Olivier Roche

Dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. A prospective, systematic, multicenter study with specific focus on postoperative dislocation

INTRODUCTION Displaced fractures of the femoral neck in the elderly are best treated with arthroplasty. The type of arthroplasty to be used, either hemi- or total hip arthroplasty, remains controversial as total hip replacements potentially have a higher rate of dislocation. HYPOTHESIS Dual mobility cups have a low dislocation rate when used to manage acute fractures of the femoral neck. PATIENTS AND METHODS In a multicenter prospective study conducted in France over an inclusion time of 3 months, all displaced fractures of the femoral neck treated with arthroplasty were operated on with insertion of a dual mobility cup. Patients had clinical and radiological assessment at 3, 6, and 9 months postoperative. RESULTS Two hundred and fourteen hips in 214 patients with a mean age of 83 years (range, 70-103 years) were included. None of the patients was lost to follow-up. The mortality rate after 9 months was 19%. Two patients (1%) had early postoperative infection successfully treated with lavage and antibiotics. Three patients (1.4%), operated through a posterior approach, presented one postoperative dislocation, all of which were posterior. Reduction was performed through closed external manipulation under general anesthesia. There was no recurrence of dislocation. DISCUSSION This low rate of dislocation after acute total hip replacement using dual mobility design cups favorably compares with hemiarthroplasties. Dual mobility cups might therefore be considered a valuable option to prevent postoperative dislocation when treating displaced intracapsular fractures of the proximal femur in elderly patients if a total hip replacement is recommended. Further study is needed before extending the indications for total hip arthroplasty following a fracture of the femoral neck, to assess the potential cost and complications of a longer procedure with its potential acetabular complication, and weigh them against the potential benefits.

Résultats des reprises pour descellement glénoïdien: À propos d’une série multicentrique de 37 prothèses d’épaule

Resume Les auteurs presentent les resultats d’une serie retrospective et multicentrique de 37 cas de reprise pour descellement glenoidien de prothese totale d’epaule avec un recul moyen de 28,5 mois. La reprise etait effectuee en moyenne dans un delai de 52 mois. Le score de Constant a ete utilise pour l’evaluation clinique preoperatoire et au plus long recul. Tous les implants glenoidiens ont ete retires. Une glene non contrainte cimentee a ete reimplantee dans 19 cas dont deux en association avec une greffe. Une « glenoplastie » sans reimplantation glenoidienne a ete realisee dans 12 cas dont 8 en association avec une greffe. Une prothese inversee a ete reimplantee dans 5 cas dont 3 en association avec une greffe. Un patient a ete laisse en resection arthroplastique du fait d’un sepsis evolue. Les resultats de l’ensemble de la serie montrent une amelioration des parametres fonctionnels dans tous les cas. Les meilleurs resultats ont ete obtenus lorsqu’une glene a pu etre reimplantee (stock osseux suffisant) ; dans les cas de glenoplastie, les resultats etaient meilleurs lorsqu’une reconstruction a ete realisee. La prothese inversee a permis une amelioration fonctionnelle dans les cas de descellement glenoidien associes a une rupture massive de la coiffe des rotateurs. Le stock osseux apparait comme la cle de l’option chirurgicale et du resultat fonctionnel.

Influence de l'exploration gléno-humérale associée sur les suites du traitement endoscopique des calcifications de la coiffe des rotateurs

PURPOSE OF THE STUDY Arthroscopic treatment of calcifying tendonitis usually includes a glenohumeral exploration first, followed by deposit removal via a bursal approach. The aim of this study was to analyze the relevance of a systematic glenohumeral exploration during arthroscopic treatment of calcified tendonitis of the rotator cuff. MATERIAL AND METHODS Sixty-four consecutive patients treated by arthroscopic removal of calcific deposits in the rotator cuff were studied retrospectively. All patients had had at least six months of medical treatment. The treatment involved a glenohumeral approach in 32 patients (group GH) and an isolated bursal approach in 32 (group B). Both groups were similar with regard to epidemiological data and deposit aspect. In all cases, the deposit was removed from the bursal side and the cuff was not sutured. Assessment included duration of pain after surgery, Constant score, and x-ray aspect at six months follow-up and the delay for return to work. RESULTS In the GH group, degenerative changes were noted on the labrum in three cases and a partial tear of the supraspinatus in two. No lesions noted in the glenohumeral joint required specific treatment. Postoperatively, the average duration of pain was significantly higher in group GH than in group B (11 weeks versus 6 weeks, p < 0.05) with a significant latency in return-to-work (12 weeks versus 5 weeks, p < 0.05). At six months follow-up, there was no difference between the groups for Constant score and deposit disappearance. DISCUSSION Systematic exploration of the glenohumeral joint is not relevant in the arthroscopic treatment of calcified tendonitis and has a negative effect. Considering these results and those previously published in the literature, we recommend using an isolated bursal approach for arthroscopic calcifying tendonitis removal.

Arthroscopic treatment of rotator cuff tear in the over-60s: repair is preferable to isolated acromioplasty-tenotomy in the short term.

INTRODUCTION The principal study objective was to compare clinical results for arthroscopic repair of rotator cuff tear and acromioplasty-tenotomy in patients aged over 60 years. HYPOTHESES Repair provides better clinical results than isolated acromioplasty-tenotomy. Shoulder function is improved when healing is obtained. PATIENTS AND METHODS One hundred and forty-two patients aged over 60 years (mean age, 67 years) presenting with reparable supraspinatus tear, extending to a greater or lesser degree to the infraspinatus, agreed to take part in a randomized prospective study. Fifteen were excluded from statistical analysis. All underwent acromioplasty and biceps tenotomy. They were randomly assigned to arthroscopic rotator-cuff repair (CR group) or not (AT group). The principal evaluation criterion was mean weighted Constant score at one years follow-up. Healing in the CR group was assessed on ultrasound at one year. RESULTS The complications rate was 7.9%. Mean weighted Constant score was significantly better in group CR: 75.8%, versus 68.8% in AT. In the CR group, the 1-year healing rate was 67.6%. Healing significantly impacted mean weighted Constant score: 80% with healing, versus 66.9% in iterative tearing. Whatever the size of the tear, mean weighted Constant score was significantly better in patients with than without (no repair or iterative tear) tendon healing. DISCUSSION The study demonstrated the interest of arthroscopic rotator cuff repair in patients aged over 60 years. The benefit of repair compared to isolated acromioplasty-tenotomy depended on tendon healing. LEVEL OF EVIDENCE Randomized prospective study, level II.

Surgical management of the infected reversed shoulder arthroplasty: a French multicenter study of reoperation in 32 patients

BACKGROUND In a retrospective multicenter study, we evaluated the efficiency and outcomes of the different therapeutic options for infection after reversed shoulder arthroplasty. METHODS Thirty-two patients were reoperated on for infection after reversed shoulder arthroplasty between 1996 and 2011. The mean age was 71 (55-83) years. The involved implants were primary prostheses in 23 cases and revision prostheses in 9 cases. The average preoperative Constant score was 34 (11-69). Six of these patients needed 2 successive procedures. A total of 38 procedures were performed: débridement (13), 1-stage (5) or 2-stage revision (14), or implant removal (6). At last follow-up (mean, 36 months; range, 12-137 months), every patient had clinical, biologic, and radiographic evaluation. RESULTS Infections were largely caused by coagulase-negative staphylococci (56%) and Propionibacterium acnes (59%). The complication rate was 26%. At last follow-up, 26 patients were free of infection (81%). The final Constant score was 46 (12-75). After débridement with implant retention, the mean Constant score was 51 (29-75), but the healing rate was only 54%. Implant revision (1 or 2 stage) led to better functional results than implant removal (46 vs. 25; P = .001), with similar healing rates (73% and 67%, respectively). Patients with low initial impairment (Constant score > 30) were not significantly improved by surgical treatment. CONCLUSION Débridement is the less aggressive option but exposes patients to healing failure. It should be proposed as a first treatment attempt. Revision of the implant is technically challenging but preserves shoulder function, with no higher rate of residual infection compared with implant removal.

Stem subsidence after total hip revision: 183 cases at 5.9 years follow-up

INTRODUCTION Secondary subsidence of a revision femoral stem is often a negative predictive sign for successful osseointegration and perfect long-term stability. MATERIALS AND METHODS We performed a retrospective study in a series of 183 revision total hip replacements between 1996 and 2000 to evaluate the importance and risk factors of secondary subsidence with a cementless press-fit design femoral stem as well as this subsidences consequences to osseointegration. RESULTS Secondary subsidence did not occur in 80 cases (53%), was between 0 and 4mm in 41 cases (27%); between 5 and 10mm in 17 cases (12%) and was greater than 10mm in 12 cases (8%). Mean subsidence of all patients was 3mm (0-30). There was a statistically significant negative correlation between subsidence and the quality of osseointegration (P=0.03). There was no significant relationship between component diameter and stem subsidence (P=0.9). The presence of preoperative bone deficiencies did not increase the risk of secondary subsidence (P=0.2). CONCLUSION In the case of revision with press-fit stems, the importance of secondary subsidence should not be overestimated, because it usually does not negatively affect satisfactory osseointegration.

Assessment of fixation in cementless femoral revision of total hip arthroplasty: comparison of the Engh score versus radiolucent line measurement

PurposeTo assess osseointegration and stability of a primary cementless femoral stem, many scoring systems have been developed, but none of them have taken into account only the radiolucent line. The purposes of this study were (1) to compare the results between the Engh score to assess osseointegration and stability of the cementless stem with results of a score called the O-SS score (osseointegration-secondary stability), which takes into account the radiolucent line, (2) to verify the relationship between these two scores and the functional results, and (3) to verify if there is a relationship between the O-SS score and secondary subsidence or a pedestal.MethodsA clinical and radiological evaluation was performed in a group of 100 hip prosthesis revisions comparing the results obtained by Engh score and O-SS score for which reproducibility was analysed.ResultsInter-observer reproducibility was estimated to be average at 0.5 and intra-observer reproducibility good at 0.7. The correlation with the Engh score was good at r = 0.59 (p < 0.0001). For the 80 cases assessed O-SS score as very good/good, Harris hip score was at 83.7 versus 78.25 for the 20 cases assessed as average/poor (p = 0.07). For the 73 cases with assessed Engh score as very good/good, this score was at 82.8 versus 82.14 for the 27 cases assessed as average/poor. No correlation between the O-SS score and secondary subsidence (p = 0.2) or pedestal (p = 0.2) was noticed.ConclusionThe evaluation of the clear radiolucent line alone, extent and location, is a sufficient condition to assess osseointegration and secondary stability of a cementless femoral stem.

Bone stock in revision femoral arthroplasty: a new evaluation

PurposeThe purpose of this study was to finalize a method allowing a qualitative and numerical evaluation of the bone stock and to confirm its reproducibility, to verify the relationship between the secondary bone stock value and the functional results, and to determine the main factors influencing the value of the bone stock.MethodsA clinical and radiological evaluation was performed in a group of 150 revisions of total hip replacements according to a new method taking into account cortical bone thickness, bone density and bone defects.ResultsInterobserver reproducibility was evaluated at an average of 0.6 and intra-observer reproducibility was considered good at 0.8. Between the initial bone stock and at the last follow-up, no significant difference was noticed. For secondary bone stock considered as “very good or good”, the gain was +38.1 points versus +29.9 points for patients evaluated as “average or poor” (p < 0.0001). Between the initial bone stock assessment and at last follow-up, a significant relation was found in numerical values for the global type of primary fixation and in the presence of osteopenia (p < 0.0001).ConclusionsDeficient secondary bone stock can result in less favourable functional results. The numerical scores confirm the importance of strategic choices during surgery in order to manage bone stock preservation.

Is rotator cuff repair appropriate in patients older than 60 years of age? Prospective, randomised trial in 103 patients with a mean four-year follow-up

BACKGROUND The objective of this randomised trial was to compare surgical rotator cuff repair to simple decompression by acromioplasty and biceps tenotomy in patients older than 60 years of age with a mean follow-up of 4 years. HYPOTHESIS Tendon repair produces better functional outcomes than simple decompression and prevents progression towards cuff tear arthropathy in the longer term. PATIENTS AND METHOD Of 130 initially included patients older than 60 years of age and having rotator cuff tears deemed amenable to surgical repair, 103 (79%) were evaluated after a mean of 4 years. These patients had been randomly allocated to acromioplasty and tenotomy (AT group, n=49) or to acromioplasty, tenotomy, and tendon suture (CR group, n=54). The tear was distal in 41 patients, intermediate in 40, and retracted in 22. At last follow-up, the evaluation included the clinical Constants Score, radiographs and, in the CR group, ultrasonography. RESULTS The complication rate was 4%. The mean Constant Score was 44 preoperatively; values after 4 years were 76 overall (P=0.01), 78 in the CR group, and 73 in the AT group (P=0.01). The tendon-healing rate as assessed using ultrasonography was 63%. The Constant Score was significantly better when tendon healing was achieved (82/73, P<0.001). In the AT group, the acromio-humeral distance was significantly shorter (6.9 mm/7.8mm, P=0.03) and eccentric humeral head position was more common (44%/26%, P=0.01). DISCUSSION Arthroscopic rotator cuff repair provides better functional outcomes than does simple decompression in patients older than 60 years and prevents cuff tear arthropathy with eccentric humeral head position in the medium term. Tendon healing is the main determinant of outcomes after rotator cuff repair. LEVEL OF EVIDENCE II, randomised trial.

Pleomorphic malignant fibrous histiocytoma at the site of an arthroscopic reconstruction of the anterior cruciate ligament. A case report.

P reviously regarded as a distinct tumor type representing the most common adult soft-tissue sarcoma1,2, the term malignant fibrous histiocytoma is now reserved for a small group of undifferentiated pleomorphic sarcomas3. The tumor is most often primary, but rare cases of secondary malignant fibrous histiocytoma in burn scars4-8 or infected or noninfected surgical scars9-12 have been reported (see Appendix). Secondary malignant fibrous histiocytoma has been described in contact with prostheses13-28, osteosynthesis material29-35, or implanted Dacron grafts36. Malignant degeneration of benign tumors35, Paget disease37, osseous infarcts38, or fibrous dysplasia39 also has been reported (see Appendix). We report a unique case of a patient with soft-tissue malignant fibrous histiocytoma that developed on the medial side of the knee six years after arthroscopic reconstruction of the anterior cruciate ligament with use of the patellar tendon. D uring a soccer game in June 1993, a nineteen-year-old man experienced an indirect injury to the right knee that caused a rupture of the anterior cruciate ligament. A magnetic resonance imaging scan confirmed the diagnosis. An arthroscopic reconstruction of the anterior cruciate ligament was carried out in October 1993 with use of the patellar tendon. Stainless-steel (alloy-316L) screws (with a diameter of 6.5 mm) were used for the femoral and tibial fixation. The rest of the intra-articular examination was normal, and the postoperative course was uneventful. In 1995, a hemarthrosis developed in the right knee subsequent to a new injury. The knee was stable, and the hemarthrosis resolved with symptomatic treatment. In 1997, the patient experienced a locking episode of the right knee, which was found to be caused by a bucket-handle tear of the medial meniscus at …