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Introduction High rates of polyethylene wear in metal-on-polyethylene-bearing surfaces correlate with peri-prosthetic osteolysis and early loosening. Hard-bearing surfaces have been used as they may decrease the production of debris and improve survival of the prosthesis. The aim of this study is to ascertain the rate of early loosening of a polyethylene cemented acetabular component with a metal-on-metal (MOM) insert.

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The aim of this study was to report cases of acetabular failure of metal-on-metal total hip arthroplasties using cemented cups with a metal-metal bearing.From 1997 to 1999, 137 patients underwent total hip arthroplasty with a 28-mm head and a metal-metal (Metasul) bearing. At mean follow-up of three years eight months (range 2-6 years), three patients had died and thirteen were lost to follow-up or had less than 2 years follow-up. The analysis thus included 118 patients (122 hips) 67 women and 51 men (mean age 61 years). The same transgluteal approach with two cemented implants (Palacos gentamycine) was used in all patients. The Postel-Merle-d'Aubigné score was used for clinical assessment with search for lucent lines in the Delee and Charnley zones and cup migration on the standard x-rays. Actuarial survival curves were drawn using revision and failure as the end events.In this series, there were no cases of dislocation or infection but there were five revisions for aseptic cup loosening: one at two years, two at four years, and two at five years. Among the remaining 117 implants, outcome was clinically very good in 101, good in 10 and fair in 6. Radiologically, there were no cases of femoral lucent lines, migration or osteolysis. For the cup, a lucent line measuring less than 1 mm and stable was observed in 81 hips. A progressive lucent line was observed in 18 hips with 11 showing signs of probable loosening. The five-year survival using surgical revision as the endpoint was 94%. Using cup failure (revision and progressive line), it was 80%. Revisions and radiographically probable loosenings were statistically more significant in small cups measuring 44 and 46 mm.In this series, cemented metal-on-metal bearings showed a rate of failure greater than observed in metal-polyethylene implants and metal-on-metal implants using a press fit cup. Other series using a metal-on-metal bearing with a cemented cup have found the same trend.We have discontinued this type of implant and recommend avoiding direct cementing of the polyethylene-metasul cup on the bone for total hip arthroplasty. The metal-on-metal bearing can still be used, but without cementing the cup.

The purpose of this study was to evaluate the 10-year results of the cemented Müller straight stem total hip prosthesis with polyethylene cup and 28 mm head.From May 1988 to May 1990, 187 cemented prostheses (second-generation technique) were implanted via a transgluteal approach for degenerative hip disease. A Protasul 10 straight stem with a 28 mm modular head and a gamma ray sterilized polyethylene cup was used in all cases. At ten years, the follow-up of the 187 implants was: 60 implants in deceased patients, 24 implants in patients contacted by telephone (all with implants in place), 90 implants in 82 patients seen for review. The series thus included 40 women and 42 men, mean age 65 years. The clinical outcome was assessed with the Postel Merle d'Aubigné (PMA) score. Radiographic assessment noted lucent lines, granulomas, implant migration, polyethylene wear, and ossifications. Survival curves were established with the actuarial method.Among the 187 implants, two patients required revision: one for sepsis and the other for posttraumatic dislocation. Among the 82 patients reviewed at 10 year, the PMA score was 16.8 (92% good and very good results). Radiographically, assessment of the acetabular component demonstrated three probable and one certain loosening, four cases of polyethylene wear greater than 2 mm. At the femoral level, osteolysis was noted in zones 1, 3, and 7 and rarified bone in zone 7 in four patients. Linear penetration of the stem into the cup was 0.09 mm/yr, corresponding to a volumetric wear of 55, 35 mm3/year. Brooker grade 3 ossification was observed in 27% of men and 14% of women.The clinical results were comparable to other series of cemented prostheses. At ten years, acetabular loosening was more frequent with active radiolucent lines present from the fifth year. It would thus appear that better results could be achieved by optimizing the bearing. Furthermore, there was no parallelism between the clinical and anatomic observations, cup loosening and femoral osteolysis were well tolerated. The prevention of ossification appears to be an important point, particularly in men.

The primary and secondary stability of a revision implant is highly compromised in cases with important loss of bone stock from the proximal femoral after severe femoral loosening. Several methods using implants with or without cement have been proposed for reconstruction after femoral bone loss. The purpose of this study was to analyze mid-term clinical and radiological outcome with the Wagner prosthesis for revision surgery.Fifty-two cases of aseptic femoral loosening were treated with this method in 36 women and 14 men, mean age 70 years (range 32-92 years). None of the patients was lost to follow-up; five who died after 18 months were retained for analysis. Mean follow-up was 44 months (range 18-88 months). The mean preoperative Postel Merle d'Aubigné (PMA) score was 10.5 +/- 0.4. These patients had major bone loss (5 grade II, 24 grade III, 23 grade IV in the SOFCOT classification). The transfemoral access was used in 17 cases and bone grafts in 32. Clinical outcome was assessed with the PMA score and leg length discrepancy was measured. Radiographically, stability was assessed by measuring stem impaction and progression of radiolucent lines.The overall functional score was significantly improved from 10.5 +/- 0.4 preoperatively to 14.6 +/- 0.5 (p0.001). All items on the score improved but pain relief was the most notable. Improvement in the gait score was limited due to persistent limping in 39 patients. Leg length discrepancies were found in 8 patients with 6 shortenings and 2 lengthenings. The clinical situation remained stable after one year. The implant remained stable in 48 patients (92 p. 100) and stem impaction was observed in 4 before 12 months. Two of these cases required a second revision. Metaphyseal reconstruction was observed in 42 patients (81 p. 100), including 24 (46 p. 100) who exhibited homogeneous reconstruction with trabeculation. The reconstruction did not progress further after 18 months postoperatively. Complications included four dislocations and five revision procedures (three for cup loosening, two for femoral pivot instability).The functional outcome was similar to results reported in the literature, including the high frequency of limping that was caused by various factors (valgus prosthesis neck, leg length discrepancy, muscle deficits). Leg length discrepancies resulted from defective positioning or impaction at loading. Standard radiographic series allowed an assessment of stem impaction. Our low rate could be due to delayed weight bearing. La reconstruction of bone loss did not progress after 18 months and was independent of bone grafting, route of access, and the initial degree of loosening. The high frequency of dislocations with this type of implant can be prevented by horizontalization of the acetabulum and use of anti-dislocation inserts at the first intention revision.Our results with the Wagner prosthesis are satisfactory both clinically and radiographically. The two drawbacks of this implant (limping and dislocation), partly due to the design of the femoral stem, have led us to study a new implant that preserves good distal anchoring and optimizes the proximal biomechanics of the hip joint.

A case of intraosseous xanthoma in a patient with a normal lipid profile is reported. Hyperlipidemia is present in most patients with xanthomas. Intraosseous xanthomas are rare, particularly in normolipidemic patients, in whom the presenting symptom is pain without skin lesions. A lytic lesion with a rim of sclerosis is seen on radiographs. Histology shows foam cells, giant cells, and fibrosis. Intraosseous xanthoma is a benign tumor, and other diagnoses must be ruled out (histiocytosis X, Erdheim Chester disease, clear cell carcinoma metastasis). Surgical excision of the lesion is the elective treatment.

We have developed a 3D computed model of the knee joint, constructed from MRI acquisitions in a living individual. We have used this model to perform an anatomic and biometric study of the posterior cruciate ligament (PCL) during flexion, and an assessment of the optimal location for an intraarticular graft. The method used a 3D computed model constructed from MRI acquisitions during knee flexion (0 to 75 degrees). The range of motion was limited by a positioning device. We took 13 acquisitions from 0 to 75 degrees of flexion. Each acquisition consisted of 21 sagittal cross sections of 3 mm slice thickness. We used the Delaunay reconstruction to obtain a 3D geometric model. A matching process to fix one part of the articulation during the movement, allows for the kinematic analysis of the tibia relative to the fixed femur. This model allows to follow the displacement of a bone point during knee flexion. Knowing the relative displacement of the bone insertions of the ligament, it may be possible to determine the length of the PCL and its bands, to evaluate the length variation during movement, and to determine the optimal location for the insertion of an intraarticular graft, that would lead to the least stretch during flexion. It was found that the mean length of the PCL was 30.2 mm, with the posterior band being 30% longer than the anterior band. During flexion the posterior band increases its length by 10% at 50 degrees flexion, and by 20% at 75 degrees flexion. The anterior band stretches more, to reach 40% elongation at 75 degrees flexion. The best position for insertion of a graft seems to be in the posterolateral portion of the anatomic tibial insertion, and posterior to the anatomic femoral insertion. This method confirms the data in the literature, states precisely the length of the different bands of the PCL, and specifies the points of insertion for a graft, which lead to the least variation in length during flexion.

The aim of this study is to suggest an anatomic study of the modifications of the length of the anterior cruciate ligament (ACL) and its bundles during flexion with the aid of a 3D computerized model of the knee in a living subject. The method of evaluation suggested is a 3D computerized reconstruction based on MRI sections, reproducing the movement of flexion of the knee from 0 to 75 degrees. Twenty-one sections were made for each of the 13 positions of flexion. The reconstruction of Delaunay and the realignment of each position provided a 3D model which allowed monitoring of a bony point during the movement. By knowing the relative displacement of the ligamentous attachments it was possible to define the biometry of the ligament by calculating the length of the bundles of the ACL in each position and to demonstrate the variations in length during the movement. The mean length of the ligament was 3.4 mm. The anteromedial bundle was longer by 30% compared with the other two bundles. During flexion the anteromedial bundle was not much modified (this feature seems to provide a reference position for a ligamentoplasty), the posterolateral bundle became taut after 30 degrees, and the intermediate bundle relaxed from the beginning of movement. Based on the data from the literature, this method allows an anatomic approach to the ACL, bundle by bundle, during flexion movement.

A clinical and radiological assessment was performed on 32 Freeman polyethylene uncemented acetabular cups, at an average of 9 years follow up. This study was dedicated to analyze polyethylene bone direct fixation.Between 1984 and 1988, 30 patients were operated for 32 total hip prostheses. Mean age of the population at the time of surgery was 66 years. In all cases the prosthesis was a cemented Müller femoral stem with a Freeman uncemented cup. The acetabular component was made with polyethylene with three pegs fitted with an offset hemispheric cup.All patients were reviewed at 1, 3, 5 years and maximal follow-up. Their functional evaluation was performed using Merle d'Aubigné's hip rating scale: pain score, motion score and walking score. Radiological assessment was performed to identify acetabular cup migration, bone lysis, and radio lucency. Revision for acetabular cup loosening was compiled.Five patients died, 27 THA were evaluated at maximum follow-up. Seven revisions were performed after the fifth years. Merle d'Aubigné's score was 14 at the time of revision. X-rays evidenced more than 5 mm migration of the cup, with massive bone lysis. Merle d'Aubigné's score was 16 for the 20 remaining THA. Radiologically, 10 cups showed migration less than 3 mm, five of which with lysis. Among the 10 cups without migration, 5 showed sclerosis near the acetabulum. The study evidenced that cases of migration exceeding 5 mm induced a revision during the next 3 years.Our study confirms failure of bone polyethylene direct fixation, with 25 per cent of revision after a five years period. This seems to be the result of micro movement, wear and bone lysis. A five years follow up is not sufficient to evaluate a component, since all revisions were performed after five years. For many authors, radiological evaluation of acetabular component migration is an important criterion for uncemented prosthesis. The EBRA computerized method is an accurate method for determining early migration, and can be used for pro and retrospective studies.Our study confirms a high rate of failures of the Freeman uncemented cup at an average of nine-year period, as previously reported in literature.

Plain radiograms are insufficient to evaluate the integrity of a graft used to replace acetabular tissue loss in reoperations for total hip replacement. The aim of this work was to compare radiographic, computed tomographic and magnetic resonance imaging findings. Two groups of patients including 12 hip joints in each were evaluated 5 years after undergoing reoperation for annular support. Allografts (5 cases) or xenografts (7 cases) were used in one group. Plain radiograms. CT-scan and MRI were performed in each patient. The graft-receiver bone borders were visible on the CT-scans but were not distinguishable on the radiograms. Bone and graft density and structure in contact with the implant could be determined on the CT-scan. MRI was difficult to interpret in most cases due to implant-induced artefacts and is not recommended in this type of reconstruction.

The accessory soleus muscle is a supernumerary leg muscle that is rare and usually clinically silent. The best diagnostic strategy is not agreed on. We report two cases in which magnetic resonance imaging contributed significantly to the diagnosis and to the pretreatment evaluation.

Scapho-capitate fracture is a rare lesion. Its mechanism is controversial. Forced extension seems to be the most frequent etiology, as this movement of the wrist induces scaphoid fracture by compression. Hyperextension of the wrist, as a result of the scaphoid lesion, allows contact between the posterior margin of the radius and the neck of the capitatum, inducing capitatum fracture. Continuation of the movement allows a two-stroke rotation of the capitate proximal pole. Analysis of a personal case and review of the literature demonstrated: the frequency of extension movement for etiology, delayed diagnosis, and the need for surgery. Surgery should be performed early with capitate reduction and osteosynthesis in case of instability, scaphoid reduction and minimal osteosynthesis a graft may be necessary. Immobilisation of the carpus and the thumb is essential until bone consolidation. Early surgery should avoid complications such as necrosis or pseudarthrosis.

Arthrography with hip aspiration was performed in 143 patients with hip arthroplasties to determine its effectiveness as a technique for diagnosing infection. Thirty-three cases of infection were found. On 26 occasions the germ responsible was isolated in the joint fluid. In six other cases infection was revealed from cytologic or arthrographic findings, or from both. Only once was a diagnosis of infection not arrived at. In this series of patients, except in cases of evolutive inflammatory rheumatism, cytologic examination of the joint fluid was a discriminative factor in diagnosis. Hip aspiration arthrography had a sensitivity of 79 per cent for the diagnosis of infection in arthroplasty with isolation of the germ and a specificity of 100 per cent. The sensitivity of the diagnosis rose to 91% when any one of the following features was observed: leucocytosis of the joint fluid higher than 10,000 elements/mm3; presence of a fistula or of fistulization on arthrography; isolation of the germ in the joint fluid or the rinsing liquid.

Sixteen cases of spontaneous dislocation of the atlanto-axial joint have been reviewed, fifteen in rheumatoid arthritis and one in ankylosing spondylitis. On four occasions there was some neurological impairment, but in eleven there was only pain and stiffness. The only case of ankylosing spondylitis was operated on after failure of conservative treatment. Three patients died between one and eight months after operation, two of them having had severe neurological impairment before operation. In the thirteen other cases, the average follow up was four years. All had satisfactory fusion after grafting from the skull to axis. Six had only a partial reduction of the displacement and united with some displacement of about 5 mm. The results were satisfactory with absence of pain and regression of neurological signs.

A multicentric study permitted us to report 94 cases of non-tuberculous infections of the hip joint in the adult (13.4% of the cases of septic arthritis observed over the same period). A local predisposing factor (37.2%) and/or general predisposing factors (22.6%) were frequently noted. The routine search for bacteria permits identification of the latter in 71.3% of cases; the germ was usually a staphylococcus, arthritis due to Gram negative bacilli were found in 12% of the cases. The authors emphasize the interest of daily joint aspiration and traction on the lower limb associated with bactericidal antibiotic therapy which are the only means able, in their view, to improve the poor functional prognosis in these cases of hip joint infections.

The authors give the results of various methods such as hardness micrometry, indentation tests and the radiographic study of fracture patterns, which they have applied to the talus and to the calcaneus. It appeared to them that: --these techniques outline the phenomenon of rupture behaviour of both talus and calcaneus; --the talus behaves as a fragile type of material whereas the calcaneus is of the intermediate type. The authors therefore think that these methods can be of great interest in a better understanding of the biomechanical properties of bone.

Eighty three cases of intertrochanteric flexion osteotomy of the hip for severe osteoarthritis are reported with a five year follow up. Osteotomy is performed in the sagittal plane with flexion of the proximal fragment. The anatomical, biomechanical and operative criteria for this procedure are discussed. The indications are based on a precise radiographic survey of hip congruity in flexion. The majority of the patients had severe osteoarthritis of the hip. Radiographs in abduction or adduction showed no improvement in congruity indicating that there would have been no benefit from a Pauwels type of frontal osteotomy. Results after five years are presented. Seventy-five per cent are good, 10% fair, and 15% are failures. Forty-five patients have a long term follow up of more than ten years which allows analysis of the evolution of this osteotomy.

The authors describe a device for measuring the resultant tensions existing at the intervertebral junction (or its constitutive elements) in all spine attitudes. The reported method has been applied to the L4-L5 junction of a spine taken from the corpse of a 50 years old man. Although incomplete, the results suggest the following points: --the L4-L5 intervertebral junction seems to be very deformable, particularly in the sagittal plane; --the intervertebral disk is probably an elastic support which sustains shear stresses during flexion, extension and bending movements in the frontal plane; --during flexion, articular processes seem to be movement leaders as well as supports; --ligaments seem to play a small mechanical role, but their proprioceptive function seems essential.

This report is based on the study of 63 intertrochanteric flexion osteotomies of the hip with a ten-year follow-up. Every patient had severe osteoarthritis of the hip where abduction or adduction osteotomies could not possibly have recentered the femoral head in the acetabulum. The only alternative would have been a total hip arthroplasty. The reappearance of a congruent joint space on the anteroposterior roentgenogram of the proximal femoral epiphysis in flexion was the criterion for intertrochanteric flexion osteotomy. At ten-year follow-up, 65% had a good result, 10% fair, and 25% poor. This per cent of poor results is comparable to some statistics of late complications following total hip arthroplasties. After osteotomy, infection seldom occurs. Moreover, intertrochanteric osteotomy does not complicate the results of total hip arthroplasty.

One case of recurrent posterior dislocation of the elbow after malunion of a supracondylar fracture is reported. The malunion was a posterior angulation of the epiphysis of about 30 degrees. A good result was obtained after osteotomy to correct the malunion.

Authors report two new cases of oculo-dento-digital syndrome, besides the classical findings concerning the eyes, nose and upper extremities, they noted a relative shortening of the skeletal structure of the ocular maxillary region. This syndrome is thought to be an hereditary disease compatible with autosomal dominant inheritance.

Twenty patients with osteoarticular infections, fourteen post-arthroplasty and six with osteitis, were treated with ofloxacin, usually in combination. Sixteen staphylococcus strains including eight aureus and eight coagulase negative (modal MIC and MBC: 0.5 micrograms/ml), three Escherichia coli (modal MIC and MBC: 0.06 micrograms/ml) and one Peptococcus (MIC: 0.25, MBC: 0.5) were isolated. Treatment was given at a mean dose of 9.81 +/- 2.46 mg/kg for a mean duration of 100 days. The serum concentration of ofloxacin was measured at 3.73 +/- 2.13 micrograms/ml for a dosage of 8.23 +/- 0.94 mg/kg (25 assays) and 7.42 +/- 4 micrograms/ml for 11.46 +/- 1.3 mg/kg (23 assays). Bacteriological control was carried out nineteen times; in one case of staphylococcal osteitis, a relapse occurred on the 43rd day of treatment when the strain isolated was resistant to ofloxacin. Three patients presented adverse effects: two cases of bone and muscle pain and one cutaneous allergic reaction: treatment was withdrawn after two restarts. The antibacterial action, the good tolerance and the easy administration of ofloxacin make it a useful antibiotic in the treatment of osteoarticular infections, where a dosage of 8 mg/kg appears to be necessary, particularly in infections due to staphylococci.

The authors have analysed the results of 97 fractures of the femoral shaft in children. In 75 instances, the treatment was conservative-traction followed by a plaster cast after three weeks. The reduction was satisfactory in only 19 cases. The plaster cast did not prevent secondary displacement. After surgical treatment, complications were observed in one third of the cases. The review of the cases with a long follow up showed that with growth, there was good remodelling. In 95 p. 100 of the children there was no loss of function detectable by the family, and only a careful clinical and radiological examination was able to demonstrate some sequelae.

Valid clinical correlations with biomechanical data require three-dimensional visualization of a joint, in order to determine the true spatial configuration of the various segments of the part studied. The CAT scan has opened a new pathway in this direction, as it supplies precise mathematical information on the segments explored. An original analytical programme was employed in humans to establish the true spatial orientation of the acetabular cavity. The validity of the method was confirmed by comparing results in 31 subjects with the rare cases where such measurements were made, reported in the published literature. The method could be extended to other body regions.

Three types of patellar complication following total knee replacement with a Freeman-I.C.L.H. prosthesis have been studied. They are: 1) Pain despite a satisfactory position of the patella. 2) Patella fractures and 3) Lateral displacement. Pain in spite of a satisfactory position of the patella occurred in 15 p. 100 of cases. The incidence of this complication was considerably diminished by the use of a patellar implant. The use of a patellar implant did not result in any specific morbidity. Five fractures of the patella were seen, three of them without displacement. Lateral displacement of the patella were seen in 5 p. 100 of cases resulting in instability of the knee and a higher risk of loosening of the tibial component. The authors propose a new type of patellar implant stabilized by a rail.

An appropriately designed implant can be fixed without cement to accurately prepared bone surfaces so as to give results comparable with those of cemented fixation in the short term. The unchanging appearance of the roentgenograms suggests that these results may be maintained in the long term. If these conclusions are valid, polymethylmethacrylate (PMMA) may be thought of as an optional alternative in joint arthroplasty. Thus, theoretically, inert materials, e.g., carbon, can be directly interfaced with the skeleton. Since the authors have achieved interlock with viable bone without relying on bony ingrowth, these materials need not be porous. It is strongly suspected (but as yet unsupported by data) that adequate fixation can be obtained without relying even on the authors' relatively unsophisticated finned peg, provided that (1) the overall shape of the implant achieves interlock on the gross scale, with acceptably low shear stresses at the interface; and (2) the surgical technique achieves a correctly positioned implant applied to accurately cut bone surfaces. However, if for any reason accurate bone cuts can not be achieved, the authors advocate use of PMMA as a valuable fixation agent.

The Imperial College London Hospital (ICLH) technique and prosthesis for the total replacement of the knee was evolved over the period 1968 to 1977. The results now reported were obtained at The London Hospital on rheumatoid knees operated upon in the period 1977 to 1979. These knees were reviewed and the results published with a one to 2 year follow-up in 1981. In the present paper this review has been extended to 3 to 5 years. We find that in successfully replaced knees the quality of the clinical result has remained unchanged over the extended period of review. Certain further complications have been encountered which are described. These complications have led us to the conclusion that whereas we previously accepted post-operative alignments between one and 10 degrees of valgus, we should now adjust these limits. We now regard a knee having anything less than 5 degrees of valgus post-operatively as having been incorrectly replaced. The limits of valgus can perhaps be extended to 15 degrees. Experience over the period 1977 to 1980 suggested the possibility of further improvements in both the operative technique and the prosthesis. Accordingly the ICLH prosthesis has now been modified. The modified prosthesis (the Freeman-Samuelson prosthesis) is described in this paper but results with it are not reported.

The shape of the standard Ender nail may result in malunion in external rotation in intertrochanteric fractures treated with this device. The nail is curved in one plane, and is usually introduced into the femur without making allowance for the bowing of the diaphysis and the anteversion present in the neck. We have measured radiographically the anteversion of the femoral neck in three groups of patients after operation using Ender nails, and also assessed the anteversion of the unoperated hip for comparison. In Group I normal Ender nails were used. The operated hip showed an average of 12 degrees of retroversion compared with the opposite side. In Group II the nails were bent anteriorly at their upper end, but an average retroversion of 14 degrees was produced compared with the other hip. In Group III the nails were bent to produce anterior bowing as well as proximal anteversion. The group showed retroversion of only 1 degree compared with the normal side. We therefore recommend that Ender nails be bent in this manner in order to reduce rotatory malunion when used for intertrochanteric fractures of the neck of the femur.