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.

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.

Purpose of the study: These fractures, and the patients, are generally unstable. Mortality associated with these fractures remains high. It is mainly due to the haemorrhagic risk of the presacral venous plexus and the iliac system. Different techniques have been described to control the haemorrhage: pelvic girdle, embolisation, ligature of the iliac arteries, pelvic packing, pelvis clamp or external fixator. Our objective was to analyse our series of fractures of this type in order to optimise patient outcome.

Material and methods: A prospective study was undertaken from January 2003 to December 2006. Among 450 multiple injury patients, 68 presented an unstable fracture of the pelvis, type B or C. The 38 patients included in this series were haemodynamically unstable. The mean ISS for these patients was 53, mean age 38.6 years (range 24–51). Fractures were diagnosed on plain x-rays of the pelvis, ap view, completed by a total body scan.

Results: All patients were victims of high-energy traffic accidents and were managed using the ATLS protocol. Five patients died early despite intensive care. The patients were divided into three groups: group X: 19 patients treated with a first-intention external fixator, with or without arteriography, 18 patients survived, 94%; group Y: 8 patients treated with a first-intention external fixator with arteriography and followed by laparotomy, 7 patients survived, 87%; group Z: 6 patients had laparotomy without an external fixator, 6 patients died, 100% mortality.

Conclusion: In our experience, the best way to control bleeding associated with unstable fractures of the pelvis is as follows: pelvic girdle at the scene of the accident to the emergency room, emergency external fixation followed by laparotomy if the ultrasound is positive. False positives occur due to suffusion of the retroperitoneal haematoma. Emergency laparotomy without prior external fixation of the pelvis lead to 100% mortality in our series. Similarly pelvic packing or the retroperitoneal approach cannot be proposed without exploration.

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.

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.

More than a million hip replacements are carried out each year worldwide, and the number of other artificial joints inserted is also rising, so that infections associated with arthroplasties have become more common. However, there is a paucity of literature on infections due to haematogenous seeding following dental procedures. We reviewed the published literature to establish the current knowledge on this problem and to determine the evidence for routine antibiotic prophylaxis prior to a dental procedure.

We found that antimicrobial prophylaxis before dental interventions in patients with artificial joints lacks evidence-based information and thus cannot be universally recommended.

We present two patients with swelling of the groin following metal-on-metal total hip replacement without radiological signs of component loosening. MRI in both patients showed a round shaped intrapelvic lesion ventral to the femoral head. During surgery we found cystic structures filled with fluid and necrotic masses. After resection the metal head and insert were changed to a ceramic head and a polyethylene insert.

Although two different kinds of CoCrMo alloy were used in the metal-on-metal THR (Sikomet: low carbon content-Metasul: high carbon content) histopathological analysis in both cases showed typical morphological signs of hypersensetively determined inflammation. Despite the distinct soft tissue reaction bony component integration was unaffected.

In our opinion open resecion of the cystic lesion and changing of the metal-on-metal articulation is the treatment of choice.

As we do not have any reliable testing for clinical use to predict a hypersensitive reaction to metal wear after implantation of metal-on-metal THR this articulation surface should not be used in cases where allergy to metal is suspected.

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.

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.