Purpose of the study: The reversed total shoulder prosthesis is one of the treatments currently proposed for excentered glenoid osteoarthritic degeneration with massive rotator cuff tears. In light of the mediocre or at best highly variable results obtained with osteosynthesis or humeral arthroplasty for four-fragment fractures of the proximal humerus, indications for the reversed total shoulder prosthesis have been widened to include this category of traumatology patients. The purpose of this prospective study was to report outcome with the reversed prosthesis used for complex fracture of the proximal humerus in subjects aged over 70 years.

Material and methods: Ten patients, mean age 76 years, underwent surgery performed by the same surgeon to insert a Delta (DePuy) reversed prosthesis for four-fragment complex displaced fracture of the proximal humerus. The deltopectoral approach was used for all patients. The rotator cuff status was assessed intraoperatively. Clinical (Constant score) and radiological assessment were noted at 24 months.

Results: During the operation, only three of the ten shoulders presented a full thickness rotator cuff tear. One patients developed a complication requiring revision: early dislocation revised with a retaining polyethylene insert without recurrent dislocation. There were no cases of glenoid loosening at last follow-up. The weighted Constant score was 65/100. A pain-free shoulder was achieved in all ten patients. Anterior elevation was 130° on average, internal rotation reached hand to buttocks and active external rotation 20°.

Discussion: In patients aged over 70 years presenting a complex four-fragment fracture of the proximal humerus, the reversed prosthesis enables improved function and restoration of satisfactory joint movement. Early postoperative recovery and the gain in pain relief are encouraging factors. There was however unsatisfactory restoration of active rotation. For the elderly subject, free of a massive rotator cuff tear, rapid recovery after insertion of an reversed prosthesis should be balanced against the possible preservation of active rotations with an anatomic prosthesis.

Purpose: Amstuz introduced the notion of a lever arm ratio to describe the relationship between the abductors and weight in arthroplasty. He demonstrated that patients may limp if defective lateralisation produces a low lever arm ratio. We analysed a continuous series of arthroplasty patients with excellent outcome at one year to compare restoration of lateralisation with the preoperative status. We also performed the same analysis in a series of patients who limped after arthroplasty, excluding cases with classical causes of failure. We then compared these two series.

Material and methods: We had a series of 100 arthroplasties with excellent results at one year. These patients had undergone unilateral arthroplasty and had a healthy contralateral hip. The centre of the arthroplasty head was identified on preoperative and one-year AP x-rays of the pelvis (same magnification). We measured the lateralisation in relation to the femoral axis. The position of the cup was measured with a U ratio. Results were expressed in percent restitution of the preoperative status. Amstutz’s lever arm ratio was also measured. Finally, we measured the distance between the pubic symphysis and the outermost point of the femur on the prosthetic and healthy side.

We also had a second population of twelve patients presenting persistent limping at one year with no objective cause. The same parameters were measured for this population.

Results: We found that we had achieved only partial restitution of the initial lateralisation and had a tendency to medialise the acetabulum. The restitution of lateralisation was significantly different between the series with excellent outcome and the series with limping.

Discussion: Deficient lateralisation appears to be a factor involved in persistent limping. There is a threshold for restitution of lateralisation; limping is always observed under this threshold. Data in the literature reveal a very wide variability in lateralisation. It would thus appear important to restore the initial lateralisation to avoid limping; this has led us, like others, to use lateralised implants for certain patients.

Purpose: We report a prospective series of 70 explantations of the femoral pivot via a transfemoral approach required due to septic and aseptic loosening.

Material and methods: Aseptic loosening was observed in 61 cases, septic loosening in 9. The extended posterolateral approach was used to remove the implant in all cases and a femoral segment (Wagner method). Reconstruction of the femur was achieved with locked stems without cement (65 patients) or a long stem without cement (1 patient). Reimplantation was not attempted in four patients. Bone grafts were not used. Mean follow-up in this series was 3.5 years. The PMA score was used for clinical assessment. Radiographic assessment of segment healing and bone regrowth around the implant was done by measuring the cortical index.

Results: We observed a significant gain in the PMA score of more than 9 points. We had one intraoperative fracture of the femoral segment and two episodes of early dislocation. All femoral segments healed. Osteogenesis failed in three cases with fracture of the locking screw. There were also two cases of late fracture of the trochanter. At one year, bone regrowth measured from the cortical index was greater than 10% on the average.

Discussion: We discuss the characteristic features of this type of surgery in comparison with other solutions for femoral revision: operative time, blood loss, choice of implants, later weight bearing. We also found that this technique allows easier implant removal and more effective cleaning of the femoral shaft in the event of septic surgery with fewer cases of intraoperative accidents (malposition, femoral fractures). We were able to demonstrate that this method of femur reconstruction without bone graft provides a stimulation of osteogenesis in the floating segment. Stem locking provides primary stability in 100% of the cases. Secondary stability was achieved in 90% due to the quality of the newly formed bone.

Purpose: A new locked nail is proposed for the treatment of proximal fractures of the humerus. This simple system with self-locking screws was designed for all types of proximal fractures. The purpose of this prospective study was to determine indications and identify limitations.

Material and methods: We used the proposed fixation method sparing the cuff muscles and using a cup-and-ball technique for complex three or four-fragment fractures with major displacement. All nails were locked proximally, with at least two screws, and distally. Early joint mobilisation recommended for this type of osteo-synthesis was applied diversely. This series included 50 fractures of the upper humerus which were all treated with a Telegraph nail between January 2000 and January 2002. We identified 18 fractures of the surgical neck and 32 cephalotuberosity fractures. Mean age was 67 years, range 23–94 years.

Results: The Constant score at maximum follow-up of 24 months was used to assess clinical outcome. Bone healing was effective in all cases but there were several complications: secondary displacement (n=3), fracture of proximal screws (n=5), nail ascension (n=3), rupture of the long head of the biceps (n=1), and stiffness at flexion (n=12), which required removal of the implant in five patients and prosthetic replacement in one.

Discussion: The self-locking screws used with this nail provide excellent stability. Despite the rigid assembly, we observed displacements which led to screw failure and tilting heads. The distal locking screw appears to play a deleterious role in impaction of the fracture. The high rate of complications, 26% in this series, has led to reconsider using plate fixation for complex fractures in young patients and ascending pinning with the Apprill or Hackethal method to avoid aggression on the rotator cuff for fractures of the surgical neck. The Telegraph nail thus does not appear to be indicated only for complex fractures of osteoporotic bone; arthroplasty should be retained for this indication.

Purpose: Fracture of the neck of the femur in elderly subjects is generally treated by arthroplasty, either using a total or intermediary hip prosthesis, but with a high risk of dislocation, estimated at about 10% in the literature. We investigated the contribution of a double mobile cup to lower this risk.

Material and methods: This prospective study was conducted by several operators in the same university unit between 1998 and 2001. A total of 177 mobile prostheses were implanted in patients with fracture of the anatomic neck of the femur (n=145), the neck and trochanter (n=22), or pathologic fracture (n=4). For six patients, the prosthesis was implanted after failed osteosynthesis of a trochanteric fracture. The postero-lateral approach was used for 136 women and 41 men (age range 61 – 92 years) living at home (n=124), or in an institution with a high degree of independence (n=53). The femoral stem was cemented (n=115) or impacted (n=62). A double mobile cup was used in all cases. A chromium-cobalt/ polyethylene couple was used and head diameters were 28 mm (n=150) or 22.2 mm (n=27). We studied outcome and risk of dislocation one year after implantation.

Results: There were six deaths during the postoperative period. Among the 171 patients, 134 were seen at two months, 108 at six months and 89 at one year: 39 were questioned to ascertain outcome. During the first postoperative year, there were 37 deaths; these patients were followed. Six patients were lost to follow-up. We had two cases of intraprosthetic dislocation related to a defect in the chromium-cobalt head retention of the polyethylene insert. These two cases required revision and were reported to material surveillance with corrective measures for the manufacturer.

There were three true dislocations (2%): 1) a posterior dislocation on day 24 in a female patient presenting a fracture with impaction of the femoral stem; 2) a posterior dislocation on day 22 in a female patient in very poor general condition (severe cardiorespiratory failure, death at 48 hr); 3) one recurrent posterior dislocation related to major acetabular retroversion, revised at four months.

Discussion and conclusion: The double-mobile cup appears to be a simple reproducible method for preventing dislocation of prostheses implanted for fracture of the neck of the femur.