Fixed-bearing versus mobile-bearing total knee arthroplasty: a prospective randomised, clinical and radiological study with mid-term results at 7 years.

Mobile-bearing (MB) total knee arthroplasty (TKA) was developed as an alternative to the established fixed-bearing (FB) design because of theoretical advantages. Short-term studies comparing these designs have not shown any differences in clinical and radiographic results. We compared the results at 7 years of a randomised study of patients undergoing TKA using either a FB or a MB variant of the same prosthesis. Fifty-two patients (52 knees) with an average age of 70 years received a FB posterior-stabilized prosthesis, and 50 patients (52 knees) with an average age of 72 years, a MB prosthesis. All implants were cemented and the patella was routinely resurfaced. Preoperatively, there were no differences between the two groups, and surgical procedure and postoperative protocol were the same for both. At an average follow-up of 7.1 years, no significant differences of FB over MB design could be demonstrated with respect to the American Knee Society score (AKSS), pain score, a questionnaire of general health (SF-12 score), range of motion (ROM), or complication rates. Radiographs showed no significant difference in prosthetic alignment or evidence of loosening. Two knees with a MB design required reoperation, one for persistent joint stiffness and another to treat septic loosening. One patient with a MB prosthesis with signs of tibial component loosening was asymptomatic. We conclude that at mid-term follow-up there is no evidence to prove the superiority of MB over FB TKA with regard to the clinical and radiographic results.

[Fixed-bearing versus mobile-bearing total knee arthroplasty: a prospective randomized clinical and radiological study]. / Prothèse totale du genou: étude prospective randomisée comparant les plateaux tibiaux fixes et mobiles.

PURPOSE OF THE STUDY: Mobile-bearing total knee arthroplasty has become increasingly popular over the last few years since this option presents several theoretical advantages compared with the fixed-bearing models. The clinical advantage remains to be demonstrated. We therefore conducted a prospective randomized trial to ascertain the potential benefits. MATERIAL AND METHODS: This study included patients treated by three senior orthopedic surgeons. Each group included 52 prostheses in 52 patients in the fixed-bearing group and 50 patients in the mobile-bearing group. The per- and postoperative protocols were the same for both groups. Implants were cemented in all cases and patellae were resurfaced. The SF-12, the Knee Society Score (KSS), the Hospital of Special Surgery score (HSS) and pain and joint motion were noted before and after surgery. RESULTS: Among the 104 prostheses implanted, 100 were reviewed at mean follow-up of 36 months (range 24-41). One patient in the fixed-bearing group died six months after surgery from an unrelated cause. Three patients were lost to follow-up: one in the fixed-bearing group and two in the mobile-bearing group. There was no difference between groups for the SF-12, KSS, HSS, pain and joint motion measured postoperatively. Postoperative femorotibial alignment was one degree varus on average in the fixed-bearing group and zero degree in the mobile-bearing group. At last follow-up, there were no radiological signs of prosthesis loosening. One patient in the fixed-bearing group developed a deep venous thrombosis, complicated by pulmonary embolism. Two of the mobile-bearing prostheses were revised, one for patellar fracture caused by a bicycle accident and one for prosthesis infection in a patient with endocarditis 1.5 years after implantation. DISCUSSION: The clinical results were similar for the two groups in terms of function, pain, general status and complications. The outcome at 36 months was considered excellent or good in 90% of the fixed-bearing group and 88% in the mobile-bearing group. This study did not reveal any difference between the two groups regarding maximal flexion and anterior knee pain, two parameters which would theoretically show short-term improvement with the mobile bearing. Mid- and long-term follow will be required to confirm these findings and to determine the survival of these two types of implants.

Celecoxib versus ibuprofen in the prevention of heterotopic ossification following total hip replacement: a prospective randomised trial.

We examined whether a selective cyclooxygenase-2 (COX-2) inhibitor (celecoxib) was as effective as a non-selective inhibitor (ibuprofen) for the prevention of heterotopic ossification following total hip replacement. A total of 250 patients were randomised to receive celecoxib (200 mg b/d) or ibuprofen (400 mg t.d.s) for ten days after surgery. Anteroposterior radiographs of the pelvis were examined for heterotopic ossification three months after surgery. Of the 250 patients, 240 were available for assessment. Heterotopic ossification was more common in the ibuprofen group (none 40.7% (50), Brooker class I 46.3% (57), classes II and III 13.0% (16)) than in the celecoxib group (none 59.0% (69), Brooker class I 35.9% (42), classes II and III 5.1% (6), p=0.002). Celecoxib was more effective than ibuprofen in preventing heterotopic bone formation after total hip replacement.

Results of derotational humeral osteotomy in posterosuperior glenoid impingement.

We identified 20 throwing athletes who continued to have pain after articular debridement for posterosuperior impingement syndrome. These patients were unable to resume sports, and we subsequently performed a derotational humeral osteotomy with a myorraphy of the subscapularis muscle. Patients were observed for an average of 46 months (range, 12 to 69). Eleven patients were able to resume the same sport at the same level, five resumed the same sport at a lower level, three changed sport secondary to persistent pain, and the last patient did not resume any sport and was worse after surgery. Patients returned to sports at an average of 6 months postoperatively (range, 4 to 44) and to their previous level of sports at an average of 12 months (range, 8 to 18). The mean increase in humeral retroversion was 29 degrees (range, 18 degrees to 44 degrees) Three women with preoperative multidirectional hyperlaxity were considered to have failed results. Derotational humeral osteotomy can be considered in the throwing athlete with posterosuperior impingement after failure of all other means of treatment. Careful patient selection and preoperative evaluation of humeral retroversion is important. Best results can be achieved in a motivated patient with low retroversion (< 10 degrees). If retroversion is normal (20 degrees to 30 degrees), the surgical indication is unclear. We do not recommend this surgery for patients with hyperlaxity.

Total elbow replacement for complex fractures of the distal humerus. An option for the elderly patient.

The treatment of multifragmentary, intra-articular fractures of the distal humerus is difficult, even in young patients with bone of good quality, but is worse in elderly patients who have varying degrees of osteopenia. We have evaluated the functional outcome of primary total elbow replacement (TER) in the treatment of these fractures in ten elderly patients followed for a minimum of one year. There were no complications in regard to the soft tissues, bone or prosthesis. The mean range of flexion obtained was 125 degrees (110 to 140) and loss of extension was 23.5 degrees (0 to 50). The mean Mayo score was 94 points (80 to 100) and patient satisfaction was high. We feel that TER provides an alternative to open reduction and internal fixation in the management of these complicated fractures in the elderly.

[Isolated splenic trauma in adults: value of Resciniti's CT scoring system to define the indications for surgery]. / Traumatismes isolés de la rate chez l'adulte. Intérêt de la classification scanographique de Resciniti dans l'indication opératoire.

The data of 62 adult patients with isolated blunt splenic trauma were retrospectively analysed to determine the value of a CT score-system in the choice of treatment: nonoperative treatment versus surgical management. 22 patients (35%) without hemodynamic instability presenting with pain localized in the left flank were primarily managed conservatively. 3 of them subsequently required splenectomy. 40 patients (65%) were operated immediately, 32 on the basis of clinical criteria and 8 on the basis of laboratory criteria. 45 patients with no initial haemodynamic disorders were investigated by abdominal CT-scan. Splenic injuries were retrospectively classified according to Resciniti's CT-scoring system. 13 patients had a splenic injury score > or = 5.5. All of them were operated, 11 early and 2 after failure of conservative management. According to our study this score > or = 5.5, which concerns 21% of our patients, can be considered to be an indication for surgery; in this case, a conservative approach should not be at tempted, even in the absence of immediate clinical and laboratory operative criteria.

[Acute acromioclavicular dislocations]. / Disjonctions acromio-claviculaires récentes.

Acromioclavicular dislocations represent over 10% of acute traumatic injuries to the shoulder girdle. The mechanism is usually a direct impact on the shoulder with the arm in adduction, producing rupture of the acromioclavicular (AC) ligaments, then of the coracoclavicular (CC) ligament, with displacement of the lateral end of the clavicle. Rockwood described 6 grades of injury. Physical examination usually provides the diagnosis, which is confirmed by radiological examination. X-rays centered on the AC joint, if necessary with forceful adduction of both shoulders or under traction, are useful to evaluate the severity of the lesion. Grade I and II lesions are usually treated conservatively by simply immobilizing the arm for 3 to 4 weeks. Surgical treatment is usually advocated for grade IV, V and VI lesions: AC or CC fixation, sometimes associated with ligament repair, depending on the surgeons. AC pinning or C-C screw fixation are the techniques most often used. Management of grade III lesions remains controversial. Some authors advocate immediate surgical treatment in young, active patients, in heavy laborers and even in slender individuals. The choice of the operative technique is controversial, as no single technique has clearly proved to be superior to others. Other authors advocate conservative treatment, which gives functional results which patients consider quite acceptable, with faster recovery; patients should be informed that results are essentially similar, whatever the treatment. The possibility of performing secondary operations with good results in cases with failure of conservative management is a further argument in favor of applying conservative therapy first in acute injuries.

[Posterosuperior impingement of the shoulder in the athlete: results of arthroscopic debridement in 75 patients]. / Conflit postéro-supérieur de l'épaule chez le sportif: résultats du débridement arthroscopique.

PURPOSE OF THE STUDY: The painful shoulder is a well-recognized clinical entity in throwers although the pathogenic mechanisms involved are still debated. In 1991 Walch then Jobe developed the concept of posterosuperior impingement to explain lesions observed arthroscopically. This impingement between the deep aspect of the supraspinatus tendon and the glenoid occurs during loaded arm movements. The purpose of this work was to study the different types of lesions observed arthroscopically and to analyse outcome after arthroscopic debridement. MATERIAL AND METHOD: Our series included 75 thrower athletes who had shoulder pain for loaded arm movements. Pain was situated in the dominant shoulder in all cases. Clinically, the Jobe manipulation provoked pain in 52 patents, expression of a supraspinous disorder. After failure of conservative treatment, the patients underwent arthroscopy for assessment and debridement. At the time of arthroscopy, the patients had suffered pain for two years (mean 22.3 months). All 75 patients were seen for clinical and radiological assessment at least two years after arthroscopy. RESULTS: Among the 75 arthroscopies, there were 67 (89%) partial tears involving the deep aspect of the cuff, associated in 90% of the cases with a labral lesion. Tears involved the supraspinatus in 40 cases, the supraspinatus and the infraspinatus in 24 and the infraspinatus alone in three. Eight patients were free of tendon lesions at arthroscopy. There were no full thickness tears. The labrum had a meniscal (45%) or non-meniscal aspect (55%) and appeared normal (18%), fringed (38%) or fissured (52%). The very large majority of the labral fissures were found behind the biceps insertion. Fissures of the labrum were found in front of the biceps insertion in only three cases (slap lesion). Arthroscopy demonstrated glenoid damage (soft cartilage, fissure, abrasion, wear). The humeral head also exhibited lesions of the cartilage facing the insertion of the infraspinatus. At last follow-up (minimum > 2 years), eight patients were very satisfied, 22 were satisfied and 45 were disappointed. Twelve patients had resumed their sports activities at their former level with loaded arm movement and one patient had interrupted all sports activities. At last follow-up, 22 patient had undergone another surgical procedure: 20 derotation osteotomies of the humerus, one anterior stabilization, one acromioplasty. DISCUSSION: The notion of posterosuperior impingement is increasingly recognized as the cause of pain in thrower athletes. Loaded arm movements produce a physiological contact between the posteriorsuperior edge of the glenoid cavity and the deep aspect of the rotator cuff. Injury results from repeated loaded arm movements in throwers. In our series, all the patients had at least one lesion, either involving the cuff or the labrum. According to the Snyder classification, 80% of the supraspinatus lesions were grade 1 or grade 2. We did not have any full thickness tears. All patients with a normal cuff were found to have a lesion of the posterosuperior labrum. At arthroscopy, dynamic assessment evidenced an impingement between the supraspinatus (or the infraspinatus) and the labrum or the bony edge of the glenoid cavity. Only three patients had a labral lesion anterior to the biceps insertion that could be considered a type 1 or 2 slap lesion. Unlike earlier reports by others, we had disappointing results after debridement: 60% of the patients were disappointed after the procedure and only 40% were satisfied (22 patients) or very satisfied (8 patients). Patient satisfaction depended greatly on the level of sports activity attained after arthroscopy, the eight very satisfied patients had resumed their former level. None of the professional athletes or those competing at the international level were very satisfied with arthroscopic debridement. There was an inverse relationship between level of competition and patient satisfaction after debridement.

Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block.

UNLABELLED: We tested the effect of epinephrine added to 20 mL ropivacaine 0.5% and 0.2% on postoperative analgesia via a femoral catheter after total knee replacement. Forty-one patients undergoing total knee replacement under combined peripheral block/general anesthesia were randomly allocated to two groups. After insertion of a femoral catheter, 21 patients in the Ropivacaine-Epinephrine (ROPI-EPI) group received 20 mL ropivacaine 0.5% plus epinephrine 1:200,000, whereas 20 patients in the Ropivacaine group (ROPI) received 20 mL plain ropivacaine 0.5%. Thereafter, a sciatic block with 30 mL bupivacaine 0.5% plus epinephrine 1:200,000 was performed in all patients, followed by general anesthesia. After surgery, patient-controlled analgesia (PCA) with ropivacaine 0.2% plus epinephrine 1:200,000 for Group ROPI-EPI and plain ropivacaine 0.2% for Group ROPI was available via the femoral catheter (200 mL ropivacaine 0.2% +/- epinephrine, bolus 20 mL, lockout 120 min). The patients were instructed to use PCA when the knee pain score was >3 cm. The interval between the initial ropivacaine injection and the first PCA injection determined the duration of 20 mL ropivacaine 0.5% +/- epinephrine, whereas the interval between the first and second PCA injection determined the duration of 20 mL ropivacaine 0.2% +/- epinephrine. The average duration of ropivacaine 0.5% was 657 +/- 345 min for the ROPI-EPI group and 718 +/- 423 min for the ROPI group (NS), whereas for ropivacaine 0.2%, the average duration was 409 +/- 245 min for the ROPI-EPI group and 419 +/- 339 min for the ROPI group (not significant). We conclude that epinephrine does not influence the duration of analgesia of the ropivacaine concentrations investigated. IMPLICATIONS: We evaluated the effect of epinephrine on the duration of analgesia of 20 mL ropivacaine 0.5% or 0.2% injected in femoral three-in-one block for pain relief after total knee replacement. Our results show that epinephrine does not alter the duration of analgesia of the two solutions investigated.