Patrice Mertl

Distal locking stem for revision femoral loosening and peri-prosthetic fractures

Revision total hip arthroplasty in the setting of a large proximal femoral deficiency or a peri-prosthetic fracture remains a challenging problem. We describe the development, surgical technique and the use of cementless revision stems with distal inter-locking screws to provide immediate stability of the femoral implant. Results were assessed in a large multicentre French study conducted with the french hip and knee surgery society (SFHG). We retrospectively reviewed 725 revisions using interlocking stems from 14 French orthopaedic departments. Seven different stems were used in this series. In-patient records were retrieved, and in addition to demographic data the indication for revision, the preoperative and postoperative PMA and Harris hip scores were documented. The bone deficiency was classified on the basis of the French National Orthopaedic Meeting (SOFCOT) classification. Intraoperative complications and problems if any were retrieved from operative notes. Clinical status and radiographs at the final follow-up were evaluated, paying special attention to the metaphyseal filling index. Average follow-up was 4.5 years. As for the clinical results, the mean Harris hip score at last follow-up was 81. Therefore, it increased by an average of 31 points. Bone reconstruction was assessed on the cortico-medullary index in the metaphyseal area and at mid-shaft increasing from 36 to 45 and 54 to 63, respectively. Radiologically, 637 implants were stable, and 40 demonstrated subsidence. Forty-eight implants have been revised. We found a significant relation between the metaphyseal filling index, the stability of the stem and the quality of bone reconstruction. Results were analysed with respect to three groups of stems: group 1 was a straight, partially HA-coated implant; group 2 was a curved, fully HA-coated implant; and group 3 was a curved, partially-coated implant. Group 1 showed a significantly higher rate of failure when compared with the others types of implants. Group 2 had better functional results than group 3, which in turn reported better results than group 1. With regard to implant fixation, group 2 had significantly better results. Both groups 2 and 3 induced less thigh pain than group 1. The distal interlocking stem has shown promising results for femoral revisions. The advantages are initial axial and rotational stability and consistent bony in-growth owing to hydroxyapatite coating. Distal locked stems are mainly indicated to treat complex femoral revision with severe bone loss and peri-prosthetic fractures.

Arthrodèse de cheville pour échec d’arthroplastie totale: À propos de 8 cas

Resume Les auteurs rapportent huit cas d’echec de prothese totale de cheville repris par arthrodese. La moyenne d’âge etait de 57 ans (36 a 76 ans). Le diagnostic initial etait une arthrose post-traumatique dans quatre cas, une polyarthrite rhumatoide dans trois cas et une arthrose idiopathique dans un cas. La revision a ete pratiquee en moyenne 36 mois (4 a 108 mois) apres la mise en place de la prothese, pour traiter sept descellements aseptiques et un descellement septique. La perte de substance osseuse liee a l’ablation de la prothese a ete le plus souvent compensee par une greffe iliaque. Une osteosynthese interne a ete utilisee dans sept cas. Dans le cas septique, la fusion a ete obtenue sans greffe osseuse avec un fixateur externe. Le recul moyen etait de 56 mois (10 a 114 mois). La fusion a ete obtenue dans sept cas avec un delai moyen de 3,1 mois (2,5 a 6 mois). Le score de Kitaoka a ete ameliore dans tous les cas passant en moyenne de 19,1 a 54. En cas d’echec d’arthroplastie totale de cheville, l’arthrodese a ete obtenue pour 87 % des cas dans notre experience. Le taux de complication est faible, mais le resultat fonctionnel est modeste et reste inferieur a une arthrodese de premiere intention.UNLABELLED We report outcome in eight cases of ankle arthrodesis after failure of a total ankle prosthesis. MATERIAL AND METHODS This series included eight patients, mean age 57 years (range 36-76) who had initially: post-traumatic talocrural joint degeneration (n=4), rheumatoid polyarthritis (n=3), idiopathic talocrural degeneration (n=1). Three patients had a New Jersey (DePuy) cemented prosthesis, four had a Star (Link) uncemented prosthesis and one, whose implantation was performed in another institution, had a spherical cemented prosthesis. The preoperative Kitaoka score was 19.1 (0-32). Seven patients had subtalar joint degeneration; one patient had a subtalar arthrodesis. The tibial component was cemented alone in two patients, the talar piece in three (two with talar fracture). Failure resulted from loosening, talus fracture or deep infection. Bipolar loosening was observed in two patients. Time to revision was 36 months (range 4-108). Arthrodesis was associated with an iliac graft for seven patients: several tricortical grafts (vertical alignment of the corticals) and cancelous grafts for filling. The height of the graft was adjusted to the substance loss. A bone graft could not be used in one patient who had a deep infection. The arthrodesis was fixed with an anterior plate bridging the talocrural space in six patients, with an external fixator in infected patient, with a conventional centromedullary tibial nail transfixing the talocrural joint and planted in the talus and the calcaneus in one. Outcome was assessed with the Kitaoka score. Mean follow-up was 56 Months (range 10-114). RESULTS The overall Kitaoka score improved to 54/100 (range 42-70) at last follow-up. The arthrodesis provided improvement in all patients although the final outcome was still considered poor in three patients. Radiographic healing was obtained in seven patients at a mean 3.1 months (range 2.5-6). Wound healing was slow in two patients. One patient developed a deep infection early. DISCUSSION The rate of fusion was 87%. This is in the general range reported in the literature; use of an iliac graft allows preserving joint height but because of the poor bone quality often encountered, residual bone stock may be insufficient to achieve complete fixation with screwing. Plate fixation appears to be a better way of achieving fixation. This provides a rate of fusion comparable with earlier series where external fixation was generally employed. For us, external fixation should be reserved for infected cases. Use of a conventional anterograde nail can be another solution in the event of poor bone quality. The overall result remains relatively modest although all the patients achieved a functional gain with arthrodesis. The results obtained are less satisfactory than after first-intention ankle arthrodesis.

Traitement des infections ostéoarticulaires par clindamycine chez l’adulte

UNLABELLED The main characteristics of clindamycin are adequate for treatment of osteoarticular infections (OAI): good bone diffusion, broad spectrum of antibacterial activity and oral use. METHOD A number of 61 patients was included in an observational retrospective study of efficacy and tolerance. RESULTS Prosthetic infections accounted for 50.8% of the cases and chronic osteitis for 36.1%. The causative micro-organisms were Staphylococci (72.2%) and Streptococci (15.3%); 86.5% of these strains were susceptible to erythromycin, 9.6% were erythromycin resistant and susceptible to lincomycin. Clindamycin was associated with either ofloxacine, rifampicin, or teicoplanin in 88.5% and the average course duration was 101 days. A surgical procedure was performed in 84% of cases. Complete cure was obtained in 91.1% at 18 months of follow up. Only one cutaneous rash and one Clostridium difficile-associated diarrhea occurred. The other adverse effects were gastrointestinal in 36%, cutaneous in 6.6%, and hematological in 1.6%, but did not lead to discontinuation of therapy. CONCLUSION Clindamycin can be used in OAI in association with or as an alternative to rifampicin, fluoroquinolones, or glycopeptides according to microbiological data.

The usefulness of 99mTc sulfur colloid bone marrow scintigraphy combined with 111In leucocyte scintigraphy in prosthetic joint infection.

AimTo assess the extent to which bone marrow scintigraphy (BMS) makes the interpretation of leucocyte scintigraphy (LS) easier and improves its diagnostic value. MethodsSeventy-three 111In LSs, 99mTc hydroxymethylene diphosphonate bone scintigraphies (BSs) and 99mTc sulfur colloid BMSs were performed in 60 patients with suspected infection related to a hip prosthesis or knee prosthesis, either in situ (+group, n=43) or after removal for septic loosening (−group, n=30). Bacteriological samples were obtained from all patients. LS was interpreted together with BS (LS-BS) or with BMS (LS-BMS) by three independent readers. ResultsThe concordance among readers, estimated by the kappa test, was average with LS-BS (κ/κm coefficients=0.58, 0.58 and 0.46, respectively, for the three pairs of readers) and excellent with LS-BMS (κ/κm coefficients=1.00 for the three pairs of readers). With LS-BS, 64/219 interpretations were equivocal whereas only one was equivocal with LS-BMS. Sensitivity, specificity and accuracy of LS-BMS were, respectively, 80%, 94% and 91% in the+group, and 33%, 100% and 93% in the−group. ConclusionWe conclude that (1) the interpretation of the results for LS-BMS is very easy, in contrast to LS-BS; (2) the diagnostic value of LS-BMS for detecting infected joint prostheses is good; and (3) additional data are needed to assess the accuracy of LS-BMS when the prosthesis has been removed.

Radiological study of the knee joint line position measured from the fibular head and proximal tibial landmarks

Restoring the joint line level is one of the surgical challenges during revision of total knee arthroplasty. The position of the tibial surface is commonly estimated by its distance to the apex of fibular head, but no study evaluating this distance accurately has been published yet. The purpose of this work was to study the distance between the knee joint line and the apex of the fibular head and the proximal tibia, particularly the tibial tuberosity. Variability with clinical data and relations with other local measurements have been evaluated on knee radiographs (an antero-posterior view, a medio-lateral view and an anteroposterior full length view) of 100 subjects (125 knees). Results showed no correlation between the joint line–fibular head apex distance and any clinical data of the patients, or any other performed measurements. Relations between tibial measurements and the sexe or the height of the subjects were noted. Besides, the review of the 25 bilateral cases did not show statistically significant side difference but the descriptive analysis showed too large discrepancies for the joint line–fibular head apex distance to be used as a landmark. We conclude that the fibular head apex cannot be used as a morphologic landmark to determine the knee joint line position. Its interest in clinical and surgical practice must be discussed.

Mid- to long-term results of revision total knee replacement using press-fit intramedullary stems with cemented femoral and tibial components

This was a retrospective analysis of the medium- to long-term results of 46 TC3 Sigma revision total knee replacements using long uncemented stems in press-fit mode. Clinical and radiological analysis took place pre-operatively, at two years post-operatively, and at a mean follow-up of 8.5 years (4 to 12). The mean pre-operative International Knee Society (IKS) clinical score was 42 points (0 to 74), improving to 83.7 (52 to 100) by the final follow-up. The mean IKS score for function improved from 34.3 points (0 to 80) to 64.2 (15 to 100) at the final follow-up. At the final follow-up 30 knees (65.2%) had an excellent result, seven (15.2%) a good result, one (2.2%) a medium and eight (17.4%) a poor result. There were two failures, one with anteroposterior instability and one with aseptic loosening. The TC3 revision knee system, when used with press-fit for long intramedullary stems and cemented femoral and tibial components, in both septic and aseptic revisions, results in a satisfactory clinical and radiological outcome, and has a good medium- to long-term survival rate.

Fractures récentes de la tête radiale associées à une instabilité du coude traitées par prothèse à cupule mobile de Judet

Resume Les auteurs rapportent une serie de 10 patients presentant une fracture non osteosynthesable de la tete radiale associee a une laxite du coude (rupture du plan ligamentaire collateral medial ou luxation du coude) traitee par prothese de tete radiale a cupule mobile de Judet. Le recul moyen etait de 31,7 mois. La mesure de la mobilite articulaire par goniometrie a permis de retrouver : une flexion moyenne de 121 (90 a 140), un deficit d’extension moyen de 20 (5 a 60), une pronation moyenne de 45 (0 a 85), une supination moyenne de 42,5 (0 a 90). Les resultats ont ete evalues selon le score de la Mayo Clinic avec 3 excellents, 2 bons, 3 moyens et 2 mauvais resultats. De nombreuses complications ont ete retrouvees dominees par quatre cas d’ossifications peri-articulaires. Dans deux cas, une explantation definitive de la prothese a ete necessaire (prothese « perchee » dans un cas et luxee dans l’autre cas). Si la prothese de tete radiale permet la cicatrisation du plan ligamentaire collateral medial en stabilisant la colonne laterale, elle ne peut empecher les complications secondaires aux lesions initiales associees qui viennent grever le resultat final. Cependant, la mise en place de tels implants nous parait indispensable en cas de fracture de la tete radiale associee a une instabilite du coude. La cupule mobile permet d’autre part une adaptation aux variations anatomiques de l’extremite proximale du radius.

Évaluation au recul de 5 ans de 100 cupules impactées sans ciment de type Duraloc

Resume Il s’agit de l’etude retrospective de 149 cupules impactees Duraloc® implantees de 1992 a 1994 chez 144 patients. L’etude a porte sur l’evolution clinique du patient et l’evolution radiologique de l’implant apres numerisation des radiographies grâce a un logiciel d’imagerie : Imagika. La cupule etait associee a un implant femoral cimente ou a une tige de Muller autobloquante avec une tete de 28 mm. Les resultats montraient une amelioration du score PMA de 10 a 16. L’usure lineaire moyenne etait de 0,5 mm soit une usure lineaire annuelle de 0,086 mm. Quarante et un des 57 espaces peri-acetabulaires constates entre l’os et l’implant apres l’intervention etaient combles a la revision. Il s’etait produit une medialisation de l’implant superieure a 4 mm dans 1 cas et une ascension de plus de 4 mm dans 6 cas sans autre signe de descellement. Des ossifications etaient presentes chez 50 patients (16 de stade I, 12 de stade II, 19 de stade III et 3 de stade IV). Les complications etaient marquees par un taux de luxation de 12 %, deux phlebites, une sciatalgie et une infection. Le taux de re-intervention etait de 5 % comprenant 4 luxations et l’infection. Le taux de survie cumulee etait de 95,4 %. Cette implant par sa forme non hemispherique comportant un polyethylene avec un chanfrein marque peut expliquer le taux de luxation eleve ; d’autant qu’aucun polyethylene a rebord n’a ete utilise. Le taux de luxation (lie en partie au dessin specifique) et la frequence d’une usure excessive nous ont fait abandonner cet implant au profit de cupules assurant une meilleure couverture de la tete prothetique.

Luxation tibio-fibulaire proximale : témoin d’un traumatisme grave de la jambe et du genou

PURPOSE OF THE STUDY Dislocation of the proximal tibio-fibular joint is a rare lesion generally described in athletes. In our experience, high-energy trauma in traffic accident victims was a frequent cause. Dislocation of the proximal tibio-fibular joint is generally described as anterolateral, posteromedial, superior, or subluxation. We describe an inferior form of dislocation. MATERIALS AND METHOD The study population included eight men aged 21-55 years (mean 31 years). One patient had bilateral dislocation. There were four superior, one posterior, and four inferior dislocations. All patients also had an associated fracture of the tibia which was an open fracture in eight cases. Five patients suffered a lesion to the common fibular nerve. Three had tibial nerve involvement in a context of inferior disclocation. The lateral collateral ligament was torn in six cases. The central pivot was involved in four. Two patients had an avulsion of the patellar ligament on the tibial tuberosity. Five patients had vessel damage. Three required emergency amputation. Two patients (one superior and one inferior dislocation) underwent emergency bypass surgery but required below-knee amputation later due to persistent ischemia. All dislocations, excepting the one case of complete fibular avulsion and one emergency above knee amputation were treated by transarticular screw fixation of the proximal tibio-fibular joint. RESULTS Mean follow-up was 5.8 years (1-9 years). At last follow-up, there were no cases of instability or pain in the proximal tibio-fibular joint. The patient with an initial neurapraxia in territory of the common fibular nerve recovered totally. The five amputated patients had prostheses and walked without crutches. DISCUSSION Dislocation of the proximal tibio-fibuilar joint is a rare entity, but the frequency is probably underestimated. The dislocation can go unrecognized in patients with multiple injuries. Careful search should nevertheless be undertaken due to the risk of secondary involvement of the common fibular nerve. The Harrisson and Hindenach classification, inspired by the Lyle classification, does not mention inferior dislocation of the proximal tibio-fibular joint, a recently described entity. Our series included dislocations resulting from high-energy trauma associated with numerous ligament, nerve, and vessel injuries. In this context, dislocation of the proximal tibio-fibular joint constitutes an epiphenomenon.Resume Les auteurs rapportent neuf cas de luxation tibio-fibulaire proximale liee a un traumatisme a haute energie chez 8 patients. Cette lesion est rarement retrouvee dans la litterature. Les luxations tibio-fibulaires proximales habituellement decrites sont des formes antero-laterales, postero-mediales, superieures et des subluxations. Notre serie se repartit en quatre luxations superieures, une luxation posterieure et quatre luxations inferieures. Les autres luxations, hormis un cas d’avulsion complete de la fibula, ont ete traitees par vissage tibio-fibulaire trans-articulaire avec un tres bon resultat au dernier recul. Les auteurs decrivent une forme inferieure de luxation de l’articulation tibio-fibulaire proximale qui a un caractere de gravite particulier puisque cette luxation associe dans tous les cas des lesions vasculaires, nerveuses et ligamentaires qui ont necessite un geste d’amputation.

Does high flexion after total knee replacement really improve our patients’ quality of life at a short-term follow-up?

PurposeA full range of motion after total knee arthroplasty has become more and more requested by our patients, leading to novel designs of knee implants, the so-called “hyperflex” knees. The aim of the present study was to confirm whether or not hyperflexion of operated knees really improves the patients’ quality of life.MethodsA retrospective comparative case–control study has been carried out to compare clinical results shown in two types of knee prosthesis, from two homogeneous paired groups of patients including 45 cases of a “hyperflex” model (RP-F), while the control group consisted of 43 cases of a “regular design” model (Triathlon) in terms of expected postoperative flexion.ResultsThe hyperflex group demonstrated significant higher mean values of passive flexion at 119.9° in the RP-F group versus 111.1° in the Triathlon group. However, global results in the “regular” control group were significantly better than the “hyperflex” study group, in both IKS knee and functional scores at 84.4 points (RP-F) vs. 89.8 points (Triathlon), and 84.6 points (RP-F) vs. 89.5 points (Triathlon), respectively. Moreover, the self-administered KOOS questionnaire was significantly in favor of the control group, with 73.5 points in RP-F knees versus 86.0 points for Triathlon knees at global KOOS postoperative scores.ConclusionThe quality of life of operated patients after TKA obviously would be considered as the main priority, which was better obtained by a “regular design” in our study. Hence “high flexion” cannot be considered as an absolute target when choosing a model for total knee arthroplasty.