Alexandre Lunebourg

Can we achieve bone healing using the diamond concept without bone grafting for recalcitrant tibial nonunions

The purpose of this study was to evaluate the efficacy and safety of a combination of recombinant human bone morphogenetic protein 7 (rhBMP-7) and resorbable calcium phosphate bone substitute (rCPBS) as a salvage solution for recalcitrant tibial fracture nonunions. Twenty consecutive patients, 16 male and four female, with a mean age of 46.8±15.7 years (21-78) and a mean body mass index (BMI) of 24.2±5.3kgm(-2) (21.5-28.5), suffering from 20 recalcitrant tibial fracture nonunions were included. The mean number of operations performed prior to the procedure was 3.3, with homolateral iliac crest bone grafts being used for all of the patients. All patients were treated with a procedure including debridement and decortications of the bone ends, nonunion fixation with a locking plate, and filling of the bony defect with a combined graft of rhBMP-7 (as osteoinductor) with an rCPBS (as scaffold). The mean follow-up was 14±2.7 months. Both clinical and radiological union occurred in 18 cases, within a mean time of 4.7±3.2 months. A recurrence of deep infection was diagnosed for one of the non-consolidated patients. No specific complication of rCPBS or rhBMP-7 was encountered. This study supports the view that the application of rCPBS combined with rhBMP-7, without any bone grafting, is safe and efficient in the treatment of recalcitrant bone union.

Long-term results of compartmental arthroplasties of the knee: Long term results of partial knee arthroplasty

Partial knee arthroplasty (PKA), either medial or lateral unicompartmental knee artroplasty (UKA) or patellofemoral arthroplasty (PFA) are a good option in suitable patients and have the advantages of reduced operative trauma, preservation of both cruciate ligaments and bone stock, and restoration of normal kinematics within the knee joint. However, questions remain concerning long-term survival. The goal of this review article was to present the long-term results of medial and lateral UKA, PFA and combined compartmental arthroplasty for multicompartmental disease. Medium- and long-term studies suggest reasonable outcomes at ten years with survival greater than 95% in UKA performed for medial osteoarthritis or osteonecrosis, and similarly for lateral UKA, particularly when fixed-bearing implants are used. Disappointing long-term outcomes have been observed with the first generation of patellofemoral implants, as well as early Bi-Uni (i.e., combined medial and lateral UKA) or Bicompartmental (combined UKA and PFA) implants due to design and fixation issues. Promising short- and med-term results with the newer generations of PFAs and bicompartmental arthroplasties will require long-term confirmation.

Lower function, quality of life, and survival rate after total knee arthroplasty for posttraumatic arthritis than for primary arthritis

Background and purpose — Total knee arthroplasty (TKA) for treatment of end-stage posttraumatic arthritis (PTA) has specific technical difficulties and complications. We compared clinical outcome, postoperative quality of life (QOL), and survivorship after TKA done for PTA with those after TKA performed for primary arthritis (PA). Patients and methods — We retrospectively reviewed patients who were operated on at our institution for PTA between 1998 and 2005 (33 knees), and compared them to a matched group of patients who were operated on for PA during the same period (407 knees). Clinical outcomes and postoperative QOL were compared in the 2 groups using Knee Society score (KSS), range of motion (ROM) of the knee, and the knee osteoarthritis outcomes score (KOOS). Implant survival rate was calculated using Kaplan-Meier analysis. Results — At a mean follow-up of 11 (5–15) years, KSS knee increased from mean 39 (SD 18) to 87 (SD 16) in the PA group (p = 0.003), and from 31 (SD 11) to 77 (SD 15) in the PTA group (p = 0.003). KSS function increased from 55 (12) to 89 (25) in the PA group (p = 0.008) and from 44 (SD 14) to 81 (SD 10) in the PTA group (p = 0.008). Postoperative ROM also improved in both groups, from 83° to 108° in the PTA group (p < 0.001) as opposed to 116° to 127° in the PA group (p = 0.001), with lower results in the PTA group (p < 0.001). KOOS was lower in the PTA group (p < 0.001). The survival rate of TKA at 10 years with an endpoint defined as “any surgery on the operated knee” showed better results in the PA group (99%, CI: 98–100 vs. 79%, CI: 69–89; p < 0.001). Interpretation — Patients and surgeons should be aware that clinical outcome and implant survival after TKA for PTA are lower than after TKA done for PA

Are Revisions of Unicompartmental Knee Arthroplasties More Like a Primary or Revision TKA

If revision is required, most unicompartmental arhroplasties (UKAs) are converted to total knee arthroplasties (TKAs) and conflicting results regarding surgical complexity and outcome have been reported in publications. 48 UKAs converted to a TKA between 1998 and 2009 were matched based on age, gender, and body mass index, pre-operative Knee Society Score, length of follow-up, and date of the index surgery to 48 primary TKAs and 48 revision TKAs. Surgical characteristics, clinical outcomes, and complications were compared at a mean follow-up of 7 ± 4 years. Even if a revision of UKA is technically less demanding than a revision TKA, functional scores, quality of life, complications and survival rate after revision UKA are more comparable to a revision than primary TKA.

No Benefit After THA Performed With Computer-assisted Cup Placement: 10-year Results of a Randomized Controlled Study.

BackgroundComputer-assisted surgery (CAS) for cup placement has been developed to improve the functional results and to reduce the dislocation rate and wear after total hip arthroplasty (THA). Previously published studies demonstrated radiographic benefits of CAS in terms of implant position, but whether these improvements result in clinically important differences that patients might perceive remains largely unknown.Questions/purposesWe hypothesized that THA performed with CAS would improve 10-year patient-reported outcomes measured by validated scoring tools, reduce acetabular polyethylene wear as measured using a validated radiological method, and increase survivorship.MethodsSixty patients operated on for a THA between April 2004 and April 2005 were randomized into two groups using either the CAS technique or a conventional technique for cup placement. All patient candidates for a THA with the diagnosis of primary arthritis or avascular necrosis were eligible for the CAS procedure and randomly assigned to the CAS group by the Hospital Informatics Department with use of a systematic sampling method. The patients assigned to the freehand cup placement group were matched for sex, age within 5 years, pathological condition, operatively treated side, and body mass index within 3 points. All patients were operated on through an anterolateral approach (patient in the supine position) using cementless implants. In the CAS group, a specific surgical procedure using an imageless cup positioning computer-based navigation system was performed. There were 16 men and 14 women in each group; mean age was 62 years (range, 24–80 years), and mean body mass index was 25 ± 3 kg/m2. No patient was lost to followup at 10 years, but five patients have died (two in the CAS group and three in the control group). At the 10-year followup, an independent observer blinded to the type of technique performed patients’ evaluation. Cup positioning was evaluated postoperatively using a CT scan in the two groups with results previously published. At 10 years, we assessed subjective functional outcome and quality of life using validated questionnaires (SF-12, Harris hip score [HHS], Hip injury and Osteoarthritis Outcome Score). Wear rate was then evaluated on standardized radiographs using a previously validated semiautomated computer analogic measurement method (dual circle method). Complications and survivorship were compared between groups. With our available sample size, this study had 80% power to detect a difference of 4 points out of 100 on the HHS at the p < 0.05 level.ResultsWith the numbers available, we found we found no differences between groups regarding HSS at last followup 95.3 ± 5.9 points (CAS group) versus 96.2 ± 4.5 points, a mean difference of 0.9 points (95% confidence interval [CI], −4.3 to 4.6; p = 0.6). There was no difference between the groups in terms of the mean (± SD) acetabular linear wear at 10 years. The mean wear was 0.71 ± 0.6 mm in the CAS group versus 0.77 ± 0.52 mm in the control group, a mean difference of 0.06 mm (95% CI, −0.1 to 0.2; p = 0.54). With the numbers available, there was no difference between the CAS group and the conventional THA groups in terms of survivorship free from aseptic loosening (100%; 95% CI, 100%–95%, versus 100%; 95% CI, 100%–94%; p = 0.3).ConclusionsOur observations suggest that CAS used for cup placement does not confer any substantial advantage in function, wear rate, or survivorship at 10 years after THA. Because CAS is associated with added costs and surgical time, future studies need to identify what clinically relevant advantages it offers, if any, to justify its continued use in THA.Level of EvidenceLevel II, therapeutic study.

Revision total knee arthroplasty: the end of the allograft era?

Total knee arthroplasty (TKA) is highly successful, with an exponential increase expected in the near future [1, 2]. More importantly, a fivefold increase in the number of revision TKAs is expected by 2030 [1, 2]. In the latest studies, the top seven reasons for revision TKA include aseptic loosening (23.1 %), infection (18.4 %), polyethylene wear (18.1 %), instability (17.7 %), pain/stiffness (9.3 %), osteolysis (4.5 %), and malposition/misalignment (2.9 %) [1, 3]. With modern implants, constraint can be effectively managed [4]. However, one of the remaining challenges in revision TKA is the management of severe bone loss [4]. Traditionally, allografts have been widely utilized to manage bone loss, with a significant failure rate at only mid-term follow-up [4]. New techniques with restoration of the metaphysis have been developed to optimize the results of revision TKA [4–8]. In this editorial, it was our aim to present contemporary management solutions for severe bone loss encountered at the time of revision TKA. The main goal of revision TKA is to restore patient function with a stable, painless, and mobile knee. As such, the surgeon must overcome three basic challenges: (1) implant fixation, (2) alignment in all planes, and (3) proper patellofemoral tracking. The unifying principle that often limits achieving these goals is marked bone loss. In modern revision TKA systems, stems and augments are very helpful. However, the main challenge remains long-lasting stability of the implants despite a significant bone loss [4]. Two types of bone defects can be observed in revision TKA: cavitary defects or segmental defects [4]. Classifications [such as the American Academy of Orthopaedic Surgeons (AAOS) and Anderson Orthopaedic Research Institute (AORI) classification] have been created to categorize the bone loss, which may be difficult to determine preoperatively, particularly when implants must be first removed [4]. In reality, preoperative radiographic assessment helps determine whether the defect is segmental, cavitary, or combined [4]. This is important because segmental defects should be re-constructed to properly support the implant. In addition, the level of constraint should be adapted accordingly if the bony insertion of the collateral ligaments is not present or functional [4]. Unfortunately, utilizing undersized press-fit stems and adding more bone cement are still utilized to manage many large bony defects [4]. Morcellized allograft still has a role & Sebastien Parratte sebparratte@gmail.com; sebastien@parratte.fr

Reply to the Letter to the Editor: Editor's Spotlight/Take 5: No Benefit after THA Performed with Computer-assisted Cup Placement: 10-year Results of a Randomized Controlled Study.

T hank you for giving us the opportunity to answer the Letter to the Editor concerning our recently published paper on computer-assisted cup placement in THA [9]. I must start by saying I have considerable respect for Dr. Dorr, who is an excellent surgeon and a visionary in hip reconstructive surgery. As mentioned in the first sentence of our Take-5 interview [5], our group is convinced that computer technology will improve our ability to perform THA in primary arthritis and complex cases, even if our paper does focus on the long-term outcome of THA performed for primary arthritis and osteonecrosis. We do agree with Dr. Dorr concerning the potential limitation of our paper regarding the number of patients included. During the last century, THA has been described as one of the most successful operations in large part due to our improved surgical techniques [4]. Because there are relatively low complication rates in THA, showing clinically relevant differences is particularly difficult [4, 11]. For example, to show a 1% decrease of a dislocation rate with 0.8 power, the number of patients included should be approximately 2000 in each arm, which simply is not practical [11]. As mentioned by Dr. Leopold in his Editor’s Spotlight [5], we can either perform prospective randomized studies powered for a particular goal or do larger studies with less robust study design and larger sample size. These limitations have been clearly outlined in our paper [9]. It is important to read our conclusion, which states that ‘‘the robotic era of THA should take into account these actual limitations and further studies are required to integrate the static and (RE: Leopold SS. Editor’s Spotlight/Take 5: No Benefit after THA Performed with Computer-assisted Cup Placement: 10-year Results of a Randomized Controlled Study. Clin Orthop Relat Res. 2016;474:2081– 2084). The authors certify that they, or any members of their immediate families, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. S. Parratte MD, PhD, M. Ollivier MD, A. Lunebourg MD, X. Flecher MD, PhD, J.-N. A. Argenson MD, PhD (&) Department of Orthopaedic Surgery, APHM, Institute for Locomotion, SainteMarguerite Hospital, 13009 Marseille, France e-mail: jean-noel.argenson@ap-hm.fr

A Bullet in the Supraspinatus Compartment Successfully Removed by Arthroscopy: Case Report and Review of the Literature

Arthroscopic removal of bullet from intra-articular compartment has been described for several joints. Only few reports dealing with this condition in the shoulder have been reported especially for the glenohumeral and the subacromial compartments. We report the story of a fifty-seven-year-old man presenting a bullet in the supraspinatus compartment of his left shoulder successfully removed by arthroscopy.