Removal of infected cemented hinge knee prostheses using extended femoral and tibial osteotomies: Six cases

SummaryExtended femoral and tibial osteotomies were performed to remove infected cemented hinged knee prostheses in five patients (six knees) with a mean age of 72 years (44–85) and a history of multiple knee surgeries. A tibial osteotomy was used to mobilise the distal quadriceps insertion and to release the tibial extension. The femoral component was extracted by downward traction and its cement mantle was cleared through an anterior osteotomy (n=4) or via the distal approach (n=2). The bone flaps were re-approximated by wire cerclage over articulating acrylic spacers. Mean time to re-implantation of a new knee prosthesis was 11 months (6–24). Revision prostheses with cement fixation restricted to the epiphyseal-metaphyseal region were used. Infection recurred in two cases at 16 and 4 months after the prosthetic re-implantation, and was managed by joint fusion for one and irrigation/lavage for the other, respectively. At last follow-up after a mean of 53 months, the mean Parker score was 4±2, the mean IKS knee score was 66±25 (28–93), and the mean IKS function score was 7±16 (0–40). This technique facilitates the removal of infected cemented components of hinge prostheses and of the cement mantle, most notably in the absence of loosening, without compromising re-implantation of a new knee prosthesis

Treatment of complex fractures of the distal radius: a prospective randomised comparison of external fixation 'versus' locked volar plating

The traditional treatment of severely impacted fractures of the distal radius involves bridging external fixation and maintaining reduction by applying continuous traction. The recent technique using fixed-angle screws within volar plates is reported restore the radial length and the articular profile whilst avoiding joint distraction. It is also believed to produce better and quicker clinical results. To test these claims, we carried out a randomised controlled comparison of the efficiency of external fixation (EF) \u27versus\u27 open reduction and internal fixation (ORIF) in treating severely impacted fractures of the distal radius. A total of 39 patients were treated with EF, eventually associated with percutaneous pinning, whereas 36 underwent ORIF with a locked volar plate. There was no significant difference in the two groups with regard to changes in the ulnar variance. Articular reduction was poor in two patients in the EF group with residual step-offs exceeding 2mm; another patient of the EF group suffered a secondary loss of reduction, healing with a severe articular malunion (>2mm). By contrast, articular reduction was satisfactory in all the patients of the ORIF group. The clinical results on the Green and O\u27Brien rating were significantly better in the ORIF group than in the EF group (p<0.01 at 6 weeks, p<0.05 at 6 months). Nevertheless, open reduction and volar plating did not yield better subjective results than EF. However, although not statistically significant, patients treated by ORIF seemed to resume their usual activities quicker than those treated with EF, suggesting that this technique may be adapted to a greater extent in the case of active, young individuals

Results of angular-stable locked intramedullary nails in the treatment of distal tibia fractures

AbstractIntroductionIntramedullary nailing in distal tibial fracture is controversial because of a lack of stability. The present study sought to assess radiological and clinical results for a new “angular-stable” locking system in difficult indications for intramedullary nailing.Material and methodA prospective study recruited 41 patients (41 tibias) with distal tibial fracture consecutively managed using angular-stable locked intramedullary nails. Radiologic assessment comprised AP and lateral lower-limb views, taken postoperatively and through to last follow-up. The mean distance was measured between fracture and joint line. Fusion, with or without malunion, primary reduction defect, non-union and secondary displacement were recorded, as were all complications.ResultsMean follow-up was 18±5 months; 3 patients were lost to follow-up. Mean fracture distance from the joint line was 63±25mm. Fusion was achieved within 3 months in 29 cases (76%); delayed fusion in 7 patients (18%) required secondary dynamization at a mean 3 months, with favorable evolution. Revision surgery was required in 2 cases: 1 for secondary displacement exceeding 10°, and 1 for non-union at 7 months. Other complications mainly comprised 4 malunions of less than 10° due to primary reduction defect.ConclusionAngular-stable locked lower-limb intramedullary nailing provided a very satisfactory fusion rate, with few complications. It is, however, a demanding procedure, especially as regards fracture reduction and nail positioning in the distal fragment.Prospective cohort studylevel IV

Extraspinal sciatica revealing late metastatic disease from parotid carcinoma

Sciatica is a clinical symptom usually caused by a disk herniation and less often by other conditions such as tumors, infections, or inflammatory diseases. We report the case of a woman in whom sciatica led to the identification of a large pelvic metastasis from a carcinoma of the parotid gland

Total knee arthroplasty for osteoarthritis secondary to extra-articular malunions

SummaryIntroductionPost-traumatic total knee arthroplasty for extra-articular malunion requires correction of the deformity, either through asymmetrical bone resection (possibly inducing ligaments imbalance) or osteotomy at the time of arthroplasty. We report the results of a continuous multicenter, retrospective series of 78 patients (18 implants with osteotomy) with a mean 4 years of follow-up. The hypothesis is that the selected procedure requires to be based on the deformity's location and severity.PatientsWith a mean age of 63 years (younger in the osteotomy group), 38 patients had femoral malunion, 36 had tibial malunion, and four had a combined malunion. There were 70 frontal deformities (48 varus and 22 valgus) and 10 rotational deformities, often diaphyseal, four of which more than 20°. Twelve patients had a history of infection; eight had frontal laxity greater than 10°, and 15 a limited range of motion in flexion. In 70 cases, semi- or nonconstrained implants were used, and in eight cases more constrained implants, including four hinge prostheses.ResultsWe observed two deep infections, one case of avulsion of the extensor mechanism, and two cases of aseptic loosening with femoral malunion and varus deformity. Two osteotomies resulted in nonunion, one with internal fixation devices mobilization requiring revision using extension rods. The function and pain scores were significantly improved. The mobility improvements were moderate but did not compromise the surgical procedure main objective. The preoperative hip-knee angle was corrected with both techniques. Only the function score gain was greater for the isolated arthroplasty procedures.Discussion and conclusionThe indications for arthroplasty alone were extended to 20° varus and 15° valgus, with no major residual laxity. Beyond 10°, hinge prosthesis should be available. Associated osteotomy can correct rotational deformities that cannot be compensated with bone cuts. In deformities that are close to the joint, osteotomy facilitates implantation of moderately constrained prosthesis. This indication is based on CAT scan rotational deformities measurements because rotational deformities require an osteotomy, and/or the presence of extraligamentous deformity that cannot be reduced with collateral ligaments surgical release.Level of evidenceLevel 4. Non-controlled retrospective study

Nouvelles méthodes d’intégration pour traiter la plasticité en X-FEM

La méthode d’intégration utilisée classiquement en X-FEM fait dépendre la position des points d’intégration de la position de la fissure, ce qui convient difficilement à l’étude de la propagation d’une fissure dans un milieu plastifié. En effet, des étapes de projection de champs sont alors nécessaires. Afin de s’en affranchir, cette contribution propose deux approches alternatives. La première s’appuie sur les schémas d’intégration standards tandis que la seconde propose de différencier les points d’intégration des points où le comportement est évalué. Les méthodes proposées se limitent aux cas des interfaces

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing

Introduction Treatment of lower extremity segmental bone loss is difficult. Masquelet et al. proposed a two-stage technique: first, debridement and filling of bone loss with an acrylic spacer; second, bone reconstruction by filling with cancellous bone in the space left free (following cement removal) inside the so-called self-induced periosteal membrane. In the originally described technique, the fracture site is stabilized by an external fixator, which remains in place throughout the bone healing process, i.e., often longer than 9 months with all the known disadvantages of this type of assembly. Following the principle of two-stage reconstruction, we modified the technique by reconstructing around an intramedullary-locking nail placed in the first stage. Hypothesis This technique prevents the mechanical complications related to external fixator use and provides faster resumption of weight-bearing. Patients and methods Twelve patients were operated for segmental tibial bone loss greater than 6 cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis (seven cases). All the patients were operated on in an emergency setting and the first stage was performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocutaneous flap (two patients) was necessary during this first step to cover the site and provide good conditions for secondary bone growth. The follow-up was 39.5 months (range, 12–94 months). Results Complete weight-bearing was resumed at a mean 4 months. After the second step, all the patients except one had apparently healed (complete weight-bearing with no pain). Five septic complications occurred after the second step, in one case leading to reconstruction failure. Four other patients had infectious complications successfully treated (as of the last follow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in two other cases, with no graft loss. Discussion The use of the intramedullary nail facilitates the Masquelet technique by allowing the patient to resume weight-bearing more quickly and avoiding secondary fractures. However, the risk of sepsis remains high but can be controlled without compromising the final bone union in four cases out of five. Level of evidence Level IV. Retrospective study