[Femoral neck fractures in patients over 50 years old]. / Les fractures du col du fémur après 50 ans.

INTRODUCTION: Despite many papers and instructional course lectures, therapeutic guidelines are not clearly defined about treatment of femoral neck fractures. The aim of this multicentric French symposium was to prospectively study the results of current therapeutic options in order to propose scientifically proven options. MATERIAL AND METHODS: Three prospective studies were carried out in order to answer to these questions: (1) is it possible with anatomical reduction and stable fixation to lower the non union and osteonecrosis rate? (2) is functional treatment of Garden 1 fractures successful in more than 65 years patients? (3) what criteria are useful to choose the kind of arthroplasty for more than 65 years patients? RESULTS: For the 64 patients between 50 and 65 years old included in the first study, 44 ORIF and 17 prostheses were performed. No open reduction was performed in this series despite a 34% malreduction rate. The risk for displacement after functional treatment of Garden 1 fractures is 31%. For patients over 65 years old, almost fractures are treated in this series by an arthroplasty. The one-year mortality rate after displaced femoral neck fracture was 17%. Functional results were better in total hip prosthesis group than in bipolar or unipolar group. Non cemented stems were not safer than cemented ones in frail patients. DISCUSSION AND CONCLUSIONS: For young patients, ORIF should be the treatment of choice: the initial displacement and its effects on the femoral head vascularisation, the quality of reduction and fixation are the two most significant factors for good outcome. For Garden 1, fractures in patients 65 years old or more, it is proposed to performed an internal fixation despite in two thirds of the cases, it should be unnecessary because non identification of predictive factors of failure. For patients over 65 years old, the type of arthroplasty to perform in displaced fractures is to be chosen according to the preoperative mobility and comorbidities. Because of acetabular erosion with long-term follow-up, it is clearly indicated to perform total hip replacement for patients with life expectancy of 10 years or more. For frail patients, unipolar arthroplasty is the best option. The place for bipolar or uncemented implants is not yet well-defined and more prospective trials are needed. In this multicentric study, results appear quite different in terms of mortality, or functional status. These differences seem to be related to technical choice, geriatric care, nutritional consideration or surgical organisation, all factors that may be of major importance for prognostic.

[Thrombosis of the posterior tibial artery complicating closed injury of the ankle]. / Thrombose de l'artère tibiale postérieure: une complication rare d'un traumatisme fermé de la cheville.

Closed ankle injury without fracture is a common finding in the emergency room. Outcome is generally spontaneously favorable, the injury having no long-term clinical impact. Exceptionally, these injuries can be associated with arterial damage. We report a case of an apparently benign closed ankle injury which was found to be associated with serious arterial damage. Forced dorsal flexion of the ankle joint during a traffic accident caused an arterial lesion without any apparent damage to the bone and joints. The posterior tibial artery was interrupted leading to subacute ischemia of the foot. The diagnosis was established 17 days after trauma. Revascularization could not be achieved and leg amputation was necessary. This case illustrates the difficulties encountered in this type of vascular injury. Most cases in the literature have also involved late diagnosis with often serious clinical impact. Clinicians should be aware of this rare complication of apparently benign ankle injury because of the risk of major loss of function.

Functional recovery, complications and CT positioning of total hip replacement performed through a Röttinger anterolateral mini-incision. Review of a continuous series of 103 cases.

INTRODUCTION: Minimally invasive approaches entail an increased risk of malpositioning and peri-operative complications. Most studies analyzed these data only on plain X-ray rather than computed tomodensitometry (CT) in assessing implant positioning. HYPOTHESIS: A Röttinger minimally invasive anterolateral (MIS-AL) approach provides rapid complication-free functional recovery with reliable implant positioning on CT-scan. PATIENTS AND METHOD: One hundred and three primary cemented total hip replacements (THR) performed by a single surgeon using a MIS-AL approach underwent clinical assessment at six weeks and three, six and 12 months on X-ray, including CT and postoperative myoglobinemia and creatine phosphokinase (CPK). RESULTS: Pain, on a visual analog scale, was graded less than 1 at 36 hours; canes ceased to be used at a mean three weeks; and mean Postel-Merle-D'Aubigné score at six months was 17.36 (range, 13-18). There were ten approach-related complications (9.7%: one femoral perforation, two dislocations, two femoral neck fissures, two cases of meralgia paresthetica and three of tensor tendinitis). Mean CPK level was 390.9 ± 252µg/L (range, 88-1095µg/L) at 24 hr postoperatively and 319 ± 256µg/L (95-1028 µg/L) at 48 hr. Mean postoperative myoglobinemia was 299 ± 152.6µg/L (75-914µg/L). Mean acetabular inclination and anteversion on CT were respectively 44.7° ± 4.6° (34° - 56°) and 9.2°±9.2° (-17°-35°) and mean femoral anteversion 23.5° ± 9.4° (2°-53°). DISCUSSION: Functional recovery was quick, but with an 8.7% complications rate (excluding four cases of spontaneously resolved tendon pain). CT showed reliable cup positioning, but a wide scatter in femoral anteversion. Elevated muscle enzyme levels possibly testified to approach-related tissue attrition. The MIS-AL approach involves a learning curve to avoid femoral perforation. It provided rapid functional recovery with reliable positioning, at least for the cup, and a low rate of associated complications. LEVEL OF EVIDENCE: III, prospective continuous study.

Component positioning in primary total hip replacement: a prospective comparative study of two anterolateral approaches, minimally invasive versus gluteus medius hemimyotomy.

INTRODUCTION: One factor of implant survivorship in total hip replacement (THR) is the quality of implant choice and positioning. The purported advantages of minimally invasive approaches are faster recovery, shorter hospital stay and less per-operative blood loss. On the other hand, there have been many reports of higher complication rates, and doubts as to the quality of implant positioning. HYPOTHESIS: The quest to minimize tissue damage is at the cost of THR positioning quality. OBJECTIVES: To assess implant positioning in a prospective comparative continuous multicenter series. PATIENTS AND METHODS: Between 2008 and 2009, a prospective comparative study was conducted on a continuous series of 141 THRs. Ninety-two were performed in two centers, using a minimally invasive Watson-Jones approach; the other 49, performed in a 3rd center, used an anterolateral approach with anterior hemimyotomy. The surgeons were in all cases experienced in their technique. Short-term follow-up comprised clinical and functional (Postel Merle d'Aubigné (PMA), Harris, SF12, WOMAC) and biological assessment (serum creatine phosphokinase (CPK), myoglobinemia, hematocrit) and analysis of complications and of implant positioning on X-ray and CT-scan. RESULTS: On the Watson-Jones approach, surgery time was longer; day-1 analgesic administration was lower; PMA, Harris and WOMAC scores were better at 6 weeks; and CPK levels were lower at 24 and 48hours. There were no significant differences on the other clinical and biological criteria. Implant positioning analysis revealed significantly greater combined anteversion and greater variation in acetabular inclination mean with the Watson-Jones approach, but no differences in cup positioning, femoral stem positioning, or limb length discrepancy. DISCUSSION: The minimally invasive Watson-Jones approach provided faster recovery and less muscular damage. However, implant positioning was less precise in terms of acetabular cup inclination. LEVEL OF EVIDENCE: Level III. Prospective, comparative, non-randomized.