Search

Background Despite the development of multimodal analgesia for postoperative pain management, opioids are still required for effective pain relief after knee arthroplasty. We aimed to identify the determinants of post-operative pain intensity and post-operative opioid requirement in this context. Methods In this observational prospective study, we recorded patient characteristics, pre-operative pain intensity, anxiety and depression levels, sensitivity and pain thresholds in response to an electrical stimulus, and mu-opioid receptor (OPRM1) and catechol-O-methyltransferase (COMT) single-nucleotide polymorphisms. Multivariate linear regression models were used to identify predictors of post-operative pain at rest and opioid requirement. Results We included 109 patients. Pre-operative pain at rest (p = 0.047), anxiety level (p = 0.001) and neuropathic pain symptoms (p = 0.030) were independently and positively associated with mean post-operative pain intensity adjusted for mean post-operative morphine equivalent dose (MED). Mean post-operative pain intensity at rest was lower (p = 0.006) in patients receiving celecoxib and pregabalin in the post-operative period, with all other variables constant. Mean post-operative MED over 5 days was low, but highly variable (78.2 ± 32.1 mg, from 9.9 to 170 mg). Following adjustment for mean post-operative pain intensity, it was independently negatively correlated with age (p = 0.004), and positively correlated with associated paracetamol treatment (p = 0.031). No genetic effect was detected in our sample. Conclusions Our findings suggest that clinicians could use the pre-operative pain profile, in terms of anxiety levels, neuropathic pain symptoms, and chronic pre-operative pain intensity, to improve the efficacy of pain management after knee surgery.

La technique d’anesthesie par wide awake local anesthesia no tourniquet (WALANT) est deja utilisee pour de nombreux gestes en chirurgie de la main. L’osteosynthese sous WALANT des fractures du radius distal est un challenge recent. Cette procedure permet de tester la stabilite du montage sous mobilisation active en peroperatoire. Nous avons evalue la faisabilite et les resultats cliniques de cette technique. Trente patients ayant beneficie d’une osteosynthese du radius distale par plaque verrouillee anterieure ont ete inclus prospectivement. Les criteres d’eligibilite etaient : âge entre 18 et 65 ans, pas d’anticoagulants et fracture fermee du radius distal. Deux groupes comparables (groupe A : WALANT n = 10 ; groupe B : anesthesie locoregionale n = 20) ont ete formes. En postoperatoire, les patients ont ete evalues cliniquement (EVA ; mobilites ; QuickDash ; reprise du travail) et radiologiquement a 6 semaines et 3 mois. L’âge moyen etait de 54,5 ans (± 6,5). Vingt-trois patients avaient une profession manuelle. Les fractures etaient toutes a deplacement posterieur avec un refend articulaire dans 9 cas du groupe A vs 14 du groupe B. L’EVA moyen durant le geste anesthesique etait similaire dans les deux groupes (0,2[±0,1] vs 0,3[±0,1], p = 0,32). Un pic de douleur (EVA = 2) a ete observe chez 3 patients dans le groupe A lors de manœuvres de reduction peroperatoire. L’EVA etait a 0 dans les deux groupes durant le geste chirurgical sans necessite d’adjonction d’antidouleur. Le temps chirurgical etait similaire entre les deux groupes (38,5 vs 32,7 min, p = 0,12). En postoperatoire, les patients du groupe WALANT n’etaient pas immobilises et l’auto-reeducation etait debutee. Les patients du groupe ALR etaient immobilises dans une attelle anterieure et l’auto-reeducation etait debutee a 3 semaines. L’amelioration des mobilites etait significativement plus importante dans le groupe A a 6 sem et 3 mois et l’EVA similaire dans les deux groupes. Le score QuickDash etait significativement plus faible dans le groupe WALANT aux deux evaluations. La reprise du travail etait significativement plus precoce dans le groupe A (7,8 j vs 34,6 jours, p = 8E-5). Le suivi radiologique etait sans anomalie. L’osteosynthese du radius distale peut etre realiser en securite sous WALANT. Cette procedure des resultats cliniques satisfaisants plus precoce que par ALR. Elle constitue une alternative majeure pour cette population active jeune.

Summary Context Meniscal lesions and isolated anterior cruciate ligament (ACL) knee injuries are common. In 2006, about 130,000 patients were admitted to hospital for meniscal surgery and 35,000 for ACL surgery in France. Surgical techniques and indications have evolved over recent years, and interest in meniscus preservation has increased due to the higher risk of femorotibial osteoarthritis following meniscectomy. Objectives To encourage good practices in meniscal lesions surgery (particularly meniscus preservation) and to clarify indications and techniques in ACL reconstruction surgery. Methods A systematic review of the literature (1996–2007) was performed. It was submitted to a multidisciplinary working group of experts in the field (n = 10) who drafted an evidence report and clinical practice guidelines which were subsequently amended in the light of comments from 50 peer reviewers. Main recommendations (i) Meniscal repair should only be used to heal peripheral meniscal lesions affecting healthy meniscal tissue (injury) in vascularised areas (red-red zone or red-white zone). The current trend is towards use of hybrid implants (fixation material combined with suture wire) and an exclusively arthroscopic technique. (ii) Traumatic meniscal lesions do not always require a meniscectomy; no surgery or meniscal repair should systematically be considered. (iii) The assessment and management of non-traumatic degenerative meniscal lesions depend on the extent of cartilage damage. (iv) All ACL ruptures do not require reconstructive surgery. The indication for reconstruction is based on symptoms, in particular functional instability. As far as acute ACL injuries are considered, reconstruction by arthroscopy should preferably be delayed to reduce the thromboembolic events or joint stiffness. (v) Bone-tendon-bone graft and hamstring tendon reconstruction give similar results. (vi) Lateral tenodesis should be limited to specific cases.

Radiation-induced sarcoma is a long-term complication of radiation therapy. The most common secondary neoplasia is the undifferentiated pleomorphic sarcoma, which is usually described in the deep soft tissue of the trunk or extremities. Radiation-induced sarcomas have a poor prognosis. An early diagnosis and management are needed to improve the survival rate of such patients. We presently report a case of a radiation-induced undifferentiated pleomorphic sarcoma of the left gluteus maximus muscle, which developed 25 years after an initial diagnosis of aggressive fibromatosis and 21 years after a tumour recurrence. This case study illustrates the risk of developing a sarcoma in a radiation field and the need for long-term follow-up after radiation therapy. Unnecessary radiation therapy, in particular in the case of benign conditions in young patients, should be avoided.

L’evaluation clinique et radiologique d’une omarthrose est indispensable avant toute decision therapeutique. L’evaluation clinique doit prendre en compte les donnees de l’examen clinique classique, mais aussi l’histoire evolutive des symptomes, l’existence de douleurs et des scores fonctionnels evaluant les incapacites. L’evaluation radiologique associe aux radiographies standard le scanner, necessaire a la decision chirurgicale eventuelle. La trophicite de la coiffe des rotateurs est evaluee par le scanner et sa rupture eventuelle pourra etre recherchee.

Resume L’etude rapporte les resultats d’une serie continue, prospective, multicentrique de 425 protheses Wallaby I ® conservant le ligament croise posterieur, posees par le groupe Guepar de 1992 a 1995. Le composant femoral de cette prothese presente des condyles asymetriques et divergents pour se rapprocher le plus possible de la cinematique du genou normal. Le plateau tibial en polyethylene est fixe. L’âge moyen des patients (70,5 ans), la repartition homme (28,3 %) et femme (71,7 %), l’etiologie (91 % d’arthrose primitive ou secondaire) et la deviation preoperatoire des genoux (65,6 % de varus > a 3° et 24 % de valgus > a 4°) etaient identiques a ceux qui sont publies dans la litterature pour ce type de prothese. Vingt-six protheses ont ete suivies moins de 1 an, 84 moins de 5 ans et 315 5 ans ou plus. Parmi les 399 genoux suivis plus de 1 an, il y a eu 4 infections (1 %) dont 3 ont necessite le changement de prothese, 3 fractures du femur toutes post-traumatiques, 2 descellements (1 global et 1 tibial) ayant necessite une reprise, 1 descellement tibial et 3 descellements rotuliens non-repris. Trois patients presentaient des douleurs anterieures du genou traitees avec succes par 2 resurfacages secondaires de la rotule et 1 section de l’aileron rotulien externe. Dix-neuf fractures de rotules (4,7 %) (dont 17 decouvertes fortuitement) constituaient la complication la plus frequente, sans retentissement fonctionnel. Le score moyen IKS genou postoperatoire etait de 90,5 points et le score moyen IKS fonction de 61,6 points. La mobilite moyenne etait de 110,5° ; 72,9 % des genoux etaient axes suivant la classification radiologique IKS, La survie de cette prothese a 8 ans (suivant Kaplan Meier) etait de 97,7 % quelle que soit la raison du changement de prothese et de 98,5 % en ne prenant comme evenement que la reprise pour descellement aseptique. Ces bons resultats corroborent ceux qui sont publies dans la litterature concernant les protheses conservant le ligament croise posterieur a plateau tibial fixe.

Resume Les pathologies des hanches s’accompagnent d’une perturbation de la marche avec boiterie liee aux douleurs, raideurs et deficit musculaire a des degres variables en fonction de l’histoire de la maladie. Un traitement chirurgical palliatif est propose pour les dysplasies peu arthrosiques ; leur reeducation comprend dans un premier temps un entretien en attente de consolidation puis une reeducation orientee essentiellement vers la relance, le renfort musculaire et le travail de la marche. Pour les arthroses evoluees ou les pathologies rhumatismales destructrices de l’articulation, l’arthroplastie est necessaire. La reeducation en est guidee par l’histoire de la maladie, l’etat clinique preoperatoire, le choix des techniques chirurgicales, les consignes du chirurgien. Elle est elaboree a partir d’un bilan clinique precis avec une analyse fine des observations puis sera adaptee en fonction de l’evolution et des objectifs prealablement definis. Cette reeducation est essentiellement manuelle et individuelle, periodiquement reevaluee, avec une attention particuliere aux signes pouvant evoquer la survenue d’une complication que le kinesitherapeute est souvent le premier a constater. La reeducation d’une hanche operee n’obeit pas a un protocole applique de maniere systematique ; elle repond a certaines regles mais s’adapte surtout a chaque hanche et a chaque patient en fonction de l’histoire de l’articulation, de la technique operatoire et de l’evolution, des suites et de la reeducation appreciee par des bilans successifs. Tantot, la reeducation se limite a sa plus simple expression, basee sur les conseils et la surveillance postoperatoire comme dans l’arthroplastie de premiere intention sur une coxarthrose primitive. Ailleurs, la reeducation prend une place primordiale, necessitant d’etre debutee dans un centre avant de se poursuivre en soins de ville pendant de nombreux mois, comme c’est le cas apres une desarthrodese ou une chirurgie de reconstruction complexe de hanche. La qualite de l’analyse initiale est la base du bon choix et de la richesse de la demarche therapeutique.

Los trastornos de la cadera acarrean dificultades en la marcha y cojera a causa del dolor, ademas de rigidez y deficit muscular en grados variables segun la historia de la enfermedad. Para las displasias poco artrosicas se sugiere tratamiento quirurgico paliativo; su rehabilitacion implica en primer termino una conducta de preservacion hasta el momento de la consolidacion, y luego rehabilitacion, orientada sobre todo a la reactivacion, el fortalecimiento muscular y el trabajo de la marcha. En las artrosis avanzadas y en las artropatias reumaticas destructivas se requiere artroplastia. La rehabilitacion depende de los antecedentes de la enfermedad, del cuadro clinico preoperatorio, de la eleccion de las tecnicas quirurgicas y de las consignas del cirujano. Se elabora a partir de un examen clinico preciso y del analisis minucioso de las observaciones, y despues se adapta conforme a la evolucion y los objetivos establecidos con anterioridad. La rehabilitacion es basicamente manual, individual y de evaluacion periodica; se pone un enfasis particular en los signos que puedan evocar una complicacion, de la que el fisioterapeuta suele ser el primero en tener conocimiento. La rehabilitacion posquirurgica de la cadera no siempre responde al mismo protocolo, sino a algunas reglas; en realidad, se adapta a cada paciente y cada cadera conforme a los antecedentes de la articulacion, la tecnica quirurgica, la evolucion ulterior y la rehabilitacion analizada mediante examenes sucesivos. En unos casos la rehabilitacion se limita a su mas simple expresion, y se basa en los consejos y el control postoperatorio: por ejemplo, artroplastia en primera intencion por coxartrosis primaria. En otros, la rehabilitacion ocupa un lugar primordial y debe iniciarse en un centro asistencial, antes de proseguir de modo ambulatorio durante varios meses, como en caso de desartrodesis o cirugia de reconstruccion compleja de la cadera. La calidad del analisis inicial es la base de la opcion correcta y de la riqueza del procedimiento terapeutico.

We have carried out a prospective, randomised study designed to compare the long-term stability of the stem of cementless femoral implants with differing surface configurations. A total of 50 hips (46 patients) was randomised into two groups, according to whether the medullary stem had been grit blasted (GB) or coated with hydroxyapatite (HA). Both femoral prostheses were of the same geometrical design. We used Ein Bild Roentgen Analyse femoral component analysis (EBRA-FCA) to assess the stability of the stem. The mean follow-up was for 8.66 years. The mean migration of the stem was 1.26 mm in the HA group compared with 2.57 mm in the GB group (Mann-Whitney U test, p = 0.04). A mixed model ANOVA showed that the development of subsidence was statistically different in the two groups during the first 24 months. After this subsidence increased in both groups with no difference between them. Our results indicate that, with the same design of stem, HA coating enhanced the stability of the femoral stem when compared with GB stems.

Summary Background Alumina-on-alumina bearings have been accepted as a valuable alternative for young and active patients. Alumina fractures, and socket loosening were the main complications reported. But, with the increasing number of prostheses implanted, noise occurrence appeared as a new concern. The primary aim of the present study was to quantify the prevalence of noticing noise in a population having received alumina-on-alumina total hip arthroplasty as well as its eventual impact on outcome. Patients and methods Two hundred and eighty-four ceramic-on-ceramic hips were performed in 238 patients from January 2003 to December 2004. The average age was 52.4 ± 13.4 years (range, 13 to 74 years). All the hips received the same prosthesis (Ceraver-Osteal™) with alumina bearing components (Ceraver-Osteal™): 32 mm liners were used for cups of 50 mm or larger and 28 mm liners for cups smaller than 48 mm; the minimal alumina thickness was 6 mm. The acetabular component (Cerafit™) was hemispherical, coated with a hydroxyapatite layer and press-fit fixed. The stem (Cerafit™) was a straight tapered cementless stem, fully coated with a hydroxyapatite layer. Clearance between femoral head and liner was between 20 and 50 microns. A retrospective survey was conducted by an independent surgeon who did not participate to surgery in 2007. He conducted phone interviews of patients using a standard questionnaire. No suggestion was offered on how they could describe the noise and they felt free to use the word that they considered to be the most adapted. Satisfaction was evaluated. When the noise was present, X-rays were taken to assess if sign of bearings fracture was present. Results Four patients (six hips) died of unrelated causes during the follow-up period. Three patients (three hips) live outside France and could not be followed (1.3%). Nine patients (10 hips) could not be traced and were considered lost to follow-up (3.8%). Two hundred and twenty-two patients with 265 hips, therefore, were included (nine using bearing components in 28 mm diameter and 265 in 32 mm). Twenty-eight hips experienced noise generation (10.6%). It was defined as a snap for six patients, as a cracking sound by six, as rustling by six patients, as a squeaking by seven patients (2.6%), a tinkling by two patients, one patient was unable to define the sound she felt. No factor related to the patient influenced the occurrence of noise. Twelve patients were dissatisfied with the result of their hip prosthesis, five of them experienced noise (41.7%); 210 were satisfied or very satisfied, 23 of them experiencing noise (11%); this difference was significant (P = 0.002). Conclusion The origins of noise occurrence are unknown. Squeaking may be related to generation of stripe wear and absence of sufficient lubrication. Other types of noise can be due to microseparation, occult dislocation, impingement between the femoral neck and the acetabular rim. Level of evidence Level IV. Retrospective study.

Total hip arthroplasty with all alumina bearings in young patients give acceptable results but it is difficult surgery. The main problem is related to socket fixation. There is an apparent improvement with metal backed alumina that needs to be confirmed with long-term results.

Management of bone stock loss remains one of the most challenging problems for revision hip surgery. The aim of this retrospective study was to report the preliminary results of peri-prosthetic femoral defect reconstruction with impacted granules of calcium phosphate ceramic.Fourteen hips in 13 patients (3 men and 10 women) were evaluated. Age at surgery ranged from 30 to 79 years (mean 66.1 years). All revised devices had been cemented. Femoral revision was indicated for loosening in eleven hips (including six septic cases), femoral osteolysis (one hip), persistent pain (one hip), and recurrent dislocation (one hip). On the preoperative radiological evaluation, bone defects were assessed as SOFCOT grade II in seven case, and grade III in fourteen. None was rated grade IV. Once the loose prosthesis had been removed, bone graft or ceramic granules (14 cases) were firmly impacted in the femoral canal. The stem was standard and always cemented using modern cementing technique.At a mean follow-up of 34 +/- 15 months (range 14-76 months), eleven of fourteen hips were rated good or very good according to the Postel-Merle-d'Aubigné score. One diaphyseal femoral fracture occurred and later united. Two hips required re-revision (one aseptic femoral loosening, one septic recurrence). Direct bonding between synthetic graft and bone was observed on standard radiographs in eleven cases. Stem subsidence occurred in two cases and was limited (mean 4.5 mm).Femoral bone reconstruction using impacted calcium phosphate ceramic in revision hip arthroplasty provided encouraging results in the short to mid term. Femoral stock restoration was achieved in the great majority. No adverse effect related to the use of a synthetic graft was noted. Further long-term evaluation is required before wider application.

Posterior Wallaby I is a fixed polyethylene tibial plateau prosthesis enabling preservation of the posterior cruciate ligament (PCL). Its asymmetrical and divergent femoral condyles articulate with also asymmetrical tibial plateaus. The purpose of this prospective study was to analyze outcome of the first 425 Wallaby I prosthesis of the Guepar group implanted for first-intention treatment.These 425 prostheses were implanted from December 1992 to February 1995 by senior and junior surgeons. Mean patient age at implantation was 70.5 years. 91% had primary or secondary osteoarthritis and only 8.9% had inflammatory rheumatoid disease. The mean preoperative IKS score was 25.34 points and the IKS function score was 29.04. 10.35% of knees were aligned normally (mechanical axis between 2 degrees varus and 3 degrees valgus) according to the IKS criteria (Ewald), 24% presented valgusor = 4 degrees and 65.6% varusor = 3 degrees. All tibial and patellar components (except one) were cemented, 5.8% of the femoral pieces were inserted without cement. All but 11 patellae were resurfaced. Clinical outcome was assessed with the IKS score and radiological outcome with the IKS criteria. The patella was considered to be tilted when the alpha angle was5 degrees and dislocated when the AA' distance was5 mm. The chi-square test was used for comparison of quantitative variables (significance set at 0.05).Early postoperative complications were rare: two infections cured with debridement-lavage and antibiotics without removal of the prosthesis, one peronal nerve palsy which regressed partially, ten late unions without clinical consequence (particularly in the inflammatory rheumatoid patients). Twenty-six prostheses were followed less than one year (eight patients died and eighteen were lost to follow-up) and 84 less than five years (27 patients died and 57 lost to follow-up before five years). 315 prostheses were followed for more than five years (5-9 years) with a mean follow-up of 6.3 years. Among the 399 prostheses followed for one year or more, we noted: four infections including three requiring change of the prosthesis (one cured by arthroscopic lavage), two aseptic loosenings which were revised (one global one tibial), one tibial loosening and three patellar loosenings which were not revised, and two femoral ossifications limiting joint motion but improved by arthrolysis and resection of the ossifications. Three patients experienced anterior pain requiring secondary patellar resurfacing in two and section of the lateral patellar wing in one. Ninteen patellar fractures (4.7%) were noted, including 17 with no significant functional impact which were not revised. The mean IKS knee score among prostheses followed for five years was 90.5 points, with mean motion 110.5 degrees. Mean IKS function score was 61.63 points. 72.9% of the knees were aligned, 22.2% in varus and 4.9% in valgus. The mechanical axis of 94.3% of the knees was between 5 degrees varus and 5 degrees valgus. Prosthesis survival at eight years (Kaplan-Meier method) was 97.7% considering all reasons for prosthesis removal and 98.5% for removal for aseptic loosening.This prospective multicentric study demonstrated that the results obtained with the Wallaby I prosthesis are as good as those obtained with other prostheses sparing the PCL and published in the literature. Preservation of the PCL enables better knee stability, correct motion (110.5 degrees in our series) with almost no radiological wear of the tibial polyethylene at eight years. The only worrisome complication is patellar fracture.

We report our experience with eleven patients treated for disabling genu valgum from 1979 to 1994.Genu valgum resulted from femoral deformation in all patients. Ten had a congenital condition and one a post-traumatic knee. IKS scores were used for the clinical evaluation. The lateral femorotibial joint space and the lateral femoral angle (LFA) were measured on plain films. Goniometry was used to measure the axis of the loaded lower limb. All patients underwent osteotomy of the distal femur for varisation and plate fixation. One patient required revision for a unicompartment lateral prosthesis subsequent to fracture of the homolateral lateral tibial plateau. Mean follow-up was 10.5 years (3.5-21.5).There were no cases of nonunion. Four patients had a good or excellent knee score. Eight patients had a good or excellent function score. Osteoarthritis worsened in two patients. The mean LFA increased from 72.5 degrees preoperatively to 83.5 degrees postoperatively and a last follow-up. Mean genu valgum was 13 degrees preoperatively and 2 degrees at last follow-up. All patients except one were satisfied or very satisfied. Insufficient correction appeared to be the main complaint.These results and results reported in the literature demonstrate that distal femoral osteotomy for disabling genu valgum is an effective treatment if the correction is complete and osteosynthesis effective, providing long lasting results when femoral deformation is involved and osteoarthritis limited.

We report a case of severe femoral agenesia in an adult and propose a new surgical approach facilitating prosthesis fitting. The procedure involves insertion of a total hip arthroplasty, arthrodesis of the knee and amputation of the foot. The final prosthesis fits on the crural area with weight bearing on the ischiatic region, the lesser pelvis, and the articulated knee. Outcome was satisfactory at one year in our patient. Other surgical alternatives are presented.

The author has attempted to assess the value of computer-assisted surgery in arthroplasty of the knee. Basic requisites in TKR include adequate alignment and ligament balance. These requisites have become easier to meet as ancillary instrumentations have improved over time. Numerical tools are now available; they are sometimes presented as an essential technical step. The author reviews the various available options, with their advantages and disadvantages. Satisfactory alignment in the three planes classically relies on anatomic landmarks, the reliability of which is limited, and on ligament tension. Targeting systems, intra- or extramedullary, all have a margin of error. Computer-assisted surgery aims at increasing the precision of implant positioning and achieving optimal ligament balance. Among the systems currently available, a distinction must be made between active and passive systems. The former correspond to the "surgical robots", which are capable of performing the various parts of the operation following adequate preparation, at least regarding the bone cuts. Passive systems remain under control from the surgeon and assist him in positioning the cutting jigs. Among localization systems, a distinction must be made between optical and magnetic systems. Certain systems require preoperative imaging--usually CT scan--in order to first reconstruct a 3-D model of the knee. This step is time-consuming, but this will likely improve in the future. Image matching requires the use of a software, with specific landmarks defined preoperatively by the surgeon. Such systems may be used in cases with major deformities; their main drawback is the need for preoperative imaging. Other systems do not require preoperative imaging: a few points are identified by kinematic analysis of the hip, knee and ankle; they are used for 2-D or 3-D reconstruction. Computer-assisted systems may improve the precision in defining anatomic landmarks and achieving accurate location and orientation of the bone cuts, but this must still be validated. Computer-assisted surgery allows for intraoperative control of the orientation of bone cuts, the mechanical axes, the ligament balance and the range of motion. It remains to be demonstrated that using these systems will result into a clinically relevant benefit for the patient, as several of the prostheses widely implanted so far have demonstrated high survivorship rates at 15 or 20 years, so that the demonstration of a possible superiority would need considerable investment. Using these techniques does not solve all problems anyway. The patellar cut remains empirical, and these techniques also do not give any information about femoropatellar joint function. The present systems make use of the classical instrumentation, but it may be anticipated that instrumentations especially intended for computer-assisted surgery will be developed in the future. Regarding imaging, some possibilities have not yet been explored, such as plain radiography or fluoroscopy. Computer-assisted surgery should be of particular interest in revision arthroplasties, but it poses additional problem. The indications are relatively scarce however, and no major advances should be anticipated in the near future. On the whole, this is an emerging technical field. Development is slow, none of the available products is fully mature and caution is warranted in the face of enthusiastic reports and presentations. The value of computer-assisted surgery in TKR has not been demonstrated and its real usefulness still needs to be evaluated. It will, anyway, by no means exempt the surgeon from mastering the classical operative technique.

Summary Background Alumina-on-alumina bearings have been accepted as a valuable alternative for young and active patients. Alumina fractures, and socket loosening were the main complications reported. But, with the increasing number of prostheses implanted, noise occurrence appeared as a new concern. The primary aim of the present study was to quantify the prevalence of noticing noise in a population having received alumina-on-alumina total hip arthroplasty as well as its eventual impact on outcome. Patients and methods Two hundred and eighty-four ceramic-on-ceramic hips were performed in 238 patients from January 2003 to December 2004. The average age was 52.4 ± 13.4 years (range, 13 to 74 years). All the hips received the same prosthesis (Ceraver-Osteal™) with alumina bearing components (Ceraver-Osteal™): 32 mm liners were used for cups of 50 mm or larger and 28 mm liners for cups smaller than 48 mm; the minimal alumina thickness was 6 mm. The acetabular component (Cerafit™) was hemispherical, coated with a hydroxyapatite layer and press-fit fixed. The stem (Cerafit™) was a straight tapered cementless stem, fully coated with a hydroxyapatite layer. Clearance between femoral head and liner was between 20 and 50 microns. A retrospective survey was conducted by an independent surgeon who did not participate to surgery in 2007. He conducted phone interviews of patients using a standard questionnaire .No suggestion was offered on how they could describe the noise and they felt free to use the word that they considered to be the most adapted. Satisfaction was evaluated. When the noise was present, X-rays were taken to assess if sign of bearings fracture was present. Results Four patients (six hips) died of unrelated causes during the follow-up period. Three patients (three hips) live outside France and could not be followed (1.3%). Nine patients (ten hips) could not be traced and were considered lost to follow-up (3.8%). Two hundred and twenty-two patients with 265 hips therefore were included (nine using bearing components in 28 mm diameter and 265 in 32 mm). Twenty-eight hips experienced noise generation (10.6%). It was defined as a snap for six patients, as a cracking sound by six, as rustling by six patients, as a squeaking by seven patients (2.6%), a tinkling by two patients, one patient was unable to define the sound she felt. No factor related to the patient influenced the occurrence of noise. Twelve patients were dissatisfied with the result of their hip prosthesis, five of them experienced noise (41.7%); 210 were satisfied or very satisfied 23 of them experiencing noise (11%); this difference was significant (P = 0.002). Conclusion The origins of noise occurrence are unknown. Squeaking may be related to generation of stripe wear and absence of sufficient lubrication. Other types of noise can be due to microseparation, occult dislocation, impingement between the femoral neck and the acetabular rim. Level of evidence Level IV. Retrospective study.

The principal cause of aseptic loosening of total hip arthroplasty (THA) in the mid and long term is caused by the reaction of the periprosthetic bone to wear particles both from the components of the implanted prosthesis (metal, polyethylene, ceramic, carbon, etc.), and from cement if cement is used. Wear debris occurs at the head-socket interface even if the prosthesis is securely fixed, and movement between prosthesis and bone is limited.

Biomaterials, whatever their applications: cardiovascular surgery, orthopaedic surgery, ophthalmology, plastic surgery, urology, membranes for renal dialysis have some common approach. It is a very interdisciplinary field that needs intervening bioengineers, M.D, biologists and materials scientists. It is a domain with special emphasis on responsability because of the very severe consequence of these material failures. After an overview of these materials and their applications, we will briefly present here the evaluation systems of these biomaterials, including laboratory tests, mechanical tests as well as biological ones. Then we will project in the future to insist on three main orientations: tissue engineering, optimised materials for some precise function and also how new techniques of applied genetic could modify this field in deep in the future.

To study the results of facet joint intraarticular steroid injections in patients with symptomatic lumbar facet joint synovial cysts.Data from 30 patients (age range, 44-82 years; mean age, 67 years) with nerve root pain due to a lumbar facet joint synovial cyst and treated with facet joint steroid injection were retrospectively studied. On the basis of MacNab criteria, the clinical course of nerve root pain was evaluated after 1 (n = 30) and 6 (n = 28) months. Data from long-term follow-up (mean, 26 months) were also available in 14 nonsurgically treated patients.After 1 month, the nerve root pain outcome was excellent or good in 20 patients (67%) and fair or poor in 10 (33%). After 6 months, 10 (50%) of these 20 patients still had excellent or good results, and 18 (60%) of the 30 patients had a fair or poor clinical status, 14 of whom underwent surgery; two patients (7%) were lost to follow-up. Excellent and good results were maintained at further follow-up (range, 9-50 months).One-third of patients with symptomatic lumbar facet joint synovial cysts had long-lasting acceptable benefit from facet joint steroid injections in this study. Steroid injection should be indicated before surgery.

The authors report an original case of Albers-Schönberg's disease and describe its surgical treatment.Comparison between roentgenogram of the pelvis at the age of 9 and 46 years showed the original evolution of coxa vara in a case of osteopetrosis. A 46 year old male had severe pain and instability in both hips related to numerous problems consisting of: 1) on the right side: subtrochanteric femoral non-union after repeated fractures, head and neck femoral disappearance associated to dislocation. 2) on the left side: acetabular dysplasia, osteoarthritis and subtrochanteric femoral fracture that had fusionned. Total hip arthroplasty was performed on both hips.Clinical result was good in both hips (PMA score = 6-6-4) at the latest follow-up (four years on the left side and three years and four months on the right side). The surgical procedures were difficult because of the hardness and brittle character of the bony substance and because of non unions and deformities. Special care was required to avoid shattering femoral diaphysis and false routes during creation of a new medullary canal.Total hip prosthesis represents a functionnal salvage procedure in patients with Albers-Schönberg's disease.

We report a retrospective study of 14 Peptostreptococcus magnus bone and joint infections, following orthopaedic prostheses or implantation of fixation devices, diagnosed in two Paris hospitals between 1992 and 1996. Five patients experienced a knee joint infection after anterior cruciate ligament reconstruction with 4 artificial grafts, and 9 caught joint or wound infections, after limb traumatic injuries or bone neoplastic ruptures involving femur, tibia, calcaneum and humerus, treated by arthroplasty or osteosynthesis with implantation of biomaterials. Septic arthritis was experienced one week to one year after reconstructive surgery, and had evolved for several months to years before etiologic diagnosis in 5 cases. Specimens of pus, tissues or removed implants produced numerous slow growing small colonies of Gram positive cocci arranged in clumps on culture media incubated in anaerobic atmosphere only. In 10 patients, the same organism was disclosed in several separate specimens. The identification of P. magnus was assessed by the enzyme profile (rapid ID 32A API strips), gaz liquid chromatography, catalase and coagulase production, resistance to novobiocin and Na polyanethol sulphonate. Antibiotic sensitivity testing performed by disc method was constant to penicillin G, amoxicillin, cefuroxime, cefoxitin, imipenem and pristinamycin with penicillin G MICs0.125 mg/l and metronidazole MICs1 mg/l. Erythromycin, clindamycin, rifampicin, tetracycline and fosfomycin were active against more than 70% of P. magnus. All patients were cured after a prolonged course of various antibiotics and surgical removal of the foreign material whenever possible. We studied in vitro binding of P. magnus with extracellular matrix proteins adsorbed onto biomaterials, by particle agglutination assays of latex beads coated with proteins. Eighty one% of strains bound to collagen, 69% to fibrinogen and 46% to fibronectin. Comparison of orthopaedic strains with strains of other infections and from skin showed a correlation between P. magnus from bone and joint infections and their fibrinogen binding ability (69% against 20%, p0.05).

It is very challenging to insure long term security and effectiveness for joint arthroplasties, artificial ligaments, extensive bone replacement and some other orthopaedic biomaterials. How can we predict the long term security and efficacy of such an implant? Only an interdisciplinary approach can provide a satisfactory answer. The surgeon must define the needs, he must find the appropriate surgical techniques and conduct the clinical trial. The material scientist must elaborate safe and secure materials with regards to their biotolerance and mechanical resistance. This has to be performed in close connection with the biomechanics lab. Biomechanic Science must predict the expected stresses. It has to design special simulator to quantify in vitro material toughness, wear characteristics, lubrication, behaviour and surface deformation. Biological and mechanical standardized tests have to be carried on. Then it is possible to conduct a clinical trial, prospectively in comparison to another already developed material. Clinical studies could serve to measure efficacy and radiological modification. After failure, it is possible to analyse retrieved specimen, to measure the material degradation in real environment, to perform biological studies on retrieved tissues i.e. : macrophagic activities, tissue response, bone ingrowth, inflammatory or immunological reaction. For more than twenty years we worked on alumina against alumina total hips. The idea was to develop a low debris system to enhance long term longevity of the prosthesis. The Charnley design has proven its effectiveness for more than fifteen years, but polyethylene wear is responsible for late failures. This is specially crucial for young patients, male sex and high activity level patients. At the beginning, biological studies and mechanical tests were performed, it appeared that the biological tolerance of alumina ceramic was excellent, the fracture toughness was adequate, but there were some problems related to alumina fixation in the body and also alumina head fixation on metallic stem. Alumina material improved with time. It was possible to diminish the fracture risks and to increase the safety. Parallel information from the first period was used to increase the material quality, the surgical techniques and also to define indication in the use of such material. It is now clear and it also has been published that alumina against alumina system has proved to be as safe as Charnley total hips. It has been proved to give better results in the young age population. Then it is now possible to operate on very young patients, to allow these patients to perform heavy work, sports and regular daily activity for their demand.(ABSTRACT TRUNCATED AT 400 WORDS)

A series of 69 one bone forearm fractures in children is reported. Thirty six ulna and 33 radius were involved. Average age was 7.6 years. The fracture type varied: compression fracture in 2 cases, greenstick fracture in 45 cases and impacted fracture in 22 cases. For 25 cases, a plastic bowing of the other forearm bone was associated. Treatment was immobilization without reduction (53), or reduction with anesthesia (16). One proximal radial fracture was treated with medullary nailing the 15th day, after 2 secondary displacements. Early radiological results were very good in 40 per cent, good in 32 per cent, fair in 19 per cent, and poor in 7 per cent. Eleven children with a poor or fair initial result had clinical and radiological evaluation with long term follow-up; functional and radiological results were always good or very good. The reduction of the plastic deformity as reported by Sanders allowed to achieve better early results.

Controversy exists on the indications and results of unicompartmental arthroplasty in the treatment of unicompartmental knee arthritis. This led us to study 135 Lotus prostheses implanted from December 1974 to February 1990. The follow-up lower than 1 year for 14 knees (11 were lost to follow-up, 3 were reoperated). One hundred and twenty-one knees were clinically evaluated with an average follow-up of 4 years and 6 months using both the GUEPAR and the Knee society grading systems. 71.9 per cent of the knees were rated good, 28.1 per cent were rated poor (19 per cent were revised). This important rate of poor results was due to poor technique (11 knees) and to poor indications (7 knees). Polyethylene wear, and radiolucent line especially when it was evolutive were significantly correlated to failures and poor results. Failures were seldom unifactorial but often multifactorial. Over or undercorrection of coronal deformity, absence or lengthening of the anterior cruciate ligament were the failure factors most often found. Decrease of good results with time, and polyethylene wear of unicompartmental arthroplasties are factors which lead us to carefully consider osteotomy for patients under 65 years. The failure rate may decrease with good indications and a better technique allowing unicompartmental arthroplasty to be a good choice for unicompartmental arthritis.

Twenty-three shoulder arthrodeses after brachial plexus injuries have been performed. Average time between injury and arthrodesis was 3.4 years. 18 patients had palliative procedures or direct approach of the brachial plexus to improve shoulder and hand function. Average follow-up was 5 years and 11 months. An analysis based on pain, function, and fusion occurrence gave 15 good, 2 fair and 4 poor results. The authors conclude that the shoulder arthrodesis is indicated when elbow and hand functions are sufficient and deafferentation pain has not occurred.

This little book aims to inform its readers about the current advances in computer-assisted total knee replacement. The first two chapters discuss what constitutes a ‘perfect’ total knee replacement and how this goal was achieved before computer-assisted surgery. The following three chapters

Objectifs Le but de cet expose est de presenter les differents systeme de chirurgie assiste par ordinateur disponibles pour la chirurgie orthopedique. Resume Les systemes de chirurgie assistee par ordinateur peuvent se diviser en systeme actif ou la main du chirurgien est remplacee par un robot. Les gestes realises ont ete planifies par un systeme d’imagerie et apres recalage entre le virtuel (l’image) et le reel (le malade) les gestes peuvent etre effectues. Les systemes passifs representent une aide pour le chirurgien qui reste maitre d’œuvre et realise les gestes chirurgicaux. Ces systemes existent pour certaines applications comme la prothese de genou ou la prothese de hanche avec et sans imagerie. Les systemes sans imagerie prenant des reperes anatomiques ou cinematiques. Conclusion Une fois le but chirurgical defini, il est possible d’y parvenir par differents moyens techniques. En l’etat actuel des connaissances, des evaluations precises restent necessaires pour definir la place de la chirurgie assistee par ordinateur dans le quotidien du chirurgien.

Objectifs Il s’agit de decrire et de montrer les performances de systemes de chirurgie assistee par ordinateur dans la mise en place des protheses totales de genou. Resume Il est necessaire pour assurer le fonctionnement a court terme et la perenite des protheses totales de genou d’assurer un positionnement optimal des implants dans un plan frontal, sagittal et horizontal. Soixante-dix huit genoux consecutifs ont ete operes a l’aide d’un systeme de chirurgie assistee par ordinateur en reconstruisant le membre inferieur prealablement a l’intervention par un scanner. L’evaluation realisee en aveugle de la methode chirurgicale par un operateur independant a permis d’obtenir un axe dans le plan frontal entre 3 ° de varus et de valgus dans 91 % des cas mesures sur une gonometrie post-operatoire en appui bipodal. Le temps operatoire etait en moyenne de 120 minutes et le saignement de 590 ml pour une chirurgie realisee dans tous les cas sans garrot. L’utilisation d’une methode d’evaluation basee sur un controle qualite (CUSUM) a permis de montrer que meme dans une periode d’experimentation initiale le controle de la procedure operatoire etait obtenu. Conclusion Ce systeme s’est avere fiable y compris dans la periode initiale de son utilisation et de son evaluation. Les systemes avec imagerie imposent des protocoles lourds en terme de temps pour le chirurgien car la reconstruction en trois dimensions n’est pas automatique, mais ces systemes peuvent trouver d’autres interets dans la chirurgie de la hanche ou dans la chirurgie tumorale par exemple.

BackgroundThe best means of ensuring knee stability after anterior cruciate ligament (ACL) reconstruction remains a core debate in sports medicine.HypothesisThere is no difference between ACL reconstruction with patellar tendon or hamstring tendon autografts with regard to postoperative knee laxity and instability.Study DesignMeta-analysis of individual patient data.MethodsPooled analysis of individual patient data from 6 published randomized clinical trials included 423 patients with symptomatic unilateral anterior cruciate ligament injury randomly assigned to reconstruction with patellar tendon or hamstring tendon autograft. Knee instability, defined as a positive pivot-shift test result, was the primary outcome, and knee laxity, defined as a positive Lachman test result, was the secondary outcome. Odds ratios were computed before and after adjustment for potential confounders and trial effect. Regression analyses were performed to look for effects of covariates on outcomes, and mixed-effects models were used to account for a trial effect. Sensitivity analyses were conducted to explore the effects of missing data and excluding each trial.ResultsAnterior cruciate ligament reconstruction with patellar tendon autograft was significantly associated with a decreased risk of a positive pivot-shift test result (adjusted odds ratio, 0.46; 95% confidence interval, 0.24–0.86; P = .016). The risk of having a positive Lachman test result was not significantly different between the 2 groups. The estimated treatment effect was not substantially changed by differences in handling missing data or exclusion of any of the trials. A positive pivot-shift test result was more common in female ( P = .003) and younger patients ( P = .017).ConclusionPostoperative knee instability was less common after ACL reconstruction with patellar tendon autograft than with hamstring tendon autograft.