Near-miss event assessment in orthopedic surgery: Antimicrobial prophylaxis noncompliance.

INTRODUCTION: Antimicrobial prophylaxis is one of the main safety measures to be enforced when implanting any medical device; surveys of practice, however, have found poor compliance. MATERIAL AND METHODS: This study is based on analysis of 153 dedicated in-depth analysis forms sent to orthopedic surgeons who had reported an antimicrobial prophylaxis-related near-miss event (NME) during the year 2008 as part of their certification report to the official organization, Orthorisq (orthopaedic Patient safety risk management agency). RESULTS: Antimicrobial prophylaxis guidelines exist in 95% of French centers, but in 14% are not available in the right place. 88% of orthopedic surgeons consider them well-adapted to their practice. Most declarations follow fortuitous discovery by the surgeon of an immediate peri-operative malfunction. Human causes were found in 92% of declarations, general organizational causes in 50% and material causes in 28%. Regarding corrective action, 65% of respondents reported implementing a second-order procedure, and only 20% were able to resume truly regular antimicrobial prophylaxis. CONCLUSION: The main reason for poor or non-performance of antimicrobial prophylaxis was "omission by negligence or oversight", reported in 56% of declarations. Proposals for improvement were: revised antimicrobial prophylaxis guidelines specifying "who does what"; guideline awareness checks on new, temporary and locum-tenens staff; patient involvement in personal data collection; and implementation of a check-list in line with WHO and French Health Authority recommendations. These improvement proposals were taken on board in the antimicrobial prophylaxis consensus update currently being drawn up by the French Society for Anesthesia and Intensive Care. LEVEL OF EVIDENCE: Level IV, Decision Analyses Study.

Double-incision mini-invasive technique for BTB harvesting: its superiority in reducing anterior knee pain following ACL reconstruction.

BACKGROUND: Arthroscopically-assisted ACL-reconstructions are currently reliable, reproducible and thoroughly used methods. Residual anterior knee symptoms however, especially after patellar-BTB graft use, are not uncommon occurrences following ACL-reconstructions, and can downgrade patient's satisfaction. Anterior knee pain contributing factors are numerous and include injury to the saphenous nerve infrapatellar branches (SNIB) and/or histologic changes at the harvest site. We thus preferably suggest a double-incision minimal approach for the patellar transplant harvesting stage in order to prevent injury to the SNIB. HYPOTHESIS: This technical variation decreases the risk of injury to the saphenous nerve infrapatellar branches while preserving the peritenon. STUDY DESIGN: Prospective controlled trial. MATERIAL AND METHODS: Two groups were alternatively constituted in 2004: ligament reconstructions were either performed via a two-incisions approach during the first 2004 semester or via a single-incision approach during the second 2004 semester. Pain, even at a mild level, was evaluated. Patients were assessed using objective pain provocative tests and sensory assessment, a Lille University femoropattelar score, the IKDC Knee evaluation, the SF36 quality of life score in combination with radiographic and ultrasonographic investigations. RESULTS: Forty patients were reviewed at a mean 33 months follow-up delay: 21 of these had a double-incision approach and 19 had a single-incision approach. Four patients from the double-incision sub-group and 11 from the single-incision sub-group reported anterior knee pain (p<0.01). The knee-walking test came out normal in 11 patients from the double-incision sub-group and in three from the single-incision sub-group (p<0.02). The Lille University patello-femoral score was 91/100, demonstrating no significant difference. At follow-up, sensory disorders were observed in 17 patients from the single-incision sub-group and in nine from the double-incision sub-group (p<0.002). However, no statistical correlation could be established between anterior knee pains and sensorial disturbances. SF36 and IKDC objective and subjective scores were similar in both groups. Ultrasonographic findings revealed a lesser degree of patellar tendon thickening in the double-incision sub-group. However, no statistically significant differences definitely emerged between the two groups (p=0.50). DISCUSSION: The results of this study strongly support our main hypothesis: The double-incision approach significantly reduces the mid-term incidence of anterior knee pains after ACL-reconstructions. Additionally, this technical variation markedly decreased the occurrence of sensory disorders and the extent of hypoesthesia. We thus advocate the use of a double-incision graft harvesting technique in ACL-reconstructions using a patellar-bone-tendon-bone transplant.

Multicentre, prospective, open study to evaluate the safety and efficacy of hylan G-F 20 in knee osteoarthritis subjects presenting with pain following arthroscopic meniscectomy.

The aim of the study was to evaluate the safety and efficacy of viscosupplementation with hylan G-F 20 in patients with mild to moderate osteoarthritis (OA) presenting with persistent knee pain 4-12 weeks after arthroscopic meniscectomy. A prospective, multi-centre, open study was carried out in patients with pain due to OA of the knee, not resolved by simple analgesics, 4-12 weeks after undergoing arthroscopic meniscectomy. To be eligible, patients had to score > or =50 mm and < or =90 mm on both walking pain and patient global assessment visual analogue scales (VAS; 0-100 mm) at baseline and be radiologically diagnosed pre-operatively with OA grade I or II on the Kellgren-Lawrence scale, with <50% joint space narrowing. Patients received three intra-articular, 2 ml injections of hylan G-F 20 in the target knee with an interval of 1 week between injections, and were followed for 52 weeks. The primary efficacy endpoint was the change from baseline in the walking pain VAS score at 26 weeks. Secondary outcome measures were the walking pain VAS scores at all other time points, the WOMAC Index at all time points, and patient and physician global assessment at all time points. The safety of the treatment was assessed using adverse event (AE) reports. A total of 62 patients (mean age 55.4 years, 52% male) were enrolled. The mean walking pain VAS score decreased by 36.8 mm from baseline at 26 weeks (P < 0.0001), and also showed statistically significant decreases (P < 0.0001) at all other time points. The change in WOMAC total and subscale scores from baseline were statistically significant (P < 0.0001) at all time points, as were the decreases in the physician and patient global assessment VAS scores. There were 18 target knee AEs (mostly pain and/or swelling and/or effusion) in 12 patients (19%) considered to be at least possibly related to treatment. The majority of these (78%) were mild or moderate in intensity. One patient (1.6%) experienced a serious adverse event (synovitis) in the target knee that was considered possibly related to study treatment. Hylan G-F 20 provides effective pain relief and improves stiffness and physical function in patients with mild to moderate OA presenting with persistent osteoarthritic pain 4-12 weeks after arthroscopic meniscectomy. Symptomatic efficacy was maximised at 12 weeks and maintained at 26 and 52 weeks. The type (pain and/or swelling and/or effusion) and the intensity (mostly mild/moderate) of AEs reported in this study are similar to those reported in other trials in different patient populations, but the incidence was higher (19%). The risk/benefit of hylan G-F 20 in this particular population of patients is favourable.

[Arthroscopic tightening of the anterior cruciate ligament]. / Retente du ligament croisé antérieur: une technique originale sous contrôle arthroscopique.

We present here the preliminary results obtained with arthroscopic tightening of the anterior cruciate ligament. Six patients underwent the technique. Four had had prior ligamentoplasty, two had sequelae of tibial spine fractures. Laxity persisted in all cases. The transplant or the ligament were continuous and insertion points were well-positioned. The procedure consisted in using a trephine to bore the tibial bone at the "foot" of the ligament or transplant in order to tighten the ligament. There was no evidence of instability after the arthroscopic tightening procedure. Mean pre- and postoperative differential anterior drawer values were successively 9.2 and 3.9 mm. For native or reconstructed anterior cruciate ligaments, which are continuous and well-positioned but not loose, arthroscopic tightening spares the need for ligament transplant and appears to be free of specific morbidity.

Magnetic resonance imaging as a tool to predict reparability of longitudinal full-thickness meniscus lesions.

Prediction of meniscus reparability is useful for surgeons to optimise surgical scheduling and to inform patients about postoperative management. This study was designed to determine the accuracy of MRI in predicting the reparability of longitudinal full-thickness meniscus lesions. We studied 100 MRIs of longitudinal full-thickness medial or lateral meniscus lesions located from the meniscosynovial junction to the axial part of the meniscus. The MRI criteria of reparability were a peripheral rim smaller than 4 mm and a lesion longer than 10 mm. At arthroscopy the menisci were considered as reparable when the lesion was located in red-red or red-white zones and when it was more than 1 cm in length. A heterogeneous or homogeneous aspect of the meniscus body was also considered. The length of the meniscus lesion averaged 17.6 mm and the thickness of the rim 3.4 mm. A heterogeneous signal of the axial fragment and of the rim was found in 11 cases and in 48 cases, respectively. In 90 cases, there was no difference between the MRI-predicted reparability and the arthroscopic findings. Global sensitivity of MRI to determine reparability of full-thickness meniscus lesions was 94%, increasing to 96% for the medial meniscus and dropping to 83% for the lateral meniscus. Global specificity was 81%, and was higher for the lateral meniscus (90%) than for the medial one (82%). Global positive predictive value was 0.94 and global negative predictive value was 0.82. A heterogeneous aspect of the rim did not compromise arthroscopic reparability whereas a heterogeneous aspect of the axial fragment indicated an irreparable meniscus. The described MRI criteria can predict meniscus reparability. Their accuracy is limited for lateral meniscus lesions close to the popliteal hiatus and for very young active patients in whom repair of white-white lesions can be attempted. Longitudinal full-thickness meniscus lesions are a good indication for repair in young active patients.

[Mini-invasive double-incision for patellar tendon harvesting in anterior cruciate ligament reconstruction]. / Prélèvement du transplant patellaire par double voie mini invasive dans la reconstruction du ligament croisé antérieur.

PURPOSE OF THE STUDY: Injury to infrapatellar branches of the medial saphenous nerve are incriminated in disorders of the anterior aspect of the knee, particularly following bone-tendon-bone reconstruction. We demonstrated in prior anatomic work the usefulness of using a double-incision minimal approach for harvesting the patellar transplant in order to spare the nerve branches. MATERIAL AND METHODS: The patellar transplant is harvested via two vertical incisions, one on the apex of the patella and the other along the protrusion of the anterior tibial tubercle. After harvesting the bony transplant from the patella, discision of the patellar tendon fibers is advanced subcutaneously towards the anterior tibial tubercle, allowing extraction of the patellar graft via the tibial incision using a small forceps and respecting the peritendon. The tibial bone is then harvested. The standard anterolateral and anteromedial approaches are used for the ligament reconstruction. RESULTS: We have conducted a case control study between this harvesting technique using the double-incision technique (42 knees) versus the conventional single incision harvesting technique. We studied the influence of the harvesting technique on anterior knee pain, the surface area of the sensorial disorders involving the anterior aspect of the knee, and kneeling problems. DISCUSSION: Our technique has enabled a significant decrease in the surface area of sensorial disorders (7.4 cm2 versus 17.4 cm2) and problems kneeling compared with the conventional method.

[Electromyographic study of stretch reflexes in the normal and prosthetic hip]. / Etude électromyographique des réflexes d'étirement intervenant au niveau de l'articulation coxo-fémorale normale et prothétique.

PURPOSE OF THE STUDY: Several studies have been devoted to the effect of proprioception on joint function. Modifications in feedback control from the cord have been observed in unstable joints due to capsule and ligament laxity. A few studies have examined the effect of knee and hip arthroplasty on proprioception, but none have established whether stretch reflexes affect function of a prosthetic joint. The purpose of the present study was to demonstrate the electromyographic characteristics of stretch reflexes of the normal hip joint and to compare them with those observed in the prosthetic hip. MATERIAL AND METHODS: Two groups of patients were studied. The first included eleven subjects free of neurological disorders whose studied limb was healthy. The second group included ten subjects with a total hip prosthesis who had undergone extensive capsulectomy during the arthroplasty. Voluntary muscle contraction was noted in each subject. In addition, electromyographic recordings were made to note response of the ipsilateral and contralateral quadriceps crural and tensor of the fascia lata during changes in joint position. Recordings were made with the subject in the supine position, the limb suspended, hip flexed at 45 degrees and knee extended. Three series of ten recordings were made in random order to measure the latency of muscle response to free fall of the limb, accelerated fall of the relaxed limb, and accelerated fall associated with calibrated contraction of the quadriceps. Mean latency of muscle response was calculated for each trial. RESULTS: In the conditions of this study, there was no statistically significant difference (p = 0.05) in the reflex time course between natural and prosthetic hips. DISCUSSION: Changes due to joint replacement and capsulectomy do not appear to affect the stretch reflexes of the hip joint.

[Patellar position and lateral approach for total knee arthroplasty in degenerative knees with lateral femoropatellar arthrosis]. / Positionnement patellaire et voie latérale dans l'arthroplastie totale pour gonarthrose avec arthrose fémoro-patellaire latéralisée: comparaison radiologique avec la voie médiale.

PURPOSE OF THE STUDY: Patellar malposition is a well-recognized patellar complication after total knee arthroplasty. Such residual malposition is particularly frequent when the knee presents lateral femoropatellar arthrosis. We compared the radiological position of the patella after total knee arthroplasty in degenerative knees with lateral femoropatellar arthrosis performed via a medial or lateral approach with elevation of the anterior tibial tuberosity. MATERIAL AND METHODS: Twenty-six total knee arthroplasties were reviewed retrospectively. Thirteen prostheses had been inserted via a medial approach and thirteen via a lateral approach. A posterior stabilized implant was used with an original technique for insertion of the patellar implant. The only difference between the groups was the approach. In the "lateral" group, the lateral approach was used to raise the tibial tuberosity and perform lateral marginal patellectomy. The tibial tuberosity was reinserted in all cases without transposition. Preoperative and 3-month postoperative radiographs (weight-bearing, AP, lateral, femoropatellar 30 degrees flexion) were reviewed. Preoperative patellar displacement was at least 5 mm. There was no difference between the two groups for age, gender, weight, height, joint motion, pre- and postoperative mechanical alignment (HKA), or preoperative patellar gliding (7.6 mm in the "medial" group and 9.7 mm in the "lateral" group). RESULTS: Recurrent patellar dislocation occurred in one patient in the "medial" group and one patient in the "lateral" group had an anterior impaction of the tibial plateau following a fall. Patellar gliding was corrected in both groups: 0.7 +/- 1.8 mm in the "medial group" and 0.0 +/- 0 in the lateral group (p > 0.05). Residual patellar tilt was +4.2 +/- 3 degrees in the medial group (lateral tilt) and -3.3 +/- 5.4 degrees in the lateral group (medial tilt) (p = 0.003). DISCUSSION: Pateller gliding was corrected irrespective of the approach. Conversely, the medial approach did not allow effective correction of patellar tilt. The lateral approach with elevation of the anterior tibial tuberosity did not increase morbidity compared with the medial approach. It enabled avoiding residual lateral patellar tilt which can be a source of patellar complications. We prefer this approach for arthroplasty on degenerated knees with lateral femoropatellar arthrosis.

[Variables influencing bleeding during total hip arthroplasty]. / Variables influençant le saignement lors d'une arthroplastie totale de hanche.

PURPOSE OF THE STUDY: The purpose of this retrospective analysis was to study the parameters having an effect on blood loss during or after total hip arthroplasty. We examined a series of 350 procedures for primary degenerative hip disease with a normal course (n = 100), rapidly destructive degenerative disease (n = 100), and secondary joint degeneration due to atraumatic osteonecrosis of the femoral head (n = 100) or rheumatoid disease (n = 50). MATERIAL AND METHODS: All arthroplasties were performed via the transtrochanteric approach using Charnley-Kerboull implants. The volume of blood loss was calculated by noting compensated blood loss (transfusion during the procedure and shortly thereafter), and estimated non-compensated loss using the Nadler and Mercuriali and Inghilleri formula. We examined the influence of age, gender, obesity, and surgeon experience. Data were analyzed with the Student-Fisher reduced deviation method was used for quantitative and qualitative variables and the coefficient of correlation for quantitative variables. RESULTS: Blood loss, calculated in ml packed red blood cells (hematocrit 100%), was 573 ml for arthroplasties with a normal course, 713 for arthroplasties secondary to osteonecrosis of the femoral head, and 950 ml for rapidly destructive degenerative disease and finally 609 ml for patients with rheumatoid arthritis. Considering 35% as normal for hematocrit, total estimated blood loss was 1,640, 2,040, 2,710, and 1,740 ml respectively in the different groups. Compared with the group of patients who had a normal course, total blood loss was significantly higher when arthroplasty was performed for osteonecrosis and rapidly destructive degenerative disease (p < 0.001). Age, obesity, and duration of the intervention had no effect on blood loss. Female gender and operator experience had a favorable influence in the group of patients who underwent hip surgery for primary degenerative disease. Blood loss occurring during or shortly after total hip arthroplasty was greater in men, when the procedure was performed for osteonecrosis, and most importantly for rapidly destructive diseases. DISCUSSION: In clinical practice, the influence of gender is not significant enough to require specific preoperative transfusion plans. Conversely, certain etiologies of the joint disease impose transfusion in all such patients, using a blood volume which usually exceeds the possibilities of auto-transfusions.

[Reconstruction of acute posterior cruciate ligament tears using a synthetic ligament]. / Cicatrisation sur tuteur synthétique dans les ruptures récentes du ligament croisé postérieur.

PURPOSE OF THE STUDY: Treatment of recent laxity of the posterior cruciate ligament is not standardized. The purpose of this work was to analyze results of reconstruction with adjunction of a synthetic ligament for major recent isolated or combined laxity of the posterior cruciate ligament (triades, pentades or dislocations). Our hypothesis was that the synthetic ligament acts like a tutor for healing of the torn ligament. MATERIAL AND METHODS: This retrospective analysis included 14 patients (1 woman and 13 men), mean age 27 years. All were competition athletes except one who did not practice sports. Three quarters of the patients were traffic accident victims. The series included three isolated posterior ligament tears, six combined laxities, and five knee dislocations. Average posterior laxity was 24 mm preoperatively. The procedure was performed 7 to 53 days after the accident. Arthroscopic reconstruction was performed for six patients and arthrotomy for eight. All associated lesions were repaired during the same procedure except for two cases (one anterior cruciate ligament and one popliteal tendon). Posterior cruciate ligament repair was achieved with the adjunction of a polyester ligament (LARS) using a one or two strand technique. Patients were reviewed at 36 months mean follow-up (10 - 88 months). The IKDC score was determined. A posterior drawer was measured manually with Telos at 70 degrees. RESULTS: Five stiff knees required either mobilization under anesthesia or arthrolysis. One tear occurred late after the accident during a new trauma. Subjectively, two patients were very satisfied, eight satisfied and three disappointed. Mean knee motion measurements were 6/0/130 degrees . A differential posterior drawer persisted in twelve knees. The Telos measurement of posterior drawer changed from a mean 24 mm to a mean 8 mm. The overall IKDC score was A: 0, B: 7, C: 3, and D: 2. Persistent posterior laxity was the predominant cause of poor scores. Outcome was less satisfactory for all items of posterolateral laxity. There was no difference between the 2- and 4-strand techniques. There were no cases of morbidity (synovitis, spontaneous tear) directly related to the synthetic ligament. DISCUSSION: The gain in posterior laxity was substantial. Results depended on associated lesions, particularly lateral involvement (stiffness, IKDC score) rather than the repair technique. The synthetic ligament appeared to play the role of a tutor: a single strand measuring 6 mm in diameter is sufficient. This technique spares tendon stock and could be proposed for major posterior cruciate ligament laxity. A longer follow-up will be necessary to confirm the durable stability.

[Comparison of the medial femorotibial joint space before and immediately after meniscectomy]. / Hauteur radiologique de l'interligne fémoro-tibial médial avant et immédiatement après méniscectomie.

PURPOSE OF THE STUDY: The purpose of this prospective study was to develop and evaluate a method for measuring the femorotibial joint space and to assess the effect of meniscectomy. MATERIAL AND METHODS: This study was conducted in a consecutive series of 36 patients undergoing arthroscopic meniscectomy for lesions of the medial meniscus on a stable knee. The height of the joint space was measured on x-rays taken in the morning before the operation then ten days later. X-rays were obtained for both knees in complete extension and in the 30 degrees flexion position. The height of the joint space was measured on the digital version of the x-rays midway between the vertical tangents of the posterior limits of the medial condyle. RESULTS: Readings were not reader dependent and demonstrated no significant difference between the pre and postmeniscectomy height of the medial femorotibial space (30 degrees flexion view, 5.2 +/- 1 and 5.2 +/- 1 before meniscectomy for reader 1 and 5.2 +/- 1 and 5.2 +/- 1 for reader 2 (p=0.05 for Student-Fisher test for paired values). The heights measured by the two readers were correlated (correlation coefficient test). DISCUSSION: The height of the medial femorotibial joint space can be measured reproductibly on plain x-rays of the knee in the standard flexion position. We were unable to demonstrate any significant difference in joint space between measures taken before and after meniscectomy.

[Influence of patellar height on patellar tendon donor site closing after harvesting a bone-tendon-bone graft for ligamentoplasty]. / Influence sur la hauteur de la patella de la fermeture du tendon patellaire après prélèvement d'un transplant os-tendon-os pour ligamentoplastie.

PURPOSE OF THE STUDY: Ligamentoplasty using an autologous transplant provides an effective and long-lasting solution for anterior instability of the knee. The most widely used transplant is the mid third of the patellar tendon. The short- and long-term stability has been proven, but there are reports of morbidity at the donor site affecting the extensor system. Different attitudes have been proposed. Certain authors leave the site open, only suturing the peritendon. Others suture the two peripheral thirds together, either directly or after combing. This different therapeutic options may modify patellar height and affect the tissue at the donor site that some authors suggest can provide transplants for repeated ligamentoplasties. The purpose of this work was to assess the influence of closing the donor site of the patellar tendon on patellar height. MATERIAL AND METHOD: Two groups of 40 patients were compared. These patients underwent arthroscopic ligamentoplasty for anterior instability of the knee, excluding all other knee pathology. In the first group, the pretendon fibrous plane was closed alone at the end of the procedure without bringing together the edges of the tendon donor site. In the second group, the peripheral thirds of the patellar tendon were sutured together directly. Patellar height was assessed according to Caton, to Blackburn and to Insall and Salvati on lateral views (20 degrees flexion) of the knee six months after arthroscopy. RESULTS: Irrespective of the method used to measure patellar height, there was no statistical difference between post-operative patellar heights between the two groups (Caton=1.002 +/- 0.176/1.023 +/- 0.215; Blackburne=0.844 +/- 0.183/0.882 +/- 0.196; Insall and Salvati=1.118 +/- 0.213/1.184 +/- 0.146 for group 1 "open tendon" and group 2 "closed tendon" respectively). Pre- and post-operative heights were not different for either group (Student t - Fisher, p=0.05). DISCUSSION: Patellar height is not significantly changed after ligamentoplasty using the mid third of the patellar ligament with or without closing of the donor site.

[Outcome after total hip arthroplasty performed for rapidly progressive hip destruction]. / Résultat des arthroplasties totales de hanche réalisées pour coxarthrose destructrice rapide.

PURPOSE OF THE STUDY: Rapidly progressive destruction of the hip joint occurs in approximately 5 to 10% of patients with degenerative hip disease. The cause and natural history remain unclear, but total hip arthroplasty is almost always necessary. We performed a retrospective analysis to determine the particular clinical and radiological features of this condition and to assess long-term outcome after total hip arthroplasty. MATERIAL AND METHODS: One hundred total hip arthroplasties were performed between 1984 and 1988 in patients with rapidly progressive hip destruction (67 women and 11 men, mean age 71 years). The transtorchanteric approach was used in all cases to implant cemented Charnley-Kerboull prostheses. Mean follow-up was 7 years 10 months. RESULTS: There were seven complications: two nonunions of the trochanter, three extensive periprosthetic ossifications, one case of recurrent dislocation, and one late hematogenous infection. At last follow-up, the Merle d'Aubigné classification showed an excellent or very good functional result in 95 hips. Stable fixation was observed for 94 acetabular implants and 97 femoral implants. Six acetabular implants showed signs of loosening: certain=1, probable=4, potential=1. Three femoral implants showed signs of loosening: certain=1, potential=2. All the femoral loosenings were associated with acetabular loosening. Four hips required revision surgery: one for nonunion of the trochanter, one for septic loosening, two for aseptic loosening. DISCUSSION: This series confirmed the radiological and clinical definitions of rapidly progressive hip destruction and demonstrated the reliability of pathological examination of the femoral head and joint capsule. Among the different hypotheses put forward to explain this condition, neither overloading nor use of antiinflammatory drugs would appear to be operating in this series. We were unable to confirm or infirm the micro-crystalline or vascular origin of this condition. Nevertheless, the vascular phenomena observed in the femoral head could be compared with those observed in ischemic joint disease. Arthroplasty led to major blood loss (2706 ml, hematocrit 35). This appears to be higher than observed for arthroplasty performed with the same technique in patients with the usual form of degenerative hip disease. Excepting this fact, the complications observed and the clinical results as well as the longevity of these implants suggest that arthroplasties performed for rapidly degenerative hips are not substantially different from those performed for common degenerative hip disease.

Blood loss in total hip arthroplasty for rapidly destructive coxarthrosis.

We studied the perioperative blood loss in 100 total hip arthroplasties performed for rapidly destructive coxarthrosis and compared it with the blood loss in 100 total hip arthroplasties for regular coxarthrosis. The treatment protocol was identical in both groups. Total blood loss was calculated as the compensated blood loss (volume transfused during and immediately after surgery) and the non-compensated blood loss using Nadler and Mercuriali formula. The mean blood loss calculated in milliliters of red blood cells (100% haematocrit) was 578 ml in regular coxarthrosis and 945 ml in rapidly destructive coxarthrosis. The blood loss after total hip arthroplasty is greater when surgery is performed for rapidly destructive coxarthrosis than for regular coxarthrosis (P < 0.001).

[Femoral reconstruction with massive allograft implanted in a split femur. Mid-term results of 18 reconstructions]. / Reconstruction fémorale par une allogreffe massive implantée dans un fémur ouvert. Résultats à moyen terme de 18 reconstructions.

PURPOSE OF THE STUDY: Extensive loss of femoral bone subsequent to implant loosening raises an unsolved problem. The purpose of this work was to examine mid-term results of 18 iterative total hip arthroplasties with femoral reconstruction using massive allografts performed between 1986 and 1997. MATERIALS AND METHODS: Using the Vives classification, the femoral bone lesions were grade 3 (n =2) and grade 4 (n =16). The reconstruction was achieved with radiated massive allografts measuring 11 to 35 cm implanted in a split host femur. Charnley-Kerboull implants with a long stem were cemented in the reconstructed femurs. RESULTS: Mean follow-up was 4 years 10 months (range 2 to 9 years). Nine complications in 7 hips were observed: 6 trochanter nonunions, two recurrent prosthesis dislocations and 1 femoral fracture. At last follow-up, the functional result was excellent or very good in 12 hips (Merle d'Aubigné classification). A stable fixation persisted for 15 implants and 3 had loosened. Graft-host femur consolidation was achieved in all cases except 1. There were 3 cases with extensive resorption of the graft including 2 associated with loosening of the femoral component. DISCUSSION: Reconstruction of the femur after extensive bone loss using a massive allograft appears to be a useful method for restoring bone tissue and providing immediate mechanical support for the femur.