Incidence of secondary displacement after osteosynthesis of proximal humerus fractures: a retrospective study of 185 cases.

Proximal humerus fractures are the third most common fracture in patients over 65 years of age. There is no clear consensus regarding their treatment. The objective of this retrospective observational study was to calculate the incidence of secondary displacement after osteosynthesis of these fractures and to identify possible risk factors. 185 cases were reviewed and all osteosynthesized fractures between January 2008 and December 2016 were included. Data collected included age, sex, body mass index, alcohol and tobacco use, bone mineral density of the proximal humerus, fracture type, initial displacement, management time, type of treatment, surgeon's experience and expertise, and postoperative reduction quality. A radiographic follow-up was done at least 3 months following the fracture (until consolidation). The definition of secondary displacement was: varus/valgus displacement >10°, tuberosity translation >5 mm, articular effraction or material breakage. 53 secondary displacements were found, with an incidence of 28.6%. Seventy-two percent were diagnosed at the first follow-up visit, which occurred at an average of 29 days postoperatively. Among all factors studied, only two were statistically significant for secondary displacement: 1) low proximal humeral bone density (defined by a Tingart index <4) appears to be a risk factor, with a calculated relative risk of 2.71 (p = 0.04); and 2) the operator's specialization in the upper limb appears to be a protective factor, with a relative risk of 0.27 (p = 0.01). A similar high incidence of complications after osteosynthesis of the proximal humerus is found in the literature, confirming the difficulty in managing these fractures. More attention should be given to patients with low bone density.

Which is the optimal orthogeriatric care model to prevent mortality of elderly subjects post hip fractures? A systematic review and meta-analysis based on current clinical practice.

BACKGROUND: While there is a general consensus of the impact of an orthogeriatric organisation in terms of elderly patient mortality post hip fracture, it is unclear which, among these various care models, is the most optimal. METHODS: A systematic review of the literature was undertaken using the keywords "Femoral fractures or total hip replacements or Accidental, falls" and "Aged, 80 and over" and "Mortality". The review is presented following PRISMA guidance. RESULTS: Eighteen studies were identified, published between 1988 and 2015. The number of elderly subjects participating in these studies was between 37 and 951; their mean age was 82.6 ± 7.4 years, and average mortality in these studies was 17.7%. The odds ratio (OR) and 95% CI for association between implementation of the orthogeriatric model and mortality in all patients studied were 0.85 (0.74-0.97). In the analysis by subgroup on the type of orthogeriatric model, the group "Orthogeriatric ward" gave homogenous results, with ORs and 95% CIs of 0.62 (0.48-0.80) unlike other models: "Shared care by orthopaedists and geriatricians "and "Geriatric advice in orthopaedic ward". CONCLUSIONS: Elderly patients with hip fracture admitted early into any sort of orthogeriatric models or more specifically to a dedicated orthogeriatric ward had reduced long-term mortality. This study has to be completed by RCT showing the efficacy of orthogeriatric ward compared to other models using outcomes such as quality of life or functional recovery.

Total knee arthroplasty with the Medial-Pivot knee system: Clinical and radiological outcomes at 9.5 years' mean follow-up.

INTRODUCTION: The "ball-in-socket" design of the Medial-Pivot knee system (MicroPort Orthopedics, Arlington, Tennessee, USA) aims to reproduce normal knee kinematics by medializing its rotational axis. The goal of this study was to measure knee range of motion (ROM) with this implant after a mean follow-up of 10 years and to report the survivorship and long-term clinical and radiological outcomes. We hypothesized the prosthetic knee would have at least 120° flexion at 10 years. MATERIAL AND METHODS: This was retrospective, single-centre study of 74 Medial-Pivot knees implanted in 71 patients (average age of 69 years) between May 2005 and November 2007. All patients who received a Medial-Pivot knee were included consecutively. The mean follow-up was 10 years. Clinical and radiological assessments were performed using the Knee Society Score (KSS) and Ewald's score. Kaplan-Meir survival analysis was used to calculate survivorship. RESULTS: Seven percent of cases were lost to follow-up. The knee ROM was 110° at 10 years. The survivorship was 93% for all revision causes and 95.9% when revisions due to trauma or infection were excluded. The mean KSS score was 195. Stable radiolucent lines were found in 14% of cases. No aseptic loosening was observed. CONCLUSION: Our hypothesis was not confirmed. Knee flexion at the final follow-up was comparable to other semi-constrained implant designs but was not as large as expected. The survival of the Medial-Pivot knee at 10 years is good. Its radiological and clinical outcomes are satisfactory. LEVEL OF EVIDENCE: IV (retrospective cohort study).

Total hip arthroplasty revision by dual-mobility acetabular cup cemented in a metal reinforcement: A 62 case series at a minimum 5 years' follow-up.

INTRODUCTION: Total hip arthroplasty (THA) requires bone reconstruction in case of severe acetabular injury, with risk of dislocation, especially postoperatively. Dual-mobility cups have proved effective in preventing dislocation in THA revision for instability, but their behavior when cemented in a metal reinforcement has been little studied. OBJECTIVES: The present study assessed results for a dual-mobility cup cemented in a metal reinforcement, in terms of aseptic loosening and postoperative instability. MATERIAL AND METHODS: A single-center continuous series of 62 patients receiving such an assembly in THA revision was assessed retrospectively at a minimum 5 years' follow-up. Failure due to aseptic loosening or instability and implant survival at last follow-up were analyzed. RESULTS: Radiological and clinical analysis was performed at a mean 77 months' follow-up. Mean Merle-d'Aubigné-Postel score was 14, Harris score 73 and Oxford-12 score 23.9 at last follow-up. Complications comprised 5 cases of loosening and 2 of dislocation. Loosening risk was significantly greater in case of<2mm cement thickness between cup and reinforcement. Eight-year infection-free survival was 91.9%. DISCUSSION: The present clinical results were comparable to those in series using the same kind of assembly; the dislocation rate was low, but the rate of aseptic loosening was higher than reported elsewhere. Cement thickness between cup and reinforcement was a determining factor for stability. Cup design may also be relevant to loosening. This technique seemed to be a good option in THA revision with severe bone loss. LEVEL OF EVIDENCE: IV, retrospective study.

Does inter-tibiofibular graft still have a role in the treatment of lower-limb non-union?

INTRODUCTION: Tibial non-union is a complication that poses a real challenge for surgeons. Several forms of treatment, depending on the type of non-union, have been described. The present study sought to assess results for treatment of tibial non-union by inter-tibiofibular graft (ITFG). MATERIAL AND METHOD: An exhaustive cohort study was performed on the files of 33 patients: 25 male, 8 female; mean age, 44years. Twenty cases involved high-energy trauma. Twenty-four were open fractures. Twenty-two concerned diaphyseal fracture, 10 of which were complex segmental. Eleven concerned distal fracture, including 4 complete articular fractures. There were 17 cases of septic non-union. There were no cases of severe bone defect. ITFG was performed at a mean 8.7 months post-trauma, as first-line treatment in 30 cases and in second line in 3. RESULTS: Thirty-one patients showed bone consolidation, at a mean 7.2 months. The 2 failures resulted from technical error. Trauma kinetics emerged as a risk factor for failure. DISCUSSION: ITFG remains a useful treatment option in tibial non-union, whether infected or not. The present results are comparable with those of the literature. Although the present series comprised only tight non-union, a study of the literature showed that ITFG can treat bone defects up to 4 or 5cm. Functional results showed tibiotalar joint stiffening, due more to immobilization and non-weight-bearing than to syndesmosis. ITFG thus remains relevant to the treatment of tibial non-union. LEVEL OF EVIDENCE: IV, retrospective study.

Outcomes and prognostic factors in revision hip arthroplasty for severe intra-pelvic cup protrusion: 246 cases.

BACKGROUND: The outcome of revision total hip arthroplasty (THA) for intra-pelvic cup protrusion is unclear. Hence, we conducted a large retrospective study to clarify the surgical strategy (hip lever arm and cup mechanical fixation) and the outcomes of reconstruction for severe intra-pelvic cup protrusion. HYPOTHESIS: We hypothesized that restoration of the anatomic hip centre in such acetabular revisions decreased the risk of recurrent loosening. MATERIAL AND METHODS: The study included 246 THA procedures (in 220 patients), with a follow-up of 5.2 ± 4.9 years (1-24.2) after the index surgery. Bone loss was estimated using the SOFCOT classification (grade III or IV in 80% of cases) and the Paprosky classification (IIIA or IIIB in 58% of cases). Quality of the reconstruction was assessed on X-rays according to the correction of the protrusion and position of the hip centre of rotation. RESULTS: After a clinical follow-up of at least 5 years, with a mean of 9.9 ± 4.1 years (5-24 years), the mean Postel-Merle d'Aubigné score was 14.2 ± 3.1 and the mean Harris Hip Score was 78.0 ± 18.7. Cup protrusion was partially or completely corrected in every case and cup position was normal in 27 (11%) cases. The centre of rotation was within 10mm of the physiological position in 158 (64.2%) cases, acceptable in 77 (31.3%) cases, ascended in 9 (3.7%) cases, and worsened in 1 (0.4%) case. Revision for cup or cup and femoral failures was required in 24 (9.8%) cases. Cumulative survival rates with cup loosening as the endpoint were 88.5% after 5 years, 79.9% after 10 years, and 63.9% at last follow-up at 13.6 years. DISCUSSION: Our hypothesis that restoration of anatomic hip centre decreased the risk of recurrent loosening was not verified: success or failure in restoring the normal centre of rotation did not correlate significantly with final cup status. Recurrent aseptic loosening was the cause of failure in 9.8% of cases. Ensuring long-term effective mechanical stability had a greater impact on global outcomes than restoring an ideal centre of rotation.

Risk of sural nerve injury during lateral distal Achilles tendinoscopy: a cadaver study.

BACKGROUND: The risk of damage to cutaneous sensory nerves located near portals has been evaluated for both conventional arthroscopy and extra-articular posterior ankle endoscopy. The objective of the anatomic study reported here was to assess the risk of injury to the sural nerve or lateral calcaneal nerve while using the distal lateral portal for the Achilles tendinoscopy procedure described by Vega et al. in 2008. MATERIALS AND METHODS: We dissected the sural nerve and its branch, the lateral calcaneal nerve, of 13 human cadaver ankles in the prone position. We defined P as the point where the Achilles peritendon was opened during the distal lateral approach used for the study technique. P was adjacent to the lateral edge of the Achilles tendon, 2 cm proximal to the postero-superior edge of the calcaneal tuberosity. T was defined as the attachment site of the most lateral fibres of the Achilles tendon to the postero-superior edge of the calcaneal tuberosity. We evaluated the origin of the lateral calcaneal nerve relative to T and we measured the shortest distances separating P from the sural nerve and lateral calcaneal nerve. RESULTS: A lateral calcaneal nerve was identified in 10 (77%) ankles and originated a mean of 39.1mm (range, 25.0-65.0mm) proximal to T. P was at a mean distance from the sural nerve of 12.3mm (range, 5.0-18.0mm) and from the lateral calcaneal nerve of 6.8mm (range, 4.0-9.0mm). The median difference between these two distances was statistically significant (P=0.002). DISCUSSION: While using the distal lateral portal for Achilles tendinoscopy, the lateral calcaneal nerve is at greater risk for injury than is the sural nerve. LEVEL OF EVIDENCE: Level IV. Anatomic Study.

Cruciate-sacrificing total knee arthroplasty and insert design: A radiologic study of sagittal laxity.

INTRODUCTION: Ultracongruent inserts avoid some of the drawbacks of central spine postero-stabilized inserts. However, early wear has been reported, and may be due to increased sagittal laxity. The principal objective of the present study was to compare sagittal laxity in rotating platform total knee replacements (TKR) according to insert design: ultracongruent versus central spine. The principal hypothesis was that insert design influences global sagittal laxity. MATERIAL AND METHODS: A retrospective comparative study recruited 3 consecutive series of patients treated for primary osteoarthritis of the knee, with a minimum 1 year's follow-up. The UC series comprised 35 knees in 34 patients, receiving a Total Knee Triathlon™ (Stryker Orthopaedics, Mahwah, NJ) TKR with ultracongruent insert, at a mean 2.0 years' follow-up. The UC+ series comprised 36 knees in 34 patients, receiving the BalanSys™ (Mathys Ltd, Bettlach, Switzerland) TKR with ultracongruent insert, at a mean 2.5 years' follow-up; in this model, the anterior edge of the insert is higher than in the UC series ("deep-dish" design). The PS series comprised 43 knees in 40 patients, receiving a Total Knee Triathlon™ (Stryker Orthopaedics, Mahwah, NJ) TKR with central spine posterior stabilization, at a mean 1.5 years' follow-up. The principal assessment criterion was sagittal laxity at 90° flexion as measured by the Telos Stress Device® (Metax GmbH, Hungen, Germany). RESULTS: Sagittal laxity did not significantly differ between the UC and UC+ series: mean 8.2mm (range: 0-19.5mm) and 8.4mm (4.5-15.8mm), respectively. Sagittal laxity in the PS series was significantly less: 1.4mm (0.2-3.9) (P<0.0001). CONCLUSION: Sagittal laxity was greater in ultracongruent than central spine posterior stabilized TKR. This anteroposterior movement may induce polyethylene wear. The ideal degree of sagittal laxity for ultracongruent inserts remains to be determined. LEVEL OF EVIDENCE: IV - retrospective study.

Fracture of the cobalt-chromium modular femoral neck component in total hip arthroplasty.

Total hip prostheses using cervico-metaphyseal modularity were designed to better replicate the geometry of the native extra-medullary femur. However, they are associated with numerous complications including corrosion, disassembly, pseudotumours and, most notably, fractures of the modular neck. All reported cases of modular neck fractures occurred with titanium components (Ti-6Al-4V). To prevent this weakness, manufacturers developed modular necks made of cobalt-chromium (Co-Cr). We report a fracture of a long, 8° varus, Co-Cr modular neck connected to a 36-mm short (-3.5mm) femoral head. The fracture occurred 22 months post-implantation in a woman who had a low level of physical activity and a body mass index of 28.7 kg/m(2). To our knowledge, this case is the first reported instance of Co-Cr modular neck fracture. It may challenge the wisdom of further developing this modularity design, as our patient had none of the known risk factors for modular neck fracture. In addition, cases of pseudotumour have been reported with Co-Cr modular necks subjected to fretting corrosion, which contributed to the fracture in our patient.

Mid-term outcomes after distally locked-to-standard primary stem exchange in 29 hip-prosthesis patients.

BACKGROUND: Cementless locked femoral stems are used for revision surgery in patients with bone loss to induce spontaneous bone reconstruction, allowing subsequent replacement by a standard primary stem. The small number of patients and short follow-ups available to date preclude a valid assessment of this strategy. HYPOTHESIS: After distally locked stem revision, replacement by a standard primary stem does not induce complications, and the quality of the bone reconstruction allows strong fixation of a regular primary stem. MATERIALS AND METHODS: We retrospectively evaluated 29 patients in whom a distally locked femoral stem was replaced by a standard primary stem between 1998 and 2010 (cemented in 27, cementless in 2 cases). The reason for the procedure was stem breakage, stem migration, or thigh pain. Mean patient age was 63 years (range, 39-78 years). Outcomes were evaluated based on the Postel-Merle d'Aubigné [PMA] score and Harris Hip Score [HHS]. In addition, radiographs were obtained to assess prosthesis fixation and the Hofmann cortical index measured the bone reconstruction. RESULTS: The distally locked stem was removed via a postero-lateral approach without femoral osteotomy in all the 29 cases. In one patient, an intra-operative fracture occurred during femoral preparation. Mean follow-up after the exchange procedure was 75 months (range, 3-188 months). Postoperative ccomplications occurred in 9 (32%) patients and consisted of chronic infection in 2 patients (after 3 and 76 months), post-traumatic peri-prosthetic fractures treated with internal fixation in 3 patients (after 100, 138, and 182 months), aseptic loosening in 3 patients (after 13, 39, and 122 months), and recurrent instability in one patient (after 63 months). All cause revision stem survival after 75 months was 72% (95% confidence interval, 47%-87%). In the 19 patients who still had their revision stem at last follow-up, the mean PMA score was 16.7 (range, 13-18) and the mean HHS was 88.2 (range, 59-99). The Hofmann index remained unchanged [36.5% (range, 28%-58%) before the exchange and 32.9% (range, 20%-57%) after the exchange; P=0.129]. DISCUSSION: This study confirms the feasibility of substituting a distally locked stem with a standard primary stem. No specific complications occurred and no technical difficulties arose when extracting the long stems. However, the 32% complication rate and, more specifically, the occurrence of loosening in 10% (3/29) of patients mandates caution in the use of this technique, which should not be proposed routinely, and suggests a need for considering cementless fixation of the standard primary stem. LEVEL OF EVIDENCE: Level IV, retrospective study.

Unicompartmental knee arthroplasty modes of failure: wear is not the main reason for failure: a multicentre study of 418 failed knees.

BACKGROUND: This study originated from a symposium held by the French Hip and Knee Society (Société française de la hanche et du genou [SFHG]) and was carried out to better assess the distribution of causes of unicompartmental knee arthroplasty (UKA) failures, as well as cause-specific delay to onset. HYPOTHESIS: Our working hypothesis was that most failures were traceable to wear occurring over a period of many years. MATERIALS AND METHODS: A multicentre retrospective study (25 centres) was conducted in 418 failed UKAs performed between 1978 and 2009. We determined the prevalence and time to onset of the main reasons for revision surgery based upon available preoperative findings. Additional intraoperative findings were analysed. The results were compared to those of nation wide registries to evaluate the representativeness of our study population. RESULTS: Times to revision surgery were short: 19% of revisions occurred within the first year and 48.5% within the first 5 years. Loosening was the main reason for failure (45%), followed by osteoarthritis progression (15%) and, finally, by wear (12%). Other reasons were technical problems in 11.5% of cases, unexplained pain in 5.5%, and failure of the supporting bone in 3.6%. The infection rate was 1.9%. Our results were consistent with those of Swedish and Australian registries. DISCUSSION: Our hypothesis was not confirmed. The short time to failure in most cases suggests a major role for surgical technique issues. Morbidity related to the implant per se may be seen as moderate and not greater than with total knee prostheses. The good agreement between our data and those of nationwide registries indicates that our population was representative. A finer analysis is needed, indicating that the establishment of a French registry would be of interest.

Mid- to long-term results of revision total knee replacement using press-fit intramedullary stems with cemented femoral and tibial components.

This was a retrospective analysis of the medium- to long-term results of 46 TC3 Sigma revision total knee replacements using long uncemented stems in press-fit mode. Clinical and radiological analysis took place pre-operatively, at two years post-operatively, and at a mean follow-up of 8.5 years (4 to 12). The mean pre-operative International Knee Society (IKS) clinical score was 42 points (0 to 74), improving to 83.7 (52 to 100) by the final follow-up. The mean IKS score for function improved from 34.3 points (0 to 80) to 64.2 (15 to 100) at the final follow-up. At the final follow-up 30 knees (65.2%) had an excellent result, seven (15.2%) a good result, one (2.2%) a medium and eight (17.4%) a poor result. There were two failures, one with anteroposterior instability and one with aseptic loosening. The TC3 revision knee system, when used with press-fit for long intramedullary stems and cemented femoral and tibial components, in both septic and aseptic revisions, results in a satisfactory clinical and radiological outcome, and has a good medium- to long-term survival rate.

One-year prospective comparative study of three large-diameter metal-on-metal total hip prostheses: serum metal ion levels and clinical outcomes.

INTRODUCTION: The good clinical outcomes and low wear obtained with 28-mm metal-on-metal implants for total hip replacement prompted the development of large-diameter heads that more closely replicated the normal hip anatomy, with the goal of improving prosthesis stability. However, the blood release of metal ions due to wear at the bearing surfaces and the high rate of groin pain seen with large-diameter implants are causing concern. To determine whether these events are related to the geometry and metal composition of the prosthesis components, we conducted a prospective study of clinical outcomes and serum chromium and cobalt levels 1 year after implantation of three different acetabular cups. HYPOTHESIS: Serum levels of metal ions are comparable with different types of large-diameter metal-on-metal total hip prostheses. PATIENTS AND METHODS: We compared 24 Durom™ cups (D), 23 M2a Magnum™ cups (M2a), and 20 Conserve Total™ (C) cups regarding serum chromium and cobalt levels, Postel-Merle d'Aubigné (PMA) scores and Oxford Hip Scores (OHS), as well as radiographic cup orientation and position at 1-year follow-up. Mean age was 66 years (45-85 years), mean body mass index was 28 Kg/m(2) (18-45), patients were almost equally divided between males and females, and the reason for hip replacement was primary hip osteoarthritis in 65 patients and avascular necrosis in two. Metal ions were assayed in serum from blood drawn through non-metallic catheters, using mass spectrometry. RESULTS: Dislocation occurred in two patients (one D and one M2a) and revision to change the bearing couple was required in two patients in the D group. Serum cobalt levels in the C group were significantly higher (P=0. 0003) than in the two other groups (7.5 µg/L versus 2. 7 µg/L with D and 2. 2 µg/L with M2a). Clinical outcomes were better in the M2a group (PMA, 17.7 [16-18]; and OHS, 15.2 [12-30]; P<0.05). The PMA score and OHS were 17.5 (16-18) and 18.2 (12-42), respectively, with D; and 16.75 (10-18) and 22. 2 (12-42), respectively, with C cups. When all three cup models were pooled, serum ion levels were higher in patients with pain than without pain (chromium, 7.1 µg/L versus 2.1 µg/L [P=0.002], and cobalt, 8 µg/L versus 2.6 µg/L [P=0.0004]). DISCUSSION: Serum chrome and cobalt levels increased after metal-on-metal total hip replacement, and the increase was greater with large-diameter implants than previously reported with 28-mm implants. Persistent pain was significantly associated with higher metal ion levels, with a probable cobalt cut-off of about 8 µg/L. Differences in modular head-neck concepts may explain the observed variations.

Posterior tibial slope changes after opening- and closing-wedge high tibial osteotomy: a comparative prospective multicenter study.

INTRODUCTION: Valgus high tibial osteotomy is considered to be an effective treatment for unicompartmental medial osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. However, the effects on posterior tibial slope of closing- or opening-wedge osteotomies remain controversial. HYPOTHESIS: We analyzed the modifications of tibial slope after opening- and closing-wedge high tibial osteotomies and compared the results of these two procedures. We hypothesized that there was no difference in postoperative tibial slope between opening and closing-wedge osteotomies. PATIENTS AND METHODS: This prospective consecutive nonrandomized multicenter study was conducted between January 2008 and March 2009 and included 321 patients: 205 men and 116 women. A total of 224 patients underwent an opening-wedge high tibial osteotomy and 97 a closing-wedge osteotomy. The mean age was 52 years ± 9 and the mean body mass index was 28kg/m(2) ± 5. The main etiology was primary arthritis. Posterior tibial slope was measured preoperatively and at the last follow-up on a lateral radiograph in relation to the posterior tibial cortex. RESULTS: In the opening-wedge group, a definite 0.6° increase in tibial slope (P=0.016) was observed. In the closing-wedge group, a definite 0.7° decrease in tibial slope (P=0.02) was found. Fourteen percent of the opening-wedge osteotomies increased tibial slope by 5° or more versus only 2% of the closed-wedge osteotomies (P<0.001). Twelve percent of the closing-wedge high tibial osteotomies led to a decrease of 5° or more of the tibial slope versus 7% of the opening-wedge osteotomies (P<0.02). DISCUSSION AND CONCLUSION: These results confirm what is generally reported in the literature, i.e., an increase in tibial slope in opening-wedge high tibial osteotomy and a decrease in the slope in closing-wedge osteotomies. These tibial slope changes appear to be very limited in this series, less than 1° on average. However, there was a bias since the open-wedge technique was preferred in cases with substantial varus deformity. We emphasize the importance of surgical technique to avoid alteration of the tibial slope, particularly in opening-wedge high tibial osteotomy for which we recommend a release of posterior soft tissue and a complete osteotomy of the posterior cortex of the tibia. LEVEL OF EVIDENCE: III. Prospective consecutive nonrandomized multicenter study.

[Reconstruction of hand dorsum soft tissue defect using anterolateral thigh perforator flap: description, case study and review of literature]. / Couverture d'une perte de substance de la face dorsale de la main par lambeau antérolatéral de cuisse : description, cas clinique et revue de la littérature.

Reconstruction of hand dorsum soft tissue defect usually requires a flap. The dorsal skin is thin and the underlying structures require coverage by vascularised tissue. We have been using perforator flaps in these cases, especially the anterolateral thigh perforator flap. After a description of the technique, we present a case report in which this flap, in a free version, was used to reconstruct a dorsal hand defect after failure of a posterior interosseous flap. The fascia underlying the flap was used to create a sliding interface for extensor tendons. Postoperative care was without complications. The indications of this flap are numerous but after a review of international literature, we found that its use was seldom reported in France compared to other countries. However, we think that its trophic qualities and minor donor site morbidity make it ideal for coverage of hand dorsum soft tissue defects.

Treatment of recurrent THR dislocation using of a cementless dual-mobility cup: a 59 cases series with a mean 8 years' follow-up.

INTRODUCTION: Instability is one of the most feared complications following total hip replacement (THR). In France, dual-mobility cups are widely used in acetabular revision for instability; few studies, however, have focused on this type of implant. HYPOTHESIS: The gain in stability provided by the dual-mobility implant allows the risk of dislocation to decrease by the sole revision of the acetabular component in case of recurrent instability. OBJECTIVES: This hypothesis was tested over medium-term follow-up of a series of cementless dual-mobility cups implanted during isolated acetabular revision for recurrent dislocation. PATIENTS AND METHODS: A series of THR revision for instability was analyzed retrospectively. Inclusion criteria were: recurrent THR dislocation treated by cementless dual-mobility cup, between 1995 and 2001. Radiological analysis used Imagika™ software. Fifty-nine patients were included; nine died before radioclinical follow-up could be performed; none of the survivors were lost to follow-up. Mean follow-up was 8 years (range, 6-11 years). RESULTS: There was one early dislocation without recurrence; the dislocation rate was 1.7%. At follow-up, mean PMA score was 16.5 (12-18) and mean Harris score 86.7 (49-99). Radiologically, there was no loosening or migration, but 19% of X-ray views showed less than 1mm wide peri-acetabular radiolucency. With dislocation as censoring criterion, 8-year survivorship was 98% (95% CI: 95-100%). DISCUSSION: The dislocation rate (1.7%) and clinical results were better than in most series of revision by constrained cup for recurrent dislocation. The high rate of peri-acetabular radiolucency would seem to relate to the external coating of the cup: aluminum oxide in the Novae-1 implant and aluminum oxide/hydroxyapatite in the Novae-E. CONCLUSION: The use of dual-mobility cups to treat THR instability gave satisfactory results. We recommend dual-mobility cups with hydroxyapatite surface treatment over a porous metallic substrate, rather than with an aluminum oxide or an aluminum oxide/hydroxyapatite bilayer coating. LEVEL OF EVIDENCE: Level IV. Retrospective Study.

Does hyperflex total knee design improve postoperative active flexion?

INTRODUCTION: The rotating platform flexion (RPF) Sigma total knee prosthesis (DePuy; Warsaw, Indiana) was designed for maintaining the contact of the condyles with their corresponding tibial plateau throughout the high-flexion range. However, this requires an additional 3-mm bone cut of the posterior condyles. Compared to the conventional design, this modification is intended to improve the flexion range. This hypothesis was tested by studying the increase in flexion (flexion gain, range of motion [ROM], active flexion) of 59 consecutive patients who had received the hyperflex design implant (RPF), whose preoperative mobility values were retrospectively compared to these same values in another 59 consecutive matched patients who had received an implant with the conventional design of the same implant (rotating platform [RP]) between June 2005 and June 2006. Postoperative mobility was measured visually with a goniometer. PATIENTS AND METHODS: Only osteoarthritic knees were eligible to be included. Knees with more than 20 degrees flexion contracture or less than 90 degrees flexion, and patients with a body mass index (BMI) greater than 30 were excluded. Both groups were comparable with regard to age, preoperative mobility values, and BMI. The sex ratio differed significantly, but preoperative mobility did not differ significantly in male and female patients in the RP and in the RPF groups. The difference in sex ratio did not appear to be a bias influencing preoperative mobility. RESULTS: Overall, the flexion gain was correlated to preoperative flexion (r=-0.75, p<0.001). The flexion gain in the RPF group was significantly greater than in the RP group (13+-20 versus 6+-13; p=0.02) as was the ROM gain (10+/-17 degrees versus 4+/-12 degrees; p=0.02). However, the one-year active mean flexions were not significantly different (118+/-14 degrees versus 116+/-6 degrees; p=0.47). In patients whose preoperative flexion was less than 120 degrees (18 and 27 RPF prostheses), the flexion and ROM gains were significantly greater in the RPF group (23+/-16 degrees versus 14+/-16 degrees; p=0.03 and 26+/-18 degrees versus 17+/-9 degrees; p=0.05), and the mean one-year active flexion was also greater in the RPF group (124+/-13 degrees versus 116+/-8 degrees, p=0.02). In patients with more than 120 degrees of preoperative flexion, the flexion and ROM gains and the final mean flexions in both groups were comparable. In particular, there were nine patients in the RP group and ten patients in the RPF group whose flexion decreased. CONCLUSION: Thus, the Sigma RPF prosthesis provided a significant additional flexion gain in patients with 90-120 degrees preoperative flexion, and less than 20 degrees flexion contracture. Patients with a preoperative flexion greater than 120 degrees were exposed to a decrease in flexion range whichever implant was used, RP or RPF. LEVEL OF EVIDENCE: Level 3, therapeutic study.

Large diameter head metal-on-metal bearings total hip arthroplasty: preliminary results.

INTRODUCTION: Although the use of the metal-on-metal bearings has been validated over the long term in total hip arthroplasty (THA) for standard 28 and 32 mm diameters, and over the medium term in resurfacing procedures, the use of larger metal head size in conventional THA has not yet been extensively reported. HYPOTHESIS: The large-diameter metal-on-metal head is beneficial in terms of implant stability without altering the result in terms of function and bone fixation compared to the standard 28 and 32 mm diameters. OBJECTIVE: The objective was to test this hypothesis by assessing the short-term clinical and radio graphic results of a metal-on-metal large-diameter heads THA system, using cups from the resurfacing hip concept. MATERIAL AND METHODS: We conducted a retrospective study on a continuous series of 106 uncemented acetabular cups (Durom) implanted in 102 patients (mean age, 66 years): 93 cases of primary or secondary coxarthrosis, 11 cases of aseptic osteonecrosis, one fracture of the femoral neck, and one case of rheumatoid arthritis of the hip. At 30 months of follow-up,the Harris Hip Score and the Merle d'Aubigné (PMA) score were calculated. The radiological investigation included comparison of the implant head with native head diameters, variations of acetabular center of rotation, inspection for implant migration, and search for a gap or radiolucent line. RESULTS: The series included two post-traumatic dislocations as well as spontaneously receding tendinitis of the gluteus medius with no further recurrence. The mean Harris Hip Score improved from 49.3 preoperatively to 91.6 at the latest follow-up and the mean PMA score ranged from 12 to 17. The results were excellent for 70 cases, good for 31 cases, fair for three cases, and poor for two cases. In the last five cases, the overall results were undermined by low pain subscore,with no identifiable explanation. Restoration of the original head diameter was verified for 65 hips. No cup migration was observed. Measurement of the acetabular centre of rotation showed a mean lateralization of 1.1mm. Of the 67 immediate postoperative gaps, only two did no disappear at follow-up. Implant head diameter, cup position, and the existence of a gap were not correlated with the clinical results. DISCUSSION: These results are comparable to 28 mm-diameter metal-on-metal heads in uncemented cups but with improved stability but without demonstrable alteration of the quality of the bone fixation. We found no mechanical or medical cause that could explain the five cases of persistent pain leading to fair or poor results. Long-term follow-up will validate these theoretical advantages in terms of wear and implant survival. LEVEL OF EVIDENCE: IV. Retrospective series.

Femoral offset: anatomical concept, definition, assessment, implications for preoperative templating and hip arthroplasty.

UNLABELLED: BACKGROUND OBJECTIVE: Femoral offset is supposed to influence the results of hip replacement but little is known about the accurate method of measure and the true effect of offset modifications. MATERIAL AND METHODS: This article is a collection of independent anatomic, radiological and clinical works, which purpose is to assess knowledge of the implications of femoral offset for preoperative templating and total hip arthroplasty. RESULTS: There is a strong correlation between femoral offset, abductors lever arm and hip abductor strength. Hip lateralization is independent of the femoral endomedullary characteristics. The abductors lever arm is highly correlated to the gluteus medius activation angle. There were correlations between femoral offset and endomedullary shape. The hip center was high and medial for stovepipe metaphysis while it was lower and lateralized for champagne - flute upper femur. A study was performed to compare the femoral offset measured by X-ray and CT-scan in 50 patients, demonstrated that plain radiography underestimates offset measurement. The 2D templating cannot appreciate the rotation of the lower limb. Taking into account the horizontal plane is essential to obtain proper 3D planning of the femoral offset. A randomized study was designed to compare femoral offset measurements after hip resurfacing and total hip arthroplasty. This study underlined hip resurfacing reduced the femoral offset, while hip replacement increased offset. However, the reduction of femoral offset after hip resurfacing does not affect the function. A pilot study was designed to assess the results of 120 hip arthroplasties with a modular femoral neck. This study showed that the use of a modular collar ensures an easier restoration of the femoral offset. A cohort of high offset stems (Lubinus 117 degrees) was retrospectively assessed. The survival rate was slightly lower that the standard design reported in the Swedish register. Finally, the measurement of offset and leg length was assessed with the help of computer assistance. The software changed the initial schedule (obtained by templating) in 29%. CONCLUSION: Therefore, femoral offset restoration is essential to improve function and longevity of hip arthroplasty. CT-scan is more accurate than plain radiography to assess femoral offset. Hip resurfacing decreases offset without effect on function. Modular neck and computer assistance may improve intraoperative calculation and reproduction of femoral offset. Increasing offset with a standard cemented design may decrease long-term fixation. Level IV: Retrospective or historical series.