Revision of total ankle arthroplasty: Survival and medium-term functional results.

BACKGROUND: The objective of this study was to analyze the results and survivorship of total ankle arthroplasty (TAA) revision surgery with standard (Salto Talaris®) or revision (Salto Talaris XT®) implants. METHODS: Between January 2005 and December 2017, all patients undergoing TAA revision at our hospital were included. Indications for revision, type of surgery performed, improvement in function assessed with the AOFAS score, occurrence of complications and implant survival at last follow-up were analyzed. RESULTS: In the end, 25 TAA patients who had undergone revision (11 unipolar, 14 bipolar) were included. The mean follow-up time was 5.1 ± 1.9 years. At the last follow-up, function was improved compared to the preoperative AOFAS score (51.3 ± 17.5 vs. 83.5 ± 10.1; p < .001), but not plantar flexion (17.5 ± 5.7 vs. 15.4 ± 7.1; p = 0.28) or dorsal flexion (7 ± 5.6 vs. 8.3 ± 4.9; p = 0.3). Complications occurred in six patients (24 %) that led to reoperation: three infections, one lateral impingement, one implant malposition, and one hindfoot alignment disorder. At the last follow-up, implant survival was 96 %, but the probability of survival without reoperation was 78.7 ± 8.5 % at 4 years. CONCLUSION: TAA revision by arthroplasty is feasible, produces good functional results in the medium term, but has a high risk of complications. The challenge of revision TAA is managing the loss of bone stock and anchoring the new implants.

Perioperative complications and causes of 30- and 90-day readmission after direct anterior approach primary total hip arthroplasty.

We aimed to report causes of readmission 30 and 90 days following a total hip arthroplasty (THA) using the direct anterior approach (DAA). METHODS: Three hundred and two patients (335 hips) underwent a DAA-THA for primary osteoarthritis. RESULTS: The main reasons for 30 and 90-day readmission were wound related problems, dislocation (rate: 0.9%) and deep infection. The readmission rates at 30 and 90 days were 1.8% and 2.7%, respectively. Age over 60 years and morbidly obese patients were at risk for complications. CONCLUSION: The DAA-THA was associated with low readmission rates. Obesity should be adressed preoperatively.

Case of femoral pseudarthrosis due to Scedosporium apiospermum in an immunocompetent patient with successful conservative treatment and review of literature.

Scedosporium apiospermum is a ubiquitous filamentous fungus, commonly found in soil, sewage and polluted waters. It is rarely pathogenic but can cause a broad spectrum of clinical diseases, which can be localised or disseminate to distant organs. The disseminated form of the disease is mostly seen among immunocompromised patients. However, some rare cases of disseminated disease have been reported in immunocompetent individuals. Treatment of these infections is challenging because of their natural resistance to many antifungal agents. Here, we report the case of a 57-year-old immunocompetent patient diagnosed with femoral pseudarthrosis due to S. apiospermum, despite having no obvious clinical sign of infection. Previously, the patient had undergone four iterative femoral surgeries following a road traffic accident which occurred 20 years before. During its last surgery for pseudarthrosis, no clinical or biological signs of infection were present. Per operative samples tested positive for S. apiospermum. The patient was successfully treated with oral voriconazole during 6 months with an excellent tolerance. We also provide a review of literature on bone and joint infections due to Scedosporium spp. (S. apiospermum, Scedosporium boydii and Scedosporium aurantiacum), discussing the evolution of their management and outcome which seems to improve since the use of voriconazole.

Clinical, histological, and biochemical predictors of postsurgical neuropathic pain.

Surgical nerve injury sometimes leads to chronic postsurgical neuropathic pain (CPSNP). The risk factors for this condition are not well understood. We prospectively assessed 46 patients scheduled for iliac crest bone harvest, 2 days (D2) and 3 months (M3) after surgery, to determine the time course of nerve fiber degeneration and expression of the TNF-α and NGF genes in skin punch biopsies. Mechanical and thermal detection and pain thresholds were evaluated at D2 and M3, by quantitative sensory testing. Skin punch biopsies were also obtained from the thighs ipsilateral and contralateral to iliac crest bone harvest. Intraepidermal nerve fiber density (IENFD) and cutaneous TNF-α and NGF gene expression were analyzed. Forty-five volunteers matched for age, sex, skin color were examined as controls. Chronic postsurgical neuropathic pain was defined as pain in an area of hypesthesia with a positive Douleur Neuropathique 4 questionnaire score. Overall, 73% (N = 32) of patients developed hypesthesia and 40% (N = 13) of these patients had developed CPSNP at M3. Quantitative sensory testing results, IENFD, and skin TNF-α and NGF gene expression at D2 and M3 did not differ between patients with and without CPSNP. However, in patients with CPSNP, burning, compression, and pain provoked by brushing were correlated with IENFD at M3, suggesting a possible association between partial nerve lesions and more intense CPSNP, than with total nerve lesion. Furthermore, preoperative pain and opioid use were higher in patients who developed CPSNP than in those without CPSNP. These findings suggest that the predictors of CPSNP development are clinical rather than histological or biochemical.

A controlled, comparative study of a fixed-bearing versus mobile-bearing ankle arthroplasty.

BACKGROUND: Total ankle arthroplasty is available with fixed-bearing (FB) or mobile-bearing (MB) versions, and there is little consensus on the benefits and drawbacks of each type. This study aimed to compare clinical outcomes of statistically paired series of FB and MB versions of the same ankle prosthesis. METHODS: The study was a multicenter retrospective comparison between 2 groups: the FB group of 33 consecutive Talaris cases and the MB group of 33 "paired" Salto cases, selected from a database of 313 consecutive cases to statistically match etiology, age, and preoperative American Orthopaedic Foot & Ankle Society (AOFAS) score. All patients were operated upon with the same operative technique and received identical pre- and postoperative clinical and radiographic assessments. The mean follow-up was 24 months for the FB group and 23 months for the MB group. RESULTS: There was no statistical difference between results of the 2 groups in terms of accuracy of positioning, clinical and radiographic mobility, and morbidity. The most recent postoperative AOFAS scores were higher for the FB group than for the MB group (P = .05). Radiolucent lines were observed in 4 FB patients versus 13 MB patients (P = .02). Subchondral cysts were noted in 1 FB patient and in 8 MB patients (P = .01). CONCLUSION: There was no notable difference in clinical performance of the FB and MB implants with the numbers available. This short-term study demonstrated that FB ankle arthroplasty had results equivalent to, if not better than, MB ankle arthroplasty. Longer follow-up is necessary to determine the success of this new generation of ankle arthroplasty. LEVEL OF EVIDENCE: Level III, retrospective case control study.

Mini-invasive technique for bone patellar tendon bone harvesting: its superiority in reducing anterior knee pain following ACL reconstruction.

Arthroscopically-assisted ACL-reconstructions are currently reliable, reproducible. Residual anterior knee symptoms however, especially after patellar-BTB graft use, are not uncommon occurrences. Contributing factors are numerous and include injury to the saphenous nerve infrapatellar branches and/or histologic changes at the harvest site. The use of mini invasive harvesting technique decreases the risk of injury to the saphenous nerve infrapatellar branches while preserving the peritenon. The double-incision approach significantly reduces the mid-term incidence of anterior knee pain after ACL-reconstruction. Additionally, this technique markedly decreases the occurrence of sensory disorders and the extent of hypoesthesia. We thus advocate the use of a double-incision graft harvesting technique in ACL-reconstruction using a patellar-bone-tendon-bone transplant.

The Salto total ankle arthroplasty: survivorship and analysis of failures at 7 to 11 years.

BACKGROUND: Despite the appearance of new-generation, mobile-bearing, cementless prostheses, total ankle arthroplasty remains controversial. Among the criteria guiding the choice between arthrodesis and arthroplasty, the long-term survival and postoperative function are of critical importance. The mobile-bearing Salto prosthesis has been used in Europe since 1997, but only 2 to 5 years of followup data have been reported. QUESTIONS/PURPOSES: We analyzed the longer-term survivorship and causes of failures of the Salto prosthesis in a cohort of previously studied patients. We asked whether this prosthesis provided a functional ankle (AOFAS score) and durable radiographic fixation. PATIENTS AND METHODS: We retrospectively reviewed 96 prospectively followed patients with 98 prostheses implanted between 1997 and 2000. Of those, 85 patients (87 prostheses) had a minimum followup of 6.8 years (mean, 8.9 years; range, 6.8-11.1 years). RESULTS: The survival rate was 65% (95% CI, 50-80) with any reoperation of the ankle and 85% (95% CI, 75-95) with revision of a component as the end points. Six prostheses were removed for arthrodesis, and 18 ankles underwent reoperation without arthrodesis. We observed three main causes of reoperations: bone cysts (11 patients), fracture of the polyethylene (five patients), and unexplained pain (three patients). The mean AOFAS score was 79 ± 12 points. Radiographic subsidence was observed in three patients and bone cysts in eight patients. CONCLUSIONS: Our data suggest a high rate of reoperations but only six revisions with arthrodesis with mid-term followup. We observed few patients with loosening and/or subsidence. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Aseptic Osteonecrosis of the Humeral Head After Anterior Shoulder Dislocation.

Anterior shoulder dislocation is a very common trauma and the main complications are well documented. We report a case of aseptic osteonecrosis of the humeral head following an isolated episode of anterior glenohumeral dislocation without fracture that, to our knowledge, has never been reported in the literature.A 17-year-old male patient sustained an anterior glenohumeral dislocation following a sport accident. It was managed by reduction and immobilization. A radiologically identified aseptic osteonecrosis appeared 6 months later. The instability had been arthroscopically treated. At a follow-up of 4 years, the osteonecrosis has been stabilized leaving a mild arthrosis with stiffness, but without pain.