M.H. Fessy

Histologic study of periprosthetic osteolytic lesions after AES total ankle replacement. A 22 case series

INTRODUCTIONnMedium-term results for total ankle replacement (TAR) are in general satisfactory, but there is a high redo rate for periprosthetic osteolysis associated with the AES implant.nnnHYPOTHESISnComparing radioclinical findings and histologic analysis of implant revision procedure specimens can account for the elevated rate of osteolysis associated with the AES TAR implant.nnnMATERIAL AND METHODnIn a prospective series of 84 AES TAR implants (2003-2008), 25 underwent revision for osteolysis (including three undergoing revision twice) at a mean 59.8 months. Eight patients had hydroxyapatite (HA) coated models and the others had titanium-hydroxyapatite (Ti-HA) coatings. Radiographs were systematically analyzed on Besses protocol and evolution was monitored on AOFAS scores. The 94 specimens taken for histologic analysis during revision were re-examined, focusing specifically on foreign bodies.nnnRESULTSnMacroscopically, no metallosis or polyethylene wear was found at revision. AOFAS global and pain scores fell respectively from 89.7/100 at 1 year postoperatively to 72.9 before revision and from 32.5/40 to 20.6/40, although global scores were unchanged in 25% of patients. Radiologically, all patients showed tibial and talar osteolytic lesions, 45% showed cortical lysis and in 25% the implant had collapsed into the cysts. All specimens showed macrophagic granulomatous inflammatory reactions in contact with a foreign body; the cysts showed necrotic remodeling. Some of the foreign bodies could be identified on optical histologic examination with polyethylene in 95% of the specimens and metal in 60% (100% of HA-coated models and 33.3% of Ti-HA-coated models). Unidentifiable material was associated: a brownish pigment in Ti-HA-coated models (33.3%) and flakey bodies in 44.4% of the HA-coated models and 18.2% of the Ti-HA-coated models.nnnDISCUSSIONnThe phenomenon of periprosthetic osteolysis is still poorly understood, although implant wear debris seems to be implicated. All the patients with HA-coated implants with modular tibial stem had metal particles in the tissue around the implant, although their exact nature could not be determined. The double-layer Ti-HA coating may induce delamination by fretting while the biological bone anchorage is forming.nnnLEVEL OF EVIDENCEnProspective cohort study - Level IV.

Autologous chondrocyte implantation for traumatic full-thickness cartilage defects of the knee in 14 patients: 6-year functional outcomes.

BACKGROUNDnAutologous chondrocyte implantation (ACI) was introduced in 1987 in Sweden by Brittberg and Peterson for the treatment of severe chondral defects of the knee. Here, our objective was to evaluate mid-term outcomes of ACI in young athletic patients with deep chondral defects of the knee after trauma.nnnHYPOTHESISnACI is effective in filling full-thickness chondral defects of the knee.nnnPATIENTS AND METHODSnWe prospectively monitored 14 patients, with International Cartilage Repair Society grade III or IV lesions, who underwent ACI between 2001 and 2006. Standard evaluation measurements were used. Mean age at surgery was 37.7 years (range, 30-45). A history of surgery on the same knee was noted in ten (67%) patients. The defect was on the medial femoral condyle in 11 patients, lateral femoral condyle in two patients, and both femoral condyles in one patient. Mean defect surface area after debridement was 2.1cm(2) (1-6.3).nnnRESULTSnAfter a mean follow-up of six years, improvements were noted in 12 (86%) patients, with an International Knee Documentation Committee (IKDC) score increase from 40 (27.6-65.5) to 60.2 (35.6-89.6) (P=0.003) and a Brittberg-Perterson score decrease from 54.4 (11.8-98.2) to 32.9 (0-83.9) (P=0.02), between the preoperative assessment and last follow-up. The visual analogic scale pain score decreased from 66.3 (44-89) to 23.2 (0-77) (P=0.0006). In two (14%) patients, no improvements were detectable at last follow-up. The remaining 12 patients were satisfied and able to resume sporting activities, albeit at a less strenuous level. Two ACI-specific complications occurred, namely, periosteal hypertrophy treated with debridement in one patient and transplant delamination in another.nnnDISCUSSIONnOur findings are consistent with previous reports but cover a longer follow-up period. Although the outcomes are promising, longer follow-ups are needed to confirm the long-term effectiveness of ACI.nnnLEVEL OF EVIDENCEnIV, prospective therapeutic study.

Comparison of quality of life following total ankle arthroplasty and ankle arthrodesis: Retrospective study of 54 cases

INTRODUCTIONnThe benefit of ankle arthroplasty compared to arthrodesis continues to be debated, but the quality of life after these two interventions has rarely been assessed. We conducted a case-control study to compare quality of life and functional and athletic ability.nnnHYPOTHESISnFunctional results, athletic ability, and quality of life after total ankle arthroplasty (TAA) are better than after ankle arthrodesis.nnnMATERIAL AND METHODSnTwo continuous series of 59xa0TAAs and 46 arthrodeses (operated on between 1997 and 2009) were evaluated retrospectively using a questionnaire including the functional items of the AOFAS score, the Foot Function Index (FFI) score, the Foot Ankle Ability Measure (FAAM), and the SF-36.nnnRESULTSnEighty-three responses (79% of the overall series) were matched in two groups: 32 TAAs [age at the intervention, 51.4years (range, 21-63years); follow-up, 52.2months (range, 30-146months); age at revision, 55.8years (range, 26-67years); BMI, 27.7 (range, 21.7-36.7)] and 22 arthrodeses [age at intervention, 50.1years (range, 24-72years); follow-up 57.9months (range, 12-147months); age at revision 54.9 years (range, 31-75years); BMI, 26.8 (range, 17.6-37)] (NS on all items between the two groups). The pain results were better after TAA, but with no statistically significant difference: AOFAS pain, (/40) 28.1±8.2 vs. 24.5±9.6; FFI pain, 16.6±18.8 vs. 24.3±21.5. The overall FFI score (/100) was better (P=0.048) after TAA (16.2±16.5 vs. 24.8±18.2). The overall mean athletic level compared to the state prior to the injury was relatively low in both groups, but significantly (p=0.007) higher in the TAA group: FAAM sports score (/100), 49.5±24.4 vs. 29.8±26.2. The quality-of-life scores, SF-36 physical health, mental health, and general health were not significantly different after TAA and arthrodesis: mental health score, 63.1±14.7 vs. 57.8±21.5; physical health score, 61.3±17.8 vs. 53.7±23.9, overall score, 63.2±16.4 vs. 55.9±23.5.nnnDISCUSSIONnVery few publications describe activities and quality of life after TAA and arthrodesis. Despite weaknesses, this comparative study demonstrates a tendency toward better functional results after TAA than after ankle arthrodesis, without the difference between the two groups being very significant. On the other hand, there was no difference in terms of quality of life. After the doubts raised by publications on severe periprosthetic osteolysis at the intermediate term with certain TAA models, these results encourage pursuit of implantation and development of TAA.nnnLEVEL OF PROOFnComparative retrospective. Level III study.

Fractures of a sandwich ceramic liner at ten year follow-up

PurposeThe aim of this study was to understand the causes of sandwich liner fractures implanted at our institution by evaluating the long-term results of this device.MethodsWe retrospectively assessed 143 patients (151 hips) consecutively operated upon in our department by the same senior surgeon between 1999 and 2001 and with a mean follow-up period of 9.9xa0years (range 8.5–11.5). The components used were Cerasul® sandwich ceramic liners within a cementless cup. Patient assessment was based on demographic factors (age, gender, body mass index), the clinical scores according to Devane (activity), the potential complications and a radiographic analysis from an anteroposterior pelvic radiograph (cup inclination). Revision cases and their cause were classified (implant fracture, loosening, dislocation, periprosthetic fracture).ResultsFive cases of liner fracture (3.7%) were observed at a mean seven year (4.5–8.5) follow-up. The risk factor for implant failure was found to be patient activity: the mean preoperative Devane score was 3.5 in the fracture group vs 2.6 in the control group (pu2009=u20090.008). Mean cup inclination was 52°. The survivorship analysis at tenxa0years was 85% with revision as the endpoint. Prosthetic complications accounted for 8.6% of all 151 hips (fractures included): one case of aseptic loosening (0.7%), two cases of sepsis (1.4%), four cases of isolated dislocation (2.8%) and one case of recurrent dislocation (0.7%).ConclusionsAlumina sandwich liners remain a subject of concern since the increasing clinical follow-up period may predispose them to fatigue failure. This system has been abandoned in our department since 2005.

Mobile-bearing insert translational and rotational kinematics in a PCL-retaining total knee arthroplasty.

INTRODUCTIONnTotal knee prostheses with a mobile-bearing insert were developed to provide nonconstrained joint range of motion while reducing friction forces. The purpose of this study was, based on weightbearing X-rays, to evaluate the mobility of the polyethylene tibial insert in relation to the femoral and tibial components. We studied the results of a cementless total knee arthroplasty (TKA) retaining the posterior cruciate ligament (PCL), with a mobile-bearing platform in rotation and anteroposterior translation (Innex Anterior-Posterior Glide, Zimmer) with a mean 23-month follow-up duration after surgery.nnnHYPOTHESISnBoth anterior-posterior tibiofemoral translation and intraprosthetic axial rotation occur between the mobile polyethylene insert and the tibial endplate.nnnMATERIAL AND METHODnIn a series of 51 primary TKA, the three-dimensional (3D) kinematics of the femoral, tibial, and mobile insert components were determined using a computerized matching system between the prosthetic 3D models and the radiographic images of the implants on three lateral follow-up weightbearing knee X-rays: films were taken in full extension, at 45 degrees flexion, and at maximum flexion.nnnRESULTSnThere was a statistically significant increase in the internal rotation of the mobile tray with flexion, (up to a mean -3+/-3 degrees between the femoral box and the mobile tray [p<0.0001] and up to a mean -5+/-7 degrees between the tibial tray and the mobile tray [p<0.0001]). The mobile tray did not translate in relation to the tibial endplate from extension to 45 degrees flexion (0+/-2 mm [range: -5 to 6 mm]). However, from 45 degrees to maximum flexion, a statistically significant mean 1+/-2 mm (range: -2 to 9 mm) of anterior translation (p<0.0001) was found.nnnDISCUSSIONnThe extent of insert mobility varies from one study to another. Some have reported relatively limited mobility stemming from a superior surface that is not highly congruent, (thus allowing anterior-posterior and mediolateral translation through gliding of the femur in contact with the insert). Other studies have reported mobile-bearing tray mobility in relation to the tibial endplate and minimal rotation at the femoral component level. In this series of PCL retaining TKA with a mobile-bearing platform, the mobile-bearing platform showed a progressive increase in internal rotation during flexion. Most of this rotational mobility occurred between the mobile platform and the tibial endplate, confirming our hypothesis. However, with flexion, the femoral component increased its mobility relatively to the platform. During flexion, an anterior-posterior translation occurred between the femoral implant and the tibial insert, and between the tibial insert and the tibial endplate, but the direction of the mobile tibial insert translation remained unpredictable with this nonconstrained implant design used.nnnLEVEL OF EVIDENCEnLevel IV. Prospective non-controlled therapeutic study.

Outcomes Following Cyst Curettage and Bone Grafting for the Management of Periprosthetic Cystic Evolution After AES Total Ankle Replacement

We present a prospective series of 50 AES total ankle replacements performed between 2003 and 2006. The present report concerns medium-term results of cyst curettage-grafting. Twenty total ankle replacements underwent revision: 6 by tibiotalocalcaneal arthrodesis and 14 by cyst curettage-grafting. With 79% and 92% rates of unimproved or worsened functional and radiological status respectively, our results in cyst grafting are poor. No previous series of curettage-graft in evolutive periprosthetic total ankle replacement cyst have been reported. In periprosthetic cyst, we recommend annual radiological surveillance, with CT in case of cyst enlargement and/or increased pain, to allow implant removal and reconstruction-arthrodesis before collapse.

Compared fixation and survival of 280 lateralised vs 527 standard cementless stems after two years (1–7)

BACKGROUNDnRestoring the native hip anatomy increases hip prosthesis survival, whereas increased femoral lateralisation creates high torque stresses that may alter prosthesis fixation. After finding lucent lines around cementless lateralised stems (Corail™, DePuy Synthes, St Priest, France) in several patients, we evaluated the effects of lateralisation in a large case-series. The objective of our study was to compare lateralised vs standard stems of identical design in terms of radiological osteo-integration and survival.nnnHYPOTHESISnLateralised stems, despite being used only when indicated by the anatomical parameters, carry a higher risk of impaired osteo-integration.nnnMATERIALS AND METHODSnA retrospective study was conducted in 807 primary total hip arthroplasties (THAs) performed between 2006 and 2010 in 798 patients with a mean age of 65 ± 14.2 years. Lateralised stems were used in 280 cases (Corail High Offset KHO, n = 169; and Corail coxa vara KLA, n = 111 cases) and standard stems in 527 cases (Corail KA). Mean follow-up was 2.3 years (range, 1-7 years). The clinical evaluation included determination of the Postel-Merle dAubigné (PMA) score. Bone fixation and stability of the implants were assessed by determining the Engh and Massin score and the ARA score on the radiographs at last follow-up. Femoral, acetabular and global offset values were determined before and after THA. Nobless Canal Flare Index was computed. Survival was estimated using the Kaplan-Meier method with surgical revision for aseptic loosening as the end-point.nnnRESULTSnThe PMA score improved from 12 (10-15) pre-operatively to 17.7 (14-18) (P < 0.05). After THA, in the lateralised stem group, femoral offset was restored in 217 (77%) hips and the mean change vs the pre-operative offset value was -2 mm; in the standard stem group, femoral offset was restored in 440 (83.5%) hips and the mean change was +1 mm. The Engh and Massin score values were similar in the standard stem and lateralised stem groups (24.4 ± 2.2 and 22.6 ± 2.4, respectively, NS). Revision for aseptic loosening was required in 5 patients with lateralised stems (3 KHO and 2 KLA) versus none of the patients with standard stems. There were no cases of excessive femoral offset and the mean change in offset was -2.3mm (-5.3 to -1.1). Nobles index was increased (4.27 ± 0.5 for the loosened lateralised stems, 3.65 ± 0.8 for the well-fixed lateralised stems and 3.82 ± 0.6 for the standard stems), with no significant difference across groups. Overall survival after 3.5 years of follow-up was 94.6% (95% confidence interval, 88.4-100%) with lateralised stems and 100% with standard stems (P < 0.05).nnnDISCUSSIONnThe risk of aseptic loosening was significantly higher with the lateralised stem (5/280, 1.8%) than with the standard stem (n = 0). Our findings indicate a need for careful preparation to obtain primary fixation of lateralised stems.nnnLEVEL OF EVIDENCEnIII, retrospective case-control study.

Metasul vs Cerasul bearings: a prospective, randomized study at 9 years.

The aims of our study were to compare metal-on-metal (Metasul) and ceramic-on-ceramic (Cerasul) bearings and to evaluate the clinical and radiographic results of these 2 different hard-on-hard bearings. We conducted a prospective, randomized study on a series of 250 cementless primary total hip arthroplasties. The prostheses were similar in all aspects except for the bearing surfaces: 50% of Metasul bearing and 50% of Cerasul bearing. All the patients were evaluated both clinically and radiographically. No patient was lost to follow-up. Clinical outcomes in both groups were similar. Considering aseptic loosening as the end point for failure, the 9-year survival rate was 100% for Cerasul and 98.4% for Metasul. Neither bearing outperformed the other both radiographically and clinically. The overall 9-year survival rate was 99.2% and 97.6% in the Cerasul and Metasul groups, respectively.

Does arthrodesis of the first metatarsophalangeal joint correct the intermetatarsal M1M2 angle? Analysis of a continuous series of 208 arthrodeses fixed with plates.

INTRODUCTIONnFirst-ray metatarsophalangeal arthrodesis is a classic surgical procedure in the treatment of severe hallux valgus, hallux rigidus, revision surgery, and inflammatory arthritis. The objective of this study was to verify if metatarsophalangeal plate arthrodesis could correct the M1M2 intermetatarsal angle.nnnMATERIAL AND METHODSnThis prospective and continuous series (June 2007 to March 2011) included 208 patients (48% severe and/or arthritic hallux valgus, 18% hallux rigidus, 16% rheumatoid forefoot, 13% surgical revision of the first ray, 5% hallux varus), with a mean age of 62.4±9.9 years (range, 19-87 years). All the patients were operated on by a senior surgeon with the same technique: spherical avivement of the joint surfaces using reamers, osteosynthesis with an anatomic plate (Fyxis-Biotech™) in Ti.6Al.4 V alloy prebent to 5° with a phalangeal arm to receive an oblique metatarsophalangeal screw in compression, in addition to four 2.7-mm nonlocking dorsal screws. The full-scale preoperative and intraoperative angle measurements were taken on AP and lateral X-rays of the weightbearing foot, as related to the etiology and the severity of the preoperative metatarsus varus (M1M2<15°, M1M2 15-19°, M1M2≥20°). The statistical analysis was done using the StatView software.nnnRESULTSnThe mean follow-up was 18.6±12.4 months (range, 2-76 months). Nearly all of the arthrodesis patients (97%) achieved bone union, and 5% of the plates were removed. The M1P1 angle decreased from 33.8±19.7° (range, -45° to -67°) preoperatively to 13.3±5.3° (range, 0-32°) at the last follow-up, and the M1M2 angle from 14.2±5.4°(range, 0-26°) to 6.5±2.3° (range, 0-12°). The preoperative M1M2 angle was <15° in 97 patients, 15-19° for 78 patients, and ≥20° for the 33 others; at the last follow-up it was 5.8±2.1° (range, 0-10°), 6.7±2.2° (0-10°), and 8.1±2.4° (3-12°), respectively. No correction of the metatarsus varus was demonstrated in relation to etiology. The M1M2 angle was >10° in only two patients (one case of rheumatoid arthritis and one case of severe hallux valgus): 0.9%.nnnDISCUSSIONnThese results show that isolated metatarsophalangeal arthrodesis of the first ray can correct metatarsus varus even in substantial deformations in any etiology.nnnLEVEL OF PROOFnLevel II cohort study.

Long-term survivorship of the Corail™ standard stem

INTRODUCTIONnThe Corail™ stem, which was first introduced in 1986, has since been modified twice: first to make the neck thinner and then to change the location of the laser markings. The survival and complications of the first-generation straight, titanium, hydroxyapatite-coated stem are known; however, there is little specific information about the latest-generation stem. This led us to conduct a retrospective study to determine the: (1) long-term survival; (2) clinical and radiographic outcomes; (3) complications; and (4) risk factors for revision of the newest Corail™ stem.nnnHYPOTHESISnThe newest Corail™ AMT (Articul/EZE™ Mini Taper) standard stem has comparable survival to prior models.nnnPATIENTS AND METHODSnThis single-center, retrospective study included 133xa0patients (140xa0hips), who underwent primary total hip arthroplasty (THA), between January and Decemberxa02004, in which a Corail™ Standard stem was implanted using a posterolateral approach. Patients who underwent revision THA, THA due to femoral neck fracture or who received lateralized (offset) stems were excluded. The mean age at the time of THA was 69±13xa0years [35-92] in 85xa0men (61%) and 55xa0women (39%) who had a mean BMI of 27kg/m2±11 [16-39]. At the latest follow-up, 32xa0patients (32xa0hips) had died and 8xa0patients (8xa0hips) had less than 3xa0years follow-up, thus were not included in the clinical evaluation. The Merle dAubigné (PMA) score was collected. The stems survivorship was calculated using the Kaplan-Meier method with revision for aseptic loosening and revision or implant removal for any reason as the end-points. The Cox model was used to analyze risk factors for revision. The mean follow-up was 10±3xa0years [3-12].nnnRESULTSnThe PMA score was 12±2.6xa0[5-17] preoperatively and 16±2.7 [7-18] at the last follow-up (P<0.00001). Eighteen complications (12.8%) were recorded at the last follow-up. There were 15xa0early complications: 6xa0dislocations, 5xa0calcar fractures (4xa0treated by wire cerclage and 1 by stem change plus wire cerclage), 2 greater trochanter fractures (treated non-surgically) and 2xa0cases of sciatic nerve palsy. There were 3xa0late complications: 2xa0cases of iliopsoas irritation and 1xa0ceramic insert fracture. Stem survival for surgical revision due to aseptic loosening was 98% (95% CI: [0.96-1]). At 12xa0years, 95% of stems had not been revised or removed (95% CI: [0.92-0.99]). Being less than 58xa0years of age at the time of surgery was the only risk factor significantly associated with stem revision for any reason (P=0.04).nnnCONCLUSIONnSurvival of the Corail™ Standard stem is similar to that of previous generation stems. The changes made in this stem solved the neck failure problem and did not induce new complications.nnnLEVEL OF EVIDENCEnLevel IV (retrospective study).