J. Allain

Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study.

Background: The alumina ceramic femoral head was introduced for total hip arthroplasty approximately thirty years ago. One of its main drawbacks was the risk of implant fracture. The aim of this study was to examine the results of revision total hip replacement performed specifically to treat a fracture of a ceramic femoral head and to identify technical factors that affected the outcomes. Methods: One hundred and five surgical revisions to treat a fracture of a ceramic femoral head, performed at thirty-five institutions, were studied. The patients were examined clinically by the operating surgeon at the time of the last follow-up. The surgeon provided the latest follow-up radiographs, which were compared with the immediate postoperative radiographs. The success of the revisions was assessed with Kaplan-Meier survivorship analysis, with the need for repeat revision as the end point. We evaluated the complication rate and radiographic changes indicative of implant loosening. The average duration of follow-up between the index revision and the last clinical and radiographic review was 3.5 years (range, six months to twenty years). Results: Following the revisions, radiographic evidence of cup loosening was seen in twenty-two hips (21%) and radiographic evidence of femoral loosening was seen in twenty-two (21%). One or several repeat revisions were necessary in thirty-three patients (31%) because of infection (four patients), implant loosening (twenty), osteolysis (eight), or fracture of the revision femoral head component (one). The survival rate at five years was 63% (95% confidence interval, 51% to 75%). The survival rate was significantly worse when the cup had not been changed, when the new femoral head was made of stainless steel, when a total synovectomy had not been done, and when the patient was less than fifty years old. Conclusions: Fracture of a ceramic femoral head component is a rare but potentially serious event. A suitable surgical approach, including total synovectomy, cup exchange, and insertion of a cobalt-chromium or new ceramic femoral ball minimizes the chance of early loosening of the implants and the need for one or more repeat revisions. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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.nnWe 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.nnIn 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 …

Macroscopic and histological assessments of the cruciate ligaments in arthrosis of the knee

We examined the macroscopic appearance of both cruciate ligaments in 52 knees during knee replacement. It was classsified as normal, abnormal or ruptured. The ligaments were also evaluated histologically: stage 0 (normal), stage 1 (degeneration of < 1/3 of the collagen fibers), stage 2 (degeneration of 1/3-2/3) and stage 3 (> 2/3). 17 anterior cruciate ligaments (ACL) were normal, 14 were abnormal and 21 ruptured. All the posterior cruciate ligaments (PCL) were normal. 14 ACL were stage 0, 6 stage 1, 8 stage 2 and 24 were stage 3. 22 PCL were stage 0, 14 stage 1, 13 stage 2 and 3 were stage 3. When the ACL was abnormal or ruptured, the PCL was stage 0 only in one fourth of the cases. The long-term results of TKR retaining the PCL should be better if the ligament is strong. The intraoperative assessment of the macroscopic appearance of the ACL reflects the histological state of the PCL.

Outcomes of anterior lumbar interbody fusion in low-grade isthmic spondylolisthesis in adults: a continuous series of 65 cases with an average follow-up of 6.6 years.

INTRODUCTIONnSurgical treatment of isthmic spondylolisthesis continues to be controversial. The fusion procedure can either be instrumented using a posterior and/or anterior approach or non-instrumented. The role of associated decompression, reduction of the slippage, disc height restoration and lordosis restoration has not definitely been established. The goal of this study was to evaluate the efficacy of anterior approach for interbody fusion (ALIF) without any reduction maneuver.nnnMATERIALS AND METHODSnSixty-five patients with isthmic spondylolisthesis were operated on, using an ALIF. The average patient age was 40 years. The preoperative maximum walking time was 20 minutes. Ten patients had radiculopathy. The average preoperative Beaujon Hospital disability index was 9/20. Standard static and dynamic X-rays were evaluated in all patients; a CT scan was performed in 33 patients 1 year after the surgery. The olisthetic vertebra had slipped by an average of 12 mm. Thirty-five of the spondylolisthesis cases had abnormal vertebral motion.nnnRESULTSnAt an average follow-up of 6.6 years, lumbar pain and radicular pain had been reduced by 4.6 and 5 points on the visual analogue scale, respectively. Twenty-seven patients could walk for an unlimited amount of time. Three patients still had radiculopathy. The Beaujon Hospital disability index had improved by an average of 7.3 points. The fusion rate was 91%. The slippage had decreased by 30%, despite no specific reduction maneuvers at the time of surgery. The disc height had increased by 177%. On the sagittal plane, lordosis had improved by 5°, without any changes in the pelvic parameters.nnnCONCLUSIONnIn situ ALIF provides results that are comparable to those obtained with other techniques. This study confirms the essential role of fusion in achieving good functional results, given that hypermobility of the olisthetic level contributes to the symptoms generation.nnnLEVEL OF EVIDENCEnLevel IV. Retrospective study.

Common femoral artery intimal injury following total hip replacement. A case report and literature review

Vascular injuries diagnosed during the course of total hip arthroplasty (THA) implantations are rare. They must be constantly feared as they sometimes put at risk the vital and functional prognosis of the operated limb. We report the case of a common femoral artery injury diagnosed by arteriography within two days of THA replacement in the presence of atypical symptoms. The vascular damage was caused by an arterial lesion resulting from positioning a retractor on the anterior wall of the acetabulum. A literature review on the topic of vascular complications arising after THA made us aware of multiple possible mechanisms and clinical presentations relating to such complications while identifying specific risk factors in THA replacement cases. Acetabular revision constitutes a major risk situation. Most of these vascular complications may be better prevented or more efficiently treated by thorough preoperative assessment and careful postoperative monitoring.

Surgical Treatment of Destructive Cervical Spondyloarthropathy With Neurologic Impairment in Hemodialysis Patients

Study Design. We have retrospectively reviewed 11 chronic hemodialysis patients with cervical destructive spondyloarthropathy responsible for neural impairment 1 year after surgery and at last follow-up. Objective. To evaluate clinical and radiologic outcomes, and necessity of vertebral block excision. Summary of Background Data. Destructive spondyloarthropathy of the cervical spine is associated with long-term hemodialysis for chronic kidney failure. Spinal cord compression and neurologic troubles occur in a few cases. Surgical treatment remains controversial because these are debilitated patients with multiple organ failures. Methods. All 11 patients had unstable cervical spondylolisthesis, and 10 had kyphotic vertebral fusion involving at least 2 vertebrae. We performed interbody bone grafting (cement in 1 case) and stabilized with a plate. In 6 of the 10 patients with vertebral block, excision of the block was performed. Results. No patients were lost to follow-up. One patient died 2 days after the operation. There were 2 other patients who required early surgical revision (i.e., a corporectomy followed by early graft expulsion). Bone healing settled in all patients. One year after surgery, patients had almost complete resolution of the pain and satisfactory neurologic recovery. Improvement was evaluated according to the Nurick classification. Conclusion. Functional and neurologic results were similar whether the patients did or did not undergo vertebral block excision, suggesting that stabilizing the unstable level may be sufficient in patients with neurologic impairment. Excision of spontaneous vertebral blocks should be avoided to minimize the morbidity of surgery in these debilitated patients with a limited life expectancy.

Trans-styloid fixation of fractures of the distal radius: A prospective randomized comparison between 6- and 1 -week postoperative immobilization in 60 fractures

We performed a prospective randomized study on 60 patients with dorsally displaced extra-articular or noncomminuted intraarticular fractures of the distal radius. All 60 fractures were treated by closed reduction and Kirchner wire trans-styloid fixation. 30 patients had 1 weeks postoperative immobilization and 30 patients had 6 weeks immobilization. All patients had a clinical and radiographic review at 6 weeks and at 1 year after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, frontal radial deviation, ulnar variance, and radial shortening were assessed radiographically. Rates of complications were the same in both groups. At follow-up, pain was similar in both groups and range of motion and grip strength were somewhat better after early mobilization--in comparison with the opposite wrist--but this was statistically significant only for ulnar deviation. The postoperative radiographic reductions were similar in both groups, with no differences in loss of reduction after bone healing. Therefore, in Colles fractures, trans-styloid fixation with two K-wires seems to give a stable osteosynthesis, which does not need additional immobilization with a plaster cast.

Total shoulder arthroplasty using the superior approach: influence on glenoid loosening and superior migration in the long-term follow-up after Neer II prosthesis installation.

Glenoid component loosening and superior humeral translation are common after Neer II total shoulder arthroplasty using the anterior approach. To determine whether the superior approach reduced these complications, we retrospectively reviewed 20 shoulders in 16 patients. Both components were cemented. Patient satisfaction, unweighted Constant score, and imaging studies were evaluated at a mean of 3.5 years and at a mean of 11.1 years. Fourteen patients were satisfied or very satisfied. The mean unweighted Constant score improved from 25/100 preoperatively to 57/100 after 3.5 years and to 51/100 after 11.1 years. Pain relief contrasted with low strength. Radiolucent lines appeared around 95% of glenoid components and 20% of humeral stems. Computed tomography showed severe glenoid osteolysis in 3 of 13 shoulders. Humeral superior translation did not occur. This study confirms the glenoid component fixation issue. The superior approach may reduce the risk of humeral superior translation and radiologic glenoid component loosening.