[Reliability of porous coating metal-backed cups: advantages and adverse effect of a posterior elevated rim polyethylene liner]. / Fiabilité d'une cupule métal-back vissée a revêtement poreux: intérêt et innocuité d'un dispositif anti-luxation.

PURPOSE OF THE STUDY: We analyzed primary implantation of the Duraloc cup associated with a self-locking Muller stem at 9.6 +/- 1.6 years (8.6-11.4). Because of its particular 3/5 semi-spherical shape, the Duraloc cup has been associated with a high rate of dislocation. The objective of this study was to evaluate the efficacy of an anti-dislocation posterior elevated rim polyethylene liner on long-term dislocation rate and wear. MATERIAL AND METHODS: The series included 89 arthroplasties implanted between 1991 and 1993 in 82 patients, mean age 56.8 +/- 12.6 years (17.2-87). The Postel-Merle-d'Aubligné (PMA) score and subjective evaluation with a visual analog scale were used for the clinical assessment. Changes in the bone-cup interface, cup migration, and polyethylene wear were assessed radiographically. RESULTS: At last follow-up, the PMA function score was 16.2 +/- 1.9 points (10-18) (81% good, very good and excellent results). The postoperative x-rays showed a low incidence of lucent lines and osteolysis, respectively 8% and 4%. Mean annual linear polyethylene wear was 0.11 +/- 0.066 mm (0.03-0.57) and only 4% of the cups showed wear greater than 0.2 mm/year. Wear was correlated with the presence of acetabular osteolysis and high activity level. Two cups migrated (3-4 cm medialization). Three cups were revised, one for deep infection, one for recurrent dislocation, and one for dislocation associated with major wear. The rate of dislocation was 2.2% (two cases). Overall survival was 97.3% at 9.6 years (95%CI 0.93-1.0). DISCUSSION: Compared with other series in the literature using this implant, the presence of a posterior elevated rim polyethylene liner reduced the rate of instability and did not increase wear. The Duraloc cup is recognized as a reliable implant exhibiting excellent osteointegration and a low rate of migration. The presence of a posterior rim is associated with a lower rate of dislocation and does not increase wear. It can thus be proposed for primary implantation. The posterosuperior position for the liner is recommended.

[Malignant fibrous histiocytoma of bone 20 years after femoral fracture treated by plate-screw fixation: analysis of corrosion products and their role in malignancy]. / Histiocytofibrome malin de l'os 20 ans après ostéosynthèse par lame-plaque d'une fracture du fémur : analyse des produits de corrosion et de leur rôle dans la malignité

We report a case of malignant fibrous histiocytoma of the bone that developed 20 years after a femoral fracture treated by plate-screw fixation. Similar cases reported over the past fifteen years in the literature suggest the possible mechanisms of sarcomatous degeneration. The possible carcinogenic effect of corrosion products is emphasized. Dispersion energy spectrometry of intracellular particles on the periphery and at the center of the tumor demonstrated the presence of chromium, iron and nickel at different concentrations. The association with other elements clearly demonstrates that the corrosion products were metabolized. The presence of metallic components in tumoral cells suggests a possible relationship between metallic implants and malignancy. These observations emphasize the importance of creating a national, or even international, registry of malignant tumors that develop in contact with metallic implants in order to search for a possible cause and effect relationship.

[Reconstruction of the anterior cruciate ligament: arthrotomy versus arthroscopy]. / Reconstruction du ligament croisé antérieur: arthrotomie versus arthroscopie.

The aim of this study was to compare the results of arthroscopic with open arthrotomy reconstruction of the anterior cruciate ligament, as treatment of chronic anterior laxity. 54 knees (among 63) were evaluated, 33 reconstructions were performed according to Kenneth Jones technique with arthrotomy (from 1990 to may 1993) and 21 were arthroscopically-assisted (from may 1993 to 1996). Meniscectomy was associated respectively in 22 and 7 cases. The average interval between initial injury and surgery was 18 and 18.6 months. Follow-up was one year at least. We evaluated mobility, amyotrophy and quadriceps and hamstrings muscular deficit: static at 1 month and using Cybex isokinetic tests at 2, 3 and 6 months and 1 year. Postoperative residual laxity and Arpege cotation were evaluated at 1 year. Student and Mann Whitney tests were used for statistical evaluation. As complication we noted respectively after arthrotomy and after arthroscopy: 7 (21.2 p. 100) and 4 (19 p. 100) algodystrophy, 1 (3 p. 100) and 1 (4., 7 p. 100) Cyclops syndrome, and 2 (6 p. 100) and 1 (4.7 p. 100) anterior knee pain. Lack of extension and flexion were respectively -5.4 degrees/130 degrees and -1.9 degrees/136 degrees at 3 months (p = 0.04) and -3.5/134 degrees and -1.5 degrees/138 degrees at 6 months (not significative). At 1 month, static hamstrings deficit was 41.3 p. 100 after open arthrotomy and 29.6 p. 100 after arthroscopic assisted (p = 0.05). At 2 months, isokinetic hamstrings deficit was lower after arthroscopic assisted (21.6 p. 100 at 60 degrees; 20.8 p. 100 at 180 degrees) than after open arthrotomy (32.8 p. 100; 32.5 p. 100) (p = 0.039 and 0.008). This difference was found for hamstrings until 3 months. At 6 months and 1 year, no difference was found for Cybex tests. In Arpege score, at 1 year, 73.3 p. 100 were very satisfied or satisfied after open arthrotomy and 77.7 p. 100 after arthroscopy. Global results were excellent or good in 66 p. 100 after open arthrotomy and 83 p. 100 after arthroscopy. Radiological laxity was less than 5 mm in 88 p. 100 after open arthrotomy and 92 p. 100 after arthroscopic assisted. So, after arthroscopically assisted procedure, the number of algodystrophy and anterior knee pain was lower, and until 3 months, range of motion was better and hamstrings deficit was lower. After 6 months, difference about range of motion or muscular deficit were not significative. At 1 year, after arthroscopic procedure, results seemed better with a lower rate of residual laxity and better global results, but the number of medial meniscectomies was lower in this group. In conclusion, the arthroscopic-assisted procedure seems to allow a faster rehabilitation.

[Giant cell tumors of the spine. Report of a case, literature review]. / Tumeurs à cellules géantes du rachis. A propos d'un cas, revue de la littérature.

Giant cell tumors of bone are uncommon in the vertebrae above the sacrum. We report the case of a giant cell tumor of the third lumbar vertebra, revealed by lumbar and radicular pain. X ray, computed tomography and magnetic resonance imaging showed osteolysis of the body and vertebral arch of L3. Histologic evaluation gave a conclusion of a giant cell tumor, grade 2. Spondylectomy of L3 was performed using a combined approach (anterior and posterior) in two stages. The patient had a good functional result without recurrence at three years and six months. A review of the literature indicates that the radiological appearance is nonspecific but shows the extent of the tumor. Diagnosis can be based only on histological features. Radiotherapy could induce malignant transformation. Radical resection limits the risk of recurrence. Total spondylectomy is recommended for giant cell tumors when both the body and arch are involved.

[Reconstruction of the anterior cruciate ligament by bone-patellar tendon transplant. Evaluation of 79 cases. Prognostic factors]. / Reconstruction du ligament croisé antérieur par transplant os-tendon rotulien-os. Evaluation de 79 cas; facteurs pronostiques.

PURPOSE OF THE STUDY: The purpose of this study was to evaluate the results of the anterior cruciate ligament (A.C.L.) reconstruction according to two scoring systems (Arpege and IKDC), to analyse the influence of different factors on the results, to study the effect of a lateral extra-articular tenodesis, the morbidity of patellar tendon graft harvesting, and the advantage of arthroscopically assisted reconstruction. MATERIAL: Seventy nine patients, 17 to 39 years old (average 27 years), underwent an anterior cruciate ligament reconstruction for chronic instability, using a free bone-patellar tendon-bone graft. In 43 cases, a lateral extra-articular plasty was added (Lemaire's procedure). The reconstruction was arthroscopically assisted in 17 cases. Interval between initial injury and surgery was 24 months (2 months to 9 years and 7 months). The average follow-up was 2.5 years (range 1 to 18). METHOD: All patients were reviewed for evaluation with two scoring systems (Arpege and IKDC). Roentgenograms of both knees, including antero-posterior weight-bearing and lateral view, patellar view, dynamic radiographs, allowed evaluation of post-operative arthrosis and residual anterior laxity in extension. Fischer's test and chi square test were used for statistical evaluation. RESULTS: Using the Arpege CLAS system, functional results were excellent or good in 75.9 per cent of cases (excellent in 44.3 per cent, good in 31.6 per cent), fair in 15.2 per cent, poor in 8.9 per cent; according to the IKDC system, 65.8 per cent were excellent or good. 84.8 per cent of the patients were satisfied in Arpege system and 91.2 per cent in IKDC system. The pivot-shift test was negative in 86 per cent, equivocal in 7.6 per cent and positive in 6.4 per cent. The radiological Lachman's test (difference between control and affected knee) was 0-2 mm in 53.2 per cent, 3-5 mm in 39.2 per cent, 6-10 mm in 7.6 per cent, never greater than 10 mm. Antero-posterior weight-bearing radiographs were normal in 83.5 per cent, showed joint remodeling in 10.1 per cent pre-arthrosis in 6.3 per cent but no arthrosis. Functional results were not correlated with age at time of surgery, interval between initial injury and surgery, nor clinical Lachman's test. Competitive sportsmen had a better result (p = 0.001). Residual laxity in extension was correlated with lesions of medial meniscus (p = 0.035). Degenerative changes in femoro-tibial joint were correlated with residual laxity in extension (p = 0.019). There was no significative difference between A.C.L. reconstruction isolated or associated with lateral extra-articular tenodesis. Time to return to work was shorter for patients with arthroscopically assisted procedure (p = 0.067). DISCUSSION AND CONCLUSION: Functional results after A.C.L. reconstruction using a free bone-patellar tendon-bone graft are satisfactory and confirm the reliability of this procedure. Arpege CLAS and IKDC systems give comparable functional results, but IKDC evaluate anatomical results, residual laxity and degenerative changes of the joint, that constitute essential long-term pronostic factors. Morbidity of patellar tendon harvesting appears to be of short duration and largely reversible. Added lateral extra-articular tenodesis doesn't improve the results. Arthroscopically assisted procedure seems to allow a faster rehabilitation.

Retrieval analyses of total hip replacements.

Metal ion release was assessed in 31 patients with loosening of total hip replacements (THR). Three types of alloys were used for these prostheses: stainless steel (9/31), Ni-Cr-Mo (5/31) and Co-Cr (17/31). The exposure periods were from 2 to 15 years.Intracellular deposits were observed in macrophages, fibroblasts, histiocytes and numerous multinucleated giant cells. X-ray microprobe analyses by energy dispersive spectrometry (EDS) on ultrathin sections revealed the presence of elements contained in the alloys (Ni, Cr, Fe, Mo) and of additional elements, in particular P, CI, Ca and S. Co was only detected in wear particles. Metal distribution in tissues and body fluids was related to the alloys used. Stainless steel THR induced the lowest metal concentrations, Ni-Cr-Mo alloys showed high increases of Ni and Cr. Co-Cr alloys induced very high Co levels: 100- to 400-fold concentrations in body fluids and 600- to 1000-fold concentrations in tissues with respect to normal upper levels. The metal clearing was studied in three patients with Co-Cr-THR. Two years after removal, only Ni reached normal values. The sometimes alarming high concentrations should lead to a systematic follow up and surveillance of patients.

[Amputation below the fracture site in pseudarthrosis complicated by infection or vascular lesion]. / L'amputation au-dessous du foyer dans les pseudarthroses compliquées d'infection ou de lésion vasculaire.

In cases of fractures of the shaft of a bone complicated by non-union, infection and vascular and/or neurological lesions, amputation may be the ultimate possible treatment. In some cases, an amputation at the level of the fracture site would produce too short a stump for a normal prosthesis. The authors consider that, in this type of lesion, it may be wise to preserve some of the distal portion of the bone below the site of the fracture, even in cases of infected non-union. They performed this technique in seven cases, the distal fragment of the bone being covered by an osteomyoplasty, infection being treated by antibiotics. Early rehabilitation was started with immediate weight-bearing in the prosthesis. In all cases, union was obtained secondarily and in five cases infection healed as well. Two still had an intermittent sinus. The authors consider that the infected non-unions healed because of suppression of the weight of the limb. The technique allowed better rehabilitation because of the presence of a sufficiently long stump.

[Scintigraphy in the evaluation of painful arthroplasties. Simultaneous use of technetium and gallium]. / Scintigraphie dans le bilan des arthroplasties douloureuses. Utilisation simultanée du technetium et du gallium.

Fifty-nine patients with 60 painful hip arthroplasties were assessed by scintigraphy using M.D.P. 99m Te and 67 Ga bone scanning. The M.D.P. 99m Te bone scanning was very reliable with 100 p. 100 of positive results. However, it did not elucidate the cause of the pain. Sixty-seven Ga scanning, when positive, allowed the diagnosis to be orientated towards an infective cause. However in 6 out of 18, the scanning was negative despite a proved infection. The technical details are described by which quicker and safer results can be obtained.

[Hinge prosthesis of the knee. Apropos of 185 cases]. / Les prothèses à charnière du genou. A propos de 185 cas.

On hundred and ninety-five hinge prostheses have been inserted between 1970 and 1981, most of them of the G.U.E.P.A.R. type. One hundred and forty-three were followed up. The etiology of five per-operative deaths is discussed. It is concluded that this dramatic event was related to gas embolism. Precautions necessary to avoid such accidents are described particularly at the time of release of the tourniquet. There were 11 cases of sepsis, eight loosenings and four post-operative fractures of the femur or tibia. The functional results were found to be satisfactory but better with the G.U.E.P.A.R. type than with the Shiers prosthesis. Most of the post-operative pain originated from the patella; this aspect of the pain should be able to be avoided by systematic use of patellar resurfacing. The authors conclude that a hinge prosthesis should be used only in cases of severe deformity, of severe instability or in cases of failure of resurfacing procedures.

Pouteau-Colles fracture: double-closed "basket-like" pinning according to Kapandji. Apropos of a homogeneous series of 70 cases.

First described by Kapandji, the double closed "basket-like" pinning is a new and quite attractive treatment of the Colles' fracture. With or without XR TV, following closed reduction the epiphysis is fixed steady with two Kirschner wires, sliding along its lateral and its posterior aspects, entering the radius at the fracture site and transfixing the bone cortex above. Plaster cast is unnecessary, and wrist reeducation begins on the first day post-op. Technical "know-how" is specified, and seventy-two patients followed up. Present findings indicate that the complication rate is very low, excellent and good results are 83%. Rehabilitation is quicker, socio-economically gratifying. We believe that the method significantly improves the conservative treatment of Colles' fracture and decide to use it extensively from now on.

[Osteosynthesis of true cervical fractures with D.K.P. screw-plates. Apropos of 125 cases]. / Notre expérience de l'ostéosynthèse des fractures cervicales vraies par la vis-plaque D.K.P. A propos de 125 cas.

One hundred and twenty-five patients had been operated on of whom ninety-two were reviewed. Seventy-four of these had severely displaced fractures of Garden type III or IV. This study confirmed the bad prognosis of fractures with a vertical line, and of those with severe displacement. It confirmed the importance of accurate reduction which should not make the fracture less stable or lead to an increase in vascular damage. It is concluded that this type of fixation lessens the incidence of non-union. The validity of bone biochemical studies is discussed. The authors consider that the device should be modified to increase its strength.

[Blind nailing with reaming in fractures of the femoral shaft. Technique, indications, and results in 399 cases]. / Enclouage à foyer fermé avec alésage du fémur selon Kuntscher. Technique, indications et résultats a propos de 399 cas

The authors have treated 399 fractures of the femoral shaft by blind nailing with reaming following Kuntscher's technique. They fully describe the necessary technical details for a safe operation. They emphasize the importance of an adequate instrumentation and report peroperative complications and the way for avoiding them (poor reduction of the fractures, difficulty for bridging the fracture site, creating of additional fragments, blockage of reamers or nails in the medullary canal). Indications and results are described. I non-union, 15 malunions and 4 sepsis were reported.

[Evolution of myeloplaxic tumors. Apropos of 21 cases]. / Evolution des tumeurs à myéloplaxes. A propos de 21 cas

21 cases of giant cells tumors were observed. Two were malignant primarily. Twelve cases treated by curetage produced 7 recurrences, one being malignant. Seven cases treated by resection produced no recurrence. The authors believe that the prognosis and the indications are based more on clinical and radiological features than on histologic grading studies.