Ten-year survival and complications of total knee arthroplasty for osteoarthritis secondary to trauma or surgery: A French multicentre study of 263 patients.

BACKGROUND: Previous surgical procedures raise technical challenges in performing total knee arthroplasty (TKA) and may affect TKA outcomes. Survival rates of TKA done after trauma or surgery to the knee have not been accurately determined in large populations. The objectives of this retrospective study in 263 patients with TKA after knee trauma or surgery and a follow-up of 10 years were to assess survival, functional outcomes, and the nature and frequency of complications. HYPOTHESIS: Knee trauma or surgery before TKA increases the risk of complications and decreases implant survival. MATERIAL AND METHODS: Two hundred and sixty-three patients (122 [47%] females and 141 [53%] males) underwent TKA between 2005 and 2009 at nine centres in France. Mean age at surgery was 61 years. The patients had knee osteoarthritis secondary to a fracture (n=66), osteotomy (n=131), or ligament injury (n=66). Mean time from trauma or surgery to TKA was 145 months (range, 72-219 months). RESULTS: Major complications were infection (n=12, 4.5%), skin problems (n=8, 3%), and stiffness (n=8, 3%). Ten-year survival to implant exchange for any reason was 89%±2.8%. Flexion range increased by 2.5°±17° (p=0.02) to a mean of 110° (range, 30° to 140°); extension range increased by 4°±7° (p<0.001) to a mean of -1.19 (range, -20° to 0°). Of the 263 patients, 157 (60%) reported little or no pain at last follow-up. Mean postoperative hip-knee-ankle angle was 179°±3.2° (range, 171°-188°). CONCLUSION: TKA performed after knee injury or surgery carries a risk of specific complications (infection, skin problems, and stiffness) and may have a lower survival rate compared to primary TKA. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Total knee arthroplasty after opening- versus closing-wedge high tibial osteotomy. A 135-case series with minimum 5-year follow-up.

INTRODUCTION: High tibial osteotomy (HTO) is effective in treating isolated medial osteoarthritis of the knee, but subsequent deterioration is inevitable, and total knee arthroplasty (TKA) is then an option. The present study sought to compare TKA following medial opening-wedge HTO (OW-HTO) versus lateral closing-wedge HTO (CW-HTO) in terms of intraoperative data and clinical results. The study hypothesis was that there is no significant difference in clinical results or complications in TKA following OW-HTO or CW-HTO. MATERIAL AND METHOD: A retrospective multicenter (9 centers) study was conducted for the French Society of Orthopedic Surgery and Traumatology (SoFCOT), including 135 TKAs following HTO (58 OW and 77 CW) at a minimum 5 years' follow-up. Mean interval between HTO and TKA was 134 months and was longer in case of CW-HTO (P<0.0001). Mean age at TKA was 65.4 years and older in case of CW-HTO (P=0.021). Tibial slope was greater in case of OW-HTO (P=0.024). Prior to TKA, 55.7% of patients could walk without canes, 98.4% found stairs difficult or impossible and only 19.1% could manage a walking distance greater than 1000m. Mean flexion was 110°; 54.2% of patients showed frontal knee stability and 87.8% sagittal stability; 60.1% had a mechanical axis in varus, without difference according to OW- or CW-HTO. RESULTS: Hardware was almost systematically removed (in 98.5% of cases): in the same step for OW-HTO (P=0.018) or often in 2 steps for CW-HTO. The primary approach was generally re-used (54.2%), but less frequently in the CW-HTO group (P=0.0004). Lateral or medial ligament release was not associated in respectively 78.2% and 79.7% of cases. The TKA implant was usually without stem (87.2%) and was fitted using a conventional technique (74.4%). At a mean 87 months' follow-up, 78.5% of patients could walk without canes, stairs were still difficult or impossible for 67%, and 74.1% could now walk further than 1000m; mean flexion was 110.5°. Overall, 91.5% of patients showed frontal knee stability and 98.2% sagittal stability, without difference according to OW- or CW-HTO. There were 15 complications within 3 months, more often in the OW-HTO group (12.3%) although not significantly, and with no difference in severity. Late complications comprised loosening (5.5%) and infection (3.6%) and were more frequent in the CW-HTO group (12%) (P<0.05). DISCUSSION: The study hypothesis was partially confirmed. The only technical differences concerned hardware removal, often performed in two steps in case of CW-HTO, and TKA approach, which differed from the primary approach in case of CW-HTO. Clinical results were comparable between OW- and CW-HTO, but late complications were more frequent in the CW-HTO group. LEVEL OF EVIDENCE: III; comparative retrospective study.

Medial unicompartmental knee arthroplasty: does tibial component position influence clinical outcomes and arthroplasty survival?

INTRODUCTION: In several recent studies, unicompartmental knee arthroplasty (UKA) produced better functional outcomes than did total knee arthroplasty with 10-year prosthesis survival rates greater than 95%. Nevertheless, UKA is still widely viewed as producing inconsistent results. Tibial component loosening is the leading cause of failure. We consequently sought to identify tibial component position criteria associated with outcomes of medial UKA. MATERIAL AND METHODS: We conducted a retrospective multicentre study of 559 medial UKAs performed between 1988 and 2010 in 421 patients (262 females and 159 males) with a mean age of 69.51±8.72 years at surgery. We recorded the following radiographic parameters: joint space height, obliquity and slope of the tibial implant, whether the tibial component was perpendicular to the femoral component, and lower limb malalignment. The International Knee Society (IKS) score was used to assess clinical outcomes. Mean follow-up at re-evaluation was 5.17±4.33 years. RESULTS: The mean 10-year prosthesis survival rate was 83.7±3.5%. Factors associated with decreased prosthesis survival were a greater than 2-mm change in joint space height, a greater than 3° change in tibial component obliquity, a slope value greater than 5° or a change in slope greater than 2°, and more than 6° of divergence between the tibial and femoral components. Residual mechanical varus of 5° or more was also associated with mechanical failure. The only factor associated with worse functional score values was joint space elevation by more than 2mm. DISCUSSION: The high level of accuracy required for optimal positioning of the tibial component during medial UKA indicates a need for considerable technical expertise and emphasises the conservative nature of the procedure. Optimal positioning is crucial to restore normal knee kinematics and to prevent implant wear and lesions to adjacent compartments. LEVEL OF EVIDENCE: IV, retrospective study.

Total shoulder arthroplasty - arthroplasty for glenohumeral arthropathies: results and complications after a minimum follow-up of 8 years according to the type of arthroplasty and etiology.

INTRODUCTION: Arthroplasty for glenohumeral arthropathies have specific complications and the final results are sometimes more dependent upon the type of shoulder arthroplasty than the initial etiology. The aim of our study was to evaluate the rate of complications and the functional improvement with different types of shoulder arthroplasties after a minimum follow-up of 8 years. MATERIALS AND METHODS: This was a multicenter retrospective study of 198 shoulders including 85 primary osteoarthritis of the shoulder, 76 cuff tear arthropathies, 19 avascular necrosis and 18 rheumatoid arthritis. Arthroplasties included 104 anatomic total shoulder arthroplasties (TSA), 77 reverse arthroplasties and 17 hemiarthroplasties. Ten patients had their arthroplasty revised, and 134 patients with TSA were able to be present at the final follow-up or provide information on their case. Function was evaluated by the Constant-Murley score and loosening by standard radiographs. RESULTS: In the group with primary osteoarthritis of the shoulder, there were eight complications (11%) including six (8.3%) requiring implant revision. In the group of rotator cuff arthropathies, there were nine (14.7%) complications including four (6.5%) requiring implant revision. In the group with rheumatoid arthritis, there was one complication, and no surgical revision was necessary. There were no complications in the group with avascular necrosis. Glenoid migration occurred in 28.5% of anatomic TSA, and 3.4% of reverse arthroplasties. This difference was significant (P<0.001). The Constant-Murley score was significantly improved in all etiologies. CONCLUSIONS: Glenohumeral arthropathies can be successfully treated by arthroplasty. Anatomic TSA was shown to be associated with a high risk of glenoid loosening at radiographic follow-up, which makes us hesitate to use the cemented polyethylene implant, especially in young patients. LEVEL OF EVIDENCE: IV - Retrospective study.

Influence of posterior condylar offset on knee flexion after cruciate-sacrificing mobile-bearing total knee replacement: a prospective analysis of 410 consecutive cases.

The range of motion of the knee joint after Total Knee Replacement (TKR) is a factor of great importance that determines the postoperative function of patients. Much enthusiasm has been recently directed towards the posterior condylar offset with some authors reporting increasing postoperative knee flexion with increasing posterior condylar offset and others who did not report any significant association. Patients undergoing primary total knee replacement were included in a prospective multicentre study and the effect of the posterior condylar offset on the postoperative knee flexion was assessed after adjusting for known influential factors. All knees were implanted by three senior orthopedist surgeons with the same cemented cruciate-sacrificing mobile-bearing implant and with identical surgical technique. Clinical data, active knee flexion and posterior condylar offset were recorded preoperatively and postoperatively at a minimal one year follow-up for all patients. Univariate and multivariate linear models were fitted to select independent predictors of the postoperative knee flexion. Four hundred and ten consecutive total knee replacements (379 patients) were included in the study. The mean preoperative knee flexion was 112°. The mean condylar offset was 28.3mm preoperatively and 29.4mm postoperatively. The mean postoperative knee flexion was 108°. No correlation was found between the posterior condylar offset or the tibial slope and the postoperative knee flexion. The most significant predictive factor for postoperative flexion after posterior-stabilized TKR without PCL retention was the preoperative range of flexion, with a linear effect.

Massive rotator cuff tears in patients younger than 65 years. What treatment options are available?

Management of massive rotator cuff tears is a therapeutic challenge in patients younger than 65 years, particularly if still working. According to our hypothesis, choice of the most appropriate treatment option mainly depends on the patient's functional status and on two predictive factors: height of the subacromial space and fatty muscle infiltration. This is a retrospective, multicenter study of a series of 296 patients younger than 65 years, including 176 males and 120 females with extensive or massive cuff tear. Patients had loss of elevation or external rotation or both in 162 cases. Four types of management of massive rotator cuff tear were performed in this study: anatomical watertight repairs, palliative treatments and partial repairs, watertight repairs using flaps or cuff prostheses and reverse shoulder prostheses. At follow-up, the Constant score (65.6+/-3.4) and active elevation (147.7 degrees +/-32 degrees) had significantly improved. Active external rotation with elbow at the side, and acromiohumeral interval (AHI) were unchanged. Work-related injuries, previous surgeries and complications were correlated with a poorer Constant score. At follow-up, the anatomical repair sub-group had a significantly better Constant score than the three other treatment groups but involved patients with unchanged AHI and a low degree of fatty infiltration of the infraspinatus muscle. The reverse shoulder prostheses sub-group showed better outcomes in terms of function benefits. The presence of a long biceps was correlated with the use of a palliative treatment. In the light of the results and literature, an approach to treatment is suggested related to the functional capacity of patients, the AHI and the degree of fatty infiltration of the infraspinatus and subscapularis muscles.

[Computer assisted orthopedics surgery]. / L'expérience de la navigation chirurgicale dans l'ouest.

Computer-assisted surgery has become commonplace in orthopedic surgery. The number of applications grows steadily as does the number of patients benefiting from these new techniques. The hearty debates heard when these techniques were first introduced have now given way to more evidence-based evaluation. Our objective here is to continue this approach by presenting our six-year experience with navigation. We will not discuss the theoretical background of these technologies nor attempt to present an exhaustive review of the literature but rather focus attention on surgical skills acquired by a group of surgeons working in a wide range of areas. The common point is that all have now integrated computer-assisted navigation into their routine surgical practices including: a) first-intention and revision knee arthroplasty; b) hip arthroplasty; c) anterior cruciate ligament surgery; d) proximal tibial osteotomy; e) shoulder arthroplasty. We will terminate this round table with a presentation of future technological advances and propose our advice for an increasingly widespread use of these new techniques.

[Deltoid muscle flap for massive rotator cuff tears: 41 cases with a mean 7-year (minimum 5 year) follow-up]. / Le lambeau deltoïdien dans les ruptures massives de la coiffe des rotateurs: quarante et un cas avec un recul moyen de 7 ans (minimun 5 ans).

PURPOSE OF THE STUDY: The aim of this study was to assess outcome after deltoid muscle flap repair of massive rotator cuff tears. We examined functional and radiological results at least five years after surgery. MATERIAL AND METHODS: We reviewed 41 shoulders operated by three senior surgeons (MC, DK, HT). None of the patients were lost to follow-up. The global Constant score was used for pre- and postoperative functional assessment. Three groups were distinguished by preoperative active flexion (group I<90 degrees, group II 90 degrees -120 degrees, group III > 120 degrees ). AP, double oblique (3 rotation views to measure the subacromial space), and Lamy lateral radiographs were obtained in all patients. Shoulder anatomy was evaluated at last follow-up in eight patients: magnetic resonance imaging (MRI) because of persistent pain in one patient and ultrasonography performed by one radiologist (NC) in seven patients. RESULTS: The study population included 26 men and 15 women, mean age at surgery 59 years (42-78, 8). Mean follow-up was 7 years (5-8.5, 0.9). In the coronal plane, there were no distal tears, the stump was in an intermediate position in 7 cases (17%) and retracted to the glenoid in 34 (83%). In the sagittal plane, the supraspinatus exhibited a full thickness tear in all cases. The tear extended anteriorly or posteriorly in all cases. Thirty-eight patients (92%) were satisfied at last follow-up; their global Constant score had improved from 37 to 62 points. Mean anterior flexion improved from 113 degrees to 148 degrees and flexion force from 1.3 kg to 2.9 kg. When preoperative flexion was less than 90 degrees (11 cases), mean gain was + 89 degrees. Inversely, 7 of the 18 patients with flexion > 120 degrees lost a mean 40 degrees at last follow-up. Twenty-seven patient were reviewed at 12 and 89 months: pain relief and force were maintained. The subacromial space, measured in 88% of the cases, was 7.3 mm preoperatively and 5.5 mm at last follow-up. The subacromial space narrowed in 20 patients (56%); none of the patients exhibited an improvement. The flap was explored by ultrasonography in seven patients and by MRI in one: the flap was continuous in 50% and measured more than 4 mm in thickness. Reviews at 12 then 89 months demonstrated good maintenance of pain relief and progression of active flexion and force. DISCUSSION AND CONCLUSION: This long-term study confirms the usefulness of the deltoid flap for the treatment of full thickness massive tears of the rotator cuff. The flap provides persistent pain relief and good function and force. This technique should be discussed for young patients in good physical condition when preoperative imaging demonstrates and irreparable alteration of the tendinomuscular structures (supraspinatus retraction, fatty degeneration, severe amyotrophy). The technique is particularly useful when preoperative flexion is less than 90 degrees. Although the population size is too small for statistical analysis, indications for deltoid flap repair should probably be limited to tears involving at most two tendons and sparing the subscapularis.

[Periprosthetic ossifications of the hip: role of the duration of postoperative indomethacin therapy in the prevention of ossifications and role of screwed acetabulum in the occurrence of ossification]. / Les ossifications péri-prothétiques de hanche: influence de la durée du traitement post-opératoire par l'indométacine sur la prévention des ossifications et influence du cotyle vissé sur l'apparition des ossifications.

After showing, as many others did, in an article published in 1987, that indomethacin administered immediately after surgery and for about 3 weeks at a dose of 75 mg/day effectively protected THA against heterotopic ossification, the authors have searched whether treatment duration could be reduced, and to investigate the existence of risk factors other than those classically known. They studied the prevalence of heterotopic ossification in two groups of THA with known risks of ossification, one with one-week prophylaxis, the other with two-week prophylaxis using Indomethacin. The results obtained were compared with a third group of THA performed during the same period, which presented no known risk of ossification and were not treated with indomethacin, and with the THAs of the initial study, where indomethacin had been administered for 3 weeks. Occurrence of heterotopic ossification was equally prevented by an 8-day course and by a longer one. No etiological, radiological or pathological risk factor other than those described in 1987 were fund (with all due caution given to hips re-operated on that had not ossified the first time): in contrast, the type or acetabular cup appears to have some influence on the occurrence of HO: uncemented prosthesis clearly favours ossification.

[Ulnar translocation of the carpus after surgery of the rheumatic wrist. Review of 54 cases]. / Le glissement ulnaire du carpe après chirurgie du poignet rhumatoïde (54 cas revus).

Fifty-four rheumatoid wrists, on which synovectomy and caput ulnar resection had been performed, were re-examined 1 to 8 years after the operation (average follow-up: 3.8 years). The clinical results were good, and the wrists pain-free in 91 per cent of cases, with a low rate of synovitis recurrence (4 per cent), and 88 per cent of the mobility in the sagittal plane was preserved. Radiological examination revealed a moderate aggravation of carpite over the years. This evolution was not linked, however, to the fact that no intracarpal synovectomy was performed in our series since a similar evolution has been reported by authors who carry out this synovectomy. Ulnar translocation of the carpus was commonly measured in relation to the ulna axis, but as the latter tends to get into a more medial position after the surgery this analysis was incorrect. Ulnar translocation should be measured in relation to the axis of the radius, which remains in the same position. Studied in this way, the average translocation in this whole series was 2 mm. A comparative study of the operated wrist and the non-operated wrist in 27 patients revealed a significant aggravation (p < 0.2) of ulnar translocation of the carpus at radiological stages 2 and 3. This translocation remained however minimal. A combined transfer of the extensor carpi radialis brevis or longus onto the extensor carpi ulnaris did not slow down ulnar translocation of the carpus, but the other hand it improved the correction of radial deviation of the carpus and ulnar deviation of the fingers.

[Early weight-bearing after osteosynthesis by THS hip screw in cervico-trochanteric fractures]. / L'appui précoce après ostéosynthèse par vis plaque THS des fractures cervico-trochantériennes.

A second generation hip screw was designed in the laboratory to allow unlimited immediate weight-bearing in elderly patients with cervico-trochanteric fractures. The use of this device in 300 operated patients demonstrated that it provided the same capacity for weight-bearing as total hip prostheses, but with a lower morbidity and better and longer lasting functional results. Thus, in patients with a mean age of 77 years, one half of whom suffered from an unstable fracture: the operation was minimally traumatic (reduction on an orthopaedic table, no surgical access to the fracture site, operating time less than one hour); complications were consequently rare (no deep sepsis, no dislocation) in contrast with 5 to 10% of deep sepsis or dislocation with prostheses; early unlimited weight-bearing was permitted by the 5th day in every case and was achieved by the 10th day in more than 80% of cases (30% of whom were able to walk unassisted with crutches); an essential point, the design of the material prevented dismantling on weight-bearing and preserved the morphology of the hip (telescoping of the fracture site never exceeded 20 mm, mean:11 mm). Consolidation was obtained in every case by 6 to 8 weeks. The mortality at 3 months was identical to that observed with prostheses (18%, related to physiological age). The length of hospital stay and the duration of rehabilitation were considerably shortened, as 37% of patients returned to their previous residence by the 45th postoperative day. This resulted in a marked saving in medical costs for each patient (as patients previously returned home after an average of 145 days).(ABSTRACT TRUNCATED AT 250 WORDS)

[Digital reimplantations and revascularizations. Factors of preservation. 183 fingers]. / Réimplantations et revascularisations digitales. Facteurs de conservation. A propos de 183 doigts.

The causes of vascular failures of a series of 183 injured fingers treated by microsurgery (80 reimplantations, 103 revascularisations) were investigated. This consecutive series was characterised by the fact that the operation was performed even in the presence of classical factors of poor prognosis: patients over the age of 40 years (27%), smoking (51%), crush injury or avulsion (32%), ischaemia time longer than 7 hours (46%). The overall intraoperative and postoperative failure rate was 49% (69% in reimplantations and 31% in revascularisations). Preoperative factors (age, smoking, mechanism, ischaemia time) were not sufficiently important to constitute contraindications to vascular microsurgery. Only storage of the segment in contact with iced water made failure almost certain. Suture of 2 arteries and one or several veins (in the absence of a skin bridge) improved the prognosis. The postoperative use of subcutaneous heparin in reimplantations significantly decreased the failure rate from 77% to 55%. Postoperative surveillance is essential to rapidly detect the arterial or venous mechanism responsible for vascular disorders and to decide appropriate emergency treatment. Arterial ischaemia warrants revision of the sutures with a success rate of about one in two. Disturbances of the venous drainage should initially be treated medically (2/3 of preservation after drainage by leeches), but, when this is not effective, surgical revision salvages one third of failures. Emergency microsurgery units must therefore have access to a specialised postoperative surveillance unit.