Les fractures du fémur de type II après prothèse de hanche

Ninety-seven patients type II were in this study. There were 35 male and 53 female patient, whose average age at revision was 74,5 year old. In this group the average time to fracture after arthroplasty was 6,2 (1–20) years. The fracture was spiral in most cases (82%), but some there were transverse (18%). Loosening of the prosthesis often occured with the transverse fracture (p=0,001). Loosening occured in 30% cases before the femoral fracture : it was rarely a major, but its duration was unknown. Three different methods of treatment were used in this study:

1. conservative treatment was used rarely, where there was a surgical risk in incomplete or undisplaced fracture. Treatment with traction involved a prolonged stay in hospital (two months average).
2. internal fixation without removal of the prosthesis was used in 44% cases. Fixation with plates in 93%. Other devices were screw and cerclage wire fixation.
3. 47,5% cases were revised with a long stem cemented prosthesis.

The most difficult was type II fracture associated with femoral loosening. The location of type II fracture may compromise the stability of prosthesis. Although there was 41% of cases whose prosthesis was not loose before fracture. In these cases, type II fracture has not compromised the stability of prosthesis: the spiral line could shape peri prosthetic mantle of cement. Healing of the fracture was obtained in most cases (97%). Thus, protetic loosening created by type II fracture has not prevented consolidation: these two events are statistically independant. The present retrospective study supports the employement of different treatment. Based on these findings, the following management of type II fracture could be recommended:

1. undisplaced or incomplete fracture in high risk patients, should be treated conservatively. If loosening of the prosthesis develops, revision of the arthroplasty can be done after fracture healing.
2. internal fixation without revision of the prosthesis should be employed if the prosthetic stem stability is not compromised.
3. revision of the arthroplasty should be done if loosening of the prosthesis developped before or during the type II fracture occured. Then, a long stem should be employed.

     

Comparaison des dispositifs Orth-Evac™ et Solcotrans Plus™ pour l'autotransfusion du sang drainé après arthroplastie totale du genou

Surgical wound blood which is ched through drains after total knee replacement surgery with a tourniquet may be returned to the patient using special collecting devices. This study aimed to compare two systems, Orth-Evac™ and Solcotrans Plus™ an to assess the safety of the reinfusion of non washed blood cells. It included 30 patients scheduled for total knee replacement surgery, free from tumoral or coagulation disease and allocated randomly in three groups of 10 each : the Orth-Evac™ group (OGr), the Solcotrans Plus™ group (SGr) and the Control group (CGr). The devices, not containing an anticoagulant, were connected to the deep suction drains in the operating room, after skin closure and before the tourniquet removal. The salvaged blood was reinfused in the subsequent six hours via a 40 μm filter. The volume of collected blood was measured and homologous blood was added as required, to maintain a hematocrit of 30 %. A blood sample was obtained the day before surgery (D − 1), before reinfusion (D0), two hours later (D + 2 h), one day later (D + 1), and from the collecting device before reinfusion. The statistical analysis used the Kruskal-Wallis test and Steel-Dwass procedure to confirm the difference between two groups. The three groups did not differ in age, weight, height and gender. The volume of salvaged and autotransfused blood was 925 ± 156 mL in OGr and 605 ± 178 mL in SGr respectivelly. transfusion of homologous blood was required in two patients of OGr, four of SGr and six of CGr. At D + 1, the hematocrit was comparable in all groups (OGr = 28 %, SGr = 28.2 % and CGr = 28.5 %). At D + 1 the moderate decrease of PT, aPTT, fibrinogen and platelets count was also similar between the groups and correlated with haemodilution (protein concentration). At D + 1, blood lipids and blood gases were comparable in all groups and no symptoms of fat embolism were seen. At D + 2 h, the plasma concentration of D-dimers, assessed by Elisa technique, was significantly higher in SGr (89 ± 99 μg · mL⁻¹ vs 39 ± 34 μg · mL⁻¹ in the OGr), and in one patient of this group it reached 306 μg · mL⁻¹. In the CGr the concentration was 22 ± 15 μg · mL⁻¹. At D + 1 no significant difference was observed. This effect may be related to the reinfused blood which contained over 1 000 μg · mL⁻¹ of D-dimers. The collected blood did not coagulate. The PT was over 120 s, the aPTT over 180 s and the presence of fibrinogen and factors V and II could not be detected. The high concentration of D-dimers in the salvaged blood can be explained by the activation of coagulation in the surgical site. As this blood is not clotable, the addition of an anticoagulant is not required. The collected blood has similar characteristics in the two devices. The amount was always more than 500 mL. Therefore the Orth-Evac™ system is more appropriate as its content is 1 000 mL vs 550 mL for the Solcotrans system. Moreover, the cost of the former is lower. The economy of homologous blood was more significant with the Orth-Evac™ system, as only two patients out of 10 required the transfusion of homologous blood. D-dimers at high concentration may decrease the platelets' aggregation. In this study, neither bleeding nor other adverse effects occurred with retransfusion of salvaged blood at amounts never exceeding 1 000 mL, which is probably the upper limit of this technique.     

Incidence socioprofessionnelle de la chirurgie prothétique de hanche avant 50 ans

Although total hip prosthetic replacement is a common surgical procedure, it is not without social and professional consequences. In a certain number of cases, return to occupational activities is not possible. In others, it is difficult. Long-term work break repercussions can be major as they often go together with financial difficulties. The medical counsultant and the occupational doctor will have an important role to play at the time of the return to occupational activities or to determine the conditions of workplace adaptation or a vocational training program.Functional recovery after insertion of total hip prosthesis observes precise rules of articular mobilization, weight bearing and muscular strengthening.In the young patient, before 50 years old, objectives will be more accurate and progress not only will concern recovery of daily living, walking and do-it-yourself activities but also return to sports, play and occupational activities. Not only will reactivation be physical, muscular and articular but also behavioral and psychological.

Disease and its consequences, surgery in particular, cause a psychological and a physical aggression which modifies the patient’s self-concept.

• ? Vulnerability and plastic wrong (limping, modifications of gesture and sports performanee as well as modifications of the living conditions). The patient unconsciously translates this physical affection into:
• * loneliness (taking away or exclusion from the usual surroundings of those who are in good health)
• * “blues”
• * lack of dynamism
• * uselessness, feeling of being incompetent “in those conditions, what’s the use of fighting?”
• ? At the same time
• - loss of social status: “Colleagues get up to go to work, children go to school, all the others are productive, I’m good at nothing.”
• - impression of uselessness, dependence; reinforcement of turning in on the self.
• ?The undertaking by a surgeon and his team (anaesthetist, nurse, physiotherapist) which implies constraints, orders, assessments, exercices turns the patient into an “under ling” and makes him lose his independence.

Patient’s self-concept is modified by the disease and its treatment. Modification of his role in the family and in the society leads him to behave as a man of leisure as an assisted person (3rd age concept).

Return to work: If it is desirable, it is not always possible, 3 cases may occur:

• 1 - occupational activity is incompatible
• 2 - occupational activity is compatible if the workplace is adapted
• 3 - occupational activity is compatible.

Occupational activity is incompatible. It only involves patients with demanding occupational activities with prolonged upright stance and load carrying or working at a height. Craftsmen and farmers adjust their activity and return to their former work.

Associated lesions are often responsable for the absence of return to work.

• * If the patient had an occupational accident: at the time of finalisation, he will be proposed a permanent partial disablement pension. His rate is determined by the medical consultant.
• * If the patient is under a sick leave scheme, he can benefit from daily compensation for a maximum of three years. Nonetheless, if his state is stabilized before the end of this period, the medical consultant can set a date of return to occupational activities.

If the patient has an employer, he can have a pre-return to work examination by the occupational doctor who will determine a temporary incapacity which may turn into definitive incapacity. The attending physician can then apply for a disablement pension and the medical consultant will be required to determine the level of incapacity exhibited by the patient. For a patient to benefit from a disablement pension, his capacity to work will have to be reduced by two thirds by the disabling affection. Several elements have to be taken into account:

• - the pathological state itself
• - the particular elements of the individual considered, these elements can increase or decrease the after-effect of the psychological factors. It involves the general state of health, the age, the physical and mental abilities, and those of vocational training and of the job carried out.
• - social elements have to be taken into account, what are the actual possibilities for the salaried employee to find a job according to the labour market context of the region he lives in.

Occupational activities possible subject to:

• - workplace adjustment
• - vocational training.

If the patient has no employer, he will be examined by the doctor responsable for the re-employment who will assess with him the characteristics of the workplace wanted.If the patient has an employer, a workplace which physical constraints will be compatible with the handicap of the patient will be searched for in collaboration with the occupational doctor.If no workplace adaptation is possible, vocational training will be considered. It observes relatively strict rules and will only be proposed to the youngest patients. This vocational training session will prolong the work break to a year. This will only be possible with the agreement of the COTOREP (vocational guidance and professional rehabilitation technical commission) and from the patient it needs strong motivation, a certain academic level and a match between the patients’ desire, their human qualities and their intellectual abilities is essential. It is a real strategy which is implemented to lead a patient to register at a vocational training centre (there are 100 of them in France).

Vocational orientation and problem assessment must be undertaken early enough so that they can repress the psychological inhibitions and take advantage of the functional rehabilitation time to determine the academic level and improve it if necessary.

• - Motivation: The patient must be personally motivated to undertake a vocational training program which will last for a long time and will keep him far away from his family and his emotional environment. The vocational training program thus cannot be undertaken following the set, the employer or right-thinking people entreaties. Sometimes secondary advantages can favour or oppose a vocational training assessment and this must be taken into account.
• - Academic level: The level of vocational training will be proportional to the academic level at that time. It will thus be assessed and remedial teaching will be planned early to reinforce academic knowledge which has been acquired but not used so may have been forgotten.

A certain number of means will be implemented:

• - Potentialities: Even if a patient has a low academic level, he may have intellectual faculties of conceptualization of practical turn of mind, of memory which will allow him to rapidly acquire a good level of knowledge. The patients will be offerred information on the subject of carreers, pathways and academic level required. It is advisable that they should be accompanied in this step by competent librarians.

Compatible occupational activity: Functional rehabilitation will be completed by retraining aiming at recovering stamina and at intensifying physical activities level essentially by play or sports activities. In some cases, retraining in a specialized centre can be considered.Conclusion: Social and professional difficulties which go together with resettlement of patients with total hip prostheses justify the therapeutic team involvment completed by the presence of the medical consultant, the occupational doctor and social organisations particularly the COTOREP. The medical consultant will be required for the pre-return examination, will determine whether a return to work is possible, the temporary incapacity, the definitive incapacity and will start the presentation before the COTOREP to obtain the recognition of disabled worker and undertake a vocational training program. He is in charge of the worker’s follow-up after his return to occupational activities.The medical consultant will decide on the return to occupational activities as soon as the medical state is stabilized and before the 3rd year, the deadline of the work break duration. He may in case of definitive incapacity apply for a fast-track disablement file. He will determine the disability rate for workers under sick leave scheme and will determine the definitive partial disability rate for patients with occupational accidents.     

L’arthroplastie totale de hanche chez l’enfant et l’adolescent

Arthritis Arthritis of the hip in children and adolescent can induce lesions of the articular cartilage and severe handicap. When conservative surgical methods are without benefit, total hip arthroplasty should be an alternative solution.Indications: Chronic pain, abnormal social life and scolarity, stiffness and impossibility for osteotomies are the main criteria to decide and to choose for an arthroplasty.

Two main groups of etiology are as follow

• * group I concerns rhumatologie arthritis. Arthroplasty is decided with pediatricians, physiotherapists… Other joints are often involved and post-operative cares need intensive physiotherapy.

Femoral head necrosis of renal disease and sickle cell disease belong to this group.* group II concerns sequelae of previous femoral osteotomy: septic osteoarthritis, severe stiffness, sequelae of hip dislocation, necrosis of slipped capital epiphysiolysis…Since 1990, Dr J.L. Jouve has operated on 11 hips in patients aged for 14 to 20. Prosthesis used were custom made, Symbios, Switzerland.Results group I: The custom made in this group is interesting because it is obvious to maintain the largest bony pool and to avoid to ream the metaphysis and diaphysis. It is also necessary to thinck in advance for further procedure because these patients are young. Technical surgical approach is without any particularity, no case of fracture was noticed. Post-operative weight-bearing was delayed for 45 days. With a short follow-up of 2 years, results are excellent.Results group II: The custom made is necessery in these cases with an abnormal morphology of the proximal femur and narrow canal following earlier femoral osteotomies. Immediate results are also excellent.Conclusion: Hip arthroplasty with custom made is a nice procedure when other surgical treatments are not possible. But further studies are necessary with a larger follow-up.

Tumors Osteosarcoma and Ewing’s sarcoma needs sometimes wide resections of the proximal femur and reconstruction of the hip joint. In our experience and ISOLS’ series, it seems that following data are favourable:

• - cemented complete prosthesis of the femur resected and no allograft,
• - excellent reconstruction of the muscles of the hip: extensors, abductors and fascia lata, without to try a fixation of these muscles on the prosthesis
• - use of an acetabular mobile cup to preserve further surgery with, for exemple, an acetabular arthroplasty.

Two cases of Ewing’s sarcoma are presented, girls aged 15 and 12.Length of the resection was 23 and 19 cm. Post-operative results are good.     

Montages chirurgicaux après exérèse totale du mésorectum pour cancer

Total mesorectal excision is one of the most important points in the surgical treatment of rectal cancer. Differents assemblies after surgical total mesorectal excision are described.     

Rachianesthésie totale après bloc du plexus lombaire par voie postérieure

We report a case of total spinal anaesthesia which occurred after a lumbar plexus block using a posterior approach. After total hip arthroplasty under general anaesthesia, a lumbar plexus block was performed according to Winnie's landmarks at the L4 interspace using a nerve stimulator. Aspiration test for blood and spinal fluid were both negative, as well as a test dose of 3 mL lidocaine 2 %-bupivacaine 0.5 %. One minute after the injection of 27 mL of the same mixture, a complete anaesthetic block occurred with hypotension and loss of consciousness requiring intubation and controlled ventilation during 3h30, without sequelae. Lumbar plexus block using a posterior approach must be performed cautiously and a slow and fractionated injection of the full dose is recommended.     

Reconstructions massives du cotyle et du fémur proximal

In revision hip surgery, allografts are useful for restoring the bone stock and allow the muscle fixation avoiding the use of massive metallic prothesis.

Material and methods: We have reviewed 51 hip reconstructions with a follow up of 4 years and half (1982 – 1991). Indications were:

• - revision arthroplasties with destroyed acetabulum,
• - bone tumors (mainly chondrosarcoma).

Results: The results are good for pain, articular movement and the consolidation of the allograft host bone junction. Some complications were encountered:

• - Post-operative death (early or late for tumoral extension) in case of major surgery for tumor (4 cases).
• - Deep infections (2 cases).
• - Weakness of the gluteus medius with hip dislocation needing anti-dislocation device.
• - Aseptic serous fluid leak meaning immunobiologic reaction of bone grafts (3 cases).

Discussion: This surgery has to be compared to massive reconstruction prostheses, arthrodesis with limb shortening, femoral head and neck resection and in some cases inter ilio-abdominal amputation which gives also major post-operative complication.     

Modes d'utilisation d'une échelle de qualité de vie personnalisée dans une étude longitudinale chez des patients opérés d'une prothèse totale de hanche

Quality of life scales are being increasingly used to evaluate patients. The earliest scales were standardized questionnaire that did not necessarily provide an optimal evaluation of the quality of life of each individual patient. A number of personalized scales are now available, including the SEIQoL, in which the patients nominate the five quality of life areas most important to them. The SEIQoL has been validated. We tested the SEIQoL in patients treated by total hip arthroplasty, a procedure that is expected to improve quality of life. Objective. To compare two methods of administration of the SEIQoL several months after total hip arthroplasty. Methods. The SEIQoL was administered before and after the arthroplasty. During the postoperative test session, the SEIQoL was administered twice, once using the items nominated preoperatively and once after allowing the patient to repeat the nomination procedure. Results. With both methods, significant improvements in quality of life were demonstrated (P < 0.05). There was no significant difference between the two methods. Conclusion. Changing the items of the SEIQoL during prospective studies does not modify the overall quality of life score. Keeping the same items throughout the study is nevertheless warranted.     

Le remplacement prothétique des uretères

Study aimThe aim of this study is to demonstrate the reliability of silicone prosthesis for the replacement of ureters. This prosthesis derives from the biliary prosthesis developed after a personal experimental study continued by Triboulet.Patients and methodsIn 38 patients suffering from a malignant disease, a right silicone prosthesis was used for the replacement of an ureter during a 20-year period. There were 30 female and eight male patients. The mean age was 71 (range: 51–88 years). Forty one prostheses were used; one patient underwent two successive operations on the same side with a change of prosthesis, and two patients required a bilateral prosthesis. There were 12 gynaecological carcinomas (three with ureteral fistula), three prostatic carcinomas, 16 cancers of the rectum and recto-sigmoid junction, four cancers of the right colon with retroperitoneal carcinomatosis, and three ureteral fistulas after extended colonic resection.ResultsEarly complications were limited to ureteral fistulas (n = 6, 16%) in patients who had already a preoperative fistula (n = 3) and in patients with peritoneal metastases on the superior wall of the bladder. The secondary destruction of the kidney (four secondary nephrectomies) occurred when the function of the kidney was already impaired at the time of the procedure. There were no secondary fistulas, no secondary obstruction of the prosthesis. The longest follow-up was 69 months.ConclusionThe silicone prostheses used for the replacement of ureters are reliable and still permeable beyond 5 years. The protection of the renal function in patients often submitted to chemotherapy improves the duration and quality of survival. These prostheses must be reserved to advanced malignant diseases with a rather long life expectancy.     

IRM après radiochimiothérapie néoadjuvante du cancer du rectum

MRI is the optimal imaging technique to restage rectal cancer after neoadjuvant treatment, which is becoming a very relevant issue for tailoring of treatment. For optimal MRI, no bowel preparation is required; a standard protocol comprises T2-weighted sequences without fat suppression in three planes, and diffusion-weighted sequences. Gadolinium contrast administration has not proven to be beneficial. Interpretation criteria are morphologic, volumetric and functional (diffusion-weighted sequences). Overstaging is the most encountered problem because fibrosis cannot be distinguished from residual tumor. Especially, accuracy of identification of complete responders is only 30-35%, and MRI has to be correlated to clinical examination and endoscopy.