C1-C2 stabilization by Harms arthrodesis: indications, technique, complications and outcomes in a prospective 26-case series.

INTRODUCTION: C1-C2 arthrodesis is a surgical challenge due to the proximity of neurovascular structures (vertebral arteries and spinal cord) and the wide range of motion of the joint, hampering bone fusion. A variety of techniques have been successively recommended to reduce anatomic risk and improve results in terms of biomechanical stability and fusion rates. Recently, Harms described a new technique using polyaxial screws in the C1 lateral masses and C2 pedicles. MATERIAL AND METHOD: The present study reports our experience in a consecutive series of 26 patients operated on by C1-C2 arthrodesis using the Goel and Harms technique, and details technical aspects step by step. Routine systematic immediate postoperative CT and 6-month CT controlled screw positioning and assessed fusion. Follow-up was at least 1 year, except in 2 cases (10 months). RESULTS: Twenty-six patients with a mean age of 57 years were included. Indications comprised: C2 non-union (n=11), C1-C2 fracture and/or dislocation (n=11), inflammatory pathology (n=2) and tumoral pathology (n=2). The results showed the technique to be reliable (no neurovascular complications and 85% of screws with perfect positioning) and an excellent rate of fusion (100% at 6 months). CONCLUSION: Anatomic and biomechanical considerations, combined with the present clinical and radiological outcomes, indicate that Goel and Harms fusion is to be considered the first-line attitude of choice for posterior C1-C2 arthrodesis. LEVEL OF EVIDENCE: Level IV prospective study.

Osteoarthritis in patients with anterior cruciate ligament rupture: a review of risk factors.

The risk factors for the development of osteoarthritis (OA) in patients who have had an anterior cruciate ligament (ACL) rupture are reviewed. Although the principle arthrogenic factor is the increased anterior tibial displacement that is associated with the rupture, other direct and indirect factors contribute. Meniscal and chondral injuries can be present before, during, and develop after the index injury, making assessment of the relative importance of each difficult. Most studies concentrate on the radiological changes following ACL rupture and reconstruction. However the rate of significant symptomatic OA needing major surgical intervention is lower. This needs to be considered when advising patients on the management of their ruptured ACL. The long-term outcome in patients who are symptomatically stable following an ACL rupture is uncertain, although in a small cohort of elite athletes all had degenerative changes by 35 years and eight out of 19 (42%) had undergone total knee replacement. At 20 years follow-up the reported risk of developing osteoarthritis is lower after ACL reconstruction (14%-26% with a normal medial meniscus, 37% with meniscectomy) to untreated ruptures (60%-100%).

[Tibial valgus osteotomy]. / Ostéotomie tibiale de valgisation.

The tibial valgus osteotomy whatever its technique has a survival rate of about 85 % to 10 years, if we consider the reoperation as a criterion of failure, with a confidence index at 78%. The age, weight, sex and functional signs have no impact on the outcome. We have found no evidence in the preoperative radiographic assessment, neither the medial pinch, or varus epiphyseal neither varisant gap, which could be a failure and a reoperation before the tenth year. Good results were observed significantly when there is an over-valgus at least 3 degrees of global axis of the lower limb. This corresponds to a valgus epiphyseal by more than 2 degrees . The substantial reduction in the gap varisant that lowers the overall time varisant below 200 kg cm provides the same positive results. The outcome will depend directly on the accuracy of the calculation of the preoperative correction performed and the quality of surgical achievement. Because of the need for precision, navigation technique appears as reliable, simple which makes it also possible to monitor the front slope and tibial rotation induced. The osteosynthesis must be stable and rigid to avoid postoperative loss of correction.

[Confrontation of the radiographic preoperative planning with the postoperative data for uncemented total hip arthroplasty]. / Confrontation de la planification radiographique préopératoire et des données postopératoires lors de la mise en place des prothèses totales de hanche non cimentées.

PURPOSE OF THE STUDY: For hip prosthesis surgery, the challenge is to obtain optimal function of the instrumented hip but also to eliminate any limb length discrepancy, correct the femur offset and guarantee the center of rotation of the hip joint. Preoperative planning for total hip arthroplasty (THA) enables determination of the appropriate length for the prosthetic neck and the size and eventually the type of implants to use. From a prospective series of 86 patients who underwent first-intention THA for implantation of a noncemented prosthesis, we studied the precision of the outcome as function of the preoperative planning. We also ascertained whether the preoperative planning was sufficient to provide the measurements necessary for correct implant position. MATERIAL AND METHODS: We analyzed a prospective series of patients who underwent first-intention THA from January 2004 through January 2006. To be eligible for inclusion, patients could not have a THA of the contralateral hip. The series was composed of 58 females and 28 males, mean age 70.2 years (range 45-93). The reasons for THA were primary degenerative disease (n=76) and aseptic osteonecrosis (n=10). The contalateral hip was intact and free of osteoarthritis with an anatomic presentation considered to be normal. The standard X-ray protocol included an anteroposterior view of the pelvis in the upright position and 10 degrees internal rotation obtained preoperatively and three months postoperatively. All radiographic measurements were made by the same investigator using a manual nondigitalized technique. We compared planning parameters (pivot size and type, length of the neck, and size of the cup) with the final outcome in order to determine the compliance with the preoperative planning. All operations were performed in the lateral supine position under general anesthesia and by the same surgeon. The posterolateral Moore approach was used. All implants were press fit without cement, both for the cup and for the femoral piece. RESULTS: All planning parameters selected for study (offset, size of the head and the cup, length of the neck) were available for 32 hips, giving an overall conformity of 37%. The length of the neck was as planned in 75% of hips, the size of the cup in 62% and the size of the femoral stem in 64%. The offset defined preoperatively was never changed during the operation. Ideal implantation (+/- 5mm for all criteria selected for study) was obtained in 60% of hips; the height of the center of rotation was reproduced in 81% and the lateralization in 84%. Femur lateralization was reproduced in 75% of the hips and hip offset in 66%. Leg length discrepancy was avoided in 85% of the patients. DISCUSSION AND CONCLUSION: Preoperative planning reliably predicts the final offset of the implanted femoral stem. It is more difficult to predict the size of a press fit cup but in our experience the difference does not greatly affect restitution of the hip anatomy. We readily changed the length of the neck during the operation if necessary and have found that the leg length has been better with this approach. This leads to the observation that all of the planning parameters are not fully accurate because of the magnification effect, anatomic conditions, or possible defective execution. While the overall rate of conformity was low, looking at the results for each element separately provided a useful element for each phase of the operation. We recommend planning a medium length neck so it can be easily changed during the operation. The availability of offset measurements is particularly important to control hip lateralization and leg length. Current advances in computer-assisted surgery should be helpful in improving the imperfections of preoperative planning.

[Original vacuum dressing for the treatment of open femur fracture with gangrene immobilized by external fixation]. / Pansement aspiratif pour gangrène sur fracture ouverte du fémur immobilisée par fixateur externe.

We report a case of gangrene, which developed following an open fracture of the femur immobilized with an external fixator in a 45-year-old patient. A conventional vacuum dressing (VAC Therapy) could not be applied with the external fixator in place. An original vacuum dressing was thus fashioned after surgical debridement. Scabs were covered with calcium alginate. The lower limb was enveloped in sterile dressings and vacuum was achieved by suction with gastric tubes under adhesive films. The dressing was redone every 48 h in a surgical setting. Antibiotic prophylaxis enabled cure of the infection. Budding appeared within two weeks enabling skin grafting. Centro-medullary nailing was undertaken on day 30 to accelerate bone healing. At three months from the trauma, the initial loss of sensitivity in the leg and foot noted at the first weight bearing required programmed disarticulation of the knee after femur and wound healing. At six months, the patient had resumed his occupational activities and was pain free. This type of dressing could be useful for tissue loss over a fracture immobilized with an external fixator. This type of assembly can easily be installed in the operating room.

[Surgical site infection after total knee arthroplasty: a monocenter analysis of 923 first-intention implantations]. / Infection du site opératoire après arthroplastie totale de genou.

PURPOSE OF THE STUDY: We report the results of a retrospective analysis of 923 cases of first-intention total knee arthroplasties. The objective was to determine retrospectively the rate of surgical site infections, including all infections diagnosed during the first year, and to search for risk factors. We also wanted to present our surveillance system planned for a 10-year period. MATERIAL AND METHODS: From January 1994 to January 2004, first-intention total knee arthroplasty (TKA) was performed on 999 knees. HLS prostheses were implanted. At minimum 12 months, follow-up data was complete for 923 implants which constituted the study group. Female gender predominated (72%). Mean patient was 71 years (range 26-93). Anterior surgery was performed for 25% of the knees. Etiologies were osteoarthritis (87.5%), and rheumatoid polyarthritis (6.9%). Cefazolin was used for systematic preoperative (one injection) and postoperative (48 hr) antibiotic proxphylaxis. Vancomycin was used for patients with a contraindication for cefazolin. Information was collected from two sources: computerized consultation charts for all follow-up visits completed prospectively since 1995 et data collected by the Hygiene and Epidemiology Unit during the year following implantation. Data on surgical site infections was collected from the hospitalization files, outpatient files and control visits. Each case of infection was validated at an annual interdisciplinary meeting. We retained for analysis deep infections requiring revision surgery with identification of the causal agent on the intraoperative samples. We identified a subgroup of infections occurring during the first postoperative year, the delay generally retained for surgical site infections. RESULTS: Twenty surgical site infections after TKA were identified during the 10-year surveillance period (2.1%). Mean follow-up was 43 months (range 12-123 months, median 37 months). The rate of surgical site infections occurring during the first postoperative year was 1.4%. Eighty-percent of the infections (n=16) occurred within the first two postoperative months. Two infections were diagnosed two to five years after surgery and two others more than five years after surgery due to hematogenous contamination. All of the observed infections involved a single causal germ. Agents identified were: Gram+ (90%) and Gram- (10%), with a clear predominance for Staphylococcus aureus (n=9). Infections developed 2.1-fold more often in patients with an inflammatory disease (rheumatoid polyarthritis). Age and body mass index did not differ between patients with and without surgical site infection. CONCLUSION: The analysis of our series demonstrated the difficulties in conducting long-term surveillance.

[Total hip arthroplasty in patients with chronic renal failure transplant or dialysis]. / Arthroplastie totale de hanche chez l'insuffisant rénal chronique greffé ou dialysé.

PURPOSE OF THE STUDY: Total hip arthroplasty (THA) is generally proposed for renal transplant patients with invalidating hip disease. For patients on chronic dialysis, the few published series report a higher rate of complications. These patients are considered more vulnerable. We report the results of a retrospective mid-term analysis of 28 renal failure patients (37 hips) with THA comparing renal transplant recipients with chronic dialysis patients. MATERIAL AND METHODS: THA was performed on 37 hips in 28 patients with renal failure between January 1993 and 2004. Treatment for the renal disease was transplantation or chronic dialysis. Mean patient age at the time of the arthroplasty was 56 years. Nine patients had bilateral THA. At review, four patients had died and none were lost to follow-up. Mean time between transplantation and hip arthroplasty was 9.9 years. Among the fourteen dialysis patients (21 hips), five had had a renal transplant. Mean time from onset of dialysis to arthroplasty was 12.3 years. At mean postoperative follow-up of six years (range 24 months to 12 years), 24 patients were living. Thirty-five hips had no surgical history. Aseptic osteonecrosis was the dominant etiology (75% of operative indications in the graft group and 52% in the dialysis group). The preoperative Postel-Merle-d'Aubigné score was 7.6 in the dialysis group and 10.3 in the graft group. Most of the cups were not cemented (n=31, 84%), as were most of the stems (n=29, 78%). All survivors were reviewed. The PMA score was determined. RESULTS: Early postoperative complications in the dialysis patients were: deep vein thrombosis (n=3), pulmonary embolism (n=4), operative site hematoma (n=2) and immediate septic complication with prompt revision and preservation of the implants (n=1). For the graft group, complications were: early dislocation (n=2), lung disease (n=3). Four patients, all in the dialysis group, died. At review, the mean PMA score was 14.2 in the dialysis patients and 15.7 in the graft patients. There were no radiological signs of loosening, nor of polyethylene wear, and no ectopic ossifications could be identified. There were no late infections. DISCUSSION: In renal transplant recipients, total hip arthroplasty is a reliable treatment for hip disease, providing good mid-term results and a morbidity close to that observed in the general population. Conversely, dialysis patients have a greater perioperative morbidity. Use of non-cemented implants is not associated with a higher rate of loosening than with cemented implants. It can be recalled that this type of surgery must be performed within the framework of careful pluridisciplinary patient management.

Salvaged viscoelastic reduces irrigation frequency during cataract surgery.

A more viscous solution may decrease the need for frequent irrigations to maintain a clear cornea during cataract surgery. Fifty-four consecutive cataract patients were prospectively randomized to receive a drop of viscoelastic or saline on the cornea at the start of surgery. The surgical scrub nurse was instructed to irrigate only when the cornea appeared hazy or at the surgeon's request. The number of irrigations, ultrasound time and energy, and surgery times were compared using the Student's t test. Only one ampoule of viscoelastic was used for each case. When the patients who received viscoelastic were compared with the patients who received saline, the mean numbers of irrigations were 2 and 18, whereas the mean numbers of irrigations per minute were 0.17 and 1.21, highly significant (P < .0001) differences. The duration of surgery, ultrasound time, and ultrasound energy were less with viscoelastic, but were not statistically significant. Viscoelastic on the cornea reduces the frequency of irrigation without increasing cost.