Cell therapy for posttraumatic shoulder osteonecrosis.

PURPOSE: This study compared the clinical and radiological results of bone marrow mesenchymal stem cell implantation with traditional simple core decompression (CD) using a matched pair case-control design for osteonecrosis of the humeral head (ONHH) after fracture of the proximal humerus. PATIENTS: We retrospectively reviewed 64 patients who had surgery for ONHH. Thirty patients had been treated with cell therapy between 2010 and October 2015, with 18 patients at pre-collapse stage (8 stages-I, 10 stages-II), and 12 patients at post-collapse stages (7 stages-III and 5 stages-IV). Using a matched pair case-control design, these 30 study patients were compared to 34 other patients who were treated with simple core decompression (CD) without cells (control group). METHODS: The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow (BM) concentration. During a mean follow-up duration of 7years (5 to 10years), radiographs performed each year were used to evaluate the radiological results; the Constant score and visual analogue scale were chosen to assess the clinical results. We assessed stage progression, collapse and arthroplasty conversion rate. Survivor rate analysis was performed using these parameters as the primary endpoints. RESULTS: Among the 30 shoulders included in the cell therapy group, three (10%) humeral heads had collapsed at the most recent follow-up, versus 25 (74%) in 34 shoulders after simple core decompression (P<0.0001). As consequence, we observed statistically significant difference (P=0.0001) in the humeral head survival (absence of arthroplasty conversion) rate at the end time point between the cell therapy group (93% survival) and simple core decompression (26% survival). Better results were obtained for early stages (stages I and II) osteonecrosis without collapse at baseline. CONCLUSION: Core decompression with cell therapy was a safe and effective procedure for treatment in the pre-collapse stages of posttraumatic shoulder osteonecrosis and improved the outcome of the disease as compared with simple core decompression without cells.

What are the predictive factors leading to ureteral obstruction following endoscopic correction of VUR in the pediatric population?

BACKGROUND: It is extremely important to not only address the short-term success following endoscopic correction of vesicoureteral reflux (VUR) but also the long-term efficacy and safety of the tissue augmenting substance utilized for endoscopic correction. OBJECTIVE: This study retrospectively evaluated all cases of ureterovesical junction (UVJ) obstruction following endoscopic treatment of VUR over the last 5 years utilizing two tissue augmenting substances, with special emphasis on the safety of Vantris®, and performed clinical and histological review of these patients. METHODS: The study population comprised 2495 patients who underwent endoscopic correction of VUR utilizing Deflux® (1790) and Vantris® (705). Tissue sections were stained with hematoxylin & eosin and trichrome, and examined under a light microscope. Nine primary obstructive megaureters after ureteral re-implantation served as controls. RESULTS: Nine (0.5%) children (three female and six male) in the Deflux group and nine (1.3%) (five females and four males) in the Vantris group developed UVJ obstruction and required ureteral re-implantation. Obstruction developed during the period ranging 2-49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in seven, IV in six, and V in six children. The mean volume of the injected material in all obstructed patients was 1.2 ± 0.6 cc (mean ± SD). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign-body giant cells surrounding the Vantris implant in all patients. The distal part of the ureters demonstrated significant ureteral dilatation without ureteral fibrosis. In all patients, additional biopsies from the muscularis propria adjacent to the injection site were examined and showed no significant abnormalities. There was an increased collagen deposition in the juxtavesical segment of the obstructive ureters following Deflux and Vantris injections, and of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux and Vantris patients and controls. Statistical analysis of the nonhomogeneous population demonstrated higher obstruction rates in patients from the Vantris group. However, no statistical difference was demonstrated regarding the obstruction rate in the homogenous group with relation to gender, age and reflux grade group of patients. Moreover, univariate analysis revealed that Grade V reflux, the presence of beak sign on the reviewed pretreatment, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. DISCUSSION: This study suggested that the underlining ureteral pathology lead to UVJ obstruction following Vantris injection. There was increased collagen deposition in the juxtavesical segment of the obstructive ureters following Vantris injection. Furthermore, these findings were similar to those discovered in patients who underwent endoscopic correction with Deflux, and in patients who required ureteral reimplantation due to primary obstructive megaureter. Additional biopsies from the muscularis propria adjacent to the injection site showed no significant abnormalities, ironing out the fact that Vantris did not led to adverse tissue reaction following injection. Univariate analysis further ironed out the hypothesis that underlying ureteral pathology was responsible for the increased incidence of UVJ obstruction and demonstrated that Grade V reflux, the presence of beak sign on the reviewed pretreatment VCUG, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. CONCLUSION: Data showed that Vantris injection did not lead to any different ureteral fibrosis or inflammatory changes to the tissue augmenting substances utilized in past and present clinical practice, and therefore did not seem to increase the incidence of UVJ obstruction. High reflux grade, presence of obstructive/refluxing megaureter and inflamed bladder mucosa were the only statistically significant and independent predictive factors for UVJ obstruction following endoscopic correction of VUR.

Is the trapezius transfer a useful treatment option for irreparable tears of the subscapularis?

INTRODUCTION: When suture of the torn subscapularis could not be performed, a superior trapezius transfer was used for repair of the tendinous defect. The aim of this article is to report the mid-term functional and radiographic outcome of this technique when complete watertight rotator cuff healings were achieved and to investigate the usefulness of the trapezius transfer. The hypothesis of this work was that the trapezius transfer could not be considered as a useful treatment option. MATERIALS: The study included 20 shoulders demonstrating watertight healing of the rotator cuff on arthro CT-scan control performed 13.5 months after open surgery consisting of a trapezius transfer and suture of all other torn tendons. The mean age at surgery was 58.4 years. The trapezius transfer operative technique is described. METHODS: The functional status of the shoulders was assessed preoperatively and at a mean follow-up of 30 months according to the non-weighted Constant score and by measurement of active external rotation, arm at the side. Radiographic and CT-scan assessments were performed preoperatively and at a mean follow-up of 28.5 months. The functional results obtained at last follow-up were compared with those "theoretically estimated" after anatomically successful suture of the torn supra and infraspinatous without associated repair of the torn subscapularis. RESULTS: Between the pre- and postoperative periods, pain, daily activities and Constant score had all statistically improved. Arthritis was not aggravated but the preoperative anterior subluxation of the humeral head persisted in most cases. The reported Constant scores correlated those "theoretically estimated" in case of non-associated subscapularis repair. DISCUSSION: This series is comparable to those evaluating the pectoralis major transfer technique and reports an identical functional outcome. CONCLUSION: Since the Constant scores obtained after trapezius transfer correlate those estimated when not combining a subscapularis repair and taking into account the very frequent lack of improvement regarding the preoperative anterior subluxation of the humeral head, the trapezius transfer does not appear as a recommendable treatment option.

Acromio humeral distance less than six millimeter: its meaning in full-thickness rotator cuff tear.

UNLABELLED: The present study sought to identify full-thickness rotator cuff tears liable to induce an acromiohumeral distance (AHD) of less than 6 mm. The hypothesis was that, less than 6mm AHD is found exclusively in association with total full-thickness infraspinatus tear. MATERIALS: A continuous single-center series recruited 109 shoulders, free of glenohumeral osteoarthritis, presenting with full-thickness tear requiring surgery. Preoperative acromiohumeral distance, rupture location and extension on the various tendons and muscular fatty degeneration (FD) were known. METHODS: Full-thickness tears were categorized by location and extension on the various tendons. For each group, the number of shoulders showing AHD<6 mm was determined. RESULTS: Total full-thickness infraspinatus tears were almost the only tendon lesions able to induce AHD<6 mm, but this only when the infraspinatus muscle showed FD equal to or greater than 2.25: i.e., when the tear was longstanding. DISCUSSION: Unlike previous reports, the present study took account of the total or partial nature of infraspinatus and subscapularis tendon tear. The findings may suggest that AHD<6 mm is induced by posterior migration of the humeral head secondary to longstanding total infraspinatus tear, reducing AHD projection height on X-ray. CONCLUSION: AHD<6 mm is a sign of rotator-cuff rupture almost systematically involving longstanding total infraspinatus tear, not always amenable to suture repair due to advanced fatty degeneration. AHD equal to or greater than 6mm is of no diagnostic relevance and in no way indicates whether there is subscapularis tear and, if so, whether suture repair is feasible.

Non-simultaneous bilateral hip fracture: epidemiologic study of 241 hip fractures.

INTRODUCTION: Hip fractures are an important public health problem given their growing incidence as well as their functional and vital repercussions. With longer survival, patients with a contralateral fracture are increasingly numerous. The objective of this study was to investigate the bilateralization of hip fractures in terms of anatomic location and time to the second fracture. HYPOTHESIS: Contralateral fractures are of the same anatomical type as the primary fractures. PATIENTS AND METHODS: This was a retrospective epidemiological study on all patients managed for hip fractures between January 2007 and May 2008. Each case of bilateralization was studied. RESULTS: We included 241 patients in the study. The mean age at occurrence of the primary fracture was 83.3 years (range, 60-99 years). The distribution showed 45.6% true femoral neck fractures and 54.4% trochanteric fractures. Twenty-six of the 241 patients had already suffered from a hip fracture (10.8%). This fracture was the same type as the recent fracture in 80.8% of the cases. The mean time between the two fractures was 5.6 years (range, 1-277 months). DISCUSSION: The contralateral fractures were the same anatomical type as the primary fracture in eight out of ten patients and the symmetry remains intact in 64-83% depending on the series. The fracture occurred on average within 5 years of the first hip fracture. In cases of asymmetry, the second fracture was more often a trochanteric fracture. The causes explaining this symmetry are several and are poorly known. The risk factors are numerous and their prevention is essential (acting on the patient's environment to prevent falls, rehabilitation to reestablish autonomy after the first fracture, and preventive treatment of osteoporosis), although these notions are often ignored by surgeons. LEVEL OF EVIDENCE: IV, retrospective study.

Intermediate term functional outcome prediction following full thickness rotator cuff tear reparative or not reparative surgery.

UNLABELLED: Although simple suturing repair of a full thickness cuff tear can be performed when the preoperative fatty degeneration index (FDI) is 2 or less, it is not known if the functional results will be better than palliative surgical treatment. The aim of this study is to describe and validate a method to predict the intermediate term unweighted Constant scores of different surgical treatments based on preoperative FDI. The hypothesis of this study is that the preoperative and final follow-up ratios FDI/final follow-up Constant scores regression lines, established on a previous "reference study"[5] (a series of 29 shoulders with cuff tears and sutured intact rotator cuff), could be used for this purpose. MATERIAL: The present study included seven series of sutured cuffs (five, which resulted in intact cuffs and two in recurrent tears) and one series of cuffs treated with palliative surgery. Knowledge of the preoperative FDI and the location of the recurrent or unrepaired tears were required criteria for these series inclusion in the study. METHOD: For each of the series in this study the Constant scores and selected score items were compared to scores calculated with the same mathematical formulas previously used to determine the regression lines in the reference study series (resulting in Constant scores in relation to preoperative and final follow-up FDI). RESULTS: The calculated Constant scores were similar to those reported by the authors, which validate the proposed method. DISCUSSION: Because of the small size of the series of sutured cuffs with recurrent tears and of cuffs that underwent palliative surgery and arthroscopic treatment it is impossible to definitely confirm the validity of this method. CONCLUSION: The intermediate term results of different surgical treatments can reasonably be predicted for full thickness tendon tears based on the preoperative FDI and the location of these tears. With this method the best treatment should be chosen for a rotator cuff tear on a case-by-case basis. LEVEL OF EVIDENCE: Level IV.

How repaired rotator cuff function influences Constant scoring.

UNLABELLED: The function level influence of an intact rotator cuff on the unweighted Constant score and its corresponding items is unknown. The aim of this study was to evaluate this contribution. The hypothesis was that the shoulder muscles other than the rotator cuff ones ensure a "basic" shoulder function level that is improved by the rotator cuff depending on its fatty degeneration index (FDI) MATERIAL AND METHODS: This study was based on a continuous series of 29 non-osteoarthritic shoulders whose sutured rotator cuff tears remained intact after 9 years of follow-up. The preoperative FDI was 0.9 (0-2) and 1.26 (0.2-2.2) at the final follow-up. The Constant score was 76.85 at the final follow-up (range 42-93). There was a strong negative correlation between preoperative and follow-up FDI's and all the Constant scores at the final follow-up. Linear regression analysis was performed. The two linear regression lines were superimposed. RESULTS: For a given FDI value, all Constant scores were lower when linear regression was based on preoperative FDI scores that included postoperative deterioration of the FDI. The two linear regression lines converged as the FDI increased and intersected at an FDI of 2.25. Thus, the impact of intact repaired rotator cuff function was null when the FDI was above 2.25, leaving other shoulder muscles (including the deltoid), to ensure "basic" shoulder function at a Constant score of approximately 62 points. DISCUSSION: The "basic" shoulder function found in this study is supported by the similar Constant scores found in reverse shoulder prostheses, and in painless shoulders with full thickness rotator cuff tears. CONCLUSION: The deltoid and the shoulder muscles other than the rotator cuff seem to be responsible for "basic" shoulder function and represent 60% of the unweighted Constant score. The lower the FDI, the more the function of an intact repaired cuff improves this "basic" function level. LEVEL OF EVIDENCE: Level IV.

Anterior dislocation of a total hip replacement. Radiographic and CT-scan assessment. Behavior following conservative management.

BACKGROUND: Hip dislocation is one of the most frequent complications of total hip replacement. The direction of dislocation matters. Most dislocations are posterior; anterior dislocation remains rare and its treatment is controversial. STUDY OBJECTIVES: To clinically and radiologically evaluate the outcomes of the conservative (orthopaedic without revision surgery) treatment of anterior hip dislocations after total hip replacement by immobilisation of the hip in 45 degrees flexion, 10 to 20 degrees abduction and neutral rotation (deck chair position). MATERIALS AND METHODS: Between 1997 and 2007, 19 patients (11 women, 7 men), aged between 36 and 89 years old (average age 64.6 years), operated on for hip osteoarthritis using a posterolateral approach, presented with anterior dislocation of their cemented total hip arthroplasty. Instability during extension associated with external rotation was noted at surgery in eight cases. Ten dislocations occurred in the immediate postoperative period (within 48 hours) and nine within an average postoperative delay of 39 days (6-82). After reduction of the dislocation by closed manipulation, the patients were treated by immobilisation in the deck chair position for an average of 2 weeks (10-21 days). Radiological and functional assessment (based on the Merle d'Aubigné score [PMA]) was performed on average at 4 years after surgery. The inclination of the cup in the frontal plane and any lengthening of the operated extremity were measured on an AP pelvic plain film with the patient in the standing position. Cup and femoral stem anteversion were calculated by CT-scan in 16 cases. RESULTS: At the last follow-up, four patients had had recurrent anterior dislocations (one patient had had two dislocations). They were again treated with immobilisation in the deck chair position for two weeks without further recurrence. None of the patients underwent revision surgery on the temporarily unstable operated hip. Thirteen patients had no pain and eleven had an unlimited walking perimeter. The final average PMA score was 16 (12-18). The patients who presented with one or two recurrences had a PMA of 18 in the final follow-up. Six patients presented with at least 5 mm of shortening (average: 10 mm, maximum 25 mm) with one case of 10 mm of lengthening. The average cup inclination angle in frontal plane views was 48 degrees (40-57 degrees). It was more than 50 degrees in seven cases. The average cup anteversion in CT-scan was 30 degrees (14-60 degrees). The average femoral anteversion in CT-scan was 24 degrees (3-52 degrees). A total of 12 implants (eight cups and four femoral stems) had at least 25 degrees excessive anteversion on CT-scan assessment. DISCUSSION, CONCLUSION: Anterior dislocation after total hip replacement is associated with approximately 10 degrees of excessive femoral and acetabular anteversion respectively. Nevertheless, correction of these architectural anomalies is not necessary because immobilisation in the deck chair position for 2 weeks effectively prevents recurrence and results in satisfactory medium-term functional results.

Common femoral artery intimal injury following total hip replacement. A case report and literature review.

Vascular injuries diagnosed during the course of total hip arthroplasty (THA) implantations are rare. They must be constantly feared as they sometimes put at risk the vital and functional prognosis of the operated limb. We report the case of a common femoral artery injury diagnosed by arteriography within two days of THA replacement in the presence of atypical symptoms. The vascular damage was caused by an arterial lesion resulting from positioning a retractor on the anterior wall of the acetabulum. A literature review on the topic of vascular complications arising after THA made us aware of multiple possible mechanisms and clinical presentations relating to such complications while identifying specific risk factors in THA replacement cases. Acetabular revision constitutes a major risk situation. Most of these vascular complications may be better prevented or more efficiently treated by thorough preoperative assessment and careful postoperative monitoring.

Results of latissimus dorsi tendon transfer for irreparable cuff tears.

Rupture of the supraspinatus and infraspinatus tendon (and teres minor) can cause loss of active external rotation (ER), entailing severe functional disability in daily activities. Latissimus dorsi tendon transfer (LDTT), proposed by Gerber in 1988, appears to be the best adapted solution in these cases of irreparable posterior and superior cuff tears. Between 2001 and 2004, 30 patients were operated on by the technique described by Gerber, with the transfer fixed anteriorly to the subscapularis tendon and laterally to the greater tuberosity by transosseous suture. One patient, subsequently requiring revision with a reversed prosthesis, was considered as a failure. Twenty-six patients were reviewed with a mean follow-up delay of 34+/-12 months. There were 14 men and 13 women. Mean age was 55.5 years (36 to 71 years). Preoperatively, active ER was symmetric in seven cases, loss of active ER was moderate with positive lag sign in five cases, significant with positive dropping sign in six cases, and severe in nine cases. Fatty muscular degeneration was present and significant in all cases for the infraspinatus muscle and in 14 cases for the teres minor muscle (associated with significant ER loss). Subjectively, 85% of the patients were very satisfied or satisfied and the Subjective Shoulder Value (SSV) was 68+/-17%. The pain score improved from 4.8+/-3 preoperatively to 12.2+/-2 postoperatively, strength from 3.7+/-2 kg to 4.2+/-1.8 kg, mean Constant score from 50+/-12 to 74+/-9, and Constant score adjusted for age and gender from 62+/-15% to 91+/-11%. Mean active ER gain was 7 degrees (-30 degrees to +50 degrees). The loss of active ER was aggravated in one case, unchanged in three, improved in nine and corrected in six. Hornblower sign was corrected in six cases and persisted in nine. Postoperatively, 8% of the patients were unable to eat and drink, compared to 64.7% preoperatively. The results of this series are comparable to those found in the literature for first-intention cases. LDTT restored active ER, but the results were incomplete and variable. Improvement was better in case of severe preoperative active ER deficit and insufficiency of the teres minor muscle. Recovery of strength was not observed in the present series. A narrow subacromial space and grade-3 Hamada classification had negative impact. In spite of an expected tenodesis effect, LDTT did not recenter the humeral head. LDTT compensates the deficient teres minor muscle rather than the infraspinatus muscle. The optimal indication for LDTT is irreparable superior and posterior rotator cuff rupture with loss of active ER associated with a deficient teres minor muscle. It is debatable whether LDTT is indicated in the absence of active motion deficiency: improvement was observed in these cases, but only in terms of subjective criteria.

Transsupraspinatus arthrotomy through an enlarged transacromial approach for total shoulder replacement.

The authors describe a step-by-step technique for anatomic total shoulder arthroplasty using transsupraspinatus arthrotomy via the enlarged transacromial approach. This technique seems ideal to ensure adequate postoperative tensional balance of the infraspinatus and the subscapularis, which is critical for the rotator cuffs to function properly and to achieve optimal arthroplasty stability. Reviewing these different steps helps understanding each rotator cuff individual component's contribution to achieve optimal arthroplasty stability.

Analysis of bone mineral density and bone turnover in the presence of polymethylmethacrylate particles.

Polymethylmethacrylate (PMMA) particles generated from joint arthroplasties appear to contribute to aseptic implant loosening through inflammation-induced periprosthetic osteolysis. However, osteolysis appears to be multifactorial; whether a direct link exists between PMMA particles and osteolysis in vivo is unproven. With the aim to define the relationship between PMMA particles and osteolysis, the authors analyzed the bone mineral density, using microCT scans preoperatively, the first day postoperatively and then every 7-10 days for 32 days, and bone turnover, using (18)F-fluoride positron emission tomography scanner (PET scan) at 8 weeks in four groups of mice that had undergone intramedullary femoral injection. The experimental group of five mice was injected with PMMA particles, and compared with two negative control groups (no injection and injection with the carrier, phosphate-buffered saline) and one positive control group (injection of PMMA particles contaminated with endotoxin). There was no significant change in bone mineral density with addition of PMMA particles, and no evidence of osteolysis. However, bone turnover was increased in the presence of PMMA particles. Even though a direct link between PMMA particles and osteolysis was not found in the short term, PMMA particles appear to influence the regenerative capacity of bone.

Efficacy of a p38 mitogen activated protein kinase inhibitor in mitigating an established inflammatory reaction to polyethylene particles in vivo.

The inhibitor of p38 mitogen-activated protein kinase (MAPK) is of interest in the nonoperative treatment of periprosthetic osteolysis due to wear particles. Previous studies demonstrated that an oral p38 MAPK inhibitor did not suppress bone formation when given during the initial phase of tissue differentiation. However, the oral p38 MAPK inhibitor also did not curtail the foreign body and chronic inflammatory response to particles when given simultaneously. The purpose of the current study was to examine the efficacy of a p38 MAPK inhibitor, SCIO-323, on mitigating an established inflammatory reaction that parallels the clinical situation more closely. The Bone Harvest Chamber was implanted in rabbits and submicron polyethylene particles were placed in the chamber for 6 weeks. The contents of the chambers were harvested every 6 weeks. Oral treatment with the SCIO-323 included delivery for 3 weeks and stopping for 3 weeks, delivery for 3 weeks after an initial 3-week delay, and delivery for 6 weeks continuously. Administration of the SCIO-323 continuously for 6 weeks with/without the presence of particles, or for the initial 3 of 6 weeks had minor effects on bone ingrowth. After establishing a particle-induced chronic inflammatory reaction for 3 weeks, administration of SCIO-323 for a subsequent 3 weeks suppressed net bone formation. The activity of osteoclast-like cells remained low among all treatments when compared with the first control. Using the present model, the oral p38 MAPK inhibitor was ineffective in improving bone ingrowth in the presence of polyethylene particles.

Retrieved Unicompartmental Implants with Full PE Tibial Components: The Effects of Knee Alignment and Polyethylene Thickness on Creep and Wear.

Creep and true wear of polyethylene are difficult to evaluate on radiographs of knee arthroplasties and for this reason the true rate of polyethylene wear in vivo after unicompartmental arthroplasty is not well known. This study evaluated the creep and true wear in fifty-five medial retrieved unicompartmental implants that had a flat articular surface at the time of implantation.All the full polyethylene tibial components had the same design and were retrieved from eleven to 224 months (mean 152 months) after their implantation. The postoperative varus deformity had been measured on weight-bearing radiographs of the whole limb (hip-knee-ankle angle). The retrieved implants were placed in a coordinate measuring machine and the coordinates of a grid of points were obtained. Using this system, a three dimensional scaled image of the implant could be created and was used to calculate the total penetration of the femoral condyle due to true wear and creep.Total linear penetration rates ranged from 0.18 to 2.6 millimeters per year (mean 0.25 millimeters per year). Linear penetration rates due to true wear ranged from 0.08 to 1.4 millimeters per year (mean 0.13 millimeter per year), and penetration due to creep ranged from 0.07 to 1.9 millimeters per year (mean 0.12 millimeters per year).The linear and volumetric penetration rates of the femoral condyle due to true wear were negatively correlated with the duration of implantation. The linear penetration rate due to creep was higher in the first two years after the implantation compared to the subsequent years. Using multiple linear regression analyses to remove the confounding effects of age, weight, gender and thickness of the implant, we found that an increase of the postoperative varus deformity was due to an increase of creep (p = 0.03) but not with an increase of true wear (p = 0.25). Thinner implants were due to an increase of creep (p = 0.02) but not with an increase of true wear (p = 0.34). Increase in age was in relation with decrease of wear (p = 0.02) and increase of weight with increase in creep (p = 0.03).Plastic deformation had a high influence on the penetration rate of the femoral condyle in full polyethylene implants. There is a risk of an increased penetration and a decrease of the remaining thickness of the tibial plateau when the implant is too thin, the knee mal-aligned and the patient heavy - each of these factors increasing the creep deformation. In conclusion, our study suggests that surgeons using the Lotus Mk I unicompartmental knee replacement for medial tibiofemoral arthritis should beware of the overweight patient (>90kg) with a tibial implant of less than 9 mm. There is a risk of increased penetration and decreased thickness of the tibial implant when it is too thin, the knee malaligned, and the patient heavy. All these factors increase creep deformation.

[Distal femoral varus osteotomy for symptomatic genu valgum: long-term results and review of the literature]. / Ostéotomie fémorale distale de varisation pour genu valgum invalidant: résultats à long terme et revue de la littérature.

PURPOSE OF THE STUDY: We report our experience with eleven patients treated for disabling genu valgum from 1979 to 1994. MATERIAL AND METHODS: Genu valgum resulted from femoral deformation in all patients. Ten had a congenital condition and one a post-traumatic knee. IKS scores were used for the clinical evaluation. The lateral femorotibial joint space and the lateral femoral angle (LFA) were measured on plain films. Goniometry was used to measure the axis of the loaded lower limb. All patients underwent osteotomy of the distal femur for varisation and plate fixation. One patient required revision for a unicompartment lateral prosthesis subsequent to fracture of the homolateral lateral tibial plateau. Mean follow-up was 10.5 years (3.5-21.5). RESULTS: There were no cases of nonunion. Four patients had a good or excellent knee score. Eight patients had a good or excellent function score. Osteoarthritis worsened in two patients. The mean LFA increased from 72.5 degrees preoperatively to 83.5 degrees postoperatively and a last follow-up. Mean genu valgum was 13 degrees preoperatively and 2 degrees at last follow-up. All patients except one were satisfied or very satisfied. Insufficient correction appeared to be the main complaint. DISCUSSION: These results and results reported in the literature demonstrate that distal femoral osteotomy for disabling genu valgum is an effective treatment if the correction is complete and osteosynthesis effective, providing long lasting results when femoral deformation is involved and osteoarthritis limited.

Variations of caudal, central, and cranial acetabular anteversion according to the tilt of the pelvis.

Variations of acetabular anteversion measured at the level of the diameter of the acetabulum according to the tilt of the pelvis are known. But the values of this anteversion at other levels of the acetabulum, near the roof or near the obturator foramen, are unknown. Attracted by the very changeable morphology of the acetabular cover, we studied the caudal, central, and cranial acetabular anteversion of 12 pelvises in four positions of dorsal-ventral inclination. The caudal, central, and cranial acetabular anteversion diminished with the ventral tilt of the pelvis. The anteversions also diminished from the caudal part of the acetabulum to the cranial part, whatever the inclination of the pelvis. These notions represent a reference that, once completed with clinical studies of healthy volunteers and patients presenting an anomaly of the acetabulum cover, will enable researchers to define threshold values of normal and pathological conditions.

Educational, occupational, and insurance status of childhood cancer survivors in their fourth and fifth decades of life.

PURPOSE: Survivors of childhood cancer who are now greater than or equal to 30 years of age are available for study in significant numbers for the first time. An evaluation of their educational achievement, current employment status, frequency of problems in the work-place, and ability to obtain affordable health and life insurance was the aim of this study. PATIENTS AND METHODS: This was a case-control study of 219 childhood cancer survivors with individually matched controls from two tertiary-care pediatric centers. Telephone interviews were used and drew on a 356-item basic instrument for both subjects and controls. Medical (including intensity of therapy), marital, and psychosocial areas were included in the survey, but statistical comparisons concentrated on educational and economic issues. RESULTS: The overall current status of survivors and controls in the relevant areas, ie, education, employment, and insurance, was similar. A history of employment discrimination for entry into the uniformed services and in other special situations, and life insurance discrimination during the initial years after the completion of therapy was noted. Survivors experienced few problems in the work-place. Survivors of CNS tumors were unique, with problems in many of the areas studied, although there were notable individual exceptions. CONCLUSION: With the exception of those individuals with CNS tumor histories, survivors who were treated in the era of 1945 to 1975 had few economic sequelae of cancer or its therapy that extended beyond the first decades after treatment.

Biodegradable pericardial implants for bladder augmentation: a 2.5-year study in dogs.

Bladder augmentation using biodegradable pericardial tissue was evaluated in canine bladders. Acetic acid and acetic anhydride treated pericardial tissue grafts were stored in 75% ethanol for 18 to 27 months before implant. Ten dogs weighing 20 to 25 kg. were subjected to a 50% partial cystectomy. After careful separation of the mucosa, bladder muscle and adventitial layers a pericardial graft volumetrically equivalent to the portion of the bladder removed was sutured to the bladder remnant in 2 layers. In 1 control dog the bladder was opened, 50% of the bladder was removed and the bladder was closed primarily. In another control dog the excised bladder was replaced with fresh chemically treated patch material that was never subjected to ethanol storage. Excretory urography and cystography were performed on all dogs. Urodynamics with filling pressures and bladder volumes measured before and after the operation at intervals of up to 36 months confirmed that adequate bladder capacity was achieved. There were no operative complications. Postmortem histological evaluations revealed a smooth epithelialized inner surface with no traces of any surface irregularities or suture lines. The bladder apex showed an intact epithelium and the absence of a smooth muscle layer. The biodegradable acetylated tissue provides an intact structural reservoir for urine and serves as a template for epithelial regeneration. This permits volumetric bladder enlargement while the graft is progressively reabsorbed with time.

Standing balance in healthy boys and in children with Duchenne muscular dystrophy.

Balance in double stance was measured on a force platform with an X-Y Plotter (stabilograph) in 57 healthy boys aged 5 to 10 years and in 13 children with Duchenne muscular dystrophy (DMD), aged 6 to 15 years. Horizontal excursions of the center of gravity were measured in the anteroposterior (AP) and right-left (RL) planes. Measurements superimposed upon foot position tracings were compared with a potential excursion defined by the outer margin of foot position. Balancing ability was expressed as a ratio of measured excursion to potential maximal excursion. The objective was to determine whether a quantitative functional measure relating to muscle weakness and standing could be obtained. The mean ratio of AP excursions for healthy children was 0.5 (range 0.29 to 0.7); for dystrophic children 0.29 (range 0.07 to 0.57). The mean ratio of RL excursions for healthy children was 0.57 (range 0.23 to 0.77); for dystrophic children 0.36 (range 0.1 to 0.63). These ratios tended to increase with age in healthy children but decreased in those with dystrophy. DMD children have less ability to move the horizontal center of gravity within the base of support on double stance than their healthy peers of comparable age. Stabilography may be useful not only for assessing balance and documenting its deterioration but also for evaluating the effectiveness of treatment in DMD.

Compression fixation of subtrochanteric fractures.

Compression fixation with a blade plate was used in the treatment of 11 fresh and 9 nonunited subtrochanteric fractures. Fifteen fractures united as fixed. Three settled into varus with eventual union in 2 and a fibrous nonunion with metal failure in one. One fracture became infected and the patient died of metastatic fibrosarcoma and one was lost to accurate long-term follow-up. The average Harris Hip Rating for 18 patients was 84, an average of 24 postoperatively. In each instance, technical errors accounted for suboptimal results. Compression fixation is designed for the subtrochanteric region for either fresh or nonunited fractures.