Cementless modular hip arthroplasty as a salvage operation for failed internal fixation of trochanteric fractures in elderly patients.

Failure of internal fixation of trochanteric fractures requires repeat surgery in order to avoid the risks of complications affecting bedridden patients. This study was conducted to assess the results of hemi- or total hip arthroplasty with a cementless modular femoral stem, as a salvage operation following early mechanical failure of internal fixation. Twenty nine patients with a mean age of 81.1 years (70-91) were included in the study. Fractures extending into the diaphysis and pathological fractures were excluded, as well as patients who presented late complications. A cementless modular stem designed for metaphyso-diaphyseal anchorage was used in all cases. Twenty-two patients underwent hemiarthroplasty and seven total hip arthroplasty. Four patients died within one year and two were lost to follow-up. The remaining 23 patients were followed for a mean of 20 months (range: 6-89). At the time of last follow-up, 20 were ambulatory with (11 cases) or without support (9 cases) and three were bedridden. There were no intra- or postoperative femoral fractures. Two patients presented an early dislocation after bipolar hemiarthroplasty. One was successfully treated by closed reduction; the other underwent revision with a dual mobility acetabular component because of recurrent dislocation. All the patients reported significant pain relief and functional improvement. Subsidence of the stem greater than 5 mm was noted in three cases, without clinical consequences. The cementless modular femoral stem used in this study appeared as a reliable implant. Primary arthroplasty with such an implant could be considered in selected cases such as markedly unstable fractures and in osteoporotic elderly patients.

The percutaneous compression plate (PCCP) in the treatment of trochanteric hip fractures in elderly patients.

We carried out a prospective study to assess the value of mini-invasive osteosynthesis with the PerCutaneous Compression Plate (PCCP) in the treatment of trochanteric hip fractures in elderly patients. Sixty five consecutive patients were included, with an average age at surgery of 84.2 years (range : 63 to 99), with more than 93% ASA 2, 3 or 4 patients. No perioperative complications were noted. All but two patients were ambulatory with weight bearing two days after operation. The postoperative blood transfusion rate was only 25%. No patient was lost to follow-up. We noted 11 deaths (17%) at the end of follow-up (5 during hospitalisation and 6 during the first 9 months). The re-operation rate was 4.5%. Osteosynthesis with the PCCP allows for decreased intraoperative bleeding and minimises injury to muscle and tendon structures. The stability and quality of the construct enable early recovery of patients while limiting morbidity for this type of fracture.

Learning curve for a modified Watson-Jones minimally invasive approach in primary total hip replacement: analysis of complications and early results versus the standard-incision posterior approach.

We analysed the learning curve of an anterolateral minimally invasive (ALMI) approach for primary total hip replacement (THR). The first 42 THR's with large-diameter heads implanted through this approach (group 1) were compared to a cohort of 58 THR's with a 28-mm head performed through a standard-incision posterior approach (group 2). No selection was made and the groups were comparable. Implant positioning as well as early clinical results were satisfactory and were comparable in the two groups. In group 1, the rate of intraoperative complications was significantly higher (greater trochanter fracture in 4 cases, cortical perforation in 3 cases, calcar fracture in one case, nerve palsy in one case, secondary tilting of the metal back in 2 cases) than in group 2 (one nerve palsy and one calcar crack). At 6 months, one revision of the acetabular cup was performed in group 1 for persistent pain, whereas in group 2, we noted 3 dislocations (2 were revised) and 2 periprosthetic femoral fractures. Our study showed a high rate of intra- and perioperative complications during the learning curve for an ALMI approach. These are more likely to occur in obese or osteoporotic patients, and in those with bulky muscles or very stiff hips. Postoperative complications were rare. The early clinical results are excellent and we may expect to achieve better results with a more standardised procedure. During the initial period of the learning curve, it would be preferable to select patients with an appropriate morphology.

Bilateral aseptic necrosis of the outer end of the clavicle.

We describe a 46-year-old woman who presented at intervals of seven years with osteonecrosis of the outer end of both clavicles. The clinical, radiological features and the appearances of the bone scans are described. Although the condition may be confused with osteolysis there is a dear histological distinction between the two conditions. If the symptoms fail to respond to conservative treatment, excision of the outer end of the clavicle is recommended.

Can ischemic hip disease cause rapidly destructive hip osteoarthritis? A case report.

Avascular osteonecrosis of the femoral head (AONFH) usually goes through the four stages described by Arlet and Ficat: normal radiographs, heterogeneity and sclerosis of the femoral head, subchondral fracture with an individualized sequestrum, and secondary osteoarthritis. Arlet and Ficat individualized a specific pattern of AONFH which they called ischemic hip disease, in which cartilage damage seen as concentric joint space loss precedes the bony alterations. Although radiological and pathological studies of ischemic hip disease have been published, no clinical data are available. We report the case of a 65-year-old man admitted for a 1-month history of severe hip symptoms with concentric joint space loss but no osteophytes. Laboratory tests and examination of fluid aspirated from the hip ruled out septic arthritis and inflammatory hip disease. Two magnetic resonance imaging (MRI) studies done 1 month apart showed diffuse edema involving not only the femoral head but also the neck and trochanter, as well as major synovial hypertrophy. This atypical MRI appearance prompted synovial membrane and pertrochanteric core biopsies, which showed reactive synovitis and stage IV osteonecrosis, respectively. The pain, disability, and joint space loss worsened. Total hip arthroplasty was performed 1 month after the biopsy. Histological examination of the femoral head showed diffuse necrosis; no evidence of another condition was found on histological sections of the entire synovial membrane. This case corroborates the hypotheses put forward by Lequesne that some cases of rapidly destructive hip osteoarthritis may be ascribable to ischemia.

A case of malignant primary non-Hodgkin's lymphoma in skeletal muscle treated by exclusive chemotherapy.

Malignant non-Hodgkin's lymphoma (MNHL) is a frequent tumour but a primary intra-muscular location is exceptional. Standard treatment combines wide surgical removal with chemotherapy and radiotherapy. The functional consequences of this large excision are sometimes very unsatisfactory. We report the case of an intra-muscular MNHL of the posterior and internal part of the thigh. The diagnostic was established thanks to selective biopsies. The treatment was purely medical and conservative with chemotherapy after a multidisciplinary oncological discussion. Three years after the treatment, the general state of health is excellent with no signs of local or remote recurrence.

Sexual function before and after primary total hip arthroplasty.

OBJECTIVES: Chronic hip pain can have an impact on the sexual activity of patients, all the more so if they are young. METHODS: Our department undertook a retrospective study using a questionnaire mailed out to 135 patients (58 women and 77 men) under 65 years of age who had undergone a total hip replacement (THA) with primary implant more than 6 months previously. The mean age of the patients was 51.8 years (22-65 years). RESULTS: The age at which sexual difficulties first occurred was on average 45 years (21-63 years), or a mean of 2.5 years after the appearance of hip pain. Nineteen percent of patients considered their sexual difficulties to be severe to extreme. This caused tension or unhappiness in their relationship for 7% of patients. The cause for the difficulty was generally pain followed by stiffness. The patients with the most marked and earliest disorders were young women with hip dislocating anomalies. Multiarticular damage (Charnley C) is a factor which is conducive to difficulties. For patients, total hip replacement is associated with an improvement in sexual relations. The frequency of relations is increased in significantly more women than men, where this is associated with a change in positions practised. Only 17% of patients benefited from information concerning sexual activity after THA (time to resumption and/or at-risk positions). CONCLUSIONS: Sexual difficulties should therefore be taken into account by medical staff, and in particular by the surgeon. He should supply clear information. The subject should not be marginalized and, on the contrary, should be taken into account in the pre- and postoperative assessment.

Intraosseous leiomyoma: a report of two cases.

Intraosseous leiomyoma is an exceedingly rare tumor, with about 15 cases in the literature. Gradually worsening nonspecific pain is the main manifestation. A unilocular or multilocular radiolucency with a rim of sclerosis is seen on standard radiographs. The findings may simulate nonossifying fibroma of a metaphysis or histiocytofibroma of the pelvis. Neither computed tomography nor magnetic resonance imaging can establish the definitive diagnosis, which requires histological examination with immunohistochemistry stains. Intraosseous leiomyosarcoma is the main differential diagnosis. The best discriminating criterion is the mitotic index, which is less than 1 to 4 mitoses per 50 high-power fields in leiomyomas. En bloc excision with wide margins is the treatment of choice for avoiding local recurrences, which are extremely rare.

Osteoid osteoma of the carpal bones. Two case reports.

Osteoid osteoma rarely develops in the wrist. The symptoms resemble atypical tenosynovitis, with variations according to the location of the tumor. As a result, diagnostic wanderings are common. In addition, the pain may seem related to an injury, as illustrated by two cases reported herein. Conventional investigations often fail to contribute to the diagnosis. The most specific investigation is thin-slice computed tomography (CT), which can be coupled to magnetic resonance imaging. CT typically visualizes a round lucency surrounded by a rim of sclerosis; in addition, CT shows the exact location of the tumor, particularly relative to neighboring joints. Complete excision of the nidus must be achieved to ensure a permanent cure. Same-stage carpal bone fusion may be required in patients with extensive joint involvement.

Compressive intrapelvic synovial cysts: an early complication of an HA-coated cup.

Synovial cysts arising from the hip are not common but can develop in response to intraarticular derangement and increased intraarticular pressures. We present a case of a compressive intrapelvic synovial cyst 3 years after a total hip replacement with a hydroxyapatite-coated acetabular component. At surgery, cracking of the coating of the acetabular component was observed in the areas where the cup was not covered by host bone. The cyst was excised and the bearing surface was replaced. Three years after surgery there has been no recurrence. Migration of hydroxyapatite granules from uncovered portions of hydroxyapatite-coated cups may be a source of third-body wear and could accelerate synovial cyst formation.

High prevalence of erectile dysfunction in young male patients after intramedullary femoral nailing.

OBJECTIVES: To evaluate, given the central role of the pudendal nerves in erection, the impact of potential infraclinical lesions on male sexual function. After intramedullary femoral fixation, countertraction on the fracture table has sporadically been involved in pudendal neurapraxia. Patients with tibial fractures served as controls. METHODS: A total of 168 patients treated for femoral or tibial shaft fractures by intramedullary nailing were mailed the International Index of Erectile Function questionnaire, which addresses all aspects of male sexual function and permits grading of the severity of erectile dysfunction (ED). Univariate and multivariate analyses were conducted to test for factors associated with ED. RESULTS: Of the 168 patients, 101 (60.1%) returned the questionnaire. A greater proportion of ED was observed in sexually active patients after femoral fracture than after tibial fracture (40.5% versus 12.5%, P <0.01). The differential prevalence of ED in both groups subjected to comparable high-energy trauma suggested that post-traumatic stress disorder was of marginal importance in ED occurring after femoral nailing. Greater intraoperative doses of curare were associated with better sexual functioning in sexually active patients after femoral fracture (10.6 versus 7.5 mg in patients without and with ED, respectively, P = 0.02), suggesting that postoperative ED could be partially prevented by optimal muscle relaxation during fracture reduction. CONCLUSIONS: Erectile dysfunction was shown to be highly prevalent after intramedullary nailing of femoral shaft fractures. Greater intraoperative curare doses, resulting in optimal relaxation and reduced pressure on the pudendal nerves by the perineal post, were associated with better sexual functioning.