The distal fibular perforating axial flap for lateral malleolus coverage: an anatomical description and surgical technique.

PURPOSE: Skin closure disorders in ankle surgery are a recurrent problem not only in traumatology but also in elective surgery. The aim of the study was to describe the anatomical basis of the fasciocutaneous vascularization of the lateral malleolus region to develop a posterior cover flap for the region. METHODS: We dissected ten fresh frozen specimens after arterial injection of an Indian ink preparation and individualized the perforating arteries. Their positions and diameters were collated. Then, the surgical technique was clinically applied for two different cases by transferring the fasciocutaneous flap posterior to the lateral malleolus to cover a loss of skin substance. RESULTS: There were in average 5 fibular perforators over the last 100 mm of the fibula. The average diameter of the first two perforating arteries was 0.6 ± 0.12 mm and 0.9 ± 0.25 mm, respectively, and the consistency of the latter makes it possible to produce a skin flap with anterior translation. This is an axial flap. Two patients were operated on using this technique. There was no necrosis of the posterior fibular flap and healing was achieved by the third post-operative week. CONCLUSION: This study showed the presence of fibular perforating arteries with a high reproducibility of their dissection. This anatomical description served as the basis for the description of a new distal fibular perforating flap.

Mid-term results of total hip arthroplasty using a novel uncemented short femoral stem with metaphyso-diaphyseal fixation.

PURPOSE: Short stems were developed with the promise of providing easier implantation, facilitating revision, reducing thigh pain and proximal stress shielding. The aim of this study is to present the mid-term clinical results of a titanium short stem with modular neck. METHODS: This is a prospective case series of 144 THAs performed on a series of 131 patients using the PROFEMUR Preserve Femoral Stem (MicroPort Orthopedics, Arlington, TN, USA). 2 surgeons, operated on the patients using a mini-posterior approach. The primary outcomes evaluated were stem revision for aseptic loosening and all-cause stem revision. Clinical and radiographic outcomes were also assessed. RESULTS: Of the 144 THAs, there were 43 males and 101 females, with an average age of 61 (range 22-92) years at surgery. After a mean of 78 (range 53-87) months follow-up, there were 2 (1.5%) femoral implant revisions; 1 for early femoral periprosthetic fracture and 1 for fatigue failure of the modular femoral neck. There were no cases of stem aseptic loosening and radiographic analysis demonstrated no cases of stem migration. The mean UCLA activity, WOMAC and Fogotten Joint scores were respectively 6.1, 10.7 and 86.6. 70% of prosthetic hips were observed as having no restriction and 99.2% of patients were satisfied with their THA. CONCLUSIONS: This short modular stem produced satisfactory clinical and radiological results at mid-term, with 98.5% implant survival for any cause of stem revision and no revisions for aseptic loosening. Long-term results are required to further evaluate the stem's promising early results.

Bone resection for mechanically aligned total knee arthroplasty creates frequent gap modifications and imbalances.

PURPOSE: The objective of this study was to calculate bone resection thicknesses and resulting gap sizes, simulating a measured resection mechanical alignment (MA) technique for total knee arthroplasty (TKA). METHODS: MA bone resections were simulated on 1000 consecutive lower limb CT scans from patients undergoing TKA. Femoral rotation was aligned with either the surgical trans-epicondylar axis (TEA) or with 3° of external rotation to the posterior condyles (PC). Imbalances in the extension space, flexion space, medial compartment and lateral compartment were calculated. RESULTS: Extension space imbalances (≥ 3 mm) occurred in 25% of varus and 54% of valgus knees and severe imbalances (≥ 5 mm) were present in up to 8% of varus and 19% of valgus knees. Higher flexion space imbalance rates were created with TEA versus PC (p < 0.001). Using TEA, only 49% of varus and 18% of valgus knees had < 3 mm of imbalance throughout the extension and flexion spaces, and medial and lateral compartments. CONCLUSION: A systematic use of the simulated measured resection MA technique for TKA leads to many cases with imbalance. Some imbalances may not be correctable surgically and may result in TKA instability. Modified versions of the MA technique or other alignment methods that better reproduce knee anatomies should be explored. LEVEL OF EVIDENCE: 2.

Total knee replacement on more than 20° valgus: A case control study.

INTRODUCTION: Lower-limb valgus deformity exceeding 20° is a particular case, with few publications assessing the impact of the severity of the valgus. The present retrospective case control study compared a series of>20° valgus versus a series of 10-20° valgus, assessing (1) operative data [approach, type of total knee replacement (TKR)], (2) complications and implant survival, and (3) clinical and radiological results. HYPOTHESIS: Severe valgus deformity requires TKR with greater constraint, incurring a higher rate of complications and poorer implant survival. MATERIAL AND METHOD: A multicenter retrospective study for the period January 2006 to December 2010 included 53 patients, with a mean age of 72±10 years, presenting>20° valgus. The study series was matched for age and gender with a series of 53 cases of 10-20° valgus. Convexity laxity was greater in the>20° group (p=0.004). RESULTS: There was no significant inter-group difference in approach (p=0.13). Greater constraint was more frequent in the>20° group (7/53 versus 1/53; p=0.03), independently of convexity laxity or Krackow grade (p=0.14). There were 7 complications (13.2%) in the>20° group and 7 in the 10-20° group (NS). Eight-year survivorship was 95.12% in the>20° group and 94.9% in the 10-20° group (p=0.63). There were no significant differences in Oxford score (p=0.30) or HKA angle (p=0.78) at last follow-up. CONCLUSION: The study hypothesis was partially confirmed: greater constraint was more frequent in>20° valgus. The number of complications was low, and survival was identical to that of a control group with less severe deformity. LEVEL OF EVIDENCE: III, retrospectivecase controlstudy.

Total knee arthroplasty in patients with varus deformities greater than ten degrees: survival analysis at a mean ten year follow-up.

INTRODUCTION: Total knee arthoplasty (TKA) is a secure procedure with more than 90% survival at ten years. The purpose of this study was to report both clinical and radiological outcomes of TKA with a varus > 10°. The second objective was to identify risk factors for failure or bad clinical results. Our hypothesis was that results and survey are comparable to TKA with lesser deformities. METHODS: Eighty-two TKA (69 patients) between January 2004 and December 2008 with a varus > 10° were reviewed retrospectively. The endpoints were clinical (range of motion, IKS knee score, Oxford, and SF-12) and radiological (HKA post-operative and the existence of radiolucent lines or loosening at last follow-up). RESULTS: Sixty-three TKA (55 patients) were assessed with a mean follow-up of 10.9 years. The global IKS score significantly increased (p = 0.04). Seven TKA needed a revision: two for sepsis, four for aseptic loosening, and one for polyethylene wear, with an overall survival of 91.6% at ten years. For aseptic loosening, the survival rate was 94.7% at ten years. Risk factors for failure were age (p = 0.001), weight (p = 0.04), and a post-operative HKA lesser than 175° (p = 0.05) for aseptic loosening. DISCUSSION: The hypothesis was confirmed: the results showed a significant improvement of function and quality of life with a survival rate comparable to those found in the literature for greater varus but also inferior to 10°. Three risk factors have been identified suggesting increased surveillance in these cases. CONCLUSION: The results of this survey confirm the work hypothesis. Total knee arthroplasty in patients with important axial deformities is a confirmed, reliable, patient-friendly and predictable good outcome procedure.

Joint Perception After Total Hip Arthroplasty and the Forgotten Joint.

BACKGROUND: Assessing patients' functional outcomes following total hip arthroplasty with traditional scoring systems is limited by their ceiling effects. The Forgotten Joint Score (FJS) has been suggested as a more discriminating option. The actual score in the FJS which constitutes a "forgotten joint," however, has not been defined. The emerging concept of joint perception led to the development of the Patient's Joint Perception question (PJP) to assess the patient's opinion of their prosthetic joint. METHODS: Two hundred fifty-seven total hip arthroplasties were assessed at a mean of 68 months of follow-up (range 57-79). Outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), FJS, and PJP. Correlation of the scores as well as the ceiling effects were analyzed. RESULTS: The mean FJS was 88.5 (range 27.1-100). PJP was correlated with the FJS and WOMAC (Spearman's rho -0.510 and 0.465, respectively). Fifty-two percent of the patients felt their hip as a natural joint (FJS: 95% confidence interval [CI] 93.3-96.0), 24.1% as an artificial joint with no restriction (FJS: 95% CI 83.1-90.5), and 23.3% as an artificial joint with minor restrictions (FJS: 95% CI 73.8-82.2). Only 0.8% had major restrictions and none reported a non-functional joint. The ceiling effect was high with both the WOMAC and FJS, with 27.2% and 31.9%. In addition, 28.6% of the patients had a WOMAC >10 and 23.4% an FJS <90 while reporting having a natural hip. Furthermore, 21.5% with a perfect WOMAC or 21.9% with a perfect FJS reported having an artificial joint with or without limitation. CONCLUSION: A forgotten hip perception corresponds to an FJS >93. In 20%-30% of the cases, the WOMAC and FJS failed to identify the forgotten joint, or reached the maximum score when the patients did not feel their hip was natural. The PJP is a simple and reliable tool that enables identification of patients who feel replaced hip is natural.

Minimal influence of the anterolateral knee ligament on anterior and rotational laxity of the knee: a cadaveric study.

Knee laxity may be impacted by rupture of the anterolateral knee ligament (ALL). The goal of this study was to measure tibial translation and rotation as a function of the status of the ALL and the anterior cruciate ligament (ACL). Five pairs of fresh frozen cadaver specimens were analyzed. The knee was positioned in 20° flexion. Calibrated posteroanterior forces and internal/external torques were successively applied. Anterior tibial translation and total internal/external tibial rotation were measured with a navigation system. Three conditions were used in each knee: intact ACL and ALL, transection of ACL or ALL (randomly assigned to each knee of a pair), and transection of both ligaments. The primary outcome criterion was the increase in tibial rotation at 8 Nm. The mean increase in tibial rotation at 8 Nm was 0.8° after transecting the ALL only, 1.2° after transecting the ACL only, and 0.8° after transecting both ligaments. The mean increase in anterior tibial translation at 250 N was 1.2 mm after transecting the ALL only, 9.0 mm after transecting the ACL only, and 6.1 mm after transecting both ligaments. There was no significant increase in the tibial rotation or anterior tibial translation after transecting the ALL only or after transecting the ALL in ACL-deficient knees. The expected role of ALL in controlling anterior or rotational tibia motion could not be confirmed.

Cementless Total Hip Arthroplasty With Metasul Bearings Provides Good Results in Active Young Patients: A Concise Followup.

BACKGROUND: A primary concern of younger, more active patients who have undergone total hip arthroplasty (THA) is the longevity of the implant. Cementless fixation and hard-on-hard bearings are recognized as options to enhance THA durability. Earlier, we published a series of 83 cementless primary THAs using 28-mm metal-on-metal (MoM) bearings in patients aged 50 years or younger; here we provide concise followup on that same group after an additional 8-year survey period. QUESTIONS/PURPOSES: (1) What is the long-term survivorship of cementless primary THA using 28-mm MoM bearings in patients aged 50 years or younger? (2) What are the clinical and radiographic results of cementless THA in this active patient population? (3) Can any of the observed implant failures or adverse events be attributed to the metallic nature of the bearing couple? METHODS: We retrospectively reviewed 83 cementless THAs performed in three institutions over a decade (1995-2004) in 68 patients with 28-mm MoM articulation. All patients (15 bilateral) had a median age of 42 years (range, 24-50 years) at the time of the index procedure and 56 of them (82% [70 hips]) had activity level graded Devane 4 or 5 before significant hip pain. A 28-mm Metasul™ articulation was used with an Alloclassic-SL™ cementless stem in all cases paired with three different cementless titanium acetabular components (one threaded and two press-fit cups) from the same manufacturer. Survivorship analysis was calculated according to Dobbs life table, patient clinical results were evaluated with use of the Postel-Merle d'Aubigné scoring system, radiographic analysis was performed by independent observers, and cobalt level was determined in whole blood. RESULTS: The 15-year survivorship (33 hips at risk) for revision for any reasons (four hips) and for aseptic loosening (one hip) was 96% (95% confidence interval [CI], 81%-99%) and 99% (95% CI, 85%-99.9%), respectively. The median Merle d'Aubigné-Postel score remained stable at 17 points (range, 10-18). Thus far, we have not observed pseudotumors or other adverse reactions to metallic debris. Eight hips have undergone reoperation: trochanteric suture removal (one), psoas tendon impingement (two), and five revisions for periprosthetic fracture (one), late infection (two), acetabular osteolysis (one, as a result of polyethylene backside wear), and one hydroxyapatite-coated cup for aseptic loosening. None of the complications, failures, or revisions observed so far could directly be related to the metallic nature of the 28-mm Metasul bearings used in this selected group of patients. CONCLUSIONS: The current survey at 13-year median followup has not yet indicated any long-term deleterious effects related to dissemination of metallic ions. Two senior authors continue to use 28- or 32-mm Metasul™ bearings with cementless THA components in young and active patient populations. Longer followup with a more sophisticated imaging study is necessary to confirm this so far positive report. LEVEL OF EVIDENCE: Level IV, therapeutic study.