Antibiotic-loaded tantalum may serve as an antimicrobial delivery agent.

AIMS: The aims of this study were to compare the mean duration of antibiotic release and the mean zone of inhibition between vancomycin-loaded porous tantalum cylinders and antibiotic-loaded bone cement at intervals, and to evaluate potential intrinsic antimicrobial properties of tantalum in an in vitro medium environment against methicillin-sensitive Staphylococcus aureus (MSSA). MATERIALS AND METHODS: Ten porous tantalum cylinders and ten cylinders of cement were used. The tantalum cylinders were impregnated with vancomycin, which was also added during preparation of the cylinders of cement. The cylinders were then placed on agar plates inoculated with MSSA. The diameter of the inhibition zone was measured each day, and the cylinders were transferred to a new inoculated plate. Inhibition zones were measured with a Vernier caliper and using an automated computed evaluation, and the intra- and interobserver reproducibility were measured. The mean inhibition zones between the two groups were compared with Wilcoxon's test. RESULTS: MSSA was inhibited for 12 days by the tantalum cylinders and for nine days by the cement cylinders. At day one, the mean zone of inhibition was 28.6 mm for the tantalum and 19.8 mm for the cement group (p < 0.001). At day ten, the mean zone of inhibition was 3.8 mm for the tantalum and 0 mm for the cement group (p < 0.001). The porous tantalum cylinders soaked only with phosphate buffered solution showed no zone of inhibition. CONCLUSION: Compared with cement, tantalum could release antibiotics for longer. Further studies should assess the advantages of using antibiotic-loaded porous tantalum implants at revision arthroplasty. Cite this article: Bone Joint J 2019;101-B:848-851.

Influence of treatment modality on morbidity and mortality in periprosthetic femoral fracture. A comparative study of 71 fractures treated by internal fixation or femoral implant revision.

INTRODUCTION: The incidence of periprosthetic femoral fracture is constantly increasing, with high associated morbidity and mortality. Surgical treatment is guided by the Vancouver classification, but the influence of type of treatment on morbidity and mortality has been little analyzed. The theoretical advantage of implant revision over internal fixation is that it should allow earlier weight-bearing, although the impact of this on morbidity and mortality and autonomy has not been demonstrated. We conducted a case-control study, to assess the influence of type of treatment (implant revision or internal fixation) (1) on mobility and autonomy and (2) on morbidity and mortality. HYPOTHESIS: The study hypothesis was that clinical results and morbidity and mortality do not differ between these two types of treatment. METHODS: A retrospective study included 70 patients with a total of 71 femoral periprosthetic fractures treated between 2007 and 2014. Two treatment groups, comparable for mean age, gender and ASA and Parker scores, were studied. Mean age was 78±13.5years (range, 23-95years). Thirty-six fractures (50.7%) were treated by implant revision via a posterolateral approach, using a revision stem with (n=11) or without cement (n=25) (REVISION group); immediate postoperative weight-bearing was authorized. Thirty-five fractures (49.3%) were treated by open reduction and internal fixation, using a locking plate (ORIF group); weight-bearing was authorized only in the third month. Mean follow-up was 43±27months (range, 0.75-107months). RESULTS: Autonomy on Parker score was reduced by 2 points at 1year's follow-up. Mean preoperative scores were 7.32±1.79 (range, 3-9) and 7.43±1.79 (range, 4-9) in the REVISION and ORIF group, respectively, (p=0.8), falling to 5.06±2.6 (range, 0-9) and 4.5±2.01 (range, 0-9) respectively at follow-up (p=0.349). Sixteen patients in the REVISION group versus 13 in the ORIF group had made adaptations in their home or changed place of residence (p=0.2). At last follow-up, 18 patients (28.6%) had died: 12 (37.5%) in the ORIF and 6 (19.3%) in the REVISION group (p<0.05). Survival with death as endpoint at a mean 3.5years was 88±11% in the REVISION group versus 51±11% in the ORIF group (p=0.02). Three implant replacements were performed in each group (p=0.83). Twelve medical or surgical complications occurred in the ORIF group (37.5%) and 11 in the REVISION group (34%) (p=0.9). CONCLUSION: Implant revision for periprosthetic femoral fracture showed significantly lower overall mortality than internal fixation, without difference in terms of treatment failure or complications requiring revision surgery. LEVEL OF EVIDENCE: Level III, case-control study.

Endoscopic or arthroscopic iliopsoas tenotomy for iliopsoas impingement following total hip replacement. A prospective multicenter 64-case series.

INTRODUCTION: Impingement between the acetabular component and the iliopsoas tendon is a cause of anterior pain after total hip replacement (THR). Treatment can be non-operative, endoscopic or arthroscopic, or by open revision of the acetabular component. Few studies have assessed these options. The present study hypothesis was that endo/arthroscopic treatment provides rapid pain relief with a low rate of complications. METHODS: A prospective multicenter study included 64 endoscopic or arthroscopic tenotomies for impingement between the acetabular component and the iliopsoas tendon, performed in 8 centers. Mean follow-up was 8months, with a minimum of 6months and no loss to follow-up. Oxford score, patient satisfaction, anterior pain and iliopsoas strength were assessed at last follow-up. Complications and revision procedures were collated. Forty-four percent of patients underwent rehabilitation. RESULTS: At last follow-up, 92% of patients reported pain alleviation. Oxford score, muscle strength and pain in hip flexion showed significant improvement. The complications rate was 3.2%, with complete resolution. Mean hospital stay was 0.8 nights. In 2 cases, arthroscopy revealed metallosis, indicating revision of the acetabular component. The only predictive factor was acetabular projection on oblique view. Rehabilitation significantly improved muscle strength. CONCLUSION: Endoscopic or arthroscopic tenotomy for impingement between the acetabular component and the iliopsoas tendon following THR significantly alleviated anterior pain in more than 92% of cases. The low complications rate makes this the treatment of choice in case of failure of non-operative management. Arthroscopy also reorients diagnosis in case of associated joint pathology. Projection of the acetabular component on preoperative oblique view is the most predictive criterion, guiding treatment.

Can three-dimensional patient-specific cutting guides be used to achieve optimal correction for high tibial osteotomy? Pilot study.

INTRODUCTION: Treatment of medial tibiofemoral osteoarthritis with a high-tibial osteotomy (HTO) is most effective when the optimal angular correction is achieved. However, conventional instrumentation is limited when multiplanar correction is needed. HYPOTHESIS: Use of patient-specific cutting guides (PSCGs) for HTO provides an accurate correction (difference<2°) relative to the preoperative planning. MATERIALS AND METHODS: Between February 2014 and February 2015, 10 patients (mean age: 46 years [range: 31-59]; grade 1 or 2 osteoarthritis in Ahlbäck's classification) were included prospectively in this reliability and safety study. All patients were operated using the same medial opening-wedge osteotomy technique. Preoperative planning was based on long-leg radiographs and CT scans with 3D reconstruction. The PSGCs were used to align the osteotomy cut and position the screw holes for the plate. The desired correction was achieved in the three planes when the holes on the plate were aligned with the holes drilled based on the PSCG. Preoperatively, the mean HKA angle was 171.9° (range: 166-179°), the mean proximal tibial angle was 87° (86-88°) and the mean tibial slope was 7.8° (1-22°). The postoperative correction was compared to the planned correction using 3D CT scan transformations. Intraoperative and postoperative complications were assessed at a minimum follow-up of 1 year. RESULTS: The procedure was successfully carried out in all patients with the PSCGs. On postoperative long-leg radiographs, the mean HKA was 182.3° (180-185°); on the CT scan, the mean tibial mechanical angle was 94° (90-98°) and the mean tibial slope was 7.1° (4-11°). In 19 out of 20 postoperative HKA and slope measurements, the difference between the planned and achieved correction was <2° based on the 3D analysis of the three planes in space; in the other case, the slope was 13° instead of the planned 10°. The intra-class correlation coefficients between the postoperative and planned parameters were 0.98 [0.92-0.99] for the HKA and 0.96 [0.79-0.99] for the tibial slope. There were no surgical site infections; one patient had a postoperative hematoma that resolved spontaneously. DISCUSSION: The results of this study showed that use of PSCGs in HTO procedures helps to achieve optimal correction in a safe and reliable manner. LEVEL OF EVIDENCE: IV - Prospective cohort study.

Pelvic fracture in multiple trauma: A 67-case series.

INTRODUCTION: Severe pelvic trauma remains associated with elevated mortality, largely due to hemorrhagic shock. OBJECTIVE: The main study objective was to test for correlation between fracture type and mortality. The secondary objective was to assess the efficacy in terms of mortality of multidisciplinary management following a decision-tree in multiple trauma victims admitted to a level 1 trauma center. MATERIAL AND METHODS: Between July 2011 and July 2013, 534 severe trauma patients were included in a single-center continuous prospective observational study. All patients with hemorrhagic shock received early treatment by pelvic binder. Patients with active bleeding on full-body CT or persisting hemorrhagic shock underwent arteriography with or without embolization. Pelvic trauma was graded on the Tile classification. The principle end-point was mortality. RESULTS: Median age was 40 years (range, 26-48 years), with a 79% male/female sex ratio. Thirty-two of the 67 patients with pelvic trauma (48%) were in hemorrhagic shock at admission. Median injury severity score (ISS) was 36 (range, 24-43). On the Tile classification, 22 patients (33%) were grade A, 33 (49%) grade B and 12 (18%) grade C. Overall mortality was 19%, and 42% in case of hemorrhagic shock. Mortality was significantly higher with Tile C than A or B (58% vs. 9.1% and 12.1%, respectively; P=0.001). CONCLUSION: Vertical shear fracture (Tile C) was associated with greater mortality from hemorrhagic shock. LEVEL OF EVIDENCE: IV, case series.

Lower limb length and offset in total hip arthroplasty.

Restoration of normal hip biomechanics is a key goal of total hip arthroplasty (THA) and favorably affects functional recovery. Furthermore, a major concern for both the surgeon and the patient is preservation or restoration of limb length equality, which must be achieved without compromising the stability of the prosthesis. Here, definitions are given for anatomic and functional limb length discrepancies and for femoral and hip offset, determined taking anteversion into account. Data on the influence of operated-limb length and offset on patient satisfaction, hip function, and prosthesis survival after THA are reviewed. Errors may adversely impact function, quality of life, and prosthetic survival and may also generate conflicts between the surgeon and patient. Surgeons rely on two- or three-dimensional preoperative templating and on intraoperative landmarks to manage offset and length. Accuracy can be improved by using computer-assisted planning or surgery and the more recently introduced EOS imaging system. The prosthetic's armamentarium now includes varus-aligned and lateralized implants, as well as implants with modular or custom-made necks, which allow restoration of the normal hip geometry, most notably in patients with coxa vara or coxa valga. Femoral anteversion must also receive careful attention. The most common errors are limb lengthening and a decrease in hip offset. When symptoms are caused by an error in length and/or offset, revision arthroplasty may deserve consideration.

Titanium-titanium modular neck for primary THA. Result of a prospective series of 170 cemented THA with a minimum follow-up of 5 years.

BACKGROUND: Although they have been in use since the end of the 1980s, modular titanium neck components are associated with a risk of wear or fracture, and their safety has recently become a subject of debate and has never been evaluated in a consecutive series of patients. The goal of this study was to evaluate: revision-free survival of these implants after a minimum follow-up of 5 years; clinical and radiographic results; and the potential complications associated with the use of modular titanium neck components. HYPOTHESIS: The use of titanium modular neck on cemented titanium THA is safe at a minimum follow-up of 5 years. PATIENTS AND METHODS: Between January 2006 and December 2008, we prospectively followed 170 patients (170 hips) who underwent primary anatomical THA with a modular cemented titanium stem design implant. The indications were unilateral THA for primary (n=160) or secondary (n=10) hip osteoarthritis (aseptic osteonecrosis of the femoral head or hip dysplasia). Mean age of patients was 75.4±5.8 years old (52-85), and mean BMI was 26.1±4.5 kg/m(2) (16.6-42.1). Patients were operated on by a modified Watson-Jones anterolateral approach based on preoperative 2D planning. All patients underwent annual clinical and radiological follow-up by an independent observer. RESULTS: At a mean follow-up of 71±8 months (60-84), 5 patients died and 7 were lost to follow-up. There was no revision of THA after a maximum follow-up of 84 months. The Harris score improved significantly from 50.4±11.3 (0-76) preoperatively to 84.5±15.2 (14-100) at the final follow-up. There was no difference in postoperative femoral offset or the position of the center of rotation compared to the opposite side. On the other hand, the neck-shaft angle (NSA) and limb length were corrected (2±5° [-11 to +14°] and 2.16±3.6 mm [-7.4 to +12.7 mm]) respectively. Fifteen patients (9%) had limb length discrepancies of more than 5 mm and 4 patients (2%) of more than 10 mm. There were no complications due to the modular implant design. DISCUSSION: Our study suggests that the use of cemented titanium implants with a modular titanium stem is safe at a follow-up of 5 years. The modular design does not prevent limb length discrepancies but restores femoral offset. LEVEL OF EVIDENCE: IV: prospective, non-comparative study.

Comparison of the inter- and intra-observer reproducibility of the Crowe, Hartofilakidis and modified Cochin classification systems for the diagnosis of developmental dysplasia of the hip.

INTRODUCTION: Developmental dysplasia of the hip (DDH) leads to multiple treatment challenges during adulthood. Surgical treatment is mainly based on radiographic evaluation of the anatomical alterations. Several classification systems have been described in the published English scientific literature, but the French Cochin classification has not been used very much. Its primary advantage lies in its ability to intricately describe the DDH alterations with a large number of grades. We hypothesized that the inter- and intra-observer reproducibility of the SOFCOT-modified Cochin classification system was equal to that of the Crowe and Hartofilakidis classifications. MATERIAL AND METHODS: Five French orthopaedic surgeons who were DDH experts classified 94 A/P pelvis radiographs (179 hips) using the Crowe (Cr), Hartofilikadis (Ha) and modified Cochin (Co) systems. This evaluation was repeated a second time one month later. The intra-observer reproducibility was determined with weighted Kappa and concordance coefficients. The inter-observer reproducibility was performed by calculating the multirater Kappa coefficient on each of the two data series. RESULTS: For the intra-observer reliability, the average weighed concordance coefficients (95% CI) were 88.62-94.52 for Cr, 89.43-93.80 for Ha and 92.14-95.71 for Co. The average weighed Kappa coefficients (95% CI) were 0.70-0.85 for Cr, 0.67-0.82 for Ha and 0.75-0.83 for Co. For the inter-observer reliability, the Kappa for each assessment round was 0.57 and 0.48 for Cr, 0.43 and 0.44 for Ha, and 0.43 and 0.37 for Co. DISCUSSION: The intra- and inter-observer reliability for the modified Cochin classification system is the same as the one for the Crowe and Hartofilakidis classifications. The theoretical advantage of this classification system should be confirmed by comparing the findings with intra-operative anatomical observations. LEVEL OF PROOF, TYPE OF STUDY: IV.

Pre-operative function, motivation and duration of symptoms predict sporting participation after total hip replacement.

There is little in the literature on the level of participation in sports which patients undertake after total hip replacement (THR). Our aims in this study were to determine first, the level of sporting activity, second, the predictive factors for returning to sporting activity, and third, the correlation between participation in sports and satisfaction after THR. We retrospectively identified 815 patients who had undergone THR between 1995 and 2005. All were asked to complete a self-administered questionnaire regarding their sporting activity. A total of 571 patients (71%) met the inclusion criteria and completed the evaluation. At a mean follow-up of 9.8 years (sd 2.9), 366 patients (64%) returned to sporting activity as defined by a University of California at Los Angeles (UCLA) score of > 5. The main reasons that patients had for refraining from sports were fear of dislocation (65; 31.6%), avoiding wear (52; 25.4%), and the recommendation of the surgeon (34; 16.6%). There was a significant relationship between higher post-operative participation in sport in those patients with a higher pre-operative Harris hip score (HHS) (p = 0.0074), motivation to participate in sporting activities (p = 0.00022) and a shorter duration of symptoms (p = 0.0034). Finally, there was a correlation between age (p = 0.00013), UCLA score (p = 0.012) and pre-operative HHS (p = 0.00091) and satisfaction. In conclusion, we found that most patients participate in sporting activity after THR, regardless of the advice of their surgeon, and that there is a correlation between the level of participation and pre-operative function, motivation, duration of symptoms and post-operative satisfaction.

Epidemiology of distal femur fractures in France in 2011-12.

INTRODUCTION: Epidemiological study of femoral fractures has been dominated by proximal fractures. Distal fracture requires equal attention for correct management. PATIENTS AND METHODS: A prospective study in 12 French hospital centres between June 1st, 2011 and May 31st, 2012 recruited cases of non-pathologic distal femoral fracture in patients over 15 years of age without ipsilateral knee prosthesis. RESULTS: There were 183 fractures in 177 patients. Mean age was 63.5 years. Female patients (60.5%) were significantly older than males (mean age, respectively 73 versus 48.4 years). Walking was unrestricted in only 83 patients (46.89%). On the AO/OTA (Orthopaedic Trauma Association) classification, there were 86 type A fractures (47%), 29 type B (15.8%) and 68 type C (37.2%). Fractures were open in 32 cases (17.5%), most frequently in male, young patients and type C fracture. Causal trauma was low-energy (fall from own height) in 108 cases, most frequently in female patients and type A fracture. Forty-five patients were proximal femoral implant bearers. CONCLUSION: Distal femoral fracture shows highly variable epidemiology. AO/OTA type A fracture mainly involves elderly, relatively dependent female subjects. Outcome study requires radiographic data and assessment of functional capacity. LEVEL OF EVIDENCE IV: Prospective cohort study.

Blade-plate fixation for distal femoral fractures: a case-control study.

BACKGROUND: The blade-plate is the earliest of the contemporary internal fixation devices introduced for distal femoral fractures. The recent development of dedicated, fixation devices has considerably limited its use. The objective of this study was to evaluate outcomes after blade-plate fixation and after fixation using other devices. HYPOTHESIS: Outcomes after blade-plate fixation are similar to those after condylar screw-plate, distal femoral nail, or locking condylar plate fixation. MATERIAL AND METHODS: We reviewed outcomes after 62 patients managed with blade-plate fixation and included in a multicentre retrospective study (n=57) or a multicentre prospective study (n=5) and we compared them to outcomes after fixation using condylar screw-plates (n=82), distal femoral nail (n=219), or locking condylar plates (n=301). The four groups were comparable for age, gender distribution, occupational status, prevalence of skin wounds, patient-related factors, type of accident, and type of fracture. The evaluation relied on the clinical International Knee Society (IKS) score and on radiographs. RESULTS: No significant differences existed across the four groups for operative time, blood transfusion use, complications, need for bone grafting, non-union rate, or IKS score values. The early surgical revision rate for removal of the fixation material was 4% with the blade-plate and 16% with the other three fixation devices (P=0.02). Post-operative fracture deformity was similar in the four groups with, however, a higher proportion of residual malalignment in the screw-fixation group. The final anatomic axis was 3.3±1.4° with the blade-plate versus 2.3±3.7° with the other three fixation devices. The blade-plate group had few patients with axial malalignment, and the degree of malalignment was limited to 3° of varus and 10° of valgus at the most, compared to 10° and 18° respectively, with the other three fixation devices. CONCLUSION: Despite the now extremely limited use and teaching of blade-plate fixation, as well as the undeniable technical challenges raised by the implantation of this device, the blade-plate is a simple, strong, and inexpensive fixation method. It remains reliable for the fixation of distal femoral fractures. The disfavour into which the blade-plate is currently falling is not warranted. LEVEL OF EVIDENCE: III, case-control study.

Relation between lower extremity alignment and proximal femur anatomy. Parameters during total hip arthroplasty.

BACKGROUND: Lower extremity alignment correlates with native femoral offset. Eventual impact of the change in femoral offset induced by total hip arthroplasty (THA) on lower extremity alignment has not been documented. HYPOTHESIS: THA significantly changes lower extremity alignment, and the change correlates with the change in femoral offset. MATERIALS AND METHODS: We conducted a prospective study of 200 patients with primary hip osteoarthritis or avascular femoral head necrosis who underwent cementless THA. Pre-operative computed-tomography templating was performed and the femoral component was then custom-manufactured to replicate the native femoral anatomy. Mean age was 58 years (range, 28-83 years). Before and at least two years after THA, two observers who were not involved in the surgical procedures used standing antero-posterior long-leg radiographs to determine the mechanical axis of the lower-limb (hip-knee-ankle [HKA] angle), femoral offset, neck-shaft angle (NSA), and lower-limb length discrepancy (LLLD). RESULTS: Mean values pre-operatively and at last follow-up were as follows: HKA angle, 179.2° ± 3.9° (range, 170.5° to 190.5°) and 177.7° ± 3.5°(range, 173° to 187°); LLLD, -0.7 mm (range, -30 mm to +25 mm) and +5.1 mm (range, -7 mm to +21 mm); NSA, 134° ± 7.5° (range, 100° to 124°) and 135° ± 4.2° (range, 124° to 146°); and femoral offset, 42 ± 7.8 mm (range, 24 mm to 68 mm) and 49 ± 7.5 mm (range, 33 mm to 70 mm). Although THA significantly altered lower-limb alignment, univariate and multivariate analyses showed no significant association between the change in HKA angle and the change in femoral offset. DISCUSSION: Lower-limb alignment was significantly affected by THA, although the HKA angle changes were small. The small impact of THA on HKA angle values may be ascribable to efforts aimed at replicating the native femoral offset during arthroplasty, as well as to the limited sample size and to potential measurement errors related to the small size of the changes. Our results suggest that, provided careful attention is directed to replicating the native femoral offset, THA in patients with limited pre-operative anatomical abnormalities may have no major impact on the biomechanical parameters of the ipsilateral knee. LEVEL OF EVIDENCE: Level III, prospective diagnostic study.

A customised collared polished stem may reduce the complication rate of impaction grafting in revision hip surgery: a 12-year follow-up study.

We describe the results of 81 consecutive revision total hip replacements with impaction grafting in 79 patients using a collared polished chrome-cobalt stem, customised in length according to the extent of distal bone loss. Our hypothesis was that the features of this stem would reduce the rate of femoral fracture and subsidence of the stem. The mean follow-up was 12 years (8 to 15). No intra-operative fracture or significant subsidence occurred. Only one patient suffered a post-operative diaphyseal fracture, which was associated with a fall. All but one femur showed incorporation of the graft. No revision for aseptic loosening was recorded. The rate of survival of the femoral component at 12 years, using further femoral revision as the endpoint, was 100% (95% confidence interval (CI) 95.9 to 100), and at nine years using re-operation for any reason as the endpoint, was 94.6% (95% CI 92.0 to 97.2). These results suggest that a customised cemented polished stem individually adapted to the extent of bone loss and with a collar may reduce subsidence and the rate of fracture while maintaining the durability of the fixation.

Posterior tibial slope changes after opening- and closing-wedge high tibial osteotomy: a comparative prospective multicenter study.

INTRODUCTION: Valgus high tibial osteotomy is considered to be an effective treatment for unicompartmental medial osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. However, the effects on posterior tibial slope of closing- or opening-wedge osteotomies remain controversial. HYPOTHESIS: We analyzed the modifications of tibial slope after opening- and closing-wedge high tibial osteotomies and compared the results of these two procedures. We hypothesized that there was no difference in postoperative tibial slope between opening and closing-wedge osteotomies. PATIENTS AND METHODS: This prospective consecutive nonrandomized multicenter study was conducted between January 2008 and March 2009 and included 321 patients: 205 men and 116 women. A total of 224 patients underwent an opening-wedge high tibial osteotomy and 97 a closing-wedge osteotomy. The mean age was 52 years ± 9 and the mean body mass index was 28kg/m(2) ± 5. The main etiology was primary arthritis. Posterior tibial slope was measured preoperatively and at the last follow-up on a lateral radiograph in relation to the posterior tibial cortex. RESULTS: In the opening-wedge group, a definite 0.6° increase in tibial slope (P=0.016) was observed. In the closing-wedge group, a definite 0.7° decrease in tibial slope (P=0.02) was found. Fourteen percent of the opening-wedge osteotomies increased tibial slope by 5° or more versus only 2% of the closed-wedge osteotomies (P<0.001). Twelve percent of the closing-wedge high tibial osteotomies led to a decrease of 5° or more of the tibial slope versus 7% of the opening-wedge osteotomies (P<0.02). DISCUSSION AND CONCLUSION: These results confirm what is generally reported in the literature, i.e., an increase in tibial slope in opening-wedge high tibial osteotomy and a decrease in the slope in closing-wedge osteotomies. These tibial slope changes appear to be very limited in this series, less than 1° on average. However, there was a bias since the open-wedge technique was preferred in cases with substantial varus deformity. We emphasize the importance of surgical technique to avoid alteration of the tibial slope, particularly in opening-wedge high tibial osteotomy for which we recommend a release of posterior soft tissue and a complete osteotomy of the posterior cortex of the tibia. LEVEL OF EVIDENCE: III. Prospective consecutive nonrandomized multicenter study.

Is a hip distractor useful in the arthroscopic treatment of femoroacetabular impingement?

INTRODUCTION: There is increasing interest in using hip arthroscopy for the treatment of femoroacetabular impingement (FAI). However, the distraction is typically done with a traction table, which can lead to complications. Our working hypothesis was that a hip-specific distractor could be used to perform arthroscopic treatment of FAI without the complications associated with traction. MATERIAL AND METHODS: Twenty-three patients were included in this prospective study with an average follow-up of 21 months (range 12-28 months). The average age was 34 ± 4 years. The technical feasibility, complications, quality of the distraction and early clinical results were evaluated. RESULTS: None of the arthroscopy procedures had to be converted to an arthrotomy. In all cases, the procedures planned for the central and peripheral compartments were fully executed. One patient (4%) had a grade 1 cartilage iatrogenic injury of the femoral head. The distraction was determined to be effective in all the patients, with an average of 15 mm of distraction achieved (range 12-21 mm). The average Merle d'Aubigne score went from 11 (range 9-18) preoperatively to 16 (range 14-18) postoperatively; the average Harris score went from 76 (range 46-80) to 91 (range 87-100); the average Christensen score went from 64 (range 48-88) to 84 (range 72-100); the average Womac score went from 58 (range 42-96) to 84 (range 74-100). No neurological, infectious or bone complications were recorded. DISCUSSION: The use of a distractor during hip arthroscopy appears to be a reliable and reproducible technique that allows FAI to be treated. Early results are consistent with those reported in the literature, and the risks associated with the use of a traction table are reduced. This technique makes hip arthroscopy safer and contributes to advances in labrum and cartilage repair, without additional complications. LEVEL OF EVIDENCE: Level III prospective study.

[Infrapatellar fat pad: anterior crossroads of the knee]. / Le corps adipeux infra-patellaire: carrefour antérieur du genou.

The infrapatellar fat pad or Hoffa's fat pad is a cylindrical extrasynovial collection of fat located in the infrapatellar region. Anatomical, biomechanical and imaging data show that the infrapatellar fat pad constitutes a true crossroads between patella, femur and tibia and helps in understanding if not describing regional pathology. Intrinsic lesions (with abnormal signal on MRI) such as hoffitis, anterolateral impingement, plica syndrome, post-arthroscopic changes, trauma, patellar dislocation and extrasynovial tumors are less frequent. On the other hand, extrinsic lesions are more frequent and may affect the synovium, patellar ligament, vascular structures, and bursae. Mucoid and parameniscal cysts may develop in the infrapatellar fat pad. In this article, the anatomical and imaging features of the infrapatellar fat pad will be summarized and the most common lesions will be illustrated.

Do tantalum components provide adequate primary fixation in all acetabular revisions?

INTRODUCTION: A number of studies have reported favorable results of cementless fixation in acetabular revisions. Nevertheless, the implant bearing on more than 50% of the patient's bone and good primary stability are required. The objective of this study was to determine whether the use of tantalum implants could provide stable reconstruction for any type of acetabular revision. PATIENTS AND METHODS: This study investigated 72 hips (71 patients) implanted with tantalum cups, some with augments, and morselized graft material. The mean age was 60 years (range, 34-84 years). There were 30 males and 41 females. The mean weight was 71 kg (range, 52-102 kg), the mean height was 1.68 m (range, 1.52-1.84 m). Twenty-five revisions were bipolar. Six revisions were performed for infected acetabular loosening. The mean follow-up was 4 years (range, 2-6 years). RESULTS: The mean Merle d'Aubigné score at follow-up was 15.8 points (range, 9-18 points). According to the Paprosky classification of acetabular bone defects, there were 13 type 1 (18%), 14 type 2A (19.5%), 14 type 2B (19.4%), 23 type 3A (31.9%), and eight type 3B (11.2%) acetabular defects, four of which had pelvic discontinuity. Postoperatively, the position of the hip's center of rotation in relation to Köhler's teardrop was 22 mm (range, 5-41 mm) vertically (normal, < 25 mm) and 39 mm (range, 13-55 mm) horizontally (normal, < 35 mm). The mean acetabular inclination was 40 degrees (range, 20 degrees -63 degrees ). The radiographic analysis found no radiolucent line after 1 year and up to the last follow-up. None of the patients required revision for acetabular loosening. Three hips were revised for instability. Two retentive liners and a dual-mobility cup were cemented in the cups that were left in place. DISCUSSION AND CONCLUSION: Given their mechanical properties (coefficient of friction, porosity), tantalum implants provide a stable primary cementless fixation without compromising the center of rotation and without necessarily requiring a structural graft. A single implant range can therefore be used for any type and severity of bone loss and for all types of acetabular reconstruction. Longer follow-up is nevertheless necessary to confirm these encouraging results. LEVEL OF EVIDENCE: Level IV, historical series.

Garden I femoral neck fractures in patients 65 years old and older: is conservative functional treatment a viable option?

INTRODUCTION: Internal fixation is the preferred treatment of Garden I femoral neck fractures in the elderly. High re-operation rates have however been reported, and the results of arthroplasty performed following internal fixation failure are not as good as those of primary arthroplasty. This is why we are advocating functional treatment. Our hypothesis is that this treatment leads to fewer decubitus complications than strict orthopaedic treatment and no more mechanical complications than internal fixation in a selected population sample. Therefore, the objective of our prospective work was: (1) to assess the results of functional treatment of Garden I femoral neck fractures in elderly subjects, and (2) to investigate predictive factors of secondary displacement. PATIENTS AND METHODS: All patients over age 65 years, admitted for a Garden I femoral neck fracture between January 2006 and May 2008, were included in this prospective study representing 56 cases (57 fractures) with an average age of 82 years. Functional treatment was performed, including early weight-bearing mobilisation, followed by radiographic evaluation at days 2, 7, 21 and 45, then at 3, 6 and 12 months. In the absence of displacement, discharge was planned at day 5 (Non-Displaced [ND] group). Otherwise, arthroplasty was performed (Displaced [D] group). Parker score and Harris Hip Score (HHS) were used for functional evaluation. RESULTS: The observed displacement rate was 33.3% (19 patients) within an average period of 10 days. In the ND group, one case of osteonecrosis was observed and treated by arthroplasty. The average Parker score was 6.9 and the HHS 82 in the ND group, and 7 and 85, respectively, in the D group. None of the factors studied (age, gender, side, fracture type, inclination angle, degree of outward displacement, sagittal displacement, general status) was statistically predictive of final displacement. DISCUSSION: The medical complication rate was only 7% in our series, which seems to be lower than that resulting from orthopaedic treatment. The observed secondary displacement rate seemed to be higher than the rate found in the literature on surgical treatment (5.4 to 20%), but the osteonecrosis rate appeared to be lower (11 to 25%). In addition, surgical treatment was the purveyor of specific complications in over 10% of cases. CONCLUSIONS: The present prospective study with minimum 1-year follow-up shows that functional treatment results in fewer decubitus complications than orthopaedic treatment and a rate of revision surgery comparable to internal fixation since 70% of included patients could have been successfully treated without surgical intervention. However, the investigation of a larger cohort would be necessary to identify predictive factors for the treatment's failure. LEVEL OF EVIDENCE: Level III prospective non-comparative cohort study.

Femoral offset: anatomical concept, definition, assessment, implications for preoperative templating and hip arthroplasty.

UNLABELLED: BACKGROUND OBJECTIVE: Femoral offset is supposed to influence the results of hip replacement but little is known about the accurate method of measure and the true effect of offset modifications. MATERIAL AND METHODS: This article is a collection of independent anatomic, radiological and clinical works, which purpose is to assess knowledge of the implications of femoral offset for preoperative templating and total hip arthroplasty. RESULTS: There is a strong correlation between femoral offset, abductors lever arm and hip abductor strength. Hip lateralization is independent of the femoral endomedullary characteristics. The abductors lever arm is highly correlated to the gluteus medius activation angle. There were correlations between femoral offset and endomedullary shape. The hip center was high and medial for stovepipe metaphysis while it was lower and lateralized for champagne - flute upper femur. A study was performed to compare the femoral offset measured by X-ray and CT-scan in 50 patients, demonstrated that plain radiography underestimates offset measurement. The 2D templating cannot appreciate the rotation of the lower limb. Taking into account the horizontal plane is essential to obtain proper 3D planning of the femoral offset. A randomized study was designed to compare femoral offset measurements after hip resurfacing and total hip arthroplasty. This study underlined hip resurfacing reduced the femoral offset, while hip replacement increased offset. However, the reduction of femoral offset after hip resurfacing does not affect the function. A pilot study was designed to assess the results of 120 hip arthroplasties with a modular femoral neck. This study showed that the use of a modular collar ensures an easier restoration of the femoral offset. A cohort of high offset stems (Lubinus 117 degrees) was retrospectively assessed. The survival rate was slightly lower that the standard design reported in the Swedish register. Finally, the measurement of offset and leg length was assessed with the help of computer assistance. The software changed the initial schedule (obtained by templating) in 29%. CONCLUSION: Therefore, femoral offset restoration is essential to improve function and longevity of hip arthroplasty. CT-scan is more accurate than plain radiography to assess femoral offset. Hip resurfacing decreases offset without effect on function. Modular neck and computer assistance may improve intraoperative calculation and reproduction of femoral offset. Increasing offset with a standard cemented design may decrease long-term fixation. Level IV: Retrospective or historical series.