Karim Tribak

Medium term follow-up of the AES ankle prosthesis: High rate of asymptomatic osteolysis☆

BACKGROUND The AES (Ankle Evolutive System) is a cobalt-chromium three-component ankle prosthesis with a hydroxyapatite coating, similar to the Buechel-Pappas ankle prosthesis, but with some modifications. Our objective was to assess its medium term follow-up results as well as its complications. METHODS 21 patients (mean age of 57.6 years) were operated by a total ankle arthroplasty (TAA), using the AES implant, according to the standard technique. Only 18 patients were included. The other three patients were excluded from the study: two had been revised for avascular talar necrosis and one patient was happy with her outcome but could not present for logistic reasons at the last follow-up. Indications for surgery included posttraumatic osteoarthritis, primary osteoarthritis, hemochromatosis, rheumatic arthritis and osteoarthritis as a sequel of ankle instability. All patients were analyzed clinically and radiologically. Special attention was given to the presence or not of areas of osteolysis around the implants as well on conventional radiography as on CT-scan imaging, according to a specific protocol. RESULTS The mean follow-up was 39.4 months. Average American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score improved from 52.2 preoperatively to 86.6 postoperatively. No intra-operative complications or early complications have been noted. Delayed complications were the following: one valgus malalignment, one recurrent painful anterior heterotrophic bone formation. Above all, we noted on conventional X-ray the presence of osteolysis in 77% (14) of our patients, with a size of 0.5-1cm or greater on conventional X-ray. The most vulnerable area seemed to be the posterior tibial plafond. The four remaining patients did not show any cyst formation on X-ray but did also, just as the other 14 patients, on the CT-scan. CT-scan, on the contrary, found more osteolysis in the body of the talus, underneath the implant, an area masked on conventional X-ray. Only one patient was revised with allograft bone filling of a symptomatic osteolysis, without the need for implant removal. CONCLUSIONS This retrospective study shows a high frequency of delayed appearance of osteolysis (77%) in 18 AES total ankle arthroplasties. Fortunately at this moment and considering one revision, this considerable amount of asymptomatic osteolysis could not warrant a durable uncomplicated outcome.

Scarf osteotomy without internal fixation to correct hallux valgus.

Scarf osteotomy of the first metatarsal bone to correct hallux valgus deformity has benefited from a number of improvements over the past two decades, most notably regarding the internal fixation method. Internal fixation was deemed mandatory by the authors of early case-series studies. Maestro suggested eliminating the proximal screw by locking the two fragments distally: a notch was created via a medial extension of the cephalic part of the osteotomy, the plantar fragment was displaced laterally, and the distal end of the proximal fragment was then fit into the notch (secondary cut and interlocking joint technique). To further develop this concept and to increase the potential range of translation, we developed an original technique involving distal locking without shortening and proximal stabilisation by impaction of a cortical-cancellous bone graft taken from the medial overhanging edge of the proximal fragment. This original technical variant has not been reported previously.

Lemierre Syndrome of the Femoral Vein, Related to Fusobacterium necrophorum Abscess of Vastus Lateralis

BACKGROUND Lemierre syndrome is an uncommon, potentially lethal disorder combining acute oropharyngeal infection caused by Fusobacterium necrophorum, with jugular vein suppurative thrombosis, complicated by anaerobic sepsis with secondary multiple metastatic abscesses. Optimal treatment outcome with reduced or absence of sequelae can be achieved with early diagnosis. CASE REPORT We present a clinical case of Fusobacterium necrophorum abscess complicated with femoral vein thrombosis, called atypical localization of Lemierre syndrome. This uncommon disease was diagnosed on the basis of clinical, biological, and imaging tests, with a favorable outcome, after a well-orientated antibiotic and surgical course of therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Since its first description in 1936, Lemierre syndrome has been reported in locations other than its initial oropharyngeal site. Because optimal treatment outcome is dependent on early diagnosis, it is imperative for emergency physicians to be aware of this uncommon disease, because in many instances they are the patients initial point of contact with medical care.

Risk of virus transmission through femoral head allografts: A Belgian appraisal

BACKGROUND To evaluate the incidence and the risk of transmitting a virus through a bone allograft from a living donor. MATERIAL AND METHODS A total 7032 femoral heads have been collected from 24 Belgian institutions. The tissue along with the screening blood tests were systematically sent to the bank. Serological screening included: for HIV, a HIV1-2 antibody test; for HBV, a HBS antigen and HBS and Hbcore antibodies; for HCV, a HCV antibody test. Syphilis was also screened with a non-specific and a specific assays. HTLV1-2 screening was recommended but not obligatory. RESULTS From the 7032 femoral heads, 1066 (15.2%) implants were definitively excluded. Hundred forty-six femoral heads, representing 2.1% of all grafts and 13.9% of the excluded ones, were discarded for positive serological testing associated with a risk of disease transmission. There were 2 donors who tested positive for HTLV1-2. The prevalence of HIV in the femoral head donor population was six times lower than in the general one. The prevalence of hepatitis B and C was similar but far higher than HIV. The risk was computed to be 0.54 out of 1 × 10(5) for HIV and HCV without quarantine or tissue processing. For HBV, the risk was 0.77 out of 1 × 10(5). CONCLUSION Current standards of tissue banking incorporated safety and quality as their main features. This policy is now regulated at the European level. With a multi-step screening-policy, stringent donor selection guidelines, the risk of viral transmission trough a tissue is minimized.

Establishing a bone bank in developing countries

Bone allografts are now an important instrument in the handling of numerous orthopedic surgical procedures. Establishing local tissue banks, able to procure, preserve and distribute bone tissues, allows the surgeons to avoid the procurement of an autograft and the important related morbidity. The missions of a tissue establishment are described and recommendations for donor selection, graft procurement and processing are done. Sawing the bone fragments in small pieces and morselisation with a surgical rongeur allow bone marrow removal with saline and alcohol. Sterilisation by autoclaving can be performed insuring a great safety. Processed bone allografts are very useful in treating bone defects observed in benign tumors, traumatology and to obliterate dead space and deliver local antibiotics in osteomyelitis.