Tolerance and microbiological efficacy of cefepime or piperacillin/tazobactam in combination with vancomycin as empirical antimicrobial therapy of prosthetic joint infection: a propensity-matched cohort study.

BACKGROUND: The use of piperacillin/tazobactam with vancomycin as empirical antimicrobial therapy (EAT) for prosthetic joint infection (PJI) has been associated with an increased risk of acute kidney injury (AKI), leading us to propose cefepime as an alternative since 2017 in our reference centre. OBJECTIVES: To compare microbiological efficacy and tolerance of these two EAT strategies. METHODS: All adult patients with PJI empirically treated with vancomycin+cefepime (n = 89) were enrolled in a prospective observational study and matched with vancomycin+piperacillin/tazobactam-treated historical controls (n = 89) according to a propensity score including age, baseline renal function and concomitant use of other nephrotoxic agents. The two groups were compared using Kaplan-Meier curve analysis, and non-parametric tests regarding the proportion of efficacious empirical regimen and the incidence of empirical therapy-related adverse events (AE). RESULTS: Among 146 (82.0%) documented infections, the EAT was considered efficacious in 77 (98.7%) and 65 (98.5%) of the piperacillin/tazobactam- and cefepime-treated patients, respectively (P = 1.000). The rate of AE, particularly AKI, was significantly higher in the vancomycin+piperacillin/tazobactam group [n = 27 (30.3%) for all AE and 23 (25.8%) for AKI] compared with the vancomycin+cefepime [n = 13 (14.6%) and 6 (6.7%)] group (P = 0.019 and <0.001, respectively), leading to premature EAT discontinuation in 20 (22.5%) and 5 (5.6%) patients (P = 0.002). The two groups were not significantly different regarding their comorbidities, and AKI incidence was not related to vancomycin plasma overexposure. CONCLUSIONS: Based on the susceptibility profile of bacterial isolates from included patients, microbiological efficacy of both strategies was expected to be similar, but vancomycin + cefepime was associated with a significantly lower incidence of AKI.

Medial patellofemoral ligament anatomy: implications for its surgical reconstruction.

The purpose of the present study, based on 23 cadaveric knees, was to perform a detailed anatomical analysis of the medial patellofemoral ligament (MPFL), especially its femoral attachment, its relationships with the vastus medialis obliquus (VMO) and the medial collateral ligament, with the objective of improving its surgical reconstruction. The femoral insertion of the MPFL was defined using an orthonormal frame centered on the middle of the femoral MPFL insertion. The whole measurements were taken using a millimetric compass with a precision of +/-1 mm. The MPFL was always observed, its length was 57.7 +/- 5.8 mm, the junction between the VMO and the MPFL always present measured 25.7 +/- 6.0 mm. When it comes to MPFL reconstruction, the key point is its positioning in the femoral insertion because it is this insertion that is going to restore isometry. By using the orthonormal frame it has to be positioned 10 mm behind the medial epicondyle and 10 mm distal to the adductor tubercle.

Microbiologic epidemiology depending on time to occurrence of prosthetic joint infection: a prospective cohort study.

OBJECTIVES: The high microbiologic diversity encountered in prosthetic joint infection (PJI) makes the choice of empirical antimicrobial therapies challenging, especially in cases of implant retention or one-stage exchange. Despite the risk of dysbiosis and toxicity, the combination of vancomycin with a broad-spectrum ß-lactam is currently recommended in all cases, even if Gram-negative bacilli (GNB) might be less represented in late PJI. In this context, this study aimed to describe the microbiologic epidemiology of PJI according to the chronology of infection. METHODS: This prospective cohort study (2011-2016) evaluated the microbiologic aetiology of 567 PJI according to time of occurrence from prosthesis implantation-early (<3 months), delayed (3-12 months) and late (>12 months)-as well as mechanism of acquisition. RESULTS: Initial microbiologic documentation (n = 511; 90.1%) disclosed 164 (28.9%) Staphylococcus aureus (including 26 (16.1%) methicillin-resistant S. aureus), 162 (28.6%) coagulase-negative staphylococci (including 81 (59.1%) methicillin-resistant coagulase-negative staphylococci), 80 (14.1%) Enterobacteriaceae, 74 (13.1%) streptococci and 60 (10.6%) Cutibacterium acnes. Considering nonhaematogenous late PJI (n = 182), Enterobacteriaceae (n = 7; 3.8%) were less represented than in the first year after implantation (n = 56; 17.2%; p <0.001), without difference regarding nonfermenting GNB (4.6% and 2.7%, respectively). The prevalence of anaerobes (n = 40; 21.9%; including 32 (80.0%) C. acnes) was higher in late PJI (p <0.001). Consequently, a broad-spectrum ß-lactam might be useful in 12 patients (6.6%) with late PJI only compared to 66 patients (20.3%) with early/delayed PJI (p <0.001). CONCLUSIONS: Considering the minority amount of GNB in late postoperative PJI, the empirical use of a broad-spectrum ß-lactam should be reconsidered, especially when a two-stage exchange is planned.

[Functional range of motion of the hip joint]. / La mobilité fonctionnelle de l'articulation de la hanche.

PURPOSE OF THE STUDY: The functional mobility of a joint represents the range of motion healthy individuals require to fulfill everyday life tasks. Oscillation angle corresponds to the entire range of motion that can be achieved by the joint. Wedge opening and direction are the characteristic features. We describe the characteristics of functional mobility of the hip joint in healthy subjects. MATERIAL AND METHODS: Hip motion was analyzed in twelve healthy subjects aged 22 to 25 years. The three dimensional analysis used the Motion Analysis System (Motion Analysis Corporation, Santa Rosa, CA) at a frequency of 60 Hz. MatLab software was used to modelize a prosthesis and determine the oscillation angle and its direction as a function of implant position and head-to-neck ratio. After determining the hip center for each individual subject, the range of motion necessary to complete a task was given by the maximal angle along each anatomic axis needed to reach a given position in comparison with the resting position. The following tasks were studied: sit to stand motion, lifting weight from a squatting position, reaching the ground with both legs abducted in extension, walking, ascending and descending stairs, getting on a bicycle, sitting cross-legged, cutting toenails. Whether or not the task could be achieved with the prosthetic conformation was then determined. RESULTS: Each task was described as a combination of motion in the three anatomic axes. Lifting weight from a squatting position combined flexion (110 degrees), abduction (9 degrees) and external rotation (18 degrees) with a standard deviation of 9 degrees. For a given task, only a few combinations of femoral and acetabular orientations were compatible with completion of that task. Combining the motions required for several tasks diminished the possible orientations for prosthetic positioning. DISCUSSION: Analyzing the motion required for these tasks shows the maximal range of motion involved in each direction. There was very little variability among healthy subjects. These results are in agreement with other values determined with other methods. Compensatory mechanisms used by disabled people to complete different tasks were not taken into consideration. The effects of changing either the head-to-neck ratio or implant position are discussed in relation to completion of a given task.

[Survival of dual mobility socket with a mean 17 years follow-up]. / Etude d'une série de 438 cupules non cimentées à double mobilité

PURPOSE OF THE STUDY: Within the framework of the 2007 symposium of the French Hip and Knee Society devoted to the dual mobility socket, we report a retrospective multicentric series of 438 first-intention total hip prostheses with a dual mobile socket at 17 years mean follow-up. The purpose of our report was to ascertain the 15-year survival and analyze failures. MATERIAL AND METHODS: The series included 438 first-intention prostheses. This was a homogeneous multicentric series. Sockets were: 80 Novae-1 titanium Serf cups and 358 Novae-1 stainless steel Serf cups. All stems were inserted without cement: 185 Pf) stainless steel screwed Serf stems, 228 PRO titanium screwed Serf stems, 25 Corail stems. The mobile polyethylene insert was retaining. All of the heads were 22.2mm chromium-cobalt heads. Degenerative hip disease was the main etiology and mean follow-up was 17.18 years (range: 12-20). Mean age at implantation was 54.8 years (range: 23-87). The actuarial method with 95% interval of confidence was used to determine the 15-year cup survival. RESULTS: At last follow-up, none of the patients had presented an episode of early or late instability. Analysis of the socket at last follow-up showed: 13 aseptic loosenings, 23 intraprosthetic dislocations, and seven replacements of the polyethylene insert for wear. The overall 15-year prosthesis survival was 89.2+/-8.7%. The overall 15-year socket survival was 96.3+/-3.7%. DISCUSSION: The fact that at last follow-up none of the implants had exhibited instability confirms the long-term stability of the dual mobility socket. The results in terms of 15-year survival confirm earlier reports. The main cause of failure was cup fixation, which is the weak point of this technique with the initial Novae cup, which did not have hydroxyapatite coating. The second leading cause was intraprosthetic dislocation, which can be divided into three main categories. The first is intraprosthetic dislocation in a context of pure wear with normal function of the dual mobility; the retaining feature of the insert looses its efficacy due to wear. The second category is intraprosthetic dislocation in a context of cup loosening with a third-body effect and increased retention wear, in which case we consider that the cup loosening is the primary event leading to secondary rapid wear and subsequent intraprosthetic dislocation. The third category is intraprosthetic dislocation cause by a cam effect in a context of fibrosis or impingement involving a large calcification. We have had only two femoral failures by aseptic loosening, most certainly related to use of noncemented implants, which limits the extension of granulomas to the polyethylene. Studying more specifically the three series from Saint-Etienne where three different configurations were used, it would appear that the titanium cup has a better survival and that the titanium used for the thinner necks would be an unfavorable factor for intraprosthetic dislocation.

Long-term survivorship of the Corail™ standard stem.

INTRODUCTION: The Corail™ stem, which was first introduced in 1986, has since been modified twice: first to make the neck thinner and then to change the location of the laser markings. The survival and complications of the first-generation straight, titanium, hydroxyapatite-coated stem are known; however, there is little specific information about the latest-generation stem. This led us to conduct a retrospective study to determine the: (1) long-term survival; (2) clinical and radiographic outcomes; (3) complications; and (4) risk factors for revision of the newest Corail™ stem. HYPOTHESIS: The newest Corail™ AMT (Articul/EZE™ Mini Taper) standard stem has comparable survival to prior models. PATIENTS AND METHODS: This single-center, retrospective study included 133 patients (140 hips), who underwent primary total hip arthroplasty (THA), between January and December 2004, in which a Corail™ Standard stem was implanted using a posterolateral approach. Patients who underwent revision THA, THA due to femoral neck fracture or who received lateralized (offset) stems were excluded. The mean age at the time of THA was 69±13 years [35-92] in 85 men (61%) and 55 women (39%) who had a mean BMI of 27kg/m2±11 [16-39]. At the latest follow-up, 32 patients (32 hips) had died and 8 patients (8 hips) had less than 3 years' follow-up, thus were not included in the clinical evaluation. The Merle d'Aubigné (PMA) score was collected. The stem's survivorship was calculated using the Kaplan-Meier method with revision for aseptic loosening and revision or implant removal for any reason as the end-points. The Cox model was used to analyze risk factors for revision. The mean follow-up was 10±3 years [3-12]. RESULTS: The PMA score was 12±2.6 [5-17] preoperatively and 16±2.7 [7-18] at the last follow-up (P<0.00001). Eighteen complications (12.8%) were recorded at the last follow-up. There were 15 early complications: 6 dislocations, 5 calcar fractures (4 treated by wire cerclage and 1 by stem change plus wire cerclage), 2 greater trochanter fractures (treated non-surgically) and 2 cases of sciatic nerve palsy. There were 3 late complications: 2 cases of iliopsoas irritation and 1 ceramic insert fracture. Stem survival for surgical revision due to aseptic loosening was 98% (95% CI: [0.96-1]). At 12 years, 95% of stems had not been revised or removed (95% CI: [0.92-0.99]). Being less than 58 years of age at the time of surgery was the only risk factor significantly associated with stem revision for any reason (P=0.04). CONCLUSION: Survival of the Corail™ Standard stem is similar to that of previous generation stems. The changes made in this stem solved the neck failure problem and did not induce new complications. LEVEL OF EVIDENCE: Level IV (retrospective study).

Cementless lateralized stems in primary THA: Mid-term survival and risk factors for failure in 172 stems.

INTRODUCTION: Increasing the femoral offset when performing total hip arthroplasty (THA) theoretically increases the stresses and risks of the stem not integrating itself into bone. But this concept has not been validated for cementless stems; this led us to conduct a retrospective study to determine: (1) the risk factors for the occurrence of symptomatic femoral radiological abnormalities, (2) the incidence of these abnormal radiological findings, (3) the revision rate for aseptic non-integration of a cementless lateralized stem. HYPOTHESIS: Young patients with significant femoral canal flare and a small cementless lateralized stem have a higher risk of abnormal osseointegration. MATERIAL AND METHODS: We analyzed retrospectively 172 consecutive lateralized stems (KHO, Corail™ product line) implanted during primary THA between 2006 and 2012 in 157 patients (mean age 68years±12.6 (20-95), 89% men). Radiographs were used to evaluate osseointegration scores, offset restoration and the Noble index. Kaplan-Meier survival analysis was performed using "symptomatic femoral radiological abnormalities" and "revision for aseptic stem non-integration" as endpoints. RESULTS: The mean follow-up was 5.9years±2.7 (range, 2-12.4years). Being more than 70years of age (HR=0.7, 95% CI: [0.3-0.9], P=0.004) and having a larger stem (HR=0.6, 95% CI: [0.4-0.9], P=0.03) were protective against symptomatic femoral radiological abnormalities, while increasing the postoperative femoral offset (HR=1.1, 95% CI: [1.01-1.2], P=0.02) was deleterious. The survival free of "symptomatic femoral radiological abnormalities" was 93% (95% CI: 89-97) at 5years and 84% (95% CI: 75-95) at 8years. The survival free of "revision for aseptic stem non-integration" was 98% (95% CI: 96.8-100) at 5years and 97% (95% CI: 95.2-100) at 8years. DISCUSSION: In this study, the risk factors for symptomatic radiological abnormalities were being less than 70years of age, having a small lateralized stem and restoring a large femoral offset. Lateralized stems used in this study had a 10% rate of symptomatic radiological abnormalities and a 4% rate of revision for aseptic non-integration. LEVEL OF EVIDENCE: IV, retrospective study.

Can a target zone safer than Lewinnek's safe zone be defined to prevent instability of total hip arthroplasties? Case-control study of 56 dislocated THA and 93 matched controls.

BACKGROUND: Various factors contribute to instability of total hip arthroplasty (THA), with implant orientation being a major contributor. We performed a case-control study with computed tomography (CT) data to determine whether: 1) orientation contributes to THA instability and 2) a safer target zone for stability than Lewinnek's classic safe zone can be defined. MATERIAL AND METHODS: We included prospectively 363 cases of THA dislocation that occurred during the calendar 2013 year in 24 participating hospitals. Of the 128 dislocations that occurred in patients who underwent THA at these centers, 56 (24 anterior, 32 posterior) had CT scans, thus were included in the analysis. The control group was matched 4:1 based on implant type, year of implantation, age, sex, bearing types and THA indication. Of the 428 matched control THA cases, 93 had CT scans. In all, the CT scans from 149 cases (56 unstable, 93 stable) were analyzed to determine the acetabular cup's inclination and anteversion, and the femoral stem's anteversion. RESULTS: In the unstable THA group, cup inclination was 46.9°±7.4°, cup anteversion was 20.4°±10.8° and stem anteversion was 14.2°±9.9°. In the stable THA group, cup inclination was 44.9°±5.3° (P=0.057), cup anteversion was 22.1°±5.1° (P=0.009) and stem anteversion was 13.4°±4.4° (P=0.362). The optimal total anteversion (cup+stem) of 40-60° was achieved in 16.5% of unstable THA cases and 13.9% of stable THA cases, thus this parameter does not predict stability (odds ratio [OR] of 0.40, P=0.144). The cup was positioned in Lewinnek's safe zone in 44.6% of patients in the unstable group and 68.2% of those in the stable group (OR 3.74, P=0.003). A target zone defined as 40-50° inclination and 15-30° anteversion was better able to distinguish between unstable cases (23.2%) and stable cases (71.6%) resulting in an OR of 13.91 (P<0.001). DISCUSSION: Implant positioning was the only risk factor for instability found in this study. Moreover, our findings reinforce the theory put forward by other authors that Lewinnek's safe zone is not specific enough to differentiate between stable and unstable THA implantations. The target zone for acetabular cups proposed here (40-50° inclination and 15°-30° anteversion) is related to a lower risk of instability. This orientation can be used as a guide, but must be combined with other technical elements to optimize stability. By balancing stability and biomechanics, the 40-50° inclination and 15°-30° anteversion target zone redefines the optimal positioning window. LEVEL OF EVIDENCE: III case-control study.

What are the risk factors for dislocation in primary total hip arthroplasty? A multicenter case-control study of 128 unstable and 438 stable hips.

INTRODUCTION: Dislocation after total hip arthroplasty (THA) is a leading reason for surgical revision. The risk factors for dislocation are controversial, particularly those related to the patient and to the surgical procedure itself. The differences in opinion on the impact of these factors stem from the fact they are often evaluated using retrospective studies or in limited patient populations. This led us to carry out a prospective case-control study on a large population to determine: 1) the risk factors for dislocation after THA, 2) the features of these dislocations, and 3) the contribution of patient-related factors and surgery-related factors. HYPOTHESIS: Risk factors for dislocation related to the patient and procedure can be identified using a large case-control study. PATIENTS AND METHODS: A multicenter, prospective case-control study was performed between January 1 and December 31, 2013. Four patients with stable THAs were matched to each patient with a dislocated THA. This led to 566 primary THA cases being included: 128 unstable, 438 stable. The primary matching factors were sex, age, initial diagnosis, surgical approach, implantation date and type of implants (bearing size, standard or dual-mobility cup). RESULTS: The patients with unstable THAs were 67±12 [37-73]years old on average; there were 61 women (48%) and 67 men (52%). Hip osteoarthritis (OA) was the main reason for the THA procedure in 71% (91/128) of the unstable group. The dislocation was posterior in 84 cases and anterior in 44 cases. The dislocation occurred within 3 months of the primary surgery in 48 cases (38%), 3 to 12 months after in 23 cases (18%), 1 to 5years after in 20 cases (16%), 5 to 10years after in 17 cases (13%) and more than 10years later in 20 cases. The dislocation recurred within 6 months of the initial dislocation in 23 of the 128 cases (18%). The risk factors for instability were a high ASA score with an odds ratio (OR) of 1.93 (95% CI: 1.4-2.6), neurological disability (cognitive, motor or psychiatric disorders) with an OR of 3.9 (95% CI: 2.15-7.1), history of spinal disease (lumbar stenosis, spinal fusion, discectomy, scoliosis and injury sequelae) with an OR of 1.89 (95% CI: 1.0-3.6), unrepaired joint capsule (all approaches) with an OR of 4.1 (95% CI: 2.3-7.37), unrepaired joint capsule (posterior approach) with an OR of 6.0 (95% CI: 2.2-15.9), and cup inclination outside Lewinnek's safe zone (30°-50°) with OR of 2.4 (95% CI: 1.4-4.0). DISCUSSION: This large comparative study isolated important patient-related factors for dislocation that surgeons must be aware of. We also found evidence that implanting the cup in 30° to 50° inclination has a major impact on preventing dislocation. LEVEL OF EVIDENCE: Level III; case-control study.

[Survival of cementless dual mobility sockets: ten-year follow-up]. / Survie a dix ans d'une cupule double mobilité non cimentée.

PURPOSE OF THE STUDY: We report a retrospective series of 106 total hip prosthesis with ten years follow-up. The purpose of this study was to analyze survival of cementless dual mobility sockets. MATERIAL AND METHODS: The series included 90 consecutive patients with 106 first-intention total hip prosthesis, all with cementless dual mobility sockets. All prosthesis (Novae-1 socket and Profil-1 stem, Serf) were implanted within a 6-month period. The stainless steal socket was coated with alumina and had two short anchorage studs and a superior mooring screw and a polyethylene retentive liner. The stem had a 22.2 mm chromium cobalt head. The main indication for arthroplasty was degenerative joint disease. Mean age at implantation was 56 years (range 23-87). All patients were seen for physical examination and x-rays every two or three years. We noted cup survival at ten years (actuarial method), defining surgical revision for cup replacement due to an aseptic cause as the endpoint. RESULTS: Twelve patients died during the 10-year follow-up and one was lost to follow-up. The Postel-Merle d'Aubligné score improved from 7.1 preoperatively to 15.8 at ten years. There were two isolated acetabular loosenings, two intra-prosthetic dislocations due to advanced wear of the polyethylene insert. The overall survival rate of the socket was 94.6% at ten years. There were no episodes of prosthetic instability in this series. DISCUSSION: This study demonstrates the good ten-year survival of the dual mobility socket, comparable to that of conventional prostheses. The absence of any case of prosthetic instability in this series confirms the good short-term and long-term stability of the dual mobility socket. Intraprosthetic dislocation, due to loss of the polyethylene retaining ring is the main limitation of this method. The incidence was however low (2% at ten years) and treatment was not a problem. We recommend using the dual-mobility socket as the first-intention implant for patients with a high risk of post-operative instability, but also recommend it for all patients aged over 70 years since instability is the leading cause of surgical revision after this age.

[Iliopsoas bursal distension revealing complication of total hip arthroplasty: five cases]. / Masse inguinale révélatrice d'une complication d'une arthroplastie totale de hanche: A propos de 5 cas.

The iliopsoas bursa is situated immediately anterior to the hip joint. Communication can develop between a hip prosthesis and the iliopsoas bursa leading to distension and formation of an inguinal mass revealing complication of total hip arthroplasty. We report five clinical cases. The five patients with a total hip arthroplasty developed a mass in the Scarpa triangle which correlated with defective prosthesis function. We chose not to dissect the cystic mass but to treat the intra-articular cause. Symptoms resolved after the intervention in all cases. This rare condition should be envisioned if an inguinal mass develops or has a functional impact, particularly on the lymphovenous circulation. Anatomic relations can be distinguished with computed tomography. Prosthetic complications include infection, loosening or wear. The work-up should include search for infection and standard x-rays of the hip joint. Before surgery, duplex Doppler should be performed systematically to search for a thromboembolic complication.

Cementless Corail™ femoral stems with laser neck etching: Long-term survival, rupture rate and risk factors in 295 stems.

INTRODUCTION: Implant neck fracture involving a non-modular femoral stem is rare in primary total hip arthroplasty (THA). Occasional cases have been reported following laser etching of the Corail(tm) stem, but risk factors have not been precisely determined. We therefore performed a retrospective study on a series of Corail(tm) stems with laser neck etching, in order to: (1) determine the exact implant neck fracture rate at 10 years, and (2) identify associated risk factors. HYPOTHESIS: Laser etching increases the rate of implant neck fracture. MATERIALS AND METHODS: Between October 2002 and December 2003, 295 THAs were consecutively performed using the Corail(tm) stem with laser neck etching, in 286 patients: 151 male (53%), 135 female (47%); mean age, 63 years (range, 18-89 years); mean weight, 73kg (range, 45-120kg). Stems were standard in 240 cases (81%) and lateralized in 55 (19%). The main assessment criterion was stem replacement for implant neck fracture. RESULTS: At a mean 10 years' follow-up (range, 1-11 years), 11 patients were lost to follow-up (4%) and 35 had died (12%) (with stem in situ). Overall 10-year stem survival was 91% (95% CI: [87-94%]). Sixteen patients (5.4%) underwent revision surgery for implant neck fracture, 6 (2%) bone and joint infection and in 4 cases (1.3%) the stem was replaced preventively for fracture risk suspected during a revision procedure on the cup. All fractures were of the fatigue type, implicating implant neck laser etching. Mean time to fracture was 4.5 years (range, 1.4-9.8 years). Risk factors comprised: weight>80kg (P=0.002) (OR=5.7; 95% CI: 1.9-17), age<60 years (P=0.02) (OR=3.4; 95% CI: 1.2-9.6), male gender (P=0.01) (OR=14.8; 95% CI: 1.9-113) and lateralized stem (P<0.001) (OR=6.5, 95% CI: 2.3-18). CONCLUSION: The present 5.4% fracture rate was higher than in registry data (<1%). Fracture mechanisms involved excessive stress in an area under tension, leading to fatigue fracture. Male gender, high weight and young age were risk factors, as in the literature for fatigue fracture. Location and depth of laser etching induced fatigue fracture. The study demonstrated that laser etching creates an area of weakness in the implant neck and should therefore be eschewed in this part of the femoral stem. LEVEL OF EVIDENCE: IV, retrospective study.

[Dual articulation retentive acetabular liners and wear: surface analysis of 40 retrieved polyethylene implants]. / Analyse de surface après explantation de 40 cupules rétentives en polyéthylène à double mobilité

PURPOSE OF THE STUDY: The original concept of dual articulation retentive liners has been implemented in routine clinical practice for total hip arthroplasty since 1976. The retentive liner improves stability and the dual mobility favors preservation of joint motion. In this study, we analyzed wear of the two concave and convex surfaces in 40 retrieved polyethylene implants in order to search for factors favoring wear. MATERIAL AND METHODS: Forty polyethylene inserts were examined. These implants had been removed after mean implantation of eight years. Mean patient age at implantation was 48 years. The inserts were removed because of prosthesis infection or mechanical failure. Macroscopic examination was followed by a surface analysis with direct measurement of alterations of the curvature radii. Internal concavity was measured in the three dimensions using a 4-mm stylus (BNH 706). External convexity was measured by lateral projection. The estimated error was +/- 5 microm for both measurement methods. Manufacturers' tolerances for these implants were approximately 50 microm. Linear and volumetric wear was determined by comparing the measured dimensions with the theoretical dimensions of new inserts. RESULTS: Macroscopically, all of the pieces studied had lost their initial striation on the convex surface; 40% of the pieces displayed visible wear of the retentive collar. Mean annual wear was 9 microm (SD 9microm) for the convex surface and 73 microm (SD 69 microm) for the concave surface. Mean total wear, taken as the sum of the wears on the convex and concave surfaces was 82 microm (SD 72 microm). Volumetric wear was 28.9 mm3/yr for the convex surface (SD 27.6) and 25.5 for the concave surface (SD 23.2) giving a mean annual total volumetric wear of 54.3 mm3/yr (SD 39.6). DISCUSSION: Total wear observed for these 40 dual articulation liners which had functioned in vivo was to the same order as reported for the metal-polyethylene bearing with 22.2 mm femoral heads. Considering the wear on both the convex and concave surface, the dual articulation was not associated with increased wear compared with the conventional metal-polyethylene bearings, but with the advantages of retention and greater stability. CONCLUSION: Use of a dual articulation acetabular liner is an attractive solution when a metal-polyethylene bearing is considered. The benefit in terms of joint stability does not increase wear.

Does arthrodesis of the first metatarsophalangeal joint correct the intermetatarsal M1M2 angle? Analysis of a continuous series of 208 arthrodeses fixed with plates.

INTRODUCTION: First-ray metatarsophalangeal arthrodesis is a classic surgical procedure in the treatment of severe hallux valgus, hallux rigidus, revision surgery, and inflammatory arthritis. The objective of this study was to verify if metatarsophalangeal plate arthrodesis could correct the M1M2 intermetatarsal angle. MATERIAL AND METHODS: This prospective and continuous series (June 2007 to March 2011) included 208 patients (48% severe and/or arthritic hallux valgus, 18% hallux rigidus, 16% rheumatoid forefoot, 13% surgical revision of the first ray, 5% hallux varus), with a mean age of 62.4±9.9 years (range, 19-87 years). All the patients were operated on by a senior surgeon with the same technique: spherical avivement of the joint surfaces using reamers, osteosynthesis with an anatomic plate (Fyxis-Biotech™) in Ti.6Al.4 V alloy prebent to 5° with a phalangeal arm to receive an oblique metatarsophalangeal screw in compression, in addition to four 2.7-mm nonlocking dorsal screws. The full-scale preoperative and intraoperative angle measurements were taken on AP and lateral X-rays of the weightbearing foot, as related to the etiology and the severity of the preoperative metatarsus varus (M1M2<15°, M1M2 15-19°, M1M2≥20°). The statistical analysis was done using the StatView software. RESULTS: The mean follow-up was 18.6±12.4 months (range, 2-76 months). Nearly all of the arthrodesis patients (97%) achieved bone union, and 5% of the plates were removed. The M1P1 angle decreased from 33.8±19.7° (range, -45° to -67°) preoperatively to 13.3±5.3° (range, 0-32°) at the last follow-up, and the M1M2 angle from 14.2±5.4°(range, 0-26°) to 6.5±2.3° (range, 0-12°). The preoperative M1M2 angle was <15° in 97 patients, 15-19° for 78 patients, and ≥20° for the 33 others; at the last follow-up it was 5.8±2.1° (range, 0-10°), 6.7±2.2° (0-10°), and 8.1±2.4° (3-12°), respectively. No correction of the metatarsus varus was demonstrated in relation to etiology. The M1M2 angle was >10° in only two patients (one case of rheumatoid arthritis and one case of severe hallux valgus): 0.9%. DISCUSSION: These results show that isolated metatarsophalangeal arthrodesis of the first ray can correct metatarsus varus even in substantial deformations in any etiology. LEVEL OF PROOF: Level II cohort study.

Compared fixation and survival of 280 lateralised vs 527 standard cementless stems after two years (1-7).

BACKGROUND: Restoring the native hip anatomy increases hip prosthesis survival, whereas increased femoral lateralisation creates high torque stresses that may alter prosthesis fixation. After finding lucent lines around cementless lateralised stems (Corail™, DePuy Synthes, St Priest, France) in several patients, we evaluated the effects of lateralisation in a large case-series. The objective of our study was to compare lateralised vs standard stems of identical design in terms of radiological osteo-integration and survival. HYPOTHESIS: Lateralised stems, despite being used only when indicated by the anatomical parameters, carry a higher risk of impaired osteo-integration. MATERIALS AND METHODS: A retrospective study was conducted in 807 primary total hip arthroplasties (THAs) performed between 2006 and 2010 in 798 patients with a mean age of 65 ± 14.2 years. Lateralised stems were used in 280 cases (Corail High Offset KHO, n = 169; and Corail coxa vara KLA, n = 111 cases) and standard stems in 527 cases (Corail KA). Mean follow-up was 2.3 years (range, 1-7 years). The clinical evaluation included determination of the Postel-Merle d'Aubigné (PMA) score. Bone fixation and stability of the implants were assessed by determining the Engh and Massin score and the ARA score on the radiographs at last follow-up. Femoral, acetabular and global offset values were determined before and after THA. Nobles's Canal Flare Index was computed. Survival was estimated using the Kaplan-Meier method with surgical revision for aseptic loosening as the end-point. RESULTS: The PMA score improved from 12 (10-15) pre-operatively to 17.7 (14-18) (P < 0.05). After THA, in the lateralised stem group, femoral offset was restored in 217 (77%) hips and the mean change vs the pre-operative offset value was -2 mm; in the standard stem group, femoral offset was restored in 440 (83.5%) hips and the mean change was +1 mm. The Engh and Massin score values were similar in the standard stem and lateralised stem groups (24.4 ± 2.2 and 22.6 ± 2.4, respectively, NS). Revision for aseptic loosening was required in 5 patients with lateralised stems (3 KHO and 2 KLA) versus none of the patients with standard stems. There were no cases of excessive femoral offset and the mean change in offset was -2.3mm (-5.3 to -1.1). Noble's index was increased (4.27 ± 0.5 for the loosened lateralised stems, 3.65 ± 0.8 for the well-fixed lateralised stems and 3.82 ± 0.6 for the standard stems), with no significant difference across groups. Overall survival after 3.5 years of follow-up was 94.6% (95% confidence interval, 88.4-100%) with lateralised stems and 100% with standard stems (P < 0.05). DISCUSSION: The risk of aseptic loosening was significantly higher with the lateralised stem (5/280, 1.8%) than with the standard stem (n = 0). Our findings indicate a need for careful preparation to obtain primary fixation of lateralised stems. LEVEL OF EVIDENCE: III, retrospective case-control study.

Similar levels of pain are reported in forefoot surgery after management as a day case and admission for 48 hours: A continuous prospective study of 317 patients.

While many forefoot procedures may be performed as a day case, there are no specific guidelines as to which procedures are suitable. This study assessed the early post-operative pain after forefoot surgery performed a day case, compared with conventional inpatient management. A total of 317 consecutive operations performed by a single surgeon were included in the study. Those eligible according to the criteria of the French Society of Anaesthesia (SFAR) were managed as day cases (127; 40%), while the remainder were managed as inpatients. The groups were comparable in terms of gender, body mass index and smoking status, although the mean age of the inpatients was higher (p < 0.001) and they had higher mean American Society of Anaesthesiologists scores (p = 0.002). The most severe daily pain was on the first post-operative day, but the levels of pain were similar in the two groups; (4.2/10, SD 2.5 for day cases, 4.4/10, SD 2.4 for inpatients; p = 0.53). Overall, 28 (9%) of patients who had their surgery as a day case and 34 (11%) of inpatients reported extreme pain (≥ 8/10). There were more day case patients rather than inpatients that declared their pain disappeared seven days after the surgery (p = 0.02). One day-case patient with excessive bleeding was admitted post-operatively. Apart from the most complicated cases, forefoot surgery can safely be performed as a day case without an increased risk of pain, or complications compared with management as an inpatient.

[Total hip arthroplasty. Risk factors and prevention of iatrogenic vascular complications]. / Arthroplasties totales de hanche. Facteurs de risque et prévention descomplications vasculaires iatrogènes.

Vascular injuries during orthopaedic hip surgery are rare. However, they must always be feared because they threaten life and limb. We present 11 vascular injuries observed over a 12-year period. Seven women and 4 men, treated by elective surgery, presented 14 vascular injuries (6 arterial, 5 venous and 3 prosthetic vascular graft). Four injuries occurred during revision procedures. They were all operated as an emergency for ischaemic syndrome (6 cases) and/or haemorrhage (7 cases). Four patients (37%) died and 4 developed sequelae, various directly attributable to the vascular injury. In the light of these cases, we tried to determine the various mechanisms of the injury and the orthopedic and vascular risk factors. Preoperative detection and well defined therapeutic rules are very important for the prevention of these severe vascular accidents.

[Value of percutaneous core needle biopsy in the investigation of a suspected bone tumor]. / Intérêt de la biopsie percutanée des lésions osseuses d'allure tumorale.

PURPOSE: To Determine the value of percutaneous core needle biopsy in the investigation of a suspected bone neoplasm. MATERIAL AND METHODS: We performed a retrospective study of 91 core needle biopsies performed between May 1995 and October 2001. Patients were excluded if they had a known primary carcinoma or if an infection was suspected by clinical, physical or laboratory findings. The results were correlated to the analysis of the surgical piece or, for the 28 patients who did not undergo surgery, to the clinical evolution over more than 12 months. RESULTS: The final diagnosis was metastasis in 29 cases, primary bone tumor in 36 cases and benign lesions in 25 cases. Sensitivity was 92.3% and specificity was 97.4%. For primary malignant bone tumors, results respected histology features and grade in 79.2%. In cases of mistake, because of the correlation of these results to the clinical and radiological context, the treatment of the bony malignant lesions were adapted in 95.8% of cases. Only one major complication was reported in these 91 biopsies. CONCLUSION: First intention core needle biopsy, confronted with radio-clinical context seems to have a place in the evaluation of bone lesions when a tumor is suspected. This technique, less expensive than an open biopsy and with fewer complications, is best performed as part of a multidisciplinary approach with the surgeon's collaboration.

[Iliopsoas impingement in 12 patients with a total hip arthroplasty]. / Le conflit ilio-psoas - prothèse dans les arthroplasties totales de hanche douloureuses.

PURPOSE OF THE STUDY: We report 12 cases of iliopsoas impingement, an under-recognized cause of hip pain in total hip arthroplasty patients. MATERIAL AND METHODS: Between January 1998 and October 2000, we diagnosed 12 cases of iliopsoas impingement among 280 total hip arthroplasty patients with hip pain (4.3%). Our population was composed of 9 women and 3 men aged 62 to 80 years (mean 72 years). Nine patients had a first intention arthroplasty and 3 had a revision prosthesis. Delay from implantation to diagnosis of impingement ranged from 6 months to 5 years. Common cases of pain after hip arthroplasty, infection, loosening, were ruled out in all cases. A standard x-ray series including an AP view of the pelvis, an AP view of the hip and a surgical false-lateral view of the hip as well as a CT scan were obtained when iliopsoas impingement was suspected. The CT series extended from the lower part of the acetabulum through the fixation screws. RESULTS: Pain had been observed immediately after implantation in 10 cases (83%) and in 2 cases (17%) 3 to 5 years later. These patients did not have to use crutches when pain started to develop. Pain projected anteriorly and was always exaggerated when moving from the sitting position to the upright position and when going up stairs. In one patient, palpation revealed a mass in the groin that corresponded to a massive iliopsoas bursitis. Two non-pathognomonic physical signs were found in all cases: groin pain induced by active flexion against force in the lateral reclining position and at hip extension, and pain in the dorsal reclining position at deflexion of the hip, starting at 45 degrees. The standard AP views showed evidence of defective anteversion of 4 press fit cups, 1 off-centered screwed cup and 3 oversized cups. The CT scan demonstrated that the impingement involved the anterior border of the cup applied against the iliopsoas tendon in 8 cases either due to anterior uncovering in a dysplasic hip or anterior cup overhang. In 4 cases the cup fixation screws protruded anteriorly in front of the ilion and came in contact with the posterior aspect of the iliopsoas muscle. A bursitis had developed in 50% of the cases. DISCUSSION: When infection and loosening have been ruled out, hip pain after total hip arthroplasty would suggest a possible impingement of the acetebular component on the iliopsoas muscle due to defective anteversion or centering, the use of oversized cups, and/or the use of fixation screws. We emphasize the importance of a correct position for the cup to avoid an overhanging anterior border and discuss the use of screwed cups for primary total hip arthroplasty and of oversized cups for revision procedures.

[Surgical treatment of acetabular fractures: outcome in a series of 60 consecutive cases]. / Traitement chirurgical des fractures de l'acétabulum: résultats d'une série continue de 60 cas.

PURPOSE OF THE STUDY: The aim of this study was to analyze clinical and radiographic results after surgical treatment of acetabular fractures. MATERIAL AND METHODS: We reviewed 60 consecutive fractures of the acetabulum with loss of joint congruency at mean 5-years follow-up after treatment. There were 49 men and 11 women, mean age 41 years. According to the R.O. grading, the fractures were: 22 class A (33.3%) including 17 type A1, 23 class B (38%) including 10 type B1a2, 14 class C (23.3%) and 1 unclassifiable. Eight of the patients had associated pelvic injury, 40 had hip dislocations and 9 had sciatic nerve injury. Ten femoral head fractures were discovered during the surgical procedure. Three surgical approaches were used: 1) Kocher Langenbeck approach (28 cases), 2) Mears and Rubash triradiate approach (8 cases), 3) extended iliofemoral approach (22 cases), 4) other approaches (2 cases). Anteroposterior and 45 degrees oblique view of the pelvis were obtained for all patients following admission. Computerized tomography scans were performed in all cases. Fracture displacement and congruency of the femoral head with the roof were documented according to the SOFCOT radiographic criteria. The quality of reduction was assessed using the Matta criteria and the Duquennoy and Senegas criteria. Clinical outcome was assessed at follow-up using the Postel-Merle-d'Aubigné score. RESULTS: Anatomic reduction was achieved in 62% of the cases (1 mm or less displacement on all views) and congruency of the femoral head with the roof was excellent in 73% of the cases. Clinical outcome was satisfactory in 80% (excellent or good). Operative complications included significant ectopic bone in 21, and in 2 others sciatic nerve palsy that had resolved at 1 year follow-up. Three patients developed avascular necrosis of the femoral head. DISCUSSION: Clinical outcome depends on the quality of the reduction. Class C and class B fractures with roof injury should thus be treated by large surgical exposure. The triradiate approach increases the incidence of ectopic bone. The higher incidence of ectopic bone in patients treated by osteotomy of the trochanter compared with patients without osteotomy of the trochanter was significant (p<0.05). Avascular necrosis of the femoral head was associated with delayed reduction (66% of the cases). CONCLUSION: Our good clinical results are encouraging; we are pursuing the use of surgical treatment for displaced acetabular fractures. Clinical outcome depends on the use of the appropriate surgical approach.