Mechanical failure of the Coonrad-Morrey linked total elbow arthroplasty: A case report

AbstractSemiconstrained (linked design) total elbow arthroplasty is indicated in a wide variety of cases. Long-term survival is better than with non-linked prostheses. However, mechanical failure of the hinge mechanism is a complication that may occur during follow-up. We report a case of failure of the axle assembly of a Coonrad-Morrey elbow prosthesis 8years after implantation for nonunion of a supracondylar distal humerus fracture. Initial revision surgery included changing the axle and the polyethylene bushings. Revision surgery was necessary 1year later when the axle failed again. A custom-designed locking axle had to be used to stabilize the hinge mechanism. After 3years follow-up, the hinge was intact, there was no loosening of the components and function of the elbow was good

Bilateral clavicle fracture external fixation

SummaryFractures of the middle third of the clavicle are frequent and their conservative treatment ends in bone union in nearly 95% of cases. Surgical treatment is unanimously indicated with open fractures or in cases of cutaneous damage, neurovascular complications, and impaction of the shoulder stump syndromes. We report herein a case of bilateral fractures of the clavicle that required double stabilization with an external fixator following major cutaneous damage appearing after the initial conservative management. The intraoperative discovery of Propionibacterium acnes infection and bone union obtained within the classical time frame, with a satisfactory functional result, all retrospectively proved the soundness of this indication

Outcomes of bipolar radial head prosthesis to treat complex radial head fractures in 22 patients with a mean follow-up of 50 months

AbstractBackgroundRadial head replacement is indicated to treat complex proximal radial fractures that are not amenable to internal fixation.HypothesisImplantation of a bipolar radial head prosthesis after radial head excision ensures stability of the elbow and forearm, thereby promoting ligament healing and restoring elbow function.Material and methodsTwenty-two patients managed with implantation of a bipolar radial head prosthesis (Guepar®) were evaluated after a mean follow-up of 50 months. The procedure was performed in the acute setting in 16 patients, including 13 with associated injuries; and at the stage of sequelae in 6 patients.ResultsProsthesis removal was required in 4 patients. Of the remaining 18 patients, 14 (77%) had satisfactory Mayo Elbow Performance Score values, 14 (77%) little or no functional impairment, and 11 (61%) little or no pain. Mean motion arcs were 100° in flexion-extension and 143° in pronation-supination. Mean elbow strength in flexion and mean wrist strength were 67% and 86%, respectively, of those on the contralateral normal side. Radio-lucent lines were visible around the prosthesis in 5 patients, radial neck osteolysis in 10 patients, and capitellar erosion in 7 patients. Seven patients each experienced a complication. Early revision surgery to treat elbow instability was required in 6 patients.DiscussionOutcomes after Guepar® bipolar radial head prosthesis implantation were disappointing in patients with complex radial head fractures seen in the acute or chronic setting. The associated injuries to bones and ligaments and the measures taken to repair them influence the prognosis. The complication rate is non-negligible and seems to increase over time.Level of evidenceIV, retrospective study

Skin preparation before hip replacement in emergency setting versus elective scheduled arthroplasty: Bacteriological comparative analysis

SummaryIntroductionHip arthroplasty needs to be performed in an emergency setting after intracapsular femur neck fracture, whereas pain makes preoperative skin preparation of the limb difficult and it may therefore be incomplete. To date no study has analyzed the patient's skin bacteriological status in these surgical conditions.HypothesisThe skin's bacterial flora is quantitatively and qualitatively different in the trauma context compared to an elective scheduled arthroplasty for chronic hip disease.Materials and methodsTwo groups of patients, undergoing hip arthroplasty and having the same preparation at the time of surgery but different skin preparation procedures the day before and the day of surgery, were prospectively compared: 30 patients operated on in an emergency setting for fracture (group A) had no skin preparation and 32 patients operated on in scheduled surgery (group B). Group A had no skin disinfection before going into surgery, whereas group B followed a predefined protocol the day before surgery. Skin samples were taken on gelose at three different stages of skin preparation at the time of surgery (before and after detersive cleaning, and at the end of the surgery) and on two sites (inguinal and greater trochanter). The bacteriological analysis took place after 48hours of incubation.ResultsBefore detersive cleaning, group A had 3.6times more bacteria than group B in the trochanter region and 2.7times more in the inguinal area. After detersive cleaning, the contamination rate in the trochanter area was similar in both groups (group A: 10%; group B: 12.5%), but different in the inguinal region (group A: 33%; group B: 3%; P=0.002). At the end of the surgery, no difference was identified. Coagulase-negative Staphylococcus and Bacillus cereus accounted for 44% and 37%, respectively, of the bacteria isolated. In addition, the frequency of pathogenic non-saprotrophic bacteria was higher in group A (38%) compared to group B (6%). At a mean follow-up of 9.7months (range: 8–11months), no infection of the surgical site was identified.ConclusionThe dermal flora is more abundant and different when the patient is managed in an emergency context. Although effective in the trochanter area, cutaneous detersive cleaning in the operating room is insufficient in the inguinal area and the frequency of pathogenic bacteria warrants identical rigor in preoperative preparation in all situations.Level of evidenceIII. Prospective case – control study

Primary total knee arthroplasty in the management of epiphyseal fracture around the knee

SummaryIntroductionOver the past few years the use of arthroplasty was broadened to treating complex epiphyseal fractures at the shoulder and elbow joints. Similar trends to treat this type of fractures at the knee are less documented. Based on a multicenter retrospective series study, the aims of this work is to evaluate the short term clinical results of total knee prostheses in the management of comminuted epiphyseal fractures around the knee, to identify the technical issues and fine tune the indications.Material and methodsFollowing the initiative of the French Hip and Knee Society (SFHG) and the Traumatology Study Group (GETRAUM), 26 charts from eight different centers in France were included in this multicenter retrospective series. Inclusion criteria were: primary total knee arthroplasty (TKA) in the management of complex articular fractures involving the proximal end of the tibia or distal end of the femur. Surgical features were identified and complications were analyzed. The assessment protocol at last follow-up was standardized and included patient demographic data, analysis of the Parker and IKS scores.ResultsDuring the immediate postoperative period, six patients (23%) reported a general complication and four patients (15%) a local arthroplasty-related complication. At last follow-up (mean 16.2 months), the overall final Parker score was 6.3 (a mean decrease of 1.7) and the mean IKS knee score was 82 points for a mean function score of 54 points.DiscussionPrimary TKA is a suitable management option for complex fractures in autonomous elderly patients suffering from knee osteoarthritis. The key technical details of this procedure should be respected and meticulously planned to achieve optimal results and limit the risk of complications. This risk in these acute complex fractures remains higher than after conventional TKA but comparable to that observed after TKA for post-traumatic arthritis.Level of evidenceIV; retrospective cohort study

Common peroneal nerve palsy complicating knee dislocation and bicruciate ligaments tears

SummaryIntroductionThe occurrence rate of common peroneal nerve (CPN) palsy associated with knee dislocation or bicruciate ligament injury ranges from 10 to 40%. The present study sought first to describe the anatomic lesions encountered and their associated prognoses and second to recommend adequate treatment strategy based on a prospective multicenter observational series of knee ligament trauma cases.Material and methodsTwelve out of 67 knees treated for dislocation or bicruciate lesion presented associated CPN palsy: two females, 10 males; mean age, 32 years. Four sports injuries, three traffic accidents and five other etiologies led to seven complete dislocations and five bicruciate ruptures. Four cases involved associated popliteal artery laceration ischemia; one of the dislocations was open. Paralysis was total in eight cases and partial in four. There were two complete ruptures, three contusions with CPN in continuity stretch lesions and three macroscopically normal aspects.ResultsAt a minimum 1 year's follow-up, regardless of the initial surgical technique performed, recovery was complete in six cases, partial (in terms of motor function) in one and absent in five. Without specific CPN surgery, spontaneous recovery was partial in one case, complete in two and absent in none. Following simple emergency or secondary neurolysis, remission was total in four cases and absent in one. Three nerve grafts were all associated with non-recovery.DiscussionThe present results agree with literature findings. Palsy rates varied with trauma circumstances and departmental recruitment. Neurologic impairment was commensurate to ligamentary damages. The anatomic status of the CPN, subjected to violent traction by dislocation, was the most significant prognostic factor for neurologic recovery. In about 25% of dislocations, contusion-elongation over several centimeters was associated with as poor a prognosis as total rupture. CPN neurolysis is recommended when early clinical and EMG recovery fails to progress and/or in case of lateral ligamentary reconstruction. Possible peripheral nerve impairment needs to be included in the overall functional assessment of treatment for severe ligaments injuries and knee dislocation.Level of evidenceLevel IV, prospective study

Trochanteric locking nail versus arthroplasty in unstable intertrochanteric fracture in patients aged over 75 years

SummaryIntroductionIn trochanteric fracture, whatever its anatomic type, internal fixation is currently the standard attitude, with arthroplasty as a relatively unusual option.HypothesisHip implants are an excellent alternative to osteosynthesis in unstable trochanteric fracture in patients aged over 75 years.Patients and methodsA non-randomised prospective multicenter study compared osteosynthesis by trochanteric nailing (n=113) to hip arthroplasty (n=134) in unstable trochanteric fracture (AO types 31 A2.2 and 3 and A3.3) in 247 patients over the age of 75 years. The series was recruited during 2007 in seven centres, four of which included only arthroplasties, two only osteosyntheses and one both. The two groups were comparable in age, sex, preoperative Parker score, pre-fracture place of residence, fracture type, time to surgery and preoperative comorbidity. The sole difference was in operators, with more senior surgeons in arthroplasty (62% versus 27%).ResultsThree-month mortality was identical in the two groups (21.2% versus 21%). General complications did not differ, although mechanical complications were more frequent in the nailing group (12.5% versus 2.8%). Functional results (Parker and PMA scores) were better in the implant than in the nail group.DiscussionThe present study validated hip arthroplasty in these indications. Cemented stems associated to a dual-mobility acetabular component gave the best results.Type of studyProspective, level of evidence III

Is the prognosis the same for periprosthetic joint infections due to Staphylococcus aureus versus coagulase-negative staphylococci? A retrospective study of 101 patients with 2-year minimum follow-up.

BACKGROUND: Staphylococcus aureus (SA) and Coagulase-negative staphylococci (CoNS) are often responsible for infections of total hip arthroplasty (THA) and total knee arthroplasty (TKA). One of the main differences between these two microorganisms is their virulence, with SA presumed to be more virulent; however, few studies have specifically investigated the impact of this virulence. This inspired us to carry out a retrospective study to evaluate whether the healing rate differed between SA and CoNS infections. HYPOTHESIS: We hypothesised that the healing rate is lower for SA prosthetic joint infections. MATERIALS AND METHODS: This was a retrospective study of 101 consecutive Staphylococcus infection cases that occurred between 2007 and 2011. There were 56 men and 45 women with an average age of 69 years (range 23-95). The infection was associated with TKA in 38 cases and THA in 63 cases. Thirty-two percent of patients had one or more comorbidities with infectious potential. In our cohort, there were 32 SA infections (31.7 %) and 69 CoNS infections (68.3 %) with 58 of the infections being methicillin-resistant (15 SA and 43 CoNS); there were 27 polymicrobial infections (26.7 %). RESULTS: With a minimum 24-month follow-up after the end of antibiotic treatment, the healing rate was 70.3 % overall (71 patients). The healing rate was 75 % in the SA group (24 patients) versus 68.1 % (47 patients) in the CoNS group (P = 0.42). CONCLUSION: Our hypothesis was not confirmed: the healing rate of SA prosthetic joint infections was not lower than that of CoNS infections. LEVEL OF EVIDENCE: III, retrospective case-control study

Periprosthetic osteolysis due to metastatic renal cell carcinoma: a case report

Failure of total hip arthroplasty through septic or aseptic loosening, periprosthetic fracture, or recurrent dislocation is well recognized and understood. We present an unusual cause of failure of total hip replacement which occurred on a 79 year old gentleman: that of prosthetic loosening secondary to malignant infiltration around components. Our aim is to highlight the fact that malignant infiltration should be considered as part of the differential diagnosis in aseptic and septic loosening of prosthetic implants