Purpose: Reaming is classically contraindicated for open leg fractures. For certain authors, reaming can favour bone healing without increasing the risk of infection (Court-Brown JBJS 90B and 91B, Wiss Coor 95). The aim of this retrospective analysis of patients treated in a single centre was to validate these notions and determine the role of locked centromedullary nailing (LN) with reaming for the treatment of open leg fractures.

Material and methods: Between 1989 and June 2000, 141 open leg fractures were fixed with locked centromedullary nailing without reaming in 103 men and 38 women, mean age 34 years, who were mainly accident victims (2-wheel vehicles 43%, 4-wheel vehicles 22%). Multiple trauma was present in 18.7% of the cases and multiple fractures in 28%. Skin wounds were (Gustilo classification): type I 81 (57%), type II 38 (27%), type IIIA 14, and type IIIB 8. There was a simple fracture in 50% of the cases, a wedge fracture in 32%, and comminution in 18% with bifocal fractures in 10 cases. Osteosynthesis was performed within a mean 5.5 hours (2–18) and deferred in six cases. The Grosse and Kempf nail was used in all cases with reaming (man 11). Static locking was used in 88% of the cases. type I, II and IIA skin wounds were sutured after debridement. Three aponeurotomies were performed as preventive measures. Type IIIB wounds were treated by early plasty. A brief antibiotic prophylaxis was given in all cases.

Results: There was one aggravation of the comminution, two dismantelings subsequent to unauthorised weight-bearing, three compartment syndromes and one lateral sciatic popliteal paralysis. Two patients died from their multiple injuries. Four patients developed infection: two healed without removing the nail, one was amputated (free flap failure). One patient consulted another unit. Ten patients who were not residents of our area were lost to follow-up. Dynamisation was performed in 31 patients (25.6%) at a mean 4.4 months. Four patients with delayed healing cured after a new nailing with secondary reaming. Delay to bone healing was related to the type of fracture (p < 0.01): 4.2 months for type A (AO classification), 5.2 months for type B and 5.9 months for type C. Bone healing was correlated with Gustilo type (p < 0.05): 4.5 months for types I, 4.6 months for type II, 5.8 months for types III. Six patients developed nonunion: four were revised with success after a new nailing and secondary reaming (two lost to follow-up). Delayed healing and non-union were related to type of fracture (A = 3.8%, B = 15.6%, C = 18%) and soft tissue damage (Gustilo I: 4.1%; II: 10.7%; III: 15.8%).

Discussion conclusion: Locked centromedullary nailing with reaming is appropriate when the skin wound is minimal; dynamisation and/or replacement of the nail with secondary reaming should be discussed early in case of delayed healing.

Purpose: We report a series of 16 GUEPAR total elbow prostheses implanted in a single centre.

Material and methods: Between 1988 and 1996, sixteen GUEPAR prostheses were implanted in 13 patients (three bilateral implantations). There were 11 women and two men, mean age 61 years (51–81). Twelve patients (14 elbows) had rheumatoid polyarthritis and one patient (two elbows) had post-traumatic degenerative disease. The V transtricepital approach was used in 15 cases and the Bryan-Morrey approach in one. Postoperatively, the elbows were immobilised at 45° flexion for the normal period (18 days) followed by active mobilisation. Results were analysed with the Mayo Clinic score. The radiographs were examined in search for lucent lines and signs of loosening and prosthetic instability.

Results: At a mean follow-up of four years (2–12), the mean Mayo Clinic score had improved from 33 to 75 points (45–100). Eleven elbows were pain free at last follow-up. Extension and flexion progressed 22° giving a postoperative amplitude of 34° to 129°. Pronation supination progressed by 15° giving a 154° rotation amplitude. The function score improved from 6 to 18 points. Seven of the sixteen elbows achieved normal function. Outcome was excellent for seven elbows, good for one, fair for three and poor for five. In two elbows, instability required changing the ulnar implant. There were four implant loosenings that required revision at 24, 36 ,36 and 48 months after the initial implantation. The radiographic analysis demonstrated a complete lucent line around the humeral and ulnar implant in one case, around the ulnar implant in one case. There were two peroperative fractures of the humerus and on postoperative fracture due to a fall. Ulnar paresthesia was observed in two cases requiring secondary neurolysis in one. There were no infections or secondary injury to the triceps.

Discussion: The GUEPAR prosthesis is a non-constrained prosthesis essentially indicated for rheumatoid polyarthritis. If the intrinsic stability is lost, the implant is contraindicated if there is loss of bone stock or if the instability is major. In selected cases, a generally painless elbow with recovery of the functional amplitude can be achieved with this prosthesis. Nevertheless, the presence of four early loosenings in our series as well as two instabilities suggest this implant should be abandoned in favour of a semi-constrained implant.

Purpose of the study: A retrospective series of 40 patients who underwent simultaneous intramedullary nailings for bilateral femoral shaft fractures was analyzed. The aim of our study was to verify that simultaneous nailing without reaming does not increased risk of fat embolism and to assess clinical and radiological outcome.

Material and method: This series included 27 men and 13 women, mean age 27.8 years, who underwent first intention intramedullary nailing between 1986 and February 1999. Thirty-two patients had multiple fractures. Mean ISS was 23 (range 9 to 59). Among the 80 femoral shaft fractures, 15 were open fractures, 3 were associated with sciatic paralysis, and 4 were complicated by an interruption of the femoral vessels. The AO classification was: type A = 44; type B = 25; type C = 11. Mean delay to simultaneous centromedullary nailing was 3.8 days: surgery was performed on the day of arrival for 25 patients. General anesthesia was used in all cases with respiratory assistance (FIO2 = 50 to 100 p. 100). Mean nail diameter was 11.6 (range 10–14). Gurd criteria and PaO2 were followed to assess pulmonary function. Clinical and radiological outcome was assessed using the modified Thorensen criteria.

Results: Preoperatively, PaO2 was < 87 mmHg in 8 patients. Four of these patients showed a discrete drop off and three improved well above the normal level. Only one patient experienced an important decrease but did not develop respiratory distress. Among the 32 patients with a normal level preoperatively, PaO2 remained in the normal range in 18, fell to a limit level but below 87 mmHg in 4, and showed a substantial drop off of 46 to 172 mmHg in 10. Two of these 10 patients developed respiratory distress due to fat embolism which was fatal in one case. One other patient died in the immediate postoperative period of an undetermined cause. All of the other patients recovered normal gas levels within a few hours or days. There were four cases of phlebitis, including one with pulmonary embolism, one case of respiratory distress by pulmonary superinfection, and one case of septicemia. Both femoral fracture sites became infected in one patient. Malunion occurred in two cases. Two vascular repairs of the femoropopliteal axis were unsuccessful, leading to above knee amputations. Thirty-four patients have been examined after a minimal 12 months follow-up (mean 30 months). Outcome was excellent for 48 femurs, good for 10 and fair for 10.

Discussion: This continuous series of simultaneous bilateral femoral shaft intramedullary nailings appears to be the only such report to date. The clinical and radiological outcomes were comparable with those achieved in one-side femoral fractures. The risk of fat embolism is inevitable after long bone fractures. Many factors favoring the risk are recognized, the most important being delay to fixation. Reaming creates excessive pressure in the medullary canal and could thus contribute to the risk. The presence of an associated chest trauma is not a formal contraindication if effective hematosis is preserved as evidenced by the blood gases.

Conclusion: Simultaneous nailing of bilateral femoral shaft fractures can be performed if blood gases remain acceptable and minimal reaming is used.