GUEPAR hinge knee prosthesis.

Early and late results of the GUEPAR hinge knee prosthesis were evaluated on a series of 184 operations performed before January 1st, 1974. There were 3 immediate deaths and 26 before 5 years. Nineteen prostheses were removed. One hundred and twenty-six knees had degenerative osteoarthritis, 52 rheumatoid arthritis. Twenty-two had been operated on before. Patellar displacement, present in 27% of the cases, was the most frequent cause of complaint: pain or instability, proportional to the severity of displacement, made re-operation necessary in 10% of the patients. Addition of a patellar prosthesis was the most successful treatment as far as pain is concerned: it is probably advisable as a primary procedure. Deep infections occurred in 8.3% of the cases, infrequently after 2 years. Healing was obtained in all cases either by revision or by removal and arthrodesis: but functional results were poor except when fusion was achieved, in half of the cases of arthrodesis. Loosening occurred in 16% of the cases, mainly as a consequence of inadequate technique. It was frequently tolerated: re-operation was necessary in 6% of the total. Late functional results were evaluated in 99 cases with a follow-up of 5 to 8 years. Apart from loosening, the results did not deteriorate. Sixty percent were evaluated as excellent or good, 29% fair, and 11% poor. In consideration of these results, the choice of this prosthesis should be limited to special cases. To prevent complications, the use of a patellar prosthesis, of reinforced models and of cementing under pressure is advisable.

[Total hip arthroplasty after proximal femoral osteotomy: 75 cases with 9-year follow-up]. / Prothèses totales de hanche après ostéotomies proximales du fémur.

PURPOSE OF THE STUDY: Clinical outcome and technical difficulties observed after total hip arthroplasty subsequent to osteotomy of the proximal femur were studied in 75 total hip arthroplasties. MATERIAL AND METHOD: Sixty-four patients underwent 75 total hip arthroplasty procedures at the Caen University Hospital between 1978 and 1995. These patients were reviewed at least two years after implantation. The Postel Merle d'Aubigné (PMA) score was used to assess clinical outcome and the Lequesne criteria to determine acetabular and femoral parameters on the weight-bearing AP radiograph. Off-set of the femoral epiphysis was determined by measuring the relation between the femoral shaft axis and the digital fossa. The population was composed of young active subjects who had had several operations. The main underlying diseases were: congenital dislocation of the hip (32%), dysplasia (23%), and primary degenerative hip disease (34%). Two-thirds of the hips were stiff and more than three-quarters were unstable. There were 28 osteotomies for varisation, 19 medial translations, 20 osteotomies for valgisation, and 7 subtrochanteric osteotomies. All femoral pieces except one were cemented. Implantation required 39 trochanterotomies, 39 Hardinge approaches, and 5 deosteotomies. RESULTS: The medial offset of the digital fossa compared with the diaphysis led to operative difficulties and femoral complications: Their were eight femoral fractures: 7 of these occurred with a digital fossa situated medially to the diaphysis. The Postel-Merle-d'Aubigné score at last follow-up was satisfactory in 57 cases (76%). Among the 18 non-satisfactory results, there was 7 failures requiring surgical revision, 5 potential loosenings, and 6 stiff hips in patients with congenital dislocation. For the 7 revisions (9.3%), 3 were for infection (2 late hematogenous), 1 for early dislocation, 2 for aseptic acetabular loosening, and 1 for aseptic femoral loosening. Medial translation of the digital fossa led to a larger number of varus positions (44%). For femoral cementing, 10 hips showed a non-progressive secondary lucent line; these prostheses were considered as potentially loose. Among them, varisation osteotomies has been performed in 5 cases, and in 8 the digital fossa was medial to the diaphyseal axis. There was only one aseptic femoral loosening requiring surgical revision. Implant survival, established according to the actuarial method, was 94.9% at 10 years. DISCUSSION: The almost 95% implant survival at 10 years observed in our patients is comparable with most reports in the literature and slightly better than those reported at the 1997 SOFCOT symposium on total hip arthroplasty after 50 years (84%). The most important factor determining surgical difficulty and operative complications at the femoral level was the position of the digital fossa, more than the type of initial osteotomy. CONCLUSION: Indications for osteotomy must account for subsequent total hip arthoplasty. Implantation is difficult after subtrochanteric osteotomy which can cause important technical problems. The rate of failure is very high. The risk of femoral complications and misalignment of the femoral stem, irrespective of the type of initial osteotomy, is greater when the digital fossa lies medially to the diaphyseal axis. We prefer trochanterotomy or desosteotomy for such cases. Osteotomy did not rule out arthroplasty for any of the femurs. There were however important operative difficulties and the frequency of complications suggest we should be most prudent about careful preoperative planning in the frontal plane.

[Post-traumatic knee degeneration]. / Le genou dégénératif post-traumatique.

Degenerative changes and arthritis are one of the most important sequelae after knee injury. The reasons of deterioration of the cartilage are different in each injury. After fractures the most important pejorative factors are incongruity of the articular surface and malunion specially in varus deformities. With long term follow up the arthrosis is observed between 15 and 50%, dependent of the localisations and the gravity of the injury. After menisco-ligamentous injury the kinematic of the knee is disturbed and the medial femoro-tibial compartment is too overlead specially when the meniscus was resected and when the patient has a morphology in genu varum. With long term follow up the arthrosis is observed between 15 and 20%. The early repair of the anterior cruciate ligamentous and the "meniscal economy" can predict significative decrease. The treatment of this knee post-traumatic arthrosis is essentially based on the good balance of frontal femoro-tibial stress by osteotomy. When the osteo-ligamentous lesions are diffuse and important, it's possible to propose a semi-contained total prosthesis.

Contribution of laboratory tests, scintigraphy, and histology to the diagnosis of lower limb joint replacement infection.

OBJECTIVE: To evaluate the contribution of laboratory tests, histology and scintigraphy for diagnosing and monitoring the treatment of lower limb arthroplasty infection. PATIENTS AND METHODS: 37 lower limb arthroplasties, 20 at the hip and 17 at the knee, were studied. Investigations included laboratory tests for inflammation (erythrocyte sedimentation rate, C-reactive protein, haptoglobin, and orosomucoid), histology (presence of neutrophils) and scintigraphy (99m Tc-HMDP bone scan, colloidal sulfide bone marrow scan, and 99m Tc-HMPAO leukocyte scan). Follow-up was at least three years after treatment of the infection. RESULTS: Acute phase reactants were more sensitive and more specific than the erythrocyte sedimentation rate. The full scintigraphy protocol had 100% sensitivity and 87% specificity. Recovery of neutrophils by aspiration or during surgery was 100% specific in the absence of hematomas or rheumatoid arthritis. Sensitivity of the presence of neutrophils varied with the collection technique.

[Incidence of arthrosis in the results of the treatment of coxarthrosis in the young adult with Chiari's osteotomy. Retrospective study of 52 hips with 10.5 years of follow-up]. / Incidence de l'arthrose dans les résultats du traitement de la coxarthrose de l'adulte jeune par ostéotomie de Chiari. Etude rétrospective de 52 hanches avec 10.5 ans de recul moyen.

PURPOSE OF THE STUDY: Fifty two of 53 Chiari pelvic osteotomies performed between 1974 and 1991 were reviewed clinically and radiographically with an average follow-up of 10.5 years. MATERIAL AND METHODS: In more than 46 per cent of cases, the osteotomy was performed on a dysplastic painful hip with severe osteoarthritis. Major complications were rare. The Chiari's osteotomy fixation screw was removed in 16 cases. Technically, the average displacement was 22 mm. A ascending osteotomy, related to the level of the osteotomy (p = 0.001), provided good displacement. RESULTS: The functional results were very good or good in 65 per cent of the patients and lasted more than 10 years. Seventy five per cent of the hips were pain free. Radiographically, the center edge angle and the femoral head covering were corrected by the procedure. Degenerative changes of the hip joint were improved or stabilized in 63.5 per cent of the cases. Fifteen hips had undergone secondary total hip replacement, seven during the first five years and 8 after 13 years. DISCUSSION: Factors associated with a positive outcome included: age under 30 at the time of surgery (80 per cent of survivorship up to 15 years of follow up), low stage (I or II) of osteoarthritis, and a technically perfect Chiari osteotomy. The outcome of initial stage III or IV initial osteoarthritis were not as long lasting. Chiari osteotomy functional results were good for the initial 10 years, after this time they deteriorated quickly. CONCLUSION: Chiari pelvic osteotomy is an alternative procedure to early total hip replacement for severe painful dysplastic hips with low stage of osteoarthritis in young patients.

[Bousquet's device in the treatment of recurrent dislocation of a total hip prosthesis. Apropos of 13 cases]. / Traitement de la luxation récidivante de prothèse totale de hanche par le cotyle de Bousquet. A propos de 13 cas.

PURPOSE OF THE STUDY: Dislocation following total hip arthroplasty (THA) continues to be a problem. An innovative treatment is described with the intermediate Bousquet's prosthesis. This study reported 13 cases and demonstrates its high reliability despite the origins of the dislocation. Recurrent dislocation following initial dislocation, occurs in between 25 to 60 per cent of the cases reported in the literature. The main cause is a malpositioned prosthetic component and especially a retroverted acetabulum. The other reasons for dislocation were: trochanteric non-union, bone or cement impingement, previous surgery, age and neurologic disorder. In every case the instability of the hip may be caused or increased by muscular insufficiency. Various methods are described to control recurrent dislocation: repositioning the component, posterior acetabular wall component, trochanteric advancement, retentive acetabular component, bracing. When the cause is clear and isolated, the rate of success may be 70-80 per cent. This study examines the results of a revision procedure with the intermediate Bousquet's prosthesis. MATERIAL AND METHODS: 13 recurrent dislocations were treated with the intermediate Bousquet's prosthesis. There were 10 women and 3 men with an average age at operation of 73 years. The main cause in 7 cases was an abductor insufficiency including 4 trochanteric non unions. The other causes were 6 component malpositions, 7 previous surgery, 1 impingement. The average delay between the first dislocation and revision was one year. The Bousquet's acetabular component is an steel cup covered with alumina, impacted without cement. The polyethylene component is free in the cup and retentive on the femoral head. The femoral positioning was not modified. RESULTS: The revision did not correct all of the causes of luxation, however we noted only one case of dislocation and no recurrent dislocations. DISCUSSION: At last follow-up, all recurrent dislocations were controlled. Nevertheless, there remained 7 abductor insufficiencies and 4 femoral malpositionings. In the literature the rate of success depends on the cause. The main difficulty is the treatment of joint laxity. Some authors propose trochanteric advancement, a larger head, a posterior wall acetabular component, retentive acetabular component. Success is not uniform. The Bousquet's acetabular component supports joint laxity and femoral malpositioning. This allows to keep the same original femoral component when the risk is too high for a cemented prosthesis or impossible for a non cemented prosthesis. CONCLUSION: This treatment of the recurrent dislocation is reliable with a short and simple operation.

[Detection of deep vein thrombosis of the limbs by ultrasound in orthopedic and traumatologic surgery. Results of 1647 studied patients]. / Dépistage des thromboses veineuses profondes des membres inférieurs par écho-doppler en chirurgie orthopédique et traumatologique. Résultats sur 1647 malades explorés.

INTRODUCTION: This study was undertaken to estimate the efficiency of duplex ultrasound scanning and its utility to detect deep vein thrombosis in orthopedic patients and to describe their features. MATERIAL AND METHODS: A total of 1647 in-patients, all receiving low-molecular-weight heparin, were investigated from 1989 to 1993, either for screening because of a high risk of thrombosis (asymptomatic group: 930 patients, mean age + SD: 63 + 17 years) or for clinical suspicion of deep vein thrombosis (symptomatic group: 717 patients, mean age + SD: 57 + 21 years). Difference between the two groups mean ages was significant (p < 10(-8)). An Hitachi EUB 450 duplex and an Acuson colour duplex 128 XP, with 3.5 MHz and 7.5 MHz linear probes were used. Veins were tested for compressibility in the transverse view from caval site to both ankles. Retrospective analysis of patients' database results was done. RESULTS: There was no significant difference in deep vein thrombosis rate between screening asymptomatic group (356/930: 38 per cent) and symptomatic group (2531717: 35 per cent). There was a linear relation, in the 2 groups, between age and deep vein thrombosis rate, from 10 per cent before twenty to 45 per cent after eighty years old. For a relative risk to have thrombosis detected before twenty definite at 1, it was 2.1 for 20-29, 4.9 for 40-49, 6.2 for 60-69 and 8.6 later than 80 years old. Proximal deep vein thrombosis was detected in only 5 per cent (87/1647) of patients. Distal muscular soleal veins were the most usual involved sites of thrombosis. Isolated soleal thrombosis were detected in 16 per cent (270/1647) of patients. There was no significant difference between the deep vein thrombosis rate after total knee or hip arthroplasty among selected patients for duplex scanning from 1989, and the true prevalence assessed among all the patients who have undergone total hip or knee arthroplasty during the last 6 months. DISCUSSION: Pessimistic results previously reported for duplex screening among asymptomatic patients are not confirmed. Calf vein thrombosis rate assessed with duplex exceeds by 15 to 20 per cent the rates assessed by contrast venography, among patients receiving low molecular weight heparins. That difference could be attributed to the isolated muscular soleal thrombosis usually missed at contrast venography. CONCLUSION: Deep vein thrombosis rate among orthopedic surgical patients, is much higher when detected with Duplex ultrasound scanning than detected with contrast venography, and is related to patient age. Soleal vein thrombosis is the most prevalent. Duplex ultrasound scanning is an efficient and useful screening method for deep vein thrombosis in orthopedic surgery. Mechanical calf venous pump stimulation in association with low molecular weight heparin, has to be evaluated in attempting to reduce those muscular soleal veins thrombosis.

[Value of continuous passive motion in the early rehabilitation of total knee arthroplasty. Prospective study apropos of 120 medical records]. / Intèrêt des appareils arthromoteurs dans la rééducation précoce des arthroplasties totales de genou. Etude prospective à propos de 120 dossiers.

The purpose of our study was to evaluate the interest of passive motion rehabilitation with an automatic device. Our protocol has been made of 120 TKA performed in the same surgical department between february 1987 to June 1990. We draw lots, a group "RC" with usual rehabilitation program and a second group "AM" with the same program added with passive motion two hours per day. The passive motion device was Toronto Mobilimb. Passive range of motion (ROM) of flexion and extension, pain level, deep venous thrombosis existence, volume of blood postop drainage, mobilisation under anaesthesia, device tolerance were studied. The results showed a flexion ROM average of 86.7 degrees in the RC group at discharge and 90 degrees in the AM group. This difference is statistically significant and evokes the efficacy of passive motion. At the term of one year postop, the flexion averages reaches 108 degrees in both groups. The extension lag falls from 8.2 degrees and 9.2 degrees average in AM and RC group at discharge to 3 degrees and 3.7 degrees in the same groups at one year. The mean of blood postop drainage by suction was very different in the RC group than AM group (1149ml-968ml). In conclusion, we can say that passive motion device is useful to reach enough flexion in the first days after surgical day and may give some comfort. In our experience the classical rehabilitation program with physiotherapist must be continued.

[The Sauvé-Kapandji operation. Analysis and results of 69 cases]. / L'intervention de Sauvé-Kapandji. Analyse et résultats de 69 cas.

The authors present the results of 69 cases operated between 1983 and 1989. The indications were dominated by two aetiologies: degenerative lesions of the inferior radio-ulnar joint in rheumatoid arthritis: 58% of cases, and traumatic sequelae, predominantly secondary to fractures of the distal radius: 34% of cases. The authors stress the effects of distant lesions: skeletal lesions of the two bones of the forearm or the superior radio-ulnar joint. A third group of rarer indications consisted of painful dislocations of the inferior radio-ulnar joint in Madelung's disease (indication only applied to adults). There were two types of complications: complications due to excessively long or intra-articular screws, which were treated by removal of the screws and, more severe, ossifications of the zone of diaphyseal resection (5 cases) which interfered with the functional result in terms of mobility. Three cases required extensive diaphyseal resection. The results are analysed for each aetiological group in terms of pain, mobility prehensile strength after more than one year of follow-up. Good results were obtained in 80% of cases of post-traumatic lesions (16 cases). The insufficient results were related to associated lesions of the elbow or the 2 bones of the forearm. A good result was obtained in 3 out of 4 cases of Madelung's disease and one case, operated elsewhere and revised by pseudoarthrodesis, obtained a moderate result. Lastly, in rheumatoid arthritis, the results in terms of pain, mobility and prehensile strength were good, apart from 2 failures due to progression of rheumatoid disease (cases unsuitable for this treatment). Radiographic analysis according to Youm and Mac Murtry's criteria showed minimal regression in the carpoulnar translation index (pre-op: 0.28; post-op: 0.22). Overall, the Sauvé-Kapandji operation provided good quality clinical results when the indications and technique were rigorously applied.

Proposed digital arthroplasty critical study of the preliminary results.

In view of the results of Swanson implants, particularly the long-term course of silicone implants, the authors studied and developed semi-constrained sliding arthroplasty designed for metacarpo-phalangeal and proximal interphalangeal joints. The preliminary study on bones and then on cadaver hands and finally on the knee of the rabbit allowed the design and experimentation of a prototype which led to the creation of a semi-constrained arthroplasty for which the elastic diaphyseal anchoring is ensured without cement and which possesses sliding surfaces composed of a metallic (proximal piece)--polyethylene (distal piece) interface. We therefore describe the principles of functioning of this arthroplasty, its technique of insertion, dorsal trans-tendon incision, its accessory (drill for diaphyseal preparations), its anatomical requirements (preservation of the palmar plate and lateral ligaments, bone section) and the postoperative course. To date, 52 arthroplasties have been inserted and we present the results of the first 36 cases for which the follow-up is equal to or a greater than one year (20 MP-16 PIP), indicating the technical modalities according to the various aetiologies (21 cases of rheumatoid arthritis--15 post-traumatic cases) and the complications. The average gain in mobility is 40 degrees with a mean range of movement of 64 degrees. In terms of pain, none of the arthroplasties were associated with pain apart from pain on cold in certain post-traumatic cases. The global and thumb-finger prehensile forces were evaluated to be an average of 90% in relation to the healthy side. Radiological assessment demonstrated fixation of the pieces in every case. Lastly, we discuss the outcome of this arthroplasty and its current indications in relation to the problems of instability essentially occurring in dislocated MP joints of rheumatoid arthritis.

[Reconstruction prosthesis of the upper part of the femur. Intermediate results in 20 resections for tumor. Current trends]. / Prothèse de reconstruction de l'extrémité supérieure du fémur. Résultats à moyen terme de 20 résections pour tumeurs. Orientations actuelles.

Twenty total hip prostheses inserted after massive resection of the upper part of the femur for tumour have been reviewed after a 3 year mean follow-up. Fifteen cases were of primary malignant tumour. The mean resection of the femur measured 175 mm in length and was reconstructed using Cochin prostheses. From the oncological standpoint, the results were comparable with those obtained after disarticulation of the hip, but the functional results were, of course, much better. Five patients were able to resume their previous professional work; 13 were able to have a normal type of life and only 2 were severely crippled. Nineteen hips were painless. Nine patients could walk without a stick, 9 used one stick for walking outside and 2 used sticks permanently. Two cases were complicated by dislocation. Despite an extensive resection of the greater trochanter, one third of the hips were stable on standing on one leg, thanks to the design of the prostheses. No prostheses broke. Two loosenings of the acetabular cup had to be revised. No loosening of the femoral stem was found, despite the frequency of osteolysis of the diaphysis to 4-5 cms below the level of resection. The authors intend now to improve the design of the prostheses and to aid the reinsertion of the muscles, which can be improved by using homografts surrounding the femoral prostheses.

Functional results of seventy-six cases of phalangeal and metacarpal fractures studied using a hand emergency computer card system.

Over a two-year period, the authors analyzed 76 records using a "hand" computer card divided into two parts: "work-up of the initial lesions" and "functional results". Analysis of 102 cases of fractures in this manner led to the conclusion that outcome was most often favorable when the fracture was extra-articular whatever the treatment, except in the case of complex compound fractures. In contrast, treatment of articular fractures often required secondary surgery (50% of cases) and led to 20% poor or average results. This was the case whatever initial treatment (functional, orthopedic or operative) had been undertaken.

[Epithelioid sarcoma. Apropos of 3 cases]. / Les sarcomes épithélioïdes. A propos de trois cas.

The authors present two cases of epithelioid sarcoma of the hand and one of the foot with clinical interest. This recently described tumor (Enzinger, 1970), is relatively rare. It occurs in the hand, forearm, pretibial region and foot and affects principally young adults. It should be emphasized, and this is borne out in the literature, that this tumor may appear perfectly benign and often has a course of long duration. The difficulty of clinical and especially of histologic diagnosis as well as the difficulty of determining the boundaries of extension of the tumor make it necessary to carry out radical surgery (amputation or rarely block excision). Every author agrees that local excision is to be condemned, there being an 85% recurrence rate. Spread of the tumor is by way of the fascial planes and tendon sheaths. Lymphatic and pulmonary metastases occur particularly when there is vascular invasion.

Epithelioid sarcomas. Three cases.

The authors present two cases of epithelioid sarcoma of the hand and one of the foot with clinical interest. This recently described tumor (Enzinger, 1970), is relatively rare. It occurs in the hand, forearm, pretibial region and foot and affects principally young adults. It should be emphasized, and this is borne out in the literature, that this tumor may appear perfectly benign and often has a course of long duration. The difficult of clinical and especially of histologic diagnosis as well as the difficulty of determining the boundaries of extension of the tumor makes it necessary to carry out radical surgery (amputation or rarely block excision). Every author agrees that local excision is to be condemned, there being an 85% recurrence rate. Spread of the tumor is by way of the fascial planes and tendon sheaths. Lymphatic and pulmonary metastases occur particularly when there is vascular invasion.