Aims

The diversity of femoral morphology renders femoral component sizing in total hip arthroplasty (THA) challenging. We aimed to determine whether femoral morphology and femoral component filling influence early clinical and radiological outcomes following THA using fully hydroxyapatite (HA)-coated femoral components.

Purpose of the study: Several series have been reported on arthroscopic treatment of anterior instability. Few authors have focused on patient outcome after recurrent instability following arthroscopic stabilisation. Did these patients undergo revision surgery? What proportion? What were the results of secondary surgical coracoids block?

Material and methods: This was a retrospective analysis of 53 failures after arthroscopic stabilisation collected among a cohort of 182 patients who underwent surgery in our institution between 1988 and 2006. At last follow-up, shoulder function was noted using the Walch-Duplay score. The degree of joint degenerative disease was noted on the radiographs using the Samilson classification.

Results: Mean time to recurrence after arthroscopic stabilisation was 21 months (range 3–114). Patients were reviewed at mean 68 months. Twenty-four patients (45%° had not had revision surgery: 17 (32%) had declined a new operation and 7 (13%) had a unique episode of instability. Twenty-nine patients (55%) had revision surgery: 27 underwent an open procedure in our institution for a coracoids block. The revision was performed in another institution for two patients who were excluded from the analysis. Mean time between the two operations was 29 months. At last follow-up, 89% of the reoperated patients were satisfied. The mean Walch-Duplay score was 83.6/100 (activity=18.5; stability=15.9; pain=23.9; mobility=24.2). The Duplay score was 100 for 48% of the reoperated patients; 41% had persistent apprehension. Three patients (11%) developed recurrent dislocation at a mean 23 months (19–29). Among the 53 patients included in the study, 26% had moderate osteoarthritic lesions (Samilson 1 or 2). The reoperated patients were free of such lesions. Hyperlaxity, age, and sport practiced did not have any impact on surgical revision.

Discussion: In this overall series of 53 patients, 20 (37%) retained an unstable shoulder. Among them, 17 had declined new surgery. Eleven percent of the reoperated patients developed subsequent recurrence. This rate is higher than after first-intention blocks. Published series of arthroscopic revisions reported a higher recurrence rate (Kim, Arthroscopy 2002: 21 % recurrence; Neri, JSES 2007: 27 % recurrence).

Conclusion: The Latarjet block is the treatment of choice after failure of arthroscopic stabilisation, despite a high recurrence rate.

Purpose of the study: There are several goals for the treatment of septic nonunion of the leg: control the infection, achieve healing, preserve function. The purpose of this work was to report the results obtained with a two-phase technique using a cement spacer.

Material and method: From 1994 to 2007, 27 patients were treated for a septic nonunion of the tibia (19 proven, 8 suspected). There were 22 women and 5 men, mean age 39 years (range 16–66). The first phase of the surgical technique involved “cancerological” cleaning and insertion of an antibiotic cement spacer. Osteosynthesis was performed if necessary. Antibiotics were adapted to sample results. The second phase involved an autologous bone graft with osteosynthesis after biological markers had returned to normal and an antibiotic window. Antibiotics were then discontinued if samples were negative. Patients were reviewed with physical examination, radiology, and laboratory tests at one year.

Results: Mean follow-up was 4 years (range 1–11). At the first phase, mean bone defect after cleaning was 5 cm (range 3–8); osteosynthesis procedures were required for 22 patients (81.5%), mainly with plate fixation. Mean time to the second phase was 4 months (range 1.5–22). At the second phase, bone loss was filled with isolated bone fragments (44%) or associated with a tricortical graft (52%) or a plate nail combination (37%). Bacteriological samples were negative for 25 patients after the second phase. Six patients required surgical revision for recurrent aseptic non-union (22%).

Discussion: All patients healed at mean one year with a tolerable misalignment in 37%. At last follow-up there were no cases of infection. Nineteen patients had residual stiffness of the ankle or knee but 80% had resumed their sports activities and 85% their occupational activities.

Conclusion: A two-phase surgical treatment of septic non-union of the leg is effective. We were able o achieve cure of the infection in all patients with per primam healing in 78% in addition to an acceptable functional outcome. The spacer offers the advantage of preparing a bed for the graft and preserving autonomy between the two phases.

Purpose of the study: The PFM-R (Zimmer) prosthesis is a straight modular stem made of sanded titanium designed to favour spontaneous bone reconstruction. The purpose of this work was to analyse the clinical and radiographic results of this implant.

Material and methods: This was a consecutive prospective series of 154 patients who underwent surgery from 1998 to 2007 (15 first-intention prostheses and 139 revisions for severe loosening [Paprosky stages 3 and 4]). Revision included a clinical evaluation (PMA score) and radiographic assessment (migration, bone regeneration, stress shielding, osteointegration, Le Béguec score) as well as a survival analysis.

Results: At mean 4.6 years follow-up (1–10 years), three patients had died, two were lost to follow-up and 18 implants were removed, 11 for infection, six for migration and one for defective technique. The PMA score improved from 8 (0–16) to 15.8 (5–18). Mean pivot impaction was 4 mm (0–50), statistically dependent on initial bone stock, form of the isthma, the corticomedullary index in the implantation zone, length of anchor, and time to weight bearing, but not femorotomy nor zone of primary stability. Bone stock was good in 73% at poor in 27% (15 stress shielding, nine infectious osteolysis, 16 absence of bone regeneration). Stress shielding was related to length and diameter of the implanted pivot (p< 0.05). Bone regrowth was statistically dependent on the number of prior operations, type of stem explanted (cemented), initial bone stock, form of the isthma and quality of the surgical reconstruction. The implant was osteointegrated in 128 cases (86%). The analysis of the prosthetic anchoring showed that primary stability was mainly diaphyseal (90%) then secondarily global (83%). Osteointegration depended statistically on the number of prior operations, initial bone stock, form of the isthma and bone regrowth, but not femorotomy. The overall Le Béquec score reached 14.7 (2–20) at last follow-up.

Discussion: The PFM-R enabled bone regeneration and osteointegration in the majority of patients. The quality of the femoral reconstruction around the implant appears to be fundamental. Massive stems should be avoided as they lead to stress shielding. The limits for use of this implant are osteopenia and absence of an isthma.

Purpose of the study: Osteotomy of the first metatarsal has become the gold standard treatment for hallux valgus. We report a study on the changes in radiographic findings as a function of the degree of translation of the distal fragment of the metatarsal during scarf distal wedge osteotomy.

Material and methods: From the cohort of patients who underwent hallux valgus surgery in our unit, we collected 118 anteroposterior x-rays of the forefoot. Computer-assisted image processing established a trigonometric analysis of each forefoot before and after standardised virtual surgery. Variations in standard morphological measurements (phalangeal valgus: M1P1; metatarsal varus: M1M2; orientation of the joint surfaces of the first metatarsal: proximally (PMAA) and distally (DMAA).

Results: The successive translations significantly modified all of the morphological measurements. For M1M2, intermediary translation corrected the metatarsal varus (< 5) in 72% of the cases, maximal translation in 97%. For the M1P1 angle, intermediary translation only corrected the phalangeal valgus (< 8) in 44% of cases, maximal translation in 31%. For the DMAA angle, intermediary translation corrected the distal articular orientation (< 6) in 66%, maximal translation in 97%. Distal translation of the first metatarsal aggravated the obliquity of the proximal joint surface from a mean 1.57±4.5 to 7.7±4.7, with intermediary translation and to 13.92±4.9 with maximal translation.

Discussion: Considering the large number of techniques proposed, the choice of one osetotomy model is reductive, but it does demonstrate via a geometric application the limits of osteotomy translation of the first metatarsal for the correction of hallux valgus.

Introduction: Treatment of acetabular defects can be difficult, especially in case of roof destruction. Since 9 years, we use a variant of Paprosky’s technique which consists in rebuilding the roof by structural allograft and acetabular reinforcement ring. The purpose of this study is to present this technique and the follow up results.

Patients: This retrospective study concerns 21 patients (23 hips) with severe acetabular bone loss (8 cases of stage 2 and 15 cases of stage 3 of Paprosky): 4 septical and 19 aseptical loosening. Between 1998 and 2005, all patients were operated with the same surgical technique using an allogeneic structural allograft (femoral head or distal femur) and an acetabular reinforcement ring (20 of KERBOULL, 3 of GANZ) associated with a cemented PE cup.

Method: Review included a clinical and X-ray evaluation (analysis of the refocusing of the hip, the positioning and the stability of implants and the graft incorporation).

Results: Mean duration of follow-up is 3,5 years [1–8,3]. Preoperative PMA score rised from 6,6 [0–12] to 15,8 [12–18] in postoperative. There was no peroperative complication. After surgery, 2 cases of early hip dislocation required PE block; 2 cases of sepsis were treated, one by washing and one by a surgical revision. In 60% of cases, immediate total weight bearing was allowed.

The immediate postoperative X-rays showed that the rotation center of the hip was 5,2 mm [0–10] far from the ideal rotation center (26% of cases: 0 mm) and the PE cup was implanted with a lateral inclination of 42,5° [30–55]. In postoperative X-ray follow up, one case of acetabular aseptic loosening was found which didn’t need hip revision. In all other cases no modification of implants position neither of hip rotation center was noted. In 79% of cases, we had total graft incorporation; in 17% of cases, an non evolutive radiolucent area between graft and bone and in 4% of cases (loosening) a graft migration.

Conclusion: The use of a structural allograft combined with acetabular reinforcement ring allows hip reconstruction in severe acetabular bone loss with good medium term results.

Purpose of the study: Orthopedic treatment is generally proposed for minimally displaced fractures of the scapula. Surgery is indicated in the event of medialization or disorientation of the glenoid cavity. The purpose of this study was to identify rules for management of problematic cases.

Material and methods: This retrospective study included 27 patients, 22 men and five women, mean age 46.7 years (range 22–83 years). The fracture was limited to the scapula in 17 and was part of thoracic syndrome in ten. Injury to the plexus was noted in three patients. Associated lesions were noted in 55% of patients. Orthopedic treatment was proposed for 15 patients (group 1) and surgical treatment for 12 (group 2): neck osteosynthesis (n=4), clavicle fixation (n=5), combined osteosynthesis (n=3).

Results: Mean follow-up was 47.3 months; 21 patients were reviewed (four lost to follow-up, two deaths). Per primam healing was achieved for all fractures. There were no complications related to the surgical procedure in group 2 and no secondary displacement in either group. Mean time to resumed occupational activity was four months (range 0.2–25 months): 2.2 months (1–5 months) in group 1 and 5.5 months (0.2–25 months) in group 2. The age and gender weighted Constant score for the overall series was 96.2% (range 80–100%) with 81% excellent and very good functional outcomes. In group 1, the Constant score was 95.4% (81–100%) with 70% excellent and very good functional outcomes. It was 97% (80–100%) in group 2 with 91% excellent results. At last follow-up, there was only one case of Samilson grade 2 osteoarthritis.

Discussion and conclusion: The functional outcome observed after treatment of scapular fractures is satisfactory. Orthopedic treatment should be reserved for non-displaced fractures. If there is significant medial offset of the glenoid cavity or instability, osteosynthesis of the scapular neck is indicated, possibly with reinforcement by fixation of the clavicle. Isolated osteosynthesis of the clavicle stabilizes the scapular ring but does not reduce the scapular fracture.

Purpose of the study: Resection of the lateral quarter of the clavicle is an effective treatment for painful acromio-clavicular arthropathy. An open procedure can create a disgraceful or painful scar or be associated with secondary instability and muscle weakness. Arthroscopic resection would avoid these complications.

Material and methods: Between 1992 and 2002, 35 patients were treated arthroscopically for isolated painful acromioclavicular arthropathy after failure of medical treatment. Twenty-seven patients (mean age 44 years) were reviewed clinically (Constant score, subjective outcome, stability) and radiographically (quality of resection, coraco-clavicular space, ossification) at more than two years follow-up. Acromioplasty was performed in all cases to improve exposure in 14 or because of an aggressive acromion (n=7). A scarf orthesis was worn to prevent pain. Self-controlled rehabilitation exercises were proposed.

Results: There were no postoperative complications excepting one case of retractile capsulitis in the context of an occupational accident. Excluding this case, mean sick-leave was five weeks (range 3–20). At mean follow-up of seven years, all scars were pain free and minimally visible. There was no problem with frontal or sagittal instability. The Constant score improved 24 points on average compared with the preoperative score with a significant gain for pain (+9 points). Two patients were disappointed: one retained a sequellar capsulitis and one persistent pain after insufficient resection. On average, the resection measured 10 mm (range 6–20 mm). Three patients had an insufficient posterosuperior resection. The coracoclavicular interval remained unchanged in all cases and four patients presented secondary ossification of the resection zone. Two patients were sensitive to acromioclavicular palpation with a positive cross arm test (one had an insufficient resection and the other ossifications at last follow-up).

Discussion and conclusion: Arthroscopic acromio-clavicular resection reduced operative morbidity. The operation does not destabilize the joint. The total joint surface area can be resected to avoid a residual pos-terosuperior impingement which would be a source of persistent pain. The presence of secondary ossifications in the zone of resection has led us to propose NSAID treatment although the prophylactic effect remains to be demonstrated.

Purpose of the study: The revision modular femoral prosthesis (PFM-R) (Centerpulse) uses a cone-shaped straight femoral stem with winglets for press-fit revision fixation in the femoral shaft. The risk of secondary migration further into the shaft is well known. The purpose of this paper was to assess the degree of PFM-R stem migration and to search for predictive factors in order to better ascertain the limits of this type of revision anchorage in the femoral shaft.

Material and methods: Fifty-three files (48 patients) were reviewed retrospectively at minimum none months follow-up. Mean patient age was 56.6 years. Revision was required for loosening (SOFCOT classification): grade 1 (n=5), grade 2 (n=8), grade 3 (n=17), grade 4 (n=10). For 13 hips, the implant to be replaced was not cemented (monobloc stem, infection), or a first-intention PFM-R.

Results: Mean migration was 4.1 mm (0–17 mm), less than 5 mm in 73.5% of cases. There was no correlation between migration and SOFCOT grade. Conversely, there was a significant difference in migration between the grade 1 and grade 3B and between Paprosky grade 1 and 4 (p=0.05). The degree of migration was correlated with the length of the persistent isthma (p< 0.0001), with the morphology of the isthma [conic/inverted conic (p< 0.01), conic/cylindric (p< 0.051)], with the cortical index (p=0.06), the length of the anchor wings (p=0.051), but not with the length of the femorotomy bridge. The length of the wing anchorage was correlated with the length of the persistent isthma (p=0.002) and with the morphology of the isthma [(conic/inverted conic p=0.02), cylindric/inverted conic (p=0.02)], but did not increase significantly with bridging length. There was a trend towards migration in osteoporotic bone (p=0.07).

Discussion and conclusion: Use of a straight stem for anchorage in the femur is associated with secondary migration which depends on the quality of the bone in the anchorage zone and the extent of the press-fit. The persistence of a cone-shaped or cylindrical isthma measuring greater than 4 cm associated with a cortical index greater than 45% and a long wing anchorage can provide excellent primary stability. It would be useless to use long stems since they do not increase the quality of anchorage. The absence of an isthma and the presence of osteoporosis are limitations for this concept.

Purpose: The purpose of this study was to analyse changes in foot dynamics secondary to tibiotalar arthrodesis and examine the adaptation mechanisms induced by wearing shoes.

Material and methods: A 3D gait analysis was performed (Vicon 370) in ten patients with a tibiotalar arthrodesis fixed in a neutral position and in ten matched controls. Recordings were made in three conditions: walking barefooted, walking at a comfortable self-chosen speed wearing shoes, and walking at maximal speed wearing shoes. We measured tibial inclination in the sagittal plane, knee flexion, and the tibia-forefoot angle produced at heel lift-off. The distance of the ground reaction force (GRF) from the heel was measured during the weight-bearing phase and at lift-off. Statistical comparisons were made with the contralateral side and the control group.

Results: Heel lift-off came significantly earlier on the arthrodesis side compared with the contralateral side and with the control group. At heel lift-off, the knee was in complete extension in all three groups. The GRF moved forward more rapidly but remained more posterior on the arthodesis side at heel lift-off in comparison with the contralateral side and the control group. Wearing shoes enabled later heel lift-off on the arthrodesis side and increased tibial inclination at lift-off as well as decreased speed of the anterior displacement of the GRF. The GRF however remained more posterior than in the control group. At maximal walking speed, heelk lift-off came earlier on the arthrodesis side and at the same time a lesser anterior tibial inclination and a more posterior position of the GRF.

Discussion: Early heel lift-off on the arthrodesis side allows anterior inclination of the tibia to continue and to increase stride length. Heel lift-off however occurs when the GRF has not yet advanced to the metatarsophalangeal position, thus increasing stress on the rear and mid foot. Wearing shoes improves the kinematic parameters and decreases stress on the joints below the arthrodesis. Increased walking speed aggravates the perturbed foot dynamics when walking.

Purpose: Management of septic nonunion of long bones is a difficult challenge requiring a multidisciplinary approach. The purpose of this study was to report our results with a two-stage technique using a spacer (Masquelet technique).

Material and methods: Between June 1997 and July 2001, eleven patients were treated for septic nonunion (n=7) or suspected septic nonunion (n= =4). There were seven men and four women: mean age 38 years (26–51). Nonunion involved the humerus (n=1), the femur (n=1), and the tibia (n=9). The same surgical technique was used in all cases: “carcinologic” debridement with gap filling using antibiotic cement and osteosynthesis when necessary, followed by a second procedure two months later to remove the spacer and insert an autologous bone graft when laboratory results had returned to normal.

Results: Mean follow-up was three years (1–5). All patients achieved per primam bone healing within 4.5 months (3–6) despite a mean bone gap of 55 mm (15–100) after avivement. Intraoperative samples taken during the second procedure were negative and there was no recurrent infection or need for revision.

Discussion: This two-phase technique has provided encouraging results in terms of “infectious cure” and bone healing. A standardised approach to the treatment of septic nonunion of long bones as used in our centre should provide data validating this technique.

Purpose: In 1988, the conclusions of the SOFCOT symposium appear to condemn use of cemented implants for revision of loosened femoral elements. Eleven years later, at the 1999 Symposium, Vidalain demonstrated that cementing remains a reasonable alternative. The purpose of this retrospective analysis was to estimate long-term results of revisions using a long cemented stem without bone stock reconstruction.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent revision surgery with this technique. We retained for analysis 95 hips (15 lost to follow-up 25 deceased patients) in 66 women and 29 men, mean age 70 years at revision (42–86). The preoperative Postel Merle d’Aubigné (PMA) function score was 8/18. Femoral implants in place had been cemented in 80% of the hips. Using the SOFCOT criteria, 65% of the loosenings were stage II, 29.5% stage III. All were aseptic loosenings and the same revision technique was used in all cases: removal-replacement of both prosthetic elements, use of a long cemented stem without associated grafting.

Results: Mean follow-up was eight years (60–157). Thirty nine percent of the patients had early postoperative complications. The mean function score at last follow-up was 14.8/18 with 62.4% of the outcomes considered good or very good. Age, restitution of the rotation centre, quality of cementing, and stem/femur fit influenced the result significantly. Radiographic analysis showed a progressive lucent line in 32% of the hips, only 36% of the femoral stems were totally free of lucent lines. Cumulative actuarial survival was 87% at 14 years and fell to 65.5% considering certain radiographic loosening as the endpoint.

Conclusion: Use of a long cemented femoral stem for revision total hip arthroplasty provides acceptable long-term functional outcome. Results are significantly affected by imperfect technique. This type of implant, which destroys any hop for restoration of bone stock, should be reserved of elderly subject where a more “ambitious” procedure were be too risky.

Purpose: The purpose of this study was to assess long-term functional outcome after arthroscopic acromioplasty for full-thickness rotator cuff tears, to evaluate the efficacy of complementary procedures (biceps tenotomy, extended acromioclavicular resection), and to examine the course of anatomic lesions.

Material and methods: From 1988 to 1994, 141 full-thickness rotator cuff tears were treated by arthroscopic acromioplasty. Ninety-eight patients, mean age 60 years, were reviewed clinically, radiographically, and sonographically at more than eight years. The mean preoperative Constant score was 48.5 points. The tear involved the supraspinatus in 18 cases, the supraspinatus and infraspinatus in 40, the supraspinatus and the subscapularis in ten, and all three tendons in 20. Coronal extension showed a distal tear in four, an intermediate tear in 52, and a retracted stump in 32. Systemic acromioplasty was associated in 36 patients with tenotomy of the long head of the brachial biceps and in 44 with acromioclavicular extension.

Results: At mean follow-up of 10.7 years (8–13.5), the mean Constant score was 60 points. The clinical outcome was excellent or good in 39.7%, fair in 45.5%, and poor in 14.8. 62.5% of the patients were satisfied or very satisfied. The height of the subacromial space was 5.19 mm at last follow-up compared with 4.3 mm preoperatively. The antalgesic effect of biceps tenotomy was significant when the initial acromiohumeral space was less than 5 mm. This procedure did not produce any significant change in the subacromial height or development of osteoarthritis at last follow-up. Sonography showed stability of the size of the tear in 83.8% of the cases. The results were significantly less satisfactory when the initial tear involved the subscapularis or all three tendons.

Conclusion: The clinical results of arthroscopic acropmioplasty for full-thickness tears show long-term stability. Biceps tenotomy improves the antalgesic effect significantly, particularly if the subachromial space measures less than 5 mm preoperatively, without causing significant radiological degradation. Extension to the acromioclavicular level should be systematic in patients with acromioclavicular pain preoperatively and/or radiological anomalies.

Purpose: Acetabular reconstruction is particularly challenging in case of acetabular loosening with important loss of bone stock. The purpose of this retrospective study was to estimate long-term results after revision procedures using a fragmented allograft and a supporting ring.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent this procedure. Ninety-five files were reviewed (15 patients were lost to follow-up and 25 died). The 95 patients retained for analysis were 66 women and 29 men, mean age at surgery 70 years (range 42–86). The preoperative functional score (PMA) was 8/18. The acetabular implants in situ had been cemented in 62% of the cases and non-cemented in 38%. According to the SOFCOT criteria, 79% of the loosenings were associated with grade 3 bony lesions, 15.8% with grade 4 lesions and 5.2% with grade 2 lesions. In all cases, the acetabulum was reconstructed with fragments of allografts. An Eichler ring was used in 56% of the cases, a Ganz ring in 25%, and a Muller ring in 19%.

Results: Mean follow-up was eight years (60–157 months); 39% of the patients developed early postoperative complications including one dislocation and two haematomas. Mean functional score at last follow-up was 14.8/18 with 64% good or excellent results. Reconstruction of the centre of rotation was the only factor significantly affecting results. Radiographically, 85% of the cups presented no sign of loosening at last follow-up. The grafts were considered to be assimilated or unchanged in 81% of the cases, with partial or total lysis in 19%. Actuarial analysis of cumulative survival, considering surgical revision or clinical and radiographic loosening as the endpoint was 87% at 14 years.

Discussion: Fragmented allografts can be perfectly stabilised with a supporting ring to reconstitute bony stock of the acetabulum. Long-term clinical and radiographic results are encouraging.

Purpose: Posterior instability of the shoulder requires surgical treatment in involuntary forms and after failure of functional treatment. As for anterior instability, a bone block can be fashioned from an iliac graft or a pediculated graft harvested from the acromion. This retrospective analysis concerned the results obtained in eighteen consecutive cases.

Material and methods: This series included ten men and eight women, mean age 26 years (15–42) at time of surgery. Fourteen (77%) practised sports activities including four at competition level. Symptoms had persisted for four years on the average. For three patients (16%) posterior instability was expressed by recurrent luxation subluxation. For nine patients (50%) posterior subluxation was a common involuntary event. Six patients suffered from painful shoulders due to an unrecognised posterior instability accident. Diagnosis of posterior instability was establised by arthroscopy in seven patients (39%). For nine shoulders the intervention consisted in a screwed posterior iliac block associated with a tension procedure on the capsule (group 1). For the other nine shoulders the block was harvested from the acromion and pediculated on the deltoid (group 2).

Results: Mean follow-up for all patients was eight years. The Duplay score was 75 points at last follow-up. Twelve patients (85% of the athletes) were able to resume their sports activities, half at the same level. Nine patients were pain free. Six patients (33%) had persistent apprehension but did not present true recurrence at physical examination. The Duplay score was 69.4 points in group 1 (follow-up 12 years) and 82.2 points in group 2 (follow-up three years). Thirteen patients (77%) did not have any sign of joint degeneration at last follow-up. One patient had advanced stage IV degeneration related to an intra-articular screw. All patients felt their shoulder had been improved by surgery and one third were disappointed with the results.

Discussion: Use of a posterior block is an effective treatent for posterior instability giving results comparable with those obtained with anterior blocks in terms of shoulder stability, pain, recovery of motion, and subjective outcome. This procedure favours joint degeneration less than anterior stabilisation. Results obtained with pediculated acromial blocks are encouraging.

Purpose: Failure of the glenoid component is the main complication of total shoulder prostheses. When surgical revision is necessary, the surgeon has the option of a new implantation or non-prosthetic plasty (glenoido-plasty). The purpose of the present work was to analyse results obtained with these two techniques in order to propose proper indications.

Material and methods: This retrospective study included 16 patients, mean age 62 years at revision surgery. Fialures included loosening of a cemented glenoid implant (n=9) and failure of non-cemented implants (3 defective anchors, 4 unclipped polyethylene inserts). Mean time to revision was 39 months (2–178) after primary implantation. A new glenoid implant was cemented in nine patients (group A). Seven patients (group 2) had glenoidoplasty with an iliac graft in four.

Results: A mean follow-up of 37 months (19–73), the Constant score had improved from 18 points before revision to 52 points (+34). Two patients experienced a complication requiring a second revision (infection, instability) and one patient underwent subsequent surgery for biceps tenodesis. For the group with glenoidoplasty with iliac graft, insertion of an inverted prosthesis was achieved during a second operative time. In group 1, the mean Constant score at last-follow-up was 63 points (+45) with the pain score of 11, movement score of 29. In group 2, the mean Constant score was 37 (+19) with pain at 6 and motion at 16. In this group, the mean score was 48 points with a glenoid graft and 21 points with simple implant replacement.

Discussion: Revision surgery for a failed glenoid implant remains a difficult procedure but can be effective for pain relief and improved motion score. The small number of patients in this series makes it difficult to perform statistical analysis but the results do point in favour of prosthetic reimplantation when the bone stock is sufficient. For other patients, a graft would be preferable to simple implant removal. This would allow secondary revision if possible.

Purpose: Maisonneuve fracture is a rare variant of malleolar fractures. Standard surgical care is not well defined. We performed a retrospective analysis of operated patients to propose a system to determine adequate care as a function of the type of lesions observed.

Material and methods: This retrospective analysis involved 20 patients who underwent surgery for Mai-sonneuve fracture between 1989 and 2000. Mean age was 42 years at surgery. Male gender predominated (16 patients). Seven patients (group 1) were treated without a syndesmodesis screw (osteosynthesis of the medial malleolus in six cases and suture of the medial collateral ligament in one). Thirteen patients (group 2) were treated via a first lateral approach and a syndesmodesis screw followed by a complementary medial approach in seven cases (two cases of medial malleolus osteocynthesis and five cases of medial collateral ligament suture). The Duquennoy functional score was determined at last follow-up. Quality of the reduction and presence of degenerative disease were determined on standard x-rays and computed tomographies.

Results: Mean follow-up was four years nine months (range 1–10 years). No case of tibiotalar diastasis was observed at at least one year. Among the five patients reviewed clinically, outcome was excellent in four and fair in one. In group 2 (syndesmodesis), we found two cases of residual diastasis and two cases of tight syndesmosis at at least one year. Among the nine patients reviewed clinically, outcome was excellent in three and fair or poor in six.

Discussion: This retrospective analysis collaborates the few data in the literature on Maisonneuve fractures. Ligament injury has varied greatly (with or without tear of the medial lateral ligament, more or less full thickness rupture of the interosseous membrane). In our experience, it is always difficult to reduce the diastasis via the primary lateral approach. Conversely, the primary medial approach has, after testing, enabled eliminating the syndesmodesis screw, with its recognised deleterious effects, in seven cases.

Conclusion: Due to the diversity of the ligament injuries encountered in patients with Maisonneuve fractures, we have adopted the following surgical strategy. If there is diastasis, after confirmation of any injury to the medical compartment, medial approach to suture the medial collateral ligament or osteosynthesis of the medial malleolus: in the case of diastasis reduction, we advocate a syndesmodesis screw; if diastasis persists, a secondary lateral approach is useful to reduce the medial malleolar rotation and insert a syndesmodesis screw.

Purpose: Does the postoperative abduction brace facilitate healing after rotator cuff repair? We have answered this question empirically using, since 1995, a premodelled abduction brace for four weeks for all patients, together with early passive rehabilitation. The purpose of this work was to assess the efficacy of this brace and compare outcome with that in patients treated in 1994–1995 with and without the brace.

Material and methods: This retrospective analysis was conducted in 72 patients, mean age 58 years. Contant functional score and imaging of the tendon healing (arthroscan 56%, MRI 44%) were used as assessment criteria. Four homogeneous groups were identified: Group 1 (40 patients, mean age 55 years) was composed of patients with a distal tear of the supraspinatus; twenty patients in this group were treated with a “elbow-to-body” sling (group 1a) and twenty others with the abduction brace (group 1b); Group 2 (32 patients, mean age 60 years) was composed of patients with an intermediary tear of the supraspinatus, partially extending anteriorly or posteriorly, fifteen patients in this group were treated with a “elbow-to-body” sling (group 2a) and seventeen others with the abduction brace (group 2b).

Results: Mean follow-up was 49 months. The weighted Constant score improved from 57.3% to 89.1%. Imaging demonstrated recurrent tears in 25 patients (35%). In group 1 (distal tear of the supraspinatus), the weighted Constant score at last follow-up was 89% (93% in group 1a and 86% in group 1b). There were eight recurrent tears (20%), (25% in group 1a and 15% in group 1b). Use of the abduction brace (group 1a) had no effect. In group 2 (intermediat tear of the supraspinatus), weighted Constant score was 88% (82% in group 2a and 94% in group 2b). There were seventeen recurrent tears (53%) (71% in group 2a and 41% in group 2b). At last follow-up, there was no significant difference for functional score or tear recurrence.

Discussion and conclusion: These findings suggest the postoperative abduction brace is not beneficial after repair of non-retracted distal cuff tears. On the contrary, for intermediate tears, it allows a clear improvement in the final Constant score and a lower rate of recurrent tears. This study provides information useful for choosing the postoperative management of patients undergoing repair of rotator cuff tears.

Purpose: Infection is a serious complication of total knee arthroplasty. Surgical strategies based on removal-reinsertion of the prosthesis in two times with antibiotic therapy has proven its efficacy. The use of a spacer between the two operations has been proposed to facilitate reimplantation. Since 1993, we have used this two-time procedure with an articulated spacer in an attempt to optimise functional outcome yet maintain anti-infection efficacy. We report our experience.

Material and methods: This retrospective series included 28 patients, 21 women (75%) and seven men (25%) who underwent surgery between December 1993 and February 2000.Mean age of the patients at revision was 67 years (18–83). Medical and surgical risk factors for infection were present in 64% and 54% of the cases respectively. Delay between prosthesis surgery and onset of the first signs of infection was 29 months (four days–222 months). A single-germ infection was involved in 18 cases (64%) and a multiple-germ infection in nine (36%). The infection was acute in 32% of the cases and chronic in 68%. There were eight fistulae (28%). Bacteriology reported staphylococcal infection in 25 cases (including 13 S. epidermidis), streptococcal infections in five, anaerobic germs in seven (corynebacterium in five) and Gram-negative germ (pseudomonas) in one. Delay between diagnosis of infection and insertion of the articulated spacer was 11 months (four days–62 months). The first operation consisted in removal of the prosthesis, wide excision of the synovial and infected tissues and insertion of the two articulated pieces, modelled with antibiotic-impregnated cement. Weight-bearing was authorised with crutches and an articulated brace. Rehabilitation exercises were performed to maintain joint amplitude. The prosthesis was reimplanted three months later (1.5–7 months). All prostheses were reimplanted with cement: two prostheses with posterior preservation, 20 posterior stabilised prostheses, and six hinge prostheses. The patients were given antibiotics for eleven months (1–25 months). The IKS score was used to assess functional outcome. Cure of infection was assessed on clinical, biological and radiographic findings.

Results: All patients were seen at a mean follow-up of 35 months (8–78). Follow-up was greater than 24 months in 68% of the patients. We had three cases (11%) of recurrent infection: one acute infection and two septic loosenings. At reimplantation, we had complications in seven patients (25%) ten of whom required revision surgery, six for mechanical complications (three dislocations, three aseptic loosenings). Mean IKS score was 136 points (50–190) with 79 points (30–100) for the knee and 67 points (20–90) for function. Mean flexion amplitude was 94° (45–115°).

Discussion, conclusion: With this method, joint mobility can be maintained between the two operations, greatly improving patient comfort. The mid-term results in terms of infection cure have been satisfactory (89% cure). Nevertheless, the final functional result can be disappointing, due to the persistence of pain (low-grade infection, difficult implant fixation…). The removal-reinsertion strategy using a single operation would in our opinion still have its indications.

Purpose: Arthroscopic arthroplasty for painful shoulder is not always successful. Repeated arthroscopy is sometimes discussed for patients with recurrent pain. The purpose of this work was to determine the technique and identify indications.

Material and methods: We conducted a retrospective analysis of 24 patients (13 men, 11 women), mean age 52 years, who underwent repeated arthroscopy after failure within 31 months of arthroscopic acromioplasty with no other intervention. Three groups were formed: group 1 (7 patients): subacromial impingement due to tendinitis with intact supraspinatus; group 2 (11 patients): subacromial impingement secondary to cuff tear; group 3 (6 patients): calcified tendinopathy. In group 1, the acromion was type 1 in three cases, type 2 in three and type 3 in one; repeated arthroscopy included complementary acromioplasty. In group 2, all patients had complementary acromioplasty; six of them with biceps tenotomy. In group 3, the remaining calcification was removed in all patients and complementary acromioplasty in three.

Results: Mean follow-up was 21 months. In group 1, outcome was satisfactory in three patients (43%), irrespective of the acromial morphology. In group 2, outcome was satisfactory in six patients (55%), including five with acromioplasty with tenotomy and only one with complementary acromioplasty alone. In group 3, outcome was satisfactory in five patients (83%); one failure was attributed to remaining calcification; acromioplasty did not influence outcome.

Discussion, conclusion: The acromion should not be considered as the principal cause of failure after first acromioplasty. In this series, only 33% of the patients who had complementary acromioplasty had a good outcome at last follow-up. Biceps tenotomy in patients with rotator cuff tears and removal of the calcium deposit in patients with calcified tenopathies should be considered first.