[Femoral reconstruction with endosteal bone allografts protected by a metallic mesh in reoperation of total hip prosthesis. 19 cases with an average follow-up of 83 months]. / Reconstruction fémorale par des allogreffes spongieuses impactées et protégées par un treillis métallique au cours des révisions de prothèses totales de hanche. 19 cas au recul moyen de 83 mois (58-111 mois).

PURPOSE OF THE STUDY: To assess after 83 months of follow-up, the results of 19 femoral revisions carried out according to an original method combining a cemented stem and bone reconstruction by means of impacted-morcelized bone allograft protected by a titanium mesh. MATERIALS: Twenty hips (18 patients mean aged 58 at surgery) were included between 1986 and 1991. Five hips had a least one previous prosthetic revision, one hip was revised because of septic loosening. No patient was lost for follow-up, but two had died during the follow-up period: one patient died one month after surgery was excluded, one other died 7 years after the index procedure and was included with his last hip rating. Loss of femoral bone stock was severe according to the SOFCOT four stage rating system: 2 femurs were grade II, 14 grade III, and 3 grade IV. Femoral stem migration was assessed with landmarks recommended by Walker. All the measurements were performed with a digitizer (OrthoGraphics). METHODS: All the procedures were carried out through a posterolateral approach, augmented by 4 trochanteric osteotomies and 5 distal femoral windows. After prosthesis and cement removal, a bone plug was placed into the medullary canal. Then, cancelous bone morcelized allografts were impacted in the femoral defects through the medullary canal. A titanium mesh cylinder was placed into the femur to separate the graft from the cement introduced later to obtain fixation of the revision stem. The stem was extended about 5 centimeters over the distal edge of the grafts in order to bridge the femoral defects. The mesh was extended only in front of the grafts and was used to protect them from excessive cement penetration. RESULTS: Functional improvement was noticeable since the Merle d'Aubigné Hip score improved from 9.8 to 16.3 at follow-up. The pain score improved from 2.1 to 5.5 and walking score from 2.3 to 5. Adverse effects occurred during the first cases and were related to cement removal: 3 greater trochanter fractures, 5 distal femoral perforations and 2 non displaced femoral shaft fractures. The septic revision had recurrence of infection associated with radiolucent lines > 2 millimeters and the only one graft resorption. One trochanteric non-union was observed but no prosthetic dislocation. Only one femoral stem migration (4.4 millimeters) was detected without any other radiographic features of loosening after 9 years of follow-up. This stem was considered as loosed, but was not revised because of few clinical symptoms. Only 2 radiolucent lines less than 2 millimeters at the bone cement interface in Gruen's zones 3 to 5. Likewise, no radiographic feature of stress-shielding was observed. On follow-up X-rays, 3 hips had corticalisation of the grafts, and 12 hips demonstrated normal cancelous trabeculations in the grafts. CONCLUSION: Satisfactory functional and radiographic results were obtained with this method after 5 to 10 years of follow-up instead of severe preoperative femoral bone stock impairement. Likewise, we observed only one recurrence of loosening diagnosed with the help of digitized X-ray examination. Only one significant (> 3.5 mm) femoral stem migration was detected. Radiographic features of femoral reconstruction were observed but without histologic proof of graft integration. This method uses a longer stem than the "Exeter", but avoids a high rate of femoral stem migration and appears compatible with femoral bone reconstruction.

Epithelioid sarcoma of the spine: a case report.

STUDY DESIGN: This case report illustrates a patient presenting with sciatica and diagnosed with epithelioid sarcoma involving the spine. OBJECTIVES: The treatment of this patient involved multiple mass resections and decompressions of the spinal canal. Radio- and chemotherapy were applied once a clear diagnosis was obtained. SUMMARY OF BACKGROUND DATA: Epithelioid sarcoma is a rare tumor mainly arising in the extremities. Confusion with a benign inflammatory process are possible. Treatment after histologic diagnosis involves wide resection. To our knowledge, this report represents the first case of epithelioid sarcoma involving the spine. METHODS: After initial discectomy, recurrent scarring and mass formation required multiple decompression procedures and fusion. The initial pathology revealed inflammatory reaction on fibrosis. In a later procedure, the histologic diagnosis of epithelioid sarcoma was made. Radiotherapy and chemotherapy were begun immediately. RESULTS: Despite aggressive resections, radiotherapy, and chemotherapy, the patient died 3 months after the last surgical procedure. CONCLUSION: Spinal epithelioid sarcoma can be mistaken for a benign inflammatory process. After a histologic diagnosis, aggressive wide resection is necessary. Multiple recurrences are documented with this tumor in other sites. Prognosis in trunk involvement is less favorable than involvement of the extremities. The role of adjuvant radio- and chemotherapy is unclear for spinal involvement.

[Kapandji enlargement plasty of A1 pulley. Results in 15 primary trigger fingers with a 5 year (2-8 years) follow-up]. / La plastie d'agrandissement de la poulie A1 selon Kapandji. Résultats sur 15 doigts à ressaut primitifs après 5 ans (2-8 ans) de recul.

We retrospectively studied 15 enlargement plasties of the A1 pulley performed in a university orthopaedic department for trigger finger. The study objectives where: 1)to evaluate whether closure of the enlarged A1 pulley led to recurrent trigger finger; 2) to determine whether the complexity of the procedure was responsible for complications. Fifteen trigger fingers operated by enlargement of the A1 pulley according to Kapandji, instead of opening of the A1 pulley, were reviewed after 5 years of follow-up (2-8 years) by an observer who did not participate in surgery. These 15 fingers (6 thumbs, 7 ringer finger, 1 long finger and 1 index finger) were operated in 14 patients (11 females, 3 males) with a mean age of 55 years at surgery. All trigger fingers were primary (no patients had pathological conditions predisposing to trigger finger). After surgery, all symptoms resolved. No recurrence was observed during the follow-up period. No loss of range of motion or loss of sensation were observed. Reflex sympathetic dystrophy was observed in one case after surgery and resolved before the sixth postoperative month. The authors recommend this procedure, which doesn not lead to recurrence despite closure of the enlarged A1 pulley. Technically more demanding than simple A1 pulley opening, this procedure was safely performed in our department despite participation of junior surgeons.

[Outcome of hip shelf arthroplasty in adults after a minimum of 15 years of follow-up. Long term results and analysis of failures of 56 dysplastic hips]. / Devenir des butées de hanche chez l'adulte après un recul minimal de 15 ans. Résultats à long terme et analyse des échecs sur 56 hanches dysplasiques.

PURPOSE OF THE STUDY: The goal of this study was to evaluate late results of hip shelf arthroplasty in adults after a minimum of 15 years follow-up. MATERIAL: 65 hip shelf arthroplasty performed for painful hip dysplasia between 1964 and 1977 were studied retrospectively in 1992. These 65 procedures were performed in 57 patients mean aged 32 +/- 14 years [17-56]. Nine patients (9 hips) were excluded (2 deceaded, 5 lost for follow-up, and two reoperated because of severe infection). Consequently, the functional results were evaluated for 56 hips (48 patients). Before surgery, according to Merle d'Aubigné's hip rating system, all the hips were painfull (mean pain score was 2.6 +/- 1.7 [0-5]). On radiography, all the hips had a dysplastic acetabulum and arthritic changes. Arthritic changes were severe in 32 hips (57.1 per cent). METHODS: The hip shelf arthroplasty was carried out according to Roy-Camille. 10 hips had additional varus femoral osteotomy. The 48 patients (56 hips) included were evaluated by means of Merle d'Aubigné's hip rating system and AP and false lateral weight-bearing Xrays. In 1992, 24 procedures were changed for total hip replacement (THR) (17 before 15 years (early failure) and 7 after 15 years of follow-up (late failure)). These 24 hips were included with their last hip rating observed just before THR. Survival analysis was performed according to Kaplan-Meier using date of revision for THR as end-point. RESULTS: After 16.1 +/- 5.6 years of follow-up the functional score for 56 hips was: excellent in 4 hips, very good in 7 hips, good in 10, satisfactory in 14, poor in 17, and bad in 4. The survival rate established for 65 hips was 60 per cent at 15 years and 40 per cent at 21 years. Only 39 hips shelf arthroplasties were still functional after 15 years (mean follow-up 19.1 +/- 3 years [16-28], but 18 hips (46.1 per cent) were painfree or slightly painful (pain score to 5 or 6). Among these 39 hips, the results were excellent in 4 hips, very good in 7 hips, good in 10, satisfactory in 10, poor in 6, and bad in 2. Arthritic change was the main reason for failures: the Kaplan-Meier survival rate at 21 years was 87 per cent when arthrosis was slight and only 15 per cent and 42 per cent when arthrosis was moderate to severe (p = 0.0001). The adverse effect of arthrosis was promoted by lack of congruency for early failures, and by severity of dysplasia and hip subluxation for late failures. The additional femoral varus osteotomies had no influence on functional or radiographic outcome. DISCUSSION: Our study indicated that hip shelf arthroplasty performed for painful acetabular dysplasia in adult has a 40 per cent probability survival rate at 21 years. The high rate of revision (42.8 per cent) could be related to the prevalence of severe pre-operative arthrosis. The low rate of lost for follow-up (8.7 per cent) and the long follow-up period (16.1 years) made our conclusion reliable. CONCLUSION: In spite of a high revision rate we recommend shelf athroplasty to treat acetabular dysplasia in adults. This procedure, very reliable in cases of moderate arthrosis, could be performed in cases of severe arthrosis to delay and make easier THR, but a low survival rate could be expected unless dysplasia, lack of congruency and subluxation were mild.

[Intra-operative fractures: analysis]. / Fractures per-opératoires : analyse et synthèse.

51 fractures during total hip arthroplasty were studied. Fractures appeared to be predisposed to several factors: osteoporosis (20%), revision (32%), neck fractures (30%), ankylosis of the hip (16%). The risk seemed greater with non cemented prostheses. Consolidation was obtained in 60.6 days : no statistical difference was found with respect to the type of fracture or treatment.Such fractures do not seem to jeopardize the stability of the femoral component in the long-term.

[Reconstruction of the acetabulum using femoral head autograft in total hip arthroplasties]. / Reconstruction de l'acetabulum par autogreffe de tête fémorale au cours des arthroplasties totales de hanche.

We have reviewed, at a mean follow-up of 63.7 months, 36 total hip replacements performed with bulk acetabular autograft. Before surgery all the hips had acetabular insufficiency. Improvement of acetabular coverage was achieved in all cases with the patient's femoral head screwed to the ilium. Only one massive graft resorption was observed, simultaneous to loosening of the socket. Partial graft resorption was observed in 6 cases, and was not correlated with loosening of the socket. In all cases we observed radiographic features consistent with graft incorporation. Periprosthetic ossifications were noted in 13 cases. At follow-up, four sockets were loose, among which were included three Weill threaded rings. The mean functional improvement scores evaluated with the Merle d'Aubigné hip rating were: 4 points for pain, 2.7 points for mobility, and 2.4 points for walking. The authors concluded that femoral head, used as a massive autograft during total hip replacement, was a safe procedure for bone stock reconstruction in case of severe acetabular insufficiency.

Causes of dislocation of total hip arthroplasty. CT study of component alignment.

We reviewed radiographs and CT scans of 38 total hip arthroplasties which had dislocated (36 posteriorly; 2 anteriorly) and compared the alignment of the prosthetic components with those of 14 uncomplicated arthroplasties. No difference was found between the alignment of the prosthetic components in the two groups. In the seven patients who had reoperations, the cause of dislocation diagnosed by CT was confirmed in only two cases (one retroversion of the cup and one protruding osteophyte). Muscular imbalance rather than malposition of the components was the major factor determining dislocation. CT allows accurate measurement of cup and neck anteversion but contributes little to preoperative planning.

[Reconstitution of femoral bone stock in loosening of total hip prosthesis]. / Reconstitution du stock osseux fémoral dans les descellements de prosthèses totales de hanche.

Between 1986 and 1990, 18 femoral loosenings were treated for severe destruction with an original technique. The average age of the 16 patients was 62 years. Two hips had a second loosening. According to the score of Merle d'Aubigné the pain was evaluated at a mean of 2.1 preoperatively. The gait was scored 1 in half of the patients. The prostheses were trochanterodiaphyseal in 14 patients and self-locking in 4 patients. The aim of this technique was: 1. to bridge the diaphyseal bone loss by healthy cortical bone, for good primary stability, 2. to reconstruct the bone stock with fragmented allografts, 3. to avoid mixing grafts and cement, by using an interposed titanium net. The frequent postoperative complications (2 fractures, 4 diaphyseal bursts, 6 false channels) occurred during extraction of the cement. Weightbearing was allowed after an average of 2 months postoperatively. With a follow-up of 33.4 months, the functional result was excellent in 11 cases (score 17 and 18). No massive resorption of the endomedullary graft was observed; trabeculation of the graft was seen in 8 patients. No migration of the prosthesis was noted. In later years, there will be a problem of extracting the rod, and there exists a risk of stress shielding, due to the length of the stem.

[Radiologic evaluation of the rotation center of the hip]. / Evaluation radiologique du centre de rotation de la hanche.

We studied 98 normal hips in 54 patients in order to assess precise settlement of the theorical hip center using the U landmark as reference i.e. determine A distance (vertical settlement) and C distance (horizontal settlement)) A being the vertical distance between U landmark and the femoral head center, C the horizontal distance between U landmark and the femoral head center. We found two indexes (A/E = 0.2 and C/D = 0.3) which allowed us to fix that center in vertical (A/E) and in horizontal (C/D) direction even in case of bilateral hip dysplasia, and which can be used either in pre-operative planning or in post-operative evaluation. D being the horizontal distance between the U landmarks, and E the vertical one between the U landmark and the sacroiliac joint.

[Percutaneous surgery of the dorsolumbar disks]. / Chirurgie per-cutanée des disques dorso-lombaires.

The authors report a new technique for percutaneous surgery of thoraco-lumbar discs. It allows nucleotomy or intersomatic grafting. This extra-articular posterolateral approach is performed under fluoroscopic monitoring by using a Kirschner's wire and some specific co-axial tubes. Scanographic polar coordinates are most suitable for valuable locating of thoracic discs and performing of technique. Indications and limits of the method are discussed with preliminary results obtained with the first 19 cases.