Differential light intensity and spectral sensitivities of Atlantic salmon, European sea bass and Atlantic cod pineal glands ex vivo

Photoperiod is perceived by pineal photoreceptors and transduced into rhythmic melatonin signals. These rhythms can be influenced by light intensity and spectral content. In this study we compared the light sensitivity of Atlantic salmon, European sea bass and Atlantic cod by testing ex vivo the effect of different intensities and narrow bandwidth lights on nocturnal melatonin suppression by isolated pineal glands in a flow-through culture system. Using combinations of neutral density and bandpass interference filters we tested a range of light intensities (ranging from 1.22x10(13) to 3.85x10(6) photons s(-1) cm(-2)) and three wavelengths of 80 nm width (472, 555 and 661 nm corresponding to blue, green and red, respectively). Results showed clear species specific light intensity and spectral sensitivities, with cod being from 100 to 1000 times more sensitive than sea bass and salmon. Regarding the influence of spectrum, red light was less efficient on suppressing melatonin than blue and green in salmon but results were not as clear in the two other species studied. Finally, the first evidence of relative photoreception in teleosts was obtained in cod suggesting that the definition of illuminance thresholds (day/night perception) would depend on the day intensity. Indeed, a single order of magnitude increase or decrease in day intensity was shown to elicit a significant shift in the intensity response curve of night-time melatonin suppression. Taken together, this study demonstrated species specific light intensity and spectral sensitivities within temperate teleosts.

Bilateral simultaneous metal inlay dissociation from the polyethylene liner of a metal-on-metal hip replacement

INTRODUCTION

Hard-on-hard bearings for total hip replacement may require a modular acetabular inlay for which polyethylene is often used in a sandwich-type configuration. However, differences in the elastic modulus of the materials make fixation of this metal insert uncertain. The aim of this study is to report a case of bilateral separation of the metal insert from the polyethylene sandwich in a metal-on-metal bearings prosthesis.

MATERIALS AND METHODS

A bilateral total hip arthroplasty was performed in two operations, four months apart, in a 53-year-old woman following a corticosteroid-induced osteonecrosis. The total hip replacement system included a cementless stem, and a press-fit hemispheric cup containing a polyethylene sandwich with a metallic insert (Sikomet).

RESULTS

Three years later, the patient consulted because of abnormal noise in her right hip which appeared normal on conventional X-ray. Three months later she consulted again for persistent noise. Separation of the metal insert from the polyethylene sandwich was diagnosed and an acetabular revision was performed selecting a metal-on-polyethylene articulation system. The postoperative course, for this revision, was uneventful, but the patient returned with the similar symptoms in her left hip four months later, resulting in the same type of revision. During the revisions, osteolysis secondary to metallosis was diagnosed, requiring synovectomy and acetabular reconstruction with morcelized allograft impaction. The left side postoperative course included three dislocations in nine months which were conservatively treated and have not since recurred.

DISCUSSION AND CONCLUSION

This is the first reported case recording an almost simultaneous bilateral dissociation of a hard-on-hard inlay from its polyethylene sandwich. This bilateral case suggests that the fixation of the metal insert inside the polyethylene was probably defective. This case is also a reminder that mechanical complications (separation, implant fracture) should be searched for in presence of any abnormal noise occurring after hard-on-hard bearings prosthetic implantation. This confirms the necessity of periodical follow-up of hip arthroplasties and the importance of knowing their radiological features. The low carbon content of the Sikomet bearing may have been the cause of this failure by increasing frictional torque on the bearing surface, causing metallosis which has already been described in the literature in this type of hip replacement system.

Total knee arthroplasty in valgus knees: predictive preoperative parameters influencing a constrained design selection

INTRODUCTION

In valgus knees, ligament balance might remain a challenge at total knee prostheses implantation; this leads some authors to systematically propose the use of constrained devices (constrained condylar knee or hinge types...). It is possible to adapt the selected level of constraints, by reserving higher constraints to cases where it is not possible to obtain final satisfactory balance: less than 5 degrees of residual frontal laxity in extension in each compartment, and a tibiofemoral gap difference not in excess to 3 mm between flexion and extension.

HYPOTHESIS

It is possible to establish preoperative criteria that can predict a constrained design prosthetic implantation at surgery.

MATERIALS AND METHODS

A consecutive series of 93 total knee prostheses, implanted to treat a valgus deformity of more than 5 degrees was retrospectively analysed. Preoperatively, full weight bearing long axis AP views A-P were performed: hip knee angle (HKA) averaged 195 degrees (186 degrees to 226 degrees), 36 knees had more than 15 degrees of valgus, and 19 others more than 20 degrees of valgus. Laxity was measured by stress radiographies with a Telos system at 100 N. Fifty-two knees had preoperative laxity in the coronal plane of more than 10 degrees. Fourteen knees had more than 5 degrees laxity on the convex (medial) side, 21 knees had more than 10 degrees laxity on the concave (lateral) side. Statistical assessment, using univariate analysis, identified the factors that led, at surgery, to an elevated constraint selection level; these factors of independence were tested by multivariate analysis. Logistical regression permitted the classification of the said factors by their odds ratios (OR).

RESULTS

High-constraints prostheses (CCK type) numbered 26 out of 93 implantations; the other total knee prostheses were regular posterostabilized (PS) prostheses. Statistically, the preoperative factors that led to the choice of a constrained prosthesis were: (1) valgus severity as measured by HKA (PS=193 degrees, CCK=198 degrees), (2) increased posterior tibial slope (PS=4.8 degrees, CCK=6.5 degrees), (3) low patellar height (using Blackburne and Peel index PS=0.89, CCK=0.77), (4) severity of laxity in valgus (PS=2.3 degrees, CCK=4.3 degrees). Among all these factors, the only independent one was laxity in valgus (convex side laxity) (p=0.0008). OR analysis showed a two-fold increased probability of implanting an elevated constraints prosthesis for each one degree increment of laxity in valgus.

DISCUSSION

This study demonstrated that it was not the valgus angle severity but rather the convex medial side laxity that increased the frequency of constrained prostheses implantation. Other factors, as a low patellar height or an elevated posterior tibial slope, when associated, potentiate this possible prosthetic switch (to higher constraints) and should make surgeons aware, in these situations, of encountering difficulties when establishing ligament balance.

LEVEL OF EVIDENCE IV

Therapeutic retrospective study.

The effect of seasonality on normal haematological and innate immune parameters of rainbow trout Oncorhynchus mykiss L

It is well established that seasonality dominates the life history of fish by controlling the timing of physiological events such as reproduction, food intake, locomotor activity and growth performance. Seasonal differences in immune competence and prevalence of disease have been well documented in humans. The aim of this study was to determine if season influences the immune response of rainbow trout (Oncorhynchus mykiss L.). Thus, a 12-month trial was carried out in which plasma lysozyme activity and respiratory burst of head kidney macrophages (two innate immune parameters) and total red and white blood cell counts (two haematological parameters) were monitored at monthly intervals. Since photoperiodic information is thought to be conveyed via melatonin secretion, plasma melatonin levels were also measured at four seasonal points (day and night). A general seasonal influence was observed in the parameters measured in these fish, with the exception of respiratory burst activity of head kidney macrophages, with the parameters highest in summer and lowest in winter for total white blood cell counts and lysozyme activity.

Delayed, transient sciatic nerve palsy after primary cementless hip arthroplasty: a report of two cases

Delayed sciatic nerve palsy is uncommon after primary hip replacement. Two kinds of sciatic palsy have been reported with regard to the time of onset: early palsy related to wound haematoma or lumbosacral nerve elongation which occurs between surgery and 18 days, is more frequent than delayed palsy, occurring between 10 and 32 months, which is usually caused by cement extrusion or heat produced by cement polymerisation. We present two cases of delayed, transient sciatic nerve palsy arising at three weeks and four months after primary cementless arthroplasty, respectively, without haematoma and with a normal lumbar spine. These palsies were possibly caused by excessive tension from minor limb lengthening of 2 cm to 4 cm required to achieve leg-length equality. As the initial symptoms were limited to calf pain and mild numbness in the foot, surgeons should be aware of this mode of onset, particularly when it is delayed after hip replacement. Both patients recovered fully by 12 months after surgery so we did not undertake surgical exploration of the nerve in either patient.

Safety of prolonged high-dose levofloxacin therapy for bone infections

The records of 84 patients with bone infections treated with high-dose levofloxacin (i.e. 0.75-1g daily) for more than 4 weeks were reviewed. Patients were given either 500 mg b.i.d. throughout the treatment period [Group 1 (n=41)], 500 mg b.i.d. for 3 weeks and then 750 mg q.d. [Group 2 (n=21)] or 750 mg q.d. for the whole treatment period [Group 3 (n=22)]. All patients had combined therapy, including levofloxacin-rifampin in 62 cases (73.8%), for an average duration of 13.7 weeks. Muscular pain and/or tendonitis were reported in 19 patients (22.6%) which affected more patients in Groups 1 and 2 than in Group 3 (14/41 and 5/21 vs. 0/22; p=0.01 and 0.001, respectively). A dosage of 750 mg q.d. may be warranted for prolonged high-dose levofloxacin treatment in patients with bone infections rather than 500 mg b.i.d. for the entire duration of treatment, or for the first 3 weeks.

[Metal-on-metal hip replacement using Metasul cups cemented into Muller reinforcement rings after a mean 5-year (3-8) follow-up: improvement of acetabular fixation by comparing with direct cementation to bone]

PURPOSE OF THE STUDY

Early loosening, before a three-year follow-up, has been observed with cemented cups having a metal-on-metal insert in a polyethylene cup. The metal-on-metal bearing has been incriminated as the source of the problem because of its rigidity (particularly for small cups measuring less than 50 mm) and the creation of stress conditions unfavorable for a cemented fixation. The purpose of this retrospective study was to determine whether this phenomenon is observed when the cement is fixed not directly into the bone, but via a Muller reinforcement ring.

MATERIAL AND METHODS

From 1998 to 2004, 23 arthroplasties using a cemented Metasul cup in a reinforcement ring were implanted in 22 patients (16 women and six men) aged on average 44 years (range 24-56 years). The series included six primary total hip arthroplasties (three for dysplasia, two for protrusions, one for rheumatoid arthritis and one for arthritic degradation) and seventeen revisions (two septic). The Metasul cup (Zimmer-Centerpulse) combined a 28 mm modular head anchored in a femoral implant (two cemented, 21 pressfit) and a polyethylene cup with a Metasul insert (13 of 23 measuring<50mm). In all cases, the cup was fixed with low-viscosity cement in a Myller metal reinforcement ring fixed with screws (Zimmer-Centerpulse). All patients were reviewed clinically and radiographically at a mean 5-year follow-up (range 3-8 years). Acetabular and femoral fixation were analysed (search for lucency and implant migration).

RESULTS

Revision was not necessary in any patient for failure of the acetabular fixation. The mean Postel-Merle-d'Aubigné score improved from 12.9 points (range 7-17) to 17.5 points (range 16-18). The radiographic analysis did not reveal any sign of lucency between the cup and ring, nor any migration of the ring. There was no evidence of femoral osteolysis but one femoral revision was needed due to fracture of the lateral cortical identified six weeks after implantation.

DISCUSSION AND CONCLUSION

Cementing the metal-on-metal cup into a reinforcement ring can avoid the risk of loosening observed after direct cementing into bone. In our study, the large number of small cups (13/23) would have been expected to produce a high rate of acetabular lucent lines and/or a high rate of early revision, as reported by others, as early as 24 months. Our series was also different from others by the use of pressfit femoral implants in most patients, which should reduce the risk of cement debris in the bearing. Longer follow-up will be necessary to confirm the good results observed to date which suggest that direct cementing of the cup into the bone should be incriminated rather than the metal-on-metal bearing to explain the reported failure of cemented Metasul cups.

GPR54 and rGnRH I gene expression during the onset of puberty in Nile tilapia

The Kiss1/GPR54 system has recently been shown to play a key role in the onset of puberty in mammals. Growing evidence suggests that this system is also conserved across vertebrates although very few studies so far have been performed in lower vertebrates. The aims of this study were firstly in the teleost Nile tilapia to screen tissues for GPR54 expression levels, secondly to measure the expression patterns of GPR54 and GnRH I receptor (rGnRH I) in whole brains during the onset of puberty and finally to determine the effects of continuous illumination (LL) on receptor expression levels. Results confirmed that GPR54 was predominantly expressed in the brain and pituitary of adult tilapia. Furthermore, a significant increase of GPR54 gene expression was found in tilapia brains at 11 weeks post hatch (wph) followed by rGnRH I at 13 wph just prior to the histological observation of vitellogenic oocytes and active spermatogenesis in ova and testes at 17 wph. These results suggest a correlation between the increase of GPR54 expression in the brain and the onset of puberty. Finally, a significant effect of LL was observed on GPR54 expression levels which were characterized by a delayed surge with significantly lower levels than those of control fish. The current study not only suggests a link between the Kiss1/GPR54 system and the onset of puberty in a tropical batch spawning teleost that would be a highly conserved feature across vertebrates but also that the transcriptional mechanisms regulating GPR54 expression could be directly or indirectly influenced by light.

Relationships between environmental changes, maturity, growth rate and plasma insulin-like growth factor-I (IGF-I) in female rainbow trout

Size reflecting growth rate, energy balance or nutritional status is regarded as an important determinant of the ability of trout to undergo puberty. The relationship of a change in photoperiod, either natural (SNP) or advancing (ADV), with growth, IGF-I and reproduction was investigated in virgin female rainbow trout. Under SNP 63% of the population attained maturity while only 29% spawned 6 months in advance in the ADV regime. Under SNP both size and growth rate in late spring-early summer appeared to determine whether an individual may initiate reproduction while condition factor appeared to be a better predictor in the ADV regime. A complete seasonal relationship between plasma IGF-I, daylength and temperature was demonstrated under natural conditions, and provides direct evidence for the relationship between reproduction and IGF-I. Conversely, trout maintained under ADV exhibited a significantly different plasma IGF-I profile relative to those under a natural photoperiod. Furthermore, IGF-I levels accurately reflected growth rate prior to elevations in sex steroids, suggesting that IGF-I may provide an endocrine signal between the somatotropic and reproductive axes that growth rate and/or size is sufficient to initiate gonad development. In addition, maturing individuals under SNP typically expressed higher circulating IGF-I levels than those that remained immature and may reflect a greater opportunity for IGF-I to act on the pituitary to stimulate gonadotropin production. We observed elevated levels in maturing fish for 3 months under SNP compared to only 1 month under ADV were observed. This may reflect a reduction in the window of opportunity to initiate reproduction under advancing photoperiods and hence explain the reduction in fish successfully recruited.

[Polyethylene liner replacement: behavior and morbidity in 68 cases]

PURPOSE OF THE STUDY

Isolated acetabular polyethylene exchange is advocated as an advantage of metal-backed cups, since the acetabular bone stock can be spared and operative time is shorter. The purpose of this study was to determine whether this is true.

MATERIAL AND METHODS

A consecutive serie of 68 THA revisions involving replacement of the polyethylene liner was analyzed retrospectively (liner replacement alone for 37 hips and liner replacement plus femoral component revision for 31). The posterolateral approach was used for the revision in all cases. This series was compared with a control series of revisions involving the acetabular component with revision of the femoral component in patients matched for age, sex, and BMI.

RESULTS

Operative time and hospital stay were significantly shorter when the revision involved the polyethylene liner alone. In 19 hips, a limited zone of osteolysis was observed around the liner before replacement. At last follow-up, new zones of osteolysis were noted in two hips and aggravation in five, one of which required revision because of acetabular loosening. Episodes of dislocation were observed in nine hips (2 anterior and 7 posterior) of which three underwent revision because of recurrence. These dislocations occurred after liner replacement (n=4) or combined liner and femoral component replacement (n=5). Dislocations were more frequent after multiple hip operations and when the cup inclination was less than 40 degrees . Ten revisions were required for: an unclipped liner (n=2), recurrent dislocation (n=3), acetabular loosening (n=1), infection which was cured after a one-stage procedure (n=1). At seven years, survival was comparable between liner replacement alone (82+/-10%), combined liner replacement and femoral component revision (84+/-11%), and femoral component and acetabular component revision (82+/-11%).

DISCUSSION

Changing the cup liner can limit morbidity compared with a more complex revision, but liner replacement alone is insufficient in the event of acetabular osteolysis. It would be preferable to combine osteolysis debridement with a graft or a complete revision. The survival rate after liner replacement is comparable with that observed after more complex revision but the risks of dislocation or unclipped insert are significant. For this reason, liner replacement alone should only be proposed if the cup is correctly aligned and if the new liner can be solidly clipped into the metal back. In addition, this simplified procedure should not be attempted after multiple hip operations.

Evidence for differential photic regulation of pineal melatonin synthesis in teleosts

The aim of this study was to compare the circadian control of melatonin production in teleosts. To do so, the effects of ophthalmectomy on circulating melatonin rhythms were studied along with ex vivo pineal culture in six different teleosts. Results strongly suggested that the circadian control of melatonin production could have dramatically changed with at least three different systems being present in teleosts when one considers the photic regulation of pineal melatonin production. First, salmonids presented a decentralized system in which the pineal gland responds directly to light independently of the eyes. Then, in seabass and cod both the eyes and the pineal gland are required to sustain full night-time melatonin production. Finally, a third type of circadian control of melatonin production is proposed in tilapia and catfish in which the pineal gland would not be light sensitive (or only slightly) and required the eyes to perceive light and inhibit melatonin synthesis. Further studies (anatomical, ultrastructural, retinal projections) are needed to confirm these results. Ex vivo experiments indirectly confirmed these results, as while the pineal gland responded normally to day-night rhythms in salmonids, seabass and cod, only very low levels were obtained at night in tilapia and no melatonin could be measured from isolated pineal glands in catfish. Together, these findings suggest that mechanisms involved in the perception of light and the transduction of this signal through the circadian axis has changed in teleosts possibly as a reflection of the photic environment in which they have evolved in.

Fiabilité limitée du plan pelvien antérieur pour l’implantation assistée par informatique de la cupule d’une prothèse totale de hanche

PURPOSE OF THE STUDY

The anterior pelvic plane, also called the Lewinnek plane, is commonly used as the reference plane to guide imageless computer assisted surgery for total hip arthroplasty (THA) because this plane is considered to be globally vertical in the standing position. To our knowledge, no study has evaluated this hypothesis or the potential variations in orientation as a function of gender, position of the subject, or THA insertion. The purpose of this work was to examine these different hypotheses in a radio-clinical study.

MATERIAL AND METHODS

The orientation of the anterior pelvic plane was measured in relation to the vertical plane on plain lateral x-rays of the pelvis in the standing position. X-rays were studied for 106 patients: 1) 82 patients with a THA (40 with at least one dislocation, 42 with a stable hip selected randomly, 19 with a standing lateral x-ray before and after arthroplasty) and 24 control subjects for whom lateral images were obtained in the supine and standing positions to assess potential position-related changes in orientation.

RESULTS

The orientation of the anterior pelvic plane was not affected by gender or age. The anterior pelvic plane formed an angle greater than 5 degrees with the vertical plane in 38% of patients and more than 10 degrees in 13%. The orientation of the anterior pelvic plane was not significantly different between the study groups (control versus THA) nor between the THA groups (stable versus dislocated). The supine position modified significantly the orientation of the anterior pelvic plane which changed on average from 1.20 degrees to -2.25 degrees ; the change was greater than 7 degrees in twelve subjects. Implantation of a THA did not modify signi-ficantly the orientation of the anterior pelvic plane in the standing position for the 19 subjects [the variations were small (-1 degrees to 7 degrees on average, range -21 degrees to 8 degrees ) but greater than 5 degrees for 7 of 19 subjects].

DISCUSSION

Most teams use the anterior pelvic plane to guide computer-assisted navigation, considering that this plane is vertical in the standing position. Our findings show however that this is not true for 38% of subjects with a margin of error of 10 degrees , i.e. about half of the anatomic anteversion of the acetabulum. Moving to the standing position would produce a significant variation in the orientation of the anterior plane of the pelvis. This is a source of error which has not been integrated into most imageless navigation systems. Similarly variations in the position of the pelvis from the standing to sitting and supine positions which can produce impingement or dislocation have not been taken into consideration.

CONCLUSION

Variations in the orientation of the anterior pelvic plane in relation to the vertical would suggest that this plane is not a reliable reference. To our knowledge, there is no reliable reference which can be easily identified during the operation which would take into account variations in the position of the pelvis. We thus believe it would be preferable to attempt to operate without a reference plane, relying on a more kinematic approach to guide computer-assisted implantation of the THA cup.

The influence of ploidy on saltwater adaptation, acute stress response and immune function following seawater transfer in non-smolting rainbow trout

We investigated the effect of ploidy on osmoregulatory, stress and immune responses in non-smolting rainbow trout during saltwater adaptation. Sibling groups of diploid and triploid trout were acclimated in freshwater (FW) and then subjected to abrupt transfer to full strength (35ppt) saltwater (SW) or back to FW. Fish were sampled pre-stress, and 1, 3, 6, 12, 24, 48, 72 and 168h post-stress. Overall mortality in SW was less than 5% in either ploidy, with no mortality in FW. Significant elevations in plasma osmolality and gill ATPase were observed within 1-3h of SW transfer, but retuned to basal levels within 72h indicative of rapid saltwater adaptation and did not differ between ploidy. Furthermore, FW-SW transfer also caused significant and sustained elevations in total blood haemoglobin, plasma IGF-I, cortisol, glucose, total white blood cell counts, increased plasma but decreased mucus lysozyme, and enhanced head kidney macrophage respiratory burst activity. Conversely, FW-FW transfer evoked more transient and less elevated responses, more typical of primary and secondary responses to a single stressor. We conclude that the more elevated levels in these parameters are a function of saltwater adaptation as well as the generic stress response, and that this did not differ between ploidy. Strong positive correlations were found between plasma IGF-I and cortisol, and with osmolality, glucose and WBC, while a negative correlation was found with plasma lysozyme irrespective of ploidy. Overall, the current results suggest that triploidy does not affect the ability of non-smolting trout to adapt to full strength seawater under optimum conditions, and that the osmotic and stress response to such transfer is similar to diploids.

[Long-term behavior of ankle fusion: assessment of the same series at 7 and 23 year (19-36 years) follow-up]

PURPOSE OF THE STUDY

Theoretically, long-term functional and radiographic degradation is predictable after ankle fusion, but sound evidence from the consecutive analysis of the same cohort is lacking. The purpose of this study was to check the hypothesis by repeating assessment in the same cohort of patients who underwent ankle fusion.

MATERIAL AND METHODS

The cohort included 52 ankle fusions which had been analyzed in 1984 at seven years (range 2-22 years) follow-up then again in 2000 using the same evaluation criteria. Among the 52 patients, six were lost to follow-up (11.5%) 20 had died (38.4%) and one had undergone leg amputation. The second analysis thus included 25 patients (48%). The comparison cohort thus included 25 patients (18 men and 7 women), mean age 62+/-12.6 years (range 40-94) at the 2000 assessment performed 23+/-4.5 years (range 19-36 years) after the fusion. Functional outcome was assessed with the 100-point Duquennoy scale. Osteoarthritis of the subtalar and mediotarsal joints were assessed preoperatively and at follow-up using the same scale.

RESULTS

The functional outcome did not deteriorate significantly between 1984 and 2000. The mean score was 65.8+/-22.6 (range 19-92) in 1984 and 64.7+/-18.3 (range 34-90) in 2000 (p=0.67). Fifteen patients (60%) had a good or very good outcome at seven years, and 14 (56%) at 23 years. Between 1984 and 2000, ten patients improved their score (on average 10.4 points, range 1-21 points), two had an unchanged score and thirteen a lower score (on average 10 points, range -1 to -24). Ten of these thirteen patients developed severe intercurrent conditions (neurological or cardiac) explaining the degradation. At last follow-up, sixteen ankles were pain free or nearly pain free. Twelve patients considered their ankle as a forgotten problem (VAS 10) and had no regrets concerning the operation. The evolution of the subtalar joint in 16 cases (nine fusions including five at the same time as the ankle fusion and four performed within four years) showed that all developed osteoarthrtic degradation early with aggravation between 1984 and 2000, leading in the majority of cases to severe degenerative disease. This osteoarthritis was painful in less than one-third of the cases (including the four secondary subtalar fusions and the four subtalar fusions which were painful at mobilization). Twenty-three mediotarsal joints were analyzed (two fusions four years after ankle fusion). The degradation was later and less severe than for the subtalar joint with a majority showing moderate osteoarthritis. Ten ankles exhibited compensatory hypermobility of the forefoot measured at more than 15 degrees without pain.

DISCUSSION

This long-term follow-up with two successive assessments using the same evaluation criteria did not demonstrated the late degradation of function expected after ankle fusion. It did show however the presence of undeniable radiographic degradation of the subtalar joint but with little or no severe clinical expression at a minimal follow-up of 19 years. There was no need for complementary fusion between 4 and 23 years follow-up.

[A new type of acetabular fracture: "true" posterosuperior fracture, a case report]

We report a new variety of acetabular fracture. This posterosuperior fracture affected the acetabular roof and the iliac wing as other superior fractures and presented a supplementary fracture line disjoining the major part of the posterior wall. Two our knowledge, in a series of 940 fractures of the acetabulum, Letournel alone described two cases of superior fractures involving the roof with a slightly anterior fracture line in the iliac wing but with an intact posterior wall in both cases. The patient was treated by osteosynthesis via the iliofemoral approach described by Judet-Letournel. This approach was warranted to achieve simultaneous exposure of both columns and the posterior wall which was separated from the proximal fragment by a secondary fracture line. At six months, the functional result was considered good as assessed by the Postel-Merle-d'Aubigné score. This case widens the Letournel classification and emphasizes the importance of computed tomography to evaluate, in superior fractures of the acetabulum, the volume of the posterior wall fragment and its continuity with the cranial portion of the acetabulum and the iliac wing. For fixation, the surgical approach must be chosen individually according to the position of the fracture lines visualized on the preoperative computed tomography.

Treatment of bone and joint infections caused by Gram-negative bacilli with a cefepime-fluoroquinolone combination

A 3-year retrospective study evaluated the effectiveness and safety of cefepime plus a fluoroquinolone for treating bone and joint infections caused by Gram-negative bacilli (GNB) in 28 patients. Intra-operative cultures yielded primarily Pseudomonas spp. and Enterobacter cloacae. Full recovery (cure) was observed in 79% of patients. There were no serious adverse effects and no resistant organisms were isolated. The results of the study confirmed the safety and effectiveness of cefepime combined with a fluoroquinolone for the treatment of bone and joint infections caused by Gram-negative bacilli.

[Bilateral Moore hemiarthroplasty: 36 years of good tolerance without loosening or osteolysis]

We report an illustrative case of bilateral Moore arthroplasty with the clinical and radiographic results at 36 years follow-up. The femoral prostheses were implanted for necrosis of the femoral head when the patient was 46 years old. At implantation the patient's physical activity level was high (Devane 4) and remained so until retirement at age 65 years. His activity level remained high (Devane 3) to the age of 82 years when the patient suffered a Vancouver B1 periprosthetic fracture on the left. At this date, both arthroplasties were free of loosening an osteolysis. Plate fixation with wiring led to fracture healing. The Postel Merle d'Aubigné score was 17 before the fracture and 16 at healing (with a pain score of 6 both before and after). Radiographically, acetabular cartilage tolerance was excellent. This case illustrates the excellent clinical outcome obtained with the Moore hemiarthroplasty at more than 35 years despite less than satisfactory initial fixation and the absence of resurfacing. The fact that this prosthesis does not have a polyethylene element prevented the development of osteolysis which could have been expected with such a long postoperative period in this a highly active patient. Favorable factors (good abductor lever arm, adapted head diameter, resistance of the acetabular cartilage in a young subject with femoral head necrosis) may have played a role in this particular case since the excellent and sustained outcome was observed on both sides. This exceptional longevity provides useful information for better determining precise indications for head cups for the treatment of necrosis of the femoral head.