dennison D Beverland J R Nixon

We performed a prospective clinical study in order to assess the effectiveness of repair of the short hip rotators, divided in the course of total hip replacement by the posterior approach, by the use of radio-opaque markers.

Fifteen patients, each with a diagnosis of osteoarthritis of the hip, were selected consecutively from a single surgeon’s operating list. Uncemented Duraloc® acetabular components and custom made cemented femoral components were implanted via the posterior approach in all patients.

Following implantation, the capsule and the short rotator tendons were sutured on to tendinous soft tissue around the greater trochanter using No 1 Vicryl. One radio-opaque marker clip was attached to the short rotators and capsule and a second marker was attached to the greater trochanter.

Standard antero-posterior pelvic X-rays were taken at three to five days post-operatively, and at three months following surgery. Significant separation of the radio-opaque markers in fourteen of the fifteen patients was demonstrated on the day three to five X-ray, indicating failure of the repair.

We conclude that this soft tissue repair is unsatisfactory. It may be of value to develop a more effective repair technique, with the overall aim of reducing total hip replacement dislocation, and as such we are currently investigating a soft tissue to bone repair.


B. F. Walker R. Muller W. D. Grant

Introduction: There is no shortage of treatments for low back pain (LBP), including medication, injections, bed rest, physiotherapy, chiropractic, osteopathy, acupuncture, massage therapy, and surgery. In addition to this are a plethora of home and folk remedies. However, there is still doubt about the efficacy or effectiveness of even the most common forms of therapy1. Also, little is known about the proportion of persons who seek care for LBP, why they sought care, the type of care sought and indeed what differentiates them from those who do not seek care at all. The objective of this study was to determine the characteristics of Australian adults who seek care for LBP, including the type of care they choose and any factors associated with making those choices.

Methods: An age, gender and State stratified random sample of 2768 Australian adults was selected from the Electoral Roll. This sample were mailed a fully structured questionnaire that included a series of questions relating to care-seeking for LBP, choice of provider and types of treatment received. In addition a series of questions were asked relating to demographic characteristics, socioeconomic variables, and severity of LBP. Also asked was cigarette smoking status, anthropometric variables, perceived cause of low back pain, emotional distress, job satisfaction, physical fitness, past 5-year health status, and whether the subject feared LBP could impair their work capacity or life in the future.

Results: The survey response rate was 69.1%. The sample proved to be similar to the Australian adult population. The majority of respondents with LBP in the past 6-months did not seek care for it (55.5%). Factors that increased care seeking were higher grades of pain and disability, fear of the impact of pain on future work and life and female sex. Factors decreasing the likelihood for seeking care were identified as the cause of pain being an accident at home and also never being married. General medical practitioners and chiropractors are the most popular providers of care.

Discussion: High levels of pain and disability equating with higher levels of care-seeking would not surprise, however fear as a motivator for care-seeking has implications for clinical practice. Another important issue is the type of care selected for LBP. Using the best evidence available for the management of LBP is now seen as a responsibility for all practitioners. It would be useful to compare care-seeking with the evidence of the efficacy and effectiveness of the various therapies utilised.


A. Fagan R. Moore B. V. Roberts P. Blumbergs R. Fraser

Introduction: Although it is well recognized that the outer annulus is innervated, the relative densities of innervation of different regions of the disc have not been quantitated. We present here the first comparative analysis of the innervation of the innervation of different regions of the lumbar intervertebral disc.

Methods: A sheep model was used allowing evaluation of the whole motion segment. Four sheep spines were used. One was processed for PGP 9.5 immunoflourescence and three were processed for PGP 9.5 immunoperoxidase histochemistry. Serial sagittal sections were obtained and a count was made of the densities of innervation of different regions of the endplate and annulus. These were compared to identify which areas of the disc and endplate are most innervated.

Results: The endplate innervation is concentrated centrally adjoining the nucleus. The mean density of innervation of the central endplate was 0.44 (SEM 0.07) nerves/ mm2 while the mean density of the peripheral endplate was 0.10 (SEM 0.03) nerves/ mm2 (p= 0.0001). There was no significant difference between the overall endplate and annulus innervation densities 0.52 (SEM 0.1) v 0.37 (SEM 0.07) p=0.2. But the peri-annular connective tissue, external to the outer annulus contained the densest innervation of any region in the motion segment 1.05 (SEM 0.16).

Discussion: The lumbar intervertebral disc has a meagre innervation. This is concentrated in the peri-annular connective tissue and the central endplate. While receptor threshold is more closely related to nociceptive function than innervation density, these findings have important implications for any treatment of discogenic pain.


B. F. Walker R. Muller W. D. Grant

Introduction: Low back pain (LBP) is a common symptom in Australian adults. In any 6-month period approximately 10% of Australian adults suffer some significant disability from low back pain1. One way of assessing the impact of LBP on a population is to estimate the economic costs associated with the disorder. This method is usually known as a “Cost-of-Illness” or an “Economic Burden” study2. The economic burden of disease is often divided into direct and indirect costs and is most often calculated using the Human Capital Method2. According to this method the direct costs are represented by the dollar value of the interventions required for diagnosis, treatment and rehabilitation of the disease and the indirect costs by valuing the loss of productivity due to morbidity and mortality2,3. We estimated the economic burden of LBP in Australian adults.

Methods: Data sources used in this study were the 2001 Australian adult low back pain prevalence survey1 and a multiplicity of Commonwealth, State and Private Health instrumentalities. Using the Human Capital Method direct costs were estimated on the basis of market prices (charges) and the indirect costs by valuing the loss of productivity due to morbidity. The conservative Friction Cost Method for calculating indirect costs was also used as a comparison4. A sensitivity analysis was undertaken where unit prices and volume for a range of services were varied over a feasible range (10%) to review the consequent change in overall costs.

Results: We estimated the direct cost of low back pain in 2001 to be AUD$1.02 Billion. Approximately 71% of this amount is for treatment by chiropractors, general practitioners, massage therapists, physiotherapists and acupuncture. However, the direct costs are minor compared to the indirect costs of AUD$8.15 Billion giving a total cost of AUD$9.17 Billion. The sensitivity analysis showed very little change in results.

Discussion: The economic burden of low back pain in Australian adults represents a massive health problem. This burden is so great that it has compelling and urgent ramifications for health policy, planning and research. This study identifies that research should concentrate on the reduction of indirect costs. This is not to suggest excluding direct cost research, as it is likely that early, efficient and evidence-based management of low back pain in the first instance may lessen the indirect costs that often follow. These startling results advocate urgent Government attention to LBP as a disorder.


B J C Freeman R D Fraser C M J Cain D J Hall

Introduction: Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but to date there are no published randomized controlled trials assessing efficacy versus a placebo group.

Methods: Ethical committee approval was obtained prior to the study. Patients with chronic low back pain who failed to improve with conservative therapy were considered for the study. Inclusion criteria included the presence of one or two level symptomatic disc degeneration with posterior or posterolateral annular tears as determined by provocative CT/discography. Patients were excluded if there was > 50% loss of disc height or previous back surgery. Fifty-seven patients were randomized with a 2:1 (IDET: Placebo) ratio, 38 to the active IDET arm and 19 to the sham procedure (placebo). In all cases the IDET catheter was positioned under sedation to cover at least 70% of the annular tear defined by the CT/ discogram. An independent technician connected the catheter to the generator and either delivered electrothermal energy (active group) or did not (sham group). Both surgeon and patient were blinded to the treatment. Patients followed a standard post-procedural rehabilitation programme.

Outcome Measures: Low Back Outcome Score (LBOS), Oswestry Disability Index (ODI), SF-36 questionnaire, Zung Depression Index (ZDI) and Modified Somatic Perceptions Questionnaire (MSPQ) were measured at baseline and 6 months. Successful outcome was defined as: No neurological deficit resulting from the procedure, improvement in LBOS of > 7 points, improvements in SF-36 subsets (pain / disability, physical functioning and bodily pain)

Results: Two subjects withdrew from the study (both IDET). Baseline demographic data, employment and worker’s compensation status, sitting tolerance, initial LBOS, ODI, SF-36, ZDI and MSPQ were similar for both groups.

No neurological deficits occurred as a result of either procedure. No subject in either treatment arm showed improvement of > 7 points in LBOS or specified domains of the SF-36. Mean ODI was 41.4 at baseline and 39.7 at 6 months for the IDET group compared to 40.7 at baseline and 41.5 at six months for the Placebo group. There was no significant change in ZDI or MSPQ scores for either group.

Discussion: No subject in either treatment arm met criteria for successful outcome. Further analysis showed no significant change in outcome measures in either group at six months. This study demonstrates no significant benefit from IDET over placebo.


K. Pauza S. Howell P. Dreyfuss J. Peloza K. Dawson K. Park N. Bogduk

Introduction: Intradiscal electrothermal therapy (IDET) is a controversial, new treatment for low back pain, whose efficacy has not been tested in randomized trials. The present study was undertaken to compare the efficacy of IDET with that of a placebo treatment.

Methods: Patients were recruited by referral and by advertising in the media. Of 4,530 individuals who enquired, 1,360 were prepared to submit to randomization. Of these, 260 were found potentially eligible after clinical examination, and 64 became eligible after discography. All had discogenic low back pain lasting longer than 6 months, with no comorbidity. Thirty-seven were allocated to IDET, and 27 to sham therapy. Both groups were satisfactorily matched for demographic and clinical features. IDET was performed using a standard protocol, in which the posterior annulus of the painful disc was heated to 90°C. Sham therapy consisted of introducing a needle onto the disc and exposing the patient to the same visual and auditory environment as for a real procedure. Follow-up at 6 months was achieved in over 85% of patients. Pain and disability were assessed using a visual analog scale for pain, the SF-36, the Oswestry disability scale, and the Back Depression Inventory.

Results: Patients in both groups exhibited improvements, but improvements in pain, disability, and depression, were significantly greater in the group treated with IDET. Pain scores improved by 24 points in the IDET group compared with 11 in the sham group. Oswestry scores improved by 11 in the IDET group, but only by 4 in the sham group. More patients deteriorated when subjected to sham treatment, whereas eight patients (25%) achieved greater than 75% relief of pain following IDET. Only one patient did so after sham treatment. The number needed to treat, to achieve 75% relief of pain, was 5. No patient suffered any adverse effects.

Discussion: IDET fails to provide relief in some 50% of patients. Consequently, its efficacy is difficult to demonstrate statistically. Nevertheless, IDET provides satisfying relief in a substantial proportion of patients. Non-specific factors account for a large proportion of the apparent efficacy of IDET, but its efficacy cannot be attributed wholly to a placebo effect. The efficacy of IDET may be related critically to patient selection and the technique used. Improvements in either of these areas may improve the effect-size of IDET. Meanwhile, IDET is a low risk procedure that constitutes a legitimate option for patients with discogenic low back pain whose only alternative is fusion.


G. Bernard

Introduction: Standard approaches to the craniocervical junction (CCJ) includes the midline posterior approach and the transoral approach. Both of them are limited laterally because of the Vertebral Artery (VA). Lateral approaches in which the VA is controlled and sometimes mobilized or transposed have been developed to reach the lateral corner of the CCJ. The surgical technique and personal experience are presented.

Methods: From our experience in the VA surgical exposure, we developed since 1980 two lateral approaches directed towards the CCJ: the posterolateral and the anterolateral approach. The posterolateral approach is a lateral extension of the midline posterior approach with control of the VA above the arch of atlas and opening of the CCJ up to the VA. Minimal drilling of the arch of atlas and occipital condyle is realized. It is mostly applied on intradural tumors but also in some extradural posterolateral lesions.

The anterolateral approach is a superior extension of the lateral approach used to control the VA from the C6 to C2 levels. The field is opened between the sternomastoïd muscle and the internal jugular vein. Then the VA is exposed between C1 and C2 transverse processes and above C1. It is essentially applied on extradural and bony lesions around the CCJ.

Experience: Posterolateral approach was applied on 109 tumors, mostly meningiomas (N=78) and neurinomas (N=22) and 4 bony malformations compressing the VA or the neuraxis. Excellent results were obtained with complete tumoral resection (Simpson grade I or II for meningioma) with only one case of worsening of the neurological condition and two cases with stabilization.

Anterolateral approach was used on 139 patients with different types of tumors including neuromeningeal tumors N=36, primary bone tumors N=51, sarcoma N=16 and others types N=21, and on 3 cases of VA compression by bone malformations. Satisfying tumoral resection could be achieved in almost all cases. Sacrifice of the VA was deliberately realized in 5 patients to ensure as radical a resection as possible in case of malignant tumors or chordomas.

There was no mortality in this series. Morbidity is very limited; injury of the VA was observed in two cases in which repair of the vessel could be done successfully. Stretching of the XI nerve was the cause of pain along the trapezius muscle in 5 patients.

Conclusion: Lateral approach to the CCJ can be realized through two different axis of work: the posterolateral and the anterolateral approach. These approaches gives very nice and safe access to the lateral aspect of the CCJ. They complete the other approaches to the CCJ and may be used in association with them.


BJC Freeman RM Walters RJ Moore B Vernon-Roberts RD Fraser

Introduction: Intradiscal electrothermal therapy (IDET) is being used increasingly as a minimally-invasive treatment for chronic discogenic low back pain, with success reported in up to 70% of cases. The mechanism of action however is poorly understood. Proposed mechanisms include the contraction of collagen and the coagulation of annular nociceptors. An ovine model was used to assess the innervation of peripheral posterolateral annular lesions and the potential for IDET to denervate this region.

Methods: Posterolateral annular incisions were made in 36 lumbar discs of 18 sheep. After twelve weeks the sheep underwent IDET at one level and a sham treatment at the other level. IDET was performed using a modified intradiscal catheter (SpineCATH™, Oratec Interventions Inc., Menlo Park, CA). Temperatures were recorded in the nucleus and the posterior annulus. The spines were harvested at intervals of up to eighteen months. Histological sections of the discs were stained with haematoxylin and eosin and an antibody to the general neuronal marker PGP 9.5.

Results: The target temperature of 90°C at the catheter tip was reached in all cases. The mean maximum TPa was 63.6°C and the mean maximum TN was 67.8°C. Vascular granulation tissue consistent with a healing response was observed in the region of the posterior annulus tear of all incised discs from 12 weeks. PGP 9.5 positive nerve fibres were clearly identified in the adjacent periannular tissue, but were scarce within the outer few lamellae of the annulus. There were no fewer nerve fibres identified in those specimens that had undergone IDET. From six weeks after IDET there was evidence of thermal necrosis in the inner annulus, sparing the periphery of the disc.

Discussion: IDET delivered at 90°C in the sheep consistently heats the posterior annulus and the nucleus to a temperature associated with coagulation of nociceptors and collagen contraction. Thermal necrosis was observed within the inner annulus from six weeks after IDET. In this model IDET did not appear to produce denervation of the posterior annular lesion.


J. Brotchi S. Gill R. Kahler A. Lubansu R. Nelson P. McCombe F. Porchet

Introduction: A prospective, randomized, controlled study has been conducted to compare the clinical outcomes of patients treated with an Artificial Cervical Disc to patients who receive fusion after cervical discectomy for the treatment of primary cervical disc disease. It is hypothesized that maintenance of motion after anterior cervical discectomy will prevent the high rate of adjacent level premature degeneration. The primary purpose of the study is to prove equivalence (non inferiority) of outcome of the disc prosthesis in the short term compared with fusion.

Methods: In four centers, 60 patients with primary, single level cervical disc disease producing radiculopathy and/or myelopathy are randomized prospectively to receive anterior cervical discectomy with either fusion or artificial cervical disc placement. The patients are evaluated with pre and postoperative serial flexion-extension cervical x-rays at 6 weeks, 3, 6, 12, and 24 months. At the same intervals, the patients have pre and postoperative neck disability indexes, visual pain analogue scales, European myelopathy scores, SF-36 general health scores, and neurological status examinations assessing the patient’s reflex, motor and sensory function.

Results: Data is presented for the first 47 patients. At 6 weeks the neck disability index reduced by 36.1 for the investigational group compared to 34.8 for the fusion group. The pain score had reduced by 8.2 for the investigational group and by 9.9 for the control group. This improvement appeared to be maintained until the 12 month followup. In general there appeared to be a slightly better outcome for the investigational group. Both pain score and disability scores improved statistically significantly compared to the pre op scores (p< 0.001 all comparisons). Analysis of non inferiority of outcome for the investigational group using ANCOVA with the preoperative score as the covariate and a non inferiority margin of 5 points showed statistical significance at 6 and 12 weeks for Neck disability index. Operative time appeared slightly less (2.3 hrs) for the investigational group compared to the fusion group(2.5hrs). Blood loss also appeared higher in the fusion group (165 mls compared to 91 mls). Hospital stay was equivalent (2.8 days and 2.9 days).

Discussion: Anterior cervical discectomy and fusion has a good short term outcome though there is a high incidence of failure at adjacent levels over time. It is hypothesized that the maintenance of motion of a segment will prevent adjacent premature degeneration. It will take long term followup studies however to prove this. In the mean time, the justification to insert artificial cervical prostheses rests on being able to prove equivalence of outcome between fusion and prosthesis in the short term. This paper shows that the outcomes appear to be equivalent. Early statistical evidence is available for some of the outcome measures at early post op followup. Further statistical power will be available when the full 60 cases are available for study and this may give further weight to the hypothesis of equivalence of outcome.


A. Abou-Hamden N.R. Jones M.A. Stoodley A. Wells M.A. Smith C. Brown

Introduction: Modern imaging techniques have demonstrated that up to 28% of patients with spinal cord injury develop syringomyelia. Cyst formation and enlargement are thought to be related to abnormalities of cerebrospinal fluid hydrodynamics, however the exact mechanism and route of entry into the spinal cord remain incompletely understood. Previous work in rats has demonstrated that experimental post-traumatic syrinxes occur more reliably and are larger when the excitotoxic injury is combined with arachnoiditis produced by subarachnoid kaolin injection. A sheep model of post-traumatic syringomyelia (P.T.S.) has been characterised and studies of cerebrospinal fluid dynamics are currently being undertaken. The aim of this study was to assess the effect of focal subarachnoid space blockage on spinal fluid pressures and flow.

Methods: Arachnoiditis was induced in 5 sheep by injection of 1.5 mls of kaolin in the subarachnoid space (SAS) of upper thoracic spinal cord. The animals were left for 6–8 weeks before C.S.F. studies were undertaken. In another 5 sheep, a ligature was passed around the spinal cord to simulate an acute blockage of the subarachnoid space. Fluid-coupled monitors were used to measure blood pressure, central venous pressure and subarachnoid pressure (1cm rostral and 1 cm caudal to the arachnoiditis or ligature). Fiberoptic monitors were used to measure intracranial pressure. In the ligature group, subarachnoid pressures were also measured prior to tying the ligature to obliterate the SAS and served as baseline control pressures. The effects of Valsalva and Queckenstedt manoeuvres on SAS pressures were examined in both groups.

CSF flow was studied at 0 and 10 minutes after injection of the CSF tracer horseradish peroxidase (HRP). Vibratome sections of the spinal cord were processed using tetramethylbenzidine and sections examined under light microscopy.

Results: The mean SAS pressure rostral to the arachnoiditis was found to be greater than the mean caudal SAS pressure by 1.7 mmHg. In the ligature group, the difference was 0.9 mmHg, being higher in the caudal SAS. Queckenstedt manoeuvre exaggerated this difference to 3 mmHg in the Kaolin group and 4 mmHg in the ligature group. The effect of Valsalva was much less marked in both groups.

Perivascular spaces were enlarged in most cases of arachnoiditis and HRP was seen to stain these spaces and the central canal within 10 minutes.

Discussion: Post-traumatic syrinxes are usually juxtaposed to the injury site with 80% occurring rostral, 4% caudal and 15%in both directions. The finding of a higher subarachnoid pressure rostral to the injury site may help explain this phenomenon. We hypothesize that a reduction of compliance in subarachnoid space increases the pulse pressure and hence increases perivascular flow of C.S.F. contributing to the formation and enlargement of PTS. We are currently investigating this hypothesis by measuring subarachnoid space compliance directly in the sheep model of arachnoiditis described above.


TJ Geraghty A West N Bellamy

Study design: Retrospective, descriptive study

Objectives: To describe the characteristics and outcomes of patients with spinal canal stenosis who suffer significant spinal cord injury (SCI) due to hyperextension injury of the cervical spine. To compare their characteristics and outcomes with all patients suffering traumatic cervical SCI and with the total cohort of patients admitted to a Spinal Injuries Unit for rehabilitation.

Setting: Spinal Injuries Unit (SIU), Princess Alexandra Hospital, Brisbane.

Methods: Demographic, injury and outcome data were obtained from an existing database and by review of the medical records of 575 patients admitted to and discharged from the SIU between July 1st, 1995 and July 1st 2002. Main outcome measures were: change in American Spinal Injury Association (ASIA) scale category, change in ASIA motor score, discharge Functional Independence Measure (FIM) score and change in FIM score, length of stay (LOS), primary means of mobility at discharge and discharge destination. Standard statistical methods were used to compare groups.

Results: A total of 18 (3%) of the 575 patients were found to have cervical canal stenosis and hyperextension injury (the CCS/HI group). This represents 8% of the total group suffering traumatic injury to the cervical spinal cord (the total cervical trauma: TCT group, n = 225). This CCS/HI group was found to have a mean age at injury of 55.1 years compared to 37.1 and 37.8 years respectively for the TCT and total groups. Ninety-four percent of patients were found to have a neurological level at admission at C1–3 or C4–5 compared to 75.6% of the TCT group and only 5.6% of patients had an ASIA Impairment Category A lesion at admission compared to 38.7% of the TCT group. Falls (55.6%) was the most common cause of injury in the CCS/HI group with motor vehicle accidents (33.8%) most common in the TCT group.

The mean change in ASIA motor score between admission and discharge was 34.7 compared to 20.4 for the TCT group. Degree of impairment (measured by a change in ASIA Category) improved in 28% of patients and mean change in total FIM score was 41.3. There was no difference seen with the TCT group. LOS was shorter for these patients (111.1 days vs. 161.6 days). The primary means of mobility at discharge was “walking” for 50% of this group (compared to 28.4% for the TCT group) while the next most common means of mobility was “power wheelchair” at 28% (17% of TCT group). Most patients (55.4%) were discharged to their previous home following rehabilitation and 22.3% were discharged to another rehabilitation unit or acute hospital.

Conclusions: Patients with cervical spinal canal stenosis who suffer hyperextension injury constitute a distinct subgroup with the total group of traumatic cervical spinal cord injuries. This study suggests that they are older at the time of injury, have more rostral cervical injuries, are more likely to have incomplete injuries and that falls is the most common cause of injury. They have greater improvement in motor function but this does not appear to result in greater function at discharge as measured by the FIM. There appears to be a dichotomy with results for mobility at discharge with patients either being able to walk or requiring a power wheelchair. LOS in the SIU is shorter but a higher percentage are discharged to another hospital or rehabilitation unit.


S.D. Cook J.D. Schwardt L.P. Patron P.M. Christakis K.J. Bailey P.A. Glazer

Introduction: The use of adjunctive techniques such as electrical stimulation may improve the rate of successful anterior lumbar interbody fusion. The purpose of this study was to determine if supplemental direct current electrical stimulation of a titanium anterior spinal fusion device increases the incidence and extent of bony fusion in a nonhuman primate model.

Methods: Anterior lumbar interbody fusion was performed at the L5–L6 level in 35 adult pigtail macaque monkeys with iliac crest graft and either a titanium fusion device or a femoral allograft ring. The fusion devices of some animals received either high current (100μA) or low current (28μA) electrical stimulation using an implanted generator for the duration of the 12- or 26- week evaluation period. All animals were studied using AP and lateral radiographs, CT imaging, nondestructive mechanical testing, and qualitative and quantitative histology. Specimens were scored for presence of fusion according to a semi-quantitative scale (0 = No healing, 1 = Minimal consolidation, 2 = Consolidation, 3 = Bridging callus, 4 = Bridging callus with trabeculations, 5= Evidence of bony remodeling of callus). A similar scale was used to score the extent of fusion.

Results: As shown in Table 1, both low and high current stimulation groups had generally increased incidence of bony fusion compared to the non-stimulated and femoral allograft ring groups. At 26 weeks, the extent of bony fusion increased with the devices from 43% to 75% in a dose-dependent fashion, compared to 25% with the femoral rings. Mechanical testing also demonstrated similar increases in mechanical stiffness in a dose-dependent fashion.

Discussion: Adjunctive electrical stimulation of an anterior titanium spinal fusion device improved success rate and overall fusion quality compared to non-stimulated devices and femoral allograft rings. Stimulated devices may be particularly beneficial in patients with known risk factors for nonunion.


RA Story GS Inglis DI Walton

Introduction: The optimal treatment for acute thoracolumbar burst fractures remains controversial, particularly in the patient with minimal or no neurologic deficit. While this group could be treated conservatively, at Burwood we prefer to utilise short segment instrumented stabilisation.

We wished to review the indications for surgical intervention and the outcomes in this group with emphasis on safety, rate of rehabilitation, function, and pain levels.

Methods: The clinical notes and X-rays were reviewed for 34 consecutive patients with thoracolumbar burst fractures with minimal or no neurologic deficit, and treated by Dick fixator between August 1995 and September 2001. A questionnaire was mailed to all patients.

Results: At presentation this group had a mean age of 30.7 yrs (range 16–59), mean kyphotic deformity (Cobb method) of 16.1°, decrease in vertebral body anterior height of 40.9%, and decrease in canal area of 41.2%. Operative fixation was successful in greatly improving both height and kyphosis. No major complication such as metal-ware breakage, thromboembolism, deep infection, or neurologic deterioration was encountered. Average operating time was 71 min, time to discharge was 8.4 days, except where an associated injury limited mobility (17.1 days).

Questionnaires were returned by 29 of 34 patients at a mean of 3 years post-injury. All of these had returned to work or usual level of activity at 14.3 weeks (4–36 wks). Pain was experienced never or occasionally by 18 (62%), in relation to activity by 9 (31%), and on most days by 2 (7%). The average visual analog pain score was 2.1/10. No patient required regular or opioid analgesia.

Discussion: This form of operative fixation appeared to benefit this group of patients by allowing rapid rehabilitation with early mobilisation, discharge, and return to work. Pain frequency and severity were both low at medium term follow up and no major complication was encountered.


Adrian Nowitzke

Introduction: Repetitive undertaking of a physical tasks results in an innate memory for that task. Development of this memory is an important component of surgical training and the ease and safety with which these changes are incorporated into a smoothly flowing procedure is represented by the so-called “learning curve”.

Changes in equipment and technology may radically alter the paradigm used by surgeons for completing the task of an operation. An example of this is the integration of endoscopy. The hand-eye orientation, field of view, angle of approach, binocularity of vision and skew of the visual field are all altered in lumbar micro-endoscopic discectomy (MED), when compared to open microdiscectomy.

Methods: This is a prospective observational study of the initial twenty-five cases of lumbar MED in the hands of a single surgeon. The twenty-five cases of open micro-discectomy immediately predating the current series are used as a cohort for comparison.

Results: A definite alteration in the ability of the surgeon to undertake a new method of discectomy occurred.

Three of the first seven cases of MED were converted to an open discectomy. None of the ensuing 18 cases was converted. The major learning outcomes to account for the change were familiarity with the radiological and videoscopic anatomy, and recognition of the importance of angles of approach.

The average time for surgery in the first ten cases was significantly longer than the second fifteen. The time for surgery in the latter group was not significantly altered from the open cohort group. The facets of surgery responsible for the increased time in the first group were techniques of exposing the nerve root, comfort of the extent of decompression of the nerve root and excision of the disc and comfort with the orientation and cleaning of the camera. The quality of illumination and visualisation of the operative field improved over the study although the significance of this could not be quantified.

Subjectively, surgeon “comfort” with the procedure developed relatively early in the “learning curve”.

There was no significant difference in clinical outcome and complications between the two groups.

Discussion: Minimal access techniques have been widely integrated into other fields of surgical endeavour. Open microdiscectomy is well accepted as a treatment for acute lumbar disc prolapse. The decision whether or not to change a surgeon’s operative technique should be based on the final anticipated clinical benefit of such a change compared to the cost and risk of changing. This study shows that there is a learning curve associated with lumbar MED, but that it can be integrated relatively easily into a surgical armamentarium.


R.E.A. Newcombe P.C. Blumbergs J Manavis N.R. Jones

Introduction: Apoptosis, or secondary cell death, has been demonstrated in a number of neurological conditions, including Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis and brain ischaemia. It is well established from studies of acute spinal cord injury that apoptosis seems an important factor in secondary cell death and irreversible neurological deficit. It is only recently that studies have emerged analysing secondary cell death in chronic injury to the cord. In this study, the spatial and temporal expression of apoptotic cells was analysed in acute traumatic spinal cord injury (SCI) (n=6) and chronic myelopathies due to metastatic tumour (n=5), degenerative spondylosis (n=6) and syringomyelia (n=4). The study aimed to demonstrate apoptosis in compressive spinal cord injury and to analyse the spatial and temporal distribution of apoptosis in acute and chronic myelopathy.

Method: Archival material from 21 spinal cords of patients with documented myelopathy during life and definitive evidence on post mortem examination were available for study. The spatial and temporal expression of apoptotic cells was analysed in acute traumatic spinal cord injury (SCI) (n=6) and chronic myelopathy due to metastatic tumour (n=5), degenerative spondylosis (n=6) and syringomyelia (n=4).

Immunohistochemical analysis of each specimen was conducted using markers of apoptosis, as well as the biochemical apoptotic marker TUNEL. A total of 1800 histopathological slides were analysed. Specimens were also analysed using confocal microscopy to identify the immunopositive cell type. A combination of morphological, immunohistochemical and in situ end-labelling techniques were used to investigate the mechanism of cell death in this experiment. The analytical techniques employed were aimed at showing firstly the presence of apoptosis and secondly the size and position of the damaged regions.

Results: Positivity for active Caspase-3, DNA-PKCS, PARP, TUNEL and active Caspase-9 was found in glia (oligodendrocytes and microglia) axons and neurons in both acute and chronic compression above, below and at the site of compression. In chronic compression, the severity of positivity for apoptotic immunological markers was positively correlated with the severity of white matter damage, as measured by APP immunostaining for axonal injury, and Wallerian degeneration. There was no correlation between the duration of chronic compression and immunopositivity for apoptotic markers. In acute SCI, axonal swellings were consistently positive for Caspases −9 and -3, suggesting mitochondrial activation of apoptotic pathways.

Conclusion: Apoptosis occurs in both acute and chronic spinal cord injury. In acute compression, axonal injury is associated with apoptotic immunopositivity of glia and neurons. In chronic compression, apoptosis of oligodendrocytes and microglia correlates with demyelination of axons within the white matter.


G Schneider M J Pearcy N Bogduk

Introduction: Contrary to the prevailing conviction that lumbar segments affected by lytic spondylolisthesis are unstable, multiple studies have failed to find evidence of increased or abnormal motion at these segments. Affected segments do not exhibit excessive anterior translation: the so-called slip. Previous studies, however, did not use techniques that might reveal abnormalities in the quality of motion, as opposed to its magnitude.

Methods: To determine if features of instability could be detected in the radiographs of patients with spondylolisthesis, a retrospective, cohort study was conducted of the kinematics of the lumbar spine of patients with spondylolisthesis compared with asymptomatic normal subjects. The flexion-extension radiographs of 15 patients with spondylolytic spondylolisthesis were analysed to determine the location of their instantaneous centres of rotation, and their magnitudes of translation and sagittal rotation. Normative data were obtained by applying the same techniques to the radiographs of 20 asymptomatic subjects.

Results: All but one of the 15 patients exhibited at least one segment with abnormal motion. Only one patient had excessive translation at the lytic segment. Four had minor abnormalities affecting either the lytic segment or ones above. Nine patients exhibited major abnormalities. Seven had paradoxical motion at the lytic segment, in which the centre of rotation was located above L5, instead of below, and in which L5 translated backwards, instead of forwards, during flexion. Two patients exhibited axial dropping of L4, instead of horizontal translation, during extension.

Discussion: Not all patients with spondylolisthesis show features of instability. However, a proportion of patients exhibit highly abnormal movements that are consistent with instability. The abnormalities involve movements within normal range but in abnormal directions. Visual inspection of radiographs will not reveal these abnormalities but they can be detected by plotting the instantaneous axes of rotation.


O.L. Osti R.T. Gun Alison O’Rioran F. Mpelasoka

Study design: A prospective study of 135 subjects with whiplash injury.

Objectives: To identify factors predictive of prolonged disability following whiplash injury.

Summary of background data: Although subjects with whiplash associated disorders lack demonstrable physical injury, many exhibit prolonged disability. Disability appears unrelated to the severity of the collision.

Methods: 147 subjects with recent whiplash injury were interviewed for putative risk factors for disability. 135 were re-interviewed 12 months later to assess degree of duration of disability. Bivariate and multivariate analyses were undertaken to measure the association between putative risk factors and measures of outcome.

Results: The bodily pain score and role emotional scores of the SF-36 health questionnaire showed a consistent significant positive association with better outcomes. After adjustment for bodily pain score and role emotional scores, consulting a lawyer was associated with less improvement in NPOS (p< 0.01) after one year, but there was no significant association with rate of return to work. The degree of damage to the vehicle was not a predictor of outcome.

Conclusions: SF-36 scores for bodily pain and role emotional are useful means of identifying subjects at risk of prolonged disability. The findings support the implementation of an insurance system designed to minimise litigation.


AR Brodbelt MA Stoodley A Watling J Tu N Jones

Introduction: It has been suggested that arachnoiditis predisposes to post-traumatic syringomyelia formation by obstructing subarachnoid cerebrospinal fluid flow and enhancing perivascular flow into the cord. In an animal model of post-traumatic syringomyelia (PTS), fluid flow in spinal cord perivascular spaces (PVS) is greater at the level of arachnoiditis and syrinx than at other levels and fluid enters the syrinx via the PVS. This study was performed to determine the effects of cerebrospinal fluid (CSF) diversion from the subarachnoid space on perivascular flow and syrinx formation in PTS.

Methods: Twenty six male Sprague-Dawley rats were investigated using the CSF tracer horseradish peroxidase (HRP), the excitotoxic and arachnoiditis model of PTS, and lumboperitoneal shunt insertion. Four experimental groups consisted of syrinx only and shunt only controls, and shunt insertion before or after syrinx formation. CSF flow studies were performed 6 weeks following the final intervention. Grading scales were used to quantify HRP staining.

Results: Syrinxes formed in all animals. Perivascular flow was greatest at the level of the syrinx. Cerebral cortex perivascular flow was significantly reduced following shunt insertion in animals with a syrinx (p< 0.05). Shunt insertion did not alter syrinx length or size, but did reduce the number of animals with evidence of sensory disturbances. There were no significant differences between shunt and syrinx first groups.

Discussion: Increasing distal subarachnoid space compliance does not affect local CSF flow into the spinal cord and syrinx. These results suggest that localised alterations in compliance, as opposed to obstruction from traumatic arachnoiditis, act as an important factor in syrinx pathogenesis.


Richard D. Guyer Scott L. Blumenthal Stephen H. Hochschuler Donna D. Ohnmeiss

Introduction: Two total disc replacement devices have been used in Europe for more than 10 years. However, there are few, if any, prospective studies evaluating their results. The purpose of this prospective study using standardized outcome evaluations was to evaluate surgical outcome following implantation of an artificial disc.

Methods: This study is based on the consecutive series of the first 57 patients undergoing total disc replacement using the SB Charité (Link) disc prosthesis. Indications included single-level symptomatic disc degeneration, failure of at least 6 months of non-operative treatment including active rehabilitation, and no previous surgery at the operated segment. Data were collected prospectively pre-operatively and at 6 weeks, 3, 6, and 12 months post-operatively (24 month follow-up data collection is continuing). Primary outcome measures included visual analog scales (VAS) assessing pain and the Oswestry Low Back Pain Disability Questionnaire.

Results: The mean operative time was 78.5 minutes and the mean estimated operative blood loss was 134.3 cc. Estimated blood loss and operating time were both significantly less for disc replacements at the L5-S1 level than at L4–5 (p< 0.05; t-test). As seen in Figures 1 and 2, there was a significant improvement in the VAS and Oswestry scores (p< 0.05) at the 6-week follow-up visit, and the improvements were maintained during subsequent follow-up visits.

There were no cases of device failure, displacement, or migration. Complications were comparable to those encountered with anterior interbody fusion.

Discussion: The results of this prospective study, using patient self-report questionnaires, demonstrated significant improvement at 6 weeks and the improvement was maintained during the 12 month follow-up period (24-month data is being collected). The disc prosthesis can be implanted safely, with complications similar to those encountered with anterior lumbar interbody fusion.


R Rahmat R J Moore S Nikoloff D Matsacos B W Oakes R D Fraser

Introduction: The development of laboratory techniques in the last ten years has enabled the successful harvest, in vitro selection, culture and transplant of chondrocytes. The study proposes that transplantation of autologous chondrocytes prevents degeneration of the intervertebral disc following outer annular injury in an ovine model.

Methods: Eight sheep were anaesthetised and five contiguous lumbar discs were exposed via a left-sided posterolateral approach. Four of the animals were given full thickness annular incisions in three alternate discs. No annular incisions were made in the other 4 sheep. Costal cartilage was harvested from the left twelfth rib of all animals. Tissue was cultured and the chondrocytes were labelled in vitro with CFSE for verification following transplantation. Six weeks later autologous cultured chondrocytes were injected into the lower two alternate discs of all animals, leaving the uppermost discs and those untouched in between as internal controls. Animals were sacrificed after three, six, twelve and twenty-four weeks. Results were based on X rays, histological, and immunocytochemical assessments.

Results: Preliminary histological results up to three months showed viability of cultured chondrocytes and matrix production post transplantation. Serial X rays suggested that progressive disc degeneration was arrested in the treated discs.

Discussion: In this pilot study we have shown that cultured autologous chondrocytes can remain viable long term in vivo. These preliminary results suggest that these transplanted chondrocytes have the ability to retard and possibly prevent disc degeneration following annular incision. Previous similar studies have reported the use of chondrocytes cultured from disc, whilst this study showed that chondrocytes from a source foreign to the disc can exert positive effects. The encouraging result from this pilot study needs to be further validated to realise its potential as a treatment for degenerative disc disease.


Michelle L Gatton Mark J Pearcy Graeme Pettet

Introduction: The complexity of the spine has made a complete understanding of its mechanical function difficult. As a consequence, biomechanical models have been used to describe the behaviour of the spine and its various components. A comprehensive mathematical model of the muscles of the lumbar spine and trunk is presented to enable computation of the forces and moments experienced by the lumbar intervertebral joints during physiological activities.

Methods: The model includes the nine major muscles crossing the region and concentrates on improving the estimated line of action for the muscles. The muscles are considered to consist of numerous fascicles, each with its own force producing potential based on size and line of action. The model respects the physical constraints imposed by the skeletal structure by ensuring that muscles maintain their anatomical position in various spinal postures. Validation was performed by comparing model predictions of maximum moments to published data from maximum isometric exertions in male volunteers. To highlight the potential novel uses of the model, three examples of muscle injury caused by surgical procedures were investigated; posterior lumbar surgery, impairment of abdominal muscles from anterior surgery and removal of the psoas major unilaterally during total hip replacement.

Results: The validation indicated that the model predicted forces similar to those measured in normal volunteers. The biomechanical changes resulting from the muscle injuries during the surgical procedures share several common features: decreased spinal compression and production of asymmetric moments during symmetric tasks.

Discussion: The results suggest that interference with muscles crossing or attaching to the lumbar spine can have a significant impact on its function.


Joel A. Finkelstein Eugene K. Wai Steven Shlomo Jackson Henry Ahn Michael Brighton-Knight

Introduction: Flexion distraction injuries (FDI)of the thoracic and lumbar spine can be stabilized with a short construct spanning one motion-segment. This fracture is functionally defined by failure of the posterior and middle columns in tension and the anterior column in compression or tension. Treatment of a predominantly bony injury with minimal deformity (Chance type) is usually non-operative. Intra-abdominal pathology, and ligamentous spinal instability are relative indications for surgery. Deformity of greater than 17 degrees of kyphosis has a poor prognosis when treated conservatively, and represents true instability in vitro. Surgical treatment is mainly through a posterior approach with instrumentation. Which construct to use and the number of motion segments to include is controversial. Multi-level instrumentation techniques both in distraction and compression have been used as well as shorter constructs, particularly in the lumbar spine. We addressed the efficacy of single motion-segment fixation by evaluating the radiographic and functional results of this treatment technique.

Methods: All patients diagnosed with a FDI were prospectively identified over a 48 month period. Non-operatively treated fractures were excluded. Other spine fractures were excluded. Demographics, comorbidity, neurological status, operative details and complications were recorded. Radiographic reviewers were blinded to the functional outcome of the patient and the time of follow-up. The Oswestry Functional Assessment Questionnaire was administered by mail.

Results: Twenty-one eligible patients were identified. A significant (p< 0.0001) correction of deformity was achieved, from a mean preoperative kyphosis of 10.1 degrees to a mean postoperative lordosis of 0.9 degrees. No loss of correction occurred. The mean Oswestry score was 11.5, with 88% of patients having minimal disability. One patient died from unrelated morbidity.

Conclusions: Hoshikawa etal showed in vitro how compression forces alone can create FDI. Compression without flexion causes burst fractures. With moderate flexion there is FDI with anterior body compression. With increasing flexion FDI becomes entirely distractive. As the forces are concentrated at a single point, reconstruction only requires that this location be addressed. As all FDI are created by the same mechanism, regardless of structures injured only short segment fixation is required.

We have demonstrated in FDI, single level fixation is biomechanically sound. Multilevel instrumentation creates loss of adjacent level motion segments. This is not necessary. The absence of a control group precludes absolute conclusions. Nonetheless most patients reported minimal disability related to their back and had excellent radiological outcomes. This study demonstrates that posterior reduction and stabilization of a single motion-segment for FDI can adequately stabilize the spine and lead to excellent functional outcomes.


Nick Birch Sean Grannum Nadim Aslam

Introduction: Discectomy for herniation of the nucleus pulposus is an effective procedure when conservative treatment has failed. However, a number of patients rapidly progress to symptomatic instability after discectomy. Those most likely to develop instability have central and multi-regional herniations. Therefore, primary posterior lumbar interbody fusion (PLIF) may be a better option than discectomy alone in this group. This paper presents the clinical and radiological outcome of a consecutive group of such patients treated in one centre by PLIF, but recognises that newer technologies may make such destructive spinal surgery unnecessary in the future.

Methods: Between June 1997 and December 2000, PLIF for central disc herniation presenting with acute, subacute and chronic back and leg pain, with or without neurological loss, using Diapason pedicle screw instrumentation and Ogival PEEK (Polyether-ether-ketone) Interbody Fusion cages was performed on 41 patients. Eight patients presented acutely with cauda equina symptoms and 33 patients had sub-acute or chronic symptoms. Formal clinic follow-up was continued for at least two years post-surgery and the final outcome at 2 to 5 years after operation was assessed using the Low Back Outcome Score (LBOS). Two independent orthopaedic surgeons assessed the radiological evidence of fusion on X-rays taken at least two years after surgery.

Results: 39 of the 41 patients completed the LBOS questionnaire (95%). One patient had died from an unrelated cause and the other could not be contacted having moved away. 34 (87%) of these had an excellent or good outcome according to the LBOS criteria. However, every patient who returned the questionnaire stated that they would undergo the operation again if guaranteed the same surgical result and all would recommend it to a friend for similar trouble. Four patients (9.7%) were dissatisfied with the process of care they experienced. Analysis of radiographs taken between two and four years post-operatively revealed that spinal fusion (as defined by the Brantigan and Steffee criteria) was present in 38 cases (92.7%). None of the patients with a non-union radiologically had a poor outcome.

Conclusions: Post-discectomy instability causing disabling low back and leg pain is more likely to occur in patients with an incompetent annulus than those with a largely intact annulus. The patients in this series all had good evidence on MRI of complete (pan-annular) failure. The decision to perform an acute single level PLIF was taken after discussion with the patients, presenting them with the option of having only a central discectomy and a later fusion if needed or of dealing with the problem at one operation. The outcomes described in this study show that this condition is a good indication for PLIF. However, newer technologies such as disc arthroplasty may be a better option for this group of patients in the future.


GEORGE Bernard

Introduction: Oblique corpectomy is a surgical technique of spinal cord decompression through a limited bone resection of the postero lateral corner of the vertebral bodies. In this study the results of this technique applied in cases of spondylotic myelopathy and tumors are presented.

Methods: The oblique corpectomy is achieved through a lateral approach with control and sometimes transposition of the VA. It can be used at any level from C2 to T1 and on as many levels as required from 1 to 5. It was mostly applied on cervical spondylotic myelopathy (N=157) or radiculopathy (N=89) but also on hourglass tumors (neurinomas N=67, meningiomas N=7, hemangioblastoma N=1, paraganglioma N=1) and different tumors N=49 involving the lateral part of the vertebral body such as osteoïd osteomas N=8, chordomas N=11, aneurysmal cyst N=3, sarcomas N=4. The total series includes 126 tumors. In most cases preservation of the main part of the vertebral bodies permitted to avoid bone grafting and plating. However stabilization procedure is still necessary when more than one disc are resected and when the discs are soft and not collapsed.

Results: Excellent decompression was obtained in every case of spondylotic myelopathy and radiculopathy. Clinical results are similar to those obtained by any other techniques of decompression through anterior approach but without the complications related to grafting and plating. Improvement of the preoperative score was noted in 79% of patients with myelopathy stabilization in 13% and worsening in 8%. In patients with radiculopathy, good and excellent results were obtained in 85%. A better decompression of the intervertebral foramen is achieved through the oblique corpectomy since the whole length of the cervical nerve root from the dural sac to the vertebral artery can be decompressed. Instability requiring further stabilization procedure was observed only in 3 cases which in fact were preoperatively unstable.

Complete tumor resection was achieved in every case especially for the lateral part located into the intervertebral foramen and around the vertebral artery. Even tumors extending from the outside of the spine to the intradural space could be entirely removed through the same approach. Grafting and plating were realized in 13 out of the 126 cases of tumor.

Conclusion: Oblique corpectomy techniques is a safe technique which permits to decompress the spinal cord and cervical nerve roots from spondylotic elements and tumors. As compared to other techniques, it achieves a better decompression on the lateral part of the spinal canal and on the intervertebral foramen up to the vertebral artery. In many cases it does not require any complementary stabilization technique and avoids the use of instrumentation.


Rosemary E Thompson Mark J Pearcy Timothy M Barker

Introduction: Structural changes to the intervertebral disc (IVD) in the form of anular lesions are a feature of IVD degeneration. Degeneration has been related to changes in the mechanical function of the IVD. This study determined the mechanical effect of individual concentric tears, radial tears and rim lesions of the anulus in an in vitro experiment.

Methods: The lumbar spines from five sheep were taken post mortem and divided into three motion segments. The disc body units were tested on a robotic testing facility, using position control, in flexion/extension, lateral bending and axial rotation. Concentric tears, radial tears and rim lesions were experimentally introduced and the motions repeated after the introduction of each lesion. The mechanical response after the lesion creation was compared to the undamaged response to assess the mechanical effect of each lesion.

Results: It was found that an anterior rim lesion reduced the peak moment resisted by the disc in extension, lateral bending and axial rotation. Concentric tears and radial tears did not affect the peak moment resisted, however, radial tears reduced the hysteresis of response in flexion/extension and lateral bending. The neutral zone was not affected by the presence of IVD lesions.

Discussion: These results show that rim lesions reduce the disc’s ability to resist motion. Radial tears change the hysteresis of response indicating an altered stress distribution in the disc. These changes may lead to overloading of the spinal ligaments, muscles and zygapophysial joints, possibly damaging these structures. This suggests a mechanism for a cycle of degeneration that is instigated by small changes in the mechanical integrity of the IVD.


Alexander R. Vaccaro Tushar Ch. Patel Eeric Truumees Jeffrey S. Fischgrund Harry N. Herkowitz Todd Albert Alan Hilibrand Frank Phillips Todd Wetzel John McCulloch

Introduction: Posterolateral intertransverse lumbar fusion is a commonly performed procedure for stabilization of the degenerated lumbar spine. A typical clinical scenario for which such fusions are used is the stabilization of a degenerative spondylolisthesis after decompression. In a recent large series reported in the literature, this type of fusion was noted to have a pseudarthrosis rate of up to 45% (Fischgrund, Spine 1997).

Methods: A pilot study was designed to evaluate the safety and efficacy of osteoinductive protein-1 (OP-1, also known as recombinant human BMP-7) in lumbar posterolateral fusion. Thirty-six patients with the diagnosis of symptomatic spinal stenosis and single level degenerative spondylolisthesis in the lower lumbar spine (L3-S1) were enrolled. The patients were randomized to either the OP-1 group or the control group. The OP-1 group received 3.5 mg of OP-1 per side in a putty carrier. The control group received iliac crest autograft alone. Outcomes were measured clinically using the Oswestry score and radiographically using dynamic radiographs evaluated independently by two blinded radiologists using digital calipers. Patients were deemed a clinical success if they showed a > 20% improvement in Oswestry score and were deemed a radiographic success if they showed bridging bone and spinal stability on flexion/ extension films.

Results: At twelve months, 18/21 (85.7%) patients in the OP-1 group and 8/11 (72.7%) patients in the autograft group were considered clinical successes, while 13/18(72.2%) of patients in the OP-1 group and 6/10 (60%) patients in the autograft group were considered radiographic successes. No adverse events related to the use of OP-1 were noted.

Discussion: Despite the non-statistical number of patients enrolled in this pilot study, these preliminary results suggest that OP-1 appears to be a safe and effective replacement for iliac crest autograft in human posterolateral lumbar fusion. The OP-1 group had a higher radiographic fusion rate than the autograft group. This correlated well with the greater clinical success experienced by the OP-1 group, as measured by improvement in the Oswestry score. None of the previously reported device related complications related to the use of BMP’s in animal studies, such as exuberant bone growth with subsequent neural impingement, ectopic ossification, or spinal stenosis, were seen in the treatment group.

Conclusion: OP-1 appears to be a safe and effective replacement for iliac crest autograft in human posterolateral lumbar fusion. The dose, 3.5mg per side, and the carrier, a biodegradable putty, appear to provide a safe and effective means of delivering the bone morphogenetic protein OP-1 to the human lumbar spine.


E.K. Wai E. Santos R.D. Fraser

Introduction: Numerous in-vitro studies demonstrating increased stress at levels adjacent to a lumbar fusion have raised concerns of accelerated degeneration. However, the significance of this increased stress in the in-vivo setting remains unclear, especially with long-term follow-up. The objective of this study is to assess the level of degeneration on MRI in this same cohort of patients at a minimum of twenty years follow-up.

Methods: Twenty-five patients undergoing one or two level anterior lumbar interbody fusion at the L5-S1 or L4–5 levels with a minimum of twenty-years follow-up were identified. Only patients with normal preoperative discograms at the level adjacent to the fusion were considered in this study. MRI scans were performed and evaluated for any evidence of degeneration by an independent radiologist. Advanced degeneration was defined as either: (1) absence of T2 signal intensity in the disk, (2) disk herniation, or (3) spinal canal stenosis.

Results: Advanced degeneration was identified in five (20%) patients, with three (12%) being isolated to the adjacent level. Fourteen (56%) other patients had evidence of early degeneration in their lumbar spine. Overall, eight (32%) patients had some evidence of degeneration isolated to the level adjacent to the disk whereas seven (28%) patients had multilevel degeneration and four patients (16%) had degeneration in their lumbar spine but preservation of the adjacent level.

Discussion & Conclusion: Without a control group, it is difficult to make firm conclusions on whether the changes seen on MRI represent the natural history of spinal deterioration or represent accelerated degeneration. However, after twenty-years, only a handful of patients developed advanced adjacent level degeneration. Furthermore, the majority of degenerative changes seen occurred over multiple levels or at levels not adjacent to the fusion, suggesting that changes seen may be more likely related to constitutional factors inherent within the individual as opposed to the increased biomechanical stresses at the adjacent levels.


G Selmon E Wai D Hall C Cain

Introduction: 360 degree combined anterior and posterior fusion is an accepted surgical treatment for the management of discogenic back pain. Controversy exists to the optimal technique of posterior fixation. Proponents of translaminar screw fixation cite lower morbidity as a result of less dissection. Despite reports of high fusion rates with this technique, there are concerns over the biomechanical inferiority of this construct compared to pedicle screw fixation. Previous studies on translaminar screws have used only plain radiographs to assess fusion. The objective of this paper is to compare radiographic outcomes, using high definition CT scans, and clinical outcomes between these two methods of posterior fixation.

Methods: During 2001, 31 patients underwent combined anterior and posterior fusion by the two senior surgeons for the management of back pain. Anterior interbody fusion was performed using the Syncage in all patients. 16 patients underwent translaminar screw posterior fixation and 15 underwent pedicle screw posterior fixation. Fusion was assessed by high definition CT scan at one year postoperatively. Function was assessed with pre- and postoperative Low Back Outcome Score and visual analogue scores.

Results: Minimum follow-up was 12 months. The incidence of pseudarthrosis in the translaminar group was over 75% which was five times greater than that seen in the pedicle screw group (p = 0.01). There were trends towards greater improvements in the LBOS and VAS scores in the pedicle screw group and amongst those patients who achieved a successful fusion. There were two surgical complications in the translaminar screw group and one in the pedicle screw group.

Discussion: With the numbers that are available, there are no clinical differences between the two methods of fixation, although there were trends towards improved function and reduced pain in the pedicle screw group. Furthermore there does not appear to be any difference in regards to complications. However, translaminar screws are associated with a significantly higher rate of pseudarthrosis compared to pedicle screws.


A Epps T K F Taylor M-C Waugh

Recent years have seen a decided swing from the longstanding inpatient model of rehabilitation to an outpatient model for all branches of medicine in Australia. This swing has been largely cost-driven and is unlikely to change. This paper reports on the development of a paediatric spinal outreach team (ORT) in NSW. The ORT was formed in 1993 and consists of a nurse, physiotherapist, occupational therapist and a social worker. It functions in close collaboration with the two children’s hospitals in Sydney. Approximately 10–11 new cases of paraplegia/quadriplegia occur in children/adolescents (up to 18 years of age) in NSW each year. Their therapeutic needs change with growth, development and maturation. Families in regional NSW have special requirements and website information services (distance education) will play an important role for them in the future. Integration with an organisation which provides ancillary services is essential for a comprehensive, state-wide program.

It is suggested that a comparable service would play an equally important role in other states. Case studies to demonstrate savings to be made with this type of service need to be done to secure recurrent government funding.


GEORGE Bernard

Introduction: Results on surgical treatment of chordomas from series published in the literature are disappointing with survival rate of 50% and 35% respectively at 5 and 10 years. In most reports, surgical resection is limited to a palliative decompression or at best to a subtotal resection. The purpose of this study is to evaluate the results of patients treated aggressively by several surgeries and radiotherapy from 1989 to 2000.

Methods: From a series of 36 patients presenting with cervical (N=8) or suboccipital (N=28) chordomas, 22 were referred primarily while 14 were sent to us for a recurrence after a previous partial surgical resection. In both groups of patients, we proposed as radical a surgical resection as possible realized in one to four surgical stages followed by radiotherapy (and protontherapy for the more recent cases).

Results: Patients seen at first presentation (group A) underwent 1,9 surgeries in average and 10 of them could have a protontherapy while in group B patients referred after recurrence, 1,4 surgeries were carried out and 3 could have a protontherapy. Follow-up extends from 1 to 11 years (mean 4 years).

Actuarial survival rate was 80 and 65 % respectively at 5 and 10 years in group A as compared to 50 and 0% in group B. Actuarial recurrence free rate was 70 and 35% at 5 and 10 years in group A and 0% at 3 years in group B. Disease related mortality was 15% in group A and 63% in group B. The rate of recurrence per year was 0,15 in group A and 0,62 in group B. The mean delay before the first recurrence was 43 months in group A and 15 months in group B.

Factors such as sex, age, duration of symptoms, severity of symptoms, extent of tumor, histological type or grading have no influence on the survival rate and the recurrence free rate. Even the comparison between patients having received or not radiotherapy and patients treated or not by protontherapy failed to show any difference. However these groups of patients are very small and include group A and group B patients.

Conclusion: Aggressive surgical treatment at first presentation of patients with chordomas seems to provide better results in term of survival and recurrence. However it requires several surgical stages (up to four) followed by radio and protontherapy. No others factors has proven to influence the prognosis. In case of patients already presenting a recurrence this aggressiveness does not seem to be justified. Therefore after this study, aggressive surgical treatment was only proposed to primary patients (N=12) and not on patients with recurrence (N=7).


Peter McCombe William Sears

Introduction: Posterior interbody fusion (PLIF) can be performed for a variety of indications and by a variety of methods. This paper presents a prospective observational study of the outcome for PLIF using an insert and rotate lordotic implant with pedicle screws for the indication of neurological compression caused by segmental deformity.

Methods: Prospective data was collected preoperatively and at regular intervals during the post operative period. Self assessed outcome measures of visual analog pain score (VAS), Low Back Outcome Score (LBOS) and SF12 general health data was obtained at intervals after the surgery. This paper presents the results of a consecutive series who have a minimum of 6 months followup. All surgery was performed by the two authors. Implants used were a carbon fibre composite ramp (DePuy AcroMed), a titanium mesh lordotic cage (Medtronic Sofamor Danek) or a lordotic PEEK spacer (R90, Medtronic Sofamor Danek).

Results: One hundred and twenty eight cases were performed. The mean age was 61.5 yrs(sd 15.1), 63 (49% ) were female and 65(51%) were male. Thirteen cases (10%) were workers compensation. Eighty seven (69%) had a single level fused, thirty three (26%) had 2 levels fused. Six cases had three or more levels fused. Forty cases had had one or more previous decompressive procedures at the target level. All cases had leg pain due to neurological compression associated with some form of deformity. Fifty three percent had a spondylolisthesis, 20 % had degenerative scoliosis with collapse of the disc space being the most common other deformity. The mean pre operative VAS pain score dropped from 6.95 (sd 2.0) to 3.2 (sd 2.4). (p< 0.0001 paired t test). The mean percentage VAS improvement was 49.7% (95% ci 42.4% to 57.1%). Twenty seven percent achieved greater then 80% pain improvement with 47% achieving greater than 60% pain improvement. The mean LBOS score rose from 21.8 (95% ci 19.6 to 24.0) to 37.9 (95% ci 35.1 to 40.6) (p< 0.001 paired t test). The mean percentage improvement in LBOS was 120.7% (95% ci 94.6% to 146%).

Complications consisted of 3 cases of minor wound drainage that settled, a possible deep infection that settled with antibiotics. There were 4 cases of transient leg weakness that recovered and one case of postoperative extradural heamatoma requiring evacuation for partial cauda equina lesion (near full recovery). Unexplained persistence of leg pain or new leg pain was present 8 cases. Three cases resolved spontaneously , 2 cases were due to screw malposition and required revision and 3 cases required re-exploration for further foraminal decompression. Other medical problems included pulmonary embolus (1), chest infection/atelectasis (2), confusional state (2), paralytic ileus (3), Atrial fibrillation (2), myocardial infarction (1).

Discussion: Posterior lumbar interbody fusion with insert an rotate implants for neural compression gives reasonable pain relief and reduction in disability with a low complication rate for the target (elderly) population.


Susan Liew

Introduction: The principles of treatment of deep wound infection around bony implants involves appropriate antibiotics, drainage, repeat debridements, and secondary closure. This type of wound management can be difficult for nursing staff and uncomfortable for the patient. This paper discusses the results of debridement and immediate closure over drain tubes in eight cases from one surgeon’s practice in two tertiary hospitals.

Methods: This is a retrospective review of patients from a personal database. Over a five year period, 178 instrumented posterior spine surgeries, in all regions of the spine, were performed. The indications for surgery included trauma, scoliosis, degenerative conditions, tumour, and other deformities in decreasing order of frequency. In this group, there were eight deep wound infections requiring debridement. All were in the thoracic and/or lumbar region. In two patients with non-fusion rods, the implants were removed. In six patients the implants were retained. All wounds were closed immediately over 16 Fr drain tubes. Follow-up times range from 4 years to 3 months.

Results: No wounds required repeat debridement or developed subsequent breakdown. No patient had any further significant septic episodes. The drain tubes remained in situ for a time ranging from five days to three weeks. Of the two patients who had their implants removed at debridement, one remained on antibiotics for six weeks and the other for three months. Four patients remained on antibiotics for one year. One patient had removal of the implants before ceasing the antibiotics but the other three have not had a recurrence of infection despite retaining their implants. Two patients remain on lifelong antibiotics.

Discussion: Debridement and immediate wound closure, in concert with the appropriate antibiotic, after post-operative deep wound infection can be successful with the benefit of less discomfort for the patient and greater ease of nursing care.


George M. Weisz Len Green

Introduction: The clinical condition was described as Ankylosing Hyperostosis of the Spine by Forestier (19501), was expanded by Resnick (1975) with the Extraspinal Manifestations2. What is the nature of this unique formation, asymptomatic in 90% of cases? Several researchers questioned whether the hyperostosis was physiological or pathological. Initially, in 1985 B.M. Rotschild called it a phenomenon 3. Schlapbach in 1989 found no associated pathological condition 4. Hutton in his Editorial “Hyperostosis…a State not a Disease“ was doubtful 5.

In recent personal observations, protection by ossification was recorded in a severe trauma case and in vertebrae weakened by malignant infiltration.

Methods: A phylogenetic review of the animal world, followed by an ontogenetic study of mammals/ humans, could assist in a decision regarding the nature (physio-or pathological) of the hyperostosis.

Results: The phylogenetic lineage on one side showed the oldest record of hyperostosis in dinosaur (144 million years ago=mya). Ossifications were found in the anterior, lateral, posterior longitudinal ligaments, in C1–C2 transverse ligament. In the other phylogenetic, Hyperostosis was in historic and contemporary mammals.

The next step in this study is in the ontogenetic line of the Humans. The oldest skeleton (Ethiopia, 4.5 mya) showed “bridged vertebrae“. The first definite hyperostosis was in the Shanidar skeleton (Iraq, 40–12,000 BCE) with“flowing osteophytes”. In the historic Humans since 9500 BCE, hyperostosis was found in Europeans, Egyptians, Indians (Chile) and Incas. In the Christian era, hyperostosis was present in Roman-British/ Celt populations, Franks, Saxons, British, Swiss and N. Americans. In the 20th C, it is pandemic.

Discussion: a. Impressions from the animal world: Paleopathology was established as a scientific branch in 1912 (Ruffer), and exemplified its value in understanding the nature of diseases. Moodie questioned the function of the long spinal “bony rods”, considered them with a protective function. Others 6 suggested spinal hyperostosis as induced by “mechanical stress”. Shore7 (1936) described the spondylitis ossificans ligamentorum as due to mechanical strain.

b. Impressions from the Hominid world: The ontogenetic line shows a constant presence of hyperostosis in prehistoric and historic periods. Parallel to human migration from Africa, hyperostosis expanded globally.

c. The theory of logical probability: It is postulated that hyperostosis is a condition, as no pathology (other than inflammatory) could have expanded and persisted in many species along millions of years, as it would have been removed by the rules of the Darwinian Selection. Possibly triggered by strain in younger age, functional in the past, it is today an atavistic older age “condition“, with increased osteoblastic activity in connective tissues of ligaments and tendons. At times it is incidentally discovered and is occasionally excessive. Once presented with clinical manifestations, it becomes defined an illness and should be called the Forestier-Resnick syndrome.


Mark J Sherwood Peter A Robertson Alastair T Hadlow

Purpose: Lumbosacral dislocation injuries are rare. Severe trauma disrupts the mechanically stable lumbosacral junction, rendering the injuries particularly unstable. Aggressive surgical management has been recommended. We present a review of our experience with these uncommon injuries defining injury patterns, surgical strategies and outcomes.

Methodology: Six patients were treated at Auckland Hospital in the last decade. Thorough review and literature search were performed to revise recommendations for management.

Results: All injuries were associated with high-energy trauma. In two cases there was evidence of previous spondylolysis, with dramatic progression after injury. All cases were surgically treated with decompression, reduction as indicated, and fusion with instrumentation. The only instrumentation failure occurred when reduction reconstituted disc height without attention to reconstruction of the severely mechanically compromised intervertebral disc. Satisfactory recovery of nerve root injury occurred in all but one case. Major cauda equina damage did not occur. Correlations with previously described classification systems for this injury were poor, and often showed injuries to span grades.

Conclusions: These highly unstable injuries require a high index of suspicion, and aggressive surgical management of these highly unstable injuries is warranted, yielding satisfactory outcomes. Existing classification systems are of little value prognostically, or in planning treatment, and it is better to classify and treat these injuries specifically relating to the anatomical injury patterns. The severe disruption to the intervertebral disc warrants special consideration with attention to a stable reduction position or three-column reconstruction. Spondylolysis may represent a predisposing factor.


Nick Birch Jules Grundy Andy Langdown

Introduction: Tarlov first described the sacral perineural cyst in 1938 as an incidental finding at autopsy. There is very little data in the literature regarding the natural history of Tarlov cysts and consequently the recommendations for treatment are vague. Various operative treatments have been suggested including cyst aspiration, cyst decompression, micro-surgical cyst imbrication & cyst plication with cement filling of bony defects. We were first presented with the difficulty of managing a patient with a large symptomatic sacral cyst in 1997 and found little in the literature to help advise the patient. This paper presents the results of a prospective observational study and describes the clinical relevance of the different types of cyst, showing how a simple clinico-radiological classification can be used to help manage patients with cysts.

Methods: Between February 1997 and December 2002, 3935 patients underwent standard three sequence MRI scanning (T1 and T2 sagittals and T2 axials) for lumbosacral symptoms in our hospitals. 62 patients had cysts in their sacral canals, an incidence of 1.6%. Additional contiguous axial and coronal scan sequences were carried out to fully characterise them. Once identified, the clinical picture was correlated with the findings on MRI.

Results: Tarlov cysts can be classified according to whether or not their presence is related to clinical symptoms. Type 1 cysts (n=38; 61%) are small, often multiple and are found at the most distal sacral segments. They are entirely unrelated to the patients’ symptoms and require no specific treatment. This has been confirmed when the primary pathology has been treated and the patients symptoms have been alleviated. Type 2 cysts (n=13; 21%) are usually single, unilateral and occur at the same level as the main cause of the patients’ symptoms, often a prolapsed intervertebral disc at L5/S1 with a Tarlov cyst in the S1 root canal. As such, the cyst itself will not require any treatment, which should be directed at the main pathology. Type 3 cysts (n=11; 18%) are the main cause of the patients’ symptoms and may require specific treatment. We have found that more than half of the Type 3 cysts can be managed expectantly with serial clinical and MRI review. However, the majority of these cysts (9 of 11) are massive and can cause both erosion of bone and compression of the lower sacral nerve roots. Three have to date required decompression to treat cauda equina symptoms.

Conclusions: The majority of Tarlov cysts are incidental findings on MRI. They may, however, either contribute to, or be responsible for a patient’s symptoms. Our classification system addresses this and offers guidance on patient management.


D Fender I Astori GN Askin

Introduction: Thorascopic techniques are an accepted and useful technique for spinal surgery. For certain clinical indications (i.e. thoracic kyphosis), an anterior spinal release followed by a posterior instrumentation may be indicated. The standard technique for a thorascopic anterior release is with the patient in the lateral decubitus position and intubated with a double lumen endotracheal tube (ETT), allowing one lung to be deflated for access to the spine. Placing a double lumen ETT and repositioning the patient before the posterior surgery both add to the duration of surgery. We report our initial experience using standard ETT ventilation, low pressure CO2 insufflation into the thorax to push the lung away from the operative field, and prone positioning, for thorascopic anterior spinal release, followed by posterior instrumentation. Although previously described for thoracic surgery 1,2, this technique has not been reported for spinal procedures.

Methods: Five male patients, mean age 15.4yrs (13–17yrs) have undergone thorascopic anterior release and posterior instrumentation as described above. CO2 insufflation pressure was maintained at 6mm Hg or less. There were three cases of Scheurmanns disease and two progressive kyphosis post laminectomy for intradural tumours. Clinical, operative (including intraoperative physiological measurements) and radiological data have been collected by a retrospective chart review.

Results: In all cases the anterior release was performed successfully followed by posterior instrumentation. Three portals were used in each and three to five levels released. Mean time from start of anaesthesia to completion of anterior release was 140 minutes. Intraoperative physiological measurements (EtCO2, SaO2, pulse, BP) remained stable in all cases during the endoscopic procedure. All patients were extubated postoperatively, spent 24 hours in ICU, and remained in hospital for a mean of 9 days (7 – 13 days). There were no significant complications. Mean kyphosis angle improved from 82 degrees preoperatively to 50 degrees postoperatively.

Discussion: Our initial experience with this new technique has been encouraging. There have been concerns regarding the physiological effects of inducing a tension pneumothorax 3, although our results are similar to others who have found low pressure CO2 insufflation to be safe 2. The prone positioning is especially suited for anterior release of a kyphotic spine as it allows the lung to fall away from the spine. Overall we feel this is a useful technique for anterior release of a kyphotic spine.


Nick Birch Steve Gwilym Nadim Aslam

Introduction: Recent evidence from the Swedish Lumbar Spine Group has confirmed the anecdotal opinions of many spinal surgeons that fusion for persistent back pain can be a very effective treatment. However, it is clear that many more variables operate in determining clinical success than just radiological evidence of solid fusion. The very careful selection of patients for low back surgery is, in the opinion of the authors, the most important predictor of success. This paper addresses this issue and presents data to show why clinical failure can coexist with radiological success.

Methods: Between October 1997 and January 2001, 3600 spinal fusion using Diapason pedicle screw instrumentation and Brantigan anterior interbody fusion cages was performed on 25 patients. During this period 5,850 new outpatients with back pain were assessed in the low back clinic. Patients were selected by the following criteria: Low back pain of two years or more duration; Pain resistant to all non-operative and minimally invasive treatments; Normal psychosocial profile; Normal body mass index; Non-Smokers; Single or two level disease on MRI proven to be painful by provocative discography; No current insurance or workers-compensation claims. Postal follow-up was at a minimum of 2 years post-surgery (mean 47 months) using the Low Back Outcome Score (LBOS) and x-rays taken at the two-year clinic follow-up were independently assessed to determine fusion.

Results: 24 patients returned the questionnaire (96%). Only 20 (83%) patients had ‘good’ or ‘excellent’ results, as defined by the LBOS. However, 92% of patients stated that they would opt to have a circumferential fusion again, if guaranteed the same post-operative result. The same number of patients stated they would recommend the treatment to friend or family member. Analysis of the post-operative radiographs revealed that spinal fusion (as defined by the Brantigan and Steffee criteria) was present in all 25 cases.

Conclusions: Our opinion that patient selection is the most important predictor of satisfactory outcome in spinal surgery is demonstrated in this study by the mismatch between the clinical and radiological results. We have identified the causes of clinical failure in this group of patients as: Multiple sites of musculoskeletal pain confounding the LBOS; Neuropathic leg pain that cannot respond to surgical treatment; More than two previous spinal operations; Excessive pre-operative disability and functional loss that confounds the LBOS; Poor psychosocial profile.

Stringent application of rigid selection criteria might improve outcomes in lumbar spinal fusion so that clinical and radiological results correlate more closely. However, even with adherence to such rigid criteria, the outcome tool (LBOS) may be confounded and a more holistic assessment of outcome, including a more sensitive subjective assessment of satisfaction, might be a better measure.


Nick Birch Steve Gwilym Matt Shaw

Introduction: The initial promise of stand-alone threaded anterior interbody fusion cages to treat chronic low back pain has not been maintained. In an attempt to overcome some of the problems associated with threaded fusion devices (endplate subsidence, failure to re-establish lordosis and displacement) a two-part ALIF cage was devised. The device consists of a rectangular frame that accommodates a threaded, open-weave cylinder holding bone graft material. The device addresses the biomechanical issues required for successful ALIF whilst providing a large area for bone in-growth and is a less invasive solution than a formal 3600 fusion.

Methods: From August 2001 to December 2002, 41 patients who fulfilled selection criteria for a single or two-level 3600 spinal fusion for low back and leg symptoms underwent ALIF using Stabilis. All patients had failed to improve with all non-invasive and minimally invasive treatments available to them. Prospective follow-up has continued for all cases using the Low Back Outcome Score and a Patient Satisfaction Score. Plain x-rays were taken at 3, 6 and 12 months post-operatively and the 12-month series included flexion and extension films.

Results: Ten patients (24.4%) have completed more than 12 months follow-up; 18 (43.9%) are between six and twelve months post surgery and the rest (31.7%) have less than six months follow-up. LBOS results for the first 10 showed 9 (90%) as excellent or good. LBOS results for the second group of 18 were excellent or good in 15 (83.3%). All but two of the 28 patients, would be prepared to undergo the procedure again and all would recommend the operation to a friend with similar trouble. Radiographic assessment at 6 months showed 16 patients had at least a partial anterior or posterior sentinel sign. Using motion criteria, all 10 cases at one year were fused on flexion and extension lateral x-rays. No devices migrated anteriorly or posteriorly and no lucent lines have been seen around the implants. Three of the two-level procedures showed some subsidence of the L4/5 implant into the L5 vertebral body, but none were symptomatic. No clear reasons have emerged to explain the clinical failure of 14% of the patients given the radiological success. In only one was there a mismatch in the LBOS outcome measure and the satisfaction rating.

Conclusions: Stabilis is a useful standalone ALIF device that not only addresses the theoretical biomechanical failures of anterior threaded interbody fusion cages, but has been shown in this early clinical and radiological evaluation to be effective, objectively and subjectively. It is likely that in the medium term future, fewer patients will require fusion to treat back and leg pain as the results from lumbar spine arthroplasty become established and non-fusion technologies become accepted. Until that time, experience in the UK and USA suggests that Stabilis is a good alternative to 3600 fusion.


Owen D. Williamson Ruth Cronje

Science is an endeavour built on facts. Scientific methods discover facts, which have force because they are believed to be directly observable and exist independently of theory. Facts so discovered, constitute the solid and reliable foundations of scientific knowledge. Science is objective and rational because it predicts and explains outcomes that are valid and reliable. Applying scientific methods to medical practice is therefore thought to protect medical decision making from arbitrariness, bias, and error.

Pain presents a particular challenge to physicians seeking to base their practice on science. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is defined as subjective, because it is an internal phenomenon, not directly observable. It represents a quality, not a fact.

Tensions arise when scientific methods attempt to include subjective experiences within its objective framework. These tensions however, must be resolved if subjective phenomena, such as pain, are to be treated in a reliable and rational manner.

This paper presents a philosophical exploration of the tensions inherent in the study of subjective phenomena, such as pain, within an objective framework, based on contemporary models of rationality.


Nick Birch Neil Orpen

Introduction: No previous cases of avascular necrosis (AVN) of the femoral head have been described in the World Literature, to our knowledge. This paper reports the catastrophic failure of the bony integrity of the hip in three patients (five hips) following prolonged hypotension during spinal surgery for spinal stenosis on a Montreal mattress and offers advice to prevent this complication of spinal surgery. A theory to explain this phenomenon is explored, but we recognize its limitations with such a small sample.

Method: The case notes of all patients undergoing decompressive spinal surgery in our hospitals between March 1997 and December 2001 were examined (168 cases). Three patients had been identified as suffering from AVN following prolonged hypotensive anaesthesia prospectively. No other cases were identified after the notes review. Clinical notes and pre- and post-operative radiographs were studied in an attempt to identify the factors that caused this complication in these three patients.

Results: Between 1997 and 2001, 168 patients underwent surgery for multi-level symptomatic spinal stenosis in our hospitals. Forty percent of the patients had an instrumented fusion as well as a decompression. During this period, three patients had catastrophic AVN of the femoral head requiring total hip arthroplasty soon after their spinal operation. All had some clinical and radiological evidence of hip arthritis at their pre-surgery visit. All subsequently, presented within symptomatic hip AVN within six months of the index operation. In two, histology confirmed the diagnosis of AVN, and typical changes of AVN were well demonstrated on MRI in the third patient.

Conclusions: The development of avascular necrosis of the femoral heads following surgery for spinal stenosis may be due to a femoral head at risk being exposed to hypotensive anesthesia, prone positioning on a Montreal mattress or a combination of the two. Careful intra-operative positioning may reduce the risk of this occurring after spinal surgery. However, close post-operative surveillance and a high index of suspicion of worsening hip pathology in patients who appear to mobilize poorly after lumbar spinal surgery may be the only method of early detection of this condition.


N. Aebli J. Krebs G. Davis B.G. Goss J.C. Theis

Introduction: Vertebroplasty (VP) is a new prophylactic treatment for preventing osteoporotic compression fractures of vertebral bodies. During this procedure polymethylmethacrylate (PMMA) is injected into several vertebral bodies. It has been shown that fat embolism (FE) with acute cardiopulmonary deterioration occurs during VP as in a variety of other orthopaedic procedures (e.g. knee and hip replacements). The aim of the study is to investigate cardiovascular changes during FE caused by multiple VP using an animal model.

Method: In six sheep, PMMA was injected unilaterally, into L1 – L6, with ten minutes in-between injections. Arterial, venous and pulmonary artery pressure, cardiac output and blood gas values were recorded pre injection and 1, 3, 5 and 10 minutes post injection. Post mortem lungs were harvested and the histopathologic score (percentage of lung fields occupied by intravascular fat globules as seen in the microscope) was calculated.

Results: The sequential injection of bone cement into six vertebral bodies from values pre injection of L1 to 10 minutes post injection of L6 resulted in: significant falls in arterial blood pressure (P< 0.0001), cardiac output (P< 0.0001) (P=0.0049), pO2 and pH (P< 0.0001) and significant rises in pulmonary arterial pressure (P=0.0005) and pCO2 (P< 0.0001),but no significant change in central venous pressure. The histopathological score was 19.1±1.94%.

Conclusion: This study clearly shows that multiple VP in sheep leads to FE with major cardiovascular reactions. Arterial blood pressure showed a stepwise, cumulative fall and was clearly the best parameter to demonstrate these reactions. This suggests, in human patients, particular attention should be paid to falls in arterial blood pressure during multiple VP.


Full Access
Richard P. Williams Richard A Emery Jon Dick Ben G.S. Goss

Introduction: Regular review [1, 2] of cervical injuries occurring in rugby players is an important step toward maximising the safety of the players. It is hoped that the recognition of recurring patterns of injury would lead to appropriate rule modification by the regulatory bodies of the sport. Serious cervical injuries in rugby have been reported to occur by a range of mechanisms, including those involved with scrummaging, tackling, rucking and mauling.

Spinal flexion is the commonest mechanism of injury and has been associated with scrum engagement, scrum collapse, rucking or mauling, and mistimed tackling. The second most common mechanism of cervical spinal injury is hyper-extension. This commonly occurs during tackling, particularly the ‘gang tackle’ involving several participants simultaneously, where sudden deceleration of a player’s head may lead to cervical hyperextension, focal spinal stenosis and potential damage to the spinal cord by a “pincer” mechanism.

The most commonly reported levels of injury are C5/6 and C4/5 [3].

Methods: A retrospective review of neck injuries presenting to a major spinal injuries facility and resulting from all codes of football (rugby union, rugby league, soccer, indoor soccer and touch) was conducted and 38 cases identified.

Results: Of the 38 patients 14 were injured playing rugby union, 15 rugby league, 3 soccer, 1 indoor soccer, 1 touch football and 4 were playing an unidentified code. 6 players were injured while scrummaging, 5 rugby union and 1 rugby league. 21 people were injured as tacklees, 4 as tacklers and 2 with unspecified involvement in a tackle. 1 person was injured whilst “heading” the ball, and 3 people were injured in a non-contact or unspecified action. At final follow-up, 4 people were found to be quadriplegic (ASIA A), 10 quadriparetic (ASIA B – 0 C −1 and D –9) and 24 recovered completely (ASIA E).


Sheryn Gillin Stuart Crozier Mark Pearcy

Introduction: An estimated 80% of all adults will experience back pain at sometime during their life. To aid in the understanding of how the spine functions as a mechanical system and assist clinicians in their diagnosis this study produced 3D models of the muscles in the lumbar spine region. The models show selected muscles at rest and during controlled activities.

Methods: The images were acquired on a Siemens Sonata 1.5T System using breathhold FISP sequences. Twenty slices of thickness 5mm and zero separation were acquired using an in-plane resolution of .68mm and Fast-Fourier-Transformed to 512 x 512. Single acquisitions were acquired per slice. Imaging time per posture (rest, extension, left rotation and right rotation) was approximately 17–20 seconds. All image series conformed to the DICOM Standard.

The code developed for this study was written in Interactive Data Language (IDL) Version 5.5 from Research Systems Inc (RSI).

Each slice from an image series was displayed to an Operator, who roughly selected the muscle(s) boundary. The user-selected points were then compared with the 24-neighbouring pixels, and the vertices moved to the minimum value in the 5x5 area, which corresponds to the muscle boundary. The adjusted region of interest was then displayed to the user for verification. Once the Operator had completed selection of the regions of interest in all slices, spatial smoothing was performed on the data, and 3D models of the muscles constructed.

Results: This analysis produces 3D images of the muscles in the lower back. The visualisation of the data enables different combinations of muscle and posture to be displayed. Typically, a muscle at rest is overlaid with one of the three controlled activities – extension, left or right extension. The 3D models can be displayed as either a meshed or solid object.

The 3D model is displayed in a window that enables an operator using a mouse to rotate, scale and/or translate the model.

To aid visualisation, the volume of each muscle of interest is calculated using the number of pixels within the region of interest, pixel spacing and slice thickness. The result, in mm3, is displayed alongside the 3D model.

Discussion: The refinement of MR Imaging techniques for subjects in a variety of postures, and the development of post processing techniques provides a useful tool for all in the understanding of the mechanics of the lumbar spine. It is envisaged that this tool with further analysis will assist in determining if there is a link between muscle volume during movement and lower back pain.


Ashish D Diwan Safdar N Khan Mike Peterkin Frank P Cammisa Harvinder S Sandhu Stephen Doty Joseph M Lane

Nitric oxide (NO) is a free radical labile gas which has important physiological functions and is synthesised by the action of a group of enzymes called nitric oxide synthases (NOS) on L- arginine. We have shown that nitric oxide modulates fracture healing1. Bone morphogenic proteins (BMP) are potent differentiating factors that augment the process of new bone formation. Recombinant human BMP-2 (rhBMP-2) enhances spinal fusion2. With progression of fusion there is a remodelling of the fusion mass bone accompanied with a decrease in the fusion mass size. It is not known whether nitric oxide has a role in spinal fusion or rhBMP-2 enhanced spinal fusion.

We studied this in a novel rat intertransverse fusion model using a defined volume of bone graft (7 caudal vertebrae) along with 157 mm3 of absorbable Type-1 collagen sponge (Helistat®) carrier, which was compacted and delivered using a custom jig for achieving a similar graft density from sample to sample. The control groups consisted of a sham operated group (S, n=20), an autograft + carrier group (AC, n=28) and a group consisting of 43μg of rhBMP-2 (Genetics Institute, Andover, MA) mixed with autograft + carrier (ACB, n=28). Two experimental groups received a nitric oxide syn-thase (NOS) inhibitor, NG-nitro L-arginine methyl ester (L-NAME, Sigma Chemicals, St Louis, MO) in a dose of 1mg/ml ad lib in the drinking water (ACL, n=28) and one of these experimental groups had rhBMP-2 added to the graft mixture at the time of surgery (ACLB, n=28). Rats were sacrificed at 22 days and 44 days, spinal columns dissected and subjected to high density radiology (faxitron) and decalcified histology. The faxitrons were subjected to image analysis (MetaMorph).

On a radiographic score (0–4) indicating progressive maturation of bone fusion mass, no difference was found between the AC and ACL groups, however, there was a significant enhancement of fusion when rhBMP-2 was added (ACB group,3.3±0.2) when compared to the AC group (1±0) (p< .001). However, on day 44, the ACLB group (3.3±0.2) showed significantly less fusion progression when compared to the ACB group (4±0) (p< 0.01). There was a 25% (p< 0.05) more fusion-mass-area in day 44 of ACLB group (297±26 mm3) when compared to day 44 of the ACB group (225±16 mm3) indicating that NOS inhibition delayed the remodelling of the fusion mass. Undecalcified histology demonstrated that there was a delay in graft incorporation whenever NOS was inhibited (ACL and ACLB groups).

Our results show that the biology of autograft spinal fusion and rhBMP-2 enhanced spinal fusion can be potentially manipulated by nitric oxide pathways.


D Fender GN Askin

Introduction: Endoscopic techniques are an established technique for anterior correction and instrumentation of thoracic scoliosis. Deterioration in respiratory function post thoracotomy for has been cited as a disadvantage of anterior approaches and led certain authors to recommend posterior methods1. Endoscopic techniques may reduce respiratory complications and respiratory compromise in both the short and long term.

Methods: Thirty eight patients, 7 male 31 female, mean age 17.3 yrs (11– 37yrs) have undergone endoscopic scoliosis surgery under the senior author. Indication for surgery was idiopathic scoliosis 36 and an underlying syrinx 2. All patients undergoing endoscopic scoliosis surgery have a standard preoperative assessment including respiratory function tests (RFTs). All patients have been followed up prospectively (mean 15 months, range 3 – 33 months) and standard data recorded. As part of this study we are in the process of performing follow up RFTs on all patients.

Results: Preoperatively no significant respiratory function compromise attributable to the scoliosis has been detected. Mean duration of intercostal drain was 2 days, one patient requiring reinsertion for a recurrent pneumothorax. No other major respiratory complication occurred. On average patients were fully mobile by day five and mean hospital stay was 6 days (4–10 days). Provisional RFTs postoperatively have shown no significant change.

Discussion: Our provisional results indicate that endoscopic scoliosis correction and instrumentation does not lead early respiratory complications or to a significant deterioration in respiratory function of the patient.


Andrew G. Hood

INTRODUCTION: Tissue growth factors have been extensively investigated as agents for acceleration of wound repair. Individual recombinant molecules have shown promise in animal models, but in humans both safety and efficacy remain questionable1,2 and costs are substantial. Recently introduced technologies allow intra-operative collection of the full naturally occurring array of tissue growth factors contained in platelets and white cells.3 These preparations rely on the normal healing cascade for their performance, and their activity is limited solely to the wound site without undesirable proliferative or inappropriate tissue formation and no systemic effects. Numerous methodologies have been proposed for intra-operative preparation of autologous tissue growth factors for topical application, and an ever widening variety of approaches and formulations are available to the practitioner.3 Physicians trying to decide which technique to adopt can easily find themselves bewildered while attempting to sift through myriad proponent’s claims.4

PURPOSE: This presentation will review the state of the art, including: a summary of the role of autologous growth factors in bone fusion; a discussion of the importance of dosage and carrier matrix effects; an outline of the mechanics of intraoperative preparation; a survey of the capabilities of various techniques, and; an overview of in vitro, experimental and clinical studies. Audience members will receive a detailed understanding of the physiology, mechanics and clinical range of applicability for this newly emerging technology. This information will aid clinicians in choosing the most appropriate methodology for their practice.


Kolban Maciej Balachowska Kolciolek Ina Zacha Slawomir Kolodziej Lukasz

Introduction: Further development of extensive spinal surgical techniques forced surgeons to find drugs helpful in reducing blood lose during surgery. These drugs are necessary in surgical treatment in patients with congenital or acquired bleeding disorders. Recombinant FVIIa appears to be an efficient haemostatic product for surgery in patients suffering from bleeding disorder Recombinant activated factor VII (rFVIIa) has recently been introduced for improving haemostasis in non-hemophiliac patients during extensive surgical procedures.

Aim: The present study evaluate the use of low dose of recombinant factor VIIa during scoliosis surgery and its influence on blood coagulation tests and hemostasis.

Material and Methods: 22 patients from evaluated group were treated with Cotrell-Dubosset distraction method with posterior spondylodesis and gibectomy during the same surgical procedure with bone grafts taken from patients iliac crest received a single 10 micrograms/kg dose of recombinant FVIIa given as a i.v. bolus.

Control group consists of 30 patients treated with use of identical surgical technique but without any factors influencing blood coagulation. Fibrinogen value, prothrombine time, APTT and INR value altogether with thrombocytes count were measured day before operation and 15 minutes, two, four and 12 hours after administration of rFVII.

Results: Authors report effective hemorrhage control, decrease in prothrombine time and INR value, reduced thrombocytes count and stabile patients hemodynamics parameters. Changes in these parameters occurred 15 minutes after intravenous administration of recombinant VIIa factor, remained unchanged up to 4 hours after dosage and it’s normalization were observed 12 hours after single intravenous bolus of 10 micrograms/kg of body mass. APTT and fibrinogen value remained unchanged.

Conclusion: Authors conclude that use of small doses of recombinant VIIa factor causes short and fast thrombin activation by relived tissue factor (TF), what effectively reduces bone ant tissue bleeding during extensive surgical procedures.

The use of recombinant VIIa factor shortens operation time and reduces number of blood transfusions.


E. Kyriakou L. Bilston M. Stoodley A. Brodbelt

Introduction: Post-traumatic syringomyelia typically occurs in the spinal cord adjacent to a region of arachnoiditis. This research tests the hypothesis that pressure pulses in the subarachnoid space (SAS) are higher adjacent to the arachnoiditis than in its absence. A fluid-structure interaction (FSI) analysis has been performed to study this behaviour under both normal physiological conditions and in the presence of arachnoiditis.

Method: A 2-dimensional axisymmetric cylindrical FSI model has been developed to represent the spinal cord and the SAS. CSF flow into the SAS is defined from MRI flow studies. Arachnoiditis is modelled as narrowing of the SAS. This model was based on a patient suffering from post-traumatic syringomyelia. Only the cervical region where arachnoiditis occurs has been modelled, that is from C1 to T1.

Results: Pressures in the SAS adjacent to arachnoiditis are almost 3 times higher (7.2 Pa vs. 21.67 Pa) than without arachnoiditis, with peak pressure occurring at the time of peak fluid inflow from the foramen magnum.

Discussion: The model supports the hypothesis that pressure pulses in the SAS are higher in the presence of the arachnoiditis than in normal unobstructed SAS. This elevated pressure may be implicated in syrinx formation.


William Sears

Introduction: Since Briggs and Milligan first described posterior lumbar interbody fusion (PLIF) in 1944, it has been a controversial technique. However, modern pedicle screw instrumentation and the use of intervertebral spreaders and implants have provided a powerful technique for the restoration of spinal balance in degenerative deformity.

This study assesses the functional outcomes and safety in a series of patients undergoing complete reduction and posterior interbody fusion (PLIF) of lumbosacral spondylolisthesis with interbody fusion spacers implanted using an Insert and Rotate technique.

Methods: A prospective, non-randomized, observational study of pre- and post-operative data, in a series of 35 patients with lumbosacral degenerative or isthmic spondylolisthesis, between April 2001and June 2002. All patients underwent decompressive laminectomy followed by complete reduction of the spondylolisthetic deformity with the aid of intervertebral disc space spreaders and pedicle screw instrumentation. Wedge shaped spacers made from Carbon Fiber, Titanium mesh or PEEK plastic were then inserted on their sides and rotated 90 degrees to support the vertebral end plates prior to placing bone graft beside them, within the disc space.

Outcomes were measured using the Low Back Outcome Score (LBOS), SF-12, visual analogue pain scores (VAS) and patient satisfaction survey.

Results: Of the 35 patients, 24 had degenerative spondylolisthesis and 11 were isthmic in type. 26 were Meyerding Grade I; seven were Grade II; one was Grade III and one was Grade IV. The indications for surgery included relief of foraminal stenosis in 26 and likely post operative instability in 24. Average time of last follow-up was 7.4 ± 3.0 months. Data is available on 34 of the 35 patients at 3 months and 29 at six to twelve months (83%). Mean pre-operative VAS and LBOS were 5.1 ± 2.5 and 26.5 ± 16.9, respectively. Mean scores at last follow up were 2.2 ± 2.4 and 45.6 ± 14.6 (p< 0.01 for both measures). At last follow-up, 30 of the 35 patients or 88.2% described their outcome as good or excellent. One patient considered himself worse. 91% said the procedure had been worthwhile but only 79% said they would have it again under similar circumstances.

There were no deaths. There were no interbody implant / PLIF related problems but five intraoperative problems related to pedicle screw placement with one screw loosening during slip reduction, requiring replacement. Post-operatively, 3 patients developed an ileus. One patient developed a probable wound infection with high fever which settled on antibiotics.

Discussion: This series represents a recent subset of a much larger total series managed with this technique for symptoms associated with spondylolisthetic deformity (187 patients to date). The author has previously reported to the society on the clinical results of the technique but without the benefit of prospective pre-operative data. This smaller series appears to confirm the results of the earlier studies and suggests that PLIF using an Insert and Rotate technique can yield satisfactory clinical outcomes with high patient satisfaction and low levels of complications.


AFM Mckee MC Oliver F Qureshi S Rajaratnam JAN Shepperd

Introduction: We report a series of 90 patients enrolled in a prospective study of Dynesys stabilisation reviewed at 12 to 30 months.

The procedure involves, at each segment, cephalad and caudad pedicle screws connected with a polycarbourethane spacer and polyethylene cord. It achieves load relief and controlled flexion. Since 1996, 7000 procedures have been undertaken globally.

Method: Indications are analogous to consideration for fusion. Entry criteria included 1) Unresolved and unacceptable lumbar back pain despite protracted conservative management and 2) Definite pathology where symptoms could be abolished by anaesthetising the target segments.

Where root compression was present, a midline approach and posterior screw placement was used in conjunction with open decompression. With back pain alone a bilateral Wiltse approach and posterolateral placement was used.

All patients were assessed pre and post surgery with SF36, Oswestry Disability Index and pain analogue scores and modified Zung. Standing radiographs were obtained post surgery and at review. Follow up was at 6, 12, 24 and 52 weeks in addition to this review.

Results: Follow up was 100%. 89 patients survived. Mobilisation was achieved on day 1 and discharge usually by day 2.Based on the above outcome measures and patient satisfaction good to excellent results were achieved in 74%(66/89). Screw loosening or breakage occurred in 8%, and was associated with a poor result.

Discussion: Dynesys flexible stabilisation offers a simple alternative to fusion with less potential for adjacent ‘Domino’ failure. It differs from tension ligament systems such as Graf. At this stage the results appear at least as good as a comparable cohort of fusion patients.

The present series is early, but gives grounds for encouragement. Screw loosening and failure are technical problems detracting from the result and require further development.

We are continuing to use the technique.


AFM McKee MC Oliver F Qureshi A Khurwal Jan Shepperd

Introduction: Treatment of discitis using conventional methods can be prolonged and unrewarding. Patients can have prolonged pain and persistently elevated Inflammatory markers. We propose a new method of treatment of severe cases, and present two cases where this method has successfully been used.

Method: Once discitis has been diagnosed clinically and radiologically, a percutaneous discectomy of the infected level is performed. Matter is sent for microbiological analysis. An epidural catheter is then left in the infected disc space cavity. This is then used to administer appropriate antibiotics directly into the infected cavity. After one week the patient is converted on to intravenous antibiotics, for a further two weeks, then a prolonged course of oral antibiotics.

Discussion: Discitis can be a difficult and unrewarding condition to treat. This novel method appears to be a new and effective mode of treatment, for both acute and chronic infections, although it does require further evaluation.


J Paige Smallhorn Clayton Adam Graeme Pettet Mark J Pearcy

Introduction: A computer model of the L4/5 human intervertebral disc is currently under development. An integral aspect of this model is the material properties assigned to its components. Detailed data on the material properties of the anulus fibrosus ground matrix are not available in the existing literature. To determine these properties, mechanical tests were carried out on specimens of anulus fibrosus harvested from sheep spines. The tests included unconfined uniaxial compression, simple shear and biaxial compression. Data on the strain required to cause permanent damage in the anulus ground matrix and data on the mechanical response of the anulus to repeated loading were obtained.

Methods: Intervertebral discs were isolated from the lumbar spines of recently sacrificed sheep. These discs were sectioned into test specimens ensuring there were no continuous collagen fibres bearing load. The edge dimensions of the cubic specimens were 3 ± 0.2mm. To ascertain the strain to initiate tissue damage, the specimens underwent successive loadings, which were carried out 1 hour apart to allow recovery. The maximum strain in each test was increased incrementally by 5% until a reduction in stiffness was observed in the following test. Separate tests were carried out to quantify and characterise the response of the anulus ground matrix in the three modes of loading and to strains greater than that which initiates damage.

Results: The strains at which permanent tissue damage occurred were between 20 and 27% in uniaxial compression and between 25 and 35% in simple shear. Testing the specimen beyond these strains showed an obvious reduction in stiffness. The biaxial compression tests showed similar changes but did not result in such pronounced losses in stiffness. The material characteristics were reproducible up to 20% strain. Following deformation to higher strains the altered mechanics were also shown to be reproducible indicating that the matrix had been deranged but not failed.

Discussion: Average physiological strains in the L4/5 intervertebral disc are in the order of 10–50% based on maximum deformations observed in vivo. The current results demonstrate that this strain will cause some permanent damage to the anulus ground matrix, however, the matrix will still be capable of carrying stress upon repeated loading. Thompson et. al.1 found that people over the age of 35 all exhibited signs of disc degeneration. We hypothesise that the regenerative ability of the anulus ceases to function effectively as we age and the continual damage caused to the anulus tissue by daily activities may lead to the degenerative changes seen in the anulus.

Knowledge of the material characteristics up to 20% strain and following exposure to higher strains will enable a more realistic model of the intervertebral disc and the effects of degeneration to be studied.


A Epps T K F Taylor M-C Waugh

Recent years have seen a decided swing from the longstanding inpatient model of rehabilitation to an outpatient model for all branches of medicine in Australia. This swing has been largely cost-driven and is unlikely to change. This paper reports on the development of a paediatric spinal outreach team (ORT) in NSW. The ORT was formed in 1993 and consists of a nurse, physiotherapist, occupational therapist and a social worker. It functions in close collaboration with the two children’s hospitals in Sydney. Approximately 10–11 new cases of paraplegia/quadriplegia occur in children/adolescents (up to 18 years of age) in NSW each year. Their therapeutic needs change with growth, development and maturation. Families in regional NSW have special requirements and website information services (distance education) will play an important role for them in the future. Integration with an organisation which provides ancillary services is essential for a comprehensive, statewide program.

It is suggested that a comparable service would play an equally important role in other states. Case studies to demonstrate savings to be made with this type of service need to be done to secure recurrent government funding.


RM Walters R Rahmat RJ Moore RD Fraser

Introduction: Infection can occur after any spinal procedure that involves entry into the disc and although it is not common, the potential consequences are serious. Treatment usually requires identification of the bacteria followed by a course of antibiotics. This treatment remains controversial since it is not clear whether antibiotics actually penetrate the disc and if so, whether they are effective, or even if the outcome would be the same without antibiotics.

For an antibiotic to be effective against the infecting organism it must diffuse through the disc matrix. Blood vessels that surround the disc facilitate the diffusion process, but with age this vascularity decreases and may impede diffusion.

The aims of the pilot study were to assess the effectiveness of antibiotic in treating infection in both normal and degenerate sheep discs and to measure the concentration of antibiotic in non-operated discs at varying ages.

Methods: In each of six Merino wethers aged 12 weeks (n=3) and 24 months (n=3), two lumbar discs were “degenerated” by incising the posterolateral annulus with a scalpel blade. After four weeks all animals had discography with radiographic contrast that contained Staphylococcus aureus at the incised levels and at two non-incised levels. Seven days after infection four animals began IV antibiotic treatment with cephazolin sodium (David Bull Laboratories, Australia) for 21 days at a dose of 50mg/kg/day. The antibiotic was chosen for effectiveness against S. aureus. One control animal from each age group did not receive any antibiotics, to follow the natural progression of infection. Lateral radiographs of the lumbar spine were taken at two, six and 12 weeks. At 12 weeks all sheep were given a single intravenous dose of cephazolin sodium as either a 1, 2 or 3g dose. The sheep were then killed after 30 minutes. The spines were removed and prepared for light microscopy to assess pathology of the discs and for biochemical analysis of antibiotic concentration. Success of treatment was judged using histologic and radiographic features.

Results: Discitis was evident radilogically as early as two weeks after inoculation in all animals. Histology at 12 weeks confirmed discitis in all discs regardless of treatment. Biochemistry results confirmed that antibiotic diffused throughout the disc but was more concentrated in the annulus than the nucleus. At all doses disc concentration of antibiotic was higher in lambs than sheep.

Discussion: Treatment with cephazolin sodium at a dose of 50mg/kg/day for 21 days administered from seven days after inoculation, did not prevent discitis. This does not appear to be due to inability of antibiotic diffusion into the disc.


AW Watling MA Stoodley Tu J AR Brodbelt

Introduction: Apoptosis has been observed following experimental contusive and transective spinal cord injury, but it is not known whether this is related to secondary excitotoxic injury or other factors. This study examines apoptosis after a purely excitotoxic injury and the relationship between apoptosis and syrinx formation.

Methods: Twenty-four male Sprague-Dawley rats were divided into six groups. Twenty rats received four 0.5 μL injections of 24 mg/mL quisqualic acid and 1% Evans blue between the rostral C8 and caudal T1 level. Ten microliters of 250 mg/mL kaolin were then injected into the subarachnoid space. Animals were sacrificed at 1, 5, 10, 20 and 50 days following the injections. There were 4 control animals. Spinal cord tissue was frozen and sectioned, and damaged DNA was detected immunohistochemically by using anti-single-stranded DNA monoclonal antibody. The area and density of single strand DNA were semi-quantitated.

Results: No significantly damaged DNA was found in the 1 day group. Light staining of single-stranded DNA was observed at C6, C7, T1 and T2 levels in 30% of the section area in the 5 and10 day groups. Moderate staining of damaged DNA occurred at C7 and T1 levels in 25–30% of the section area at 20 day group. Syrinxes formed in this group. Heavy staining and larger syrinxes were noted in the 50 day group.

Discussion: Apoptosis increased with time after excito-toxic injury. These findings suggest that apoptosis may play a pivotal role in syrinx pathogenesis.


L.A.M. Honorez V.F. Harding I-H. Jeon J.L. Ford W.A. Wallace

Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. It has been observed that CS values decrease with age and attempts have been made in Canada (Constant, 1986), Germany (Tempelhof, 1999), Switzerland (Gerber, 1992) and US (Romeo, 2002) to produce national norms. Unfortunately the methods used for measuring the “Strength” category of the CS have varied. This study aimed to establish UK norms.

Methods: 200 patients stratified for age over 50 were invited to take part in this study for which Local Ethics Committee approval had been obtained. Of these 200, 46 patients (21 males) attended and all attendees had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a Nottingham myometer – M(max); 3) mean force from 2 to 4 seconds using a Nottingham myometer – M(mean). Results: The results for the 25 females and 21 males using M(mean) show a general trend of decreasing Constant Score with increasing age for the left and right shoulders of both the male and female subjects. There were some outliers, particularly in the female results, which were reflected in widened 95% confidence intervals. Paired student t-tests found statistically significant differences between M(mean) and FSB (max) results (left, p< 0.01; right, p=0.013) and M(mean) and M(max) (left, p< 0.01; right, p< 0.01).

Discussion: The results confirm deterioration in the CS with age in both men and women. Constant Score values from our study differ from previous studies, with up to 15 points difference between our results and those from Romeo 2002.

Significant differences were identified between the 3 methods of “Strength” measurement, highlighting the need for a uniform method of carrying out the CS. Conclusion: The UK pattern of deteriorating CS with age mirrors that seen in other countries but the values are different. These differences are significant and make it necessary to reconsider the use of the corrected CS. It is probably wiser to use the uncorrected CS but refer to normal values as a guide for the expected CS at different ages.


D J Cloke J R Williams

The aim of the present study is to compare the Oxford Shoulder Score (OSS), the Shoulder Pain and Disability Index (SPADI) and the SF36 in terms of their correlation and sensitivity to change in a group of patients with subacromial impingement.

Patients attending a specialist shoulder clinic over a six-month period with a diagnosis of subacromial impingement completed the OSS, SPADI and SF36 on each of up to four attendances at six-week intervals, regardless of treatment. The data were analysed by creating scatter plots for each scoring system compared with each other, calculation of correlation coefficients, and calculating the effect size for each scale between subsequent visits (the difference in mean score divided by the standard deviation of the change in score for all individuals). This is a measure of sensitivity to change.

Three-hundred and twenty-three sets of scores were obtained in 110 patients. Scores were recorded across the whole range of the OSS and SPADI in our population. Similarly, the physical functioning component of the SF 36 ranged from 0 to 100. However, total SF 36 scores ranged only from 478 to 831.

There was good correlation between the OSS and SPADI scores (correlation coefficient = 0.86), although in 71% of observations the SPADI score was greater than the OSS when expressed as a percentage. The correlation between the OSS and SPADI was less good with the physical functioning component of the SF 36 (0.57 and 0.51 respectively), and worse with the total SF 36 (0.37 and 0.27 respectively) The OSS and SPADI showed good effect sizes (0.211 and 0.212) compared to the physical functioning and total SF 36 scores (0.104 and 0.063).

The OSS and SPADI show close correlation between each other, and were similarly sensitive to change in a group of patients with impingement. However, the SF 36 shows a poor spread of scores and less sensitivity to change in this group. These data support the use of the OSS or SPADI in these patients.


V.F. Harding L.A.M. Honorez I-H. Jeon K.J. Fairbairn K.H. Lateif J.L. Ford W.A. Wallace

Introduction: This study was designed to investigate which parameters of the Constant Score are most influenced by the presence of a Rotator Cuff Tear (RCT).

Methods: 28 patients attending the Shoulder Clinic took part in this study for which Ethics approval had been obtained. Strength measurements were assessed in three ways: 1) maximum force using a fixed spring balance (FSB) 2) maximum force using the Nottingham Mecmesin Myometer 3) mean force during 2nd to 4th seconds using Nottingham Myometer. The CS assessor was blind to the volunteer’s history and state of their rotator cuff. Ultrasonography was used to establish the presence of a full-thickness RCT.

Results: The CS values for the left and right shoulders were analysed separately. No statistically significant difference (p> 0.05) was found between shoulders with a RCT and without a RCT in the pain, ADL and ROM parameters. Left shoulders with a RCT scored significantly different strength scores to those without (p< 0.05) but this significance was not seen in the right shoulders (p> 0.05). Shoulder strength measurements were highest with the FSB and lowest when measured using the mean force.

Discussion: The results obtained so far suggest that a shoulder with a full-thickness tear of the RC may obtain a significantly lower strength score than a normal shoulder. It does not suggest that any of the other three parameters of the CS can indicate the presence of a tear.

Conclusion: A reduction of shoulder strength alone might be a good indicator of a full-thickness RCT. However, this study indicates the importance of standardising the method of shoulder strength assessment for the Constant Score.


ES Powell IA Trail J Haines

87 patients (51 male, 36 female; mean age 57, range 30 to 82) underwent arthroscopic subacromial decompression (SAD) and were followed up for one year. We calculated the ASES, the Constant, the DASH Disability/ Symptom, and the SF-36 Physical Function scores.

All the scores improved throughout the follow-up period, although the SF36 score showed less marked improvement. Comparing the preoperative and one year values there were significant improvements at one year (p < 0.001) for the three upper-limb-specific scoring systems (ASES, Constant and DASH), and for the SF36, but less so (p = 0.001). Comparing the 6 months and one year scores there were significant improvements in the ASES, Constant and DASH scores, but not in the SF36 score. This suggests that improvement may still be continuing at one year.

No significant differences in the postoperative scores for the four acromion operative appearance groups (normal, minor scuffing, marked damage, bare bone areas) were found, or for the operative cuff appearance groups (normal, minor scuffing, partial tear, full thickness tear, massive cuff tear).

We also asked for the patients’ assessment of their outcome at one year, using a satisfaction visual analogue scale (VAS), and two category selection questions relating to satisfaction and to perceived room for further improvement respectively. Patients were coded as successes or failures on their responses to the VAS and the two questions. There seems to be an association with cuff appearance and success or failure as determined by the response to the room for improvement question. More specifically, this difference seems to be due the infraspinatus. A normal infraspinatus is associated with a successful outcome as perceived by the patient.

In conclusion, with SAD recovery may not be complete at one year. The three limb-specific scores are equally useful in monitoring progress, whereas the more general SF36 score is less useful. The state of the acromion or cuff does not have an effect on outcome as measured by the commonly used scores. The appearance of the infraspinatus may be predictive of success as measured by the patient.


I Bisbinas A Mirza M Green DJA Learmonth

Rotator cuff or long head of biceps tendon tears are common in patients with degenerative shoulder rotator cuff disease. Most often they are investigated with an MRI scan. Diagnosis prior to surgery is useful for the appropriate surgical planning.

We present 63 consecutive patients who had arthroscopic shoulder surgery and prior to that had MRI investigation between 1994 and 2001. Their medical records were reviewed; arthroscopic operative findings as well as the report of the MRI scan were recorded and compared retrospectively. The aim of our study was to assess the accuracy of MRI findings comparing the arthroscopic ones regarding rotator cuff and biceps tendon pathology.

There were 63 patients with mean age 58 years. All of these had MRI scan investigation and the waiting time prior to surgery was 10 months. It was found that there were 6 false (−)ve, 1 false (+)ve and two cases with full thickness cuff tears which were reported as probable tears. Further to that, there were 11 frayed biceps tendons, 8 partially ruptured, 3 subluxed, 4 complete ruptures and 1 SLAP lesion. All biceps lesions were not commented in the MRI scan reports.

MRI scan is very sensitive detecting soft tissue pathology in shoulder investigation. However, even on that basis, rotator cuff and in particular biceps tendon pathology can be missed. The shoulder arthroscopy is the best method to accurately diagnose those lesions. However, it should be noted that often the surgeon has got to alter to working surgical plan in order to address the problem intraoperatively.

In this study it is demonstrated the MRI scan often misses rotator cuff or long head of biceps tendon pathology. The most sensitive method for the diagnosis of it is the shoulder arthroscopy, which address its treatment in the same time.


D J Cloke C T Gibbons A N Stirrat

A prospective study to assess the long-term outcome of ASAD (arthroscopic subacromial decompression) in the presence of un-reconstructable large and massive cuff tears using a modified Constant score.

All patients under the care of the senior author admitted for ASAD had a modified Constant score recorded pre-operatively, excluding the power component. Review of patient notes between May 1994 and August 2000 identified 40 patients (45 shoulders) with un-reconstructable rotator cuff tears found at the time of surgery. Nine patients failed to attend. Thirty-one patients (35 shoulders) were scored by a single independent observer. Five shoulders were excluded having undergone subsequent surgery. Five pre-operative scores could not be retrieved. The preoperative and review scores were compared in the remaining 25 patients (25 shoulders).

The average age at review was 75 years (range 39–85) with mean review of 51 months from surgery (range 20–94). In the studied population the mean score increased as follows (95% confidence limits in parentheses). Mean pain score improved from 4.8 (+/−2) to 8.5 (+/−1.6), the mean activities of daily living score increased from 8.9 (+/−1.5) to 12.6 (+/−2.4) and the range of motion improved from 22.9 (+/−2.9) to 31.3 (+/−3.3) points.

The total score improved from 36.6 (+/−4.6) to 52.4 (+/−6.5). The average gain for each patient was 15.8 (+/−6.5)

The 95% confidence limits indicate significant improvement for pain, range of motion and total score.

In our study population of patients undergoing ASAD in the presence of un-reconstructable cuff tears, the 95% confidence limits of the preoperative and follow up scores do not overlap. ASAD confers significant benefit in patients with large cuff defects.


J Szymankiewickz R Ramesh T Bunker

Development of a novel technique of arthroscopic rotator cuff repair which adapts the proven strong open technique using the Arthrex Post (low profile screw) into an arthroscopic technique by using the Arthrex Biotenodesis screw technique. The theoretical advantages of this technique are the ability to use stronger suture material, with a simple, tolerant, knotless and adaptable technique

Prior to use of this technique on patients we required laboratory confirmation of its benefit over present techniques. We have previous experience with laboratory testing at Exeter University using a MONSANTO TEN-SIOMETER for the previous Arthrex Post system. A similar experimental model was used for this study comparing two methods of fixation:

standard arthroscopic technique with Corkscrew anchor to decorticated footprint area on fresh frozen porcine humerus.

New technique with number 2 Ethibond to biotenodesis screw in metaphyseal area of fresh frozen porcine humerus

Initial results show a significant advantage of the biotenodesis technique with failure at over 1,000 N compared to 113N for a 2cm bone tunnel and 180N–600N for anchors. This shows promise for use in patients.


M Almaiyah B Fourie L Goodchild P Finn A Rangan

To determine if the surface area of partial thickness (< 50%), Bursal side tears of the cuff influence outcome following Subacromial Decompression.

Shoulder function using Constant score (CS) was recorded before and a minimum of one year after Arthroscopic Subacromial Decompression (ASD) in patients undergoing surgery for primary impingement. In patients who had partial thickness, Bursal side tears (BT), the length of the tear in its largest dimension (surface area) was measured. These patients were divided into two groups according to the tear surface area (≤9 mm and ≥10mm) .To determine whether having a BT (< 50% thickness) or its surface area affect pre and postoperative CS, t-tests were performed.

110 patients underwent ASD over a one-year period for primary impingement. 22 patients with partial thickness BT and18 patients with intact rotator cuff were included in this study. In 10 patients, the BTwas ≤9 mm (mean7mm) and in 12 patients BTwas ≥10mm(mean13mm). Statistical analysis of Pre-& postoperative Constant scores showed that, in ≤9 mm group CS increased significantly by 21.5, p=0.02, 95% CI (4.9, 38.1). CS increased in ≥10mm group by 22.8, p< 0.01, 95%(11.5, 34.1). Comparing the change in CS between these two groups with different tears size, there was no significant difference (2-sample t-test, t=0.15, 20df, p=0.88).

To determine whether having BT tear affects pre- and post-operative Constant scores, all BTs were grouped together and compared with the group of patients with intact cuff.

In the group with BTs, average Constant scores increased significantly (paired t-test,t=5.24,21df,p< 0.01) by 22.2 with 95% CI (13.4, 31.0). In the group with no tears, average Constant scores increased significantly (paired t-test,t=5.17,17df,p< 0.01) by 26.6, 95% CI (15.8, 37.5).

Comparing the levels of absolute change in Constant scores from pre- to post-operation between the two groups there is no difference in outcome between patients with a tear and those without a tear (2-sample t-test, t=1.03, 38df, p=0.31).

We conclude that ASD yields satisfactory results in patients with BTs involving < 50% thickness, irrespective of the surface area of the tear.


I Bisbinas A Mirza M Green DJA Learmonth

Rotator cuff pathology is common in orthopaedic patients. However, there are still debates about the best way of treating those patients. We present the clinical experience from our Unit.

We present 85 patients who had arthroscopic or arthroscopically assisted shoulder surgery for full thickness rotator cuff tears between 1994 and 2001. Their medical records and radiological investigations were reviewed, and the management as well as the outcome of their treatment were recorded. The aim was to review those patients and determine if optimum assessment and management was implemented to them.

There were 47 male and 38 female patients with average age 58.8 years and weight 79.9 kg, 32 of the patients reported trauma prior to their symptoms. 63 patients had MRI scan and they had average 2.6 years of symptoms and 2.4 steroid injections before their operative management. 27 patients had arthroscopic and 58 mini open rotator cuff repair. From those with recorded pain management 32 patients had interscalene block and 21 infiltration with local anaesthetic. Their average hospital stay was 1.4 and 1.8 days for the arthroscopic and mini open repairs respectively. In 69 (77.7%) patients the result was considered overall satisfactory; 8 (9.4%) patients had temporary shoulder stiffness and/or pain, which were treated conservatively with steroid injections and physiotherapy. 11 (12.9%) of the patients required reoperation, 5 from which required cuff resuturing and 4 manipulations under anaesthetic for postoperative stiffness. 3 patients (3.5%) had other than shoulder complications including CVA, chest infection, and CTS.

Rotator cuff surgery remains a challenge where often the working surgical plan is altered intraoperatively and tissue quality is of major importance for the final outcome. Arthroscopy has reduced patient’s hospital stay and rehabilitation time. However, a not durable repair, or postoperative stiffness can be a potential risk complicating the surgical result.

In this study it is demonstrated that treatment of patients with rotator cuff disease is still a challenge, time in hospital is reduced with arthroscopic management, but the overall risk for reoperation/MUA either for not durable previous repair or postoperative stiffness was still quite high (12.9%).


E Rath T Even H Brownlow SA Copeland O Levy

Use of shoulder manipulation in the treatment of frozen shoulder (FS) remains controversial. One of the purported risks associated with the procedure is the development of a rotator cuff tear. However the incidence of iatrogenic rotator cuff tears has not been reported. The purpose of the study was to assess the effect of manipulation of the shoulder on the integrity of the rotator cuff.

In a prospective study 20 consecutive patients (21 shoulders) with FS underwent manipulation of the shoulder under anaesthesia (MUA). The average duration of symptoms was 7.3 months (4–18 months). Patients were assessed pre and post manipulation using the Constant score. An ultrasound scan of the rotator cuff was performed before and at 3 weeks after manipulation.

In all patients, pre and post manipulation ultrasound scans showed the rotator cuff to be intact. At 12 weeks after manipulation all patients indicated that they had none or only occasional pain. The mean improvement in motion was 83 degrees (range, 20 – 100°) for flexion, 95 degrees (range, 20 – 120°) for abduction, 58 degrees (range, 0 – 80°) for external rotation and 3 levels of internal rotation (range 3–5 levels). These gains in motion were all significant (p < 0.01). No fractures, dislocations or nerve palsies were observed.

In conclusion manipulation under anaesthesia for treatment of frozen shoulder resulted in significant improvements in shoulder function and pain relief as early as 3 weeks after surgery and was not associated with rotator cuff tears. When performed carefully this procedure is safe and leads to early improvements in pain relief, range of movement and shoulder function.


G Gillespie H Dabke P Roberts R Kulkarni

A previous study done in our unit showed good results in terms of union, stability and function following 2-suture repair of proximal humeral fractures. Healing took place usually with a mild degree of varus angulation but one failure of this technique when the fracture slipped into varus prompted us to re-evaluate our technique. The addition of a third (lateral) suture to the repair has been used as routine following this.

A prospective series of 24 patients with displaced Neer 2 and 3 part proximal humeral fractures was studied. The patients were reviewed at a mean of 22.5 months post fixation. The patients were reviewed clinically and graded according to the Constant Shoulder Score to assess range of movement, power, function and pain. This was compared to the contralateral uninjured shoulder.

Radiographic evaluation of fracture union, avascular necrosis and malunion was performed, and any complications of treatment were noted.

There were 24 2- and 3-part fractures. All the fractures united with no radiological evidence of avascular necrosis. At follow-up there was a mean Constant Score of 71.05 compared with a mean score of 84.5 on the uninjured contralateral shoulder. Active abduction of > 120° was achieved in 9 patients. Intraoperative stability in the varus/valgus plane was noted to be better.

All patients were satisfied with the results; the problem of instability in the coronal plane has not been a problem and the fractures have healed with no varus mal-union. There have been no additional complications with this technique compared to the 2-suture method.

We have successfully achieved stability after open reduction and suture fixation of 2- and 3-oart fractures of the proximal humerus. Following one case of varus instability using a 2 suture technique,

We have routinely supplemented this with a third (lateral) suture. There have been no additional complications using this method, the angulation of the fractures once healed are improved and none of the repairs have had a problem with varus slip.


A Bebbington A Al-Allak P Lewis S Blease R Kulkarni

To identify any shoulder joint pathology on MRI of young patients (< 35 yrs) with a single simple antero- inferior dislocation of the shoulder at minimum 5-year follow-up.

Patients aged 16–35 years with a single antero-inferior shoulder dislocation with a minimum 5-year (range5–9 yrs) follow-up were identified. A history of recurrent dislocation or surgery excluded patients from study. Ethical approval was obtained and identified patients were asked to volunteer for clinical review and have an MRI scan. Shoulders were clinically examined, noting specifically any signs/symptoms of rotator cuff pathology or instability. All shoulders were imaged with a 1.5 Tesla open MRI scan to assess any pathology.

In a 5-year period (1994–1998), 349 patients sustained an antero-inferior dislocation. 251 were in patients aged 35 years or less. 136 of these were excluded either due to recurrent dislocations. 62 patients were lost to follow-up of 53 eligible patients 7 could attend for study. Only one patient had a positive anterior apprehension sign but he did not have any symptoms of instability in his daily activities or sport. The only abnormality demonstrated on MRI was of a united greater tuberosity fracture in one shoulder. The glenolabral and bicipitolabral complexes were normal in all shoulders imaged.

Bankart lesions, both bony and labral, are known to be associated with recurrent anterior shoulder dislocations.This study has shown no shoulder joint pathology on MRI at minimum 5-year follow-up in young patients who have sustained a single antero-inferior shoulder dislocation, confirming that labral pathology seems to be important in recurrent dislocations. Further study to image more patients is underway. These results indicate that acute imaging of dislocated shoulders may be useful to help predict young patients who are unlikely to re-dislocate and thus unlikely to require surgery.


M Freudmann S Hay

To discover how traumatic anterior shoulder dislocation in the young patient (17–25) is managed by shoulder surgeons in the UK.

A comprehensive postal questionnaire was sent to 164 orthopaedic consultants, all members of BESS. Questions were asked about the initial reduction, investigations undertaken, timing of any surgery, preferred stabilization procedure, arthroscopic or open, detail of surgical technique, period of immobilization and rehabilitation programmes instigated in first-time and recur- rent traumatic dislocaters.

The response rate was 82% (n=135)

The most likely treatment of a young traumatic shoulder dislocation:

It will be reduced under sedation in A& E by the A& E doctor.

Apart from x-ray, no investigations will be performed

It will be immobilised for 3 weeks, then given course of physiotherapy

Upon their second dislocation, they will be listed directly for an open Bankart procedure (with capsular shift as indicated) during which subscapularis will be detached and metallic bone anchors used

Following surgery, they will be immobilised for 3 to 4 weeks, before being permitted full range of movement at 2 to 3 months and allowed to return to contact sports at 6 to 12 months

On the other hand, 54% of surgeons indicated they would investigate prior to surgery, 18% said their first choice operation would be arthroscopic stabilisation, the number of dislocations normally permitted before surgery ranged from 1 to more than 4, and the period of immobilisation post operation from nil to 6 weeks.

We now know how shoulder surgeons in the UK are treating this common injury. The results reveal that in Britain, we do not have a consistent approach, raising many discussion points. Open stabilisation remains the firm favourite. Does this mean arthroscopic stabilisation is regarded as an experimental procedure?


TJW Matthews O Levy

Arthroscopic shoulder surgery is evolving rapidly and several methods of stabilisation have been described. We present a simple new technique which addresses both the Bankart lesion and the capsular stretching together with the short-term results.

The technique can be performed using just one anterior working portal and one posterior viewing portal. The labrum and capsule are elevated from the anterior glenoid neck by sharp dissection. One suture anchor is placed at the half past four position. One suture limb is passed under the labrum at 6 o’clock, the other limb is passed under the labrum at 2 o’clock and the two ends are tied. This has a purse string effect, tightening the capsule in only the superior/inferior plane, which also creates a bumper of labrum at the anterior glenoid rim.

This technique was used in 35 patients (36 shoulders) with recurrent antero-inferior instability due to a traumatic Bankart lesion. The patient group included 33 men and 2 women with mean age 25 years (16–49). They had sustained an average of 5 dislocations per shoulder (1 to 11). The cohort included 4 professional and 6 semi-professional sportsmen all of whom were involved in collision or overhead sports. All the patients were assessed by an independent investigator at an average of 14 months (6–48) post surgery.

Only one patient developed recurrent instability. This occurred without sustaining trauma. The average postoperative Rowe score was 93 (55–100), Walch-Duplay score was 93 (70–100), and Constant score was 97 (77–100). 65% of patients returned to the same level of sports and all the professional athletes were able to resume full activities.

In conclusion, this technique is simple in concept, straightforward to perform, and demonstrates excellent short-term results.


HM Zaw G Barwell J Sinha

To assess the functional outcome after open shoulder stabilisation a retrospective study was performed with patients undergoing modified Bankart repair for traumatic shoulder instability.

47 consecutive patients were selected from theatre records over a five-year period who underwent open shoulder stabilisation under a single operator. 38 of these were successfully contacted by telephone (80% response) for functional assessment using two questionnaires – Oxford and Disabilities of the Arm, Shoulder and Hand (DASH). Of these patients 22 agreed to undergo examination for the Constant and Walch-Duplay shoulder scoring systems. The Constant score included measuring strength of pull using the Nottingham myometer. The average follow-up period was 31.3 months (6–60months) and return to work and/or sport was the focus of the study.

The results from the Oxford and DASH questionnaires showed that 30 patients (79%) had returned to work, 6 patients (16%) were unemployed for reasons other than their shoulder and only 2 (5%) had put their shoulder as the reason for being unable to return to work. 13 patients did no sport out of choice so of the remaining 25, 22 patients (88%) had returned to their chosen sport. The study revealed that 2 patients suffered recurrent dislocation. The results of the Constant and Walch-Duplay scoring averages were encouraging – 91.5% and 85% respectively. Only 2 patients scored below good or excellent grading. These outcomes compare favourably to other studies. A criticism of the Walch-Duplay scoring system is that it is strongly orientated towards sports activities. Our results showed a significant variation in outcome between individuals and it may be that such a scoring system is not applicable in an inner city population as studied here.

The effect of shoulder instability after traumatic dislocation can be devastating on the lifestyle and work of an individual. The Bankart repair has been shown in the literature to be successful in stabilising the shoulder joint with a low rate of recurrent dislocation and minimal loss of range of movement. However the gold standard for a successful repair must ultimately be a return to premorbid function, in particular, work and sport. This study reveals a high rate of return to work and sport after a short period following open shoulder stabilisation using a modified Bankart repair.


In-Ho Jeon N Rosenberg A Modi I J Merisch L Neumann W A Wallace

This study investigates the survival (with gross radiological loosening) rates of prostheses following uncemented Total Shoulder Arthroplasties (TSAs) focusing on the glenoid baseplate fixation.

All uncemented TSAs inserted in one shoulder unit from 1989 to 2001 were entered onto a database prospectively and the patients monitored to death or failure of the implant, resulting in revision surgery. Over 80% of the surviving implants were monitored on sequential radiographs and the radiological loosening rate was observed. 273 TSAs have been monitored – 193 with a porous coated glenoid baseplate and 80 with a hydroxyapatite coating on top of the porous coating.

The Survival rates (%) of the non-HA coated base-plates at 1 to 12 years using the Life Table Method were:- 97, 93, 89, 83, 83, 81, 79, 79, 77, 75, 75 & 75% respectively. The Survival rates for the HA coated glenoid baseplates at 1 to 4 years were 100, 97, 93, & 93% respectively. Failures were predominantly due to mechanical loosening and glenoid disassembly with only 3 cases of infection documented. Thus by 4 years there was a statistically significant improvement in survival of the glenoids. Survival rates were further reduced when radiological loosening was taken into account. The earlier series was analysed to assess the survival of prostheses inserted for RA and OA. The survival rates at 5 & 10 years were 78% & 70% for OA and 96% & 88% for RA.

This Life Table analysis confirms the early benefit from the use of hydroxyapatite coating of the glenoid implant of a TSA. Further improvements, particularly in relation to reducing further the small risk of disassembly are underway.


L Funk E Koury O Levy SA Copeland

Avascular necrosis (AVN) of the humeral head is an extremely disabling condition (Gerber et al, JSES 1998. 7(6):586–90). The results of stemmed arthroplasty for this condition are good, with Hattrup and Cofield reporting 79% subjective improvement at nine years (JSES 2000;9:177–82). This study reports the outcomes of surface replacement shoulder arthroplasties for AVN over a 16 year period. Between 1986 and 2001 twenty-seven arthroplasties were performed in patients with advanced avascular necrosis of the humeral head. All patients had secondary degenerative changes. AVN was secondary to corticosteriods and trauma in most cases.

The mean age of the patients was 60 years (range 35 to 86). These included 16 hemiarthroplasties and 7 total shoulder arthroplasties. All prostheses were of the Copeland Surface Replacement Arthroplasty (CSRA) type.

The average follow up period was 6 years (range 1 to 13). The average preoperative Constant score was 17. This improved to 74 at follow-up. Forward flexion improved from 63 degrees preoperatively to 133 degrees at follow-up. Abduction improved from 49 degrees to 118 degrees. External rotation improved from −3 degrees to 61 degrees. Pain scores improved from 0 to 11.7, using a 15 point visual analogue scale. 81% of patients had slight and no difficulty performing their routine activities of daily living. The remaining 19% still had some difficulty with routine activities. Four of the patients performed regular overhead activity and recorded some difficulty in doing this, whereas they had great difficulty pre-operatively. There were no cases of loosening. No difference was seen in any of the results between the hemi-arthroplasty and total shoulder replacement patients.

Surface replacement arthroplasty is a suitable procedure for degenerative disease secondary to AVN of the humeral head, with results similar to stemmed prostheses. It has the advantage of preserving bone stock.


D Nuttall IA Trail JF Haines

To measure any observed differences in migration and rotation between keeled and pegged glenoid components using roentgen stereo-photogrammetric analysis.

Between 2000–2001 in a prospective randomised study, 20 patients with osteoarthritis had a TSR with roentgen stereo-photogrammetric analysis. Five tantalum markers were introduced into the scapula and acromion, spaced widely apart. Another 4 markers were placed in either a pegged or keeled glenoid component.

RSA radiographs were taken postoperatively, three, six, twelve and eighteen months. The radiographs were digitised and analysed using dedicated software (UmRSA). The relative movement of the glenoid with respect to the scapula was measured.

The largest translation for the keeled components was in the proximal/distal direction with a mean of 1.3mm, the pegged group mean was 0.27mm. This difference was significant, P = 0.001. Both other translation axes showed no significant difference between the two component types. Medial/lateral migration gave means of 0.38mm(keel) and 0.52mm(peg) and the anterior/ posterior translation with means of 0.54mm(keel) and 0.41mm(peg). Maximal total point motion mean values at 18 months were 2.6mm for keeled and 1.1mm for pegged glenoid components. This difference was also significant P=0.001

The largest rotation was anterior/posterior tilt with means of 3.5°(keel) and 1.1°(peg) this difference was significant p=0.005; varus/valgus tilt with a mean of 3.2°(keel) compared to 20(peg) was again, significant P = 0.002. and finally anteversion/retroversion means were 3.3°(keel) and 2.7°(peg). Multivariate analysis identified 2 principal components from the keeled data each accounting for 35% of the variation in the data. The first included transverse and saggital translation together with rotation about the longitudinal axis; the second component consisted of translation on the longitudinal axis with rotation about the transverse axis.


AD Barrow D Nuttall IA Trail JF Haines A Birch

Between 1992 and 2000, 120 shoulder arthroplasties have been inserted in patients with osteoarthritis at this hospital. Shoulder function was assessed using the ASES patient self-evaluation form and the Constant-Murley clinical index as well as evaluation including routine measurements of shoulder motion and pain. The mean follow-up was 4.4years (2 to 10years).

Movement, pain and both shoulder function scores significantly improved after operation with t-test values significant at P< 0.001 level. Three sub-groups of primary osteoarthritis (OA), avascular necrosis (AVN) and post traumatic arthritis (PTA) were analysed separately. Although each group was significantly improved after arthroplasty the AVN and PTA patients had significantly poorer results than OA patients for pain and the functional scores, except the AVN group for the Constant Murley score. General linear model analysis indicated that both Constant-Murley and ASES shoulder function scores were shown to be sensitive to change after treatment and that improvement was maintained for up to 8 years post-operation.

Kaplan-Meier analysis showed a significant difference in survival between the 3 sub-groups of OA, PTA and AVN with 5 of 16 PTA operations needing revision. This was reflected in function measurement with PTA values 20 points lower in both clinical (P=0.014) and self assessed functional status (P=0.004).

At each visit a true AP radiograph was taken. Radiological lucency was graded using the method of Matsen. The humeral components were inserted without cement and there were no signs of loosening. Just four components had lucency at one of 7 zones. There was a noticeably higher incidence of glenoid lucency, Proportional hazards analysis was used to model the hazard rate of glenoids at risk. A hazard model for the glenoid components consisted of only one variable – presence or absence of glenoid erosion noted at operation. The model is significant (P= 0.02) with erosion having a hazard rate 6 times greater than that if not eroded.


A Ali N Adla SA Shahane D Stanley

The Copeland shoulder arthroplasty has been reported to give good results over a 5 to 10 year follow-up period. In this series all the humeral implants were inserted without cement. There was evidence of radiolucency in 30% of the humeral components.

In our unit since 1995 we have implanted the Copeland shoulder hemiarthroplasty using cement around the stem of the prosthesis. We radiologically reviewed 40 patients with a mean radiological follow-up of 4.5 years. There was radiological evidence of loosening in 5%.

Of this group, twenty-five patients had a minimum follow-up of 5 years, with a radiological loosening rate of 8%.

We would suggest that the use of a small amount of cement around the stem of the humeral component is beneficial in reducing the rate of loosening.

We also feel that, as the amount of cement is small and only around the stem, if revision is required it can be undertaken without the difficulties usually associated with cemented prostheses.


AD Barrow IA Trail JF Haines A Birch D Nuttall

The purpose of this study was to analyse the reason for failure of shoulder arthroplasties performed for osteoarthritis, looking specifically at factors associated with either hemi or total shoulder replacement.

Over an eight-year period over 80 consecutive patients undergoing a Global hemi-arthroplasty or total shoulder arthroplasty were looked at. All patients underwent at least two years of follow up. All patients were assessed pre and post operatively using the Constant and ASES scoring systems. A bio-engineer or physiotherapist performed these evaluations. X-rays were analysed for demarcation, loosening and glenoid erosion. Failure was defined as the need for revision surgery. Reasons for revision were predominately pain, loosening and instability. In these instances the differences between hemi and total joint arthroplasty were recorded. A distinct pattern was present with several early revisions being performed for continuing pain in the patient group who underwent hemi-arthroplasty.

In conclusion, this study supports total shoulder replacement as the operation of choice, in suitable patients, as compared to hemi-arthroplasty. This would appear to reduce the risk of the need for early revision on account of pain. This must be weighed against the potential for late glenoid loosening.


G Kumar R Page IA Trail

The composition and morphology of the glenoid are integral to the support of a glenoid component in total shoulder arthroplasty (TSA). This study was performed to identify the morphology of glenoid cavity in pre and post replacements in a cadaveric model.

Eleven normal cadaveric shoulders (Right – 5, Left – 6) were dissected down to the bone such that the glenoid labrum was left intact. Computerised Tomography (CT) scanning at 0.5 mm thickness was performed on each of the specimens in a standardised fashion to evaluate the morphology of the glenoid and glenoid medullary cavity. CT scanning was repeated after a mixture of cemented pegged and keeled glenoid components were inserted into all the specimens using standard instrumentation.

Five reproducible lengths (Body width), Posterior wall length, Anterior Wall length. Glenoid body length and corrected body width) and the retroversion angle of the glenoid were identified on the CT scans. These measurements were taken at the 25th, 50th and 75th percentiles of the height of each glenoid both pre and post replacements. Further post glenoid replacement CT scans were analysed for cement-fill of the glenoid cavity and cortical encroachment of the prosthesis.

There was significant correlation of all the measurements including the retroversion angle between the pre and post glenoid replacements at all levels. All but one pegged prosthesis had insufficient cement mantle or critical penetration or abutment at one of the pegs at least. Most often the penetration or cortical abutment was along the posterior wall. All keeled prosthesis had a sufficient cement mantle all around.

The designs of the glenoid prosthesis were satisfactory with some respects like radius of curvature, size and to a certain degree the shape. The margin of error for insertion of the pegged prosthesis was very narrow. Design changes are required in the glenoid component for better bony fixation.


Full Access
S Sathyamurthy J Wilson T Bunker

One of the major long term problems of total shoulder replacement is loosening of the glenoid component. Since 1997 we have been using atmospheric pressure to drive cement into the interstices of the glenoid trabecular bone by lowering the intraosseous pressure. This is achieved by introducing a wide bore needle into the base of the coracoid process and attaching it to surgical suction. During this period approximately 200 Tornier Aequalis shoulder replacements were performed by the senior author. For the purpose of this detailed study 20 consecutive cases were studied.

Good exposure of the glenoid is achieved using an extended approach and aggressive surgical releases. The surface is prepared according to the manufacturers recommendation. The base of the coracoid is now exposed and drilled with a 3.5mm AO drill bit, angled so as not to collide with the keel of the glenoid component. A Verres needle is hammered into the glenoid at this point and connected to a separate, second suction apparatus, placed on high suction during final lavage, cement insertion and cement curing. Blood and lavage fluid can be seen to be sucked from the glenoid during preparation and cementation.

Standard true antero-posterior radiographs were taken by the same experienced radiographer in the plane of the glenoid face two days following surgery, and at 3 months and one year. A Mitotoyu digital microcalliper with a resolution of 0.1mm was used to determine the depth of cement intrusion and presence of lucent lines. Three independent observers measured each radiograph. Analysis of interobserver error shows agreement between observers. For assessment the glenoid was divided into five zones – Superior flange; superior slope of keel; base of keel; inferior slope of keel; inferior flange.

No patient had a complete lucent line around the glenoid component. Four patients had a single zone lucent line (ranging from 1.1mm to 1.7mm) None of these patients had a lucent line around the keel, and those four areas of lucency under the superior or inferior flange were more likely due to incomplete removal of articular cartilage than a failure of cement technique.

The reported prevalence of glenoid lucent lines varies from 22% to 89%. The significance of glenoid lucent lines is controversial but several studies have reported a direct relationship between the presence of radiolucent lines and the development of loosening of cemented components.

Secure cement technique is more difficult in the shoulder than in the knee or hip. Access is tighter, bleeding more difficult to control and peroxide should not be contemplated because of close proximity of the axillary nerve to the glenoid. Classic socket pressurisers can not fit into such a small space. We have found that the second sucker technique is extremely effective in establishing a secure cement-bone interface during glenoid replacement.


HC Brownlow AJ Freemont T Even SA Copeland O Levy

The coraco-acromial ligament (CAL) is partially resected during a subacromial decompression. Clinical studies have reported the regeneration of a structure which appears to be a new CAL. Histological studies of regenerated CAL have demonstrated an abundance of relatively acellular collagen fibrils orientated in the line of a ligament and mechanical testing of the regenerated tissue has properties similar to those of normal CAL. However it is still not clear whether this structure represents scar tissue or truly reformed ligament. Defining the major collagen constituent of this regenerated tissue would allow the distinction between ligament and scar tissue. Therefore the aim of this study was to examine the level of expression of types I and III collagen in regenerated coraco-acromial ligaments (CAL) in humans.

Samples of regenerated CAL were obtained during open surgery for repair of small rotator cuff tears at an average of 24 months (range 14 to 52) after arthroscopic subacromial decompression from 4 men and 3 women with an average age of 58 years (range 44 to 68). A standard protocol radio-active in-situ immunolocalisation technique was used to quantify the ratios of mRNA collagen I to collagen III in the samples.

The results demonstrated that the average ratio of collagen I to collagen III was 6.5. This ratio is similar to the value for normal hip capsule (5–6:1) and human posterior cruciate ligament (8:1).

We conclude that the reformed CALs are ligamentous structures, not scar tissue, and therefore represent truly regenerated ligaments.


P Durani I-H. Jeon T.A. McCulloch A. McLeod W.A. Wallace

The Nottingham Hood is a polyester soft tissue reinforcement device for the treatment of weakened or torn rotator cuff tendons (RCTs). The device was introduced in 1987 and has undergone a number of modifications from a close weave polyester modified aortic vascular graft (Mark 1) to an embroidered trefoil shape (Mark 4 – Pearsall’s Ltd) which has now been available since 2000. While this device has been under development it has been used on a named patient basis for 10 years on humanitarian grounds as an alternative treatment option for patients with massive RCTs. Approximately 30 Nottingham Hoods have been inserted over the past 10 years. This study investigates the histological changes and ingrowth associated with this device.

Four patients who have had the Nottingham Hood inserted for massive RCTs have had re-operations for various reasons on five occasions. Excised material from the rotator cuff has been subjected to histological investigation. Excised biopsy material has been obtained 6 weeks, 6, 9 & 12 months and 14 years following implantation. Transmitted and polarised light microscopy has been used in all cases.

At 6 weeks birefringent clear material similar to suture material was identified, invested by fibrin and occasional red cells i.e. old thrombus. The fibrin was partly calcified and insinuated between bundles of the meshwork material. No true ingrowth of material was seen at this stage. At 6 months the material was seen macroscopically to be covered with collagenous material, rather like fascia which interdigitated closely with the embedded polyester material. At 14 years the mesh appeared to be invested, sandwich-like into a collagenous fascia-like structure with dense hyaline bands of collagen. Some fibrin was also present between the fibrils and a low grade foreign body giant cell response with light chronic inflammation. The local synovium showed detritic synovitis.

The histological features show that there is an early organisational response to the insertion of the new tissue, which is then accompanied by long-term incorporation into host tissues by fibrosis and scarring. A small fibrin and foreign body response lingers on.

This long-term follow-up assessment provides evidence that long-term implantation of polyester as reinforcement for the rotator cuff tendons is not associated with serious biological problems. However the problem of stretching of the repaired rotator cuff muscles does occur and needs to be considered in more depth.


AM Hill AMJ Bull M Urwin P Aichroth AL Wallace

The scapulo-humerothoracic rhythm, which can be described by up to 12 spatial variables, is either responsible for, or affected by the genesis of shoulder pathology and trauma, and therefore, imaging the articulations of the shoulder through a global range of motion is desirable in aiding the diagnosis and management of both movement deficiency and osseous lesions.

4 control volunteers were seated between the toroid of the scanner and maximally slewn table on a customised tripod. The subjects were asked to carryout a sequence of defined movements, each over a period of 5 seconds. These included adduction to abduction in the scapular plane, internal rotation to external rotation at 0° and 90° abduction and flexion to extension. An EBCT C300 scanner was used with a multislice sequence imaging protocol to collect 8 transaxial slices per volume by sweeping an x-ray beam sequentially over 4 tungsten target rings and recording x-ray intensity via two fixed detector rings after the reflected beam passes through the body, enabling the acquisition of 20 volumes per movement with minimal radiation exposure. Each slice was post-processed by semi-automatic segmentation using Amira software, and reconstructed to produce three-dimensional reconstructions. Following this, a kinematic description of the joint complex was developed using SIMM, enabling quantification of up to 5 Degrees of Freedom at the Glenohumeral joint.

EBCT provides a quick and efficient method for direct real-time dynamic imaging of the shoulder girdle, although currently crude. As such, we hypothesis the ability of EBCT to image traumatic disruption to shoulder rhythm, and are currently pursuing this work. These reconstructions promise great potential for further clinical experience and quantitative analysis of small translations aided by achievable limited technological refinement of the modality.


R Chidambaram D Mok

The aim of the study was to determine the value of clinical assessment in the diagnosis of SLAP (Superior Labral Anterior Posterior) lesions of shoulder.

A retrospective clinical review of 48 patients who underwent arthroscopic stabilisation for SLAP (Snyder Type II to Type IV) lesions between 1997 and 2003 was undertaken. The patients were assessed preoperatively by the senior author using a combination of clinical tests including Neer’s impingement test, anterior apprehension test, compression rotation test, O’Brien, Speed, Gerber and Yergason tests.

The mean age of the patients was forty-four. Thirty-nine patients had persistent shoulder pain after injury. Seventeen were sport related. Pre operative diagnosis of SLAP was made in only eleven cases. We found the Neer impingement test positive in twenty-one, anterior apprehension test in twenty-six (sensitivity 54%), O’Brien test in twenty-three (sensitivity 48%), Compression rotation test in six and Speed’s test in five patients.

Our study does not support any single or combination clinical tests that can diagnose SLAP lesions with confidence. In a young patient with persisting shoulder pain after injury, positive anterior apprehension test should alert suspicion. Arthroscopic examination remains the most reliable assessment of the damaged labrum.


M Hayton AJA Santini PJ Hughes SP Frostick IA Trail JK Stanley

Tennis elbow (lateral epicondylitis) is a common upper limb condition, possibly resulting from angiofibroblastic degeneration. Conservative treatment comprises corticosteroid injections, rest and splints, however, occasionally surgery is necessary.

Recent data comparing Botulinum Toxin Type A (BTX-A) (Botox®, Allergan Inc, Irvine, CA) with surgery suggested BTX-A is effective in treating resistant tennis elbow by providing temporary, reversible paralysis of affected muscle, thereby alleviating tensile forces and allowing tissue healing.

This double-blind, randomised, controlled trial compared BTX-A with placebo in 40 patients with chronic tennis elbow (> 6 months). Recruited patients were randomised to 50U BTX-A+2mL normal saline or 2mL normal saline (placebo). Injections were administered 5cm distal to the maximal area of lateral epicondyle tenderness. Quality of life (SF-12), pain (visual analogue scale) and grip strength (Jamar dynamometer) were assessed pre- and 3 months post-injection in both affected and non-affected arms. Following BTX-A treatment patients had average 19% improvement in grip strength in the affected arm compared to average 2% for placebo, however, this difference did not reach statistical significance (p=0.08, 95% CI −2.31, 35.64). No difference between the groups was seen for the unaffected arm (BTX-A 4% improvement, placebo 1% improvement).

Both groups showed similar improvements in pain assessment and also in quality of life.

BTX-A treated-patients demonstrated improved grip strength in the affected arm compared to placebo, however this difference was not statistically significant.


H Al Hussainy W Hekal M Farhan

To ascertain the effect of the site and number of loose bodies on the functional outcome of Outerbridge-Kashiwagi (O-K) procedure in management of osteoarthritis of the elbow.

12 patients were reviewed after having O-K procedure, and assessed using Mayo Elbow Performance score, and radiographs assessed using Derby Elbow Osteoarthritis Radiography score.

There were 10 male and 2 female patients with mean age of 47 years. The mean follow up was 24 months. In 8 (66%) patients the diagnosis was primary osteoarthritis, and 4 (34%) had post-traumatic arthritis. Nine (75%) patients had osteoarthritis of the dominant elbow, and three were non-dominant. Nine patients had locking and catching symptoms. 7 patients had < 2 loose bodies, and 5 had > 2 loose bodies. 7 had anterior loose bodies alone and 5 had both anterior and posterior loose bodies.

The Mayo Elbow Performance score improved from a mean preoperative value of 51 to 85 points postoperatively (p< 0.0001). There were 3 excellent, 7 good, 2 fair, and no poor results. Visual analogue pain score improved from a mean of 7.4 to 2.6 postoperatively (p< 0.001). The Derby Elbow Osteoarthritis Radiography score improved from preoperative mean of 6.5 to 5.3 postoperatively (p< 0.013). There was no significant difference between functional outcome of primary osteoarthritis and post-traumatic arthritis (p> 0.42). Number of loose bodies had no significance on the functional outcome (p> 0.39), neither did the site of the loose bodies (p> 0.44). There was no significant difference of the number of loose bodies on the overall total score of Derby Osteoarthritis Elbow Score (p> 0.2). In two patients revision had to be undertaken due to persistent locking that improved postoperatively.

The number and site of loose bodies, the type of osteoarthritis and the duration of symptoms have no significant prognostic value in predicting functional outcome


MP Espag A Birch DI Clarke D Nuttall IA Trail JK Stanley

The purpose of the project was to develop a questionnaire for completion by patients with elbow pathologies which is short and practical, internally consistent, valid, responsive and sensitive to changes of clinical importance.

The first, pilot phase included 43 patients who each completed a 19 item questionnaire relating to elbow function. The 19 ADLs produced a total scale Cronbach Alpha of 0.96., two different groups of ADLs were identified by multivariate analysis. Group 1 consisted of ADLs requiring moderate to high isometric loading and Group 2 of ADLs requiring high flexion. From the 19 items the best 10 which represented both groups were selected. A summary score was used to create the Wrightington Elbow Disability Score (WEDS).

In the second phase 89 patients completed the new WEDS form, reliability studies produced a Cronbach’s alpha value of 0.91. Internal validity of the groups of ADLs all correlated at p< 0.001 level with strength (Group1) and flexion (Group 2). A sub set of 40 patients undergoing total elbow arthroplasty were assessed for sensitivity to change in disability, the WEDS indicated a significant improvement at the p< 0.001. Convergent validity was demonstrated by the correlation with the ASES-e score at p< 0.001 level. The WEDS was significantly correlated with the ASES-e but not the DASH score.

Our study confirms that the WEDS questionnaire which is short and practical, is internally consistent, valid, responsive and sensitive to changes of clinical importance.


Helen Douglas T Cresswell D Stanley

Although it is generally accepted that revision total elbow replacement may be necessary for loosening, instability, peri-prosthetic fracture and infection there is less agreement as to whether surgery should be performed as a one or two stage procedure. This can be of vital importance since the soft tissues around the elbow are often relatively poor making a single operation desirable. However, a one stage procedure in the presence of undetected low grade infection will result in joint failure with early loosening.

In our unit we have found the use of a preliminary aspiration/drill biopsy prior to revision surgery helpful in evaluating whether a one or two stage procedure should be performed.

Over an 8 year period 18 revision total elbow replacements have been undertaken. 9 patients were revised for aseptic loosening, 4 for proven infection, 3 for instability of an unlinked implant and 2 for peri-prosthetic fracture.

With this experience we have devised the following management plan: Early instability of an unlinked implant is due to either poor implant positioning or soft tissue balancing and is suitable for a one stage revision without the need for aspiration/drill biopsy. Late instability is due to implant wear or low grade infection. In this situation we regard an aspiration/drill biopsy as necessary. A negative result allows a one stage revision whereas a positive aspiration indicates the need for a two stage revision.

In a peri-prosthetic fracture if the bone cement mantle is intact a one stage revision without aspiration/ drill biopsy can be performed. If however, there is bone cement lucency we would advise an aspiration/ drill biopsy.

We have found the aspiration/drill biopsy helpful prior to revision total elbow replacement and we have used it to guide us as to whether a one or two stage procedure should be performed.


G Choudhury JA Chapman SC Halder

Displaced fractures of the distal humerus are very difficult to treat. Numerous techniques have been developed for internal fixation, e.g. plating, Rush nail fixation, IM nailing etc. Results are not very good in majority of the cases. Conventional ‘antigrade’ nailing sometimes may not be suitable for these types of fractures. This new nail is inserted by a close retrograde technique using a special interlocking system to avoid axillary nerve and rotator cuff damage. This nail also allows stable fixation of these distal fractures via a plate welded its distal end, which maintain the rotational stability.

Since 1997 we have treated 15 displaced extra particular fractures using this device. 12 of them were widely displaced fractures, some comminuted, and 3 were pathological fractures. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate.

In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees

This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations.


A. Daher J. Sinha

This prospective evaluation of early experience using this technique. Patients with fracture of the distal clavicle were surgically treated with clavicular hook plate fixation. They were reviewed clinically and radiographically by one observer.

12 patients, 7 male, 5 female, were treated in our unit. Mean age (34.7) range 25–60 years. 10 were the results of low velocity injury.

9 were treated within one week of injury. 3 were treated at 13, 14 and 16 weeks post injury. Mean hospital stay 2.7 range 2–5 days. All patients healed, 10 within 12 weeks. All resumed full activity by 24 weeks. 2 had superficial wound infection, treated successfully with oral antibiotics without implant removal. One had a seroma, which resolved spontaneously. One patient developed limitation of movement at 20 weeks ultrasound confirmed impingement. Plate was removed and patient regained full range of movement after six weeks. No implant fracture or loosening was observed.

Based on experience to date the clavicular hook plate is a safe and reliable method of fixation. Relatively simple implant with good results. Allows early mobilisation and has little complication.


MB Davies D Stanley

The purpose of this study was to design a clinically useful classification for distal humeral fractures that would provide guidance to the surgeon with regard to surgical approach and operative management.

This classification was assessed using the original radiographs from a study comparing distal humeral fracture classifications previously undertaken in Oxford, and validated using the exact methodology of that study. Nine independent assessors (3 orthopaedic consultants, 3 orthopaedic registrars and 3 musculoskeletal radiologists) were asked to classify 33 sets of radiographs on two separate occasions using the Riseborough and Radin, Jupiter and Mehne, and AO classifications as well as the new classification system. The assessors were unaware of the origin of the new system as this had been given a fictitious name. Using the Kappa statistic, the level of inter-observer and intra-observer agreement was determined and interpreted using the Landis and Koch criteria.

Amongst all observers, the new classification is both a substantially reliable (k=0.664) and reproducible (k=0.732) classification system. The new classification achieved superior inter- and intra-observer agreement compared to the other three classification systems with a low proportion of unclassifiable fractures comparable to the AO method (3.7%).

In reproducing materials and methodology from an independent study, we have been able to validate this new fracture classification system. Used in conjunction with a management algorithm, we believe the new classification aids the surgical decision-making process for these complex fractures.


IAR MacLeod RJH. Emery

The management of proximal humeral fractures is determined by fragment displacement. Intra-operative and radiological classification systems have been proposed, namely AO and the Neer classifications to assess therapeutic options.

This study evaluates the usefulness of these classification systems by the creation of physical 3D models using a rapid prototyping technique avoiding the problems associated with 3D illusions on a 2D screen.

Seven consecutive patients with complex fractures of the proximal humerus were investigated using the data from multi-sliced spiral CT scans. Fractures associated with dislocation were excluded. The data from these CTs was segmented to reveal the anatomy of interest and converted to a stereolithographic format from which the physical models could be made of the proximal humerus via a laser guided filament deposition process. Further manipulation with software allowed angulation and displacements of fragments to be measured.

Inter-observer agreement: All models were assessed by three surgeons. A consultant with a special interest in shoulder surgery, a fellowship trained surgeon and a senior house officer in basic surgical training. Independent assessment of the fractures from the models was made using the Neer and AO classifications. In only 1 incidence did all 3 observers agree on the classification, in 5 incidences only two observers agreed and on 8 occasions none of the observers agreed. Indeed there were 9 occasions that at least one observer thought the fracture pattern could not be applied to a classification.

Fracture Patterns: Observation of the individual models together with measurements of angulation and displacement by further software analysis, demonstrated major subtypes namely valgus and varus angulation with minimal displacement of the greater tuberosity. Appreciation of the integrity of the medial hinge and buckling could be made in relation to the different fracture patterns.

This study highlights concerns on the validity of current classification systems. It also questions whether the existing systems reflect the pathophysiological subtypes of these fractures allowing comparison of surgical results in order to evaluate treatment options.


AM Hill IT Jones A Suri J Moss U Hansen AL Wallace

Surgical joint stabilisation can be achieved by ligamentous plication or thermal shrinkage, and as such, we hypothesized that there is no difference in mechanical and morphological properties after reduction of laxity in ligaments treated by either technique.

Methods: 30 mature female rabbits underwent either ‘thermal’ treatment of their left medial collateral ligament (MCL) using a bipolar radiofrequency probe, or plication with two 4/O non-absorbable sutures following division along its midsubstance and loaded positioning of the free ends. After 12 weeks convalescence, the animals were euthanised and MCL complexes were procured from left and contralateral knees to undergo viscoelastic (creep) testing, quantitative Transmission Electron Microscopy (TEM) and immunohistochemistry. The TEM data was quantified by two data procurement protocols; computational analysis and manual graticule.

Mean creep strain in both thermal (1.85 +/− 0.32%) and plicated ligaments (1.92+/−0.36%) was almost twice that of the control (1.04+/−0.15%), although there was no difference between treatment modalities. Similar findings were seen in the thermal (1.77+/−0.45%), plication (1.85+/−0.40%) and control groups (0.92+/−0.20%) for viscoplastic deformation. However, collagen morphological parameters of all three groups were significantly different (p< 0.001). The thermal ligaments demonstrated predominantly small fibrils, whilst the plicated group displayed an intermediate distribution of heterogenous fibrils. Immunohistochemistry followed by TEM revealed a sparse random distribution of alpha-smooth muscle actin staining fibroblasyts in both thermal and plicated groups. There was an insignificant difference in computational and manual procurement methods (p=0.84).

Susceptibility to creep, and residual deformation after recovery, is similar after thermal shrinkage or plication, although inferior to intact ligaments. However, the plicated results suggest remodeling on a pre-existing fibrillar scaffold, yet the thermal group demonstrated histomorphometry similar to scar tissue, suggesting de novo synthesis. The absence of contractile myofibroblasts suggests that these cells may have an insignificant role in regulation of matrix tension during healing.


KS Satheesan VRM Reddy NC Bayliss

This study presents the clinical outcome of Boyd-McLeod procedure for lateral epicondylitis of elbow. 29 cases with lateral epicondylitis with failed conservative management (rest, physiotherapy, analgesia and steroid injections) were included in the study. There were 14 male, and 15 female cases of which two had bilateral surgery. Data collection included details of patients’ occupation, number of steroid injections, radiograph evaluation and postoperative complications. Post-operative clinical out come was evaluated by Hospital for Special Surgery Total Elbow Scoring System (HSS2), clinical notes review, and telephone questionnaire.

Average age: 47 years (range: 34–65), mean post-op follow up time: 16 months (range: 6–32). 93% were manual workers. Dominant elbow involvement was seen in 64%. Mean number of steroid injections: 3 (range: 1–10). Conservative measures included NSAIDS (90%) and physiotherapy (83%). Average tourniquet time: 32 min (range: 18–59). Mean HSS2 score pre-op and post-op were 38 and 92 respectively (p value: 0.0001). 91% reported excellent/good results. Average post-op time for the continuation of professional/recreational activity was 5 weeks. 2 cases (9%) had poor results. One case had ectopic bone formation.

Boyd-McLeod procedure is done as a day case procedure involving excision of degenerative tissue from common extensor origin, decortication and decompression of lateral epicondyle and partial release of annular ligament. Although an extensive procedure, this procedure addresses the management of all offending factors that are likely to contribute to pain and disability in tennis elbow. There are few studies regarding the outcome of Boyd-McLeod procedure. There was no evidence to suggest that late presentation had any adverse effect on the post-op success. This study revealed a high success rate and a low complication rate. We conclude that Boyd-McLeod procedure is an effective treatment option in patients with resistant lateral epicondylitis.


S A Stapley R S Page E Powell M Clements J Haines I A Trail

The study assesses the efficacy of commonly used suture materials with commonly described arthroscopic knotting techniques in as close a physiological pattern as possible.

The investigation was carried out in three phases. Initially the suture material strength was tested. The suture was then tested to failure using the different knotting techniques. Finally the test was repeated after soaking the suture with normal saline.

A Hounsfield tensometer was utilised with a load cell of 1000N, strain rate of 25mm/min, bar separation of 7.5mm and standard temperature and pressure. Suture material tested was 2 ethibond, 1 PDS and 1 Panacryl. Knotting techniques compared were the Tennessee slider, Tautline hitch, Duncan Loop, SMC knot and Surgeon’s knot. Two surgeons tied each knot 10 times after first becoming practiced with each technique. Each knot was tested to failure on 10 sequential experiments.

Ultimate strength of the suture material and of the knotting techniques was assessed. In addition the mode of failure, whether the knot slipped or suture material fractured was investigated.

As expected, 2 ethibond has a higher ultimate strength than either 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had a significantly lower slippage rate when compared to the other knotting techniques. (P value < 0.002). The Tennessee slider, Duncan Loop and SMC knots slipped in more than 50% of experiments. No difference was observed when the suture material had been soaked in normal saline. The number of half hitches required to provide maximum knot holding capacity was 3, confirming previous experimental findings by other investigators.

The Tautline hitch is recommended for use with all suture materials due to low slippage rates, ease of tying, ease of sliding and overall high knot strength


Mr T Cresswell Miss H Douglas Mr D Stanley

Although it is generally accepted that revision total elbow replacement may be necessary for loosening, instability, peri-prosthetic fracture and infection there is less agreement as to whether surgery should be performed as a one or two stage procedure. This can be of vital importance since the soft tissues around the elbow are often relatively poor making a single operation desirable. However, a one stage procedure in the presence of undetected low grade infection will result in joint failure with early loosening.

In our unit we have found the use of a preliminary aspiration/drill biopsy prior to revision surgery helpful in evaluating whether a one or two stage procedure should be performed.

Over an 8 year period 18 revision total elbow replacements have been undertaken. 9 patients were revised for aseptic loosening, 4 for proven infection, 3 for instability of an unlinked implant and 2 for peri-prosthetic fracture.

With this experience we have devised the following management plan.

Early instability of an unlinked implant is due to either poor implant positioning or soft tissue balancing and is suitable for a one stage revision without the need for aspiration/drill biopsy. Late instability is due to implant wear or low grade infection. In this situation we regard an aspiration/drill biopsy as necessary. A negative result allow a one stage revision whereas a positive aspiration indicates the need for a two stage revision.

In a peri-prosthetic fracture if the bone cement mantle is intact a one stage revision without aspiration/ drill biopsy can be performed. If, however, there is bone cement lucency we would advise an aspiration/ drill biopsy.

We have found the aspiration/drill biopsy helpful prior to revision total elbow replacement and we have used it to guide us as to whether a one or two stage procedure should be performed.


Full Access
P Reilly A Bull A Amis AL Wallace A Richards A Hill R Emery

This study aimed to quantify the relationship between passive tension of rotator cuff repair and arm position intraoperatively and to examine the effect of the passive tension on gap formation in cadaveric rotator cuff repairs.

Five patients undergoing open surgical reconstruction of the rotator cuff were recruited. The operations were performed by a single surgeon using a standardised technique, which was acromioplasty, minimal debridement, mobilisation of tissue, bone troughs and transosseous suture tunnels.

A Differential Variable Reluctance Transducer (DVRT) was placed at the apex of the debrided tendon. An in situ calibration was performed to relate the output from the DVRT to actual tension in the tendon. The tension generated was recorded as the supraspinatus tendon was advanced into a bone trough and secured.

The relationship between arm position and repair tension was measured, by simultaneously collecting data from the DVRT and a calibrated goniometer. Particular attention was paid to the three standard positions of post-operative immobilisation; full adduction with internal rotation, neutral rotation with a 30° abduction wedge and ninety degrees of abduction.

Five cadaveric shoulders were used for the creation of standardised rotator cuff tears which were then repaired using the technique described above. The difference in tension measured between full adduction and 30° abduction was statically applied for twenty four hours and the gap formation measured.

Repair tension increased with advancement of the supraspinatus tendon into the bone trough. Abduction reduced the repair load, this was observed mainly in the first 30° of abduction. The mean reduction in load by 30° of abduction was 34 N.

Twenty four hours of 34N static loading caused gap formation in each cadaveric rotator cuff repairs, the mean was 9.2 mm.

Rotator cuff repairs tension can be reduced by postoperative immobilisation in 30° abduction. The change in tension with full adduction was caused gap formation in cadaveric rotator cuff repairs.