Purpose: The floating shoulder is a special entity in traumatology of the upper limb. Bioechanically, the floating shoulder corresponds, as defined by Goss, to a rupture of the suspensor complex. Management is not well defined but must target the proper balance between the need for anatomic restauration and quality functional results obtained in the majority of cases treated orthopaedically. This apparent paradoxical situation is probably related to the precision of indications.

Material and methods: Forty-five patients managed between 1980 and 2001 were reviewed retrospectively. Thirty-five presented a scapulo-cleido-thoracic syndrome, ten a scapulocleidal syndrome. Mean age at the time of trauma was 39 years and mean follow-up was 2.4 years (1–16). The patients, 36 men and nine women were mainly (76%) traffic accident victims (58% motorcycle, 33% automobile, 9% pedestrians) and 76.8% had multiple injuries. Cleidal lesions were 18 mid-third fractures, 12 acromiocleidal dislocations, three sternocleidal dislocations, seven bifocal fracrturs, three lateral third fractures and two medial third fracturs. The scapular lesion involved the body of the bone in 19 patients, the neck in 14, the glenoid cavity in two, the coracoid process in one, and multifocal fractures in nine.

Results: Thirty-two patients were treated orthopaedically and twelve patients surgically, four with cleidal osteosynthesis, eight with both. The postoperative x-rays were used to assess anatomic results and the Constant score to assess functional results. Complications included six deformed calluses, with four causing major functional impairment and one requiring revision. All resulted from orthopaedic treatments.

Discussion: While most patients have an indication for orthopaedic treatment, analysis of the displacemens can lead to a surgical indication. We retained the following criteria for surgical treatment: scapular neck fracture causing more than 40° angulation, glenoid medialisation-ventralisation greater than 2 cm, and displaced articular fracture. Osteosynthesis of the clavicle for floating shoulders with a major displacement appears to be the minimum prerequisite if the multiple injuries prevent optimal management.

Purpose: We studied the effect of rhBMP-2 in patients with open leg fractures to determine the impact on the number of revision procedures and on late bone healing or nonunion.

Material and method: Four hundred fifty patients with an open tibial shaft fracture that could be treated with a stratified nail (Gustilo-Anderson) were included in the study. Patients were randomly assigned to three treatment arms: control, with rhBMP-2 0.75 mg/ml, and with rhBMP-2 1.5 mg/ml. The proteins were carried on a biodegradable collagen sponge. The rhBMP impregnated sponge was placed on the wound in contact with the fracture after reduction and nailing. A dynamic or locked nail was used, with or without reaming.

Results: Follow-up data were available for 93% of the patients at 12 months after nailing. Compared with the control group, the number of reoperations for delayed healing was lower in the rhBMP-2 groups (p = 0.0017). Results were better in the 1.5 mg/ml group (−44%, RR=0.56, 95CI = 0.40-0.78, p=0.0005). The number of major reoperations (bone grafts new nailing) was considerably reduced (−49%, p = 0.0264). Between the 10th and 52nd week, the proportion of patients with a healed bone was significantly higher in the 1.5 mg/ml group than in the control group. At six months, 58% of the patients treated with 1.5 mg/ml had healed, compared with only 38% in the control group. Mean delay to healing was significantly lower in the 1.5 mg/ml group compared with controls (Kaplan Meier, p=0.022) and mean delay to healing in 50% of the patients was 145 days, compared with 184 days. Rate of infection was similar in the three groups, but there were significantly fewer infections in the 1.5 mg/ml group patients with a grade 3 fracture than in controls (p=0.0219). There was also a lower rate of fixation material failure in the 1.5 mg/ml group (p=0.0174). Anti rhBMP-2 antibodies (< 6%) or anti-collagen bovine antibodies (< 20%) were observed without presence of anti-human collagen antibodies and without any clinical expression or apparent effect on the clinical outcome.

Conclusion: At the dose of 1.5 mg/ml, rhBMP-2 associated with centromedullary nailing significantly improved outcome, with fewer reoperations for late healing and fewer major reoperations. Fracture healing was accelerated and rate of infection was lower in patients with the most severe fractures.