Purpose of the study: We report the clinical and radiographic results of a series of revision total hip arthroplasties performed for aseptic loosening using a non-demented modular femoral implant (PP).

Material and methods: From 1991 to 2003, 146 revisions of total hip arthroplasty were performed using the same non-cemented modular femoral implant (PP). At mean nine years follow-up (3.5–17 years), 24 patients had died, 26 had insufficient data for review and 39 were lost to follow-up. The analysis thus included 54 cases. All revisions were performed for aseptic loosening. Mean age at surgery was 60 years. Preoperative bone damage, according to the Sofcot classification, was grade I and II (69%), grade III (26%), grade IV (5.5%). Clinical outcome was assessed with the Harris and Postel-Merle-d’Aubigné scores. The radiological review analysed stem anchoring, lucency and periprosthetic reconstruction.

Results: At mean nine years follow-up, the mean Harris score was 71 points, the mean PMA score 12.8 points. Patient satisfaction was 70%. There were five cases with deep infection (9%), five with dislocation and six intra-operative periprosthetic fractures. Trochanterotomy non-union was noted in 26% of patients. Mean impaction of the femoral stem was 5 mm (range 0–16 mm). There was a statistically significant association between the degree of bone damage and the quality of the bone reconstruction (p=0.012). Mean increase in cortical thickness in zones 1 and 2 (Gruen) was 1.1 mm and 1.6 mm respectively. In Gruen zones 2 and 6, the gain was 6 and 10 mm respectively. There were nine surgical revisions (17%) for deep infection (n=4), recurrent aseptic loosening and fracture of the femoral implant (n=1). The ten-year survival taking aseptic loosening as the endpoint was 90%.0

Discussion and Conclusion: Our work showed the good long-term results obtained with this implant for revision total hip arthroplasty. It allows clinical improvement, periprosthetic bone reconstruction and a low rate of surgical revision.

Purpose of the study: Correct implant position is one of the factors of long-term success of total hip arthroplasty (THA). Acetabular architectural defects caused by trauma can create difficult situations leading to potential complications and poor outcome. The purpose of this study was to examine retrospectively the results of THA implanted after fracture of the acetabulum treated surgically. The objective was to analyse the specific features and search for factors favouring poor outcome.

Material and method: The series included 43 patients who had a THA implanted after treatment of an acetabular fracture. Mean age at trauma was 44.5 years (range 16–87). Five patients had a THA immediately, mean age 75 years (63–87). Thirty eight patients had osteosynthesis. According to the Letournel classification, the fracture was elementary in 12 cases and complex in 26. In ten patients, there was residual joint incongruence measuring more than 2 mm after osteosynthesis. The hips evolved to degenerated joint (n=34) and or necrosis (n=10).

Results: Mean time from acetabular osteosynthesis to THA was 94.6 months (range 3–444), excluding those patients whose THA was implanted at the time of the osteosynthesis. Arthroplasty required removal of the osteosynthesis material (n=11), insertion of a supportive ring (n=14) associated with a bone graft (n=13). The acetabular implant was considered to be well positioned according to the Pierchon criteria in 16 hips and was lateralised (n=21) and/or ascended (n=17) in the other hips. Inclination was 42.8 on average, range 10–18. The five-year survival was 80%.

Discussion: Arthroplasty after surgical treatment of an acetabular fracture is a difficult procedure. Complementary procedures are often necessary complicating the surgery and increasing the risk of perioperative complications, particularly infection. It is difficult to position the acetabular implant, increasing the risk of postoperative instability and early loosening. This study demonstrated the difficulties of implanting a THA in this context where the revision rate is significantly higher than in first-intention THA.

Background: The Rangeuil orthopaedics surgical team has developed a special installation using a rigid corset for the combine Kocher Languenbeck and ilioinguinal surgical treatment of complex acetabular fractures. The purpose of this study was to retrospectively evaluate the results of 53 complex acetabular fractures treated by open reduction and internal fixation with a combined double approach facilitated by this particular operative installation.

Methods: A retrospective review of the cases was performed. The functional outcome, operative times, blood loss were recorded. Pre-operative, post-operative and last follow-up radiographs were assessed for fracture classification and adequacy of reduction. The development of heterotopic ossification, the presence of infection, avascular necrosis and post-traumatic osteoarthritis were also noted.

Results: The mean follow-up was 5.2 years. The clinical outcome at the time of final follow-up was graded as excellent in 16 patients, good in 22, fair in 7 and poor in 8 The reduction of the fracture, as determined with plain radiography, was graded as anatomic in 32 patients, unperfect in 15 and unsatisfactory in 6. Bony union was achieved in all cases. 6 patients had Brooker 3 or 4 heterotopic ossifications. 9 patients developed osteoarthritis. 4 patients developed avascular necrosis. An arthroplasty was necessary for 10 patients. 3 patients had a delayed wound infection.

Conclusions: The combined simultaneous approach remains a reliable surgical solution in selected complex acetabular fractures. The installation using the corset we developed considerably simplifies the operation and access to the operated site.

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure.

At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively).

We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided.

Purpose of the study: Percutaneous compressive plating (PCCP) enables minimally invasive surgery using closed focus technique. We report a prospective consecutive series of 67 fractures (December 2003 – February 2005) followed to bone healing.

Material and methods: Mean patient age was 83 years (range 37–95) with 83% females in a frail population (ASA 3, 4). Two-thirds of the patients had unstable fractures (AO classification) which were reduced on an orthopedic table under fluoroscope. Two minimal incisions were used to insert the material without opening the fracture and without postoperative drainage. Blood loss was noted. Verticalization and weight bearing were encouraged early depending on the patient’s status but were never limited for mechanical reasons. Patients were reviewed at 2, 4 and 6 months.

Results: Anatomic reduction was achieved in 84% of hips, with screw position considered excellent for 45, good for 14, and poor for 6. There were no intraoperative complications. The material was left in place. The hemoglobin level fell 2.2 g on average. Mean operative time was 35 minutes and the duration of radiation exposure 60 seconds. Mean hospital stay was 13 days. General complications were: urinary tract infections (n=10), phlebitis (n=2), talar sores (n=5). Gliding occurred in three cases (4%) with telescopic displacement measuring less than 10 mm in ten cases. There were two varus alignments with no functional impact. There were four deaths within the first three weeks. All fractures healed within three months.

Discussion and conclusion: PCCP has its drawbacks (mechanical, stabilization) as do all osteosynthesis methods used for trochanteric fractures. The technique is reliable and reproducible and is indicated for all trochanteric fractures excepting the subtrochanteric form. PCCP has the advantage of a closed procedure with a minimal incision and limited blood loss for a short operative time. An advantage for this population of elderly frail subjects (ASA 3, 4). PCCP enables immediate treatment with a low rate of material disassembly compared with other techniques.

Purpose: We evaluated male sexual function after utilisation of the orthopaedic table for centromedullary nailing in patients with femoral shaft fractures treated between 1995 and 2001. The objective was to determine the frequency of altered function and search for favouring factors.

Material and methods: Sexual function was assessed with a self-administered questionnaire using the International Index of Erectile Function (IIEF). We contacted by mail 109 patients aged 20 – 50 years treated in the orthopaedic traumatology unit between 1995 and 2001. The Mann-Whitney test was used to compare quantitative variables and Student’s t test for classed variables.

Results: Seven patients declined to respond and three died; 55 responded (81.8%). Patients were grouped by erectile function (EF) score (< 22 or 22) according to Cappelleri. Erectile dysfunction was identified in 19 patients. Altered sexual function did not appear to be related to age, weight or height. The duration of the operation was not different between the two groups.

Conclusion: This study demonstrates a increase in iatrogenic lesions having an impact on erectile function in patients treated on an orthopaedic table when curare is not used during the intervention. The frequency of these lesions decreases significantly if the surgery is performed by a senior surgeon.

Material and methods: Two series of 35 total hip arthroplasties (THA) implanted by the same surgeon using the posterior approach were compared. The first group underwent surgery in 1999 and the second in 2001. Ligation of the posterior medial circumflex artery was systematically performed in the second group. The same prosthesis was used in all cases: an omnicase stem and a Schuster (Centerpulse) or polyethylene cup. The series included cemented (n=37) and non-cemented (n=32) prostheses with one hybrid implant. We analysed retrospectively, intra- and postoperative bleeding, haematocrit before and just after surgery, and the number of packed red cell units transfused during and after surgery in order to determine the degree of intra- and postoperative bleeding. Statistical tests were applied.

Technique: Via the posterior approach, before sectioning the pelvitrochanteric muscles, the upper third of the fibres of the quadratus femoris muscle were dissociated. The artery runs upwardly and anterior toward the posterior border of the greater trochanter and is difficult to identify in the fatty tissue. Ligation is performed at this level with the satellite veins. Ligation decreases bleeding when the pelvitrochanteric muscles and the capsule are sectioned. Likewise, section of the femoral neck appears to be less haemorrhagic as is the preparation of the proximal greater trochanter.

Results: Intra- and postoperative bleed, expressed in ml, was significantly decreased by ligation of the posterior circumflex artery and its two satellite veins. Mean intraoperative bleeding was decreased by more than half. Six of the 35 patients who did not have ligation lost more than 600 cc blood during the operation. This degree of bleeding was not observed in the ligation group. The postoperative haematocrit was significantly higher in the ligation group and the difference in pre- and postoperative haematocrit was decreased 7-fold. Postoperative transfusion became exceptional. Finally, it is interesting to note that among the variables studied, mode of implant fixation did not affect blood loss.

Discussion: The conventional technique without ligation of the posterior circumflex artery does not always lead to significant bleeding. It is quite possible to perform such procedures with less than 200 cc blood loss. Use of posterior circumflex artery ligation leads to much more regular control of intraoperative bleeding, making autologous blood collection and postoperative transfusions unnecessary. The ligation is a simple procedure. Electric coagulation is generally insufficient for the calibre of these vessels and veins are not always accessible to effective coagulation. Intraoperative bleeding due to section of the circumflex artery is underevaluated due to the tension created by the forced internal rotation. Haemostasis after section is difficult due to retraction of the proximal segment under the muscles.

Purpose: Improved surgical technique and facilities enable emergency salvage of very damaged limbs. Functional outcome after this type of conservative treatment is generally satisfactory but at the risk of more or less quiescent osteitis. In the event of chronic osteitis, the neighbouring skin can undergo malignant degeneration (squamous-cell carcinoma). The purpose of our work was to report three such transformations and discuss therapeutic indications.

Material and methods: The study series included three patients with chronic osteitis of the tibia after trauma. During surveillance, several years later we observed changes in local signs: increasing pain, purulent discharge and bleeding (Rowlands triad). In each patient, biopsy led to the diagnosis of transformation to squamous-cell carcinoma. All patients were treated by above knee amputation.

Results: Outcome was satisfactory with an excellent quality scar formation. The search for extension was still negative a three years follow-up.

Discussion: The frequency of carcinomatous degeneration near zones of chronic osteitis varies depending on the series to 0.2% to 1.7%. This is in sort the cost of conservative treatment. Changes in the clinical presentation, Rowland’s triad, associated with modification of the bacterial flora and development of a nauseous odour are important signs which should be followed by a biopsy. The treatment of choice for most authors is amputation in order to increase patient survival.

Conclusion: The desire to pursue conservative reconstruction surgery even in the most difficult cases should not mask the risk of potential malignant transformation. Secondary amputation should not be considered as a failure in these extreme clinical situations.

Purpose: The floating shoulder is a special entity in traumatology of the upper limb. Bioechanically, the floating shoulder corresponds, as defined by Goss, to a rupture of the suspensor complex. Management is not well defined but must target the proper balance between the need for anatomic restauration and quality functional results obtained in the majority of cases treated orthopaedically. This apparent paradoxical situation is probably related to the precision of indications.

Material and methods: Forty-five patients managed between 1980 and 2001 were reviewed retrospectively. Thirty-five presented a scapulo-cleido-thoracic syndrome, ten a scapulocleidal syndrome. Mean age at the time of trauma was 39 years and mean follow-up was 2.4 years (1–16). The patients, 36 men and nine women were mainly (76%) traffic accident victims (58% motorcycle, 33% automobile, 9% pedestrians) and 76.8% had multiple injuries. Cleidal lesions were 18 mid-third fractures, 12 acromiocleidal dislocations, three sternocleidal dislocations, seven bifocal fracrturs, three lateral third fractures and two medial third fracturs. The scapular lesion involved the body of the bone in 19 patients, the neck in 14, the glenoid cavity in two, the coracoid process in one, and multifocal fractures in nine.

Results: Thirty-two patients were treated orthopaedically and twelve patients surgically, four with cleidal osteosynthesis, eight with both. The postoperative x-rays were used to assess anatomic results and the Constant score to assess functional results. Complications included six deformed calluses, with four causing major functional impairment and one requiring revision. All resulted from orthopaedic treatments.

Discussion: While most patients have an indication for orthopaedic treatment, analysis of the displacemens can lead to a surgical indication. We retained the following criteria for surgical treatment: scapular neck fracture causing more than 40° angulation, glenoid medialisation-ventralisation greater than 2 cm, and displaced articular fracture. Osteosynthesis of the clavicle for floating shoulders with a major displacement appears to be the minimum prerequisite if the multiple injuries prevent optimal management.

Purpose: Insertion of the femoral stem during total hip arthroplasty provokes a bridge between the proximal femoral forces leading to well-documented bone resorption. A review of the literature concerning the behaviour of the contralateral femur and the spine reveals conflicting data. Some authors report variable bone mineral density of the lumbar spine while the contralateral neck, studied with non-cemented prostheseis in all cases, shows a significant fall in bone density. All patients in these studies needed an unloading period to achieve definitive fixation of the hip prosthesis. The purpose of this study was to assess bone behaviour in the contralateral femur and the lumbar spine after unilateral cemented total hip arthroplasty with immediate postoperative weight bearing.

Material and methods: The study series included 52 patients who underwent unilateral cemented total hip arthroplasty for degenerative hip disease. All were followed with standard x-rays and DPX of the contra-lateral hip and the lumbar spine. These examinations were performed one month before surgery then on D8, M3, M6, one year and two years. Bone mineral density (BMD) was measured in the femoral neck cortical and the L2–L4 trabecularlar bone. Patients were verticalised and encouraged to walk with full weight bearing on the average on day 3 to 4 after surgery.

Results: DPX did not demonstrate any significant decrease in BMD in any of the patients included in this study, neither in the lumbar spine nor in the contralat-eral femoral neck.

Discussion: Several studies in the literature point out the difficulty in recovering bone mass lost after a period of immobilisation or unloading. This bone loss could reach 10% of the bone mass even for short periods of unloading. Furthermore, minimal bone loss, to the order of 2.5% could accelerate the transformation of osteopenia into osteoporosis and increase the risk of fractures. The importance of minimising periods of unloading in older patients is thus evident.

We describe a 46-year-old woman who presented at intervals of seven years with osteonecrosis of the outer end of both clavicles. The clinical, radiological features and the appearances of the bone scans are described. Although the condition may be confused with osteolysis there is a clear histological distinction between the two conditions. If the symptoms fail to respond to conservative treatment, excision of the outer end of the clavicle is recommended.

Purpose: Van Den Bosch reported diminished quality of sexual intercourse in 40% of the patients victims of pelvic fractures. Using the Rosen self-administered questionnaire, five aspects of sexual activity were analysed: erectile function and orgasm, sexual desire, satisfaction with sexual intercourse and overall satisfaction. This retrospective series included patients with pelvic ring fractures in 1999.

Material and methods: The situation of 46 patients, aged 30 to 70 years was assessed with the International Index of Erectile Function self-administered questionnaire and a questionnaire concerning the patient’s status. The radiographic analysis included the Tyle classification. Associated injury to the membranous urethra were noted. Students t test was used to compare the IIEF scores in the study population and in a control population constituted for validation of the questionnaire.

Results: Forty-six patients responded (60.1%). None of the patients complained of disorders before the accident. Thirty-seven patients had sexual activities during the four weeks before responding including 11 (29.7%) with variable degrees of dyserection. Pubic dysfunction was the only factor associated with impaired sexual activity, leading to lower satisfaction and erectile function. There was no relationship between the five IIEF items and age, duration of follow-up, Tyle classification, branch fractures.

Discussion: This study is the first using the IIEF score to ascertain the degree of male sexual dysfunction after pelvic fractures. This self-administered questionnaire provides a tool adapted to the patient’s needs. Compared with the control group, we noted a prevalence of erectile dysfunction to the order of 30% with a significant diminution of overall satisfaction (p < 0.05). There was no significant correlation between male sexual sequelae, type of fracture and the notion of urethra injury. Pubic dysjunction is regularly correlated with decreased erectile function and overall satisfaction, probably in relation with injury to the cavernous bodies. Impaired sexual function, found long after the trauma (mean follow-up 26.8 years) suggests a permanent injury.

Conclusion: The IIEF self-administered questionnaire is interesting for young male patients victims of pelvic trauma, particularly in case of pubic dysjunction. Used during rehabilitation, it can identify patients with sexual sequelae (erectile function) in an overall medical and medicolegal management scheme.

Purpose: Prevention of post-trauma infections is basically aimed at streptococcal, staphylococcal and anaerobic germs. An increasing number of open fractures are however contaminated with Bacillus cereus leading to a multidisciplinary discussion involving infectious disease specialists, orthopaedic surgeons, and bacteriologists concerning the appropriate management. Bacillus is an ubiquitous genus of sporulated telluric Gram positive germs found in soil and plants. B. cereus can lead to local wound infection. This environmental (including hospital) bacterium is often a temporary host of the skin flora and its isolation can be taken as a simple contamination with no therapeutic consequence. B. cereus is sensitive to fluoroquinolones.

Material and methods: Between August 1995 and December 2000, B. cereus was isolated in 41 patients from surgical specimens taken from deep muscle and bone tissues. Ordinary medium was used for culture. Genomic analysis was used to type the Bacillus. Statistical analysis was conducted in cooperation with the epidemiology unit.

Results: In our unit, isolation of B. cereus was significantly associated with severe open leg fractures (Gustilo grades IIA and IIIB) with soil contamination. Samples were taken due to fever, wound discharge, elevation of C reactive protein despite antibiotic prophylaxis beyond 48 hours using the standard protocol of aminopenicillin + betalactamase inhibitor, constantly inactive against B. cereus. The strains identified presented different genomic types ruling out nosocomial contramination. One amputation, one chronic osteitis and one anteriolateral leg compartment necrosis resulted from B. cereus infection in this series.

Conclusion: Arguments developed here allow us to recall the importance of careful surgical debridement of open fractures and to emphasise the requirement for bacteriological samples and appropriate antibiotic therapy for 48 hours, combining, in agreement with the 1998 Consensus Conference, aminopenicillin + betalactamase inhibitor and gentamycin which is active against B. cereus. Severe open leg fractures which follow an unfavourable course should suggest possible B. cereus infection requiring early antibiotic therapy using a regimen with good bone diffusion including a fluoroquinolone which is always active against B. cereus.

Purpose: Bone remodelling and osteolysis around total hip arthroplasty (THA) is a highly debated subject in the medical literature. Such bone behaviour is poorly understood around femoral stems used in revision THA. The main problem is to obtain an objective assessment of bone remodelling and bone reconstruction over time, reconstruction techniques being very variable. Conventional radiology is insufficient, but dual energy x-ray absorptiometry (DEXA) provides a means of following changes in the bone around first intention femoral stems.

Material and methods: We studied bone behaviour around revision femoral stems using the non-cemented “P.P. system”. This type of femoral stem is implanted after trochanter osteotomy to facilitate access and stimulate reconstruction. The series included 31 patients who underwent revision total hip arthroplasty. Follow-up examinations included standard radiographs and DEXA of the operated hips, the contralateral hip and the lumbar spine. Periprosthetic zones defined by Grüen were compared with the same zones in the contra-lateral femur. Mean follow-up was six years.

Results: The standard radiographs did not demonstrate any significant change in periprosthetic cortical thickness. The DEXA demonstrated a significant an average 19.97% reduction in bone density in zones 2, 3, 4, 5 and 6. There was no significant difference in zone 7 and an increase in zone 1 (torchanter osteotomy). These figures are to be compared with the variable thickness observed for first intention pros-theses even shortly after implantation.

Discussion: Our results are the first to our knowledge demonstrating the behaviour of bone around revision femoral stems.

Conclusion: Digastric trochanterotomy appears to be an effective means of stimulating reconstruction of the proximal femur. At equivalent follow-up, the quadrangular section of the revision P.P. stem is more favourable in terms of bone loss compared with first intention stems.