Evora® chromium-cobalt dual mobility socket: results at a minimum 10 years' follow-up.

INTRODUCTION: The Evora chromium-cobalt alloy dual mobility socket claims to display a large articulation tribology different from that of stainless steel models, limiting the risk of intraprosthetic dislocation and wear. The present study reports a minimum of 10years' follow-up in a multicenter prospective series of 200 sockets previously reported on at 5years. HYPOTHESIS: The use of chromium-cobalt in dual mobility sockets provides a low rate of failure at 10years, especially as regards to osteolysis and intraprosthetic dislocation. MATERIALS AND METHODS: Two hundred hydroxyapatite-coated molded chromium-cobalt sockets without titanium interface were implanted without cement in 194 patients with a mean age of 70 years (range, 32-91 years). Clinical results were assessed on Postel Merle d'Aubigné and Harris scores, plain radiographs and survival analysis. RESULTS: At a mean 11 years' follow-up (10-13 years), 56 patients had died and 31 were lost to follow-up. Four underwent surgical revision (3 femoral components, and 1 socket for migration at 9 years with complete disappearance of the hydroxyapatite). A total of 109 implants were analyzable in 107 patients with a mean age of 81 years (55-93 years). At follow-up, the mean Harris score was 90 (75-96) and the PMA score 16.3 (14-18). There were no cases of loosening (except for the case reoperated on at 9 years) and no acetabular radiolucency or cysts. There were 2 cases of non-evolutive femoral radiolucency and 10 of femoral granuloma, involving head size > 22 mm (P<0.0001) and a cemented titanium stem (P=0.004) as risk factors. There were no dislocations in the large or small articulation. Ten-year survival was 99% (95% CI: 97.3%-100%) with socket revision as censorship criterion. DISCUSSION: The absence of dislocation in both small and large articulations confirmed the efficacy of the dual mobility concept and suggested an advantage for chromium-cobalt sockets in reducing the rate of intraprosthetic dislocation and preventing blockage of the large articulation by a better performance in the friction couple. Granulomas were associated with wear in cemented titanium stems and with heads greater than 22 mm in diameter. Ten-year survival was 99% (censorship criterion: revision for socket failure); there was, however, one case of socket loosening with disappearance of the hydroxyapatite, indicating that surveillance should be continued in this cohort.

[Ligamentoplasty of the anterior cruciate ligament after 40 years: a series of 41 patients]. / Reconstruction du ligament croisé antérieur après 40 ans: a propos de 41 cas.

PURPOSE OF THE STUDY: Ligamentoplasty for tears of the anterior cruciate ligament (ACL) is generally thought to be unreliable after the age of 40 years. The purpose of this retrospective analysis was to assess the five-year outcome after ACL plasty in patients aged over 40 at the time of surgery. MATERIAL AND METHODS: Between 1990 and 1997, 41 patients aged 44.5 +/- 4.5 years (28 men, 25 right side) underwent intra-articular reconstruction of the ACL. Clinical and radiological assessment using the IKDC criteria was obtained at a mean 62 months postoperatively using manual instrumental measurements with KT-1000. The indication for reconstruction was instability in daily life activities for 40 patients and difficulties encountered in sports activities in one; there were three cases of remodeling. Arthroscopy was used in all cases to perform a patellar tendon graft (bone-tendon-bone in 30 cases associated with extra-articular lateral reinforcement in eleven). RESULTS: There were no significant complications. Among 12 patients who initially participated in competition sports, seven were able to resume their activity at their former level. At last follow-up, global IKDC score was A for 12, B for 25, and C for three and D for one. All patients scored C or D had a poor IKDC symptom score, basically because of pain. Motion was not modified. The IKDC radiology score was A for 25, B for 15 and C for one, but the three cases of remodeling did not progress. Prognostic factors for overall IKDC result were: age of the patient at the time of reconstruction (under 45 years), and the delay to surgery for accident victims (less than one year). The following criteria had no effect at last follow-up: gender, sport practiced, type of initial laxity (anterior alone or global anterior), presence of meniscal damage, preservation of the medial and/or lateral meniscus, chondral injury observed peroperatively, and use of a lateral reinforcement. Radiographic remodeling observed in this group of 41 patients was related to delay from accident to surgery (p=0.0007) and preservation of the medial meniscus (p=0.03). Age, gender, type of activity before surgery, degree of initial and residual laxity had no statistically significant effect on remodeling. CONCLUSION: Age over 40 years is not a contraindication for arthroscopic free patellar tendon graft for the treatment of chronic anterior laxity. Using rigorous preoperative assessment criteria (delay from accident to surgery, absence of joint space narrowing on the AP and lateral view before intervention, symptomatic instability in daily life activities and motivated patient) this type of procedure can be performed safely and provides good functional outcome at five years. The current follow-up is insufficient to judge potential joint degradation. Age is not a contraindication if certain precautions are taken.

Arthroscopic medial meniscectomy on stable knees.

We reviewed 74 partial medial meniscectomies in 57 patients with stable knees, to assess the long-term functional and radiological outcome. The International Knee Documentation Committee score and the residual laxity were assessed in both knees. At the time of surgery the mean age of the patients was 36 +/- 11 years and the mean follow-up was 12 +/- 1 years. All had a limited medial meniscectomy. The anterior cruciate ligament was intact in all cases. The meniscal tear was vertical in 95% and complex in 5%. The posterior part of the meniscus was removed in 99%. A peripheral rim was preserved in all cases. After 12 years 95% of the patients were satisfied or very satisfied with their knee(s). Objectively, 57% had grade A function and 43% were grade B. The outcome correlated only with the presence of anterior knee pain at final follow-up. In the 49 cases of arthroscopic meniscectomy for which there was a contralateral normal knee there was narrowing of the 'joint-space' in 16% of the operated knees. There was no correlation between this and other parameters such as age or different meniscal pathologies.

[Arthroscopy-assisted revision in failed reconstruction of anterior cruciate ligament: 32 cases]. / Reconstruction itérative du ligament croisé antérieur sous arthroscopie.

PURPOSE OF THE STUDY: The aim of this retrospective study was to analyze mid-term outcome after anterior cruciate ligament (ACL) revision performed arthroscopically with a patellar tendon graft. MATERIAL AND METHOD: The series included 32 revision arthroscopies for ligamentoplasties of the ACL performed after primary intraarticular plasty. Outcome was assessed using the IKDC score at least 2 years after revision surgery. A free patellar autograft was used in all cases in association with an anterolateral plasty in 9 cases using the Marshal-MacIntosh technique. There were 25 men, mean age 28.5 years. Mean follow-up was 4 years. The initial plasty was done with a synthetic ligament in 15 cases and an autograft in 17, including 12 patellar tendons. In 3 cases, the revision was needed for synovitis involving the synthetic ligament. In all the other cases, revision was indicated for instability, most of the failures resulting from a defective femoral position (particularly for autografts) or renewed trauma. RESULTS: Among the 23 patients who were initially competition-level athletes, 18 recovered their sports activity, 8 at an equivalent level. At last follow-up, the IKDC global scores were: A 5 patients (15.6%), B 16 patients (50%), C 8 patients (25%), D 3 patients (9.4%). Certain residual laxity was present in 3 cases (C and D laxity score for 2 of them). A tibiofemoral narrowing was present in the medial compartment in one patient alone. Factors of poor prognosis for the IKDC score were: long delay from accident to initial treatment (p=0.04), associated medial meniscectomy (p=0.02). Presence of an initial femoral tunnel had no effect on revision due to its very anterior situation. DISCUSSION: The technical difficulty of revision of an intra-articular ligamentoplasty of the ACL is to position the new transplant so it will satisfy the same requirements as the initial plasty. This position depends particularly on the femoral component due to the importance of the position of the initial femoral tunnel and the degree of bone loss (osetolysis, ablation of an interfering screw.). The homolateral patellar tendon was used for the graft in all cases except one and iterative use of the patellar tendon for grafting did not cause supplementary morbidity. The patellar tendon remains the transplant of choice for ligament reconstruction. Meniscectomy had a deleterious effect on the final outcome. As for first intention plasty, the therapeutic strategy should preserve as much meniscal stock as possible, depending on the type and degree of damage. CONCLUSION: Revision ACL plasty can provide good anatomic results although functional outcome is less satisfactory than after primary intention ligamentoplasty. A precise clinical and radiographic analysis of the cause of failure of the primary plasty must be obtained in order to establish a surgical strategy allowing the most clinically effective plasty with well positioned bone tunnels.

[Angulation deformity of a finger after local radiotherapy]. / Déformation angulaire d'un doigt après radiothérapie locale.

The authors report a case of a third finger angulation deformity. This radial deviation deformity is owed to a local radiation for verrucae vulgaris at 16 years old. The treatment by corrective osteotomy of the phalange was performed with satisfactory correction and full restoration of function.