Purpose of the study: Treatment of supra- and inter-condylar fractures of the femur remains a difficult challenge, irrespective of the method used, because of the high risk of infection, disassembly, nonunion, joint stiffness, osteoarthritis, and multiple operations. Use of a supracondylar retrograde nail, accepted for C1 and C2 fractures, can be used for some C3 fractures depending on the stability of the epidphyseal assembly.

Material and methods: This series included 19 C3 fractures (AO classification) operated on in 1993–2000. Mean patient age was 54 years (range 30–81), 11 females and 8 males. This consecutive series of patients had: high energy trauma (n=14), low-energy trauma (n=5), multiple fractures (n=16), open fractures (n=10). Osteo-synthesis was performed on an ordinary table in the dorsal supine position with arthrotomy and epiphyseal screw and pin fixation followed by static supracondylar retrograde nailing (Smith and Nephez GHS), completed in two cases with an autologous corticocancellous graft. Kinetec was used for mobilization and weigh bearing delayed until bone healing.

Results: Twelve secondary operations were performed: cover with muscle flap (n=1), early revision for rotation misalignement (n=1), autologous graft (n=4), surgical arthrolysis (n=6), revision for nonunion (n=4). There were no infections. Among the four cases of nonunion, three involved epiphyseal screw failure, two cases having involved grafts. All four cases were treated by decortication, graft and plate fixation; healing was achieved. Mean time to bone healing per primam was 23 weeks on average. The 19 patients were examined at mean 44 months follow-up (range 16–78 months). Pain was noted: absent (n=8), mild (n=3), moderate (n=6), severe (n=2). Gait was noted: normal (n=7), slight limp (n=9), important limp (n=3). Mean flexion was 114° (range 85–150°). Five cass had permanent flexion < 10°. Radiologically, misalignment of +5° in the frontal plan was observed in six cases.

Discussion: Retrograde nailing of C3 fractures is difficult, but possible and requires first epiphyseal fixation then diaphyseal solidarization. The assembly is reliable, allowing immediate mobilization. Weight bearing must however be delayed to bone healing. Complementary surgery to graft bone stock or for relative arthrolysis has to be integrated into the operative plane for more than half of these difficult cases.

Purpose of the study: The place for total ankle arthroplasty versus fusion remains a subject of debate for the treatment of painful stiff ankles.

Material and methods: This series included 58 total ankle arthroplasies performed in 56 patients between 1991 and 2003. Mean paient age was 52 years (range 27–84). The underlying cause was multiple trauma (n=27), rheumatoid arthritis (n=17), chronic instability (n=11), hemophilia (n=2), primary disease (n=1). Four implants were used: New Jersey (n=22), Albatros (n=4), Star (n=10), AES (n=22). Associated procedures were: lengthening of the Achilles tendon or vastus (n=28), lateral ligamentoplasty (n=6), fibular osteotomy (n=2), medial ligamentoplasty (n=1), calcaneal osteotomy (n=3), double arthrodesis (n=1). The patients wore a plaster cast for 21 to 40 days.

Results: Eight patients were removed from the analysis: death (n=4), foreign residence (n=1, 3 follow-up shorter than one year (n=3). The analysis retained 50 total ankle arthroplasties in 48 patients reviewed with a mean 49 months follow-up (range 1–12 years). Reasons for surgery were: trauma (n=25), rheumatoid disease (n=12), instability (n=10), hemophilia (n=2), primary (n=1). Implants were: New Jersey (n=17), AES (n=19), Star (n=9), Albatros (n=3). Complications were: intra-operative medial malleolar fractures which were pinned (n=8), immediately revised radiological instability (n=2), wound dehiscence treated with a flap (n=1), secondary fusion (n=4). There were no cases of infection. There were six failures (12%) leading to implant removal for loosening (n=3), pain (n=2), instability (n=1) and revision arthrodesis (n=4) or new arthroplasty (n=2). The 44 remaining cases were analyzed: AOFAS score improved from 40/100 to 73/100 at last follow-up. Joint motion was 24° preoperatively and 20.5° postoperatively (dorsal flexion −1° to +6°, plantar flexion 25° to 14.5°).

Radiographically five prostheses were unstable with potential loosening (3 tibial and 2 talar components), one presented varus misalignment, and the others were considered correct. Moderate to severe intra-articular osteophytes were noted in 11 ankles. Three presented an undetermined defect image in the tibia.

Discussion: Indications for total ankle arthroplasty are exceptional and different from total prostheses for the knee or hip joints. Patients are young subjects with stiff, misaligned, unstable ankles, generally resulting from traumatic injury. Surgery is a challenge and requires several complementary procedures. Failure rate is higher than for the knee or the hip but mid-term results are encouraging. Further follow-up is needed for long-term confirmation.