Aims

Mechanical impingement of the iliopsoas (IP) tendon accounts for 2% to 6% of persistent postoperative pain after total hip arthroplasty (THA). The most common initiator is anterior acetabular component protrusion, where the anterior margin is not covered by anterior acetabular wall. A CT scan can be used to identify and measure this overhang; however, no threshold exists for determining symptomatic anterior IP impingement due to overhang. A case-control study was conducted in which CT scan measurements were used to define a threshold that differentiates patients with IP impingement from asymptomatic patients after THA.

Mechanical irritation or impingement of the iliopsoas tendon accounts for 2–6% of persistent postoperative pain cases after total hip arthroplasty (THA). The most common trigger is anterior cup overhang. CT-scan can be used to identify and measure this overhang; however, no threshold exists for symptomatic anterior iliopsoas impingement. We conducted a case–control study in which CT-scan was used to define a threshold that differentiates patients with iliopsoas impingement from asymptomatic patients after THA.

We analyzed the CT-scans of 622 patients (758 CT-scans) between 2011 and 2020. Out of this population we identified 136 patients with symptoms suggestive of iliopsoas impingement. Among them, 6 were subsequently excluded: three because the diagnosis was reestablished intra-operatively (one metallosis, two anterior instability related to posterior prosthetic impingement) and three because they had another obvious cause of impingement (one protruding screw, one protruding cement plug, one stem collar), leaving 130 patients in the study (impingement) group. They were matched to a control group of 138 patients who were asymptomatic after THA. The anterior cup overhang (anterior margin of cup not covered by anterior wall) was measured by an observer (without knowledge of the clinical status) on an axial CT slice based on anatomical landmarks (orthogonal to pelvic axis).

The impingement group had a median overhang of 8 mm [IQR: 5 to 11] versus 0 mm [IQR: 0 to 4] for the control group (p<.001). Using ROC curves, an overhang threshold of 4 mm was best correlated with a diagnosis of impingement (sensitivity 79%, specificity 85%, PPV = 75%, NPV = 85%).

Pain after THA related to iliopsoas impingement can be reasonably linked to acetabular overhang if it exceeds 4 mm on a CT scan. Below this threshold, it seems logical to look for another cause of iliopsoas irritation or another reason for the pain after THA before concluding impingement is present.

The hip-shelf procedure is less often indicated since the introduction of peri-acetabular osteotomy (PAO). Although this procedure does not modify pelvic shape, its influence on subsequent total hip arthroplasty (THA) is not known. We performed a case-control study comparing THA after hip-shelf surgery and THA in dysplastic hips to determine: 1) its influence on THA survival, 2) technical issues and complications related to the former procedure.

We performed a retrospective case-control study comparing 61 THA cases done after hip-shelf versus 63 THA in case-matched dysplastic hips (control group). The control group was matched according to sex, age, BMI, ASA and Charnley score, and bearing type. We compared survival and function (Harris, Oxford-12), complications at surgery, rate of bone graft at cup insertion, and post-operative complications.

The 13-year survival rates for any reason did not differ: 89% ± 3.2% in THA after hip shelf versus 83% ± 4.5% in the controls (p = 0.56). Functional scores were better in the control group (Harris 90 ± 10, Oxford 41/48) than in the hip-shelf group (Harris 84.7 ± 14.7, Oxford 39/48) (p = 0.01 and p = 0.04). Operative time, bleeding and rate of acetabular bone grafting (1.6 hip-shelf versus 9.5 control) were not different (p > 0.05). Postoperative complication rates did not differ: one transient fibular nerve palsy and two dislocations (3.2%) in the hip-shelf group versus four dislocations in the control group (6.3%).

The hip-shelf procedure does not compromise the results of a subsequent THA in dysplastic hips. This procedure is simple and may keep its indications versus PAO in severely subluxed hips or in case of severe femoral head deformity.

Cementless distally locked stems were introduced in revision hip arthroplasty (RTHA) in the late 1980s to deal with severe femoral bone loss. These implants have not been assessed over the long-term, particularly the influence of the design and porous coating. Therefore we performed a retrospective case-control study at a minimum 10-years' follow-up comparing the straight Ultime™ stem with 1/3 porous coating versus the anatomical Linea™ stem with 2/3 proximal coating with hydroxyapatite.

We performed a single-center case-control study measuring survival, function based the Harris and Oxford-12 scores, and rate of thigh pain. X-rays were done at regular intervals and at follow-up. No femoral bone graft was used at insertion.

The two groups were comparable in terms of age, sex and follow-up (mean 12.2 years in Ultime and 10.8 years in Linea cohorts); however they differed in the severity of bone loss therefore the results were adjusted according to this variable. Ten-year survival considering revision for any reason was 63.5% ± 5.4 for Ultime and 91.6% ± 2.7 for Linea (p < 0.001). Merle d'Aubigné scores and Oxford-12 were higher in the Linea group 82.9 ± 12.4 and 26.3/48, respectively, versus 69.5 ± 16 and 21/48 in the Ultime group (p < 0.001). Thigh pain was observed in 30% of Ultime cases versus 3% of Linea cases. Bone reconstruction measured via cortical thickness was better in the Linea group and correlated to metaphyseal filling at insertion.

This study confirms the benefits of using of locked stems in RTHA with severe bone loss. Better metaphyseal filling and optimized porous coating help to minimize thigh pain and the revision rate.

Aim

The treatment of a chronic prosthetic joint infection (PJI) is a combination of the bacteria's identification, a «carcinological» surgery and an appropriate antibiotherapy. In case of gram positive cocci infection, rifampicin is often used.

The aim of this study is to determine which factors are responsible for the development of resistance to rifampicine.

There is currently no consensus on the use of suppressive antibiotic therapy (SAT) in prosthetic joint infections (PJI) (1). We describe herein the experience of a French Reference Centre for Complex Osteo-Articular Infections on use of oral cyclines (doxycline and minocycline) for SAT.

A retrospective analysis was performed on consecutive patients with PJI who received oral cyclines (doxycycline or minocycline) for SAT between January 2006 and June 2014. All patients had surgical management, followed by systemic antibiotic treatment and SAT instauration thereafter. Remission was defined as an asymptomatic patient with a functioning prosthesis.

Seventy-nine patients with a mean age of 63.8 ± 16.8 years were included. Sixteen patients (20%) had neoplasia, 9 (11%) diabetes mellitus, 10 (13%) rheumatoid arthritis, and 6 patients (8%) were receiving corticosteroids or chemotherapy.

There were 37 knee (47%), 36 hip (46%), 4 elbow (5%), and 2 shoulder (3%) infections, with a mean delay from implantation of 7.37 ± 6.94 months (range 1–27). Surgical management consisted in debridement and implant retention for 60 patients (76%), or in implant exchange for 19 patients (24%).

Main pathogens were coagulase-negative staphylococci (37%) and Staphylococcus aureus (41%); 23 patients had polymicrobial infection (29%).

The most frequent initial antibiotic regimens debuted before SAT were rifampicin combinations (70%). Mean duration of curative antibiotic therapy was 103 ± 75 days.

Indications of SAT were (i) patients unsuitable for or refusing further surgery (n=23), suboptimal (ii) surgery (n=26) or (iii) curative antibiotic therapy (n=11), (iv) complex orthopaedic surgery (n=11), and (v) immunosuppressive status (n=8). Seventy-three patients received doxycycline and 6 patients received minocycline as SAT (n=48). Mean SAT duration was 625± 536 days (range 30–2900), with a mean follow-up of 765 ± 572 days.

Adverse events were reported in 13 patients (16%), leading to SAT discontinuation in 5 (6%).

During follow-up, 59 patients were considered in remission (75%), and 20 failed including 13 relapses (16%) and 7 reinfections (9%). Among failure patients, 10 pathogens resistant to doxy/minocycline were identified, including 5 with acquisition of cycline resistance.

In our study, SAT with cyclines is associated to a 75% remission rate, with an acceptable tolerability.

Further studies are warranted to determine ideal regimens and optimal duration of SAT.

We would like to thank Dron Hospital and Lille University Hospital medical teams.

The authors declare that there are no conflicts of interest.

Introduction

In valgus knees, ligament balance remain difficult when implanting a total knee arthroplasty (TKA), this leads some authors to systematically propose the use of constrained devices. Others prefer reserving higher constraints to cases where it is not possible to obtain final satisfactory balance: less than 5 of residual frontal laxity in extension in each compartment, and a tibiofemoral gap difference not in excess to 3mm between flexion and extension. The goal of the study was to assess if is possible to establish preoperative criteria that can predict a constrained design prosthetic implantation at surgery.

Introduction

The same cup orientation is classically applied to all cases of hip replacement (45° abduction, 20° anteversion). We hypothesize that this orientation must be adapted to the patient's hip range of motion. We tested this hypothesis by means of an experimental study with respect to hip range of motion, comparing the classical orientation (45° and 20°), and the orientation obtained with computer-assisted navigation.

Introduction

The prosthetic impingement occurs if the range of motion of the hip exceeds implant mobility or in case of component malorientation. This retrieval study was designed to assess the frequency and the risk factors of this phenomenon.

Purpose of the study: Factors affecting the course of Staphylococcus aureus (SA) infected total hip arthroplasty (THA) and total knee arthroplasty (TKA) are poorly understood.

Material and methods: The microbiology laboratory database on patients hospitalised from June 2001 to June 2006 for medical and surgical treatment of an SA infected THA or TKA were reviewed. Data collected were: clinical, radiological, and biological (CRP) status known at least two years after the end of the antibiotic treatment. Success was defined as normal findings in all three domains at last follow-up and failure for any other situation.

Results: The series included 87 patients (43 male and 54 female, mean age 66.5 years, 62 THA, 35 TKA). Material was removed in 51 patients (52.6%). The infection was related to met-R SA in 14 patients (14.4%) and polymicrobial infection in 24 patients (24.7%). Mean duration of intravenous treatment was 7.3±9.4 days and total duration of antibiotic treatment was 115.472.2 d. At mean follow-up of 54.1±19.4 d, the overall success was 62/97 (63.9%). The only parameters significantly associated with failure were delay to management after first signs revealing longer infection (67.9 days vs 144.8 days) and an antibiotic therapy not adapted bacteriological results to immediately after surgery. (28.6% vs 3/28; 4.8%). In this series, met-R SA was not a risk factor of failure.

Conclusion: This work suggests that delayed surgical management and quality of antibiotic treatment for the first revision are factors affecting the prognosis of SA infected THA and TKA. These results are in favour of a multidisciplinary approach to care for these patients.

Purpose of the study: The objectives of this work were to assess the stability of outcome achieved after Duquennoy procedure to tighten the lateral capsule-ligament structures of the ankle joint. To do this, we reviewed the same series of patients at 3 and 25 years follow-up to analyse the very long-term stability, laxity, and stiffness of the ankle joint and any osteoarthritic degradation.

Material and methods: From 1975 to 1986, we performed 75 Duquennoy procedures on the lateral capsule and ligament structures of the ankle joint. At mean 25 years follow-up (2007) we were able to review 28 ankles (27 patients) with the same method as applied in 1980 (3 years follow-up). The function outcome was assessed with the Good, Karlsson, Duquennoy and Tegner scores. Clinically, other than joint range of motion, were noted varus laxity or anterior drawer. Static x-rays were obtained to search for signs of osteoarthritis and stress images to measure talocrural laxity, in comparison with the preoperative figures and the 1980 data.

Results: There were two early technique failures (one persistent talocrural instability, one subtalar instability). Good and Karlsson scores were good or excellent in 92% of cases. Patients were very satisfied with the operation and the VAS was 8.9/10. Pain and occasional instability were reported by 27% of patients. There was no talocrural no subtalar stiffness at last follow-up. Radiographic laxity declined significantly between the preoperative value and the last review. Only one patient presented a narrow talocrural space (less than 50% narrowing). Eight patients had osteophytes whose presence was not correlated with poor functional outcome. These osteophytes were also present on the controlateral side. Importantly, there was no significant difference in the mean function scores between 3 and 25 years follow-up (Duquennoy score). Similarly joint range of motion and radiographic laxity remained stable over time.

Discussion: The Duquennoy procedure to tighten the lateral capsule and ligament structures is a simple technique with rare complications which provides excellent results both in terms of ligament stability and in terms of preservation from degenerative osteoarthritis. These results remain stable over time. Conversely, the technique has no action on the subtalar joint and should not be proposed as treatment for associated subtalar laxity, if diagnosed.

Purpose of the study: For young active patients, implantation of metal backed socket with a metal-on-metal bearing is an attractive tribological alternative when a standard prosthesis cannot be implanted. Metal ion assays have not been reported in this type of population. The purpose of this work was to present the clinical, radiographic and metal ion results.

Material and methods: Between 1998 and 2003 23 total hip arthroplasties (THA) (six primary and 17 revision) were implanted with a cemented Metasul™ bearing in a Muller inlay. Mean follow-up was 6.1 years (5–10). None of the patients was lost to follow-up. The Harris and PMA scores were noted as were signs of implant loosening or migration. Metal ions were assayed in total blood (Cr and Co) by mass spectrometry and atomic emission spectrometry (Ti).

Results: At follow-up, the mean Harris and PMA scores were significantly increased, from 62.2 to 95.2 (p = 0.01) and from 12.9 to 17.4 (p = 0.02) respectively. No revisions were required for aseptic loosening or failure of fixation. The radiographs did not reveal any signs of osteolysis or lucency. The mean levels of Cr, Co and Ti were 1.85μg/l (0.8–3.2). 1.24μg/l (0.5–1.86) and 9.62μg/l (5–18) respectively. Ti > 10μg/l was noted in six patients; Ti > 10 μg/l and Cr > 2μg/l in five patients. There was no correlation of metal ion levels with size of the implants, activity level, gender, clinical scores or cup inclination.

Discussion: The mean Co and Cr levels observed in this series were similar to those reported in the literature for standard THA (cementless press fit cups). Ti levels have only been reported in rare studies so that comparison with other series is hazardous. The Ti level observed here appeared to depend on the femoral stem resurfacing (in our series, the porous surface of the stem was coated with a Ti-6Al-7nB alloy).

Conclusion: Cementing the metal-on-metal bearing in the supporting inlay appears to be a reliable and attractive technique for this young and active population. Levels of Cr and Co in blood were the same as reported for standard implants. These levels of metal ions should be followed to confirm the long-term results.

Purpose of the study: Locked implants have yielded favourable results for femoral bone reconstruction for revision total hip arthroplasty, but defective integration has also been reported due to insufficient bioactive coating. The purpose of this work was to evaluate a locked pivot with a two-third proximal hydroxyapatite coating.

Material and methods: From 1996 to 2007, 158 femoral implants (Linea™) were implanted for hip arthroplasty revision. The 143 cases with more than one year follow-up were reviewed (14 deaths, 1 lost to follow-up); 83 revisions for aseptic loosening, 41 periprosthetic fractures, 19 revisions in an infected context. Patients were reviewed retrospectively by a non-operator observer. These were older patients (mean age 68 years, range 31–93) and 36 patients had complex situations requiring at least two prior prostheses; 25% had severe grade 3 or 4 (SOFCOT) bone lesions and 59% diaphyseal damage.

Results: Clinical improvement was significant, the Postel Merle d’Aubigné score improved from 7.7 + 4.3 (0–17) to 15.6 + 2.2 (8–18) at mean 50 months (14–131) (p< 0.001). At last follow-up, 14 patients (10%) reported thigh pain and only seven pivots (5%) had not achieved Engh osteointegration (five with thigh pain two without). There were no fractures. There was on non-union of the femorotomy. According to the Hoffman index, femoral bone regeneration was significant at the metaphyseal and diaphyseal levels. Eighteen of the 19 infections cured, all periprosthetic fractures healed. The implant survival was 88.9% at 91 months (65–96.7%). There were five pivot replacements for non integration and/or thigh pain which resolved in all cases; there were no other pivot replacements. The quality of the metaphyseal and diaphyseal filling was predictive of the quality of the bone fixation of the pivot (p< 0.01).

Discussion: Compared with older models of locked pivots, this implant reduced the rate of thigh pain while allowing constantly satisfactory bone reconstruction. The metaphyseal and diaphyseal filling index is the main factor predictive of clinical and radiological success by favouring osteointegration. Maximal filling, obtained with a full range of implant diameters and lengths, contributes to this good result.

Purpose of the study: Hip resurfacing (HR) is becoming popular again with the advent the the metal-on-metal bearing. This type of surgery is proposed for young, often very active, patients for whom restoration of optimal hip joint range of motion constitutes and important objective. The purpose of this work was to analyse anterior translation of the femoral component to optimise joint range of motion (particularly flexion).

Material and method: From September 2007 to May 2008, 68 hip resurfacing prostheses were implanted in 66 patients aged on average 45 years (range 19–61). All procedures were performed by the same operator using a posterorlateral approach and the same surgical technique. Anterior head-neck offset was a constant objective. The Postel-Merle-d’Aubigné and Harris scores as well as the Devane classification and the WOMAC and the SF-12 were noted. Joint range of motion was noted preoperatively and at last follow-up by and independent operator. Anterior head-neck offset was measured radiographically on the Dunn view using an original technique and calibrated by the Imagika software according to the known diameter of the implants.

Results: All clinical scores as well as the activity level and the subjective scores improved significantly. There were no revisions. The mean anterior head-neck offset was 4.5 mm (range 2–9). Significant correction was observed for gain in postoperative flexion and increased offset (p< 0.005). The group of patients who had an anterior offset considered to be significant (> 4 mm) exhibited significantly better flexion than the group of patients with a small anterior offset.

Discussion: Hip resurfacing has a poor head-neck ratio, depending on the patient’s anatomy, which compares unfavourable with conventional hip prostheses (THA). Nevertheless, the joint range of motion after resurfacing, as observed in our study and in the literature, does not show any decline compared with THA. The greater gain in flexion is an important factor to take into consideration, especially in a young active athletic subject. Each millimetre of gain in anterior offset produces a significant increase in flexion. This offset can be improved by the surgical technique (implanting the femoral component tangentially to the posterior cortical), but also by the design of the resurfacing prosthesis (thick femoral component, increased cement sheath). After hip resurfacing, anterior offset appears to be an essential biomechanical factor for restoration of joint motion.

Purpose of the study: Drilling along yields disappointing results for osteonecrosis of the femoral head due to the high failure rate despite prolonged rest and also because of the risk of fracture. To prevent these problems, we have developed a new drilling technique which was evaluated prospectively.

Material and methods: The procedure performed percutaneously uses a lateral cortical orifice measuring 5mm, non-concentrated autologous bone marrow was injected after drilling. Osteoinductive protein (BMP7) was associated in random fashion (groups BMP+ and BMP−). Ficat stage 1 and 2 necrosis was included. Outcome was the rate or revision for prosthesis.

Results: Forty hips (36 patients) were included and assessed at mean four years (range 2–6). The necrosis was related to: alcoholism (n=5), cortisone (n=25), barotraumas (n=2), metabolic disease (n=4), idiopathic condition (n=4). Group BMP- (drilling+bone marrow) included 24 hips and group BMP+ (drilling+bone marrow+BMP7) 16 hips. The groups were comparable regarding necrosis stage (15% stage 3, 65% stage 2, 20% stage 1) and mean Koo index (27 BMP+ vs 34 BMP-; NS). There were no infections and no fractures despite immediate and complete weight-bearing. The revision rate for prosthesis was higher in the BMP- group (67%) than in the BMP+ group (43%) but the difference did not reach significance (p=0.10). The failure rate was not affected by the severity of the necrosis in the BMP+ group: all stage 3 hips were revised in the BMP- group versus none in the BMP+ group. The only variable predictive of revision for prosthesis was the Koo index (p=0.02).

Discussion: Adjunction of BMP did not improve significantly the success rate of drilling with bone marrow adjunction but adding BMP appeared to limit the unfavourable impact of server necrosis observed in the BMP- group. To reach a statistical power of 80%, 40 cases would be needed in each arm. This threshold has not yet been reached. It can be noted however that the proposed method does ensures early weight bearing without the risk of complications. Similarly, since it is a percutaneous procedure, later arthroplasty is not compromised. The principle confounding factor, the richness of the bone marrow, was not assessed, motivating a new randomized trial with measurement of CFU-F.

Introduction: The prosthetic impingement occurs if the range of motion of the hip exceeds implant mobility or in case of component malorientation. This phenomenon is rarely studied in the literature and most data have come from sporadic cases. This study was designed to assess the frequency and the risk factors of this phenomenon.

Material: The frequency and the severity of the impingement were calculated from a continuous series of 413 cups retrievals. These cups were examined macroscopically twice by two independent observers. The cam effect was noted as: absent, grade 1 (visible at gross inspection but measuring < 1 mm), grade 2 (notch measuring 1–3 mm), grade 3 (notch measuring > 3 mm). The risk factors were analyzed for 298 retrievals that had complete clinical charts.

Results: Among the 413 cups explants, the frequency of impingement was 51.3 percent (grade 3 in 12% and grade 2 in 24%). The impingement was the reason for removal in only 1.7 percent (only for hard bearings), meaning that impingement was mainly an unexpected event (98.3 percent). The impingement was more frequent when revisions were performed because of instability (80 percent; odd-ratio 4.2 (1.1–16.2)) than for loosening (52%) osteolysis (59%) or infection (38%) (p =.002). Likewise, impingement was more frequent when the sum of hip motion exceeded 200 degrees (sum of motion in the 6 degrees of freedom of the hip) (66% versus 45% if the sum was below 200°). The other risk factors were: use of heads with skirts (78% versus 55%), liner with an elevated rim (73% versus 55%), and head-neck ratio below 2.

Discusssion and conclusion: This study underlines the impingement is common when assessing cup retrievals (over 50 percent). One should be aware of impingement when performing hip replacement in patients having a high range of motion. This situation may require prostheses with a high head-neck ratio, as well as use of computer-assisted surgery. One should avoid liners with elevated rim as well as heads with skirts to prevent dislocation, particularly when other risk factors are detected.

Introduction: Cementless revision hip arthroplasties require a stable initial fixation that does not compromise a subsequent bone reconstruction. In case of severe femoral bone loss, stems usually requires distal fixation that may induce stress shielding and finally reduce the spontaneous bone reconstruction. We introduced the use of distally locked revision stems in 1993 hoping strong fixation and bone reconstruction. The goal of the current study was to assess if these components fulfill these two objectives.

Materials and Methods: 101 cementless femoral revision stems with distal locking by screws (Ultime™ Wright-Cremascoli) were inserted from 1993 to 2001. These stems were smooth distally and porous coated with or without HA 1/3 proximally. The indication to use these components was severe bone loss (Paprosky grade IIC and III in 51%) when press fit distal fixation could not be obtained. The use of bone graft was limited to segmental defects or to treat trochanteric non-union. An extended trochanteric osteotomy was performed in 89%. The revision was performed because of aseptic loosening in 43,4%, periprosthetic fracture in 24,2% and infected loosening in 25,2%. The results were assessed after a mean follow-up of 6 years (5–12).

Results: 13 patients deceased and 2 were lost for follow-up. All the extended trochanteric osteotomies healed. Merle d’Aubigné hip score increased from 8.3 to 13.4, but thigh pain was observed in 44%. Bone reconstruction was significant according to Hoffman index at 3 levels of assessment. The 5-year survivorship was 87% considering aseptic revision for any reason. Seventeen repeated femoral procedures were performed: 9 related to thigh pain (because there was no proximal osteointegration) that were revised for short primary stems, 8 because of stem fractures (all occurred at the level of the proximal hole with the same stem size because there was no proximal fixation as long as the stems were smooth or without HA-coating.

Discussion: This serie has the longest follow-up using locked revision stems. Despite severe pre-operative bone loss, primary fixation and significant bone reconstruction were obtained for all the cases without extensive bone grafting. The major weakness, thigh pain and stem break, were related to unadequate femoral coating for these cementless stems that did not achieved osteointegration. Conversly, the reoperations were simple, allowing the use of short primary designs as bone reconstruction was achieved in all cases without extensive bone grafting. These locked stems allow a strong primary distal fixation that does not compromise bone regeneration. An improvement of femoral coating (extension to 2/3 and use of hydroxyapatite) may reduce the rate of thigh pain and reoperation.

Purpose of the study: The incidence of revision hip arthroplasty is increasing. In order to overcome certain problems related to loss of femoral bone stock, an original technique was developed combining fragmented allograft material and a metallic mesh with a non filling stem cemented distally in a healthy zone to ensure stability.

Materials and Methods: The clinical data (Postel-Merle-d’Aubigné, PMA score) and radiographic findings (implant migration, loss of bone stock using the SOFCOT and PAPROSKY classification, quality of cementing, filling, and graft aspect, graft lysis, periprosthetic lucency, final aspect of the graft) were collected retrospectively. The operation and the technical difficulties and intraoperative complications were noted.

Results: We report a series of 32 hips treated with this technique and having a mean follow-up of 12.5 years (range 8–20 years). The population studied had particularly significant bone loss (78.2% SOFCOT stage 3 and4). These hips underwent revision for aseptic loosening. The implantation technique required a femoral window in 39.1%. Preventive cerclage was often used (39.1%) but did not prevent fracture or missinsertion in 30.4%. The PMA score improved significantly from 10.6 (7–18) preoperatively to 17 (12–18) at last follow-up. Radiologically, femoral bone regeneration at last follow-up had an aspect of corticalisation in 63.6% of hips, and of cancellous trabeculation in 36.4%. Femoral implant survival was 100% at eight years, and 92.8±6.88% at mean follow-up of 12.5 years. There was only one revision at eleven years for secondary osteolysis related to polyethylene wear in a very active subject implanted before the age of 50 years.

Discussion: The clinical and radiographic results are very satisfactory for this series of femoral revisions using an impacted fragmented graft material and with the longest follow-up reported in the literature. Distal fixation limited migration observed when the stem is entirely cemented in the graft, but did not affect reconstruction which demonstrated long-term stability. This technique, initiated in 1986 without a specific instrument set, had now demonstrated its long-term reliability. The only problem is the length of the operation and the complications related to femoral preparation.

Implantation of a large-diameter femoral head prosthesis with a metal-on-metal bearing surface reduces the risk of dislocation, increases the range of movement, minimises the risk of impingement and, in theory, results in little wear.

Between February 2004 and March 2007 we implanted 100 consecutive total hip replacements with a metal-on-metal bearing and a large femoral head into 92 patients. There were 51 men and 41 women with a mean age of 50 years (18 to 70) at the time of surgery.

Outcome was assessed using the Western Ontario McMaster University osteoarthritis index and the Harris hip score as well as the Devane activity score. These all improved significantly (p < 0.0001). At the last follow-up there were no cases of dislocation, no impingement, a good range of movement and no osteolysis, but seven revisions, two for infection and five for aseptic loosening. The probability of groin pain increased if the other acetabular component inclination exceeded 50° (p = 0.0007). At 4.8 years of follow-up, the projected survival of the Durom acetabular component, with revision for any reason, was 92.4% (sd 2.8) (95% confidence interval 89.6 to 95.2).

The design of the component made it difficult both to orientate and seat, which when combined with a poor porous coating, produced unpredictable fixation and a low survival at five years.

Purpose of the study: Theoretically, long-term functional and radiographic degradation is predictable after ankle fusion, but sound evidence from consecutive analysis of the same cohort is lacking. The purpose of this study was to evaluate the same cohort of patients who underwent ankle fusion.

Material and Methods: The cohort included 52 ankle fusions which had been analyzed in 1984 at seven years (2–22 years) of follow-up then again in 2000 using the same evaluation criteria. Among the 52 patients, six were lost to follow-up, 20 had died and one had undergone leg amputation. The second analysis thus included 25 patients (18 men and 7 women), mean age 62±12.6 years (40–94) at the 2000 assessment performed 23±4.5 years (19–36 years) after the fusion. Functional outcome was assessed with the 100-point Duquennoy scale. Osteoarthritis of the subtalar and mediotarsal joints were assessed preoperatively and at follow-up using the same scale.

Results: The functional outcome did not deteriorate significantly between 1984 and 2000. The mean score was 65.8±22.6 (19–92) in 1984 and 64.7±18.3 (34–90) in 2000 (p=0.67). Fifteen patients (60%) had a good or very good outcome at seven years, and 14 (56%) at 23 years. Between 1984 and 2000, ten patients improved their score (on average 10.4 points, range 1–21 points), two had an unchanged score and thirteen a lower score (on average 10 points, range −1 to −24). Ten of these thirteen patients developed severe intercurrent conditions explaining the degradation. At last follow-up, sixteen ankles were pain free or nearly pain free. Twelve patients considered their ankle as a forgotten problem and had no regrets concerning the operation. The evolution of the subtalar joint in 16 cases (nine fusions including five at the same time as the ankle fusion and four performed within four years) showed that all developed early osteoarthrtic degradation with aggravation between 1984 and 2000, leading in the majority of cases to severe degenerative disease. This osteoarthritis was painful in less than one-third of the cases (including the four secondary subtalar fusions and the four sub-talar fusions which were painful at mobilization). The mediotarsal joints degradation was later and less severe than for the subtalar joint with a majority of moderate osteoarthritis. Ten ankles exhibited compensatory hypermobility of the forefoot measured at more than 15° without pain.

Discussion: This long-term follow-up with two successive assessments using the same evaluation criteria did not demonstrated late degradation of function expected after ankle fusion. It did show however the presence of radiographic degradation of the subtalar joint but with little clinical expression at a minimal follow-up of 19 years. There was no need for complementary fusion between 4 and 23 years follow-up.