D. Goutallier

Poor eight-year survival of cemented zirconia-polyethylene total hip replacements

Between January 1988 and January 1991 we performed 100 consecutive cemented total hip replacements using a zirconia head, a titanium alloy stem and a polyethylene cup. We reviewed 78 of these hips in 61 patients in detail at a mean of 5.8 years (1 to 9). Aseptic loosening was seen in 11 hips (14%). Eight needed revision. In total, 37 cups (47.5%) showed radiolucent lines, all at the cement-bone interface, with 18 (23%) involving all the interface. Of the 78 femoral implants, 17 (21.7%) showed radiolucent lines, and two, which had a complete line of more than 1 mm thick, definite endocortical osteolyses. There was also an abnormally high incidence of osteolysis of more than 2 mm at the calcar. Survivorship analysis showed that only 63% were in situ at eight years. These worrying results led us to abandon the use of zirconia heads, since at the same hospital, using the same femoral stem, cement and polyethylene cup, but with alumina femoral heads, the survival rate was 93% at nine years. We discuss the possible reasons for the poor performance of zirconia ceramic.

In vivo kinematics for subjects with and without an anterior cruciate ligament.

The objective of the current study was to compare kinematic patterns of anterior cruciate retaining total knee arthroplasty and posterior stabilized total knee arthroplasty. Fifteen patients received an anterior cruciate retaining total knee arthroplasty and 15 received a posterior stabilized total knee arthroplasty. All total knee arthroplasties were clinically successful (Hospital for Special Surgery score > 90). Each patient was examined during level walking using fluoroscopy. Femorotibial contact paths for the medial and lateral condyles were determined using a computer automated model-fitting technique. Ten of 15 (67%) patients receiving an anterior cruciate retaining total knee arthroplasty and 12 of 15 patients (80%) receiving a posterior stabilized total knee arthroplasty experienced anterior contact at some phase of the gait cycle. Anterior contact in anterior cruciate retaining total knee arthroplasty can be attributed to the presence of the anterior cruciate ligament, resisting the anterior tibial shear forces during gait. The reason for anterior contact observed in posterior stabilized total knee arthroplasty is unclear, possibly related to the sagittal topography (dwell-point position) of the tibial component. Increased axial rotation was seen in anterior cruciate retaining total knee arthroplasty possibly because of the preservation of the four-bar linkage within the knee. Patients receiving an anterior cruciate retaining total knee arthroplasty experienced kinematic patterns more similar to the normal knee.

Failure of a Stainless-Steel Femoral Head of a Revision Total Hip Arthroplasty Performed after a Fracture of a Ceramic Femoral Head. A Case Report*

There is considerable interest in ceramic implants because of the increased awareness that wear debris from a metal-on-polyethylene articulation of a total hip prosthesis can cause osteolysis around the implant4. The excellent mechanical and sliding characteristics of ceramic have been reported previously1,5,6,20,21. Nevertheless, some cases of fracture of the ceramic femoral head have been reported8,10,13,16,19,23. The revision operation after this complication may be problematic in terms of the choice of the type of femoral head to be inserted; it may be stainless steel, cobalt-chromium, or ceramic. If a new ceramic femoral head is used, the femoral stem may have to be removed to provide a new Morse taper with the appropriate shape to receive the ceramic head. We do not believe that a stainless-steel femoral head should be used because we observed early abrasion of such a femoral head, with periprosthetic metallosis and rapid failure, in the patient described in this case report. We present the case of a fifty-four-year-old woman who had considerable wear of a stainless-steel femoral head with extensive periprosthetic metallosis two years after a revision of a total hip replacement because of a fracture of a ceramic femoral head. The aim of this report is to discuss the choice of both the operative procedure and the implant material to be used after such a fracture. In 1990, a fifty-four-year-old woman was operated on for pain in the left hip secondary to arthrosis of the hip due to congenital hip dysplasia. A total hip arthroplasty was performed with use of a Harris socket with a polyethylene cup (Zimmer, Rungis, France) and a titanium stem with an alumina femoral head that was twenty-eight millimeters …

Acromio humeral distance less than six millimeter: Its meaning in full-thickness rotator cuff tear

UNLABELLED The present study sought to identify full-thickness rotator cuff tears liable to induce an acromiohumeral distance (AHD) of less than 6 mm. The hypothesis was that, less than 6mm AHD is found exclusively in association with total full-thickness infraspinatus tear. MATERIALS A continuous single-center series recruited 109 shoulders, free of glenohumeral osteoarthritis, presenting with full-thickness tear requiring surgery. Preoperative acromiohumeral distance, rupture location and extension on the various tendons and muscular fatty degeneration (FD) were known. METHODS Full-thickness tears were categorized by location and extension on the various tendons. For each group, the number of shoulders showing AHD<6 mm was determined. RESULTS Total full-thickness infraspinatus tears were almost the only tendon lesions able to induce AHD<6 mm, but this only when the infraspinatus muscle showed FD equal to or greater than 2.25: i.e., when the tear was longstanding. DISCUSSION Unlike previous reports, the present study took account of the total or partial nature of infraspinatus and subscapularis tendon tear. The findings may suggest that AHD<6 mm is induced by posterior migration of the humeral head secondary to longstanding total infraspinatus tear, reducing AHD projection height on X-ray. CONCLUSION AHD<6 mm is a sign of rotator-cuff rupture almost systematically involving longstanding total infraspinatus tear, not always amenable to suture repair due to advanced fatty degeneration. AHD equal to or greater than 6mm is of no diagnostic relevance and in no way indicates whether there is subscapularis tear and, if so, whether suture repair is feasible.

Les lésions histologiques des tendons des supraspinatus dans les ruptures transfixiantes de la coiffe des rotateurs

Resume Les auteurs ont essaye de savoir si les ruptures iteratives apres simple suture tendon-os des coiffes des rotateurs rompues pourraient etre expliquees par la presence, sur les moignons tendineux repares, de lesions histologiques qui, ont le sait, diminuent leur qualite mecanique. Trente-deux moignons de supraspinatus rompus, reseques sur plus d’1 cm pour eliminer les lesions tendineuses macroscopiques (tendons fins, dilaceres, clives ou indurees et blanchâtres) et pour retrouver un moignon tendineux suffisamment epais et legerement saignant ont ete etudies sur des coupes histologiques longitudinales. Tous les moignons tendineux reseques etaient histologiquement anormaux. L’etendue des lesions histologiques etait en moyenne de 4 mm inferieure a celle de la resection tendineuse. Dix-huit fois cependant tout le tendon reseque etait histologiquement anormal. Les lesions histologiques des moignons tendineux des ruptures de coiffe pourrait etre au moins en partie a l’origine des ruptures iteratives apres simple suture tendon-os. La resection des moignons tendineux macroscopiquement anormaux apparait logique mais elle expose, en dehors d’artifice technique, a des sutures sous tension elles memes generatrices de rupture iterative.

Comments on: Muscle fatty infiltration in rotator cuff tears: Descriptive analysis of 1688 cases by B. Melis, C. Nemoz and G. Walch, published in 10.1016/j.otsr. 2009.05.001

We read with great attention the very interesting artile by B. Melis et al., ‘‘Muscle fatty infiltration in rotator uff tears: descriptive analysis of 1688 cases’’. We were leased to see that the authors have been able to prove tatistically what we believe we have demonstrated in our arious reports. Here we shall discuss only muscle degenertion assessment. The five-stage classification according to the respective mounts of fat and muscle, which we drew up with J. ernageau, has been followed. Combining stages 0 and 1 nd stages 3 and 4 for statistical purposes does not worry s: we have come across stages 0 and 1 in normal shoulders, nd muscle function is severely impaired in both stages 3 nd 4. On the other hand, we would criticize:

Absence of the medial malleolus. A case report with a 20-year follow-up study.

This may be the second case report of the absence of the medial malleolus in the orthopedic literature. A six-year-old girl had an open fracture with a loss of the medial malleolus. During the 20-year follow-up study, she had no instability of the ankle, as in the first report, but after time she developed degenerative arthritis in the tibiotalar articulation.

Transsupraspinatus arthrotomy through an enlarged transacromial approach for total shoulder replacement

The authors describe a step-by-step technique for anatomic total shoulder arthroplasty using transsupraspinatus arthrotomy via the enlarged transacromial approach. This technique seems ideal to ensure adequate postoperative tensional balance of the infraspinatus and the subscapularis, which is critical for the rotator cuffs to function properly and to achieve optimal arthroplasty stability. Reviewing these different steps helps understanding each rotator cuff individual components contribution to achieve optimal arthroplasty stability.

Reproductibilité des gonométries en position couchée après implantation d’une prothèse totale de genou. Comparaison avec la reproductibilité des gonométries des genoux non prothésés

PURPOSE OF THE STUDY Outcomes after total knee replacement are correlated with the postoperative HKA angle. Therefore, it seems crucial to determine the precision of the whole lower limb X-rays which are currently used to determine the frontal knee alignment. The aim of the study was to analyze the precision of the whole lower limb X-Rays made in supine position, after total knee replacement. MATERIAL AND METHOD A prospective study included 100 knees which were analyzed with two whole lower limb X-rays made at eight days interval. Seventy knees were non-replaced and 30 had total replacement with a posterior stabilized knee prosthesis. The X-rays were made in supine position and neutral rotation using the patella as a reference mark. One independent observer compared the HKA angle on the two consecutive X-Rays in order to evaluate the reproducibility of the X-Rays. RESULTS In the group of patients with total knee replacement, the reproducibility was poor with a low correlation coefficient (0.5) and a poor precision of 5 degrees . On the contrary, in the non-replaced knee group, the reproducibility was very good with a high correlation factor between the two X-rays (0.99, p<0.0001) and a very good precision of 1.7 degrees (p<0.05). The group of patients with an HKA angle of less than 8 degrees had a significantly better precision (1.5 degrees ) than the group of patients with an angle HKA above 8 degrees (3 degrees , p<0.04). CONCLUSION Reproducibility and precision of whole lower limb X-rays made in supine position is poor in patients with total knee replacement. Thus, we should be very careful for the analysis of the influence of the mechanical axis on the outcomes after total knee replacement.

Reparación de las roturas trasnfixiantes del manguito de los rotadores

El manguito es una envoltura musculotendinosa escapulohumeral que rodea la articulacion glenohumeral. Esta constituido, en sentido anteroposterior, por tres musculos principales, el subescapular, el supraespinoso y el infraespinoso, a los que debe anadirse el redondo menor. El espacio situado entre el subescapular y el supraespinoso esta ocupado por el ligamento coracohumeral, del que una expansion que se inserta en el troquiter constituye una polea de reflexion que centra la porcion larga del biceps a su entrada en la corredera bicipital del humero. Los tendones del supraespinoso, del infraespinoso y del redondo menor forman una capa tendinosa continua. Los limites entre cada uno de los tendones no pueden distinguirse. Solo pueden apreciarse si se prolongan los limites de los cuerpos musculares correspondientes. Los tendones, sobre todo el del supraespinoso, se adhieren a la capsula. Los tendones del supraespinoso y del infraespinoso, pero no siempre el del subescapular, estan recubiertos por la bolsa serosa subdeltoidea. Se adhieren a su capa profunda. Esto explica que, en las roturas de los tendones del supra e infraespinoso, la bolsa subdeltoidea aparezca inyectada con material de contraste en las artrografias, mientras que puede que no sea asi en las roturas aisladas del subescapular.