Jean-Paul Carret

Can Dual Mobility Cups prevent Dislocation in All Situations After Revision Total Hip Arthroplasty

UNLABELLED The outcome of a single design of dual mobility cup was prospectively evaluated in a continuous series of 994 revision THAs with respect to dislocation and intra-prosthetic dislocation (IPD). At a 7.3-year mean follow-up, the dislocation rate was 1.5% and the IPD rate was 0.2%. The 2 IPD occurred in acetabular-only revisions and were related to a poor head-to-neck ratio with early impingement and wear at the polyethylene mobile component chamfer. Dual mobility cups demonstrated a low dislocation rate in revision THA but did not compensate for potential perioperative technical errors. In addition, IPD did not appear to be a concern with respect to the benefit in term of instability prevention though caution is advised in acetabular-only revision associated with a poor head-to-neck ratio. LEVEL OF EVIDENCE Therapeutic study-Level IV.

Acetabular Reconstruction Using a Kerboull Cross-Plate, Structural Allograft and Cemented Dual-Mobility Cup in Revision THA at a Minimum 5-Year Follow-Up

The current study aimed to evaluate the outcome of a continuous and prospective series of 61 revision THAs with AAOS grade III and IV acetabular bone defect reconstruction using a Kerboull cross-plate, structural allograft and cemented dual mobility cup (Saturne, Amplitude, Valence, France). At a 7.5-year mean follow-up, no instability was reported after revision. In addition, no failure of the acetabular reconstruction was observed in 98% of the patients with complete allograft osseointegration and no evidence of mechanical rupture of the Kerboull cross-plate and/or loosening of the cemented dual mobility cup. In conclusion, such reconstruction technique demonstrated excellent results at mid-term follow-up in terms of prevention of instability after revision, restoration of the acetabular bone stock, and stable cemented fixation of the dual mobility cup.

Hip squeaking: a 10-year follow-up study.

The aim of the study was to analyze the incidence of squeaking with ceramic-on-ceramic total hip arthroplasty (THA) after 10 years of follow-up and the potential complications that could occur related to this phenomenon. One hundred THAs implanted between November 1999 and December 2000 were evaluated. Incidence of squeaking was investigated clinically with a questionnaire. Implant positioning was analyzed on x-rays and computer tomography. Of the 100 THAs, 5 patients presented with squeaking. All of them were active, sporty, and heavy men. Functional scores were comparable with nonsqueaking patients. There was no malpositioning on the x-ray analysis, no wear, and no loosening. We could not demonstrate any relation between squeaking and ceramic fracture. Squeaking noise appeared at a mean of 66 months postsurgery. It appears to be an isolated phenomenon without any consequences at 10-year follow-up.

Nine years follow-up of 100 ceramic-on-ceramic total hip arthroplasty

The aim of this study was to evaluate the first 100 cementless ceramic-on-ceramic total hip arthroplasty (THA) performed at our institution with more than nine years of follow-up. Clinical evaluation was performed using Harris hip score. Radiological evaluation was performed by two surgeons. Four patients were lost to follow-up. Harris hip score significantly improved at latest follow-up. Radiological analysis showed calcar osteolysis for 75 patients and one cup loosening. One patient required a revision five years postoperatively for cup loosening. Based on these results and the routine use of a navigation system to optimise positioning of the implants, we advocate the use of uncemented hydroxyapatite coated ceramic-on-ceramic THA in young and active patients in our current practice.

Arthroplastie de hanche pour séquelle de fracture de l’acétabulum

Resume L’objectif de cette etude retrospective etait d’analyser les complications et les difficultes techniques rencontrees lors de la mise en place d’une prothese totale de hanche pour les sequelles de fractures de l’acetabulum. Quarante patients ont eu une prothese totale de hanche apres fracture de l’acetabulum. Vingt-trois de ces patients avaient initialement ete traites chirurgicalement et dix-sept orthopediquement. Trente-deux cupules sans ciment recouvertes d’hydroxyapatite et huit cupules scellees ont ete mises en place. Cinq pivots femoraux ont ete scelles. La planification preoperatoire devait restaurer le centre de rotation de hanche initial afin d’eviter, une medialisation excessive de la cupule. Un seul patient a presente une complication peroperatoire. Parmi les complications postoperatoires, on denombrait une phlebite, une infection, deux paralysies du nerf fibulaire commun, quatre luxations et sept ossifications heterotopiques. Le taux de complications postoperatoires etait statistiquement plus eleve dans le groupe de patients traites initialement chirurgicalement (52,2 % versus 17,6 % : p = 0,02). A la revision, au recul moyen de cinquante mois, le score fonctionnel de Merle d’Aubigne etait en moyenne de 16,7. Le taux de revision acetabulaire etait de 15 % avec quatre cupules scellees qui ont ete reprises a plus de dix ans pour descellement aseptique et deux cupules sans ciment qui ont ete reprises precocement, pour infection dans un cas et pour demontage dans l’autre cas. Malgre un taux eleve de complications, les resultats a moyen terme sont bons et nous encouragent a utiliser en premiere intention, soit une cupule impactee plus ou moins associee a une autogreffe, soit une cupule scellee dans une armature metallique de type Kerboull ou Burch-Schneider.

Arthroplastie totale de hanche chez l’insuffisant rénal chronique greffé ou dialysé

Purpose of the study Total hip arthroplasty (THA) is generally proposed for renal transplant patients with invalidating hip disease. For patients on chronic dialysis, the few published series report a higher rate of complications. These patients are considered more vulnerable. We report the results of a retrospective mid-term analysis of 28 renal failure patients (37 hips) with THA comparing renal transplant recipients with chronic dialysis patients.Resume Le but de l’etude etait d’evaluer de maniere retrospective la morbidite, la mortalite et les resultats a moyen terme de l’arthroplastie totale de hanche chez les patients souffrants d’insuffisance renale en dialyse et/ou greffes. De janvier 1993 a janvier 2004, 37 protheses totales de hanche ont ete implantees chez 28 patients (14 dialyses et 14 greffes). L’osteonecrose aseptique etait l’etiologie principale. Trente et une cupules et 29 tiges implantees etaient non cimentees. Tous les patients vivants ont ete revus avec un recul moyen de 6 ans (24 mois-12 ans). Les complications precoces et secondaires ont ete recherchees. Les resultats cliniques ont ete evalues par les scores de Merle d’Aubigne et de Harris. Les complications post-operatoires precoces etaient representees chez les patients dialyses par trois thromboses veineuses profondes, quatre embolies pulmonaires, deux hematomes et une infection. Chez les greffes renaux, nous avons observe deux luxations precoces et trois pneumopathies. Quatre deces sont survenus, tous chez des patients dialyses. Le score PMA moyen preoperatoire etait de 7,6 chez les patients dialyses et de 10,3 chez les patients greffes ; progressant a la revision respectivement a 14,2 et 15,7. Les radiographies ne retrouvaient aucun signe de descellement, aucune usure du polyethylene et l’absence d’ossifications ectopiques. L’arthroplastie totale de la hanche chez les patients greffes est une intervention fiable avec de bons resultats a moyen terme et une morbidite proche de celle de la population generale avec possibilite d’utiliser des implants non scelles. En revanche, chez les patients dialyses une morbidite perioperatoire elevee etait retrouvee. Il est necessaire de favoriser le traitement chirurgical apres la greffe renale plutot que sur un patient en dialyse. En cas de chirurgie, celle-ci doit etre effectuee au sein d’une equipe pluridisciplinaire medico-chirurgicale.

Désarthrodèse-prothèse de hanche pour séquelle d’arthrite septique: À propos d’une série de 17 cas à 6 ans de recul

PURPOSE OF THE STUDY Revision total hip arthroplasty (THA) after hip arthrodesis is an uncommon and challenging operation. The task would appear to be even more difficult if the arthrodesis was performed because of septic arthritis due to the theoretical risk of recurrent infection. We report our fifteen-year experience. MATERIAL AND METHODS This retrospective study concerned 17 procedures performed in 17 patients (11 women, 6 men) between 1988 and 2003 on 5 right and 12 left hips. All of the patients had arthrodesis for sepsis: eight subsequent to tuberculosis and nine subsequent to septic arthritis (Staphylococcus aureus). We examined the impact of the initial arthrodesis (surgical technique, position, leg length) on neighboring joints and indications for de-fusion. Mean age was 53 years (range 32-74) and on average, the patients had a fixed hip for 36 years (range 7-59). Mean follow-up was six years (range 11 months to 15 years). Revision surgery was performed via a posterolateral approach for 12 hips (nine trochanterotomies) and via an anterolateral approach for five hips for implantation of nine cemented implants, six press fit implants, and two hybrid implants (cemented cup and press fit stem). Clinical assessment at last follow-up noted pain, walking capacity and joint motion. Leg length discrepancy was measured and complications were noted. RESULTS The position of the original arthrodesis was considered satisfactory (flexion 20 degrees , adduction 0-10 degrees , external rotation 0-20 degrees ) for eight hips; leg length discrepancy was 4 cm (2-8 cm). Neighboring joints involved concerned the lumbar spine in 15 patients, the ipsilateral knee in ten patients, the contralateral knee in eight and the contralateral hip in six. The decision to remove the arthrodesis was based on functional needs related to lumbar pain (n=6), the homolateral knee (n=10, limping and leg length discrepancy), or an operation on the ipsilateral knee. After surgery, 14 hips (83%) were free of pain with improvement of the lumbar pain and pain of the homolateral knee. Six patients walked without support but 16 still had a limp. Flexion was 78 degrees . Leg length discrepancy was 2.5 cm on average and seven patients had balanced limbs. The postoperative period was uneventful for 14 of 17 patients (one paresia of the common fibular nerve, one femoral phlebitis, one early infection). Six late complications were noted: nonunion of the greater trochanter (n=2), recurrent ankylosis (n=1) and loosening (n=3). DISCUSSION AND CONCLUSION An earlier history of infection does not appear to be a contraindication for implantation of a total hip arthroplasty after hip arthrodesis. Despite the long recovery period and the modest gain in joint motion, 80% of patients were satisfied after having had a blocked hip for 36 years on average.Resume Nous rapportons le resultat des desarthrodese-protheses pour sequelles d’arthrite septique pratiquees sur une periode de 15 ans, cette intervention presentant un risque theorique de recidive de l’infection ancienne. Il s’agissait d’une etude retrospective concernant 17 patients (11 femmes, 6 hommes). Toutes les arthrodeses avaient ete effectuees pour des raisons septiques (8 coxalgies, 9 arthrites septiques a germes pyogenes). La technique d’arthrodese etait dans 10 cas intra-articulaire, et dans 7 cas extra-articulaire. L’âge moyen, au moment de la desarthrodese, etait de 53 ans (32-74). La position de l’arthrodese initiale etait jugee satisfaisante pour seulement 8 cas. L’inegalite de longueur preoperatoire etait de 4 cm (2 a 8). L’atteinte d’une articulation de proximite concernait le rachis lombaire (15 cas), le genou ipsilateral (10 cas), le genou controlateral (8 cas) et la hanche controlaterale (6 cas). L’anciennete de l’arthrodese etait de 36 ans (7-59). Cinq abords anterolateraux et 12 abords posterolateraux (9 trochanterotomies) ont ete realises. Les implants utilises etaient : 9 implants cimentes, 6 implants sans ciment et 2 implants hybrides (cupule cimentee et tige sans ciment). Le recul moyen etait de 6 ans (11 mois - 15 ans). Au recul, 14 hanches operees (83 %) etaient indolores avec amelioration des douleurs lombaires et du genou ipsilateral. La marche s’effectuait sans canne pour 6 patients, mais 16 patients conservaient une boiterie. La flexion moyenne etait de 78 . L’inegalite de longueur residuelle etait de 2,5 cm avec 7 patients equilibres. Les suites etaient simples pour 14 patients (1 paresie du nerf fibulaire commun, 1 phlebite femorale, 1 infection precoce). Six complications tardives etaient deplorees : 2 pseudarthroses du grand trochanter, 1 recidive d’ankylose et 3 descellements. Un antecedent septique ancien ne semble pas contre-indiquer l’implantation d’une prothese totale de hanche pour une desarthrodese. Malgre une recuperation longue et un gain de mobilite modeste, on releve 80 % de satisfaction, concernant ces hanches bloquees depuis en moyenne 36 ans.

Le fibrome desmoplastique ou fibrome desmoïde osseux : À propos de 2 nouveaux cas d'une tumeur osseuse rare

Desmoplastic fibroma or desmoid bone tumor is a rare tumor described for the first time by Jaffe in 1958. It accounts for 0.1 to 0.3% of all benign bone tumors. To date, about 150 cases involving the locomotor system have been reported. Histology is required for certain diagnosis of desmoplastic fibroma. The tumor is composed of sparse fibroblasts in a rich background of collagen fibers, a histological presentation exactly the same as soft tissue desmoid fibroma. We report two new cases of desmoplastic fibroma of the locomotor system. The observations illustrate the radiological diagnosis. MRI was used to search for local extension in bone or soft tissues. Biopsy is necessary to confirm the diagnosis. The histological presentation may be difficult to recognized and distinguish from low grade fibrosarcoma. After treatment, the rate of local recurrence is high in the event of partial resection. Surgery is the optimal treatment, with tumor resection as wide as possible depending on the localization.

270 Navigation et prothèse totale de la hanche ; analyse d’une série de 130 PTH

Introduction Les conflits intra-prothetiques sont a l’origine des problemes d’instabilite, d’usure et de descellement. Nous presentons notre experience de l’utilisation d’un logiciel de navigation pour prothese totale de la hanche permettant d’optimiser le positionnement et le fonctionnement relatif des implants prothetiques. Materiel et methode Nous avons etudie de facon prospective et continue 130 protheses totales de hanche implantees chez 128 patients de septembre 2005 a fevrier 2007. Les indications etaient 93 coxarthroses, 23 necroses de la tete femorale et 14 arthrites inflammatoires. Les patients etaient 68 hommes (58 ans en moyenne) et de 60 femmes (60 ans en moyenne). Les implants utilises etaient sans ciment recouverts d’hydroxyapatite, avec un couple metal/polyethylene dans 16 cas et ceramique/ceramique dans 114 cas. La technique chirurgicale naviguee etait basee sur l’acquisition peroperatoire des structures osteoarticulaires et sur un referentiel fonctionnel prenant en compte la hanche en position neutre, simulant la position debout. Nous avons etudie les resultats a court terme de cette technique naviguee concernant : la morbidite propre a la navigation, le positionnement radiologique des implants acetabulaires et la lateralisation ou medialisation globale du membre et sa longueur. Resultats La longueur du membre opere etait restituee de facon satisfaisante dans 85 % des cas (ILMI Discussion et conclusion Il s’agit d’un systeme de navigation permettant de s’affranchir du plan anatomique pelvien anterieur. Cette navigation nous parait reellement fonctionnelle, liant la cupule au femur dans un cone de mobilite stable et sans conflit intra-prothetique. Cette technique nous a permis de reproduire la programmation preoperatoire de facon fiable. Il ne nous semble pas exister de position « standard » de l’implant acetabulaire : la position de l’implant acetabulaire est a adapter a l’anatomie fonctionnelle propre de chaque patient et egalement au positionnement de l’implant femoral. Ceci permet d’optimiser la stabilite et le fonctionnement du couple prothetique. La simulation de la position du membre inferieur patient debout est le point-cle du systeme. Elle reste perfectible car on ne connait pas l’impact de la liberation de la hanche sur la position erigee notamment dans le plan sagittal, au niveau du complexe lombopelvi-femoral.

Infection aspergillaire et faux anévrisme mycotique fémoral au cours d’un descellement de prothèse totale de hanche avec migration intra-pelvienne de l’implant acétabulaire

We report a case of Aspergillus fumigatus infection of a total hip arthroplasty. This rare infection was demonstrated at surgical revision of a loosened prosthesis with migration of the cup into the pelvis associated with a false aneurysm of the femoral artery. A vascular time was required before the orthopedic revision. This case illustrates the importance of the preoperative work-up in the event of cup migration. The double approach was required in our patient to control and repair the vascular structures. The difficult treatment of Aspergillus fumigatus is also discussed.We report a case of Aspergillus fumigatus infection of a total hip arthroplasty. This rare infection was demonstrated at surgical revision of a loosened prosthesis with migration of the cup into the pelvis associated with a false aneurysm of the femoral artery. A vascular time was required before the orthopedic revision. This case illustrates the importance of the preoperative work-up in the event of cup migration. The double approach was required in our patient to control and repair the vascular structures. The difficult treatment of Aspergillus fumigatus is also discussed.