The ilio-inguinal approach for recent acetabular fractures: ultrasound evaluation of the ilio-psoas muscle and complications in 24 consecutive patients.

INTRODUCTION: The ilio-inguinal approach is used to achieve internal fixation of acetabular fractures. Although the outcomes of this procedure have been extensively reported, information is lacking on potential complications. More specifically, the effect on the ilio-psoas muscle, whose iliac attachments are almost completely released, has not been accurately evaluated. HYPOTHESIS: Endopelvic dissection does not alter the ultrasound structure of the ilio-psoas muscle compared to the normal side at a distance from acetabular internal fixation via the ilio-inguinal approach. PATIENTS AND METHODS: We retrospectively evaluated 26 patients who underwent internal fixation of acetabular fractures via the ilio-inguinal approach between 2006 and 2010. Two patients with multiple injuries died shortly after the procedure, leaving 24 patients with unilateral fractures for the study. In 2012, an observer who was not involved in the surgical treatment of these patients conducted an assessment (Oxford score except in the 8 patients who required revision surgery for arthroplasty and evaluation for a deficit of the lateral femoral cutaneous nerve in the full cohort). At the same time point, ultrasonography was performed to compare ilio-psoas muscle morphology on the two sides. Any other complications (vascular, nervous, or parietal) were recorded. RESULTS: Of the 24 patients, 11 (45%) experienced complications, of whom only 3 required further surgery, 2 with infections that recovered fully after lavage and 1 with a haematoma responsible for compression of the urinary bladder. The lateral femoral cutaneous nerve was injured in 8 (33%) patients, including 4 who had achieved a full recovery at last follow-up. At last follow-up, none of the 24 patients had ultrasound evidence of a significant difference in ilio-psoas muscle size at the lateral window: mean transverse diameter was 51.8±0.8mm (range, 44-58 mm) on the operated side versus 51.7±0.79 mm (range, 44-59 mm) on the other side (P=0.9). After a mean follow-up of 49 months (range, 31-70 months), the mean Oxford score in the 16 patients who had not required further surgery was 20.5/60 (range, 12-44). DISCUSSION: Our results show that, despite extensive endopelvic dissection, the ilio-inguinal approach has no effect on the ultrasound morphology of the ilio-psoas muscle. There is a high risk of injury to the lateral femoral cutaneous nerve that should be disclosed to the patient before the procedure. In contrast, no parietal complications were recorded. In selected patients, the Cole-Stoppa approach is an alternative that spares the lateral femoral cutaneous nerve. LEVEL OF EVIDENCE: Level IV, retrospective study.

Interprosthetic femoral fractures: analysis of 14 cases. Proposal for an additional grade in the Vancouver and SoFCOT classifications.

INTRODUCTION: Interprosthetic fracture is a rare but serious entity, impairing consolidation and stability due to adverse mechanical conditions related to bone fragility and implant volume. OBJECTIVE: The present study highlights the difficulties involved in managing such fractures, details treatment options and reports findings leading to a proposed additional grade in the comparable Vancouver (hip) and French Orthopedic and Traumatologic Surgery Society (Société française de chirurgie orthopédique et traumatologique: SoFCOT) (knee) classification systems. PATIENTS AND METHODS: A multicenter retrospective series included 14 interprosthetic femoral fractures: eight type double C (typeC for both hip and knee), five type C for hip and B for knee, and one type double B (type B for both hip and knee) on the Vancouver and SoFCOT classifications. Fracture occurred on standard (n=15) or revision (n =13) implants. Six cases involved a femoral shaft encumbered by a total knee replacement (TKR) femoral extension stem and eight cases TKR without femoral long stem, assimilable to type C fracture. RESULTS: None of the six fractures proximal to a constrained TKR with stem-achieved union by primary intention, whereas seven of the eight type-C fractures did so. Finally, 12 cases showed favorable evolution, with three secondary total femur replacements (TFR) and one death at 6 months without bony union or revision and one patient waiting for TFR. DISCUSSION: To describe the status of the intermediate femur and its medullary canal encumbrance, we propose adding a category D to the SoFCOT and Vancouver classifications, corresponding to interprosthetic fracture on TKR with diaphyseal extension stem. Interprosthetic fracture internal fixation should begin with long devices bridging the two prostheses. When the implant is loose, it may be replaced; in case of diaphyseal extension, however, the residual femur between the two extensions should be protected against peak stress by a plate extending upward and downward. In case of limited bone stock, due to osteolysis or initial femoral medullary canal compromise, especially if one or both implants are loose, TFR may be indicated as consolidation, is jeopardized by the uncertain mechanical situation.

Anterior hip subluxation following fixation of a T-shaped acetabular fracture through an extended iliofemoral approach.

We report the case of a 34-year-old female patient who, six week following her acetabular fracture ORIF through an extended iliofemoral approach, presented with anterolateral incomplete dislocation of the femoral head. In the absence of joint incongruence as demonstrated on radiographs and CT images, a capsular tightening was performed via the anterior Hueter approach. This capsular plasty stabilized the hip for 2 years, but gradual osteoarthritis deterioration resulted in the need for arthroplasty. At the 2-year follow-up, this secondary arthroplasty showed satisfactory result. The substantial muscle exposure of the lateral aspect of the acetabulum and the circumferential capsulotomy related to the use of the iliofemoral approach were retained as factors promoting this complication. In case early postoperative mobilization is impossible, temporarily maintaining the limb in abduction and flexion can be recommended after an extended iliofemoral approach with circumferential capsulotomy.

Metal ions levels measurments for early total hip replacement malfunction diagnosis with "plasma-sprayed ceramic" bearings couple.

Diagnosis of total hip arthroplasty malfunction is usually based on clinical and radiographic findings, while metal ion blood levels monitoring is generally recommended for metal-on-metal bearings hip replacements. However, these measurements may be very useful in detecting anomalies in other bearing surfaces such as plasma sprayed ceramic bearings. We report on the case of a patient with a painful cementless ceramic-on-ceramic total hip prosthesis (Plasmaceram) for which metal ions blood levels suggested revision surgery in the absence of any demonstrable radiographic anomaly. The high Cobalt and moderate Chromium ion levels in blood suggested a mechanical dysfunction of the bearing couple which revealed to be a severe cam effect requiring revision surgery of both components. Measurement of metal ion blood levels may play a substantial role in the assessment of a total hip prosthesis mechanism when using another bearing surface than metal-on-metal for which this measurement is usually recommended.

Bilateral simultaneous metal inlay dissociation from the polyethylene liner of a metal-on-metal hip replacement.

INTRODUCTION: Hard-on-hard bearings for total hip replacement may require a modular acetabular inlay for which polyethylene is often used in a sandwich-type configuration. However, differences in the elastic modulus of the materials make fixation of this metal insert uncertain. The aim of this study is to report a case of bilateral separation of the metal insert from the polyethylene sandwich in a metal-on-metal bearings prosthesis. MATERIALS AND METHODS: A bilateral total hip arthroplasty was performed in two operations, four months apart, in a 53-year-old woman following a corticosteroid-induced osteonecrosis. The total hip replacement system included a cementless stem, and a press-fit hemispheric cup containing a polyethylene sandwich with a metallic insert (Sikomet). RESULTS: Three years later, the patient consulted because of abnormal noise in her right hip which appeared normal on conventional X-ray. Three months later she consulted again for persistent noise. Separation of the metal insert from the polyethylene sandwich was diagnosed and an acetabular revision was performed selecting a metal-on-polyethylene articulation system. The postoperative course, for this revision, was uneventful, but the patient returned with the similar symptoms in her left hip four months later, resulting in the same type of revision. During the revisions, osteolysis secondary to metallosis was diagnosed, requiring synovectomy and acetabular reconstruction with morcelized allograft impaction. The left side postoperative course included three dislocations in nine months which were conservatively treated and have not since recurred. DISCUSSION AND CONCLUSION: This is the first reported case recording an almost simultaneous bilateral dissociation of a hard-on-hard inlay from its polyethylene sandwich. This bilateral case suggests that the fixation of the metal insert inside the polyethylene was probably defective. This case is also a reminder that mechanical complications (separation, implant fracture) should be searched for in presence of any abnormal noise occurring after hard-on-hard bearings prosthetic implantation. This confirms the necessity of periodical follow-up of hip arthroplasties and the importance of knowing their radiological features. The low carbon content of the Sikomet bearing may have been the cause of this failure by increasing frictional torque on the bearing surface, causing metallosis which has already been described in the literature in this type of hip replacement system.

Avoidance of patellar eversion improves range of motion after total knee replacement: a prospective randomized study.

Minimally invasive surgery has recently been introduced in TKA surgery. The purpose of this study was to evaluate the effect of eversion of the patella, on safety and functional result after TKA. In a prospective, randomised, double blinded trial, 60 patients were divided in two groups: group A underwent TKA through a standard medial parapatellar arthrotomy, with patellar eversion. Group B underwent the same exposure, except for the fact that the patella was subluxed laterally. All other treatment protocols were identical. Outcomes were measured until 1 year postoperatively. Radiographic evaluation included AP, lateral, skyline and full leg standing radiographs. VAS, WOMAC score, Knee Society Knee and Function score were performed. Active and passive range of motion (ROM) and knee proprioception was measured. All patients underwent isokinetic strength testing. The mean passive ROM changed from 121 degrees preoperatively to 121 degrees postoperatively in group A, compared to 118 degrees -131 degrees respectively in group B at 1 year (P = 0.003). The mean active ROM changed from 112 degrees to 115 degrees in group A, and from 108 degrees to 125 degrees in group B (P = 0.005). All other parameters were not significantly different. Patellar dislocation without eversion for exposing the knee during TKA is a safe procedure and improves ROM at 1 year postoperatively.

[Metal-on-metal hip replacement using Metasul cups cemented into Muller reinforcement rings after a mean 5-year (3-8) follow-up: improvement of acetabular fixation by comparing with direct cementation to bone]. / Résultats cotyloïdiens favorables du couple métal-métal scellé dans des armatures métalliques.

PURPOSE OF THE STUDY: Early loosening, before a three-year follow-up, has been observed with cemented cups having a metal-on-metal insert in a polyethylene cup. The metal-on-metal bearing has been incriminated as the source of the problem because of its rigidity (particularly for small cups measuring less than 50 mm) and the creation of stress conditions unfavorable for a cemented fixation. The purpose of this retrospective study was to determine whether this phenomenon is observed when the cement is fixed not directly into the bone, but via a Muller reinforcement ring. MATERIAL AND METHODS: From 1998 to 2004, 23 arthroplasties using a cemented Metasul cup in a reinforcement ring were implanted in 22 patients (16 women and six men) aged on average 44 years (range 24-56 years). The series included six primary total hip arthroplasties (three for dysplasia, two for protrusions, one for rheumatoid arthritis and one for arthritic degradation) and seventeen revisions (two septic). The Metasul cup (Zimmer-Centerpulse) combined a 28 mm modular head anchored in a femoral implant (two cemented, 21 pressfit) and a polyethylene cup with a Metasul insert (13 of 23 measuring<50mm). In all cases, the cup was fixed with low-viscosity cement in a Myller metal reinforcement ring fixed with screws (Zimmer-Centerpulse). All patients were reviewed clinically and radiographically at a mean 5-year follow-up (range 3-8 years). Acetabular and femoral fixation were analysed (search for lucency and implant migration). RESULTS: Revision was not necessary in any patient for failure of the acetabular fixation. The mean Postel-Merle-d'Aubigné score improved from 12.9 points (range 7-17) to 17.5 points (range 16-18). The radiographic analysis did not reveal any sign of lucency between the cup and ring, nor any migration of the ring. There was no evidence of femoral osteolysis but one femoral revision was needed due to fracture of the lateral cortical identified six weeks after implantation. DISCUSSION AND CONCLUSION: Cementing the metal-on-metal cup into a reinforcement ring can avoid the risk of loosening observed after direct cementing into bone. In our study, the large number of small cups (13/23) would have been expected to produce a high rate of acetabular lucent lines and/or a high rate of early revision, as reported by others, as early as 24 months. Our series was also different from others by the use of pressfit femoral implants in most patients, which should reduce the risk of cement debris in the bearing. Longer follow-up will be necessary to confirm the good results observed to date which suggest that direct cementing of the cup into the bone should be incriminated rather than the metal-on-metal bearing to explain the reported failure of cemented Metasul cups.

[A secondary bleeding false aneurysm of the superomedial genicular artery after distal femoral epiphysiodesis: a case report]. / Pseudoanévrisme secondaire hémorragique de l'artère géniculée supéromédiale après épiphysiodèse fémorale distale.

A 16-year-old male developed a false aneurysm of the superomedial genicular artery five weeks after medial distal femoral epiphysiodesis. The aneurysm was revealed by inexhaustible bleeding from the medial aspect of the knee and the presence of acute hemorrhage which resolved spontaneously. Physical examination disclosed disunion of the surgical wound at the apex of a pulsatory tumefaction over the medial aspect of the knee. AngioCT enabled the diagnosis of a false aneurysm of the superomedial genicular artery. Emergency surgery was undertaken to drain the hematoma and exclude the false aneurysm by ligating the superomedial genicular artery.

[Long-term behavior of ankle fusion: assessment of the same series at 7 and 23 year (19-36 years) follow-up]. / Evolution à très long terme de 25 arthrodèses talo-crurales: comparaison des résultats d'une cohorte à 7 ans et 23 ans (19-36 ans) de recul.

PURPOSE OF THE STUDY: Theoretically, long-term functional and radiographic degradation is predictable after ankle fusion, but sound evidence from the consecutive analysis of the same cohort is lacking. The purpose of this study was to check the hypothesis by repeating assessment in the same cohort of patients who underwent ankle fusion. MATERIAL AND METHODS: The cohort included 52 ankle fusions which had been analyzed in 1984 at seven years (range 2-22 years) follow-up then again in 2000 using the same evaluation criteria. Among the 52 patients, six were lost to follow-up (11.5%) 20 had died (38.4%) and one had undergone leg amputation. The second analysis thus included 25 patients (48%). The comparison cohort thus included 25 patients (18 men and 7 women), mean age 62+/-12.6 years (range 40-94) at the 2000 assessment performed 23+/-4.5 years (range 19-36 years) after the fusion. Functional outcome was assessed with the 100-point Duquennoy scale. Osteoarthritis of the subtalar and mediotarsal joints were assessed preoperatively and at follow-up using the same scale. RESULTS: The functional outcome did not deteriorate significantly between 1984 and 2000. The mean score was 65.8+/-22.6 (range 19-92) in 1984 and 64.7+/-18.3 (range 34-90) in 2000 (p=0.67). Fifteen patients (60%) had a good or very good outcome at seven years, and 14 (56%) at 23 years. Between 1984 and 2000, ten patients improved their score (on average 10.4 points, range 1-21 points), two had an unchanged score and thirteen a lower score (on average 10 points, range -1 to -24). Ten of these thirteen patients developed severe intercurrent conditions (neurological or cardiac) explaining the degradation. At last follow-up, sixteen ankles were pain free or nearly pain free. Twelve patients considered their ankle as a forgotten problem (VAS 10) and had no regrets concerning the operation. The evolution of the subtalar joint in 16 cases (nine fusions including five at the same time as the ankle fusion and four performed within four years) showed that all developed osteoarthrtic degradation early with aggravation between 1984 and 2000, leading in the majority of cases to severe degenerative disease. This osteoarthritis was painful in less than one-third of the cases (including the four secondary subtalar fusions and the four subtalar fusions which were painful at mobilization). Twenty-three mediotarsal joints were analyzed (two fusions four years after ankle fusion). The degradation was later and less severe than for the subtalar joint with a majority showing moderate osteoarthritis. Ten ankles exhibited compensatory hypermobility of the forefoot measured at more than 15 degrees without pain. DISCUSSION: This long-term follow-up with two successive assessments using the same evaluation criteria did not demonstrated the late degradation of function expected after ankle fusion. It did show however the presence of undeniable radiographic degradation of the subtalar joint but with little or no severe clinical expression at a minimal follow-up of 19 years. There was no need for complementary fusion between 4 and 23 years follow-up.

[Measurement of head penetration on digitalized radiographs: reproducibility and accuracy]. / Mesure de la pénétration céphalique sur des radiographies numérisées: reproductibilité et précision.

PURPOSE OF THE STUDY: Wear of the acetabular component of total hip arthroplasty (THA) is incriminated as the cause of loosening and bone resorption. Consequently, an accurate evaluation of wear can contribute to the prediction of mechanical failure of the arthroplasty. Among the different methods proposed, digitalized imaging using a high-resolution scanner associated with data processing procedures appears to be a simple easily accessible technique. A system based on this concept has been introduced in orthopedics. To our knowledge, there has been no report on the system's reproducibility and accuracy. MATERIAL AND METHODS: Thirty-nine radiography series for THA served as the basis for the evaluation of intra- and interobserver reproducibility. We evaluated the error induced by digitalization, the error induced by digitalized measurement, the accuracy of the measurements as a function of the material constituting the bearing, the intra- and interobserver reproducibility for repeated measures of THA wear (six observers and two observations). All measurements were done after digitalization and analyzed with a specimen designed software. RESULTS: The inter and intra-observer coefficients of concordance were 0.6 and 0.58 respectively, i.e. moderate reproducibility. Depending on the prosthetic material, the error and accuracy of the system varied from 0.112 to 0.44 mm and 0.28 to 1.29 mm respectively. To obtain valid inter-observer reproducibility, the number of observers had to be limited to three (coefficient = 0.82). The type of implant had an influence on measurement error. The error was 0.342 for polyethylene cups and 0.118 for press-fit metal back cups. Likewise, for a metallic head measuring 22.2 mm, the error was 0.138 mm while for a ceramic head or metal head measuring 28 mm, the error was 0.28 mm and 0.112 mm respectively. DISCUSSION AND CONCLUSION: The accuracy and error depend directly on the type of implant. The accuracy was better for metallic heads associated with metal-backed cups. To obtain satisfactory interclass correlation, the number of observers should be three. The proposed digitalized measurement system should be relatively accurate and reproducible. Its use can be recommended for the evaluation of wear after five years of follow-up, limiting the number of observers to three.