Monocyte procoagulant activity and membrane-associated D dimer after knee replacement surgery.

We have recently shown that monocyte membrane-associated cross-linked fibrin derivatives (D dimer) can be evidenced by immunogold staining. Using this method, the procoagulant activity (PCA) expressed in vitro by endotoxin-stimulated monocytes has been found to correlate significantly with the number of D dimer-positive monocytes. The incidence of postoperative thrombosis in patients undergoing total knee replacement has been reported by Stulberg et al to be 57%. Since monocytes can play a role, via increased PCA, in the activation of intravascular coagulation, we sought to determine the level of monocyte PCA ex vivo after knee replacement surgery and its possible correlation with the number of D dimer-positive monocytes. Finally, we examined the possible link between these modifications and the occurrence of postoperative deep vein thrombosis (DVT). The PCA expressed by monocytes with or without suboptimal stimulation, the number of D dimer-positive monocytes and the plasma level of D dimer were measured pre- and post-operatively in 11 patients undergoing total knee replacement. Phlebography was performed on day 10 after surgery. A significant increase in the PCA of stimulated monocytes was observed on day 10 after surgery. Moreover, both the number of D dimer-positive monocytes and the plasma level of D dimer increased significantly post-operatively. The number of D dimer-positive monocytes correlated with both monocyte PCA and the plasma D dimer level. The relation between these parameters is discussed. However, neither monocyte PCA nor the number of D dimer-positive monocytes was found to correlate with the occurrence of deep vein thrombosis.

Results of 203 total hip replacements using a smooth, cementless femoral component.

We implanted 203 smooth-stemmed femoral components before January 1988. The femoral component used was anatomically shaped, fluted and made of titanium. Thirty-two hips were revised due to mid-thigh pain, and the femoral implant was found to be loose in all. In the 157 patients with a two-year follow-up, the Merle d'Aubigné and pain scores for completely cementless arthroplasties were similar to those for hybrid prostheses (cemented acetabular cup and cementless femoral stem). Of the 145 cases with two-year radiographic follow-up, 59 had extensive radiolucencies and 22 were unstable. The five-year cumulative survival rate was 77%. Implantation of this stem should be restricted to patients in whom cement fixation is contra-indicated.

Total hip replacement in irradiated hips. A retrospective study of 71 cases.

We retrospectively reviewed 56 patients (71 hips) treated by total replacement for severe disability after pelvic irradiation. Symptoms were associated with various radiological lesions due to irradiation, including atraumatic femoral-neck fracture, osteonecrosis of the femoral head or of the acetabulum, and radiation osteitis of the whole pelvis. From 1970 to 1982 we used standard cemented components in 49 hips and had a high rate of acetabular loosening (52%) at a mean follow-up of 69 months. This was probably due to the mechanical insufficiency of irradiated periacetabular bone. From 1983 to 1990 we routinely used acetabular reinforcement rings. The rate of aseptic acetabular loosening in 22 hips at a mean follow-up of 40 months was 19%, but there were two septic loosenings emphasising the risk of infection in these patients. When total replacement is required for an irradiated hip, we recommend reinforcement of the acetabulum using a metallic ring, but there is still an increased risk of infection and in difficult cases such as severe acetabular destruction or soft-tissue or vascular injuries, a Girdlestone procedure may be indicated.

[Post irradiation bone lesion of the pelvis (author's transl)]. / Les complications osseuses de la radiothérapie du bassin.

Post-irradiation bone lesions of the pelvis, rare but grave functionally, may appear from few months to some years after irradiation. The most severe lesions occur in the hip, with necrosis, fracture or cartilaginous lesions. Radiological appearances may be dissociated, giving a false impression of progression. Undisplaced fractures may consolidate. In other cases an arthroplasty is indicated, often total, but the bad quality of the bone receiving the prosthesis explain certain poor results caused by loosening.

D-dimer and thrombin-antithrombin III complex levels uncorrelated with phlebographic findings in 11 total knee replacement patients.

D-dimer and thrombin-antithrombin III complex (TAT) were assayed in 11 patients at various times pre- and post-operatively in order to determine the possible value of these parameters in screening for thromboembolic complications. Phlebography revealed distal thrombosis in 6 of the 11 patients. The D-dimer level, already elevated before surgery, increased at day 1 and remained high at days 5 and 10. Two methods were used for the assays and showed strongly correlated results. The TAT level increased at day 1 and then progressively returned toward basal values. No difference was observed at any time between patients with or without thrombosis. The results in surgical patients undergoing knee replacement suggest that neither D-dimer nor TAT assays are valid screening procedures for post-operative DVT. Nevertheless, in view of the small number of patient studied, further work is required to confirm these results.

[Prosthetic arthroplasty in recent and old complex injuries of the shoulder]. / L'arthroplastie prothétique dans les traumatismes complexes récents et anciens de l'épaule.

Thirty-four acute and 22 old injuries of the shoulder have been operated on, using either a humeral prosthesis (24 cases) or a total Neer prosthesis (32 cases). The mean age of the patients was 66 years. There were 32 acute and 13 old four-part fractures of the upper end of the humerus and 6 dislocations of the shoulder. The surgical technique and the method of rehabilitation are described. There were 17 post-operative complications, including 4 dislocations, 2 cases of secondary displacements of bone fragments and 2 loosenings of the glenoid component. In only 4 cases was a further operation needed. The results were analysed in 43 cases with a follow-up greater than one year. In 34 cases, there was no pain, but only 17 cases had more than 90 degrees of active flexion. There were no loosenings of the humeral stem. In two cases of humeral replacement, a narrowing of the joint space was noted. There was moderate peri-articular ossifications on 6 occasions. An upward displacement of the prosthesis was noted on 10 occasions, due to rupture of the rotator cuff. The results were much better in acute lesions than in chronic ones. The authors conclude that prosthetic replacement is indicated in severe fractures of the upper end of the humerus, whether acute or chronic, and if the patient is elderly.

[Total hip prosthesis with screw rings. Results over 2 years of a series of 198 consecutive prostheses]. / Prothèses totales de hanche avec des anneaux vissés. Résultats à 2 ans et plus d'une série de 198 prothèses consécutives.

198 screw rings implanted before january 1988, 156 were combined with cementless femoral components, and 42 with cemented femoral components (hybrids). Fifteen cases, which were initially included in the first group, became hybrid at 2 years due to replacement of the femoral component by a cemented stem. 21 screw rings (11 per cent) were revised, and replaced with cemented polyethylene sockets. In 7 cases, acetabular reconstruction was required. Revision was justified by roentgenographic instability in only 6 cases. Four other implants were revised due to persistent postoperative pain, although there was no measurable migration on successive roentgenograms. In the 10 remaining cases, revision was initially justified by the femoral component: screw rings were found to be mobile and were replaced in the same time. Symptoms related to screw rings were easier to identify in hybrid arthroplasties, in which cemented femoral components were usually asymptomatic. Fourty five cases had a complete 2 year follow-up (34 were initially hybrid, 11 became hybrid due to revision of the femoral component). Twenty four patients complained of durable postoperative groin pain. In 18 of these cases, pain completely disappeared within the 18 first months. At 2 years, 28 patients had no pain. In 149 cases with complete 2 year roentgenographic follow-up, 126 implants had never migrated, 6 migrated early but stabilized within the first postoperative year, and 17 showed progressive migration over the first two postoperative years, in which 7 were finally revised. These results are inferior to those reported with cement. Some failures were explained by poor implantation techniques or by wrong indications. Other failures remained unexplained, thus justifying a reduction of their use in our institution.

[Fractures of the tibial spina and tuberosity, or fractures with subluxation of the upper end of the tibia]. / Fractures spino-tubérositaries ou fractures avec subluxation de l'extrémité supérieure du tibia

The authors describe several types of fractures of the upper tibial extremity associating some degree of dislocation of one tibial plateau. They analyse the mechanical conditions of such fractures(axial compression with strain in the frontal plane), describe the associated (menisci, ligaments). Therapeutic conclusions are drawn.

[Fracture-dislocations of the upper end of the humerus]. / Les luxations-fractures de l'extrémité supérieure de l'humérus

30 cases have been collected and treated by the authors. They classify the anatomical types according to the direction and nature of the fracture line. The treatment is more difficult when the fracture is intra-capsular than when it is extra capsular, that is metaphysial or below the tuberosities. A particular type was described, called "vertical fracture" by the authors. The major complication was a persistent joint stiffness, commonly bound to an avascular necrosis of the humeral head, especially in intra-capsular fractures. An orthopaedic reduction should always be attempted when the fracture is impacted. In the other cases, the treatment should be surgical aiming at obtaining a reduction of the dislocation and fixation of the fracture. The opportunity of an early arthroplasty in intra-capsular, comminuted fractures with extruded capital fragments is discussed.

[Surgical treatment of metastases of the acetabulum]. / Le traitement chirurgical des métastases du cotyle.

The lytic metastasis of the acetabulum are frequent, causing pathologic fractures, pain and disability. The authors analyze 42 acetabular metastases operated on between 1976 and 1986. Thirty-nine total hip replacements were made, 9 conventional arthroplasties for minor lesions, and 30 metallo-acrylic reconstructive surgery of the acetabulum combined in 8 cases to bone grafting of more extensive lesions. These arthroplasties allowed immediate weight-bearing. In three cases of very extensive acetabular destructions, hip resections were only possible. The complications were essentially: 3 early deaths, 2 acetabular loosening by tumor osteolysis, and one deep infection. Mean follow-up was 15 months. Results were assessed by pain and walking which are in the whole satisfactory in these patients with limited life expectancy. Surgical indications should be wide in disable patients. It is a palliative surgery aiming to improve the quality of life, giving the patient a functional autonomy.

[Covering losses of cutaneous substance of the leg and foot using skin flaps. Apropos of 76 cases]. / La couverture par lambeau des pertes de substance cutanée de la jambe et du pied. A propos de 76 cas.

Between 1983 and 1987, 76 flap grafts were performed in the leg and foot. In general, 3 types of flap were used: --51 ipsilateral flaps, the majority of which were musculo-cutaneous flaps from the medial head of gastrocnemius (17 cases). --17 cross-leg flaps from the opposite limb, the majority of which were medial fascio-cutaneous flaps (13 cases). --8 free flaps, making use of microsurgical techniques. The indications for cross-leg flaps and free flaps have become more limited in favour of local regional pedicle flaps. The lower part of the leg and amputation stumps in the foot are easily covered by distal leg pedicle flaps and amputation stumps of the upper third of the leg can be covered by a flap of fascia lata with a distal pedicle based on the superolateral branches of the peri-articular plexus of the knee.

[Treatment of aseptic acetabular loosening by reconstruction combining bone graft and Müller ring. Actuarial analysis over 11 years]. / Traitement des descellements acétabulaires aseptiques par reconstruction associant greffe osseuse et anneau de Müller. Analyse actuarielle sur 11 ans.

INTRODUCTION: One reason for the limited longevity of total hip replacement is the progressive bone loss resulting from iterative loosenings of acetabular components. In the early 80's was developed an experience at our institution for revision surgery of aseptically failed cemented acetabular components using a Müller ring. At that time, this device was used in combination with structural grafts. This appeared to us to be the safest method to address severe acetabular destructions. We are now able to report long term results. MATERIAL AND METHODS: We carried out a retrospective study on 81 cemented acetabular revision arthroplasties performed at our institution between 1981 and 1991. In all cases, there was a segmental or an important cavitary roof defect. Reconstruction of the acetabulum was performed using a superior structural bone graft combined with a Müller ring. Results are given with a mean follow up of 8 years (5-14 years), except in the survivor analysis, in which all patients were included. RESULTS: There was 15 iterative aseptic loosenings of the acetabular component (in which 5 repeated revisions). Using iterative aseptic loosening of the acetabular component revised or not as an end point, the 10 year cumulative survival rate (CSR) was 0.72 +/- 0.14 and the 11 year CSR was 0.55 +/- 0.24. The position of the hip biomechanical center, the polyethylene thickness, or the type of the superior defect (segmental or cavitary) were not found to influence significantly roentgenographic results. DISCUSSION: Reconstruction of severely destroyed acetabuli using this method gave satisfactory results within the first decade. However, the hip function could not be reliably maintained over 10 years. Mechanical failures were related to resorption of weight bearing structural bone grafts. Aseptic iterative loosenings are often moderately symptomatic and yearly roentgenographic controls are necessary to detect late migrations. The lack of long term follow up may result in major bone loss, which can impair the conditions of iterative acetabular reconstructions.

[Radiation-induced sarcoma of the hip. Apropos of a case]. / Sarcome radio-induit de la hanche A propos d'un cas.

The authors describe a case of post radiation sarcoma of the hip, rare complication in the post radiation lesions. This case associates a post radiation coxopathy treated by total hip arthroplasty, a socket loosening with pelvic fracture, and a post radiation sarcoma. This last complication was fatal.

[Correction of architectural defects by femoral osteotomy and/or shelf procedure in the treatment of secondary coxarthrosis in adult]. / La correction des vices architecturaux par ostéotomie fémorale et/ou butée dans le traitement des coxarthroses secondaires de l'adulte.

One hundred and forty-nine cases of secondary osteoarthritis of the hip have been analysed. Twenty-eight were treated by a simple shelf operation, 60 by a varus upper femoral osteotomy with or without derotation and 61 by a combination of the two, in an attempt to re-establish the anatomy of the hip to as near normal as possible. The consequences of the operations and their morbidity were analysed for the whole series. Thirty-four patients, only five of whom were operated on both sides were reviewed after a 10 year follow-up or more with 30 good results in 39 hips. The results seem to depend above all on the quality of the articular congruence and the acetabular cover. These procedures are intended, in general, for young adults between 20 and 45 years of age. They can equally be considered up to the age of sixty as an alternative to total hip arthroplasty when the clinical and radiological condition makes it possible.

[Resection-reconstruction of the knee for bone tumor (author's transl)]. / Résection-reconstruction du genou pour tumeur osseuse.

The authors report 17 cases of primary tumors of the knee treated by wide resection, removing "en bloc" the entire epiphysis in 14 cases and in the remaining 3 most of the epiphysis. The series consisted of 8 giant cell tumors of which 6 were followed for between three and fifteen years, and for 9 tumors of moderate malignancy amongst which 1 fibrosarcoma, 1 parosteal osteosarcoma and 3 cartilaginous tumors which were followed between five and fourteen years. All were free of metastatic spread except 1 fibrosarcoma whose resection was debatable. Arthrodesis was carried out on all but 2 patients received prosthesis. The arthrodeses were made by autogenous grafts protected in 11 cases by intramedullary rod, in 1 case by a plate, and in 3 cases by both. The series contains one amputation and three fractures necessitated secondary grafting with replacement of rod in two cases. The results are analysed in carcinological and technical shemes. The value of resection and the importance of grafting over the arthrodesis are emphasised. In the long term, resection-arthrodesis means the conservation of a stable and functional limb, permitting an active life one year postoperatively. Massive prosthesis are only exceptionally indicated.

[Radiographic and histologic observations of autoclaved and non autoclaved allografts in the distal femoral metaphysis in dogs]. / Observations radiographiques et histologiques d'allogreffes autoclavées et non autoclavées dans la métaphyse fémorale inférieure de chien.

PURPOSE OF THE STUDY: A canine experimental work was performed, to study osseointegration of cortico-cancellous bone allografts implanted in the lower femoral metaphysis. Particular attention was focused on observing the effects of autoclaving, used as a sterilizing method, on the osseointegration of bone allografts. MATERIAL AND METHODS: Eighteen dogs were operated on and three groups were formed according to the type of graft: the first group included 4 autoclaved autografts and one animal, in which no graft was implanted. The second group included 11 frozen allografts in which 4 had been autoclaved. The third group included 2 animals, who received autoclaved allografts and were sacrificed at 10 months. In the first two groups, all animals were treated with the same protocol: graft stabilization using a plate, and specimen harvest at 4 months after surgery. In the third group, graft stabilization was obtained by press-fit only, and no plate was used. RESULTS: Overall roentgenographic results were satisfactory, suggesting graft fusion with the host. Histological results were inferior to roentgenographic results, and showed graft resorption, but only some signs of bone formation at the periphery of the graft. DISCUSSION: Roentgenographic results appeared optimistic, when compared to histological results. This suggests that roentgenographic results should not be considered as a reliable criteria for graft osseointegration. Despite favorable experimental conditions (cortico-cancellous graft implanted in the metaphyseal region, in a loaded segment of the skeleton, optimum graft stabilization using lateral plating), histological results were poor. New bone formation was observed at the periphery of the graft, but the major part of the graft remained fibrous. No difference was found between autoclaved and non autoclaved allografts in this small series. CONCLUSION: These preliminary results suggest that autoclaving does not impair osseointegration of frozen bone allografts, which anyway remains incomplete.

[An unusual case of clear-cell chondrosarcoma with intrasynovial tumoral localization]. / Un cas inhabituel de chondrosarcome à cellules claires avec des localisations tumorales intra-synoviales.

A case of a clear-celled chondrosarcoma of the femoral condyle extending into the knee joint is reported. At operation, many nodules looking like benign osteochondromata were found. They were found to be due to dissemination of the chondrosarcoma. An electron-microscopic study showed that the matrix was different in the osseous tumour from that in the synovial nodules. The result was satisfactory five years after resection followed by arthrodesis.

[Autoclaved tumoral autografts. Apropos of 12 cases, 6 of which highly malignant]. / Autogreffes tumorales autoclavées. A propos de 12 cas dont 6 tumeurs à haut grade de malignité.

Twelve patients presenting with a bone tumor were operated on using autoclaved bone autografts for reconstruction following carcinologic resection. According to the Enneking grading system, 6 were high malignancy tumors (3 osteosarcomas and 3 grade 2 chondrosarcomas), 4 were low grade tumors (1 paraosteal sarcoma, 1 chondrosarcoma, 1 secondary chondrosarcoma, 1 liposarcoma). One was a metastasis from a kidney tumor. The last patient had a femoral osteoid osteoma. Six local recurrences were responsible for 4 reoperations: 2 disarticulations and 2 iterative resections. With a 1-6 years range of follow-up (average follow-up 2.5 years), osseointegration of autoclaved grafts was studied. Fusion at the host/graft junction was roentgenographically observed. In three cases, proximal resorption of the humeral graft occurred. Five biopsies were obtained during reoperation after 1 year, which showed partial revascularization of autoclaved bone autografts. The authors conclude that autoclaved tumoral bone grafts, are reliable and discuss indications. They point out the main contraindication, represented by chemosensitive bone tumors, in which conservation of the removed tumor is necessary to quantify the response to chemotherapy.

[Surgical treatment of radiation-induced lesions of the hip in adults]. / Traitement chirurgical des radiolésions de la hanche chez l'adulte.

The authors report their experience in the surgical management of lesions of the adult hip following radiotherapy. The diagnosis of a hip problem occurring after pelvic radiotherapy for malignant tumors is made by clinical and radiological examination. The problems include femoral head necrosis, necrosis and/or fracture of the acetabulum, or involvement of the entire hip joint (radiation coxopathy). Fractures of the femoral neck have been described in the literature, but are now very rare following the routine use of external shields as protection during irradiation. Post-irradiation lesions are often bilateral 21%. They appear after a variable latency period of two to twenty years and they progress remorselessly. A diagnosis of simple radio necrosis can only be made after using radio isotope bone scanning, MRI or CT to exclude malignant disease as acetabular metastasis, and radio-induced sarcomas. Hemiarthroplasty is often followed by collapse of the acetabulum and should no longer be used. The treatment generally practised nowadays is a Total Hip Replacement (THR). We report a retrospective study of 71 hips in 56 patients treated, between 1970 and 1982, by the use of conventional cemented components. In 49 hips this was followed by a 52% incidence of acetabular loosening resulting from the poor quality of the irradiated bone which had become necrotic and porotic. Between 1983 and 1990, we modified the technique by regularly using reinforcing the acetabulum with a metallic ring fixed by long screws, (as used in revision surgery for THR). Bone grafts were also used in 9 cases. We had a 12% incidence of loosening in 22 hips with a mean follow-up of 40 months. There were also two post-operative infection which need removal of the prostheses. This emphasizes the risk of infection in this type of surgery and is probably increased by the associated lesions of the soft tissues (lymphoedema, radiodermitis). The authors wish to stress the poor prognosis of radiation lesions of the hip which often occur in patients who have otherwise recovered from their pelvic tumour. These radiation lesions have to be recognised and treated in a specific way. Our experience and the reports in the literature suggest that the generally used conventional THR gives uncertain results, and therefore we propose a THR employing metallic reinforcement of the acetabulum with or without any necessary bone grafts. It is vital to warn the patients that the results may not be as excellent as with THR for other types of hip disorders. When there is severe destruction of the acetabulum the choice between a THR combined with massive bone allograft, and a Girdlestone hip resection must be very carefully discussed with the patient. This latter "salvage" procedure may in any case become necessary if there are local and otherwise unmanageable problems.