Can a target zone safer than Lewinnek's safe zone be defined to prevent instability of total hip arthroplasties? Case-control study of 56 dislocated THA and 93 matched controls.

BACKGROUND: Various factors contribute to instability of total hip arthroplasty (THA), with implant orientation being a major contributor. We performed a case-control study with computed tomography (CT) data to determine whether: 1) orientation contributes to THA instability and 2) a safer target zone for stability than Lewinnek's classic safe zone can be defined. MATERIAL AND METHODS: We included prospectively 363 cases of THA dislocation that occurred during the calendar 2013 year in 24 participating hospitals. Of the 128 dislocations that occurred in patients who underwent THA at these centers, 56 (24 anterior, 32 posterior) had CT scans, thus were included in the analysis. The control group was matched 4:1 based on implant type, year of implantation, age, sex, bearing types and THA indication. Of the 428 matched control THA cases, 93 had CT scans. In all, the CT scans from 149 cases (56 unstable, 93 stable) were analyzed to determine the acetabular cup's inclination and anteversion, and the femoral stem's anteversion. RESULTS: In the unstable THA group, cup inclination was 46.9°±7.4°, cup anteversion was 20.4°±10.8° and stem anteversion was 14.2°±9.9°. In the stable THA group, cup inclination was 44.9°±5.3° (P=0.057), cup anteversion was 22.1°±5.1° (P=0.009) and stem anteversion was 13.4°±4.4° (P=0.362). The optimal total anteversion (cup+stem) of 40-60° was achieved in 16.5% of unstable THA cases and 13.9% of stable THA cases, thus this parameter does not predict stability (odds ratio [OR] of 0.40, P=0.144). The cup was positioned in Lewinnek's safe zone in 44.6% of patients in the unstable group and 68.2% of those in the stable group (OR 3.74, P=0.003). A target zone defined as 40-50° inclination and 15-30° anteversion was better able to distinguish between unstable cases (23.2%) and stable cases (71.6%) resulting in an OR of 13.91 (P<0.001). DISCUSSION: Implant positioning was the only risk factor for instability found in this study. Moreover, our findings reinforce the theory put forward by other authors that Lewinnek's safe zone is not specific enough to differentiate between stable and unstable THA implantations. The target zone for acetabular cups proposed here (40-50° inclination and 15°-30° anteversion) is related to a lower risk of instability. This orientation can be used as a guide, but must be combined with other technical elements to optimize stability. By balancing stability and biomechanics, the 40-50° inclination and 15°-30° anteversion target zone redefines the optimal positioning window. LEVEL OF EVIDENCE: III case-control study.

Is determination of the hip rotation center during computer-assisted surgery influenced by the pinless femoral sensor attachment method? An in vitro preliminary study comparing osseous pin fixation.

INTRODUCTION: Computer-assisted surgery improves the positioning of hip prostheses but requires use of transosseous pins requiring a complementary approach exposing the patient to rare but at times serious complications. The use of sensor arrays attached to the skin could advantageously replace pins provided that comparable results are obtained, but their validity has not yet been assessed. We conducted a prospective in vitro study to: measure the possible error of a cutaneous versus transosseous fixation to determine the hip rotation center (HRC) position and determine the inter- and intraobserver reproducibility of the cutaneous versus the transosseous fixation. HYPOTHESIS: Use of cutaneous sensor arrays while recording the HRC is sufficiently reliable for its calculation algorithm to provide measurement accuracy within 5mm. MATERIALS AND METHODS: A rigid array attached with either a silicone strap or an adhesive were compared to a transosseous array. Four series of 96 HRC measurements were collected by four operators on two cadavers, half with an array attached with a strap and half with an adhesive. The results were compared to those obtained by a sensor attached with transosseous pins. RESULTS: On condition that the hip-knee is mobilized in extension, a sensor array attached with an adhesive gives results with comparable accuracy (standard deviation [SD]: 2.89mm [1.9-4.8]) to the results obtained with a transosseous fixation (SD: 1.2mm [0.9-1.6]), with no significant inter- or intraobserver variation (0.97

Can the presence of an infection be predicted before a revision total hip arthroplasty? Preliminary study to establish an infection score.

INTRODUCTION: The diagnosis of periprosthetic joint infection can be challenging, in part because there is no universal diagnostic test. Current recommendations include several diagnostic criteria, and are mainly based on the results of deep microbiological samples; however, these only provide a diagnosis after surgery. A predictive infection score would improve the management of revision arthroplasty cases. The purpose of this study was to define a composite infection score using standard clinical, radiological and laboratory data that can be used to predict whether an infection is present before a total hip arthroplasty (THA) revision procedure. HYPOTHESIS: The infection score will make it possible to differentiate correctly between infected and non-infected patients in 75% of cases. MATERIAL AND METHODS: One hundred and four records from patients who underwent THA revision for any reason were analysed retrospectively: 43 with infection and 61 without infection. There were 54 men and 50 women with an average age of 70±12 years (range 30-90). A univariate analysis was performed to look for individual discriminating factors between the data in the medical records of infected and non-infected patients. A multivariate analysis subsequently integrated these factors together. A composite score was defined and its diagnostic effectiveness was evaluated as the percentage of correctly classified records, along with its sensitivity and specificity. RESULTS: The score consisted of the following individually weighed factors: body mass index, presence of diabetes, mechanical complication, wound healing disturbance and fever. This composite infection score was able to distinguish correctly between the infected patients (positive score) and non-infected patients (negative score) in 78% of cases; the sensitivity was 57% and the specificity 93%. DISCUSSION: Once this score is evaluated prospectively, it could be an important tool for defining the medical - surgical strategy during THA revision, no matter the reason for revision. LEVEL OF EVIDENCE: Level IV - retrospective study.

Painful patellofemoral instability secondary to peroperative patellar fracture during bone-patellar tendon-bone autograft harvesting for anterior cruciate ligament reconstruction.

Reconstructive surgery of the anterior cruciate ligament (ACL) of the knee in young active patients is a routine procedure, but with certain risks that need to be taken into account. Peroperative patellar fracture after bone-patellar tendon-bone autograft harvesting is a rare complication, which can significantly impair the functional outcome of ACL single-bundle reconstruction. We report the case of a patient presenting with disabling patellofemoral syndrome 3 years after arthroscopic ACL reconstruction by bone-tendon-bone autograft, revealing unnoticed mal-union of a iatrogenic sagittal patellar fracture. Patellar osteotomy corrected this painful iatrogenic patellar instability.

A well-fixed femoral stem facing a failed acetabular component: to exchange or not? A 5- to 15-year follow-up study.

INTRODUCTION: There is no consensus about the necessity of exchanging a stable femoral component during revision total hip arthroplasty (RTHA) when only the acetabular component requires replacement. Sparing the femoral component reduces morbidity, but can make acetabular replacement technically more difficult. Moreover, the outcome of the retained femoral component is also a question, especially with older implants. HYPOTHESIS: Isolated acetabular component RTHA results in lower surgical morbidity, and does not increase the risk of later femoral complications. PATIENTS AND METHODS: Eighty-nine patients, mean age 68, underwent surgery (anterior approach on traction table) for isolated acetabular component revision between 1994 and 2005. The femoral component had been implanted a mean 10.5 years before revision. RESULTS: Fifteen patients died, mean age 84.5. Eleven patients, mean age 81.3, were lost to follow-up and four underwent revision due to a subsequent infection (range 14 months - 11 years). Fifty-nine patients were evaluated after a mean 8.6 years (range 4 - 15 years). At follow-up the mean Harris score was 89.2 [IC=6.89; 44 - 100] and the mean Merle d'Aubigné score was 15.3 [IC=1.57; 11 - 18]. Five patients (5.6%) underwent surgery again due to postoperative dislocation. Six patients underwent surgery for recurrent acetabular loosening due to allograft resorption. The size of the bone defects did not increase the risk of these failures (P>0.6). Fractures occurred in two femoral components 6 and 9 years after revision. Polyethylene wear occurred in three patients requiring two repeat revisions at 6 and 7 years. In both cases the femoral component included a titanium head, which caused the wear. Implant survival at 8.6 years was 85.16 ± 0.117% all causes of revision combined, 88.47 ± 0.113% if infectious causes were excluded and 93.6 ± 0.07% if only cases of acetabular component failure were taken into account. CONCLUSION: Intermediate term outcomes are satisfactory if stable femoral components are retained. Nevertheless, this procedure should be performed in situations of correctly oriented modular components. In single piece (monoblock) femoral implants, or in implants with a history of failure, this technique should be restricted to elderly and/or fragile patients. LEVEL OF EVIDENCE: Level IV, Retrospective study.

Near-miss event assessment in orthopedic surgery: Antimicrobial prophylaxis noncompliance.

INTRODUCTION: Antimicrobial prophylaxis is one of the main safety measures to be enforced when implanting any medical device; surveys of practice, however, have found poor compliance. MATERIAL AND METHODS: This study is based on analysis of 153 dedicated in-depth analysis forms sent to orthopedic surgeons who had reported an antimicrobial prophylaxis-related near-miss event (NME) during the year 2008 as part of their certification report to the official organization, Orthorisq (orthopaedic Patient safety risk management agency). RESULTS: Antimicrobial prophylaxis guidelines exist in 95% of French centers, but in 14% are not available in the right place. 88% of orthopedic surgeons consider them well-adapted to their practice. Most declarations follow fortuitous discovery by the surgeon of an immediate peri-operative malfunction. Human causes were found in 92% of declarations, general organizational causes in 50% and material causes in 28%. Regarding corrective action, 65% of respondents reported implementing a second-order procedure, and only 20% were able to resume truly regular antimicrobial prophylaxis. CONCLUSION: The main reason for poor or non-performance of antimicrobial prophylaxis was "omission by negligence or oversight", reported in 56% of declarations. Proposals for improvement were: revised antimicrobial prophylaxis guidelines specifying "who does what"; guideline awareness checks on new, temporary and locum-tenens staff; patient involvement in personal data collection; and implementation of a check-list in line with WHO and French Health Authority recommendations. These improvement proposals were taken on board in the antimicrobial prophylaxis consensus update currently being drawn up by the French Society for Anesthesia and Intensive Care. LEVEL OF EVIDENCE: Level IV, Decision Analyses Study.

Pyoderma gangrenosum following an orthopedic surgical procedure.

Pyoderma gangrenosum is a severe neutrophilic dermatosis that may occur as a complication following any kind of surgery. Although mainly reported secondary to breast surgery, it may also arise in orthopedic surgery. Misdiagnosis risks serious sequelae, due to inappropriate or delayed treatment. Unlike the infections, which it mimics, it is to be managed by corticosteroids, and debridement is absolutely contraindicated, as it will cause dermatologic lesions in the traumatized areas, worsening and accelerating the pathologic process. As anatomopathology tends to shed little light, it is essential to bear the diagnosis in mind in case of any early superficial pustular lesion showing rapid extension despite correctly administered antibiotherapy. We report a case of pyoderma gangrenosum secondary to hip replacement surgery, and detail diagnostic factors and means of treatment.

Total hip arthroplasty for osteoarthritis in patients aged 80 years or older: influence of co-morbidities on final outcome.

BACKGROUND: In osteoarthritic patients aged 80 years or older, total hip arthroplasty (THA) offers well-established benefits; however this selective group of population is known to carry a high morbidity rate. HYPOTHESIS: The higher morbidity rate carried by this group does benefit more from identification of risk factors than from improved surgical and anesthesia techniques. MATERIALS AND METHODS: Seventy-two patients, operated between October 2003 and December 2006, were retrospectively analyzed. The interventions performed on the traction table, through an anterior approach, involved implantation of a cemented total prosthesis combined to a retentive, cemented acetabular component. RESULTS: At an average delay of 31 months (minimum 5 months, maximum 54 months), no patient was lost to follow-up and no prosthesis had to be revised. In total, 19 patients presented 27 complications, which were not influenced by their American Society of Anesthesiology (ASA) score (p>0.1) nor by the presence of co-morbidities (p>0.5). No perioperative deaths or infection occurred. Twenty-eight patients required blood products transfusion. ASA score (p<0.03) and body mass index<25 (p=0.01) appeared to be risk factors for transfusion. Seventeen patients were pain-free and walked without restriction, and 19 had a Merle d'Aubigné score under 15. We noted two isolated dislocations (2.6%). Eleven patients were hindered in their walking ability by an associated orthopaedic condition and five by unrelated medical problems. Although preoperative ASA score did not seem to be of predictive value to the quality of surgical outcome (p>0.5), the occurrence of an associated orthopaedic condition (p<0.001) and, even more the patient's categorization in Charnley class B or C (p<0.001) strongly correlated to this outcome quality. DISCUSSION: While THA for the treatment of osteoarthritis in patients older than 80 years exposed them to a complication rate of 27%, no specific risk factor was identified. Other neuro-orthopaedic disorders hampered the quality of the functional outcome. The use of a retentive cup could not eliminate the occurrence of two dislocations (2.6%). LEVEL OF EVIDENCE IV: retrospective therapeutic study.

[Modified Exeter technique in revision hip surgery]. / Révision fémorale par allogreffes spongieuses impactées et tige cimentée Evaluation d'une technique d'Exeter modifiée améliorant la stabilité primaire de l'implant fémoral avec un recul moyen de 84 mois.

PURPOSE OF THE STUDY: The Exeter technique opened new perspectives for the treatment of femoral bone stock loss in revision hip arthroplasty. Implant migration in the cement sheath is, however, a frequent finding. According to the promoters of the technique, this would favor transformation of the allograft into living bone. For others it is a worrisome problem since it alters the heterogeneous cement sheath, leading to loosening and final surgical revision, with an incidence up to 20%. We propose an analysis of the mid-term results of the modified Exeter technique with the objective of cementing the distal part of the implant directly into the recipient bone in order to achieve satisfactory primary stability. The purpose of this work was to analyze the consequences of this method on the long-term evolution of the allograft. MATERIAL AND METHODS: After preparing the femur, a specific gun is filled with allograph dough obtained from frozen femoral heads fragmented with an acetabular reamer. The Mersilene mesh enables the deposit of a tube of graft material at the desired level. The implant is sealed after impaction of the graft to enable direct distal cementing in contact with the recipient bone. Partial weight bearing is allowed as early as the fifth day and increased progressively to complete weight bearing at three months. Forty-five patients (46 hips) were treated between June 1996 and January 2002. Six patients were not retained for analysis due to insufficient follow-up. For three patients, graft outcome could not be properly assessed due to a major complication. In addition, two patients died and one was lost to follow-up. In all 39 patients (40 hips) were analyzed at mean follow-up of 84 months (range 48-110). There were no cases of revision for femoral loosening. Femoral bone loss was mainly moderate to severe type II and III hips (Sofcot classification) but limited in height (no grade IV in the Endo-Klinik classification). RESULTS: Clinical outcome was excellent in 13 hips, good in 16, fair in nine and poor in two (Postel-Merle-d'Aubigné score). Defective distal cementing with implant migration (less than 5 mm) was noted in four cases followed by secondary stabilization. Transformation of the allograft occurred in 36 cases, associated with corticalization of the recipient bone in 14. CONCLUSION: This technique is reproducible since primary stability was obtained in 90% of hips, without hindering transformation of the allograft. The results, which are sustained over time, are the same as with the princeps technique and no radiographic evidence of stress shielding could be found.

[Influence of body mass index on outcome of total hip arthroplasty via a minimally invasive anterior approach]. / Influence de l'indice de masse corporelle sur la réalisation d'une prothèse totale de hanche par voie d'abord antérieure réduite.

PURPOSE OF THE STUDY: The purpose of this prospective study was to evaluate the influence of the BMI on the feasibility of minimally invasive total hip arthroplasty (THA). MATERIAL AND METHODS: This prospective study included 86 patients (88 THA) operated on via a single minimally invasive incision (7 cm) using an anterior approach on Judet's orthopedic table. Mean age was 63.7 years and mean BMI was 58.8. Forty-one patients were classified in group I (BMI<25) and 46 in group II (BMI >=25). Perioperative data, pain, postoperative blood loss, duration of the procedure, and length of the incision were noted. All patients were reviewed at three months and radiographic analysis was performed to asses the position of the socket and the quality of the cementation. RESULTS: BMI did not appear to be a strict contraindication for a minimally invasive procedure. Nevertheless, bleeding and operative duration were statistically correlated with BMI (epsilon=4.28 and epsilon=2.66). Extension of the wound noted at the end of the procedure in patients with BMI > =25 (t=5.01) may have resulted from greater pressure on the skin and soft tissue due to stronger traction and more abrasion of the skin edges by reamers and rasps. Such damage may lead to more wound complications even though in our experience there was no statistical difference. On the other hand, socket position and cementation did not appear to be correlated with BMI. DISCUSSION: Results concerning duration of procedure, bleeding, hospital stay and rate of complications are contradictory in the literature. At the same time, criteria for patient selection remain unclear. It thus appeared to be of interest to determine whether BMI was a good criterion to determine the feasibility of THA via a minimally invasive procedure. CONCLUSION: BMI appears to be a good criterion to evaluate the risk of wound complications after minimally invasive surgery. On the other hand, other criteria must be found since BMI does not evaluate muscle mass which seems to be of major concern in minimally invasive procedures.

[Impaction posterior wedge osteotomy for the treatment of postsurgical flatback: 22 cases]. / Ostéotomie de fermeture postérieure par impaction intracorporéale pour dos plat postopératoire: à propos d'une série de 22 cas.

PURPOSE OF THE STUDY: There is increasing interest in sagittal balance as an important element when planning treatment of spinal deformations. Posture disorders, particularly flatback, can be observed after surgical treatment of scoliosis. The frequency of flat back syndrome has increased with the development of spinal surgery. MATERIAL AND METHODS: Posterior osteotomy is designed to resolve these problems. Two techniques are used: the Smith-Petersen procedure and transpedicular subtraction osteotomy. We adopted the second procedure, adding two technical modifications: installation on an orthopaedic table and intracorporeal cancellous impaction. We performed closed posterior osteotomy by intracorporeal impaction and report here our results in a series of 22 patients with postoperative flat back treated between July 1999 and June 2002. Mean age at surgery was 52 years. There were sixteen women and six men. All patients had a history of spinal surgery with fusion. They had had 2.1 spinal operations on average with a maximum of seven. All patients complained of severe postural pain. They had difficulty bending forward and standing back up. Radiographically, we noted altered spinal and pelvic angles and an abnormal plumb line from C7 to the promontory. RESULTS: We analyzed outcome at 21 months on average. Preoperatively five patients had 12 levels of non-union. Osteotomy was performed at L4 in nineteen patients and L3 in three. A rigid instrumentation was used in all cases. Osteosynthesis material was implanted after correction of the deformation with no particular problem for spinal stability or reduction. Mean operative time was 180 minutes and mean blood loss was 1680 ml. A complementary anterior approach was required in one patient. Intraoperative complications were dominated by dural breaches in five patients, high paraplegia not directly related to the osteotomy in one patient, regressive S1 paresia occurred in one patient and transient cruralgia which regressed in 4 to 6 months in four patients. We also observed functional intestinal obstruction in one patient and severe depression in another. There were no infections or deaths. We also observed two cases of predominant correction at the discal level and not the vertebral level. All operated patients felt their posture was improved and were able to maintain the upright position for prolonged periods. Flexion of the lower limbs was improved. Mean correction of lumbar lordosis was 25.1 degrees (range 12-39). Mean sacral slope was 33 degrees . Mean correction of the position of C7 on the promontory plumb line was 72 mm. This variable was highly altered preoperatively (95.6 mm) and was improved after osteotomy in all patients. At last follow-up, there was one case of nonunion which had been successfully revised. DISCUSSION: The literature on osteotomy for the treatment of flat back is sparse. Our series of subtraction osteotomy is the largest reported to date. Preoperative and intraoperative planning remain a topic of debate and require further study.

[Role of sagittal spinal curvature in early dislocation after revision total hip arthroplasty: prospective analysis of 49 revision procedures]. / Rôle de la courbure rachidienne sagittale dans la survenue des luxations précoces après reprise de prothèse totale de hanche. A propos d'une analyse prospective de 49 reprises de prothèse totale.

PURPOSE OF THE STUDY: Hip dislocation after revision total hip arthroplasty (RTHA) is a frequent post-operative complication. Certain risk factors are well identified (nonunion of the greater trochanter, history of recurrent dislocation or infection, multiple procedures), the role of spine morphological remains to be fully examined. The purpose of this prospective analysis was to assess the role of spine morphology in post-operative dislocations. MATERIAL AND METHODS: Forty-nine patients who underwent RTHA between September 2002 and March 2002 were evaluated prospectively. A complete pre- and postoperative spinal work-up was available for all patients to evaluate the lumbopelvic static using the Legaye and Duval Beaupère morphology criteria and the pelvic-femoral angle to assess hip joint extension. Pre-, per- and post-operative data including the usual risk factors for dislocation related to the clinical situation and the technique used were recorded on a digital datasheet. Five patients developed postoperative dislocation despite the absence of defective implant position. There was no relation with access (p=0.832) or pelvic-femoral angle (p=0.515). RESULTS: The mean value of the sacral slope was significantly different (p=0.006) in patients who developed dislocation in comparison with the other patients. This difference remained significant (p=0.017) for the cohort of 33 patients who had no associated risk factor for postoperative dislocation (history of recurrent dislocation or infection, multiple procedures, tight nonunion of the greater trochanter). DISCUSSION: Our results suggest that the morphology of the lumbar spine can be involved in the risk of postoperative dislocation. The morphology of the lumbar spine affects the pelvic static and thus the landmarks usually used for implantation, but it can also limit the amplitude of pelvic movement when changing from the sitting to the standing position, which would be compensated for by greater hip movement, particularly extension. The method we used did not fully take into account the consequences of changes in spinal balance due to thoracic deformations nor to analgesic (or not) hip flexion and subsequent deformation of the lumbar spine.

[Contribution of the Gigli saw for ablation of non-loosened surface-treated femoral stems inserted without cement: six cases]. / Apport de la scie de Gigli pour l'ablation d'une tige fémorale sans ciment non descellée à effet de surface réhabitée: à propos de six cas.

The purpose of this work was to present a technique using the Gigli saw through a transfemoral approach in removal of surface-treated femoral implants without cement. Results from six cases are reported. For five patients, ablation of the implant was achieved easily and rapidly with the Gigli saw, taking a mean nine minutes once the cortical window had been achieved. The technique failed in one patient. We had one fracture of the cortical window at its removal and one transverse shaft fracture in the lower part of the femorotomy related to movements of the Gigli saw. A standard length stem was implanted in four of the five successful cases. Complete weight bearing was authorized between the 3(rd) and 7(th) month. Bony healing of the cortical window was achieved in 4 out of 5 cases before the end of the first year.

[Value of preoperative planning in total hip arthroplasty]. / Etude critique des résultats de la planification préopératoire sur l'anatomie de la hanche prothésée.

PURPOSE OF THE STUDY: Preoperative planning enables an assessment of the size of the implants needed before total hip replacement. Eggli and Müller demonstrated the reproduciblity of preoperative planning but did not evaluate its contribution to reducing limb length discrepancy. As femur lateralization and the position of the prosthetic center of rotation affect joint mechanics, it would be useful to assess their contribution to the efficacy of preoperative planning. PATIENTS AND METHODS: We reviewed the files of 57 patients who underwent total hip arthroplasty for primary joint degeneration or necrosis limited to one hip. The healthy hip served as a control. The surgical plan was elaborated from the preoperative pelvis x-rays (AP and lateral views) and anatomic measurements on films obtained three months postoperatively. RESULTS: In 49 cases, preoperative planning predicted a restoration of the normal anatomy of the operated hip (center of rotation, femur lateralization, length of the operated limb). This objective was achieved in only 22.5% of the cases. Femur lateralization was the most difficult objective to achieve (59.2%). Equal limb length and good position of the center of rotation was achieved in 70% of the cases. For eight patients (14%) preoperative planning was not satisfactory, the implant offset not being adapted to the patient's anatomy. DISCUSSION: There are limits to preoperative planning, particularly for restitution of adequate femur lateralization. This difficulty appears to be related to three factors: inadequate adaptation of the implant to hip anatomy (14% of the cases in our experience), stiff rotation in degenerative hips inhibiting proper assessment of the length of the femoral neck, and relative imprecision of operative evaluation of femoral anteversion affecting femur lateralization and the level of the femoral cut. CONCLUSION: Although imperfect, preoperative planning is, in our opinion, essential before total hip arthroplasty in order to avoid major positioning errors and operative difficulties.

[Perioperative complications after total hip revision surgery and their predictive factors. A series of 181 consecutive procedures]. / Complications péri-opératoires après reprise de prothèse totale de hanche et leurs facteurs prédictifs. A propos d'une série continue de 181 interventions.

PURPOSE OF THE STUDY: We conducted a retrospective study to assess morbidity and mortality in patients undergoing revision total hip arthroplasty (THA) procedures. MATERIAL AND METHODS: Perioperative complications were recorded in 181 revision procedures (162 patients) performed between January 1995 and March 1999 (117 bipolar revisions and 64 acetabular isolated revisions). RESULTS: There were 86 complications (68 patients) leading to 21 new revisions. About half (50/86) were related to the surgical procedure (dislocation, femoral fracture, infection.). Life-threatening complications (3.6%) ended in patient death in 1.6% of the cases. Complications were more frequent in patients with an ASA score=3 (p<0.01) or aged over 75 years (p<0.05). Age was also predictive of femoral misalignment and fracture (p<0.05). Dislocations (8.8%) were observed more frequently in patients who had undergone more than 2 procedures prior to the revision (p<0.05) (4.8% of the dislocations in patients undergoing a first revision procedure and 14.3% in the others). In addition, peroperative blood loss and duration of the procedure were significantly greater in case of bipolar replacement than for isolated acetabular replacement (sigma > 1.96). DISCUSSION: Our experience and data in the literature point to the important age factor in the development of complications. Preservation of a well-fixed femoral component does not appear to worsen prognosis and leads to fewer complications than bipolar changes. CONCLUSION: The decision to revise a THA must take into consideration the functional impairment but also the risks inherent in revision procedures, particularly in old patients who have undergone several procedures. Revising the acetabular component alone can be an interesting option if the femoral component remains well-fixed although our follow-up is insufficient to determine whether this attitude provides better long-term outcome than complete biopolar revision. Better patient selection and improved operative technique, in particular in femur preparation, should help reduce morbidity and mortality in this type of procedure.

A simple technique to remove well-fixed, all-polyethylene cemented acetabular component in revision hip arthroplasty.

Well-fixed, all-polyethylene acetabular components may have to be removed in cases of recurrent dislocations, infection, or fracture of ceramic femoral heads. We describe a simple technique using acetabular reamers that allow cup thinning. Through this technique, the polyethylene rigidity is diminished considerably, allowing its easy removal without any risk of fracture, particularly of the acetabulum walls.

[Detection of asymptomatic venous thrombosis after lower limb prosthetic surgery. Retrospective evaluation of a systematic approach using Doppler ultrasonography: 400 cases]. / Détection des thromboses veineuses asymptomatiques après chirurgie prothétique du membre inférieur. Evaluation rétrospective d'un dépistage systématique par échographie Doppler: 400 cas.

OBJECTIVES: The purpose of this study was to evaluate a pragmatic approach using duplex ultrasonography (US) for detecting deep vein thrombosis (DVT) after total hip (THA) and total knee (TKA) replacement. METHODS: Venous B-mode and color duplex US examination of both legs including a systematic evaluation of calf veins was performed twice during hospital stay (Between day 1 and day 4 for the first exam and between day 7 and day 11 for the second) in 400 consecutive patients. RESULTS: Deep vein thrombosis was diagnosed in 53 patients (13.5%) including 7 patients with proximal DVT. Thrombosis was asymptomatic in 46 patients (85%), and was bilateral or concerned the non-operated leg in 8 patients (14.5%). No clinical pulmonary embolism (PE) occurred during hospital stay (mean hospital stay: 12.3). Prior phlebitis and age over 70 were identified as a statistically significant risk-factor for post-operative DVT (p = 0.001 and p < 0.01 respectively) concerning the whole series and the THA series (p < 0.02 and p < 0.04 respectively). No statistically significant risk factor was founded for the TKA series (p < 0.2 and p < 0.2 respectively). All patients were seen at three months. Four patients (1.16%) developed DVT between hospital discharge and the 3-month follow-up visit. One patient with coronary disease died suddenly on post-operative day 24, without clinical signs or symptoms of PE or DVT. CONCLUSION: Venous US performed twice after total hip replacement detected asymptomatic DVT in 85% of patients. This approach might explain the absence of PE in our series and thus justify systematic ultrasonographic evaluation of lower limb veins after prosthetic replacement.

[Treatment of comminuted fractures of the lower end of the radius with internal osteosynthesis, traction and early mobilization]. / Traitement des fractures comminutives de l'extrémité inférieure du radius par ostéosynthèse interne, distracteur et mobilisation précoce.

Goals for treatment of comminutive fractures of the distal radius include restoration of the articular profile of the proximal part of the joint, while axial loading forces must be avoided as much as possible to prevent secondary displacement. The choice of an internal fixation protected by an external wrist distractor-fixator, with early activo-passive mobilisation, seems to achieve the goal. Twelve patients with a comminuted fracture of the distal radius, including axial articular impigment displacement were reviewed for this study. All fractures were Frykman's type III, IV, VII or VIII. Distraction was done with a specific external apparatus, allowing an internal fixation, using an anterior plate and posterior Kirschner wires for the more complex cases. Distraction was released at the end of the surgical procedure, while the distractor was left in place. The wrist was mobilised early in the post-operative period, and the distractor was removed two months later. At a mean follow-up of 8.5 months, two patients were still painful. Mean motion of the wrist joint was 115 degrees for flexion-extension and 35 degrees for radio-ulnar deviation. Radiological results were good (10 cases), in both planes sagittal and frontal, and stable with time. The radio-ulnar index was correct in 11 cases. Only two cases of Sudeck's atrophy were noted. Authors use a specific external wrist distractor to obtain and maintain reduction in comminuted fractures of the distal end of the radius, using internal fixation in combination. Early motion of the wrist, protected by the wrist distractor seems to lower rates of Sudeck's atrophy.

[Orthopaedic treatment of colles' fractures according to judet's method]. / Le traitement des fractures de Pouteau-Colles selon la technique de Judet.

Revision of 109 Colles' fractures treated by Judet's method confirm the safety of that technic and the overall good results (73% of anatomical results). The authors show that the results are quite different in presence or in absence of metaphyseal comminution (50 to 90% of anatomical results) and when anterior cortex of the distal fragment has crossed the anterior cortex of the proximal fragment. They also emphasise the necessity of pre-operative Xrays under traction to assess that comminution, and sometimes to correct the wrong diagnosis of strictly extra-articular fractures.