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AimsThe 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 vitromedium environment against methicillin-sensitive Staphylococcus aureus(MSSA).Materials and MethodsTen 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.ResultsMSSA 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.ConclusionCompared 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 J2019;101-B:848–851.

L’incidence des fractures fémorales péri-prothétiques (FPP) de hanche est en augmentation constante avec une morbi-mortalité élevée. La prise en charge chirurgicale est guidée par la classification de Vancouver mais l’influence du type de traitement sur la morbi-mortalité reste mal décrite. L’avantage théorique de la révision prothétique par rapport à l’ostéosynthèse est d’autoriser une remise en charge plus précoce, sans que cette possibilité n’ait démontré un intérêt sur la morbi-mortalité et l’autonomie. Nous avons mené une étude cas-témoin afin d’évaluer : 1) l’influence du type de traitement (révision prothétique ou l’ostéosynthèse) sur la mobilité et l’autonomie, 2) la morbi-mortalité.

La littérature récente décrit des potentiels facteurs mécaniques dans le développement et l’aggravation de l’ostéonécrose de la tête fémorale (OTF), mais ceci n’a pas été confirmé par des études mécaniques spécifiques. Aussi nous avons mis au point un modèle 3D par éléments finis à partir de données in vivo sur des patients souffrant d’OTF débutante afin de déterminer si la zone de nécrose se superposait à celle des contraintes maximales au niveau de la tête fémorale.

Pour optimiser le positionnement des cupules prothétiques, les relations entre l’équilibre sagittal du rachis et l’orientation acétabulaire sont fréquemment investiguées. Cependant, il n’a pas encore été démontré de corrélation entre l’incidence pelvienne (IP) et l’orientation acétabulaire anatomique. Aussi, nous avons mené une étude radiologique afin : (1) d’établir des corrélations entre l’IP et les paramètres anatomiques acétabulaires ; (2) de décrire l’angle sacropubien (ASP), formé à partir de repères osseux pelviens fixes et ses relations avec la version acétabulaire ; (3) d’établir si les données anatomiques (IP, ASP) étaient corrélées aux données démographiques.

Les interventions préalables aux prothèses totales de genou (PTG) compliquent la technique opératoire et peuvent modifier le devenir de l’arthroplastie. Notamment les taux de survie des PTG après un antécédent traumatique ou chirurgical ne sont pas connus avec précision sur de larges séries. Cette étude rétrospective portant sur 263 PTG avec antécédent traumatique ou chirurgical au recul maximal de 10 ans avait pour objet d’évaluer : (1) la survie, (2) les résultats fonctionnels, (3) la nature et la fréquence des complications.

Le positionnement cinématique (KA) des implants actuels de prothèse totale de genou (PTG) génère une trochlée prothétique aux paramètres morphologiques différents de ceux qui seraient obtenus après un positionnement mécanique (MA). L’objectif de notre étude était de tester les hypothèses suivantes : (1) l’implantation mécanique ou cinématique d’un composant fémoral génère, comparativement à la trochlée native, un sous-encombrement de la surface articulaire et un sillon trochléen orienté plus en valgus ; (2) les paramètres morphologiques prothétiques diffèrent selon que le composant fémoral est positionné MA ou KA.

Le indicazioni dell'artroscopia dell'anca sono aumentate in questo ultimo decennio con la conoscenza maggiore del conflitto femoro-acetabolare e sembra oggi difficile per un chirurgo dell'anca non imparare a utilizzare questo strumento. Come ogni nuova tecnica, il chirurgo deve conoscere le basi anatomiche e il materiale necessario prima di lanciarsi. Lo scopo di questo articolo è affrontare punto per punto tutto quello che il chirurgo deve conoscere prima di iniziare: deve disporre di specifici strumenti artroscopici, di un tavolo ortopedico la cui installazione deve essere molto rigorosa se si vuole realizzare questo intervento evitando le complicanze della trazione. Gran parte della tecnicaoperatoria è specifica dell'anca, con vie di accesso particolari e sollecitazioni di distrazione per raggiungere la parte centrale, cartilaginea. Questa chirurgia ha pertanto una specifica curva di apprendimento, sicuramente più breve se si ègià un chirurgo specializzato in artroscopia preparato in altre articolazioni, ma che deve idealmente iniziare in laboratorio di anatomia e proseguire con un periodo di affiancamento.

Les résultats fonctionnels des prothèses totales de genou mécaniquement alignées (PTG MA) sont bons mais insuffisants, et l’amélioration de la qualité des implants et des techniques de pose ne semble pas avoir eu un effet bénéfique significatif. Cela suggère l’existence probable de limitation(s) technique(s) intrinsèque(s) et donc le développement de techniques alternatives de positionnement (ou d’alignement) des implants PTG. Cette revue vise à classer les différentes philosophies d’alignement des implants PTG et à répondre aux questions : (1) les techniques alternatives de positionnement ont amélioré les résultats fonctionnels des PTG ? (2) Existe-t-il une anatomie non adaptée à l’implantation cinématique d’une PTG ? Une revue systématique de la littérature existante en utilisant les moteurs de recherche PubMed et Google Scholar a été réalisée en février 2017. Seules les études publiées en anglais ou en français dans des revues évaluées par des pairs et au cours des dix dernières années ont été examinées. Nous avons identifié 569 articles dont 13 répondent à nos critères d’éligibilité. Quatre techniques alternatives remettent en question la technique traditionnelle d’alignement mécanique d’une PTG : techniques d’alignement anatomique (AA), mécanique ajustée (aMA), cinématique (KA) et cinématique restreinte (rKA). L’analyse de littérature suggère que la technique KA permettrait une récupération plus rapide et générerait des résultats fonctionnels supérieurs à ceux de la technique conventionnel MA. Bien que les études comparatives publiés ont inclus des patients ostéoarthritiques sans déformation frontale sévère du membre, l’analyse de la littérature n’a pas permis de définir une anatomie impropre à la réalisation de la technique KA. La technique d’alignement cinématique semble améliorer les résultats fonctionnels des PTG ; néanmoins un suivi à plus long terme est requis afin d’évaluer sa valeur réelle. Il est probable que certaines formes anatomiques puissent être peu favorable à la réalisation d’une technique KA en affectant les résultats cliniques ; dans ces cas précis, la réalisation parallèle d’une ostéotomie de réalignement ou la réalisation d’une technique rKA semblerait pertinente. La valeur et les indications de chacune des techniques alternatives restent à définir.

L’ostéotomie tibiale de valgisation (OTV) est une technique efficace pour le traitement de la gonarthrose médiale isolée, mais la détérioration reste inéluctable. La prothèse totale de genou (PTG) est alors une option. L’objectif de ce travail était de comparer les PTG après OTV par ouverture médiale ou fermeture latérale en termes de données techniques peropératoires et de résultats cliniques. L’hypothèse était qu’il n’apparaissait pas de différence entre les PTG après OTV par ouverture ou fermeture pour les résultats cliniques et les complications.

L’injection intra ou périarticulaire de ropivacaïne (RI) est courante après chirurgie du genou. Le but de cette étude était d’évaluer les effets de la RI sur les propriétés mécaniques (PM) du tissu ischio-jambier.

Les prothèses totales de genou (PTG) implantées selon la technique d’alignement mécanique (AM) génèrent des résultats fonctionnels bons mais insuffisants. Ces résultats n’ont pas été significativement améliorés par l’amélioration de la qualité des implants et des techniques de pose, suggérant l’existence de probables limitations intrinsèques affectant la technique AM. Notre étude vise à mesurer les différences entre les surfaces articulaires trochléennes native et prothétique, et à estimer la fréquence et l’ampleur du déséquilibre du genou techniquement non corrigible par un geste de libération des ligaments collatéraux, lorsque les implants PTG sont alignés mécaniquement.

La prise en charge des arthroses fémoro-tibiales médiales par ostéotomie tibiale de valgisation (OTV) est d’autant plus efficace que la correction angulaire est optimale. L’instrumentation conventionnelle est limitée lorsque qu’une correction dans plusieurs plans de l’espace est nécessaire.

La gestion des pertes de substances osseuses (PSO) importantes est un enjeu majeur des révisions de prothèse totale du genou (RPTG). Les cônes en métal trabéculaire de tantale (TM™) semblent optimiser la fixation prothétique grâce à la reconstruction métaphysaire. Les objectifs de ce travail étaient d’évaluer lors des RPTG avec cônes de tantale : les résultats radiologiques, les complications, et les résultats cliniques.

Partial knee arthroplasty (PKA), either medial or lateral unicompartmental knee artroplasty (UKA) or patellofemoral arthroplasty (PFA) are a good option in suitable patients and have the advantages of reduced operative trauma, preservation of both cruciate ligaments and bone stock, and restoration of normal kinematics within the knee joint. However, questions remain concerning long-term survival. The goal of this review article was to present the long-term results of medial and lateral UKA, PFA and combined compartmental arthroplasty for multicompartmental disease. Medium- and long-term studies suggest reasonable outcomes at ten years with survival greater than 95% in UKA performed for medial osteoarthritis or osteonecrosis, and similarly for lateral UKA, particularly when fixed-bearing implants are used. Disappointing long-term outcomes have been observed with the first generation of patellofemoral implants, as well as early Bi-Uni (ie, combined medial and lateral UKA) or Bicompartmental (combined UKA and PFA) implants due to design and fixation issues. Promising short- and med-term results with the newer generations of PFAs and bicompartmental arthroplasties will require long-term confirmation.Cite this article: Bone Joint J2015;97-B(10 Suppl A):9–15.

La mobilité finale en flexion, après la mise en place d’une place d’une prothèse totale de genou (PTG), est un facteur important pour le confort du patient. Certains patients ont un gain de flexion, d’autres non. Existe-t-il des facteurs propres au patient qui permettent de prévoir le gain de flexion ?

Les techniques d’arthroplastie bicompartimentales (BC) ont été développées dans le but de traiter une arthrose bicompartimentale fémoro-tibiale médiale et fémoro-patellaire du genou tout en conservant les ligaments croisés antérieurs pour conserver au maximum la cinématique du genou. Les objectifs de cette étude prospective contrôlée appariée étaient : (1) de comparer le taux de genoux « oubliés » et (2) les résultats fonctionnels des patients porteurs de BC et de PTG avec un suivi minimum de 2ans. Notre hypothèse était que les patients porteurs de BC modulaires modernes auraient de meilleurs résultats fonctionnels que ceux porteurs d’une prothèse totale de genou à un recul minimum de 2ans pour des états anatomiques et des dégénérescences arthrosiques similaires.

Les cols modulaires en titane sont exposés au risque de corrosion et de rupture et bien qu’ils soient utilisés depuis la fin des années 1980, leur sécurité, remise en cause récemment, n’a pas été évaluée sur une série continue. Le but cette étude était d’évaluer : (1) la survie sans révision de ces implants après un recul minimal de 5ans, (2) les résultats cliniques et radiographiques, (3) les complications potentielles liées à l’utilisation de cols modulaires en titane.

En novembre 2011, la Knee Society publiait le nouveau score IKS, évaluant avant et après la prothèse totale de genou (PTG), les données cliniques objectives, mais aussi les attentes des patients, leur satisfaction, et la fonction du genou à travers des activités physiques variées. Nous avons entrepris son adaptation transculturelle en langue française selon les recommandations actuelles.

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 (sd2.9), 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.Cite this article: Bone Joint J 2014;96-B:1041–6

Substantial healthcare resources have been devoted to computer navigation and patient-specific instrumentation systems that improve the reproducibility with which neutral mechanical alignment can be achieved following total knee replacement (TKR). This choice of alignment is based on the long-held tenet that the alignment of the limb post-operatively should be within 3° of a neutral mechanical axis. Several recent studies have demonstrated no significant difference in survivorship when comparing well alignedversusmalaligned TKRs. Our aim was to review the anatomical alignment of the knee, the historical and contemporary data on a neutral mechanical axis in TKR, and the feasibility of kinematically-aligned TKRs. Review of the literature suggests that a neutral mechanical axis remains the optimal guide to alignment.Cite this article: Bone Joint J2014;96-B:857–62.

L’esecuzione di un’artroplastica totale dell’anca in ragione di una lussazione congenita rappresenta probabilmente tutt’oggi una delle sfide più insidiose che si possano affrontare nel campo dell’artroplastica primaria dell’anca. È opportuno capire i desideri funzionali del paziente, talvolta poco realistici, analizzare i disturbi anatomici, servendosi anche di radiografie, e prevedere le eventuali complicazioni. La conclusione delle indagini deve permettere una pianificazione rigorosa e dettagliata. Tale documentazione comprende una radiografia frontale del bacino, che consenta di stabilire la gravità della lussazione, radiografie frontali e laterali dell’anca, una telemetria frontale, se possibile da supini e, in funzione dell’esame clinico, una radiografia del rachide, del piede (equino varo) e una telemetria laterale (deformità in flessione). L’analisi dell’allungamento dell’arto, spesso diversa da una semplice valutazione della differenza di lunghezza, deve essere rigorosa. È utile avere a disposizione uno scanner che permetta analisi 3D. Si può procedere secondo la classica via chirurgica, anche se, storicamente, la via transtrocanterica è quella maggiormente descritta. Si deve prevedere una trocanterotomia nel caso in cui essa permetta un più facile accesso al paleocotile o se il grande trocantere necessita di essere riposizionato. A livello del cotile, sono spesso necessari degli impianti di dimensioni ridotte e un innesto nella parte superiore; a livello femorale, invece, può essere utile ricorrere a impianti miniaturizzati. È inoltre importante occuparsi dell’antiversione femorale, che è molto variabile e nella maggior parte dei casi diversa dall’antiversione protesica definitiva. Nel caso si faccia ricorso a uno stelo senza cemento, la radiografia consente di prevedere l’utilità di uno stelo a collo modulare, se non addirittura su misura. Tenendo conto di tutte le specificità elencate, il risultato funzionale viene spesso valutato come “miracoloso” da pazienti con handicap preoperatori importanti e datati, nonostante il tasso di insorgenza di complicazioni sia più elevato rispetto alla globalità delle protesi totali dell’anca.

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.

We retrospectively reviewed 35 cemented unicompartmental knee replacements performed for medial unicompartmental osteoarthritis of the knee in 31 patients =50 years old (mean 46, 31 to 49). Patients were assessed clinically and radiologically using the Knee Society scores at a mean follow-up of 9.7 years (5 to 16) and survival at 12 years was calculated. The mean Knee Society Function Score improved from 54 points (25 to 64) pre-operatively to 89 (80 to 100) post-operatively (p < 0.0001). Six knees required revision, four for polyethylene wear treated with an isolated exchange of the tibial insert, one for aseptic loosening and one for progression of osteoarthritis.The 12-year survival according to Kaplan-Meier was 80.6% with revision for any reason as the endpoint. Despite encouraging clinical results, polyethylene wear remains a major concern affecting the survival of unicompartmental knee replacement in patients younger than 50.

We have evaluated in vitrothe accuracy of percutaneous and ultrasound registration as measured in terms of errors in rotation and version relative to the bony anterior pelvic plane in computer-assisted total hip replacement, and analysed the intra- and inter-observer reliability of manual or ultrasound registration.Four clinicians were asked to perform registration of the landmarks of the anterior pelvic plane on two cadavers. Registration was performed under four different conditions of acquisition. Errors in rotation were not significant. Version errors were significant with percutaneous methods (16.2°; p < 0.001 and 19.25° with surgical draping; p < 0.001), but not with the ultrasound acquisition (6.2°, p = 0.13). Intra-observer repeatability was achieved for all the methods. Inter-observer analysis showed acceptable agreement in the sagittal but not in the frontal plane.Ultrasound acquisition of the anterior pelvic plane was more reliable in vitrothan the cutaneous digitisation currently used.

A clinical and radiological study was conducted on 97 total hip replacements performed for congenital hip dislocation in 79 patients between 1989 and 1998 using a three-dimensional custom-made cementless stem. The mean age at operation was 48 years (17 to 72) and the mean follow-up was for 123 months (83 to 182).According to the Crowe classification, there were 37 class I, 28 class II, 13 class III and 19 class IV hips. The mean leg lengthening was 25 mm (5 to 58), the mean pre-operative femoral anteversion was 38.6° (2° to 86°) and the mean correction in the prosthetic neck was -23.6° (-71° to 13°). The mean Harris hip score improved from 58 (15 to 84) to 93 (40 to 100) points. A revision was required in six hips (6.2%). The overall survival rate was 89.5% (95% confidence interval 89.2 to 89.8) at 13 years when two hips were at risk.This custom-made cementless femoral component, which can be accommodated in the abnormal proximal femur and will correct the anteversion and frontal offset, provided good results without recourse to proximal femoral corrective osteotomy.

The aim of the present study is to set out our thirty-year experience in conservative surgical management of developmental dysplasia of the hip (DDH) in the young adult, using either periacetabular or intertrochanteric osteotomies.All the patients have the same radiographic assessment which allows evaluating the lateral center edge angle, the obliquity of the acetabular roof by the HTE and the anterior centre edge angle. According to the Hip Study Group classification, hips were classified as average DDH when VCE and VCA are between 25° and 21°, severe between 20° and 5° and extreme below 5°. The study of the articular congruency is conducted through the surgical profile evaluating the S/FH ratio (S=projected acetabulum surface, FH=1/2 projected femoral head surface) and recentring radiographs by abduction. The presence of osteoarthritis is evaluated according to Tönnis. An additional CT-scan with intraarticular injection may actually be realized. No hip arthroscopy was performed.Several original modifications have been realized, including a single intrapelvian approach allowing all the cuts and a modification of the ischial cut (“2/3 PAO”) in order to leave the posterior horn attached to the ischium when the S/FH ratio is below 3/4. The femoral posterior head coverage is then not modified whereas the periacetabular fragment is moved anteriorly.In our experience, PAO is an effective procedure for patients under 30 years of age without intraarticular damage and with average or severe DDH, to avoid a total hip arthroplasty in the future. For patients over 30 years old with a beginning of osteoarthritis or extreme DDH, it seems reasonable to avoid a major operation and maybe to consider less invasive techniques to delay a total hip arthroplasty.

The anatomical deformities encountered in osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH) may lead to some technical difficulties when performing total hip arthroplasty The aim of this study is to present our experience in anatomical analysis of OA following DDH and its treatment using cementless THA with a customized stem and a reinforcement ring.In anatomic X-rays and CT-scan studies of 83 hips with osteoarthritis following DDH, a great individual variability was shown despite the subluxation class considered with a reduced mediolateral and anteroposterior dimensions of the intramedullary femoral canal in all groups. Greater anteversion (ranging from 2° to 80°) in all the DDH groups and a femoral neck shaft angle increased only for femora of class II were found. Another group of 116 luxations of the hip was clinically followed. Clinical outcome was found to be not correlated with the severity of luxation. The problems encountered to restore the center of rotation in THA for DDH correlated well with the severity of dislocation. The postoperative limp was correlated with a vertical position of the acetabular component of more than 35 mm from the interteardrop line. Taking into consideration hip revision for stem or acetabular replacement, the cumulative survival rate was 94.7% ± 2.7% at 12 years.Cementless custom stem is certainly a step forward in the future of hip arthroplasty in a young and active population with DDH to probably include in a preoperative and intraoperative computer assisted surgery

Using radiography and computer tomography (CT) we studied the morphology of 83 hips in 69 Caucasian adults with osteoarthritis secondary to developmental dysplasia of the hip (DDH). A previously published series of 310 hips with primary osteoarthritis was used as a control group. According to the Crowe classification, 33 of the dysplastic hips were graded as class I, 27 as class II and 23 as class III or class IV.The intramedullary femoral canal had reduced mediolateral and anteroposterior dimensions in all groups compared with the control group. Only in Crowe class II hips was the femoral neck-shaft angle increased. The proximal femur had more anteversion in all the developmental dysplasia of the hip groups, ranging from 2° to 80°. Templated measurement of acetabular dimensions for plain radiography closely matched measurements taken by CT.The results of our study confirm the observations previously confined to the Japanese population.