Purpose of the study: Indications for disc prosthesis is generally established on the basis of the MRI findings (MODIC classification) and the discography. We considered that knowledge of the preoperative disc height is also important. We report a multicentric study of the results of lumbar arthroplasties as a function of preoperative height of the operated disc.

Material and methods: A Mobidisc prosthesis was implanted in 93 patients and followed prospectively for at least one year (mean follow-up 5 years). Disc height was compared with the height of the suprajacent disc and divided into three groups: > 66% of height (GI) i.e. a subnormal disc height (n=30), 33–66% (GII) moderate impingement (n=36), < 33% (GIII) total impingement (n=27). A MODIC signal was found for 19% in GI, 42% in GII and 40% in GIII.

Results: The lumbar VAS improved from 6.7 to 3.2 (GI), 6.2 to 2 (GII) and 6.2 to 1.5 (GIII). The radicular VAS improved from 4.8 to 3.1 (GI), 5.7 to 2.4 (GII) and 5.5 to 1.6 (GIII), respectively 69, 75 and 85.5% of the patients were satisfied or very satisfied for relief of the lumbar or radicular pain. The Oswestry score improved from 50 to 22% (GI), 49 to 20% (GII) and 46 to 12% (GIII). By MODIC, the lumbar VAS improved from 6.5 to 2.8 (MODIC 0) and from 6.6 to 2 (MODIC 1). The radicular VAS was improved from 5.5 to 2.9 (MODIC 0) and from 5.3 to 2.1 (MODIC 1). The Oswestry score was improved from 52 to 24% (MODIC 0) and from 48 to 15% (MODIC 1). Independently of MODIC, the VAS was always better for very tight discs and lower if the disc height was preserved.

Discussion: An influence of the disc height was found for all parameters studied, irrespective of the type of disc disease as described by the MODIC classification. The presence of a tight preoperative disc height appeared as the essential prognostic factor for discal prostheses. For a MODIC 0 discopathy, without loss of disc height, only 67 and 61% of the operated patients were satisfied or very satisfied with relief of lumbar and radicular pain (VAS 3.6 and 3.4) for respectively 88 and 75% of the MODIC0 discopathies with discal impingement (VAS 1.5 and 1.5). Though it should not be formally ruled out, surgery for discopathy with a preserved disc height should be examined prudently before implanting a disc prosthesis.

PURPOSE: Oldest elderly trochanteric fractures treatments are common but long term follow up studies are indistinct. Previous data about all outcomes are not reported for oldest one. The purpose was to update all the results for these oldest old patients.

METHODS: A prospective, longitudinal study was undertaken of 455 “31 A1, A2, A3” (OTA) peritrochanteric femur fractures through 2002. There were 84% female patients. The age was 88 (80–105) ±5 years. Associated hip arthritis rate was 10%. 31 A1 and 31 A2 really trochanteric fractures were 90% (31 A1: 52% and 31 A2: 38%), 31 A3 subtrochanteric were 10%. Surgical treatment was achieved for 97%: [extramedullary internal fixation (dynamic hip screw): 36%, intramedullary (trochanteric nail): 56%, hip arthroplasty: 5%]. Functional treatment (not displaced or contra-indicated) was achieved for 3%. Katz, mental, Parker, walking scores, live place before and at long term after fracture, radiological healing and complications were registered.

RESULTS: The radiological healing rate after 3 months was 85% and after 6 was 97%. Complications rate: the general complications rate during 1st month was 12% and between 1st and 3rd month was 8%. The local complications rate during the 1st month was 4% (local infection: 1%) and between 1st and 3rd month was < 1%. The new surgical procedures rate during the 1st month was < 0.5%, between 1st and 3rd month was 3%, between 3rd and 6th month was 3%. Clinical results: Post-operative weight bearing was uncertain. 6th month after fracture 72% of the patients were alive (dead: 28% and non-surgically treated: twice more). All scores and live place demonstrated dependence increase. > 6th month after fracture mortality was common.

CONCLUSION AND SIGNIFICANCE: Intra/extra capsular hip fractures ratio increases after 80. These are older, more dependant and help demanding. Hip arthritis inflates hip fracture risk. Success points technical procedures had been demonstrated by randomised studies: dynamic hip screws for stable fractures and trochanteric nails for unstable; hip prosthesis for arthritis or poor bone. Practice surgery for all trochanteric fractures. Don’t separate trochanteric/subtrochanteric. The prognostic is rather poor (mortality rate, functional outcomes), depending on initial functional score and dependence. Modern internal fixation is reliable. Arthroplasty should be considered.

Purpose of the study: The theoretical usefulness of a disc prosthesis in comparison with arthrodesis would be to restore physiological segmental motion without perturbing the kinematics of the adjacent levels. The purpose of this study was to determine the rotation centers of the lumbar segments before and after implantation of a disc prosthesis with a mobile insert (Mobidisc™).

Material and methods: Lateral flexion and extension views in the sitting position with a stabilized pelvis were obtained before and after implantation of the lumbar disc prosthesis in 32 patients. Spineview™ was applied to the digitalized images for semi-automatic recognition of the vertebral body contours and calculation of the rotation centers. The detection threshold for this automatic system was 5° motion.

Results: Rotation centers were difficult to determine preoperatively because of the absence of mobility. A pathological position was found for three patients. Postoperatively, at three and twelve months, the position was «physiological» in 13 patients, in the posterior half of the disc or inferior body near the vertebral end plate. IN 14 patients, the center could not be determined because motion measured 5° or less. For three patients, the center was too anterior on a prosthesis implanted to anteriorly. There were no changes in the rotation centers for the adjacent levels.

Discussion: Demonstration of an abnormal rotation center could be an additional indication of presumed instability. In certain cases, a disc prosthesis appears to restore the physiological rotation center. But the position and the thickness of the implant can influence their localization.

Conclusion: Restoration of a physiological rotation center for the instrumented intervertebral segment and the absence of change in the rotation centers for the adjacent centers are arguments in favor of disc prosthesis for reducing the incidence of osteoarthritic degradation of adjacent discs in comparison with fusion, under the condition that the implantation and the size are correctly adapted.

Leakage after simple suture repair of rotator cuff tears depends on the overall preoperative fatty degeneration index (FDI) of the muscles and preoperative fatty degeneration (FD) of the infraspinatus. When the FDI is = 2, cuff leakage is always observed after repair. The risk of recurrent tears of the supraspinus is high if the FD of the infraspinatus is > 1. However if the FDI is very low or nil, the rate of recurrent tears is 15%. These tears can be explained by tension on sutures in macroscopically and histologically abnormal tendons.

Purpose: The purpose of this study was to determine whether repair of rotator cuff tears using sutures without tension after removal of abnormal tendon stumps, a technique requiring tendon plasty, can improve the leakage rate.

Material and methods: Total repair of 24 rotator cuff tears was performed without tension on the sutures after resection of at least one centimetre of the supraspinatus tendon stump. This consecutive series was studied prospectively. The tears involved the supraspinatus and the infraspinatus in ten cases, all three tendons in 13 cases and only the supraspinatus in one case. Mean preoperative FDI was 1.18 (0.5–2.16); pre-operative FD of the infraspinatus was a mean 1.19 (0–2). The supraspinatus stump was resected from the trochiter in 14 cases, on the apex of the head of the humerus in seven and facing the glenoid cavity in three. Repair required translation advancement of the supraspinatus in 24 cases, translation advancement of the infraspinatus in six (associated with a rhomboid flap) and a trapezeal flap in three cases. Postoperative leakage was assessed with arthroscan (n=23) and ultrasonography (n=1) at one year.

Results: No leakage was observed in 20 of the 24 cuffs (83%). Recurrent tear of the supraspinatus was observed in three cases and in the supraspinatus and infraspinatus in one case each. The FDI of cuffs with recurrent tears (1.31) was not significantly greater than the FDI of cuffs without leakage (1.15) (p = 0.085). Preoperative FD of the infraspinatus of cuffs with recurrent tears (1.5) was significantly higher than that for cuffs without leakage (1.12) (p = 0.16). For the supraspinatus and the subscapularis, there was no significant difference between preoperative fatty degeneration of cuffs with recurrent tears and cuffs without leakage. The number of repaired tendons had a statistically significant effect (p = 0.012) on postoperative leakage: 23% of the recurrent tears after repair of three tendons showed no leakage compared with 9% after repair of one or two tendons (there was no significant difference for preoperative FDI, p = 0.33).

Discussion: Resection of macroscopically abnormal tendon stumps which requires tendinomuscular plasty, gives better anatomic results than simple suture. For an equivalent FDI, this allows fewer cases of leakage (83% without leakage compared with 50% after simple suture). Results were also better for an equivalent number of tendons repaired: 77% and 50% for three tendons and 91% and 55% for two tendons respectively).

Conclusion: Despite the almost constant need for plasty, rotator cuff repair using sutures without tension after resection of macroscopically abnormal tendon stumps gives, for an equivalent preoperative degree of fatty degeneration and an equivalent number of tendon repairs, better anatomic results than simple suture.

Purpose of the study: Surgical treatment of degenerative spondylolisthesis generally requires spinal fusion. Arthrodesis can be achieved via an anterior or posterior approach. Over the last ten years, minimally invasive methods have been developed to limit operative trauma secondary to the anterior approach. There have however been few studies comparing outcome after this new technique with classical open surgery. The aim of this work was to compare spinal fusion achieved with a cage implanted retroperitoneoscopically with conventional screw-plate fixation using open lombotomy.

Material and methods: Sixty two patients with degenerative spondylolisthesis (L3-L4, L4-L5, L5-S1) were reviewed: 39 had had conventional spinal fusion (group 1) and 23 had undergone a minimally invasive procedure (group 2). Clinical (Beaujon score) and radiographic assessment was recorded at last follow-up. All patients in group 1 were operated on by the same surgeon via lombotomy (L3-L4 or L4-L5 fusion) or subumbilical laparotomy (L5-S1 fusion). An intersomatic graft was combined with screw-plate fixation in all cases. Patients in group 2 were also operated on by the same surgeon (different from group 1) who used a retroperitoneoscopic approach (L3-L4 or L4-L5 fusion). An intersomatic cage was filled with cancelous bone and screwed into the intersomatic space.

Results: Mean follow-up was four years in group 1 and two years in group 2. Mean Beaujon score improved from 8 to 17 in group 1 and from 9 to 16.5 in group 2. All patients achieved bone healing at last follow-up without secondary displacement or disassembly of the osteosynthesis. There were no neurological complications and no infections of the operative site. One patient in group 2 developed a vascular complication requiring conversion to classical lombotomy. Blood loss was 1100 ml in group 1 and 200 ml in group 2.

Conclusion: Anterior fusion with implantation of an intersomatic cage via retroperitoneoscopic access is a reliable and effective method for the treatment of degenerative spondylolisthesis. It reduced postoperative morbidity but must obviously comply with classical indications for lumbar fusion.

Between January 1988 and January 1991 we performed 100 consecutive cemented total hip replacements using a zirconia head, a titanium alloy stem and a polyethylene cup. We reviewed 78 of these hips in 61 patients in detail at a mean of 5.8 years (1 to 9).

Aseptic loosening was seen in 11 hips (14%). Eight needed revision. In total, 37 cups (47.5%) showed radiolucent lines, all at the cement-bone interface, with 18 (23%) involving all the interface. Of the 78 femoral implants, 17 (21.7%) showed radiolucent lines, and two, which had a complete line of more than 1 mm thick, definite endocortical osteolyses. There was also an abnormally high incidence of osteolysis of more than 2 mm at the calcar.

Survivorship analysis showed that only 63% were in situ at eight years. These worrying results led us to abandon the use of zirconia heads, since at the same hospital, using the same femoral stem, cement and polyethylene cup, but with alumina femoral heads, the survival rate was 93% at nine years. We discuss the possible reasons for the poor performance of zirconia ceramic.

A 65-year-old man presented with a painful hip five years after a cemented replacement. Histological examination of a biopsy taken from tissue surrounding the femoral implant showed infiltration of a squamous-cell carcinoma. Further investigation revealed a primary growth in the left lung. This rare example of a metastasis in relation to a joint replacement illustrates the necessity for histological examination of the tissue adjacent to a loose prosthesis.