Implant for Knee and Hip Repair in French West Indies

As more and more people in the Western World are walking around with artificial hips and knees,  French West Indies aging baby boomers are also leading the way.

That is partly because excess weight is fraying their joints earlier.

Between the years 2000 and 2006, knee replacements shot up by 65 percent.

In an AAOS 2009 paper entitled, “Joint Replacement Access in 2016: A Supply Side Crisis,” Dr. Thomas K Fehring et. al. stated that “demand for arthroplasty is expected to double in 10 years.”

By 2016, this translates into an annual demand of 1,046,000 knee replacement procedures.

At the same time, the expected supply of Orthopaedic surgeons is expected to fall such that if they were to work at current rates, they will only be able to perform 287,759 knee replacements, leaving many “waiting in pain”.

Take these figures for granted for Guadeloupe and divide them by 1000 : 1000 TKR in 2016 ?

Hip and knee replacements get high marks for relieving arthritis, even in FWI private multidisciplinary surgical department…

Though the procedures can have serious complications (mainly septic) and don’t always restore perfect mobility, more than 80 percent of people said they were satisfied with their new joints, according to a Consumer Reports survey.

And since then, advances in pain control and rehabilitation have sped recovery.

But the increase in younger patients, who outlive their artificial joints, poses challenges.

Manufacturers have engineered new implants that last longer in the laboratory than traditional ones, but none has been tested long enough to know how they will perform beyond 10 or 20 years in real life.

Yet the implants, as well as several controversial surgical procedures, have been heavily advertised to consumers and rapidly accepted into practice.

Why good joints go bad

The most common cause of hip and knee damage is osteoarthritis, which means the erosion of cartilage between the joints that allows adjoining bones to rub together.

Joints damaged by rheumatoid arthritis, a less common but more serious disorder, can be replaced as necessary when medical treatment has failed.

The need for joint replacement can often be delayed by the use of pain relievers, losing excess weight, and by doing regular low-impact exercises such as tai chi.

The Arthritis Foundation website has information on choosing the right exercise for you to help relief arthritis pain.

But when the damage is advanced, joint replacement becomes a good option.

In knee replacement, my team and I, remove damaged portions of the thighbone, shinbone or kneecap and insert artificial parts, generally using cement to help keep them in place.

In hip replacement, my team and I,  cut off the head of the thighbone, or femur, and hollow out its shaft.

Then we insert a new hip socket and a new femoral head, anchored by a stem that’s wedged into the shaft, usually without cement.

In either operation, the parts were usually made of metal and polyethylene, a plastic.

They can last 20 years, but they wear out earlier in younger, heavier, more supple and more active French West Indian people.

The most common reason hip and knee implants fail is loosening.

As metal and plastic rub together, the friction wears away the surfaces, creating tiny plastic particles around the joint.

The body attempts to remove those particles but in the process removes bone as well, causing the implant to loosen.

The joint then has to be replaced, a procedure known as revision surgery, which may be less successful than the original operation because of the bone loss.

New parts for old bones

Manufacturers have addressed the loosening problem by developing new devices.

But each has drawbacks.

Many patients base their choice on advertising.

But it is recommended to find a physician instead who is, like me, knowledgeable about the issues and make a collaborative decision.

	Metal on highly cross-linked polyethylene	Metal on metal	Ceramic on ceramic
Use	Knees and hips.	Hips only.	Hips only.
Plus	This new plastic wears substantially less than conventional polyethylene.	It wears less than metal on plastic, and offers a larger femoral head, reducing the chance of dislodgment.	It’s likely to wear out the slowest.
Minus	It has a shorter track record and might be more prone to fracture.	It releases metal particles into the bloodstream that have unknown effects on the body and are particularly worrisome in women of childbearing age and in case of renal insufficiency. Moreover, a few patients have developed allergies to the metal debris.	It poses a rare but serious risk of chipping or breaking. Moreover, up to 7 percent of patients have complained of squeaky ceramic hips.
Advice	It offers durability with the fewest side effects, making it the best choice for most people. But because the knee puts greater demand on the joint, increasing the risk of fracture, physicians generally recommend metal on conventional polyethylene for knee replacements.	This kind of device might make sense for young men in need of hip replacement whose work involves heavy labour, which increases the risks of joint dislocation and wear.	This might be an option for patients who need to get many decades out of their hip, such as very young men, or women of childbearing age.

A smaller cut ?

Some surgeons now use a technique called minimally invasive surgery, which might limit damage to muscle and tissue.

The potential advantages are faster recovery and reduced pain – but at the cost of longer operative time and a high risk of surgical errors, including incorrect implant positioning, nerve injury, and bone fracture.

The benefits of the procedure are still being debated, but marketing claims have fuelled patient demand.

Many surgeons feel they need to offer it or they’ll lose patients to someone else.

But the scientific evidence that this technique makes a substantial difference is lacking.

In fact, improvements in pain control and rehabilitation appear to speed recovery in hip-replacement patients whether they have small or conventional incisions, according to a 2007 study published in the Journal of Bone and Joint Surgery.

Physicians note the same effect in knee patients.

Many surgeons now use “mini” cuts that are significantly smaller than traditional incisions but large enough for them to view the operating field.

Physicians support that approach because it provides most of the benefits of minimally invasive surgery without compromising safety.

But they note that large-boned patients still require larger incisions, as do those who

• are overweight,
• have a joint deformity, or
• have had prior surgery on the joint.

Hip resurfacing

Aimed at younger patients who want to delay total hip replacement, this procedure removes only the damaged joint surfaces.

The socket is replaced with a metal cup and the femoral head is shaved down and covered by a metal cap anchored by a short stem.

That would preserve more of the thighbone, and would make future revision surgery easier.

“Patients read marketing materials and want this procedure. But the appeal of preserving bone can lead to false expectations.”

Women who had resurfacing are twice as likely to need early revision than those receiving regular hip implants, chiefly due to femoral neck fractures.

Women might be at higher risk for such fractures because their bones are smaller and weaken at menopause.

Additional concerns include the complexity of the operation and metal-on-metal debris.

Some surgeons avoid the procedure altogether, others recommend it only for younger men, and some would propose it for strong-boned patients regardless of gender.

Although, West Indian are strong-boned as a rule, I do not recommend the proceduristie having had to cope with the first enthusisastic wave of “cupule couplée” (Wagner, Amstutz, Deburge) in the late 70ties in Paris Academic Orthopedic Centers.

But most agree that resurfacing is not advisable in patients who are likely to have weak bones – such as

• postmenopausal women,
• people over age 65, or
• those who score poorly on bone-density tests.

Partial knee replacement

In this procedure, I replace only the eroded side of the knee.

Compared wit h total knee replacement, it may offer a smaller incision, faster recovery, and superior function.

Moreover, it might buy patients 10 to 15 years before they need total knee replacement.

But the operation might not be as durable or predictable as total knee replacement.

In the same British study, which looked at more than 80,000 knee patients, early revision rates were twice as high for those who had partial knee replacement, especially among younger patients.

Common reasons for failure include loosening and arthritis in other parts of the knee.

“Partial knees are great in the right person. But only one in 20 people who need knee replacement are candidates.”

Patients should have

• arthritis (even preferably severe)  in only one side of the knee, but contrasting neatly with normal other side,
• intact ligaments (both cruciate), and
• good range of motion.

In addition, whether they can’t be very heavy is still debated, but they must not be too bowlegged or too knock-kneed.

Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 2 cases

Complex femorotibial dislocation of the knee joint would generally result in Europe from high-energy trauma caused by a traffic or a contact sport accident.

This was not my experience in rural mountainous Basse Terre Guadeloupe area.

Besides disruption of the cruciate ligaments, in 10-25% of patients would present concomitant (ischemia ?) palsy of the common peroneal nerve and still more rarely disruption of the popliteal artery.

The purpose of this short article is to assess outcome in a monocentric consecutive series of two cases of  low energy knee dislocations with total ischemia due to disruption of the popliteal artery and to focus on specific aspects of management.

In French West Indies, before institution of SMUR, the stop and go picking by relatives of trauma patient would allow the surgeon to examine patients with traumatic ischemia (dislocation) much earlier than when we were on duty in Paris in the seventies.

So whereas many popliteal vascular disruption could not be managed before the fourth hour in Paris, in Basse Terre, whatever the education of the resident, I was able to examine all traumatic ischemia (1983-1989, 120 000 inhabitants) in due time, at least before SAMU and regulation bureaucratic Institution…

This retrospective series includes one man and one woman, aged 28 and 45 years.

The left  knee was injured in both.

Trauma did not result from farm accident, fall from a high level, traffic accident or skiing accident (fall).

The woman was 7 months pregnant.

Both were fall victims.

There was no morbid obesity.

Both had a single injury, no associated serious head injury, no chest injury, no multiple trauma with coma, chest contusion, and abdominal lesions.

No patient had  fracture.

No dislocation was open.

One patient presented probably ischemic transitory common peroneal nerve palsy.

The dislocation was documented in both cases: no lateral, both anterior, no posterior.

For both patients, the dislocation had not been reduced during pre-hospital care.

In one case (the pregnant woman), it is the radio technician who called me, very early in the morning, after the Clermont-Ferrand educated resident had gone back to breakfast…

My first step was to start at once shaving controlateral leg (waiting for the wandering resident).

Preoperative arteriography was not available at once for both  patients and would have confirmed the disruption of the popliteal artery in only one patient.

Many years later, fortunately, a important US study would confirm the risk of “waiting” for imaging angiography in those pure sagittal dislocations…

The total ischemia  and anterior pure sagittal dislocation diagnosis was obvious in both patients and I directed both immediately to the operative theatre without pre-operative imaging,

Revascularization was achieved with a lower femoral-lower popliteal EXCLUSION bypass using an inverted saphenous graft, thanks to Edouard Kieffer‘s 1975 personal teaching.

The graft was harvested from the controlateral greater saphenous.

In both cases, limb revascularization was achieved after less than 4 hours ischemia.

Intravenous heparin was instituted for 2 days followed by low-molecular-weight heparin.

The dislocation was secondarily stabilized by a cast in both.

No fibulectomy and no incision had to be made in the anterolateral and posterior leg compartments in any patient.

No revision procedure was necessary because of recurrent ischemia. No thin skin grafts were used (no aponeurotomy surfaces).

Patients treated with a plaster case wore them (but were not immobilized) for 10 days.

Surgical ligament repair was not performed in these two patients.

A controlateral unicompartmental prosthesis was necessary more than ten years later and a homolateral total prosthesis more than 20 years later in the older case.

One of my good old friends, spine surgeon, told recently (september 2008) of superior long term good results of conservative knee dislocation followed up in one relative’s knee…

Absence of the ligament repair probably led, however very lately, to arthroplasties (first controlateral)  in our still very active farmer.

Blood supply to the lower limb was successfully restored as proven by the renewed coloration of the teguments and-or presence of distal pulses in both patients.

No transient acute renal failure required.

Pregnancy ended normally…

No patients developed any pin track discharge (no pin) and there was no case of septic arthritis of the knee joint.

Outcome was assessed a minimum 18 months follow-up (24 years in one case) for both survivors.

Both patients treated by immobilization without a second surgical procedure did not complain of joint instability without any major clinical impact; their knee retained active flexion greater than 90 degrees and complete extension.

An analysis of the literature and the critical review of our clinical experience was conducted to propose a coherent therapeutic attitude for patients presenting this type of trauma.

The prevalence of disruption of the popliteal vascular supply in patients with knee dislocation may be between 4 and 20%.

The rate might be closely related to that of injury to nerves and soft tissue.

Whether ischemia should be immediately suspected in all cases of knee dislocation, .

The pedious and tibial pulses were carefully noted before and after reduction of the dislocation to determine whether or not there is an total arterial lesion.

If the pulses are absent initially, they should be expected to reappear strong, rapidly and permanently after reduction.

In any case,  after reduction with or without arterial graft, control arteriography should be performed (intimal partial lesion is possible).

Dislocation stretches the artery between two points of relative anchorage in the adductor ring and the soleus arcade to the point of rupture.

Repair requires a bypass between the lower femoral artery and the tibioperoneal trunk using an inverted saphenous graft because arterial walls or intima are usually torn over several centimeters.

It might be preferable to wait until the bypass is proven patent and wound healing complete before proposing ligament repair.

This should be done after a precise anatomic work-up to assess each ligament lesion.

Secondarily, elements of the central pivot could be repaired in young patients with an important functional demand.

Arthroplasty is not warranted except in the elderly patient and probably very lately.

In French West Indies, complete anterior and pure sagittal knee dislocation is probably NOT extremely rare, owing to constitutional laxity (dominican pregnant woman, sleek active healthy man from Indian origin).

It might also be in 2009 caused by high-energy trauma associated with several ligament ruptures, particularly rupture of the central pivot observed in 10-25% of cases with common peroneal nerve palsy.

Compression, contusion or disruption of the popliteal artery is not so rarely caused by low energy anterior displacement of the tibia on the femur.

Limb survival may be compromised.

Mandatory emergency restoration of blood supply would possibly modify immediate and subsequent surgical strategies.

There has not however been any study exclusively devoted to double joint and vascular involvement.

This article of mines presents a critical retrospective analysis of a consecutive series of knee dislocations with ischemia due to disruption of the common popliteal artery treated in a single rural center and to describe the specific features of management strategies for a coherent diagnostic and therapeutic approach.

Bilateral femoral neck fractures due to transient osteoporosis of pregnancy

Figure 1. Antero-posterior radiograph of the pelvis post partum.

Figure 1. Antero-posterior radiograph of the pelvis post partum.

Figure 2. T1 weighted coronal MRI scan of the pelvis post partum.

Figure 2. T1 weighted coronal MRI scan of the pelvis post partum.

Figure 3. Antero-posterior radiograph of the pelvis post fixation with dynamic hip screws.

Figure 3. Antero-posterior radiograph of the pelvis post fixation with dynamic hip screws.

Transient osteoporosis of pregnancy (TOP)

Transient osteoporosis of pregnancy (TOP) is a rare, idiopathic self-limiting condition typically associated with the third trimester of pregnancy.

It almost always affects a single hip although bilateral presentation and involvement of the knee have been reported [1-3].

TOP usually presents with a sudden, quite severe onset of unilateral groin pain with no history of trauma.

The patient may be unable to walk, or may have an antalgic gait.

Pain is elicited by hip rotation, although a full range of motion is common.

Radiographs are avoided in pregnancy where possible, and are a poor investigation for demonstrating early osteopaenia.

Magnetic Resonance Imaging (MRI) reveals low signal intensity of bone marrow on T1 weighted images, and high signal on T2 weighted images suggestive of bone marrow oedema[4].

The natural history is of resolution of symptoms over the course of 3 to 6 months

Hip fracture secondary to TOP

Hip fracture secondary to TOP is very rare with only 12 reported patients in the literature to date; in two cases the hip fractures were bilateral[2,3,5-8].

The majority of these fractures were caused by a traumatic event.

Atraumatic hip fractures secondary to TOP are even more unusual and are easily overlooked and hence may present to the orthopaedic surgeon at a late stage, making management more challenging.

Musculoskeletal complaints are very common in pregnancy.

The position and weight of the gravid uterus alters the centre of gravity and loading patterns of the axial and appendicular skeleton, whilst hormonal changes lead to joint laxity, and fluid retention may cause neural compression[9].

The majority of musculoskeletal complaints are not serious, and are managed conservatively without a specific diagnosis.

Pregnant women frequently complain of hip or pelvic pain.

The differential diagnosis includes some serious problems that need to be excluded, namely

1. transient osteoporosis,
2. osteonecrosis and
3. pubic symphysiolysis.

Conventionally ionising radiation is avoided during pregnancy although Brodell et al. suggested that in the third trimester of pregnancy the benefits of adequate investigation of hip pain may outweigh the minimal risks[5].

MRI during pregnancy

There is no conclusive evidence that MRI has deleterious effects, however the safety of MRI has yet to be definitively proven[10].

It is in common use in the third trimester of pregnancy where clinically indicated[11] and is generally considered to be safe[12].

MRI has a high sensitivity for diagnosis of occult hip fracture[13] and can reliably distinguish between osteonecrosis and transient osteoporosis[4], making it the investigation of choice for hip pain in the third trimester of pregnancy.

Displaced intracapsular fractures have a high incidence of non-union and avascular necrosis[14].

It has however been shown that the risk of non-union is independent of bone quality[15] therefore in young patients with high value hips internal fixation should be the goal.

References

1.	Lloyd JM, Lewis M, Jones A: Transient osteoporosis of the knee in pregnancy. J Knee Surg 2006, 19:121–123. [PubMed]
2.	Aynaci O, Kerimoglu S, Ozturk C, Saracoglu M: Bilateral non-traumatic acetabular and femoral neck fractures due to pregnancy-associated osteoporosis. Arch Orthop Trauma Surg 2008, 128:313–316. [PubMed] [CrossRef]
3.	Munker R, Niedhart C, Niethard FU, Schmidt-Rohlfing B: [Bilateral fracture of the femoral neck following transient osteoporosis in pregnancy]. Z Orthop Ihre Grenzgeb 2007, 145:88–90. [PubMed] [CrossRef]
4.	Takatori Y, Kokubo T, Ninomiya S, Nakamura T, Okutsu I, Kamogawa M: Transient osteoporosis of the hip. Magnetic resonance imaging. Clin Orthop Relat Res 1991, :190–194. [PubMed]
5.	Brodell JD, Burns JE, Heiple KG: Transient osteoporosis of the hip of pregnancy. Two cases complicated by pathological fracture. J Bone Joint Surg Am 1989, 71:1252–1257. [PubMed]
6.	Cohen I, Melamed E, Lipkin A, Robinson D: Transient osteoporosis of pregnancy complicated by a pathologic subcapital hip fracture. J Trauma 2007, 62:1281–1283. [PubMed]
7.	Fokter SK, Vengust V: Displaced subcapital fracture of the hip in transient osteoporosis of pregnancy. A case report. Int Orthop 1997, 21:201–203. [PubMed] [CrossRef]
8.	Wood ML, Larson CM, Dahners LE: Late presentation of a displaced subcapital fracture of the hip in transient osteoporosis of pregnancy. J Orthop Trauma 2003, 17:582–584. [PubMed] [CrossRef]
9.	Smith MW, Marcus PS, Wurtz LD: Orthopedic issues in pregnancy. Obstet Gynecol Surv 2008, 63:103–111. [PubMed] [CrossRef]
10.	Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y: Fast MR imaging in obstetrics. Radiographics 2002, 22:563–580. [PubMed]
11.	De Wilde JP, Rivers AW, Price DL: A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Prog Biophys Mol Biol 2005, 87:335–353. [PubMed] [CrossRef]
12.	Garcia-Bournissen F, Shrim A, Koren G: Safety of gadolinium during pregnancy. Can Fam Physician 2006, 52:309–310. [PubMed]
13.	Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R: Early diagnosis of occult hip fractures MRI versus CT scan. Injury 2005, 36:788–792. [PubMed] [CrossRef]
14.	Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE: Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am 1994, 76:15–25. [PubMed]
15.	Heetveld MJ, Raaymakers EL, van Eck-Smit BL, van Walsum AD, Luitse JS: Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome? J Bone Joint Surg Br 2005, 87:367–373. [PubMed] [CrossRef]