Background

Smoking has been associated with poor tissue oxygenation and vascularisation, predisposing smokers to a higher risk for postsurgical infections. The aim of this study was to estimate and compare the incidence of prosthetic joint infection (PJI) following primary total joint arthroplasty (TJA) according to smoking status.

Large-head metal-on-metal (MoM) total hip replacements (THR) have given rise to concern. Comparative studies of small-head MoM THRs over a longer follow-up period are lacking. Our objective was to compare the incidence of complications such as infection, dislocation, revision, adverse local tissue reactions, mortality and radiological and clinical outcomes in small-head (28 mm) MoM and ceramic-on-polyethylene (CoP) THRs up to 12 years post-operatively.

A prospective cohort study included 3341 THRs in 2714 patients. The mean age was 69.1 years (range 24 to 98) and 1848 (55.3%) were performed in women, with a mean follow-up of 115 months (18 to 201). There were 883 MoM and 2458 CoP bearings. Crude incidence rates (cases/1000 person-years) were: infection 1.3 vs 0.8; dislocation 3.3 vs 3.1 and all-cause revision 4.3 vs 2.2, respectively. There was a significantly higher revision rate after ten years (adjusted hazard ratio 9.4; 95% CI 2.6 to 33.6) in the MoM group, and ten of 26 patients presented with an adverse local tissue reaction at revision. No differences in mortality, osteolysis or clinical outcome were seen.

In conclusion, we found similar results for small-head MoM and CoP bearings up to ten years post-operatively, but after ten years MoM THRs had a higher risk of all-cause revision. Furthermore, the presence of an adverse response to metal debris seen in the small-head MOM group at revision is a cause for concern.

Cite this article: Bone Joint J 2014; 96-B:868–75.

The maintenance of quality and integrity in clinical and basic science research depends upon peer review. This process has stood the test of time and has evolved to meet increasing work loads, and ways of detecting fraud in the scientific community. However, in the 21st century, the emphasis on evidence-based medicine and good science has placed pressure on the ways in which the peer review system is used by most journals.

This paper reviews the peer review system and the problems it faces in the digital age, and proposes possible solutions.

Cite this article: Bone Joint J 2014;96-B:436–41.

Whether patients with asymptomatic bacteriuria should be investigated and treated before elective hip and knee replacement is controversial, although it is a widespread practice. We conducted a prospective observational cohort study with urine analyses before surgery and three days post-operatively. Patients with symptomatic urinary infections or an indwelling catheter were excluded. Post-discharge surveillance included questionnaires to patients and general practitioners at three months. Among 510 patients (309 women and 201 men), with a median age of 69 years (16 to 97) undergoing lower limb joint replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic bacteriuria, mostly due to Escherichia coli, and 181 (35%) had white cells in the urine. Most patients (95%) received a single intravenous peri-operative dose (1.5 g) of cefuroxime as prophylaxis. On the third post-operative day urinary analysis identified white cells in 99 samples (19%) and bacteriuria in 208 (41%). Pathogens in the cultures on the third post-operative day were different from those in the pre-operative samples in 260 patients (51%). Only 25 patients (5%) developed a symptomatic urinary infection during their stay or in a subsequent three-month follow-up period, and two thirds of organisms identified were unrelated to those found during the admission. All symptomatic infections were successfully treated with oral antibiotics with no perceived effect on the joint replacement.

We conclude that testing and treating asymptomatic urinary tract colonisation before joint replacement is unnecessary.

Cite this article: Bone Joint J 2014;96-B:390–4.

Introduction

Conventional pre-operative planning for total hip arthroplasty mostly relies on the patient radiologic anatomy for the positioning and choice of implants. This kind of planning essentially remains a static approach since dynamic aspects such as the joint kinematics are not taken into account. Hence, clinicians are not able to fully consider the evolving behavior of the prosthetic joint that may lead to implant failures. In fact, kinematics plays an important role since some movement may create conflicts within the prosthetic joint and even provoke dislocations. The goal of our study was to assess the relationship between acetabular implant positioning variations and resultant impingements and loss of joint congruence during daily activities. In order to obtain accurate hip joint kinematics for simulation, we performed an in-vivo study using optical motion capture and magnetic resonance imaging (MRI).

Introduction

Today, there is no clear consensus as to the amplitude of movement of the “normal hip”. Knowing the necessary joint mobility for everyday life is important to understand different pathologies and to better plan their treatments. Moreover, determining the hip range of motion (ROM) is one of the key points of its clinical examination. Unfortunately this process may lack precision because of movement of other joints around the pelvis. Our goal was to perform a preliminary study based on the coupling of MRI and optical motion capture to define precisely the necessary hip joint mobility for everyday tasks and to assess the accuracy of the hip ROM clinical exam.

We undertook a retrospective case-control study to assess the clinical variables associated with infections in open fractures. A total of 1492 open fractures were retrieved; these were Gustilo and Anderson grade I in 663 (44.4%), grade II in 370 (24.8%), grade III in 310 (20.8%) and unclassifiable in 149 (10.0%). The median duration of prophylaxis was three days (interquartile range (IQR) 1 to 3), and the median number of surgical interventions was two (1 to 9). We identified 54 infections (3.6%) occurring at a median of ten days (IQR 5 to 20) after trauma. Pathogens intrinsically resistant to the empirical antibiotic regimen used (enterococci, Enterobacter spp, Pseudomonas spp) were documented in 35 of 49 cases (71%). In multivariable regression analyses, grade III fractures and vascular injury or compartment syndrome were significantly associated with infection. Overall, compared with one day of antibiotic treatment, two to three days (odds ratio (OR) 0.6 (95% confidence interval (CI) 0.2 to 2.0)), four to five days (OR 1.2 (95% CI 0.3 to 4.9)), or > five days (OR 1.4 (95% CI 0.4 to 4.4)) did not show any significant differences in the infection risk. These results were similar when multivariable analysis was performed for grade III fractures only (OR 0.3 (95% CI 0.1 to 3.4); OR 0.6 (95% CI 0.2 to 2.1); and OR 1.7 (95% CI 0.5 to 6.2), respectively).

Infection in open fractures is related to the extent of tissue damage but not to the duration of prophylactic antibiotic therapy. Even for grade III fractures, a one-day course of prophylactic antibiotics might be as effective as prolonged prophylaxis.

Cite this article: Bone Joint J 2013;95-B:831–7.

There are no recent studies comparing cable with wire for the fixation of osteotomies or fractures in total hip replacement (THR). Our objective was to evaluate the five-year clinical and radiological outcomes and complication rates of the two techniques. We undertook a review including all primary and revision THRs performed in one hospital between 1996 and 2005 using cable or wire fixation. Clinical and radiological evaluation was performed five years post-operatively. Cables were used in 51 THRs and wires in 126, and of these, 36 THRs with cable (71%) and 101 with wire (80%) were evaluated at follow-up. The five-year radiographs available for 33 cable and 91 wire THRs revealed rates of breakage of fixation of 12 of 33 (36%) and 42 of 91 (46%), respectively. With cable there was a significantly higher risk of metal debris (68% vs 9%; adjusted relative risk (RR) 6.6; 95% confidence interval (CI) 3.0 to 14.1), nonunion (36% vs 21%; adjusted RR 2.0; 95% CI 1.0 to 3.9) and osteolysis around the material, acetabulum or femur (61% vs 19%; adjusted RR 3.9; 95% CI 2.3 to 6.5). Cable breakage increased the risk of osteolysis to 83%. There was a trend towards foreign-body reaction and increased infection with cables. Clinical results did not differ between the groups.

In conclusion, we found a higher incidence of complications and a trend towards increased infection and foreign-body reaction with the use of cables.

In foot and ankle surgery incorrect placement of implants, or inaccuracy in fracture reduction may remain undiscovered with the use of conventional C-arm fluoroscopy. These imperfections are often only recognized on postoperative computer tomography scans. The apparition of three dimensional (3D) mobile Imaging system has allowed to provide an intraoperative control of fracture reduction and implant placement. Three dimensional computer assisted surgery (CAS) has proven to improve accuracy in spine and pelvic surgery. We hypothesized that 3D-based CAS could improve accuracy in foot and ankle surgery.

The purpose of our study was to evaluate the feasibility and utility of a multi-dimensional surgical imaging platform with intra-operative three dimensional imaging and/or CAS in a broad array of foot and ankle traumatic and orthopaedic surgery.

Cohort study of patients where the 3D mobile imaging system was used for intraoperative 3D imaging or 3D-based CAS in foot and ankle surgery.

The imaging system used was the O-arm Surgical Imaging System and the navigation system was the Medtronic's StealthStation.

Surgical procedures were performed according to standard protocols.

In case of fractures, image acquisition was performed after reduction of the fracture. In cases of 3D-based CAS, image acquisition was performed at the surgical step before implants placement. At the end of the operations, an intraoperative 3D scan was made.

We used the O-arm Surgical Imaging system in 11 patients: intraoperative 3D scans were performed in 3 cases of percutaneus fixation of distal tibio-fibular syndesmotic disruptions; in 2 of the cases, revision of reduction and/or implant placement were needed after the intraoperative 3D scan.

Three dimensional CAS was used in 10 cases: 2 open reduction and internal fixation (ORIF) of the calcaneum, 1 subtalar fusion, 2 ankle arthrodesis, 1 retrograde drilling of an osteochondral lesion of the talus, 1 Charcot diabetic reconstruction foot and 1 intramedullary screw fixation of a fifth metatarsal fracture. The guidance was used essentially for screw placement, except in the retrograde drilling of an osteochondral lesion where the guidance was used to navigate the drill tool. Intraoperative 3D imaging showed a good accuracy in implant placement with no need to revision of implants.

We report a preliminary case series with use of the O-arm Surgical Imaging System in the field of foot and ankle surgery. This system has been used either as intraoperative 3D imaging control or for 3D-based CAS. In our series, the 3D computer assisted navigation has been very useful in the placement of implants and has shown that guidance of implants is feasible in foot and ankle surgery. Intraoperative 3D imaging could confirm the accuracy of the system as no revisions were needed. Using the O-arm as intraoperative 3D imaging was also beneficial because it allowed todemonstrate intraoperative malreduction or malposition of implants (which were repositioned immediately). Intraoperative 3D imaging system showed very promising preliminary results in foot and ankle surgery. There is no doubt that intraoperative use of 3D imaging will become a standard of care. The exact indications need however to be defined with further studies.

Introduction

Currently, a validate scale of ankle osteoarthritis (OA) is not available and different classifications have been used, making comparisons between studies difficult. In other joints as the hip and knee, the Kellgren-Lawrence (K&L) scale, chosen as reference by the World Health Organizations is widely used to characterize OA. It consists of a physician based assessment of 3 radiological features: osteophyte formation, joint space narrowing and bone end sclerosis described as follows: grade 0: normal joint; grade 1: minute osteophytes of doubtfull significance; grade 2: definite osteophytes; grade 3: moderate diminution of joint space; grade 4: joint space greatly impaired, subchondral sclerosis. Until now, the K&L scale has never been validated in the ankle. Our objective was to assess the usefulness of the K&L scale for the ankle joint, by determining its reliability and by comparing it to functional scores and to computerized minimal joint space width (minJSW) and sclerosis measurements. Additionally we propose an atlas of standardized radiographs for each of the K&L grades in the ankle.

Introduction

Among patients with ankle osteoarthritis (OA) a post-traumatic origin is much more frequent than among those with knee or hip OA. However, long-term studies evaluating risk factors for the development of OA after ankle fractures are lacking.

Introduction

A recent review of the literature on metal-on-metal total hip arthroplasties (THA) revealed the lack of comparative clinical studies with a sufficient sample size and the inclusion of patient-reported outcomes as well as patient activity levels.

Introduction

Large diameter metal on metal cups have been used in total hip arthroplasty advocating superior results with respect to dislocation rates, range of motion and long term survival. The Durom cup used as part of the Durom hip resurfacing system has been incriminated with poor short term results sometimes correlated to incorrect positioning of either the femoral or acetabular component. Our objective was to evaluate short term results of the Durom cup used in conjunction with standard stems.

Introduction

Orthopaedic surgeons are frequently asked to perform a revision total hip arthroplasty (THA) in patients over 80 years of age. Our objective was to evaluate the outcomes after revision THA in patients 80 years or older and compare them to a cohort of patients less than 80 years of age.

Purpose of the study: Stiffness of the ankle joint is a common complication after fracture, surgical repair, or total ankle arthroplasty. Dorsiflexion is generally the most limited movement. A few older papers have focused on this common problem in orthopaedic surgery of the ankle joint but have been controversial. The purpose of this anatomy study was to evaluate the efficacy and quantify the impact of releasing the collateral ligaments of the ankle joint on dorsiflexion stiffness.

Material and methods: The two main ankle ligaments implicated in this type of stiffness, the deep bundle of the posterior tibiotalar ligament (dPTTaL) and the posterior talofibular ligament (PTaFL), were studied. We dissected 16 talocrural joints on fresh cadavers and measured with electronic goniometry coupled with electronic dynamometry their movement in dorsiflexion after section of the dPTTaL in the first group and after section of the PTaFL in the second.

Results: The results showed a significant difference (p< 0.0003) between the two populations of ankles. Section of the dPTTaL was more effective against dorsiflexion stiffness than section of the PTaFL, even though the overall benefit in dorsiflexion was less than 10° (mean 7.45 versus 3.45). Combined section of the two ligaments did not provide a statistically significant improvement in the gain in dorsiflextion (p=0.88) compared with isolated section of the two ligaments.

Discussion: If limitation of active and passive dorsiflexion persists after classical release or lengthening of the posterior periarticular tendons of the ankle joint, or after gastrocnemius lengthening, our results show that the following surgical step could be meticulous release of the dPTTaL.

Background: Among patients undergoing total hip arthroplasty (THA) 24–36% are obese. The most important long-term complication is periprosthetic osteolysis. While patient activity, implant type and quality of fixation are known risk factors for osteolysis, the literature concerning obesity is sparse and controversial. Our objective was to evaluate the influence of obesity on femoral osteolysis five and ten years after primary THA with a cemented stem.

Methods: Prospective cohort study conducted between 1996 and 2003 among patients undergoing THA (uncemented cup, cemented stem, 28mm head and ceramic-polyethylene bearing surface) inserted with a third generation cementing technique. All patients were seen at either five or ten years, with information regarding BMI and activity, and with radiographic follow-up. BMI was evaluated in three and four categories (< 25, 25–29.9 (reference category), 30–34.9 and ≥35 kg/m²). Activity was assessed using the University of California, Los Angeles (UCLA) activity scale (1–10 points). Main outcome was the radiographic assessment of femoral osteolysis. Secondary outcomes were polyethylene wear and revision for aseptic loosening.

Results: We included 503 THAs in 433 patients. Of those 241 THAs (48%) were seen at five years and 262 (52%) at ten years. Osteolytic lesions were identified in forty-four cases, twenty-four in 181 normal weight patients (13.3%), eleven in 205 overweight (5.4%), seven in ninety-six obese class I (7.3%), and two in twenty-one obese class II patients (9.5%). Activity was highest in normal weight patients (mean UCLA score 5.5, ±2.0) and lowest in patients obese class II (mean UCLA score 4.8, ±1.7). Univariate as well as multivariate logistic regression analysis adjusting for activity, cementing quality, age, and sex did not show an increased risk of osteolysis in obese compared to overweight patients (adjusted OR 1.4, 95% CI 0.6; 3.7). A significantly higher risk was found in normal weight patients (adjusted OR 2.6, 95% CI 1.2; 5.7). Total mean polyethylene wear was significantly lower in obese compared to normal/overweight patients (p=0.024). Revision for aseptic loosening of the stem was necessary in 4 patients (3 normal weight patients and 1 overweight patient).

Conclusions: We did not find an increased risk for femoral osteolysis or revision for aseptic loosening in obese patients five and ten years after primary THA with a cemented stem.

Purpose: We aimed to provide an anatomical basis for surgical techniques in rotator cuff reinsertion. The purpose of this study was to investigate the 3-dimensional trabecular bone mineral density (BMD) in the humeral head bone and determine areas of low density. Limited information exists for humeral head to understand its mechanical behaviour.

Materials and Methods: 15 unpaired fresh humeral heads were harvested and frozen. The mean age was 75 years old. All abnormal bones underlying fractures, major arthrosis or surgical interventions were excluded from the study All the heads were scanned using a three-dimensional HR-pQCT system providing 80 microns slices nominal resolution. Manually outlining of the contours of cancellous bone was done in different areas: lesser tuberosity, greater tuberosity, articular part and centre. The parameters included in the analysis were: bone volume density (BV/TV, Trabecular thickness (tb.Th)(mm), Trabecularseparation(TB.Sp)(mm), Trabecular number(TB.N. (1/mm)

Results: The average density of the lesser tuberosity is the highest of the whole head (BV/TV= 0,228). The centre of the head is devoided of large trabeculae with a very low density (BV/TV =0,1). The greater tuberosity is rich in thin trabeculae (Tb Th = 0,265) separated by large spaces (1,5). The articular part presents the higher density (BV/TV =0,3).

Conclusions: Emphasis has traditionally been placed on cortical bone as quality predictor due to its stiffness for achieving primary stabilisation. However screws and anchors are mainly in contact with cancellous part of bone, and mechanical characteristics of cancellous bone also influence the load-bearing capacity of implant –bone union This studies is interesting in showing areas of poor cancellous bone quality and may help to improve surgical techniques.

Introduction: An ankle fracture represents the most frequent osseous injury in both the elderly and non-elderly population. To date, only a limited number of retrospective studies have addressed medium-term outcome following ankle Open Reduction and Internal Fixation (ORIF). The purpose of this study was to assess residual pain and functional outcome 10 to 20 years after operative treatment of ankle fractures and to evaluate the incidence of symptomatic and radiographic ankle osteoarthritis (OA).

Methods: We designed a retrospective study including all consecutive patients who underwent ankle ORIF between January 1988 and December 1997 in a University Hospital setting. Pilon and talus fracture as well as pediatric patients were excluded. Patients were seen by two senior residents 10–20 years after their index surgery. Residual pain was measured using the Visual Analog pain Scale. Function and general health status were assessed using the Olerud and Molander Ankle Score, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and the 12-item short-form health survey (SF-12). Ankle OA on standard radiographs was scored according to the revised Kellgren and Lawrence (K& L) scale.

Results: 374 patients (56% men) underwent ankle surgery during the defined period. 10% of the patients had a Weber A fracture, 57% a Weber B and 33% a Weber C fracture. Mean age at the time of operation was 42.9 years (+/− 17.1; range 16–86 years). 10–20 years after surgery, 47 patients had died, 126 had left the country and were lost to follow-up, 99 did not respond or refused to participate, and 102 patients were seen at the follow-up visit. These patients did not differ in terms of age, gender distribution, BMI and type of fracture from those who were not seen. The mean duration of follow up was 17.3 years (+/− 3.3). Advanced radiographic OA (K& L grade 3 and 4) was present in 34.3 % of the patients. Symptomatic OA was reported by 34.3 % of the patients (AOFAS pain score < 40). Both clinically symptomatic and radiographic ankle OA was found in 18 patients (17.6%). Function was good in 85% of the cases (total AOFAS hindfoot score between 80 and 100 points; mean total AOFAS hindfoot score 89.9, +/−14.6). The mean Olerud and Molander ankle score was 86.5 (+/−18.7). The general health status (SF-12) was similar to representative values of the general population with a similar mean age.

Conclusion: 10–20 years after operative treatment of an ankle fracture, the incidence of advanced radiographic post-traumatic ankle OA was 35%, symptomatic OA was present in one third of the patients and about one fifth had both. The majority of the patients reported good function.

We conducted a longitudinal study including patients with the same type of primary hybrid total hip replacement and evaluated patient activity and femoral osteolysis at either five or ten years post-operatively. Activity was measured using the University of California, Los Angeles scale. The primary outcome was the radiological assessment of femoral osteolysis. Secondary outcomes were revision of the femoral component for aseptic loosening and the patients’ quality of life. Of 503 hip replacements in 433 patients with a mean age of 67.7 years (30 to 91), 241 (48%) were seen at five and 262 (52%) at ten years post-operatively. Osteolytic lesions were identified in nine of 166 total hip replacements (5.4%) in patients with low activity, 21 of 279 (7.5%) with moderate activity, and 14 of 58 (24.1%) patients with high activity. The risk of osteolysis increased with participation in a greater number of sporting activities. In multivariate logistic regression adjusting for age, gender, body mass index and the inclination angle of the acetabular component, the adjusted odds ratio for osteolysis comparing high vs moderate activity was 3.6 (95% confidence interval 1.6 to 8.3). Stratification for the cementing technique revealed that lower quality cementing increased the effect of high activity on osteolysis. Revision for aseptic loosening was most frequent with high activity. Patients with the highest activity had the best outcome and highest satisfaction.

In conclusion, of patients engaged in high activity, 24% had developed femoral osteolysis five to ten years post-operatively.

Objective: The Morscher press-fit cup is a cementless, porous-coated acetabular component. The objective of this study was to assess clinical and radiological outcomes, patient satisfaction and complications at 10 years.

Methods: Prospective cohort study including all consecutive primary THAs with the Morscher cup operated by multiple surgeons of a University hospital between March 1996 and April 1998. Patients were evaluated at 120 months (±7.2 months) with clinical and radiological follow-up, patient satisfaction and questionnaire assessment, using the Harris Hip Score (HHS), WOMAC and SF-12. Follow-up examination was done by two physicians who had not performed the operations.

Results: 421 THAs were performed in 389 patients (54.6% women; mean age 69.3, range 28–98). In 80% the diagnosis was primary osteoarthritis. All stems were cemented except for 18 patients (4.3%). One-hundred-twenty-two patients (29.0%) had died, 27 (6.4%) were lost-to follow-up, 24 (5.7%) were unable to attend because of poor general health and 27 (6.4%) refused, thus leaving 221 hips, for which 176 x-rays were available.

None of the patients required cup revision for aseptic loosening. Complications included 12 dislocations and 3 deep infections resulting in 2 total revisions. In 3 patients the stem was revised for aseptic loosening at a mean of 63 months. At 10-years the survivorship was 98.6% (95% CI 96.7; 99.4) with endpoint revision for any cause.

Mean total wear was 0.89 mm (±0.5). 32 cups (18.8%) with a cup inclination > 45° had a mean wear of 1.06 mm (±0.5), whereas 138 cups (81.2%) with inclination < 45° had a mean wear of 0.86 mm (±0.5), p=0.036. In 16 cases osteolytic defects around the stem were present. The outcome scores at 10 years were: HHS 85.9 (±14.1), WOMAC pain 70.7 (±24.7), WOMAC function 68.8 (±24.5), SF-12 physical score 40.3 (±9.2) and mental score 47.0 (±10.4). Ninety-four percent of the patients were satisfied or very satisfied.

Conclusions: The Morscher acetabular replacement cup provides excellent results at 10 years. None of the patients had to be revised for aseptic loosening of the cup, patient satisfaction was high, and clinical results were very good.

Introduction: Early mortality associated with unstable pelvic ring injuries is often secondary to continuous pelvic bleeding. Hemostatic measures such as pelvic binders or external fixation may help to control low pressure bleeding from lacerated veins or broad fracture surfaces, while control of high pressure arterial bleeding may require embolization.

Purpose: Evaluate our experience with the control of hemorrhagic shock associated with pelvic ring injuries during initial patient management.

Methods: From January 2003 until December 2006, all [105] patients admitted to our level I trauma center with a pelvic or an acetabular fracture were prospectively entered into our polytrauma data base. Of 105 patients, 67 were classified with a type B or C pelvic fracture. All these patients received a pelvic strap belt by the paramedic team at the scene of the accident. Pelvic fractures were diagnosed on the initial anteroposterior pelvic radiograph and computed tomography. From this initial group of 67 patients, we identified 38 as unstable requiring blood transfusion and intensive care monitoring. The results and survival rate were evaluated according to the initial sequence of surgical procedures and the patients were divided into 3 groups, X,Y, and Z Follow-up physical examination and radiographs was performed for all survivors at an average of 10 months post-injury (range, 6 months to 3 years).

Results: The average age of the 38 patients was 38.6 years (range, 24–51 years) and their average ISS was 53 (range 21–75).All were injured in a high velocity motor vehicle accident or a fall from a height. The patients were managed in the emergency department by a multidisciplinary team according A.T.L.S. guidelines. Of the 38 patients, five died shortly after arrival in the emergency department despite resuscitation efforts. Within the first 24 hours, pelvic stabilization was performed in 27 patients with either an anterior external fixator frame (n=13), pelvic clamp (n=11) or primary open reduction internal fixation (n=3). In group X, of 19 patients initially treated with external fixation and eventual arterial embolization without laparotomy, 18 (94 %) survived. In group Y, there were 8 patients treated by external fixation, eventual arterial embolization and laparotomy, and 7 (87 %) survived. In group Z, all 6 patients in whom a scratch laparotomy with packing prior to any skeletal fixation was attempted,no patient survived ! All survivors underwent definitive open reduction and plate and screw fixation, with an average ICU stay of 10 days (3–15).

Conclusion: This study shows that optimal control of bleeding associated with pelvic ring injuries is achieved by initial skeletal fixation prior to any other surgical procedures. Immediate laparotomy was associated with a high rate of intraoperative death due to the failure to control bleeding.

Objective: Dislocation is a well known complication after total hip arthroplasty (THA), and the second cause of revision surgery. Our objective was to assess the effect of a pre-operative patient education session on the occurrence of hip dislocation within 6 months after primary THA.

Methods: Between 1998 and 2007 we conducted a prospective cohort study at the University Hospital Department of Orthopaedic Surgery including all primary THAs performed via a transgluteal approach and with use of a 28mm diameter head. The preoperative education session was introduced in June 2002 and included advice on muscle strengthening exercises and postoperative restrictions of range of motion as means of preventing dislocation. Main outcome was the incidence of dislocation within 6 months of surgery. The following potentially confounding factors were assessed: age, sex, body mass index, number of co-morbidities, presence of a neurological disorder, history of alcohol abuse, American Society of Anaesthesiologists (ASA) score, diagnosis (primary or secondary osteoarthritis), previous surgery of the hip, surgeon experience, preoperative functional status, pain level, and motion (Harris Hip Score), preoperative general health status (SF-12), and private or public health care insurance (as proxy for socioeconomic status). Multivariable logistic regression was used for adjustment.

Results: 597 patients who underwent 656 THAs between June 2002 and June 2007 participated in the education session, while 1641 patients who underwent 1945 procedures did not. Forty-six dislocations occurred over the study period, 5 (0.8%) in participants and 41 (2.1%) in non-participants (risk difference 1.3%; 95% CI 0.4; 2.3), with the time interval between surgery and dislocation being significantly shorter among participants (0.2 vs. 1.2 months, p=0.016). Preoperative counselling of 77 patients allowed for preventing one dislocation (number needed to treat). Non-participants had a 2.8 times higher risk of dislocation than participants (unadjusted odds ratio 2.80, 95% CI 1.10; 7.13). Adjustment for age, sex, co-morbidities and prior surgery did not change the results (adjusted odds ratio 2.79, 95% CI 1.09; 7.15).

Conclusion: Preoperative patient education reduced the dislocation risk within 6 months after THA, and particularly after the patient had returned home. Other peri-operative benefits from patient education have been reported and should be considered in a cost-effectiveness analysis.

Objectives: The aim of this study was to quantify bone microarchitecture within the glenoid fossa of the scapula.

High-resolution micro-computed tomography ([mu]CT) imaging have been instrumental in providing true quantitative and qualitative three-dimensional data on baseline bone morphology

Materials and Methods: 25 fresh-frozen human cadaveric shoulders were analysed. The mean age of the specimens was 66 years. All scapulae were inspected for normal anatomic landmarks.

The glenoids were cut at the glenoid neck and at the base of the coracoid process.

The total, trabecular, and cortical BMDs of the 5 regions of the glenoids were determined by use of peripheral quantitative computed tomography (pQCT) (Xtrem Ct;Scanco, Zurich, Ch) Each glenoid was fixed horizontally in a custom-made jig, and axial pQCT scans (pixel size,1536/1536; slice thickness 80 microns), perpendicular to the articular surface, were obtained at the level of each area. From the resulting binarized three-dimensional reconstruction, Scanco software was used to calculate the bone volume per tissue volume; mean trabecular separation; mean trabecular number, connectivity density.

Results: The total BMD of the posterior and superior glenoid were significantly higher than those of the anterior and inferior glenoid. Trabecular BMD of the posterior glenoid was significantly higher than that of the anterior glenoid, and cortical BMD of the superior glenoid was significantly higher than that of the inferior glenoid.

The mean total BMD in different regions of 20 glenoid specimens ranged from 0,243 to 0,489 g/cm2. The center of the glenoid was surprisingly poor in trabecular structures as we found a bony gap at 8 mm of distance from the articular surface.

Conclusions and clinical relevance: Although the specimen age was quite high in our material, we believe aging does not affect our study as shoulders prosthesis are generally performed on old patients.

In the future, component design should use areas of stronger subchondral bone. Posterior and superior bone area could be another alternative for fixation in decreasing glenoid-loosening rates. As the inferior center of the glenoid is an area devoided of trabecular bone, center-keel design component doesn’t seem to be the best choice.

Purpose of the study: This was an analysis of long-term outcome of 260 consecutive total hip arthroplasty (THA) procedures performed with a press-fit CLS-Spotorno cup. This easy-to-position cup preserves bone stock if revision should be needed.

Material and methods: From January 1990 to December 1994, 260 THA were implanted with a CLS-Spotorno cup in 221 patients. The clinical and radiological outcome was assessed with minimal ten years follow-up. Mean age at operation was 63 years (range 26–82 years). Sixty eight patients (68 hips) died before ten years follow-up. Five patients (five hips) could not be transported for review and four patients (four hips) were lost to follow-up. This study thus concerned 183 Spotorno cups (70.3%) in 144 patients (65.1%) who were reviewed clinically at 120–166 months follow-up. One hundred twenty-five patients agreed to undergo a radiological work-up. X-rays were analyzed by several independent operators. Two hundred sixty prostheses were implanted by two senior surgeons using the transgluteal approach. The Harris score and the De-Lee-Charnley radiological assessment as well as the Kaplan-Meier survival curve were determined.

Results: Seven cups were revised (3.8%): three because of aseptic loosening, two during stem revision because of polyethylene wear, and two for recurrent dislocation. Radiographically, four cups (2.2%) had migrated and there was a lucent line adjacent to the cup in at least one of the three De-Lee-Charnley zones for 23 cups (12.5%). There were no cup wing fractures. The mean Harris score for 144 patients (183 hips) was 90 points (range 37–100) at last follow-up. Outcome was considered excellent for 123 hips (67%), good for 34 (18.5%), fair for 20 and mediocre for five. The Kaplan-Meier 10-year survival with revision as the end point was 99% (CI: 94.8–99.8%).

Discussion: The 10-year survival of CLS-Spotorno cups is excellent with a low rate of revision. These results can be tempered by the radiological findings, although the lucent lines were already visible on the 12-month x-rays with no visible progression.

Conclusion: This cup provides excellent long-term results with a survival curve comparable to other press-fit cups. It is easy to position and revise.

Purpose of the study: Coxofemoral conflicts can sometimes lead to early degenerative disease in young patients. Open surgery for surgical dislocation with joint cleaning had provided promising short- and mid-term results. Arthroscopy of the hip joint is a less invasive alternative. The purpose of this work was to compare prospectively the outcome achieved with open surgical or arthroscopic treatment of coxofemoral conflicts after a minimum follow-up of two years.

Material and methods: Sixty-three patients, mean age 30 years (range 19–54) with arthroMRI-proven coxofemoral conflict were evaluated two years after treatment. Surgical dislocation was used for 31 patients and arthroscopy for 32. Clinical outcome was assessed on the basis of WOMAC scores noted preoperatively, postoperatively and at two years follow-up. Complications were noted.

Results: Results were similar in the two groups at two years: preoperative WOMAC score: 65/100 (41–95) pour open dislocation, 57/100 (15–96) for arthroscopy; postoperative WOMAC score at two years: 79/100 (41–99) for open dislocation, 84/100 (50–99) for arthroscopy. The rate of patient satisfaction was similar: (open dislocation: 75% and arthroscopy: 82%). Complications: open dislocation : 3 case of POA including 1 Brooker stage III and one 1 case of ossifying myositis of the thigh; arthroscopy: 2 case of hematoma (spontaneous resolution) and 1 case of transient irritation (48 h) of the lateral femoral cutaneous nerve. Surgical revisions at two years: open dislocation: one total hip arthroplasty at 15 months and one resection of ossification (POA) at 15 months; arthroscopy: two total hip arthroplasties at 5 and 15 months.

Discussion: The results obtained with the two methods are encouraging at two years. A satisfaction rate of 80% can be expected.

Conclusion: Arthroscopy appears to be the more advantageous alternative for young patients since it is less invasive and provides similar results at two years.

Purpose of the study: Coxofemoral conflicts can sometimes lead to early degenerative disease in young patients. Hip arthroscopy is a less invasive alternative which can remove all of the coxofemoral conflicts. Like open surgery, a purely arthroscopic technique enables all the necessary corrections, even involving the rim. Arthroscopy has provides promising short- and mid-term results. The purpose of this work was to present the surgical technique, its drawbacks and complications, and present suggestions for improvement.

Material and methods: Fifty-one patients, mean age 31 years (range 15–54 years) underwent purely arthroscopic treatment of coxofemoral conflicts between February 2001 and November 2003. Prospective follow-up was at least six months. The type of conflict and the corresponding corrections were noted. The Pre- and postoperative WOMAC scores were used for clinical assessment. Complications were noted as well as means for avoiding them.

Results: The operative technique, the potential dangers, and suggestions for successful arthroscopy are presented. The clinical outcome with at least six months follow-up was: hip R/L: 21/31. Head and acetabular correction: 46 cases. Head correction alone (head/neck offset): 5 cases. Preoperative WOMAC score: 59/100 (15–99). Postoperative WOMAC score: 85/100 (49–99). Complications: spontaneously resolutive hematoma (n=2), transient (48h) irritation of the lateral femoral cutaneous nerve (n=1).

Discussion: Purely arthroscopic correction of a coxofemoral conflict is as safe as the open surgical technique. The arthroscopic method provides very promising short- and mid-term results with no major complications. The lower morbidity with this technique enables ambulatory treatment with shorter recovery time.

Purpose of the study: Revision total hip arthroplasty (rTHA) is associated with higher mortality than primary total hip arthroplasty (pTHA). The functional outcome after rTHA is globally satisfactory but less so than with primary implantation. Nevertheless, data are scarce. Patients undergoing revision procedures are older and have more co-morbid conditions. In this context, we evaluated quality-of-life and patient satisfaction five years after implantation, comparing rTHA versus pTHA. We analyzed the impact of age, obesity, and co-morbid conditions.

Material and methods: The study cohort included all patients undergoing pTHA (n=471) OR rTHA (n=124) in our unit between 1996 and 2000. Five years postoperatively, we noted the Harris hip score (HHS) and patient satisfaction, assessed on a visual analog scale (VAS) from 1 to 10.

Results: The rTHA patients were older (72 yeras versus 68 years, p=0.004), more frequently obese (BMI30: 33% versus 19%, p=0.003) and presented more co-morbid conditions involving medical ( 2: 46% versus 21%, p< 0.001) and orthopedic ( 2: 13% versus 7%, p=0.053) problems. Five years after surgery, quality-of-life and patient satisfaction were much lower after rTHA than after pTHA (HHS < 70; 31% versus 9%, p< 0.001; satisfaction score 8: 68% versus 85%, p< 0.001). Adjustment for the preoprative status (ASA, medical and orthopedic comorbidity, BMI, gender, age) attenuated these differences which nevertheless remained significant [non-adjusted HHS difference: 11.5 (95%CI: 7.4–15.7); adjusted difference: 8.8 (95%CI: 5.5–12.1)]. In both groups, a low HHS was associated with BMI ≥ 30, poor preoperative function, 2 joints affected, elderly age. Obesity was associated with even poorer results after rTHA than after pTHA (non-adjusted difference, p=0.026).

Discussion: Quality-of-life and patient satisfaction at five years were clearly poorer after rTHA than after pTHA. This is in agreement with data in the literature. The difference is explained in particular by greater patient age and more associated comorbidities for rTHA. Obesity is a prognostic factor which is more unfavorable after rTHA than after pTHA.

Conclusion: Considering the risks and benefits of revision surgery, it is important to recognize not only the surgical factors but also the characteristic features of the patients.

We examined whether a selective cyclooxygenase-2 (COX-2) inhibitor (celecoxib) was as effective as a non-selective inhibitor (ibuprofen) for the prevention of heterotopic ossification following total hip replacement. A total of 250 patients were randomised to receive celecoxib (200 mg b/d) or ibuprofen (400 mg t.d.s) for ten days after surgery. Anteroposterior radiographs of the pelvis were examined for heterotopic ossification three months after surgery. Of the 250 patients, 240 were available for assessment. Heterotopic ossification was more common in the ibuprofen group (none 40.7% (50), Brooker class I 46.3% (57), classes II and III 13.0% (16)) than in the celecoxib group (none 59.0% (69), Brooker class I 35.9% (42), classes II and III 5.1% (6), p = 0.002). Celecoxib was more effective than ibuprofen in preventing heterotopic bone formation after total hip replacement.

Objective: To evaluate the outcome of open reduction and internal fixation of displaced proximal humerus fractures using a new locking plate.

Design: Prospective.

Setting: Level I university center.

Patients: Twenty-eight women and 22 men (mean age, 62.9 ± 19.l years). Twenty-nine patients were 65 years of age or older (mean age, 76.8 years). Fractures were classified according to AO/OTA as 11-A2 (n=3), A3 (n=12), B1 (n=4), B2 (n=18), B3 (n=1), C1 (n=1), and C2 (n=11). Mean follow-up was 19.8 months (range, 12 to 39 months).

Intervention: Open reduction and internal fixation with a proximal humerus locking plate.

Main Outcome Measurements: Raw and adjusted (sex and age) Constant score.

Results: Forty patients were available for follow-up. The mean raw Constant score was 66.6 (adjusted, 82.0). In patients under 65, the raw Constant score was 78.2 (adjusted score, 86.7). In patients over 65, the raw Constant score was 56.1 (adjusted score, 77.8). An excellent or good result was found in 72.5% overall. There was no secondary loss of position or implant cut-out. Seven patients (17.5%) developed avascular necrosis (AVN), 6 in C2 fractures in the older group. Their mean adjusted score was 60.7, as compared to 86.6 ± in those without AVN (p = 0.001).

Conclusions: The outcome was equally good in the younger and older age groups of patients, except in those who developed avascular necrosis. While the latter might be due to the nature of the fracture, it is also possible that surgical technique plays a role.

Introduction One of the most difficult aspects of shoulder arthroplasty is retroversion. The ideal angle is about 30 of posterior rotation of humeral head with regard to the frontal plane so that the humeral head squarely faces the glenoid surface in the resting position. The axis, lateral epicondyle- medial epicondyle is often taken as reference and serves as landmark in many arthroplasty instrumentation. [1,2]

Clinical experience has shown that estimating a 30 angle in space is definitely not easy even with the help of diverse goniometers.

Methods Each operator has to put 3 prostheses with a 30 degrees retroversion according to the position of the forearm so we had proceeded to 52 putting of prostheses .

The measures were made by taking into account of the humerus axis, the plan of condyles and angle of inclination of the collar, given by the angle of cutting. Three barycentres of the three humeral sections have determined the humeral axis. The condylar axis is determined from the 2 barycentres of the digitalized points on the anterior articular condylar surfaces. These 2 axis determine the frontal plane on which a reference mark R(x, y, z) is attached with Z lined up with the humeral shaft and X lined up on the condyles. Different angles could then be determined.

In the sagittal plan (perpendicular in the humeral axis), the retroversion angles of the prosthesis and the angle of cutting are calculated.

Results The standard deviation of the retroversion angle of the prosthesis is 14,22 which is really too high. In fact, 4 prostheses were inserted with poor retroversion (17°, 17°, 18°, 4,4°) and 20 with excessive retroversion (max =65°). This retroversion angle is not dependant on the other factors (cut angle, inclination angle...) The implant height was not taken into account

Conclusions Only 28 of the prostheses were placed in the right orientation within 20° to 40° of retroversion angle. It shows the difficulties to place a shoulder prosthesis in good position.even in standard conditions and with the standard marks.

Purpose: Fracture of the lateral process of the talus is exceptional. Diagnosis may be missed in 50% of patients, the fracture often being confused with severe ankle sprain. Through the seventies, less than 60 cases were reported in the literature. We report a retrospective study of seven cases treated surgically between 1990 and 2001.

Material and methods: We examined the different mechanisms leading to fracture of the lateral process of the talus and propose a therapeutic algorithm. All patients were seen at follow-up consultations. We used the AOFAS hindfoot evaluation scale, radiographs (anteroposterior view of the ankle and 3/4 lateral view of the foot, Broden views). Outcome was scored excellent, fair, or poor. Mean patient age was 33 years (20–51). Mean follow-up was six years (1–12). The patients incurred the fracture during a snowboard accident (n=1), motocycle accidents (n=3), defenestration (n=1), and mountain climbing accidents (n=2). Fractures resulted from forced eversion in one patient and high-energy trauma in six. Fracture classification according to Hawkins was type 1 (n=4, type 2 (n=3), and type 3 (n=1). Time from the accident to diagnosis was less than 15 days except in one patient where the diagnosis was made ten months after the trauma. Associated lesions were subtalar dislocation (n=2), talar neck fracture (n=1), medial malleolar fracture (n=1), and open fracture of the first cuneiform (n=1). The procedure consisted in fixation of the fragments without resection in four cases, resection of small fragments and fixation of large fragments in two, and osteotomy of a deformed callus of the lateral process of the talus in one. Weight bearing was not allowed four six weeks except in one patient with subtalar dislocation whose calcaneotalar pin was withdrawn at eight weeks.

Results: Complications were one case of superficial infection which resolved with antibiotic treatment and two cases of subtalar osteoarthritis at more than ten years. The overall score was 85 on average. The outcome was excellent in six cases and poor in one.

Discussion: A review of the literature shows that fracture of the lateral process of the talus occurs in 1% of all ankle lesions. Five mechanisms have been described. The two most frequent are ankle inversion in dorsiflexion and high-energy trauma. The three other mechanisms are eversion, direct trauma and stress fracture. The consequences of inadequate treatment include: late healing, non-union, deformed callus (one case in our series), avascular necrosis, subtalar instability, and joint incongruency with risk of subtalar and/or talofibular osteoarthrosis. The appropriate treatment depends on the time of diagnosis, the size and nature of the fracture and the degree of displacement. The therapeutic algorithm used in Geneva is as follows: orthopaedic treatment (plaster resting boot for six weeks followed by physiotherapy) associated with close surveillance in the event of a fracture measuring less than 5 mm which is generally extra- articular. If the patient considers this treatment is insufficient, removal of the fragment can be proposed. For fractures measuring more than 1 cm, which are generally intra-articular, surgical treatment is needed if the fragment is displaced more than 2 mm. In the event of late diagnosis, it may be necessary to remove the fragment or perform subtalar arthrodesis, or as needed resection of a deformed callus. If the diagnosis is established early and appropriate treatment given, the results have been excellent at six years.

We have assessed the long-term results after operative and non-operative treatment of undisplaced and displaced calcaneal fractures.

At a mean of 6.5 years, we reviewed 70 patients with a calcaneal fracture who were divided into four groups: group 1, 18 patients with undisplaced fractures and a normal Böhler’s angle (BA) who had been treated non-operatively; group 2, 23 with intra-articular fractures and a BA < 10° who had been treated non-operatively; group 3, 13 with intra-articular fractures and a BA > 10° who had been treated surgically; and group 4, 16 with intra-articular fractures and a BA < 10° who had been treated surgically.

The results were assessed by a clinical score considering pain, return to work, return to physical activity, change in shoe-wear and the requirement for subtalar arthrodesis.

Patients with undisplaced calcaneal fractures had a good outcome. Those with displaced fractures treated surgically who presented at follow-up with a BA > 10° had a satisfactory functional outcome and those with displaced fractures who had non-operative treatment had a poor outcome. The poorest outcome was consistently seen in patients who were treated operatively without restoration of BA. Open reduction and internal fixation of intra-articular calcaneal fractures can only be expected to benefit those patients in whom nearly anatomical reconstruction is obtained.

Aims: To describe the proþle of patients older than 65 years of age with a fracture of the upper extremity, and the consequence of such an injury. Methods: Retrospective cohort study of 667 patients presenting to the emergency department between January 1999 and December 2000 with a fracture of the upper extremity. Variables included sex, age, location of fracture (± additional fractures), treatment, length of stay (in hospital and convalescent care), and place of habitation before and after injury. Follow-up continued until patientsñ deþnitive residential status. Results: The majority of patients were women with fractures of the wrist and proximal humerus. 42% were treated and returned to their previous residence. 37% were admitted to the hospital, of whom 90% had an operation; 97% returned to their previous residence. 21% of patients did not require an operation, but were unable to function independently and were admitted directly to our Geriatrics Hospital. This group was signiþcantly older and more frequently sustained a fracture of the proximal humerus or 2 fractures. 20% required long-term placement. Conclusions: Fractures of the upper extremity in this age group are frequent. A particular subset of signiþcantly older patients are unable to function independently, thus requiring hospitalization, extended periods of convalescence, and a greater likelihood of a permanent change in habitation.

Aims: To determine the precision of conventional versus computer assisted techniques for positioning the acetab-ular component in total hip arthroplasty (THA). Methods: Using a lateral approach, 150 cups were placed by 10 different surgeons in 10 identical plastic pelvis models. Only the immediate operating þeld was visible. Preoperative planning was performed with a computerized tomographic scan. Fifty cups were placed free hand, 50 others with the standard cup ancillary, and the remaining 50 cups using computer-assisted orthopaedic surgery. The accuracy of cup abduction and ante-version was assessed with an electromagnetic system. Results: Using conventional techniques, free hand placement revealed a mean precision of cup anteversion and abduction of 10¡ [range: 5.5–14] and 3.5¡ [2.5–5] respectively. With the cup positioner, these angles measured 8¡ [5–10.5] and 4¡ [3–5.5] respectively, and using the computer assisted method, the mean cup anteversion precision was 1.5¡ [1–2] and mean cup abduction measured 2.5¡ [2–3.5]. Conclusions: Computer assisted cup placement is a very accurate and reproducible technique during THA. It is clearly more precise than either of the two traditional methods of cup positioning, even for well-trained surgeons.

Aims: The diagnosis of a prosthetic joint infection is difþcult, but crucial for appropriate treatment. Scintigraphy with speciþc markers for infection (labeled white cells or immunoglobulin-G) has been reported as a more reliable diagnostic tool than clinical assessment (fever, þstula), laboratory studies [polynuclear neutrophils blood count (PNC), erythrocyte rate sedimentation (ESR), and C-reactive protein (CRP)], and preoperative aspiration. Methods: In the þrst part of this study, we retrospectively reviewed 230 patients admitted with a suspected prosthetic joint infection and compared the validity of these different diagnostic tools. 209 patients had an infection. Results: Pain, fever, ESR, and PNC are unreliable for identifying occult infection. The presence of a þstula is inconstant, but when present is very reliable to detect infection. Our study revealed sensitivity, speciþcity, positive and negative predictive value as follows: CRP: 97%, 81%, 98%, 71% respectively; aspiration: 82%, 94%, 99%, 43% respectively, and labelled scintigraphy 74%, 76%, 91%, 44% respectively. In the second part, we reviewed 23 articles which included 1,722 prosthetic joints with preoperative evaluation of infection. Conclusions: Both our study and the literature review indicate that CRP and joint aspiration are the best tools to diagnose prosthetic joint infection.

Purpose: Heterotopic ossification is a recognised complication after total hip arthroplasty. Prevalence can reach 53%, particularly if prophylaxis is not given, leading to postoperative pain and limiting the functional prognosis. Non-steroidal antiinflammatory drugs have proven efficacy but also present the risk of gastroduodenal toxicity making postoperative administration hasardous. Recently, selective COX-2 inhibitors have been shown to have a similar antiinflammatory activity with a clear reduction in gastrointestinal disorders. We hypothesised that selective COX-2 inhibitors could be as effective as classical NSAID for the prevention of heterotopic ossifications.

Material and methods: This clinical trial was conducted according to a prospective randomised protocol comparing a group of patients given prophylaxis with Celecoxib (Celebrex®) and another group of patients given ibuprofen (Brufen®). All patients scheduled for total elective prostheses were radomised in a prospective manner to one of the two groups, either Celecoxib 200mg b.i.d. or ibuprofen 400mg t.i.d. for ten immediate postoperative days. Radiological assessment was performed by two independent investigators blinded to the study (an orthopaedic surgeon and a radiologist) who scored calcifications according to the Brooker classification (type I to IV) at three months after surgery. Reproducibility of radiogram reading was tested and analysed with a kappa test K=0.74).

Results: Two hundred ten patients were randomised and 73 have had their three-month radiograms. The Cele-coxib group included 37 patients: 24 with Brooker stage 0, eleven with stage 1, two with stage 2. The ibuprofren group included 42 patients, 15 with Brooker 0, 16 with Brooker 1; nine with Brooker 2 and two with Brooker 3. The statistical analysis will be performed at the end of this study (June 2002).

Discussion: The preliminary results show that Celecoxib appears to have the same efficacy as ipubrofen for the prevention of heterotopic ossification after total hip arthroplasty. There was a clear trend in favour of Celecoxib.

The aim of the study was to determine the precision of conventional versus computer-assisted techniques for positioning the acetabular component in total hip arthroplasty (THA).

Malposition of the acetabular component during THA increases the occurrence of impingement, reduces range of motion, and increases the risk of dislocation and long-term wear. To prevent malpositioned hip implants, an increasing number of computer assisted surgery systems have been described, but their accuracy is not well established.

Using a lateral approach, 150 cups were placed by 10 different surgeons in 10 identical plastic pelvis models. Only the immediate operating field was visible. Pre-operative planning was performed with a computerised tomography scan. Fifty cups were placed free hand, 50 others with the standard cup positioner, and the remaining 50 cups using computer-assisted orthopaedic surgery (Medivision). The accuracy of cup abduction and anteversion was assessed with an electromagnetic system (Fastrak™).

Using conventional techniques, free hand placement revealed a mean precision of cup anteversion and abduction of 10° [range 5.5 to 14] and 3.5° [2.5 to 5] respectively. With the cup positioner, these angles measured 8° [5 to 10.5] and 4° [3 to 5.5] respectively, and using the computer assisted method, the mean cup anteversion precision was 1.5° [1 to 2] and mean cup abduction measured 2.5° [2 to 3.5].

Computer assisted cup placement is a very accurate and reproducible technique during THA. It is clearly more precise than either of the two traditional methods of cup positioning, even for well-trained surgeons.

To determine the precision of conventional versus computer assisted techniques for positioning the acetabular component in total hip arthroplasty (THA).

Malposition of the acetabular component during THA increases the occurrence of impingement, reduces range of motion, and increases the risk of dislocation and long-term wear. To prevent malpositioned hip implants, an increasing number of computer assisted surgery systems have been described, but their accuracy is not well established.

Using a lateral approach, 150 cups were placed by 10 different surgeons in 10 identical plastic pelvis models. Only the immediate operating field was visible. Pre-operative planning was performed with a computerised tomography scan. Fifty cups were placed free hand, 50 others with the standard cup positioner, and the remaining 50 cups using computer-assisted orthopaedic surgery (Medivision). The accuracy of cup abduction and anteversion was assessed with an electromagnetic system (Fastrak™).

Using conventional techniques, free hand placement revealed a mean precision of cup anteversion and abduction of 10° (range 5.5 to 14) and 3.5° (2.5 to 5) respectively. With the cup positioner, these angles measured 8° (5 to 10.5) and 4° (3 to 5.5) respectively, and using the computer assisted method, the mean cup anteversion precision was 1.5° (1 to 2) and mean cup abduction measured 2.5° (2 to 3.5).

Computer assisted cup placement is a very accurate and reproducible technique during THA. It is clearly more precise than either of the two traditional methods of cup positioning, even for well-trained surgeons.

Purpose: The Less Invasive Stabilisation System (LISS) for fixation of the proximal femur is an automatic preformed fixator with three sizes. The self-perforating self-threading screws are locked into the plate fixator providing angular stability. Unlike conventional implants, the LISS plate is not applied directly to the bone, avoiding friction forces and periosteal damage. Precise adaptation of the implant to the form of the bone is not necessary. The system can also be easily and rapidly used as a “gliding” plate. After reduction via a proximal incision, the plate-fixator is inserted between the anterior tibial muscle and the periosteum and fixed with monocortical screws inserted percutaneously.

Material and methods: Between January 1999 and August 2000, we treated 18 multiple trauma patients with fractures of the proximal femur in 17 patients (nine men and eight women) using the LISS in a prospective multicentric study. Mean age was 50 years (20–89), median, 43 years). The AO classification of the fractures was four type A, four type B, and 13 type C. There were 14 open fractures. We used the LISS in one patient to stabilise a valgus osteotomy. One patient had a 41-C2.3 (Schatzker type VI) fracture with a compartment syndrome. Bone allographs were used in two cases. Clinical and radiographic follow-up data was collected at 6, 12, 24 and 48 weeks.

Results: Two foreign subjects with 41-A3 and 41-B1 fractures were lost to follow-up. For the other patients, bone healing was achieved between six and twelve weeks. Mean follow-up was ten months (three to twenty months). We had one complication, the compartment syndrome mentioned above, which healed without sequelae after fasciotomy and secondary thin skin graft. Joint motion was symmetrical and pain free in all patients three months after surgery. There were no nerve or vessel lesions secondary to epiperiosteal displacement of the fixator, and no case of infection or loosening. We did however observe secondary loss of reduction with development of minimal varus in three patients with complex fractures.

Conclusions: These preliminary results with the LISS demonstrate its usefulness as an alternative to conventional fixation systems. It is undoubtedly a most useful method for intra-articular and metaphyseal fractures with diaphyseal fracture lines and for fractures with two levels. Complications appear to depend on the type of fracture and the quality of the reduction, as with other types of fixators.

The treatment of multifragmentary, intra-articular fractures of the distal humerus is difficult, even in young patients with bone of good quality, but is worse in elderly patients who have varying degrees of osteopenia. We have evaluated the functional outcome of primary total elbow replacement (TER) in the treatment of these fractures in ten elderly patients followed for a minimum of one year. There were no complications in regard to the soft tissues, bone or prosthesis. The mean range of flexion obtained was 125° (110 to 140) and loss of extension was 23.5° (0 to 50). The mean Mayo score was 94 points (80 to 100) and patient satisfaction was high. We feel that TER provides an alternative to open reduction and internal fixation in the management of these complicated fractures in the elderly.

The optimal regime of antithrombotic prophylaxis for patients undergoing total knee arthroplasty (TKA) has not been established. Many surgeons employ intermittent pneumatic compression while others use low-molecular-weight heparins (LMWH) which were primarily developed for total hip arthroplasty. We compared the efficacy and safety of these two techniques in a randomised study with blinded assessment of the endpoint by phlebography.

We randomised 130 patients, scheduled for elective TKA, to receive one daily subcutaneous injection of nadroparin calcium (dosage adapted to body-weight) or continuous intermittent pneumatic compression of the foot by means of the arteriovenous impulse system.

A total of 108 patients (60 in the LMWH group and 48 in the mechanical prophylaxis group) had phlebography eight to 12 days after surgery. Of the 47 with deep-vein thrombosis, 16 had received LMWH (26.7%, 95% CI 16.1 to 39.7) and 31, mechanical prophylaxis (64.6%, 95% CI 49.5 to 77.8). The difference between the two groups was highly significant (p < 0.001). Only one patient in the LMWH group had severe bleeding.

We conclude that one daily subcutaneous injection of calcium nadroparin in a fixed, weight-adjusted dosage scheme is superior to intermittent pneumatic compression of the foot for thromboprophylaxis after TKA. The LMWH scheme was also safe.

We studied the position and rotational changes associated with elevation of the glenohumeral joint, using a three-dimensional magnetic-field tracking system on nine fresh cadaveric shoulders. The plane of maximal arm elevation was shown to occur 23 degrees anterior to the plane of the scapula. Elevation in any plane anterior to the scapula required external humeral rotation, and maximal elevation was associated with approximately 35 degrees of external humeral rotation. Conversely, internal rotation was necessary for increased elevation posterior to the plane of the scapula. The observed effects of this rotation were to clear the humeral tuberosity from abutting beneath the acromion and to relax the inferior capsular ligamentous constraints. Measurement of the obligatory humeral rotation required for maximal elevation helps to explain the relationship of the limited elevation seen in adhesive capsulitis and after operations which limit external rotation.